For the Defense - Vol. 6, Issue 1 - 31

and individual county policies. It is important to be
clear who is paying the expert's fees, as the Court
may need to be petitioned. Fees may be paid by
the private attorney, the Public Defender's Office,
the District Attorney's Office, the prosecuting
county or by the client. If the client is responsible
for payment, a medical expert may demand that a
defense attorney agree to undertake responsibility
and receive advance payment for expert fees. 	
	
Clear documentation, such as court orders and
signed agreements are needed to specify who
is responsible for paying the fees as well as the
hourly rate and/or caps imposed by the court or
otherwise. An estimate of the hours needed by a
medical expert to review the records and prepare
a report if needed can only be made if they are
informed of the types and volume of records and
the details of the case, as the amount of time
needed can vary significantly. It is also necessary to
clarify and document the initial services required as
well as those that may be needed in the future. For
example, I initially review all records and provide
verbal opinions to each defense attorney. That
timeframe needs to be established. Additional
fees need to be discussed and agreed upon for any
reports needed, regardless of whether a medical
expert can support the case. Also required is the
timeline for completion of any reports. Finally, it
needs to be established if a medical expert may be
needed to testify during a trial or deposition along
with any scheduled dates. Trial testimony may
involve travel as well as lodging, food, time, and
other related expenses that require reimbursement.

Medical Records
Once all of the above information is exchanged
and I am retained, I review with the attorney in
more detail the records that are available and which
of those records I need to adequately formulate my
opinions. I know that the discovery materials from
the prosecution may only provide limited records. I
will often request additional records either initially
or after I receive and review the initial set. For the
individual alleged victim(s), I want to see birth and
complete prior pediatric records in order to be
able to evaluate the child's injuries and medical
findings for possible underlying medical causes,
such as prior bruises, fractures or prematurity
and birth problems. Included in these records will
be a family history involving medical illnesses or
other problems. The family records can lead me to
identify a risk of the child having certain genetic
or metabolic diseases. In addition, there may be
important social history and physical findings
documented.

A complete set of the medical records relating to
the injuries or problems resulting in the allegations
is vital to formulate an opinion pertaining to
causes other than inflicted trauma. These records
may include office or emergency room visits for
injuries before the ultimate hospitalization or child
advocacy center (CAC) evaluation. It is important
to look at additional records other than records of
care immediately prior to the ultimate diagnosis.
Medical visits even weeks or months earlier may
also provide valuable information. For instance,
what may have been initially thought to be benign
bruises or accidental skin injuries may have been
what are called " sentinel injuries. " Sentinel injuries
are early inflicted injuries that were missed, which
escalated to more serious and potentially lifethreatening injuries over time.5
The medical records for the hospitalization
relating to injuries may be very lengthy, particularly
with electronic medical record systems. The records
that are the most important for me as an expert
to review include the admission and discharge
histories and physical exams. The records may be
voluminous because of initial emergency room
evaluations and inpatient hospital pediatric as well
as pediatric subspecialty evaluations on admission
and discharge. Each of these exams and other
records include important history for the injuries as
described by parents or caretakers. The exams may
also include the family and social history, a review
of each body system for symptoms or signs at the
time and a full exam of all body systems. There
may be differences in accuracy and consistency.
These differences are important in the assessment
of the case, including, but not limited to, the
credibility of the alleged perpetrator, or a red
flag for abuse. In addition, there are often several
pediatric subspecialists who may be consulted
during a hospital admission. Included among this
group may be general surgeons, trauma surgeons,
radiologists, neurosurgeons, ophthalmologists,
orthopedic surgeons, pulmonary specialists,
hematologists, endocrinologists, and geneticists.
Reviewing initial and follow up notes by each
specialist helps to determine the nature and extent
of the findings as well as potential explanations or
causes and differential diagnosis of the injuries. It
also helps to have a broad view as well as a detailed
evaluation of each type of injury or finding. 		
	
In addition to physician records and notes by
other medical providers, such as nurse practitioners,
reviewing nurses' comments and notes can reveal
important information that could support or
undermine a theory of the case. For example, these
records may provide insight about the behavior of

Vol. 6, Issue 1 l For The Defense

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For the Defense - Vol. 6, Issue 1

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