Wednesday, March 7, 2012

Is it Hot in Here?

Hi all,

I hope all of you had a less eventful weekend than I did. I was busy. Friday night was a 50th birthday party. Saturday, I woke at 4:10 a.m. to go for a long run (18 miles). I was at the ball fields for a 9 a.m. game, then to a funeral at 10 and lacrosse game at 11:30. Then I had a couple hours to do chores before I got the green light to go to the Magic game.

Woke up Sunday and got in the car at 8 a.m. to see the UF vs Kentucky basketball game. Sucky outcome, but great times. Did I tell you that I am a huge Gator basketball fan? This year, the band was moved to the second level which opened up a bunch of seats on the first level. I somehow got awesome second row seats.

You have all seen the "face guy" from the Alabama student section. Well, I had this idea since the beginning of the season, but I just never did it. I actually had my face at the printer when this guy broke. I had my poster face made and this is what I looked like at the game You will see I busted out the throw-back jersey and the orange and blue scarf (not really manly, I know) to see if I could muster up some old school luck. Didn't happen. Here is what it looks like during free throws:

Pretty awesome, huh? This was on the Gainseville Sun website.

Friday's blog was on an emergency I had on Friday afternoon. I have to say that my wanting to take this tooth out for this man (and it wasn't about money) so he could get a good night sleep clouded my judgment. This was a man who was 56 and had a very complicated medical history. I don't' have to make excuses. I probably would have done it differently if I had a chance. If I could do it differently, we all know I would refer him. There was a really good comment about the pros and cons of working on a patient like this. The commenter basically said it just isn’t worth it.

But I am always about growing. I have been looking at how I treat people's health as a whole. I have to admit that I am a bit cavalier when it comes to people's health. I have discussions with people at my new patient exam. We discuss anything medically that is going on in their lives.

For an emergency appointment, I still discuss their medical history and meds. Other than a patient like I had on Friday (56, three strokes, 14 meds), no real red flags go up. (By the by, I called the wife and it turns out that he just fainted. He got the tooth taken out yesterday.)

I don't know if I would change much. I don't know what on a medical history would really throw up some red flags. High Blood pressure? Are you checking blood pressure on everyone? One comment said, "Please tell me you took his blood pressure?"
Okay here is my thing about blood pressure. I don't buy it. I don't buy that if someone has high blood pressure 5 minutes before a dental appointment they are at risk. I am about as fit as they come. I am a marathon runner.

I went to my physician for a physical. She took my blood pressure and it was high that morning. I was shocked because I have never had an issue with that. I wasn't nervous or anything. Turns out that I had a cup of coffee about an hour prior to the appointment and that raised my blood pressure.

Now, if we are checking blood pressure, are we sending people home if it is high? And what is high? Anything over 140/90? Do you tell them that they can't be seen in your office unless they get that blood pressure under control? That would mean we are sending home everyone that has had a cup of coffee before their appointment. And if they are a little nervous and had a cup of coffee? Have 911 on speed dial.

What if the patient hasn't seen a doctor in about 15 years, like most 40-year-old males, and they just don't know how healthy they are? (I guess this would be a great reason to take the blood pressure.)

Yes, I am being a little sarcastic. Yes, I understand the need for being diligent. I am just playing devil's advocate here.

I went to the doctor the other day when I wasn't feeling well; they took my pulse and blood pressure. She said my pulse was 65 and my bp was 125/80. I knew that was wrong. I am a runner and my pulse has been in the 40s for the last 6 years.

When I went to the pharmacy to pick up my prescription, I sat in one of those machines. Sure enough, pulse 47 and my blood pressure was 117/70. If a doctor’s office can’t get a nurse that knows how to take blood pressure...

How about blood thinners? Are you sending people home for being on anticoagulants or antiplatelet meds? And if you are or are not, where are you getting your info from? I don't know squat about meds, so I make no decision on my own. I called my periodontist and asked him if he takes his patients off blood thinngers before a cleaning or extraction.

He said, "No." He said he would rather them bleed a little after an extraction than stroke out. Hmm. So we don't have anyone come off blood thinners before a cleaning or a simple extractions here.

What about diabetes? Are you checking blood sugar? I ask, if they have checked their sugar today and if they have eaten but again, no real checks. What about if people have a history of fainting?

I am at the one side of the scale when it comes to med history. What are you guys doing? Are you easily sending people away for fear of a lawsuit? Or fear for the patient’s overall health?

The only thing that would require me to tell the patient that we can't work on them (on a regular basis) is artificial joints (knees, hips and the like). They can't be seen here without an antibiotic one hour before their appointment. Also, I usually send out medically-compromised patients (like the guy that was here on Friday). Like the commenter said, "All this for a simple exo fee, thank you, no."

Anyway, tell me how you deal with overall health. What do you send people away for? If you never send someone away, I want to hear you too.

Thanks. Have a great Wednesday.


Anonymous said...

Here is my deal. . . first of all I do sedation, so my office is equiped for emergencies. ACLS is great training. Hope I never have to use it. But, I have always felt that it is in the best interest of the patient if we (dental community) look at a patient's overall health and refer them back to their physician if there are red flags. I check patients' skin, the neck for nodules and that includes the thyroid. I have had two thyroid malignancies diagnosed because I could palpate a change that the physician could not until he had the patient in a reclining position. One of those thyroid tumors was the size of a nerf football and was caught because everytime he was reclined in my chair his BP went WAY up. And I mean everytime. Turns out, the tumor was growing into his trachea and occluding his airway in a reclined position which naturally made him more anxious than afraid of my white coat. I have a pulse ox and I use it on every patient for a baseline. Do you use epi?? You should take BPs. Just a couple of months ago a teenage African American male came into the office with a toothache. BP 160/100. I gave him an Rx and I sent him for a physical. His mother was in the office too and it gave me the opportunity to educate his family on the dangers of high BP and their diet. I may have been the only healthcare professional to see him for several more years. It is not a service to just treat the oral cavity. WE need to look at the total human. We do them a service and we elevate our profession. BTW, skin lesions are easily identified especially with our loops and lights. And yes, we've caught several of those malignancies. I'm Irish so there are a lot of skin lesions in my clan. I know the MOHS surgeon so well that I can refer directly to him without a dermatologist.
My path prof used to say, if you are not looking for lesions you will never diagnose them. We owe it to our patients to treat them to the best of our ability and to recognize and refer what we cannot.

Anonymous said...

I guess it's a lot like Dr. Jackson's article of a few weeks back - are you a physician of the mouth or just a dentist.

I look at med hx before committing to every single treatment. Commonplace polypharmacy today demands that we be experts with drug interactions, side effects and their dental sequelae.

I don't take blood pressure or check blood sugar but ask if it is controlled. Thinners will get you if you don't respect them. So will Parkinson's meds. So will bisphosphonates. The list goes on.

When in doubt, or more commonly, when I know there is much more medical ground work to do before a "simple" dental procedure, I'll refer it to an OMFS for more advanced medical handling. I've never regretted being too cautious.

Anonymous said...

I try to keep up with the most recent medico -dental issues through the ADA,

and journals. I always combine my evidence based practice with practice based evidence(ie what the patient reports and what I find). I know only too well that relying solely on EBP has to be carefully assessed as is often targetted at the "norm" and many of my patients' dental and medical issues are far
from the norm.
I consult with the patient's medical doctors and call on the expertise of my local pharmacists, radiologists and dental specialists where required. I'm also fortunate to have a physiotherapist who is a head and neck specialist nearby.
Most cases though are straight forward even where there are complex medical medical issues and don't need input other than the patient's but neither do I practice in isolation. I've found providing good aftercare information saves many complications and an afterhours phone number - rarely get called, but extraction/surgey/endo cases leave feeling less stressed.

gatordmd said...

I totally agree. Great comment.


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