A DOCS Education member seeks the faculty’s advice:
I had a partly successful appointment yesterday. My patient was a 54-year-old male heavy smoker with controlled bp, Mallampati class 3, had premed with 10mg diazepam the night before and 0.25mg triazolam in the AM before the appointment.
I administered an additional 0.25mg triazolam and 40mg hydroxyzine and the patient became comfortably sedated. I performed two crown preps on 21 and 28 with mental blocks successfully. I then administered more buccal and lingual anesthetic (lido and septo) to extract 22 and 23.
I then administered ligamental anesthetic and couldn't get the patient numb. I gave a block and could still comfortably luxate, but couldn't use the forceps or elevator without complaint of pain.
I finally chose to refer the patient to an OS for IV extractions.
Now is when the procedure got out of control. We called the companion (his wife) to pick up the patient at 11:30 and she said she had a job interview until 2:00 and could not pick him up until then. At this point the patient was quite alert and standing up. He became upset at his wife and then wanted to go outside to smoke. A team member of course accompanied him. He absolutely refused to stay in the office or sit in the chair.
At one point, he said he was going to walk home and we all had to convince him to stay there. He then lay down on the lawn and (this is so embarrassing) took a nap. I believe we lost control of this appointment.
We sat with him for about 10 minutes and then got him to go inside and wait for his wife. He did wind up going to an OS and completing his procedure in the PM.
Not that we are ever treating this patient again, but if we ever wind up in a similar situation, what else should we do other than making companions stay at the office for entire procedure? Should I have called the police when he refused to stay in the office?
Dr. Anthony Feck, DOCS Education faculty, responds:
Forcing a patient to stay in the office who is a heavy smoker and go more than 3-4 hours without smoking is asking a lot. This combined with the irritation with his wife made for the perfect storm. Always have the companion come one hour prior to the expected time of completion of the appointment. Confirm this at the sedation work-up, the day before the appointment and the day of the appointment.
The information contained in this, or any case study post in Incisor should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.
