Editor’s note: This week’s case is about a peri-procedural complication, but the care was provided by OMFS physicians as opposed to anesthesiologists.

A 15-year-old boy with a history of neurodevelopmental disorder/autism was booked for extraction of third molars and supernumerary teeth.

He was sedated in the OMFS dental clinic by the OMFS attending and 2 OMFS residents.

The dental clinic was attached to a large tertiary care hospital.

He received these medications;

At 09:25 he was in recovery.

At 09:45 he became unresponsive and agitated with jerking of extremities and intermittent hyperventilation and apnea.

There was initial concern for status epilepticus, but an EEG was normal.

2d later he was extubated, but now had difficulty recalling his name, the year, or where he was.

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Plaintiff’s attorneys use similar tactics whether the defendant is an anesthesiologist, OMFS, or other specialty, so there’s always information that can benefit you.

A brain MRI revealed slight irregularity of gray and white matter suggesting cortical dysplasia.

Speech and memory improved on the floor, but he refused to ambulate, and showed regression using baby talk when asking for things.

He refused discharge and refused to participate in PT.

Neuro felt his symptoms were consistent with a functional neurological disorder.

Other documentation referenced his symptoms as purely behavioral.

After being hospitalized for 2 weeks, his mother brought him home in a wheelchair with scheduled home nursing visits.

His parents initiated a lawsuit.

The plaintiff’s attorney hired an anesthesiology expert:

Outcome

In regards to the 2 OMFS residents, one had been performing the surgery and the other in charge of administering anesthesia. They were both dismissed from the lawsuit.

The patient (now 22-years-old) was made a $300,000 offer to settle. He refused.

Unable to come to an agreement, the case headed toward trial.

Expert disclosures were released including the economic impact on a patient with baseline learning difficulty and cognitive issues.

A neurologist was found to testify that the patient does not have any neurological reason that he can’t work or ambulate.

The case settled before trial with the OMFS.

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MedMalReviewer/Anesthesiologist Opinion

1. The evidence that there was any kind of anoxic injury in this patient at all was based on the MRI finding of cortical dysplasia. This is largely a congenital diagnosis and a frequent cause of epilepsy. It can be acquired from a perinatal/neonatal injury such as ischemia or infection, or as an adult from tumors. It can take many years to show up at all on imaging. It makes sense that it may not appear on this patient’s MRI from twelve years ago when he was only three. The research I did does not indicate cortical dysplasia can even be acquired from a hypoxic injury later in life. In addition, the inpatient neuro team was not impressed at all by this finding, and did not think there was an anoxic injury. Experts are hired to do a job and they will look for any ammunition to strengthen their case. This unfortunately can turn into stretching and hyperbolizing the truth. From a medicolegal approach of your own practice it may be important to keep in mind what incidental or ambiguous findings/results in a case may be embellished in a negative light. Some things will unfortunately just look bad even if they are unrelated. The MRI in this case is a perfect example. It’s possible that the patient had some kind of in utero injury that resulted in his neurodevelopmental disorder, and that injury was also responsible for his MRI finding that did not appear until he aged further and his brain more completely myelinated.

2. I’m not entirely sure what the recovery setup is in this OMFS office, or how many staff they have there. However, I’m pretty sure they were not equipped to handle a 15 year old boy with autism experiencing emergence delirium and agitation. Since nothing significant on workup was found, this seems to be the diagnosis. I am skeptical that he is an appropriate patient for the dental clinic. If he is high functioning and cooperative then it may be suitable. He is high risk for emergence delirium, so the facility needs to have the ability to safely manage him post operatively.

3. Oral surgeons are among the highest sued specialty of dentists in the U.S. Most claims against them are from nerve injuries or failed implants. A recent study reviewing claims in the National Practitioner Data Bank found around 3-4% of claims against OMFS were anesthesia related. However, these claims were more likely to result in significantly higher payouts. I’ll publish more cases this year surrounding anesthesia mishaps in dentistry.