by Christopher Rothman, DDS, and John B. Roberson, DMD
You cannot put a dollar amount on a life, but if a death or a bad outcome occurs in your office and you failed to prepare, it can cost you your livelihood, financial security and peace of mind.
As the population ages and grows along with its list of medications and health-related issues, the dental profession cannot ignore them. The need to prepare for medical emergencies becomes prevalent. Dental teams that lack training for medical emergencies, do not have an emergency plan, emergency drug kit, or proper resuscitative equipment, do not perform mock drills or have the documentation to prove they are prepared, may face significant financial hardship and damage to their reputation in the event of a catastrophic medical emergency.
Some dentists argue that they are more liable if they have the proper equipment and are prepared to respond to a medical emergency than if they are not. This is simply not the case.
Has there ever been a documented case of a dentist losing a lawsuit for being prepared? Many cases have been lost due to negligence, not having an emergency plan, poor documentation, and lack of preparation and equipment. Fortis Insurance Company recently broached the litigious nature of society regarding managing risk in the dental office. “Dental malpractice is skyrocketing, even ‘good’ dentists are getting sued. Managing risk is more important than ever.”
The ADA (American Dental Association) recognized this by reflecting it in the new proposed guidelines. “The (ADA) expects patient safety will be the foremost consideration of dentists.” These proposed guidelines state that dentists are responsible for the “adequacy of the facility and staff, diagnosis and treatment of emergencies.” These statements by the ADA reinforcing their commitment to patient safety should not be ignored by dentists and will not be ignored by attorneys. The package insert on all local anesthetics is a legal document that contains some form of language regarding management of emergencies. The following is from the package insert from Kodak Cook-Waite on 2 percent lidocaine with epinephrine:
WARNINGS:
DENTAL PRACTITIONERS WHO EMPLOY LOCAL ANESTHETIC AGENTS SHOULD BE WELL VERSED IN DIAGNOSIS AND MANAGEMENT OF EMERGENCIES WHICH MAY ARISE FROM THEIR USE. RESUSCITATIVE EQUIPMENT, OXYGEN AND OTHER RESUSCITATIVE DRUGS SHOULD BE AVAILABLE FOR IMMEDIATE USE.
This point is further illustrated by the fines levied by OSHA (Occupational Safety and Health Administration). The most recent data available from OSHA revealed $159 million in federal and state fines. Of the standards cited most frequently in dental offices and clinics, medical services and first aid was the fourth most common fine.
There are five deadly misconceptions that can ruin your practice, reputation and financial freedom faster than anything else. They are:
In all of the recent incidences that resulted in the death of patients, 911 and EMS were called and eventually responded. Studies have shown that average response time is 11 minutes in urban settings and 15 minutes in rural areas. In some situations, EMS may be overwhelmed and unable to respond.
Do you and your staff have the training, knowledge, emergency drugs and equipment necessary to rapidly and effectively assist people in emergency situations, during the critical period before EMS medical professionals arrive? The new proposed ADA guidelines squarely place the burden on dentists and staff members to be able to respond quickly and appropriately in life threatening situations.
There are six key components to making sure your office is prepared to handle an emergency. The Institute of Medical Emergency Preparedness refers to them as the Six Links of Survival. If any of these links are missing, the survivability of a victim decreases.
I hope no one ever has this happen, but ask yourself, “If my child or spouse had a life-threatening medical emergency, would I feel comfortable treating the crisis with my staff until EMS arrived?” That is a powerful and uncomfortable question, but it is important. The patients in your office are someone else’s husband, wife, son, daughter, mother, father and loved one. If you and your staff cannot confidently and comfortably answer that question with, “Yes, but I hope I never have to,” then you are not prepared. Dentists are held to a higher standard. We have taken anatomy and physiology, have been instructed on medical emergencies in school. We are expected to know how to manage emergencies.
Every office needs an emergency plan. This should be a written document reviewed on a monthly basis while performing mock emergency drills. Documenting the events during an emergency, performing mock drills, and reviewing the medical emergency plan will assist you in the event of any litigation revolving around a medical emergency.
The Emergency Response System is designed to help offices prepare for an emergency and includes emergency treatment records for proper documentation, a written medical emergency plan, monthly mock drills, multiple workbooks to enable systematic uniform training, and tabbed algorithms of the most frequently encountered emergencies. It also maintains testing records and enables up to 20 people in the office to earn 12 hours of continuing education annually.
Federal tax code provides a Section 179 exemption of up to $125,000 in 2007 for equipment to improve your office. Consult with your tax advisor and accountant, but most of the emergency equipment, such as automated external defibrillators (AEDs), vital sign monitors, portable oxygen, emergency drug kits and the Emergency Response System from the Institute of Medical Emergency Preparedness, will fall in this category.
Cardiopulmonary Resuscitation and Basic Life Support (CPR/BLS) courses teach how to use AEDs, which is the only treatment for sudden cardiac arrest (SCA). This makes it more difficult for any dentist or health-care professional to justify not having an AED. The good news is that the cost of AEDs dropped considerably the past few years, and the prices range from just under $1,000 to nearly $5,000. Some manufacturers have developed AEDs that can be used on children. These must be used with special pediatric pads or a pediatric key that reduces the joules delivered to the pediatric victim. Approximately 7,000 children will die from SCA in the United States this year. If you treat children these upgrades are well worth the investment.
Additional equipment all offices should have includes blood pressure cuffs or vital signs monitor and a stethoscope. The biggest advantage of an automated vital signs monitor is during a crisis. Automated blood pressures cuffs free a team member to assist in treating the emergency instead of monitoring manually. Most vital sign monitors have pulse oximeters to measure oxygen saturation, which evaluates adequacy of the airway. In 2004 the ADA, in conjunction with other professional organizations, established new guidelines stating that all dentists should take patients’ blood pressure at initial evaluations, prior to any significant procedure, and periodically. This recommendation makes an automated vital sign monitor worth the investment.
Emergency drug kits may be purchased commercially or assembled by you. The advantages of the ready-made kits from manufacturers such as Southern Anesthesia & Surgical, Banyan, HealthFirst, and Sav-a-life is that the commercial kits have the option of an auto update program that ensures the drugs will not expire.
The initial cost of a drug kit can range from the upper $200s for the basic kits to $1,000 for the deluxe editions, which contain the ACLS drugs, airway supplies and portable oxygen. The cost of the automatic refill programs range from $150 to $250 annually. A portable “E” cylinder of oxygen can be purchased from your local gas supplier for around $300. Ambu-bags with masks for administering positive pressure oxygen are available for less than $30.
If your office has an emergency drug kit, vital sign monitors and all the resuscitative equipment, the next question is, does everyone know how to use it? This is the responsibility of the doctor to have the staff trained and comfortable with all the emergency treatments. Don’t let a small investment of less than $5,000 ruin the reputation of your practice and the name you have worked so hard to build. Get prepared today and enjoy the freedom that comes with it.Drs. John B. Roberson, DMD, and Christopher M. Rothman, DDS, are oral and maxillofacial surgeons who are in private practice. They are both Board Certified by the American Board of Oral & Maxillofacial Surgery and the National Dental Board of Anesthesiology.
Editor’s note: The authors of this article are the developers of the Emergency Response System and are the co-founders of the Institute of Medical Emergency Preparedness. The ERS is a comprehensive medical emergency preparedness package developed for dentists and their staff. The ERS may be viewed at www.emergencyactionguide.com. Contact Dr. Roberson at [email protected].
