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Thursday, January 3, 2013

Vet Vs. Vet? Making Sense Of Differening Findings

Last weekend I saw a dog for a very unusual fluid accumulation around the hind end and legs that had started a couple of months ago.  Neither myself nor my associate had ever seen anything quite like this, and that's about 35+ years of combined experience looking at the pet.  It was certainly a strange case!

I collected fluid from the swelling, placed a urinary catheter, collected urine, and took some x-rays of the abdomen.  The fluid looked similar to urine, but when comparing certain values to what came directly from the bladder there were some significant differences.  The x-rays and catheter also showed that there didn't appear to be any obvious communication from the bladder to the fluid swelling, so I concluded that the bladder wasn't involved and something else was going on, perhaps a serum-secreting tumor.  The dog's exam was otherwise normal and he was acting perfectly fine at home.  The tests we performed were routine and minimally invasive, things we do virtually every day without consequence.

Two days later he was euthanized at an emergency clinic.

When I came to work Tuesday I was shocked to see the report from the ER.  He had been doing great just three days before and though I had referred them to a specialist for further diagnostics, I didn't have any immediate concerns.  The lab tests they ran showed extreme blood and infection in his urine, elevated kidney and liver values, and an extremely low white blood cell count.  In essence he had a very aggressive systemic infection that was causing organ failure.  Chances for survival were very low so the client elected euthanasia.  None of that was evident on his exam and tests Saturday.  I was stumped and concerned as I hadn't seen any of this coming.  I tried to call the doctor at the emergency clinic but had no luck as I work 9am to 7pm and she works 8pm to 8am.

Since I'm human and care about my patients and clients I've fretted over this case for a few days.  I've reviewed the x-rays and gone over what we did to see if I missed anything or did anything wrong.  Obviously there was some unexpected complication after seeing him, but I couldn't find anything inappropriate with what we did or found.

Today the owner's mother called me, upset about what happened.  According to her the emergency vet had told her that the dog did have what I said he didn't have.  Basically we had contradictory stories, with me saying one thing and the other vet saying the opposite.  With such conflicting information I can certainly see why the client would be distraught and confused.

There are a few good lessons in this story, as tragic as it turned out.

First, clients and even vets need to understand that an exam and lab tests are like a photograph rather than a movie.  When we look at a pet and do diagnostics we are looking at a particular frame of time.  That picture may change if we look earlier or later.  In this case I didn't see the things the other vet did because they weren't there at the point that I did my exam.  Something happened between my exam and the other vet's that caused a difference.  So I didn't "miss" something because there wasn't something easily detected.

Second, when dealing with a situation like this the emergency vet and I don't have a complete picture of what happened at each place.  She could only go by what the owner told her and didn't have access to my lab tests and medical records.  I could never talk to her and her handwriting was almost illegible so I didn't completely know what happened there.  Here's a hint to all vets or future careful when contradicting a colleague's findings or conclusions.  You may not know everything that happened before and should give the first vet the benefit of the doubt in most cases.  Owners aren't going to be deliberately deceptive (well, most of them won't) but may not have fully understood what happened initially and may not be able to accurately explain that to the second vet.  I've had owners tell another vet that I said something when I absolutely know that I didn't.  Call and talk to the other vet and speak doctor-to-doctor to make sure everything is clear. 

Third, even the simplest of things can go wrong sometimes.  This was a strange case anyway, and I must have punctured a tumor, abscess, or something else that led to the serious complications.  Yet there was no evidence of this at the time and I still can't see an obvious issue when reviewing the x-rays.  There are cases that go wrong even with the best care, and situations that simply can't be predicted.  These are always tragic, perhaps moreso because they are unexpected, but you can't predict or avoid something you can't detect.

Sometimes lessons are hard.  But there often is a reason why vets may find different things and both be right.