How would you handle this situation?
Healthy 21-year-old woman presents for extraction of her wisdom teeth with intravenous sedation. She presented with her mother who was her escort and they lived about 30 minutes east of my office. She sat in attendance with her mother fully prepared for the treatment and was completely consulted with review of her history and physical exam including a cursory neurologic exam and auscultation of her lungs and heart and her extremities prior to the procedure.
The process to complete her treatment was explained to her and her mother prior to the surgery. A surgical and anesthesia consent was obtained with documentation of pre-operative vital signs including, BP, pulse, EKG, Sat.PO2, respirations, head and neck and airway exam all noted. The patient underwent extraction of four partial boney impacted wisdom teeth with inhalation of nitrous oxide and oxygen. Parenterally she received glycopyrrolate, midazolam, ketamine, fentanyl, Decadron, and Propofol infused in small doses. The patient tolerated the procedure well with excellent vital signs throughout her treatment and her recovery time a little slower than average. The patient’s mother was brought to the recovery room where the patient was being attended to, her mother was given post-operative instructions verbally and in writing and the assistant showed her how to change the gauze packs if needed. The mother was anxious to leave the office and kept requesting we discharge her daughter. The patient at the time did not meet all the discharge criteria so I explained to her mother that she will have to wait until the patient meets all the discharge criteria. Explaining to her that the patient must be able to open her eyes and remain awake and alert and subsequently breath easily without suppression. The patient’s vital signs must be stable, and she must have the ability to ambulate freely. Especially with this patient who was still too sleepy to be discharged and the concern is with a long car ride she may become sleepy again which requires close monitoring. Certainly, if her escort was her means to get her home then there will be no one watching and coaching the patient to wake up and take a deep breath.
When the assistant changed the patient’s intraoral gauze to look at the wounds and evaluate for hemostasis, unknowingly her mother became nauseous. Then without forewarning the patients mother became vasovagal, lost consciousness fell and struck her head on the floor in the recovery area, next to the patient. She had an episode of syncope, the most common medical emergency in the dental office. Immediately the dental assistant went into action and attended to the patient’s mother on the floor where she almost immediately awoke and I administered O2 via a facemask and had the other assistant attach the monitors to obtain BP, pulse and respirations. The mother was furnished with fruit juice to ameliorate possible low blood glucose. This episode woke the patient up and she became concerned for her mother. Very quickly the mother woke up and said “I’m fine we can leave now”. The mother denied any significant medical history and had eaten that morning but said the sight of the blood affected her and she felt a little hungry before. We explained she should sit and relax because she has a long ride home and may feel this way again. I recommended they call someone to bring them both home but they both insisted there was no one to call and they offered no names.
What would you do at this juncture? Allow the mother to leave with the daughter on a 30-minute ride home? It is my duty to ensure that the patient has a capable escort and, in this situation, I am not sure that her mother didn’t suffer a head injury that may cause her to lose consciousness again.
Although the patient’s mother was quite upset about it I called 911 to take her to the hospital and to take her daughter as well.
By the time the EMT’s presented to the office and took her out on the stretcher it was more than an hour since she was in recovery and the patient was fully awake and alert. She left with the EMT’s with her mother on the stretcher but once in the parking lot the mother changed her mind and she and her daughter left together in their car.
later that day we called the patient to do our post-op check and was told they left the EMT in the parking lot and went home and both of them were feeling well. The patient and the mother were appreciative of our attending to them efficiently. The patient had an otherwise uneventful post-operative course.
The Girldoc😉
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