Friday. I was the first to arrive at the hospital today. Yesterday had been uncharacteristically busy with sick animals so I was trying my darnedest to get in early enough to check in with the previous day’s casualties before 9 AM. This way anyone needing immediate attention could be factored into the morning’s already-hectic schedule.

I made my first few calls without incident, everyone on the mend and scheduled for follow-ups. Bloodwork discussed. Feeling more chipper, now, I rang Mrs. Barnes about her fifteen-year-old chow-mix, Lucky.

Lucky hadn’t been eating for a couple of days and was moping about the house. He had no fever, wasn’t dehydrated, and, except for his obvious arthritis and the loss of muscle that comes with it, generally looked pretty decent for his age. I ordered a CBC, a chemistry panel, urinalysis, fecal exam, and a full set of X-rays (chest and abdomen).

Although I could elicit no pain or feel any fluid or mass-like structure, his abdomen worried me. His owner said Lucky looked somewhat bloated. The X-ray confirmed a whole lot of inflammation consistent with gastroenteritis, but was there a mass hiding there? All other tests were surprisingly devoid of any major abnormalities.

So Lucky went home with GI-specific antibiotics and a recommendation to discontinue Rimadyl (an NSAID used commonly for arthritic pain that can upset GI function). We would follow-up with an ultrasound or barium study tomorrow should he continue this way. So, onto the early morning call:

Hi, Mrs. Barnes, I hope I didn’t wake you. How’s Lucky feeling this morning?

Lucky is dead, thank you very much. (crisply)

Oh my God, Mrs. Barnes, I am so very sorry.

Long pause.

Yes. You are. (delivered pointedly)

Please, Mrs. Barnes, could you tell me what happened?

He died last night. We took him to the emergency hospital where they did an autopsy. They said his intestines ruptured. But you can call Dr.X (my partner) he knows about it. I called him at home and told him. (hang-up)

Now, of course, I’m shell-shocked at this point. It was the last thing I had expected after seeing this relatively robust geriatric dog only yesterday. I kept thinking, what did I miss? what did I miss? I went over everything in his chart. I scrutinized the X-rays again. I found nothing. Is there anything else I could have done?

Quite aside from the obvious personal stress at having lost a patient and interrogating myself over whether or not I could have made a difference, I felt thoroughly beaten down by the client’s anger. She was accusing me of negligence, at best, with outright stupidity not far behind. Considering how I felt at that point, I was in no position to fault her logic.

After discussing this case with my colleagues, however, I was able to tone down my self-recriminations. They helped me pick through the case and suggested a couple of tests that might have helped. Both were invasive, however, and there was not yet any indication that Lucky needed them. He looked too sound to warrant anything more uncomfortable than an ultrasound.

The surgeon at the specialty hospital was even more sympathetic. His view was that no test helps in these cases except exploratory surgery. And there was absolutely no reason to have gone there given his clinical signs. He said: Sometimes things break in ways we can’t fix. That’s life, given our technology. A young dog might have lived long enough after a rupture to save him (with extensive surgery) but a fifteen year old? Even if Lucky could have survived it, who would have recommended a radical surgery at that point?

I still can’t help but feel all of this is mental masturbation. Of course I’m going to question myself, of course I feel terrible. That’s human nature and I wouldn’t be any good at what I do if I didn’t feel horribly human at these times.

Yet the reality is that the client’s anger is what hurts the most. While I understand she has a right to her emotions I do regret that she has to spread them around hurtfully. But this, too, is a fact of life. To dwell on this aspect only clouds proper judgment of a poor outcome that has only one positive angle: It’s when we lose our patients that we learn the most.