The Last Word

Understanding the urgency

Immediate intervention If the complication requires immediate intervention, for example you suspect vascular occlusion following dermal filler treatment, you will be faced with the challenge of making a very quick decision. In this instance, treating someone else’s complication, where you are competent to do so, could be considered to be in the best interest of the patient, in my opinion. However many problems also start here, with unqualified practitioners treating outside of their remit.5

Solution An intervention is not without its own potential complications and undesirable results. We know that hyaluronidase, as used in cases of vascular occlusions, is related to oedema and even severe allergic reaction.6 For that reason, unless you are experienced, prepared and equipped to deal with any eventuality, in my opinion, you should not get involved in treating the complication.

If you’ve already concluded that you’re unable to address the complication directly, you can still support the patient until help is arranged. The first port of call should be to the primary treating practitioner; have the patient call their practitioner and narrate the problem to them. You should then give them your professional assessment and recommendation as indicated. By doing this it demolishes the idea of competing between practitioners and shows a more seamless and professional relationship. Also, I would argue the importance of not being afraid to ask the practitioner if they are suitably qualified, experienced and competent and have the appropriate protocol for dealing with such an event. You can then be assured that the patient’s urgent complication will be dealt with in a proper and timely manner.

Nurse prescriber Jodie Nightingill argues when and why it may be deemed appropriate to take on another practitioner’s dermal filler complication

There is no denying that the popularity of non-surgical procedures, or ‘tweakments’ as they are sometimes referred to, is booming.1 With many one-day courses promising the title of ‘aesthetic practitioner’ and pop-up clinics in every town, non-surgical cosmetic procedures are now more accessible than ever before. Unfortunately, as the number of aesthetic procedures carried out each day rises, the possibility of being presented with a complication also increases.2,3 But when should we, as responsible medically qualified and competent practitioners, step in and treat someone else’s complication?

The problem In my opinion, the problem really is multifactorial. The first being that in an ideal world, all aesthetic practitioners would be able to manage and resolve their own complications or, when unable to do so, should take responsibility to appropriately refer their patient to another professional who can help.4 However, with the lack of regulation and professional standards in the field of aesthetic practice, this is not the reality we are faced with. Aside from the lack of regulation however, practitioners may be unavailable at the time the complication presents – they may be away on holiday for example. I believe that practitioners should always make arrangements for periods where they are inaccessible to their patients and linking with another local practitioner is a great management plan for holiday cover. Even when the practitioner is available, the problem might actually be that the patient simply feels uncomfortable returning to their original practitioner or perhaps they had a negative experience and don’t wish to relive it. It’s important to note that practice guidelines and policies are usually a fundamental ‘go to’ for healthcare professionals. Unfortunately, as there are no standardised guidelines on how to deal with such a scenario, the decision you make will need to be based solely on your experience and clinical judgement. Another issue is that many in the specialty don’t always understand a complication’s urgency. Before taking on a complication, I believe we should be asking ourselves, ‘Is this an emergency or can the intervention wait?’.

An intervention is not without its own potential complications and undesirable results

Keep accurate records of your involvement, no matter how limited

Delayed intervention On the other hand, can intervention wait? Is the complication related to patient satisfaction? Perhaps there is asymmetry for example? In this scenario, you will have more time to consider your next step or may even choose not to get involved at all.

Solution In an intervention that you believe doesn’t require immediate treatment, you might like to explore the complication history of the patient. However, before you do so, you need to be confident that you have enough training and experience to safely decide that the complication couldn’t be any more serious. For example, many misdiagnose vascular occlusions as bruising.7 Once you are comfortable with your decision, you can ask what effort the patient has made to contact their original practitioner, if any, and what has been the outcome of this?8 I believe that promoting referral back to the original practitioner is key for continuity of care and, in my opinion, it develops improved relationships with patients and ultimately leads to improved clinical outcomes. I would advise that practitioners contact the original practitioner personally and discuss the case at hand, perhaps offer your assessment and advice and mediate a transition of the patient back to their care. If a patient has been unsatisfied with the cosmetic outcome from an aesthetic treatment performed elsewhere, consider if their expectations are realistic; ask yourself if you are confident you can manage these expectations before getting involved. Where there is no risk of harm to a patient my preference is to avoid involvement and encourage referral back to the original practitioner. Complications can arise for even the most experienced and skilled injectors and dealing with them can be complex, unpredictable and time-consuming. Complication history It is important to note that if you do decide to treat the complication, in an emergency situation or otherwise, it is crucial to think about the possibility of any future implications. If the patient chooses to make a formal complaint about the original complication, by intervening you are now directly involved in the history of that complaint and you should check with your insurance company about the appropriate cover.9 This is particularly important with the compensation culture that is becoming commonplace in the UK.9 It is good practice to keep accurate records of your involvement, no matter how limited, detailing communication with the patient, assessment of the complication, communication with the original practitioner and any advice you have given. I think that the value of accurate documentation (including written notes and before and after pictures) should never be underestimated. Good record keeping takes a short amount of time but will be extremely valuable if you’re ever called to discuss a case.

Seek support Until the time comes when there are more robust regulations and restrictions for people accessing training courses and emerging as aesthetic practitioners, I don’t anticipate this complex area of care will come to an end any time soon. For now, and until such a time occurs, I believe practitioners must continue to educate themselves on managing complications and consider joining a forum or association such as the ACE Group,10 the International Association for Prevention in Complications in Aesthetic Medicine (IAPCAM),11 the British Association of Aesthetic Nurses (BACN)12 or the British College of Aesthetic Medicine (BCAM).13 All of which enable you to access a wide range of support from an expert group of aesthetic professionals. This will not only give you credibility and peace of mind in your aesthetic practice, but will ensure your patients receive the best and safest possible care. Whether you chose to take on treating someone else’s complication or not will depend on a number of factors relating not only to the complication itself, but patient and practitioner circumstances too. Evaluating complication urgency, patient expectations and practitioner skill and competence are all key considerations; however, I believe that statutory guidelines around this would eliminate fear and help to implement best practice regarding when you should be taking on someone else’s complication.

Jodie Nightingill is an aesthetic nurse prescriber, BACN member and ACE Group registered practitioner. She completed her aesthetic training with Cosmetic Courses and The Allergan Medical Institute. Nightingill is currently working as an NHS clinical nurse specialist for malignant haematology as well as running her clinic, The Dolls House Essex.

REFERENCES

1. The American Society for Aesthetic Plastic Surgery, Statistics 2018 <https://www.surgery.org/sites/default/files/ASAPS-

Stats2018-Trends.pdf> 2. Saner E, The rise of non-surgical beauty: My mum said my lip looked liked a rubber dinghy, Guardian, April 2017 <https:// www.theguardian.com/lifeandstyle/2017/apr/03/non-surgicalcosmetic-procedures-botox-lip-filler-beauty> 3. Save Face. Consumer Complaints Audit Report 201718. Available at: https://docs.google.com/viewerng/ viewer?url=https://www.saveface.co.uk/wp-content/ uploads/2018/11/Save-Face-Consumer-Complaints-Report2017-18-FINAL.pdf&hl=en 4. Cosmetic Standards, JCCP and CPSA Guidance for

Practitioners Who Provide Cosmetic Interventions <http:// www.cosmeticstandards.org.uk/uploads/1/0/6/2/106271141/ jccp_cpsa_code_of_practice.pdf> 5. NMC (2018) The Code, <https://www.nmc.org.uk/ globalassets/sitedocuments/nmc-publications/nmc-code.pdf> 6. Summary of Product Characteristics (2015) Hyalase 1500 I.U.

Powder for Solution for Injection/Infusion or Hyaluronidase <https://www.medicines.org.uk/emc/product/1505/smpc> 7. Grunebaum L.D. · Funt D.K. Goldberg DJ (ed): Dermal Fillers.

Aesthet Dermatol. Basel, Karger, 2018, vol 4, pp 128-140 8. Sudhakar-Krishnan, Vidya, and Mary C J Rudolf, ‘How important is continuity of care?’Archives of disease in childhoodvol. 92,5, 2007 9. Data on file. 10. ACE Group <http://acegroup.online/welcome-ace-groupwebsite/> 11. International Association for Prevention of Complications in

Aesthetics Medicine <https://iapcam.co.uk/> 12. British Association of Cosmetic Nurses <https://www.bacn. org.uk/> 13. British College of Aesthetic Medicine <https://bcam.ac.uk/>

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