Michelle Dawn Mooney: Hello, and welcome to the “Health First Talks” podcast. I’m your host, Michelle Dawn Mooney. Today, we’re talking about recognize, respond, reassure patient evaluation in medical emergencies. When a patient begins showing signs of distress, the first few minutes are critical, and this episode focuses on how dental teams can quickly assess the situation. They can identify warning signs, determine severity, and then decide on the appropriate next steps before treatment escalates. This discussion will center on practical patient evaluation strategies, team communication, and decision-making during real-world emergency scenarios commonly encountered in dental settings. And I am so honored to have our guest today. Dr. Amanda Okundaye is a dentist anesthesiologist and will be guiding this conversation. Doctor, thank you so much for joining me today.
Dr. Okundaye: Thank you so much. I was honored to really be able to do this podcast. I truly believe that this is a fantastic topic because obviously, as an anesthesiologist, this gets to the heart of everything we need to know about anesthesia and emergency preparedness. So I love it.
Michelle Dawn Mooney: Yeah. Absolutely. So important. Life-saving information that we’re talking about here today. Before we dive into that conversation, though, would you mind giving us a brief bio, if you can, please?
Dr. Okundaye: Sure. Absolutely. So again, as Michelle Dawn Mooney said, my name’s Dr. Amanda Okundaye. I am a dentist anesthesiologist, board-certified. I went to UCLA for my anesthesia residency, and now I am the associate program director here at UNLV School of Dental Medicine, where I’m here part-time, and then I do mobile anesthesia the other days.
Michelle Dawn Mooney: Perfect. So we talked about how important this conversation is, so I want to start off with talking about the very start of really where we begin here. Why the first few minutes of a medical emergency are so critical. So can you give us that insight when it comes to those emergencies in a dental office?
Dr. Okundaye: What I like to teach, and I tell my students and CE doctors, anyone I’m talking to about emergency preparedness, is that the emergency started before the emergency. Right? And so it’s really important to us to understand that most bad outcomes in dentistry aren’t because someone failed CPR. It’s because we failed to recognize all the things that came before there was an emergency. And so especially in a dental office, outside of hospital settings, you have to understand that you can’t treat a stranger. This is not the ED. You can’t just bring a patient in, not knowing their full health history, and assess the patient, not that moment, but knowing them before they’re in your chair in an out-of-hospital setting.
Michelle Dawn Mooney: So what should the very first assessment look like when something does seem wrong with a patient?
Dr. Okundaye: Well, the first few minutes are critical, right? Those first few minutes are going to tell you if you can stabilize a patient or if that patient is going to deteriorate. And so those first few minutes are really critical to the outcome of the patient.
Michelle Dawn Mooney: What would you say are the most important signs and symptoms that teams should be paying attention to immediately? Because, as you said, minutes matter here.
Dr. Okundaye: So I think the first thing to talk about is team. So the most important thing in an out-of-hospital setting is recognition, as I said before. A lot of times in an out-of-hospital setting, teams are so focused on the procedure that they lose their focus on the actual patient. So when we’re talking about signs and symptoms, well, you have to be paying attention to the vitals. And in this new world of electronic health records, we figure out a lot of times that they’re not really paying attention to a patient’s symptoms soon enough because they’re so focused on the procedure because the computer itself is taking those vitals for them and looking at trends. If that makes sense. And so for me, the biggest challenge is recognition, and from the team perspective, they’re just thinking, “Oh, a patient’s anxious,” or, “A patient’s just a little sleepy.” And they kind of put it off as that’s their norm without seeing a trend of something happening slowly. Most patients don’t just have cardiac arrest. There are things that happen before that happens that are missed.
Michelle Dawn Mooney: So how important is responsiveness when you are evaluating a patient to determine if there is something wrong?
Dr. Okundaye: Well, you have to look at it from the approach of systematic. So when you’re talking and teaching your teams about medical emergency preparedness, you want to have a certain way to talk about things in the sense that you say, “If you look at those five things, the patient’s appearance, responsiveness, airway, breathing, circulation,” it allows you to assess a patient in a systematic way to figure out what is happening with the patient.
Michelle Dawn Mooney: I’d like to dive a little deeper if we can. You mentioned some important things to keep note of, but can you actually walk us through the basics of how you do that? Because there could be circumstances, I would assume, that people can kind of skim through some of those. So when it comes to evaluating airway, breathing, circulation in a dental setting, what does that look like in real-time?
Dr. Okundaye: So let’s keep it first simple. Is the patient awake? Conscious versus unconscious. Okay? Is the patient breathing? Breathing, not breathing. You have to know a patient’s baseline and normal to assess those questions with it being… Or is the oxygen adequate for the patient? Yes or no? These are the things that will help you then break down airway, breathing, and circulation, but you have to keep it simple. Does the patient have a pulse or no pulse? Okay? And so when you’re breaking it down, you’re doing this in a very quick manner. So airway, is the patient breathing? Okay. Is the patient obstructed? Is the patient hypoxic? Are the patient’s lips blue? What does the vitals look like on the monitor? Breathing then goes into what is your oxygenation on your SpO2? Are you seeing chest rise, or is the patient struggling to breathe? Right? That’s what we’re looking at in breathing. Circulation means how well the body is perfusing. Is the blood pressure okay? Are they hypertensive or hypotensive? Is the heart rate tachycardic or bradycardic? But again, we can do airway, breathing, circulation, but if you don’t know your patient and have a good patient evaluation, you have no idea what their baseline was.
Michelle Dawn Mooney: I want to ask you about that because it is so important in a case-by-case basis when you talk about having that specific medical history for that patient. So how much can a patient’s medical history help guide emergency decision-making?
Dr. Okundaye: It is everything. You should not even treat a patient until you know who they are. What you see on paper when a patient fills out their medical history is who they are that day. Most times, patients fill out their health history and forget a ton of information. We are very poor historians. So you may have a patient in the chair who doesn’t believe that their podiatrist appointment or their dental appointment is important to write down that they have a history of COPD. Right? What does that have to do with my feet or my teeth? And so when you’re talking to a patient, they may say, “No medical problems at all.” So the first question we ask in patient evaluation is, “When was the last time you had a full physical?” You’re going to hear things like, “I don’t go to the doctor. They always tell me something’s wrong.” Or they’ll say, “I haven’t been in 10 years. I don’t have insurance.” So your paperwork that you filled out for me is who you are today. That is not what is going on with you probably systemically because you haven’t had labs, you haven’t had an EKG, you haven’t had a full assessment from someone. So I can’t treat you until I know the full story, and that day is not the full story.
Michelle Dawn Mooney: When certain things come to light, are there certain medical conditions that should put teams on higher alert before treatment even begins?
Dr. Okundaye: Yeah. Since we’re talking about preparedness, medical emergencies, in the sense of patient evaluation, are predictable. So if my patient has severe asthma, that is a predictable medical emergency outcome that I would be trying to make sure my patient’s optimized before I treat them, in any way, whether that’s awake or with sedation. Right? If my patient has obstructive sleep apnea and is not compliant with their CPAP at night, right? That is a predictable medical emergency that if I’m sedating this patient, I know that my patient’s not compliant with their CPAP, they can have breathing issues or obstruction. If my patient has a history of diabetes, what is their hemoglobin A1C? Right? We don’t want to treat a patient who has anything uncontrolled. But if you don’t know that health history, those are some of the things that I believe to be significant, like significant cardiac disease, a patient who has a history of uncontrolled hypertension or dysrhythmias or aortic stenosis. There’s so many. We could talk like this for six weeks about a true patient evaluation. But I think the most important thing is understanding history. And if you don’t ask the right questions, history of allergic reactions, history of street drug use, history of nausea and vomiting, as simple as that, you don’t know your patient. And so I say medical emergencies are predictable because if you know your patient, you really can get ahead of a possible medical emergency.
Michelle Dawn Mooney: So you mentioned before that we are not the best historians, which I would agree wholeheartedly. So let’s flip it, though. On the professional side of things, though, what details are often overlooked during a patient evaluation?
Dr. Okundaye: A lot of times, we just trust a patient who says, “I’m healthy.” Yeah. Okay, great. You’re healthy. That, to me, means nothing at all because I will tell you that “I’m healthy” means nada. They don’t know their weight. They don’t know their BMI. They forget about allergies. They haven’t been to the doctor. They just assume no medical problems because they haven’t had an actual exam. Okay? So we, as practitioners, take their word, and we don’t get a medical consult. And our medical colleagues know our patients better than we do in an outpatient setting because they are to see them more often. And so then we do our homework, and we get a baseline EKG, and we see that they have a dysrhythmia, let’s say. We’re just throwing something out there. Well, that’s good for me to know because when I put them on an EKG when they come in my office, then at least I know it’s not normal, and now I know what their baseline is, so then I’m not canceling and wasting our day. Right? Something as simple as anxiety. They say, “No medical problems,” but they don’t consider that they have severe anxiety, which can be a medical emergency. Right? So to them, these things are not a big deal, but that’s why we treat the patient and not the paperwork.
Michelle Dawn Mooney: Yeah, absolutely. So say something comes to light. How do teams determine whether to stop treatment immediately?
Dr. Okundaye: I think the best thing to say here is that the procedure you’re doing, unless you’re in the ED, is not more important than the patient. And so it doesn’t matter what your treatment is. If something doesn’t look right, you don’t know what normal is, but you see abnormal, you absolutely stop the procedure and go get a medical consult. Have the patient have the right testing and the labs and such because no matter what you’re doing in an outpatient setting, a lot of times it’s elective. An elective treatment can be stopped. Have the patient optimized before you push a narcavalier.
Michelle Dawn Mooney: So a follow-up to that, then. What factors help determine when EMS should be activated?
Dr. Okundaye: Oh. Early. Always call EMS early because not late, not after the intervention has failed. You activate EMS when you are thinking, “This is something that is beyond my capacity in this setting.” Right? And so for us, we say, “Listen. Symptoms are worsening. I’m pulling out epinephrine. This diagnosis is uncertain. My airway concerns are valid, and I can’t manage them. The cardiac symptoms are beyond my understanding because I’m not a cardiologist. Neurologically, the patient has altered mental status. EMS should’ve already been called.” So never late, always early.
Michelle Dawn Mooney: Yeah. And of course, it’s always better to be safe than sorry. And again, we’re talking about life-saving situations, potentially, if there is a dire emergency. So I want to ask you, figuring out, okay, maybe we should stop this procedure, figuring out whether or not EMS needs to be called in sooner than later, as you just said, but how important is the role of communication when it comes to those first few minutes?
Dr. Okundaye: Well, this is the team approach. This is where closed-loop communication comes in. This is where you have to have trained staff in BLS and ACLS, because for me, communication saves lives. And unless you can understand what the patient’s baseline vitals were, and our assistants are so vital in a team setting, right? Our assistants can make or break a case, because a lot of times, our surgeons, our practitioners are just so focused on what they’re doing, that we need to be surrounded by people who are there to augment us as practitioners, right? So communication saves lives. And the staff must know what’s happening, what the patient’s status is, who’s doing what, what is your role? Are you calling EMS? Are you getting medications? Are you starting CPR? Everyone must have a role, and you also must cross-train. We have so much turnover nowadays, just a revolving door, unfortunately, of auxiliary staff that you have to cross-train, because confusion delays treatment. Confusion creates delays. Confusion doesn’t save patients’ lives. And to me, it’s really important that that communication is clear.
Michelle Dawn Mooney: I want to ask you, because I have this vision when you’re talking about knowing who’s going to do what, of somebody who’s in the outfield going to catch the baseball, and four people go at the same time to try to catch it.
Dr. Okundaye: Absolutely. Right? Because that’s literally what can happen.
Michelle Dawn Mooney: So how should those responsibilities be divided among team members during an emergency?
Dr. Okundaye: Well, I’m a baseball mom, so I will tell you. If my son’s in the right field, and it’s going between right field and center field, they better run and bump into each other, and somebody better catch that ball, okay? So that is the same thing in an outpatient setting when it comes to emergencies. You have to have clear responsibilities. And sometimes you do bump into each other, but somebody knows, like, “Oh, okay, okay. They’re closer to center field. It’s my ball.” Okay? So each emergency should be already established before the emergency happens. That should be done with four people, so person one, two, three, and four. Person one is the one who leads the evaluation. That’s usually the doctor, the practitioner, who says, “This is what I think the emergency is. This is the differential diagnosis. I will start, let’s say, high-quality BLS.” Person two is usually the person who goes and gets the house first kit, the oxygen, the AD. They retrieve all emergency equipment. Person three is usually your scribe. So that’s the person who’s going to be looking at your monitor, recording events and vital signs, and keeping the team abreast of where the patient is in their vital signs as far as whether it’s working, what you’re doing, or whatever. And then person four is the person who calls EMS. They go ahead and give them the diagnosis that the doctor gives them. They tell EMS what the suspected differential diagnosis is, where your office is, the address, and that you’ll meet them at the elevator or the front door and help bring the first responders in.
Michelle Dawn Mooney: What are some common mistakes or maybe delays you see during emergency responses?
Dr. Okundaye: First and foremost, number one is continuing treatment too long. Just assuming this will pass, just assuming, oh, it’s just one low blood pressure. Oh, that was just one little blip on the EKG. You continue treatment too long. At some point, you delay EMS too long, and you can’t fix the damage that has been done. Okay? Poor communication, as we just talked about. That will, for sure, be a huge common error. Failure to reassess the patient. So you assess the patient. You saw that there was, let’s say, this low blood pressure. You continued treatment but didn’t reassess to see if the patient has then fixed it. So poor assessment or reevaluation. And truly, another big one is not practicing emergency drills. And if you don’t do that quarterly, and again, you don’t cross-train, I cannot say that enough. You have to train for an emergency. When it happens, your brain goes absolutely blank, and you may have this beautiful kit of all these emergency drugs and oxygen and AED, and you will forget all of it. And so we do know that the literature’s very clear that a manual does help in these situations, but you still must practice at least quarterly. So I would say that’s the most common errors.
Michelle Dawn Mooney: So talking about that and the cautionary tale of what we need to be wary of so we can fix it, but in the big picture, how can practices improve confidence in patient evaluation and emergency readiness?
Dr. Okundaye: Simulation, mock drills. So personally, in my practice, if I have a patient who’s under general anesthesia or a sedation with my residents, I’ll say, “Okay, this patient has a history of hypertension. God forbid the patient went into hypertensive crisis. What would we do? What medications do we use?” And so mock drills just thrown out here and there, I do think it keeps your brain going in a direction that allows you to get ahead of a possible emergency. That’s what I would say. So mock drills are important. Simulation’s important. There are a lot of companies that will come out and do a simulation with your staff and simulation training in-office. So you kind of go through it in your own practice instead of just in a CE course. Role assignments are huge, and then equipment checks. It’s not okay to have an emergency, go get your health first kit or oxygen tank, turn it on, and it’s empty. We failed.
Michelle Dawn Mooney: And well, speaking of that then, have you seen situations where subtle symptoms maybe were initially underestimated? Falling in line, you’re talking about the prep beforehand, but just the actual situations of an emergency case.
Dr. Okundaye: Absolutely. And what I’ve seen is that teams perform the way they train. So if you don’t train, you perform terribly and horribly, and the outcome is terrible. The teams that practice often perform beautifully and handle the situation, and it’s calm, and it’s in a manner that saves patients’ lives. And we don’t really have time on our side once they do recognize that there is an emergency. You just don’t have time. It takes EMS anywhere between eight to 12 minutes nationally to get to most practices, unless you’re in a very rural area, right? So you have 10 minutes to be prepared to manage this patient until you can pass on to a first responder who can take over that treatment for you. But if you do not practice, that 10 minutes feels like 10,000 hours.
Michelle Dawn Mooney: Yeah. I’m sure. And unfortunately, I’ve heard from several people in conversation, having dealt with that type of emergency, and sometimes it has been a loss of life involved, which I can’t even imagine. So with that in mind, what lessons do experienced clinicians learn after managing real emergencies?
Dr. Okundaye: Well, that’s twofold. So to go back to your initial question, because I answered it, but I didn’t answer it. But if a patient says to you, “I feel funny,” right? Or, “I can’t catch my breath. I feel like I have tight chest. Something doesn’t feel right. I’m getting lightheaded.” And you don’t respond immediately, and you overlook those as subtle symptoms, you miss the bigger picture. Right? And so to me, when you said, the question I believe was a situation where subtle symptoms were kind of not initially ignored, but they just weren’t recognized as being a serious thing. I think those subtle symptoms often precede the major event. Right? And so we get so busy, and we get so caught up, especially in an outpatient setting with elective treatment. Patients are paying for this. All of it clouds your brain from paying attention to the little things. And it is the Swiss cheese model, and that hole, and then that hole, and then that hole, and now you’ve got Swiss cheese model, and it’s something so much bigger that you’re not prepared to handle. And so that was the first part of that. And I believe your question is one of the biggest lessons in seeing these things in real time is humility. And the biggest lesson for me in looking at case reports that have come across my desk or talking to other practitioners that have had emergencies is that it really does humble you, because you just assume it’s not a big deal. I’m not going to see these things. I see otherwise healthy kids or things like that. Well, the biggest lesson to me with experienced, really good clinicians is humility. And once you realize that most emergencies don’t follow the algorithm in the textbooks, they don’t always look as cut and dry, then you realize that preparation is what matters. And then once you’re prepared, then early recognition matters. Then you just get better at patient evaluation, because now you can see through the red flags, and that’s where the humility comes in and you say, “You know what? In the past, I may have treated a patient with aortic stenosis, but I know firsthand that those are not good candidates for sedation in the office.” And that’s where the humility comes in. And I think that’s super important. I do work with a lot of young people, and I go to a different office every day, and the ones who think they’ll never have an emergency, statistically it’s not a big deal. Those are the ones when it happens, you’re like, “Oh, sorry I told you so.” Right? You have to be prepared. It’s like anything else. Not to mention the fact too that textbook learning is quite different than when it’s happening in real time. And I think a lot of people underestimate, and this is in any field, when emergency situation happens, we underestimate, as you’re a caregiver, you’re somebody in a field where you can help the other person, our emotions coming into play, right? Because that’s a whole other story with how we may react to being in that emergency situation.
Michelle Dawn Mooney: So if every dental team remembered one thing about patient evaluation during emergencies, what should it be?
Dr. Okundaye: Don’t treat a stranger. Honestly. I cannot emphasize that enough. Know your patient before treatment. Please, I beg you, understanding their medical history, understanding their risks, understanding their baseline conditions will get ahead of recognizing that this is what normal looks like, and this is what abnormal looks like, and you will be able to get ahead of a possible medical emergency if you know your patient. Patient evaluation is the ultimate practice, all the things. I just, I can’t emphasize it enough. Patient evaluation is everything.
Michelle Dawn Mooney: Let’s take that one step further, literally and figuratively when I refer to steps. What practical steps, then, can practices take today to improve emergency preparedness?
Dr. Okundaye: Take the time to review medical histories. Decide if that patient needs a medical consult. Take baseline vitals at every single appointment so you know if that is normal or abnormal. I can’t emphasize it enough. Conduct regular emergency drills. Make yourself a manual for your office with the specific roles for each person for the emergency. Maintain and check all the expiration dates on your emergency drugs. You should have one or two people who maintain all the emergency equipment and medications. Practice airway management skills. If a patient goes deeper than the level that was intended in your sedation, or even just with nitrous oxide, understand that you still need to practice airway management so that you can be prepared to rescue a patient. Those, I would say, would be the most practical ways to be prepared for an emergency.
Michelle Dawn Mooney: I know you touched on this more than once during our conversation, but I think it’s something that we cannot hear too often. How often should teams rehearse or review emergency response protocols?
Dr. Okundaye: So quarterly is, I think enough, right? If every four months you say, “Okay, we’re going to have a lunch and learn,” or utilize a patient who has an extensive health history and say, “This patient has medical consults that are needed from a pulmonologist, a cardiologist, a neurologist, an endocrinologist,” and go through that with your team. So quarterly is what I say they should do.
Michelle Dawn Mooney: I really do think that they should take the time to go through medical histories with their staff all the time, honestly.
Dr. Okundaye: Sure. But as far as the actual medical emergency preparedness, at minimum quarterly.
Michelle Dawn Mooney: Any final thoughts before we wrap up today?
Dr. Okundaye: Don’t treat a stranger. But no, I truly mean that, and if I was to write a snippet, I would say, “The most important emergency management occurs before the procedure ever begins.” How about I say it like that? And so to me, if you don’t know your patient’s medical history, their medications, their allergies, their functional status, then the procedure shouldn’t happen, because then you won’t have surprises. And we don’t want surprises. Oh, I don’t like surprises. Nah. No. Surprises are not good in this situation. No. Remember, the other thing is, if you need a snippet, the procedure’s optional, the patient is not. Mm. Everything we do is optional, but having a healthy patient leave your office the same way they came in, it’s not up for discussion.
Michelle Dawn Mooney: Yeah. Great way to look at it. And perfect way to close here. Very important conversation. We talked about this right from the get-go. This would be information that potentially can be lifesaving. So Dr. Amanda Okandayi, dental anesthesiologist, I appreciate your time, doctor, for being here, for sharing the pros and the cons of being prepared and how that can benefit our patients, that we hopefully don’t have to talk about any tragedies, and we only talk about lifesaving situations where we can get our crew on board, get them doing what they need to do beforehand so they are prepared, and that every patient can be healthy, and we don’t have to worry about them being in a situation where we don’t want to talk about. I love it. Dr. Amanda Okandayi, dentist, anesthesiologist, thank you so much for your time, doctor, for being here. Very important conversation, as we said several times here. Really lifesaving information. So appreciate you being here today. Thank you for your time.
Dr. Okundaye: Thank you. Know your patient. Don’t treat a stranger. Know the right patient, the right plan. I promise you, you will get ahead of any emergency that can come about.
Michelle Dawn Mooney: Yeah. And that’s exactly what we want. And I want to thank all of you for tuning in and listening to the “Health First Talks” podcast. Of course, you can visit healthfirst.com for more information there, and we would invite you to subscribe to the podcast if you’d like to hear more engaging conversations like the one you heard today. I’m your host, Michelle Dawn Mooney. Thanks for joining us again. We hope to connect with you on another podcast soon.
