Medhaps

Don’t Point that Thing at Me!

Posted on 03. Sep, 2009 in Case Reports

Case Synopsis

In what at first seemed to be a simple case, when we dug a little deeper beneath the surface, we were surprised at what we uncovered. (You’ll notice that the actual case files are 21 pages long!)

About Dr. Dunham

Having graduated from medical school in 1969, Dr. Dunham entered the Navy family practice residency until 1973. He then started but did not finish a residency in psychiatry and a fellowship at the Reproductive Biology Research Foundation. In 1975, Dr. Dunham became certified as a sex therapist and sex educator. It was this time when he opened a private practice training therapists as well as treating psychiatric patients.

Next door to his office was a business that offered electrology services for removal of body hair. There was also a dermatologist in the building who would give lidocaine injections to the electrologist’s clients if they wanted an area numbed (like a bikini line or on the face) before she performed the hair removal procedure.

Innocent Beginning

Around 1987, the electrologist, Lauren, asked Dr. Dunham if he would be willing to inject her patients with lidocaine. He agreed. Over the years, he averaged about two or three patients a week. In 1994, Dr. Dunham reduced the size of his practice. In addition, his lease was up and did not want to sign another seven-year lease. Coincidentally, Lauren was moving office locations, so an agreement was made for Dr. Dunham to rent some of her space. He continued to provide services to Lauren’s clients as needed.

Generally charging $65 per injection, Dr. Dunham kept his own records and chart as well as obtaining a routine history and physical exam prior to treatment. Typically, Dr. Dunham would give an injection but not use it up completely. He would then give the syringe with the leftover lidocaine to Lauren in case her client needed a “touch up.” If so, Lauren would have the client return to the Dr. Dunham’s office for additional injections.

Things Turns Cloudy

In May of 1994, Dr. Dunham hired a part-time receptionist, Tina. Tina had no background in nursing and had never given an injection. During the course of her employment, she received treatment from Lauren at no charge. But instead of Dr. Dunham performing the lidocaine injections, Lauren numbed the area herself.

In 1995, Tina decided to attend electrolysis school. Throughout the 600-hour program, she continued to work. The program never taught her how to inject lidocaine. She received her license in 1996 and started to work for Lauren. Also around that time, Cheryl, another electrologist, began working for Lauren. Dr. Dunham then taught both Tina and Cheryl how to give lidocaine injections. He taught them how to insert the needle under the skin and how not to go too deep. However, he did not teach them how to aspirate before injecting (to make sure the lidocaine is not injected into a blood vessel which could be fatal) and did not tell them about the risks involved.

In 1996, Tina, Cheryl, and another electrologist decided to leave Lauren and start their own business. They asked Dr. Dunham what can be done about the injections. He told them that they could come to his office or his home. Later, he told Tina that they could continue giving injections even if he was not there because they were simply moving offices and that they had been trained by him. He made sure however that they only gave injections to clients who he has previously seen – new clients must still see him first.

The Raid

In 1997, investigators from the Division of Investigation of the Department of Consumer Affairs conducted an investigation of the new office. They seized bottles of lidocaine and syringes (lidocaine is a prescription only medication). Immediately after the raid, Cheryl called Dr. Dunham because she was terrified. Dr. Dunham reassured her that she was not breaking the law and that everything would be all right – after all, he was the one providing the lidocaine, he trained her, and he has trained many people to perform many kinds of injections from bee stings to insulin. Tina also called Dr. Dunham in a panic. Dr. Dunham told her the same thing as he told Cheryl.

A few weeks after the raid, Cheryl called Dr. Dunham and asked him what should be done about clients who had still wanted injections. He told her it was legal and to continue giving it. She wanted something in writing, so Dr. Dunham wrote prescriptions for the clients, some in arrears.

The Investigation

Review of patient records revealed at least one patient who felt drugged and tired after being injected by Tina. He was afraid to drive home so he slept in his car for a half hour first. There was also evidence the chart contained false information such as a history form that was backdated indicating that Dr. Dunham had given an injection when in fact he had not.

In 1997, the board interviewed Dr. Dunham. He denied training any of the electrologist to do injections when he was not available, but admitted he showed them how it was done as he was performing it himself. He denied that Tina would do injections for him when she worked for him. In addition, Dr. Dunham said that after Tina and Cheryl left Lauren, their clients would either come to his office or home, or he would go to their place of business to perform the injections. In reality, Dr. Dunham never went to the business and no client ever came to Dr. Dunham’s home.

Dr. Dunham also indicated that he wrote 11 prescriptions for the electrolysis clients he had seen as patients so that they could give themselves the injections. He did not see any danger in this. He did this at Cheryl’s request because he thought “she was covering her ass” but never ever expected anyone to actually fill the prescriptions and then use the lidocaine.

While it was clear that the lidocaine bottles that were used were supplied by Dr. Dunham, he denied it and speculated that Tina and Cheryl may have just taken it from his office as they were not kept in a locked place. And while he most likely gave express permission for his wife, he denied knowing his wife supplied lidocaine, needles, and syringes. He also denied he knew he was receiving checks from Tina for the injections she performed. He claimed during the interview that Tina and Cheryl had asked him many times if they could inject the lidocaine if he were not there, and he claimed he told them that he did not want them to do anything as it would place his license in jeopardy.

The total amount of money he made from the unlawful injections through the years was around a few hundred dollars to $1000.

Numerous letters from patients, colleagues, and friends of Dr. Dunham written in support describe him as someone who frequently goes out of his way to render excellent medical and psychiatric assistance to those in need, often without being paid. He is uniformly described as caring, compassionate, and generous. In addition, he owns a home in a village in Mexico where the closest medical facility is about 8 hours away by car. He has treated the sick and injured there for free and has taught the locals how to render medical treatment, including how to sew up an injury using lidocaine.

Case Outcome

Tina had her electrologist license suspended for 12 months and required to perform 200 hours of community service. In addition, she was required to take 100 hours of additional electrolysis training.

Cheryl surrendered her license as a result of her giving lidocaine injections.

Dr. Dunham had his license revoked, but was stayed (revocation put off) with 3 years probation with terms and conditions including 1 year of actual suspension.

Our Analysis

We wanted to do something a little different just for this particular case. Instead of having an analysis followed by two responses, we decided to take snippets from the state board’s report. We rewrote parts of it to help it read in context with our case synopsis:

In his defense

First of all, while the electrologist gave numerous injections of lidocaine, no client was injured and none complained to the state medical board. Lidocaine is a safe medication and is commonly used in doctor’s offices and hospitals every day without incident. Dr. Dunham has had a long and distinguished career and has never had any discipline imposed in the past. The amount of money he made from the unlawful lidocaine injections was small, perhaps a few hundred dollars or as much as $1000. His motive for providing lidocaine to the electrologists was to assist them and their clients, not to enrich himself.

He cooperated with the board’s investigator by agreeing to two interviews and instructing his staff to assist her in obtaining records and other information from his office.

The numerous letters written in support of Dr. Dunham describe a physician who is providing needed services to the community in a caring and compassionate way.

Against him

However, although no actual damages occurred, there was potential for serious harm which could result from injections given by persons who were untrained and unsupervised. Neither Tina nor Cheryl had any medical training. Their electrology course did not teach them how to give injections. And while Dr. Dunham may have shown them how to give an injection, he did not teach them what the risks and consequences were, what to look for if a patient were experiencing an adverse reaction, or how to handle an adverse reaction. He did not provide them with any emergency equipment or emergency training. They did not know how much lidocaine was safe, and while they were instructed to inject the medication directly below the skin, there was no assurance they knew how to tell the difference between an injection just below the skin and one in deeper tissue or in a blood vessel.

Also against him was that he was not truthful in his interviews and in his medical charts. He wrote phony prescriptions when he learned of the investigation and entered phony blood pressure readings. He blamed the electrologist and his wife for his troubles. He did not admit any wrongdoing on his part, accept any responsibility, express any remorse, or provide any basis to conclude such misconduct would not recur.

Decision

The choice of an appropriate penalty in this case is a difficult one. It is noteworthy that little of the misconduct shown in this case had anything to do with his actual practice of medicine. Thus it is not Dr. Dunham’s ability as a physician which is in question here but rather his judgment. He knew or should have known electrologists cannot give injections. But he did not accept responsibility for his misconduct. It is therefore imperative a penalty impress upon him the seriousness of his error in judgment. If that is done, the public would be adequately protected. balancing all the competing factors, it is concluded an outright revocation of Dr. Dunham’s license is not necessary.

Therefore, a revocation, stayed, with a lengthy actual suspension, prohibition against possession and furnishing of lidocaine and other pain substances, and attendance at an ethics course, would satisfactorily protect the public from respondent repeating the misconduct proven in this case.

Medhaps's DAISE Score - What is this?

Score
3.6

Damage	Anger	Ineptitude	Shock	Ethics
2	3	3	3	7

The DAISE Score

The DAISE (Day-see) Score is comprised of 5 metrics. Each component measures different aspects of the case to determine it's severity. This is done so different cases can be compared and contrasted, along with bringing attention to the many aspects of the stories.

Damage	The amount of damage caused by the perpetrator(s) in the story. This typically will include the patient and family, but sometimes it may include other factors as well, such as the environment, society, etc.	0 = No actual damage 10 = Heaviest damage
Anger	The amount of anger and animosity you feel toward the doctor(s) while reading the story.	0 = Cool serenity 10 = Seething, white anger
Ineptitude	How much of this medhap was caused by the doctor's incompetency and negligence?	0 = Not really the doctor's fault 10 = Should never be a doctor
Shock	How shocked/surprised were you after reading this story?	0 = Hear about it all the time 10 = O..M..G...
Ethics	Or rather, the lack thereof - How much did the doctor breach the code of ethics?	0 = No breach in ethics 10 = Criminal

The final Score is an average of the 5 metrics. The higher the score, the worse the case.

Tags: Featured, Loss of License/Stayed, Probation, Suspension