Fall has arrived in the ER.
The new interns are developing some confidence, the senior residents are developing some leadership and so I can relax my summertime hyper-vigilance a little bit and observe the passing parade of life in the ER.
There is happiness when pain is alleviated, sadness when a life ends. There is grit and resilience in the face of unbelievably bad news and bad luck. There is frustration and tears at one more setback, however slight. There are parents who care unceasingly for children who will never become adults no matter how many decades pass. I have never once heard them complain.
There is often gentle humor, too, for no one could face so much suffering without an antidote.
On a recent shift a new intern rushed over to me, breathless and slightly panicked.
“Come quickly, I think my patient is having a stroke! He came in for an ankle sprain and while I was taking his history he suddenly lost the ability to speak, right in front of me, like mid-sentence!”
I went to the bedside to find two agitated nurses and a patient who looked terrified. His eyes were wide open, darting in every direction. His mouth was also wide open. A silent scream.
“Sir, are you having trouble speaking?”
Garbled gargling sounds rattled around deep in his throat as he vigorously nodded his head.
“Can you close your mouth?” I asked him. He waggled his jaw a little and then emphatically shook his head no.
“What happened?” I asked him.
“Yaaagghn,” was his strangled reply.
“Well, he is not having a stroke,” I told the nurses and the intern. Everyone including the patient looked relieved.
“But maybe you could work on your bedside manner a little, doctor. I think you may have bored him into this predicament.
“Yeah. Listen to him, he is telling you what happened. Sir, what happened just before your mouth got stuck open?”
“Well, there you have it then,” I said as if it was now so obvious that even an intern would get it.
To their puzzled looks, I explained, “He yawned so hard while you were talking to him that he dislocated his jaw. It is stuck open. That is what he is saying—‘Yawn’.”
I reassured the patient that we would be able to relocate his jaw easily in just a few moments.
The human jawbone (mandible) is attached to the temporal bone of the skull via a small joint called the temporomandibular joint or TMJ. You can feel your TMJ if you place your index finger in your ear or just in front of your ear and open and close your mouth. Now wiggle your jaw from side to side to get some idea of the different motions this joint can accomplish.
Many of you probably already know where your TMJ is; TMJ dysfunction (TMJD) with pain occurs in 20 to 30 percent of adults and can be quite troublesome. There are really few good treatment options. The best direction I heard a dentist give a patient with TMJ had nothing to do with soft diets or night splints but was rather his observation. “You carry your stress in your jaw.”
Recognizing this as true, the patient subsequently did much better. I guess we all have to carry our stress somewhere.
The TMJ is a ginglymoarthrodial joint. This Scrabble-worthy word means the joint can both hinge and slide at the same time and that is precisely how and why they can spontaneously dislocate. The first inch or so of mouth opening is a hinge motion, the next inches are a forward sliding motion. Put your fingers back on your TMJ and open your mouth slowly and widely and see if you can appreciate this (Not too widely though!). You should be able to feel the mandible slide forward as your mouth opens wide.
My patient’s mandible had slid so far forward with his giant yawn that it had dislocated out of its socket and gotten stuck wide open.
We sedated him and the intern carefully stuck his gloved thumbs into his mouth. I cautioned him to avoid placing his thumbs atop the molars. He pressed the mandible firmly downwards and backwards and it slid back into place with a chomping sound as the molars came back together. Hence my warning about the molars. Don’t ask me how I know this. Let’s just say for a while I carried my stress in my thumbs.