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Sunday, February 10, 2013

The Toughest Cases Aren't Because Of Pets

My last case of the day yesterday was one that hit me hard.  The health problem with the pet was sad, but what really hit me was the situation with the owner.

The puppy was a 19 week old shih-tzu.  The owner had taking him to be groomed and the groomer noted odor and discharge around the eyes.  So she came to us to have the puppy checked out.  I immediately noticed several serious problems.  The puppy's skull was large and asymmetrical, with a large open fontanelle on the right side.  The eyes were bulging and pointing down and to the sides.  He didn't seem to blink much and seemed to have some difficulties seeing.  When walking he would often start circling in one direction.  It was quickly obvious to me that this puppy had hydrocephalus.

This is a very serious condition where the fluid within the brain accumulates and starts to expand.  Over time the fluid starts to push outward, compressing the brain tissue against the inside of the skull and causing pressure against the eyes and bones.  This is a picture of a very advanced case in a dog.

The central black areas are where the fluid is and the thin tissue around it is the brain.  As you can likely imagine, this can lead to severe brain damage.  Unfortunately, treatments are limited and usually involve expensive and risky surgery to put a permanent drain.

This was the worst case of hydrocephalus I have ever seen, as well as the most obvious.  I could see early neurological signs which gives a very poor prognosis.  So I began to explain this to the owner.

That's when the case gets bad.

The owner has a 16 year-old daughter who has been struggling with an eating disorder and who has cut on herself in the past.  They wanted to try having her around a therapy horse, but her daughter is afraid of horses.  So they got a puppy and her daughter immediately fell in love.  The owner is a single mom and has been struggling with her daughter's problem.  There have been successes and relapses, and now I had to tell her that the puppy had a life-threatening problem.

The owner herself is a teacher who had a $15,000 pay cut last year.  She teaches both day and night classes to try and make ends meet.  So her life isn't exactly easy.

To top it off, she started telling me that one of her friends was on a parade float in another state several months ago when a train came through, hitting the float.  People were killed and her friend lost a leg and has been in an area hospital since then.

Here I have a puppy with a severe congenital defect that was likely going to cause severe neurological problems and even death.  This puppy was meant to help out a girl with significant psychological problems.  The owner had virtually no money and had tragedy all around her.

Oh, and then I found out that one of my assistants had a sister with an eating disorder, so she started having a hard time as she could relate to the owner's situation.  There I am getting teary-eyed right along with my assistant, all while the owner is in the exam room crying over what she knows she has to do.

We ended up euthanizing the puppy and the owner had to go home and tell her daughter, who had no idea what had happened.  I simply can't imagine how that went.

In vet school we're taught how to diagnose and treat disease.  We learn how to recognize symptoms, calculate drug dosages, and perform surgery.  We're not taught human psychology and don't get training in how to handle rough situations like this.  Most of us pick up some things with practice and experience but it's still never easy.  We go into this profession because we like dealing with medicine and surgery on animals, not because we enjoy the human side of the equation.  But for every pet that comes in there's at least one human associated with them.  It's something that you learn you can't ignore.

I honestly wish the woman and her daughter the best and will keep her in my prayers.


  1. We are getting a lot more training about this type of thing in vet school now. We get lectures on compassion fatigue, grief counseling, and similar topics. I'm actually currently preparing for a formal euthanasia roleplay in which I have to break the news to a professional actor that their dog or cat needs to be euthanized (on video!). The two cases are quite different - in the case of the cat, it's due to chronic renal failure; in the case of the dog, it's because it has been hit by a car and is paralyzed in both hind limbs. I have to prepare for both of them, and supposedly the actors take their jobs pretty seriously (read: crying, angry etc) ... needless to say it's pretty stressful! But it's an invaluable experience that forces you to at least think about these issues before being faced with them in practice.

    I think vet schools are getting the message that there is more to being a doctor than diagnosing and surgery.

  2. This post really pulled at my heartstrings today. I had four emergencies today - of them, three were euthanasias. Since I am a new doctor at the practice (4 months), I haven't had time to get to know many patients or their owners. That being said, even when I euthanize a patient I haven't met before, I am moved to tears because of my empathy for the client. I imagine how I feel when I lose one of my pets or family members and then it becomes very hard. I know clients appreciate my care, but boy, some days are rough :(

    I practice in a very low income area so we see difficult cases quite frequently. I've not had one quite to the extent that you had today (!), but boy, some of these stories are rough. Some people I feel like God has given them more than they can handle! Then I remember that it's my job to help make that decision easier and as a vet I can be supportive of those people emotionally (though not often financially). As vets we have to be prepared to help these people that probably won't go see a professional counselor - we're it!

    On a somewhat brighter note, I wanted to share one slightly happier euthanasia example. One of my cases I had today was a 12 year old chihuahua that presented yesterday with seizures, heart failure and secondary pulmonary edema (from the heart or seizures, or both). I said that I probably wouldn't be able to save the dog, but that I would try giving some medications overnight and we would see. Come find out, the owner had no money and had been living on disability for years. The amazing thing, though, was that each of the members of her family from around the country (PA, CA, etc) called in with their credit card numbers and each contributed small amounts to her final bill that ended up paying for most of her costs. We ended up euthanizing the dog, but I was floored by the family support network and the love they had for their sister/aunt/mother.

    Keep up the good work. I bet after all these years you've figured out in most situations what are the best words to say and how to deal with some of the strong emotions surrounding these difficult discussions. :)

  3. LeAnne, I've heard of programs like that. They didn't have such things when I was in school and I'm glad they're more common now. Having those lessons is very important to a vet's daily practice.

    Katie, I wish I could say that I have it all figured out. While I do think I'm good at it and have learned how to handle most situations, I certainly haven't mastered things.

    In times like this I've found that the best option is to drop "Dr. Bern" and just be "Chris". I always try to maintain professionalism, but in difficult situations most people want compassion from their doctor. In this case I touched her shoulder and put my arm around her. I didn't charge her for the visit or euthanasia, and I told her that I'd keep her in my prayers. Simply being a caring person is the best decision.


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