Changing Gears, Changing Lives

March 1, 2003
A frail elderly woman seated in a wheel chair, her legs pumping air as if she is running, her stick arms slowly propelling the wheels of her chair forward, called out frantically, "Dorothy, please come back.

A frail elderly woman seated in a wheel chair, her legs pumping air as if she is running, her stick arms slowly propelling the wheels of her chair forward, called out frantically, "Dorothy, please come back. Don't leave me. Dorothy..." Dorothy is briskly walking away, brushing back tears. A concerned nurse looks on. I am on the sidelines and just happened upon the scene of mother and daughter parting at a nursing home. A nurse quickly rescues the distraught older woman and offers her a sedative to ease her into her first night at the home.

Obviously, my thoughts are with both women. I wonder who will comfort Dorothy. Later, when I am on rounds, I approach the lady in the wheel chair. We smile and chat. She has obviously forgotten the farewell. Sometimes dementia is kind.

This is one of a dozen vignettes Lynne Durham, RDH, shared with me about her experiences in caring for those who cannot care for themselves. Her recollections are riveting. I invite you to experience caring for the elderly through the eyes of two caring individuals, Lynne Durham, RDH and Kim Hall, RDH.

Lynne Durham is a natural change agent — a real go-getter. She is a full-time clinical hygienist and also president of the new North Texas Dental Hygienists' Association. Kim Hall was burning out. She knew her interest in dental hygiene was waning. She longed for someone to enter her life — a mentor who could lead her into a new and exciting dental hygiene arena. Fortunately, the lives of these two women became intertwined. They spearheaded the Texas nursing home project. Their lives are changed forever.

Lynne's account of her visit with Martha leaves her longing for a portable X-ray machine. Her visit with Velma taxes every critical skill, honed through years of clinical practice, people skills, and hygiene skills. Her encounter with Betty will make us all question "the system" — a system that is built around rules, rules that can defy all logic, and keep scores of administrative staff employed. Lynne's story opens with the following encounter.

Time stands still occasionally and all of a sudden assessing oral health and cleaning teeth seems irrelevant compared to questions from a patient, "Do you know my son Mike? He hasn't been here in a long time. I wish he hadn't put me here. I know what he's up to. He wants to be free to @#$%#$ women."

Something tells me if I want to do a dental hygiene oral assessment, I better leave Mike out of the conversation. I try to talk about myself, "Hello Martha, I am Lynne Durham. I am here to check your mouth. How are you feeling today?" I make sure to lean closer to her and touch her arm. I wait patiently for her response. She looks closely at my face noticing my scrubs. The conversation revolves around her lovely room decorations and eventually to my visit.

After her oral assessment, I am relieved to see that she will be compliant with a prophylaxis and, from a visual exam, it appears that she only has a few decayed teeth and no apparent infection. I wish I had portable X-ray equipment, but that is a piece of equipment our volunteer project could not afford. The project is designed as a visual evaluation only.

The next patient on my roster of six is supposed to be the one resident who all the nurses affectionately say will bite my hand or at the very least run me out of her room. Velma has never had her teeth cleaned. However she does have considerable crown and bridgework.

In the last few years Velma has endured treatment for oral cancer — the result of years of chewing tobacco. Velma's loving and very attentive daughter requested that her mother receive an oral assessment. I note that the guardian permission slip is signed and the physician's health release for dental treatment is complete.

I feel the same way I did on the first day of a summer job at a dude ranch when I was in college. All new wranglers were expected to ride a mount known to unseat his riders by rearing. I rode the horse all day and didn't get dumped until we got back to the barn. I hope Velma doesn't kick too. Velma is just like an alpha mare; she likes to run the herd. Once you get her attention and keep her focused, you can perform your duties. I walk in, big smile, and confidently assert, "Good morning, Velma! I am Lynne Durham. I am a dental hygienist. I am here to check your mouth. I hear you have had some oral cancer. I want to check that everything is OK. May I take a look?"

At this point, I am within firing range and touching her arm. She gives me a wary look. "I don't want any work done in my mouth." I quickly respond, while I am putting on my headlamp and gloves, "Yes, ma'am, I am only going to do an exam and report my findings to a dentist." Velma's daughter reassures her that I will only check her mouth.

As I lean down, Velma opens wide and I record my data. Velma fidgets. I bravely palpate her head, neck, and oral cavity. Everyone is relieved to know I do not visually detect any abnormalities, but I go over everything twice just to be sure.

Velma is getting agitated. "Aren't you done yet?" I get out fast. "If you're done with my mouth, when are you going to check that sore on my butt?" Velma's daughter laughs and says, "Mom, Lynne isn't here to do that. I told you the doctor comes next week."

I discuss my findings with Velma's daughter, making sure that she understands that my evaluation is not a comprehensive dental exam. I let her daughter know that X-rays and a dental referral are things that should be done for her mother. Velma has multiple fractured and carious teeth, which she claims do not hurt; however she needs further evaluation. We also decide that it is unlikely that Velma would be compliant for dental hygiene preventive services. My job is done.

I walk on to catch up to my duties as a volunteer dental hygienist at Lake Forest Good Samaritan Village in Denton, Texas. My friend, Kim Hall, and I are in the middle of a multi-week nursing home project. Today we are trying to finish the dental screenings of the 30 residents of Lake Forest. Some days are easier than others depending on the health or mood of patients and how many of our five volunteer hygienists can be free to work.

Betty is lying semi-prone in bed, her mouth constantly blabbering. She sounds like she is speaking in tongues. She is blind but can hear. Her daughter-in-law is present and helps me hold my flashlight as she fills me in about Betty. Betty is on hospice, which usually means she has less than six months to live. I have read her three-inch-thick medical record cover to cover. I can tell this visit is more for Betty's family reassurance than for Betty.

When I introduce myself, Betty responds to my quiet voice as if she can understand everything I have to say. She turns her head toward me slightly as I begin to palpate her head and neck. I continue to speak softly about who I am and why I am here and all about the project. I ask her questions just to keep the monologue going and she responds by slowing her banter.

Orally, she is remarkably healthy for the teeth she has left, but I am greatly concerned about one lower molar that is completely fractured from the mesial to distal. The buccal half is firm, but the lingual portion exhibits Class three mobility. I show her daughter-in-law the mobile tooth and explain that Betty is at high risk of aspirating the piece if it becomes dislodged.

Since Betty can't communicate, this fractured tooth may have been present for a long time. When I palpate the soft tissue around the tooth she does not wince or moan. I assume she is not in pain, but she needs immediate attention. Luckily, her diet of pureed food and the lack of opposing teeth will reduce the chance of mastication that could dislodge the fractured tooth. I wish I had the emergency training and licensure to handle this situation now.

I discuss Betty's situation with the director of nursing and the social worker. Betty has a number of medical complications, which require the expertise of an oral surgeon, however she is a transportation nightmare. It will require a $500 ambulance call to take her to an oral surgeon to evaluate her condition. This cost would be repeated on the day of treatment.

I call Betty's dentist, who tries to contact an oral surgeon to see if Betty can be treated at her initial visit, reducing the overall cost to her family. Ultimately, a mobile dental practice is called, but they don't treat hospice patients.

So Betty remains with a broken tooth, waiting for the family to finance her visit to the dentist. She is in no apparent oral pain or obvious infection. She is on hospice care. I leave her in God's hands. As soon as I complete my Report of Findings to the ordering/referring dentist, director of nursing, the patient's record, and their guardian, my job is done.

Texas legislation and regulations allow me to conduct one set of dental hygiene services for Betty and no additional services until a dentist sees her. I cannot legally go back and check on Betty if she has not seen a dentist.

We are all practicing hygienists, mothers and wives. We visit the home on Fridays and assist each other with patients when we don't have volunteer assistants. We are not moving at the same pace as a dental office. The nursing home environment has so many limitations. It is just not the same as a private dental practice. The patients are, for the most part, much more complex. The environment is not conducive to delivering dental hygiene services in ways that are comfortable to both the patient and the hygienist.

Lynne Durham and Kim Hall mentored each other in times of doubt. They grew together personally and professionally. They spent a lot of time and emotion on this project and came out on the other side enriched. Their emotions and experiences are real. Their recollections are vivid. They are a credit to our profession.