Dr. Smith (name changed for privacy) had no idea when the case began that by the time it was over his career would be in ruins and he would be the subject of a criminal investigation by local law enforcement.
By every measure, Dr. Smith had crafted a successful career in dentistry. He was respected by his peers and patients and had reached a level of financial success. 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 could not prevent the 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), was understandably nervous about being in the dentist’s chair. To calm Stuart’s anxiety, Dr. Smith decided to administer anesthesia—a cocktail of the narcotic painkiller Demerol and two antianxiety drugs.
What Dr. Smith didn’t know or didn’t remember was a warning published in the journal Pediatrics. It stated that “‘conscious sedation’ is an oxymoron for many children under six.”1 The report went on to say that “deep sedation is usually required to gain the cooperation of this age group.”1 Dr. Smith resorted to what causes concern among many regarding the actions of dentists with young children. He pushed the bounds of conscious sedation to make his young patients sleepy without making them unconscious.
This approach usually works until the dentist has a patient who doesn’t respond to the medications as normally expected. Unfortunately, Dr. Smith’s patient , Stuart, did not respond normally, and he and his staff were not prepared for the resulting emergency.
During the procedure, the child’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 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 a five-year 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 successful practice, and—worst of all—Dr. Smith will carry to his grave the crushing memory of Stuart’s death and the anguish he caused the child’s parents.
What can we learn from Dr. Smith’s experience?
Experts reviewing this case highlight three issues with the procedure: (1) inadequate knowledge of the effect of sedation/anesthesia medications on pediatric patients; (2) the inability to recognize and respond to trouble if a patient reacts abnormally; and (3) failure to have an inspection by an outside entity to ensure that the office is ready to handle emergencies.
In fact, experts say that sedation’s biggest safety issue is not the administration of the medications themselves, but the failure to recognize trouble immediately and 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 during a recent four-year period. In New York State, during a nine-year period, insurers reported making payments for dead patients on behalf of 31 dentists. Since 2010, Texas has received 85 reports of death. Nationwide, that’s a few more than 1,000 deaths. A dental patient dies approximately every other day in America, according to an estimate by The Dallas Morning News.2
Clearly, career-ending patient deaths due to problems with sedation/anesthesia is a growing trend. The American Society of Anesthesiology (ASA) has taken notice of this deadly trend. They 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, or resuscitative or related emergency protocols.”
State statutes and regulations that govern dentists, dental practices, and dental office credentialing, licensing, and permitting are changing in light of increasing sedation-related 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 who provide sedation/anesthesia services.
This emerging standard of care for dentists who provide sedation/anesthesia services has three components: (1) possessing the proper medical knowledge about the administration of sedation/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 certifying that an office and staff are ready for medical emergencies.
Failing to meet these criteria will become a failure to meet the standard of care. Should you encounter a case like Dr. Smith’s, 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 such as the following:
- 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 your 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 or sedation emergency?
- Can you produce your training log outlining medical/sedation mock emergency practice drills?
- How often do you perform emergency practice drills?
- Who inspected your office to ensure that medical/sedation emergency preparedness was in place?
- Can you produce their readiness report for your office and staff?
If your answers to these questions have you wondering whether you’re ready to meet the standard of care, and you assume that you have the necessary medical knowledge about sedation/anesthesia, take these two important steps: (1) start practicing medical emergencies related to sedation/anesthesia by conducting mock emergency drills, and (2) undergo a sedation/anesthesia medical emergency readiness inspection.
Dentists have invested years of their lives to acquire the knowledge, skill, and licensing to build a successful practice. Just as happened to Dr. Smith, their life’s work can be ruined in an instant due to poor performance during a medical emergency, especially one related to sedation/anesthesia. While many people believe it can’t happen to them, the sad truth for dentists and their patients is that “it” is happening more frequently.
If and when “it” happens to you, you will not get a second chance to save your patient’s life. No patient deserves to die because you and your staff were not ready for an emergency. Every dentist must 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.
A leading consultant with Dental Compliance Specialists LLC, Duane TinkeR, CHC, CPCO, helps dentists establish and maintain their compliance programs. He has audited hundreds of dental offices and thousands of dental records. He applies his knowledge and experience to helping make dental offices safer for dentists, patients, and staff. Visit dentalcompliance.com, call (817) 755-0035, or email t[email protected].
Rob McCrary, MBA, is the president of the Accreditation Association for Dental Offices. He has spent 25 years in various aspects of the health-care industry, including in private clinics and hospital systems. He has a Bachelor of Science degree in banking and finance from the University of Southern Mississippi and an MBA from the Crummer School of Business at Rollins College. Visit aafdo.com, call (855) 902-2336, or email [email protected].
References
1. Cote CJ. “Conscious sedation”: Time for this oxymoron to go away! J Pediatr. 2001;39(1):15-17.
2. Egerton B. Elusive numbers, Part 2 of 7. Dallas Morning News website. Published December 9, 2015. http://interactives.dallasnews.com/2015/deadly-dentistry/part2.html.
