Mr M, a 38-year-old financial adviser, was an existing patient of Dr V, a dermatologist. He had a history of acne keloidalis nuchae. Besides the skin disorder, he was a healthy individual with no known co-morbidities or allergies. There was no pre-existing surgical history, or family history of cancer.

The keloids in the occipital region of his scalp were secondary to his existing skin condition, for which he was treated with a combination of antibiotics and topical ointments daily.

Mr M received further treatment in the form of intralesional corticosteroids in January and February 2015 respectively. Mr M had returned for his third treatment at Dr V’s rooms in April 2015. Because the administration of the corticosteroids had proven painful during previous visits, Dr V decided to use local anaesthetic before proceeding on this occasion.

The procedure was explained by Dr V to the patient before commencing. Due to the nature and presentation of the keloid, the insertion of the needle was difficult. It was asked whether the patient could feel anything, to which he replied that he could not feel any pain but he was not feeling well. The procedure was immediately halted and Mr M was asked once more how he felt. At this point he began to breathe heavily, subsequently becoming unresponsive.

When the procedure was halted, the time noted was 10:12. Mr M was placed into the recovery position while help was called for. Mr M was transported on an emergency trolley to the operating theatre, one floor down from Dr V’s rooms, by Dr V, the hospital matron, an anaesthetist and an ENT surgeon. 

At approximately 10:16, Mr M was still unresponsive, with no pulse detected.

He was intubated, a drip inserted and 1ml of adrenalin was administered intravenously. Chest compressions began at about 10:19, followed by defibrillation. Further adrenalin infusions up to 5ml and atropine 1mg were administered intravenously.

Mr M was sadly declared dead by the anaesthetist at about 10:28.

A claim against Dr V

Mr M’s wife sued Dr V, alleging that Dr V was negligent and that this led to Mr M’s untimely death.  It was alleged that the cause of death was anaphylaxis due to the anaesthetic used during the procedure. Among other things, it was alleged that Dr V failed to warn Mr M that the local anaesthetic could be fatal. It was further alleged that Dr V failed to obtain informed consent for the procedure.

Expert opinion

Dr S, an emergency medicine practitioner, provided the following expert opinion:

Adrenaline is a critical medication in the treatment of anaphylaxis and is found to be ineffective in only 10% of most cases. It appears that there was a significant delay in the administration of intramuscular adrenaline, and delayed administration is often associated with a poor outcome. Adrenaline should have been administered at the earliest possible time, which would have been around 10:13, had the ampoule and other stock (ie needle and syringe) been readily available in Dr V’s rooms.

It was not established exactly when Mr M was noted to be pulseless. This should have been among the first diagnostic tests performed in order to proceed with the correct protocol for the treatment of cardiac arrest, which is to immediately begin chest compressions. As per Dr V’s chronology of events, this commencement of chest compressions had begun in theatre.

Considering that fatality as a result of medicine-induced anaphylaxis is rare and often difficult to predict, it is reasonable to expect a practitioner to be adequately prepared should this type of complication occur.

Mr M could have potentially had a 90% chance of responding to early adrenaline administration, but  it was impossible to accurately opine on Mr M’s statistical chances of survival since there was no data to show that the delay specifically would have led to death from anaphylaxis. There was nothing in Mr M’s medical history to identify him as a high-risk patient for anaphylaxis. He gave verbal consent to the procedure, and Dr V could not have predicted this outcome. That said, every procedural practitioner is reasonably expected to be prepared for anaphylaxis.

Outcome

Dr V was vulnerable to criticism by a court on the basis that she did not have the necessary resuscitation equipment in her rooms when she should have. Given expert opinion that Mr M potentially would have had a 90% chance of survival had the adrenaline been administered sooner, it was agreed that the matter should be settled. The attorneys appointed by Medical Protection to represent Dr V negotiated a settlement with the plaintiff’s attorneys.

Learning points

When undertaking to perform procedures within the practice, it is prudent to obtain written consent from the patient, which clearly states the name of the procedure, what it is for, how the procedure will be conducted and what the potential side effects could be.

Adequate emergency equipment should be available as the reasonable practitioner should be prepared for any reasonably expected adverse events. Emergency stock should be readily available and kept as close as possible to the procedural area. Emergency stock should be checked daily for expiry dates and should be replaced immediately if used. Stock should be stored appropriately and at the correct temperatures.

Practitioners should always keep abreast of current protocols and procedures, in order to act efficiently and appropriately should an emergency arise.

Basic preoperative examinations should be carried out in order to have a baseline of the patient’s condition before the procedure, as this could be an early indicator of any abnormality present, which would directly influence the outcome of the procedure.