Your older cat’s sudden bout of vomiting led your vet to tentatively conclude that his kidneys were failing. Indeed, his renal values were significantly elevated and abdominal X-rays were fairly normal. He was hospitalized. Your regular vet goes out of town and leaves the case to her associate.
When significant hydration failed to resolve the vomiting your vet’s associate solved the case by insisting on another round of labwork and X-rays, thereby eventually identifying the foreign body in her intestines. He was cured surgically almost a week after his initial presentation.
You’re pleased that he’s doing great but you’re more than a bit miffed that your regular vet missed such an obvious diagnosis. After all, isn’t it a stretch to say the kidneys caused the kind of vomiting brought on by something stuck in her intestines?
It’s not really the fact that you spent all this money hospitalizing her to begin with; it’s irksome more because he had to suffer in the meantime…because someone less experienced could be so much better that a vet you’ve trusted for years and years. It makes you distrust your earlier allegiance to your regular vet. You want to see the “golden vet” from now on.
***
Last Friday’s post on complications and sloppy work in veterinary medicine (and a post by fellow vet blogger whose post I can no longer find) gave rise to this topic: the near-inevitable success of the second vet on any given non-straightforward case.
Yes, the “golden vet” is sometimes yours truly…and sometimes it’s not. Unless we somehow manage to practice in a vacuum where no other veterinarians exist, we’ve all found ourselves on both sides of that second opinion dividing line that separates the “loser” vet from the “golden” one.
But the moral of the story is not that sometimes you win and sometimes you lose. The honest truth is more complex than that: Veterinarians granted the opportunity of offering a second opinion are much more likely to “happen upon” the solution. Three major reasons for this come to mind:
1-The second vet has the benefit of all your previous vet’s work. They know a whole lot more than your first vet did and they have the benefit of a “clean slate, “ as it were.
2-The pet’s owner is more willing to take things a step further, whereas with the initial vet they’ve lost some faith and have been more hesitant to accept taking the diagnostics or treatment in a different direction.
3-The animal’s condition has progressed in all that time (in the above example, instead of a dehydrated cat with elevated liver enzymes, the second vet has a hydrated cat with a painful belly and a climbing white blood cell count). The signs at this more advanced stage are now more indicative of the disease process.
Let’s face it, some conditions and their presentations are not amenable to easy diagnosis. That’s why any medically trained person will usually advance in an orderly fashion, identifying first the problems that are most likely to exist with any given set of symptoms and carefully ruling them out…step by step.
So when the first vet misses what seems like an obvious diagnosis to you (an invested party who may or may not be medically trained), the conditions that led to this clinician’s decisions are hard to second guess—that is, if said clinician explained the problems, was correct in his fundamental assessments and offered you all of your choices.
It’s hard sometimes to accept that suffering and expense are inevitably within the realm of the sick, especially when it’s YOUR loved one on the stainless steel table. But that’s the way it goes.
When my eleven year-old Frenchie, Sophie Sue, suffered abdominal surgery (after a workup by an internist and surgical team) on her way to being handed an eventual diagnosis of a brain tumor (by a neurologist and oncologist team), I could not fault the original specialists’ logic along the way. But I could see how someone might have.
No, in spite of how it looks, it’s almost never the case that the first vet sucked and the second vet rocked. More than likely, the difference lies in the simple luck of being the one on the “golden” end of the case.
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I stated in the previous "missed diagnosis" case that we are all our pets guardians, and part of the onus lies on US to ensure that our pets are receiving appropriate care. A little easier to do in the times of the internet and online studies/veterinary journals/support groups/information pages.
In this particular case (noting that you failed to mention whether you were the "golden" vet in this "hypothetical") I have to say that my original thoughts entering the office, given the sudden onslaught of the vomiting, would have been obstruction. My kitties are always eating things they shouldn't... my friends kitty recently swallowed a sewing needle. Not pretty...
My vet is always trying to save me a few bucks whenever he can, so while I would have went in with the intention of x-rays (although I would have insisted on barium - when searching for blockages, it's been my experience with past vets we always end up doing the first set which is "inconclusive" and then forced to pay for a second set + barium - we now do barium immediately) he most likely would have suggested we wait until the blood results came back before proceeding with a potentially unnecessary procedure. The elevated kidney values would have immediately caused me to hospitalize with fluids, just like the "regular vet" here, and I would have gone so far as to most likely forgo the x-rays (preferring instead to opt for ultrasound if things didn't improve quickly).
I suppose the point is, I would have screwed up too. The second point is, thanks for the incredibly informative post... vomiting + elevated kidney values will now equal fluids + further testing and xrays.
Also, given my immediate assumptions, I wouldn't have held it against the vet at all... although admittedly, I would be much more willing to see the new "golden vet" whereas before I would INSIST on seeing one of my regulars.
Regarding little Sophie Sue - I don't imagine brain tumours are that common in dogs, or at least certainly aren't diagnosed that often due to the cost constraints of the necessary testing, so I suppose I, too, could forgive that the blunder - although it would take a bit more soul searching on my part given that you were dealing with an internal "specialist" who should, IMO, be held to a higher standard. After all, why else do we pay them the big $$$$?
Kim December 7th, 2008 07:23:10 PM
why wouldn't the golden vet put up both sets of x-rays & lab work, side by side to illustrate "why" the loser vet did not come up with the true diagnosis?
Seems to me that this would be the ethical thing to do, and perhaps point out why as the case progressed, it became more obvious as to an alternate diagnosis.Especially since they are working colleagues at the same clinic!
I have to commend golden vet for his initiative in the cat's welfare by not automatically making assumptions, nor possibly 'covering up' for loser vet's lack of discovery (if that could have been a possibility)
Barb A.
Pocket's Story from NH December 7th, 2008 07:33:48 PM
This doesn't just happen in medicine -- I run the support team for a software company, and honestly, I'm not really any better at figuring out issues than any of my staff... the second pair of eyes is just a handy thing to have. There've been plenty of times when I couldn't figure something else and had to pass it off to someone else and they had it in a snap.
But, because I'm the manager, and the "hmm, dunno" issues get escalated to me, all of our customers think the sun sets and rises upon my whims -- and a few will *only* deal with me, because I'm "the only one who knows what I'm doing."
Not true, I don't hire people who don't know what they're doing. :D I don't think they realize that insulting my staff isn't a compliment, they're insulting me by proxy -- who hired & trained them?
Still, people get it in their head that only one person is awesome, and they stick with it. That's fine. But fear the day that the "golden tech" (or golden vet) gets it wrong. People are SO much angrier when someone they have previously adored isn't perfect as opposed to the random guy on the end of the phone...
Donna December 7th, 2008 08:08:47 PM
Surely in vast numbers of cases, the second, "golden" vet benefits from the prior vet's work, the fact that time has passed in which the results or lack thereof of the first vet's treatment reveal additional information, etc.
However, the vet who repeatedly examined my cocker spaniel and said "allergies" and treated "allergies" was just a lazy idiot. The vet that looked at her, after we reached this conclusion, and said "mange," really was signifcantly more competent.
Lis December 7th, 2008 10:03:37 PM
Here in Israel, there are only two board certified veterinary radiologists.
A week before my dog Julie passed away, when the only symptoms we had was that she lacked apetite and lacked enregy (and generl "ADR"), one of them did an US on her, finding nothing.
Then the day before she died, we did an US again, by the other one.
Not because we didn't think that the first one was good, but because by now Julie was vomiting, very very weak (she was hostpitilised at the emergencgy center by this point), so we where hoping that now something (that wasn't there before) will show on the US, and that a fresh pair of eyes might spot it.
UUnfortunately, the US was clean, so then we did a CT which reavealed the grave diagnosis (and 24 hours later we lost her).
Xslf December 8th, 2008 03:31:09 AM
Completely off-topic, but since Xslf mentioned that s/he is in Israel - I'm considering a move there and am wondering how the veterinary care and overall experience compares to that in the States? Are most of the vets situated in Tel Aviv or therabouts?
shavy December 8th, 2008 04:00:35 AM
Shavy- feel free to email me xslf at xslf.com and I'll be happy to give you detailed answers :)
My name is Shoshannah (yup, I'm a she).
In general, the care level here (if you go to the good vets) is pretty much on-par of what you get in the US.
There are more vets in the urban areas, which I persume it's similar to the US.
Cost here tends to be lower, but salaries are lower too, so it evens up.
As a small country, some things are limited however: as I mentioned above, there are only two board certified veterinary radiologists, and there is only one board certified veterinary cardiologist (one of the nicests vets I ever met) in the whole country. There are similar numbers in other specilites, although I understand that work is being done to improve this.
There is no MRI in the speciality centers here- only a CT.
There is only one pet health insurance program, and it isn't very good (for example, it only covers pets until they are 8 years old).
Xslf December 8th, 2008 05:02:18 AM
As for being in Tel Aviv are- yes, the closer you are to the Tel Aviv area, the more veterinary care options one has.
The two veterinary speciality centers in the country, while not being in Tel Aviv itself, are in the central part of the country (less than an hour drive from Tel Aviv).
On the other hand, the town of Sderot (that gets hit with rockets fired from Gaza on a too regular basis) doesn't have any vets at all, and there have been cases of pets being hurt/traumatized by the rockets (as well as people, of course),
Xslf December 8th, 2008 05:45:20 AM
At the risk of straying even more off topic, I should say that Israel is well respected for its veterinary education. not every country deserves this distinction, as you can well imagine. Though Israel suffers a dearth of specialists, a close relationship with the US means that Israeli vets often come here to do further training. But the high salaries here for vet specialists tends to mean that many of apply for residence in the US and end up staying. I'm sure that's changing, though, with pet owners like Xslf clamoring for their services. ;-)
Dr. Patty Khuly December 8th, 2008 08:32:43 AM
Adding to the stray, not to long ago, in my never ending search for answers, I happened upon a (kind & generous)certified radiologist DVM equivalent in Great Britain, who's career takes him travelling to teach with many Middle East stops included.
No question that many countries are interested in becoming versed in advanced veterinary care
Barb A.
Pocket's Story from NH December 8th, 2008 11:04:08 AM
Funny...there is a Dr. Ellman-Murray who practices in the OKC area originally from Slovakia and Israel...I've heard wonderful things about her. Didn't know these "transplants" were so common!
anna December 8th, 2008 11:22:57 AM
Can I blush for my country as a response to Dr. Patty's comment? ;-)
Actaully, at the moment no specialist training is done here locally, so the specielist who are available here are trained abroad (mainly in the US and UK), and it's not uncommon for "regular" vets to do their internship in those countries.
I know that in the clinic where I go to, there are 4 vets:
* The owner, trained in the UK
* Assosiate (who just left :-( He was "my" vet)- trained in Penn (US- the same place Dr. Patty got her training), and is an VMD Diplomate ABVP (for cats and dogs).
* Assosiate #2 (my current vet)- trained in Israel, did a year of internship at Colorado state uni.
* Assosiate #3 is the "young" vet, trained in Israel (graduated 2005).
It might be worth noting that the only vet school in Israel will only accept about 40 students every year, so many vets get their training in Europe. A friend of mine just finished her training at the vet school in Barsa, Spain (she will be moving to Berlin, Germany, for more studies- she is on a research track).
Well, enough off-topic chat for now ;-)
Xslf December 8th, 2008 11:33:25 AM
The subject of foreign body hits close to home. I had one vomiting cat last year and in spite of the fact that she's a puker and she's not one to chew on inedible things, the NATURE of her vomiting had me terrified she'd ingested something, because she was vomiting what looked like undigested meals 4-8 hours after eating, keeping nothing down. Her BUN was high (from dehydration due to vomiting). Xrays were not indicative of an obstruction and they told me to take her home and feed her a bland diet. In spite of my morbid fear she'd ingested something, I was happily wrong. For some reason, inoffensive little "Wellness" was the culprit, and was added to the ever-growing list of foods she simply, for some reason, can't eat.
Then, this year, my youngest cat started vomiting. Unlike the other, he's not usually a puker. I called the vet and watched him 24 hours but again I became convinced he'd swallowed something. This time, the vet told me the pattern was suspicious for an obstruction even though they could not see an object, and because he was stable she gave me the option of waiting till morning to see if it passed. I chose instead to go straight for the surgery, not wanting him to take a risk of peritonitis. Since the object turned out to be thread, I was happy I'd made that choice.
The vet who did the surgery told me up front she could be wrong and find nothing; she was basing her diagnosis of probable linear foreign body on the pattern discernable in the intestines, not viewing an object. But with the spectre of peritonitis looming, combined with his habit of eating all kinds of stuff, she advised surgery and I went with it and am glad I did.
I accept that it is often hard to distinguish between foreign body and something else, when the foreign body is something that can't be seen on an xray.
If it is an object that is viewable on an xray, though, I would expect a vet to see it. Not too much to ask.
Stefani December 8th, 2008 12:14:40 PM
We just walked through a series of veterinary visits where the vet didn't do any bloodwork on a cat that lost over 50% of her body weight.
I demanded my boyfriend take her back for blood--turns out the staff didn't really want to deal with the demoness (aka princess to my boyfriend).
Once blood was taken (no urine though) she admitted she was wrong on her first guess (duh--without blood work) and still didn't notice the hyperthroid issues glaring up from the bloodwork results--just the liver abnormalities.
No real course of action was prescribed so I sent my boyfriend a list of feline specialists and said that he needed to pick one.
Because I've speciality training for exotic animal management and handling(both in the classroom and side by side with exotic vets) I think I am a bit more savvy and pushy than most pet owners.
The bottom line here is that the vet clinic didn't move beyond their comfort zone to get a diagnosis that nearly cost the cat her life.
Many, many hundreds of dollars later and two hour commutes each way over the last six months finds the cat recovered--gaining weight. Needless to say the new vet gets lots of referrals!
Mistakes happen and perhaps second opinions do benefit from previous work but I happen to think it is a matter of listening to the client, really looking at the animal, and running the tests based on hunches and experience.
Nobody is going to be right all of the time but we are more comfortable with a specialist that is keeping up with the latest developments and has a feline specific practice.
We believe this vet is apt to catch something because she is more attuned to the feline specifics--plus she isn't overloaded with a multitude of critters. The clinic staff have great feline skills and cares--which is a glaring contrast to the local hillbilly clinic we left.
Find me blogging at Ark Animals
Ark Lady December 8th, 2008 01:28:24 PM
Ark Lady, good observations.
That's why when given a choice between those large corporate hospitals that cost an arm and a leg and generate a computer list of "ruleouts" a mile long for every symptom, and that charge you $300 just to walk in the door, not to mention the $1k worth of tests they'll be recommending (one or more for each computer-generated ruleout whether it makes sense or not). . . vs. the basic-office-visit-send-you-home vet, I somewhat reluctantly seek out the former. I'm getting better at saying 'no' to some tests that don't make sense to me.
Like: I brought the old dog with kidney failure in for distressed breathing a week ago, you took xrays; there is no chest infection. I brought him in for the same thing 3 days ago, you took xrays yet again to be "sure," but there was no chest infection. I'm bringing him in again today with the exact same symptoms, and you want to do xrays again. Two times in a week, same symptoms, nothing on the xrays both times. It's only a few days later. The xrays are hundreds of dollars and what is the liklihood they will show anything this time? Let's go down another path, please.
Stefani December 8th, 2008 03:09:43 PM
Stefani - <hugs> for you and your sick pup. Renal failure is not an easy thing to deal with emotionally.
What about an ECG or ultrasound of his heart?... in an old dog, breathing problems not obviously chest related send me immediately to thinking about the heart... or possible airway constriction?
Please do keep us posted on how your old boy is doing. We just lost one of our old guys very suddenly to heart failure - he had just been in for his regular checkup a few months before, but he had an enlarged heart the vet missed - not his fault, really. Everything else was stellar, bloodwork, fecals, overall condition, etc. He was showing no signs of fatigue after exercise... particularly in breeds like Labs, Goldens and Rotts, heart issues can seem to pop up out of nowhere.
Best of luck :O)
Oh, and a kick in the B-hind to your vet... how frustrating!
Kim December 8th, 2008 05:38:45 PM
Kim, thank you for your kind words.
The dog, a Yorkie named Wolfie, belonged to my mom and I took care of him the last 8 months or so of his life. He was euthanized a couple of months ago. What I described happened in his last weeks. I never got a definitive answer but the apparent respiratory distress was mostly panting. Xrays showed nothing and I was told it might be related to his worsening renal values. However, after 3-4 days of intensive care his renal values came down, and 24 hours after returning home his panting was back. His regular vet kept repeating that the panting was probably from pain but the ICU vet wanted to do the THIRD round of xrays . . . since he'd already had 2 sets in the preceding week with no infiltrates) I said no to that.
He'd had neurological symptoms also for quite a while, and up to that point, his neuro status was not rapidly declining. His vet thought he might have a brain tumor, but with no dramatic progression or seizures, we all began to doubt that. Unfortunately, when he came back from hospitalization for his kidneys, not only did he resume panting in 24 hours, but he then had a big seizure. Within a half hour he was back up on his feet, but he was clearly uncomfortable and things were unravelling. We decided it was time.
He was REALLY old tho. We aren't sure how old but he was already old when my mom got him 7 years ago.
He was quite a character, and although he had cataracts and was nearly deaf and had all those problems, he was adorable. He would clasp onto me when I carried him out to go potty. He ate with gusto and barked menacingly at my cats until his dying day. Made me love Yorkies . . . what big big dogs they are in such little packages.
Stefani December 8th, 2008 06:51:54 PM
PS. In retrospect, I believe that his regular vet was probably right about all of it. The brain tumor. And the panting being a sign of pain. :(
I am very sorry you lost your dog so suddenly. It must have been quite a shock.
Stefani December 8th, 2008 07:21:41 PM
The fellow vet-blogger's post that you can't find wouldn't be the "Creepy-Crawlies" entry at Vet On The Edge, would it...? (Just wondering). These are points well-taken, because ANYONE looks better if they have more info to work from, and you also have good points about an owner being more willing to go for diagnostics if a more conservative course has failed or if the condition has progressed (these are often true even if the owner is seeing the SAME vet on re-check.) OTOH, there's been many a time I've had to remind myself of this phenomenon when I'VE been the first vet. This is a knife that cuts both ways, and I try always to remember that, because I've been on both sides of the issue.
AKDD December 10th, 2008 06:15:23 PM
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