3 Tips for Managing Emergencies in Your Practice
Robert A. Strauss, DDS, MD, FACS
Professor of Surgery
Director, OMFS Residency Training Program
VCU Medical Center
An emergency is defined as “a serious unexpected and often dangerous situation requiring immediate reaction.” It’s also an event that strikes fear, or at least should strike fear, into the heart of any practitioner.
I have quite a bit of experience in this area. As a professor of Oral and Maxillofacial Surgery at a large dental school, I’m the one who teaches medical emergency management to dental students. I was trained as one of the early ACLS instructors in the United States and, as a surgeon in practice at a large, tertiary medical center, I have to manage medical emergencies on a semi-regular basis.
That said, I still pucker a bit every time that red phone rings indicating we’re being called to manage yet another urgent issue in our clinic. Even in a general dental practice, it’s important to realize that it’s not if, but rather, when a medical emergency will occur.
When teaching how to manage medical emergencies, I use a few of what my students call “Strauss-isms”. Little tips to keep in mind when dealing with medical emergencies.
“It’s always better to have an asymmetrical patient than a symmetrical corpse.”
Dealing with a dental or surgical issue always takes a back seat to an impending medical emergency. A recent case example proves this. A general dentist was providing sedation to a patient. The dental assistant kept telling the doctor that the patient wasn’t breathing correctly, but the dentist was so intent on the tooth issue that the impending emergency was ignored. The patient eventually did have an emergency and a fatal outcome ensued. Bottom line, worry about the patient not the tooth!
“Never treat a stranger.”
Every time you see a patient, you should at least verbally get an update on their medical history, including any new medications. Even after dental school, medical school, and 35 years of practice, I still have to look up drugs every day. I suggest you do too.
“The best defense is a good offense.”
Okay, I borrowed this from Vince Lombardi but it still applies. Preparing for a possible medical emergency will often, if not almost always, negate the emergency totally. Recognizing a diabetic patient who hasn’t eaten before his appointment but took his or her insulin, for example, will allow for dietary adjustment and prevent a significant hypoglycemic event.
While you can’t always predict or prevent emergencies in your practice, you can prepare for them. I hope you’re able to remember and apply these three tips to make your own practice a bit safer!
Having the proper emergency procedures in place is essential to reducing your malpractice risk and improving the safety of your patients.
So, here is MY story. A few weeks ago I was called down to our resident clinic for a medical emergency. A young lady was under deep sedation for extraction of her wisdom teeth. The patient had some respiratory obstruction (which is not uncommon) that was appropriately recognized by the surgical assistants and the junior resident managing the case. Normal interventions such as airway opening maneuvers were instituted but were ineffective and the patient’s oxygen saturation dropped down into the 60s (anything below 90 is considered emergent). I arrived just as the chief resident had administered a paralyzing drug (succinylcholine) and was intubating the patient. I recognized that the endotracheal tube was filling with patient secretions and needed to be suctioned. I asked for a suction tube to clear out the secretions. That request was met with blank stares…by everyone. Nobody knew where the suction catheters were. A basic and common piece of emergency equipment and nobody knew where they were. I ran over to our crash cart and was luckily able to find the catheters at the bottom of the cart. We suctioned the patient and her oxygen saturations came back up to acceptable levels just as the paramedics arrived and transported our intubated patient to the emergency department at our hospital. The patient did well overnight and was discharged the next day no worse for the event. When questioning the mom, she told us that the patient had had an upper respiratory infection the week before and she didn’t think to tell us.
As is always a good idea after a medical emergency, a debrief can be very useful clinically and emotionally beneficial. Our debrief brought out both some positive and some negative issues.
The impending emergency was recognized early by both the staff and the junior resident, allowing for early, if ultimately ineffectual, intervention.
Upon his arrival, the most senior resident took charge. Since he had the most experience (until I arrived and took charge myself), his bold decision to give a paralytic drug and intubate the patient likely saved her life.
Everybody remained calm and did their jobs very well.
Ok, now for the bad news and their corrections:
Nobody seemed to be exactly sure what their job was. It reminded me that we don’t have an actual written plan for medical emergencies. That needs to include who does what during the emergency (i.e., who gets the crash cart, who calls 911, etc.). As we are a large clinic with extensive turnover of assistants, a written plan is important to insure continuity.
Despite the fact that I have 32 years at this location, I have luckily never actually had to use the crash cart myself before. So, even though we keep it up to date, nobody including me could immediately find a simple suction catheter. Clearly, regular inspections of the crash carts need to be done by everyone so that they are familiar with its contents and their locations.
Had we done a review of the medical history (which had changed in the two weeks since our original consult) we would have found out about the URI and postponed the surgery.
Now, I may be old but I do learn from my mistakes. Last week our entire clinic was shut down for an hour and we ran two emergency simulations. We did everything as if it was real. Although it went pretty well, we found several issues that we were unaware of and needed correction (the front desk did not know how to clear the waiting room after calling 911, we had no aspirin in the crash cart for an MI, some of the staff did not know how to use an autoinjector for epinephrine in case of an allergic reaction, etc.). We simply didn’t know what we didn’t know. Once we recognized these areas they were easily and quickly corrected. Every single one of us felt that these simulations were helpful and we agreed to do them every six months.
You should too…