Waiting for water to boil

Editor's Note: Sometimes the earliest experiences are the most memorable, especially for veterinarians tossed into the real world of medicine. This new blog chronicles the life and career of Dr. Andrea Honigmann, an associate veterinarian at Smoketown Veterinary Hospital in Smoketown, Pa. There is no question that the first few years of a veterinarian's career set the stage for a lifetime of stories.

03-05-08 -- When a couple thinks about marriage, certain topics usually come up before they commit their lives to one another. When will we have children? When will we buy a home? How will we deal with finances? These are some of the big questions my husband, Mark, and I discussed. In fact, I remember discussing potential names for our future children one night at a restaurant. Those names now reside in an e-mail sent to myself, waiting for the day when we have two-legged children (in addition to our four-legged ones.)

Mark and I moved to Lititz a little more than a year ago. We looked at rentals in several parts of Lancaster County, including a house on the edge of a chicken farm. Luckily, we did not end up on that chicken farm and found a great three-bedroom townhouse in the borough. After getting settled, we realized this house would be plenty adequate for us until we had our first baby, and in all likelihood, until that baby learned to walk.

That plan was just fine until about three weeks ago. I walked into the exam room to see Oscar, with his yellow-tinted teeth (from tetracycline as a young dog, before I knew him). Oscar came to see me for a recheck related to his drug therapy for atopic dermatitis. I have finally gotten him to every third day dosing, and he and his family seem much happier. The recheck was relatively quick. I discussed the medication with the client, asked her about how he was doing at home, did a brief physical, and wrote up a refill. I was thrilled that I would have a few minutes to make a phone call or two since I was destined to finish this appointment early.

But not so fast...Toward the end of the appointment, the conversation turned to life outside of the hospital and, suddenly, I was in the middle of a real-estate discussion and wondering how we so quickly deviated from Oscar. The client wanted to send some real-estate listings to my e-mail address.While the thought of purchasing a home in this "buyer's market" was intriguing, I had a pretty good feeling that it wasn't going to fly with my husband. We had a plan. Our mantra was "stick to the plan."

As promised, she sent listings that fit some criteria that I knew we wanted (eventually). When I received them, I was en route to Kansas for a Hill's Pet Nutrition seminar on evidence-based medicine. Even though I was still thinking that this was not an option for me and Mark, I forwarded the e-mail back home to my husband, noting that I kind of liked one of the homes on the list of three choices.

Imagine my surprise when I read my husband's reply that said he thought about the situation, and we should at least look for a house. With that, I e-mailed the client/realtor and set up a viewing of the house that looked promising based on the MLS listing. Was this really happening? Were we going to be homeowners?

Sitting in the hotel room, I started crunching some numbers and playing with mortgage.com calculators. It turns out that it would be possible, but it would mean that I would have to pick up some shifts at the local emergency hospital, at least through the summer. I looked at it as a double-edged benefit: It would be extra cash for us to put toward a mortgage and also allow me to practice emergency medicine and become a better doctor.

The morning of the scheduled showing, I felt my cell phone vibrate in my pants pocket. I realized then that I forgot to drop it off at my desk. I finished the appointment that I was in, and just before surgery, went to the doctors' office to listen to the message. It was the client/realtor, who informed me that the showing was off. The house went under contract before we could see it. With my trip to Kansas, we did not have the opportunity to act quickly, and the house was going to be someone else?s home. She reassured me that there were other properties. The meeting was still a go, and we planned to meet at Starbucks in Lititz later that evening.

After grabbing some Starbucks hot chocolate for me and my husband, we were off in the client/realtor's car, with GPS set, to find three homes for showings. The first, a corporate relocation, was empty, sterile and devoid of any charm. While I immediately noticed the resemblance to the home of one of our friends, my husband simply noticed the plainness of the house and didn't feel like it could be made into a home for us. That house was off the list as fast as it went on the list.

The second house was in a neighborhood that Mark recognized right away as the one that we got lost in shortly after moving to our current home. We walked through downtown, and on the other side, ended up in this neighborhood. At that time, I remember Mark saying it was the "land of milk and honey," as the neighborhood was immaculate, with gorgeous homes lining both sides of the street. I also remember us joking that we would never be able to afford living in this particular neighborhood.

Our only saving grace, the client/realtor told us, is that some of the owners in this neighborhood have found that they cannot afford their mortgages in this economy. Some of the houses were entering foreclosure, which could mean that we could get a great property, but in our price range. And with that, we entered one of the milk-and-honey houses and were in awe. It was perfect. It had the number of bedrooms and bathrooms that we wanted with a large great room and even a whirlpool tub in the master suite. The basement was finished, too! The real selling point, though, was the friendly gray cat that helped to give us a tour.

The next night, this time at McDonald's, Mark and I signed a bid for the house. We were pre-approved for a mortgage earlier in the day. We sat there realizing that in the land of inexpensive cheeseburgers, we were making a move that could change our lives forever. It was surreal for both of us. And so, the waiting started. We hoped to have an answer from the bank in two to five business days.

The waiting is the worst part, I realized. To top it off, a weekend and a bank holiday broke up that two- to five-day window. By Wednesday morning, the fifth business day, my husband and I were anxious and nervous.

The day came and went with no word from the client/realtor. Frustrated, we were told that patience was key and that the two to five days was "only a guideline." Many different scenarios were presented to assuage our irritation and explain away why the bank had not answered our bid. Perhaps the mortgage lender of the seller was a two-person operation in the middle of Montana, snowed in and without power. I checked the Internet. There was no such snowstorm. Perhaps the mortgage lender was swamped with other foreclosures. I envisioned our bid in a pile of paperwork on someone's desk that resembled the man sitting in the basement of "Office Space." I had my doubts, but it was more plausible than the first.

Amid my frustration was the encouragement of my parents, mainly my mother, who has completed several real-estate transactions in her lifetime. She admonished me to call my realtor/client and insist that she do something. Of course, I had been doing that, sending her multiple e-mails daily but only getting back "be patient" responses.

So, Mark and I will continue to "be patient," although it is probably the hardest thing we have been asked to do together as a married couple. While we go about our daily lives, or try to, every cell phone vibration and overhead page makes me think that this could be the call. So far, I've been disappointed. Eventually, maybe disappointment will turn into our dream home, but at this point, real estate is just a bunch of new language to learn (with a glossary included), lots of paperwork and even more waiting.

Karmic punishment or a silver lining?

03-03-2008 -- Being away for nearly two weeks attending continuing education does two things: The first few days back to the hospital on a normal working schedule make me very tired! So much so, the Starbucks' baristas recognize me and recite my drink order before I can open my mouth. Secondly, there's some sort of karmic punishment for being away. It seems like a fair number of interesting -- sometimes even difficult -- clients flock to my schedule.

The clichd silver lining to these aforementioned clients is Harley, a young kitten that I?ve been seeing for several weeks. It started on Tuesday morning. Typically, I see appointments until 10 a.m. and then head to the surgery room until lunch time. This day was different; I did not have any surgeries scheduled. So, I picked up a transfer from another hospital. The other hospital was sending the client with her kitten to us for a blood transfusion. As I heard it, the little one had a PCV of 8! Single digits are never good news, but I was willing to give it a shot. The only bit of fear that rose up in me was in knowing that I had not participated in a blood transfusion since veterinary school.

A couple hours later -- after reviewing the kitten's history (mostly unremarkable and the owner had done everything her veterinarian had asked), completing a physical exam and then pouring over a couple textbooks to figure out the math behind transfusion medicine -- the kitten was receiving a blood donation from one of our senior doctor's cats. The kitten was so lethargic and didn't seem to care that there were two IV lines flowing into her. Warmed up, the smelly, soft kitten food didn?t interest her either. If I could get her PCV up, I would feel more confident about telling her owner that the prognosis was at least guarded. I crossed my fingers and toes, and continued to monitor her.

Two days later, her PCV was up to 15 and holding steady after several PCV checks. She was not out of the woods yet, for sure, but she was eating her kitten food, cuddling up to me and the other team members. She wanted to be a kitten again. She was discharged the next day, on my day off. One of my colleagues instructed Harley's owner that it was important to realize that we still did not know what caused the anemia, and we needed to monitor Harley for several weeks. (CBC revealed no blood parasites, and two separate FeLV/FIV tests were negative previously.)

The call went out to an internal medicine specialist at a diagnostic laboratory. We established that the kitten had a mild regenerative anemia, and that it might take several rechecks to Harley's hematocrit and white-cell count to normal levels.

The little one finished her antibiotics and continued to come in regularly. At her last recheck before I left on my traveling spree, her hematocrit was normal (34!), and her WBC count was coming down, slowly.

Harley was my first patient yesterday morning. She had become a Velcro kitten, quite attached to her owner. I still have not heard her "meow," but she seemed so bright and happy. Her mucous membranes were the pinkest I've seen, and her owner, who had been diligently checking them, agreed. I was confident that the CBC results would be fantastic. Her owner and I discussed that as long as her CBC results were within normal limits, we could schedule her spay in the near future, too.

That was good news for the owner; Harley is the only pet in the home that isn't spayed or neutered, and the owner wants it done as soon as possible.After all the "interesting" clients in between Harley and the end of the day, I saw that Harley's CBC results were returned sooner than I had expected. Her chart made its way back to my cubby with the lab report sticking out perpendicular to the medical record. I pulled out the lab report and was disheartened to see that the hematocrit was only 0.3 points higher than it was three weeks ago. And my heart sank even more to see that she still had a leukocytosis, and it was significantly higher than the value three weeks ago.When I return to the office, the very first thing I will do is place another call to the laboratory to seek another opinion on Harley's not-as-wonderful-as-I-had-hoped bloodwork. It does not match her clinical picture. I think the next step might be a bone-marrow aspirate, but before proceeding with an invasive diagnostic such as that, I want some reassurance that I am moving in the right direction to figure out her case. While I'm waiting on the return phone call, I will definitely talk to my colleagues, too. It is a benefit of being in a practice with a large number of doctors. There's always another colleague to consult with and perhaps give me a different perspective or ask a question that I had not thought of before that will be the missing link in a definitive diagnosis. Harley's story will continue soon?

Medical intuition

2-15-2008 -- Something stirred me from sleep. A sound that was distant, but somehow close. Five minutes later, as my eyelids came unwillingly apart, my brain registered that I had fallen asleep on the couch after my husband left for work. The TV was still on, showing some dramatic movie on cable that I didn't recognize. And then I realized that the sound I had heard was my cell phone. The missed call had come from the overnight technician at the hospital.

Ten hours earlier, I met the patient that provoked the middle-of-the-night phone call. In Lancaster County, there is a considerable Amish population. Because our hospital sits near many Amish farms and homes, we see a significant number of Amish-owned pets, mostly dogs. Instead of seeing dogs hit by cars, we see dogs hit by buggies, wagons and other farm implements. For the most part, these cases are treated in a very similar fashion, but client management is slightly different with the Amish due to, in part, their means available for communication.

The 5-month-old Sheltie puppy came in with an obvious traumatic wound on the left rear leg, a wound that was created when the pup and a hay wagon wheel did not agree on traveling in opposite directions. The skin had slipped up creating a parallelogram-shaped wound extending several centimeters proximally and distally from the stifle. The rest of the exam was consistent with patient in shock after a traumatic injury, and certainly, the internal organs and vascular status needed to be addressed. Although I joke sometimes with clients that doctors are not allowed to use the computers because we just mess them up, I created a quick estimate for the owner.

There will always be someone who says "no" to the cost of treatment, as did this Amish client. But I was not prepared for him to raise his voice to tell me in no uncertain terms that he did not want or agree to sign an estimate for pre-surgical blood work, radiographs or anything but "stopping the bleeding and suturing up the leg." As professionally and even-toned as I possibly could, I told this middle-aged man that it was not necessary to raise his voice to me in the exam room.

I do not think he was expecting me to say anything back to him, but I took the opportunity to stand up for myself. During my time at this hospital, I have learned that being a female veterinarian amid a culture that does not have a favorable view concerning women in the workplace is a touchy and sometimes difficult situation to overcome. Against my better professional judgment and fearing that there was some type of internal damage, I admitted the dog and sutured his leg during my dinner break. I phoned the owner and spoke to his answering machine in the barn, knowing that I had a small chance of contacting him.

After evening appointments, I checked on the puppy, sleeping in his cage, but still breathing heavily. Just a few short hours later, the technician's phone call relayed information about the dog's deteriorating condition. The puppy was turning pale, could not breathe well on its own, and had a tense abdomen. What I had feared earlier had to be true. And in the middle-of-the-night, surely the client was not in the barn to hear the phone ring.

I sped into the hospital, hoping that the area's police officers were nodding off somewhere not along my path. The pup was in the oxygen cage when I arrived.

Although the sutured wound looked wonderful, the puppy needed life-saving measures. Radiographs revealed a pneumothorax and a diaphragmatic hernia. Suturing the leg earlier in the day was like throwing an eyedropper's worth of water on a house fire. I tried to make the dog as comfortable as I could, and called the owner to no avail. My best chance was to hope that he had cows to milk early in the morning and would listen to his messages.

Unfortunately, the dog passed away at 4:30 in the morning, and I left my last message on the phone in the barn for the client.

I was angry. But when I calmed down, I realized that I did all I could, based on my experience in practice and my communication with the client. Next time, I think I will take the radiograph anyway, even if the client isn't charged for the service or is only charged a percentage of the fee. I do not like to give away my services. But in this instance, I should have followed my instincts. A single radiograph would have saved this dog a significant amount of distress later in the evening.

Saturday, Jan. 26, 2007

Most of our doctors work every other Saturday. It's a half day, working until noon. Often, the only thing typical about Saturdays are the atypical appointments. Most of the cases are emergent, with the occasional vaccine appointment for those clients who cannot come in at any other time. Friday evening, I reviewed my schedule and saw that I had a 13-year-old cat coming in with the chief complaint listed as “urinating and defecating outside of the box; vomiting also.”

Mrs. Fable (names of clients and pets have been changed), her husband and daughter all arrived on time with their cat, Trouble. I introduced myself politely and commented on the husband's college football sweatshirt. (I'm one of the few Ohio State football fans in a Penn State world.) After reading the chart and having a discussion with the owners, it became clear that this cat had not been to the veterinarian since his kitten visits. He had been vomiting at least weekly (or more, according to the husband) since then. And as for the urinating and defecating outside of the litter box, that bad behavioral habit had been ongoing for about two years (or longer, again, according to the husband).

I did a physical exam, and other than dental disease as you would expect, nothing spectacular jumped out at me. I made some recommendations for diagnostics and environmental modifications at home and offered to take Trouble to our treatment area for a blood sample. With a blank look from Mrs. Fable and a quick glance between Mr. and Mrs. Fable, she asked if they could speak with me outside of the room. My technician stayed behind with the daughter, and I spoke with the Mr. and Mrs. in the next exam room.

As it turns out, Mr. and Mrs. Fable were very frustrated with this cat, and in their mind, had done all that they could with the feline.

The appointment was a farce. After discussing their annoyance, they wanted me to tell their young daughter that the cat was very sick, and there was nothing that could be done for it.

I offered a transfer to a no-kill shelter, or even a farm (with plenty of those in the area), but the Fables were not hearing it. Ultimately, I told them that ethically I would not lie to their daughter. My ethics were tested again when they asked me to euthanize Trouble.

Later that same day, my husband and I drove over to Philadelphia for a Flyers' game. The Flyers were playing the New Jersey Devils, which according to the veterinary hockey fans I meet, was a rival match-up. While neither of us are hockey fans (we're baseball people), a particular pharmaceutical company was sponsoring a continuing education event, followed by dinner, drinks and the game in a private box. I tried to watch the action on the ice, but quickly became frustrated by a lack of knowledge of the game. And contrary to what I expected, there were not any knock-down, drag-out fights on the ice. I've seen better brawls in baseball! I had more fun interacting with the other attending veterinarians and their guests, including two of the doctors from our practice.

One of those veterinarians has been practicing for many years and has much wisdom in handling difficult situations with clients. I told him of the morning's appointment; he smiled and said he would have put the decision back in the Fables' court. By explaining to the daughter that more tests were needed to determine what, if anything, was wrong with Trouble, he would have then waited for permission from the parents to continue.  I'm not a parent yet, and the thought of using the daughter to my advantage never occurred to me. It was a situation that I filed away in my memory bank, hoping never to have to use such tactics again. I also mentally kicked myself for not thinking of a better resolution for the Fables and their cat.

Live and learn, and move on to Monday.