by: Nachman Brautbar
"Intoxication, Drugs of Abuse Testing
& Forensics Application
By Nachman Brautbar, M.D.
Case #2:
This is a 32-year-old female patient, a driver of a vehicle who was involved in a car collision and suffered internal bleeding (ruptured spleen), and a fracture of a bone of the lower extremity. She had requested medical benefits from her insurance carrier for medical expenses as well as time lost from work, and has filed a lawsuit since these were denied. The physician who examined the patient on behalf of the insurance carrier, and whose report was the basis for the denial, noted in his reports that upon admission to the emergency room on the date of injury, urine screening test for toxicology was done, and was positive for amphetamines. The physician who examined the patient on behalf of the insurance carrier failed to note the time of the testing, the time the urine was obtained from the patient, whether the patient was taking any medications which contain amphetamines, such as ephedrines or pseudoephedrines. The medical records examined carefully by the patient's physician, found notes from the house doctor who attended the patient at midnight on her admission. The house doctor took a good detailed history recorded in his handwriting which clearly stated that the patient is an allergic individual, and has for the last two weeks been using compounds which contain both ephedrine and pseudoephedrine. The physician who reported on behalf of the patient further was able to show in the medical records that all examining physicians clearly stated that the patient was alert x 4 on admission to the hospital, despite her pain and despite medications received from the paramedics and emergency room physicians. There was no clinical evidence of impairment, there was no history of drug abuse, there was no evidence of drug impairment. The problem with this case, is that the urine screening test was a false positive, because of the patient's use of over-the-counter ephedrine and pseudoephedrine containing medications to treat a cold and nasal congestion. Had a follow-up been done on that sample with gas chromatography/mass spectrometry showing a specific type of amphetamine, the story might have been different if indeed the patient was a user (which is not the case here). This case further illustrate: 1. The need for a very in depth evaluation of the chart and notes, as far as to the patient's mental capacity before and after the collision. 2. A detailed analysis of past and present prescription and over-the-counter medications. 3. The need to follow-up on urine screening test if it is positive for drugs of abuse in a case where such suspicion is indicated. Gas chromatography/mass spectrometry is the ultimate tool to eventually follow-up on such a suspicion.
In summary, while drug abuse and intoxication is a problem, the diagnosis of Aintoxicated@ is a scientific one and cannot be based on Apersonal beliefs@ or Afeelings@ of a defense examiner.
About Dr. Brautbar
Dr. Brautbar is board-certified in internal medicine, forensic medicine, and nephrology, with a specialization in toxicology. Dr. Brautbar has provided expert medical opinion and scientific evidence in product liability, personal injury, medical & nursing home standards, and toxic tort cases throughout the United States. Dr. Brautbar is a Clinical Professor of Medicine at USC School of Medicine, Department of Medicine, and served as Chairman and Vice-Chairman of the Department of Medicine at the Queen of Angels/Hollywood Presbyterian Medical Center. He has published over 240 journal manuscripts, abstracts, and book chapters in the fields of internal medicine, toxicology, and nephrology. His resume includes past and present membership in 25 National and International Scientific Societies including the Collegium Ramazzini. Dr. Brautbar has been on the faculty of the National Judicial College and lectured to Judges on the issue of Scientific Evidence, and was a peer reviewer for the Federal Judicial Center (Reference Manual on Scientific Evidence, Second Edition, 2000). Dr. Brautbar has also been a peer-reviewer for the ATSDR.
"
About the author:
Dr. Brautbar is writing article for www.environmentaldiseases.com,specializes in Internal Medicine, Nephrology, Toxicology, Pharmacology, and Occupational Medicine. He is a Clinical Professor of Medicine at the University of Southern California, School of Medicine, teaching medicine, and actively engaged in the practice of medicine.
"Intoxication, Drugs of Abuse Testing
& Forensics Application
By Nachman Brautbar, M.D.
Case #2:
This is a 32-year-old female patient, a driver of a vehicle who was involved in a car collision and suffered internal bleeding (ruptured spleen), and a fracture of a bone of the lower extremity. She had requested medical benefits from her insurance carrier for medical expenses as well as time lost from work, and has filed a lawsuit since these were denied. The physician who examined the patient on behalf of the insurance carrier, and whose report was the basis for the denial, noted in his reports that upon admission to the emergency room on the date of injury, urine screening test for toxicology was done, and was positive for amphetamines. The physician who examined the patient on behalf of the insurance carrier failed to note the time of the testing, the time the urine was obtained from the patient, whether the patient was taking any medications which contain amphetamines, such as ephedrines or pseudoephedrines. The medical records examined carefully by the patient's physician, found notes from the house doctor who attended the patient at midnight on her admission. The house doctor took a good detailed history recorded in his handwriting which clearly stated that the patient is an allergic individual, and has for the last two weeks been using compounds which contain both ephedrine and pseudoephedrine. The physician who reported on behalf of the patient further was able to show in the medical records that all examining physicians clearly stated that the patient was alert x 4 on admission to the hospital, despite her pain and despite medications received from the paramedics and emergency room physicians. There was no clinical evidence of impairment, there was no history of drug abuse, there was no evidence of drug impairment. The problem with this case, is that the urine screening test was a false positive, because of the patient's use of over-the-counter ephedrine and pseudoephedrine containing medications to treat a cold and nasal congestion. Had a follow-up been done on that sample with gas chromatography/mass spectrometry showing a specific type of amphetamine, the story might have been different if indeed the patient was a user (which is not the case here). This case further illustrate: 1. The need for a very in depth evaluation of the chart and notes, as far as to the patient's mental capacity before and after the collision. 2. A detailed analysis of past and present prescription and over-the-counter medications. 3. The need to follow-up on urine screening test if it is positive for drugs of abuse in a case where such suspicion is indicated. Gas chromatography/mass spectrometry is the ultimate tool to eventually follow-up on such a suspicion.
In summary, while drug abuse and intoxication is a problem, the diagnosis of Aintoxicated@ is a scientific one and cannot be based on Apersonal beliefs@ or Afeelings@ of a defense examiner.
About Dr. Brautbar
Dr. Brautbar is board-certified in internal medicine, forensic medicine, and nephrology, with a specialization in toxicology. Dr. Brautbar has provided expert medical opinion and scientific evidence in product liability, personal injury, medical & nursing home standards, and toxic tort cases throughout the United States. Dr. Brautbar is a Clinical Professor of Medicine at USC School of Medicine, Department of Medicine, and served as Chairman and Vice-Chairman of the Department of Medicine at the Queen of Angels/Hollywood Presbyterian Medical Center. He has published over 240 journal manuscripts, abstracts, and book chapters in the fields of internal medicine, toxicology, and nephrology. His resume includes past and present membership in 25 National and International Scientific Societies including the Collegium Ramazzini. Dr. Brautbar has been on the faculty of the National Judicial College and lectured to Judges on the issue of Scientific Evidence, and was a peer reviewer for the Federal Judicial Center (Reference Manual on Scientific Evidence, Second Edition, 2000). Dr. Brautbar has also been a peer-reviewer for the ATSDR.
"
About the author:
Dr. Brautbar is writing article for www.environmentaldiseases.com,specializes in Internal Medicine, Nephrology, Toxicology, Pharmacology, and Occupational Medicine. He is a Clinical Professor of Medicine at the University of Southern California, School of Medicine, teaching medicine, and actively engaged in the practice of medicine.
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