Dermal Injection Administered Without Patient History
In Arkansas in 2008, the defendant dermatologist organized a teaching conference, where a dermal injection technique was to be demonstrated. The dermatologist asked for volunteers from among the attendees, and a cardiologist’s nurse came forward.
The injection that the nurse received was a volumizing filler, intended to reduce wrinkles. Immediately upon receiving the injection, the nurse claimed, she experienced significant pain, and her face began to swell.
The plaintiff claimed that the injection had caused an arterial occlusion, leading to a facial infection that resulted in permanent disfigurement. The plaintiff alleged negligence by the defendant dermatologist in that before administering the injection, he had failed to take a complete history; otherwise he would have realized that the plaintiff was not a good candidate for the injection, as she had a history of shingles and other medical conditions. Also, she had been consuming alcoholic beverages during the dinner that was served at the conference.
According to a published account, a defense verdict was returned.
How often have we practiced medicine at a self-sponsored, three-hour–long conference and had something go wrong? Too many times to count, right? OK, for most of us, never. But I submit we have all done something dangerously similar that could lead to trouble—and trouble for those we most care about.
When we treat patients in our usual clinical setting, we have the patient’s chart, the patient’s history, a full set of vital signs, good lighting, communicational privacy, and the patient in an examination gown (or at least reasonably exposable). We conduct an appropriate examination and record the visit in the patient’s chart. Perhaps most importantly, we have a clinician-patient relationship with a dynamic that permits us to do things that would normally be considered improper: to ask invasive questions, to touch and examine, to speak frankly and directly. Thus, when we treat our patients, we have all the elements of a formal clinician-patient visit.
When we treat someone outside our usual clinical setting, we have none of this. We usually have a friend or family member with a problem—your uncle at Thanksgiving dinner, or the mother of your daughter’s playmate at the park. But you have seen the same problem before, hundreds of times, and you want to help—of course you can help.
This temptation is perhaps greatest for newly minted clinicians, anxious to demonstrate their considerable skill and new prescriptive powers to friends and family in need. But be careful, and proceed cautiously. The formality of a full visit is generally observed because it is indispensably useful, and our routines keep us from making errors. If you skip these formalities to practice outside your usual environment, you may be headed for problems.
Recall the physician who appeared on ABC-TV’s live Home show in 1993, in an effort to convince a national audience to get a flu immunization—an admirable aim. The problem: He injected the show’s host, Sarah Purcell, with the same needle he had just used on co-host Gary Collins—on live TV, before millions of viewers. Immediately recognizing his error, the clinician said, “I don’t want this on television.” The response: “Too late.” The visibly shaken physician insisted, “I’ve never, ever done this . . .”
And he probably hadn’t. He was outside a typical practice environment and made an error he would have never have made, practicing in a conventional environment.
In this malpractice case, I cannot say that the plaintiff’s theory would have prevailed—ie, that a history of shingles and recent alcohol consumption contributed to her poor result. However, it is probable that the physician’s usual routine was broken: she may not have had adequate lighting, she may have been distracted and misinjected the agent, which can have a sclerosing effect when injected into a vessel.
The jury was not persuaded that the case warranted recovery. However, we know that the clinician skipped taking the patient’s history and probably did not discuss the risks and benefits of the injection before her large audience, as she would have with an individual patient in a private exam room. These are things she would never do in her usual clinical environment.
Like this dermatologist and the doctor who appeared on TV, we can make similar mistakes when we operate outside of the formality of an office visit. Proceed cautiously, and be quick to point out that “curbside” treatment cannot replace formal evaluation and treatment. In cases that could be complicated for any reason, politely decline providing care, citing the patient’s best interests. You can always explain, “I wouldn’t want your health care provider to be upset with me.”
There are additional reasons to be cautious: Sanction by your state’s board of medicine or nursing. A review of state medical board of medicine disciplinary records shows that a common reason for clinician discipline is “failure to keep adequate and accurate medical records.” In cases of “curbside” care, there are no records. Furthermore, if applicable, you could run afoul of supervision requirements and frustrate your supervising physician. Know your state’s rules, and your supervising physician’s, to stay out of hot water.
Additionally, many malpractice policies provide coverage “arising out of” clinical responsibilities within the practice setting. Your policy may not cover actions outside that setting.
Lastly, if you are asked to prescribe narcotics for friends and family—well, put it this way: I would say the word never isn’t strong enough; as both an attorney and a clinician, my advice is to never, ever start down that snake hole. It is sure way to risk irrevocable loss of your license.
When friends and family request “curbside” treatment, be quick to make a referral—to the patient’s own clinician. For anyone you feel comfortable treating, the best course of action is to record your findings and treatment and forward this information to the patient’s primary care provider; email is good. If you must use the back of a business card to make a quick, dated note of your findings and treatment—do it. In sum, be very selective as to what is safe and appropriate. Remember, a plaintiff’s attorney or state investigator is guaranteed to have a field day with the “curbside” visit gone wrong. —DML