I blurted to my clients, “She might be trying to die.” Self-doubt immediately gripped me as I watched the woman’s face crumple in pain and her husband struggle to maintain his composure, his red-rimmed, watering eyes pleading for a different outcome. Cooper, their 10-year-old female Australian shepherd, lay recumbent and on an oxygen mask in our Tulsa, Oklahoma, surgery room. She had presented weakly, having barely eaten for two days and breathing heavily with dull mentation. I’d examined her and now was seeking every crumb of background information to help me tell these traumatized folks what was wrong with their dog.
A smarter veterinarian would know how to handle this case, sniped my inner critic, who took the helm as usual as I outlined my diagnostic plan of bloodwork and radiographs. I felt inadequate and coarse, not coolly self-confident as I imagined my peers to be.
This is the story of the day I proved myself to myself. I am one mean critic.
A Panoply of Problems
Cooper had been seen at our clinic three months earlier for urinary incontinence. She was diagnosed then with a urinary tract infection and calcium oxalate crystalluria and treated with antibiotics and a therapeutic diet. As the incontinence continued, she was started on phenylpropanolamine. Mr. Client told me that Cooper seemed to “feel kind of bad” on the anti-incontinence drug, but he and his wife continued the medication because it helped to some extent. Cooper was having breakthrough urination, and they accepted that fact. After all, she was geriatric, and a veterinarian had examined and treated her.
Cooper’s health had been declining for about two weeks, but she had stopped eating entirely for the past two days and now could barely stand. There could be a hundred reasons for her condition, and I did not feel smart enough to solve the case. To her owners, I had called it as I saw it. Even though I knew I was looking at a dying dog, my critical side flooded me with miserable uncertainty.
Alisha, my technician, set up a complete blood count and serum chemistry bloodwork. She took three-view abdominal radiographs, which sucked me into a whirlpool of confusion. Cooper’s urinary bladder was huge and appeared to be dorsally displacing the descending colon, which contained feces. On the left lateral view, I saw what appeared to be a roughly vertical fluid line at the apex of the bladder. Yet, the rest of the abdominal contents were visible, with no fluid appearance or bladder stones. Could there be abdominal bleeding? Was the bladder leaking?
I reviewed the bloodwork results. Cooper’s white count was slightly elevated to 18,000. Also, hematocrit 29% and red cells 3.5, which indicated anemia. The chemistry panel showed normal liver and kidney enzymes but amylase of 1800 and glucose of 334. The electrolytes were normal.
Could this dog, I wondered, be an untreated diabetic in a ketoacidotic episode? The high amylase was suggestive of pancreatitis, which could be linked to diabetes. I looked up ketoacidosis in Blackwell’s Five-Minute Veterinary Consult: Canine and Feline. Cooper’s bloodwork did not show the electrolyte abnormalities described, and the reference didn’t mention anemia. I felt like a new veterinary school graduate. I wanted one of my fellow veterinarians to hold my hand. But then, something different happened.
A Moment of Clarity
From somewhere inside me came a clear message: “You need to show the clients the radiographs and describe what you see. It’s OK to share your uncertainty about the cause. Show them the bloodwork results and explain what they can mean.”
“She’s really sick,” I began. “I’m wondering whether she’s been diabetic and it was lost amid the other urinary issues. A complication of untreated diabetes is urinary ketones, which can make a dog very sick. The next step would be to do a urinalysis to see if she’s got glucose and ketones in her urine. She’s also anemic. Her amylase is high, which could mean pancreatitis. The pancreas produces insulin, so sometimes diabetes and pancreatitis are interrelated. I can do a pancreatic lipase test for that if you want to.”
I showed them the radiographs and described what I saw.
My mind flashed back to the previous week, when I felt battered by unhappy clients who expected me to diagnose complicated problems quickly and who resented spending money to rule out possibilities and not finding a solution.
Looking into the eyes of Cooper’s owners, I saw they were relying on me and clinging to any information I could produce. They approved the tests, which to me meant spending more of their money, coupled with the stress of my insecurity about my diagnostic course.
As it turned out, Cooper’s pancreatic lipase results read nearly off-the-chart high, and her urinalysis was positive for glucose and ketones. So I got it right, although I could not explain her anemia or the bizarre appearance on the radiographs.
When I returned to the exam room, my clients had decided to euthanize Cooper. They told me they knew this day was coming and thanked me for everything I did. I told them how sorry I was. “I always hate doing this, but she’s suffering, and you are truly doing the kindest thing you can for her,” I said.
There will always be a smarter veterinarian than me. But for Cooper and her parents that day, I was the best veterinarian.
TULSA TOUGH
Dr. Lou Anne Wolfe first wrote about work and life at Marina Animal Clinic, a multicultural walk-in hospital, in the December 2020/January 2021 issue. Read that story at bit.ly/TulsaTough-TVB.