Girl dies after getting dental treatment

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r_salis

r_salis

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*Yikes*. I feel bad for this dentist.

http://news.yahoo.com/s/ap/20060927/ap_on_re_us/dentist_coma_2

Girl dies after getting dental treatment

CHICAGO - A 5-year-old Chicago girl who never awoke from her sedation during a visit to the dentist died Wednesday at Children's Memorial Hospital, a hospital official said.

Kindergartner Diamond Brownridge had been in a coma and on life support since the weekend dentist visit, said Julie Pesch, a spokeswoman for Children's Memorial Hospital.

Family members have said Diamond received a triple dose of sedatives — an oral agent, an intravenous drug and nitrous oxide gas — during Saturday's exam at Little Angel Dental. The girl was having two cavities filled and caps placed on her lower front teeth.

The girl's mother, Ommettress Travis, has said she was asked to leave the room during the half-hour procedure. When she returned, her daughter was lying in the dental chair, not breathing, Travis said.

The girl's dentist, Hicham Riba, was certified to administer anesthesia to patients and his state license was current, said Susan Hofer, a spokeswoman for the Illinois Department of Financial and Professional Regulation.

Speaking to the Chicago Sun-Times before the girl died, the 40-year-old Riba said he was traumatized by what happened. "I don't think I will ever go back to a normal life after an experience like this," he said.

The telephone rang unanswered at Riba's home Wednesday night.
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r_salis said:
*Yikes*. I feel bad for this dentist.
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Yeah, and for the 5-year-old girl...

I guess these things happen. I hope it wasn't due to negligence from the dentist.
 
Why the heck did the dentist administer an oral agent, an intravenous drug and nitrous oxide gas all at once? Dont you usually stick with one?
 
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not always

i've seen oral given to calm them before IV

i've seen oral given before nitrous


ShawnOne said:
Why the heck did the dentist administer an oral agent, an intravenous drug and nitrous oxide gas all at once? Dont you usually stick with one?
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I also read tht article. I really feel bad for both the girls's family and the dentist too.
 
Someone stopping breathing during a sedation isn't the end of the world, provided you monitor them appropriately (which they apparently did not) and you remember how to intubate your patients. If you are uncomfortable with intubation, you certainly shouldn't be taking patients that deep or using medications that depress the breathing reflex.
 
Jediwendell said:
Someone stopping breathing during a sedation isn't the end of the world, provided you monitor them appropriately (which they apparently did not) and you remember how to intubate your patients. If you are uncomfortable with intubation, you certainly shouldn't be taking patients that deep or using medications that depress the breathing reflex.
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is it that common???
 
ShawnOne said:
Why the heck did the dentist administer an oral agent, an intravenous drug and nitrous oxide gas all at once? Dont you usually stick with one?
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Very common. Versed PO to relax the kid to make setup and IV placement easier. Nitrous can enhance the effect of the IV meds and lower the actual dose that's necessary. On top of that, with the nitrous you are also giving the patient more oxygen than they would get breathing room air. At the highest if n20 is at 50-60% the pt is getting at least 40% of 02, more than the 21% or so of ambient.

The sad thing is the media is acting like this guy gave the kid a "triple dose of anesthesia", when in reality this combo is done daily all across the country.
 
The only thing that I see that this dentist did wrong was to not properly monitor the patient. A pulse ox would have probably saved this girls life had she been wearing one and it alerted the dentist. It isn't all that uncommon to overly depress a patients resp reflex and the dentist should have been looking out for that. If he had been on top of things and given the appropriate reversal agents then it would have been a good scare but with much better outcomes. Then again I only know what was in the article and we know how the media likes to leave things out to make for a better story.
 
TucsonDDS said:
The only thing that I see that this dentist did wrong was to not properly monitor the patient. A pulse ox would have probably saved this girls life had she been wearing one and it alerted the dentist. It isn't all that uncommon to overly depress a patients resp reflex and the dentist should have been looking out for that. If he had been on top of things and given the appropriate reversal agents then it would have been a good scare but with much better outcomes. Then again I only know what was in the article and we know how the media likes to leave things out to make for a better story.
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My thoughts exactly. With 65-87% of fatalities from anesthesia due to human error and the majority of those cases are due to failure to ventilate; although dose amounts are not listed this is my hunch.
 
Sprgrover said:
My thoughts exactly. With 65-87% of fatalities from anesthesia due to human error and the majority of those cases are due to failure to ventilate; although dose amounts are not listed this is my hunch.
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So it sounds like respiratory depression or failure is somewhat common, and practitioners should just be ready with ventilation?? Wow! Sounds intense. I worked at an office where the OS had an assistant who got his dental license in another country. While he was trying to switch over to an American license, he was assisting, mainly in the capacity of monitering pts under IV sedation. Good to have someone else around, I suppose!
 
Depending of funds and liability I plan on having an ICU nurse a day a week for concious sedations. If I could trust them to monitor my patients it would free me up to do other procedures and the 30 or 40/hour would probably pay for itself in productivity and peace of mind.
 
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The fact that pediatric dentists are doing these type of procedures across the country and you rarely hear of anything like this. Just shows that it is realatively safe. There are risks make no mistake. But hypothethically what if the morning of the appointment the child grabbed a ambien or some deppressant from the top of her moms dresser? This will be a wake up call to all pediatric dentists of how important it is to properly monitor patients.
 
Dentcraze said:
The fact that pediatric dentists are doing these type of procedures across the country and you rarely hear of anything like this. Just shows that it is realatively safe. There are risks make no mistake. But hypothethically what if the morning of the appointment the child grabbed a ambien or some deppressant from the top of her moms dresser? This will be a wake up call to all pediatric dentists of how important it is to properly monitor patients.
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With a name like Diamond I think that is probably a very real possibility.
 
Its very common in pediatric dentistry to be doing oral conscious sedation , but uncommon to be doing IV sedation. For IV sdation in an office setting, you need to have a dental anesthesiologist to administer IV drugs , at least in the State of TX. I am assuming that this kid first recieved an oral dose of maybe Versed and then an IM narcotic like Demerol, which is very common in Pedo. And like the article says that the mom found the kid unconcious and without breathing when she was brought to the room----seems unusual. A pediatric dentist who does a dozen sedations in a week and has been doing it for a while--about 10 yrs, will not leave the kid in such a state, if he did I guess he will have a hard case ahead of him. N2O is used always to supplement with oral/ parenteral sedations--thats common too. But again recently the use of multiple drug regimens for kids is being criticized by several authorities in the field of pediatric dentistry. Inadequate monitoring has been the major cause of deaths due to sedations and therefore AAPD has always had guidelines for sedating kids and they have revised it recently.
Here is the link for all of you who are interested --

http://www.aapd.org/media/Policies_Guidelines/G_Sedation.pdf

It is indeed a sad news and we as professionals need to be increasingly aware of the risks that we face in everyday practice.
 
I'mFillingFine said:
So it sounds like respiratory depression or failure is somewhat common, and practitioners should just be ready with ventilation??...
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If you are going to be performing deep sedation or general anesthesia you must monitor ventilation (among other things), have reversal agents on hand and a knowledge of how to use them as well as be able to restore ventilation in a patient. Leaving a patient unable to breathe only to be discovered by their mother isn't exactly a practice builder.
 
We don't have all the facts and we only have one side of the story. You guys are all just pissing in the wind. You can't make assumptions based on what a news reporter interprets, and this goes double with anything some mom says she "saw".
 
asulikeit49 said:
Its very common in pediatric dentistry to be doing oral conscious sedation , but uncommon to be doing IV sedation. For IV sdation in an office setting, you need to have a dental anesthesiologist to administer IV drugs , at least in the State of TX.
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Not so in most states. Also not true that IV sedation is rare. It's very common on the west coast, expecially in california.
 
toofache32 said:
We don't have all the facts and we only have one side of the story. You guys are all just pissing in the wind. You can't make assumptions based on what a news reporter interprets, and this goes double with anything some mom says she "saw".
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Latest update ......
State suspends dentist's license
Cites 'imminent danger' in practices after 5-year-old died

September 30, 2006
BY RUMMANA HUSSAIN Staff Reporter
The state suspended the dental license of Hicham Riba on Friday -- two days after 5-year-old patient Diamond Brownridge died -- calling his practices an "imminent danger to the public."

The Illinois Department of Financial and Professional Regulation said Riba failed to properly monitor Diamond's blood pressure, pulse and respiration during a visit last weekend and recorded that she was "alert and responsive" even though her mother found her in a comatose state.
----------------------------
The man did a sedation without a pulse ox on. It is sad and unfortunate, but there is absolutely no excuse for failing to monitor vitals when doing a sedation. This is not heresay, it has been reported that he was not using one.
 
My God!!!

God Bless That Girl!! But What I Feel Is There Must Be Something Wrong Apart From Oversedation.
There Might Be Somethings Undiagnosed.
And There Must Not Be Dentist's Fault.
 
Sprgrover said:
If you are going to be performing deep sedation or general anesthesia you must monitor ventilation (among other things),
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there is a difference between ventilation and oxygenation. I'm assuming you mean oxygenation (pulse oximetry) versus ventilation (end tidal CO2). Nobody measures ventilation in a deep sedation, but you definitely monitor oxygenation.

On another note, I find it interesting that people think oral sedation is safer than IV sedation. It's not. IV sedation is safer if you know what you are doing. Oral sedation does not allow titration and reversal (unless you start an IV for emergency drugs). And, thinking oral sedation is safer can prove to be a pitfall because one may think that the same monitors aren't necessary.
 
maybe the girl had some strange allergic reaction to the sedatives and unfortunately, found out this way. it would be nice to know if the dentist had her on pulse ox, etc to monitor while she was out. its easy for the public to get on the doctor's case. no doctor, unless they have psych problems, would do something so careless, especially to a 5 yo girl.
 
scalpel2008 said:
there is a difference between ventilation and oxygenation. I'm assuming you mean oxygenation (pulse oximetry) versus ventilation (end tidal CO2). Nobody measures ventilation in a deep sedation, but you definitely monitor oxygenation.

On another note, I find it interesting that people think oral sedation is safer than IV sedation. It's not. IV sedation is safer if you know what you are doing. Oral sedation does not allow titration and reversal (unless you start an IV for emergency drugs). And, thinking oral sedation is safer can prove to be a pitfall because one may think that the same monitors aren't necessary.
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From a couple of hundred concious sedations I am pretty sure that we monitor both ventilation and oxygenation. Unless you are practicing in a hospital and have the ability to get an ABG or VBG you are going to look at both vitals to get a feeling for the level of sedation. It is quite possible suppress a respiratory rate into the low single digits while maintaining a decent saturation, especially if someone is on supplemental O2. Does that mean that the patient is perfusing the O2 in the blood, not necessarily. Although it is much more common to see the drop in the saturation. This dentist did a couple of things wrong and unfortunately the little girl is the one that suffered from his mistakes.

And I agree with you 100% that IV sedation is much safer than oral sedation. When giving IV medications you know exactly how much medication it takes to knock the patient out and you are much less likely to totally snow them and have a situation like this. Also reversal medications like flumazenil and narcan work much better in that you know the patient won't be absorbing any more medication.

Once again, none of us know what actually happened in this office other than somebody screwed up. That could have been the parent who left the bottle of ambien on the dresser and the little girl got into it befor the appointment or it could have been the dentist who gave 5mg of versed instead of 0.5mg. What we do know is that the patient wasn't adequately monitored (I am assuming) and that her condition wasn't conveyed to dentist early enough. It is a tragity and hopefully many people will learn from it.
 
TucsonDDS said:
From a couple of hundred concious sedations I am pretty sure that we monitor both ventilation and oxygenation. Unless you are practicing in a hospital and have the ability to get an ABG or VBG you are going to look at both vitals to get a feeling for the level of sedation. It is quite possible suppress a respiratory rate into the low single digits while maintaining a decent saturation, especially if someone is on supplemental O2. Does that mean that the patient is perfusing the O2 in the blood, not necessarily. Although it is much more common to see the drop in the saturation. This dentist did a couple of things wrong and unfortunately the little girl is the one that suffered from his mistakes.

And I agree with you 100% that IV sedation is much safer than oral sedation. When giving IV medications you know exactly how much medication it takes to knock the patient out and you are much less likely to totally snow them and have a situation like this. Also reversal medications like flumazenil and narcan work much better in that you know the patient won't be absorbing any more medication.

Once again, none of us know what actually happened in this office other than somebody screwed up. That could have been the parent who left the bottle of ambien on the dresser and the little girl got into it befor the appointment or it could have been the dentist who gave 5mg of versed instead of 0.5mg. What we do know is that the patient wasn't adequately monitored (I am assuming) and that her condition wasn't conveyed to dentist early enough. It is a tragity and hopefully many people will learn from it.
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I am not sure what you mean by your first paragraph. so are you using capnography during your sedations (if you are, that's great. i wish we did)? If not, you are not monitoring ventilation. Are you saying that because you are looking at he respiratory rate and pulse ox that you are monitoring ventilation (gas exhange) ?
 
We use the capnography on the one machine that will monitor it, but not with our other machines.
 
toofache32 said:
We use the capnography on the one machine that will monitor it, but not with our other machines.
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i saw a new machine in our sedation room a few days ago. i wonder if it has capnography. our old machines don't.
 
A guy from my school is a 3rd year now, and he was doing his EMED rotation at the hospital where the girl died. Apparently he saw the whole thing. Crazy.
 
i retract my statement..

anyways i have question, the article mentions IV drug, i assume this isn't considered iv sedation correct? --- otherwise shouldn't an anesthesiologist been in the OR, and he/she would of been the responsible one?
 
rocknightmare said:
i retract my statement..

anyways i have question, the article mentions IV drug, i assume this isn't considered iv sedation correct? --- otherwise shouldn't an anesthesiologist been in the OR, and he/she would of been the responsible one?
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If you give sedatives through the IV, then that's IV sedation. And why does an anesthesiologist need to be around when there's an IV sticking out of the arm?
 
scalpel2008 said:
I am not sure what you mean by your first paragraph. so are you using capnography during your sedations (if you are, that's great. i wish we did)? If not, you are not monitoring ventilation. Are you saying that because you are looking at he respiratory rate and pulse ox that you are monitoring ventilation (gas exhange) ?
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After rereading my post you are right. Seemed to make a lot sense after my wife and I celebrated her quiting her job over 2 bottles of wine. You are right, ventilation isn't the same as respiration. At the hospital that I was working at in Arizona we did ruitinely monitor ET CO2 during concious sedations for about the past year. We actually had a monitor that would plug into our IV pumps and used a canula. This was a very easy setup to use and provided accurate results. However this setup was also a pain in the ass because it could also be used to monitor a patient while they were on a PCA or narcotic gtt. Although this is pretty cool in theory it proved to be a total pain in the ass when the patients would take the canula off and the pca would turn off.
 
I haven't really been following this story very closely, but our professor just mentioned this in our anesthesiology class today and said that the dentist has had to move and that he's even received death threats - sounds pretty crazy.
 
TucsonDDS said:
After rereading my post you are right. Seemed to make a lot sense after my wife and I celebrated her quiting her job over 2 bottles of wine. You are right, ventilation isn't the same as respiration. At the hospital that I was working at in Arizona we did ruitinely monitor ET CO2 during concious sedations for about the past year. We actually had a monitor that would plug into our IV pumps and used a canula. This was a very easy setup to use and provided accurate results. However this setup was also a pain in the ass because it could also be used to monitor a patient while they were on a PCA or narcotic gtt. Although this is pretty cool in theory it proved to be a total pain in the ass when the patients would take the canula off and the pca would turn off.
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bottoms up, to your wife quitting her job. capnography on a pt on a PCA sounds like something that would happen at a private hospital where patients actually pay for their treatment (something I know nothing baout)
 
USUaggie said:
I haven't really been following this story very closely, but our professor just mentioned this in our anesthesiology class today and said that the dentist has had to move and that he's even received death threats - sounds pretty crazy.
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Ditto.

This is a very unfortunate situation for the family of the child and the dentist and his family. While I am sure there was no ill intent, mistakes may have been made, but not necessarily so. Everyone is fallible, no one gets through their life without making mistakes, dentists included.

We can only hope that this dentist's license is reinstated after review. His income, more than likely, is his family's primary means of support. This is a nightmare for everyone involved.

I had lunch yesterday with an older woman in her early seventies. She is a graduate of Julliard and an excellent pianist. Her daughter is an MD trained in cosmetic surgery. Due to a law suit scare of which she did not elaborate and I did not probe and increasing malpractice costs, her daughter now does work, according to her mother, one step above an esthetician. Her mother asked her daughter if it bothered her to have acquired so much education and not put it to full use, but her daughter is comfortable with her practice as it is now. She's not even doing botox, but considering it.

Taking the time to review the patient's medical history, keeping up with the literature, allowing enough time per patient to do good quality dentistry and doing procedures within our comfort zone, it's the best we can do for our patients and ourselves.
 
Lesley said:
Ditto.

This is a very unfortunate situation for the family of the child and the dentist and his family. While I am sure there was no ill intent, mistakes may have been made, but not necessarily so. Everyone is fallible, no one gets through their life without making mistakes, dentists included.

We can only hope that this dentist's license is reinstated after review. His income, more than likely, is his family's primary means of support. This is a nightmare for everyone involved.
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Getting his license back is the last thing I think he's worried about. This is a big if, since it's mainly based on the news reports, but there is a good chance he will be facing criminal charges on negligence. Again, this is all heresay, but according to most reports the mother found the child herself, alone in a room, apneic. Again, this is according to the mother. However, if it is true that this patient was not monitored with a pulse ox during the treatment, and had no supervision (not even an asst) afterwards then this dds will likely face criminal action.

The reports state that once they realized there may be a problem, he attempted to hook up the pulse ox but it was broken. He is board certified and has records of doing 100s of these sedations so to think he had a broken pulse ox amazes me because it means he had done many other cases in this fashion. The child was only around 35lbs and he gave her a high level of sedatives.

As I said, until proven it's all heresay. Allergic reactions and mistakes happen in healthcare but if the lack of monitoring is true there really is no excuse for it. The sad thing is not that he may go without a license, but that a poor girl had to die because of it.
 
capisce? said:
Getting his license back is the last thing I think he's worried about. This is a big if, since it's mainly based on the news reports, but there is a good chance he will be facing criminal charges on negligence. Again, this is all heresay, but according to most reports the mother found the child herself, alone in a room, apneic. Again, this is according to the mother. However, if it is true that this patient was not monitored with a pulse ox during the treatment, and had no supervision (not even an asst) afterwards then this dds will likely face criminal action.

The reports state that once they realized there may be a problem, he attempted to hook up the pulse ox but it was broken. He is board certified and has records of doing 100s of these sedations so to think he had a broken pulse ox amazes me because it means he had done many other cases in this fashion. The child was only around 35lbs and he gave her a high level of sedatives.




As per my "ditto", I have not been following the facts of this story closely. The facts will be uncovered and confirmed and a judgement will be determined by a professional board and as you said a criminal court, if indicated.

This remains, as I said before, a nightmare for everyone involved. It goes without saying that to lose a child would be the biggest nightmare of all. It is difficult to imagine how her parents and family are coping.
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toofache32 said:
You know the dosages?
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by heart, not yet since i've yet to do sedations this early in my residency, in lectures, yes.

The comment was made by our program chair and also our director, both of whom are big sedation guys. They discussed this case w/ us ad nauseum and said the regimen used was pretty much like ga and overkill for a child at her wt.

if you want me to pull out lectures and list dosages, by all means :love:
 
aphistis said:
Dangit, would you quit harassing people with relevant questions so they can get back to the witch-hunting?
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sedating a kid without any form of monitoring is not witch-hunting.

Quick! Someone over in the pre-dent forum spilled some milk. I think they need some "super-duper moderating".
 
capisce? said:
by heart, not yet since i've yet to do sedations this early in my residency, in lectures, yes.

The comment was made by our program chair and also our director, both of whom are big sedation guys. They discussed this case w/ us ad nauseum and said the regimen used was pretty much like ga and overkill for a child at her wt.

if you want me to pull out lectures and list dosages, by all means :love:
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I guess I was referring to the dosages that the dentist was using on that kid.
 
toofache32 said:
I guess I was referring to the dosages that the dentist was using on that kid.
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duh. i was on call last night :confused:

my director may, he was the one who made the comments.
 
S Files said:
interesting....would like to hear from pedo residents on the appropriateness of the meds / dosages....atropine??
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The atropine was probably given to dry out the oral cavity. Sounds like a lot of other medication though unless the kid had a nice history of drug use:eek:
 
S Files said:
interesting....would like to hear from pedo residents on the appropriateness of the meds / dosages....atropine??
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Ok, here's the best I can offer.
Diamond weighed 35 pounds
A typical oral valium dose is 1mg/10lbs. SHe should get 3.5mg. So 7.5 was a little excessive. However, you then add on 1.3ml then 1.2ml IV 5 minutes later. The IV dose is usually 0.5mg/lb q15-30 min. so that would be 1.75mg. So he was ok with this dose, he just gave it a litte quickly. It's the combo of oral and IV that puts you over the edge. It seems like a little much to me. I give valium as part of my cocktail every day and I would have given her 2.5-4mg oral and no more.
The Midazolam dose is a little hard for me to determine since it was quoted in ml in the article, and it doesn't say if it was oral or IV. Versed doses are in mg, not ml. Typical oral dose is 1-2mg/lb. she got 1.3ml... So it all depends on what the concentration was in the bottle.
Not real sure why he needed 2 benzos to do the job...
50% nitrous is typical
Talwin is a narcotic pain med and I really have no idea what the IV doses are of this med. she got "2.5ml IV." I'm guessing it should be in mg also.
Atropine dose is also in ml instead of mg.... who knows.
2 carpules of lido is fine
The big thing is that benzos potentiate narcotics, meaning apnea is more likely, and it decrease heart rate and blood pressure. So if you gave her too much of both those drugs and you weren't monitoring her pulse... bad things happen. God, I feel like I just took a test!
Jedi's wife
 
I love reading Jedi's posts about Pedo and wondering "how the hell does he know all this stuff?" only to see "Jedi's wife" at the end.
 
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