Lost in Translation

Sometimes, especially when I am deeply tired or having a migraine, I'll have a little mental lapse and substitute one word for another. Usually this will take the form of a similar-sounding word beginning with the same letter.... "county" for "country", for instance. Luckily, even when tired, my ears still work, so usually I'll hear myself say the wrong word, have a little internal "Eh...?" and correct myself. Usually. I'm sure this accounts for some of the mangling of medical terms we hear from our clients.... but maybe not all of it.

One of the entertaining things about the brain is how it sometimes places new and context-less information into the best approximation it has for a context. Doubtless there's some theorized mechanism for this and it probably has a name of which I am unaware. However, it does sometimes lead to amusing requests from clients. One of my receptionists (and former office manager), SS, who has been in the biz for over 30 years, has a tale or two to relate. For instance, one day a client came in and asked for her dog's leprosy medication.

Eh? Leprosy? As this isn't Texas and we hadn't recently treated any armadillos, SS is fairly certain they don't mean leprosy.

"Let me just pull your chart," SS says. She peruses it quickly. Ah. Here it is. The dog doesn't have leprosy; it has epilepsy. Those are almost the same, right? (Well, at least you can kind of imagine how those particular brain wires got crossed.)

Another time a client remarked that the doctor had told them their dog was a tomb-lilly. SS is mystified. She can think of no disease or condition that sounds like "tomb-lilly". Again, she goes to the documents for clarification, and pulls the record. Turns out the dog is a cryptorchid, a male with one or more undescended testicles. It makes a neat sort of sense: A crypt is like a tomb, an orchid is maybe kind of like a lilly. Tomb-lilly. Of course. How silly of us. We know just what you mean. Kind of an elegant little mental side-step, really; the brain took what context if had and used it to keep the two alien words together. Still, given the funereal association that sometimes goes with lillies, I have to wonder what mental image the client had of this condition.

There are words that none of us expect the average client to know: Nystagmus, blepharospasm, epistaxis, urticaria, countless others. We aren't surprised or dismayed when terms like those come up mangled, although we ARE sometimes confused. Most of the time, this is cause for no more than a temporary blip before we're back on the same page again. Sometimes, though....

One night - or early morning, really - when I was an intern, a woman came screaming into the clinic at approximately 4:30 in the morning. She was carrying a laundry basket full of shar pei puppies.

"I need five cc's of detracycline, STAT!" she shouted.

"Stat"? Really? It might be wrong of me, but my estimation of what this client really knows about medicine takes a sharp and immediate dive. I myself have never used the word "stat" in a medical context, nor do I recall anyone ever saying it (except in jest) during the entire four years of vet school. Moreover, having worked with any number of clients who are medical professionals in their own rights, not a single one of whom has ever come blasting in during the wee hours demanding things "stat", I immediately suspect that this client's medical knowledge comes primarily from television medical dramas, where they LOVE to use the word "stat". Furthermore, to the best of my knowledge there is no such drug as "detracycline", and why would I allow a client to diagnose and prescribe medications for their own pets anyway? They can do what they want at home, but if they're in to see me, even if I agree 100% with their assessment (which sometimes I do), legally it has to be me who makes the decisions about treatment and medications. That's what that whole veterinary licensure thing is all about.

I search my mental banks. The closest thing to "detracycline" I come up with is tetracycline, an antibiotic. Tetracycline is a calcium chelator, though, and is therefore not generally given to puppies, as it binds into their bones and can cause enamel dyscrazias.

"There's no such drug as detracycline," I say mildly. "If you mean tetracycline, we don't give tetracyclines to puppies." Before I can ask her what concern she has that makes her want an antibiotic for her puppies, she interrupts me.

"You HAVE to! They're DYING! Oh! Oh no!" she exclaims, her attention returning to the basket of peacefully-sleeping puppies. She grabs one and shakes it roughly, so that it wakes up and starts to make plaintive little cries. She feverishly cycles through the puppies until all of them are chorusing in their thin, warbling newborn voices.

Observing this with some bemusement, and not at all clear on what she believes is the problem, I ask her, "Why do you think they're dying?"

"Because they stopped breathing!" She exclaims. "Are you stupid?" She goes back to jostling puppies, as some of them have fallen off to sleep again.

"They haven't stopped breathing," I say patiently, "they're just sleeping. It's the middle of the night, after all," I point out, with mild asperity.

"No, they're DYING! They stop breathing all the time! My breeder who I got my dog from told me this happened to her litter! She told me that if it happened to mine, I needed to get detracycline, 5 cc's right away!"

I get out my stethoscope and listen to the puppies. All of them have steady little heartbeats, and all of them - even the ones not crying - have normal breath sounds.

"They all sound completely normal," I tell her. "All of them are breathing fine, they all have normal reflexes, and they all have good color."

"No! They're DYING, I tell you! You have to call my breeder! Call her right now!" she demands.

"Ma'am, I'm not going to wake someone up at quarter to five in the morning about normal puppies," I tell her.

"You HAVE to!" she demands. "She told me to call her any time day or night, so you have to call her right now! She'll tell you!" she adds, in a slightly triumphant tone, as if savoring my future comeuppance at the hands of her wise and experienced and all-knowing breeder, who obviously knows a great deal more about medicine than some stupid doctor.

Sigh. I consider for a moment. Is there a better way out of this? Well, it's now coming on five, an ungodly hour to wake someone, but I don't see a way of getting this woman to calm down or leave the hospital without a lawsuit otherwise, so I give in. I take the breeder's phone number and, with great reluctance, dial it.

"Hello...?" says a sleepy voice.

"Ma'am, this is Dr. H calling from the veterinary hospital and I am very sorry to bother you at this hour, but I have Mrs. X here with a litter of shar pei puppies. She said you were her breeder and that it was okay to call you at any hour. I hope that was correct," I add.

"Yes, that's fine," she says, sounding more alert. "What seems to be the problem?" Bless her.

"Well, she feels that the puppies are having trouble breathing," I say, carefully not saying that I think so, since I don't. "She says that you told her that when your own puppies were having respiratory problems, your vet gave then five cc's of something called 'detracycline'...?"

The woman laughs merrily. "No, no," she says. "Five milligrams of dexamethasone."

"Oh," I say, looking pointedly at the fuming client. "Five milligrams. Of dexamethasone."

"It's the same thing!" she shouts, stomping her foot.

"No," I say firmly, "It's not. Tetracycline is an antibiotic, and dexamethasone is a steroid." Returning to my phone conversation, I say, "Thank you very much for clearing that up, and again, I am SO sorry I had to wake you at this hour."

"Oh, no problem at all," says the (astonishingly cheerful) woman on the phone. "Tell her she can call me at home if they're having trouble later."

I hang up and pass this information along to the client, who is at last looking a bit chastened (although also truculent, perhaps because I've told her - and can now prove, thanks to the all-powerful authority of the breeder, since my mere doctorate in veterinary medicine is obviously of no importance - that she is wrong.) Now I am faced with a dilemma. Do I give these puppies what is (in terms of their respiratory health) an unnecessary medication, or do I refuse?

Well, the oath says "First, do no harm." I weigh the options: I can refuse to medicate, leaving her to go elsewhere and repeat her act (plus or minus trying to take action against the hospital), during which time she will undoubtedly continue to shake the puppies awake every minute or two. Or I can medicate and give her instructions that will make her leave the puppies alone for a while, so the poor things can get some much-needed sleep. Clearly sleep is vastly in the best interests of the puppies, and I can't just pretend to medicate, as the client will not allow me to take them out of her sight.

Can I make a case for the need for a steroid? Well, yes, actually; as much ungentle shaking of puppies as has gone on, I'm actually a bit concerned about shaken-baby syndrome, puppy version. I weigh puppies and carefully calculate a safe and tiny does of steroids and administer it to each puppy. By the time I am done, they are all asleep again.

"Now," I say to the client, fixing her with a stern look. "These puppies need to sleep, and I don't want you messing with them for at least 8 hours. Put them back with the mother and let her take care of them. You can look in on them, but don't bother them unless she has pushed one of them away and it is completely unresponsive. Also, you have to handle them gently, they're tiny newborns." [In reality, the bitches are often shockingly rough with them when they're whelping them, but I trust a great deal more to the instincts of the bitch than to the judgement of this owner.] "This is a strong medication and it will last for a minimum of 48 hours. It completely takes all the swelling out of the soft palate, so the puppies will be very quiet when they're sleeping, making hardly any noise at all. If they're nursing and the mom is still taking care of them, they're fine," I add, hoping to avoid a repeat performance later in the week. I can only imagine what crisis will be next for her, given that as a breed, the shar pei tends to be predisposed to entropion, ear infections, skin conditions of various kinds, and (I will admit) sometimes respiratory issues.

Mrs X departs into the dawning morning with her basket full of (peacefully sleeping) puppies. My technician, the redoubtable Larry (who has watched this entire performance with commendable restraint), gives a little chuckle and a head-shake after the door closes behind her.

"I'm thinking maybe the shar pei isn't the best breed for her," he says.

Hmmmm. Ya think?