Thirteen: Trigger Point Injection Disaster:
In 1988, I seriously harmed a patient. There was no gross negligence, just an unfortunate complication which could have led to a slam-dunk-win lawsuit for pain and suffering. I don't know if I was more upset about having hurt someone or fear of suit, but I spent considerable personal energy on and with this patient. I did not get sued.
Rebecca Mason came into the emergency department one spring afternoon with exacerbation of long-standing neck and back pain. Her regular doctor was unavailable at the time, and she had no medication to help with the discomfort. She had been through physical therapy for pain in her trapezius (the large muscle of the uppermost back between the shoulder and the neck) area, with minimal improvement. Medications were used, with variable success. No one had trigger pointed (injected the painful area with a combination of local anesthetic and corticosteroid - a ‘cortisone shot’) her pain. The diagnosis was myofascial (muscle and connective tissue) pain syndrome and I offered this modality of treatment with the recommendation that it was very often effective, produced only brief discomfort, and if ineffective, was unlikely to cause any harm. I discussed the minimal risks and potential benefits of injecting cortisone medication, and she agreed to the procedure.
The only complications I had seen prior to this case, in fifteen years of doing trigger point injections, was one bicipital rupture (broken biceps tendon causing a ‘popeye’ biceps from the muscle rolling up on itself) and one subcutaneous atrophy (dimpling of the skin from temporary destruction of the fat layer). I avoid the first complication by carefully controlling the injection technique. The skin dimpling is uncommon and generally goes away with time. The complication that occurred on this day had never entered my mind. But now it is forever branded on my cerebral cortex, never to be forgotten whenever I place a needle anywhere near the upper trapezius muscle group.
Rebecca's pain was centered in the upper portion of the right trapezius, a typical myofascial trigger point. I was impressed with the convex contour of her muscle. It appeared to be enlarged, probably from chronic spasm, I thought. As I put the needle into the muscle, aiming down and forward at about 45 degrees, while pulling back on the plunger, as is the routine, air came back into the syringe. The pullback technique is to determine whether the needle is in a blood vessel. If so, the needle is moved to avoid injecting the medication into the bloodstream. I had gone only about 1.5 cm into this large muscle belly and I got air! I had to have punctured the lung! I immediately pulled back the needle into the muscle, out of the lung, and injected while praying that a tiny needle hole in her lung lining would seal itself without consequence. Ninety nine percent of the time (when done for other procedures), it does. She told me that she was suddenly in pain and I reassured her that this discomfort would pass. During the few minutes after the injection, I had her recline on the gurney, waiting for the discomfort to pass, for the local anesthetic to numb the muscle, and for the lung puncture to prove itself to be of no consequence. She tried to reassure herself that she was OK, as we both suspended reality. As she stood at the desk to sign out, I could see that her discomfort was growing and I had to admit to myself that she could have a pneumothorax - a real hole in the lung that might require aggressive surgical therapy. Maybe just a little pneumothorax, but painful and requiring quite a bit more than an aspirin and a call in the morning.
Within minutes, she was in agony with respiratory distress. Resigned to the grim reality, I got a chest x-ray that showed a large tension pneumothorax (a particularly dangerous, large, high pressure lung collapse which can be fatal if not rapidly treated with pressure release maneuvers). I was blown away. Sweat and terror conspired to confuse and disorient me, but poor Rebecca, in her helpless innocence and terrible pain, pulled me back into professional mode. It was time to tell her everything.
"Rebecca, I'm so sorry that this has happened. When I put the needle into the muscle, the tip went through the bottom of the muscle into your lung that was unusually close to the surface. At the moment the tiny needle went through, you were probably in a portion of your breathing cycle in which there was movement of the lung membrane at that spot. That caused the needle to rip a larger hole in your lung and now the air has leaked out of your lung, into your chest, and is putting pressure on the collapsing lung. This hurts a lot and must be treated by putting a tube into your chest to get out that extra air. The lung will seal itself in about three days but during that time, you will have to be in our ICU (intensive care unit) where we will take care of you, help your pain, and deal with any other problems that might arise. I can't tell you how badly I feel about having hurt you and I want you to know that I will do everything to make sure all ends well. I will give you pain medicine now and the surgeon will be here in a few minutes to put the tube in your chest. OK?"
She replied, through the veil of her distress, that this was all right and conveyed no anger towards me. Yet. Evidently the convex appearance of her trapezius was her anatomic variation with a high domed lung upper aspect (apex) under a typically thin female trapezius muscle. We started her IV, began oxygen, and the surgeon relieved this tension pneumothorax with a chest tube (insertion of a half inch plastic tube in between the ribs, through the chest, into the lung space and attached to a vacuum system). She was made more comfortable with Demerol, and was sent to the ICU. My head was spinning. How could I have done this? How could the tiniest of lung membrane punctures become a tension pneumothorax, and, how could I help make this OK for Rebecca.
After my shift was over, in the early evening, I went back to the ICU to check on Rebecca. Narcotics had relieved her terrible distress, but she was cogent enough to talk a little. I again told her of my distress at having caused such a complication, such an intimate assault, however unintended. She told me that she knew that sometimes, things just happen. She wasn't angry. I asked her about her life, her family, and her marriage. She spoke of great conflict at home, an abusive husband, and her search for happiness. I asked her if she had pursued counseling for this struggle. Not in a few years, and she couldn't afford it now. We talked until the spaces between words were filled with narcotic dozing (hers, not mine). I took her hand and told her I would be thinking about and praying for her tonight. I would be back in the morning and between now and then, if she had any questions for me, or if the nurses needed me, I would be available, even though not officially on call.
I came back the next morning to find her stable and in relatively good spirits, except for periods of pain. She was glad to see me. We talked about the discomforts of the night, the kindness of the ICU nurses, and her growing perspective on this experience. She expressed a desire to get on with her life, to get through some of the more confusing and tormenting aspects of her marriage. Searching my insides for something I could give her after taking away her health, I decided to try to arrange affordable sessions with a competent therapist I knew. Living and working in a small, close community, I was able to get a counselor to see her for whatever she could afford (if anything) for at least two sessions. Rebecca gratefully agreed to make an appointment as soon as she was well. We talked about different options for marital or post-marital life choices, and I shared with her some of my own mistakes, lessons, and shreds of wisdom. When it was time to go, she took my hand and thanked me. I was deeply moved by this new intimacy. I felt it to be stronger than her medical condition or the pressure society exerts to exact payment for bad outcomes, regardless of the big picture. Was this manipulative on my part? I don't know, maybe partly, but it was also genuine, spontaneous, and real. I cared about Rebecca and her pain. But I also cared about myself, my bad outcome and the possible price of this mistake. Which comes first? Parts of both.
Rebecca had an uneventful recovery. I visited with her every day until discharge and made sure she had an appointment for therapy. She looked forward to this. I told her that if there was anything I could do for her, she should not hesitate to call. I saw her a few weeks later. She was well and had some new plans for her life about which she was quite excited. She thanked me for my caring and I never saw or heard from her again. I spoke with the therapist who said things had gone well and she was moving on. To this day, many years later, I haven't seen or heard from her, or her attorney.
In risk management we speak of suit avoidance through bad outcome avoidance and good communication skills. We do not often get to experience not getting sued after a bad, painful outcome. Talking to the patient as a kindred spirit, on the same planet, empathetically, is a way to create the union in which the patient becomes connected enough to the caregiver to feel the impact of their (the patient’s) behavior on the doctor, thus reducing risk of suit. The patient may sue if they are angry. The patient may sue without anger, simply if there is a bad outcome, especially if the patient is kept at a distance from and by the doctor. When the doctor or the patient minimizes distance, suit is far less likely. If we all could feel the impact of our actions and thoughts on one another, we would find ourselves in an age of peace. As this is not likely to happen in our lifetime, the best we can do is to take one relationship at a time, whether at home or at work.
a doctor is sued for a bad outcome, even when no malpractice has occurred,
the attorneys tell the defendant (the physician) they must
not talk to the plaintiff (the patient). The reason stated for this is
something to the effect that the doctor may shoot himself in the foot
by saying something which could be used against him or herself. Many
of us believe this is legal subterfuge that serves to make sure the case
continues and ultimately, is self-serving for the attorney. After all,
if the doctor and patient come to some new level of understanding, the
case could evaporate. Though I have not been sued, some of the best doctors
I know have, and their tribulations have been an outrage to the human
spirit. Let there be no mistaking - the fox is guarding the henhouse.
Until this distribution of power is remedied, every patient and every
doctor will pay, more and more. Sometimes monetarily and eventually by
losing access to some of society’s best and brightest. This is
not to say that there isn’t a place for legal retribution in medical
malpractice cases. But the system that supports these actions also supports
abuse of these powers. We can only understand this when we follow the
All Rights Reserved © 2004 Jon Sterngold