Be as insistant as you want, but you're still not coming back there

The BBQ Pit
1

Sometimes I really have to wonder what the hell it is people think happens in the employees-only area of an emergency clinic. I don’t know how many times I’ve had to explain that this is a medical facility, and that we cannot perform medical procedures with owners in the area; thus, owners are only allowed in the back in very extreme cases, and NEVER while we are working on an animal. I’m thinking it’s somewhere in the neighborhood of a million times.

Last night was the million and first. A couple brought in a little dog who appeared to be in hard-core respiratory distress, and we snatched him up and ran him back to the treatment area without getting any history on him. With the other four techs starting the little guy on oxygen and setting up for IV fluids, and the vet listening to his chest, I went up to talk to the owners. Usual procedure for this sort of situation is for us to explain that the animal will probably need a lot of work to get it stablized, and have the owners sign a critical care consent form, along with finding out what kind of code status they want. This saves us running back and forth to get permission for oxygen, and for fluids, and for bloodwork, and for radiographs, and to tell them the animal’s not breathing and what do they want us to do, and so on and so forth.

I’m trying to have this conversation with the couple, when the woman says “I want to go back there.”

I explain to her that owners are not allowed in the treatment area, but as soon as the dog is stablized, the doctor will be out to talk to them and then they can see the dog.

“No, you don’t understand. I’m insistent. I’d hate to have to scoop him and take him out of here.” Very snotty, very condescending, very nobody-ever-dares-tell-the-Queen-no tone of voice.

What I thought was: No, bitch, YOU don’t understand. It doesn’t matter a fart in a high wind how insistent you are, your ass ain’t coming through that door while the crash cart’s out. You can fucking threaten to deny your dog life-saving medical intervention to get what you want, but that shit ain’t gonna fly here. You can sit down and shut up and let us do the work you asked us to do, or I can go get you an AMA form so you can take your dog out of here and watch him die. Your choice, toots.

What I said was, “Well, that certainly wouldn’t be in your dog’s best interests. Right now he doesn’t look particularly stable, and we’re putting him on oxygen and probably starting him on fluids so that we can get him stable.”

“Well, I can pet him while you do that.”

“No, ma’am, you can’t. There are currently four technicians and a vet working on your dog, and there’s no room for non-medical personnel to be around him right now.”

“He needs me; he’ll be scared back there.”

“Ma’am, what your dog needs right now is for us to be able to work on him, and we cannot do that with you back there. When he’s stable enough for visitors, I will personally come out and get you.”

She finally mutters, “Okay, a few minutes.” But the whole time, she’s got this look on her face, a really ugly mixture of fury at being balked and disbelief that a lowly peon like myself would dare not give a customer what she wanted.

What are people like this thinking? When someone asks you to clarify code status for someone you’ve just brought into the ER, that generally indicates that things are pretty fucking grim, right? Or at least that the patient isn’t in any shape to be having visitors at the moment. Or is it only medical personnel who interpret such questions to mean that the patient seems likely to die? Am I really that out of touch with the non-medical world? Do people just not realize that an animal ER is first and foremost an ER, and making people happy has to take a backseat to doing what’s in the best interest of the animals?

I don’t care that the woman wanted to be with her dog; I’ve had a lot of distraught owners try to talk their way into the treatment area before, and many of those think that they’ll be able to comfort or restrain the animals better than we can. I’ve even had to take a few by the arm and lead them away from the door to the treatment area. Those people don’t bother me a bit; they’re distraught, after all, and they’re just trying to help. Once you inform them of the policy and tell them that this is what’s best for their pet, they bite the bullet and sit down to wait for an update.

This woman, though…she had a pretty crappy attitude about the whole thing, and that annoyed me. And the threat about taking her dog away and letting it die unless she got what she wanted, that just pissed me right the fuck off. I know what she thought would happen. She figured we’d give let her come back rather than let the dog go without treatment. She had no intention of actually refusing to let us treat him, she was just using it as an empty threat. But what kind of person uses their pet’s life as a bargaining chip? How twisted do you have to be for something like that to even occur to you?

2

I can understand the person wanting to be with the pet to comfort it, but once one of the medical staff explains why that’s not possible, I can’t understand why they wouldn’t do whatever is going to best for the animal. I’ve only had to use an emergency clinic once, after Auggie, The Cutest Dog on the Planet ™, was attacked by another dog while we were on our evening walk. They were both on leashed, the other dog just disliked poor Auggie on sight and got away from her owner and bit min twice before we were able to separate them. Our vet was closed, so we took him to the emergency vet.

 Since he was more scared than hurt, they let me stay with him, but I was prepared to have to wait somewhere else if they told me to.  Hell, if they told me that I needed to stand on my head in dog poop to help my dog, I'd do it.
3

So, um…

Was the puppy OK?

4

For the moment, I guess, but in the larger sense probably not. He was having a lot of neurologic symptoms typical of vestibular disease, and the respiratory problems were because he was so stressed by everything getting all topsy-turvy on him. After some blow-by oxygen, a sedative and some subcutaneous fluids, he settled down enough that they were able to take him home for the night. Unfortunately, the fact that the symptoms came on full-blast out of the blue suggests that the dog probably has a brain tumor or lesion, rather than just old dog vestibular problems.

Of course, neither the owner nor I knew any of this at the time of conversation. All we knew was that the tech who took the dog in felt it was serious enough to snatch the dog and run, and that the vet told me to get the crash cart and some trach tubes, then go get a critical consent form, code status, and history on the dog. For all either of us knew, the dog was coding while she kept pushing to go back there.

5

Damn, I had a long post typed out, and then the server ate it. I’ll try again.

“Coding” does not automatically equal “emergency” to me - it’s a piece of medical jargon that I recognize, but it doesn’t evoke any kind of “shut up and listen - this is important” response in me. I most often hear the word either in the context of computer programming, or in the context of indexing boxes of discovery documents so we can find what we need when preparing for trial. Maybe if you said, “we need consent before we can do some kinds of emergency lifesaving measures - could I go over this with you quickly, so I can get it to the doctor right away?” it would sink through her skull a little better.

I get cold chills at the thought of one of my cats in that back room, with strangers doing kindly-intended but probably painful things, and without me even able to stand in a corner and tell him, “I’m right here, it will be OK, just please stay strong for Mommy.” I understand how it can be necessary, but in the heat of the moment, I might say anything trying to get back there. I don’t think I’d act like your queen bitch, but I just don’t know.

I hope the dog ends up OK.

6

I wouldn’t dream of getting in the way of my vet or her techs while they are working on my dog or cats. But I am grateful that her’s is a small informal sort of place where if I ask to be with my pet, her answer has (so far) always been “of course.” There is even a chair in that dreaded back room, over to the side a bit, for people like me who would prefer to be there.

7

Thank you!

8

My father underwrote the liability insurance for the AVMA for many years. One of the things they told their vets was to never…NEVER work on an animal with the owner present. And for good reason. An animal in distress can behave violently, and someone can get hurt.

Case in point: an owner simply HAD to be in the stall when the vet was performing some procedure or another on the horse. The vet said NO, the owner said YES…yadda, yadda…the vet caved and let the owner hang around. Well, the horse spooked and kicked the owner in the head, catapulting him into a permanently vegetative state. And…you guessed it…the owner’s family sued the vet for the accident (and rightly so).

Case #2 (and I was the dork on this one…): My vet (a rather small-time neighborhood guy) asked me to hold my cat while he gave her a rabies shot. My kitty spooked and he accidentally stuck me with the needle! I was scared shitless, but kicking myself for not saying, “NO. You and your staff are paid to treat my animal.”

Vets don’t think you love your pet any less if you don’t carry on like a hysterical twit right there in the room with your animal. Use your head and let the doctor use his. Everyone will be better off.

9

No offense, but she doesn’t sound “twisted” to me at all. She didn’t scream or rant and rave or knock you down trying to get back there, at least according to your detailed account. She just sounds really scared to me.

Her beloved pet was terribly sick and she isn’t the veterinary professional you are. With some insistance from you she did concede the point. She didn’t call you a lowly peon. Really, I think it understandable someone might lose their head a bit in such a crisis. Isn’t that an understandable faux pas?

10

So scared she threatened to leave with an animal she thought was dying, eh? I’m sorry, but normal people do NOT think of their pets as footballs that they can just take home when the game doesn’t go their way.

11

My little dog had an encounter with a Ford Excursion in front of our house as we were loading the car for vacation. Fortunately for all of us, she hasn’t a brain one in her hard little head, and the tires did minimal damage to her. I also firmly believe that her head getting ran over saved her life ultimately. I don’t think her belly would have survived it.

Anyway, we rushed her off to the 24 hour emergency vet as we didn’t think anything was broken, but she was bleeding from a couple spots and I obviously couldn’t ascertain if she had any internal injuries or not. We told the gal at the front desk what had happened, and we were immediately taken back to the back room. I was actually quite surprised by this, as I expected her to be whisked from my hubby’s arms. They got her history from us while we were keeping her calm (she was just a shaky little thing, she’s a very sensitive little dog) and then began the seperation process. Hubby and I were both quite distraught over the whole incident, but they handled both us and our dog very well. It’s the only time I’ve been to an emergency vet where they took us back with the pet.

We ended up leaving her there overnight for observation and got some xrays done. We picked her up the next morning. She had a cut over her eyebrow, and some abraded areas on her paw and elbow that they gave her stitches for. The only other thing that was wrong was one of her little paw bones was dislocated. They told us that it’s a bothersome injury, and we were going to have it taken out surgically if it bothered her after a few months. Fortunately it worked itself out after about 4 months, and she’s a happy little dingbat again.

12

You sound kind of like a prick to me. I don’t think I woulld bring my animal companions to a place like yours.

13

Yeah-huh. This means bupkiss to me. What are you saying?

14

I think you should cut the owner some slack. Clearly she was highly upset. OK, so she threatened to take the dog away. But she didn’t. The dog stayed and got the treatment it needed and she stayed out of the treatment room.

So she wasn’t entirely pleasant to deal with during this highly stressful time. Unfortunately, civility can be the first thing to go when we are stressed. I wouldn’t take it personally.

Haven’t you ever said anything you’ve regretted later when you’ve been upset?

15

county, you’ve been so well-behaved lately. I’m sorry to see you’re back to your drive-by, asshole self. I was enjoying the new you.

CrazyCatLady said this has happened a million times before, and she said this woman was condescending. You don’t need a building to fall on you to snap, you just need a straw. If this is just a representative sample of the countless repeated situations, I’m sorry for her frustration.

My instinct would be to go in with my animal, and hold it until its last breath. I see, logically, that it wouldn’t be the right thing to do, but only because I’ve read this thread. Must be a tough job to counter instinct, and heartbreak.

I don’t think the woman was acting out of anything but love for her dog, and using “tactics” to get to the little fellow. Tactics that have probably worked for her before. But CrazyCatLady has every right, in the heat of the moment, to get upset at the snideness, to keep her head while in the situation, and to come to the boards to release the tension later.

Um, yeah, in other words, what Frank said. All bravado in the face of fear.

16

My dear CatLady is still asleep, but I’m pretty sure she didn’t phrase it as “could you clarify your cat’s code status for us?” “Code status” is “how far we should go to keep the patient alive”.

In my world (medicine for people), this could be “full code”, in which we intubate the patient, perform CPR, and give any drugs necessary to keep things going. It could be “No Code Blue”, aka “Do Not Resuscitate”, in which case we hold all such measures. Unfortunately, it can also be a “limited code”, where we are limited to some combination of mechanical ventilation, shocks, and drugs. (I say unfortunately because there is evidence to show that these codes are almost never successful.)

(The combinations can be bizarre–one person I know had a patient whose daughter said that they gave her uncle atropine and he died. so we’d better not give him any atropine. Since atropine is part of most ACLS algorithms, and is thus often given after one’s heart has stopped, this is probably the best example of post hoc ergo propter hoc I can think of.)

So “clarifying code status” simply means explaining the things that could happen to the patient, the interventions that could be made, and the likely outcomes, and agreeing on what is appropriate. I do this with most people who are being admitted to the hospital, but when the tech at the emergency clinic is doing it, it is not a good prognostic sign. (“Don’t buy any green bananas,” as we say.)

In any event, I run a lot of codes and I’m around for a fair number of emergent procedures, and as a rule, they are not pretty. I would most certainly not want to see it done to anyone in my family–in which I include my dogs and cats–nor have them see it done to me. Our code team includes one person whose job it is to get the family and/or visitors out of the room. If the code is unsuccessful, you don’t want your last memory of your family member to be him sprawled out naked with tubes going in everywhere, getting his chest pounded and writhing with electrical shocks. (It’s a rather violent process, which is why we don’t like to do it when we think the chances of meaningful recovery are low.) The same is true for Fluffy or Fido.

Besides, this situation is only complicated by the presence of extra people; my first order at a code is often for people who aren’t actively doing anything to wait outside the door until we need them.

All in all, there are enough reasons why family and other visitors shouldn’t be present while a patient is being stabilized that a blanket policy is appropriate. In any event, it was clearly not her desire to be back there that so bothered CrazyCatLady, but her threat to take the (possibly dying) animal elsewhere if they didn’t let her.

(That was more long and rambling than I expected it to be. Shouldn’t post before my AM Diet Pepsi.)

Dr. J

17

It sounds to me like CCL has dealt with similar situations in the past, where family members wanted to be with their pet, and that this woman was unusually hateful and condescending, even in light of the situation. Anyone who works any kind of emergency medicine has been in this position, and you get good at handling people in a sensitive and caring way; we all understand how stressful and frightening it is to know that your loved one may be dying. But your first order of business still has to be the patient – keeping the room clear of extra people and distractions so that the code team can focus their entire attention on saving a life.

Also, what Dr. J said: codes are messy, ugly, and violent. No one should have to see their loved one put through that.

18

Perhaps I should have been more specific in my earlier post. When we go up to talk about code status for animals in respiratory distress, the spiel goes something like this: "Your [fill in species] is having a lot of difficulty breathing, and right now he’s in pretty bad shape. He’s going to need supplemental oxygen, and we’ll probably want to put an IV into him so we can give him drugs and fluids so we can get him stablized. Right now, we’re looking at $200-$300 just to get him stable, most likely. If that’s what you want to do, we’ll need you sign this consent form. With the shape he’s in right now, there’s a good chance his heart could stop, or he could stop breathing. If that happens, do you want us to do CPR, or do you want us to let him go? "

Trust me, we don’t just charge up to people and ask, “What’s your dog’s code status?” When you routinely get calls asking if a neutered cat can impregnate a female, you don’t have a lot of faith in the medical knowlege of the general public. Still, I’d think when someone asks you what you want them to do if your dog’s heart or lungs stop, most folks would take that as a bad sign.

19

Crazycatlady, if I tell you that I completely sympathize with you and am sorry for you having to deal with a condescending twit like that woman, do you mind if I hijack your thread briefly to tell my latest slightly relevant story?

I work at a humane society, and one of our programs is offering free spay/neuter vouchers for folks who receive Medicaid, food stamps, or a handful of other programs (technically the vouchers are for their pets, smartass). We get all kinds of questions about what sort of animals can get spaded, whether boys are spaded or only girls, whether an old animal can be spaded, etc.

Recently, I had a conversation with a woman who started off by saying, “I’m gonna tell you what I’m gonna do, and you ain’t gonna like it, but I’m gonna do it anyway, and you can’t stop me.”

Okay, fine, I thought. She went on to explain to me that she wanted to get her female cat spaded, but she wanted her to have a litter of kittens first.

I didn’t argue – even though I thought this was a terrible idea (given the roughly six and a half thousand animals our shelter has to euthanize every year due to overpopulation in our community), she’d told me I wouldn’t be able to convince her otherwise. So I saved my breath.

“Now, my cat’s half-Siamese,” she continued. “And she’s got a brother who’s also half Siamese. So I’m thinking about breeding them together, see if I can get some full-blooded Siamese.”

:eek:

Thank god, while I was trying to work out where to begin with everything wrong with her plan, she told me she’d decided to breed her cat with a non-relative. She went on to ask whether her neighbor could come pick up the voucher, because she was disabled; she was asking because her neighbor was also disabled, one of his legs was longer than the other, so he wore a platform shoe on the short leg, it was a real nice shoe, I’d probably recognize the brand and had friends who wore the same brand…

My experience was just the opposite of yours, CCL. Up to that point I’d been having a terrible day, fighting a losing battle against computer viruses on our network; this fifteen-minute rampbling conversation with a crazy, lonely old lady brightened my day right up.

Daniel

20

I think the situation here is that everyone is sympathizing with the scared, grieving pewt owner saying, “Well, I can pet him while you do that” and “He needs me; he’ll be scared back there.”