Tragic death during dental procedure

[Dr. Rude]

Dentists are just so foolish and dumb. Can’t believe they did this !!

Some are. Just like some anesthesiologists.

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[Eli Manning]

They are all dumb fools ! Over in the spawning ground of the dental forums. They must be stopped!
Sound the alarms!

 

[702]

Remember when you were an anesthesia resident 6 months jn? How competent did you think u were in dealing with anesthesia emergencies?

OMFS’s anesthesia training continues throughout PGY 2, 3, 4, 5, and 6 while they do hundreds or thousands of outpatient TIVA’s on adult and pediatric patients while simultaneously operating on an outpatient basis. The 6 month anesthesia off service rotation is only introductory.

 

[teacher2md]

But how confident were you that you could competently and safely sedate PS 1 and 2 and select PS 3 patients without incident?

Uh, not confident at all?

I remember dealing with a bad MAC case laryngospasm at the end of my CA-1 year (12 months in).

I was gave propofol, jaw thrusted, couldn’t mask, sats in the tank, STAT paged attending, fumbled to try to set up for intubation under the drapes…

Attending saved the day and I needed new underwear.

So no, I don’t trust a CA-1 to deal with complications without backup.

 

[Dr. Rude]

Uh, not confident at all?

I remember dealing with a bad MAC case laryngospasm at the end of my CA-1 year (12 months in).

I was gave propofol, jaw thrusted, couldn’t mask, sats in the tank, STAT paged attending, fumbled to try to set up for intubation under the drapes…

Attending saved the day and I needed new underwear.

So no, I don’t trust a CA-1 to deal with complications without backup.

I don’t trust a Ca-1 either without back up. That wasn’t my question. My question is how confident is the typical 6 month in CA-1 to handle MACs solo on mostly healthy patients?

 

[deleted875186]

OMFS’s anesthesia training continues throughout PGY 2, 3, 4, 5, and 6 while they do hundreds or thousands of outpatient TIVA’s on adult and pediatric patients while simultaneously operating on an outpatient basis. The 6 month anesthesia off service rotation is only introductory.

I never understood how one could argue this is safe. Are you operating or are you giving anesthesia? Anesthesia 101, if your doing the procedure you can’t be monitoring the patient under anesthesia.

 

[702]

You can, depending on the patient’ health history, and type and length of surgery. Thousands of omfs do it on a daily basis and have been for decades and decades. Their track record is unquestionable. Safety of Outpatient Procedural Sedation Administered by Oral and Maxillofacial Surgeons: The Mayo Clinic Experience in 17,634 Sedations (2004 to 2019) - PubMed

THE KEY IS PATIENT SELECTION. A routine set of third molar extractions takes 10-15 minutes and is on an ASA 1 or 2 patient. No omfs on their right mind operates on an ASA III or IV pt. for hours while simultaneously anesthetizing in an outpatient setting. No omfs is anesthetizing while doing a double or triple jaw corrective surgery, panfacial trauma, tmj replacement, or cancer ablative surgery.

 

[coffeebythelake]

They are all dumb fools ! Over in the spawning ground of the dental forums. They must be stopped!
Sound the alarms!

Hey I remember you. Welcome back!
Everyone. This is the guy who that thinks holding a scalpel makes him a master of rescuing airways.

No substance Eli.

I don't need to stop you. The public is fed up and they are doing it. Perhaps you should cry about it to them, how you poor dentists are so mistreated.

 

[702]

Hey I remember you. Welcome back!
Everyone. This is the guy who that thinks holding a scalpel makes him a master of rescuing airways.

No substance Eli.

I don't need to stop you. The public is fed up and they are doing it. Perhaps you should cry about it to them, how you poor dentists are so mistreated.

Post with no contribution to the discussion whatsoever and purely instigatory in nature.

 

[vector2]

You can, depending on the patient’ health history, and type and length of surgery. Thousands of omfs do it on a daily basis and have been for decades and decades. Their track record is unquestionable. Safety of Outpatient Procedural Sedation Administered by Oral and Maxillofacial Surgeons: The Mayo Clinic Experience in 17,634 Sedations (2004 to 2019) - PubMed

The conclusion that stems from a single center study which says there is no association between age/ASA class/use of profound cardiorespiratory depressants like propofol and AEs/death isn't that the people at that single center who provided anesthesia are doing it safely.

The conclusion is that the study is terribly underpowered.

 

[teacher2md]

Here's a really good listen about pediatric dental anesthesia.

TLDR; The public and lawmakers are catching on, and changes have been made (most significantly in California), despite huge pushback from the ADA and AAPD.

 

[IMGASMD]

Post with no contribution to the discussion whatsoever and purely instigatory in nature.

It has been discussed, if it wasn’t taken down by the dental forum.
Why are you all here again then?

 

[deleted875186]

You can, depending on the patient’ health history, and type and length of surgery. Thousands of omfs do it on a daily basis and have been for decades and decades. Their track record is unquestionable. Safety of Outpatient Procedural Sedation Administered by Oral and Maxillofacial Surgeons: The Mayo Clinic Experience in 17,634 Sedations (2004 to 2019) - PubMed

THE KEY IS PATIENT SELECTION. A routine set of third molar extractions takes 10-15 minutes and is on an ASA 1 or 2 patient. No omfs on their right mind operates on an ASA III or IV pt. for hours while simultaneously anesthetizing in an outpatient setting. No omfs is anesthetizing while doing a double or triple jaw corrective surgery, panfacial trauma, tmj replacement, or cancer ablative surgery.

You can do anesthesia and operate simultaneously, but the quality of either the anesthesia or the surgery suffers. The fact that it is done routinely does not mean it’s best practice. I would never allow it on myself or a family member, but to each their own I suppose.

 

[Agast]

You can do anesthesia and operate simultaneously, but the quality of either the anesthesia or the surgery suffers. The fact that it is done routinely does not mean it’s best practice. I would never allow it on myself or a family member, but to each their own I suppose.

Apparently this is the norm during veterinary procedures with sedation, which is why so many dogs (even healthy puppies) die during dental cleaning. I refused to let the vet clean my dog’s teeth after a certain age because of this.

 

[VA Hopeful Dr]

Apparently this is the norm during veterinary procedures with sedation, which is why so many dogs (even healthy puppies) die during dental cleaning. I refused to let the vet clean my dog’s teeth after a certain age because of this.

Are veterinary anesthesiologists even a thing?

 

[Agast]

Are veterinary anesthesiologists even a thing?

The veterinarian is also the anesthesiologist. Chatted with one who said they were trained to use isofluorane.

 

[propadope]

I think we can all agree that 6 deaths in the last 4 years in NC is about 6 too many. Clearly something is wrong and something needs to change. Nothing is without risk but it seems like a lot of these (most?) mortalities are preventable.

 

[IMGASMD]

Apparently this is the norm during veterinary procedures with sedation, which is why so many dogs (even healthy puppies) die during dental cleaning…..

I just want to quote this.

 

[deleted875186]

The veterinarian is also the anesthesiologist. Chatted with one who said they were trained to use isofluorane.

Plus iso or sevo is fairly safe, especially in lower than 1 mac doses with an ETT. If I had no concern for awareness, this would be a straightforward anesthetic, dial into 2/3 MAC, give muscle relaxation, put on vent.

Dental sedation we are talking giving meds that need to be titrated, in a open airway, spontaneous ventilation, no breathing tube, in potentially not perfectly healthy patients, no backup available, what could go wrong.

 

[Dr. Rude]

 

[nimbus]

Are veterinary anesthesiologists even a thing?

Yes. They have residencies. Pauline Wong, veterinary anesthesia faculty from UC Davis, was a frequent contributor to gasnet during the early days of the internet.

 

[nimbus]

Plus iso or sevo is fairly safe, especially in lower than 1 mac doses with an ETT. If I had no concern for awareness, this would be a straightforward anesthetic, dial into 2/3 MAC, give muscle relaxation, put on vent.

Dental sedation we are talking giving meds that need to be titrated, in a open airway, spontaneous ventilation, no breathing tube, in potentially not perfectly healthy patients, no backup available, what could go wrong.

No one would dream of doing a tonsillectomy that way but it’s the norm for dental procedures. Molars are pretty close to the tonsils.

 

[greatnt249]

Apparently this is the norm during veterinary procedures with sedation, which is why so many dogs (even healthy puppies) die during dental cleaning. I refused to let the vet clean my dog’s teeth after a certain age because of this.

The issue not mentioned here is that anesthesia reactions can vary wildly across dog breeds/different species, so I don't think it's quite the same thing to compare the two. I'm not defending the practice of "dentist/oral surgeon-is-also-anesthetist," by the way.

 

[pgg]

Shower thought: I wonder if canine sleep apnea is a thing, and if veterinarians have more anesthetic complications with morbidly obese dogs, or stupid-looking dogs like pugs.

I've done a little (very little) anesthesia for military working dogs but they were canine athletes with great airways. ASA 1 dogs, if you will. I wonder if vets dread doing the breeds that should never have been bred, like purse sized rat dogs, the way we dread the BMI 62 butt pus cases.

 

[leggo_my_ecmo]

Shower thought: I wonder if canine sleep apnea is a thing, and if veterinarians have more anesthetic complications with morbidly obese dogs, or stupid-looking dogs like pugs.

I've done a little (very little) anesthesia for military working dogs but they were canine athletes with great airways. ASA 1 dogs, if you will. I wonder if vets dread doing the breeds that should never have been bred, like purse sized rat dogs, the way we dread the BMI 62 butt pus cases.

I’ve been told that the brachycephalic dogs like pugs have to be extubated fully awake due to their anatomy. And usually having the tube in is the best they’ve ever been able to breathe.

 

[Ashers]

My

Apparently this is the norm during veterinary procedures with sedation, which is why so many dogs (even healthy puppies) die during dental cleaning. I refused to let the vet clean my dog’s teeth after a certain age because of this.

One of my 14yo cats was just refused a dental cleaning because he has HOCM, CKD, and started having seizures. I was not upset, and neither was he. He got to eat breakfast when 2 others were NPO.

I met one vet who showed me around a clinic where they did surgeries and explained vet anesthesia in more detail than I had heard before (5 years ago), but still doing both surgery and anesthesia at the same time. He was an MBBS (hematology) from England, and he moved to the US and went to vet school.

 

[nimbus]

 

[nimbus]

My

One of my 14yo cats was just refused a dental cleaning because he has HOCM, CKD, and started having seizures. I was not upset, and neither was he. He got to eat breakfast when 2 others were NPO.

I met one vet who showed me around a clinic where they did surgeries and explained vet anesthesia in more detail than I had heard before (5 years ago), but still doing both surgery and anesthesia at the same time. He was an MBBS (hematology) from England, and he moved to the US and went to vet school.

Years ago we took an 18yo cat with a lump on her side to our wise old vet. We asked if we should do anything about it. He replied, “do not touch this cat!!”

 

[IMGASMD]

A little scary looking.

 

[forchinet121]

You can do anesthesia and operate simultaneously, but the quality of either the anesthesia or the surgery suffers. The fact that it is done routinely does not mean it’s best practice. I would never allow it on myself or a family member, but to each their own I suppose.

What do you do though if your oral surgeon office doesn’t have an anesthesia professional there? Do you go somewhere else? Do some oral surgeons have an anesthesiologist on staff? Would you trust a CRNA for your family or you would want an MD?

 

[Ashers]

Years ago we took an 18yo cat with a lump on her side to our wise old vet. We asked if we should do anything about it. He replied, “do not touch this cat!!”

Smart, my mom's 15 year old cat that she raised from a day old died in PACU after removing a massive sarcoma. She should've just let it be.

And that duck airway is crazy. I went down a youtube wormhole once at work as a resident watching videos of animals being intubated (with the team, on the regional service). It's interesting.

 

[chessknt]

What do you do though if your oral surgeon office doesn’t have an anesthesia professional there? Do you go somewhere else? Do some oral surgeons have an anesthesiologist on staff? Would you trust a CRNA for your family or you would want an MD?

Are you talking about needing oral surgery in an office? Why the hell would you want to be put under an anesthetic in an off site location with half trained staff over a hospital? I am low risk and wouldn't even let my gi sedate me for an endoscopy with versed in their off site Endo center because I learned that they had no anesthesia staff, I waited for a slot to have it done in the hospital. Why would you opt for the inferior choice?

 

[forchinet121]

Are you talking about needing oral surgery in an office? Why the hell would you want to be put under an anesthetic in an off site location with half trained staff over a hospital? I am low risk and wouldn't even let my gi sedate me for an endoscopy with versed in their off site Endo center because I learned that they had no anesthesia staff, I waited for a slot to have it done in the hospital. Why would you opt for the inferior choice?

I wouldn’t I completely agree

 

[Agast]

A little scary looking.

If you think that is funky looking, you should look up duck penis and read the little blurb about how it got that way

 

[PikminOC]

View attachment 349691

This is the late Dr Patel. Not a large man. By his external airway anatomy I wouldn't have expected his airway to be difficult to mask ventilate or intubate. Was he overly sedated and became apneic? Did he laryngospasm?

So again goes to question how adept the dentist was at with these basic anesthesia knowledge and skills. And if he can't mask ventilate or intubate despite his 6 months of anesthesia training, or go through a quick 5 second differential diagnosis for hypoxemia, what makes him think he knows how to do a crash trach?

This is an old pic of him.

 

[PikminOC]

When seconds count, anesthesiologists are minutes away. Look at the knowledge of crnas too.

 

[sevo00]

When seconds count, anesthesiologists are minutes away. Look at the knowledge of crnas too.

How am I minutes away if my practice doesn’t use CRNAs and I sit the stool for all my own cases?

 

[Dr. Rude]

How am I minutes away if my practice doesn’t use CRNAs and I sit the stool for all my own cases?

"When seconds count, anesthesiologists are minutes away."

This is a sound bite used by AANA in the past. Railing about the lack of value provided by anesthesiologist supervision of CRNAs.

 

[Gern Blansten]

Molars are pretty close to the tonsils.

Dangerously close, if you ask me.

 

[PikminOC]

How am I minutes away if my practice doesn’t use CRNAs and I sit the stool for all my own cases?

That's not most hospital practices

 

[PikminOC]

"When seconds count, anesthesiologists are minutes away."

This is a sound bite used by AANA in the past. Railing about the lack of value provided by anesthesiologist supervision of CRNAs.

Really? What I'm saying is that crnas are useless.

 

[IMGASMD]

Really? What I'm saying is that crnas are useless.

You just needed to make that clear….
Amongst anesthesiologist, CRNAs, dentists and dental assistants.
I will take my chances with the CRNAs….

That's not most hospital practices

Peds dental cases for our practice are always staffed by docs.

We once in a while will do some adult dentals in the hospital, for those cardiac cripples who’s about to get their procedures. We tend to staff those with docs only too.

 

[Dr. Rude]

Really? What I'm saying is that crnas are useless.

Many of them have a similar opinion of anesthesiologists who supervise.

In AANA’s opinion, anesthesiologists who sit their own cases are overtrained for the job and don’t add anything.

 

[PikminOC]

Many of them have a similar opinion of anesthesiologists who supervise.

In AANA’s opinion, anesthesiologists who sit their own cases are overtrained for the job and don’t add anything.

No different than what they say about any other physician in any other field. Anesthesia infiltration was first

 

[anaesthetic]

Many of them have a similar opinion of anesthesiologists who supervise.

In AANA’s opinion, anesthesiologists who sit their own cases are overtrained for the job and don’t add anything.

I really am racking my brain to think of how "overtraining" is even possible when it comes to medicine, or anything in general. The mental gymnastics and sheer audacity required to make such a statement unironically--it just blows my mind.

At our shop, there's no question about the role of an anesthesiologist. We pull many patients from death's grip every day, so the respect (from everybody) comes naturally.

 

[vector2]

I really am racking my brain to think of how "overtraining" is even possible when it comes to medicine, or anything in general. The mental gymnastics and sheer audacity required to make such a statement unironically--it just blows my mind.

It doesn't require any mental gymnastics or audacity....because they're in full-blown Dunning-Kruger mode. Their erroneous belief about "overtraining" is simply a manifestation of the cliche line "you don't know what you don't know."

Look at it this way. They've never taken the MCAT, gone to medical school, taken all the steps, taken all the ITEs, taken all the boards etc, ergo they have no frame of reference as to how insanely large the scope of medicine is nor how insanely deep the knowledge base can theoretically go. Most mid-levels get some cursory basic science education, cursory generalized medical training, and then some cursory specialty training in whatever field they want to "specialize" in. When the core of a CRNA's knowledge and procedure base is so shallow, then of course to them it must seem insane that a highly trained physician would choose to do anesthesiology.

 

[Ashers]

It doesn't require any mental gymnastics or audacity....because they're in full-blown Dunning-Kruger mode. Their erroneous belief about "overtraining" is simply a manifestation of the cliche line "you don't know what you don't know."

Look at it this way. They've never taken the MCAT, gone to medical school, taken all the steps, taken all the ITEs, taken all the boards etc, ergo they have no frame of reference as to how insanely large the scope of medicine is nor how insanely deep the knowledge base can theoretically go. Most mid-levels get some cursory basic science education, cursory generalized medical training, and then some cursory specialty training in whatever field they want to "specialize" in. When the core of a CRNA's knowledge and procedure base is so shallow, then of course to them it must seem insane that a highly trained physician would choose to do anesthesiology.

This sounds like exactly what my mom tells people. She's a nurse; she married my dad when he was in ortho residency. My sister and I are doctors. She said that nurse training is no where near what med school/residency/fellowship are, and she has refused care by CRNAs. She spoke with people at the ASA who were lobbying against independent CRNAs about her experiences with a big well known medical system when she was told by day surgery that CRNAs and MDs are the same when she asked if she'd have an MD, and they said "No, CRNA." She asked, "What about medical school?" The preop day surg nurse said, "Well, aside from medical school, they're the same." My mom said, "No they're not, I want an MD." So they gave her a CA-1 (which I was at the time, and she was totally cool with that. She was having a knee scope.)

My mom hasn't been through med school, but she knows what she did in nursing school vs what we did for our training.

 

[PikminOC]

This sounds like exactly what my mom tells people. She's a nurse; she married my dad when he was in ortho residency. My sister and I are doctors. She said that nurse training is no where near what med school/residency/fellowship are, and she has refused care by CRNAs. She spoke with people at the ASA who were lobbying against independent CRNAs about her experiences with a big well known medical system when she was told by day surgery that CRNAs and MDs are the same when she asked if she'd have an MD, and they said "No, CRNA." She asked, "What about medical school?" The preop day surg nurse said, "Well, aside from medical school, they're the same." My mom said, "No they're not, I want an MD." So they gave her a CA-1 (which I was at the time, and she was totally cool with that. She was having a knee scope.)

My mom hasn't been through med school, but she knows what she did in nursing school vs what we did for our training.

She was married to an Ortho. Most midlevels have no clue because they don't have that frame.

 

[Ashers]

She was married to an Ortho. Most midlevels have no clue because they don't have that frame.

Right, but she does speak up. My dad advocates on our behalf too. He has had to sign CRNAs charts in rural areas when he was doing locums. He said he has no idea if what they are doing is right, so when he was doing locums in places with CRNAs only, he sent medically complex cases in the access hospitals to larger centers for MDs to take care of.

 

[DrZzZz]

NC Dental Board approves anesthesia changes, stops short of requiring separate anesthesia provider

Despite a loud push for the dental board to require a separate anesthesiologist or certified registered nurse anesthetist (CRNA) be present when a patient is sedated for dental procedures, the board declined to adopt that change. They have proposed several other changes aimed at improving...

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