The killer dental abscess

Mistakes cost lives in the medical profession

Having been in the medical profession for over 22 years I have seen some pretty costly mistakes made by highly educated people, but never intentionally. Mistakes are inevitable with humans unfortunately no matter how well educated or careful you think you are being something can always happen when you least expect it.

One of the worst ones I recall was a young person who presented with a simple dental abscess. She came to the department as the antibiotics she had been put on made her vomit.

Whilst in the department she had the usual ‘complementary bloods’ everyone seems to get when the present to A&E no matter what is wrong with them! They also did a venous blood gas.

The doctor that saw this patient gave her some intravenous fluids and anti-sickness drugs then discharged her home when the ‘routine’ bloods came back normal, which seemed reasonable. The doctor had discussed the case with the Consultant in charge, who agreed with the decision to discharge her.

Two days later the patient was discovered in her bedroom by her partner unconscious and holding onto her life by a thread.

She was rushed into us by paramedics with a temperature of 28 degrees (normal being 36–37 degrees), completely shut down with an unrecordable blood pressure, pulse of 28, the blood sugar reading was ‘High’ and the blood ketones reading was also ‘High’. She was a known type 1 diabetic.

The venous blood gas showed a initial Ph of 6.8 Bicarbonate of 5 and a base excess of -12. She was in diabetic ketoacidosis with severe hypothermia and sepsis from her dental abscess. She was very difficult to stabilise and it took a whole team of experts from the intensive care unit several hours to get her stable enough just to transfer her to ICU.

I had a feeling something must have been missed on her initial presentation so I did some digging and pulled out his old notes. Her bloods were indeed normal 2 days before, however her blood gas reading was far from normal. Her Ph was within normal parameters but her bicarbonate and base excess were very low and his carbon dioxide level was also very low. It showed a metabolic acidosis with respiratory compensation. She must have been hyperventilating to maintain his Ph level.

I did of course submit an incident report so that we could learn from this event and try and prevent it from ever happening again in the future.

She did survive but at a huge cost.

I believe the lesson to learn from this is never underestimate minor illness conditions with patients who have significant co-morbidities. Make sure you check all the results and if you are unsure how to read them get someone who understands the readings to check them. When discussing cases with Consultants make sure you give them all the facts especially significant co-morbidities as this will make a big difference in their decision making.