Episode #320 Dental Anesthesia Safety Gaps, PART 1

Opening Clip: “I think all anesthesiologists at heart are interested in patient safety, right? I mean, that’s so much of what we do. We can see how easy it is to harm patients if we’re not vigilant or we’re not patient paying attention.”

We have a great show for you today! Some of you may have listened to this interview back in December when we talked to Dr. Rita Agarwal all about keeping patients safe during office-based dental anesthesia. We are going to revisit that conversation today.

Hello and welcome back to the Anesthesia Patient Safety Podcast. I’m your host, Alli Bechtel. Whether you are tuning in on your drive to work or listening while taking walk, we’re glad you are here.

Before we dive further into the episode today, we’d like to recognize Blink Device Company, a major corporate supporter of APSF. Blink Device Company has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Blink Device Company – we wouldn’t be able to do all that we do without you!”

Dr. Rita Agarwal is a pediatric anesthesiologist at Stanford and Lucille Packard Children’s Hospital. Dr. Agarwal was the Pediatric Anesthesia Program Director at the University of Colorado for 18 years and has served as the editor for the Society for Pediatric Anesthesia Newsletter, Communication Chair, and Member of the Board of Directors. She is the past chair for the American Academy of Pediatrics section on anesthesiology and pain management, and the vice president for the Society of Pediatric Pain Management. Dr. Agarwal is passionate about patient safety during dental procedures and an expert in this area. And now without further ado, my conversation with Dr. Rita Agarwal.

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“To get us started today, can you introduce yourself and tell us a bit about your anesthesia training, career, and your current role? And how did you become interested in pediatric anesthesia as a focus for your practice?

Thank you. Good morning, and thank you for letting me be on the show. I went to medical school at Baylor College of Medicine in Houston. That’s where I started. I kind of grew up all over the world, but ended up in Houston with my family. I didn’t really know anything about anesthesia or pediatric anesthesia when I started medical school. I was 100% sure that I was going to be a neurologist. That’s what I went to medical school for, thinking, oh, the study of the brain, it’s so interesting. That’s what I’m going to do. And then I did my neurology rotations. And I actually, I mean, I really enjoyed them in that I loved the people I worked with. I really liked the patients. But at that time, this was back in the late 80s, there was very little we could do for a lot of these medical problems. And so I kind of was like, oh, I don’t really want to do this. I’m not really sure what I want to do. I think maybe I’ll do surgery. So, like many people who end up in anesthesiology, I started in surgery. And um, I had like one elective month left in my medical school year. And a lot of my colleagues and friends suggested doing anesthesia as an elective. So I did a month elective. I had had very minimal exposure to anesthesia prior to that. I really didn’t know much about it. And oh my gosh, I fell in love with it. And at this point, I had already matched into surgery, so I was already committed to doing that. And throughout my first year of internship, I’m like, you know, I really like this surgery thing, but I really, really liked that anesthesia so much more. And it these hours are really insane. And I know that I want to have a family and I’m married to a surgeon and who’s going to stay home. And I, gosh, I really, really enjoyed anesthesia. And so um, through a variety of different events that occurred during that year, I became more and more convinced I wanted to do anesthesia. And my thought at that time was because I liked the acute care kinds of aspects of surgery and anesthesia, I could do critical care. So I went into anesthesia. I switched um after my internship year, went into anesthesia, basically thinking I would do critical care. And actually had started applying for and interviewing for and having been accepted for a couple of different fellowships when I did my peas anesthesia rotation um in my in residency. And that was it. I think within a week, I was like, oh my, it was an epiphany. It’s like a light went off for me. And it was like, this, this is what I am supposed to be doing with my life. This is this is what I want. And so, you know, I had to, because I had to sort of do an about face. I had to really sit and think about it. At that time, um, believe it or not, at Baylor College of Medicine and Texas Children’s, there actually was not a fellowship available in PEEDS anesthesia. So I knew I was going to have to leave Houston. And my husband was working in Houston at the time. But um, yeah, so that’s kind of what led me to pediatric anesthesia.

That is so interesting. And it’s so cool that you found the right path for yourself, even after exploring all these other areas too. Since this is the Anesthesia Patient Safety podcast, we like to start the conversation off about patient safety. So, what got you interested in patient safety in your practice?

I mean, I think all anesthesiologists at heart are interested in patient safety, right? I mean, that’s so much of what we do. We can see how easy it is to harm patients if we’re not vigilant or we’re not patient paying attention. I think though there were a couple of events early in my career interestingly involving wrong drugs. There was an event when I was still a resident where one of, and it was this wasn’t my case, but I was actually rotating in the ICU at the time and ended up taking care of this patient for a really long time. It was an um a pregnant mom who had was having twins and had to have a crash C-section. And unfortunately, at the time, the esmolol vial and the etomidate vial, both beginning with E, were both glass vials and looked very, very similar. And the resident inadvertently drew up the esmolol vial instead of automated and injected that into the patient uh for induction. She naturally, it was, I mean, a huge overdose of a very strong beta blocker instead of an anaesthetic agent. She had a cardiac arrest. She was out for a long time. They were able to get the twin the babies out successfully. She ended up actually, and when she first was transferred to the ICU for us to care for, I took care of her. It was at the beginning of my rotation. I ended up taking care of her for, you know, close to a month. And um, certainly at the beginning, we really didn’t think she would survive. By the end of the time, she was showing signs of improvement. And I actually got to see her about a year later. And even though she still had, you know, some deficits, but that was, I think for me, the first thing as a resident that made me realize how important patient safety is and how important all the work that we do, or all the work that the Patient Safety Foundation does, is particularly around different medications in similar, in similar containers and how profound, profoundly that can affect a patient’s life and outcome. So, I would say that was the first thing that really got me interested in the importance of really looking out for patient safety.

Medication safety is a topic that we talk about on this podcast quite a bit, and the APSF has done a lot of work on medication safety. And it’s interesting because we still see wrong drug or wrong route errors today. So there’s still more work to be done in this space. I know that you have spent a lot of your career focusing on patient safety, especially when it comes to patient safety during dental procedures. So can we just get started on that topic by talking about the history of dental anesthesia and how did you first become aware of the threats to patient safety during dental procedures?

Yeah, great. So, as probably most of the listeners know, it was actually dentists who invented anesthesia, right? So um, anesthesia predates physicians administering it. It was dentists who invented nitrous oxide and ether. Um, and it was dentists who used it originally. And so there’s sort of been these two parallel routes that have existed and developed side by side, which I think a lot of people probably haven’t recognized, especially in the medical profession. We’ve never really paid attention to what happens on the other end. When I started my fellowship in pediatric anesthesia, it was in Colorado at the then the Denver Children’s Hospital. There’s a very, and there still is, a really fantastic dental school there and a really, really strong pediatric dental department. And the dental school was right next to the hospital, and the dental clinic was right next to the hospital. And so we actually took care of a lot of patients for dental anesthesia, all under general anesthesia. They had a clinic, they did some, they did some sedation. The clinic was actually right next to our outpatient surgery centre, which was right next to, or they were all attached to the main hospital. So um it was done in a very controlled, very careful, very thoughtful manner. So it was never something I really thought about as being problematic until I actually moved out to California, which was about 11 years ago now. At that time, I was the chair of the American Academy of Pediatrics section on anesthesiology and pain medicine, as well as having gotten very involved with the California Society of Anesthesiology. There was a young child, Caleb Sears, who’s was six years old at the time. He went in to had an extra tooth in his mouth that needed to be removed. So he went to his oral surgeon’s office. The oral surgeon said he would need general anesthesia for it. He reassured the family that there would be somebody there, quote unquote, monitoring Caleb the entire time. Caleb’s aunt was a surgery resident who, so she just assumed that the same standards that apply to sedation and anesthesia in medicine also applied in dentistry. It never occurred to her, as it didn’t occur to me and many others, that there was a whole other parallel system that had grown up alongside of medical anesthesia and sedation. So Caleb went in, he received midazolam, nitrous oxide, ketamine, fentanyl, propofol, and he naturally stopped breathing. Unfortunately, at that point, the oral surgeon didn’t seem to know what to do. There was no bag mask ventilation, there was no effort to ventilate him. He did try to intubate Caleb, breaking several of his teeth in the process and not being successful with his intubation attempt. They at some point called 911, and there’s a lot of question about how long it was before that occurred. When the paramedics arrived about 10 minutes later, no one was doing CPR, no one was administering oxygen, no one was trying to ventilate him. Pretty much nothing was happening. And so I got involved and I became aware of this through Annie, who is Caleb’s aunt, and through the American Academy of Pediatrics and the CSA. Because what Annie and her family did, what Caleb’s family did, was go to the legislature and say, how is this possible? How can there be, you know, how can this happen? Caleb went on to pass away. Um, they were able to resuscitate him, but at that point he had been down for so long that he ended up passing a few days later. So their entire family, you know, was as you can imagine, devastated. And he started looking into like what’s available. What are what is what is what are the numbers of complications that occur in dental offices in patients undergoing anesthesia? Nobody knows. What’s the number of deaths? Nobody knows. The California Board of Dentistry ultimately was able to pull up, I forget the exact number, but some number of reports. And the data is very sparse. It’s very thin. And so she went to the legislature and had a law passed called Caleb’s Law that basically required, and I’m sorry, this is a long, a long haul to answer your question, but it really underpins how I got involved and why I’m still so passionate about this. Um, so this initial law basically asked the dental board to do a study on pediatric anesthesia or sedation deaths and complications and anesthesia in children undergoing dental care. It asked them to create a separate consent form so families understood that in fact the person monitoring the child is not a medical professional. They are a dental assistant. And a dental assistant is wonderful, right? We all go to the dentist regularly. I go to I go every six months. I love my dentist, I love my dental assistants, I love my dental hygienist. But they are required to have no more than a high school level education, um, plus some on-the-job training. And some may go on to have some additional online medical training through what’s called the JANT program, which is the dental anesthesia assistant national certifying exam, where they get like 36 hours of online training and then they have to pass an online exam. That’s it. So that was one of the things was the consent. And then there were a few other parts of that, one of which is included, and this is one of the calls that I have, is uh to create a robust data system to actually track complications and deaths in dental offices. So that happened. The California Board of Dentistry actually did this study, and they came up with several recommendations. So I was involved because Annie, then working with her local congressman, tried to create a law to pass through the California Assembly to improve dental safety by actually following the recommendations of the dental board. And these recommendations included better data collection, better pre-op to have separate people available if they’re going to do deep sedation or general anesthesia. And there was there was a few other things in there. They wanted content experts. The AAP reached out to me as the then current chair of the section on anesthesiology, and also someone who lived in California and actually lived in the same Bay Area that that Annie and her Annie Kaplan and her family lived. And then the CSA also was brought in for the same reason. So that was my initial introduction to this. And I will tell you, it took me a while with people trying to explain to me why this was a problem. I’m like, well, I don’t understand if they have the dentists or the oral surgeons do anesthesia training as part of their oral surgery training. So I don’t understand why they can’t do this. Plus, I had worked with dentist anesthesiologists in Colorado who had all done three-year residencies in anesthesia in dental. One had done it in formal anesthesiology when that was still available. Several had done it, actually, I’d worked with several dentists who had were anesthesiologists back in the day when dentists could actually do anesthesiology programs. More recently, though, I had worked with dentist anesthesiologists who had gone through special training programs for dentists, but it was a three-year program with pretty intense training around how to safely anesthetize children in sort of the office-based setting, and taught them a variety of techniques, and they spent a lot of time in the hospital as well as in the clinic. So that was my initial introduction to all of this. I just, I remember it took me, like they kept trying to say, you know, there’s someone monitoring, but they have no more than a high school education. And I’m like, oh no, they’re exaggerating. There’s no, there’s no way. I mean, nurses have more than that, right? No, but the thing is, dental assistants are not nurses. They don’t have even the bare minimum medical training. They have at most, at most, maybe this 36-hour online course. And at most, all they can really do is sit and watch the monitors. They can’t actually help with resuscitation. They can’t draw up drugs, they can’t help manage an airway, they can’t, they can’t administer drugs per their, you know, per their rules and regulations. They could, if they’re basic life support certified, they could at least do CPR. Um, but it didn’t sound like, at least in Caleb’s case, that anybody was doing any of that.

Wow, what an introduction into the scope of this problem. And I think you’re right, this is something that not a lot of people think about because we just think about going to the dentist as something that is thought of as being routine and safe. And it’s not always the case. Now, when we’re thinking about the scope of the problem for patient safety for dental procedures, could we just step back a little bit and talk about? So, what are the different options for anesthesia for dental procedures? Because I think this will lead us into how patients can be harmed later on in our discussion.

Sure. So we actually published a recent paper that gives a little bit more of a backdrop called Why Do Deaths and Catastrophic Injuries Still Occur in Dental Anesthesia. So there are a lot of different options, starting with straight local, which most of us have probably received for either fillings or some tooth removals or something like root canals, that kind of stuff. Straight local works really, really well. There’s a lot of people, however, who have a lot of anxiety around getting local anesthesia. Either it’s still, even though they’ll put like a topical on your gum first before they inject, it still can be a little bit uncomfortable. And there are a lot. Of people who have real dental phobia or needle phobia for a variety of different reasons, for whom straight local is really very scary. And this is for both children and for adults. And just to be clear, this is not just a pediatric problem. Some of the deaths and some of the people that we’ve worked with have had adult loved ones who have passed away because of dental sedation. Then it goes all the way from mild anxiolysis to basically general anesthesia in the dental office. Because I think that’s a very different kettle of fish than what occurs in the office setting. So we start right there with one of the issues that that occurs in dental anesthesia. First of all, sedation and anesthesia for dentistry is guided and regulated differently for every single state. Every state sets their own requirements, their own guidelines, their own policies and procedures around who, what, where, what’s required, emergency drugs, you know, all of that kind of stuff. Not only that, but they actually define anesthesia and sedation differently than we do in our medical profession of anesthesiology. They use terms like oral conscious sedation or parental moderate sedation or oral moderate sedation. And so there’s in a lot of dentistry, the route of administration actually is how they define the level of care, I guess, that they’re providing. Because as you can imagine, not all dentists’ office are going to be equipped to start IVs, right? Something as basic as starting an IV is not going to be present in all of these kinds of situations. And so if you can just do medications by mouth, then you don’t have to worry about an IV. It also then will go on, you know, you’ll follow a different path in terms of what you need to have available in your office. And of course, that’s going to impact cost. If you need to have IV equipment, if you need, you know, you then you have to be checking it, you have to be checking your fluids, you have to make sure things are up to date. You may have to dispose of them. So it increases the cost if you’re going to have IV stuff available. So many dental offices will just offer basically what they’ll call oral mild or minimal or conscious sedation. Again, the terms vary depending on the state and what you’re doing. So that can include some kind of a benzodiazepine. It may also include some oral opioid. It may include, you know, hydroxyzine or, you know, some other kind of sedative medication just to try and sort of quote unquote take the edge off. Then again, depending on the state, depending on the office, depending on the particular dentist and what kind of training they have and what kind of training they need for that state’s requirements for various sedation levels, they may offer more. They may offer IV sedation, they may offer what they’re going to call moderate or deep sedation. Um, what we would call moderate or deep sedation. They have, like I said, different terminology for it. Most of their rules do not require a separate anesthesia provider, even if they’re doing, and a lot of what is really general anesthesia with a natural airway, they’re calling sedation. Basically, the patients aren’t moving, they’re not responding to painful stimulus, but they’re still calling it sedation. So those are some of the various things that are offered. And dentists can use, again, depending on their training, depending on their state requirements, they can use all the medications that we use. They generally don’t use, I don’t think, I don’t actually know about muscle relaxants, but they have propofol, they have fentanyl, just like in Caleb’s case. They have ketamine, they have midazolam, um, they have other types of opioids, you know, Demerol, morphine. Um, what else is there? I think those are the main things. They have, you know, they have most of the types of anaesthetics that we would think of being associated with general anesthesia. They have those available. Some places may have gas if they have an anesthesia machine and they have a scavenging system. Some traveling anesthesiologists will have their own little portable anesthesia machine that they can bring with them. And to continue with kind of what’s available, so there’s also a difference in who’s providing the anesthesia. Um, in many dental situations, it’s the dentist or the oral surgeon. Dentists have to have additional training. And again, state determined what that additional training is to provide deeper levels of sedation and anesthesia. Whereas oral surgeons, because of the fact that they’ve done five months of anesthesia as part of their oral surgery residency, are almost always automatically given a license to do general anesthesia or, you know, anything up to general anesthesia. So it may be the dentist by themselves, it may be the oral surgeon by themselves, they may have a colleague, either, you know, again, a dentist who’s licensed or an oral surgeon to help, or they may have a CRNA in states where they’re independently licensed, or in states where they’re allowed to be supervised by the dentist or oral surgeon, or it may be a separate anaesthesiologist who comes in to, you know, to provide the anesthesia in their office. Uh when my children had their wisdom teeth out, I made sure I paid. And it’s, of course, it’s out of pocket. It’s not covered by any of the insurance. Whereas if I had let the oral surgeon do the anesthesia, there would have been some, some of it would have been covered by the insurance. I paid out of pocket to have a separate anaesthesiologist who worked with that office come in and do the anesthesia for my kids. And they were adults, they were young adults, they were like 19 or 18, 19, 20-ish in that range. So they were not children at that point. But I still was not going to, you know, not going to take the risk.

Well, and speaking of rest, one of the APSF patient safety priorities is clinical deterioration with the focus on preventing, detecting, and determining pathogenesis and mitigating clinical deterioration in the perioperative period. This is something that anesthesiologists really focus on for our patients when it comes to providing safe anesthesia care. And this is also something that seems vital when keeping patients safe during dental procedures. So it sounds like there may be options to have an anesthesiologist present during the procedures. But what do you see as the most important considerations when it comes to preventing this clinical deterioration during dental procedures?

So I think there’s two things. And increasingly, as I’ve spent more time in this world and in this field, I think one of the most important things is patient selection. Because I don’t think, and I I’m not a dentist or an oral surgeon, I don’t know what they were taught, but I do work with um dentists. So many of the deaths, particularly in adults that we hear about, and even some in children, it’s clear that that patient was not an appropriate candidate for an outpatient setting. And most surgeon centers or ambulatory surgery, you know, surgical centers, they wouldn’t be considered a candidate because they have too many comorbidities, such as obstructive sleep apnea or such as underlying cardiac disease, or you know, some other thing that would make them a poor candidate to be cared for in a purely outpatient setting. So I think the first thing is a really increased emphasis on patient selection, that not every patient, even for quote-unquote minimal sedation or conscious sedation or whatever they want to call it, that they may not tolerate a little bit of midazolam. And this is something anesthesiologists have learned the hard way, right? We’ve spent years in years the APSF being, you know, at the forefront of some of this research, really advocating for and recognizing that not all patients are the same. And you can’t take, you know, they may all be maybe a 50-year-old and a 50-year-old and a 50-year-old. But if the one 50-year-old is running marathons and the other 50-year-old is on um, you know, has really severe sleep apnea and is on a uh BAP machine at night, and the other 50-year-old maybe has had bad cancer, and they may be healthy, or they may have been in remission now, but they’ve been exposed to all these oncology medications, they are not the same person and they can all react and respond differently. So I think starting out by really recognizing and having respect for the significance of comorbidities and how they may impact a patient’s response and reaction to sedation. So I think it starts there. Then the second thing is really having people like how can you have someone recognize, like you said, the first thing is recognizing and diagnosing causes of deterioration. But how can anyone recognize that as a problem if they don’t have any medical background? So I think that’s a huge part of it. I really truly believe that anyone getting deep sedation or general anesthesia is best cared for by an independent practitioner who is trained. Personally, of course, I think it should be a physician anesthesiologist, obviously, but I recognize that there’s also not enough. There’s not enough of us to go around. And so, you know, that creates a problem that is difficult to solve sometimes without bringing in other people. So I think a CRNA is better than an oral surgeon doing this by themselves. I think another oral surgeon is actually fine. If you have a separate oral surgeon whose job it is to monitor the patient, they are hopefully trained well enough to recognize when deterioration is occurring, when there’s a clinical problem occurring before it becomes, you know, too late, before they have a cardiac arrest or before they become profoundly hypotensive or have a, you know, have a heart attack or whatever the issue is going to be. So I personally think for deep sedation and general anesthesia, there should be someone else there. There are a lot of physicians, for example, emergency room physicians. And I’m not advocating for this, but again, I’m recognizing I’m being pragmatic in that there is not enough people to do this. And I do know that within my state, there are intensive care physicians who provide sedation for dental patients because I guess there’s more of them than there are of us. And maybe they have more time. I don’t know. I’m not quite sure why, but I know that that is a practice in in parts. And I still, again, I believe that that is a heck of a lot safer than a single. Doesn’t matter who it is. I mean, we don’t have surge surgeons, don’t provide their own anesthesia. They don’t, you know, they may do sedation for patients, but they don’t provide their own, they don’t provide their own deep sedation or general anesthesia for the most part. So those are the two things that I think would really make this safe. And then the third thing, and I, and this again is something that anesthesiologists have really led the way, is having good data collection tools. So we know what’s happening. We can identify when there are problems occurring, what is the cause of the problem. In dentistry, it’s still very much a finger-pointing blame and shame. Oh, it was this dentist or this oral surgeon who did this. It was this um, you know, it was this patient who had this one singular issue that led to this problem. The, you know, that was 30, 40 years ago in anesthesia. We’ve moved well beyond that and much more into root cause analysis and looking for systemic issues and how to cope with systemic issues. And I the dental world has really not done that in the same way. And I do think that’s the third part of it is to have probably a separate group who will look at so that I know they’ve created a dental patient safety foundation that’s supposedly based somewhat on um our patient safety foundation. I don’t know because we’re not privy to any of that. So I don’t actually get to see any of that information, but there clearly needs to be a very robust way to track when problems do occur, including near misses. And I think in in probably more importantly, near misses, right? Because that’s where you can identify the opportunities to improve care.

Absolutely. And I just wanted to ask too, are there monitoring requirements? And have those changed over the years? It sounds like they’re probably going to be different state by state or office by office, but it seems like that could be a really big step for improving safety, would be to make some monitoring standards like we have in anesthesiology.

There are no monitoring requirements. I mean, well, let me rephrase that. It is very much state by state. There are a number of states that don’t even require pulse oximetry for deep sedation or general anesthesia. So, yes, that obviously would make that would be a start, right? And not just, I mean, there’s a story. Sorry, if you don’t mind my telling the story, of a little boy, uh, this was in Arizona, who went to the dentist, had multiple, you know, levels of work that he needed to have done, had a successful anaesthetic, had a successful dental procedure, was then taken to the recovery room or their recovery area and left with a dental staff. And we don’t know what the qualifications of this dental staff were. We’re suspecting it was just, you know, somebody in the front office was hooked up to a pulse oximeter and an oxygen tank. The pulse oximeter kept alarming, the dental staff kept silencing the alarm, and then at some point just took it off and said, Oh, these things never work on children. The child went on to have a respiratory rest and later passed away. And it turned out the oxygen tank was completely empty. So here was this child who was not getting oxygen, whose pulse oximetry was continuing to alarm, but was completely ignored. So it’s more than just a requirement for monitoring. It also requires that you have people available who understand what the significance of the monitor is. And if there’s a problem, know how to both troubleshoot the monitor because we all know there are definitely times when the monitors are giving us false alarms and are just super annoying. But there’s also probably many, well, the definitely many, many, many more times when that is not the case and there’s an actual problem. So back to your, you know, the pillars of what the APSF is trying to achieve this year is to know how to do the differential diagnosis to figure out what the pathogenesis

is of the problem. You can’t do that if you don’t have medical personnel available or looking. I know that for a lot of the anesthesiology groups or private practitioners that do mobile anesthesia, particularly in dentist’s office, they often, so they come in with all of their equipment. They often will bring in at least an EMT trained person or a nurse with them so that there’s always at least one other person available that can assist when there’s issues.”

[Bechtel] We are going to stop there for today, but have no fear we’ll be back next week to continue the conversation. Before I sign off for today, I’ll leave you with a few important takeaways.

1. The fundamental problem is not simply “bad anesthesia” in the dental office, it is a systems problem. There are opportunities here to re-design the system to detect and rescue clinical deterioration early.
2. Terminology matters and the how we define “Sedation” is vital because this may influence equipment, personnel, monitoring, and rescue.
3. Patient selection is a major safety intervention. This is definitely an area where anesthesia professionals are experts.
4. Monitoring is only useful if someone knows what to do with the information. It’s a key ingredient in the recipe for patient safety: Monitoring + trained professionals + appropriate response
5. Patients requiring deep sedation or general anesthesia should have an independent practitioner providing the anesthesia.
6. Dental anesthesia has a major data problem and we need reporting on adverse events, deaths, complications, and near misses if we want to see systems changes and improvements.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

We received an email from a longtime listener of the podcast, Dr. David Moss, who is a pediatric anesthesiologist. He also runs AnesthesiaHub which is a curated anesthesia resource site that now includes searchable archives of active anesthesiology podcasts and blogs. You can find the Anesthesia Patient Safety Podcast there…all 320 episodes and counting…and so much more. I really like the Tools heading which makes it easy to find recent guidelines and clinical calculators and even has a link to the Stanford Emergency manuals. We hope that you will check it out.

Until next time, stay vigilant and stay informed so that no one shall be harmed by anesthesia care.

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