38 Comments
Nov 1, 2022Liked by Med Mal Reviewer

This is a nightmare for all involved. While I think the ED doc made some errors here, I can easily see how that oddly non-acute radiology report and the fever/seizure led him/her onto the wrong diagnostic pathway. Truly a horrible situation. As an IM hospitalist I am always a bit nervous to take care of young patients because of catastrophes that can happen like this, but 99% are not very sick. I also feel super bad for the ED doc (and would never be one myself) because it seems like they were totally unsupported. It seems that the neurologist never came in to assess the patient in person overnight and the ICU wasn't even staffed by a physician overnight. Though our legal system pretends otherwise, it doesn't seem reasonable to expect ED docs to catch everything especially since they are pulled in a million directions at once. We are each other's safety mechanism. Two or three extra sets of trained eyes can be crucial in preventing catastrophes like this one. I've been a busy private practice doc on call and it SUCKS to get numerous calls from the ED overnight and have to continuously make that decision of whether I need to drag myself out of bed to go see that patient right away or if it can wait til morning. There's no perfect way to do it but certainly a younger patient with a story like his (even just bits and pieces) would probably perk up my ears enough to wake the hell up and investigate further. Or maybe I'd just like to think that's what I'd do.

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Agree, from an ED doc perspective this is one of the biggest nightmares I've seen. He started off going down the right path but got thrown off by the fever/seizure combo and then actively sabotaged by the radiology report.

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Nov 1, 2022Liked by Med Mal Reviewer

That is an incredible amount of money for an outcome that was unfortunately inevitable. Very little would have changed even if the diagnosis had been clinched with a good neuroradiology report and neurology evaluation. It’s unfortunate that the chiropractor likely had a much lower settlement despite being the source of the injury.

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Agree. I am unsure how the financial side of this will be handled... the verdict form does mention the doc AND his employer as the negligent parties, so I'm hoping the doc escapes financial ruin. I'm sure it'll get appealed.

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Nov 1, 2022Liked by Med Mal Reviewer

Please keep us posted. As a practicing EM physician this kind of case and settlement makes me want to quit medicine.

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Agree, very demoralizing to see docs being held responsible to fix other people's complications AND have to do it while being actively sabotaged, all for a once-in-a-lifetime diagnosis.

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Mar 28Liked by Med Mal Reviewer

This is exactly why I will NEVER EVER live or practice in states without meaningful tort reform....let them find out what its like when no one will work there.

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Mar 26, 2023Liked by Med Mal Reviewer

I practiced general and interventional radiology until I quit at the age of 62. I had intended to work much longer, but the fear of ruinous law suits motivated me to leave early. I had a fully funded retirement in the bank and I did not want risk being financially wiped out by some contingency fee sucking criminal with a law school diploma. In my state of Pennsylvania, like most states, the state house is dominated by lawyers. In their smoke filled back rooms they write laws to benefit themselves. The doctor is held to a standard of perfection. There can never be a bad outcome. Some crafty lawyer will try to convince the jury that it was "malpractice". The "jury" is the 12 dumbest people in the room. These uneducated gullible "peers" will be lied to by the theatrical trial lawyers and dishonest "expert" witnesses. Then, based mostly on their emotional reaction, they will come out with a dollar amount. All too often, it is an outrageous sum that sounds like a military defense budget. This is an extortion racket that was created by lawyers to benefits lawyers. This story has had 2 effects on me. First, it makes me furious. Second, it confirms that I was correct to walk away before the lawyers had a chance to steal everything I worked my life for. So, if you live in a state with no "caps" on what lawyers can steal and you have enough money to retire on, then get out before you are force to play Russian roulette with the trial lawyers in a casino that they own.

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Nov 1, 2022Liked by Med Mal Reviewer

awful outcome for this poor patient! one interesting tidbit: the mention of the scribe at the very end. this is something that I'm sure the scribe was kicking him/herself for after. it's so easy to overlook the premade template, especially for the often untested Neuro exam. having been a scribe, i am intimately familiar with the anxiety of thinking we forgot to document or delete something in the note!

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Yep this is a good case for scribes to read too. Its hard to appreciate the importance and relevance of what you're doing when you're just trying to type notes as fast as possible, but they really made life miserable for this doctor. But on the other hand, its the doctors job to make sure its accurate.

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I learned that a "dizzy" patient after a chiropractor adjustment of the cervical spine is due to vertebral-basilar insufficiency until proven otherwise. Patients aren't warned of the complications of chiropractic manipulations.

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Nov 1, 2022Liked by Med Mal Reviewer

Dreadful case. A cascade of failures from start to finish. Thing is, sounds like the ED doc was on the right track, but completely dropped the ball after reading the CT report.

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Hard to even say the EM doc dropped the ball after the CT report... it did mention some vertebral abnormality but it was on the other side and there was no mention of basilar disease. If EM calls the radiologist to say "are you sure?" every time a scan doesn't match the clinical picture, they'd be getting calls on dozens of scans per day.

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Nov 1, 2022Liked by Med Mal Reviewer

Yes, but here's the thing. The EM doc suspected a dissection. The report was inconclusive. Now, I've worked in a big academic center ED, a 60 bed ED in a medium-large city, and a 12 bed Critical Access hospital ED. I can say with absolute certainty that if I had a high risk patient with an inconclusive study, I would be on the phone with the radiologist to clarify the findings and discuss what other imaging might be needed. Here, the report was distinctly abnormal.

2 out of the 3 institutions where I worked had remote radiology overnight. That wouldn't stop me from making the call. I was on great terms with our in-house radiologists, who would actually call US to ask for clinical info if the indications for the study weren't clear or if an abnormality didn't match the data provided.

I diagnosed vertebral artery dissection 2° chiropractic manipulation 3 times in my EM career. One did well, one recovered with deficits and one remains in SNF.

I think the fact that the EM doc suspected dissection is the key learning here. And why the jury assigned 60% of the culpability.

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Jul 4, 2023Liked by Med Mal Reviewer

I'm scratching my head on this case because it looks like everyone in the entire case missed the whole problem.

As I was reading through the case and I saw the right vertebral artery finding in the CTA report, my reaction to that finding was "so what?" Taking the CTA report to be true, full flow through the left vertebral and basilar should not cause ischemia. It would be completely reasonable to interpret the right vertebral finding as an incidental finding. It's reasonable to ask whether the additional history of chiropractic neck adjustment would have prompted a typical physician to look harder with that history, but it doesn't change the fact that a CTA has a strong negative predictive value against dissection, and makes the question of what was communicated between the ED physician and neurologist largely irrelevant to the case. It was only when the plaintiff's neuroradiologist statement came up that things made sense -- the left vertebral/basilar dissection was present but missed on the original read. I'm surprised the ED physician's defense didn't hammer on this as the proximate cause for the entire case, and IMHO the liability should be 100% on the radiologist for that misread.

The second thing about this case which bothered me is that there is no discussion about causality/damages. The portion of the deposition quoted here has the plaintiff's lawyers focusing on the delay in starting heparin. I find this problematic in that heparin doesn't actually do anything to make the condition better. It is a recommended treatment because it will stop further progression in clot and make it easier for the body to eventually naturally lyse the clot, and IMHO had heparin been started in the ED, the patient's outcome would likely have been similar. I didn't seen anything about this being brought up at trial. (Now, a stat neuro intervention aimed at the dissection may have made a difference, but I didn't see anything about the hospital's neuro-IR capabilities, and the fact that the patient was transported by "rural ambulance service" suggests that this event did not take place in a comprehensive stroke center with emergent neurointerventional capabilities.)

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The ED physicians defense attorney was fairly aggressive in pointing out the radiologist's miss. I think the jury understood that but maybe didn't grasp that gravity of that miss, and were distracted by the ED doctor's alleged mistakes.

Agree re: the point about heparin. The plaintiffs attorneys are not interested in a true discussion of the utility of heparin, they're mostly going for a "they could have done something and didn't" argument, without acknowledging (or understanding?) this point. This was indeed a smaller hospital without neurointerventional capability, although they could have transferred to a large academic center about 30 minutes away. Seems that (especially at that time) they might not have even tried to go after the clot given the challenging location.

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As a practicing radiologist of 20 years, i would like to reconfirm that the stated indication does make a difference.

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Thanks for the comment! Do you think the radiologist would have been more likely to find it if they had included "chiropractic neck manipulation" in the stated indication? The requesting clinician put "dissection" and it was still missed, which makes me think probably not. Hard to know for sure.

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Apr 6, 2023Liked by Med Mal Reviewer

When I see chiropractor, i think tear. To your question though, maybe a bit, it gives the sense that something happened followed by acute change. In general, I have found that indications with a few words will change what I say and see a couple of times per day. Mostly tweaks, but sometimes much more.

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Neuroradiologist here been reading overnight ER studies for 12 years. The CTA report is frankly awful and I am surprised it was dictated by a neurorad. We all make mistakes, and while mistaking a dissection for a hypoplastic vert is somewhat understandable, missing near occlusion of most of the basilar is just a devastating mistake which is difficult to understand. I wonder if the cerebellar arteries were visible; they can usually be traced for a few centimeters. But, given the strokes seen on the MR, several may well have been occluded on this scan. The small vert obviously spooked the rad but instead of making the diagnosis he/she was unsure which led to an embarrassing report full of waffling and hedging with devastating results for the patient. if the rad was unsure about such a crucial diagnosis he/she should have gotten another rad to look and give their opinion. As an aside, while vertebral artery size is highly variable, the key to identifying dissection is that the caliber of the dissected vessel will vary throughout its course (or occlude) while a hypoplastic vessel will be uniformly small in caliber or taper distally. Hypoplastic vessel will also have a small transverse foramen thru the cervical vertebrae. If the dissected vessel is big enough (and they usually are) you can see the clot in the false lumen narrowing or occluding the true lumen. I feel terrible for the patient and also the ER doc; based on the case summary the correct response to the CTA images would be a stat call to the ER recommending neurointerventional consult.

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At trial the neurorad's lawyer talked about falling victim to the "satisfaction of finding". Basically said the congenital abnormality of the right vert distracted him which led to missing the left vert dissection and basilar clot.

The ED doc got a lot of flack for being (allegedly) untruthful, but something that got overlooked here was the fact that the rad claimed (under oath at deposition) that he called the ER doctor tell him the CTA findings. But its not documented anywhere in his read. I've never gotten a call from a radiologist and NOT had it documented. Makes me wonder if he was being untruthful as well, trying to cover himself.

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Very sad. This is what happens when there is no PMD involvement in ER at the time of arrival. . It’s like driving a car without a driver. ER MD has other patients to care for.

Now it’s happening all over In NJ. Once pt. Is seen by ER MD a health team NP or PA becomes in charge of patients instead of PMD.

Often I end up going to ER at patient’s/family request because things are going wrong. The health team providers don’t know the patient well. They do shifts and leave .I can’t see patients in ER /observation . I can only make suggestions.

This patients MRI should have been done same night. Neuro should have evaluated pt. Same night. Even though outcome would have been the same.

Unfortunately this is going to be the future of medicine so hospitals can bill for services provided by health team .

It has become all about $ instead of patient care for these hospital management corporations .

I am very worried about the direction of healthcare system .

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Does the fact that the chiropractor settled require the jury to find him 0% at fault or could they still assign him fault even if his settlement excludes him from being held responsible for whatever they determine to be his contribution? Alternatively, is it possible the jury was not properly instructed to include him even though they settled? I can easily see how, even if it's not the case, the jury assumes that a settlement means they aren't allowed to assign blame even if they thought he deserved it.

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As I understand it, the jury could still have assigned fault to the chiropractor even though he was no longer a party to the lawsuit. So its very bizarre to me that they had him down at zero percent. Generally I think juries are pretty good but this one really seems to have missed the mark. I wonder if neither the defense or plaintiff focused much on the chiropractor because he was already removed from the lawsuit, so they weren't given the relevant info to assign him fault.

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The jury can assign fault in this case. It's called "apportionment of fault." In this case whatever percentage they would have assigned to the chiropractor (he/she wouldn't pay because they already settled) would have reduced the amount the other two docs were on the hook for.

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I worked with this physician when he was a resident. It’s severely unfortunate that this happened to him because he was not a bad resident, and I’ve seen plenty of dangerous ones graduate. Seems like everyone got hyper focused on the changing of the documentation and he took the brunt of it.

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I feel so bad for him. Rough case, a lot of things could have gone better but there were also a lot of factors against him. I hope he's doing ok.

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Bottom Lines: The chiro shouldn't have touched the patient and should have known enough to NOT adjust him. The dissection was the cause of initial symptoms and the question is if chiro made it worse. It is extremely rare for a chiro to CAUSE a dissection.

Communication is the key, even when busy. ER doc and neuro communication grade, fair at best and eliminated the most important part, the interpretation of films.

Neuro should have checked on that prior to his action and NOT rely on someone else's word.

The real question is could catastrophe have been avoided and further injury avoided? Answer: unknown, but possibly if dissection had begun on presentation of the patient to the chiro which is likely it had.

A life nearly lost and quality of life likely forever. Lessons to be learned for chiro and docs involved for sure. Given the same circumstances, they would have made sure they took the time and made different choices. As far as how much money, the lives of the doctors involved are important too. Question is will they learn from the experience? It certainly is likely and they are needed.

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The chiropractor absolutely made it worse (or may have fully caused it), the guy walked in with a bit of neck pain and was rolled out with a massive posterior circulation stroke. There was room for improvement at the hospital (arguable if it would have changed the outcome), but the chiropractor is the root cause and should bear the vast majority of liability (both morally and legally).

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My opinion is that the ER doc should have bore even more responsibility.

1. The report of "age-indeterminate dissection vs congenital" should trigger the ER doc to realize that in a 32-year-old, is almost certainly acute. There were vision changes and cerebellar findings status post chiro manipulation. At the very least that warrants a stroke consult.

2. The ER doc would have exponentially increased his chances of making the right choice if he presented the history of a chiro neck manipulation to either the neurologist or the radiologist. Choosing to falsify documentation to me shows that he knew that he made multiple critical mistakes that night.

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I had the misfortune of being a co-defendant in a malpractice case this past Spring also in Georgia (fortunately we won). Georgia tort reform requires the jury to determine if the physician is to follow "standard of care" or in the event of a true medical emergency they follow "gross negligence." In general, gross negligence is explained as slight diligence in that degree of care which every man of common sense, however inattentive he may be, exercises under the same or similar circumstances. The absence of such care is termed gross negligence. This was a big sticking point in our case. To me there clearly was a medical emergency and the jury should have been looking at this from a gross negligence standpoint. Whether or not the ED doc mentioned the CTA or the chiropractic manipulation (which I believe he did, or at least he documented) this would likely not prove gross negligence. I expect this case to be appealed, especially given the waffling radiology read and the less than helpful neurologist.

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Agree, its a very important point about gross negligence here, which I didn't fully appreciate when I first published this. I'm going to add a bunch more information soon to clarify it. The plaintiffs attorney directly asked the ER doctor at trial "would it be gross negligence if xyz happened?", and he said yes, and then the plaintiff attorney basically showed that xyz did actually happen.

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Who pays for this at the end of the day? Most coverage limits are $1 mil / $3 mil at most. Where is $75 mil going to come from?

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Short answer I've gathered from some experts: they'll probably never get the $75 million. The businesses involved (EM employer) will probably just go into bankruptcy after coughing up a few million. Physician's assets are theoretically at risk via garnishing wages and taking his assets but its pretty uncommon for that to actually happen.

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Nov 18, 2022Liked by Med Mal Reviewer

This is correct. Typically plaintiffs will settle for coverage limits, because it's guaranteed. If it goes to appeal no money will be paid. Appeal would be very costly and verdict could ultimately be overturned. The big numbers are so the plaintiffs attorneys can advertise these huge verdicts on their website and billboards.

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