Who am I? Medical Emergencies in the Dental Office 10/11/2018. Conflicts of interest. Other disclaimers. What is our game plan?

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1 Medical Emergencies in the Dental Office Robert G. McNeill, DDS, MD Diplomate, American Board of Oral & Maxillofacial Surgery Who am I? Grew up in Canada Oral and maxillofacial surgeon in North Garland Fellowship, Integrative Medicine from the University of Arizona School of Medicine Former staff dentist, TSBDE Former member, Blue Ribbon Panel on anesthesia safety Board member, TSBDE Conflicts of interest No conflicts with any products I will be speaking about today I am not here in my official capacity as a representative of the TSBDE Other disclaimers I might come across like I have it all figured out I don t.i just have a different set of experiences I don t know many of the questions let alone the answers What you do in your office will be dependent upon your training, experience and preferences What is our game plan? Discuss actual cases that exist in the public domain Discuss some example made up cases Preventing common emergencies Managing common emergencies Office drills Customize an emergency plan My intent is to have this be a different type of lecture I hope to help you to evaluate how prepared you are for an emergency in your office We will go through scenarios and discuss drills for your office I will try to use my experiences to hopefully have you look at this process a little differently 1

2 We are going to talk about stress How stress contributes to emergencies in your office Staff can play a big role here My hope is also to look at the issue more globally from case selection/patient management (what is their PMH and what and how you are going to do it) Discuss legal/state board issues Management of emergencies Who are you? Dentists? Hygienists? Dental assistants? How many of you feel very well prepared to manage a medical emergency in your office? How many of you provide sedation? How many of you treat a fair number of ASA III or IV patients? Why are we not talking more about the actual prevention of medical emergencies in our dental offices? 2

3 Preventing emergencies We are in the Perfect Storm Let s try to prevent them from happening in the first place Case selection Not doing too much at one time Will you request to modify or not modify their medical management? How are you going to manage their stress (and yours)? Sugar consumption with increased caries in young children Increased obesity causing poor airways Increased rates of depression and anxiety for all ages Increased drug use Increased rates of ADHD and Autism People are living longer and how is that going to change your decision making? Medically compromised patients Everyone is on a blood thinner 3

4 What is a basic emergency protocol? Prompt implementation of basic emergency management protocol can significantly increase the likelihood of a successful result when medical emergencies occur in the dental office Position Airway Breathing Circulation BLS Keep them alive until someone better trained in emergency management takes over or the patient recovers Keep them alive until someone better trained in emergency management takes over or the patient recovers Who in this room has participated in a medical emergency at their office? 4

5 The Five Deadly Misconceptions Six Links of Survival 1. Doctor training BLS AED Using EpiPen or other form of epi Administering oxygen (practice during BLS training) Medical emergency training Six Links of Survival 2. Staff training Trained to recognize the signs and symptoms of medical emergencies They might be the only one with the patient!!!!! Their quick response to can make the difference between life and death for a patient They need to know their role in an emergency They need to know where the equipment is Six Links of Survival 3. Medical Emergency Plan Every office needs one Everyone should know their roles The dentist will be the team leader (if they are available) Quickly make decision about calling EMS If in doubt, call EMS out! 5

6 Six Links of Survival ADA Council on Scientific Affairs 4. Emergency Drug Kit What you have in it will be determined by your training and type of practice If you provide sedation you will have more drugs (such as reversal agents) and perhaps different airway devices Don t have something in the kit if you do not know how to use it Make sure your drugs are not expired (keep and practice with your expired drugs) Oxygen with the ability to administer positive pressure Epinephrine Benadryl Aspirin Bronchodilator Nitroglycerin (spray or tablets) Glucose source Six Links of Survival 5. Proper Equipment Some of this will be determined by your level of training and what you do in your practice Six Links of Survival 6. Mock drills None of this matters if you and your staff do not know how to respond appropriately during an emergency How often should you practice? All staff should participate Avoiding a medical emergency in the office: Know when not to treat 6

7 When is the blood pressure too high? 64 year old patient presents for crown on #19. Pt. is without pain. PMH: elevated cholesterol PE: BP: 220/120 What do you do? Retake BP: 222/121 Do you treat them that day? 45 year old male presents for RCT #7. Pt. is without pain but has severe dental phobia. PHM: reports nothing on health history questionnaire and has not seen his MD in 5 years PE: Height:5 10 Weight: 310 P: 122 BP: 182/112 (lowest of several readings) What are you going to do? 45 year old male presents for RCT #7. Pt. is without pain but has severe dental phobia. PHM: reports nothing on health history questionnaire but has not seen his MD in 5 years PE: Height:5 10 Weight: 310 P: 122 BP: 182/112 (lowest of several readings) Defer tx and get him to MD? What would you do if BP came down to 170/105 after you helped him to relax? How would your management change? 7

8 Is it easy then to say when tx should be deferred? Everything is fine until it isn t PMH of patient (history of heart disease or stroke) Age and physical condition of patient Is the patient in pain? Can you provide something to help relax them Is it a long procedure? Do you re-check blood pressure? Let s go back to this patient 64 year old patient presents for crown on #19. Pt. is without pain. PMH: elevated cholesterol PE: BP: 220/120 What do you do? Retake BP: 222/121 Other retake after your assistant calms the patient down and you start nitrous is 165/92 Now what do you do? Avoiding a medical emergency in the office: If you proceed will you use epinephrine in your local anesthesia? Pt. starts to get SOB You start oxygen Patient develops chest pain You give ASA and call 911 EMS arrives and transports pt. to the hospital Patient had an MI and is released from the hospital after 4 days Know when to stop Is it okay to fail Are we giving local anesthesia enough time to work? Doctors, listen to your assistants Encourage your team to feel comfortable speaking out Avoiding a medical emergency in the office: What are you learning from the physical exam and patient interview? Auscultation Are they short of breath walking in your office? Pre-tibial edema 8

9 Avoiding a medical emergency in the office: Are there concerns about their PMH? Cardiac issues Blood thinners Anxiety issues Respiratory issues Sleep apnea Cardiac issues Get a good cardiac history Angina how often do they take Nitro? what are they doing when it happens? Congestive heart failure when did you last see your doctor? ask if you can see their pre-tibial area and press on it (fluid retention) are they huffing and puffing getting in and out of the chair Cardiac issues Cardiac issues Heart attack When did they have it, how many? When are you going to treat? 3 months, 6 months Pain or infection? Is it safe to give epinephrine and how much? Are you going to stop the blood thinner? Remember that many cardiac patients do not know they have heart problems and therefore you do not know they have heart problems Should you manage a patient as though they have cardiac issues? Comorbidities: smoking, obesity, diabetes, physical activity, cholesterol meds, hypertension, age Cardiac issues Do you reach out to the patient s physician/cardiologist? Is their heart condition optimized? Does it make sense legally to get a consult? Are you trying to take them off blood thinners? Is a pre-op work up prudent for more involved procedures? Avoiding a medical emergency in the office: Can the patient tolerate a lengthy procedure? Does it make sense to break things up into smaller procedures? 9

10 Looked at 3,817,113 patients having major non-cardiac surgery Looked at three risk factors Currently smoking Treatment for hypertension Treatment for diabetes Risk Factors 42% had none of the RF 40% had one RF 17% had two RF s 1.2% had all three RF s They found that the incidence of an acute MI or death within 30 days climbed in a stepwise fashion ASA classifications Do you know the ASA classifications? 10

11 Very important ones to know Why is ASA classification important? MI (heart attack) CVA (stroke) TIA (mini-stroke) CAD with stents If any of these are recent (<3 months) then this makes it an ASA 4 A mechanism for risk stratification If you don t get the classification right it might effect your patient management You might run into legal/state board problems You may need additional training if ASA 3 or 4 and plan to sedate level 2 or higher Time for audience involvement Would you treat this patient? Would you contact physician about the treatment if performing this with local anesthesia and nitrous oxide? Would you ask for patient to stop Coumadin or Aspirin? How many would stop Coumadin only? How many would stop Aspirin only? What INR number is too high to remove this tooth? How are you going to treat this patient? Avoiding medical emergencies Tannins: tannic acid is an astringent that is present in many plant leaves and bark Used since ancient times for clotting Has anti-microbial, antioxidative and antiinflammatory activity Soltani R, et.al. Evaluation of the Effect of Green Tea Extract on the Prevention of Gingival Bleeding after Posterior Mandibular Teeth Extraction: A Randomized Controlled Trial. Evidence-based Complementary and Alternative Medicine : ecam Limit epinephrine with older patients Use appropriate local anesthesia Keep on current medications when possible, including blood thinners 11

12 Blood thinners 86 y.o. female 2 fractured teeth with discomfort Vitals stable PHM: DM CAD on coumadin Osteopenia COPD Would you get a medical clearance? Chest X-ray Atherosclerotic calcification of aortic arch EKG: LBBB, cardiac ischemia with old infarction Medical consult showed: Intermediate risk for non-cardiac surgery Plan: Nitrous oxide, local, local measures, stay on coumadin Limit epi (no epi versus 4 carps 1:200,000 at a maximum) Continue when possible if benefits > risks Coming off the blood thinner puts the patient at risk whilst sitting in your chair Be careful with Rx of meds when patients are taking Coumadin (antibiotics and antifungals) Blood thinners Local hemostatic agents? Do you need them? Legal protection? Hemostatic rinses? How do you deal with bleeding in the office? What works well in your hands? Are you going to follow MD advice? Stress 1) patient stress increases the risk for an emergency in your office 2) how can you decrease your stress during an emergency? Differentiate yourself! Physicians are not discussing stress with their patients We see the consequences of stress and are in a great position to discuss it What would it be like if you could help your patients (and yourself) better manage stress? Increase empathy How can you tell if your patient is stressed? Eyes Forehead Hands Shoulders/posture Heart rate Blood pressure 12

13 Symptoms of anxiety: The mind body effect working against us! Racing heart or skipped beats Hyperventilation Breathing difficulty Choking sensation Tingling or numbness Shaking Chest pain, pressure or discomfort Perspiration Diarrhea Nausea or vomiting Psychology versus physiology Very often the two are interconnected A problem with one causes a problem with the other (e.g. panic attacks) Is it safer to maintain baseline physiology during a dental appointment? All dental staff can have an impact on this! Music Essential oils A systemic review found that music can moderately reduce pain and anxiety Effects before, during and after surgery No side effects Benefits for the staff Hole J., et.al. Lancet Marconi breathless (YouTube) To investigate whether ambient orange fragrance, compared with no fragrance, can reduce patient anxiety before and during surgical removal of an impacted mandibular third molar. DAS (dental anxiety scale) used, only those with moderate to high levels of anxiety included BP, HR, RR taken before, during and after procedure The mean blood pressure, pulse rate, and respiratory rate were significantly lower in the fragrance group during surgery (from sitting in the dental chair to the end of surgery; P <.05). Hasheminia, Dariush et al. Journal of Oral and Maxillofacial Surgery, Volume 72, Issue 9, How can this work? Volatile molecules of the oil reach the nasal mucosa and lungs and rapidly diffuse into the blood, causing brain activation Neocortex activation occurs, which has an effect on perception of odors and reaches the limbic system Levels of hormone and emotions are then altered Salivary cortisol levels and pulse rate decrease 13

14 Safer alternatives Silexan lavender essential oil 80mg Relaxing but does not make them sleepy Burping or mild lavender aroma Smoking Increases risks for surgery and anesthesia Often related to stress How would your life be different if you stopped smoking? Deep breathing Significant impact on anxiety and pain perception Focused attention Stimulation of the parasympathetic chain Reduction of sympathetic discharge Many different forms such as Practice is important Use negative cues as a reminder Important in an emergency What is the worst way you can interact with a patient to increase their sympathetic tone and therefore increase their risk of a medical emergency in your office? Communication and word selections Patient presents for full mouth extractions Patients are terrified of pain Don t use the pain word Implant suggestion of some discomfort after the procedure that will be controlled with antiinflammatories Modify how you talk Post procedure suggestion Post hypnotic suggestion 59 year old male, farmer VS: 138/84 P: 87 PE: general exam normal Oral exam: generalized decay A/P: Generalized decay Plan to remove all teeth (25) with IV sedation and place immediate dentures 14

15 IV sedation performed: 5mg Versed (titrated to effect) 50 µg of Fentanyl (titrated) 2 carpules 0.5% Marcaine with 1:200k epi 4 carpules 2% Lidocaine with 1:100K epi Nitrous oxide and oxygen Vital signs stable during procedure After the procedure, IV was removed and the patient complains of right shoulder pain to my assistant Started MI protocol Oxygen started ASA crushed between two spoons and given orally 911 activated, re-started IV and gave fentanyl, monitors reapplied ST segment changes, PVC s on EKG (change from baseline) Quickly decompensated, decreased blood pressure (so we elevated legs and pushed IV fluids) Stress reduction protocol (including for yourself) I packed sites with gelfoam in cardiology suite whilst they removed clots His wife was thankful What did I learn? Limit epinephrine when possible (use 1:200,000 dosage when possible) Use non-epi containing local anesthesia (alone or in combination) You don t know if they have cardiac disease Should I have sent him to his MD for a pre-op evaluation? Call 911 early When something happens, sit down and figure out if you would do anything differently Call 911! Call 911 early!!! When should you call for help? You get that gut feeling You don t know what to do 15

16 Not doing something might be as important as doing something Do not do an intervention if you are unsure and especially if it is a high risk intervention! Sometimes that is the most difficult thing to do What are our obligations as doctors in an emergency? Keep the patient alive until they get better Keep the patient alive until someone comes who is better trained & takes over Basic Life Support: Always do this first! Position: Lay flat or head slightly down and elevate legs (asthma or cardiac patients may want to sit up) Airway: Head tilt, chin lift (place oxygen) Breathing: Get close and listen/feel Circulation: Check pulse You are going to be in for a very long seconds Stay as calm as you can Call for help when you don t know what to do If you are not sure, don t give a drug Give oxygen (unless hyperventilating) Emergency protocol sheet An emergency protocol sheet will help you to methodically go through an assessment and intervene as needed Use the sheet that you and your staff have been practicing with 16

17 Survey of 4,300 dentists with 30,000 emergencies, Stanley Malamed, DDS Most emergencies occur when the patient s stress level is highest Increased stress, increased epinephrine/norepinephrine 55% during the injection 25% during treatment (majority being extractions and endodontic access) If you can decrease the patient s stress then you can reduce the chances of them having an emergency at your office Be mindful of fear versus pain stress and manage both Get good at a stress reduction protocol (premed sedation, breathing exercises, music, relaxation techniques, hypnotic techniques, nitrous/iv sedation..) Good pain control is crucial Let s look at 95% of the emergencies that you will see Syncope vasovagal reaction: passed out Reposition them and they recover quickly Usually big tough guys that are trying to hide their fear Try to avoid this with a stress reduction protocol Act quickly when you see the early signs Do you call 911? Should they drive home? Place patient in reclining position and elevate the legs Maintain the airway Oxygen and support respirations if needed Take vital signs Cold compress to forehead and back of neck Consider spirits of ammonia 17

18 Remember Often the hardest thing is to do no specific intervention Postural hypotension Get dizzy when they stand up too quickly Sit them up before you leave the operatory Position the patient with head down and legs up if necessary Talk in a calm reassuring voice (hypnotic) Allergic reactions: Mild Identify the cause if time permits Remove or dilute if possible Consider diphenhydramine adult dose 25-50mg PO or 10-50mg IV not to exceed 25mg/minute or 100mg deep intramuscular injection Auscultate their lung fields (to listen for wheezing and air exchange) Allergic reactions: Severe Skin rash Watery eyes and nose Abdominal cramps Wheezing Tachycardia Hypotension This is a patient will have the look of acute distress Risk of impending cardiovascular collapse Allergic reactions: Severe Stop the antigen Call 911 Follow the ABC s Maintain airway and provide oxygen Support respiration and breathing IV fluids for volume loading Consider epinephrine Allergic reactions: Severe IM injector Adult: 0.3mg epi Pedo: 0.15mg epi This may need to be repeated at minute intervals Should EMS be there already? 18

19 Allergic reactions: Severe IM Adults: titrate 0.2 mg to 0.5 mg to effect and repeat every 2-5 minutes as needed Children: 0.01 mg/kg Albuterol inhaler 4-5 puffs for an adult 2-4 puffs for a child auscultation Consider diphenhydramine, H2 blocker, steroids The patient may need a more advanced airway Pharyngeal edema and upper airway obstruction can occur even after epinephrine The patient may need a vasopressor if fluid volume and epinephrine are not adequate to sustain blood pressure Seizures may develop (diazepam or versed for treatment if able) Should the patient be hospitalized and observed for 24 hours? Anaphylactic reactions can recur as counteracting drugs wear off You are not going to like this one Patient history is essential Keep them safe - BLS It should stop soon, if not activate EMS IV/IM/nasal benzodiazepines Prevent it from happening Good medical control and stress reduction Seizures Angina If a patient has a history of angina then they will diagnose it for you No history of angina, activate 911 immediately Oxygen Nitroglycerin if SBP not too low (<90mg HG) or pulse <50 Chew aspirin (non-coated) Set up AED and use if chest pain continues Angina: Let s prevent it Limiting epinephrine (put away your 1:100,000 epinephrine) Stress reduction Medical evaluation Should you modify your treatment plan? 19

20 Hyperventilation Asthma Try to calm them down Psychology is causing a physiological problem Use a paper bag for rebreathing (recapture inhaled carbon dioxide) Have them hold the bag Do not use oxygen unless they lose consciousness The patient will likely diagnose this for you Auscultation Albuterol inhaler, oxygen They might even tell you when to activate EMS Prevent it will prophylactic inhaler use and stress reduction Hypoglycemia Check blood sugar (get a glucometer) Give oral sugar gel if appropriate IV access if able (dextrose/glucagon) Prevent with appropriate medical management of diabetes, shorter morning appointments Epinephrine reaction to injection Heart racing with injection Slow and easy The more white knuckled the patient, inject a very small amount first Consider 1:200,000 epi or none at all Stress reduction Get good at your injection technique! Local anesthetic overdose Dizziness Tachycardia Anxiety and agitation with confusion Seizures Respiratory depression Stop before you have to get out the calculator to figure out how much more local anesthesia you can give Treatment includes activating EMS, airway and BLS Seizures managed with valium or versed Fat emulsion may be used at the hospital 20

21 The other 5%: MI/cardiac arrest: MONA: oxygen, nitro spray, ASA..probably not going to give morphine ACLS protocol if trained Don t give a drug if you are unsure Prevent with medical consultation? Stress reduction Continue all meds when possible The other 5% True anaphylaxis Activate EMS immediately IM epi ( mg) q5 minutes as needed Oxygen Inhaler, steroids Start IV Establish a culture of safety Make sure all team members are aware of their role in an emergency Make sure everyone feels comfortable stopping the doctor if they have a concern Listen to your staff Evaluate and discuss near miss or problems that happen How can we prevent/manage an emergency in our office? Recognize this can happen to you in your office Be mindful of case selection Learn stress management techniques Be cautious with respect to certain health parameters: Cardiac disease and history of stroke Smoking, hypertension and diabetes Get to know and follow dental board rules Have an emergency plan that you and your team use for drills Call EMS early What are the take aways? Have a written emergency plan Practice your plan with your staff Practice the doctor down drill Don t be afraid to say no or stop what you are doing 21

22 Time for a break So what do you need in your emergency kit? This will be different for each of us! Oxygen with regular/bag valve mask and oral airway device Stethoscope, BP monitor 325mg Aspirin (non-enteric coated) Nitro spray Albuterol Glucose source and glucometer AED Know how to use your equipment Do no harm When you do your BLS take the opportunity to get familiar with the your equipment Use your bag valve mask and oral airway Ask instructor for pointers Are you ventilating too quickly? Write a reminder on your bag! Are you doing the chin tilt/lift? BRP data for Texas Six major sedation events (death/permanent disability) Child under 8 or adults with high risk factors A deeper level of sedation than intended occurred in many cases Poor pre-op evaluation, drug over dosage, poor monitoring and poor emergency management Anesthesia mishaps in the State of Texas mishaps with 8 involving children under 8 or high risk adults (obese, compromised health or elderly) Poor pre-operative evaluation Drug overdose Premature discharge Bolus drug administration Not using required monitors Poor problem recognition Poor emergency management Emergency Failures from BRP Report Emergency drugs given at the wrong dose Ventilation equipment was available but used ineffectively Ventilation equipment was not available Supplemental oxygen was available but not administered when indicated The provider was slow the activate EMS!!! (most common finding) 22

23 What can you do? Have an emergency plan and use it for emergency drills with your staff Activate 911 early Practice using ventilation equipment Careful sedation usage Limit medications Avoid local anesthesia over dosage Do you record weight? Be careful with 4% solutions Is it really a failure of local anesthesia? Limit epinephrine when appropriate to 0.04 mg (4 carps of 1:200k versus 2 carps 1:100k) What is the maximum dose we can use? What is the minimum dose we can use? Failure Risk management It is okay to have your sedation technique fail It is okay to say NO to a procedure or abort a procedure We do not need to do everything It is likely not the best thing for you or the patient Should the patient be managed in a different environment? 23

24 Reporting cases to the dental board Board process Investigators will gather information from your records, EMS and the hospital based on your selfreport In a case such as this the information will likely be reviewed by the Dental Review Panel (DRP) The first DRP dentist will make a report to opine if standard of care was followed (SOC) as it relates to your patient management, treatment, records and other factors as it relates to the dental board rules A second DRP dentist will then look at the case and the first report If they can not agree on SOC issues then it goes to a third DRP member to break the tie What would a reasonable and prudent dentist do in a similar circumstance? Did you defer care to get them to MD? Did you flood them with 1:100,000 epi? Were rules followed? Did you take blood pressure or was EMS the first person to take BP? How quickly did you activate EMS? If there is no SOC violation then the case is dismissed If there is an SOC violation then the respondent (dentist/hygienist/dental assistant) may need to go to Austin for an informal settlement conference (ISC) This is their chance to discuss the case details with a board member The board member will then offer to dismiss the case or recommend a remedy (warning, fine, CE, suspension) 24

25 Dental board rule: (1) Patients name; (2) Date of visit; (3) Reason for visit; (4) Vital signs, including but not limited to blood pressure and heart rate when applicable in accordance with of this title. (5) If not recorded, an explanation why vital signs were not obtained. (c) Further, records must include documentation of the following when services are rendered: (1) Written review of medical history and limited physical evaluation; (2) Findings and charting of clinical and radiographic oral examination: (A) Documentation of radiographs taken and findings deduced from them, including radiograph films or digital reproductions. (B) Use of radiographs, at a minimum, should be in accordance with ADA guidelines. (C) Documentation of the findings of a tactile and visual examination of the soft and hard tissues of the oral cavity; (3) Diagnosis(es); (4) Treatment plan, recommendation, and options; (5) Treatment provided; (6) Medication and dosages given to patient; (7) Complications; (8) Written informed consent that meets the provisions of 108.7(7) of this title; 25

26 Rule (c) On or after September 1, 2019, a permit holder may not administer sedation/anesthesia under a level 2, level 3, or level 4 permit to a high-risk patient unless the permit holder has completed the requirements of paragraph (1) or (2) of this subsection. Permit holders must have: (1) completed a university or hospital-based residency at least 12 months in length. All permit holders completing a university or hospital-based residency after September 1, 2019, must confirm that during the residency, the permit holder completed satisfactory management of sedation/anesthesia in at least ten (10) cases involving high-risk patients sedated/anesthetized at the highest level of permit held. At least five (5) of the cases must involve the hands-on administration of sedation/anesthesia as the primary provider. No more than five (5) cases may be observed. The ten (10) cases must involve either live patients and/or high-fidelity emergency sedation/anesthesia simulations; or (2) completed a board-approved education program that includes a minimum of sixteen (16) hours of didactic training and instruction in sedation/anesthesia of high-risk patients. The entire board-approved education program, including all didactic and clinical requirements, must be completed within a two-year period of beginning the Board-approved program. Successful completion of the program must include passing an evaluation to demonstrate satisfactory completion of the course requirements. Rule (b) On or after September 1, 2019, a permit holder may not administer sedation/anesthesia under a level 2, level 3, or level 4 permit to a pediatric patient unless the permit holder has completed the requirements of paragraphs (1) or (2) of this subsection. Permit holders must have: (1) completed a university or hospital-based residency at least 12 months in length. All permit holders completing a university or hospital-based residency after September 1, 2019, must confirm that during the residency, the permit holder completed satisfactory management of sedation/anesthesia involving pediatric patients sedated/anesthetized at the highest level of permit held. The cases must include: (i) at least three (3) live cases in which the permit holder is the primary sedation/anesthesia provider, or (ii) at least fifteen (15) cases involving pediatric patients sedated/anesthetized where no more than seven (7) cases are observed on live patients, and at least eight (8) cases are performed as part of a hands-on high-fidelity sedation simulation center or program; or (2) completed a board-approved education program that includes a minimum of sixteen (16) hours of didactic training and instruction in sedation/anesthesia of pediatric patients. The entire board-approved education program, including all didactic and clinical requirements, must be completed within a two-year period of beginning the Board-approved program. Successful completion of the program must include passing an evaluation to demonstrate satisfactory completion of the course requirements. Rule (c) Regardless of issue date, all level 2, 3 and 4 permit holders will be subject to at least one inspection prior to September 1,

27 Rules For good or bad there are rules in place Following and being mindful of the rules can help protect you and your patient Equipment you need to have available for emergencies Monitors for different levels of sedation Mandated emergency drills Continuing education for sedation for pediatrics or high risk patients 27

28 What are the big take aways? 1. Have an emergency plan and use it to do drills with your staff 2. Customize it to your practice 3. Practice the doctor down drill 4. Get familiar with the board rules Thank you! Full presentation PDF and downloadable word documents for emergency plans are available at: Dfwdentalimplants.com Go to referral doctors section and click on patient safety 28