Bentley's Baffling Bug

It’s always going to happen on the busy nights.

You are booked, you get an emergency call, and then the avalanche hits you.

No chance of keeping your head above water. You just put your nose to the charts and plow on hoping to see sunlight sometime again, and avoid an angry client who will set you even further behind.

I understand why the other veterinary clinics around me turn people away when they call at 6:30 pm “begging to be seen immediately.” Where do these people AND our clients turn when they get home from work and realize their pet needs to go to the vet immediately? Why, into our doors, of course.

Does it infuriate some of our clients? Of course.BUT, if they need us in an emergency are they are going to call us, and we are going to tell them to come on in.

How else do I ethically take care of my clients?

I grapple with this.. There is not an easy answer.

On this particular night I was booked. It was another one of my usual just barely able to stay on time booked. And then the phone rang.

A very good client of ours had just gotten home to find their beloved four year old Welsh Terrier, Bentley, standing in the middle of the room acting oddly. He explained to us that nothing was disrupted in the home. Nothing seemed out of the ordinary, but Bentley just stood there shaking. He didn't know what was wrong but they were sure something was so we told them to come in.

When they arrived Bentley was quiet and calm in the arms of his dad. But when placed on the bench Bentley looked anxious, nervous, scared, and refused to move an inch from his dad.

I took my cursory two second glance over to try to mentally assess him and determine his place in line. Due to Bentley’s lack of distinguishing emergency features his file went in the line in the order of arrival.

Over the next two hours I visited Bentley three times.

The first official visit was to give him an examination.
Bentley on outward appearance had the look of a 'back' dog. He stood legs stiff slightly away from the body as if to distribute his weight as evenly and widely as was possible. A dog with back pain will stand as rigidly fixed as possible. The neck, legs, and torso resemble a star. They have short shallow breathing to minimize the movement of the chest. And a fearful guarded look in the eye, as if to say “Please, please, don’t touch me.”

On his exam I found very little to help me localize his lesion (source of pain/problem). Or even provide me any additional clues than my eyes and my gut were giving me.

Based on my belief that his problem was pain I ordered a heartworm test to look for Lyme disease. Because this requires a blood sample be taken I asked the technician to take enough to run a CBC and chemistry. About 45 minutes later I was still empty handed. When our diagnostics fail to provide an answer we term it “ruling out.” We ruled out Lyme, infection, organ failure, and a handful of endocrine bad guys.

Still no dice.

I was not getting any "Ah! Ha!" clues from Bentley.

He was painful and that was all I could deduce.

When I cannot make a physical exam make sense I look at everything. I even checked his anal glands. (I always check anal glands. Nobody else does, I know, but I have had more than one poor dog display odd behaviors because their butt feels plugged up). They were empty.

Back to the drawing board..I went back to check on him.

Bentley was also lying down now. His breathing had slowed and he seemed more comfortable.

I confided to his dad that I thought he might have a disc or nerve problem. In which case I was going to recommend rest, an NSAID, and a re-check in the morning.

The busy night was pulling me away again and it was nearing closing time. So we decided to give Bentley a band-aid treatment to get him through the night. I asked the techs to give him some sub-Q fluids and get him packaged to going home. Packaged to go home with a band-aid treatment plan includes a copy of the medical record, all diagnostics, and a flyer for the emergency clinic, just in case our band-aid fails.

After the fluids were given I went to take a last glance at Bentley.

Before I could get to him I saw fear in his dads eyes. He was petrified his dog was dying. I stopped dead in my tracks.

There are a few important lessons to learn on the way to being a successful seasoned vet.

1. Listen to your patient. Their opinion trumps everything else. I don’t care if every diagnostic is perfect. If your patient believes they have a big problem they probably do. Hedge your bets on them.
2. If your client thinks there is a big problem you best be sure you know there ISN’T before you send them on their way. Because if you are wrong you will never regain their trust and all of your years of hard work at accumulating all of your precious grey matter are for nothing.

I looked at Bentley. He was right back to his rigor mortis paralysis bugged-eyed painful self.

I repeated his exam at 8 pm.

Closing time was here and I still didn't know what was wrong with Bentley. I decided that we should run the only diagnostic that I hadn't done already. We took an x-ray. It was not normal. His lung field was cloudy instead of the normal black.

So I did what every competent doctor does. I punted.

Now the puzzle pieces were starting to make sense.

Bentley was in pain because his chest hurt.
Specifically something in our around his lungs was not allowing them to function normally.

To compound my ability to read his x-rays fully I had given him some sub-Q fluids. Those fluids were superimposing the lung fields.

(Small moment of regret and self-loathing).

Bentley and his go-home kit went directly to the ER.

He spent a day there and went home.

I called to check on him 2 days later hoping that he would be on the mend. His dad told me that he still was reluctant to move, wouldn't eat, and that he didn't know if it was because of the medications he was on.

I told him what I tell myself.

Trust your dog.

Listen to your dog.

I told him to come in tomorrow for a re-check. The next day Bentley was seen by another vet at our clinic. (The more minds the better). He agreed with me that Bentley was definitely in pain and we agreed it was time to once again do what every competent doctor does. Punt.

Bentley went to the referral hospital the next day. It took them two days and multiple specialties to think that he might have a lung lobe torsion.

Bentley then was transferred to the University of Pennsylvania’s teaching hospital for an exploratory thoractomy.

When Bentley arrived at UPenn it had been two weeks of anorexia, seven days of fever, and a handful of vets, car rides, diagnostics, and cash.

Do I think that his owners are incredible? Yes!! I admire their tenacity, dedication, and determination. There were so many leaps of faith. So many twists, turns, and unknowns, and they never ever gave up.  

But it got them their dog back.

 Do I believe that most people would follow through like Bentley's parents did? No. Most people cannot afford to. And most people use excuses to feel better about their decision. Are some of them justifiable? I don’t walk in their shoes, I cannot answer that.

But I know that every single illness, disease, and patient has a diagnosis AND a treatment plan. Some are merely easier, and cheaper to come to.

I saw Bentley 5 days later. Half of his torso was cleanly shaven and he had a long incision from his spine to his sternum to show as the tell to his story. But he was once again his happy, animated, and prancing self. You don’t need to be a seasoned vet to diagnose happy, you just have to be a person who identifies pain, joy, and all of the shades in between in another living soul.  

It has been almost 3 months since Bentley's surgery.

He was here yesterday and is as he has always been, all smiles!

And yet still happy to leave us..
Who can blame this dog for not liking a vet's office?

Bentley's mom has loads of photos of him.
He is naturally photogenic,
and one of a small handful of pets that actually enjoy having their picture taken.It's almost impossible to decide who is more adorable?

If you have any questions about this, or any other pet related item you can ask me at Pawbly.com, or find me on Twitter @FreePetAdvice, or @pawbly.