Photo by Arron Choi on Unsplash
Photo by Arron Choi on Unsplash
Photo by Bill Oxford on Unsplash
Good morning. I’d like to take this opportunity to thank the fine folks at the National Business Institute for making this CLE possible.
Today I’ll be reviewing the concepts of masking symptoms and differential diagnosis as well as the features of several common injuries you’ll have to deal with as personal injury attorneys practicing workers’ compensation law.
Along the way, we’ll touch on a few ancillary, yet critical topics: discovery challenges you’ll face as you construct your case, the claimants’ rights to a second opinion, her duties to comply with authorized treatment and the consequences of failing to do so, independent medical evaluations, what they are and when to use them, crafting compelling medical interrogatories, what functional capacity evaluations and how to deploy them, and lastly, the role vocational rehabilitation.
My goal is not to examine the leaves on the trees of all these topics, as such a lecture would necessarily exceed the time allowed, but I do hope that after my talk you will have a bird’s eye view of the features of the medical evidentiary and procedural challenges you’ll likely encounter.
I’ve designed this presentation for those attorneys just starting out in their practice and for those with less than five years handling workers’ compensation cases. But I hope that attorneys with more experience may also pick up a few things that would prove helpful to their practice. My analytical vehicle will be a case study based on an actual case I handled a few years ago. The names of the dramatis personae have been changed of course.
So, let’s jump right in. Adrian Phillips, a new workers’ compensation client, was twenty minutes late for his initial interview with me. He finally appeared with his wife, sauntering into my office, ostensibly without a care in the world. He smelled like a combination of cigarette smoke and marijuana. But his thoughts were lucid, and he spoke clearly. I concluded he understood his rights and possible remedies we would pursue, so I proceeded with the interview.
Adrian is a 42 years old male, Caucasian, standing d six feet-four inches and weighing 165lbs — underweight for his height. His medical chart noted an impressive 117 over 70 blood pressure. Large veins traced intricate designs on sinewy forearms. Richly burned by the Carolina sun, you could tell Adrian worked outside a lot. Adrian’s handshake was firm and absent was any overt display of the power you knew lay in those arms.
It was easy enough to sense the years of hard work to which Adrian’s leathery hand had been subjected, a tough hand which tapered into long, nicotine stained fingers. His small finger curled at an odd angle, as if he’d once fractured it, but decided it wasn’t worth the trouble and expense to treat.
Adrian claimed he drank 1-2 beers a day and was a moderate marijuana user, but never drank nor used at work and never partook when operating a car or heavy machinery. He had fallen into the marijuana habit in the early nineties as a teenager when the main recreation for his peer group was smoking pot while listening to grunge.
He had dropped out of high school at 17 “because he wasn’t learning anything anyway”, but, prompted by his wife Rita, whom he met and fell for at 24, he completed his GED just fine, receiving the highest score in his class. His favorite subject was math. He had no vocational training, picking up the skills he did possess OTJ. Despite a good mind, Adrian was still only an assistant manager in the warehouse he’d worked in for the last 18 years. He earned 19 dollars an hour.
Adrian’s driving record was clean, but his RAP sheet revealed a typical hell raiser – a kid who failed to grasp the seriousness of the trouble he courted, a kid raised on Star Wars movies that features as one it’s heroes Han Solo, a self-confessed thief and swindler, that is, a typical male example of his generation who grew up too late and thought movies and television were an accurate reflection of reality and proper human behavior. His most serious charge was possession with intent to distribute crack cocaine at 21 for which he received a five-year sentence, suspended to one with four years’ probation accompanied by alcohol and drug counseling, but he had been arrested several times since for simple assault, a few fraudulent checks and once for receiving stolen goods. It had not been an easy road for Adrian; and no doubt contributed to making the road harder than it needed to be.
These criminal shenanigans occurred in his late teens and early twenties. But now he truly appeared to be a dedicated worker and faithful husband, ready to lend a hand to a newbie employee brave enough to breach Adrian’s quasi- ersatz fearsomeness to ask for guidance.
Now, Adrian always “took a rain check” when the guys invited him for a “few pops” at the local bar. He liked to get home, see Rita, fix old cars – his second love, and rummage around junk yards on weekends for car parts, occasionally rescuing a serviceable kid’s bicycle save a missing part or two– bikes which he would then refurbish and donate to a nearby home for parentless kids. Rita knew about the bikes, but only Adrian and the staff at the local SPCA knew he would donate a 20-pound bag of kibble on most Fridays, usually his first purchase after cashing his paycheck. He never talked about the dog food, and it never occurred to him to claim it as a deduction on his tax return.
Adrian and Rita were in significant financial distress, Rita having lost her job several months previously due to the stagnant economy. According to them, their monthly income had fallen by at least 60%, and the fact that Adrian had not received any TTD (temporary total disability) since his accident despite a note from the doctor excusing him from work meant that financial collapse was imminent as the couple lived from paycheck to paycheck and had no savings.
Apart from the injuries due to the accident, Adrian had no pre-existing conditions or chronic conditions save one. He had suffered 2 herniated discs in his cervical region when he was 31 resulting from a motorcycle accident. He underwent several ESI treatments (a process we’ll cover later) and had not complained of cervical pain since the wreck.
On October 27, 2015, Adrian suffered an injury arising out of and in the course of employment. As mentioned, Adrian was a warehouseman, employed in Shipping and Receiving for a company called International Automotive Parts, based in Easley, South Carolina.
Delivery trucks routinely backed up into one of Shipping and Receiving’s 14 loading/unloading docks. Standard operating procedure required the trucks to “hook onto” a ramp that connected the rear of the truck with the warehouse, so workers could use forklifts and other heavy transportation devices to deliver the pre-fabricated parts to stations within the Easley plant where they were counted, verified for quality and then entered into a database before being transferred for final assembly.
Adrian had worked in Shipping and Receiving at for the last eighteen years, had had a few “write ups” for being late and belligerent, but he was generally liked by management and co-workers.
Adrian stated he didn’t like one of his supervisors and that he was out “to get him” for some off-color comment Adrian denied making. Adrian had not risen in the organization as quickly as he and Rita had hoped, most likely a result of his truncated education and sheer lack of ambition, an early casualty of chronic THC use.
As Adrian told his story, I noticed he nurtured a permanent frown, as if he was mad at the whole world, but nevertheless told his accident story clearly, succinctly, while generally omitting the usual recriminations about fellow employees and management. In fact, Adrian rarely digressed from his tale. Unfolding it in a calm, articulate, deliberate manner. His nervousness was betrayed only by the fact that he continuously rubbed his hands together.
The facts of the accident were as follows: as Adrian unloaded a 250-lb. piece of equipment at approximately 1100 a.m. on a Tuesday, he stepped onto the ramp connecting the truck to the bay. The ramp, apparently unable to bear the weight of the load and himself collapsed along Adrian.
On the way down Adrian’s right upper extremity, right shoulder and the temporal part of his skull severely impacted the truck’s bumper.
He lay on the ground for about 5 minutes, stunned, breathless, and confused. Shards pf pain coursed down his right arm — from his shoulder to his hand. His neck pulsed with pain.
Co-workers who witnessed the accident notified the safety manager, Shirley Jenkins. Upon arrival, Shirley was more interested in how the accident happened instead of how Adrian felt, completing all the fields of the incident report form — information supplied by employees, some of whom had failed to actually see the accident but nevertheless felt compelled to get in on the action. Apparently, it was better to rubberneck an accident scene than work.
The injury scene looked gorier than it had a right to be as most of the blood resulted from Adrian’s head wound as the skull is vascular-rich.
Although meticulous, Shirley neglected to take Adrian’s statement. Nor did she give him a copy of the report. She called the head office that called the nearest hospital which dispatched an ambulance to the scene.
At the ER, Adrian complained of pain in his right arm and neck which led the ER physician to the preliminary diagnosis of cervical radiculopathy. Dr. Fleming, the authorized neurologist, employed by the company’s workers’ compensation carrier, and to whom Adrian was subsequently referred ordered a series of MRIs which disclosed two bulging discs in Adrian’s neck accompanied by spinal cord impingement, resulting in radiculopathy which would account for his arm pain.
As we’re getting in to diagnostic and anatomical terms, let’s take this opportunity to discuss the human spine.
Of all the pathologies we face as personal injury lawyers, few are as common as pathologies to the spine. The spine and spine related disorders due to some type of trauma is the bread and butter of our practice. You’ll find that most motor vehicle accidents, or MVA’s, and Worker’s Compensation cases involve spinal injuries – from its most common form, soft tissue sprain and strain to major multilevel nerve compromise requiring invasive procedures and long-term treatment.
So, let’s get acquainted with our friend and foe — the human spine. See Exhibit lateral view of the human spine. The terminology and concepts I’ll be using will become second nature to you very soon. So, relax. It’ll come, if not via diligent study then through intellectual osmosis.
The human spine is composed of five distinct parts: the cervical section, or neck, the thoracic section forming the middle of the spine, the lumbar section forming the lower section which together with the cervical section presents the most problems, the sacrum, this flat piece of here, and the coccyx, the last set of vertebrae representing the vestiges of our ancient ancestor’s tails. Although the coccyx is vestigial, injuring what is commonly called our tailbone is quite painful as anyone here can attest to who has fractured, bruised or otherwise injured his or her “butt-bone”. The whole area is obviously nerve rich.
The spine, along with the brain. forms the central nervous system. See Exhibit , Central nervous system. The spine connects to the brain via the brainstem and the medulla oblongata, See Exhibit, Closeup of brainstem and medulla oblongata. The nervous system is a vast network of nerve cells sending electrical signals, many automatic, some voluntary, between different corporeal destinations, up through the spine and into the corresponding parts of the brain and back again. A huge enclosed organic circuit, breathtaking in its complexity and capabilities, a masterpiece of evolution, responsible for finest poetry as well as the basest instincts.
Now, the spine itself is composed of bony structures called vertebrae which, amongst many other functions, forms the skeletal architecture of the spine. Each section of the spine has a specific number of vertebra – the cervical contains 7, the thoracic 2, and the lumbar 5. Injuries to the sacrum and coccyx exist of course, but within the scope of this module I’m going to omit a discussion of the disorders of these body parts.
Tubular spaces run throughout the spinal vertebrae, called foramina, through which the spinal cord, a complex bundle of nerves, flows, itself branching into lesser and lesser branches throughout the body called the peripheral nervous system. See EXHIBITS Diagram of foramina and the peripheral nervous system.
Other foramina dot the edges of the vertebrae allowing ligaments and other soft tissue structures to access the spinal column supplying support as well as supplying it with blood and oxygen. As you can see every vertebra share structural similarities but can dramatically differ depending on their placement in the spinal structure.
The vertebrae are dynamic, meaning they allow us to twist, turn, bend, reach and so forth – necessary functions in our daily life, and if injured can significantly affect a person’s livelihood, especially if her job if it is mainly physical.
Nature has provided us with shock absorbers between the vertebrae preventing them from mutual impact as we move, called intravertebral disc’s, and therein lies the rub (excuse the pun) of most spinal pathologies. EXHIBIT. DISC
Intervertebral discs are circular structures within which rest the nucleus pulposes, a soft, spongy tissue surrounded by tougher tissue called the annular fibrosis, the tough outside of donut, if you will. Intervertebral discs are elastic, compressing or expanding depending on the upright or supine position of the client and account for a quarter of the length of the spine
When these structures tear, they allow the nucleus pulposes to herniate and impinge upon the spinal cord, that vast bundle of nerves running up and down and through the spinal column – the body’s information superhighway. This impingement in turn usually results in pain down the extremities, i.e., the arms and legs. If the herniation is serious enough it can affect bowel and bladder function. The most serious derangements can result in permanent paralysis.
Now, MRIs are your best bet in detecting herniations. They are the gold standard test in this area even if the basic technology is about 40 years old. The radiating pain is medically referred to as radiculopathy, and we saw it in Adrian’s presentation of pain in his right arm.
If the pain’s locus lies in neck and the upper extremities, cervical herniation is the likely culprit. Radiculopathy in the lower extremities results from a lumbar herniation. Radiculopathy in the
Lower spine radiating into the extremities is commonly referred to as sciatica. Keep in mind also that the patient may be suffering from multiple herniations. The classical symptoms or signs of radiculopathy include numbness, tingling and pain within the extremity often coupled with a loss in range of motion (ROM). EXHIBIT Rad
It’s important to note the difference between a disc bulge and a disc herniation. An MRI may reveal several disc bulges, and yet the patient remains asymptomatic. This is generally because the herniation has yet to impinge on , i.e. contact, the spinal cord to such an extent as to generate radiculopathy. Vertebral bulging absent impingement on the spinal cord usually presents no problem. However, if the bulge does impinge upon the spinal cord, pain, at times quite severe, accompanied by numbness and tingling in one or both upper extremities may point to a serious tort case if the impingement is a proximate result of negligence or a job injury. EXHIBIT Herniated Disc impinging on spinal cord.
Moreover, bulging discs do not respect age. I’ve seen clients in their 20s test positive for disc bulges, but which were asymptomatic. Most people by their mid to late 30s experience some bulging discs, even multi-level bulging, so if your MRI reports notes disc bulging absent the word impingement or words to that effect, especially if the client does not report pain, don’t get too excited as this is probably unrelated to the type of disc herniation resulting in radiculopathy which might require more radical intervention.
Also, the herniation’s severity in individuals depends on the person’s genetics, lifestyle, and job duties. For example, smoking can aggravates discopathologies, and a person with a desk job might not experience the same level of pain as a construction worker.
I have also encountered cases where the client exhibits radiculopathic herniations by the age of 25. I have seen older patients, well into the 50’s, who exhibit minimal bulging with no impingement and are entirely asymptomatic. This despite similar types of work, lifestyles, education, socioeconomic status. In short, no absolute litmus test in this medical area.
Herniated discs are neuro – orthological in their nature. In my experience, defense counsel has never objected to my introducing medical evidence based orthological rather than neurological opinion or vice versa, although I tend to employ neurological experts. The key to prevailing in the choice of medical experts lies in their experience, board certification, and reputation in the legal and medical community. I’ve seen an instance where a credibility issue ensued over whether the examining physician was board certified or not. So, obviously, try to employ a board-certified specialists for serious spinal injuries, which, by the way are not easy to come by.
A short aside, arthritis is a “cousin” to disc degeneration. Spinal pain can at first appear neurological in its origin when in fact it’s etiology is most likely arthritic. The test is the absence or presence of radiculopathy.
For some reason many of my assistants, beginning attorneys and paralegals, upon first interviewing a client fail to ask the simple question of whether the client’s pain is radiating into the extremities, or is localized, a fundamental question you should ask in your initial interview. It’s an easy enough concept to grasp and can be integral to your medical theory especially when helping your treating physicians locate the most likely source of the offending pathology.
As far as arthritis goes, as we age, assuming all other systems are healthy, osteoarthritis rears it’s painful head as cartilage articulations separating bony structures degenerate – cartilage separates bones and when it deteriorates bone begins to rub on bone generating a full spectrum of pain. Traumatic injury proximately causes, aggravates or accelerates osteoarthritis, even if the arthritis was asymptomatic before the traumatic event. Car wrecks, slip and falls, and job injuries fall into this category. Don’t let the defense try to sell you the idea that your damages are weak because of pre-existing arthritis. I’ll show you how to counter this ploy in a few minutes using an independent medical evaluation.
So, just because osteoarthritis is a natural occurrence does not mean that it’s a pre-existing condition severing proximate causation. Another source of arthritis is rheumatoid arthritis but a discussion of this is beyond the scope of this module, but I strongly suggest your studying this disease independently.
Now, having filed the Form 50 in Adrian’s case, it was time to begin discovery. I always prepare my cases as if they are headed for litigation, despite the fact that 90% of my cases settle. So let’s talk discovery tools.
When preparing for adjudication, there are two mistakes a budding attorney can make regarding her subpoena power. One is to underutilize it, and the other is to abuse it. As I told new attorneys who worked for me: you have subpoena power. Don’t come to me and say this or that person, this or that professional is ignoring you. If you take one thing away from today regarding discovery, it’s this: use your subpoena power even if the penalty for failing to comply with a workers’ compensation subpoena is a misdemeanor fine of two hundred dollars. See CITE.
Of course, if the opposing party attempts to enter the subpoenaed, yet undisclosed material into its case, one remedy is to move to exclude. Another one is to appeal the issue should you, because of the missing evidence, fail at the Single Commissioner level. Yet another remedy is to seek substitute evidence.
That said, like most powers, subpoena power is circumscribed. The party upon whom the subpoena is served can move to quash it. In the workers’ compensation context, there exists no statute or regulation governing quashing subpoenas. If the legality of compliance becomes an issue, the subpoenaed party may file a motion with the Commissioner hearing the case and argue standard objections via counsel. Traditional rationale for noncompliance can be found in Rule ___, The South Carolina Rules of Civil Procedure. These include undue burden, privilege, etc. and is divided into required and permissive bases to quash. I’ll leave it to you to read the details of the statute.
Deposing physicians, who function as expert witnesses in workers’ compensation cases, can be challenge. At my shop, we try to build upon the relationships we’ve carefully developed with the physician’s administrative staff when scheduling a deposition. It’s only after we’ve diligently attempted to informally schedule the depo do we resort to issuing a subpoena, and we make the depo site my office. This usually gets the attention of the doctor, to say the least, and we usually get a depo scheduled at the doctor’s office at his earliest convenience — which we were trying to do in the first place.
The moral: nurture your relationships with outside support staff. They hold the keys to the kingdom and can either guide you to fertile valleys or desolate plains. This is a fundamental rule of business etiquette, but you’d be surprised how many experienced attorneys neglect this nostrum. Don’t make that mistake in your practice.
If you’re seeking information from a doctor’s office regarding your client, make sure you spell out , in a letter, the body parts involved, the date of accident, and what other records have disclosed as a preliminary diagnosis.
Clients suffer other conditions affecting other body parts and systems, and the last thing you want are reams of irrelevant, expensive, medical records. On the other hand, don’t totally tie their hands. Word the letter to assure the staff that they may look for other pathologies you may have missed which are nonetheless related to the accident.
Now, if you’re seeking answers to specific legal questions that doctor’s usually do not address in their notes, such as proximate cause, and for some reason you can’t depose her, send her a Medical Interrogatory. They’re not as exact as depositions since the attorney cannot easily ask follow up questions, but they do rather well in a pinch.
What’s a Medical Interrogatory? It’s a tool, a document containing specific questions to be completed by the authorized or unauthorized physician. Remember that the employer enjoys the right of choosing the treating physician and overall course of care in a workers’ compensation case, while the employee has the right to procure a second medical opinion. I usually send the MI only to the unauthorized doctor from whom I’m seeking a second opinion, as I’m not in the business of making my opponent’s case. However, like anything else, there are exceptions.
The MI helps crystalize the salient medical/legal points you need to make to support a prima facia case against the carrier. So rather than have the Commissioner fish for the information she needs, I make it easy for her and try to wrap everything I can into a single medical document. See Exhibit, example of medical Interrogatory.
Follow the SOAPPI method when crafting your MI questions. Ask the doctor what symptoms the client complains of, what objective tests, if relevant, he’s undergone, what the diagnosis (es) most probably is, what the treatment plan is, future meds, whether the accident proximately caused the injury, whether the patient has reached maximum medical improvement, and what the impairment rating for the body part may be according the AMA Guidelines for Permanent Impairment. I also ask what the probability is of the client’s condition worsening within one year. Remember, that this is a right that must be negotiated during settlement by clincher discussions, as a properly executed clincher agreement between the parties extinguishes this right, and you want some consideration for your client.
Also note that it can be difficult for an examining physician to determine if an injury is pre-existing if he does not have a prior MRI or other test to compare it to. Therefore, collect such prior objective testing, as well as other pertinent records and forward to your expert along with the MI and cover letter. I usually just send an entire copy of my medical file to the retained doctor which is complete by the time my expert makes an appearance.
Be sure to send the MI to the correct unauthorized doctor, usually a specialist, i.e., don’t send an eye case to an orthopedic surgeon. Simple enough point but you’d be surprised the number things that are “common sensical” get passed over. The unauthorized physician must also know how to evaluate a client for permanent impairment, that is, know how to apply the AMA Guidelines to Permanent Impairment.
Moreover, specify whether you want an evaluation or an evaluation plus treatment. And make sure the retained doctor actually physically examines your client and doesn’t simply consult the other physicians’ medical notes.
So let’s return to our case study. After filing the Form 50, the carrier filed its response in the Form 51, denying liability. In other words it filed a demurrer, which is a perfectly reasonable thing to do in the initial phases of case since the defense is stuck with any admission and doesn’t want to discover later it was the wrong move .
Additionally, the carrier hired Dr. Fleming, a neurologist, to handle the medical case. Based on a cervical MRI which showed possible impingement, he opined that Adrian was suffering from a cervical herniation at C-4 scheduled a series of corticosteroid injections (CSI’s) – a procedure whereby steroid therapy reduces the inflammation of the disc, alleviating the pressure on the spinal cord and hence the pain.
CSI’s can be squirrelly procedures. Sometimes one round of injections work miracles. The pain just never returns, and for all intents and purposes, the client is “cured”. In most cases, however, CSI’S ultimately fail, providing relief for a short period of time only for the pain to return within a few weeks.
Unfortunately, Adrian fell into the second class of clients. After two sets of CSI’s his pain had not abated. The thought of his malingering began to seep into my judgement after recalling his criminal past, but I felt it was out of character given his performance in the last ten years. Moreover, there was no basis for retaliation or other motive of which I was aware.
I called him to request a follow up office meeting. As we reviewed his symptoms he off-handedly mentioned that his pain radiated upwards from his wrist into the shoulder. I thought he had misspoken, and he stated his pain usually radiated down from his shoulder through his arm to his hand, but he reiterated that on this day the pain radiated upward from the wrist to the shoulder. I had stumbled upon a symptomological anomaly.
As I’ve mentioned, cervical radiculopathy flows from the neck down the arm — southward as it were. Adrian was reporting this but also reporting pain flowing northward from his wrist. Either my medical theory was wrong, the radiologist had misread the MRI or Adrian was malingering.
It didn’t help that I’d had never seen such a symptomatology in my twenty years of practice. Which I have a feeling really isn’t saying all that much. I could probably practice fifty years and encounter disorders I’d never seen before, such is the complexity of medicine. But it was obvious that the physician and I had to now engage in differential diagnostic analysis.
I called a neurologist I work with and explained the facts of the case to her. She agreed that the symptoms were inconsistent. What was left? Applying the process of differential diagnosis, we kicked around the possibility that Adrian could be suffering from an ulnar neuropathy which consists of either carpal tunnel or cubital tunnel syndrome, or, on the darker side of the spectrum, what I referred to as Adrian’s northward upper extremity pain could be signaling a case of complex regional pain syndrome, a somewhat mysterious and disconcerting ailment which in its nastier manifestations could mean years of pain management.
We also discussed the possibility that the previous cervical corticosteroids injections may have masked the northward symptoms and may have accounted for the late reporting. But it was also within the realm of reason that Adrian, once he realized that the more injuries he claimed, the greater the compensation he’d probably receive, was simply malingering.
After further discussion with the neurologist, I decided referred him for nerve conduction study. Perhaps Adrian was suffering simultaneously from multi-level cervical radiculopathy as well as ulnar neuropathy – a condition which expresses itself in carpal tunnel or cubital tunnel syndrome—with the ulnar neuropathy flowering only when the CSI reduced the cervical inflammation. Let’s take a few minutes to discuss some features of these pathologies.
The ulnar nerve runs medially down the upper extremity. See Exhibit Diagram of ulnar nerve. Its location makes it liable to entrapment or pinching. One of the easiest way to determine if a client suffers from ulnar nerve entrapment is difficulty forming the OK sign, which is a common symptom of ulnar nerve entrapment pain. This pain usually begins at the wrist and may travel up as far as the shoulder.
The major culprit of cubital tunnel syndrome is the humerus bone compressing the ulnar nerve. Exhibit. Diagram of Humerus Bone. As the ulnar nerve passes through a tunnel-like structure near the humerus, it can become compressed for a variety of reasons: excessive exercise and sleeping with the affected arm behind the head are common causes. Many times, the cause is idiopathic, meaning that we cannot tell what’s causing the compression.
Cubital tunnel syndrome is not to be confused with tennis elbow – the former being neurological while the latter is a soft tissue condition resulting from the over use of the involving the muscles and ligaments associated with the elbow.
Carpal tunnel syndrome was another candidate possibly responsible for the character of Adrian’s upper extremity pain. This condition also involves the medial nerve as it passes through a tubular like structure in the wrist aptly called the carpal tunnel. Like ulnar neuropathy or cubital tunnel syndrome pain results if this nerve is compressed and in many cases the pain shoots upward into the upper extremity.
The last condition I considered was the least likely cause of Adrian’s complaints, but it is quite serious and deserves at least a rudimentary explication — namely complex regional pain syndrome, CRPS, formally referred to as a reflex sympathetic dystrophy or RSD.
The symptoms of CRPS are vary between individuals and can be quite cruel. One of the ironies of CRPS is that the symptoms usually bloom near or at the site of minor injuries. In my experience CRPS usually attacks the upper extremities.
Symptoms include severe swelling, reduced temperature at the injury site, discoloration with where the skin exhibits a purplish hue, severe pain in the form of and stabbing, burning and throbbing pain coupled with an intense sensitivity to touch. EXHIBITS Photo of CRPS Symptoms.
Treatment includes various of neurological exercises, medications, even amputation of the offending limb. The pain is continuous but varies in severity, and symptoms can respond well to treatment and simply cease. Future medical costs for chronic CRPS can be astronomical, that is, a very serious and expensive case.
CRPS remains a mystery disease, no consensus yet exists as to its etiology, although there exist a number of theories.
Now, as I noted, we ruled out CPRS as Adrian exhibited none of the symptoms I just described except for the pain, and his pain was not severe enough to signal a provisional diagnosis of CRPS. Therefore, we thought that the best course of action at this point was to run a nerve conduction study, or NCS, which is a neurological procedure measuring the amount of electromagnetic energy flowing through the suspected compressed nerve. The less energy, the more the likelihood of compression.
The NCS report disclosed medial nerve compression at the cubital tunnel. The surgeon performed a nerve release, and the patient reached maximum medical improvement within a few weeks for both the cubital tunnel and his cervical neuropathy.
The attorneys clinched the case soon after MMI, and Adrian is back at work before and most of his original duties. The physicians thought it prudent to limit his weight lifting to 30 pounds for the next six months in order not to reactivate or aggravate the conditions. And to everyone’s satisfaction we haven’t heard from him since.
Although Adrian’s case did not require a functional capacity evaluation, I’d like to talk about this with you for a few minutes, as well as the topic of vocational rehabilitation. In order to do this, we must back up a bit to discuss the theories behind a claimant’s right to receive worker’s comp benefits.
Two basic theories exist.: the medical theory and the loss of earning capacity theory. In a nutshell, the medical theory supposes that an injury to a body part or parts proximately resulting in full or partial permanent impairment justifies, in and of itself, compensation. In my experience, the medical theory is the most common justification for compensation. It recognizes that an injured worker not only loses the use, or partial use, of a body part or parts as it affects his ability to work, but also loses its use vis-a vis other areas of life, i.e., relationships, hobbies, hygiene and so forth. This articulation of the “why” of damages therefore more closely resembles classical tort damages theory. It recognizes that a person is more than just a worker, an object that merely produces goods and services. It is , therefore, in theory, the most humane justification for damages.
Loss of earning capacity, on the other hand, posits that compensation should be based on the extent to which the injured body part diminishes an employee capacity to earn. The question then becomes, how is loss of earning capacity measures and then translated into dollars and cents.
South Carolina worker’s compensation law specifically lays out for you a way to calculate damages based on LOEC. See SC Code of Laws
This calculus unfolds as follows: Once a claimant reached maximum medical improvement, claimant’s attorney refers his client to a vocational expert who examines him and opines, in writing, probable loss of salary as a proximate result of his injury. The difference between claimant’s former salary and his diminished post-injury salary is multiplied by two-thirds and then that product is multiplied by the statutory multiplier for that particular body part or parts.
For those of you who like the elegance of mathematical notation, the equation for loss of earning capacity is:
2(S1 -S2)/3 x SM = indemnity
Where S1 = the pretax preinjury salary per week; S2 = the pretax postinjury salary per week; and SM= the statutory multiplier. (Note that SM does not include ancillary damages such as past and future medical specials, out of pocket expenses, mileage, etc. Nor does SM account for the value of the claimant’s right to file a worsening of condition within one year of the original Order.)
The functional capacity evaluation, or FCE, is merely another tool the vocational expert may use to determine loss of earning capacity. The body part in question is tested for strength, range of motion, ability to repeat a motion and a variety of other variables. The defense usually employs FCE’s in a bid to counter the claimant’s vocational expert’s opinion, o to counter a claim for permanent and total disability. Therefore, I use an FCE to block the defense somewhat, hoping that “my FCE” aligns, and enhances, other parts of my damages theory.
Now, one of the problems with the FCE is the examiner’s subjective opinion of whether the claimant is fully exerting herself in the various physical tests administered. The test is, in my opinion, too prone to mistake, and can transform a negative opinion regarding exertion into a wider, otherwise unwarranted full-scale credibility attack upon your client.
If I seem to be biased against the loss of earning capacity theory, I’m not. In fact, in cases involving high compensation rates, I run the indemnity numbers under both methods, and, everything else being equal, use the method which yields the best outcome for my client.
I’d also like to point out to you that vocational rehabilitation is free to South Carolina residents. The fine folks down there will test your client’s various mental and physical vocational abilities and train her in another field if warranted. In many cases, vocational rehabilitation will unearth capabilities your client never knew existed, ushering in a phase of self-discovery and possibly a better standard of living for your client. It’s a great benefit our state provides and you should seriously discuss the option with your client.
A final takeaway for today. Legal rules are more than just the “rules of the game.” This is a facile observation. Rather, regard rules and doctrine as weapons, tools of leverage, in your quest to vouchsafe your client’s interests. Deploy them strategically, and if appropriate, in number to establish the strongest bargaining position possible for you and your client at the time of negotiation and resolution.
I hope these few remarks on some of the medical and discovery aspects of workers’ compensation practice has highlighted the amount of legal and medical information a PI lawyer must master before he can consider himself competent. Try to stay up to date with all the legal and medical developments in our field. Restoring and maintaining our clients’ physical and financial well-being is a serious and I would argue noble life pursuit. And the more you put into it, the more it will reward not only your client, but you.
Thank you for your kind attention.
Photo by Harlie Raethel on Unsplash
Good morning. I’m Attorney Thomas Gagne. I’d like to thank the fine folks at NBI for making this CLE possible. I’m a Personal Injury Attorney with a practice in Greenville, South Carolina. I’m entering my twenty – seventh year as a trial attorney. This is my seventh CLE module.
This afternoon I’ll be discussing a few litigation principles I’ve found helpful. During my career, I’ve prosecuted and defended hundreds of criminal and administrative cases as well as hundreds of personal injury cases.
I must cover several topics today, each of which could easily occupy the entire time allotted me. So, excuse me if I proceed with some haste. But that said, please feel free to ask a question at any point. I believe dialogical exchanges are more fruitful than pedagogical monologues, and your question is likely on the minds of other participants. And since you have a complete copy of my remarks, occasional colloquies should be no problem.
So, why study trial techniques, when the number of cases that make it to trial decrease every year, when many commentators see ADR, even the discovery process as the new forum for dispute resolution? The short answer is: if you don’t prepare your case as if it’s going to trial, you’re likely to miss a strength or weakness of your or your opponent’s case, thereby handicapping your bargaining positions come negotiation time.
So, let’s begin by exploring opening statements. For the sake of argument, let’s assume we’ve already developed our legal and factual theories as well as our preliminary strategy.
What is a trial? A trial is simply an argument – an argument about which party’s version of the law and facts makes the most sense, is the most emotionally compelling, and is the most equitable, or just. Therefore, argue. Novice attorneys tend to merely recap the testimony of their witnesses at closing. Which is fine. But you ultimately must move from what your evidence is to what your evidence shows, what your evidence means, and how your version of things is superior to your opponent’s.
What we are talking about is rhetoric one of the oldest art forms known to man. Western rhetoric emerged from the courts and political assemblies of antiquity. Lawyer were arguing contract, criminal and tort cases at least half a millennium before Christ. Aristotle that theorized the best arguments are logical in form, graceful in delivery, and equitable in result. Logos. Ethos. Pathos. As your entire case executes these rhetorical principles, so should your opening.
Now, a legal argument is not a formal argument, the kind you may suffered through in high school debate, as I did. Trial lawyers deliver cases in the form of a story, or narrative.
At the simplest level, the opening is a summary of your case, cluing the jury in to who you and your client are, why you’re at trial, what evidence is, what you propose to prove, how the trail will proceed, the roles of the plaintiff, defendant, witnesses, judge and jury, and, most importantly, what you want, i.e., your damages. The opening should also introduce the jury to the law of the case. No easy task as the law is terra incognita to most jurors, despite what they believe. To help them understand the law and its nuances, not to mention the medical concepts involved, feed the concepts to them in bite-sized chunks.
Even still, this poses a challenge at times as some legal concepts are inherently confusing. What’s the difference between likely and most likely? What is a reasonable degree of medical certainty? Doesn’t certainty, by definition, exclude degree? The law is a fine tool. But like anything man made is imperfect, yet I believe it is perfectible, as human understanding expands, as long as we are careful, diligent, compassionate and patient.
Remember, you’re a product of intense legal education. You probably have some litigation experience. But jurors are largely babes in the wood when it comes to law and medicine, and if the jury fails to grasp the ideas, you’ll lose them, and you most certainly will pay the price.
As you compose your opening, avoid big words. The jurors probably don’t have your degrees and may not understand complicated, technical jargon. Even with professionals, simple words usually have the most punch. Not only does the misuse of technical language mar your style, but you also run the risk of looking pompous.
Now, the opening is your golden opportunity to begin selling your case, your client, and yourself to the judge and jury. While the closing is concerned with arguing why your theory of the law and facts should prevail, by the time you get there the jury has probably already made up its mind. So your opening must not be merely a summary of what’s to come but must signal to them why, considering the totality of the circumstances, your theory of the facts and law makes the most sense – why your theory is the most credible.
But, you say, you’re not supposed to argue in your opening statement, that the rules prohibit argument in the opening. This makes absolutely no sense since, as argument is the soul of litigation. If your opening is meant to summarize, the why exclude the main element? Especially if the judge knows pretty much what evidence will be offered, which she can easily do in a pretrial conference. If anything inappropriate does get in, it can be cured. Moreover, it’s obvious the opening is not the closing, and I feel it’s our duty that the jury should be familiar with each side’s basic arguments going in. If you’re going to talk about what evidence you will present, it’s sensible to talk about what the evidence means. To proceed otherwise is like staging Hamlet without Hamlet.
But if you are artful enough, get to where the fight will be and occupy that ground in your opening. That point, the point at which the contending hypotheses collide is called, in the formal theory of argumentation, the stasis, to be differentiated from the same term used when discussing the story structure.
The stasis usually involves the credibility of witnesses. Remember, the battle goes to the “firstest with the mostest” — which means you must cultivate your ability to anticipate how the contest will unfold. This advice may be your most important takeaway today. You must learn to think in terms of moves ahead, and be prepared for them, like a chess player. In fact, if you don’t play chess, I suggest you take it up. Some people have an uncanny talent for the game from the beginning.
Now, unfortunately, plaintiff’s attorneys have the additional burden of overcoming juror bias against claimants and their lawyers. To neutralize this bias, impress upon the jury that you are only seeking justice — a fair result. That whatever compensation the plaintiff may receive, it’s just that — compensation, not profit. Your client is not looking for a payday. Show the jury that the plaintiff is in the red entirely because of the negligence of the defendant, and all you are trying to is return her to the status quo ante – of course without using that term.
Also, do not personally attack the defendant, even and especially during the cross. Just be business-like. Neutral. While other parts of the process demand some degree of “passion”, your relationship with the defendant is cool and matter of fact or you’ll run the risk of alienating the jury. However, and this is an important caveat, this does not mean you cannot present evidence of egregious behavior by the defendant.
Another thing, you want to create empathy for your client, not sympathy. As you work with the plaintiff before trial, stress the importance of her not breaking down on the stand. Nothing turns a jury off like a blubbering witness, or its corollary, bellyaching. Life sucks for everyone, occasionally. As she relates the hardships she’s endured since the accident, she must relate them in an emotionally neutral way. Later on, I’ll explain how to transform your client’s recitation of her damages into a compelling narrative. Steer clear from phrases like “I’m sick and tired of being sick and tired.”
Also, write out your opening statement. In fact, write out your entire case. The sheer act of writing will unearth elements of your case you might otherwise have overlooked. And while you should write it, don’t read it to the jury. Use an outline if you must, but your delivery must look unrehearsed, authentic, and heartfelt.
Hit the damages portion of your case hard. In fact, two-thirds of your case should concern damages. Damages are the plaintiff’s ground. Causation belongs to the defense, and liability should have been settled before trial. If liability is still an outstanding issue by trial time, seriously consider settling. Fighting liability and proximate causation is a tall order.
Lastly, unless the circumstances absolutely demand it, do not waive your right to an opening statement. It’s tantamount to giving a competitor in a footrace a fifty-meter head start. You’ll be playing catch up for the balance of the race.
So, that said, let’s turn to the opening’s structure. I’ve mentioned the classical framework of argumentation, and that the opening should be a “story” introducing the larger “story” of your case. Most trial handbooks will tell you that the opening statement functions as a roadmap for the jury. This is true — as far it goes. But if you take a closer look at the opening, a far more interesting structure emerges.
Figure one imagines the opening as a set of intersecting ovals. (See Exhibit One) One is the story of your case, and I’ll talk about the story elements in depth as we proceed. The next is the theme, a nice slogan encapsulating your story. Then the encapsulation itself – an opening for the opening if you will. The next ring is your legal/ factual theory. I don’t separate the two as these are, by nature of syllogism, intertwined. And lastly, the prayer — what you’re seeking by way of compensation – the whole point of your being there.
This diagram is a bit misleading as these elements are actually one line of action interweaving and supporting one another, delivered in a polished, integrated whole.
What does a polished, integrated whole mean? It means writing it out, revising, revising, revising, weaving the elements together, and then sanding your language down to its barest essentials until the fine-grain emerges. And if your language is not fluent, don’t despair, at least it’s efficient. Don’t make the mistake many lawyers make when they talk – that more is more.
The story. This is where the English majors out there get excited. There’s a scene in the movie Amistad where John Quincy Adams, played by Anthony Hopkins, shares a bit of wisdom about trials. He said that the side with the best story usually wins. This is true. If you bore the jury, or worse, alienate them with a dry recitation of the law and facts, they will certainly penalize you. But if you tell them a story, you’re comforting them. A story is something that they recognize. All of us have been steeped in narrative since the crib. You can say narrative and the structure of narrative is hardwired in our DNA, or at least it’s a major component of our environment.
So, what is the essence of narrative? Every narrative involves a quest. The Odyssey —Ulysses’ quest for home. Moby Dick — Ahab’s quest for vengeance. Even contemporary pieces like Waiting for Godot, where there is no plot, no setting, minimal characterization, none of the conventional architecture of a story except for a quest – a quest for meaning.
You can see how easily this applies to a trial. For what is a civil trial if not a quest for compensation? My point is you can use “a quest” as a universal theme if a more particular theme doesn’t suggest itself. For instance, your theme might be a quest to overcome adversity. The advantage of this theme is you can then implicitly enlist the jury in your quest. How? By the structure of the story itself. Let me explain.
Return to your eighth grade English class for a moment and remember the fundamental elements of a story your teacher outlined: stasis, conflict, complication, climax and dénouement — except the teacher discretely omitted that the fundamental structure of a story mimics coitus – conflict (contact), complication (arousal and tension), climax (the word speaks for itself) and dénouement (cigarettes). So when I said that stories are hardwired, I meant hardwired.
But stories operate on more than a primitive level. A story is the best way to communicate information, if only because a good story naturally retains our interest. Why does this happen? Why is The Catcher in the Rye such a perennially popular novel? We don’t know too many Holden Caulfields, and I’ll wager that if we did we’d steer clear of them. Nevertheless, Holden’s struggle is, in many ways, our struggle, our interior struggle to survive in a society populated by shallow, ill-intentioned, inauthentic personalities. Complications, or adversity, can be interior or exterior, usually both. Because of the universality of adversity, we empathize with the character. We share in his struggle, we identify with him (hey, the author is talking about me!) And thus we pay closer attention to the protagonist’s plight and hence his story.
This is why you don’t want your client to appear pathetic. We all struggle. And we turn a cold eye to whiners. What people really want to know, and what they respect and engage with — what do we make of the struggle? Does it destroy us, like it does Ahab, or do we triumph?
Of course, it’s probably safe to say that most people prefer happy endings. So the story is a story of overcoming. The audience unconsciously wants the protagonist to suffer adversity, so that the tormented protagonist learns something in the process. There must be a point to suffering. Therefore many stories become what the Germans call a bildungsroman –a story about the maturation, the growth and learning of the hero. A cursory examination of religious and secular thought about the nature of suffering bears out the popularity of the bildungsroman.
Take Buddhism: compulsive study and contemplation of suffering liberates our souls. (Exhibit Two) Or the Muslim view: suffering is our fault, a result of sin, which prompts us to pursue more virtuous lives. (Exhibit Three) And then there’s the Christian perspective where Christ’s suffering signifies no less than the wholesale redemption of mankind. (Exhibit Four)
Secular thought also eschews pointless suffering. Consider John Keats, the famous 19th century English Romantic poet, and his rhetorical question: “Do you not see how necessary a world of pains and troubles is to school an intelligence and make it a soul?” (Exhibit Five) And then there’s Nietzsche’s charming Teutonic version: “That which does not kill you makes you stronger.” (Exhibit Six)
The implicit question, “is suffering for naught?” is an opportunity for the plaintiff to engage the jury on a deeply psychological level. How? By answering this question with a resounding “of course not.”
Therefore, consider constructing your case within the context and theme of personal growth. Showing the jury how your client’s injuries revealed strengths she never knew she had, or how adversity honed her appreciation of life. Showcase her indomitable spirit. Not only will her ordeals lend meaning to her suffering, and by extension “suffering” in general, the jury will respect her fortitude and make it more likely they’ll “reward” her. The opening then becomes more than a mere “road map” or summary of your case-in-chief. It sets the stage for compelling human drama, transforming workmanlike narrative into a poignant story of courage.
Let me share with you a workers’ compensation case history that illustrates what I’m talking about. The theme of the case is “Ride the Bull.” Matt, a sheet metal mechanic, injured his spine arising out of and in the course of his employment with an aircraft manufacturer. An MRI ultimately disclosed that Matt suffered a herniated disc at L4-L5. He reported the injury to his supervisor, who failed to make out a report or refer him to a doctor. In pain, Matt referred himself to a chiropractor.
On the intake form, Matt checked the box indicating that his injury was not work-related. He even stated that he injured his back at home a few days earlier while working on his boat. This is not unusual. Upon realizing that it might jeopardize their jobs, many claimants fail to claim their injury is work-related, only later to seek legal counsel when circumstances are no longer tolerable. However, such prior action usually handicaps their case. Factfinders show little patience for claimants who lie, regardless of the circumstances.
As I examined Matt, he mentioned that his co-workers often horseplayed with him in a particular way. They would jump on his back and cry “ride the bull!” Now, Matt was overweight, and as many people in that predicament can attest, they are often the butt of jokes or rude behavior. On top of that, it’s culturally normal when a group of men horse-plays with a fellow – its manifest purpose is to make the object of the horseplay believe he’s “one of the gang.” It’s a form of hazing. Feeling that we belong to a group is perhaps the single greatest psychological motivator that exists. It stems, of course, from ancient survival instincts. Tribal exclusion almost certainly meant death, and still survives in many forms – ex-communication, exclusion, bullying and shunning to name a few.
Matt’s experience, however, exceeded good-natured kidding hazing. What’s worse, according to uncontroverted testimony, management was aware of this “horseplay” and turned a blind eye.
Accordingly, I shifted strategy from an “apology” for inconsistent notice (a weak, defensive stance) to attacking the employer’s egregious behavior for allowing these assaults to continue unabated. I largely ignored the inconsistent behavior and argued that the “ride the bull” episodes probably accounted for his back injury.
But I didn’t leave it there. Why was he picked on? Matt is an average fellow. Competent, not an overachiever. Overweight. On the short side. Had a hard time socially. Never really fit in at school or later with the gang at work. But he struck me as a sincere and kind individual. When his co-workers “rode him,” he misinterpreted it as the kind of horseplay that binds male groups. Matt thought he had achieved the social acceptance he had silently yearned for. This partially accounts for why he didn’t want to rock the boat by reporting the incidents.
But the cruel reality was that his co-workers were just getting their jollies. In fact, until discovery, Matt was unaware that they never invited him out for beers after work, or otherwise included him in other reindeer games. Despite what he thought, he was never a member of the tribe. When he learned the score, he thanked me and seemed a more mature person for the experience – the classic elements of the bildungsroman.
In telling Matt’s story, my goal was not to evoke sympathy for him, although I’m sure it generated some. Rather, I wanted his story to be full-blooded. As far as the storyline is concerned, there’s little that’s new under the sun. But if you dig, you’ll find a unique angle to your client’s tale that makes it real.
Of course, you don’t want to give the impression from all this that your client’s injury was a blessing in disguise or some such nonsense. Getting hurt in an accident is never a good thing. But if someone is injured, she must play the cards dealt. Help your client play them in the best possible way. Convey your client’s fortitude in the face of adversity. The jury will respect this.
Remember, as a plaintiff’s attorney, your strategy is to 1.) Play your opponent 2.) All else being equal, play the damages 3.) Stay on the attack, even in defense — keep your opponent on her heels 4.) Cases boil down to credibility 5.) Find your own unique voice to deliver your client’s story.
Ok, I want shift to a discussion of cross examination. If you haven’t tried many cases, most of what you know probably comes from studying for the bar. You’ve learned a lot of techniques but not how to use them.
As you investigate the facts of your case and develop your factual and legal theory, you should simultaneously be developing a strategy of attack and defense. This strategy requires you to know as much as possible about your case and about your opponent’s case. That is, you must build a context from which to deploy your litigation weapons, especially cross – examination.
What are the strengths and weaknesses of your respective cases? Where is your opponent’s case Achilles’s heel(s)? If it has only one weak point, attack there. If several, concentrate your attack on the weakest. Don’t dissipate your force. Concentration of attack is key. And when you breach your opponent’s case, don’t give her the opportunity to regroup and establish the initiative. Maintain the momentum of your argument by insisting it is the relevant point of the case.
A few do’s and don’ts. Don’t cross a witness unless you have to in order to maintain the integrity of your strategy. If the witness’ testimony does not weaken your case or strategy, leave it. Never cross for the sake of crossing, because you do have absolute control over what the witness might say.
If a witness helps, or at least doesn’t harm your legal/factual theory, why cross him on the basis of his, say, criminal record? It’s counterproductive, wastes time, confuses the issues, and runs the risk of unintentionally eliciting harmful information. That’s probably the best piece of advice about cross examination that I can give you today.
Settle on a factual and legal theory, theme and trial strategy and stick to it if you can. Don’t be diverted. If your opponent throws a red ball, don’t feel compelled to chase it. On the other hand, throw red balls to confuse and divert your opponent, her time and energy.
About cross techniques. The simplest solution is usually the best and ironically the first to be overlooked. Everyone wants to be novel. Call it avant-gardism. But just as in sports, it’s wise to stick to the fundamentals. So question a witness on the details of her assertions, not at trial, mind you, but at the deposition.
Never ask a question at trial unless you already know the answer. Sooner or later, if the witness is lying, she’ll fabricate a detail that wrecks her story, a detail that just cannot be.
Don’t corner her in the deposition though. Save it for trial. Remember, to tell a good lie, you have to be really smart, know all the pieces, and most witnesses are not that smart. Also, remember that the truth is usually simple. You can easily tell a lie by its elaborate structure. Other tells – the witness is vague, speaks in sentence fragments, is overly loquacious, is defensive and tight-lipped, tries to change the topic, or answers questions not asked.
As far as specific techniques are concerned, one of the most effective cross-examination techniques is to attack the witness’ conduct, her actus reus. We are used to seeing witnesses crossed with their depos or some other pre-existing statement. This is fine, but actions speak louder than words. I have always found that attacking a witness’ previous inconsistent conduct, as well as post inconsistent conduct, is extremely effective.
When I cross, I begin by determining if I need to cross at all. If so, I begin by eliciting all the favorable evidence I can from the witness, and then I attack inconsistent actions, and only then do I attack previous inconsistent/impossible statements.
Another effective technique is to elicit testimony in conflict with another opponent’s witness’ testimony. You cannot “pit” witnesses’ testimony, but you can certainly argue the inconsistent evidence in closing.
Also, don’t waste time bringing up things like the expert is paid, (so is yours), or that the defendant was arrested for a bounced check 9 years ago. It’s weak and unnecessarily diverts the jury’s attention.
Also very effective — revealing a witness’ basis, or lack thereof, of knowledge. More often than not it’s hearsay or supposition or assumption. And if the basis of the witness’ knowledge is, in fact, empirical, test the witness’ opportunity to observe or hear as well as the quality of her sense organs. See if her drivers’ license requires her to wear corrective lenses.
Also, since many statements are susceptible to multiple interpretations, don’t allow a witness to get away with mushy language. Hold their feet to the fire by insisting they testify in simple, concrete language. Make her specify, specify, specify. Deconstructionists hold that language (and its meaning) is inherently unreliable.
Rubbish. English is a marvelous tool — surgical in its precision. People are mushy, not language. The more interesting question is if there is one, true reality, or is reality always a matter of interpretation?
Once you finish your cross, sit down. Do not extemporize unless your back is against the wall. You should know all the questions you plan to ask as well as the answers.
Don’t break the cardinal rules of cross – never ask a question you don’t know the answer to, and never ask a question that gives the witness free rein, i.e., open ended questions.
Also, don’t lose heart if you’re not very good at any of this in the beginning. I certainly wasn’t. And I’m learning all the time. Cross is not a natural or polite way to interact with others. Actually, it’s quite rude. But you’re not at a tea party. Just keep plugging away, and one day you’ll be in the middle of a trial, and while hardly realizing it, you’re doing very well, and you’ll say to yourself – hey, I’ve got this.
Ok. Let’s pivot a bit and talk about direct examination. The watchwords for direct exams are thoroughness and preparation. Make sure you know the legal elements of your claim, the caselaw, as well as the facts. Concentrate first on making a prima fascia case. Keep it simple. The more your witness talks, the more issues are introduced, the more she opens herself up to attack. Make your prima fascia case and follow up with a few pieces of choice evidence that anticipates and counters the defense strategy. Prepare your witnesses thoroughly, especially for cross. Thoroughness and less is more are the keys to direct. Remember, cross cannot go beyond the scope of direct. Hence, keep your direct powerful, yet lean.
Also, understand that most witnesses ramble, including experts. Many people are unable to come to the point quickly or stay on topic. The remedy is practice, and don’t shy from employing tough love. Let your witness in on exactly what’s going on, your strategy, the legal issues involved, her role, what you are trying to prove with her testimony and why. Clue her in on the big picture. Dig. Educate. Rehearse. Repeat. The key to learning is repetition. The key to understanding is inquiry.
Also — make sure that your witnesses are in synch with each other’s testimony and your theory. Nothing is as gut wrenching as your own witnesses contradicting each other. You want to blame the witness for her stupidity. Wrong. It’s your stupidity. Every witness can be trained. Moreover, internal contradictions reflect poorly on you as a trial lawyer. Remember, your credibility is also on trial.
As far as the quantity of your witnesses is concerned, first, and I’ll repeat, less is more. I’d rather have two or three high – quality, credible witnesses than five or six moderately credible witnesses. But be careful. Every witness, even hi-quality ones is a potential time bomb, primed to demolish your case by one careless remark.
The more witnesses you have, the greater the chance of this happening. Credible, smart witnesses trump quantity every time.
Doctors and cops present a special problem. I’ve had them flip on me at trial. So consider deposing them to lock them into their testimony. If your witness flips, inform the court and move to treat her as a hostile. If your motion is granted, you can cross her using the depo. It’s not elegant, and it’s embarrassing, and probably fatal to your case, but you can still see daylight. Which means you better have some substitute witness you can call, or substitute evidence to admit to make your prima fascia case. Bottom line: be careful with doctors and cops. Most are perfectly fine. Some have their own agendas which may not match yours.
Ok. Let’s move on to Daubert, or the admissibility of expert evidence. Since we are discussing personal injury cases, I’ll discuss Daubert in that context. Recall from your study of constitutional law that cases such as Daubert establish minimum standards binding on lower courts. However, South Carolina’s Rule of Evidence 702 mirrors the federal standard.
The challenge of admitting expert evidence may be broken down into three categories. Qualifying the expert, establishing the validity of the general theory upon which the expert relies, and establishing the factual basis of the expert’s opinions.
As far as qualifying the expert, record her degrees, whether she has had any specialized training in the field, if she has published, professional associations she belongs to and if she has previously testified as an expert.
This last prong is a two – edged sword as an expert may be cross examined on the fact she’s a “professional witness”, i.e., she’s only available for expert testimony. Also, an expert’s credibility is vulnerable if she’s strictly a plaintiff’s or defendant’s witness. You need to unearth this information before you retain her. Demand she furnish her CV which must include her forensic history. Try to use an expert who’s testified for both sides.
If your expert is a doctor, it’s better if she’s board certified. And make sure you get the right kind of expert in professional negligence cases. If it’s a podiatry case of malpractice, don’t call an orthopedist, because you want to establish the standard of care for podiatrists under your set of facts, and if that standard was breached.
Furthermore, the standard of care may differ from region to region. A Manhattan podiatrist may have a higher duty of care than one, say, from Appalachia.
Regarding the general theory the expert relies on, the elements are: that the expert used a particular theory to evaluate facts, that the theory has been experimentally verified, and that the theory is generally accepted in the particular field.
In PI practice, the expert physician may base his opinion on a personal examination of the plaintiff, or upon the medical records. I strongly recommend the former: where and when the examination took place, who was present, how the examination was conducted, and of the expert’s conclusions.
Frankly, I can’t recall an incident when I’ve had a problem admitting an expert or her testimony. Just make certain you establish on record the foundation for her opinion, that she is definitely on your side, and that her testimony is compatible with other evidence in your case.
You can shortcut the process a bit by requesting that counsel stipulate to your experts’ qualifications. That way you can proceed right into the substance. That’s what I generally do. For tactical reasons, however, you may not want to do this if you want to impress upon the jury just what a hotshot your expert is.
Impressive credentials include board certification, published work in recognizable periodicals, like The New England Journal of Medicine, a teaching position at a top university, and other honors and awards of generally agreed upon weight.
Opposing counsel will make an ad hominem attack on your expert or contest the facts upon which your expert bases her opinion, or both. In the case of expert doctors, make certain she has a thorough knowledge of your client’s medical history.
Don’t depend on the client for an accurate history. Get the records yourself and make sure your entire team — lawyers, paralegals, as well as your client and other witnesses know claimant’s past and current medical history.
Your expert should be able to effortlessly recite the claimant’s symptoms, tests conducted and their findings, previous assessments or diagnoses, and the course of treatment you client has undergone — drugs, surgery, PT etc. You don’t want your physician to be unaware of an important fact in your client’s medical history, such as a history of hypertension, even if it’s not directly relevant to your client’s injury, or a previous disorder or injury to the same body part. It could sink your whole case.
The credibility of your expert is usually a fulcrum point in your case. I am constantly amazed by doctors who have to rifle through records to answer simple questions at a deposition, even more when the doctor happens to be the treating physician.
The bottom line is: never let your expert – physician appear ignorant, disorganized or unprepared on the stand. The best expert is one who can effectively joust with opposing counsel during cross. Insist on preparation. Make sure she uses simple language, easily understood by laypersons, and is unambivalent in her opinions. Professionals usually, and rightly so, qualify their answers, but this does not wash well at trial. Don’t buy the excuse she’s too busy to prep or that “she’s got it.” In the litigation context, this is hubris of the most disturbing kind.
One more point. Pay your expert on time, even early. She is an important ally, critical in the construction of your case-in-chief as well as providing grist for your cross of the opposing expert. Make her happy.
Now, as I was thinking about this CLE, I couldn’t avoid the question — what wins trials? Understand that there is no magic bullet. Preparation? No, that’s no guarantee. Preparation is necessary, but not sufficient. Superior speaking skills? Talented jury selection? Good witnesses? Yes. Yes. And yes. All necessary, yet all insufficient.
I will say that many trials usually boil down to witness credibility. Does the jury believe, and like, your witnesses more than your opponents’? If so, you’re on your way to winning. Does the jury like you?
I believe the key to doing well at trial is to keep in mind that trials are won “point by point,” in a process of evidentiary accretion. And you should try to know more than your opponent – factually, legally, strategically, and tactically. This, in addition to making fewer mistakes than your opponent goes a long way to prevailing. Let me share with you a couple of war stories. The first is a DUI trial that shows success at trial is sometimes just weird luck.
I was the defense attorney. A witness appears during trial and asks the prosecutor if he could testify. It was a military case, and the witness was in the defendants’ chain of command — one of his superiors. The prosecutor assumed he would testify for the government. On the other hand, I hadn’t the slightest idea what the witness would say, and I wasn’t about to give him the chance. So I vehemently objected to his testifying, arguing that I had received notice.
The prosecutor really wanted this witness to testify arguing that she also had received no notice. But I thought the prosecution was pulling a fast one. I stood there stunned, apoplectic, as the judge admitted his testimony.
The government directed him, and to everyone’s surprise, he testified that he had observed defendant half an hour before his arrest and that he had appeared sober. That was it for the prosecution. My client was acquitted. As much as I had prepared for the trial — and I was prepared — there was no way I could have foreseen this turn of events. I wondered how much of what I had done really mattered.
Sometimes the outcome depends on what appears at first to be marginal evidence. In another criminal matter, I was prosecuting a strong arm robbery in which the issue was identification. The responding officer had failed to arrest the defendant while he was in hot pursuit, but not before noting that the defendant had a bite mark on his left arm.
Since my witness was not a doctor, I doubted his opinion about the nature of the mark would survive a motion to strike. During prep, I thought this detail too weak to hit hard, but it came out at trial nevertheless.
Under cross, defense counsel breached a fundamental rule – never ask a question unless you know it’s answer. Defense counsel asked him how he knew it was a bite mark. He stated he had a similar scar on his arm courtesy of his three-year-old daughter.
The trial had been a draw up until that point. But as the responding officer uttered these words, you could feel the momentum of the case shift to the prosecution. It was not a detail that I had failed to unearth; I erred in failing to follow through my examination — a mistake which, again by sheer luck, did not negatively affect my case. I should have dug deeper into how the officer knew it was a bite mark. And instead of summarily dismissing the bite mark as inadmissible, I should have at least considered trying to admit it and risk suppression instead of not developing a potentially compelling piece of evidence. Moral of the story: in general, if the evidence is “iffy,” don’t automatically write it off. Keep investigating until you are certain of its probable effect.
The other point of this case is that trials can turn on a dime. Chess is a good example of this principle. Depending on the configuration of the board, a pawn, nominally the least valuable piece on the board, can, depending on the big picture, morph into a piece dearer than your queen.
The unpredictability of litigation combined with inevitability of human error turns litigation into what I frequently refer to as “a wild west show.” It makes it fun for someone like me who enjoys the action, but negotiated settlement is usually the saner alternative.
Thank you for your kind attention.
Thomas Gagne, Esq
Photo by Bill Oxford on Unsplash
Hello. My name is Thomas Gagne. I am a personal injury attorney from the Greenville Spartanburg area, and I’ve tried civil as well as criminal cases for the last 27 years. I begin my career as a prosecutor for the United States Army, where I served three years active duty in five years reserve duty. During that time also tried administrative cases as a defense attorney. I also worked as a county prosecutor for Richland and York counties as Assistant Solicitor.
For the last 19 months you have been helping your team leader with discovery. You feel ready to take the lead on a case, and today is the day you get your wish. Marcus Jones, your client, injured himself while within the scope of his employment with North American Security Services at a Boeing plant. He suffered several injuries and had to undergo surgery on both his knees. One of his knees required complete replacement. You have finished the workers compensation claim, and you’re ready to proceed with the third-party claim. You are seeking past and future damages as well as punitive damages. The defense is denying all your allegations.
We’re here today to discuss how to enter various non-testimonial types of evidence under Federal Rules of Evidence. I will not complicate things by including evidence rules promulgated under South Carolina rules of evidence, but FYI they pretty much track the federal rules.
Before we get to admission problems, let’s briefly discuss the importance of developing a coherent legal and factual theory of your case. Given the plethora of information every case offers, you just can’t go off in your discovery in any direction and expect to get traction. You need a factual/legal theory of the case from which to view evidence and from which drive your questions, drive your analysis of your case.
But here’s the dilemma, at the beginning of the case, usually you don’t have enough facts to fashion a decent case theory. It’s a matter of pulling oneself up by the bootstraps. Fortunately, there’s a solution to this dilemma. If you are a PI lawyer, your client should provide you with 50 to 80% of the facts of your case at the intake. That’s enough for you to form a preliminary thesis. Of course the problem with this approach is: how reliable is your client? No matter how truthful your client seems, take nothing on faith. Verify everything your client says at the beginning of your case. Verify through questions and corroboration all other evidence in the case. It will save you a lot of headaches later on.
The elements we learn in law school and for the bar concerning causes of action are somewhat misleading. They are misleading in the sense that they are incomplete and only touch on making a prima fascia case. This is why you need a solid legal theory which takes into account all the parameters of the law before building your case. Take for example premises liability. Like any tort and negligence case you must prove duty, liability, proximate causation, and damages. However this is not the end of the story. As you know you must first determine the legal status of your client. Is she a business invitee or a licensee? You must determine if there was a notice, either actual or constructive.
You must determine if the danger was created by the defendant or was it, say, weather related? This affects many other elements of a premises liability case. You must determine if the tort was merely negligence or did it rise to the level of recklessness? What about damages? Are you seeking past and future? Are you seeking punitive damages? All of these are “elements“which are not specifically addressed by black letter law in the same space. As you can see, many more elements coming to play, revealing themselves as you proceed. This requires you to really dig into the legal requirements of your case. Consult treatises and other educational materials, especially those written by lawyers who practice in your state.
Once you have developed a preliminary theory and developed your evidentiary goals, you are ready to proceed. At every stage of your preparation remain skeptical. Always try to falsify your case by looking at it from the point of view of your opponent. The greatest attribute of a good litigator is to anticipate and prepare for trouble before it exists.The greatest sin a litigator can commit is to be gullible. Your attitude toward any piece of evidence should be good natured skepticism. Be skeptical of your opponent’s evidence. Most importantly be skeptical of your evidence. Try to get down to the studs, as they say, in the structure you are creating. Identify assumptions and personal bias and interrupt them.
Before you tackle any evidence problem, you have to ask yourself why do I need this piece of evidence, how does it help my case, what are the virtues besides meeting an element of my cause of action? Does it fit into my overall legal theory and or factual theory? What objections are likely to be raised by opposing counsel, and, most importantly, what are its downsides. Every piece of evidence has its strengths and weaknesses that vary according to what it is, what it proves, and how it fits in with other evidence in your case an in your opponent’s case. Can the evidence be viewed from a perspective that is antithetical to your case? How likely will the jury interpret it that way? Understand that juries are not monolithic. There can be as many interpretations of evidence as number of jurors. And remember, jurors view evidence from their own experience. Their thinking is pattern driven. They usually don’t conduct formal syllogistic analyses.
Also, don’t be satisfied with the prima fascia showing. Remember, you’re appealing to a jury of lay persons, and you have to be sensitive as to what they are likely to consider. In the OJ Simpson case, for instance, jurors considered not only the evidence presented in court, but the out of court evidence of a police department with an abysmal record in race relations.
So, you know the evidence you are going to use to prove your elements. Now you have to get them admitted. Tip: don’t wait until trial to try to introduce your evidence. See if opposing counsel will stipulate to admission. If not, consider making a motion in limine. Judges generally don’t like to admit evidence before trial because, again, evidence assumes its full color within the context of the entire case, within the context of other evidence. Judges generally like to wait until a more appropriate time during trial to decide on admissibility issues.
As with other types of evidence, documentary evidence must meet the following requirements: it must be relevant, it must not violate a privilege, it must not be inadmissible hearsay, it must be authentic, it must not violate the best evidence rule, and its probative value must exceed any prejudicial effect it may have. Again, don’t wait until the last minute to meet these requirements. Trial and hearing schedules are not as flexible as you may think. Always behave as if you’re running late. Get things done early because believe me there are always glitches which will put you behind the eight ball.
Admissibility needs witnesses. Witnesses can be cross-examined while documents cannot, yet we are relying on what the documents have to say on many occasions and generally the witnesses who shepherd them in have not themselves produced, in the sense of having written, the document. Think about the fairness of that for a moment. Because the document needs a “shepherd,” make certain the witness is available, is able to testify as you wish, and most importantly, is subpoenaed for trial. If you fail to subpoena her and she fails to show for trial, you may not get a continuance.
Let’s begin then with the most common type of record — the business record. Proper custody of the record is the key to authentication. Authentication — the thing is what the moving party contends it is. Thee witness must know the business filing system, has retrieved the record from the right file and recognizes the record as the one retrieved. Make certain the custodian specifies precisely how she recognizes the record as the one she retrieved, after which you ask the court to enter the document into evidence. The sequence is as follows:
Have the court reporter mark the record before showing it the custodian and say something like —“I am handing you what has been marked as Plaintiff’s Exhibit 1 for identification.” At the end of the presentation and testimony say: “Your Honor, I’d like to offer what has been marked as Plaintiff’s exhibit 1 for identification into evidence as Plaintiff’s Exhibit One.” At that point ask the court to enter it into evidence. The court will ask opposing counsel if she has any objections to its admission, and if she doesn’t, then the record is introduced.
Photographs. It’s best to get the photographer to testify to photos’ authenticity. If one of your investigators took the picture, make sure she signs and dates the hard copy of the photo and can account for where the photo has been stored pending trial. I have never had a chain of custody objection, but it is a possibility. It’s easy to tamper with photos, especially these days with sophisticated programs. But anyone familiar with the scene or the object will do.
The elements of the foundation are: the witness is familiar with the object or scene that the photo depicts, the witness explains why and how she is familiar with the scene or object, the witness recognizes the object or scene in the photograph, and the photo fairly represents the object or scene. If you plan to use the photo as demonstrative evidence, make sure you blow it up. Photos are much more compelling to the jury when they are enlarged. If you plan to use several photos during final argument, set them up all at once so the jury has the maximum amount of time possible to view and digest their significance. It also provide a neat physical structure to your argument.
Which brings us to the admissibility requirements of demonstrative evidence. This is similar to the verification of photos. The diagram depicts a scene or object, the witness is familiar with it, the witness explains how she knows the object or area, and in the witnesses opinion the diagram accurately reflects the scene or object. Show the diagram to opposing counsel before you admit it. If there is something objectionable in the piece of demonstrative evidence, make sure your diagram or whatever can accommodate the change without having to throw the entire exhibit out.
Video recordings. Again, reproductive fidelity is the key. The foundation includes: the videographer is qualified, the videographer videotaped a thing or person at a particular time and place, the equipment was in good working order, proper procedures were used, the recording is a fair reproduction of the subject, the recording has been in the possession of the videographer since it was made or you can establish a chain of custody. For chain of custody issues, start planning early as witnesses may be unavailable, especially if the evidence is old.
Letters and private writing. This type of evidence generally involves wills and contracts, but they can be anything. This is why you have multiple witnesses to this documents during their execution. The foundational requirements for these documents are: the witness recognizes the document; the witness actually observed the document’s execution, when the document was executed, who else was present, what happened (witness testifies to its execution). Make sure you have the original as the terms of the writing are usually in dispute. I’ll get to the best evidence rule a little later.
Medical evidence, X-rays, MRI’s etc. Juries eat these things up. They believe that tests are the gold standard in evidence. And they are to some extent, but they are often misread, or they are inconclusive. So, like other types of evidence, medical evidence in the form of test results are vulnerable to attack. Also, take note that you are not entering the actual MRI or X-ray, but the test result which is a written document. Call the doctor who recorded the result. The actual picture does us no good, but I’m sure there’s always a jury member who fancies himself a radiologist who wonders why the actual picture has not been admitted.
The foundation for medical test results include: The witness is qualified to testify as to the validity of the process, the underlying theory is valid, that is, the theory is both generally accepted as valid by other experts in the field, the theory has been empirically verified, the instrument used was reliable, the machine itself is generally accepted as reliable and has undergone proper inspections and validations, the witness is qualified to interpret the results, the instrument was in good working order at the time of the test, the witness is qualified to conduct an interpret the results, the witness used the instrument to conduct the test, the witness used proper procedures, and finally the witness testifies to the results of the test.
Now, concerning the best evidence rule, note up front that it only applies to writings and only if the terms at issue. It is only applicable if the writing is offered to prove it contents. If you using it to cross – examine, the issue is credibility and therefore you don’t have to worry about establishing the writing as the best evidence. The foundation for the best evidence rule is: the witness recognizes the writing, the witness testifies as to how she is familiar with the writing, and the witness testifies it is the original.
Expert testimony. Many trials boil down to a battle of the experts. If you’re a PI lawyer, you will most certainly be using at least one doctor if not several others with an additional expert to testify to the appropriate standard of care. Try to choose an expert who is pre-eminent in her field and who has testified for both the defense and plaintiff. You want your experts to seem as objective as possible. Also I generally try to use board certified doctors.
Choose an expert who has had trial experience. Even top notch experts have trouble standing up to a good cross examiner. Show them how to stand their ground by questioning opposing counsels assumption in his cross and drill them with likely cross examination questions so they know what to expect and can prepare for it. Also, make sure she testifies to firsthand knowledge if possible. If you are trying a premises liability case, and the issues are standard of care and its breach, the expert should actually visit the site. If you are putting on the medical case, the doctor should have actually examined the patient, rather than simply relying on the patient’s chart as their source of information.
If you can, stipulate to the expert’s qualification unless you want the jury to hear what a hot shot your guy is. The foundation for an expert’s opinion is: The witness has acquired degrees from an educational institution in the field (you don’t want an eye doctor for an ortho case, use a chiropractor for a chiropractor case, etc.), the witness has specified training, she is licensed to practice and has done so for a significant amount of time, the expert has taught in the field, she has published in the field, she belongs to a professional organization or organizations, and she has previously testified as an expert on the subject.
As far as the actual MRI, CT Scan or X-Ray, I do not enter it into evidence as the jurors are not radiologists, even if you did enter it, you can bet some jurors would try to interpret the results.
Photo by Bill Oxford on Unsplash