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Tuesday, January 3, 2017

Case Management--Anxiety, Fear, Then Relief

As I've mentioned before, most vets (and medical professionals in general) really do worry about their patients.  I know that I do.  It's not uncommon for me to fret over a case for days, especially if it's complicated or doesn't go well.  Most of the time it's not my fault if things go bad, but I will worry anyway because I'm my own worst critic.
 
One of the surgeries that I occasionally do is to correct "cherry eye".  For those not familiar with the disorder, it is common in certain breeds (English bulldogs, Shar-peis, Shih-tzus, and cocker spaniels are the most prone) and results when the tear gland under the third eyelid becomes inflamed and prolapses.  This causes a very obvious red, fleshy bump on the inside corner of the eye.  If untreated there is a risk of chronic inflammation and damage to the gland, which is responsible for the majority of tear production in the eye.  We don't want to remove the gland because we would decrease the tear film and cause dry eye problems.  The only real fix is surgery.
 
The most common method, and the one that I do, involves making an incision on either side of the gland, forming a pocket under the tissues, placing the gland within this pocket, and then closing the edges over the gland with sutures.  Because the eye is so sensitive we use very small suture material, typically about the thickness of a human hair or smaller.  While the surgery is typically successful there is about a 20-30% "failure" or recurrence rate even with the best surgeon.  The gland can re-prolapse because the suture breaks, the technique was poor, the tissues fail to heal, or the inflammation is too persistent.  Most of these reasons have nothing to do with the doctor, which is why the failure rate is so high compared to other surgeries.
 
I've been performing this procedure for all of my nearly 20 years in practice and have become pretty proficient with it.  Though I haven't specifically tracked the numbers I would say that my recurrence rate is around 20-25%, right within expectations.  Even so, I really hate it when one of my patients has a relapse and I worry about whether or not my technique was correct or if somehow I had failed as a surgeon which led to the failure of the surgery.
 
A couple of months ago I had that happen.  About three days after the surgery the client called to say that it had prolapsed again.  I had her bring the dog in and it looked like the suture had broken.  We would have to repeat the surgery, and I said that I'd give her a $100 discount on the second procedure due to the inconvenience.  Even though it didn't look like it was my fault, I worried about it, and started to doubt myself.  I promised that the next time I did this type of surgery I would be even more careful with my steps and method.
 
That opportunity came in late November, with a shar-pei puppy who had both glands prolapse.  When I did the surgery I was extra-careful about my incisions, suture placement, knots, and generally everything that I could potentially control.  The surgery went well and the patient looked great post-operatively.  I was very hopeful that this one would be successful but I remembered my last case.
 
About 10 days after the surgery I came in to work and there was a note for me that the client had called and I should check the medical records.  My heart dropped into my stomach and my first thought was "crap, one or both of the eyes failed and relapsed".  I first saw the note around 8:15 am.  I didn't actually look at the record until around 5:00 in the afternoon.  I had time to do so, but was worrying about it the whole day.  I just knew that the client was calling to say that it had happened again and perhaps be angry that it had done so.  I always tell my clients two or three times what the rate of failure is, but that doesn't always stop people from being upset when it happens.  I dreaded what I would see in the notes.
 
As the day went on I started thinking and worrying even more, to the point of being a bit sick to my stomach.  I doubted my abilities, and even started thinking that maybe I should stop doing this particular surgery if I was going to have a high recurrence rate.  Maybe I should be referring them out if I wasn't going to get it right the first time.  Maybe I should never have attempted it in the first place.
 
So I finally steeled myself, gritted my teeth, and pulled out the medical records to read the notes from the previous day, preparing myself for the worst.
 
The client had called to ask if they could take the Elizabethan collar (e-collar or cone collar) off.
 
That was it!  The client wasn't reporting any problems, only asking if it was okay to stop using the e-collar!
 
I breathed a deep sigh of relief and called the client.  The dog was doing great and the eyes were perfectly fine.  There was no sign of any problems or any recurrence and his puppy was acting like nothing had happened to her.  We talked about taking the e-collar off and watching her for any other problems.
 
I had worried for nothing.  I spent almost nine hours being anxious for no reason whatsoever.  I had doubted my abilities when my personal success rate in these cases is right in line with the profession.
 
That's not uncommon for me and many of my colleagues.  Most of us care deeply to the point of doubting ourselves if something doesn't go exactly right.  It's easy to forget all of the "good" cases when we are presented with a "bad" one.  Many of us worry ourselves sick for things that are beyond our control.  Because of this veterinarians have a high rate of clinical anxiety and depression.  It's not easy having someone's beloved pet depend on you for their life and health.
 
 

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