Friday, October 15, 2010

Failure 101

Hi all,

It's Friday. What can I say? My life is just getting back to normal.

I forgot something in Wednesday's blog - the signs. As I was running ,thinking things were going fairly smoothly and that I might not have anything to write about, I started to memorized some of the crazy signs that people were holding up. It seemed that I had a bunch of them memorized but after my "passing out" episode, it seems they all didn't stay in my brain. Here are a few that I can remember.

"It takes an idiot to run, but it takes a special idiot to run a marathon."

"You are doing fine; your nipples aren't bleeding yet."

"Your legs will forgive you... eventually."

"Mortuary ahead... look alive."

Then I saw this shirt that said, "Dear God, let someone be slower than me so they can read this shirt." I'm looking down at my toes and one of my toenails is coming off because of this run.

Okay now that you are awake...

I started this blog almost three years ago to try to make people feel less alone in this crazy thing they call dentistry. I use to read the magazines and feel so insecure because I wasn't producing $4,000,000 in a three-day week. I used to go to the annual meetings and talk to my lying friends about how it was going and apparently I was the only one that didn't have it all together.

It appears to me that I have done the same thing to you guys. I talk about things that go wrong in the office but I rarely talk about things that go wrong in the operatory, and there are reasons for that.

First, it doesn't happen very often. I am talking about catastrophic failures. Sure, I get the marginal ridges chipping off one of my fillings or a two year old filling that looks like crap, But on this one I am talking about the "Oh S!#t, I have to tell the patient something went wrong."

Second, I don't like to talk about it. I think this is definitely a problem. I want you to think that I have it all together. I want you to like me and think I am funny. If you think I am great at teeth and you like me and think I am funny then I am in blogger's utopia. But we all know there are cracks in this armor. Or maybe you don't, because I haven't told you.

About two years back, I wrote a blog telling you how I pulled the wrong tooth but I quickly took it down after about 4 hours. I was embarrassed. It was a kid. The script from the orthodontist said to take all of her laterals out except one (so I didn't really take out the wrong tooth, just one I wasn't supposed to). See, she was born without #10 and the orthodontist was going to save #G through the first phase of ortho. Not after I got ahold of her.

I didn't read the script right; simple as that. But does anyone really like to to just admit they screwed up? Would that make me less credible? In a place where there are a lot of your dentist friends around and you tell that story, do they understand where you are coming from or do they start to distance themselves from you? I have got to think the latter.

Well, last Friday I did it again. Twice in three years, that's not too bad right? Are you distancing yourself from me yet?

My father sees this patient for the first time. He has two teeth broken down to the gum line that are unrestorable. #18 is a long tooth. It has post endo of 40 years (with silver points in the mesial roots). You know what that means - that tooth is not coming out easily. Even my oral surgeon told me that teeth like this break like a cracker.

To all you non-dental people, let me explain. After a tooth has a root canal it loses its vitality and becomes more brittle, and because it has no life in it, something happens to the tooth bone interaction. The tooth starts to become one with the bone over time. So you have to cut the bone away from the tooth sometimes to loosen it up.

I talked to the patient at length about how this tooth was going to break. And we would do our best to get it all out. There was a good chance this tooth was going to break and we were going to have to make a decision on whether to go after a root tip or not.

So we began and it went about as expected. I would get a purchase point and it would break. Things were not very stressful because it was going about as we expected. It got so far down that I asked my assistant if we had any longer burs. This was my mistake. I never use the longer carbide burs and I don't have a real good feel for how they cut (I usually use a diamond to cut through bone). I started blasting away and got a little farther down and the root broke again. It was at this point, I told him that we were going to stop because I didn't want to cut anymore. I thought we got enough of the tooth out that it wasn't going to cause any issues. He was fine with it.

I suggested that we take an X-ray to see how much was left. I told him that if there was too much tooth left he was going to have to see an oral surgeon. Very clear lines of communication at this point.

I stepped out of the room as my assistant took a quick picture of the tooth.
I came back in and this is what I saw:

(marinate on that for a second)

Are you thinking of distancing yourself from me? Am I losing my credibility with you?

Okay, so I knew the next couple of minutes with this patient would be crucial. We were looking at this X-ray together and full disclosure is a MUST (at least it is to me).

I told him what appeared to have happened. I told him that I must have angled the bur the wrong way and clipped the adjacent tooth. I told him it was on me, that if he ever had any issues with this tooth that I would take care of it. I told him that in two weeks I was going to bring him back and see what I can do about filling in the hole that I created. I told him that I thought it was going to be okay and if it isn't I would take care of it.

I said it very casually so as not to get his hear rate up, even though I had some pretty good butt sweat going. He was totally okay. I, on the other hand, was a basket case. I hate this. I like sharing successes with people. I don't like having to disclose things like this to people. It ruined my day. I haven't stopped thinking about it since. But I guess it is supposed to feel like this. It is supposed to hurt because that is how you learn.

I hope this is going to make me more careful in the future. This is going to make me sharper because it will be in the back of my mind every time I pick up a bur during an oral surgery appointment.

I screwed up and I am going to learn from it. I still want you to like me. I still want you to think I am a good dentist. This is why people don't share in magazines or at a dental conference. It isn't easy, and it isn't fun. It kind of burns. Know that if you screw up, you are not alone, but it is going to burn. And if it doesn't burn then you need to look at yourself in the mirror and ask yourself why it isn't burning.

Sorry so heavy on a Friday.

Have a great weekend,


Cesar said...

HUGE points for sharing this, and even more for stepping up and doing the right thing (i realize it's your professional obligation, but we both also know of cases where the pt has not been advised of a negative outcome or sequelea)

chin up! it's great that you have such a fantastic relationship with your patients that you can tell them the bad news, convey your feelings, and still have them "be cool" about it.

Tom Gilbert said...

John, You handled this in the correct way. We all make mistakes, those of us who make them so seldom tend to dwell on the negative impact. I'm sure your patients and bloggers know what an honest, caring dentist you are. Congrats on finishing the marathon. I run the Columbus marathon on Sunday. The other day I was talking to a patient/friend and I almost numbed the wrong tooth, thankfully I have an awesome assistant who grabbed my arm. Whew! We can't be perfect all the time. Have a great weekend and keep up with the great blogs.

Anonymous said...

I want to say that I agree with the way you handled it. I too have had 'situations' that for whatever reason, be it my eagerness, inexperience or plain ignorance have not gone the way I wanted. I think honesty is the best policy, but I live in Canada where the dental business is not nearly as litigious as the US. I hope that you don't have any negative fallout from this, I know that you are always putting your best foot forward. That being said, I gotta say that from your radiograph, it appears that you went about this extraction the wrong way. Sectioning interproximally between the roots of 18, even at the expense of bone (which can be easily grafted) would have been much safer and then you could have used some leverage to luxate those roots slightly. In any case you hopefully will NOT have to pay for an implant on tooth 19. I love your blog, read it all the time. Keep up the good work and honesty, you are a credit to our profession.
Sorry for the criticism, but we are friends, are we not?

Anonymous said...

Great that you told the pt right away. Just put some Glass Ionomer in it and it should be fine. Or MTA would be even better.

Next time lay a flap and use the east, west or learn to use the osteotome and mallet.

gatordmd said...

Of course we are friends.
And I am up for constructive criticism....and I appreciate it.
I am also a big proponent of separating the tooth. I started with that method and the roots wouldn't move. I then tried to remove more furcal bone and the tooth kept breaking. I then tried to remove bone all around the tooth to try to grab it with a forcept. This is when I got in trouble.

I appreciate you,

Warren Bobinski said...

I really appreciate the way you write - you are a big influence on the way that I write! I enjoy the personal touch John - its' good to know that we are all human :)
I have spent much of the last week talking about this post in particular and I think there are several friends here that can appreciate what you do, as a matter of fact a couple of them are probably starting blogs themselves.

I have held several comments from the last few posts - but only because I couldn't post from my iPad! Probably something to do with flash, or whatever - I just couldn't read the captcha, so I took all the time to write - but couldn't post!

The summary would have been the same - keep doing what you are doing. Its' inspirational and motivational...

Warren Bobinski
Success in Dentistry and Life.

gatordmd said...

Thanks Warren,
I am glad you are liking what I am doing. I just try to be me. That is all.

About your friends blogging....
We watch NBA guys and complain when they miss a wide open three point shot but when I go and shoot around I can't even shoot the ball that far with out throwing it.
What I trying to say is... we are professionals, we make it look easy.
Just kidding.
Hope they have success.

Talk to you later,

rutcanal said...

But the real question is: What did you learn from this experience?

Would better visibility and better light have helped you locate the structures on which you were working ? Have you considered how, perhaps, a surgical operating microscope could have helped prior to the unfortunate iatrogenic misadventure?

Its no crime to make a mistake like this if that is all it takes for you to have a "Eureka" professional moment that makes you a better dentist.

Our patients deserve our absolute best, all the time.

"Do every case like its your last"


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