Monday, August 23, 2010

suboptimal

Well we got in off the waitlist for an appointment with the dentist today, and I took extra call this Sunday night in order to be able to take him, but anyway, Cal got his cavity taken care of. It was...kind of terrible.

They did it with nitrous and local, and I think it was a sub-total block, because he was real good up until they started doing the pulpotomy, at which point he started screaming how much it hurt, and they had to call in two nurses to hold him down. I was waiting outside the door (per practitioner request), but basically bullied myself in when I heard the screaming. I know it sounds pretty barbaric, and it looked that way to eyewitnesses on the scene (that is to say: me), but I appreciate the fact that once they started getting into the pulp, no matter how much Cal was struggling, the important thing is to get in and get out with as much expediency as possible. However, I have to say that as an anesthesiologist, who every day lays hands on the tools and the meds that could have made things better, having to watch this particular procedure on this particular patient under suboptimal anesthesia was no less than psychological torture. It kind of reminded me of...what's that Greek myth with the guy who has to be thirsty for eternity, and every time he reaches down to get a drink of water from the pond he's standing in, the water line recedes? Oh right: Tantalus. It was like that. I knew exactly what I would have to do to stop my own child from freaking out in pain, and I had absolutely no means nor authority to do it. Again I say: torture.

Anyway, they at least did the pulpotomy (which, despite it all, I'm glad they did--still remains to be seen if there was an abscess but it was at least pre-abscess stage), and he has a temporary filling in place. The rest of the dental work, which consists of the permanent crown and two smaller fillings, will be completed with a Pediatric Anesthesiologist and IV sedation. And of that I am grateful. Cal seems to have recovered nicely from the experience and is running around as we speak (I started pushing Motrin basically the second he was out of the chair and will continue it round the clock for at least 24 hours, in an attempt to at least tamp down the inflammation to a low roar) but I will need some counseling for the PTSD. Parents of chronically ill kids, I don't know how you get through it all.

Anyway, after we left the dentist, I kept Cal out from school for the rest of the day (it was already noon, so whatever), and then took him to the toy store with basically blank check privileges to get whatever damn thing he wanted. And I don't care how overpriced it was. (Though: Playmobil, you are overpriced! OK, now I said it. I'm good.)




We'll be back at the dentist in a month and a half to finish the job with an actual anesthesiologist on hand. Anesthesia saves the day again, I guess.

21 comments:

  1. As a child who went through MANY painful dental ordeals.. I am glad that for his next one it will be don with better meds on board! Your first instincts were right, when you wanted it done wtih more than NO. Glad he is more or less back to normal now though :)

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  2. JESUS FREAKING CHRIST!! Why couldn't they at least have given him more Novocaine? Tooth pain it the absolute WORST.

    I'm glad he's ok now....

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  3. Regarding anesthesia saving the day: Here, Here Sister ! Clearly, the block was sub -total :( Glad the next go round will be handled by professionals.

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  4. as a dentist, i can safely say treating paediatric patients is one of the hardest things to do. local anaesthetic with inflammed pulps are touch and go even in adults let alone children. You cant always give more novocaine as there is a max dosage for children before the anaesthetic can start causing side effects (like death...). Don't blame the dentist for the unpredictability of human anatomy esp as they are paediatric dentists and are highly trained professionals.

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  5. No blame at all, I just think that a pulpotomy and crown in a five year-old probably warrants more anesthesia than in an adult patient, and even a pretty reasonable and compliant five year-old is still, you know, five years old.

    Also, totally agree about the inflammation. I tried to do an infected AV graft revision under local once (granted, the patient was really, really compromised, so I had my reasons for wanting to avoid general anesthesia at all costs), and I learned all to well about how pKa in infected tissue can adversely affect the effectiveness of local anesthetics.

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  6. And I realize I just referenced "pKa" in my own blog comments. Officially the nerdiest blog on the internet!

    Thanks for the input, Jean. Pediatrics is a tough gig, to be sure. I've lived it myself.

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  7. Anonymous7:50 PM

    Perhaps Cal grinds his teeth at night.

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  8. Brooke11:27 PM

    Not that this is in any way comparable, but my son is 4 and autistic, and dental procedures are always terrible. He had to have a filling not too long ago, and they used PO midazolam and nitrous. The midazolam made ALL the difference. He is very skittish at dentist's office, even for routine cleanings. All he says once we get there is "want to get in mommy's car" over and over while fighting back tears and shaking. Which, of course, causes me to fight back tears and shake, because he's just so darn SCARED. Once the midazolam took effect (in about 10 minutes), he was Mr. Chill.

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  9. My daughter had a filling and molar extraction at age five using just local and nitrous. She was totally fine until the extraction. In her case I think it was the weird numbed-out wrenching sensation more than dissipating anesthetic. Now, a year later, she needs another extraction and is adamantly opposed to going to the dentist. Her dentist does not believe in using force, a policy I fully support. So we're at a stalemate. I'm not normally one for bribery but in this case I'm issuing the blank check, up to and including allowing her to dye her hair hot pink.

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  10. Lisa C.5:10 AM

    I'm hard to numb even as an adult, and I've had some terrible dental experiences as a result. I have now learned the key... Valium, and lots of it. It makes the experience completely different.

    I'm glad Cal has recovered, and I've been the parent trying to comfort a kid during a painful medical procedure.... it sucks, for all parties, to say the least.

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  11. That is horrible! Tooth pain is scary because its so unusual.

    The last time I went to the dentist it was a fancy office and they gave me hooked me up to the gas, plus headphones, a movie and massaging chair. I was sooooo relaxed. Then 30 min later realized I was still sitting there grinning with a mask on and opp! Guess I was not supposed to have sooo much gas. Oh well, I had a FUN afternoon plus got my tooth fixed.

    It sucks you could not just bring in your own rx and take care of him yourself.

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  12. Anonymous8:08 PM

    I mean this with a lot of love.

    As a dental student (sorry, ain't got the credentials like the poster above), you can't always attribute the success of anaesthesia to the skill/professional level of the person adminstrating it. Like Jean said, the complex anatomy of structures around the tooth may lead to unpredictable results. In fact, we often don't know how each patient would respond exactly unless we have a history of it documented.

    You simply can't just load the patient (especially a child) with more lidocaine or insert med of choice. These people know what they are doing, especially if they are paedo specialists - they know how kids are and their need for sedation/anaesthesia. I have a lot of respect for pediatric specialists. You take your kid to see your family MD for some flu shot. The worst is over before anyone knows it and they are out the door. After giving the LA or what have you, it's only the beginning for the pediatric dentist. Not only that, they often have to juggle the kid AND the parents at the same time.

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  13. Anonymous8:25 PM

    Oh and to add, anaesthesiology is a pretty significant field in dentistry, due to obvious reasons. The pediatric anesthesiologist may be an anaesthesia specialist (DDS), though I don't know how it is at your neck of the woods.

    If I'm wrong at any of the above, I'm sorry. You are the anaesthesiologist, not me. But it irks me a little to see the profession misunderstood/not understood fully - again, not by you, but by the general public. (I personally blame it on the professional governing bodies but that's another topic for another crowd on another day). Anyway, love your blog. Please update often!

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  14. Anonymous11:32 PM

    Poor Cal! I am glad he is okay. My kids are so uncomfortable at the dentist that they had to have nitrous to have sealants put on their molars.

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  15. Hey dentists, I have no animus towards your profession! I just meant that there are certain anesthetic agents that would have worked well in this case (and in fact I gave anesthesia for a good number of pediatric dental cases while in training) that usually you can't get without an anesthesiologist. But I'm not blaming the dentist, he did a good job, and kept his focus on the most important thing, which was to get in and out safely.

    I occasionally provide anesthesia for colonoscopies and endoscopies. That said, the majority of these procedures at the hospital are routinely done under "conscious sedation" (something of a misnomer, but that's a story for another day) provided by the gastroenterologist or other non-anesthesia professional--usually a combination of an IV benzo and a narcotic--and most patients do fine with that. However, oftentimes the patients that make their way to anesthesia services for endoscopies are people who "failed prior sedation," meaning they tried having "conscious sedation" in the past and were either difficult to sedate, too uncomfortable despite the medications they were offered, or they have some sort of medical issue requiring a higher level of monitoring and attention. Does that mean I think that the gastroenterologists are at fault somehow for not doing a good enough job sedating or caring for them? Absolutely not. In fact, I give them a big thumbs up for recognizing when patients require a higher level of anesthesia than they are trained to provide. Knowing when to refer a patient to anesthesia can be the better part of valor, and the patients have a much better experience as well.

    Anyway, dentistry. A goodly field. Thanks for helping my kid.

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  16. Anonymous9:59 AM

    My son had to get a few VCUGs done between the ages of 6 & 9. Picture: multiple catheters in multiple openings, filling bladder, measuring kidney pressure and imaging as he was instructed to eliminate on command. Sedation or even relaxation was not possible to successfully do the test. It was horrible. God Bless the child life therapists in the world. The first vcug failed--the second one worked. Problem: huge bladder diverticulum Solution: Surgery. after a while the chronic kids get jaded. It is tough. Everyone thank a child life therapist today!!!

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  17. I have to agree entirely about the ability to freeze infected teeth and the doses for pediatric patients (though, as the anesthesiologist/parent, I might have been saying... "just try a higher dose! I'll resuscitate him if he seizes or has a cardiac arrest - at the moment that would be preferable to the torture of watching you hold him down!")

    Anyway - I get what you are saying and as both an anesthesiologist and a mother, you have loads of sympathy from me. So glad to hear that the next visits will be with a pediatric anesthesiologist. We do lots of peds dentals in the OR here - mostly kids under 5, but for an infected pulpotomy, I don't think a GA would have been overkill.

    Aside: I love the word 'suboptimal' - my current favourite term for all failed epidurals. As in, "I am sorry your epidural is suboptimal, would you like to switch to PCA?"

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