My philosphy

My philosphy

Monday, December 3, 2012

Diplomatic Answers

Today is the last day of classes for the semester, and tomorrow finals begin. I wrongfully assumed that the seemingly slow schedule  at work would allow me to leave at a decent time, study for my first final, and head to bed at a decent time. We were all caught up at work, and just waiting on the final 3 appointments when the walk-in arrived.

The dog was lethargic and not wanting to walk. I took the appointment once the receptionist got them in the room. My job is to take a thorough history, without asking leading questions, trust me it is harder than it sounds. A good history helps aid the Veterinarian with the diagnosis and treatment. This patient presented with lethargy x 2 days, anorexia, increased water consumption, vaginal discharge, last heat cycle was a month ago, and the dog was middle aged. Leaving the room, I knew the diagnosis, however I am unable to diagnosis, prognosis, prescribe or preform surgery because I am not a Veterinarian. It is a fun game with sometimes play in the back, "guess the diagnosis", and most of the time us technicians are dead on. Today was one of those days. This dog had a pyometra.

A pyometra is an infection of the uterus. It can occur after subsequent estrus (heat) cycles where the female is not bred, and usually occurs within 4-8 weeks after estrus. There is either an open or closed pyometra, which means the pus is either draining or it is not. One hopes for an open pyometra, because at least the pressure building in the uterus is not as high, and the diagnosis is easier. This patient had an open pyometra, which meant the Veterinarian could make the diagnosis within 5 minutes of looking at her.

Pyometra is an emergency. The patient needs to be stabilized (or at least less critical) with intravenous fluids (IVF's), antibiotics (ABX) and needs to go to surgery ASAP. More often than not these critical cases show up in the evenings where the best chance of survival is heading to the emergency clinic where surgery can be done later in the evening. Some patients can deteriorate within 8 - 12 hours, sepsis sets in and death will follow. Even though we are open extended hours on Mondays and Fridays, we simply do not have the staff for such a critical case. She would require a few hours of IVF's, abx, bloodwork, then head to surgery, and there is no guarantee that she would survive surgery. There was certainly no way she would survive the night with out surgery.

We are lucky enough to have three, fully staffed, twenty-four hours a day, seven days a week, emergency facilities within 30 minutes of our clinic. However, these are not without a price. Money is tight everywhere, we certainly understand this. Not having money doesn't make you a bad person, it simply means you don't have any money. One thing that always needs to be considered is Quality Of Life (QOL). QOL not only for the patient, but for the human. How can you take care of your beloved four-legged family member, if you maxed out a credit card and cannot keep the roof over your head? Money makes the world go round, but it also makes the tough decisions. We discussed Care Credit, and that perhaps applying just to know if it is an option or not might help. This way, we were working up every avenue and if they were declined, at least they tried. Care Credit was not an option and we were back to square one. Surgery is curative, she was critical, she would certainly die without surgery, but she might not survive it either. Even if money wasn't an option, we simply didn't know the outcome.

The final option was euthanasia. Now first let me state my pet peeve. Euthanasia *literally* translates to "Good Death". Euthanasia is *NOT*murder, it is a gift, and should be treated as such. Euthanasia is the ending of suffering. Euthanasia is a comfort even in a cold and callous world. I am picky about terminology and cannot stand the euphemism "put to sleep" or "put her/him down". I feel like these add to the negative connotation that surrounds what should be the last peaceful, loving, and beautiful gift we can give. Sometimes Euthanasia is the only option. If surgery is too costly, and the patient will die otherwise, why let them suffer? If the patient has lived a long, and otherwise healthy life and develops a terminal illness, why let them suffer? A majority of clients tell me they would be in the veterinary field but they couldn't "put dogs and cats to sleep" and how it must be the "worst part of the job". I honestly think it isn't. I will not be a part of a convenience euthanasia, where the client simply *won't* follow through on something that is treatable. I don't enjoy the euthanasia's where the patient was obviously suffering and the client waited too long before making the decision. However, there are those cases where euthanasia is preformed at the appropriate time, and those I am at peace with. Thankfully the veterinarians I work with will refuse to do an euthanasia unless it is medically appropriate. No euthanasia's for behavior problems.

After some more discussing and reiteration of the scenario, the decision was made. Euthanasia would end her suffering, and his. It is difficult saying goodbye to a companion of a decade, but it was honestly the best choice for a stroke of bad luck. We always give the option for the client to stay present or not during the procedure. There is no right or wrong. It comes down to personal choice. If the client chooses to stay, we place an intravenous catheter to assist in the administration of the thick solution. I always explain what they can expect to see, and it is nothing like a Hollywood portrayal of death. The eyes do not close, any urine or fecal material may leak as the muscles relax, muscle twitching is common, a deep exhalation is normal, but all of this is the normal physiologic response to which is essentially an overdose of a concentrated anesthetic. It is peaceful, no pain is felt, it is quick, and by the time the injection is almost finished, they are gone. This is one thing we do not leave to chance. A euthanasia *MUST* go smoothly. For us, for the client and most importantly, for the patient.

As we were placing the catheter, the dreaded question came, "Is this my fault?" "Could I have prevented this?". The other technician and I exchanged quick glances of horror, and I responded,

"We know that as an intact female goes through each subsequent heat cycle, her risk of developing a pyometra increases. However, there is no magic formula to know if/when exactly it will occur. Some dogs live out their whole lives without a pyometra, others develop the infection at 3 years of age. Spaying at 4-6 months of age is the only thing to 100% prevent this problem, and other female hormone related problems before they occur."

I hoped that my diplomatic response answered his question, without making him feel any more guilty about the outcome. It seemed to have at least directed his attention elsewhere, because we then discussed anesthesia and spaying risks vs benefits and then we were ready.

The euthanasia went smooth, the client took her home, and my headache persisted. We left work after 8pm, and here I am typing this while Todd made dinner and cleaned the kitchen. Days like today make me think real hard about my career choice. I love Vet Med, I love client education, I love making a difference, and I know that I did just that with this appointment...but some days it is really hard.

I know what I want to do with my life, but then I don't. I am not sure of *how* I want to use my DVM, I just know that I want it. Right now the "Flavor of the Week" is Public Health. At least then I can be in a field of Vet Med that is not run by client finances, heartache and sorrow, but instead be involved in zoonotic disease, and helping to eradicate some of the aliments that plague both people and animals. There is plenty of time for me to figure this out, and whatever I end up doing, I know I will do 110%. I am so thankful to have Todd in my life, he supports me 100% in everything I do. He is okay with me being a career student, he is okay with me working part time due to classes, he is okay with us moving out of state for school. He even dropped off Advil at work today because I sent a text about having a headache and not having anything at work to take. At the end of the day, he is all I need after a stress-filled afternoon.



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