Death Following Extraction on Coumadinized Patient
Marc Leffler, DDS, Esq.
March 15, 2022
Reading time: 7 minutes
An experienced oral and maxillofacial surgeon (we’ll call him Dr. A) on the verge of retirement from practice was greeted as he entered his office one morning by a process server who handed him a Summons and Complaint — it alleged that he caused the wrongful death of one of his patients, but it had no further details. At first glance, the oral surgeon had vague recall of the patient whose estate filed the suit, but he did not remember any problems with the patient’s treatment which was over a year earlier.
He immediately pulled the patient’s chart – all handwritten – to review it, in advance of getting in touch with his dental malpractice carrier. He was soon contacted by the assigned attorney representing him, and they agreed to meet the following day, as strict time limits existed regarding when a response on behalf of the oral surgeon needed to be filed.
The oral surgeon’s attorney contacted the attorney for the plaintiff to try to understand the underlying circumstances. The plaintiff’s attorney conveyed back that this was a simple case: Dr. A had extracted the patient’s tooth, which led to a significant post-operative bleeding event on the day of extraction, which caused the need for emergency transport to a local hospital, where the patient (age 77) died. The plaintiff’s attorney suggested a quick settlement to save the family a stressful legal process. As would later be learned, those reported case facts were all true, but critical events – which would guide the entirety of the litigation and its resolution – were left out of the description.
Dr. A and his attorney went through the dental chart together to work through the course of treatment. The patient initially presented, on referral from a general dentist, for evaluation of a non-restorable tooth. Then, the patient said that he was unable to understand the questions on the medical history form, so the oral surgeon, instead, verbally discussed with his new patient any existing medical conditions: the patient disclosed that he was taking Coumadin due to a history of a “blood clot” (deep vein thrombosis), and Toprol for hypertension. Dr. A simply noted “Coumadin and HTN” in the chart for medical history, and called the patient’s physician after determining that the patient needed an extraction; the physician said a subsequent dental appointment should be scheduled a week later rather than treating that day so that the physician could see and evaluate the patient.
Unbeknownst to the oral surgeon, the physician then told his patient to stop taking Coumadin for 4 days prior to that upcoming dental appointment and to obtain a blood test the day prior to it. The patient did exactly that, and his physician then advised him to tell Dr. A that he may proceed with the planned procedure, and that the patient should re-start his Coumadin 2 days after the extraction. The patient reported to Dr. A only that his physician had told him that he may proceed, but he did not mention, nor was he asked about, Coumadin stoppage and testing. All went forward without complication, with Dr. A having never again communicated with the physician.
The patient next appeared nearly a year later for what would be his final visit, complaining of a loose, annoying upper first molar. Radiographic and clinical examination demonstrated a periodontally hopeless tooth, so the oral surgeon, after calling the patient’s general dentist, suggested extraction and the patient agreed. Dr. A asked the patient how his health was, and he responded – according to Dr. A – that he was doing well, but his blood pressure medication had been changed to better control it. That was the entirety of the conversation, with the issue of Coumadin never mentioned by doctor or patient, although the subsequent medical records clearly revealed that he continued to take Coumadin as of that time.
Dr. A routinely extracted tooth #14 and debrided the associated granulation tissue. He applied gauze pressure to the site and good hemostasis was achieved. The patient was discharged home with a packet of extra gauze, and instructions to place additional gauze on the site as needed. The patient’s son, who knew his father was going to the oral surgeon that day, was unable to reach his father that evening, so he drove to his father’s house, to find him conscious, but lying on the floor with blood seeping out of his mouth. An ambulance was called to transport the patient to a local hospital.
At the hospital, the patient was admitted and transfused. Laboratory values showed that the patient had an elevated INR, as would be expected in a Coumadinized patient. A hematologist managed the patient’s anti-coagulation and was able to medically stabilize him within a fairly short time. However, the laboratory studies also, unfortunately, revealed that the patient had an advanced, aggressive form of leukemia, which had not previously been diagnosed. After a work-up and a discussion of treatment options, the patient agreed to start a course of chemotherapy, but he stopped it several days later due to side effects that he found intolerable. Palliative therapy was provided at the hospital, but he soon passed away.
Legal steps taken
Once defense counsel obtained all relevant medical records and had experts review them, it was apparent that Dr. A was negligent in failing to take an adequate medical history at the subject extraction visit — so as to have ignored questioning the patient as to whether he was still taking Coumadin, thereby leading to the bleeding event which hospitalized him. But, it was equally clear that it was the entirely unrelated leukemia which caused the patient’s death.
Defense counsel contacted the plaintiff’s attorney, asking for discontinuance of the action because there was no good faith basis to maintain a wrongful death claim. Plaintiff’s counsel argued that it was the oral surgeon’s negligence which put him in the hospital due to uncontrolled bleeding, but the oral surgeon’s attorney reminded him that the only claim was for wrongful death, which was not caused by the defendant, and that the statute of limitations had expired as to any potential bleeding-related claim, thereby precluding its addition at that point. Ultimately, the plaintiff’s attorney relented, and discontinued the case.
However, the estate executor and plaintiff – the patient’s son – was upset that Dr. A was not held accountable for his negligent actions, so he filed a disciplinary complaint with the State. Disciplinary bodies, unlike courts in malpractice litigation, do not consider what result came of a dentist’s claimed improper actions, but only whether those actions constituted professional (i.e. appropriate) or unprofessional conduct — the latter of which is sanctionable. In this case, the disciplinary agency determined that Dr. A had acted improperly with regard to his record-keeping, specifically relating to his taking and recording of the patient’s medical history at the extraction visit. The oral surgeon was given a stayed suspension and a fine, and was required to take continuing education classes in the subjects of history taking and dental charting during his next license renewal cycle.
Beginning with a legal issue, this case demonstrates the importance of immediate reporting to the malpractice carrier, so that counsel may be immediately assigned — not only for the purpose of filing timely response papers, but to allow counsel to evaluate the lawsuit’s pleadings to assess what the claims specifically are. Here, defense counsel was able to determine that the sole claim involved a wrongful causing of death, so that the review of the oral surgeon’s chart and the subsequent medical records could be focused toward assessment and defense of the pending legal claims. Yes, this patient died after dental treatment – albeit well after that treatment, a fact not initially disclosed by plaintiff’s attorney – but it turned out to be unrelated to the defendant’s care. For a valid claim in dental malpractice, there must be negligent treatment which directly causes the injuries claimed.
A common theme explored in legal case studies is the importance of proper record-keeping, which simply cannot be emphasized enough. In this case, even if Dr. A did appropriately discuss medical history with his patient, he did not record having done so. Therefore, a reasonable inference may be drawn, including by a jury, that what was not recorded did not happen. While that issue did not play out in this malpractice case scenario, it was the focus of the discipline levied against the oral surgeon.
Dental providers are well served to present their patients with printed medical history forms, which are then supplemented through a back-and-forth discussion, so nothing of relevance is omitted; if patients, as here, are unable to complete such forms on their own, then a thorough reading through with the patient is in order. Simply asking a patient, “Are you in good health?”, as is done with surprising frequency, leaves it to the patient to evaluate and report what conditions might be significant. Furthermore, a patient’s failure to disclose on a written form carries far more defense weight before a jury than conflicting stories about what was or was not said. Similarly, if physician consultations are requested, a written response from the physician, or minimally, a contemporaneously documented conversation between dentist/oral surgeon and physician will eliminate issues associated with gaps in patient recall and/or which may confuse a patient.
While the purpose of this case study is not to dictate what actions practitioners should or should not take in given situations, it is worth pointing out that health conditions which might quite reasonably affect dental treatment outcomes should be given due consideration, and that can only happen through careful taking and review of medical histories.
Finally, this case demonstrates the value of open communication and a strong professional relationship between oral surgeon and defense counsel familiar with the subject matters at hand.
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