ACOMS Review - Summer 2019 ACOMS Review July 2019 | Page 11

tooth 13 for unknown reasons, debrided the
defending a medical malpractice case,
J U two
L Y 2 critical
0 1 9
extraction site of 14 and prescribed azithromycin
elements are (1) that the physician practiced in
and analgesics. The following day the patient was full compliance with the standard of care, and
seen by Dr. J and seemed slightly improved on
(2) that this compliance can be proven. In trials
physical exam. She was scheduled one day later
of any type, the jury does not necessarily decide
for follow-up with Dr. J, but requested to skip
the case based on the facts; rather they decide
a day and Failure
presented
days later. On
exam
the case
on the evidence presented to
to two
Diagnose
Infection
Leads
to based
Sepsis
there was decreased facial swelling and pain but
them. As a result, the written narrative of the
and a Malpractice Suit against OMS
she now showed some intraoral breakdown of
patient’s treatment experience (as contained in
Robert
Strauss,
DDS, MD with granulation
the wound
and A.
bone
exposure
the patient’s health record) is invaluable.
tissue. Dr. B J’s
notes stated “…very inflamed. Pt is
ACKGROUND
getting better,
additional surgery not indicated
In this case, no cultures were taken to guide the
When complications persist and do not respond to routine therapies, it is incumbent on the OMS to consider
now”. There
was no
of the diagnoses.
patient When
being appropriate,
delivered
which
to the use of at
alternative
and note
less common
referral to a therapy,
tertiary care
center led
for consultation
febrile, having
chills,
or
other
systemic
signs.
least
fve
different
antibiotics.
After one course
should be considered. This case illustrates how seemingly routine cases can become malpractice allegations.
Nevertheless, she was prescribed clindamycin,
of empirical antibiotics, culture and sensitivity
C
A
S
E
D
I
S
C
U
S
S
I
O
N
chlorhexidine and nystatin. Although she was
testing should have been considered and
was a 53-year-old
female
who
presented
general dentist, in
Dr. the
M, for
treatment of
pain in Deviations
the
scheduled The
for patient
follow-up
four days
later,
due
to a to her
documented
patient’s
chart.
upper left quadrant.
medical history
only significant
for a what
permanent
work-related
partial
disability. The the
national holiday,
a family The
member
of the was
patient
from
could
normally
be considered
social history revealed a 1 PPD smoking history and 3-6 drink per day alcohol history.
called Dr. J to cancel the patient’s appointment
standard of care should be documented in the
because she
having Dr. GI M issues
and
patient’s
chart of along
a clear
explanation of
After was
examination,
scheduled
the mental
patient one week later
for extraction
teeth 14 with
and 15
and prescribed
confusion. Cephalexin
She was and
rescheduled
another
the for doctor’s
reasoning.
Darvocet in the for
interim.
The patient returned
that appointment
and had the two teeth
appointment
four
days
later
but
unfortunately,
extracted without incident.
later that same day she was hospitalized for
Next, a case that is medically defensible can
weeks later the patient went back to Dr. M with the sometimes
complaint of pain
and thermal
sensitivity in the
area
sepsis and Seven
endocarditis.
become
indefensible
due
to a
of the surgery. X-rays showed no obvious abnormal findings. Thermal testing showed the remaining maxillary
poorly documented chart. In this case, more
dentition in the upper left quadrant was vital and Dr. M diagnosed a likely maxillary sinusitis. He then referred
The patient subsequently had multiple strokes,
often than not the notes in the patient’s chart
the patient to her primary care physician, Dr. B, for management.
underwent mitral valve replacement and suffered did not explain why some of these procedures
permanent
physical
disabilities.
therapies
it is After
imperative
to
The cognitive
primary care and
provider,
Dr. B, saw
the patient the same and
day and
prescribed were
Ceftin utilized;
and analgesics.
two
Dr. J was weeks
sued the
for patient
failure
to
diagnose
and
document
both
the
actions
being
taken
and
the
felt no better. She followed up with Dr. B who prescribed a 10-day course of Ciprofloxacin
properly manage
an a CT
infection
which
led
to the
for the actions. Failure to do so can make
and obtained
scan of her
sinuses,
which
revealed no reason
abnormalities.
complications. The patient questioned why
defensing most cases extremely diffcult.
Another eleven days passed before Dr. M referred the patient to Dr. J, our insured oral and maxillofacial surgeon,
she had not
been admitted to the hospital for
who examined the patient, reviewed the CT scans and felt that there was no acute odontogenic infection that
intravenous antibiotics. It is unknown if Dr. J had
Additionally, there were multiple surgical pro-
required treatment. Dr. J prescribed chlorhexidine and advised the patient to improve her daily oral hygiene. Of
hospital and admitting privileges at an inpatient
cedures that did not seem to match the original
note, the patient verbally requested another systemic antibiotic prescription because she was “afraid of getting
hospital. an infection.” Dr. J explained that she had just come off the patient
complaint. Progressive, serial extractions
10-day course of Ciprofloxacin and that he felt a
of teeth not in the original plan due to continu-
further course of empirical systemic antibiotics was not advised.
ing patient complaints should be a red flag to
Risk Management Considerations
The patient returned to Dr. M three days later with left sided
facial
tenderness,
and swelling.
diagnosed
the
surgeon.
In pain
situations
like He
these,
the surgeon
an
acute
abscess,
prescribed
Clindamycin,
Zofran
(for
an
undocumented
reason
but
presumably
for
antibiotic-
should
be
extra
cautious
and
documentation
of
Robert A. Strauss, DDS, MD
related nausea) and analgesics. Importantly, no surgical management
was
undertaken
at
that
time.
The
patient
changes to the patient’s complaint, or a change
Bridget Murphy, JD
was not seen by Dr. J for another four days, at which time she
found to
stable, continued
facial
in a was
course
of have
treatment,
is vital.
Given the significant and permanent nature
Finally, it became unclear to all involved which
of the patient’s injury, this is the type of case
provider was responsible for managing the care
that may likely result in a malpractice suit. In
Malpractice Minute
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