ABC Diane Sawyer: Death, Greed at the Dentist: American Children at Risk.

Recently Diane Sawyer has released this news report, it is a decent report but also very misleading.  Here is the link the to news report: http://abcnews.go.com/Blotter/death-greed-dentist-american-children-risk/  Not to make enemies of the media, but sometimes they can be very ridiculous, and they don’t represent the full facts and both sides of the situation.  Dr. Punwani, the AAPD representative and head of pediatric dentistry at UIC, was grilled for 4 hours asking the same questions over in different ways until they get an answer suitable for “broadcast” to capture the attention of the viewers.  After all that, they only produced only a 10 sec blip of the interview.  They would refuse to report what kind of training the dentist have that consumers should be looking for to provide safe and adequate anesthesia to children who are uncooperative to the dentistry.  At the same time they produced a report are few months ago: http://www.insideedition.com/news/8092/inside-edition-investigates-the-use-of-papoose-boards-by-dentists.aspx  So basically, there are no longer a treatment method for uncooperative children?!  Since both methods are vilified by the media there is a no win situation for treating young uncooperative children.  Do they report that caries are on the rise for children?  Children are at risk for dental infections that can potentially cause meningitis, or Ludwig angina which both are deadly.  The truth is, there are a few bad apples in the mix ruining it for the rest.  Yes there are some inadequately trained dentist, and yes the trained practitioners can make mistakes because they are human, and yes even physicians, lawyers, dentists, politicians, journalists are ALL human and there are always bad apples somewhere in the mix.  If someone is perfect, I should be on my knees worshiping them and I am not worthy.

Here is American Association of Pediatric Dentist response to the story that ABC will refuse to report : http://www.aapd.org/aapd_responds_to_abc_news_story_on_drbicuspidcom/  .  Here’s the other response to the papoose board, http://www.aapd.org/aapd_update_on_inside_edition_story/?F_All=y.  As a Dentist Anesthesiologist, I still support these methods of treating children as long as the dentist is properly trained in those methods and follow the AAPD guidelines.

There are also good news on some oral medication Chloral Hydrate.  It has been discontinued as a oral suspension for oral sedation use. http://www.ashp.org/DrugShortages/NotAvailable/bulletin.aspx?id=902 I know some people may disagree, but having done some research for Dr. Yagiela, I have to agree with Dr. Yagiela Chloral Hydrate is a dangerous drug and have a very small window of therapeutic value.  Yeah, it can be used safely, but in most circumstances its hard to use it right.  There has been case studies where the drug can last 48 hours, and a lot of problem arises on the recovery phase.  The drug can have the patient lapse back into the deep sedation state which can cause airway issues.  Majority of the deaths surrounding dentistry with oral sedation, Chloral Hydrate was used.  Right now I would recommend the use of Midazolam, and Vistaril, Nitrous Oxide, as single agent or combination for oral conscious sedation.

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Remembering Dr. John Yagiela

News of my mentor’s death came all too sudden and was very shocking.  I was tremendously saddened by the news, and couldn’t quite enjoy my time off at my latest IFDAS (International Federation of Dental Anesthesiology Societies) conference in Hawaii.  A group of us were supposed to join him in Hawaii for the conference but, unfortunately, this untimely incident happened.  It took me a few days to absorb the news and much longer to blog here about how much we are missing him already.  I suppose I can go over all his achievements, but that would be way too many pages.  Here’s a link to a nice summary: http://www.ada.org/news/6818.aspx .  Instead, I would like to share my relation and connection I had with him.

To start it off, I feel so deeply honored, privileged, and lucky to have received tutelage from him, and would bet every one of the residents who had trained under him and Dr. Chris Quinn would feel the same way.  Dr. Yagiela and Dr. Quinn were like our “Mom and Dad” for anesthesia.  I know it sounds funny, but we are like a family.  Former residents and attendings of the UCLA dental anesthesia program would always gather one night to have dinner at all the dental anesthesia meetings.

At Scottsdale, Arizona, we were gathered at the lobby of the hotel we were staying at, getting ready to go dinner, and a colleague came over to say hi to John.  He introduced us to him, pointed to all of us and said “these are what I live for now.”  From that statement alone, you can tell that he had put his heart and soul into the UCLA dental anesthesia residency program.  We are essentially an extension of his family, and he treated us as such.  All the residents also share a bond, even if we didn’t train at the same time, we took care of each other.

Dr. Yagiela is super smart, feared during our meetings for asking questions because he is almost always right, at least in the subject of anesthesia and dentistry.  Part of the reason I latched on to him so easily was that he was very similar to my father.  My father is a well known economic scholar in Taiwan and has written textbooks for finance and other subjects.  After he retired from the banking industry, he was invited to be a professor at local universities.  They both have mirror personalities, except one in the anesthesia and pharmacology field and the other in economics and finance.  I was able relate to Dr. Yagiela real quick, and I picked up a lot of hobbies that Dr. Yagiela had enjoyed, from photography to scuba diving, and also got quirks like becoming a mac user.

Continue reading

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Dr. Steven Shafer is my hero!

Following the Dr. Conrad Murray trial, I came across a testimony from Dr. Steven Shafer.   Totally my kind of guy, to donate his time pro-bono to help dispel the fears of propofol to the public.

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MJ Dr. Murray Trial: Truth about Propofol.

Michael Jackson murder trial has captivated many audiences around the world. I hear about it everyday, on the radio, TV, and at work. What Dr. Murray did, of course, is looked down upon in all health profession. A cardiologist not trained in sedation/anesthesia providing propofol sedation as a sleep aid. Everything about it, was wrong. No monitoring equipment, no ACLS(advance cardiac life support) equipment, no oxygen, no personnel in the room, and lastly no understanding of the drugs being used. Is this malpractice or criminal negligence? That’s up to the jury to decide. Just a note though, Schwarzenegger went out of his way to deny a parole granted (parole committee already granted parole) to a 61 year old dentist who served 25 years of his life sentence for negligently killing 3 patients with anesthesia, and also halved a sentence on a kid who committed a violent crime. That’s our justice in California.

Dr. Conrad Murray

Propofol in its various form

So let’s talk about Propofol. Hot topic! I have notice there are a lot of misinformation about the drug. I heard on the radio Dr. Drew calling it a barbiturate, and everybody saying how short acting it is. It is not a barbiturate, and depends on the circumstances it could be a very long acting drug. It is the safest anesthesia drug in the right hands, in my opinion. Extremely hard to abuse, which almost always requires a 2nd person to help (I’m sure a trained anesthesiologist can do it himself). Here is the except from the package insert:

DIPRIVAN Injectable Emulsion is an intravenous sedative-hypnotic agent for use in the induction and maintenance of anesthesia or sedation. Intravenous injection of a therapeutic dose of propofol produces hypnosis rapidly with minimal excitation, usually within 40 seconds from the start of an injection (the time for one arm-brain circulation).

Before you can understand more what this one arm-brain circulation mumble-jumble, let me give you a quick pharmacology lecture. When you give an IV(intravenous) drug, the drug travels in a specific pattern throughout the body. Your body’s circulation has areas where there are more blood traveling there. We called that “vessel rich tissue”, and that is where the drug goes first. These area include the brain, heart, lungs, kidney, liver and some other organs. But we are most interested in the brain. A certain blood concentration of the drug is required to achieve the anesthesia. With IV administration, good thing the brain is a vessel rich tissue, so the drug effect is pretty fast and you’ll notice the anesthesia effects. Propofol is very lipophilic, so it crosses the blood-brain barrier very efficiently and is fairly potent because of that. Over time, the circulation will “Redistribute” the drug to the rest of the body, which will lower the drug concentration in the brain and the anesthesia effect will start to subside. Propofol being very lipophilic, after it has redistributed it likes to sit in the fat. So you can call this a “third” compartment, where the propofol gets removed from the blood and sit in the fat while it awaits liver metabolism and kidney excretion. Below is a visual of how the drug travels and its effect.

The two compartment model, taken from www.rxkinetics.com

Typically it takes about 23-50mL/kg/min which translate to a few hours for propofol to get eliminated from the body, mainly because it likes to sit in fat and not hit the liver very often. So someone who just had anesthesia the day before does not really need to worry too much about it and can go about their business the next day. However, it is a different story when propofol is infused for a very long period of time. It is typically used in the ICU(intensive care unit) for patients who requires long term sedation to help with healing, and/or they are intubated for safety. If you continue to infuse propofol for long periods of time, the “third” compartment will fill up and the equilibrium of the drug concentration of the full body will rise, and eventually reach a drug concentration to achieve anesthesia in the brain. It has been documented many times describing this effect. Since the fat is filled, the effect of the propofol will last till the liver can metabolize the drug till the decreases the blood concentration to an awake level. Below is extracted graph from the package insert of Diprivan(brand name).

Blood Concentration of Propofol throughout time.

As you can see the 10 day continuous infusion, the blood levels hover very close to anesthesia level. Whenever the plasma propofol concentration is about that “awakening” dotted line means the patient should be asleep. For Michael Jackson’s case, he has been infused with propofol for over months for 8 hours a day! He would be in this exact situation. Dr. Murray made a statement he gave 25mg of the drug. He probably gave more…, BUT with this profile, 25mg can be enough to keep Michael asleep for a while. We know Dr. Murray had purchased gallons of propofol, there must be a way to force him to produce the remainder of the purchase, and then we can tell for sure Michael has been infused for a long long time. This will explain the high blood levels of propofol found in Michael Jackson post-mortem. It may not be enough to cause respiratory depression to a point where Michael Jackson stops breathing, but the number one cause of respiratory failure in anesthesia is obstruction. Without anybody in the room and zero monitors, nobody knows how his death really happened. Some people say he got up and pushed more propofol, and the defense ridiculous claim of ingesting propofol that was hidden in the juice box next to Michael Jackson. Whatever the trigger that caused his death shouldn’t even matter because the daily infusion of propofol, and no careful monitoring is what really killed him.

Here is my personal opinion about the case. Dr. Murray has definitely showed criminal negligence in not monitoring, and also not understanding the pharmacology behind propofol. If a dentist can be criminally charged for using inappropriate anesthesia, I don’t see why he should fall under the same charges. All propofol use should be used with a monitor can that watch blood O2 saturations, ECG, blood pressure, some form of breathing confirmation(CO2 monitoring, or pre-cordial stethescope), a personnel trained in airway management in the room at all times, and ACLS equipment to manage an airway/respiratory crisis. Four years may not be worth the tax money? I think the criminal charge to forcibly remove his license to practice medicine is more important than the punishment. We do not need a physician out there practicing dangerous medicine.

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Adventures with Foundation for Worldwide Health at Nicaragua (Part I)

I haven’t updated this blog in a while, my apologies. My most recent humanitarian effort was with Foundation for Worldwide Health at Nicaragua. http://fwwh.org/index.html. They have been coming to Nicaragua every year for the past ten years. It is an ongoing effort to help Nicaragua become more self sustaining; besides providing clinical care, they also bring education and infrastructure planning to help them eventually not rely on foreign country missions and be able to care for their own people in the long run. Some of their projects for self sustainability include helping local farmers of coffee beans establish a more profitable business venture with US retailers. In exchange for establishing this trade route, a percentage of the earning must go into building clinics, hiring medical professionals in the local area near the farms. Future projects includes, having televised lectures with live interactions through the internet for dental schools in Nicaragua, and many other beneficial educational opportunities. This organization is doing a great service to Nicaragua and US’ image, it would be a worthy cause to help out if any of you are interested.

When I stepped off the plane and went into immigrations, we encountered some problems with the customs with our equipment and luggage. Even though the organization has done this for 10 years in a row, and filed the correct papers, it seems there were new personnel and some confusion or maybe expecting some extras. There I learned that Nicaragua receives a lot of charity groups, and they have well over 100 groups visiting every year to help their citizens and we were not so special anymore to their eyes. It has seemed the country began to rely on these mission groups to take care of their many issues. More the reason to go forward with the self sustainability projects.

 

 

 

 

 

 

 

Out here in Nicaragua, I participated in the Nathan’s Project division of FWH. http://fwwh.org/id58.html. Nathan’s project originally formed to provide dental care to the special needs population of Nicaragua. Dr. Mercado was visiting Nicaragua, and had notice a few Down’s syndrome children not receiving proper dental care and realize this population will probably never get dental care as many requires sedation or general anesthesia. In collaboration with FWH, he helped formed the Nathan’s project in memory of his own Down’s syndrome son. We worked in Hospital Metropolitano which is primarily a burn center for children. Most of the population of Nicaragua still uses fire wood to cook everyday, and they would usually leave the embers in the back yard. So there is a high incident of children playing in the back and falling or tripping into the embers resulting in severe burns. This hospital and their directors have graciously donated space and resources to help our cause. Other organizations have also used this hospital such as, Project Smile and a group from John Hopkins. Now we are here to provide this unique service in Nicaragua.

Continued in Part 2

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An attempt to bring back sanity to an insane incident…

I got a call by Dr. Schrodi in Granada Hills to see if I was willing to do a pro bono case. Dr. Schrodi told me a sad story of road rage that ended in tragedy for a family. Here is the story in LA Times :
http://latimesblogs.latimes.com/lanow/2010/08/road-rage-shooting-death-downey.html
To summarize, there was some aggressive lane changing and some words exchanged. The passenger of a blue Honda Accord pulled a gun and shot a 28 year old father in front of his family with both his 4 and 5 year old sons in the back seat. He had enough will power to pull the car to safety before he passed out and later died in at the hospital.

His two sons were Dr. Schrodi’s patient, and the wife was of course devastated by the incident had a hard time taking care of everything.  The whole family was traumatized and required a tremendous amount of counseling. Luckily, they had very good support from their extended family. The children’s aunt brought them in and the little one required a lot of dentistry, and was very afraid of strangers due to this incident. According to their aunt, they would be so terrified of getting on the freeway, and would beg to get off every time. Dr. Schrodi recommended general anesthesia due to his condition, but the family couldn’t afford it.  So to bring back some sanity, I agreed to do this case pro bono to help the family out.

Little Johnny did great and had all his teeth fixed. I know it isn’t much, but I hope it shows the family there are still sane people out there and not everybody are evil and ruthless. Just trying to bring back some sanity in this insane world out there.  I thank Dr. Schrodi for this opportunity to give back to the community.

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Funny Videos

Just want to share with you some You-Tube discoveries 😀

Those who don’t understand you need to see this first!

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Why can’t I be in the procedure room with my child under anesthesia?

This a very common question I get when I talk to the parents of the patient.  It is a common standard that is applied everywhere in the US.  I think most parents will have a hard time finding a surgery center, hospital, or anywhere that provides anesthesia that allow the parents to be in the room with their child during anesthesia.  There are several reasons for that, and that is why nobody wants to take the risk of having parents in the room.  I will outline some of the more common reasons here:

1.  Patient Safety.  During the procedure, there is always a chance that some emergent situation can occur.  At that time, every second counts.  We will not be able to answer any questions and interference can results in very unsafe conditions.  We as health care providers would need to provide life saving support without distractions.  As you can imagine, in a emergent situation we are trying to focus as hard as we can on your child, and any distraction from the parents could possibly impair our judgment.  Just like in an airplane.  Passengers are not allowed in the cockpit, especially during take-off and landing.  I am sure the pilots know what they are doing and I leave the control of the airplane to them and not me.  I know everybody wants to have control over their child’s safety, but you will have to trust the doctors and me, just like you trust your pilot.

2. Parent’s Safety.  We are also concerned about YOU!  Not everybody can handle to visual of blood, having their child out of their control.  We also tape their eyes and head to protect them.  It is not an everyday sight to see, and you may not like it.  Why stress yourself?  Some parents claim to be able to handle blood and emergent situation, but when it comes to your own child, things will change.  If anything were to happen to you, we are not equipped to handle two unconscious patients at the same time and it would lead to a dangerous situation.

3.  Space.  Space is limited!  Some procedure rooms are small.  We must always have 3 people in the room when a procedure is happening.  The fourth person in the room maybe become cumbersome, and access to my equipment may be hampered.  Again, seconds count, and all that shuffling around is losing time.

Questions:

“I want to make sure the doctors are doing what they are supposed to do!?”

By law, we are required to have 3 people participate in the procedure.  With me, there will be two doctors, and an assistant.  Some doctors like to work with two assistants with one on stand-by to grab miscellaneous equipment or just help out.  I am sure we are all here to help your child.  If you do not find me or the other doctor trustworthy, then maybe you should find someone you do trust.

“I’m pro! I can handle blood and gore.  That’s what I do!”

I definitely heard that before, and when that parent held their child while I give an injection they almost passed out.  It is very different with your own child.  I had another father who would not consent to the procedure because he was not allowed in the room, but later agreed.  After everything was done, he was so nervous he kept throwing up in the bathroom and couldn’t watch his daughter recover.

“Can I sign a waiver, where you won’t be liable if I pass out or become manic?”

You can not consent for sub-standard of care.  The law will always favor the consumer, and even if you sign something like that we are still liable.  Same for taking a taxi home by yourself after anesthesia.  It is like, “Hey, I wanna get in trouble, just let me do it in your office.”  To protect myself and the staff at the office, this will not be allowed.

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Adventures with Hearts with Hope @ Peru (Part 2)


I decided to go again after skipping one year. By now the organization has already made a good name in Peru, and was requested by many people to go visit several schools. More parents brought their children to have us take a look at them. We were averaging 160 kids a day for evaluation, then treating about 60 kids for dentistry. We would also sedate average 30 kids a day to do the dentistry. Getting consent for anesthesia was easier than the dentistry! We had to educate them what are decayed and infected teeth because many assumed having foul smelly mouth and black teeth was just part of growing up! Good thing we had great volunteers with a lot of patience to educated them. The amount of work we did was very overwhelming and was nothing like how it was 2 years ago. We went home late almost everyday, tired, hungry, but satisfied!

The most challenging location we had treatment was this special needs school. Over there, all the patients has some sort of special needs like: Down’s syndrome, cerebral palsy, autism, etc. The anesthesia was pretty challenging because the patients were not always norm. We had one patient that was 9 years old and only weighed 12 pounds! I had to consider the anesthetic management, and just the blood loss from extracting teeth could potentially put her in danger. So we only lightly sedated her and extracted about 5 teeth. Rest of her treatment needs to be done when she fully recovers from the blood loss some other day. The poor single father struggles so hard to help her daughter get well, but he must be devastated watching his daughter get more cachectic as time goes on. The poverty I’ve observed there is very devastating, here is a picture showing the living conditions.

Another challenge we faced were going into regions with no power and running water. Good thing we had scouted the area first before we went there. We brought along a power generator and several big bottles of water. It was so dry and dusty, by the time we were all done, I was covered in sweat and dust.

Besides hard work during the day, we do have fun at night! Including dancing, parties, etc. Some days the locals would throw a party to thank us. One night we had some pyrotechnician did his own version of the Burning Man. We thought we were gonna all catch on fire! There was so much smoke and fireworks it would definitely be illegal over here in the states. I also made a trip to Mt. Chichani and mountain biked down a trail for a day. Air was so thin up 16,000 feet, and I had my first asthma attack ever… terrible feeling. Took a break and continued down. The view was so spectacular, and the ride was tough, but enjoyable. We being amateurs called it quits about 2/3 down the mountain and took some sunset photos.

Overall, the trip was very fun, rewarding, and culturally educating. I would encourage anybody to come to these humanitarian missions. It’s an opportunity to explore and meet great people who have the similar goals and interests. For sure, I’ll venture out to do more of these missions.

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Adventures with Hearts with Hope @ Peru (Part 1)

Just want to share with you my experiences in Peru with Hearts with Hope.

Here’s what they are; copied from their website www.heartswithhope.org.

Founded in 1994 by Pediatric Cardiologist Dr. Juan Alejos at Mattel Children’s Hospital at UCLA.

The primary goal of the foundation is to instruct local medical personnel in the treatment and care of children with congenital heart diseases, as well as providing financial, educational and emotional support for their families.

One of the successful heart surgery patients

Staffed by volunteer physicians, allied health personnel and community members with extensive experience in the treatment and care of children with congenital heart disease. The foundation works in conjunction with local children’s hospitals often severely understaffed, limited in supplies and unable to provide adequate facilities for the overall population. Medical and humanitarian supplies donated by physicians, UCLA Medical Center, international corporations and community volunteers.

This is my 2nd mission with them, and it’s been a wonderful experience both times!  My first time with them, Dr. Eric Sung, co-director of UCLA’s hospital dentistry, had asked me to come with them to help with the outreach team.  I helped with dental exams, treatment and also provided anesthesia to the children. Most of the staff there started to look at me weird when I was providing anesthesia, and when all the patients that needed anesthesia was done, I was extracting teeth and placing fillings.  They forget I am still a dentist!

Our Dental Outreach Team, Peru 2008

Typical street of Arequipa

Peru is generally a well developed countries in the big cities.  They have a lot of the modern conveniences you’ll usually find in big cities.  In my first visit, the government had held a lot of our medication and supplies for “inspection”.  So I didn’t have any drugs available on our first day in outreach!  We went to a pharmacy around the corner from the hotel and acquired a few ampules of Ketamine, Midazolam, and some other emergency drugs.   Didn’t ask for license or “DEA”.  I thought it was hilarious, but they probably gave it to us knowing we were foreign volunteer doctors.

Main church in Arequipa at night. Quite beautiful isn't it?

Peruvian food definitely has some interesting characteristics.  Lots of potato in the diet, and their specialty drink is Pisco Sour.  A pisco sour is cocktail containing pisco, lemon or lime juice, egg whites, simple syrup, and bitters.  It tastes great!  Another cuisine that’s interesting is Cuy, its a guinea pig!

Yummy Cuy with Peruvian Corn and Potato.

I definitely had some fried guinea pig.  It tastes like chicken :p  It was pretty good actually, other meats like alpaca kinda tastes like lamb.

After a weeks work, some of us went to Macchu Picchu.  We stopped by Cusco and did some sightseeing.  Definitely observed more of the local culture here.  There were also remnants of the Inca culture all around.  Inca temples were made so precise with no mortar or cement.  The stones were cut and smoothed to fit each other by the micrometers.  So when the Spaniards try to blow up their temple with cannons, only very little would break off.  Instead, they just built cathedrals and buildings over the temple.  If you visit you’ll be amazed at the architecture these Inca’s were able to build.  Macchu Picchu is definitely worth being one of the 7 modern wonders of the world.  It was huge city built with the same stone work.  Those who really want to experience in full, should definitely get in shape for the hike!  It’s high altitude and steep slopes almost killed me :p  I was gasping for air most of the time, and left in the dust by those more fit.  I didn’t give up and made it to the top, but by then it was time to go…

Next blog I’ll go more into my second trip with them!

The tall peak is Wynna Picchu, wanted to go up there but they closed it off due to weather conditions.

My attempt at being National Geographic photographer.

What's without hanging out with llamas and alpacas in Peru?

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