Vet Stress When it all goes to hell, guilt gets the final word

September 25th, 2009  

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I have been in the pet owner's position unfortunatly. We had a scheduled c-section.  My girl, who looked like a watermelon on legs, waddled into the clinic wagging her tail.  That was the last I saw her alive.  She crashed on the table as they were closing.  Everyone in the clinic was in a state of shock.  Thank goodness I had a friend with me so she could drive as I was in no shape to do so.  This was to be a happy time with new life.  We did find a foster mum for the litter a few hours away and with that we made new friends.  I cried for my girl for months afterwards.  I also did not get a bill for the surgery.  And I never blamed the clinic.  They did their best and when your time is up, the Lord calls you home.  We just were not planning it that way.

Holly September 25th, 2009 10:27:16 AM

Well, that had to be a shocker of a day and I can understand how the pet owner felt. That said, it is not as though you had any control over the event and I know that does not lessen the feeling of helplessness. Guilt? The only thing you were/are guilty of is being empathetic and devoted to your patients. It is not as though you started the day with the intention of seeing a 16-year old dog leave this life in such a dramactic fashion.

We hold vets to a higher standard than ourselves, we expect miracles, we know they will make everything right, they cannot let us down. We seem to forget that vets are human and subject to the same laws of nature and life as we are.

In the end, as a pet owner, my comfort is in knowing that my dogs and I trust our vet implicitely, even if they error. And when it is time for our dogs to die, I would not have our dogs leave under anyone else's care - no matter how painful or unexpected. It won't lessen the pain or the shock but it it provides a measure of comfort.

Nancy September 25th, 2009 10:29:41 AM

I had to de-lurk for the first time on this post. (Well, I think that's true.) More than a decade ago, I noticed one of my cats breathing with his tongue hanging out. Concerning. I took him to my favorite vet and waited in the waiting room forever before being taken to the back. While waiting, I talked to people and petted dogs and (remember this part) let a new puppy sniff my cat through the carrier though my cat was hissing.

When the tech inserted a thermometer to take my cat's temp, he did exactly what you just described: cried out, defecated, seized and went limp. Within five minutes, despite heroic efforts, he'd died. He was blocked, I was stupid and didn't notice, and to add to the guilt, I'd let a puppy harass him while he was in pain a mere thirty minutes before he died. I didn't comfort him or empathize with him or even love on him. I played around in the waiting room and then suddenly he was dead. This many years later I still carry the guilt - of not knowing, of not being more caring in spite of not knowing, of letting his last minutes be frantic and panicked rather than loving and calm.

I understand the guilt, but I can tell you that as shell-shocked and stunned as I was, I never once thought to blame my vet and her staff.  And I most certainly did realize -- even if it was a week later -- that I never got a bill.

I'm so sorry you all went through this, and I admire your caring nature.  If he's a good, normal person, he'll notice your efforts... just not right away.

Marisa September 25th, 2009 10:42:40 AM

I had a dog that collapsed and died at the vet's office.  It's a horrible, horrible situation.  Totally not the vet's fault, but the shock of something like that happening is devastating.

My sympathy to you and to the owner. :(

 

Janice in GA September 25th, 2009 10:43:10 AM

How tragic for you and your client, albeit quick and (I presume) relatively painless for the old pup. Bless you for doing everything you could.

Try not to let it haunt you. Like any dog, your attention needs to be totally in the now – prepared for that next tragedy, or blessing, coming your way.

tripawds.com September 25th, 2009 11:17:45 AM

Dr. K, I'm not sure which is worse -- being there to witness the shocking event or getting a phone call delivering totally unexpected news. At least when the initial shock wore off, this dog's owner knew what happened and that the dog was getting proper care. Neither you nor he have any real cause for guilt, just grief.

About six years ago I lost my dear cat after bringing him to the vet to be checked out because he was losing weight. We ended up leaving him overnight because he was constipated and they needed to clear him out before the test. We were woken by a phone call from the vet's office -- our cat had died in the night. I was hysterical. I felt so terrible for leaving him there. I had a necropsy done because I had to know why, and they told me it was cancer. But he had not been acting sick -- only the weight loss had caught our attention. I had pulled that cat through a bad case of hepatic lipidosis and I had become an old hand at nursing my badly-bred Bulldog through one illness after another and sensing when something wasn't right.  To be honest, I never had the same confidence in that vet again.

Susan September 25th, 2009 11:58:08 AM

My heart goes out to both of you.  The story brought tears to my eyes - I can only imagine how you and the owner feel. 

Jenny September 25th, 2009 12:35:46 PM

most doctors keep pretty cool when faced with these tragic emergencies, but it does result in some significant strain/stress ...at least for me.  there's a lot of "what did i do?" and "how could we have avoided this?" questioning that goes through my head as i'm doing chest compressions or figuring out epinephrine doses.  and whether or not the patient survives after going into cardiac arrest (and they usually don't), i'm wiped out afterwards.  i've even had to cancel the rest of my appointments after treating a case like the one described by dr. k.  over the past three years, i've had the luxury (or burden!) of being able to review timestamped video recordings of our treatments.  this has helped my team streamline our response to all emergencies.  since 2001, i've had tragedy strike 3 times during an otherwise routine visit, and i can recall the details of each patient as if they happened yesterday. with each of those cases, we learned some lessons, created new hospital policies and became better healthcare providers.  but it still doesn't change the fact that i am so programmed to fix things that it's very difficult to cut myself some slack when dealing with an irreparable situation.  but that's what therapy is for :)

Dennis Leon, DVM September 25th, 2009 12:38:58 PM

It sounds like you acted immediately to the emergency.  As others have said, the owner will likely come to appreciate your hard work once the shock wears off.

The fact that you cared enough to feel guilt over the dog's death shows just how important your patients are to you.  If I were the owner, I'd bring other pets to you for that reason alone. 

Posey September 25th, 2009 01:38:10 PM

Marisa,

Please don't feel guilty about your cat, I think he knew when you brought him to the vet office that you were trying to help him.  Any cat in that situation would probably hiss at a dog.  I had a similar thing happen to me.  It took some time before I noticed that my cat had been eating very little (I should have noticed the litter usage.)  He had been loosing weight at about the same rate as he was filling up with fluid from right sided heart failure, so he looked like the usual same fat cat I always had.  Cats hide their pain and sometimes it is hard to notice that something is wrong.  I was a little worried about him and then I went on vacation for a week and had a cat sitter checking in on him daily.  When I returned he was coughing and I made an appointment with the vet not really realizing that he was as sick as he was.  The vet did and x-ray and found that he had two ribs broken, one of the ribs in two places and I never new it.  Never noticed much out of the ordinary except his cough which brought me into the office.  The vet also took some fluid off his heart that was highlighter orange in color.  I don't think he anyone ever figured out what that was.   I had to euthanize him 2 days later after he had a massive stroke.  Looking back I remember noticing that when I petted him his spine seemed more pronounced (duh, he was losing weight even though he looked the same in the belly.)  I guess perhaps something happened to his ribs when the cat sitter was there, he was the kind of cat that was underfoot especially on the stairs and maybe she wasn't used to that.  I could not bear to ask the cat sitter if anything happend while I was gone.  I feel some guilt also, but he had a home in which I loved him and cared for him for almost 15 years and I have to think that counts for something.  PS. It has been almost 3 years and I have a new cat now and I watch him like a hawk and obsess about keeping him trim and I take him to the same vet who walks on water as far as I'm concerned.

Dr. K.,

You did what anyone would have done and you are a hero in my book.  I think anyone with a dog that old knows that every day is borrowed time.  No-one is ever really prepared for someone they love to leave them and your client must understand that you could not have anticipated the events of that day, nor would it have happened any differently for anyone else.  I hope your feeling better today.

Stacy

Stacy September 25th, 2009 02:11:01 PM

If you need a silver lining, consider this. How much worse would it have been if the owner witnessed the same inevitable episode AT HOME? The lasting painful question would have been, "If only I was at the Vet's, maybe they could have saved her." The answer is obviously no, it wasn't possible, even with expert care. But you've considerably reduced owner guilt here, which is pretty much the best outcome you could ask.

This gets at the one expectation I've seen in medicine that is totally unrealistic. That everything can be fixed, that there should be car-like guarantees over organic procedures. That doctors should be held responsible to always and perfectly fix problems in patient's lifestyles and genetics. It's why I'm for tort reform. We've become so accustomed to the benefits that medicine can provide that we've greedily fooled ourselves into demanding miracles.

As Vet medicine continues to provide the same services (and at similar prices!) to human medicine, expect more pressure from your clients to be a miracle worker. I think it's inevitable.

That doesn't mean that you should harbor guilt over the expert service you do provide. It's not your calling to do the impossible and work miracles, it's just your calling to try.It sounds like you gave this dog and the owner the best chance they had, and the result is not failure, it's the peace of knowing that it really was "time" and that no human endeavor could have changed that.

Playing the "when is the right time to put the dog down" game comes with this possibility: that you wait too long and don't get the "beautiful death" of euthanasia. If you want a guaranteed peaceful exit, you have to decide to take that step before the lingering, bitter, end. With my dogs, I know that I've traded in weeks, even months of life there at the end for a peaceful exit with dignity. In both cases, I could have spent thousands of dollars and put my dogs through perhaps torturous "do everything possible" procedures. But I don't regret making the hard choice. And I don't regret NOT putting my vet through what you had to go through.

 

Christopher @ BorderWa September 25th, 2009 03:03:47 PM

It's totally the pits having a patient pass on in  your office.. We've had a patient with ALS.. pass away .. It's not a good feeling.. There was absolutely nothing we could do.. and we tried.. We've had a bunch of patients in the middle of MI's, and we just pray they get to the hosptial in time.. I've  even driven someone over instead of waiting for the EMS..

Yes.. Your heart continues to skip beats for a long while after.. and you try to replay what just happened in you head, over, and over..

Barri September 25th, 2009 06:17:20 PM

Dr. K, your word "agonal" will stay with me forever.

That sad, painful things happening to animals hurts a human witness is testimony to his/her compassionate character. Burdensome as that is, where would we all be without it?

oh holland September 25th, 2009 07:41:27 PM

Not long ago I brought my cat to an emergency vet on a Saturday night of a holiday weekend. He was vomiting and lethargic.  After he woke from his nap he came over and sat with me. I put him in his carrier and we went to have him checked out.

I gave him 17 peaceful years. They gave him 17 traumatic minutes. They took him away from me knowing nothing about him to get his vital signs. Whatever they did put him in such distress that I had to have him euthanized. They had no problem giving me the bill.

From what you write I can tell you are very competent and so caring.  Had you been the veterninarian there that night with the same outcome I would have felt better knowing my cat had the best care possible and it was something beyond anyone's control. 

Carin September 25th, 2009 10:30:28 PM

Great blog, Dr. K. Your description reminds me of what I witnessed with both my old Sealyham and actually same with my Mom. Both had what looked like "seizures" but were really mini-strokes , not knowing how "mini" that is.

Do you suspect stroke, MI, splenic hemorrhage ? I saw my dog with neck tremors, then an up and down head bobbing---that ended up with corneal ulcers, later her one eye luxated-lens. That looked so bad, I broke out in a cold sweat and became sick. Then another event that caused continuous circling in one direction. Actually she overcame all of these "events" and did eventually receive a compassionate & kind euthanasia. She ate up until then. But boy, it might not have gone that way.

My Mom was being treated for seizures , but in fact, I was with her for her  last appointment when she had one of those "seizures" just before the in the office. Sure enough, the phys. asst. asked her to stick her tongue out and it was off to one side. I said Mom, do that again, but straight out, and again it went to one side. Then, I knew.

My Sealyham & Mom died 13 days apart---my Mom with a huge stroke at the end, 3 days unresponsive to shutdown. Uggh, sometimes I think despite compassionate administration of morphine, maybe euthanasia should be available for humans. The indignity of those 3 days... 

Barbara A./NH September 25th, 2009 10:40:57 PM

15 years ago, the fabulous surgeon I go to for tricky things, odd things or orthopedic things with my dogs had a young, healthy dog of mine die on the table from a WTF reaction to Isoflurane. She took two breaths of the gas and went into arrythmia.

Well equipped facility, a cardiologist present. state of the art monitoring equipment. They worked on her for a hour. External CPR, internal massage, paddles, drugs,  nothing would keep her heart in rhythm.

My husband recalls a patient dying the same way at Stanford when he was a resident. It shook the hell out of even seasoned attendings. He tells me it's the reason that anesthesiologists will always carry high insurance premiums. It's thoroughly unpredictable and so rare many will never see it in their careers, thank God.

The point?  it shook the hell out of both myself, the surgeon, and his staff. Yesterday I had a little dog at his practice to have what looks to be a benign lump off. As he has anytime I leave a dog in his care since the day Taz died, he calls me after surgery and never says "Hi, it's me". No, the first words are always "Ralph's OK" or "Snogs OK" Yesterday it was "Chuck's OK!" 

Unexpected, unplanned loss is a traumatic experience. It clearly leaves it's mark. My heart still skips at the moment I realize surgery will be inevitable. And it's clear that the surgeon has not forgotten that day either.

 

JenniferJ September 26th, 2009 02:00:41 AM

Do dogs get MH (malignant hyperthermia)? That's usually the cause of unexpected death under anesthesia. MH patients can be saved but it takes an enormous amount of staff, resources, drugs and ICU-level care. Since pets' anesthesia is not provided by anesthesiologists, the staff present are not likely to have a good understanding of MH and how to treat it.

I am interested now in whether dogs get it, I will do some research.

(nurse anesthestist here)

Mandy September 26th, 2009 05:22:18 PM

Mandy, dogs do get malignant hyperthermia. Pigs do too! JenniferJ's dog doesn't sound like a dog that died from MH.

Virginian September 26th, 2009 05:40:08 PM

I'm certainly not a vet, but dogs do indeed suffer malignant hyperthermia. I believe a genetic test for it was developed based on a family of dogs and has cross over value to human medicine. It was not the cause of Taz's death. In her case it was an electrical conduction FU in response to the anesthetic gas. The surgeon remembers it happening to a dog at the vet school in his second year, he was in practice 22 years when Taz went down.  his only one before or since to die that way. The center she was at has technicians who specialize in anesthesia and critical care. There were several surgeons, a cardiaologist, an endocrinologist and several internists there when she crashed. Outside of a teaching hospital, you won't find much better facilities. It's why I drive 3 1/2 hours to reach it. 

Dr Khuly, they did not charge me. And while I was numb at the time, believe me, I did appreciate the gesture. Your client will probably do so too, in the fullness of time. 

I'm told by people whom I trust that in her case, even at a vet school, she was highly unlikely to have survived. The human who died durning my husband's residency was a healthy, fit young man in for a minor procedure. 

On an aside, I believe anesthesia to be very safe, and routinely have dogs put under for PennHIP etc.... but I still do get that little flutter and chill. You don't forget the unxpected but unpreventable loss.

JenniferJ September 26th, 2009 08:16:54 PM

And yet we forget the cases where there really appears to be no hope.....and we bring them back from the brink.

Take Blue the working collie, presented in complete collapse, agonal gasping, sporadic pulse.

We attempted resuscitation, intubation, adrenaline down the tube and finally a colleague went to deliver the bad news to the owner.

Whilst cremation was being discussed in one room three to four minutes passed.....and then a nurse yelled 'My God I think this dog is breathing!'

 

Every day the farmer would come to visit.  He never patted her, he just stood by the kennel.

Four days later Blue went home. Four months later she appeared on the television show 'Farmers weekly' during a sheep dog

trial.

http://littlevet.blogspot.com/

 

 

 

 

 

LittleVet September 27th, 2009 03:15:46 PM

I think modern medicine has us all believing, somewhere inside, that there is a miracle for every situation.

So often there is, and we get spoiled.

I think all of us are shocked when we crash into a situation for which there is, as yet, no miracle........  By a sudden death, for sure, but also by the absence of that miracle............

 

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