Medicolegal Issues

Malpractice Counsel: Necrotizing fasciitis, corneal abrasion



On physical examination, the patient’s left eye was closed, and he appeared to be somewhat uncomfortable. His vital signs were all normal. His visual acuity was 20/20 in the right eye and 20/60 in the left eye, which was due to tearing and blurriness from the injury. To facilitate the examination, the EP placed two drops of proparacaine hydrochloride ophthalmic solution 0.5% in both of the patient’s eyes, which provided immediate and near total relief of the left eye pain. On fluorescein and slit-lamp examination, the EP found a small foreign body at approximately the seven o’clock position on the cornea, as well as a surrounding abrasion. The corneal anterior chamber was normal. The EP removed the foreign body, prescribed a topical ophthalmic antibiotic cream. and instructed the patient to return to the ED in 24 hours for a recheck. The EP also instructed the patient to take ibuprofen for any associated pain.

While waiting to be discharged, the patient took the vial of proparacaine that had been left on the counter in the room. He did so without informing anyone and without permission. After the nurse returned to the room and gave the patient his discharge instructions, he was released home. Neither the nurse nor the physician realized the patient had stolen the topical anesthetic.

Four days later, the patient presented back to the same ED with severe pain and decreased vision in his left eye. On examination, he was noted to have a large, deep corneal ulceration. Upon further questioning, the patient admitted to taking the proparacaine drops and using them nearly every waking hour to treat his eye pain. Before the patient was referred to ophthalmology services for emergency evaluation, the EP instructed him stop using the proparacaine drops and explained to him that his symptoms were directly related to his abuse of the medication.

The patient sued the EP for leaving the “miracle” pain-relief medication in the room and thereby facilitating his actions. The plaintiff argued that the immediate and complete pain-relief effects of the medication were too tempting for a nonmedical person to resist, and that the drug should not have been made available to him under any circumstance. The EP argued the patient stole the medication and that any resulting injury was completely the result of the patient’s own actions. The suit was eventually dropped.


It is unfortunate that this ever became a malpractice case, since it is clear to any layman that the stealing of medications is inappropriate and illegal; moreover, any damages resulting from that action are completely the responsibility of the transgressor. With that said, a significant amount of time, discomfort, and inconvenience could have been avoided had the nurse or physician simply removed the medication from the room. While I certainly do not think this is required from a medical-legal standpoint, it is a good common-sense practice.

Corneal abrasions and corneal foreign bodies are very uncomfortable, and medications such as nonsteroidal anti-inflammatory drugs or acetaminophen only provide partial pain relief. It is easy to see how a young person, lacking any medical knowledge or the concepts of adverse side effects or toxicity, would be tempted in such a situation. In retrospect, it would probably have been best to have avoided leaving the medication within the patient’s reach in the first place.

With respect to evaluating and treating corneal abrasions, the most commonly used topical ophthalmic anesthetics are proparacaine and tetracaine. When used appropriately and in the hands of trained healthcare workers, these drugs are safe, effective, and exhibit nearly no side effects. However, as this case demonstrates, these drugs can be toxic when abused. The most common toxicities are to the ocular surface and include superficial punctate keratitis, persistent epithelial defects, stromal infiltrates, and corneal edema. More serious injuries can also occur, such as deep corneal infiltrates, ulceration, and eye perforation.1 The toxic effects associated with these drugs are the reason these medications are never prescribed for home use.


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