Scenario
You are about to extract the upper right first molar on a patient. You apply the forceps and begin to mobilise the tooth. Suddenly, the patient screams in pain and forces your hand away. They are now visibly upset and demand to have another dentist extract the tooth. How would you manage this situation?

Take a few minutes to consider your answer to this and then compare to the suggested answers below.

Which issues/standards are involved?

Remember to consider general issues as well as GDC/CQC standards:

  • Put patient’s best interests and safety first (GDC Standard 1) – patient safety is crucial – they are in obvious pain and distress, which needs to be managed. You must also respect their choice and dignity.
  • Communicate effectively with patients (GDC Standard 2) – careful communication with the patient is necessary to resolve the situation.
  • Complaints procedures and handling (GDC Standard 5) – the patient may want to make a complaint due to the trauma that’s been caused.
  • Maintain, develop and work within professional skills and knowledge (GDC Standard 7) – you need to evaluate your technique and consider if you were carrying out the procedure properly.
  • Clinical governance – you may want to audit complications during extractions and reflect on your findings.
  • Referrals – the patient may need referral to other colleagues or potential anxiety management.

What is your short-term management?

You short-term management is about patient safety and mediating the initial situation:

  • Stop and apologise to the patient – you are not admitting liability by apologising but it is seen as a good way to defuse the situation, as the patient has been caused unnecessary pain. The patient may be placed at ease from this.
  • Listen to the patient’s concerns – it’s important to allow the patient to express how they feel and what is worrying them – there may be an easy solution.
  • Explain the situation to the patient and reassure them – it would be important to distinguish if they are in fact feeling pressure or pain. If it’s pressure, they need reassurance and a discussion as to whether they can tolerate a local anaesthetic for extraction. If it’s pain then the patient needs to understand further local anaesthetic can be given if needed.
  • If the patient has responded to discussion – continue treatment, ensuring you are listening to their concerns and managing them as required.
  • If the patient is still unhappy, you may call your supervisor – the patient may want a second opinion or further reassurance. The patient may be happy for you to carry the extraction out under supervision. Your supervisor may be able to provide you with some more solutions and information.
  • Refer the patient to a colleague – if the patient still refuses treatment, then it may be suitable to refer to a colleague. If they require anxiety management then you may consider referral for sedation.
  • Ensure patient is stable before going home – do not neglect any post-operative instructions and, if required, prescribe antibiotics.
  • Refer to complaints procedures if needed – the patient may want to complain about their treatment and unnecessary pain suffered, therefore direct them to the appropriate avenues. Ideally, you want to solve any conflicts in-house before escalating elsewhere.
  • Discuss with your indemnity provider – your indemnity provider will help ascertain if you need to be concerned about any other issues with the colleague.
  • Document complete, concise, clear and contemporaneous notes – documentation is vital to demonstrate that you did everything correctly in case any complaints are brought forward.
What is your long-term management?
  • Discuss case with your supervisor – arrange a meeting with your supervisor to discuss the case in more detail and reflect on the situation of unnecessary pain and what could have been done differently.
  • Ensure appropriate patient follow-up and complaints handling – don’t forget about the patient who started off the scenario and their treatment! Ensure referrals have gone through and are being managed.
  • Audit – if you’re concerned that this is happening often, it may be worth auditing your complication rates.
  • CPD – it may be worth attending courses and tutorials on extraction techniques and local anaesthetic delivery, to ensure your technique is the best it could be.
  • Team meetings – if this was an accident or there were concerns about things like complaints procedures, then this should be discussed with the entire team.
  • Reflection and portfolio – reflect on the situation and record this in your portfolio to see what you have learnt from the situation.

Attempt some other scenarios to help you prepare here.

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