Don't try to get personal

I apologize for the long absence.  I've transitioned into the life of a new parent, returned to work and am re-inspired to continue to share my crazy experiences at the animal ER.

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Last month, a client arrived at our clinic doors. With her was a visibly pregnant Irish Setter, who appeared bright and alert.  Our clinic was busy, however the new client stepped right in front of another transaction, interrupting the receptionist, and started with her demands.

"I need a shot of PERTUSSIN, in a room, RIGHT NOW." 

My receptionist, who was confused because this is not a medication (in fact, it is a made up word; similar to whooping cough 'pertussis,' but not a veterinary illness nor medication), asked the client to tell her what was going on with her pet so that we could help.

"I just need a shot of PERTUSSIN, RIGHT NOW. She's stalling out in labor and she needs the shot."

The receptionist asked her to please fill out the intake paperwork, and escorted her to an exam room where a technician would be in shortly to obtain vitals and a history.

I could overhear the conversation from the treatment area while working on another patient.  Given my long history at the ER, I knew that the breeder/owner was asking for pitocin, the trade name for oxytocin, which is a medication utilized to induce or augment labor in both dogs and humans.  She'd already displayed a bad attitude and being not-the-best-kind-of-breeder, she walked in to our clinic demanding medications, without a medical degree, or the knowledge to back up her demands.

Not even 30 seconds after being placed in the exam room, where I would be in to see her as soon as possible, she stormed out again, slamming the door.  She again interrupted the receptionist, who was trying to go over instructions to check out another patient.

"Is someone going to be in here or what?" The client yelled. "She needs her pertussin, like, right now! Can't we just get her the shot and deal with the formalities later!!!???!!!"  The receptionist kindly reminded her that the technician would be in momentarily, and that the paperwork is unfortunately a requirement for treatment (This isn't a novelty to veterinary medicine -- just like a human doctor's office, the dentist, a mechanic, or pretty much any other professional service, you have to give us your name, phone number and associated information, and sign a statement agreeing that you will pay your bill).  

The receptionist tried to bring blankets and towels which would be needed for the expectant delivery, however, incredibly, the client threw them back at her, hissing, "We don't need your stupid towels!!"  

As I continued to work on my patients in the treatment area, one of the technicians went to obtain vitals and a history on Susie, the Irish setter.  

The client was increasingly agitated.  She demanded to get 'the shot', without a doctor's exam, and without filling out the required information.  The technician was forced to be firm -- she frankly told the client she could either fill out the paperwork and cooperate, or she could leave.  The doctor will do an exam, and determine what treatments are recommended.  You are not a veterinarian; you cannot prescribe medications.  We want to help you. Let us do our job.

  The client finally informed us that her dog, Susie, had delivered two puppies at home, but none for the last two hours. Contractions had ceased. This was Susie's third litter. She had a similar problem last breeding.  

I entered, introduced myself, and started to examine Susie.  She had many puppies remaining, easily palpable from the outside of her abdomen and on sterile vaginal exam, a wide open cervix. I could palpate a puppy at the tip of my finger. Susie was still having contractions and otherwise appeared in good health.  As always, I made my medical recommendations based upon the most current information and what I believed was best and safest for my patient. I explained the risks of using pitocin without any testing, and why I did not recommend doing so; I explained the possible outcomes.  The owner agreed to start with a few basic things, including checking electrolytes, performing an x-ray to make sure there was no puppies stuck, and from there we would determine if medications were the correct next step.

While we worked with Susie, she started to develop active labor as a result of manual stimulation. I was able to deliver another live puppy without any medications. I returned the puppy to the eager clients; I thought they would be excited and grateful, and happy that at this time no medications were need and labor was progressing normally.  Instead the clients, who had since brought in three tubs worth of their possessions and set up camp in our exam room, were vile and angry.

"Don't you DARE come back in here," the client yelled.  "Don't even think about bothering us.  I'll tell YOU if there's a problem.  You don't enter these doors without my permission. If Susie sees you you'll halt her labor and make things worse."

I was flabbergasted.  Didn't you come to my hospital for help? Didn't I already help by getting her labor going? Wasn't the labor stalled at home and I got her labor re-started and delivered a puppy to you?

I tried to politely remind the clients that they were here for help, and it was my job to ensure the safety of my patients, which would necessitate checking on them once and awhile. The client would not relent.  She yelled, she tried to intimidate me with her voice; she would not listen to reason.  Exasperated with her attitude, I was forced to talk over her - and firmly stated - It is my job to ensure the safety of my patients.  I will be checking on your dog when I feel it is required. I'm here to help you, and I hope you can understand that I cannot just leave you in here, alone, for hours on end." She did not understand. I closed the door and walked away as there was no point in continuing to debate this with her.

Several more puppies were delivered.  The clients refused any assistance.

After about an hour, a car alarm started in our client lot.  It did not belong to any staff members, and no other clients were in our building.  After 5 minutes went by and the alarm continued, I cracked the door - 

"I TOLD YOU NOT TO COME IN HERE!!!"

"I'm sorry to interrupt, but I wanted to let you know your car alarm is going off---"

"IT'S PROBABLY NOT EVEN OURS, IS IT A RED PICKUP?!"

"Yes. It is."

"Oh....."

They went to attend to their vehicle.

Another hour and a half passed with no news of puppies.  I cracked the door, and quietly asked how things were going; and mentioned that a significant amount of time had passed and that it may be time to re-assess the situation.

"WE ARE FINE. WE HAVE THREE MORE PUPPIES. I TOLD YOU NOT TO COME IN UNLESS WE TELL YOU THERE IS A PROBLEM."

"Ma'am, that's just not going to happen.  If you let us know when puppies are delivered, we will not interfere unless there is a problem.  Stalling labor is a sign of a problem, and it's why you're here.  I will not be bullied into not caring for my patient in an appropriate manner.  If you do not want us to bother you, you are welcome to go home." I closed the door.

About 30 minutes later, the owner came out with a puppy in her hands, blood running down her arms.

"I cut the cord too short, and he's bleeding.  I tried to hold pressure, but it's not working...."

I immediately took the puppy while a staff member escorted her back to her exam room.  There was barely enough tissue left for me to ligate the badly hemorrhaging umbilical stump.  I monitored the puppy and then returned it to the family.

I fail to understand why this client was so vicious and rude.  She spent over 12 hours in our clinic, and we assisted with the delivery of 8 more puppies.  We were prompt, kind, competent and efficient. We had nothing but Susie's best interest at heart; and the client never bothered to thank us for our help. Her adversarial attitude made this case much more difficult than necessary.  

Practicing medicine and performing surgery are the easy parts of being a veterinarian. Dealing with horrible people like her is emotionally taxing and seemingly unnecessary.  

My son isn't a liar..... except for when he is!

A client and his adult son arrived last night to have their kitty evaluated after a cat fight. Dad let my staff know right away that his son had some mental illness difficulties and would be mostly outside during the evaluation for personal reasons.

The cat, Misty, had two bite wounds on the right thigh and was limping on the right hind limb, but was otherwise very stable.  I discussed the finding of the bite wound and recommended minimal wound care. We presented an estimate for wound treatment, antibiotics, pain medicine and an e-collar to prevent Misty from chewing or licking at the area.

Immediately upon reviewing the estimate, the client became irate.

"YOU HAVE UNETHICAL BUSINESS PRACTICES!"  he screamed at my receptionist.  "My son called three times and was told the entire visit would cost $80, and that's the only reason we're here! Now you're telling me that $80 only covers the exam and consultation?! We never would have come in! This is ridiculous!"

The receptionist tried to de-escalate the situation.  She knew that our exam and emergency consultation fee was indeed $80, but that none of our staff would imply this covers all care, nor would they give specific over the phone estimates.  It's impossible to know what the situation is for each pet without evaluating the problem in person. She excused herself and found the staff member who had taken that call.

As we suspected, the staff member who did take the call had told the caller that our EXAM fee was $80, and from there we would provide a written estimate for any testing, treatment or medications.  The caller continued to demand to know exactly how much the bill would be - WE CAN'T KNOW THIS WITHOUT SEEING YOUR PET.  So the staff member told him it could be "hundreds to thousands, there's just no way to know over the phone."

Armed with this information, I stepped into the exam room to chat with the angry client.

"Your staff member tricked my son," he yelled. "You told him it would be $80 for everything, and then we get here and that's just the exam fee.  You should tell your customers over the phone what they're going to spend. Otherwise you're just giving us the bait and switch."

I tried to reason with the angry man; explaining that first of all, he was NOT told it would be $80 for everything, that we cannot give specific estimates over the phone because we have no way of evaluating how serious or not a problem is without seeing it in the hospital.  Nothing would satisfy the angry fellow, and he continued to yell at me.  I offered to remove treatments from the plan, and let him know that he was welcome to decline any services he desired.

"MY SON IS NOT A LIAR.  YOUR STAFF MEMBER DID NOT TELL HIM THAT. YOU ARE UNETHICAL BUSINESS PEOPLE!"

He stormed out of the room and approved only minimal care.

At the time of checkout, the man's demeanor had changed.

Suddenly, he apologized for his abhorrent behavior.  His son had finally admitted that he WAS told the exam only was $80, and then lied to his dad so that he'd bring the cat in to our clinic.


An apology does not excuse acting like a fool.

Unsupervised and furious

On a spring Saturday shift at the ER, I met a lovely family and their 7 year old German Shepard named Reggie.  Reggie had been diagnosed as an epileptic at the young age of 2 years old, but had done incredibly well over his lifetime with proper medications and monitoring.  Unfortunately, in the few hours before his arrival to my emergency room, he had experienced 20-30 seizures in rapid succession.

Reggie was admitted to the hospital for medications, monitoring and testing.  Additional anti-seizure medications were added to his therapy, and gradually, his seizures abated.  

When Monday morning arrived, Reggie's family decided it was time to head back to their primary care veterinarian -  a very common occurrence in our world.  We stabilize pets in the emergency, and then send them back to their veterinarian for ongoing care.

Later that day, after the general practice had closed, lab testing returned for Reggie.  I called his owner to give the results and check on him.

"Reggie didn't have any seizures today," the client reported. "He's there right now."

"Okay," I said. "I hope he feels better soon."

The client seemed nervous, and concerned.  "There's someone in their clinic all night, right?" she asked. "They have overnight staff, don't they?"

Our emergency room serves a large part of our community - so primary / daytime veterinarians don't have to be on call at night.  It's hard enough to work all night (just ask me!) but it'd be impossible to work all night and the next day, too.  For this reason, almost no other clinics in town have overnight techs, and none of the clinics have doctors scheduled on duty overnight.  Sometimes they make exceptions, but the vast majority of clinics transfer any unstable patient to us for monitoring overnight.

"I don't know what their staffing schedule is," I replied. "You should ask them about that tomorrow. Sometimes clinics will have a tech stay late,  but there's no way for me to know."

"WHAT THE $*#*!" The client replied. "You're saying he's there, by himself, all night?"

"I don't know."

The client thanked me for my help, and hung up.  I thought that'd be the last I heard from her - but about 45 minutes later we received another panicked phone call.   She had just driven past the clinic, looked in the windows and noticed there was no cars in the parking lot, nobody in the building and she knew her dog was in there, unobserved.  Reggie could be having any number of seizures, or stuck in constant seizure that won't end, and eventually will lead to death (called status epilepticus) and nobody would be able to help him.  The client was in tears, hysterical and upset that nobody had told her he would be alone all night - otherwise she would have just brought him back to our ER or taken him home, where at least someone would know if he was having a seizure.

I couldn't blame her for being upset.  Of course, I have no idea if she was told there was nobody in the clinic and chose to ignore it - it wouldn't be the first time a client has twisted their doctor's words - but her reaction seemed genuine.

At her request, I called her doctor at home.  He was noticeably intoxicated on the phone, but since he was at home -- there's obviously nothing wrong with a few adult beverages.  I offered to return the call for him after I noticed his state, but he unfortunately requested to do so himself.  Oh, to listen to that conversation - I can't imagine any positive outcome. 

I just hope Reggie is okay.

The lesson here:  Before you leave your pet anywhere overnight, make sure to ask if a doctor and / or technician is in the hospital all night.  Some states now require written disclosure of hours of operation and if the pet will be left unattended.  If nobody is in the clinic overnight, you should be advised of a 24 hour option and or discuss the risks of leaving your pet unattended. Some stable patients (such as orthopedic surgery, declaws, etc) are truly fine left on their own.  Although ER stays can be expensive, it's the cost of having doctors and staff up all night long to monitor and care for your pet. Many ill patients, such as those with seizure disorders, should NEVER be left in a clinic unattended.

~Erdoc

Somebody hold me back, I'm gonna punch him....

It's taken me a few shifts to gather myself to be able to write this story.  That's how angry I was.

Two clients arrived with their 10 year old pomeranian.  The presenting complaint was difficulty breathing; it was easy to see at triage that "Syclla" was breathing too quickly and too hard.  Her mucous membranes were pale, and she was definitely ill, but still able to walk and wagging her tail.  My technician asked for permission for immediate emergency treatment and diagnostics, which was declined.  We placed Syclla in an oxygen cage and I immediately went to talk to the family.

"Hi, I'm Erdoc, and I'm sorry to meet you at such a difficult time.  What's been going on with Syclla the last few hours?" I started to ask the pertinent questions that are vitally important for a patient history and to help sort out the more likely conditions.

The husband and wife (both in their late 40s) were immediately rude.  As hard as I tried to be compassionate, kind, and understanding of what is never an easy situation, they remained cool, crispy and unfriendly.  Their answers were short and their attitudes impatient.  Certainly I respect that different people grieve differently, so despite their attitudes, I moved on to my recommendations for their pet.

Just like any other case, I gave the clients the findings based upon my exam, and options for diagnostics (to figure out what's wrong) and possible treatment options (which would depend on what's wrong).

"Our dog is old. Don't you think this is a bit ridiculous? She's 10 for god's sake."

"I certainly agree that Syclla is older.   I understand if you don't think testing or treatment is in her best interest.  I meet different kinds of people all day long, and so I just want to make sure you understand the options, the risks and benefits of each option, and make a choice that's best for you and your dog.  Certainly euthanasia is something we never want to go through, but is a understandable choice in this situation, and if you felt it was right, I would support your decision."

The clients asked me to leave while they talked.  When I returned, they had made the final decision for euthanasia.  I told them that I supported their choice 100% and I was sorry for their hard day.

The euthanasia was smooth and painless; the clients held Syclla in their arms as she passed.  

After she was gone, I again expressed my sympathies for their loss.  "I'm so sorry you had to say goodbye.  Take as much time as you need, and whenever we can help you with anything just ----"

The husband stopped me in mid-sentence by putting his hand (open palmed) 1 inch from my face, effectively telling me to shut up and definitely the most disrespectful thing that any client has ever done to me.

 It took all of my professionalism, grace and restraint to walk out of that room and shut the door without saying or doing anything I would have regretted later.  I'm still angry about how much emotional energy I spent trying to be kind, caring and compassionate only to have my kindness returned with disrespect.

How dare he?

Joy and sadness.

On a busy weekend in my ER, I worked efficiently through trauma patients, removed a plastic toy from a lab's intestines, repaired lacerations, and treated this and that throughout the day.


Our lobby was a hotbed of emotions. It remained packed with waiting pet owners all day; each sharing in the joys and sadness of those around them.   One of the most memorable cases was a much loved 14 year old miniature poodle.  The parents, a husband and wife, and their children, both younger than the dog, huddled around their pet as I listened to the history, performed a physical exam, and discussed options.  Ultimately, the family decided that their beloved friend had been in failing health for too long, and euthanasia was the best answer for her.  The kids had never lived without their dog; they had no memories without her yet in their life.  This was clearly the first time they had experienced this type of grief, and it was truly heartbreaking.  I watched as the dad comforted his family, and we all shed a few tears together.  As they exited through the lobby, the entire crowd of waiting patrons was in tears.



Several hours later, after continuing with a busy shift, we were ready to discharge a patient who I had performed surgery on the day prior to remove a plastic toy he had eaten.  The dog practically ran up to his clients, tail in full wag, and licked them hello.  The clients had shared their story with those in the lobby who also shared the joy of a life saved and another pet going home to his loving family.


A roller coaster of emotions. Another day in the journey of an emergency veterinarian.

Disconnect

Last night we received a call from a frantic pet owner.  Her 4 year old dachshund was no longer able to walk.  The most likely all-to-common and devastating condition was intevertebral disc disease, and is notorious amongst the breed.

She arrived, and a physical exam confirmed my suspicions.

Tearfully, the client explained to me that her dog was "her child" and she'd do anything for him.  I explained to her that her dog needed a hemilaminectomy, a detailed and complex surgery near the spinal cord to relieve the problem and allow her pet to (most likely) recovery completely.  The surgery is typically only performed by surgical or neurological specialists, given the difficulty of operating near the spinal cord.

 Without surgery, his prognosis to walk again was significantly worse, meaning he might end up paralyzed or need a cart in the future.


"What! The surgery costs WHAT?  There's no WAY I'd spend more than $300 on this dog! It's just a dog!"


.....?


Glad I'm not your kid.

Doctor google

Today I saw a young female puppy for the symptoms of bloody urine, straining to urinate, and small frequent urinations.  In a female dog, these signs typically indicate lower urinary tract disease; such as a urinary tract infection, bladder stones, or other causes.

I recommended a urinalysis, a simple test to look at the urine under a microscope to look for bacteria, crystals, or cells indicating the cause.  The clients and I talked about the likelihood of their puppy having a recessed vulva (a poor conformation), resulting in an easier pathway for bacteria to reach the bladder.  Other possible causes included ectopic ureters, which may require surgical correction in the future. Read more about that here.

Pending test results, I recommended starting amoxicillin, the most common first line urinary tract antibiotic, as it actually is excreted in the urine, making it an exceptionally effective choice for UTIs.  A typical course of therapy for an uncomplicated UTI is 7 days. (Many other reasons may indicate longer therapy).

The clients called a technician into their room.

"We looked on google, and we read that amoxicillin is a bad choice for UTIs", they said.  "We want cephalexin for now, and a 30 day supply of baytril to go home just in case."

Oh GOOD! You read google for 5 minutes, so you are DEFINITELY more qualified to choose antibiotics than a doctor who spent 10 years training to do this job.

I tried to be patient and explain that cephalexin is typically a choice for skin, based upon the properties of the drug. Baytril is reserved for more serious or resistant infections, and is avoided in puppies because it may have a risk of cartilage damage in puppies under a specific age.

The clients didn't argue any more, but you could tell they weren't happy.  I just CAN'T understand this mentality. Of course it's not the first time this has happened - I've had people diagnose their dogs with many, many ailments based upon google, only to find out that they've diagnosed their dog with a disease that doesn't even occur in our area. (Or similar. You get my point).  Google search is an amazing tool, but is NOT even close to a substitute for medical training, testing, and experience.