Michelle Budd, D.D.S, Patient Safety Consultant, dentalcorp; Julian Perez, Senior Vice President, Risk Management & Compliance, dentalcorp
“Failing to prepare is preparing to fail.” — Benjamin Franklin
Dentists are highly trained and skilled health care professionals and, as such, are legally and professionally obligated to recognize and manage medical emergencies. This includes iatrogenic events and emergencies occurring by chance, such as a patient fainting in the waiting room. Adequately preparing for medical emergencies requires not only the proper drugs and equipment, but also training, teamwork, and a culture of safety that permeates throughout the entire dental practice.
Notwithstanding best intentions to keep patients safe, nearly every dentist will have to manage a number of emergency situations throughout their professional career. As a result of the increasing average age of dental patients, dentists are treating more patients with complex medical conditions and comorbidities, who take an increasing number of medications with possible interactions and side effects. As a result, it is expected that the frequency of emergencies in dental offices will grow. While any medical emergency can happen in a dental practice, increased anxiety in dental patients coupled with the administration of agents such as local anesthetic makes certain medical emergency scenarios more likely. Syncope/fainting, postural hypotension, epinephrine reaction, hypoglycemia, allergic reaction, and cardiovascular events are some of the most common emergencies reported in the literature.
When the time comes to manage a medical emergency in your practice, you should be equipped with the knowledge and training to recognize when something is wrong, and have an emergency kit readily available. That said, you and your team should reflect on whether you are truly prepared to react efficiently and effectively in stressful and chaotic situations. The moment a medical emergency happens is not the time to figure out where the necessary drugs are, try to remember dosages and how to administer them, or determine who is supposed to be doing what. While adverse outcomes may still occur even if an emergency is handled correctly, adequate training and preparation of the dental team will greatly improve the chances of a favourable result or, in the gravest situations, survival.
In The Unthinkable: Who Survives When Disaster Strikes – and Why, Amanda Ripley observes that “the best way to get the brain to perform under extreme stress is to repeatedly run it through rehearsals beforehand.” The U.S. military, an institution required to act under the highest degrees of stress, summarizes the same notion with eight Ps: “Proper prior planning and preparation prevents piss-poor performance.”
Specific life support techniques and emergency drug requirements change over time; nevertheless, there are fundamental, timeless concepts that dentists should incorporate into their practice. Borrowing mnemonically from the U.S. military, dentists and their teams can follow the six Ps laid out below to ensure preparedness for whatever emergency may arise.
1. Prevention: The best kind of emergency is the one that never takes place. But this does not mean one should embrace optimism bias or leave such matters to pure luck. There are steps dental teams can take to prevent emergencies from happening. Clinically, this includes obtaining a comprehensive medical history, plus information about current medications and compliance, allergies, vital signs, consideration of the patient’s American Society of Anesthesiologists physical status classification, as well as any potential airway obstructions. This information should be reviewed at every dental visit, updated as needed, and be readily accessible in the patient’s chart.
To safely manage the care of a medically compromised patient, the nature and extent of the dental treatment being contemplated must be considered, as well as whether a medical consultation is necessary before proceeding. Medical emergencies can also be prevented by taking the time to really listen to and address patients’ concerns. Studies show that medical emergencies are more likely to occur during dental procedures that patients perceive to be more stressful and painful, such as root canal treatment and complicated extractions. Any opportunity to reduce patient anxiety and pain is a potential opportunity to prevent a medical emergency.
Emergencies can also be prevented by learning from near misses and low-harm events that could have been more severe. Any time that a patient slips on the ice outside the practice, has a hypertensive episode during treatment, or nearly receives the wrong prescription, to name a few examples, the event should be viewed as a valuable learning opportunity. Too often, such matters are viewed as isolated events when they may well be warning signs that systems or processes contain gaps that expose you and your patient to latent risks.
2. Protocols: The Royal College of Dental Surgeons of Ontario (RCDSO) recommends that every dental practice maintains a written medical emergency protocol that outlines the expected plan for responses to medical emergencies. This is sound advice wherever you practice dentistry. Emergency plans should be readily accessible to everyone in the practice and kept in a location where they will serve as a constant reminder of the importance of safety in the dental practice. To be effective, a plan must be a living document that is revised and improved regularly through the ongoing effort of the entire dental team. A successful plan will let everyone in the practice know the various roles and responsibilities they may be assigned. Role assignments may look something like this:
a. Person 1 – Team leader, usually the dentist, primarily provides direct emergency care to the person involved in the medical emergency and makes the decision whether to call 911. Always remember: when in doubt, make the call!
b. Person 2 – The most available person, often the dental assistant, assists the team leader directly, and is responsible for patient monitoring, vital signs, and the application of oxygen.
c. Person 3 - The next available person, such as a team member from an adjacent operatory, retrieves the emergency kit and supplies, prepares emergency drugs, and whatever else may be required.
d. Person 4 – An administrative person, such as the dental receptionist, calls 911 if advised to do so, records vitals and all interventions, and keeps track of the time each drug is administered.
3. Personnel: All dentists and clinical staff must have the training and ability to perform basic life support (BLS) techniques. The RCDSO strongly recommends that dentists maintain current BLS certification (equivalent to CPR Level HCP). Dentists providing sedation will have additional requirements depending on the level of sedation provided and the age of the patient being sedated. Regardless of what training is required, the entire dental team should be able to recognize signs of patient distress and initiate appropriate action when required. During an emergency, procrastination is the enemy. A person who doubts there may be an emergency or feels uncertain about their ability to respond is a person who delays. As your practice grows or staff turnover, it is important to ensure that new team members receive training and adequately fulfill the applicable roles in the medical emergency plan. All records of training should be kept on file and updated as necessary.
4. Practice: Practice makes perfect! Ongoing training and review should occur on a monthly basis to ensure that the necessary knowledge and skills to recognize and manage medical emergencies are fresh in everyone’s mind. An effective way to do this is by running mock emergency drills of the most common medical emergency scenarios. Mock drills can act as effective team-building activities where dental team members can practice in a variety of roles to ensure that everyone is prepared should a team member be absent when a medical emergency arises. Mandatory attendance by all team members is very important, as medical emergencies can happen at any time, including when most of the dental team has left for the day, and anywhere in the clinic.
5. Pharmaceuticals: To successfully manage a medical emergency, the appropriate drugs must be readily available. The RCDSO provides a list of the drugs that must be included in the emergency kit: oxygen (portable E-size cylinder), epinephrine (at least two sources), nitroglycerin, diphenhydramine, salbutamol inhalation aerosol, and ASA (non-enteric coated). It is also recommended to have a quick source of glucose available in the event of a hypoglycemic crisis. For dentists providing sedation, there are additional requirements depending on the level of sedation administered. It is important to have all the accessories/equipment required to administer these drugs, to have written guidance with the indications and dosages for each drug, to know how to use reversal agents and any devices such as an EpiPen, and to have a process in place to remove and replace any expired products. With drug overdoses at record highs in much of the country, having a naloxone kit on hand is also good practice.
6. Products: All dental practices should have the equipment required to monitor vital signs, but the ability to obtain a person’s temperature, oxygen saturation and blood glucose readings can also prove beneficial during a medical emergency. The RCDSO recommends that all dental practices are equipped with an automated external defibrillator (AED). The ability to access and properly use such equipment should be considered when developing your practice’s emergency kit, training routine, and when executing mock drills.
Taking a little time to follow through with the above steps will help ensure that the entire dental team can act quickly when time really counts. As Howard Kunreuther, co-author of The Ostrich Paradox: Why We Underprepare for Disasters, puts it, “the real challenge is for people to pay attention before something happens, rather than afterwards.” While the ostrich instinct — burying our heads in the sand — may be natural, it is not helpful over the long run.
Failing to have the necessary measures in place to respond to a medical emergency can not only lead to the loss of life, but it can also have a profound negative effect on your mental health and professional career. Liability may follow if the clinic’s response did not meet the standard of care expected. The fact that a dental team member did not cause the onset of a medical emergency does not necessarily provide a defense to a malpractice lawsuit. In the aftermath of a worst-case scenario, dental professionals may be required to demonstrate that they took all appropriate steps to prepare for and manage the medical emergency.
Republished with permission of the Ontario Dental Association and Ontario Dentist, 2021.
References
1. American Dental Association (ADA). Oral health topics: Aging and dental health. Chicago, IL: ADA; 2019 Jul 2. Available from: https://www.ada.org/en/member-center/oral-health-topics/aging-and-dental-health
2. Morrison A, Goodday R. Preparing for medical emergencies in the dental office. Journal of the Canadian Dental Association. 1999; 65:284-6.
3. Vaughan M, Park A, Sholapurkar A, Esterman A. Medical emergencies in dental practice–management requirements and international practitioner proficiency. A scoping review. Australian Dental Journal. 2018 Dec;63(4):455-66.
4. Haas DA. Management of medical emergencies in the dental office: conditions in each country, the extent of treatment by the dentist. Anesthesia Progress. 2006 Mar 1;53(1):20-4.
5. Royal College of Dental Surgeons of Ontario (RCDSO). Preparing for a medical emergency in the dental office. Toronto, ON: RCDSO; 2019 Jan 24. Available from: https://www.rcdso.org/en-ca/rcdso-members/dispatch-magazine/articles/1310
6. Royal College of Dental Surgeons of Ontario (RCDSO). Standard of practice: Use of sedation and general anesthesia in dental practice. Toronto, ON: RCDSO; 2018 Nov 1. Available from: https://az184419.vo.msecnd.net/rcdso/pdf/standards-of-practice/RCDSO_Standard_of_Practice__Use_of_Sedation_and_General_Anesthesia.pdf
7. Ripley A. The unthinkable: Who survives when disaster strikes – and why. New York, NY: Three Rivers Press; 2009.
8. Kunreuther H, Meyer R. The ostrich paradox: Why we underprepare for disasters. Philadelphia, PA: Wharton School Press; 2017.
About the Authors
Julian Perez is Senior Vice-President of Risk Management & Compliance at dentalcorp, where he is responsible for the development, implementation, and oversight of company-wide standards, programs, and systems to support practices in the delivery of optimal patient care. Prior to joining dentalcorp, Julian worked at the RCDSO, first as a Complaints Investigator and later as Senior Legal Advisor to the Professional Liability Program. Having practiced law in New York City prior to moving to Canada, Julian has extensive legal expertise. He earned his bachelor’s degree from Yale University and a JD from Columbia University’s School of Law. He also has a master’s degree in international law.
Dr. Michelle Budd works with dentalcorp’s Risk Management & Compliance team as a Patient Safety Consultant. She graduated from Western University with a DDS degree. While running a busy dental practice, she also earned a master of public health degree. Michelle has been a dental consultant for several insurance companies and government agencies, and has travelled throughout Canada to help dental practices achieve and maintain professional compliance.