Wednesday, February 4, 2009

Lucky - Not so much

I'll apologize in advance that my first guest post is not funny or particularly happy. Typically my stock in trade is a scathingly sarcastic sense of humor from which nothing is considered sacred and for which I've gotten into trouble (or should have had I been caught) more times than I can count. Considering, however, that my personal life of late has been really crappy and that my patients lately have been mirroring what happened to some of my own children, it's been rather difficult to have a humorous outlook.

If you are a veterinarian or know anyone who is, you'll soon discover that we are, by nature, a somewhat superstitious lot of people. There are certain things that are just taboo. For instance, never ever ever say 30 minutes to 1 hour before closing time or the end of your shift "Gosh, it's been really slow today." Never say a surgery will be quick and easy until it's over. Never bet on what a client will decide. There are many of these taboos but probably the most universally known is that no one should ever name their pet "Lucky!" You have just doomed your pet to something horrible. We don't know what but, rest assured, it will be bad. So, for all you people reading who have a "Lucky" at home, please, I beg of you, change the poor soul's name immediately to something nice and healthy like George or Fido or Bouncer--ANYTHING BUT LUCKY!!!!!

There are those cases that we see on occasion (all too often for me recently) for which we realize we can do absolutely nothing. I despise having to admit this because I like to believe that I am a superhero veterinarian who can right wrongs, change the world, and cure all ills but there are those that, to put it bluntly, are A*F*U or F*U*B*A*R. If ever those acronyms appear in your head as a differential diagnosis, you know it's bad.

Case in point that prompted this post...A 17 or 18 year old mixed breed dog that we saw on the medicine service as a consult. (I have a particular weakness for geriatrics, by the way.) Her owner was so frustrated because he had seen his rDVM previously and the rDVM never even touched his dog simply saying it is time to euthanize. He then took her to a specialty hospital who performed a metastatic screening series of her thorax (when you see an old dog that is sick you always have to think of "the big C," cancer, and rule out metastasis early in the game because it really changes the prognosis you can offer) and radiographs of her abdomen. They found no evidence of metastasis but there was what appeared to be a mass in her abdomen (I say appeared because I personally saw these films and would not have made a definitive diagnosis based on them but would have done better quality films first). Their next step was to tell the owner that he could either do the whole 900 yards (i.e. ultrasound, bloodwork, surgery) or do nothing and that surgery was the only possible way of reaching a definitive diagnosis.

So, I'll now back up a little and describe what I assessed. I was speaking to an owner who obviously loved his dog dearly and told me that if euthanasia was the best thing for her, he would make that decision but he was unwilling to do so if he could not make an informed decision - that seemed imminently reasonable to me. Lucky was unable to stand at the time of examination. She had a history of weakness in her hind legs but until 10-14 days prior had been walking unassisted except for going up and down stairs. She had been battling diarrhea for 6-8 weeks which was not being treated appropriately nor had any diagnostics been done to determine a cause. She had a large mass on her face arising from the medial canthus of her right eye that was pedunculated and beginning to bleed at times; her rDVM had refused to remove this mass over 2 years before because did not want to anesthetize the dog but had no reason other than age. She also had a history of suspected Cushing's disease that was supported by previous bloodwork and clinical signs. Her abdomen was distended but not fluid filled, her liver was large with rounded edges, and there was a mass palpable in the cranial abdomen but because of her size I could do little more than touch the edge without really being able to appreciate from where it arose or the actual size. She had generalized scales and patchy alopecia with a classic "Rat's tail." Her right front leg was moderately edematous from the shoulder to the paw. Yes, A*F*U went through my mind but I would have been the same in wanting to know why I was making a decision before making such a permanent decision.

We wound up doing an abdominal ultrasound and determined that Lucky had an adrenal tumor that was already beginning to invade the caudal vena cava (large vein that drains blood from the back portion of the body taking it back to the heart.) Removal of an adrenal tumor is not an easy surgery in a completely healthy dog and prognosis is considered approximately 50% of coming off the surgery table alive. Additionally, Lucky had a large left adrenal gland, multiple nodules in her extremely large liver, and a bladder mass that may have been benign based on location but we don't really know without a sample. Due to the poor prognosis and huge risk, we did not attempt ultrasound guided aspiration of the tumor. Obviously we could not offer any definitive treatment or any hope for long term survival. We did, however, help the man to know what exactly he had to face. We also were able to offer some palliation for the diarrhea and pain. And our alternative medicine doctor offered some homeopathic remedies that may help with quality of life. Her owner, like everyone including myself, hopes that she will die peacefully in her sleep at home without the necessity of euthanasia but I think we also set his mind at ease about that decision should he need to make it.

It was a very depressing consultation but I did walk away feeling as if we made some little bit of difference. At least it did not end in euthanasia immediately because I don't know if I could have dealt with another. I'm currently so emotionally drained that I did my first ever euthanasia without crying - very atypical of me. I believe that Lucky's owner will know when it is time and I hope that we gave him the information and assurance he needs to be able to make the decision when it is needed. Hate to criticize my colleagues but where has the compassion gone? It is not that difficult to feel what your clients feel and try to help them in a difficult time. And, yes, sometimes that includes advising them that it is time to stop; but, I ask of my colleagues, would you be comfortable ending a life when the doctor never even touched your pet?

So, if I have gained anything from this depressing post, I hope I have convinced anyone who reads it to never name your pet Lucky. Only a "Lucky" would wind up with both pituitary dependent Cushing's and an adrenal tumor. I could tell many other horror stories about not so lucky, Luckys; so I leave today with the ultimate message of please change your pet's names!


Can'tSpell, DVM said...

I wonder if this will get emailed to me or you..... :)

JV said...

That's so very true. Just this Wednesday I saw a 3 year old dog with what I can only assume is a nasty fibrosarcoma or something of that ilk on its scapula (still waiting on biopsy.) The owners thought it was the ubiquitous bug bite- size of a softball. And of course, his name was Lucky. Of course.