When Patient Phobias Turn Into Medical Emergencies
Laura M. Cascella, MA, CPHRM
Patient anxiety or fear related to medical or dental treatment can be problematic and concerning in various ways. These fears may manifest as nonadherence to treatment protocols or appointments schedules, behavioral issues, or — in extreme cases — medical emergencies. The case studies below offer two examples of how patient anxiety and fear contributed to medical emergencies.
Case Example 1
A patient who had an extreme phobia of dental care was diagnosed with generalized periodontitis and agreed to a treatment plan of root planing, chemotherapy, and aggressive maintenance.
The night before the patient's appointment, she took 10 mg of diazepam, which the periodontist prescribed. The morning of the patient's appointment, she ate breakfast and inhaled a moderate amount of cannabis on her way to the appointment to try to relax.
Because of the patient's anxiety, she was offered the option of having the procedure done using nitrous oxide analgesia. Unfortunately, the practice had no nitrous oxide protocol in place. Thus, few questions were asked about the patient's recent ingestion of food or other substances.
Prior to starting the procedure, the patient's nitrous oxide level was increased twice due to her anxiety. Shortly into the procedure, the patient vomited, aspirated some of her vomitus, and lost consciousness.
Emergency medical services was called; while awaiting their arrival, the doctor tried to establish an airway but was unsuccessful. Despite attempted resuscitation at the scene and the hospital, the patient died.
Case Example 2
A patient who had broken his wrist in a motorcycle accident presented to an ambulatory surgery center for repair of the fracture. The patient, who was visibly anxious upon arrival, was seated in the waiting area to fill out forms. Once the patient completed the forms, he was instructed to remain in the reception area until called. More than 40 minutes went by, with the patient becoming increasingly nervous.
Eventually the patient was moved into the preoperative area, where a nurse attempted to place an intravenous (IV) line. After several unsuccessful attempts, the nurse commented that the anesthesiologist "might have to go through the foot," and then abruptly left the area.
The patient, who was already sweating and jittery due to his anxiety, began to panic upon hearing how they might insert the IV line. He stood up from the bed and began to pace, complaining that he felt short of breath. Although his wife — who was in the preoperative area with him — tried to calm him and get him to return to the bed, the patient continued to wander around the area. A few seconds later, the patient fainted, falling and hitting his head on a medical cart and then the floor.
Emergency medical services was called, and the patient was transported to the hospital where he was treated for a concussion and edema.
Risk Management Strategies for Phobic Patients
When developing policies for managing anxious or phobic patients, healthcare providers and organizations may want to consider establishing:1
- Protocols for premedication (e.g., providing sedation the night prior to surgery or treatment), with clear and specific instructions about when and how the patient should use the medication as well as any potential risks
- Policies related to appointment scheduling and treatment duration (e.g., scheduling phobic patients in the morning to reduce compounding apprehension, or splitting lengthy procedures into shorter sessions when possible)
- Strategies for minimizing the time patients spend in the reception or pretreatment areas (e.g., asking patients to fill out forms prior to their appointments to reduce waiting time)
- Requirements for monitoring patients' vital signs (e.g., establishing baseline measurements at a visit prior to the surgery or procedure, which providers and staff can compare with perioperative measurements)
- Protocols for sedation during treatment and pain management during and after the surgery or procedure
In addition to office protocols and administrative considerations, healthcare providers also can implement other risk-reduction strategies for working with anxious or phobic patients, such as:2
- Developing open lines of communication with patients through active listening and attentiveness
- Explaining to the patient in advance what to expect and what steps will be taken as part of treatment
- Expressing empathy and reassurance (e.g., reassuring the patient that he/she is not alone in feeling anxious or fearful)
- Fostering positive nonverbal communication (e.g., through eye contact and comforting gestures)
- Using behavioral or relaxation techniques to reduce patient anxiety (e.g., the show-tell-do technique)
- Introducing distractions to help divert the patient's attention (e.g., pleasant background music and short breaks from treatment)
- Offering environmental accommodations (e.g., lowering or raising the temperature in the operatory to the patient's liking or providing the patient with a blanket)
Even with the utilization of these strategies and techniques, some patients might still suffer from medical or dental treatment phobia. For patients who are extremely anxious or fearful, a referral to a mental health professional for evaluation and treatment might be beneficial.
Endnotes
1 Malamed, S. F. (2010). Knowing your patients. Journal of the American Dental Association, 141(Suppl 1), 3S–7S.
2 Appukuttan, D. P. (2016, March). Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, Cosmetic and Investigational Dentistry, 8, 35–50. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC4790493/; McMaster, R., & Garristo, G. A. (2012, February). Practical considerations for treating the anxious dental patient. Oral Health Group. Retrieved from www.oralhealthgroup.com/features/practical-considerations-for-treating-the-anxious-dental-patient/
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