Sticking Up For The Underdog

So the other day I was zinging around at work, in a freakishly cheerful mood (and after several days of that, I think I'm starting to annoy the more sour-puss types at the clinic), and for some reason it reminded me of this from my intern year.

As an intern, I worked at a hospital group htat had several different hospitals including two 24-hour care centers. One weekend day I'm manning one of those, and L, my tech, comes back and says I have an appointment in room one.

"What is it?" I ask him. He gets A Look on his face.
"A woman with her finger in a dog's mouth," he says.

Eh?

"Ummm... did she say WHY she had her finger in the dog's mouth?" I ask, wondering if we should be calling the human ER, plus or minus the local nut hatch.

"She says if she takes it out the dog will die," L reports, shaking his head - just the once, mind you, but that's a lot coming from him. Apart from being a top-flight tech, he is also well-nigh unflappable. I've seen him take the most hysterical and unreasonable clients, not to mention the most difficult patients, right in stride. I can only imagine the bizarreness that has him shaking his head.

Well, as it turns out, I CAN'T imagine the bizarreness. Even with the description, I wasn't QUITE prepared to see a woman standing calmly in the exam room with her index finger inserted to the last knuckle into the mouth of a Chihuahua.

Now, you have to picture this. Here's this little Chi standing on the exam table with an entire human finger in his mouth. Naturally he can't turn his head, thus restrained, so when I walk in he rolls his buggy and protuberant little eyes (perhaps a bit MORE buggy and protuberant than usual, in view of his current oral circumstances) in my direction. I detect a distinct note of alarm in them, but for once it seems not to be directed at me - arriving in my white coat and no doubt armed with an absolute plethora of rectal thermometers just waiting to be pressed into duty (so to speak) - but instead to be focused on the woman who has his little head gripped firmly in one hand, and the (handsomely be-ringed) index finger of the other pushed quite far into his little mouth.

"What seems to be the problem?" I inquire with a cheerful grin (which is mainly engendered by the ridiculousness of the tableau, but which luckily passes for bedside manner).

"He's having seizures. I stopped them by putting my finger in his mouth, but if I take it out, he starts having another one. I'm afraid he'll choke to death," the woman reports.

Hmmm. Well, apart from the fact I don't recall the head of Neurology ever mentioning anything about finger-down-the-mouth being a preferred treatment for epilepsy, I am having a hard time imagining what kind of seizure might be precipitated by NOT having a finger down your mouth. Hence (and here I know you'll think I'm being rash) I conclude that the dog is not having seizures and instead has some other problem, as yet undetermined.

I get a bit more history - young dog, no prior seizures, otherwise healthy, but as it turns out, not her dog. He belongs to some friends, currently waiting in the parking lot, too upset to come in, in case I say the dog needs to be put down. It just happened that she was with them when the behavior started and was the only one cool-headed enough to do something when they all returned to their respective cars after getting Slurpees in the 7-11. She's had her finger in the dog's mouth ever since, though - this having understandably impaired her ability to drive her own car - they all piled into one to make the trip to the hospital. I nod as she tells her story and do a physical exam, working around the woman's fingers. The Chi watches me as best he can, rolling his eyes to and fro to follow my movements, now more white-walled than ever with fresh alarm.

"Okay, take your finger out of his mouth, " I tell the client.
"I can't, he'll have a seizure," she protests.
"You have to; I need to complete my exam," I tell her patiently. "Besides, you're at the hospital," I add soothingly. This apparently does the trick, because she removes her (somewhat dog-slimed) finger from the Chi's mouth.

The effect is immediate. The dog throws his head back and whips it from side to side, making gnashing motions with his diminutive jaws, at the same time as tongue-thrusting so vigorously that it appears he is hoping his tongue is all grown up now and ready to be out on its own.

"Okay, you can put your finger back," I say, which the client does promptly, because I have ascertained the source of the mysterious seizure disorder. There is a stick jammed between the upper carnasial teeth, and the dog's gargoyle-esque facial contortions are his attempt to remove it with his tongue.

"Hmmm, I think I have something in the back that will cure him completely," I tell the client, who is suitably impressed that I can cure seizures with some exciting new advancement in medical technology. "Wait here."

I go in the back to grab a hemostat. L looks up from his treatments.
"Did she take her finger out of its mouth?" he asks; I nod. "What is it?" he asks.
"Stick in mouth," I reply, to his chortling glee. I snag a handy pair of hemostats and return to the room.

"Okay, take your finger out, " I say, wielding my hemostats. The dog goes immediately into his gargoyle routine, jaws helpfully opened to their fullest extent, and I nip in and pop the stick out in under two seconds.

"There," I say with satisfaction. "Cured."

The client goggles at the stick, now clenched between the jaws of my hemostats, and then at the Chi, who is magically restored to complete equanimity by stick removal, and is now standing quietly on the table having his first unimpeded look around. The woman bursts out laughing.

"Oh, I can't WAIT to tell them," she says. Evidently her friends had gotten some kind of jerky which is impaled on a stick like a kebab skewer, and the Chi, yielding to his gluttonous instincts, decided to eat it. All of it, including the stick.

With admonitions to watch for other stick-related disorders, we release our miracle-cure Chi to his grateful (and uproariously relieved) owners. That was by no means the only stick I've pulled out of a dog's mouth, but I have to say it was one of the most dramatic, thanks largely to the patient's facial gyrations. It's also not the only time I've cured "seizures" by taking something out of a dog's mouth, but that's another story....

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.