David M. Lang discusses how mechanism of injury can impact a jury's view of a case (and subsequently, the verdict).
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
Wrong Imaging for Neck and Shoulder Pain
A 54-year-old Wyoming man was injured while driving a pickup truck for his employer in icy conditions. His vehicle left the road and rolled 3.5 times before coming to rest on its roof. The roof was crushed to the level of the dashboard.
The man complained of neck pain to emergency responders. His neck was braced in a cervical collar and he was placed on a backboard before being taken to a county hospital emergency department (ED), where he was examined by the defendant emergency physician. The patient later claimed that he complained of neck and shoulder pain, but the physician did not examine his neck and ordered neither x-rays nor CT scans of his neck. Rather, imaging of the skull, facial bones, and thoracic spine was ordered.
The patient was discharged and went to the home of a co-worker. Four days later, he felt a sudden jolt of pain throughout his body when he turned his neck in the bathroom. He then experienced extreme pain in his neck and left shoulder and weakness in his left arm. He was taken back to the ED, where imaging revealed a comminuted fracture of the C5 vertebra. Surgery was performed.
The plaintiff claimed negligence on the emergency physician’s part for failure to scan the cervical spine immediately after his accident. The plaintiff claimed that he had sustained permanent neurologic damage to his left arm.
The defendant denied any negligence and claimed that the plaintiff’s condition was the result of a progressive, untreated rotator cuff injury sustained in the accident.
According to a published report, a $7 million verdict was returned for the plaintiff. His wife was awarded $2 million for loss of consortium.
It is unclear why cervical spine imaging was not ordered here. Under the Canadian C-Spine Rule, a 3.5-times rollover qualifies as a “dangerous mechanism.” The physician may have attempted to clinically clear the patient using the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria. However, since imaging studies of the patient’s skull and face were ordered, we can conclude that his facial injuries may have been painful enough to distract him from reporting his neck pain in the ED. Even by NEXUS standards, though, the C-spine may not be clinically cleared if a patient has a “distracting injury.”
It is not clear if the medical record indicated whether the physician did or did not examine the patient’s C-spine, or whether the patient exhibited tenderness on exam. Midline cervical tenderness would have warranted imaging under any decision rule.
This is a substantial verdict, including $2 million for loss of consortium—a separate award recovered on behalf of the spouse of an injured plaintiff, generally based upon “loss of companionship, society, and comfort” that the noninjured spouse suffers as the result of the patient’s injury.
Most jurors would have little trouble concluding that examination and imaging were both warranted here. Even putting aside the patient’s claim that he reported pain in the ED, the mechanism of injury was substantial. In Advanced Trauma Life Support (ATLS), mechanism of injury itself is an important independent factor to guide decision-making. EMTs and paramedics commonly see the mechanism of injury; clinicians ordinarily do not.
In sum, fully weigh the mechanism of injury when making clinical decisions. Jurors will accord significant weight to how a patient was injured, and we as clinicians should also. —DML