When you hear hoofbeats…

The Dalmatian stood hunched in the corner of the exam room, barely lifting his head high enough to scan his surroundings. His discomfort was obvious, even from a distance.

I watched as he made several unsuccessful attempts to lie down. The sound of his anxious panting echoed the sound of the blood rushing in my ears. My eyes fixated on the tiny drops of blood-tinged urine slowly trickling from the underside of his belly that contrasted so starkly against the gleaming white of the tile floor of the hospital.

I’d examined the dog about an hour prior, a few minutes after he’d arrived, but I’d just completed telling his owner my recommendations for how to move forward.

She spoke slowly and deliberately, “To be honest, I’m extremely uncomfortable with everything you are telling me. I’m taking my dog home and I will see my regular veterinarian tomorrow when his office is open. You clearly have no idea what you’re doing. You’ve only just graduated from veterinary school. And I’m not paying for this exam.”

The words reverberated in my skull and my already flushed skin prickled and reddened to an even deeper shade of crimson. I rubbed my sweaty palms along the tops of my scrub pants, rigid with the newness of unwashed polyester. They’d only been in my possession for a few days, along with my pristine white lab coat and shiny laminated plastic name tag bearing the identification, “Dr. Joanne Intile.”

It was my first shift working on the emergency service, during the first week of my veterinary internship, and my first experience seeing a case on my own as a newly minted veterinarian.

Countless years of preparation, weeks spent toiling on the clinic floor of vet school, hours of studying and experience all led up to this moment. It was my quintessential time to shine. Yet, I found myself stumbling over what to do, what order to do it in, and what to tell the owner.

I was seeing a young male Dalmatian with signs of stranguria (straining to urinate) and hematuria (blood in the urine). Though the causes of such signs are numerous in dogs, we are taught in veterinary school that “when we hear hoof beats we are to look for horses, not zebras.”

Dalmatians, especially young males, are predisposed to forming a specific type of stone in their urinary tract called urate stones. Urethral obstruction can occur when stones that formed in the bladder or kidneys become lodged in the urethra. It is a life-threatening complication.

Obstruction can lead to severe bladder distention and eventual rupture. The blockage can also lead to buildup of toxic waste products of metabolism in the bloodstream, as the kidneys are unable to filter the blood properly from the back pressure from the stone.

The conversation with the dog’s owner should have been straightforward. I should have immediately recommended first stabilizing my patient, treating his pain, confirming the diagnosis by obtaining a radiograph (X-ray) and visualizing the stone lodged within his urinary tract, followed by an immediate effort to remove the stone by sedating him and passing a urinary catheter, and surgery to remove the stone.

Within the recesses of my mind, I knew what I should do, but under the stressful situation of being an inexperienced doctor, in the unfamiliar position of working on an emergency service, and an abrasive owner questioning my qualifications, I had zero confidence in my ability to help this dog.

Instead of doing the “right” thing, after I performed my exam I spent the next 40 minutes pouring over my textbooks and class notes, relearning the pathophysiology of urate stone formation in Dalmatians and the intricacies of their surgical removal.

I fumbled over creating an estimate of what it would cost to enact the plan I wanted to offer the owner. My voice trembled when I talked with the on-call surgeon, informing her she might need to come in to perform surgery that night. She aggressively chastised me for calling her without having a definitive diagnosis and hung up the phone.

By the time I re-entered the exam room to talk to the owner, the damage was done, not only to the dog, but also to my fragile newborn doctor ego.

I’ve come a long way since that first emergency case ten years ago, and despite possessing a great deal of confidence in my ability to treat my cancer patients accurately and ethically, there are times where I still find myself questioning my decisions about a particular recommendation or conversation with an owner.

Humility is a trait not often associated with medical professionals, but I’m certain it would be far more dangerous for me to be overconfident rather than conservative when practicing my craft.
I’m certain I’ve saved more patients by second guessing a biopsy report or lab work result. I know I’ve made more allies than enemies by calling owners and admitting I’d made a mistake rather than brush it off and pretend it didn’t happen. I’ve never regretted recommending an owner seek a second opinion when I felt I could not meet their goals.

Some would argue these characteristics make me a weak and self-doubting doctor. I’d argue these are the things that keep me human.

I still wonder what happened to that Dalmatian. And despite how horrible the events of the visit were, I’m still grateful for the experience. The most important lesson I learned is that a follow-up phone call after a difficult appointment can do much to ease the minds of both doctor and owner.

Even when the outcome isn’t the optimal one, in the end it’s communication and caring that matters the most.


One thought on “When you hear hoofbeats…

  1. Anna says:

    One would think that as a dalmatian owner she would be very aware of the danger of stones and be right on board with your recommendations, no matter how inexperienced you appeared.


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