Geoff Harding: Court injects doubt on jab techniques

A RECENT decision in the NSW Court of Appeal raises concerns for doctors, particularly those practising musculoskeletal medicine.

The decision, which upheld an earlier court judgment against a GP, involved an infection that developed after an injection of cortisone for lateral epicondylitis. The GP was found to be negligent on the basis that the original judge said he believed the evidence of the patient over that of the doctor.

The patient said the doctor touched the sterile area prior to injecting and that had caused the infection. The doctor gave evidence that he used a clean “no-touch” technique.

The GP appealed against the original judgment but in a 2:1 decision the Appeal Court upheld that decision.

The issue that most concerns me and the Australian Association of Musculoskeletal Medicine is that the original judge was swayed by evidence from experts who suggested the doctor should have been wearing sterile gloves and gown and disinfected the skin.

This is astounding. The idea that GPs — or any doctor — giving an injection for lateral epicondylitis should be both gowned and gloved is a nonsense.

GPs are going to become deskilled if this case sets a precedent. Most legal minds are of the opinion that this one case won’t mean a change in practice but we need to make sure it doesn’t. We need to raise our voices.

There is no real evidence which supports the use of a fully sterile technique for these injections. Doctors of all kinds — GPs, rheumatologists, orthopaedic surgeons and sports physicians — have used the “no-touch” clean technique for decades without a significant rate of infections. This case appears to be the exception worldwide.

In 2001, Professor Chris Del Mar and colleagues writing in the MJA (2001; 174: 306) suggested that even isopropyl alcohol swabbing prior to injecting was unnecessary. There was also a report in The Lancet in 1969 highlighting the fact that in a trial of more than 5000 injections of all kinds, including intravenous injections — without prior swabbing — not one case of infection occurred.

There are other issues in the case which should concern any doctor going into court — such as not being able to get your point of view across. Those other issues should motivate doctors to read the transcript, but the main concern is the issue of sterile gowns and gloves.

If this were to be adopted as standard care, patients would soon find that their GP had ceased performing injections or that the cost to the patient would rise enormously. To be gowned and gloved you would then need a third person in the room to hand over the sterile syringe. Who is going to pay for this?

The possibility of a change from the “no-touch” technique raises the issue of vaccination techniques used in schools, phlebotomy and even self-injecting rooms. Where does it end?

The AMA and the Royal Australian College of General Practitioners have been alerted to the need for some attention to this matter and it appears that the issue will be raised on the agenda of the next meeting of the Committee of Presidents of Medical Colleges.

The profession must stand up and be heard. If there is a forced change in injection practice the consequences could be far reaching.

Dr Geoff Harding is the president of the Australian Association of Musculoskeletal Medicine and practises musculoskeletal medicine full-time in Brisbane.

Posted 4 July 2011