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Sunday, July 19, 2009

Tough Decisions & Lucky Breaks

Yesterday I saw a young boxer named Rocky. He came in for very vague signs of acting lethargic, not eating, and not drinking. When I examined him, he was overall in good condition, but obviously didn't feel well. Mysterious malaise usually necessitates running a battery of tests to try and figure out what the problem may or may not be. Unfortunately in this case the owner was a young man with extremely limited funds. The lab tests were $155, and that's with giving him a free office visit as a courtesy. He had an upper limit of $150, and that was with his father chipping in $50 and him not really eating for the rest of the week. So not only could he not afford the recommended tests, but if we did find something wrong he couldn't afford any treatment.

That left us with tough decisions. We couldn't completely waive his fees, but we had to work within his budget. We needed to run a full series of tests (chemistry panel, blood cell count and differential, electrolytes, and urinalysis), but he couldn't afford it. And we couldn't just randomly pick a medication and try it, because we had no idea what was wrong. We struggled to decide which tests to run, trying to do it piece-meal. The problem with doing it this way is that the test you leave out may be the one that gives you your diagnosis; you don't know that until you run them all.

After going around the issue a few times, I decided to run some blood tests, as it would at least rule out serious issues like kidney failure, pancreatic issues, or liver disease. We usually collect blood from the jugular vein in the neck because it's an easy and large vein to access. When we lifted his neck to get to the vein, he whined in pain. That surprised me, and totally changed the picture. Instead of drawing blood, I began to manipulate his neck. It became quickly obvious that he was reluctant to move it, and would cry in pain when we tried to move it too much.

Severe neck pain was the likely cause of all of his symptoms. It was also a very specific sign that we could consider a limited list of possible problems. When we talked to the owner, we discovered that Rocky lived with and played with a lab that was literally twice his size. My suspicion was that they played to rough and the other dog accidentally injured his neck. There was a strong likelihood that it was simply a bad muscle sprain or twist, though there was also a possibility of a slipped disc in the neck.

Our whole game plan changed. X-rays were the next step, but they would have been far above the owner's budget. However, now we had an identifiable problem that we could direct treatment at. I sent him home with some medicine for pain and inflammation, with instructions to strictly restrict activity and exercise, use a harness rather than a collar, and not let the other dogs play. The owner gets paid next Friday, and if the problem persists, he is going to come back for radiographs. However, we may have already put him on the right treatment, and were able to get him out for about $30.

If we hadn't decided to run blood tests, we wouldn't have moved his neck significantly enough to cause pain. And then we wouldn't have isolated the problem to neck pain. We got a lucky break yesterday. And the owner was left with enough money for gas and food.