Is There a Doctor in the House?
Making sure your entire staff is prepared can help save your patient during a life-threatening medical crisis in the dental office.
Introduction by Morton Rosenberg, DMD
Medical emergencies can and do happen in all dental practices. Although their etiologies may differ, every dental office must be prepared at some basic level to address these emergencies in a timely and effective manner. These emergencies may be directly related to dental treatment (eg, local anesthesia issues, reactions to and interactions with medications administered by the dentist, or psychogenic responses to the dental environment), the exacerbation of pre-existing medical conditions (eg, angina, hypertension, bronchospastic disease, and glycemic issues), or by chance (eg, myocardial infraction, sudden cardiac death, and cerebral vascular accident).
Surgical and medical advances are increasing the numbers of patients with medical considerations impacting on dental treatment plans. Solid organ transplants, complex surgical repair of the cardiac valve replacement and coronary artery revascularization, artificial joint replacements, implanted pacemakers and automated cardio-defibrillators, and insulin pumps are just some examples of medical advances that continue to increase the number of patients with increasing medical complexity presenting for dental treatment.
Therapeutic choices for dentists are increasing with the introduction of new generations of antibiotics, postoperative analgesics, local anesthetics, and sedatives. Every drug has its own inherent indications, contraindications, and side effects. Most importantly, these drugs have the capacity to interact with each other and with other prescribed and over-the-counter medications, abused substances, and herbal supplements. In general, the growing number of medically stabilized yet chronically ill patients is thought to parallel a concomitant increase in the incidence of medical emergencies during dental treatment. Moreover, dental advances such as intraosseous implants and comprehensive periodontal treatment combined with extensive restorative dentistry is leading to “life-long dentistry” attracting an older, less-healthy population to dental offices.
All of these factors are magnified in the geriatric and special needs populations. As the numbers of elderly individuals increases, their risks also increase as a result of physiologic and pathologic changes associated with the aging process. In addition to the normal deterioration of major organ systems that inevitably occurs with age, the geriatric population is more likely to exhibit chronic clinical conditions that may become acute during the dental visit and require intervention. Aging alters the pharmacokinetics of many drugs; pharmacodynamic and physiologic changes may result in greater sensitivity to many drugs, especially central nervous system depressants. The pandemic of obesity in all age groups and its direct correlation with the increased incidence of adult-onset diabetes and associated disease states also increases risk.
Although having appropriate emergency drugs and equipment is of utmost importance in preparing the dental office to respond to medical emergencies, it is the training and expertise of the dentist and his or her team that is paramount. The first step in reducing the possibility of encountering a medical emergency is a thorough review of the patient’s medical history with special emphasis on pre-existing medical conditions, medications, and herbal supplements and allergies. Preoperative vital signs and a focused physical examination will yield important information as to physical status, the need for additional consultations, and whether alterations are necessary in the dental treatment plan.
Dentists should be able to diagnose and manage anticipated medical emergencies, decide immediately whether additional help is need, and manage the airway in the unconscious patient, but it is the involvement of the dental team that will make a difference. Whether as expressed in the aviation model or the emergency medical one, crisis resource management (CRM) and team training has been proven to improve outcome. Working together, learning and understanding the important roles and contributions of each team member can only be achieved by practice and discussion. Every dental office should be conducting mock drills and rehearsing emergency scenarios as a team on a regular schedule. Defining roles and expectations, acquiring skills and, most importantly, developing communication skills all will increase the ability of the office to respond appropriately and calmly to emergency situations. Continual attendance by the entire staff at continuing education courses and re-certification in the appropriate Basic Life Support (BLS) offerings will hone the skills of the entire team.
Guidelines that are standards of care must be dynamic and based upon evidence-based medicine and should be updated periodically. It is imperative for all dentists to stay current in Basic Life Support for Health Care Providers (BLS-HCP). Recent changes that will be implemented in Spring 2011 include important new algorithms in the basic approach to treating the unconscious patient, and every dental office should be aware of these updates.
Only after ensuring the educational qualifiers of the dentist and staff can we turn toward preparing the office with equipment and drugs. The ability to provide supplemental oxygen for the spontaneously breathing patient and under positive pressure for the patient who is apneic or hypoventilating is the most important aspect of this preparation. Drug kits can range from the very simple to the complex and depends on the dentist’s training, comfort level, and if sedation/anesthesia is administered. Basic and critical emergency drugs and emergency airway and monitoring equipment must be present in every dental office. Every office should consider purchasing and, more importantly, understanding the operation and indications of an automatic external defibrillator (AED) as part of BLS-HCP.
Although any medical emergency can be encountered in the dental office, chest pain and allergic reaction are two emergencies where immediate response will determine outcome. There is no time to wait for emergency medical services and withhold treatment. A definitive diagnosis of differentiating chest pain, angina, and myocardial infarction may be difficult, but chest pain can never be ignored. An understanding of the importance of early diagnosis and following established algorithms will save lives.
An allergic reaction is a major medical emergency that must be anticipated in dental offices especially because dentists administer or prescribe triggering agents such as antibiotics and postoperative analgesics. For an anaphylactic or anaphylactoid reaction with respiratory and cardiovascular involvement, only immediate diagnosis and treatment will prevent its progression to a serious outcome.
This month, five experts in medical emergencies address the key areas in preparing your office for a medical emergency from the global ones of adopting and instilling a team approach, a suggested drug and equipment review, and a synopsis of the latest updates in BLS. Two medical emergencies that can be anticipated in the course of dental practice, allergic reaction and chest pain, are reviewed to assist in the diagnosis and management of these acute medical emergencies.
Preparing for a medical emergency in the dental office is not simple and requires time, an organized approach, and continual review and training for the entire staff, but it is our professional, ethical, and legal responsibility to provide a safe and responsive environment to anticipate and treat acute medical emergencies that may arise during dental practice. This knowledge and preparedness is what makes us healthcare professionals and every dentist should make this an important part of his or her practice.
About the Author
Morton Rosenberg, DMD
Professor of Oral and Maxillofacial Surgery Head
Division of Anesthesia and Pain Control
Tufts University School of Dental Medicine
Associate Professor of Anesthesiology
Tufts University School of Medicine