The preparedness of private dental offices and polyclinics for medical emergencies

Discussion

Last year, the death of a 20-year-old healthy woman in a private dental office in Jeddah, Saudi Arabia was reported in a Saudi newspaper. Her death was secondary to an undisclosed emergency that the dentist could not manage. Moreover, 13 deaths in dental offices were reported in Jeddah, in which the Directory of Health Affairs is currently investigating with a forensic committee.14 The MOH, which oversees the private dental offices, conducts periodic checks on valid practice licensing and proper infection control. The MOH does not mandate that dental offices have an emergency drug kit or equipment. It does not conduct unannounced visits or field-checks for medical emergency training and availability of emergency drugs and equipment. The average emergency response time of emergency response systems varies from one country to another. The only study assessing the response time in Saudi Arabia was in the capital city of Riyadh, where the average response time to the scene of an emergency was 10.23±5.66 minutes.15 No similar data was found in the Western region of Saudi Arabia, or Jeddah city. The response time may vary according to the traffic and availability of units in the nearby vicinity. In Makkah and Jeddah and during the Holy month of Du-Hijja, where the annual Islamic Pilgrimage takes place, Red Crescent units are dispatched near the Holy City where approximately 3 million people aggregate to perform the Hajj pilgrimage. This creates a serious potential delay in the response of an ambulance.

Dental offices must be prepared to diagnose and manage an emergency until an ambulance arrives, and the patient is transported to a hospital setting, particularly those who exist as dental practices or polyclinics that are not connected to a hospital with an emergency department. The basic algorithm for management of acute medical conditions in the dental office is; position (P), airway (A), breathing (B), circulation (C) and definitive treatment, differential diagnosis, drugs, and defibrillation (D).1,8

The 6 links of survival is a checklist of educational needs and physical items necessary to fulfill the needs of a dental patient in that time period between the identification of a medical problem and arrival of outside assistance. The links consist of doctor training, staff training, mock drills, medical emergency plan, emergency drug kit, and proper equipment.9 The emergency number to contact in case of an emergency in Saudi Arabia is 997. It was alarming that only half of the dental offices reported that all their personnel were aware of this number. When a medical emergency occurs, it is critical that office personnel respond without delay, and not knowing the number creates chaos and delays the summoning of professional help.

The Saudi Commission for Health Specialties requires proof of valid BLS training for license renewal for dentists and dental assistants. A valid BLS certification is a requirement for issuing or renewal of the Saudi Commission for Health Specialties license, which is mandatory for work in the private sector. Therefore in any dental clinic, 100% of all dentists and dental assistants in any private dental clinic or polyclinic are required to possess a valid BLS certification.

Although BLS training is considered fundamental to cope with medical emergencies, training of personnel extends beyond BLS. It also includes attending continuing education courses, practice drills, and online courses to sharpen the diagnosis and management skills of acute medical events. In a study of Brazilian dental practitioners,4 only 41% of the dentists reported feeling confident to diagnose a medical event in the dental office. The majority of them felt unable to treat anaphylaxis, myocardial infarction, or perform cardiopulmonary resuscitation (CPR) or an intravenous injection. In the UK, 20.8% of dentists felt competent to diagnose a medical emergency,2 while a study in Germany reported that 57% of the surveyed dentists believed they are able to perform bag/valve ventilation, and 49% were confident performing BLS.5

According to the American Heart Association, brain death, and permanent death start 4-6 minutes after cardiac arrest.17 The time to defibrillation is the most important determinant of survival from cardiac arrest.16 The victim’s survival rate is reduced by 7-10% with every minute that passes without defibrillation and advanced life support intervention. Few attempts at resuscitation succeed after 10 minutes.17 The use of an automated external defibrillator (AED) is essential skill in BLS training, yet this device was found in only 10% of the dental offices. Therefore, the dentist may have a BLS certificate to practice, yet the office lacks the necessary equipment to implement the BLS protocol set forth by the American Heart Association. The data presented by Muller et al5 in Germany shows that 84% of the responding dentists own an emergency bag, which contains a ventilation bag, airway equipment and oxygen, while only 2% of the dentists own a defibrillator.

For emergency drugs in the dental office, a dentist should never administer a poorly understood medication because there is no drug that can take the place of properly trained health care professionals in diagnosing conditions and treating patients in emergency situations.1,18 In this survey, there was a significant lack of availability of emergency drugs. Oxygen is essential in any medical emergency, and must be available in a portable E-cylinder to administer to a spontaneously breathing patient or under positive pressure in situations in which the patient is unconscious and not ventilating adequately.18 It was interesting to find that while approximately half the responding offices claim they have an oxygen tank, only 10% actually have at least one type of oxygen delivery device, including a bag-valve mask. The oxygen tank becomes a useless piece of equipment that cannot be utilized during an emergency without a delivery device. Syncope and pre-syncope were the most common medical emergencies in the dental office according to many studies.5,19 The initial treatment of syncope, which occurs due to inadequate cerebral perfusion consists of placement in a supine position and oxygen delivery.19 The management of emergencies in the dental office starts with prevention by obtaining a good medical history, vital signs, and referral to a specialist for further investigation if necessary. One study in Belgium found a link between the years since graduation and obtaining a medical history, the older the dentist, the less consistent was the medical history updated.19

Monitoring equipment that provides basic information for primary assessment should include a stethoscope and a sphygmomanometer or an automated blood pressure device. An automated vital signs monitor can provide physiological data, including systolic, diastolic, and mean blood pressure, along with the patient’s oxygen saturation level, heart rate, and temperature.18 Furthermore, the management of medical emergencies in the dental office is limited to supporting the vital functions of the patient until emergency medical services arrive. There is a significant concern that approximately one-fourth of the surveyed dental offices in this study owned a blood pressure monitor and glucometer. This indicates that not only are the patients not being assessed properly before the dental procedure, but it posses a risk that proper vital signs monitoring during a medical emergency cannot take place.

The limitation of this study is the number of surveyed dental offices and polyclinics as the study utilized a random sample of different geographic locations in Jeddah. Future studies should aim at including other cities and comparing the preparedness in rural and suburban office locations.

In conclusion, there is a deficiency in the preparedness of the dental offices for medical emergencies in Jeddah, Saudi Arabia in 3 main areas, personnel preparedness and training, availability of drugs, and availability of emergency equipment. Polyclinics scored higher on the preparedness score for availability of emergency drugs and emergency equipment. A preparedness of less than 100% is unacceptable. More stringent regulations for the preparedness of these dental offices should exist. The renewal of clinic licenses should be based on criteria, such as the implementation of practice emergency drills, continuing education hours in medical emergencies, a written protocol, availability of emergency drugs and equipment. Unannounced field evaluations of emergency drug and equipment availability should take place regularly by the MOH. Staff and personnel should have periodic exams to test their knowledge of emergency phone numbers, basic action plans, and protocols. A written and readily accessible protocol should exist in every dental office, for basic action plan and management of the more common emergencies that occur in the dental office, such as vasovagal syncope, hypoglycemia, chest pain, and seizures. Further studies are necessary to evaluate the prevalence of medical emergencies in private dental offices over the course of a few years. This enables the health legislator to custom-fit specific emergency algorithms according to the community’s needs and health-care problems. Additionally, a national database of adverse outcomes secondary to medical emergencies in the dental office, across Saudi Arabia, is necessary to ensure patient safety.