This case involves a forty-two-year-old woman who complained of severe shooting pain down her forearm after a nurse placed an IV line in her wrist. The patient continued to complain of persistent pain and requested that the IV be removed, but the nursing staff did not comply. The patient now suffers permanent damage to the median nerve that has not been resolved with electric stimulation hand therapy.
Question(s) For Expert Witness
- 1. Have you seen this before in your practice and, if so, how can this be avoided?
Expert Witness Response E-004540
If a patient complains of an electric shock-type sensation radiating down into his or her hand as the needle is being inserted, the appropriate intervention is to remove the needle immediately. The outcome will be minimal nerve damage without permanent injury. If the nurse continues to advance the needle farther into the nerve, however, a permanent, progressive, and painful disability resulting in reflex sympathetic dystrophy (RSD) or complex regional pain syndrome (CRPS) can result. Patient symptoms can include a mottled and cold hand and forearm, hypersensitivity to temperature changes, excessive nail and hair growth, and the inability to lift heavy objects. CRPS is diagnosed by patient history and nerve conduction studies. Treatment options include long-term pain control with narcotics, multiple nerve blocks, and even implanted morphine pumps, as well as splints, casts, and TENS (transcutaneous electrical nerve stimulation) units. Best practice mandates nurses avoid areas of high-risk nerve injury by using landmarking techniques. The three-inch area above the thumb and the three-inch area on the inner aspect of the wrist should always be avoided since the radial and median nerves can be superficial in these areas. The risk of permanent nerve injury outweighs the benefit of IV insertion in these areas.