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.
Friday, March 30, 2012
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."
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.
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.
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.
Tuesday, February 14, 2012
Saved two birds with one stone
It's not every day that my diagnosis saves TWO lives.
Last weekend, a 15 year old cat arrived at the clinic for evaluation. His clients rushed in the front door, stating that he had been attacked by their 2 year old boxer.
The patient, "Stewart" was tilted to the right, with frequent eye movements (nystagmus) and meowing. He could not stand, but could move all four of his legs. We placed an IV catheter, and gave him oxygen. I looked over his entire body, and I found dirty ear canals, dental disease, and a cat who could not stand, but nothing to support a trauma event. No saliva, no open wounds, no fractured legs, no blood, nothing.
I went into the exam room to discuss the history in more detail.
"What happened tonight?" I asked. "Did you see Stewart get attacked by your dog?"
"No," the clients said. "We heard no scuffle, no indication of a fight, but all of a sudden, while Stewart was in the other room, we heard him start meowing loudly. When we went to go see what was going on, he was like this."
I smiled, realizing that this was a case of a wrongly accused boxer.
Stewart's clinical signs included brown foul smelling discharge in both ears, a head tilt, inability to stand, especially falling to one side, and nystagmus. These symptoms point to dysfunction of the vestibular system, which is the part of the brain responsible for balance. Common causes of this include stroke, inner ear infection, blood clot, or brain tumor. Trauma is a possible, but much less likely cause, given the cat's indoor only status and the specific nature of the symptoms.
I discussed with the clients these facts. They simply could not believe that the boxer was not responsible. Apparently, he had been known for rough play, and was responsible for an accidental broken limb of their other pet about 6 months prior. Again, I poured over the cat, looking for any evidence of injury. I found nothing. I looked at his ear debris under the microscope, and found a raging infection. I took radiographs and found again, nothing.
The clients started to take a deep sign of relief. Inner ear disease is treatable, and the most likely cause of the symptoms for Stewart that evening.
With tears in their eyes, they earnestly told me, "Doc, you've just saved a boxer's life tonight. We didn't want to have to put him down for his behavior, and now you've helped to prove that he probably wasn't responsible for Stewart's illness. Thank you so, so much."
Last weekend, a 15 year old cat arrived at the clinic for evaluation. His clients rushed in the front door, stating that he had been attacked by their 2 year old boxer.
The patient, "Stewart" was tilted to the right, with frequent eye movements (nystagmus) and meowing. He could not stand, but could move all four of his legs. We placed an IV catheter, and gave him oxygen. I looked over his entire body, and I found dirty ear canals, dental disease, and a cat who could not stand, but nothing to support a trauma event. No saliva, no open wounds, no fractured legs, no blood, nothing.
I went into the exam room to discuss the history in more detail.
"What happened tonight?" I asked. "Did you see Stewart get attacked by your dog?"
"No," the clients said. "We heard no scuffle, no indication of a fight, but all of a sudden, while Stewart was in the other room, we heard him start meowing loudly. When we went to go see what was going on, he was like this."
I smiled, realizing that this was a case of a wrongly accused boxer.
Stewart's clinical signs included brown foul smelling discharge in both ears, a head tilt, inability to stand, especially falling to one side, and nystagmus. These symptoms point to dysfunction of the vestibular system, which is the part of the brain responsible for balance. Common causes of this include stroke, inner ear infection, blood clot, or brain tumor. Trauma is a possible, but much less likely cause, given the cat's indoor only status and the specific nature of the symptoms.
I discussed with the clients these facts. They simply could not believe that the boxer was not responsible. Apparently, he had been known for rough play, and was responsible for an accidental broken limb of their other pet about 6 months prior. Again, I poured over the cat, looking for any evidence of injury. I found nothing. I looked at his ear debris under the microscope, and found a raging infection. I took radiographs and found again, nothing.
The clients started to take a deep sign of relief. Inner ear disease is treatable, and the most likely cause of the symptoms for Stewart that evening.
With tears in their eyes, they earnestly told me, "Doc, you've just saved a boxer's life tonight. We didn't want to have to put him down for his behavior, and now you've helped to prove that he probably wasn't responsible for Stewart's illness. Thank you so, so much."
Friday, February 10, 2012
Emotionally drained.
This week was long and frustrating. Case after case came in with $20 or less available to fix life threatening illnesses. As you all know, veterinary care isn't free; in fact, nothing in life is free. I can't count the number of times I've been called names, yelled at, or told that I don't even care about animals, and the reality is that those statements couldn't be further from the truth. It hurts each and every time I have to deny an animal care it needs - because it's never the animal's fault. We do what we can to provide affordable care, but unfortunately like any small business, we have to be able to pay our employees, pay for our equipment, electricity, water, rent, restock our shelves, and at the end of the day, be able to pay our own personal mortgages, school loans, and afford food. There's a very, very small limit to what we can do without payment. This isn't a matter of loving animals enough - it's a matter of the costs of keeping a business running.
Unfortunately, when faced with this, some of my clients turn into an extra-special form of nasty. Personal choice involving money are a complicated and emotionally charged issue, and I am definitely no expert in sociology or economics, however I can point out a few especially frustrating observations:
1. Don't call me a money-grubbing asshole if you are driving a new Lexus SUV (Mercedes, BMW, etc), wearing more diamonds on your hands than a small country's worth, and carrying a Prada bag. You have chosen to spend money on other (ridiculously unnecessary!) things, and it is NOT MY FAULT that now you have terrible credit.
2. If you think of your dog/cat as "your child," and you then why did you notice that it stopped eating and started vomiting TWO WEEKS ago, and do nothing about it until 2am tonight, when your dog/cat is unable to move, and in critical condition?
3. Don't try to guilt me into treating your pet for free because you paid your taxes this year! (Someone actually stormed into my office and demanded care with the statement "Where does my f***** tax money go, anyway"!!!) Veterinary hospitals are not owned, operated, or supported by government funds!
4. If your friends, family members, neighbors, and multi-million dollar credit card companies refuse to let you borrow money, then how can you possibly expect my clinic to take on that risk?
5. If you choose to do drugs, whatever. If you choose to drive yourself to our clinic, high on heroin, and demand free care, whatever. HOWEVER, if you do these above two things and bring a CHILD with you.... you can bet your ass I'll be calling the police to pick you up and take that kid away from you, you sick evil bastard.
6. (Unrelated to #5) I'm sorry, I can't hold your child (yes, adult human child) for collateral. Don't even bring it up again, or I'm calling the police.
7. Furthermore, no, I can't pawn your clothes and jewelry. I'm a doctor, not a pawn-shop owner or a consignment shop.
These are just a few examples of the depths to which people can sink when they feel trapped. Don't get me wrong, I empathize with anyone who is in a crisis with limited resources, however as the recipient of the nastiness, it gets really hard not to take it personally. There's only so much a person can take, and in the ER, we get way more than our fair share.
It's been a full week filled with this emotionally draining, burn-out producing crap, and I'm ready for a new leaf. Here's hoping for a good weekend at work.
~ERDoc
Unfortunately, when faced with this, some of my clients turn into an extra-special form of nasty. Personal choice involving money are a complicated and emotionally charged issue, and I am definitely no expert in sociology or economics, however I can point out a few especially frustrating observations:
1. Don't call me a money-grubbing asshole if you are driving a new Lexus SUV (Mercedes, BMW, etc), wearing more diamonds on your hands than a small country's worth, and carrying a Prada bag. You have chosen to spend money on other (ridiculously unnecessary!) things, and it is NOT MY FAULT that now you have terrible credit.
2. If you think of your dog/cat as "your child," and you then why did you notice that it stopped eating and started vomiting TWO WEEKS ago, and do nothing about it until 2am tonight, when your dog/cat is unable to move, and in critical condition?
3. Don't try to guilt me into treating your pet for free because you paid your taxes this year! (Someone actually stormed into my office and demanded care with the statement "Where does my f***** tax money go, anyway"!!!) Veterinary hospitals are not owned, operated, or supported by government funds!
4. If your friends, family members, neighbors, and multi-million dollar credit card companies refuse to let you borrow money, then how can you possibly expect my clinic to take on that risk?
5. If you choose to do drugs, whatever. If you choose to drive yourself to our clinic, high on heroin, and demand free care, whatever. HOWEVER, if you do these above two things and bring a CHILD with you.... you can bet your ass I'll be calling the police to pick you up and take that kid away from you, you sick evil bastard.
6. (Unrelated to #5) I'm sorry, I can't hold your child (yes, adult human child) for collateral. Don't even bring it up again, or I'm calling the police.
7. Furthermore, no, I can't pawn your clothes and jewelry. I'm a doctor, not a pawn-shop owner or a consignment shop.
These are just a few examples of the depths to which people can sink when they feel trapped. Don't get me wrong, I empathize with anyone who is in a crisis with limited resources, however as the recipient of the nastiness, it gets really hard not to take it personally. There's only so much a person can take, and in the ER, we get way more than our fair share.
It's been a full week filled with this emotionally draining, burn-out producing crap, and I'm ready for a new leaf. Here's hoping for a good weekend at work.
~ERDoc
Thursday, February 2, 2012
IMPORTANT.
Everyone, spread the word. Bloat kills. Any owner of a deep-chested at-risk breed should know the signs and symptoms.
Tonight, a young, intelligent client called. "My dog has a distended abdomen, and he's trying to vomit. This has been going on for three hours. What can I give him?"
My tech immediately, and directly informed the man that this is a critical emergency, and that his dog required IMMEDIATE medical attention.
The client arrived, and his dog was already deceased. We attempted CPR, to no avail.
His dog was only 9 months old, and if he had come in when he first noticed the problem, we could have saved her. The saddest part is that I saved her after being hit by a car only 4 months ago, and now this.
I know I've posted on GDV before, and I know that sometimes, if you aren't home, there's nothing you can do. But if you ARE home, don't wait. These symptoms require IMMEDIATE action, or it's quickly too late.
Spread the word, save a life.
Tonight, a young, intelligent client called. "My dog has a distended abdomen, and he's trying to vomit. This has been going on for three hours. What can I give him?"
My tech immediately, and directly informed the man that this is a critical emergency, and that his dog required IMMEDIATE medical attention.
The client arrived, and his dog was already deceased. We attempted CPR, to no avail.
His dog was only 9 months old, and if he had come in when he first noticed the problem, we could have saved her. The saddest part is that I saved her after being hit by a car only 4 months ago, and now this.
I know I've posted on GDV before, and I know that sometimes, if you aren't home, there's nothing you can do. But if you ARE home, don't wait. These symptoms require IMMEDIATE action, or it's quickly too late.
Spread the word, save a life.
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