The Six Links of Survival By Drs. John B. Roberson and Christopher M. Rothman

Clinical Scenario

Assessment

Looking at the above scenario poses some questions:

1. Were the doctor and staff properly prepared and trained?>
2. Was there an emergency response plan in place? How do you notify the office that an emergency has occurred? Do you know your EMS response times as well as when to call them?
3. Did the office have the proper equipment, such as portable oxygen and an AED?
4. What about an emergency drug kit? Did everyone know where it was? Were the drugs “in date”? Did the proper people know how to use the drugs?
5. Did the doctor and staff ever practice mock drills on emergencies?
6. Had the doctor or staff ever attended some type of emergency medicine lecture?
7. Do you see any negligence or unpreparedness?

Clinical Scenario Problems:

1. Doctor/Staff communication: Very poor in this scenario.
2. Medical Emergency Plan: No evidence of having one. Staff and Dentist not well coordinated on specific duties
3. Patient Vitals: None taken. No Emergency Treatment Record to document everything that occurred as well as to give to EMS. Some form of portable blood pressure monitoring equipment is imperative for the dental office.
4. Portable Oxygen: None in this office. Every office must have some form of portable oxygen
5. Emergency Drug Kit: Never mentioned to obtain. Did the office even have one? If so, was it up-to-date? Unconsciousness has several causes such as hypoglycemia, bradycardia, hypotension, cerebrovascular accident, myocardial infarction, epilepsy, adrenal crisis, drug overdose and dysrhythmia.
6. Calling EMS (9-1-1 in most areas): This should have been initiated as soon as a medical emergency was recognized. You can never be faulted for calling EMS.
7. Automated External Defibrillator (AED): There was none.

Follow-up revealed that this patient had a sudden cardiac arrest. The only treatment for this is the AED. Early defibrillation is crucial and critical for patient’s survivability.

Medical emergencies can and do occur anywhere, anytime and anyplace. Every dentist should be able to recognize and manage a medical emergency that occurs in his/her office until emergency medical personnel arrives to transport the patient to a hospital.

Proper preparation, education and training are the key when dealing with medical emergencies. The ADA Council on Scientific Affairs published a preparedness statement. It reads:

Preparedness to recognize and appropriately manage medical emergencies in the dental environment includes the following:
• Current basic life support certification for all office staff
• Didactic and clinical courses in emergency medicine
• Periodic office emergency drills
• Telephone numbers of EMS or other appropriately trained healthcare providers
• Emergency Drug Kit and equipment and knowledge to properly use all items

Furthermore, on every package insert (PI) that is attached to the local anesthetic canisters or packages, it discusses the readiness for medical emergencies. Here is an example taken from the PI of Lidocaine 2% with Epinephrine from Kodak-Waite:

WARNINGS:
DENTAL PRACTITIONERS WHO EMPLOY LOCAL ANESTHETIC AGENTS SHOULD BE WELL VERSED IN DIAGNOSIS AND MANAGEMENT OF EMERGENCIES WHICH MAY ARISE FROM THEIR USE. RESUSCITATIVE EQUIPMENT, OXYGEN AND OTHER RESUSCITATIVE DRUGS SHOULD BE AVAILABLE FOR IMMEDIATE USE.

Every dentist uses local anesthetics as well as dental hygienists in 36 states; therefore, this stresses the importance of being ready and prepared even more. These warnings on the PIs indicates to the dentist that s/he could be considered negligent should a medical crisis occur and s/he not have the proper resuscitative equipment or drugs.

The Five Deadly Misconceptions

1. A medical emergency will not happen to me.
2. A medical emergency will not happen in my office.
3. Calling EMS/9-1-1 is the answer.
4. My staff and I will not panic during a medical emergency.
5. CPR is all we need to know.

Each dental team member needs to evaluate the misconceptions above to see how s/he views them. Does s/he see any deficiencies that need to be corrected?

The Six Links of Survival are imperative for every office when confronted with the issue of being prepared for medical emergencies. Any missing link will cause a decrease in the survivability of the patient. What are these Six Links?

1. Doctor training
2. Staff training
3. Medical emergency plan
4. Emergency drug kit
5. Proper equipment
6. Mock drills

1. Doctor Training

Every dentist should have current Basic Life Support (BLS) certification (required every two years). AED training is now being taught along with BLS. The importance of an AED in the office can’t be stressed enough especially due to the number of sudden cardiac arrests that occur each year (see Table 1). Other areas that need to be evaluated for any deficiencies are proper use of an EpiPen (if that is your source of epinephrine for your office), administration of oxygen as well as the emergency medications via intravenous (IV) or intramuscular routes. Advanced Cardiac Life Support (ACLS) is the next level of training a dentist can receive that will teach him/her life-saving techniques such as intubation and other airway techniques, IV access, recognition of cardiac dysrhythmias and defibrillation.

Every dentist should attend an emergency medicine lecture annually to maintain the current treatments or updates. Another excellent reference is Medical Emergencies in the Dental Office by Dr. Stanley Malamed. Finally, it can’t be stressed the importance of staying current with emergency protocols.

2. Staff Training

Auxiliary staff members need to be trained to recognize signs and symptoms of medical emergencies, since they may be the only people present when a crisis occurs. Proper recognition, resulting in a quick response to a medical emergency, can be the difference between life and death. Training, reviewing, and practicing responses of the different medical emergencies, using mock drills, should be a regular part of every practice – monthly. The repetition of training with simulated emergencies and crisis response will ensure the victim will have the best chance for a positive outcome.

New employees need to be immediately integrated into the medical emergency plan, learning their role and being able to assist in a crisis. Having a uniform, structured training system installed can make this transition quicker, more efficient and eliminates oversights and variation in training modalities.

Every member of the staff needs to know where the equipment, drugs and supplies are kept in the event of an emergency. These materials should be readily accessible and the entire staff should have a working knowledge of these items. The time to become familiar with the armamentarium, drugs and supplies is not during a crisis. The team members need to have defined roles and be able to execute their individual responsibilities efficiently when a crisis occurs.

Emergencies are chaotic! A knowledgeable staff that functions as a cohesive unit, has defined responsibilities and is knowledgeable of the other team member’s duties will give an emergency victim the best chance of survival. All employees involved in patient care need to have current certification in BLS with AED training. Many organizations, such as the Red Cross and American Heart Association, offer training in the use of an EpiPen and other emergency equipment as well as other courses which may be helpful in an emergency situation. All staff members also should attend emergency medicine lectures annually.

3. Medical Emergency Plan

Every office should have a medical emergency plan or emergency response plan. This plan needs to be placed in a location where it can be a constant reminder to all in the office. The plan should have a Team Leader which will be the Dentist. Then, each member of the team will be assigned his/her duties. Each team member should thoroughly, without a doubt, know his/her role as indicated on the plan. Should a team member be absent from the office, another person should be assigned for that person’s role and be familiar with it. When a medical emergency occurs, there should be an organized, controlled fashion of alerting all team members. This includes an alarm system, paging system, lighting system or something similar that will let team members know that an emergency has happened within the office.

The team leader must recognize and initiate rather quickly the decision to notify EMS. When the order to call EMS is given, one person on the team should know that this is his/her responsibility. There should be no doubt whether EMS was called or not. It is important to be familiar with EMS service in your town. Time of arrival to your office in the event of an emergency should be identified prior to the event. An average EMS response time for urban areas was 9 minutes and for rural areas it was 15 minutes. This time could be longer if your EMS is occupied with another emergency. Time is of the essence and must not be ignored. There should never be any embarrassment about calling EMS. If in doubt, call EMS out!

4. Emergency Drug Kit

The ADA Council on Scientific Affairs recommends all dentists have an emergency drug kit which contains the seven drugs listed below:

• Oxygen with ability to administer positive pressure
• Epinephrine
• Benadryl
• Aspirin
• Bronchodilator
• Nitroglycerin (spray or sublingual tablets)
• Glucose source

If any sedation technique (oral, conscious, deep, intravenous, nasal, intramuscular, rectal) or general anesthesia is used, a dentist should maintain medications and emergency equipment necessary for patient resuscitation. These drugs need to be checked regularly to ensure that they never expire. There are several commercially available drug kits on the market. These companies will be responsible for maintaining your kit as it pertains to the expiration of the drugs. It doesn’t matter which course of action you choose for your drug kit, the main issue is that you have an emergency drug kit with the right medications. Healthcare professionals need to be comfortable with protocol, dosing and routes of administration of emergency drugs. It should be noted that some states do not require EMS to carry epinephrine. Therefore, if an anaphylactic reaction were to occur in your office, the EMS personnel that arrives may not have the life-saving medication (epinephrine) that your patient needs. You are urged to find out this information from your local EMS provider. Don’t wait until you need help!

5. Proper Equipment

In today’s dental office not having an AED likely would be viewed as negligent. AED training is a required skill for passing BLS and has been used effectively for years by lay people. The cost of an AED is variable, starting at around $1,000. An AED is simply part of the cost of doing business today. All dentists need to have a stethoscope, a portable method of administering positive pressure oxygen, all emergency drugs as well as the equipment to take a blood pressure.

Additional equipment includes, pulse oximeter and back-up suction and lighting which all need to be functional when there is a power failure (see Table 2 for a more detailed list). This equipment needs to be checked regularly to ensure it is in working order. Healthcare professionals and staff need to be comfortable with the equipment needed for resuscitation.

6. Mock Drills

In order to stay prepared, the dental office must conduct mock drills. Performing mock drills on a yearly basis is not good since team members will not have much exposure or possible staff turnover. Mock drills should be performed on a monthly basis on a set date and time. Mandatory attendance by all members should be stated. All members should take their role as indicated on the medical emergency plan very seriously. All members should be educated on the contents of the emergency drug kit as well as the AED. The team leader (AKA the dentist) may never know when an AED may have to be used on him or her.

Conclusion

The dentist must NOT take the attitude of “this will never happen to me” when confronting office preparedness for medical emergencies. Medical emergencies can and do happen, and that includes the dental office. Medical emergencies are a very stressful, chaotic event for all in the office. Under these types of conditions, anxiety and confusion can exist as well as the inability to recall proper treatment protocols. Many facilities have an emergency drug kit, but are not familiar with its contents. The time to become familiar with the emergency drug kit is not during a crisis, but through continuing education and mock emergency drills.

A medical emergency plan should be developed so that every person knows and understands his/her role during any emergency situation. Do you regularly practice and train for the most common medical emergencies seen in the dental office? Do you practice mock drills as a team and take your role seriously? This creates more efficient and effective treatment during the emergency. The dentist should ask this question, “If I were to have a sudden cardiac arrest, could my staff save my life?” A dental office should never rely solely on its EMS service to respond quickly and manage its emergency. You need to be proficient in handling these emergencies until EMS arrives. It should be noted that adverse outcomes and death may result even if an emergency is treated correctly. However, education and preparation will optimize the chances of a favorable result. As the old saying goes, “Luck favors the prepared.”

Drs. John B. Roberson and Christopher M. Rothman are Oral & Maxillofacial Surgeons who are in private practice. They are both Board Certified by the American Board of Oral & Maxillofacial Surgery and the National Dental Board of Anesthesiology. Drs. Roberson and Rothman co-founded the Institute of Medical Emergency Preparedness (IMEP). IMEP developed the RED E System which was created to help remedy the lack of medical emergency preparedness that exists in dental offices today. The RED E System is an easy-to-use, uniquely-branded, ready-to-react emergency response system that can be taken to the victim’s side. For more information on the RED E System, please go to the Web site, www.GetRedE.com.