No, this entry is not about travel experience, it is about life experience while providing dental care. People are more interesting than their teeth. Each person has their own story. Feel free to skip this one. We will get back to travel very soon.
Martha Caigambal:
While on an oral surgery rotation in my Comprehensive
Dentistry Program, I encountered an especially interesting patient. Martha Caigambal was an elderly lady with a
very complicated medical history. She
was specifically accepted to our program as a challenging learning case and
would not have otherwise been accepted.
Our normal mission was dental treatment for active-duty military only. She was assigned as my patient.
Martha was a family member (mother or grandmother) of a US
military member. She was from the
Philippines and a ‘reverse smoker’; that is, when smoking she would put the lit
end of the cigarette inside her mouth.
Having spent time in the Philippines, my guess is that the habit
originated due the rainy climate there.
The consequence is that the oral palatal tissue on such people is dry
and scarred from being subjected to intense heat. But that was a small part of her medical
problems. I remember that she had CHF,
congestive heart failure, and diabetes, plus other issues beyond my memory. She brought her medications to us in a
shopping bag, from which she took pills sporadically.
Dentally, all her molars were beyond repair and needed
extraction. The hospital internal medicine department refused to
be responsible for her admission; she was admitted by one of our board-certified
oral surgeons. Anesthesiology
recommended that we use local anesthetics only; they were worried that if a
deeper ‘numbing level’ were used, she may not recover consciousness. Her heart condition plus bleeding problems
were two Immediate concerns. Diabetes increased the risk of infection.
Nevertheless, an anesthesiologist was present with their equipment and an
IV started in the OR, operating room, in case of an emergency. Martha was admitted to the hospital two days
in advance, to ensure that her long list of medications was taken properly and
that her laboratory values were stabilized and optimized. Her anti-coagulant therapy was temporarily discontinued.
I am happy to report that her dental treatment was completed
without further complication, and healing was uneventful. I do remember her crying, “You are killing
me!” during the surgery. It wasn't from pain, but from the obvious trauma involved in removing multiple teeth. Those
multi-rooted molars with rotted crowns can be difficult to remove. The fact that infection had spread to
adjacent bone, with some abscess formation, reduced the quality of bone support
and made tooth removal physically easier.
Did she subsequently improve her dental hygiene? Removing those infected teeth had to help her general health status. She was only accepted for this treatment for training purposes in our residency program. I remember her name because of the complex medical problems to be evaluated and managed.
General Alexander Haig
When I oversaw the Walter Reed Hospital dental clinic in
Washington, DC, 4-star retired General Alexander Haig had ‘his people’ request
an appointment for dental care at our clinic.
He is a very senior guy, also the past US Secretary of State, and past
Supreme Commander of NATO forces. But
you notice, he was “retired”, not on active duty.
Our major Army mission at the Walter Reed clinic was to
treat active-duty soldiers (as well as any emergencies that occurred on
hospital grounds). We were also tasked
with providing specialty care for US government employees involved in overseas
terrorist attacks, i.e. Africa. Occasionally,
under special circumstances, we saw and treated heads of foreign countries who
would come to the US for state-of-the-art care (very high security, on a weekend
when the clinic was otherwise vacant.)
If a retired General is deserving of appointments, then why
not retired lower-level enlisted soldiers? What
should a changed policy include? My
reply was that our dental clinic did not treat retirees, active duty only. Haig’s ‘people’ then contacted the one-star General in
charge of Walter Reed, and he commanded that we provide an appointment for
General Haig. (Patient standards for
medical care were more inclusive than prescribed for dental patients. I believe they still are.)
My reaction was to contact the two-star US Army General in charge of
the entire Army Dental Corps to see what policy to follow. I couldn’t countermand the hospital commander
without the Dental Corps Commander’s backing.
Meanwhile General Haig was already scheduled for his initial
appointment.
The awaited reply from the US Army Dental Corps commander, a
man I knew personally, came only a few hours before the scheduled
appointment. I could not properly cancel
that appointment at the last moment.
Instead, I saw General Haig at the appointed time, did a complete
examination, and corrected a simple defect in one of his restorations.
Then I explained his overall treatment needs to him. He had some long-term needs which would
require multiple appointments. Using the
most diplomatic words I could muster, I explained that the clinic was focused
on active-duty military. Fortunately, he
took it well, stating that, of course, he had the means to afford dentistry wherever
he chose. His concern was for those
military retirees who could not afford such options. He then made a parting joke about President Clinton.
I learned in my career (sooner would have been better) that
politics are universal. This situation
ended amicably. The next incident I will
describe did not end so well.
The Retiree from New Jersey
The driving time from New Jersey to Washington, DC, is 3-4
hours, with the route passing by the major cities of Philadelphia and
Baltimore. Thus, I was surprised when a military
retiree from New Jersey showed up at our reception desk demanding care for his
“dental emergency”. Our reception
personnel, whom I had great faith in, explained our policy of care for active
duty, but he was insistent. Being in charge of
the clinic, I was not going to let our trusted reception personnel take the
brunt of his displeasure. Fortuitously,
we had records of a previous visit by this same person. He had shown up almost a year prior, been
seen for a different problem, and, on that visit, was told that he also had a
tooth that needed to be extracted.
Now that tooth was hurting.
I explained to him that his situation did not qualify as an emergency. He would not be seen here. When a patient is told they need an
extraction but then elects to wait until it becomes painful, the pain is the
result of their poor planning. How many other
dental offices did he drive by on his 200-mile trip to DC? He was unwilling to spend any of his own money on
his neglected dental needs. Dental care
was worth zero to him, but he wanted us to redirect our efforts away from our
designated active-duty mission toward his schedule for his needs.
I was adamant. I had
seen the same thing happen with middle-of-the night patients who came in when
it was convenient for them. They didn’t
want to pay, and they didn’t want to take time off from work and lose wages. This could be true even if it was their
children experiencing pain. But they
didn’t mind inconveniencing our dental staff with a night-time visit.
He cussed me out roundly in front of the reception personnel
and scheduled patients awaiting care. He
loudly declared that he hoped I would “rot in hell.” It did not bother me. I wanted it to be known to our staff that I
would support them, and I would support established policies.
A month or more later, I received a letter forwarded to me
from President Clinton's office. This same
retiree vented his written displeasure with Walter Reed, and specifically with
me, and sent it to the highest authority he could think of. I received no reprimand or other unfavorable repercussions. Just part of the job.
When determining dental care priorities, I was never concerned about military rank or cost. I had three criteria: 1) Will
the patient appreciate and maintain good dental health after the care given? 2) Will the patient show up for needed
appointments? 3) Will the patient be
available long enough to complete all required steps in the procedure? My time and the taxpayer's money are not to be wasted.
I have little regard for those who expect me to care more
about their teeth than they do personally.
When it was my turn for emergency call, and I had come in
late at night, often the patient was someone who did not see a dentist for
routine care but only came in for ‘emergencies’. If it was a tooth that needed to be extracted
and they asked me to “pull it”, I would generally write them a script for pain
medication and tell them to get an appointment.
If they asked me only for pain medication for the tooth, I would usually
go ahead and extract the tooth. I wanted
to change their habits away from midnight visits and towards regular scheduled dental
care. Some of those encounters, when asking
only for pain medication, were more interested in getting drugs that having
their ‘problem’ treated.
