Friday, March 30, 2012

Compassion fatigue - and then the remedy.

Earlier this week, I was suffering from a pretty stiff case of compassion fatigue, mostly as a result of mean, downright awful clients, and several cases with sad outcomes.  Compassion fatigue is a known occurrence among medical professionals who experience sadness, high emotional cases and drama on a daily basis. Experiencing these negative feelings over and over again results in a numbness or a lack of compassion for the suffering of others; usually this is temporary. Read more about it here.

After several prior days of bad cases, mean people, and frustrating situations, last night was long-awaited.  All evening, we had friendly, reasonable, logical clients who spoke to us like normal human beings, who asked smart questions, who treated us with the respect that we afford to them, and who all truly cared about their pets.  Not once yesterday was I called a name or screamed at; not once did I have to explain to an angry client that I'm not a millionaire.  This might not seem so shocking to those who are not in the field; unfortunately ER medicine has a propensity for the absurd.  I'm sure those of you who have worked with the general public (retail, customer service, etc.) have seen some idea of the ridiculous actions of people; mix in with that the high drama of an ill or injured pet and the odd hours of the day that we are working, and an explosive mix results.

The pinnacle of the evening was a 13 year old Basset hound, "Eva," who presented for a distended abdomen.  Eva was owned by a lovely older woman.  At first glance, Eva had a rough hair coat and a moderate amount of flea dirt; her client was quiet but kind.  Initial diagnostics confirmed that Eva indeed had a bloat, or gastric dilatation and volvulus (see several previous entries about this condition).  Given her condition, she was relatively stable, thanks to her very observant client noticing symptoms almost immediately and quickly responding by bringing Eva to us.

Immediate surgery was required; unfortunately, I was suspicious that instead of treatment, Eva would be euthanized due to her advanced age and the cost of surgery.  Definitely an understandable decision in this situation - however, after discussing the risks of anesthesia, surgery, as well as an honest discussion about a typical lifespan for a dog of Eva's breed, I was excited and surprised at the client's decision.

"She's my family" the client said. "Do whatever you need to do.  I know she's an old girl, but I want to give her a chance, even if she only has a few more months or years to live. I know we can't pinpoint how long she'll live, but I want to give her a chance."

YES.  This is why I do my job. I hurriedly prepared Eva for the procedure; it would be a challenge to get her safely through anesthesia and surgery.  Amazingly, she performed exceptionally well under anesthesia, and surgery was a success.  She recovered well.

My favorite part of the day was reuniting Eva and her mom.  Truly, a heartwarming moment that for me, melted away the crusty shell of compassion fatigue.

Saturday, March 10, 2012

down with the man!

Client had seen us a few days ago because his cat had been attacked by another animal and developed an abscess. The wound was treated, and his cat was sent home with a liquid antibiotic.  This medication must be kept in the refigerator, and the client was informed of this.  We even put a "keep refrigerated" sticker on the box as a reminder.

The client called today because he left the antibiotic out on the counter for 2 days, and could no longer use it.  He needed to replace the bottle.  No problem, come right on down and pick it up!

But there was a problem.

My technician fielded the call.
Client: "I shouldn't have to pay for this second bottle of antibiotics" he claimed.  "I already payed the mark-up on the first one, and the second one should be at cost.  You know, those pharmaceutical companies are just taking over the world, man, and it isn't fair."

 "..... But we told you to keep in the fridge?"

"Yeah, you did. And I forgot."

".... and so you admit that it's your fault the antibiotic can't be used?"

"Yeah. I'm not arguing that.  I'm arguing that since I already paid the mark up, I shouldn't have to pay again. The government, man, they're taking over.  And it's guys like you, the bureaucracy, man, that's making this country bad. I've got to stand, up, man, and take a stand."

"Okay, so I understand your frustration, however I'm not able to change the prices; our prices reflect the cost of keeping our doors open.  If you've ever taken economics, you'd understand the importance of fixed costs, which have to be distrubted over the entire business.  For example, we don't charge you for the water or electricity you use while you're here - and those costs, among all the other things we have to pay for, are spread out over everything we do.  Secondly, you admit that it was your error that resulted in the mistake.  We can't be responsible to pay the mistakes of all our clients.  Third, we have nothing to do with the government, or pharmaceutical companies, other than we need drugs to treat our patients. You are welcome to come down and pick up your medicine, but it will be $X.xx, just like last time."

"Well, I'm standing up for myself and I'll tell anyone who will listen.  This country is unjust and the government is takin--

"I'm sorry sir, I'm hanging up now.  I can't debate politics with you, and I have patients and emergencies to tend to.  If you want to pay for the medication, you can come get it anytime."

Balancing act, continued

Whereas the previous story was a very gray zone, the following story is a little more black and white.

A 12 year old, male neutered lab presented to a colleague of mine for a second opinion.  Gus, a family pet, had experienced a sudden onset collapse, pale gums, and a distended abdomen.  I'd venture that the vast majority of veterinarians would start by looking for the most obvious condition; a hemoabdomen.  And they'd be right.  Hemoabdomen is when a large amount of blood pools in the belly; typically from a ruptured tumor (spleen is the most common culprit; it can also be a tumor on the liver).  (Hemoabdomen can also be caused by trauma, such as being hit by a car, but typically this sort of history is known, as well as there are other signs of injury on the pet which lead towards a trauma diagnosis).  This is a condition that must be treated quickly, or the pet will die from blood loss.  Unfortuantely, often the underlying cause is cancer, so many of these patients are euthanized as the prognosis is not very good. Regardless, some clients choose to proceed with therapy, which includes surgery (to remove the bleeding tumor), blood transfusion, supportive care, followed by chemotherapy once the specific type of tumor is known.

Gus presented for a second opinion because the first veterinarian who saw the case told the clients gave them no options; offered no diagnostics, and no therapy plan.  The vet gave them a bottle of prednisone (a steroid anti-inflammatory medication), sent them home, and told them that "he won't make it long enough to finish the bottle."

Again, I don't want to speak ill of others, but this is just plain wrong. There's nothing wrong with not knowing, but if you don't know, REFER. 

This didn't feel right to the clients. They left this office; presented to my friend and got the real diagnosis, treatment plan, and proceeded with care.

The bottom line; there's good and bad in every profession, including medicine.

Balancing act

On a weekly basis, I struggle with the balance between being a good colleague, and being honest with clients.  Veterinary medicine has grown so much in the last 20-30 years that some older standby "treatments" are simply outdated and no longer recommended, and in some cases downright harmful.  Further complicating the situation is that, in the exam room, it's impossible to know if what I'm being told by the client is the actual truth, or just their interpretation/memory of the truth. As a result, I try really hard not to judge the medical decision made by others, until I see the medical record and/or speak with them about the case.  Unfortunately, sometimes, it's impossible to sort out why things happen the way the do.

Case and point -
A 6 year old Chesepeke bay retriever, "Grizly" presented as a transfer to me one afternoon.  The dog had started to have hematemesis, or bloody vomiting.  3 weeks prior, the dog had been lethargic, vomiting and not eating.  Blood testing had showed very severe liver disease; this was confirmed with abdominal ultrasound.  The dog was not placed on any medications, and was basically sent home for "observation" with re-testing of labs to occur weeks later.  Unfortunately, Grizly didn't make it to that recheck.

On presentation Grizly was weak, pale and listless.  He was thin, having lost 6lbs in the last 2 weeks.  He hadn't eaten or held down a full meal in weeks. His clients wanted every possible intervention for Grizly, and agreed to aggressive supportive care, with the eventual goal for liver biopsy to gain a definitive diagnosis and plan the perfect treatment strategy.  Unlike many cases, cost was no object; they only wanted to give their dog a chance to recover.

Unfortunately, by the time I saw Grizly, it was much too late.  He was debilitated, and having severe GI bleeding; we could not stop this bleeding and he quickly progressed to a comatose state.   In the last few minutes before he died from his disease, his clients were with him and allowed euthanasia to ease the passing.

A post-mortem exam was performed, and confirmed a bleeding stomach ulcer, which ultimately lead to his death.  His liver was also diseased, and the original source of his illness.  I am left to wonder - if he had been placed on the appropriate GI protection, liver supportive, and proper medications weeks earlier, could he have survived? If referral to a 24 hour care facility like ours had been offered originally, would he have had a recovery and normal life span?  Had the clients given some indication to the original doctor that they did not want these things and only changed their minds once he fell more seriously ill?

I'll never know.