9.15.2016

Sepsis: Know the Signs and Symptoms



What is Sepsis?

Sepsis is the body’s overwhelming and life-threatening response to an infection, which can lead to tissue damage, organ failure, and death. Sometimes called blood poisoning, it can be caused by a seemingly minor infection due to a scrape or cut. It is often the cause of death of people suffering from other diseases (see Sepsis and Other Diseases). For instance, people with cancer can die as the result of the actual tumor or from an associated condition such as sepsis. Anyone can get sepsis but children and older adults tend to be more vulnerable.


Know the signs and symptoms of Sepsis

There is no single sign or symptom of sepsis. It is a combination of symptoms. And because sepsis is the result of an infection, symptoms can include signs of infection such as diarrhea, vomiting, sore throat, etc.) in addition to ANY of these symptoms:

    • Shivering, fever, or very cold
    • Extreme pain or discomfort
    • Clammy or sweaty skin
    • Confusion or disorientation
    • Short of breath
    •  High heart rate.


What to do if you suspect Sepsis

Sepsis should be treated as a medical emergency (as quickly as possible) with antibiotics and fluids. If you think you or a loved one has sepsis you should be clear and firm that you suspect sepsis and demand urgent attention.
  • Call your doctor or go to the emergency room immediately if you have any signs or symptoms of an infection or sepsis. This is a medical emergency.
  • It’s important that you say, “I AM CONCERNED ABOUT SEPSIS.”
  • If you are continuing to feel worse or not getting better in the days after surgery, ask your doctor about sepsis. Sepsis is a common complication of people hospitalized for other reasons. 
Sources and for more information on sepsis, see the CDC website and the Sepsis Alliance website.

Failure to diagnose sepsis or an infection leading to sepsis can sometimes lead to a medical malpractice lawsuit.

View our main website at LubinandMeyer.com - Lubin & Meyer PC.
Attorneys licensed and practicing in Massachusetts, New Hampshire and Rhode Island.

CONTACT US.

8.11.2016

Have Prostate Screening Guidelines Put African-American Men At Risk?

A recent prostate cancer study which found a 72% increase in advanced (metastatic) cancers in a decade has drawn renewed attention to prostate screening guidelines.

The PSA test, the best tool in diagnosing prostate cancer, also can create false-positives or detect cancers that are not life-threatening and for which treatment may cause undesired outcomes.
According to an op-ed in the New York Times, most medical guidelines recommend men weigh the benefits and limitations of PSA screening. However, in 2012, the U.S. Preventive Services Task Force recommended against prostate-specific antigen (PSA)-based screening for prostate cancer.

The op-ed reported:
"The government guidelines stunned doctors who recognize the greater dangers of prostate cancer in African-American men. Many believe that the disadvantages of routine PSA screening are outweighed when it comes to high-risk populations, and they worry that the guidelines will lead to less screening for men who might benefit the most from it. Their concerns have been borne out: Recent studies note a decrease in PSA screening for all populations, including African-American men."
The American Cancer Society recommends men discuss the risks and benefits of PSA tests with their doctors — starting at age 45 for black men or younger for men with family history of prostate cancer.

The op-ed authors recommend:
"The discussion should acknowledge that African-American men are at a higher risk of developing and dying from prostate cancer, that they have an increased risk for aggressive disease at diagnosis, that there are significant advancements in the detection and staging of prostate cancer, that the PSA test is just one of many available to help make an educated decision, and that the importance of seeking high-quality cancer care with supportive services and clinical trial opportunities are paramount."
Read the full article: Prostate Cancer Isn’t Colorblind
Authors: Lannis Hall, Arnold D. Bullock, Angela L. Brown, Graham Colditz

We encourage all men to discuss prostate screening with their doctors.

View our main website at LubinandMeyer.com - Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law

7.22.2016

As Prostate Cancer Screenings Have Decreased; Advanced Cancers Have Skyrocketed

Study shows 72% increase in metastatic prostate cancer cases in the past decade


A dramatic rise in advanced prostate cancer has been reported by a Northwestern Medical study published in Prostate Cancer and Prostatic Diseases, July 19, 2016, a Nature journal.

The study shows a 72% increase in new cases of metastatic prostate cancer in the past decade from 2004 to 2013. The study discusses two possible causes for the increase — a recent trend of fewer men being screened and that the disease has become more aggressive.

Prostate Cancer Video image


“One hypothesis is the disease has become more aggressive, regardless of the change in screening,” said senior study author Dr. Edward Schaeffer, chair of urology at Northwestern University Feinberg School of Medicine and Northwestern Medicine. “The other idea is since screening guidelines have become more lax, when men do get diagnosed, it’s at a more advanced stage of disease. Probably both are true. We don’t know for sure but this is the focus of our current work.“

“The results indicate that screening guidelines and treatment need to be refined based on individual patient risk factors and genetics,” said lead author Dr. Adam Weiner, a Feinberg urology resident. “This may help prevent the growing occurrence of metastatic prostate cancer and potential deaths associated with the disease. This also can help minimize overdiagnosing and overtreating men with low-risk prostate cancer who do not need treatment.”

“Prostate cancer is 100 percent treatable if detected early, but some men are more likely to develop aggressive disease that will recur, progress and metastasize,” said Dr. Jonathan W. Simons, president and CEO of the Prostate Cancer Foundation.

“Not all men with prostate cancer need immediate surgery or radiation. But every case needs precision prostate cancer care. We urgently need smarter and more targeted cancer screening, so we don't leave men at highest cancer risk unprotected from early, curable disease being missed and turning into incurable disease,” said Simons.

Link to the study:  Increasing incidence of metastatic prostate cancer in the United States (2004–2013)

Northwestern News Service: Metastatic Prostate Cancer Cases Skyrocket

Failure to Screen for Prostate Cancer

doctor ordering prostate screening photo
Did your doctor fail to screen or fail to offer you screening or delay in the diagnosis of your prostate cancer?

Our attorneys are licensed and practicing in Massachusetts, New Hampshire and Rhode Island.

Lubin & Meyer has successfully represented many clients whose prostate cancer has gone undiagnosed, most recently obtaining a $2.84M verdict for Failure to Screen for Prostate Cancer.

View our main website at LubinandMeyer.com
Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law

CONTACT US.

7.12.2016

Cardiology Malpractice Claims Study: Why Patients Sue

Missed Diagnosis Is Leading Cause of Cardiology Malpractice Lawsuits

What leads cardiac patients to file medical malpractice lawsuits? According to a review of 429 cardiology claims that closed between 2007 and 2013 by The Doctors Company — a physician-owned medical malpractice insurer — the most common reason is diagnosis related. That is, either a failure to diagnose, a delay in diagnosis, or a wrong diagnosis.

A brief summary of the top 5 reasons for the lawsuits (as reviewed by the insurer) are:
  • Diagnosis related = 25%
  • Improper management of treatment = 14%
  • Improper performance of treatment/procedure = 12%
  • Improper performance of surgery = 11%
  • Improper medication management = 6%
Click to view enlarged version of the infographic below.

cardiology medical malpractice infographic


Getting the Right Diagnosis

For information to help you receive a proper diagnosis of heart disease symptoms, please visit this web page at rightdiagnosis.com.

Cardiology and Heart Attack Lawsuits in MA, NH, RI

Attorneys at Lubin & Meyer PC have successfully represented cardiac patients in many types of malpractice claims including:
To read the trial reports of other heart attack related lawsuits, click on: Cardiac Malpractice Verdicts and Settlements.

View our main website at LubinandMeyer.com - Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law

Attorneys licensed and practicing in MA, NH and RI.

Do you have questions about a possible cardiac care malpractice lawsuit?

CONTACT US.

6.10.2016

$16.7M Judgment in Misdiagnosed Lung Cancer Death Case Upheld on Appeal

The Massachusetts Appeals Court has upheld a $16.7M judgment from June, 2014, in a wrongful death medical malpractice lawsuit involving misdiagnosed lung cancer. The lawsuit was brought by the daughter of a 47-year-old woman who died from a 13-month delay in diagnosis of lung cancer at Brigham and Women's Hospital, where a radiologist failed to identify and report a 1-1.5cm nodular density in the upper part of the right lung.

Attorneys Robert Higgins and Barrie Duchesneau represented the plaintiff at trial. After 3 hours of deliberations, the jury returned a verdict against the radiologist for negligence in care and treatment for $11,000,000. The jury awarded $1,000,000 for conscious pain and suffering, $3,000,000 for the plaintiff’s loss of consortium up to the time of the verdict and $7,000,000 for the plaintiff’s loss of consortium into the future. The total judgment was $16,764,603 after the addition of pre-verdict statutory interest.
View our main website at LubinandMeyer.com - Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law

4.27.2016

Lubin & Meyer Lawsuit Leads to FDA Ban of Electronic Shock Devices for Use on Autistic Children

When the U.S. Food and Drug Administration (FDA) announced last week a proposal to ban electrical stimulation devices (ESDs), it was a long awaited final chapter in a lawsuit brought by Lubin & Meyer on behalf of Cheryl McCollins whose son Andre had been severely injured due to repeated electrical shock treatments while a student at the Judge Rotenberg Center.

"Many children and families have long awaited this historic news," said Benjamin Novotny, who represented McCollins at trial. "It is encouraging that the FDA is following the United Nations' footsteps and labeling this practice for what it is, torture."

The disturbing video evidence presented at trial, helped to reach a settlement, mount public outrage and move an FDA panel to hold a hearing to consider banning the practice of aversive electronic shock treatments. That hearing led to a recommendation to ban the practice, and now — two years later — the FDA has issued a proposal to ban the devices.
"The FDA takes the act of banning a device only on rare occasions when it is necessary to protect public health. ESDs administer electrical shocks through electrodes attached to the skin of individuals to attempt to condition them to stop engaging in self-injurious or aggressive behavior. Evidence indicates a number of significant psychological and physical risks are associated with the use of these devices, including depression, anxiety, worsening of self-injury behaviors and symptoms of posttraumatic stress disorder, pain, burns, tissue damage and errant shocks from a device malfunction.
In addition, many people who are exposed to these devices have intellectual or developmental disabilities that make it difficult to communicate their pain or consent. As these risks cannot be eliminated through new or updated labeling, banning the product is necessary to protect public health."
The proposed rule is available online at www.regulations.gov for public comment for 30 days.

See our previous posts on this subject:



View our main website at LubinandMeyer.com - Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law

CONTACT US.

4.14.2016

Concurrent Surgeries at MGH Spur Federal Investigations

Lubin & Meyer lawsuits are at the center of widening probe into double-booking surgeries


Recent investigative reporting by the award-winning Boston Globe Spotlight Team on "Concurrent Surgeries" at Mass General Hospital and lawsuits filed by Lubin & Meyer on behalf of patients there, continue to have a ripple effect — and have resulted in federal inquiries into the practice of double-booking surgeries without a patient's knowledge.

See these articles as federal scrunity of the practice unfolds.
See our prior post on this topic:
Concurrent Surgeries in the Spotlight: Is it Safe To Run Two Operations at Once?

View our main website at LubinandMeyer.com - Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law

Attorneys licensed and practicing in MA, NH and RI

CONTACT US.

3.17.2016

6 Ways To Be A Safe Patient

In recognition of Patient Safety Awareness Week, we would like to share this infographic from the CDC on what patients can do to help prevent healthcare-associated infections (HAIs) in the hospital setting. We've reported on HAIs before, see our post: Tracking Infection Control in U.S. Hospitals.

According to the CDC,
On any given day, approximately one in 25 U.S. patients contract at least one infection during the course of their hospital care.
Be an informed and empowered patient and play an active role in your care including questioning your healthcare team about infection control.

You can download this infographic from the CDC.



6 Ways To Be A Safe Patient  


1. Speak Up. Talk to your doctor about infection and what they are doing to protect you.

  • If you have a catheter, ask each day if it is necessary. 
  • Ask your doctor how he/she prevents surgical site infections
2. Wash Hands. Make sure everyone cleans their hands before touching you.

3. Monitor Antibiotics. Ask if a test will be done to make sure the right antibiotic is prescribed.

4. Watch for Infection. Some skin infections, such as MRSA, appear as redness, pain, or drainage at an IV catheter site or surgery site. Sometimes these symptoms come with a fever. Tell your doctor if you have these symptoms.

5. Monitor Diarrhea. Tell your doctor if you have 3 or more diarrhea episodes in 24 hours.

6. Vaccinate. Get vaccinated against flu and other infections to avoid complications.

CONTACT US.

Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law
Attorneys practicing in Massachusetts, New Hampshire and Rhode Island

1.15.2016

Massachusetts State Medical Board Takes Action on Simultaneous Surgeries

Following a Spotlight report by the Boston Globe and lawsuits filed by Lubin & Meyer regarding "concurrent surgeries," the Massachusetts Board of Registration in Medicine approved new regulations requiring surgeons to document each time they enter and leave an operating room.

A January 7, 2016 article in the Boston Globe details,
"The board also approved a requirement that the primary surgeon identify the backup doctor who would assume responsibility if the first surgeon is going to leave the operating room. The new rules, among a series of regulation revisions that the board passed by a vote of 5 to 1 late Thursday, need the approval of several state agencies by the end of March before they can go into effect."
 — See full article: State acts on simultaneous surgeries
A letter to the editor by Nancy G. Brinker, board member and founder of Susan G. Komen for the Cure, supports regulation of the practice of simultaneous surgeries and asks the medical community to decide if it is in the best interest of patient safety. (See below.)
View our main website at LubinandMeyer.com - Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law

12.14.2015

The Problem with Problem Lists: How Medical Records Policy Can Backfire

Largest Medical Malpractice Verdict of the Year Hinges on "Problem List"


When a 28-year-old woman suffered a severe stroke after giving birth to her first born child, it was an unexpected outcome given that the woman's life-threatening and previously diagnosed brain abnormality was not properly entered into her medical record. The ensuing medical malpractice case of Larkin v. Johnston (tried by Lubin & Meyer's Benjamin Novotny) returned a verdict of $35.4 million. The landmark case illuminates the topic of "problem lists." In the October issue of Healthcare Risk Management, the article Problem Lists Can Threaten Safety, Pose Liability Risks digs into problem lists as illustrated by the Larkin case — one of the largest medical malpractice verdicts of the year.*

According to the article,
"Many hospitals use problem lists as a way to catalog all health issues affecting a patient, or at least those that are particularly noteworthy for other physicians. A recent study and malpractice case, however, highlight the risk posed by having a policy on problem lists and not following it."
One recent study published in the October 2015 issue of International Journal of Medical Informatics found the levels of completeness of problem lists varied from 60% to 99% across 10 facilities in the study group, with an average of 78%. (See more on the study here.)

According to Attorney Novotny the health system’s problem list backfired...
"The existence of the problem list encouraged clinicians to depend on it for important alerts about a patient’s conditions, he says, which in turn made them lax about digging through the entire patient record in search of important information. When key findings were left off the problem list, the policy ended up causing the very thing it was meant to prevent."
Said Novotny, “They actually had a policy that was right on point for trying to prevent this kind of disaster, and they didn’t follow it. That will always come back and hurt you in court if you have a policy and procedure and don’t follow it.”

For more coverage of this case, see the Channel 5 news story below.



* The National Law Journal Verdict Search database from July 1, 2014 through June 30, 2015 ranks the Larkin v. Johnston verdict as the 20th largest verdict in the nation, and #1 in Massachusetts.

View our main website at LubinandMeyer.com - Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law.
Attorneys licensed in MA, NH and RI.

CONTACT US.

11.16.2015

Concurrent Surgeries in the Spotlight: Is it Safe To Run Two Operations at Once?

The Boston Globe Spotlight Team has exposed a practice at Massachusetts General Hospital of some leading orthopedic surgeons double-booking operating rooms in order to run "concurrent surgeries" — that is, having two patients in two operating rooms at once.
At the center of the issue is transparency — whether patients are clearly notified that their surgeon may not be present for the entire surgery — and, of course, the impact on patient safety. MGH claims the practice has not caused any patient harm...
"Still, the Spotlight Team found that the 2012 Meng case [represented by Lubin & Meyer] reignited an extraordinary, long-running controversy at one of the nation’s top-rated hospitals over the propriety and safety of a fairly common but little studied practice that goes to the heart of a doctor’s obligation to his unconscious patient. Is it right, some MGH medical staff asked, for surgeons to divide their attention between two operating rooms — especially when the patients don’t know? Can they really do two overlapping operations equally well?"
Link to the in-depth Boston Globe investigative team report and multimedia presentation at: Clash in the Name of Care.

View our main website at LubinandMeyer.com
Lubin & Meyer PC - New England's Leader in Medical Malpractice Law
Attorneys practicing in MA, NH and RI

CONTACT  US

10.12.2015

Diagnostic Errors and How To Avoid Them — A Critical Checklist for Patients

We have reported repeatedly on studies related to medical errors and infections that happen in hospitals. However, diagnostic errors (which often happen outside of the hospital in a doctor's office) have escaped the kind of tracking that other medical harms receive. Research from Johns Hopkins School of Medicine, shows that "diagnostic errors — not surgical mistakes or medication overdoses — accounted for the largest fraction of claims, the most severe patient harm, and the highest total of penalty payouts." According to a press release announcing the study, "diagnostic errors could easily be the biggest patient safety and medical malpractice problem in the United States."

What is a diagnostic error?


A diagnostic error can be defined as a diagnosis that is missed, wrong or delayed, as detected by a subsequent definitive test or finding. The ensuing harm results from the delay or failure to treat a condition present when the working diagnosis was wrong or unknown, or from treatment provided for a condition not actually present.

“Overall, diagnostic errors have been under appreciated and under-recognized because they’re difficult to measure and keep track of owing to the frequent gap between the time the error occurs and when it’s detected,” said the study leader David Newman-Toker. “These are frequent problems that have played second fiddle to medical and surgical errors, which are evident more immediately.”

How can patients help to ensure they receive the right diagnosis?


The National Patient Safety Foundation has created a Checklist for Getting the Right Diagnosis with some tips for patients.



This 8-point checklist can be printed and taken with you when you meet with your doctor.

View our main website at LubinandMeyer.com
Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law. Attorneys practicing in MA, NH and RI.

CONTACT US.

9.26.2015

Cauda Equina: A Dangerous Outcome When Patient Complaints Are Not Taken Seriously

Lubin & Meyer settled a NH medical malpractice lawsuit this month involving a 50-year-old woman who now suffers from significant weakness of her legs and bowel and bladder incontinence due to a delay in the diagnosis and treatment of cauda equina syndrome.


Attorney Benjamin Novotny who represented the claimant in this lawsuit said that cauda equina syndrome is often misdiagnosed as simple back pain. "It is a big patient safety concern that only arises because health care providers often do not take patient complaints as seriously as they should."

What is cauda equina syndrome?


Cauda equina syndrome is a serious medical emergency involving extreme pressure and swelling of the nerves at the end of the spinal cord. If patients with cauda equina syndrome do not get appropriate treatment, adverse results can include:
  • permanent paralysis
  • impaired bladder and/or bowel control
  • difficulty walking
  • other neurological and physical problems.
"Hospitals and care providers must accurately and timely diagnose this condition before the nerves become permanently injured," said Novotny. In this case, the patient's primary care doctor dismissed her complaints as lumbar disc disease and sciatica without requesting a consultation or imaging study and despite repeated complaints of pain, muscle spasms, weakness in the legs with numbness and tingling. She was eventually diagnosed with cauda equina 11 days later, after a visit to St. Joseph's Hospital and a transfer to Lahey Clinic.

Read the full trial report here: Delay in Diagnosis of Cauda Equina.

Lubin & Meyer has extensive experience successfully pursuing claims involving cauda equina syndrome, including but not limited to:
View our main website at LubinandMeyer.com
Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law. Attorneys practicing in MA, NH and RI.  

CONTACT US.

8.21.2015

29 Mistakes That Should Never Happen In A Hospital, But Do

Massachusetts is well known as home to some of the world's most prestigious hospitals, including Mass. General Hospital recently named the "Top Hospital in the Nation" by U.S. News & World Report and Best Hospitals.® However, even here in Massachusetts, serious medical mistakes continue to happen to far too many patients.

As a follow up to last week's post on Massachusetts Hospital Errors, we dug deeper into the data that hospitals and surgery centers are required to report to the Department of Public Health on "Serious Reportable Events." There are 29 such events, also known in hospitals as "never events," and we list them here with the total instances reported by the state's acute care hospitals, non-acute care hospitals and ambulatory surgery centers combined (for 2014).

Some of the most common of the 29 "Serious Reportable Events" reported by
Massachusetts Hospitals in 2014. See detail highlighted in red below.

Massachusetts Serious Reportable Events

Surgery Events
1. Wrong body part, side or site surgery of procedure = 30
2. Wrong patient surgery or procedure = 0
3. Wrong surgery or procedure performed = 11
4. Foreign object left in patient after procedure unknowingly = 41
5. Death of ASA Class I patient during surgery or within 24 hours = 1

Product Events
6. Contaminated drugs, device or biologics = 37
7. Device misuse or malfunction = 15
8. Intravascular air embolism = 6

Patient Protection
9. Patient discharged to unauthorized person = 2
10. Serious injury or death during patient disappearance = 0
11. Suicide or self-harm = 57

Care Management Events
12. Serious injury or death from medication error = 37
13. Unsafe blood transfusion = 0
14. Maternal serious injury or death associated with labor or delivery = 6
15. Newborn serious injury or death associated with delivery = 27
16. Serious injury or death after a fall = 416
17. Stage 3, Stage 4 or unstageable pressure ulcer = 294
18. Artificial insemination with wrong egg or sperm = 0
19. Serious injury or death from loss of irreplaceable biological specimen = 2
20. Serious injury or death from lack of follow up or communication of lab result = 5

Environmental Events
21. Serious injury or death from electric shock = 0
22. Oxygen or gas delivery error = 0
23. Serious injury or death from burn = 32
24. Serious injury or death from physical restraints = 6

Radiology
25. Serious injury or death from metallic object in MRI  = 1

Potential Criminal Events
26. Impersonation of a health care provider = 0
27. Abduction of patient = 0
28. Sexual abuse or assault of patient or staff member = 7
29. Serious injury or death after physicial assault of patient or staff = 32

The Massachusetts Health and Human Services website makes the total number of "Serious Reportable Events" (SREs) by hospital available to the public. Hospitals and ambulatory surgery centers are required by law to report SREs to the Massachusetts DPH. The law also prohibits hospitals from charging for these events or seeking reimbursement for SRE-related services. 

View our main website at LubinandMeyer.com
Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law. Attorneys practicing in MA, NH and RI.

CONTACT US.

8.04.2015

Massachusetts Hospital Errors — Amount of Preventable Medical Mistakes Is Staggering

The Boston Globe reported last month on a Department of Public Health (DPH) annual study showing that full-service hospitals in the state reported "821 preventable errors that harmed or endangered patients last year." Some of the top hospital errors reported were:
  • Surgical objects left behind (41)
  • Operation on wrong body part (24)
  • Serious injury or death after a fall (290).
Our own Andrew C. Meyer, Jr. was quoted in the article,
“It’s extraordinary the amount of medical errors and deaths that occur on a yearly basis. Medical error is becoming one of the leading causes of death in Massachusetts.”
     
— Andrew Meyer, Attorney
Whether these instances are increasing or decreasing is open for debate, according to the article, Mass. hospitals continue to make preventable mistakes, as definitions for the reporting of serious events has recently changed, and not all errors may be reported.

How Do Massachusetts Hospitals Compare? 

The Massachusetts Health and Human Services website makes the total number of "Serious Reportable Events" (SREs) by hospital available to the public. Hospitals and ambulatory surgery centers are required to report SREs to the Massachusetts DPH. The law also prohibits hospitals from charging for these events or seeking reimbursement for SRE-related services. Click here to view: Massachusetts Hospital Error Data.

View our main website at LubinandMeyer.com
Lubin & Meyer PC - New England's Leader in Medical Malpractice and Personal Injury Law. Attorneys practicing in MA, NH and RI.

CONTACT US.