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Vet Talk

The Limitations of Being a Specialist
June 24, 2019 (published)
Cora, the cause of the commotion. Photo by Lauren Graham Garcia

A cough is a cough, right? Vomiting is vomiting, diarrhea is diarrhea. Seems like these should be simple things to figure out. The list of causes should be the same for old doc at the small rural practice as it is for Herr Professor at his prestigious university clinic. You’d think so, but you’d be wrong.

Recently, I was embarrassingly reminded of the limitations of my specialty. I’m a veterinary cardiologist, and every day I deal with dozens of cardiac cases: dogs with heart failure, cats with cardiomyopathy, pocket pets with arrhythmias. It’s all fair game and, as we say, in my wheelhouse. I proffer advice on additional diagnostic steps, potential treatments, and prognoses. I travel the world speaking at national meetings on all things cardiac.

Everyone knows I’m a cardiologist except my family and close friends. Despite specializing in two disciplines and getting a PhD (OK, OK, I really never left school!), to them I'm just a vet. Period. I went to vet school, so I can fix animals. All animals. With every problem, from anal gland impactions to zinc toxicity (get it? A to Z). And that makes me the “go-to” for solving all their pets’ ailments. Ella’s lame? Call Mark. Ezra just got into a cannabis cookie he found on the street? Call Mark. Byron launched himself through a window and is bleeding? Call Mark. Sampson ate rat bait? Call Mark. Willy has a cat bite abscess on his back leg? Call Mark. You get the picture.

So, the other night I was sitting on my couch when my phone rang. It was my brother-in-law. He lives in the next town over.

“Cora just came in from outside and keeps gagging and throwing up mucousy bits. But no food. And she ate only an hour ago. What should we do?”

Cora is a 3-year-old Labrador. I also have a Labrador, Yarra. I know Labs. They eat first and question later whether it was edible. Immediately my thoughts went to things that get stuck in pipes. She might have inhaled a stick and has a piece lodged in her wind pipe. She might have found a deer carcass and eaten a neck bone that lodged in her gullet.

“She seems fine but just keeps gagging and… there, she did it again. But she’s wagging her tail,” reported my B-i-L.

“OK, this doesn’t sound like an emergency. I wouldn’t rush her into the ER because it will cost you a fortune. Just watch her, and if it persists, she can be seen tomorrow. Unless it gets a lot worse,” I responded.

The next morning I received a text: “We’re at the emergency room.”

“OK, I’ll be there in about 30 minutes.”

I drove in. I was thinking that we would probably need to anesthetize Cora and perform a laryngoscopy (examination of the back of the throat), a bronchoscopy (a look-see down the airways) and an esophagoscopy (a look-see down the esophagus). I see my B-i-L and his wife with Cora outside the clinic entrance: “They’re getting set up to see us." I looked Cora over. She seemed bright enough. She had a bit of sensitivity around her throat when I pinched it a bit. “Well, let me know what they find and decide.”

An hour later, I got the report: “She has kennel cough."

HUH???? WHAT??? How did I miss that? It’s simple: because I’m a specialist.

As a specialist, I never, ever, ever see a dog with kennel cough. Why? Because no self-respecting general practitioner would send one in as a referral to cardiology. No GP would ever miss a case of kennel cough that presented to them. It would be the number one rule-out for any GP, especially after finding out that Cora had been playing with a puppy the previous weekend (a little piece of information that had been omitted in the initial panicked discussion the night before). Had I still been in general practice — which I was for several years before specializing — I would have nailed the diagnosis.

Which goes to show that “coughing is not coughing.”

Vets and physicians are taught that common things occur commonly. Kennel cough is common. A tracheal foreign body? Not so much. But that adage only works in particular contexts. What is common for a GP is generally rare for a specialist. What is common for a specialist might never be seen by many GPs. For example, I might deal with two to three patent ductus arteriosus cases every month. To me, they’re common. A GP might see a couple in their career. For most GPs, a vomiting dog has “garbage gut” until proven otherwise. For an internist, that vomiting dog probably has a gastrinoma, Zollinger-Ellinson syndrome, or Addison’s disease, things that would not be on a GP’s rule-out list, or if they are, they’re nowhere near the top.

A couple of days later, M-i-L called about her dog, Ella. "She's hacking." Off goes my internist brain, thinking: "It's canine influenza. It might be coccidiomycosis. Or sporotrichosis. Maybe she has a Filaroides hirthi infestation. Or it's mesothelioma." It's like a regular episode of House in my head! Or, maybe, just maybe, she had played a few days earlier with her "cousin" Cora and has also contracted kennel cough. Settle down, stupid specialist brain!

So, if you have a relative or family friend who’s a veterinarian, you can only hope they’re not specialists when it comes to problems with your own pet. Because if you come to me to solve your pet’s problem, my imagination goes into overdrive in a bad way. The probability of it being something bad approaches 100% when in reality, as a "common pet with a common problem," it's much more likely to be that rarity to specialists - kennel cough or garbage gut.

3 Comments


Nancy
June 23, 2019

Excellent article!!!


Frances Bell
June 22, 2019

Sadly it's not just RTAs that cause the decline in numbers. Just as concerning is climate change and global warming which will skew sex ratios so that in many species we're going to get a lot of females and precious few males to inseminate them - with all the knock on effects of (eventual) inbreeding depression due to a reduced gene pool. We might even get to the point where we have to artificially incubate turtle/tortoise eggs at lower temperatures to get any males


David Gjestson
June 19, 2019

Well done Ms DeGioia. As a retired wildlife biologist, your article is the most factual, complete I have ever read on the topic. Your advice is sound and very helpful. I have no doubt it will save many lives...human and amphibians...over time. Well done!




 
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