911, Where’s Your Emergency?
It is not a matter of ‘if’, but which (and how severe) a medical emergency will occur in your dental office. People, your patients, are sick as they have ever been. Even without sedation in the equation you never know when it will be someone’s time to have an emergency. When it occurs in your office you have to be able to competently deal with it to ensure the best patient outcome.
In many states, dentists are required to have a written medical emergency plan, written medical emergency policies/procedures/protocols, and medical emergency training for their staff. This is new for Texas dentists, but not so for those in California, Washington, and other states. The states that have these requirements also (usually) have a requirement for the use of a Pre-Op Anesthesia Checklist.
Let’s break these elements down:
MEDICAL EMERGENCY PLAN
First, it is said that failure to plan is a plan for failure. No one wants to fail (certainly not when it comes to sedation emergencies that can arise at any time). It is essential that every dental office that provides any level of sedation (including ‘just’ nitrous oxide) have a written plan that is trained on and posted throughout the office. The ‘Plan’ identifies roles and responsibilities to be fulfilled in the event of an emergency. I recommend the ‘KISS’ method (Keep It Super Simple).
Dentist, as the team captain, should remain with and assess/treat the patient (or direct and supervise treatment)
1st Assistant (in this case, not necessarily a dental assistant, but the 1st person to enter the room to assist) – assess Circulation, Airway, and Breathing – correct problems as encountered
2nd Assistant (next person in the doorway when an emergency is declared) – grab emergency equipment and bring it to the patient’s side (emergency drug kit, oxygen, and AED)
3rd Assistant – scribe/ 911 caller
Practice scenarios while changing roles. Consider assigning roles by order of arrival, not by person/name, as it could REALLY throw everyone off if Susie’s job is to grab the emergency equipment, but she’s out of the office the day a real emergency occurs. Be mindful of Murphy’s Law (what can go wrong, will); it’s a real thing!
Policies are written statements of what you are allowed or required to do. Procedures are how you are expected to do something. And “protocols” is a fancy word for procedures.
You are required to have policies and procedures that require annual medical emergency training (above and beyond CPR/BLS) at least annually. You are also required to have, as a minimal, protocols to address airway management and sedation emergencies. However, there are other emergencies that can (more likely) occur in your dental office, such as syncope, diabetic emergency, seizure, allergic reaction/anaphylaxis, breathing difficulty, heart attack/chest pain, Sudden Cardiac Arrest (SCA), emotional/ psychological, overdose, and et cetera.
Protocols guide you and your staff’s actions between the time you recognize an emergency and EMS arrival, which, believe it or not, will feel like an eternity if you are ill-prepared. Gone are the days when it acceptable for dental offices to call 911 and wait for the paramedics. If you do that today, you run the risk of losing your dental license for good. The standard of emergency care by dentists is ‘active’ emergency care using currently acceptable care and equipment.
Training should be regular, scenario-based, tactile, multi-sensory, and should challenge you physically and mentally. Don’t train until you get it right, train until you can’t get it wrong because every life is worth the very best life-saving.
On every commercial flight around the world while passengers board, the pilot and first officer complete a pre-flight checklist. They check the flaps, inspect the hull for damage, check the tires, and so on. They’re checking everything they will need/use during the flight to make sure it will work as expected. In essence, the flight crew is looking for any reason why the flight should not take place. If something does not check out, the flight is a no-go meaning the flight is postponed or canceled.
In a dental office, the pre-operative sedation/anesthesia checklist is a process for the dentist and dental team to check the patient and situation to make sure all is well before ‘go’ time. The pre-op checklist is a formal means to give pause and consider the patient's rights. What are the patient's rights? Simple. Is this the right patient? Is this the right sedation for this patient? Is this the right time for the sedation of this patient? Do we have right-eous consent for treatment/sedation? Is everyone all right if we proceed right now?
Pre-Op Sedation/Anesthesia Checklists ensure the dentist/anesthesiologist reviews the patient’s medical history; medication history; allergies; past history of sedation for the patient, parents, siblings, and children; social history (tobacco, alcohol/drug use), and medical consultations. It brings an element of formality to what is known as a ‘time out’ process, its completion causes the dentist and staff to make sure that appropriate monitors and emergency drugs/equipment are near and ready. Whether required in your state or not, consider using a pre-op sedation/anesthesia checklist in an effort to minimize medical errors, because the errors you avoid could save a life.
When it comes to sedation & patient safety every member of the dental team should be encouraged (by the dentist) to speak up if there is ANY concern or ANY reason why the dentist should consider a ‘No-Go’. This should be a time when a gut feeling, hunch, or intuition should be given consideration as much as the dentist and staff’s education, training, experience.
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