Lawyers PI Program
From the Desk of:
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
“Reporting Multiple Accidents”
Mrs. Jones was in a car accident 2 years ago, had multiple herniations in her neck and mid back, and was treated for 6 months until she reached MMI. She was still in discomfort, so she self-treated with over-the-counter analgesics until she was in another car accident last week. She is now coming to you for care of her neck and low back for another 6 months and her lawyer wants a report separating what injuries were from what accident. He also wants you to apportion the percentage of the injuries to the respective accidents.
I get phone calls weekly on how to write reports like this with multiple accidents and it can be a daunting exercise…or not! The truth is, it’s closer to the “not.” It’s so easy it is scary! The most important part of ferreting out what injuries arose from what accident is critically dependent upon the completeness of your history and ensuing objective findings. In this scenario, your clinical findings are secondary, as exacerbations can cause positive clinical findings and you have to draw a line between bodily injury and an exacerbation. In the medical-legal arena, lawyers can argue exacerbations and prevail based upon the exacerbation. Therefore, understanding what is and isn’t an exacerbation is very important.
Again, your job is not to make the case for the lawyer. In fact, we do not really care (at all) about the lawyer’s case, we are concerned with an accurate diagnosis, prognosis and treatment plan that is solely based upon bodily injury. We just happen to be expert in reporting that in an admissible format.
This is a critical point that needs to be made when communicating with lawyers. They, too, want the facts and not fiction to make a case look good because at the end of the day, those facts will surface and will be the prevailing factor in their verdict or settlement. If they realize you are pandering to them and rendering fiction (bullcrap), your relationship will be short-lived and you will be a one-and-done!
Your history should be thorough, covering all primary and elicited complaints that include pain scales and radiation. The key is eliciting a history, not just taking a history, as you will uncover many problems that are “gated off” by the primary complaint. Your evaluation template should prompt you to elicit complaints of every joint in the body. Patients will only be focused on the primary complaint. The evaluation form I sell online does just that and so should yours. The process is rather simple; 1 sheet of blank paper with a line drawn down the middle. In column #1 are the symptoms and objective findings from the first accident and column #2 is the same for the second accident. Whatever symptoms or findings are new in the second column are from the second accident. Whatever is the same is an exacerbation of the first accident and needs to be reported as such. If there are areas of degeneration on film in the same areas of bodily injury, it could be a result of the first accident and the weakened tissue, making it more susceptible to being injured again. This is explained clearly in the research paper associated with the research report on bi-monthly flier #15. If you need a copy of the report, go to the box.net folder where we keep all of the articles. If you don’t have this link, e-mail Alli for it.
It is also common to have a herniation superimposed on a disc bulge. If you do not understand that concept, you need to take the MRI Certification Course. This is a huge issue for the lawyer and you must understand it. The reasoning behind it is that the tissue is weakened in a bulge and can herniate with less trauma. Beyond the simple reason, you need to have an in-depth knowledge of the subject.
You also must understand the differences between bulged, herniated, protruded, extruded, sequestered and fragmented discs. These, too, can be found in the MRI Certification Course. When you are apportioning bodily injury to cases, it will help you understand causality and better guide you to an accurate conclusion.
Some lawyers will request that you apportion a percentage to each case. This is where it gets a bit tricky and can be subjective. You can simply take the total number of injuries and create a straight percentage based upon the number of injuries for each. This is where you need to qualify the injuries. As an example, if your patient was involved in two accidents and the first rendered a finding of a small central herniation and the second rendered a finding of a broad based extrusion, the apportionment would be 50/50 with an asterisk (*). Although each accident caused a herniation, the second accident’s herniation is much more severe, creating more bodily injury. All parties involved will now understand more about the role each accident played and be able to represent the injuries in an honest and equitable manner.
When reporting on multiple accidents, it is all dependent upon the objective findings, while your clinical findings, as we have discussed, play a very minor role. This also underscores the reason why you need to be responsibly aggressive in ordering tests when clinically necessary. Do not make the mistake of caring for a patient and “hoping” that the signs and symptoms will resolve.
Last week, I hosted a “roundtable” discussion with a neuroradiologist, neurosurgeon and 7 chiropractors. The MD specialists were both very direct with the chiropractors around the table about their level of clinical involvement and ordering of tests. They see, all too often, the chiropractic patient that was injured as a result of chiropractic care. The primary reasons were that either the chiropractor did not order films to evaluate the patient in a timely fashion or the films were interpreted by an incompetent radiologist and the chiropractor treated based upon that incorrect interpretation. They urged at the highest level that the chiropractor learn how to read MRI’s, as it would have protected the patients and licenses of those doctors who have hurt their patients.
As a note, the neuroradiologist and neurosurgeon are extremely pro-chiropractic and understand this is not an indictment against chiropractic, but against those who abdicate the decision of care to others outside of their specialty. In fact, the neurosurgeon stated that there is no difference between his decision to operate and the chiropractor’s decision to adjust his patient. It has to be based upon the result of the test(s) performed, in both clinical and imaging. This is going to be the subject of many consultations going forward; I just wanted to let you know that the implication is very germane to apportioning percentages in multiple accidents and everything else we do in practice.
The patient with multiple accidents also underscores the necessity to get a complete past medical history and gather all past test results. I usually do not apportion the values unless requested by the lawyer. I will always mention the past accident(s) in the past medical history section and note the date of last treatment for the previous accident. I will also comment on the injuries of the prior accident. In the imaging section, I will have a separate discussion paragraph explaining what is from the current accident and what is from the previous accident. The following is language I used in a narrative I wrote 2 years ago:
MRI Discussion: Ms. Smith has had many MRI’s reveal that she has 3 herniated discs, and we have the advantage of having an MRI 2 years prior to the accident giving us a baseline of pre-existing injuries. Her herniated discs at C4-5 and L4-5 are directly from the accident while the central herniation of L5-S1 was pre-existing. However, it was originally only midline and was exacerbated by the accident to now protrude left. This is very significant, as a left herniation is now abutting and displacing the S1 nerve root posteriorly which explains the severe pain in the left leg and necessitates her multiple epidural injections to function without pain.
You can go into as much depth in explanation as you feel is warranted based upon the results. In addition, do not be intimidated by the MRI language and description; it is much easier than you think. If you need help with it, just let me know…but you need training to understand the basics.
Again, this is a topic for a future consultation. I will explain, in detail, how to become very proficient in reading MRI’s. I currently disagree (respectfully) with 40% of the MRI reads from general radiologists and the neuroradiologist and neurosurgeon disagree with 70% of the reads they get from general radiologists. Once again this underscores the necessity to interpret your own films!!!
Handling multiple accidents is just keeping score and creating a visual to extrapolate the injuries. Once you have created the scorecard, the rest is easy.