Death in dental office

[NPO]

Case that may be interesting to follow up on what exactly happened.
http://blog.cleveland.com/metro/2011/01/elyria_girl_13_dies_after_oral.html

Basically same story but with an interesting quote: "The Cuyahoga County Coroner's Office says it appears Marissa Kingery died as the result of a lack of oxygen to the brain while she was under anesthesia during the surgery."
http://www.fox8.com/news/wjw-girl-dies-after-dental-procedure-txt,0,5306622.story

More speculation
http://www.clevescene.com/scene-and...yria-teen-dies-after-trip-to-dentist-goes-bad

Not OMFS's first death
http://cp.onlinedockets.com/LorainCP/case_dockets/Docket.aspx?CaseID=156093

edited for added information

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[Tuohy]

This guy should have hung it up at least 10 years ago-Wow, 81 years old-should have retired-move to Florida or something. Sounds like a lost airway and/or late recognition of hypoxia-bradycardia-asystole...

 

[pgg]

I'm gonna go out on a limb and guess it was the usual polyroute dental-triple-play. PO Valium, inhaled nitrous, IV midaz +/- fentanyl.

Tragic.

 

[hoyden]

This is the exact reason why dentists ( or any other medical providers) should not administer any type of sedation/anesthesia ( except pure local) without being able to manage the airway with regular reexaminations and re-certifications of the airway management skills.
What a tragedy 🙁

 

[fakin' the funk]

I'm gonna go out on a limb and guess it was the usual polyroute dental-triple-play. PO Valium, inhaled nitrous, IV midaz +/- fentanyl.

Tragic.

What kind of monitoring do they use/require?

 

[hoyden]

.

 

[jwk]

What kind of monitoring do they use/require?

Pulse ox or not, if you lose an airway, it goes downhill quickly, especially if you haven't had to deal with complications on a "routine" patient. Most office oral surgery is moderate-heavy sedation, although there are those who do general anesthesia.

Keep in mind that this article looks like a lot of "facts" are from the plaintiff's lawyer.

 

[sevoflurane]

Yeah... I've heard of INSANE amts. of sedation in the dentist office (my own dentist btw). It is sad that a perfectly healthy 13 y/o had to go out that way. If you are giving ANY sedation whatsoever and are not an anesthesiologist or ED physician, PLEASE, at the very least, learn how to mask ventilate... it is a life saver.

 

[bogatyr]

The State Dental Board and the Cuyahoga County coroner's office are investigating her death. Three or four dental patients die each year in Ohio while under anesthesia, officials said.

Are you kidding me? They are okay with this?

 

[NPO]

updated for more speculation

 

[CanuckDDS]

The State Dental Board and the Cuyahoga County coroner's office are investigating her death. Three or four dental patients die each year in Ohio while under anesthesia, officials said.

Are you kidding me? They are okay with this?

This has to be misquoted. There are not that many deaths in OMFS's office in North America in a decade or longer... unless Ohio is an anomaly.

Those stats are bogus. And certainly, no OMF would be "okay" with this if that was the case.

I came over hear to see what you guys had to say about this. This guy needed to retire-effff...that makes OMFS's look real bad. This guy has had 2 deaths!

Have a look..."death in the dental office!" This was a board certified anesthetist. I was living in Waterloo at the time, the media ripped apart the OMF. It was proven that he had nothing to do with the death. I guess it can happen to all of us. Very ****ty. http://www.canada.com/montrealgazette/news/story.html?id=d08fa6ab-dbce-4555-b7c2-fa0ed4843fdb

Inadequate training (in the 1950's!) and lack of re-certification is likely the cause of this situation. I wouldn't let any of the ancient anesthesiologists at my hospital run my anesthesia either- some of them are freakin' dangerous, they can hardly see the sat monitor, let alone manage an airway...

Please don't lump us in with this steaming pile....

 

[Idiopathic]

could include patients undergoing dental procedures under general anesthesia while in the hospital, but i agree we would be hearing more about it if that many people were dying in dental clinics.

 

[pgg]

This has to be misquoted. There are not that many deaths in OMFS's office in North America in a decade or longer... unless Ohio is an anomaly.

I figured the death count stats were wrong. 4 in Ohio per year doesn't seem right.


But we have a thread just like this one every 6-12 months after a dental office death, so deaths are occuring. It's always polyroute polypharmacy, +/- lack of monitoring, and +/- delayed or inept resuscitation.

 

[sevo85288]

you don't hear about the other deaths and disability or hundreds of "close calls"

 

[michaeltavallae]

I can't believe that.

 

[CanuckDDS]

you don't hear about the other deaths and disability or hundreds of "close calls"

Really?! Why don't we hear about them? It must be a conspiracy...

I think we hear about every single one of them. The media picks them up and runs with them. This is case and point.
Also, check the literature on safety and efficacy of sedation in OMFS's offices, see what you turn up.
Your point doesn't make any sense, but thanks for making it- and I bet you'll keep making it to whoever will listen...👍


I agree, the whole multi-route poly-pharm thing is a gong show and needs to be re-examined. We don't do anything like that at our hospital, we run appropriate sedation and provide a much needed service to thousands and thousands of patients a year. In addition to our outpatient sedation clinic we have a ton of OR time so for cases that are unsuitable for clinic.

 

[lobelsteve]

Really?! Why don't we hear about them? It must be a conspiracy...

I think we hear about every single one of them. The media picks them up and runs with them. This is case and point.
Also, check the literature on safety and efficacy of sedation in OMFS's offices, see what you turn up.
Your point doesn't make any sense, but thanks for making it- and I bet you'll keep making it to whoever will listen...👍


I agree, the whole multi-route poly-pharm thing is a gong show and needs to be re-examined. We don't do anything like that at our hospital, we run appropriate sedation and provide a much needed service to thousands and thousands of patients a year. In addition to our outpatient sedation clinic we have a ton of OR time so for cases that are unsuitable for clinic.

The point of the thread is that everybody does it like you do, except this old guy. And another kid dies. If they would incorporate airway management as part of renewing license for any non-anes docs who provide MAC, maybe progress would be made and those extremely rare cases of death in the office would be even less. Bad things happen and people can die, but if there is a way to make this never happen, it should be part of everyday practice.

 

[Licoricestick]

The articles seem to be implying that the dentist doing the procedure was also doing the sedation. If so, that is likely part of the problem.

 

[toooldforthis]

The articles seem to be implying that the dentist doing the procedure was also doing the sedation. If so, that is likely part of the problem.

This is basicaly a standard. In the USAF OMFS clinic where i worked our residents did all of the anesthesia for routine tooth extractions. Monitoring is key here folks. These OMFS residency trained doc do 4-6 years depending on the residency program. Heavy, Heavy, Heavy anesthesia rotations.

In the 7 years there i would have placed my trust in all of the docs i worked with. And usually we are talking about light sedation...i.e. we can give the pt voice commands and they respond. It's not full on general sedation where the patient is intubated and relies solely on the anesthesiologist for airway mgmt.

Usually in the dental treatment room there is at the very minimum: Pulse monitoring, Oxygen monitoring, and EKG. all of which have visual and auditory alarms to indicate when the patients oxygen saturations are low. 2 providers, 1 patient and teeth. usually there is nothing going on where you cant stop for a pause and maintain airway of the Pt. (sometimes they get positional occulsion, move the chin/head and airway resumes) To the extreme you an reverse the patient and wake them up mid procedure if you absolutly have to.

My guess is short of a undiagnosed genetic problem/disease there was a serious lack of attention on the providers and staff's side of the house. Unless her airway was blocked due to a foreign body. (tooth, blood clot, gauze)


Not knowing what was tried in the office: intubation, Cric, alerting EMS, etc... its hard to say for sure.

 

[drgoro]

I am indeed sorry for this child and the family. The training we as oral surgeons get with regard to anesthesia is heavily accounted for in our curriculum, at the very minimum we spend 4 months on anesthesia acting as a anesthesia resident and most place, such as mine, spend an addition month doing solely pediatric anesthesia. We then go on to provide ambulatory anesthesia, MAC cases for the outpatient clinic at the hospital (i.e with anesthesiologists on hand if needed) for the next 4-6 years before graduation. I believe this heavy emphasis is the reason why our track record for safety is pretty good. Can more be done? yes, always, in everything. But the fact is even though we and all other health care providers evolve our respective training to match our changing practice environments, accidents will always be a fact of life (even in the most controlled of environments). We try our best to ensure pt safety on all levels. This is indeed unfortunate.

 

[midazme]

Usually in the dental treatment room there is at the very minimum: Pulse monitoring, Oxygen monitoring, and EKG. all of which have visual and auditory alarms to indicate when the patients oxygen saturations are low.'

i was in an M&M last month where the presenting R-2 explained how the anesthetized patient was hypotensive for 15 mins by saying "I didn't have the alarms set to go off for that MAP". as a rule, our M&M's are non-confrontational, but she really caught heat for saying that.

in baby miller, the chapter on anesthetic monitoring starts with "The most important monitor in the OR is a vigilant anesthesiologist...". In fact, the ASA's motto used to be "Vigilance" (in fact, it still may be).

i realize that there are many important differences between sedation and GA. but it's often a fine line between the two, and all the more reason to have the properly trained people providing the care.

so i would argue that this wasn't just an 'accident'. it was an inevitable and tragic outcome from our current healthcare system's efforts to decrease costs by increasing risk.

 

[ZachNear]

By the time this doc had finished his procedure and attempted to "wake the patient from sedation" he found he was unable to wake her. Which suggests that she had stopped breathing some time ago. Also, once he found that he could not "wake her" he called EMS. In the time between, recognizing her as non-responsive and the arrival of EMS, he did not perform CPR or any form of ACLS or PALS protocols. If you are licensed to administer anesthesia, there should absolutely be a requirement to have certification in ACLS/PALS or at the very least BLS.
Anyone know the recertification process for OMFS guys?

 

[Sapdaddy]

My cleaning lady just went to that guy for a routine tooth extraction (in December?), tooth was not impacted. She was told to be NPO for it. She said that it it was just a really old guy and an assistant (dental assistant, not anesthesia assistant) in the room. Said she didn't remember too much past the IV placement (versed). She thought that he chose to knock her out because she had to pay an extra $175 to him out of pocket for GA. She feels like she dodged a bullet after that story came out. She was pretty well freaked out after this story came out!
I told her that to find a good dentist is invaluable because there are some crooked dentists out there who perform all sorts of unnecessary procedures so that they can get paid (finding cavities that aren't there, drilling out baby teeth that don't give the kid any pain, etc.). This includes giving and charging extra for GA when she probably just needed local. I'm sure many of you give GA for dental, but it may be for a combative MR patient. I'm sure this girl would have sit still for the procedure, as my cleaning lady would have as well.
I was about this girl's age when I had tooth extractions prior to getting braces and the OMF gave me local and a little bit of nitrous and I was fine. So my heart goes out to this girl's family for this unnecessary tragedy that was motivated (IMO) by $175 of greed and the lack of vigilance by the dentist.

 

[drgoro]

My cleaning lady just went to that guy for a routine tooth extraction (in December?), tooth was not impacted. She was told to be NPO for it. She said that it it was just a really old guy and an assistant (dental assistant, not anesthesia assistant) in the room. Said she didn't remember too much past the IV placement (versed). She thought that he chose to knock her out because she had to pay an extra $175 to him out of pocket for GA. She feels like she dodged a bullet after that story came out. She was pretty well freaked out after this story came out!
I told her that to find a good dentist is invaluable because there are some crooked dentists out there who perform all sorts of unnecessary procedures so that they can get paid (finding cavities that aren't there, drilling out baby teeth that don't give the kid any pain, etc.). This includes giving and charging extra for GA when she probably just needed local. I'm sure many of you give GA for dental, but it may be for a combative MR patient. I'm sure this girl would have sit still for the procedure, as my cleaning lady would have as well.
I was about this girl's age when I had tooth extractions prior to getting braces and the OMF gave me local and a little bit of nitrous and I was fine. So my heart goes out to this girl's family for this unnecessary tragedy that was motivated (IMO) by $175 of greed and the lack of vigilance by the dentist.

How do yo know what constitutes an impacted tooth? Have you ever performed exodontia of 3rd's or even witnessed the procedure? GA is a service to the patient for an otherwise uncomfortable procedure. Your comments shows you clearly have limited understanding of what we do, so please avoid sweeping and exaggerating comments...it almost borders trolling. Oh, and please avoid pulling the greed card...ya' know Dr Murray may be reading your post...how much was he getting form MJ? psst...didn't want to bring it there but some people love to call the kettle black

 

[CanuckDDS]

By the time this doc had finished his procedure and attempted to "wake the patient from sedation" he found he was unable to wake her. Which suggests that she had stopped breathing some time ago. Also, once he found that he could not "wake her" he called EMS. In the time between, recognizing her as non-responsive and the arrival of EMS, he did not perform CPR or any form of ACLS or PALS protocols. If you are licensed to administer anesthesia, there should absolutely be a requirement to have certification in ACLS/PALS or at the very least BLS.
Anyone know the recertification process for OMFS guys?

Every OMF has to have up to date ACLS. In Canada you can't maintain your facility licence without it.
Full monitoring is also required. I'm not sure what is required in Ohio though. This is where the story gets fishy. If he had appropriate monitoring you can't just finish the procedure and try to wake your patient. You would know something was going on long before you "could not wake her".

 

[CanuckDDS]

My cleaning lady just went to that guy for a routine tooth extraction (in December?), tooth was not impacted. She was told to be NPO for it. She said that it it was just a really old guy and an assistant (dental assistant, not anesthesia assistant) in the room. Said she didn't remember too much past the IV placement (versed). She thought that he chose to knock her out because she had to pay an extra $175 to him out of pocket for GA. She feels like she dodged a bullet after that story came out. She was pretty well freaked out after this story came out!
I told her that to find a good dentist is invaluable because there are some crooked dentists out there who perform all sorts of unnecessary procedures so that they can get paid (finding cavities that aren't there, drilling out baby teeth that don't give the kid any pain, etc.). This includes giving and charging extra for GA when she probably just needed local. I'm sure many of you give GA for dental, but it may be for a combative MR patient. I'm sure this girl would have sit still for the procedure, as my cleaning lady would have as well.
I was about this girl's age when I had tooth extractions prior to getting braces and the OMF gave me local and a little bit of nitrous and I was fine. So my heart goes out to this girl's family for this unnecessary tragedy that was motivated (IMO) by $175 of greed and the lack of vigilance by the dentist.

This is an assinine comment. Thank you for it. Most people that end up in an OMF office go because they "won't let anybody stick a needle in their face". They choose to have the anesthesia! The OMF surgeon gives them the option of local vs. sedation, and 99% of people want sedation- that is why it is done- in 99% of cases NOT for $175 as you stated.

No dentist wants to "drill out baby teeth" for fun or for money. That is one of the worst and most stressful things that you can do. If you have ever had a kid in your chair crying and flailing about, you would understand this. Unfortunately if GOOD dentists didn't provide this service they would end up in the ED with facial cellulitis and I would have to deal with them in a urgent, not-so-nice manner- like taking out their teeth and draining their face at 2:00 am. That sounds way better than getting a dentist to fill their cavities doesn't it?

I agree, don't pull the greed card...there are ****ty people in every profession my friend- Don't kid yourself.

 

[toooldforthis]

My cleaning lady just went to that guy for a routine tooth extraction (in December?), tooth was not impacted. She was told to be NPO for it. She said that it it was just a really old guy and an assistant (dental assistant, not anesthesia assistant) in the room. Said she didn't remember too much past the IV placement (versed). She thought that he chose to knock her out because she had to pay an extra $175 to him out of pocket for GA. She feels like she dodged a bullet after that story came out. She was pretty well freaked out after this story came out!
I told her that to find a good dentist is invaluable because there are some crooked dentists out there who perform all sorts of unnecessary procedures so that they can get paid (finding cavities that aren't there, drilling out baby teeth that don't give the kid any pain, etc.). This includes giving and charging extra for GA when she probably just needed local. I'm sure many of you give GA for dental, but it may be for a combative MR patient. I'm sure this girl would have sit still for the procedure, as my cleaning lady would have as well.
I was about this girl's age when I had tooth extractions prior to getting braces and the OMF gave me local and a little bit of nitrous and I was fine. So my heart goes out to this girl's family for this unnecessary tragedy that was motivated (IMO) by $175 of greed and the lack of vigilance by the dentist.

Seriously can get mired here with the sheer amount of responses to your post. Off the top of my head:

#1 routine extraction-riiiiight, one can argue that there is no such thing. Decay? Fracture? bone loss? infection? All these questions help to weed out why he/she chose to extract in the first place...and some necessatate sedation as you cant get the patient as numb as you like if the have a localized infection. Or if the tooth is fractured you can be fishing a root tip out for literally hours. Ever had a metal instrument scrape on your bone? (i had my 3rds removed whle awake as i had a bad reaction to sedation. All 4 were impacted, 2 were mesially angulated) Not fun.

#2- Some Doc's dont extract in priv prac unless the pt is sedated. Period.

#3- "retrograde amnesia" is a wonderful thing to reduce traumatic pt expierence. (overheard whining/yelling/screaming does nothing for the patients in the waiting room or the nerves of the staff)

#4- i can go on and on here.....

Are there some doc's that are looking for the best way to get cash across the counter? Yes there are. And then there are some docs who had problems in the past and CHOOSE to sedate in the best intrests of themselves, their staff and the patient. Unless i know the guy/gal i can't say. But blanket statements don't really serve anyone well.

-i've spent over 10 years in dental/OMFS, over 500 general anesthesia surgeries assisted, countless CS/local procedures, if you wonder where this comes from.

 

[Sapdaddy]

Sorry to have offended the DDS's. I was just trying to submit a comment that I know someone who very recently went to that guy and said she felt that he unnecessarily knocked her out, and had that "that could have been me" kind of feeling.

If it came across that I was lumping dentists together with him, that was not my intent, as I am friends with many dentists and OMFS, and they are outstanding practitioners! ...and definitely would trust them with my sedation for a dental procedure.

 

[armorshell]

Every OMF has to have up to date ACLS. In Canada you can't maintain your facility licence without it.
Full monitoring is also required. I'm not sure what is required in Ohio though. This is where the story gets fishy. If he had appropriate monitoring you can't just finish the procedure and try to wake your patient. You would know something was going on long before you "could not wake her".

Not to mention that every contemporary oral surgery resident spends a minimum of 4 months as a fully functioning anesthesia resident, and that requirement is likely going to move to 6 months in the near future including at least 1 month entirely spent on pediatric anesthesia.

 

[pgg]

Not to mention that every contemporary oral surgery resident spends a minimum of 4 months as a fully functioning anesthesia resident,

I think that's overstating things a bit.

Don't get me wrong, the OMFS guys who rotated through the department were very smart and talented people. Most "rotators" were viewed as anchors or boulders to push up hills by staff, but the OMFS guys were generally respected more.

That said, they did not participate as completely when it came to academic events, formal lectures, informal pimping, and so on. They were generally assigned high turnover low acuity rooms so they could maximize their MAC and airway experience (which I think is appropriate) but few cases where anesthetic management was difficult. They didn't take anesthesia call.

None of this is intended to be a slight to OMFS'ers. They tend to be squared away high achievers, but let's not get carried away with how intense their anesthesia training is(n't).

 

[fakin' the funk]

 

[fakin' the funk]

I know this is a well-appreciated point on this forum, but I would just like to emphasize for those who may be visiting the importance of learning and practicing effective noninvasive airway management.

Sniffing position, chin lift, jaw thrust, supplemental oxygen, positive pressure if needed, oral/nasal airway solves the vast, vast majority of airway obstructions.

Who knows if it would have preventing the death that's cited here, but it's worth repeating nonetheless.

 

[CanuckDDS]

I think that's overstating things a bit.

Don't get me wrong, the OMFS guys who rotated through the department were very smart and talented people. Most "rotators" were viewed as anchors or boulders to push up hills by staff, but the OMFS guys were generally respected more.

That said, they did not participate as completely when it came to academic events, formal lectures, informal pimping, and so on. They were generally assigned high turnover low acuity rooms so they could maximize their MAC and airway experience (which I think is appropriate) but few cases where anesthetic management was difficult. They didn't take anesthesia call.

None of this is intended to be a slight to OMFS'ers. They tend to be squared away high achievers, but let's not get carried away with how intense their anesthesia training is(n't).

👍 All valid points. It is impossible to learn anesthesia in 4 months, 6 months, or even 1 year. No question. Anesthesia is a long residency for a reason.

I think the purpose of our training is to become comfortable with conscious sedation and airway management. It is equally important to know our boundaries and when things cannot be appropriately managed by the OMF surgeon and when the experts (you guys) NEED to be on board. I realize that the **** may hit the fan at any time (as is the case with this old guy), but by completing our training hopefully we can minimize/eliminate the chances of this happening. I'm not sure that is possible though.

If any OMF feels slighted by your statement, that they should give their head a shake. It is accurate and fair by most assessments.

I think the real key here is trying to make things safer for patients. This includes re-cert, legislation with regards to monitoring etc. For this, anesthesia and OMF need to work together.

Up in Canada, we don't have the resources to take everyone to the OR that require sedation for simple OMF procedures (we will even do some simple trauma under conscious sedation in our OMF clinic). That is just the reality in our public health model, that way no one lacks treatment and we are not wasting OR time needlessly...hopefully, everyone (patients, anesthesia, OMF) goes home happy at the end of the day.

 

[armorshell]

I think that's overstating things a bit.
*snip*

None of this is intended to be a slight to OMFS'ers. They tend to be squared away high achievers, but let's not get carried away with how intense their anesthesia training is(n't).

Not trying to overstate anything, but I'll begrudge that my N=1 is different than your N=1

 

[pgg]

Not trying to overstate anything, but I'll begrudge that my N=1 is different than your N=1

My N is > 1. I guess it's still anecdotal and there's surely some interinstitution variability.

Just as a transitional intern doing a month of general surgery is not the same as surgery intern doing a month of general surgery, an OMFS resident spending a few months in anesthesia is not the same as an anesthesia resident during those months.

I suppose there's room for disagreement.