Legal Review & Commentary

Teen’s undetected spinal fracture leads to paralysis

News: A 16-year-old high school football star was in the back seat of a car when the driver lost control and ran off the road. He underwent emergency surgery at a hospital for a ruptured stomach. However, the treating physicians and staff failed to diagnose and treat his fractured spine. The delay in treatment and failure to immobilize the patient resulted in the teen-ager being permanently paralyzed. The teen brought suit against the hospital and four treating physicians. Two of the practitioners settled prior to trial for undisclosed amounts. The jury found damages to be $4 million; $400,000 of which was apportioned to the remaining health provider defendants.

Background: The 16-year-old high school football player spent that winter Saturday afternoon hanging out with friends. That evening, several went to a teen dance club. Around midnight, he and his friends left the club. A girlfriend of his was driving, and he was a rear-seat passenger in the car. The car was traveling about 70 miles per hour when the driver lost control of the vehicle and drove off the road. It was a serious crash and a very shaken football player climbed out of the Pontiac sedan. Fearing that the car might be on fire, the young man crawled eight feet from the car. The paramedics found him in the grass at about 12:31 a.m.

He was taken to the nearest community hospital and arrived at 1:15 a.m. The emergency department (ED) staff, attending physician, and radiologist evaluated the patient. While seriously injured, the teen was alert, oriented, and even making jokes. At this time, he had movement in his legs.

The examination revealed that he suffered from a serious abdominal injury. A surgeon, roused from his bed, arrived at the hospital, and surgery was initiated around 3:25 a.m. The procedure concluded at 4:55 a.m., and his ruptured stomach was successfully repaired. After recovery, he was taken to the intensive care unit (ICU).

Several hours later, his second and more serious injury was noted. The teen had sustained an L2 dislocation fracture, described in testimony as "nearly tearing his spine in half." The decision was made to transfer him to a teaching hospital because of the severity of the injury.

When he arrived at the tertiary care facility, the teen could still feel his toes although he could no longer move his extremities. That soon changed, and he has since suffered from permanent paralysis from his waist down. He has returned to school but is in a wheelchair and always will be.

The plaintiff brought suit against the ED physician, radiologist, surgeon, and community hospital. While there were subtleties to each claim, the essence of his complaint was that all the health care providers failed to detect the L2 fracture, and did not protect and immobilize it from causing further injury. The plaintiff cited numerous communication breakdowns between the ED and the radiology department, noting that while the radiologist saw an abnormality in the spine, she did not report it to the other caregivers. The plaintiff maintained that the failure to immobilize his spine caused him to suffer motion injury to it, all of which lead to the permanent paralysis. His best evidence of the timing of the injury was that at the accident scene, and even after arriving at the hospital, he had motion in his legs.

Nine days into trial, the surgeon and ED physician settled for undisclosed amounts. The heart of the remaining defendants’ defense went to one simple event — the high-speed crash, which subjected the teen’s spine to incredible forces. The radiologist and hospital countered that regardless of their care, it was the wreck that caused the injury. A common theme to all defendants, which was incorporated in the instruction to the jury, was the role of the initial accident. The court’s first instruction asked if "the wreck was a substantial factor in causing the injury." In this way, the accident could also share the blame for the teen’s paralysis.

The jury found a deviation from the standard of care by all four defendants, including the two settling defendants. The wreck was also found to be a causal factor. As to comparative fault, 81% was assessed to the wreck, 4% to the ED physician, and 5% to the surgeon. To the still-standing defendants, 3% was assessed to the hospital and 7% assessed to the radiologist. Damages were valued at $1.7 million for a life care plan and medical expenses, $1.5 million for pain and suffering, and $800,000 for the impairment. The radiologist was assessed $280,000, and the hospital $120,000.

What this means to you: The ED offers lots of potential for negligence claims. In serious trauma cases, the ED staff frequently knows nothing about the patient, except what the emergency transport provides. Trauma patients often arrive unconscious, incoherent, and near death. Frequently the patient presents with multiple injuries requiring complex care rendered by a variety of personnel who must interact in what is often a time restrained response.

Modern communications and emergency response teams have allowed for the ED to have some advance notice of what’s on the way. But until the patient arrives, the preparations are theoretical.

"A detailed assessment upon arrival to the hospital is essential to the establishment of all possible injuries and the implication of those injuries — regardless of the level of the sophistication. Without an accurate evaluation of the trauma to its fullest extent, the patient may be subjected to additional injury that may in fact be more serious than what has already been sustained," says Lynn Rosenblatt, CRRN, LHRM, risk manager, HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, FL.

In this case, the teen was awake on arrival at the ED and able to provide some details of the accident and its aftermath.

"Given the nature of the crash, one of the most common responses is to immobilize the back and neck until any spinal injury has been conclusively ruled out. The narrative does not indicate how the emergency medical squad handled the patient, but back immobilization in serious motor vehicle accident is standard protocol. The transport team was not included as a defendant, so it appears that the lack of stabilization began at the sometime after the patient arrived at the ER," notes Rosenblatt.

The physical assessment indicated that the teen had movement and sensation in his legs upon his arrival at the ED. This may indeed have spoken to the possibility that the paralysis could have been prevented with proper attention to back immobilization. The narrative indicates that the radiologist had reason to believe that there may have been injury to the spine, but did not notify the rest of the response team of that fact, which leads to some question as to the communication lines between the teen’s caregivers," says Rosenblatt.

Since they were not notified of this significant diagnostic finding, the other staff was unaware that the potential for permanent injury to the cord existed.

"Any notification of an abnormality to the spine’ — particularly given the circumstance of the accident — would have triggered very aggressive care protocols including surgical stabilization and administration of steroids in order to minimize injury to the cord," notes Rosenblatt. "Given these facts, it would be impossible to attribute the full extent of spinal cord damage to the to the motor vehicle accident. The manner in which the patient was handled over the course of his surgery and immediate post-surgical recovery now becomes a mitigating factor."

In some jurisdictions, an adverse occurrence that may have caused serious irreparable harm to a patient that could have been avoided, such as the radiologist advising the ED staff of the spinal abnormality, is reportable to the state. There also is a requirement that such incidents are reported to the Joint Commission on Accreditation of Healthcare Organizations as sentinel events. Sentinel events under the Joint Commission standards require root-cause analysis, which is used to scrutinize the mishap to the minutest detail.

A root-cause analysis would be a means to determine what procedures could have been established that would have counteracted the failure of the radiologist to communicate her findings.

"In this case, the triage assessment apparently included the need for radiological studies, but the outcome of that was not reported. The development of assessment tools, which integrate potential injury with identification of signs and symptoms and with diagnostics, can be highly beneficial to an interdisciplinary care of the patient. Policies and procedures that outline time lines and reporting responsibilities between disciplines promote effective communication in an often-chaotic situation," says Rosenblatt.

Keeping in mind that the defendant has no true means to accurately determine what a jury will award, many are willing to negotiate. The root-cause analysis is helpful in determining how defensible the situation is and if mediation would be more prudent. In this case the breech of the radiologist appeared to be the initial weak link. Given the fact that the trauma sustained in the auto accident was an acknowledged causation, the overall award and the contributions of the defendants could have possibly been mediated to a lesser amount. This approach also saves the enormous expense of court preparation and trial, adds Rosenblatt.

Also, peer review of the physicians involved would be appropriate. The radiologist’s breech may have been sufficient to warrant disciplinary action and a report to the Board of Medicine. Another aspect is that the settlement of the surgeon and the ED physician may not have been sufficient to cover the jury awards attributed to them. In some jurisdictions under the theory of joint and several liability the remaining two defendants can be held responsible for covering the difference between the settlement amount of the first two defendants and the actual jury award for the entire case.

"This is the type of occurrence that no one would anticipate as it was based on human error, but the consequences were so severe that any failure to protect against a similar happening in the future is a worst type of negligence," concludes Rosenblatt.

Reference

Robert Blevins v. Muhlenberg County Hospital, et al., Muhlenberg County (KY) Circuit Court, Case No. 99 CI 0492.