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Spinal Column |
Department of Radiology, University of Colorado Health Science Center, Denver, Colorado
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One question that might arise when reading this study is, if a physician fails to obtain a CT scan of the cervicothoracic junction in an intubated, obtunded polytrauma patient, who has an undetected fracture on plain film, will he be held liable for that patient's injury? Analyzing the authors' conclusion in terms of the fundamental concepts of medical malpractice law, the answer is "no."
Every successful medical malpractice action must satisfy certain basic criteria in order to find the defendant party negligent. These requirements are that a duty must have been established between the physician defendant and the patient plaintiff, and a breach of that duty must be the cause of the patient's injury. The concept of standard of care establishes and describes the particular duty that is owed to the patient. The legal implications of this study are best evaluated by examining the concepts of standard of care, causation, and injury.
In a traditional negligence action, when a duty has been established between a defendant and a plaintiff, the defendant must be found to have breached the duty of acting as a "reasonably prudent person" in the same circumstances. An extension of the reasonable man standard has developed in medical malpractice law. When a duty has been established between a physician and a patient, the physician must act in accordance with the knowledge, judgment, and skill possessed by other persons in the specialty under the same or similar circumstances in diagnosing and treating that patient. This is the standard of care. As the court in Mann v. Cracchiolo stated, "The courts require only that physicians and surgeons exercise in diagnosis and treatment that reasonable degree of skill, knowledge, and care ordinarily possessed and exercised by members of the medical profession under similar circumstances" (1). In using the word "only," the court is reinforcing that a perfect result is not required, only that a physician exercise reasonable care and skill.
In the legal arena, evidence of the required standard of care is established by experts in the field. The court in Williamson v. Prada wrote that standard of care is "a matter peculiarly within the knowledge of experts; it presents the basic issue in a malpractice action, and can only be proven by their testimony, unless the conduct required by the particular circumstances is within the common knowledge of the layman" (2). Experts are used because the facts of a medical malpractice case are beyond the common knowledge of most jurors and judges. In defining the standard of care, an expert will find persuasive, authoritative material to support her testimony, citing such evidence as government-mandated requirements (eg, in mammography), the dominant and accepted literature in the area involved in the suit, American College of Radiology guidelines, and the prevalence of a certain procedure or practice. After deliberating over the facts of the case and the expert testimony, the trier of fact–either judge or jury–concludes what the standard of care is, and then, if the defendant physician acted in accordance with the standard of care.
The current standard of care in imaging of the cervicothoracic junction in the setting of trauma is, arguably, to evaluate with plain film, and if negative, stop imaging unless there are other indications for CT such as a focal neurologic deficit, fall from a significant height, or high-speed motor vehicle accident (3,4). The current study does not support changing this standard of care. In fact, this study supports plain film as the standard in this patient population as only one "clinically significant" fracture went undetected on plain film, and even this fracture would have been diagnosed at the CT the patient was to undergo for better characterization of his known fractures at C5 and C6. Indeed, even the authors of this article state, "We cannot advocate the routine CT scanning of the cervicothoracic junction." This is not a strong case for changing the standard of care and being legally held to that standard.
Evaluating this study in terms of injury is also instructive. The law demands that a plaintiff be injured by the defendant. The plaintiff must suffer an actual loss which is definable and provable. Remote, contingent or speculative damages cannot be recovered (5). Indeed, "mere breach of professional duty owed causing only nominal damages, speculative harm, or threat of future harm...does not suffice to create a cause of action for negligence" (6).
Although the law can often be counterintuitive, compensable injury as defined by the law generally corresponds to what physicians would consider to be a clinically significant injury. By "clinically significant," physicians usually mean that the diagnosed injury can have a detrimental short- or long-term effect on the patient, and that this diagnosis will affect patient management if it is treatable. If a "clinically significant" injury negligently goes undiagnosed or untreated, a compensable injury may result for which a patient may be entitled to compensation.
Moreover, a physician cannot be held liable for an injury which remains undiagnosed, but for which there is no treatment. Although this may appear to not fulfill the element of damages, the actual legal reasoning is that the physician is not the proximate cause of the patient's injury. In Smith v. United States the court found that a physician was not liable for not diagnosing German measles in a woman in her first trimester, whose child was subsequently born with birth defects, because the physician's negligence was not the cause of the child's injury as there was no treatment for German measles (7).
In the current study, only one out of the nine fractures (in seven patients) which were undetected on plain film was "significant clinically," the other injuries consisting of rib and transverse process fractures. (This assumes the fracture does not extend to the transverse foramen.) These fractures are treated only symptomatically, and if left undiagnosed will result in no compensable injury to the patient. If left undiagnosed the injury caused by the physician would only be nominal and would not result in an actual loss as these "clinically insignificant" fractures are not treatable. Obviously, a physician could in no way be held to have caused the injury directly (unless he caused the traumatic event leading to the injury). Similarly, the other studies cited by the authors do not convincingly reveal that any "clinically significant" injuries would be detected if routine CT evaluation of the cervicothoracic junction was performed.
There are many clinical situations where performing a CT scan of the craniothoracic junction is the standard of care in the setting of trauma, and if not performed can result in legal liability. However, based on this article, routine CT imaging of the cervicothoracic junction in intubated, obtunded polytrauma patients who do not fulfill other clinical criteria has not proven that it should be the standard of care.
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