The Case of the Dirty Dentist

English: Putting toothpaste on a toothbrush. T...

English: Putting toothpaste on a toothbrush. The toothpaste is Crest Pro-Health Clean Cinnamon, 0.454% stannous fluoride, 0.16% w/v fluoride ion. Deutsch: Zahnpasta auf eine Zahnbürste auftragen. Русский: Выдавливание зубной пасты из тюбика на зубную щётку (Photo credit: Wikipedia)

Most of us wouldn’t think twice before checking that our silverware is clean at a restaurant.  But, when we sit in the dentist’s chair nervously eying the tray of gleaming stainless-steel instruments laid out beside us, we don’t pick them up and make sure they’re clean. We rely on our dental professionals to sterilize anything going into our mouth. That reliance may be a mistake.

Last week the Board of Dentistry performed a surprise inspection of oral surgeon Dr. Scott Harrington‘s Oklahoma office and found numerous problems with sterilization of instruments. The good doctor’s response when questioned?

“Dr. Harrington referred to his staff regarding all sterilization and drug procedures in his office,” the complaint read. “He advised, ‘They take care of that. I don’t.'” His attitude seems to be that not infecting his patients with blood-borne diseases is someone else’s job.

Other issues that came to light during the inspection included the doctors reuse of needles, disregard of expiration dates (one bottle of morphine expired in 1993) and his use of unlicensed assistants to perform tasks only a licensed dentist should perform, such as giving IV sedation.

Now over 7000 patients will undergo  testing to see if they contracted hepatitis or HIV due to the oral surgeon’s noncompliance with basic infection control practices.  In the meantime, don’t be fooled into thinking this is an isolated problem caused by one errant doctor.  On March 22, 2013 the Rhode Island Board of Dentistry temporarily shut a practice down after finding debris on multiple instruments in ‘sterile’ packages in exam rooms. No word on whether that dentist took responsibility for his office practice.

But, speaking of responsibility, how much responsibility do patients have to protect themselves from healthcare acquired infections? People have been trained not to touch someone else’s blood unless they wear gloves. People are encouraged to use barrier devices, such as condoms, during sex to prevent STD’s. Should our public health officials start a campaign to encourage patients to protect themselves during invasive procedures such as dental procedures, colonoscopies, and injections? If so, how can that be accomplished?

Recent articles have suggested patients ask dentists to prove they’re following guidelines in the care and maintenance of sterilization machines.  They’ve also advised patients to request to inspect the instruments prior to being removed from their sterile packages.  Other tips are to watch the dentist’s glove use, look at the overall office cleanliness, and quiz the dentist and staff as to how they handle reusable instruments. All excellent points, but it also requires a level of doctor-patient transparency and discussion that’s not usually seen. More importantly, how is your dentist going to react to his judgement and cleanliness being questioned?

In my work in the healthcare field, even the idea of a patient (or another healthcare team member) questioning whether someone has washed their hands before patient contact is a source of controversy. In a Swiss study, 76% of patients felt uncomfortable asking a nurse if she’d washed her hands and 77% felt uncomfortable asking a physician the same question. If patients don’t feel comfortable asking a simple question like that, do we really expect them to ask complicated, technical questions about sterilization procedures? Asking for clean instruments should be as easy as asking for a new knife or fork at a restaurant when the one on the table is dirty, but it isn’t.

English: South China Sea (May 16, 2006) - Hosp...

English: South China Sea (May 16, 2006) – Hospital Corpsman Steffon Corna sets up dental tools for a tooth extraction in the Dental Department aboard the Nimitz-class aircraft carrier USS Abraham Lincoln (CVN 72). Lincoln and embarked Carrier Air Wing Two (CVW-2) are currently underway in the Western Pacific operating area. U.S. Navy photo by Photographer’s Mate Airman Apprentice Brandon C. Wilson (RELEASED) (Photo credit: Wikipedia)

Will I stop going to my dentist? No. Will I ask to inspect the instruments for debris before my next procedure or cleaning. Yes. Hopefully he’ll understand, but if he doesn’t, I’ll tell him I’m holding him to the same standards I’d hold a restaurant to. I’m sure he doesn’t like eating off dirty forks any more than I do.

 

 

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Can You Hear Me Now?

Vaseline Glass Bowl-Hat

Vaseline Glass Bowl-Hat (Photo credit: Paul Garland)

When I was younger, I thought wearing glasses was the biggest humiliation I would have to suffer. Without glasses I can’t see the computer screen I’m sitting in front of, but glasses have a downside. In cold New England a walk from the chilly outside to toasty inside results in a thick layer of condensation that renders glasses wearers temporarily blind. In the summer, going from air conditioning to humidity does the same thing. Aquatic endeavors require a decision to either see what’s going on (my preference in a lake) or swim blind (my preference in the ocean. I believe if I don’t see the shark, it won’t see me).

PhotonQ-Under the Shark

PhotonQ-Under the Shark (Photo credit: PhOtOnQuAnTiQuE)

I’ve made my peace with wearing glasses, but now I’m confronted by a problem many of my fellow baby boomers are also facing,  hearing loss. Yes, we didn’t wear helmets when we biked/skied/played sports and we didn’t wear hearing protection when we shot guns, listened to our Walkmans at full blast, or spent time in noisy environments. Our youthful ignorance of the damage caused by loud noises has led to an explosion in the number of baby boomers with hearing loss.

The National Institute for Health reports that 18% of adults in the 45-64 year old category, have hearing loss. The percentage of Americans with hearing loss increases in the 65-74 year old group to 30%, and for adults over 75, a whopping 47% of them are struggling to hear.

How many of those hearing impaired people are wearing hearing aids? Less than 15 percent. There’s a lot of people out there who have no idea what you’re saying.

Seems like a minor problem until you read the early studies that indicate adults with hearing loss are 3 to 5 times more likely to develop dementia than those with normal hearing.

Scary.

So why don’t we embrace hearing aids in an attempt to increase our thinking skills and ward off dementia (as well as not blowing out the volume controls on the TV)?

Hearing aid

Hearing aid (Photo credit: Soitiki)

Maybe it’s because hearing aids are equated with old people and we’re a nation dedicated to never growing old.  Not all of us can afford facelifts, botox, or tummy tucks, but we can dye our hair, buy anti-wrinkle cream, and pretend we can still hear.

And most people don’t know how much sound they’re missing. When I trialed hearing aids, I couldn’t believe what a noisy house I lived in. The refrigerator cycled on and off, the dryer had a strange squeak, and with the windows open I could hear my neighbor’s children playing outside. All sounds that hadn’t existed for me before the hearing aids.

I wanted to turn the volume down.

But without hearing aids I struggle to carry on a conversation in certain decibel ranges. I lean in closer and keep a semi smile on my face because I’m not sure if the correct response is to laugh or to  cry. Most of the time I can piece together what’s being said through context, but once in a while I can’t. It’s embarrassing when someone asks me a question and I don’t understand enough words to even guess what they’re saying. It’s like suddenly I’m hearing a foreign language and my ears can’t process it.

As easy as it is to downplay hearing loss or make a joke about it, the sad truth is that it has a profound effect on quality of life and, it seems, the risk of dementia. Maybe instead of being fixated with the idea that wearing hearing aids makes us old, we should think about all of the sounds we miss without them. If it’s a choice between hearing my daughter whisper “I love you” as she leaves the house or looking and feeling old, I think I’m going to choose to hear.

There’s only a finite number of “I love you’s” we’re privileged to hear and I’d like to hear every single one of them.

Who Gets to Decide to Withhold CPR?

I’m not sure what I’d do if a patient collapsed in front of me and the administrator said, “No CPR. It’s our policy.” Since I’ve been a nurse, I’ve heard of slow codes, where the unspoken agreement is that if the person stops breathing the staff will purposely react as slowly as possible to give the person a chance to die, but I’ve never participated in one. The decision to either be resuscitated or be a DNR (do not resuscitate) is a personal one and the slow code takes that decision away from the individual. That goes against my philosophy of nursing.

English: CPR training

English: CPR training (Photo credit: Wikipedia)

Today’s news involves a nurse who did, in fact, stand by and refuse to do CPR when a patient went down. The facts seem simple. A woman collapsed in the dining room of an independent living facility. A nurse called 911 to report the incident. The 911 dispatcher asked the nurse to start CPR. The nurse refused, stating it was against company policy.

The 911 dispatcher didn’t give up. She asked the nurse to find someone who would start CPR, asking “Is there anybody that’s willing to help this lady and not let her die?” Again the nurse said no. The dispatcher continued to plead, as if the provision of CPR was the only surefire way to prevent this woman’s death.

Seven minutes 16 seconds later, emergency personnel arrived. The woman had no pulse and was not breathing. They started CPR.  The 87-year-old woman was declared dead at the hospital.

This has upset a lot of people. Upset some to the point that the police are trying to figure out if they can charge the nurse with a crime. The belief is that CPR would have saved this woman and the absence of CPR caused her death, and that’s not entirely correct.

According to Dr. Robert Shmerling in a post entitled, CPR: Less Effective Than You Might Think

“As opposed to many medical myths, researchers have reliable data concerning the success rates of CPR (without the use of automatic defibrillators) in a variety of settings:

  • 2% to 30% effectiveness when administered outside of the hospital
  • 6% to 15% for hospitalized patients
  • Less than 5% for elderly victims with multiple medical problems”

Another study that looked at out of hospital cardiac arrests found that successful resuscitation decreased with age. 40 and 50 year olds had a 10% chance of a successful resuscitation while patients over 80 only had a 3.3% survival rate.

No magic bullets here. There is no guarantee that CPR would have prevented this woman’s death. If she’d survived, there’s no guarantee of the quality of life she’d enjoy afterwards.

In this case, the independent living facility (not assisted living, not a nursing home, not a rehabilitation unit) maintains the residents are advised that in the event of a medical emergency staff members will call emergency services, but not provide CPR.  Employees are told the same thing.

The dead woman’s daughter said, “I don’t believe if CPR were done it would’ve helped or changed the result. This is not about my mother or me, this is about the policy of the facility, and we understood the policy, and I agree with what was done.”

Which brings me back to the original question. If the woman collapsed in front of me and, as a condition of living in the facility she’d agreed the staff wouldn’t perform CPR, would I have stood by and done nothing? With an underlying belief that the patient gets to make the decisions, I very well might have.

Not Dealing with Dementia

 

June and Ward Cleaver (Barbara Billingsley and...

June and Ward Cleaver (Barbara Billingsley and Hugh Beaumont). (Photo credit: Wikipedia)

Television moms and dads are kind, generous, clean, independent, and a source of wisdom. Real life moms and dads can be mean, self-centered, critical, and looking for a handout.  Such is the cards some children are dealt.

 

Dementia

Dementia (Photo credit: Fulla T)

These abusive moms and dads don’t miraculously turn into saints as they age, either. Most of the time the dysfunctional behavior they’ve exhibited worsens, rather than improves, as they age. If they’ve abused drugs, alcohol, or neglected their health, they may get much worse.

 

What to do when bad mom or bad dad (or both) are no longer functioning well at home alone? I don’t mean the not able to shovel out their driveway or lift the air conditioner out of the window type problems. I mean when they think strangers are coming in through the drainpipes and they think one of the intruders stole their gun. That scary not functioning well may be dementia.

 

Dementia is a broad term used to describe difficulties in the areas of language, judgment, behavior, thinking, and memory. Some causes of dementia, such as metabolic disorders and tumors, can be reversed. Other causes of dementia, such as Alzheimer’s disease, can only be slowed down, not cured. Repeat, not cured.  Pay careful attention to the part of the happy pharmaceutical commercials that caution,  “All patients will get worse over time, even if they take wondrous dementia drug.”

 

If you’ve had a great relationship with your parents, filled with mutual respect and assistance, it’s easy to say you’ll do whatever it takes to keep mom and dad safe. Even if it means moving them out of the home they’ve lived in for the last thirty years. Even if it means hiring someone to stay with them so they don’t burn the house down. Even if it means hiding the car or car keys to prevent them from driving to their favorite store that went out of business twenty years ago. Even if it means taking time off from work to accompany them to doctor’s appointments or leaving work early to rush home to deal with emergencies.

 

But if you haven’t had a great relationship with your parent, maybe haven’t even talked to them in five, ten, fifteen, or twenty plus years, what’s your responsibility when the neighbors start calling with their concerns? Do you forget the past and hope they’ll become nice? Put on your martyr uniform and hope for the best? Make an anonymous call to Elder Services and wash your hands of it?

 

There is no easy answer to these questions. Letting your conscience be your guide doesn’t mitigate the guilt that comes with the decision to keep your distance from a demented parent. If you decide to re-engage with the parent, there will still be the resentment that comes with putting your own life on hold to care for a parent who never cared for you. It’s an intensely personal decision that each adult child must wrestle with and decide based on all of the myriad considerations and individual details of their life. If you do decide to ride to the rescue, don’t expect the parent to be grateful for your efforts. Age doesn’t make people any less dick-ish, nor does dementia.

 

As someone who has wrestled with this issue, rest assured I don’t take my abandonment of my parent lightly. There’s a better than average chance that I am the best suited of my siblings for understanding and navigating the complexities of having someone declared incapable of making decisions to pave the way for admission to a nursing home. Not just because I’m a nurse, but also because I’m the oldest. Unfortunately I can’t forget or forgive the toxic parent-child relationship that ultimately ended with my decision to stop speaking to my parent over twenty years ago. I can’t let that go, even though part of me says it’s my duty and part of me feels incredibly guilty that I can’t caretake this person who can no longer caretake themselves.

 

I won’t deny that seeing my parent in their current state, even from a distance without saying a word or them being aware of my presence, breaks my heart. I wish I could find it within myself to soften, bend, and do what some would insist is the right thing. But I can’t.

 

And as much as I salute those who can, I acknowledge that there are those of us who can’t. Age and infirmity doesn’t turn a toxic parent into a saint, it only turns them into a old, sick toxic parent. Don’t judge me for turning my back.  It’s like they say when you fly, if the oxygen mask drops down, you have to put it on yourself before you can help someone else. Unfortunately my parent has demonstrated that they would suck up all the oxygen in my world if they could. As bad as I feel about their condition, I won’t let them.

Day 3: flight to Yazd - inflight safety card

Day 3: flight to Yazd – inflight safety card (Photo credit: birdfarm)

 

Plumbing the Depths of Grief

american somme cemetary Bony

american somme cemetary Bony (Photo credit: Wikipedia)

The death of a loved one is an impossibly agonizing, soul-crushing experience that never completely heals and only lessened by time. When my brother died in a car accident at the age of 25, I thought my tears would never stop.  From the moment I first heard the news, until the moment we lowered his body into the ground, I cried with a ferocity and singleness of purpose I didn’t know I possessed.  All the awful details of death, going to the hospital to get his personal possessions, cleaning out his apartment, picking out a coffin and the clothes he was to be buried in, were done with eyes blurred by tears and a voice hoarse from crying.  The procession of people bearing food and flowers seemed never ending, but I only hungered for alcohol and cigarettes.

After he was buried, the dreams started. Dreams of the two of us on a subterranean train system, the only illumination strobes of light that made him and the other passengers appear and disappear to the background sound of a speeding train racing over wooden tracks.  I was the only one who spoke in the dreams. He sat quietly, attentively, listening. I started out by speaking slowly, normally, and as the train raced along my words hastened to match its speed. I’d talk faster and faster, cognizant in my dream that the time to talk was soon coming to an end, and then he’d disappear.

I’d wake up crying, thinking I would pay any price for him to still be alive. Eventually my grief ebbed to where I could say his name without crying, and then to where I could look at his picture without my eyes growing teary, and now I survive without him. Still, 28 years later, I mist up whenever I hear the lines from “White Christmas” that promise “I’ll be home for Christmas, if only in my dreams”  because my dreams are the only place I can hope to see him.

Was I depressed during the grieving period? Yes. Did my doctor put me on antidepressants to numb the pain of my loss? No, and I’m glad he didn’t. My brother’s death was something I had to work through and plumbing the depths of my grief informed how I have dealt with the deaths of all of the loved ones that have followed him.

The American Psychiatric Manual has traditionally warned against diagnosing depression during bereavement, but now psychiatrists with ties to drug companies have helped to remove that warning and the makers of antidepressants stand to benefit from the change. If grief equals depression, grief is a treatable condition. A treatable condition is billable and amenable to interventions, in this case, prescription medications. Instead of providing a shoulder to cry on, doctors will provide a prescription pad to write on. And where does that leave the patient? Once again a normal part of life is medicalized, this time because drug companies want to take advantage of a market that increases every day, with every death.

Recently I heard the story of a mother who stood up at her son’s funeral and apologized because she had nothing to say to eulogize her son. She stood dry-eyed, unable to cry, and said she was on too many medications to feel anything but numb.  I wonder about her now, many  months after her son’s death, and whether she’s allowed herself to experience the pain of grief in all of its snot-drenching messiness. I hope so. I can’t imagine any crueler prison than not being able to let go of that pain.

In mourning death, we open our heart and let it bleed. Even though a scab may form, for a long time every memory rips it open and starts the bleeding again. It’s an unpleasant, unpredictable process, but as Henry Rollins says, “Scar tissue is stronger than regular tissue. Realize the strength; move on.”

The grieving process helps us to do that far more than any chemical ever will.

A Magic Pill

Pills

Pills (Photo credit: madcowIV)

 

Pills (white rabbit)

Pills (white rabbit) (Photo credit: erix!)

 

 

At least twice a week someone tells me about a magic pill. They discovered it on Dr. Phil or Dr. Oz, an infomercial or a magazine, from the recommendation of a friend or with the help of an alternative healer. No matter what the magic pill cures/heals/improves, it never requires the taker to do anything except remember to take the pill.

 

I’m always a little skeptical. Most things in life, to me at least, require some effort.

 

And it’s not like the people who believe in a magic pill are dumb. Incredibly intelligent people look me straight in the eye and tell me about the latest one. On some level, we all desperately want to believe there’s a shortcut to our dreams or a work around to our pain. But that’s not the case.

 

Life isn’t easy, it isn’t fair, it’s full of pain. If a magic pill could cure that, wouldn’t we all take one?

 

Except there’s something to be said for fighting the good fight and emerging successful. Whether it’s losing fifty pounds, marrying the man of your dreams, or conquering an addiction, the journey is the part that helps us to grow. The magic pill takes that away from us. It makes us believe in trickery.

 

It’s time we value the work of improving ourselves and our lives more than we value the magic pill. Yes, working through our problems is hard, but it is only when we fully accept and embrace the tough times and the difficult choices that we move forward.