Bloodstain Patterns and the Stories They Tell by Lori Combs BS, RN, LNC

The human body is an amazing creation. The body can reveal health and disease in very minute signs and symptoms. In life, it can heal and repair itself with the blood that flows through the organs and vasculature. Human blood can reveal a great deal of information in life, but what stories can it tell in death?

Please click on the link below for access to the full article.

AALNC Journal Article 2014


For any questions please contact me at or 432 661 3639.

Lori Combs BS, RN, Legal Nurse Consultant

Critical Analysis Consulting, LLC



Is That Drug Screen Result Proof Positive? By Lori Combs BS, RN, Legal Nurse Consultant

In many situations in the legal system, the results of a toxicology screen or breathalyzer exam is valued to reveal whether or not an individual has been under the influence of a particular substance.  Urinary toxicology examinations reveal a wider variety of substances than do blood exams, but there are several other areas of the body that can be examined to reveal toxicology levels.  Samples such as, fluid from the eye, called vitreous humor, saliva, and samples from other body structures, such as the liver and hair, can also be utilized to examine the potential use or abuse of a substance.  But are these results proof positive?

In urinary toxicology examinations, there are many substances that can be tested for, not only illicit drug use.  With the advances in technology in this area sophisticated methods of testing, such as gas chromatography and mass spectrometry, can analyze for specific chemical molecules within the substance, but this type of technology in not accessible in many facilities.  The immunoassay technique is the most common procedure for the analysis of substance recognition, but does not hold the sensitivity of the gas chromatography/mass spectrometry methods.  With these immunoassay techniques comes the potential for false-positive results.

There are many common substances that can result in a false-positive on a urine drug screen.  Not only are these substances ones that are absorbed in our bodies in some form or fashion, but there are other household substances that can interfere with urinary drug testing methods.  In the chart below, there are some common and not so common medications that can result in a false-positive on a urine drug screen.

Amphetamine and Methamphetamine Selegiline (Used on the symptom control of Parkinson’s),

Vicks Inhaler



Ranitidine (Zantac)

Barbiturate NSAIDs (Non-steroidal anti-inflammatories)

Phenytoin (Seizure medication)

Benzodiazepine NSAIDs

Sertraline (Zoloft)

Cannabinoid (THC) NSAIDs

Promethazine (Phenergan)

Riboflavin (Vitamin B2)

Opiates Fluoroquinolone (Antibiotics)

Rifampin (Treatment of TB)

Chlorpromazine (Thorazine)

Poppy Seeds

Diphenhydramine (Benadryl)

Phencyclidine Venlafaxine (Effexor)

Amitriptyline (Depression)

Chlorpromazine (Thorazine)

Dextromethorphan (Cough Suppressant

Diphenhydramine (Benadryl)

Ketamine (Sedative)

Meperidine (Demerol)

(Vincent, Zebelman, & Goodwin, 2010)

Among medicinal substances, there are other substances that can interfere with the urine toxicology testing to result a false-positive.  Substances such as alcohol, ammonia, bleach, Drano, hydrogen peroxide, salt, soap, sodium bicarbonate, sodium chloride, vinegar, and Visine are to name a few (Leiken & Paloucek, 1998).

Solely relying on the results of a urinary toxicology screen, performed using the immunoassay method, can result in errors that may have serious implications.  The use of the immunoassay testing techniques can result in false-positives. This information is imperative for the medical provider to be aware of, but also the individuals involved in the legal arena, such as law enforcement and criminal/civil attorneys.

If you have any questions regarding the potential of false-positives in your case, please contact me at 432 661 3639 or and I would be happy to discuss you case and answer any questions you may have.


Lori Combs BS, RN, LNC

Critical Analysis Consulting, LLC

432 661 3639




Works Cited

Leiken, J. B., & Paloucek, F. P. (1998). Poisoning and Toxicology Compendium. Hudson, Ohio: Lexi-Comp.

Vincent, C. E., Zebelman, A., & Goodwin, C. (2010, October). What common substances can cause false positives on urine screens for drugs of abuse? Retrieved from Journal of Family Practice:




Pulmonary Embolism: The D-Dimer….Is it accurate for everyone? By Lori Combs B.S, R.N, Legal Nurse Consultant

The recognition of the seriousness of deep vein thrombosis and pulmonary embolism has had heightened attention in the media over the past several years.  A pulmonary embolism is a blood clot that usually originates in the legs and travels up through the vascular system into the right side of the heart and then into the pulmonary vasculature.  If not detected and treated immediately, this condition can be deadly.  Some of the symptoms one can experience are severe chest pain, shortness of breath, cough, diaphoresis (sweating), and an irregular heartbeat.

Upon arrival at a medical facility, a patient can expect to undergo diagnostic testing to diagnose and/or confirm the presence of a pulmonary embolism.  An immediate diagnostic work up will be ordered along with treatment of the patients symptoms.  In the diagnostic testing, a test will be completed on the blood called a D-Dimer.  The D-Dimer is a diagnostic test that detects the protein fragments that are present in the blood when a blood clot starts to breakdown.  The test itself will produce a numbered value based on the amount of fragmented protein in the blood.  Based on the numbered value, the medical provider can assess whether there is potentially a blood clot in the body or not.  But is this D-Dimer diagnostic test an absolute?  No, it is not.

Unfortunately, the D-Dimer is not an absolute in its diagnostic ability to detect a blood clot.  There are many factors that can create a “false-positive” in the D-Dimer test.  Conditions such as cancer, trauma, infection, myocardial infarction (Heart Attack), surgery, pregnancy, and liver disease.  Another issue that is being researched regarding the accuracy of the D-Dimer is patient age.  D-Dimer levels can be elevated in the older population, over the age of 50.  This results in a limited specificity of the test in the older population.

In a study reported in April 2014, in a multicenter trial, 3000 patients with suspected pulmonary embolism had D-Dimer levels drawn and had age-related adjustments made to their “cut-off levels.”  In low-probability patients it was determined if an individual patient was to be observed or undergo diagnostic imaging.  In an increased number of patients, the pulmonary embolism was able to be ruled out without imaging (40% versus 20%) and the patients that were observed were negative for pulmonary embolism at three months (Grayzel & Wiley, 2014).

At this point in the clinical diagnostic evaluation of a pulmonary embolism, the age-adjusted considerations are not yet applied throughout the clinical providers practice.  A clinical provider does have to keep in mind that the D-Dimer is not a 100% accurate tool for diagnosis and that clinical presentation and other diagnostic tools are still required to diagnose this potentially deadly condition.

For further information regarding the above information or any questions, please do not hesitate to contact me at 432-661-3639 or  Please visit my website at for further information of our litigation support for attorneys.


Lori Combs B.S, R.N, Legal Nurse Consultant.

Critical Analysis Consulting, LLC.

432 661 3639



Grayzel, J., & Wiley, J.F. (2014, April). What’s new in adult and pediatric emergency medicine. Retrieved from UpToDate:


Tips and Tricks to Present an Effective PowerPoint Presentation by Lori Combs BS, RN, Legal Nurse Consultant.

With the use of technology, the PowerPoint has become a fantastic way to present information to your audience with amazing graphics and animations. With the popularity of the software, how can YOU create a presentation that will be both informative and engaging?

I am sure that I do not know of anyone that has not either prepared or viewed a PowerPoint presentation. I bet that if I surveyed everyone in the U.S., we would have all been subject to a PowerPoint presentation at some point in our schooling or careers. With that being said though, how many of you have been bored or confused by the presentation due to the PowerPoint slides?

When preparing any presentation, you obviously need to know who your audience is. Are they college level, school aged, or professional career individuals? Once you have that determined, you then need to focus on the content of your presentation. When building a PowerPoint, you need to be aware that you will need to cater to your audience and that some individuals will be auditory learners and others will be visual. During the development of your presentation, you need to keep each of these learners in mind.

Some of the tips and tricks in preparing PowerPoint slides are to choose a font that can be read easily and by the people in the very back of the room. Do not choose a font that is too large, as this can create a long presentation, or too small as everyone will not be able to read your information. Also, be careful on the background colors that you use in your slides. Neon green or pink is not going to be as effective as you think; you will cause you audience to go blind! Keep in mind the colors of your slide backgrounds as well as your font colors. Bright colored fonts such as yellow or orange or pink do not show up well to the individuals in the back of the room and are hard to read.

During the creation of your slides, you also need to keep in mind that less is more. The PowerPoint should be used as an adjunct to your presentation and not become a hindrance. Prepare slides that are not crammed full of information as you will lose some of your audience. They will be too busy trying to read what is on the slide and not pay attention to a word you have said. In order to reach the majority of your audience, the visual learner will learn from what you show him and the auditory learner will learn from what he hears. You need to find a balance between your visuals in the slides and what you are speaking about.

Graphics are an excellent way to present information and engage your audience. Here again, less is more, but do not go too small; remember the people in the back. Do not present complicated and confusing graphics. Keep them simple and uncluttered. You can engage your audience with the amazing animation PowerPoint can provide and graphics can be an effective way to present pertinent information. You can even add audio to your presentation.

PowerPoint presentations are an effective tool to present a great deal of information in an engaging manner. Preparation of the slides need to cater to your audience otherwise you will lose their interest, or you will frustrate them. Make your slides meaningful to what you are discussing. Keep the balance of your audience listening to what you are speaking about and provide them with visual learning as well. Keeping this balance will keep your audience captive and engaged.


Lori Combs BS, RN, LNC

Critical Analysis Consulting, LLC

432 661 3639



Plaintiff Attorneys….Why are YOU not using a Registered Nurse in your medical related cases when the large defense firms are? By Lori Combs BS, RN, Legal Nurse Consultant

I know that once you read the title to this blog, you will have an immediate response to my question. Most of you are going to say to yourself, or at me via the computer screen, that “a Nurse Consultant costs a great deal of money and I cannot afford one”. I can appreciate your concern with this, but we will discuss that shortly.

I know you may also say, “Because I can review the medical records myself and my paralegal can organize and prepare a chronology”. I can understand that statement as well, but I would like to bend your ear a bit here and provide you with some information as to why it is cost effective to utilize a Registered Nurse in your medical cases.

First off I would like to say, if you have continued to read, I thank you for your time and attention to do so. Now, I can understand your concerns regarding the cost of hiring a Nurse Consultant. So, let’s think about this for a minute. Do you actually know what a Nurse Consultant costs? Have you invested the time to search for one in your area? The costs of a Nurse Consultant is majorly dependent on the area to which you are practicing and are actually quite affordable when you truly examine what they can do to raise your bottom line. You know that the large defense firm that you are going up against does utilize a Nurse Consultant on their team, right?

So let’s discuss what a Nurse Consultant can do to actually increase your bottom line.  The biggest areas you will see the cost effectiveness of a Nurse Consultant is in the preliminary review (merit screen) and in a comprehensive review of the case (although we do much more than just that). In the preliminary review, the Nurse Consultant can evaluate the specifics in the case within hours to determine if the case should be pursued. The costs accrued by the plaintiff attorney to proceed with a case can run into the $50,000 t0 $60,000 range.  The huge savings you will accrue for a Nurse Consultant to analyze the records should be evident to you in the last statement alone.

Ok, so, you’ve decided to pursue a case and you were just delivered several large boxes of medical records, now what?  Who is going to look through those records and put them in some semblance of order? I know that you are going to tell me your paralegal is going to do it. I understand your thinking, but the Nurse Consultant is much more efficient in organizing those huge boxes of medical. Now, I know that you may be thinking, “How hard can it be to organize records”?  Well, the process of organizing records is not only just for your ease of use, but it is also for the ease of use by your experts. Having the records organized in a method that is familiar to the physician or nurse expert will save you the high cost of their review time. Oh yes, and speaking of all of those huge boxes, the Nurse Consultant could have determined if you truly needed all of those records you’ve just obtained which would have saved you some money.

So, now that you have all of those medical records organized, who would be the BEST professional to review them? Now, when I have a question or concern related to something in the legal arena, I go straight to my attorney for the answer because I know that I do not know everything about the law and would not even pretend to. So, if you needed an individual to interpret all that is involved and contained in those medical records, I think that you would consider a medical professional to do so, right?  Now, I know that you may feel that you can interpret those records yourself, and you may to some extent, but the time involved for you to do so is not cost effective and you may not really see what a medical professional sees.  An experience Nurse Consultant knows where to focus and obtain the information imperative to the case. The Nurse Consultant can hone in on what is important and what is not and therefore, evaluate your cases quicker and more cost effectively, which then leads to your cases being tuned over quicker and saving you money.

Now, I do not want to take up anymore of your time as I have a great deal more information to provide you regarding how the Nurse Consultant can save you money.  I will leave it at that for now and so, stay tuned for part II of this blog where I will talk about how the Nurse Consultant can the save you money in relation to preparing and evaluating the chronology.

If you have any questions at this point please do not hesitate to contact me at 432 661 3639 or at


Lori Combs BS, RN, Legal Nurse Consultant

Critical Analysis Consulting, LLC

432 661 3639

The Paralegal and the Legal Nurse Consultant: Why the attorney needs both by Lori Combs, BS, RN, Legal Nurse Consultant.

There is no doubt that an attorney needs a paralegal for his or her law firm, no matter the size. They are a “must have” to the attorney to provide them with the needed organization of their case load,  organization of scheduling motions, depositions and trial dates,  prepare court documents, and increase the productivity of the firm, to name a few roles. Paralegals are specifically trained in the legal arena to aid the attorney with these tasks and are experts in this field.

There are many different areas of litigation an attorney can practice and a paralegal can fit well into any of those areas. Now, for attorneys involved in litigation with medical malpractice, product liability, or personal injury, they have an added issue of dealing with medical records, whether they be hand written or the ever so growing use of electronic medical records. Paralegals are experts in the litigation aspects of a firm, but should they hold the responsibility of organizing and analyzing those records?

With time, a paralegal may become successful at organizing medical records in a manner the attorney accepts, but are they organized in a manner the physician expert can easily review and interpret? This task should be completed by a professional experienced in the most effective way to organize medical records.  This will eliminate the expert fumbling around in the records and increasing costs.

A paralegal may also, over time, be skilled at reading medical records and be able to create a chronology. An experienced attorney can also read medical records, but the question is can the paralegal or attorney “interpret” those records? Reading medical records is tremendously different from “interpreting” records.  A Legal Nurse Consultant uses their medical knowledge to see beyond the facts of the case and to help the attorney understand the implications of the details.

The role of the Legal Nurse Consultant goes beyond the organization and interpretation of medical records. A Legal Nurse Consultant recognizes when critical medical records are missing or when the records have been tampered with.  This role also encompasses providing peer reviewed scholarly literature to strongly support the issues. The Legal Nurse Consultant will also assist the attorney in preparing interrogatories for depositions and assist in preparing demonstrative evidence for trial.

As you can well see, the role of the Legal Nurse Consultant is an extension and an adjunct to the role of the paralegal.  Each role can function without the other, but the marriage of these two roles increases the firm’s productivity and decreases cost which then will always increase the bottom line.

Lori Combs BS, RN

Legal Nurse Consultant

432 661 3639

The Attributes of a Legal Nurse Consultant Part I by Lori Combs

The exciting career of a Legal Nurse Consultant (LNC) has been active and growing for more than 20 years.  Registered nurses bring their invaluable medical knowledge to the law arena and are a priceless addition to the attorney.  Successful Legal Nurse Consultants know the value of their medical knowledge and successful attorneys have discovered the benefits of employing a Registered Nurse to assist them in many aspects of the litigation process.

There are three specific attributes that a successful Legal Nurse Consultant brings to the attorney:  intelligence, effective communication skills, and curiosity.  Intelligence and the ability to learn quickly are crucial assets that a Legal Nurse Consultant should possess.  Attorneys will expect that the LNC can jump right into their role and quickly grasp the legal processes immediately.

The ability to communicate effectively and efficiently is imperative to the LNC if she/he is to be successful.  Attorneys are individuals that communicate in a straightforward line and do not want a long curvy process to arrive at the point.  Attorneys expect straight-to-the point communication without a bunch of fluff.  The ability to communicate in a straightforward manner, both written and verbal, is imperative to the attorney as time is money.

Curiosity is another essential characteristic that the attorney will absolutely love in the Legal Nurse Consultant.  The determination to dig deep into the medical records is something a successful LNC thoroughly enjoys.  Never leaving a stone unturned is what the Legal Nurse Consultant will do for the attorney.  Knowing the medical aspects of the case inside and out will allow the LNC to communicate their findings to the attorney and to aid in the litigation process with discovery, depositions, research, and finding that perfect expert.

Many attorneys do not know the value of having a Legal Nurse Consultant on their team.  They struggle with trying to decipher the medical records on their own, which can be frustrating, time consuming, and detrimental to their case.  Attorneys that utilize the Legal Nurse Consultant in their practice eliminate the frustration and time-consuming tasks of organizing, reviewing, and deciphering medical records and they leave that to the professional LNC.


Lori Combs B.S., R.N., Legal Nurse Consultant

Davies, McFarland, & Carroll, P.C.

Pittsburgh, P.A.

432 661 3639