The premedication dilemma

The uncomfortable feeling you described was, no doubt, your own conscience telling you that there was something terribly wrong with this picture.

Dear Dianne,
Recently, a patient arrived for her appointment but related to me that she had forgotten to take her premedication. This patient has an artificial heart valve that was placed about 10 years ago. I told the patient that we would need to reschedule her appointment.

Suddenly, the patient became very irate and demanded to see the doctor. I told the doctor privately that my patient had forgotten to take her premedication and that she had become angry when I told her we would need to reschedule her appointment.

The doctor listened to the patient tell about what a hassle she had gone through to get off work and fight the traffic to make her appointment. She also said she did not feel premedication was necessary, since her previous dentist never premedicated her before dental appointments.

I fully expected my doctor to support me in the necessity of rescheduling this patient. Instead, he said, "I have some antibiotic in my office. I'll give you four tablets now, and we'll be just fine!"

I was flabbergasted! With my schedule full, he knew I would not be able to wait the recommended hour before I began the prophylaxis. When I expressed this to him privately, he said, "It will be fine for you to proceed immediately. Don't worry about it."

Not knowing what else to do, I went ahead and treated the patient. Thankfully, this patient did not have much calculus, and her tissue was generally healthy. There was very little bleeding. I skipped the periodontal probing completely, however.

I was very uncomfortable treating this patient. To my knowledge, no untoward results occurred. Since this incident transpired, I have wondered what would have happened if she had become ill as a result of her dental visit.

Now I am worried that this will happen again in the future. I never want to go through this mental anguish again! What should I do to ensure that this scene is not repeated?

Sleepless in Seattle

Dear Sleepless,
The scenario of a patient arriving for his/her dental appointment but forgetting to premedicate happens every day in dental practices everywhere. It is always a frustrating and uncomfortable experience.

The American Heart Association describes three categories of risk associated with endocarditis — high risk, moderate risk, and negligible risk. In the situation you described, the patient has an artificial heart valve. This puts this patient in a high-risk category for endocarditis.

Certainly, you were justified in telling the patient that rescheduling her appointment would be necessary. However, I suspect you may have been a bit hasty with your reply to the patient. You might have taken more care to inform the patient gently and tactfully of the 'bad news" that her appointment would have to be postponed. After she told you she had forgotten to premedicate, you could have said, "Oh, really? Now that presents a problem. Please excuse me while I place a call to your cardiologist to get permission to proceed." This gives you a little time to leave the room and place the call. Of course, you know ahead of time what the cardiologist is going to say in this situation. So, you can go back to your patient and say, "I'm so sorry, Mrs. Jones, but your cardiologist said under no circumstances should we proceed with your dental appointment without premedication taken one hour before your visit. It is just too risky, and we certainly do not want to risk damage to your heart." By doing this, you let the specialist become the 'bad guy," and you do not have to compromise your patient or yourself. Also, by involving the cardiologist, you prevent your doctor from being trapped in the middle of the controversy. I doubt any prudent doctor would override the word of a specialist.

Most dentists are nonconfrontational by nature. It sounds to me like your doctor gave in to the patient's pressure to be treated that day. He simply wanted to give the patient what she wanted. Yet, if he had taken time to discuss the seriousness of possible consequences to the patient, she probably would have backed off of her demand. If he had told her that this was a possible life-and-death issue, I expect all arguments would have ceased.

By seeing this patient, you took a terrible, unjustified risk. It looks as if you were unwilling to go against the word of your employer, even when you knew it was wrong. The uncomfortable feeling you described was, no doubt, your own conscience telling you that there was something terribly wrong with this picture. You should have been bold enough to tell the doctor: "I am not willing to risk this patient's life and my hygiene license over this. Are you? I will be happy to see her if the schedule can be rearranged so she can have the necessary one hour for the antibiotics to become established in her system. Otherwise, maybe you should see her."

Doctors, like hygienists, are not perfect. We all make unwise decisions at times. In this situation, I believe two unwise decisions were made — one by the doctor and one by you.

However, consider the consequences if the patient had developed bacterial endocarditis. Can you see yourself on the witness stand at the trial where her family is suing the doctor for malpractice or operating outside the standard of care? Testifying "I went ahead and saw her because the doctor told me it would be all right..." probably would not protect you. Your own professional education teaches you otherwise. In addition, consider the worst case scenario — the patient's death. Would you want that on your conscience for the rest of your life?

We all should be aware, however, that the guidelines on premedication have been modified a bit because of resistant strains of bacteria that are emerging. For example, the American Academy of Orthopedists has issued a paper stating that premedication for a joint-replacement recipient is required only for the first two years after surgery. Additionally, premedication for mitral valve prolapse is no longer required unless there is valvular regurgitation. (See below.)

To ensure that this will not happen again, I suggest you have a heart-to-heart talk with the doctor. Tell him of the mental anguish you have endured because of this incident and that you are unwilling to go through it ever again.

I hope you and everyone who reads this will remember that we must keep our patient's well-being in the forefront of our minds at all times. Whether our decisions cause an inconvenience for us or our patient is not important. What is important is that we all practice to the standard of professional care we know to be best for our patients. Refuse to compromise those standards!
Dianne

Dianne Glasscoe, RDH, BS, is an adjunct instructor in clinical hygiene at Guilford Technical Community College. She holds a bachelor's degree in human resource management and is a practice-management consultant, writer, and speaker. She may be contacted by e-mail at [email protected], phone (336) 472-3515, or fax (336) 472-5567. Visit her Web site at http://www.professionalden talmgmt.com.

• High-risk category
• Prosthetic cardiac valves, including bioprosthetic and homograft valves
• Previous bacterial endocarditis
• Complex cyanotic congenital heart disease
• Surgically constructed systemic pulmonary shunts or conduits
• Moderate-risk category
• Most other congenital cardiac malformations (other than the above and below)
• Acquired valvular dysfunction (rheumatic heart disease, for example)
• Hypertropic cardiomyopathy
• Mitral valve prolapse with valvular regurgitation and/or thickened leaflets

• Negligible-risk category
• Isolated secundum atrial septal defect
• Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus
• Previous coronary artery bypass graft surgery
• Mitral valve prolapse without valvular regurgitation
• Physiologic, functional, or innocent heart murmurs
• Previous Kawasaki disease without valvular dysfunction
• Previous rheumatic fever without valvular dysfunction
• Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators