DUBLIN, Texas (KXAN) — She remembers feeling dizzy and then, what seemed like seconds later, bright lights.

“I felt like I was in a dream,” she said. “Then waking up, I just saw everyone was – was panicking.”

She had fainted, and an EMS report detailed she had a five-minute seizure and was vomiting.

It’s not the result she expected from her decision, on a whim, to get Botox. She told KXAN she saw a social media post about a summer deal and drove from a nearby town to Dublin, a small city north of Austin, to get her first injection in the back room of a store.

It’s not illegal for someone to inject Botox — in fact, a KXAN investigation uncovered anyone in Texas can get certified to be an injector and practice anywhere. But because of what happened at the store, Dublin police are now investigating whether the injector was “practicing medicine without a license” — and hoping to shape the future of safety in the state.

An open investigation

“We went specifically for a lip flip. So just Botox in my lips,” said the woman, who wanted her privacy to be protected because “It’s such a small town… everyone knows everyone… everything gets spread pretty easily.” 

She recalled walking through a store towards the back room, a small space like a closet with a curtain for privacy. She described feeling fine after getting the injections in her bottom lip but said as soon as the injector started on the top one, she knew something was wrong.

“The injector did ask our EMS staff, you know, ‘What do I do to make sure this doesn’t happen again?’ Well, the only way to make sure this doesn’t happen again, is to, you know, ensure that your patient qualifies for the injection,” Dublin Police Chief Cameron Ray said.

The town of almost 3,700 people has a police force of 10 sworn officers. The department has been investigating this case for months. Since the injector hasn’t been charged with anything at this time, KXAN is not naming her or the store. 

“We will handle any charges that come to the person who did the injection,” Ray explained.

He added that they’ll take the case to the District Attorney’s office once their investigation is complete, pushing for accountability and, ultimately, oversight across the state.

“The goal in this investigation is to spur change to the system,” he said.

Botulinum toxin, commonly called Botox, can be used to treat medical or cosmetic concerns like facial wrinkles, the Centers for Disease Control and Protection said. The agency warned it can have adverse effects including botulism, which is a rare but serious illness caused by the toxin attacking the body’s nerves and causing blurred vision, difficulty breathing and muscle paralysis. 

In Texas, Botox injectors must have someone licensed in medicine supervising them, like a physician assistant, an advanced practice registered nurse or a doctor serving as a “medical director” in case there are complications. 

The injector in the Dublin case had completed training offered by Texas-based MySpaLive, according to the company’s attorney. Police explained the company’s medical director listed online back then was a pediatrician in Tyler – more than three hours away – who hasn’t returned KXAN investigators’ repeated calls and emails.

“When you’re 190 – 200 miles away, how are you going to have direct oversight if complications arise out of that injection?” Ray said.

The company’s attorney would not respond to questions about the specific case for privacy reasons but said in an email that MySpaLive “does not provide any medical procedures” and has developed an app to connect injectors with a licensed medical practitioner without having to go into an office. The attorney added that the practitioner can then supervise and authorize an injection.

Dublin police would only confirm medical staff was not at the shop the day of the emergency. Other steps that might have been taken are part of an ongoing investigation.

KXAN investigators made two trips to Dublin to talk to the injector about the medical emergency.

On the first trip in March, KXAN stopped by the store where police said she was doing the cosmetic procedures. The store owner showed KXAN four training certificates framed on a wall near where the injections take place. She said the injector was not there at the time. KXAN called, texted the injector and went by her home. She had agreed to meet with our team but then changed her mind. 

“My attorney that handles all my business said I am not interested in interviewing,” she responded back in a text. 

On the second trip to Dublin in April, KXAN went back to the store to try to talk to her one more time about the open investigation, but she didn’t want to talk. KXAN was able to reach her attorney after several attempts, but he said they have no comment. 

Where’s the oversight?

In Texas, there is not a state licensing board or regulatory agency that directly oversees the people, supervising physicians, and practices of those who operate in the medical spa industry and provide Botox injections.

KXAN found Texas is one of only four states in the U.S. that doesn’t have a dedicated state agency with direct oversight that requires various degrees of licensing or registration for med spas.

As a result, the Texas Medical Board and local law enforcement agencies must rely on complaints or referrals to take action against individuals and physicians who are illegally or improperly running med spas.

KXAN asked the TMB about the current laws regarding Botox injectors, med spas, and physicians who serve as medical directors and ultimately delegate authority that allows others to provide Botox and non-surgical cosmetic procedures.

“There could always be more done to protect patients,” TMB stated, and further clarified that while it cannot lobby for or against a law change, it is aware of trending concerns and has been proactive in addressing complaints related to “Botox parties” and physician supervision/delegation in the med spa industry.

“If a complaint is received, the agency will investigate the supervising physician (if one is involved) and those involved in such activity,” it explained. “If there is no physician involved, TMB does also have cease and desist authority against those involved in this type of activity.” 

Additionally, law enforcement can pursue criminal charges for unlicensed practice of medicine, a third-degree felony offense in Texas.

“Everybody says law enforcement is there to protect and serve. Well, I believe, in this instance, we’re doing that protection by holding those people accountable,” Chief Ray said. “Never in my wildest dreams did I think we would be, you know, investigating what somebody’s injecting in people’s lips.”

When law enforcement, Texas Medical Board take action

A recent Houston arrest provides an example of how the accountability process can play out. Last month, the Houston Police Department arrested a man on three felony charges of practicing medicine without a license or permit causing harm, as well as a fourth charge of aggravated assault causing serious bodily injury.

According to court records, the man owned a med spa in the Houston area, and his title listed in court documents was “Injector.”

Court records state he “intentionally and knowingly” practiced without a medical license and caused harm to multiple patients after injecting an unknown substance into his clients.

KXAN found the same man was issued a cease and desist order by TMB in 2020.

The cease and desist states the man “admitted to administering skin treatment injections including Botox for a period of several years and without proper physician involvement.”

KXAN asked TMB how it ensures that a cease and desist order is followed.

In response, TMB stated: “A cease and desist primarily serves as a notice to the public regarding the individual. This information is also referred to law enforcement. Continued violations of a cease and desist can impose civil penalties recoverable by the Office of the Attorney General.”

TMB further clarified that local law enforcement and prosecutors would be the only authority to pursue criminal charges.

KXAN reviewed TMB disciplinary records since 2018 and found 63 actions taken against individuals and/or physicians specifically related to med spas and/or non-surgical cosmetic procedures.

Of those 63 actions, 55 were cease and desist orders issued against individuals for engaging in the unlicensed practice of medicine by providing non-surgical cosmetic procedures without proper physician or midlevel oversight.

The remaining eight actions taken by TMB were against licensed physicians for improper supervision or delegation of cosmetic procedures.

Each of the physicians received a public reprimand, were issued a monetary fine of $2,000-$10,000, and were required to complete various amounts of continuing medical training.

Over 75% of the TMB’s actions were taken since 2021, further supporting the “trending concerns” TMB acknowledged related to “Botox parties,” and physician supervision/delegation in this industry.

From 2018 to 2022, TMB actions grew from three to a high of 15. As of March of this year, the TMB has already taken action against 11 individuals and/or physicians for their roles in providing non-cosmetic surgical procedures.

Hampered by a lack of laws

Lawmakers have heard of these investigations and concerns and tried to take action.

State Sen. Charles Schwertner, R-Georgetown, filed legislation during the 2023 regular session which would have prohibited estheticians and cosmetologists from doing injections — including Botox — unless they are licensed in medicine or certified and have medical supervision. The bill stalled after passing the Senate, but he plans to re-file next session. 

“I think it is incumbent that we as a state, protect Texans and their health and safety and welfare when it comes to any sort of invasive procedure,” he explained.

Schwertner, who is an orthopedic surgeon, explained the medical board can take disciplinary action against doctors authorizing injections. He added that current law has no oversight when it comes to estheticians or cosmetologists who fall under the Texas Department of Licensing and Regulation. His bill aimed to give that agency authority to discipline those professionals if needed. 

“Any individual that is involved in the care — in this case, the cosmetic care of an individual — is held accountable when something goes wrong, and that they should have had the proper level of education, experience and training,” he said. 

CDC and FDA open investigations following Botox outbreak

As Texas considers possibilities for oversight, warnings related to Botox are growing on a national level.

A recent outbreak of people experiencing harmful reactions after receiving injections of counterfeit or mishandled Botox has prompted investigations by the Centers for Disease Control, the U.S. Food and Drug Administration, and 11 state and local health departments.

As of April 18, CDC has received reports of 22 individuals who from Nov. 4, 2023, to March 31, 2014, have experienced various symptoms of botulism:

Half of the 22 individuals required hospitalization, six of whom needed to be treated with botulism antitoxin due to concerns that the Botox could have spread beyond the injection site, the CDC stated.

All 22 of these individuals reportedly received Botox from unlicensed or untrained providers and/or in a non-healthcare setting, such as homes and spas, according to the CDC.

The Texas Department of State Health Services told KXAN there is currently one Texas case that meets CDC’s outbreak definition. According to DSHS, this is still an ongoing investigation and the Texas individual was treated and has recovered.

The FDA has also issued a black box warning for the medication used for Botox, which is the highest safety warning the agency requires. The warning is contained inside a box with a black border and provides a brief summary of the information that is critical for a prescriber to consider.

The effects of BOTOX and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects.”

FDA Black box warning for Botox

The FDA is also reviewing a petition by consumer group Public Citizen asking it to strengthen the risk warning language on all approved Botox products due to concerns of temporary paralysis, hospitalization and even death. The consumer group is pushing for the FDA to clarify that adverse effects could happen even at recommended dosages.

If someone is considering an injection of Botox, the CDC recommends that person always ask if the provider is licensed and trained to perform the injection and ask if the product is FDA-approved and acquired through a legitimate source.

“If in doubt, don’t get the injection,” the CDC said.

Inside a cosmetic injection training 

Even some in the industry think injectors need more oversight. It’s why Master Injectors exists, according to Chief Marketing Officer Mike Rocha. His Texas-based training company certifies injectors.

“These individuals are going to take training somewhere. If they don’t have a medical license, they’re going somewhere to get trained. We want them to train with us, because we’re going to teach them and train them properly and safely,” Rocha said.

KXAN investigators learned that several months after the medical emergency in Dublin, that injector was certified with Master Injectors. The company explained she had only had that certification for a few weeks before it learned about the police investigation and revoked her certifications. 

Master Injectors allowed KXAN to attend a recent weekend training in San Antonio. It covered everything from having a clean treatment area, to how Botox should be stored, facial anatomy and where people can and can’t inject. There were several tests throughout the day. Trainers who are registered nurses also walked around and worked closely with smaller groups to make sure safety measures were followed and understood.

“A big reason that we wanted to start this training is that non-medical people can take it, so we wanted to make sure that they were trained properly in the anatomy, and the physiology and blood-borne pathogen training to make sure they had that background,” explained Brenda Rocha, who is the chief nursing officer and oversees all the training. 

Training can cost upwards of $2,500 and not everyone becomes certified after a weekend. On average, the company said about 15% of a training class doesn’t get certified. 

“There have been people that — that I have turned away and said ‘I do not feel comfortable and do not feel like you are safe for the public and we cannot certify you,'” Brenda Rocha added. 

Master Injectors said it not only has oversight from a Medical Director who is an anesthesiologist with esthetics training out of Dallas but also from owner Brenda Rocha who is a registered nurse.

Master Injectors also works with a compliance company to make sure protocols are in place for itself and its clients, like nurses looking over medical charts daily, overseeing products purchased, and making sure people getting the injections are receiving a medical exam.

“We’re looking at all their procedures, protocols, trainings, all of those things, just, you know, going through it with a fine-tooth comb, just to make sure that it’s meeting industry standards,” said Amber Bechthold, owner of Aesthetic Business Consulting, the compliance company. 

KXAN investigators reached out to associations for estheticians, cosmetologists and med spas to ask them about their training and oversight but there have been no responses. 

‘Do you want to play Russian Roulette?’

“My plea to the public is ‘educate yourself, ask questions, don’t assume that somebody in a white coat or in scrubs is actually knowledgeable about what it is they’re proposing to do to you,'” said retired pediatric neurosurgeon Dr. Patricia Aronin. 

Dr. Aronin is with Texas 400, a grassroots group of doctors advocating for patient safety across the state, who describes the current industry as the “wild west.” The nonprofit said it will be watching closely next session as Schwertner refiles the oversight legislation.

She added that it’s tough to track the size of this problem because people don’t always know how or where to file complaints and it can be embarrassing for some to share what happened. Complaints should be filed with the Texas Medical Board. 

Data KXAN obtained shows 91 complaints have been filed with the medical board since 2019 for things like Botox and other cosmetic procedures. The agency said it has nine open investigations related to improper providing of nonsurgical cosmetic procedures.

“Do you want to play Russian Roulette just because you don’t want your face to have wrinkles?” she said.

The woman in Dublin who got the Botox said she’s had no complications since the medical emergency. She’s sharing her experience to warn others. 

“I think it’s definitely important to have proper training for sure, especially with… injections going into the face,” she said. “It’s a very scary thing. … I feel like it’s not something to be messed with.”

The injector in Dublin is still working. Police added that they are working to wrap up their investigation soon.

“If we’re able to, you know, shine the spotlight on this problem, we can work with our lawmakers to provide the government oversight that is needed for the safety of our citizens,” Chief Ray said. 

Graphic Artist Wendy Gonzalez, Director of Investigations & Innovation Josh Hinkle, Investigative Photojournalist Chris Nelson, Digital Special Projects Developer Robert Sims, Graphic Artist Christina Staggs, and Digital Director Kate Winkle contributed to this report.