Why the most nervous patients are often the easiest to treat.

I was thinking today about a lady i recently treated in Cheltenham. She was generally a very anxious person, reluctant to get in the chair, especially scared of the idea of implants, a lady who hand off your every word and the way you said it, got more nervous when we needed to talk more seriously. 

“I want to be asleep, you’ll make me go to sleep won’t you?”

The dentist has mentioned to me beforehand that she was one of the most nervous patients he had come across. 

After another discussion with her about “conscious sedation” and what other people’s experience in her shoes has been she was ready to go. 

Thankfully got the vein first time and after quite a low titrated dose, her shoulders dropped, her speech slurred and her eyes started to close. As she was becoming more and more relaxed the amazing nurse was talking to her about lying on a beach in the Caribbean, her eyes closed and she was comfortable. 

Not even a slightly raised eyebrow with the local anaesthetic, teeth out no problem and not a hint of worry in the patient during the implant procedure. 

After the last stitch went in, she was pretty well ready for discharging. As she got up she said –

“You’ve actually done it? I had no idea. That was easy.”

If you are like me and have carried out quite a few sedations under IV, you will have come across this rather a lot. The patient fills in the MDAS form, gets a top score of 25, you are tempted to think “this is going to be a real challenge”. It often needs up being nice and straightforward. 

Ive always argue that the MDAS is not an numerical indication of how hard the session is going to be, how much movement the patient will have, how deep the sedation needs to be. 

Having a look through my data for the last few years it is often the case that paradoxically, the lower the MDAS score, I.e the less nervous the patient reports they are, the more challenging the session was for the sedationist, nurse and dentist, even though a quality outcome was achieved. 

I believe this is down to the patients expectations. If they’ve never had sedation before they can only think of two states, awake and scared, and asleep and obvious. They’ve never had the experience of being “sedated” and how that seriously reduces the escalation curve of anxiety. 

Their expectations are so low, they think it’s going to awful, painful and stressful so even a little anxiolysis surprises them. 

Two problems though, I don’t think we can ignore the MDAS score entirely. It pre-warns us what the patients state of mind is before we cannulate. It affects how we talk to people, what we say, our mannerisms and what support the patient needs. 

The second thing I believe it’s important to look out for us those patients with a clinical mental health condition, with or without medication. Ive treated adult patients with severe ADHD, chronic depressive illnesses, bipolar disorders and whilst the final outcome is generally very good for the patient is isn’t necessarily an easy session for the team!

In conclusion – 

One of the conversations I love to have with really nervous patients is about the other patients I have treated before in a similar boat and what the outcome was for them. Patients are reassured that you have experience of dealing with patients in a worse state than them and that successes can be easily discussed. 

This all leads to a happier calmer patient and a better outcome for all!