Legal Review & Commentary
Patient's halo slips off head, causing paralysis and incontinence: $1.195 million settlement in Michigan
By Radha V. Bachman, Esq.
Buchanan Ingersoll & Rooney PC
Tampa, Florida
News: A man injured his neck and back after diving into the bottom of a shallow lake. He was transported to the hospital, where physicians became concerned that the man's central spinal canal had been compromised. He was fitted with a halo to reduce the spine's interlocking facets, and the resident began applying manual pressure to increase the traction. The resident increased the pressure too much, though, causing the halo to rip off the man's skull and causing the his head to fall back. An MRI was conducted, and the man was taken to surgery to repair the fractures and separate the vertebrae. The man was able to return to work despite the permanent injuries he sustained. He sued the hospital, claiming that the attending physician, and not the resident physician, should have fitted the man for his halo. The hospital principally argued that the man's injury was the result of the original injury and not the slipped halo. A $1,195,000 settlement was reached with the hospital before a lawsuit was filed.
Background: A 47-year-old man felt pain between his shoulders and numbness in his upper arms and hands after diving into a shallow lake and lodging his head into the lake bottom. The man was lifted onto a back board and transported, via ambulance, to a local community hospital. Despite the fact that the man was able to move all of his extremities, the hospital's ED conducted a CT scan that showed a fracture of the C7 facets, full thickness anterior subluxation of C6 on C7, and bilateral interlocking facets. The results of the CT scan caused the ED personnel major concern that the man's central spinal canal had been compromised in the accident.
An orthopedic consult was performed by a third-year resident physician who noted tingling in the man's upper extremities and loss of grip strength in one hand. At no time did the resident or ED staff call an orthopedic surgeon or neurosurgeon in to consult on the man's injuries. The resident continued his examination and determined that a halo with tractions would be the most beneficial method for reducing the interlocking facets. Halo traction is a method of keeping a patient's head and neck still while the patient recovers following an accident or operation and is based on the attachment of the halo to a device worn around a patient's torso. The halo vest attaches through adjustable metal bars to a rigid vest that fits the patient's chest and provides continuous stability to the cervical spine while simultaneously allowing the patient to be mobile.
Traction was provided with weights that were steadily increased as the resident observed the vertebrae with a fluoroscope. When the weights reached 70 pounds, the resident began applying manual pressure to increase the traction. During this process, the man communicated to the resident that he felt the pins slipping. The resident failed to heed the man's warnings, and the halo ripped off the man's skull, causing the man's head to fall back and the man to suffer shooting pains through the his extremities. According to studies, pin loosening is by far the most common of potential complications of halo use. Those studies have shown that pin loosening occurs in about 60% of patients over a three-month course and can result in severe pain at the pin sites. However, this situation is easily remedied by ensuring tightness of the pins.
Following the slipping of the halo, the resident conducted a neurological exam that showed no changes despite the fact that the man told the resident that he was losing motor function in his extremities. An MRI was conducted and the man was taken to surgery to repair the fractures and separate the vertebrae. Despite extensive rehabilitation following surgery, the man remains paralyzed and is incontinent of bowel and bladder. The man ultimately regained most function in his arms and was able to return to his profession as an engineer.
Malpractice cases in which halos are improperly fitted are quite common. For instance, in late 2007, Wake Forest University Baptist Medical Center was found liable when it was shown that halo screws were inserted too far into a patient's skull. In that case, an 11-year-old boy had been struck on the shoulder by a falling tree limb ripping out all five brachial plexus nerves from his spine. A week after the accident, orthopedic surgeons concerned about long-term stability of the boy's spine installed a halo device on the boy's head. During the procedure, the physicians screwed one of the four pins on the halo too far 1.8 cm inside the skull or close to three-quarters of an inch. As the screw penetrated the skull, it caused extensive damage that led to bleeding inside the boy's head. The mistake was not discovered for six hours, during which a large epidural hematoma developed from the bleeding, causing a subfalcine herniation and midline shift of at least 9 mm. After discovering the hematoma, neurosurgeons performed emergency surgery, but the damage had been done. The boy was left with permanent brain injuries and neurocognitive deficits. After four weeks of trial, the jury returned a unanimous verdict in the amount of $10,437,093, which represented less than the past and projected future medical and other expenses.
In the case of the 47-year-old diver, the plaintiff claimed that manual pressure should not have been applied without the presence of the resident's attending physician and that the resident should have discontinued applying manual pressure when the plaintiff expressed his discomfort. Unlike the Wake Forest case in which the hospital had no strong defense, the hospital in the case at hand countered and claimed that the final injuries sustained by plaintiff were caused by the initial act of diving into the shallow lake and not the subsequent acts of the resident.
Damages for the plaintiff's future medical expenses were supported by a detailed life care plan. No specific claim for lost wages was made by the plaintiff since plaintiff was able to continue in his career as an engineer. The hospital and the plaintiff settled prior to suit in this case for $1,195,000.
What this means to you: "Until the time that this patient had the unfortunate luck of encountering a third-year resident who was not only overly confident, but also appeared totally unaware that he was way beyond his scope, the patient received appropriate treatment given his situation," says Lynn Rosenblatt, CRRN, LHRM, risk manager at HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, FL. The emergency squad accurately assessed the man for a potential spinal injury and transported him using appropriate precautions such as a back board. While it was not explicitly mentioned, a stiff collar is typically utilized to prevent the injured individual from rotating the neck and causing additional trauma.
Once at the hospital, the patient received a CT scan that was certainly appropriate, given the facts surrounding his injury and his symptoms. In fact, at this point, a neurosurgeon should have been contacted. If such a specialty was not readily available at the receiving hospital, the patient should have been transferred to a facility with a higher level of care.
There was no discussion in the narrative regarding the scope of services available at the local community hospital to which the patient was initially transported. Given the absence of specific language, one may deduce that the community hospital did not have big-city trauma capabilities. In most cases, patients with that type of injury are triaged at the local community emergency department and transported, frequently by helicopter, to a designated trauma center. The hospital did not pursue that course of action and, having not done that, may have been guilty of its first act of negligence in this case.
A trauma center is equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries. Trauma centers were established because the medical establishment has come to realize that traumatic injuries often require complex and multidisciplinary treatment, including surgery, in order to provide the patient with the best possible opportunity for survival and recovery.
To qualify as a trauma center, a hospital must meet certain criteria as established by the American College of Surgeons (ACS). Trauma centers vary in their specific capabilities and are identified by "Level" designation: Level I (Level 1) being the highest, to Level IV (Level 4) being the lowest. Higher-level trauma centers will have trauma surgeons available, including those trained as neurosurgeons and orthopedic surgeons. Such centers have highly sophisticated medical diagnostic equipment and the technicians and physicians trained to use such equipment. Lower-level trauma centers may be able only to provide initial care and stabilization of a traumatic injury and arrange for transfer of the patient to a higher level of trauma care. Studies have confirmed that trauma centers save lives and that patients treated at trauma centers are more likely to survive their injury and be alive one year following the event which caused the trauma injury.
A Level I trauma center provides the highest level of surgical care to trauma patients. It has a full range of specialists and equipment available 24 hours a day and admits a minimum required annual volume of severely injured patients. Key elements include 24-hour in-house coverage by general surgeons and prompt availability of care in varying specialties such as orthopedic surgery, neurosurgery, anesthesiology, and emergency medicine.
A Level II trauma center works in collaboration with a Level I center. It provides comprehensive trauma care and supplements the clinical expertise of a Level I institution. It provides 24-hour availability of all essential specialties, personnel, and equipment. Minimum volume requirements may depend on local conditions. These institutions are not required to have an ongoing program of research or a surgical residency program.
A Level III trauma center does not have the full availability of specialists, but does have resources for emergency resuscitation, surgery, and intensive care of most trauma patients. A Level III center has transfer agreements with Level I or Level II trauma centers that provide backup resources for the care of exceptionally severe injuries.
As a community hospital, it is likely that the ED was designated at a minimum a Level III or possibly the lower Level IV designation. This level of care provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. It also may provide limited surgery and critical care services as defined in the scope of services of trauma care, but such services are limited to availability of the specialty required given the nature of the injury. A trauma-trained nurse is immediately available, and physicians are available upon the patient's arrival to the ED. Transfer agreements exist with other trauma centers with higher levels when conditions warrant a transfer.
A fracture of the C7 facets, full thickness anterior subluxation of C6 on C7, and bilateral interlocking facets with the probably of central spinal canal compression is a neurologic emergency. In this case, a higher level of care was certainly warranted, and an existing transfer agreement would have mandated that the patient be transferred to a center with the immediate availability of a neurosurgeon. Even the average orthopedic surgeon may have been out of his or her element for that type of injury, given the severe consequences of improper intervention.
There was no description of the clinical specialty of the resident or his immediate supervisor. The narrative refers to an orthopedic consult, but the possibility also exists that the resident's specialty was emergency medicine not orthopedics. Had he called his supervising physician, one must believe that given the facts presented, the senior physician would have transferred the patient rather than risk serious complications due to limited availability of services at the community hospital.
The extent of the patient's cord injury was not fully established. Direct injury, such as cuts, can occur to the spinal cord, particularly if the bones or the disks have been damaged. Fragments of bone (from fractured vertebrae, for example) or fragments of metal (such as from a traffic accident) can cut or damage the spinal cord. Direct damage also can occur if the spinal cord is pulled, pressed sideways, or compressed. This may occur if the head, neck, or back are twisted abnormally during an accident or injury. Bleeding, fluid accumulation, and swelling can occur inside the spinal cord or outside the spinal cord (but within the spinal canal). The accumulation of blood or fluid can compress the spinal cord and damage it. None of those possibilities appeared to have been evaluated by the resident.
The next major error in judgment was the resident's decision to apply a halo device without consulting a neurosurgeon. A neurosurgeon would have had the greater expertise in determining the extent of injury and the proper course of treatment. A halo is an external fixation device for the spine. It provides traction in the manner described but requires specialized training and competency to safely initiate the application of the device as well as maintain it over a substantial wear period.
In most cases, the application of a halo device is done after a neurosurgeon has evaluated the patient and determined that there is no evidence of cord compression, and a surgical reduction and fixation is not necessary as an initial intervention. While a halo may be utilized after surgery, it is not common for that to occur. Rather, a hard plastic collar is utilized to maintain the surgically established alignment.
Halos are generally used when surgery is not necessary and the cord is not compromised or at risk of being damaged, but some sort of method is necessary to maintain anatomical alignment while the fracture heals. In this case, the patient had experienced a subluxation, and a compromise of the central cord was probable. The subluxation would need to be reduced into alignment without further compromise to the cord. Such a maneuver clearly would be a neurosurgical intervention.
The resident attempted a treatment for which he was either untrained or not fully competent. His failure to respond to the patient's warnings that he felt the pins slipping indicated a callous disregard for the patient's well-being and a serious lack of professional judgment. As a result, the man suffered an additional injury that has ensured a lifetime disability that may have been avoided had the patient been transferred to an appropriate level of care.
The resident's obvious bumbling in his attempt to stabilize the man's fracture may be indicative of the hospital's failure to properly credential and determine the practitioner's skill level at various tasks. The credentialing process not only verifies the practitioner's education, licensure, and certifications, but also assesses and verifies the competency of certain technical skills that would fall within the scope of the individual's specialty. In this case, the resident's specialty was unknown, and there is no indication as to where this procedure would fall within his training and scope of practice.
In a teaching environment, the liability is shared by the institution that is responsible for the resident staff and the hospital itself. The resident most likely was not fully competent in such a risky procedure and should not have attempted it without backup support. At the very least, his supervising physician should have been on site and overseeing the procedure, and a neurosurgeon should have been consulted prior to any attempt to apply the device.
Either the resident failed to follow the chain of command or the hospital failed to assert its policy in this regard. Either way, the hospital had liability and was smart to reach a settlement. The hospital had little evidence to substantiate its claim that the diving injury was responsible for the patient's sudden deterioration, and it would have been unusually difficult to find expert opinion that supported that contention.
Settling for slightly less than $2 million represents a serious loss but is hardly a fraction of what the cost may have been had the individual suffered full tetraplegia and could not return to gainful employment. The case provides a clear example of the amounts juries are willing to award in botched halo cases precisely because the consequences of negligence are extremely severe. The hospital must have fully considered the amount a jury may have awarded for what would have no doubt been portrayed as an act of premeditated negligence. Given the potential for lifelong injuries as a result of the improper fitting of halos, hospitals should be certain that halo fittings and maintenance are pursued only by physicians who have received proper training and experience with spinal cord injuries, and that a proper analysis is conducted as to whether the current hospital is the most appropriate setting for treating such injuries.
(Editor's note: This case had an anonymous plaintiff and defendant and was settled prior to trial. No case reference is available.)
News: A man injured his neck and back after diving into the bottom of a shallow lake. He was transported to the hospital, where physicians became concerned that the man's central spinal canal had been compromised.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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