Here’s a story that’ll haunt you into your golden years. Doctors say their elderly patient endured a nightmarish week of his throat bleeding out and weeks more of surgeries and hospital care, all because surgeons had forgotten to remove his dentures – dentures that then became lodged in his throat.
According to one of the 72-year-old man’s UK doctors, who wrote about the case in BMJ Case Reports on Monday, his trouble began soon after a successful and seemingly well-done surgery that removed a benign lump from inside his chest. He was constantly finding blood in his mouth, while also experiencing throat pain and trouble swallowing. By the time he visited the emergency room six days after the surgery, he couldn’t even eat solid food.
Doctors initially suspected his symptoms were the result of a respiratory infection, possibly mixed with the after-effects of having been intubated during the surgery. And they sent him home with antibiotics and other drugs. Two days, however, he returned in worse shape, not having been able to swallow the medication they gave him. He was hospitalised, though doctors still mistakenly assumed he had developed severe pneumonia, possibly caused by having inhaled food, stomach acid, or saliva into his lungs.
But when a new set of doctors actually looked inside the man’s throat, after the man again complained about his symptoms, they quickly spotted something lodged across his larynx. And that’s when the man revealed that his partial dentures had mysteriously gotten lost about a week earlier. The most likely scenario is that the man had inhaled them when he was intubated.
Keeping people’s dentures in is thought to make it easier for anesthesia to be given to them through a bag-mask, but they should obviously be taken out immediately before any intubation starts, the report noted.
“Presence of any dental prosthetics should be clearly documented before and after any procedure, and all members of the theatre team should be aware of the perioperative plan for them,” study author Harriet Cunniffe, an ear, nose and throat specialist at James Paget Hospital, wrote.
Though doctors soon removed the clandestine throat teeth with forceps, the man’s suffering wasn’t over yet.
Over the next six weeks, he was trapped in a cycle where the bleeding from his throat seemed to stop and he was discharged from the hospital, only for him to start bleeding again and being readmitted. The bleeding got so severe that he needed multiple blood transfusions. Eventually, following several procedures that cauterised his wounds and repaired a torn artery caused by the dentures, he finally began to recover. A check-up six weeks after his last surgery found that his blood cell count had climbed back to normal and he hadn’t needed any other emergency care since.
Amazingly, this isn’t the first time doctors have accidentally caused people to inhale their dentures during a procedure or while being administered anaesthesia. Cunniffe was able to find at least 83 such cases reported during a 15-year-span, including one case that tragically ended in death.
Even beyond the medical error, she added, there’s a lesson to be learned by doctors about just listening to your patients.
In this case, the man had consistently complained about a sore throat and trouble swallowing from the first time he visited the emergency room. But the chest scans and blood tests he was given led the doctors on staff to first suspect infection. If they had simply physically checked his throat at the very beginning, as these doctors eventually did, he would have been spared days of unneeded suffering.
“Listen to the story the patient is telling you and do not be distracted by positive findings on investigations,” Cunniffe wrote.
Featured image: Harriet A Cunniffe (BMJ)