Emergencies

(What to do when things go wrong)Dr. Hillam

Team Meeting

August 24, 2005

Let’s just say…

• A fire erupts in the corner by the sandblasting unit…

Or what if…

• While you are alone with a patient, she starts wheezing heavily and panicking

• A patient calls shortly after an appointment, and says that he has hives and his throat feels tight.

Or…

And finally, what if…

Are these unrealistic?

• No• Obviously some are more serious than

others• With regard to medical emergencies:

– Pts are becoming older on average– Dental procedures are increasingly lengthy

and complicated– There are more medical risk patients today– More and more drugs are on the market

Presentation Outline:• Introduction• Prevention and Training• Three types of emergencies in the dental office

– Equipment/Facility Emergencies• Smaller things• Power outages• Fires

– Medical Emergencies• Prevention

– Thorough Health History– Understanding common health problems– Always treating people with care

• Training– Specific emergency conditions– Equipment– In-office emergency protocol

– Occupational Emergencies. • Universal Precautions• Material Safety Data Sheets (MSDS) • First aid kit• Needlestick protocol.

Two ways to deal with emergencies:

Prevention &

Training

Prevention is a universal concept…

Especially among dental teams

With this said…

• Not all emergencies are preventable. • That’s where training comes in.

Training is knowing what to do…

In the midst of risk.

And in the midst of risk,

You have to do the right thing at the right time.

Robert D. Hales:

“In the process of preparing to be a pilot , I was required to have training in a Link trainer, which simulated real flight. There, an instructor would acquaint us with the emergencies which could occur when flying a jet fighter, sometimes at the speed of sound.

For each emergency, we were taught the procedures for avoiding disaster. We would practice each procedure over and over, so if a real emergency came along we would have an automatic, preconditioned response. We would know exactly what we were to do if there happened to be a technical failure in the airplane. We would even choose the altitude at which we would bail out if the plane went out of control.

In our squadron I had a dear friend who… had not learned to listen to those with more knowledge and experience. When his turn would come to learn emergency procedures and to precondition his mental and physical responses so they would be automatic, even instantaneous, my friend would put his arm around the airman instructor and say, “Check me off for three hours of emergency procedure.” Then, instead of training, he would go to the pistol range or play golf or go to the officers’ club. But he never learned the emergency procedures.

On one occasion he was asked what he would do in an emergency. His answer: “I am never going to bail out; I am never going to have an emergency.”

On an evening mission a few months later, fire erupted in his plane, and it dropped below 5,000 feet, spinning in flames. Noting the fire warning light, the younger pilot who was with him said, “Let’s get out of here.” And with the centrifugal force pulling against him, the younger man, who had taken his training seriously, bailed out. His parachute opened at once and he slammed to the ground, receiving serious injuries. But he survived.

On the other hand, my friend stayed with the airplane and died in the crash. He paid the price for not having learned the lessons that could have saved his life.”

3 Kinds of emergencies

1. Equipment/Facility Emergencies.

2. Medical Emergencies.

3. Occupational Emergencies.

Equipment/Facility Emergencies

• Sometimes our equipment/facility goes wrong. • In the past year, we have seen:

– Total power failure– Tripped fuses– Burned out light bulbs– Empty O2 or N2O tanks– Security breeches– No suction– Dead/sick fish– Icy walkways

Equipment/Facility Emergencies

• Thankfully, there are several emergencies that are much less common, such as: – Flood– Tornado– Bomb threat– Lightning strike– Burglary– Fire

The following emergencies vary in magnitude…

Light Bulbs

O2/N2O Tanks

Security Breeches

No Suction

Way to go, Mandy!

Power Outages

• What problems does this pose?– Pt. treatment– Loss of light– Phone failure– Power surge– Refrigeration failure

• Several months ago:– Nearby construction crew hit underground powerline,

and a fuse was tripped.

Power Outages, cont.From Provo City Web Site, http://www.provo.org/index.php?module=ibcms&fxn=

ppd.Power_Outages_main:

During the Power Outage– Check your fuses or circuit breakers. – Check and see if your neighbors’ power is out. – Call the Provo City Power “Help Line” at 852-6000 to report outage. If phone lines are busy, please try

again. Report things you have seen or heard that may be helpful such as a broken pole, a tree on a line, downed lines, a loud boom, or a flash of light.

– Unplug all your appliances. The surge of power that comes when power is restored could ruin appliances. – Turn off all but one or two light switches so you will know when your service is back on. – Open refrigerator door only to take food out, close as quickly as possible. A refrigerator or freezer will

maintain foods for up to 12 to 48 hours or longer, depending on the room temperature and frequency of opening.

– Use camping equipment outside, six feet away from everything. Use only a fireplace, properly installed wood stove or a new style kerosene heater in a safe area with outside air coming into area.

– Do not allow children to carry lanterns, candles or fuel. After the Power Outage

– When power is restored, plug in appliances. – Be patient. Provo City Power will repair major electric lines which serve hundreds of customers before they

can repair scattered outages. Emergency services, major communication facilities, and customers on life support equipment must also take priority.

– Examine your frozen food. If it still contains ice crystals, it may be refrozen. If meat is off color or has an odd odor, throw it away.

FIRE!

What fire hazards are in our office?– Computers– Autoclaves– Ultrasonic– X-Ray processors

Wasatch Jr. High Fire

• July 12, 2005• “A school once filled with

the chatter of students and lessons from teachers, is now a hollowed-out, charred shell.”

• “Principal Doug Bingham said…the fire was found coming from a computer server in the media center.”

Two ways to deal with emergencies:

Prevention &

Training

FIRE! cont.

• Prevention– Turn off flames– Keep things clean – Turn autoclaves, towell warmers off– Turn computers off at the end of the day

Fire! cont.

• Emergency protocol:– Fire extinguishers

• Where are they?• How do we use them?

– Call 911– Evacuation protocol

Fire! cont.

• Fire extinguishers – Where are they?– How do we use them?

Where are they?

Where are they?

Where are they?

Medical Emergencies

• Most medical emergencies are caused by:– Physical or emotional stress– Drug reactions– Preeixisting systemic disease

• On the rise:– Pts are becoming older on average– Dental procedures are increasingly lengthy and

complicated– There are more medical risk patients today– More and more drugs are on the market– Conscious sedation tecniques

Two ways to deal with emergencies:

Prevention&

Training

Prevention of Medical Emergencies

• Thorough Health History

• Understanding common health problems

• Always treating people with care

Thorough health history:

• Written med hx, regularly updated

• Dialogue hx

• Blood pressure

• Physical exam (watch gait)

• ASA categories

Common health problems:

• Diabetes• Pregnancy• Post radiation treatment• Post M.I.• Asthma• Allergies• Kidney disease• Liver disease

Treating people with care:

• Some of the most common emergencies are related to anxiety:– Syncope– Hyperventillation– Angina– Asthma– Seizures

• Other emergencies are related to carelessness:– Sitting patients up too fast– Not aspirating during anesthesia– Finishing N2O too quickly

Training for medical emergencies

• Understanding common medical emergencies

• Knowing location of all equipment, and basic info regarding their use

• Agreeing upon an in-office emergency response protocol*

*This is the most important thing we will discuss.

What medical emergencies are most common?

• 10 year study by Stanley Malamed

• 4200 questionnaires, 3800 participants

• Question: how many of the following emergencies have you seen in the last 10 years?

Among 3800 dental offices:

• 15, 407 episodes of Syncope• 2,583 episodes of mild allergy• 2,552 episodes of Angina• 2,475 episodes of Postural (orthostatic) Hypotension• 1,595 Seizures• 1,326 episodes of Asthma• 1,326 episodes of hyperventilation• 913 epinephrine reactions• 890 episodes of insulin shock• 336 episodes of cardiac arrest• 304 anaphylactoid reactions

Emergency Medical Equipment:

• Oxygen tank

• Drug kit

• AED (Automatic External Defibrillator)

• Telephone

Oxygen tank

• In the lab• Positive pressure

Drug Kit

• “Sav-A-Life Systems”• Under the sink in Tx

room #2 (Debbie)• Emergency drugs• Updated regularly

Drug Kit, cont.

AED

• AED = Automatic External Defibrillator

• More and more prevalent• “Cardiopulmonary

resuscitation, usually known as CPR, provides temporary artificial breathing and circulation.It can deliver a limited amount of blood and oxygen to the brain until a defibrillator becomes available. However, defibrillation is the only effective way to resuscitate a victim of ventricular fibrillation.”

More on AED’s• What is AED?

Automated External Defibrillators or Automatic External Defibrillators or AEDs or AED Defibrillators, are small, lightweight devices that look at a person's heart rhythm (through special pads placed on the torso) and can recognize ventricular fibrillation (VF), also known as "sudden cardiac arrest" or SCA. If SCA is present, an AED will advise, and will talk the responder through some very simple steps to defibrillate. AEDs are designed to be used by lay rescuers or "first responders".

• Who Can Use an AED? Anyone, even children 11 years of age and up can be trained to use an AED.

• Are All AEDs the Same?While all AEDs are designed to defibrillate, they vary in the capabilities of their waveform technology (i.e. the “therapy” itself), rhythm recognition, ease of use, safety, weight, and manufacturer's support. It is important to consider these issues as well as the quality of research that has gone into any particular AED when evaluating them.

• Are There Limits Regarding Who the AED Can Be Used On?Typically, children over 55 lbs (25 kg) or 8 years of age are defibrillated as adults. AED defibrillation therapy is appropriate for infants and children, as well as adults, as long as the appropriate pads are used.

• Are There Any Warning Signs of SCA? No, and sadly enough the first sign of heart problems in most men is sudden cardiac arrest. SCA claims more than 350,000 lives each year, primarily because lifesaving treatment, that is, early defibrillation, does not reach the victims within the first critical minutes.

• Does the AED Take the Place of CPR? No. The AED is part of CPR. For maximum benefits (that is, best chance of survival) you must use the two tools together!

• Can I Hurt Someone with an AED?No! There are two things to remember here:- AEDs will not shock someone who does not need to be shocked. It’s that simple. - A victim of SCA is essentially dead. Early defibrillation represents that person’s only chance for survival.

• What About Using an AED on Metal or Wet Surfaces?Always check with the manufacturer, but most AEDs because they are self grounded, can be safely used in wet environments and on metal surfaces with no risk to the victim or rescuer.

• Reference: http://www.aedsafety.com/

Still more on AED’s• Heart disease is the number 1 killer in the United States. Every day, more than 2600 Americans die from

cardiovascular disease, which amounts to 1 death every 33 seconds. • Most of these deaths occur with little or no warning, from a syndrome called sudden cardiac arrest. The

most common cause of sudden cardiac arrest is a disturbance in the heart rhythm called ventricular fibrillation.

• Ventricular fibrillation is dangerous because it cuts off blood supply to the brain and other vital organs.• The ventricles are the chambers that pump blood out of the heart and into the blood vessels. This blood

supplies oxygen and other nutrients to organs, cells, and other structures. • If these structures do not receive enough blood, they start to shut down, or fail. • If blood flow is not restored immediately, permanent brain damage or death is the result.• Ventricular fibrillation often can be treated successfully by applying an electric shock to the chest with a

procedure called defibrillation.• In coronary care units, most people who experience ventricular fibrillation survive, because defibrillation is

performed almost immediately. • The situation is just the opposite when cardiac arrest occurs outside a hospital setting. Unless

defibrillation can be performed within the first few minutes after the onset of ventricular fibrillation, the chances for reviving the person (resuscitation) are very poor.

• For every minute that goes by that a person remains in ventricular fibrillation and defibrillation is not provided, the chances of resuscitation drop by almost 10 percent. After 10 minutes, the chances of resuscitating a victim of cardiac arrest are near zero.

• Cardiopulmonary resuscitation, usually known as CPR, provides temporary artificial breathing and circulation.

• It can deliver a limited amount of blood and oxygen to the brain until a defibrillator becomes available. • However, defibrillation is the only effective way to resuscitate a victim of ventricular fibrillation.• Reference: http://www.emedicinehealth.com/articles/10873-1.asp

Why do we need to have emergency systems in place? :

• General Rule: You will be nervous, you will not think clearly in an emergency. Therefore: – Habits take over– Be calm (don’t yell down

the hall)– Systems must be in place.– Systems must be reviewed

and rehearsed

What systems need to be in place during a medical emergency?

• Chairside assistant will:– Position patient.– Administer O2, turn off N20– Activate in-office emergency protocol, using an agreed-upon

term (“code orange”?)– Monitor vital signs

• Agree upon a term, such as “code orange.”• Front desk will:

– Be ready to call EMS– Gather doctor(s)– Take drug kit/equipment to emergency site

• Assistants and hygenists will:– Stay with patients. Temporize with cavit if necessary.– Be ready to help in other ways if necessary.

N20 Overdose?

• Nitrous Oxide affects some more profoundly than others.

• Keep the following in mind with everyone:– Diffusion hypoxia is prevented by using

straight O2 for ~5 min. – Don’t underestimate the need recovery time.

CPR Review:

• What are the age categories?

• How many compressions and breaths?

• When to activate EMS?

• What is the sequence to follow upon finding an unconscious patient?

Occupational Emergencies

• Like any work environment, we are around several hazards, including high heat, sharp objects, blood, etc.

• Eyewear: it is available, and we recommend you wear it.• Material Safety Data Sheets (MSDS) for potentially toxic

materials are available.• First aid kit• Needlestick protocol.

– The risk of occupationally related blood borne viral infection from patient to dentist or vice versa is exceptionally low. The introduction of universal precautions and hepatitis B immunisation by the dental profession has done much to reduce the risks of such occupational infections.

– Use good re-capping technique• More OSHA related training is available.

Needle-Stick Procedures, From July/August 2005 UDA Journal

1. The employee reports to the dentist-employer.2. The dentist immediately (within two to three

hours if possible) makes available at no cost to the employee:

1. A confidential medical evaluation from a health care professional which includes:

1. Evaluation of the exposure incident2. Counseling to your employee about what has happened3. Instruction to your employee about how to prevent further

spread of any potential infection4. Testing of the employee and the source patient (unless the

status is already known) for symptoms related to HIV5. All test results being given to your employee

Needle-Stick Procedures, From July/August 2005 UDA Journal

1. The employee reports to the dentist-employer.2. The dentist immediately (within two to three

hours if possible) makes available at no cost to the employee (cont’):

1. A confidential medical evaluation from a health care professional

2. Follow-up medical care including post-exposure prophylaxis, if medically indicated

3. The dentist: 1. Receives a written report from the health care professional 2. Provides a copy of the written report to the employee within

fifteen days of receipt.

Questions?