Veterinary dentistry, nerve blocks, complications...and late posts
Today started late. That was my fault. From there, things devolved in ways that evoked Hieronymus Bosch’s version of Hell more than they did a pre-New Year’s Eve weekday. Not so much my fault. But that’s debatable.
Picture me wearing my veterinary dentist’s hat. This was around 9 AM. First patient of the day. The anesthetics went well. My older patient was doing great. The results of full mouth X-rays talked me into removing a significant percentage of her teeth, but that was to be expected based on her physical the week before.
I started on the left side where four extractions worked out beautifully. Here’s the process for each tooth: Inject a nerve block for local pain relief (very useful even though the patient is under general anesthesia), make an incision over the gums, flap the tissue back, apply the high speed drill to remove the adjacent bone, tease out the tooth with an elevator, finish the “pulling” with an extractor, smooth out any leftover bony spicules to eliminate bacteria-hiding crevices, take another X-ray to make sure the whole tooth is out, and then...sew up the gap.
It’s easy. Not really, but by now it’s old hat for vets like me. Though every tooth is different and some prove a b---- to extract, the process is almost always the same. The tough part is dealing with the vagaries of the canine and feline anatomy: working with funky tooth fractures and other interesting pathology, getting all the way back in a mouth with a tiny opening, sewing up teensy holes with almost no tissue to work with, running up against vessels that aren’t typically so large or superficial... It all makes for an interesting time, but it’s 99% uneventful, nonetheless.
Too bad today’s patient didn’t turn out that way. While the waiting room was filling up with “emergencies” (some of whom had been months in the making), I suddenly realized––after finishing up on the four left-sided teeth, turning her over and starting on her right side––that my patient’s right eye had suddenly become swollen. I mean really swollen. Next thing I know and my patient’s eye is literally out of its socket.
It all happened so fast I almost couldn’t believe it was happening. To my tech: “Tell me I’m not crazy and you see the same thing I do.” And just to make sure: “She wasn’t like this when she came in, right?”
Most definitely this was worsening by the second. Which is when I applied a cold compress and pressure after adding some lubricant to the cornea. Then a review: Calmly now, let’s recap this dog’s physical findings, labwork and recent events. 1) Normal bloodwork, urinalysis and physical exam (except for periodontal disease, of course), 2) evidence of abscessed tooth roots nearby (for teeth which I hadn’t yet extracted), and 3) I’d just given a local nerve block seconds before.
If I were a betting woman, I was thinking––as I tried to think rationally, against the clock––I’d stake a good bit on this being the nerve block’s doing. Though I can’t for the life of me figure out how, seeing as it’s never happened to me before, seeing as I’ve never read about this as a possible complication, seeing as I couldn’t imagine how a 1/2 cc dose of bupivicaine might lead to an eyeball on the loose... I just. couldn’t. figure. it. out. Not on the fly in the middle of an early-ish morning stress-fest, anyway.
Good thing I managed to get the eyeball back in, sew it in place and keep it moist and happy. I abandoned all efforts to extract the abscessed teeth on that side, of course (thinking that any extra swelling would not be a good thing), and that’s when I did what I do best: read up on what might’ve gone wrong and call around to my colleagues for insights.
In the end my book smarts won out and it turns out I’d more than likely lacerated the palatal artery in my attempt to alleviate pain. The needle I’d used for my nerve block probably did the deed, slicing through a big bleeder in a place I’d not imagined it would be (sometimes blood vessels do this). Though I’d aspirated before injecting the nerve block, it took me a teensy bit of “fishing” before I’d entered the safe spot in the skull through which I inject the local anesthetic. That did it, I figure. Nothing less than a lucky stick would do with a big artery in the way.And mine was decidedly NOT a lucky one.
So was it my fault? Hell no (even Bosch would agree). But it WAS my doing. Which is why I comped all the owner’s costs related to the eye care––including the visit to the ophthalmologist tomorrow, just to be sure everything checks out 100%.
So you know, not everyone agrees that’s how things should be done. If it’s an “accepted complication” (and vessel laceration IS an accepted complication when it comes to pain-relieving nerve blocks) then the owner should pay for any necessary work after the fact. After all, if all doctors were responsible for all costs associated with all complications there would be no OB/Gyn’s, no anesthesiologists and no neurosurgeons since complications are common for these fields.
But then...where do you draw the line? Was there human error in my work or was it just bad luck and/or atypical vasculature? However you slice it, I did a good job. I know that. But it doesn’t keep me from feeling guilty...or entering this post as late in the day as any I’ve ever submitted. :-(
PS: My day...by Dr. Patty Khuly ;-)
PPS: That's me in the lower left hand corner.
Image: hz536n/George Thomas / via Flickr