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It's Not “Who Did It?” but “What Caused It?”

Chuck Coil, 29, first saw Stephanie Vets, DC, in December 2005 for complaints of lower back pain. Over a six-year period between December 2005 and January 2011, Chuck was treated for back, neck and shoulder pain on a fairly routine basis more than 90 times.

On Jan. 24, 2011, Chuck returned to Dr. Vets after a six-week hiatus. His presenting complaint was discomfort on the left side of his neck and left upper trapezius muscle. He further thought he was coming down with the flu and/or an ear infection. He indicated he had some discomfort in his left ear and above his left sinus area.

Objectively, Dr. Vets noted Chuck had a restricted cervical range of motion with pain upon forward flexion and rotation. Taut and tender fibers in the cervical region and the upper thoracic region and cervical distraction created some discomfort in Chuck’s trapezius muscles. Dr. Vets performed an adjustment and instructed Chuck to follow up in two days.

Chuck returned to see Dr. Vets on Jan. 26, 2011. Though his congestion had improved only minimally, he had some improvement in his neck discomfort and movement. Chuck continued to suffer flu-like symptoms and left frontal sinus pain. He told Dr. Vets he had an appointment with his family physician that morning to have his ear pain evaluated.

Patient Doesn’t “Feel Right” Post-Adjustment

Dr. Vets noted that Chuck continued to have restricted motion of his cervical spine, which was aggravated by forward flexion and rotation. He also had taut tender fibers in his cervical region and upper thoracic region.

While Chuck was seated, Dr. Vets made contact with the restricted segment at C-5 on his left side. Holding this contact for an instant, Dr. Vets performed the adjustment without cavitation. Dr. Vets attributed the lack of cavitation to Chuck’s tight muscles. Her documentation noted that the next restricted segment at C-6 was on the left, and she adjusted it in the same manner without cavitation. These adjustments required very little extension and rotation because they were performed in the lower neck area.

Dr. Vets then had Chuck lie on the table, and she performed several adjustments in Chuck’s thoracic region and she used a vibratory treatment over Chuck’s mid- and low-back region. During this treatment, Chuck began feeling warm, and he mentioned that his left arm didn’t “feel right.” Dr. Vets initially thought that this may have been due to Chuck’s position, so she asked Chuck to turn onto his side, and she performed a lumbar adjustment with Chuck in the side position.

Chuck still didn’t feel right when he stood up, so he returned to the table in a prone position. Because his cervical muscles remained tight, Dr. Vets applied digital pressure in the area. She did not perform another adjustment. Chuck then sat up and complained of nausea and feeling faint. Dr. Vets noted that Chuck might be having a stress/anxiety reaction.

Dr. Vets took Chuck into another room for interferential current treatment, and she also applied a cold pack to his neck. Chuck again said his left arm did not feel right and couldn’t control it. His arm then knocked over a cup of water. Dr. Vets evaluated him and found no signs of neurologic involvement, but his blood pressure was 150/100. As Chuck tried to stand up, he lost his balance.

Dr. Vets attempted to catch him, but because of the size difference between the two, Chuck slid slowly to the floor. Dr. Vets’ office called for an ambulance, and Chuck was transported to a local hospital. Dr. Vets later said approximately 15 to 30 minutes commenced between when Chuck began to experience symptoms and the arrival of the ambulance.

ER Doctors Step In

The initial report by the hospital’s ER physician noted that a chiropractor had adjusted Chuck’s neck, which resulted in sudden tingling/numbness of his left chest and arm up into his face and down his left abdomen to the left leg. There was also slurred speech. Chuck’s current medications were listed as Zithromax, Tussiones and Deconamine SR, implying that Chuck had recently been treated for sinus congestion.

On physical exam, Chuck’s BP was 142/72. He was markedly dizzy with right pupil dilation and right eye nystagmus, as well as left hemiataxia and left-sided sensory deficit. He had a CT angio of his head and neck that showed “no gross abnormalities of the carotid arteries and intracranial arteries, as well as the basilar artery.”

There was asymmetry of the vertebral arteries, with the right being smaller than the left, but this was noted to be a common variation. Multiple MRI studies were performed on Jan. 26, 2011, with “no evidence of signal abnormality on the diffusion weighted images to suggest an acute or subacute infarct.”

An MRI of the brain was repeated on Jan. 28, 2011. Findings were suggestive of a left-sided brainstem infarction involving the medulla, more specifically, the left half of the medulla near the cervical cord junction.

The hospital transferred Chuck to a nursing home for rehabilitation on Jan. 31, 2011. The hospital discharge diagnosis was left brain infarct, likely secondary to vertebral artery dissection, hypertension, hyperlipidemia, gastro-esophageal reflux, tobacco dependency and obesity. The discharge medications were lisinopril, warfarin, Wellbutrin, Crestor, Protonix and multivitamins. Chuck stayed at the rehabilitation center until Feb. 21, 2011, when he was discharged to his parents’ home.

Patient Improves Steadily, But Complaints Remain

Chuck steadily improved following his discharge from rehabilitation. At that time, his major complaint was blurred vision and difficulty reading a computer screen. As of March 2011, he still used a cane. He was diagnosed with Wallenberg syndrome, characterized by sensory deficits affecting the trunk and extremities on the opposite side of the infarct, as well as sensory and motor deficits affecting the face and cranial nerves on the same side as the infarction. He was also described as having mild Horner syndrome.

When Chuck’s treating neurologist saw him for the last time on Aug. 6, 2012, the record stated that Chuck had suffered a brainstem stroke, with residual cross sensory findings involving the left side of his face and right lower extremity. He continued to have pain in his right arm, leg and body, as well as on the left side of his face.

Chuck had normal pinprick on the right side of his face and normal leg touch and pinprick on the left side of his body. The record reflected that Chuck had lost his ability to sneeze, which is not uncommon in brainstem stroke patients. He had no visual disturbances, double vision or eye discomfort with ocular versions. He also had been sleeping fine. Chuck still felt dizzy when he moved or turned quickly, had erectile dysfunction, and became easily fatigued and tired. The treating neurologist stated that Chuck needed to be careful not to injure himself, and he placed him on Provigil for fatigue and on Viagra for ED.

Patient Pursues Lawsuit

Chuck Coil retained an attorney, who in turn, wrote a letter to Dr. Vets on March 18, 2013. This letter informed Dr. Vets of the malpractice claim against her by Chuck Coil. It alleged the treatment she rendered on Jan. 26, 2011 fell below the standard of care and caused his client to suffer a stroke. The letter demanded a settlement in the amount of $687,556.45.

Dr. Vets tendered the claim to NCMIC to handle on her behalf. An NCMIC claims representative requested specific documentation from Chuck’s attorney, including medical reports, records and imaging studies. The claims rep also requested any other information Chuck’s attorney believed would substantiate his client’s alleged loss and claim of improper treatment from Dr. Vets. Since the statute of limitations was about to expire, Chuck Coil’s attorney filed a lawsuit instead of providing NCMIC with the requested documentation.

The lawsuit theorized that Chuck Coil suffered a vertebral artery dissection when Dr. Vets administered a second more forceful adjustment on Jan. 26, 2011. It alleged this adjustment exceeded the tissue thresholds and injured the vertebral artery. The lawsuit also included an allegation of lack of informed consent, even though the records indicated the risks and benefits of chiropractic care, as well as the risk of stroke during a cervical adjustment, were explained to the patient.

Plaintiff Experts Weigh in

Chuck Coil’s attorney retained a chiropractic expert who opined that the injury to the vertebral artery occurred following spinal manipulation of the cervical spine on Jan. 26, 2011. He further opined that, based on Chuck Coil’s comments, Dr. Vets’ second, more forceful adjustment, did not result in joint cavitation. This expert alleged that the amount of force exceeded the tissue threshold. This resulted in the injury and meant the treatment fell below a normal standard of care.

When this doctor was deposed, he admitted that:

  • His opinion was completely based on the temporal relationship between the adjustment and the onset of symptoms.
  • Chuck Coil had clinical signs of an impending stroke before arriving at Dr. Vets’ office.
  • Dr. Vets adjusted the patient’s cervical spine on Jan. 26, 2011, exactly as she had the prior 50-plus times.
  • The radiology studies did not demonstrate a VAD.
  • A stroke is a random event that occurs in the background.

Chuck Coil’s treating neurologist was also named an expert witness for the plaintiff. The neurologist followed the party line that the stroke was the result of the chiropractic manipulation because of the temporal relationship. He admitted, without equivocation, that there was no evidence of a dissection on any radiology study or report. In spite of this, the neurologist changed his opinion from a “possibility” of causal relationship to a “probability.” Therefore, though his opinion started out reasonably, his anti-chiropractic bias soon came through.

Defense Counters

The defense team assembled a neuroradiologist, a neurosurgeon and a chiropractor as experts.

The neuroradiologist reviewed the following serial imaging studies from Jan. 26, 2011: MRA neck, CTA head/neck, MR brain and MR C spine. According to this neuroradiologist, these documents showed Chuck Coil clearly suffered a brain stem infarction temporally related to being treated by a chiropractor. However, he reported that there was no evidence to support the contention that a chiropractic manipulation caused the brainstem infarction. For manipulation to be considered causative, a vascular injury must be apparent on the CTA and MRA. Yet, neither of these exams showed evidence of vascular injury. What’s more, none of the imaging studies showed evidence of any vascular injury or dissection. In short, it was this expert’s professional opinion that the imaging studies ruled out chiropractic manipulation as the cause of the brainstem infarct.

The neurosurgeon retained on behalf of Dr. Vets expressed the following expert opinions:

  • Cervical manipulation was not the cause of Chuck Coil’s stroke.
  • There was no evidence of any VAD to the patient. Therefore, it could not have been caused by Dr. Vets.
  • The stroke was inside the brain/skull, which Dr. Vets did not manipulate.
  • The stroke was caused by a blood vessel in the brain that did not bring sufficient blood to the brain.
  • Blood vessels outside the brain showed patent and normal blood flow. There was no evidence of trauma or tears to the blood vessels. Therefore, there was no evidence of injury from the chiropractic manipulation.

The chiropractic expert for the defense reviewed the records submitted to him, and he found no evidence that Dr. Vets’ chiropractic treatment fell below the chiropractic standard of care. This expert offered the following opinions to support this conclusion:

  • Chuck Coil had received more than 50 cervical adjustments (out of a total of 90 chiropractic treatments) by Dr. Vets prior to the cervical adjustment on Jan. 26, 2011. There was no evidence that any of these cervical adjustments used excessive force or improper technique.
  • When the patient began to show signs of dizziness on Jan. 26, 2011, Dr. Vets’ actions were clinically appropriate. Specifically, she did not attempt to adjust him again, she evaluated and monitored his condition appropriately, and she called for EMTs promptly.
  • The imaging studies revealed no findings of vertebral, carotid or basilar artery dissection.
  • Chuck Coil had many known risk factors for brain infarction, including tobacco dependence, obesity, hyperlipidemia and hypertension.

Defense Assesses Settlement Demand

Once discovery was completed, the plaintiff renewed his settlement demand of $687,556.45. Dr. Vets and her NCMIC-appointed attorney rejected this demand and told the plaintiff that no counteroffer would be forthcoming. As such, the case proceeded to trial.

From the time of the jury selection to the start of jury deliberations was a span of 4.5 days. During this time, the experts all testified consistently with the opinions they rendered during discovery.

Dr. Vets did an impressive job of testifying, but she confided in her NCMIC-appointed attorney that this was by far the scariest experience she had ever faced. Yet, she also felt it made her a more thorough doctor.

Chuck Coil didn’t overstate his residual damages when he testified, so he gained credibility with the jury. However, some of his credibility was lost when lay witnesses for the plaintiff cried on the stand and exclaimed in an over-the-top manner how much Chuck Coil had changed since suffering the stroke.

Once the jury received the case for deliberations, they only took 40 minutes before returning with a defense verdict in favor of Dr. Vets.

What Can We Learn?

By Jennifer B. Herlihy

Take nothing for granted and act immediately. Even when a patient has had previous chiropractic care, do not become complacent. In this case, Dr. Vets treated the patient more than 90 times. Yet, she still recognized the clinical signs and the need to get Chuck Coil to a hospital quickly. Because she did the right thing post-adjustment, the patient was able to be treated promptly. Consequently, Dr. Vets did not violate the standard of care.

Document the care rendered. When something unusual occurs in the office, it is always good to make a contemporaneous note of what occurred and what you did in response. If a patient later tries to claim additional symptoms or complaints were present at the time of the event, documentation that they were not reported at the time and/or did not occur will be helpful to defense counsel.

Understand temporal relationships. Fortunately, research has demonstrated that while there may be an association between chiropractic manipulations and CVAs, there is not necessarily a causative relationship between the two. This is an area where an attorney and experts with the right knowledge and credibility can redirect the case for the benefit of the defense.

Evaluate the patient. When taking a case history, it is important to identify the potential health issues and complications that could manifest in the patient. In this case, Chuck Coil was only 35 years old—certainly not the typical age for a brainstem infarction. However, the patient’s full and complete history brought to the forefront his many known risk factors, including tobacco dependency, obesity, hyperlipidemia and hypertension.

Trials are uncertain. In this case, both sides had experts willing to testify on behalf of both parties. It is important to have a company like NCMIC backing you with attorneys, claims representatives and reputable experts who understand the complicated clinical issues involved in a malpractice case. The legal costs of defending a case, including the cost to have top experts in many fields of expertise, are often overlooked by doctors. In this case, the $254,391 in legal defense costs spent by NCMIC was essential in obtaining a defense verdict.

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