Abstract：
This column is the first of a 3-part series illustrating the importance of medical knowledge, including clinical pharmacology, in a forensic context. This first case involved an 18-year-old high school student who suffered an anoxic brain injury and remained in a state of permanent decorticate posture, unresponsive except for grunts and primitive movements until he died several years later. Our investigation began by ruling out plausible causes that were suggested by the defense in the malpractice suit. Once those possibilities were eliminated, the focus was on what accounted for the damage to the patient using general medical knowledge and clinical pharmacology. The 4 Ds of forensic psychiatry (duty, damages, dereliction, and direct cause) are the 4 elements that the plaintiff is required to prove in civil court to prevail in a malpractice suit and are applied to this case with a special focus on dereliction and direct cause. This catastrophic outcome was due to 3 factors. First, the patient had physiologically significant dehydration to the point that he had developed a reflex tachycardia to maintain his blood pressure. Second, the patient had been switched from extended to immediate-release quetiapine, resulting in a doubling of the peak concentration of the drug, which produced higher occupancy of alpha-1 adrenergic, histamine-1, and dopamine-2 receptors, causing a further drop in his blood pressure as well as increased sedation and impairment of his gag reflex. These effects occurred quickly because of the faster absorption of the IR formulation of the drug. Third, the patient had gone to sleep in a reclining chair so that his brain was above his heart and his lower extremities were below his heart, resulting in an increased \"steal\" of cardiac output going to his brain. These 3 factors together led the patient to aspirate and suffer a hypoxic brain injury after an episode of vomitus. This column explains the process by which the cause of this sad outcome was determined, how it was related to a dereliction of duty to the patient, and how other proposed causes were ruled out.
摘要：
本专栏是由三部分组成的系列文章中的第一部分，阐述了医学知识的重要性，包括临床药理学，在法医背景下。第一例涉及一名18岁的高中生，他遭受了缺氧的脑损伤，并保持着永久性的脱皮姿势，除了咕噜声和原始动作外，他反应迟钝，直到几年后去世。我们的调查首先排除了辩方在医疗事故诉讼中提出的合理原因。一旦这些可能性被消除，重点是使用一般医学知识和临床药理学对患者造成损害的原因。法医精神病学的4Ds(职责，damages,失职,和直接原因）是原告在医疗事故诉讼中需要在民事法院证明的4个要素，适用于本案，特别侧重于失职和直接原因。这种灾难性的结果是由于三个因素。首先,该患者在生理上有明显的脱水，以至于他出现了反射性心动过速以维持血压。第二,患者已从延长喹硫平改为立即释放，导致药物的峰值浓度加倍，这产生了更高的α-1肾上腺素的占有率，组胺-1和多巴胺-2受体,导致他的血压进一步下降，镇静作用增加，呕吐反射受损。由于药物的IR制剂的更快吸收,这些效应迅速发生。第三，病人睡在躺椅上，他的大脑在心脏上方，下肢在心脏下方，导致他大脑的心输出量增加。这三个因素共同导致患者在呕吐发作后吸气并遭受缺氧性脑损伤。本专栏解释了确定这一悲惨结果的原因的过程，这与病人失职有关，以及如何排除其他拟议的原因。
