A Philly-area woman was severely burned after a Main Line Fertility doctor mistakenly injected acid into her body

Lying on a medical exam table, Christine braced for the slight cramping that her doctor at Main Line Fertility said to expect during a routine procedure to check her fallopian tubes for blockages.

But almost immediately after the doctor injected a fluid-filled syringe into her uterine cavity on Dec. 19, 2022, Christine said, she felt searing pain.

“I felt burning,” said Christine, 33, a Montessori preschool teacher from the Philadelphia suburbs, who had come to the fertility practice’s Havertown office while she and her husband, Jason, were trying to conceive.

“I kept saying, ‘Something is off. Something is wrong. Is it supposed to burn?’ ” Christine said.

» READ MORE: Here’s what Cherelle Parker has been up to since winning the Democratic nomination for mayor

The Inquirer is identifying the couple by first names only at their request because of the intimate medical details involved.

Christine recalled that the doctor, Allison Bloom, ignored her complaints, saying, “No, it’s just saline.” As Christine writhed, Bloom watched the ultrasound monitor to see whether the liquid flowed through Christine’s right fallopian tube.

Soon after Bloom finished the procedure and left the room, angry red welts started spreading along Christine’s inner thighs and legs.

Only then did the ultrasound technician check the solution bottle — and realize a horrific error: Trichloroacetic acid, at an 85% concentration, rather than saline, had somehow gotten drawn up into the syringe. Bloom then injected the acid into Christine, medical records show.

Trichloroacetic acid, or TCA, is so caustic that the fumes alone can sting the nose and throat. The bottle reads: Danger! Causes severe skin burns and eye damage. Suspected of causing cancer.

“All hands on deck! Get everybody in here!” Christine heard Bloom yell, as the doctor ran back into the room.

A medical error as egregious as mistaking flesh-burning acid for harmless saline is called a “never event” because it’s preventable and should never happen. The fiery pain that Christine felt inside her abdomen and lower torso would later be diagnosed as first- and second-degree internal and external chemical burns.

Seven months later, her reproductive organs are marred with scar tissue, resembling “leather,” she said. The couple do not know whether they can realize their dream of filling their farm-style, pale yellow Montgomery County house with their offspring.

Main Line Fertility, which is not affiliated with Main Line Health, has never explained how it botched her procedure, nor apologized for its error, according to Christine and Jason. The couple are seeking answers and monetary damages through a lawsuit filed in March in Philadelphia’s Court of Common Pleas. It alleges the error resulted from negligence, recklessness, and failure to follow best practices.

The practice, which serves thousands of hopeful, would-be parents annually at eight offices across Pennsylvania, has denied reckless conduct or other failings in recent court filings.

Bloom acknowledged the error in Christine’s medical records, but a spokesperson for Main Line Fertility said that the doctor was not responsible for the acid being in the room, and that she did not fill the syringe.

The practice has since removed trichloroacetic acid from all offices and has stopped using it to treat patients, spokesperson Mia Humphreys said in response to follow-up questions from The Inquirer.

“Main Line Fertility also takes training of safety protocols and operations very seriously,” Humphreys said in a statement. “Our dedicated staff are comprehensively and regularly trained to strictly adhere to all operational protocols.”

During a tearful, two-hour interview, Christine and Jason said they decided to speak with The Inquirer to advocate for patient safety and reforms at Main Line Fertility.

“If it wasn’t Christine who was in the room, it would have been another woman,” Jason said.

Christine expected to be at the fertility clinic for no more than an hour on the Monday before Christmas last year. She took an early lunch break after the clinic moved her afternoon appointment to 11 a.m. She planned to return to work after grabbing Chick-fil-A at a drive-through.

The 15-minute procedure, called a saline infusion sonogram, was supposed to be so routine that she told her husband not to come. It involves filling a syringe with saline and injecting it into the uterus. The doctor then sees whether the saline flows through the fallopian tubes, or whether a blockage is causing infertility.

Seconds after the injection, Christine was in agony. She couldn’t concentrate as Bloom explained next steps in her fertility treatment.

After Bloom left the room, a nurse looked at Christine and said, “You don’t look good. Maybe you should lie back down,” Christine recounted.

“I gotta get up,” she told the nurse. She went to the bathroom and fluid gushed down her legs. It looked like boiling water had been poured on her.

“Is this normal?” Christine asked.

Bloom rushed back into the room. She immediately used saline to wash out Christine’s uterus, tubes and abdomen. In her medical notes, Bloom later wrote that she could see “white plaques consistent with burns from the acid” in Christine’s vagina and on her legs.

The staff laid cold, wet paper towels over her scalded legs and thighs. “That hurt even worse,” Christine said.

“I don’t know what labor feels like, unfortunately, but I felt like,” she paused, crying, “this is the worst thing I’ve ever experienced.”

A nurse brushed her sweaty, blonde bangs aside, and acid residue on the nurse’s fingertips stung Christine’s face.

“Did someone call Jason?” Christine repeatedly asked.

Don’t pass out, she told herself. She feared that her husband wouldn’t know her whereabouts.

After an ambulance arrived, 911 paramedics thrust Christine onto a gurney. She was still naked from the waist down. They rushed her through the waiting area as staffers and patients looked on, down three building flights and out to the curb.

She felt on display. Even worse, she had no idea what was wrong.

Jason, 30, who works in finance, was working from home on back-to-back business calls. A Main Line Fertility staffer contacted him and said he needed to get to the burn unit at Crozer-Chester Medical Center, an hour away in Delaware County.

“There was an incident,” the staffer told him, offering little else. He felt raw panic during the drive.

Christine’s terror escalated on her 35-mile ambulance ride. A paramedic gave her fentanyl for the pain, but it didn’t help much.

Narberth Ambulance paramedics bypassed two closer hospitals to take her to Crozer’s specialized burn center. She was confused why they brought her there, because she thought she had suffered an allergic reaction to saline.

She learned what happened from a paramedic. “Oh, honey, they didn’t put saline solution through you, that was acid,” she recalled being told.

“I didn’t believe him. I didn’t understand,” Christine said.

Saline and acid are clear liquids, indistinguishable to the eye once poured.

At a fertility clinic, saline is used frequently during sonograms to help visualize and diagnose abnormalities, such as uterine fibroids, polyps, or a misshaped uterus that may cause infertility. Saline is harmless to the body.

Trichloroacetic acid is used sparingly, with a “tiny, tiny dot” of it on a cotton swab, to treat genital warts, said David Barad, an ob/gyn and reproductive endocrinologist at the Center for Human Reproduction in New York City. It’s highly caustic.

“Once the stuff hits the tissue, you can’t fix it,” Barad said. “When you brush it onto tissue, it turns white because it’s basically cooking it.”

Up until the late 1980s and early 1990s, trichloroacetic acid was primarily used as an herbicide to kill certain grasses and weeds harmful to crops. It also has been utilized to etch the surface of metal and remove tattoos, but diluted to 30%.

The U.S. Environmental Protection Agency classifies it as “a possible human carcinogen,” based on animal experiments.

New Jersey has placed trichloroacetic acid on the state’s “special health hazard substance list.” The state has flagged the corrosive chemical as a possible reproductive hazard, potentially impacting fetal development and increasing risk of miscarriage.

There is little research on its carcinogenicity in humans.

Saline and trichloroacetic acid should never be stored together, said Barad, who performs the saline-based procedure that Christine went in for about three or four times a week.

He opts to draw the saline into the syringe himself, rather than leaving the task to a technician. If the lining of the uterus is damaged by acid, it would be difficult to implant an embryo, even if the ovaries can still produce eggs, he noted.

“It’s like having a garden replaced with cement. There’s nowhere to plant the flower,” Barad said.

When Christine arrived at Crozer’s burn treatment center, doctors were unsure what to do because they had never seen such an injury.

“There were at least five doctors who came in and said, ‘Can I see it? Can I see it?’” she said. “They kept saying, ‘We don’t know what the next step is, but I have to see it.’”

Inside her reproductive tract, they saw “white blotches” against fire-red inflammation. They told her the lining of her uterus was “just all burned.”

Doctors worried that the acid had eaten through her fallopian tubes to her colon.

Initially, doctors proposed diagnostic surgery. They’d make an incision, insert a tiny camera, and examine her organs for possible signs of acid spread.

After deliberating, doctors instead decided to do a CT scan to see whether the acid had “eaten through” her uterus and seeped into her digestive system, Jason recalled.

Christine drank dye to help doctors examine her organs and tissue for any acid breach. Doctors didn’t see anything that warranted next-step exploratory surgery or emergency removal of her colon, Jason said.

They spent two days at the hospital. The only treatment doctors could offer: pain medication and estrogen cream.

About a month after she left Crozer, a doctor called Christine and asked whether she’d participate in a research paper to help other burn specialists learn from the case. She agreed. They’d also like to study any long-term health effects.

Christine said she’s still in pain. She has a permanent trail of white scars down the back of her legs. She can’t lift the preschoolers she teaches. Just sitting hurts.

Many of the couple’s friends are either expecting babies or just became parents, and that’s been hard. She’s in therapy, but she feels depressed.

“How do we make ourselves happy and pretend everything’s fine?” Christine said.

Although relatively rare, devastating medical errors like what happened during Christine’s fertility treatment are so serious — and avoidable — that the profession has vowed that they should never happen.

Last year, Pennsylvania recorded 9,741 “serious events” — instances in which medical care resulted in death or unanticipated, grave injury. This represents an increase of 7.7% statewide from the year prior, according to the state’s Patient Safety Reporting System, the largest repository in the nation. Of the 9,741 serious events, 32 involved electrical, thermal, or chemical burns, state data show.

A state law, enacted in 2002, requires reporting of many errors, but such reports are confidential, said Mark O’Neill, a spokesperson for the Pennsylvania Department of Health, who could not confirm whether Main Line Fertility made a report.

Although state health officials do not license Main Line Fertility’s Havertown office, the practice is required by law to report lawsuits against a doctor to a state licensing board within 60 days.

The 2002 law also requires a facility to investigate errors and make recommendations to eliminate future ones.

Main Line Fertility declined to answer specific questions about how the error happened, what safety protocols were in place at the time, and whether employees were disciplined.

The practice also would not say whether it had reported its error to the state, but noted that Main Line Fertility complies with all regulations.

At the end of the doctor’s Dec. 19, 2022, patient note about the mistake in Christine’s case, Bloom wrote that an “incident report and root-cause analysis will be initiated.”

Given that the circumstances involved two look-alike clear fluids stored in bottles, a medical worker could easily confuse the two, especially if moving quickly between patients in multiple procedure rooms, said Zane Robinson Wolf, dean emerita at La Salle University’s School of Nursing and Health Science, who has lectured and written extensively on patient safety.

Even so, that does not excuse an egregious error, she said.

“The infusion of a scarifying, burn-inducing fluid is definitely a ‘never event,’” Robinson Wolf said. “The pain of it — to be burned internally and externally — is very traumatic.”

The doctor who performed the procedure, Allison Bloom, runs Main Line Fertility’s egg donor and freezing programs. Bloom joined the practice in 2017 as a fellow before becoming an attending physician in 2020. She did not respond to a phone call or a note left at her Havertown office by an Inquirer reporter.

Although Bloom is named in the couple’s lawsuit, Main Line Fertility’s statement noted that she was not at fault.

“We can share that Dr. Bloom was not responsible for the acid being in the procedure room. She also was not involved in prefilling the syringe,” Main Line Fertility spokesperson Humphreys wrote in a statement.

Main Line Fertility is not a subsidiary of Main Line Health, a hospital system, though the couple are suing both entities. Bloom, as an independent physician, is a member of the Main Line Health medical staff, according to the hospital system, which said in a statement that “Main Line Health is not a proper defendant in the lawsuit and will vigorously defend the case and seek dismissal.”

A lawyer for the couple, Robert S. Miller, said Christine and Jason are disappointed by Main Line Fertility’s efforts to discount Bloom’s role in what happened.

“We intend to hold Dr. Bloom and other Main Line Fertility defendants accountable for the grossly irresponsible actions that led to this unthinkable scenario unfolding in the first place,” said Miller, of the Center City firm Wapner Newman.

Julianna Merback Burdo, another lawyer for Christine and Jason, said the couple hope to get answers through the lawsuit. On July 12, Common Pleas Court Judge Daniel Anders issued an order giving Main Line Fertility 20 days to provide responses.

Christine, through tears, said she feels forgotten by Main Line Fertility.

And the long-term effects of the acid on Christine’s health aren’t yet known; the chemical gets absorbed by the body, Jason said.

“There’s not a day that goes by that you’re not reminded, ‘Oh, yeah, this happened to me,’” Christine said. “It doesn’t stop, and I feel like they just put it behind them, that it was just a blip in their day, ‘Oops a mistake was made. Carry on. Forget it ever happened.’”

Main Line Fertility said in its statement that it “repeatedly followed up with the patient following the incident to check on her condition.” In the days after the procedure, Bloom was in contact with Crozer doctors, medical records and interviews show. A staffer at Main Line Fertility also tried to contact Christine and Jason, but the couple said they were too distraught to talk to Bloom or anyone else at the practice at the time.

Main Line Fertility says it informed the couple they would not have to pay for the procedure, yet Christine gets a bill from it every month for $538.14. The practice is now threatening to send her to a collection agency if she doesn’t pay by mid-August.

The most recent invoice, dated July 13, lists a charge for “saline infusion sonohysterography.”