Dental Death = Pause and Reflect

The news story this week should cause us all to pause. Medical emergencies are a reality for which we should all be prepared. When an incredibly sad news story regarding a dental death occurs, we owe it to ourselves, our team, and our patients to pause and ensure that we are as prepared as we can possibly be. In an effort to remind us all, Dr. Kuba and Bethany have resurrected a recent episode regarding medical emergencies. Together they reflect on several REAL scenarios that recently occurred in the dental field. They discuss the appropriate steps to take during an emergency in order to protect your patients, your practice, and yourself. In addition, they discuss preventive steps that can be taken to ensure that your team responds well before, during, and after an emergency. Do yourself a favor and take notes today!  

Dr. Kuba and Bethany dig much deeper into this subject in the May digest. For non-subscribers, if you missed the May content, you can purchase it through our Hub/Shop. 

Don’t miss your chance to attend The Leadership Summit. In eight weeks, on Friday, September 18, Dr. Kuba and Bethany will join up with attendees at Homewood Suites in The Colony, TX for an entire day dedicated to practical leadership topics. With only a few spots remaining and the early bird special coming to an end, don’t hesitate to register TODAY! 

HUB HIGHLIGHT

May Dental Digest Bundle

Prepare your team for medical emergencies with the May Dental Digest Bundle, featuring training scenarios, a team emergency quiz, and a clear action plan for addressing gaps in your practice. 

Dental Assistant Checklist Bundle 

Keep your dental assistants organized and your practice running smoothly with editable checklists for daily duties, downtime tasks, and ongoing responsibilities. 

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Transcript

00:02 Hey, lady. Question for you. Yeah. So, you talked about the leadership seminar. Yes.

00:08 Why should a doctor come to that and bring their team? What are we talking about at the leadership seminar?

00:13 Oh my gosh, so many content things that are important, like team morale, um, accountability, how to manage without micromanaging.

00:22 Things like how to do performance reviews and compensation reviews.

00:26 Okay. So, I am going to challenge you on that a minute, because if I was seeing this come through, like my email or whatever, I’d be like, “What? How is—

00:34 This any different than what I could find on any number of sources or a webinar? Why should I come to Dallas?” Yeah.

00:41 Why? Hands-on practice. So, we’re going to be talking about all of those subject matters, but we’re also going to be practicing some of the content—

00:50 Which is, I think, going to make it very exciting, but also practical. And that’s the game changer right there, because I think I go to a lot of webinars, listen to a lot of things, and—

00:59 I’m still like, “What do I do with this information?”

01:01 But at the leadership course, we’re going to show you hands-on. Yes. How to do these things.

01:07 So, everybody needs to be there. September 18th is the day. Sign up.

01:20 Hey, friend. I know we just recorded the episode on the crash cart earlier this year, but I’m just thinking, in light of—

01:27 What’s going on in the news with the, um, fatality.

01:34 Um, I just—my heart goes out for that family. My heart also goes out to the dentist. I just feel like none of us—

01:43 Intends to ever cause harm. We’re actually trying to help. I’m betting the dentist probably thought she was good to—

01:50 Go with her crash cart and her protocols and all of that. And I just always, anytime any of these things hit—

01:57 The news, my first thought is always, “Could this happen to me?” And, um, I feel like the episode where we talked—

02:04 About the crash cart, like, you know, I think we all go, “Yeah, yeah, it’s fine.”

02:08 But that really—like, this is why that made my veins icy when I opened our crash cart earlier this year and saw the mess that it was in. Because I think—

02:17 About all the things that I do to make sure that it stays in check, and whatever I was doing was not enough. We fixed it up. We cleaned it up. And I just—

02:26 Wondered, you know, like, if everybody could, in light of what just happened in the news, really take a minute to pause and go, “Could this happen to me? Let me—

02:35 Not brush this off. Let me not point fingers and judge and go, ‘Oh, she was this negligent, crazy dentist.’” Like, it could happen to any of us. Um, even—

02:44 Those that don’t sedate, there are things in our offices that could happen to us because we are just in autopilot—

02:51 Mode and think we’re okay. Um, anyway, just didn’t know if you would consider playing that episode again because I think, in light of what’s in—

03:00 The news, it puts a whole new—um, sheds a whole new light. Maybe people pause, really, like, actually take a minute to pause.

03:19 What’s up?

03:20 Hey, lady. You haven’t eaten breakfast, have you? I have, but I’m prepared to vomit it all up because I know what we’re talking about.

03:26 [Laughter]

03:28 You know what I was going to bring up?

03:29 Um, so I think it’s, uh—so, anybody listening, if you’re eating your breakfast sandwich, put it down.

03:34 Put it down. [Laughter] If you’ve eaten, turn this off and wait for an empty stomach, please. Um, I—

03:42 Don’t think we’re talking about anything that we all haven’t had nightmares about or haven’t experienced some—or, you know, it’s not new or—

03:51 Uncharted territory. But I still think it’s important to talk about because I’ve had a colleague—

03:57 Call me, um, gosh, it was a couple months ago, and this happened in his office. And then, um, I think two colleagues, actually—

04:06 One happened in her office, one in his office. Uh, and so, I think the question that I—

04:15 Was being asked was, “What should I do here?”

04:19 Um, and so I kind of was like, “Uh, why—hang on. Let me ask Bethany.” So, um—

04:28 Anyway, it’s liability stuff, which is why it always makes me queasy, which is why I’m saying, “Did you eat something?” Because it always makes me—

04:36 Want to barf. Um, so one was a swallowed bur. The other one was a swallowed stainless steel crown.

04:46 And so, one, if we could talk about what do we do in those cases, but then also, for me, from a, um—

04:54 Legal, “What do I do legally?” and some of those nuances? So, can we get—

05:01 Into all of that? Let’s do it. Okay.

05:04 Let’s do it. Which one should I—and then you’ve got one. Yeah.

05:08 So, where do you want to start? Which is the—let’s start with the least throw-uppy, and then we’ll—

05:16 Okay. Well, let’s start with the swallowed bur because you do hope the patient throws that up, and when they don’t, then what do we do?

05:26 So, yeah. Obviously, I’m assuming, hopefully, the client of—

05:34 Yours, or the person that you were talking to, knew right away, I would assume, that the bur was swallowed, right?

05:43 Yes.

05:44 Uh, yes. I’m trying to remember. Yes, I think so.

05:47 Okay. So, yes, he knew that it—he could tell it. He knew the moment it flew out of the handpiece.

05:55 Okay. And then the patient was like—and then ended up swallowing it.

06:00 Okay. So, in that case, and you can totally disagree with me on this, but I would always want to assume the worst—

06:07 Case scenario. So, in this case, we would want to assume that it was aspirated unless—

06:16 They throw up and it comes back up and we see it. So, can we go, like, as if this was real time? So, we are about to—

06:23 Finish our prep, or we’re mid-prep, and the bur disappears. Mhm.

06:28 So, what am I doing? I’m stopping right away. Mhm.

06:32 And I am—I think I probably would be stopping and kind of going, “You okay, buddy? Like, did you—whatever?” And then—

06:41 Seeing what the patient’s doing, but then maybe making eye contact with my assistant and being like, “Check the suction trap,” or whatever.

06:49 Yeah. So, what am I doing if a parent is in the room?

06:54 That’s what makes [unclear]. A parent or any care—I mean, any loved one. I mean, if this is an adult patient, that doesn’t always preclude that there’s another—

07:02 Adult in the room. So, I do think, um, first of all, this is going to go back for a minute. We’ve got to make sure—

07:09 That our team is prepared for emergency scenarios like this. I know you guys do regular emergency training. This is one—

07:18 Of—I don’t want to say the more common things that could happen, but oftentimes we plan for, in our emergency training—

07:26 Like, “Oh, somebody has a heart attack in the waiting room.” We plan for things that are—I hate to even say unlikely to happen—

07:34 But it’s like rare scenarios. But, to me, plan for this with your team, which I don’t think I’ve ever planned for this with the team. Like, what would—

07:43 And I think I’m getting nauseous now thinking about going, “Okay, which of my assistants could be in the room with me? Are any of them savvy enough to know—

07:52 That the bur was lost and I’m panicking and Mom’s sitting right there, and if I say, ‘Go check the traps,’ ‘What do you mean—

08:00 Go check the traps right now? What am I checking the trap for?’ Like, are we going to have that kind of dialogue? Is it going to be like, ‘What? What am I—?’ So, I’m—

08:07 Just trying to imagine that scenario in my head. So, to me, this is a part of the medical emergency training. Again, I—

08:15 Think sometimes we focus too much on the technical, like, who’s calling 911 and who’s doing the—you know, which is still helpful. We’ve got to do—

08:23 That. But, to me, a part of medical emergency training is going, “How do we communicate in the moment—

08:32 When there is an emergency?” And I know a lot of people will develop code language. I’ve had a lot of offices that are like, “What is our code for this?” or—

08:40 “What is, you know, for a—?” And we think of all the scenarios. What if an angry patient walks in at the front? We’re nervous they’re going to go off the—

08:49 Radar. How are we getting the doctor’s attention? Um, what if something clinically is going wrong in another room and we don’t want to sound the—

08:57 Alarm to the whole office? And so, you go through, “How are we communicating?” But then you have to repeat that information over and over and over. This is why—

09:06 Schools do fire drills and active-shooter drills and all of that. It’s like the repetition of it is what’s most important so that, hopefully, that comes—

09:14 Back in the moment. And the communication is, to me, a pivotal part of medical emergency training. It’s why—

09:22 When you have people come in and train medical emergency, or you do it yourself, you talk about not just the technical—

09:30 Aspect of what you’re doing, but what you’re saying to one another. Like, I think it’s important to go, especially because I think a lot of times, like, in—

09:37 Texas, for example, you’re required to yearly do emergency training, but we all know how turnover can go. And, like, okay—

09:46 You did it in January, but now Susie left and Mary started, and Mary may not know where the AED is or may not know where the fire extinguisher is, and—

09:54 You don’t want to be caught off guard in those moments. So, it’s important to talk about stuff like that. But I think what you’re saying here, too, is not only do you literally need to know where—

10:02 The fire extinguisher is, but what are we saying in front of the patient? And what are we, you know, if all you’re doing is saying, “Okay, guys, like—

10:10 Remember, these are the emergency exits, and this is where we keep our oxygen,” that’s just the very, very, very tip of the iceberg.

10:17 Yes, it is. So, I would hope that you’ve got some kind of code with your assistant where, if I look at you in this—

10:26 Way, or if I look at you and blink, you know, very strongly a few times, you know we’re in an emergency situation.

10:34 So, whatever I say next, don’t question it. So, have some kind of visual way. If you haven’t created that—

10:42 Yet and you find yourself in this situation, well, let me say, if you haven’t created that yet and you’re listening to this podcast, do not go—

10:50 Another day without creating these communication structures.

10:55 Can you create some stuff for the Digest? Absolutely.

10:59 Like maybe a checklist of sorts or verbiage or suggestions. Not the typical, I think all of us can look—

11:07 Online and print off an emergency whatever. Like, that’s not what I’m talking about. I want something more like, how can we train our teams? Things maybe we need to think about—

11:17 Yes, plan for. Um, yes, be on the lookout for that in the May Digest. We’ll make sure to have—

11:24 That. That’s a great suggestion. So, yes, if you haven’t done that yet, don’t go a day further without at least having a—

11:31 Conversation with your clinical team to figure out, what would we do in these scenarios? And a lot of times, I’m surprised at how many times a clinical—

11:39 Team member has fears of something that could or might happen, and they don’t know what they would do in that scenario. So, a lot of times, you could—

11:48 Even just have a clinical meeting where you’re like, “What are the scenarios y’all worry about? And let’s start with those.” Which is so funny you say that because I think my team is opposite.

11:58 They are so confident in, “Oh yeah, we’ve been to the Southwest Dental Conference, and we sat on that hour lecture where they talked about, and look, our emergency—

12:06 Drug kit, we’ve got aspirin, and we’ve got nitroglycerin, and we’ve got the cake icing for, you know, hypoglycemia. We’re good.”

12:14 Yeah. It was very eye-opening because, in Texas, we have to have PALS every two years for our sedation permits. And—

12:23 So, myself and a colleague of mine were taking PALS together, and we had our own little private trainer. And, um, he mentioned how he does emergency—

12:32 Trainings in the office for your team and can go through your office to kind of show things, whatever. And so I was like, “Hey, Jose, can you come to my—

12:39 Office? I’ll pay you whatever.” We had him come to the office, and he made us do, like, hands-on type, “Let’s go into the—

12:47 Operatory now. Pretend you need to put the AED on. Like, let’s practice putting the pads on.” Like, to that level. And he—

12:55 Said something, and I was like, “You know what? I need to go back and look at our crash cart.” Bethany, I looked at our—

13:01 Crash cart, and I was—I thought it was funny. I was pissed. I—

13:09 Was scared because I opened the top drawer that’s labeled whatever it was labeled, and I’m seeing all this mishmash of—

13:18 Stuff, and I’m like, “What is this?” In the top main section, and then I, like, the drawer you would probably go to—

13:26 The drawer you would go to first if you need—I’m like, “What is this?” So then I went to the next drawer that was labeled Band-Aids or whatever. Well, in the—

13:34 Band-Aid drawer is, um, which I’m like, “Why are Band-Aids in the emergency cart?”

13:38 Because, anyway, but it was Band-Aids and, like, a nasal—

13:44 Cannula and a, um, what else was in there? A diabetes—the glucometer. Yeah.

13:52 Okay. Open the third one. There’s literally trash in the third one.

13:56 There’s, like, wrappers. So, somebody opens something and there’s those. And I’m like, “What is going on in this crash—

14:03 Cart?” So, I was like, “Thank God we had that training,” because otherwise I wouldn’t have thought about it. I haven’t looked at the crash cart. Knock—

14:10 On wood, we haven’t needed it. So, we’ve got a team and a checklist in place that you go and you check the expiration dates on everything, and we have our—

14:18 I think, our compliance guy that sends us our checklist. Make sure you’ve got your, you know, LMAs and your oral airways and whatever else we need for—

14:26 Our sedation checklist. Great. We have all of that. So, the drawers are sitting nice and pretty, thinking that we are—

14:32 Good to go. Bethany, I opened that top drawer. You know what was in that top drawer that I said was the mishmash? What? Expired stuff.

14:41 Why?

14:42 I do not know, but for some reason, my team thought that that was a good place to put expired stuff, in the crash cart at the top.

14:53 Oh.

14:54 So I’m like, “Okay, so if I needed Narcan and I open that top, because that’s the first thing I would think to open, and I—

15:02 See Narcan, you’re telling me basically I’m going to be giving expired Narcan?” Because I don’t think I would have—

15:10 Pulled anything from that top because it was so disorganized.

15:14 But I don’t know what I would do in an emergency situation. And so, if that was my first thing, was like, “Ah, there’s some Narcan,” or if I said to somebody—

15:20 Else, if I knew Narcan is in drawer three or in the drawer marked whatever, but my front desk, who’s not a clinical person, is the one helping me in this emergency—

15:29 Yeah.

15:30 And they’re like, “Does it look like this?” Yeah. And I don’t know where they’ve pulled it from. Why are expired meds and expired equipment? I don’t—

15:38 Have an answer for that. I couldn’t ask because I think my face would have crushed whoever gave that answer. So, I just ignored it, and I pulled everything out and was like, “Where’s a trash bag?”

15:50 Um, and then, like, yeah, let’s clean the trash out. Let’s—and so, and then as we’re going through, I’m like, “What is this?” And they’re like, “Oh, it’s the—

15:59 Syringe for blah blah.” And I’m like, “But Narcan is nasal now. We don’t need a syringe for this anymore. Can we throw—

16:08 That away?” We discovered some of the vials of meds from the pharmacy have changed.

16:15 Like, previously, it was in this type of vial, so you needed this type of syringe. Oh, wow.

16:20 Well, that doesn’t match up. So, I guess, for me, I’ve been thinking, we do our emergency trainings.

16:28 This should be in order. Well, I wasn’t physically doing it myself. And I’ll say, even if I was doing it, I don’t know that I would—

16:36 Have thought about a syringe matching up.

16:39 Um, but I hadn’t done our emergency training for the team in a while. My associate was doing all of that.

16:46 So, I don’t think he was paying attention to, is the syringe adding up? Because he’s not the one who orders the meds. So, he’s probably thinking, “Well, Kuba orders the meds. She’s checking the—

16:54 Syringes.” And I’m like, “Well, I didn’t realize the vial changed.” Wow.

16:58 So, right. So, all of this was like, “Oh my God.” Like, so we revamped the entire thing, threw out a bunch of—we had an—

17:05 Emergency suction that, it turns out, doesn’t work anymore. So glad we had a backup one.

17:14 Yeah.

17:15 But in the moment, y’all, check this. So, basically, they see that the power works. They plug it in every month, and they check that the power works.

17:23 But does it suction? Right.

17:25 And the part that needs it. So, I was like, “Well, have y’all put a suction on there?” So, we tried practicing then. It wouldn’t suction.

17:32 So, I’m like, “Can somebody YouTube this to figure out why this is not working?” Wow.

17:37 Well, one of the parts was broken. Turns out that part doesn’t exist anymore. Can we just throw this unit away? So, I—

17:44 Can’t fault the team. They were doing what they were tasked to do. On the checklist, it says once a month, check the AED. Once a month, check this. So, they flip it on. The power works. They—

17:53 Think they’re done, right? But they weren’t taking it further.

17:57 But they weren’t taking it further. And so, anyway, all of that was making me want to vomit and go, “Thank God I haven’t needed any of these things in—

18:05 This emergency kit,” because I wouldn’t have had the right syringe I needed. Yeah.

18:08 So, it made me—and new associate has been on board now for, at this point, about four months. And I’m like, “You know what? What better timing to make sure—

18:16 That both of us are in sync?” And we really simplified our system a little bit. Good.

18:22 So that we could have up-to-date—we had a, um, a, uh, what are those called? Those Broselow tape things that come in the PALS—

18:29 Book, and my assistant had taped it to the wall. And maybe I had told her to tape it to the wall. I’m betting I did at some point.

18:38 But then I’m looking at this Broselow tape, and I’m like, “None of this stuff—we don’t have atropine in our office. We don’t have adenosine in our office. We don’t have XYZ in our office.”

18:48 Why do I have this Broselow tape up? And in an emergency, are we all going to be trying to read this thing and then discovering at that point that we don’t even have these drugs? Like—

18:56 So anyway, get rid of that tape. Like, it’s a false sense of security right now because we’re not—let’s make this really like, what can we use in an emergency? Because—

19:05 That’s what we’re going to need, not all these false hopes of, “Well, we have some syringes in there. We’ve got some vials in there.” So, y’all, I just went—

19:14 Through it myself, and it was embarrassing for myself to go, “How did I let this happen?”

19:21 Because I have prided myself. Every year, I make sure we go to a medical emergency training. I make sure I’m on top of my PALS and CPR card.

19:30 I thought we had all of this in line, and it was very embarrassing and concerning that we did not have things the way we needed them.

19:39 We do now. But, um, so anyway, back to the swallowed bur.

19:43 Back to the—okay, let’s assume the parent’s not in the room. Let’s assume you check your trap and you’ve determined that the patient did swallow it. Then what am I doing?

19:51 So then we’ve got to get the patient to a treatment-stable spot. Um, so whatever—

19:59 Whatever procedure you’re in, you’ve got to at least get the patient to where, once that, um, anesthetic wears off, they’re not going to be in pain or at risk of further injuring that tooth.

20:10 So, you’ve got to at least get them stable in some way. And then we do have—

20:16 To inform the patient of the issue. So, again, clinically, you could probably—

20:23 Speak to this more than I, but I would say get the patient stable before the communication of what has occurred. Um—

20:32 And then let’s do—do you have any advice on the communication of it? I was going to ask you that. Like, it should be the doctor.

20:40 Yes. Oh, a great question. Yeah, because I would love to throw my manager in there and just be like, “Oh my God, I can’t face this patient. Can you?” It’s got to be the doctor.

20:48 Yeah. And the reason being is the doctor is going—the, even though it’s—

20:57 Not the doctor’s, quote-unquote, fault, like a bur faulty, you know, popping out is, like, in most situations, the doctor—

21:06 Couldn’t have done a thing about it, you know? Um, but if there’s anybody that’s going to get blamed for said—

21:15 Accident, it’s going to be the doctor. And I think it actually implies guilt if the doctor steps away from that situation—

21:23 And tags another team member in. So, we don’t want the patient, who might not have cast blame, to then be like, “Why is—

21:32 The assistant telling me this? He or she must have done something wrong.” So, we want to just be straight out in front—

21:39 Like, “This is what happened.” But the communication needs to be very clear. So, chances are, the patient would know they swallowed something.

21:50 Most likely. Okay. You would think that they’ve recognized in that moment. Um, but as far as—

21:59 Clarity, we need to know exactly what the next steps are. We can’t be like, in our head, “I don’t know what I’m about to—

22:07 Tell this patient on the next steps,” because I myself don’t know the next steps. So, make sure that you’ve collected your thoughts enough to be—

22:14 Like, “Okay, you have swallowed a bur. Um, this happened at this point, you know, when—

22:22 We stepped away, and I’ve been monitoring you, but we do need you to take some next steps. I need you to do this. I—

22:29 Need you to, you know,” and then, so have your plan in place. And if there are options to that plan, like, for example—

22:37 You mentioned, uh, swallowing a stainless steel crown. We do have options. I mean, you don’t have to go immediately to the—

22:44 Doctor. You can evaluate, watch, poop for the next few days.

22:48 I’m going to argue that. I think standard would be you need to go to make sure it’s not in the lung.

22:52 Exactly. But clinically, if you’re just like, “Hey, I think there are options here.”

22:57 I’m with you. I feel like the cleaner you can make it, where you’re like, “As your doctor in this scenario, I want you to do this, this, and this, and I’m—

23:05 Going to coordinate with you on step two,” or whatever the case may be. But if, as a clinician, you’re like, “Well, if it were my kid, I would do this.” Okay, then—

23:14 Present two very clear options to the parent or to the patient in this particular case. But all that to say, have your plan, plan for what you’re—

23:24 Going to say, in place. And, of course, communicate with as much calmness and confidence as you can muster. We want to—

23:33 Be clear about the potential consequences of the situation, but we also don’t want to cause panic in this, like a typical emergency.

23:42 So, let’s say, let’s go to crown, crown scenario. And so now the kid swallowed a crown, and, uh, you tell the parent, and you’re like, “Well, we were trying to fit—

23:51 This, and the crown slipped, and he swallowed it. Um, we need to make sure—

23:58 That it’s not in the lungs. So, I want you to go to urgent care or go to the ER.” Yeah. And go get—and I would even do the homework of which ER.

24:09 Not that you’re making a recommendation, but just say, “I want you to go to either urgent care or the ER. By the way, the two closest to us are this one and this one.”

24:19 You’re not saying, like, “I want you to go to this urgent care,” or, “I want you to go to this ER,” but you’re just communicating to the parent, the two—

24:26 Closest ones are these. Um, so I think that the question that comes to mind for all of us is then, who is paying for said ER visit?

24:35 So, this is where I’m going to say, don’t fork out a dime until you talk to your malpractice.

24:45 So, this came up recently with a client of mine who asked the same question, like, “Oh, I’m sending them—a swallowed—

24:53 Crown—I’m sending them to the ER, urgent care, I can’t remember which it was. Do I need to go ahead and pay for that?”

25:00 And I was like, “Whoa, whoa, whoa, whoa, whoa. No, no, no.” Because malpractice needs to guide you on that—

25:09 In the safest way possible. In my mind, if you pay for something, it’s implied guilt. And then you’re on the hook for—

25:17 Anything, any surgery that they might need to remove this crown from the lungs or whatever. To me, if you paid that—

25:24 First ER bill, in my mind, you would be paying then for all of it. So, I can’t even tell you what to do other than—

25:33 Don’t do anything. Talk to malpractice first and let them tell you.

25:36 And I think you had mentioned, too, to me at some point that, um, malpractice, if you did pay without consulting them and without them—

25:45 Guiding you, and you just were like, “Oh, it’s just the ER. It’s just for the chest X-ray.” Yeah. “You know, I don’t want to get into this issue with Mom.”

25:51 “I’ll just pay for it. It’ll be fine.” Um, might they say—might malpractice say, “Well, you went rogue, so now we’re not—

26:01 Involved in this at all.” So, let’s assume that a surgery was needed. If they were going to cover it—

26:05 Now they’re like, “No, you’re on your own.” So, I think, just not knowing any of that, I’m like, “Oh my God.” Because, to me, I think this is just me—

26:12 Personally, which I get that there’s, you know, there should be some—

26:21 Inherent—the patient should know there are inherent risks. It’s in our consent form that, you know, that you could move or that you coughed, and it made me drop—

26:29 The crown and whatever. But I still feel like I would just feel bad for this patient now having to pay 300 bucks or—

26:37 500 bucks or 10 bucks, whatever it is, for this chest X-ray, the inconvenience of it all, and doing all of that, and now they’re getting a bill for it, and—

26:45 Potentially, you know, if it was a permanent crown I was seating, like, do I pay for that? Do they pay for that?

26:52 Like, say we were seating a PFM on tooth number 30, and it fell, and the patient swallowed it, and it came out in—

27:01 Their poop. Well, they don’t want to dig it out of the poop, and they don’t want the poop crown in their mouth, right? So, do I pay for the lab bill for that? Right.

27:09 Do you pay for it? Like, what? And, like, so I think, to me, that’s where I’m just like, “I have no idea.” And, to me, because I—

27:17 Tend to be a people pleaser, and I don’t want people upset, I’m already going, “Are you blaming me? Are you blaming yourself? What are you doing? Maybe I should just offer to pay for that.”

27:25 But then, like, it could get me in trouble, too. So, I just—the whole thing, I’m like, “Oh my God, my stomach hurts. I don’t know. I don’t know what to do with—

27:33 That.” And, again, this is why we have—one of the many reasons why we have malpractice, because we don’t—we can’t make the best—

27:42 Decision in the moment because our feelings are like, “Oh, if I were in this case, this is what I would want.” But you have to come back to—

27:49 Leaning on your resources, and your malpractice is there to protect you from situations like this. So, let them protect you, and let them guide you, and—

27:58 Then you follow their lead. You’re under their guidance at that point. Um, I don’t know why I’m so suspicious of insurance—

28:06 In general. I think, you know, but even malpractice, and then maybe even the incident that I’ve talked about, you know, before, where, yeah, like I had insurance, and yeah, they guided me, and—

28:14 They settled the case, and they paid the patient and whatever. That was for that kid that fell, and, um, so it wasn’t my malpractice. It was my—

28:23 General liability for the building, whatever. But I just fundamentally disagree with that. I don’t think that that was fair. And I’m just suspicious—

28:31 Like, when you’re saying they’ll guide you and tell you what to do, I think I tend to go, “But you’re not my friend.” And it’s like, “Yeah, they’re not your friend. They’re making a business decision because that’s what—

28:40 Insurance does.” And could what they do cause a board complaint because they’re saying, “Don’t—

28:47 Pay for it,” and now the patient’s blasting me all over the place and badmouthing me in the community? Like, all of that goes through my mind. But—

28:56 Obviously, you are right. Like, that’s number one, is contact your malpractice. Yeah. And, um, they are. They’re making a very—

29:04 Non-emotional business decision. They are making a decision that they believe puts you at the least risky—

29:11 Spot. Um, and I don’t know if malpractice has, like, a protocol that every malpractice—

29:20 Follows. I don’t know. I don’t know how they work to determine what’s the right course of action. Um, but I know that—

29:28 Ultimately, it’s going to—it needs to be on them. If we play out worst-case scenario and this bur is in the lungs, and we’re talking a—

29:37 Surgery and all of this, like, they have—it needs to be on them. You’ve paid for them to ultimately financially protect you from a scenario like this.

29:47 And so, they’ve got to be in the loop from the beginning. Um, so as far as paying, not paying, I don’t—I can’t—

29:55 I can’t advise. I won’t advise on that, just because that’s ultimately got to be something that you talk about with malpractice.

30:00 So that too, like, it would be like, okay, well, now we don’t want poopy crown back in our mouth. Am I—I mean, is that one fair enough to say, “Yeah, we’ll just get your new crown made”? If it were me, I would say absolutely.

30:11 You pay for the lab bill to get a new crown—

30:16 Okay.

30:16 Made. And because that’s within the confines of your office versus a medical facility that you are paying a bill for somebody—

30:22 Else. That’s your own financial decision that you’re getting to make. And yes, I would not make the patient pay for a new—

30:30 Crown on top, after—we don’t want to do anything to inflame them further. So yeah, make the new crown.

30:38 Like, just—I think I just start going through, again, like, “Miss Smith, you’re the one who sneezed. You’re the one who said you couldn’t tolerate that rubber dam.”

30:47 “You’re the one who said proceed without, and so I did, and now I get to pay for the new bridge. Like, how fair is that?” It’s not. It’s not.

30:57 It really isn’t. But it’s the crap we have to put up with. So, and thankfully, it’s not an everyday thing.

31:03 But it’s like, when it does happen, you want to—the main thing is, set the feelings aside and mitigate risk. How can I reduce this patient getting upset?

31:13 How can I reduce the, you know, chance that I might be on the line for a surgery? That’s where malpractice comes—

31:20 In. Like, how do I, uh, mitigate the risk that they’re going to panic and freak out? Well, I have my plan for what I’m going to say to them before I say it.

31:29 I’m going to have real clear instructions. Uh, you know, just mitigate risk is the best thing that I can think of. Every decision that you—

31:37 Make needs to be a chance of quelling the potential negative outcome.

31:44 Well, it goes—I, the one I think about too is the guy that fell off a bench in our office, and I was asking you, and my—

31:52 One, um, team member was like, “Oh, we should get him a gift card for a massage because he fell and whatever.” I’m like, “Oh, that’s a great idea.” And then I stopped, and I was like, “Whoa, whoa—

31:59 Whoa, whoa, whoa, Reena McNeely. Like, no. Like, you need to use your brain on this.” And if we do that, then we’re admitting that we broke the bench, or we gave you a bad bench, or whatever.

32:09 Um, and then I waited for you to kind of tell me how to manage that situation. I think we talked about that two or three years ago on a podcast, but—

32:17 Um, that flashes back to my mind because you’re right. In the moment, I tend to be the feel and make sure they feel good and make sure they feel, but—

32:26 People’s feelings are all over the place. That could come back to bite you real quick. And it’s sad that we have to think that way, but it is the reality of—

32:32 The situation, that just every—every step you take can lead—every step you take has a ripple effect, positive or—

32:41 Negative. And what you’re trying to do is to eliminate the negative ripples that could happen. And something as simple as, “Oh, I’m just going to write—

32:49 This person a real sweet note and, you know, apologize that he fell in the practice and send him this massage card.”

32:56 Guilt, guilt, guilt. We did something wrong. You should be mad at us. You should, you know—which is so sad because it’s like the human side of you wants to—

33:03 Do something really sweet and kind, but there’s a potential negative to that that has to be considered. And you don’t know what those potential negatives are—

33:10 Without talking to your resources, ultimately.

33:14 Um, what else? You had that one other example that’s not, uh, that’s not one of these swallowed-crown things, but—

33:22 It was more of a medical emergency in the office that a team member did not, um, do what they needed to do. Do you mind talking about that one?

33:32 This ends up being a mishmash of things that can go wrong.

33:36 Yeah. Emergencies that can happen. Yes. So, you know, registered dental assistant had the, uh, licensing to be able to—

33:45 Monitor, uh, nitrous. So, doc started the nitrous, um, stepped in a few minutes later, and noticed that the patient—

33:53 Sorry. So, they started nitrous, stepped out, let’s say, to do a hygiene check, who knows, comes back in, which assistant, of course, had been in—

34:00 The room the whole time, comes back into the room and notices a physical twitching with the patient in the chair—

34:09 And he immediately takes the steps that he needs to take to get the oxygen flowing and, uh, looks at the assistant—

34:17 And was like, “How long has this been happening?” And the assistant was like, “Well, pretty much the whole time.” And so—

34:26 We think of a situation like that, and we’re just like, “How? How?” Like, you’ve been trained. You have the certification to be able to watch the—

34:34 Patient, and yet you’re clearly watching the patient and not doing anything to a physical manifestation or reaction to—

34:42 The nitrous. So, what do you do in a situation like that? You know, same scenario. Now, he obviously jumped in and immediately—

34:50 Addressed the immediate physical concern, and the patient is fine. It’s all fine.

34:59 But it begs the question, like, how did this happen? How do we have an assistant that didn’t respond to the signs or treat it with the appropriate—

35:08 Amount of, um, action?

35:08 Action. That was quite—she just sat there.

35:15 Yeah. Yeah. So, even that, it’s like, what do you do in that situation? And so, um, what—I guess, what would you do in that situation?

35:24 I think I would want to know what happened. Yeah.

35:27 Like, what? Did you just freeze? Did you panic? Did you—yeah. What happened? Yeah. Do we know what happened?

35:35 No.

35:37 Because, basically, she saw the signs and just didn’t think it was a big deal—

35:45 Which is—I don’t know. I—I—I—I don’t know. So, because you’re exactly right. So, he immediately was like, “What in the heck?” You know, and he—

35:54 Ended up, uh, sending her home right away because he’s like, “You’re obviously not in the right state of mind to be assisting,” even though there was nothing wrong.

36:03 There was—there was nothing wrong. Well, I mean, there was. She wasn’t going through a personal trauma. She—the assistant was fine. But it was an eye—

36:11 Opener for him, where he was like, “Oh my gosh, the practice is at risk. The patient is at risk if you can’t recognize that that—

36:20 Was not normal. Like, that was the point of your certification.” Yeah. Yeah.

36:23 So, what were you doing in class? Well, you’re just checking a box, right?

36:27 Did you not realize that you were the one now in the room monitoring?

36:27 Monitoring. Yeah.

36:33 Like, you are a part of this. You’re not just the checkbox person. Exactly.

36:36 You’re a part of this, the care for this patient. Yeah.

36:39 I think, for me, the only reason I have a little empathy for that is because I wonder, for myself, like, I’ve always been like, this is why medical emergency stuff—

36:46 Scares me. Because yes, I’m trained. Yes, I’ve been through PAL a number of times—uh, PALS—but, um, will I be able to perform in that moment?

36:56 Like, what will my emotional state be? And how will I process the situation?

37:01 Um, so I wonder, for her, is that where she has never dealt with another emergency? Does she—is she just—

37:10 Not that bright of a person? Did she just panic? Was she, you know, looking at her Apple Watch and not even noticing?

37:17 Like, who knows? It could have been, yeah, a number of those. But I think it’s—you’re exactly right. It’s like every—

37:24 Person’s going to respond differently to an emergency or even be able to recognize an emergency. So, to me, in this—

37:33 Case, or any case where there’s an emergency that happens in the practice, there’s got to be this, like, deal with it—

37:42 Right then and there. Get the patient safe, obviously, but then there’s got to be some debrief that happens. Like, okay, what can we learn from this scenario that we just walked through?

37:53 And not just with the one person or, you know, but it’s got to cause this, like, what do we learn from this, and how do we—

38:02 Protect ourselves from something like this happening again? Because we’ve got, as awful as it sounds, we’ve got to take advantage of these scenarios when they—

38:10 Hit us, and not just to navigate successfully in that moment, but to go, how do we prevent this from happening again? What training do we need, and how—

38:20 Can we learn from this? Which I think is the best—we talked about silver linings in a recent episode. That’s the—

38:27 Silver lining to, uh, any type of emergency, is we’ve got to fight to actually learn something from it. Um, and not that it’s always preventable, or—

38:37 But we can always go back and self-reflect and go, “Is there anything that we would have done better in this situation? If it ever happens again, how could we handle it better?” So—

38:46 I guess takeaways from this mishmash episode. I guess number one is, if you do have something happen, uh, an adverse outcome with a patient—

38:53 Like swallowing a bur or doing whatever, get them to where they are in a safe, stable—like, to the ER to make—

39:01 Sure that they’re—the crown can pass and all of that.

39:04 Um, but as far as what are we doing in the office, I guess that would be a documentation debrief, like making sure we’ve documented—

39:12 Yes.

39:12 That day, so that it doesn’t look like we’re fudging notes later. I think sitting and talking with your clinical team to go, “How did this happen?”

39:20 Um, you know, was this a handpiece that we knew was on, you know, and we kept not sending it off? Is that me—

39:29 Being cheap, doc? Is it you guys not reminding me of that? Um, is it, you know, airway, where, you know, next time—

39:38 No matter what the patient says, we have to use a rubber dam or Isodry or whatever. I don’t—you know, kind of going through those steps, like—

39:45 How do we prevent this from happening? Um, calling medical malpractice—

39:53 To go, “Okay, what are my next steps here? What am I talking to the patient about? What am I making sure—” Even getting them to guide you on your documentation.

40:01 Even—yes. Um, I even, actually, the other day, I had a, uh, a newer assistant, and, um, we ended up—

40:11 Having to—I can’t remember—extract an over-retained something, whatever. And I went back, and I looked at her—

40:17 Notes, and, um, she did not put that we did the throat screen with the gauze. And I was like, “Remember when we had that—

40:25 There?” And she’s like, “Yeah.” I was like, “You have got to document that, because if, for some reason, the kid had swallowed whatever and we don’t have in our notes—

40:33 That we had—we tried to protect the airway, we’re hosed. It’s over.” So, um, I was like, “You’ve got to remember those—

40:41 Details.” Like, that is—that is not just, uh, “What shade of composite did we use?”

40:46 That’s a vital note that we need in there. Anyway, so kind of talking through our, what is going to be our—

40:53 Plan? How far are we pushing with this patient who claims they have this gag reflex? Are we referring them? Are—

41:00 We sedating them? Are we refusing to see them because we don’t want to be back in this situation again? But I think you have to kind of look back and reflect and go, “How did this happen?”

41:08 Yeah. Um, even though it may be no fault of your own, like, she sneezed and the crown dropped, but still having to talk through it.

41:16 Yeah.

41:16 To—to—to, I think that’s important to do, is another takeaway. Calling malpractice, documentation, all of that. Um, crash cart stuff.

41:25 I was going to say crash carts. The other takeaway on this, when—and/or your systems. When was the last time you went through your own, um, binder—

41:33 Of your medical emergency list? For me, I’m like, “We don’t even have that drug anymore. Why is it that that’s what we would grab?”

41:42 Because if I were to pull this at the time of an emergency and go, “What am I supposed to do again?” If a patient is having a, you know, anaphylactic—

41:50 Reaction, and I look, and I’m like, “We don’t even have that form of Benadryl anymore.” Yeah.

41:55 Or we have that vial, but the syringe doesn’t work. Or I don’t know how to use the syringe. I don’t remember what I’m drawing up.

42:00 Was it 0.1? Does my syringe—is it a 0.1 syringe? Is it a one syringe? Like, I have no idea. That’s what we discovered when we were going through our crash cart. We were like, “This is not—

42:08 The syringe that even matches up with—

42:08 Wow.

42:08 That dosage.” Um, so anyway, so have you—have you done your due diligence to make—

42:16 Sure that you are protecting yourself with all of that? And my guess is a lot of us don’t because, number one, it’s yucky.

42:22 Yeah.

42:22 Two, it’s time-consuming.

42:23 Yeah.

42:24 Three, it’s kind of like, “Eh, I don’t want to jinx myself. Like, if we’re going to assume the crash cart’s fine, and we’re going to assume we never need it.”

42:30 Yeah. “The minute I look at the crash cart, somebody’s going to have an emergency. So, let’s not jinx ourselves. Never mind. And I’m not going to look at it.”

42:35 But you can’t.

42:36 Yeah, it—yeah, we can’t avoid it. Like, we’ve got to just dig in, and even if this episode prompts all—

42:44 Of these little, like, protect-yourself-type things, that’s kind of the point. That it is like, don’t—don’t listen to this episode and do nothing with it.

42:53 Like, really make sure that you’re protected on all sides. Maybe reevaluate your—

43:00 Medical emergency training and go, “Hey, have we been thorough enough with that?”

43:05 Have we talked about the communication that needs to occur? Do we have code words that we all need to be, you know, remembering? Maybe we need to—

43:13 Increase the frequency of our medical emergency trainings because we don’t feel, you know, super adequately prepared. Like, well, I will tell you—

43:20 The one—my takeaway from after our crash cart stuff, where I was just like, “Oh my God. Oh my God.” And here my team is patting themselves on the back, and—

43:28 Frankly, me too, patting ourselves on the back, that here we go. We are—we’ve got our, you know, nothing’s expired.

43:34 It’s all—well, it was expired. It was just stuck in an expired drawer. But, like, in the kit itself—

43:41 Yeah.

43:41 There was nothing. But anyway, um, but when we had our guy, Jose, come in and do that training for us, and then we—

43:50 Subsequently went through the crash cart and cleaned it up, I was like, “You know what? I’m bringing somebody in twice a year, and I’m going to bring Jose in every February, and then we’ve got, uh, one of—

43:59 Our hygienist’s, um, husband’s a paramedic firefighter. And so, he’s always said, ‘Oh, if you ever need me to come,’ whatever. I—

44:06 Reached out to him. I was like, ‘Give me some dates, and then we will come up with content for you to come in and show us how to rig up this, show, you know, test us on how—

44:15 We draw up that. Make sure we’ve got spot checks.’ So, I’m like, ‘You’re going to come every September. Jose’s going to come every February.’ Like, we’re going to do this twice because I don’t know what staff differences there are. I don’t know.

44:27 There are too many things that can slip through the cracks, as I found.

44:30 Yeah.

44:31 Things that I thought I was on top of that we were not.

44:34 Yeah. I think that’s a great takeaway from this, too, is just go over and above on the emergency training. You know—

44:41 Bring in resources that you feel like would be helpful and really challenge your team to think about things differently. Different perspectives from different trainers, I think, is a great—

44:50 Takeaway, too. Rather than having Jose twice, it’s like you’re having two different perspectives, which I think is important as well. So, yeah, do—

44:58 Something with the content from this episode. Thanks for joining the conversation today. We hope that you are—

45:05 Comforted in knowing that you are not alone, but we also hope that you’re walking away with some really great tips and tricks to try in your practice.

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