The Painful Truth About Coercing Your Client. Heidi's Story.

As a veterinarian there are so many talks that you discuss so many times that you feel as if it might just be a whole lot easier to video tape the discussion, push play when the next appropriate patient presents, and pop back in the exam room to discuss the final details of the treatment plan.

Wouldn't it be so simple? You bring your pet in, I diagnose the problem, tell you how to fix it, and then we schedule it the following day.

No wasting time, no idle insignificant chit chat, no silly feelings about your pet "not wanting to go through any procedures," or ridiculous excuses about “sparing them from the hardships of recovery,” etc. etc.

It can be frustrating to feel as if I need to repeat the same thing over and over.  And yet, I’ll do it tomorrow, and the day after, and the day after,.Its my job. To tell you what disease, condition, ailment, need, etc., that your pet has and how I suggest it be treated.

How do I keep myself from feeling like a broken record? Well, I employ my clients to serve as future character witnesses, provide their own personal experiences, and pass it forward.

Here is one story I find myself repeating often. It is about bone tumors.

In large breed older dogs that present to me with swelling, lameness and intense pain at the site I will place a bet that your dog has a bone tumor. The diagnosis is usually pretty easy. OK, well, I should back track a bit and clarify.

In the earliest stages of bone cancer it can be difficult to pin the diagnosis exactly. Because your pet knows before the x-ray does that there is a problem.

The typical presentation of a bone tumor is a progressive limb lameness that persists.

On the first trip to the vet we corroborate your suspicion; The leg hurts and the pet is limping.

The normal course of events after that first trip is to prescribe an NSAID, (a non-steroidal anti-inflammatory) and monitor for response to treatment and resolution of clinical signs, (they stop limping). These work very well on pain and inflammation associate with osteoarthritis (OA). Most older dogs, just like most older people, have some joint pain because their joints get sore after years of wear and tear.  A response to treatment is a quick, cheap, easy way to help confirm a diagnosis. If we are right, and if it is just OA, then the medications lessen the inflammation which in turn will help alleviate the pain. If we are wrong then the owner will call back in a few days/weeks and report that the lameness is worse, or no different.

Trip number two is for a re-check and x-rays. Depending on the degree of bone destruction we may or may not have visible evidence on the x-ray. (One little tip here from a weathered vet; take the x-ray of the whole foot..shoulder /hip to toes. It makes you look like a bone head when you miss the big lytic (destruction of bone) lesion in the foot because you cut the film short).

If there is a lytic lesion on the bone it is most likely a bone tumor, and the most common bone tumor is an osteosarcoma.

Osteosarcomas are incredibly painful aggressive tumors. They essentially eat away at the bone until it crumbles. They also spread fast! Those little microscopic cancer cells will hijack a ride through the bodies internal highway system (blood stream or lymphatics) and land in remote areas where they then lay down roots and begin to eat away at another part of the body.

After you and I have gotten to this point the waters get muddy and the navigational gear gets all screwy. The dance of the decisions, the debating, the doubt, the second guessing, hesitation and indecision begins.

Here’s where I want to take the conn and remove you from the bridge. What I really want to say, “OK, I got the wheel. I am steering the ship. Here's what you need to know: The estimate for surgery is $800 - $1000, average lifespan after surgery 6 months. But, trust me, your pet will be happier because they will no longer be in pain."

At which time you say, “OK, thanks doc, see you tomorrow for surgery.”

Now, I understand there is a lot to discuss. But remember I have had this discussion about 300 times before you, so in truth, I’m not looking forward to number 301.

Here are the arguments and points of discussion that pet parents have;

Number One: 
“I don’t want to put my dog through that.” OK, I’m going to put on my best “be nice” face. Your dog is in an immense amount of pain. That pain is manageable only for a short period of time. At some point we will be putting your dog down because they refuse to move, or eat, or do anything because they are in so much pain. SO, if you are telling me this I will remind you that not taking that leg off is not wanting your pet to be pain free. Be honest. I think that most people use this excuse because they don’t want to put their wallet through the procedure.

Number Two:
“He will be unhappy with three legs. I can’t do that to him.” My response; Your dog is already three legged. They are just three legged with one additional painful rotting limb stuck to them. Another important point to remember is that at some point the cancer will eat away so much of the bone that it will fracture, or crumble.

Number Three:

“The recovery will be too much on him.” Like the current excruciating minute to minute with no chance of relief in sight is better?

Now, I understand that I am not being subtle. Here’s why. I cannot stand seeing an animal in pain if there is anything that can be done about it.

So get over your phobias, and cosmetic disfigurement, and get that damned leg off!

Here is a story of a patient of mine. Her name is Heidi.

Heidi was an older mixed breed dog who presented with the above scenario.

Her dad is one of the most devoted genuine guys around. He is direct, honest, and not at all uncomfortable making you uncomfortable when it comes to his pets. I like him all the way around. We are kismet. I get him. I don’t mince words, and he doesn't tolerate it to begin with.

When Heidi first came to see me she was lame, exceptionally lame. She was in pain all the time. He knew he had to do something and he was leaning towards putting her down. When he said this I started to pull out all of the tricks of my medical bag.

There was arm wrestling, and some somewhat questionable, unethical promises. I also pulled out the “past experience” card. He was so stubbornly stuck on not being able to put her through surgery that I had to double down and confided to him that “if Heidi was my dog I would take her leg off.”

Now I’m going to be really honest. I hate when vets do this. It is coercion in my opinion. We should never ever use this as a way to persuade. While I’m being so honest I will also admit that I do say this. For my friends I feel OK saying it.

Before I convince you to take a bad terminal leg off, do your due diligence. A pet that is a candidate for amputation should have a full bloodwork and urinalysis done. They should also have a full 3 view set of chest x-rays. If everything is clear and normal I recommend amputation. If there is evidence of metastasis to the chest than the prognosis is poor and the floor is opened up again for discussion and debate.

I have some distinct advantages to being so sure footed here. I have years and years of cases to use as my precedence. I have never had one owner tell me that they regretted amputating a leg after they did it. Every single pet a week later was a thousand times happier than they were the day before their surgery. Taking pain away from a pet is giving them back their life.

When I told Heidi's dad that I wanted to write about her story he sent me the following;

Krista,

Please find attached several pics of Heidi.  She's such a house girl that oftentimes when she's outside...and this was long before her surgery...she looks sad and bent-out-of-shape.  

Here's an impromptu paragraph on Heidi:

Heidi was found wandering in the street on a summer afternoon near Lake Redman, PA.  As I already had two dogs, I coaxed her into my truck and drove straight to the York County SPCA.  After checking on her over the course of a week, I was told that since she hadn't been adopted within a two week period, she was likely to be euthanized at any time.  I couldn't allow that and immediately drove up there to adopt her.  I then had three dogs for a short time until one of my "kids" died after 15 years of blessing me with her company.  

I must confess that Heidi, almost from Day 1, endeared herself to me.  I've had many, many canine kids through my 61 years, but Heidi, for whatever intangible reason, became my favorite of all time.  Then, after she developed a "limp", which after several weeks I finally realized wasn't the result of her stepping into a gopher hole somewhere on my two acres, I brought her to my long-term veterinarian, Jarrettsville Veterinary Center.  Initially, I was devastated when I was told that her diagnosis was Sarcinoma (you'll have to help me with this, Krista).  I also struggled with mixed feelings about whether Heidi would have any kind of fulfilling life when I learned that she would have to have her leg amputated up through the shoulder area.  After several days of tormented feelings, I decided to go ahead with the amputation, hoping that her cancer could be excised.  I might add, that financially that was a hardship at the time, but I felt as if I had no other choice that I could live with. 

Within 24 hours of her amputation, Heidi was remarkable.  I brought her home, using a towel sling to carry her into the house.  What did she do immediately after I released pressure on her towel sling? She took off on her own accord across the house to go to her water bowl and then down the hall to her bed.  We were moved beyond words by her strength and resilience. 

Within several weeks, she began to exhibit a deep, horrible cough.  We thought the worst, as we read online about how cancer when it spreads to the chest is often accompanied by such a cough.  Initially we put her on cough medication to suppress the cough.  When that wasn't real effective, we were able to obtain an antibiotic medication and her cough went away.  That was more than six months ago.  Her operation was almost ten months ago.  

Heidi had been my "special" child now for those ten months.  She's doing well.  She's not the same alpha dog that she was back before her illness.  These days she's a sweet, trusting, loving survivor.  I am so happy that's she's in my life!

Update, 12/1/13.

Heidi passed away at the clinic with her dad and I on 11/24/13. She was unable to hold herself up anymore. Before her surgery her hips were weak and arthritic and the additional stress and strain her body had to carry with the loss of her front leg made the hip stress more pronounced. Her dad bought a special harness for her with a handle to help her get up and provide an extra point of stability. The harness was also the way that her dad could help carry some of her weight and keep her from slipping or falling.

This was the email I received from Heidi's dad on November 21. 

Heidi has really taken a turn for the worse.  Her back legs sway and are wobbly...she's unable to cintrol her bladder...acts as if she is in a daze...takes one or two steps and stops...pants a lot more..and in the last few days has had little appetite.  We're thinking that her quality of life sucks and that it's time. Are you going to be there at all this weekend?

I saw them on the 24th, and it was time to say goodbye.

A week later her dad sent me this.

Happy Thanksgiving!  Now that a week has passed, I was finally able to log on to read the "Heidi" blog.  Thank you so much for being so candid and forthright.  I had wanted Heidi's struggle to end on a positive bend.  I'm grateful to you for being that enabler.  

I also want to say to all those who might know of many conflicting emotions that the "journey" with Heidi encompassed...I would do it again in a heartbeat!  Heidi taught me about compassion, perseverance, strength, and how to love more deeply.  

Thank you, Krista.

Heidi's "Dad":)

For related stories;

three stories of three heroic three legged dogs.

Cesar Milan's story on three legged dogs.

Related Posts;

Donner. My three legged cat's story.

A new Immunotherapy for canine osteosarcoma yields promising findings so that perhaps amputation is no longer indicated?

If you have any pet related questions you can find me, and a whole bunch of amazing people at

Pawbly.

Or you can find me on Twitter @FreePetAdvice.

The Finish Line

I think that I have shared with you all already that one of the things I love most about this job is learning why people name their pets what they name them. I get some funny names and some even funnier explanations. (For those of you new vets out there, this is a great "ice-breaker" for a new client, or a new pet, and it's also a great way to help you remember a client and your patient).

One day I received a call from a very good vet friend of mine who doesn't particularly enjoy surgery. Her clinic is very close to my home and we have been very good friends for as long as I have lived in my home. She has a beautiful clinic on her in-laws farm and it is the quintessential picture perfect rural small animal practice. But not all vets love surgery, so for those that work in a 1 doctor practice they have to "farm" out some of the things that they cannot do in-house. For her it is the big surgeries. She called me and said that there was a very nice family who had an older lab mix dog who had a bone cancer and that the dog needed her right hind leg amputated.

Dogs with advanced bone cancers most often are recommended to have their affected leg amputated to prevent the cancer from spreading and also to stop the chronic terrible pain associated with a bone tumor. Bone tumors are aggressive bone eating cancers that will spread to other organs and other places in the body if not excised completely. I have seen many bone tumors over the years and seen many owners try many different kinds of treatments for them. Veterinary oncologists and surgeons have tried many kinds of operations, radiation, and chemotherapy's to try to treat this devastating kind of tumor. I will say that for the bone tumors I have seen I still stand by the choice of amputating that chronically uncontrollably painful leg and the care of a vet oncologist. The difference in a pet when you take off that broken bone that never heals, is like light and day. I actually have discussions with owners and say to them "I am happy to give you the numbers of some of my clients who have done this surgery and actually said "Thank-you," after we amputate the leg. These dogs are soo much happier because they are finally pain free." I fully understand how hard it is to decide to amputate a leg, but in all cases these dogs aren't using the leg anymore. They are just dragging around a broken crumbled bone that hurts them every second of everyday.

When I met the owners that my friend was referring to me I knew I did not have to convince them that doing this surgery was the right thing to do. When I met this dog I had to ask if her name was correct as it was written on her chart. "Finish Line? Is that correct?" "Yes," was returned with a smile and a bob of blonde Shirley Temple curls. Finish Line's mom is a cheerful, always smiling kind, thoughtful, gentle woman. She never speaks without a smile and direct eye contact. She has the aura of pure sunshine. I liked her from the starting line. She explained to me that her husband is a race car driver, (we live in the middle of nowhere between Baltimore MD and Philadelphia PA, so I can't imagine where he is a race car driver at, but I am sure it is a drive to get there. Someday I will ask). She has two dogs, Finish Line and Checkered Flag. (Maybe I will move from naming my dogs after southern cities, what I currently do, to veterinary instruments? "Here hemostat," "Heel thumb forceps," "Sic needle driver," Umm? I guess I'll stick to southern cities.

It was grossly apparent that Finish needed her right leg to go away. She would barely walk at all, because even placing her toe on the ground sent shooting pains up her leg. So she would just lay still and growl or threaten to bite if you even thought of approaching her to touch her. We checked her blood work, (all normal), took x-rays of her body, (we check the lungs to make sure we don't see any evidence of metastatic lesions) and decided that everything looked very normal except for that wretched leg.

Finish Line was scheduled for surgery on the next day and successfully had her right rear leg amputated. Within 2 days she was up, walking, and feeling like the dog she hadn't been in months. Her mom and dad were thrilled by how happy she was, and how good she felt. At 13 she was playing, jumping, running, taking the stairs to spend the night in the kids room, and in general doing things that they had not seen her do in a long time.

Two weeks later I got a phone call that haunts me to this day. I was at the front desk when the phone rang and I saw the receptionist answer and then heard nothing but blood curdling screams. I immediatley took the phone from the receptionist and tried to understand what was happening on the other end of the line. It took me a few times to understand who I was talking to, and what they were talking about. I clearly remember hearing "SHE'S BLEEDING OUT!"

"What? How can that be, it's been 2 weeks?" I said to her.

She replied, "I heard a yelp from her in the kitchen, and I ran in, and there was blood squirting out of her leg. It's everywhere! So I just took a towel and put pressure on the incison where her leg was."

"Ummmm, OK,,,,Umm, well,,,keep pressure on it." I sounded like a fool as my brain tried to digest, comprehend and process what she was telling me. And my heart was breaking hearing her sound so desperate and so scared. She said to me, "I called **** (the vet who had referred her to me, and lived much closer to her than my practice was) and they told me if I brought her there they could only euthanize her." I knew that that clinic was equipped to do an exploratory on poor Finish Line.

I said "can you get her here?"

"It's only me here, with the kids, and if I take my hand off of her leg it starts gushing blood again."

Damn It! I thought, "I will send someone to get you."

"No, I can drive 1 handed I will get there faster if I go." She hung up and I waited the longest 15 minutes ever. I was certain that Finish would arrive at our clinic dead. And I grappled with the thought of "How can this have happened? Because I couldn't imagine how this could have happened.

I am so careful with my surgeries. I dissect out everything. I put ligatures on every vessel, and the big ones I put at least four ligatures on. I thought that she must have fallen or bumped something and punctured an artery? Or avulsed (pulled the blood vessel away from its attachment) the artery. Any scenario I could come up with were all very very bad based on her owners description of how much blood was coming out of Finish.

Finish's mom arrived covered in blood and clutching a black mass of frantic fur. Sometimes (actually quite often) owners significantly exxagerate how much blood they are seeing. But in this case she was right on. It was an incredible volume of blood. And she was right by saying that if you took your hand off of the gusher it would pump out blood like a geyser. I took one look at her, and one look at Finish, and took her hand off of the place where her right rear leg used to be and I knew I was going into surgery NOW! The clients in the waiting room also took one look at her and her dog and they all volunteered to come back another day. Within minutes Finish was on the OR table and I was dissecting out a huge hematoma to try to find the tiny coffee stirrer sized straw that was the remnent of her femoral artery. Only this little monster could produce this much blood at this fast of a pace. I was determined to find it before it pumped its last remaining drop of her blood.

What an incredible mess that almost completely healed leg was. Within 5 minutes I had found a tiny nubbin' of the femoral artery and I was lassoing to save her life. Where my first surgery was pretty and precise, this one was sloppy, immediate and vengeful. I didn't care about how it was going to look when I was done (which is how I approach every other surgery, I think about how I am going to finish before I start), I just tied and tied and tied again. I didn't have much rope to strangulate but I was going to put as much suture as I could around that artery to get it to stop spewing, and I was serious about how angry I was at it.

It was the quickest life-saving surgery I have ever done. I got in, got my revenge, and got out.

Finish walked out of our hospital from her second leg surgery the next day. I spent the next three weeks as worried as her parents were. But she did great. I don't know what slipped, or how it could have slipped, but I am sure that it was her femoral artery and I am also sure she is one lucky pup.

It has been 23 months since that day. I saw Finish last night. She has a recurrence of the melanoma tumor that we surgically removed 2-1/2 months ago. She is now 15.5 years old. She is every bit the happy, playful, companion to her family that she has always been.

But we know her time is near, and this tumor is too aggressive and invasive to treat. Her parents are trying a new melanoma vaccine, because it is all we have left to offer.

We will all hold out for one last miracle, if anyone can catch one it is Finish Line.

UPDATE

2/7/2012

"Fini," as her mom called her, was euthanized tonight. She had some moments of running and playing with the kids, but yesterday and today was unable to stand and refused to eat or drink. When she arrived at JVC it was evident to us all that it was her time. She was unable to move and her eyes were all any of us needed to know that her struggle was too  much to bear for anyone anymore. Her mom cried and told me that Fini had been with her for 16 years, long before her children were born. And that she had never had to have a pet put down before. Fini passed gently, quietly, and peacefully. We send her family our deepest sympathies, and hope that they always remember how much she loved all of them.