Monday, July 23, 2007


I am not a dentist. I know more about teeth and injured teeth and abscessed teeth than most folks but I can not fix your cavities, your meth-mouth, or your impacted wisdom teeth. I know you know this but you come to me anyway and I'm tired of it, especially when the conversation goes like this:

Me: "How long has your tooth been hurting?"

Patient: "Eight months, but it's much worse today."

Me: "What does your dentist say?"

Patient: "I don't have a dentist."

Me: "Why?"

Patient: "Because no one will see me without payment up-front."

Me: "Well how are you going to pay your bill here today?"

Patient: "Oh, the government pays for me to come to the ER."

Me: "The government?"

Patient: "Yeah, I have _____-Care, it's free."

Me: (swallowing hard and doing tantric breath control) "Well, I can't fix your tooth I can only make it feel better. You are going to have to see a dentist or you may end up with a severe abscess and have to go to the operating room. If you see a dentist they may arrange a payment plan with you and you can get your tooth pulled for a few hundred dollars. If you wait and have to go to the operating room your bill will probably be over ten-thousand dollars and some people die if they let these get away from them."

Patient: "I can't afford it."

Me: "Do you smoke?"

Patient: "Yes."

Me: "How do you afford your cigarettes?"

Patient: "My father buys them for me."

Me: "Maybe he can pay for you to see a dentist."

Patient: "Oh, he can't afford that."

Me: "How did you get here today?"

Patient: (cell phone ringing, pt answers it and tells caller that the doctor is in the room) "I drove."

Me: "Well how do you pay for your gas?"

Patient: "Oh, it's my brother's car."

Me: "Well maybe he can help you pay to see a dentist."

Patient: "No, he barely let me borrow his car."

Me: "Well, as I said, I can't fix this, only a dentist can, so you are going to need to figure out a way to afford the dentist. I can give you some motrin, pain medicine, and antibiotics but they won't fix this, only make it more tolerable."

Patient: "Do you have samples?"

Me: "No we do not."

Patient: "Well I can't afford any medicine."

Me: "Well why did you come in then?"

Patient: "Because it's free."

Me: "Your medicines will cost about $15. You will have to find a way to get them. Good day."

Dentists are outside the scope of EMTALA, they must have a good lobby. I don't blame them and, in retrospect, dental school looks pretty sweet.


  1. Can't you pull the tooth in the ER?

  2. as i understand it it is not that hard to do but we are not trained to do it nor are we credentialed to do it. there are complications that we could create such as a fractured mandible or maxilla. so no, we can't do it. good question though.

  3. We have a big 'ol packet of "Free or Reduced Price Dental Clinics" we give people. If your place doesn't have one of those, someone should make one.

    The packet, abx, and a local anesthetic. Very unfun treatment to ensure non-repeat customers.

    Speaking of dental schools, every dental school in the world will pull your tooth for cheap.

  4. we have the list. we give it out. we do local anesthesia. they keep coming! in semi-rural-burbia where we are there is no dental school. the 'free clinics' take 3 months to get into. that being said the local guys will do payment plans so my sympathy does not runneth over.

  5. I really don't know how you do what you do and still manage to like people. I get so frustrated when people don't at least make an attempt to try and solve their problems that I can just not stand it. If I had to deal with it all day like you do, I would not be fun to be around! I am extremely patient with kids, but with adults I seem not to be!

  6. radioactive,

    You make a great point. Sometimes even I wonder how I can do this and keep liking people.

    It's the 19 year old girl with PSVT (rapid heart rate) who you fix w/o meds (more than once.) She needed the doctor.

    It's the 35 year old in an MVA (not his fault) who needs stabilization and eventually walks out of the hospital.

    It's the 55 year old heart attack victim who gets to the cath lab and gets that artery opened.

    THAT'S why I do it. The others...just a job complication, something to do in between real emergencies.

  7. I can't tell you how many times I have been told that "I can't afford a dentist". And this not only by ____care people, but also by selfpays. I try to explain to them that it is like buying a car to get the radiator by coming to the hospital instead of the dentist for teeth problems

  8. Every time I start getting my ass handed to me in the department, I ask my self why oh why didn't I become an orthodontist.

  9. Grrrrrrrr. People can push my buttons so easily with stuff like that. I am impressed you kept your temper under control.

  10. I bet Dr X can pull teeth... and i bet (for some odd reason) he doesnt bill for a local anesthesia either....

    Doc H, USN

    Btw, ever since the HM/DT merger, us HMs have been supposed to be completing our dental cross training.. needless to say, it hasnt gotten done.. "Dammit Jim, Im a corpsman, not a fang fairy"

  11. Oh yes I can pull them! But I've never pulled one on someone who really wanted it pulled.

    раскройте ваш рот!

  12. My town has a dental school and the dental students do rotations at the county hospital, where most of the work is extractions.

    The dental school does work for cheap - $14 for a cleaning in a town where the dentist who has a license with DRY ink charges $60 - but even the dental school requires a $50 cash deposit before undertaking emergency dental work.

    That's the deal you need. The ability to charge $50 to anybody capable of ambulating through the door under their own power.

  13. ahh yes, dental school. Still a worthy option for me... medical school headaches = scary.

  14. Yes dentists have a much better lobby. Physicians and surgeons have been subsidizing the dental profession in this country for decades. It's just proof of how stupid politicians really are that they haven't figured out how to fleece this golden lamb.

    And yes people DO die of bad teeth. I've taken care of these folks when they've been admitted. Is ANY number of cigarette cartons, cell phones, cars, big screen TV's worth risking this complication?

  15. This is so utterly inane, that I think it'll make a great opener to a chap in my book.

  16. Nary a day goes by that I don't regret not going to dental school. Out of college I didn't know what I wanted to do so I took the DAT and the MCAT. Got accepted to medical and dental schools and basically flipped a coin. Should have chosen tails.

    The teeth thing- until our/your hospital gets an NP in triage and kicks 'em out at the door, you still have to say "hi, I'm Dr jackass. how can we help you?". The thing is they wouldn't think twice about plopping down cash for a new water pump or alternator for the car that doesn't take them to a job they don't have. But to fix a tooth? Noooo.

  17. Was that patient Dennis Kucinich in disguise?

  18. dear john,
    i must admit that the kucinich reference is lost on me only because i can't stand the aggravation of following politics anymore... reminds me too much of work.

  19. NYET! Dr X

    you stay away from me you bad bad man!

    Doc H USN

  20. Link

    President Bush suggests uninsured children go to hospital emergency rooms for their care.

    After the Senate Finance Committee approved an expansion of the federal Children's Health Insurance Program to cover nearly 10 million kids, President Bush offered a strange rationale for threatening to veto it.

    "People have access to health care in America," he told an audience in Cleveland. "After all, you just go to an emergency room."

  21. mark,
    please see previous post on paul krugman.

    as much as i disagree with the statement "just go to the emergency room" it is, in fact, true. everyone who comes gets seen, it may not be in 30 minutes, but they get seen.

    also, as you no doubt know, i am a fan of personal responsibility and believe that the attitude that the government is the solution for social ills is a bit, well, crazy, based on, well, a million times it has been tried here and elsewhere.

    cheers and power to the people

  22. I just copy and pasted. I also think emergency rooms should be for emergencies. Just showing pres Bush has the wrong perception of what an ER should be for.

  23. agreed. i also think that there is no separating what he or any president says from the politics. i think he's playing chess, or checkers if you like, and trying to avoid growing another govt. beaurocracy. that being said i am soured on politics and having to have four people check your public statements for fear of offending person X or group Z. i do think that with incrementalism ruling in our system that expanding government funding of any service will never be reversed. in other words, a little here and a little there will lead to a whole lot later. simply look at the near bankrupt ponzi scheme of social security which started as a little acorn but has grown into a grotesque, deformed, diseased oak.

  24. sorry, never could spell bu·reauc·ra·cy

  25. This drove me CRAZY when I worked in the ER...

  26. Just today I had 2 such dental pain patients. Unfortunately, they were both to abscessed (golf-ball size).

    With no dentists in sight and two uninsured, unable-to-pay-for-a- dentist patients, these cases can be tricky and frustrating.

  27. I create a problem for none of you other than my primary care doc,

    Trip to ER is 150 clams with private insurance out of pocket regardless if it is an itch scrath or I am dying. My scars and chewings from the primary care"why the hell didn't you go to the ER tightwad, too late to stitch now" confirms this. The few times I have gone < than 30 minute wait, admitted more times than sent home. 3 of 5 to be exact and " why the hell did you wait this long?" from ER doc. 2 I wasnt admit same answer for er doc.
    As for teeth, Rip them baby teeth out so I can get me some permanent teeth. What sit in a jar at night.

  28. Please ignore :2 I wasnt admit same answer for er doc.
    i just typed it and have no freaking idea what I was trying to say

  29. In my experience, the only friggin time I've ever had tooth pain just happened to be on a friday night after 8 pm...and on a 3 day holiday weekend no less....however, so many years ago, I had horrible wisdom tooth pain while I was pregnant with child #2, one of the big city hospitals actually had a dental clinic inside, so I get a ride 40 miles to the hospital at 11:30 at comes in, does reason he can tell that I should be in that much pain other than the tooth itself wasn't aligned he could figure was that it was more of a "nerve", he gave me a couple of shots of novacaine and I went home with some tylenol with codeine...that was labor day weekend and he gave me enough tylenol to make it til wednesday til I could see the dentist...nice guy that doc...really helped me out..but it just so happens that the few times I've had tooth problems, it happens to be a Friday night...
    that's just NFR!!!
    but that's my luck! LOL

  30. Of course, the ADA has not sold out to the govt (AKA Medicaid/Medicare!!!!!) Yes, people suffer and in fact people actually DIE (INFECTION!) but they refuse to be bullied by bureaucrats!. The AMA has sold their soul to the devil (in the form of contracts with the gov', medicare/medicaid.)Why they would do such a thing is so beyond me!!!!! The ADA has not. Dentists are true capitalists.
    Oh, and btw, my daughter was born without her maxillary lateral incisors.
    I considered getting her implants at the local big city (45 mil away) dental school (renowned--so they say) and in fact, decided to pay less(!!!!!!--they actually quoted me a price that was so ridiculous that I laughed out loud on the phone!) to a local dentist for implants (of course not anything like Medicaid would pay!--in fact, I'm paying for this guy's first born's college education!) My daughter, so far looks gorgeous, I have not sucked out any tax payer dollars and I am certainly still working my butt off to pay for her implants!!!!
    Maybe one day, I will live my dream and become a dentist!

  31. Doc,

    I think that client doesn't need a dentist.

    He needs a psychiatrist.


    Maybe he can get rid of his aching tooth for free by signing up as a sparring partner of Mike Tyson. Instead of paying, he could even get paid.

  32. People like this guy (patient) have caused many ER to close their doors. ER can't deny patients and they wouldn't pay their medical bills. "Government pays for it," a B.S!!! Tax payers pay for it. And then, all the real people who really need medical attention from doctors have to suffer.

  33. I know this is old, and I apologize, but I have been going back and forth trying to decide MCAT or DAT, and I work in a dental office which was causing me to lean towards MCAT(!). This post was a push in the other direction. Sheesh!

  34. It's doctors like you that are assholes.I'll tell you what.I've worked my whole life and had health benefits with a dental plan and I couldn't afford the dentist.
    I've got bad teeth,and always have.My mom would bring me regularly to the dentist and the idiot would drill and fill everytime.He would drill so much that my teeth were very fragile and being a grinder in my sleep mit wasn't long before root canals were needed.
    Dental insurance only allows so much and when a dentist insists on doing different procedures than what you came for,it eats into your allowance.I'd get a root canal and not be able to afford $1000.00 crown out of pocket.Other obligations you know.
    Anyway...I'm not a meth or crack head and took care of my teeth as best I could.
    But like I said...I grind my teeth in my sleep and have had overzealous and greedy dentists destroy my teeth further and never end up getting the needed dental work.
    You are an ER Dr....don't pass judgement and just do your freaking job

  35. thank you, anonymous, for explaining in very clear terms, why i am quitting ER medicine. good luck in life, you will obviously need it, pretty soon your gravy train will not be pulled by me anymore.

    oh, by the way, the whole point of this post was to explain, in very clear terms, that i am not a dentist, i am not trained as a dentist, i can not do dental procedures, and that people who come to me wanting dental care are wasting their time and money because i can not help. it's like, in the title dude. people with dental problems need, drum roll please, a dentist, and the only reason people like you come to me is because you know you will not pay me but will have to pay the dentist. so, in all seriousness, fuck you.

    yet i remain, as ever,
    your humble servant,


    You fuckin' idiot. Think there's a dentist hanging around the ED just waiting for someone who can't/won't pay him/her for his service?


  37. To a dentist, there's no such thing as a "dental emergency" unless you've got cash. I've HAD dental emergencies and I empathize with patients.

    Still, I can't do much about their problem. Patients refuse to believe that there is no dentist on a medical hospital staff, and not one that I can call in, nor one sleeping in the next room with gown and glove waiting to whisk into the room and perform a painless full mouth extraction with dental implants for free.

    Nor do they believe that I had no dental school training, have no hospital credentialing to perform dental procedures, no dental equipment, and no malpractice coverage for dental procedures.

    I do what little I can to help (when appropriate: local anesthesia; packing; I&D; antibiotics; pain medication; education; etc), but as this Anon demonstrates so well, these are very, very ungrateful patients!


  38. I know exactly what it's like. I have been experiencing severe toothaches for a year now and although I have dental insurance, I have just used up my deductible, no dentist is willing to help me. The next dental schools are too far away and for the free clinics I earn too much. I am right in the middle and have to rely on Advil to get by one day at a time till the next year begins and I can have another of those wonderful root canals. Then it's wait another year and probably the other tootch will start aching and this will go on and on because by the time I am through the other teeth will have gone bad because I couldn't afford to have them checked upon. And they call lawyers bloodsuckers, even they work for free sometimes.

  39. Why should they work for free? Why dont you take whatever job it is you do, and try doing it for free for a month. How'd you feel about that? Not too great? Well, go figure.

  40. LMFAO!!! I am working the graveyard shift in the ER RIGHT NOW and it is so slow but i seriously just discharged a pt (patient) with a tooth ache and had almost the exact same conversation hahahaha! this is awesome!