Your pet is sick, and you are suddenly facing the need for what could be an expensive, and invasive, medical procedure. It has all happened so quickly, that you had no time to prepare emotionally or financially.
The veterinarian is making recommendations for diagnostics and treatment, and it seems like he or she is speaking another language. You know you should be asking more questions and expressing concerns, but you are worried that your dog has a life-threatening condition, and now they are talking surgery. You just listen, and trust that whatever you are being told to do will treat the problem effectively.
On the other side of that conversation is a veterinarian, who does not yet have enough information to say exactly what the problem is. But this is a medical professional and, as such, must appear confident and knowledgeable. He, or she, has presented a list of possibilities, otherwise known as “differential diagnoses,” or “rule outs,” but likely has a short list of prime suspects in mind. The initial diagnostics are generally directed at what is considered most likely.
The vet saw a client nodding in agreement, apparently understanding what was being said, asking few questions and raising no concerns. The client saw a confident medical professional and filled the gaps in understanding with assumptions, and trust. The client assumed that the recommendations were based upon knowing what the problem is, and the vet assumed that the client understood that they were based upon what it probably is. This gap in understanding ensures that the only way both parties will be happy is if the problem is the prime suspect. Inevitably, there will be times when this is not the case.
A young dog, with a known tendency to chew things up, like the children's socks, recently was brought to our (Henri Bianucci) emergency clinic. The dog appeared painful in its abdomen, and could keep nothing down.
Basic testing ruled out parasites or certain viral diseases, while abdominal X-rays were strongly suggestive of an intestinal obstruction. This determination was rendered by a board certified radiologist. There are other tests that could help confirm the diagnosis, such as a CT scan, or abdominal ultrasound, but even these may not yield a definitive answer, and they would constitute a delay and additional, possibly unnecessary, expense.
Virtually any veterinarian would, at this juncture, recommend an abdominal exploratory surgery. Further diagnostics would likely add little, and the risk of waiting includes severe damage to the intestine, which could result in perforation, leakage and a life-threatening infection, known as peritonitis.
This is what the vet was explaining. She also explained that there are things that can cause similar signs, which do not require surgical intervention. In other words, this exploratory procedure may serve only to rule out an obstruction, because it failed to find one. This is known as a “negative exploratory.”
There is a saying: “Better a negative exploratory than a dead dog.” This doesn’t mean that we don’t try and avoid that occurrence. It simply means that when the preponderance of evidence supports the need to treat, or rule out, an obstruction, and the risk of waiting includes a much more severe illness or death, we often suggest an exploratory.
In our example case, the client agreed to the exploratory. Upon opening the abdomen the surgeon identified abnormally distended intestines. They were bruised and inflamed looking. However, there were no perforations, and there was no obstruction. A hard object was found in the colon, which turned out to be a walnut. It appeared that there had been an obstruction, but by the time of surgery, it had cleared itself.
The good news was that things were going to get better. No intestinal incisions were needed, so the risk of post-op complications was low. We now knew that with a little more supportive care, the patient would improve, and we were not missing something else.
While we did not find an obstruction, we ruled out that anything worse was happening and determined that the prognosis is excellent. We gained a diagnosis, guidance for continued care and peace of mind. Although “negative,” this exploratory yielded a wealth of information. But did the client see it that way? Not at all.
Prior to surgery the client was under severe emotional stress. She thought her dog might be dying. Afterwards, that stress was immediately alleviated. Maybe that made her see things differently. Suddenly, not only was the dog not dying, he now had a surgical incision that now seemed to be unnecessary. She greeted the news by exclaiming, “So we did surgery for nothing?”
This is simply a cautionary tale to both sides of an exchange such as this. To this client, everyone appeared to believe an obstruction was likely, and the her perception was that the goal of surgery was to remove it. Finding that there was not an obstruction made surgery seem a failure.
The client needed to understand that they had reached a point where it was critical to rule out an obstruction, because if there was one, things were likely to get worse.
The goals were to rule it out or confirm and remove it. With that understanding, the surgery would inevitably reach at least one goal.
In the course of a medical emergency, emotional states can range widely. As these change, so will the ability to comprehend and interpret information. An awareness if this factor, on both parts, is critical to preventing a disappointing or frustrating outcome to the course of medical or surgical treatment.