Category: Chew on This

By: Dennis Stone M.D.

Anesthesiology in Great Britain and Europe developed during the Enlightenment almost exclusively as a medical subspecialty on equal footing with Surgery. American Anesthesiology has roots in three medical disciplines; Dentistry, Nursing and Medicine.  

In the 1840’s Dentists and others discovered anesthetic properties of N2O (Colton and Wells), Ether (Jackson, Long, Morton) and Chloroform (Simpson). It was the dentists who developed the first practical clinical applications when dentistry consisted mostly of extraction of painful, infected teeth. John Snow developed a directional valve apparatus for the administration of ether and became the first known full time medical anesthesiologist publishing a book on ether administration in 1847.     

The Civil War during the 1850’s spurred the advancement of trauma care.  Unfortunately, early in the war the skill of a surgeon was judged by 30 second amputations.  Later in the war, nurses were recruited to provide open drop ether allowing more skilled surgical treatment. Officers were given scarce anesthetics and the southern General Stonewall Jackson was an early victim of silent aspiration (Mendelson’s) syndrome during anesthesia. He died of aspiration pneumonia 3 days postop.

After the Civil War medical/surgical treatment advanced and intra thoracic and abdominal surgery became possible but with a high mortality.  Macewen in 1878 reported the first elective endotracheal intubation for anesthesia. Anesthesia care improved with the pioneering work of physicians and surgeons such as (Hewitt, Dragger, and Boyle) who developed safer anesthesia machines capable of titration of anesthetic gases.  Lewis Wright 1940 introduced curare for muscle relaxation and the era of modern anesthesia was begun.  Halothane (1954) was a significant improvement over ether and chloroform but there were problems with cardiac depression and rare instances of liver damage. Sevoflurane was introduced in 1971 replacing Halothane and Propofol in 1989 replaced Pentothal. Both agents were much safer than their predecessors.

Until the 1980’s there were incremental improvements in drugs supplies and equipment yet injury or death from anesthesia related causes remained high in the neighborhood of 1:10,000 anesthetics with anesthesiologists paying malpractice premiums similar to neurosurgeons , cardiovascular surgeons , general surgeons and obstetricians.

What happened in the 80’s? Three things; the invention and clinical use of pulse oximetry and capnography; and the establishment of the American Society of Anesthesiologists (ASA) Closed Claims Project (1984). The Anesthesia Closed Claims Project’s goal is to identify anesthesia-related major safety concerns, patterns of injury and prevention strategies in areas where anesthesiologists provide care. The idea of analyzing closed malpractice claims as a method of improving patient safety was that of Drs. Pierce (Chairman) and Richard J. Ward, M.D., (Professor Emeritus) , of Anesthesiology University of Washington in Seattle. Jeff Morray M.D. a pediatric anesthesiologist at the University of Washington in Seattle was one of the original committee members.

Lessons learned from the closed claims data were published in peer reviewed journals and incorporated into anesthesia training programs as well as Continuing Medical Education (CME) materials for practicing anesthesiologists. Patient safety became the central focus for the ASA leadership resulting in the eventual creation of subspecialty fellowship training and board certification of anesthesiologists in Critical Care Medicine (ICU), Obstetrical Anesthesia, Cardiovascular Anesthesia, Pain Management and Pediatric Anesthesia. Improved surgical and anesthesia care allowed some procedures to move from the hospital to more cost effective surgery centers and office based facilities. Safety Committees established by the ASA developed policies, procedures and guidelines to assist anesthesiologists in providing safe care in these new practice environments. Dr. Hector Vila (Cofounder of PDAA) was chairperson of the Office Based Safety committee and led the effort to provide practical safety guidelines.  Today thanks to these efforts injury or death from anesthesia related causes has improved 100 fold to 1:1,000,0000 anesthetics with anesthesiologists paying much lower malpractice premiums, similar to the low rates of pediatricians  and family practice.

Children sedated in dental offices by dentists have a higher risk of morbidity and mortality because of age (younger the patient the greater the risk), site of the procedure (dental care is in the patients airway), single operator model of dental sedation (dentist attention divided), and sedation effects are difficult to predict (some patients go completely to sleep others are not fazed). Pediatric sedation tragedies continue to occur, are highly publicized and someone on the news report will usually be quoted “No child should ever die in a dentist’s office”. Thus the community standard set by the media is a fantasy of PERFECTION.

Dentistry should consider a Closed Claims Project so that cases are analyzed, lessons are learned and deaths could be avoided. Closed claims analysis could lead to the adoption of Pediatric Dental Anesthesia Standards which are most likely to improve outcomes.                                  

I have been a pediatric anesthesiologist for over 40 years and I love to tell the story of my chosen profession’s journey of continuous improvement. Pediatric Dental Anesthesia Associates (PDAA) is a national leader; we have adapted our anesthesia medications, techniques and equipment to deliver advanced pediatric specialty care in the pediatric dental office. We gather outcomes on every one of over 30,000 cases performed each year and we review and compare outcomes to modify our practice protocols which are uniform across the 26 states and over 600 Pediatric Dental Practices served. The investment in quality improvement and safety has been the single most important factor in the success of our practice.

Today, pediatric dentists are able to provide excellent care to children using lasers, innovative materials and techniques. Yet, expert dental care is difficult to deliver because of high rates of dental decay, and changes in parenting and social norms. Modern restorative pediatric dental care means more young children than ever need sedation. 

Pediatric dentistry requires safe, humane and predictable anesthesia for short and longer dental procedures. Our patients deserve the highest standard of care when it matters most.

 Dennis Stone MD 8/23/2022