Sunday, January 1, 2012

Day of the dead

Atul Gawande is a human surgeon who writes fascinating books on medical errors and how they can be avoided. I have read all 3 of his books: Better, Complications, and The Checklist Manifesto. Having done so, you would think that I'd be prepared to recognize when I attempt to make them. Yet, that's not the case. Just like every doctor, there are errors in my logic/rational thought process that lead to misdiagnosis and mistakes.

I saw a case recently. It was an old dog Golden Retriever (13 years old). She came in for collapse, labored breathing, pale gums, and extreme lethargy. Based on the history and my physical exam findings, I suspected she was suffering a hemoabdomen - likely secondary to a ruptured splenic or hepatic tumor. I focused heavily on this diagnosis, although I did consider others - heart failure, rodenticide poisoning, etc. Still, in my mind, hemoabdomen until proven otherwise.

This is the first cognitive failure. Focusing too heavily on one diagnosis due to previous/recent experiences. I see these types of cases (hemoabdomens with ruptured abdominal tumors) ALL THE TIME. Thus, it is always a forefront diagnosis. This is an important step in formulating a differential list - recognizing patterns. The problem with recognizing patterns is that often we as doctors stop seeing the forest for the trees. That diagnosis pervades in our minds as THE diagnosis based on previous experience, making it difficult to see and accept any evidence that does not support that diagnosis.

On my physical exam, the patient had a significant arrhythmia - possibly consistent with hemoabdomen (very common), but also possibly primary heart disease (which can also lead to collapse, labored breathing, pale gums, and lethargy). I recommended xrays and bloodwork to the owner.

Then I went to pump while my techs took care of testing. About 30 minutes later, my technician came to me and said, "abdominal mass with metastatic cancer in the chest."

Error #2 occurred here. I went into the radiology room to review the xrays, and I already had an idea of what I was going to see. Thus, I tried to make what I saw on the xrays fit what I had already suspected (a ruptured abdominal tumor) and what my technician had diagnosed.

The dog did indeed have an abdominal mass. It was not ruptured. I recognized that immediately. The chest xrays were a little sticky. Initially, I diagnosed the dog with extremely enlarged tracheobronchial lymph nodes. I called this metastatic cancer.

The problem? The typical cancer of the spleen (hemangiosarcoma) doesn't usually show up in the lymph nodes like that when it metastasizes. The metastasis I should have seen (were this truly a metastatic hemangiosarcoma) would have been ill-defined, patchy nodules in the lungs. Instead, what I saw was likely a pneumonia/collapsed lung with retracted lung lobes (possibly a chronic lung disease). There are other cancers that this could have been that WOULD show up in the lymph nodes - like lymphoma. So it's not entirely impossible that this was metastatic cancer. It could have been pneumonia/chronic lung disease however.

I saw these things (the retracted lung lobes, the consolidation of the lung tissue) and yet, I must have subconsciously wanted a simple diagnosis to give the owner - a neat package to wrap up with a bow. So I ignored them (not deliberately, I am only understanding this in hindsight).

My next step was ultrasounding the abdomen. I did not see free fluid, so I knew that the tumor hadn't ruptured. I did find a large abdominal mass, but it didn't look like your typical malignant tumor. It wasn't cavitated and "nasty" looking - it was large but more smoothly marginated.

Bloodwork was fairly normal other than a pretty good anemia.

So, what I should have recognized was that several things were occurring here: the anemia was likely secondary to chronic disease of some sort. The lungs were probably a chronic problem, although possibly not. The splenic mass may have been an incidental finding or it may been cancer on the verge of rupturing. I **should** have recognized that this might be many different problems.

Yet my mind had decided this was metastatic cancer before seeing the xrays, and I made this fit, even though all the pieces weren't there.

In the end, the owner decided to euthanize her dog based on my diagnosis. Was it the wrong decision? Likely no. I do believe this dog had cancer. She was obviously very ill and needed a blood transfusion. I do not think my original clinical picture was correct though. In retrospect, I committed at least 2 significant cognitive errors that led to making a leap in deduction. I have to struggle to overcome this and find a way to prevent this in the future.

I've sent the xrays to a board-certified radiologist for review (professional interest). Once I have a better idea of what I was dealing with, I'll decide whether I need to contact the owner.

What do you think? If your dog was extremely ill, very elderly, and needed at least $1500 of treatment with a guarded prognosis for survival - would it matter if the doctor was right about the tentative diagnosis? If it was metastatic cancer versus some other terminal illness? If the doctor made a mistake in diagnosis and your pet was euthanized, would you want to know after the fact? Keep in mind that this dog was very ill and likely had some form of cancer - so the ultimate outcome would have likely been the same.

When I have the xrays back, I will let you know what the radiologist says. Try not to judge me too harshly.


Lise said...

1. Sounds like a diagnosis of one cancer vs. another wouldn't make much practical difference in the owner's choice.

2. People vary, of course, but if I were the owner I would want to be told what you found out. And even if your original diagnosis had been completely off base, I'd actually be impressed that you followed up to figure out the truth. Knowing that you cared that much even when it could make you look bad would make me respect you, not judge you.

Holly said...

Yes, I would want to know, but not to bash the doctor. I read on the internet a LOT. I read a lot of different blogs and I want to be informed. So I would want to know, in order to discuss and remember this if it should crop up again (either with this vet or another). Knowledge is good and although I deeply love my dogs, if I lose one, I at least want to learn from that.

Anonymous said...

Good for you for being open-minded, and taking the opportunity to continue learning - everyone should do so, for their entire career. Everyone makes mistakes - not everyone takes the opportunity to learn from them.
As an owner, once the dog is euthanized, and a mistake such as you are desribing was made - NO, I do not want to know! Because, I would then torture myself with guilt forever. Should I have tried something with you anyway? Should I have taken the dog to a specialist? Did I wait too long to bring it in? Etc. etc. etc.
The mistake, if there even was one, was yours - I'd say that you should keep that burdon, don't share it with the owner. Especially since the outcome was probably right, and it was an old dog.
The kindest thing, and I believe ethical here, is to keep it to yourself. You told the the truth, as you knew it, at the time. They can gain nothing by hearing differently now, except pain.

Anonymous said...

Thought of a caveat - if you learned something that had the potential to affect related dogs, and this dog was used for breeding, then you'd need to say. But that doesn't sound very likely in this case.

elizabeth said...

What a great post. I do this ALL the time - make a guess as to a diagnosis and then try to get the diagnostics to fit. It really takes effort to clear my mind and evaluate the physical exam, images, bloodwork, etc. objectively, but makes such a difference when I do! I also suffer from thinking that owners generally want a tidy diagnosis, rather than something more complicated, expensive or difficult to treat, etc...

foffmom said...

Uhh, as a pet owner, elderly dog, dying. Whether dying of abdomenal cancer, pulmonary cancer, metastatic cancer, heart disease, COPD, bottom line is elderly dog dying.
While I recognize and applaud your need to be diagnostically specific ( because it could someday make a difference in a younger dog) the bottom line does not change in this case. So learn and continue to improve, but in this case, nada difference.

N said...

Here's my short answer. As a client in those circumstances, it wouldn't matter to me if the diagnosis was different if the prognosis was the same.

My husband and I specialize in senior and hospice adoptions. We live by one rule when it comes to end of life decisions, they must have a good quality of life. A poor prognosis while putting a senior through multiple procedures does not equal quality of life. We sadly learned this at the expense of our wonderful cat, Shadow.

If the diagnosis changed, I do believe our vet would discuss this with us. There are specific reasons for this though. First, we have an excellent, working relationship with her. She has helped us tremendously through many confusing medical issues as most of our pets come to us with multiple health problems.

Second, she knows that we will likely come across such problems again and therefore, we need to know what symptoms to look for and what they might be telling us. As we also work in animal rescue, she generously helps educate us so that we can improve our caregiving.

We don't expect our vet to know all the answers or to not make mistakes. Indeed, there are certainly times we have seen specialists for just those reasons. The bottom line is we value our vet because she knows she is not infallible and thus works all the harder on our pets behalf.

sp said...

thank you for posting this, i really appreciate that you both took the time to re-evaluate this case and are willing to share this with us, even under the threat of the ever-present Wrath of the Internet.

if i were in this owner's situation i would want to know as much information as possible, even after the fact. but i also know i'd be pissed that i wasn't given the information before i chose to euthanize my pet, even if it wouldn't have changed my decision to euthanize. but i do know some people would rather not know. it's a tricky situation because it's so emotionally charged and because people vary widely in their preferences.

Fi from Four Paws and Whiskers said...

I think that medicine has got to a point where vets expect be able to pinpoint it all accurately, on a budget. It probably makes sense in human medicine - but the reality is the cost of making a diagnosis, let alone treatment, was unlikely to change the outcome for this dog and owner. An elderly human would still have been placed into palliative care - regardless of the precise terminolgy used to describe the cancer/ condition. I find myself wondering if the intensive training that vets now go through to get to this level of knowledge, is making it harder for them to cope in practice - most vets would be happy to realise the animal was at the end, and focus on supporting an owner through the loss. I still feel too many vets are trying to work at multiple specialist levels, oncologists etc - which you dont get in human medicine. The stress must be enormous, and the successful graduates all seem to be struggling - OCD, perfectionism, lack of empathy, stress, mismatch of skill vs what clients can pay.
Even as a vet - I really dont want to pay squillions to treat may own animals - but I do want to be treated well as an owner, given some options for the future, and handled gently when I have to grieve. Because I am a vet ( and non practicing as in not working at a clinic) , when my dog was taken ill, the bill ran rampant in five days of intensive care. It is the second time it has happened to me one ever gave me a quote, or options... and it hurt to find the money at the time as we had a mortgage, four children and a lot of bills. In both cases, I would actually have chosen euthanasia at the time if presented with al the facts. I have however taken out medical insurance on our latest dog - first time ever - to expand my choices.

Don't beat yourself up - I don't know how you manage with what you are doing now!!!!

Anonymous said...

Don't be too hard on yourself - I saw one last week I thought was dying of renal failure that turned out to (also) have a ruptured hepatic tumor, which was more likely the cause of the GI symptoms I was seeing. Bad disease is bad disease, as I pointed out to the owner: there was nothing left to treat.

Curious Cat said...

I think the order of importance is appropriate treatment (including euthanasia), then accurate prognosis, then correct diagnosis. Obviously these are generally tightly interconnected, but not always. In this case, you probably had the first two right.

The question, then, is whether or not a correct diagnosis, or your expressing greater uncertainty about the dx, would have changed anything. Would this client have been willing and able to pursue emergency stabilization followed by costly diagnostics (ultrasound, etc) and possibly extensive and expensive long term treatment in light of a more open diagnosis and prognosis? Conversely, was it difficult for them to afford the preliminary diagnostics that you performed?

I think a point to keep in mind is that ultimately, the clients did make the decision to euthanize. Of course your counsel influenced them, but you didn't force them to do anything. I am sure you told them the likely survival time for hemangiosarcoma with the different treatment options (e.g. surgery +/- chemo). You didn't lead them to believe there were no treatment options at all. One question, though, would be if they would have been likely to make a different decision in light of a non-surgical diagnosis. There is a qualitative difference between, say, chemo to treat lymphoma and the major abdominal surgery required for splenic hemangiosarcoma. For some this is a significant difference and for others it is a distinction without a difference.

If you do learn significant new information, a good option might be to contact the client's regular veterinarian. Here you will (or should) have someone with a professional interest in what you have learned as well as a relationship with the client. S/he may be able to advise you on whether these clients would be likely to want this information.

I definitely think that whatever you tell the clients, the appropriateness of their decision must be reinforced. Their dog's death is final and unambiguous and adding any uncertainty to their grief will probably be more painful than helpful. Their decision to euthanize a very sick, geriatric dog was reasonable no matter what and they need to feel like you still believe this even if your diagnosis changes.

Thank you for your honesty and courage in posting this story. You are the type of doctor I'd trust with any of my furkids and I am sure your clients and colleagues (the good ones, at least!) feel the same way.

Anonymous said...

Have you read "How Doctors Think" by Jerome Groopman? I found it really helpful to challenge my set thought patterns.

In re: your patient, I think you are such a kind, caring and conscientious veterinarian, I wish I could bring my pets to you! If this case were my dog, I'd love to have the vet call me up and explain what she thought might actually have happened, but I'm also a vet assistant and am really interested in vet med. The only think I can think might be an issue for me would be having the dr. send out things for a 2nd opinion w/o my approval, although I don't know why that bothers me. I think it's just me.

Angie in MN said...

If it were me, I'd want to know, and would feel exactly as Lise said in the first comment.

However, as is clear from some of the other comments, not everyone would feel the same way. So unless you knew a client well enough to know they'd absolutely want to hear about the follow-up, I think you're much better off learning what you can learn and moving on.