Whilst medical emergencies in the dental environment are uncommon, there is an expectation from regulators such as the General Dental Council and the Care Quality Commission, as well as our patients that should such an emergency arise the dental team will be adequately prepared to manage it; this is a fair expectation.
Clearly dental teams need to be aware of the common medical emergencies with respect to signs, symptoms and early management. There is also an expectation that dental teams will have access to recommended emergency equipment and drugs and have current and regularly updated training in their use. The key is preparation and dentistry can learn from both the military and aviation industries where simulation training is paramount in managing uncommon events.
We can all remember the water landing of US Airways flight 1549 on the Hudson River in January 2009. Captain Chesley Burnett Sullenberger III and crew were rightly hailed as heroes in safely landing the aircraft and the subsequent evacuation of passengers following a bird strike soon after take-off. This favourable outcome has been credited by all investigators to the regular simulator training by aviation crews to prepare them for such uncommon events. This Crisis Resource Management was a concept developed in 1970’s with the realisation that 70% of airline crashes were due to human error resulting from teamwork failure. Crisis Resource Management training improves performance and reduces errors and refers to the non-technical skills required for effective teamwork in a crisis situation.
Regular Rehearsals
The General Dental Council in its Principles of Dental Team Working clearly states that ‘all members of staff who might be involved in dealing with a medical emergency are trained and prepared to deal with such an emergency at any time, and practise together regularly in a simulated emergency so they know exactly what to do’.
Practice owners reading this will be carrying out fire drills regularly but not many will be carrying out medical emergency drills. It is more likely that a dental practice will have a medical emergency than a fire. So my recommendation is to have simulated training involving the whole dental team in the dental practice environment every three months. This does not need to involve external trainers or any elaborate or expensive equipment. Simple role play exercises, familiarisation of equipment and the drug kit as well as short discussions of common medical emergencies will help in reducing unfavourable outcomes and improved patient care.
In the United Kingdom a not insignificant percentage of hospital admissions have an adverse outcome. This is not a reflection on the qualification or knowledge of the medical staff but a lack of awareness of duties, roles and accountability as well as a reluctance to challenge senior colleagues in their procedures. Often there is a lack of communication between colleagues which leads to adverse outcomes. Regular training will help in reducing these unfavourable outcomes and written minutes of this training will be looked on favourably by regulators and are good team building exercises.
Medical History Updates
Another key risk management tool in dentistry is the medical history form which should be updated and signed by the patient and clinician at each new course of treatment. It is essential to ensure that the patient has understood the often complex terms written in the medical history form and to offer assistance with its completion.
Patients will often tick ‘no’ if unsure of the question. Where a positive response has been given to any condition it is mandatory to follow up in detail. For example, if a patient gives a positive response to asthma then the follow-up questions would include:
- How long has the condition existed?
- What medications are taken and has the patient brought them to the appointment?
- When was the last attack?
- Have they ever been hospitalised for the condition?
- What triggers their attacks?
This last question is particularly relevant as latex can be a trigger point. A large proportion of UK dental practices are still using latex examination gloves as well as latex rubber dam in endodontics. 6% of the general population have developed allergic antibody to natural rubber latex protein and approximately 10% of health personnel, who are occupationally exposed to rubber gloves and other rubber products have been found to suffer symptoms on contact.
A simple solution to preventing allergic reactions as well as safeguarding staff is to switch to non-latex products. It is interesting to note that certain tropical fruits contain the same protein molecule as natural rubber latex and patients sometimes suffer allergic reactions by cross-reacting to these. The commonest fruits causing problems in this way are avocado, banana, kiwi fruit, melon and chestnut. If a patient makes casual reference to fruit allergy those practices where natural latex gloves are in use may need to show extra vigilance due to cross reactions.
Stay Calm and be Prepared
Dentistry heads the top three phobias in the country above spiders and heights! Almost half of UK adults have a fear of the dentist and 12% of these suffer from an extreme dental anxiety. When patients are anxious their heart rate, breathing rate and blood pressure can all rise. It is not difficult to imagine that someone in this category who also suffers from conditions like angina or asthma may be more likely to suffer an emergency in a dental environment so special care and awareness are important.
Familiarisation and regular checking of emergency drugs and equipment also form an important part of risk management. Oxygen cylinders should be checked daily to ensure no leaks have taken place and the drug kit should be checked weekly ensuring all packaging is sealed and in-date. All drugs and equipment should be stored so that it is secure but accessible to staff.
Dental practices that take proactive steps in risk management with respect to medical emergencies may lead to more positive outcomes for patients and will have demonstrated readiness and preparation with less likelihood of criticism in cases of unfavourable patient outcomes.
