Vet Talk

No Guarantees

Medicine is a bit of a gamble

Published: March 11, 2013

Medicine is a strange service. When I pay for a coffee, I feel entitled to a reasonable certainty that I will be provided with coffee – not tea, not water, and not an empty cup. If I pay for a haircut, I expect that when I exit the salon, my hair will have a different shape than it did when I entered.

I think that many people, even if they don’t verbalize it, have the same expectation of medical services. I took my pet or child to the veterinarian or physician, and now they should be better. Unfortunately, in medicine, there are factors at play beyond payment and service. Coffee doesn’t generally fight to stay out of the cup. Hair rarely mutates as it’s being cut. However, biological creatures (animals and humans) often don’t have a predictable fee-for-service response when it comes to injury or illness.

Despite the best efforts of all involved, sometimes, success just isn’t a matter of skill or planning. Sometimes there just aren’t any guarantees.

Lucky wasn’t. Dusk was just settling in as I pulled onto the farm where I was greeted by a crying boy and his fast-moving, visibly stressed mother. In a small paddock behind the house, a chocolate-colored mare whickered at a limping, golden foal.

The owners had come home from school and work to find the eight-week old colt not scampering about the paddock as usual. Instead, he was stuck, with one leg trapped between the panels forming the corral. Between his struggles and the pressure of the pipes on his skinny leg, the skin, tendons, and ligaments surrounding the pastern (ankle) joint were shredded.

“Three-legged lame” is a term that makes the blood of equine veterinarians and horse owners turn more than a little sludgy. There is something deeply unsettling about seeing an animal designed to run across deserts and prairies hopping with one leg dangling above the ground. It’s hard to explain to the non-horse person, but this is a level of wrong-ness akin to an arm or leg pointing the wrong direction on a human being. Even worse perhaps, since, while humans can function without an arm or a leg, limb injuries in horses can mean the end of the horse.

Lucky was almost the worst imaginable illustration of three-legged lame. Even in the dim light, the wound was dark and disturbing. Once we sedated the foal to lay him down for an exam, it was worse. Using forceps to pick blades of grass out of a joint is not a good prognostic sign. My first thought and the first words out of my mouth were “Refer” and “Surgeon.” Reality intruded. The owner gave me that ‘I already know the answer’ look. “What will it cost?”

There are a number of ways to answer this question. The most correct is to say that I don’t really know the charges of other facilities and that the costs will depend upon what the surgeon finds and recommends, etc. Realistically, and honestly, however, I had a good ballpark idea, and she knew it. “Lots. Probably five thousand. Maybe less, probably more.” I also knew her answer before she ever asked the question. They couldn’t afford it.

She and I both knew what needed to be done. But before the word could leave either of our mouths, the boy burst into tears and flung himself on the foal’s neck.

Picture the scene: mare circling the paddock, darkness falling, and a foal, waking up from sedation, surrounded by an end-of-shift field veterinarian, stressed owner, and crying child – the word “euthanasia” hovering in an unspoken cloud above the group.

To make a long story short, we wound up finding a middle ground. I cleaned and bandaged the wound, splinted the leg, started the foal on antibiotics, and the owner agreed to bring it in to our clinic in the morning for further care. The cost was still going to run into four digits, and I couldn’t give her any promise of a good outcome. I was pretty blunt. “The best thing we could hope for is pasture soundness. At best you’ll have a big lawnmower. At worst, we’ll get a couple grand into this and have to euthanize him. We may even get a couple of years down the road and have to do it. There aren’t any guarantees.”

Amazingly, Lucky actually was. Despite several heart-stopping moments (including one day where the damage looked so bad that the only thing that saved him from euthanasia was that I couldn’t reach his owner by telephone while he was still under anesthesia) and months of extensive care – we almost made him and his mother the official clinic mascots – the wound eventually healed, and the pastern joint fused. When I last saw Lucky, he was a five-year-old stallion, racing around the pasture.

However, despite the great outcome, his owner once confessed that if she had it to do over, she would have made a different decision. The financial and emotional investment wound up being more than she had bargained for, despite all of our communication on the front end.

Sometimes it’s difficult to remain dispassionate and know that the right decisions are being made even when you have weeks to consider the options. During his stay at our hospital, Lucky had a buddy. Moolah was brought in on emergency one evening. She had been seen by another colleague in the field a few days before for a nail puncture to the foot. This can be a big deal in horses since a lot of important structures live inside that hard and seemingly impenetrable hoof. Moolah’s initial injury apparently hadn’t seemed particularly severe, and she had been placed on anti-inflammatory drugs and the foot was bandaged to keep it clean.

However, by the time she limped into my exam area, she was barely touching the toe of the injured foot to the ground and the leg was swollen almost to the hock (the pointy joint on the hind leg of a horse).

I had much the same conversation with Moolah’s owner as I had held with Lucky’s owner a week or so previously. “Referral.” “Surgeon.” “Expensive.” “Serious.” Moolah was going to cost a lot of moolah. At least this time, there were no sobbing children in the picture.

Moolah’s owner also chose the middle-ground option. For months I had two hospitalized horses in our two-stall facility. Both were receiving every treatment I could manage as a general practitioner. Both were racking up bills that were much higher than I was used to charging (though considerably smaller than what would have been seen at a referral center with optimal treatment) and both animals took multiple turns toward the dark side. Each time either of them had a clinical setback, my mental and emotional health took a similar plunge. What was I doing? Was I just building up these people’s hopes and wasting their money? I knew I had colleagues who thought exactly that. A lot of soul-searching happened during that period.

Moolah seemed to specialize in backsliding every time things started to look good. We drained an abscess in her hoof, and she began to improve. Then she developed a tendon sheath infection. As we started to get that cleared up, the tendon itself began to contract because she wasn’t bearing enough weight on the leg. At every turn, it seemed as though we had to stop, reconsider, and have the same “is the outcome going to be worth it” discussion.

Moolah was discharged at about the same time as Lucky. At her last recheck, she had some residual stiffness, but was sound enough that she and her owner had been able to resume the trail rides that they both enjoyed. Her owner not only didn’t regret the cost, but she presented us with a lovely laser-cut metal wall-hanging that hangs in my home office even now.

As much as I wish otherwise, and despite Moolah’s and Lucky’s lucky outcomes, this story isn’t just about success.

There have been plenty of instances where clients have paid large amounts of money for procedures with a much grimmer outcome. The first case that comes to mind is one that happened early in my career. I’ve talked about this episode from time to time but never written about it before. The taste of failure is still a little metallic on the back of my tongue when I dig into this one.

Tragedies shouldn’t happen on beautiful spring days. Death and sadness shouldn’t occur when there are puffball clouds in the sky and lacy blossoms on the trees. They shouldn’t, but they do. And, if you are an equine veterinarian, spring doesn’t just mean cherry blossoms and Easter eggs. It also means foaling season.

A new colleague once asked me, at the start of his first spring as a veterinarian, about foaling calls. “How do they go? How is it different from delivering calves?”

My answer was simple and maybe overly blunt. “If you get called out to deliver a foal, it’ll probably go one of two ways. Either the foal will already be on the ground by the time you get there, or it will be a bloody disaster and you’ll wish you were somewhere else.”

This was one of the latter times. There was no way this foal was coming out the way nature intended.

Foals are typically born head and front legs first, with the front feet extended forward and the nose between the front knees. (Picture a fuzzy high-diver.) Because horses are prey animals, a mare’s contractions are hard and fast, designed to shove that little bugger out into the world within a matter of minutes. In fact, the average duration of active labor from the mare’s water breaking to the foal lying in the straw is 15 minutes. When things go right, it’s nothing short of beautiful. But if that foal fails to get properly positioned, all manner of badness unravels.

Badness was coming hard and fast. The foal’s front legs were bent at the knees and crossed over each other making it virtually impossible for me to reposition them. I had sedated the mare to try to decrease the strength of the contractions, but no luck.
Now, the other unfortunate side of the speedy equine labor model is that if it takes longer than 90 minutes to delivery, the foal (unlike your average pizza) is not free, but dead.

These clients lived over an hour from the nearest referral center, and we were about an hour into the process. The math didn’t look good. The foal’s head was out and there was no sign of life.

That was actually a bonus for me and for the mare. There is an unsavory but very important procedure used in obstetrical emergencies for cows and horses (and some other species) called a fetotomy. If the fetus has died, we have a special tool that enables us to remove a leg (or other body parts impeding the process) and deliver it in sections. Icky and sad, but lifesaving for the mother.

I started toward the truck to get my fetotome. At that moment, the foal’s head raised and it took a breath. Damn. Options were running low. The mare was now beginning to show signs of shock; her life was in increasing jeopardy.

I then made the owners an offer prompted by inexperience, naiveté, and the foolish optimism of youth. I had done a number of successful field C-sections on cattle, and I knew that the only way the foal would come out alive was via C-section. The mare was lying on the ground, heavily sedated, and had begun bleeding from the rectum. Things didn’t look good for her, but the foal, or at least his head, looked downright perky by comparison.

I took a deep breath. “I think we have to make a decision. This foal isn’t coming out this way. Do you want to try to save the foal or the mare? I can euthanize the foal and do a fetotomy, or we can try a C-section. Either way, both of them might die. There aren’t any good choices here."

If I’d been older, I might have given them the third option outright. Euthanize the mare and be done.

It was Good Friday. My Catholicism was a bit lapsed, but I found myself sending up prayers fast and furious as I knelt at the mare’s side, quickly prepping for my incision. The owners had chosen C-section.

Both the mare and foal survived the surgery. However, my boss got uncharacteristically quiet and more than a little pale when I transferred the case to him for the weekend.

“You did a C-section? On a mare? In the field?” He shook his head. “Well, you do have guts. I only know one other guy around here who’s tried that. Both the mare and foal died.”

“Well, mine are still alive.”

I spoke too soon. Before the weekend was over, that would change.

It turned out that there was a reason I couldn’t unflex and uncross the foal’s front legs. The knee joints were ankylosed, essentially frozen in a bent position. My boss euthanized the foal. The mare developed peritonitis, a severe abdominal infection. He euthanized her, too.

Clients I liked, for whom I thought I was doing my best, wound up with a bill just under a thousand dollars and two dead horses.

It’s easy to say that they knew the pros and cons. I hadn’t been sunshine and roses going in. But if it’s hard to make a dispassionate decision with a night, or even weeks, to reflect and reconsider, it is even more challenging to feel confident that you are making the right choices in the middle of a highly emotional emergency.

Essentially, medicine is a bit of a gamble. Practitioners do our best with the resources available, but there are no guarantees. I don’t know how to emphasize, other than through these stories, that this troubles us as much as it does you. The variability of outcome never stopped me from offering my clients every option that I could, but cases like these made me more aware of the stakes and of the need for open communication, no matter how difficult some of the conversations were.

1 Comment

April 11, 2013

One of the things I've discussed candidly with DD, is the top limit I'll put into a pet. The amount will be used up far more quickly with one of the horses, than with one of the dogs (dogs are both cheaper and easier for nearly everything than horses). Horses seem born to give their owners and vets, cardiac stress tests frequently. I do not know how foaling barn managers do what they do. I will never breed either of my mares for a bunch of reasons, but part of it is, that most people do not understand how hard and expensive it is to get a foal on the ground and what a high risk endeavor this is, not just the birth but keeping that foal safe while it grows some brains. I am grateful for vets like yourself, who deal with these kinds of emergencies...I know I could not do it as frequently as you do.

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