Fundamentally, I just want to share someone's story of a borderline medical miracle....on a human patient....by a small animal veterinarian. I saw it on Facebook on a private page. I received permission to share it, but wanted to do more than just share it. I think it needs some context. The medical miracle is not an exaggeration, but let me set it up briefly.
There's a movement out there amongst the broader health community termed 'One Health.' Technically, it's not new as it was advocated by Rudolf Virchow - the father of pathology - in the mid 1800s. But the idea of 'One Health' experienced a resurrection in the recent 25 years, especially with respect to some infectious disease events - Ebola outside Washington DC in the early 90s with vets running to the rescue; West Nile Virus in New York 1999 with the human medical experts squashing the correct answer offered by the Bronx Zoo veterinary pathologist; the anthrax events of 2001; and on and on.
The simplest construction of 'One Health' is that there is a continuum of human health, animal health, and environmental health and true health success must address all three elements. Again, for obvious contemporary events, the infectious disease angle has been the easiest element of One Health for people to understand.
But, let's stay in 'One Health' but move away from infectious diseases.
Here's the medical miracle - human patient - animal doctor - with anonymized names and animal circumstances, as told - excerpted verbatim with permission - by Dr. Dan Harmer.
<Begin excerpt>
Had a fantastic case that I just had to share!
8y/o pitbull came in with vestibular disease. When my assistant came out of the room, she told me that she could smell ketones very strongly (I can't smell them, so she always gives me a heads up).
Anyway, I worked up the vestibular problem and ran blood work to check for diabetes. It was completely normal, so I was really confused. I went in and talked with the family. The mom said something like "well, at least it's not diabetes, 'Timmy' has diabetes and it's miserable."
So, I look over at 'Timmy', her teenage son. He's really quiet and sort of a gray, pasty color.
Me: "Timmy, what's your blood sugar this morning?"
Him: "136"
Me: "BS. What was it really?"
Him: "250-something"
I didn't believe that one either. Anyway, I told the mom that she needs to take him to the ER right now. Owners are terrible about following our vet advice, but do believe our medical advice. Haha. She took him in. Today she came back for a recheck. The kid was in DKA and they are still treating him. (The dog is ok, too).
<End excerpt>
For the medically unacquainted, a few things defined:
1. Dog with vestibular disease. This is a nervous system disorder. The dog likely had an unexplained head tilt.
2. Ketones. The most commonly recognized ketone is ACETONE. Most of you know this as fingernail polish remover. Ketones are produced by human and animal bodies in situations of insulin deficiency or resistance. Blood sugar cannot be turned into energy, and the body begins to burn fat and turns this into ketones. When the body has reached a certain level of bad/abnormal ketone production in the blood, it can be detected through our breath. Bottom line: If a human or an animal smells like fingernail polish remover, then it is a medical emergency. The ketones in high levels can contribute to an acidic blood profile that can be fatal.
3. Blood sugar: 136. In most instances, that's on the high end of normal or low end of an elevation. "250-something" is very high. When ketones are detected via smell, blood sugar is often 400+. I recall several cases of cat blood sugar being 600+. That's why the vet knew 'Timmy' was lying.
4. DKA. This is an acronym for Diabetic Ketoacidosis. It is diabetes that is so uncontrolled that blood sugar is high (cannot be metabolized), ketones are produced, and ketones are produced in high enough levels to produce an acidic blood characteristic. It can be and often is FATAL.
"Animals Get Diabetes?"
Yes, animals get diabetes. Lay people are often surprised at that, and that is unsurprising. But here's a surprise ---- I've lost count of the number of veterinarians who have told me their personal physician (M.D. medical doctor) had no idea that animals get diabetes.
(Guess which side of the veterinarian-physician divide is the strongest advocate for One Health.)
An important 'rabbit trail' into CLINICAL REASONING and the ART and SCIENCE of MAKING A DIAGNOSIS.
The odor of ketones as detected by the vet's tech set off a second problem based hunt. As a reminder, the dog was at the vet because of a head tilt (problem #1). With the vet tech's sniffer, and the vet's mind, he reasoned that diabetes was likely (given the ketone odor) and also knew that diabetic complications could sometimes affect the brain. So, he did blood work. Blood glucose on the pit bull was within normal limits. The vet KNOWS that severe diabetes resulting in detectable ketones does not happen with normal blood glucose. Thus, the thought process.....perhaps he thought: "Hmmmm....who is removing fingernail polish right now?" A quick glance around the room and the remainder of the clinic probably ruled out that brief - but appropriate - thought.
But the vet remained 'confused.' Sadly, we tend to negatively stigmatize confusion. Confusing situations and signals SHOULD be expected in medical practice, and as a quick aside - I recommend anyone to be skeptical of any physician or any veterinarian who immediately declares irrefutable diagnoses. It's just bad and dangerous practice. It's important to emphasize it is absolutely OK to be confused. Too often we react with: "Don't just stand there - do something." Sometimes, the most appropriate response for a medical professional - vet or human - is to reverse that: "Don't just do something - stand there!"
To a modest extent....I believe Dr. Harmer just 'stood there.' Oh....he went on about his appointments and his day, but I assure you - this perplexing case was occupying a tremendous segment of his brain while he performed other tasks.
So the vet updates the dog's owner. I imagine the conversation went like this:
DVM: "Well, Fido's head tilt is what we call vestibular disease. There are many possible causes for this. We're checking some out. My team and I thought it might be diabetes, but Fido's blood glucose is normal, so diabetes is ruled out. We need to begin the process to investigate other possibilities."
Owner: "Well at least it's not diabetes. 'Timmy' has diabetes and it's miserable."
DVM: (thinking....no one is using fingernail polish remover.....)
DVM: (Looking at 'Timmy'....quiet....pasty....pale)
DVM: "Timmy....what was your blood sugar?"
And the rest is included above in the original story.
Thus, back to CLINICAL REASONING....the vet knew that a diabetic patient was in his exam room. He knew it was not the dog. He saw no fingernail polish remover. Presumptively, other boarding and waiting patients were a fair distance away. Fortunately, the DVM education and training program is inherently COMPARATIVE - how else do veterinarians acquire expertise and confidence to treat more than one species. It is imperative that we ALWAYS think comparatively. And light bulb! The vet knew that one of the human clients might be producing these ketones. Whether from a dog, or a cat, or a bottle of fingernail polish remover, or from a human, ketones smell like ketones. The vet knew this and exercised a "heuristic" - a problem solving approach - that via process of elimination, one of the humans in his animal exam room was producing these ketones. A quick cursory examination and recognition of the quite, pasty teenage boy, followed by some brief, yet pertinent and focused, questions revealed the source.
"Get Thee to an ER! Now!"
Dr. Harmer quite likely saved this boy's life. DKA in 'Timmy' was confirmed at the recheck visit for Fido.
And so, we return to One Health. It's not all about infectious diseases. It's also metabolic diseases. Vets know diabetes....they know and manage obesity in pets....and know it compromises the long term health of their patients in the same way that physicians know that it compromises the long term health of their human patients.
It truly is "One Health." Thank your local veterinarian today! Someday they may save more than your pet's life!
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