Thursday, August 23, 2012

But it doesn't hurt...

A frantic lady arrived, screaming "He's choking, he's choking! My baby is choking!"

The technician who answered the door quickly took at look at the 3lb hairless chihuahua who was clearly not choking.  He growled as she approached him to look at his mucous membrane color.  His vitals were normal, and he and his family were placed in an exam room so I could come take a look.

I entered the room, introduced myself as usual, and asked the client what she'd been seeing at home. Clutching the dog to her chest, she told me that the dog had eaten some cat food and suddenly started choking so she rushed right in.

I tried to get a look at her dog, but she clutched him closer, burying him in between her breasts.  Without touching something inappropriately (which I was obviously not willing to do), there was no way for me to access even one square inch of her 3 pound dog.

"You're going to have to put Zorro on the table so I can take a look at him," I said.  "I can't see him when you've got him held that tightly to your body."

She set Zorro on the exam table, and then leaned over, burying him again in her generous bosom.

"Ma'am, I am really sorry, but I need you to allow me to see your dog and get my hands on him so I can help you figure out what the problem is.  You can hold on to him with your hands, but you'll have to take a step back from the table so he's not buried in your ..... body."

Finally, she complied.  At this point, Zorro started to show his true colors.  He growled, snapped and snarled when I even attempted to place a stethoscope on his chest.  He refused to allow me to look at his face, and forget thinking about approaching his mouth.

The client picked Zorro up and clutched him desperately, as if I'd beat him with a bat.

"I'm sorry, I'm not going to be able to look in Zorro's mouth," I said.  "He's too scared and aggressive, and if I get near his face, he's going to bite me."

"He doesn't BITE!" the client shrieked, and at the exact time, Zorro proceeded to bite her hands and fingers 5-10 times, repeatedly.  "HE DOES NOT BITE!"

"Ma'am...... he's biting you right now....." I said, incredulous that I was having this conversation with an adult.

"Well, it doesn't HURT.  You just need to stick your finger down his throat! He's choking!"

"It's irrelevant how much it hurts if he bites me; I can't have your dog biting me at all.  First of all, I don't think he's choking based upon his physical appearance, but if you still want me to be able to look in his mouth, he'll need to be sedated. My hands are vital to me being able to do my job, and I can't be bitten by my patients; not to mention the risk of infection....." (Really?!? Do I really need to explain why I can't be bitten by a dog?)

The client refused to have her dog sedated, and I offered him some food, which he ate.  Pets who are choking can't and don't eat, so I tried to explain to her, again, that he doesn't appear to be choking and she can watch him at home for any problems.

As medical records must be complete and accurate, I filled in the section for oral cavity exam, truthfully: "not able to examine, patient will bite."

The client was furious, and demanded I retype the medical record, because of course...... her dog doesn't bite!

Of course I refused to falsify my medical record, and the client stormed out.  Really?!?

Friday, August 17, 2012

fuzzy thinking

Few things frustrate me more than lack of a proper diagnosis.  Certainly, there are some cases where a diagnosis isn't attainable for financial, logistical, or medical reasons, but a lot of times, it's a failure on the part of the doctor.

A 10 year old great dane presented to me for a 5 week history of dribbling urine, which had progressed to not really being able to pee a full stream.  He wasn't straining, the urine was clear (not bloody) and he was otherwise acting normally.  His regular veterinarian had prescribed antibiotics 5 weeks ago, without any testing, and when those didn't help, prescribed a second antibiotic. The first error in logic is in this decision. Dribbling urine is not a common symptom of a urinary tract infection.  Antibiotics only help if a UTI is present and won't help a long list of other problems.  Signs of a urinary tract infection include frequent small urination, bloody urine, or straining to urinate.  Furthermore, male dogs are very unlikely to get a urinary tract infection without a mitigating factor, primarily due to the length of their urethra.  If a male dog indeed does have a UTI (confirmed with a urinalysis or culture), a search is indicated to look for the underlying cause (such as bladder stones, diabetes, etc.)

Medical training teaches the new doctor to start with a history (to gather a list of symptoms) and physical exam (to look for abnormalities), and then create a list of medical problems, followed by a list of most likely causes (differential diagnoses in medical terminology), which should each be ruled in or ruled out with testing.  This dog's problem list consists of dribbling urine, which could be a result of urinary incontinence, inability to empty his bladder (due to obstruction, bladder stones, mass, or spinal cord problems), or a long list of other possibilities.  The job of the clinician is to determine the cause of the symptoms, and most of the time, that requires testing.  I can't (nor can any human) be 100% sure if there's bladder stones, or bacteria, or a mass in the bladder without imaging (such as ultrasound). The treatment for each of these is very different, and so a diagnosis must be achieved to select the proper course of therapy.

Unfortunately, the regular vet did not recommend nor offer any testing, such as a urinalysis or imaging to the clients.  When their dog didn't improve after the antibiotics, the vet added pain medications to "relax" the dog's muscles, which also didn't provide any relief or ability to urinate.  When the patient still didn't get better, referral was not offered or any sort of diagnosis as to the cause of his symptoms.  The clients didn't know to ask for any other testing (as most laypeople have no way of guessing at the proper tests, and trust their doctor implicitly to do the right thing). When the clients felt their dog was simply too uncomfortable, they showed up at the ER for evaluation.

Immediately upon hearing the history I knew that this dog never had a urinary tract infection.  As I mentioned above, UTIs are rare in male dogs.  More likely, the cause of an adult/geriatric male dog to be dribbling urine is a bladder mass or bladder stones. I recommended an ultrasound, which was immediately authorized, and found the large mass with ease.

Breaking the sad news to the clients was beyond devastating.  I am frustrated at the poor diagnostic process and lack of options the clients were given; perhaps 5 weeks ago, the tumor would have been operable.