OHSU whistleblower: There was no reason patient needed to die
Tens of millions of teeth get pulled each year in the United States, often from patients who dread it.
Larry Dean Black, however, was excited.
Getting the normally routine procedure done was the 52-year-old's first step toward reclaiming his life. He'd contracted Hepatitis C as a kid from a bad tattoo, and now suffered from a failing liver.
To get a new liver at Oregon Health & Science University, he had to get his mouth fixed first, with the removal of 12 infected teeth. To get healthy, he'd been off drugs for years and was riding his bike every day in anticipation of a transplant. Then he could go back into construction work.
"He was so excited to have a liver and go back to building houses again," said his sister, Lenora Houser.
Instead, two days after the surgery, on Oct. 22, 2015, he was dead.
The case has led to accusations of cover-up at OHSU, and sheds light on a medical problem for liver patients that is largely unrecognized even among many doctors.
This past January, the Oregon Board of Dentistry approved a proposed consent decree accusing Pamela Hughes, the OHSU divison chief of oral and maxillofacial surgery at OHSU, of two separate violations of the state dental code by providing "unacceptable patient care" in the Black case.
In March, Black's death spawned a case in which two trial lawyers are not only suing OHSU, but also demanding millions personally from the two OHSU providers on the case, Hughes and oral surgery resident Philipps Kupfer. The suit claims the two providers, through negligent failure to account for potential bleeding problems, deprived Black of his life without due process.
The suit also claims that Hughes attempted "to cover up the negligent acts listed above by falsely accusing colleagues of their involvement, altering chart notes including the anesthesia record and lying to the Oregon Dental Board throughout its investigation of her actions on October 20, 2015."
Hughes, Kupfer and OHSU all largely declined to comment.
But unlike in most such cases, one participant is willing to speak out. Oral surgeon David Lambert says he has a better-than-average vantage to comment on the suit. That's because when it comes to the allegation about covering things up, he had to fight that in order to keep his job. He was initially fingered for a surgery he had nothing to do with.
"I was the fall guy," he said.
The case also is significant because it shows the bleeding risk for some chronic liver disease patients, said Dr. Neeral Shah, part of a crusading team of researchers at the University of Virginia School of Medicine who have been tackling the issue for more than a decade. He said bleeding risk from liver disease is largely unrecognized even by many medical doctors, who lack the tools and training to predict it.
Black's death, Shah says, "illustrates that there is a need to figure out this bleeding because it happens so frequently in this population." Shah noted that a conference on the subject scheduled for October is expected to draw researchers from 18 countries. "It's a really important area that we're studying."
Why teeth had to go
Born in Idaho, Black was the youngest of eight. The family moved to Oregon when he was young.
"He was a happy, mischievous little guy," recalls Houser, his sister.
Besides getting a tattoo, Black got into meth and burglarized some homes in his 20s and 30s, court records show. But he cleaned up his act starting in the 1980s and '90s, Houser and his other sister say.
He moved from the Eugene area to live with Houser in Bend about five years ago. Houser has been a paid care-giver and the move made sense for the close-knit family.
But Black's liver was failing, or decompensating, and he needed a transplant. To get one of those, he needed to have only healthy teeth in his mouth, and that meant about a dozen dead, infected teeth had to go.
Why? Because liver transplant patients are subjected to drugs that suppress their immune systems so their body does not reject the new organs. Because of that, even a minor cavity can turn into a big abscess that feeds infection directly into the bloodstream, Shah says.
On the big day, Oct. 20, 2015, Houser's husband, George, drove Black on the three-and-a-half hour trip to get the surgery done at OHSU's Hatfield Research Center, adjacent to the OHSU hospital.
The extractions had been slated to happen in the morning, when Hughes, the attending physician for the clinic, was expected to supervise residents performing surgeries. She had met with Black in August, and in October helped prepare the surgical plan and workup with Kupfer, an oral surgery resident.
But instead, Black had to wait for a new round of lab tests.
For a patient with a failing liver, those tests have a special significance. As the numbers change, your life expectancy goes down.
One marker of liver-disease severity measures one aspect of how well your blood clots, called the International Normalized Ratio or INR. There's also your blood platelet count, which needs to stay above 50,000. And then there's what's known as your MELD score, the Model for End-Stage Liver Disease, which suggests your overall odds of dying in the next 90 days.
The lab tests were not issued until 11:47 a.m. A half-hour earlier, Hughes had texted Lambert, the oral surgeon, who was scheduled to start work at 1 p.m., to confirm he could cover for her. "I will be up on the hill a bit if you need me to staff it," she texted.
"No worries," he replied, "I got it covered."
To Lambert, he was affording some clinic space for a Hughes patient. But only later would he learn Black was a most fragile patient. He would never have approached the surgery in the manner that Hughes approved, he says.
The lab tests came back. While the platelets were OK, the MELD score was worrisome. And the INR level registered at 2.95, three times what a healthy person's would be — suggesting a potential weakness in clotting, according to the suit.
Lambert, the oral surgeon, said that when he reported to the clinic that afternoon, Kupfer, the oral surgery resident, was almost done with a procedure to remove all 12 teeth. Hughes, the division chief, was present.
After awhile, Black was sent home to Bend. At about 2 a.m. the next morning, he awoke to realize he was bleeding profusely, according to the lawsuit.
Paramedics rushed him to St. Charles Medical Center in Bend. It looked like he had already lost a liter of blood, according to the lawsuit.
St. Charles had no beds available, and neither did OHSU. So the medics transported him by air to Providence St. Vincent Medical Center.
Shortly after noon on Oct. 22, 2015, Black died of blood loss from his mouth.
Houser, who had been traveling in California, had rushed to an airport to fly home. Less than an hour after her brother's death, she was waiting for a flight when she received a cheerful call from an OHSU staffer.
"She said 'I have good news: Larry is on the live transplant list now,' " Houser recalled.
"I have some not so good news," Houser remembers replying. "Larry just passed away."
That night she received a call from her brother's transplant doctor with condolences — but no explanation, she said.
OHSU spokeswoman Tamara Hargens-Bradley says the university can't comment on pending cases.
"Patient privacy laws prohibit OHSU from being able to respond to questions about this specific case, but we strive for the best possible outcome for every patient," she said in a prepared statement on Monday. "This is a calling for our faculty and staff, so the passing of a patient, under any circumstance, is devastating to all involved."
The lawsuits filed against OHSU, Hughes and Kupfer claim the lab tests showed Black was at risk of excessive bleeding and he either shouldn't have had 12 teeth removed at once, or he should have been monitored closely and kept overnight in the hospital.
Three doctors and dentists with expertise in oral surgery issues involving chronic liver disease provided insights about a hypothetical case provided by a reporter, while stressing they were not commenting on a specific case. For the most part, they echoed the lawsuit's critique, citing a variety of factors.
James Guggenheimer, a professor at the University of Pittsburgh School of Dental Medicine, recently contributed a chapter to a new book about performing oral surgery on liver patients. He said that given the lab tests and scores indicating medical fragility, providers should never have taken out 12 teeth in one fell swoop.
"I think the major departure from standard of care here was to take out 12 teeth" at once, Guggenheimer said. "I think they should have done a test of one or two teeth to see how the patient did, had him back and do some more. But with 12 teeth you have bleeding from so many sites that it could not be controlled."
Oral surgeons consult with hematologist Bruce Mathey of Skagit Valley Hospital in Washington before they conduct procedures on liver disease patients.Test results similar to those registered by Black would give him pause.
"Most doctors and dentists would probably be reluctant to do a procedure where the patient might bleed, particularly if the INR was baseline above 1.5," Mathey said, adding that given the risks, he probably would keep such a patient overnight. The red flags in the test results "are clear," he added.
Shah, the expert in clotting and liver disease, has studied the INR test for years. He echoed several published papers and said that physicians' reliance on INR results is disturbing, because the results of this particular test vary from lab to lab. He said that different surgeons can handle things differently.
That said, he agreed that he'd probably have kept a patient like Black overnight given how far away he lived, and he also would have administered heavy clotting agents to stop the bleeding. The clots formed by liver disease patients are often "flimsy," he said.
To combat that, Shah said oral surgeons frequently pack the extraction site with gauze soaked in anti-clotting medicine.
In this case, the extraction sites were packed with gel foam, a product thought to absorb blood and help with clotting but which actually includes no medicine to accelerate clots, as Shah typically uses.
"We tend to be a little more conservative because we've seen the poor outcomes that can happen," Shah said.
For months after his death, Black's sister, Houser, had only a generalized suspicion that something was wrong.
Then, in April 2016, she got the phone call that changed everything. On the other line was Lambert, the doctor who almost attended to Houser's brother.
Lambert's message then was the same as it is now.
"There was no reason why he needed to die," he told the Portland Tribune. He said the allegations describe "a major breach" of patient care standards. The death, he added, "was totally preventable."
Hearing Lambert's story threw Houser for a loop.
"After I talked with him I had so much hatred for OHSU over this that I really had to talk to my pastor about this and my sister and my husband," she said. "And it was like 'OK guys, what do we do, because in our faith and our reading of the Bible, you're not supposed to sue people.' "
Lambert had no reservations.
"They tried to cover this up, and it really goes against my grain, for God's sake," he said.
Part two, on Lambert's fight, will run and be posted Tuesday.