Ontario women suffer botulism symptoms after Botox

By the time Chytros was admitted to a hospital in Cambridge, Ont., she hadn’t eaten solid food in a week, her eyes were completely shut, and her body was too weak to move.

“All sorts of thoughts were going through my head, like: I didn’t leave the way I wanted to,” said the 48-year-old, choking up while recalling her first night in the intensive care unit.

She didn’t know at the time that just 20 kilometres north, another woman, Gosia Jurgiel, was hospitalized with almost identical symptoms in a Kitchener hospital.

As they endured the creeping paralysis of their muscles, their doctors made the same urgent decision to request an antitoxin so rare and expensive that it sounded alarms in the local and national public health systems. The Ontario Provincial Police was tasked with swiftly delivering the vials needed to treat botulism, a potentially life-threatening neuroparalytic syndrome.

The two women found each other as they slowly emerged from their protracted recoveries and started searching for answers.

Chytros and Jurgiel then learned they had something else in common: They both received the same cosmetic treatment from the same injector.

Contrary to what the women say they were led to believe, their injector was not authorized to inject them without supervision. She was also not a doctor licensed to practice in Ontario, as she suggested to some patients, the Star found.

Their quest for accountability, however, floundered in the regulatory dead zone surrounding the esthetics industry in Ontario, where unauthorized staff perform unsupervised medical procedures in beauty clinics and med spas.

While Ontario’s physician watchdog has in recent weeks strengthened rules around how doctors should delegate injections and other medical procedures to staff, an ongoing Star investigation has found there’s no agency dedicated to directly overseeing these injectors in the billion-dollar esthetics industry. They remain out of reach of the regulatory colleges that police and discipline licensed doctors and registered nurses, leaving patients with no clear path to justice.

“I’m so mad. So no one gets any consequence for what happened?” Chytros said.

Botox has enjoyed widespread popularity as a non-surgical way to smooth out facial wrinkles. It has a well-established reputation for being generally safe when properly administered by a qualified professional.

Although Botox is the name of one of five brands approved for cosmetic use in Canada, the term “botox” is the commonly used moniker for botulinum toxin type A, a potent protein that can relax the muscles that pull on the skin.

The toxin was once a scourge. It was identified as the cause of a slew of food poisoning-related deaths throughout the kingdom of Württemberg in South Western Germany in the late 18th century. It was tested on human subjects for potential weaponization in World War II.

After rigorous clinical trials and studies, the toxin was approved for cosmetic use and other therapeutic purposes, and is heavily regulated. Only approved products should be administered by authorized health care providers.

Though the treatment delivers the solution in small, controlled doses into targeted areas of the skin, cosmetic botulism can develop if the toxin spreads beyond the injection site, if excessive doses are administered, if the shot is given improperly, or if unlicensed or counterfeit products are used, according to Health Canada.

This disease, a type of iatrogenic botulism, is very rare. Over the last 60 years, Health Canada has received only eight reports of suspected botulism associated with botulinum toxin injections.

After getting the requests for the botulism antitoxin, known as BAT, a Health Canada official asked the hospitals to take blood serum samples from the two women, so that they could be tested for botulinum toxin.

Iatrogenic botulism is rarely “laboratory confirmed” and there has never been a confirmed case in Canada, said Richard Harris of Botulism Reference Service for Canada of Health Canada, in an email to a manager at Region of Waterloo Public Health, which was investigating the two suspected botulism cases.

When Chytros’s lab results came in, Harris was not surprised to see that the toxin was “not detected.” He noted it could be a “false negative” because her blood samples were drawn after she took the antitoxin. Jurgiel told the Star her tests also came back inconclusive.

Then the research scientist posed a question: “Was the outbreak caused by an unlicensed product?”

Chytros, a child protection worker, was on leave from work last summer when she decided to smooth a few wrinkles to lift her spirits.

At a friend’s recommendation she visited Margaret Drabek at DrD Aesthetics, a beauty clinic in Oakville, in July, she said. At a glance, Drabek checked all the boxes as a qualified injector.

At the time, the clinic’s website billed her as “Dr. Margaret Drabek,” listed under “experts and partners” alongside Dr. Yaroslav Dvorskyy, a licensed physician in Ontario.

When the treatment didn’t work as expected, Chytros said she texted Drabek. The injector said she could administer additional doses at Chytros’s home for free.

On Aug. 9, Drabek arrived carrying vials of the substance in a purse, Chytros said.

Three days earlier, at her house in Cambridge, Drabek had injected Jurgiel, 61, in her forehead, around the eyes and the jaw, the Waterloo resident recalled. Jurgiel said she had visited her for treatments at a spa in the Waterloo area and had experienced no complications.

Nine days later, Jurgiel was admitted to the intensive care unit at Grand River Hospital in Kitchener. After experiencing difficulty swallowing, she had a feeding tube inserted into her nose. “I was scared because the symptoms were progressing,” she said. “I couldn’t swallow, I couldn’t eat, I couldn’t drink.”

Still believing the injector was a doctor who could help her, Jurgiel said she sought assistance from Drabek via text messages when her symptoms first flared up. While Drabek responded with care and concern, Jurgiel said she provided no relief to her worsening symptoms.

“That’s upsetting. Her claiming being a doctor and all that,” Jurgiel told the Star. “You have to always put first … the human life, and in my opinion she didn’t.”

Drabek disputed the accuracy of the information the two women shared with the Star. “I did not perform injections in the locations you describe, and the dates and alleged complications you provided are incorrect and inconsistent with documented records,” she said in an emailed statement.

She said botulism was excluded as the cause of their illness. “Comprehensive medical documentation, photographs, and other evidence exist and do not support the narrative described.”

Drabek did not answer many of the Star’s questions and did not provide any documentation, citing patient privacy and regulatory and legal proceedings.

She stressed that she has “never represented myself” as a physician licensed by the College of Physicians and Surgeons of Ontario (CPSO). “I am an International Medical Graduate (IMG), and I have consistently disclosed that status,” Drabek told the Star.

An IMG has a degree from a medical school outside of Canada. Before practicing in Ontario, an IMG must register with the CPSO, which typically requires passing standardized national examinations or assessments. 

In a text exchange in Polish between Drabek and Chytros, the injector called herself an “aesthetic physician” working under another doctor and discussed prescription medication.

Within days of leaving the hospital, Chytros filed a complaint against Dvorskyy, Drabek’s delegating physician, to the CPSO.

While unregulated injectors are supposed to be overseen by a delegating doctor or nurse practitioner in Ontario, that supervision has often been on paper only, the Star has found.

A previous Star investigation revealed doctors and nurse practitioners were listed as medical directors at some spas and beauty clinics but had little to no involvement in their delegated treatments. The absence of oversight meant that unregulated practitioners were left to administer medical treatments without supervision, putting patients’ safety at risk.

In September, the CPSO made the first of a series of new changes to strengthen its rules around delegation of controlled medical treatments. During the Star’s ongoing investigation, the college further tightened its policy to require that delegates, except in certain situations, are not left to independently manage a practice or patient population.

The policy changes seem great, Chytros said, but policies don’t make a difference unless they’re enforced.

In her complaint, Chytros alleged the delegating physician Dvorskyy failed to supervise Drabek during the injection of the prescription drug, inconsistent with the CPSO policy in place at that time.

Dvorskyy told the CPSO that he never met or assessed Chytros and was unaware of any complications she experienced. Though he and Drabek, an international medical graduate, worked under a medical delegation agreement, he said to the college that he did not know that she might have misrepresented herself as a medical doctor in Ontario.

Drabek told the Star that her “professional activities have been conducted under lawful delegation arrangements compliant with Ontario regulations.”

Dvorskyy said in his response to the CPSO that he had since terminated his delegation agreements with Drabek.

As a result of the investigation, the CPSO in February found Dvorskyy did not adequately monitor his delegate and advised him to bolster his supervision. Also known as an “educational disposition,” the college’s guidance is a remedial measure to assist the physician in improving future practice.

Through a lawyer, Dvorskyy denied wrongdoing and declined to answer specific questions from the Star, citing confidentiality rules around the CPSO proceeding.

“This matter has now been investigated by both the CPSO and Halton Region Public Health, which resulted in no criticism of Dr. Dvorskyy or any further action taken in respect of Dr. Dvorskyy,” his lawyer Derek Hooper said.

Chytros was disappointed. The CPSO decision was “pointless,” she said. “Are they waiting for someone to die for them to take action?”

While the physicians’ college does not have authority to regulate unlicensed or unregistered individuals, it may send a cease-and-desist letter to a nonregistrant, or pursue a court injunction related to their conduct when there is evidence of non-compliance or a potential risk to the public, according to spokesperson Laura Zilke.

“Ultimately, CPSO cannot impose disciplinary sanctions on individuals who are not registrants,” Zilke said.

Chytros has asked the Health Professions Appeal and Review Board to review the CPSO’s handling of her complaint, arguing it “does not sufficiently protect the public.”

“Allowing cosmetic injections to occur in private homes without physician knowledge or supervision is not a minor technical lapse,” she wrote in her request. “It is a systematic failure of oversight.”

Chytros found the website for the Canadian Board of Aesthetic Medicine (CBAM), where Drabek was listed as a “board-certified” doctor. Her bio on the site described her as a “PhD MD” in Poland, who graduated from Jagiellonian University and an eminent figure in the field of medical expertise who has practiced extensively across Europe and North America.

Despite its official-sounding title, the Canadian Board of Aesthetic Medicine is not a regulator. A board certification with CBAM does not grant authorization for a member to practice medicine, according to Mohsen Talani, director of CBAM. It means the practitioners have completed the CBAM training program.

“Technically, board certification is a kind of marketing title these doctors use for their own promotion that they show their knowledge is approved by a private organization like us,” Talani said.

Talani said CBAM may still publish the profile of an international medical graduate that is not licensed to practice medicine in Canada but recognized as a doctor elsewhere. CBAM tries to confirm foreign licensing details, he added.

“We are not legally or professionally responsible for their individual practice outside of our institution,” a CBAM spokesperson told Chytros.

When Dr. Ihab Matta hears stories about alleged harms after Botox injections, the veteran of the cosmetic industry immediately questions the authenticity of the drug, the dosing or technique. “Those are the only three things that can account for it. And it’s usually the authenticity of the drug,” said Matta, head of a Woodbridge-based cosmetic clinic.

Unauthorized products are not assessed for safety, effectiveness and quality, and may pose serious health risks. It is illegal to administer unauthorized products in Canada.

Drabek told the Star that “all products used in my practice are legitimate and sourced through authorized channels, both in Canada and in every country where I have practiced. Any suggestion to the contrary is false.”

She refused to answer questions from the Star on where she obtained the product she used on the two women, saying the information and dosage has been shared with Health Canada. The federal regulator says it does not have any information about the product used. 

After getting the antitoxin, it took a couple of days for the two women to show improvement. A 2018 study in the U.S. said that BAT treatment can cost anywhere from $38,000 to $94,000 (USD) depending on the severity of symptoms at the time antitoxin was prescribed.

Jurgiel had to be fed through a tube for weeks even after her discharge from the hospital in Kitchener. She then relied on prescribed liquid food for a month and a half because she could not swallow. For the six months that followed, she remained under a dietitian’s watch as she was underweight. The 61-year old said she still struggles to fully open her eyes and swallow dry food.

”What if I died?” asked Jurgiel who wonders when the government will get a grip on unauthorized injectors.

“It is just totally insane that it’s not regulated.”