Sunday, March 16, 2008

let it be

i knew these owners were going to be trouble when i walked into the room. they were older but no less vocal for it. immediately annoyed that they were dealing with a student, even one as close to graduation as i, it looked like a pain in the ass from the start.

they had brought us their 3 year old maine coon cat. she was in severe respiratory distress when she arrived, and we immediately placed her in an oxygen cage while gathering a history from the owners. she was so distressed that we couldn't place a catheter or get blood or even perform a physical exam on her. nope - it was straight into O2 for her. while she stabilized, i talked to the owners. the story went something like this: her mother was a york chocolate (???) cat and her father was full-blooded maine coon cat. she'd started having breathing problems which the referring vet worked up and diagnosed as asthma. she was placed on an asthma inhaler, maybe steroids (??), and sent home. her condition continued to deteriorate. the owners - alarmed (per their own words) at her health problems, shopped her radiographs around to (by their own admission) 6 other vets asking for 2nd opinions. mind you - they took the radiographs, not the cat to 6 different vets and demanded diagnoses. they insisted to me that all 6 vets adamantly diagnosed heart disease and that all 6 vets verbally lambasted their vet - who made an incorrect diagnosis.

this story immediately set off warning bells in my head. very few vets will ever openly badmouth another vet. most vets will certainly not outright say that another veterinarian made a misdiagnosis without at least seeing the pet in question. but whatever - i decided to ignore this and move on with my discussion of heart disease with them.

**sidenote: what i really think happened here is that the owners self-diagnosed the cat using the good old internet, and then went around to other doctors confirming this diagnosis. and for the record, we talked to one of the vets they saw - and as it went - the owners showed up with radiographs and refused to tell the doctor age, species, sex, or anything else about the cat, demanding a disease diagnosis from the radiographs.***

once they had a diagnosis, they took the cat to the vet mentioned above and demanded an echocardiogram. he conducted it. and then - again per the owners - refused to discuss the results with them. they were extremely huffy about this. infuriated. they spent 5 minutes verbally abusing this veterinarian for his cold-hearted behavior towards them and their cat. they also proceeded to explain - at great length - how the veterinarian's handwriting was so absolutely sloppy that they couldn't read it - and thus, had no real idea what was wrong with their cat.

after talking to them, i examined the cat briefly and found a gallop rhythm (heart sounds like a galloping horse) and decreased compressibility of the chest. the gallop rhythm goes along with heart disease (hypertrophic cardiomyopathy or restrictive cardiomyopathy). the decreased "smooshability" of the chest definitely doesn't. we discussed with the owners our concern that not only did the cat have heart disease but that she might also have a mass in her chest. we then turned our attention to diagnostics. at the very least, we recommended an echocardiogram. these run about $205 at our school (we have 2 board certified cardiologists on staff). before the rest of the plan was out of my mouth, the owners told us they only paid $80 for their original echo. after discussing the benefits of an echo at a teaching institution, they still elected to forego it. they wanted us to prescribe them medications and send the cat home.

sighing, i went to relay this information to my resident clinician. our cardiologist, being the heart lover she is, did a truncated echo on the cat anyway - just to see what she could. sure enough - severe, severe heart thickening and left heart enlargement. so severe that she predicted the cat would be dead in a month or 2. on top of that - there was the issue of muffled / absent heart sounds on the right side of the chest and the firmness of the cat's chest. lymphoma? thymoma? some other weird cancer in the chest? we weren't sure - but we suspected it was there.

i relayed this information to the owners, who again declined all other diagnostics. did i mention that these owners were also self-medicating their cats based on internet information (which, in this case, happened to be sound)? they were also increasing the dose of lasix (a potent diuretic) without consulting their doctor or anyone else. this is dangerous because lasix makes you pee constantly. this incredibly high rate of diuresis can lead to dehydration and electrolyte imbalances rapidly - something these owners (claiming to be well-educated on the subject of feline heart disease) seemed to be ignorant of...

back to the clients i went, explaining to them that our cardiologist wanted to help them out - and had done the echo anyway. i told them of our findings and our desire to keep the cat in ICU. they declined and demanded their cat. i said i would happily procure her, and it would take us a little bit to get the paperwork and prescriptions together. i wasn't gone 5 minutes - working on discharge instructions and prescriptions when the front desk girl came back and told us that the owners were being rude and demanding that we give them their cat so that they could leave. NOTE: these are the people that bitched and moaned that their other veterinarian wouldn't take the time to thoroughly explain the findings of the echocardiogram to them. and here i was - carefully and thoughtfully writing down all our findings, medication recommendations, and prognosis. i returned to the clients and told them that we were getting everything ready - but that it would take a bit. this is - after all - a hospital - NOT the jiffy lube of the pet medical world (ok, that last part was in my head...) i went back to continue gathering everything together - and when i returned - they pointedly told me that they had jobs - you know. ones they had to get back to immediately (they'd been at the vet school maybe - just MAYBE - an hour and a half, at most). this - after we did a free echo on their cat.

finally, everything was complete - including signatures on the paper that said they were taking their cat home against medical advice.

and guess who called me yesterday - asking for us to mail the bloodwork to them - not a referring veterinarian - but to them (we did an electrolyte panel to make sure the cat wasn't a total raisin from fluid loss) so that they could take it to their new vet?

some people make me want to bang my head slowly and repeatedly against a brick wall.

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