We often worry about complications from difficult procedures. What might happen if a patient has anesthesia for 12 hours. Or, operating on a redo-redo cervical spine. And we’re right to be cautious.
But, even simple things can be fraught with hazards; hazards that are easily prevented.
Such an argument is being propelled in Nelson v. Emory Healthcare. The 55 year old patient, Chris Nelson, had blood drawn as part of a wellness exam. He was seated upright on an exam table. Nelson lost consciousness, fell off the table, and was found on the floor, prone, bleeding from his head. It’s not clear from the report whether he fell during the blood draw, or after the venipuncture (when he might have been left alone).
The doctor entered the room, performed a neurological exam, and implemented cervical spine immobilization (given the high index of suspicion for a cervical spine injury).
Once the patient regained consciousness, he complained of tingling in his arms and legs. He was transported to Atlanta Medical Center where he was diagnosed with a broken neck and spinal cord injury.
It’s unclear from the reporting whether his cord injury is complete or partial. It’s also unclear what level his quadriplegia/quadriparesis starts.
What is clear is his plaintiff’s attorney is arguing Nelson will require nearly $5M in economic damages alone – including medical bills and lost wages. That’s before any calculation on pain and suffering.
His lawyer is arguing that it was foreseeable venipuncture could trigger syncope and he should not have been on an exam table. He should have been in a padded chair that would prevent or cushion a fall.
Syncope after blood draw is not unusual. Losing consciousness after any needle stick happens – this includes Botox, trigger point injections, etc.
We’re right to think about complications after complex procedures. We also need to prevent complications after simple procedures.
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For 28 years I had a private practice with emphasis on dermatologic surgery including Mohs surgery. I performed over 26,000 Mohs surgeries under local anesthesia and I performed tens of thousands of biopsies using local anesthesia. For 17 years I taught dermatologic surgery to dermatology residents at UT medical school here in San Antonio and I emphasized and reemphasized and reemphasized again to the residents that every time you put a needle in a patient, that patient should be lying down unless of course they are unable to do so or have a contraindication. Padded chairs are not necessary. All that is necessary is that the patient be supine. In medical school and residency I saw innumerable patients who had syncopal episodes because they were given injections while sitting up and several of those barely missed having a serious falls. Information about this lawsuit I pray will be disseminated widely especially to those physicians who teach at medical schools and in residency programs. There are of course some patients who for medical reasons or other reasons cannot lie supine. likewise there may be some types of injections were being supine is contraindicated. But for the vast majority patients who do not have a contraindication they should be lying supine while receiving their injection. Special padded chairs except perhaps in uncommon circumstances are not necessary .
I agree with Dr. Day. However, regardless of any and all other circumstances, I believe that keeping the patients attended and under observation until they are able to tolerate the erect position without symptoms is the sine qua non.
There are a number of circumstances that can result in unexpected syncope in an office or clinic. Another common one occurs when an operative pin, sutures/staples remove, catheter extracted or installed, etc.
Sometimes syncope occurs outside a clinic. When I was a teenager applying for a job at a day camp, I was asked by the owner’s wife for a blood sample for an academic project she was doing. I submitted to the venipuncture and immediately fainted. I realized the problem: the woman who withdrew my sample was drop-dead gorgeous.
But the patient above fell directly on the floor. His injuries and the resulting lawsuit are no joke. Sometimes no matter what we do or don’t do, bad luck intervenes. I agree with all of the posters who say that the patient should be observed and placed into a position where they will not come to harm.
I used a blood-drawing chair (used by blood clinics) where the patient was always in the “right” position if they fainted, and would come to no harm from falling, since they were lying down anyway, when I pulled sutures, operative pins and gave injections. A lot of innoculations are given by nurses with patients sitting upright in a chair. Perhaps that practice should be “modified.” A nurse who weighs 120lbs will not be able to assist a patient (who weighs 320 lbs) in the process of sliding off the chair.
If you own your own clinic you also need “slip and fall” insurance for patients who are entering your office. This means that you also have an obligation to clear your driveway and walkway of ice and snow, when necessary. This includes putting down salt or sand to reduce falling risk.
I don’t wish anyone harm but just ONCE I would like to read or hear about a plaintiff attorney who was sued from one of his/her own clients after a slip and fall accident at THEIR office.
Michael M. Rosenblatt, DPM
We have seen more cases of vaso-vagal syncope during or after a needle-assault, than you can imagine. This is why God invented Trendelenburg which is immediately curative. You can often see patients’ respiratory rate increase, followed by pallor and lightheadedness before vaso-vagal syncope occurs. After administering a needle assault, I always observe the patient and ask the patient if they feel like they may pass out before making the examination chair vertical and leaving the room.
That said, vaso-vagal syncope can come on quickly. I had a young lady pass out when I raised the exam chair – she slipped on her butt off the chair and onto the foot rest. I controlled her ride down and lifted her legs, and she immediately awoke. She asked me if she hit her head, since that happened to her in the past. Once a vaso-vagaler, always a vaso-vagaler. We should all ask our patients if there is a personal history before commencing a needle-procedure.
After reading this post, it now seems unusual that every time I’ve had blood drawn, its been in the seated position, in a plastic “phlebotomy chair”. Time to get phlebotomy chairs with a Trendelenburg switch. This is common sense.
It’s probably safer phlebotomizing on an exam table, as opposed to a static chair chair, since the lightheaded patient can be instructed to lie flat with knees bent to increase venous return to the heart and brain. A phlebotomist could lift the legs of a supine patient as an adjunct.
Broken neck after falling off an exam table? Oy.
Anybody notice it’s not the women who faint, but the strong young men?
No surprise, of course.
Men weak!
Women strong!
Anybody notice it’s not the women who faint, but the strong young men?
No surprise, of course.
Men weak!
Women strong!