electronic fetal monitoring (EFM)
A board-certified neurologist and an attorney, Dr. James C. Johnston serves as medical director of Legal Medicine Consultants in San Antonio, Texas. Dr. James C. Johnston has written numerous articles on topics intersecting medicine and law, including a recent peer-reviewed article, coauthored with Thomas P. Sartwelle, entitled Neonatal Encephalopathy 2015: Opportunity Lost and Words Unspoken, which was published in the Journal of Maternal-Fetal & Neonatal Medicine.
The article addresses the Task Force Study on Neonatal Encephalopathy Second Edition 2014, which recommended the use of electronic fetal monitoring (EFM). In the 19th century, it was believed that cerebral palsy and other conditions such as encephalopathy were caused by asphyxia during birth. EFM machines are intended to monitor the infant’s heartbeat during labor and indicate whether a physician should perform a caesarian section to prevent health issues associated with birth asphyxia.
EFM has never been subjected to a clinical trial, however, and has been shown to have a 99 percent false positive rate. Further, studies have proven that cerebral palsy is not caused by birth asphyxia. The use of EFM greatly increases the rate of caesarian sections, exposing both mother and baby to all of the potential risks and complications of that often unnecessary procedure. More importantly, it does not prevent or reduce the rate of cerebral palsy.
Thus, recommending the use of a test that has been shown to be at best imprecise and at worst harmful by exposing more women to cesarean sections is ethically dubious and goes against the fundamental medical tenet of “first do no harm.” While EFM may be useful in some contexts, it causes more harm than good and, the article concludes, should certainly not be used as legal evidence against physicians.
American Headache Society
A consultant neurologist for Legal Medicine Consultants, Dr. James C. Johnston earned his doctor of medicine from The University of Texas Health Science Center in San Antonio, and complete residency at the Texas Medical Center in Houston. Dr. James C. Johnston has written numerous scientific articles, including co-authoring a text entitled Migraine and Medical Malpractice for the American Headache Society.
In Migraine and Medical Malpractice, the authors discuss the role of neuroimaging in a patient with migraine headaches and a normal examination. The article specifically addresses the situation of a woman with a long history of migraines that progressively worsened despite an initial improvement on triptan medication.
In considering the woman’s condition, the authors pose the question of whether the evaluation should incorporate an MRI of the brain even though her neurological examination was normal. They concluded that she should have an MRI. Dr. Johnston recommended that physicians perform a complete history and physical examination on every patient with headache to determine the possibility of a serious underlying etiology such as brain tumor, aneurysm or other structural disease. The presence of warning signs – such as the increasing frequency of headaches in this patient – mandates further evaluation including neuroimaging.
The article goes on to answer questions such as how to respond if the MRI request receives denial in precertification, how to properly discuss medication side effects and other relevant points.
Crimean Congo Haemorrhagic Fever
A graduate of the University of Texas Health Science Center in San Antonio, TX, and the founding director of Global NeuroCare, Dr. James C. Johnston strives to increase the effectiveness and accessibility of neurology care worldwide. Focused particularly on the needs of sub-Saharan Africa, Dr. James C. Johnston co-authored a paper on the use of ribavirin as a treatment for Crimean Congo haemorrhagic fever.
Crimean Congo haemorrhagic fever is a viral infection with a fatality rate of 30 to 40 percent. It occurs most commonly in Africa, as well as in those areas of the Middle East, Asia, and the Balkans that lie south of 50 degrees above the equator. First discovered in the Ukraine in 1944, it made itself known in the Con go in the late 1960s and thus acquired its current name. It spreads as a tick-borne illness and is prone to amplification in the bodies of host animals, whose blood can then pass the disease on to humans. Similarly, humans may spread the disease among their own populations through contact with infectious bodily fluids.
Crimean Congo haemorrhagic fever has a typical incubation period of 1 to 13 days, depending on the source of infection. Once symptomatic, it presents with the sudden appearance of fever, dizziness, neck and back pain, and headache. Patients are also likely to experience muscle aches, photosensitivity, and eye pain, as well as early digestive distress and subsequent emotional agitation. As the disease progresses, a patient may become lethargic and develop haemorrhagic rashes, liver enlargement, and swollen lymph nodes. Patients who recover may begin to see improvement 9 to 10 days after symptom onset.
Neurologist and Attorney Dr. James C. Johnston recently co-authored an article with Thomas P. Sartwelle entitled “Neonatal Encephalopathy 2015: Opportunity Lost and Words Unspoken.” The peer-reviewed article was published in the Journal of Maternal Fetal and Neonatal Medicine, 2015, early on-line.
The authors consider why the 2014 Task Force Study on Neonatal Encephalopathy failed to address electronic fetal monitoring (EFM) and its 40 years of clinical futility, and ignored the ethical breaches EFM’s use compels physicians to commit daily. The Task Force acknowledged EFMs impotence, concurring with the authors earlier paper in the Journal of Child Neurology (Sartwelle TP, Johnston JC. Cerebral Palsy Litigation: Change Course or Abandon Ship), and yet recommended continued EFM of all women in labor, without providing informed consent. This paradox is explored by the authors in their latest article.
A private practice neurologist and lawyer, Dr. James C. Johnston currently serves as director of Legal Medicine Consultants, and as a partner in Global Neurology Consultants. Dr. James C. Johnston is also committed to advancing the legal and medical fields through scholarship, including through a recent peer-reviewed article he coauthored, published in the Journal of Child Neurology: ‘Cerebral Palsy Litigation: Change Course or Abandon Ship.’
In the article the authors assert that the majority of cerebral palsy litigation is driven by electronic fetal monitoring, a 40-year practice that lacks scientific support, yields a false positive rate higher than 99 percent, and increases the cesarian section rate with all of the attendant morbidity and mortality from that procedure. Despite its inability to predict cerebral palsy, electronic fetal monitoring continues to be endorsed as an effective practice by professional birth-related organizations around the world.
The authors further explain that electronic fetal monitoring is propagated by trial lawyers who have a monetary interest in using the results of the monitoring to their benefit. According to the article, electronic fetal monitoring reinterpretation in the courtroom has remained widespread, unreliable, and significantly biased.
The article goes on to explore how various legal tactics have failed to reduce cerebral palsy litigation. In conclusion, the authors propose using the Daubert doctrine to eliminate unsound science in the courtroom and thereby reduce the use of electronic fetal monitoring and, with it, the occurrence of cerebral palsy litigation.
The authors Thomas Sartwelle and Dr. James C. Johnston discuss cerebral palsy litigation further in a chapter they contributed to the 9th edition of the American College of Legal Medicine textbook: ‘Legal Medicine and Medical Ethics.’
Neurologist and lawyer Dr. James C Johnston is a consultant for GlobalNeurology, an independent organization that focuses exclusively on neuroscience. Dr. James C Johnston aids the organization by providing consultation services regarding a variety of neurological afflictions and diseases, such as headaches.
Migraine headaches are one of the most common headache disorders. Significantly more problematic than a tension or muscle contraction headache, migraines involve a constellation of severe neurological symptoms that result in debilitating pain and discomfort. Attacks can last between 4 and 72 hours. Associated head pains typically occur on only one side, although one in three attacks will cause pain on both sides. Additional symptoms vary and include nausea, vomiting, visual disturbance, and visual and aural hypersensitivity. Classified as a syndrome by neurologists, migraines vary from person to person.
Migraines affect over 10 percent of the total US population. Over 90 percent of patients diagnosed with a migraine cannot work or perform everyday functions during attacks and approximately 10 percent of school-age children experience migraines. Additionally, individuals with chronic migraine often experience depression, sleep deprivation, and anxiety as a result of the syndrome’s severity and unpredictability. While some individuals may have one or two attacks each month, others will suffer attacks at least 15 days per month.
There has been significant improvement in the treatment of migraines over the recent years. Before its recognition as a legitimate ailment, doctors believed migraines resulted from a psychiatric condition. Researchers today theorize migraine is related to nerve pathway and brain chemical issues. Current treatments focus on relieving symptoms, reducing attack intensity and frequency, and preventative measures such as exercise, proper diet, and relaxation techniques.