The day before my six-year old nephew, Caleb, passed away my sister-in-law and I had taken our kids to buy them new bicycles. Caleb was the oldest and could ride circles around his little sister and my girls. I remember his smiling face as he deftly showed his younger sister and cousins how amazing it is to ride a bike.
The next day Caleb had an appointment at an oral surgeon’s office to have a mesiodens tooth extracted under general anesthesia. My family understood that all anesthesia carries risk, but did not understand the differences in safety precautions and risk when anesthesia is administered by dentists and oral surgeons. My brother and sister in law trusted the oral surgeon and followed his advice when he recommended general anesthesia for the procedure.
Caleb went in to the oral surgeons office for this elective procedure the next morning. Moments after, my sister in law sent me a text, “Help! 911 Lost airway. Come to Children’s Hospital Oakland now,” I met my family in the Emergency department moments after Caleb was admitted. The Emergency Medicine attending had immediately intubated Caleb, the ED team had paralyzed him and was working to stabilize his heart. What felt like moments later, the EM attending pulled me into the hallway and recited his condition: “He was possibly without an airway for 45 minutes but we don’t know,” Then: “All his teeth were broken. A surgical airway had been attempted and failed. He coded 3 times in the ambulance.” I saw in the attending physician’s eyes and knew in my heart that my nephew was gone.
Grief takes many forms. For me, I needed to find out what had happened. I already knew my nephew did not have an allergic reaction or some latent heart defect. He was not a high-risk patient. He should not have died. I analyzed Caleb’s medical records and learned the oral surgeon had both operated on Caleb and administered his anesthesia in a private office. There was no separate anesthesia provider, not even a nurse. And this is normal; oral surgeons call it the “operator-anesthetist model” of sedation. Caleb’s oral surgeon pushed propofol, ketamine, fentanyl, and versed, then went to work on Caleb’s teeth. The manual notations showed no one noticed Caleb’s oxygen saturation drop until it hit 60%. I could picture the oral surgeon’s desperation as he failed to intubate and his panic that led him to futilely cut into Caleb’s throat looking for an airway. An anesthesia provider would have noticed immediately and deployed any number of interventions to maintain airflow until Caleb could maintain his own airway. How could an oral surgeon operating alone be the standard of practice?
Prompted by that question, I started digging into the state of dental anesthesiology. The California Dental Board informed me that they did not track the number of deaths caused by dental anesthesia. Nor do any other state dental boards. I also searched the medical and dental literature. What I learned was chilling: despite the surfeit of research on anesthesia outcomes in hospitals and ambulatory surgery centers, the dental community had not one paper systemically looking into near misses or adverse outcomes from dental anesthesia. Instead the dental journals bemoan the lack of evidence on this topic. Yet several medical papers that studied anesthesia across medical and dental clinical contexts, noted a trend in death associated with dental anesthesia.
Eventually, I turned to media reports and found nearly twenty stories about children dying from dental anesthesia in the past decade. I asked Facebook’s Physician Mom’s Group if they had seen adverse outcomes from dental anesthesia; hundreds of doctors around the country responded. One replied that any time they hear of an ED admission related to anesthesia they assume it’s from a dental office. Many others agreed. These stories are likely only a small sample of the total number of adverse outcomes. Yet the standard of care and applicable regulations remained the same: woefully inadequate.
Ultimately, finding out what happened could not assuage my grief because what I learned was how preventable Caleb’s death really was. Each time I felt tears in my eyes missing my nephew, I’d tell myself: “I can change this.”
I approached our local Assembly member, who agreed to author legislation making dental anesthesia safer in California. Caleb’s Law, which has now been signed by the Governor, will begin to modernize dental anesthesia. The legislative journey was long and difficult. During the process, I was joined by the American Academy of Pediatrics and the California Society of Anesthesiologists to support enacting this legislation, and was the bill’s spokesperson as we faced strong opposition from the California Dental Association and Association of Oral and Facial Surgeons.
With each new audience—legislators and their staff, reporters, lobbyists—I’ve been met with skepticism that a grieving family member could craft good policy. But that disbelief evaporated when I revealed the depth of my knowledge of the medical and dental literature and the procedures involved, knowledge, which rests on a solid foundation of medical training and research skills.
As physicians, we are afforded the public’s trust because our opinions are rooted in reason and because we put our patients first. Emergency department doctors are on the front lines for seeing what problems contribute to suffering in our society. Health policy, or any policy that affects our patients, needs more physician voices. To make change, we need to speak up loudly when we see problems, but also understand why others might not want to make the change. The status quo always has inertia; change requires applying the force of strong opinion and persistent advocacy. It will make a lot of people uncomfortable; but that discomfort is the mark of real change. With the passing of Caleb’s Law in California, and the resulting spotlight on the issue of anesthesia safety in dental offices, the dental community has been put on notice, and hopefully nationwide change will soon come.