odds and ends and where did you get your veterinary medical training??

so, since i got so many interested commenters on the whole lymphoma saga - here's the REST of the story:

i worked sunday with 2 vets pulling relef shifts for us. one of them was THE referring vet for that case. the boxer is still doing well. we are both perplexed and highly skeptical of the cytology report. if it is lymphoma, we'll know in about 1.5 months. not that spectacular of an ending, but so goes medicine.

in other news, i did an exploratory surgery on a 120lb dog that came into work on sunday collapsed with a PCV of 23 (packed cell volume = what percent of blood is cells versus plasma - normal is 35-45), and white gums. he was bleeding into his abdomen. i talked to the owners about the likelihood that he had a bleeding splenic tumor. we talked about prognosis for this, and they decided to do initial staging of the possible cancer (bloodwork and xrays), then if everything was clear - take him to surgery. the chest xrays were pristine, especially for an old dog. the bloodwork revealed dehydration and a VERY MILD elevation in ONE liver enzyme. all other liver enzymes, as well as liver function values were normal. the one enzyme that was elevated was about 1.5 times normal - which can be secondary to old age, dehydration, mild inflammation. it wasn't a value that i even glanced at twice. it was that benign and non-specific of a finding.

so to surgery we went. i suctioned about 4.5 liters of hemorrhage out of this dog. that's a MASSIVE amount of fluid. when i could finally see the liver, i was saddened to see that - despite normal testing - it was covered in metastatic cancer. the bleeding was coming from an angry looking mass on the caudate lobe. the spleen itself did not have a bleeding mass, but it did have masses all over it (benign or malignant could not be determined by looking). we euthanized on the table per the owners' decision.

i was satisfied with the job i had done. i knew i had gone to surgery and given the dog a chance. the outcome sucked, but i was happy with my performance. apparently, the owners were not. they called disputing their surgery bill, claiming that they shouldn't have to pay because the dog was no longer alive. they also claimed that i should have KNOWN that the liver was covered with metastatic cancer because of the EXTRAORDINARILY mild elevation in a liver enzyme (ALT - the value was 156 - the reference range is 0-80). despite the fact that all other liver enzymes and function was normal (even the clotting times were normal!), i should have intuitively KNOWN that the cancer was in the liver.

i spent 20 minutes on the phone with the female owner explaining as patiently as possible that despite the fact that her dog was euthanized, i still took 2 hours to do surgery, used THREE technicians to do it due to the extensive suctioning and bleeding, used suture, anesthesia, injectable medications, etc. i also tried to point out as tactfully as possible that if you go to the ER, receive emergency treatment, and die - then you're still responsible for the bill. surgery in a human hospital is no different. the expertise, materials, time, and staffing are the same - regardless the outcome. i also spent 10 minutes explaining bloodwork values to her, liver function versus liver damage, and what exactly ALT means and what such a minor elevation could indicate. i had to repeatedly resist the urge to ask her where she received her medical training?

she told me that she thought i "downplayed" the changes in the bloodwork and that they would have euthanized if they'd known what they knew now (AS WOULD I HAVE...OBVIOUSLY - HINDSIGHT IS FLAWLESS, but alas, my crystal ball and xray vision were on the fritz this week). she said that she felt that they were pressured to go to surgery.

the kicker?? she actually admitted to me the following piece of information: "maybe i watch too much grey's anatomy. you know - they're always dying to go to surgery on that show."

i almost screamed when i heard that. i resisted the urge and calmly informed her that i have NO financial or personal incentive to go to surgery, that i avoid surgery unless it is absolutely necessary, and that her dog had lost about 1/2 of his blood into his belly, and would have died on his own had we not done something (either surgery or euthanasia).

in the end, the owners were nice to me. unfortunately, i have the feeling i haven't heard the last of them.

we'll see.