Listen on iTunes
Watch Video here
VIDEO - DUwHF #934 - Allan Schwartz
Stream Audio here
AUDIO - DUwHF #934 - Allan Schwartz
Allan is a 1980 graduate of Baylor College of Dentistry in Dallas, Texas. After dental school he attended a General Practice Residency at the Jewish Hospital in St. Louis, Missouri where he experienced dental O.R. cases delivered by Certified Registered Nurse Anesthetists. After ten years of private practice he said, " I want to do Anesthesia." So while still practicing dentistry part-time, he got his Bachelor of Science in Nursing degree through the Accelerated Option at St. Louis University, worked in the ICU at the VA in St. Louis for a year, and then attended the Nurse Anesthesia program at Washington University in St. Louis at Barnes Hospital.
Howard: It's just a huge honor for me today to be podcast interviewing Allan Schwartz DDS C.R.N.A.
C.R.N.A. would stand for Certified Registered Nurse Anesthetist. Allan is a 1980 graduate of Baylor College of Dentistry in Dallas, Texas. After dental school he attended a general practice residency at the Jewish hospital in St. Louis, Missouri were he experienced dental O.R. cases delivered by certified registered nurse anesthetist. After ten years of private practice, he said, "I want to do anesthesia." So while still practicing dentistry part-time, he got his Bachelor Science in Nursing (inaudible 00:40) through the accelerated option at St. Louis University, worked in the ICU at the VA in St. Louis for a year, and then attended the nurse anesthesia program in Washington University in St. Louis at Barnes Hospital.
You know, I'm so excited to I have you on the show. We were together two years ago at a dental convention?
Allan: We were. I was your chauffeur.
Howard: Well, when you're a bald guy they always get you a bald chauffeur. I have a shout out to-- my dad passed away, his brother Jerry passed away, but his little brother, Mike, is still alive and Mike, I'm pretty sure, at least, he believes he was the first male nurse, R.N. nurse, in Kansas. Did you know that?
Allan: Didn’t know.
Howard: Do you know why he was?
Allan: Why is that?
Howard: He graduated from-- when they graduate from high school in Parsons, Kansas back in the day, he was so sad because he’d never get to see my Aunt Shirley again and she never went out with him either so he was so bummed out and then he heard that she went and applied to nursing school. So, he thought, "Oh, damn!" So he went and applied to nursing school and became a nurse and it took him until junior year or third year of nursing school before Aunt Shirley married him and they're still married to this day.
And talk about sexism. You know they will say how men make more money than women, so you look around your life or what evidence that you see. When he got out of school, he was offered all the head nursing jobs at all the hospitals and he had like a three-point grade point average and Shirley was a straight As and she'd get the entry-level jobs, third shift, weekends but since he was a man he got all the good job offers. So, what are you passionate about today?
Allan: I am passionate about anesthesia. I love doing it. I blog on the website quite a bit on Dentaltown and I'm here to help talk about dental office emergencies with you.
Howard: I want to answer this. This is Dentistry uncensored. We don't want to talk about anything that everyone agrees on. Let's go right for the jugular.
Allan: Go for it.
Howard: Every hospital - you're in a hospital right now - you practice out of Columbia Missouri, but right now you're in a hospital in St. Louis Missouri. In every hospital in America, you can't be the cardiovascular surgeon and do the surgery and the anesthesia. If you're going to do prostate surgery on me, you can't do the prostate surgery. They separate those two skills and the only place you see those skills combined are pretty much oral surgeons and periodontists and dentists. Do you agree with that or disagree?
Allan: It's a lot to watch and I have seen and talked to oral surgeons about it, that are doing general anesthetic, and I have to say it's tough to watch both of them. Especially when you're doing a general anesthetic. If you're doing sedation, yes it is possible to watch both. But if you're getting deeper into sedation and then general anesthesia, that is tough to watch and to be able to deal with the problems there and then if the patient develops any problems.
Howard: And you never hear about this, that the skills should be separated until it happens to someone like Joan Rivers.
Allan: I mean they were separated. There was a separate anesthetist during the case.
Howard: Was there with Joan Rivers?
Allan: Yes. With hers.
Howard: Oh, okay. I'm sorry. Then?
Allan: You've posted, I think it was several months ago on Dentaltown, I think it was you that said that Alberta, Canada has finally said we're not doing this anymore. We are separating the two. Didn't you put that out there?
Howard: Yeah. And it was a couple years ago it was the U. K. Ryan and I were in London lecturing in London, in Glasgow and Paris and the dentists were all showing me this amazing data. Even though death under anesthesia is very rare, let's just say it was one out of a million. The UK was looking at it and saying, "OK, it's one out of a million, but for oral surgeon and periodontists like three out of a million." The difference between one and three out of a million doesn't matter until it's your granddaughter. Then you're like--
Allan: I was gonna say, especially since it's you. If you're the one of out the three, or the three out of the million or whatever, if it's you.
Howard: It's easy for medical economists to say, "Well, this is the cost savings and this and that, and it's more efficient faster, easier." Yeah, I get all that, until it's you and then you're like…
Howard: And then you’re like: "I wished I wouldn't have died under anesthesia."
Allan: Right. You have to put it to the family tester to you. Would you want that to be you on the other end of the propofol syringe?
Howard: So now it's Michael Jackson. That was what he was addicted to, right? Propanol?
Allan: He wasn't-- it was Propofol. He wasn't addicted to it. He was using it because he had that new show coming out and he could not fall asleep and he had a non-qualified anesthesia provider giving him the anesthesia. He was a cardiologist. He was using a butterfly needle in his arm as opposed to an IV catheter. There were no monitors and apparently the guy was in the other room while the drip was dripping and Michael obstructed. His tongue fell, it relaxed, and his chin fell and he asphyxiated. He died while he was sleeping. He could've just tilted his chin up and we probably wouldn't even be talking about him.
Howard: That is so sad. Me and Michael share our birthday. We're both born on August 29th. I was born in '62, I think he was '58. Would you Google us the year? He was the greatest singer-songwriter-dancer of all time.
Allan: Extremely talented. What a waste.
Howard: What was it? He was born on '58 of August 29, I was '62. He's the number one musician all time. My mom thinks it's Frank Sinatra. I always tell my mom, "Mom, I've seen kids jamming out to Michael Jackson on boomboxes in India, China, and Brazil. I've never heard anyone listen to Frank Sinatra outside of the United States one time."
Allan: It's a different generation.
Howard: He was just a legend. So, you agree that a doctor, dentist, oral surgeon, periodontist should not do their own anesthesia?
Allan: That's the way that I feel and I do anesthesia. I am still a dentist. I'm still a licensed dentist in Missouri and I'm one of two general dentist said that have deep sedation general anesthesia permit the way an oral surgeon does, and I do the anesthesia, the dentist, whoever his patient is when I come into their office, they do the surgery. So, we separate it.
Howard: You go around with your own stuff in the dental offices in Colombia?
Allan: Throughout the state of Missouri. I just got a few select offices I do and it's not a full-time job. I just do that for the dentists that are my clients, that have patients that come up, and then we get the patient worked up medically, and then I come in with all of my equipment and supplies.
Howard: People talk about how to build your practice you should offer on same-day dentistry or church site mailing, same-day ground. You got half of America is afraid of the dentists. Having someone like you come in would be ten times bigger than buying a laser. Do you agree or disagree with that?
Allan: I agree with that. I think that if we can get rid of the fear. In a lot of times, I'll just have people that are just shaking in the chair and I'll say to them, "You know, I've been doing this for a lot of years, I want you to stop what you're doing right now and let me show you." We are in the show me state, so I want to show them that we're going to get them comfortable and they do. They'll stop, they'll relax a little bit. I said, "let me get the IV, and we're going to get you comfortable."
Howard: And what drugs are you using these days and are they safer than when you when I got out of school back in the day?
Allan: Propofol is unbelievable. That came out in about 1992-ish, early 1990s and it was quite expensive so I use Propofol and Ketamine and then we rely on the local anesthesia for them to be still be comfortable. But we do it after I get them off to sleep, get them really deeply sedated.
Howard: So, why do you like Pro-- how do you say it? Pro--
Allan: Yes, that's it.
Howard: The only D I ever made in my life was in Spanish, and I can still remember San Martin telling my mom that I was linguistically retarded, and then a couple years after that, my mom and my five sisters, we all take piano lessons and my mom had some fixation on the piano. I was the only child where the teacher fired me. She told my mom, she goes, "He couldn't carry a tune in a lunch pail." So why do you use Propofol and Ketamine instead of like Versed and Reversed?
Allan: Well, there's no Reversed. But the reason I like Propofol - I was going to give you a mnemonic to remember--
Howard: I thought Reversed is an antagonist. If you put some on--
Allan: It does, that was the joking name about the reversal was the Flumazenil. They did Reversed. You were right.
I got a mnemonic for you. Remember the pronunciation, "nobody falls like Propofols," how is that?
Allan: You like that?
Howard: I do! Nobody falls like Propofol. Nice. OK.
Allan: I remember when I was in dental school, I had a prosthodontist that taught us at Baylor. He said he could make plastic walk across the street - danger plastic. Well, I feel that way with Propofol since I've been using it so many years. It's real quick on and it's real quick off but there's no reversal for it. When I say real quick it's like within minutes, depending on how you give it. Now, we can put the patient totally to sleep with it or we can have them just really light, but that's the art of anesthesia is to get them to the level that you want them to be, that they need to be.
Howard: Beside anesthesia, talk about medical emergencies. What would you say is the most common medical emergency in a dental office?
Allan: Probably the most common is you're going to have these patients that are extremely fearful and they will go (inaudible 00:11:26). They'll go hypotensive, they'll faint in other words. So that's the one I think that you're going to treat the most or the most frequently.
Howard: Do you think they're fainting from fear or because they just saw the dentist and the dentist is just so hot?
Allan: It was that one, Howard.
Howard: It was that one.
Allan: When they're at your office, for sure.
Howard: Yeah, I'm lucky. I'm one mile away from the fire department and once a decade I have to call the fire department. One was because my own office manager fainted.
Allan: There you go. There would be one you should probably be able to handle and we have algorithms that we follow and that I teach in my sedation classes, and certainly I can make those available to the listeners if there's-- if you don't mind, they contact me.
Howard: How should they contact you?
Allan: They can email me at email@example.com. It's our lecture company, sedationconsult.com. So, I would be happy to send them, I got dental office emergency algorithms that I follow, there's a quick and dirty emergency cheat sheet that I put together for emergency drugs in your kit and then I got the ADA safety checklist I'd also like to send.
Howard: Ryan, will you-- also his course on Dentaltown and share that right now. There's a link to share it on Facebook, Twitter, LinkedIn, Pinterest and Google Plus. You also did a course for us. Do you know 'The Most Common Medications Found in Dental Emergency Kits' by Doctor Allan Schwartz for you and your staff on these common meds and dosages, and all the reviews on it we're amazing. Thank you so much for doing that
Allan: Thank you and we've got four parts and we still got two more than I'm going to write for you. So, that's going to be upcoming. One of them is going to be for sure next year. We'll get your part three or four.
Howard: Nice. Thank you so much for that. I'm just posting that I am podcasting Allan. So, you said they can email you at firstname.lastname@example.org but you also have a website.
Allan: Right. That's www.sedationconsult.com. General related anesthesia lectures for sedation dentists and anybody else that's interested in the different topics we have.
Howard: So, sedation consult, anesthesia and sedation continuing education taught by experienced dentists for dentists, dental hygienists and dental assistants. Very nice. What are they all going to find there? Basically what?
Allan: Well, there's a number of online courses but then we do some live courses too, such as monitoring. We've got a big IV certification class. That's different than the dentist all want IV certification. Not all, but a lot of them do. This is a requirement in Minnesota for Dental Assistants and it's a great review of course for hygienist and dentists but the dental assistants are required to have and they're allowed to put IVs in up there but they have to have this course. It's an IV certification course.
Howard: So why do you have Doctor Kenneth Polke, his book 'Conquering Your Adversities'. We did a podcast with them. Why is he--
Allan: I know you did. He is a bud. He's going to be teaching with me, eventually. We're going to get him worked into some of the lectures. He is a friend of mine.
Howard: He said to me, "why do you want to interview me?" I said, "dude! you're the only dentist on earth who not only was a quarterback in the NFL but played for two different teams. You don't think that's the coolest damn thing!"
Allan: He is such a neat guy and like I said we're friends so we talked about it before he even started talking to you.
Howard: Now, did you ever ask the politically incorrect question, does he think he suffered concussions for being a quarterback for two different NFL teams.
Allan: I'm sure he'll listen to this, so I'm going to say that I think you took a couple head shots fired (inaudible 00:15:26) power.
Howard: A couple of head shots. See, mine were just from drinking but he had a noble reason. I think that sport is dying. I really do. You know why? Because there's NFL players who live in Ahwatukee who don't want their kids play football and then they say that if you go talk to the people in Phoenix, the interest in putting flag football is rapidly declining. So, if you lose all your farm fields of flag football and all that stuff, eventually that'll affect high school, eventually that'll affect the NFL.
Allan: But they're still going to be a group of people that want to make the big bucks that are going to play it, don't you think?
Howard: Oh, yeah, but I'm just saying there'll be less. if you get less inputs at the five, six-year-old level in flag football, you have less outputs and the high school. What do you think dentists should be doing better to prevent medical emergencies?
Allan: I think that you've got to make sure that you have got the patient tuned up and ready to go through their health history. If you have any questions get with their before you start doing treatment on them. Make sure that their heart, lungs, liver, kidneys, everything's in good shape. You just want good thorough medical history and ask them questions.
Howard: Well, you know, 100% of the time that you go to your physician - before you even see the physician - the nurse put you on which on a scale, weighs you, takes your blood pressure and your temperature, and you almost never see that in dentistry. Even when you're working-- I notice the only three publicly traded dental office in the world. Two in Australia, (inaudible 00:17:19) inner smiles and Pacific Smiles Group and the other one is in Singapore - Q and M.
They won't allow anybody, even like you, anesthetists, to come in and do anesthesia on anyone twelve and under or sixty-five and over because they're Wall Street lawyer say, "when anything goes wrong, they're under twelve or over sixty-five," and I got to ask you, "how many pediatric dentist weigh the child and take the temperature and blood pressure and then how many general dentist, if grandma and grandpa are coming over sixty-five and they're going to give a bunch, and do some root canals ground bridge. How many of them even take your vitals?
Allan: I would imagine... I'm not a 100% in the field anymore. What you're trying to say is how a lot of them do it? Is that what you're-- is that where you're going with it?
Howard: Absolutely. I have never seen it.
Howard: I mean, there's not one dentists listening to you right now that even has a scale in his office, but he's going to turn out and put carpules of anesthesia in some two and three-year-old little child and do a pulpotomy. We had a death here in Phoenix. It was back in the days, probably 10 years ago. He gave a little girl too much local and she died. No one knew her weight and then it turned into crazy trouble because he tried to alter the charts.
Allan: Oh, boy. You can't do that.
Howard: That turned out to be more of a legal crime than overdosing a child who resulted in death.
Allan: Right. You're just masking, you're just telling everybody you're guilty. I meant to tell you too, I have an Arizona connection, we moved to Phoenix when I was a teenager, seventeen years old, from Minneapolis. So, I went to Arizona state, I know Ahwatukee when that was just dirt over there. You still live up in sunny slope in North Phoenix.
Howard: Wow! My guy, you should have just bought one acre of land in Ahwatukee and then work at Taco Bell and then you would have been a multi-millionaire. So, do you recommend weight in vitals on your-- do you do that? What do you recommend on your health history?
Allan: I do. I have the fill in the blank things. So, we need to do that. Now, do I weigh them? If it's a child, yes. If it's an adult, I ask them their weight and they get me pretty close, and I say, "you know, if you're fibbing on your weight then I'm not going to be able to give you enough medicine," and then they'll fess up and tell me what they're really true weight is, because a lot of dosages is based on their weight.
Howard: Well, boys don't lie on age or weight, only women do. They always lie on their age and their weight. What is the average spread between what she said the first time and in the second time?
Allan: I think you got a couple of twenty, thirty pounds there. (inaudible 00:20:36) factor. You know what I'm saying?
Howard: Yeah. That's like online dating. I remember I did that back in 2005 and now, oh my god, every time, every single one time you showed up you know the picture is ten years old and you're almost shocked. You talked about the twelve most common medical emergencies in the dental office. You want to go through those?
Allan: Sure. Give me just a second because I want to make sure I don't forget any of these puppies.
Howard: Twelve is so interesting. The numbers ten and twelve are very interesting. Twelve is so interesting because that was the-- what is that astrological signs? The zodiac and then that turned into the twelve months of the calendar, then it turned into the twelve apostles. Is that why you picked twelve because--
Howard: Humans just love the number twelve.
Allan: I didn't. What I did is when I was researching this, I went to a number of textbooks especially emergency room textbooks, and these were the ones that stuck out in my mind. The ones that I saw the most common since I've been doing anesthesia for the last twenty-three years. So, these are the ones that I picked out. Fortunately, some of them are extremely work rare, Howard. We don't ever want to see them but hypotension is probably like I said the most common.
Howard: That's fainting.
Allan: Right. Exactly. Drop in blood pressure. I put the general emergency response protocol, we don't-- reminds me to tell everybody, but you don't always call 9-1-1 for every emergency in your dental office. Some of it you should be able to handle and some of it you do have to handle quickly. Like, number three is laryngospasm. If somebody starts choking, we're going to make sure we're able to clear that and they're going to start breathing again.
Howard: What was number two?
Allan: Two is hypotension.
Howard: What was one?
Allan: One was general emergency response protocol.
Allan: Three is laryngospasm. Four is acute airway obstruction. Man, we don't want to see the Cardiopulmonary arrest, where we have to start CPR and ACLS. Number six is the acute allergic response to drugs. Seven is the angina pectoris possible MI - myocardial infarction. Emesis and aspiration of vomitus is number eight. Convulsions and seizures is number nine. Ten is over sedation - that's one of the ones you said you liked, that you caught your eye. Hypoglycemia is number eleven, and then asthma bronchospasm is number twelve.
Howard: Gosh, man! Every one of these things you said just brought back a nightmare. You should call that your stress list.
Allan: Yeah, really. There's a couple in there I'd like to take off the list. That I never want to see in real life. The cardiopulmonary arrest type thing and the acute allergic response to drugs. Those are pretty bad.
Howard: What is the drug usually?
Allan: For the acute allergic reactions?
Allan: That's going to be an antibiotic probably most of the time. For the stuff that we would give in a dental office, I rarely have ever heard of a lidocaine fentanyl or versed allergy response, or even ketamine for that matter.
Howard: So what emergency equipment, do you think, you should have on hand? And then it gets into the legal deal of what do you think they should have and then what do you think they legally have to have.
Allan: You know, I would tell people look at your dental board rules. They're going to tell you what you need to have in your office especially if you're doing sedation in the office. There's a list of things that I had to buy when I set up my anesthesia practice. Probably the most common and we don't think of it this way but drug is going to be oxygen. So, one of the first things I throw on the patient, and I don't mean to use the word throw but you know what I'm saying. So that they've got oxygen going to all their tissues and especially their brain.
Howard: That had to be positive pressure oxygen. This isn't a nitrous oxide oxygen?
Allan: No. It can be that.
Howard: It can be that?
Allan: You still have positive pressure available though, but if they're breathing spontaneously let them move air. They're going to be the most efficient.
Howard: OK. So, oxygen would be the main thing. What would be next?
Allan: If I were to look at the next most common drug, it's going to depend on the emergency. If it's hypotension and they've got an IV and I'm going to crank the fluid up. There's a couple of other drugs that I would consider giving at that point, but how many of the bar dentists are going to have an IV in the patient.
Howard: I never have started on IV. I did in school when we had to, but I was scared of that from day one and I just think it's frightening how many dentists go to the Holiday Inn, and take some sedation course and the next thing you know they're talking about sedation.
When you're a journalist in dentistry - I've had a magazine since 1994 that's gone to all the general dentists and ten thousand orthodontist - these medical malpractice people would always send me their cases for the last month and they would do it because they wanted to get the word out because they want to collect premiums, they don't want to pay claims. The thing I noticed from reading those claims, that whenever it was over a million dollars or two million or three million they all had one thing in common, they had an IV in their arm. When that dentist gets put on the witness stand and they bring in somebody like you who's done this for twenty-three years, that dentist trained in a Holiday Inn doesn't look very smart to the jury. Do you agree or disagree?
Allan: I agree. I think that you really need to have good training and you need to be able to follow up with somebody, that you can ask questions to. I've had students that I've trained that have been more than the Holiday Inn that I've taught IV sedation to. It is teachable. I learned it. Anybody that does it has learned it from somebody but you've got to be able to choose your patients properly, know how to handle the emergencies, and know when to say when. Like Clint Eastwood said you have to know your limitations. A man has to know his limitations.
Howard: But dentistry is going in the wrong direction. In 1900 there were no specialties and health care was only 1% of the economy. By 2000, it was 14% of the economy with fifty specialties with the MDs and nine with the dentist. These dentists, I mean, well I'm going to learn IV sedation. I'm like "well, dude, just learning that, that is so much." Then you just said to me earlier that you're also going to learn how to place implants which is so much, and then and then you're going to a sleep apnea course, and then you're going to learn Invisalign, do you really think 1900 is a business model where there's a Super-Batman-Walmart-Dentist that can do endo, perio, anesthesia?
I always tell these young dentists, "when you say you're going learn IV sedation, what are you going to give up?" They never, ever, say they're going give up anything because how many hours would it take to totally master before I'd let you start IV in my arm or my granddaughter Taylor's arm and start putting Propofol in her.
Allan: Right. Well, the ADA came out in October of last year, and said that you need sixty hours of didactic, and twenty individual cases that you run. So, that is our Dental Association telling us that, that that's the number. I think you shouldn't have, definitely, more experience than that, Howard. Every case I do I'm still very careful of the powerful tools I've got and I recognize that they're pretty powerful. I don't take them for granted.
Howard: In Ahwatukee, where I live, only has one oral surgeon. He's an amazing man. He's a legend - Greg Edmonds. He was one of the first oral surgeons I know. This back in the day, over a decade ago, where he actually brought in a full-time anesthesiologist. He said that, not only said oral surgeons not do it themselves for a practice manager reason, a dentist do this cleanings. He loves the fact-- he actually does more cases in a day than an average oral surgeon, because when he goes in there all he has to do is plow for wisdom teeth and he's gone.
For me, from a practice management point of view, you should be a conductor and the conductor isn't going to learn the organ, and the piano, and the drums, and the clarinet. She finds amazing people to do that for her, and she just conducts the orchestra. I just think from an economic, legal, everything makes sense, just have someone like you come in. I don't see how in the world it makes any sense for dentists to commit to learning all this and doing it himself.
Allan: Let me just throw this out to you, you know that anesthesia is a continuum. We go from a level of minimal sedation to a level of general anesthesia. If you look on the website, the first picture on the sedationconsult.com website shows that continuum. A person can still maintain somebody in one of the smaller levels, if you will or not as deep levels, and still be safe. You're talking about deep sedation and general anesthesia
Allan: and I agree with you there. But somebody can still maintain somebody in the minimal to moderate range, and it's been done, and it's been done safely.
Howard: Yeah. I was totally just ranting on general sedation.
Allan: Right and you're talking about-- take a look at that continuum and see how that line can very quickly go from the left to the right. Like I said through minimal sedation, moderate, deep sedation, and then into general anesthesia.
Deep sedation and general anesthesia take a lot of attention, and a lot of skill to maintain and I'm not saying that the other levels don't, but it's still safe for someone to hold somebody there. I mean, you could take a valium the night before and put somebody on nitrous and take them to a moderate level of sedation and those are both pretty darn safe.
Howard: Is that your oral medication drug of choice, just plain old valium, or do you like some other shorter-acting?
Allan: I don't use it. I use all IV. I'm not a good answerer for that question. I am a Versed, Propofol, Ketamine. We get into the deeper sedation than the general anesthesia drugs.
Howard: Right. How do you like to prepare your staff for medical emergencies?
Allan: We have to train them. In Missouri, they're required to have that training every five years. There's a monitoring course that we put together but that is available for them to train staff. It goes over very well. We have that online available also if somebody's interested, but you have got to talk about monitoring and you've got to talk about emergencies and actually go through them in so that people are clear, and then they can refer back to those references that I told you, those things that we can email.
Howard: I wonder how many dentists have even read their state's boards. There's a thread on Dentaltown, because the orthodontists are starting to sue smilesdirectclub.com and Smiles Direct Club. Where they mail you impressions to your house, you take an impression and they make you the Invisalign aligners, so you don't have to see that middleman called the orthodontist. It's amazing.
I think the Orthodontic Association, the American Orthodontic Association state is sued for thirty-nine states but it's amazing how many people on Dentaltown (Inaudible: 33:19) I've never even gotten to my state's website and everybody's looking. They've sued them in thirty-six states, but everybody's looking at their state boards and there's a lot of stuff there that most dentists listening to us right now have never even gone to their State Board of Dental Examiners website and looked at all their rules and regulations.
Allan: You have got to do that. It's imperative that you do that. Just yesterday I got a call about our monitoring course that's coming up here in St. Louis from a dentist in Illinois and I said: “You know, I hate interpreting your guys' rules for you. I know Missouri but I don't know Illinois, and I ask you to look at it to see if the course would be something that's required,” but what I'm trying to say is that they have got-- you've got to know that.
In Missouri, you talked about what drug can you give if they faint. We're required to use or to have available smelling salts, believe it or not - the ammonia capsules, and it's in our rule. So do I carry them? Yes. Is it something that I would use in the O.R or in the operatory for a sedated patient to wake them up from hypotension? No, but I'm required to carry it and I’ve got it. There’s better and different things that we use and you would never know that unless you read your rule.
Howard: Most dentists only deal with their State Board one time and that's when they go get their license. They go down there and that's probably only time they physically walk in there, they sign their form, they get their license and they don't stay up on the rules and now they've been practicing, ten, twenty, thirty, forty years and they don't know all these changes and a lot of these young kids, a lot of them just don't know that some things are even worse than other things, like patient abandonment, that's one thing when a dentist will start going under and just say, "screw it! I'm just going to close my doors. I'm gonna to do a bankruptcy. I'm walking away from this," and then he walks to the airport gets on Southwest Airlines and flies back to mom and dad's house and he's got patients running around with temporaries on their teeth. That's a huge legal crime. To be determined, can I really just send you an Amazon box with impression material and you bite into a wafer, and send it back, and then I make Invisalign trays and I do ortho on Allen Schwartz while I'm in Phoenix and you're in Missouri? That's what's going down right now. Do you think that's legal?
Allan: Boy, that just seems pretty hokey. I want somebody there that sees me and takes care of me. That they've actually looked at the tissue and, I mean, it's your body so why would you do that?
Howard: Well, the courts have been in favor of the consumer usually. Remember that bleaching case where the state did a cease and desist, that they couldn't do bleaching in the malls and there's a company sued and that went all the way to the Supreme Court. These state boards act more as a lobbying group for their members than they do for the consumers and they tell everybody they're there to protect the consumers, but we think they're there to protect their incomes. The judge, the jury and executioner, they have to license the dental schools, the applicant, they control supply and demand. They said you can, in fact, do bleaching at the malls. I think this one will be interesting.
I know what all my homies are going to say on Dentaltown. I know everybody on Orthotown's going to say, "oh, it's totally illegal." But I don't know. They'll have the burden of proof because ortho is $6,000. Not every Americans got $6,000 so they'll have to stand in front of a judge and a jury and explain to them what could go wrong doing Invisalign through the United States Mail Department and that'll be interim. Do you think they can prove that a lot can go wrong, so much so that they shouldn't be able to do it, that you have to have an orthodontist watching it?
Allan: Boy, I don't know.
Howard: I don't think so.
Allan: All I know is that I want them to have the best, I don't want somebody just mail ordering, whatever. I want somebody that's taken a proper impression and has worked the case up properly. I just don't want him to cut corners, it's my teeth. I just want it done right. I was going to tell you since you were talking about the dental boards, if people Google 'licensing board cartels', I don't know if you've ever seen that article, but take a look at that.
Howard: Can you show me that?
Allan: There's a tremendous article on exactly what you're talking about, where dentists and interested parties are running the dental boards and how it's a really kind of a cartel.
Howard: Right. Ryan, try finding that quote. Say it again so Ryan can hear. What is it? Licensing...
Allan: Licensing board cartels. Just do it in the Google words and you'll see a PDF come up of an article on that. It's really interesting.
Howard: I'll try to find the quote. What did Adam Smith say? He said, "whenever two or more men are gathered, they're conspiring against the masses," or something like that. Can you find that quote, Ryan?
Basically, Adam Smith which, that was an exciting year in the world. It was 1776 and two different thirty-two-year-old Scots published the most profound papers in world. One was Adam Smith, which was the first economic treatise free markets and the other one was-- who wrote the Declaration of Independence? He's credited that - Thomas Jefferson! So, here's two thirty-two-year-old Scots. One is writing on free markets out of Scotland, and one is writing on free people out of America and that's what America was. It was really the first time that free people collided with free markets, and it was a beyond a economic explosion, so much so that half a millennium later, Americans really (inaudible 00:39:37) three hundred and twenty-five million out of seven and a half billion, there are only 5% of the planet and they got a quarter of all the money and now you're just watch that whole thing be ruined because-- you ask anybody from Adam Smith to Thomas Jefferson what was the greatest thing about America. They said everybody coming to this free country or free markets and then in 1912, because of the labor unions, they shut down Ellis Island and started unions and we've been declining ever since. It's so funny because you'll never find a single American economist businessman ever that thought, immigration, I say it's from 1500 to 1900, that was the only secret sauce that made America. That would not have happened. We'd have been no different than Venezuela or Peru.
Then you say, "well, don't you think we that would go back to that and we go back to Ellis Island and just let unmitigated free immigration for all these people come here," oh no. That is a bad idea now and we need a state dental board to not let them do bleaching in the malls and not let them start Invisalign without having to go through mine. It's all cartels. When people say they want to fix America, my god, you don't need a new idea. Just go back and look what America did in the 1700s, 1800s, 1900s and go back to that. Do you know what I mean?
Allan: It's so interesting.
Allan: It's so interesting.
Howard: They talking about all these jobs, going to call centers in India. Well, nobody wants to use a call center in India. Just that those people over there that would work for that wage can't move here. You look at all these big companies and they're outsourcing their program to India. They don't want to outsource their program in India. They just don't have any programmers in America. Do you know I mean? If you tore down and went back to the Ellis Island days, those Indian programmers and call center people would be moving here in droves and this economy would just be screaming again. Don't get me started. You talking about--
Allan: You started! You already started.
Howard: No, you started with the cartel. When you said cartels, because I think that's what Americans turn into, just this cartel. You talk about Russia's oligarchs. Well America, everything you do in DC is just to protect about eighteen hundred billionaires. So, but you talked a lot about algorithms. First of all, what the hell is an algorithm and why it doesn't interest you?
Allan: An algorithm, I don't know the exact definition, but it would be a series of steps that you would take to take care of a problem. The ACLS people when we learn that the American Heart Association, you follow basic recipe. Of course, you can deviate from that but at least you've got something in your brain that you can follow that will get you started. It's going to depend on how the patient responds. If the patient woke up when you were doing chest compressions, for CPR, certainly you don't keep going and they start talking to you or whatever. It's just a basic steps that you follow for, especially it's so hard to think during an emergency.
Howard: Interesting. Who do you think in the dental office should be trained for medical emergencies? Is this a dentist thing would you train the assistant hygienist? What about the receptionist--
Allan: Everybody. Everybody's involved. Everybody could talk and give input. We need somebody to call 9-1-1. We need somebody to run down outside the office and flag 9-1-1. The rescue paramedic said everybody's involved. Someone might be really good at starting IVs, again we're on that but I'm just saying. Someone might be very good at the chest compressions. Somebody's good at just all the different tasks there are to do.
Howard: I think another bias that dentists don't realize-- they always think it's a patient that they're working on because that's how humans think, they always think of it from their perspective but sometimes it's someone in the waiting room. I've called the fire department 9-1-1 three times, once a decade for three decades, and one of those three was from my office manager. I was working on a patient, I heard a thump and I was, "what the hell was that?" It was her head hitting the carpet. So that's why the whole office should have to be trained because you might be back in your room doing a root canal and your staff member up front or a patient in the waiting room has a problem.
Allan: Who is to say that you're at an Arizona State game over at watching football in Sun Devil Stadium and you could be involved with something that you witnessed there to help that person? We're more than just drillers on teeth and fillers and all that sort of thing. We should be more inclined to help with taking care of the whole patient and that's why I think we should know how to handle emergencies.
Howard: Yeah and you got to be careful. I got too over-involved in a medical emergency one time and it was the most embarrassing thing I ever did. I was driving home from work - this is back in the 80s - and I glanced over and it looked like this woman was over a man and so I pulled over. I just had a quick glance, I pulled over. I looked out, I got out of my car and she was looking at her golf bag.
Allan: I thought you're going say something else.
Howard: Oh my god, but that flash while I was driving, I thought it was a, for some reason I thought was a human and I assumed as her husband. But she looked-- she looks stressed and I just instantly thought medical emergency.
Allan: Wow. Well, that's good.
Howard: It's pretty amazing when you're warming up to a grandma, she's looking at you and you're about to do CPR on her golf bag. That was one of the more stupidest moments I've ever had. What else do you think my homies should know about your website sedationconsult.com?
Allan: Well, like you guys are people out there to know that we offer a lot of courses, a lot of it are online. We've just put one on there. I posted it this week - on herbals and anesthesia. It could apply to our herbal medications that patients are taking in dentistry but we've got a lot of things. If anybody's wanting to take ACLS, I've got a preparatory class for that. We've got on how to read EKGs for dentists. I'm a dentist, so I get it that we need to learn how to do that sort of thing if you're taking ACLS. There's just a number of courses and they all have ADA serve credit so you're able to actually use that towards your license for the CE credits you need.
Howard: How much are these courses?
Allan: They're varied. I am fair. I believe in the prices they're going to vary anywhere from $75 to $125, just depending on how many hours you get and that includes the certificate. A lot of them require online testing and we have an online testing service. We're actually able to do that live through Skype - the way that you and I are talking. The dental boards love that because that way we're able to have you tuck your notes away and take a test.
Howard: Wow! That is amazing! These young dentists, they always say one thing and then they act another. A fool and their money always part. They come out of school and they cry that they have $350,000 of student loans. Then to learn this little bitty amount of information they're always getting in an airplane, flying across the country, dropping $500 in airfare and dropping $1,500 on a course and all that stuff and you're like dude, you could have learned that online for $75 at sedationconsult.com. Why do you always have to get in an airplane and fly across the country?
They just had the ADA meeting in Atlanta and what does everybody talk about? What's the biggest news coming out of the ADA Atlanta? That the number of dentists showing up it just gets less and less and less and less. All the vendors were screaming. They were all posting on social media. Look at these aisles, they're empty. Well, where are they going? They're going online. Why do you have to fly to Atlanta, Georgia to learn about a root canal?
I love these courses. Anesthesia and slimy green saliva, essentials of intravenous fluid, essentials of sedation, pharmacological aspects, essentials of EKG for dentist, essentials of monitoring for sedation dentistry, emergency medicine every dentist should know, sixteen tough patients, an in-depth look at sixteen tough patients, dental office medical emergencies adult version. Now, is that rated R? It's adult version.
Allan: I've never thought of that.
Howard: Or rated X?
Allan: That could be a marketing tool.
Howard: Essentials-- yeah, if you want to see the greatest adult movie ever put online, click here. What do they call that? Clickbait? "You won't believe this adult online video I just watched." You should post that. That would be a perfect clickbait.
Essentials of nitrous oxide. I love nitrous oxide. I really do and sometimes I even share with my patients.
Allan: A lot of these courses--
Howard: You didn't catch my joke.
Allan: Yeah, I love it. You share with your patients--
Howard: That's right. I share with some of my patients. "Do you like nitrous?" I said, "I love nitrous! In fact, sometimes I even share it with my patients."
Ryan found that out Adam Smith quote. "People of the same trade seldom meet together even for merriment and diversion, but the conversation ends in a conspiracy against the public or in some contrivance to raise prices," that's exactly what's going down. People of the same trade seldom meet together even for merriment and diversions but the conversion ends in a conspiracy against the public or in some contrivance to raise prices.
Greg and Ryan went with me when I lectured in-- where was it in Scotland? Glasgow. I actually got to see his statue there. Adam Smith and Thomas Jefferson, two of the greatest men that ever lived. Just amazing people and what's so funny is everything they always tell you about Scottish people, it's all true. They say the copper wire was invented when two Scots were fighting over a penny. The dentist in Scotland is-- they have more control over their overhead. They penny pinched on supply-- I've never seen a culture, I lectured in five (inaudible 00:50:43), the whole country is penny pinchers.
There's dentist there, (inaudible 00:50:53) what are your supply costs? Whatever the number he tells us not even right. I don't know 4 or 5, 6 %. Your lunch with four dentists in Scotland, one would say, "well, mine was four point eight," and then one would say, "well, mine was four point two. I took it from four point eight to four point five." They know the prices of all their supplies. It's just a whole culture. That the easiest dollar earned is a dollar and expenses saved. It does not surprise me at all that that's where Adam Smith came from. It's a culture obsessed with cutting costs and saving money. There's no one cheaper than a Scot and when you tell that, they don't even think that's an insult. They think that's a compliment because they'll say a fool and their money always part, and rich people have money because they don't part with it.
Allan: Excellent. Can you tie in the drinking of scotch or the invention of scotch with any of the things that you just said because that is a good beverage?
Howard: Well, actually that's a great segue question. A lot of these young dentists - when they get out of school - they don't realize a lot of their patients are self-anesthesia, doing their own self-medications and they're coming in. I remember when I was young and I just got out of school, I kept smelling like Ketones or something and I thought maybe they had kidney problems and I would ask them and I said, "well you know your breath smells like Ketones." I had this lecture like ten or fifteen patients before some old guy said, "Dude, I don't know what the hell a Ketone is, but I did have a couple of belts of whiskey before. I have to have a couple belts..." When he said that, it was just like pie in my face, that's what I'm smelling.
I think it's very common in older men. You get grandpa on there, he's far less likely say, "Allan, I'm afraid of the dentist. I'm scared." He ain't going to do that but what's he going to do? He's going to drink a big old belt of whiskey before he walks in there and now we're seeing the legalization of medical marijuana, so people are eating edibles before they go in there. What should a dentist be thinking about if his patients are pre-medicating fear, drinking whiskey, and eating marijuana edibles?
Allan: That is where the pre-op evaluation comes in. I do a pre-op assessment on every patient. There's a form I fill out in things like this and if I suspect anything I ask them directly, "what is going on here?" Because we can't have sedation medications and alcohol. As far as marijuana goes, it's so new. I don't even know what these patients other than if they're really inebriated, what they're going to show, but they've started the sedation process for me and remember I said-- I haven't really said, I can titrate my drugs and I could give them what they need to get them through so it's going to depend on a patient by patient basis, Howard.
54.01 Howard: Right. You summarized all of health care into a individual case. They just put in the first medical marijuana dispensary in our town - Ahwatukee. What's it called? Sunflower Medical Marijuana. It was about a year ago. I went in there. I was thinking (inaudible 00:54:18), and these chocolates and edibles. I didn't buy anything, obviously, but I went in there and you know what blew my mind? Number one, it's right next to a dental office and that dental office has never seen that. It’s in a medical dental professional plaza. Oh my god, there's so much traffic now. It used to be that all the other people, oral surgeons and whatever. What was amazing, what I didn't see coming was that thing was built to be ambushed with an AK-47.
Nobody will use their credit card at a medical marijuana shop, so it's all cash. I was talking to the manager and he has to have a money truck come every single day - it's that much cash and looking on the counters there, I've never seen that much cash in my life. You don't think, it's in like the drawer, it's tucked away whatever right there, this is just—you’re talking through bulletproof glass and the windows are caged because they don't want some rival gang. They tried to actually come into my center or not my center, but where I own my land, a building, in the Safeway Chase Bank, you know this twenty-acre plaza – they tried to go in there and the Landlord had the space to rent them and he wouldn't rent it to him and I was talking and I said, "how come you wouldn't rent to him?" He says, "because I'm looking at the mortality rates-"
Howard: Of retail centers in California and the only thing that causes mortalities is when you put in a medical marijuana deal and then a local gang will come in there and take it out.
He was showing a lot of the tenants and landlords these murder rates and he goes, "look, we don't want that kind of trouble." It didn't register. Look, I thought it was interesting. But then a year later goes across the street from me. I was with a couple of my boys, so we'll just stop and check it out because maybe the owner will be a new patient or something and I’m always out there pressing the flesh, running for mayor, and oh my god, you couldn't have robbed that place if you and your five best drinking buddies all had an AK-47.
Howard: They are prepared for war.
Allan: That's scary. That is really something
Howard: Yeah. Amazing. Well, Allan that was the fastest hour I've done. Did I forget anything?
Allan: I just wanted to touch on one thing, if they do take courses with us, which I really hope people will get interested in, you've got access to me. Not only to talk to you on the phone but to email. I'm there to back up what you're learning if you have any questions or anything like that. I just wanted to add that.
Howard: Well, you're a great guy - that's that old Midwestern, Missouri values.
Allan: You went to school out here, you know it.
Howard: I know. I grew up in Kansas - Wichita, Kansas. Went to undergrad at Creighton in Omaha. Went to dental school in Kansas City and now I live out here and I'll tell you what - those Midwest values, you know, we were talking about Scottish values. Those Midwest values, one of the reasons they have so many fewer problems cause them people were just born to work. They're just not afraid of work and then you go to some of these bigger, fancier cities and a lot of people they spend half their life trying to avoid work. There's just nothing like good 'ol homework. You being transparent, you letting your customers call you, Skype you. You're a hell of a guy, Allan. I just want to thank you so much for taking an hour out of your life and spending it today with my homies. Thank you very much, Allan.
Allan: I thank you too and since you said you never started an IV on anybody I got to get you trained. We'll have to have you do it on some of the practice arms we've got. I'll teach you how to do it, Howard.
Howard: Practice arms? I'll just bring my monkey, Ryan. I only wanted two boys and he was the third. So, Zach and Ryan are just extras. Ryan can I use you as a primate research IV monkey? I mean, what could go wrong. Right?
Allan: Him start lifting weights and drink lots of fluid, Howard.
Howard: OK, buddy! Thank you. Thank you so much.
Allan: All right. I enjoyed the heck out of it. Thank you.