Tag Archives: challenging situations

Treat the patient, not the numbers

Dog Silhouette

Photo Credit: Lewis Cole

I remember in vet school, one of the clinical instructors said, “Treat the patient, not the numbers.” One of our patients was a miniature schnauzer with pure red cell aplasia–her bone marrow wasn’t making red blood cells. Her hematocrit hovered around 8%!! Yet, besides tiring easily, she seemed perky and continued to eat well. We were discussing when to do a blood transfusion, and someone asked how low does the hematocrit have to be before you would transfuse her. But there is no absolute number–it depends on the patient.  Her anemia progressed slowly over time, so her body had time to compensate for the decrease in systemic oxygen delivery. (Side note: this is also the patient I will never forget because–sad part warning–she died mid-venipuncture to collect a tiny sample of blood. She literally couldn’t part with another drop of blood! Her final hematocrit was 5%.)

Another version of this saying goes, “Treat the patient, not the disease.” I can especially see how this rings true in human medicine. You go to the cardiologist for your heart. You see the ear/nose/throat doctor for your sinuses. You talk to a urologist about cystitis. You can end up on so many medications for this and that, with none of the doctors seeing the big picture: the person as a whole.

I try hard to not get too carried away with numbers, but I’m sure there are times when I could do a better job. For example, don’t we get all up in arms about elevated Alk Phos levels? I mean, how many clinically normal patients do you see with an Alk Phos greater than 800 and otherwise normal blood work? For me, it’s probably once a month or so? I do think further testing is warranted, to check for disease that is not yet clinical but may become so.

Going back to my first example of gradual-onset anemia. Take the flip-side. If you were presented with a patient who was white as a sheet and lethargic with a history of possible rat bait exposure, and the hematocrit was 20%, would you recommend a transfusion?

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Filed under General medicine

The Hallway Consultation

Do you engage in hallway consultations? That’s when someone you know–colleague, friend, family member–casually asks you advice for a potentially serious problem. As in, “By the way, do you have any suggestions on what I should do about Dezzie? He has absolutely destroyed our door frame, sofa, and blinds, and I don’t know what his deal is. But my dad is really mad and wants me to get rid of him. I’m willing to try anything!”

Or maybe the request relates to inappropriate elimination, or aggression, or excessive barking, or anxiety. Whatever the problem is, the one thing I can guarantee you is, I can’t solve it in that setting.

I find behavior fascinating, and I appreciate the opportunity to help restore or improve a family’s bond with its pets, but taking on behavior cases can also be extremely frustrating and unrewarding. That’s because, too often, I’m brought into the picture too late. (Example: Client called about her 8 month old Great Dane who is so anxious when left alone that she becomes extremely destructive. The owner was requesting some anti-anxiety medication so they could see if the dog would improve enough to warrant keeping her and thus paying for her spay surgery. If she’s not going to get better, they don’t want to spend any more money on her and want to find her a new home. My repeated explanation that meds alone are not going to help her improve, that she needs intense behavior modification, which will take weeks to months, fell on deaf ears. For right or wrong, I prescribed some fluoxetine for the dog, knowing full well that they won’t implement any kind of behavior modification and the dog will ultimately need to be rehomed. Where did I miss my opportunity to really help these people? Why do I feel so responsible that I can’t help them more?)

I do try to make a habit of bringing up behavior in the exam room, so I can try to help “nip problems in the bud” before they spiral out of control, but I have to do it in such a way that I can address an owner’s concerns during a routine office visit. Often, what this means is I have to say, “This sounds like a serious concern. I’d like to help you with it, but I need some more information, and it’s more than we can cover during our appointment today. I’m going to send you home with a behavior evaluation form. Please fill it out and return it to me, and we’ll go from there.”

That’s what I’ve had to do for my hallway consultations, too. I try to explain, as helpfully as possible, that to adequately address their concerns, I need a full history, in a written format (otherwise, people try to give me an entire history verbally, and that is REALLY not a good idea–unless you have all the time in the world and a perfect memory, and I certainly have neither). I also like to schedule a time to sit down and review the history and concerns with them. If THEY can’t find the time to meet with me for said consultation, then I know they aren’t likely to follow a prescribed behavior modification plan, either. If it’s a priority for you, it’s a priority for me. If it’s not a priority for you, it’s not fair to make it a priority for me–and no matter how many times this happens to me, I still feel bad and partially personally responsible when therapy fails and a pet has to be rehomed or, worse, euthanized as a result of its behavior.

What do you do when family/friends ask for your help or input on a case where you don’t have all the information?

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Filed under Behavior-related