Monday, April 13, 2015

A Big Deal

Several years ago The Dental Amazon Empress took me to the Annual Meeting of the American Dental Association.  I must confess that despite over thirty years of medical school, residency, and clinical practice, I truly have no idea what dentists actually do. It certainly hasn't helped my knowledge base that I'm also terrified of dentists, so there was no way someone like me was ever going to become fast friends with Penelope Pick and Doris Drill and Linda the Especially Long Needle and Tabitha the Gritty Toothpaste.  (Speaking of Tabitha, I've come to understand that it's gritty because it has abrasives in it, like little piece of rocks, which is why the ancient Egyptians had rotten teeth because they wound up with sand in their bread.  Which begs the question of why we now use high-speed sanders to make sure the grit gets a chance to erode EVERY SINGLE SURFACE of your teeth while we listen to that constant RRRRRRRRRRR sound and savor the flavor of the dentifrice which tastes like you always thought a toilet cake might when the bully threatened you in the grade school restroom.  Which is why I went dry the entire fourth grade.

Being an ER doc, it's not that I'm a stranger to things like needles and knives and plastic tubes of varying sizes and shapes; and I'm certainly not adverse to their use on anyone but me.  That being said, nothing could have prepared me to browse past the displays of dental instruments for sale.  Wooden and metal tool boxes full of chisels and clamps and pliers and picks and saws and spackle guns.  And all of them sharp.  Bowel and bladder control was increasingly difficult the deeper I got into the exhibit hall.  Even the textbook vendors were parties to the terror.  When you look at the cover of a medical book, it's usually some embossed words letters upon a plain cloth cover.  (An example would be "Smith's Guide to Intra-articular Ant Farms, 3rd Edition," with perhaps the word "New and Revised" in italics because everyone knows the literature has been rife with developments in the diagnosis and treatment of intra-articular ant farms since the last go-round.  See page 483, "Call Uncle Milton.")  However, dental books have cover photos of sharp edged pliers pulling decayed teeth from gaping bloody holes in skulls, with the titles usually printed in red so you have to hunt down the letters in the sanguine field.  And if that's not creepy enough, to demonstrate products they have these plastic disembodied mouths...not heads, just mouths...connected to freshwater pipes where you can sit and practice using your spikes and picks and drills and gouges and pliers and bone splitters in the ultimate test drive in these plastic orifi gazing skyward, just asking to be violated.  (Given that this was in New Orleans, you can take that any way you wish.)

I found myself especially interested in the chairs, but not those cushy ones that move every direction from here to Cleveland and present the illusion of comfort though a closer inspection reveals attachment points for straps and clamps.  No, I was looking at the chairs the dentists have to sit in.  To be fair, I had never even contemplated the comfort of the dentist, so wrapped up was I in my own terror, which was selfish of me.  I really should have been considering the welfare of that health care professional who was about to put power tools in my head. I did not realizethat dentists often suffer from chronic neck and back problems from having to position themselves all day at odd heights and angles, and to hold still for what must seem like epochs while doing delicate procedures.  And I also realized that it was now, as it never had been before,  in my best interest to think of these things, because if the The Empress came home one night aching and tired on a day I was off, I should probably not respond to her distress with acompetitive, "Oh, yeah?  Well, I only got in a three hour nap, not four like I planned, AND my afternoon cocktail by the pool was ruined because we were out of the good vodka and I had to use that cheap stuff instead.

So the thought of dental backaches is percolating through my mind as The Empress and I stroll up Canal Street later that evening.  A rather large individual waddles past us on the sidewalk in the other direction, knocking us off our route by the expanse of their…ummm…personality.  I hear her sigh.  “Lean over that for an hour and hurt for a week.”  Which is how I learned that the pannus has become a scourge of the dental world.

A pannus, you say?  What's a pannus?  The word pannus was not part of my training twenty-five years ago. Due to the expanding American waistline, it's now everyday vocabulary.  A pannus, briefly put, is that belly fat that overhangs the lower abdomen and all parts nether and below in the morbidly obese.  The Pillsbury Dough Boy, while pleasingly plump, does not have a pannus. Santa Claus...and bless his heart, he can't help it, he only gets out once a year and offsets that one day of exercise with Lord knows how many cookies...does. Some people are so big they have more than one.  There is no official medical word I know of for multiple pannuses, so let's call them pannini.  I've also independently determined that the possessor of a pannus is a pannerian; a pannerian from the United States, Canada, or Mexico in known as a PanAmerican.  (Thanks.  I'll be here all week.)

So I'm trying to work out how a dentist deals with a pannus, and I'm not going to ask the Amazon Empress because if she tells me, I'll know that at some point in her professional life some part of her has encountered one, and as much as I care for her there are some things about her I just don't want to know, like if any part of her ever touched a pannus, whether by accident or intent.  I figure you have to lay the chair down almost flat, move as far up to the head as you can but you still have to navigate around those huge arms and neck rolls. No wonder dentists wind up with bad backs.  But it you bring the patient too far back and lower the head so you can work on them sitting near the crown of the scalp to avoid the neck and arms, you run the risk of the pannus flipping over and whatever's been hiding under that fold tumbles onto your freshly laid carpet.  (And you don't want whatever's been hiding under there.  I can personally attest to finding a ham sandwich.  No, you don't want to know.)

Because of the increasing number of Larger Americans, it's not uncommon for me to see folks with pannini in the ER.  I had a three-folder in the other day.  She quite literally weighed close to a quarter ton and had two major complaints.  One was that she had gained 10 pounds in the last three days and wanted to know why.  The other was that she said she couldn't eat.

There are three ways to handle a scenario like this:

1) You can be forthright and honest.  "You weigh a quarter of a ton.  You can eat. You've proven it.  And as for gaining ten the hell would you even know?"

2)  You can look thoughtful and empathize.  "I understand how weight can be deceiving. When you're a larger person such as yourself, common household scales often have trouble with accurate readings.  We'll do some lab tests to make sure your weight gain isn't related to fluid retention or some other medical condition.  We'll also check to insure that your lack of appetite hasn't made you dehydrated or malnourished.  If everything looks good, we can probably let you follow up with your doctor.  I'm sure your own doctor who knows you best will do a great job of sorting out your problems, much better than we can do here in the ER."

3)  You stifle a laugh behind a grimace, roll your eyes while standing behind the patient listening to the lungs so they can't see, move to the pat their least I think it's an ankle, it might be a hock...leave the room as quickly as possible, walk twenty feet away onto a tiled floor, and drop a tray of instruments so no one can hear you say "WTF?"

Because I am an exemplary physician (or at least act like one, my Academy Award for Best Supporting Doctor in a Caring Role standing proudly on my mantelpiece).  I prefer a mixed approach.  I will begin by providing thoughtful counsel and a promise that we will, to the best of our ability, alleviate her concerns that she may have an emergency medical condition.  Then when I realize I have not reassuringly patted the ankle, but the tip of a similarly descended breast (the feel is no different, but the widening smile and dreamy sighs cannot be mistaken), I go immediately to option three, but rather than simply using the acronym I painstakingly articulate every syllable contained within the phrase as I immerse my hands in a tsunami of bactericidal foam.

We are still left with an acute clinical problem.  What's the best way to determine if the patient is able to eat or not?

I am a great believer in the power of donuts.  I am certain that the root cause of most pain in the morbidly obese is donopenia, which is a lack of active donut molecules in the body.  I think that if you told these folks that I could make your poundage-provoked pain go away forever with diet and exercise, or I could make you feel better right now with a doughnut, the vast majority (pun intended) would opt for the little fried ring.  I also believe that if offered morphine or doughnuts, most patients would find more relief from the latter.  It's only because you can't do a double-blind experiment...for there is no placebo for a doughnut...that my theory remains unexplored.

(I also have great faith in the power of bears.  I have a Bear Theory of Pain Control.  There is a lot of focus now on pain as a "vital sign," and any number of scales have been devised to assess pain.  All of them are subjective, and all of then are total crap.  But I do like the ones where 10/10 means the pain is so bad you're unconscious.  So if you come to the ER and tell me your pain is10/10 or greater...something you need to be conscious to do...I will ask you if your pain is worse than being mauled by a bear.  If you say yes, I will bring a bear into the room, liberally apply a slave of salmon paste and honey, and see what happens.  If your original pain is still 10/10 after being mauled by the bear, I will then, and only then, actually believe you and give you a narcotic.)

This patient offered another opportunity to explore the clinical use of the doughnut.  When you have a patient who says they can't eat or drink, it's incumbent upon the physician to address this before discharging the patient home.  Feeding and watering the patient is called a "PO challenge." (PO is for the latin "per oris," or "pie 'ole.")  This is actually one of the very few rules in emergency medicine.  If someone can normally eat, drink, walk, and talk before they get to the ER, you'd better have a good reason if they go home unable to do so.  Making certain that someone can keep down some fluids, and possibly the ubiquitous ER turkey sandwich as well, is actually a critical point in clinical disposition.

So we thought that what we could do is give the patient a doughnut.  If they can eat the donut, then they will be able to keep themselves fed and watered at home.  And what better place to put the doughnut than on top of the pannus.  It's a large, flat surface that is easily accessible to the patient, even when recumbent and at rest.  We were so delighted by our Eureka moment that we broke out into song:

There's a doughnut on your pannus.  Eat it now.
There's a doughnut on your pannus.  Eat it now
There's a doughnut on your pannus.
It can be your PO challenge.
There's a doughnut on your pannus. Eat it now.

(Sung to the tune of "She'll Be Coming Round The Mountain")

 This song caught fire in the ED, and now it's close to the top of Our Hit Parade (#1 this week:  "We Are Never Never Ever Giving You Drugs in the ER" by  Michael Barton.)  But like most clinical advancements, more questions arise.  Which doughnut works best?  (Answer:  Hostess Donettes.  Small, convenient, each package contains six tests, and your patronage supports the economically crucial plastic snack cake industry).  And if the doughnut is indeed gone, how do you know the patient ate it and it did not roll on the floor?  (Answer:  Powdered sugar leaves a trail).

Science marches on.

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