Another I don't understand

Today I was reminded of a case I meant to post about several months ago primarily as yet another example of how I fail to understand people.

I saw a dog today that had a lovely bladder stone. Everything about the case went smoothly and the surgery was beautiful. Such a nice case brought to mind one that was not so nice...

My boss saw a small breed dog with a bladder stone and did a cystotomy to remove the stone. He then left on vacation and I picked up the case the following day being told it was doing well and could go home. I had some qualms by the end of the day because the dog was just not quite right but there was really nothing I could put my finger on and the owner had already been told to pick up and was very insistent to do so. I think it was a weekend and I gave her contact numbers, I know, for myself, my boss (although out of town), and the local ER clinic. Didn't hear anything from her until the following Monday when she brought the dog in for a "recheck."

The dog was flat out, almost non-responsive, bradycardic, and had uremic breath. Bloodwork showed severe azotemia, hyperphosphatemia, and hyperkalemia. Diuresis brought the potassium levels down and I re-explored as soon as the dog was semi-stable. The bladder had dehisced and there was a lovely uroabdomen. Both before and after the second surgery, I reiterated how sick the dog was and that there was a definite chance she would not survive. At one point the owner very bluntly asked if I was saying her dog might die. Yes. I have said that repeatedly!! Her response was to ask when the boss would be back in town.

I put a lot of effort into that dog and it did survive but it was very dicey there for a while. Since discharge, the owner refuses to see me and only wants to see my boss. Now, I'm not saying he did anything wrong surgically, dehiscence is certainly a possible post-op complication, but I guess I do resent it a little that she apparently is mad about the fact that I was blunt enough to tell her the dog was in critical condition. It takes a lot out of you when you put that much effort into a patient only to find that the owner fails to appreciate it at all.

On the other hand, though, with my current fatalistic viewpoint, maybe it wouldn't have mattered what I did anyway.

Like the little hit by car dog Tuesday evening. One of our good clients saw it get hit and brought in the little stray. She was severely shocky but warming and IV fluid boluses had made a significant improvement by the time we closed. My boss usually checks on patients after hours since he lives only 5 minutes from the clinic and he reported that all was well at the last overnight check. She was dead when we arrived this morning. I really don't know why since radiographs, blood, etc. didn't show me anything too bad other than the shock and an acetabular fracture. You can even do it "right" and make no difference, it seems. That is one thing I hate about private practice is not having the overnight care that is available in ER, specialty, or university settings.

I do, however, envy the client's attitude. I wish I were more practical or whatever you want to term it, like she is. When I called to tell her the dog had died she said, "At least she had a chance and was warm and cared for rather than being out on the street." I agree but, of course, am still beating myself up on what I may have missed or could have done differently / better.