Download Abusive Steroid Skin Injections in a Diabetic Patient, without Proper

Abusive Steroid Skin Injections in a Diabetic Patient, without Proper Sterile Technique
Causing Severe Infections, not Timely Diagnosed
According to the medical records, this patient was a borderline diabetic for one year. Steroid
medications significantly affect diabetics and borderline diabetics. It makes their diabetes worse
while under the effects of those steroids.
Based on that fact, a patient must be fully informed of that risk. In addition, steroids used other
than for acute purposes pose a risk to the weight bearing joints (hips and knees) for a unique
form of gangrene (aseptic necrosis). It also causes muscle wasting and significantly interferes
with the immune system, making the risk of acquiring an infection much greater, and markedly
interfering with the ability of the body to control and to cure such an infection.
The long acting steroids that are injected into skin lesions do get absorbed into the bloodstream
and do have these “systemic” effects.
It is my opinion that the risks to her outweighed the benefits.
I do not believe she should have been given antibiotics with the injections. However, I feel that
she should not have received these injections.
Furthermore, her skin should have been thoroughly cleansed with an antiseptic solution. In
addition, proper sterility conditions were required, as I shall describe below. Because the same
Staph aureus germ was involved in the three widely spaced abscesses, it is my opinion that the
solution and/or device were not maintained in the sterile condition that is required.
Was the steroid medication from a multi-dose vial and was this the first patient it was used for?
If not, how was the rubber stopper cleansed prior to each use, and was it kept refrigerated
between uses?
In my opinion, the Doctor and not the Nurse should be using the “Dermajet” injecting device.
A skin biopsy was performed by Dr. #1 in his office. The pathology report is missing and needs
to be obtained.
If, as you allege, the solution was spilled, then the Nurse is not competent to use the device and
probably broke sterile technique.
On March 26, Dr. #1, an Osteopathic Physician (D.O.) Dermatologist used the Dermajet to inject
lichenified plaques on her iliac crest (pelvic/hip bone area). He used Intralesional Triamcinolone
at the dose of 40 milligrams/cubic centimeter (1/30 ounce). That is a standard concentration.
What volume (which is proportional to the amount of steroid injected) was used each time?
You note that on May 7, one of the Doctor’s Nurses used the Dermajet over 30 times to inject the
Triamcinolone steroid into her hip, thigh and back areas. That is abusive.
As a Medicaid patient, how were they billed for these “services?”
When an injection is given, it is standard for the patient to be lying down so that if they get
“lightheaded” or faint, they will not injure themselves. The Nurse injected her sitting, which is
negligent, but the patient did not faint.
Pain coming two days after the injection (of this steroid, especially in a borderline diabetic) is
pathologic and infection should have been considered since that is what it was. The patient said,
“she feels that it has knots deep inside.” This was a red flag that was not heeded. Dr. #1 noted
she had tenderness but no overt signs of infection. He considered ordering muscle enzyme tests
and they were normal the next week. He meant to order the serum aldolase too, but instead the
next week ordered and received the serum amylase (pancreas gland) enzyme result (normal). He
said: “I have no other explanation for her complaints,” having felt that a steroid myopathy
(muscle damage) was not reasonable.
On May 14, he ordered the muscle enzyme tests but did not order a Complete Blood Count
(CBC) or blood sugar test. On her back, she had “a well demarcated thickened (lump)
erythematous (red) area that is tender to touch with no epidermal (skin) changes” (except it was
red). Was it hot? Pain and redness and a deep lump are consistent with an abscess. She should
have been referred to a Surgeon for a second opinion. His explanation was “Arthropod (spider)
bite, cannot rule out (r.o.) infection.” The copy stamp “happens” to be over “cannot.” “Spider
bites,” especially in a borderline diabetic who had been injected with steroids can be serious and
should have triggered a consultation since he “cannot rule out infection.” He prescribed the
antibiotic Keflex at the standard dose of 500 milligrams but ordered it to be taken only twice a
day. It should have been ordered every six hours, but a consultation was also needed to put a
needle into it (aspirate) to see what was there (pus: germs and white blood cells). I believe his
actions and inaction were negligent.
On May 28, “Patient presents with a very striking problem.” She was red from her chin down all
over her body. And “The arthropod bite versus infection on the back is now more larger (sic),
somewhat fluctuant (fluid (pus) filled by feel), with an area of desquamation (skin loss) over the
top.” The infection was trying to drain itself. He was negligent for not immediately draining it
or having her see a surgeon that day. The hip also “has some thickening and swelling in a
localized area…denies any systemic toxicity.” He must be blind. She was red all over and
sometimes had a chill. That is systemic toxicity. She was not in shock. He concluded that “2.
Staphylococcal scalded skin syndrome,” which is from the Staph aureus bacterial germ poison
and is “systemic toxicity,” and continuing an oral antibiotic without draining is negligent care
and led to worse infection and cosmetic damage.
On May 27, the previous day, she saw Dr. #2. Her temperature was 100.8 and her pulse was
elevated to 120. Her respiratory rate was twice normal at 32. She diagnosed “abscess” and
prescribed the oral antibiotic Cipro and noted she had a yeast mouth infection (from antibiotics)
and prescribed an anti-yeast mouthwash drug. She failed to drain it or send her to a Surgeon.
She and her clinic are negligent. Furthermore, she billed $35 for a Decadron (potent steroid)
injection. This was neglicence on top of previous negligence.
She had previously seen Dr. #2 on April 29 and her pulse was 112 and respiratory rate was 32.
Neither time did the doctor ever take notice of it, or its “systemic” significance, which is further
negligence.
On May 30, a Healthcare Professional #1 saw her in Dr. #1’s office and noted similar findings as
May 28. But also said that the lesion on the back was “certainly fluctuant” and noted the
previously documented “localized swelling on her left anterolateral hip.” Their concern was for
her to continue to take the antibiotic (which was not resolving the infection), and an abscess
(fluctuance) must be drained in order to control and cure the infection, and the gross negligent
failure of all to do or arrange for this as an urgency made it into a life threatening emergency, and
cosmetic disaster for her. That was her last visit to that office, fortunately!
She was seen in the clinic office of Dr. #2 on June 3 with a pulse of 120 and they noted that the
wound has opened, and her hip was tender. They noted she had “abscess back” and did nothing
to aid her. It needed open deep drainage and the hip needed to be aspirated with a needle/syringe
to diagnose it, and then it had to be drained.
The Complete Blood Count differential smear blood test on May 27 from Dr. #2’s office was
received in the laboratory on May 28, and it had “18% Bands” (normal is 0-5). These are
immature white blood cells that pour out of the bone marrow to fight a very serious infection. I
found no comment in their office records on this very abnormal test, further negligence.
On June 14, Dr. #3 saw her in the Hospital #1 Emergency Room and noted “…a very large
abscess on the right gluteal and right outside of the thigh extending into the abdominal wall.
This area is quite indurated (swollen), red and very tender.” He opened the wound to drain it and
said: “There was pus with a lot of air coming out. The patient has a lot of necrosis.” This was a
gas gangrene and he saved her life. That mass was “orange to softball size.” Her pulse was 153
and respiratory rate was 40. She was septic (overwhelming infection almost putting her into
septic shock, which is deadly). The culture was Staph aureus. She was immediately transferred
to the Hospital #2 with intensive intravenous (by vein) antibiotics, en-route.
On June 15, she underwent a radical débridement (cutting out of dead and infected flesh) of her
left thigh abscess which contained 300-400 cubic centimeters (10-13 ounces) “of frank pus.”
On June 16, more pus was drained from the right thigh, the left thigh drainage site was repacked
with gauze, and the back wound was opened further and packed.
The care at thes two hospitals was excellent.
The “care” by Dr. #1 and his Nurse, and by Dr. #2, her associate and her clinic office, were
incredibly negligent, as described in detail above.
Once the infection was fully resolved, and after she was off all steroids (it had to be tapered so
she would not go into steroid withdrawal shock), her diabetic state should return to its preexisting state. However, it may be more difficult for her to use her exercise bicycle because of
the thigh scarring. She should be examined by a local Doctor in Physical Medicine and
Rehabilitation to assess that potential problem. Her foot problem resulted in some disability and
decreased exercise and therefore weight gain. Usually if a borderline diabetic loses some of their
excess weight, their type II diabetes will disappear.
We continue to remain available assisting you with this case and I would recommend that you
authorize us, per our Fee Schedule, to obtain Expert opinions by a Dermatologist, Infectious
Disease Physician, a Family Practitioner (re: Dr. #2), and a General Surgeon.