Perspective was everything sometimes.
“So how did it go?”
Jamie didn’t bother to look up at the door. Dr. Zeigler (who liked to be called Dr. Z), the only staff doctor working that day (Dr. Shapiro, the man who actually ran the clinic, was on vacation in Buffalo for the holiday weekend), possessed a deep, jovial baritone that could not be confused with the voice of any of the assistants or other residents who worked at the clinic.
“I had to refer him to a pediatric dentist. The kid was already hysterical when he sat down, and his mother only made things worse.”
“The only thing you could do. I wrote the mom a prescription for antibiotics. Should help some.”
“Still, I feel bad that I couldn’t do anything for him. Number A was rotten to the gums.” Baby teeth were referred to by letters, adult teeth by numbers.
“It’s hard,” Dr. Z agreed, “but one of the most important lessons you learn when it comes to dentistry, as well as most other things in life, come to think of it, is knowing when you’re getting in over your head and stopping before you even start. Knowing your limitations as a person and a professional. There’s a reason why god created specialists.” He emitted a low noise that was cross between a grunt and a laugh at his own joke. “You can’t save the world, Dr. Whitman. But we do what we can and only what we feel comfortable doing.”
Jamie couldn’t help but to smile. He sighed and lifted his head and looked at Dr. Z. The big man always knew what to say. Not only had he toiled away in private practice for twenty-five years, he had also served as the president of the American Dental Association for four years. The man was a practically a dental god who understood the profession from the practical, business, and legal angles. Jamie couldn’t have asked for a better mentor.
“Thanks,” Jamie said as he stood. He walked past the attending’s six foot two, two hundred and fifty pound frame towards the door. A true gentle giant Dr. Z was, always cradling a cup of water in his right hand, always willing to get his hands dirty for the sake of education. His hands were large, his fingers sausage thick and requiring extra-large gloves, but the delicacy with which he manipulated dental instruments inside even the smallest mouth was awe-inspiring. Jamie wondered if he would ever be as skilled. He doubted it.
Jamie left the faculty lounge and turned into the hallway which contained all eight of the clinic’s operatories, four to the left, four to the right. The place was empty today, bereft of the bustle and noise that six resident dentists, two teaching doctors, ten assistants and dozens of patients, caused on a normal day. But it wasn’t a normal day. It was the Friday after Thanksgiving and everyone else was off. He could have taken off, too, but he had nowhere better to be. Dr. Z had asked if anyone would volunteer to see some squeeze-in patients and emergencies, and Jamie had volunteered when no one else would. If he had known how hectic it was going to be, maybe he would have taken off, too.
Jamie made his way to Operatory 2, where thirty-five year old Bunny Watkins was recovering from the simple extraction he had performed before attempting to get Khalif Jones numb.
Bunny was a new patient who had presented with severe pain of three weeks duration in her upper left jaw. She experienced sensitivity to cold and air as well as pain upon chewing. She claimed she had no allergies and was taking no drugs for any chronic conditions such as diabetes or hypertension. She denied use of any narcotics. Jamie knew that this was a lie but he hadn’t pushed her for the truth.
She was five foot five, as Jamie judged, and easily weighed one eighty. Her clothing was tasteless and inappropriate for someone of her shape; she wore a tight yellow tank top cut off above her belly button despite the bitter weather outside, exposing a rotund and heavily scarred stomach, and a pair of spandex tights which accentuated her large ass and bulging thighs. Her dirty blond hair was braided into a field of filthy cornrows, each braid tied off at the nape of her neck with a yellow ribbon. Her face was a topographical nightmare of crusty craters, acne and wrinkles. Her eyes were dark, the heavy bags underneath even darker. Her mouth was a nightmare.
Jamie had performed a quick clinical exam after reviewing her history. A normal adult, assuming the four wisdom teeth had been extracted, had twenty-eight teeth: fourteen up top, fourteen on the bottom. Bunny Watkins had half of the normal fourteen in each arch, and most of what remained was fractured or dark with decay. Bunny would be in dentures by forty at the latest.
In a mouth filled with so much pathology, it was sometimes difficult to determine which tooth was causing the patient distress. Oftentimes, it was more than one tooth. But Jamie was lucky this Friday. He tapped each tooth in the upper left with the handle of his mirror. When he tapped the last tooth, the woman’s first molar, Bunny moaned, a truly disgusting, pathetic sound. He wondered if those were the same noises she made when having sex, gagged a bit, then chastised himself for even thinking that thought. He swung the head of the mirror around the tooth, examined it from every angle, and mentally formulated a diagnosis in seconds. The gums were strawberry red, unhealthy, infected. A large abscess throbbed beside the tooth on the cheek side. The tooth itself was heavily decayed, the rot probably into the nerve. A quick x-ray confirmed Jamie’s diagnosis. The pulp was infected, the blood vessels and the nerves within the tooth nothing but pus. In addition, the bone around the roots of the tooth was infected. In a healthy mouth with healthy gums, Jamie would have suggested a root canal followed by a cap. But Bunny Watkins’ mouth was far from healthy and her gums were as infected as the tooth itself. So much bone had been lost to rampant periodontal disease that the molar moved when he applied light pressure.
Jamie had told Bunny that his diagnosis was a necrotic pulp accompanied by severe periodontitis. The prognosis for the tooth was poor. It was not salvageable. The only possible treatment to alleviate the pain was to extract it, and she had readily agreed.
Five minutes after getting her numb, Jamie held the bloody molar in his hand. The extraction had hardly been a challenge; the bone which still encased the roots was so compromised that it gave up the tooth without much struggle. Still, despite the ease at which he had performed the extraction, he felt a sense of accomplishment. After all, he had relieved his fellow human being of pain. At least until the next tooth began to rot and fester and abscess.
Jamie had compressed the now-empty socket with his fingers to decrease the bleeding then had the patient bite on gauze. Leaving another assistant in the room to monitor Bunny and make sure she didn’t pass out, Jamie left to attend to Khalif.
Now, twenty minutes after leaving Bunny Watkins to recover from the procedure, he re-entered the small operatory. Smiling, he stood before the woman, who still looked as if she might pass out. “How are you feeling?”
“Like you pulled a fucking tooth out of my head.” There was little humor in her raspy voice.
“At least you’re taking it well,” Jamie returned, trying to lighten the air. He had Bunny open her mouth so he could remove the gauze. He examined it quickly and determined that the bleeding was basically at an end. He stuffed a new piece in and had her close.
“Okay, before you leave, I’ve got some post-operative instructions for you.” Jamie had done this dozens of times, and he ticked each instruction off in his head as he spoke. “Keep your diet soft for the next twenty-four to forty-eight hours. Also, nothing too hot or cold or spicy. For the next forty-eight hours, no doing anything that will change the pressure in your mouth. No sucking through a straw, no spitting, no smoking.” Bunny’s eyes widened, which didn’t surprise Jamie. The amount of stain on her teeth, the stink of stale smoke on her breath, and her harsh voice betrayed her addiction to cigarettes. He continued. “Doing any of those things can dislodge the blood clot at the base of the socket, exposing bone and causing extreme pain.” He doubted she would heed his warning, especially when it came to the prohibition on smoking, but he wasn’t her mother. His responsibility ended at giving the instructions and explaining them as best as possible. He couldn�
��t enforce them. “Use an old pillowcase tonight or put a towel over your pillow. Even thought this was a routine extraction and the bleeding has stopped, there is always the chance that it will ooze overnight, and I don’t want you ruining a good pillowcase.” As if this woman had good pillowcases. “And lastly, for pain, take whatever you normally take. Advil or Tylenol or Motrin will work fine. Just stay away from Aspirin because it can interfere with the clot and cause bleeding.”
“Aren’t you gonna’ give me something stronger for the pain?”
“No,” Jamie said. “It was a simple extraction—no cutting of tissue or bone was required. The tooth came out easily. Regular Tylenol or Ibuprophen or Naproxen will be enough.”
“You don’t understand.” Bunny stood. “That stuff, it don’t work on me. I need a prescription.”
Jamie steeled himself. This wasn’t the first time, nor would it be the last time, a patient tried to wheedle narcotics from him. Five months ago he would have given in, written her a script just so she would go away and leave him alone. To avoid confrontation. But not now. He wouldn’t be a dealer. He only gave pain meds if he thought the procedure warranted it.
“I’ll give you an antibiotic, some Penicillin if you want, but I’m not giving you any drugs.”
“Drugs?” Bunny’s desperation instantly turned to anger. She threw her arms out to the sides, displaying a considerable amount of ink on her flabby arms. “So because I have all of these tattoos, you think I’m a drug addict?”
Jamie had taken note of Bunny’s arms when she first sat down, admiring the various flowers and butterflies and birds and cartoons which had been stenciled on her pale flesh. But he had seen more than the tattoos. No, Jamie thought to himself. It’s not the tattoos, it’s the track marks. She had at least a half a dozen on each arm, hidden among the dozens of pieces of body art and dozens of varicose veins. He would never have seen them if he hadn’t been looking for them. Five months ago he wouldn’t have even thought to check. Now it was second nature. What a difference half a year made.
“It’s not you,” Jamie lied. “We simply don’t dispense narcotics unless we feel there’s a need to.”
“I’m not leaving here until I get something stronger than fucking Tylenol. I need some Percocet or Vicodin. My mom’s sick these days, with cancer, and I can’t take care of her if I’m crazy with pain.”
There were so many things wrong with that statement that Jamie didn’t feel like arguing. In a single minute, this mountain of a woman had drained him. He sighed. He knew what she was doing. She was bullying him every which way she knew how, hoping that he would break down and bestow upon her the drugs she was looking for simply to get her to leave. He wasn’t going to bite, though. Not even on a Friday. “Look, wait here a minute and I’ll see what a can do.”
Bunny crossed her arms over her massive breasts and smiled in victory. The look was not pretty on her piggish face.
Five months ago, when he started the residency, Jamie would have run to the attending for advice. Or he would have asked the attending to talk to the patient. Shifted responsibility. But he wasn’t new at this gig anymore. He would be in the real world in a little over six months and he would have to deal with difficult patients and their difficult demands on his own. And sometimes that meant making tough decisions and standing his ground before an obstinate and demanding patient. He couldn’t allow himself to be shoved around just because he was young.
While in school, Jamie would have considered two options: Give the patient what she wanted, or give her nothing. But five months of real world training, hundreds of hours of patient care, had taught Jamie that there truly was more than one way to skin a cat.
He slipped into the staff room and pulled a prescription pad from a drawer. He scribbled the word Dolobid on the blue sheet, followed by the number he wanted dispensed—fifteen—and directions. He filled out a second sheet, this one for Penicillin, with the same info. He brought them to Dr. Z in the back, who was browsing the latest ADA newsletter, and asked him to sign them. Dr. Z gave the ‘scipts a cursory glance and signed his name and DEA number. Jamie quickly returned to Bunny’s room. Lunch was in forty minutes and he had one more patient to see. He wanted to end this.
“Here.” Jamie thrust the two sheets at Bunny, who snatched them from him. She looked at one, then the other. Her eyes darkened and her lips curled in a scowl.
“What the fuck is this?” she asked. “This isn’t what I asked for.”
“I know. You aren’t getting what you asked for. Dolobid is stronger than Tylenol or Aspirin or Advil, but it’s not a narcotic. You’re not getting anything with codeine or oxycodone or hydrocodone in it, Ms. Watkins.”
“But I need it. You don’t know how much pain I’m going to be in tonight, and I’ve got to take care of my sick mother and my son.”
Now a son added to the picture. “More of a reason not to give you Percocet. It’ll only make you groggy, and you can’t be tired if you have so much responsibility.”
For a moment, Bunny was at a loss for words. She had tripped up badly and she knew it. Whether the sick mother and child were real or invented was inconsequential. The words had left her mouth, and Jamie would be derelict to give a woman with so much responsibility a drug which would cause her to fall asleep.
Jamie and Bunny looked at each other, neither speaking, for several moments. The silence was broken finally when Bunny said, “I’m not leaving until you give me something stronger. You just tore a tooth from my fucking head and I need something for the pain.”
“Yes,” Jamie returned, “you do need something.” Like drug counseling and detox. “Advil and Dolobid. Nothing more. That’s all you’ll need.”
“And who the hell are you to tell me what I need?” Bunny Watkins suddenly hissed. She tossed the two prescriptions on the floor.
“Who am I?” Jamie said, tiring of this circular banter. “I’m your doctor.”
“You’re not a real doctor.” This with venom. “You’re a fucking med-school drop out.”
Jamie had the sudden urge to wrap his large hands around the rolls of skin which hung from Bunny’s neck and throttle her until her pasty features turned blue. Such a lovely color for you. Perfect lyrics from one of his favorite bands, A Perfect Circle. But he restrained himself. He was a professional, not an animal. He was a doctor and he would behave accordingly. He saw his mother, bloody. He saw his father, gleeful. He gave Bunny Watkins the coldest look he could muster and curled his own lips into a small, icy smile. “Please leave, Mrs. Watkins. And keep in mind that if you ever come back here, whether it be in five weeks, in five months, in five years, you will never be given Percocet at this clinic.” He reached into the bin next to the door and pulled out her chart. He held it up between them. “This is your chart. This is your permanent record. This incident will be recorded in detail. Now go.” And never come back. Without waiting for a riposte, Jamie left the room.
But he knew she would be back, though, if she ever had a toothache again. The clinic was the only dental center in a thirty mile radius that accepted Medicaid. Maybe the next resident who saw Ms. Bunny Watkins would be more sympathetic to her needs than he was. Maybe he would be more intimidated by the woman, more susceptible to her bullying than he had been. But in the end, that was inconsequential. All that mattered right now was that he knew he had done right by his own ethical compass.
Without missing a beat, he walked into the operatory next door and picked the chart up from the bin on the wall, slipping Bunny’s chart into the now-vacant bin. Paul Rogers. Another emergency patient.
“How are you doing today, Mr. Rogers?”
“Not good,” the man in the chair replied. He was wearing a three-piece suit, charcoal, with a white shirt and blue tie. His salt-and-pepper hair and his moustache were groomed precisely. His black wing-tips were spit-shined.
“I’m Dr. Whitman. How can I help you today?”
“I need all of my silver fillings taken out, doc.”
/> It was a request that Jamie heard often these days as the media perpetuated a mercury scare that had no basis in actual science. Just like the imaginary vaccine-autism link. He would do it, remove silver fillings, had done it several times before, but only if the fillings to be replaced were small. And only after he had educated the patient on the true nature of silver fillings. “That’s doable, Mr. Rogers,” Jamie said, “but I would hardly consider that an emergency. You really need an exam and some x-rays so we can develop a treatment plan first.”
“It really can’t wait, doc. You see, there are aliens who are contacting me through the metal fillings. They want me to do things. Bad things. I need to get them out now before I do something I regret.”
Jamie sighed as he sat down the chair. He thought he had heard everything but this was a new one. He wondered if he would get to lunch.
Chapter 3
Jamie did eventually get to lunch, though he only enjoyed a forty-five minute break instead of the usual hour. He had spent way too much time dealing with Mr. Rogers, and the conversation had run into his lunch break. But that was okay. He had taken some x-rays, conducted an exam, and successfully (he hoped) convinced the man that no one was talking to him through his fillings. He hadn’t done any actual work, just told him that he needed to return for a cleaning and only then would he consider replacing some fillings if he really wanted to. Mr. Rogers had left content, and Jamie wondered if he would actually return.
He wondered if the man would possibly go on a shooting spree or kill his wife. He doubted it, but there was always that small chance… He would have to watch the news tonight.
Jamie’s afternoon schedule proved to be very similar to the morning: a brutal exercise of patience and self-control. His first patient after lunch was Gary Surhoff. He was there for an initial exam and a cleaning. X-rays and a clinical exam revealed nothing of interest except for a lower molar with an old root canal which had become re-infected.
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