Dr. Smith had no idea when the case began, that when it was over, his career would be in ruins, and he would be the subject of a criminal investigation by the local law enforcement.
By every measure, Dr. Smith (name changed to protect his privacy) had crafted a successful career in dentistry. He was respected by his peers and patients and reached a level of financial success. Practicing in a large metropolitan area, Dr. Smith generated enough revenue from Medicaid alone to be ranked in the top 25 dentists in his state. Nevertheless, his professional and financial success couldn’t prevent an abrupt end to his practice.
The day his career ended, Dr. Smith started what he thought would be a routine procedure to prepare four teeth for crowns. His patient, a four-year-old named Stuart (name changed for privacy reasons), was understandably nervous about being in the dentist’s chair. To calm Stuart’s anxiety, Dr. Smith decided to use medications – a mixture of the narcotic painkiller Demerol and two anti-anxiety drugs.
What Dr. Smith didn’t know, or didn’t remember, was a warning published in the prominent journal Pediatrics “...that ‘conscious sedation’ is an oxymoron for many children under six.” The report went on to say that deep sedation “is usually required to gain the cooperation of this age group.” Dr. Smith resorted to what experts say many dentists do with younger children - pushing the bounds of conscious sedation to make children sleepier without making them unconscious.
Experts agree that this approach usually works until you get a patient who doesn’t respond to the medications as normally expected. Unfortunately, Dr. Smith’s patient didn’t respond normally, and he and his staff were not prepared for the emergency that resulted.
During the procedure, Stuart’s heart began to beat twice as fast as normal. Mucus had to be suctioned from the back of his throat. His lips turned blue due to a lack of oxygen. Eventually, Dr. Smith and his staff were unable to detect a pulse. They called 911 and EMTs arrived to transport Stuart to the hospital. After a heart-wrenching four-day stay in the ICU, Stuart died.
As a result of this case, state health officials put Dr. Smith on five years of probation and assessed a financial penalty. More importantly, the state board removed Dr. Smith from the Medicaid program, obliterating his revenue stream. Local law enforcement began a criminal investigation. He closed his formerly successful practice. Worst of all, Dr. Smith will carry to his grave the crushing memory of Stuart’s death, and the anguish of Stuart’s parents.
What can be learned from Dr. Smith’s experience?
Experts reviewing this case highlight three issues with the procedure that ended his practice: inadequate knowledge of the effect of sedation/anesthesia medications on pediatric patients, the inability to recognize and respond to trouble if a patient reacts abnormally, and failure to get inspected by an outside entity to ensure the office is ready to handle emergencies.
In fact, experts say that sedation’s biggest safety issue isn’t the administration of the medications themselves; it is the failure to recognize trouble immediately — and to respond perfectly under pressure to prevent a patient’s death in the dental chair.
Unfortunately, Dr. Smith’s case is not an isolated incident. In California, 55 dental patients died in a recent four-year period. In New York State, over a nine-year period, insurers reported making payments for dead patients on behalf of 31 dentists.
Since 2010, Texas has received 85 death reports. Projected out to the whole U.S. population, that’s a little over 1,000 deaths.
A dental patient dies approximately every other day in America, according to an estimate by The Dallas Morning News.
In recent years state regulators took public action against dentists in connection with at least 57 patient deaths. Most of the cases, about three-fourths, were related to sedation and/or anesthesia issues.
Clearly, career-ending patient deaths, particularly those due to problems with sedation/anesthesia, are a growing trend. The American Society of Anesthesiology (ASA) has taken notice of this deadly drift and recently said this about Dental Office Based Anesthesia, “…these events have continued to occur with unacceptable frequency. No patient should be unduly endangered by lack of training and education, inadequate facilities, poor patient selection or lack of safety, resuscitative or related emergency protocols."
State statutes and regulations that govern dentistry, dental practice, and dental office credentialing, licensing, and permitting are changing in light of increasing patient deaths.
State dental boards and regulators are considering, and sometimes imposing, new requirements, including medical emergency drills and office inspections from outside entities. These requirements are setting a new standard of care for dentists, especially those providing sedation and/or anesthesia services.
This emerging standard of care for dentists has three components:
1) possessing the proper medical knowledge about the administration of sedation and/or anesthesia medications,
2) routinely practicing emergency drills to ensure readiness for a patient’s abnormal reactions to medications, and...
3) getting an inspection from an outside entity that certifies an office and staff are ready for medical emergencies.
Failing to meet these three criteria will likely become a failure to meet the standard of care.
Should you encounter a case like that Dr. Smith experienced, failing to meet the standard of care will be indefensible in the eyes of the state dental board, malpractice carrier, state and federal regulators, attorneys, judges, and juries.
To ascertain that you provided the standard of care in a case like Dr. Smith’s, the malpractice attorney retained by your patient’s family will, in deposition, ask you questions like these:
What is your training in medical or sedation emergency preparedness?
What is your staff training in medical or sedation emergency preparedness?
Do you have BLS? ACLS? PALS training? What about the staff?
Have you attended a medical/sedation emergency course? If so, when?
Do you have all of the necessary emergency medications? Are they "in date?"
What kind of training do you and your staff have with the AED?
Can you produce copies of the documentation that you use during a medical emergency?
Can you produce your training log outlining medical mock emergency practice drills?
How often do you perform emergency practice drills?
Who inspected your office to ensure medical emergency preparedness was in place?
Can you produce their readiness report for your office and staff?
If your answers to these questions leave you wondering if you are, indeed, ready to meet the standard of care for medical emergency preparedness, and assuming that you have sound medical knowledge and clinical expertise, the two most important steps you can take now are:
1) start practicing medical emergencies by conducting mock emergency drills, and...
2) undergo a medical emergency readiness inspection.
Mock Emergency Drills
U.S. Navy SEALS are guided by the principle that “under the pressure of an emergency, you don't rise to the occasion, you sink to the level of your training.” This principle is also true in dental care. Your performance in a medical emergency, especially in a sedation/anesthesia-related emergency, will never be any better than what you have displayed during your mock emergency drills.
If you and your office staff haven’t ever practiced any mock drills, you really have no idea how you will perform when your patient’s life is in the balance. To prevent a career-ending disaster and provide the standard of care expected by your patients and regulators, dentists should be proficient and competent in responding to these emergencies:
Diabetes (Insulin Shock)
Sudden Cardiac Arrest (SCA)
Cerebrovascular Accident (Stroke)
Foreign Body Obstruction (FBO) with airway management
Local Anesthetic Toxicity
Dentists providing any form of sedation should be competent with all of the above emergencies PLUS the following:
To develop competence in managing a medical emergency, you and your dental team must practice mock emergency drills. If you've never done this, or don't practice them often, you can get a sample MOCK MEDICAL EMERGENCY DRILLS GUIDE here.
Medical Emergency Readiness Inspections
Once a schedule of mock drills is in place and being conducted, dental practices should undergo a Medical Emergency Readiness Inspection performed by an outside entity.
If this is not possible, start with a self-audit. You can download an excellent EMERGENCY READINESS SELF-AUDIT here.
A thorough inspection by an outside entity, conducted by experts who have collated all of the nationally accepted standards for credentialing, licensing, and permitting as well as the criteria for training, education, facility standards, patient selection principles, safety, resuscitative and emergency protocols makes a dental practice more defensible during legal proceedings should the unthinkable happen.
If anesthesia or sedation is being performed in your office, an effective inspection should also be specific to the type of sedation used. Your inspection should be specialized for:
Local Anesthesia and/or Nitrous Oxide
Deep Sedation/General Anesthesia
Effective inspections also audit the following areas:
Personnel qualifications and training
Suitability of the Office Facility for sedation/anesthesia
Presence, training, and use of “in-date” Emergency Medications
Presence and use of written emergency protocols
Presence, training, and use of Emergency Equipment such as basic ventilation equipment and capnography
Proper training through the use of Simulated Emergencies with mock emergency drills
Each item of emergency equipment to verify that it is in good working condition and fully operational
The medical emergency training logbook that documents the completion of monthly mock emergency drills
Participation by all office staff in a medical or sedation emergency training lecture once per year
You have invested years of your life to acquire the knowledge, skills, and licensing to create a successful practice. Just as happened to Dr. Smith, your life’s work can be ruined in an instant by poor performance during a medical emergency – especially one related to sedation/anesthesia issues.
Everyone thinks, “It can’t happen to me.” The sad truth for dentists and their patients is that “it” is happening more and more.
If, and when, “it” happens to you, you will NOT get a second chance to save your patient’s life! No patient should die because you and your staff weren’t ready. Every dentist must decide now to take the necessary actions to be ready for the inevitable moment of truth. Your decision to act now to be prepared, or not, could be the defining decision in your career.
Will you be ready?