Thoughts on using epinephrine to achieve profound anesthesia
By Thomas A. Viola, RPh, CCP
I could feel her staring at me long before I recognized who she was. I had noticed her a few minutes before, a shadowy figure waiting patiently at the back of the room. When I invited the audience to take a much-deserved break during my presentation, I watched as she approached me, weaving her way through the sea of people with the skill of an NFL rusher.
When she was in range of my ever-fading vision, I recognized her immediately. It was Betty, one of my dental hygiene students from a few years ago. She had an easy smile and hearty laugh that, in a moment, could light up the room and provide her fellow students with both solace and encouragement.
Yet today, there was no smile, no laugh. When at last I had the chance to greet her, I could see she was troubled.
“Hi, Professor Viola,” she said. Suddenly, tears welled up in her eyes and she looked away. Then she said softly, “You will be so disappointed in me ...” Her voice trailed off and the tears that had hung precariously to the margins of her eyelids now cascaded freely down her cheeks.
My mind raced away as I tried to comprehend. What had happened to this wonderful person to make her so sad? Why would I be disappointed in her? Why would what I think possibly matter so much to her? Although I did not yet know all the details, I did know that she had come a long way to see me and she was seeking some sort of consolation, some redemption.
Quickly regaining her composure and looking flushed and embarrassed, she said, “I’m sorry, I should not have come,” and she turned to walk away.
I hesitated, struggling desperately to find just the right thing to say to her. Imagine that? Tom Viola at a loss for words! Just as it seemed almost too late, I finally blurted, “Betty! Wait! You could never disappoint me!” As she turned to face me, I looked in her eyes and I said, “Who’s the best hygienist?” I had often started or ended lectures with these words, a sort of rallying cry for my students. I paused and prayed for the expected response. Finally, it came.
“I am,” she said, reluctantly and quite unconvincingly.
Well, it was a start.
Over my years serving as instructor of pharmacology to some of the best dental hygiene students in the country, I have learned that each comes away from the course with a different impression of the experience. Some students view pharmacology as a wart, which produces nothing but grief and gives them great joy when it is gone. Some view it as an intense workout at the gym, a necessary evil to endure in order to achieve their ultimate goal. And some view pharmacology as a career-changing experience, where they learn tools and techniques they can use for years to come. Betty was firmly in this last group. She, along with a few other students, would often gather at the end of a lecture with questions about what they had learned and how it related to their current clinic patients. I had heard it before; “It’s like you’re in my head,” they would tell me. “I hear your voice over and over again, like a whisper, reminding me to make sure I ask my patient this or make sure I do that.”
Now, despite my parents’ near-constant reminders during my youth that I would surely drive them to insanity, I don’t attribute these students’ description of their experience with pharmacology to any sort of mental illness that I may have induced. Also, I don’t consider myself some all-knowing “Drug Whisperer” who needs a show on a cable channel.
To be honest, I live in awe of all of you, who, in a few short years, have to master a challenging didactic curriculum, the art and skill of instrumentation and clinical practice, and demonstrate sufficient proficiency in both for final accreditation by standardized and peer-judged examination.
Betty described how she had recently seen a patient who was scheduled for scaling and root planing and required local anesthesia. Betty had reviewed the patient’s medical history with the dentist, and they agreed that the patient required no special precautions for the use of local anesthesia with epinephrine. Betty administered the injections with precision; the patient had even complimented Betty on her technique, exclaiming that she had never experienced such painless injections.
However, about 30 minutes into the procedure, the patient complained to Betty that she did not feel well. The patient said that her heart was pounding and she felt shaky and light-headed. After 20 minutes, the dentist decided to call 911. The patient was transported to the emergency department of the nearby hospital for evaluation. Upon arrival at the hospital, the patient’s symptoms had already improved and she was discharged without incident. Betty called the patient at home later in the day. She said she was fine and suffered no ill effects. She even asked to reschedule her appointment.
Following the incident, Betty painstakingly reviewed every detail of the procedure again and again, yet she could find nothing wrong with her technique. She described how she had agonized over the situation for days, how she couldn’t sleep, and how it affected the other aspects of her practice. She had lost confidence in herself and her skills. In the end, she was so unnerved by the experience, she decided she would never administer local anesthesia again.
She said, “I know you always said I should never give up, no matter what. But I just can’t help it. I’m sorry, I feel like I wasted your time as my instructor. I just thought you should know ...” And she turned to walk away again.
“Wait, Betty!” I said. “Please have a seat.”
Her timing could not have been more perfect. I was just starting the part of my presentation where we discussed local anesthesia. Abandoning the usual order of my presentation, I jumped ahead and asked the audience about their experiences with using local anesthesia with epinephrine. While I left a few scratching their heads and flipping pages back and forth, many audience members immediately raised their hands and were eager to weigh in on this long-standing issue.
The question has always been the same: Do the benefits derived from using epinephrine to achieve profound anesthesia — slow systemic absorption thereby minimizing local anesthesia-induced effects on other organ systems — outweigh the risk of unwanted epinephrine-induced adverse effects in some patients? I asked the audience to share any encounters they had with patients who had experienced adverse effects from the use of local anesthesia with epinephrine. One after the other the stories came, adding further fuel to the already blazing discussion.
At the next break, Betty shook my hand and said, “Thank you, Professor Viola. You don’t know what this means to me.” As she turned to leave, she said, “I can never repay you for what you have done for me” and gave me that great, big Betty smile.
Little did she know, she just did. RDH
Thomas A. Viola, RPh, CCP, is a practicing pharmacist and pharmacy consultant as well as a professional speaker and writer. He is a member of the dental hygiene faculty at Harcum College, Manor College, Middlesex County College, Burlington County College, and Bergen Community College. Tom offers CE presentations on dental pharmacology and local anesthesia to dental professionals nationally. To contact him for speaking engagements, call (609) 504-9252 or email [email protected] his website at www.thomasviola.com, and find him on Facebook at www.facebook.com/dentalpharmacology and www.facebook.com/dentallocalanesthesia.
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