Let the Facts Lead You to the Conclusion

One of the duties of a judicial law clerk is to help the Judge write his or her decisions. To do this the law clerk will review and summarize the facts of the case, research existing law in similar cases, write a draft of the decision and present those to the Judge for discusion, editing and publication.

When my husband Bill was a Law Clerk, he was given his first assignment to research case law for a recently finished trial. Not knowing how to even start, he asked the Judge who should win. The Judge gave Bill the advise he follows to this day as a Judge himself; "Let the facts lead you to the conclusion not the other way around." It sounds obvious, but sadly, it is not unusual for some judges to have a pre-conceived idea of what the final outcome should be and look for facts that lead to the decision they want to make rather than letting the facts lead to the conclusion they should make. By promoting their own ideas of how things should be rather than deciding the case on its merits, the Judge does a disservice to justice.

Every day, we Veterinarians find ourselves in a similar position. In my previous post I wrote how we are like Detectives sorting though the facts of a case. Just as it is important for the Judge to let the facts lead them to a conclusion, it is important for us to do the same. We develop our differentials list(the list of possible causes) based on the patient's medical history and our exam findings. Additional testing such as blood & urine tests, x-rays and/or ultrasound help us put the differentials higher or lower on the list. This, in effect, leads us to a conclusion, or in our case, a Diagnosis.

If we presume to judge a case by choosing only to use the history, exam or test findings that support our "diagnosis", we are not doing justice to our clients and patients. We need to use all of the information and let it lead us to wherever the diagnosis lies.

Why might we even choose to pre-diagnose and use the tests to lead us to what we want to find? There are many reasons. Perhaps because it is the quickest or easiest way to finish the case or maybe because we think we are doing our patient or client a favor by providing a quick answer, or saving them money, or sparing them from a diagnosis they don't want to hear. Ultimately, we are doing them a disservice by providing the wrong treatment and delaying or missing the opportunity to provide the correct treatment.

I'd like to share Bubba's story with you.

I met Bubba and his owners on April 16. His owners were concerned about his recent weight loss. Also, they observed that some of the urine clumps in the cat litter box were larger than they were in the past, and that one of the cats was vomiting every other week.

During my exam, I found that Bubba had lost almost 1 1/2 lb since last August, his right kidney was smaller than the left and he had a tooth with a resorptive lesion (similar to a human tooth cavity in it's effects on the tooth, but not due to the same cause).

I suspected that kidney or thyroid disease, diabetes, intestinal disease, pancreatitis or cancer were possible causes for his symptoms. I ordered initial testing including blood & urine tests and x-rays to give me additional information.

Results showed that Bubba had degenerative changes in his kidneys. His thyroid hormone level suggested that he had an overactive thyroid. Because the test results fit 2 of the diseases I suspected, I could make a case for starting treatment. However, to do so, I would have had to ignore other test findings and history. I needed to let the facts lead me to a conclusion.

So, I ordered additional testing. Abdominal Ultrasound and a recheck of thyroid hormone levels was performed a few days later. Bubba's weight continued to decline and his appetite was lower than normal. Ultrasound showed that there were irregularities in his kidneys, as well as changes in his intestines which can be seen with an overactive thryoid or intestinal disease. Again, the results matched diseases on my differentials list but given the fact that the changes were mild, I decided to set aside the information and re-test.

Repeat thyroid hormone testing was normal...confirming that I would have done a disservice to my patient if I had started treatment based on fitting the facts to a quick and easy "answer".

All of the facts lead me to conclude that Bubba did have chronic kidney disease and that he needed to start a special diet. However, when searching for the cause of decreased appetite and weight loss, the facts were not leading me to a conclusion that was on my list so I had to go back to the start.

Up to this point, I had focused on weight loss due to several causes, and had put taking care of Bubba's teeth on hold. After all, it was only 1 bad tooth and lots of cats show no ill effects from a single bad tooth. But the fact is, a painful tooth CAN cause decreased appetite, and decreased appetite CAN lead to weight loss, and intense pain CAN cause vomiting. As skeptical as I was that this one tooth was the source of the remaining problems, it was time to address his dental disease. Bubba needed an oral exam, dental x-rays and dental work. I had to let the facts lead me to a conclusion.

My surgery technician completed her dental probes and cleaning and was the first to see Bubba's x-rays. I was stunned to see the extent of his dental disease. It wasn't just the one tooth with a cavity-like hole in the enamel, there was also a loose tooth and both lower canines had roots that were being eroded away and were surrounded by large areas of abnormal jaw bone. Most likely I was seeing osteomyeleitis, bone infection, but was concerned about the possibility of bone cancer. My technician cleaned Bubba's teeth, I treated the tooth with the resoprtive lesion, I removed the loose tooth and the remaining parts of the lower canine teeth, and took biopsy samples from the diseased bone. I treated Bubba with antibiotic and painkillers during the dental procedure and he went home.

Bubba responded well. He ate. He gained weight. At his recheck earlier this week, I could see that the extraction sites were healing nicely.

Bubba is fortunate to have 2 very loving and committed owners who allowed me to use the advice given to my husband by a very wise mentor. Let the facts lead you to a conclusion. Had I stopped when I had enough facts to fit my initial suspicions, I would have been doing Bubba a great disservice and would have treated medical problems he didn't have while failing to treat him for the painful medical problem he did have.


This is a photo of Bubba's normal looking lower canine teeth


This is the x-ray of Bubba's lower canine teeth (what's left of them)

Normal x-ray appearance of lower canine teeth

The Veterinarian as Detective

We all wear many different hats throughout the day...spouse, child, parent, co-worker, friend, neighbor, sounding board...and your Veterinarian is no different.

A veterinarian may already know what the diagnosis is when initially presented with a sick patient, ...an owner may have walked into the room just as her cat swallowed the last string on the pot roast sitting on the counter (foreign body), or there may have been vomited plant material near a shredded diffenbachia leaf (the toxins mostly act as oral and GI irritants).

But what about a patient that has vague symptoms, or symptoms that are common to any number of conditions? Simple. We can ask, and we can listen to what we're being told.

Dr. Dolittle could talk to and understand animals in their own language but we can't. Fortunately for us, it's the rare cat that comes to the veterinary clinic unaided by a human who can help tell their story.

I was surprised to learn that Dragnet's detective Sargent Joe Friday never said "Just the facts ma'am." exactly. Nevertheless, that's how we all start our own detective work. It's called the medical history. By listening to the owner, and asking our own questions, we receive the first pieces of a complicated puzzle. For example, a casual remark from an owner about how she found ants at the spot her cat urinated (true story) was just the clue that I needed to check her cat for diabetes (bingo!).

The next step in our detective work comes during our physical exam. It is here where we make use of ALL of our senses to determine what our patients body is telling us.

While Dr. Cal Lightner on TVs "Lie to Me" isn't a detective, he's hired by law enforcement to do detective work in the form of interpreting clues gained through careful observation of body language, voice changes and expressions.

You all know basic cat language. You can distinguish the difference in your cats "feed me" meow from the one that says "I really don't like this car ride." You can recognize the difference between your cats straight up happy tail and a straight up fearful tail.

An experienced Veterinarian often picks up more subtle signals. For example a suddenly "finicky cat" may have a particular and recognizable lip licking that often accompanies nausea even if the cat isn't otherwise viually sick.

Sight, sound, touch,and yes, even smell give us clues.

An experienced Veterinarian will go where most owners dare not to go, into the mouth, to find a broken tooth that is so painful that our patient will eat it's canned food but not kibble. A stethoscope allows us to hear a heart murmur, for example, prompting us to check for heart disease, anemia or high blood pressure. We will palpate the abdomen and may feel an empty colon and that lets us know that our patient is not constipated as the owner had thought, but is empty because the cat isn't eating. We then need to look further to discover why. What was dismissed as "kitty breath", may actually be ketoacidosis, a complication of diabetes; an indication that uremic toxins are building up in the bloodstream due to kidney failure, or an infected tumor.

We've just scratched the surface up to this point and often need more clues to reach a diagnosis. Blood & urine tests, x-rays and in some cases, even more special testing round out our fact gathering. Hmmmm, do I sense another hat here? Just like the archeologist, as we dug deeper, and by doing so discover more about our subject.

We've gathered the facts and have used our observational skills and senses. We've gathered more clues with diagnostic testing. We've generated our differential list. Now we're ready to be the ultimate detective, Sherlock Holmes, and sort though the jigsaw pieces, and to put them all together to reach a diagnosis.

"I got worms in me"

Before sitting down to write my previous post, I turned on the TV and started channel surfing to find something to watch as I typed. I came across "Untold Stories of the ER" on TLC. I had missed the beginning, but became intrigued with the story about a woman who kept repeating "I got worms in me".

I watched as the perplexed ER physician tried to make sense of what this meant...she had intestinal parasites? how did she know? she swallowed worms? why?....and I, like him, was surprised as he discovered that his patient had actually placed earthworms under her skin in several locations. No doubt, this was the last thing on his mind as he ran though his differential list for a patient telling him she had worms in her!

It reminded me of the day a client had called our clinic saying that her cat had worms coming out of his abdomen. With the client still on the phone, the same process the ER physician went through was begun. What could "worms coming out of the abdomen" mean?

Knowing that tapeworm segments can be passed out of the intestinal tract in stool or on their own, and knowing they can move like inch worms once out of the body, we asked if there might be a small worm or worms moving on her cats fur....no, these were coming out of the skin. Having seen only 2 cases of maggots (and hoping never to see another case) we asked if the cat had cuts or sores on the abdomen...no, just the worms coming out of the skin. Might these be something other than worms...no the worm heads were sticking out of the skin. Unable to determine what we were dealing with without seeing the cat, an appointmet was made.

The worried owner and her nervous-at-being-at-the-vet but otherwise happy & healthy appearing cat arrived. Wishing to end the suspense, I eagerly began my exam. Several minutes later I happily reported to the concerned owner that I saw no evidence of worms coming out of the abdomen, her cat was fine. Skeptical, she proceeded to point out 8 "worms" evenly spaced, 4 in a row each on the left and right sides of her cats abdomen.

Have you guessed it by now? Sure you have. I let her know not to worry, these were nipples and very normal looking ones at that. She was quite surprised to hear my diagnosis, and skeptical of my diagnosis, pointed out to me that this was a MALE cat. Seeing that she was wearing a wedding ring, I gently asked "have you ever seen your husband with his shirt off?" and waited for her to make the connection.

A sheepish owner left the clinic with an anatomy lesson that will never be forgotten. A cat left the clinic with a diagnosis of good health and nothing more than a good "massage". And I reaffirmed my belief that a diagnosis can't be made over the phone, the patient needs to be seen.

Introduction to the Cat Care Clinic

Before letting you know more about myself and sharing stories and experiences accumulated during 20 years of feline-only clinical practice, I want to introduce you to the place I work, the Cat Care Clinic, in Madison, Wisconsin.

http://www.catcareclinic.net/

Not content to follow the "cats are small dogs" approach so common at the time, my employer Dr. Ilona Rodan, realized her dream to practice the best medical care for cats as well as provide excellent service and education for their owners in January 1987 when the Cat Care Clinic first opened its doors.

We are members of the American Animal Hospital Association (AAHA), the only organization that accredits animal hospitals throughout the U.S. and Candada. AAHA membership is voluntary. To acheive accreditation, we are evaluated on 900 standards, and must demonstrate an exceptional level of medical care and client service. We are re-evaluated every 3 years to be sure we are keeping up with industry standards.

Besides myself, there are 2 other Veterinarians at the Cat Care Clinic. Clinic owner and Medical Director, Ilona Rodan, has practiced veterinary medicine for over 31 years. In addition to working with her feline patients and their owners, she has compiled a distinguished list of accomplishments including becoming one of the first group of veterinarians to receive American Board of Veterinary Practitioners (ABVP) certification in Feline Medicine; having been President of the American Association of Feline Practitioners and Academy of Feline Practitioners; as well as co-authoring several AAHA Veterinary Guidelines.

Dr. Mandy Miller joined our staff 12 years ago. While here, she has completed an ABVP-approved Feline Residency Program and is now also board-certified in Feline Medicine. In addition to practicing veterinary medicine Dr. Miler has launched Roving Woolens TM; premium, handcrafted, eco-friendly petwear. Check her out at http://www.rovingwoolens.com/
A portion of the profits help to support "Pets for the Planet TM".

Now that you know more about the clinic and the other veterinarians I work with, let's start to have some fun!

Welcome

Welcome to my Blog!

My name is Dr. Laura Challoner, DVM.

After graduating from the University of Wisconsin School of Veterinary Medicine in 1990, I began to practice feline veterinary medicine. I only care for the animal I love most, cats!!!! I work at the Cat Care Clinic in Madison, Wisconsin. It is the only veterinary medical job I ever applied for and the only job I have had for 20 years.

I hope to share my thoughts in this Blog, offer some tips and tell some stories (I have a TON of them). I'll try to update the blog periodically and hope someone will read and comment (try to be nice, LOL!) as we share the world of the animals we love and cats, in particular.

Talk to you again soon!

Cat Dr Laura