Poor Advice can be Expensive 

D. E. Larsen, DVM

The phone jarred me awake. I rolled over and looked at the clock. It was six in the morning. Sunday morning, I liked to sleep in on Sunday morning. I got up and walked out to the kitchen to answer the phone. Amy woke up with me, the meant there was going to be no sleeping in this morning.

“You go back and get in bed with Mom,” I said to Amy as I reached for the phone.

“Good morning, this is Doctor Larsen,” I said, trying to sound wide awake.

“I’m sorry to bother you so early, Doc. This is Jim and Sara,” Jim said. “We are just getting ready to leave from San Francisco and will be getting into Sweet Home around five this afternoon. Sally was hit by a car last night. We took her to the emergency clinic last night. She is doing pretty well, but the doctor said that Sally has radial nerve paralysis in her right front leg. They gave her a steroid injection and said she should have one we get home. We are hoping that you could look at her when we get back to town.”

“That’s no problem, Jim,” I said. “We are going to be around. Just give me a call when you get to town. Is Sally doing okay other than the paralysis?”

“She is a little sore, but everything else looks good,” Jim said. “They took a chest x-ray last night, and they said the heart and lungs look good, and they didn’t see any fractures. They said this leg should return to function with time.”

“I’ll get a look at her when you get to town, Jim,” I said. “But I can tell you one thing right now, I have never seen a leg with radial nerve paralysis return to function.”

“The emergency vet was pretty confident in his advice,” Jim said.

“I will see you when you get to town, and we can look at things then,” I said.

“Who was on the phone?” Sandy asked as I squeezed back into a now full bed.

“It was Jim, from out in Holley,” I said. “Sally was hit by a car in San Francisco, and she has a paralyzed leg.”

“Is there anything you can do for her?” Sandy asked.

“Not much, but that is the least of the problem,” I said. “The problem is the emergency vet down there told them it would return to function. I have never seen that happen. And they are bonafide Californians, they will never believe me after a Californian vet gave the advice contrary to my opinion, but time will tell.”

***

Jim was right behind me, carrying Sally, as I unlocked the clinic door. Sally, a young petite female Irish Setter. I had seen Sally several times before. 

“Set her on the exam table, and I will give her a good exam before we set her down to walk,” I said as I retrieved their file.

Sally looked fine except for an abrasion on the left side of her face. Her right leg hung limply from her shoulder, and the paw rested on the table on its dorsal surface.

“The radial nerve supplies all the extensor muscles of the front leg,” I explained as I closely examined Sally’s leg. “It runs across the lateral surface of the humerus, the upper leg bone, and when she was hit, the nerve was crushed between the vehicle part and the bone.”

“Yes, that is pretty much how the vet in California explained it,” Jim said. “He said with some medication to relieve the inflammation, we should expect it to return to function in a few weeks.”

“Jim, I have no real problem with trying some medication for a while,” I said. “But, I worry that you have expectations of a return to function, and I have never seen that happen.”

“Why would the vet in California tell us otherwise?” Jim asked.

“I don’t know, he maybe reads a different book than I do, or he knew he didn’t have to deal with you for the follow-up. The problem we will have in the immediate future is Sally is going to wear the skin off the top of her paw as she drags it on the ground.”

“How do we deal with that?” Jim asked.

“I guess we could try to keep a wrap on it,” I said. “To be honest with you, I don’t usually deal with that problem. These dogs will do far better with an amputation. People have problems with that consideration, but after a few days, you will have to count legs on her to know she is missing one.”

“I think Sara and I are pretty sure we don’t want to consider an amputation,” Jim said. “Can we set up some medication and see how things go for a while.”

“I have no problem with that,” I said. “I just want you to watch the surface of the paw. We also have a new neurologist in Portland. If you would like to see him, I could make a referral,”

“We will think about that, but for now, let’s see how the next week or two goes,” Jim said.

I got Sally medicated and sent them out the door with pills and instructions to look at Sally every week. And to check her earlier if the paw becomes an issue.

***

It was late Thursday morning when Jim rushed through the door with Sally.

“I know you close on Thursday afternoon,” Jim said. “But could you get a quick look at Sally for us?”

Sally’s paw was a mess. Most of the skin was gone from the upper surface of her toes. The paw was swollen and painful from the infection. The muscles on the leg were already starting to atrophy. Obviously, we were heading for a wreck if this leg didn’t come off.

“Let’s clean up this paw and get a wrap on it,” I said. “Then we need to get Sally on some antibiotics. Have you noticed that her muscles are getting smaller on this leg?”

“Sara and I talked last night, and we think we would like to go see the neurologist in Portland,” Jim said.

We got Sally cleaned up, wrap applied, and started her antibiotics. Then I gave the doctor in Portland a call, and he was delighted with the referral, and I handed Jim the phone to make the appointment.

“He sounds nice,” Jim said. “And he could get us right in. We will go up there tomorrow.”

“Yes, he is just getting started up there,” I said. “He is probably not too busy yet.”

I hated sending a client to a specialist who I had not met personally. But if anyone would set these two straight, it would be a specialist.

***

Several weeks later, Jim stopped by just to update me on Sally’s status.

“He has tried several treatments,” Jim said. “He has continued the anti-inflammatory medication, and he has used some high-frequency sound waves to try to stimulate some healing. There hasn’t been any change in Sally’s leg yet, but we are hopeful. He is planning to do surgery next week to try to free up some adhesions along the path of the nerve.”

“I hope he can help her out,” I said. “But, Jim, remember what I said when I first looked at Sally’s leg. You have to prepare yourself for how you will handle things if he recommends an amputation.”

“Doc, he hasn’t mentioned amputation one time,” Jim said. “He is very hopeful for a recovery. And so are we. Hopefully, this surgery will solve Sally’s problems.”

***

The following week, Jim and Sara came through the door carrying Sally; Sara was in tears. Sally was still not completely recovered from surgery, and her right front leg was amputated.

“He didn’t even call us to let us know what he was going to do,” Jim said as he handed me a folder with notes from the doctor.

I quickly scanned through the papers until I came to his surgery notes.

The notes read: “I was working along the tract of the radial nerve, freeing up adhesions as I progressed, when I finally realized that there was no hope for returning this nerve to function. I proceeded to do a full amputation.”

“Doesn’t sound like the best client relations to me,” I said. “Did he give you any heads up that an amputation was a possible endpoint to the surgery?”

“No, he didn’t,” Sara said. “I was horrified when we returned to pick Sally up today. He didn’t even call last night following surgery. We spent a lot of money up there, and we got nothing in return.”

“I can assure you, Sara, that he will hear from me on how I expect client communication to occur with my clients,” I said. “But, sad as it may seem, he did what needed to be done. When that nerve is crushed against the bone, there is almost no chance of returning to function. If it is a minor blow, maybe you could see some return to function, but that would occur in a day or two, sort of like you bumping your crazy bone in your elbow. The truth is that you got some really poor advice in San Francisco. I would guess that was just from inexperience. But it turned out to be costly advice for you guys.”

“What do we do now?” Jim asked.

“Take Sally home and make her comfortable,” I said. Give her the pain medication you were given, and in a few days, she will be back to her old self. She is a small setter, and the only thing you need to watch as she grows older is that she doesn’t get heavy. She will not miss this leg at all.”

***

And that is how it turned out. Sally healed, and she did wonderfully on her three legs. Sara and Jim came to realize I was their best source of advice. 

I consulted with the neurologist in Portland on rare occasions in later years. Still, I never sent another client to the man. As the years passed, I think he improved in his bedside manner, but I could never trust him again. And in the future, I never referred a client to a specialist I had not met personally.

Photo by Camylla Battani on Unsplash

Run for Your Life, From the Archives

D. E. Larsen, DVM

Joe always wanted Comet checked for one thing or the other. He was waiting for his turn in the exam room with Comet on his lap. Comet was a young Whippet. There was not an ounce of fat on his entire body. I could about define every muscle on him, just looking.

“What’s up with Comet today,” I asked as Joe placed him carefully on the exam table?

“I have been reading about heartworms, Doc,” Joe said. “I thought maybe I better have you check Comet and get him on some medication.”

“We have just completed a statewide heartworm survey,” I said. “One of the drug companies paid for it. Most of the clinics in the state collected blood samples from 100 dogs. They ran all those samples, and they say we have about a two percent incidence of heartworms in native Oregon dogs.” 

“That doesn’t sound like it is too serious,” Joe said. 

“Not too serious at this point, but they claim that is pretty standard for how heartworms invade an area. It will be in low numbers for several years, and then all of a sudden, it is a major problem.”

“Well, even if it is a low-risk thing, I think I want to get Comet on some medication,” Joe said. “You know how I am about him. He means as much to me as any of the kids.”

“I know, Joe, you have him with you all the time,” I said. “The kids come and go.”

“Now, don’t you tell my wife that I said that. She would be upset with me,” Joe said.

“Let me get a blood sample from Comet, and we will see if we can get him on some medication,” I said. “This new drug, Ivomectin, is a little bit of a problem with Greyhounds and Whippets. But the dose used for heartworm prevention is low enough that it is not an issue.”

“Whatever you think, Doc,” Joe said. 

“The risk of the medication causing a problem is very small, Joe. But then, the risk of infection is also minimal. At this point, where you live out on a hillside with few neighbors, I think it is your call.”

“That hillside is one of my concerns,” Joe said. “We are getting into quite a coyote problem. They are getting so brave that they come right down into the yard and bother Comet. I don’t want him catching anything from them.”

Comet tested negative for heartworms, and we started him on a new preventative medication. 

“You give him one of these tablets once a month,” I said. “Try to give it on the same day of the month, but you have a few days leeway if you forget.”

It was several months later when Joe returned to the clinic. He was distraught, and his body odor told that he had not bathed in several days.

“Doc, Comet is gone,” Joe said as he leaned hard on the counter, tears welled up in his eyes. “Those coyotes ate him, I am sure.”

“What happened,” I asked?

“Three of those damn coyotes came into the yard and started to attack Comet. Before I could do anything, Comet took off like a shot. You know those Whippets can run. The coyotes were right on his tail.”

“I doubt that those coyotes could catch Comet. I know of ranchers in Colorado who keep Greyhounds to hunt coyotes. Those Greyhounds just run them down.”

“Maybe a half-hour after they left the yard, the whole pack of coyotes were yipping up a storm. I am sure they got him. And he hasn’t been home, and that was four days ago. I don’t know what I am going to do without him.”

“Joe, you need to go home and take care of yourself. Take a shower and get cleaned up. Maybe have the kids help you build a little memorial in the yard of Comet. Then go out for a good dinner. Comet would want you to have a normal life.”

“Yes, you are probably right, Doc,” Joe said. “I brought this package of pills back. I only used a few, and maybe you can give them to someone who doesn’t have the money to afford them.”

“We are not supposed to do that, but we keep a few things in the cabinet, just for such a client.”

“That poor man,” Sandy said after Joe left. “That dog was his whole life.”

“He will be okay,” I said. “It will just take a little time and some diversion.”

It was only a few days later when Joe exploded through the door. Exuberant, he had a smile from ear to ear. He had combed his hair, and he was well dressed.

“Doc, I want to thank you for your advice,” Joe said.

“You look happy,” I said.

“Let me tell you the story,” Joe said. “I went home the other day and tried to take your advice, but I couldn’t get myself up to it. I laid around another couple of days. Finally, I looked at the yard, and boy, it needed to be mowed. So I went out and started the lawnmower, mowed the yard, and then I took the boys down to Hoy’s Hardware to buy stuff for a memorial. And what do you know, when we got home, there was Comet, sitting in the middle of the driveway, waiting for us. I was so happy. I almost ran the pickup into the house.”

“That is great news,” I said. “I bet that Comet ran so fast and so far that he didn’t know the way home. When you started the lawnmower, you probably gave him some bearings on how to get home. I didn’t think a coyote could catch him.”

“You are probably correct,” Joe said. “This time of the year, I mow the lawn at least once a week, maybe twice, if I get bored. So Comet would know the sound for sure.”

“I would give you those pills back, but I gave them to an old guy this morning,” I said with a smile on my face.

“That’s okay. I will gladly buy some more,” Joe said.

“No,” I laughed. “I will grab them for you. I was pulling your leg a little.”

Photo by Mitchell Orr on Unsplash

Nessie’s Demise 

D. E. Larsen, DVM

It had been several years since I had seen Ayers when I noticed Sandy showing him and Nessie into the exam room. I knew he had a few tough years, as is always the case when an old man loses his wife.

Nessie was a rough-looking little miniature schnauzer. She wouldn’t win any contests at the dog shows, but she was one of the best little farm dogs I knew. She has been Ayers’ sidekick for many years, and now I would guess that she is his only companion.

“What’s up with Nessie?” I asked as I entered the exam room.

“I don’t rightly know, Doc,” Ayers said. “She has really slowed down the last week or two. And this morning, she wouldn’t even chase the squirrel out of the manger. You know she’s a tough little rascal, so when she quits doing her job, she has to be hurting.”

I leaned over and lifted Nessie onto the exam table. She tensed and groaned at the procedure.

“Something really hurts,” I said. “It is either her back or her abdomen. Has she been eating okay?”

“She ate a few bites yesterday, but she hasn’t touched her food today,” Ayers said.

I ran my finger down her spine, applying only moderate pressure, and Nessie showed no response. She tensed her abdomen with the slightest touch to her belly wall. I petted her and held her right side close to my body, and I lightly blotted her abdomen with the fingers of my left hand. I bounced off of a large abdominal mass.

“Ayers, she has a large mass in her abdomen,” I said.

“What does that mean for her?” Ayers asked.

“We need to investigate it a bit,” I said. “Abdominal masses can be anything. Location-wise, I would guess this is a splenic mass, but it could be her liver or something else. Sometimes we can define things with an abdominal x-ray. Still, it often requires surgery to determine if we can do anything with it. If it is on the spleen, we can remove the whole thing with surgery. Then it just depends on if it is malignant or not. If it is the liver, those are usually over my head here, and I send them to a guy in Eugene.”

“Doc, I have been bringing Nessie here since she would fit in my coffee cup,” Ayers said. “We will be here until she dies. I don’t want any discussion of going somewhere else. If you can’t get it done, it won’t be done.”

“Okay, I will need to get some blood out of her and do an x-ray,” I said. “Then we can talk about what needs to be done.”

“Whatever you think is okay,” Ayers said. “But it sounds to me like you just need to open her up and take a look. You are either going to be able to fix her or not. If her kidneys aren’t going to be able to take the surgery, so be it. And if she only has a short time to live, if she is out of pain, that is all I care about.”

“You’re right, of course,” I said. “A lot of the testing is just to generate dollars and cover my butt. In Nessie’s situation, if we aren’t going to be referring her, I just need to look and fix it if I can. I can do that surgery later this morning. I have some surgeries scheduled for this morning, but I can do those another day or do them this evening.”

***

With Nessie on prepped and on the surgery table, I draped her abdomen for a long ventral incision. I started the incision about an inch below her xiphoid process and extended it to an inch below her umbilicus. As soon as I entered the abdomen, I could see a massive splenic tumor.

I carefully worked the spleen out of the incision. I was worried that this tumor could easily rupture is I handled it roughly. When I had it out of the abdomen and laid on a moist towel, I could get a good look at the tumor.

This tumor looked like it had a mix of tissue in it, and it was unlike any splenic tumor I had seen before. That was probably not going to be good news for Nessie and Ayers.

The good thing was it was contained within the spleen, and by removing the spleen, we would be sure to get the entire tumor. The bad thing was if it was a malignant tumor, it had likely already spread elsewhere in the body at this size and appearance.

Starting at the tail end of the spleen, I started ligating the row of vessels, and I tied the ligatures close to the spleen. It was a tedious job, requiring over two dozen double ligatures. I severed the vessels between each double ligature as I progressed to the head of the spleen.

When the spleen was removed, and I double-checked all the ligatures, I returned everything remaining to the abdomen. I explored the abdomen for any other tumors. Finding none, I closed the incision in three layers, and we recovered Nessie. 

Nessie recovered well and was bouncing around the kennel when Ayers came back to pick her up at five. 

“Boy, that’s my Nessie” Ayers said. “She is back to her old self already. We can’t thank you enough, Doc.”

“Ayers, Nessie’s spleen had a large ugly tumor on it,” I said. “It will take several days, if not a week, to get results. But, Ayers, this tumor didn’t look good to me.”

“But you got it all, didn’t you?” Ayers asked.

“Yes, that is the good thing about a tumor in the spleen,” I said. “We just take the entire spleen out, so yes, I got it all. But if it is malignant and has already gone elsewhere in the body, we have probably only bought her a few months.”

“Well, like I said before surgery, Doc, if you can give her what time she has pain-free, we will be happy.”

***

The lab seemed to take forever, and I finally called them.

“This is Doctor Larsen in Sweet Home,” I said when the receptionist answered the phone. “I sent some tissues in over a week ago, and I haven’t heard a word out of you guys. I was just calling to check on the status of the tissues.”

“Yes, it has been a long time,” the receptionist said when she retrieved my file. “Let me connect you to the pathologist.”

“Doctor Larsen, this tumor is really unusual to see in a spleen,” the pathologist said. “I would say rare, in fact. I have been hitting the books on this one and doing some special stains, and I am just writing the report now. It looks like it is a schwannoma. These are rare tumors in the dog and exceeding rare in the spleen. Often a schwannoma is benign, but this one looks aggressive to me. I would give the owner a very cautious prognosis.”

“Is there anything else that can be done?” I asked.

“I don’t think there is a word written in the literature on the treatment,” the pathologist said. “There is scare little written period, only a couple of sentences that mention an occurrence.”

“Sort of the luck of the draw,” I said.

***

When Ayers was in with Nessie for suture removal, Nessie was still feeling great, and her incision was well healed.

“Boy, you should see her chase that squirrel out of the manger now,” Ayers said. “I think she is acting like she is five years younger.”

“These dogs are always amazing,” I said. “When I had my appendix out, I didn’t walk upright for three weeks. And Nessie is out there chasing squirrels before her sutures are out.”

“Have you heard anything from the lab?” Ayers asked.

“Yes, this was a very rare tumor,” I said. “It is a big word; it’s called a schwannoma. There is not much written about it being in the spleen. Often a schwannoma is benign, but you remember that I said it didn’t look good to me. The pathologist thinks it is likely an aggressive tumor.”

“How much time do you figure she has, Doc?” Ayers asked.

“I have no idea, Ayers,” I said. “When dogs have the most common malignant tumor in the spleen, they seldom live more than two months. But there is nothing written about this tumor. We just need to take things one day at a time. I like to tell people to count the good days and the bad days. When the bad days outnumber the good days, we should start thinking about putting her to sleep. But dogs are tough, Ayers. This tumor has probably been bothering her for some time, and she only slowed down in the last couple of days. She will probably go the same way, acting normal right up to the end until she can’t go another step.”

 ***

True to my words, Nessie lasted about six months following surgery. Ayers came in to tell me that he had found her dead in the manger that morning.

“I figure she was chasing that squirrel and just fell over dead,” Ayers said with a tear in his good eye. “I don’t know what I’m going to do now. I guess I will have to tame down that old tomcat that started living in the barn last winter. I have to have something to talk to, you know.”

“I know, Ayers,” I said. “You know, you can always come by here and spend some time telling stories here if you want. And I would bet that that old tomcat will think he is in heaven.”

Photo by Blue Bird from Pexels

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