Medical legal case:
Congenital Transposition of the Great Arteries

Client: Dr. Leila Lax
Media: Adobe Photoshop, Adobe Illustrator, iPad Procreate.
Format: Four-panel (30"x 40" each) courtroom exhibit.
Audience: Lay audience; courtroom judge.

Objective: Make a clear and comprehensive graphic representation of the key events involved in a medical malpractice case. Following guidelines for admissibility of demonstrative evidence, scaffold knowledge necessary to understand the relevant anatomy and pathology. Since our client was representing the defendants (Orry and Gill), our goal was to provide visuals that would allow them to make the case that arterial switch surgery was necessary for the plaintiff (Dobby) and completed successfully, and that the complication was unlikely to have been caused by actions of the defendants.

Collaborative project with Felix Son, Maurita Hung, and Shawn Liu ("Vein Studios").

 

Completed in December, 2018.

I rendered the assets including human figures from the first, second, and fourth panels (below). I added details to the hearts in the third panel, which were rendered by Shawn.

1. Communication objectives

 

After reviewing the legal documents provided, our team came up with the key questions that our visuals would need to answer in order for the judge to fully understand the medical information involved in this case. We presented our proposed visualization solution to the client. We decided that each of our four panels would focus on one key event in the case, with a summary at the beginning.

2. Co-design plan & style sheet

Once our proposal was accepted, distributed tasks based on our individual strengths and preferences.

Felix did most of the layout work, Maurita took care of most of the administrative work, I did most of the drawing/rendering work, and Shawn did all the tracing.

 

However, there was plenty of cross-pollination and rapid feedback based on the needs of the moment.

Felix designed the style sheet , which was used to ensure consistency in our use of colour and graphic elements.

3. Draft conceptualization

 

For our first (low-fidelity) drafts, we made sketches and composited the scans in Adobe Illustrator. Our first iteration of the layout had a horizontal timeline running continuously across the four panels.

4. Asset corrections and refinements

While taking into account ongoing internal and client feedback, individual assets were gradually digitized and iterative changes were made to refine layout and anatomical accuracy.

Asset Corrections and Refinements

 

Sketches were gradually digitized and changes were made throughout iterations to reflect accuracy and better design.

5. Refining layout

 

Layout design was also improved to resolve communication concerns that arose during feedback sessions.

References (Annotated)

Agur, A. M. R. & Dalley, A. F. (2017). Grant’s Atlas of Anatomy 14th ed. Philadelphia: Lippincott Williams &
Wilkins.

 

- Figure 1.3 (pg. 4-5) were used as a reference for illustrating the vertebrae

- Figure 1.20 (pg. 26) was used as a reference for the pelvis
- Figures 6.5 (pg. 472) and 6.18 (pg. 488) were used as a reference for innervation of the legs


Aljishi, M. & Abernethy, D. (2015). Spinal cord infarction. New Zealand Medical Student Journal, 20, 18-21.


Amato, A. & Stolf, N. (2015). Anatomy of spinal blood supply. Jornal Vascular Brasileiro. doi10.1590/1677-5449.0004.

 

- Figure 2 was used as a reference for illustrating the anatomy of spinal arterial supply including the Adamkiewicz artery

 

Cochard, L. R. (2002). Netter’s Atlas of Human Embryology 1st ed. Teterboro: Icon Learning Systems.
 

- Figure 3.12 (pg.63) was used as a reference for illustrating the spinal cord and vertebral column in the newborn
- Figure 4.22 (pg. 105) was used as a reference for understanding postnatal circulation
- Figure 8.26 (pg. 211) was used as a reference for illustrating the nerve innervation of the lower extremities


Deeg, K. H., Lode, H. M., & Gassner, I. (2007). Spinal sonography in newborns and infants--Part I: method, normal anatomy and indications. Ultraschall Med, 28(5), 507-517. doi:10.1055/s-2007-963052


Hoehmann, C. L., Hitscherich, K., & Cuoco, J. A. (2016). The Artery of Adamkiewicz: Vascular anatomy, clinical signicance and surgical considerations. International Journal of Cardiovascular Research, 5(6). doi:10.4172/2324-8602.1000284


Lemke, R. P., Idiong, N., al-Saedi, S., Giddins, N. G., Ward, C., Hamilton, A., . . . Odim, J. N. (1996). Spinal cord infarct after arterial switch associated with an umbilical artery catheter. Ann Thorac Surg, 62(5), 1532-1534. doi:10.1016/0003-4975(96)00778-3
 

- Figures 1 (pg. 1533; Chest roentgenogram showing tips of umbilical arterial and venous catheters) and 2 (pg. 1533; MRI
image showing hemorrhagic infarction) were incorporated into panels 2 and 4, respectively.


Moore, K. L., Agur, A. M., & Dalley, A. F. (2015). Essential Clinical Anatomy. Philadelphia: Wolters Kluwer Health.

 

- This textbook was used to reference general circulatory and bone (vertebra, spine) anatomy.
- Figure 1.28 (pg.82) and gure 1.37 (pg. 91) was used for illustrating the vessels of the heart
- Figure 1.44 (pg.100) was used as a reference for illustrating the descending aorta in the lateral view
- Figures 5.14 (pg. 334) and 5.23 (pg. 343) were used as a reference for illustrating innervation of the lower limbs.

Muller, K. I., Devik, K., Vorren, T., & Johnsen, S. H. (2013). A man in his 60s with chest pain and pareses. Tidsskr Nor Laegeforen, 133(12-13), 1320-1324. doi:10.4045/tidsskr.12.0979

- Figure 4 (pg. 1323) was used as reference for course of arteries supplying the spinal cord in relation to the spine and aorta
in a lateral view.


Ponrartana, S., Aggabao, P. C., Dharmavaram, N. L., Fisher, C. L., Friedlich, P., Devaskar, S. U., & Gilsanz, V. (2015). Sexual Dimorphism in Newborn Vertebrae and Its Potential Implications. J Pediatr, 167(2), 416-421. doi:10.1016/j.jpeds.2015.04.078


- Figure 1 (pg. 418) was used as reference for positioning of newborn spine for lateral illustration in panel 4.


Sadler, T. W. (2010). Langman’s Medical Embryology 11th ed. Baltimore: Lippincott Williams & Wilkins.


- Figure 12.31 (pg. 184) was used as a reference for understanding the pathology of Transposition of the Great vessels.


SickKids Sta. (2016). Arterial switch procedure Risks of an arterial switch procedure. Retrieved from https://www.aboutkidshealth.ca/Article?contentid=1656&language=English


Vargas, M. I., Gariani, J., Sztajzel, R., Barnaure-Nachbar, I., Delattre, B. M., Lovblad, K. O., & Dietemann, J. L. (2015). Spinal cord ischemia: practical imaging tips, pearls, and pitfalls. AJNR Am J Neuroradiol, 36(5), 825-830. doi:10.3174/ajnr.A4118

The Vertebral Column and Spinal Cord. (1997). Retrieved from http://www.emory.edu/ANATOMY/Anatomy-Manual/back.html

- Figure 1 was used to cross-reference newborn spine curvatures.

Wang, C., & Ehnmark, B. (2010). Intraspinal extension, tethered cord in 2-week-old. Retrieved from http://clinical.netforum.healthcare.philips.com/us_en/Ex-
plore/Case-Studies/MRI/Intraspinal-extension-tethered-cord-in-2-week-old

- First MRI image was used to cross-reference positioning of newborn spine.


Yoo, S.-J., MacDonald, C., & Babyn, P. (2010). Chest Radiographic Interpretation in Pediatric Cardiac Patients. New York: Thieme Medical Publishers, Inc.
 

- Figure 8.1 (pg. 77; lateral chest radiographs) was used as a reference to check the size of the heart in comparison to
the thoracic cage

©2018 by Mona Y. Li. All rights reserved.