Death of Cardiologist Spurs Calls For Anesthesia Oversight

[2021Doctor]

Published: Aug. 3, 2022 at 10:37 AM CDT
WILMINGTON, N.C. (WECT) - August 3rd marks two years since Henry Patel’s death. The beloved cardiologist was 53 years old when he died from being over-sedated during a routine dental procedure. On this difficult anniversary, Patel’s widow, ****al, is renewing her push for dental anesthesia reform. The North Carolina State Board of Dental Examiners plans to consider a rule change to requirements for dental anesthesia and sedation at their meeting in September.

Bobby White, the Dental Board’s CEO, says they’ve received more public comments on this topic than any other issue in the Board’s history. The Board has reviewed 1,300 pages of comments. Many have come from friends and family of the Patels, as well as members of the medical community at large, who were shocked over Dr. Patel’s senseless death. They would like to see the Dental Board require a Certified Registered Nurse Anesthetist or Anesthesiologist be present anytime a dental patient is put under deep sedation, which is already required when patients are put under for other medical procedures.

Two years after dental anesthesia death, widow still waiting for reform

August 3rd marks two years since Henry Patel’s death. The beloved cardiologist was 53 years old when he died from being over-sedated during a routine dental procedure. On this difficult anniversary, Patel’s widow, ****al, is renewing her push for dental anesthesia reform. The North Carolina...

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[DocVapor]

Thanks for posting, but this has already been discussed here:

Tragic death during dental procedure

https://www.wect.com/2022/02/03/after-dental-patient-dies-following-routine-procedure-widow-calls-changes-anesthesia-requirements/?fbclid=IwAR1IS2LHMrCY2IXsS8xdF62GAT6RiDsi3IJ0GFltjXAZyOImPY-SBB7QMFY Extremely sad story and unfortunate loss of life. Thoughts?

forums.studentdoctor.net

 

[Beeftenderloin]

 

[chocomorsel]

Thanks for posting, but this has already been discussed here:

Tragic death during dental procedure

https://www.wect.com/2022/02/03/after-dental-patient-dies-following-routine-procedure-widow-calls-changes-anesthesia-requirements/?fbclid=IwAR1IS2LHMrCY2IXsS8xdF62GAT6RiDsi3IJ0GFltjXAZyOImPY-SBB7QMFY Extremely sad story and unfortunate loss of life. Thoughts?

forums.studentdoctor.net

This is an update post.
Things are gonna change apparently. Lol. I doubt it.
One thing I have learned is don’t try to come between people and their money. They will fight tooth and nail to prevent any changes to their pocket books.

 

[DocVapor]

This is an update post.
Things are gonna change apparently. Lol. I doubt it.
One thing I have learned is don’t try to come between people and their money. They will fight tooth and nail to prevent any changes to their pocket books.

Sure, I get it's an update post. Doesn't mean it can't go in the old one. I hopefully did not come off as mean or annoyed, if I did I apologize. Just wanted to be informative.

Agree with you on the rest.

 

[coffeebythelake]

The dental industry is going to fight tooth and nail to prevent any meaningful change from happening. Its a lot of money we are ralking about They are perfectly happy with the status quo. Just hop over to the dentist forum on SDN and you will get a flavor for the arrogance among dentists-in-training what they think about safe anesthesia practices. This behavior is instilled upon them in their dental schools.

 

[IlDestriero]

Maybe they can learn to drill a little cric hole in case of emergency?

 

[Ashers]

The dental industry is going to fight tooth and nail to prevent any meaningful change from happening. Its a lot of money we are ralking about They are perfectly happy with the status quo. Just hop over to the dentist forum on SDN and you will get a flavor for the arrogance among dentists-in-training what they think about safe anesthesia practices. This behavior is instilled upon them in their dental schools.

I haven't ever looked at what they say on SDN. I talked to a periodontist who did sedation for my brother. He was only supposed to have an oral benzo, but he had a paradoxical reaction to it. We had gone out for lunch since he was allowed to eat. I was sent home to get his headphones. When I came back, he was on nitrous at 50%. I was like, "He's getting anesthesia? But he's a full stomach!" The dentist said "it's just anxiolysis, it's not anesthesia." I said if I were doing his case, I would've canceled it. I had the same procedure a few days before with just local. I wasn't impressed with the dentist's attitude that I was concerned at all. I hung around at the office because I was my brother's ride, but also in case of an emergency (I had to sit there for a few hours).

 

[lane]

I haven't ever looked at what they say on SDN. I talked to a periodontist who did sedation for my brother. He was only supposed to have an oral benzo, but he had a paradoxical reaction to it. We had gone out for lunch since he was allowed to eat. I was sent home to get his headphones. When I came back, he was on nitrous at 50%. I was like, "He's getting anesthesia? But he's a full stomach!" The dentist said "it's just anxiolysis, it's not anesthesia." I said if I were doing his case, I would've canceled it. I had the same procedure a few days before with just local. I wasn't impressed with the dentist's attitude that I was concerned at all. I hung around at the office because I was my brother's ride, but also in case of an emergency (I had to sit there for a few hours).

When their “standard of care” is not THE standard of care…

 

[vector2]

When their “standard of care” is not THE standard of care…

It's like the EM guys who have no problem giving 50 of propofol and a 100 of ketamine for a joint reduction to a guy who ate a bucket of fried chicken and drank 30 beers before crashing his ATV an hour ago.

Laughably different "standard of care" in their professional society guidelines.

 

[Beeftenderloin]

It's like the EM guys who have no problem giving 50 of propofol and a 100 of ketamine for a joint reduction to a guy who ate a bucket of fried chicken and drank 30 beers before crashing his ATV an hour ago.

Laughably different "standard of care" in their professional society guidelines.

PE has an ungloved hand firmly up the @ss of the ABEM and adhering to NPO guidelines for procedural sedation doesn’t “move the meat”.

Likewise, requiring dedicated trained anesthesia personnel to deliver (and bill for) the anesthetic takes money out of the dentists pocket.

It’s all about the $$$.

 

[Xman5678]

It's like the EM guys who have no problem giving 50 of propofol and a 100 of ketamine for a joint reduction to a guy who ate a bucket of fried chicken and drank 30 beers before crashing his ATV an hour ago.

Laughably different "standard of care" in their professional society guidelines.

Outcome data? I agree that their standards are lots looser than ours, but how many aspirations from an ER physician doing procedural sedation requiring intubation and ICU care have any of us seen? I have seen one in 30 years. Patient got extubated next day.

 

[vector2]

Outcome data? I agree that their standards are lots looser than ours, but how many aspirations from an ER physician doing procedural sedation requiring intubation and ICU care have any of us seen? I have seen one in 30 years. Patient got extubated next day.

The bulk of the EM data is based on pediatric patients coming for emergency department sedation. For instance, in this article from a "EM should sedate literally anyone at literally any time" evangelist...*NINE* out of the twelve papers he cites in favor of his position are from pediatric studies.

Now, I'm not saying the data supporting the ASA npo guidelines are incredibly strong. In fact, they're mostly equivocal. But what I disagree with is EM citing studies with very small n's (given the rare event frequency of aspiration) in a very specific population to say everyone else is an overcautious idiot for delaying anesthesia or sedation in a 55yo diabetic fatso in a c-collar who was scarfing cheeseburgers and milkshakes an hour ago.

 

[Agast]

There was a gynecologist on Facebook asking where she could get trained to start giving IV fentanyl and versed for her small in office procedures like IUD insertion. She was very offended that the anesthesiologists reacted poorly to this idea and remarked that she had worked in the ICU as a resident and had intubated people there. Frightening stuff.

 

[coffeebythelake]

There was a gynecologist on Facebook asking where she could get trained to start giving IV fentanyl and versed for her small in office procedures like IUD insertion. She was very offended that the anesthesiologists reacted poorly to this idea and remarked that she had worked in the ICU as a resident and had intubated people there. Frightening stuff.

She should tell her patients to pop a xanax before her procddure. Why all this other stuff for minor procedures? And If her solution is to intubate the patient when there js a problem I think that IS a problem

 

[coffeebythelake]

The bulk of the EM data is based on pediatric patients coming for emergency department sedation. For instance, in this article from a "EM should sedate literally anyone at literally any time" evangelist...*NINE* out of the twelve papers he cites in favor of his position are from pediatric studies.

Now, I'm not saying the data supporting the ASA npo guidelines are incredibly strong. In fact, they're mostly equivocal. But what I disagree with is EM citing studies with very small n's (given the rare event frequency of aspiration) in a very specific population to say everyone else is an overcautious idiot for delaying anesthesia or sedation in a 55yo diabetic fatso in a c-collar who was scarfing cheeseburgers and milkshakes an hour ago.

The data presented here is very suspect. Jusr at my hospital we've had to rescue several major aspiration events in the ER in the exact same scenario

 

[kidthor]

The data presented here is very suspect. Jusr at my hospital we've had to rescue several major aspiration events in the ER in the exact same scenario

I've seen/heard of multiple ED sedation related aspirations. Lots of them are shrugged off as "they were really sick" events and not really reported anywhere. IMO the "they were really sick" obfuscation logic excludes tons of reporting of preventable events from both EDs and MICUs.

 

[BLADEMDA]

The risk of aspiration during ED PSA appears extremely low, and that the literature provides no compelling evidence to support specific pre-sedation fasting periods for either liquids or solids. Existing fasting guidelines for elective patients are of necessity arbitrary and based upon consensus opinion. Despite this, EPs should maintain the safety systems already in place and control sedation depth to minimize aspiration risk. Noncompliance with the ASA/AAP elective procedure fasting guidelines is not a contraindication to PSA in the ED. Emergency physicians should continue to assess the timing and nature of oral intake prior to PSA, and balance the remote potential for aspiration with the timing and urgency of the procedure at hand and the anticipated sedation depth

https://onlinelibrary.wiley.com/doi/epdf/10.1197/aemj.9.1.35

 

[vector2]

The risk of aspiration during ED PSA appears extremely low, and that the literature provides no compelling evidence to support specific pre-sedation fasting periods for either liquids or solids. Existing fasting guidelines for elective patients are of necessity arbitrary and based upon consensus opinion. Despite this, EPs should maintain the safety systems already in place and control sedation depth to minimize aspiration risk. Noncompliance with the ASA/AAP elective procedure fasting guidelines is not a contraindication to PSA in the ED. Emergency physicians should continue to assess the timing and nature of oral intake prior to PSA, and balance the remote potential for aspiration with the timing and urgency of the procedure at hand and the anticipated sedation depth

https://onlinelibrary.wiley.com/doi/epdf/10.1197/aemj.9.1.35

That paper is from 2002 and most of the studies it cites are from the 80s. So unless ED physicians were using big slugs of propofol and near dissociative doses of ketamine to sedate full stomachs in the 80s it's mostly irrelevant to what I see today.

 

[coffeebythelake]

So the ER

That paper is from 2002 and most of the studies it cites are from the 80s. So unless ED physicians were using big slugs of propofol and near dissociative doses of ketamine to sedate full stomachs in the 80s it's most irrelevant to what I see today.

Exactly 💯

How do the ER folks define Procedural Sedation? Using some versed and fentanyl with a responsive patient is NOT the same as propofol and ketamine in a quasi general anesthetic with an unsecured airway. And the issue isn't vomiting. The issue is regurgitation.

That Morganstern guy is an arrogant fool. "Well I’m very sorry, but you are just going to have to wait. Next time, remember that you need an empty stomach if you are going to have an emergency…" Total straw man. Just acknowledge there is a risk vs. benefit analysis in this scenario, and just accept that there is an alternative to sedating a full stomach patient you turd.

 

[Ashers]

It's like the EM guys who have no problem giving 50 of propofol and a 100 of ketamine for a joint reduction to a guy who ate a bucket of fried chicken and drank 30 beers before crashing his ATV an hour ago.

Laughably different "standard of care" in their professional society guidelines.

I dealt with that stuff when I was in charge of sedation at a hospital. Fortunately, they did follow NPO, or they documented they did, and I never got to review a case of an aspiration. But their patients hallucinated like crazy because they gave huge doses of ketamine THEN propofol a few minutes later. They said they wouldn't change their practice to give something before the ketamine because that's how they did it in the ER. I would take care of patients who complained about the horrible hallucinations they had. But what would I know about ketamine and propofol using them almost every day?

 

[nimbus]

She should tell her patients to pop a xanax before her procddure. Why all this other stuff for minor procedures? And If her solution is to intubate the patient when there js a problem I think that IS a problem

Patients want to drive to the office and drive home. Too inconvenient to arrange a ride.

 

[nimbus]

That paper is from 2002 and most of the studies it cites are from the 80s. So unless ED physicians were using big slugs of propofol and near dissociative doses of ketamine to sedate full stomachs in the 80s it's mostly irrelevant to what I see today.

That’s funny because we were still using a lot of Pentothal in the early 1990s. Propofol lady was still buying us a lot of food.

 

[Xman5678]

There was a gynecologist on Facebook asking where she could get trained to start giving IV fentanyl and versed for her small in office procedures like IUD insertion. She was very offended that the anesthesiologists reacted poorly to this idea and remarked that she had worked in the ICU as a resident and had intubated people there. Frightening stuff.

There is a big difference between an EM trained physician using sedative/hypnotic drugs and other specialties doing so.

 

[leviathan]

I still remember a dentist charging me $1000 for sedation when I got my wisdom teeth out. That sedation consisted of checking my blood pressure once and giving me an oral benzo before they started, which did literally nothing to sedate me.

 

[Angus Avagadro]

Had a relative in the Midwest, high school was highest ed level, worked for an oral surgeon. She wanted to ask me a question about one of their patients who had a problem with a " Tubal". I was puzzled and asked her why an oral surgeon was doing a tubal. She looked at me like I was an idiot for not knowing a tubal was when they put a tube in your nose for anesthesia. I asked her what her job was and she said she squeezed the bag for breathing. What happened to the 18 yo? She said his heart stopped and they did cpr. I asked if the paramedics were able to help him. I got the " you're an idiot look again" and she said we didn't call them. They finished the extractions and didn't tell the family. I told her to resign today..which she did. Incredible.

 

[vector2]

Had a relative in the Midwest, high school was highest ed level, worked for an oral surgeon. She wanted to ask me a question about one of their patients who had a problem with a " Tubal". I was puzzled and asked her why an oral surgeon was doing a tubal. She looked at me like I was an idiot for not knowing a tubal was when they put a tube in your nose for anesthesia. I asked her what her job was and she said she squeezed the bag for breathing. What happened to the 18 yo? She said his heart stopped and they did cpr. I asked if the paramedics were able to help him. I got the " you're an idiot look again" and she said we didn't call them. They finished the extractions and didn't tell the family. I told her to resign today..which she did. Incredible.

 

[Angus Avagadro]

View attachment 358179

My response exactly.

 

[abolt18]

IMO the "they were really sick" obfuscation logic excludes tons of reporting of preventable events from both EDs and MICUs.

I'm confident there are many in the OR as well. I have many times gone to close a chart and the crna literally checked the "no complications" button on Epic when the patient aspirated or needed intubation unexpectedly or whatever.

 

[coffeebythelake]

Patients want to drive to the office and drive home. Too inconvenient to arrange a ride.

and how would IV sedation change this plan? vs. oral xanax?

 

[nimbus]

and how would IV sedation change this plan? vs. oral xanax?

It would be the same. But both Xanax and IV sedation require a ride which is why most women get nothing nowadays. Fwiw, I know 2 women who said iud insertion and removal were completely painless. So it’s not the same for everyone.

 

[VisionaryTics]

View attachment 358179

I re-read that post like four times to confirm I was actually reading what I was reading....

 

[IMGASMD]

I re-read that post like four times to confirm I was actually reading what I was reading....

Now juxtapose what you read with the uproar at the dental forum when some of us pushed back on their trainings.

 

[osumd]

A&A published an editorial on this when ACEP published their most recent guidelines on the topic:

Nil Per Os Consideration for Emergency Procedures:... : Anesthesia & Analgesia

An abstract is unavailable.

journals.lww.com

It’s a good read. The author goes through some of the evidence, or lack thereof, and rationale for the ASA guidelines and the ACEP guidelines.

In his last paragraph he states an obvious point, but one worth remembering when called down to the ED to help with a hip reduction, “While developing or recommending a sedation plan, they should consider that if aspiration were to occur, they would be held to the guidelines and standards of care of the ASA, not the ACEP.”

 

[coffeebythelake]

Now juxtapose what you read with the uproar at the dental forum when some of us pushed back on their trainings.

Dentist owns their own clinic: think they run a strip mall hospital with an ICU.

 

[IMGASMD]

Dentist owns their own clinic: think they run a strip mall hospital with an ICU.

With their training, they’re surely capable of dealing with anything that come their way.

 

[PTPoeny]

My family changed dentists after the last one wanted to do wisdom tooth extraction on my obese husband with OSA and a full beard with deep sedation and couldn't answer my questions regarding their safety plans for when he obstructed. And they had already promised him he wouldn't have to shave🙄

 

[Ashers]

Dentist owns their own clinic: think they run a strip mall hospital with an ICU.

I have a pediatric dentist acquaintance. One day she texted me asking what to do with expired narcotics in the dental clinic. I googled something for her and told her I looked it up on google. She asked me what I did, and I said the pharmacist dealt with all of that sort of stuff. She said they didn't have one, and I said, I have no clue what you're supposed to do, but you should probably figure it out from someone.

At one point, I almost needed sedation for going to the dentist, then I changed dentists. I just don't know what to do after my good dentist retires.

 

[coffeebythelake]

My family changed dentists after the last one wanted to do wisdom tooth extraction on my obese husband with OSA and a full beard with deep sedation and couldn't answer my questions regarding their safety plans for when he obstructed. And they had already promised him he wouldn't have to shave🙄

Assassins.