emergency medicine

emergency medicine

CONCEPTS, COMPONENTS, AND CONFIGURATIONS Interdisciplinary Training: Hospital Dental General Practice/Emergency Medicine James 7". Amsterdam, DMD, MD...

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CONCEPTS, COMPONENTS, AND CONFIGURATIONS

Interdisciplinary Training: Hospital Dental General Practice/Emergency Medicine James 7". Amsterdam, DMD, MD* David K; Wagner, MD t Louis F. Rose, DDS, MDt Philadelphia, Pennsylvania

The interaction between the residency training program in hospital dental general practice and emergency medicine at The Medical College of Pennsylvania is discussed. The contribution by the emergency medicine resident to the training of the dental resident and the role of the dental resident in the education of the emergency medicine resident are described in detail. Methods for enhancing this unique relationship between two departments are presented. Amsterdam JT, Wagner DK, Rose LF: Interdisciplinary training: hospital dental general practice/emergency medicine. Ann Emerg Med 9:310313, June 1980.

education, graduate, interdisciplinary; residency programs, interdiscTplinary, emergency medicine'and dental medicine INTRODUCTION In an attempt to enhance educational communication between medicine and dentistry, a unique affiliation between The Medical College of Pennsylvania and the University of Pennsylvania School of Dental Medicine was developed in 1972. The vital characteristic of the program has been the development of an environment which encourages direct educational interaction between dental and medical students, residents, and their faculties in providing professional care and generating a meaningful dialogue between these disciplines. Hospital dental general practice and emergency medicine are two residency training programs that are gaining increasing popularity among recent dental and medical graduates. At The Medical COllege of Pennsylvania, the programs maintain a close interaction in the training of their residents. Hospital Dental General Practice Residency Residents in dental medicine begin their first three months at the hospital bn off-service rotations consisting of one month of anesthesia, one month of surgery, three weeks of medicine, and two weeks of emergency medicine: The anesthesia rotation provides the resident with a basic understanding of respiratory physiology and pharmacology, airway management, anesthetic evaluation, and technique. On medicine, the resident gains experience in medical history taking and techniques of physical examination, and learns to appreciate how systemic disorders are investigated and treated. On surgery, the resident develops an u n d e r s t a n d i n g of pre- and post-operative management, including From the Departments of Dental Medicine and Surgery,*:~ and Surgery and Emergency Medicine,t The Medical College of Pennsylvania, and the Department of Periodontics, Universityof Pennsylvania School of Dental Medicine,* Philadelphia, Pennsylvania. Address for reprints: James T. Amsterdam, DMD, MD, Chief Resident, Division of Dental Medicine/Surgery, The Medical College of Pennsylvania and Hospital, 3300 Henry Avenue, Philadelphia, Pennsylvania 19129.

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wound care, control of infection a n d fluid balance, and surgical techn i q u e . The r o t a t i o n in e m e r g e n c y m e d i c i n e is an i n t r o d u c t i o n to t h e emergency unit and staff, as this will be a f a m i l i a r t r a i n i n g ground for the entire residency year, especially w h e n the resident is on call. The r e m a i n i n g nine m o n t h s of t h e y e a r a r e s p e n t in t h e d e n t a l center, where a family of p a t i e n t s reCeive comprehensive care. E m p h a s i s is placed on providing care to medically compromised, handicapped, and r e t a r d e d p a t i e n t s who are u n a b l e to receive such care in d e n t a l offices. The long-term objectives of a residency in hospital d e n t i s t r y are: 1) to t r a i n a d e n t i s t to be f a m i l i a r w i t h the hospital; 2) to t r a i n a dentist to b e b e t t e r e q u i p p e d to m a n a g e t h e medically compromised patient; 3) to t r a i n a d e n t i s t to be better p r e p a r e d to m a n a g e a medical e m e r g e n c y in the dental office; and 4) p e r h a p s most i m p o r t a n t l y , to t r a i n an educator in the field of d e n t a l medicine.

Emergency Medicine Residency The emergency medicine residency consists of a t h r e e - y e a r postg r a d u a t e t r a i n i n g p r o g r a m in which the resident spends the m a j o r i t y of t i m e on rotations in the emergency u n i t at the medical scho61 or a t affiliated community hospitals, or in a pediatric or a d u l t critical care unit. N o n e m e r g e n c y rotations include spec i a l t y r o t a t i o n s in a n e s t h e s i a , orthopedics, cardiology, and o p h t h a l mology. The long-term objectives of such a p r o g r a m a r e to t r a i n t h e e m e r gency p h y s i c i a n as: 1) a specialist in acute care, including evaluation, diagnosis, and stabilization; 2) a prov i d e r of p r i m a r y care; 3) a n organizer of the EMS activities in t h e commtmity; 4) a p a r t i c i p a n t in c o n t i n u i n g emergency care to facilitate completion of the acute episode; and 5) an educator for medical and dental students and the house staff who part i c i p a t e in e m e r g e n c y u n i t c a r e . E m e r g e n c y medicine residents p l a y a major role in t r a i n i n g general practice residents in dentistry.

RESIDENCY TRAINING Training the Dental Resident During the rotation in the emergency unit and t h r o u g h o u t the residency y e a r when on call, the d e n t a l general practice resident should l e a r n the following from the emergency medicine resident.

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Triage Concept -- The emergency p h y s i c i a n ' s concept of t r i a g e in the e m e r g e n c y u n i t has t a k e n on a b r o a d e r a s p e c t t h a n o r i g i n a l l y int e n d e d . N o t o n l y does he r e f e r to other specialists after definitive s t a b i l i z a t i o n , but completion of the acute problem is often accomplished b y e x p a n d i n g the concept of t r i a g e to include i n i t i a l t r e a t m e n t . Emergency History and Physical E x a m i n a t i o n - - P a r t of the evalua-

tion and t r e a t m e n t concept described is the e m e r g e n c y history and physical. A l t h o u g h s t a b i l i z a t i o n m a y h a v e to s u p e r s e d e c o m p l e t e e m e r g e n c y h i s t o r y and physical, t h e y m u s t be p e r f o r m e d at the a p p r o p r i a t e time. The h i s t o r y a n d p h y s i c a l e x a m i n a tion m u s t focus on all i n f o r m a t i o n r e l a t i v e to t h e a c u t e e p i s o d e , y e t m u s t be s u c c i n c t . T h e e m e r g e n c y physical e x a m i n a t i o n , a l t h o u g h likely to c o n c e n t r a t e on t h e s y m p t o m s t h o u g h t to be involved with the curr e n t p r o b l e m , m u s t be broad enough n o t to o v e r l o o k h i d d e n p a t h o l o g y . The dental r e s i d e n t observes and participates in this process, l e a r n i n g focusing questions and r e l e v a n t exami n a t i o n techniques. Emergency Data Base -- The e m e r g e n c y e v a l u a t i o n m a y include a d a t a base of l a b o r a t o r y tests. Tests generally ordered provide baseline e v a l u a t i o n s and a r e l i m i t e d in scope. T h e s e r v i c e s of ra'diology a r e freq u e n t l y required. The knowledge of " w h a t and when" to order is based on an u n d e r s t a n d i n g of which s t u d i e s a r e most efficient. The d e n t a l resid e n t g a i n s s o m e of~his knowledge, in part, through interaction with the e m e r g e n c y physician. D i a g n o s i s i n the E m e r g e n c y U n i t

Utilizing limited information, the d e n t a l r e s i d e n t p a r t i c i p a t e s with the e m e r g e n c y r e s i d e n t in m a k i n g t h e "emergency diagnosis." Such a diagnosis occasionally is definitive, but commonly r e p r e s e n t s early different i a t i o n of t h e p r e s e n t i n g p r o b l e m . The d e c i s i o n m u s t be m a d e to observe, to a d m i t , or to r e l e a s e . The e m e r g e n c y p h y s i c i a n m u s t be capable of u s i n g a l i m i t e d d a t a base to m a k e critical decisions. The d e n t a l r e s i d e n t l e a r n s how a n d w h y such decisions are made. -

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In the emergency medicine p r o g r a m a t The Medical College of Pennsylv a n i a , e m p h a s i s is placed on the concept of c o n t i n u i n g e m e r g e n c y care (CEC). Indeed, m a n y p a t i e n t s t r e a t e d on an a c u t e basis need s h o r t - t e r m follow-up care for procedures such as e a r l y w o u n d e v a l u a t i o n or s u t u r e

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removal. W h e n the problem is of a c h r o n i c nature~ s u c h p a t i e n t s are b e t t e r followed i n Other specialty clinics. E m e r g e n c y p h y s i c i a n s have t h e r e s p o n s i b i l i t y for i n s u r i n g the completion of t r e a t m e n t for the acute problem, either p e r s o n a l l y or by appropriate referral arrangements. A m o n g o t h e r s , d e n t a l h o u s e staff f r e q u e n t l y p r o v i d e c o n s u l t a t i o n in t h e CEC clinic. T e c h n i q u e - - I n addition to the u n i q u e philosophical and conceptual a p p r o a c h to which the d e n t a l resi: d e n t is e x p o s e d in t h e emergency unit, experience t h e r e also serves to educate the resident in certain basic techniques. F o r example, wound care a n d s u t u r i n g , v e n i p u n c t u r e , placem e n t of i n t r a v e n o u s catheters, and d r a w i n g of a r t e r i a l blood gases are c o m m o n l y c a r r i e d o u t by graduate trainees. The emergency resident assists the d e n t a l r e s i d e n t in learning t h e p r i n c i p l e s of r a d i o g r a p h i c int e r p r e t a t i o n of films of the chest, abdomen, and extremities. N o n - t r a u m a t i c E m e r g e n c i e s - - In addition to m a n i p u l a t i v e techniques, t h e d e n t a l r e s i d e n t is exposed to a wide v a r i e t y of medical emergencies. M a n y of these m i g h t be encountered in practice in the hospital, clinic, or p r i v a t e p r a c t i c e s e t t i n g . These in. clude r e s p i r a t o r y d i s t r e s s and card i o v a s c u l a r a n d n e u r o l o g i c emergencies. The dental r e s i d e n t can gain practical experience in applied card i o p u l m o n a r y r e s u s c i t a t i o n , emerg e n c y a i r w a y m a n a g e m e n t , and e m e r g e n c y fluid, blood a n d electrolyte replacement. The c o n t r i b u t i o n s of the emergency medicine r e s i d e n t to the traini n g of the d e n t a l g e n e r a l practice resi d e n t a r e i n v a l u a b l e ; however, the d e n t a l r e s i d e n t also contributes to an i m p o r t a n t aspect of the emergency r e s i d e n t ' s training.

Training the Emergency Medicine Resident Head and Neck Examination

M a n y p a t i e n t s p r e s e n t to the emerg e n c y d e p a r t m e n t w i t h c h i e f comp l a i n t s involving the head and neck, especially oral structures. A n import a n t role of the d e n t a l resident is to show the e m e r g e n c y resident how to e x a m i n e t h e oral cavity. Practical application of n e u r o a n a t o m y is demonstrated, especially as it relates to a d m i n i s t r a t i o n of local a n e s t h e t i c blocks or e v a l u a t i o n of facial fractures. Because the d e n t a l resident is more accustomed to i n t e r p r e t i n g facial bone or m a n d i b u l a r series and

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panoramic films in the e v a l u a t i o n of facial features, he assists the emergency resident in the t r e a t m e n t of dental and maxillofacial emergencies. Dental and Maxillofacial Emergencies - - As a consultant, the d e n t a l

resident assists in the e v a l u a t i o n and m a n a g e m e n t of emergencies of odontogenic origin. T h e emergenCy resident is t r a i n e d to a p p r e c i a t e the differences b e t w e e n the periodontal or periapical abscess and pericoronal infection with or w i t h o u t subperiosteal or cellulitis involvement. He l e a r n s the techniques of incision and drainage in the oral cavity; use of w a r m saline rinses; a n d a p p r o p r i a t e antibiotic choice, dosage, and regimen. The resident m u s t be able to evaluate the seriousness of infection and the c o n s e q u e n c e s of i t s s p r e a d through fascial planes. A knowledge of when to call the dental resident is acquired only after working closely with the d e n t a l c o n s u l t a n t in such circumstances. The e m e r g e n c y r e s i d e n t should be able to e v a l u a t e and d e t e r m i n e a differential of bleeding, eg, t h r o m bocytopenia p u r p u r a , l e u k e m i a , or trauma. The d e n t a l resident assists in this e v a l u a t i o n and d e m o n s t r a t e s techniques for achieving hemostasis. Many p a t i e n t s p r e s e n t w i t h postsurgical ( e x t r a c t i o n ) b l e e d i n g ; t h e e m e r g e n c y r e s i d e n t is t a u g h t t h a t those who do not r e s p o n d to local measures, such a s g a u z e p r e s s u r e , local a n e s t h e s i a with vasoconstrictor, or sutures, require careful a t t e n t i o n and w a r r a n t coagulation profiles. A n i n v a l u a b l e p a r t of the emergency r e s i d e n t ' s t r a i n i n g from t h e dental r e s i d e n t is the e v a l u a t i o n and m a n a g e m e n t of dento-alveolar trauma. The e m e r g e n c y resident should have a c o m p l e t e k n o w l e d g e of t h e m a n a g e m e n t of avulsed and subluxated teeth. He is t a u g h t to diagnose alveolar fractures. Although the emergency r e s i d e n t is not expected to stabilize d e n t o - a l v e o l a r trauma~ he a p p r e c i a t e s t h a t such s t a b i l i z a t i o n will be r e q u i r e d a n d u n d e r s t a n d s that such procedures should precede closure of a n y intra- or e x t r a o r a l lacerations. F i n a l l y , the emergency resi d e n t l e a r n s t h a t m a n a g e m e n t of dento-alveolar t r a u m a m a y be different in children and adults. The dental r e s i d e n t h e l p s t h e e m e r g e n c y physician to u n d e r s t a n d the growth and development of the tooth and its supporting s t r u c t u r e s and how this relates to t r e a t m e n t . As t h e r e a l m of the d e n t i s t extends beyond the oral cavity, t h e r e are m a n y emergencies of non-odont-

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ogenic origin to which the d e n t a l resi d e n t (with oral s u r g e r y c o n s u l t a tion) can a d d r e s s h i m s e l f a n d cont i n u e to c o n t r i b u t e to the t r a i n i n g of t h e e m e r g e n c y medicine resident. The dental/oral surgery team can aid t h e e m e r g e n c y r e s i d e n t in h i s t o r y takir/g, clinical e x a m i n a t i o n , o r d e r i n g a n d i n t e r p r e t i n g appropriate radiographs, and u n d e r s t a n d i n g the m a n a g e m e n t of facial fractures. Pathology involving the temp o r o m a n d i b u l a r j o i n t (TMJ) and its associated l i g a m e n t s and capsule is f r e q u e n t l y a c a u s e for e m e r g e n c y problems. The e m e r g e n c y r e s i d e n t is t a u g h t the function of this j o i n t app a r a t u s , a n d t h e v a r i o u s t y p e s of T M J dysfunction. A f t e r i n s t r u c t i o n in g r o w t h a n d d e v e l o p m e n t , t h e e m e r g e n c y r e s i d e n t a p p r e c i a t e s the serious consequences of u n d i a g n o s e d or m i s m a n a g e d condylar fractures in t h e c h i l d a n d is t a u g h t in w h i c h s i t u a t i o n s such fractures are l i k e l y to Occur.

F a c i a l lacerations a r e frequently h a n d l e d by both t h e e m e r g e n c y resident and t h e d e n t a l resident. Mana g e m e n t of combined extra- and int r a o r a l lacerations is a p a r t i c u l a r l y difficult p r o b l e m , for t h e y m u s t be closed in p r o p e r sequence a n d cove r e d with antibiotics as appropriate. In this situation, the d e n t a l resident teaches t h e e m e r g e n c y r e s i d e n t int r a o r a l a n e s t h e t i c b l o c k s so t h a t wound m a r g i n s are not distorted and gives instruction in m a n a g e m e n t of i n t r a o r a l tissues. A t the same time, t h e residents s h a r e t h e i r knowledge of closure techniques for the extraoral facial laceration. The e m e r g e n c y m e d i c i n e r e s i d e n t f r e q u e n t l y calls on the d e n t a l r e s i d e n t for consultation in the mana g e m e n t of e m e r g e n c i e s r e l a t e d to the s a l i v a r y glands. The d e n t a l resid e n t d e m o n s t r a t e s e x a m i n a t i o n of the s a l i v a r y glands and gross clinical d e t e r m i n a t i o n of t h e i r function. The m a n a g e m e n t of s a l i v a r y g l a n d infection or e v a l u a t i o n of obstruction also is explained. A subject that causes equal p e r p l e x i t y to both d e n t a l and emergency residents is t h a t of myofascial p a i n dysfunction. The e v a l u a t i o n of such p a t i e n t s is difficult. Some have underlying, subtle occlusal abnorm a l i t i e s or d e f o r m i t i e s of the T M J a p p a r a t u s . It is n o t for t h e e m e r g e n c y p h y s i c i a n to d e a l w i t h such etiologies, b u t he is given a knowledge of how to comfort such p a t i e n t s , t r e a t the s i t u a t i o n p a l l i a t i v e l y , and r e f e r to t h e a p p r o p r i a t e u n i t for treatment.

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Medically Compromised Patients The t r e a t m e n t of medically comp r o m i s e d p a t i e n t s is a special a r e a of c o n c e r n for e m e r g e n c y a n d d e n t a l residents. A n i m p o r t a n t role of the d e n t a l resident is to teach the emerg e n c y m e d i c i n e r e s i d e n t such concerns as SBE prophylaxis in t h e app r o p r i a t e p a t i e n t p r i o r to d e n t a l m a n i p u l a t i o n ; dental m a n a g e m e n t of t h e d i a b e t i c , s e i z u r e , h e p a t i t i s , or sickle cell patient; or m a n a g e m e n t of p a t i e n t s with b l e e d i n g disorders. Alt h o u g h m a n y of these p a t i e n t s do not commonly present, their managem e n t should be in the repertoire of t h e e m e r g e n c y p h y s i c i a n ' s protocol for dental emergencies. I n the a r e a of oral medicine, the d e n t a l r e s i d e n t discusses the m a n y oral m a n i f e s t a t i o n s of systemic disease, eg, t h e effect of d i a b e t e s on p e r i o d o n t a l tissues, oral manifestation of Chron's disease, and oral indications of coagulopathy. The dental r e s i d e n t helps to introduce the emergency r e s i d e n t to a w e a l t h of inform a t i o n p r e s e n t in the oral cavity.

Formal Training Interaction I n t e r a c t i o n between the general dental practice resident and the e m e r g e n c y m e d i c i n e r e s i d e n t is g a i n e d foTmally d u r i n g t h e d e n t a l resident's rotation through the emergency department and during the e m e r g e n c y resident's elective on d e n t a l medicine/oral s u r g e r y (two or four weeks). D e n t a l house staff attend weekly emergency medicine g r a n d rounds. P e r h a p s the most significant experience occurs during the d e n t a l r e s i d e n t ' s on call time, when he acts as the dental consultant to t h e e m e r g e n c y u n i t (with an oral s u r g e r y or chief d e n t a l resident and oral s u r g e o n for back-up). In addition to the i n t e r a c t i o n between residents, a d e n t a l s t u d e n t on e x t e r n s h i p acc o m p a n i e s t h e d e n t a l r e s i d e n t and t h u s g a i n s experience from this exposure. In addition, medical students r o t a t i n g t h r o u g h the e m e r g e n c y dep a r t m e n t or on d e n t a l medicine elective increase t h e i r knowledge from i n t e r a c t i o n w i t h t h e d e n t a l house staff.

SUMMARY We h a v e described the interaction t h a t exists between the Departm e n t of D e n t a l Medicine/Oral and M a x i l l o f a c i a l S u r g e r y and t h e Dep a r t m e n t of Emergency Medicine at The Medical College of Pennsylvania. The hospital general dental practice resident's experience is m a r k e d l y in-

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creased by his a t t e n d a n c e at weekly emergency medicine grand rounds a n d exposure to e m e r g e n c y conditions in concert with the emergency medicine resident. I n the same m a n ner, the depth and scope of the emergency medicine resident's knowledge a n d experience of the head and neck is e n h a n c e d . As d e n t o - f a c i a l e m e r gencies p r e s e n t more f r e q u e n t l y to the e m e r g e n c y d e p a r t m e n t , the emergency physician must be t r a i n e d and prepared to m a n a g e such prob-

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terns, especially w h e n a general dentist or oral surgeon may not be immed i a t e l y a v a i l a b l e . This t r a i n i n g is achieved through interaction with the dental house staff.

REFERENCES 1. Rose LF, Brown IS, Cohen DW: The combined medical-dental degree: new perspectives and applications. J Dent Educ 38:456-458, 1974. 2. Rose LF, Brown IS, Lynch MA: An interdisciplinary training program in a

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hospital. J Dent Educ 38:156-160, 1974. 3. Rose LF (ed): Hospital Dental Practice. Dental Clinics of North America, vol 19, Philadelphia, WB Saunders Co, 1975. 4. Hendler B, Rose LF: Common medical emergencies: a dilemma in dental education. J A m Dent Assoc 91:575-582, 1975. 5. Schwartz G, et al (eds): Principles and Practice of Emergency Medicine. Philadelphia, WB Saunders Co, 1978. 6. Laskin D: The role of the dentist in the emergency department. Dent Clin North A m 19:675-692, 1975.

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