By Barbara Bellione
The claimant is a 55-year-old divorced father of two adult children.
He is a heavy smoker and an alcoholic with a host of medical problems including hypertensive cardiovascular disease, sleep apnea, morbid obesity, and chronic obstructive pulmonary disease (COPD).
When the claimant was in his 20s, he was involved in a motorcycle accident, which crushed and shortened his right femur by approximately one inch. As a result, he was left with a gait discrepancy and subsequent low back pain.
He had also been unemployed and on disability for four years because he developed diaphragmatic paralysis on the right when he suffered smoke inhalation during a house fire.
One morning the claimant awoke with neck pain. As the pain continued throughout the day, he decided to obtain chiropractic treatment and made an appointment for the following day.
The claimant presented to the chiropractor as a new patient with a chief complaint of worsening neck pain that radiated bilaterally and was exacerbated by coughing and looking up. He denied that the pain was related to any trauma. The claimant’s blood pressure was 181/120 and his pulse was 81.
Since the claimant’s blood pressure was above his personal treatment protocol range, the chiropractor initially declined to provide a chiropractic adjustment and referred the claimant to his primary-care physician for a blood pressure evaluation.
The claimant, however, pressured the chiropractor for an adjustment and stated he had just forgotten to take his blood pressure medication that morning. The chiropractor succumbed to the claimant’s persistence and provided a cervical adjustment.
The following day the claimant was in significant pain with weakness of all four extremities and impaired fine-motor function that hindered his ability to walk. He went to the emergency room where an MRI showed a herniated disc at C3-C4 with cord compression. A neurosurgeon was consulted, and the claimant underwent a C3-C4 discectomy with bone graft fusion.
The claimant had a successful post-operative outcome that improved his arm and hand strength, as well as his gait. He did, however, have some residual dexterity problems with his hands and minor numbness in his forearms.
As a result, the claimant hired an attorney who sent the chiropractor a letter making a presuit claim, stating he wanted to give the chiropractor a chance to settle the claim prior to a lawsuit being filed.
The claimant alleged the chiropractor failed to properly examine, evaluate, x-ray, and document his situation. He also claimed the chiropractor was negligent in his spinal adjustment of the neck, which led to or exacerbated a disk herniation.
As it turns out, the only documentation the chiropractor provided in the patient’s record was the patient’s blood pressure and pulse.
There was no documentation of an initial history or physical examination, the type or level of cervical adjustment performed, the claimant’s response to treatment, or any plans for follow-up.
Although it could be argued that the herniated disc was already present at the time of the claimant’s visit and an office x-ray would not have revealed the disk herniation, the defense team felt this case would be virtually indefensible given the lack of documentation in the chiropractic record.
In turn, the chiropractor violated his own standard of practice in manipulating the neck of the hypertensive patient and the temporal relationship between the spinal manipulation and the diagnosis of the C3-C4 disk herniation the following day requiring immediate surgery.
The claimant initially demanded $300,000 to settle the claim. Settlement negotiations ensued and the claim was settled for $150,000.
Due to the early presuit settlement of this claim, significant savings in defense cost were realized.
Barbara Bellione is the director of risk management for the OUM Chiropractor Program (www.oumchiropractor.com), provider of professional liability insurance underwritten by either PACO Assurance or PICA.
DISCLAIMER: This column is provided for educational purposes only. The information presented is not legal advice.
This case provides a number of learning points:
• Perform and document a thorough history and physical examination prior to chiropractic treatment of new patients.
• Do not allow patients to dictate treatment. If a patient is not a candidate for chiropractic treatment, or if a patient needs to be seen by another specialist for treatment or further evaluation prior to developing a chiropractic plan of care, explain your rationale for the necessity of the referral and document your rationale in the patient’s record.
• If a patient needs an urgent referral, assist the patient in scheduling an appointment and contact the doctor to whom you are referring the patient to discuss the reason for the referral. Document your discussion or place a copy of the referral letter in the patient’s record.
• If the patient refuses to comply with your recommendations, obtain and document the patient’s informed refusal. Then explain to the patient that you cannot perform treatment against your better judgment.
• For patients who are candidates for chiropractic treatment, thoroughly document your care and treatment in the patient’s record.
**Documentation requirements can change relative to patients’ first visit to subsequent visits. Learn more at www.ChiroEco.com/visits.