A Lesson for the Veterinarian: Trust the Client

Dog being examined by vet with stethoscope
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When I first met my client Martha in 1985, I was an internal medicine resident at the University of California, Davis Veterinary Teaching Hospital. Right from the get-go, Martha impressed me as a kind, soft-spoken, intelligent woman who was clearly devoted to her 1-year-old Cocker Spaniel, Murphy. Upon entering the exam room I learned that I would be providing a fourth opinion. The three vets before me had run most every test in the book but could find nothing amiss. According to Martha, they believed the patient was normal and the client was a hypochondriac.

Martha readily admitted to me that she could not identify any clear-cut symptoms. Yet she was certain beyond a shadow of a doubt that something was troubling her beloved Murphy. His appetite and activity level at home were completely normal. There had been no vomiting, diarrhea, coughing or sneezing. It was while Murphy was on his daily walks that he appeared abnormal to Martha — a bit less exuberant than usual.

Going on Gut Instinct

I examined Murphy from teeth to toenails hoping for the clue that would help guide the diagnostic process. I found nothing. I reviewed all of the laboratory test results and X-rays generated by the three vets preceding me. Still nothing. Was I truly face to face with a hypochondriac? Listening to Martha and observing her body language, my gut told me otherwise. I believed her conviction that something truly was wrong with her dog — something a trio of veterinarians had yet to figure out. More than anything, I admired Martha’s calm perseverance. She had been turned away three times. Yet here she was in my exam room in her ongoing efforts to be an effective medical advocate for her beloved dog.

Although Murphy had no heart murmur, based on the change in his energy level while out on walks, I opted to proceed with an echocardiogram — an ultrasound examination of the heart. Lo and behold, this study revealed the abnormality responsible for Martha’s concern. Murphy had a birth defect within the heart known as a patent ductus arteriosus (PDA). The ductus is a normal structure through which blood flows in the developing fetus. The ductus normally closes shortly after birth. In some puppies, it remains open, causing abnormal blood flow that can ultimately result in heart failure. This abnormal flow typically moves from the left side of the heart to the right and is associated with a loud heart murmur.

The left-to-right PDA can be corrected surgically or via nonsurgical placement of a ring within the ductus. In rare instances, as was the case with Murphy, the abnormal blood flow moves from the right side of the heart to the left. The right-to-left PDA does not cause an audible heart murmur — the reason three vets before me had been stumped. Unfortunately, there is no feasible way to correct a right-to-left PDA, and symptoms invariably progress. 

When I delivered the diagnosis to Martha, I recall that she burst into tears, a combination of sadness and relief that her concerns had finally been validated. Martha expressed profound gratitude. The search for a diagnosis was over and she now knew what to expect. Martha and Murphy enjoyed an additional 18 months of quality time together. When his symptoms intensified, Murphy was euthanized, after which Martha sent a note once again thanking me for having believed in her.

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