Complaint
The Commissioner received a complaint from a complainant on behalf of her daughter, the consumer. The complaint is that in mid-January 1998 during a wart removal procedure, the provider, a practice nurse, failed to take reasonable care and burnt the skin surrounding the consumer's wart with liquid nitrogen.
Investigation
The complaint was received on 26 January 1997 from the complainant and an investigation was commenced. Information was obtained from:
- The Complainant / Consumer's mother
- The Provider / Practice Nurse
- A General Practitioner, a Medical Centre
Clinical notes from an Emergency Medical Service and Medical Centre were reviewed and a nurse practitioner gave advice to the Commissioner.
Outcome of Investigation
On a Friday in mid-January 1998 the complainant took her daughter, aged five years, to her GP to have two warts on her right heel removed. The complainant first asked for the warts to be cut out but was advised removal with liquid nitrogen would be the best method although it would still cause some pain. The complainant agreed for this to be done. The nurse practitioner advising the Commissioner stated that:
Most warts are either frozen, or treated with wart paint or paste... Surgical excision of warts is not usual practice.
The provider consulted with the Medical Centre's GP before undertaking the procedure, giving the complainant the impression that the provider had never done the procedure before and was asking for instructions. However, the provider stated that she is familiar with the procedure and that she consulted with the doctor to get his authorisation.
The nurse practitioner advising the Commissioner stated that:
It is common practice for the Practice Nurse to seek consultation with the GP to say whether or not a lesion is suitable for freezing... It is not within the responsibility of the nurse to make decisions on the nature and treatment of skin lesions.
The consumer lay on the plinth while the complainant held her heel so that the provider could perform the procedure. While both agreed that the consumer was distressed by the procedure, the provider and the complainant each gave conflicting accounts of what happened next. The complainant reported that the provider took a chunk of cotton wool and wound it around two cotton-tipped applicators. This was grasped by a pair of tongs and inserted into the liquid nitrogen, which was then taken dripping to the consumer's heel and applied for what seemed like a long time.
The provider reported she took in her hand one cotton tipped applicator with an extra piece of cotton swab wrapped around the tip and dipped it into the liquid nitrogen. The provider did not use tongs and could not recall any dripping of the substance. The provider then applied the liquid nitrogen to the area for 10 seconds, timing it with her watch. There was a sound of sizzling as the skin was being burnt and she observed the area turn white to indicate it had been frozen. The provider reported that the area covered was larger than what she had intended but not excessively so. The advantage was that it had burnt the other wart as well and so meant the procedure did not have to be repeated. The provider reported she had no concerns about the process at the time. As part of the investigation, the provider submitted an applicator identical to the one that she reported using, which was a cotton swab of about six inches long with extra cotton wool wrapped around the tip. This swab was submitted to the nurse practitioner advising the Commissioner who stated that:
Liquid nitrogen is commonly applied with a cotton tipped applicator like the one used in this case. It is also commonly suggested that extra cotton wool be wrapped around the tip as commercially available tips are too tightly wound so do not hold enough liquid nitrogen for the procedure.
The recommended technique is to apply light pressure until a white halo of skin is seen around the lesion... With the cotton bud technique it is not always easy to see the area being frozen so it would not be uncommon to freeze a larger area. However... it would have been preferable to freeze each wart using a smaller applicator. The use of tongs was not mentioned in any of my research. Contact with the skin does cause a "sizzling" sound. Liquid nitrogen evaporates at a temperature of -196ºC so there is a lot of apparent steam and dripping and condensation when it is exposed to the air.
The complainant then walked the consumer to the bus stop and observed she was still distressed and limping. Later that evening the area was weeping and a blister appeared about the size of a 10-cent piece. The nurse practitioner advising me stated that:
Infection from freezing is rare. However, if the blister breaks, infection is more likely. It sounds as if [the consumer's] blister broke soon after the procedure allowing an infection to set in. Anything on the foot is probably more prone to infection especially if there was rubbing from footwear. I don't believe there was anything in [the provider's] technique that could have prevented this other than freezing each wart separately so that smaller blisters were produced.
The wound continued to seep fluid and therefore the complainant took the child to the after-hours medical service on Sunday, two days after the procedure. The area was cleaned and redressed with antibiotic cream. On the Monday following the incident the complainant reported that she telephoned the Medical Centre's GP to complain but no apology was forthcoming. The complainant then decided to look for another doctor and went into the surgery a few days later to uplift her notes. The provider commented in her response to the provisional opinion that the complainant shouted at her and was verbally abusive. In response the complainant said she did not speak loudly at this time but did demand her notes from the provider. The complainant's new GP advised daily dressings.
The nurse practitioner advising the Commissioner stated that:
More time and care could have been taken with an explanation of the procedure so that informed consent was given by [the complainant] and [the consumer]. Also more attention to explaining after care of the heel may have prevented this unfortunate incident
The following Rights are applicable:
RIGHT 4
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
RIGHT 6
Right to be Fully Informed
1) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including-
b) An explanation of the options available, including an assessment of the expected risks, side effects, benefits, and costs of each option
Opinion: Breach
Right 4(2)
In my opinion the provider breached Right 4(2) of the Code of Health and Disability Services Consumers' Rights.
The provider followed the usual procedure in removing the warts using liquid nitrogen. There are conflicting accounts on whether or not the provider used tongs to grasp the applicator(s) to apply the liquid nitrogen. However to do so would be an unusual variation on the technique and there does not appear to be any reason why the provider would choose to do so. Both the provider and her employer state that the provider is experienced in the application of liquid nitrogen and I accept that this part of the procedure was carried out effectively.
Opinion: Breach
The provider's application of liquid nitrogen was excessive. It is inappropriate to excuse the excess coverage by stating this removed the need to repeat the process on the other wart. Each wart should be treated separately to maximise success and minimise risk.
Opinion: Breach
Right 6(1)(b)
In my opinion the provider breached Right 6(1)(b) of the Code of Health and Disability Services Consumers' Rights. The provider did not provide adequate information to the complainant including a description of the forthcoming procedure and the risks and side effects of applying liquid nitrogen to the skin. The complainant needed to be informed that a blister would form some hours after the procedure and that this would require special care to avoid becoming infected. This was especially important given that the blister would form in an area that was prone to rubbing from footwear.
Actions
I recommend that the provider:
- Apologises in writing to the complainant and her daughter for her breach of the Code. The apology is to be sent to the Commissioner who will forward it to the complainant.
- Spends time before wart removal procedures discussing the process and after-effects including wound management.
- Applies the correct amount of liquid nitrogen using appropriately sized applicators, dependent on the size of the wart.
- Reads the Code of Health and Disability Services Consumers' Rights.
A copy of this report will be sent to the Nursing Council of New Zealand and the GP at the Medical Centre where these events occurred.
Further Actions
I recommend that the GP provide an information leaflet for consumers who undergo wart removal procedure by liquid nitrogen. An example can be found in New Zealand Practice Nurse, December 1993.