Aesthetics speaks to nurse prescribers Sharon King and Linda Mather about the world’s first and only emergency helpline for aesthetic complications
If you were to occlude a vessel while injecting your patient tomorrow, how would you deal with it? You need to be able to quickly diagnose the problem, have the necessary emergency equipment to hand, and undergo the step-by-step process for management. But would you know who to turn to for guidance if you needed a second opinion or assistance of any kind? At the end of 2018, the Aesthetic Complications Expert (ACE) Group set up the world’s first and only helpline dedicated to assisting practitioners who need immediate expert assistance to manage emergency complications.1,2 In this article, Aesthetics speaks to ACE Group co-founder and aesthetic nurse prescriber Sharon King, and ACE Group board member and aesthetic nurse prescriber Linda Mather, to learn more about the unique ACE Group Emergency Helpline, how it works and how practitioners can make the most of the service for optimum patient outcomes.
The Emergency Helpline was born out of need, King says, which was clearly identified after she performed an audit of the Group’s Facebook Forum. “We noticed a huge number of practitioners requesting help for dermal filler complications – at the time of audit we had 389 filler-related complications, with 207 relating solely to the lips alone and many of these were potential vascular occlusions.3 Although our forum is great for practitioners getting together, sharing ideas and debating, it’s not ideal for what could be an emergency situation. A lot of people really needed to speak to somebody, and fast, and hence the helpline was born,” King explains.
Now, in a normal week, its call handlers receive around four to five emergency calls from its 4,000 plus members. Most calls are regarding suspected vascular occlusions following dermal filler injection, as well as delayed onset nodules and infections.
Mather and King first advise that before performing any aesthetic treatment, practitioners should be knowledgeable in diagnosing and managing complications. Mather highlights, “Before you go near a patient you should have complications training and have a rehearsed plan set out. Always have an emergency kit on the premises, and this should be stocked and ready.” King adds, “It’s amazing how many people don’t have a plan – when you are working in a hospital environment you have plans for everything so you should do the same in private practice. Your staff should also be trained and prepared to know what to do if you need to start your complication process. Tell them where your emergency kit is and what they need to do to assist you.”
Patients also need to be consulted on the risks and how you will manage them appropriately, Mather says, noting, “As a call handler I have found that many patients have no idea what’s going on during their complication because they haven’t been consulted properly. This is really important not only for consent purposes, but so they understand the risks associated with treatment and how a complication will need to be handled if it arises.”
According to Mather, a vascular occlusion following dermal filler injection is the main emergency practitioners should be using the service for. However, she adds that many practitioners struggle with diagnosing a vascular occlusion. Mather says, “Of the calls we have had regarding suspected vascular occlusions, 25% have turned out to be bruising, while around 75% have been a confirmed occlusion. For anaphylaxis or visual impairment, practitioners should be dialling 999 and seeking urgent referral, not calling the helpline. Delayed onset nodules and infections are not normally ‘emergencies’, however, there are lot of really distressed and frightened practitioners out there who don’t know who else to call for help, so may call us. At the end of the day, because we are ultimately talking about patient safety, we will always be happy to support that practitioner so the patient can get the best treatment outcome.” Therefore, King and Mather say practitioners should use their clinical judgement on when it is appropriate to call.
King notes that in many cases, particularly those that are not time sensitive, practitioners should refer to the ACE Group Guidelines before dialling the helpline.4 She says, “If it’s a delayed onset nodule or infection, for example, that’s not absolutely time sensitive, then you can refer to the guidelines – they should be easily accessible in the clinic. I recommend putting them in the same place as your emergency kit.”
Practitioners need to be ACE Group members in order to access the helpline. There is one number that will call through to seven call handlers, each with significant experience in managing aesthetic complications. Mather says, “One call handler will pick up the call and will usually hear a panicked practitioner at the end of the line saying they need help. We will firstly ask them to remain calm and take a breath because we need a concise and clear story of what’s happened. It can be really traumatic for the practitioner when something like this happens, but staying calm is really important.” Mather says that the call handler will then ask the practitioner to give their name and their phone number in case the call is cut off.
The practitioner should then go through what has happened in as much detail as possible. The call handler might ask when the procedure was carried out, the product used, how much, the injection technique and entry points, what concerns the patient is presenting with, what you saw and how the patient was feeling. For suspected vascular events, the call handler will also ask what the capillary refill time was before you started injecting and what it is now. Mather notes, “Don’t forget your hygiene standards in a vascular emergency. Wear gloves when you are pressing for capillary refill – I have seen numerous practitioners pressing on a patient’s newly injected lips with dirty finger nails!” King adds, “Following this, we will then ask to look at the patient via a video call through something like FaceTime or WhatsApp. The practitioner can show us what is going on and we might ask them to send us photographs if the video quality isn’t very good. We will also ask for the patient’s name and use that while addressing them so that we can make them feel as comfortable as possible through this process.” King and Mather advise practitioners to consider image and video quality, taking note of the lighting and angles, as well as your internet connection. “Really think about the call handler trying to interpret what you are looking at to help them provide the best advice to you,” Mather says, adding, “Again, always stick to strict hygiene practices; I actually had one person take a picture of a patient sitting on the toilet, which is not ok.”
The call handler will then provide advice on what the practitioner should do to manage the situation. King highlights that the advice given is always related to evidence-based medicine and the ACE Guidelines that have been collated and published,4 as well as the call handler’s own experience. “At this time, we will either leave the call and let the practitioner implement our advice, or perhaps we might stay on the call and consult with them for the whole treatment, watching while they inject the hyaluronidase, for example,” King says, adding, “Sometimes it’s a matter of advising them to refer on to a specialist, such as an ophthalmologist for visual impairment or a plastic surgeon for wound management, as has happened in one particular case, or perhaps it’s just a bruise; in which case, we are no longer needed.”
Usually the call handler will follow up with the practitioner, depending on the severity of the complication and the state of the practitioner. Mather has written an article about the psychological impact of causing a serious complication on the practitioner, as well as a dissertation for her Master’s. She says often practitioners will need support through this time, which she is happy to give. King and Mather encourage members to contact their call handler again should they need any further assistance. “Sometimes the practitioner just needs to call back for advice on the best antibiotics to use in that circumstance, or skincare recommendations afterwards,” says King.
King and Mather encourage practitioners to ring during normal business hours if possible; however, they acknowledge that they have taken calls outside of this for genuine emergencies. Callers should be respectful of the call handler, and know that any breaches of professional standards could result in the call handler reporting them to the practitioner’s professional body. Patient consent must be obtained before sharing the patient’s information with the ACE Group. For example, Mather says, “My paperwork says that the patient consents to having their photos taken and stored safely, as well as that I may need to share the photos in the case of an emergency with a third party, so it should be in writing before the complication occurs.” Data sent electronically must also adhere to GDPR.2
King and Mather both say that if practitioners are treating patients, it’s not a matter of ‘if’ they will cause a complication one day, but ‘when’ and they need to be ready and prepared for this possible eventuality. In the ideal world, they say that practitioners would be so educated and prepared that there would be no need for the Emergency Helpline. However, even the best practitioners may seek guidance from their peers and the helpline is there to help direct practitioners to use the appropriate pathways.
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