toby carlsson and david morrison - compass …...thank you [email protected] title prosthetic...
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Prosthetic Rehabilitation – Important Considerations in Litigation
Toby Carlsson and David Morrison
HCPC Registered Prosthetists22nd November 2019
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Public Provision in Scotland
Introducing David:
• Extensive experience from England and Scotland
• Lead prosthetist at Westmarc
• Part of Specialist Prosthetics Service
• All round good egg
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Prosthetic Rehabilitation at Pace
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Caseload
General• Elderly
• Dysvascular
• Diabetic
• Low mobility
• Sedate life
• “Cared for”
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Caseload
NHS
• Elderly
• Dysvascular
• Low mobility
• Sedate life
• “Cared for”
Pace• Trauma
• Working age
• Co-morbidities
• Active
• “Caring for”
• Litigation pressures
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Scope of practice:
“1.1 The purpose of the personal injury claimsprocess is to restore the individual as much aspossible to the position they were in before theaccident. The Code provides a framework forthe claimant solicitor and compensator to worktogether to ensure that the claimant’s health,quality of life, independence and ability to workare restored before, or simultaneously with, theprocess of assessing compensation.”
2015 Rehabilitation Code
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Scope of practice:
“1.1 The purpose of the personal injury claimsprocess is to restore the individual as much aspossible to the position they were in before theaccident. The Code provides a framework for theclaimant solicitor and compensator to worktogether to ensure that the claimant’s health,quality of life, independence and ability to workare restored before, or simultaneously with, theprocess of assessing compensation.”
2015 Rehabilitation Code
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Rehabilitation in litigation environment
Considerations
• Rehabilitation must be priority
• Lawyers can hinder or help!
• Facilitates funding-or not!
• Long term view needed
• Consider treatment v expert conflict?
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Treatment v Expert conflict?
Important considerations:
• Separate documentation system with restricted access
• Experts and treating clinicians separate individuals
• Treatment first, expert later
• Experts must have sub specialism experience
• Decision lies with instructing party
• Treatment is much more fun!
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Expert role
• “…duty to the court overrides any obligation…”
• “…all matters relevant to the issues…”
• “…true and complete professional opinion…”
• “…no conflict of interest of any kind...”
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The Expert Dilemma
“There are known knowns. These arethings we know that we know. There areknown unknowns. That is to say, thereare things that we know we don't know.But there are also unknown unknowns.There are things we don't know we don'tknow.”Donald Rumsfeld on weapons of mass destruction, 2002
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Rumsfeld in prosthetics
Known knowns:
• The landscape changes quickly
• Research quality evidence is scarce and outdated by the time it is published
• All amputees are different
• Prosthetics can be very expensive
• Expert predictions are not always accurate
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Rumsfeld in prosthetics
Known unknowns:
• Without experience of use-No certainty of outcome
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Rumsfeld in prosthetics
Known unknowns:
• Without experience of use-No certainty of outcome
So, experience using it!
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Prosthetic trial principles
Record performance of default prosthesis• Prosthesis currently in use or of “established” specification
Introduce component under investigation• Produce trial prosthesis, optimize, practice and use
Establish outcome• Compare and contrast objective and subjective outcome
measures
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Objective outcome measures:
• 2 minute walk test
• Timed up and go
• Gait analysis (force plate, video footage)
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Subjective outcome measures:
• Pain (Visual analogue scale)
• Confidence (ABC)
• Self perceived mobility (Plus-M)
• Qualify of life impact (PEQ)
• General Feedback…
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Rumsfeld in prosthetics
Unknown unknowns:
• A historical example
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Modular transfemoral prosthesis with silicone interface,
flexible socket, Genium X3 knee and composite foot.
Including turntable above the knee, and 6 year extended
warranty.
Year 1 Cost of provision £70,354.00
Year 2 Approx maintenance costs £850.00
Year 3 Approx maintenance costs
Including socket renewal £6.021.00
Year 4 Approx maintenance costs £850.00
Year 5 Approx maintenance costs
Including socket renewal £6,021.00
Year 6 Approx maintenance costs £850.00
Cycle of provision start again at the end of year 6.
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Modular transfemoral prosthesis with silicone interface,
flexible socket, Genium X3 knee and composite foot.
Including turntable above the knee, and 6 year extended
warranty.
Year 1 Cost of provision £70,354.00
?Cycle of provision start again at the end of year 6.