HEN'S TEETH

Missing some medical rarities may be substandard; causing, or even failing to disclose the risk of, others may not.

Heart attacks, Bronchial Asthma and Atopic Eczema are individually common diseases. On routine blood analysis, eosinophilia is a finding suggestive of allergy. The combination may represent the very rare Churg-Strauss Syndrome, medically and medicolegally important because it is a preventable cause of heart-attack¹.

The majority of heart-attacks are caused by Coronary Heart Disease, which is only partially preventable by long-term modification of largely "life-style" factors - smoking, overweight, high blood-pressure, sedentary life-style and high cholesterol.

By contrast, failure to prescribe, or withdrawal of, low-dosage steroid medication may cause a series of heart-attacks in Churg-Strauss Syndrome. Rare it may be, but this is "diagnosis by pay-off".

PRACTICE POINT Even nonspecialists are trained and required to recognise rare causes of symptoms, if those diseases are treatable

Common procedures - intramuscular injection in this example - may have devastating consequences so rare and unpredictable that to require disclosure of material risk is not realistic. Nicolau Syndrome² is the gangrenous destruction of skin and muscle, often over a wide area, following inadvertent injection into a small artery of a wide range of drugs. Antirheumatic medications are the commonest culprits, and there have been calls³ to avoid injecting them for just this reason. The standard routine of drawing back on the syringe plunger to confirm the needle is not in a blood vessel is not foolproof, particularly for small arteries.

PRACTICE POINT Serious and unexpected complications of common procedures do not necessarily imply substandard technique

Copyright © 2008 Electronic Handbook of Legal Medicine