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Basic Guide
to
Dental Sedation Nursing
BASIC GUIDE
TO
D E N TA L S E D AT I O N N U R S I N G
SECOND EDITION
Nicola Rogers
Dental Nurse Tutor
Pre and Post Registration Qualification Training
Bristol Dental Hospital
Bristol, UK
This edition first published 2020
© 2020 John Wiley & Sons Ltd
Edition History
John Wiley & Sons (1e, 2011)
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Library of Congress Cataloging‐in‐Publication Data

Names: Rogers, Nicola, 1962– author.
Title: Basic guide to dental sedation nursing / Nicola Rogers.
Description: Second edition. | Hoboken, NJ : John Wiley & Sons, Inc.,
[2020] | Includes bibliographical references and index.
Identifiers: LCCN 2019030082 (print) | LCCN 2019030083 (ebook) |
ISBN 9781119525776 (paperback) | ISBN 9781119525882 (adobe pdf) |
ISBN 9781119525868 (epub)
Subjects: LCSH: Anesthesia in dentistry.
Classification: LCC RK510 .R676 2019 (print) | LCC RK510 (ebook) |
DDC 617.9/676–dc23
LC record available at https://lccn.loc.gov/2019030082
LC ebook record available at https://lccn.loc.gov/2019030083
Cover Design: Wiley

Cover Image: Courtesy of Nicola Rogers
Set in 10.5/13pt Sabon by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
I am dedicating this book to our families’ memories of my mother‐in‐law,
Patricia Ah‐Zhane, who will never be forgotten.
Contents
How to use this book ix

Acknowledgementsxi
1 Introduction 1
Definition of conscious sedation 2
Why dental sedation is provided 2
Reference5
2 Medico‐legal aspects of dental sedation 7

Introduction7
Recommendations currently in place when providing dental sedation 7
Medico‐legal considerations when providing dental sedation 14
References22
3 Role of the dental nurse and equipment 23

Introduction23
General role of the dental nurse 24
Intravenous sedation 25
Inhalation sedation 43
Oral sedation and pre‐medication 46
Transmucosal (off‐licence) sedation 48
Clinical monitoring and equipment used 49
References64
4 Patient selection 65
Introduction65
The assessment appointment 65
Medical history 66
Physical examination 67
Dental history 69
Social history 69
Conclusion70
Reference70
5 Types of sedation 71
Introduction71
viiiContents
Pharmacology72
Intravenous sedation 72
Transmucosal (off‐licence) sedation 84
Inhalation sedation 86
Oral sedation and pre‐medication 111
Reference115
6 Medical emergencies 117

Introduction117
Minimising the likelihood of medical emergencies 118
Legal aspects of medical emergencies 119
Dealing with medical emergencies 119
Common medical emergencies 125
Airway control and ventilation 144
References156
7 Essential anatomy 157

Introduction157
Blood157
Heart160
Respiratory system 163
Dorsum of the hand and antecubital fossa 172
References175
Index177
How to use this book
This book is a basic guide to dental sedation nursing, which has been written
with dental nurses in mind. However, it could be used by other members of the
dental team, as it is a self‐explanatory resource.
It provides an appreciation of what can be expected of the sedation nurse
when patients receive conscious sedation techniques. It has been compiled in
order that any dental nurse, whether working within a dental practice that
provides sedation or not, after reading it would have a clear understanding of
the roles and responsibilities of the dental nurse, enabling them to recognise
good practice. It can also be used in conjunction with any course material that
may be provided to dental nurses who are sitting the sedation examinations
offered by the National Examining Board for Dental Nurses or any other seda-
tion examination, as it has been written in a user‐friendly manner covering all
aspects relevant to the examination.
There is no intention of instructing or criticising clinicians, anaesthetists or
any professionals on their roles in the surgery, which have only been explained
to further the knowledge of dental nurses. Any offence is entirely unintended and
apologies are tendered for any perceived affront.
Dental nurses are subsequently reminded and warned that on no account
should they undertake any duty that is solely the province of the clinician, anaes-
thetist or any other professional.
Acknowledgements
To David, my husband, who is my rock and safe place and is always there to
support me in all I do. For his love and patience, expert IT skills and for taking
the photographs, along with Jamil Havizavi courtesy of Bristol Dental Hospital.
To Sean, who we are proud to call our son, and his partner Zoe, who is like a
daughter to us.
To our adorable grandchildren Elsie Rose and Lochlan Patrick, who have
enriched our lives and never cease to amaze us.
To Nigel and Valerie, my parents, who have always encouraged and supported
me in everything I do, especially my father, who has constantly given his time to
reading and correcting the chapters.
To Wiley Blackwell for publishing this second edition.
Chapter 1
Introduction
LEARNING OUTCOMES
At the end of this chapter you should have a clear understanding of:
• Why conscious sedation can be offered as part of treatment planning.
Patients deserve to receive dental care to suit their needs, therefore offering a
form of conscious sedation can be an appreciable part of treatment planning.
Patients’ needs vary, with some being able to accept dental treatment without
any adjuncts; however, others actively avoid attending a dentist due to fear.
Whereas many patients who attend the dentist declare themselves anxious in a
dental environment, a small percentage of patients are classified as being
dental phobic. Anxiety is a normal emotion which can be experienced at dif-
ferent levels dependent upon the treatments being received or situations
encountered.
The appropriate provision of conscious sedation, often referred to as dental
sedation or shortened to sedation, whether in intravenous, inhalation or oral
transmucosal (off licence) form, helps to overcome patients’ fears and anxieties,
but not always their phobia. However, by accepting conscious sedation they are
able to undergo the dental care required to maintain a healthy mouth. These
forms of conscious sedation are explained in detail in Chapter 5.
Apart from fear and costs, other reasons for patients’ non‐attendance can
be attributed to a lack of dentists in their area, difficulty registering with a
dentist or that they are unable to access one due to factors such as mobility
problems.
Basic Guide to Dental Sedation Nursing, Second Edition. Nicola Rogers.

© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
2 Basic Guide to Dental Sedation Nursing
D E F I N I T I O N O F C O N S C I O U S S E D AT I O N
Conscious sedation is defined as ‘a technique in which the use of a drug or drugs

produces a state of depression of the central nervous system enabling treatment
to be carried out, but during which verbal contact with the patient is maintained
I N T RO DUCT IO N
throughout the period of sedation. The drugs and techniques used to provide
conscious sedation for dental treatment should carry a margin of safety wide
enough to render loss of consciousness unlikely.’ This definition was originally
suggested in the 1978 Wylie Report and has been applied ever since by many
organisations associated with regulating the practice of conscious sedation [1]. It
means that patients must remain conscious and are able to understand and
respond to any requests, for example if the patient is asked to take a few deep
breaths they are able to do so. Deep sedation is not provided, as an agent that
causes any loss of consciousness is classed as a general anaesthetic and compro-
mises patient safety. The definition explains the state of conscious sedation, but
not how it should be achieved. Nevertheless, it is widely recognised that clini-
cians use different techniques, with one or more drugs being administered
through different routes, all of which provide patients with safe sedation.
W H Y D E N TA L S E D AT I O N I S P R O V I D E D
Human i t a r ia n r e a s o n s
For patients who suffer anxiety and phobia regarding treatment, sedation tech-
niques can help them to accept it.
A nxi e ty a n d p h o b ia
Anxiety is a state of unease that a person can often relate to because of the
memories of whatever is causing them to feel anxious. This existing memory
may be something that was experienced by the patient or it could be a translated
experience from their family, friends or the media. Very often the patient is able
to explain and relate to the specific cause or occasion in their life that results in
their anxiety when faced with a similar situation/experience. As anxiety is con-
trollable to a degree, patients who are anxious will attend the dentist for treat-
ment and with good patient management undergo treatment, with or without
the aid of sedation, depending upon their treatment plan. These patients are
often found to have sweaty palms and an elevated heart rate, so monitoring their
vital signs is very important to ensure their well‐being.
Most patients are worried or concerned when attending the dentist, whilst
some are actually frightened. Feelings of fear are a major contributing factor to
Introduction 3
how elevated a person’s anxiety level will be. Basic fears experienced by patients
are based on the following factors:
• Pain. Nobody likes pain. Patients can associate the dentist with pain and think/
feel that they will experience some pain during their treatment.
• Fear of the unknown. Not knowing what is going to happen allows a person’s
I N T RO D UCT IO N
imagination to flourish. Patients who associate the dentist with discomfort
may think that they will experience pain when receiving treatment.
• Surrendering oneself into the total care of another. This could possibly make a
person feel helpless and dependent, leading to them feeling trapped and not in
control.
• Bodily change and disfigurement. Some dental treatments can lead to an irre-
versible change in the person’s appearance. Patients may fear that it could alter
their appearance drastically and they would not be happy with this.
• Claustrophobia. During treatment lots of instruments are used in the patient’s
mouth. Some patients find this intolerable and are concerned that an item
could be lost in their airway or that their mouth may fill with debris, making
it impossible for them to breathe.
Phobia is an abnormal, deep‐rooted, long‐lasting fear of something which
rarely goes away, making it very difficult to manage and treat someone who expe-
riences this in the surgery. It is very hard to overcome this condition or to alter the
way the patient thinks and feels, and in certain cases cognitive therapy may prove
useful. The cause of phobia is usually deep rooted and is often initiated from a
previous experience that the patient cannot recall (i.e. something that happened
at a very early age which is now embedded in their subconscious). The patient
quite often cannot explain its origin or why they are phobic about a specific thing.
They have no control over it. This category of patient may never visit the dentist
or will only do so when they are in extreme pain. If they do, they very rarely
return for follow‐up treatment once they are pain free.
It is only normal to feel anxious when attending the dentist and anxiety is a feel-
ing which most people encounter. However, a small percentage of the population
is dental phobic, with the condition being more common amongst women. Dental
phobia starts in childhood or during adolescence and can be associated with the
fears felt by parents. The parents’ phobia/fear can be transferred to the child by
observation and the way they respond and talk about the dentist. It may also be
associated with the fear of blood, injury or hospitals, due to a personal experience.
Some phobias can occur on their own without there being a rational explanation
for their presence. Patients who are classed as dental phobic particularly fear dental
injections and the hand‐piece. If treatment is possible, the patient reacts by tensing
their muscles, expecting more pain than they actually experience during treatment.
Research has shown that patients who are dental phobic may have the same level
of pain tolerance as patients who are not dental phobic. However, if their pain
threshold is lower, or even if their threshold is the same, they feel more pain.
Naturally, patients’ level of phobia can vary and affect them differently. Some
dental phobics can cope with the unpleasant symptoms they feel at the thought
of attending the dentist, whereas others would rather extract their own teeth and
be in pain than visit a dentist. Unfortunately, some dental phobics also have a
sensitive gag reflex. This action is normal and provides protection against swal-
I N T RO DUCT IO N
lowing objects or substances that may be dangerous. However, a hypersensitive

gag reflex can be a problem, especially when it encompasses all sorts of foreign
objects (e.g. aspirating tips and water from the hand‐piece) in the mouth. This
makes treatment difficult because of constant retching, which affects the patient’s
cooperation and leads to concern that they may choke.
Patients who have a dental phobia can benefit from treatment with conscious
sedation, as any form will reduce their anxiety and relax them. In the case of
intravenous sedation, which has an anterograde amnesic effect, most patients
will not remember their treatment despite being aware of it at the time. However,
excellent patient management is essential, with lots of tender loving care being
provided. It must be recognised that dental‐phobic patients will be poor attend-
ees, whilst some may never accept treatment, even with the aid of conscious
sedation. If they do, they will be very difficult to manage.
P hysi o l o gic a l r e a s o n s
When a person experiences pain or anxiety, it can lead to their sympathetic nerv-
ous system overreacting, possibly resulting in hypertension, tachycardia and so
on. This can have an adverse effect on their myocardium, especially in the mid-
dle‐aged and patients with pre‐existing hypertension and coronary artery dis-
ease, as it places additional strain on their heart, which could lead to an emergency
situation. Providing a form of conscious sedation to this category of patient
allows them to receive treatment without unnecessary strain being placed on
their myocardium. The reason this occurs is attributed to whichever method of
conscious sedation is used, as its mode of action on the body will relax the
patient and reduce their anxiety. This causes their sympathetic nervous system to
work normally, with little or no reaction, thus also reducing the risk of a medical
emergency.
Co mpl ex d e n t a l t r e a t m e n t
Most patients attending the dentist will happily receive routine treatment with-
out the aid of conscious sedation. However, on rare occasions they may require
an unusual procedure such as minor oral surgery. This can be more stressful,
more complex and may take longer than routine treatment. A form of conscious
sedation can be offered at the treatment‐planning stage, or the patient may
request it. This makes their treatment easier to cope with and less stressful for
them and the team.
Introduction 5
When managing and planning treatment for patients, it is vital to remember

that their needs and safety are paramount, that patients are individuals with dif-
fering needs and that these can change and evolve for whatever reasons. At all
times it is important to respect a patient’s diversity and right to choose, in order
to forge good relationships with them and provide a patient‐centred approach [1].
I N T RO D UCT IO N
REFERENCE
1. Intercollegiate Advisory Committee for Sedation in Dentistry (2015). Standards for

Conscious Sedation and the Provision of Dental Care. London: RCS Publications.
Chapter 2
Medico‐legal aspects of dental
sedation
LEARNING OUTCOMES
• The legal and ethical issues involved when providing dental sedation.
INTRODUCTION
Law and ethics within dentistry are very interesting, but dry, subjects that quite
naturally go hand in hand. However, this aspect must be taken seriously in order
to provide safe, effective treatment and to avoid patient complaints. The General
Dental Council (GDC) regulates the practice of dentistry to protect patients. It
provides every GDC registrant with a booklet entitled Standards for the Dental
Team. This publication addresses the legal and ethical issues that the sedation
team faces on a day‐to‐day basis, providing an overview of what is expected to
prevent problems occurring.
R E C O M M E N D AT I O N S C U R R E N T L Y I N P L A C E W H E N
P R O V I D I N G D E N TA L S E D AT I O N
In April 2015, the Intercollegiate Advisory Committee for Sedation in Dentistry

(IASCD) published a document entitled Standards for Conscious Sedation in

the Provision of Dental Care. This document was written by a group of profes-
sional bodies along with lay persons. It describes techniques available for use
and environments that would be appropriate in which to administer them so
that safe sedation is provided. This document has now replaced the following:
• Conscious Sedation in the Provision of Dental Care (2003)
• Standards for Conscious Sedation in Dentistry (2007)
M EDI C O ‐L EG A L A S P ECT S O F
• Conscious Sedation in Dentistry (2012)

It is intended to be read in conjunction with these publications:
DEN TA L S EDAT I O N
• Safe Sedation Practice for Healthcare Procedures, published by the Academy

of Medical Royal Colleges in October 2013
• Sedation in Children and Young People, published by the National Institute
for Health and Care Excellence (NICE) in December 2010
This document now provides a national standard in the delivery of dental care
when providing conscious sedation techniques, which previously did not exist. It
was published in response to the Safe Sedation Practice for all Healthcare
Procedures: Standards and Guidance, produced by the Academy of Royal
Colleges in October 2013. The latest publication naturally has an impact on
dentistry, of which pain and anxiety control are an integral part, and applies to
any staff involved with the provision of conscious sedation. An overview of this
document and additional information are offered in this section [1].
En vi ro nme n t
• Any dental establishment providing sedation should be inspected to ensure

that the necessary standards are in place so that safe sedation is provided. This
should be the responsibility of relevant agencies within the UK.
• The surgery will of course be suitable for the provision of sedation, with both
the treatment and recovery areas being spacious enough for the team to under-
take treatment and manage an emergency should one occur, with the chair’s
equipment allowing the head‐down tilt position. The dental premises must
offer easy access for the emergency services to enter and transfer patients. All
equipment must be in good working order, maintained as per manufacturer’s
recommendations, with any documentation being kept for inspection.
• All emergency drugs must be available, restocked and kept secure, coupled
with a means of administering them to patients. They should be checked on a
daily basis to ensure they are in date, with equipment serviced and maintained
according to the manufacturer’s guidelines. A means of securing a patent air-
way and administering oxygen must be available. Risk assessments must be
undertaken in order to control the provision of sedation and to reduce the risk
of accidents or mishaps. Dental practices should undertake audits to police the
quality of care provided, ensuring best practice.
Medico‐legal aspects of dental sedation 9
P at i e nt pa t h w a y a n d s e d a t i on s t af f
• What was previous termed the second appropriate person is now known as a
sedation nurse. Any dental nurse assisting with sedation should be encouraged
to take a formal qualification, as currently less than 10% of nurses assisting
with sedation are qualified. The reason that the IASCD document has not
insisted on all nurses assisting with sedation being qualified is that this would
M EDI C O ‐L EG A L A S P EC T S O F
present problems for service providers, resulting in possible closures.
• When a patient receives treatment with sedation, all members of the team
must have undergone suitable practical and theoretical training, with any
staff member in training being adequately supervised by a mentor. Any per-
son acting as a mentor must be occupationally competent. All exposure to
sedation techniques should be documented in a personal log book so that
activity can be audited if necessary. Another rationale for recording exposure
to sedation techniques is to provide evidence for future employers. Any train-
ing undertaken must encompass the drugs and equipment used so that the
team will recognise the difference between a normal and an abnormal
response. As a consequence of their training, they will understand the action
of each drug and also know how to use the equipment. They will be able to
clinically monitor patients, identify complications and be aware how to rec-
tify them.
• Training establishments must be quality assured by gaining accreditation
through an external body. The reason for this is that they are preparing dele-
gates for independent practice once they have progressed from supervised prac-
tice. Any accreditation gained will be reviewed every three years. This means
that any person organising training for others must ensure that the training is
delivered by appropriate instructors and in suitable settings. Dental nurse train-
ing could be provided through the National Examining Board for Dental Nurses
(NEBDN) or an equivalent. The NEBDN offers three qualifications:
• Certificate in dental sedation nursing
• Award in intravenous sedation dental nursing
• Award in inhalation sedation dental nursing
• As outlined by the GDC, enhanced continued professional development
(ECPD) is essential for dental nurse registration to be maintained. Anyone
involved with sedation must plan as part of their ECPD 12 hours of sedation
training/updating within a five‐year period to be revalidated. This reflects the
guidance in place and ensures that the practice of sedation is safe, relevant and
up to date. The revalidation training received must be pertinent to the person’s
area of practice. If a member of the sedation team is not regularly involved,
they must consider discontinuing practice, being mentored and/or retraining.
All training received must be documented.
• Should any complications occur, the team must be able to respond accordingly
and be aware of the associated risks. The entire team must be familiar with
emergency procedures, having received training and updates on a regular

basis. Simulations should be held within the practice. Training on immediate
life support (ILS) and, if treating paediatric patients, paediatric immediate life
support (PILS) must be undertaken. It is not essential to undertake a
Resuscitation Council (UK) accredited ILS/PILS course. It is acceptable to
source alternative courses with equivalent content so that the needs of the
dental practice are met. These might also include the management of common
sedation, and medical and dental emergencies.

• Clinical visual monitoring must be in place, and where intravenous sedation is
administered it is mandatory to use electrical monitoring via a pulse oximeter

and blood pressure machine. The team providing sedation must be capable of
monitoring a patient’s colour, pulse, respiration, blood pressure, level of con-
sciousness and anxiety, also ensuring that the patient maintains a patent air-
way. It is recommended that a non‐invasive blood pressure measurement is
taken at regular and appropriate intervals: at the assessment appointment, on
the day of sedation prior to commencement of treatment, peri‐operatively and
post‐operatively.
• Ideally, only American Society of Anesthesiologists (ASA) 1 and 2 Medical
Fitness Classification patients should be treated in the dental surgery (this is
explained in Chapter 4). The clinician will of course know that the mainstay
of pain and anxiety control is local anaesthesia and this must be the starting
point before providing any sedation. They will also know that on occasion one
sedation technique may not be successful and that they may have to adopt
two, for instance a needle‐phobic patient could be administered inhalation
sedation to allow cannulation to take place. However, if the clinician chose to
adopt this approach, they would take into account the drug combination of
the two techniques. The need for a patient to fast prior to sedation is still
debatable, but the clinician must record the advice provided to a patient in
their notes and justify their decision should this be required. It must be remem-
bered that when providing sedation, good communication and a sympathetic
approach are paramount for maximum patient cooperation.
• The provision of sedation avoids a general anaesthetic for the treatment of
patients who suffer anxiety and/or phobia and for patients who are happy to
attend but require a more complex procedure. However, a general anaesthetic
would if required enable a patient to receive dental care, as may good behav-
ioural management and a local anaesthetic. The clinician will justify each pro-
vision of sedation, ensuring that the technique employed is relevant for the
patient’s medical, dental and social history and that the sedation technique to
be undertaken will reduce the patient’s anxiety levels without being too inva-
sive. This is established by a thorough patient assessment being carried out,
with a clinical examination and consent being taken to formulate a treatment
plan. The clinician will ensure that the patient has the capacity to consent and
will take into account all discussions and clinical findings to establish the most
suitable form of sedation for each patient. The assessment appointment should
be at a separate time to the treatment session to allow a cooling‐off period,
unless it is an emergency situation. If an emergency situation does arise, the
clinician must justify their decision to assess and treat the same day. The patient
must be able to meet any pre‐ and post‐operative instructions attracted to the
form of sedation being received. All instructions will be provided verbally and
in a written format. Information must contain details relating to the chosen
sedation and the experiences that patient can expect to feel. They should be
given to the escort as well as the patient. This means that different formats
must be available so that they are tailored to the patient’s understanding, for
example in pictorial form for a child.
• To conform to clinical governance standards, excellent record keeping is
important. All sedation staff should keep a log book of the number and types
of sedation cases they undertake or assist with. Any complications such as
over‐sedation should be recorded. Both of these actions will allow audits to
take place. Patients’ records must reflect their treatment pathway and consent
to treatment. Therefore they must contain:
• Patients’ medical, dental and social history, including any previous treat-
ments, general anaesthetic and/or conscious sedation. Any change in the
medical history/status.
• Details of the assessment appointment.
• The mode of sedation and the treatment being provided, the justification for
its use and any patient preferences.
• Written consent and that verbal and written pre‐ and post‐operative
instructions were provided. That the patient is still happy to proceed with
the planned treatment. That they have adhered to all instructions, the
responsible escort is in attendance and details of the mode of transport
home.
• Details of the treatment appointment.
• All monitoring details, cannula site, drug used, batch number and expiry
date, drug titrations and times administered.
• The recovery information and that the patient was assessed for discharge.
• Any complications and statements of how the patient responded to the mode
of sedation used and/or reactions within the recovery phase.
• Any dentist referring patients for treatment with conscious sedation will have
explored all other avenues of pain and anxiety control before doing so. They
will also be confident that the establishment to which they are referring their
patient is practising treatment with sedation to reflect the guidelines. Following
treatment, any referred patients are discharged back to the care of their den-
tist, with an outcome letter being sent advising them of any further treatments
required. Any radiographs supplied will be returned.
Treatme nt o p t io n s
• Most patients are suitable for and conducive to sedation techniques as adjuncts
to aid them in the acceptance of treatment. Midazolam in oral transmucosal
and intranasal form should only be administered if there are no other titrata-
ble forms of sedation appropriate for that patient. If practised, it must be
administered by a clinician who is competent in intravenous techniques in an
appropriate setting, as it is a less controlled method of using midazolam. If

administered in this way, the clinician would have to justify its use, providing
the same level of care as for intravenous sedation.

• A child has been classified as a person under the age of 12, which makes it
difficult for the sedationist to assess their maturity and level of understanding.
It has however been stated that further work should be undertaken to meet
this obligation. The treatment option for children under 12 is inhalation seda-
tion only. Patients aged 12–16 years can receive inhalation, intravenous, oral
or intranasal sedation. Any patient over the age of 16 is classed as an adult and
therefore can receive any sedation technique. Naturally, local anaesthetic
would be provided where necessary. A clinician treating young patients must
possess skills equivalent to those of a paediatric specialist/consultant.
• To prepare patients for sedation, written and verbal pre‐ and post‐operative
instructions must be provided to the patient, any carer who will be involved in
the patient’s after‐care and their escort, in order that they all understand their
role before, during and after the appointment. Any written instructions must
be easy to understand and be appropriate to their individual needs and require-
ments. These must include the effects the patient could experience, precautions
to adhere to and emergency contact numbers.
• As recovery is a progression from the peak effects of sedation following treat-
ment, patients must be supervised by an appropriately trained member of the
team who will monitor them and respond should an emergency arise, with all
emergency drugs and equipment being available. The recovery phase will com-
mence in the dental chair and last until the patient is assessed as being ready
to be moved to a recovery area, if available. It is not acceptable for any patient’s
recovery to take place in the waiting room. The patient must be allowed time
to recover and during this period the clinician must be available. Not all
patients recover at the same rate, with this being dependent upon the drugs
and amounts provided.
• Before being discharged, patients must be able to walk without help, be steady
on their feet and be deemed street safe. It is the decision of the clinician/
sedationist to discharge the patient. They will assess the patient following a
protocol and discharge them into the care of the responsible escort, who will
be in receipt of the post‐operative instructions for both the sedation and the
dental treatment. For inhalation sedation an escort is not required, unless the
patient has brought one along for support or the patient is a child.
• For inhalation sedation, only dedicated machines for dental use should be used.
They must conform to British Standards, be regularly serviced and cared for as
per the manufacturer’s guidelines, with records of such being kept. The oxygen
and nitrous oxide cylinders must be stored securely. For piped machines, the
colour‐coded pipes must only fit into their respective outlet. They must also
comply with the set standards and have fail‐safe mechanisms installed so that
the patient cannot receive a hypoxic mixture. Scavenging systems to remove the
waste nitrous oxide from the atmosphere must be installed and used to prevent
any health problems for the team. The nasal mask provided to the patient must
be a good fit to avoid excess nitrous oxide being exhaled into the surgery.
• For intravenous sedation, the surgery must be stocked with all the required
sedation and emergency equipment in order for it to be provided to patients,
with all members of the team involved having sufficient and suitable knowl-
edge and skills. All electrical equipment used must be calibrated, serviced and
maintained according to the manufacturer’s guidelines, with records of such
being kept. Drugs and syringes must be labelled for correct identification and
any drug should be administered according to accepted current guidelines
when titrated against the response of the patient.
• Midazolam using a titrated dose will normally be the first choice for intrave-
nous sedation. For intranasal sedation, also referred to as transmucosal seda-
tion, midazolam should only be used when it is not appropriate to use a
titratable technique. Midazolam with an opioid can be used for patients where
midazolam does not provide them with adequate anxiolytic properties. This
technique involves a small amount of an opioid being administered prior to a
titrated amount of midazolam.
• Midazolam and propofol can be useful when a longer dental procedure takes
place. This involves a titration of midazolam followed by continual infusion of
propofol. If this technique is used, a dedicated sedationist is required.
• The use of propofol involves a target‐controlled infusion pump and is useful
when a patient has a tolerance to benzodiazepines. This technique can be
employed for short or long procedures and requires a dedicated sedationist.
• Oral sedation is where the patient is provided with a larger dose of a drug at
the dental surgery. Oral temazepam was historically the first choice of drug
administered for oral sedation. Midazolam has now largely superseded it. As
oral sedation is not titratable, it should only be used when a titratable tech-
nique is not appropriate. It should be administered by a clinician who is com-
petent in intravenous techniques, and the same level of care should be provided
as for intravenous sedation, in a suitable setting where the team has the knowl-
edge and skills to provide this mode of sedation.
• For oral pre‐medication the lowest possible dose should be prescribed, only
sufficient to allow the patient to sleep the night before their appointment and
to reduce their anxiety level. Further doses may be provided once the patient
arrives at the surgery, but this would be dependent upon patient response.
• All of these treatment options using midazolam require patients to be advised

that they will have to adhere to the same pre‐ and post‐operative restrictions
as for intravenous sedation and must be accompanied by a responsible escort.
• The report does refer to ketamine being used for paediatric patients, but it
states that more evidence is required on its use and safety before being able to
offer further guidance to the sedation team.
Mi scel l ane o u s
• There should be a system to report any adverse incidents, developed for

c linicians working in independent practice. Any system in place should be
comparable to that currently used within National Health Service (NHS)
institutions. An example of an adverse incident would be if a patient required
hospitalisation. It must be remembered that over‐sedation should be avoided,
but that to under‐sedate a patient can be just as detrimental for future provi-
sion. Safe sedation is to be practised at all times. This can be achieved
through knowledge of the drugs’ onset, peak effect and duration of action,
along with ensuring that the initial bolus has taken effect before providing
additional titrations. Careful patient management, good staff training, regu-
lar monitoring and adhering to the recommendations/guidance in place are
all required.
• Transitional arrangements were put in place as it was recognised that there are
many experienced clinicians providing sedation who do not hold a formal
qualification. If it were mandatory for all of the document’s contents to be
enforced, it would result in sedation services in some areas closing overnight.
This would naturally have an impact on patient care. Moreover, any clinician
who works outside their country of origin must ensure that they work within
the laws where they are employed. This document does recognise that some
areas of its content require further research and work, and it is stated that it
will be regularly updated.
M E D I C O ‐ L E G A L C O N S I D E R AT I O N S W H E N P R O V I D I N G
D E N TA L S E D AT I O N
These are no different than those that the team must consider on a day‐to‐day
basis when providing treatment, that is:
• The taking and recording of consent
• Maintaining a patient’s confidentiality
• Dealing with accusations of assault
• Avoiding negligence
T he co n sen t p ro c e s s
Consent is when one person gives another permission to undertake something
such as dental treatment. It is granted once the person consenting is aware of
what is going to happen and it can be withdrawn at any time. Consent can be
written, verbal or a compliant action. For most procedures within dentistry it is
the latter two, as the patient enters the surgery, opens their mouth for a dental
inspection and then agrees verbally to undergo treatment(s).
Consent is classed as either:
• Expressed. The patient either verbally agrees or completes and signs a consent
form to receive treatment.
• Implied. The patient accepts treatment by a compliant action such as sitting in
the dental chair and opening their mouth.
Obtaining expressed consent from patients for dental treatment is good prac-
tice, with many clinicians routinely taking written consent for various dental
procedures where complications may occur, such as the extraction of impacted
wisdom teeth. There is no recommended form, but whichever one is used it must
contain both the patient’s personal details and the practice details. It must be
completed in ink without abbreviations and signed by both parties involved,
with the patient receiving a copy. Only a qualified clinician can obtain consent
from the patient and this should be done in a quiet, private area to preserve the
patient’s confidentiality, allowing them to ask questions. A completed consent
form provides confirmation that the patient has consented to the proposed
treatment(s) and that consent was formally obtained, with an explanation being
offered to the patient. The form gives evidence of what was agreed between the
clinician and the patient. No alterations should be made to a consent form. If
there is a change in the planned procedure, the patient must be consulted and a
new consent form completed and signed.
If the patient is to receive sedation, consent should ideally be acquired during
a separate assessment appointment. This allows a cooling‐off period, giving the
patient time to reflect, as consent should never be taken under duress. When
patients attend in pain and request immediate treatment, it is impossible for a
cooling‐off period to occur. In this circumstance the clinician would document
this in the notes, and if the need arose would have to justify their decision to
treat under this premise.
Of course, for any sedation technique to be given the patient would have to
meet the pre‐ and post‐operative instructions supplied in advance and attached
to the consent form. If a patient has been sedated and it is identified that the
patient has not consented to treatment, the clinician would have to decide how
to proceed. They would more than likely treat under the best interest principle,
especially if it was a patient who attended in pain. This situation can be avoided,
however, and it is considered good practice for the sedation nurse to ensure that
consent is in place prior to treatment. Consent is not a one‐off action but an

ongoing process and it should be regularly checked and updated, especially if the
course of treatment is lengthy, involving several appointments.
When conscious sedation is provided, a patient’s written consent must be
obtained, especially with intravenous sedation, with all eventualities being dis-
cussed and recorded, allowing the patient to detail any treatments that they do
not wish to undergo. This is because midazolam, the sedative drug used, pro-
duces anterograde amnesia, which means the patient may not be able to remem-
ber anything after the induction of the drug, including any conversations held.
Therefore, if the treatment plan needed to be changed while the patient was
sedated, for example after failed root canal therapy, the appointment would
have to be suspended, the patient allowed to recover and an appointment made
for another day. This would give them the opportunity to discuss their options
and give further consent, as they would not remember the conversation despite
appearing to be alert. This would naturally be time consuming for both parties
and inconvenient for some patients, due to the arrangements they would have
to make in order to be eligible to receive intravenous sedation. Nevertheless, it
is a mandatory process, because if the clinician undertook a dental procedure
without consent the patient could have cause to complain and possibly sue, as
this could constitute assault. The written consent in situ would provide evi-
dence of the agreement, since it would detail the discussions held and the treat-
ment to which the patient consented. If any treatment undertaken was not
documented, it could mean that the clinician might be considered negligent and
at fault.
Why consent is required

Consent is required for the following reasons:
• For patient education. Since the treatment plan is discussed in full, the patient
is aware of what is involved.
• To maximise patient cooperation. If a patient is aware of the treatment plan
and has been given the opportunity to ask questions, they are more coopera-
tive as they know what to expect. There are no hidden aspects for them to be
concerned about, so they need not fear the unknown.
• To improve clinician and patient communication. The clinician will discuss the
treatment plan with the patient so that they can decide whether to proceed or
not. This builds rapport and the patient will feel more able to approach the
clinician at any stage.
• To protect the clinician from complaints, claims and charges. If the patient has
had their treatment plan explained in full and this process is recorded, there
can be no misunderstandings or misinterpretations, as documentary evidence
will be available.
When consent is required

Consent is required in the following circumstances:
• All sedation techniques
• General anaesthesia
• Clinical examination
• Radiographs
• Photographs
• Treatment
• Student observations
• Research
• Possible keeping of body parts
Validity of consent
For consent to be valid, the patient:
• Must be able to give consent. They must be able to understand and retain the
information being provided, consider it and come to a decision themselves.
• Must give their consent to treatment without feeling pressurised by anyone, so
that it is given voluntarily.
• Must be provided with adequate information. The clinician will discuss the
following with patients so that they can make a decision regarding treatment:
• They must be advised of the proposed treatment they require, together with
the mode of sedation being provided.
• They must be made aware of the advantages and disadvantages of any pro-
posed treatment and the advantages and disadvantages of the mode of seda-
tion.
• They must be made aware of any alternative treatments and other forms of
sedation that could be offered.
• They must be made aware of any risks associated with the treatment that are
higher than 0.5%.
• They must be advised of the timescale of the appointment and be able to
make the necessary arrangements, to reflect the pre‐ and post‐operative
instructions for the mode of sedation they are to receive.
• The patient must be advised of the cost of the treatment and associated costs
for the provision of sedation.
The information a clinician offers will vary from one patient to another, as
they have to decide how detailed it should be. This allows the patient to make a
decision regarding the proposed treatment and whether or not they wish to pro-
ceed. Tailoring the information to suit individual patients prevents them from
reaching a biased or unbalanced decision due to not being in receipt of all the
information, or indeed too much information. Once a patient has the necessary
knowledge they can consent to treatment, providing that the clinician deems
them competent to do so. If a patient is considered not to have the mental capac-
ity to consent, then any treatment provided would have to be in their best inter-
est. Some patients do not want to know the details of their treatment and this
should be recorded in their notes.
As conscious sedation is a specialist area within dentistry, patients may be referred
for treatment to clinicians who specialise in this field, for instance at the local dental
hospital. It is therefore imperative that the clinician undertaking the procedure
obtains consent, as it is their responsibility to do so and not that of the referring

clinician. If there are any changes to the planned procedure, then the patient must
be informed and consulted, with a new consent form being completed.
Who can give consent

Always
A competent adult can decide whether to accept or refuse any medical or dental
treatment. Only they can make decisions on their own behalf regarding the treat-
ment they wish to receive or refuse. Being competent means that the person
understands and has as a fundamental right to give or withhold consent to an
examination, investigation or treatment, therefore giving that person autonomy.
Any treatment or investigation or deliberate touching carried out without con-
sent may constitute battery and could result in action for damages, even criminal
proceedings.
When a clinician is obtaining consent from patients between 16 and 18 years
old, they need to establish if they are competent; if they are not, consent will be
sought from the person who has parental responsibility for them. All people of
this age are classed as competent and able to consent unless they are known to
be otherwise. Their confidentiality must not be breached unless there is cause for
concern for their health. However, if a patient between 16 and 17 years old
refuses treatment, the person who holds parental responsibility can override that
decision if a refusal is not in the patient’s best interest.
A legal guardian, appointed by a court, or a parent taking parental responsi-
bility for the child can give consent where a child is deemed not competent.
However, any decisions made must be in the best interest of the child and if they
are not they can be overruled by a court. In an emergency, where treatment would
be vital to prevent a child being put at risk, treatment would proceed while wait-
ing for parental consent. In this situation the clinician should consult with a col-
league to determine what action would be in the best interest of the patient.
Sometimes
Adults considered incompetent in other aspects of life may be able to consent to
simple treatments, but not complex procedures where detailed information
needs to be provided. This is because they may not be able to understand all of
it and will not be able to rationalise or realise its significance in order to give
valid consent. In these circumstances, the clinician would undertake treatments
that were in the patient’s best interest. The clinician could possibly take advice
from close relatives and friends or carers to determine their knowledge of any
opinions the patient may have relating to the proposed treatment.
For children under 16 years of age, the clinician must assess whether they are
deemed Gillick competent, meeting the Fraser guidelines, which means that the
patient has the maturity and capacity to understand, retain information and
make a decision based on the facts presented, fully understanding the implica-
tions of receiving or not receiving treatment. It is only the clinician who can
make an assessment of the patient’s capacity to consent. When a child is classed
as Gillick competent, they can consent to treatment without the person who
holds parental responsibility being informed or giving their permission. The law
states that a person who holds parental responsibility for a minor does not have
rights over them other than to ensure they come to no harm and therefore can-
not prevent them from receiving treatment. Gillick competency is normally only
used in special or exceptional circumstances. As with persons between 16 and
18 years of age, the patient’s confidentiality must not be breached, which includes
preventing the person who has parental responsibility accessing a minor’s dental
records without their consent, unless there is cause for concern for their health.
Good practice would be to include the person who has parental responsibility in
any discussions and if this is not possible to seek the minor’s consent to inform
them. However, if a child under 16 years old refuses treatment, the person with
parental responsibility can override that decision when a refusal is not in the
patient’s best interest, despite the patient being deemed Gillick competent.
Never
The natural father cannot give consent if he is not married to the child’s mother,
unless his name is recorded on the child’s birth certificate, with the registration
of the birth having taken place before 1 December 2003. For other natural
fathers to hold parental responsibility, they must either marry the mother of their
child, make a parental agreement with her or obtain a court order.
Friends and relatives cannot give consent to treatment as they do not hold
parental responsibility.
C o nfi de ntia lit y

Patients expect any information they provide to the dental team to be confiden-
tial, as they are putting their trust in them. Therefore, all members of the team
have a legal and ethical responsibility to maintain confidentiality in all matters
relating to the patient. They must not divulge any information relating to patients
and must ensure that all measures are taken to prevent any information being
inadvertently disclosed. They must never provide details of a patient without
their expressed consent and must keep all patient information secure, so that no
unauthorised person can access it.
Patients may discuss sensitive issues with the clinician relevant to their treat-
ment. Therefore, on receipt of such information it must only be used for the
purpose for which it was given. Information relating to patients can only be
disclosed without seeking the patient’s consent in exceptional circumstances. For
example:
• If it was of benefit to them (i.e. their health was at risk)
• In the interests of the general public

• If it was considered that a serious crime was imminent
If this course of action should become necessary, where possible the patient’s
consent should be sought and if it is not given, despite persuasion, minimal infor-
mation should be released. If any person considering the release of information
without the patient’s consent is unsure, then advice should be taken before doing
so. A court of law may request patient information without their consent, but
only necessary and sufficient details should be provided. The person providing
the information must be prepared to justify their action.
Patients must be made aware that their information may be shared with other
healthcare professionals and given the privilege of consenting, after having the
rationale for doing so explained. If a patient has died, their information must
still be treated as confidential.
Protection of patient information

Any information received must be handled under the General Data Protection
Regulations 2018 (GDPR) and be kept confidential unless permission is granted
to share it. The member of the team in receipt of such information is responsible
for maintaining its confidentiality – therefore, they must ensure that it is stored
safely. If information is forwarded, that must be done securely and when finished
with it must be destroyed in an appropriate manner. Dental records must be
stored away from other patients, the general public and other healthcare profes-
sionals who have no need to access them. When discussing any patient’s case,
conversations should be held in private where the content cannot be overheard.
Screen savers are important to mask computer screens when others enter the
room, and computers should be password protected. Sensitive telephone calls
must be conducted away from the reception area.
Any telephone enquiries regarding information relating to another person’s
appointments or a patient calling for any results of treatment and so on should
be politely refused, because confirmation of identity is impossible. Furthermore,
such a conversation would be difficult to verify at a later date, as there would be
no written documentation to support it [2].
A ccusati on s o f a s s a u lt
Any treatment undertaken without a patient’s consent is regarded as assault,
and therefore the clinician concerned could be liable and accountable for any
implications arising from that action. Patients do sometimes make allegations of

assault, so a clinician must never be left alone with a patient, as it would be one
person’s word against another, irrespective of gender and the treatment pro-
vided. Serious accusations can occur when patients are left alone with a clinician
who is providing treatment using intravenous sedation. This is because the drug
used can alter the patient’s perception of what is occurring. Some may have
vivid dreams, believing that what they dreamt really took place. They are, of
course, more vulnerable than patients who are not being provided with mida-
zolam, a sedative which relaxes them, reducing their anxiety and providing
amnesic effects. If an accusation is made and the clinician has not been chaper-
oned by a sedation nurse when providing sedation, then the clinician would be
unable to defend themselves.
Preventing allegations of assault

Consent is a must for any treatment, whether in written or verbal format. If it is
thought that the patient may make an allegation, the clinician must ensure that
written consent is obtained in advance. The clinician should never undertake any
treatment unless the patient fully understands the treatment plan and is happy to
proceed. The clinician must never be left alone with a patient, but should instead
ensure that there is a witness, in case an allegation of assault is made.
N e g l i g enc e
For a clinician to be negligent, they will have acted outside the law and/or will
have undertaken dental treatment that is not acceptable. All clinicians have a
duty of care, to ensure that patients are treated safely, with a high standard of
dentistry. When a patient is provided with sedation to receive treatment, the cli-
nician’s duty of care extends to the patient’s after‐care. Once the patient is
assessed for discharge, the clinician will, of course, be confident that they will be
properly cared for by the patient’s escort, as documented in the pre‐ and post‐
operative instructions, given both verbally and in a written format.
Avoiding allegations of negligence

Communicating with patients effectively regarding their treatment is vital. To
avoid any misunderstanding, patients must be fully aware of which treatments
are to be provided and which are not. Obtaining written consent for the provi-
sion of treatment with sedation or when there are any associated risks is para-
mount, as this will provide documentary evidence of the discussions that took
place and the agreed treatment. Contemporaneous record keeping of dental
notes is also imperative, as their contents will provide a record of the patient’s
past, present and future treatment. They will contain any advice given and dis-
cussions held, indicating how motivated a patient is towards their care and if
they have chosen not to take the advice given. Any and all patient concerns
should be highlighted.
The clinician should inform the patient if they are monitoring anything within
their mouth, such as an early carious lesion or other pathology. Staff should be
well trained and know their role within the team to ensure that they do not work
outside their remit, only undertaking duties that they have been trained for and
those they are competent to carry out with confidence. Staff should immediately
record any conversations they have held with the patient over the telephone,
with the summary being factual, as patients can request access to their notes.
They should also record any cancelled or failed appointments and non‐payment
for treatment. Dental records should be kept for the recommended time so that
they can be referenced, should a case of negligence be brought by a patient who

is no longer registered at that surgery. A safe environment should be provided for
all, with all equipment being serviced at recommended intervals.
REFERENCES
1. Intercollegiate Advisory Committee for Sedation in Dentistry (2015). Standards for

Conscious Sedation and the Provision of Dental Care. London: RCS Publications.
2. Gov.uk (n.d.) Data Protection. https://www.gov.uk/data‐protection.
Chapter 3
Role of the dental nurse
and equipment
LEARNING OUTCOMES
• The importance of the role of the sedation nurse during a patient’s treatment when
receiving any form of conscious sedation.
• The importance of clinical monitoring.
• The equipment used when conscious sedation forms part of a patient’s treatment.
INTRODUCTION
During any treatment that a patient receives, the dental nurse must remain in the
surgery. When any form of conscious sedation is used as an adjunct to allow
patients to accept treatment, it is imperative that a sedation nurse be present at
all times and that they have received the appropriate training. This is due to the
extended role that the team has to undertake when caring for a patient during
treatment. Two trained members of staff must be present when sedation takes
place. The normal situation is that the second trained person is a dental nurse,
but in some clinical settings it could be another clinician. However, in some sur-
geries where there are numerous members of staff, there could be the clinician, a
nurse to assist with treatment and a nurse assigned to the conscious sedation
aspect of the patient’s appointment.

G E N E R A L R O L E O F T H E D E N TA L N U R S E
When a dental nurse acts as the sedation nurse in the surgery, assisting with
patients who are receiving any form of conscious sedation, their role will encom-
pass a wide range of tasks. They will utilise many skills which they have acquired
during the early stages of their basic training. The required additional knowledge
and skills will have been attained by accessing a recognised course in conscious
sedation. Best practice is to gain a qualification. One pathway by which a dental
nurse could achieve this is to take a course that leads to either the National
Examining Board for Dental Nurses qualification in dental sedation nursing,
R O L E O F T H E DEN TA L N U RS E
which qualifies the sedation nurse to assist with all forms of sedation, or a sepa-
rate award in inhalation or intravenous sedation. Whichever award is under-
taken, it will qualify the sedation nurse to assist with that sedation technique.
A N D EQ U I P M EN T
Advanced training is important so that the sedation nurse fully understands their
role within the team, in order that they do not work outside that remit and are
able to recognise the areas of a patient’s care for which they are responsible. The
sedation nurse must also undertake immediate life support (ILS) training or
equivalent. If the sedation practice involves treating paediatric patients, then
paediatric immediate life support (PILS) training must also be completed [1].
In order for a patient to receive treatment with conscious sedation in a safe,
relaxed and calm atmosphere, it is good practice for the team not only to work
together on a regular basis, but to establish a routine, so that there is a good work-
ing relationship that provides a patient‐centred approach. Before a patient attends
their appointment, it is important that the team prepare for their arrival so that
every aspect runs as smoothly as possible. It is here that the sedation nurse would
start their duties and responsibilities within the patient’s treatment care plan.
When a patient is receiving treatment with conscious sedation, the sedation
nurse will start by preparing the surgery, ensuring it is disinfected and identifying
primary and secondary zones. Also, they should make sure that all instruments
for the procedure are sterilised and all materials and medicaments are prepared.
They will lay out the appropriate equipment to reflect the type of sedation the
patient is to receive, along with all the equipment required to undertake the
medical checks and monitoring equipment. They will collect the patient’s dental
notes and radiographs and ensure that a signed consent form has been com-
pleted. They will at some stage read the patient’s notes, paying particular atten-
tion to the medical history to make themselves aware of the patient’s medical
status and be prepared for an emergency should one arise. They will refer to any
previous treatments that the patient has undergone with conscious sedation to
establish if there were any complications experienced during the treatment and
recovery stages, as well as the amount of sedation the patient received. Keeping
good contemporaneous notes is vital in order that the team can refer to them
subsequently. They provide a history of the patient’s treatment with the use of
Role of the dental nurse and equipment 25
conscious sedation and allow modifications to be made at future appointments

to reflect any written comments.
A very important role before any conscious sedation treatment takes place is to
ensure that the medical emergency equipment is present and functional by check-
ing the drug expiry dates, ensuring that the oxygen cylinder content is sufficient
and that portable suction is present. If intravenous sedation is being administered,
the reversal drug flumazenil must be available. If inhalation sedation is being
administered, it is important to ensure that the machine is safe to use, the scaveng-
ing system is attached and there is good ventilation within the surgery.
I N T R AV E N O U S S E D AT I O N
B e fo re t he a p p o in t m e n t
Once the surgery is prepared to receive a patient, the sedation nurse will greet the
patient, introduce themselves and their role and take the patient into the surgery,
or preferably into a separate room in order to undertake the medical checks
required to ensure that they are fit to undergo treatment using conscious seda-
tion. Upon entering the room, the nurse will ask the patient and escort to take a
seat and take care of the patient’s belongings. They will have previously prepared
a blood pressure machine, pulse oximeter (Figure 3.1), weighing scales if required
and a method of documentation to record the patient’s response to mandatory
questions, ensuring that they have and will comply with the pre‐ and post‐opera-
tive instructions. Some dental practices formulate a pro forma that they can use
as documentation to record the patient’s treatment pathway from start to finish,
Figure 3.1 Pulse oximeter.

whereas other practices may record this information in the patient’s notes. It is a
good idea to request that the patient’s escort accompany them at this stage, so
that it can be established if after‐care for the patient is going to be adequate. This
reinforces the importance of the role of the escort and the post‐operative instruc-
tions that were provided at the assessment appointment.
Once the patient and the escort are seated, the sedation nurse should inform
the patient that they will be looking after them during their treatment. They
should commence by asking the patient the following questions:
• Are you normally fit and healthy?
• How do you feel today?
• Has your medical history changed since the assessment appointment?

• Has any of your medication changed since the assessment appointment? (Any
self‐medication must be explored.)
• Have you recently visited the doctor?

• Have you any allergies?
• When did you last have any food or drink?
• Have you had any alcohol today?
• What arrangements have been made for you to travel home?
• Who will be looking after you at home?
• When are you planning to go back to work?
Once these questions have been answered and documented, it is important to
clarify with the patient’s escort some of the answers given in respect of after‐care.
Record the escort’s name and take their mobile telephone number, so that if they
decide to leave the premises for the appointment duration they can be contacted.
Once satisfied that the patient will be properly cared for at home, the sedation
nurse will take the patient’s pulse rate (Figure 3.2), respiratory rate, blood
Figure 3.2 Pulse being taken.

pressure (Figure 3.3), oxygen percentage saturation levels (Figure 3.4) and weight if
required and document them. They will then present the readings to the clinician
who will act as the sedationist. It is useful to take the patient’s pulse manually, as
this provides the rate per minute, the quality and strength of the pulse and whether
it is irregular. This information is useful when monitoring a patient during treat-
ment to identify any changes in their status, and in particular for comparison
when dealing with and diagnosing an emergency. The nurse will note the colour
of the patient’s skin, their demeanour and whether they have false nails or are
Figure 3.3 Blood pressure being taken.
(a) (b)
Figure 3.4 (a) Patient with pulse oximeter attached to finger. (b) Pulse oximeter monitor.
wearing nail vanish. If they are, it must be removed to prevent interference with
the pulse oximeter readings or another site selected, for instance a toe. Finally, the
sedation nurse will ask the patient if they have any questions, answer them accord-
ingly and if necessary explain the procedure for both the mode of sedation and
the treatment being received and arrange a stop signal. Once this pre‐assessment
stage is complete, the sedation nurse will ask the escort to take a seat in the wait-
ing room, advising them of the approximate length of the treatment.
B efo re t he t r e a t m e n t
The sedation nurse will ensure that the patient is seated comfortably in the dental
chair and request their permission to apply personal protective equipment. They
will, if necessary, introduce the patient to the clinician and wait attentively until
the clinician is ready to commence. When all aspects of the appointment that the
clinician wishes to discuss with the patient are complete, treatment will begin.
Depending upon the sedation being used, the role of the sedation nurse will differ
slightly and this will be explained as the chapter progresses. For any sedation
being provided, the role of the sedation nurse will include the following aspects:
• Check whether a signed consent form is present.
• Ensure that the patient has followed all pre‐operative instructions relevant for
the type of sedation they are to receive.
• Act as a chaperone to both the patient and the clinician, irrespective of gender,
so that if the patient had reason to believe that the clinician had acted inap-
propriately, the sedation nurse would be able to confirm that this was not the
case. Accusations can occasionally occur as the drug administered for intrave-
nous sedation can lead to the patient experiencing dreams or hallucinations.
• Help the clinician in the clinical and electrical monitoring of the patient’s vital
signs, alert the clinician to any changes and respond accordingly. Monitoring
should commence from the point the patient comes into contact with the seda-
tion nurse.
• Assist with the procedure.
• Reassure the patient throughout the treatment.
• Respond to and assist the clinician in the event of an emergency.
• Assist with the recovery of the patient. Some clinicians may decide to place this
responsibility upon the sedation nurse. In this instance the clinician should still
remain on the premises.
• Assist when assessing the patient for discharge.
• If the clinician decides it is in order, give the patient and escort appropriate verbal
post‐operative instructions, relevant to the mode of sedation received and the
procedure undertaken, as well as providing written instructions for reinforcement.
• Book a follow‐up appointment.
• Take payment for the treatment and the method of sedation provided. Payment
should be taken prior to any sedation being provided using midazolam, as the
patient may not remember making it due to its anterograde amnesic proper-
ties. This avoids confusion and also safeguards the dental practice.
• Throughout the appointment, practise excellent cross‐infection control, ensur-
ing the health and safety of all; maintain respect for the patient’s preferences,
dignity and rights; and uphold patient confidentiality.
Duri n g can n u la t io n
Before the patient’s treatment can commence, they have to be prepared for can-
nulation. The sedation nurse gives a simple explanation, advising them that its
use is mandatory in order that the drug being used to sedate them can be admin-
istered. Discussions should be held with the patient as to whether they have any
preference for the site of the cannula. The normal sites used are the antecubital
fossa, the inner surface of the elbow or the back of the hand, known as the dor-
sum. The patient should be advised that on insertion of the cannula they will feel
a small, sharp scratch and that the cannula will be secured in place using tape or
dressing, and tested to ensure that it has been correctly inserted by administering
a solution (sodium chloride). Once successful cannulation is achieved, the patient
is told that the drug will be administered and that it will feel cold upon entry,
with no pain being experienced. They will start to feel more relaxed and conse-
quently less anxious.
The sedation nurse will have already prepared the following items for can-
nulation and administration of the sedation drug:
• A tourniquet (Figure 3.5) to restrict the venous return, thus engorging the vein
so that cannulation can take place. Many clinicians prefer disposable tourni-
quets as they are single use.
Figure 3.5 Non‐disposable and disposable tourniquets.

• A disinfectant surface medi‐wipe (Figure 3.6) to cleanse the selected cannula-

tion site. The skin must be allowed to dry prior to inserting the cannula,
because medi‐wipes contain alcohol which on insertion of the cannula will be
taken into the vein and the patient will experience a stinging sensation. It is
also not acceptable, once the cannulation site has been disinfected, for the area
to be tapped to increase the engorgement of the vein, as this would result in
potential cross‐contamination and possible infection at the cannulation site. If
this action is performed, then a new medi‐wipe should be used.
Figure 3.6 Medi‐wipe.
Figure 3.7 22‐gauge Venflon.

• A cannula, either a 22‐gauge Venflon (Figure 3.7), a safety‐shielded 22‐guage

Venflon (automatically the introducing needle is covered by a spring‐type
guard and end block when removed; Figure 3.8) or a Y‐can (Figure 3.9), to
gain access into the vein and administer the drug. (The gauge relates to the
width or thickness of the needle, i.e. measuring the internal hole.) Once sited,
this is known as an indwelling cannula. Many clinicians are using safety‐
shielded Venflon, as these reduce the number of needle‐stick injuries. When
placing a cannula the clinician will not probe, but be decisive. Probing can be
very painful for the patient.
• Two 23‐gauge drawing‐up needles (Figure 3.10), one to draw the drug into a
sterile syringe and the other to draw the flush into a sterile syringe. There are
other available sizes of drawing‐up needles, with the 23‐gauge being the ideal
choice as it is a filter needle, which means that it will filter any potential min-
ute particles of glass that may have dropped into the ampoule. This prevents
such particles from being drawn into the sterile syringe and being adminis-
tered to the patient. The length of the needle means that it will reach the bot-
tom of the glass ampoule, drawing the entire drug into the syringe.
• A 5 ml sodium chloride flush (Figure 3.11), administered to ensure that the can-
nula is correctly sited. Sodium chloride is used because it is compatible with the
Figure 3.8 Safety‐shielded 22‐gauge Venflon.
Figure 3.9 Y‐can. Source: [2]. Reproduced by permission of John Wiley & Sons.
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"Nowhere! You must have been somewhere!" Gloria cried. "Come
on, Pill, where were you?"
Flip knew that Gloria would persist until she had found out; so she
answered in a low voice, "in the chapel."
"The chapel!" Gloria screeched. "What were you doing in the
chapel!"
"You mean you went there when you didn't have to go?" Erna asked.
Flip nodded.
"What for?"
"Pill, are you nuts?"
They were all looking at her as though she were crazy and laughing
at her.
—Oh, please! she thought, I can't even go to chapel to be quiet
without its being something wrong.
Kaatje van Leyden one of the senior prefects responsible for keeping
order, called out, "Quiet!" and the girls subsided.
But she knew that that would not be the end of it.
Gloria said one morning as they were making their beds and Erna
and Jackie had not yet come up from breakfast, "I say, Philippa, you
don't mind my saying something, do you, ducky?"
"What?" Flip asked starkly.
"I mean because of us both being new girls and everything, I thought
I ought to tell you."
"What?" Flip asked again.
"Well, Pill, if I were you I wouldn't keep running off to chapel, that's
all."
Flip smoothed out her bottom sheet and tucked it in. "Why not?"
"The kids think it's sort of funny."
"I know they do." Flip pulled up her blankets and straightened them
out.
"How do you know?" Gloria asked.
Flip's voice was tight. "I'm not deaf. Anyhow I heard you laughing in
the Common Room with them about it."
"I never did."
"I heard you."
"You eavesdropped."
"I didn't. I walked into the Common Room and I couldn't help
hearing. Anyhow, I don't go running off to the chapel. I just go there
once in a while. There's nothing wrong with that."
"You know, Pill," Gloria said, cocking her head and looking at Flip
curiously, "somehow I never thought of you as being particularly
pious."
Flip looked startled. "I don't think I am. I mean, I never thought about
it."
"Then what do you go running off to the chapel for? Don't you go
there to pray or something?"
"No," Flip said. "At least I usually do say a prayer or something
because if I go there I think it's only courteous to God. But I really go
there to be alone."
"To be alone?"
"Yes. There isn't any other place to go."
"What do you want to be alone for?" Gloria asked.
"I just do," Flip said. "If you don't know why I can't explain it to you,
Gloria."
"You're a funny kid, Pill," Gloria said. "You'd be all right if you just
gave yourself a chance."
Jackie and Erna came in then and Gloria turned back to making her
bed.
9
Jackie pulled Flip aside one evening after chapel. They waited until
everyone had gone into the Common Room; then Jackie pulled Flip
into the dining room. The maids had finished clearing away and the
tables were already set for breakfast the next morning. Jackie
seemed embarrassed and unhappy.
"Philippa, I want to say something to you." They stood under the long
box of napkin racks, each little cubby hole marked with the inevitable
number. Flip stared at Jackie and waited. Jackie looked away,
looked up, over Flip's head, over the napkin racks, up to the ceiling.
"I want to apologise to you."
"What for?" Flip asked.
"My mother said I should apologise to you," Jackie said rapidly, still
looking up at the ceiling, her hands plunged deep into the pockets of
her blue blazer, "about our laughing about your going to the chapel. I
always write my mother everything and I wrote her about our thinking
it was funny and laughing and she wrote back and said who am I of
all people to laugh. She said if you got down on the floor in the
middle of the Common Room and bowed towards Mecca I should
honor and respect your form of worship."
"Oh," Flip said. She felt that she ought to try to explain to Jackie that
it really wasn't a burning question of religion that led her to brave
Miss Tulip's annoyance and go to the chapel but she was afraid that
Jackie would not understand and might even be angry.
Jackie had finished her uncomfortable quoting from her mother's
letter and she looked down at her feet. "So I do apologise," she said.
"I'm very sorry, Pill."
"That's all right," Flip answered, embarrassed, but making an effort
to sound friendly.
Jackie heaved a sigh of relief. "Well, I've got to go now," she almost
shouted. "The others are waiting for me." She tore off and Flip was
left standing under the napkin racks.
10
Saturday afternoons they had free time. Most of the girls
clustered in the Common Room, talking, shrieking, laughing, playing
records. Flip stood by the balcony window thinking that she had
been at the school only a few weeks and yet it seemed as though
she had been there forever. She felt in her pocket for her father's
latest letter that she had already read several times in the peace of
the chapel. When she read his letters, those wonderful wonderful
letters, full of little anecdotes and sketches, she would look at the
drawings of forlorn waifs, ragged and starving, and feel ashamed of
her own misery which for the moment at any rate seemed completely
unjustified. She had had a letter that morning from Mrs. Jackman,
too, written on heavy expensive paper saying that she hoped that
Flip had settled down and was happy, and signed, affectionately,
Eunice. Flip had read it in the hall by the mail boxes, torn it up and
thrown it in the trash basket.
"I love you—u—u—" the phonograph wailed.
"And then he said to me, 'your legs are fascinating'," Esmée was
saying.
"He was the most divine boy," she heard Sally saying, "until I heard
he had a whole set of false teeth and a toupee."
"During the holidays," Gloria screeched, "I smoke at least a pack of
Players a day."
Flip turned away from the window, slipped out of the Common
Room, tiptoed through the big lounge, and slipped out the side door
when the teacher on duty was busy talking to someone. The air was
crisp and a light wind was blowing. She took deep breaths of it and
walked swiftly, exulting in the unaccustomed freedom. She climbed
the hill behind the school, knowing that as she got into the pine trees
clustered thickly up the mountainside she would be safe from
detection. She ran until she was panting and her weak knee ached,
but soon the trees got thicker and thicker and she dropped down
onto the fragrant rusty carpet of fallen pine needles. As soon as she
had regained her breath she walked on a little further, rubbing her
fingers lovingly over the rough, resiny trunks of the pines. She felt
free and happy for the first time since she had been at school. The
air was full of piney perfume; the needles were soft and gently
slippery under her feet; high above her head she could see the blue
sky shining in chinks and patches through the trees; and the sun
sifted down to her in long golden shafts like the light in a church. She
lay down on her back on the pine needles and looked up and up and
it seemed that the trees pierced the sky. Oh, trees, oh, sky, oh, sun,
something in her sang. Oh, beautiful, beautiful, beautiful. And she
was happy.
After a while she stood up and brushed and shook the pine needles
off her uniform and climbed still further. There was a small clearing
where the railroad track cut through on its zigzag way up the
mountain. She crossed the track and climbed higher. She did not
know where the school bounds ended and forbidden territory began;
she had forgotten that there was such a thing as a boundary line,
and she kept on pushing up, up the mountain.
Then, suddenly, out of nowhere, rushing in her direction with the
most hideous baying she had ever heard, bounded a wild beast. Her
heart leaped in terror, beating frantically against her chest, then
seemed to stop entirely, before she realized that the beast was Ariel.
"Ariel!" she cried. "Oh, Ariel!" as the bulldog knocked her down in the
ecstasy of his greeting. "Ariel, please!" The dog began bounding
about her, barking wildly, and she lay quietly on the fallen pine
needles until he stopped and stood at her feet, sniffing her anxiously.
"Where's Paul?" she asked, and she was amazingly pleased to see
the dog's hideous face with the drooling, undershot jaw.
Ariel barked.
Flip sat up; then, as Ariel waited quietly, she stood up, and looked
around, but she could see no sign of the boy she had met down by
the lake on the morning of the day she came to school.
"Paul!" she called, but there was no answer except from Ariel, who
barked again, caught hold of her skirt, released it, bounded up the
mountain, then came back and took her skirt in his teeth again.
"But I can't go with you, Ariel," she said. "I have to go back to
school."
Ariel barked and tried again to lure her up the mountain.
"I have to go, Ariel," she told him. "I'm sure I'm out of bounds or
something, being here. I have to go back to school." Then she
laughed at the serious way in which she had been trying to explain to
the bulldog, turned away from him, and started back down the
mountain. But Ariel pranced along beside her, always trying to head
her back up the mountain, catching hold of her skirt or the hem of
her coat, tugging and pulling, gently, but persistently.
"Ariel, you can't come back to school with me, you just can't!" Flip
tried to push the dog away but he barked, reached up, and caught
hold of the cuff of her sleeve.
"Oh, Ariel!" she cried, half exasperated, half pleased because she
knew the dog was going to win. "All right!"
And she turned around and headed back up the mountain.
Ariel bounded ahead of her, running on a few yards, then doubling
back to make sure she was following. Soon she saw grey slate roof-
tops through the trees and as Ariel led her closer she saw that the
roof-tops belonged to a chateau. When the trees cleared and Ariel
began to crash through the heavy undergrowth she realized that the
chateau was old and deserted, for the shutters hung crazily by their
hinges; some of the windows were boarded up; and at others the
boards had come off and the glass was broken and jagged. Grass
and weeds grew wild and high and late autumn flowers bloomed in
undisciplined profusion. Birds flew in and out of the broken windows
and as she pushed through the weeds they began calling to each
other, screaming, someone is coming! Someone is coming!
Her heart beating with excitement Flip pressed forward, following
Ariel, who suddenly leaped ahead of her, bounded across the
remaining distance to the chateau, and disappeared. Flip pushed
after him, calling, "Ariel! Ariel! Wait!" but there was no sound, no sign
of life about the chateau except for the birds and the banging of a
shutter against the gray stones. She crossed what had once been a
flag-stoned terrace to a row of shuttered French windows. One of the
shutters was open and hung by one hinge, and all the glass in the
window was gone. It was through this opening that Ariel had
disappeared. Flip peered in but could see nothing through the
obscurity inside.
"Ariel!" she called, then "Paul! Paul!" There was no answer and her
words came faintly echoing back to her. "Ariel! Paul! Paul!"
At last she turned and started back to school.
CHAPTER TWO
The Page and the Unicorn
SHE studied French verbs in study hall that night, but because of her
afternoon's adventure school seemed different and she seemed
different, and even while she was dutifully memorizing a difficult
subjunctive she was thinking about the chateau and about Ariel and
Paul, and when she thought about them her heart would lift suddenly
and begin to beat rapidly inside her chest so that it seemed like one
of the wild excited birds flying in and out of the broken windows of
the chateau. She sat at her desk and said, "Please, God, let me see
Paul again. Please. Please let me see Paul again."
That night she and Gloria were already in bed, and she was lying
there thinking that the next time she could escape from the school
she would go back and look for Ariel and Paul again, when Erna and
Jackie came in from the lavatory in their pajamas and bathrobes.
Gloria was staring critically at Flip's cotton underthings folded over
her chair at the foot of her bed.
"I can't stand anything but silk next to my skin," Gloria said.
"Mummy's always dressed me in silk. She says she's going to send
me some new silk undies from Paris."
"You and Wagner," Flip said. Jackie laughed.
Erna was tapping her foot on the floor impatiently. "Hey, we just
remembered," she broke in. "You're new girls and we haven't
initiated you yet."
"Oh, Erna," Gloria groaned. "Do we have to be initiated?"
Erna pulled off her barette, pulled her hair back more tightly, and
clasped the barette again as she always did when she felt important.
"Well, you don't have to be, but it just means we can't accept you if
you aren't. You want to be accepted, don't you?"
"Oh, okay," Gloria said. "I suppose we'll survive. Go ahead."
"Do you want to be accepted, Pill?" Erna asked.
Flip answered in a low voice. "Yes."
"Okay. I'll continue. Oh, first you'd better get out of bed and sit on
your chairs, please."
Obediently Flip and Gloria sat on the chairs at the foot of their beds.
Erna nodded in satisfaction. She stood, hands on hips, looking at
them, while Jackie lounged more comfortably on her bed.
"Do you promise to keep our dormitory secrets till the death?" Erna
asked.
Flip and Gloria nodded.
"And to do anything we tell you to do during the period of probation?"
Flip and Gloria nodded again.
"Good. Now we want to ask you a couple of questions."
Jackie took over. She sat up, her feet half in and half out of her
crimson woolly slippers, dangling over the foot of the bed, and
pointed at Gloria. "Who do you like most in the school?"
"You and Erna," Gloria answered promptly.
"I told you she'd say that." Erna nodded at Jackie.
Jackie pointed at Flip. "And you?"
"Madame Perceval."
"Percy? Well, she'll do all right." Jackie kicked one slipper onto the
floor and pointed at Gloria. "Where were you born?"
"London."
"Where?"
"London."
"Where?" Erna asked.
"London."
And Jackie asked again, "Where?"
"Oh, Brazil where the nuts come from," Gloria cried in exasperation.
"Where did you say you were born?" Erna asked.
"I've told you three times," Gloria muttered.
"You seem sort of confused." Jackie kicked off the other slipper.
Erna tightened her bathrobe belt. Miss Tulip had taken her over to
Lausanne that morning and the gold braces on her teeth had been
tightened; her teeth hurt and her voice sounded cross. "If you don't
know where you were born we certainly can't accept you. Where
were you born?"
"London," Gloria mumbled sulkily.
"Are you sure?"
"Yes."
"It wasn't Brazil?"
"No."
"Why did you say it was Brazil?"
"I don't know."
"You mean you say things and you don't know why you say them?"
"No."
"But that's what you just said."
Gloria wailed, "You're trying to confuse me."
Erna put her hands in the pockets of her bath robe and smiled
tolerantly. "Why should we try to confuse you? We're just trying to
find out whether or not you're sure where you were born."
"Of course I'm sure."
"Where was it?"
"London."
"All right. We'll let it go this once. But we can't have people in our
room saying things without knowing why they say them. So be
careful." She turned to Flip. "Okay, Pill. Where were you born?"
"Goshen, Connecticut." Warned by Gloria, Flip answered firmly while
Erna and Jackie asked her seven or eight times.
Jackie slipped over the foot of the bed and pushed her feet back into
her slippers. She smiled ravishingly at Flip and Gloria. "Well," she
told them, "I think you've passed the preliminary examination."
Gloria stood up and stretched. "What's next?"
"You each have to prove yourself."
"How?"
"By some courageous deed. If it's good enough then you can help
with the initiation Saturday afternoon."
"The initiation?" Gloria asked suspiciously.
Erna grinned in anticipation and the light flashed on the gold braces
on her teeth. "Oh, the big general initiation. All the old girls in our
class are going to initiate the new girls who haven't done a
magnificent enough deed by Saturday lunch. It was my idea."
Saturday afternoon, Flip thought. That was when I was planning to
go look for Paul and Ariel. Well, maybe I can go tomorrow after Quiet
Hour though it doesn't give me too much time. I do want to see Paul
again. He was nice to me by the lake and I don't think he disliked
me. Going off to see Paul would be quite a Deed only I can't tell
anyone.
Gloria was smiling a secret pleased smile to herself.
"What's the joke?" Jackie asked, always eager for something to
laugh at.
Gloria twined her arms about her ginger colored head and tried to
look mysterious. "I was thinking of a Deed."
The door opened and Miss Tulip burst in. "Girls! The Light Bell rang
five minutes ago. Just because I wasn't able to get here sooner is no
reason for you to be out of bed. Get in at once. Do you all want
Deportment marks?"
"We didn't hear the bell, Miss Tulip," they chorussed, making a mad
scramble for their beds.
The matron waited until they were lying down and the covers drawn
up; then she switched off the light. "Now I don't want to hear another
sound from this room or I'll have to report you to Mlle. Dragonet.
Good night." And the door clicked shut behind her.
2
Every morning before classes, Call Over was held. All the students
gathered in the Assembly Hall and one of the teachers called the roll.
On Saturday and Sunday mornings Call Over was held as usual,
although it was not followed by lessons. On Saturdays the girls
trooped into the Common Room for sewing, and on Sundays they
remained in formation and marched from the Assembly Hall down to
the chapel.
The morning after Erna's and Jackie's inquisition, Gloria did her
Courageous Deed during Call Over. Fräulein Hauser, the gym
teacher, was calling the roll. She was considered one of the strictest
of all the teachers (though not so strict nor so quickly obeyed as
Madame Perceval) and when it was her turn to take Call Over the
girls stayed very quietly in their lines, answering smartly as their
names were called. It wasn't long, then, this Sunday morning before
Flip and most of the girls in her class, and the classes standing near,
noticed that Gloria, with an expression of unconcerned innocence,
was chewing something. Chewing gum was strictly forbidden and
although the girls frequently smuggled it in, none of them would have
dared chew openly in the presence of a teacher.
"Anne Badeneaux," Fräulein Hauser was saying, "Moire Beresford,
Anastasia Bechman, Hanni Bechman, Lischen Bechman, Jacqueline
Bernstein, Esmée Bodet, Ingeborg Brandes, Dorothy Brown, Gloria
Browne...." As Gloria answered to her name Fräulein Hauser looked
at her sharply. "Gloria Browne," she said.
Gloria, still chewing, answered meekly. "Yes, Fräulein Hauser?"
"You know chewing gum is forbidden?"
"Oh, yes, Fräulein Hauser."
Fräulein Hauser held out her hand. "Come here."
Gloria detached herself from the lines of girls and went up to the
platform. "Yes, Fräulein Hauser?"
Fräulein Hauser kept her hand outstretched. "Spit," she said.
Gloria spat, and there in Fräulein Hauser's upturned palm lay a gold
plate attached to which were Gloria's four front teeth. Gloria turned
around and smiled a brilliant, toothless smile at the assembly.
Fräulein Hauser said icily, "Get back into line. You may report to me
immediately after chapel."
"Yef, Fäulein Haufer. May I haf my teef, pleef, Fäulein Haufer?"
Gloria lisped. Fräulein Hauser handed her the teeth and Gloria
resumed her place in line.
Throughout the entire school shoulders were shaking in ill-
suppressed laughter. Erna let out one snort and turned almost purple
in her effort to keep the rest of her rapture inside. Tears of mirth were
streaming down Jackie's face, and even Flip felt an ache of laughter
in her chest. Fräulein Hauser looked at the Assembly coldly. She
clapped her hands and the sound cut sharply across their laughter.
"Silence!" she hissed, and her face was pale with anger. "Silence!"
She stared wrathfully at the girls until their amusement was
somewhat controlled. Then she went on with the roll. "Cornelli Bruch,
Margaret Campbell, Elizabeth Campbell, Maria Colantuono, Bianca
Colantuono, Goia Colantuono, Jeanne-Marie Crougier...."
3
After Call Over they marched down to the chapel where the
English chaplain from Territet gave them a sermon, and after chapel
Gloria was haled off by Fräulein Hauser and they did not see her
until they met in the dining room for Sunday dinner. Gloria stood,
looking bloody but unbowed, behind her chair as they waited for
Mlle. Dragonet to say grace.
Grace ended, Mlle. Dragonet pulled out her chair, and then all the
other chairs in the big dining room scraped across the floor with a
sound of ocean waves. Tables were changed weekly but the girls
were seated according to classes and the whole of dormitory 33 this
week was together, with Solvei Krogstad and Sally Buckman. Miss
Armstrong, the science teacher, was at their table for that week, but
she had gone down to Montreux to have lunch with a friend who was
passing through.
"Thank goodness Balmy Almy's not here!" Erna cried joyfully. "What
did old Hauser do to you, Gloria?"
And Jackie was squeaking simultaneously, "How did you do it,
Gloria? How did you do it? Tell us quick!"
Gloria clicked her tongue around inside her mouth and suddenly she
was grinning with the four front teeth outside her lips. It was a
macabre and horrible grimace. Another click and they were back in
place.
"You stinker, why didn't you tell us before?" Sally asked, pushing her
fingers against the flat little nose that made her look so much like a
pug dog.
"I was saving it," Gloria said. "It's my Deed so I can help with the
initiation. Will it do?"
"Okay with me." Sally nodded violently.
"What happened to your teeth anyhow?" Erna asked.
"I lost 'em in the blitz. We got bombed out the night before Mummy
was going to take me to the country." Gloria rubbed the tip of her
tongue over her teeth. "I don't know how I ever used to put up with
my own teeth. These are ever so much more useful."
"Daddy sent me back to America before the blitz," Sally said
enviously. "I was in Detroit the whole time."
"Alphabet soup!" Gloria cried as plates were put in front of them.
"The last letter left in the soup is the initial of the man you're going to
marry. Mine is always X. Imagine marrying a man whose name
begins with an X! At the last school I was at there was a girl who lost
an eye in the blitz, and she had a glass eye she used to take out
whenever she got in a row; she'd hold it in her hand and the mistress
could never go on rowing her properly. But I think she used to carry it
too far. One day at dinner the mistress at the table was rowing her
about something and she took her eye out and put it in her glass of
water. Now I call that too much. She was heaps of fun, though. She
got kicked out the same time I did."
"You got expelled!" Jackie exclaimed. "Ooh, what did you do, Glo?"
"Well, Pam—this girl—and I sneaked out of school one Saturday
afternoon and went into town to meet Pam's brothers and of course
one of the mistresses saw us and we got bounced. We didn't care,
though. It was a beastly school, not half as nice as this one."
"But weren't your parents upset?" Jackie asked.
"Who, Mummy and Daddy? They didn't care. There was only a
couple of weeks till the summer hols and they'd have had me on
their hands soon enough anyhow and this gave them a good excuse
to send me off to stay with some people in Wales for the whole
summer. I say, let's play Truth and Consequences, seeing Balmy
Almy isn't here."
Erna, Jackie, and Sally agreed vociferously. Flip looked across at
Solvei and watched her quietly eating her potatoes. She liked the
Norwegian girl who was the Class President and who seemed able
to assume responsibility without putting on any airs. Now Solvei said,
"Let's wait till after lunch. Black and Midnight's been cocking an ear
over here and looking disapproving, and you know how she hates
games at the table."
Gloria stuck out her lower lip. "That old minge. Always poking her
nose in other people's businesses. Why can't she leave us alone?"
"She has a special 'down' on our class," Sally said. "And she says
the middle school's more trouble than the lower and upper schools
together. What a dreep. Oh, my golly, will you look! Suet pudding
again. You can feel every bite of that stuff hit the soles of your feet
five seconds after you've swallowed it. I'd like a good American
banana split."
"Here it is dessert," Gloria wagged a finger at Flip, "And Pill hasn't
said a single word since we sat down. What's the matter, Pill? Cat
got your tongue?"
"No," Flip answered, blushing.
"I don't think I've ever heard Pill say anything." Sally grinned at Flip,
but somehow there seemed to be nothing pleasant about the grin.
"Can you talk, Pill?"
"Yes," Flip said.
"Well, say something, then."
"There isn't—I don't—I haven't anything to say," Flip stumbled.
"Don't we inspire conversation?" Sally asked. "A lot you must think of
us. Does she ever talk in the room?"
Erna was gobbling her suet pudding. "She sometimes answers if you
ask her a question, if you insist. Yes, or no. That's all."
"What do you do when you go out on a date, Pill?" Sally asked. "Or
don't you ever go on dates? Hi! kids, what kind of a line do you think
Pill uses on a boy?"
Flip said nothing.
"Well, what kind of a line do you use, Pill?" Sally persisted. "Maybe
you could teach us something. Well, for john's sake say something,
can't you!"
"Oh, do leave her alone," Solvei said impatiently. "If she hasn't
anything to say she hasn't anything to say."
"But how can someone not have something to say!" Gloria
exclaimed incredulously. "There's always something to say. Any time
I can't talk I'll be dead."
"Well, maybe Pill's dead," Sally suggested. "How about it, Pill. Are
you dead?"
"No," Flip said.
Solvei interfered again in her behalf, but Flip felt that it was only from
a sense of duty, that privately Solvei considered her just as much of
a 'pill' as the rest of the girls did. "Madame Perceval says your
father's an artist, Philippa."
Flip nodded, then said, "Yes. He is."
"How'd Percy know? Did you tell her?" Erna asked.
Flip shook her head. "No."
"Oh, Percy always knows everything about everybody," Jackie said
with admiration. "I don't know how she does it. And you can't ever
get away with anything with Percy but you never mind how strict she
is. Sometimes I think I love Percy almost as much as my mother."
"You have a crush on her," Sally said.
Jackie looked at the grey lump of suet pudding remaining on her
plate and turned up her nose in disgust. "I merely have a great
admiration for her."
"Oh, for john's sake, Jackie, I was just kidding. Can't you take a
joke? Let's change the subject. Tell us a story, Glo. Have you heard
any good ones lately?"
"Well, Esmée told me one yesterday," Gloria started.
Solvei broke in, "Not at the table. Save it for the Common Room if
you feel you have to tell it."
Flip looked at Solvei in gratitude. Mlle. Dragonet at the head table
stood up before Gloria could retort; all the chairs in the dining room
were scraped back and the girls filed out.
4
On Sunday afternoons all the girls were supposed to spend a rest
period in their rooms, but after the rest period there would be two
hours when Flip could try to escape and go back to the deserted
chateau. She sat curled up on her bed with the dog-eared calendar
she carried around with her in her blazer pocket and looked at the
small block of days that was marked off and then at all the days and
days that stretched out to be lived through somehow before the
Christmas holidays and her father would finally come. Sometimes
she was afraid that the Christmas holidays would never be reached.
She knew already that the one certain thing in an uncertain world
was that time always passed; but as day followed day, each one
exactly like the other, she felt that nothing, not even time, could put
an end to their unbearable monotony.
—Oh, please God, please, God, make Christmas come quickly, Flip
prayed, her hand still moving softly over her dog-eared calendar; and
because time did not wheel faster in its vast circle for her she
became filled with despair and homesickness and bitterness at her
misery and she shoved the book she had brought up with her off the
bed so that it fell on the floor with a thud. Across the room Gloria
yawned noisily over her required weekly letter to her mother; Erna
and Jackie, as usual, were whispering and giggling together.
"They're so childish," Esmée was always saying to Gloria, but she
was careful to keep on good terms with Jackie because Jackie's
father was a movie director.
Flip leaned over and picked up her book, smoothing out its pages in
swift apology, and waited for the bell.
5
She hurried out of the room after Quiet Hour, got her coat from the
Cloak Room, and started up the mountain. She knew that the others
would think she had gone to the chapel. She ran almost until she
stood at the edge of the forest where the trees thinned out and
mingled with the underbrush that surrounded the chateau, and there
was the chateau as it had been the day before, cold and beautiful
and deserted. She stood looking at the grey stones and at the birds,
her heart thumping; but no Ariel came rushing towards her to knock
her down with his greeting, and after a moment she began pushing
her way to the chateau, jumping like a startled woods animal each
time a twig snapped or the wind moved in the high grasses. Just as
she had almost neared the decaying walls of the building she heard
a low whine and there was Ariel standing in the shadow of a shutter
that hung drunkenly. The shadow seemed to move and she saw that
Paul was there, too, holding Ariel by the collar.
"Paul!" she called softly.
For a moment she thought Paul was going to go back into the
chateau; then he stepped out of the shadow of the shutter and held
out his hand in greeting.
"Oh," he said. "It's you."
She took his hand. "Who else would it be?"
"There are a great many girls in your school, aren't there? And you
might be any of them."
"I'm not any of them," she said. "I'm me."
"How did you get here?" he asked, still holding back Ariel who was
trying to leap at Flip. "How did you find me?"
Flip retreated a little because it did not seem to her that he really was
glad that she had come. "I didn't find you," she said. "Ariel found me.
I went for a walk yesterday afternoon and he found me and made me
come to the chateau."
"And you came back today," Paul said.
There was neither welcome nor rebuff in his voice but Flip felt that
she had been rejected and she said haughtily, "I'm sorry I'm not
welcome. I'll leave at once."
"No, please!" Paul cried. "I said I was glad it was you. I was afraid it
was someone I didn't know. I came here to be alone and I didn't want
just anybody coming around."
Flip said swiftly, "If you wanted to be alone I won't stay, then. I know
how it is to need to be alone. I need to be alone, too."
Paul reached out for her hand again. "No, don't go, it's good to see
you. I know I sounded inhospitable, but come and sit down." Still
holding her firmly by the hand he led her across the terrace to a
marble bench half hidden by weeds. "Now," he said, sitting down
beside her. "Do you like your school?"
She shook her head. "No. I hate it."
"And you really have to stay? You can't ask your father to take you
away?"
"No." She looked down at Paul's hand beside her on the bench. It
still held a warm tan from summer, and his fingers were very long
and thin and at the same time gave an appearance of great strength.
They were blunt at the tips, the nails square and clean. "I couldn't be
with father while he's traveling about," she said, "and I had to be
somewhere and Eunice suggested this school. Father always seems
to do what Eunice suggests about me...."
Her voice trailed off. Paul saw that she was looking at his hand on
the bench between them and for a second his fingers twitched the
way she had noticed someone's foot would do if you stared at it long
enough in a subway or bus or even in the classroom at school. Then
he reached down and fondled Ariel.
"Ariel is a beautiful dog," she said politely. "Where did you get him?"
"I found him in the street. He had been hit by a car and left there and
his leg was broken. I set it myself and took care of him and now he is
fine, he doesn't even limp, and when I showed him to Dr. Bejart—a
friend of mine—he said he was a very fine dog."
"But that's wonderful!" Flip cried, gazing admiringly at Ariel. "How did
you know about setting a leg?"
Paul looked pleased at her praise. "I intend to be a doctor. A
surgeon. Of course I must go to college and medical school and
everything first. Right now I don't go to school at all. I am trying to
study by myself and my father is helping me but of course I know I
must go back to school sooner or later. I think that it will be later." A
shadow swept over his face and it seemed to Flip as though the day
had suddenly darkened.
She looked up startled and indeed the sun had dropped behind the
mountain. She rose. "I have to go. I didn't realize it was so late. If I
don't get back quickly they'll miss me."
Paul stood up, too. "Do go, then," he said. "If you're caught they
wouldn't let you come back, would they? Will you come back?"

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Basic guide to dental sedation nursing

Second Edition Rogers

Limit of Liability/Disclaimer of Warranty

Library of Congress Cataloging‐in‐Publication Data

Cover Design: Wiley

Set in 10.5/13pt Sabon by SPi Global, Pondicherry, India

How to use this book ix

2 Medico‐legal aspects of dental sedation 7

3 Role of the dental nurse and equipment 23

6 Medical emergencies 117

7 Essential anatomy 157

Basic Guide to Dental Sedation Nursing, Second Edition. Nicola Rogers.

Conscious sedation is defined as ‘a technique in which the use of a drug or drugs

lowing objects or substances that may be dangerous. However, a hypersensitive

When managing and planning treatment for patients, it is vital to remember

1. Intercollegiate Advisory Committee for Sedation in Dentistry (2015). Standards for

In April 2015, the Intercollegiate Advisory Committee for Sedation in Dentistry

Basic Guide to Dental Sedation Nursing, Second Edition. Nicola Rogers.

• Conscious Sedation in Dentistry (2012)

• Safe Sedation Practice for Healthcare Procedures, published by the Academy

• Any dental establishment providing sedation should be inspected to ensure

emergency procedures, having received training and updates on a regular

sedation, and medical and dental emergencies.

administered it is mandatory to use electrical monitoring via a pulse oximeter

appropriate setting, as it is a less controlled method of using midazolam. If

the same level of care as for intravenous sedation.

• All of these treatment options using midazolam require patients to be advised

• There should be a system to report any adverse incidents, developed for

consent is in place prior to treatment. Consent is not a one‐off action but an

Why consent is required

When consent is required

obtains consent, as it is their responsibility to do so and not that of the referring

be informed and consulted, with a new consent form being completed.

Who can give consent

C o nfi de ntia lit y

• In the interests of the general public

Protection of patient information

implications arising from that action. Patients do sometimes make allegations of

Preventing allegations of assault

Avoiding allegations of negligence

they can be referenced, should a case of negligence be brought by a patient who

1. Intercollegiate Advisory Committee for Sedation in Dentistry (2015). Standards for

Basic Guide to Dental Sedation Nursing, Second Edition. Nicola Rogers.

conscious sedation and allow modifications to be made at future appointments

Figure 3.1 Pulse oximeter.

• Has your medical history changed since the assessment appointment?

• Have you recently visited the doctor?

Figure 3.2 Pulse being taken.

Figure 3.5 Non‐disposable and disposable tourniquets.

• A disinfectant surface medi‐wipe (Figure 3.6) to cleanse the selected cannula-

Figure 3.6 Medi‐wipe.

Figure 3.7 22‐gauge Venflon.

• A cannula, either a 22‐gauge Venflon (Figure 3.7), a safety‐shielded 22‐guage

Figure 3.8 Safety‐shielded 22‐gauge Venflon.

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How to use this book ix

2 Medico‐legal aspects of dental sedation 7

3 Role of the dental nurse and equipment 23

6 Medical emergencies 117

7 Essential anatomy 157