By Dr Andrea Smith
I was working as a young graduate dentist some years ago. I had three years of experience since graduating, and like many dentists starting their careers I worked at two different practices. I had recently started doing three days per week at a practice unsupervised and I felt confident in my clinical experience to do this, comforted by the knowledge that I could refer if required.
On my first day I noticed there were two EpiPens on the bench near the laboratory, and I had seen an oxygen bottle in the store room. I felt good that the practice had these emergency items, but did not ask to see a full first aid kit. At the other practice I worked in, I knew there was a full emergency medical kit, with emergency drugs, bag / valve / mask, and even an automatic defibrillator. I assumed that all practices would have this equipment, and that the staff would know where it was located.
My patient, Mr X arrived for his fourth appointment with me. He was a middle aged male with no known allergies, high cholesterol treated by Lipitor and mild hypertension, 140/90 untreated.
On his previous appointments we had completed restorative treatment. This had included composite resin restorations and a crown. We had used Lignocaine with adrenaline 1:80k local anaesthetic for each appointment with no complications. This appointment was for extraction of a broken down and unrestorable 47. Mr X consented to treatment, and was aware that this procedure had the possibility of requiring a surgical approach and was warned about the unlikely chance of damage to IAN or lingual nerves.
I gave him an IAN block injection, and also a buccal and lingual infiltration of Lignocaine. In total 2 x 2.2ml cartridges. After some minutes Mr X assured me that his lower lip and right side tongue was completely numb, however application of an elevator on this tooth caused pain. I elected to use a different local anaesthetic, and injected an infiltration of 2.2cc Articaine with 1:100k adrenaline in the buccal and lingual mucosa. Immediately that I recapped my needle I noticed that Mr X’s face had become very red. Red like a tomato! This was the reddest face I have ever seen.
Mr X became agitated immediately and ran across the room. He was shouting “SO HOT, IM FEELING SO HOT”, and then he turned on the tap and placed his head under the running water of my hand washing basin.
I approached Mr X and tried to get him to sit down, which he did. Then I noticed that his lips were becoming extremely swollen, and within seconds of the injection he was already making a rasping noise with every breath. I realized that Mr X was having a severe allergic reaction. I asked my dental assistant to go and get the oxygen bottle from the store room. I yelled out to the receptionist to get me the EpiPens that I had seen on the bench, and asked a second dental assistant to call an ambulance. I thought things were under control.
The oxygen bottle arrived, but there was no mask and the screw handle was missing so it could not be turned on. No one could find the EpiPens; they had not been seen in a few weeks. I began to panic. The staff member on the phone to the ambulance advised us they would be 15 to 20 minutes, and asked if I thought this would be okay. “No”, I shouted, “that is not okay”.
I looked at my patient and by this time he was no longer red in the face, instead he appeared pale and grey in colour, and was sweating. His breathing was laboured.
I now had a feeling of panic. I had no EpiPen and no oxygen. I sent my first dental assistant running up the road to a nearby medical practice to ask for oxygen and a doctor to help. I screamed out to the person on the phone that this was an emergency, and the patient was having an allergic reaction, his face was swollen. I was worried that he would stop breathing soon. They could not give me a time estimate.
All the while I was trying to reassure Mr X. I had a scalpel ready for the extraction, and was hoping I would not have to try to do anything else with it.
Just as I thought my patient was going to take his last breath, the paramedics came in the door, injected him with some adrenaline and took him away. I collapsed into a heap, cancelled the rest of the patients for that day and went home.
As my patient was being wheeled out, he yelled (his breathing now improved) “DON’T TELL MY WIFE. SHE IS SICK AND I DON’T WANT HER TO WORRY”.
So I didn’t tell her. I later called the emergency department, they reported that they could not be sure what initiated the allergic reaction but he should not have any further dental treatment until the cause could be identified. He was given a referral to an allergy specialist but it would take months to get an appointment.
Later that afternoon I got a phone call from our receptionist. Mrs X had called and asked where her husband was, she was very concerned that she had not heard from him and he was meant to return home hours before. I called Mrs X, not knowing what to do. I ended up telling her that that Mr X had had a reaction during treatment and had been taken to hospital. She was noted on his medical history as the emergency contact.
Two days later Mr X phoned demanding an appointment to have his tooth extracted. He was angry that I had caused him to have this reaction. Also he was very angry that I had told his wife that he was in hospital. I told him that I did not want his wife to worry, so that is why I told her, but I was not sure that I had done the wrong thing. I also told him that he should have no further dental treatment until the cause of the reaction was identified.
Mr X yelled at me down the phone, and said that he would take his business elsewhere. He planned to see another dentist, and told me that he wouldn’t tell them what had happened to him so that he could get the extraction over and done with. This made me very concerned, I told Mr X this could be very dangerous, but he hung up the phone.
I don’t know if Mr X ever got his tooth extracted, and I don’t know if the cause of his reaction was ever identified. I suspect it was the Articaine.
What did I learn?
- Expect that the worst could happen at any time.
- Know where the emergency medical equipment is. (It turns out the EpiPens I saw in the practice were for another dentist’s child, and they had been taken home. The oxygen bottle screw was found in the back of a cupboard later, as was the tubing and face mask.)
- Know how to use the emergency equipment.
- Have staff trained in what to do in an emergency.
- Don’t be coerced by patients into doing treatment that you don’t feel comfortable with.
Luckily Mr X survived. I didn’t do anything wrong, but could have been more prepared for this to happen, and believe me I now know where everything is in my surgery at all times! The dental assistant and the doctor with oxygen arrived 5 minutes later after the patient had been taken away by the ambulance. I doubt the patient would have survived until then.
The dentolegal adviser's perspective
Dr Mike Rutherford
I can assure you that this story is even more frightening when Andrea tells it with accompanying quavering voice and hand gestures. I thank her for her candour and her wish to relate this story to a wider audience. Andrea has neatly summarised her lessons learnt that we could all benefit from rather than waiting for a personal experience. Statistics tell us that while most dental practitioners will not have to deal with an anaphylaxis incident, we are all likely to have to face a medical emergency of some kind in our surgery at some stage of our career; and our patient’s future well-being may be dependent on our training and preparedness.
Andrea also poses the issues of whether to comply with a patient’s requests when they are in a distressed (and in this case a medicated) state, as well as issues of a patient’s privacy rights under these same conditions. If sufficient time is available one of Dental Protection’s dentolegal advisers can offer advice over the phone. If, however, time is of the essence and a decision has to be made, a post-incident phone call to Dental Protection is important. Decisions made can be reviewed objectively and advice given if required, on how to best follow up on such an incident.
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