No medical procedure is without risk

The Practice

    It's the fall of 2011, and I’m standing in the brightly-lit treatment room of a practice I want to work for. I've spent the first year of my career as a veterinarian in a rotating small-animal internship; an intense year that packed several years of experience into one by working closely with specialists in Internal Medicine, Surgery, Oncology, Dermatology, and Emergency/Critical Care.

    With the internship now over, I’ve found a practice that checks most of my full-time employment boxes: high standard of care, multi-doctor practice with a collaborative atmosphere, highly trained staff, the opportunity for me to perform surgery, clients who approve recommendations, and cool bells and whistles.

     Though it's geographically nowhere near where I envisioned myself living, I want this job. It’s the morning of my working interview, which is a veterinarian test-drive where I will see appointments and treat patients.

     The treatment room is all glass and grey. To my right is a two-tone gray wall with a long countertop and cupboards; to my left is a bank of stainless steel cages from cat-size up top to Great Dane-size at ground level. Two stainless steel treatment tables connect to a tower in front of me, forming an island in the center of the room. The far wall is a giant picture window looking in on a state of the art surgical suite. The effect is like a black and white photograph on a cinema screen.

                                                                       Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

    The wall behind me has more cupboards and a countertop; more windows occupy the space between both. These windows serve a dual purpose, allowing the two or three doctors that work here each day to see into the treatment room while seated at their desks. It also allows the sunlight streaming through the large exterior windows behind the doctors to flood the space. It’s at once a cool and warm place, definitively medical while also cozy.

Complications

    “Dr. Calhoon, can you come take a look at this, please?”

    I take a couple of steps forward to join my prospective boss, a veterinarian who’s looking into the mouth of an anesthetized cat. The veterinarian is in her mid-fifties, with a slight, fit stature. She has an excellent tan that I learn is from a life spent sailing, and she gives off a warmth that makes you feel special just to know her. She and her husband built the practice from the ground up, with her focusing on the medicine while he focuses on the business. Both of them will be watching my performance as a potential new hire.      

      I adjust the bright spotlight above us and lean over her shoulder to see what she sees in the cat’s mouth. The cat has severe dental disease and during extraction of a lower canine tooth, her weakened jaw broke. This is a rare complication for an experienced practitioner to encounter, though its specter chases many general practice veterinarians away from even attempting the procedure, preferring instead to punt the risk to a veterinary dentist.

Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

    “Has this ever happened to you, Dr. Calhoon?" She asks. "What would you do?”

    Immediately, my mind starts asking questions. Am I being tested or consulted? Until this very moment, my relationship with other veterinarians has always been unequal - me in the role of student or intern; them in the role of teacher or mentor. My anxiety, a lifelong foe kept in check by years of self-work and the right prescription, buzzes a little louder in my brain and a little more intensely between my shoulder blades. I fight the contraction of my back muscles and remind myself that I have seen this before.

    “It depends on your client and your local specialist options. If you or someone mobile has experience with these and is available, fix it now. If not, I’d postpone any more dental work, wake the cat up, manage pain, and transfer ASAP for definitive repair by a dentist. A surgeon would be my second choice. Wet food until then, she’ll be hungry after being fasted for surgery.”

    It turns out we have the same approach. The conversation with the client goes smoothly, a testament to the thorough pre-surgical setting of expectations by the veterinarian. Client dissatisfaction grows in the distance between expectation and outcome. Let the client know what may happen and meet the expectations that are within your control, and disappointment rarely progresses to conflict.

    The veterinarian places the phone in its cradle and turns to me. “No medical procedure is without risk. But it feels shitty.” This is a woman I want to learn from.

The Patient

    My interview shift progresses uneventfully through the morning and afternoon - cases of itchy skin, diarrhea, some vomiting, the usual. I can tell some clients are ringers -  trusted agents who will report back to the practice owners about my exam room performance. I have a lot of fun working with the staff and feel confident as the end of the day approaches.

    With fifteen minutes left in the workday, a receptionist approaches me tentatively. “Dr. Calhoon, are you willing to squeeze in a walk-in ear hematoma?”

    “Of course!” As if I’d say no, especially on a working interview! Always Johnny Helpful, into the room I go.

    This exam room is a smaller version of the treatment room. I enter to meet a petite woman with wavy red hair and her shy daughter, who’s around six-years-old and sporting bright blonde curls. Standing on the stainless steel exam table is a short-haired brown dog of undeterminable parentage (a mutt) who weighs about fifty pounds.

     Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

    He’s nervous, panting, with a small puddle of drool accumulating on the table at his feet. His body and limbs are taut and trembling, but he doesn't have wide eyes, pinned ears, or a tucked tail, nor does he shy away from my approach. His left earflap flops downward normally, but his right sticks out level with the floor, visibly swollen like a balloon.

History

    With the dog’s head facing to my right, I pet his right shoulder with an open palm and a relaxed rhythm, working my hand in front of his chest without breaking contact. This is less threatening than reaching straight for his face, painful ear, or collar. It provides him an opportunity to move away or otherwise communicate that he’s not open to being touched while giving me a little lead time in case he elects to snap at me before communicating his intent. He leans into my hand slightly and I place my left hand on his back just behind his shoulders, petting him calmly.

    Over the dog's back, I make eye contact with the client and smile. “Hello! I’m Dr. Calhoon, please call me Derek.” I have a baby-face and find it useful to be explicit about my doctor title, but also to immediately communicate that I prefer informality.

“Tell me about why you brought Samson in today.” Even when the problem appears obvious, this phrase helps prevent tunnel vision - the ear may have brought her here, but most pets need several things addressed at each visit. Samson, for example, is also due for recheck labwork and has not been getting his flea, tick, and heartworm preventatives on a regular basis.

I spend a couple minutes taking a thorough medical history while letting Samson warm up to my presence, my touch, my voice, my smell. 

Physical Exam

    With the ear problem being highest on the owner’s priority list, I address that first. I speak out loud while performing my physical exam, working from nose to tail. “Any time a dog shakes his head, the cartilage in the ear flap can break, creating an empty space that gets filled with fluid like a water balloon. This fluid accumulation is called a hematoma.”

    I lift Samson’s lips to evaluate his teeth, then I look in his mouth, inspect his eyes, and evaluate his face and skull - all are within normal limits (WNL). I tap on certain parts of his face, shine a light in his eyes, and move his head around - vision and cranial nerves WNL. I skip over his ears for now; it’s always best to leave the painful parts till last.

    “In addition to treating the hematoma, we need to figure out why Samson was shaking his head in the first place. Ear infections are most common, but it is foxtail season and we need to rule that and some other possible problems out.” Remembering the lack of consistent flea prevention, I add, “The ears are basically an extension of the skin and anything that causes skin problems, such as fleas, can lead to an ear infection.”

    I feel Samson’s lymph nodes, the small glands that serve as surveillance and training centers for the immune system. They collect inflammatory cells and debris, display it to immune cells, and trigger a response if anything dangerous is detected. The grape-sized blip I feel under Samson’s skin at the rear of his jaw tells me that this lymph node is enlarged, probably due to the ear infection I can see and smell under his swollen right earflap.

    “An ear swab will tell us whether we need to treat bacteria, yeast, parasites, or a combination. There are a few options for how to address the hematoma itself, ranging from simple drainage (often the ear just fills back up before the cartilage heals) to surgery.”

   I run my hands over Samson as I speak, feeling for masses and evaluating his skin and coat - WNL. I briefly manipulate and feel his front legs and detect no musculoskeletal or neurological abnormalities. I decide to skip the stethoscope for the moment so I can continue talking to the client.

Complications, Part II

    Next, I press my hands flat on both sides of Samson’s belly. He’s still tense, so I gradually increase pressure and give him a few seconds to relax. When he finally does, I press firmly so I can feel his liver and stomach first. Suddenly, Samson’s abdominal muscles tense back up and I expect him to look back at me, maybe even growl at me. Instead, he looks straight up at the ceiling, his limbs go rigid, and he falls forward, his chin making a sickening crack sound on the exam table.

    Samson is completely still, not breathing or moving. My hands still hold his abdomen. The client stares back and forth between her dog and me in utter shock. “WHAT DID YOU DO?!” she exclaims.

    I have no idea what my face is broadcasting, but my brain is RACING. Adrenaline floods my system, time slows, and my brain automatically ticks through possibilities. After what feels like ages, Samson begins to tremor, but remains unconscious. “It looks like Samson is having a seizure, I need to take him and treat him immediately, is that okay?”

“Of course! Get out of here!” replies the owner.

Mad Dash

    I swoop Samson up and rush out of the room, cross the hallway in a single stride, and blow through the stainless steel swinging door into the treatment room. The staff and doctors turn toward me in unison, staring back and forth between me and the violently spasming unconscious dog in my arms. “WHAT DID YOU DO?!” exclaims one of the technicians.

                                                                         Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

                                                                       Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

    I’ve dealt with a fair amount of emergency cases through school and my internship, so, despite the shock, I’m confident in how to proceed. I move directly to the nearest treatment table, speaking loudly and firmly as I go. “Seizure, unexpected. Valium, 3ml IV right now, please. Someone come put a hand on this guy and put oxygen near his face, but be careful of his mouth, don’t get bitten. I need monitoring equipment, IV catheter, and start prepping fluids.”

    The technicians snap into action, well versed and competent. The valium bottle comes off the shelf in a fluid, practiced motion. The oxygen, set up first thing every morning, is ready in a flash. Monitoring equipment - blood pressure cuff, ECG wires, etc. - come out immediately. The IV catheter tray, ready at all times in case of emergency, rolls toward my destination.

    I can feel Samson’s tremors improving as I carry him across the room. I lay him down and his eyes immediately start to flutter. I recognize the look of an unconscious brain coming back online after a sudden shutdown. The fluttering stops and his eyes remain open but completely unseeing.

    Samson lies, panting and dazed for one or two seconds, then suddenly pops up just as the valium-filled syringe gets in range. He looks to his right -  where he last saw me standing beside him in the exam room - and then to his left where I’m now standing. He licks my face once.

Diagnosis

     A technician stops short and nods toward the valium in her hand. “Sooooooo…?” she trails off, questioningly.

     “Wait,” I say. This doesn’t fit.  Seizures don’t resolve that abruptly; they have characteristic after-effects. My brain reflexively tests what I’ve just witnessed against possible causes. If it’s not a seizure, it has to be syncope (pronounced SINK-oh-pee, also known as passing out). I place my stethoscope against Samson’s chest just behind his left elbow. Instead of the sharp “lub-dub, lub-dub” of healthy heart valves snapping shut, I hear the very loud and squishy “whoosh-whoosh, whoosh-whoosh” of blood flowing through a diseased valve that’s failing to close. This sound, called a murmur, is loudest toward the lower end of the heart on the left side.

    “Pulmonary arterial hypertension,” I announce to nobody in particular.

Explanations

    Normally, the muscular ventricle at the bottom of the heart receives blood through a one-way valve - the mitral valve on the left, tricuspid valve on the right - from the less-muscular atrium, which sits on top of the heart (like the glass-ceilinged atrium atop a building). When the ventricle contracts, the mitral valve should snap shut, forcing blood to the body through another one-way valve.

     Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

    Samson’s murmur volume, sound, and location tell me that the mitral valve is not snapping shut, allowing a large amount of blood to flow backwards. The reverse flow causes a traffic jam, driving up blood pressure in the lungs - which is known as pulmonary hypertension. When the lung veins are most affected, fluid will accumulate in the lungs, causing coughing, weakness, and other signs. When the lung arteries are most affected, the patient is at risk of passing out, especially with sudden changes in heart rate or blood pressure.

    I suspect I caused exactly that kind of change when I pressed on Samson’s belly to feel his abdominal organs. The pressure I applied with my hands drove up pressure in his vena cava, a huge vein that flows directly to the right side of the heart. This spiked blood pressure and congestion in the lungs. Pressing on Samson’s belly also stimulated the vagus nerve, a large nerve that connects the intestinal tract, heart, and brain. When stimulated, the vagus nerve lowers heart rate.

    The combination meant that Samson suddenly had less blood flowing through his lungs and to his body, so his oxygen-starved brain turned off until blood flow improved several seconds later. I’ve never run into anyone else who’s ever induced syncope in a dog just by pressing on his belly. Just my luck to do it during a working interview!

    I inform the client that Samson’s episode has resolved and that I need to investigate his heart. Her daughter, excited that Samson is alive and well, exclaims, “His heart?! I thought you hit an off button or something!”

Imaging

    I confirm the diagnosis with ultrasound, the same tool used to check on babies during pregnancy. In a small room next to the surgery suite, we lay Samson on his right side and I shave the fur on his chest where I’d listened earlier with my stethoscope. We turn off the lights, and then I apply some sound-conducting gel and press a small sensor against his bare skin. Samson’s beating heart leaps onscreen in black-and-white, and I fine-tune the view by angling and rotating the sensor to point at the structures I need to see. The client stands immobile, staring at the flashing images with intense focus.

    Samson's mitral valve is visibly thickened, the edges unable to reach one another when they should easily overlap. The ultrasound machine can indicate the direction of blood flow. Blue indicates flow toward the probe, red indicates flow away from the probe. The intensity of the color indicates speed. I turn on this function and instead of a quietly pulsing blue stream, I see a chaotic mixture of red and blue with intense red jets shooting backwards through the abnormal mitral valve whenever the ventricles contract.

Treatment

    I explain to the owner what I’m seeing and how it led Samson to pass out. His disease is advanced, and he will need medication to avoid future episodes. The client asks which medication. “Viagra,” I reply.

    She stares at me with her arms crossed and her brow furrowed, incredulous. “I brought him in for an ear problem, he collapsed in your hands, and now you’re saying he needs Viagra or he could die?”

“Yes, that’s one way to put it,” I reply, tensing for the onslaught.

    “Well, it’s worked wonders for my husband, and I already know where to get it!” She breaks into a huge grin and we all laugh. “This is going to be a fun conversation at the pharmacy, picking up Viagra for my husband AND my dog!”

    We drain Samson’s swollen ear and infuse an anti-inflammatory drug. This method works a little under half the time for ear hematomas, but Samson’s heart disease makes him a poor candidate for surgery, so it's the best solution. We then clean and medicate his infected ear with a long-acting medication so his family won’t have to wrestle with him twice a day to apply one.

    We call in the Viagra prescription, put the client in touch with a cardiologist for a more thorough workup, and book a recheck appointment for Samson’s ear. The client and her daughter leave with smiles and waves. “I can’t wait to tell my husband about this!”

                           Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

Outcome

    I wave from the reception desk and watch the client lead her daughter and Samson down the stairs and across the parking lot. Having stretched our workday beyond normal closing time, the staff lock the front door. I don’t hear it. My hearing has momentarily disappeared as my ears fill with the sound of my own rushing blood. I swallow hard and breathe deeply to tamp down the buzz of adrenaline and anxiety. Did that really just happen? I know I made the right calls, but what in the world do the practice owners think of me? What are they going to say?

    I go back to the treatment room and the practice owners are waiting for me, barely restraining huge smiles. Again, I brace for impact. “Viagra?” Says the husband.

    “Viagra,” I reply.

    He looks at his wife, who is quick to quip, “Derek, when I said ‘no medical procedure is without risk,’ I didn’t mean for you to prove it! Now I know... NO medical procedure is without risk, even a physical exam!”

    I got the job.