Wednesday, October 15, 2008

The Jaws of Victory

So one day, when I was an intern working an emergency shift, I walk into an exam room to find five people - two adults and three children - all huddled, weeping, around a small and somewhat elderly Pomeranian. The Pom is walking cheerfully around on the exam table, waving its fluffy tail, and at a casual glance doesn't look even a little ill, let alone ill enough to put the entire family in tears.

Hmm. Clearly there is something more to this case than meets the eye.

I ask the clients what we are seeing the pom for. The husband gathers himself together and says in a choked voice, struggling for control, "We think we have to put her down. She's having seizures. Our neighbor, who used to be a vet tech, says there's nothing you can do about it and it's best to just euthanize her."

Grr. First of all, there's LOTS that can be done about seizures in general (although specific cases may prove refractory, we haven't yet established if this is one of those cases.) Secondly, if you are not a doctor, you should not be diagnosing your neighbor's pet - especially with fatal diseases and grim outcomes that will needlessly upset the owners for no valid reason, since you have done no workup and are not a doctor and are therefore not legally qualified to make a diagnosis. Thirdly, DON'T tell me what I can and cannot do about things medical, especially if you have never met me and are just making an (incorrect) assumption that I will euthanize your neighbor's dog out of hand without even working it up. Suddenly I don't like the neighbor lady too much, even if she DID used to work for a vet. (Normally, having once worked for a vet - in any capacity - is something that predisposes me to like people, but in this case I may make an exception.)

Back to my clients. The kids are gathered protectively over the dog, crying softly, and the parents are doing their best to suck it up and answer my questions.

"Can you describe the episodes?" I ask (unwilling to call them seizures until we know that they are.)

"Well," the dad says, "She'll be walking around perfectly fine and then all of a sudden she throws her head back and turns it from side to side, making chewing motions."

"Like this," says the mom, helpfully pantomiming.

Hmm. Well, that could be any number of things, but the mom's act doesn't look that much like a seizure, at least not of the typical sort. I ask a series of questions: Does she fall over? No. Paddle her legs? No. Lose consciousness? No. Go rigid? No. Vomit? No. Urinate or defecate? No. Vocalize? No. Appear disoriented during the episode or after it? No and no. Which leaves us with: Is she perfectly normal in all respects except for what she does with her head? Yes.

Hmm. "How long do the episodes last?" I ask them.

"A few seconds," says the dad.

"And how often do they occur?"

"It varies," says the mom, wiping her eyes. "Sometimes she'll do it every few minutes, sometimes not for a day or two."

"Okay," I say. "Let's do a physical exam."

I get out my stethoscope and have a listen. The Pom's heart sounds fine and pulses are normal and synchronous, so the episodes, whatever they are, are unlikely to be of cardiac origin. I palpate the belly. Normal. As I am checking ears for potential infections that might lead to vestibular signs (which can be mistaken for seizures, strokes or poisonings) the dog suddenly points her nose at the ceiling, turns her head from side to side and makes gnawing motions with her mouth, her lips drawn back as far as they will go. This is accompanied by a soft, peculiar creaking/grinding noise.

"There! She's doing it!" exclaim at least three of the family in unison (somewhat unnecessarily).

"Okay," I tell them, as the dog, true to their observations, stops her odd behavior after about six seconds and resumes meandering over the table, sniffing industriously and wagging her tail. During the episode, I have learned two things: One, the dog has horrific teeth, and is seriously in need of a dental. And two, this is the cause of her so-called seizures.

"I'll be right back," I tell them, and I nip into the treatment area to grab a hemostat. I return to the exam room, where there is confusion and just the faintest glimmer of hope appearing on the faces of the parents. I grasp the little pom and gently ease her mouth open. She immediately goes into her act, jaws agape and pointed skyward, lips snarled back from her awful teeth, the strange creaky grinding noise emanating quietly from her mouth - because her upper right carnasial tooth has so rotted out of her gums that it is hanging loosely by a single root, and every so often when she opens her mouth it falls nearly out, tilts to the side, and wedges itself in between her dental arcades. Not surprisingly, this causes her to make all sorts of faces, and she makes gnawing motions because she has something - her own tooth, in this case - wedged between her jaws. The grinding noise is her other teeth working against the cross-wise loose one which will, after a few moments, get pushed more or less back into correct anatomical position, slipping the other two roots back into their sockets and terminating the dog's "seizure".

While the pom helpfully has her mouth open wide, her lips drawn back out of my way and her nose pointed usefully skyward, I dart in with my hemostats, grab the hanging tooth and pull it out. This requires good aim but little effort, because the tooth is literally hanging by a thread (if even that). I display the offending carnasial to to pop-eyed astonishment of the entire family. After a moment of wide-eyed silence, the mother starts to laugh.

"Is THAT what was causing her seizures?" she asks.

"Well, yes, although they weren't seizures," I say. "She does need her teeth cleaned; there are quite a few others not much better off than this one was," I add.

"We knew she had bad teeth," said the father, "But our neighbor told us she was too old to have them cleaned."

Sigh. That neighbor is really annoying me now.

"There certainly would be some risk to consider," I allow, "but the vast majority of the dental cleanings we do are on older animals, since young ones usually have good teeth. It's not impossible for there to be a problem under anesthesia, but it's rare, at least in our hands. And you can do bloodwork beforehand to minimize your risk," I add. "That would allow you to know ahead of time if there are any other health issues to consider before anesthesia, and if there were, your vet could then take precautions to make the procedure safer. Meanwhile it's not a bad idea to do some antibiotics, since that would make her mouth healthier, protect her heart and other organs from infection - and make her breath better," I add, since the Pom's breath is indeed eye-watering.

"Her breath does just about strip paint," the father agrees, chuckling now in his relief. Two of the children are snuggling the dog, despite her breath, and the other, burrowed into her mother's side, is still crying (although with relief, now, instead of sorrow.)

"Okay, so I'm going to advise that we begin antibiotics today, and that you see your usual doctor on Monday and arrange some bloodwork and if that looks good, a dental. And maybe don't let your neighbor diagnose your dog any more," I add, mildly.

"Oh, don't you worry about that," says the mother, darkly, looking at the tear-stained faces of her children. "I'll be sure to tell her exactly what was really going on with our dog." There is a certain grim and steely light in her eye, and I feel a bit sorry for the neighbor for a minute.

Now, I will faithfully report that the vast majority (with one or two notable exceptions) of the veterinary nurses I've worked with are worth their weight in gold. A good one is of inestimable value. Nearly all I have known are intelligent, capable, compassionate, skilled and tactful, and would never presume to diagnose an animal without a doctor's input - although several of them have, when asked by friends and neighbors to diagnose the dog, said, "Well, it could be X or Y or Z, but I'm not a doctor so I can't tell you for sure. I'd go see your vet and ask them about those things, and maybe ask for these two tests to make a diagnosis." This is entirely acceptable, and causes a good many dogs to get appropriate care. Most of them would not be so arrogant as to decide they knew what had to be done (in the absence of any workup or input from a doctor whatsoever), and would be kinder and more tactful (and more cognizant of the potential impact on the children) than to announce to a family who is devoted to their dog that it needed to be destroyed. It is possible that the neighbor in question wasn't actually a tech, but a less-educated assistant, or that she didn't spend long in the veterinary profession and didn't know any better, or that it was a looooong time ago that she worked in medicine, or that she worked in a practice that didn't do the workup before making the decision. I guess at the time, witnessing the deep distress that she caused - inadvertently, one hopes - I felt that she ought to have had the common sense and the kindness to suggest a trip to the vet rather than baldly announcing that the dog was having seizures (which it wasn't) and needed to be euthanized (which it didn't).

Still... in the end it worked out well, because the owners had the sense to come to the vet rather than believing to the neighbor and (for example) dropping the dog off at the SPCA to be euthanized. And it was a good one for me, because it's not often that you get to cure "seizures" with six seconds and a hemostat, and look like a hero while you're at it.

So maybe this wasn't quite snatching victory from the jaws of defeat, since the dog's problem wasn't of a fatal nature to begin with, and the only real threat here was if the owners had listened to the neighbor without checking. And after all, the alleged seizures actually resulted in the dog getting some good dental care (resulting in improved comfort and longevity for the dog), so those jaws resulted in victory for everyone.

Except maybe that neighbor.


MaskedMan said...

Some people... Grrrrr...

No doubt, neighbor-lady was trying to be helpful. Thinking first would've been much more usefull, though.

AKDD said...

She probably WAS trying to be helpful; however, pronouncing a dog's fate without benefit of diagnosis is never a good idea, and in general I think one should consider the consequnces of one's actions before one actually makes a Big Mess Of Things. I also believe that unless one is *actually* qualified to say, one SHOULD NOT SAY, especially with the air of authority that evidently this person adopted.

But, that's just my personal bias. I tend to feel protective toward my clients - even ones that are just seeing me once for an emergency and will never see me again - so I may be inclined to be more irritated by these things than is truly warranted.

I admit it: I'm weird that way.

Bill Fosher said...

Wanda: Hi June!

June: (gloomily) Hi.

Wanda: Why so glum?

June: Our old dog is acting strange and I don't know what's up.

Wanda: Have you taken her to the vet?

June: No. The kids have hockey and Dan's away hunting.

Wanda: Well, you really should. Back when I was a vet tech a thousand years ago, we had an old dog come in with seizures that we could have probably helped if only the folks had brought him in earlier. He ended up having to be put down.


Yes, it's true. I was there, a fly on the wall while these two ladies dropped their kids off at school one morning and overheard the conversation. The stressed out hockey mom came away with the notion that her dog was having seizures and needed to be put down because she hadn't gone to the vet right away.

As soon as Dan got back (and he's such a loser, he didn't even get a moose) they rushed to the emergency vet clinic where a miracle worker doing her internship discovered that the only problem was a rotten tooth.

The next day, Wanda got an earful about what an idiot she was, and how the genius vet said Wanda should mind her own business from now on.


Okay, here's an actual true story. A fellow shepherd whose farm is on the ropes financially (even more than mine is, which is saying something) crosses my path at the feed store. We're chatting about lambing, shearing and whatnot. He mentions that his good dog has not been up to snuff lately.

"He hardly wants to come out of the kennel, and he acts like he's in trouble all the time. He seems a little lame on his left front leg, but it comes and goes."

"Have you been to the vet?"

"Yeah. $55 later and we're told to watch him and see if it doesn't get better on its own."

"Did the vet check him for Lyme disease? The way he's acting sounds like some of my dogs when they've had Lyme disease."

"Nope. It couldn't be Lyme disease because the temp was normal."

Okay, now I'm in a tough spot. I know from experience with my own dogs that lack of a fever doesn't rule out Lyme disease, but I also wasn't there. Did the vet recommend bloodwork, but my friend refused because it was expensive?

As it happens, I have a bottle of doxycycline in my truck. I know how to find out of this dog has Lyme disease. All it would take is a half dozen of those capsules and two or three days. If it were my own dog, I would start the course of doxy and see if he responds to treatment.

But it is not my dog, I am not a vet, and it would be against the law for me to give him those pills and instruct him on how to use them.

So I take the middle road. "If I were you, I'd go back to my vet and tell him that you've just talked with a fellow shepherd who has had seventeen cases of Lyme disease in his kennel in the last five years, and this is what he would do ..."

My fellow shepherd took my advice. The vet was offended, refused to prescribe doxy and refused to do bloodwork. Would not do it. No fever, no Lyme disease. No need for test. Shepherds have no business diagnosing dogs. No business, you understand!

Dog suffered needlessly for another few weeks. Shepherd paid another $55 office call.

Shepherd went to another vet, told the same story, presented dog with more advanced symptoms of Lyme disease (now including a fever), got blood work, got doxy, cured dog.

Morals of the story: sometimes the information reported to you isn't going to be an accurate representation of what your client was told by the well-meaning neighbor, and sometimes -- just sometimes -- the well-meaning neighbor might know something you don't.

MaskedMan said...

Bill: Nice presumption about the 'old biddies' conversation. Whatever passed between the neighbor and the client, the correct information was not conveyed - That much is clear. A medcial professional, even a former, less-than-thoroughly trained professinal, shuold know how to convey information without causing undue distress. You, in your anecdote, did not convey that you were a medical professional, whereas the neighbor in question here did.

The correct way to have approached this was along these lines: "Hmm. That's strange. It could be a number of things, but I couldn't tell you which - You'd better take your dog to your vet, and have him take a look." That approach, or any of a thousand variations on the theme, does not convey "your dog needs to be destroyed."

See? That's not hard, is it? And just a moment's thought was all that was required. Again, I say: "Some people... Thinking first would've been much more useful."

AKDD said...

Bill, you did right. You didn't claim to diagnose the dog (although your hunch, based on experience, proved to be correct); you made a suggestion to the owner that he take a specific concern to his vet (who ought to have at least considered it, so s/he evidently has issues of his/her own.) You also, as MM points out, didn't present yourself as a medical expert, but instead as an experienced stockman and dogman (which is entirely appropriate, as you are both). Moreover, you didn't suggest something disturbing and fatal, nor something irreversible(as euthansia is). You suggested investigating a course of action that would be neither excessively expensive NOR irreversible, and had a decent shot at answering the question, without being unduly stressful to the owner.

I don't have a problem with that; it's kind of like when my nurses tell those who ask them "Hmm, it could be X or Y, so I'd go see the vet and ask for these two tests."

So I guess my point isn't that I'm always right and that I've never had a non-doctor come up with a good (or excellent) idea about pursuing treatment or diagnosis, or have I thought I'd not initially considered. (I have one nurse in particular who is quite good at this.) I guess my point was more that one should consider the thought: What if I'm wrong? What would be the consequences to the owner and the dog if I'm wrong? I think this is MM's point (if I understand it correctly).

In your case, the negative consequences would be A) spending a small amount of money on a medication and B) using antibiotics unnecessarily for a few days. (I don't count running a diagnostic test as a negative consequence, since testing is how we answer questions). Neither consequence of your course of action is severely distressing, expensive or fatal.

In the case of the euthanasia proponents (in both your story and mine), both presented themselves as experts ("I was a tech and worked in the industry so I know") and both suggested a fatal course of action that was deeply distressing to the owner. So THEIR negative consequences were A) they cased the owners pain and distress for no good reason, and B) they COULD have caused the dog's death. Needlessly. Luckily both owners actually checked with a vet and figured things out, but had htey not, both dogs would have died. The one I saw was actually brought in with the expectation that it would be put down at that visit.

At any rate, I'm glad you made mention of Lyme disease and that the other shepherd listened to you (and sought another vet, who would listen to HIM) - and I'm glad you stopped by the ol' blog! Stop by any time - but just don't ask me why I'm up at 4 a.m.! <_<

Bill Fosher said...

MM and akdd:

You did it again!

Note what the helpful neighbor in my story did not say: she did not say "Based on my experience as a vet tech, I think your dog is having seizures and should be put down." She used, perhaps clumsily, a story from her past life experience to illustrate the importance of having a veterinarian see an older dog that's acting strangely before the condition deteriorates to the point where euthanasia is the best or only course of action.

The point of my story is to illustrate that you should not assume that what your clients say transpired between them and helpful neighbors is really what happened. And that when someone is stressed out, worried, and agitated they often carry away the worst possible interpretation of a conversation.

Did I do the right thing by my friend's dog? I'm not sure. I am pretty sure that the first vet committed malpractice, or was at least a jerk. If my friend hadn't trusted me -- an informed and experienced layman -- over the pro, his dog would probably be dead.

Bill Fosher said...

An addendum:

I am not trying to be a jerk about this, although I may be accomplishing that better than I'd wish.

Obviously, we all have to believe some level of what is reported to us, and in this case the way the family reacted is probably more important that what was said to start the process in motion.

I also don't live in a place where you can drop animals off somewhere to be euthanized, so that risk didn't occur to me.

Love the blog, and the stories often remind me of the scenes in House MD when he's on clinic duty.

AKDD said...

Bill, in the case of my own story, I did in fact - because I wanted to know - quiz the owners as to EXACTLY what their neighbor had said. (This made for tedious and disjointed story-telling, since I did it after the fact, when I was doing my release; so, I didn't include the three-times-going-around series of questions.) Both adults - who, I will point out, were not upset until AFTER their neighbor told them their dog had to die "because she was suffering and could not be helped", and were NOT upset when I was quizzing them, since by then they knew the dog was going to live - reported the same thing. Was I there when the neighbor made her pronouncement? No. So in that sense, you're right that I can't be 100% sure what was said. However, these were intelligent, reasonable people. I have no reason to think they'd have fabricated it, nor do I think they misunderstood. They were pretty clear about it. I might be wrong, but my assessment was that I'd been given accurate information.

I admit that I may not have read your story as carefully as I might have, having unintentionally been up at a wee hour, and a bit bleary. However, IIRC, I think I said that there was the *suggestion* of euthanasia, not that she said "Your dog has to be put down" (which actually DID happen in my story, if the owners are to be believed.) When I said "euthanasia porponants" I was just looking for a convenient handle, which a agree might have been misleading as to my meaning.

However, I will grant you that I've heard any number of things reported to me by clients that I'm fairly certain were NOT actually said, in part becuase sometimes they report to me things said by other vets who I happen to know and do not believe said any such thing. In most cases I feel this is simply a misunderstanding. Once in a while I suspect another motive, but I'm in no position to judge so I try to just move past it and go forward with the case.

One further thing, something you indirectly pointed out by remarking on the reaction of the family. IMO, it is incumbent upon me, as an expert, to be cognizant of the impact of my words. The fact that I am a doctor means that my words carry more weight to a client than those of a layperson. This is also true of a veterinary technician. Hence it is much more important that those who do (or have) worked in this profession be extremely careful what we say and what meaning we are imparting. In the case of your story, Wanda presented herself as someone with special knowledge (I used to be a tech) and then brought up the spectre of euthanasia, which IMO is careless and fraught with the potential for disaster; she has coupled together "I am a person of special knowledge/old dog with seizures had to be put down becasue it didn't get care soon enough". The things that will stick in the owner's head are "seizures" and "death", spoken by someone with more expertise than the owner posesses (and IRL, most people DON'T really know the limits of a vet tech's knowledge, and their words may carry undue weight as a result.)

This is just my opinion, and my own set of ethics, but I feel strongly about it.

Now I guess I'm going to have to start watching "House"! This is the second time someone has mentioned that.

Bill Fosher said...

Get the show on Netflix or your video source of choice, starting with the first season. There's less and less medicine and more and more sex and relationship stress in the later seasons that will be less interesting if you haven't seen the earlier episodes.

House is a diagnostician who assumes all his patients are lying idiots, hates meeting with them, and has his suspicions confirmed every time he does his mandatory clinic duty. The clinic cases always have a funny twist to them, as do many of your clinic stories.

When I realized that I was being a jerk about this, I realized that what set me off was someone being criticized based on the report of a family in crisis. Of course vets and technicians have a special obligation to choose their words carefully, but when you're obtaining information indirectly you also have to be more than a little skeptical. Sounds like you were.

There is a reason why most hearsay testimony is not allowed in court.

AKDD said...

Fair point. :)

I'll look at the local mom-and-pop place for "House"; they usually have such items. It's getting dark out, to the point where having something to watch whilst on the treadmill may be a real advantage.

And if they don't have it, maybe it's time I signed up for Netflix....