Putting The Stroke Issue to Bed

We don't know if she presented with any signs or symptoms that the chiroprac- tor should have responded to or failed to. This could have been a very straight- forward presentation as mechanical neck pain. No signs of neurological compli- cations. No signs that anything else to be concerned about but we know obvi- ously that those developed over time but at that initial presentation, there may have been things there to respond to that the chiropractor didn't look at and quite honestly, it could have been nothing that would have triggered the per- son to think that this is a more complicated circumstance. We also don't know if the chiropractor involved made any recommendations to Ms. May about what she should do in response to her circumstances in terms of should she seek a referral from a neurologist. Should she consult an emergency room and so on. The record is just simply si- lent in this or I shouldn't say the record. The information said is silent at this point. Also, we don't know if Ms. May was offered an informed consent to care prior to the time that she received chiropractic care and if she was offered an informed consent gives that detail to any association between vertebral artery dissection and chiropractic care. Next slide, please. As we noted before, we had not had a chance to see the coroner's report. We don't know the detail beyond what was reported by the Pittsburgh Post-Gazette but we do know one thing that did come out from the coroner himself where he was quoted in the press as saying he has never seen a case of this type in his career. Now I certainly don't mean to impune the integrity or the competency of the coroner in any way. I'm sure the gentleman is qualified and quite competent. It's also a reality that he sees various causes of death very commonly and re- peatedly overtime. For this to be the first time that he saw something of this nature in his career means it's very unique. We know that. We know how rare this condition is. It also causes us to bring into question as to whether or not the coroner, with all due respect and appreciation for the nuance nature of this problem and was aware of the literature associated with it. If it was a quick search and review of case studies that have talked about this, the conclusion could be drawn one way. As the person went to the depth of the literature looked at the key pieces of the literature that we'll talk about in just a moment, it may have come to a dif- ferent conclusion. We don't know what the thought processes were. We don't know how extensive that evaluation was on the coroner's part. We're left with the comment again that he's never seen one of these in his career. Obviously, very rare. Next slide, please. Now, one very important thing relative to how does this square with the evidence published to date? This case appears to fit the scenario of a dissection in progress perfectly. That is that the neck pain the patient presented with on January 27 was a sign of the dissection underway. Now historically, we know that 20 years ago, the discussion was, patient pre- sents to a chiropractor. Patient gets adjusted.

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