Dr. Cecil Cameron ran an established general dentistry practice in a suburb of a major metropolitan area. Ethan Gardiner, 55, stopped by Dr. Cameron's office and picked up a new patient information packet to complete at home.
Posted in Articles on Tuesday, November 1, 2022
At his visit the next day, Ethan advised the staff and Dr. Cameron that he needed dental work due to a broken tooth and that he wished to have his mouth “fixed.”
Ethan was unemployed at the time of the visit but didn’t mention why. In answering a question regarding previous dental care, Ethan revealed that he had seen another dentist in the last five years, but didn’t give the individual’s name or practice, the history of that relationship, why he wasn’t seeking treatment there now or how long ago that was. Dr. Cameron didn’t inquire further, and there was no further documentation on the issue.
The health history form also indicated Ethan’s only health issue to be high blood pressure and the only medication as Catapres (one per day). He indicated his physician’s name but no other contact information. There is no indication on the form or in the records that it was reviewed by or discussed by either Dr. Cameron or his staff.
The consultation and examination—including radiographs—was completed by Dr. Cameron. The resulting treatment plan was to extract four teeth—numbers 7, 8, 9 and 10. Dr. Cameron proposed two options: a bridge or implants after extraction. Before any treatment could begin, it was necessary to refer Ethan to Dr. Dana St. Claire, a periodontist, for severe periodontal disease.
The referral was made via a short, pre-printed form which indicated the patient’s name, reason for referral (severe perio) and a request for a letter after evaluation. The X-rays were sent with the patient. No other information was provided to Dr. St. Claire and there was no other documented communication between Dr. Cameron and Dr. St. Claire.
Dr. St. Claire saw Ethan two days later. The health history information completed for Dr. St. Claire was more comprehensive than what was provided to Dr. Cameron. On his health history form, Ethan revealed that he was taking seven different medications. In the cardiovascular section of the health history form, he answered “yes” to the question of congestive heart failure and wrote in “weakened heart muscle,” as well as high blood pressure. As a result of this information, Dr. St. Claire sought medical clearance from the physician identified on the health history form prior to commencing treatment—Ethan’s cardiologist. He had been a patient at the local university heart institute for over three years due to his cardiovascular health issues.
In the medical clearance, the cardiologist noted the patient’s high blood pressure was controlled and he could tolerate extended treatment but suggested extractions with monitoring. Furthermore, he indicated pretreatment or post treatment antibiotics were not necessary. The cardiologist advised against using 2% lidocaine with 1/100,000 epinephrin.
Dr. St. Claire proceeded with the perio treatment. After root planing was completed, Dr. St. Claire referred the patient back to Dr. Cameron. The referral consisted of a brief letter in which Dr. St. Clair recommended the patient be treated for lower partial dentures to replace the missing lower incisors (#23, #24, #25 and #26), evaluation of other restorative treatment for older restorations, and a long-range plan to include periodontal therapy and fixed replacements. No other documents were included or health issues noted, and no further communication is documented to have occurred between Dr. St. Claire and Dr. Cameron.
Ethan visited Dr. Cameron approximately one week after completion of the initial periodontal treatment performed by Dr. St. Claire. Upon presentation, Ethan’s blood pressure was 138/90. As a result of this reading, the records indicate Dr. Cameron inquired as to whether the patient had taken his Catapres (blood pressure) medication that morning. Ethan indicated he had. Dr. Cameron initiated extraction of teeth #7, #8, #9 and #10 with no complications. As he prepared #6 and #11, Ethan began to shake. The procedure was stopped as the patient complained of labored breathing. He became flush with palpations. Dr. Cameron initiated oxygen via ambubag and then, when the pulse was lost, CPR. Emergency services were called. According to Dr. Cameron’s documentation, they arrived approximately 30 minutes later. Dr. Cameron received a call from the hospital later that day advising the patient had expired.
A Request for Records
Twelve days after the event, a request for records was received by Dr. Cameron’s office from an attorney representing Ethan’s widow. The allegation? Deviation from the standard of care resulting in Ethan’s death, with a demand of $1,000,000.
An early review of the records by defense experts were generally favorable to Dr. Cameron’s care. The patient was not truthful in completing the health history form, his blood pressure of 138/90 was within range, Dr. Cameron had confirmed (and documented) Ethan’s affirmative response to taking his blood pressure medication that morning, and the epinephrine was administered approximately one hour prior to any distress being noted. At the time, the dental office was properly prepared for a cardiac event. AEDs were not in wide use yet.
If Dr. Cameron was found to have deviated from the standard of care, the reasonable case value of this situation was estimated in the $750,000-$1,000,000 range. This estimate was based on the age of the patient and his life expectancy, his dependents (a 16-year-old still at home) and his contributory negligence for not revealing the true nature of his heart condition to Dr. Cameron.
After investigation, counsel sought mediation of this case due to several issues:
- The case was brought in a county with a history of very high verdicts in favor of plaintiffs.
- Dr. Cameron was currently on probation with his dental board.
- Dr. Cameron had two other open claims pending at the time.
- Although the board issue and claims may not have been admissible in court, both are public records and accessible.
- There was no documentation that Dr. Cameron or his staff reviewed the health history form or investigated the health history information to determine Ethan’s work history, previous dental care or health issues.
- Had Dr. Cameron pursued the previous dental care, he would have found the patient had seen another dentist 6 months earlier and that dentist had documented uncontrolled high blood pressure and sought medical clearance from the cardiologist prior to his treatment.
- Dr. Cameron did not communicate with Dr. St. Claire regarding the treatment he provided which may have brought to light the medical clearance information from the cardiologist
- Records from the EMS revealed they arrived 12 minutes after the initial call, not 30 and no explanation can be provided for the time lapse
Mediation resulted in a settlement of $600,000.
What Can We Learn?
The primary issue in this case is the fact Dr. Cameron did not adequately review the medical history of the patient and prior treatment although Ethan had stated that he had seen another dentist within the last five years. The patient had requested and received copies of his dental records from the previous dentist whom he had visited six months prior to seeing Dr. Cameron. Those records clearly indicated a history of uncontrolled high blood pressure, seven medications and heart issues and a request for pretreatment medical clearance. Ethan did not (or at least it is not documented) provide those records or share that information with Dr. Cameron.
There was also a disparity in formation received between the general dentist and the specialist. Dr. St. Claire did not share any of the information he gathered on the patient with Dr. Cameron and Dr. Cameron did not ask. With the patient’s noted medications and affirmative answer to a heart condition, the specialist followed up with the physician who turned out to be the patient’s cardiologist. Upon referring the patient back to Dr. Cameron for continuing care, the specialist did not share the information he received regarding the health issues, even though the medical clearance and the specialist’s recommendations for future care referenced extensive dental treatment which would have required monitoring and use of an anesthetic. Dr. St. Claire believed, according to his notes, the missing teeth, #23, #24, #25 and #26, had been removed by Dr. Cameron.
Referrals can be tricky and are usually thought of when the primary provider refers to a specialist, but it is two-way street. The specialist is also providing a referral back to the primary provider and this can be where there is a breakdown in information. This situation illustrates the value of what is known as “closing the loop” to make sure all the providers are on the same page. When a patient is referred out (or returning to your office from a specialist), a thank you note simply stating the patient was seen and a summary of the services provided may not be sufficient. It is good practice to provide/inquire as to:
- The patient’s active problem list which they identified
- An updated medication list
- A list of medical allergies obtained
- A summary of any significant medical and surgical history obtained
- A summary of any significant family history obtained
- A summary of any significant behavioral habits/social history obtained
- Any additional information pertinent to the continuation of care
- List of providers (care team) discovered during the treatment
Upon questioning, Dr. Cameron confirmed that had he known of the patient’s heart issues and history, he would have monitored the patient more closely and avoided the epinephrine.
Patients have a responsibility to provide thorough and accurate information. The health history form is a legal document. The provider can only rely on the information provided by the patient when providing treatment. However, the information gathered may have details which should be reviewed and questioned. Not unlike an informed consent, a health history form requires a conversation to make sure the patient understands all the questions being asked and the importance thereof. Discuss the form with the patient to review the answers they have provided. After the discussion, you can have the patient sign off on the form confirming the discussion and document the records that there has been a review and discussion of the form and the patient has confirmed all the information is complete and correct. Finally, make sure the forms being used are current. Review them annually and compare them to those being offered by the local/national dental association.
Know what to do in the event of an emergency. Have a written medical emergency plan with which all staff is familiar. For example:
- The dentist should remain with the patient while emergency services are contacted.
- The order to call emergency services should be repeated back by the individual making the call so there is no confusion as to who is calling and when.
- If the practice is located in an office park with other offices, have someone stand outside to wait for the emergency vehicle so they know where to go.
- Document what medications, etc. were provided so the EMTs know what has been administered by the staff.