Sedation mix-up sends high school senior to ICU

Apr 20, 2009

2009 04 20 13 30 32 30 Nitrous Oxide Oxygen 70

When Austin Stone, a high school senior in Lawrence, KS, needed his wisdom teeth removed, he went to veteran oral surgeon S. Kirk Vincent, D.D.S.

In fact, on March 30, he was the very first patient in Dr. Vincent's new dental surgery center, which had just opened.

“Before you get a building permit, you need to have a certified plumber.”
— S. Kirk Vincent, D.D.S.

Hours later he was in the intensive care unit at the University of Kansas Hospital, where he remains today, the victim of improper installation of the medical gas lines, according to Dr. Vincent.

"There are a lot of cities throughout the U.S. that do not have adequate inspection criteria for medical gases, and we are trying to get this changed," he told DrBicuspid.com. "Before you get a building permit, you need to have a certified plumber. And at the completion of the process, you need verification performed on your system before you get your occupancy permit stamped."

Dr. Vincent declined to provide details of what happened on March 30, but a story published April 17 in the Lawrence Journal World said that after Stone was sedated, "complications occurred" and he was taken to a local hospital "after he stopped breathing."

The newspaper quoted a letter it said Dr. Vincent wrote to the Lawrence building inspection department on April 8 in which Dr. Vincent states, "The individual manifolds used to connect the oxygen and nitrous oxide were inadvertently transposed. I was given the go-ahead to begin practicing, and a serious injury occurred to a young man in my office. The problem was solely related to the incorrect hookup of the manifolds."

Scott McCullough, director of planning and development services, which oversees the city's inspections department, told the Lawrence Journal World that the city is not legally obligated to ensure that a qualified private firm was hired by the builders to inspect the medical gas system, but that city code does require the contractor to hire an outside inspection company to conduct a variety of tests on the medical gas system. He also told the newspaper that Dr. Vincent should have received a certificate from the contractor showing that the medical gas inspection had been completed.

Dr. Vincent never received that certificate nor was he aware he needed it, so he didn't know to ask for it, he said.

"Being an oral surgeon, I am not a plumber or an electrician or a contractor," he told DrBicuspid.com. "The assumption was made that the plumbers were certified."

In his April 8 letter, Dr. Vincent asked that the city be required to verify that a proper inspection of medical gas systems has been done before a building is allowed to be occupied.

A Web site set up by the Stone family has been chronicling the young man's condition; a posting on April 15 reads in part:

"Austin has been up and down since the last posting. ... They have moved him to a different ICU unit that requires a little less one-on-one. ... Austin has started physical therapy and when the therapist asked him to squeeze her hand he did as she asked. ... Please know that if Austin's (web site) isn't updated that everything is staying on an even keel."

According to a new posting on April 22, "Austin doesn't seem to be doing some of the things that he was before. Such as responding to voices and touch. He is still moving his limbs and opening his eyes but he is still mentally somewhere else. Austin will be moving to a rehabilitation facility hopefully in the near future. ... Austin isn't quite well enough for this today or tomorrow but probably within a week. He won't be able to go until they feel he is stable in his condition."