|Year : 2021 | Volume
| Issue : 3 | Page : 336-342
|Awareness and preparedness of dentists at handling medical emergencies in Delhi-National Capital Region – A cross-sectional survey
Pooja Dudeja1, Manisha Lakhanpal Sharma2, Dhirendra Srivastava3, Krishan Kumar Dudeja4, Vinita Dahiya5, Deepak Passi6
1 Department of Conservative Dentistry and Endodontics, ESIC Dental College and Hospital, Rohini, New Delhi, India
2 Department of Oral Medicine, Diagnosis and Radiology, I.T.S Dental College and Hospital, Greater Noida, Uttar Pradesh, India
3 Department of Oral and Maxillofacial Surgery, ESIC Dental College and Hospital, Rohini, New Delhi, India
4 Department of Prosthodontics, Dental Wellness Centre, Noida, Uttar Pradesh, India
5 Department of Periodontics, I.T.S. – C.D.S.R. Dental College and Hospital, Ghaziabad, Uttar Pradesh, India
6 Department of Dentistry, Sub-divisional Hospital, Ranchi, Jharkhand, India
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|Date of Submission||20-Apr-2019|
|Date of Decision||21-Aug-2019|
|Date of Acceptance||15-Jun-2021|
|Date of Web Publication||23-Feb-2022|
| Abstract|| |
Context: A medical emergency (ME) may come as a surprise during our busy appointment schedules. Whether or not the office has prepared for this emergency generally decides how it will turn out. Aim: This cross-sectional survey aimed to evaluate the awareness and preparedness of dentists at handling MEs in a dental office. Settings and Design: The study was conducted over three months (December 2015 – February 2016) at two dental colleges of Delhi-National Capital Region (NCR). Materials and Methods: The total number of participants was 384, which were divided into four groups of ninety-six participants each, i.e., Group 1 (Interns); Group 2 (Academicians); Group 3 (Postgraduate students (PG)) and Group 4 (Private practitioners (PP)). Statistical Analysis: The collected data was analysed on the Statistical Package for Social Sciences (SPSS) version 20 and subjected to ANOVA and Posthoc Bonferroni tests. Results: Academicians were found to have the maximum awareness about MEs occurring in the dental office, while, interns had the minimum preparedness for the same and their difference with the other groups was statistically significant (P < 0.05). Conclusion: A huge gap exists between the awareness and preparedness of dentists at managing MEs. Sound knowledge of essential drugs reinforced by regular practical training, mock drills and properly equipped dental offices is the need of the hour.
Keywords: Awareness, dental office, dentists, medical emergency, preparedness
|How to cite this article:|
Dudeja P, Sharma ML, Srivastava D, Dudeja KK, Dahiya V, Passi D. Awareness and preparedness of dentists at handling medical emergencies in Delhi-National Capital Region – A cross-sectional survey. Indian J Dent Res 2021;32:336-42
|How to cite this URL:|
Dudeja P, Sharma ML, Srivastava D, Dudeja KK, Dahiya V, Passi D. Awareness and preparedness of dentists at handling medical emergencies in Delhi-National Capital Region – A cross-sectional survey. Indian J Dent Res [serial online] 2021 [cited 2022 May 26];32:336-42. Available from: https://www.ijdr.in/text.asp?2021/32/3/336/338124
| Introduction|| |
Medical emergencies (MEs) are like intruders in our professional lives who can play havoc with our reputation. The statistics state that MEs are 5.8 times more likely to occur in dental offices than in medical offices. This is not surprising because dentists not only administer drugs but also perform invasive procedures in a large number of medically compromised patients under the stressful dental environment.
According to the joint findings of two surveys from United States; 96.6% of dentists (n = 4309) reported to have faced a ME in the past ten years. Approximately, half of these emergencies were syncope and one-fourth came under potentially fatal respiratory, cardiovascular and cerebrovascular emergencies.
The knowledge about the timing of occurrence of these emergencies and the type of dental care being administered then is also critical. Matsuura evaluated the systemic complications at dental offices in Japan and found that the maximum (55%) emergencies occurred at the time of administration or just after administration of the local anaesthetic. A study done in Great Britain suggested that 52.2% of the mishaps arose during conservative dental treatment and 23.5% occurred during dentoalveolar surgery. Surprisingly, only 1.1% MEs developed during orthodontic treatment. These statistics suggest that fear, pain, anxiety, or discomfort may predispose some patients to an emergency.
The importance of being prepared to manage these emergencies cannot be overemphasized. Modern dental offices/hospitals must be adequately equipped to impart prompt treatment, should such a disaster occur. With the average age of the population increasing, the need to be prepared is further spiralling.
Our survey aimed to assess the awareness and preparedness of dental professionals at managing MEs in dental offices/hospitals in Delhi-National Capital Region (NCR), India. A few studies have assessed the preparedness of dentists at managing MEs in their dental offices but they have focussed either on private practitioners (PP) or on dental graduates in a single dental school only.,,, Our study tries to cover the existing gap by including subjects from four different groups, i.e., interns, academicians, postgraduate students (PG) and PP in Delhi – NCR. This was done to understand the differences in their ability to deal with MEs so that corrective measures can be taken at an appropriate level.
| Methods|| |
The present cross-sectional study was conducted over three months (December 2015-February 2016) at two dental colleges of Delhi-NCR, India. The study being a questionnaire-based survey received the approval of the Institutional Ethical Committee (IEC) under the exempted review category. The inclusion criterion was that the participants were practising the dental job and confirmed so. The subjects unwilling to participate were excluded from the study. A self-structured survey questionnaire was used keeping most of the questions closed-ended. A pilot study was conducted among forty participants which included ten representatives from each group and the questionnaire was re-corrected and validated so. According to the pilot study, the prevalence rate for awareness and preparedness was found to be 50%. Keeping the population size as infinite, we applied the formula for sample size N = z2pq/d2, where z = 1.96 at 95% confidence level, p (prevalence) = 50% (determined from pilot study), q = 1-p (1-0.5 = 0.5), d (precision rate/least permissible error) = 5% (0.05). The final sample size came out to be 384. The respondents (n = 384) were further divided into four groups of ninety-six participants each, i.e., Group 1 (interns), Group 2 (academicians), Group 3 (PG) and Group 4 (PP). The participants were selected according to the convenient sampling technique. Written informed consent was obtained from all the participants after apprising them of the objectives of the study.
The demographic details of the respondents such as their degrees (MDS/BDS) and current job profile were recorded and kept confidential. First sixteen questions of the questionnaire assessed the awareness; the last four questions evaluated the preparedness of the participants about MEs [Table 1].
|Table 1: Response of the participants reflecting their awareness and preparedness in recognizing and handling medical emergencies in their dental offices/hospitals (in percentage)|
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There were two investigators in the study. The participants were given half an hour to complete the questionnaire in front of the investigators. The data collected was tabulated and analysed on SPSS version 20. Mean values of all the groups were calculated, compared and expressed as awareness score and training score. Descriptive statistics was applied and P-value was calculated. P-value <0.05 was considered statistically significant.
| Results|| |
There was 100% participation in the study (n = 384). The age of the participants ranged from twenty-one years to sixty years. The responses obtained from the participants were expressed in percentage [Table 1].
100% of participants claimed that they were aware of MEs. However, 70% - 75% of participants had actually faced a ME at their dental offices. The emergencies most commonly faced by all the four groups were syncope (50% - 52.5%), asthma (5% - 7.5%), angina (2.5% - 5%), and mild allergic reaction (2.5% - 10%). Around 65% PP, 82% interns and academicians each and 90% PG had emergency kits at their dental offices. However, less ratio (20% - 47.5%) of participants had correct knowledge of the essential medications required in an emergency kit [Figure 1].
|Figure 1: Comparison of percentage of respondents in each group having knowledge of basic medications required in an emergency kit; percentage of participants obtaining informed consent from the patients; recording their vital signs and knowing correct emergency helpline number in India|
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A total of 95% interns, 90% academicians and PP each and 100% PG recorded medical history before starting with the treatment procedures. Almost 87.5% interns, 82.5% academicians, 62.5% PG and 95% PP obtained informed consent from the patients before undertaking the treatment [Figure 1]. Majority of the participants (85% - 97.5%) recorded vitals before undertaking any minor surgical procedure [Figure 1]. 80% interns, 37.5% academicians and 45% PG and PP each were unaware that the emergency helpline number in India is 112 [Figure 1].
Very less percentage of interns (37.5%) were aware that an unconscious hypotensive patient is placed in a supine leg raised position, an unconscious pregnant female is laid down in the left lateral position, and an unconscious heart disease patient is seated in a half-sitting position with head support [Figure 2]. Only 12.5% interns, 25% academicians, and 27.5% PG and PP each understood that anxiety hyperventilation is best treated by coaching the patient to breathe slowly [Figure 2].Similarly, 17.5% interns, 47.5% academicians, 20% PG, and 15% PP were aware of the correct dose of adrenaline (0.1 mg IV or 0.3-0.5 mg IM) used to treat anaphylaxis on a dental chair [Figure 2]. Nearly 60% of all participants could identify an episode of asthma and knew the correct treatment.
|Figure 2: Comparison of knowledge of prompt action among all four groups when faced with a medical emergency like knowing the correct position in which a hypotensive, pregnant and a heart disease patient should be made to lie down on fainting; correct treatment of anxiety hyperventilation; concentration of adrenaline used to treat anaphylaxis on a dental chair and the best site to give an intramuscular (IM) injection|
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Barely 12.5% interns, 32.5% academicians, 30% PG, and 42.5% PP were aware that the quadriceps (thigh muscles) is the best site to give an intramuscular injection. However, the majority (60% - 90%) could answer the full form of CAB in CPR. Most of them also knew that the carotid artery is the best site to check the pulse of a patient in an emergency [Figure 3].
|Figure 3: The graph depicts the percentage of respondents having knowledge of the full form of CAB; ratio of participants knowing the best site to check pulse of a patient in an emergency situation; percentage of respondents agreeing that management of medical emergency was a part of their curriculum during BDS/MDS and percentage of respondents who had attended seminar on medico-legal implications of medical emergencies during their careers|
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Though 10% interns, 55% academicians, 37.5% PG, and 25% PP stated that management of ME was a part of their BDS/MDS curriculum; [Figure 3] less than half of them claimed to have received training for recognition of an emergency. Only about one-third of interns, academicians, and PP had undergone training for giving IV and IM injections. PG; however, fared slightly better at giving IV (42.5%) and IM (45%) injections. Very few interns (17.5%, 2.5%) and PP (7.5%, 15%) claimed to be trained in using emergency drugs and performing CPR respectively, whereas, academicians (55%, 32.5%) and PG (47.5%, 47.5%) performed better.
On self-evaluating, 0% interns admitted to being ready to deliver supplemental oxygen and relieve airway obstruction. Likewise, the maximum ratio of PP among all groups claimed to be confident to administer IV injections (45%) and IM injections (50%). Comparatively, less percentage of interns (32.5%) and PP (35%) attended seminars on medico-legal implications of ME than academicians (50%) and PG (55%) [Figure 3].
Mean values of all the groups were calculated and expressed as awareness scores [Figure 4] and preparedness scores [Figure 4]. ANOVA and Posthoc Bonferroni tests were applied and P value was calculated. Academicians had the maximum awareness about MEs, and the difference with other groups was statistically significant (P < 0.05) [Table 2]. Interns were the least prepared at handling these precarious situations, and this difference with other groups was statistically significant (P < 0.05) [Table 2].
|Figure 4: Calculation of Awareness and Preparedness score of the four groups of participants|
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|Table 2: Levels of Significance for Awareness and Preparedness Scores among different Groups (ANOVA with Posthoc Bonferroni)|
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| Discussion|| |
A questionnaire study conducted in Saudi Arabia (n = 145 dentists) showed that about 67% of the respondents had encountered episodes of MEs in their practices. In our study, more than 70% of participants had faced them at some time during their practice. The high ratio of interns (70%) facing them may be due to their exposure in the departments during their clinical posting. Also, several interns could be reporting the same event occurring in dental school. The most commonly faced ME by all our participants was syncope, followed by asthma and mild allergic reaction. A questionnaire survey evaluating the knowledge of interns (n = 105) of Belgaum city, India about MEs also showed that syncope (40.9%) was the most commonly experienced ME followed by hypoglycaemic attacks (37.1%) and allergic reactions (17.1%).
According to the Council on Dental Therapeutics of the American Dental Association report issued in 2002, all dental offices must have at least the essential recommended emergency equipment and drugs. In our study, the least ratio of PP (65%) had these kits in their offices, which may reflect their casual attitude and inadequate knowledge to prepare a proper emergency kit. Other studies have shown mixed results regarding this. A study evaluating the preparedness of 301 dental practitioners in Khammam town, Telangana, India showed that around 82% - 83% of participants maintained emergency drug kits in their dental offices. However, a cross-sectional study of 250 dental graduates done in the dental offices of Ahmedabad and Udaipur, India showed that emergency kits were available with only 24% of participants.
Very less ratio (<28%) of respondents in all groups except academicians (47.5%) knew the essential medications required in an emergency kit [Figure 1]. A Brazilian study found the knowledge of undergraduate students (n = 253) about the use of drugs in dental practice to be highly deficient. The higher ratio of academicians being aware of these essential medications may be attributed to their active involvement in teaching.
The best handled medical emergency will always be the one that never happened. A key measure in prevention is recording the medical history and vital signs of every patient. In our study, more than 90% of participants obtained the medical history of the patients. These findings are similar to other questionnaire studies, where 94.02% of the respondents enquired about the same. A high ratio of PG (97.5%) and academicians (85%) recorded vital signs of the patients [Figure 1]. A study evaluating the preparedness of 100 dentists (BDS = 74, MDS = 26) for MEs showed that 94.5% BDS enquired about vital signs whereas, only 9.4% determined them. Similarly, 80.7% MDS enquired about vital signs, while 69.2% measured them.
Both in our study, [Figure 1] and in a study of 282 dental practitioners of Dakshina Kannada, India, almost half of the respondents were unaware of the emergency contact number in case of a ME. The dental care providers must be aware of this, because, even though they may provide the first line of treatment, the patient must be moved to a higher centre for specialized care. Important phone numbers, e.g., of the ambulance, nearby physician trained in emergency medicine and the nearby hospital must be displayed at prominent locations.
When compared to academicians, a low ratio of interns was aware of providing suitable treatment to patients in special conditions like hypotension, pregnancy, cardiac disease (37.5%), hyperventilation (12.5%), and anaphylaxis (17.5%) [Figure 2]. A study of 335 interns of Chennai city, India also showed that about 51% interns knew the correct position in which an unconscious patient should be rested. The study also reflected that only 29% interns were aware that epinephrine should be given IM and approximately 40% knew its correct dose in case of anaphylaxis.
It is pertinent not only to know about the signs and symptoms of ME, but also about their management. A low ratio of interns (12.5%) knowing the best site to give an IM injection (quadriceps) suggests inadequate training at the undergraduate level. Less than half of the other groups could answer this question correctly, reflecting their poor knowledge about management of ME [Figure 2].
Every dentist should have current Basic Life Support (BLS) certification, including the use of an automated external defibrillator offered by the American Heart Association (AHA). The certification must be renewed every two years. The 2010 AHA guidelines for CPR and Emergency Cardiovascular Care recommend a change in earlier A-B-C (Airway, Breathing, and Chest Compression) to C-A-B (Chest Compression, Airway, and Breathing). Only 60% PP knew the full form of CAB, which was even less than that of the interns (62.5%) [Figure 3]. This reflects their lack of up-gradation of knowledge about CPR/BLS. A cross-sectional study on 104 BDS students, tutors/resident doctors, private dental practitioners, and dental faculty in New Delhi showed that less than half of the respondents (42.3%) knew the correct sequence of CPR in adults as CAB.
A good percentage of respondents (62.5% - 87.5%) knew the best site to check the pulse of the patient in an emergency [Figure 3]. These findings are; however, in contrast, to a cross-sectional study of 104 dental care providers in New Delhi in which only 18.27% of respondents knew the correct site.
Only 10% interns accepted that management of MEs was a part of their curriculum (BDS) [Figure 3]. Though 47.5% interns were trained to recognize an emergency, very few interns were trained in establishing IV access, IM access, drug use and CPR. This reflects the suboptimal standard of practical training at the undergraduate level in our country. Though PP fared below par in all these categories; academicians and PG managed to do better. These findings are similar to a study of 124 Brazilian dental students, which suggested that the knowledge and training of the dental school students on ME was below desirable standard.
Since life-threatening emergencies occur only infrequently, members of the dental office quickly become rusty and often become nervous when faced with an actual crisis.
In our study, less ratio of respondents felt themselves to be trained and ready to go. This was especially evident in giving mouth to mouth breathing, chest compressions, administering supplemental oxygen and relieving airway obstruction. In a survey of Australian dentists, 96% dentists accepted that they should be competent in CPR; however, only 55% admitted that they were skilled in CPR. Mixed results were revealed regarding the preparation and confidence of respondents for administering IM and IV injections. Except for interns, other respondents were more confident in administering them. A study of 282 dental practitioners in Dakshina Kannada, India showed that PG/MDS practitioners were more confident than BDS graduates in administering CPR, IV drugs and performing Heimlich manoeuvre.
The higher level of awareness of academicians is due to their constant touch with academics to keep themselves updated [Figure 4]. The lower level of preparedness of interns may be attributed to the curriculum pattern followed in our country, where theoretical knowledge of drugs and equipment is provided; but practical training is a big question mark [Figure 4].
Limitations of the study
Convenient sampling method was used for selecting the sample due to which actual representation of the whole population might not be there. This could limit the generalization of the actual results of the study. The participants of the study were restricted only to Delhi-NCR and may not represent the true level of knowledge and awareness of dentists at the national level.
| Conclusion|| |
The results of our study suggest that a gap exists in the knowledge and preparedness of the dentists at handling medical emergencies. Academicians had the maximum knowledge about medical emergencies while interns were the least trained to manage them. It is, therefore, necessary to make the practical training and examination a mandatory part of both undergraduate and postgraduate teaching curriculum.
Educational programs such as conferences, refresher first aid courses, simulated basic and advanced life support programs and regular mock emergency drills can go a long way in increasing awareness and preparedness levels of the dentists in preventing and managing medical emergencies.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Dr Mohit Dadu, Reader, Department of Public Health Dentistry, IDST Dental College, Modinagar, Uttar Pradesh for his excellent statistical support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Pooja Dudeja
Professor, Department of Conservative Dentistry, ESIC Dental College and Hospital, Sector 15, Rohini, New Delhi-89
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]
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