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innovations in learning. A
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3D live video journal
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in association with SI, surgical neurology international, a 2D internet journal
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are pleased to present another in the SI digital series
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in spine surgery, a 3 part lecture series in discussion on the Cotto Aquinas Syndrome.
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A title of this talk is a review of the diagnosis and management of Cotto Aquinas Syndrome and related malpractice issues.
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It's given by Nancy Epstein, who is the professor of clinical neurosurgery at the School of Medicine at the State University of California, and has been a very successful clinical nurse in the SI
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She is the editor-in-chief of Surgical Neurology International.
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The talks in this series on Lumbar Cotto Aquinas Syndrome are part one anatomy, imaging, clinical presentations, and surgical lessons in diagnosing and treating the Lumbar Cotto Aquinas Syndrome.
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Part two is avoiding malpractice issues in Lumbar spine surgery, and part three is avoiding malpractice in the treatment of CSF leaks. Lumbar Cotto Aquinas Syndrome part one is on the anatomy,
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imaging, clinical presentations and surgical lessons in treating this syndrome.
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Part three of the Lumbar Cotto Aquinas Syndrome talk is on avoiding malpractice in the treatment of CSF leaks.
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So, part 3, the failure to diagnose and treat corticornic syndrome is negligence CSF weeks and their treatment, and then we're going to go through this and then the best timing of surgery for
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corticornic syndromes.
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The anatomy of the meninges, probably people are very familiar with this. You have the dura,
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and then you have the arachnoid, and below the arachnoid, you have the spinal fluid, and then the pia is just on the surface of the nerve tissue itself
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Dural tears, everybody will say, especially lumbar spine, coder-cointed syndromes, it just comes with the territory, it's a complication. However, if you've done the wrong operation, or you're
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doing an inadequate exposure, or technically poorly performing that operation, then it is negligence, and it is not just a complication. It is the technical error of your ways. And here's just an
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illustration of, you know, identifying the Dural Chair that may be present, obviously doing valsalvin maneuvers. We'll tell you if it's there. If you're just using loops, get out your microscope.
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If you didn't even put on your loops, get out your loops. But it is best to use a microscope if that microscope, again, has been the corner, take it out. If you do not have a assistant helping
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you in that case, this is a great time to ask for an assistant. It's really difficult to repair these adequately if you don't have an assistant Running sutures, you do not use a running suture.
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You do interrupted sutures, even if there are papers out there saying, Oh, they're just comparable, whether or not, because if you get one suture loosening, the whole thing is going to fall
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apart, and that's not gonna be the way to repair this. The repair, gortecks sutures. I was using 70 gortecks suture. The needle is very, very small
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The size of your exposure has to be enough to allow the curve of that needle to get in so that you can actually do the repair and you can see as you go up the different sizes how wider and wider the
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bevels get this is a non-resorbable suture and what's great about the suture is that the suture itself is bigger than the needle so that means every time you go through the dura you are obliterating
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that hole with the suture itself if you're using neural line and some of these others the needle is bigger than the suture and you're going to have constant leak still coming from that but the gortek
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sutures they're non-resorbable and they have higher risks of resistance to pressure neural lines and basically the single sutures they leak at lower pressures and again they start to unfurl they can't
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you don't get as tight a knot with those and they loosen so that's not the suture to use the best durable repair is to use your interrupted sutures. If you need it, you can add a muscle graft, or
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actually you can get fascia as well. I would not use, could have a graft any longer. It's got too many problems with it. I would not use fat. Fat is gonna shrink up and disappear and resort. You
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do a primary 70 suture repair, and you then want to do your valsales to make sure it's as watertight as possible So here's your dural repair with your sutures. Again, you can add a muscle patch
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graft to that if you need it. You can test the quality of your closure with a valsab maneuver. If it's still leaking, you can put in another suture. You can also add what are called micro-dural
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staples to facilitate that repair. So here's just an example. This happened to be a tumor case. Here you can see your dural edges above and below, and here's your quarter point of sitting here.
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And then in this instance, we've got seven-o-gortic sutures, we were taking out a neurofibromin in this case, but you've got your retraction sutures. So once you've taken out the tumor, what you
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can do, each of these sutures, retraction sutures is on a clamp. So you can flip the clamp one side to the other, one side to the other to bring the leaves of that dura together. And then what
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you do is if these are dura, you try and evert the dura to then with a pen field forceps and you then bring your suture around and through the dura on each side and you do suture by suture by suture,
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et cetera, as you go up to repair that. And then in between that, you're going to put your micro dural staples. Micro dural staples are like 14 millimeters. So you then get a valsave at this
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point. You really want to make sure it's as water tight as possible If it's not watertight, this is when you put in your muscle patch graft. If you put an onlay graft over an open CSF leak, it's
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going to float away. It's not going to work. It's going to get worse. And you can put in the dirge and you want, you can put in the, you know, as I said, dirseal, which is big and blue and
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glommy, and it takes about three weeks to resort. But when it resorts, you're going to have a massive CSF leak underneath this So if you don't have the microclubs, you just put more sutures in,
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right? That's right. That's right. And if you, if it still doesn't work, take a, take a piece of muscle. Muscle is great for occluding the leaks. It doesn't have to be a live muscle graph. We
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were doing that for a while where you, you know, make it a pedicle graft and we didn't really bother with that anymore. But just a, you really have to keep going. The other thing you can do, you
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put your, you know, you do this, you do your muscle graft, et cetera. And then, you know, you can put in your first layer of five concealant over that. And that's what that is, but, and by
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the way, don't leave gel foam behind or flow seal because that can actually swell and cause a quarter coin of syndrome. But over that, the microfibular collagen, there are two kinds, one is for
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just onlay application, okay? That's if there's no leakage. If there's leakage, you put in a little fiber and sealant, you may put in what's called the non-suturable derogen, and then above that,
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okay, that's what it looks like when you put it in, it usually deforms to the shape of the dura, etc, but don't be fooled, you're going to put another thin layer of fiber and sealant over that
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microfibular collagen or derogen, but then you're going to want to take suitable derogen where you get out your 70-grotech sutures, and you just, on a perimeter around it, you're going to directly
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repair
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that leak And this is what it actually looks like. So here's your suitable derogen. And I put a final layer of fiber and sealant on the outside and see all these little sutures here, here, here,
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here. There's some under there as well. This way it's not gonna float away. It's not gonna disappear. I can't remember the last time that a sutured derogen repair failed. So it takes throwing in
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the kitchen sink. It takes much longer, but this is the way to do it because as soon as you're coming back again, then you're really ending up with trouble much less possibly an infection.
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Here's a case of negligent minimally invasive surgery that can lead to an avoidable leak and
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recurrent post-op leaks because you didn't repair it the first time, you didn't enhance or enlarge your exposure and it might take a lot of enlarging of your exposure to get it, but it can lead to a
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quarter-point syndrome if you have a lot of compression from it. And here, a negligent minimally invasive discectomy, poorly repaired, recurrent post-op leak. This is your post-op leak caused a
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quarter-point of syndrome. And then in this case, you know, led to that patient's continued deficit. Okay. So the best timing of surgery for quarter-point of syndromes and you can take away the
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message the sooner the better and then forget everything else. Certainly less than zero to one days, but you don't have those 24 hours, especially if you already have a patient with a significant
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deficit. The clock starts ticking as soon as that patient gets that deficit. The studies that say you have 48 hours, they're wrong and they're poorly done. The studies that say you have 24 hours,
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well, they're counting from the time that the patient had the onset of the deficit in general. And a lot of the other studies are saying, you know, less than six hours, less than 12 hours, or
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basically the sooner or the better. This was a very good study by Hogan et al. He looked at less than six, less than 12, less than 24 hours. Nearly 21, 000 cases of corticoidis syndromes. I
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mean, this is big data, obviously. Best results, surgery day zero to one. From the initial onset, better at less than six to less than 12 hours. So don't let your colleagues, don't let your
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friends, don't let any of your spine surgeons get away with just, oh, well, you know, I had 24 hours. So it's within that 24 hour period. Wrong. You wanna do the best for your patient. You
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want that patient to have the best outcome. Get out of bed, stay out of bed. Do the operation that night. Don't wait till the next morning. And this applies to both partial and full-quarter coin
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of syndromes. Worst outcomes were found at days two or greater. And again, this is a huge national inpatient sample database. So 21, 000 cases. So these are the big studies, forget the small
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studies, the poorly done studies that said you have 48 hours, that's not correct. Carissa study, quadratic syndrome is a potentially devastating spinal condition. Timely diagnosis and treatment
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is imperative for outcomes, for avoiding also the medical legal ramifications Emergence spinal surgery is indicated and urgent decompression and enhances your chance of recovery. I'd written an
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article the sooner the better surgical morality international 2022. After writing just a review article, this was really the sort of the perspective. This is again looking at the nation in patients
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sample that was over 25, 000 cases. It was from one of the other authors. And again, early surgery, the earlier the better And this is just documenting and reminding patients. Surgeons, doctors,
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patients, everybody's, especially the emergency room and your physician's in your hospitalists, there's something called the partial cordicornia syndrome incomplete, you don't have to have
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everything. And here's the complete cordicornia syndrome where you have the paralysis, the sensory loss, the sital anesthesia, urine and bladder discontin, et cetera, incontinence. So the
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emphasis again on partial versus just complete cordicornia syndrome, that is the biggest message to get out there, especially to our adjunct of personal and friends. Do the right operation, the
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adequately extensive operation might be your laminectomy, or your coronal hammy
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laminectomy, as I had shown people before, adequate exposure, decompression. Doing these the sooner the better, the clock starts ticking, as soon as that patient started developing that deficit.
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Not just when they hit your emergency room, it's not at your convenience negligent and delayed surgery likely results in the - poorest of outcomes. And again, malpractice makes perfect or really
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imperfect. So the conclusion is that surgery, the earlier the better or the sooner the better, certainly less than 24 hours, six and 12 hours, the sooner you can decompress these patients, the
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better they're gonna be, choose the right time and the right surgeon and the right operation to get the best ones ads
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Well, it's an excellent job, Nancy. I just toured a fourth screen. Don't make sure any better. No,
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I think, as I was thinking as you were going through all this, you know, it gets down to some basics. I'll just take a couple minutes here, but it takes a history. You mentioned that so many
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times. You have to take the history. Don't let somebody else do it. Don't hear it from somebody, even the emergency room You gotta go down and get the history. When did you stop urinating the
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last time? When did your legs start getting weak? They don't know how to ask these questions. When did you just start getting tingling and so forth? When did you notice your foot was dropping and
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then you were dragging it? Well, a month ago or so, you gotta get a very good history and then you find out I'm uncommitted or I'm on some blood thinners or I've had heart trouble. I mean, all of
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these things are relate to your outcome and do an examination, do an examination. Obviously, you wanna do it yourself and it's doing examination. You have telemedicine, you can have somebody do
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it. I think you mentioned that you can get some pretty good examination if you're there directing them to do the things. And then you come near differential diagnosis. What do they got? And if the
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differential diagnosis contains a threatening disease, you don't wait. It's like waiting live, it could have an aneurysm, I don't know, I'm gonna take two weeks to figure it out. No, you can't
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do that. And so you get a differential diagnosis, you got to do imaging, we've talked to you. If you don't have the finest imaging in the world, you can still do basic imaging. We all did this
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years ago, you can put in some dye, you can take a do a myelic damage, you can get a very nice image of what's going on. Obviously, if you have a CT and an MR that's only better and it's quicker,
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and it's surgery, it's an emergent operation. Everybody in the hospital doesn't want to think about that. Well, we're off, we've got to call it a special crew or this, the next thing, there is
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no reasonable excuse. What you have to decide is what would you want or your family needs if they had the same problem And
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the other thing is you're going to have enough exposure. Don't be convinced by representatives and other people I can do this minimally invasive, not saying that all the minimally invasive is wrong.
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I'm saying that what Nancy said, you've got to find the right operation for the right circumstance and the right environment. And just because they may report some cases from
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some country where they've done 10, 000 through a minimally invasive exposure, doesn't mean you can do it. And it doesn't mean you're inadequate if you don't do that. Do the job, do it right.
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And complication admitted immediately and fixing. I mean, that's - And if there is a complication, recognize it and do a diagnostic study that can allow you to diagnose what the problem is and then
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fix it. That's the amazing thing to me is what they, The extent that the. many surgeons will now go to to basically ignore that there's a post-operative deficit or problem, even a life-threatening
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problem, and just,
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I might call that, make your diagnostic studies. If that's what it means, look, we all make mistakes. Fix it. That's what surgeons do. Fix it
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And don't hand everything off to your adjunctive personnel. Not everything should be the PA, the nurse practitioner, or whoever else you happen to have in your office. I mean, so many of these
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patients go back and forth and back and forth post-operatively to the office never seeing the surgeon, and it's supposed to be transmitted or discussed with the surgeon, and they have some have no
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knowledge of it, some refuse to admit that they had knowledge of it and they don't do anything about it. Let me just uh just show people uh if they're looking close. Yeah, I'm sorry. Some
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literature, now there's some literature on this and here's another that they can take a look at and hear yet another paper that they can look at. And I think that's -
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No, they can - Well, nice. Screams is pretty much done. It's not always such good. Right, right. So, but yeah, I mean, it's, what's very educational, actually one of the reasons that I,
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you know, we've discussed this before, that I do medical legal work. First of all, patients need to have representation. And there's a great effort out there to make sure that they are not
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represented by decent surgeons and they are being hurt and injured. And some surgeons are repeatedly injuring patients. And in some states, they're even being brought up on charges in those states
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and their licenses are coming under consideration. we all have to recognize that if that's right. If application, if adverse events are observed intraoperatively, postoperatively,
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the point is not to ignore them, but to treat them and fix them and try and optimize that patient's outcome. Because basically this should be all for the patient.
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I think, can I add one other thing here? And that's about admitting a mistake. You tell the patient I made a mistake Or I had this problem at surgery and this is what I did and these are the things
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I'm looking for. You gotta help and see if you can recognize these problems. So we know, but you try to hide the information. I've been in cases where the hospital, they go to the lawyers. The
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lawyers say, don't say anything about it. And it just is one more problem after the other. Remember, no matter what they tell you, you're the one who goes to court.
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They don't pay the price. The patient pays the price. And if you don't do it right, you're gonna pay a price. So there's no easy way out of this. You agree with that? Oh, absolutely. And they
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will circle the wagons and then leave you, hang you out to dry. So you have to. We had a patient, we took a
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vascular tumor out of the posterior fossa that was referred to us 'cause nobody else wanted to do it. We did it, it was very successful. We had an interventricular drain. You know why they were
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after surgery so that they could decompress and so forth. And then we went to the patient to go down for an imaging study. And the radiologist injected the dye into the ventricular drain. The
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patient seized and died. Oh my God. I found out about that. We went and talked to the husband immediately. I called the lawyer. the university, I said, settle this.
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It's indefensible, settle it. And it was settled, and the family was understanding. They were very reasonable about it. And the amount of settlement was very reasonable. And so nobody tells you
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that. And they tell you how to cover it up and do all kinds of things that you would never do in your life. You don't do that. You pay the price, the patient and pay a surprise. Don't do that.
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So thank you very much, Nancy, just this spectacular job.
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