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Falls, Medical Liability, and My Mom
My 90-year-old mom had another fall on Sunday afternoon. She has had A-fib and heart failure for more than a decade, and her cardiologist struggles to control that without causing her dizziness and low blood pressure. Which results in falls. After enjoying a warm spring afternoon on the patio, she lost her footing on the porch steps and fell backward onto the car and hit her head. Fortunately, she had her cordless phone with her, so she called me to come over and help her up. Her neck hurt badly, so I helped her gently into the car and took her to the ER. And there fear of lawsuits started driving medical decisions.
When we arrived at the excellent rural ER in Marion, Kansas, the nurses immediately immobilized her neck in the car and put her on a stretcher. I think they already suspected the problem. They called their radiology tech in from her Sunday afternoon, and she did a CT scan. As I later learned, the radiology tech immediately spotted a dangerous, potentially fatal, fracture in the C2 vertebra in her neck and pointed it out to the PA in charge of the ER. I could tell they were more concerned than usual about my mom, but I didn’t know why. Following procedure, the PA e-mailed the scan to some M.D. somewhere to interpret it. An hour later the interpretation came back, “All OK.” At that point the PA told me what was going on. She made a very polite call to the faraway M.D. and asked if he had seen the fracture. He was appalled at what he had missed and sheepishly corrected the interpretation.
Why couldn’t they trust the radiology tech’s immediate detection of the fracture? Why did they have to contract with some faraway M.D. to look at it? I’m sure he had an Official Certification in Interpreting CT Scans, while the local tech did not. If they trusted an uncertified local tech and she was wrong, they could be sued. But the tech was focusing on the one scan she did that day. She had personally wheeled my mom’s gurney into the CT room. She had an incentive to look carefully at the scan. I’m sure the M.D. had lots of training and had seen thousands and thousands of scans. But he didn’t know my mom. He probably had a stream of scans coming at him to be interpreted quickly for maximum profit. It was evening, so he was probably coming to the end of a long weekend shift. But his Official Certification would be a bullet-proof defense in a liability lawsuit.
But the protocol demanded another step that I think was only for liability defense. The ER called an ambulance, and they gingerly transported her 50 miles to the trauma unit at a regional hospital in Wichita. The trauma team did more scans and evaluations, all while my mom has endured 12 hours of IVs, blood draws, no food or water in case they needed to operate, beeping machines, and on and on. By today, Monday afternoon, she looks much worse than she did when she left the rural ER Sunday evening.
The trauma team decided it was too risky to operate due to her age and heart condition, a conclusion I wholeheartedly support. They decided to send her home (or to rehab, that hasn’t been decided yet) with a collar and strict prohibitions on what she could not do. But why couldn’t the local ER have made that decision, perhaps in consultation with her cardiologist? They should have told me to take her home Sunday evening with the collar in place. It would have avoided all the expense and the draining stay in the Wichita ICU. And we would have wound up in the same place.
Fortunately, Mom is a strong, plucky woman, so I think she will make it through this. But it’s been a lot for her to go through. And it’s cost the taxpayers and her supplemental insurer a lot of money. All to avoid exposing themselves to medical liability.
Published in General
In Wichita they did a bunch of cognitive tests to make sure she wasn’t senile. “What is today’s date?” “Where are you?” “What season is it?”
But they also asked “Who is president?” Since she didn’t know the political leanings of her trauma team, she had the presence of mind to say Biden instead of Let’s Go Brandon or that the election was stolen and Trump was the legitimate president.
I’m praying for your mom and your whole family, Steve.
Not meaning to detract from your post (and prayers for your mom), son #1 was concussed during a rugby game in college in 2010. He was out cold.
As I heard the story years later:
When the emergency personnel finally got him awake, they asked, “Who is president?” He replied “George Bush”.
EMT looked at his buddy and said, “Man, is he going to be pissed off when he comes to.”
Thanks for your prayers and those of everyone else.
If this gets promoted, I’ll send it to my brother who owned/operated a clinic in Idaho until recently retiring.
Steve, Just wondering, since the location came up, have you heard anything lately about the Marion Record newspaper?
That’s how they manage to keep that medical malpractice insurance.
Bless you, your mother, and your family. Having a broken vertebra is no fun at all.
Oh, how worrying. Prayers all round, and that your mom continues to improve.
LOL. I credit Bill Clinton with saving my mother-in-law’s life in a somewhat similar circumstance:
She’d had a very bad internal bleeding episode, and only her innate toughness got her through contacting Mr. She’s first wife who only lived about 1/2 mile away from her. By the time she’d been transported to the emergency room and we got there, she was on a gurney with her eyes rolled back in her head, she didn’t have her teeth in, was the color of cement, and looked like one of those carved dried-apple dolls. We thought it was the end. Then the questions started. “How many fingers” am I holding up?” “What day of the week is it?” “Do you know where you are?” If there was any response to each of them, it was a weak head movement, or a moan.
Then the guy hit the jackpot: “Do you know who the President of the United States is?”
Instantly, Grandma reared up to a sitting position, stuck a bony finger in his face, like one of Shakespeare’s Ghosts, and shouted, “THAT NO GOOD SON OF A [expletive, expletive, expletive]!!!! And we knew she was going to be alright.
I like your mom. You are lucky to have such a sound relationship with her. I envy that. She is probably very able to talk directly with you about her treatment and what she would like to have happen in future. It sounds awful. Maybe you can agree with her how much man handling she wants to put up with. You’re lucky you didn’t get Dr Rookie at the ER – now you know what intentional care by well trained and experienced clinicians looks like.
Marion is very unlikely to have the local medical expertise to evaluate her situation. A town that small will not have a neurologist, much less a neurosurgeon. It likely didn’t have a radiologist in town covering at that time- hence the teleradiology (even less likely a neuroradiologist).
You should be glad-you mother was transported to a facility with expertise in her care. In some countries that wouldn’t happen.
God Bless ‘er!
Wishing for her rapid recovery, Steve!
I’ll do a post on it since it would make a long comment.
That would be great. It seems to have disappeared from wider media.
In this case the limited local medical expertise (a radiology tech) got it right, and the expensive telemedicine doctor with his fancy certifications blew it. I’m not saying that a consulting radiologist available to review certain scans is never a good idea. I’m just saying it’s way overused as a defense against medical malpractice lawsuits.
Transporting her to Wichita has been very hard on her. They were probably never going to operate on her because of her age and heart issues, so they should have sent her straight home from the Marion ER. Nonetheless, she’s endured almost 48 hours of ICU for no reason. They don’t have a regular hospital bed available to move her to, so she is stuck in ICU. I’m afraid she’ll get stuck in the medical system and decline. Yes, she might have come home and the fracture slipped and she died on the spot, but that would be better than dying from medical treatment.
It’s a risk whatever you do – whether she goes home wearing a collar, gets surgery, or gets stuck declining in the hospital. But at 90, she doesn’t have a whole lot of years left. I would rather she spend whatever time she has left at home doing as much as is possible than becoming a victim of medical treatment.
I didn’t understand that pair of options to start with. It sounded like “You have a very serious life-threatening injury, requiring dangerous surgery and a long recovery… or (flowery music and cheerful voice) we can send you home with a collar and maybe some Tylenol.” The implied “Tra-Lah!” being silent.
Fractures can heal w/o surgery- in her case she will need to keep her neck properly immobilized for probably 6+ weeks. While she avoids the risks of surgery she has a risk of not keeping the fracture immobilized until it is adequately healed and thereby damaging her spinal cord- at the high cervical level that is an exceedingly unpleasant outcome.
Been through some of that with my dad in last month. Sending you prayers, warm thoughts, and a full recovery for your mom.
Then maybe that point isn’t made clearly enough. As Hermes Conrad would say, “Oh, you don’t want that.”
I totally agree. There are significant risks with either approach. In her case, I think the risks are greater if she gets surgery.
Didn’t read the comments yet but there is such a thing as a halo, a bolted-in metal circle screwed to the skull and attached to shoulder supports, which greatly stabilizes the neck and can be worn at home and which petty much takes weight and movement off the cervical vertebrae.
And are so much fun to wear! The joy of having screws screwed into your skull!
Seriously, the halo is the typical stabilization device in such cases. But there is still the risk of inadequate stability, so the risks still need to be weighed. I have known patients that had to have halos emplaced to protect their cervical spine for non-spinal operations, and they typically hated it. I became involved b/c they were seeking ways to have the surgery w/o a halo. Another challenge is that the halo isn’t perfect protection and if patients with it need to have a breathing tube placed it seriously increases the risks.
addendum- there is also the risk of non-union, meaning after many weeks the fracture doesn’t heal and remains unstable. A more likely possibility in an older, probably frail, women. Advanced age & female sex are associated with an increased incidence of non-union, as are comorbid medical conditions.
God bless you and your mother. Take it one day at a time.
It sounds like this is your specialty, so it’s been interesting to read your comments. Maybe I underestimated the complexity of the decision, but to me it seemed that, since there was an option to surgery, that was the one we had to take. And that there wasn’t really a lot of choice in the matter. Her cardiologist had nixed yet another heart valve repair and a knee replacement a couple years ago. I didn’t think she would survive surgery with her heart condition.
Well, clearly the seating on the shoulders is a point of flexion, so it’s not perfect, but for C2 fractures it’s more stable than a collar.
Radiology techs are not licensed to interpret X-rays. Actually they are not supposed to express their opinion to a patient or family. Any doctor worth his salt will take their opinion in consideration. But the ultimate responsibility and legal liability is the doctors.
The radiologist has 4 years of college, 4 years of medical school, at least 3 years of residency training, maybe a 2 year fellowship and has passed his Radiology board examination. the tech probably has 2 years of training in a community college ( my daughter is an X-ray tech and now teaches in our local community college).
The local ER does not have the facilities or expertise to definitively diagnose and treat a spinal fracture. A C2 spinal fracture if mismanaged can result in quadriplegia , and being permanently on a ventilator with a tracheotomy. Or death.
If in fact the local Er had sent your mom home, and she ended up paralyzed and on a vent, I doubt you would be happy.
As an ER doc with 30 years of experience before I retired, nothing I mean nothing is as aggravating as having family or another physician look at a case through the “Retrospectoscope”.
Thats when in retrospect, after hours or days of additional tests and information and evaluation of multiple specialists , the answer is so obvious . ” It was obviously indigestion and not an MI” ( after multiple cardiac enzymes, ekgs and a nuclear medicine scan) ” It was obviously a TIA ” ( After a detailed exam by a neurologist, CT, MRI, MRA, and EEG).
We don’t have the luxury in the ER of not using higher level resources when the potential error is life altering or death.
By the way, one type of C2 fracture is referred to as a ” Hangman’s Fracture”. Because thats what a legal hanging does.
The tech did a lot better with her 2 years of community college than the radiologist did with his 13 years of education and his certificate. If the local ER staff had listened to the radiologist, they would have said my mom was OK and sent her home.
Surely there were extenuating circumstances – this was the 500th CT scan the radiologist had seen that day, he was tired at the end of his shift, he only has a limited time to examine a scan so that his employer can make a profit on his services, etc. etc. But the tech nailed it and the radiologist blew it. My point is that the personal attention of a lowly radiology tech is sometimes better than years of education.
there is a serious chance the teleradiologist wasn’t on this continent….
People are human. The radiologist made a mistake. When the ER pointed it out he recognized his error. I have missed X-rays in my career. I have also picked up misses by radiologists. It’s great the tech spotted it. I would not want to bet on the tech against the radiologist on a regular basis.