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I thought doc2doc members might be interested in this case published recently, it comes from the Medical Protection Society:
Twenty-eight-year-old Miss T was a pillion passenger on her boyfriend’s motorbike going at high speed on a motorway. He lost control of the bike and tried to regain it by braking, which threw them both over the handles, landing some distance away. Miss T’s boyfriend was certified dead at the scene..The paramedics who dealt with Miss T removed her helmet, following appropriate guidelines, and then immobilised her neck with a rigid collar and head blocks. She was then moved on a long spinal board and rushed to the local emergency department (ED).Dr W was the consultant in charge where he took a brief handover from the Paramedics. Miss T was fully conscious on arrival with a GCS of 15/15 and was hemodynamically stable. Dr W performed a primary survey and then requested a series of trauma x-rays, including c-spine, pelvis and thorax. On a full secondary survey, Dr W suspected fractures of left clavicle, left wrist, right hand and left tibia and fibula, which were all confirmed soon after by x-rays. Dr W removed the collar and felt for tenderness in Miss T’s cervical spine - there was none, so Dr W removed the collar and wrote in his notes: “C-spine cleared”. The orthopaedic team took over Miss T’s care and she was then moved to theatre for surgical management of her fractured tibia and manipulation of her wrist. When she was still in the recovery room following surgery, Miss T mentioned that she had some tingling in her legs and that her legs felt heavy and weak. This was documented in the nursing notes but was not acted upon. Once she was moved to the orthopaedic ward, Miss T continued to complain about paraesthesias in all her limbs; she also mentioned that her head felt unstable as if “it was falling backwards”. She also had a long episode of hypotension that did not respond to fluids. Two different orthopaedic junior doctors made entries in her clinical notes about this and they both commented that Miss T’s c-spine had been cleared earlier on by the ED consultant. They both felt that the symptoms could be related to the multiple limb fractures.Three days after the accident, the orthopaedic consultant in charge requested a c-spine CT during the ward round since Miss T continued to mention that her limbs felt weak and numb. The CT was done but it was not reviewed by the radiologist until the following morning, when he immediately acted upon it and contacted the orthopaedic team; it was finally confirmed that Miss T had a displaced fracture of C6. Unfortunately, the final outcome was not good and Miss T was left tetraplegic. She made a claim against all the doctors involved in her care.
On this occasion all the holes in the 'swiss cheese' were aligned. Any comments?