Frustrations and limitations

As anyone who reads this blog knows, one of the more difficult aspects of my job is helping people deal with their finances. Finding ways to help people treat their pets while staying within their budgets is a crucial part of my job. It's something I do very frequently.

Yet sometimes I am faced with clients that have endless resources, and this can be just as difficult for me.

If you - as a human being - become ill and are admitted to the hospital, you will have a bevy of professionals taking care of you. This includes nurses, a specialist doctor for your particular problem, a hospitalist, a patient care advocate, and on and on. Your health insurance pays for this. Every patient gets some version of this model.

Now, say you come to the emergency clinic with your seriously ill or injured pet. You have all the money in the world to spend. You would expect that your pet will receive 100% of our attention. The problem? There are only a few of us to go around - 1 doctor and 2-3 techs in my case. We are serving multiple clients and pets with problems ranging from the mundane to the very, very serious.

Friday night, I was faced with several critically ill patients. All of them had owners willing and able to pay the expensive fees for aggressive treatment. The problem? I had 2 surgeries to conduct, as well as two circling the drain septic patients to deal with. I had 2 technicians to triage new patients, conduct bloodwork and xrays on new patients (and those in the hospital), and take care of the patients that were already in the hospital - a couple of which required significantly intensive care.

I wound up extremely frustrated with the situation. Trying to stretch my brain to manage the two septic patients (which are nightmares requiring careful monitoring of IV fluids, the additions of medications such as dopamine and the like to regulate blood pressure, and other intensive care) was draining enough. Then I was faced with the surgeries.

If I were an MD, I would be dealing with one aspect of these cases - the surgery perhaps, or the management of the septic patient.

As a veterinarian, I have to deal with them all. The limitation is obviously myself and my technicians. We can only do so much so fast. Mistakes get made when we try to handle too much. Further, I am still young in my career, and I still have a great deal of learning to do. This necessitates researching complex cases, which further takes time away from the actual care of my patients.

Sometimes, I wish I WAS an MD. I think my job would be simpler on some levels.

Holy cow

It's been a week since I posted? I had promised myself to do better, then the weekend came and swept away all good intentions. It was CRAZY at work. Then, I had one day to reset before driving to Florida (Tuesday) for the North American Veterinary Conference that begins on Saturday. We combined it with a family trip, so the 3 of us drove down yesterday so that Evaline could meet her aunts, uncles, cousins, and great-grandparents. It was the most perfect trip we could have hoped for with a 3 month old baby. She slept most of the way, and she only had one 20 minute fussy spell. We made it in 10.5 hours, exactly what Google predicted!

This past weekend at work had a mix of significant highs (a GDV/"bloat" that the owner caught within 5-10 minutes of occurrence and underwent almost immediate surgery, home within 24 hours) and significant lows (3 septic patients that required incredibly intensive care). We were so busy that on none of the 3 nights (Fri-Sun) did I get to lie down even for 30 minutes to nap. It was exhausting.

A typical weeknight for us in the winter can be dreadfully slow - seeing as few as 1-2 patients the entire night. The average production for a winter weeknight is somewhere around $1000. On Friday night, we made $6000!! It was quite crazed.

The first patient of the night was a cat that had been shot through the leg with an arrow! The very large arrow head and barbs went straight through the poor cat's femur, snapping it in 2. It was a horrible injury, requiring amputation. Next through the door were 2 transfer cases from local veterinarians. Both had suffered severe, severe injuries when attacked by other dogs. They'd both undergone extensive external wound cares and were transferred to me as "stable" patients for monitoring.

Unfortunately, neither of them were stable. One I suspected was suffering severe intra-abdominal trauma, and the other I suspected was rapidly developing sepsis. I was right in both cases. The first went to surgery and was found to have a hole in his intestines, torn mesentery, and a section of jejunum about 4 inches long that was totally dead (due to trauma and damaged blood supply). The second patient was septic and circling the drain. For reasons upon which I will not elaborate, the discovery of this sepsis was so delayed that by the time we knew what was happening, treatment was likely useless.

On the heels of those nightmares came a cat with a chestful of fluid, a positive feline leukemia test, and a large mass growing in his chest. This is a clinical syndrome that we see somewhat frequently in young cats - a combination of lymphoma (cancer) and feline leukemia virus. The owner wasn't prepared for euthanasia, so she elected to palliate the cancer. In the meantime, I had to tap the chest to remove the fluid.

It got so crazy that I was forced to call in the other doctor for back-up, something I haven't done in the 2.5+ years I've been working at this clinic.

By the time Monday morning rolled around, I was thrilled to be leaving! I was exhausted - physically but also emotionally. Dealing with such difficult, complicated cases (especially sepsis) drained me to the point of near tears come Sunday.

Thankfully, there's nothing that a little R&R with my family (in the form of a car trip to Florida) and some sleep can't fix.

Happy(er) news

I had a great case this weekend that turned out to be much, much more rewarding than I originally thought. I was presented with a large breed dog weighing in at a hefty 150 pounds - a mastiff breed. He'd been normal the prior today, but that morning, he'd started vomiting and acting lethargic. He'd become progressively more and more lethargic to the point where he could not rise. After some finagling, the owner was able to get him into the car and to us.

On my physical exam, I found a very quiet/depressed dog. His heart rate was very high for a dog of his size, breed, and current lethargy. His pulses were somewhat bounding. The biggest concern I had however was the mass lying along his abdominal floor. It was huge and took up most of his abdomen. Palpating it did not make him happy, as he hunched his back and hardened his abdomen in response to my touch.

I was a bit stumped, but I recommended to his owner (an MD) that we start with xrays. Xrays were a bit confusing and worrisome. The stomach was being pushed very far cranially, and there was a significant mass effect in the abdomen. My first thought was a liver tumor. Bloodwork findings did not support systemic illness though. The patient had a mild anemia, but his liver enzymes were normal.

Hmmm.

Thank god for radiologists. I sent the films off for review. While awaiting a response, I spoke to the owner and relayed my concerns (mass v. something else). She was very sad to hear that this might be a mass, but I cautioned her to not worry yet, as there were other possibilities (who says I don't learn from my mistakes?).

The radiology report came back fairly quickly. Like a typical radiologist, the answer was a list of 10 different possible things. Getting a straight answer out of a radiologist is like trying to nail jello to a wall. It didn't matter, the first differential she listed hit me like a ton of bricks. Splenic torsion.

Splenic torsion occurs for reasons that we fail to understand. In large breed dogs, the spleen will start to twist on its axis, cutting itself off from its blood supply. The spleen rapidly becomes engorged with blood that is trapped, enlarging within the abdomen.

The symptoms fit. A perfectly healthy dog the day before, now vomiting (likely from the massive spleen pushing on the stomach) and lethargic. I relayed the findings to the owners and recommended an exploratory surgery.

Two hours later, the MASSIVE 10 pound spleen was removed, and my patient was alert and recovered from surgery. He did very well post-operatively, and he is now home with his very grateful owners. It was a great end to a very, very hard day.

How doctors think

One of my readers asked if I read the book "How Doctors Think." I have and that is how I recognized these thought processes and the mistakes I am prone to making. It was an enormously helpful and insightful book. I might read it again soon.

It seems to be divided 50/50 as to whether people would want to know or not. For what it's worth, the final radiologist decision was aspiration pneumonia. After reviewing the rads again, I had come to this conclusion, but I sent the xrays for professional review just to be sure. So, aspiration pneumonia and an abdominal mass. This was coupled with a pretty serious anemia. All told, in a dog that old, it wasn't good.

After much soul-searching and discussing the situation with fellow, scrupulous veterinarians, I have decided there is nothing to be gained from telling the owner. I do not want to make her question her final decision, as I still think it was the right thing. She was anguished when euthanizing the dog, and I think introducing any uncertainty into her decision would be selfish of me. I don't want to unburden my guilt onto her - relieving myself but hurting her further.

It's not an easy decision, but I hope it is the right one.

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.

Status quo

I haven't blogged because I've been off work for 9 days (delightful), and my first 2 nights back were very dull. I think that's a good thing honestly. Every time I start wishing for a difficult case that requires intensive management, I remember my first week back to work and the 3 incredibly challenging and scary surgeries I did. Then I'm thankful that winter is slow and that I can get 6-7 hours of sleep per night at work. At least for now. Work is the only time I get much sleep!

Christmas was lovely. We spent a week with our families. I feel particularly lucky to not only have a wonderful family of my own, but for the fact that I love my in-laws so much and get along with them so well. Evaline was spoiled by constant loving attention. I think she has been somewhat dissatisfied with the relatively lower level of attention she's been getting since we came back (fear not, she gets PLENTY of attention).

My metastatic cancer patient (the partial liver lobectomy, etc) is doing very well at home. The owners are pleased that we bought him some time, and so am I. I questioned myself heavily on whether I had done the right thing for the dog and owner. Knowing he made it through the holidays with his family - and made it through happy and bouncy - was a great relief.

Today is my husband's birthday, but we have no exciting plans other than a nice dinner at home (chicken pot pie, his favorite) and spending time with the butterbean. Life is pretty awesome right now.

Another rock and hard place story

I was confronted with a very difficult situation recently. It was difficult on many levels and forced me to make some hard decisions. One of the major ones was finances, as it always tends to be.

I was presented with a less than 1 year old, female Labrador retriever. This Labrador was DEPRESSED. She could barely lift her head, and she noticeably winced when I palpated her abdomen. She'd been vomiting for 24 hours, unable to hold anything down. On a rectal exam, there were absolutely no feces in her colon. She was extremely dehydrated. Everything told me that she had a foreign body. Xrays confirmed it. Not only was it a foreign body, it was the nastiest of the nasty: a linear foreign body. Her intestines were bunched tightly on each other - like a tightened drawstring.

Sighing, I went to deliver my recommendation for surgery to the distraught owners. They'd come through the doors with zero finances and had applied for CareCredit right away. They were really nice people, and they owned a really nice dog. That automatically equals a bad scenario...it's one of those stereotypes of ER medicine. Nice owner, nice pet = bad disease.

At any rate, given how sick the dog was, I suspected that the linear foreign body might have already poked a hole in his intestines. Surgery was indicated right away. I made up an estimate - being as conservative as I could (no pre-operative bloodwork, etc). The low end was $1600. The high end was $1700. This was being CONSERVATIVE, mind you. Really and truthfully, the estimate should have been at least $2100-2500.

They were approved for $1500 only with CareCredit.

My options? 1) Doing the surgery knowing that it would cost more, charging them full price, and billing them 2) Doing the surgery and discounting the bill steeply 3) recommending that they wait until the next day to see their regular veterinarian so that they could have the surgery done cheaper (but risking the dog dying and/or the internal scenario worsening significantly overnight) or 4) euthanasia.

These people were nice. They applied for credit, as we'd requested. They got a stout $1500 approval. It still wasn't enough. If they waited on surgery, the dog would either die or be in a much, much worse situation by the time surgery was conducted. If they did surgery with me, it would be much more expensive than $1500. Further, it would leave them NO funds for transfer to the day veterinarian. The dog would not be able to go home in the morning; it would have to go to a day veterinarian, which would also cost money (all of which I would've spent).

What to do?

What I did was gave them the $1600-1700 estimate, deciding to roll with whatever happened. Of course, it was the worst it could possibly be. There was a small hole in the intestines. There was string/fabric throughout the small intestine. It was a long, frustrating surgery. I had to make 5 enterotomies (openings in the intestines), cut out about 3 inches of intestine, and open the stomach. Instead of taking me the projected 1 hour it generally takes me, it took me a full 2 hours. I knew this dog would have a long and rough recovery with a high chance of dehiscence at one of the sites, at least.

The final bill was $2300. I deducted that down to the high end of the estimate - meaning I knocked off $600+. Further, I stayed after my shift by about 3.5 hours to do this difficult surgery. Time I could've spent with my daughter, who I'd barely seen over the last few days due to my work schedule. Lastly, I made no money on that surgery. Deducting the $600 meant that I deducted off my production. Thus, I spent 3.5 hours of my own time on that dog.

And yet, people call vets money-grubbing.

The patient had a rough recovery and spent 9 additional days in the hospital with his veterinarian. I called to apologize for sending a new patient (the owners had just moved into town) to this clinic with no money. I'd spent it all. I had to. I had to cover the expense of surgery (i.e. doing it at cost), since I was not free to give away clinic supplies.

It was a very difficult and frustrating scenario, but the dog is alive and home with the owners' young daughter for the holidays. That's what matters to me.