Not as it seems

As a public hospital-based registered nurse and a private sector dentist, I have seen many examples of successful multidisciplinary teamwork. However, I have also seen (and been involved in) situations where professionals have failed to communicate and work together, which has resulted in compromised patient care.

I saw Mr X the first time in April for an emergency dental appointment (his last dental visit was eight years ago). Mr X is a young and fit gentleman with no relevant medical history. He presented reporting severe toothache in the left upper second molar that had been present for six months. Limited oral examination showed necrotic pulp and symptomatic periapical periodontitis; the tooth was extracted without difficulty under local anaesthesia, with no immediate postoperative complications.

Four hours later, I received a phone call from an emergency department Medical Officer, who told me that Mr X was admitted to the local hospital due to sepsis of unknown aetiology. Both the Medical Officer and Mr X believed that it was related to the dental extraction. I was shocked by this, and informed the Medical Officer about Mr X’s initial presentation – no sign of fever, facial swelling or draining sinuses – such that antibiotic prescription was not indicated. After gaining consent from Mr X, I visited the hospital after hours to discuss possible diagnosis and treatment planning with the hospital doctors. Mr X recalled that within two hours of the extraction, he felt fatigued but was able to go back to work. Four hours later, he experienced rigor and syncope, and an ambulance was called. Laboratory workup was performed to identify the source of infection, and intravenous antibiotics (ampicillin 1g every six hours) were commenced.

Postoperative recovery was dramatic for Mr X – on the second day he developed an allergic reaction to the penicillin-based antibiotics, and as a result was diagnosed with febrile neutropenia. Later that day, I received a verbal complaint from Mrs X, who was understandably angry. The medical team had informed her that her husband’s sepsis was likely caused by my not prescribing antibiotics post-extraction.

I was confused. I still remember that our university professors told us only to prescribe antibiotics where clinically appropriate. The emergence of resistant bacterial strains due to overuse of antibiotics is a worldwide concern. I acknowledged her complaint, but I stand by my professional judgment that antibiotics were not required based on Mr X’s initial presentations and evidence-based studies. I reviewed Mr X again that day; there was no evidence of infection or alveolar osteitis at the extraction site, so I discussed this case with some senior dentists and contacted the Australian Dental Association and Dental Protection for further guidance and advice. Both were very supportive and understanding – they provided useful recommendations in managing the situation.

I was then able to discuss Mr X’s diagnosis and treatments with the hospital Medical Officers, while Mr X and his family were present. I felt overwhelmed by the complexity of this case, particularly as I had received little training in how to communicate in such a difficult and stressful situation. During the meeting, I raised my concerns about the inconsistent information given to the patient and family members, which in my opinion had led to the misunderstanding. The clinical examinations revealed aetiology other than the dental source, so I urged for a further investigation. I also recommended a second opinion from an independent dentist within the public sector; upon this review, the dentist agreed that Mr X’s condition was unlikely to be solely dental related.

On the fifth day, Mr X’s condition had deteriorated. He was admitted to the acute care unit, and required noradrenaline infusion and combination antibiotics therapy. Laboratory results indicated neutropenia with uncertain aetiology. After 10 days, Mr X was diagnosed with prostate cancer and was sent to an oncology hospital for further treatment.

Implementing an effective primary care team – and the extent of a clinician’s role in this team – provides various healthcare challenges, and this has been a good learning experience for me in that regard.  

However, the notion that dental practitioners are part of a multidisciplinary team is not recognised by many, sometimes including other healthcare team members. In this case, I learnt a great deal about the importance of effective communication with the patient, families and colleagues. I witnessed how the patient and carer can quickly trust or mistrust a clinician over a minute detail. Unfortunately, once the rapport has been lost, it will take ten times more effort to re-establish it.

The frustration and anxiety of waiting for a diagnosis can be incredibly difficult. I was so glad that a definite diagnosis was finally reached and treatments were provided in a timely manner for Mr X.