FINAL-YEAR DENTAL STUDENTS’ OPINIONS OF THEIR TRAINING IN MEDICAL EMERGENCY MANAGEMENT G BELL1, H JAMES 2, H KRECZAK3, M GREENWOOD4
ABSTRACT The management of medical emergencies is clearly of vital importance in dental practice. The starting point of training in this area is the undergraduate dental degree programme. The aim of this study was to examine the opinions of finalyear dental students at Newcastle School of Dental Sciences in relation to their undergraduate training in medical emergency management. Overall the responses were positive but the need for further practical training in the use of emergency drugs and equipment was highlighted. Prim Dent J. 2013; 3(1) 46-51
Introduction Medical emergencies are often considered to be relatively rare in the dental setting, with an average prevalence of 0.22–0.7 per dentist per year in general practice1,2 and 1.8 per year in a dental hospital setting.3 Nevertheless, such situations could occur at any time. With an increasingly ageing population due to advances in medicine, a greater proportion of dental patients are likely to be medically compromised. It is anticipated that the complexity of patients’ medical conditions is likely to increase with time, making a medical emergency in dental practice a more common occurrence.4
1
Gavin Bell
Specialty Trainee in Orthodontics, Yorkshire 2
Hayley James
SHO in Oral and Maxillofacial Surgery, Sunderland Royal Hospital 3
Helen Kreczak
Specialty Doctor in Oral and Maxillofacial Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust 4
Mark Greenwood
Consultant in Oral and Maxillofacial Surgery Newcastle upon Tyne NHS Foundation Trust and Honorary Professor of Medical Education in Dentistry Newcastle University
46
It is clearly important that undergraduate teaching should be comprehensive and appropriate to students’ future roles as dental practitioners. Dentists should be able to initiate primary management of a medical emergency, which is essential in minimising morbidity and mortality.1 Studies in the past, however, have highlighted that many dentists have not felt prepared by their undergraduate training to manage these emergencies. In a postal survey of 1500 general dental practitioners in Great Britain, published in 1999, only 29.9% of dentists reported that they had felt ‘very well’ or ‘fairly well’ prepared to manage a medical emergency at graduation.5
Other authors have presented a similar lack of confidence among dentists across the world when dealing with medical emergencies.1,6,7 A study in New Zealand found that ‘dealing with medical emergencies’ was one of the greatest anxieties of dental students,8 highlighting the prevalence of this apprehension in dental undergraduates internationally. In the document The First Five Years: A Framework for Undergraduate Dental Education (2008), the GDC9 highlights the need for dental graduates to: • Be competent at obtaining a relevant medical history • Have knowledge of diagnosing medical emergencies and delivering suitable emergency drugs using, where appropriate, intravenous techniques • Be competent at carrying out resuscitation techniques and immediate management of cardiac arrest, anaphylactic reaction, upper respiratory obstruction, collapse, vasovagal attack, haemorrhage, inhalation or ingestion of foreign bodies, and diabetic coma • Be familiar with the complex interactions between oral health, nutrition, general health, drugs and diseases that can have an impact on dental care and disease
P R I M A R Y D E N TA L J O U R N A L
FIGURE 1
FREQUENCY OF RESPONSE TO QUESTION 1 ‘I feel that the training I received in medicine in relation to dentistry has adequately equipped me for…’ (the listed parameters) 70 60 50
A more recent document from the GDC, Preparing for Practice: Dental Team Learning Outcomes for Registration (2012), outlines the requirement and importance for dentists to be able to ‘Identify, assess and manage medical emergencies’. The document further outlines the requirement for dentists to be able to ‘Identify general and systemic disease and explain their relevance to oral health and their impact on clinical treatment’. The management of patients with more complex medical histories and medical emergencies is therefore a vital skill that all dentists must acquire.
10
Many current teaching curricula follow the principles outlined by a United Kingdom and Ireland document, published in 2011,4 with medical emergency training closely linked to Resuscitation Council (UK) guidelines.11,12 This is part of an effort to establish a common core for clinical medical sciences undergraduate courses. Significant variations in teaching have been identified in the past and more recently these variations have been highlighted among UK4 and US13 dental schools.
Aim The aim was to assess and evaluate the perceptions of final-year dental students at Newcastle School of Dental Sciences of the teaching that they had received on the management of medical emergencies during their clinical medical sciences (human diseases) course and identify areas for improvement within the undergraduate teaching.
Method The study was conducted from November 2011 to February 2012 and focused on 89 final-year dental students at the Newcastle School of Dental Sciences. A basic assessment of face and content validity was completed by taking a convenience sample of students to
VOL 3 NO 1 FEBRUARY 2014
I Strongly Disagree I Disagree
Number of students
40
I Neither agree nor Disagree
30
I Agree I Strongly Agree
20 10 0
Assessing a patient’s medical history during final year clinics
Assessing a patient’s medical history in clinical practice following qualification
Dealing with medical emergencies during final year clinics
ascertain their comments on the clarity of questions and any suggestions for further content, prior to finalisation of the questionnaire. The questionnaires were distributed to the students after teaching sessions at the dental emergency clinic. The purpose of the questionnaire was explained by one of the investigators and its anonymous nature emphasised. The questionnaire (see FGDP(UK) website) was divided into three sections: background information, medical emergencies and application to clinical practice. A series of questions was included to determine how competent the student felt about different aspects of medical emergency management. For the majority of questions, students were asked to rank statements on a five-part Likert scale14 or provide dichotomous responses. The questionnaires were collected, optically scanned and those with more than 10% of questions left unanswered were rejected as they were considered to be incomplete. The data were collated and analysed using SPSS (version 19, New York, USA) using simple descriptive statistics.
Dealing with medical emergencies in clinical practice following qualification
reflected the male to female ratio of the year. All questionnaires were designated as completed. None of the respondents reported a previous healthcare qualification. Overall, for the majority of the Likert responses, students responded positively by either agreeing or strongly agreeing. One hundred per cent of students felt able to adequately assess a patient’s medical history in an undergraduate clinic or practice setting but the percentages were lower regarding dealing with medical emergencies in an undergraduate clinic or practice setting, with 97% and 94% respectively (Figure 1).
Results A response rate of 78% was obtained (n=69) with a 68% female cohort, which
47
FINAL-YEAR DENTAL STUDENTS’ OPINIONS OF THEIR TRAINING IN MEDICAL EMERGENCY MANAGEMENT
FIGURE 2
FREQUENCY OF RESPONSE TO QUESTION 2 ‘As a result of my undergraduate teaching in medicine in relation to dentistry I feel able to perform the initial management of the following emergencies’ 70 60 50
I Strongly Disagree I Disagree I Neither agree nor Disagree
30
I Agree I Strongly Agree
20 10
Adrenocortical (Addisonian) crisis
Hyperventilation (panic attack)
Hypoglycaemia
Epileptic seizure
Anaphylaxis/significant allergic reaction
Asthma attack
Respiratory arrest
Cardiac arrest
Angina
Myocardial infarction
0
Vasovagal syncope
Number of students
40
FIGURE 3
FREQUENCY OF RESPONSE TO QUESTION 3 ‘As a result of my undergraduate teaching in medicine in relation to dentistry I feel able to use the following drugs in the appropriate medical emergency situation’ 70 60 50
I Strongly Disagree I Disagree I Neither agree nor Disagree
30
I Agree I Strongly Agree
20 10
48
Adrenaline (Epinephrine) 1 in 1000 (IM injection) Midazolam buccal liquid solution (buccal/intranasal)
Salbutamol inhaler
Oxygen
GTN tablets/sprays (sublingual)
Glucagon 1mg (IM injection)
Oral glucose solution/tablets/gel
0
Aspirin 300mg (oral)
Number of students
40
Figure 2 demonstrates the responses relating to the students’ confidence to perform the initial management of specific medical emergencies. One hundred per cent of students surveyed either strongly agreed or agreed that they felt able to manage angina and asthma attacks, with over 95% feeling similarly confident about the management of vasovagal syncope, myocardial infarction, cardiac arrest, anaphylaxis and hypoglycaemia. There was some uncertainty, however, about the management of adrenocortical crisis and epilepsy, with 35% and 19% respectively not being confident in their management. This cohort of final-year dental students at Newcastle felt confident in their ability to administer emergency drugs in the appropriate medical scenario (Figure 3). All the emergency drugs listed had scores of over 80% of students either agreeing or strongly agreeing that they felt competent in their use. Four per cent of students, however, did not feel they could administer epinephrine, glucagon or oxygen and 3% could not deliver buccal or intranasal midazolam. Opinions were divided on the use of emergency equipment and the ability to perform clinical skills (Figure 4). These revealed the greatest number of negative responses of any part of the survey. The majority of respondents (91%) did feel confident in the use of automated external defibrillators; however, only 1% of respondents felt very confident in carrying out venepuncture in comparison to 41% with cannulation. Airway management also demonstrated a lack of confidence as 51% of students could not use an oropharyngeal airway and 19% could not use a pocket mask with oxygen port. In terms of the distribution of medical emergencies experienced by the final-year dental students in their undergraduate training, the following results were obtained. Vasovagal syncope was the most common situation encountered, with 36% of students having managed it at least once. Eleven per cent of students had dealt with hypoglycaemia, 9% hyperventilation, 6% angina, 5%
P R I M A R Y D E N TA L J O U R N A L
FIGURE 4
FREQUENCY OF RESPONSE TO QUESTION 4 choking and 3% asthma. The remaining emergency scenarios listed had not yet been encountered.
‘As a result of my undergraduate teaching in medicine in relation to dentistry I feel able to perform the following clinical skills or use the equipment stated’ 70
50
VOL 3 NO 1 FEBRUARY 2014
I Neither agree nor Disagree
30
I Agree I Strongly Agree
20 10
Glucometer
Automated External Defibrillator
Pocket mask with oxygen port
Oropharyngeal airways
Venepuncture
Cannulation
Assessing vital signs
0
FIGURE 5
FREQUENCY OF RESPONSE TO QUESTION 5 (application to clinical practice). ‘Following my training in medicine in relation to dentistry I feel able to assess a patient’s fitness for a local anaesthetic forceps dental extraction when they give a history of a medical problem involving the following systems 70 60 50
I Strongly Disagree I Disagree I Neither agree nor Disagree
30
I Agree I Strongly Agree
20 10
Mental Health Issues
Kidneys
Liver
Haematological system
Central nervous system
0
Gastrointestinal system
Number of students
40
Respiratory system
The questionnaire used in this study was limited to the perceptions of the final-year dental students and may not provide an accurate reflection on their actual abilities
I Disagree
40
Discussion A significant barrier to obtaining a 100% response rate from this questionnaire was that on any given day, a number of finalyear dental students were on attachments outside the dental school and therefore did not attend the dental emergency clinic in the scheduled session. To try to overcome this, the survey was repeated on subsequent weeks; however, this will have led to a variation in clinical experience at the time of sampling. It is unlikely that this would have significantly skewed the results.
I Strongly Disagree
Cardiovascular system
The training provided by the human diseases course left 97% of final-year dental students feeling confident that they could provide the initial management for a patient losing consciousness in the dental chair. The remaining 3% neither agreed nor disagreed with the statement.
60
Number of students
The application of knowledge to a clinical scenario was analysed by finding out how confident students felt in assessing a patient for a local anaesthetic forceps dental extraction when a history was given of a medical problem related to a body system (Figure 5). When making this assessment, students were more confident in interpreting some aspects of the medical history than others. Mental health issues constituted the area of greatest concern, with 16% feeling unable to assess these patients and 39% responding ‘neither agree nor disagree’. The only medical problems to produce any responses of ‘strongly disagree’ were those relating to the gastrointestinal and renal systems (1%). However, on the whole, most students felt confident enquiring about these systems, with high levels of confidence in the interpretation of cardiovascular (97%), respiratory (97%) and haematological (93%) problems.
49
FINAL-YEAR DENTAL STUDENTS’ OPINIONS OF THEIR TRAINING IN MEDICAL EMERGENCY MANAGEMENT
and competence. This concept was demonstrated by Laurent et al (2009), who found that despite 53% of dental students considering themselves able to manage a cardiac arrest, when a crosssection of the respondents was actually evaluated using an emergency scenario, no respondents were able to combine an adequate cardiac arrest diagnosis with appropriate cardiopulmonary resuscitation.15 A more accurate method to measure the students’ ability could have been achieved by carrying out a medical emergencies objective structured clinical examination (OSCE), alongside the questionnaire, to ensure the students’ competence matched their perceptions. Such training has now been introduced to the undergraduate programme. Overall, the study found that final-year dental students at Newcastle School of Dental Sciences felt adequately equipped to assess medical histories and manage potential medical emergencies. Naturally the dental students felt more confident managing patients in the safety of an undergraduate clinic than as independent practitioners, with 67% feeling very confident in their ability to assess patients’ medical histories, in comparison with 52% in practice. This was also reflected in their confidence in managing medical emergencies. Although the scenario itself had not changed, the students felt they could manage better in a hospital environment in comparison to a practice setting. This is more likely to be a reflection of students’ anxiety of working without the ‘safety net’ of their clinical supervisors than their actual ability to manage medical emergencies.
Confidence in the management of medical emergencies was high among the finalyear dental students, with over 95% feeling able to manage vasovagal syncope, myocardial infarction, angina, cardiac arrest, asthma, anaphylaxis and hypoglycaemia. This showed a striking contrast to the study by Girdler and Smith in 19991 of qualified dental practitioners in northern England, where only vasovagal syncope had a positive response rate greater than 95%. In their study, confidence rates were low regarding the management of anaphylaxis (38%), myocardial infarction (45%) and cardiac arrest (61%). It is clearly important that once qualified, regular training in medical emergency management should be undertaken in order to maintain the knowledge, skills and confidence acquired at undergraduate level. Indeed, it is now a mandatory requirement for this to be achieved in order to maintain GDC registration. A notable outlier was management of adrenocortical crisis where only 65% of students felt that they could manage it competently. This was followed by epilepsy (81%) and respiratory arrest (88%). Carvalho et al (2008) assessed Brazilian dental students’ perceptions about medical emergencies and also identified a lack of confidence.16 They concluded that a lack of knowledge about medical emergencies and their aetiology “causes feelings of insecurity, dissatisfaction, and a limited appreciation of the dentists’ responsibility”. These findings need to be addressed in the delivery and content of the human diseases courses to ensure that adequate emphasis is given to students on the management of these conditions. Excluding vasovagal syncope and hyperventilation, only 19 students had encountered another medical emergency in their undergraduate training. Therefore, for many practitioners the first real medical emergency is likely to be when working in general practice, where they could be expected to lead an emergency response. Such a concept highlights the importance of excellent medical emergency training at undergraduate
50
level and the need to maintain and enhance this knowledge and skill with regular continuing educational courses.5,7,17 Although the students seemed to be self-assured in the use of emergency drugs, there are certain medications where students lack confidence in their administration, particularly epinephrine, glucagon, oxygen and midazolam. The lack of confidence in handling these drugs did not directly correlate to the students’ confidence in managing medical emergencies in which the use of these medications is key. It was interesting yet disconcerting to discover that 99% of students agreed that they could provide the initial management for a patient suffering a cardiac arrest, yet when questioned further only 84% agreed they would be able to administer oxygen when required and even fewer (55%) agreed that they would be able to use a pocket mask with oxygen port. This is particularly concerning because the provision of oxygen is one of the most fundamental requirements for the management of the most common medical emergencies. This finding was reflected by a 2009 study, which revealed that 50% of thirdand fourth-year dental students at the University of Michigan School of Dentistry could not successfully operate the tank regulator to administer oxygen correctly.18 The ability to perform clinical skills and the use of emergency equipment were highlighted from the results as areas of concern. Although application of the skills that scored poorly, such as venepuncture and cannulation, is not advised by the Resuscitation Council12 in the primary management of medical emergencies by general dental practitioners, the use of oropharyngeal airways and pocket masks with oxygen ports is vital. Such results do call into question the reliability of some of the findings. If students do not feel confident to use the emergency drugs and equipment required, can they truly be competent to manage the medical emergency? A reason for such a trend may be that although, students feel that they have acquired sufficient theoretical knowledge from their undergraduate teaching, in
P R I M A R Y D E N TA L J O U R N A L
reality they have had only limited practical experience in its application. This highlights the need to provide more opportunity within the human diseases course for practical, hands-on teaching and emergency simulations. Although no amount of role playing can simulate the pressure of a ‘real-life’ medical emergency, Sopka et al (2012)19 found that participation in a practical training course significantly enhanced students’ self-confidence in managing emergencies and completing specific tasks. Additionally, a recent Australian study concluded that “realistic simulation training in management of medical emergencies for dental students is an effective adjunct to traditional” teaching.20 Although 52% of respondents felt strongly that they could assess a patient’s medical history in practice, when asked to apply this medical history knowledge to a clinical scenario the students’ confidence decreased. This was particularly evident
REFERENCES 1
2
3
4
5
Girdler NM, Smith DG. Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation. 1999;41:159-67. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 1: Their prevalence over a 10-year period. Br Dent J. 1999;186:72-9. Atherton GJ, Pemberton MN, Thornhill MH. Medical emergencies: the experience of staff of a UK dental teaching hospital. Br Dent J. 2000;188:320-4. Mighell AJ, Atkin PA, Webster K, Thomas SJ, McCreary CE, Healy CM, et al. Clinical medical sciences for undergraduate dental students in the United Kingdom and Ireland: a curriculum. Eur J Dent Educ. 2011;15:179-88. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in
for patients with mental health issues, where only 4% of students felt very confident in their management; however, the question used to examine the students’ confidence did cover very broad topics. Had the questioning been more specific, the response may have differed. For example, students may feel confident managing patients with depression but less so when dealing with patients with severe learning difficulties. This may be a reflection of their undergraduate exposure in clinic to patients with these conditions. It is encouraging that overall the responses to the questionnaire showed a degree of confidence of final-year dental students in the management of medical emergencies. What should be gained from undergraduate education is the ability to assess which patients are safe to treat in general practice and when they should subsequently be referring to secondary care. This ability helps to minimise the number of medical emergencies that they are exposed to. They should also have
general dental practice in Great Britain. Part 3: Perceptions of training and competence of GDPs in their management. Br Dent J. 1999;186:234-7. 6 Chapman PJ. Medical emergencies in dental practice and choice of emergency drugs and equipment: a survey of Australian dentists. Aust Dent J. 1997;42:103-8. 7 Broadbent JM, Thomson WM. The readiness of New Zealand general dental practitioners for medical emergencies. N Z Dent J. 2001;97:82-6. 8 Kieser J, Herbison P. Clinical anxieties among dental students. N Z Dent J. 2000;96:138-9. 9 General Dental Council. The First Five Years: A Framework for Undergraduate Dental Education. 3rd ed (interim). London: GDC; 2008. 10 General Dental Council. Preparing for Practice: Dental Team Learning Outcomes for Registration. London: GDC; 2012. 11 Greenwood M, Seymour RA.
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12
13
14
15
16
sufficient clinical and academic knowledge to diagnose and manage medical emergencies and administer appropriate medication as outlined in The First Five Years.9 This knowledge must then be built upon through their postgraduate training and continuing professional development.
Conclusion Final-year dental students felt that their undergraduate medical emergency training was adequately preparing them for their future role in the management of emergencies in a practice setting. On the whole, the final-year dental students showed greater confidence in their academic knowledge than clinical skills, which emphasises the need for a more practical approach to their education. Although students felt prepared to manage medical emergencies, their lack of confidence in the use of the emergency equipment and drugs necessary in their management highlighted the need for more emphasis to be placed on this during undergraduate teaching.
Human diseases: the Newcastle experience. Br Dent J. 2007;203:595-8. Resuscitation Council (UK). Medical Emergencies and Resuscitation: Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice. London: Resuscitation Council; 2006 (rev 2012). Clark MS, Wall BE, Tholström TC, Christensen EH, Payne BC. A twenty-year follow-up survey of medical ermergency education in U.S. dental schools. J Dent Educ. 2006;70:1316-9. Likert R. A technique for the measurement of attitudes. Arch Psychol. 1932:140:1-55. Laurent F, Augustin P, Nabet C, Ackers S, Zamaroczy D, Maman L. Managing a cardiac arrest: evaluation of final-year predoctoral dental students. J Dent Educ. 2009;73: 211-7. Carvalho RM, Costa LR, Marcelo VC. Brazilian dental students’
17
18
19
20
perceptions about medical emergencies: a qualitative exploratory study. J Dent Educ. 2008;72:1343-9. Rosenberg M. Preparing for medical emergencies: the essential drugs and equipment for the dental office. J Am Dent Assoc. 2010;141 Suppl 1:14S-9S. Le TT, Scheller EL, Pinsky HM, Stefanac SJ, Taichman RS. Ability of dental students to deliver oxygen in a medical emergency. J Dent Educ. 2009;73:499-508. Sopka S, Biermann H, Druener S, Skorning M, Knops A, Fitzner C, et al. Practical skills training influences knowledge and attitude of dental students towards emergency medical care. Eur J Dent Educ. 2012;16:179-86. Newby JP, Keast J, Adam WR. Simulation of medical emergencies in dental practice: development and evaluation of an undergraduate training programme. Aust Dent J. 2010;55:399-404.
51
ABSTRACT The management of medical emergencies is clearly of vital importance in dental practice. The starting point of training in this area is the undergraduate dental degree programme. The aim of this study was to examine the opinions of finalyear dental students at Newcastle School of Dental Sciences in relation to their undergraduate training in medical emergency management. Overall the responses were positive but the need for further practical training in the use of emergency drugs and equipment was highlighted. Prim Dent J. 2013; 3(1) 46-51
Introduction Medical emergencies are often considered to be relatively rare in the dental setting, with an average prevalence of 0.22–0.7 per dentist per year in general practice1,2 and 1.8 per year in a dental hospital setting.3 Nevertheless, such situations could occur at any time. With an increasingly ageing population due to advances in medicine, a greater proportion of dental patients are likely to be medically compromised. It is anticipated that the complexity of patients’ medical conditions is likely to increase with time, making a medical emergency in dental practice a more common occurrence.4
1
Gavin Bell
Specialty Trainee in Orthodontics, Yorkshire 2
Hayley James
SHO in Oral and Maxillofacial Surgery, Sunderland Royal Hospital 3
Helen Kreczak
Specialty Doctor in Oral and Maxillofacial Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust 4
Mark Greenwood
Consultant in Oral and Maxillofacial Surgery Newcastle upon Tyne NHS Foundation Trust and Honorary Professor of Medical Education in Dentistry Newcastle University
46
It is clearly important that undergraduate teaching should be comprehensive and appropriate to students’ future roles as dental practitioners. Dentists should be able to initiate primary management of a medical emergency, which is essential in minimising morbidity and mortality.1 Studies in the past, however, have highlighted that many dentists have not felt prepared by their undergraduate training to manage these emergencies. In a postal survey of 1500 general dental practitioners in Great Britain, published in 1999, only 29.9% of dentists reported that they had felt ‘very well’ or ‘fairly well’ prepared to manage a medical emergency at graduation.5
Other authors have presented a similar lack of confidence among dentists across the world when dealing with medical emergencies.1,6,7 A study in New Zealand found that ‘dealing with medical emergencies’ was one of the greatest anxieties of dental students,8 highlighting the prevalence of this apprehension in dental undergraduates internationally. In the document The First Five Years: A Framework for Undergraduate Dental Education (2008), the GDC9 highlights the need for dental graduates to: • Be competent at obtaining a relevant medical history • Have knowledge of diagnosing medical emergencies and delivering suitable emergency drugs using, where appropriate, intravenous techniques • Be competent at carrying out resuscitation techniques and immediate management of cardiac arrest, anaphylactic reaction, upper respiratory obstruction, collapse, vasovagal attack, haemorrhage, inhalation or ingestion of foreign bodies, and diabetic coma • Be familiar with the complex interactions between oral health, nutrition, general health, drugs and diseases that can have an impact on dental care and disease
P R I M A R Y D E N TA L J O U R N A L
FIGURE 1
FREQUENCY OF RESPONSE TO QUESTION 1 ‘I feel that the training I received in medicine in relation to dentistry has adequately equipped me for…’ (the listed parameters) 70 60 50
A more recent document from the GDC, Preparing for Practice: Dental Team Learning Outcomes for Registration (2012), outlines the requirement and importance for dentists to be able to ‘Identify, assess and manage medical emergencies’. The document further outlines the requirement for dentists to be able to ‘Identify general and systemic disease and explain their relevance to oral health and their impact on clinical treatment’. The management of patients with more complex medical histories and medical emergencies is therefore a vital skill that all dentists must acquire.
10
Many current teaching curricula follow the principles outlined by a United Kingdom and Ireland document, published in 2011,4 with medical emergency training closely linked to Resuscitation Council (UK) guidelines.11,12 This is part of an effort to establish a common core for clinical medical sciences undergraduate courses. Significant variations in teaching have been identified in the past and more recently these variations have been highlighted among UK4 and US13 dental schools.
Aim The aim was to assess and evaluate the perceptions of final-year dental students at Newcastle School of Dental Sciences of the teaching that they had received on the management of medical emergencies during their clinical medical sciences (human diseases) course and identify areas for improvement within the undergraduate teaching.
Method The study was conducted from November 2011 to February 2012 and focused on 89 final-year dental students at the Newcastle School of Dental Sciences. A basic assessment of face and content validity was completed by taking a convenience sample of students to
VOL 3 NO 1 FEBRUARY 2014
I Strongly Disagree I Disagree
Number of students
40
I Neither agree nor Disagree
30
I Agree I Strongly Agree
20 10 0
Assessing a patient’s medical history during final year clinics
Assessing a patient’s medical history in clinical practice following qualification
Dealing with medical emergencies during final year clinics
ascertain their comments on the clarity of questions and any suggestions for further content, prior to finalisation of the questionnaire. The questionnaires were distributed to the students after teaching sessions at the dental emergency clinic. The purpose of the questionnaire was explained by one of the investigators and its anonymous nature emphasised. The questionnaire (see FGDP(UK) website) was divided into three sections: background information, medical emergencies and application to clinical practice. A series of questions was included to determine how competent the student felt about different aspects of medical emergency management. For the majority of questions, students were asked to rank statements on a five-part Likert scale14 or provide dichotomous responses. The questionnaires were collected, optically scanned and those with more than 10% of questions left unanswered were rejected as they were considered to be incomplete. The data were collated and analysed using SPSS (version 19, New York, USA) using simple descriptive statistics.
Dealing with medical emergencies in clinical practice following qualification
reflected the male to female ratio of the year. All questionnaires were designated as completed. None of the respondents reported a previous healthcare qualification. Overall, for the majority of the Likert responses, students responded positively by either agreeing or strongly agreeing. One hundred per cent of students felt able to adequately assess a patient’s medical history in an undergraduate clinic or practice setting but the percentages were lower regarding dealing with medical emergencies in an undergraduate clinic or practice setting, with 97% and 94% respectively (Figure 1).
Results A response rate of 78% was obtained (n=69) with a 68% female cohort, which
47
FINAL-YEAR DENTAL STUDENTS’ OPINIONS OF THEIR TRAINING IN MEDICAL EMERGENCY MANAGEMENT
FIGURE 2
FREQUENCY OF RESPONSE TO QUESTION 2 ‘As a result of my undergraduate teaching in medicine in relation to dentistry I feel able to perform the initial management of the following emergencies’ 70 60 50
I Strongly Disagree I Disagree I Neither agree nor Disagree
30
I Agree I Strongly Agree
20 10
Adrenocortical (Addisonian) crisis
Hyperventilation (panic attack)
Hypoglycaemia
Epileptic seizure
Anaphylaxis/significant allergic reaction
Asthma attack
Respiratory arrest
Cardiac arrest
Angina
Myocardial infarction
0
Vasovagal syncope
Number of students
40
FIGURE 3
FREQUENCY OF RESPONSE TO QUESTION 3 ‘As a result of my undergraduate teaching in medicine in relation to dentistry I feel able to use the following drugs in the appropriate medical emergency situation’ 70 60 50
I Strongly Disagree I Disagree I Neither agree nor Disagree
30
I Agree I Strongly Agree
20 10
48
Adrenaline (Epinephrine) 1 in 1000 (IM injection) Midazolam buccal liquid solution (buccal/intranasal)
Salbutamol inhaler
Oxygen
GTN tablets/sprays (sublingual)
Glucagon 1mg (IM injection)
Oral glucose solution/tablets/gel
0
Aspirin 300mg (oral)
Number of students
40
Figure 2 demonstrates the responses relating to the students’ confidence to perform the initial management of specific medical emergencies. One hundred per cent of students surveyed either strongly agreed or agreed that they felt able to manage angina and asthma attacks, with over 95% feeling similarly confident about the management of vasovagal syncope, myocardial infarction, cardiac arrest, anaphylaxis and hypoglycaemia. There was some uncertainty, however, about the management of adrenocortical crisis and epilepsy, with 35% and 19% respectively not being confident in their management. This cohort of final-year dental students at Newcastle felt confident in their ability to administer emergency drugs in the appropriate medical scenario (Figure 3). All the emergency drugs listed had scores of over 80% of students either agreeing or strongly agreeing that they felt competent in their use. Four per cent of students, however, did not feel they could administer epinephrine, glucagon or oxygen and 3% could not deliver buccal or intranasal midazolam. Opinions were divided on the use of emergency equipment and the ability to perform clinical skills (Figure 4). These revealed the greatest number of negative responses of any part of the survey. The majority of respondents (91%) did feel confident in the use of automated external defibrillators; however, only 1% of respondents felt very confident in carrying out venepuncture in comparison to 41% with cannulation. Airway management also demonstrated a lack of confidence as 51% of students could not use an oropharyngeal airway and 19% could not use a pocket mask with oxygen port. In terms of the distribution of medical emergencies experienced by the final-year dental students in their undergraduate training, the following results were obtained. Vasovagal syncope was the most common situation encountered, with 36% of students having managed it at least once. Eleven per cent of students had dealt with hypoglycaemia, 9% hyperventilation, 6% angina, 5%
P R I M A R Y D E N TA L J O U R N A L
FIGURE 4
FREQUENCY OF RESPONSE TO QUESTION 4 choking and 3% asthma. The remaining emergency scenarios listed had not yet been encountered.
‘As a result of my undergraduate teaching in medicine in relation to dentistry I feel able to perform the following clinical skills or use the equipment stated’ 70
50
VOL 3 NO 1 FEBRUARY 2014
I Neither agree nor Disagree
30
I Agree I Strongly Agree
20 10
Glucometer
Automated External Defibrillator
Pocket mask with oxygen port
Oropharyngeal airways
Venepuncture
Cannulation
Assessing vital signs
0
FIGURE 5
FREQUENCY OF RESPONSE TO QUESTION 5 (application to clinical practice). ‘Following my training in medicine in relation to dentistry I feel able to assess a patient’s fitness for a local anaesthetic forceps dental extraction when they give a history of a medical problem involving the following systems 70 60 50
I Strongly Disagree I Disagree I Neither agree nor Disagree
30
I Agree I Strongly Agree
20 10
Mental Health Issues
Kidneys
Liver
Haematological system
Central nervous system
0
Gastrointestinal system
Number of students
40
Respiratory system
The questionnaire used in this study was limited to the perceptions of the final-year dental students and may not provide an accurate reflection on their actual abilities
I Disagree
40
Discussion A significant barrier to obtaining a 100% response rate from this questionnaire was that on any given day, a number of finalyear dental students were on attachments outside the dental school and therefore did not attend the dental emergency clinic in the scheduled session. To try to overcome this, the survey was repeated on subsequent weeks; however, this will have led to a variation in clinical experience at the time of sampling. It is unlikely that this would have significantly skewed the results.
I Strongly Disagree
Cardiovascular system
The training provided by the human diseases course left 97% of final-year dental students feeling confident that they could provide the initial management for a patient losing consciousness in the dental chair. The remaining 3% neither agreed nor disagreed with the statement.
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Number of students
The application of knowledge to a clinical scenario was analysed by finding out how confident students felt in assessing a patient for a local anaesthetic forceps dental extraction when a history was given of a medical problem related to a body system (Figure 5). When making this assessment, students were more confident in interpreting some aspects of the medical history than others. Mental health issues constituted the area of greatest concern, with 16% feeling unable to assess these patients and 39% responding ‘neither agree nor disagree’. The only medical problems to produce any responses of ‘strongly disagree’ were those relating to the gastrointestinal and renal systems (1%). However, on the whole, most students felt confident enquiring about these systems, with high levels of confidence in the interpretation of cardiovascular (97%), respiratory (97%) and haematological (93%) problems.
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FINAL-YEAR DENTAL STUDENTS’ OPINIONS OF THEIR TRAINING IN MEDICAL EMERGENCY MANAGEMENT
and competence. This concept was demonstrated by Laurent et al (2009), who found that despite 53% of dental students considering themselves able to manage a cardiac arrest, when a crosssection of the respondents was actually evaluated using an emergency scenario, no respondents were able to combine an adequate cardiac arrest diagnosis with appropriate cardiopulmonary resuscitation.15 A more accurate method to measure the students’ ability could have been achieved by carrying out a medical emergencies objective structured clinical examination (OSCE), alongside the questionnaire, to ensure the students’ competence matched their perceptions. Such training has now been introduced to the undergraduate programme. Overall, the study found that final-year dental students at Newcastle School of Dental Sciences felt adequately equipped to assess medical histories and manage potential medical emergencies. Naturally the dental students felt more confident managing patients in the safety of an undergraduate clinic than as independent practitioners, with 67% feeling very confident in their ability to assess patients’ medical histories, in comparison with 52% in practice. This was also reflected in their confidence in managing medical emergencies. Although the scenario itself had not changed, the students felt they could manage better in a hospital environment in comparison to a practice setting. This is more likely to be a reflection of students’ anxiety of working without the ‘safety net’ of their clinical supervisors than their actual ability to manage medical emergencies.
Confidence in the management of medical emergencies was high among the finalyear dental students, with over 95% feeling able to manage vasovagal syncope, myocardial infarction, angina, cardiac arrest, asthma, anaphylaxis and hypoglycaemia. This showed a striking contrast to the study by Girdler and Smith in 19991 of qualified dental practitioners in northern England, where only vasovagal syncope had a positive response rate greater than 95%. In their study, confidence rates were low regarding the management of anaphylaxis (38%), myocardial infarction (45%) and cardiac arrest (61%). It is clearly important that once qualified, regular training in medical emergency management should be undertaken in order to maintain the knowledge, skills and confidence acquired at undergraduate level. Indeed, it is now a mandatory requirement for this to be achieved in order to maintain GDC registration. A notable outlier was management of adrenocortical crisis where only 65% of students felt that they could manage it competently. This was followed by epilepsy (81%) and respiratory arrest (88%). Carvalho et al (2008) assessed Brazilian dental students’ perceptions about medical emergencies and also identified a lack of confidence.16 They concluded that a lack of knowledge about medical emergencies and their aetiology “causes feelings of insecurity, dissatisfaction, and a limited appreciation of the dentists’ responsibility”. These findings need to be addressed in the delivery and content of the human diseases courses to ensure that adequate emphasis is given to students on the management of these conditions. Excluding vasovagal syncope and hyperventilation, only 19 students had encountered another medical emergency in their undergraduate training. Therefore, for many practitioners the first real medical emergency is likely to be when working in general practice, where they could be expected to lead an emergency response. Such a concept highlights the importance of excellent medical emergency training at undergraduate
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level and the need to maintain and enhance this knowledge and skill with regular continuing educational courses.5,7,17 Although the students seemed to be self-assured in the use of emergency drugs, there are certain medications where students lack confidence in their administration, particularly epinephrine, glucagon, oxygen and midazolam. The lack of confidence in handling these drugs did not directly correlate to the students’ confidence in managing medical emergencies in which the use of these medications is key. It was interesting yet disconcerting to discover that 99% of students agreed that they could provide the initial management for a patient suffering a cardiac arrest, yet when questioned further only 84% agreed they would be able to administer oxygen when required and even fewer (55%) agreed that they would be able to use a pocket mask with oxygen port. This is particularly concerning because the provision of oxygen is one of the most fundamental requirements for the management of the most common medical emergencies. This finding was reflected by a 2009 study, which revealed that 50% of thirdand fourth-year dental students at the University of Michigan School of Dentistry could not successfully operate the tank regulator to administer oxygen correctly.18 The ability to perform clinical skills and the use of emergency equipment were highlighted from the results as areas of concern. Although application of the skills that scored poorly, such as venepuncture and cannulation, is not advised by the Resuscitation Council12 in the primary management of medical emergencies by general dental practitioners, the use of oropharyngeal airways and pocket masks with oxygen ports is vital. Such results do call into question the reliability of some of the findings. If students do not feel confident to use the emergency drugs and equipment required, can they truly be competent to manage the medical emergency? A reason for such a trend may be that although, students feel that they have acquired sufficient theoretical knowledge from their undergraduate teaching, in
P R I M A R Y D E N TA L J O U R N A L
reality they have had only limited practical experience in its application. This highlights the need to provide more opportunity within the human diseases course for practical, hands-on teaching and emergency simulations. Although no amount of role playing can simulate the pressure of a ‘real-life’ medical emergency, Sopka et al (2012)19 found that participation in a practical training course significantly enhanced students’ self-confidence in managing emergencies and completing specific tasks. Additionally, a recent Australian study concluded that “realistic simulation training in management of medical emergencies for dental students is an effective adjunct to traditional” teaching.20 Although 52% of respondents felt strongly that they could assess a patient’s medical history in practice, when asked to apply this medical history knowledge to a clinical scenario the students’ confidence decreased. This was particularly evident
REFERENCES 1
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Girdler NM, Smith DG. Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation. 1999;41:159-67. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 1: Their prevalence over a 10-year period. Br Dent J. 1999;186:72-9. Atherton GJ, Pemberton MN, Thornhill MH. Medical emergencies: the experience of staff of a UK dental teaching hospital. Br Dent J. 2000;188:320-4. Mighell AJ, Atkin PA, Webster K, Thomas SJ, McCreary CE, Healy CM, et al. Clinical medical sciences for undergraduate dental students in the United Kingdom and Ireland: a curriculum. Eur J Dent Educ. 2011;15:179-88. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in
for patients with mental health issues, where only 4% of students felt very confident in their management; however, the question used to examine the students’ confidence did cover very broad topics. Had the questioning been more specific, the response may have differed. For example, students may feel confident managing patients with depression but less so when dealing with patients with severe learning difficulties. This may be a reflection of their undergraduate exposure in clinic to patients with these conditions. It is encouraging that overall the responses to the questionnaire showed a degree of confidence of final-year dental students in the management of medical emergencies. What should be gained from undergraduate education is the ability to assess which patients are safe to treat in general practice and when they should subsequently be referring to secondary care. This ability helps to minimise the number of medical emergencies that they are exposed to. They should also have
general dental practice in Great Britain. Part 3: Perceptions of training and competence of GDPs in their management. Br Dent J. 1999;186:234-7. 6 Chapman PJ. Medical emergencies in dental practice and choice of emergency drugs and equipment: a survey of Australian dentists. Aust Dent J. 1997;42:103-8. 7 Broadbent JM, Thomson WM. The readiness of New Zealand general dental practitioners for medical emergencies. N Z Dent J. 2001;97:82-6. 8 Kieser J, Herbison P. Clinical anxieties among dental students. N Z Dent J. 2000;96:138-9. 9 General Dental Council. The First Five Years: A Framework for Undergraduate Dental Education. 3rd ed (interim). London: GDC; 2008. 10 General Dental Council. Preparing for Practice: Dental Team Learning Outcomes for Registration. London: GDC; 2012. 11 Greenwood M, Seymour RA.
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sufficient clinical and academic knowledge to diagnose and manage medical emergencies and administer appropriate medication as outlined in The First Five Years.9 This knowledge must then be built upon through their postgraduate training and continuing professional development.
Conclusion Final-year dental students felt that their undergraduate medical emergency training was adequately preparing them for their future role in the management of emergencies in a practice setting. On the whole, the final-year dental students showed greater confidence in their academic knowledge than clinical skills, which emphasises the need for a more practical approach to their education. Although students felt prepared to manage medical emergencies, their lack of confidence in the use of the emergency equipment and drugs necessary in their management highlighted the need for more emphasis to be placed on this during undergraduate teaching.
Human diseases: the Newcastle experience. Br Dent J. 2007;203:595-8. Resuscitation Council (UK). Medical Emergencies and Resuscitation: Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice. London: Resuscitation Council; 2006 (rev 2012). Clark MS, Wall BE, Tholström TC, Christensen EH, Payne BC. A twenty-year follow-up survey of medical ermergency education in U.S. dental schools. J Dent Educ. 2006;70:1316-9. Likert R. A technique for the measurement of attitudes. Arch Psychol. 1932:140:1-55. Laurent F, Augustin P, Nabet C, Ackers S, Zamaroczy D, Maman L. Managing a cardiac arrest: evaluation of final-year predoctoral dental students. J Dent Educ. 2009;73: 211-7. Carvalho RM, Costa LR, Marcelo VC. Brazilian dental students’
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perceptions about medical emergencies: a qualitative exploratory study. J Dent Educ. 2008;72:1343-9. Rosenberg M. Preparing for medical emergencies: the essential drugs and equipment for the dental office. J Am Dent Assoc. 2010;141 Suppl 1:14S-9S. Le TT, Scheller EL, Pinsky HM, Stefanac SJ, Taichman RS. Ability of dental students to deliver oxygen in a medical emergency. J Dent Educ. 2009;73:499-508. Sopka S, Biermann H, Druener S, Skorning M, Knops A, Fitzner C, et al. Practical skills training influences knowledge and attitude of dental students towards emergency medical care. Eur J Dent Educ. 2012;16:179-86. Newby JP, Keast J, Adam WR. Simulation of medical emergencies in dental practice: development and evaluation of an undergraduate training programme. Aust Dent J. 2010;55:399-404.
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