AME: The Incidental Finding

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[00:01:22] If you're looking to improve your workspace and well-being, check them out at bqe-usa.com. This is a production of the Very Dental Podcast Network. Alan Mead is a dentist with too much time on his hands and too much recording equipment in his basement.

[00:01:45] Armed with an obsession to bring entertaining and informative content to the dental world in a way that's never been done before, I give you the Alan Mead Experience. Well, hello and welcome to another episode of the Alan Mead Experience. I'm your host, Dr. Alan Mead. I'm a dentist, podcaster, and an excellent waiting room companion.

[00:02:11] I didn't want to be that. When I woke up this morning, it was not my intention to be that. Yet, here we are. I got a good story to tell you. So, I'm going to come right out with it and say, I spent hours today in the emergency room with my youngest son. And he's fine. Literally symptom-free. He's not having any troubles. No pain, no bleeding, no nothing.

[00:02:39] And so you're wondering to yourself, and frankly, I'm wondering to myself, why did we bring him to the emergency room? Well, let me explain to you. Let me explain to you. And we'll talk a little bit about the magic of incidental findings and how I'm beginning to wonder if medicine is worth what we pay for it. I'm not beginning to wonder that. Who am I kidding? Of course it's not worth what we pay for it. And the whole medical industry is completely fucked. I'm sorry.

[00:03:08] I'm going to come right off the handle and say we're screwed for medicine. The way that it gets paid for, the way that it's done, everything about it is completely messed up. Dentistry is trying hard to do the exact same thing as far as I'm concerned, but I just got to get this off my chest. Literally, the only upside about my entire day today is, I'm like, oh, let's make a good podcast. So here we go. My three-day-a-week hygienist since before COVID,

[00:03:39] actually, she was a one-day-a-week hygienist before COVID. My other three-day-a-week hygienist, or four-day-a-week at the time, hygienist quit right like a week before they closed this down for COVID. So five years ago, basically at this time. I ended up convincing my one-day-a-week person to become my full-time person, full-time in my office anyhow. And she accepted. I threw some money at her. She accepted. And it's been great. And then earlier this year, she quit. She found a job closer to home.

[00:04:09] Her husband got a promotion, and she needed to be around the kids more, and yadda, as you know. So I've spent some time early this year finding a hygienist and hiring. And as you've heard me say a million times, I'm not a big fan of hiring. It actually was not – it's a mess. Hiring nowadays is a mess. And basically, my overhead continues to get higher and higher, and it's a hot mess, of course.

[00:04:35] But so anyhow, one of the side effects of all this was that my kids got – they were on the schedule for hygiene along with my wife, and we freaking tossed them because it's an easy way to – we'd reschedule them back when life was back to normal with a hygienist. So I realized today was a good day. My wife had stuff she had to do at the farm. I'm like, okay, let's go – I was going to take the boys over to the office. I was going to clean their teeth and get that done with.

[00:05:02] So at my office, particularly when I'm the one cleaning teeth, which I have to say, since the hygiene situation has changed in the last year or so, I actually do a little bit of hygiene. Not much. Typically, it's a second column in my column, and I typically only do it on patients that we know are relatively healthy, so I know it's not going to take me a super long time. I mean, I actually don't mind doing it. To be honest, I'm quite proficient at it.

[00:05:30] And hygienists listening to this, if you think a dentist can't do hygiene, come at me, bro, because I got all kinds of words for you. But anyhow, basically, I was doing hygiene, and I tend to start – when I'm doing hygiene, I start with the exam. And I do essentially all of my recall exams on video through my microscope. I have a microscope in every operatory, and I can record the exams. And what's nice about that is I've got exams going back five or six years from when I started doing this for comparison's sake, and it's pretty great.

[00:06:00] So my son Jacob is first in the chair. He's 15, a healthy kid. He went through Invisalign some years back, and he's got healthy teeth for the most part. Got really deep grooves. He's got the deepest grooves probably about any kid I've ever seen, but we've really worked on him a lot. We've sealed his grooves up or done quite a few restorations, honestly, just all groove things. So he was looking good. I'm doing a soft tissue exam. And when I get to the part where I'm, like, looking at the soft palate and evaluating the tonsils and the – you know, I say, ah,

[00:06:30] I see on his right side this giant purple lesion thing. Like, his entire tonsil is swollen up huge, huge, and purple, like bloody. It looked horrible. It looked like my first thought – I literally said this out loud. The poor kid was looking at the screen I have mounted on the ceiling of my operator. So what the hell is that? I've literally never seen anything like it.

[00:06:58] And I will – in the show notes, I will try and put a little snippet of the video of the exact time when I first saw it. Because to be perfectly honest, it's very dramatic and a little horrifying, and I was freaked out. But no symptoms at all. Like, literally, he had no idea it was there. No sore throat. No nothing. The only thing he's been going – that's been happening to him over the last two weeks is he's been very stuffed up. His nose has been stuffed up. And he has been blowing his nose vigorously.

[00:07:28] Like, sounds like a trombone. You can tell he's really, really blowing his nose hard. I still, after all has been said and done with this thing, I suspect that's what's going on here. But anyhow, I'm looking at it going, holy crap, is this cancer? And honestly, we don't know. I'm pretty sure it's not cancer, but after everything that we went through today, we don't have a – we don't even have a differential diagnosis. So this was relatively horrifying.

[00:07:52] I did end up cleaning his teeth, and then I sent images and video to my good friend of mine who's an oral surgeon and my sister-in-law who's our family physician. And basically, both of them said, I don't know what it is. I've never seen anything like this. It might be good to go to the ER because part of our differential was what they would call a tonsillar bleed or basically like – like basically an internal bleeding in the tonsil where some blood vessels broke.

[00:08:21] And he's – and of course, the scary part about that is airway. So if you look at Google for tonsillar hematoma or tonsillar bleed, you see some images that are pretty horrifying. Honestly, they're more horrifying because of the sheer size of what those bleeds look like than what Jacob looked like. But it was still pretty scary, and we're thinking to ourselves, okay, we want to know that it's not a tonsillar bleed because that's – we're worried about airway stuff at that point. So I wrap up cleaning his teeth.

[00:08:48] We kind of wrap up, and then I basically take him home and take him to the ER. And the ER was jammed, of course. When else? I mean, I – the last time I was in the ER was because I got hit by a truck, and it was jammed then too. It took them a while to get me back, and it took him – we probably waited an hour and a half before we got back in a room. We got back in a room, and the nurse and doctor were there pretty quickly, and I just told him kind of what I had seen, and he couldn't see it at first.

[00:09:19] You're probably going to have to get a tongue depressor, and he did. He got a tongue depressor, and he had him say, ah, and he got a light in there. He said, I've never seen anything like that either, which wasn't comforting. This is an ER doc, so let's be honest. I think probably most ER docs don't see things in the back of your throat that don't have any symptoms. You know what I'm saying? Like, they might see strep throat. They probably see some of that, but like this was wild.

[00:09:47] This thing is wild and literally asymptomatic. I spent all day asking questions of people that wanted to know, does it hurt? Can you tell it's there? Can you feel it? And he can't. He didn't know it's there. The only reason he knew it was there is because I saw it, and I happened to be cleaning his teeth, doing an exam, and I saw it. If we had decided not to clean his teeth and do an exam on him, we would have been none the wiser of any of it. Still no symptoms. And I'm thinking to myself, airway, which in retrospect is a little bit stupid

[00:10:16] because he didn't complain of anything. Anyhow, it is what it is. So he's like, I don't know what it is. So, of course, what do they do when you go to the ER? They take blood. They do blood tests. They did take a strep throat test, which actually kind of makes sense. I mean, it would be a pretty weird thing to see strep throat on one side and not the other, but whatever. I mean, I get it. And then they did a CT. They did a dye, like a contrast dye CT of the head and neck area.

[00:10:42] And so we were in the room for probably an hour, hour and 15 minutes. It wasn't too bad, which is tough when you've got a 15-year-old kid and the battery on his phone and tablet are dying and he's bored. And he had plans to be out doing Pokemon Go and, you know, literally was – I mean, it's one thing when if he weren't feeling good, but he was feeling fine. All of this was complete BS to him. This was like, yeah, he did see it because I showed it to him, but he wasn't worried about it.

[00:11:12] And, of course, I forgot to mention this. The very first thing he says, is it cancer? I'm like, boy, I don't think it's cancer, Jacob, but I don't know what it is. So, I mean, everyone that I talked to is like, boy, he's going to need an ENT referral. And, of course, that's exactly what he needs because the ENT is the only person who's going to figure this out, whether it's by biopsy or them looking at it and knowing exactly what it is. An ER doc doesn't see very much of this stuff. And that's essentially what they – they basically ruled out anything

[00:11:40] that would show up in a blood test. They ruled out strep throat. And there were no soft tissue. You know, there was not scary swelling in the soft tissues that we couldn't see from the CT. That's all we got. And so they said, well, we're going to send you to an ENT. So, this is where I come back to my thoughts on medicine in general. What I found in Jacob was what they call an incidental finding. Jacob wasn't saying, dad, my throat's really sore. Would you take a look? It was nothing like that.

[00:12:09] It literally – I found it because I happened to be cleaning his teeth and doing an exam in his mouth. That's how I found it. So, it was completely incidental. I used to think the word was an occult finding. And occult finding is a little bit like that, but it's something that's very hidden that you wouldn't be able to see without doing special tests or whatever. So, it wasn't really a cult. It was incidental. I found it when I wasn't looking for it. And I got to tell you, I worry a little bit about my reaction. I worry about my reaction.

[00:12:38] And, of course, my reaction was my reaction because it was my kid. If I had found this on someone else's kid and it was a Tuesday, I probably would not have – I wouldn't have freaked out. I would have shown the mom and I would have said, boy, you really need to talk to your doctor really quick. You need to have your doctor take a look at this. They're going to likely do an ENT thing. I kind of doubt I would have sent them to the ER. But because it was Saturday, I wasn't going to have – there was no chance a doctor was going to be – I wasn't in any place to send them to.

[00:13:05] So – and I felt like, man, I was worried about the airway because it's my kid. So, I guess I might have told the parent, I'm a little worried about the airway. I want you to seek out a doctor's opinion immediately. I don't know. I might have. But in the back of my mind, I'm like, this is weird. There's no symptoms. He didn't even know it was there. And so the reality is, is like we rolled the dice and it just so happened I was cleaning his teeth today and saw it. It's likely it's been there for a while. I mean, it's pretty likely.

[00:13:34] What are the chances that I find a freaking tonsillar bleed the day that it starts by chance? It's like zero chance of that. It's probably been there on some level. And the other thing that adding it up, again, this is my theory. I don't know for sure. He's been blowing his nose really hard the last few days, last couple weeks actually. He's had between allergies and a cold. He's just not felt he's been stuffed up and he can't breathe very well through his nose. So he's blowing his nose like crazy.

[00:14:02] And like if you heard him blow his nose, you're like, whoa, he's really so he's really going after it. And so I'm wondering if he's traumatized the tonsillar tissues just by blowing his nose so hard. I, you know, everyone that thought about did you, I mean, did you jab it with a toothbrush? Did you when you're biting something where it like everyone wanted to come up with an injury because this was look like it looked like an injury back there. And he couldn't come up with anything like the poor kid was like busting his head to think what in the world could. But he couldn't come up with it because he had no symptoms.

[00:14:31] He didn't remember anything. It's very frustrating. So this incidental finding. Drove me to take him to the emergency room for fear of the things that I've learned over the years in dentistry. Oh, my God, is his airway compromised. He's going to die in the middle of the night because he can't breathe. He didn't tell me anything. He was having no symptoms whatsoever. So that's a little silly now. But at the time, it was like, I want to know that he's not going to die. Well, guess what? I don't know anything more now than I did when I brought him in. I know that he doesn't have strep throat.

[00:15:02] I know that the ER doc said, I've never seen anything like this. Well, that's I don't know how soothing that is or not. I'm not sure. But what I do know is that I'm sure that the ER bill is going to come up to several thousand dollars today. And it didn't tell us anything. So and I know that, shoot, this is a weird thing that happened. Like, this is a bizarre finding in a bizarre condition. So I can almost excuse myself for being a little over the top for bringing him into the ER.

[00:15:31] But I'm thinking to myself, how many people go to the ER just because there's something a little weird? And the ER is literally the most expensive place to freaking do anything. Everything costs a lot there. And the doctors are really good at handling emergencies, but they're not really great at giving you a differential diagnosis on something weird or exciting. OK, everyone in their right mind knows an ENT needs to see this.

[00:15:58] And unfortunately, this hospital did not have an ENT walking around that could take a look at it. So in the fact that he's not having symptoms and he's not having airway issues, probably. He you know, Monday is going to be fine. It's Saturday now. Monday is probably going to be fine. But I brought him to the ER out of, you know, just to be safe. Well, just to be safe. I get it. It's important. Allegedly makes you feel better. Although, frankly, I don't feel any better because I don't have any differential diagnosis.

[00:16:28] No one knows anything what's going on there. And the thing that kills me by the time we get into an ENT, I wonder if it'll still be there. I wonder if it'll still be there. If this is something that was short term, that's already healing. God, can you imagine us getting him to an ENT? And he's like, I don't see anything. So, yeah, I'm going to be checking his freaking throat multiple times a day to make sure that everything's OK there and also that it's still there. And I don't seem like a complete idiot.

[00:16:51] So, the bottom line is my incidental finding is I found it. I saw it. But they have no answers. I likely won't have any answers until we see an ENT. And frankly, I'm not convinced that we'll have answers then. And that's one of the things that is bugging me about medicine, because I feel like the natural thought process about medicine and doctors and this we need to go to the doctor to make sure that we can treat our conditions.

[00:17:21] I don't know that we know stuff as much as we think we do. And I'm not I'm not saying this as a negative thing against specific doctors. I don't know. I really am not. But as a whole, the medical system is not as good at answers as we kind of feel like they should be. Take the fact that I had. OK, so back in. I mean, I know I talked about this years ago and it's it's so dumb, but literally. I stepped on some glass.

[00:17:52] Back in. God, it was 2000. It was 2022. I think 2022. Yeah. So it was. Yes. January 2022. Literally, I went to I went to voice dentistry that year and I had a limp because I had stepped on this glass. It's a big wound on my foot because I stepped on glass. And of course, because I'm diabetic and I've jacked up feet, every doctor I talked to was convinced I was lying about stepping on glass, except like I could hand you the piece of glass that I stepped on.

[00:18:22] I know exactly where it went and what happened. They are like, no, no, you're diabetic. You have a sore on your foot because you're poorly controlled. I'm not poorly controlled. I'm very well controlled. But more than that. So I was in wound care for better part of a year, actually more than a year. But I was in wound care at one hospital for. Nine, 10 months and with very, very little improvement. And to be honest, they had custom shoes for me. They had a custom orthopedic boot for me, everything. And not a one of them ever unweighted me off that stupid thing.

[00:18:52] Unbelievable. All the answers in the world from all the people who are supposed to know what's going on and nothing, nothing helped. Nothing helped. I finally left wound care against medical advice because every time I asked them why it wasn't getting better, they would point, you know, two weeks back saying that I had gone backwards. I mean, they hadn't even said anything. They didn't tell me, you had a relapse on this thing. You're getting worse. They didn't say anything. Everything.

[00:19:17] Basically, what I do know is every time I went in there, it cost me two to three thousand dollars because they were grafting skin on my foot and all this stuff. So I went for a second opinion. And the first thing that the person that I saw in Saginaw said, oh, my God, your feet are deformed. They are. I have if I have the highest arches of any person you've ever seen your entire life. And they're terrible. And my feet are super jacked up. And so I walk on the very outsides of my feet. And that's where I stepped on this class.

[00:19:45] So no matter what we did, they couldn't really off weight the wound. So if you can imagine, it's a wound that I'm constantly walking on. OK, so I finally took an orthopedic surgeon who was doing part time in the in a wound care to say, oh, my God, it's an orthopedic problem. This isn't this isn't a diabetes wound healing problem. You're stepping on a wound. We get we got off weight this. And so he he did some he worked a little bit on the custom boot that they had for me and it helped a little bit. But I ended up I ended up walking.

[00:20:15] They rang me out of the the wound care clinic there, too, because I'm pretty sure they just didn't want to see me anymore either. So and then so I went for like maybe better part of a year just with this sort of low grade wound. I was in I'd have some days were worse than others and it hurt. And so I got to tell you, this thing was still kind of oozing a little bit. It was never completely healed over. So I finally went back. I found a podiatrist here in town and he took a look at it and literally he said, yeah, it's your orthopedic. You got to off weight this thing.

[00:20:44] So he sent me to a different guy who knows shoes, the cobbler shop. He put me in a regular pair of shoes and he actually made me an insert. You know, I have thousands of dollars in custom shoes for the stupid thing. And I do think that helped. But I have to say what I really think helped is going to the podiatrist and he just he just debrided the wound every six weeks or so. And I kept I had some shoes that were actually off weighting and just honestly over time getting better. And pretty much now I don't have a wound on my foot anymore.

[00:21:15] That was 2022. It is 2025, more than three years dealing with this wound thing. And no one knew. No one knew enough to do this. No one knew enough to do this because they didn't. It was a weird question that they didn't have the answer to. So they threw whatever treatment they thought was going to work at it without without evaluating this, making it any better. I come back to my son. In my mind, he needs to see a doctor. I see this crazy thing that I cannot account for.

[00:21:44] He doesn't have any symptoms. He's not sick. He's breathing fine. But I'm freaking out. Medicine is happy to treat a condition even if they don't know what the condition is or what the solution is going to be. That's part of the problem. We have lots of treatments where I think sometimes we're not 100 percent sure what the problem is or if it's going to help. It comes back to the fact that, you know, prevention is not really part of medicine anymore. It's not really part of dentistry anymore. I think there's people that say, oh, we do prevention.

[00:22:13] But the reality is the patients are not doing the preventive things. Most everything has to do with what the patient does on a day-to-day basis, not what they do in the doctor's office or in the dental office. Most everything that we're treating is some kind of a lifestyle thing, almost all of it. Jacob's, whatever this thing is in the back of his throat, I kind of think it's probably not cancer. I kind of think it's probably that nose-blowing thing or some kind of a trauma, I hope.

[00:22:42] It was scary looking to me. I saw it up close and personal in the microscope and I took him to the hospital. And now I'm second-guessing that because we kind of have no answers. We spent a lot of money and we're going to get the same referral to an ENT that I was thinking to myself, that's probably what we should do. So I'm part of the problem. Don't get me wrong. I'm part of the problem. But I think the problem, I think we need to take a good hard look at this. I'm a little embarrassed to have had this interaction today, but I also feel like I've learned something from it.

[00:23:11] I would love to hear how you other people are thinking of this sort of thing. How do you feel about medicine? How do you feel about how medicine points at problems instead of, basically we hand them problems and they offer the solution that they have. I don't know, man. I'm kind of freaked out about this. I'd love to. And literally this is raw. Like I just got home from the hospital like two hours ago. So this is, I haven't been able to really think much about it.

[00:23:37] I'm worried about my kid, even though the way he's acting is no different than he ever does. So I don't know. I don't know, folks. I got no answers. I'm a little worried about medicine. I'm a little worried about the incidental finding. I'm a little worried about us as a, the way that we handle healthcare. I think we're a little screwed that way. And I'm curious to hear what you guys think. So if you're not part of the Very Dental Facebook group, you need to go join. So go to Facebook. Look up Very Dental. It's going to ask you for a password for your invite.

[00:24:03] The passwords are Timmerman, McQuethy, Hornbrook, Papa Randy, or Lipscomb. Any of those five passwords will get you in and we can talk about this. I would love to have any advice or hear what you guys think about this. Because I think, I think we have a lot bigger problems than healthcare, healthcare premiums. And I'm going to tell you what, my premiums are freaking ridiculous. It's insane. And they go up hundreds and hundreds of dollars every year. And I don't think it's doing us a lot of good.

[00:24:33] But I feel like, I feel like on some level, our medicine is, is not, not as glorious as we think. So I don't feel a little down about this, but I'd be curious to hear what you guys think. Thank you so much for listening. You guys, I appreciate it. Appreciate all the support. Go to the Very Dental Facebook group or, or, or message me online or whatever. I'd love to hear from you. And thanks a ton for listening. We'll talk to you again soon. Bye.