Journal of Indian Academy of Oral Medicine and Radiology

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 31  |  Issue : 2  |  Page : 107--116

Competence of handling medical emergencies among dental graduates and post-graduate students – A cross-sectional questionnaire study


Aveek Mukherji1, Mohit Pal Singh2, Prashant Nahar3, S Bhuvaneshwari3, Saurabh Goel4, Hemant Mathur4,  
1 Senior Lecturer, Department of Oral Medicine and Radiology, Pacific Dental College and Hospital, Rajasthan, India
2 Professor and HOD, Department of Oral Medicine and Radiology, Pacific Dental College and Hospital, Rajasthan, India
3 Professor, Department of Oral Medicine and Radiology, Pacific Dental College and Hospital, Rajasthan, India
4 Associate Professor, Department of Oral Medicine and Radiology, Pacific Dental College and Hospital, Rajasthan, India

Correspondence Address:
Dr. Aveek Mukherji
33-D, Prasanna Naskar Lane, Budir Bagan Complex, Picnic Gardens, Kolkata - 700 039, West Bengal
India

Abstract

Introduction: Dentists are encountering a growing number of geriatric and medically compromised patients and at the same time are performing more invasive and possibly painful dental treatments. Medical emergencies are 5.8 times more likely to occur in dental offices than in medical offices. So, it is essential for the dentists to be adequately prepared and equipped to manage the common medical emergencies that may occur during their work. Aims and Objectives: To observe the knowledge, experience, and perceptions of the interns and post-graduate students regarding emergency medical care and its practical application. Materials and Method: A cross-sectional study was carried out among post-graduate students and interns (with or without medical emergency training) of a dental college and hospital through a self-administered structured closed-ended questionnaire. Results: The participants lacked the knowledge to handle medical emergencies and were unconfident to face them. Conclusion: Undergraduate health courses should develop strategies to teach appropriate management of life-threatening emergencies in dental clinics to ensure safer dental healthcare services for the population. The available medical emergency training is alarmingly inadequate.



How to cite this article:
Mukherji A, Singh MP, Nahar P, Bhuvaneshwari S, Goel S, Mathur H. Competence of handling medical emergencies among dental graduates and post-graduate students – A cross-sectional questionnaire study.J Indian Acad Oral Med Radiol 2019;31:107-116


How to cite this URL:
Mukherji A, Singh MP, Nahar P, Bhuvaneshwari S, Goel S, Mathur H. Competence of handling medical emergencies among dental graduates and post-graduate students – A cross-sectional questionnaire study. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2019 Jul 19 ];31:107-116
Available from: http://www.jiaomr.in/text.asp?2019/31/2/107/261086


Full Text



 Introduction



Medical emergencies in dental practice are generally perceived as being rare. Nonetheless, recent studies have shown that such incidents occur on a regular basis.[1] Medical emergencies are 5.8 times more likely to occur in dental offices than in medical offices. Stressful environment, that the patient has to go through, may be considered as the cause.[2] Effective management of an emergency situation in the dental office is ultimately the dentist's responsibility. The lack of training and inability to cope with medical emergencies can lead to tragic consequences and sometimes legal complications.[3] Girdler and Smith (1999) estimated that an average dentist might expect to encounter some form of medical emergency as often as every 16 months.[4] Dentistry is a health science profession that should focus on the whole patient instead of being limited to the oral cavity. However, students' minimal knowledge about medical emergencies and their etiology causes feelings of insecurity, dissatisfaction, and a limited appreciation of the dentist's responsibility.[3]

 Aims and Objectives



To observe the knowledge, experience, and perceptions of the interns and post-graduate students regarding emergency medical care and its practical application.

 Materials and Method



A cross-sectional study was carried out among 100 randomly chosen post-graduate students and interns of a dental college and hospital through a self-administered structured closed-ended questionnaire [Questionnaire]. A comparison of capability was made between the students who had undergone medical emergency training and those who did not.

 Results



Among the 100 participants, 25 had undergone medical emergency training, while 75 had not.

Syncope was the most commonly encountered (100%) medical emergency condition and most of them showed confidence (85%) in handling it [Table 1]. Most of the participants displayed good knowledge about the emergency drugs that are required in the dental office with greatest priority given to adrenaline and the hemostatic agents (100%) followed by glucose (98%) [Table 2]. However, they lacked the knowledge about the administration of the drugs [Table 2] and the use of necessary equipment [Table 3]. Most of them were aware of the importance of the measurement of blood pressure (BP) before the beginning of a dental procedure [Table 4]. In case of chest pain, most of the participants preferred the arrival of help (41%), and only a few (30%) opted to give aspirin and nitroglycerine [Table 5]. Majority of the subjects (61%) were aware that in the case of anaphylaxis, adrenaline is the first drug to be administered [Table 6]. They knew the right time to apply cardiopulmonary resuscitation (CPR) and defibrillator [Table 7] and [Table 8]. The idea about the rate of chest compression was good among the participants, but the ideal site of compression was not correct as most of the participants opted to apply the pressure over the apex-beat [Table 9] and [Table 10]. The sequence of approach to handling an emergency situation was correctly chosen to be P(position) - A(airway) - B(breathing) - C(circulation) - D(definitive care) [Table 11]. All the participants wished to undergo suitable medical emergency training.{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}{Table 9}{Table 10}{Table 11}

Though participants with prior medical emergency training showed better competence in handling emergency situations, even they lacked a clear understanding and confidence to manage life-threatening emergencies [Graph 1], [Graph 2], [Graph 3]. Surprisingly, the untrained participants showed better knowledge in a few areas like using the blood sugar measuring device [Table 3].[INLINE:1][INLINE:2][INLINE:3]

 Discussion



Medical emergencies can happen. If they do take place in a dental practice, the staff should be adequately trained to deal with the problem quickly and correctly.[5]

A cross-sectional study was carried out among 100 randomly chosen post-graduate students and interns of a dental college and hospital through a self-administered structured closed-ended questionnaire. Majority of the participants had not undergone any training on management of medical emergencies. The participants were asked to tick the answers which they thought to be the most appropriate. Some questions had remained unanswered because of doubts in the subjects' mind.

The most common emergencies that may be encountered are:-[6]

Vasovagal/hypoglycemic syncopeAnginaEpilepsyAsthmatic episodeAnaphylaxis.

Being aware of the most common medical emergencies can help in saving lives. In this study, syncope was found to be the most commonly encountered medical emergency condition and most of the participants showed confidence in handling it [Table 1].

Dental practice settings should have a minimum level of emergency equipment and medications to effectively respond to potentially life-threatening medical emergency situations and to support patients until the arrival of the emergency services.[7]

Minimum emergency drugs to be kept:- [Resuscitation Council UK (2013)][4]

Glyceryl trinitrate spraySalbutamol aerosol sprayAdrenaline injectionAspirin dispersibleGlucagon injectionOral glucose solution/tablets/gel/powderMidazolamOxygen.

1. Glyceryl trinitrate:-

It is to be given if the patient complains of sudden chest pain and particularly if he/she has angina.[8] It is administered by applying one or two sprays or placing a tablet under the patient's tongue.[7] The sublingual spray formulation acts more rapidly than the sublingual tablet.[9] It is contraindicated if signs of a drop in blood pressure (BP) (e.g. faint or dizzy feeling) is exhibited, or if the patient has taken sildenafil (Viagra) within the previous 24 h.[10] The drug should ideally be administered when the patient is sitting or lying down.[7]

2. Salbutamol aerosol inhaler (100 mcg/actuation):-

It is a bronchodilator used to treat an acute asthmatic attack.[10] The normal dosage is two sprays; however, in a severe attack, 4–10 puffs may be administered.[7]

3. Adrenaline/epinephrine (intramuscular):-

Epinephrine, the single most important drug when an anaphylactic reaction occurs, should ideally be available in a preloaded syringe.[10] Majority of the subjects in the study were aware that in the case of anaphylaxis, adrenaline is the first drug to be administered [Table 6]. As more than one dose may be needed, a minimum of two or three 1 mL glass ampoules of epinephrine 1:1000 should be present in the emergency kit. There is no medical contraindication to the use of epinephrine in an anaphylactic reaction.[10]

4. Aspirin (dispersible):-

One aspirin tablet (325 mg) chewed, not swallowed, is recommended for patients suffering from chest pain.[10] It is given for its antiplatelet qualities.[7] The drug is contraindicated when the patient is allergic (asthma) to aspirin, has a bleeding disorder, or has a gastric or peptic ulcer.[10]

5. Glucagon (1 mg intramuscularly):-

This medication is particularly useful if the patient has any impaired consciousness as a result of low blood sugar level and is unable to tolerate anything orally.[7] These usually occur during mid to late afternoon in insulin-dependent diabetics, who have taken their morning insulin and missed lunch.[8] A single dose is usually sufficient to reverse the patient's hypoglycemia. As glucagon relies on glycogen stores, it may not be effective in cachectic patients, those with liver disease, and young children. It may also cause the release of more insulin and create the potential for secondary rebound hypoglycemia.[7]

6. Oral glucose (gel/powder/tablets):-

These products should be available to treat any patient who has low blood sugar, yet is fully conscious and orientated.[7] The patient should be given a sugary drink while they are cooperative. If they are unable to drink this, then glucogel (10 mg glucose in gel form) should be squeezed into the buccal sulcus. Both should be repeated every 10 min to ensure a full recovery.[5]

7. Midazolam (buccal or intranasal):-

The Resuscitation Council UK has reiterated the importance of administering buccal midazolam if “seizures are prolonged (convulsive movements lasting 5 min or longer) or recur in quick succession.”[11] It comes in a glass ampoule with a breakable top. Once broken, it is possible to draw up the medication into a syringe with a needle. In order to administer, the needle is to be removed, and the required dosage is to be squirt into the patient's nose or under their tongue—whichever is most practical. The adult dosage of 10 mg has little in the way of danger associated with it.[7] Presently, midazolam nasal sprays (Midacip) are available in India.

8. Oxygen:-

Can be used in any type of physical distress. It is used in 100% concentration in a medical emergency condition. It aids in the decrease of tissue damage and recovery of vital organs when there is less oxygenation. When used for emergency procedures, it is administered in a 100% concentration.[2]

Minimum equipment required in the dental office:-

[Resuscitation Council UK (2006, revised in 2012)][12]

Portable oxygen cylinderOxygen mask with reservoir and tubingPocket mask with oxygen portPortable suction with suction catheters and tubingSingle-use sterile syringes and needlesSpacer device for inhaled bronchodilatorsAutomated blood glucose measurement deviceAutomated external defibrillator

1. Oxygen cylinder (D size)-

The cylinders should be capable of delivering a flow rate of 15 L/min. In any critically ill patient, the initial administration of high flow oxygen (15 L/min) is the correct course of action (British Thoracic Society, 2008). When oxygen saturation levels can be accurately measured, the given amount of oxygen can be titrated accordingly.[7]

2. Oxygen face mask with tubing-

These are used to deliver oxygen to patients who are breathing adequately for themselves. Some of these masks will have an attached reservoir bag, which must be inflated before use and only used with a minimum of 10 L/min of oxygen flow. They are intended for single patient use only.[12]

3. Pocket mask with oxygen port:-

Pocket masks are intended to allow rescuers to deliver expired air ventilation without direct contact with the patient. They are equipped with a one-way valve which permits air to flow from rescuer to the patient but not the other way, thus reducing the risk of cross-infection. These masks are transparent to help in detection of vomit or secretions. Many of these devices will have a port for attaching oxygen, and this should be used wherever possible to maximize oxygenation of the patient.[12]

4. Portable suction:-

It should be fully charged at all times and be able to provide suction at 500 mm Hg. A wide bore suction catheter, available in adult and pediatric sizes, will be useful to remove obstructions in liquid form (saliva, blood, vomit, secretions). Suction should not exceed 120 mm Hg in children under 1 year old.[12]

5. Single-use sterile syringes and needles:-

Many prefilled syringe products are available and should be encouraged for ease of use. If no prefilled syringes are available, a selection of sterile syringes (1 mL, 5 mL, 10 mL, and 20 mL) and needles should be available.[12]

6. ”Spacer” device for inhalation of bronchodilators:-

Spacer devices have a chamber that receives the drug before it is inhaled. Their main function is to overcome difficulties in coordinating the timing of the inhaler actuation and inhalation. The required number of doses of the inhaler should be administered into the spacer while the patient breaths through the spacer, thus inhaling all the medication.[12]

7. Automated blood glucose measuring device (glucometer):-

Most diabetics are encouraged to measure their blood glucose at different times during the day or week—this is most commonly done by obtaining a small blood sample by pricking the skin. The sample is placed on a test strip, which is then read by an electronic glucose test meter.[12]

8. Automated external defibrillator

An automated external defibrillator (AED) is a small, lightweight defibrillator that analyzes and interprets the patient's heart rhythm and determines whether electricity is required to try and normalize the heart rhythm (Resuscitation Council UK, 2011). Little knowledge is required from the operator apart from recognizing and determining cardiac arrest and applying two adhesive pads in the correct position onto the patient's bare chest and following the guided step-by-step prompts of the AED.[12]

Apart from the above, a BP-measuring device (sphygmomanometer) is also essential. The importance of identifying high BP has been discussed below.

Most of the participants displayed good knowledge about the emergency drugs that are required in the dental office with greatest priority given to adrenaline and the hemostatic agents followed by glucose [Table 2]. However, they lacked the knowledge about the administration of the drugs (especially glucagon) and the use of necessary equipment (especially defibrillator) [Table 3].

Vital signs are key to assessing a patient in trouble. If the vital signs (respiratory rate, pulse, and BP) are normal, probably the patient will be fine. If they are not, the goal is to normalize them until the patient can receive appropriate medical attention.[13]

Dental treatment for patients with elevated BP:-[14]

If the Patient is asymptomatic, and the BP <159/99 mm Hg, with no history of target organ disease:-

-No dental modifications are needed.

-Can safely be treated in a dental outpatient setting.

If the patient is asymptomatic, with BP = 160–179/100–109 mm Hg, and has no history of target organ disease:-

- Assessment should be done on an individual basis with regard to the type of dental procedure.

If BP = 180/110 mm Hg, even with no history of target organ disease:-

-No elective dental care should be provided.

Target organ disease or poorly controlled diabetes mellitus.

- Elective dental care is to be provided only when BP is controlled, preferably <140/90 mm Hg.

Though the participants were aware of the importance of measuring BP before dental procedures [Table 4], they lacked a clear knowledge about safety values.

That dentists initially should manage all medical emergencies in the same way by using what is known as the basic algorithm:-[15]

P-position the patientA-assess airwayB-assess breathingC-assess circulationD-definitive treatment, consisting of differential diagnosis, drugs, and defibrillation

Most of the participants were aware of the above sequence [Table 11] of handling medical emergencies.

Cardiopulmonary resuscitation (Resuscitation Council UK, 2010)

If the patient is not responsive, not breathing, and the carotid pulse is not felt (check for no >10 s), one should call for medical help and start giving CPR. Thirty chest compressions (depth 4–6 cm, and allow full chest recoil) in <18 s at the center of the chest, at the nipple line, with the heal of one hand on top of the other (positioning oneself vertically above the victim's chest with straight arms), at a ratio of 100–120 compressions per minute should be given. After giving 2 breaths (1 s each), the second cycle of 30 compressions should be delivered in the same manner. CPR should be continued until help arrives. Ideally, an AED should be used simultaneously.[16] Most of the participants were aware of the right time to apply CPR and defibrillator [Table 7] and [Table 8]. The knowledge about the rate of chest compression was good among the participants, but the ideal site of compression was not correct as most of the participants opted to apply the pressure over the apex-beat [Table 9] and [Table 10].

Early correct intervention in a medical emergency can prevent further deterioration and possibly death. The Resuscitation Council 2013 recommends that staff receive refresher training on an annual basis.[4]

The results of the study confirmed that the undergraduate health courses need to develop strategies to teach the students appropriate behavior and attitudes when facing life-threatening emergencies.

Theoretical information with demonstrations but without practice is not enough to ensure competence in handling medical emergencies. Repeated training with the use of mock scenarios in the environment where the emergency response will be delivered is recommended to elicit better results.

 Conclusion



The study found deficiencies in the way the dentists are trained to deal with medical emergencies and identified a need for improvement. A better knowledge of medical emergencies will ensure safer dental healthcare services for the population. The entire staff and designated in-office emergency team must be trained, and emergency equipment and drugs must be available. Continual training in the environment of a dental clinic, where the emergency response will be delivered is essential.

Financial support and sponsorship

Department of Oral Medicine and Radiology, Pacific Dental College.

Conflicts of interest

There are no conflicts of interest.

 Questionnaire



COMPETENCE OF HANDLING MEDICAL EMERGENCIES AMONGST DENTAL GRADUATES AND POST-GRADUATE STUDENTS – A CROSS SECTIONAL QUESTIONNAIRE STUDY.

NAME:-

Please tick the options you think would be the right answer. There may be more than one answer to a particular question.

1) HAVE YOU UNDERGONE ANY MEDICAL EMERGENCY AND/OR BASIC LIFE SUPPORT TRAINING?

[INLINE:4]

2)

[INLINE:5]

3)

[INLINE:6]

4)

[INLINE:7]

5) WHAT IS THE MAXIMUM BLOOD-PRESSURE UPTO WHICH THE PATIENT CAN BE TREATED WITHOUT ANY PHYSICIAN'S CONSULTATION ?

[INLINE:8]

6) IF THE PATIENT HAS SUDDEN CHEST PAIN IN THE DENTAL CHAIR, WHAT WILL BE YOUR FIRST STEP?

[INLINE:9]

7) IN CASE OF ANAPHYLAXIS, WHICH IS THE SINGLE MOST ESSENTIAL DRUG TO BE ADMINISTERED?

[INLINE:10]

8) DEFIBRILLATOR SHOULD BE USED WHEN…..

[INLINE:11]

9) C.P.R SHOULD BE GIVEN WHEN YOU SUSPECT ….?

[INLINE:12]

10) DURING C.P.R, WHAT IS THE RATE OF CHEST COMPRESSION EVERY MINUITE?

[INLINE:13]

11) WHERE DO YOU PLACE YOUR HANDS WHILE DOING CHEST COMPRESSIONS ON A PATIENT ?

[INLINE:14]

12) IFA =AIRWAY, B =BREATHING, C =CIRCULATION, D =DEFINITIVECARE, P =POSITION

WHAT SHOULD BE THE ORDER OF YOUR APPROACH TO HANDLE AN EMERGENCY SITUATION?

[INLINE:15]

13) WOULD YOU LIKE TO UNDERGO ANY MEDICAL EMERGENCY COURSE?

[INLINE:16]

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