by Joanne Iannone Sheehan, RDH
"Aloha, Miss Helen! Look at me!"
Lani's proud smile highlighted her new front teeth as she pedaled a wobbly bike. Her 18-year-old brother, Keoki, jogged behind her. It was a beautiful morning on the secluded island of Kauai. Helen, a transplant from Maine, was surprised to see anyone on this private dead end street, although it was perfect for learning to ride a bicycle. Helen smiled to herself. Keoki must have the day off from dealing with tourists in need of kayaks. The Hawaiians called the main industry on the island eco-tourism, and they weren't complaining. The constant visitors kept the job market buzzing.
"Wow! I'm impressed! Good for you, Lani!" Helen called out, feigning shock at Lani's riding skills. She felt at home with the locals and made every effort to get to know them. They were a peaceful people. She turned and unlocked the studio door while juggling her coffee and new art supplies. The only way she could afford to live in Kauai was to share a small cottage with her sister, Laura, a hygienist who worked at the Free Dental Clinic in town. Between Laura's pay and Helen's thriving art sales, they earned just enough to make a dream come true ... to live and work in a tropical paradise.
The art gallery was having a weekend exhibit, and Helen had left for the studio early to finish her last entry, a tropical flower done in pastels. But as she pushed the studio door open, a scream and a crash made her whirl in horror.
Lani and her bike lay in the road. Out of control, an ancient, brown pickup truck careened into the bushes, bags of harvested leaves spilling from the truck bed. The studio's Colors of Paradise sign protruded through the shattered windshield.
"Lani!!!" Keoki screamed as he ran to his sister. Helen stood in a moment of disbelief ... then dropped her things and sprinted for the phone to call 911. She barely felt her scalded feet as she rushed back outside. The driver, bloody-faced and disoriented, tumbled out of the truck, waving his arms. Keoki jumped up to confront him.
"Are you crazy? Didn't you see her!?"
"She was in the middle of the road," the flustered man gestured.
"She was on the side of the road, not in the middle!"
"I don't know what happened ... I was driving and I started getting ..."
"I know what happened! You hit my sister!" Keoki shouted, marching up to the man.
"No. I was trying to find ... I don't know where .... auwe!" the man stuttered with labored breath, now standing nose to nose with the irate Keoki.1
Helen knelt beside the moaning child. The radius of Lani's arm was poking through the skin in an open fracture.2 Helen removed her scarf and tried to cover the protrusion and stop the bleeding. Lani's right leg was bent in an unnatural position and her face was covered with bloody abrasions. Both her upper centrals were avulsed. Helen searched the area quickly and found them on the road. This was one time she was glad her sister was a hygienist and not an accountant.
She picked them up carefully by the crowns, remembering what Laura had read to her from a dental journal. The critical factor for success of the replanted avulsed tooth is not the length of extraoral time, but the physiological status of the PDL cells on the root surface.3 Laura's translation was, "OK, so just don't touch the root, and soak the tooth in saline, saliva, water, or milk."
Keoki saw that it was useless to argue with the strange man and returned to his sister's side.
"Stay with her while I get these teeth in some water. And grab a couple of towels to keep her warm, Keoki. She's going into shock," Helen called, running past him and into the studio. With Helen inside and Keoki preoccupied, no one noticed the man slip into the lush, dark vegetation behind the building.
A short while later, the ambulance found their street.
"I'm going with her," said Keoki decisively, daring them to try and stop him. Helen retrieved the glass of soaking teeth and watched as the paramedics placed it and the girl carefully in the ambulance. Keoki jumped in next to her, and the vehicle began its race to the hospital. Helen sent a prayer after the screaming vehicle.
Walking slowly to the bike, which was mangled beyond repair, Helen knew not to disturb the crime scene. Instead, she went inside to call her sister, who was still at home preparing for work. Shaking from adrenaline, Helen sat down and told her sister the whole story. Laura was impressed.
"Good job with the teeth, Helen! I'll make a hygienist out of you yet!"
"Fat chance," Helen said. "I'm not putting my hands in people's mouths. That's your thing!"
"OK, whatever! Tell me more about this guy. What did he look like?"
"He looked like he might be a farm hand from the way he was dressed," Helen said. "He may have been drunk. I don't know. He seemed confused, almost staggering. I thought Keoki was going to deck him. Keoki and Lani are very close. He's practically been raising her since their parents died two years ago. Their grandmother is too old to be of much help"
"So where is this man now? Did the police take him into custody?"
"I thought the police would come with the ambulance, but they didn't. I don't know where he went. He's gone. Wait ... someone's at my door. It may be the police. Gotta go!"
"Well, keep me posted. I'm late for work now anyway. Later!"
Helen hung up and ran to the door. A handsome young man in uniform stood on Helen's porch.
"Good morning, Miss. I'm Sergeant Makua, here about the accident this morning."
"Aloha, come in, Sergeant Makua. I'm Helen Murry, please ... sit down."
"I'm sorry for the delay. I was just getting back from a funeral for a family member when the call came in. That makes the second relative this year that died from the same disease."
"I'm sorry to hear that," Helen said, wondering how such a beautiful place could affect it's native population so harshly. "As far as this morning goes, I didn't actually see the accident happen. I saw Lani before and then right after she was hit. That's the truck that hit her," Helen said, pointing out the window. "Keoki's with Lani at the hospital now, but he's the one who got a close look at the man. I was too busy with Lani to give you a decent description. I think he was a local, and he may have been a farm hand. The truck is filled with leaves, and there's a taro farm not far from here. The guy just wandered off when we had our backs turned. Acted really weird."4
"We'll find him, don't worry. I'll need to look at the truck now," said the sergeant, standing up.
Keoki had stayed with Lani as much as they had allowed him to. She was X-rayed, scanned, set, and sedated. Her brother sat and stared at the small battered form in the bed.
"I'm sorry, Lani," Keoki groaned. "I should have seen that truck coming."
"Why don't you get something to eat?" a nurse suggested. "She's sleeping now."
Keoki knew he couldn't eat, but he needed to get some air. Leaving the hospital, he walked a block to Sea Breeze Park and wandered aimlessly for a while. With the accident on continuous replay in his head, he broke down on a bench, overcome with remorse and helplessness.
"Keoki!" It was Laura. She often came to eat lunch at the park, working so close by. "Helen told me what happened this morning! I'm so sorry! How is Lani?"
"She's beat up pretty bad. Broken arm and leg. May have internal injuries, I don't know yet. She knocked two teeth out and the doctor said she has a concussion..." Keoki couldn't trust his voice. "She said her helmet was too small and it hurt, so I let her ride without it..." Keoki said, shaking his head.
"I've done things like that babysitting Helen. Hindsight is 20/20. Did you know this guy who hit her?" Laura asked, hoping to lift Keoki's self-condemnation.
"Never saw him before. Sounded like he might be from another island. I thought it was safe to have Lani ride on your private road. No traffic. She was just learning. What was he doing there?"
"I don't know," Laura said softly. "Lost, maybe? I heard you almost leveled him."
"I wanted to but ... he was so messed up. Smelled like he was drinking ... punch or something. I'm sorry, Miss Laura, I need to get back to Lani now."
"I understand. I'm praying for you both. She'll be OK, Keoki."
The 'thank you' stuck in Keoki's throat. He could only nod and leave.
In front of the studio, the sergeant was finishing his investigation of the truck cab. He found several candy bar wrappers, receipts, soda cans, broken glass, and a pair of boots. The steering wheel was splattered with sticky blood, of which the sergeant took a sample. He recognized the leaves in the truck bed immediately and shook his head.
"Taro farms harvest the roots, not the leaves, Miss Murry. It's the roots that they make poi out of," he said with a soft chuckle and a smile.
How silly of her! Of course, Helen knew that! She was embarrassed, but somehow didn't mind his correction. The sergeant made note of his findings while Helen retrieved the remnants of her studio sign from the windshield.
"Can I get a copy of your report when it's done?"
"Of course, Miss Murry. Come by the station this afternoon around four. It may be ready."
The sergeant called the dispatcher to send a tow truck to the studio's address. "They're coming to get this truck, but don't let anyone touch it in the meantime. It's still evidence. Now to find Keoki. Mahalo, Miss Murry. Aloha."5
The dental clinic was unusually busy, but Laura's four o'clock patient had meandered in 10 minutes late. It would be Kei's first time in Laura's chair. She had been thinking of Lani, Keoki, and the hit-and-run driver all day. As Kei sidled up to the reception desk, Laura noticed his nails, his clothes, his shoes, and his hair.
She realized that he could be a farmhand. "Have a hard time finding a parking space?" Laura asked, as she ushered him to her chair. "It's so busy today!"
The man just stood and stared at her for a second. "No, Auntie, my truck is in the shop.6 I had to walk," he replied sarcastically, then sat down. He didn't seem thrilled to be there.
Laura nodded, disregarding the insult. Three of his upper anteriors were missing.
"What happened there?" Laura asked, pointing to the vacancies.
"An accident," Kei said, defensively, and offered nothing more.
Again, Laura just nodded. Kei claimed no changes in his medical history, and Laura noticed he was overdue for X-rays. While placing the lead apron, she noticed a strange smell from his clothes. The cause was confirmed when he opened his mouth. The linguals of his lower anteriors were green, a classic sign of marijuana use.
"Pakalolo?" Laura probed.7
The man just flashed a self-incriminating smile. Laura thought it ironic that his name was Kei, which meant "dignified" in Hawaiian. She exposed the films, asking no more questions of her non-responsive patient.
With her brain in overdrive, she literally ran into Malia, the doctor's assistant, in the hall. They were both headed for the darkroom. Laura needed time to think, and she offered to develop Malia's Panorex. Malia thanked her and rushed back to her emergency patient. Laura closed the door to the darkroom, unlocked the cassette, and inserted the Panorex first. As it disappeared into the whirring machine, Laura stood in the dark, wondering what she should do.
Laura fed her bitewings into the developer. Somehow, she had to find out if her patient was the hit-and-run driver. Leaving the darkroom, she passed by the doctor's operatory. Malia was in the process of getting information from her patient, who seemed to be in pain. Laura hurried toward her operatory. She had to check the site of those missing teeth. If she had been thinking straight, she would have consulted the chart about them. But before she could reach her operatory, the receptionist caught her in the hall, handing her the portable. Helen was on the phone.
"Hey, sorry to call you at work, but I just picked up the accident scene report on my way to the gallery. They're still looking for the guy. He must have been a sweets freak, with all the candy wrappers and soda cans in the cab. I thought they would find a few bottles of Primo, the way he was acting, but they didn't.8 They've got the guy's blood type from the steering wheel. It's AB, the least common of the Hawaiian population. Keoki told Sergeant Makua the guy hit his face in the crash. And the leaves in the truck were ti leaves.9 Oh, and I stopped in at the hospital. They put Lani's teeth back in. She's on pain medication and antibiotics, but awake. The doctor told Keoki there were no internal injuries, just a mild concussion. Keoki's staying there tonight. Just thought you might want to know. "
"Thanks for the great news, Sis. You did good! I may be able to help the police find that guy. Can't talk now! Tell you tonight! Later!"
Laura rushed back to her room. It was already 4:30, and she had barely started treating her patient. But as she entered the operatory, there on the bracket table was an upper partial sporting a lateral and two central incisors in dire need of tartar and light stain remover.
"Wanna clean these too, Auntie?" he grinned, and Laura's hopes were dashed. His "accident" was not recent. She put on some gloves, scooped up the partial, and, on her way to the lab, heard the doctor's patient complaining.
"First the medical clinic says I have a disease and now you are telling me this? Auwe!"
Laura popped the partial in a solution-filled plastic bag, dropped it in the ultrasonic cleaner, and draped the top over the side, securing it's position with the metal lid. Before returning, she checked on her films. They weren't ready yet, but the pan was out. While waiting for her films, she held the Panorex up to the hall light to distinguish right from left. The doctor wanted the name labels on the left. It was then that she noticed the fracture line extending downward from the #24, #25 area. Had he been in an accident? Laura put a blank name label on the Panorex and brought it to Malia. She promptly placed it on the viewer for the doctor, who was wondering why Laura was more interested in his patient than hers. Laura caught his quizzical glance and returned to the darkroom for her bitewings. From there, she could hear the doctor's diagnosis.
"Looks like you caught a good punch right in the chin! You've got yourself a nice fracture. He must have been a big guy! Usually, with an anterior blow like this, we see bilateral condylar fractures. Unfortunately, a Panorex is not the best diagnostic tool for that. I'm going to send you back to the medical clinic for a Panelipse with Townes. We can see a lot more with that kind of film.10 They have a procedure that is used for this type of injury called ORIF.11 That just means open reduction and internal fixation. When we get that other film, our oral surgeon can figure out if open or closed reduction is the best thing to do here. And if we can get you on antibiotics and have that surgery done within 72 hours, we can decrease your chances of an infection setting in."12
"Auwe! I am just a poor man from Oahu trying to make some money at Cousin Kona's ti farm," the man lamented. "And he is a hard man to work for. First time you're in trouble with the police, you're fired! Kona wants no criminals working for him! I don't want any trouble either. And now this! Auwe!"
"I know. I'm sorry. Life isn't fair. We'll get you fixed up," the doctor sympathized. "Malia, call next door and talk to the doctor who treated our patient this morning. Tell him I want a Panelipse with Townes right away." Then he turned to the patient. "I'll stay here until you get back with it. I have paperwork to do anyway."
OK, Laura thought, this is getting serious. Keoki said he didn't recognize the man, thinking he might be an off-islander. He has a fractured jaw from an anterior blow and he is in pain. It had to have happened recently, she thought to herself. But he told the doctor somebody beat him up. Keoki said he never touched him.
Laura returned to her room, mounted the bitewings, washed, gloved and sat, ready to start. Kei was reading a magazine in the chair.
"Thought you left for the day, Auntie," he commented without lifting his eyes.
Annoyed, Laura said, "My name is Laura, and I'm sorry I'm running late. Seems both of us are having a hard time keeping on schedule today." She reclined his chair. "Now turn this way please." She began his oral exam. Just then, the doctor's patient walked by as he was leaving, and Laura finally got a look at his face. It was badly cut and bruised. Laura added that to her checklist and continued working, knowing he would be coming back with the X-ray.
Malia picked up the portable and called the Free Medical Clinic next door. The lack of sparkling conversation in Laura's room afforded her the chance to hear one side of the conversation. "Hello, is Dr. Okomoto available please? Dr. Harrand needs to order an X-ray, and I have a question about one of your patients this morning. OK, I'll wait."
Laura wished she had a newer ultrasonic tip, a prophy jet, a spoon escavator, anything to get that heavy stain off faster. Amazingly, there was little calculus and pocket depths were within normal limits. But he made up for it in shades of green.
"Hi, Dr. Okomoto? It's Malia, from the dental clinic. Dr. Harrand would like a Panelipse with Townes of that jaw fracture patient you treated this morning. Did you get the name of his assailant? What? Well, that's what he told us. Yes, he said you diagnosed him with that, but.... He has medication now? OK, well if your technician could get us that film, we'd really appeciate it. Dr. Harrand will wait for it. Yes, he's coming over right now. Thanks! Bye!"
"Malia!" Laura called, as the doctor's assistant whisked past her doorway.
"Yes?" Malia poked her head in.
"What did your patient tell the medical clinic?"
"He told them that he couldn't remember much of what happened. A hotel employee found him wandering in the road and brought him in. They were lucky to get him to state his name the same way twice. And they're not sure that was correct," Malia sighed. "There's a partial in the lab. Do you want it or should I see how much I can get for it?"
"Yes, thanks. I'm sorry. I've been preoccupied today."
Laura now had one more item for the checklist, confusion. The driver was said to be confused. But if this patient didn't remember, why did he make up that assailant story? Had he lied to Dr. Harrand to save his job? And why had he been acting so strange? He wasn't high, and he wasn't drunk; in fact, Keoki said he smelled like punch ... fruit punch? Fruity breath! Confusion! Candy bar wrappers, soda cans ...
"Here's your partial, Laura. There's a delivery charge for that," Malia teased.
"Malia, what was your patient diagnosed with at the medical clinic?" Laura asked, as she hung up her polisher.
"Diabetes," she answered. "He was told he was borderline years ago and never followed up on checking it. He had three candy bars and a can of soda for breakfast. Hadn't gotten his paycheck yet and that's all he could afford. At the medical clinic, he said the last thing he clearly remembered was losing his bearings and then getting really drowsy. Want me to get the doctor to check Kei?".13
"Great, thanks!" The last two pieces of the puzzle were a phone call away. Not only could the police and clinic compare blood types and DNA, but also his blood sugar level.14 She located the portable and pushed redial.
The medical clinic confirmed the AB blood type, then called the police station for an implicating lab report on the blood sample. Sergeant Makua was immediately dispatched to the Medical Clinic.
It was a little after five when Laura flossed Kei's sparkling teeth and gave him a toothbrush and some floss.
"Thanks, Laura," said Kei, actually sounding sincere.
Laura smiled and in her best Dragnet monotone, quipped, "Just doing my job, sir."
Joanne Iannone Sheehan, RDH, is a 1974 graduate of SUNY in Farmingdale, N.Y. She has been licensed in five states and is currently practicing with Pro Dental Temps in Huntsville, Ala. Winner of the grand prize in a Chicken Soup for the Dental Soul writing contest for dental professionals, she has been a frequent contributor to RDH magazine since 1997. She can be reached at [email protected].
The Hawaiian pastel artwork were done by the author's sister, Helen Turner, a Kauai resident and consultant to the story.
1 Auwe — Hawaiian lamentation. Native term for "Why me?"
2 American Academy of Orthopedic Surgeons — "Children are more likely to break the lower arm bones (radius and ulna). To slow bleeding and reduce swelling, elevate the injured arm above the level of the person's heart. If a broken bone sticks out from the skin (open fracture), do not try to push it back in. Use a clean, dry cloth or bandage to cover it until medical help arrives.
3 Avulsed Tooth Treatment: Paul R. Krasner, DDS, Henry J. Rankow, DDS — "The critical factor for success of the replanted avulsed tooth is not the length of extraoral time, but the physiologic status of the PDL cells on the root surface. General handling tips: Handle tooth by crown at all times, never touch periodontal ligament. To remove debris, soak in Hank's solution. Colgate Gel-Kam 0.9% stannous fluoride solution is suitable for the SnF2 soak."
4 Taro — Taro root is a starchy tuber vegetable that looks like a potato. Poi muffins, cakes, ice cream, biscuits, bagels, dinner rolls, and cheesecake can also be made from this root.
5 Mahalo — Thank you
6 Auntie — Term sometimes used sarcastically by Hawaiian locals for a single, middle-aged woman.
7 Pakalolo — marijuana
8 Primo — popular Hawaiian beer
9 Ti (pronounced tee) leaves have many uses, including roof thatching; as fly whisks or fans; wrappings for cool food storage, preservation and protection; for wrapping of food to be cooked, especially for laulau; as plates or cups; as fishing lures on hukilau nets; as wearing apparel, such as rain capes, sandals and as hula skirts called pa`u. http://www.hawaii-nation.org/canoe/ki.html
10 Panelipse with Townes — "The anterior-posterior Townes projection is an excellent plain radiographic technique for visualization of true condylar morphology from a frontal perspective. Both the medial and lateral poles of the condylar heads are clearly seen in addition to the anterior and posterior aspect of the condylar articulating surface. Along with the transcranial projection, the Townes affords essentially a 3D view of the temporomandibular joint." Basic Imaging Requirements For The Temporomandibular Joint: Richard W. Greenan, http://www.cfoo.com/ newsletters/volume_7_issue_1.htm
11 ORIF — Open reduction and internal fixation, a surgical option for bilateral condylar fractures associated with midface fractures, sometimes brought about by an anterior blow to the chin.
12 If treatment is delayed more than 72 hours, intravenous antibiotics must be used on any infection at the fracture site before surgery to ensure adequate blood distribution during surgery. American Association of Oral and Maxillofacial Surgeons.
13 Diabetic coma — This condition occurs when there is too much sugar and too little insulin in the blood and body cells do not get enough nourishment. Diabetic coma can be caused by eating too much sugar, by not taking prescribed medications, by stress, and by infection. Diabetic coma develops more slowly than insulin shock, sometimes over a period of days. Signs and symptoms include drowsiness, confusion, deep and fast breathing, thirst, dehydration, fever, a change in the level of consciousness, and a peculiar sweet or fruity-smelling breath. The incidence of diabetes in the Hawaiian population is extremely high, rivaling that of the American Indian. The U.S. Department of Health and Human Services' Office of Minority Health states that native Hawaiians are more than five times more likely than non-Hawaiians to have diabetes between the ages of 19 and 35. The Native American Research and Training Center (NARTC) in Hawaii reports: "Approximately 70,000 to 90,000 of Hawaii's native population have Type 2 diabetes. Native Hawaiians also have a diabetes-related mortality rate that is six times that for the general U.S. population."
14 HbA1c is stable in whole blood stored at room temperature for 52 days.