Trip to dentist turns tragic for Windward Oahu girl

[vinny808]

I was just wondering what will happen to this dentist if the board finds her negligent? If she loses her ability to practice, will she be covered by her malpractice insurance? If so, to what extent? Also, if she does lose her license, in what ways can she use her DDS degree and stay in the dental field somewhat, because i'd imagine she would be paid the most by staying in the dental field somehow. News story below:

KAILUA, OAHU (HawaiiNewsNow) -
A three-year-old girl is in critical condition following a procedure at a local dentist in Kailua, Oahu.

Three year old Finley Boyle is at Kapiolani Medical Center. It's unknown if she had any pre-existing medical conditions but we do know a lot of lives have been changed forever.

Photos show three year old Finley Boyle's bright smile. Family friends say on December 3 she was brought in for a dental procedure at Island Dentistry in the Kailua Professional Center when something went horribly wrong.

The friends say Finley was given too much anesthesia and sedatives. She then went into cardiac arrest and now has severe brain damage and will never be the same.

Friends say the dentist is Dr. Lilly Geyer. Her office, called Island Dentistry for Children, has a sign up saying it is currently closed. Not even the delivery man was let in. There were people in the office but they weren't talking.

"We have no comment," said an unidentified man inside the office.

The Island Dentistry website has also been taken down, but a screen grab from the archived website says the practice opened in 2006 and has 2,000 patients.

The "about us" section of the site also says Dr. Geyer "is certified in Basic Life Support, Advanced Cardiac Life Support, as well as Pediatric Advanced Life Support." However friends say when Finley began having complications the staff ran to the pediatrician's office down the hall and that doctor came to help with CPR.

Checks with the State show Dr. Geyer hasn't had any complaints filed against her, however there are mixed reviews of her performance online.

Finley's family has hired an attorney and may talk about the case soon.

We're also told Finley and her mom moved to Hawaii about three years ago. Her family from the mainland has been meeting here at the hospital for support.

http://www.hawaiinewsnow.com/story/...g-procedure-by-kailua-dentist?app&hpt=us_bn10

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[txaggie03]

It is all speculation at this point. The child could have been dosed correctly and had a bad reaction.

Given the limited info in the article, brain damage to me suggests respiratory distress, not cardiac arrest (adults = cardiac, children = respiratory).

Too many variables to really guess what happened (was it the right dose, was a history taken, was consent given, was there supplemental O2 there, was a reversal agent given, was the airway improperly secured, was …..).

Another fine example of why documentation is so incredibly important.

 

[vinny808]

It is all speculation at this point. The child could have been dosed correctly and had a bad reaction.

Given the limited info in the article, brain damage to me suggests respiratory distress, not cardiac arrest (adults = cardiac, children = respiratory).

Too many variables to really guess what happened (was it the right dose, was a history taken, was consent given, was there supplemental O2 there, was a reversal agent given, was the airway improperly secured, was …..).

Another fine example of why documentation is so incredibly important.

It was caused by cardiac arrest according to this article.

http://www.hawaiinewsnow.com/story/24210356/parents-plan-to-file-suit-after-toddler-l
KAILUA, OAHU (HawaiiNewsNow) -
The parents of Finley Boyle say their only child will never be the same -- and plan to file suit against the dentist they say is responsible.

The three-year-old girl brought joy to her parents, Evan and Ashley Boyle of Kailua.

"If I was every upset, she was the best," Ashley Boyle said. "She would just come to me and rub my arm and say, 'Mommy, I'm here. Don't cry, it's okay, I'm here.'"

Ashley Boyle brought Finley to Island Dentistry on December 3 for a pediatric root canal from Dr. Lilly Geyer. Boyle said the little girl was given sedatives before the procedure, and then was taken to the dental chair.

Boyle, who works as a nurse at Castle Medical Center, said no one offered to allow her inside the room where the procedure was taking place. She said she was even told that she could leave and get some coffee if she wanted.

"I work on people every day, no one questions my judgment on things, so as a mom, sometimes you just want to step back and be a mom, and not question everything," said Boyle.

Boyle was in the waiting room and was unable to see everything that was going on. She said she only knew something terrible had happened when she could see emergency medical technicians arriving through a back door.

"I saw the EMT's come up through the other glass door and go back there, so I took it upon myself to just go open the door and go back there," said Boyle. "I mean, how do you not tell me we called 911 on your daughter?"

Her lawyer said the girl was given too many sedatives and anesthesia, and she went into cardiac arrest.

"We're just shocked that these drugs, in these doses, in this combination, could be given to a child of this size," said attorney Richard Fried.

Her parents said Finley's brain was damaged when it was deprived of oxygen during cardiac arrest.

"The MRI was more consistent with a lack of oxygen for five or more minutes," said Finley's dad, Evan Boyle.

There was no comment from Island Dentistry, which remained closed Thursday.

Her parents are holding out hope, but admit that the prognosis is not good.

"Probably never going to walk again, or possible be able to feed herself again," said Ashley Boyle. "She's not even responding to commands."

Ashley Boyle cried as she recalled memories of her only child.



"Just sociable, really loved people. Just a really good kid."

 

[txaggie03]

I realize what the article says. It is also words coming from a lawyer.
All I am saying is that we are taught that with kids, your sedations are more likely to get into a hypoxic state from respiratory distress than from cardiac arrest. This is due to the fact that children's metabolism already puts them at a 2 fold increase of anaerobic requirement. Couple that with the fact that children's larynx is more cephalic and anterior and that children have much smaller functional residual capacity, and you have a kiddo needing 3-4 times the O2 requirement of an adult and one who is more prone to airway obstruction.
You'll get yourself in trouble with a kiddo much faster. Which is why I made the comment above about having supplemental O2 handy.

But again, this is all speculation. The dentist could have done everything right, or everything wrong. Sometimes things just happen.

 

[Sublimazing]

When a child has respiratory arrest for even a short time they brady down and go into cardiac arrest...way faster than adults...seen it a few times myself in the last year

This child either went apneic (no drive to breath) which lead to cardiac arrest, or they had an obstructed airway which lead to respiratory compromise and then cardiac arrest.

Everything else you said was right though.

 

[Contach]

I'm confused. The child didn't die though, the child was unable to supply oxygen for 5 minutes. It could simply be hypoxic respiratory failure due to narcotic overdose. What makes us think anything happened to her heart?

This was a general dentist doing oral sedation on kids, right? The general thought among pediatric dentists I know seems to be that oral sedation with versed alone barely sedates the kid. Maybe this led to the dentist trying a stronger concoction including narcotics, but with a stronger concoction comes the risk of something like this happening.

 

[txaggie03]

When a child has respiratory arrest for even a short time they brady down and go into cardiac arrest...way faster than adults...seen it a few times myself in the last year

This child either went apneic (no drive to breath) which lead to cardiac arrest, or they had an obstructed airway which lead to respiratory compromise and then cardiac arrest.

Everything else you said was right though.

Thanks. We were also taught that at the first sign of brady to push supplemental O2. Is that usually all that is needed to pull those kids back?

 

[Sublimazing]

Thanks. We were also taught that at the first sign of brady to push supplemental O2. Is that usually all that is needed to pull those kids back?

To ventilate them yes and hopefully you've already increased the Fio2, and they usually recover very quickly.

 

[Maka]

I'm guessing she was using oral sedation and thus did not have a pulse ox on, much less capnography? I personally hate oral sedation because you cannot REALLY titrate your meds (despite what people may try to tell you). Very sad story.

 

[IHO]

probably apnea/hypoxia--->bradycardia---->cardiorespiratory collapse. Circulation/oxygenation was restored after the cortex was burned (5-6 minutes) but before the brain stem died (7-10minutes). Therefore she was left with a brain capable of supporting life but devoid of anything that makes us human. Horrible tragedy for dentist, little girl and her fam. No one will win but the lawyers. Was the dentist negligent? who knows, but was a PALS code run to the standard of care of the local PICU or peds ER? I bet not. That is the standard to which the dentist will be held. It should give great pause to those providing sedation in the office. Kids freak me out a bit. Personally I would not consider sedating someone under the age of 5ish in the office. I would book a date in the OR...if the parents balked at that, I would invite them to seek care somewhere else.

to answer the OP's ? to my understanding, her malpractice insurance will cover her even if she is negligent; kinda like your auto insurance will still cover your accident even if you were speeding/drunk and texting. She may not be able to get coverage after this, though. They will cover her to the extent of her policy...It varies, but usually a mil of coverage is typical for a doc providing IV anesthesia. A mil sounds like a lot, but the jury may award LOTS more for a tragedy like this...hell, you can get a mil for spilling coffee on yourself.

If she loses her license, maybe working at a dental school in a non-clinical role, maybe research...who knows.

 

[yappy]

*Read the comments on the original article - WOW - the angry masses are clamoring; "there will be blood". Even the Weston A. Price trolls are getting in their anti-dentist talking points lol.

i.e

Greedy Pig!! The dentist should be lynched

It will be interesting to see if this was a bad outcome or malpractice. It looks like the public-court has already ruled; but, if it turns out to be the former then the dentist can practice in other locals that have not inappropriately demonized her. If it is the latter than it seems like justification for disciplinary action.

Horrible situation.

 

[steiner2]

I guess the girl would have better luck if she was from the leeward side? Ridiculous article of course. Right now the national news headline is on the girl who is brain dead after having her tonsils removed. Gasp, they said. Complications can arrive when one sneezes and not just having a huge brain aneuyrism or massive heart attack. Thats what insurance is for. Sometimes, crap just happens. But thanks to the lawyer for the LA girl, he tried to win in the court of public opinion while the hospital kept their mouths shut due to patient privacy laws, etc. So now the brain dead child is on life support for no reason; and no one speaks about who is paying for the costs. The parents insist she will miraculously wake up one day despite the brain being dead.

 

[Health guy]

Why was a 3-year-old getting 4 root canals and 6 fillings anyway?
"Fried said that the child was diagnosed by the dentist and scheduled for procedures on 10 teeth, including root canals on four teeth and fillings in the others."
What kind of primary teeth have that kind of damage?

 

[EtchNRinse]

Why was a 3-year-old getting 4 root canals and 6 fillings anyway?
"Fried said that the child was diagnosed by the dentist and scheduled for procedures on 10 teeth, including root canals on four teeth and fillings in the others."
What kind of primary teeth have that kind of damage?

I dont know the specific details of this case, but these types of ECC cases are quite common (multiple carious infections involving almost every tooth). Its unfortunate but very much a reality.

 

[jeffity]

I dont know the specific details of this case, but these types of ECC cases are quite common (multiple carious infections involving almost every tooth). Its unfortunate but very much a reality.

Yeah, they mention over-treating, which might have occurred, but regardless, this Tx plan is hardly far-fetched. Their free use of 'root canal' appeals to adults...sort of fanning the flame.

 

[Jord]

Why was a 3-year-old getting 4 root canals and 6 fillings anyway?
"Fried said that the child was diagnosed by the dentist and scheduled for procedures on 10 teeth, including root canals on four teeth and fillings in the others."
What kind of primary teeth have that kind of damage?

Its very common for children to have this decay. We usually refer to baby root canals as puplectomies, and pulpotomies.

 

[Xigris14]

probably apnea/hypoxia--->bradycardia---->cardiorespiratory collapse. Circulation/oxygenation was restored after the cortex was burned (5-6 minutes) but before the brain stem died (7-10minutes). Therefore she was left with a brain capable of supporting life but devoid of anything that makes us human. Horrible tragedy for dentist, little girl and her fam. No one will win but the lawyers. Was the dentist negligent? who knows, but was a PALS code run to the standard of care of the local PICU or peds ER? I bet not. That is the standard to which the dentist will be held. It should give great pause to those providing sedation in the office. Kids freak me out a bit. Personally I would not consider sedating someone under the age of 5ish in the office. I would book a date in the OR...if the parents balked at that, I would invite them to seek care somewhere else.

to answer the OP's ? to my understanding, her malpractice insurance will cover her even if she is negligent; kinda like your auto insurance will still cover your accident even if you were speeding/drunk and texting. She may not be able to get coverage after this, though. They will cover her to the extent of her policy...It varies, but usually a mil of coverage is typical for a doc providing IV anesthesia. A mil sounds like a lot, but the jury may award LOTS more for a tragedy like this...hell, you can get a mil for spilling coffee on yourself.

If she loses her license, maybe working at a dental school in a non-clinical role, maybe research...who knows.

Completely agree. I am a oral surgeon and I sedate all the time. Kids is where I draw the line. Its not worth my career to sedate some 4 year old to take out a couple of bad teeth. First you hope you can get them down on nitrous if not you may elect for po meds which I HATE. Or ketamine dart. Or mask sevo down if you have this.

Ok now you get to start the IV on this little guy which at times is just a butterfly or 24g. Then comes the IV meds. Still have not done the procedure.
Ok local and then finally, finally take out some roten teeth for pennies on the dollar.

Great now lets recover and hope all went well. Nervous parents probably already asking front desk girl ten times whats going on, can I come back???Why not??? Pacing in the waiting room…


No Thank You. For those macho men or women that like doing that please forward me you contact name so I can refer all these little kids to you for sedation. I take mine to an outpatient facility and I don't sweat a thing. If parents refuse, then the exit door is marked in my office.

 

[Sublimazing]

Completely agree. I am a oral surgeon and I sedate all the time. Kids is where I draw the line. Its not worth my career to sedate some 4 year old to take out a couple of bad teeth. First you hope you can get them down on nitrous if not you may elect for po meds which I HATE. Or ketamine dart. Or mask sevo down if you have this.

Ok now you get to start the IV on this little guy which at times is just a butterfly or 24g. Then comes the IV meds. Still have not done the procedure.
Ok local and then finally, finally take out some roten teeth for pennies on the dollar.

Great now lets recover and hope all went well. Nervous parents probably already asking front desk girl ten times whats going on, can I come back???Why not??? Pacing in the waiting room…


No Thank You. For those macho men or women that like doing that please forward me you contact name so I can refer all these little kids to you for sedation. I take mine to an outpatient facility and I don't sweat a thing. If parents refuse, then the exit door is marked in my office.

Dental Anesthesiologists do these cases everyday. On a normal day in residency we see 5-7 cases...most of them 2-4 year olds. After 2-3 years of this training we're certified in GA...why anyone without that training or more would attempt pediatric anesthesia is incomprehensible to me.

I second what you've said xigris, the best training in any subfield is knowing when you're out of your comfort zone.

 

[Xigris14]

Dental Anesthesiologists do these cases everyday. On a normal day in residency we see 5-7 cases...most of them 2-4 year olds. After 2-3 years of this training we're certified in GA...why anyone without that training or more would attempt pediatric anesthesia is incomprehensible to me.

I second what you've said xigris, the best training in any subfield is knowing when you're out of your comfort zone.

Exactly. There are those that sedate kids all the time and are good at it. Its a skill. Taking a weekend course or a week long course does not give you that skill. These dentist listen to these idiots that are just trying to make money, talk about how much money dentist are missing out with sedation. "Your patient wants it so provide it for them" "Its not that hard, just give this amount of po meds and if after a certain period of time give some more" Sedation is not a cook book. These courses are terrible and I wish they would be banned. Sure for most its fine and most patients some versed and fent will be fine. But, but with kids its different. And with everyone else including kids when s-it hits the fan can you recognize and correct the issue? Most freak out and panic. Why because they are not properly trained to handle emergencies.

may I ask some graduates of these weekend or week long programs. Did the weekend course allow you to manage emergencies??? no. You read it in a book or were told by someone else what to do. Totally different then real life. And thats the problem and why we see some of this fatalaties from sedation.

 

[Daymon Capers]

What a great discussion at here. Very nice. Thanks for this information.

 

[T00TH D0C]

This was a terrible tragedy. However, simultaneously this could of very easily been avoided and ironically very difficult to avoid.
First of all, I agree, the reason to do this in a hospital setting is in case of things not going correctly. Patients die under general anesthesia from a slew of different reasons. Even if everything was performed perfectly, this tragedy could have happened to anyone. That is why in the hospital setting, faster emergent life saving capabilities may have saved her life.
On the other side, this specific dentist was grossly negligent. She delivered overdose levels of medication, did not properly monitor the patient, and did not properly respond to the emergent situation. Shame on her and may the little girl rest in peace.
Experience and proper education are the most important in general anesthesia and sedation. I have seen negligent behavior from OMFS's and seen top notch provision of care by general dentists. So let not the OFMS snub their noses at perceived lesser qualified practitioners. Both can be excellent and both can be terrible.
Just last month the State of North Carolina has its first dental patient fatality in 30 years. It was the same situation; patient under sedation stopped breathing because of overdose levels of drug, the Dr failed to properly monitor and respond. The patient died.
Remember my fellow colleagues, " Do no harm first".

-t00th d0c

 

[Xigris14]

This was a terrible tragedy. However, simultaneously this could of very easily been avoided and ironically very difficult to avoid.
First of all, I agree, the reason to do this in a hospital setting is in case of things not going correctly. Patients die under general anesthesia from a slew of different reasons. Even if everything was performed perfectly, this tragedy could have happened to anyone. That is why in the hospital setting, faster emergent life saving capabilities may have saved her life.
On the other side, this specific dentist was grossly negligent. She delivered overdose levels of medication, did not properly monitor the patient, and did not properly respond to the emergent situation. Shame on her and may the little girl rest in peace.
Experience and proper education are the most important in general anesthesia and sedation. I have seen negligent behavior from OMFS's and seen top notch provision of care by general dentists. So let not the OFMS snub their noses at perceived lesser qualified practitioners. Both can be excellent and both can be terrible.
Just last month the State of North Carolina has its first dental patient fatality in 30 years. It was the same situation; patient under sedation stopped breathing because of overdose levels of drug, the Dr failed to properly monitor and respond. The patient died.
Remember my fellow colleagues, " Do no harm first".

-t00th d0c

Hey Tooth Doc. Read my post above. I stated clearly that i am not personally atacking GP or snubbing my nose at them. You have to admit that these week long courses for GP to sedate patents is a joke. I would never allow my loved one be sedated by a GP that completed one of these courses. Sure there are GP that are very proficient at sedation and thus are very skilled at sedation but these are usually GP that did more then a week long course and take it seriously. Meaning they sedate all the time and took appropriate courses with live hands on sedations or did a dental anesthesia program. Not a week long course. So yes I snub my nose at those docs that sedate but not the others. OMFS are not perfect and by no means do I think that.

But these courses promote dentist to sedate and unfortunately some of them should not be doing it and don't understand the true danger that it can pose to a patient. But as you state that you have seen negligent behavior from OMFS, I would challenge you that OMFS are one thousand times more qualified to sedate patients then a GP. But no one is perfect and accidents happen to the best of us.

This response I am writing is just to put the word out that our ability to sedate will be gone in the near future. It will happen to GP first followed by OMFS. Mark my word. These cases don't help our cause and our ability to provide sedation to patients.

 

[Grammie]

Just wanting to put this out there...I'm Not a Doctor or Dentist (my husband owns his own Dental Lab) but back in July of 2013 our son had his wisdom teeth extracted at the age of 16 and 2 months later went into a psychosis and after 9 months of MRI's MRA's and bloodwork we found out that he was born with a gene that when the versed was used it threw him into a chemical imbalance he also had the hormonem thing going on at the same time so it was a combination of the three.
I think that if the dentist are pushing for wisdom teeth to be extracted before the age of 18 they need to come up with a different anesthesia I have reviewed a lot about the versed and have not seen nothing good about it at all. The brain is such a fragile thing. I also believe that if anyone is going to be put under they should do it at the hospital!! I do know that a lot of Oral Surgeons that my husband works for has stopped using versed for numerous reasons.

 

[KidsDDS]

This is a very tragic death. I won't comment on hearsay from a lawyer. Rather, as a dentist who has treated children for three decades, I suggest to future pediatric dentists the following:
1) Chloral hydrate has no reversal agent. It is not approved for use in the United States. If something goes wrong, it would be hard to defend the use of chloral hydrate. Besides, do you really want to give a child something that basically metabolizes to alcohol (trichloral-ethanol if memory serves me correctly). Perhaps a shot of whiskey and stick to bite on would be just as effective? [sic]
2) Consider benzodiazepines as the drugs of choice. Midazolam p.o. (0.5mg/kg). It has a wide range of safety (effective/LD50). It is reversible. It has amnestic effects. If you need a little longer effect, consider adding 2 mg diazepam to the p.o. cocktail mix. It is also reversible with flumazenil.
3) My opinion, for what it's worth: I know p.o. meperidine (Demerol) is commonly used. Hydroxyzine (Vistaril or Atarax) is usually given as an anti-emetic along with the meperidine. The reason it is commonly used is because the offices are busy and some dentists like to have the prolonged effect, in the event they are running over. I don't like it because it takes too long to take effect, and my patients are monitored from start to finish.
4) It is critical to see and evaluate your patient before administering drugs. Check the patients vitals. Review the health history with the parents, give informed consent and alternative treatment options. An informed parent can make an informed decision.
5) Consider allowing the parent to stay in the room with you, from start to finish. Set guidelines for parental "timeouts".
6) If the procedure takes very long to do, then perhaps outpatient GA is in order? Just a thought. I know parents often can't afford GA. Safety is priceless, however. An alternative would be ART and wait for the child to mature.
7) AAPD (The American Association of Pediatric Dentistry) recommends minimally that a pulse ox is used with moderate sedation. With the more frequent use of loops, and all the noises in the operatory you may miss visual or audible (pulse ox) alarms. Consider a precordial stethoscope taped into position for continuous monitoring of breathing. Some are available with Blue Tooth, so you can move around more efficiently. This will give you immediate feedback in the event of respiratory depression or arrest, wheezing, stridor, etc.
8) If a child is quiet and eyes are closed, stop immediately. Say to the child "open your eyes". If the child opens their eyes (i.e.-responds to verbal commands), you are still in the moderate sedation realm. If the child requires stimulation to wake up, they were deep. This is not where you want to be. If the child doesn't wake with stims, then your patient is GA. Call it a day. Stay with your patient, support breathing and deliver reversal agents. Be prepared to stay with the patient for several hours. Do not send them home after reversal, in the event of re-sedation.
9) Great local anesthesia is your "best sedative". Pain will reverse and benefits afforded by moderate sedation. Learn to deliver local anesthesia well. Remember, local anesthetic also has cardio-pulmonary effects. I personally do not administer more than one 1.8 cc cartridge of 2% lidocaine w/epi 1:100k per 10kg on a sedated child.
10) Take a breathing, talking and even crying sedated child any day to a child who is deep. If the child is deep or deeper, then you're in too deep. It's not worth it, even if there is only a one in a million chance your patient dies or remains in a vegetative state for the remainder of their days.
11) If none of the above convinces you, go to the Island Dentistry, Inc. website which has the following announcement:
Island Dentistry is now closed permanently.
To contact Island Dentistry please email [email protected]
or mail to Island Dentistry, Inc
30 Aulike St. Ste 503
Kailua, HI 96734

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