Peds Dental Tragedy

[OB1🤙]

http://www.staradvertiser.com/newsp...n_coma_after_overdose_during_dental_work.html

Girl in coma after overdose during dental work
By Susan Essoyan

JAMM AQUINO / [email protected]

A 3-year-old Kailua girl with a sparkling personality and aquamarine eyes suffered massive brain damage after receiving an overdose of sedatives at a dentist's office, according to her parents and their attorney.

Finley Puleo Boyle has been in a coma at Kapiolani Medical Center since Dec. 3, after her mother, Ashley Boyle, brought her to Dr. Lilly Geyer, a dentist at Island Dentistry for Children in Kailua, for a root canal.

"She was the happiest little girl, completely healthy her whole life," her mother said, choking up. "She loved her friends. She loved animals, she loved her dog. … She loved people."

"Her condition has not improved in the past week that she has been at the hospital," Boyle said. "She's opening her eyes a little, but she's not responding to commands. She has had two MRIs. The second one came back really devastating. She suffered massive brain injury."

Ashley Boyle was in the waiting room, unaware of what was happening to her little girl in the dentist chair until she happened to see emergency medical technicians arrive on the other side of a glass door. She rushed to her daughter's side and found her unconscious. She said the dental staff had not told her they called 911.

"They never at any time came out and alerted me that anything was going on," she said. "I'm a nurse. I'm trained at CPR. … They were giving her Narcan, so I knew it was an overdose." Narcan can reverse the effects of opioids.

Attorney L. Richard "Rick" Fried Jr. said the child, who weighs 40 pounds, had received a heavy dose of Demerol along with two other drugs, Hydroxyzine and Chloral Hydrate.

"What happened to her was an egregious overdose of three central nervous system suppressant drugs," said Fried, who plans to file a lawsuit. "Things went horribly wrong. We are just shocked that these drugs in these doses in this combination could be given to a child of this size."

A technician administered the drugs even before the dentist arrived, Fried said. The dentist later started the procedure and, when things went awry, summoned a pediatrician whose office is nearby to help revive Finley.

"As we all know a few minutes can make an enormous difference in this sort of situation," Fried said. "If you are giving drugs of this kind, you must have the appropriate resuscitative measures in the office and must have the competence to keep an airway open."

Calls to Island Dentistry for Children went straight to voice mail Thursday, and no one responded to a request for comment from Geyer. Its website has been replaced with a photo of blue sky and clouds.

Geyer is a licensed dentist, and there are no records of complaints against her or Island Dentistry for Children on file with the state Department of Commerce and Consumer Affairs. She was first issued a licence to practice in Hawaii in July 2005, and her current license is due to expire Dec. 31, 2015, according to the licensing division.

Online reviews of Geyer's practice are mixed. Some praise its efforts to cater to children, which include the use of flavored gloves and a TV set for children in the dentist chair, as well as a chalkboard wall for kids.

Boyle said her daughter first visited Geyer in November and had X-rays done. The dentist recommended extensive work involving four teeth. Boyle said she trusted the dentist's judgment but now wishes she had not.

"Obviously, as a professional, I work on people every day, and no one questions my judgment on things," Boyle said. "Sometimes you just want to step back and be a mom and not question what people are doing. … Now I'm regretting not questioning it."

Finley, who was born in Jacksonville, Fla., has lived in Hawaii since she was 3 months old with her mother and father, Lt. Evan Boyle, a naval officer. She is their only child.

Evan Boyle said the doctor told him it appeared his daughter was without oxygen for five or more minutes, judging from the brain damage.

Her parents are trying to hope for the best, although the future is uncertain and they don't know whether she will ever be able to walk or feed herself again.

"She was very well behaved, very loving," Evan Boyle said. "She used to verbalize to Ashley and myself without any prompting, ‘I love you Daddy,' ‘I love you Mommy.'"

Now they and other family members are keeping a vigil by her bedside, waiting to hear that sweet voice again.

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Finley's godparents are raising funds for her medical expenses. To help, visit www.fundly.com/fundly-for-finley.

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[chocomorsel]

Damn, that sucks. I was even weary of having a simple procedure at a surgery center just in case something awry goes wrong. Would rather be in a hospital. At least surgery centers have code carts and anesthesiologist.
No one should be giving sedatives without a crash cart and definetely no techs should be administering sedatives. Really? That sounds scary.
I had my wisdom teeth done by an oral surgeon at a mil hospital. Thank God, because I didn't know any better. But the dentist on post only used local and no sedatives. Thats why I insisted on sedatives because of horror stories about the needles in the hard palate and thank God they did it at a hospital. Dentists gotta think of these things. Certainly could have been preventable in the correct environment.

 

[IlDestriero]

When your emergency plan includes call the pediatrician next door, that's a problem.
I wonder if she was ACLS or PALS trained or if she had any kind of emergency airways at all?
Probably not.
Completely avoidable disaster driven by cost containment and the 1 in a million risk.
The fact that the mother was 10 yards away and had the skills to intervene is especially devastating.

 

[Sublimazing]

Pediatric dentists, depending on the state are licensed to do oral sedation (like this case), nitrous oxide, and sometimes even IM. I'm sure that this person was PALS certified...but seeing how they responded they probably have never once gone through a real code.

The fact that a technician was giving the drugs is confusing to me, I haven't heard of this before.

Sad sad news.

 

[chocomorsel]

They should just do Versed and Ketamine if the are not properly trained in anesthesia for dentistry or don't have a code cart and know how to use it. They should be required to have a code cart if they are dong sedation. Does dental school not expose their students to Anesthesia for the basic stuff?
And to me it doesn't sound legal for a tech to be administering sedatives at all.

 

[somedumbDO]

They should just do Versed and Ketamine if the are not properly trained in anesthesia for dentistry or don't have a code cart and know how to use it. They should be required to have a code cart if they are dong sedation. Does dental school not expose their students to Anesthesia for the basic stuff?
And to me it doesn't sound legal for a tech to be administering sedatives at all.

If they are not properly trained they should use NOTHING ! There is a reason why the peds dentist I work with won't consider doing in clinic sedation for kids younger than 6, and bring them to our peds hospital. Knowing what you don't know is a true sign of brilliance.

 

[chocomorsel]

If they are not properly trained they should use NOTHING ! There is a reason why the peds dentist I work with won't consider doing in clinic sedation for kids younger than 6, and bring them to our peds hospital. Knowing what you don't know is a true sign of brilliance.

You are right. I take it all back.

 

[deleted171991]

Why does a 3 year-old need a root canal (on a temporary tooth)??? Just take it out; I bet it can be done with much less anesthesia, risk and... dentist income.

This is not only egregious malpractice, this is greed, and should be punished accordingly. The mother is guilty of stupidity, too. She is a nurse; she should have known better.

This crap reminds me of allergy testing on 6 month-old babies who have rash after cow milk. Seriously? Is Earth round??? Where is common sense?

 

[Sublimazing]

Why does a 3 year-old need a root canal (on a temporary tooth)??? Just take it out; I bet it can be done with much less anesthesia, risk and... dentist income.

This is not only egregious malpractice, this is greed, and should be punished accordingly. The mother is guilty of stupidity, too. She is a nurse; she should have known better.

This crap reminds me of allergy testing on 6 month-old babies who have rash after cow milk. Seriously? Is Earth round??? Where is common sense?

Lots of pediatric dental treatment include "root canals" called pulpotomies...it has nothing to do with money, it's a perfectly legitimate treatment. You can't just rip teeth out without causing problems later on. This was a tragedy, which appears to stem from negligence and malpractice, but nothing here indicates greed.

 

[deleted171991]

Lots of pediatric dental treatment include "root canals" called pulpotomies...

I didn't realize they were calling the pulpotomy "root canal". I thought it was an abscessed tooth.

 

[Idiopathic]

They should just do Versed and Ketamine if the are not properly trained in anesthesia for dentistry or don't have a code cart and know how to use it. They should be required to have a code cart if they are dong sedation. Does dental school not expose their students to Anesthesia for the basic stuff?
And to me it doesn't sound legal for a tech to be administering sedatives at all.

your sedation plan is certainly no less problematic than one they used, btw

 

[Spinach Dip]

....it appeared his daughter was without oxygen for five or more minutes, judging from the brain damage.

I may be the noob on these forums, but isn't this something that could have been prevented with pulse oximetry? Or maybe a 3-lead heart monitor?

....Of course, assuming that it was followed up with appropriate airway management and resuscitative intervention....

 

[lemoncurry]

You can't expect a three year old to sit still and tolerate dental treatment or even respond properly to commands, hence the sedation. Second, the practice of doing "baby root canals" is quite common and is an effort to preserve tooth function for as long as possible and prevent crowding of the permanent dentition. Nothing about the treatment plan indicates anything improper to me. Having said that, there were definitely mistakes made at the point of treatment and this is a very tragic event. As a father myself, I can only imagine the anger I would feel if it happened to my three year old.

 

[Sublimazing]

I may be the noob on these forums, but isn't this something that could have been prevented with pulse oximetry? Or maybe a 3-lead heart monitor?

....Of course, assuming that it was followed up with appropriate airway management and resuscitative intervention....

You are almost def. correct. These tragedies happen about once a year...and my guess is like the others this wasn't "too much" oral sed, but poor monitoring. The patient probably obstructed (since they were using a dental dam and open airway) and no one noticed until the patient was blue. In most states there is no legal requirement for pulse oximetry with oral sed.

It doesn't, however, make sense to take all of these to the hospital because thousands of patients get sedation in the dental office everyday...and I've never seen a hospital that does more than 5-10 a week.

 

[norwood]

I may be the noob on these forums, but isn't this something that could have been prevented with pulse oximetry? Or maybe a 3-lead heart monitor?

....Of course, assuming that it was followed up with appropriate airway management and resuscitative intervention....

The pulse ox much more than the EKG (one hopes we're catching hypoxia before being pre-arrest), but yes. It's a perfect example of the ability to ventilate pts with a bag-mask (and knowledge of when to do so) being the difference between tragedy and a bad day at the office.

Back when a pulse ox cost as much as a car, I could at least understand the economics of why places were without them. Now they're $90 on fleabay. I bought one out of curiosity a few years back - worked decently. Displayed a little pleth trace and everything. I'm sure it's no Masimo, but hey, if the other choice is nothing at all...

 

[IlDestriero]

your sedation plan is certainly no less problematic than one they used, btw

I'm not so sure about that. I've given a good bit of ketamine to kids to set fractures in the ED, darts in the combative autistic, etc. and they can be catatonic and minimally responsive to painful stimuli but they don't stop breathing. I could see giving dental cases a small dose of versed, some ketamine, then local, and doing the drilling +/- a bit more ketamine as needed.
That seems much safer than the nonsense they did. Our usual procedural sedation is more like ED sedation than nursing or dental sedation. Though I think they could learn to use ketamine more safely than versed/fent/morphine/etc. They rely on the potential reversibility of opiates and versed, but clearly you have to do it before you're already in the death spiral. When you're too far gone, narcan isn't going to bring you back without some ACLS and airway skills.

 

[jwk]

I'm sure that this person was PALS certified....

Why?

 

[jwk]

You can't expect a three year old to sit still and tolerate dental treatment or even respond properly to commands, hence the sedation. Second, the practice of doing "baby root canals" is quite common and is an effort to preserve tooth function for as long as possible and prevent crowding of the permanent dentition. Nothing about the treatment plan indicates anything improper to me. Having said that, there were definitely mistakes made at the point of treatment and this is a very tragic event. As a father myself, I can only imagine the anger I would feel if it happened to my three year old.

IMHO - the fact that several practicing dentists posting on this thread see nothing wrong with the "treatment plan", except for the bad outcome, is truly scary. A pulse ox is a cheap monitoring device. Doing sedation without one borders on criminal negligence.

 

[nap$ter]

IMHO - the fact that several practicing dentists posting on this thread see nothing wrong with the "treatment plan", except for the bad outcome, is truly scary. A pulse ox is a cheap monitoring device. Doing sedation without one borders on criminal negligence.

i think when they spoke of the "treatment plan" they were speaking about the pediatric root canal, not the sedation. you should reread for the context. none of the dentists here advocated doing sedation without pulse oximetry.

indeed, it has not been established on this thread that pulse oximetry was not used. that is not mentioned in the story - just assumed by all of us.

the lawyer (not a medical professional) comments are incriminating - but they would be, right?

3yo imho is the wrong age for sedation in a dental office, but what's the data? is this common practice? i don't honestly know.

the speculation on here is probably right - pulse ox was probably not used, obstruction not recognized or managed appropriately, but don't jump to too many conclusions without all the facts. this a news story about a catastrophic event in a 3 year old, not a medical record.

 

[deleted171991]

Pulse ox is a must (it's absence is indefensible in 2013 - gross negligence and incompetence). A person with good knowledge of basic airway management and resuscitation, oxygen and emergency airway bag (including LMAs) are a must (patients can have idiosyncratic reactions to sedative medications). Try to avoid any drugs that could depress breathing, especially irreversible ones. I have a feeling a lot of these requirements were not satisfied.

The general population must be indoctrinated that even "sedation" is a form of anesthesia, so it requires a good level of professional competence in airway management and resuscitation. This seems to be just another example of Michael Jackson anesthesia (just look at the drug mix).

 

[Sublimazing]

Why?

Because legally to do oral sed you need to be PALS certified.

And yes we were all referring to the actual dental treatment, obviously not the method of sedation or monitoring.

Also like I said, I don't think the ketamine would have mattered. This patient most likely wasn't apneic, they were most likely obstructed/laryngospasmed. I guess until we know the dosing and see the charting we won't know.

Finally, like I said thousands of 10 month to 4 year olds need dental work everyday. They will not tolerate this treatment. And strapping them down is barbaric. There's no infrastructure in place. The solution in my eyes is better trained sedation amongst dentists.

 

[jwk]

i think when they spoke of the "treatment plan" they were speaking about the pediatric root canal, not the sedation. you should reread for the context. none of the dentists here advocated doing sedation without pulse oximetry.

indeed, it has not been established on this thread that pulse oximetry was not used. that is not mentioned in the story - just assumed by all of us.

the lawyer (not a medical professional) comments are incriminating - but they would be, right?

3yo imho is the wrong age for sedation in a dental office, but what's the data? is this common practice? i don't honestly know.

the speculation on here is probably right - pulse ox was probably not used, obstruction not recognized or managed appropriately, but don't jump to too many conclusions without all the facts. this a news story about a catastrophic event in a 3 year old, not a medical record.

I have no argument with the procedure itself - I have no basis from which to argue the merits of that. But while I'm admittedly not familiar with routine dental office sedation - but speaking purely from my 30+ years of experience - chloral hydrate + hydroxyzine + Demerol (is this all given PO???) on a 3 year old child sounds like a crazy amount and combination of drugs and would be something I would certainly have questioned had it been my child - although I would never have put my child in this situation in the first place. Sedation IS part of the treatment plan, not just the procedure itself. If the treatment plan includes PO sedation (unpredictable by it's very nature) without monitoring (the chances of this happening WITH appropriate monitoring is limited) no provision for managing an airway (obvious) and no backup plan except for calling the pediatrician next door and 911, then I'll stand by my original statement.

 

[dhb]

The solution in my eyes is better trained sedation amongst dentists.

More teeth brushing maybe??

 

[Sublimazing]

I have no argument with the procedure itself - I have no basis from which to argue the merits of that. But while I'm admittedly not familiar with routine dental office sedation - but speaking purely from my 30+ years of experience - chloral hydrate + hydroxyzine + Demerol (is this all given PO???) on a 3 year old child sounds like a crazy amount and combination of drugs and would be something I would certainly have questioned had it been my child - although I would never have put my child in this situation in the first place. Sedation IS part of the treatment plan, not just the procedure itself. If the treatment plan includes PO sedation (unpredictable by it's very nature) without monitoring (the chances of this happening WITH appropriate monitoring is limited) no provision for managing an airway (obvious) and no backup plan except for calling the pediatrician next door and 911, then I'll stand by my original statement.

Everyone is agreeing with you that the sedation, monitoring, and response was severely lacking...I have only commented on the dental treatment not being out of the realm of routine treatment...which had nothing to do with the sedation. The sedation is not part of the dental treatment plan in our preferred nomenclature.

I'm also not arguing with you that oral sedation amongst dentists needs tighter regulation and scrutiny. The cocktail listed is very standard across the country used by many training programs, and I agree oral sed can be risky and unpredictable.

Also you comment that you wouldn't put your child in that situation...but when you have a 3 year old with 20 teeth and 15+ need restorations with the child in 10/10 pain crying with no sleep and facial swelling or intra-oral abscesses what would you do?

My point is that there isn't an easy answer. Strapping them down is going to take at least 3-4 savage apts of your child in sheer pain and trauma. And taking them to the hospital? Through whom? Pediatric Dental Residencies are typically the only ones doing it and most of them do very few cases a month with a long long waiting list.

And if the more teeth brushing comment was meant to be humorous it is inappropriate. If you meant better prevention, then I agree...we all do...but good luck.

 

[jwk]

Also you comment that you wouldn't put your child in that situation...but when you have a 3 year old with 20 teeth and 15+ need restorations with the child in 10/10 pain crying with no sleep and facial swelling or intra-oral abscesses what would you do?

They'd be done in a hospital or ASC-setting. There have always been private-practice pediatric dentists on staff at all of the hospitals I've worked at - we did pediatric dental restorations fairly frequently. These guys also did plenty of office work, but they also knew when to punt.

 

[nap$ter]

I have no argument with the procedure itself - I have no basis from which to argue the merits of that. But while I'm admittedly not familiar with routine dental office sedation - but speaking purely from my 30+ years of experience - chloral hydrate + hydroxyzine + Demerol (is this all given PO???) on a 3 year old child sounds like a crazy amount and combination of drugs and would be something I would certainly have questioned had it been my child - although I would never have put my child in this situation in the first place. Sedation IS part of the treatment plan, not just the procedure itself. If the treatment plan includes PO sedation (unpredictable by it's very nature) without monitoring (the chances of this happening WITH appropriate monitoring is limited) no provision for managing an airway (obvious) and no backup plan except for calling the pediatrician next door and 911, then I'll stand by my original statement.

the "amount" ie dose has not been established. the lawyer called it a "heavy" dose of demerol and an "egregious overdose". the lawyer.

i agree the combo of demerol/chloral hydrate/hydroxyzine sounds weird. but so do many of the recipes of my very experienced and effective partners.

i think all agree 3yo is too young for outpt dental sedation, and all agree a pulse ox should be used with any sedation. anyone undertaking sedation should understand patient selection, environment selection, and be capable of monitoring and managing an airway.


"IMHO - the fact that several practicing dentists posting on this thread see nothing wrong with the "treatment plan", except for the bad outcome, is truly scary."

this is your original statement - you misquoted and called out the dentists contributing to this thread. you missed the context of their comments and are imposing your semantics.


you make a lot of suppositions about the sedation plan in this news story based on comments from a lawyer. you don't know the sedation was PO. demerol coulda been IM, ie. you don't know if child was monitored or not. you don't know what the provision for managing the airway was. you don't know that there was no backup plan. we don't really know anything about what happened from the lawyers statements in a news story except that there was an anoxic catastrophe in a 3yo for dental sedation.

everything else is just supposition.

 

[Sublimazing]

They'd be done in a hospital or ASC-setting. There have always been private-practice pediatric dentists on staff at all of the hospitals I've worked at - we did pediatric dental restorations fairly frequently. These guys also did plenty of office work, but they also knew when to punt.

Well I agree with you that's a great option. I guess in my limited experience those providers are almost non-existent. I've been on both sides as both the dentist and the anesthetist, and getting these patients to the hospital was just a tremendous amount of work and the financial costs were just boggling.

I'll stand by my own statement that this was an avoidable tragedy which appears to be the result of negligence, but it represents a much grander problem without a simple answer.

 

[deleted171991]

The cocktail listed is very standard across the country used by many training programs

Holy Crap! You guys are using a nineteenth-century FDA-unapproved drug (chloral hydrate) for deep sedation? How do you reverse it, if anything goes wrong? Same question for hydroxyzine.

 

[pgg]

Polypharmacy seems to be a universal feature of these dental clinic deaths. And chloral hydrate? WTF?


My son had root canals of his two front upper incisors when he was very young ... age 2. He fell and went face first into something unyielding and killed those two teeth. The dentist said that pulling them so young would cause problems with how the adult teeth came in. He got general anesthesia in a hospital by an anesthesiologist. Insurance wouldn't pay for it. We paid cash. $400 to the anesthesiologist, money well spent.

 

[ssmallz]

You are almost def. correct. These tragedies happen about once a year...and my guess is like the others this wasn't "too much" oral sed, but poor monitoring. The patient probably obstructed (since they were using a dental dam and open airway) and no one noticed until the patient was blue. In most states there is no legal requirement for pulse oximetry with oral sed.

It doesn't, however, make sense to take all of these to the hospital because thousands of patients get sedation in the dental office everyday...and I've never seen a hospital that does more than 5-10 a week.

Holy Crap.......This is incredible to me that your specialty can let something like this happen once/year and still not require basic monitoring for all sedation cases. I would never even give 2mg of versed for procedural anxiolysis w/out at least a pulse ox. IMO if you're not using at least a pulse ox for every sedation you are criminally negligent and should be thrown in jail. Healthy kids just shouldn't die b/c of oversedation.....I understand that kids won't sit still for root canals and painful procedures but if you can't get the procedure done with basic sedation you should abort the case, do it in the hospital or wait for an anesthesiologist to administer GA or deep sedation w/proper monitoring. Once a year is an unacceptable rate and I hope that every dentist who reads this thread understands the importance of proper monitoring. When you're doing a case you just can't be monitoring the anesthetic yourself, it's too difficult so having a pulse ox and capnograph to alert you to impending danger is critical. IMO if you're doing a lot of procedural sedation in your office, especially on kids you should have all the basic asa monitors along with capnography. Kids go down quick so it's important to catch obstruction early. Just no excuse for this type of tragedy except ignorance and laziness.

 

[nap$ter]

Holy Crap! You guys are using a nineteenth-century FDA-unapproved drug (chloral hydrate) for deep sedation? How do you reverse it, if anything goes wrong? Same question for hydroxyzine.

FDA approval is meaningless - the FDA does not dictate our standard of care. For example, Dexmedetomidine isn't FDA approved for anyone under 18 (But this didn't stop Hospira from applying for, and getting (from the FDA, no less) a 6 month extension on their patent for dexmed with a PEDIATRIC exclusivity). Propofol isn't approved for the induction of children under the age of 3. etc, etc...

 

[deleted171991]

Except that chloral hydrate is not approved for anything, after 150+ years. Why don't we just go back to ether?

 

[ssmallz]

I'll stand by my own statement that this was an avoidable tragedy which appears to be the result of negligence, but it represents a much grander problem without a simple answer.

Actually there is a simple answer, monitor your patients per ASA standards!!!!! You can download the standards pretty easily so there's no excuses on that one. Understand when you are in trouble and should abort a case. Know when you're out of comfort zone and call for help before you need to call a code. Have a proper crash cart stocked and know what to do when you get in trouble. Hint: calling the pediatrician next door is nowhere in the ACLS protocol. If you can't run a code by yourself you shouldn't be doing your own sedation.

I'm not trying to pick on you Sublimazing but it seems that every few months there's a discussion about why we need anesthesiologists or how we're being minimized and this a perfect example of why we are paid well to do what we do. It's not about knowing what to do, it's about being able to recognize when action needs to be taken and taking action in a timely manor. What we do isn't rocket science but when the poop hits the fan you need someone whose been there before and won't get flustered b/c (s)he's gone over that scenerio hundreds or thousands of times in their head and real life.

 

[IlDestriero]

One of the other problems is they call room air general with an unsecured airway "deep sedation". We have sedation nurses that do the same, but they work in the hospital with a trained pediatrician immediately available, and of course 50 pediatric anesthesiologists are about a hundred yards away.
I would have my kids done in a hospital or ASC. And some companies must pay because we do dental cases almost every day. As with PGG, I'd happily pay cash as needed, because we know better.

 

[Sublimazing]

Actually there is a simple answer, monitor your patients per ASA standards!!!!! You can download the standards pretty easily so there's no excuses on that one. Understand when you are in trouble and should abort a case. Know when you're out of comfort zone and call for help before you need to call a code. Have a proper crash cart stocked and know what to do when you get in trouble. Hint: calling the pediatrician next door is nowhere in the ACLS protocol. If you can't run a code by yourself you shouldn't be doing your own sedation.

I'm not trying to pick on you Sublimazing but it seems that every few months there's a discussion about why we need anesthesiologists or how we're being minimized and this a perfect example of why we are paid well to do what we do. It's not about knowing what to do, it's about being able to recognize when action needs to be taken and taking action in a timely manor. What we do isn't rocket science but when the poop hits the fan you need someone whose been there before and won't get flustered b/c (s)he's gone over that scenerio hundreds or thousands of times in their head and real life.

I agree with you. And a lot of it is indefensible. I've done 3 years (soon) of residency in a hospital since dental school doing mostly anesthesia with medicine and other hospital rotations thrown in...so I know how important and true everything you are saying actually is to this topic. I am also fully aware that I'm on the physician portion of this website and you will of course endorse the ASA guidelines and frown on almost anyone providing sedation other than yourselves (which I completely understand). But I can tell you that we have our own guidelines that include full monitors including precordial steths for open airway or etCO2 when tubed...but getting everyone to follow that protocol is harder.

And as my final post on this thread (starting to feel like a witch hunt ) deaths in the dental office are blown up by the media, and you can bet that whenever it happens it makes the news. But healthy people die in the hospital too. There are inept and lazy providers in all aspects of healthcare that don't follow protocol and cause errors with grave outcomes, I am just defending my own specialty as a whole that there are some areas that need some immediate attention to be sure, but don't condemn the whole lot of us based on the errors of individuals.

 

[Mman]

I am also fully aware that I'm on the physician portion of this website and you will of course endorse the ASA guidelines and frown on almost anyone providing sedation other than yourselves (which I completely understand).

I have no desire to be involved in every sedation. In fact, I'd like to have nothing to do with most of them.

 

[Gastrapathy]

So scary. I sedate tons of patients and get help with tons more. It's the riskiest part of my practice but I've had more problems with anesthesia than alone. I think there are two reasons, 1) anesthesia providers shoot for deeper sedation and 2) I give them the tougher patients and longer cases. I also get crnas more than physicians.

Did that article really say that sedation was given without the dentist in the room? That seems closer to murder than medicine. And what was the deal with that cocktail?


Sent from my iPhone using Tapatalk

 

[ssmallz]

I agree with you. And a lot of it is indefensible. I've done 3 years (soon) of residency in a hospital since dental school doing mostly anesthesia with medicine and other hospital rotations thrown in...so I know how important and true everything you are saying actually is to this topic. I am also fully aware that I'm on the physician portion of this website and you will of course endorse the ASA guidelines and frown on almost anyone providing sedation other than yourselves (which I completely understand). But I can tell you that we have our own guidelines that include full monitors including precordial steths for open airway or etCO2 when tubed...but getting everyone to follow that protocol is harder.

And as my final post on this thread (starting to feel like a witch hunt ) deaths in the dental office are blown up by the media, and you can bet that whenever it happens it makes the news. But healthy people die in the hospital too. There are inept and lazy providers in all aspects of healthcare that don't follow protocol and cause errors with grave outcomes, I am just defending my own specialty as a whole that there are some areas that need some immediate attention to be sure, but don't condemn the whole lot of us based on the errors of individuals.

Why is this so? What's so hard about following a protocol? NIBP, pulse ox, EKG, and respiration monitoring for all sedations, simple, easy and done. That's ASA standard, are the standards really much different for your societies? I have no desire to be doing all dental sedations b/c you shouldn't need a physican to give light sedation to your pts needing basic procedures but I cringe when I hear things like those bolded above. You guys are doctors of dental sciencies, leaders in your field and you should accept nothing less than standard of care for all memebers. Crap like what I bolded above is what I hear from nurses and techs w/out the knowledge to know better. You guys have that. Getting everyone to follow the standards should be easy and basic. Why is it hard to get everyone to follow the simple monitoring protocol? I just don't get it. We as anesthesiologists follow it on every sedation we do and it has nothing to do w/us going to medical school. The devices are easy to use and interpret by a tech let alone a dentist. I guess the point I'm trying to make is that while our expertise may not be necessary for dental sedations if dentists can't follow a simple monitoring protocol they shouldn't be sedating anyone period. No excuses, you're better then that

 

[ssmallz]

FWIW I'd feel the same way if it was an anesthesiologist who did this

 

[nap$ter]

Except that chloral hydrate is not approved for anything, after 150+ years. Why don't we just go back to ether?

what is this an exception to?

 

[Southpaw]

I'm an anesthesiologist, and if my child needs dental work an anesthesiologist will manage the sedation/anesthesia. It'll be money well spent. I've seen and read about too many disasters in perfectly healthy kids at the hands of the untrained.

I firmly believe that what happens more often than not in dental clinics across the country is room air general anesthesia. Is it even remotely feasible to have an anesthesiologist there for every case? No, but that doesn't change my belief. I guess I don't understand why the most trained person available (the anesthesiologist) uses all of the safest equipment available for monitoring, but some who are very poorly trained at airway management (pediatric dentists) use little to no monitoring and induce room air general on a daily basis. That seems very cavalier to me, and I'm only surprised these threads don't come up more often.

 

[deleted171991]

I am not surprised. The general population has been indoctrinated to believe that anesthesia is 100% safe, especially when "it's just sedation". Patients are more afraid they will wake up in the middle of the surgery, than not wake up in the end. This is why we get less and less respect, why some think we are not doctors etc.

I am glad that my institution's anesthesia consent has a long list of possible serious complications, including death. It definitely prompts some discussions that would never come up otherwise. I think these warnings should be compulsory by law for every form of anesthesia, similarly to tobacco products.

 

[Spinach Dip]

I had to undergo some dental surgery earlier this year in a clinical setting.

The anesthesia provider was a CRNA and the primary agents were versed and morphine.

What made me feel safe and secure was all the monitors. I got a pulse ox, a 3-lead EKG, a cannula at 3L O2/min, and a BP cuff on a 5-minute cycle. Right before the 'induction dose', the CRNA apologized for all the wires and monitors. I told her that I preferred it that way, just in case something went wrong. Then I asked her where the ambu bags were. She sort of nodded to the back wall with a laugh.... and I don't remember much of anything after that.


Anyway.... point is.... I would not go in for procedural sedation of ANY sort without proper monitoring. It would be like flying in a plane without an altitude gague. Sure, it's possible. But when the sh#t hits the fan, there's no rewind button.

 

[ProwlerturnGas]

I am an anesthesiologist and my current gig is doing in-office pediatric anesthesia for peds DDS. All general anesthesia with ASA monitoring, intubation, the whole works. Very safe and effective. The only way to go in my opinion. Kids stay safe and comfortable. Very nice work BTW

 

[For Dentistry]

Its crazy to think an assistant would be delegated the duties of administering meds to a peds patients. However, I have seen offices where SOCIALISM prevails and all employees are equal to the doctor. The dentist in this office thought that her unlicensed assistant should feel important and its something she learned from Hillary Clintons " It takes a village". But you and I know in the real world that the dentist is always held accountable and the assistants feelings don't matter or add up to a hill of beans. Dentists need to run their office with an iron fist and don't let uneducated management or assistants call the shots. Too
much is on the line not to put your foot down and create order.
TS