Locum Tenens and a Spreading Odontogenic Infection
A locum tenens dentist agrees to cover a rural Nebraska practice for 10 days while the owner is on a cruise. On day 3, the owner cannot be reached by phone or text. A 24-year-old man walks in with a 4-day history of swelling after a lower molar extraction performed by the owner. He has a temperature of 38.6°C, trismus, dysphagia, and a firm, tender swelling in the submandibular space. The locum has a Nebraska license and malpractice coverage, but the practice's EHR is down and the owner has the only password. The receptionist says the patient owes a balance and asks the locum not to see him until payment is arranged. The locum has no hospital privileges and the nearest oral surgeon is 90 minutes away. The locum wonders whether there is a duty to treat, how to obtain records, and whether antibiotics can be prescribed without the chart.
1. Does the locum have a duty to see the patient despite the unpaid balance? Explain the abandonment and emergency issues.
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The locum should not refuse to see the patient because of an unpaid balance. A patient with spreading submandibular swelling, fever, trismus, and dysphagia has a dental emergency with potential airway risk. Although EMTALA governs hospitals, the professional duty not to abandon a patient and the practice's established relationship support evaluation. As locum, the dentist has assumed the practice's obligation to provide coverage. The receptionist may discuss payment, but cannot condition emergency evaluation on payment. The locum should triage immediately: assess airway, breathing, swelling, temperature, and ability to swallow; obtain vital signs; and arrange urgent referral to an emergency department or oral and maxillofacial surgeon. The locum should not attempt definitive treatment beyond capability. Document the emergency nature, the refusal to delay care, and the referral. If the patient leaves against advice, document warnings. The legal reasoning is that financial policy cannot override the duty to address an emergency; abandonment risk arises if the dentist dismisses the patient without evaluation or referral.
2. How should the locum handle records, prescriptions, and follow-up without EHR access?
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The EHR outage does not excuse a complete record. The locum should create a paper chart or timed progress notes with the patient's identity, history, examination findings, vital signs, diagnosis, treatment, prescriptions, referrals, and instructions. The locum should ask the patient to sign a release or consent for treatment and for release of prior records, and should request the extraction records from the owner or the previous office when access returns. Treatment should not be delayed solely because the old chart is unavailable. Prescribing antibiotics is appropriate only as an adjunct when there is systemic involvement and drainage or referral is arranged; the locum should choose a regimen, document the indication, check allergies, and give instructions. Antibiotics do not replace source control. The locum should refer urgently and confirm the receiving clinician accepts the patient. The locum should notify the practice owner or a designated covering dentist as soon as possible and document the attempts. The reasoning is that record access supports care but is not a precondition for emergency treatment; the standard is to document what was known and done.