A patient has a fatal coronary event immediately after leaving his chiropractor's office. Should the DC have recognized the signs before sending his patient home?
Posted in Case Studies on Tuesday, October 8, 2024
John DeAlba, a 41-year-old mechanic at a tractor manufacturing plant, sustained a low-back injury while working on the tractor assembly line. Charles Perkins, DC, was authorized by the tractor company to treat employees who suffered work-related injuries, so John DeAlba made an appointment with Dr. Perkins in hopes of alleviating some of his low-back complaints.
Upon his arrival at Dr. Perkins’ office, Mr. DeAlba filled out a form with questions about his past health problems, his current health condition, his hobbies, his family life, etc. Dr. Perkins immediately recognized that the two of them had quite a bit in common: They both enjoyed flying model airplanes, had four children of similar ages, and enjoyed riding snowmobiles and sailing.
Dr. Perkins and Mr. DeAlba developed a nice rapport immediately. After they got to know each other, Dr. Perkins examined Mr. DeAlba and identified subluxations in Mr. DeAlba’s lumbar spine. Dr. Perkins was able to effectively treat these subluxations with chiropractic modalities and after five weeks of treatment, Mr. DeAlba was free of low-back complaints, and he left the care of Dr. Perkins.
Patient Returns with New Concerns
Approximately one year later at approximately 2 a.m. on a Friday, Mr. DeAlba woke up and complained to his wife about back pain and shortness of breath, but ultimately went back to bed. When he felt the same at 7 a.m., Mr. DeAlba decided to see Dr. Perkins because of his previous positive experience. He was able to get in at 9:30 a.m. the same day.
Mr. DeAlba filled out an updated history form with complaints as follows: “Pain between shoulder blades and at breast bone, left arm at shoulder and also neck pain increases while lying down or bending forward. Breathing is difficult.” Dr. Perkins documented in his records that Mr. DeAlba informed him that he had awakened at 2-3 a.m. with these symptoms, and that thinking back, his symptoms had begun the previous day at work when he heard a “pop” in his upper back while working on a tractor motor.
Dr. Perkins found Mr. DeAlba’s breathing difficulties occurred only when he took a deep breath. When Dr. Perkins held Mr. DeAlba’s rib cage, the difficultly seemed to disappear.
Dr. Perkins then turned to Mr. DeAlba’s musculoskeletal complaints. His spine was painful from T3-T8, sharp in some areas and achy in others. There was radiating pain from Mr. DeAlba’s left medial elbow to his two little fingers. He had even strength in both hands, and Dr. Perkins noticed no difference in temperature between his two hands.
Upon palpation, Dr. Perkins found fixations at C5-7. When checking Mr. DeAlba’s cervical ROM, Dr. Perkins found muscle spasms in the patient’s left rhomboid major and minor, as well as left levator scapulae erector spinae and intercostals muscles from T3 to T8.
Treatment that morning consisted of muscle work on the rhomboids, levator scapulae and intercostals muscles using active resistive technique. This provided some relief to Mr. DeAlba, but he still had pain in the mid-upper back. Dr. Perkins adjusted the upper thoracic region with a thoracic lift while Mr. DeAlba was lying down, but Mr. DeAlba still was experiencing pain. Dr. Perkins adjusted Mr. DeAlba’s mid-thoracic spine in the standing position, and Mr. DeAlba felt better. Dr. Perkins then adjusted the patient’s cervical spine at C5-7, and Mr. DeAlba reported feeling better. He thanked Dr. Perkins and set an appointment for the following Monday.
Tragedy Strikes After Another Appointment
Later that same afternoon, Mr. DeAlba phoned Dr. Perkins’ office, stating that his symptoms had returned and asking if he could see Dr. Perkins before the weekend because the treatment earlier that day had provided some relief. At approximately 5 p.m. that day, Dr. Perkins adjusted Mr. DeAlba at T3-T8, and Mr. DeAlba noted that he obtained relief. Dr. Perkins documented in his records that Mr. DeAlba was not experiencing shortness of breath at this visit. Dr. Perkins reminded Mr. DeAlba to seek emergency room assistance if his back flared up again over the weekend. Mr. DeAlba thanked Dr. Perkins and departed.
The next day, a DeAlba family member called Dr. Perkins and reported that after Mr. DeAlba had driven a short distance from Dr. Perkins’ office immediately following the Friday afternoon appointment, he had died of a massive coronary event resulting in a minor accident between the front of his vehicle and the rear of another car. The driver of the vehicle called 911, at which point Mr. DeAlba was transported to the hospital and pronounced dead on arrival.
The DeAlba Family Sues for Negligence
Mrs. DeAlba filed a lawsuit against Dr. Perkins, alleging that Dr. Perkins’ negligence caused her husband's death.
Failure to Refer is an Issue
Two chiropractors were retained for Dr. Perkins’ defense to give their opinions. The first to review this case supported Dr. Perkins’ decision not to refer Mr. DeAlba on the first visit, since his symptoms improved with treatment, and the pain seemed to have been caused by a musculoskeletal strain based on the history provided by Mr. DeAlba. This expert also felt that Dr. Perkins’ failure to refer Mr. DeAlba to an MD later that afternoon at the time of the second visit was likely a breach of the standard of care.
The second chiropractor who reviewed this matter indicated that, in his opinion, any potential cardiac problem should have been ruled out by way of immediate referral to an MD. He indicated that he could not support our insured because of our insured’s failure to refer.
Record Dates Come Into Question
To further complicate the defense of this matter, Dr. Perkins dated his records for Mr. DeAlba’s Friday afternoon visit with the date for the following Saturday. Upon vigorous questioning by plaintiff’s counsel at Dr. Perkins’ deposition, Dr. Perkins admitted that he had written his records after learning of Mr. DeAlba’s death. This brought into question Dr. Perkins’ credibility and certainly caused his records to appear self -serving in anticipation of litigation.
Further Medical Attention Could Have Saved the Patient
Several cardiologists and cardiac surgeons were consulted on this case. They all felt Mr. DeAlba was suffering from unstable angina, chest pain unrelated to physical activity, both in the morning and in the afternoon of the date of his death. Someone with unstable angina is susceptible to immediate hemorrhage of the coronary arterial walls, which in turn forms a thrombus, which causes the blockage of an already stenosed coronary artery and propels the heart into ventricular fibrillation, which cuts off the heart’s perfusion and leads to death.
Every one of the cardiologists and cardiac surgeons who reviewed this case opined that had Mr. DeAlba received further medical attention on the day he visited Dr. Perkins, he almost certainly would have averted the dysrhythmia that killed him.
The Outcome
Plaintiff retained an economist to assist that side with valuing its case. Their economist estimated that from an economic-loss perspective, taking into consideration Mr. DeAlba’s lost earning capacity, pension benefits, health coverage, household services, and maintenance expenditures, the economic loss of the estate of John DeAlba was between $1,487,258 and $1,795,440, depending on whether Mr. DeAlba worked until age 61 or 65. The defense economist retained couldn’t challenge the opinions of the plaintiff’s economist.
Because the Friday afternoon records were not written contemporaneously, and most likely would be construed to be self-serving for Dr. Perkins, the possibility existed for an award of punitive damages if the jury believed that Dr. Perkins’ charting was fabricated to support his defense. Dr. Perkins’ limit of liability with NCMIC for this case was $1,000,000. Plaintiff’s initial settlement demand was well in excess of the doctor’s policy limit. After nearly one month of negotiations, and with the assistance of a structured settlement company, the plaintiff agreed to accept Dr. Perkins policy limits to resolve this matter.
What Can We Learn?
- Always write your records contemporaneously.
- Don’t let friendships that develop as a result of getting to know your patients mask your good judgment and cause you to cut corners. Always conduct thorough exams and histories no matter how well you know the patient.
- Any time you suspect a cardiac problem with a patient, an immediate referral to a MD is warranted.
- Being cautious and being an alarmist are not the same things. If you feel a patient should be sent to an emergency room, don’t hesitate for any reason.
The accompanying text is offered solely for general information and educational purposes. It is not offered as, nor does it constitute, legal advice or opinion. You should not act or rely upon this information without seeking the advice of an attorney.
All names used in Examiner case studies are fictional. Any use of real names is purely unintentional.