Iatrosedation on the “Firing Line”

The patient whose iatrosedative interview revealed she feared painful injections is now on the “firing line” – the first clinical encounter in which the injection will be given.

Doctor: “How are you feeling this morning?”

Patient: “Fine, thank you… I’m a lot less nervous about the shot than I was before we talked, but I’m still somewhat nervous.”

Doctor: “Well, I would expect that… but I think you will learn today to be a lot less nervous than you are now. As I told you I am confident that I can give you an anesthetic with very little, if any, pain. Should you feel anything I think it will be something you will be able to handle very well. I will keep you informed as we go along as to what you can expect… I will be responding to you and between us I feel sure you will develop a new set of feelings. Okay?”

Patient: “Okay.”

Doctor: “Is there anything else you would like to talk about?”

A combination of manual and communicative techniques are involved in order to carry out, as succinctly as possible, the promise of an atraumatic experience with this injection. Although we are using the injection as a model, this concept should be carried out in all aspects of clinical treatment. Each doctor must develop his own style of iatrosedative behavior.

The Manual Component (Infiltration)

The syringe is prepared beforehand with a needle that has been tested for sharpness and a warm cartridge. It is kept out of sight behind the patient, to be passed over the shoulder below the line of vision. The objective of penetrating the tissue noiselessly and painlessly (or with the minimum amount of pain) is achieved by:

  1. painting a topical at the site of penetration (in this case the reflection of the alveolar mucosa);
  2. making the mucosa as taut as possible by pulling the lip or cheek out without discomfort;
  3. establishing a firm finger or hand rest to provide maximum stability and control of the syringe;
  4. delicately penetrating the taut mucosa, the bevel toward the tissue, to the depth of the bevel (1-2mm) only;
  5. very slowly injecting a drop or two of anesthetic. After a few moments, penetrate 1-2mm and deposit a few more drops. Move slowly into an anesthetized area until the target area is reached.

This manual technique is combined with preparatory communication in the following manner:

“I am going to put a surface anesthetic on your gum to numb it so that you will be more comfortable.” This is said as you approach with the topical. The mucosa is pulled taut with syringe poised to penetrate.

“I don’t expect you to feel this.” The needle is inserted to the depth of the bevel, stopped and a few drops injected.

“Do you feel it?” If the patient indicates that he does not, the doctor answers:

“Good, I will be injecting very slowly… it may take longer than usual. I won’t be using any more than the normal amount, but it will be easier for you. Do you feel anything?” If the patient indicates “No”, reply: “Good.”

If the patient indicates in any way that she does feel something it is wise to respond by saying, “I’m sorry, but I don’t think you will feel anything from now on. I will be going very slowly.” This is not said defensively, but merely to let the patient know that you care.

These simple preparatory communications carry much more weight for the patient than one would suspect. An interpretation of what they may mean follows:

  1. Using a topical anesthetic communicates the concern of the doctor and the wish to minimize pain.
  2. “I don’t expect you to feel this” states, “I am about to inject and will do all I can to do it without pain”.
  3. “Did you feel it?” I have already started injecting and I want to know how it is with you. This is a continuing involvement and I want feedback from you.
  4. “I will be injecting slowly, no more than usual… etc.” I am keeping you informed, explaining in case you get upset because you may think I am using too much anesthetic, etc.