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Medical intuition

Article

Something stirred me from sleep. A sound that was distant, but somehow close. Five minutes later, as my eyelids came unwillingly apart, my brain registered that I had fallen asleep on the couch after my husband left for work.

Something stirred me from sleep. A sound that was distant, but somehow close. Five minutes later, as my eyelids came unwillingly apart, my brain registered that I had fallen asleep on the couch after my husband left for work. The TV was still on, showing some dramatic movie on cable that I didn't recognize. And then I realized that the sound I had heard was my cell phone. The missed call had come from the overnight technician at the hospital.

Ten hours earlier, I met the patient that provoked the middle-of-the-night phone call. In Lancaster County, there is a considerable Amish population. Because our hospital sits near many Amish farms and homes, we see a significant number of Amish-owned pets, mostly dogs. Instead of seeing dogs hit by cars, we see dogs hit by buggies, wagons and other farm implements. For the most part, these cases are treated in a very similar fashion, but client management is slightly different with the Amish due to, in part, their means available for communication.

The 5-month-old Sheltie puppy came in with an obvious traumatic wound on the left rear leg, a wound that was created when the pup and a hay wagon wheel did not agree on traveling in opposite directions. The skin had slipped up creating a parallelogram-shaped wound extending several centimeters proximally and distally from the stifle. The rest of the exam was consistent with patient in shock after a traumatic injury, and certainly, the internal organs and vascular status needed to be addressed. Although I joke sometimes with clients that doctors are not allowed to use the computers because we just mess them up, I created a quick estimate for the owner.

There will always be someone who says "no" to the cost of treatment, as did this Amish client. But I was not prepared for him to raise his voice to tell me in no uncertain terms that he did not want or agree to sign an estimate for pre-surgical blood work, radiographs or anything but "stopping the bleeding and suturing up the leg." As professionally and even-toned as I possibly could, I told this middle-aged man that it was not necessary to raise his voice to me in the exam room.

I do not think he was expecting me to say anything back to him, but I took the opportunity to stand up for myself. During my time at this hospital, I have learned that being a female veterinarian amid a culture that does not have a favorable view concerning women in the workplace is a touchy and sometimes difficult situation to overcome. Against my better professional judgment and fearing that there was some type of internal damage, I admitted the dog and sutured his leg during my dinner break. I phoned the owner and spoke to his answering machine in the barn, knowing that I had a small chance of contacting him.

After evening appointments, I checked on the puppy, sleeping in his cage, but still breathing heavily. Just a few short hours later, the technician's phone call relayed information about the dog's deteriorating condition. The puppy was turning pale, could not breathe well on its own, and had a tense abdomen. What I had feared earlier had to be true. And in the middle-of-the-night, surely the client was not in the barn to hear the phone ring.

I sped into the hospital, hoping that the area's police officers were nodding off somewhere not along my path. The pup was in the oxygen cage when I arrived.

Although the sutured wound looked wonderful, the puppy needed life-saving measures. Radiographs revealed a pneumothorax and a diaphragmatic hernia. Suturing the leg earlier in the day was like throwing an eyedropper's worth of water on a house fire. I tried to make the dog as comfortable as I could, and called the owner to no avail. My best chance was to hope that he had cows to milk early in the morning and would listen to his messages.

Unfortunately, the dog passed away at 4:30 in the morning, and I left my last message on the phone in the barn for the client.

I was angry. But when I calmed down, I realized that I did all I could, based on my experience in practice and my communication with the client. Next time, I think I will take the radiograph anyway, even if the client isn't charged for the service or is only charged a percentage of the fee. I do not like to give away my services. But in this instance, I should have followed my instincts. A single radiograph would have saved this dog a significant amount of distress later in the evening.

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