Depressing times

Re: Depressing times

Anthony Dennison — Tue, 20 Aug 2013 17:44:58 GMT

I had a similar feeling today. Saw a dog that has unstable diabetes and unstable cushings last friday. Little quiet in himself, but licking his feet. I found sweaty axillae that were starting to go red, so dispensed some CLX wipes. Saw him the next day, even more quiet, he had vomited in the morning. As he had put weight on recently and was slightly painful in his cranial abdomen I thought it might be pancreatitis. Gave cerenia and opioids and told them to see how he went.

He went to our 24hr hospital the next day and was put to sleep.

About half an hour after the dog had left on Saturday I though 'Hmm. Should have done a spot BG really, what a numpty. Nevermind'

Now I'm convinced the dog had DKA and me not doing anything killed it. However, the dog was 12, had bilateral diabetic cataracts and hadn't been stabilised for either condition since diagnosed... that shouldn't make me feel better, but it does slightly

Re: Depressing times

Thomas Johnson — Tue, 20 Aug 2013 15:36:43 GMT

[quote user="Mark Hedberg"]

I just checked with Dr Google, so I know what it is now!

[/quote]

Me too, hadn't heard of it before either.

Re: Depressing times

Mark Hedberg — Tue, 20 Aug 2013 15:02:28 GMT

[quote user="Hannah Wynne Richards"]

BTW I'm another of the "What on earth is Pneumocystis ?" brigade-there's plenty of us .

Wynne

[/quote]

I just checked with Dr Google, so I know what it is now!

Re: Depressing times

Anthony Todd — Tue, 20 Aug 2013 14:57:18 GMT

[quote user="Gillian Mostyn"]I'm also guilty as charged - it wouldn't have occurred to me either![/quote]

We could turn a negative into a positive tutorial/discussion.

What was the history, age, litter mates mother?

Physical findings? Nothing in the throat ? etc.

What else could it be, and why or how or why not.

'cos I'm sure we'd all like to know ,and those who haven't been there [again and again] aren't on this forum.

Re: Depressing times

Robert Jenkins — Tue, 20 Aug 2013 14:13:38 GMT

Anon, I hit Google etc after reading your post.

Thank you, there are many more of us aware of this disease now.

Re: Depressing times

Hannah Wynne Richards — Tue, 20 Aug 2013 13:49:56 GMT

BTW I'm another of the "What on earth is Pneumocystis ?" brigade-there's plenty of us .

Wynne

Re: Depressing times

Robin Grimmer — Tue, 20 Aug 2013 13:25:32 GMT

I only heard about Pneumocystis when I was doing my Cert SAM and went to a referral centre, and since then I've only heard of one confirmed case, so it's pretty rare. Don't beat yourself up over it, you did your best. It's good that you care so much, but you have to learn to move on and don't fret about it so much, otherwise you will end up getting stressed and depressed.

Re: Depressing times

Mark Holmes — Tue, 20 Aug 2013 13:10:00 GMT

Before beating yourself up, just check it hadn't had a yank on the collar. Neck trauma and neurogenic oedema is FAR more common. - young pup, learning to lead exercise, just a thought. Looks a bit like asp pneumonia too!

Re: Depressing times

bob lehner — Tue, 20 Aug 2013 12:42:49 GMT

[quote user="An On MRCVS"]You're right, I don't know for sure, but a cavie with resp distress - and not giving TmpS? Stupid! Stupid![/quote]

Well I think you are being unduly harsh on yourself - and I am glad to read that I am not the only on here who has either never heard of this condition, or certainly would not have it high on the list of differentials. Perhaps recent grads have been taught about it, but I doubt many of us older bods at the coalface know much about it.

if you are working in general practice you need to judge yourself by your peers. I'm pretty damn sure that if you took 1000 GP vets at random very few would have handled this case better than you did. (Most of us struggle with interpretation of chest X rays if we are honest and have probably got it wrong more often than not!).

Re: Depressing times

Wren — Tue, 20 Aug 2013 12:31:58 GMT

As an ER devotee I've heard of pneumocystis - it's the classic secondary infection for HIV patients. They go into the ER thinking they've got boring old pneumonia and come out with a diagnosis of HIV or AIDS.

However I've never heard of it in animals. Glad to hear I'm not alone!

OP - you've had some good advice, nothing that I can add that hasn't already been said. Now implement it!

Re: Depressing times

Hannah Wynne Richards — Tue, 20 Aug 2013 09:30:52 GMT

You really care-which is why you have the potential to develop into one of the best veterinary surgeons around.

Don't give up-the professsion needs you-it really does.I'm ready tobet very few veterinary surgeons reach the first aniversary of qualification without regreting something-and those that do will be absolute menaces to the animal population 30/40 years down the line.

It's horrible now-but try to put it behind you. Best wishes.

Wynne

Re: Depressing times

Dagmar Steele — Tue, 20 Aug 2013 09:16:46 GMT

Some excellent advice here, I'd definitely second Lorna's remarks re physical exercise. Apart from that brace yourself for the fact that you WILL make many more mistakes! It's inevitable (as Lorna said we are human after all) and we need to accept it to stay mentally healthy somehow. I have killed many an animal because of the mistakes I made, some I know of and I guess many more I don't. I am far from happy about it and I make sure I learn from every mistake. The most important thing is that the same mistake never happens again. On the other hand I'm also sure that I have saved a lot more animals than I have killed!!!! In your case you don't even know you made a mistake, you're only assuming it because things didn't go the way you wanted them to. It could have been aspiration pneumonia as well, not all of them make it and you cannot do more than trying. Yes, IF you had given TRMP you would know now IF it had worked. But you didn't so you don't even know for sure it was your fault that it died. Next time take a sample or add TRMP - maybe the pup will die anyway but then you'll have no reason to beat yourself up.

Re: Depressing times

An On MRCVS — Tue, 20 Aug 2013 08:01:54 GMT

And I second Gillian: YOU DIDN'T MAKE IT ILL!

Re: Depressing times

Evelyn Barbour-Hill — Tue, 20 Aug 2013 03:00:14 GMT

[quote user="An On MRCVS"]but fact remains I SHOULD have given TmpS, and I didn't.[/quote]

Oh rubbish.

You got emotionally attached because this was a cute liddle pup. Now you're looking for reasons to flagellate yourself.

Re: Depressing times

CatherineThomas — Tue, 20 Aug 2013 02:49:12 GMT

It would not have crossed my mind as a differential either. I didn't really know anything about it so I did a quick search and this is what came up:

http://vdi.sagepub.com/content/8/1/124.full.pdf

This was a dog that was referred to a university referral centre so presumably had specialists treating it. Even so it was 3 days before pneumocystis was diagnosed and it died before treatment could be effective. A couple of quotes from the article:

"As a clinical disease, it often has had a fatal outcome"

"the affected dogs have been young, and usually suffered a fatal outcome, suspected to be due to congenital immunodeficiency"

It seems to me that this puppy would have most likely died whatever you did and you did better than a lot of us by even having pneumocystis on your differential list.

Re: Depressing times

vetbl.locum — Tue, 20 Aug 2013 01:18:47 GMT

Same here

Never heard of it until now Just how common is it?

OP would seem to have done what could reasonably been expected

Stopped using TmpS (even took a while to remember what this was) due to bad reactions in small animals years ago

Re: Depressing times

Suzanne Kelly — Tue, 20 Aug 2013 00:44:37 GMT

I'd never even heard of it, had to look it up, so there you go! If it was my case I'd have been in blissful ignorance and thought "you win some you lose some." Anon no-one can be expected to save them all, you just can't. No-one is perfect, we all make mistakes .It's hard but that's the way it is.Hindsight is 20:20 vision. It may have had it, it may not. If it had then wouldn't it be immunocompromised and have a whole host of other problems too? Also how easy is this condition to diagnose ? I remember an elderly vet that lectured me in college many years ago that said "remember most things will get better DESPITE what you do to treat them, not because". Also trimethoprim sulphas are not without their risks, especially in pups and especially in cavaliers ( KCS and immune mediated anaemias and thrombocytopenia). So what if you HAD given them in the absence of a definitive diagnosis and it developed IMHA and died?

Re: Depressing times

An On MRCVS — Tue, 20 Aug 2013 00:32:13 GMT

[quote user="Mark Holmes"] Is there a chance you are over diagnosing pneumocystis? We are all susceptible to "pet" diagnoses. Particularly after CPD. Were they all confirmed or did they look similar and simply respond to the correct drugs?[/quote]

I'm afraid the previous two were confirmed by bronchoscopically guided BAL- I admit though I only diagnosed one of them, the other diagnosis was made by a colleague.

I guess I may be wrong and it may have been 'simple' aspiration all along but fact remains I SHOULD have given TmpS, and I didn't. This is one of those cases that will stick with me for the rest of my life. Maybe I shouldn't get emotionally attached but I did.

Re: Depressing times

Linda Filshie — Mon, 19 Aug 2013 23:21:01 GMT

[quote user="Gillian Mostyn"]

[quote user="An On MRCVS"]Another anon here: I honestly think you did everything I would have done in that situation. The difference is: pneumocystis would probably never even have registered on my list of differentials. So when the puppy died, I'd have gone home very sad and down, but without the guilt that's crippling you. Ignorence is bliss! Does that make me a terrible vet?[/quote]

Don't know why you posted anon- I'm also guilty as charged - it wouldn't have occurred to me either!

[/quote] Likewise!

Re: Depressing times

Michael Woodhouse — Mon, 19 Aug 2013 23:03:15 GMT

Anon - don't know how old you are, but I hope every single patient currently on our books dies before I do. Neither them nor us are getting out of this alive. You did your best. That is all anyone can ask.

You must not beat yourself up about these things. Sometimes you do everything right and they don't make it.

Re: Depressing times

Mark Holmes — Mon, 19 Aug 2013 22:53:09 GMT

[quote user="An On MRCVS"]

Thank you everyone for your replies; it means alot, everyone is very kind.

Anon no 2: I actually think that the problem is that pneumocystis WAS on my differential list and I dismissed it. That's what makes it so unbearable, I have seen it (twice) before and am aware of the breed susceptibility for this disease.

I actually thought 'shall I give TmpS?' then decided not to. I think I could live with it if I had tried it and failed. But not trying it - that's what makes it so hard to swallow.

owners declined PM so we'll never know....

[/quote] Given this would be your 3rd case of a condition most of us haven't been aware of having seen. Is there a chance you are over diagnosing pneumocystis? We are all susceptible to "pet" diagnoses. Particularly after CPD. Were they all confirmed or did they look similar and simply respond to the correct drugs?

Re: Depressing times

An On MRCVS — Mon, 19 Aug 2013 22:41:41 GMT

Thank you everyone for your replies; it means alot, everyone is very kind.

I actually thought 'shall I give TmpS?' then decided not to. I think I could live with it if I had tried it and failed. But not trying it - that's what makes it so hard to swallow.

owners declined PM so we'll never know....

Re: Depressing times

Gillian Mostyn — Mon, 19 Aug 2013 22:37:23 GMT

Don't know why you posted anon- I'm also guilty as charged - it wouldn't have occurred to me either!

Re: Depressing times

An On MRCVS — Mon, 19 Aug 2013 22:35:25 GMT

Another anon here: I honestly think you did everything I would have done in that situation. The difference is: pneumocystis would probably never even have registered on my list of differentials. So when the puppy died, I'd have gone home very sad and down, but without the guilt that's crippling you. Ignorence is bliss! Does that make me a terrible vet? How do you even know that it was pneumocystis? Did you PM it?

Re: Depressing times

John Flynn — Mon, 19 Aug 2013 22:30:22 GMT

Sure sounds like aspiration pneumonia to me?

I wouldn't beat yourself up about it because it sounds like you did a really thorough job to me.

Pneumocystis pneumonia isn't a diagnosis that I've ever made (but then I guess I could have missed quite a few in my blissful state of "unconscious incompetence"), but would you not expect a pretty different distribution of lung lesions from the classic aspiration pneumonia pattern?

Even if the case was such, what's to say that TMPS would have cured it?

You can't blame yourself at all for the pup dying. You did a decent professional job (at least as good if not better than most of us on the forum would have managed), were probably entirely correct in your initial assessment and management, and in the off-chance that there was something else such as a pneumocystis pneumonia it would quite possibly have ended the same in spite of your best efforts.

In the same way we can't always congratulate ourselves every time a patient gets better (who knows if it was really down to our treatment?), we shouldn't blame ourselves when one doesn't (who knows if there was any chance that the outcome could have been any different had we acted differently?)

I've certainly had sick pups, with what I would have expected to be a bright future ahead of them, die under my care before - and it's absolutely gutting, especially if they've been nursed intensively. Unfortunately, all you can do is move on, and you'll help many more pups if you don't let this get you down too much.

It's normal to be upset after a case like this, but if you find you're not able to think about the rest of your work because of it or are feeling genuinely ill as a result, then it would be best to talk to someone:

Ring the VBF (07659 81 11 18) and speak to a vet anonymously who'll understand exactly what you're going through - you have no idea how much it can help to discuss something like this and not be alone with those feelings. [Or send me a private message - you can do this from the Anon account even if you like - if you want to talk just now and I'll give you my mobile number - I'll be around the next hour or so].