WILL YOU HAVE AN ANESTHESIOLOGIST FOR YOUR WISDOM TEETH EXTRACTION SURGERY?

Will you have an anesthesiologist for your wisdom teeth extraction surgery?

Probably not.

In the United States, oral surgeons perform most wisdom teeth extraction surgeries.  This is a very common surgery, with the operation performed on up to five million times in the United States each year. Most patients are healthy teenagers.  Wisdom teeth can be extracted under local anesthesia alone, but most patients and oral surgeons do not prefer this option. Oral surgeons perform wisdom teeth surgeries in their office operating rooms, and most oral surgeons manage the intravenous sedation anesthesia themselves, without the aid of an anesthesiologist.

Oral surgeons are trained in the airway management and general anesthesia skills necessary to accomplish this safely, and a nurse assists the oral surgeon in delivering sedative medications.  Oral surgeons must earn a license to perform general anesthesia in their office. To administer general anesthesia in an office, most oral surgeons complete at least three months of hospital-based anesthesia training. In most states, oral surgeons then undergo an in-office evaluation by a state dental-board-appointed examiner, who observes an actual surgical procedure during which general anesthesia is administered to a patient. It’s the examiner’s job to inspect all monitoring devices and emergency equipment, and to test the doctor and the surgical staff on anesthesia-related emergencies. If the examinee successfully completes the evaluation process, the state dental board issues the doctor a license to perform general anesthesia.  Note that even though the oral surgeon has a license to direct anesthesia, the sedating drugs he or she orders are often administered by a nurse who has no license or training in anesthesia.

In an oral surgeon’s office, general anesthesia for wisdom teeth extraction typically includes intravenous sedation with several drugs:  a benzodiazepine such as midazolam, a narcotic such as fentanyl or Demerol, and a hypnotic drug such as propofol, ketamine, and/or methohexital.  After the patient is asleep, the oral surgeon injects a local anesthetic such as lidocaine to block the superior and inferior alveolar nerves.  These local anesthetic injections render the mouth numb, so the surgeon can operate without inflicting pain.  Typically, no breathing tube is used and no potent anesthetic vapor such as sevoflurane is used.  The oral surgeon may supplement intravenous sedation with inhaled nitrous oxide.

The oral surgeon has all emergency airway equipment, breathing tubes, and emergency drugs available, but these are rarely used.

The safety record for oral surgeons using these methods seems excellent.  My review of the National Institutes of Health website PubMed reveals very few instances of death related to wisdom teeth extraction.  Recent reports include one patient who died in Germany due to a heart attack after his surgery (Kunkel M, J Oral Maxillofac Surg. 2007 Sep;65(9):1700-6.  Severe third molar complications including death-lessons from 100 cases requiring hospitalization).  A second patient died in Japan because of a major bleed in his throat occluding trachea, one day after his surgery (Kawashima W, Forensic Sci Int. 2013 May 10;228(1-3):e47-9. doi: 10.1016/j.forsciint.2013.02.019. Epub 2013 Mar 26. Asphyxial death related to postextraction hematoma in an elderly man).

Most oral surgeons have no interest in publishing their mishaps or complications, so the medical literature is not the place to search for data on oral surgery deaths. Deaths that occur during or after wisdom teeth extraction are sometimes reported in the lay press.  In April 2013, a 24-year-old healthy man began coughing during his wisdom teeth extraction in Southern California, and went into cardiac arrest.  He was transferred to a hospital, where he died several days later. (http://www.nbcbayarea.com/news/national-international/NATL—SD-24-Year-Old-Man-Dies-Following-Wisdom-Teeth-Removal-Surgery-201239551.html)

In 2011, a Baltimore-area teen died during wisdom teeth extraction. The family’s malpractice claim was settled out of court in 2013. (http://www.baltimoresun.com/news/maryland/howard/bs-md-ho-olenick-settlement-20130403,0,3496441.story).

Every general anesthetic carries a small risk, even when the patient is young and healthy, such as these two cases of death following wisdom teeth extractions.  All acute medical care involves attending to the A – B – C ‘s of Airway, Breathing, and Circulation.  During surgery for wisdom teeth extraction, the oral surgeon is operating in the patient’s mouth. Surgery in the mouth increases the chances that the operation will interfere with the patient’s Airway or Breathing.  The surgeon’s fingers, surgical instruments, retractors, and gauze pads crowd into the airway, and may influence breathing.  If the patient’s breathing becomes obstructed, altering the position of the jaw, the tongue, or the neck is more challenging than when surgery does not involve the airway.

I’ve attended to hundreds of patients for dental surgeries.  For dental surgery in a hospital setting, anesthesiologists commonly insert a breathing tube into the trachea after the induction of general anesthesia.  A properly positioned tracheal tube can assure the Airway and Breathing for the duration of the surgery.  Because an anesthesiologist is not involved with performing the surgery, his or her attention can be 100% focused on the patient’s vital signs and medical condition.  When anesthesiologists are called on to perform general anesthesia for wisdom teeth extraction in a surgeon’s office, we typically use a different anesthetic technique. Usually there is no anesthesia machine to deliver potent inhaled anesthetics, therefore intravenous sedation is the technique of choice.  Usually no airway tube is inserted.  A typical technique is a combination of intravenous midazolam, fentanyl, propofol, and/or ketamine.  Oxygen is administered via the patient’s nostrils throughout the surgery. The adequacy of breathing is continuously monitored by both pulse oximetry and end-tidal carbon dioxide monitoring.  The current American Society of Anesthesiologist Standards for Basic Anesthetic Monitoring (July 1, 2011) state that “Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. … Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment.”

The motto of the American Society of Anesthesiologists is “Vigilance.”  If the patient’s oxygen saturation and/or end-tidal carbon dioxide numbers begin to decline, an anesthesiologist will act immediately to improve the A – B – C ‘s of Airway, Breathing, and Circulation.

Let’s return to our opening question: Will you have an anesthesiologist for your wisdom teeth extraction surgery?  I cannot show you any data that an anesthesiologist provides safer care for wisdom teeth surgery than if an oral surgeon performs the anesthesia. The majority of wisdom teeth extractions in the United States are performed without an anesthesiologist, and reported complications are rare.  If you want an anesthesiologist, you need to make this clear to your oral surgeon, and ask him to make the necessary arrangements.  If you do choose to enlist a board-certified anesthesiologist for your wisdom teeth extractions, know that your anesthesia professional has completed a three or four year training program in his field, and is expert in all types of anesthesia emergencies.  As a downside, you will be responsible for an extra bill for the professional fee of this anesthesiologist.

Whether an anesthesiologist or an oral surgeon attends to your anesthesia, the objectives are the same:  Each will monitor the A – B – C ‘s of your Airway, Breathing, and Circulation to keep you oxygenated and ventilated, so you can wake up and leave that dental office an hour or so after your wisdom teeth extraction surgery has concluded.

DO ANESTHESIOLOGISTS HAVE THE HIGHEST MALPRACTICE INSURANCE RATES?

Do Anesthesiologists Have the Highest Malpractice Insurance Rates?

In a word, “No.”

Anesthesia mishaps can lead to critical events such as death or coma, but in recent decades improvements in operating room technology and education have led to fewer such events.

Prior to 1985, anesthesia malpractice claims for death or brain death were most often due to lack of oxygen the patient’s heart or brain.  Two significant breakthroughs arrived in the 1980’s to help anesthesiologists care for you:  1) the pulse oximeter, and 2) the end-tidal carbon dioxide monitor.

The pulse oximeter, developed by Nellcor and Stanford anesthesiologist William New, M.D., is a device that clips to a patient’s fingertip.  A light-emitting diode shines a red light through the finger, and a sensor on the opposite side of the finger measures the degree of redness in the pulsatile blood flow within the finger.  The more red the color of the blood, the more oxygen is present.  A computer in the pulse oximeter calculates a score, called the oxygen saturation, which is a number from 0-100%.  An oxygen saturation equal to or greater that 90% correlates with a safe amount of oxygen in the arterial blood.  A score of 89% or lower correlates with a dangerously low oxygen level in the blood.  The pulse oximeter monitor enables doctors to know, second-to-second, whether a patient is getting sufficient oxygen.  If the oxygen saturation goes below 90%, doctors will act quickly to diagnose and treat the cause of the low oxygen level.  A patient can usually sustain a short period low oxygen saturation, e.g. up to 2 or 3 minutes, without permanent damage to the brain or cardiac arrest by an oxygen-starved heart.

The end-tidal carbon dioxide (CO2) monitor is a device that measures the concentration of CO2 in the gas exhaled by a patient on every breath.  During normal ventilation, every exhaled breath contains CO2.  When no CO2 is measured, there is no ventilation, and the doctor must act quickly to diagnose and treat the cause of the lack of ventilation.

Prior to the invention of these two monitors, it was possible for an anesthesiologist to mistakenly place a breathing tube in a patient’s esophagus, instead of the trachea, and not know of the error until the patient sustained a cardiac arrest.  With the addition of the two monitors, the lack of CO2 (there is no CO2 in the stomach or esophagus) from the end-tidal CO2 monitor immediately indicates that the tube is in the wrong  place.  The anesthesiologist can then remove the tube, resume mask ventilation with oxygen, and attempt to replace the tube into the windpipe.  If the oxygen level to the patient’s blood dips below 90%, this is a second piece of data that indicates that the patient is in danger of brain damage or cardiac arrest.

In addition, in the early 1990’s the American Society of Anesthesiologists created the Difficult Airway Algorithm, which is a step-by-step approach for anesthesiologists to follow when the task of placing a breathing tube for an anesthetic is challenging or difficulty.  This Algorithm dictates a standard of care for practitioners, and this advance in education lowered the number of mismanaged airways.

In the 1980’s, surgical anesthesia claims were 80% of closed malpractice claims against anesthesiologists (American Society of Anesthesiologists Closed Claims database).  By the 2000’s, this number dropped to 65%.   Brain damage represented 9% of claims, and nerve injury accounted for 22% of claims (23% were permanent and disabling, including loss of limb function, or paraplegia or quadriplegia)  Less common claims were airway injury (7% of claims), emotional distress, (5% of claims), eye injuries including blindness (4% of claims), and awareness during general anesthesia (2% of claims).

Decreasing anesthesiologist malpractice premiums reflect the decrease in the number of catastrophic anesthesia claims for esophageal intubation, death, and brain death.

In 1985, the average malpractice insurance premium was $36,224 per year for a $1 Million per claim/$3 Million per year policy.   By 2009, this decreased to $21,480, a striking 40% drop.

(Anesthesia in the United States 2009, Anesthesia Quality Institute http://aqihq.org/Anesthesia%20in%20the%20US%202_19_10.pdf).

Specialties with the highest risk of facing malpractice claims are neurosurgery (19.1 percent), thoracic and cardiovascular surgery (18.9 percent) and general surgery (15.3 percent). Specialties with the  lowest risks are family medicine (5.2 percent), pediatrics (3.1 percent) and psychiatry (2.6 percent).  Anesthesiologists rank in the middle of the pack, at 7%.  (Malpractice Risk According to Physician Specialty

Jena, et al, N Engl J Med 2011; 365:629-636.) From 1991 to 2005, this article identified 66 malpractice awards that exceeded $1 million dollars, which accounted for less than 1% of all payments. Obstetrics and gynecology accounted for the most payments (11), followed by pathology (10), anesthesiology (7), and pediatrics (7).

The take-home message is that anesthesia has serious risks, but those risks have decreased significantly in recent years because of improvements in monitoring and education.  Compared to other specialties, the risk of an anesthesiologist being sued is about average among American medical specialties.