"Baby girl dies after dental procedure in North Austin."

[chocomorsel]

I think this is the take-home message here, for the residents. Whatever you do, put the patient first. It might not score points with the surgeon/dentist, or with your employer/partners, but it's the right thing to do. Don't just roll over; as an anesthesiologist, you are also a patient advocate.

But don't just say No. Get all the facts, and communicate with all parties, without prejudice. You might be missing something. So ask the surgeon what are you missing.

Much easier said than done. I would not have a job if I did this ****. However, maybe it's time for a different gig. Tell me how you tell a spine surgeon that this spinal fusion is not going to help. In your opinion.

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[deleted171991]

Much easier said than done. I would not have a job if I did this ****. However, maybe it's time for a different gig. Tell me how you tell a spine surgeon that this spinal fusion is not going to help. In your opinion.

That you can't. I completely understand. You don't have a leg to stand on. Same goes for all the crappy pain procedures I used to provide sedation for. At least most of the pain docs were decent people.

But when the patient is scheduled for valve surgery and the valve looks fine on TEE, there needs to be a discussion before cracking the chest. If the patient doesn't meet criteria for the surgery, and you can prove it, that's a battle to pick.

 

[Chloroform4Life]

http://keyetv.com/news/local/parents-of-daisy-torres-look-for-answers-after-14-month-olds-death


"I asked them 'is something wrong with my daughter? Is she okay?' and the dentist said 'we have everything under control. We did CPR. She is fine.'"

We did CPR and she is fine should never be in the same sentence or paragraph.

 

[IkeBoy18]

That you can't. I completely understand. You don't have a leg to stand on. Same goes for all the crappy pain procedures I used to provide sedation for. At least most of the pain docs were decent people.

But when the patient is scheduled for valve surgery and the valve looks fine on TEE, there needs to be a discussion before cracking the chest. If the patient doesn't meet criteria for the surgery, and you can prove it, that's a battle to pick.

When I was on CT surgery as a med student, there was a pt scheduled for aortic valve replacement, hx of IVDU, huge vegetation seen on TTE. After induction the anesthesiologist dropped a TEE and there was only a very small flagellated mass on the valve, with no valve dysfunction, nothing that warranted surgery to her knowledge. She informed the CT surgeon and in the next 30 min, there was a room of at least 10 cardiologists all taking their shot at visualizing the mass, 7 said it wasnt worth the surgery, 2 were indifferent and one said definitely yes, the anesthesiologist said no. Surgeon decided to go ahead with surgery. Long story short pt ended up not doing to well in the CVICU for a couple of weeks and ultimately died, Im not sure of the cause.

Long story short, even with 8 physicians agreeing a patient doesnt need surgery, the patient got surgery. Def a tall task for a lone anesthesiologist.

 

[WholeLottaGame7]

Still unclear to me what happened. Anesthesiologist or dental anesthesiologist? Protected airway or no airway? It sounds like maybe a dental anesthesiologist and a native airway but that's pure speculation.

I hate reading these stories. Almost always totally avoidable, at multiple stages (from decision to do procedure, to choice of anesthetic, to recognition of problems, to treatment of problems).

 

[Noyac]

Still unclear to me what happened. Anesthesiologist or dental anesthesiologist? Protected airway or no airway? It sounds like maybe a dental anesthesiologist and a native airway but that's pure speculation.

I hate reading these stories. Almost always totally avoidable, at multiple stages (from decision to do procedure, to choice of anesthetic, to recognition of problems, to treatment of problems).

Yes, totally avoidable.
But we have all been in the situation were its a soft call. One soft call after another. And then the next thing you know, your in up to your neck in ****.

 

[Temeraire]

One soft call after another. And then the next thing you know, your in up to your neck in ****.

I'm gonna make myself remember this quote when I hit CA-1 year.

 

[jwk]

You absolutely should tell the surgeon you don't want to do a procedure if you think it's unnecessary or pointless or unethical. I can't believe you're that defeated that you let others dictate the way you practice to that point that what you do will send you to hell. If that is the "world of anesthesiology" then I shudder at it. Do all anesthsiologists roll over so easily?

With your rationale, elective cosmetic surgery of any sort should never occur.

 

[Noyac]

With your rationale, elective cosmetic surgery of any sort should never occur.

What about D&C's?

 

[Ignatius J]

Still unclear to me what happened. Anesthesiologist or dental anesthesiologist? Protected airway or no airway? It sounds like maybe a dental anesthesiologist and a native airway but that's pure speculation.

I hate reading these stories. Almost always totally avoidable, at multiple stages (from decision to do procedure, to choice of anesthetic, to recognition of problems, to treatment of problems).

I only have heard hearsay so please take this as a grain of salt. What I heard secondhand from someone that would know is that the anesthesiologist very well may have made a "res ipsa loquitur" type of mistake.

Again- this is real life and serious so don't hang your hat on that. The facts will eventually come out.

 

[DavesNotHere]

With your rationale, elective cosmetic surgery of any sort should never occur.

That's not at all what I said. I said [if the anesthesiologist thinks] the procedure is unnecessary or pointless or unethical they shouldn't do it.

 

[DavesNotHere]

just going to bud out. this was a tragedy.

 

[WholeLottaGame7]

just going to bud out. this was a tragedy.

Not sure why you edited your post; I was going to reply earlier but was busy. I was just guessing because kids don't "stop breathing" in the middle of a case with an ETT in place, unless it becomes dislodged (possible, but most of the peds dentists I work with are pretty careful about that kind of thing and would communicate that if it happened). Even though it's an article for laypeople, the description and the timing made me think native airway. There was also that other recent event with the kid cocooned that may have primed my assumptions. And I guessed dental anesthesiologist based on the assumption of native airway and the fact that peds anesthesiologists don't usually practice in dental clinics and I don't know many non-peds trained anesthesiologists who would feel comfortable taking care of 14 month olds in a dental clinic.

But like I said, that was all 100% assumption, and I could be totally wrong. It could have been an actual anesthesiologist, and there was a secured airway, and s*** still went bad. Totally possible. I'm just contributing my opinion based on the very scant facts presented.

 

[DaleDoback]

Not sure why you edited your post; I was going to reply earlier but was busy. I was just guessing because kids don't "stop breathing" in the middle of a case with an ETT in place, unless it becomes dislodged (possible, but most of the peds dentists I work with are pretty careful about that kind of thing and would communicate that if it happened). Even though it's an article for laypeople, the description and the timing made me think native airway. There was also that other recent event with the kid cocooned that may have primed my assumptions. And I guessed dental anesthesiologist based on the assumption of native airway and the fact that peds anesthesiologists don't usually practice in dental clinics and I don't know many non-peds trained anesthesiologists who would feel comfortable taking care of 14 month olds in a dental clinic.

But like I said, that was all 100% assumption, and I could be totally wrong. It could have been an actual anesthesiologist, and there was a secured airway, and s*** still went bad. Totally possible. I'm just contributing my opinion based on the very scant facts presented.

As an oral surgeon, my group has a pediatric board certified anesthesiologist who comes into my office (where I have a fully functioning anesthesia machine) maybe once a month for what we call "Pedo Morning". Any healthy kids with simple procedures younger than 10 or so will get intubated (if needed, sometimes just an LMA) for our 10-15 minute procedure. Of course it all depends on the patient and the procedure. I've been fully involved in an airway emergency in the room even with this guy there. No matter who you are, what your training, **** can still hit the fan and it can possibly be a tragedy. I don't pretend to be an anesthesiologist, but I'm smart enough to know that.

That's what scares me about all the super-dentists thinking IV anesthesia after a weekend course is ok. I'm fighting that in my state currently. They are even trying to teach it in the dental schools now. Very dangerous time for dentistry and its involvement in anesthesia.

Always enjoy scanning your threads to further my education.

 

[PainDrain]

As an oral surgeon, my group has a pediatric board certified anesthesiologist who comes into my office (where I have a fully functioning anesthesia machine) maybe once a month for what we call "Pedo Morning". Any healthy kids with simple procedures younger than 10 or so will get intubated (if needed, sometimes just an LMA) for our 10-15 minute procedure. Of course it all depends on the patient and the procedure. I've been fully involved in an airway emergency in the room even with this guy there. No matter who you are, what your training, **** can still hit the fan and it can possibly be a tragedy. I don't pretend to be an anesthesiologist, but I'm smart enough to know that.

That's what scares me about all the super-dentists thinking IV anesthesia after a weekend course is ok. I'm fighting that in my state currently. They are even trying to teach it in the dental schools now. Very dangerous time for dentistry and its involvement in anesthesia.

Always enjoy scanning your threads to further my education.

Well said.

 

[PainDrain]

I don't know what to tell you. I saw rough estimate 20 last year in one hospital that had to stay tubed 24h past i+d by ENT or oral surgery. Far more than that who had to stay in for 3 days of iv abx.

edit - that ***17***were patients that went to the MICU and included mostly adult or adult size patients. I went back and counted 78 infections attributed to dental or oral source in 13 months requiring inpatient stay for 3 days or more that I had contact with or was on the patiet lists i have access to. Admittedly, staying intubated isn't the norm. My jimmies were rustled for no good reason and i went with an extreme.

Again, don't mean to call this bull**** but in 7 years of anesthesia practice I have yet to see a dental issue requiring intubation and prolonged mechanical ventilation. I have seen OMFS issues such as jaw wiring and facial reconstruction/trauma that required such but those instances I can count on one hand. Where the hell do you practice? Perhaps you should hand out some toothbrushes, listerine and some floss.

 

[DaleDoback]

Again, don't mean to call this bull**** but in 7 years of anesthesia practice I have yet to see a dental issue requiring intubation and prolonged mechanical ventilation. I have seen OMFS issues such as jaw wiring and facial reconstruction/trauma that required such but those instances I can count on one hand. Where the hell do you practice? Perhaps you should hand out some toothbrushes, listerine and some floss.

I'll vouch for it. Odontogenic infections (from bad teeth) get treated weekly at my institution. The bad ones include the parapharyngeal spaces. Requires extraoral incision and drainage. True Ludwigs maybe once every 6 months. My anesthesiologist team is great at awake fiberoptic which is required often. If it's a difficult airway, we keep them intubated for a few days in the MICU.

It's a complete waste of money. I wish I knew what it cost for their total stay. Definitely more expensive than a toothbrush.

 

[jwk]

That's not at all what I said. I said [if the anesthesiologist thinks] the procedure is unnecessary or pointless or unethical they shouldn't do it.

But you did.

Unnecessary - breast augmentations, facelifts, ad nauseum
Pointless - any number of surgical procedures on patients in "persistent vegetative states" - debated numerous times on SDN
Unethical - many would argue elective abortions fit this category

Yet we do these cases every day.

 

[WholeLottaGame7]

As an oral surgeon, my group has a pediatric board certified anesthesiologist who comes into my office (where I have a fully functioning anesthesia machine) maybe once a month for what we call "Pedo Morning". Any healthy kids with simple procedures younger than 10 or so will get intubated (if needed, sometimes just an LMA) for our 10-15 minute procedure. Of course it all depends on the patient and the procedure. I've been fully involved in an airway emergency in the room even with this guy there. No matter who you are, what your training, **** can still hit the fan and it can possibly be a tragedy. I don't pretend to be an anesthesiologist, but I'm smart enough to know that.

That's what scares me about all the super-dentists thinking IV anesthesia after a weekend course is ok. I'm fighting that in my state currently. They are even trying to teach it in the dental schools now. Very dangerous time for dentistry and its involvement in anesthesia.

Always enjoy scanning your threads to further my education.

It can totally happen to anyone, that's part of the point. The article definitely mentioned anesthesiologist; it just wasn't clear what type. I presumed that some places had a setup like yours, but it wasn't clear if that's what this was or not.

Even as a peds trained anesthesiologist, I'd be a little nervous being the sole provider at a remote off-site location with that age group. We will do sedation solo down in MRI for instance, but if we know we're going to be instrumenting airways, we usually call in assistance (CRNA, resident, other attending, etc).

And I am admittedly not fully in the know about dental anesthesia training, but I'm pretty sure it's not 3 dedicated years of anesthesia plus a year of pediatric fellowship. I applaud you for recognizing your limitations and feel like most of your colleagues (at least the ones I work with) are the same.

 

[DaleDoback]

It can totally happen to anyone, that's part of the point. The article definitely mentioned anesthesiologist; it just wasn't clear what type. I presumed that some places had a setup like yours, but it wasn't clear if that's what this was or not.

Even as a peds trained anesthesiologist, I'd be a little nervous being the sole provider at a remote off-site location with that age group. We will do sedation solo down in MRI for instance, but if we know we're going to be instrumenting airways, we usually call in assistance (CRNA, resident, other attending, etc).

And I am admittedly not fully in the know about dental anesthesia training, but I'm pretty sure it's not 3 dedicated years of anesthesia plus a year of pediatric fellowship. I applaud you for recognizing your limitations and feel like most of your colleagues (at least the ones I work with) are the same.

100% agree. Personally, I think dental anesthesia training does not make you adequate to be the sole provider in a setting like that, especially on an 18 month old. Dental anesthesia is not even a recognized specialty within the ADA. I think that speaks worlds.

Youngest kid we've ever done in our office with a peds anesthesiologist is still like 5. Anything less than that, they are going to the OR.

Honestly, I wish I never had to do kids at all in the office. When I see the 4 year old consult on my schedule, I start to pucker regardless. Pedi dentists shouldn't "walk to hell" because these kids need treatment. Parents should be arrested because of it.

Still, saying baby teeth don't need treatment just because they will fall out is false and uneducated.

 

[DavesNotHere]

But you did.

Unnecessary - breast augmentations, facelifts, ad nauseum
Pointless - any number of surgical procedures on patients in "persistent vegetative states" - debated numerous times on SDN
Unethical - many would argue elective abortions fit this category

Yet we do these cases every day.

Again...No, I didn't. You're putting your own bias on my words. I said the anesthesiologist should only do cases he/she thinks are necessary, ethical, and have value. I think cosmetic procedures have value and I don't think all abortions are unethical. My point is that the anesthesiologist shouldn't do a case they don't approve. So stop trying to imply I'm saying something that I clearly am not.


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[DavesNotHere]

Again, don't mean to call this bull**** but in 7 years of anesthesia practice I have yet to see a dental issue requiring intubation and prolonged mechanical ventilation. I have seen OMFS issues such as jaw wiring and facial reconstruction/trauma that required such but those instances I can count on one hand. Where the hell do you practice? Perhaps you should hand out some toothbrushes, listerine and some floss.

Not sure what to say...our hospital does a good amount of submandibular/subligual and deep neck space abscesses which stay intubated after I+D that are 2/2 to a dental infection. Of course they are managed by OS or ENT and not a dentist, but the problem could have been abated by the dentist. It's a very low socioeconomic place, but this stuff isn't rare.


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[DavesNotHere]

It can totally happen to anyone, that's part of the point. The article definitely mentioned anesthesiologist; it just wasn't clear what type. I presumed that some places had a setup like yours, but it wasn't clear if that's what this was or not.

Even as a peds trained anesthesiologist, I'd be a little nervous being the sole provider at a remote off-site location with that age group. We will do sedation solo down in MRI for instance, but if we know we're going to be instrumenting airways, we usually call in assistance (CRNA, resident, other attending, etc).

And I am admittedly not fully in the know about dental anesthesia training, but I'm pretty sure it's not 3 dedicated years of anesthesia plus a year of pediatric fellowship. I applaud you for recognizing your limitations and feel like most of your colleagues (at least the ones I work with) are the same.

The training is 3 years after dental school. Usually 3-4 months is spent doing internal medicine as an intern. Depending on the program residents dedicate about half their time to outpatient GA on peds. I'm fully aware that convincing a board of anesthesiologists that this training is adequate is totally fruitless but the safety record is unparalleled, and the programs have been around for 60 some years.

I agree 100% that having a second set of trained hands available makes it far safer. And patient selection above all else may be the most important skill.

The bottom line is that many cases are not suited for outpatient, regardless of provider training. And I really hope that in the future patient safety is emphasized despite whatever economic climate anesthesia providers may find themselves in


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[jwk]

I said the anesthesiologist should only do cases he/she thinks are necessary, ethical, and have value. I think cosmetic procedures have value and I don't think all abortions are unethical.

I agree that cosmetic procedures have value - but they're not by and stretch of the imagination "necessary".

 

[Psai]

The training is 3 years after dental school. Usually 3-4 months is spent doing internal medicine as an intern. Depending on the program residents dedicate about half their time to outpatient GA on peds. I'm fully aware that convincing a board of anesthesiologists that this training is adequate is totally fruitless but the safety record is unparalleled, and the programs have been around for 60 some years.

I agree 100% that having a second set of trained hands available makes it far safer. And patient selection above all else may be the most important skill.

The bottom line is that many cases are not suited for outpatient, regardless of provider training. And I really hope that in the future patient safety is emphasized despite whatever economic climate anesthesia providers may find themselves in


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Are you a dental anesthetist?

 

[Chloroform4Life]

Are you a dental anesthetist?

Yes he is.

 

[periopdoc]

How many teeth could this kid possibly have and how decayed could they have been that it required a cavity filling?

All of them, and they will likely need crowns not just fillings. If they don't get treated now the decay will spread to the permanent teeth before they erupt (and that's ignoring the reasonable likelihood the child will have failure to thrive from the pain of eating and a fair risk of developing a life-threatening infection). We see a ton of these where I live now. After having never seen them before moving here, it really is eye opening.

When I was on CT surgery as a med student, there was a pt scheduled for aortic valve replacement, hx of IVDU, huge vegetation seen on TTE. After induction the anesthesiologist dropped a TEE and there was only a very small flagellated mass on the valve, with no valve dysfunction, nothing that warranted surgery to her knowledge. She informed the CT surgeon and in the next 30 min, there was a room of at least 10 cardiologists all taking their shot at visualizing the mass, 7 said it wasnt worth the surgery, 2 were indifferent and one said definitely yes, the anesthesiologist said no. Surgeon decided to go ahead with surgery. Long story short pt ended up not doing to well in the CVICU for a couple of weeks and ultimately died, Im not sure of the cause.

Long story short, even with 8 physicians agreeing a patient doesnt need surgery, the patient got surgery. Def a tall task for a lone anesthesiologist.

One of the reasons I love my surgeon. If I told him definitively that the patient didn't need surgery, he would cancel it right then and there. If I had any doubts, we would call the cardiologist to come up and give an opinion.

Incidentally, a small, flagellated mass on the aortic valve is a clear indication for replacement. One might argue for delay if there were concerns about the patient's current health and ability to tolerate bypass, but the valve should be replaced.

-bsd