Fool Me Twice

Let's call my patient "Dorito".

Not because he was a Chihuahua—though he was. But more because he was 15 or 16 years old, and for whatever reason, that aged dog always reminds me of a bag of Doritos as you get close to the bottom. You never know exactly how many more chips you have at that point, though of course you hope there's enough get your sense of dignity together before they completely run out and you turn the bag upside down, desperately huffing fumes of Cool Ranch™.

Anyway! The other morning, Dorito's owner woke up and noticed a few spots of blood on the couch.

That was his presenting complaint–"blood spots on couch". Sure, fine. These things happen. Presumably, the dog was responsible for the bloody spots, and so I set to work on solving this mystery. But my physical exam showed absolutely nothing wrong. I checked all the orifices–no blood, no spots.

Dorito seemed fine.

Now, I'm a fairly lazy person—I’d rather not do any more work than is absolutely necessary—so I naturally thought I could quickly reassure Dorito's owner that although I believed his history, I couldn't provide a conclusive explanation at this point. I could speculate, and pontificate, and even prognosticate if you really were gonna twist my arm, but I couldn't prove jack squat at this point.

Which– to me at least–wasn't a big deal, since Dorito seemed so fine otherwise. It was perfectly reasonable to monitor things at home for a little while. I would have loved to prove where the spots came from, and be the hero and all of that, but that is laughably rare in veterinary medicine, so I just shrugged and wished the man would go enjoy his dwindling bag of Doritos at home.

Of-freaking-course, I offered diagnostic testing, since I've been trained to always do that even if it seems about as necessary as bear traps on the International Space Station. I mean, it's not wrong, it's just that people with ancient Chihuahuas usually don't want to dump money into testing unless they really have to. This did not seem to be one of those situations

So I made a clinical judgement–dammit!–that this dog was fine and could go home ASAP. It was busy and I needed to get on with my cases. But I did offer testing, even if half-heartedly and with a series of obstructive caveats (it can be expensive, we might end up over-treating, etc.). But come on! Read between the lines, Mr. Dorito Owner Man! 

Not everyone who climbs Mt. Everest trusts their sherpa though, so after a disappointing conversation with the client and a stack of "true" emergency charts piling up, I ordered some baseline diagnostics for Dorito!

Fine. Fine. I’m a medical professional, I don’t mind running some test. If you tell me your 100-year-old Chihuahua is “off”, and you want diagnostics, you’ll get diagnostics! I mean, you gotta pay for them and all of that, but I’m happy to run them! I even know how to read them and figure out what’s going on, or what might be going on, or if there’s completely contradictory evidence that makes no sense whatsoever and hopefully there’s somebody smarter than me hanging around nearby (the only three possibilities). 

So all Dorito's initial tests were normal. Smashing job everyone! A Chihuahua older than the Golden Girls are now, happens to have perfect bloodwork. Hooray!

You know who wasn't happy about that? Dorito's owner! Because normal labs didn't explain the spots on the couch! You know, the thing he had seen with his own eyes but no one else had been able to corroborate with any other physical evidence?!

He was pissed. I should have picked up on that. I should have realized he really wanted (needed?) an explanation for the blood spots and that, “Gee, I dunno–were you painting with Kool-Aid on the couch last night?” wasn’t gonna cut it. 

But like I said, it was busy and I’m lazy and I thought the dog was fine so I just relayed the perfectly normal diagnostic results indicating that his Ian-MacKellan-impersonating Chihuahua had fantastic internal organ function. Which didn’t go well, and took a round of (frankly) heroic client communication skills on my part to get back to a collaborative, forward-focusing team effort. 

At which point, unfortunately, I had to mention that there was actually another test we could technically offer, if you really want to get crazy, and it is theoretically possible that it could give us an answer, but didn't we all just learn an important lesson? Tragically, offering another test sometimes happens reflexively. 

But I swear I really laid on the futility of such diagnostic folly. I probably sounded like a dramatic female actress from the 1950s. I pour it on thick–think of the impracticalities! Low yield rates! The cost! My god–the cost!

Go home, buddy. Take your ancient dog home and go happily sit on the blood-spotted couch. Enjoy each other’s company. You have no idea how long he has left, but I can assure you this–his kidneys are working great, and he does not appear to be losing blood or have any clotting abnormalities. I'm sorry I can't explain the blood spots, but trust me, all evidence points to the fact that your dog is miraculously healthy for its age, some red spots on the couch are no reason to panic. So go enjoy your time, and forget this nonsense! Or, you know, just follow up if it happens again. I mean, the dog’s eating and drinking and acting completely normally. GO HOME!

But yeah–technically I offered an advanced diagnostic and yep, he wanted to do it. He said he didn't care about the cost, he just cared about Dorito. So we ran the damn test.

Guess what–it was normal. 

Okay, I admit it, I kinda lost my temper a paragraph ago. I’ve got things back under control now, and I’d like to take full responsibility for what happens next. Because, at this point, don’t you think I really should have known to tread carefully with this client when delivering news about normal diagnostic results?

I messed up. I didn’t bury the lede, and just flat out told the guy the test was normal. Thinking, maybe he’ll take the dog home now?

Huge mistake. There was a bilious eruption. An ejection of hot, toxic fumes that overpowered the senses and flung chaos in all directions. He was soooo mad!

Memorable phrases such as “you’re the worst veterinarian ever” and “I will never pay for any of this” stick out. I clutched the phone like I had brushed up against an electric fence. The outburst clocked in at 20 minutes before I had a chance to speak. By then, I had noticed and silently deactivated my sympathetic nervous system, analyzing his sentiment and preparing a reassuring message to get this rabid rhinoceros out of rampage mode (metaphorically speaking, of course).

It wasn't easy– there were tense moments: blood pressure spikes, heart rate spikes, a quivering trill in my voice that belied my autonomic arousal. Dorito's owner swore an oath on his grandmother's soul that he would never pay the clinic a single cent and that we were dog abductors and essentially human filth.

But I gotta say, these clinical communication techniques work. It took another 30 minutes or so, but the client eventually showed up in our lobby, paid his bill in full and received a kindly-and-carefully worded set of discharge instructions describing how to navigate the world of normal dogs and blood-stained couches. It welcomed future collaboration in case follow up was needed. It took all of my mental jiu jitsu skills, and left me exhausted and depleted for all my other patients, family, friends, and creative pursuits, but I guess it was technically a measured success! 

Was it worth it? Well–to him, no. I never found the source of the blood, remember? Which… is fine. This stuff happens all the time. We rarely find an answer in these situations. I tried to tell him that, but I had failed. I had also failed to recognize and anticipate what was coming until it was spewing out of the phone’s receiver.  

And should I have put up with all that verbal abuse? Well–hmmm... I mean sure, he did get to me (my nervous system, at least). But at this point in my career I can let that stuff go pretty easily. You know–I know more about veterinary medicine than he does, and I tried to explain that sometimes–lots of times, actually–we don't get an answer. It happens!

But ultimately, with this one client, it just didn’t work out. I tried to anticipate his needs and help him out. Turns out he was a lot more concerned about cost than he let on. Hey–sometimes that happens!

At least he took Dorito home.