Sunday, August 3, 2008

imperfections on the brain

i've been flipping through my patient cards and trying to decide which one would garner the most interest. i'm sure that after the july 4th weekend madness (i'm working friday through monday - "12" hour days...and by 12, i'm guessing 16-20) i will have lots of interesting stories to tell. but what i'm really doing is avoiding talking about something over which i've been fretting.

sunday 2 weeks ago - i was presented with a small dog that had been mauled by another, much larger dog. on cursory, hands-off exam - i saw 2 things that immediately worried me: schiff-sherrington posture and a very large abdominal hernia.

schiff-sherrington posture describes when the front limbs are rigidly extended and the back legs are flaccid or normal. with this posture - mentation is normal - the animal is alert and aware (unless there's concurrent head trauma). this represents a lesion in the spinal cord between the third thoracic vertebrae and third lumbar vertebrae (thoracolumbar area). in the case of trauma like this - the cause is almost 100% a spinal fracture.

coupled with that, the dog had a very large bulge running along his body wall and abdomen. i palpated carefully and was confident that i was feeling small intestines herniated. there were multiple puncture wounds along the flank and abdomen. the dog was in very poor shape. he was in excruciating pain and shock. i started fluids and heavy opioids and went to talk to his distraught owner.

she was not alone. her mother and daughters (both younger than 7) were present. they were well-behaved but naturally upset at the state of their 2 elders (mom and grandmom). i talked them through the condition of their dog. i told them that i suspected a spinal fracture. we discussed the cost of diagnosing this (radiographs for the spinal fracture) and other diagnostics. the owners were very strapped for money. they agreed to xrays, and then they went to apply for CareCredit (a line of credit that can be used for medical needs like plastic surgery, dentistry, and veterinary work). while they attended to that, we took our little patient to xrays. sure enough, L2 was badly damaged. the transverse process (the point on top of the vertebrae that you can feel if you run your finger along a dog's spine) was destroyed. the vertebral body was half the length of a normal one, having fragmented, and the spine was luxated. it was bad.

back i went to the owners with this news. i gave them a poor prognosis. they had failed to qualify for carecredit and money was a definite issue. we discussed stabilizing the dog and sending him to UT for spinal fracture repair (stabilization surgery). that coupled with the hernia would have cost $3000-5000. the owners couldn't afford the $350 that it cost for what we had already done. further, the dog would have most likely faced a life in a dog cart, with bladder expressions, and physical therapy.

so - what - you might wonder - has been bothering me exactly? i handled the case well. i gave good pain control, i managed the shock, i did diagnostics in the correct order so that i could give the owner's my best guess at how he would do and what he would need. we discussed everything at length - the dog's condition, their financial state, the likelihood that he would recover well. i gave them an accurate estimate...i did it all right. right?

except i forgot to check deep pain. deep pain sensation is the last thing to be lost in spinal injury. if it's gone - the prognosis for return to walking, bladder control function, and the like is extremely poor. if it's intact, the prognosis is much better. and i forgot to check it! it's a basic part of a neurological exam, something i've done a hundred times at school. and yet - in the craziness that is sunday afternoon - i forgot.

the owners elected euthanasia. it was terrible. it took them 4 hours to proceed with it. we had to wait until the husband came, then the grandfather. at the end, there were 6 people present, plus me, plus a technician. the dog was in terrible pain, despite my extremely heavy hand with the opioids. though i repeatedly warned them to not move him around (as they were saying good-bye), the owner and her mother both did - leading to the owner receiving a bite on her thumb. it was stressful and emotional. before it was over - the mother asked me 1) was i the REAL doctor? and 2) was i sure that the xrays belonged to their dog?

but don't get me wrong - they weren't bad people. just incredibly distraught at the horrible trauma that had befallen the smallest member of their family. in the end, he went peacefully.

they could only pay $320 of their bill and post-dated a check for the $30 difference. the dog was in terrible shape. he likely had other internal injuries along with his herniated intestines and spinal fracture. the chance that he would have survived and had quality of life was very small. i knew all of this. i know i handled it well. and yet, i beat myself up for forgetting to check deep pain sensation for a week. after talking to many experienced veterinarians, i have been able to let it go and focus on the fact
that nothing i did or didn't do affected the outcome of that case.

but it's this experience that makes me realize why vets have the 2nd highest suicide rate of all medical professions. don't get worried, i'm not considering suicide! but i realize how hard it is to let the little things go. i want to do the best i possibly can for all of my patients, all the time. i want to be absolutely perfect in my pursuit of correct diagnostics, absolutely vigilant in my physical exam and monitoring, and never forget or miss ANYTHING. EVER. and i'm realizing that it's not possible. that it would require a god-like perfection. and - cliched as it sounds - humans are far, far from perfect. unfortunately for me (and my fellow vets and human counter-parts) doctors are held to a different standard. understandably. we carry the weight of lives on our shoulders. some people scoff and say to me that i just treat animals. i challenge those who would laugh to spend one day with some of my owners - some of the people that view their animals as small, furry children. judge it if you will - but regardless of how you personally view animals and their place in the family dynamic - those people love their animals as they love their family members. sometimes they are the family. i'm not putting my job on par with that of an MD, but i take it as seriously - that i can assure you. and it hurts when i feel as if i missed something - no matter how small and insignificant in the long run.

No comments: