Cali dental anesthesia death

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W222 said:
I am only speculating on this but I am assuming there was no anethesiologist present. No one should go for a wisdom teeth removal and die.

http://usnews.nbcnews.com/_news/2013/04/03/17580165-24-year-old-dies-after-wisdom-teeth-surgery?lite
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I didn't know oral surgeons are allowed to administer propofol. I hope this guy hired Johnny Cochran, cause he is gonna need a good lawyer.

As far as mortality from wisdom teeth extraction, there are some cases of air embolism, but that doesn't sound present in this case.
 
As far as I know, oral surgeons can do general anesthesia, ET tube, the whole gamut. In residency, the OMFS residents spent 3 months on anesthesia and were just like CA-1s, taking CA-1 call, doing the whole range of cases (with an emphasis on OMFS cases). In general they were very good. Should they be providing general anesthesia while concurrently performing surgery? I don't think so, but I think it is commonplace.
 
My oral surgery friends ask me what I think about them administering anesthesia in their offices and I tell them flat out I don't think it's safe. I would never allow my sons to be put under GA by some office based dentist. They have no clue what they are doing and if there is a major complication they realllllyy have no clue.
 
Now, I realize the media is far from accurate in their description but it sounds like he started to get agitated and the oral surgeon simply decided he needed more propofol. Sounds also like he may have lost the throat pack. Surgeon likely panicked and it all hit the fan.
 
W222 said:
Now, I realize the media is far from accurate in their description but it sounds like he started to get agitated and the oral surgeon simply decided he needed more propofol. Sounds also like he may have lost the throat pack. Surgeon likely panicked and it all hit the fan.
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Or that agitation was the first presentation of hypoxemia.

But one thing I've learned is to not judge others when you were not there, especially based on information presented by lay media over the internet.
 
cincincyreds said:
I didn't know oral surgeons are allowed to administer propofol. I hope this guy hired Johnny Cochran, cause he is gonna need a good lawyer.

As far as mortality from wisdom teeth extraction, there are some cases of air embolism, but that doesn't sound present in this case.
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That would be neat, since Cochrane's been dead for 7-8 years now 😳

But yeah, OMG.

Also, still demonizing Propofol in that article: "the drug that killed Michael Jackson". Good gracious.
 
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Its good that they are demonizing it. It needs to be respected. Thats the point.
 
I think this is essentially the one scenario where you can successfully sue a dentist in CA.
 
Heartbreaking story. Terrible tragedy. I agree with RSGill. Without being there, it is hard to pass judgment about what occurred based on the little that we know.
It is tough to lose someone so young.
 
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Seba said:
My oral surgery friends ask me what I think about them administering anesthesia in their offices and I tell them flat out I don't think it's safe. I would never allow my sons to be put under GA by some office based dentist. They have no clue what they are doing and if there is a major complication they realllllyy have no clue.
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It's quite common for oral surgeons to give deep sedation in their office for things like wisdom teeth extractions, which in most cases is fine. Some of the more aggressive ones do general anesthesia, but if they're smart, they'll leave that to someone else and not try to do both at once. Oral surgery residents do in fact get 3-6 months of formal anesthesia training, and function as an anesthesia resident, so the idea that "they have no clue what they are doing" is baseless.
 
usnavdoc said:
Its good that they are demonizing it. It needs to be respected. Thats the point.
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All prescription drugs deserve some respect. But it would be nice to see the sensationalists be more specific - the incorrect use of Propofol and subsequent events related to incorrect use killed MJ.
 
I was recently involved in a review of our hospital's policy on sedation done by non-anesthesia personnel. In it, there are provisions for dentists to perform deep sedation and general anesthesia, provided the following requirements are met:

They have to have been credentialed to do so, they have to have someone else in the room be responsible solely for monitoring, and if the sedation line is crossed into GA, they must bring another credentialed attending into the room during that period of time.

I have no idea how often this actually occurs.
 
cchoukal said:
I was recently involved in a review of our hospital's policy on sedation done by non-anesthesia personnel. In it, there are provisions for dentists to perform deep sedation and general anesthesia, provided the following requirements are met:

They have to have been credentialed to do so, they have to have someone else in the room be responsible solely for monitoring, and if the sedation line is crossed into GA, they must bring another credentialed attending into the room during that period of time.

I have no idea how often this actually occurs.
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As I am sure you know, a distinction must be made between dentist and oral surgeon. As mentioned, oral surgeons have some training in anesthesiology (more than just classroom).

I let my kids get theirs done with sedation at an oral surgeons office, but I took the day off and was 15 feet outside the room with the promise that they would step out and get me if there was any type of event. The whole thing was done in 20 minutes.
I was worried enough about it to take the day off and I like to think they would have called me in if anything bad were occurring, but you never can tell if, in the heat of the moment, they would have done that.

I definitely have a fear (respect) of deep sedation or general anesthesia in a dentist or oral surgeon's office.
 
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UCSFx2017 said:
http://www.ncbi.nlm.nih.gov/m/pubmed/19022119/

RESULTS: The frequency of office anesthetic complications occurring in 2004 were consistent with our previous studies. There was 1 office death, for a mortality rate of 1/1,733,055. The incidence of other specific anesthetic-related complications is documented.
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They know the stats. Don't have to bring it up.

As you can tell by the comments, they are actually pretty nice about the situation of oral surgeons doing sedation.

They train us, now for a minimum of 5 months, to do our in office sedations. This is unheard of in medicine as everyone fights over turf. Sure everyone spends a little bit of time on a whole slew of other services but nothing like we do on anesthesia's service.

And someone died. Which even when it's 1/million, its still one.
 
B-Bone said:
As far as I know, oral surgeons can do general anesthesia, ET tube, the whole gamut. In residency, the OMFS residents spent 3 months on anesthesia and were just like CA-1s, taking CA-1 call, doing the whole range of cases (with an emphasis on OMFS cases). In general they were very good. Should they be providing general anesthesia while concurrently performing surgery? I don't think so, but I think it is commonplace.
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There is a reason why this residency is 3 years. 3 months of anesthesia is basically nothing in my opinion. Also, these 3 months are done way before the OMFS resident finally becomes an attending so they are "rusty" with providing anesthesia at best. Don't know how it works elsewhere but The OMFS residents at my place do the routine easy cases. How could they possibly do anything other than easy cases if they are just spending 3 months in anesthesia? So they are NOT like CA-1's doing the whole range of cases because the actual CA-1's may be in the 10th month of CA-1 year and that makes a huge difference on what cases they do. A pt who does not have any spontaneous purposeful activity (verbal/physical) is under GA and an anesthesiologist should be present IMO. "Deep sedation" is a BS term..
 
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gasp said:
There is a reason why this residency is 3 years. 3 months of anesthesia is basically nothing in my opinion. Also, these 3 months are done way before the OMFS resident finally becomes an attending so they are "rusty" with providing anesthesia at best. Don't know how it works elsewhere but The OMFS residents at my place do the routine easy cases. How could they possibly do anything other than easy cases if they are just spending 3 months in anesthesia? So they are NOT like CA-1's doing the whole range of cases because the actual CA-1's may be in the 10th month of CA-1 year and that makes a huge difference on what cases they do. A pt who does not have any spontaneous purposeful activity (verbal/physical) is under GA and an anesthesiologist should be present IMO. "Deep sedation" is a BS term..
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Amen to this post. I have witnessed several "dental anesthesia" F ups and couldn't agree more with the above.
 
Seba said:
My oral surgery friends ask me what I think about them administering anesthesia in their offices and I tell them flat out I don't think it's safe. I would never allow my sons to be put under GA by some office based dentist. They have no clue what they are doing and if there is a major complication they realllllyy have no clue.
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They are trained to do what they do very well. 99.99% of the time they do not have complications, and I would suspect their overall complication rate is similar to ours. If oral surgeons were out killing people over wisdom teeth we wouldn't be making a big deal out of a singular case (out of the millions performed every year).
 
gasp said:
There is a reason why this residency is 3 years. 3 months of anesthesia is basically nothing in my opinion. Also, these 3 months are done way before the OMFS resident finally becomes an attending so they are "rusty" with providing anesthesia at best. Don't know how it works elsewhere but The OMFS residents at my place do the routine easy cases. How could they possibly do anything other than easy cases if they are just spending 3 months in anesthesia? So they are NOT like CA-1's doing the whole range of cases because the actual CA-1's may be in the 10th month of CA-1 year and that makes a huge difference on what cases they do. A pt who does not have any spontaneous purposeful activity (verbal/physical) is under GA and an anesthesiologist should be present IMO. "Deep sedation" is a BS term..
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Nobody is claiming they're experts at anesthesia, but you gotta remember they're looking at a relatively narrow slice of "anesthesiology". No blocks or regionals, no invasive lines, no CCM, no chronic pain management, no hearts, thoracic, vascular or neuro, etc., etc. The oral surgery residents where I trained did a fair amount of big cases though, particularly head and neck and, oh yeah, OMF cases, and ours did as much as six months. They're not ready to do hearts on their own, but they can handle (and routinely do) far more than you give them credit for.

You should review the distinctions between the different levels of sedation and anesthesia. Deep sedation is not a BS term - it has a specific definition, but along with that goes the concept that one should be able to manage one level "deeper" than the level you intend to use, meaning if you're using deep sedation, you should be able to manage GA as well.
 
jwk said:
Nobody is claiming they're experts at anesthesia, but you gotta remember they're looking at a relatively narrow slice of "anesthesiology". No blocks or regionals, no invasive lines, no CCM, no chronic pain management, no hearts, thoracic, vascular or neuro, etc., etc. The oral surgery residents where I trained did a fair amount of big cases though, particularly head and neck and, oh yeah, OMF cases, and ours did as much as six months. They're not ready to do hearts on their own, but they can handle (and routinely do) far more than you give them credit for.
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Even if they are adequate for common cases after 3 month training, they probably will never induce and manage GA again for the rest of residency or their life. They lose these skills quickly.
 
jwk said:
They're not ready to do hearts on their own, but they can handle (and routinely do) far more than you give them credit for.
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They are not ready to do ANYTHING on their own period
 
Historically the common thread in these dental deaths is usually polypharmacy. Something like PO Valium, then some IV Versed, IV fentanyl, maybe some nitrous. Multiple drug classes, multiple routes.

This is the first dental death I recall reading about that involved propofol.


Every once in a while I get sucked into doing dental sedations for wisdom teeth extraction. (A stupid consequence of our anesthesia department 'owning' all of the sedation nurses, being responsible for their scheduling at all sites, and being responsible for covering for them if they call in sick.) I am convinced that straight propofol is the wrong drug for this, no matter who's doing the sedation.
 
One time a patient died under an anesthesiologists care; therefore, anesthesiologists should not perform anesthesia. The end.



gasp said:
They are not ready to do ANYTHING on their own period
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Hey everyone first post on this forum. Just saw this thread from
one of my medical co-residents who is on rotation with me at the
Children's hospital.

Anyway, I was wondering what you guys thought about Dental
Anesthesiologists? I am sure most of you do not know what this is or
even that exists so let me explain. There are only 10 total programs
(9 in the US 1 in Canada). Most of these programs are two years in
length, some are 3 years. My program is 27 months. However, they will
all be moved to 3 years starting next July 1st (2014). Some programs
are very hopsital based (more than 95% of residency is in the hospital
doing anesthesia or on rotation related to anesthesia). While others
will spend a good portion of residency completing anesthesia cases in
an outpatient dental environment. Even these programs will spend more
than half of the residency in the hospital.

I can only speak of my program at Ohio State but I would think
there would be some similarities to the other programs. I am currently
a first year resident at Ohio State in Dental Anesthesia. I will do my
best to explain our program. Below is link to our curriculum.

http://dentanes.osu.edu/aboutus/curriculumplan/index.cfm

When we are not in the hospital are focus is on Dental Cases. These
vary from the healthy 18 year old for wisdom teeth, the MRDD 35 year
old, the 2 year old pedatric patient, and the 70 year old patient with
a few co-morbities. I would say 80% of our patients are intubated (the
ones who are not are generally third molar extraction cases on healthy
14-30 year olds).

Upon completion of our program almost everyone practices
anesthesia only. Like you, we feel the medical model of anesthesia is
far superior then the operator/anesthetist solo provider model. Most
of our graduates will practice in an outpatient mobile anesthesia
practice. Some will join large dental groups are provide the
anesthesia for that office and a very few will practice in a hopstial
setting.

Just some answers to a few questions you guys may have below.

#1. Why is this even needed? Can't dentists just bring their cases to
the hospital or surgery center?

You are absoltely correct, dentists can bring cases to these
enviroments. However, dentists have found they recieve minimal time
(have huge patient waiting lists) or the costs are very substantial
even with insurance.

#2. Why can't MD/DO Anesthesiologists or CRNAs do cases at the dental office?

They can and in fact some do. However, most dentists have
had difficulty getting these providers to argee to leave their
insituations and complete cases in the dental office. Most Dental
Anesthesiologists have thier practice set up like a small business.
They provide all the neccessary equipement/medications necessary to
safely and legally provide anesthesia in a dental office.

#3. Some patients are not healthy enough to recieve anesthesia in an
outpatient environment.

I complete argee with this statement and believe a very
important point of residency is learning who is and who is not a
candiate for outpatient anesthesia.

In no way do I claim to be the equal to a MD/DO
anesthesiologists. We do different cases (more simple) and in
different environements. I do not go into the heart rooms during my
residency (do go into cath rooms) or get very much exposure if any to
big neuro cases. I do my best to be the equal of my MD co-residents
when we do the same procedures kidneys, GS, ortho, etc or on AKTs. I
then try to out perform them when I do cases more familar with my
territory (MRDD patients, large jaw surgeries, open airway, etc). As
of now I basically function as a CA-1 during my time in residency, but
hopefully when the program moves to three years we get exposed to
bigger cases (Neuro, Cardiac) and take CA-2 call. You may argue we
will not do this in practice. However, we will take care of patients
with a history of these problems, and I personally believe you (dental
anesthesiologists) should be trained at a level above your intended
practice area.

Anyway, I greatly respect my Medical colleagues and just
wanted to hear your thoughts. Feel free to tear me down or ask any
questions you like.
 
Appreciate the mostly respectful remarks from the anesthesia side. It is absolutely devastating to hear of this one in a million scenario and agree that it is one too many. You are correct in that no one should go in for wisdom teeth removal and die, just like no one should die from other simple surgeries in the OR with anesthesiologists (T&A, Myringotomy), but unfortunately, it has happened too. As a science-based profession, you know there will always be that 1/million case that would defeat that logic. Even with a 3-year fully-trained anesthesiologist, I would guess that there's a chance for a 1/million mortality rate.

Side Note: Based on this logic, no one should be murdered with a gun. People in the last hour have been murdered with a gun. Therefore we should have no more guns. Someone's been watching the news.

No one knows exactly what happened. I can promise you that the OMS community respects and understands the expectations of safe anesthesia practices. At my program, we appreciate and are thankful for the anesthesia department to open up their wealth of knowledge to assist in our training. At my program, we do 6 months of anesthesia with an abundance of cases and are treated like CA-1s. While I feel comfortable with my level of training, I do not and will not do hearts anytime soon. I would guess 99% of OMS leave the sick patients for our well-trained anesthesia friends (even when we do their wisdom teeth).

I have to disagree that we don't use our training for 3 more years. Our skills rarely become rusty because we practice anesthesia every single day in the office when taking out thirds and doing our other procedures. Have I handled every single situation that could possibly happen in my office? No, neither have you, but with my training, I feel confident that I could provide an airway (LMA, ETT, Cric, Trach) if I needed. Because of my understanding of the depths of anesthesia and proper monitoring, I hope I don't have to.

Again, we respect and understand the responsibilities associated with office-based anesthesia. Even more, we are grateful for the training we receive from our anesthesia friends. Personally, when I see an anesthsia resident/attending vouch for us, it's a very proud moment.
 
DaleDoback said:
Appreciate the mostly respectful remarks from the anesthesia side. It is absolutely devastating to hear of this one in a million scenario and agree that it is one too many. You are correct in that no one should go in for wisdom teeth removal and die, just like no one should die from other simple surgeries in the OR with anesthesiologists (T&A, Myringotomy), but unfortunately, it has happened too. As a science-based profession, you know there will always be that 1/million case that would defeat that logic. Even with a 3-year fully-trained anesthesiologist, I would guess that there's a chance for a 1/million mortality rate.

Side Note: Based on this logic, no one should be murdered with a gun. People in the last hour have been murdered with a gun. Therefore we should have no more guns. Someone's been watching the news.

No one knows exactly what happened. I can promise you that the OMS community respects and understands the expectations of safe anesthesia practices. At my program, we appreciate and are thankful for the anesthesia department to open up their wealth of knowledge to assist in our training. At my program, we do 6 months of anesthesia with an abundance of cases and are treated like CA-1s. While I feel comfortable with my level of training, I do not and will not do hearts anytime soon. I would guess 99% of OMS leave the sick patients for our well-trained anesthesia friends (even when we do their wisdom teeth).

I have to disagree that we don't use our training for 3 more years. Our skills rarely become rusty because we practice anesthesia every single day in the office when taking out thirds and doing our other procedures. Have I handled every single situation that could possibly happen in my office? No, neither have you, but with my training, I feel confident that I could provide an airway (LMA, ETT, Cric, Trach) if I needed. Because of my understanding of the depths of anesthesia and proper monitoring, I hope I don't have to.

Again, we respect and understand the responsibilities associated with office-based anesthesia. Even more, we are grateful for the training we receive from our anesthesia friends. Personally, when I see an anesthsia resident/attending vouch for us, it's a very proud moment.
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Thanks for the thoughtful post.
 
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DaleDoback said:
Side Note: Based on this logic, no one should be murdered with a gun. People in the last hour have been murdered with a gun. Therefore we should have no more guns. Someone's been watching the news.
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many things to discuss with this post, but the act of living in a world with guns means you know that the sole purpose of guns, the reason they were invented, is to kill people. I dont think there is anyone that would reasonably argue that we should have no guns.

However, we SHOULD have laws restricting the sale and usage of guns from people that will not (criminals) or can not use them safely (children) and may not appreciate the consequences of their actions (children and others).

replace guns with propofol, and you will understand the concern of the anesthesiologists in the room. We get so tired of hearing 'just a quick MAC' or 'just stun him with a little propofol while i take a look at the cords' because we know what can happen.

with that said, im sure there was a provider in the room providing and monitoring the sedation for the oral surgeon, whether it was another surgeon or a nurse, I dont know.
 
yappy said:
One time a patient died under an anesthesiologists care; therefore, anesthesiologists should not perform anesthesia. The end.
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When a pt dies under the care of an anesthesiologist, it is assumed that even the many years of training this person had in anesthesiology was not enough to prevent/fix this anesthetic death (one can argue that well this anesthesiologist sucks but every field has people who suck so lets not use this as an argument). When a pt dies from anesthetic complications under the care of a dentist/OMFS, it is entirely different. Both of these pts deserve to get the most knowledgeable and technically skilled person in the field of anesthesia because people CAN DIE. I can pull teeth too (now lets assume i spend 3-6 months of my residency pulling teeth), but I guarantee you my complication rate in pulling teeth is going to be higher than a dentist/OMFS pulling teeth. Don't you agree? That is why I leave it up to the expert in that field (and pulling teeth doesn't even come close to having potential for fatal complications like anesthesia does). I always hear other fields say stuff like "anesthesia is so easy even a monkey can do it". I guess not ??
 
It is, of course, not our place as anesthesiologists to dictate what does and doesn't fall within the standard of care or credentials/privileges of dentists or other physicians.

But for those non-anesthesiologists (dentists, OMFS'ers, etc) who are posting and reading, there's something you have to understand:

When you ask a bunch of anesthesiologists their opinions on things like sedation and anesthesia, the only answer you can expect, and the only answer you're going to get, is one grounded in our own standard of care. What else are we going to say?

Threads like this, as civil and polite and collegial as we're all being, usually seem to come down to the non-anesthesiologists defending their practice (which is fine) and seeking some sort of approval from us (which isn't going to be forthcoming).

In that sense, this isn't much different than asking us what we think of EM physicians' disregard for NPO considerations when "lightly" sedating people with etomidate for reductions. 😉 We back away slowly with a :uhno: look on our faces because we just don't do things that way ...

We're well aware of the fact that you and they aren't leaving a wide trail of dead bodies behind you, and this is perhaps evidence that we are overly conservative with our society's guidelines and standards.

Even so, there's only one answer you're going to get from us: Safe sedation requires a qualified person, dedicated to the task of sedation and monitoring, not also doing the procedure, with appropriate monitors (to include etCO2 as a de facto standard as of a couple years ago), with appropriate equipment and supplies for resuscitation immediately at hand, with appropriate time space and personnel for recovery prior to discharge. Most dental offices don't meet our standard.

We're not critical because we think you're dumb, or because we're defending our turf. We just think you're doing it wrong. 🙂
 
gasp said:
When a pt dies under the care of an anesthesiologist, it is assumed that even the many years of training this person had in anesthesiology was not enough to prevent/fix this anesthetic death (one can argue that well this anesthesiologist sucks but every field has people who suck so lets not use this as an argument). When a pt dies from anesthetic complications under the care of a dentist/OMFS, it is entirely different. Both of these pts deserve to get the most knowledgeable and technically skilled person in the field of anesthesia because people CAN DIE. I can pull teeth too (now lets assume i spend 3-6 months of my residency pulling teeth), but I guarantee you my complication rate in pulling teeth is going to be higher than a dentist/OMFS pulling teeth. Don't you agree? That is why I leave it up to the expert in that field (and pulling teeth doesn't even come close to having potential for fatal complications like anesthesia does). I always hear other fields say stuff like "anesthesia is so easy even a monkey can do it". I guess not ??
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I'm still in undergrad and I'm unaware of a great number of things. But how much training is enough training? Before dental hygienists and dental therapists existed, people argued that these people had insufficient training/education to do permanent procedures on patients. I could be comparing apples to oranges when I'm contrasting the arguments of (dentists vs midlevel providers) with the (limited anesthesia training of OMFS and their equally limited scope of anesthetic practice compared to the broad, intensive anesthesia training of anesthesiologists and their broad, intensive scope of anesthetic practice) but I think this is worth thinking about.

I agree that our patients deserve the utmost training possible but sometimes this is not economically viable.
 
DaleDoback said:
Appreciate the mostly respectful remarks from the anesthesia side. It is absolutely devastating to hear of this one in a million scenario and agree that it is one too many. You are correct in that no one should go in for wisdom teeth removal and die, just like no one should die from other simple surgeries in the OR with anesthesiologists (T&A, Myringotomy), but unfortunately, it has happened too. As a science-based profession, you know there will always be that 1/million case that would defeat that logic. Even with a 3-year fully-trained anesthesiologist, I would guess that there's a chance for a 1/million mortality rate.

Side Note: Based on this logic, no one should be murdered with a gun. People in the last hour have been murdered with a gun. Therefore we should have no more guns. Someone's been watching the news.

No one knows exactly what happened. I can promise you that the OMS community respects and understands the expectations of safe anesthesia practices. At my program, we appreciate and are thankful for the anesthesia department to open up their wealth of knowledge to assist in our training. At my program, we do 6 months of anesthesia with an abundance of cases and are treated like CA-1s. While I feel comfortable with my level of training, I do not and will not do hearts anytime soon. I would guess 99% of OMS leave the sick patients for our well-trained anesthesia friends (even when we do their wisdom teeth).

I have to disagree that we don't use our training for 3 more years. Our skills rarely become rusty because we practice anesthesia every single day in the office when taking out thirds and doing our other procedures. Have I handled every single situation that could possibly happen in my office? No, neither have you, but with my training, I feel confident that I could provide an airway (LMA, ETT, Cric, Trach) if I needed. Because of my understanding of the depths of anesthesia and proper monitoring, I hope I don't have to.

Again, we respect and understand the responsibilities associated with office-based anesthesia. Even more, we are grateful for the training we receive from our anesthesia friends. Personally, when I see an anesthsia resident/attending vouch for us, it's a very proud moment.
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The difference between a CA-1 at 6 months and at 12 months is astounding.
No disrespect, but I would NEVER let a CA-1 take care of a generally anesthetizing a loved one without any supervision (which essentially is what you guys are doing).
 
gasp said:
When a pt dies under the care of an anesthesiologist, it is assumed that even the many years of training this person had in anesthesiology was not enough to prevent/fix this anesthetic death (one can argue that well this anesthesiologist sucks but every field has people who suck so lets not use this as an argument). When a pt dies from anesthetic complications under the care of a dentist/OMFS, it is entirely different.
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So it's quite possible the OMFS guy in question that left in the throat pack (duh!) was one of the ones in their field that sucks. You can't compare the good anesthesiologists, minus the ones that suck, wtih the entire field of OMFS including the ones that do suck. I understand defending your profession, but a little objectivity goes a long way.

Deaths from anesthesia are exceedingly rare, with most reports putting it in the 1:250k range. One in a million would be a stretch, unless you're taking out the ones that are related to true malpractice in some way e.g. unrecognized esophageal intubation or outright drug errors. And, like it or not, this is where the problems come in with comparing anesthetic safety of anesthesiologists only vs CRNA only vs anesthesia care team environments. The mortality rates are really really low regardless, making comparisons difficult at best.
 
jwk said:
So it's quite possible the OMFS guy in question that left in the throat pack (duh!) was one of the ones in their field that sucks. You can't compare the good anesthesiologists, minus the ones that suck, wtih the entire field of OMFS including the ones that do suck. I understand defending your profession, but a little objectivity goes a long way.

Deaths from anesthesia are exceedingly rare, with most reports putting it in the 1:250k range. One in a million would be a stretch, unless you're taking out the ones that are related to true malpractice in some way e.g. unrecognized esophageal intubation or outright drug errors. And, like it or not, this is where the problems come in with comparing anesthetic safety of anesthesiologists only vs CRNA only vs anesthesia care team environments. The mortality rates are really really low regardless, making comparisons difficult at best.
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You're missing the point. I never said OMFS sucks at providing anesthesia. What I am saying is that in the general population and statistically speaking, an anesthesiologist is going to provide a safer anesthetic than a dentist/OMFS (I really hope you don't disagree with this statement or you will have lots of people fired up). Everything is not about death. Other complications from anesthetics far exceed deaths from anesthetic. Also, I never said this guy sucked, maybe he lost the throat pack because the pt started bucking.. Another thing you gotta think about is that an anesthesiologist doesn't just administer anesthetic, we also have the knowledge/ability/preparedness to prevent complications and deal with them if they do arise...
 
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UCSFx2017 said:
I agree that our patients deserve the utmost training possible but sometimes this is not economically viable.
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Right, and sometimes the consequence of this choice that society makes is that at the end of the case the patient is not viable.
 
gasp said:
You're missing the point. I never said OMFS sucks at providing anesthesia. What I am saying is that in the general population and statistically speaking, an anesthesiologist is going to provide a safer anesthetic than a dentist/OMFS (I really hope you don't disagree with this statement or you will have lots of people fired up).
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I didn't miss your point, and I don't disagree with it - the problem lies in proving it, and is the crux of the CRNA's claims that they are "just as safe as an anesthesiologist".
 
gasp said:
When a pt dies under the care of an anesthesiologist, it is assumed that even the many years of training this person had in anesthesiology was not enough to prevent/fix this anesthetic death (one can argue that well this anesthesiologist sucks but every field has people who suck so lets not use this as an argument). When a pt dies from anesthetic complications under the care of a dentist/OMFS, it is entirely different. Both of these pts deserve to get the most knowledgeable and technically skilled person in the field of anesthesia because people CAN DIE. I can pull teeth too (now lets assume i spend 3-6 months of my residency pulling teeth), but I guarantee you my complication rate in pulling teeth is going to be higher than a dentist/OMFS pulling teeth. Don't you agree? That is why I leave it up to the expert in that field (and pulling teeth doesn't even come close to having potential for fatal complications like anesthesia does). I always hear other fields say stuff like "anesthesia is so easy even a monkey can do it". I guess not ??[/QUOTE]

Unrecognized esophageal intubations cause death. It is not because the many years of training wasn't enough to prevent/fix that death. It's because bad things happen to people and our job is to prevent it. If your complication rate in pulling teeth was 1/million like ours with anesthesia, you should be pulling teeth as well as gas. It's very lucrative. 👍

At my program, I have heard many surgery residents say "anesthesia is so easy even a nurse does it." Never heard a monkey. And you won't hear an OMS say that. If you have, I apologize on behalf of our profession. It's not easy.

pgg said:
It is, of course, not our place as anesthesiologists to dictate what does and doesn't fall within the standard of care or credentials/privileges of dentists or other physicians.

But for those non-anesthesiologists (dentists, OMFS'ers, etc) who are posting and reading, there's something you have to understand:

When you ask a bunch of anesthesiologists their opinions on things like sedation and anesthesia, the only answer you can expect, and the only answer you're going to get, is one grounded in our own standard of care. What else are we going to say?

Threads like this, as civil and polite and collegial as we're all being, usually seem to come down to the non-anesthesiologists defending their practice (which is fine) and seeking some sort of approval from us (which isn't going to be forthcoming).

In that sense, this isn't much different than asking us what we think of EM physicians' disregard for NPO considerations when "lightly" sedating people with etomidate for reductions. 😉 We back away slowly with a :uhno: look on our faces because we just don't do things that way ...

We're well aware of the fact that you and they aren't leaving a wide trail of dead bodies behind you, and this is perhaps evidence that we are overly conservative with our society's guidelines and standards.

Even so, there's only one answer you're going to get from us: Safe sedation requires a qualified person, dedicated to the task of sedation and monitoring, not also doing the procedure, with appropriate monitors (to include etCO2 as a de facto standard as of a couple years ago), with appropriate equipment and supplies for resuscitation immediately at hand, with appropriate time space and personnel for recovery prior to discharge. Most dental offices don't meet our standard.We're not critical because we think you're dumb, or because we're defending our turf. We just think you're doing it wrong. 🙂
Click to expand...

You, sir, have a great argument and I respect it. 🙂 The only portion of your safe sedation standard that an OMS office (not dentist office) lacks is the "sole dedication to the sedation and monitoring". Like you said, we don't need your approval, just appreciate your opinion.
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jwk said:
I didn't miss your point, and I don't disagree with it - the problem lies in proving it, and is the crux of the CRNA's claims that they are "just as safe as an anesthesiologist".
Click to expand...

If you don't disagree with my point, then I don't have to prove it to you. The very fact that you would ask for proof shows that there is some doubt in your mind. Anyone who comes to anesthesiology forum and asks for proof that an anesthesiologist is better/safer at providing anesthesia than an OMFS attending is arrogant/ignorant. These kind of things should be common sense. And this has nothing to do with CRNA's, they are still trained in providing anesthesia.
 
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had all 4 taken out a few years ago. when the oral surgeon said he would be doing general I just requested that he do it in the hospital instead of the office. he didn't seem to have a problem with it and insurance paid the bill so everyone was happy. not saying that he wouldn't have done a great job in the office as well, but it was nice to know that if something went wrong everything that could be done, would be done.
 
gasp said:
If you don't disagree with my point, then I don't have to prove it to you. The very fact that you would ask for proof shows that there is some doubt in your mind. Anyone who comes to anesthesiology forum and asks for proof that an anesthesiologist is better/safer at providing anesthesia than an OMFS attending is arrogant/ignorant. These kind of things should be common sense. And this has nothing to do with CRNA's, they are still trained in providing anesthesia.
Click to expand...

I'm not asking you personally for proof of anything. I think you're the one missing the point.

Common sense tells us that an anesthesiologist should be better/safer than an OMFS. No argument there. That same common sense tells us that an an anesthesiologist should be better/safer than a CRNA. No argument there. I'm on your side.

BUT - the OMFS who does anesthesia in his office on his own, as well as the CRNA practicing solo or in a CRNA-only practice, will both tell you that they are as safe and every bit as competent as an anesthesiologist. How will you refute that point, besides telling someone they're arrogant/ignorant because they don't understand what you think is intuitively obvious? Your stellar credentials and high sense of self worth won't impress a lot of hospitals, AMC's, ASC's, etc., who ASSUME quality and are looking to same $$$. The only thing that does that are FACTS, and the FACT that the mortality rate related to anesthesia is on the order of 1:250k regardless of who provides the anesthetic is not a stat that is particularly useful.

These are the battles being fought on your behalf every day by the ASA and ASA-PAC and you've got to understand the argument on an objective level rather than a subjective and emotional one.
 
Bottom line is that in the administration of anesthesia, you would like a highly-trained person doing it AND you want that to be the ONLY thing that person is doing. No other surgeon does the anesthesia AND the surgery. The same should be true of OMFS. I think having a CRNA would be fine for office-based anesthesia because the anesthesia is simple and short. The point is that the surgeon should not be doing surgery AND anesthesia. You cannot adequately do both. The fact that anesthesia personnel here would never allow an OMFS to perform the anesthesia should tell you something.
 
Silent Cool said:
Bottom line is that in the administration of anesthesia, you would like a highly-trained person doing it AND you want that to be the ONLY thing that person is doing. No other surgeon does the anesthesia AND the surgery. The same should be true of OMFS. I think having a CRNA would be fine for office-based anesthesia because the anesthesia is simple and short. The point is that the surgeon should not be doing surgery AND anesthesia. You cannot adequately do both. The fact that anesthesia personnel here would never allow an OMFS to perform the anesthesia should tell you something.
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cardiologists directing RNs to give sedation in the cath lab.

GI docs directing RNs to sedate for endoscopies.

Emerg medicine docs doing painful procedures and giving deep sedation.

These things happen every day without us. Haven't responded to a STAT page for one of these in years.
 
dr doze said:
cardiologists directing RNs to give sedation in the cath lab.

GI docs directing RNs to sedate for endoscopies.

Emerg medicine docs doing painful procedures and giving deep sedation.

These things happen every day without us. Haven't responded to a STAT page for one of these in years.
Click to expand...

We get anesthesia stat / code blue pages to the GI lab almost weekly (every single time is an airway issue).
 
Anesthesia provided by OMS in an out patient setting has a lower mortality rate than any other setting or provider. It's not so easy that a monkey can do it - but - an OMS can in their limited case and practice setting.

gasp said:
When a pt dies under the care of an anesthesiologist, it is assumed that even the many years of training this person had in anesthesiology was not enough to prevent/fix this anesthetic death (one can argue that well this anesthesiologist sucks but every field has people who suck so lets not use this as an argument). When a pt dies from anesthetic complications under the care of a dentist/OMFS, it is entirely different. Both of these pts deserve to get the most knowledgeable and technically skilled person in the field of anesthesia because people CAN DIE. I can pull teeth too (now lets assume i spend 3-6 months of my residency pulling teeth), but I guarantee you my complication rate in pulling teeth is going to be higher than a dentist/OMFS pulling teeth. Don't you agree? That is why I leave it up to the expert in that field (and pulling teeth doesn't even come close to having potential for fatal complications like anesthesia does). I always hear other fields say stuff like "anesthesia is so easy even a monkey can do it". I guess not ??
Click to expand...
 
yappy said:
Anesthesia provided by OMS in an out patient setting has a lower mortality rate than any other setting or provider. It's not so easy that a monkey can do it - but - an OMS can in their limited case and practice setting.
Click to expand...

This simply isn't true because the study has never and could never be done. You cannot compare what you do to even lap choles on Asa 1s, it apples to oranges. Maybe if you compared Oms with anesthesia providers compared to without then, but comparing it to anesthesia in general is absurd. Lastly, some of the studies linked to before are a joke. One is based solely on a questionnaire sent to Oms surgeons asking if they have ever screwed up. No bias there.


Also, please don't kid yourselves about your reasons for doing "anesthesia" during your training. The only reason you do it is because it makes you money.
 
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