The Profession Reacts to the Death of Ms. Katie May
FEATURE
Stuart Hoffman
The chiropractic profession, long known for its excellent levels of patient satisfaction and clinical safety, recently found itself at the center of the untimely death of Ms. Katie May. Ms. May, a high-profile social media personality and model, died at the age of 34 of a brain infarction that developed secondary to dissection in both of her vertebral arteries. Family members, friends, and even the Los Angeles County coroner concluded that the arterial dissections involved were the result of cervical spine manipulations she received in the days prior to her death. In contrast, the chiropractic profession viewed that conclusion as a rush to judgment that does not consider other probable scenarios, which include Ms. May presenting for care for neck pain that was the result of a dissection in her vertebral arteries.
Media Interest
Media interest in this case began in early February 2016 with the hospitalization and subsequent passing of Ms. May. It gained considerable momentum in late October 2016 with the release of the coroner’s report, which asserted blunt force trauma as the origination of the sequence of events ending her life. In many cases, the availability of a coroner’s report answers questions and is an important step in bringing a case to close. Unfortunately, in this situation, this report has had the exact opposite result.
In February 2016, various news outlets reported that Ms. May had experienced a significant fall during a photo shoot resulting in an injury to her neck. This perspective was subsequently contradicted by family, friends, and business associates who indicated that there was no fall involved. It was then reported that Ms. May had been asked to hold her head and neck in an odd posture for an extended period during the photo shoot. She immediately experienced neck pain. Subsequently, she commented on social media that she had experienced a “pinched nerve.” She sought care from a Beverly Hills chiropractor on January 27 and 29, 2016, and on February 1, 2016 for the neck pain that developed during the photo shoot.
How a Dissection Can Develop
Persons unfamiliar with vertebral artery dissection and its
■ ■ Blood chemistry tests do not provide early answers since, by definition, the body is already losing the struggle to maintain homeostasis by the time a test result is beyond normal limits. 5 5
dozens of originating events find it hard to understand and appreciate how a dissection can develop from a sustained, straining posture. A good parallel to this case is what is known as a “bow-hunter’s stroke.” Imagine an archer holding a bowstring at tension as she sights her target; her arms are at a right angle to her body and her head is rotated 90 degrees looking out over the point of her shoulder. In this posture, it has been reported repeatedly in scientific literature that fit, young persons have experienced a dissection of their vertebral artery(ies), resulting in the development of a stroke and brain infarction.
The facts of the case at hand will unfold over time, and a fall in the process of the photo shoot will be either confirmed or refuted. However, the coroner’s report referenced a series of contusions on Ms. May’s left side that would be consistent with a fall. These contusions were suspicious due to
their location as well as their color, indicating that they were about a week old at the time of autopsy. The issue of the fall notwithstanding, there remains the unquestioned view that Ms. May experienced neck pain from the position she was requested to hold during the photo shoot. Either circumstance is a plausible explanation for the origin of her dissection and confirmation that the dissection preceded the neck pain and the care that followed.
The Coroner’s Report
The rush-to-judgment perspective on the part of the Los Angeles County coroner is supported by portions of his report, as well as by comments attributed to him in the media. The coroner was quoted as saying that this was the first case of this type he had ever seen in his career. This is not surprising to anyone familiar with vertebral artery dissection. Vertebral artery dissection is estimated to occur once in every 100,000 population per year. When vertebral artery dissection does occur, it is fatal in approximately 5% of the cases. This means that one person among 2,000,000 per year would have a dissection with a fatal outcome. The coroner has never seen a case like this, not because he is unqualified or inexperienced, but because this is such an incredibly rare fatality.
The coroner relied upon a single literature citation in coming to his conclusion. He referenced a 2007 case study of a patient in whom no arterial dissection was demonstrated on imaging
and in whom no dissection was discussed on autopsy. In addition, his choice to rely on such a low level of evidence—a case study—when far more sensitive studies, such as case-control, case-crossover, and meta-analyses, were available is puzzling. Finally, the coroner erred in stating that the literature cites neck manipulation as a common cause of bilateral vertebral artery dissection. This is simply an incorrect statement. Bilateral arterial dissection is more likely associated with metabolic abnormalities and connective tissue disorders.
Looking in the Wrong Direction
The problem with getting the origin of problems like this wrong is that it misdirects the attention and focus of people involved in patient care in the wrong direction. The family and friends of Ms. May feel a need to blame someone for her circumstance. That is understandable and a very common response in the presence of any undesired patient outcome. Healthcare providers are expected to go beyond the blaming phase and explore the origins of unexpected outcomes. The goal should be to change procedures, education, training, and patient advice to make care even safer. The easy approach to assigning causation is to say the chiropractor caused it. Regrettably, this conclusion has several confounding aspects that are inconsistent with the basic science, the clinical science and the demographic data involved. Taking the “low-hanging fruit” approach creates another very critical problem: It takes our eyes off the problem and causes us to look in the wrong direction.
Who and What Is Walking Through the Door
If this matter is about what chiropractors do in their offices, then when you aggregate data from millions of patients over many years, you would expect to see trends related to prevalence and incidence parallel the care of the chiropractor. The data do not point to such trends, and in fact they point in the opposite direction. It is not about what is happening in the chiropractor’s office, but it is about who and what is walking through the door of the office.
If you focus on improving how you apply your care and your care is not causing these problems, then you are missing a huge opportunity. If, however, you refocus on the patient walking through the door with neck pain and headache as a potential “dissection-in-progress” patient then you are far more alert to the implications of the dissection-in-progress scenario. The opportunity gets even bigger when you understand that this isn’t something that chiropractors alone need to be alert to. Then you realize that everyone who assists patients with neck pain and headache needs to have a similar level of appreciation and suspicion for neck pain and headache. This includes the primary medical care provider, the emergency room physician, the physical therapist, and so on.
A Related Teaching Opportunity
We can take it out one level further. The American Stroke Association has done a wonderful job popularizing the FAST
acronym of “face, arm, speech, and time.” The public is becoming increasingly aware of the signs of stroke, including drooping of the face, inability to move an arm, difficulty in speaking, and then appreciating that the sooner a patient receives care, the better.
Perhaps it is time to develop a related teaching opportunity that encourages the public to associate neck pain and headache with changes in swallowing, speaking, eye movements, and mobility as signs of a unique but important origin and type of stroke.
Lessons to Learn
For chiropractic and for each of us, much can be learned from this tragedy, and there is no better time than now to understand what those things are.
1. Young people can have strokes too. The American Stroke Association states that strokes don’t only happen to “elderly, overweight smokers who have high blood pressure or high cholesterol.” In fact, 35 percent of strokes happen to people under 65, and a full 10% of strokes happen to people under the age of 45.
2. More women die from strokes than breast cancer. According to the CDC, one in five US women will have a stroke, and a lot of people don’t know about the risks. In fact, stroke kills twice as many women as breast
cancer does every year.
3. Certain things can increase the risk of stroke, including hormone replacement therapy, trauma, pregnancy, and birth control pills, as well as congenital anomalies, and you should be aware of these.
4. Signs, symptoms, and observations of a stroke in progress are what we call the 5 Ds, the A, and the 3 Ns (detailed information regarding these are available from ChiroSecure at [email protected]) and you need to know these, as does your staff.
5. The social, clinical value and legal value of informed consent procedures and documentation. As stated by the 2014 American Heart Association’s Stroke Council report that declared there was an association between stroke and neck manipulation, “...patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.”
In today’s litigation-happy (or many might argue litigationcrazy) society, even the best, most conscientious, and responsible doctors of chiropractic, applying the highest standards and most established procedures and protocols, can still be named in a malpractice claim. When it comes to informed consent, a whole new dimension of malpractice reasoning comes into play, where patients and their attorneys regularly argue that if a patient was fully informed of all risks and possible negative outcomes, then they may have decided not to receive the care and would not, as a result, have been injured. The proactive doctor of chiropractic will respond accordingly, with sound and well-researched forms and procedures, all consistently applied and included in the patient’s file. It pays to do the work and, consequently, minimize the risk.
In addition, as every doctor of chiropractic should know by now, a reliable malpractice insurance carrier is your best partner in protecting your practice and yourself from malpractice claims. In that process, ChiroSecure stands ready to serve and assist you in making sure that you have the coverage you need, and in implementing risk-management procedures that will provide the best possible firewall to jeopardy.
practor Chiropractor has also Stuart of the been Hoffman Year of for recognized the 2015 Year has from been and by the Life honoredasICA’s was previously Michigan awarded University Council. President ChiroHe Dr. Guy Riekem an for his success, leadership, and vision through his contributions supporting the mission of the President’s Circle. He is a successful 35-year practitio-
ner who owned and operated 14 chiropractic offices and employed many associate DCs. For the past 25 years, he has sensed as founder as well as owner and operator of ChiroSecure, a malpractice insurance company that he personally spearheaded to become the second largest program in that market. His expertise and lovefor chiropractic allow him to stay on the cutting edge of risk management and continue to be one of the most sought after speakers in the chiropractic profession by state associations throughout the country, as well as a favorite at the chiropractic college campuses. For a copy of his highly recommended and regarded Informed Consent Packet, text the word TECHNIQUE to 480-500-6574.
