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Neck injury leads to an $18 million verdict in LA
News: A young woman injured her head and neck in a severe car accident. Before transporting her to the hospital, emergency medical technicians (EMTs) secured her neck with a cervical safety collar. Upon arrival at an emergency department (ED), doctors took only an X-ray of the woman’s neck but did not perform a CT scan or MRI. As a result, the doctors neglected to find that the woman had three fractured vertebrae in her neck. After doctors removed the cervical collar, the woman moved her neck around, leading to the development of quadriplegia two days later. She filed suit against her doctors alleging negligence, and a jury awarded the woman more than $18 million in damages.
Background: In 1995, an 18-year-old nursing student was a passenger in a pickup truck. Another vehicle forced the truck off the road, causing it to roll over. The young woman suffered head and neck injuries.
EMTs arriving on the scene immediately began treating the woman for blunt trauma. Although unaware that the young woman had three fractured vertebrae in her neck, the EMTs followed suggested protocol by stabilizing the woman’s head and spine and applying a c-collar to immobilize her neck. The EMTs transported her to an ED, where doctors performed a CT scan of her abdomen and head. As for the woman’s neck, however, the doctors took only an X-ray. They failed to properly assess the patient’s bone and soft-tissue components, which some experts suggest can be achieved only by a performing an MRI. As a result, the doctors incorrectly determined that the woman’s neck was not severely injured and they removed the cervical safety collar.
Two days later, the young woman developed quadriplegia. She conceded that the fractures occurred in the truck accident but she argued that the paralysis occurred when she was flipping her head back and forth in the ED with no cervical spine protection.
The woman filed suit against the ED physician and the attending neurosurgeon. In her complaint, she alleged that the physicians violated the standard of care by not ordering an MRI or CT scan of her neck before removing the collar. If they had done so, they would have detected the three fractured vertebrae in her neck. By leaving her condition untreated, the fragments of the broken vertebrae eventually pierced her spinal cord, causing complete paralysis from the shoulders down. The plaintiff’s attorney noted that the woman was able to move her extremities on the way to the hospital, demonstrating that she was not paralyzed in the accident.
The jury returned a verdict of $18.2 million for the plaintiffs. In Louisiana, however, medical malpractice caps limit awards for noneconomic damages to $500,000 per patient per incident. The liability of each qualified health care provider is limited to $100,000 plus interest per patient per incident. Awards in excess of $100,000 per provider are paid out of the Patient’s Compensation Fund, which is subsidized by the state of Louisiana and surcharges paid by private practitioners to the Louisiana Insurance Rating Commission. These caps on damages reduced the plaintiff’s award to $10.5 million.
What this means to you: This case highlights a breakdown in procedure in caring for a woman injured in an automobile accident.
"At the outset, emergency personnel at the scene carried out the proper emergency trauma care and procedures," says Leilani Kicklighter, RN, ARM, MBA, CPHRM, director of risk management services at Miami Jewish Home and Hospital for the Aged and past president of American Society for Healthcare Risk Management.
Emergency care protocol calls for the careful handling of victims of motor vehicle accidents because of the potential risk of spine injury. An EMT should assume that unconscious victims have spine injuries and should carefully assess conscious victims for evidence of neck or spine injuries before attempting to move them.
Accident victims with numbness in their arms or legs are usually assumed to have spinal injuries. First, an EMT should place the victim’s head in a neutral in-line position, unless it were difficult to do so or the patient were to complain. Next, the EMT should place the victim’s head in alignment with the spine and maintain constant, manual in-line immobilization until the patient is properly secured to a backboard with the head immobilized. Then, the EMT should perform an initial assessment of the victim’s extremities and vital signs and apply a properly fitting cervical safety collar.
Despite the proper procedure implemented by the EMTs, the process broke down in the emergency department. However, the exact source of medical error is unclear. Kicklighter suggests conducting a series of inquiries to get to the heart of what should have been done to prevent this injury and to prevent recurrence. A root-cause analysis might be appropriate for this situation. It may be that the error resulted from not having an official reading of the X-ray by a radiologist. If a radiologist were available on site, it should be questioned why the film wasn’t read immediately. It is also important to examine the hospital’s process for comparing wet readings to the official readings, and to question whether there is a system in place to track and analyze discrepancies between the two readings. Furthermore, a risk manager should question to what specialty the patient was admitted. If she were admitted, the specialist should have known the standard of care and, in reviewing the record, he should have recognized it was not met and taken appropriate remedial steps. Similarly, it is important to know if a neurologist was called in to examine the patient and to discover who removed the c-collar.
Kicklighter also recommends evaluating whether there was a standing protocol for caring for a patient with potential neck or head trauma. If such a protocol were in place, then a risk manager should ascertain whether it was followed and whether it has been updated so as to meet all the standards of care in a situation such as this. Indeed, the basic question is, Kicklighter says, "If an MRI is the standard to identify significant swelling, a subluxation or a fracture is the standard for performing a MRI to verify a lack of subluxation, then why wasn’t it followed?
"All of the above questions should be addressed in your own institution, and steps should be taken to remedy any deviations from the standard process," Kicklighter recommends.
Specifically, all staff, nursing, and physicians should be educated so that the nurses can remind the physician when certain steps in the process are not met. In any event, this event should be referred to both the ED department chair and to the medical staff QA peer review committee to evaluate the care given.
When addressing this particular type of potential injury, the task force should include nurses and physicians from the emergency department, radiology, orthopedics, neurosurgery, and trauma.
"After all," says Kicklighter, "it appears as though this woman’s ultimate injury was preventable."
• Jefferson Parish (LA) District Court, Case No. N 557-708.