Lawyers PI Program
From the Desk of:
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
“A Critical Lesson in Clinical Protocols”
If You DO NOT KNOW...
You Do Not Touch
The following is what happened to me and a former patient and dear friend of mine last week. There is both a good and bad ending to the story, one that I sincerely hope none of you will experience and one that I hope this doctor learned from.
I received a call 8 days ago from my former patient and good friend that she was in exquisite agony from her low back radiating down her leg. 15 years ago, she was pulling out shrubs, herniated a disc and spent 2 weeks in pain, but the problem was non-surgical and she has been doing fine since then. Last month, she was shoveling snow and felt something weird in her lower back, but thought nothing of it until 8 days ago. Since I no longer actively practice and have no managed care inclusions, I instructed her to go to a DC I have a relationship with and get evaluated so that an MRI could be approved.
Knowing her history and spine, I spoke with the doctor and shared her history with him. I shared with him that if the MRI proved negative, the patient would continue under his care, but if there was a problem outside of the scope of chiropractic, I would get the patient an immediate appointment with a neurosurgeon. I asked that nothing be done without the MRI. Half listening to me, he said he would see the patient immediately and do what needed to be done, and I appreciated the effort in such a short time. I, once again, emphatically told him she needed an MRI, which I would arrange with the neuroradiologist in a facility that utilizes the correct protocols.
I spent the next hour asking for favors to get this patient an immediate scan and knowing her problem, I made an appointment for her with the neurosurgeon. I had all bases covered, primarily the neurosurgeon, as it is not an easy appointment to get at the last minute. I also knew I could cancel the neurosurgeon’s appointment should the MRI prove me wrong. However, simply based on her current symptomatically and knowing her spinal history, I knew at the end of the day she would be in the surgeon’s office. I had every base covered and I asked the treating chiropractor to please call me after the patient saw him. The call never came.
I waited another hour and called my former patient who told me that the chiropractor said that she had a minor problem and that he adjusted her after spending an hour with her in the office. I inquired as to what x-rays he took and what procedures he did. She said that he took no x-rays, but did spend a lot of time with her and she felt a little better. He also told her that he wanted to wait to order an MRI, as he thought it was a knee problem because she also had knee pain. The chiropractor recommended she see an orthopedist for her knee problem and wouldn’t get clearance for her MRI until then.
Fuming, because I knew better, I called the chiropractor and asked him what was going on. He said that there were no positive clinical findings (reflexes, motor, sensory or orthopedic) and that it was a simple S-I problem coupled with a knee problem and that no MRI was warranted. I asked him how he could rationalize the radiating pain and he said it was not related to her spine, that she had a knee problem. Having not evaluated the patient myself, I made my first mistake; I didn’t insist that my patient go elsewhere because I knew better. I thought for a fleeting second that he might be right.
The patient called me later that night crying that she had excruciating pain in her right knee. I told her that I would get her an appointment with an orthopedist for her knee, but to go back to the chiropractor and get the prescription for an MRI, which was the original plan. I didn’t hear from the patient for 24 hours until she called again in agony. This time, I couldn’t sit idly by. I tried to make an appointment for the next day for the MRI, but they were totally booked and we had to wait until the following day at 7 AM (with a favor) and I made an appointment with the knee orthopedist for her at 10:30 AM (again another favor).
By noon, the orthopedist called me and said there was nothing wrong with her knee and his clinical neurological evaluation revealed abnormal findings on the right side, primarily that she had an absent right patellar reflex and it was purely radicular.
The MRI came back with an extruded fragmented disc at L4-5 on the right. I made an immediate appointment at the neurosurgeon’s office for the following day, as he was in surgery that day. My next call was to the chiropractor who fought me every step of the way.
I said to the chiropractor, "Let’s talk in hypothetical for minute," because I have a very good relationship with him and wanted him to learn from the experience. The doctor hadn’t yet gotten the results from the MRI, as he wasn’t involved in the process. His practice protocol is to write the prescription and let the patient make the arrangements, including getting managed care approvals for the MRI. Not my way, and not a great way to run a practice, but it’s not my practice.
I said to the chiropractor, "What if your patient had an extruded herniated disc that fragmented and you treated her not knowing what was going on?" He said that he had no evidence of that and that his examination was negative and proceeded to get very angry at me, as there were “too many chefs,” and if I wanted to manage the case, why did I send the patient to him in the first place? He stated that when he got the MRI report, he would make a decision as to what to do with the patient.
I explained to him that, in fact, there was a fragment shown on the MRI and that she needed an immediate neurosurgery appointment. His retort was that all I wanted to do was to refer patients to the neurosurgeon so why didn't I just do that? He also felt that I was taking the side of the patient and he felt he needed to be defensive in case the patient sued. WOW!!!!
My answer to him was one of diplomacy, as I was fuming. My patient suffered for 5 days in exquisite pain delaying necessary care because of his incompetence and he was angry at me. My answer to him was, “I am not on the side of you or the patient. I am only looking to do what is right and no one is talking lawsuits.” I went on to add, “You had better get a copy of the MRI report and add to your notes that the patient needs to be seen by a neurosurgeon,” as that should be your protocol. I finished the conversation by telling him that after he hung up the phone, called me an asshole 50 times and calmed down, he should take a good look at his practice protocols and make some changes in how he conducts his practice.
My first question is, if he was going to order a spinal MRI on day 2, why didn’t he order it on day 1 instead of treating with blinders on? His next biggest mistake was that he didn’t call the patient to apologize for delaying the MRI. The patient hasn’t heard from him since. Her story is as follows.
I went with her to the neurosurgeon’s office the following day, as she is a very good friend. She had an appointment for 11 AM. By noon, she was in the hospital being prepped for immediate surgery, as she had a disc fragment that was floating in her spinal canal. IF...I had not sent her to the specific MRI center that has neuroradiologists and thin slice protocols, the fragment would have been missed, as it was very stealthy, hiding behind a pedicle. In fact, it was only seen on the sagittal, confirmed by the axial, which is upside down for the norm. The MRI center takes 2 mm slices in the lumbar spine which is ½ of the American College of Radiology’s recommended guidelines and the neuroradiologist was Dr. Peyster who teaches our MRI Spine Interpretation Course. The neurosurgeon was Dr. Shady who did an arthroscopic discectomy and partial lamenectomy and within 2 hours of the surgery, the patient was out of her radicular pain and home soon thereafter with no stitches, just “skin glue.” It was where the patient belonged in the first place.
One of the lessons I learned a long time ago follows the adage, “It takes a village to raise a child.” It also takes a whole village to properly care for patients because no one person has the answer for every ailment known to mankind. This doctor could have saved his patient 5 days of intolerable pain and potential future licensure and legal issues by simply getting an MRI and treating the patient with an examination only. Yes, I did say treat the patient with an examination. That is a treatment as well as an adjustment. The rule of thumb is, if you don’t know, you don’t touch. This doctor thought he knew, but really had a very poor rationale for the radiating pain. It could have been her knee or it could have been related to her spine. In spite of his inaccurate clinical test results, there was still a diagnostic dilemma. The fact that he adjusted her without even an x-ray to rule out osseous pathology is inexcusable and actionable. The fact that he never called the patient is the #1 reason why doctors get sued and eventually lose their licenses. Patients often take action, as a rule, more so from anger than the outcome.
Being the best-of-the-best means knowing when to adjust aggressively and every technique course you take will teach you how to do that. My role is to ensure you have an accurate diagnosis and prognosis so you can deliver your treatment plan aggressively. This case is the classic example of why.