The opinion of the plaintiff's expert seems sloppy. I've never heard of an ECG described as "asymptomatic." And the argument that the dentist was negligent seems to boil down to the syllogism "1. This reaction was caused by the local going intravascular, and 2. that doesn't happen with competent technique, so 3. the technique must have been incompetent." Pretty shaky.
Yeah... no offense to dentists but I don't think reading EKGs is in their wheelhouse. Also very bizarre - if I'm reading this right, he's saying he never even looked at the dentist's records??? How can you have an opinion without even reviewing the records? Very odd.
Seems a bit much but also don't know the extent of the issue. Is it just a mild irritation or is it crippling lifelong pain? Could be a lot of different outcomes that influenced the judge.
He was in the hospital for multiple days so he at least missed that time. I hope it was a minor injury but there's really no telling. I think we need to be honest that it could be extremely painful.
Interestingly, I did and if it affected the entire course of my practice. Very early in my career a college friend who became a lawyer said he had a great dental malpractice case. He sent me a lot of the clinical information and I commented. It’s an extremely common procedure worldwide and I doubt you’re gonna prevail in plaintiff action. To make an extremely long story short, he faxed me a copy of his $3 million settlement check which was paid by CNA insurance, which was also my malpractice carrier!!!which was an insane amount for 1985 and even today it seems excessive.
At the time it was the largest settlement in the world for dental malpractice. It affected me greatly, and I did a lot of research on technique and came up with the guidelines of the very slow injection and multiple aspiration attempts on insertion with the techniques I described earlier. It’s pretty obvious if you’re in vasculature because there’s very rarely any resistance felt in the syringe. Most of the time we use one to 80,000 or one to 100,000 EPI .
I’m a dental surgeon with 44 years experience. I’ve given probably 10-20 thousand IAN blocks. The secret is to inject slowly taking over a minute so there is zero chance of a 1.8 ML bolus.
Also, you must aspirate with proper aspiration technique, including careful needle, insertion, needle, repositioning, needle, retraction, and needle rotation which can clear the minute tissue debris that can block aspiration.
The expert's comment "intravenous injection can still be avoided if proper aspirating technique is used" is dubious. What most likely happened in this case was that anesthetic was injected intra-arterial and caused rapid CNS toxicity. It would be helpful to know the volumes injected but it doesn't take much if injected intra-arterial around the head and neck to cause seizures. Don't rely on aspiration to safegaurd against vascular uptake. I commonly do cervical transforaminal ESIs and use digital subtraction angiography (DSA) to see vascular flow patterns and I'm amazed at how aspiration technique will be negative and vascular flow patterns light up with DSA.
That's an interesting point... I learned toxic dose of lidocaine as a fixed mg/kg, but it probably varies but body site and if its intra-arterial or not. Kind of scary to hear that even with negative aspiration you're still seeing vascular flow. I guess it's kind of similar to an IV that won't draw but will flush and is good for meds.
I know this is speculative, but do you have a theory as to why docs are more likely to win with a jury than with a judge?
Also, I have to admit I don’t usually aspirate first when performing the inferior alveolar block, I guess I should start, but the most I ever inject is like 5 cc. I think bupivicaine is more dangerous for vascular injection than lidocaine.
It's easier to criticize a peer than someone you look up to. Judges see doctors as peers. Despite everything you read online, most people really do still trust doctors, so when they get on a jury they usually still trust them.
Intravascular injection of bupivicaine is absolutely contraindicated as it is notoriously cardiotoxic and sends the heart into non-resuscitatable V-fib. A 30ml dose of intravascular 1% bupivicaine is an absolute fatal dose, even assuming that much of the injection did not enter the circulation.
Sounds like this dentist just impaled the nerve and may have caused permanent injury like a traumatic neuroma. I say this because the anesthesiologist who testified against me in my bupivicaine Bier block case ( the nurse handed me Bupivicaine when I had clearly asked for xylocaine) testified that for the procedure I was doing, he would NOT have done an axillary block but instead would have done the Bier block because he was worried about a stray needle impaling one of the nerves in the axillary plexus and causing permanent injury.
Unlike vascular catheterizations which nowadays are guided with ultrasound, when doing a nerve block, the position is "tested" by seeing if transient paresthesias are elicited as one advances the needle before injecting or at least that was how it was done while I was still practicing before my license suspension in my above case. Not sure, but they would also perform aspiration because of the proximity of the axillary artery and vein. But for an alveolar sensory nerve block? Come on.
But this dental expert's opinion seems rather vague in that it is based more on theory and possibility.
I think this case should have been tried in front of a jury. I got smoked in Natchez, Mississippi in 2016 when I treated a 50 year old female with an IM rod for an open fracture that later got infected and ultimately required an BKA. I was a white male surgeon who was leaving Natchez. My patient was black. The female judge was black. Her husband was black and a plaintiff's attorney and this court in Natchez had a reputation for being very Plaintiff friendly. And my case was a bench trial in front of this judge. Now what chance did I have?
Just to clarify, I think the toxic dose of lidocaine you quoted assumes local injection. I’m pretty sure the toxic dose if injected intravascularly is much lower. After all, 100 mg of intravascular lidocaine can have cardiac consequences since it’s the therapeutic antiarrhythmic dose.
That's an interesting point I hadn't thought of but actually makes sense. A brief search didn't turn up any research on toxic doses between local and intravascular, have you come across anything?
Nope, they never do that. I saw a case once where the jury asked the judge if they could give an explanation attached to their verdict, and the judge said no. Attorneys will sometimes ask to speak with the jury after the trial to get feedback, but the jury doesn't have to do so if they don't want to, and what they do say isn't put in any official court documents.
That is true. Personally, when I do nerve blocks, I avoid epi (I don’t want the block to last too long, and i’ve seen more of these episodes of vasovagal syncope with brief pseudoseizures than without). I’m not a dentist, just a humble ER guy working in UC, so what do i know?
Ok, yeah. The Epi concentration is 1:100,000, so if injecting a few mL not a big deal, but, I would think that if you did get a vein it might have some effect....
The opinion of the plaintiff's expert seems sloppy. I've never heard of an ECG described as "asymptomatic." And the argument that the dentist was negligent seems to boil down to the syllogism "1. This reaction was caused by the local going intravascular, and 2. that doesn't happen with competent technique, so 3. the technique must have been incompetent." Pretty shaky.
Yeah... no offense to dentists but I don't think reading EKGs is in their wheelhouse. Also very bizarre - if I'm reading this right, he's saying he never even looked at the dentist's records??? How can you have an opinion without even reviewing the records? Very odd.
Does anyone think 350 sounds a bit excessive? Is it from the tariffs? Lol.
Seems a bit much but also don't know the extent of the issue. Is it just a mild irritation or is it crippling lifelong pain? Could be a lot of different outcomes that influenced the judge.
I can’t imagine he missed more than half a day of work for this, even $46k seems high!!
He was in the hospital for multiple days so he at least missed that time. I hope it was a minor injury but there's really no telling. I think we need to be honest that it could be extremely painful.
Interestingly, I did and if it affected the entire course of my practice. Very early in my career a college friend who became a lawyer said he had a great dental malpractice case. He sent me a lot of the clinical information and I commented. It’s an extremely common procedure worldwide and I doubt you’re gonna prevail in plaintiff action. To make an extremely long story short, he faxed me a copy of his $3 million settlement check which was paid by CNA insurance, which was also my malpractice carrier!!!which was an insane amount for 1985 and even today it seems excessive.
At the time it was the largest settlement in the world for dental malpractice. It affected me greatly, and I did a lot of research on technique and came up with the guidelines of the very slow injection and multiple aspiration attempts on insertion with the techniques I described earlier. It’s pretty obvious if you’re in vasculature because there’s very rarely any resistance felt in the syringe. Most of the time we use one to 80,000 or one to 100,000 EPI .
Crazy story. Thanks for the tips!
I’m a dental surgeon with 44 years experience. I’ve given probably 10-20 thousand IAN blocks. The secret is to inject slowly taking over a minute so there is zero chance of a 1.8 ML bolus.
Also, you must aspirate with proper aspiration technique, including careful needle, insertion, needle, repositioning, needle, retraction, and needle rotation which can clear the minute tissue debris that can block aspiration.
Great tips! Have you ever seen something like this case happen?
The expert's comment "intravenous injection can still be avoided if proper aspirating technique is used" is dubious. What most likely happened in this case was that anesthetic was injected intra-arterial and caused rapid CNS toxicity. It would be helpful to know the volumes injected but it doesn't take much if injected intra-arterial around the head and neck to cause seizures. Don't rely on aspiration to safegaurd against vascular uptake. I commonly do cervical transforaminal ESIs and use digital subtraction angiography (DSA) to see vascular flow patterns and I'm amazed at how aspiration technique will be negative and vascular flow patterns light up with DSA.
That's an interesting point... I learned toxic dose of lidocaine as a fixed mg/kg, but it probably varies but body site and if its intra-arterial or not. Kind of scary to hear that even with negative aspiration you're still seeing vascular flow. I guess it's kind of similar to an IV that won't draw but will flush and is good for meds.
I know this is speculative, but do you have a theory as to why docs are more likely to win with a jury than with a judge?
Also, I have to admit I don’t usually aspirate first when performing the inferior alveolar block, I guess I should start, but the most I ever inject is like 5 cc. I think bupivicaine is more dangerous for vascular injection than lidocaine.
It's easier to criticize a peer than someone you look up to. Judges see doctors as peers. Despite everything you read online, most people really do still trust doctors, so when they get on a jury they usually still trust them.
Intravascular injection of bupivicaine is absolutely contraindicated as it is notoriously cardiotoxic and sends the heart into non-resuscitatable V-fib. A 30ml dose of intravascular 1% bupivicaine is an absolute fatal dose, even assuming that much of the injection did not enter the circulation.
Sounds like this dentist just impaled the nerve and may have caused permanent injury like a traumatic neuroma. I say this because the anesthesiologist who testified against me in my bupivicaine Bier block case ( the nurse handed me Bupivicaine when I had clearly asked for xylocaine) testified that for the procedure I was doing, he would NOT have done an axillary block but instead would have done the Bier block because he was worried about a stray needle impaling one of the nerves in the axillary plexus and causing permanent injury.
Unlike vascular catheterizations which nowadays are guided with ultrasound, when doing a nerve block, the position is "tested" by seeing if transient paresthesias are elicited as one advances the needle before injecting or at least that was how it was done while I was still practicing before my license suspension in my above case. Not sure, but they would also perform aspiration because of the proximity of the axillary artery and vein. But for an alveolar sensory nerve block? Come on.
But this dental expert's opinion seems rather vague in that it is based more on theory and possibility.
I think this case should have been tried in front of a jury. I got smoked in Natchez, Mississippi in 2016 when I treated a 50 year old female with an IM rod for an open fracture that later got infected and ultimately required an BKA. I was a white male surgeon who was leaving Natchez. My patient was black. The female judge was black. Her husband was black and a plaintiff's attorney and this court in Natchez had a reputation for being very Plaintiff friendly. And my case was a bench trial in front of this judge. Now what chance did I have?
Just to clarify, I think the toxic dose of lidocaine you quoted assumes local injection. I’m pretty sure the toxic dose if injected intravascularly is much lower. After all, 100 mg of intravascular lidocaine can have cardiac consequences since it’s the therapeutic antiarrhythmic dose.
That's an interesting point I hadn't thought of but actually makes sense. A brief search didn't turn up any research on toxic doses between local and intravascular, have you come across anything?
Is there an explanation on how the judge arrived at these numbers?
Nope, they never do that. I saw a case once where the jury asked the judge if they could give an explanation attached to their verdict, and the judge said no. Attorneys will sometimes ask to speak with the jury after the trial to get feedback, but the jury doesn't have to do so if they don't want to, and what they do say isn't put in any official court documents.
A nerve block using Lidocaine WITH Epi? The Epinephrine is unnecessary for a nerve block, and may have contributed to the initial symptoms.....
The epi makes the nerve block last longer
That is true. Personally, when I do nerve blocks, I avoid epi (I don’t want the block to last too long, and i’ve seen more of these episodes of vasovagal syncope with brief pseudoseizures than without). I’m not a dentist, just a humble ER guy working in UC, so what do i know?
I do them without epi but I don't think it's necessarily wrong as far as I'm aware.
Ok, yeah. The Epi concentration is 1:100,000, so if injecting a few mL not a big deal, but, I would think that if you did get a vein it might have some effect....
It’s not unheard of- my prior dentist used epi with the anesthetic.