A patient becomes unconscious and unresponsive in the operatory. She may be dying. Do you know what to do?
Brian K. Smith, DDS, MD
You just sat down to do a cleaning on a 25-year-old healthy female. You start the exam and are chatting with the patient when she tells you she isn`t feeling well. Suddenly, she flops back in the chair and becomes unresponsive. Startled, you yell for help but no one responds. You try to awaken the patient, but she does not respond. Your mind races. You desperately try to get someone`s attention until the receptionist comes running into the room. "Call 911! Get someone in here to help!" you scream frantically. The dental assistant arrives and becomes hysterical. You tell her to get the emergency oxygen. As she runs down the hall, you realize that, even if she finds the oxygen, you don`t know how to use it. The patient is now cyanotic and the emergency squad is nowhere to be found. Seven minutes have passed.
With recent legislative changes in 33 states which allow hygienists to practice with minimal or no supervision, we will soon become acutely aware of the often-overlooked responsibility of regular emergency training. Hygienists practicing independently will become responsible for emergency care in a dual-role capacity — that of an assistant to the doctor and that of a team leader.
The false sense of security that we can derive from the apparent overall safety of local anesthesia and non-local procedures can be shattered with a death or near-death event in the office. Thousands of emergencies occur in the dental setting every year. Despite what most people rationalize, emergencies can happen at any moment, without respect for person, place, or time. With increasing age, complexity of new diseases, and our lack of continuing emergency-medical education, dentistry is fertile ground for more frequent emergent disasters.
We who work in the non-IV sedating realm are basically capable of treating emergencies comparable to that of a layperson, yet we are responsible for our patients just as a physician is responsible for those in his or her care. The recent courses required by the dental boards for hygienists will help promote the opportunity to improve our knowledge and better our systematic capacity to diagnose and treat medical emergencies. Hopefully, we as a profession will become so uncomfortable with our inadequate knowledge of diagnosing and treating emergencies that we will proactively progress into the next century.
Hygienists will soon become painfully aware of the responsibilities of recognizing, maintaining, and promoting life during an emergency.
Preparing for an emergency
The pre-emergency preparation can begin with the knowledge that an emergency can happen at any time and without warning or reason. As a result, the basics of the "ABCDs" plan (airway, breathing, circulation, definitive care/defibrillation) should be ready to be used as a team. To be ready, the team must practice. It will feel awkward, but your return on the preparation will be extraordinary. It is highly recommended that the hygienists discuss the plan with the office team prior to treating patients. These plans need to be practiced at least twice each year. In addition, everyone must understand how and when to use the emergency instruments and medications. Each member of the team must know his or her role and be cross-trained to understand other roles as well.
Here are some other helpful "pre-emergent event" ideas:
- Your staff should meet with local emergency workers. During this meeting, they can give you instructions on how to help the patient before they arrive on-scene, and you can supply them with the needed information on entrances into the office. It`s also a great time to ask questions.
• If an emergency occurs without the doctor present, your team must have a plan. Discuss how you will reach the doctor and brief him or her on the situation. I recommend that the doctor is called immediately after 911 is notified.
- Know who will run the rest of the code. This will be a tough decision and may be specific to each emergency.
- Discuss your malpractice considerations with the doctor prior to seeing patients.
- Improve your emergency medical knowledge on a regular basis by gathering information from the American Medical Association (AMA), American Dental Association (ADA), the Internet, and/or through your doctor`s library.
The emotions evoked during the emergency can prevent efficient life-saving activities. It`s not unusual to "go blank" or lose your composure, but the most important aspect of treating an emergency is staying calm. You can neither think nor act effectively without maintaining your composure. A good way to stay calm during an event is to prepare before it occurs — keep things simple, gather information, and practice, practice, practice. Remember, the average person will forget 60 percent of basic life-support techniques within six months of learning them.
The event must be recognized rapidly. Time is not in the patient`s favor. You have roughly six minutes to get oxygen to the patient`s brain before permanent brain injury occurs. Frequently, you will be unable to decipher what is happening, so the assessment of the airway, breathing, circulation, and possible defibrillation are critical.
First clear the surgical site, then try to get the patient to cough. Ask the patient what is happening. Have someone check his or her medical history while you think and concentrate on staying composed.
The airway is best assessed and maintained with the "look, listen, and feel" method. Use the "chin lift, jaw thrust" method, then look, listen, and feel. If the patient is not breathing after the airway maneuvers, check for a pulse (cartoid). If the patient is unresponsive, has no pulse, and is not breathing, you must begin CPR. A witnessed arrest can necessitate a precordial thump in which you strike the unresponsive patient on the sternum in an attempt to stimulate the heart. If there is still no response, begin CPR on a firm surface according to standard American Heart Association guidelines. Rapid assessments of the airway, breathing, circulation, and mental status should be made every two to three minutes. These assessments should be thoroughly documented. The working of the "ABCDs," coupled with your knowledge of the patient`s history and training, will help you recognize what may be happening.
If you can`t make a working diagnosis, continue basic life support vigorously. No matter what you think, never stop the resuscitation. This is very important since the emergency squad may be delayed by traffic or other circumstances. Studies have shown that delays could be up to 20 minutes.
When the emergency squad arrives, have a rapid briefing ready. For example, "The patient is a 25-year-old caucasian female who, during a routine cleaning, became unresponsive. Basic life support was started at 9:30 and the patient has remained unresponsive."
When the emergency squad takes the patient to the hospital, I highly recommend accompanying them because communication can become muddled. Your patient`s life is at stake, and clear communication with hospital staff could be critical. If you opt to stay in the office, follow up with the hospital and the patient`s family.
Other things to remember:
- Gather yourself privately in order to keep your composure in public. No matter how much you have prepared and practiced, you will be an emotional wreck at this point. You must now consider what you want to do about the rest of the day. It may be wise to cancel all or some of your remaining appointments.
- The doctor and the entire staff needs to be briefed after the event. Learning from the event as a team is crucial. Debriefing intellectually and emotionally will benefit all members.
- The team leader and doctor must document the emergency in time. Documentation is best done in SOAP (subjective, objective, assessment, plan) note fashion.
- Be compassionate and concise with the patient`s family members. "Your sister had an apparent seizure, and we are doing everything that we can. I will keep you posted."
- Consider your state regulations for an office emergency. Each state has guidelines that must be followed.
We are in a society of information explosion, legal irresponsibility, and media frenzy. The process of obtaining and proactively using emergency knowledge will play a critical role in saving your patient`s life. If we do not learn this information, we will hurt our family, our staff, our profession, and our patients.
Brian K. Smith, DDS, MD, maintains oral and maxillofacial surgery practices in Lakewood and Bay Village, Ohio, and is on staff at Lakewood Hospital.
Anatomy of a 911 call
* Call quickly.
* Have a phone available (portable is preferable).
* Designate a staff member to call 911.
* Document the time of the 911 call.
* Give the name and address of the office.
* Give a working diagnosis of patient (heart attack, seizure, etc.)
* Give the status of patient (responsive/unresponsive, vital signs, etc.)
* Have a staff member waiting at the door for the EMS.
* Document the time of EMS arrival and departure.
Instruments you may need in an emergency
* IV set-up (including butterfly, 18 gauge catheters, and fluids)
* Adult and pediatric blood pressure cuff
* Oxygen with positive pressure
* Emergency kit
* Syringes (3cc)
* Adult and pediatric masks
* Magills forceps
* Suction with Yankar suction catheter
* Flat board for CPR