Doctors PI Program
From the Desk of:
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
Narrative Causality and Accident History
The narrative accident history is a critical component of the report triad: Clinically correlating 1) causality to 2) bodily injury to 3) persistent functional loss. If your reports accomplish correlating all three, then you have an outstanding narrative report that will be superior to most doctors nationwide, including both in chiropractic and medicine.
Causality refers to a very simple concept. Is the accident the competent producing cause of your patient’s injury or injuries? If the answer is yes, then the lawyer gets to go to the next step and clinically correlate those injuries to the accident. Our responsibility as doctors is not to focus our reports to do the job for the lawyer. We must accurately gather the accident information to help us understand the forces our patients were exposed to in determining bodily injury to conclude an accurate diagnosis.
Once we understand the causal relationship and have created the diagnosis, it further helps us form an accurate prognosis for our patients. In addition, we can also rule out malingering based upon causality, in many cases, if the complaints do not match the nature of the injury and the clinical findings. Once all of the information is gathered, we must be able to accurately report the historical facts. Although we do not pander to lawyers in any way, it is important to understand from the lawyer’s perspective the importance of accurately reporting the history.
There is a tool in law called “summary judgment for dismissal.” This is a claim that either side can make when a lawyer feels that the claim does not meet the standard of law required to have a valid case. If the courts (judge) agree with the written argument based upon the merits of the case, the entire case can be dismissed and end even before it begins.
A merit of a personal injury case is causality. Was the accident the competent producing cause of the injury? Your history is a crucial factor, along with the police report and the statements of all parties involved in the accident, in determining whether it was. Therefore, if your history does not accurately reflect the nature of the accident, the entire case can be dismissed, as often the police report is cryptic and the courts rely on the word of the doctor over the statements of the individuals involved.
A final decision by a judge that resolves a lawsuit in favor of one of the parties. A motion for summary judgment is made after discovery is completed but before the case goes to trial. The party making the motion marshals all the evidence in its favor, compares it to the other side's evidence, and argues that a reasonable jury looking at the same evidence could only decide the case one way--for the moving party. If the judge agrees, then a trial would be unnecessary and the judge enters judgment for the moving party.¹
When writing a narrative, the opening section should be the ACCIDENT HISTORY, which includes an accurate description of the accident. When writing the account of the accident, it should always start with, “The patient reported…” as you were not there to witness the details and you are reporting what was said to you. This also limits your liability if the account of the accident is fraudulent. Include whether the patient was the driver or a passenger, and if a passenger, what seat, front or rear, was he in. Note whether seat belts were worn and whether or not the air bag deployed. (As a note, the air bag sensors are in the front of the car, so if the patient says the air bag deployed in a rear impact injury, he is incorrect.) What direction was the patient looking at the time of impact? Where were their hands? Did they see the impending collision or was it unexpected?
Do not quote speed, such as, “I was hit at 50 mph.” The patient has no way of knowing the speed. Therefore, I generally ask the patient, “Were you hit at a slow, moderate or high speed?” This will give a general idea that is more accurate. Ask what type of car the patient was in and what type of car the bullet car was. This is critical (as explained in the Crash Dynamics module of the PI Bootcamp) in determining injury potential by understanding the energy (E=mv²) transference from the bullet car to the occupant of the target car.
Did the patient’s body move after impact? Did they slide up, down or sideways? Did their head hit the steering wheel, dashboard or windshield? Were there any physical marks left from the seatbelt, such as discoloration or black and blue marks. This includes both the shoulder area and the chest. As explained in the MRI, Bone Scan module of the PI Bootcamp, this is where you must consider a bone scan after x-rays to ensure there are no costal-sternal fractures, if clinically indicated. This is seen primarily in females where the breasts force the seatbelt into a vertical position over the sternum exposing the female patient to a higher incident of costal-sternal fracture then males.
Ensure you describe the location of the impact. In a rear impact collision, we know the first motion of the occupant is up (called the ramping effect, again as explained in the Crash Dynamics Module). Therefore, asking the patient to be specific in their recollection of the damage to the vehicle becomes acute to the lawyer.
With no apparent damage to the outer shell of the vehicle, it now becomes vital that you have a conversation with the lawyer about the injury potential to an accident victim with little or no damage to the vehicle. Again, not to be too obnoxious, this is where you get to educate the lawyer with what you have learned in the Crash Dynamics module. Although your job is not to look to create a case for the lawyer and you should never do that, here is where educating the lawyer on crash dynamics will give them the knowledge to better serve their clients from an ethical scenario and you become their source for information…In other words, their expert based upon your clinical excellence.
You must also include whether the police and paramedics were summoned to the scene and whether the patient was transported to the hospital via ambulance or if they went afterwards independently. If they went to the hospital via ambulance, were they immobilized with a neck brace, were they put on a backboard and/or what other types of services did the first responders perform? What was done in the hospital? X-rays, medication administration, advanced imaging? Did a specialist examine them? What were the recommendations by the emergency room staff upon discharge? Was the patient admitted to the hospital, and if so, what was done?
All of this should be included in the opening statement of the report to accurately report what happened to certify causality. Once this has been established, you can proceed to the balance of the report. If I have not critiqued your report, please e-mail it to me immediately in a Microsoft Word attachment.