| (D) Abdominal incision to correct injury.
(h) Hematic and lymphatic system.
(1) Transfusion of blood and blood components.
(A) Serious infection including but not limited to
Hepatitis and HIV which can lead to organ damage and permanent impairment.
(B) Transfusion related injury resulting in impairment
of lungs, heart, liver, kidneys, and immune system.
(C) Severe allergic reaction, potentially fatal.
(2) Splenectomy.
(A) Susceptibility to infections and increased severity
of infections.
(B) Increased immunization requirements.
(i) Breast surgery (non-cosmetic).
(1) Radical or modified radical mastectomy.
(A) Limitation of movement of shoulder and arm.
(B) Permanent swelling of the arm.
(C) Loss of the skin of the chest requiring skin graft.
(D) Recurrence of malignancy, if present.
(E) Decreased sensation or numbness of the inner aspect
of the arm and chest wall.
(2) Simple mastectomy.
(A) Loss of skin of the chest requiring skin graft.
(B) Recurrence of malignancy, if present.
(C) Decreased sensation or numbness of the nipple.
(3) Lumpectomy.
(A) Loss of skin of the chest requiring skin graft.
(B) Recurrence of malignancy, if present.
(C) Decreased sensation or numbness of the nipple.
(4) Open biopsy.
(A) Loss of skin of the chest requiring skin graft.
(B) Recurrence of malignancy, if present.
(C) Decreased sensation or numbness of the nipple.
(j) Male genital system.
(1) Orchidopexy (reposition of testis(es)).
(A) Removal of testicle.
(B) Atrophy (shriveling) of the testicle with loss
of function.
(2) Orchiectomy (removal of the testis(es)).
(A) Decreased sexual desire.
(B) Difficulties with penile erection.
(C) Permanent sterility (inability to father children)
if both testes are removed.
(3) Vasectomy.
(A) Loss of testicle.
(B) Failure to produce permanent sterility (inability
to father children).
(4) Circumcision.
(A) Injury to penis.
(B) Need for further surgery.
(k) Maternity and related cases.
(1) Delivery (vaginal).
(A) Injury to bladder and/or rectum, including a fistula
(hole) between bladder and vagina and/or rectum and vagina.
(B) Hemorrhage (severe bleeding) possibly requiring
blood administration and/or hysterectomy (removal of uterus) and/or
artery ligation (tying off) to control.
(C) Sterility (inability to get pregnant).
(D) Brain damage, injury or even death occurring to
the fetus before or during labor and/or vaginal delivery whether or
not the cause is known.
(2) Delivery (cesarean section).
(A) Injury to bowel and/or bladder.
(B) Sterility (inability to get pregnant).
(C) Injury to ureter (tube between kidney and bladder).
(D) Brain damage, injury or even death occurring to
the fetus before or during labor and/or cesarean delivery whether
or not the cause is known.
(E) Uterine disease or injury requiring hysterectomy
(removal of uterus).
(3) Cerclage.
(A) Premature labor.
(B) Injury to bowel and/or bladder.
(C) Rupture to membranes and possible infection.
(l) Musculoskeletal system.
(1) Arthroplasty of any joints with mechanical device.
(A) Impaired function such as stiffness, limp, or change
in limb length.
(B) Blood vessel or nerve injury.
(C) Pain.
(D) Blood clot in limb or lung.
(E) Failure of bone to heal.
(F) Infection.
(G) Removal or replacement of any implanted device
or material.
(H) Dislocation or loosening requiring additional surgery.
(I) If performed on a child age 12 or under, include
the following additional risks: problems with appearance, use, or
growth requiring additional surgery.
(2) Arthroscopy of any joint.
(A) Blood vessel or nerve injury.
(B) Continued pain.
(C) Stiffness of joint.
(D) Blood clot in limb or lung.
(E) Joint infection.
(F) If performed on a child age 12 or under, include
the following additional risks: problems with appearance, use, or
growth requiring additional surgery.
(3) Open reduction with internal fixation.
(A) Impaired function such as stiffness, limp, or change
in limb length.
(B) Blood vessel or nerve injury.
(C) Pain.
(D) Blood clot in limb or lung.
(E) Failure of bone to heal.
(F) Infection.
(G) Removal or replacement of any implanted device
or material.
(H) If performed on a child age 12 or under, include
the following additional risks: problems with appearance, use, or
growth requiring additional surgery.
(4) Osteotomy.
(A) Impaired function such as stiffness, limp, or change
in limb length.
(B) Blood vessel or nerve injury.
(C) Pain.
(D) Blood clot in limb or lung.
(E) Failure of bone to heal.
(F) Infection.
(G) Removal or replacement of any implanted device
or material.
(H) If performed on a child age 12 or under, include
the following additional risks: problems with appearance, use, or
growth requiring additional surgery.
(5) Ligamentous reconstruction of joints.
(A) Continued instability of the joint.
(B) Arthritis.
(C) Continued pain.
(D) Stiffness of joint.
(E) Blood vessel or nerve injury.
(F) Impaired function and/or scarring.
(G) Blood clot in limb or lung.
(H) If performed on a child age 12 or under, include
the following additional risks: problems with appearance, use, or
growth requiring additional surgery.
(6) Vertebroplasty/kyphoplasty.
(A) Nerve/spinal cord injury.
(B) Need for emergency surgery.
(C) Embolization of cement (cement passes into blood
vessels and possibly all the way to the lungs).
(D) Collapse of adjacent vertebrae (bones in spine).
(E) Leak of cerebrospinal fluid (fluid around the brain
and spinal cord).
(F) Pneumothorax (collapsed lung).
(G) Failure to relieve pain.
(H) Rib fracture.
(7) If the following procedures are performed on a
child age 12 or under, problems with appearance, use, or growth requiring
additional surgery should be disclosed.
(A) Arthrotomy (opening of joint).
(B) Closed reduction with or without pin or external
fixation.
(C) Surgical management of open wound.
(D) Partial excision or removal of bone.
(E) Removal of external fixation device.
(F) Traction or casting with or without manipulation
for reduction.
(8) Amputation of limb.
(A) Pain and/or phantom sensation in removed limb.
(B) Need for further surgery.
(C) Infection.
(D) Hemorrhage (severe bleeding).
(E) Difficulty with prosthesis fitting.
(m) Nervous system treatments and procedures.
(1) Craniotomy, craniectomy or cranioplasty.
(A) Loss of brain function such as memory and/or ability
to speak.
Cont'd... |
