Six-year-old Caleb Sears:  His death was preventable

I’m not a pediatric anesthesiologist. Most of us in anesthesiology – even those who take care of children in the operating room or the ICU every day – probably will never give anesthesia to a child in a dentist’s or oral surgeon’s office. So why should we care what happens there? Dental anesthesia permits and regulations, after all, are under the authority of state dental boards, not medical boards.

The reason we should care is that healthy children have died under anesthesia in dental office settings, children like Marvelena Rady, age 3, and Caleb Sears, age 6. Unfortunately, they aren’t the first children to suffer serious complications or death in our state after dental procedures under sedation or general anesthesia, and unless California laws change, they won’t be the last.

In 2016, officers and past presidents of the California Society of Anesthesiologists (CSA) have made multiple trips to meetings of the Dental Board of California (DBC) to discuss pediatric anesthesia. We’ve provided detailed written recommendations about how California laws concerning pediatric dental anesthesia should be updated and revised. We’ve explained in testimony before the Dental Board, and in meetings with lawmakers, why we believe so strongly that the single “operator-anesthetist” model (currently practiced by dentists and oral surgeons in many states) cannot possibly be safe.

The DBC on December 30 published new recommendations for revision of California laws pertaining to pediatric dental anesthesia, posted them on its website, and sent them to the Senate Committee on Business, Professions, and Economic Development. But these recommendations ignored many of our concerns, and don’t go nearly far enough to protect children.

Further, the DBC cites statistics claiming that pediatric dental anesthesia is currently safe. But there is no database! The Dental Board has admitted to discarding records after review. They have reported on “only nine” recent cases involving death, ignoring other tragic cases of permanent brain damage and prolonged ICU admissions. Pediatricians in California recently surveyed 100 of their members and found that 29 of them — nearly one-third — knew of patients in their practices who had experienced adverse events in a dental office.

What is a single “operator-anesthetist”?

You may never have heard of a single “operator-anesthetist” because such a thing doesn’t exist in medical practice.

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4 COMMENTS

Alan Schneider M.D.

The real shocking statistic is that there are not more deaths if Dentists, along with their assistants, are allowed to provide sedation to children. Because one thing for sure it will not be moderate sedation in a child. I am amazed they are even able to get the IV started I trained decades ago as a pediatric anesthesiologist, although supervise mostly adults now, but even my adrenaline would be pumping if I provided sedation to a child in an office setting
Unnecessary dental sedation deaths persist. The practice of single-operator anaesthetist should have been stopped many many years ago. Thank you for an excellent article.

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“I’m your friend,” Harvard Business School Professor Michael Porter, MBA, PhD, told a sometimes skeptical audience during his keynote address at the ASA’s annual meeting, ANESTHESIOLOGY 2016. “I’m trying to help you see a better way forward, and avoid the bad outcomes that may happen if we don’t transform healthcare.”

Porter is a well-known economist, an expert on business strategy, and the author of the book Redefining Health Care: Creating Value-Based Competition on Results. In his speech to the ASA, he argued the case for redefining health care by making “value for the patient” the unifying purpose, and he urged anesthesiologists to forget pay for volume.

“How should anesthesiologists engage in bundled payments?” Porter asked. “Jump on them!”

Explaining that he has spent the past 15 years immersed in studying health care delivery, Porter said that he looks on health care as one of the world’s “most fundamental and intractable problems.” He asked listeners to think again about anesthesiology practice, and its role and responsibilities in the future of health care.

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1 COMMENT

Richard Ogden

I have spent the best part of 26-years working in the operating theatres in the UK, alongside some magnificent anaesthetists; and I must say this article is rather a sad one. The Anaesthetist, from a rather prejudiced point of view, is by far more important than the surgeon: if not because they facilitate safe operating conditions for the surgeon, then because they are the patients brain (Dr A Vohra Cons Anaesthetist) whilst under anaesthesia. Moreover, the Anaesthetist has the ability to provide considerable skill and ...Read More

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Classic rock music lovers who think they don’t like poetry, and literary purists who think they don’t like popular music, may have been equally baffled to hear that Bob Dylan is a winner of the Nobel Prize in Literature. As an unrepentant English major, I’m delighted.

I can’t remember a time when Dylan’s music wasn’t a part of my growing up, from the rebelliousness of the anti-Vietnam era to the bittersweet maturity of “Tangled Up in Blue“, my all-time favorite.

When you think about it, any time you listen to a song — a current popular hit, a 1950’s oldie, or a centuries-old ballad like “Greensleeves” —  you’re listening to poetry, only with a tune. In ancient times, before most could read or write, people turned stories into poetry and sang them because rhyme and melody made the stories easier to remember and retell. Much of rap music is poetry (often crude, but still poetry) with complex use of rhyme and assonance, and the musical element reduced to a backdrop of pounding rhythm.

Poetry set to music can convey any and all human emotion. Love, of course. Jealousy — absolutely. Just pick a musical genre, and there’s a hit song about jealousy. In pop music, Taylor Swift’s “Blank Space” lets her revel in her psycho side. In country music, Carrie Underwood graphically explains in “Before He Cheats” what can happen when a woman wants revenge on her faithless lover, and takes it out on his car. And the still-creepy “Every Breath You Take“, the 1983 classic rock hit by The Police, blurs the fine line between devotion and obsession.

Then there’s the universal human experience of grief. There was a time when every parent expected to lose a child, or more than one, because children often died from pestilence and poor sanitation. When my daughter Alexandra died unexpectedly at the age of five months, I couldn’t decide which was worse — thinking that I wouldn’t survive, or being horribly afraid that I would.

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4 COMMENTS

Beautiful. When we practice medicine and when we practice life with vulnerability we often find just what we're missing -- inevitable connection.

Rick Novak

Well said. Dylan wrote love songs, angry songs, sad songs, uplifting songs, protest songs, long fable songs, and mystifying songs, . . . like no one before him.

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You may have read about the recent tragic deaths of two healthy children – Marvelena Rady, age 3, and Caleb Sears, age 6 – in California dental offices. Unfortunately, they aren’t the first children to die during dental procedures, and unless things change, they probably won’t be the last.

State Senator Jerry Hill has asked the Dental Board of California (DBC) to review California’s present laws and regulations concerning pediatric dental anesthesia, and determine if they’re adequate to assure patient safety. Assemblymember Tony Thurmond has sponsored “Caleb’s Law”, seeking improved informed consent for parents.

On July 28, I had the opportunity to attend a stakeholder’s meeting at the Department of Consumer Affairs in Sacramento, to hear a presentation of the DBC’s report, and to be part of the delegation offering comments on behalf of the California Society of Anesthesiologists (CSA). We hope this is the beginning of some long overdue upgrades to the current regulations.

By long-standing California state law, dentists and oral surgeons are able to provide anesthesia services in their offices even for very young children or children with serious health issues. They may apply for one of four different types of permits for anesthesia:

General anesthesia

Adult oral conscious sedation

Pediatric oral conscious sedation

Parenteral conscious sedation.

But the route of administration – oral or intravenous – isn’t the point, especially for small children, and oral sedation isn’t necessarily safer. Sedation is a continuum, and there is no way of reliably predicting when a patient will fall asleep. Relaxation may turn into deep sedation, and deep sedation into a state of unresponsiveness which is equivalent to general anesthesia. Oral medications have led to deaths in children, sometimes even before the dental procedure has begun or well after it has finished. There’s no logic in California’s lower standards of emergency equipment and monitoring for procedures done under sedation as opposed to under general anesthesia.

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11 COMMENTS

karen

Dear Dr. Silegy, Apparently the province of Alberta, Canada, disagrees, after a four-year-old ended up with brain damage: http://globalnews.ca/news/3036086/alberta-dental-association-suspends-single-operator-model-for-deep-sedation-anesthesia/ The second anesthetist could be one of your partners, or a dentist with additional training in anesthesia as required by state law. Again, it's all about having a second trained independent anesthesia provider whose only job is to watch the child's airway, vital signs, and breathing. Just as I would want for my own child. Best, Karen Sibert, MD

Dr. Tim Silegy

Dear Karen: As I stated in my earlier comment, there are no facts to support your argument that two provider anesthesia is safer than single in these particular cases. Your allegation of oral surgery assistants administering anesthesia is unsubstantiated and NOT factual. I take exception to your comment that my defense of the single operator/anesthetist model is financially self serving. Itinerant medical and dental anesthesiologists have much more to gain from potential new regulations than I do.

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Is there a direct connection between communication skills and the art of successful leadership? Most of us would agree that there is. But is there a direct connection between blogging and leadership? That may be more of a reach.

Can the process of writing a blog help to develop communication skills that will prove useful in leadership? In my opinion the answer is yes, but a qualified yes. Writing a blog won’t help anyone become a good writer who never learned to write competently in the first place. Perhaps even more important, writing a blog won’t help anyone become a thought leader who hasn’t developed any original thoughts.

Communicating a vision

To make a real mark in history, a leader has to communicate a vision that people understand. The vision must be powerful enough to motivate them to follow. In decades past, for instance, the men who became President of the United States typically were graduates of liberal arts education, trained in the arts of debate, oratory, and essay composition. They knew how to make their points.

No matter which end of the political spectrum you favor, most of us would agree that Presidents John F. Kennedy and Ronald Reagan were gifted communicators. Though obviously they benefited from the help of speechwriters behind the scenes, both were skillful writers on their own, as proved by their private documents and letters.

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2 COMMENTS

Physician on FIRE

I found this article in the ASA Monitor, which led me here to visit your site and the sites of the other great bloggers you listed for us. Thank you for introducing me to a bevy of talented anesthesiologist writers. I'll be busy reading for some time. Cheers! -Physician on FIRE
Thanks for the shout out!. Haven't written for awhile - you've inspired me to get something out there.

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