On-line version ISSN 0375-1562
S. Afr. dent. j. vol.70 n.1 Johannesburg Feb. 2015
BDS (Lon), LDS.RCS (Eng), MDPH (Lon), DDPH.RCS (Eng), MChD (Comm Dent), PhD (US), PG Dipl Int Research Ethics (UCT), DSc (UWC). Senior Professor and Principal Specialist, Faculty of Dentistry, University of the Western Cape, Department of Community Dentistry, Private Bag X1, Tygerberg 7505. E-mail: firstname.lastname@example.org
Medical emergencies can occur at any time in the dental surgery. Routine dental operations and procedures that generally cause no harm or distress to fit and normal patients may give rise to symptoms, alarming and of sudden onset, in patients suffering from some non-obvious ailment. Some of these patients may be receiving medical treatment, and the medical emergency may arise from the disease itself, or as a direct result of the treatment they are receiving.1 While there will inevitably be some degree of ambiguity with what constitutes an emergency, emergency care is care without which the patient will or may be subject to serious harm, including professional harm. Dental emergencies cannot be isolated from medical emergencies. An abscess, for example, can evolve into a potentially life-threatening situation. For a dentist to ignore any or all foreseeable consequences of inaction is unprofessional and could well lead to the patient seeking a legal remedy on the grounds of negligence. It has been estimated that one or two life-threatening emergencies will occur in the life-time practice of a general dental practitioner. This experience may increase as the aging population rises and more patients with underlying medical conditions seek dental care.
From an ethical perspective, the provision of emergency care is based on the duty of care to protect the health of the patient, causing minimal harm in the process. A dentist should be socially responsible and act humanely in both professional and personal matters. For example, even though there is no legal requirement to provide care and assistance in an emergency situation to a stranger that one encounters outside normal professional settings, it would still be deemed morally questionable not to do so. The question that always has to be answered is: would you wish to be abandoned in similar circumstances?2 The preamble to the Health Professions Council of South Africa is clear about the answer.3 It states: "To be a good health care practitioner requires a life-long commitment to sound professional and ethical practices and an overriding dedication to the interests of one's fellow human beings and society. In essence, the practice of health care professions is a moral enterprise."
It is in this moral context that all health care practitioners (private and public sector) are obliged to provide emergency care to all patients irrespective of the patient's ability to pay for services.4 The preamble to the National Health Act refers to section 27 (3) of the Constitution that provides that no one may be refused emergency treatment and section 5 of Chapter 2 of the Act says "A health care provider, health worker or health establishment may not refuse a person emergency medical treatment". This is re-iterated in section 5.7 "....in an emergency situation practitioners shall be obliged to provide care in order to stabilize the patient and then arrange for an appropriate referral to another practitioner or facility where the required care can be provided. Furthermore, in emergency situations, practitioners must provide health care within the limits of their practice, experience and competency".4
All oral health care workers as part of the dental team should be able to manage and handle any medical emergencies. In addition, they should be familiar with current treatments and protocols for handling medical emergencies. Failure to do so may have serious legal implications usually on the basis of a lack of the standard of care. Failure to do so may have serious legal implications and there are many components to consider. The standard of care is essentially "what a reasonable prudent person with the same level of training and experience would have done in the same or similar circumstances".3 It is made up of two parts - the first being a 'duty to act'. Health care workers are required to provide necessary emergency care to an individual in the surgery whether the individual is a patient, family member or employee. In a public health care facility it is an expectation of the public that its employees are trained for emergencies. The second part is an 'act of omission or commission'. An act of omission would be failing to carry out some task that the "reasonable prudent person" would have performed under the circumstances. An act of commission would be an attempt to provide care beyond what was normally accepted under the circumstances or by failing to have taken an action that would have prevented an emergency. Dental professionals can avoid these situations by ensuring that the best interests of the patient are paramount, by doing what is required in an emergency and by acting within their scope of practice.3
While taking into consideration these legal aspects concerning emergency treatment, it is important to bear in mind the following:
- When an emergency arises call the Emergency Medical Services (EMS) immediately
- If there is a problem such as a tooth going down a patient's throat, be honest with the patient as to the nature of the problem
- Refer patients to medical professionals where necessary. Never attempt to treat situations that require specialist care or hospital management
- Be knowledgeable about the National Acts and HPCSA requirements for dealing with emergencies
- Take a complete medical history for new patients and update at every visit. Maintain adequate records - document emergency treatment rendered
- Take vital signs regularly especially if an anaesthetic was administered
It is critical that a thorough medical history is sought when dealing with medical emergencies and that a dental emergency kit is available at all times. The best interests or well-being of their patients should be regarded as a dental practitioner's primary professional duty. Lifelong learning is the cornerstone that supports every profession and professional bodies (the HPCSA, in South Africa) may have very specific mandatory requirements (to maintain registration) both in terms of the number of hours prescribed as well as the subject matter that should be updated and this often includes basic life support and managing emergencies.
Obtaining a medical history and determining vital signs is the first step in identifying the patient likely to develop a medical emergency. With proper training, thorough preparation, and regular practice, the staff of any dental surgery or clinic will be able to provide appropriate medical care should the need arise.
1. Seear J. Law and Ethics in Dentistry. Dental Practitioner Handbook No.19. Bristol, John Wright & Sons Limited, 1975. [ Links ]
2. Dental Protection Limited. Ethics, Values and the Law. Module 3: Professionalism and Integrity. DPL, 2009. [ Links ]
3. Health Professions Council of South Africa. General Ethical Guidelines for the Health Professions. Booklet 1. Guidelines for good practice in the health care professions. Pretoria, May 2008. [ Links ]
4. South African Parliament. National Health Act of No 61 of 2003, Chapter 2 Section 6. Government Gazette, Pretoria, July 2004. [ Links ]