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.

hold on to your hats people...

i usually work 3 sundays out of 4 in a month. on those 3 sundays, i always wake up about an hour and a half before work. i lie in bed, and i think to myself how - at that moment, in that time - i don't hate my job, i don't hate myself, i don't hate people and the universe at large. i lie there and revel in that feeling - there in the pre-sunday calm.

sundays are unabashedly nighmare-ish at our clinic. we are the only ER clinic in this area, and we see a massive influx of animals in dire need of medical attention on sundays. i HATE sundays. i dread going to work on sundays and sundays alone.

today was .... hang on to your hats people ... NOT BAD.

i had a good day at work, despite 2 euthanasias. i was chipper, upbeat, and relaxed - in spite of having to go to surgery on a 120 pound dog with 4 liters (or more) of hemorrhage in his abdomen and despite putting down a small miniature pinscher that was out for his nightly walk and was mauled by a stray dog.

all that said - i still had a good day.

my last patient of the day was a bit of a mystery at first. a 7 lb mixed breed dog that presented for vomiting, lethargy, and "bruising." when i rolled his lip up, i was astounded to see that his gums were paper (and i'm talking PAPER) white. i went to get a blood sample with the tiniest needle imaginable, hit the vein on the first flawless stick, and watched in amazement as the vein began to blow and a huge hematoma spread under my needle. i took another look at the "bruising" and went to find my owners.

"any chance he got into rat poison?" i asked innocently.

the owner looked at me and with a straight face said, "oh no! absolutely not. well...now that you say it...we caught his brother with a mouth full of rat poison about a week ago and we made him throw it up...but his little guy...no, not possible."

so little puppy is getting himself a plasma transfusion (probably finishing it up as we speak), as well as some vitamin k to help him start clotting again. i hope he will do well, but we shall see. he was pretty anemic, too. thankfully, the owners gave their dog aspirin today because they thought he was painful. YES, i said ASPIRIN - as in the medication that causes "blood thinning" i.e. decreased clotting.

gotta love self-medicating owners!

the life and inanities contained therein

here are some non-veterinary tidbits...to lighten the mood a bit:

1) we dropped sprint like a hot potato. sure, i enjoy having no to 1 bars in my house at all times, as well as getting about 50% of my voicemail (where the other 50% goes is anyone's guess. the ether?)...but it was time for a switch. we are now with verizon. and yay, i got a new phone that i keep playing with (an EnV2). hopefully it'll be a few months before i drop it in a) the toilet b) a cup of coffee c) a large glass of water or d) throw it at the windshield in an absolute fit of PMS-induced rage

2) i gave up reading atlas shrugged for the time being. i'm about 250 pages in. i really like it, and i'm intrigued. i just can't bring myself to finish it. i did go back and finish reading 'the last days of dogtown' - which turned out to be fantastic and tear-inducing. i really enjoyed it. i was reminded of diamant's other book i read, 'the red tent.' it took me a bit to get into it, but it was incredibly rewarding. same with dogtown. i highly recommend it.

3) i'm a total and complete music snob. i like prog rock and obscure music. pandora.com has become my favorite internet music browser, and i buy independent music from emusic. i'm recently addicted to for against and interpol (they've been around a while). all that said, i can't help but admit that i'm totally infatuated with the new and totally idiotic britney spears song (womanizer) and pink's anti-marriage anthem (so what?). "yes, hello. my name is catherine. i have been clean and sober from terrible pop for all of 30 seconds. i'm back off the wagon." ***Sigh*** at least i own up to my problem.

4) i'm doing relief work next week at another local clinic (haven't been to this one yet). the pay is only $38/hr instead of the $45-50 i'm accustomed to...but i want to work, and i'm getting a new computer (YAY!), so i need to finance it.

5) the credit card is really and truly paid off. now our debt merely consists of student loans. merely. hahahahahahaha.

6) i've been firmly offered a position next year at my current place of work. i haven't decided what to do. one moment i'm squarely 100% committed to taking it. the next second, i'm totally against it. look for a pro/con list coming to a post near you soon.

7) the husband has been mistaken for the actor gale harold (jackson from desperate housewives) at least 3 times this week, including today at verizon. i've seen pictures, and the similarity is astounding and uncanny. we're trying to figure out how to use this to our advantage.

8) mike wasowski has become firmly entrenched in the household cat-ranking. apparently, she will be staying with us permanently. damn cute kittens. i think 5 cats borders on mentally unstable.

9) i got new perfume (in gel form) from my mom for xmas. i was thrilled, because it was the perfume i wanted. when i went to work, my boss and sometime mentor was also wearing the same perfume. thus, i used some xmas money to buy another perfume. the techs already refer to me as her "mini-me".

10) while home for xmas, i watched a BBC miniseries with my MIL called 'north & south' - it was ridiculously addictive and ridiculously good and rather like jane austen, with a twist.

i guess that's all here for the moment. look for more self-centered posts ... oh wait. they're all self-centered.

peace out, yo.

in the words of the teletubbies...BIG HUG.

as in, i need a big hug.

saturday was a nightmare from start to finish. the morning began with me oversleeping. i was rushing around, trying to put on makeup and look halfway decent when the full length mirror in the bathroom decided to fall onto my foot. it managed to hit the joint between my big toe and the rest of the tarsals. i screamed after the 10 second period of absolute numbness (that split second when you KNOW how bad it's going to hurt but it hasn't started hurting yet). i thought my foot was broken for sure. so first on the agenda at work - xray myself. thankfully, it looked ok - other than a horrible bruise and swelling. i just had to limp around all day.

it only got better from there. my 2nd case of the day was a 5lb fluffy dog that drank antifreeze. his owners' car blew its radiator. the dog was frolicking around and licked the fluid coming out from under the hood. by the time he got to us, he was already vomiting. the owners had NO money. not a single cent. they didn't even have the money to pay the $103 emergency fee. the female owner was on drugs of some sort - i'm not sure what - valium, oxycontin, some sort of downer. at any rate, we saw the dog about 4 hours after ingestion - which is still in that golden period when the antidote might work. problem? the antidote is $830 a bottle. what did i charge them in the end? $90. yup. i said $90 (the clinic pays about $300 for the bottle). i didn't even recoup expenses. i'll be interested to see how this turns out when i go back to work on thursday. maybe i won't have a job anymore. the kicker? the woman owner treated me like garbage - yelling loudly in the lobby about how unfair it was. after all, why should i expect money?

that was followed by an african grey in severe respiratory distress. she was a 21 year old bird that was well-loved by an elderly gentlemen. i worked on her like mad for 2.5 hours trying to save her, but in the end - i was no match for the disease process that had her in its grip. i had to euthanize her. it broke my heart in two pieces. mostly because i could see my own little fluffy grey bird in her.

on the heels of that came a little dog with an eye problem. i recognized the name as the dog i had done a conjunctival pedicle graft on months before (a delicate, difficult eye surgery). i was thrilled to see that when they followed up with ophthalmology - the ophthalmologists were impressed with the surgical technique. unfortunately, as i talked to the owner, it became clear that my surgery had failed, and it had been redone by another vet.

i finally made it out the door, depressed, distraught, and feeling like a failure - only to have to get up and do it all over again yesterday. sundays suck. yesterday was no exception. at the end of a 13 hour shift, i had to pack in a mad rush to drive 4 hours to our hometown so that we could celebrate christmas with my husband's family today.

the car trip was miserable. i was exhausted, had a migraine, and had to stop halfway so that i could vomit.

i have 2 more days off before i have to go back to work for 5 days - the christmas weekend. it promises to be hellish.

BLEH.

um.......quoi?

so remember how i had the patient that i "mis-diagnosed"? i sent the cytology out to the state lab, and they agreed with my diagnosis of lymphoma.

now - the answer to this question might seem easy. call the owner and tell her that her dog - in all likelihood - has cancer, right?

wrong.

i'm an emergency doctor. i don't have an established relationship with this owner. further, she doesn't like me, and she was upset that i incorrectly diagnosed her dog. she was seen by her veterinarian for follow-up care after my diagnosis. that vet - with whom she does have an established relationship - diagnosed something different and is treating accordingly.

so there's the difficulty of navigating the emergency doctor/referring vet relationship to consider. and here's the other part of the dilemma: lymphoma can be a tricky diagnosis on cytology. usually it's very straightforward. unfortunately, there are occasions where lymphoid hyperplasia (hyperactive lymph node) occurs and can mimic lymphoma. i've know cytologists to say that the two can be mistaken for one another. it's possible the cytologist is wrong. possible but likely? biopsy is the gold standard diagnosis - which is what the referring vet offered to the owners. they declined.

the dog is doing well on antibiotics appropriate to the disease the referring vet diagnosed (doxycycline for suspected tick-borne disease) and prednisone (which will TREAT AND SHRINK lymphoma, if present).

i've done my part. the owner is not going to like me, regardless of what happens. the results have been sent to the regular vet and now she can decide what to do from here on out, right? i should be out of the picture. the ball is in the rDVM's court as to how to proceed. and yet, it niggles at me. the owner of said dog was rude to me on the phone, had no faith in my abilities (this was even apparent the night i saw the dog as a patient), and it irks me - ESPECIALLY when i see that the cytologist agrees with my assessment of the cytology.

it is no matter. if it is lymphoma, and the dog is only treated with steroids - it has about 1-3 months of life left - at the very most. so i'll have the real answer, one way or another eventually.

i need to learn to swallow that desire to be right about everything, to have people know i'm right and know i'm a good doctor, learn what i can from the situation (which was still a valuable lesson, despite the fact that i turned out to be right), and MOVE ON.

ok.

moving on now.

any minute the moving on will begin.

seriously.

i'm just worried that in all this tiptoeing around the referring vets and irate owners, the animal's well-being will suffer. and that is strictly against the creed of "first, do no harm." i'm doing harm if my patient's illness is not managed accordingly.

dammit.

i lost a follower...

i hope it wasn't my story about the indecent man in new york city that sent follower #6 packing. if it was, i'm sorry to have offended. please come back and follow me again:)

bleh.

first day back...not fun. i had a really hard time getting my head straight this morning. i was foggy and kind of just...out of it. that - coupled with the fact that i'd been away from veterinary medicine for a whole week - was a bad combination.

i also found out that i likely mis-diagnosed a patient last week. i saw a 3 year old boxer with gigantic (and i'm talking lemon-sized) lymph nodes. my suspicion (given breed and history) was lymphoma. i did an aspirate (sucked cells out of the lymph nodes and made a slide) and thought it was lymphoma. i discussed sending out the slide to a cytologist for review - explaining to the owners more than once that i am NOT a cytologist and would prefer that one review the slides. they declined, because i did tell them that i was ... eh ... 90% certain of my diagnosis. we discussed further diagnostics, as well - including bloodwork and xrays. the owners declined that and took the dog home to talk about what to do.

that was the saturday before last. i called today to check on the dog because there were no notes in the computer that they scheduled for a follow-up visit. it turns out that the referring vet diagnosed the dog with tick-borne disease after conducting actual bloodwork. after treatment with appropriate antibiotics and steroids (due to the low platelets found on the bloodwork), the lymph nodes are normal in size, and the dog is back to his old self.

i feel rotten. yes, the dog is doing fine - and my mis-diagnosis was caught and no harm done. the owners were actually considering euthanizing this dog though, because he was so sick! they called their vet, and the vet recommended at least doing bloodwork and trying antibiotics.

i'm upset with myself because 1) i saw that my patient was a boxer with enlarged lymph nodes and immediately thought lymphoma (boxers are one of the most predisposed breeds) and 2) the owners might have euthanized him without doing further diagnostics based on my mis-diagnosis.

now, here's the catch. it could still be lymphoma. there's a free animal diagnostics lab in our state, so i sent the slides to them for reading, just to be sure. after spending 20 minutes talking to the (very, very nice) referring vet though, i think she was spot-on with her diagnosis.

and so i feel rotten.

on the bright side, the c-section i did on my last night before leaving for new york is doing well. the puppies are not, 2 were dead in utero and had been for a while, and the 2 live puppies were not fully developed. mama is doing fine though, despite a bloody and frightening surgery.

bleh. not a good first day back. maybe tomorrow will be better.