1. Title Page Title MEDIATION MEDIATION March 3, 2008 James Rasnake, vs Grand Strand Regional Medical Center, LLC 1

2. COMPARTMENT SYNDROME A condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space. RAMPANT – UNCONTROLLED SWELLING 2

3. Mechanism of Injury COMPARTMENT SYNDROME FRIDAY Dec 2, 2005 Triple bypass mammary & saphenous vein grafts ICU increased output surgical drain Re-explored ICU 3 Aortic Valve Replacement (mechanical)

4. Mechanism of Injury COMPARTMENT SYNDROME Post Operative Edema 24 hours SATURDAY December 3, 2005 PCU 4 Abnormal buildup of fluids that leads to SWELLING Responded to Diuresis

5. Symptoms COMPARTMENT SYNDROME SYMPTOMS High Alert for Signs and Symptoms 5 Non-specific aching of the hand Disproportionate pain Loss of digital motion Continued swelling

6. Mechanism of Injury COMPARTMENT SYNDROME Increased pain and swelling in right arm and hand SUNDAY December 4, 2005 PCU Mr. Rasnake conscious and complaining 6 Doctor not notified

7. Diagnosis COMPARTMENT SYNDROME DIAGNOSIS 7 Pain out of proportion to injury Palpable tense compartment Pain with passive stretch Parethesia Pallor

8. Mechanism of Injury COMPARTMENT SYNDROME Increased pain and swelling in right arm and hand with Parethesia MONDAY December 5, 2005 PCU 8 DIAGNOSIS: Compartment Syndrome Swelling increased over right arm and hand over past two days Thomas J. Chambers, MD Consult

9. Duty GRAND STRAND MEDICAL CENTER MONDAY December 5, 2005 9 “ This appears to be most likely a reperfusion injury.” Thomas J. Chambers, MD Consult Fasciotomy 12/05/05

10. COMPARTMENT SYNDROME December 2005 Mon Tues Wed Thurs Fri 1 2 3 4 5 6 7 8 9 Bypass ICU ICU PCU Swelling SURGERY Discharged 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Doctor not notified of increased pain and swelling in hand and forearm Sat Sun 10 Swelling PAIN Weekend PAIN Swelling

11. Mechanism of Injury COMPARTMENT SYNDROME Bone Compartment 11 Nerves Veins Arteries

12. COMPARTMENT SYNDROME Pressure – No Outlet – Blocked by Fascia Tissue, Nerves & Veins Compressed Mechanism of Injury 12 Damaged or Dead Fascia

13. Damage & Death COMPARTMENT SYNDROME Tissue Survival 13 3-4 hours – reversible changes 6 hours – variable damage 8 hours – irreversible changes Muscle Nerve 2 hours – looses nerve conduction 4 hours – neuropraxia 8 hours – irreversible changes

14. Treatment COMPARTMENT SYNDROME Incision through skin & fascia to release pressure 14 FASCIOTOMY

15. Treatment Tissue, Nerves & Veins Decompressed COMPARTMENT SYNDROME 15 Fascia

16. Thenar Muscles – Thumb Dexterity 16 Right Hand FASCIOTOMY

17. 17 Median Nerve Thenar Muscle Right Hand FASCIOTOMY

18. Dorsal Interrosei Muscles - Grip 18 Right Hand FASCIOTOMY

19. Right Arm FASCIOTOMY Forearm Extensor Compartment Grip 19

20. Duty GRAND STRAND MEDICAL CENTER Patient’s Rights Pain Management 20 Pain relief measures A concerned staff committed to pain prevention and pain management Health professionals who respond quickly to reports of pain Your reports of pain will be believed State-of-the-art pain management

21. Duty GRAND STRAND MEDICAL CENTER Policies & Procedures 21 Unconscious exam Examine in orderly, symmetrical fashion (Ensures all areas are assessed; compare one side to the other so abnormalities are more easily identified.) Do a brief exam at shift change Page 37 Critical care patients with change in condition Page 58 POLICY: The physician will be notified Immediately of any significant deterioration in the patient’s condition.

22. Duty GRAND STRAND MEDICAL CENTER Wednesday December 8, 2005 Noon 22

23. Family JAMES RASNAKE 23

24. Grip & Fine Motor JAMES RASNAKE 24

25. Grip & Fine Motor JAMES RASNAKE 25

26. DAMAGES SUMMARY 26 DAMAGES SUMMARY MEDIATION: $960,000 Medical Expenses $ 63,663 Pain & Suffering Past and current 7-10 on scale of 10 at end of work week $ 200,000 Nature, Extent & Duration of injury Permanent disability & disfigurement $ 250,000 TOTAL DAMAGES: $ 1,211,127 Lost Wages and benefits 14 years remaining work life $ 707,464

27. END 27 END