I am feeling so much better. I was so sick when I wrote Wednesday’s blog that I was begging for the day to be over. By about 2:30 p.m., I started to sweat while working. About 20 minutes later, it was like a miracle. I was feeling so much better. I had already had made a doctor’s appointment for the next morning. I went to my appointment anyway and was feeling pretty good by the time I got there. She gave me a Z-pack because she thought I might be harvesting a post-viral bacterial infection. My glands were still swollen and I was still having pain on swallowing. A day and a half later, I feel like a million bucks. It makes me not take feeling well for granted.
Today, I was having a normal day. Got patients coming and going. Some were actually walking in. A man walked into my room and he was swollen on the lower left side. He told me that he hadn't slept at all last night. We took an x-ray and then I started talking to him about his medical history. He has had three strokes. He is on an antiplatelet medication, aspirin, and about 4 other meds for his heart. Oh, and he is 56 years old.
Looking at the x-ray, he has a molar crown that has history of a root canal and crown with through and through decay and abscess all around both roots. The tooth needed to come out. This guy, although not in good shape medically, is having a dental problem that could possibly make his fragile health even worse.
I looked in his mouth and pushed around looking for spontaneous bleeding. Things looked okay. I wanted to get this tooth out, so I told my assistant I wanted topical. She looked at me and said out loud, "Where do I sign to say that I am not responsible?"
"Shut up and stop telling me what to do." I numbed him up and realized he had lost his color. I asked him if he was okay. I started to talk to him to make sure he was responding to me. We were having a conversation. I started to numb the tissue around the tooth. He told me that he has always hated the dentist and always gets nervous around needles. He asked to sit up, and this is the time I thought I might be in trouble.
He was sitting up and we were still having a conversation. But for safety’s sake, I called out to the reception area and had his wife come back. She was a trooper; she had obviously been down this road before with him. She started talking to him and he started to fade. He was sitting up and passing out at the same time. She said, "I think you better make that call." WHAT!!!????
I said as calmly I as could, "You mean call 911?"
And she said, as calmly as she could, "No, I mean call Domino's pizza and get some lunch while my husband is here dying in your chair."
No, she didn't say that. She said, "Yes, call 911."
While I was talking to the operator, he had come to and started feeling better. He was saying all the things that dudes say when they pass out. "Did I pass out? Are you going to make me go to the hospital?"
He really was fine and he was talking, but I still put in him in the Trendelenburg position and had him breathe oxygen until help arrived.
The guys came in and did their tests. They hooked up an EKG machine and blood pressure cuff and did their exam. Heart was good; blood pressure was little high but okay. Then they asked him what he wanted to do. He looked at me and asked me if I wanted to go ahead and finish. I said, "No fricking way."
The paramedic said, "Everything looks okay, I would recommend you going to the Primary Care physician when you get a chance. But for now let’s have you just stand up and see what happens." He stood up and, about 3 minutes later, he started to fall over. We made him sit down and the paramedic changed his tune. "I think you should go ahead and ride in bus to the hospital." They brought the chair in and wheeled him out.
I guess if you are going to have an emergency, this is the kind to have. You don’t want the kind that require CPR. Or the kind where lawyers have to get involved in later. Having the guy talking and laughing on his way out is definitely the way to go.
Just a great way to end a really crummy week. Now I have a good reason to hit the sauce tonight (I am not going to tell you how the AGD feels about drinking your stress away. I make that up by the way).
Have you had this happen to you? Anything crazy? Tell me, tell me.
Have a great weekend.
john
I had a patient years ago that callapsed at a grocery store about 5 hours after I had seen him to do a DL composite on a max. rt cuspid. He died of a heart attack on the way to the ER. The story around town was he had been to the dentist and had too much novacaine. He had 1.5 carpules of carbocaine 3% plain. That was 28 years ago, my records were sent to a lawyer and nothing ever came of it. For patients with major health issues and 15 different medications, God gave us oral surgeons.
ReplyDeleteInteresting especially when compared with Monday 27th post. What prelims were done , bp,etc, as there were obvious signs for caution? We are seeing many more medically compromised people so our basic medical assessment training has to be increased- Or there will be an imposed requirement to a medical degree and then dentistry as a specialty -imagine the cost of dentistry then!
ReplyDeletePlease tell me you took an initial BP on this patient you had never met before, had an active infection, and had a history of cardiovascular disease before you decided to anesthetize for extraction…
ReplyDeleteSavor the weekend, you earned it!
Ive been in that situation TWICE before...not fun,,
ReplyDeleteScott..
At one dentist, they didn't believe it when I told them that I pass out with any type of numbing agent ... so they went ahead with a large dose of something. Procedure occurs, I walk out of the room, go to pay my bill ... "Can I sit down?"
ReplyDelete30 seconds later I'm back in the room, feet are elevated, watching Regis & Kelly. Next thing I know, I'm waking up with 5 faces peering down at me.
Me: "What's going on?"
Them: "You passed out. We called 911"
Me: "I told you!"
Wouldn't do another procedure on me ... and now people actually believe me.
You have a very smart assistant, listen to her next time.
ReplyDeleteI have had needed to call 911 in the past. It was a patient that I knew well who was returning to my office for 1 week recall after I inserted her denture. She had a similar cardiac history to your patient, and had a history of unstable blood pressure. She was followed by her physician and even still was having a hard time finding the right balance of medication to control her condition. She presented to my office and while in the waiting room she started to feel dizzy. I brought her back so that she could lie down in the chair in private with her blood pressure monitored. It continued to rise and she began slurring her words. I called 911 and the EMTs arrived and took her to the hospital. She was OK, but it was very scary. Some patients are complicated, and yes, sometimes they do present with an emergency. However, I would recommend always seeking a medical consult on a medically complex patient any time local anesthetic would be administered. As we know, some patients require special precautions even for cleanings. The physicians appreciate it, and it helps to bring us all on the same page as far as patient care. The patient may need to sign a HIPAA waiver for you to talk with their PCP, but honestly, I've never had a physician refuse to speak with me about a patient, and I always let the patient know I need to speak with their doctor and why. Then I document everything in the patient record. If untoward happens it doesn't mean that you aren't responsible, but at least you did everything you could to manage the risk.
ReplyDeleteOi. I don't mean to bust your balls here, but that was a rookie mistake. I evaluate exo's (and endo's for that matter) in 3 phases: Preforcep, Forcep and Postforcep. If any one of these raises a red flag, it gets referred - I don't need any more hassles these days. In this guy's case, the phase 1 red flags are huge: blood thinners, a phobia and infection. The forcep phase, pretty simple by sound of it. Postforcep is a problem - he might not clot well if at all and he'll bruise to his knees which of course if your fault. This guy needs antibiotics and a referral to OMFS who will probably draw labs for a coag panel looking for platelets and INR. The simple exo will probably then be booked with IV sedation and depending on his fragility and labs it may be left til he is medically more stable. All this for a simple exo fee, thank you, no.
ReplyDeleteI think another issue here is that the lack of busyness that we are all struggling with these days has a tendency to warp our thinking. We may succumb to 2 things: moral hazard or wading into treatments that when we are all fat and happy, we normally wouldn't get involved in. It is always better to go broke not doing treatment than it is paying to defend a lawsuit, frivolous or otherwise.
I totally agree with you.
ReplyDeleteI wanted that tooth out more than I wanted to think.
I think I needed to get my balls busted on this one.
You are right, I know it.
I will be better next time.
Thanks
john
I had to do that twice. After that I swore off extractions. Pt lie about their health history. In my case there was no mention of the chronic copd and multiple visits to the hospital anywhere in the health history filled out by the pt. I learned that the hard way lucky for me, when I called the hospital later they said yeah she is here all the time and she is fine.
ReplyDeleteYou just lied to yourself and blinded yourself into ignoring the pts health history.
Hmmmm, I had it the other way. Sort of. Adjusting dentures for a patient that had no significant medical history, he started getting chest pains, so we made a few calls (this was in a hospital practice) and he had a 12 lead ECG connected in short order, and got led off out of the clinic.
ReplyDeleteI followed up the story and it turned out he was disagnosed with Tietze's syndrome or possibly Bornholme's Disease which have very similar intial symptoms to myocardial infarct, so there was no embarrassment at our end, and no tragedy either as both of these are relatively benign. Better safe than sorry, though.