In March 2011, what was supposed to be a routine wisdom
tooth extraction on a 17-year-old girl from Woodstock,
Maryland, went horribly wrong. Jenny Olenick had been given
the standard dose of anesthesia, but it didn't sedate her adequately.
The anesthesiologist administered more, and the procedure
began. Then Jenny began experiencing bradycardia, or a
slowing heart rate, and the oxygen saturation in her blood
started dropping. Soon she went into hypoxic arrest.
Emergency responders were called and restored Jenny's
pulse within four minutes of their arrival, but the damage had
been done. Jenny was rushed to the hospital, where she
died after being in a coma for a week. The autopsy showed
that Jenny had brain edema and acute hypoxic-ischemic
encephalopathy due to lack of oxygen. The death was ruled
accidental, but Jenny's parents sued the anesthesiologist and
oral surgeon for medical malpractice.
No one likes to think that a dental medical emergency will
happen in his or her office. But as professionals we need to realize
that a single dental medical emergency can alter the course of
our professional careers and the lives of our patients forever.
As a dentist, my defining emergency lived in the body of an
out-of-control asthmatic with a less-than-truthful medical history. Her dental treatment was being performed with the use of
IV sedation. The first 60 minutes of the procedure were
uneventful, with stable vitals and no indication of what was yet
As we began the second hour of what we hoped would be a
three-hour full-mouth restorative treatment, she began to experience
respiratory distress that initially exhibited as slight wheezing.
When I first noticed her labored breathing, I called for an
inhaler, repositioned her into a more comfortable, upright
breathing position and encouraged her to assist with inhaling
the Albuterol. Her attack progressed from mild wheezing to a
high-pitched crowing, accompanied by an obviously more
occluded airway. It was apparent the inhaler was not providing
any relief of the attack and this was much more severe asthma
than she indicated on her medical history. She became combative
due to her restricted airway and my mind began to race.
What do I do next? My thoughts were disorganized and chaotic.
But one thought predominated all others: How did this happen?
What did I miss?
Research done at the University of Texas Health Science
Center San Antonio reveals that practicing U.S. dentists will
face approximately eight potentially life-threatening medical
emergencies in their offices every 10 years. That means there will
be approximately 150,000 dental medical emergencies in the
U.S. every year.
More and more dental emergencies are due to unanticipated
interactions between sedation and the medications a patient is
taking. According to the AMA, in 2010 the average American
between the ages of 35 and 50 was currently taking seven prescribed
medications (an increase from four in 2002). These
drugs are primarily used to treat hypertension, diabetes, high
cholesterol and cancer-related illnesses. And since the five leading
causes of death in the U.S., as released from the CDC's
National Center for Health statistics, are heart disease, cancer,
stroke, respiratory disease and accidental death, the average
American is taking seven medications that are used to treat the
five leading causes of death.
How does this affect you and your practice? Medical emergencies
due to adverse drug reactions have dramatically
increased. Every year in the United States, 30 million prescription-
dispensing errors out of three billion prescriptions filled
occur at outpatient pharmacies, according to the National
Patient Safety Foundation. The number of pharmacy errors has
increased due to a greater quantity of medical services being rendered
outside the hospital-type setting. Most errors are minor
and are recognized by the patient, but the more serious errors
cause drug interactions that can be potentially fatal.
Imagine the compound effect of administering local anesthetics
or providing sedation to a patient possibly taking the
wrong medication, or with a potentially fatal interaction of medications. If you're not adequately prepared, you, your
patients and your practice could be in for significant problems.
How confident are you that your current medical history accurately
captures the medications your patients are taking? And are
you (and your team) ready to deal with a life-threatening medical
emergency like the one I faced?
In that emergency 10 years ago, after I administered the
Albuterol, I knew time was of the essence. My reaction involved
two primary responses: first, assist her respiratory efforts. Second,
mobilize the staff to summon emergency assistance. The next five
minutes were a technical blur. We located our emergency drug
kit, but which drug should I request? The inhaler I used previously
was an easy find... it was hers! Did I ask someone to phone
911 or did I just think I did? Where was the ambubag? Should I
reverse the sedation? My rote learning from ACLS that accompanied
my IV sedation training reminded me to use an epipen. I
administered it through her pant leg, and this provided her a
slight amount of relief. But she struggled so violently for breath,
it was impossible for her to assist with the placement of any positive
pressure oxygen supplementation measures.
I'd like to say this story ended wonderfully, but that wouldn't
be the truth. The paramedics arrived in approximately 10
minutes (ADA average is 11). She was intubated in the ambulance
and remained intubated for three days in ICU, during
which time it was determined that she was pregnant. While I
was at the hospital with her family, they tried to console me by
telling me this wasn't my fault and this kind of episode had
occurred twice before! When I asked them why she didn't tell me
during our pre-treatment consultation, they said she was afraid
I wouldn't treat her.
I returned to the office later that evening to examine the disaster
I left behind that afternoon: the operatory, the emergency
equipment, and the tapes from the EKG. I couldn't rest until I
dissected this tragedy into its basic components. And I decided
this would never happen to me again.
The incident with the asthma patient almost 10 years ago
began with an inadequately designed medical history. That small piece of paper altered my life and my practice completely. I redefined
my mission in dentistry and began a quest to design a
better emergency system for dentists – an area of dentistry that
has been neglected.
"Medical Emergency Mastery" was designed to take the
guesswork out of emergency preparedness. It empowers general
dentists and their staffs to recognize and manage medical emergencies
in their office through (1) an expertly crafted medical
history, (2) a targeted emergency drug kit specifically for general
dentists and (3) staff emergency training that is reproducible for
staffs of any size. This three-pronged approach will prepare you
to proactively lead your staff, protect your patients and give you
the peace of mind you have earned.
A Properly Constructed Medical History
The composition of a thorough medical history is the singlemost
significant diagnostic tool we possess. In my emergency, a
well-crafted medical history may not have alleviated the severity
of the emergency but would have helped me determine the ability
of this patient to tolerate routine dental treatment.
The majority of dentists purchase pre-packaged medical
questionnaires that are far too generic and ask questions in an
alphabetic type order (such as asthma, allergy, angina, etc.).
These questions require the practitioner to look at each question,
determine if the response is acceptable and then ask an
appropriate follow-up question. What if we forget the next right
question? What if we don't know the next question? What if
we're too busy?
The medical history should be constructed to include questions
that you believe are relevant to your patient population,
asked in a way that will give you maximum access to the information.
I've designed the "Dental Safety" medical history to ask
questions in a sequential order by systems – for example, all the
questions regarding cardiac concerns are grouped together. This
computer-generated system follows the patient's positive
responses: he or she completes the questionnaire on the computer
and a positive response generates the next series of questions.
By asking the questions in a systems format, you are able
to follow a logical progression of questions and answers to
achieve a greater understanding of your patients' health. I've
divided the questions into three sections: (1) physical systems,
(2) psychological systems and (3) dental experiences.
Examples of questions that relate to a physical system
- When was your asthma diagnosed?
- When was your last attack?
- Do you consider your asthma controlled?
- How often do you have an attack?
- When was your last medical evaluation of your asthma?
- Have you been hospitalized due to your asthma?
- Do you carry an inhaler with you?
- When was the last time you replaced your inhaler?
- What causes your asthma attacks?
- What medications do you take for asthma?
- Have you ever had an attack in the dental office?
- Do you leave your inhaler in the car?
- How often do you replace your inhaler?
Examples of questions that relate to psychological system
- Are you under the care of a psychiatrist of psychologist?
- Does a psychiatrist prescribe medications to you?
- What medications have been prescribed to you?
- How long have you been taking medications?
- What is your diagnosis?
- Have you been hospitalized in relation to mental health issues?
- Do you drink alcohol?
Examples of questions that relate to dental experiences include:
- At what age did you have your first dental exam?
- When was the last time you were at the dentist
- Do you have specific fears concerning dental treatment?
- Do you have a strong gag reflex?
- What did you like most about your last dentist? The least?
- Is there anything we should know about your previous dental
experience that would help us understand you better?
The patient is requested to complete the form prior to the
first visit, so the dentist has adequate time to review it. (If the
patient doesn't have a computer or doesn't have the opportunity
to complete it, the information can be obtained in the office.)
The dentist or reviewing staff member is able to review the completed
health history, highlight areas of concern and question the
patient in greater detail prior to the initiation of dental treatment.
This allows you to assess the overall health of your patients
more effectively, and prevent potential medical emergencies.
A Properly Constructed Emergency Drug Kit
As a provider of in-office IV moderate conscious sedation in
the practices of my colleagues, I have had the unique opportunity
to examine many commercially prepared emergency drug
kits. The large majority of these kits have far too many components
that general dentists aren't qualified or comfortable using.
And many specialists currently not providing sedation are
uncomfortable using any kind of injectable emergency drug.
My goal became quite simple: construct an emergency drug
kit specifically for general dentists or specialists not providing
sedation. I simplified the components of this drug kit to reflect
the drugs used to treat the seven most commonly occurring
medical emergencies in the dental office: syncope, hypoglycemia, asthma, mild allergic reaction, severe allergic reaction,
angina and heart attack.
The current kits include:
- Ammonium ampules (x3)
- Benadryl (50mg) tabs x 100
- EpiPen (.3mg) single use pen or Twin Jet pen
- Glucose substitute (name brand)
- Nitro Tabs (.4mg)/nitro spray (.4mg)
- Albuterol inhaler/Proventil inhaler
- Aspirin (81mg) (aka baby aspirin)
Each drug is in a waterproof pouch and labeled individually
with its name, the medical and laymen's terms for the emergency
that it is used to treat and directions for its use. In my discussions
with my colleagues one theme was consistent: they
knew what the drugs are used for in theory, but they were afraid
they wouldn't remember what and how to administer the drugs
in an emergency. My packaging and directions solved that problem!
The drugs are kept together along with an emergency manual
that outlines the signs, symptoms and treatments for the
most commonly occurring emergencies, including ones that
don't require medical intervention.
For example, if your patient begins to experience chest pains
(angina), the manual outlines the possible causes of the pain and
which emergency drugs would be used to treat it. The directions
for the nitro tab administration are clearly indicated on the label
as well. This removes any guesswork from administration. You
are now able to consult a chairside guide to provide your patient
the best medication to treat any possible emergency.
A properly stocked drug kit is essential, no doubt. But of
much greater significance is the awareness that the majority of
our patients' emergency needs will be those that require knowledge
of airway management. With this in mind, I developed an
inventory of the necessary equipment and supplies required to
provide airway maintenance. By creating spreadsheets to inventory
emergency equipment and supplies, your team can
methodically review the use of equipment and inventory their
supply in as little as 15 minutes a month (Fig. 1).
A Properly Trained and Empowered Staff
The most integral component of the dental safety system is
the staff training. We all know we have amazing staff members,
so why not let them shine? Each team member has specific
duties and responsibilities to assist us chairside and maintain
office equipment and supplies; why not apply that to emergency
preparedness? That is exactly what I decided to do. We started
our training with the premise that we would stop being afraid of
what could go wrong and start being positive about what could
go right. I designed specific roles for staff members that could be
modified for a staff with as few as three members. Included is
the exact text for a 911 call, a method for documentation of an
emergency incident as well as flow sheets for staff review.
The most simplistic system is one that requires the fewest
staff members but is adaptable for large practices. This training
regimen requires three team members, not including the doctor.
Two of the team members will have the predominate roles and
the third will primarily summon emergency assistance. (This
staff member may be non-clinical if necessary.) The doctor's primary
role is to remain with the patient, direct the response
efforts, maintain the patient's airway, administer CPR, if necessary,
and direct the administration of emergency drugs.
The primary responder will be the staff member with the
most dental or emergency experience. She should have experience
in recognizing the signs of an emergency and be knowledgeable in
the treatment. She will know the location of the emergency drugs,
equipment and their uses. This responder will follow only the
doctor's direction. After receiving instructions from the doctor,
she will direct a third responder to be on standby to notify 911
and prepare for emergency intervention. The call to 911 will be
placed only when requested by the doctor.
The second responder remains chairside with the doctor to
provide assistance with drug or equipment administration as
needed. She also will communicate with any staff as necessary
and complete any documentation. Her focus will remain on
monitoring vitals and airway maintenance.
The third responder will actually place the 911 call. (The
content of the call is scripted and the script remains at the front
desk (Fig. 2). This staff member monitors treatment in adjacent
rooms and surveys patients in the reception area to provide reassurance
and dissipate any anxiety.
In order to facilitate this training, I implemented a flow
sheet for my staff that outlined each responsibility. Written protocols
ensured that emergency scenarios could be reviewed on a
monthly basis: equipment maintenance sheets would only
require about 15 minutes a month to monitor (Fig. 3).
Cross training was essential to prevent any lack of knowledge
due to absence or staff changes. Initially, my staff felt awkward
and clumsy when they spoke to each other, even slightly confused.
Combining the emergency protocol with the staff responsibilities
caused frustrations and self-doubt in even the most
talented members of the staff, but after a few sessions, the team
was relieved that we had a system in place.
The Dental Safety System in Action
To put my system to the test, I phoned a friend and
requested she masquerade as a new patient with a complex medical
history. We decided she would feign syncope. After two sessions
of "verbal drills" and one "play date" of a reenactment with
a non-clinical staff member, I thought surely syncope could be
managed without any difficulty. That proved to be incorrect.
After the initial examination, diagnosis of a restoration and initiation
of treatment, our "new patient" indicated she felt faint.
The ensuing few minutes found my staff primarily startled.
After the initial "shock" wore off, they first looked at each other
and seemed to forget the patient. I remained by the patient and
initiated my chairside responsibilities.
Once I began to instruct the first responder in her duties, a
calm rhythm began. Ever so slowly the staff began to move, like
inexperienced athletes beginning their first race. I prompted,
waited, praised and assisted them in their efforts. When the
emergency drug kit arrived with the ammonia, the patient
My feelings of pride in a staff that just a month before had
cried at the end of an asthma attack were beaming with pride.
Syncope obviously paled in comparison to the more severe
asthma attack, but nonetheless, the crisis had been averted by
teamwork, knowledge and application of simple principles. It
wasn't necessary to tell the team that this was "only a test." They
I shared my system with my colleagues, and this kit of simple
tools worked incredibly well in practices of every size and
composition. I constructed kit after kit, improving upon each
with recommendations from my friends. I began to share my
experiences with doctors in their offices, training their staffs and
empowering their teams. The greatest satisfaction came in the
feedback I received; the office managers who phoned to report
how they had handled an emergency without incident; the doctors
who remained calm as they requested the appropriate drug
from their kits and their staff responded instantly.
It is impossible to predict what will occur in our practices on
a daily basis. What I have learned to predict is that medical
emergencies will happen to each one of us. The shape, form and
fashion will be unique to your patient population, but no matter
what, you are responsible for your reaction to them. I reacted
to a horrific occurrence and moved toward a solution. And I
want to encourage you to be ready to respond long before you
face a severe medical emergency with one of your patients.
When evaluating the three integral components necessary
for a well-established emergency preparedness protocol, ask
yourself the following questions:
- When did I last objectively review my medical history
- Do I know what question to ask next in response to a positive
answer from a patient?
- Do I know how to effectively and correctly use all the
drugs in my emergency drug kit?
- When was the last time I trained my staff in emergency
Do not delude yourself into thinking a medical emergency
will never happen to you in some form or fashion. Whether it's
a patient's reaction to anti-hypertensives and local anesthesia, a
hypoglycemic reaction or an anaphylactic shock, do you want to
take the chance that your staff will forget their roles in an
unfolding emergency? Don't wonder what the answer will be for
one moment longer. Assess and evaluate your present systems of
emergency preparedness. With a modest effort, a well-structured
framework and an enthusiastic staff, your training protocol can
reflect a comprehensive vision of patient care that has left no