Thursday, April 19, 2012

Deep thoughts by Dr HP

I've been ruminating a great deal lately on the nature of being a good veterinarian and how one goes from being a cutting edge, up-to-date practitioner to an out-of-date, "good 'ole doc," ready with the steroids and antibiotics and not so much on the diagnostic testing and advanced treatments.

Recently, I was faced with a patient that I feel I failed. "Snook" was a 3 year old rat terrier. He'd been seen at his vet a week prior for neck and back pain. Therapy with standard anti-inflammatories, pain medications, and muscle relaxants had not relieved his pain at all. In fact, the owners reported that he was worsening, despite his medications. The night he saw me, he suffered a seizure. Snook had never had seizures before, so this was very alarming to the owners.

Snook presented to me around 10pm. He was alert and responsive. He was able to stand, but he had a very pronounced hunch to his back. He was whimpering. I examined him carefully. He didn't have a fever, and I could find no other significant abnormalities other than back pain. Snook responded to me and didn't seem to have any cranial nerve deficits.

As I talked to the owners, it became apparent that they were not properly resting Snook. They'd allowed him to jump on/off furniture. Anyone with any personal experience in back pain can tell you that there is nothing worse for it than overdoing it! One of the most important components of treating back pain in dogs is strict, strict rest - in a crate or kennel. The reason? If you give a dog a few doses of pain medication, they start to feel miraculously healed, so they start acting like dogs again, and voila! back pain returns.

Further, Snook had absolutely no other signs of serious illness - just the seizure. So, I assumed the 2 things were not related. I didn't make a crucial connection between back/neck pain and seizures. I gave him a shot of opioid and muscle relaxant/sedation, tweaked the medications his vet had dispensed for him, recommended very strict cage rest, and sent him home.

The next morning, he was in a coma. He went to his vet, and he had another seizure on the way. He died about an hour later, having never become conscious again. The veterinarian who saw him claimed that he was "over-sedated."

Beside myself, I combed through his record, through all the medications I gave and prescribed, and double-checked my medical record against our controlled drug log, as well as the hand written amounts given by the technicians. Everything was right.

And then I realized that this dog likely was suffering meningitis - either GME or NME. It explained the non-responsive pain, the seizure, the progression to stupor, and death. And I missed it. Not that it would have mattered much - as the patient died within 8 hours of seeing me. GME/NME are terrible diseases which are almost always fatal, even with aggressive, early care.

What it did to me though was really got me thinking about my mindset. How I approach cases. How I might miss things. How I might be becoming stuck in my ways, and how I might not be learning anymore.

See, I work predominantly alone. On the weekends, I overlap with the other doctor, but it's a short time period. I have only been out of school for 4 years. I still have so much to learn. I keep up with my journal reading, so I am exposed to new knowledge that way. I attend the required CE yearly and actually go to all of the lectures that I can. I haunt VIN (Veterinary Information Network). I post cases on VIN when I am confused or have no answers and seek to learn how to better my diagnostic approach and treatments.

And still, is it enough? In a few years - will I be 'ole doc? Stuck in my ways? Afraid of change?

It's something to think about...


Holly said...

it is enough. For now. Speaking from 22 years in a job where you have to make big decisions right now and make sure you get the right information, there is no other way to do it than years of experience. You are a fine doctor, and will become even better when you have some more years under your belt.

foffmom said...

Hmmn. I think if you make this transition you fear, it will likely take 20 or 30 years to get there. With any luck, you may be ready to retire then!

Nicki said...

I always worry I'm not keeping up with everything. Especially since I work in rural practices that are somewhat behind the times. But I do the things you do and hope I'm doing my best. I try to keep an open mind about the cases, even though so many are routine and pay attention to exam and history. No one is perfect but you try harder than most. I think you will be fine.

Anonymous said...

You are being way too hard on yourself. You ARE learning, as is evidenced by your analysis of this (and I suspect EVERY) case you handle when the outcome isn't perfect. The non-learning good ol' doc wouldn't even be asking these questions, much less researching and trying to do better. Do you think you'll make this same mistake again? I doubt it. You have learned from this, and will continue to learn from every case. That doesn't mean you won't ever miss something or make a mistake. You're human, but you'll move on and do better the next time. Good ol' doc would have justified his diagnosis/treatment and never questioned it.
~Angie in MN

SMHDVM said...

I think that you have enough of a support system in place WRT VIN and your FB pals that the holes in the "most current" information are constantly being plugged. And there is enough discourse between people that don't always agree, you will get several sides of the story...and several references. The mere fact that you question yourself means that you are unlikely to become over confident. And a dog with GME that dies that quickly was circling the drain with one foot on a banana peel anyway.