As someone who has spent most of my career as a hospital-based academic pediatric anesthesiologist, tertiary pediatric care is something I take very seriously. Although I’m no longer practicing in a hospital, I’ve been able to continue my work at the highest and safest standards through office-based anesthesia.
I spent 30 years in academic anesthesia. Throughout those years, I was the division chief at two different institutions—Stony Brook School of Medicine in New York and West Virginia University School of Medicine, in Morgantown—as well as a pediatric anesthesia fellowship director. At a certain point, I burned out and lost the joy in the work. I was old enough to retire, but I didn’t want to retire; I wanted a way to keep contributing to a field I was passionate about without the mounting stress.
When a friend recommended that I start working as an office-based anesthesia provider, it just made sense. I could keep the parts of the job I loved—having control over my schedule and working with pediatric patients, and eliminate the parts I didn’t—administration, paperwork, scheduling and insurance checks.
Now, I’m able to provide care to more patients while keeping safety the No. 1 priority. And I’m able to do this by working together with teams of local dentists and third-party clinical support staff.
Access to Anesthesia Care
The reality of hospitals is they have the capability to provide top-quality care for the patients who need it, but the flip side is the hospital is meant for patients who need it most urgently. Due to high acuity, hospital-based care has traditionally resulted in longer wait times to book a procedure, longer case times and higher costs for dental patients. With limited OR space, it’s not uncommon for dental patients to have to wait six months or more for a procedure. Once scheduled, day-of-surgery delays also are common.
As we work to bring health care access to all, issues such as the physical distance and accessibility of location can limit families’ access. There is a huge population gap that can’t be adequately served through a traditional OR, and as a result, these patients are not receiving needed care.
The good news is there are many patients who also don’t need the acuity of the hospital. For example, children who just need treatment for unhealthy teeth can be appropriately served in their local dental office with the assistance of a certified anesthesiologist. And more often than not, the ability for pediatric dental patients to stay out of a hospital is a better choice for the children and their families.
Reducing Risks, Slowing Disease Progression
When it comes to safety, the goal is to provide care that is equal to that of a hospital OR. To that end, I have found that mobile anesthesia teams are able to maintain standards of care that match an OR experience. The teams I work with ensure that all necessary medical resources—emergency drugs, tools, protocols and relationships with local emergency rooms—are secured before a patient will ever undergo anesthesia at any site where we provide care.
First, though, it starts with patient screening, a step that—although it may sound tedious—can never be taken too seriously. It is the first and possibly most significant step toward assessing and reducing individual patient risk. A specific person who understands the ins and outs of anesthesia risks is required for proper screening. They must understand what it means to have a patient who was born as a premature twin and now has asthma, or they must know what questions to ask when a child is presented as obese on paper. These are nuances that are picked up through exposure and training in the field.
There are compounding risks and variables, and for every anesthesia provider, there are risks that are too great. I know my boundaries, and I will raise my concerns if I’m brought a patient who is not a good candidate for office-based care and instead should be treated in a hospital or an ambulatory surgery center setting. I want to provide them efficient care, but more importantly I want them to be safe.
Once we make the appropriate candidate selection, we can begin the preoperative discussions. Even then, as we work with the families to set up appointments, if we uncover anything that’s cause for concern, we are always able to stop the process and refer them to a higher acuity setting.
This is where my expertise as an anesthesiologist is critical. Day in and day out, dentists see children who are miserable, children who are in pain with oral abscesses or rotting teeth. Naturally, they want to help. As the anesthesiologist, I help weigh the risk versus reward of scheduling the procedure sooner if they’re a healthy candidate, or scheduling later for an appointment in an OR if they are at greater risk for complications with anesthesia.
Establishing a Hospital-Grade Environment
After appropriately vetting a patient and having everything in place in case of an emergency, the next crucial step toward meeting the safety standard of a hospital OR is the staffing and setup.
I always work in a three-person team: a dedicated nurse for pre- and post-op, a certified paramedic and myself, a certified anesthesiologist. The security of having a paramedic on hand cannot be overstated. We’ve done everything we can to reduce the chances of an emergency, but we never truly know which patient will require emergency care. A paramedic is trained to handle emergency situations in the least ideal of environments, making them a critical part of my team, and one that I am not willing to work without.
There are some lobby groups who believe that dentists/OMFS [oral and maxillofacial surgeons] can be safely trained to play the role of surgeon and anesthesia provider in their office. I am of the firm belief that a person cannot—and ethically should not—divide their attention between procedure and sedation. It is not safe. It’s possible to get away with it, but that dual practice is dangerous and gravely irresponsible. Having a dedicated anesthesiologist—even better when they are supported by additional anesthesia health care providers—optimizes safety and decreases the risk for complications.
To set up the physical operating space in a dentist's office, flexibility is required because every office is different. It’s important to make sure that not only is the operating space private, but that there’s also an isolated area for pre-and post-op patients. Although it isn’t always possible, having as much physical space as you can between procedure operations and regular dental practice patients helps keep things running smoothly, while also giving your sedated patients the privacy they need.
Aside from the space, I try to need very little of the dentists and offices we work with. My team and I use their chairs that are used for dental care, and we bring our own essential equipment, including an anesthesia delivery system, full monitoring, all medications and gases, IVs and fluids, even blankets to keep patients warm. We do such extensive patient vetting and office setup approval prior to any cases, making the last step of working together in the space much smoother.
Every part of this process, no matter how tedious or trivial it seems on paper, is a critical step in ensuring a safe procedure for the patient. Having the confidence that the teams I work with have performed their due diligence to set up a safe system that protects both patients and providers has allowed me to continue to do a job that I love.
Seidman is a board-certified pediatric anesthesiologist in Cleveland. She partners with SmileMD, a mobile anesthesia services company founded by anesthesiologists, to provide anesthesia services for local dental procedures.
Editor’s note: As with all Commentaries, the views expressed in this piece belong to the author and do not necessarily reflect those of the publication.
Please log in to post a comment
how much do you charge anesthesia?. Do you apply spontaneous ventilation of the patient or controlled with intubation or laryngeal mask? Inhalation or e.v anesthesia?
I am a dentist anesthesiologist with over 40 years experience who trained in a physician anesthesia program and practices as both a mobile anesthesia provider in dental offices and as the dual surgeon/anesthesia provider in my own office.With any discussion regarding the merits and risks of each delivery system,it is critical to differentiate between intubated and non intubated(open airway) cases.During non intubated cases(the vast majority of those that I have reviewed),if the anesthesia provider is not continually and directly watching the oral cavity,water volume ,suction efficacy,handpiece use,restorative and surgical materials then they have relinquished control of the airway to the dental assistant who rarely has any formal anesthesia training.Having provided expert witness testimony in numerous pediatric non-intubated dental cases that ended with death,severe neurological deficit or airway fire,there has been a wide range of training of the anesthesia provider.This includes pediatric anesthesiologists,physcian anesthesiologists without fellowship certification,dentist anesthesiologists and CRNAs as a separate anesthesia provider.While I would concur with the author's opinion for a separate anesthesia provider in intubated cases,I disagree with her assertion for open airway cases(including supraglottic devices) as the anesthesia provider no longer controls what is happening in the airway as opposed to the combined operator anesthesia provider model which has an excellent safety record in the hands of properly trained dentists.Norbert Kaminski DDS
Valid point however i would agree as an anesthesiologist, there are many cases in which we operate without the airway secured and the hob rotated away from us. Thisnsituation is exactly when an anesthesia provider is needed as were trained to anticipate the emegencies without necc having to stare directly into the oral cavity. In your reviews were there any dentists that had similar issues during there operations/anesthetics?
Dear Dr. Seidman and the Editor of Anesthesiology News.
I read with interest the article regarding hospital-grade anesthesia in the dental office. As a former clinical professor who provided anesthesia care for 21 years at a major medical center as well as a large College of Dentistry, I agree with the sentiment that trained anesthesiology providers can bring a high level of expertise and safe anesthesiology care to the dental office. What Dr. Seidman demonstrated, unfortunately, was also a lack of familiarity with the formal training of the recognized specialty in dental anesthesiology. Dentist Anesthesiologists complete a minimum of 3-years full-time accredited residency training in anesthesiology. The majority of that training is in a hospital-based environment side by side with their physician colleagues. In addition to that, there is a minimum requirement for provision of anesthesia care within the office-based environment, something that is NOT currently required of our physician colleagues. There is a minimum number of cases that is required for children under age 6 and a minimum number of nasal endotracheal intubations. There is a certifying board for our specialty (The American Dental Board of Anesthesiology) that has both a calibrated written and oral components. Dentist Anesthesiologists are private practitioners, but also educators, researchers as well as National and International speakers in the field of anesthesiology. Our National organization has been engaged directly with the ASA in issues related to safety and standards of care.
I respect the opinion given but accuracy needs to be part of this publication versus expression of feeling and invoking ethics as part of it. I invite Dr. Seidman to join us in our National Meeting sometime and become familiar with our specialty.
Best regards,
Zak Messieha, DDS
Dentist Anesthesiologist
President, The American Society of Dentist Anesthesiologists
???????? 43 ???? ?????????? ? ?ICU ? ?????? ????????, ?? ??????? ? ???????????? ???????????? ??? 90% ????.
History Caleb Sears of California will be studying.
Dear Editor,
My comments below relate to both the article by Dr. Seidman and the comments of Dr. Messieha. At first, I should mention that I know both Dr. Seidman and Dr. Messieha well. Dr. Messieha trained at LIJ where I was an attending and he then worked for me in my private office before moving to Illinois. At Stony Brook University Hospital, Dr. Seidman was Chief of the Division of Pediatric Anesthesiology where I worked with her as a colleague in my position as Program Director of the Dental Anesthesiology Residency program. Both Dr. Messieha and Dr. Seidman are very well qualified anesthesia providers who advocate for and administer the highest levels of care to their patients.
Unfortunately, I think Dr. Messieha misinterpreted Dr. Seidman’s essay. During our tenure together at Stony Brook, Dr. Seidman was and still is an advocate for accredited training programs in dental anesthesiology. She was and is aware of accreditation requirements as set forth by the Commission on Dental Accreditation and helped guide me in developing the training program at Stony Brook Medicine. My interpretation of Dr. Seidman’s article is that she was attempting to explain the incredible need for general anesthesia services for pediatric dental patients. At Stony Brook and in many other hospitals, children and patients with special needs may wait at least a year for dental care with general anesthesia. From my knowledge of working with Dr. Seidman, she is first and foremost an advocate for children receiving the best anesthesia care possible, whether the anesthesia provider is a physician or dentist anesthesiologist.
In conclusion, it is my firm opinion that if Dr. Messieha and Dr. Seidman met they would find that their professional philosophies agree more than disagree.
Respectfully,
Ralph Epstein, DDS
Program Director, Dental Anesthesia Residency program, Stony Brook University Hospital
Past President, The American Society of Dentist Anesthesiologists