Week 3 of the injured stray conundrum: Enter the doctor
By Dr. Tony Johnson
December 7, 2009
Welcome back, my beloved tinies! Grab your green shoes, and let’s mess some stuff up.
We will venture into some new territory in our exploration of what happens to injured strays that are caught in the gears of the veterinary medical system.
This is the 3rd week of our thought experiment — we will stay by our stray’s side and maybe get to know him a bit better this week.
When we last left our hapless hero, Raul, he chose option “C” from the first week: Pay for the immediate care, and see if the owners show up.
Well, 36 hours have passed and no one has shown up despite a very thorough and broad-ranging search. Internet, newspaper, flyers — nada from the whole enchilada.
Raul was kind, conscientious and caring, even if he had poor taste in footwear, but it is time to bid him adieu and introduce the doctor. Raul made sure that the stray was taken care of in the initial phase, and even paid $445 towards his initial stabilization and workup.
This week, I think we will send Raul packing, and you will experience life on the other end of the stethoscope. You will become the doctor in this case.
You are Dr. Mantooth Codpiece, a 42 year-old emergency veterinarian.
You collect Precious Moments figurines, and have a mole that looks vaguely like Rush Limbaugh on your right ankle.
You are the co-owner of the Blood and Guts Veterinary Emergency Clinic, a 24-hour emergency facility in beautiful downtown Burbank, Calif. The clinic caters to a mostly middle-class clientele, with the occasional foray into both ends of the bell curve – the hyper-rich and the destitute. Most clients are caring, realistic and, like Raul, have some income available to pay for ER care, but cost is always a factor. The clinic has always had a biggish heart with regards to the care of strays, with lots of things that never make it onto the balance sheet, but the hard economic times of late have your partner (Dr. Chaleco Salvavidas) looking at every expense with that freakish monocle of his.
You used to be able to provide carte blanche medical care to stray animals, but over the last year that carte has a little less blanche to it. For paying clients, you are finding that you are having to perform many more euthanasias for financial reasons than ever before, and the cookie jar is almost empty when it comes to care of strays lately. People are fearing for their jobs at Blood and Guts, and there are those on staff who see a direct correlation between job security and funds used to pay for the care of strays.
And…you know that Dr. Salvavidas is going to tell you not to shoot the works with this stray unless you think you have a good chance of getting the owners:
a) found
b) to pay for the care
The stray dog is a neutered male who you estimate to be about 4 years old. (Your favorite method of aging pets – cutting them in half and counting the rings – won’t work here so you have to go with the backup plan: how much wear and tear on their teeth.) He is mostly comfortable on his drip of narcotics and very friendly. He seems to be some sort of lab/pibble cross and has an adorable habit of wagging just the tippity tip of his tail when he sees you. He weighs in at about 50 pounds and is a bit on the slim side (like you were in your ballerina days…oh, the satin shoes, the taffeta tutus!), but is by no means malnourished.
He really hurts from his injuries when he is moved, and he hasn’t walked since he came to you 36 hours ago. Periodically, he will try and get up and he really howls when he tries to bear weight on that broken leg. The nurses muzzle him when they have to do his treatments as a matter of course and personal protection – you know that even nicest dog can take a chunk out of you if they are hurt.
The tests that Raul paid for, while not absolutely conclusive, revealed the following (when doctors work up a case, whether it is trauma, cancer or a bad case of the doggy farts, we make a “problem list” like the one below to help us organize our thinking):
- Closed right femur (long bone of the thigh) fracture
- Left ischial (part of the pelvis) fracture
- Hypotension (low blood pressure) and shock – now resolved with therapy
- Superficial abrasions of the left lateral thigh and right hind paw
- 3cm laceration of the left forepaw
- Mildly elevated liver enzymes
- Mild pulmonary contusions (bruises on the lungs)
The problems are not serious except for the broken thigh bone. The lung bruises are not impairing his ability to breathe and you have dressed and cleaned all the skin wounds. The liver enzyme elevations are probably from blunt, Buick-induced trauma and will need some follow-up blood work in a week or two.
The ischial fracture is a minor issue – it should heal on its own. It will complicate things though, as it is like having a broken rib; it hurts until it is healed. Since it is on the opposite side as the thigh fracture, he’s not going to want to walk any time soon – that femur needs to be fixed so he doesn’t just lie there and develop bedsores and the dreaded “urine scald.”
That damn thighbone! If it weren’t for that one injury, the stray (who you have come to think of as Twinkletoes) could be on oral pain medications (much cheaper than IV) and just get three hots and a cot while we wait for the owners to show. But with that broken bone in there, he is in real pain without his IV meds and doesn’t want to walk — so he is depending on the nursing staff to keep him clean and with some dignity. If he could walk, he could go outside to eliminate, but in his current state he needs to be assisted outside and has to be bathed and have his dressings changed twice a day to keep him clean.
In addition to our stray, you have three cases you are taking care of in the hospital (two of them are pretty sick, too) and emergency cases keep coming in needing your attention. You have a set of owners of one of your inpatients that keeps calling every 45 minutes for an update, and you have spoken with what seems like 27 different family members about the case, including one guy you are pretty sure is their dry cleaner.
The hospital is busy, but not lethal.
By your estimation, the thighbone can be fixed here for about $900. (That means the hospital’s cost would be about $450). You are no whiz with orthopedics, but you think you could do it without referring it to a specialist. You have asked around, but most the staff are too strapped for money to help pay for any of the care — the holidays are coming, after all. (You pay them well, but even the highest paid still only make between $15 and $20 and hour.) One or two said they could help do anesthesia on their off time, and a couple said they would donate some funds. You are willing to write off some of the bill and donate some of your time and money, but you aren’t made of euros either – your medical school loan payments are $886 a month, and you have the usual lineup of mortgage/braces for the kids/car payment/ballet lessons/expensive Scotch habit that everyone else does, too.
Before your day in ER goes into full swing, you ponder your options for the stray:
A) Continue the current course: IV meds, ICU-level nursing care for the wounds, and wait for the owners to show. The down side to this is the dog lingers with a broken leg and is using up a lot of your staff’s time. You are staring to worry that they are spending so much time taking care of the stray that the paying customers aren’t getting the best care
B) Jump in and fix the leg today: This means the dog will be able to walk sooner and be less reliant on your staff, but could be something the owners (if found) don’t approve of and end up costing you and the clinic real money.
C) The unthinkable … euthanize the dog. He has not walked since admission, and has periods of severe breakthough pain when he tries to get up, so you are starting to have that “Am I being inhumane?” voice whisper in your ear (the same one that pipes up from time to time when you are pushing the envelope or when clients are making you go beyond what you think is fair to the pet). You might have angry owners to deal with, or ones who look you in the eye and say “Thanks for relieving my dog’s suffering when I couldn’t be there”.
D) Some other option I haven’t thought of.
Think it over and post your replies of what course you would pick for Twinkletoes. Just like the first week, there is no right or wrong here. I will wait a week or so and tally up the responses then post them in a follow-up. I sincerely thank you all for your time, interaction and interest — the answers people give to these conundrums are helpful and informative to me as well!
Ready? GO!
D) Networking.
Try raising the money. Call your local radio station, and ask for a spot, to ask for “900 Holiday Angels”, each who will give $1.00 for the dog’s care. Post on Twitter, on Facebook. Contact local pet stores (the good, non-animal-selling ones), and ask for donations, ask to put up posters. Contact local dog clubs, and ask for money. Ask, ask, ask.
Yes, the good Doctor is busy. And yes, so is his staff. But this could potentially turn into a larger fund, one set up (and administered) by a “charity” group, to help animals like this year ‘round.
And in all honesty, the good Doctor can’t be expected to pay for this all himself - else, what would the poor whisky makers do??
Comment by K.B. — December 7, 2009 @ 11:01 am
So you’ve totally rejected the option of having the dog moved to Raul’s regular vet as was suggested several posters?
Okay - how about contacting local rescue groups to see if any of them want to take responsibility for the stray? You’d offer them the rescue discount (would that be the $450, or would it be somewhere between the $450 and the $900?) which would get the dog patched up and give him a place to go upon discharge.
By the way, what are the legalities involved in WHO the dog can be released to and WHEN?
Comment by The OTHER Pat — December 7, 2009 @ 11:11 am
Oooh, I like D. That’s how you end up with someone to take him home, too when the owners never show!
I’ll bet some of the staff would gladly donate their off time to network, too.
Comment by mikken — December 7, 2009 @ 11:11 am
Is there a less expensive treatment option, like amputation?
And combine with fundraising?
Often, too, if vet has a good relationship with a solid rescue group, the two can partner effectively on these cases.
Comment by One rescue — December 7, 2009 @ 11:20 am
Wouldn’t amputation be painful?
Comment by Snoopys Friend — December 7, 2009 @ 12:26 pm
I have very little experience with ‘found dogs’.
What are the seat of the pants odds that you would find a dog’s owners after 36 hours of unsuccessful looking? I would probably continue maintenance until those odds dipped below the highly scientific value of ‘reasonably good’.
That said, I have no problem with euthanasia of an injured dog if he does not have a home (owners, Raul, a staff member, or a rescue organization) waiting for him at the end of treatment.
Comment by puppynerd — December 7, 2009 @ 12:30 pm
Mantooth Codpeice of the Blood & Guts Clinic ????
(You are sooo wasted in your day job !!! LOL)
I don’t imagine I could continue with option a, I’m getting the feeling that the poor dogs been through enough fruitless maintenance, and it’s about time something more productive was done.
I like to think option b, but I’m a realist. Unless I was quite happy to think that I would keep him myself if nobody showed up for him this would not really work. As we know a criminally high number of perfectly nice, rehomeable pets are euthanized every year. I know it’s not feasible, otherwise I’d be fixing up all sorts of charity cases (and I like Raul do not have a limitless budget, and being a vet would absolutely KNOW that this is not going to be the only such case)
Sadly I would opt for option c. If the owners did turn up eventually of course I would feel like sh*t, but I’d feel like that anyway… But I would have a clear conscience.
Comment by Alison — December 7, 2009 @ 1:00 pm
I’d choose B or D. I obviously would be bankrupt if I was a vet ! I also agree with Alison- Mantooth Codpiece ? You need to writing comedies !
Comment by Leslie K — December 7, 2009 @ 7:01 pm
Put a collection box out front. Ask those who come in if they would donate $10 to help Twinkletoes.
I was at emergency with Pepper a few weeks back (refractory epilepsy) and I felt awful watching people have to decide between helping their animals and paying the rent. I couldn’t afford their bills (I had $1,250 of my own to manage!), but I would have given $10 (or more) if there was a collection box for a stray needing care.
People in that situation KNOW what it feels like. If they can help, they will.
Comment by Lisa — December 7, 2009 @ 8:25 pm
What about the day practices that feed your ER? At the ERs I worked at, there were usually at least 4 or 5 day vets who were both talented at surgery and wanted more experience with fracture repair than they saw in their own practices. Combine that with a rescue or employee willing and able to house the dog after surgery til healed and ready to find a home, and I bet you could get that femur repaired for just supply costs ($150-200?). That’s what I used to do, adding in some unpaid tech time as needed.
Comment by Maria Shanley — December 7, 2009 @ 8:28 pm
Snoopy’s Friend,
Amputation is generally very well tolerated in a young healthy dog, most of whom seem to rebound astonishingly fast. In this dog’s case, amputation post op pain may be less than that of an unstable fracture of a femur.
Death vs a leg. I’d choose life. Amputation seems brutal and cringeworthy to us humans, but dogs and cats don’t have our big brains and hang ups. :-)
On the other hand it does twinge hard to remove a limb that could be returned to normal pain free function with one straightforward, albeit expensive, surgery.
But if the opposite limb is compromised, especially with a chronic condition, it becomes a matter of fix or euthanize.
With a concurrent pelvic fracture on the opposite side, amputation is a sticky wicket for this theoretical dog. And even though the dog would not give of a care about being a tripod, they can take more time to re-home.
Comment by JenniferJ — December 7, 2009 @ 9:50 pm
Given that I, Dr. Codpiece, view Option C as “the unthinkable”, then Option B as the only reasonable alternative. Option A is the worst choice as it will only lead to Option B or C, and in both cases, there’s no reason to leave the dog to suffer longer. Option A also prolongs the emotional, mental, and physical stress on myself and my staff as I waffle over making a decision. I only have time to waffle because the hospital is not at maximum capacity and staff currently have the capability of extra-special care for a half-treated patient. Option A (last but not least) also unnecessarily prolongs the dog’s suffering.
Option D, contacting a rescue organization for assistance, may or may not be effective, but is just another variation on Option A, which is waiting until the money turns up to make a move; it’s just not a reasonable option. To be honest, I’m not happy with taking on this animal’s financial burden myself, but if all else fails, maybe it’s time to sell my Precious Moments figurines on ebay. (Or dig into that special fund I’ve set aside to pay for mole removal).
(Precious Moments and Rush Limbaugh? LOL)
Comment by perri — December 7, 2009 @ 10:43 pm
perri, I’m not sure how you’re envisioning the rescue organization option here, but it sounds like you’re assuming it would be a “giveaway”. And as I made my suggestion, that’s not what I had in mind at all.
My experience is that many vet practices will cut a deal for rescue orgs - either at or near cost for procedures. In such a scenario, the ER (WHY is this dog STILL at the ER?) vet clinic doesn’t make money - or at least not much. But they are also not LOSING the entire amount it takes to care for this dog, which was the basis for the objection of the ER practice partner. The rescue org pays for the treatment - they just don’t pay as much as owner clientele would pay.
So no - “Option D, contacting a rescue organization for assistance” is NOT “just another variation on Option A” because it does NOT involve “waiting until the money turns up to make a move”. The money is there (once a rescue org agrees to take on the case). It’s just LESS money.
Whether or not this option is acceptable to the practice, however, is a question which remains unanswered so far . . . . . . . . . . .
Comment by The OTHER Pat — December 8, 2009 @ 5:20 am
Awesome comments and ideas, everybody - many thanks.
So you’ve totally rejected the option of having the dog moved to Raul’s regular vet as was suggested several posters?
No, OP, that was a good one - but I had to chose something. I wanted to have a few different viewpoints on the actors in this one. If we run this again sometime, I can throw that in the mix.
Is there a less expensive treatment option, like amputation?
And combine with fundraising?
Reasonable choice - artfully discussed by JenniferJ. I agree with her. We hate to take the leg if it can be saved, but it is an option that shouldn’t be tossed out the window out of course.
My experience is that many vet practices will cut a deal for rescue orgs - either at or near cost for procedures. In such a scenario, the ER (WHY is this dog STILL at the ER?) vet clinic doesn’t make money - or at least not much. But they are also not LOSING the entire amount it takes to care for this dog, which was the basis for the objection of the ER practice partner. The rescue org pays for the treatment - they just don’t pay as much as owner clientele would pay.
Good point, OP - I just left the dog here for continuity and to throw a spanner in the works. Makes for some good theoretical ethical stickiness, no? I agree with your comments - most vet hospitals will offer a secret deal to rescue orgs in order to help in situations like this. It can be a mess of red tape and unreturned phone calls unless you have an in with the organization.
The nice thing about the recues is that they often have a great network of caring people who know how to get stuff done - they are often willing to provide potential owners or foster homes, too.
I lOVE the interaction so far - thank you all so much and happy holidays to all of you!
Comment by Dr. Tony Johnson — December 8, 2009 @ 6:31 am
If I were Dr. Codpiece, I would choose Option B, followed up with some variation of Option D. In other words, I’d fix the medical problem first, and worry about the money afterword. I don’t pretend that this is the smartest path to take, but the dog is fixable, and much effort has already been expended on his behalf. Why stop now?
Comment by Rori — December 8, 2009 @ 8:02 am
I have nothing to add, except that I now have a vivid and probably permanent confabulated image seared into my brain, of a Limited Edition Rush Limbaugh Precious Moments figurine.
You will be hearing from my attorney.
Comment by H. Houlahan — December 8, 2009 @ 8:22 am
If you have a dog with good temperament who’s got a good outlook to be adopted, certainly seeking out a rescue organization is a great idea. Our little stray here is a great candidate, though he’s a little old (you could fudge that a bit to say 3 yrs, though, since you don’t know for sure). In my experience, a middle-sized mix with a good temperament is adopted rather quickly, especially in a populated area.
However, having worked in rescue lately, finding a rescue to take him may be tough. Funds are quite scarce right now. It can be done, though. Thus, I can’t see not taking option B given his theoretical personality, size, and prognosis, with a donation box in the lobby and active searching for a rescue org.
All that said, surgery on his leg entails what in recovery time? Are you setting the bone with pins/screws and then a cast from the hip down? How much time for crate rest? What needs to be done in rehab? In the immediate, will his recovery need more or less from the ER staff compared with the status quo?
Comment by Another Kate — December 8, 2009 @ 9:00 am
Amputation is painful. My girlfriend had her leg amputated and said it was the worst pain and experience in her life and she had phantom pains also after the fact.
My large Coonhound had his tail docked as an adult, medical reasons, and it was painful. He would moan and I’d up the pain meds.
I can’t imagine a dog’s leg amputated and not being traumatic for the animal.
I wish all dogs could be saved and loved with homes and these tough decisions were not a part of reality, but they are. Money is tight and vets are pressed into these moral dilemmas. I’m glad I don’t have to make the decision. But no one can make it for the vet, not even us, it is up to each Vets conscience and resources.
Comment by Snoopys Friend — December 8, 2009 @ 10:46 am
Snoopy’s Friend,
believe me, no one is going to argue that amputation is painful.
But an un-stable femur fracture is also incredibly painful.
A dog with a necrotic foot is and has been in horrendous pain.
A dog with severe arthritis that will not even permit the leg to be touched is living with horrendous pain. Ditto for the dog with an unset, badly healed fracture or a severe angular deformity.
I’ve had all of these to deal with in rescue (well, a tib-fib break, not a femur), and in the cases of those for whom amputation was an option, they all displayed less pain almost immediately after the limb was removed. The dog with the necrosis and the angular deformity dog were both up and moving better in a few days than they had been before surgery. They seemed relieved to be rid of the thing.
In this theoretical case, we are not talking about a healthy limb. It’s a broken femur. The dog is reported to howl in pain if he tries to rise, even with meds onboard. If at all possible, fixing that leg pronto is the way to go.
But if we are talking life or death, then if amputation could be done for a third to half the cost of repair, it needs to be discussed. With his other fracture however, it may not be a viable choice.
As for tail docks done on adults, I have 22 years involved in rescue with a screw tailed breed and I have been down that road a dozen times. All I have to say is ” Laser!”. Honestly, the use of a laser to surgically help remove the tail has changed a horrific, messy, very painful procedure to a clean, dry and only moderately painful one, easily managed. Talk about a game changer!
I am sorry to hear about your girlfriend and her experience. All I can say is that dogs and cats, when adequate pain control is used, seem to recover from the procedure astonishingly well.
Comment by JenniferJ — December 8, 2009 @ 12:07 pm
Thank you JenniferJ for your insights. The dog in question obviously needs care and should not be left in pain struggling to stand while the owner is no where around.
Comment by Snoopys Friend — December 8, 2009 @ 12:18 pm
Have the TV news stations do several stories on the dog and ask for donations for the surgery.
Works every time here in Michigan.
Comment by VJ — December 9, 2009 @ 5:21 am
Presumably injured strays are an ongoing problem for the clinic? Is there any scope for trying to set up a partnership with a local animal rescue organisation so that they have a permanent fundraise/rehome program running in association with you.
That might not be in time to help this particular dog, but it would be better than having the same frantic scrabble around every time something similar happens.
My local equivalent of you would be on the phone to us pretty well as soon as they’d assessed the dog.
The clinic might be well placed to promote donations to the rescue organisation (hint, hint if anyone from Village Vets is reading this).
Comment by Rosemary Rodd — December 10, 2009 @ 2:57 am
Thanks to all of you for your comments and interaction! Keep em coming!!
Comment by Dr. Tony Johnson — December 11, 2009 @ 8:29 am