Red Flags and Alarm Bell Scenarios – IC024

Listen to that voice inside your head! We all get those clues and a bad feeling in your gut when you see a red flag patient. The challenge is being receptive to this feeling and acting upon it tactfully. I share 2 examples of encounters where I either ignored the alarm bells, and 1 scenario recently where I avoided a disaster.

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Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

  • 1:34 ‘Alarm Bells Scenarios’
  • 2:20 Case No. 1 (Extraction on a 78-year-old patient)
  • 7:47 Case No.2 (Heat Burn on Patient’s inner cheek/lip)
  • 9:20 Warning Signs

If you loved this episode, you will like 12 Rules for Dentistry 

Click below for full episode transcript:

Opening Snippet: Hello, Protruserati. I'm Jaz Gulati and welcome to one of my ramblings, okay? We're gonna do this as an interference cast. And I'm gonna teach you a few lessons that I've learned before, I guess I've learned them in very traumatic ways.

Jaz’s Introduction:
When you make mistake and think, Wow, I never want to make this mistake ever again. And then you want to share it with everyone so that it helps others too.

So the theme of today’s rambling is the following. It’s about listening to that voice that we all have inside of us, during a consultation or during a patient interaction, you know that deafening sound of alarm bells you sometimes get. And yet, for some stupid reason, you might decide to ignore it. Well, today, guys, I’m happy to report that I didn’t fall for it. I heard those bells, loud and clear. And I acted appropriately, and I dodged a bullet. Okay, let me give you the exact example.

And in fact, I am going to liken this example to a really significant thing, which I picked up from a book, like one of my favorite books is Outliers by the author Malcolm Gladwell, if you haven’t read Outliers yet, please check it out. It is my all-time favorite book. And I think it’s in chapter seven, where it discusses why aeroplanes fall. It’s a random divergence, I know, but hear me out. Aeroplanes fall not because the engine has an error. And that’s it. And that’s why airplanes fall and that could happen. That’s rare.

‘Alarm Bells Scenarios’
Airplanes actually fall, when they do fall, when there’s an issue, a big problems do happen in aviation when lots of little things, lots of minor things that all happen at once. And they usually surrounding communication, and teamwork so it’s accumulation of all those minor errors that would result in it. So for example, the pilot was hung over, right? That’s one thing, right? And then the pilot was working with a co-pilot, and they’ve never worked together before, okay? And the guy who was supposed to do the final checks on the aircraft vehicle, had COVID or something, and he couldn’t come into work that day. And therefore, all of those little things combined and bad weather that day, is the reason that the airplane fell not because of one big error, it’s accumulation of little errors.

Main Episode:
So what lessons can we learn in dentistry? Well, think of those little errors lining up in your patient in front of you. So let me give an example.

Case No. 1 (Extraction on a 78-year-old patient)
I saw a 78 year old patient today who was referred to me for some surgical extractions, okay? Age doesn’t bother me too much. Yes, we know sometimes it can be more difficult to extract and we need to take care, but it’s a medical history that really bothered me. So let me tell you the accumulation of minor errors. So error number one, there was no up to date medical history, it was last filled-in in 2019, okay? So I was like, oh, god dammit, why is this patient referred to me without a medical history?

Error number two, he comes in and I get an update of medical history from him. And he conveniently has forgotten his sort of long list of medications and he’s going by memory, okay, that’s another little alarm bell that I’m hearing in my head.

Error number three is that he was taking Apixaban, which is an anticoagulant, so it’s a blood thinner. So that is, for someone who’s doing surgical extractions of upper canines, and I’ll show you the X ray of these upper canines, long roots, but really mushy crowns, subgingival dentistry, I was planning, based on a radiograph I was planning already to raise a flap and remove some bone because I was anticipating a difficult extraction. So he’s on Apixaban.

And error number four is that he wasn’t instructed to miss his morning dose. So the usual way I would manage someone who’s on Apixaban, is that what we would instruct them if it’s safe to do so to skip their morning dose and see them first thing in the morning, so he had his morning dose already so that was increasing his bleeding risk.

Error number five, or complication number five is that this guy had a stent placed three months ago following a suspected heart attack, right. So that is also a real big concern, doing invasive treatment, and someone who only just three months ago, had a heart attack. Okay.

Error number five or six, I’ve lost count now. The next one is that he had, believe it or not, his toes amputated around about nine months ago and he had a major bleeding complication. So why did he have his toes amputated? It’s because he’s severely diabetic. And that’s a negative cinquante of that. So that was also ringing alarm bells that this person already had some surgery before and that didn’t go so well. There were some complications with bleeding.

And the final issue I had was that he was on lots of antihypertensive medicine. So his medical health, it was poor health combined with all other factors and I did not feel comfortable treating him today. And he wasn’t even in pain. It was just teeth that need to come out their, but he wasn’t in pain today. So I made the judgment call to refer to a hospital and explain to him all the things that were all the reasons and he took it really well. He noticed that okay, this guy really cares for me, I didn’t want to do anything risky.

So sometimes I’ve in the past, not weird, like extractions or whatever, sometimes are difficult extractions but taking on patients or cases or treatment plans that had all the signs there, when you look back, you can see that, hey, why did I ignore all those signs of the small errors? Why did I take this patient on when all the alarm bells were there? And sometimes you don’t listen to that voice. So it’s important to listen to that voice. And it’s a totally an acceptable thing to do to say to the patient that look, I don’t think we should proceed with this and justify why and stick to your guns, okay?

Now I’m going to admit to you another mistake that I had made around about a year ago, and I’m embarrassed about it, but I want to share it with you because it was a clear example of the many small accumulations of errors that resulted in my patient’s inner cheek getting burned, and a massive, painful ulcer or a significant burn that took a long time to heal.

Well, I say a long time was it was a week of me feeling really bad for the patient and the patients send me photos and it’s not nice. No, I’m really sad. And sorry that happened. In fact, she very kindly let me share the photo. So those who are watching, can see the photo now up there. That’s her cheek about two days later, in a lot of pain. That’s a nasty ulcer there. And I asked her I said can I please share this story with my colleagues so we can learn something here.

So let me tell you what happened and how I burnt this patient’s inner cheek. I was doing some routine composites in the lower quadrant I think it was like lower right second premolar DO composite, right? And I’m a big fan of using rubber dam especially for lowers, the tongues in the way, anything that’s, you know, deep caries subgingival etc. I’m all rubber dam, right? But the problem that we had this day is that my usual blue, non-latex rubber dam wasn’t there. We had that horrible green rubber dam and I really don’t like working that green rubber dam. I think I was just being a little bit of a diva. Okay, so my hands up in the air. My bad that was not a reason to not use rubber dam I guess.

But for me, on that day in the mood that I woke up in. I was like, No, I’m not going to use this rubber dam. This is disgusting. I don’t have my usual rubber dam. So yeah, I didn’t use rubber dam and 99% of time I do. So A) I wasn’t using rubber dam and then B) it was like stressful for me. So as someone who’s regularly using rubber dam, rubber dam reduces my stress, but now that I had no rubber dam, my stress was greatly increased.

2) It was subgingival. It was difficult dentistry. Okay, so that was stressful. Okay, 3) and this is something I really should have picked up on. The handpiece was making a funny sound. I didn’t think much of it was like, Oh, this sounds a little bit higher pitch. This doesn’t sound right. But I ignored that. And then I can’t believe I look back at now, I just felt as though the hand piece was warmer than usual, okay?

Case No.2 (Heat Burn on Patient’s inner cheek/lip)
Now the patient was anesthesized. And the patient didn’t feel any of this. But as I was doing her prep, the handpiece was actually burning her cheek. And then I realized that Woah, my gloves getting really hot here. Let me see what’s going on. And then once I finished my restoration at the end, I had a look at the cheek and I could see that it was a bit traumatized. And I realized what happened

So all those little error I didn’t pay attention to A) I didn’t use rubber dam. So that’s a small, you know, a small error. I anesthesized the patient so the patient can give me feedback, obviously. So that’s another alignment that not an error, but another reason why it happened. I didn’t pick it up. It was difficult dentistry. The handpiece was making a funny sound, and I did feel a bit warm and I didn’t stop to think why is this handpiece warm. So naturally I felt devastated. So how did I settle this?

Well, when I found out what happened? I made sure that I got I went on Amazon and I’ve got delivered a gift to a house So it wasn’t like flowers or anything. It was some Gengigel, right? So something that contains, I believe it contains hyaluronic acid. I might be wrong here but I know that Gengigel was good for soft tissue lesions. So I got some delivered as a gift to her house.

I was following up daily, I recommended some benzydamine hydrochloride or aka Difflam mouthwash and all those things and she got better, and actually ended up refunding of her money as well. I just felt so bad that I refunded her money of that restoration appointment because I felt like I let her down, right? I wasn’t acting in my best interest. And so I think she was quite pleased about that. And she thought I handled it really well as well. So that’s my admission to you that I burnt my patient’s cheek, and I’m not going to let it happen again.

Warning Signs
But it’s a time that I ignored the warning signs. But that first patient I told you about that as for today, I didn’t ignore all the warning signs. Another classic warning signs to find out things I sign off is another classic warning sign is that the patient has seen another dentist and the other dentist for whatever reason has declined to treat the patient for whatever reason. That is a massive red flag.

So I remember seeing a patient who saw a dentist I don’t know which dentists but she, the patient told me that, that dentist won’t treat me without orthodontics. That dentist thinks that I can only get a good result with orthodontics. And me being me a young dentist at the time, I’m still a young dentist, but like one or two years qualified, I was thinking well, I’ve been to few composite courses, I think we can do it composite.

And I look back and I think you know what, I do regret not sticking to what I should have done, which was yes, I should have agreed and recommended orthodontics because the result in the end wasn’t quite as wow and I do feel it could have been better with orthodontics. So anytime a patient says that I saw dentists X and the dentist X strongly believes that I should be treated this way. And you might disagree to that Dentist and that’s okay. But take that as an alarm bell. Take that as one of the alarm bells. And if you start to see all these alarm bells, sort of accumulate all these small errors if you’d like accumulate, then that could be why the aeroplane could fall.

Jaz’s Outro:
So I hope that was useful. And it’s a reminder for you in that consultation or at that moment in time that when you get that funny feeling in your stomach, don’t ignore it, act on it. There’s no shame and picking things up before they happen, before they go wrong in the best interest of your patient, and so that you have a smoother ride throughout treatment. Hope you enjoy that little quirky, little short episode. If you enjoyed it, please do leave a review on Spotify or Apple or YouTube or wherever you watch it. It means a lot to me. Thanks so much.

Hosted by
Jaz Gulati

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