On Fridays, Being Thrown Under the Bus, and Other Odds and Ends

It is absolutely amazing, the difference in the hospital on a Friday evening in comparison to any other day. While most things move at the speed of molasses in the winter, on Friday, suddenly, it's as if a new life is infused. Let a back dog come in at 4 and it's guaranteed that the imaging, including CT scan, will be done by 5 and the dog will be well on its way to surgery. Any other time, the molasses would slowly move and it would take hours to be done.

The other amazing thing about Friday is how quickly everyone hits the door. Better not count on someone being there at all late 'cause it ain't happening. By 5:00:01 they are gone. WHOOSH!! The gust from their leaving could knock you down and you'd better get out of the way.

And, in the vetmed world, Friday is often "dump day." All the nearby rDVM's decide that they should unload the challenging cases in their hospital that they don't want to deal with over the weekend. I've never quite understood this since most of the time further work-up won't be possible until Monday anyway, even in the referral hospital. It's even worse when the dumping "rDVM" is the in university hospital community practice (CP) service. There were at least 2 cases sent home abruptly today that I doubt were really sent home for the well-being of the patient. No, I would distinctly say that it had to do with the convenience of the clinician... To explore the motives can sometimes be a frightening prospect (even your own motives at times).

Interestingly, I have only gotten one "dump case" tonight; or, to put it better, this one is what I sometimes refer to as a "prefergency." It is a not extremely critical patient that needs further diagnostics and it was "easier" to come tonight rather than wait until Monday. Guess they have the financial means to pay for the preference as well.

Yesterday, on the other hand, was an entirely different ballgame. Yesterday, though, was more of a "thrown under the bus" type of day. Sadly, not by outside sources but by people working side by side as colleagues. Not that the occurrence is abnormal in this place. It is actually quite commonplace and you feel more surprised when it fails to occur.

A snake bite case showed up at quarter til 5, the ER overnight shift starts at 5. Guess upon whom it was dumped. I think that the icing was when the CP clinician then tried to dump callbacks for their cases on us and later called to ask about the snake bite and criticize the planned treatment regimen. Out of last night was born the repeated quote (and very atypical attitude for me) of "Not my problem!" I guess there comes a point for all of us at which we are tired of lying down and saying here, why don't you wipe your poop covered shoes all over me as you walk across my prostrate form.

This particular rotation, or I guess I should just say the last few weeks, has been particularly bad. It's easy enough to deal with small problems but when they mount up to an enormous pile they become overwhelming and that is when tempers flare and patience becomes frayed. In fact, it is usually the pile of small things that make me break much faster than the big issues - those I just take in stride. And no matter what anyone says, it always seems that if a shift begins one way, it just can't seem to be turned around and made better!

So much for Fridays...When you hear the ka-thump, just look for the big yellow bus that ran me over then backed up for a second chance.

Money

I'm going to tackle a tough subject that comes up all too often, particularly these days with the current economic situation.

It's 2:16a.m., I receive a call that wakens me from my catnap stolen on the recliner in the faculty lounge. "We have a 6 week old puppy that got stepped on and has blood coming from its nose. What should we do?"

I ask the usual questions that I use primarily to get the owner to calm down a little and also to ascertain how bad of a situation we have. I advise the owner that the puppy should be seen then advise them of the emergency fee and payment policy. We are supposed to do this with every call unless they indicate the pet is actively dying and I have learned to do so anyway in order to save grief when clients arrive with no money.

"Do we have to pay it all now?"

How often do I get asked this question. "Yes, you do or if the pet stays in the hospital you would leave a deposit of half the high end of the estimate."

"Oh."

"Are you coming in?"

"I'll call you back."

Translation = No, not spending the money.

Why do people seem to believe that veterinarians should not charge for their services? "But I thought you loved animals!!!" Like any other professional, we deserve to be paid for the things that we do as well as the materials that we use. And how many other professions allow you not to pay up front? I've always wondered why people look at us differently in that aspect.

I should point out while I'm saying this that I tend to be one of the worst when it comes to letting things slide. I've been in trouble with my boss at every place that I have worked thus far for not charging for some things. I immensely dislike "nickle and diming" people. Really, you want me to charge for the 3 staples I used on that laceration separately? Yes, I know that realistically, it all adds up to a far larger sum than I realize but sometimes it just seems unfair.

One of the worst is when a very critical patient arrives and you still have to charge the ER fee just to euthanize. It's hard enough trying to get money from people when they have nothing much less from people whose pet you just killed.

And I know that one of the arguments is not to have pets if you haven't the money but I'm not sure that I consider that particularly fair either. I couldn't have pets right now if that were the rule 'cause I sure can't afford them. If I didn't have them, though, I would truly be pushed over the edge; they allow me to maintain what little sanity I have left.

Tonight, I got a call from a guy who has $100 total and his dog just did something to hurt its nose. Sounds like the dog will survive the night and I bluntly told him that he will be able to stretch that money farther by waiting until morning and seeing a local vet sans emergency fee. People have a hard time swallowing that information but I'm nothing if not honest. That then becomes difficult when people get angry saying you are refusing to see them and don't care about their pet. The bottom line is that in the situation I'm in currently, there's really nothing I can do about the financial policy and if I were to admit the pet to the hospital, they would just rack up a lot of cost which they cannot afford then get sent to collections. Unfortunately, they are usually too upset to see that I'm trying to make my best judgment call decision for their pet's welfare.

Sticky situations always seem to revolve around money. And they wonder why veterinarians seem to feel as if they don't deserve to get paid for their knowledge....

To Dr. May B. Insane

Don't you know? When people own dogs, common sense flies out the window! Kind of like the owner I see constantly who "breeds" blue heelers... he *never* brings his puppies in for taildock and dewclaw removal in the established 3-5 day old window as "ideal" for doing this procedure. Instead, he brings them in usually from 8-14 days old... the then require local anesthesia to do the procedure... even though I've told him fifteen million flippin' times to bring them in 3-5 days of age... People are STUPID!!!

Dear Stupid Client from the Insane One

I fail to comprehend people and have determined that common sense does not exist!

Last night at 8:30, I received a call from a client whose cat has a chylothorax and has chest tubes in place. They reported that the cat had been open mouth breathing although it was resting comfortably at the time of the call. They live 3+ hours away.

I advised the clients that they should ideally find a local ER clinic and have the cat evaluated immediately. The alternative plans I offered if a local ER clinic could not be found were as follows: If the cat remained stable, have him evaluated by the regular vet first thing in the morning or head in this direction.

I heard no more from them until 4:20a.m. at which time they called, in a panic and in tears, to report that the cat was "still" open mouth breathing and no one would see them without their being an established client.

Need I point out that they could have been here hours ago had they listened to my advice...

Display of my Insanity

Really hit me again tonight, something I've thought often about since making the decision to come here for a year. Prior to coming, I was aware that a certain person that I had known when I was a fourth year student and she was an intern was here in a medicine residency. Still, yet, I chose to come.... What the heck was I thinking???

Misinformation - Ignorance is NOT bliss!

I've decided to come briefly out of hibernation to relate a story of a recent case that I saw.

The radiographic images that follow have only been altered to remove the names and other identifying features.

Received a call the other night from a rDVM (referring vet) regarding a dog with caval syndrome that he wanted to send this way. The confusing part of the story is that the description I was receiving of the case and the classification of caval syndrome did not really fit.

Caval syndrome is when heartworm disease becomes so severe that there are adult worms present in the right atrium of the heart. For those unfamiliar, calling it heartworm disease is a bit of a misnomer anyway since the adult worms are typically found in the pulmonary artery, not in the actual heart. When caval syndrome occurs, the affected dog is in right heart failure with all the bells and whistles including peritoneal effusion, pulmonary hypertension, congestion of the liver, etc. etc. etc. Often these patients are also in DIC (disseminated intravascular coagulation aka dog in cooler if you have the morbid sense of humor that most in our profession do) and are at high risk for thromboembolic events such as pulmonary thromboembolism (PTE) which is most often fatal. In other words, you have a really sick patient who is not a good candidate for anesthesia. What is the treatment? Anesthetize the animal and surgically remove the adult worms from the heart.

In addition to the above listed problems, dogs with heartworms often get a secondary pneumonitis or severe inflammatory response in the lungs. There is no such thing as waiting to make these patients more stable and a better candidate for the surgery.

Back to the patient at hand. She was described as an approximately 8 year old, spayed female, Basset Hound who had a bicavitary ultrasound showing adult worms in the right atrium, only mild changes to the heart, no evidence of failure including no peritoneal effusion or changes in the liver. I was also told that the dog was bright, alert, and responsive and that the worms had been visualized approximately 48 hours previously. What part of this description makes no sense to you???

Recommended that the dog be sent immediately. As a side note, they were supposed to arrive around 11pm but got lost and rolled in around 1am. The dog was BAR with nothing to indicate to me that it was a caval syndrome dog. We obtained some baseline data including CBC, Chemistry panel, PT/PTT, and d-dimers. Nothing particularly exciting on the bloodwork other than mildly elevated liver enzymes. We then obtained thoracic radiographs. Four views to follow:

Ventro-dorsal thorax

Dorso-ventral thorax


Right lateral thorax


Left lateral thorax

So the obvious is the large heart with a "reverse D" appearance that is oh so typical of heartworm disease. The interesting part to me is the suggestive appearance of pulmonary edema consistent with left heart failure that is not really pulmonary edema. What you see, particularly in the DV and right lateral views, is an extremely huge, tortuous pulmonary artery (I would put in an arrow or outline it but couldn't figure out how - hmmmmm.....). Pretty impressive isn't it?

Blood pressure was normal, ECG was normal. Called in the cardiologist who did an echocardiogram and determined that there were no worms in the right atrium. We then looked at the echo video sent by the rDVM and there were indeed worms present two days prior. She apparently "resolved" her own caval syndrome so to speak. Clearly, she did not develop severe symptoms therefore the worms must not have been present for long. I find it extremely amazing the things that our patients can deal with and still be okay.

In talking to the dog's owners, I found them to be extremely concerned and caring people. The dog had been diagnosed with heartworms a minimum of 3 years previously because she was positive at the time when they adopted her. So why didn't they do anything?!? Misinformation. Either through their misunderstanding or incorrect information given by someone (could have been rDVM or other vet or some random person since I have learned people often listen better to what "Aunt Polly" found off the internet than they do to trained veterinarians) they were under the impression that heartworm disease is incurable.

We opted to treat for presumptive pneumonitis and use a medication to decrease the risk of thromboembolic events then begin a two stage adulticidal therapy with required hospitalization during each stage of the therapy. The prognosis is still guarded since the same risk factors enumerated earlier still apply but it's probably better than having to go to surgery (although surgery would have been way more cool!) With some luck, this very sweet dog will get treated, do well, and still have some really good years ahead.