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TOP Education’s2018 Synergy ConferenceTOP’s Ten Risk Concerns1 CEU
Presented By:Mark A. Davini, DC, DABCN
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Mark A. Davini, DC, DABCN■ 1981 graduate of Palmer College of Chiropractic
■ 24 years in active practice
■ Diplomate in Chiropractic Neurology
■ Certified Chiropractic Industrial Consultant
■ Past Chairman of the MA Board of Registration of Chiropractors
■ Mass Chiropractic Society, Vice-President of Public Information and Education
■ Mass Chiropractic Society, Chairman of the Ethics Committee
■ Lecturer for various state and national associations continuing education programs to include chiropractors, nurses,dentists, the Council on Licensing, Enforcement and Regulation for the Commonwealth of MA, and 2nd and 3rdyear medical students at the University of Massachusetts Medical School.
■ Dr. Davini co-developed and teaches the Chiropractic Assistants Procedures Program (C.A.P.P.)
■ Co-Developer of TOP Education, LLC
■ Active in the defense of chiropractors involved in malpractice litigation.
■ Compliance Auditor/Clinical Monitor as well as a pattern practice analyst
■ Awarded 2 U.S. Patents on the “M-Brace” for Carpal Tunnel Syndrome
■ Chiropractor of the Year by the Massachusetts Chiropractic Society in 1996.
■ Doctor of the Year” by the Worcester County Chiropractic Society in 1987
Myth # 10
You have the memory of an elephant
Myth # 10
➢ Batch notes at the end of shifts, or worse days later.
➢ As you go along they get less and less complete leaving and more detail out
➢ If you only record the positives you can’t say for sure what you did
Myth # 9
Ignorance is Bliss
Myth # 9
➢ When was the last time you reviewed your State Law, Regulations and Policies. This is part of compliance.
➢ The “Devil Made Me It” defense doesn't work
➢ Respondent Superior Defense
➢ “I didn’t know” is not an excuse
Myth # 8
I have treated them for years,
we’re friends
Myth # 8
➢ Many malpractice cases are from regular “friend” patients
➢ Being too nice…deviating from procedure increases risks
o Out of schedule
o Out of office
o No staff
➢ Too casual/familiar
➢ Remember to treat all visits like it is their first
Myth # 7
OATs are for breakfast!
Myth # 7
➢ Patient’s perspective is important and too often minimized.
➢ Outcome Assessments:Anatomical:
1.Visual Analog Scale/Verbal Numeric Scale
2.Pain Diagrams
Functional:
1.Functional Rating Index
2.Modified Oswestry
3.Neck Disability Index
4.Etc.
Myth # 6
Less is more
Myth # 6
➢ Initial exams have too little supporting procedures to justify Dx
➢ Re-Exams too far apart or non-existent
➢ No new exams with new conditions
➢ No tests ordered when indicated
➢ Treating acute patients without being fully informed o Patient flares up after Tx, goes to MD who tells them you caused the problem.
Myth # 5
There are no guarantees in life
Myth # 5
➢ Patient’s perception is, “I pay, you get me well”
➢ Large balances places the relationship out of exchange.
➢ They use as an excuse you have not lived up to your part
➢ Large balances promotes dissatisfaction with care
➢ Collections may incite patients. Review case before filing
Myth # 4
You think a SOAP note
is a message left in the shower!
Myth # 4
➢ The clinical chart should reasonably represent what happened
➢ History is critical. Take the time to listen…. each visit…
➢ If hand written, must be legible
➢ Incomplete notes open to interpretation-both way
➢ If not written, it didn’t happen
➢ All notes must tell a story and like all stories they should have a
Beginning
Middle
and End!
➢ There should be documentation of end result - resolution, MMI, self-discharged etc.
➢ Discharge status of the patient is crucial if challenged later down the road
If at first you don’t succeed try,
try again…
Myth # 3
➢ NEVER CHANGE A NOTE!
➢ Reference note that is being amended.
➢ Record date of addendum.
➢ Rationale if applicable.
➢ NEVER CHANGE A NOTE
Myth # 3
I know what I meant
Myth # 2
➢ Communication is key, often there is no ROF
➢ New procedures just added in with no discussion
➢ Informed Consento Differs from “Consent”
o Patients have "a right to be informed and decide” if they want to treat.
o Patients should be presented pertinent info so they can make an informed decision
o Signed by the patient.
o With minors, obtain a signed consent from the guardian.
o New Informed Consent should be completed issued if there has been important change in their condition, and/or type of Tx.
o Tell them what you are going to do, tell them what you did, tell them why.
Myth # 2
Myth # 1
Chiropractic adjustments cause strokes
Background Information
• U.S. population is 350 million, the estimated occurrence rate of VADs is 3,500 per year.
• Therefore, spontaneous VADs occur in 1 out of every 100,000 people per year.
• The prevalent age is 39 to 45.
• There is a slight dominance of females over males.
• Most VADs exhibit a pre-existing anomaly that is asymptomatic and unknown until after the fact.
• Simple ADLs can result in VADs and or strokes, e.g. going to a hairdresser, driving a car, playing sports,
sleeping positions, coughing or simply holding the phone receiver with your head in lateral flexion for
extended times. Playing soccer statistically results in death frequency of 1 in 25,000.
• Clinical considerations; patient is a smoker, oral birth control, vascular disorders and HTN.
• Vertebral Artery Dissections (VAD) are a rare cause for ischemic strokes, less than 2%.
• Multiple vessel insult occurs in 15% to 20% of the 2%.
FYI On an average, 1 in 1,200 patients taking NSAIDS for at least two months will die from
gastrointestinal complications who would not have died had they not taken NSAIDs.
Vertebro-Basilar Artery System
■ Posterior
■ System supplies 20% of the blood to the brain
■ Rotation can restrict blood flow to contralateral side
■ Redundant blood flow from 4 sources
V1: Arise from the subclavian arteries to C6transverse foramen (only 7.5 % are at thelevel of C7).
V2: Continue through the transverse foramenof C6 to C2 accompanied by the vertebralveins and sympathetic nerves.
V3: Emerges from the transverse process of C2and sweeps laterally to the transverse processof C1. From there is passes around theposterior border of C1 lateral mass and along agroove in the posterior arch of C1 and proceedsuperiorly piecing the dura into the skull.
V4: Once in the skull the two vertebral arteriesthen join to form the basilar artery.
Vertebral artery has a right angle around
the lateral mass of atlas,
and then right angle into the foramen magnum.
Posterior Inferior Cerebellar Artery (P.I.C.A.)
Is located off the vertebral artery outside the skull.
Supplies portion of the posterior medulla and
cerebellum
It is true that most intra-cranial strokes cause
weakness on one side of the body. However, if
PICA is involved the symptoms can quite
different.
A stroke in this area is called Wallenberg’s
Syndrome. This area of the brain contributes to
balance, coordination, sensation of the face and
body, sense of body position and midline, vocal
cord function, and eye movement coordination.
PICA
Variation:
• Left vertebral artery is usually largerthen the right 50% percent of the time,25 % the right is bigger and 25% equal
• Right may terminate in PICA. Thatmeans there is no right vertebral arteryconnecting to the basilar artery.
• In 3-5% = If the posterior arch groovehas bony bridge this called the arcuateforamen or Ponticulus Posticus (littleposterior bridge), covers the groove
Risk Factors For VAD■ ‘Dysfunction’ does not always mean a Dissection’
■ Underlying pathology which weakens the blood vessels
■ Mechanical forces that can alter haemodynamics
• Trauma
• Hypertension
• Hypercholesterolemia
• Hyperlipidemia
• Diabetes Mellitus
• Infections
• Genetic clotting
disorders
• Smoking
• Family History of
Vascular Pathology or
Early Strokes
Blood vessel compromise may be in the middle layer causing blood clots and flow disruption and is a cause of bruits.
Once the intima tears the risk of stroke increases from freed up blood clots.
Frequency Occurrence of Injury Sites:
• C1C2
• C2C3
• C1 transverse process or sub occipital’
• C4C5
• C5C6
MD or DC…No Difference.
The likelihood of a patient presenting to a practitioner with the VAD and/or stroke is discussed in
a study published in the medical journal SPINE and recently confirmed by Cassidy et al.
The study states that although there is a slight increased occurrence rate when presenting to any
professional because patients with symptoms will most likely present to a health care provider.
Since the occurrence rate is not affected by the type of provider, i.e. chiropractor v. medical
doctor, or adjustment v. no adjustment, the association is separate from and unrelated to the
procedures performed.
This begs the question, “why do chiropractors have to discuss this issue, and medical doctors do
not”?
A Rose By Any Other Name May Not be as Sweet…..
There is a common misperception of the risks of VAD associated with chiropractic adjustments.
A contributing reason for the misinformation comes from biased reporting.
JMPT published a study identifying the inaccurate use of the terms chiropractic and chiropractor
when reporting incident rates of VAD/stroke combining manipulations from all providers.
The study revealed frequently the procedures were inappropriately grouped together putting all
types of practitioners in one category.
This presents the impression all disciplines and manipulation techniques performed by all types
of practitioners are essentially the same, carrying the same concerns and risks; a fact we know to
be false.
VAD is not the same as a Stroke
I didn’t do it…
The Council on Chiropractic Colleges stated after extensive examination of the literature that
there has been no established causal relationship between a VAD/stroke and a chiropractic
adjustment and any association is temporal and unrelated to the procedure.
Again, simply, these things happen independent of the adjustment, and statistically, there will be
times it occurs in and around a visit to a chiropractor.
What Ever Happened to George’s Test?
There was a fair amount of controversy over the years regarding what, if any, relationship exists between a
chiropractic adjustment, VADs, strokes and vascular screening tests.
In the late 70’s, to early 80’s the current thinking was to perform a pre-adjustment protocol to screen for the potential
vertebrobasilar insufficiency.
The logic was based on the clinical observation that vertebral artery occlusions may occur on the contralateral side
of cervical rotation and exaggerated by the addition of extension. This anatomical observation was the clinical
foundation behind tests like "George's Test".
Subsequent research revealed pre-adjustment screenings did not necessarily indicate vascular insufficiency.
Research further revealed the unreliability of performing these protocols, rendering them clinically useless. Too many
false positives and negatives.
The greater likelihood is… patient enters the office with the VAD in progress and unless there are frank neuro signs
there is way for the doc to know or test for it (even with Doppler studies the artery must be over 55% damaged to
register. Auscultation isn’t reliable).
The Council on Chiropractic Colleges has determined screening procedures have little to no predictive risk value and
have since recommended the discontinuation of such screening procedures to the practitioner.
History and examination together are the best screening.
As stated, there are common situations, treatments, and activities that have higher occurrences
than those associated with a chiropractic adjustment.
This raises the discussion of what may constitute an appropriate routine Inform Consent.
Given the extreme rarity of a temporal relationship even beyond the estimated occurrence
rates, what obligation does any practitioner have to review a circumstance that statistically
will never occur in their practice lifetime?
All that being said, the current observed risk of a VAD temporally related to a chiropractic
encounter is between 1 incident per 1 to 2 million cervical manipulations.
Bottom Line
Keys To A Successful Outcomes
1. Don’t panic
2. Don’t alter records
3. Don’t discuss details with colleagues/staff
4. Keep personal notes for your memory
5. Trust your lawyer
6. Tell your lawyer everything
7. Don’t speculate
8. Be prepared to explain all of your notes
Please scan OUT as you leave
If you are staying in this classroom for the next session you must have your badge scanned OUT for this session and scanned IN for the next session
Thank you!Mark & Paul
Some of our Synergy teachers are making their
presentations and other materials available for download
at the conclusion of the weekend.
www.toolsofpractice.com/ppts
TOP Education, the instructors teaching on behalf of TOP Education are here this weekend to educate.
They are not representatives nor speak on the behalf of any particular government entity, insurance company or TOP Education, LLC.
Any specific discussions are for example purposes only.
All specific policy or procedure questions should be directed to the entity that authors those policies
