When I saw on social media that another person had died from chiropractic adjustments, I wasn’t immediately convinced that it was the chiropractor’s fault. But now that I have read the news, it seems like may be. Maybe not.
According to BBC News, Joanna Kowalczyk, a 29-year old from United Kingdom had died after seeking treatment at both a public hospital and a chiropractor.
Based on the coroner’s conclusions, it seems that the death was attributed to the failure of the chiropractor not checking her medical records. The medical history in question was that she had regular migraines and joint hypermobility issues.
What happened prior to Joanna Kowalczyk’s death?
I am not sure of the exact sequence of events, in terms of the dates of treatments, but here’s what I found:
26 Sep: Personal training at the gym where Joanna felt a crack to her neck, and subsequently developed a severe headache. The coroner stated in her report this is likely when she sustained tears to the arteries on both side of her neck (i.e., bilateral vertebral arterial dissections).
27 Sep: Underwent a CT scan at the hospital A&E. The scan did not reveal a stroke. She was recommended to go for a lumbar puncture to rule out stroke (i.e., subarachnoid haemorrhage) but she self-discharged from the hospital.
28 Sep: First treatment at a chiropractor and Joanna did receive manipulation to her neck. She was diagnosed with acute severe cervical facet dysfunction and associated muscle dysfunction after assessment. Both conditions are musculoskeletal in nature so it seems like the chiropractor did not think Joanna’s neck pain was a stroke symptom. Joanna felt better after treatment and had three more sessions on 2 Oct, 9 Oct, and 16 October.
19 Oct: Joanna passed away.
The final chiropractic treatment
16 Oct: After a neck chiropractic adjustment, Joanna experienced immediate dizziness and later developed double vision, tingling in her right hand, and right foot, and was struggling to speak. She also vomited at the clinic.
At this point, I think a stroke diagnosis is very probable. The coroner did also indicate that the manipulations likely caused tears to the arteries. In fact, she thinks there were also acute tears as a result of the manipulations in the earlier three sessions as well.
To recap, the coroner’s stance is that Joanna’s first injury to her arteries occured at the gym. Following that, there were further tears at each of the four chiropractic treatments she received.
Stroke awareness: FAST
Based on Joanna’s symptoms, a lay person should be able to suspect stroke. At least for us living in Singapore. In 2016, Health Promotion launched the FAST as a stroke awareness campaign. The idea is so members of the public can identify early symptoms of stroke and seek early medical attention.
Face: Is it drooping on one side?
Arm: Can they lift both arms and keep them there?
Speech: Does it sound strange or unclear?
Time: Call 995 immediately if you spot any of these signs.
What did the chiropractor do after treatment?
The chiropractor did had suspicious of strokes and performed a FAST test. I am not sure if their FAST test was the same as what I shared earlier. But based on the coroner’s report, Joanna tested negative.
The chiropractor (as well as another chiropractor colleague in the clinic) also advised Joanna to seek medical attention at the hospital. However, Joanna declined. No ambulance was called as Joanna symptoms improved.
A handwritten note of the signs of stroke (as per NHS website) was given to Joanna. She was advised to seek treatment at the A&E if any of the symptoms appeared.
Joanna was at the clinic for a few hours. When she left, she was unable to walk properly and had assistance from her partner.
Two ambulances were called
16 Oct: On the same day after her chiropractic treatment, an ambulance was called but Joanna was not sent to the hospital. The paramedic performed FAST test and diagnosed Joanna’s symptoms as migraine.
The paramedic was assured by the chiropractor via telephone that symptoms of dizziness and migraine were normal after chirorpactic treatment.
17 Oct: Another ambulance was called. This time, Joanna had reduced level of consciousness so no FAST test could be performed. Her condition worsen on the way to hospital and required intubation and ventilation.
At the hospital, a CT scan revealed significant brain damage (i.e., infaction) but no treatment was available.
Coroner: Not possible to ascertain if outcomes could change
According to the coroner’s report, it is not clear if earlier detection could allow different clinical management that would avoid the tragedy. However, there are two issues that she found of concern:
Paramedic did not know stroke symptoms could stop
The paramedic who attended to Joanna did not know that stroke symptoms could stop after some time. She claimed it was not part of her training. However, it was part of paramedic training and also part of her annual professional development.
I am guessing what the coroner meant was that the paramedic should have known that Joanna could possibly be having a stroke, even in the absence of symptoms at point of assessment. In other words, Joanna should have been sent to the hospital.
Again, it is the coroner’s stance that it is unclear if early detection could have changed the outcome.
Chiropractor did not request GP or hospital records
The second issue the coroner identified was that the chiropractor did not think it was necessary to request GP records or hospital records. The coroner’s stance was that records should have been retrieved since the chiropractor was aware that Joanna self-discharged against medical advice.
At this point, it’s important to appreciate that the healthcare system in the United Kingdom works differently from Singapore. Based on what I am reading, I am guessing there is a channel for chiropractors in the United Kingdom to retrieve medical files of patients from hospitals. I am not entirely sure.
Would hospital records have changed anything?
This is also where things are, in my opinion, not very clear. Joanna did discharge herself from the hospital against recommendation. It sounded like she was already aware of the risks when she left the hospital.
She also told the chiropractor that the doctor (at the hospital) was aware she was going to seek chiropractic treatment. Assuming that Joanna wasn’t lying, wouldn’t the medical doctor had already recommended against chiropractic treatment?
It was also unclear if the hospital records did explicitly indicate “no manipulation”. Because, if there wasn’t, I am not sure if retrieving the records would have changed anything.
Sure, the current chiropractor could have decline to treat her. But if Joanna feels fine another to leave the hospital against recommendation and looked up one chiropractor, there is a good chance that she will just go to another? During the first visit, Joanna already had a clean CT so I am guessing the chance of stroke while still probable is small.
Joanna was fine for three weeks
Bear in mind, Joanna seemed fine for at least three weeks and had a clean CT. I think based on this alone, in the absence of further investigation, stroke is very low in the differential list.
It is also true that stroke cannot be totally ruled out. This, I believe, Joanna was already aware of.
What could have been better?
In hindsight, it is of course easy to discuss what could have gone better. In actual truth, we don’t know if any of these could have helped Joanna avoided the tragedy. With that in mind, whatever I share is based on what I think could benefit people. Not based on who was at fault or how could Joanna been saved.
Long waiting times at hospital
One of the things that was not discussed was that Joanna researched alternative treatments while waiting at the hospital! I am guessing waiting time was an issue.
Since Joanna did a CT and was clean. I am guessing she will be very low in the priority list to be seen for a lumbar puncture to rule out stroke.
The current A&E standard in the United Kingdom is that 95% of patients should be seen, admitted, or discharged within four hours. Apparently only 58% of most urgent cases are seen within a four-hour window. More than 1.5 million patients per year waited for over 12 hours to be seen in A&E.
I think this could be an issue?
No outpatient referral for lumbar puncture
I actually don’t know if she did receive an outpatient referral for lumbar puncture or not. But I am guessing she didn’t cos it didn’t come up in the coroner’s report.
Personally, I don’t think it makes sense for hospitals self-discharge to be all for nothing. If a doctor is going to tell me “hey, I think a lumbar puncture is good for you”, I would think that’s what I need. If I am rejecting one (i.e., self-discharge against advice) at the A&E, for whatever reasons, it doesn’t change that that’s what I need? So, I kinda think, having an outpatient referral appointment for one should be provided.
There was 22 days between her first hospital visit to when she passed. I feel that should be enough time for her to get an outpatient lumbar puncture. If not, then it will be back to my previous point where long waiting time could be an issue.
Maximum waiting time for referrals in United Kingdom
According to NHS’s website, the longest waiting time for non-urgent referral is 18 weeks or 126 days. If that is the case for Joanna, it may have been too late.
For urgent (cancer) appointments, the waiting time is much shorter (~2 weeks). This could have helped Joanna but who knows.
Is FAST the best assessment tool for healthcare providers?
I am going to assume that the FAST performed by the chiropractor and paramedics are the same FAST we use here. If so, is it possible for healthcare providers to use better assessment tools?
FAST honestly sounds more like something that is used for everyday people. I personally don’t think that should be used in a clinical setting.
At least for myself, we were taught to assess for 5Ds and 3Ns aka the cardinal signs that someone may be having a stroke (i.e., cervical ischemia). The signs that we look out for are: diplopia, dizziness, drop attacks, dysarthria, dysphagia, ataxia, nausea, numbness, and nystagmus.
If we want to go even more technical, NHS has their own stroke assessment called NIH Stroke Scale. It more or less covers the same areas as 5Ds and 3Ns. And, whichever we are inclined towards, has to be better than FAST!
How can I keep myself safe while seeing a chiropractor?
It’s true that you can eliminate the risk of vertebral artery dissection (aka tear to the blood vessels in the neck) if you completely avoid spinal manipulations. This can include chiropractic adjustments but also other types of joint manipulations performed by physiotherapists, osteopath, thai masseuse, etc. Thus far, it does not seem like there is any association between other areas of manipulation (e.g., thoracic spine, lumbar spine) and risk of stroke.
Many orthopaedic surgeons in Singapore believe spinal manipulation to be dangerous. For example, Dr Wang Lushun, an orthopaedic surgeon at Arete Orthopaedic Centre, claimed that aggressive, forceful and sudden twisting of the neck can contribute to injuries to the blood vessels in the neck.
Dr Huang Yi Lun of Total Orthopaedic Care and Surgery believes it can cause fractures and dislocation of the spine or even injuring the spinal cord. While he did explicit acknowledge its rare, he believes it’s better to err on the side of caution (i.e., not necessary to take the risk).
Different types of adjustment techniques exist
In my opinion, some adjustments are more dangerous than others. For example, a Y strap neck adjustment is complete unnatural to me. And, based on the course of the vertebral arteries, it seems unnecessarily risky.
There is also no-twisting adjustments such as those performed via an Activator Adjusting Instrument. The Activator works by delivering a short but quick impulse to a joint without any form of twisting. While its efficacy is questionable (to me), it certainly appears to be safer than a hands on, manual adjustment. Adjustments performed via instruments is readily available in Singapore and is offered by chiropractors from The Chiro Lab, One Spine Chiropractic, etc.
BOOK A CHIROPRACTOR IN SINGAPORE
Based in Singapore, Square One Active Recovery offers treatments with a very big difference. With our evidence-based exercise approach, you can achieve your recovery goals in just 12 weeks. Not getting results from your chiropractor, TCM doctor or physiotherapist? Talk to us and find out how we can take your recovery to the next level.
Our goal? To make our own services redundant to you.
*We do not offer temporary pain relief such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.
