Wednesday, February 25, 2009

Unnatural Appetites

In vet school, there is (at least there was at my U when I was attending) an entity known as "Grand Rounds".

Regular rounds are when all the docs (and in the University setting, students, plus or minus the techs) get together (usually twice a day) and go over cases. At the University, that is in part so everyone can learn from all the cases, and in all settings it's in part so things don't fall through the cracks and we keep everything in mind and stay abreast of progress or lack thereof. It provides an opportunity to bounce cases off one another, if we're stumped, and lets us learn from each other. And of course, if I'm about to have a day off, I want someone to be up to speed on my cases so they get good care while I'm gone.

At any rate, during vet school, each senior gets a Grand Rounds case. Grand Rounds are presented once a week to the entire school - any member who cares to attend, be it doctors, techs, students, ancillary staff, what have you. Generally speaking it's seniors and some juniors (those who are not actively tied up in class or on rotations that can't spare them), plus clinicians and some technicians. However, especially in the summertime, underclassmen sometimes attend. Generally two or three students present cases each time, and all seniors have to do one in order to graduate. At the beginning of senior year you are assigned a clinician to be your Grand Rounds advisor, and you pick a case from his or her service (for instance, if you are assigned Dr. B from equine medicine as your Grand Rounds advisor, you pick a case from your equine medicine rotation, not one from your small animal dentistry rotation). Sometimes this meant that you didn't have a particularly exciting or happy case to present; there's no controlling what comes in on a given week to a given service, so you have to take what you get.

Naturally, this is cause for consternation for most of the seniors; not only can a roomful of clinicians eviscerate you in front of your peers and future colleagues if they choose - and sometimes they do, if they think you haven't done your homework - but a great many people would rather run into a burning building than get up and speak in front of a room full of people. For some reason this doesn't trouble me as much as it does many people, which has always puzzled me; on personality assessments I test as a relatively strong introvert. I should hate this. But I actually kind of like it. Go figure. That's not to say I wasn't nervous and stressed; it could, after all, affect my ability to graduate, and no matter how you slice it, it's scary to get up in front of the gauntlet, knowing they could decide to mow you down in a hail of verbal bullets.

However, I had two things going for me: One was that I had already had a trial by fire of a similar sort (although of a much smaller scale) when I passed my oral exams during my master's program. The other was that I had the good fortune to be assigned Dr. B, the head of small animal soft-tissue surgery, as my advisor. This was fortunate in part because he was easy to get along with and liked me; it was even more fortunate in that I inherited, the week I started that rotation, an excellent case that would make a very interesting Grand Rounds case. The case had actually begun the week before, but bridged a rotation switch, so the student who had started the case was on to another service, and I inherited it.

So, I did my homework and prepared intra-op and post-op slides (with the help of the excellent G, the visual aids and media expert at the teaching hospital). My Grand Rounds presentation was scheduled for the spring, several months after the case in question; as I got close to the scheduled time, I called the owner to get an update on the dog so I'd have follow-up to report. I did the best I could to have my ducks in a row, which to some degree alleviated my anxiety. Certainly I was less nervous than the other student presenting that morning, the soon-to-be-doctor S. Graves (poor man; imagine going into an exam room and having to say to a client, "Hi, I'm Dr. Graves." Too bad he didn't share my internship, when - I am not making this up - I worked with Drs. Grimm and Dier.) At any rate, on the morning of our presentation, SG was pale and clammy and more than a bit shaky-looking; when he asked me if he could go first, I wasn't inclined to argue. We'd all heard horror stories about students who got up, opened their mouths to begin, and promptly vomited all over the front row, or else been unable to force a single word from their mouths, or else pitched into the laps of the audience in a dead faint. SG was whipcord lean, but tall and broad shouldered and with a certain rawboned solidity. I didn't fancy having to try to break his fall - since, as a presenting student, I was front and center. He survived his presentation without seizure, syncope, emesis or vocal paralysis (although I believe at one point he felt cardiac arrest might be imminent). He fielded questions, concluded his presentation and sat down with an enormous sigh of relief and a rather sickly grin of encouragement for me. All right, then. I'm up.

Fortunately for me, I had as my case the aptly named Muttley G, an endearing creature, not lacking intelligence so much as being of slightly less common sense than soap. Muttley was enormously engaging, possessed of tremendous bright-eyed (albeit scruffy-faced) charm. He was an Airedale mix of indeterminate origin, having come into his owner's possession as a stray. Muttley lived peaceably with Mrs. G - a pleasant, active, 50-ish tennis matron of comfortable means and kindly demeanor - without incident, for many years. However, owing to an unfortunate inclination to ingest everything in his immediate vicinity without regard for its edibility, Muttley found himself one day at his usual vet's office, having swallowed an intact half of a tennis ball (apparently without taking the precaution of chewing it into smaller bits first). For reasons I cannot explain (although I was not there at the time and thus am in absolutely no position to criticise), the vet, on finding the tennis ball inMuttley's duodenum, decided to try to milk it down to the colon, where it could be expected to pass without further incident. I'm not clear on why this choice was made; the duodenum is pretty tolerant of surgery, and if you have to milk it somewhere, why not back into the stomach, which not only is WAY closer by, but seems to be delighted to have surgery, and tends to heal rapidly and without incident? - Well, as I say, I wasn't there, and no doubt it seemed like a good idea at the time. In any case, the hemi-tennis ball made it to the ileocecocolic junction - where the small intestine, the cecum and the colon all meet - and apparently decided to take a stand. This is a narrow spot in the gut anatomically, so it only makes sense that things might get stuck there. Unfortunately, if you're going to do gut surgery, this is a spot to avoid; it has the second highest bacterial load of the entire gut, second only to the colon, and it is also the place in the entire GI tract most likely to dehisce. So, if you add high bacterial count plus high likelihood of the incision line rupturing, and then add in maximum tissue handling during the milking and cutting procedures, which in itself increases the chances of the incision line failing... well, you get the picture.

Evidently Muttley's ileum got the picture too, and a few days after surgery he re-presented to his doctor with a painful abdomen, spiking a high fever and vomiting. He got punted to the U, where we unzipped his previous incision, only to be confronted with an entire belly full of semi-digested kibble swimming in an inflammatory soup of horror-film proportions. I don't know if you can imagine how many zillions of tiny nooks and crannies there are in an abdomen; the organs are all neatly packed in there, but with myriad folds and flexures in the intestines, long deep clefts between the lobes of the liver, channels and alleys that run along the vessels and around the bladder and spleen, small secret pockets of potential space in every possible location. Add to that the omentum, a large lacy membrane as thin and pliant as fine silk and several square feet in area, draped and folded all over everything, and the possible hiding places for tiny granules of wet kibble become astronomical. With each little speck of food go zillions of bacteria. Small wonder then that Muttley had a peritonitis of biblical proportions, and was officially In The Land Of Deep Doo Doo.

What kills these dogs is generally the infection; it's like having a biiiiig abscess where your abdominal cavity is supposed to be. This, as they like to say in the trade, is a condition Incompatible With Life. The treatment for an abscess is to drain it. How to do that in an abdomen? If you poke a big hole in it, the guts show an unfortunate penchant for falling out onto the floor, which can really mess up your carpet.... not to mention your whole day.

The solution for this is open peritoneal lavage. This means leaving a nice 10 or 12 inch incision open for 4 or 5 days, and going in once a day to rinse the cavity thoroughly. You discourage any unauthorized fraternization between abdominal contents and the outside world by loosely whip-stitching the body wall together, leaving about a one-inch gap for drainage, and then packing that gap with about an acre of lap sponges. In the skin you set a series of nylon sutures in big loose loops, like the eye part of a hook and eye fastening. Using these, you lace a length of umbilical tape over the lap sponges like you're lacing up a tennis shoe; the lap sponges are like the tongue of the shoe and the abdominal contents are like the foot in the shoe, snugly laced in place. The whole assembly gets covered with a waterproof plastic Stick-Tight drape, which serves the dual purposes of keeping fluids from seeping out, and keeping urine from seeping in (a non-issue in female dogs, but sort of an issue with males. Seeing as how Muttley could piss on his own front legs and abdomen with the best of them, this was an essential precaution for him.)

Every day Muttley got anaesthetised, un-stuck, un-laced, un-whip stitched, filled with several liters of sterile saline warmed to body temperature, agitated like a Maytag on the extra-power cycle, suctioned out, sorted through, hand-plucked of any debris, washed and suctioned at least twice more, and then re-closed. He took this all in a spirit of good fun, apparently believing that part of the game was to turn counter-clockwise in his cage at least 6 turns every hour or so, thus twisting his IV line, his EKG lines and his bedding into bizarre ropey creations which required de-tangling by harried ICU students at least 18 times a day (they got a break when he was actually in surgery and anesthesia recovery).

Five days later Muttley was well on the road to recovery and feeling fine, a fact he demonstrated by eating a student's lunch (including brown bag, baggies and napkin) while no one was looking (fortunately he declined to eat her fork - or maybe he just hadn't gotten that far when we caught him). In case he was missing anything else that was ingestible but not (strictly speaking) edible, he also spent considerable effort attempting to raid the trash at every opportunity. We took this as our cue that Muttley would like to go home now. We sent him back home with a happily smiling Mrs. G and a really big E-collar, since Muttley had thoughtfully indicated before leaving that his abdominal sutures were next on the menu.

Having detailed Muttley's adventures and itemized his final bill for the Grand Rounds audience (you don't want to know), I was fair game for questions. I tried not to look like a deer in the headlights. Luckily, everyone was charmed by Muttley's shiny brown button eyes peering out of his wiry and riotously curly face - since, in a craven (and fortunately successful) attempt to distract my inquisitors I had as my last slide a picture of his triumphal departure from the hospital, posed with me and the best-looking technician I could find - and most of the questions were either easy or ones my advisor had prepared me for. I'd taken the precaution of salting the audience with buddies who would ask easy questions if no one had any real questions (too demoralising to stand there with them all staring blankly at you after the gig, as if so stunned by your incompetence they don't know what to ask). And at last someone (I swear not one of my "plants" - actually an ICU student who had had to untwist Muttley enough times to make him regret that whole career-in-vet-med thing) gave me the one question I'd been waiting for.

"How is Muttley doing now?" he asked. In hopeful anticipation of this question I had called Mrs. G the day before to check on Muttley's progress. She had laughed merrily at this inquiry, blessed my heart for asking, expressed happiness that Muttley's case was to be presented to the entire school, and updated me on his progress.

"I spoke to Mrs. G yesterday," I replied - as if I kept up with her weekly - "and Muttley is doing fine - although apparently he learned to flop his E-collar cone-down on the ground so he could conveniently trap and eat grasshoppers, and last week he ate a dead frog and half a bar of soap." Naturally this got some laughs, although I got a sort of sour look from the girl whose lunch he'd eaten, as she hunched protectively over her morning bagel.

I sometimes wonder how he did in the long run. Mrs. G sent me some pictures of him about 6 months post-op, his hair grown back and his eyes bright and happy as ever. I imagine he's died of natural causes by now, bless his pointy little heart; he was seven or eight when I knew him and that was in 1993-94. I hope it was a peaceful end, and not precipitated by some unfortunate attempt to recycle the world's goods through his GI tract.

Tuesday, February 24, 2009

Reality Bites

Sometimes, people just don't want to hear the facts.

This week, I am standing in the office, looking at some blood work, when I notice SS getting A Look on her face. I pause and listen for a moment; sometimes this indicates a question that a doctor has to answer. But it appears that SS is discussing travel regulations. She is (quite patiently) repeating herself over and over, in a loop that goes something like this:

"Yes, sir. The Canadians will require a current rabies in order for you to enter Canada. They usually will not require a health certificate, but if you are passing back into the United States, you may be asked for one at that border. No, sir, we don't insist that you get the health certificate OR the rabies vaccine, but if you don't, you may be stopped at the border. No, sir, that rabies certificate is expired. Yes, the Canadians will require a valid and current rabies certificate at the border. No, the CANADIANS aren't the ones who will require the health certificate. That may be required in order for you to re-enter the United States. No, sir, WE don't require you to get the health certificate or the rabies vaccine. That will be the people at the border. Yes, sir, you DO need a current rabies vaccine....."

While I am wondering what is so difficult about this, SS is clearly wondering the same thing. Finally (after several minutes of this) she appears to have settled the question, and hangs up.

"Man, I'm glad I'm not that guy," she says. "I could hear his wife in the background the whole time, screaming about the rabies vaccine and how it's just a conspiracy to get their money. I don't envy him the chance to drive 3,000 miles with her harping at him all the way."

"Well, he doesn't have to get a rabies vaccine; he can take his chances," I say.

"So I told him," SS agrees.

I think nothing of this until a few minutes later, when KD comes back.

"Can you talk to this woman?" she asks SS. "She has all these questions about health certificates and rabies vaccines."

"I just talked to them," SS says, exasperated.

"Well, can you talk to them again? This lady is getting pretty nasty with me and I don't know what else to tell her," KD says.

"I'll take that call," I say. "What line is she on?"

This is one of those situations in which sometimes the client has to talk to the doctor. Although, having listened to SS, I know that she has accurately (and civilly, and with considerable restraint and patience) dispensed the correct information, sometimes clients will not believe it until the doctor tells them the same exact thing. In addition, certain people feel perfectly comfortable rudely abusing the staff, but will rein themselves in when talking to the doctor, so sometimes it is best that one of us just steps in and takes the call. I admit I take a small amount of lurking pleasure from this; I figure that if a caller has already been abusing my staff - particularly when I am aware that said staff has been more than professional and forbearant about it - the caller is then due a firm reality check, delivered calmly and with professional detachment, but without equivocation or ambiguity. This is in part to defend my staff, who work damn hard for me; partly to stave off future assaults on them by repeat attacks by the same client; partly because I personally feel that anyone who believes that the rules shouldn't apply to them has another think coming; and partly because I am, by being a doctor, engaged in a lifelong battle against ignorance and misinformation, and I love to slay those monsters.

I pick up the line and say, in a pleasant tone of voice (because after all I am not averse to slaying this particular dragon), "This is Dr. H. Did you have a question about rabies vaccine?"

"Yes," says the client. "I just want to know why rabies vaccine is better up here than in New Mexico."

"Better....?" I ask.

"Yeah, why is it only good for a year in New Mexico and it's good for three years in Alaska?"

"For one thing, that depends on the age of the dog; the first rabies is good for only a year in Alaska, too. It's only the adult boosters that are a three-year vaccine here," I tell her. "In addition, each individual state sets its own laws for the required frequency of rabies vaccine. This is dependant on the risk of exposure and what the public health officers of the individual states have determined to be appropriate in that environment."

This checks her for a moment.

"But you're saying I have to get another rabies vaccine because it says it's only good for a year in New Mexico, even though Alaska says the shot is good for three years," she protests. "We got the shots two years ago."

"If the certificate is expired, then it can't be used as proof of current rabies vaccine, no matter when the vaccine was given," I tell her.

"So you're telling me you're going to MAKE me get another vaccine," she says, waspishly.

"No," I tell her, "I'm not telling you that, the state and national officials who require the paperwork are telling you that that. If the state of issue will only honor the vaccine for a year, then the certificate is expired, and can't be used as proof of current vaccine."

"This is all scam just so you can get our money!" she accuses me.

Ah, yes. She's caught me. I personally invented this scam just so I could force her to pay me seventeen dollars (of which only a small percentage will actually go into my pocket). Yep, and highly worth it, too, for that princely sum. I resist the temptation to bang my head against the filing cabinet beside which I am standing, and settle instead for gazing out the window at a lovely view of the mountains, serene and peaceful under a crisp white mantle of fresh snow.

"No, Ma,am, it's not a scam so we can get your money," I tell her patiently. "WE don't set any of these laws, but we do comply with them."

"My brother is a - a biochemical - a biochemical physicist," she says, stumbling over the term (and leading me to speculate that he is no such thing.) "HE says that if you get one vaccine then you're immune for life." (Ah, yes. The well-known medical authority of the biochemical physicist. Whatever that is.)

"Well, ma'am, that's not actually true. A great deal depends on the health of the animal in question, not to mention their age, the agent being vaccinated against, the type, condition and quality of the vaccine, and the immunological status of the animal - in addition to which, if you want to have aggressive immunity sufficient to prevent infection and not just enough to hopefully stave off death, you do need to do boosters. Some animals will have longer immunity than others and some might even have lifelong immunity, but some animals are non-responders and will have no immunity at all. The only way to tell the difference and know which one your animal is, is to run titers."

There is a momentary silence.

"So what you're saying is that I have to get vaccines for my pets whether I want them or not," she says acidly.

"No, ma'am. I'm not saying that at all. We personally have no stake in whether or not your pets are current on vaccine. What I'm saying is that if you want proof of current rabies vaccine then, yes, you are going to have to have your dog boosted."

"What a crock of shit!" she spits. "This is all just a big conspiracy to get our money, isn't it?" (this last delivered in a tone of demand, as if she is insisting that I agree with her.)

"Ma'am, the state of issue has determined, for whatever reason, that in that environment it is appropriate for companion animals to be vaccinated yearly for rabies. Since rabies is a fatal disease of humans, in the interest of public health, they have set a protocol which they feel to be appropriate to protect human life and the public well-being. If you wanted to prove that your pets did NOT need rabies vaccines, you'd have to do titers, which run around $200 per animal. The state has determined that if you adhere to their rabies vaccination policy, they won't require you to do the much more expensive titer and will instead accept a rabies vaccination certificate as adequate proof that your pet does not pose a risk to the public health."

Now there is a pause. Since she can no longer return to the "this is a scam to make money" theme - given that the state could make a LOT more money if they insisted on titers - she takes up a new position.

"Well, it's a stupid law. All the states should be the same."

"Ma'am, not all states have the same risk of exposure. Moreover, it appears that your biggest obstacle right now is actually the Canadian border, and we in the United States do not have the right to set policy for another nation. They have the right to protect their citizens and animal populations from fatal infectious diseases in whatever way they see fit."

"Well, someone should make sure all the states do it the same way," she repeats, truculently.

"Perhaps so, in which case I suggest that you contact your local legislators about that when you reach your destination," I say.

"What I want to know is why you can't do something about this."

Sigh. That filing cabinet is looking better and better.

"Ma'am, this is not a legislative body," I tell her. "This is a private practice clinic. If you want to change the law, I recommend that you contact your legislators in whatever community you settle in at the end of your move."

"Oh, like that's going to help," she retorts sarcastically. "If 80% of the people didn't want a bailout and it went through anyway, it won't matter what I say, they won't listen to me. I think you guys should do something about it."

"Ma'am, I am not a legislator, I'm a private practice veterinarian," I say, increasingly baffled as to what this client wants from me, and unsure how government bailouts have anything to do with rabies vaccines.

"Yeah, but you'd have more pull than I would," she says.

"Ma'am, I have no pull whatsoever in New Mexico, as I do not live there and am not licenced in that state, nor do I practice there," I tell her.

"Oh, I'm not going back to New Mexico," she says. "That's just where I got the rabies shots the last time."

"Be that as it may, I can't affect any state law outside the state in which I live, and your beef isn't with the state of Alaska, it's with the state of New Mexico," I say.

"I still don't see why I have to get another rabies shot."


"You don't have to get one," I tell her. "It's up to you if you comply with state and federal law. We don't set those laws, we just comply with them."

"I DO have to get one," she contradicts. "You're telling me that I can't leave the state without another shot and a certificate."

Ah, I knew we could be back to square one eventually. I narrowly resist the temptation to say, "So, did you just want someone to listen to you bitch about this?" and say instead, "Did you just want someone to listen to your concerns about this, ma'am, or can I help you in some way medically?"

"Well, I just think it's a stupid law," she says, running out of steam. "I guess I'll call back about the shots."

"Okay, then," I say.

Shaking my head a little, I turn away from my window mountain view to hang up the phone. Unbeknownst to me, I have gathered a little audience. SS, KD, and Drs. S and G are all standing behind me in a little ring. SS and KD (having both already had the pleasure of chatting with these clients) are grinning appreciatively. Drs. S and G are looking at me with eyebrows raised.

"What was that all about?" asks Dr. G.

"Some people didn't want to get rabies vaccines. Said it was a scam to get their money," I tell him, going to take the next appointment and leaving him shaking his head.

I thought no more about it until the next day when I look up from a chart to see my receptionist B ushering Dr. G into a room. She whispers that it's "those rabies people" from yesterday. Oh, goodie. I am cravenly glad it is not me taking the appointment, and return to making call-backs.

Thirty minutes later Dr. G comes back out of the room. He has an expression of incredulity on his face.

"What?" I say.

"They came in for rabies vaccines for their dog and cat, but he asked me while I was there if I could look at these bumps on the dog. So I felt under the jaw where he said the bumps were and the dog has these huge lymph nodes. So I checked the other lymph nodes and they're all huge. So then I feel the dog's abdomen and he has a giant cranial abdominal mass. So I tell him all that and that I can't be sure where the mass is coming from but I suspect spleen or liver and I think the dog might have lymphoma," he says. I suspect the same thing; it's not a certainty, but it would absolutely be a big enough suspicion to take up the top three slots on my rule-out list.

"So what'd he say about treatment?" I ask; having gone the rounds with the wife yesterday, I figure the dog's hope of treatment isn't good. At the best of times, lymphoma in dogs is regarded as an incurable cancer. But curable or not, it can certainly be treated, prolonging good-quality time for the dog. Depending on the type of therapy, treatment can be relatively inexpensive (although the remissions achieved with minimal therapies are short). Longer remissions require more complex regimens and are correspondingly more expensive, and more taxing in the short run for the dog (although this is paid back by the greater duration of good-quality time on the other side of chemo.)

"He declined anything, even pred," Dr. G says. Pred is an inexpensive treatment for lymphoma, and while it doesn't provide a long remission, it at least provides good quality time while it lasts. Still, given the previous day's conversation, I'm not surprised to learn the owners won't consider it, and I'm not even all that surprised when Dr. G adds, "He says his wife has a bunch of herbals which will cure the dog." Well, or not; I'm not averse to alternative therapies, but if there were herbals out there that would cure lymphoma, we'd all be investigating them pretty eagerly.

"He says the cancer is there because of the Chinese poisoning the dog food with bugs," Dr. G continues.

"Bugs?" I repeat, not sure I'm hearing him right.

"Yes. The Chinese put bugs in the food to poison it, and the white cells attach to the bugs, which mutates them. Normally the liver filters out the bugs, but due to the mutation, the liver doesn't recognize the bugs. The second line of defense is the spleen, which sends a registry to the rest of the body."

"A registry?" I ask.

"A registry," Dr. G nods. "Then, because the bugs have mutated, the spleen misses it too and the registry isn't sent to the rest of the body and so the kidneys get cancer, which is how the poisoned Chinese food causes kidney failure. [Here I will point out that Dr. G told the client the dog had lymphatic cancer, not kidney disease.] But evidently it's all okay, because the owner's wife has herbals and grapefruit extract and these will obviously cure it, so I shouldn't worry about it."

I goggle at him for a moment.

"What did you say to him?" I ask.

"I was trying not to laugh about the mutating Chinese bugs," Dr. G says, "so I was mostly just biting my tongue. But I figured it was a lost cause anyway. I told him what I think going on there, and I even showed him the other lymph nodes were enlarged and that I didn't think grapefruit extract was going to do it. He doesn't want to listen to me. I don't figure he's going to, no matter how many more times I say it."

Well, he has a point. Some clients are so attached to their belief systems that no amount of logic, proof, persuasion or sweet reason will shake them loose from their delusions.

Reality: It's not for wimps.

Wednesday, February 11, 2009

Know Your Anatomy

One of the entertaining things about being a vet is that you have the opportunity to learn some new and interesting things about animals, on nearly a daily basis. I have learned, for instance, that when people mention that their dog "has his lipstick out", they most decidedly are NOT talking about cosmetics (despite the fact that there is every possibility that said "lipstick" may in fact at some point come into close proximity to the dog's lips.) I've also learned that when someone refers to the "yayhoo" they are not discussing some rube they saw on the road or at a grocery store. They're referring to some body part for which they either don't know the anatomical name, or else know it but don't feel comfortable mentioning it in front of a doctor. Ditto with "doodydads", "marbles", "jewels" and "boys" (testicles); "ninnies", "teetees", "tatas" and "boobies" (nipples or teats, depending on the species, plus or minus the actual mammary gland); "hoohoo", "cooch", "purse" (?!), "twink" and "her - um...." (vulva); "down there" and "you know" (penis or vulva, depending on the gender referred to); "manhood", "thing" (always tempting me to ask with a cheerful grin, "What thing is that, specifically?"), "peepee" and "wiener" (penis.)

Okay, I get that. People are either trying to be polite by being euphemistic, or are actually embarrassed to say certain words in public, much less in front of (gasp!) a doctor - who in reality might be expected to be less dismayed by such terms than the general public, after all - or, worst of all: in front of a female doctor. So I firmly suppress any evidence of hilarity and pretend that yes, I DO daily use the term "doodydads" when speaking to my colleagues about testes, and of course "purse" is commonly understood always to mean "vulva" in medical circles. Most of the time I can pull this off with a strait face and nary a twitch. Luckily I have mastered a thoughtful expression involving me biting my lower lip whilst nodding and going "Hmmm..." which passes for careful consideration of the medical conundrum at hand, rather than an attempt not to either grin widely or burst out laughing. ("Purse"?!? I ask you!) If I fail in this - which occasionally I do - people are generally mollified by me saying (so long as I can do it with a friendly smile and a twinkle), "I understand exactly what you are referring to - I've just never heard that particular term before. Good one!"

Then there are the other oddities. For some reason, about 30% of people tell me about problems they've observed with their dog's "back hips" (as if there were "front hips" to compare to). Likewise, we often get requests to examine the "front shoulder" (as if there were back shoulders) or the "back rear leg" (is there a front rear leg no one told me about in vet school?) I kind of get this too. For instance, my techs are constantly tweaking me for referring to the "back leg" of birds. They patiently remind me that birds have WINGS in front, not legs, so there are only TWO legs to choose from, not four. I DO actually know this - promise! - but habits die hard. I'm thinking "pelvic limb", for which my usual and owner-friendly term is "back leg"; sometimes I just reach in the "pelvic limb" box in my head and pull out "back leg" even when talking about birds. My bad.

So those all make a certain amount of sense to me, even if they do amuse me at times (especially that thing where I say "back leg" about birds. I don't know why this cracks me up when I forget and say that, but it does.) Not everything makes as much sense to me, though.

One time a dog was in for a surgical procedure, and it was noted to have a very large mat behind each ear. We shaved them off - these pull mercilessly at the underlying skin, and create infections by trapping moisture and bacteria against the skin, so it's a big favor to the dog. The owner was enraged. They thought that the mats were extra ears, and that their dog had a unique mutation that made for four ears. I ask you. Did they not notice that in its original form the dog only had the normal number of ears? Did they think their dog just suddenly decided, as an adult, to grow more ears? It's not a starfish. It's a dog, and dogs don't spontaneously grow extra ears. And worst of all, did they never LOOK at the mats and recognize them for what they were?

Yesterday Dr. G had a client come in asking him to examine their cat's dew claw. If you didn't know, the dew claw is the thumb, the pollux, the first toe, the little claw on the inside of the foot, the one above the other four toes (always assuming a normal number of toes.) Some dogs have this removed in the first week of life; this is very common in sled dogs, for instance, since booties rub on them and make a giant mess out of them. It is also not uncommon on hunting dogs that work in rough terrain where the dews can get caught or torn, injuring the dog. Some people who breed show dogs or pet dogs also routinely remove the front dews (and in nearly all breeds the back ones are taken off, if present, even if the fronts are left alone; the rear dew claw is generally not a normal toe and unless the breed standard requires its presence - as in Pyrenees, for example - the dog is generally better off without them, as they very often create a problem by getting caught on things or being a nail-trimming pain in the rump.) My personal opinion is that unless the front dew is likely to cause the dog a problem - as in deformity of the toe, or in sled dogs or other working dogs where the dew would be an issue - it should be left alone. It is a functional toe, and in dogs that do a lot of lateral movement (like Border collies or any agility dog) or dogs who make turns at speed (like any sight hound, and many "other breed" dogs who love to run and do it fast) it engages the ground and stabilizes the foot, minimizing the risk of toe dislocation. But I digress.

At any rate, the clients come in and ask Dr. G to examine their cat's dewclaw. Obligingly, he has a look at it. It seems perfectly normal, as he remarks to the client.

"No, no - it's on the OTHER side of the foot," the client says.

Well, no. It's not. The dew claw is always on the medial side, toward the midline of the cat. If there's something on the outside of the foot, it might be any number of things, many of which would be cause for concern - but one thing it unequivocally is NOT, is a dew claw. It turns out it's an abscess, already ruptured, with the fur cemented to the skin in a hard carapace, including two small spiky projections, stiff as paper mache`, that the owner (not understanding the anatomy) has mistaken for a dew claw.

The same day I have a dog in that the owner says needs a wire removed from its mouth. The dog got its foot caught in the chain link fence and commenced to trying to chew himself free. The owners, discovering this an unknown span of time after the onset, cut the dog loose from the mangled chain link. But the dog's mouth was making a strange clinking noise, as from metal chiming against teeth.

I examine the dog - a cheerful, strongly-built Labrador - who is remarkably cooperative about me prying around in his mouth.

"Hmmm, let me borrow him to the back for a minute, where I have some instruments that might help," I say, having ascertained the source of the problem. The dog happily trots to the treatment area with me, where he is persuaded to plunk his muscular hindquarters (that would be the back hind legs, if you're confused) onto the floor. I grab a tissue clamp and, with the redoubtable J holding the dog's mouth open for me, extract a large slab fracture off the surface of the carnasial tooth. Inspecting it, I learn two things: One, the tooth is fractured into the root. Two, this is an old fracture, as the root is already discolored, indicating that it is many many days from the time of the original fracture. The fence-chewing has just displaced it.

About then, Dr. S comes in. "Is that the wire-in-mouth dog?" she asks. I nod. "What kind of wire was it?" she asks.

"Wire made of tooth," I tell her, holding up my slab of carnasial. She gives me an incredulous look.

"Why did they think that was a wire?" she asks.
"Probably didn't look at it; it was making a sort of metallic chiming noise," I say, demonstrating by tapping the slab against the counter. For whatever reason, the tooth slab does make a musical ching that sounds exactly like a bit of metal pinging on the counter.

I go show this to the owner, advising them that the dog needs the rest of the carnasial tooth extracted; the open root canals are a source for infection, which means an abscess is pretty much guaranteed. Marvelling, the owner takes the musical tooth fragment, making an appointment on their way out for the tooth extraction (for which they do not show up.) Oh, well. Guess I'll see them during the next year or so, when the tooth abscesses. Poor dog.

On Monday, Dr. G gets to see a dog who is being brought in because it has a ball stuck in its throat. Really? And it hasn't suffocated? Reasonably enough, my receptionist SS asks if they're sure there's a ball stuck in the throat. Oh, yes, she is assured. The owner can see it. However, the dog is perfectly happy, in no distress, and wandering around under its own steam. SS is even less convinced that it is a ball in the throat, as this is likely to be life-threatening in short order, if not fatal. But the owner insists that they can see the ball. Okay, then. Bring it on in.

Two hours later, Dr. G brings back a dog who has a large swelling on its jaw. I can tell at a glance that it's a nice big juicy abscess.

"Ooooh, nice abscess! You lucky brat," I tell him, because I love abscesses.

"This is the ball-stuck-in-throat dog," he tells me. I goggle at him.

"Didn't the owner say they could SEE the ball stuck in its throat?" I ask.

"Yes," says Dr. G. "It was the owner's sister who looked at it and swore she could see the ball in its throat. The owner didn't even look, just took her word for it. She's pretty mad now, because she thinks here sister made her look like an idiot." Dr. G looks as though he thinks the owner has a valid point.

I look at the dog. It has short hair. There's absolutely no question that the swelling is NOT in the mouth, it's on the outside of the jaw. I can't figure out how anyone could even begin to mistake that for the back of the throat. After all, the owner AND her sister both themselves posses a throat. I'm virtually certain that both of them have at least once in life swallowed something - say, food. Now, maybe I'm wrong, but I'd just about bet that on its course down the throat, their food did NOT suddenly form a large round swelling on the outside of their jawbones. Of course, I didn't watch them eat, so I could be wrong. I'm just basing my assumption on several decades of swallowing food and drink (and once, accidentally, a marble) and never once having a baseball-sized swelling - or any other sized swelling - appear on the side of my jaw. Now, I know you'll think I'm bragging, but I'm fairly certain I was aware of this even before I went to vet school. I know! Amazing!

Sigh. Just another reason why it pays to know your anatomy.

Tuesday, February 10, 2009

Diva Las Vegas

[Author's note: I hereby apologize for the gap in posting. I'm fine, just catching up from the trip, my cold, and some extra scheduling. For two weeks in a row my usual writing days were consumed by non-standard scheduling events. With any luck, that's over for a while. Meanwhile, my sincere thanks to all who have inquired after my welfare and offered help should my stock dog (in the air as we speak, on her way home to me) become stranded. That's generous, and much appreciated. It only confirms that "animal people" - whether they currently own animals or not - are the best, warmest, most generous and good-hearted people around. In my Very Humble Opinion, of course - but feel free to join me in this opinion! And now, back to your regularly scheduled programming....]

Sometimes, in my more frustrated moments, I wonder about things. For instance, hardly a week goes by that I don't run smack up against some logical inconsistency that brings me up short, stopping me dead in my tracks and making me wonder: Is it me? Am I expecting too much? Am I the one who's off-step here, while everyone else is on the same page, but one different than the one I'm on?

Sometimes, mind you, it becomes obvious that I AM out of step, and that the clients ARE on the same page, which happens to be one I have not yet turned to.

Meanwhile.... I get it that not everyone processes information the same way, and that some people can't process factual information until their emotional state has been addressed. I get that. I also get it that for such people, pointing out their logical inconsistencies (no matter how gently, diplomatically and carefully it is done) quite often makes them feel picked-on, defensive, insulted. This is a difficult position to be in, as a doctor; not only is logic my personal default position, it is also my job to impart factual information and arrange it in a logical fashion, accessible to the client. It is in addition my job to disabuse them of harmful notions. This is difficult to do, sometimes; it is impossible to overestimate the passion with which an emotional client will cling to a wrong idea if they fall into this group, assuming you have not first disarmed them by addressing their emotional state. Sometimes I have the distinct feeling that the client KNOWS they are clinging to a wrong, mistaken, irrelevant or downright idiotic idea, but they cannot stop: they will cleave to it more and more tightly until someone soothes the emotional child within. Assuming this is even possible, which sometimes it appears not to be.

This is not, strictly speaking, my job, but at times it's the only way to get the job done. I admit I find this kind of poutiness and contrariness tedious, and in some cases both petulant and self-absorbed, although I assume it is largely involuntary and may result from things beyond the client's control. So, in general, I suck it up and do what I have to do. Unfortunately, I don't always recognize that the client is veering that direction until after they've gone all the way to their internal limits and have reached a point where they can't be moved off the position they've staked out, with any amount of coaxing, reason, logic or dynamite.

A case in point: One day a woman comes in to the clinic with a puppy and a poop sample. I am up in the reception area handing over a file and some medication for a dog, while the dog's owner waits patiently for his meds and his bill. The woman is at the reception desk looking antsy; she has in her hand a fecal sample, hermetically sealed (the stool wrapped in a paper towel, inserted into a sealed Ziploc, and then contained in a tightly-closed Tupperware-style container). The receptionists are all tied up with other clients - it being a busy time of day - and my own client and his dog's meds are next, but the woman with the poop says, gesturing with her carefully-sealed stool sample, "Who do I give this to so I can stop holding it?"

Well, okay. There is no chance that the tiniest poop molecule can possibly escape its confinement in the multi-layered bomb-proof arrangement she has created, but some clients are squeamish. Mucus and diarrhea may be MY life, but they certainly aren't EVERYONE'S, so I understand that not everyone has my level of comfort with what might be termed "biological samples". This particular client is extremely pretty, with a beautiful manicure, and an air of someone who has more than the usual degree of fastidiousness. Well, nothing wrong with that, exactly; poop isn't everyone's gig.

"I'll take it," I say, relieving her of the stool sample; she is getting edgy and impatient, so I ask TN, who has taken the meds and chart for my previous client, to quickly look up the antsy woman's number so I can record it on the sample and get it started. My previous client - who, I will point out, was there first - waits patiently and with all evidence of good humor while I slip this small task in ahead of him, and makes no protest.

A few minutes later I am in the room with the antsy client, her husband, her son, and her three small dogs. First we vaccinate her two adult Poms, dogs she informs me are "her babies", and that she cries every time they get shots. She warns me the dogs will scream and struggle when vaccinated, although neither of them do; only one appears to feel the vaccine, and does not protest. The client is shocked and amazed and admiringly asks me if I can give her HER next shot, as I appear able to do it without hurting her sensitive Poms. Then we are on to her puppy, a new acquisition. Amongst other things, this dog has an ear infection. The ear hurts - is in fact quite tender, crusty and raw and swollen inside - and despite the dog's good nature and generally friendly and willing attitude, she ducks away from my hand every time I try, gently, to examine the affected ear. Finally, with patience, I manage to get an ear swab and thence a diagnosis.

I go back into the room and explain that we have to put medication in the ear twice daily. Because the infection has proceeded up the pinna - the "flap" part of the ear, which in this case has small red bumps and some pinpoint scabs on it - I advise her and her husband that in addition to dripping the meds into the cup of the ear, they'll need to smear a little medication over the pinna: anywhere the lesions are. The wife - on the far side of the table from the infected ear, so not getting anything like a up-close view - none the less turns away immediately, her mouth dragged down in a grimace disgust, her eyes squinty with distaste.

"Oh, GOD!" she exclaims loudly, in complete disgust, shuddering. "URGH! That's disgusting!" She can't even watch while I do this extremely minor - and much-appreciated - service for the dog. I can't decide what is so completely ghastly about this; after all, I'm just touching the flap of the ear, not inserting my finger into the the canal, and the lesions on the pinna are in fact pretty dry and non-disgusting, as skin lesions go. The husband looks on, nodding intelligently, closely observing my actions.

"It's not really so bad," I reassure the client. "She's pretty cooperative, and this kind of feels good to her." I go on to detail ear-cleaning instructions.

"Don't tell ME," she says, shuddering again. "Tell THEM. THEY'RE going to have to do that," she says, grimacing at her husband and son.

Looking at her acrylic nails - which are not only meticulously manicured, but long and filed to sharp square tips - I say, "Well, that might be best, actually; as pretty as your nails are, they aren't the best shape for cleaning little bitty ears like this. Her ear really hurts, and we want to make this as easy on her as we can." I think I'm agreeing with the client, but evidently I'm insulting her.

"I'd wear gloves!" she tells me, waspishly, completely missing the point.

"It's not that," I tell her patiently. "These are small ears, and it's hard to get a finger in there when you have long nails, without scratching the ear. If it were a big dog you might have no problem, but with these little ones it's a lot harder." I glance at the husband's hands, which are large and capable, but not the best size for inserting into the canal of a small dog's ear to wipe away debris. "It might be best, based on the size of your hands, to use a Q-tip moistened with the ear cleaner, rather than trying to clean the ear the normal way," I smile at him. "I don't think your finger would fit in there." He smiles back, looking down at his big fingers and the dog's tiny head and evidently seeing my point.

"I'd better clean them before I go back to the Slope," says the husband, musingly.

"I'm not incompetent!" the wife snaps at him. "I do things with my other dogs! I kill animals! I can do stuff!"

Hmm. Maybe it's just me, but are you not the self-same person who could not hold a heavily-sealed packet of poop for five minutes because it grossed you out? Did you not just gag and turn away with extreme grimaces of disgust rather than watch me medicate your dog's ear - a minor and decidedly un-gross event, lasting no more than ten seconds, but still too much for you to bear? Did you or did you not just tell everyone here that you weren't going to treat the dog's ear because it was disgusting and that everyone else in the room was going to be responsible for it, but you refused to be? And maybe I'm missing something here, but what does killing animals (yikes!) have to do with your ability to clean and medicate an ear without hurting the dog?


Probably what the client needed me to do was to say that I could see that she was deeply caring and tender hearted and sensitive and so of course we wouldn't expect her to do this and it would be no problem; we'd let her husband do that part and she could handle the cuddling and praise, a team effort with everyone playing to their strengths. Unfortunately, I did not recognize where the owner was going until it was too late, at which time I find it is generally a waste of time to try to jolly them out of it: no matter what you do by then, they will become more and more insulted and self-righteously furious, which solves nothing. At that point the best result is usually to be calm, cheerful and matter-of-fact, because nothing you do will break the owner's tantrum, and most things will just make it worse. As this client is now in full-blown pout mode, I give it up as a bad job, convey the information as factually and unemotionally as possible, and bail out.


Is it me....?