Patient Requires Skin Graft After Cryotherapy

This case involves the removal of actinic keratosis with cryotherapy by a physician’s assistant on the right arm of a 67-year-old male patient with an arteriovenous fistula. Over a period of 3 weeks, the wound on the right arm began to fester and did not show signs of healing. The patient’s cousin had a collagenase ointment used from a previous injury that the patient used on his right arm in an attempt to encourage the healing process. However, the wound still did not heal after a few days and he ultimately needed a skin graft on his right arm.

Question(s) For Expert Witness

1. Do you regularly treat actinic keratosis with cryosurgery?

2. Do you work with a PA and are you able to comment on the level of supervision required, what they are certified to do and what they are certified not to do?

3. Would you be concerned performing a procedure on the same arm as a patient with an arteriovenous fistula for dialysis access?

4. Have you reviewed similar cases?

Expert Witness Response E-004454

I regularly treat actinic keratosis with cryotherapy. As far as the arteriovenous fistula, the actinic keratosis had to be removed and I think cryotherapy was a reasonable choice for this patient, especially if that was their only resource. I train PA’s for a university in my private practice and am currently working with two. I reviewed a similar case but the PA misdiagnosed a perineural SCC for actinic keratosis.