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 vets....be 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.

Let The Doctor Know

My wife has been on a medication that we're hoping will help with some non-serious but annoying problems she's been having.  Unfortunately she is having some common side-effects which are bothering her.  Tonight she said that she's thinking about stopping the medication because of how it's making her feel.  While I certainly understand her concerns I imagined how I would feel if one of my clients did this.  I insisted that she call her doctor, talk about it, and at least let him know what she was doing.

This afternoon at work I saw a dog that had been seen by my associate back in October for an eye problem.  She had started him on a medication and scheduled a follow-up for five days later.  That was over two months ago.  The medication didn't help and the problem got worse. It was initially in one eye and now is affecting both, as well as worsening.  What was initially likely inflammation of the eye is developing into glaucoma in one of them.  It may not have reached this point if the client had come in for the follow-up or at least called to talk about it.

Communication with your doctor is very important.  Whether the treatment is for yourself or your pet, always keep your doctor in the loop.  Changing dosages without first talking to your vet or physician can lead to side-effects, serious consequences, or lack of improvement.  Drugs have durations, intervals, and dosages are all done for specific reasons and changing any of that could be a real issue.  

There are few things more frustrating that having a patient come in and finding out that they stopped a medication without consultation, or altered the dosage.  Sometimes it is appropriate to do so because of side-effects or lack of response, so we as doctors may agree with you.  But if we don't know about these things we may make inappropriate recommendations for care or even misdiagnose something because we assumed a treatment that wasn't actually happening.

Most doctors will actually pay attention to what you say.  I've had to alter medications many times due to client-reported problems and am always glad that they've informed me about it.  That's how a client-doctor relationship is supposed to work.

So please, let your doctor know what's going on with your pet.  Is the medicine causing side-effects?  Is it not working?  Did it work well?  All of these things are important for the vet to know as they can help us plan for future situations with that pet.  

Keep your vet informed.

Facing Setbacks In Vet School

Time to close out the year by closing out my inbox.  Here's an email from Rachel....

Happy holidays!  I am a 25yo 4th yr vet student in Kansas.  I have only recently discovered your blog and find it an enjoyable respite from the 24/7 stress at a teaching hospital.

I have not always wanted to be a veterinarian, but there was never a moment I could not admit that animals were fascinating to me.  The past 3.5yrs have not been kind or easy.  But I made it to 4th yr despite the challenges.

My previous rotation was anesthesia.  I did not pass the rotation.  I readily admit that pharmacology has never come easy to me, ever.  And I am allowed to continue on with my last year here, finishing up with repeating anesthesia after graduation.

My question for you is did you ever face a similar challenge, this far along in your journey?  This upset has made me question if I am the person for the job, the work.  The doubt makes continuing on with the rotations, ICU duty, and emergency shifts almost impossible.  Job searching seems like a fantasy, as I won't be able to gain licensure until all my transcripts are received.  The transcript for repeat anesthesia won't be available till August/September due to academic bureaucracy.

How did you keep going, moving forward?  I would appreciate any words of wisdom.

Veterinary school is extremely difficult.  Learning how to detect, diagnose, and treat diseases is complicated and requires a lot of hard work and knowledge.  This is compounded with veterinarians because the physiologies and anatomies of the different species can be quite different.  Not everyone can make it through the process and not everyone that does make it did so easily.

I graduated in the dead middle of my veterinary class, right at the 50th percentile.  I never failed a class, but I got several Cs and some of those were only by the skin of my teeth.  Some classes and rotations were much easier for me than others due to my interest and the complexity of the subject.  None of it was easy.

It frustrated me to see some of my classmates seeming to breeze through the classes, especially the ones that maintained a 4.0 average.  Yes, I probably could have studied and worked harder, but I didn't exactly goof off.  So when I was struggling and one of my friends aced a test I felt pretty down.  And Rachel, pharmacology was difficult for me as well, and was one of my Cs.

While I didn't fail anything, one of my classmates did.  In our third year he was doing very poorly and was placed on academic probation.  His grades continued to stay low and get lower, so after discussions with the Dean and administration, he agreed to stay back and repeat the third year.  I can't imagine how he felt, watching his classmates advance while it was well known that he had failed and was lucky to still even be in school.  It must have been depressing and discouraging.

So what happened to him?  He made it through school and went on to be a very successful veterinarian in Las Vegas.  I've talked to him a couple of times over the years and he seemed to be happy with where he was, and I knew he had done well for himself.  Despite his challenges and setbacks he overcame and followed his dream.

Rachel, the road ahead is not going to be easy for you.  You first have mental and emotional struggles to face, trying to overcome your own sense of failure.  But keep in mind that you failed one class, not your whole education.  Once you graduate nobody is going to care what your grades were or how narrowly you may have made it through school.  If you've done well in your other classes you can succeed in this.  It's going to be difficult and you're going to have to work even harder to make up this class.  You'll also be delayed in getting your first job.  But now that you know your areas of deficiency you can spend the next several months preparing yourself.  In a way you have an advantage over your classmates because you know exactly what you're facing and what you need to do to perform well.  Spend all of your spare time (little though it may be) becoming an expert in anesthesia.  You have the time.

As far as your other rotations, start cracking the books.  If this is really your dream, cancel any social life or fun and spend all of your time studying and preparing.  Yes, this has hit you mentally and makes you doubt yourself.  But you can make the choice right now.  Are you going to throw in the towel, or are you going to dig your heels in and work even harder?  Sometimes when you have a hard time seeing yourself walking down the entire road, switch your focus and concentrate only on the next step.

On that note I wish everyone a blessed and joyous new year!

Finding God's Will

I don't often blatantly discuss religion on this blog (that's what my other one is for), but I also don't hide that side of me.  My faith in Christ guides just about everything I do, including my work as a vet, and that will come out from time to time.  So I received this email from Rachel:

I am so glad to have come across your 7/24/11 post called 'God and Veterinary medicine'. I have a pressing question which I know only God knows the answer to, but I wanted to open it to you for honest insight... 

My name is Rachel and I'm a pre-veterinary student at the moment, after having graduated with an unrelated bachelor's degree a few years ago. I don't know how to put my passion for helping animals into words that don't sound cliche. I want to help and heal them to my highest ability, which is why I changed my course and returned to school in pursuit of a career as a veterinarian. At the time when I made this decision, there were many signs that this is the way, and many wondered why I hadn't chosen this path in the first place. Simply put, I'm crazy about God's animals, and to see them ailing brings me to my knees.

I have always believed in God, but only a few weeks ago I fully accepted Christ into my life and my relationship with Him is growing everyday. Before, I admit to being guilty of putting animals above humans - honestly, I was people-fearing, even loathing. After reading the Bible, I realize that as a follower of Christ, I cannot live or think that way - we must love one another as Christ does. I heard a sermon not too long ago that said once you accept God into your life, He does with your life as He pleases, and He will take/make you far from who you think you are, and you certainly may not like it at first. 

Thinking of this brings me anxiety, panic, and confusion, because not long after, a thought came to my mind (from me or God, I do not know) that I should be a human doctor, and specialize in oncology to be exact. I don't know if this was God talking to me, or me messing with mind trying to stir up anxiety again (not uncommon). I feel that everything that has happened for me in the past two years - volunteering, participating in veterinary mission trips abroad, meeting wonderful contacts in the field, finding inspiration in the veterinarians I have followed - all of these things I feel were/are blessings from God. They all came to me at the right place and time; coincidence is impossible. I enjoy and am fulfilled when I help people day to day, but animals have been in my heart, as are many other God-given passions and talents, since my beginning.

Perhaps it is God trying to tell me that I need to balance myself out and dedicate more time to helping people in need? This I can believe. I have merely just begun my walk with God and I am just starting to learn more about Him. Of course I want to always say 'Yes' to God! He knows what is best for us. I can only hope it was a silly 'what-if'  thought that came to mind. Now I can't help but worry as I continue my studies that I am displeasing God, and being selfish for pursuing what I love. I have prayed about this, but nothing is yet clear to me. 

I am coming to you because I trust your honest insight, and I am sure you understand more about God's character than I do right now. What are your thoughts?

First I want to say that I'm not an expert on God, just a devoted layperson who makes mistakes and still sins.  I'm no better than anybody else, so take any of my advice with a grain (or three) of salt.  And I can't say that I understand more about God....I'm still trying to figure a lot of it out myself!

God is not the author of confusion.  That's the domain of Satan.  But we as fallible, sinful humans can mess with our own minds without the Devil's help.  I've certainly had plenty of doubts and confusion of my own and have doubted what God wants for me, yet I don't think Satan is behind all of that.  We have our own free wills, and that includes the freedom to doubt.  But if you're moving in a direction that God wants, Satan can certainly intervene and muddy the waters.

I agree that too many people put animals over humans.  Humans have a special place in God's creation, and though animals are special they are not on the same level as people.  I do believe that animals have emotions and can show love and devotion, but that alone doesn't place them above or even equal to humans.  In Genesis God gives Adam (and therefore all his descendants) authority over animals.  But that doesn't mean that we can do whatever we want to them with impunity.  God still wants us to take care of His creation.  Animals are there for us to be able to use, but also for us to act as caretakers.  That is a big responsibility and ties directly to those of us in the veterinary profession.  But no matter how much I love animals, I firmly believe that any human has more value to God than any animal.  As a follower of Christ, I need to mirror that attitude.

Rachel, I can't tell you what God wants from you, even if I knew you.  I would first recommend finding a local pastor, priest, or other spiritual leader that you respect and with whom you feel comfortable.  Talk to them and ask them to pray for you.  Also spend daily time with God, praying and above all listening.  I think that too much prayer time is spent with us talking while God wants his turn to speak to us.  Be quiet and focus on His will and His presence.  Read the Bible daily and get to know His character.  You'll find great wisdom in His words that will help you understand what He wants from you.

Think about where your true passions and interests lie.  When I think about human medicine I get a bit weirded out.  I find things related to humans rather disgusting and could never imagine myself being part of that, even though I deal with the same things on animals.  I also don't feel a burning desire to help people in this way.  God has never given me a heart or passion to be involved with human medicine.  That's not me being selfish, that's just how I've always been.  God creates each of us with innate talents and interests, even before we turn to Him.  He creates us to do certain things, even if we may not realize it at the time.

He did the same thing with you, Rachel.  If you feel strongly drawn to human medicine and oncology, start to look into that.  Perhaps volunteer at a hospital where you can work with cancer patients.  If you feel your heart crying out to these people and wanting to be around them, then consider switching your path.  But if you feel uncomfortable and nervous in this situation, it may not be right for you.  If you go into human oncology you can still help animals by giving to charitable organizations and volunteering at shelters or as a foster parent.  If you pursue veterinary medicine but still feel that God wants you involved with human cancer patients you can do something similar, volunteering at a hospital or with hospice, or giving to cancer research foundations. It is possible to have a passion for one thing but still help out in another area.

Both veterinary and human medical schools will stress and tax you in ways you can't imagine.  Both are worthwhile pursuits, but you should be sure of which one you want to pursue before starting.  Spend more time with God, listen to Him, and find a local pastor to help you.  I hope that some of my words may also help, and I will pray for you.

A Dog's Night Before Christmas

In a couple of days I'm going away with my family to the Tennessee mountains to have some private Christmas time away from the rest of the world.  Just me, my wife, and our kids having some quality family time.  So no new blogging for about a week, though I hope that most of you will be enjoying your own families rather than reading my little corner of the Internet.

I wish all of you a Merry Christmas and Happy Holidays!

The Night Before Christmas graphic produced by Pet365 and Dogorama. Click here to view the original post.

Vet + Dad = Pressure

Regular readers of this blog should remember the loss of my daughter's rat, Adara, a few weeks ago.  That was a tragic day in the Bern household and my little girl was distraught for several days.  We added a new rat, Princess Leia, and my daughter's heart was healed.

Leia always seemed a little odd compared to most rats.  A little withdrawn and less active.  However, rats have different personalities like any animal, so I chalked it up to that.  I hadn't handled her much after the first day or two, relying on my daughter to let me know if there were any issues.  

A week ago my wife surprised all of us by actually holding Leia.  This was a momentous occasion!  She had always been averse to rats and never even wanted to touch one.  I made sure to take pictures to celebrate.  But when we had Leia out I noticed that she seemed a bit thin.  She was being fed and my daughter is a very responsible pet owner, so I knew it wasn't due to a lack of care.  I made a mental note to check on her more often.

This evening I went and checked on her.  I became worried when she was thinner than the last time I held her.  She was also making some snuffling sinus-related sounds.  I went into vet mode and started really looking her over.  Besides being thin and having upper respiratory sounds she was dehydrated.  And though she was active, she didn't seem exactly energetic.  Then I looked at her mouth and noticed a problem.  Her upper incisors were missing and her lower ones were severely overgrown to the point of pushing into the roof of her mouth.

I couldn't believe that I had missed that.  If a sick rodent came to see me in my office I would examine the mouth as part of a routine exam.  For whatever reason I hadn't done that on my own daughter's pet and it was almost disastrous.  I should have done a quick exam when we first got her at the pet store.  The little thing had been gradually suffering for weeks, not being able to eat or drink enough, and I had missed it.

At times like this it's really hard to balance being a vet and being a father.  If it was a client-owned pet I would have some degree of objectivity and could have handled it.  But this was the pet of my own 10 year-old girl.  She had just lost a pet that she really loved and I was worried that the same thing would happen with Leia.  Of course my daughter came upstairs while I was trying to handle it and I had to figure out how much to say and what to do.

I think there is more pressure in a situation like this than with a client's pet because it's my own family and my own child that is affected.  My wife and kids know that I'm a vet and expect me to be able to take care of our pets.  I have to play double duty as doctor and father/husband and if I fail in the first part I worry that I've failed in the second.

I feel lucky that I caught the problem with Leia before it went any further.  I trimmed her teeth and when I put her back in her cage she began drinking and drinking.  It was encouraging to me because it meant that she was better enough that she could start replacing the lost fluids.  If I had a bag of fluids and syringes at home I would have given her some subcutaneously.  The hole in the roof of her mouth is pretty deep and likely is at the point of going into the sinuses, so tomorrow when I go in to work I'm going to get antibiotics.  I'll also have to keep her teeth trimmed monthly, but I can do that from home with a Dremmel tool.  

If she responds well everything will be okay, though she will need more maintenance than an average rat.  If she doesn't do well I'll have a heartbroken daughter.  I'll keep my fingers crossed and hope that I caught the problem early enough.

Being a dad and a vet at the same time is tough!

Veterinary Christmas Wish List

Seth emailed me with the following question.  I was a bit surprised, because in over four years of blogging I haven't been asked this and honestly haven't thought much about it.  

Question please, What do vets want for Christmas? I have been dating vet who own's her own practice and I am trying to think of things that a vet would want for him/herself but may not necessarily buy. Is it a super sweet stethoscope or otoscope? If so which one? Is it something else cool and different? What would you want to get for x-mass? I am a computer guy so, while I minimally understand and appreciate the business end of being a vet, I am pretty clueless about this end of things. Looking forward to your response.

A gift for a vet doesn't have to be specific to veterinary medicine.  In fact, I prefer gifts that have nothing to do with my profession.  I typically ask for action figures, cool geeky t-shirts, books, DVDs, and so on.  The gifts I want generally revolve around my non-veterinary interests because by the time I get home I want to be Chris, not Dr. Bern.  But that's just me.

Personally I wouldn't recommend getting a practical piece of equipment.  First of all, you may break your budget.  A high-quality stethoscope will cost $100-200.  Otoscopes and and other instruments can go higher than that.  If you have that money and want to spend it on her, great.  But just be aware of the costs involved.  Since she owns her own practice she probably already has those things, and if she needs more it becomes a business expense for her and therefore a tax deduction.  It would also be tough for you as a non-vet to pick just the right thing that she wants, as there are many technical issues and preferences that you wouldn't be easily aware of.

Lastly, and forgive me if I'm being a "guy" here or sexist as it's not intended, you're talking about practical gifts.  In my experience a woman really doesn't want gifts like that for gifts and birthdays, despite what the commercials make you think.  Would you give her a new, fancy vacuum cleaner?  What about a set of kitchen utensils?  Probably not.  I know that my wife certainly wouldn't want those as gifts since it's not really "special" and just has to do with day-to-day household tasks.  A stethoscope would be the veterinary equivalent of a vacuum.  It's something you need and a good one does a much better job than a cheap one, but in the end it's a tool and not an object to cherish.  Now if the object was specific to her interests, that would be a different story.  For example, if the kitchen utensils had Mickey Mouse or Tinker Bell my wife would be very interested in them.

So what to get her?

Start with her likes and dislikes.  Depending on what she wears and uses in work you can find medical-related gifts that may show those interests.  For example, I have a scrub top that has "Starfleet Medical Academy" and the logo printed on it (from Star Trek for you non-geeks).  That kind of thing would be a great gift for someone like me!  You can find scrub tops and cloth surgical caps with all kinds of prints and patterns, such as sports teams, animals, cartoon characters, and so on.  There are stethoscopes and stethoscope covers that you can also find with different prints.  Those stethoscopes are an acrylic mold and have a bell on one side, so she may not like that style.

Does she have a favorite breed of dog?  You should be able to find a business card holder that has that breed on it.  Or you can find a desk set with a theme that she likes.  My wife has a Tinker Bell desk set that includes a business card holder, stapler, tape dispenser, paper clip holder, and so on.  I have a similar kind of set that is a Pirates of the Caribbean theme.  As a practice owner I'm sure she has a desk, so that is something that is practical for her to use daily yet can show some fun and personality.

If you want to get her something to use in her practice, get sneaky and question her staff.  They will know her day-to-day pattern and usage better than anyone else.  Her assistants will know if she loves or hates her stethoscope, or if she has dreamed of a fancy electronic one (very pricey but very cool!).  The staff will know if she has a favorite kind of coffee or snack.  They'll know what equipment she's always talking about or what is breaking down in the place.  If they've worked for her for long they'll also know a lot about her personality as a vet.  All of that can help you figure out the gift.

But in the end remember that she's a woman and a person before she's a vet.  She has interests outside of veterinary medicine and may have more passion in those areas than in her job.  Don't limit yourself to a gift related to her profession if she really might like something else.

So what about all of you veterinarians and vet students who read this blog?  Am I on the right track or are there vet-specific gifts you're dying to have?  If this was your boyfriend, would you want him to get you a veterinary gift or something else?  I'd love to hear your comments!

Seth, this is a GREAT topic, and I'm really glad you wrote it!