Dental Case Study: Death following extraction on Coumadinized patient
Marc Leffler, DDS, Esq. – November 2021
An experienced general dentist (we’ll call him Dr. A) on the verge of retirement 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, and had no further details. At first glance, the dentist 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 dentist needed to be filed.
The dentist’s attorney contacted the attorney for the plaintiff to try to understand the underlying circumstances. The plaintiff’s attorney conveyed 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 67) 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 several years prior for a check-up. The dentist, who never had a medical history form as part of his chart, verbally discussed with his new patient any existing medical conditions: he was taking Coumadin due to a history of a “blood clot” (deep vein thrombosis), and metoprolol for hypertension. Dr. A simply noted “Coumadin and HBP” in the chart for medical history, and called the patient’s physician after determining that the patient needed a deep scaling; the physician said a subsequent dental appointment should be scheduled a week later rather than treating that day.
Unbeknownst to the dentist, 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 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 scaling. 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.
The patient next appeared nearly a year later for what would be his final visit, complaining of a loose, annoying upper first molar. Radiograph and exam demonstrated a periodontally hopeless tooth, so the 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, although the subsequent medical records clearly reveal 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 dentist 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 prothrombin time, 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. 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 clear that Dr. A was negligent in failing to take an adequate medical history at the extraction visit — so as to have ignored the important fact that the patient was 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 dentist’s negligence which put him in the hospital due to uncontrolled bleeding, but the dentist’s attorney reminded him that the only claim was for wrongful death, which was not caused by the dentist, 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 dentist was given a stayed suspension and a fine, and required to take continuing education classes in the subjects of history taking and dental charting during his next license renewal cycle.
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 dentist’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 dentist’s care. For a valid claim in dental malpractice, there must be negligent treatment which directly caused 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 dentist.
Dentists would be 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. 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 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 dentists should or should not take in given situations, it is worth pointing out that it is far from uncommon that dentists are caught in situations which would appropriately differentiate between the initial stoppage of bleeding and the development of a stable clot. As a general principle, blood initially stops due to the actions of platelets, whereas stable fibrin clots are created after the body later completes a coagulation cascade; drugs such as aspirin and conditions such as thrombocytopenia may interfere with the formation of an initial platelet plug, while medications like Coumadin and conditions like hemophilia interfere with the clotting cascade to inhibit clot formation later. Here, the hemostasis achieved in Dr. A’s office was attributable to platelets (which are essentially unaffected by Coumadin), but the platelet plug which is normally replaced by a clot was not so replaced in this case, thereby accounting for the delay in the onset of bleeding.
From a risk management perspective, it is always a good idea to regularly review medical conditions and medications, especially as they arise in treatment circumstances; it is never a problem to consult literature or field experts.
Finally, this case demonstrates the value of open communication and a strong professional relationship between dentist and defense counsel familiar with the subject matters at hand.
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Other than the clinical situation presented here, for what dental procedures might Coumadin be a concern, and how should a general dentist best handle such circumstances?
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