Medical Emergencies Part 2 – CORE CPD for Dentists – PDP242

Teaser:
When you’re becoming a dentist and you have to choose between medical and dental school, you either look up one and you look down the other, and so I said, let me look down, not up. So here we are.

That made me realize, and the advice on that Facebook post was, anyone age five or under choke on grapes. And so you totally agree with that?

I do. I do. I just think it’s not worth it. Sweaty. Sweaty. Very, very clammy. You know, there’s pools of sweat that I mentioned with hypose. You can get exactly the same with an MI.

Yeah. Nausea, vomiting, sweaty, clammy, impending doom. So again, a bit like anaphylaxis, they say they feel like they’re gonna die. Blood pressure drops usually. Not always-

But here’s the thing where this is happening, right? I’m going back to-

Jaz’s Introduction:
Welcome back to Part Two of Medical Emergencies to get you that big fat tick for your annual CPD requirement for medical emergencies, and hopefully in a way that you can leverage the time of commuting so it doesn’t feel like something extra you’re doing.

Also in a way that was conversational, something that was easy to listen to, and hopefully the retention will be really good. And to enhance that retention, don’t forget, we have got our premium notes, like a revision summary done for you notes for every episode for our premium subscribers. If you’re not on the already, head to www.protrusive.app.

In the last episode, we covered the most common medical emergencies that we see or could see vasovagal syncope, anaphylaxis, which is worrying and common nowadays, but with serious consequences. And we talk a lot about oxygen, like which medical emergencies should we be giving oxygen for and how do you actually give the oxygen?

The thing is right, we as dentists, we hardly ever administer oxygen. We only are told to do it when there’s a medical emergency, but I want to cover it because when push comes to shove and we need to deliver the auction, I’m hoping you found it useful to hear and to watch for those of you’re watching how to actually activate the damn thing.

And what it all looks like and works like. So that was all covered in part one. In this part two, we’re covering seizures, how to handle a patient that is having a seizure, including how you might actually deliver the buccal midazolam. What does it actually look like and feel like? And interestingly why in many scenarios you may not even need to give it.

Then we moved to choking. And we all know about back slaps and abdominal thrust, but we simulated choking and we discussed choking specifically for your patient that is like laying down the chair the exact steps you should do when your patient’s in your dental chair and why. Therefore, you may need to do a one handed abdominal thrust.

And so you get to hear about that and watch that again, if you’re watching on the app. The last two things we discussed were diabetics and how the whole glucose and glucagon works and how to administer each one, as well as our cardiac risk patients. These ones are very common patients that make me a little bit nervous.

These are patients with a history of angina, history of heart attacks in the past, and so therefore, should we be avoiding using adrenaline containing local anesthetics. And what should be doing if they’re having some sort of an episode in your chair. So once again, we’re joined by Rachel King Harris, or today’s part two, Deep Dive into Medical Emergencies.

Dental Pearl
Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite Dental Podcast. Every PDP episode I give you a Protrusive Dental Pearl. In the last one it was to download for each condition the kind of like cheat sheet prompts that when you open up your medical emergencies drug box, like it’s so reassuring to see the step by step what you’re looking for, what to do next.

It was like a really helpful thing. I think every single medical emergency is boxing. Every dental practice should have this. So that was last episode’s Protrusive Pearl. This one is a bit more simple, but equally important is that are you checking the expiry date of your meds?

Who has been allocated as someone who takes a lead on this? Not only is this important to satisfy CQC or regulatory requirements to make sure your practice can run and stay in business. But this is life saving stuff. So who’s the person who’s checking monthly or quarterly to make sure that nothing is running out of date and that all the supply is there and it’s working and you haven’t run outta oxygen or your glucagon’s not outta date, and all those things.

So make sure you have a clear lead because that’s how you Protruserati, these little things are the big things. Hope you enjoy the episode. I’ll catch you at the end. I’ll give you more instructions of how to claim the CPD.

Main Episode:
Rachel, welcome back again to the Protrusive Dental Podcast for part two. 

[Rachel]
Thank you for having me again.

[Jaz]
So in the last episode, we covered the common things. What I wanna do is make a really tangible piece of content with your help. So we covered the things that most likely common to happen. Okay. So, vasovagal syncope, ie the faint, super common, went deep into that. We went into anaphylaxis and I think we covered it really well.

We also talked about the oxygen, about what is the right dose of oxygen? Can you actually do harm by giving oxygen? And generally the consensus was, no, actually, it’s a good thing to have in practice. And I also took out the drug kit and it was really nicely how it was organized. And that might be inspiration for other practices.

So one thing I did promise from the last episode, part one, is like the other, attach some downloads. So the laminated sheets you can actually put in your emergency drug kit box. But I wanna do in this episode cover the other more common ones. And also like I was thinking, should we do angina and should we not?

But actually more important angina might actually be choking ’cause something that we might actually see out in the community. And also, like I’m using products all the time, which could are always a choking risk. 

[Rachel]
Absolutely. 

[Jaz]
Appliances. I remember using one of our drills before, like diamond drills and it was probably my silly error, but when we actually put, it’s a friction grip.

So you put the diamond in and then we release a chuck and then it stays. And so I always, since then, I always check, every time I put my bow in, I always check to make sure it’s in. But I must have not checked that time. And I was, as I’m drilling, and it sort of flew to the back of the throat, now remain calm, got my tweezers, picked it out.

Like literally kissing the uvula. Yeah. And took it out. But sometimes I can go in the wrong hell or someone can start choking on something. 

[Rachel]
Exactly. 

[Jaz]
And so to know how to manage it is important for what we do. 

[Rachel]
It’s a good life skill. 

[Jaz]
And it’s a good life skill out in the community. So I think let’s definitely talk about choking. And if we go through the emergency drug kit, I just wanna do an overview of that. Before we also talk about a few other common ones. So, I promised the emergency drug PDF, and we’ll put that on there. So as you open this kit, we see one for fainting, which we talked about last time.

Interestingly, there’s a glucose gel over here. What do you think about that? Do you think it’s important for us when we see a vasovagal syncope or a faint to give a glucose gel? 

[Rachel]
It’s not something that we would do. We would probably, as I’ve said in the last episode, one is that we would just raise the leg. We wouldn’t go for the glucose gel. 

[Jaz]
But you kind of see it’s like the hardly-

[Rachel]
Is it a placebo? 

[Jaz]
Yeah. Yeah, probably. 

[Rachel]
Yeah, and then if so, if it makes the patient feel better, then that’s fine. It’s not gonna cause any harm. But obviously if they’re diabetic, it could cause harm. If they have a normal blood sugar that you could then shoot quite high. So just use with caution. 

[Jaz]
Okay. They do. We talked about anaphylaxis last time. Okay. So if you haven missed that first part episode, check it out. Where we went through what’s inside here and what to do in terms of ampules and stuff. We have all the sort of guidelines and cheat sheet, which I’ll make available to you guys.

Seizures. Okay, so while we’re on this, let’s talk about that. Then we’ll come back to choking later. So, seizures, how many have you seen in your sort of time as a nurse? 

[Rachel]
Lost count. 

[Jaz]
Wow, that many. Why is that? 

[Rachel]
Because we get a lot of patients that not necessarily come in. We have, there’s two groups, right? One’s that come in in something called Status, which is where they’re continuing to seize, so they haven’t come out of their seizure. And then we get patients that come in through other medical reasons, but can also make their epilepsy worse. So then they all end up having a lot of seizures in hospital.

And just through being in the wrong place at the wrong time. I also have seen people having seizures in the community that I’ve caught over to help because as a medical professional, you don’t walk past somebody that’s in trouble. 

[Jaz]
Do you find that as a medical professional, that you are a magnet for these issues in the community?

[Rachel]
The amount of text messages I get with people showing their kids’ rashes is unbelievable. Yeah, I feel like I’m 111. So yeah. It is. And you know what, if me responding to a message about a rash in a text makes that parent feel, my friends, feel better about going to bed that night, then more than happy to. But you’re right. You probably get, can you do my root canal? It’s the same- 

[Jaz]
Pictures of teeth, awkward pictures of gums in like a really poorly taken image. So. 

[Rachel]
So yeah, I have actually come across a fair few sort of people just being in trouble out and about are just on my journey day to day. And seizures is one of them. So- 

[Jaz]
I mean, nasty stuff, unfortunately, one of my cousins had his first seizure recently and if I showed you photos of him, it’s not a pretty scene. You’d think that he’s going into a fight. And so this is a very scary thing when it happens. Or we worry about in the dental practice if a patient has his seizure. How can you make it safe for that patient? 

[Rachel]
Correct. 

[Jaz]
How do you make sure you don’t panic? And then how do you recognize it and get them the correct treatment? So let’s talk about that. How many seizures happen and it’s like, oh, that my first one? Do you see what I mean? 

[Rachel]
Well, interesting you say that. ‘Cause actually just a personal story. My nephew started having seizures at a very, very young age. I think he was about two or three, but we didn’t realize they were seizures. Because not all seizures drop, go unconscious and start shaking. They can sometimes be conscious when they’re having them and they can just literally move.

And what he used to do was his leg used to just shake like this, but just one of his legs and we just associated with, he did the toilet. So for years went by, unfortunately, but fortunately they did find and he had a tumor in his brain. And he had it surgically removed a couple of years ago. Gosh. And he’s been seizure free now for two years.

[Jaz]
Amazing. 

[Rachel]
But it went on for years. But they don’t all look like seizures, is what I’m trying to say. 

[Jaz]
So in the dental practice that we think that, keep everything safe, move everything away. Because we’re imagining someone really going for it, wailing around, but it’s always like that.

[Rachel]
And some patients can tell you they’re about to have one, which actually can be quite helpful. ‘Cause they can say, I’m about to have a seizure and you can actually prepare the station if they are. The biggest thing for dentistry is the equipment that you have around, because we talk about danger, like check for danger.

Now, what’s the most dangerous thing? Is all your instruments, they’re sharp. They are literally by the patient’s head. So the key thing with seizures, above all else, forget the medications. Forget is actually maintaining safety, your safety and their safety. So have a quick look around your surroundings. Make sure that you’ve clear- 

[Jaz]
So for us, that’s moving away our bracket table where the instruments move out the way, move the suctions stuff out the way. 

[Rachel]
Yeah, making sure that anything that they may thrash their head against, ’cause you don’t wanna cause a bit of a head injury if they are-

[Jaz]
In that classic group.

[Rachel]
Yeah. And then once you’ve maintained safety, then you can move on to, okay, how are we gonna support this patient? The only thing about the suction that’s quite helpful is if they bite down on their tongue, the tongue being a very big organ will bleed, bleed, bleed. So actually your nurses are perfect.

Because they are the kings and queens of suction, should I say? They’re great. So actually having suction nearby is quite helpful, particularly in your area. But it’s about maintaining their airway if they stay in that seizure for a prolonged period of time. It just depends- 

[Jaz]
What would collapse that airway from seizure? Just, oh, blood. Blood and blue ears. Okay. 

[Rachel]
And the fact that like, some of them aren’t in a very conscious state, so the tongue may fall back. So unless you open up their airway using head tilt, chin lift, or if you do pop them into the recovery position, make sure that you stabilize them.

But also, if you notice, when you put people into the recovery position, what people tend to do is keep their head down. What you need to make sure you always do ’em in a recovery position is pull their airway up- 

[Jaz]
As a stage one. 

[Rachel]
Yes. 

[Jaz]
But here’s the thing though, like from memory, I thought if someone’s having a seizure. You let them do it and you don’t kind of touch them. And so what you’re suggesting is that you may need to put them in a recovery position. So what would that look like in a dental practice, let’s say it’s happened to us and is it easy to diagnose a seizure? 

[Rachel]
If it’s a very, yes, it is. If it’s a very obvious seizure, whether sort of shaking quite vigorously, my first thing to do was maintain safety. So move all of your equipment out the way, call for help ’cause you need support. 

[Jaz]
Ambulance? 

[Rachel]
Definitely. Yeah. And then what I would do personally is I might just leave them on their back but keep their airway open. Some people like to get patients on their side and that would involve kind of you maybe having to get more than one hand. ‘Cause of course what you don’t wanna do is your back or anything. So you may need to turn the patient on the side, but just make sure if you do do that, you keep that airway open.

And really with seizures it’s about just reassuring them because you know if they can hear you and stuff- 

[Jaz]
Can they? 

[Rachel]
Yeah. Some patients- 

[Jaz]
So when, okay. Yeah. I dunno where it’s like, if you’re having any seizure, I dunno how receptive you are to what’s happening around. 

[Rachel]
Hear what exactly what’s going on.

[Jaz]
I never thought. 

[Rachel]
Yeah. When they’re having a seizure, so afterwards they’ll say, oh, like, I remember the dentist was really kind or, so it’s just about, it also makes us feel better as medical professionals to reassure, it’s okay, we are here and then- 

[Jaz]
Yeah. I’m so glad you said that, Rachel. ‘Cause in my mind if someone’s having seizure it, they’re not with it. 

[Rachel]
No. 

[Jaz]
And then once younger. Not that we ever say anything inappropriate in that scenario, but to give that empathetic tone. Don’t worry. We’ve got you. They’re gonna do this. You know- 

[Rachel]
And even just catching them, just having your hands on them. 

[Jaz]
I’m gonna put my hand here, I’m gonna do this and what you’re doing.

[Rachel]
Okay. Yeah. So reassure. And it is a little bit of a waiting game because with seizures we don’t usually intervene for five minutes. And then we would very much. 

[Jaz]
But you pull the ambulance though. 

[Rachel]
You called the ambulance- 

[Jaz]
You can’t get oxygen on. Or should you? 

[Rachel]
You can pop the SATs probe on, see if they need it. You don’t necessarily need to give them oxygen. If their SATs start to drop, yeah, then definitely get the oxygen out. And then actually the ambulance are very good at guiding you through what to do with seizures. They’ll usually say, wait until it gets to the five minute mark, and then they’ll advise to give your drugs, which is where we come to with your seizure pack.

[Jaz]
Well, the seizure pack. So firstly, let’s open up to everyone. Guys, this is a really cool way that the practice I work in manages the drug kit. It’s got the A for laminated card for epileptic fits and seizures, and so it says irregular jerky, movements rocking, shaking, stiffness, change to vision, hearing smell, change to breathing rate hallucinations, lost consciousness. It says Midazolam Okay. Here’s what we need to do. And it says, located on the top of antibiotic cupboard in staff room. 

[Rachel]
Great. So it even tells you where it’s- 

[Jaz]
Perfect. ‘Cause I would’ve forgotten. Yeah. 

[Rachel]
I’m not sure. It might be worth looking up, but in hospital Midazolam is a controlled drug, so we have to keep it in a twice-locked cage.

[Jaz]
In a locker. Yes. So it’s a locked. So you have to get in through back lock first staff room, and then we’ve got a key. Yeah. So- 

[Rachel]
Because the CQC will want it to be (stored) properly. 

[Jaz]
Yes. And so since, since we had the CQC, we’ve now got that on board. Uh, right. So what I’ll do then is let me go get it and let’s look at the pack. Okay. So I found my key very quickly. I’m very proud of myself and we have two, I didn’t expect this, but we have two buccal midazolam.

So one brand is called Buccolam. It’s 10 milligrams. And it says four prefilled oral syringes. This one expires this month which is why we have another one. And it’s called MidaBuc. Same thing. It’s 10 milligrams in one mil, but this is a five mil. So I dunno how this is. We’ll have a look. Alcohol free, sugar free. We’ll have a look. But what I like about this already is, the management here made it very easy. They’ve written the dose very clearly on here, on a sticker by pen.

So age 10 plus give one mil, five to 10, give three quarters of a mil, one to five, give half a mil, and so on, so forth. So it’s nice and easy there, which is good. And I’m looking at it now and it’s a bottle which has a little bit of liquid. I mean, it’s mostly empty in in there. And I’ve got four what looks like Calpol, type syringes in there and goes up to one mil. Any comments? 

[Rachel]
No, just that obviously being that Buccal Midazolam, it’s a very good drug. The downsides are, it’s costly. A lot more expensive than the alternatives. And the second thing- 

[Jaz]
What are the alternatives? 

[Rachel]
We use rectal diazepam. 

[Jaz]
Oh gosh. 

[Rachel]
But I remember coming to speak to you once Jaz and you saying that you deal with one hole only and it’s the mouth and not anywhere else.

[Jaz]
When you’re becoming a dentist and you have to choose between medical tool and dental school. You either look up one and look down the other and so I said, let me look down, not up. So here we are. 

[Rachel]
So I’m not sure you are gonna wanna go down the rectal right? 

[Jaz]
Let’s not talk about that.

[Rachel]
So when I suggested it to the team and said you could save yourself a bit of money and you wouldn’t have to have the stress of having it a locked, locked cupboard. It was very much a no thanks. We’ll stick with the Buccal Midaz. 

[Jaz]
So rectal, we’re not gonna go there. But, if we’re not giving rectal, so obviously in dentistry you also use Midazolam for IV sedation.

[Rachel]
Yeah. 

[Jaz]
So like, but to have to think in that scenario when someone’s having a seizure to then access venepuncture, it doesn’t make, obviously someone’s already in the middle of an IV procedure. Yeah. I mean it wouldn’t happen ’cause they’d be having them as in the system. But really the main way dental practitioner is, should be doing it, is Buccal Midazolam.

[Rachel]
Yeah, absolutely. And it’s easier for you and it’s so easy because of the fact that it’s buccal, so you don’t have to start cannulating them. It’s a lot, that’s a smaller dose, which also helps. So you’re not gonna kind of hopefully over sedate. But you do need to be mindful. And that’s why they don’t really like people in the community giving more than two benzodiazepine in the community.

And that they would then tell you to stop and wait for the ambulance. ‘Cause obviously knowing that it’s got sedation effects is it can sort of effect- 

[Jaz]
Respiratory suppression. 

[Rachel]
And then you end up causing them not to breathe and then you go down a whole different route. So there is a limit to how much you can give in the community, which is the right thing to do because I know you wanna get them out of the seizure, but what you don’t wanna do is cause more problems for yourself. 

[Jaz]
Well, and like you said, is that, look, if you notice this, very quickly and then you get all the team on board. You call the ambulance for the first five minutes. There’s actually nothing to do except reassure and calm.

And then by then the ambulance kind of remotely taking over and guiding you. And so, and when I learned about buccal midazolam, I thought it’d be like a gel. And you point your finger and then you deliver to the mouth is up. 

[Rachel]
It’s a bit, no, so, well, you’re probably thinking of that because of the whole glucose gel where you do kind of rub it round the gums. But no. 

[Jaz]
It’s a liquid. 

[Rachel]
It’s a liquid. The other thing is that most- 

[Jaz]
This is nice. This one actually, by the way. 

[Rachel]
Nicer. 

[Jaz]
Wow. Buccolam. Guys, I’m digging Buccolam way more than Midazolam. 

[Rachel]
Yeah, that’s already pre-filled. 

[Jaz]
Like a, very nice. Look at this. It’s all like pre-filled, all fancy pants. And just squirt it.

[Rachel]
No wonder it’s 40-odd pounds for- Yeah. Yeah. 

[Jaz]
Just squirt it into the mouth around the side. I mean buccal. 

[Rachel]
But the good thing is, and in majority of cases, and I won’t have the exact statistic, but most seizures should self terminate within the five minutes. 

[Jaz]
So in most cases you won’t actually need to give that.

[Rachel]
Yeah. You’re hoping. Yeah. So hopefully- 

[Jaz]
And all the ones that you’ve seen. 

[Rachel]
Wow. 

[Jaz]
How much times do you have to get the gloves out? 

[Rachel]
They are in it. Most days we would not probably cannulate them at that point and even try and avoid that. But yeah, if they’re coming to A and E, they probably are more likely to be in status because they would’ve tried at home to get them out of it. And the fact that they’re in A and E means that they’re struggling with them. 

[Jaz]
But epileptics in the community and they’re home. Do they keep buccal midazolam in their home and they’re allowed to? 

[Rachel]
Parents keep buccal midaz so they are allowed, they’ve got care plans and they would give them a dose of before even some of the parents who’ve children frequently have seizures, don’t even come into hospital.

They just know how to manage their children at home. And the older you get, you get different methods of managing it. ‘Cause it’s not, I wouldn’t say common, but parents are actually, funnily enough, one of the best in terms of your children. They’re the best carers. They know their children’s condition better than even hospital staff because they’ve been living with it for years. So, so yeah. Buccal Midaz is a very good drug. It’s just, it’s expensive and it’s hard to- 

[Jaz]
It’s expensive, but it’s mandatory. We need to have it. 

[Rachel]
Correct. 

[Jaz]
So there’s no way around it. And both these products, seeing them today for the first time. I mean, I know I’ve heard about it. You talked about it, but it was actually nice to- 

[Rachel]
It’s a good thing that it’s your first time seeing it. ‘Cause otherwise that means you had have used it. 

[Jaz]
Exactly. So this is all good and I’m learning as well. It was nice. See how it’s live again, I’m really happy with the fact that the dose is written here. It’s really helpful. It says here, age 10 plus two mil because this is for the Buccolam. It’s a different dosage- 

[Rachel]
It’s a different strength, maybe? 

[Jaz]
Maybe. Let’s have a look. Contains 10. So there’s two mil of the buccalam contains 10 milligrams. 

[Rachel]
This is 10 milligram of- 

[Jaz]
So the main thing is for the adult dose is 10 milligrams.

[Rachel]
You need to make sure that whatever you order you to make your life easier, that you write it down almost like what your, do your dental nurses check your box? Do they the ones that check it and keep it? 

[Jaz]
Practice manager and Chris and there’s a Zoe Okay. Lead as well. So plenty of people. And I’m looking at our cheat sheet again. And yeah, it matches nicely, which is good. Brilliant. Well, I think it’s one of those where it’s good to know and keep the environment safe. We need to have this drug buccal midazolam.

It’s good to see it and we talk about it, but it’s nice to know that probably we won’t need to give it because the ambulance will guide you. And then involve them the care. So top tip to call the ambulance right away. 

[Rachel]
Yeah. And the other thing is- 

[Jaz]
Don’t wait. Don’t think that, oh, let me just give you some Buccal Midazolam. 

[Rachel]
Yeah. And also just remember that actually safety comes first. So making sure that your patient is not freshing around, that you’ve moved all of the dangerous equipment around, and that you reassure. 

[Jaz]
Yeah. For me, the biggest takeaway in this conversation is just talk to the patient because for me, for some reason I thought, someone’s having a seizure, they will be outta it.

[Rachel]
Yeah. Whereas my nephew, William, he always was like fully aware of like what was going on around him when he was having them. So we used to just talk to him. Yeah, yeah, yeah. Tell him it was all right. 

[Jaz]
That’s really good to know. Hopefully I’ll never see one, but now I feel better if I was to, right. So I’m going through the medical emergencies box again. There’s a heart attack stuff, which we may not get to ’cause it’s very niche and I just want to, in the time that we have, we may cover it ’cause it’s important. But I’m just want basically talk out loud about what’s in my kit.

Stroke. Okay. And in the stroke there was no meds in the stroke, so that’s fine. Low blood sugar. And so I see the glucose gel inside here and that looks like out of date you are gone, but it’s labeled out of date. Because it then kind of tells you in look in the fridge kind of thing. So fine. We may get to talk about that today. And then the last one here is asthma. 

[Rachel]
Which we kind of covered, didn’t we?

[Jaz]
You covered a- 

[Rachel]
Yeah. Okay. 

[Jaz]
But I just wanted to do an overview of what’s inside the emergency drug kit and we’ll see how the rest episode goes. But let’s talk about choking. ‘Cause something that we’re gonna help out in the community and patients sometimes choke on what we use.

So in the dental practice and in the community, what is the current standard of care that the recess guidelines are recommending to us? 

[Rachel]
So recognizing choking is the first thing. So if this was you, Jaz, what do you think? If you were choking, what was your kind of, what do you think your instinct would be to do to try and tell someone you were choking?

[Jaz]
Make some sort of sound or wave my arms or- 

[Rachel]
Classically hold onto your neck. ‘Cause that’s kind of what we’ve noticed in seeing patients is that they grab hold of their throat and then they kind of point to their back, which kind of indicates like, help me because pure choking, you wouldn’t hear any airway sounds at all.

So if you’ve got some airway sounds, you’ve got partial, and actually we’re at a better place. But if you’ve got complete silence, the patient’s probably is choking on something, whatever they’ve- no, it tends to be nothing. 

[Jaz]
Wow. Wow. That’s good. 

[Rachel]
Yeah. I mean, you might get something initially, but if it’s completely blocked, then there’s no sound at all. So the first thing you’re gonna ask them is, are you choking? And if they don’t answer you and they’re kind of doing this, you can then-

[Jaz]
They might nod though. 

[Rachel]
Well, if they’ll nod probably, or they’ll just kind of, ’cause they’re so panicked, I think you’re in this position where you literally can’t breathe. You are gonna be so scared. So yeah, they may nod and say yes, you know, not say yes, sorry. But they may nod to tell you that they’re choking.

The next thing you are gonna do is ask them if they can cough. Because what you’re gonna try and get them to do is cough themselves to try and get it out. But if they can’t, then you need to intervene. So best position is if they’re standing up, we’ll get them to stand up and then tilt them as far kind of forward as you can. So that gravity helps. 

[Jaz]
So if then they’re in the chair, they’re choking on something, you need to bring the chair up. 

[Rachel]
You bring the chair up and actually try and even get them even more forward than that. So, I don’t know if those of you who are watching- 

[Jaz]
So what we’re just describing, we was driving to those who are listening, bring the chair up to the lower position and then get the patient to lean forward. And now you’ve got space here too. And give them back slaps. 

[Rachel]
Exactly. And the advice is give up to five back blows. So obviously if they spit out on two, don’t feel the need to keep going with the good measure. 

[Jaz]
Depending on how much you like. 

[Rachel]
Exactly. So you’re gonna support their chest so that they don’t go flying forward. And then between the shoulder blades you are gonna deliver. 

[Jaz]
But I’m just gonna pause you before you get to the stage again. Like the other medical emergencies we’re like, it’s a team effort. So, but here, I mean- 

[Rachel]
You might not have any for the room. 

[Jaz]
Yeah, that, but also like at this stage you just want to get the back those in. There’s no ambulance just yet on. 

[Rachel]
I mean, if you had one of your dental nurses in the room, you could shout with. Not shout, but you could ask her to go and call the ambulance. 

[Jaz]
Okay. So it’s still fair to -? 

[Rachel]
Yeah, absolutely. But you need to get on with this part. ‘Cause this is, you know- 

[Jaz]
And it’s worst case scenario to get the obstruction out, then tell the ambulance, oh, we’re sorted now. And they’d be happy to hear that. 

[Rachel]
Unless you do abdominal thrust and they should still go to hospital because you could have caused a bit of trauma.

[Jaz]
Okay. So basically abdominal thrust equals should definitely go to hospital families. Okay. 

[Rachel]
So yeah, up to five black blows each time, checking to see if the objects come out. When you get to five, if they’re still choking, then you need to move to abdominal thrusts. 

[Jaz]
Which used to be called the Heimlich maneuver.

[Rachel]
It used to be known as the Heimlich. Apparently the family didn’t wanna be associated with choking, so they changed the name. 

[Jaz]
I associated it with the resolution of shape, not the choking itself. Come on. 

[Rachel]
So the position is, and this is the bit that people always get confused, is you are aiming above the belly button below the xiphisternum, so below the rib cage, essentially. So it’s this space here. For those of you that are- 

[Jaz]
What was confusing? 

[Rachel]
Just because people dunno what a xiphisternum is. If you are a layman and you’re not medical, and what’s a xiphisternum to my husband? 

[Jaz]
I’ve had sternum, but I’ve never had some xiphi. 

[Rachel]
Xiphisternum. Yeah. I can’t remember how you spell it.

[Jaz]
Even I haven’t. Yeah. Okay. 

[Rachel]
It gets confusing. So when I explain it to people, I always say, just aim for above the belly button. 

[Jaz]
Above the belly button? 

[Rachel]
Yeah. Okay. Make a fist and then just above in that space I just told you about, and then with your other hand, you’re gonna wrap round, and then you are gonna do an inwards and upwards motion. In and up, up to five times. 

[Jaz]
Now, let’s talk about the patient in the chair. As they’re leaning forward, yeah. You’ve done the back blows, at this point now is this something that you expect me to deliver? Like from- 

[Rachel]
If they could easily get up, if they weren’t frail, you could ask them to stand up. The difficulty is if they’re frail, it’s gonna take you so long to get them out of the chair and stood up. That actually you may then need to- 

[Jaz]
So push comes shove, just do what you can. 

[Rachel]
So what I would do is I then sit them back in the chair. And essentially come round to the front and then with the palm of your hand in exactly the same position. I’m gonna do an inwards and upwards motion. 

[Jaz]
Okay, so this is like a modified correct racial technique of the ratio. So this is a modified abdominal thrust using one hand. 

[Rachel]
One hand in and up. Just dodge a bit of food that might come out and get you if you are from the front. 

[Jaz]
Or the dental instrument or whatever, obstructing. 

[Rachel]
Because obviously you are right in front of them now, so you are in. 

[Jaz]
We’re using wearing loops and glasses and that kinda stuff anyway, so we are good and mask and stuff, so fine. And so do that five times. 

[Rachel]
Up to five times and then if that doesn’t work and the object is still in the mouth, then you go back to tilting them forward and back to, so you alternate every five, five back blows, five abdominal thrusts, five back blows, five abdominal thrusts until the object comes up. 

[Jaz]
But if you’ve done even this one handed abdominal thrust, they really should be able to get the stuff out. They should be- 

[Rachel]
Ideally. 

[Jaz]
Looked after. 

[Rachel]
Unless they used, and you can’t do anything about that. If they say, I don’t want to go to hospital, I’m fine, then that’s- 

[Jaz]
Your advice should be, your guidelines would be- 

[Rachel]
You might cancel the ambulance and then you’d let them get their own way up there. Because they won’t need a time to call ambulance. 

[Jaz]
But the most important thing is that while this is happening, like I can imagine like, one person is dealing with the actual, the abdominal thrust, the other person, the phone’s right there speaking to the ambulance, right. Put ’em on speaker kind of thing. So that makes sense. 

[Rachel]
And then hopefully it comes up. If it doesn’t, eventually they’re gonna become hypoxic and they’re gonna collapse into cardiac arrest. And then you would go down your CPR with airway defib management. 

[Jaz]
Okay. That’s very helpful. And this is actually a very serious thing because I know a friend of a friend, unfortunately, who passed away at an airport, he was literally just eating a donut. Yeah. And then he started choking and he died. And so this is the- 

[Rachel]
I think we talk about grapes, we talk about sausages, we talk about blueberries, steak, red meat seems, but we don’t talk about the other things that still, I mean, I was just speaking to a GP earlier and they said that their husband choked on bread. So, yeah. It’s not always your, we are very good at chopping up grapes, but- 

[Jaz]
Yeah. And I’m so glad you mentioned grapes, right? Because my wife is really particular about my kids and the grapes and stuff, but I was a little bit blase, right. Because my little one just loves to grab it and go for it.

Yeah. And I’m not gonna chase him to take the grape off and cut half. However, literally two days ago on my Facebook, I saw a radiograph of a great stuck in the airway, but it was like partially obstructing it so the child was able to breathe. Uh, sorry. Yeah, yeah. They done that shifts. Exactly.

So that made me realize, and the advice on that Facebook post was anyone age five or under choked on grapes. And so you totally agree with that? 

[Rachel]
I do. I do. I just think it’s not worth it. It’s funny ’cause I don’t chop my grapes for my 8-year-old now unless she goes to school and then I do because for some weird reason, if she’s around me eating grapes, I feel fine because I always say sit down, don’t talk when you’re eating them.

But at school, I don’t trust that she’ll shove ’em in her mouth and chat to her friends and then get up and go and get something. So I still chop them for my 8-year-old. 

[Jaz]
Okay.

[Rachel]
Once it’s there. You can’t ignore it, can you? And you never- 

[Jaz]
Now that I’ve seen that radiograph, honestly, I like, once someone listens to this and they got like young children, they’ll realize that. Okay, now- 

[Rachel]
So sausages are a big one and I think we don’t talk about them as much, but I guess we all just need to sit down and not talk when we eat. And do have good- 

[Jaz]
Mindful eating. 

[Rachel]
The only difference between what I’ve just discussed is for the under one. So for your under one, we tend to not do abdominal thrusts because we don’t wanna cause any injury to their liver.

So we move to chest thrust. So exactly the position where we do CPR. So sort of lower, further sternum. Between the nipples. For an under 1-year-old, we would do two fingers and we would do five short, sharp chest thrusts. So kind of one- 

[Jaz]
While they’re into- 

[Rachel]
Kind of over your knee kind of head down. So you’ve still got gravity. And then if you imagine the baby’s kind of on my arm, I’d be doing like one, two on their chest. She like me to get more mannequin out. 

[Jaz]
You got baby mannequin? 

[Rachel]
Yeah. 

[Jaz]
Alright guys. Rachel will describe what she’s doing with the baby mannequin, again, as she’s doing it. But I just wanna see it, for those of you who are maybe watching this. But she’ll describe it. Oh, I go, we got a baby mannequin as well. 

[Rachel]
So here’s my little mannequin. So essentially you would still start over your knee, so get yourself into a sitting position there. 

[Jaz]
These face down, face down over your legs.

[Rachel]
And the reason you wanna sit down is not ’cause you’re feeling lazy, it’s because actually you don’t wanna drop the baby. So get them into the kind of over the knee position between the shoulder blades. Same as sort of adults. You’re gonna deliver up to five back blows each time checking to see whether that object has come out.

Once you get to five, you’re gonna rotate the baby over supporting the head as you do so, and you’ve still got gravity on your side. And then mid nipple line, you are gonna do five short, sharp chest thrusts. And then if they still, no luck- 

[Jaz]
In this position isn’t like, if the food’s in- 

[Rachel]
I know what you mean. It will go to the roof and then you can turn them over and it’ll fall out. 

[Jaz]
So you’re kind of almost holding the baby upside down. 

[Rachel]
Yeah. ‘Cause you just kind of want, and also what you don’t wanna do is do this. ‘Cause then obviously you might. 

[Jaz]
Yeah, yeah, yeah. So you’re sat down to prevent the baby falling where the baby is. Almost upside down. Vertical. And then if the food comes out, you can just turn ’em over- 

[Rachel]
Send ’em over, and you could give them a gentle squeeze of their cheeks if you want. We try not to start rooting around in people’s mouths with fingers because we could push the object further down cause no problem. 

[Jaz]
Yeah, great. I’m very happy with covered choking because again, it’s like you said something, a life skill for community. So beyond just dentistry. So I thought it was worthwhile covering. 

[Rachel]
It’s a very good life skill, and actually a lot of the stories I hear isn’t, again, isn’t even in A and E, isn’t even in the hospital.

It’s not in the dentistry, it’s not in the GP practice. It’s at home with your young children. Because they’re naughty, aren’t they? They love to explore. And my daughter used to have this thing where she’d stick things in her mouth, look at me and run away ’cause she thought it was hilarious. And I have to try not to react. If you react, she runs faster. So yeah. They’re little pickles. 

[Jaz]
Yep. You’re definitely saying things. I’m seeing day to day my household. 

[Rachel]
Yeah. 

[Jaz]
Right. Great. The next one we wanna cover Rachel, is hypoglycemia because I think you made a wonderful point before we started to record. A lot of patients think it’s okay and they that they should be skipping breakfast. I dunno, from the medical background, go for GA or whatever and they think, oh, I shouldn’t eat. Whereas before and a plan extraction appointment, I’ll tell my patients, please eat. I want you to have energy and feel good.

So unless that’s normal for you. Okay. So patients come in maybe potentially starved. And then this may lead to a hypo, but does that work for all people or people who are diabetic and just tell us more about- 

[Rachel]
Maybe diabetic. 

[Jaz]
So why is that? 

[Rachel]
Because they find it difficult to regulate their blood sugars, so that’s their condition. So it depends on whether you’re a type one or a type two diabetic. Type. One more relying on sort of insulin type two could be diet or tablet form of insulin instead of injecting. That’s a general sort of description of it. But the tricky thing is, is that, I mean, I’ve been there before where I’ve had a morning appointment with the dentist and I’ve not wanted to eat just ’cause I don’t want any food in my teeth even.

And then like, I brush my teeth now so I’m not gonna eat. And what we worry about with diabetics is that if they have to eat regularly to maintain their kind of blood sugars, they may have even given themselves their own insulin that morning, particularly if they’re a type one diabetic. So they might have injected themselves with insulin.

They’ve not eaten to kind of balance out the insulin, and then they’ve come in thinking it’ll be fine, and then suddenly their blood sugars have dropped. And the effect of that can be, people can manage it with no symptoms at all. Or some patients can really show symptoms of a hypoglycemic attack.

[Jaz]
Classically, it’s like that someone’s drunk. You think they’re drunk? 

[Rachel]
Absolutely. So you can get confused. 

[Jaz]
Oh, without the smell of being. 

[Rachel]
Yeah. 

[Jaz]
Okay, fine. 

[Rachel]
So you can feel confused. You can be clammy. Sweaty, and I dunno if you’ve ever seen it, but patients that I’ve seen that are having a hypo usually get these like pools of sweat on their head.

They’re like little circles of sweat. Confusion. Some patients can be aggressive ’cause they’re not quite sure what’s going on, so they can get quite aggressive. One occasion where me and my husband were driving around where we live. We were following this car and the lady, it was a lady in front of us and she was swerving all across the road, and my husband being in the job that he’s in, just assumed straight away she was drunk or intoxicated or under the influence of something.

So he said to me, right, you need to call 999 now, she’s drunk and intoxicated and you need to tell them that we were in pursuit of a drunk driver. So I was like, we’re in pursuit of a drunk driver. 

[Jaz]
He’s a copper. Yeah? 

[Rachel]
He’s a copper. And so we followed her and she was pulling out on roundabouts with not checking. She was mounting curbs. And he was furious in his head. He was like, right, she’s in, you know. Anyway, so we called her in. They sent out a response team. They ended up boxing her in ’cause she was so unaware. She ended up meeting boxing in, she got out of the car and we were kind of sat further back in the car, in our own car and I said, oh, she doesn’t look well, Dan.

And he was, he was like, wow, that’s because she’s under the influence anyway, it turns out she was the type one diabetic and her blood sugar was something like one, oh, she’s severely low. And she was probably borderline going into a coma. And fortunately one of the police officers had a can of coke in his car. Gave it to her when she came round. 

[Jaz]
Oh, the brands of her diet. Sodas do exist. 

[Rachel]
Yeah. And when she came round, she was mortified. ‘Cause she hadn’t even, she wasn’t even aware that she was driving like that. It had almost gone so far down the line. 

[Jaz]
Wow. 

[Rachel]
So she was completely oblivious to the fact that. She was having a hypo and it was, you know, of course my husband had to sit there when the officer came over and said, well, I thought she might be unwell, but they might not be able to tell you is the kind of story, the purpose of that story is they might not be able to tell you they’re having a hypo.

Not everybody knows they’re having one. So just be mindful that taking a history, asking them are they diabetic? If they’re acting slightly great. 

[Jaz]
Yeah. So if a non-diabetic, your body’s adaptive mechanisms and homeostasis really wouldn’t let your blood sugar get below four. 

[Rachel]
Exactly. Yes. But whereas when you’re diabetic and you can’t regulate and your pancreas isn’t working correctly, that’s when you need help. And my worry is just the fact that if I feel like I don’t want to eat before coming to the dentist, how many other people feel like that? And then you might have be presented with somebody that does have a low blood sugar and you don’t have the equipment to check it.

The good thing about medicine these days is a lot of people have these sort of internal devices that measure- 

[Jaz]
Tried one for a week, John give it two weeks. It wasn’t Zoe, the Libre. 

[Rachel]
Okay. Yeah, I’ve heard of it.

[Jaz]
Libre. Yeah. It was brilliant to get an insight- 

[Rachel]
To what Spike and what, yeah. 

[Jaz]
So I had this birthday cake and I was waiting for the spike. It never came. I had a Cajun chicken wrap from Costa and it shot up like the moon. So yeah, it was really interesting. 

[Rachel]
It helped, really helped. My dad did the same thing and it really helped him to know, but you know, so you could always even ask your patient, do you have a monitor on that? We can have a look on your phone.

‘Cause again, they might not be aware. So if you can identify or even just take a clinical history that you think that they are having a hypo low, that always helps me remember hyper high. Then administer your emergency hyperglycemic pack, which you, I have seen, you’ve got glucose gel. 

[Jaz]
Okay, let’s get that out guys. So labeled as low blood sugar and again, in this zip wallet, this a four zip wallet. I’m gonna open this one up guys. And I’ve got administration of adrenaline that shouldn’t be in there. Okay. That was probably me. Okay. So I’m gonna put that one where it belongs. Okay. So hypoglycemia, shaking, trembling, slurred speech, tingling of lips and tongue hunger, palpitations, sweating, double vision, unconsciousness.

Okay, so that, that’s all there. And then it says drug glucose, stroke, sugar, different forms. So, non diet fizzy drinks, glucose powder and water glucose tablets, glucose gel. And then in severe cases, GlucaGen® HypoKit. 

[Rachel]
Glucagon. 

[Jaz]
It should be gone. 

[Rachel]
Yeah, but it’s this- 

[Jaz]
There’s a typo in this guy.

[Rachel]
So this one’s got writing all over it, essentially. But in your practice, you’ll have something called, well I call it- 

[Jaz]
Hypertop. 

[Rachel]
Well, it actually does say Glucagen, but oh, glucagon. There you go. Glucagon, hydrochloride. 

[Jaz]
Oh, that’s a brand name. So glucagen is like the brand name. 

[Rachel]
And Glucagon is a hydrochloride. So yeah. The good thing about this is it’s not pre-filled, but it’s got the, in fact, I can open it. Yeah. It’s got a little powder. And then it’s also got a syringe with some water in it. And what you do is you administer the syringe into the powder, give the powder a bit of a shake, and then pull back and drop as clean.

[Jaz]
So you open the lid of the needle though? 

[Rachel]
Yeah. 

[Jaz]
You put the needle into the powder? 

[Rachel]
Correct. 

[Jaz]
And then you make the like antibiotics. So like with children’s antibiotic. Okay. If I know all too well about that. Okay. And then you draw it up again. 

[Rachel]
And then you administer it. 

[Jaz]
Okay. And does it say the dose here. 

[Rachel]
You give it subcutaneously or intramuscular. So you took the whole thing. 

[Jaz]
Like, adrenaline? 

[Rachel]
Yeah. 

[Jaz]
Okay. And then I’m just trying to find the dose. Inject one mil for an adult. 

[Rachel]
Yeah. And this is really helpful for your patients that are, you are worried that aren’t safe to swallow. So if you look down your little signs and symptoms, if you are getting to the point of unconsciousness, you’re not gonna want to give oral sugar because the patient could end up in the lungs, they’ll aspirate sugar in the lungs is not great. So you would move on to your IM. 

[Jaz]
So you move straight to that. 

[Rachel]
Correct. 

[Jaz]
But here’s the thing, then let’s try and understand. At what point should we thinking go get a biscuit or go get a sugar drink. 

[Rachel]
So I guess it depends on if they’re alert and they can swallow normally, then absolutely go for the kind of oil.

[Jaz]
So we’ve got like water, so the dextrose is powdered or whatever it’s and give that to them. 

[Rachel]
All your gels here? 

[Jaz]
Yes. The gel. Yeah. 

[Rachel]
Let them swallow one of these, rub it around their gums and let them swallow the deck with the dextrose gel. They’re really great. You can also, it’s simple things if they’re like low, but actually they’re not severely low and they’re not even confused yet. But, they tell you that their blood sugar’s like 3.5, they’re not feeling great. 

[Jaz]
Okay. So the instances where I’ve done this we’re without really thinking much of it and actually putting the label of hypo is patients who just, they’ve skipped breakfast, but I know it’s not normal for them. And before I start my extraction, I was like, look, can I just give you this? And I’ve done it preemptively. 

[Rachel]
Yeah. Digestive biscuit. Cup of tea with some sugar in juice. 

[Jaz]
Yeah. Orange juice. 

[Rachel]
Yeah, orange juice. The best things for people having a hypo usually is jelly babies because they are very good at bringing it up quite quickly. If you speak you- 

[Jaz]
You saying both swears by jelly babies before a race. 

[Rachel]
Yeah. Well I can imagine. Maybe that’s what we’re missing out on. Well, having spoken to some of the diabetic nurses that I work with, there is, they say that sweets are much better than chocolate. ‘Cause chocolate, the carb count is quite high.

[Jaz]
Dairy. Is that okay with it? 

[Rachel]
I don’t know. I think it’s more to do with the carb count in chocolate and it gives spikes and whereas apparently jelly babies are better. 

[Jaz]
There we go. 

[Rachel]
So that’s what I stick with. Buy yourself a packet of jelly babies. Keep ’em in your drawer. I know dentist- 

[Jaz]
They’re not gonna survive a day in past- 

[Rachel]
But they will in dentist. Because you guys don’t have sugar. 

[Jaz]
We never ever have a waiting room, uh, sorry. A staff room full of sugar. 

[Rachel]
So, yeah. So in terms of what I would give, if they’re awake and alert and their swallow is fine, I would always go for, just start with your cup of tea and your sugar, digestive biscuits, jelly babies. If you feel like they’re quite severe, or that’s not gonna work. You can go for your glucagel- 

[Jaz]
Now, again, I’ll ask you this question again. You are assessing this, it’s kind of dynamic and you are giving the glucose gel at this stage. Is it worth calling ambulance at this stage?

For me, I think it’s preemptive and perhaps it shouldn’t be. At this stage-

[Rachel]
If they know their diabetes really well, then no, because they know they’re, these patients, if they’re well controlled usually, or even just they know themselves, I would be guided by them because actually they might get hypos quite a lot and they know exactly what to do and not necessarily need to go to hospital.

If you’ve given them sugar and it’s still low and just still not happy and you’re gonna be sending home a patient with a low blood sugar, then I absolutely would advise. 

[Jaz]
So maybe, so put it this way, if you’re thinking to give glucagon, is that a good point for your nurse we call in the ambulance while you are, while someone’s looking after and while you gone.

[Rachel]
I think you’re giving IM sugar or glucagon. Yeah. Then you need to- 

[Jaz]
That makes sense. 

[Rachel]
Am I really happy to discharge this patient back into the community? 

[Jaz]
Good point. Yeah. Okay. 

[Rachel]
‘Cause you don’t wanna be lying there at night worrying about did they get home okay. Or you know, it’s a tricky decision. 

[Jaz]
Have you ever had to administer glucagon? 

[Rachel]
Oh, lows. Yeah. 

[Jaz]
Okay. So again, it just like the adrenaline. 

[Rachel]
Yeah, exactly like that. I tend to either do subcut in the tummy or- 

[Jaz]
You don’t do subcut though, do we? We do intramuscular. 

[Rachel]
You probably are more used to, or in the arm. You could go in the arm. But to be honest, we’re a bit luxurious and hospital, ’cause we have IV fluids, so we would probably skip the glucagon and we’d go straight for the IV dextrose glucose because we have access to that. But for you guys’s, that’s a brilliant. 

[Jaz]
So because we’re already, we’re taught for the adrenaline to go up out thigh, we can do the same thing.

[Rachel]
Yep. Correct. 

[Jaz]
And then let’s say- 

[Rachel]
As I am. 

[Jaz]
Yep. Point. So we do that. And then how long do we wait for to see a response? 

[Rachel]
Oh, I’d probably give it a good 15 minutes for it to kind of kick in. And then I- 

[Jaz]
By this point you’ve called the ambulance ’cause we’re now in glucagon territory. 

[Rachel]
Yeah, yeah. 

[Jaz] And you get them guidance from there as well?

[Rachel]
And then I would see how they respond to it. Obviously you’ve only got one chance with glucagon, but meanwhile, what you don’t wanna do is overload them. Like, you see them pick up, but then you’re still shoving jelly babies in their mouth ’cause of course you’ll get a massive spike.

So I would genuinely just give the glucagon, see how they feel. Have they started to react to it? Have they started to come round a bit more? They’re a bit more alert. They’ll usually say, I feel much better. Because of course when you’re having a hypo, you feel dreadful. Whereas when you start to get sugar, you feel a lot more human.

So be guarded by your patient. If they’ve got a monitor, great. Obviously-

[Jaz]
Nowadays, with these diabetic patient, like I said, the technology is amazing. 

[Rachel]
It is. 

[Jaz]
To have that. 

[Rachel]
If they accept it. 

[Jaz]
That’s true. Right. So last one guys, let’s discuss an important one. Something that often worries me because the one that worries me the most day in, day out is my patient who I’m doing some sort of surgery on. And they have like a heart stent or history of myocardial infarction, or they’re on loads of blood pressure medicines and a history of angina and that kinda stuff. And I worry about that. I kinda can, anything that I’m doing exacerbate and flare up or cause myocardial infarction.

So the one we worry about is them having adrenaline in our anesthetic. And that causing their heart to race. And then actually putting their heart under stress. And there’s actually lots of mixed opinions in dentistry about this. So some people think that there’s no point in worrying about it ’cause adrenaline is natural and the body market up and that.

Exactly. And actually, if you cause pain to that patient, then that’s gonna cause an adrenaline spike anyway. And that’s probably worse. Yeah. Whereas other people say that actually avoid all these anesthetics that can train adrenaline, use adrenaline free anesthetic. But of course, regardless of anesthetic, it doesn’t work as fast and it’s just how long it actually lasts for in general is shorter as well.

Yeah. But that’s just one facet of it. Just generally doing, working any treatment on these patients who are cardiac risk. It doesn’t have to be anesthetic. They could present with some sort of symptoms in the chair. 

[Rachel]
They could. 

[Jaz]
So tell me about the classic things that we should be looking out for in our patients. So obviously the first one being the medical history. Having that kind of kind of stuff. But you taught me, Rachel actually, and I think it was you that taught me this the first time someone has a heart attack, I think half of them actually pass away. Is that right? 

[Rachel]
Oh, I’m not sure I told you that. Maybe someone else told you that. 

[Jaz]
But is that right there? 

[Rachel]
I’m not sure, to be honest. I wouldn’t know whether that statistic was right. But I mean, let’s talk about the classic symptoms. Should we cover that? So you can have an MI myocardial infarction anywhere. And it would just happen to be very unfortunate if it ended up happening with you.

Do I think that having a procedure could increase the cardiac workload? Yes. Do I know enough about whether giving them adrenaline would push that further? Not so sure. 

[Jaz]
It’s just something that we think about as dentist. 

[Rachel]
But in the end, I think you can scare yourself so much that you then end up, do you undertreat? I dunno, that’s a question for you. 

[Jaz]
I do think though, for these cardiac risk patients, I use a plain anesthetic and I feel as though it works a lot. 

[Rachel]
Lots of people use a plain anesthetic now. I’ve actually not seen a dentist surgery that has adrenaline anymore in their anesthetic in a while. But you’re absolutely right. You’re taking a good history as you do that every time a patient comes that yes.

You are asking them if they have any cardiac history, whether they have angina, whether they have heart failure or anything like that. And then what do you think the key or the classic symptoms of a heart attack are? Or a myocardial infarction if you’re using the correct term? 

[Jaz]
So, pain in the chest. Radiating. 

[Rachel]
Yeah. So what about the pain would you be really worried about? Because let’s be honest, the chest is a big area. 

[Jaz]
Crushing pain. 

[Rachel]
Yes. Absolutely. So it’s that tight crushing pain that we really are concerned about where one of my patients described it as he felt like an elephant that sat on his chest. And he’s never had an elephant sat on his chest, I think. But it was that description of that such pressure going on on his chest. So yeah, that’s one of them. 

[Jaz]
It can sometimes radiate to the arm. Jaw. 

[Rachel]
Yeah. Up into the jaw and down predominantly the left arm. Pins and needles down the left arm. And what else? Anything else? Nausea. 

[Jaz]
Okay. Yes. Sweat. 

[Rachel]
Sweaty. Very, very clammy. There’s pools of sweat I mentioned with hypo. You can get exactly the same within MI. Yeah. Nausea, vomiting, sweaty, clammy, impending doom. So again, a bit like anaphylaxis, they say they feel like they’re gonna die. Blood pressure drops usually. Not always- 

[Jaz]
But here’s the thing where this is happening, right? I’m going back to that very first episode we did. Right? You’re thinking, oh, are they just feeling a bit faint? ‘Cause I’ve given adrenaline and then could it be a faint? Could it be a vasovagal syncope?

[Rachel]
Panic attack. 

[Jaz]
Panic attack. Yeah. So there are still a few differentials now. Yes. You’re gonna treat, you’re more likely to treat it as a cardiac issue. If they have a cardiac history. So if they have a cardiac history, I think your safer treat is a cardiac issue than a faint.

So you’re treating it as that, but at this point then, okay, get on the ambulance. You call the team and let’s start working on it together at this stage, right? 

[Rachel]
Yes, exactly. So the other thing slightly with more panic attacks slash faints is that they’re very brief. So they would come along quite quickly, quite suddenly, and then they would go, ’cause of course you can’t keep up a faint forever, can you, we talked about it earlier, but you are, in your experience, it’s 90 seconds to two minutes. Whereas with an MI, it’s gonna go on, it’s not gonna just stop.

So I guess the time also makes a difference. The history makes a difference, like medical history in terms of obesity, smoking, that kind of thing, that all adds to a picture, doesn’t it? If you’ve got those classic symptoms. And there has been a lot of studies that have been going on for years now about classic symptoms, but also sometimes women complain of generalized chest pain radiating to the back.

Kind of around the bra strap line. So we also just need to be mindful that you’re not always gonna present if you’re having an MI with your classic crushing up into the jaw, down the left arm. So you’re presented with someone that you suspect might be having an MI. You’re gonna call 999, because you definitely don’t want them staying in your dental practice for too long.

[Jaz]
Someone’s gonna get the drug kit. 

[Rachel]
Someone’s gonna get the drug kit. What? 

[Jaz]
And oxygen. 

[Rachel]
Yeah. From memory, what do you think’s gonna be in your drug kit? 

[Jaz]
Well, nitrates is what, remember? 

[Rachel]
Yeah. GTN spray. 

[Jaz]
So let’s have a look. Let’s get it out. So here we are. Someone’s got a heart attack, suspected, and then here is the zip wallet for heart attack. Again, guys, I’ll make this all available to you guys. And again, it says severe crushing chest pain may radiate to neck. This is so helpful. Yeah. Pale, sweating, nausea. It’s like a little cheat sheet just to give you some reassurance. And then it says, drug, GTN spray, aspirin, if no known allergy, and over 16 years and oxygen.

[Rachel]
Perfect. So with the aspirin, it’s the 300 milligram dose that you’ve got, which you can see that you’ve got in there. It’s actually a really handy drug to have at home aspirin because it’s cheap. Cheap. 

[Jaz]
It’s dread for aspirin. Yeah. 

[Rachel]
And it’s actually just- 

[Jaz]
So the standard dose, like 75, right?

[Rachel]
Yeah. People take 75 like headaches and things. But for a heart attack, they advise you have 300. Something that you can buy over the counter, something you can have in your home, but also really easy to have in the dental practice. Then you’ve got your nitrate. 

[Jaz]
So we’ve got two in here.

[Rachel]
That’s a lot. 

[Jaz]
So maybe ’cause one’s out date. Maybe. Let’s see. So one, oh, they both expire Feb 2026. So we’ve got two something. 

[Rachel]
May be easier to order two. 

[Jaz]
Buy one, get one free. 

[Rachel]
Yeah. Obviously be mindful what I said in episode one about the fact that it’s a vasodilator. So your patient’s blood pressure will drop.

So one spray at a time. If the pain goes after one spray, that usually does mean it’s cardiac related because it’s helping with the the pain. So- 

[Jaz]
I mean, your job, if you’ll experiencing something like this, your job is to keep the patient alive and well until the ambulance come basically.

[Rachel]
Absolutely. Yeah. 

[Jaz]
We’re not treating anything, we’re just managing it until help comes. 

[Rachel]
You’re with their pain, you are giving them some aspirin. I would probably wait till the ambulance advises that. Just because it’s very good to have them kind of knowing what you- 

[Jaz]
So do you think it’s, while the nurse calling the ambulance- 

[Rachel]
Get it ready. 

[Jaz]
So don’t you suggest, because now it’s so easy to quick and get the ambulance and dental practice. 

[Rachel]
Take their advice.

[Jaz]
Maybe hold off giving anything until we’re through them. Obviously it’s taking, if there’s a delay for any reason, then then go for it. 

[Rachel]
Yeah, absolutely. Because the only worry is, is like you say, if they don’t know they’re allergic to stuff, but actually this is, you’re kind of trying to weigh up, this is life and sort of death situation, isn’t it?

Like what you don’t want to do is not give something and then think further down the line. Or would the aspirin would’ve helped, you know? Anti clotting, antiplatelet drug. That could have made a difference. But- 

[Jaz]
So realistically, you’re suspecting this. You are gonna call the team. Okay. Someone get the immersive drug here. Someone called the ambulance. Speak to the patient. Yeah, try and think, you know what the ambulance, describe what’s happening. Hopefully the ambulance will get connected soon. They’re like, this is what we suspect, you know their medical history already. And so GTN- 

[Rachel]
And then give some aspirin, one tablet, 300 milligrams of aspirin. Reassure your patients, because obviously they’re gonna feel really panicky this point and the key treatment which you have-

[Jaz]
And oxygen as well. 

[Rachel]
As required. So they did a study a few years ago, which showed that actually you don’t need to give 15 liters of oxygen, somebody having an MI if their SATs are above 94%.

So we hold off. So pop the SATs, probe on them ’cause you’ve got it. If their SATs are above 94, you don’t need to give oxygen. If you don’t quite trust the saturations and their peripherally shut down and they’re cold and you think that they look gray and awful, then by all means go for oxygen because it’s better, as I said, to treat. That way around. And then time is muscle. So I dunno if you’ve ever heard that saying, but- 

[Jaz]
Heart muscle. 

[Rachel]
Heart muscle. So they need to be within a cath lab within 90 minutes, ideally with a stent. So they need APPCI. So they need to go to, our local one would be reading care. There are 24/7 centers, so they have an on-call cardiologist and they would pop in the stent and try and get the perfusion back to the, they would pop stent in the coronary artery to get perfusion the heart back perfused, essentially. So time is muscle, ie, we don’t want part of that heart muscle dying every sort of minute that we leave it. So the priorities are ambulance, reassurance, get the defib nearby because of course, what we don’t, what’s could happen is the patient could end up in cardiac arrest. 

[Jaz]
It’s like we did mention that. 

[Rachel]
Yeah. Yeah. So I would actually, along with your medical box, I would also bring the defib in the room just in case. 

[Jaz]
I think when something like that happens, you know, God forbid, but like the team would just bring everything. So the emergency drug kit, so you can access to your GTN and your aspirin. The defib in the side, the ambulance on the phone, on speaker, yeah. 

[Rachel]
Basically in numbers. 

[Jaz]
Yeah. 

[Rachel]
So, and everyone’s brain brings something new to it. So, you might have an idea, someone else might remember to bring the defib in. But the key thing is preventing cardiac arrest and trying to reperfuse that heart. 

[Jaz]
I think one thing we follow is that someone, when someone’s had a recent MI or recent acute episode in a transit ischemic attack. ‘Cause that’s like a mini stroke, isn’t it? Or not?

[Rachel]
Yes, it is. That’s another term for it. Yeah. 

[Jaz]
So those kind of patients, we kind of defer anything elective. For a while. Just trying to stay safe, but looking at the medical history and identifying that at risk patient. But again, if it’s their first time having this, yeah, then it could be anyone.

[Rachel]
Exactly. 

[Jaz]
And so we gotta be, just have our wits about. 

[Rachel]
And it would be that day that no one’s got heart cardiac history, and actually no one’s even coming into your surgery for an appointment. But they’ve had chest pain in Costco at Costa and they’ve stumbled in because they knew you’ve got a defib and they’re not feeling well and your access to ’em.

And actually a lot of these times that I’ve heard stories. It’s never their patients. It’s always someone came in with chest pain. One of the surgeries told me about a patient that pulled up outside in a car. He’d had pain at home down the road and his friend had driven him to the local surgery and he was in cardiac arrest when he arrived. And they had to try and resuscitate him in the back of a car. 

[Jaz]
Wow. 

[Rachel]
Really sad. But I kind of understand why they came. So that’s ’cause they knew that they had a defi and they knew that they had some sort of medical professional. So it’s always like, oh, well hopefully it’ll never happen to us. But you just never know. It’s always good to have the skills. 

[Jaz]
Well, I think we’ve covered a lot and we’ve covered our one hour each now which is great. I think we made something that is gonna help everyone in the community, but also the more common things that we think about. Any last tips for our dentist listening and watching today?

[Rachel]
I think just constantly refreshing. I think it’s really important to be a really safe practitioner and making sure that you keep up to date with your yearly reviews and your yearly training. And in between that there are also some really good resources available online, like the resuscitation council.

There’s an app called Lifesaver, which you can actually, do a bit of hands-on CPR on your phone. You can answer questions within so many seconds. So there’s lots of resources out there that are free, that you can get hold of. ‘Cause ultimately the idea is to save somebody’s life, or, prevent any further damage to them.

So my top of advice really is just make sure that you keep up to date and you’re the safest practitioner you can be. Thank you for having me. 

[Jaz]
No, thank you. And you do some teaching in dental practice. Please tell us about that. Plug yourself please. 

[Rachel]
Yeah. So yeah, I tend to, so alongside my main sort of full-time role as a nurse, I also teach emergencies and adult and pediatric basic life support in the community to GPs dentists.

I also do, in fact, I’ve also taught just people that have bought a defibrillator for their local community center and they’ve all kind of, got together and said they want a trainer. So yeah, happy to help, but also just happy to be part of this podcast and no, it’s, yeah. 

[Jaz]
It is been amazing to have you and appreciate you just covering everything so nicely and simply and so clearly, that really helps. I’ll put your details, so if anyone wants to reach out, if any bookings and that kinda stuff. But, thanks so much Rachel. Appreciate. 

[Rachel]
Thank you very much. 

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. You’ve done it, you’ve listened to two parts of medical emergencies.

You can totally claim your CPD certificate. It comes in one part each, so two hours in total, but that is the annual requirement. It is done. You can relax and not have a panic in December. And of course, if your practice is organizing some CPR training, some medical emergencies. Please say yes, do it. The requirements are a minimum and nothing ever beats hands-on, but once and again to do some online learning like this one can be great.

This topic is a lifesaving topic, so anytime you can cover it, you should. For those of you watching on Protrusive Guidance, scroll down, answer our CPD quiz. Make sure you get 80%, and the CE Queen Mari will send you this certificate. If you’re not already on Protrusive, why don’t you start a free trial?

The free trial’s only available on the website, so if you actually go on your mobile or on your desktop, www.protrusive.app, pick the plan that you think you want. If you want access to everything, you want the ultimate education plan and try one week. I know you’ll love it. You’ll come for the content, but you’ll stay for the community, right?

It’s the community of the nicest and geekiest dentist in the world. So all the links as ever are below, and I thank you so much again for watching all the way to the end. I’ll catch you same time, same place next week. Bye for now.