Written by John B. Roberson, DMD, and Christopher Rothman, DDS Monday, 07 February 2011 13:58
Ronald Reagan said, "Failing to prepare is preparing to fail." That philosophy is nowhere more evident than during a medical crisis, when minutes can be the difference between life and death.
When it comes to being prepared for a medical emergency, what 3 letters are imperative for a dental office to know in order to initiate patient rescue? They were A-B-C, or better known as airway-breathing-circulation. The new American Heart Association (AHA) 2010 Emergency Cardiovascular Care Guidelines released on October 18, 2010, now recommend a C-A-B sequence (compression-airway-breathing) with compressions performed before ventilations if the patient is not breathing normally and has no obvious pulse. This is the foundation of basic life support (BLS). There are also 6 "links" that must be known by the dentist and the entire dental team; these are the foundation for medical emergency preparedness.
THREE LETTERS, SIX LINKS OF SURVIVAL: KEYS TO MEDICAL EMERGENCY PREPAREDNESS
Is it too much to ask for dental professionals to be prepared for a medical emergency? One would think not. However, many dental offices do not know these simple concepts because they are not practicing medical emergency preparedness on a regular basis. Many dental professionals take the approach that a medical emergency will not happen to them. Others before them have probably felt the same way, but then it did happen to them. Were they truly prepared? History would suggest that they were certainly not. Read about the cases where patients died in dental offices, and take note of the state of medical emergency preparedness of these offices during the crisis. Much can be learned from these cases to assist dental offices in being ready for an unthinkable event. Most importantly, that preparation is the key to saving lives.
In order to possibly prevent a medical emergency, one must prepare the entire dental office. BLS training is one of the fundamentals of good preparation. BLS is the one course that dentists are required to have to practice in 44 states. The skills that you learn through BLS can be the difference between life and death. Lay providers use BLS to save lives every day. As dentists, we need to be confident in our ability to assess a victim and in our abilities to deliver basic medical emergency treatment when it is indicated.
As medical advances continue, the population grows and life expectancy increases; and the number of medications taken increases as health-related issues proliferate. As a profession we are offering more advanced and extensive treatments to our patients. The dental profession cannot turn a blind eye to these facts that make an emergency in our offices more likely. Managing a crisis in the office goes beyond BLS; we need to be prepared to prevent a medical emergency and to handle a medical emergency when it occurs. This is where the 6 links of survival fits in. This comprehensive team approach builds on BLS and encompasses doctor training, staff training, medical emergency plan, proper resuscitative equipment, emergency drugs, and regular mock drills. In his recent Viewpoint article, "Medical Emergencies: Are you Prepared?" (September 2010, Dentistry Today), Dr. Larry Sangrik wrote about the 6 links of survival. The authors would encourage you to take the time to read it (dentistrytoday.com).
Unfortunately there are still 6 states that do not require BLS. Even in states that do, many dental offices lack components to respond optimally to medical emergencies. Data from unpublished surveys we have conducted show most do not have a scripted emergency plan, and many do not have emergency drug kit and proper resuscitative equipment, nor do they regularly perform mock drills. That is why BLS and the 6 links of survival for medical emergency preparedness are the cornerstones of patient safety in the dental office. The ADA recognizes these facts, and its Council on Scientific Affairs published a preparedness statement in 2002 that emphasizes these points; it reads:
"Preparedness to recognize and appropriately manage medical emergencies in the dental environment includes the following:
- Current BLS certification for all office staff
- Didactic and clinical courses in emergency medicine
- Periodic office emergency drills
- Telephone numbers of emergency medical services (EMS) or other appropriately trained healthcare providers
- Emergency drug kit and the equipment and knowledge to properly use all items."
The ADA has taken measures within the past year to expose dental offices to more medical emergency information by the release of the Journal of the American Dental Association supplement in May 2010, as well as upgrading its Web site to reflect more resources related to medical emergency preparedness for dental offices.
PREPARE TO SUCCEED: KNOW THE C-A-Bs OF BASIC LIFE SUPPORT
BLS consists of life-saving techniques with the emphasis on the C-A-Bs of emergency care:
• Compression: provides an adequate blood supply to the body, especially the heart and brain, by delivering oxygen to all cells and removing carbon dioxide, via the perfusion of blood throughout the body.
• Airway: the protection and maintenance of a clear passageway for oxygen and carbon dioxide to pass between the lungs and the outside of the body.
• Breathing: inflation and deflation of the lungs (respiration) via the airway.
In an emergency, BLS helps the patient ensure the C-A-Bs, or assists in maintaining them for the patient who is unable to do so. For airways, this will include positioning of the patient to maintaining optimal angles or possible insertion of oral or nasal adjuncts, to keep the airway unblocked. For breathing, this may include artificial respiration, often assisted by emergency oxygen. For circulation, this may include bleeding control or cardiopulmonary resuscitation techniques to manually stimulate the heart and assist its pumping action. In each case, the BLS provider is trained to detect C-A-B problems and attempt to correct them.
PREPARE TO SUCCEED: KNOW THE SIX LINKS OF SURVIVAL
Link No. 1: Doctor Training
Every dentist needs to have current BLS certification, at the healthcare provider level, and be proficient in stabilizing a patient until emergency medical services arrive. Automatic external defibrillator (AED) training is a core component of the BLS certification courses. The importance of an AED in the office cannot be stressed enough; between 350,000 and 400,000 people will die in the United States this year from sudden cardiac arrests. In addition, the dentist should have knowledge and competency in the efficient and proper use of an epinephrine auto-injector, such as Twin-ject or EpiPen (if that is your source of epinephrine for your office), administration of oxygen, as well as all of the emergency medications.
Every dentist needs to stay current with emergency medicine and with emergency protocols. BLS and medical emergency training should be taken once per year to stay proficient. The new AHA guidelines state that, "the current 2-year certification period for basic and advanced life support courses should include periodic assessment of rescuer knowledge and skills, with reinforcement or refresher information provided as needed." So, while BLS certifications are still going to be good for 2 years, emphasis is now placed on more frequently refreshing of BLS skills.
Advanced cardiac life support (ACLS) is the next level of training a dentist can receive. ACLS teaches life-saving techniques such as: intubation and other airway techniques, intravenous access, and recognition of cardiac dysrhythmias (also known as arrhythmias).
Link No. 2: Team Training
All team members in the dental office need to have current BLS certification at the healthcare provider level. The new AHA guidelines stress a team approach to BLS now. While one person does compressions, another person calls EMS/911, another gets the AED, and another gets the emergency drug kit, etc. AED training is a core component of the BLS certification courses. Every dental team member needs BLS and medical emergency training once per year to stay proficient.
All team members should have knowledge and competency in the efficient and proper use of an epinephrine auto-injector, such as Twin-ject or EpiPen (if that is your source of epinephrine for your office), administration of oxygen as well as all of the emergency medications. In addition, every member of the dental team needs to stay current with emergency medicine and emergency protocols. Every member of the dental team 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.
New hires need to be integrated rapidly into the medical emergency program, by learning their roles and being able to assist in an emergency. A structured training system that is uniform and consistent will make this transition quicker, easier, and more efficient, and reduces oversights, omissions, and variation in training modalities.
Link No. 3: Medical Emergency Plan
Every office should have a medical emergency plan or emergency response plan.
A solid medical emergency plan is not a one-page document, but rather an active, ongoing monthly effort by the entire dental office to practice and rehearse their roles.
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 or her duties. All team members should thoroughly, without a doubt, know their roles 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.
The team leader must recognize and initiate rather quickly the decision to notify EMS/911. When the order to call EMS/911 is given, one person on the team should know that this is his or her responsibility. There should be no doubt whether EMS/911 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!
Link No. 4: Emergency Drug Kit
The ADA Council on Scientific Affairs recommends all dentists have an emergency drug kit which contains the 7 drugs listed below:
- Oxygen with ability to administer positive pressure
- Nitroglycerin (spray or sublingual tablets)
- Glucose source.
There are several commercially available drug kits on the market, but it does not matter whether you build your own kit or purchase a commercially prepared kit; the main issue is that you have an emergency drug kit with the right medications. Dentists and their teams need to be comfortable with dosing and routes of administration of emergency drugs. Most companies will be responsible for maintaining your kit as it pertains to the expiration of the drugs, but the expiration dates should be checked again at regular intervals.
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 arrive 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!
The authors recommend that you read the article entitled "Call 9-1-1 Now and Start Treatment" published in the May 2009 issue of Dentistry Today which focused on the emergency drug kit (dentistrytoday.com).
Link No. 5: Proper Equipment
The following need to be purchased and available for use:
- AED—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 providers. The cost of an AED is variable, starting at around $1,300. An AED is simply part of the cost of doing business today.
- A stethoscope
- Equipment to take a blood pressure whether it be manual or automated
- Pulse oximeter
- A portable method of administering positive pressure oxygen
- All emergency drugs (as listed in Link No. 4)
- Backup suction and lighting set up to be functional even during power failures
Dentists and their teams need to be comfortable with the equipment needed for resuscitation and all equipment must be checked regularly to ensure it is in excellent working order.
Link No. 6: Mock Drills
In order to stay prepared, the mock drills must be conducted. The ADA and AHA both recommend that providers frequently refresh their skills. Mock drills should consist of the most common medical emergencies that occur within the dental office, and should be performed on a monthly basis at a set date and time. All team members should use this time to regularly review the contents and proper use of the emergency drug kit as well as the AED. Mandatory attendance by all team members should be required and everyone needs to take his or her role as indicated on the medical emergency plan very seriously.
Medical emergencies can and do happen anywhere at any time, and that includes in dental offices. 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. The dentist and the entire team need to be proficient in handling these emergencies until EMS arrives. Adverse outcomes and death may result even if an emergency is handled correctly. However, education and preparation will optimize the chances of a favorable result.
Three letters (C-A-B) and 6 links are the cornerstones of patient safety. Are you BLS compliant? Are you 6 links compliant? Make it your goal to remain due-diligent with both during your practice lifetime.
Disclosure: Dr. Roberson reports no disclosures.
Disclosure: Dr. Rothman reports no disclosures.