Re: PREPARING FOR MEDICAL EMERGENCIES

[sushantpatel_doc]

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
Epinephrine
Benadryl
Aspirin
Bronchodilator
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
Glucometer.
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.

CLOSING COMMENTS
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.