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.