This month we look at the issue of informed consent, something that normally brings to mind surgical consent forms. In this case we learn that it means a lot more than that.

The patient in the case, Mrs D, was involved in a single-car rollover crash. Paramedics extracted her from the vehicle, placed her on a backboard and in a cervical collar, and transported her to the hospital. She reported pain in her neck, back, left shoulder, and tingling in her left arm. The patient had preexisting high blood pressure, pneumonia, kidney stones, and diabetes.

Dr H, the attending physician in the ED, conducted a physical exam and ordered laboratory tests, an electrocardiogram, and computerized tomography (CT) scans of Mrs D’s head, cervical spine, abdomen, and pelvis. The radiologist who interpreted the CT scans noted fractures of the patient’s cervical spine at the C3 level.

At the recommendation of the radiologist, Dr H contacted a neurosurgeon who regularly consulted with other physicians at the hospital via phone. After reviewing the scans, the neurosurgeon told Dr H that the fractures appeared stable and did not require surgery. Neither the radiologist nor the neurosurgeon identified a fracture through the transverse foramen, which would increase the risk of injury to the vertebral artery. The neurosurgeon recommended that Mrs D be placed in a cervical collar for 8 weeks, with a follow-up CT scan to check for healing and alignment.

Dr H initially informed Mrs D and her family that she had sustained a neck fracture and would likely be transferred to the trauma unit. However, after the consultation with the neurosurgeon, Dr H advised the patient that she did not need hospitalization or surgery, and could be discharged with a hard cervical collar, with follow-up on an outpatient basis. The physician asked the family whether they were comfortable taking Mrs D home, and they said yes. Dr H prescribed pain medication, nausea medication, and a muscle relaxant, and sent Mrs D home without further treatment or testing.

The next day Mrs D went to her primary care physician for a follow-up. While at the office, her vital signs were unstable and she complained of severe neck pain made worse by coughing. The physician called an ambulance, and while they waited for it to arrive, Mrs D suffered a stroke. The stroke was later determined to have been caused by a vertebral artery dissection sustained when her neck fractured during the accident. She was hospitalized for 3 weeks and then transferred to an assisted living facility where she currently resides.

The Trial

Mrs D retained an attorney and filed suit against Dr H and the hospital, alleging medical negligence and failure to obtain informed consent. She alleged that Dr H breached the standard of care by failing to admit or transfer her for observation and treatment, or by failing to order additional imaging, such as a CT angiography (CTA) to check for vertebral artery dissection prior to discharge.

The defense made a motion asking the court to dismiss the informed consent claim, which the court granted.

At trial, the jury heard expert testimony regarding whether Dr H breached the standard of care of an emergency medicine physician. Dr H testified that he had considered and rejected a diagnosis of vertebral artery dissection, and that his care of Mrs D met the standard of care. An expert for the defense testified that Dr H “absolutely met the standard of care” by performing a broad workup exam, identifying Mrs D’s neck fracture, and consulting with the neurosurgeon prior to making a disposition decision. The expert also testified that the standard of care in the state does not require a CTA scan for every C3 fracture. The plaintiff’s expert testified that a differential diagnosis of vertebral artery dissection requires a CTA scan and that it was not safe for Mrs D to be sent home.

After deliberation, the jury found Dr H not negligent.