Monday, January 14, 2008

Child Dead From Papoose Board and Sedation

SANTA ANA--Four-year-old Javier Villa, who died after having his teeth drilled, was treated by dentists "who were incompetent and grossly negligent in sedating or monitoring the boy," according to a dental expert cited in court documents.

In addition, Dr. Richard Mungo said, Javier may have died because the dentists and their assistants failed to do something as simple as place a towel behind his neck to keep his airway open.

Dr. Miguel Garcia, who supervised the Megdal Dental Care clinic where Javier was treated, also destroyed the boy's chart, altered records, withheld evidence and concealed the amount of drugs given the boy, according to witnesses quoted in a search warrant affidavit filed in Municipal Court.

Separately, the state attorney general's Bureau of Medi-Cal fraud said Thursday that it is investigating the Megdal Dental Care chain for possible criminal fraud, but it would not provide details.

"We cannot comment on an ongoing investigation," Hardy Gold, supervising deputy attorney general, said in a statement.

The Board of Dental Examiners also is investigating a possible licensing violation by the Megdal clinics. State law requires that a dentist who owns two or more offices must be in each office at least 50% of the time.

Dr. Philip Megdal owns nine clinics in Southern California, said Jeff Wall, chief of enforcement for the dental board. Given the nearly full-time hours these offices keep, "I can't imagine" how he can be in compliance, Wall said.

Neither Megdal nor his attorney William Kent could be reached for comment Thursday. Both denied last week that there had been any fraud regarding Medi-Cal, the federally funded program of medical and dental care for the poor. They also said Megdal was the owner of the buildings where the dental clinics are, not the clinics themselves.

The Santa Ana police and the dental board are investigating Javier's death.
Javier, who stopped breathing in a dentist's chair Aug. 4 and died at a hospital a few hours later, had been taken to the Megdal Dental Care office in Santa Ana to have half a dozen cavities treated. He was given an oral sedative and an injection of painkiller.

An attorney for Garcia denied wrongdoing on his client's part, as did an attorney for the second dentist involved.

Mungo told state dental board investigators "Javier was not properly sedated or monitored" by Garcia, who prescribed the oral sedative chloral hydrate, or Dr. Gabriella Pham, who did the actual dental work.

Mungo also said improper positioning of Javier on a restraint board could have been a major factor in the boy's death and that numerous routine safety procedures were not followed.

Javier was strapped to a papoose board, used to immobilize young patients. Mungo said it was vital that the heavily sedated patient's airway remain open. That could be done by placing a rolled towel or pillow under the patient's neck and shoulders, he said.

That was not done, according to statements made to investigators. Nor was the patient's blood pressure, pulse or breathing monitored with standard equipment, according to the affidavit.

"I'm not sure chloral hydrate is the culprit," Mungo said in an interview Thursday. "My concern is the monitoring and positioning of the child. The papoose board is fine, but you need to know how to use it."

Mungo and other pediatric specialists said it was crucial to give the proper dosage of choral hydrate, based on the child's weight, and to have constant, mechanical monitoring of the child's heart rate and amount of oxygen in his blood.

"In the wrong hands it's [chloral hydrate] not so wonderful, it's potentially deadly," said Mungo, a Huntington Beach pediatric dentist who teaches at USC Dental School.

The case highlights a problem involving the sedation of dental patients, experts said. The state requires dentists administering general anesthesia or conscious sedation drugs intravenously to undergo special training and licensing and have equipment to handle emergencies. However, no such rules apply to dentists who sedate patients with oral doses.

Dr. Ray Stewart, president of the California Society of Pediatric Dentists, said Javier's death might put needed pressure on the state to regulate oral sedation.

"There's been resistance on some people's part to have any more governance, but it's just exactly situations like this here that force the governing bodies to say OK, something has to be done," Stewart said.

Neither Garcia nor Pham had been issued general anesthesia or conscious sedation permits, said officials at the state dental board.

A dental assistant gave Javier chloral hydrate at Garcia's direction, according to the affidavit, and injected Lidocaine in his gums to deaden feeling in his mouth. But the affidavit shows a sharp dispute about the amount of drugs the boy received and also alleges Garcia tried to conceal what happened from investigators.

Pham and dental assistant Alejandra Juarez told investigators that Garcia ordered Juarez to destroy Javier's dental chart, which included the notation that the boy had received 16ccs of chloral hydrate. He began a new chart, the affidavit says, showing the boy received 6ccs.

"That is the story," Garcia said to Pham and Juarez when they met shortly after paramedics took Javier to the hospital, according to the affidavit.

Garcia told investigators he ordered a 6cc dose of chloral hydrate and "does not recall" if he was in the room when Juarez administered it, according to the affidavit.
The manufacturer's maximum suggested dose for a child of Javier's size is 9ccs, according to the affidavit.

Garcia declined to discuss those allegations Thursday. "I wasn't the treating dentist," he said. "Even I don't know all the things that went on."

Juarez also said that on the day of Javier's death, Garcia apparently concealed from a coroner's investigator the amount of Lidocaine administered to Javier. Juarez told dental investigators she "retrieved the [Lidocaine capsules] from the trash and handed both of them to Dr. Garcia, and Dr. Garcia gave only one to the coroner," according to the affidavit.

Mungo was critical of the office procedures, training and the fact that one dentist administered the oral sedation while another treated the patient.

Pham told investigators it was "standard procedure" not to place anything under the necks of papoose children, according to the affidavit. During a demonstration with investigators of the technique the office used on Javier, Pham gave no indication that either dental assistant was instructed to keep Javier's airway open, according to the court document.

In addition, dental assistant Claudia Briseno told investigators she understood that her job was to hold the boy's head so that he did not move side to side and he did not cut himself.

Click here for another investigative report from Colorado as far back as 2004 and still there are no national laws saving out children.
My word on this: A little patiences would have saved this child's life!

1 Must Read Comments:

barry1817 said...

I was an expert witness in this case and would be happy to discuss issues with anybody that might have questions about this case. Barry1817@aol.com

But there were other issues in question that the reporters did not take up and that the dental board did not deal with that may have made the outcome different.

If the dental board has an obligation to protect the public one must question why this office, and all these office owned and operated by Megdal were doing business, especially with the number of complaints and suits that were filed.

There was also an issue about the initial call to 911 and the delay in making that call. When time is of the essence delaying a 911 is, to me, a huge problem.

This case also showed that having a cpr certificate and being able to administer cpr are very different.

As a matter of fact in discussing dental responses to a crisis, a person that I highly respect, mentioned that until dentists are actually placed in the emergency situation the response may be far from what is expected, so the question as to cpr training might need to be visited.