This case takes place in Rhode Island and involves a patient with a past medical history of joint inflammation. Her condition was stable and she had been managed effectively for several years under the care of her rheumatologist. The patient eventually suffered an injury and presented to the hospital complaining of back pain. She was still ambulatory, and walked into the ER on her own after driving herself there. The patient was worked up for her pain and a CT scan revealed no new pathology outside of her pre-existing conditions. The ER physicians prescribed some pain medication and she was not admitted. Although her back pain was persisting, she was discharged again in stable condition. The patient was eventually able to return to work.
She presented to the hospital some time after her initial visit complaining of tingling in her lower extremities. The physicians decided that the patient needed an emergent MRI in addition to the original scans that were done during her last visit. During these scans, the patient had difficulty lying flat; however the physician decided that the patient should be given analgesia and forced to lay flat. There were no significant findings on the imaging. Another MRI was ordered, during which the patient was medicated to tolerate lying flat, while also being held still during the scan. During the MRI, the patient began experiencing numbness in her legs. While the patient was still in the MRI, it was reported that she appeared to have several injuries that would require immediate treatment. Emergent surgery was ordered, however the patient is now permanently injured.
Question(s) For Expert Witness
- 1. Do you believe this patient should have been sent to a trauma care unit, where she wouldn't have needed to lay flat for an MRI to be performed?
- 2. Since her spinal condition was known and well documented, was it a departure for the ER physicians to order significant pain meds to have her lay flat?
Expert Witness Response E-008123
This patient clearly needs an MRI study because of concern for cauda equina syndrome and the danger of permanent paralysis. Nearly all MRI studies of the spine require the supine position. There are some upright MRI scanners, but they are very few and quite widespread geographically. It is not at all unusual for people with back pain to have pain when lying down, in a scanner or elsewhere. Giving pain meds to assist the study when needed is routine.
Expert Witness Response E-000954
In order to determine whether standard of care was met, I would need to review the initial ER records and radiology results. I work in a level 1 Trauma center and manage/supervise trauma patients daily. I teach Emergency medicine residents the importance of practicing conservatively in patients who have trauma in the setting of underlying bone disorders or chronic pain.