Cervical Manipulation and a New Neurologic Symptom
A 47-year-old woman is on her third visit for mechanical neck pain. Findings are unremarkable: cervical range of motion mildly reduced, no neurologic deficits, blood pressure 138/86, heart rate 92. The chiropractor performs a diversified cervical adjustment. Within two minutes the patient reports a sudden severe occipital headache, dizziness, diplopia, and nausea. She is alert but frightened and asks the chiropractor to 'adjust it again' because the first adjustment 'must have moved something.' The clinic has no physician on site and no imaging. The patient drove herself and refuses to call 911, saying she will 'lie down for twenty minutes.' The chiropractor has a full schedule and a 15-minute slot before the next patient. The record contains a signed general consent to treatment but no specific discussion of vascular risk. A chiropractic assistant is available to help.
1. What is the immediate clinical and legal priority, and what should the chiropractor do about the request for another adjustment?
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The priority is to treat the new symptoms as a possible emergency, not as a reason for another adjustment. Sudden severe occipital headache with dizziness, diplopia, and nausea after cervical manipulation is a red-flag constellation that can signal vertebral artery dissection or another serious event. The chiropractor should stop treatment, stay with the patient, call EMS, and arrange emergency transfer. Performing another adjustment would breach the standard of care and could worsen a vascular injury. If the patient refuses EMS, the chiropractor should document capacity, the specific risks explained, the refusal, and the advice not to drive, and should offer alternatives such as calling a family member. The busy schedule does not justify delay; another staff member can reschedule patients. The legal analysis turns on foreseeable harm and the duty to act on red flags, not on whether the chiropractor can diagnose the cause.
2. What should be documented, and why does the general consent form not resolve the consent issue?
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Document the time symptoms began, exactly what the patient reported, vital signs, neurologic observations available in the office, the adjustment performed, the advice given, the EMS call, the patient's refusal and stated reasons, and who witnessed it. Record that no further manipulation was performed and that the patient was advised not to drive. A general consent to treatment proves only that the patient agreed to ordinary care; it does not show that she was informed of material risks or that she made an informed refusal of emergency evaluation. The consent issue is secondary, however, because the immediate duty is emergency response. Do not alter the earlier record or add retrospective consent language. If the patient later claims she was not warned, the contemporaneous note is the best evidence of what was said and done.