Unforeseen Outcome

Observation, touch and intuition make up a diagnostic trifecta
By Nick Trout, June 2011

Ordinarily, I’ll take serendipity over failure to make a difficult diagnosis every time. The trouble is, in my world, not every diagnosis is desirable, and serendipitous isn’t always the same as positive. I’ll call him Murphy: a rambunctious two-year-old Golden Retriever who bounced into my examination room, all billowing feathers, Hollywood smile and a nose searching for a friendly hand.

“So, he’s a little sore on his left front leg?”

Murphy’s owner, Mr. Crowe, managed a tepid nod. I imagined he was in his 50s—thinning gray hair, goldrimmed spectacles prone to sliding down his nose—but what struck me was his uneasy posture. He stood with his arms folded tightly across his chest as though he were trapped inside an invisible straight jacket.

“It’s both legs,” he said, “worse on the left. Did you not get the elbow x-rays?” I had in fact reviewed the films taken by his veterinarian, images that confirmed elbow dysplasia. “Dysplasia” simply means abnormal growth and, in this context, defines abnormal development of a dog’s elbow joints

“Yes. Thank you. When did you first notice a problem?”

“Last few weeks,” said Mr. Crowe.

“Really?” I said, trying to hide my surprise. “Nothing as a younger dog?”

Most (but not all) dogs with elbow dysplasia show signs of lameness in their first year, or conversely, much later in life, when they develop secondary arthritis. Clearly, Murphy’s timing was off.

Mr. Crowe shook his head, eyes narrowing as he searched my face.

“No. Does that matter?”

The challenge of clinical intuition is not just registering its presence; it is whether you can make sense of it.

“Of course not,” I said, my reassuring smile failing to find its target. “A lot of my patients don’t read textbooks.”

Mr. Crowe’s deadpan stare was my cue to get on with the examination. Murphy played along; the feel of his elbows and the changes on the x-rays jived perfectly with his history and clinical signs. I ended by discussing treatment options, and Mr. Crowe decided to pursue surgery as soon as possible.

A week later, Murphy stood me up, a no-show for our OR date. Mr. Crowe apologized—something had come up. He rescheduled but, once again, on the morning of surgery, he found another excuse. I imagined that Mr. Crowe was torn, vacillating at the 11th hour. So, more than two months later, I was surprised to be greeted by a familiar Golden Retriever, eager to get his elbows fixed.

Looking back, I know I got lucky. Murphy was anesthetized, lying left side up, while an eager technician waited to be told where to clip his fur. As I demarcated a line on Murphy’s skin, I felt a subtle boney bump and decided to chance a new x-ray. What I saw took my breath away: solid bone reduced to fragile honeycomb.

I called Mr. Crowe.

“I’ve found something other than Murphy’s elbow problem, something that’s destroying his left shoulder blade.”

Silence. Then he asked the obvious, and logical, question: “Why didn’t you find it last time?”

“Back then, there was nothing to feel; no lump, and Murphy exhibited no pain.”

More silent deliberation—then, “So now what?”

“We should get a biopsy.”

The biopsy confirmed that in just two months, Murphy’s problem had transitioned from a niggling elbow disorder to a highly malignant bone tumor of his shoulder blade—from low-grade lameness to terminal cancer. Two months earlier, I would have subjected him to elbow surgery and watched him falter through recovery before facing an owner rightly furious at my failure to diagnose the real problem in his shoulder. Fate and Mr. Crowe’s uncertainty had saved me. I wish the same could have been said for poor Murphy.

“His tumor is inoperable. Even if I remove Murphy’s leg, I can’t get it all. And chest x-rays confirm that it’s already spread to his lungs.”

The precept, “first do no harm,” echoed in my mind as Mr. Crowe vented his frustration. “My mother had cancer. It was misdiagnosed. By the time they knew for sure, it was too late.” I wondered if this was the cause of his unease and hesitation. No matter. Armed with this painful new perspective, I had to justify the limitations of what I could offer.

“I wish there had been something to find when we first met,” I said, “but there wasn’t. I looked. I felt. There was nothing, no response from Murphy. I don’t like to lose, but winning at all costs isn’t worth it if Murphy pays the price. I can take his leg, take parts of his lungs, fill his veins with chemo, radiate his body and maybe, if we’re lucky, we can prolong his life a little. But what kind of extra life would he have? Not having a treatment option is our fault, not yours.”

I refrained from mentioning the twomonth delay, the opportunities missed for an early diagnosis. What purpose would it serve? Besides, there was a lesson here for me. If dogs could verbally communicate the subtleties of disease, vets might be less vulnerable to clinical red herrings. When alarm bells ring, we must resist the seductive power of an easy diagnosis. Observation and touch were all I had, and I worked hard to silence intuition.

“Undiscovered” is not the same as “overlooked.” Sometimes, the real culprit bides its time. And sometimes, the only constant I can guarantee, to client and patient alike, is the sincerity of my intent, even when I cannot guarantee a cure.

Names and identifiers have been changed.

Nick Trout is a Diplomate of the American and European Colleges of Veterinary Surgeons and a staff surgeon at Angell Animal Medical Center in Boston.

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