A misdiagnosis ultimately ends in the amputation of a patient's fingers. Who's to blame—the DC that failed to refer, the MDs who failed to restore blood flow right away, or the surgeon who performed her operations?
Posted in Case Studies on Wednesday, November 5, 2025
Kandi Kotz, a 35-year-old manager of an upscale women’s boutique, was plagued by headaches, pain in her neck and upper trapezius, aches in her right arm, coldness in her right hand, and a sensation that made her feel as if she had hit her funny bone. She was also concerned about small black spots on the tips of her fingers. She turned to Nolan Mills, DC, for care and treatment.
Upon exam, Dr. Mills found that Kotz's muscle strength and right-hand grip were reduced. Eight views of the cervical spine revealed C5-6 moderate disc compression as well as an anterior spur formation at this same level. Dr. Mills’ provisional diagnosis was:
Cervical:
- Hypolordosis/kyphosis
- Disc degeneration
- Cervicobrachial syndrome
- Subluxation at C6, C7-T1, C2, C3-C4
- Hyperreflexia: bilateral triceps
Thoracic:
- Segmental dysfunction/ subluxation T1-2, T2-3.
Rule out neurovascular dysfunction, thoracic outlet syndrome, disc syndrome producing brachial plexus irritation.
Dr. Mills treated Kotz on 13 occasions over a five-week period, pursuing the neurological aspects of her complaints. Treatment consisted of cervical traction followed by manual correction of cervical spine subluxations. Soft-tissue technique was utilized in the upper thoracic spine along with ultrasound. Kotz noted that more ulcerations and black dots continued to appear on her hand over this time period.
Throughout his records, Dr. Mills repeated that the patient was suffering from weakness and numbness in her right arm and hand. Three weeks into treatment, Kotz’s complaints included diminished grip strength and a burning sensation in her forearm. At that time, Dr. Mills referred Kotz for a cervical and upper thoracic CT. That study revealed:
Limited exam at the C6-7 level and very limited examination within the upper thoracic spine due to prominent artifact from the patient’s shoulders. If there is a high clinical index of suspicion of abnormality at these levels, an MRI scan is recommended for further evaluation. MRI would also be valuable to exclude abnormality in the region of the brachial plexus.
Dr. Mills chose not to refer Kotz for an MRI.
Patient Discontinues Treatment; Asks for Referral
During a gynecological exam, Kotz’s obstetrician found that the vein under her right arm was pressing against her ribs. The MD also found decreased blood pressure in her right arm as compared to her left.
Kotz informed Dr. Mills of these findings, which he documented. He also documented that Kotz was now complaining of blanching and coolness of the last digit of her right hand. Shortly after this, Kotz chose to discontinue treatment with Dr. Mills and asked her obstetrician for a referral to a specialist.
A vascular specialist saw Kotz the following day, and found:
- Significant pallor and cold with three large ulcerated areas and cyanosis on Kotz's fingers
- A positive Adson’s Sign on elevation of the right arm
- Ischemia of the right hand
- Embolic areas of the ulnar and radial arteries as well as significant interruption of the vascular arch of the hand
- A right forearm arterial occlusion
Kotz underwent a brachial embolectomy. Postoperatively, she regained her radial pulse with improvement in all fingers, and was discharged after two days.
She was re-admitted the following week with increased pain in her right hand and no right radial pulse. The doctor’s initial impression was ischemia from thoracic outlet syndrome, compression of subclavian artery and post-stenotic dilatation. The only treatment during this admission was to infuse a low dose of urokinase at the level of the distal brachial artery in an effort to dissolve emboli.
The Diagnosis: Thoracic Outlet Syndrome
The following week, Kotz again returned to the hospital and was seen by Dr. Ellis, a thoracic and vascular surgeon.
Kotz reported that over the preceding week she had experienced increased pain in the shoulder, inner aspect of her upper arm, outer aspect of her arm and severe burning and pain in the thumb, index, ring and middle fingers. Upon exam, Dr. Ellis found necrotic gangrenous ulcerations on Kotz’s thumb, index and middle fingers. He noted:
- Severe thoracic outlet syndrome on the right
- Multiple emboli, old, to the right upper extremity
- Causalgia, right upper extremity
Dr. Ellis performed a transaxillary resection of the first rib that same day. Post-operatively, Kotz's pain disappeared and the first three fingers were extensively debrided in the areas of the necrotic ulcerations. She was discharged in good condition with planned revision of the first three fingertips of the right hand at the Hand Center.
When Kotz presented to the Hand Center, gangrenous changes remained in her thumb, index finger and long finger. Emergency surgery was performed, amputating her entire thumb, index finger at the middle knuckle and the long finger to the distal interphalangeal joint. The amputated stumps healed nicely, although hypersensitivity persisted.
Kotz Sues Dr. Mills for Malpractice
In the suit, Kotz alleged that Dr. Mills failed to recognize signs of a vascular problem—coldness, numbness, pain, discoloration, and ischemia of the right hand—and should have diagnosed thoracic outlet syndrome.
Defense expert Don Rex, DC, found Dr. Mills’ exam and assessment generally adequate but believed he erred by not referring the patient for vascular evaluation once conflicting blood-pressure readings and suspected vein involvement arose. Rex also noted that ultrasound was contraindicated because it could dislodge a clot.
Vascular surgeons Hall and Kim were also consulted. Dr. Hall thought the case difficult to defend but believed Dr. Mills’ actions didn’t cause enough delay to prevent corrective treatment. He faulted hospital doctors for not removing the cervical rib or exploring the subclavian and axillary arteries, which might have restored blood flow.
Dr. Kim emphasized that only Dr. Mills was sued, though others may have provided substandard care. He stated the symptoms should have prompted immediate concern for vascular issues and referral for an arteriogram within days. He added that delayed diagnosis increased the risk of clot migration and permanent tissue loss.
After Dr. Mills’ first deposition, defense counsel found him knowledgeable but paranoid and obstinate, making him appear uncertain under cross-examination and reluctant to go to trial.
Plaintiff Demands Dr. Mills’ $1 Million Policy Limits
Considering the poor witness Dr. Mills made at his deposition, the opinions of the experts retained for his defense and the permanent disfigurement to plaintiff’s dominant hand, the decision was made, with Dr. Mills’ consent, to settle this matter for $265,000.
What Can We Learn
Don't adhere to preconceived notions.
Many times, non-spinal conditions mimic what doctors of chiropractic would consider “spinal," so DCs may not consider other conditions as the underlying cause. We must refuse to adhere to preconceived ideas.
If non-spinal conditions are suspected, a DC must order additional diagnostic tests to rule out those possibilities. Appropriate and timely referral is essential since delaying referral may create or exacerbate complications.
Clinical evaluation relative to the amount of care and monitoring patient progress is an important consideration in every case. If care is administered and outcomes are not considered adequate, reevaluation and/or referral should occur.
Symptoms can indicate need for referral.
Litigated cases ultimately end up being viewed by others who know the outcome and diagnosis. Doctors need to consider the constellation of symptoms that will be viewed “after the fact” as important clinical red flags. In this case, the skin color, temperature changes, grip strength, burning sensation and blanching should have raised a clinical index of suspicion that there may be complicating factors involved.
Thus, the time interval in which a patient is treated can be a significant issue in a legal action alleging that “failure to diagnose” and “failure to refer” caused complications — and had proper referral been made, the consequences would have been mitigated.
In many cases, the plaintiff’s expert will allege that the delay in treatment was important, and therefore the interval of time the patient is under care is a consideration.
The defense was also compromised because the CT Scan ordered by Dr. Mills suggested additional testing, which would have helped diagnose the underlying condition.
The defensibility of a case may hinge on whether the doctor did an appropriate diagnostic test, or conversely performed a diagnostic test and ignored the recommendations.
The initial doctor is held responsible.
In this particular instance, Dr. Mills also failed to heed the clinical warnings from the obstetrician who “found a vein under her right arm pressing against her ribs,” which clinically should have been pursued by Dr. Mills. The level of responsibility and accountability rests upon the treating doctor. Many jurisdictions follow the law that the initial tortfeasor (Dr. Mills in this instance) is legally responsible for the negligence of any subsequent health-care provider(s).
While an injustice to the initial tortfeasor, the rationale is that subsequent treatment would not have been necessary but for the original negligent act. Therefore, even if Kotz’s subsequent treating physicians were negligent, Dr. Mills is still legally responsible for their negligence and any resulting damages.
Appropriately documented early referral by Dr. Mills in this case would have considerably limited the potential for any allegation against him. Thus, the timing of the referral, limiting the delay-in-care allegation, coupled with proper documentation of the referral, would have provided a basis for a sound defense in this case.
The most valuable lesson to be learned from this case is to always consider the possibilities that may exist when symptoms can mimic a host of conditions.