COVID 19. Part 5. A Personal and Professional Reflective Journey into an unknown and uncertain Future. Whole Dental Health, A Brave New World.

Introduction

Screenshot 2020-04-11 10.32.26

Reflection will soon become a requirement of re certification as a Dental Hygienist in New Zealand. I’m not certain how many within the profession have written reflectively but what you find below is a quick example of reflective practice about my recent and ongoing experiences regarding the COVID 19 pandemic as a Dental Hygienist. It is both personal and professional, it could be written in a variety of ways, using different approaches of reflection from Kolb, Gibbs or Schon as examples but I’ve decided to use a What, So What, Now What pathway for its ease of use. For more information and examples please use the referenced links at the end of the piece. Good luck and remember how beneficial it is the think about what you’ve experienced, how it has affected you and the changes you may consider making as a consequence of them.

“Necessity is the mother of all invention”. Old Proverb

What

Just three months ago I was looking forward to March, especially the 17th, when I was completing a six month locum stint in a practice in Blenheim, Marlborough. I had work organised in Nelson to replace what I was leaving behind and my professional life, for once, looked peachy. Little did I know that by that date I had reappraised and adapted my clinical approach to dental hygiene treatment. At the same time I was feeling underwhelmed by the lack of concern and fragility of fellow professionals being displayed in the clinical environment and in online professional chatline on social media. COVID 19 was a “Clear and present danger” to me and those I respected and cared for both personally and professionally. I had started giving it consideration by about mid-January, when news was slowly filtering from Wuhan via the media that a novel virus was causing lockdowns, infections and, the start of what was to be, many deaths being reported and the concerns of a rising epidemic becoming very real.

reflect

So, What

After listening to RNZ I began to think about how I’d respond if it came to New Zealand.  I could potentially be seeing asymptomatic, pre viral or even viral cases not far off in the distance.  Ironically the first thing I did was to pick up a few masks and brought them home, we had a few boxes of gloves in the house from my Wife’s old locum midwifery practice. My wife had given me the “are you a conspiracy theorist” look initially but found a quiet place for them, just in case. My Son, Daughter and their respective partners had recently been to Europe on holiday and all but 1 had experienced colds and fevers either during or on their return. I kept my distance from them and as the epidemic continued the realisation of it going pandemic grew. I started to consider how I was going to modify how I worked, my concerns being the safety of my clients and myself. About this time, a rush on not only toilet roll but hand sanitizer saw both items being panic bought and dental supply companies running out of stock rapidly over night.

We had intended to have a practice meeting, scheduled on the 25th February, and I was going to present on a “Sustainable Approach to Dental Health”. This I withdrew from and advised the Practice Owner and Manager to consider the meetings topic changed to what might potentially happen over the next few days and weeks regarding COVID 19 and how were protect our clients and ourselves. It felt like we were transitioning to a weird kind of war footing (I had experienced this during Gulf War 1 in 1991) and felt some of our colleagues weren’t as aware of all the facts and even concerned as much as they should be. I’m glad we had the meeting as it began the process of mental adjustment for all and adapting to the threat of COVID. We placed information notices on doors, put out hand sanitizers for clients to use and took stock of the supplies we had and began to order more, especially hand gel, masks and gloves. The unknown became very real when on February the 28th when” case of COVID 19 in New Zealand was announced.

One of my wife’s friends is an Emergency Department Nurse who lives in Canada. Her Son, a young healthy man in his early Thirties was one the first to die of COVID in his country. We heard this sad news about mid-March, Toni was devasted. She and I began to make the growing COVID risk more apparent to all our friends and family. Some found it too extreme, others were still unconcerned but very soon the reality was setting in that things were not going to stay normal for much longer. The MarchFest in Nelson, a Beer Festival, on the 14th, March was the last event I was to attend with my Sons for some time to come. New phrases like “Physical distancing” and “Flattening the curve” began become accepted norms, similar as our fore fathers call to action with phrases such as “Dig for victory” and “Careless talk costs lives”. Regular visits to the shops to quietly stock up on food and groceries gathered a pace and our cupboards, once empty began to fill to support our “Bubble” isolation for the weeks to come.

Screenshot 2020-04-11 09.42.08

The government initiated a COVID 19 strategy of “Going hard and fast” on protecting the population, stepping up testing and self-isolation for those returning to New Zealand after the 25th March. That week, a rapidly created Alert state had been implemented, we were at level 3 by the 23rd and total lockdown, Level 4, by the 25th, March. My routine and regular practice, something very familiar to me in various clinic guises for some 30 years, ceased that Monday and we held a final impromptu “socially distanced “practice meeting. The future and our careers seemed very uncertain, all of a sudden.

Now What

Way before the end of March I started to reduce and then cease all my aerosol producing clinical activity, despite others continuing it. In particular I hung up my ultrasonic and airflow systems and began making sure that I displayed to my clients super visual hand washing techniques as reassurance. However, I did continue to use slow handpieces continued, which do create a droplet field. My dilemma was very real, that clients were paying and expected to feel that their teeth were effectively cleaned. Aspiration was the best barrier to reducing its potential contamination. Cleaning down after treatment and set up processes for the next client were more deliberate and measured. I work without chairside support. This will need to change.

The New Zealand Dental Council with the Ministry of Health directed all unnecessary treatment cease from the 23rd, March as previously stated. They drew up very clear guidance on what is deemed an emergency and what is not. It was crushing to think that everything I did was effectively non-essential and that would remain true until we drop back to Level 2 from 4. The initial 4 week lockdown could be extended, if required, and no suggestion of when the Level 2 is on the horizon as yet. However, the Prime Minister is now asking businesses to plan and consider how they restart or reset when that time approaches. What does this mean to me? I’m using the time to catch up on many things, educational I’m writing the blog and this is fifth so far. I’ve a plan, set out last year and every excuse under the sun has held me back completing it. Not now. Additionally, and perhaps more importantly, I need to familiarise myself with all the recent updates and mentally preparing myself for an alternative, uncertain professional future.

Screenshot 2020-04-11 09.41.16

I am also a little uncertain of this new clinical reality, one which will mean the wearing of Personal Protective Equipment beyond my previous norm in the course of routine dental hygiene treatment. One very visual video I saw on YouTube by the Auckland DHB demonstrated how to dress with PPE, hand sanitization four times for one process of gown, gloves, masks and protective eyewear being put on and taken off. How many would our practice need and where in these times of shortages of such items would we get them from? How much would they cost and would our clients accept the changes and additional fees if added to the treatment costs? These decisions I fortunately don’t have to make but how I approach my clinical practice, beyond the PPE debate, is very clear to me.

  1. PPE will need to be uprated with visor and if required gowns. A few trial runs getting to know how to put it on, that’ll be interesting.
  2. Aerosol creation limited or ceased.
  3. Really good evaluation and assessment.
  4. Hand instrumentation, even for perio cases.
  5. Dental Assistant required for helping with aspiration, note taking and infection control.
  6. More time will be required to undertake treatment.

So, as per NZDA guidance, all my cases will be categorised as Low Risk Care, not positive for COVID 19 or any associated exhibiting symptoms, or in close contact with those who do. The international travel aspect will shortly not apply for certain, for a while. No aerosol generating equipment, all PPE equipment required including gowns and our normal surgery use.

I wonder how many of the profession think everything will return to normal rapidly? Some, like myself, may align to that notion only when a vaccination is developed and tested, produced in the numbers required to globally distribute and facilitate it. Essential healthcare and general workers, those at risk, the immuno- compromised and the elderly will undoubtedly and rightfully be first in the queue. This will take time and until then I will subscribe to the immortal words of the great Clint Eastwood, “Improvise, Adapt and Overcome” because “Tomorrow is promised to no one”. However, the lingering thought is this, how much will it ultimately cost the profession, additionally the client and will they return in the numbers they used too?

Screenshot 2020-04-11 10.33.30

References and resources

1. Ministry of Health, Dental Council and Professional Associations’ joint statement: COVID-19 update*https://www.dcnz.org.nz/resources-and-publications/updates/update-on-covid-19-novel-coronavirus/

2.     https://youtu.be/vGyjF9Ngd8Y What is a Critical Reflection?                Introducing the “What, So What, Now What” Model – Use the Course  environment as your workplace and learning environments

3.     https://youtu.be/_mQ_zDUX9nE Reflecting on a Personal Experience Using the “What, So What, Now What” Model

4.     https://youtu.be/8Lxp_TA6AI4 Sample Reflection: Reflecting on a Course Activity

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