The Dental Team Approach to Medical Emergencies
By Daniel A. Haas, DDS, PhD
The successful management of a medical emergency is one of the great challenges in dentistry. In practice, it is most likely that the dentist will not be alone when a patient is experiencing a medical emergency. Even a solo practitioner will have the presence of at least one dental assistant, a receptionist, and likely a dental hygienist. This article summarizes an approach to accomplish the objective of appropriate staff preparation for medical emergencies in the dental office.1
The specific roles of team members will, in part, depend on the number within the team. One may assume that there will be at least three team members in any office—namely a dentist, a dental assistant, and a receptionist. As the office size increases, duties can be shared among more members. Team Member 1 is the team leader, but after that the other team roles often can be interchangeable. The following suggests specific roles for the team members.
Because Team Member 1 is the leader, this person is usually the dentist of the patient having the emergency. Exceptions to this can be made, taking into account individual circumstances. This person’s role is to be in charge and lead the management of the crisis. The leader decides when to call the emergency. If in doubt, it is better to call an emergency early rather than late, bearing in mind that the "crying wolf" approach of calling help unnecessarily too often may be detrimental when it is truly needed. This person calls for assistance, positions the patient, and initiates the ABCs until the assistance arrives. The leader should remain with the patient throughout the emergency until recovery or until Emergency Medical Services (EMS) has taken the patient away.
Being the leader requires leadership skills which include knowing how to prioritize actions by determining what is important at any point in time relative to what actions can be deferred. Leadership skills include the ability to appear calm and in control. Although deep down inside the leader may well be worried about the events unfolding, a calm demeanor must prevail. Panic can be infectious. If the team members see their leader panicking, they may follow suit. Remaining calm and collected will help allow rational thinking and action during a stressful time.
Team Member 2 knows the location of the emergency kit, portable oxygen, and automated external defibrillator (AED), and can bring them as instructed. This person can also be assigned to be the one to check on the emergency kit on a regular basis to ensure all contents are present and within the expiration date. This person also ensures that there is sufficient oxygen remaining in the tank. Team Member 2 also assists the team leader with BLS.
Team Member 3 can fulfill various functions, including calling EMS (911) and then going out to the building’s main entrance to meet the paramedics and lead them to the site where the patient is being managed. This team member also can assist with BLS, monitor vital signs, and provide assistance in any way that is needed. This same person, or Team Member 4 if present, may prepare emergency drugs for administration and measure vital signs. One of these team members keeps a written chronological record of all events, including vital signs, timing and amount of drug administration, and patient response to treatment.
Additional team members may be other dentists or support staff that are present in the office. Any one of them should be able to come in and relieve individual team members as required. Every team member should be able to check vital signs. In the context of a medical emergency, this means measuring heart rate, blood pressure, and respiratory rate.
An effective team not only needs to understand each other’s roles but also needs to communicate effectively. The team leader should consider using a closed-loop approach.2,3 This means that when the leader gives a message, that team member acknowledges receiving the command, which confirms that the message was heard and understood. This same model is used successfully in aviation among pilots and air-traffic controllers.
The next task should be given only after receiving a clear response back. This approach reduces the likelihood of key steps being missed through oversight, such as shouting to no one in particular "call 911," and everyone assumes that everyone else has done it, when in fact no one has acted on this comment. An example of a correct scenario is: the team leader states, "Susan, call 911." Susan replies, "I am going to call 911." The team leader then listens for confirmation that, in fact, the task was performed. This happens when Susan returns and says, "I’ve called 911 and the paramedics are on their way." Another example of a correct scenario is: the team leader states, "Jane, bring the oxygen tank." Jane replies, "I am going to get the oxygen tank." When she returns, acknowledgment to the team leader is given, "Oxygen tank is here," to which the team leader responds, "Good. Now attach the bag-valve-mask." This continues in a similar way with all team members.
An important part of effective communication is for each team member to speak clearly and directly. Good eye contact should be maintained when giving instructions. It is not appropriate to let the stress of the situation result in yelling or shouting. If any instruction is not clear, the recipient should reply asking for clarification. The best teams are comprised of members who mutually respect each other and work together in a supportive and collegial way.2 There should be an open exchange such that any team member can speak freely to any other team member, without fear or embarrassment. No one should be made to feel patronized. Any perceived dental office hierarchy should be ignored for this purpose. For example, any team member should feel comfortable making a suggestion to the team leader, in particular if it is felt that something important was missed or is being done incorrectly. The team leader should welcome any comment that could benefit the patient outcome. The team must concentrate on what is right for the patient—not who is right during the management.2
It is useful to have a planned protocol of what to say when calling 911. There are important pieces of information that should be given clearly to the dispatcher. These include a preliminary diagnosis; information on the patient with respect to age, gender, signs and symptoms; and office location.
Ideally, the dental office should have a written plan that describes the expected roles of the various team members. Staff meetings should take place where an effort is made to review these roles and ensure that everyone is clear about their individual assignments. There should be opportunities to provide practice by arranging emergency simulation or drills. The EMS number should be posted if it is other than 911.
The final decision regarding the exact roles of each team member will be determined by a number of factors, including the individual dentist’s and staff member’s training and ability. Taking the time to prepare office staff to work as an effective team for medical emergencies will be well worth the effort.
References
1. Haas DA. Preparing dental office staff members for emergencies. Developing a basic action plan. J Am Dent Assoc. 2010;141:8S-13S.
2. American Heart Association. Part 3. Effective Resuscitation Team Dynamics. In: Advanced Cardiac Life Support Professional Provider Manual. 2006;11-17.
3. Gaba DM, Fish KJ, Howard SK. Principles of anesthesia crisis resource management. In: Crisis Management in Anesthesiology. Philadelphia: Churchill Livingston; 1994;31-52.
About the Author
Daniel A. Haas, DDS, PhD
Associate Dean Clinical Sciences, Faculty of Dentistry
Professor and Head of Dental Anaesthesia, Faculty of Dentistry
Professor, Department of Pharmacology Faculty of Medicine
University of Toronto
Toronto, Ontario, Canada
