Simply the worst day of my practising life

This case study is told from the perspective of Dr X...

Nobody gets up in the morning intending on harming someone, I know that, and I am no different. 

I decided to become a dentist because I like people, and I wanted to make a difference. I wanted to be better than the school dentists who scared me half to death, and I wanted to help.

I found dental school tough in some ways, but made it to the end and threw my hat in the air with the rest of them. My first job was an exciting prospect, and I had quite strong ideals and ideals about the type of dentist I wanted to be, and the kind of reputation I wanted to hold within the community. I opted to work regionally because the benefit of sea air outweighed the aggravation of limited retail choices (as long as I had Wi-Fi that was easily fixed) but I did not factor in the limitations this can place on having a convenient centre for referral, or even the proximity of another dentist to talk cases through with. Some of the patients I see travel for hours to see me, because there is no one else, and I in turn feel committed to seeing them and doing what they need and want in the time available wherever possible.

Sue was one of those patients. She always booked for a mid-morning appointment and despite the four hour drive she had to get to me, she was never late. She had been one of my first patients, and really stood out in my mind because she was so nice and friendly. I used to make sure she had a cup of tea made for her when she arrived after her long drive, before she saw me, and I think she really appreciated it. 

I think in a lot of ways I was really lucky that Sue was the patient in question as, because we already had a strong relationship I think she was more forgiving of me than a stranger would have been. That said I would never want to harm anyone, least of all someone who had been so kind to me.

One of the things you have to get quite proficient at very quickly, when working in a remote area, is extractions. I had been keeping an eye on a heavily filled 16, as Sue did not want to have the repeat visits of an RCT – she simply could not do the travel, so she knew that if the tooth gave her trouble, she would be looking at an extraction.  On that Monday it had already been hurting for several days.

Sue had tried all the usual remedies, but the pain was getting worse, and she wanted the tooth gone. I am lucky enough to have an OPG machine at our practice, so took a radiograph to assess the extraction. I assessed the tooth as one I could comfortably extract as although I identified that the tooth was heavily filled with a hooked mesio-buccal root, it did not seem close to the sinus, and to all intents and purposes it looked like every other heavily filled 16 I had successfully extracted over the previous 18 months. My principal took Mondays off anyway, and I really did not want to inconvenience Sue.

I showed Sue the x-ray and told her all of the things that could go wrong. She laughed, and said she trusted me. I numbed her up and began to elevate and luxate the tooth. When I placed forceps, the inevitable crack occurred as the crown came off, but we had planned for this, and I confidently proceeded to divide the roots.

The palatal root came out, but the buccal roots were splintering, and I was finding it harder and harder to get purchase on them so I asked my DA to set up the surgical kit. As she had to go and get it from my principal’s surgery I thought I would just have a feel around the distal root again, just to see. I began to apply pressure, and to my horror it disappeared, and I found myself looking into a black hole I had created.

I cannot even begin to tell you how time slowed down for me. I felt light-headed and did not know if I was going to cry, vomit, faint or run out of the room. I rapidly assessed what I could do for Sue, and realised, I had done enough… the full horror hit. Sue had a root in her sinus and there was nothing I could do about it.

My nurse walked back in and started bustling about with the tray. I put my hand up to catch her attention, as I did not want to dirty any more equipment. She did not see me, so I had to speak up. I was honestly surprised how easily those words came. I explained to Sue, that something bad had happened, and that she would need to see a surgeon for repair. I apologised, probably too many times, and told Sue what my plan was moving forwards.

In the three breaths I had taken standing over the damage I had caused, I had realised what I needed to do. I put a gauze pack in and sat the chair up as I went to make a few phone calls. I knew of a maxillofacial surgeon who flew in and performed a list once a month and I knew he was due in the next two to three weeks. Appointments with him were hard to come by, but when I called his offices his receptionist was great.

She looked at his book, and found some time for Sue, just over two weeks away. She also got the surgeon and he came on the line to speak with me. To him it was such a normal occurrence that it helped me find my balance and calm down a bit. He gave me some advice about what treatment to do now, and what to prescribe, and his email address to send the referral and x-ray.

I also called Dental Protection and they were very supportive. They helped me with all of the necessary paperwork, and gave me a much needed shoulder to cry on.

Sue was great too. When she left the surgery she gave me a big hug and told me not to worry as these things happen, got in her car and left. I called her the next day, and she told me she was a bit sore, and had a black eye, but continued to reassure me that she was OK.

I lost sleep.

Sue’s appointment for remedial treatment was a success and she still sees me now. I am glad that she has recovered and I am glad she still has confidence in me, as a dentist. I still do not know what went wrong, even though I have looked at the x-ray again 100 times, and in my heart I cannot say I would do anything differently if I were faced with the same situation. I am grateful that there were no lasting ill effects for Sue, and I think this is just one I have to chalk up to experience.

One of the most difficult conversations we have in our career is one in which we have to inform a patient that an adverse outcome has arisen. Grasping the nettle and talking things through at an early stage may not be easy, however if a complication is not discussed with the patient at the time and instead comes to light at a later date, not only is the patient upset at the need for further treatment but there is a sense of deception which inevitably drives patients towards an adversarial complaint, often with referral to our regulators.

A trusting professional relationship with a patient helps buffer bad news and this case demonstrates how investing in your relationship with patients can pay dividends when problems arise.