grand canal

I went to bed last night with the start of an ache in one of my upper right molars.  Nothing terrible, but it got worse overnight, occasionally waking me up from sleep, to the point that I realized that I might need to go in to the dentist post-call on Thursday in order to get it looked at.

By early this afternoon, the pain was, shall we say, exquisite.  It was like a ball of flaming nails inside my head.  It hurt so much I couldn't even think straight.  And I knew I was to be on call all day tomorrow, in a job that requires above all that I can think critically and pay attention and be able to make big decisions in a split second without being distracted by the fact that my mouth felt like it was going to freaking explode.  It could not wait another two days.  So after work, I made an emergency appointment with my dentist, and soaked a gauze pad with lidocaine to mash on my gum over the tooth.  (Pathetic topical attempt though it was, it kind of worked, enough for me to drive to the dentist's office anyway.)   My dentist, who very nicely carved out a spot for me in his schedule, took one look at my tooth, took one look at me, and promptly did a root canal.

So, that was my afternoon.  Well, that, and the fact that I found out, while I was in the dentist chair waiting for the calcium hydroxide (or whatever that stuff is that they use) to exercise its bacteriocidal action on the inner workings of my molar, that my response to Dr. Sibert's Op-Ed in the Times this Saturday was quoted in The Wall Street Journal online.  So I guess this day wasn't all bad.

on being "that parent"

Perhaps this is an overly strong sense of introspection on my part, but reflecting back on our dental experiences of late, I wondered if I was being "that parent;" that is to say, the kind of parent that, as a former peds resident, I dreaded. You know...THAT PARENT. One thing that I appreciate now (that I didn't appreciate when I was a peds resident, because I didn't have kids yet) was that the many of the parents that I found difficult to deal with were simply tireless advocates for their children, parents who had been around the block enough times that they realized how fallible the medical system and the people behind it really are, and as such felt the need--or perhaps to obligation--to push and prod and question every single move. As residents, people still growing into the notion that we truly belonged in those white coats, this advocacy from parents tended to rub us the wrong way. There's nothing that exposes the naked insecurity in a young doctor more than a patient (or the parent of a patient) questioning whether or not we really knew what we were doing. Do I know what I'm doing? Of course I know what I'm doing! I went to medical school! See this nametag? Says "MD" on it right here! M fucking D! Now let me go hide in a corner and consult my Harriet Lane obsessively.

Cal's doing really well, by the way. He rested on the couch after his dental appointment, took a long nap that afternoon, and since that time has been basically back to normal, with the exception of a puffy lower lip where, I think, some instruments were positioned. His gum abscess looks much, much better, and we're just going to finish out the antibiotic course for the rest of the week (as counseled by our dentist) and then return to business as usual. I did have a slight fear that our dentist would be somehow annoyed at us ("Ugh, those parents!") for starting the antibiotics in the first place, or for overstepping our bounds in some way, but since he basically told us, "Thank god you didn't wait to start him on that Augmentin" in so many words, I'm a little less concerned at being perceived as a practitioner's worst nightmare--that is to say, overly protective parents with a key to the apothecary.

I also don't know why I'm so worried about perception when it comes to me and my level of participation in my own children's medical care. The few times that I haven't spoken up in a clinical setting with my kids in an effort to be polite and unobtrusive, I've regretted it. Is my desire to be a "good patient" at odds with my efforts to be a "good parent"? Are they necessarily mutually exclusive? Part of me feels like the answer is yes: I recognize the inherent hypocrisy but I know there's nothing that a doctor loves more than a patient that just nods and says yes and defers to your every decision. We've thankfully been very lucky in that our interfaces with the medical community have been brief and goal-oriented, and we've never disagreed with any of the medical decisions that our practitioners have made, but it certainly makes me think about where the boundaries are when you are both the medical practitioner and the parent. Anyone have any insight? Where do you draw the line? For example, I personally would never administer anesthesia to a family member or someone I was close to--I think emotion gets in the way of clear-headedness. But outside of the OR, I'm still not really sure.

Anyway this entry is starting to meander and it's a school night so I'll just close with this last: I am not above using toys to defray trauma from endured unpleasantness, and this latest visit to the dentist office was no exception.




It's Cal's first Lego set. I know a lot of kids play with Legos, and it's not like he's some kind of prodigy or anything, but I really was impressed with his ability to assemble these, because some of the pieces are very, very small, and there is a fair level of complexity to these designs. (He just followed the instructions that came with the box, not like he synthesized them from scratch, but with minimal adult assistance--I just came back in the room after an hour and there they were.) I think it's going to be a Very Lego Christmas around here.

so about that root canal




I noticed about a week ago that the gumline around Cal's tooth, the one that was halfway fixed (hardwon pulpotomy without a crown) was looking a little friable and red. Actually, to be quite frank, it was bleeding. Bleeding Gums Murphy, he was. It was also a little tender, and when I felt it, it was kind of boggy and bubbled out from the toothline. Fearing abscess and just a mere eight days away from when we were scheduled to go back into the dentist to finish our dental work under IV sedation, I asked Joe to pick up some Augmentin on the way home from work (one of the benefits to being and/or marrying a doctor is that you can have your spouse pick up prescription medication on the way home from work as you would for a eggs or milk) and had Cal on an twice daily schedule of antibiotics to try to minimize the chance that whatever it was would progress to some bigger problem.

Funny how your fears are totally steered by your area of expertise--Joe, being a facial surgeon, was worried about osteomyelitis of the jaw. I was more worried about a rapidly growing trachea-displacing abscess. (I've had to do a couple of cases with airway-threatening dental abscesses, and the lesson I have learned from these are that the human mouth is an absolutely disgusting cesspool. Almost makes one wish they had chosen a different specialty.) Anyway, when we got to the dentist this morning, we told the dentist what we saw and what we'd done (the gum swelling was much better already), and even though we were worried that the week of antibiotics would mask any worse signs of infection and possibly cloud the picture for Cal's definitive treatment, apparently what the dentist saw inside was enough for him to opt for this:




The definitive definitive treatment. (Also shown in the picture above, evidence that I wash my hands too much. FOR WORK HYGIENE, not for the crazy.)

So anyway, the dentist said that Cal definitely had an abscess forming up in there, he's glad that we'd already had him on antibiotics for a week, and feels that we should continue on them for another seven to ten days. I'm not thrilled that Cal's tooth was bad enough to require extraction, but glad that at least we took what in my mind was probably the safer and more conservative approach, as opposed to capping the abscessed tooth and then ultimately needing to extract it anyway. We had anesthesia there, might as well get it done and cleaned out and end ToothWatch 2010: Will it or Won't it?

We still need to go back and get Cal fitted for a spacer, because apparently when his six-year molars come in all his teeth are going to get pushed around and that gap is going to screw up the orientation of all his tooth parts (DENTAL TALK! I love it!) but in theory that should not be painful and we still have a little time before that needs to get done, so we can...just think about that another day. (Even with the wonders of anesthesia, Cal has requested that we never ever take him back to "that place"--I for one plan to dodge the subject for as long as possible.) So right now, let's concentrate on the fact that it looks like the Tooth Fairy's going to be visiting our house a little earlier than we expected.

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.

teeth: the cause of, and solution to, all life's problems

So Cal needs a root canal.

The dentist calls it a "pulpotomy and a baby cap," but I figure anything that involves drilling and reaming out of pulp and covering with a little tooth hat sounds close enough to a root canal to me. I'm not sure how it quite got this far--I mean, we don't have the Sonicare toothbrush and a water pick, but we do, you know, brush his teeth twice a day and all try not to pack his molars with caramels or anything. But a few weeks ago Cal started complaining that one of his back teeth was hurting and I took him to the dentist and now here we are.




Cal has not notoriously been great with doctors (I blame poetic justice) but now that he's five and is at least approaching the age of reason, some combination of preparation and rationalization will temper the flight-or-flight response that typically characterized his medical interactions between the ages of two and four-and-a-half. Meaning he understands the need for doctors (occasionally) and will even comply with their exams, but when the pointy things start coming out, may the good lord help us all. Which is why I'm not really feeling great about the prospect of this root canal.




However, we're going to a pediatric dentist, and that helps immensely. Not only are they much more accustomed to dealing with kids (dur) but they have all sorts of enticements and incentives to get the kids to comply with their picking and drilling. I counted a total of four giant flat screen TVs playing all Pixar all the time, and that along with the embarrassment of riches that was the reward rack. (Strangely, the "treat" that captivated Cal the most was the new toothbrush and mini toothpaste, though certainly there were stickers and erasers and other tchotchkes that I'm still finding underfoot.) They made sure his first visit was a benign one, with just a tooth cleaning and X-rays, but obviously the next time we go we're going to have to Get Down To Business and I'm just not sure how that's going to fly.

However, to his (and their) credit, Cal did tremendously well the last time we were there (see the above picture, and his feigned nonchalance with the hand behind his head), and they say they use a little low-grade nitrous for sedation, at least during the local injection, so that's as much as I could ask for, I suppose. Actually, what I would ask for would be a pediatric anesthesiologist and a propofol infusion, but I will take what I can get.

60 posts in 60 days, day 8: teeth!