Why I joined SmileMD - Anesthesiologist's Perspective
How Mobile Anesthesiologists Can Help Provide Hospital-Grade Care for Dental Procedures
Peggy Seidman, MD
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.