Wednesday, December 11, 2013

First True Emergency

Statistically speaking, the odds of a life threatening event occurring in a dental office is very rare.  The last time I read an article on the subject, I believe the average TRUE emergencies experienced in a general dentists career was something like 0.8.  This means not everyone will see even ONE over a 30-40 year time span.  Well I’ll be damned, but I’m only out 1.5 years and have had the privilege of a real “OH SHIT” moment just this past Friday.

I’ve had some time to process the emotions involved and feel pretty good about posting this on ye olde blog.  If nothing else, so I can remember the event with clarity although I think I will probably remember this forever.

A true emergency is NOT vasovagal syncope (fainting).  A true emergency is when there is a real threat to life that needs to be managed until the Calvary arrives or the problem remedied in-house.

Here is the situation.  I have just consulted a patient who needs a referral and am walking through the office to write one up.  As I’m meandering through, I notice an assistant essentially sprinting towards the front with a look of purpose and abject terror.  I b-line the direction she had come from and find a mother clutching her 7-week old baby in her lap.  The mom is entering the early stages of hysteria and I immediately can see why – the baby is blue.  Like Violet from Willy Wonka and the chocolate factory blue.

This is that moment in life which really determines who you are in a crisis.  I have always been confident in a controlled setting, but have secretly feared that if someone truly needed help in an emergency, that I would shy away and spectate. 

I don’t know exactly what went through my head, but I do remember acting and sequencing.  I entered the room and scooped the baby away from mom, sat down and had the baby supine in my lap, head close to my core for assessment and immediate airway management.  Why do we turn blue?  When we are not getting enough O2 – simple as that.  How do we not get enough O2?  Air is either not being processed by the lungs or it is obstructed from getting to the lungs.

The baby is conscious and moving arms about.  Chest is rising sporadically.  He is making clear choking and snorting sounds.  Baby is conscious, I skip checking for pulse.  I immediately head-tilt and chin lift and ask mom – “Has he had anything to eat or access to any object he might try to eat.”  NO.  Child is 7 weeks old, all soft diet, was strapped to mom all morning, no access to foreign body.  So while he appears to be choking on something, it isn’t a toy car or food particulate.

Observation: It is bone-chillingly cold outside and baby has tons of snot visible in his nostrils.

9-1-1 has already been called by the assistant, I ask for O2, and it is brought about with a passive air mask.  Head-tilt chin lift has not resolved blue coloration and breathing difficulties.  Passive O2 is also not helping.  I ask for a hand-mirror and proceed to jam it down the little guy’s throat.  Depressing the base of his tongue and pulling it down and forward.  Voila, baby lets out loud cough starts crying and turns pink in about 10 seconds.  Paramedics arrive and I hand the infant off to the pros.

My current cause is that the infant was choking on his own secretions.   A 7 week old infant is such a smushy and compressed human, that the airway can EASILY be compromised.  Whether or not my dx is correct is yet to be determined.  All we know so far is the baby was hospitalized with some sort of virus.  I hope to learn the exact cause in the next few weeks.

This happened about 740AM, so now I have the rest of the day to take care of.  I moved forward and returned to talk with my patient about the referral.

The entire office staff has been non-stop bragging about me and congratulating me and giving me all this hero talk.  Quite frankly, while I feel phenomenal that the situation turned out OK, it is sort of embarrassing to get all these accolades.  All I did was manage an airway for 4 minutes and help clear an obstruction.  The assistants who calmly called 9-1-1 and got everything I asked for quickly and efficiently all played an important role.  The mom herself managed to stay (somewhat) calm and answered every single question I asked her immediately.  Everyone played their part well and the outcome was positive.

Here is what I would do differently:

1 – Positive pressure O2 rather than passive (we have an ambu bag hook-up, but I did not specifically ask for it)

2 – Surgical suction up the baby’s nose to clear some of the mucous.

3 – Use mirror for tongue depression faster

Several of my colleagues suggested the baby equivalent of the Heimlich maneuver which is turning him over on his stomach and giving him two strong back slaps.  This may have worked, but I went with the mirror head because all signs pointed to a collapsed airway and not a foreign obstruction

What I am happy with:

1 – My demeanor was calm and collected throughout.  My mind processed the event and made the right decisions.  I would like to have arrived at the need to depress the tongue sooner, but I probably was doing it within 30 seconds of sitting down (time completely vortexed and distorted for me).

2 – staff in general did a great job, could have moved faster, but definitely acceptable

3 – Baby is OK!!!

So what should you young dental guns take from this?
Every single one of us should know how to manage an airway.  It is so easy to do, and so critical to life.
I credit my experience in the GPR greatly to my action as well.  This isn’t the first time I’ve seen a youngster turn blue, we had a few SPC IV Sed cases where this happened as well – that was in a very controlled environment though and with a lot more airway management equipment (not to mention a dental anesthesiologist to bail our asses out as necessary).  Each time I saw it happen, I either witnessed or performed the necessary maneuvers to remedy the situation.  These experiences were terrifying, but ultimately made me a better clinician.
Now just the day before this event, I received an asking price for a dental practice out in the western burbs.  Won’t even bother countering – asking price was in the stratosphere.  But I will get into that in my next post!
Hoping to get that up before the New Year - fingers and goes crossed!
If I don’t though, have a Merry Christmas and a Happy New Year!