Sunday, February 10, 2013

More cancer

I missed a giant tumor last month. A dog (old, large-breed) came in for coughing, and the owners thought he had kennel cough, because he'd been groomed a week before. I was more worried about other things, given his age, and took chest rads. There might have been some hilar lymphadenopathy, but it wasn't dramatic. The cranial abdomen was also in the films, and I took a quick glance at it and noticed a little piece of bone in the stomach, but he has a history of dietary indiscretion so I didn't think too much of it, and went back to ruminating over whether the hilar lymph nodes were actually big or not. Well, he came back last week, for GI upset, and had a large splenic mass removed. So I went back and looked at the rads I took a month ago, and there is obviously a splenic mass on those films. It was squishing the stomach. I totally missed it.

I also (tentatively) diagnosed a dog with ALL this week. That was pretty bizarre! I can add this one to my list of patients who came in with diarrhea, and went home with terminal cancer. The peripheral blood was so screwy that our machine couldn't even read the CBC, so I made a smear, and there were abnormal lymphocytes EVERYWHERE. They almost outnumbered the RBCs in circulation! No peripheral lymphadenopathy. Giant spleen. Referred him to an oncologist, but it probably won't matter much. The owners were very upset, cried a lot, and asked very thoughtful questions - I was impressed. I'm very curious to see if the oncologist agrees that it's ALL.

Another dog came in with hematuria, and ended up having a giant bladder mass. That client can't afford surgery or chemotherapy, so she'll probably be euthanized soon. She was mildly coagulopathic and moderately thrombocytopenic, so I'm actually more worried about bleeding out than about the mass, in the short term. I didn't recommend a transfusion, because at my hospital it costs almost $1000 and the guy could barely afford the $500 in initial diagnostics, but in retrospect I wish I'd at least mentioned it.

On the pettier side, I got yelled at by a client this week on the phone. Her husband had brought in their geriatric cat on emergency, with urinary signs. I recommended a urinalysis, abdominal radiographs to look for uroliths (and tiny or giant kidneys), and bloodwork, both to look at her renal values and because she was also not eating very well. I didn't push him to do all those things, I just explained why I was recommending each thing, and he opted to follow that plan. She did end up having an uncomplicated UTI, and the wife was furious that I hadn't JUST done a urinalysis. She even talked to her regular vet, who AGREED with her that my plan was excessive and unnecessary. I explained that even if I'd just done a UA, the cat STILL could have had bladder stones, neoplasia, GI or liver disease, etc, and finding a UTI doesn't rule out any of those other possibilities. AND that I hadn't pushed her husband into following my recommendations, I just made and explained my plan, and he elected to follow it. She was still disgruntled when we got off the phone. The part that really galls me is her other vet telling her the rads and bloodwork were unnecessary and excessive. I would never say that about another doctor. Especially since I still think it was a perfectly reasonable plan.

Being a doctor is really stressful. REALLY stressful. I'm constantly worried about missing something, not ordering the right diagnostic tests, not interpreting the tests I DO order correctly, not asking the owner the right questions to elicit the complete history, making a mistake with a drug dose or combination . . . . . . . I frequently wake up at 4 AM and can't go back to sleep because I'm so worried about patients I should have pushed harder for, or should have done another diagnostic on, or should have explained something a different way to their owner, or should have emphasized something harder. It's stressful.

16 comments:

The Snowboarding (and Crossfitting) Veterinarian said...

I had the exact same thing happen (husband approved full treatment plan, wife peeved at me for doing more than just a U/A)!

Life in vet school said...

So annoying!!! She complained when they came to pick the cat up that night (had to hospitalize for SQ fluids since bladder was too small for cysto and husband didn't want to drop off a free-catch sample) and then AGAIN when I called her later in the week with the results.

Nicki said...

Don't worry, it gets better.

Jenna said...

To be fair, you can't be sure that the other veterinarian told this woman what you did was unnecessary. That's what she said the veterinarian said. Over the years I've heard accounts of what clients have said to other veterinarians, or to their friends who are also my clients, and it often bears no resemblance to what I actually said. Sometimes, when a client tells me "I did exactly what you said" I then ask, "What did you do?" to find out what they think I told them to do. On occasion, with particularly obstinate clients, I've asked "What did I say?", a question that never fails to be informative.

That said, you did what you were supposed to do. This is a marital, not veterinary, problem.

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Ceres said...

Thanks for posting stories about stress. I go off to an internship in a couple of months and it's nice to see reminders of both the good and bad parts of vet med, after being in a grad program that is completely oblivious to its existence.

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Stacey Beck said...

How should I pick a veterinarian in Toronto. We just got our first puppy and I love her to death and want to pick a good doctor for her!

Jak Manson said...

The blog is really well put together and I really like the post. It is good to know that they will take care of your pets. It is a veterinarians job to take care of them and make sure they are well.

Katie D said...

Still hanging in there? I'm a DVM class of 2012 too (from Mizzou), and I'm pretty sure my 1st year out gave me an ulcer. No joke. I've got an ultrasound scheduled next week...to be followed by an upper GI. LOL. Your blog just came out on a google search. I forgot what I was actually looking for. From 1 new grad to another: Hang in there!!

Katie

Nicki said...

Hey Katie I'm a 2004 MU grad-go Tigers! Stop on by Borderblog for vet stories! And some rescue dog stuff...I'm a bit of a proud mom :)

Life in vet school said...

@Katie - thanks for the mini pep talk! :) I am still hanging in there, sort of (considering asking to modify my hours at work, or possibly making an even bigger change) but that's on the back burner at the moment because I'm one week into maternity leave. :)

@Katie and Nicki - MM is a Mizzou grad! He predates both of you (although Nicki, you may have met him at some point since you overlapped a little) and loved it. We're actually discussing moving back to the area (we met in the midwest) because the cost of living and pace of life in general are a lot more family-friendly than our current locale.

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