Wednesday, October 8, 2008

uh...come again?

whilst managing and discharging my post-operative patients from "surgery" day on tuesday, as well as caring for my new emergency patients from the previous evening, and trying to be involved in internal medicine cases...i received a phone call from a local veterinarian asking if we could see an emergency of sorts. it was a geriatric dog weak in the rear limbs. i told him to send the dog.

a couple hours before the end of my shift, said patient shows up. 16 years old, emaciated, with foul breath, and significant rear limb weakness. i did a physical exam carefully and thoroughly. despite weakness/falling in the hindlimbs, a neurological exam was normal. the problem likely wasn't in the brain or nerves then. i gently palpated the dog's wasp thin waist and was dismayed to note two small kidneys. two too small kidneys. ugh.

further, the dog had gone acutely blind 2 weeks previously, had a 3 month history of vomiting and diarrhea, as well as 12 lbs of weight loss (which in a dog that should weigh 30ish pounds is a LOT).

i discussed my fears with the owner that kidney disease might be contributing to the signs i was seeing. i recommended starting with bloodwork and a urinalysis. i also checked the blood pressure, as well as examined the retinas to see if i could elucidate a reason for the acute blindness.

while the blood pressure was elevated - it wasn't "blow your retinas off high" - so the blindness remained a mystery - at least temporarily. then i saw my bloodwork. BUN and creatinine were extremely elevated (as was her phosphorous level). BUN and creatinine are 2 values that are used to assess renal disease. when elevated, they indicate a condition called azotemia. you see - your kidneys are rather important in many ways. they filter blood - yes - removing toxins that are nasty to you and getting them out of the body. they are crucial in maintaining electrolyte status (sodium, potassium, calcium, phosphorous, etc). when the kidneys start to fail - many bad things happen - nausea, vomiting, electrolyte imbalances, oral ulcers due to uremic toxins, neurologic changes, respiratory disease even. kidney disease is B-A-D.

azotemia itself can be classified as pre-renal, renal, and post-renal. pre-renal is an elevation due to dehydration usually, renal is due to primary kidney disease, and post-renal is due to something like an obstruction (bladder/kidney/urethral stones). in this case, with the history of progressive disease, emaciation, vomiting and diarrhea, i suspected chronic renal failure (or an acute episode of renal failure on top of a chronic kidney disease).

the prognosis i gave the owners was very guarded. the dog looked terrible. hospitalization with aggressive fluids and other treatments were absolutely needed to give this dog a shot. at the age of 16 and in such an advanced stage of disease - euthanasia was a very viable option. i discussed this with the understandably distraught owners at length - making sure they understood kidney failure and its attendant symptoms.

they asked me for some time to consider the options, so i stepped out of the room while they talked. after about 5 minutes, they called me back in - and i went - mentally preparing myself for a euthanasia. what happened was not what i expected.

"we want to take her home."

ok, i thought. i can deal with that.

i though that they wanted to take her home and spend some time with her than see the referring vet in the morning. but no. i had misunderstood. they wanted to take her home and bring her back to the vet when the dog got bad. i had to physically remind myself to keep my jaw closed - else it might have hit the floor.

i explained to them again in somewhat gentle terms that kidney failure is horrible horrible death. i made the point clear. treatment - ANY treatment - was better than nothing. the owners declined. they wanted to take her home until she got bad.

this dog had lost half of its body weight in 3 months. the ribs and spine were prominent. she was partially blind, limping terribly, deaf...and in severe kidney failure. also - totally anorexic with vomiting and diarrhea. BAD??

no amount of discussion would persuade these owners that their dog required intensive care.

in the end, they took the dog home after subcutaneous fluids and a shot of anti-emetic.

these weren't cruel or malicious owners. they'd owned and loved the dog for 16 years. they brought her to us hoping that the news we gave them wouldn't be terrible news - and that is precisely what i gave them. i don't think they were ready to accept what i had to tell them. i was torn. i could be harsh - explain to them in absolutely brutal terms the death that their dog would likely suffer in the next few days or i could accept that my hands were tied - that the owners loved their dog - and that there was nothing more i could do.

in the end, i chose the latter. my job sucks sometimes.

1 comment:

all but 1 said...

Are you allowed to have clients sign an AMA form? I swear, sometimes that form is the only thing that keeps me from throttling a person.