Saturday, September 3, 2011

Lost in Translation

There is a lot of very true discussion these days about vets needing to actually hear what their client says rather than just the surface comments. (Of course this is true in life, period, but that is beyond the scope of the current comments right now.) For instance one of the more common examples is when someone says they don't want to put Fluffy through a procedure the underlying meaning may have more to do with lack of finances, or something else. As a general rule, probably because of the particular dysfunctions that I have grown up with in my dysfunctional family, I think I'm pretty good at reading between the lines. Lately, however, there has been one that really puzzles me; see if anyone else has an idea how to translate this one.

A 4 year old large mixed breed dog presented for routine vaccinations and exam. I detected a heart murmur (not previously noted in chart) that lacked any of the "characteristic murmur" sounds and there was an arrhythmia very briefly heard. I recommended that the dog get a cardiology work-up offering the owner options of referral immediately or that we perform part of the work-up then refer when necessary. The owner wanted to do whatever possible here but had "no problem" with referral including cost. We discussed DCM (dilated cardiomyopathy) as a possible etiology given his age and large breed status but I explained that by no means would I have a definitive diagnosis until we had performed other tests. The owner had Dobermans previously and has dealt with the disease so I assumed there was some knowledge base to build on if we ultimately reached that diagnosis.

We do not own an ultrasound but there is a human cardiology ultrasonographer locally who comes and does echoes with me interpreting; she is very good. Not like having a cardiologist but it gives me some freedom to at least glean information for a base. Usually, it is fairly easy to get her out quickly and I had intended to do all of the work-up (thoracic rads, blood work, echo, etc.) together for convenience' sake but the ultrasonographer failed to return multiple calls. Finally I was able to reach her and found that her mother was in the hospital therefore it would be a delay before the echo could be done.

I called the client and explained the situation, encouraging her to go ahead with referral rather than waiting since I didn't know how long of a delay we might encounter. She declined then started talking about how they had cut back on the dog's food and were trying to get him to exercise more so that he could lose weight, not be so large, and have less chance of having DCM.

Honestly, I was speechless. It's his breed, not that he's overweight. I thought I had explained that clearly... And now there was an adamant refusal for referral. Money? Did they think about it and decide the cost was too much? I'm honestly puzzled. So, for now, the work-up is on hold until the echo can be done which will hopefully not be too late for me to help the dog. I can only pray that he does not have DCM and maybe that brief arrhythmia was insignificant and won't result in sudden death... Thoughts anyone?

The other weird one happened several months ago. I saw a pup for its first vaccinations and picked up the lovely classic "washing machine" murmur indicative of a PDA. I explained in detail to the owner what this meant and offered them options of referral (option #1 and best choice) versus returning puppy to breeder versus our attempting to perform surgical repair if no other choice. (Not that I wouldn't love to do it but it would definitely be better done by people who do that sort of thing all the time...)

These folks opted for referral and headed out within a couple of days. I told them that the vet school was often slow in updating their rDVM's therefore I would appreciate it if they could call and let us know what was found. I never received a call, time slipped away as it often does when one is busy, then I finally received a letter from the folks at the vet school stating a PDA was identified on echo, could not be found surgically (thank God they didn't want us to do it!), and that the cardiologist had used a stent or coil to repair the defect. The puppy was reportedly doing well but had been supposed to come to us for suture removal... Hmmmmm......

The next letter stated the pup had come back for follow-up and was doing great and instructed the owners to contact a different vet in our locality for any concerns or follow-up. I'm still not really sure what made them change vets but obviously we (or I, basically) did something to annoy them. Have no idea what. By the time I realized, it was really too late to rectify and I never tried to call because I figured it would be like dragging out dirty laundry with no real resolution to be reached anyway.

If I ever really figure people out, I'll let someone know. Or maybe I should charge for the info...

In relation to the last post; the answer is that the shock is wearing off, unfortunately, and that sense of numbness is slowly disappearing allowing pain to begin to seep in. I think I preferred the numbness even though I didn't (and still don't) like myself very much when I think and feel that way...

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