Dr. Angie Krause (00:00)

Welcome back to Tails of Truth, where we tell the truth about veterinary medicine. I'm Dr. Angie, and this is my co-host and veterinary nurse extraordinaire Jojo. And today we're going to talk about stuff you can decline in the emergency room.

JoJo (00:10)

Hello.

That feels really hard to do in the moment I guarantee you. When you're in the ER, you feel like you need to say yes to everything.

Dr. Angie Krause (00:22)

Totally.

Well, I think it's how it's presented to you too. And I've had some, well, I've had an increasing number of cases that have gone to the ER or my own patients that are going to the ER and I'm reading the records and I am cringing. And this episode is not to throw any veterinarian under the bus. I am going to roughly talk about veterinarians in generational terms.

JoJo (00:42)

Hmm.

Dr. Angie Krause (00:52)

But I want this episode to be more to empower pet parents. And I know I'm gonna get some pushback. Like I'm gonna make some fellow veterinarians upset. Yeah.

JoJo (01:05)

Uh oh. Okay.

Put on the armor, the thick skin. I I utilized you just over New Year's Day for this. I'm like, this is what I'm being quoted. This is what's happening. You're like, you don't need to do all that. So I know what's happening. I just experienced it as a consumer, as a customer, and I felt like I wanted to say yes to everything. Yeah.

Dr. Angie Krause (01:10)

Yes.

Yeah.

Yeah.

Well, you feel like you're a terrible person if you don't.

And I think this is my formal diagnosis. I think newer veterinarians, and this is where I'm going to talk about veterinarians in a generational term. I don't know if it's the way they were taught, if it's the way they are socialized in the world, but there are a lot of veterinarians that are offering things that are inappropriate, like that are overkill.

For example, I had a dog, I had a little dog that came to see me, young little dog, who had been vomiting and having diarrhea. And the diarrhea at this point was just frank watery blood. I ran some blood work and everything on that blood panel was consistent with a disease called hemorrhagic gastroenteritis. It's got its own thing. And you know what? These dogs do really well.

with IV fluids and some antibiotics. But I'm in day practice and I think this dog needs to be hospitalized overnight. He needs a full day of fluids. So, and the history did not, there was nothing about this dog that made me think this dog has a foreign body, that he's eaten something and just become obstructed. It was so clearly HGE that I just, I was like, I felt so comfortable. I called

over to tell the ER, Hey, here, this is the signal of the case. This is what I think is going on. And the veterinarian, the ER vet said, did you take x-rays? And I was like, no, I really think this dog has HGE. And he was like, okay. And so they go, they go to the clinic and they are quoted for x-rays, which I, know, it's like, it's not wrong to take x-rays, but it's also ⁓

maybe a little overkill in my opinion because you're already hospitalizing doing IV fluids is all expensive. And then they offered an abdominal ultrasound. And then when they looked at the ultrasound and it wasn't an ultrasound done by a radiologist, it was just them scanning, which I was kind of like, what are we doing? Now, side note, I come from a generation of veterinarians. I know how to practice without ultrasonography And so I'm

very comfortable living my life without an ultrasound probe. And so I cannot look in abdomens like this and I'm okay. And then they anesthetize this dog and put a nasogastric tube in because when they took an x-ray, they felt like there was too much fluid or they did the ultrasound, there was too much fluid to see if there was a foreign body. So they sedated this dog.

placed a nasogastric tube, so tube up the nose, down into the stomach, to remove stomach contents so that they could then take another x-ray to see if there was a foreign body.

JoJo (04:19)

Could they not have just waited till this dog vomited again?

Dr. Angie Krause (04:21)

I have, I don't, I was just like, what? I could not figure out what was happening. And meantime, the veterinarian there texted me and said, Hey, your clients, did you tell them how much this is going to be? And I was like, no, I don't know. Well, I didn't plan on that circus happening. I mean, like what? And so I just said, Hey, you know, I, I didn't. And then when I saw

JoJo (04:24)

No, yeah.

Why would you tell them how much it's gonna be? Do you know how much it's gonna be?

Yeah.

Dr. Angie Krause (04:50)

Every he's like, well, they almost walked out and now I understand why. And I think the conversation probably went a lot like this. If I were to like make up what I thought happened, some veterinarian probably young said, this could be a foreign body and we need to take x-rays right now. And by the way, x-rays are notorious at missing foreign bodies. And so just because you have a clean x-ray doesn't, you still don't feel good, but there was nothing about this case.

JoJo (05:13)

Mm-hmm.

Dr. Angie Krause (05:18)

that was screaming foreign body, you know? And so I just, so they're like, well, it could be really serious if we sit on this overnight and it's a foreign body, we better take these X-rays. That's what was in the notes. And I was just thinking, wait, what, where are you practicing? Like on what planet are you practicing? Because we sit on foreign bodies all the time.

JoJo (05:21)

Mm-hmm.

I was just gonna say, the dog is in emergency. So should it worsen?

Dr. Angie Krause (05:43)

Yes.

Then you take that X-ray. Right. But no, this dog is like, has projectile diarrhea, water diarrhea coming out. It's just like diagnostic between that and the blood work and the signalment. It's a little dog. It's a young little dog. It's just like check, check, check, check. And no, they do. And then they, don't, I don't even know what was happening, but here's my concern is that these people then no longer have money.

to pay their rent, to buy food, now they're in debt. All because we couldn't just wait 12 hours to see how the dog responded to fluids and you decided to anesthetize this dog to place an NG tube so that you could remove stomach contents. it's just not okay. It gets me worked up. It makes me really upset because this is why people are gonna stop trusting veterinarians.

JoJo (06:28)

Yeah, that is expensive. Yeah.

Dr. Angie Krause (06:39)

I don't think that veterinarian's a bad veterinarian, but there is part of me that feels like we have this generation of veterinarians that just look at the history and say, we have vomiting and diarrhea, could be a foreign body, let's do everything, instead of using critical thinking to do some treatment and then see how it goes, or do one diagnostic test at a time and see.

I feel super upset. Yeah. I feel, yeah. And I, I feel really upset about it because it's not the first time because it feels really personal when I know these people, I know this animal and I know that if they would have just given the dog IV fluids and antibiotics, it would have been fine in the morning. And guess what? That dog was fine in the morning.

JoJo (07:03)

Yeah, I can tell you feel fiery about that.

Dr. Angie Krause (07:24)

⁓ and so now next time this dog needs care because HGE does need fluids. Like that dog needed to be fluid resuscitated, but it did not need 10 million x-rays or an NG tube.

or an ultrasound? It just didn't. Okay, so.

JoJo (07:45)

Well,

I have a theory on that. I heard in your description of it, age of the veterinarian as a possibility of what's happening, of what they're being taught in school, what the new generation of vets are coming up with. And I've also seen veterinarians that work in emergency posting on socials about how they have a threshold of which they have like a numerical threshold, a financial threshold. So if your dog walks in with X,

they're going to present you with a certain number of diagnostics to hit that financial threshold. And I saw other veterinarians commenting on it and I wish I could find it again because I thought, is this what's happening with this huge takeover with I don't know what kind of ER you sent your client to, but is this what's gonna happen with corporate? so I wonder if it's also a piece of that that they have. Okay.

Dr. Angie Krause (08:32)

They're all corporate.

JoJo (08:39)

dog comes in with XYZ, here's the protocol. Try to hit that mark.

And I'm total conspiracy theory over here that it could be that and I would hope not, but I think it could be.

Dr. Angie Krause (08:51)

That just lights my hair on fire because part of me felt like what was happening in that ER was laziness. But maybe it's not laziness. It's just, God, surely it's not greed. ⁓

JoJo (09:03)

Well, I hope not.

It could be insecurity. It could, right? Just not feeling as confident because this vet doesn't have 20 plus years of experience. So the rule outs still matter. All those diagnostics help check their box of comfort. Maybe it's because we live in a litigious society. So, right? I don't know. It could be all the things.

Dr. Angie Krause (09:06)

Okay, could be insecure.

Yeah.

Right, that's true. Yeah.

Well, here's what I want to teach all the baby vets or the veterinarians that really struggle to speak with people. This is how that conversation needed to go. Hey, I agree with your veterinarian. I think your dog likely has HGE. This is how we treat HGE, just some fluids and some antibiotics. But I want you to know it's always possible that your dog could have an obstruction in their intestines. We would likely find out if they don't get better on fluids.

JoJo (09:31)

Yeah.

Dr. Angie Krause (09:54)

But if you want to, we could take x-rays. We could do an ultrasound. This is available to you. I think it's less likely. We can do it now if you want, or we can do it 12 hours from now if your dog's not getting better. That's all it takes is to say, we could start with this, but I just want you to know we could also start with the whole thing. Like that is how most of my conversations go. And I feel like that's the lost art.

because when you walk into these emergency clinics and this happened to you too, they will put every diagnostic test on that estimate and then hand it to you.

JoJo (10:30)

Well, now they

don't even hand it to you, they text it to you. I was in there, so they text it to you. So I just open it up on my phone. They're all doing their own thing. And I'm just like, there's not a place to decline any of it. There's just a pay button. And they don't start anything until you pay. And so that's when I'm sending it to you saying.

Dr. Angie Krause (10:44)

really?

JoJo (10:52)

Well, because one, also didn't know that the ultrasound was not done with a radiologist, that it was just like a free, I'm like, how much did they really just learn from that ultrasound when he's not shaved standing up, not positional?

Dr. Angie Krause (11:03)

Right.

JoJo (11:03)

Did I really just learn anything? I don't know.

Dr. Angie Krause (11:05)

Yep, they learned

that maybe there's no free fluid. That's all. Yeah.

JoJo (11:08)

Right. Yeah. And

the fluids, I was just like, my gosh, that's so much money for fluids. He's drinking just fine. yeah, his gums are a little tacky. But I did, I did say yes to things that I probably didn't want to, but I ended up having to do it in three different payments, four payments, because I'm like, could we just do this? And then when that comes back, I can decide if I want to do the next thing. So I ended up with four texts and four payments and

Dr. Angie Krause (11:15)

yeah!

Yeah.

Yeah. Yes.

Yeah.

JoJo (11:33)

But I

had to go find them to have the conversation, because there was no way to decline it.

Dr. Angie Krause (11:37)

Yeah, so that makes you feel like, hey, I can pay $3,000 right now or feel like the worst person in the world when I say, hey, is all of this necessary? And anytime I have a dog come into the clinic that's really ill, I usually start with an x-ray or blood work. It's very rare that I do both immediately. Usually I'll say, hey, sit tight, me 10 minutes, we're gonna get some blood, I'm gonna run a complete blood count and some chemistries.

and then we're gonna regroup. I rarely say here are all the things that we're gonna do. I get a piece of information and then we make a new plan. And I feel like that is such a missing piece to this. Like that dog, my HGE patient, they should have said, hey, we can do fluids. Let's just do it for 12 hours. Let's see how he responds. Great. And then if we need to do something more at that time, we can talk about it. But like.

JoJo (12:29)

Yeah, I think if the veterinarian's not giving the client permission to have that conversation, most clients are not going to know that they can have that conversation. I think that's what you're trying to advocate for here. But on top of that, when you are that customer or that client, your brain is not fully, I feel like we're vulnerable in those moments.

Dr. Angie Krause (12:39)

Yes.

Mm-mm.

well, if you're an emergency clinic, your cortisol is high, you're scared, you're emotional, you're vulnerable. like, just, yeah, of course not. And so here's what I want everyone to ask their veterinarian. And I felt like the veterinarian you worked with, I did not like their answer. What are you thinking might be going on? Mm-hmm. Yeah.

JoJo (13:05)

yeah, I asked specifically that. said, what are your rule outs right now that are happening?

And her response was, ⁓ there's so many. Yeah.

Dr. Angie Krause (13:14)

And that was the wrong answer.

That was wrong. ⁓ so wrong. And like, you know, what are, what are our rule outs right now? What are you thinking could be happening? And I want to find out what each test is going to tell you and what it's going to change for us. What is it going to do? Why are we doing this test? And I think, I'm not sure. mean, of course I went to Texas A & M the best veterinary school in the entire world. I know, but like Mike Willard.

JoJo (13:29)

I love that.

Dr. Angie Krause (13:42)

my internal medicine, canine internal medicine professor taught me and he taught us through, you know, maybe third, fourth year. When you think about medicine, you have to think critically about what you're looking for and what you're going to glean from each test. And I guess I just don't see that happening. Like, what am I going to get from this test? And if I'm not, if it's not going to change anything I do, why would I do it? And so that

Like the whole idea of placing an NG tube so they could pull out contents of the stomach so they could take a better x-ray is the most, yeah, I'm like, what is going on? What is happening? You don't need to do that. And so like what, you know, so they could take a better x-ray and because a foreign body is of course was still on the list, but it was low on the list. And so I think.

JoJo (14:15)

I've never heard of such a thing.

Yeah.

Mm-hmm.

Dr. Angie Krause (14:35)

That's what I want to encourage people to do and to really figure out like, is this what needs to be done? I wish everyone could just have my cell phone number and I could help them through this.

JoJo (14:43)

I feel so lucky.

I kept Angie up for like a whole night. Like, what's this? I could make decisions for myself and I have the knowledge. Yeah. Yep.

Dr. Angie Krause (14:54)

I know. I know.

And it's like, am not trying to pick fights with younger veterinarians. I'm not trying to pick fights with an ER vet because we all know that, you know, a career in ER medicine would just shred me to pieces. And so I, I have so much respect for them and it's really not even the majority of them. I feel like this is kind of an emerging trend that I'm seeing, but like I doubt a veterinarian, emergency veterinarian that's been practicing for 20 years. I'm not going to have this interaction with them.

JoJo (15:19)

Mm-hmm.

Dr. Angie Krause (15:26)

So I'm sorry to the younger generation of veterinarians. And I remember when I first got out of veterinary school, I would look at, you know, the older generation of veterinarians and be like, my gosh, can't believe she's prescribing steroids again or whatever.

JoJo (15:38)

You

Right, and now it's Metro nidazole is All. I see all the young vets talking

about Metro nid az ole

Dr. Angie Krause (15:46)

Oh my

God, you're going to pry that Metro nid az a ole of my cold dead hands. No, I use it less now. I am. I'm trying to, I'm trying like, but sometimes like I'm still in customer service. And if that dog has kept their people up for three nights in a row, pooping every hour, I'm going to give everyone some sleep. So.

JoJo (15:50)

Yeah.

Mm-hmm.

Yeah, well, I would think that

ER vets tend to be younger.

Dr. Angie Krause (16:09)

think so?

JoJo (16:10)

Do you really wanna start doing that in the second half of your career?

don't think so.

Dr. Angie Krause (16:14)

Yeah, yeah. I mean, think it also helps if, well, if they've been in day practice. It's interesting. Some of the ER vets that have never been in day practice, you're like, oh wow, you don't have like a grasp on general medicine, which is not, I mean, it's not always a bad thing, but you can sometimes.

JoJo (16:27)

Yeah, well, I mean, I am impressed with what they do. I will say that because I had the fortune of being in one of the open concept clinics. And I'm just like, wow, it is happening in here. They are tackling a lot. And so I left there thinking, okay, their job really is just to make sure everyone goes home stable, not necessarily fix the problem. Just stabilize.

Dr. Angie Krause (16:37)

Yeah.

Yes.

Yes.

No. And

they're not thinking about their relationship. So when I am in an exam room with my patient and my client, like I'm thinking about my long-term relationship with them. We're, you know, we're together for that life of, for the life of that animal. And I, I want to make sure that they trust me and they know I am being transparent. And I think that's really important. And that's why when we have these really hard situations where

JoJo (17:02)

Mm-hmm.

Dr. Angie Krause (17:18)

these people walk away probably paying $3,000 and they never want to go back to the emergency clinic again. And so I never want that in my, the clinic I'm practicing in. I don't want people to feel like, oh, every time I see Angie, there's another $1,500, you know? I don't want them to feel like, I know I didn't make that choice.

JoJo (17:26)

No.

Right. Yeah, but you didn't make that choice.

Yeah. I know that's hard. That is hard. Well, some day practices will keep their patients overnight, right? Like they have an overnight tech Or not so much anymore.

Dr. Angie Krause (17:47)

Really not anymore. No.

I mean, not in the metro here. I've never seen that. Yeah. Yeah.

JoJo (17:52)

Yeah, that's hard.

And it would have been nice if that ER vet had checked in with you. Say, I am kind of leaning this way. Because you established contact and.

Dr. Angie Krause (18:02)

yeah, no.

I did. And I was annoyed when he texted me saying, hey, it would be nice if you were to give them an estimate. And I just wanted to think I could never have known all the extraneous diagnostics you wanted to do.

JoJo (18:16)

I

Well,

how are you supposed to give an estimate? I mean, I told you when I saw with my discount, which was a significant discount, what they charged me for sub-q fluids. I was, what? It would have been $147.

Dr. Angie Krause (18:31)

Yeah.

Yeah. Yeah.

First up, yeah, I know.

JoJo (18:37)

That took all

of five minutes and I know what that bag cost.

Dr. Angie Krause (18:40)

Yeah, I know.

JoJo (18:41)

So how would you ever know what to estimate?

Dr. Angie Krause (18:44)

I don't know, I don't usually. Usually people ask me like, hey, do you have any idea? I mean, I would say it's about $1,000 to walk in the door if you want to hospitalize for 24 hours. Minimum.

JoJo (18:53)

it's

gotta be so much more than that. mean, I walked out close to like 2500.

Dr. Angie Krause (18:58)

But did you hospitalize? You did a bunch of diagnostics. Anyways, I, I do want to support all my fellow veterinarians, but I do think it's a problem that we all need to talk about.

JoJo (18:59)

No. Yeah. Okay. That bill's coming.

Yeah, so let's hear your emergency stories. And if you are a young vet who's listening, what are you learning in school right now? they teaching you to do all the diagnostics? Like, what is it? Tell us.

Dr. Angie Krause (19:27)

Yeah,

what's going on? And it's not that we think that you can't practice medicine. It's never wrong to do all these diagnostics.

JoJo (19:32)

No,

it's probably really good medicine in terms of medicine. Like gold star if you can do all the things, but that's expensive for people.

Dr. Angie Krause (19:36)

Yeah.

Like where does that ivory tower mentality meet the real world and what we can really do and expect people to continue to take care of their animals?

JoJo (19:52)

That's a good ending question. Okay. Huh. I feel like we could probably vent more and more on that. Not going to. Yeah.

Dr. Angie Krause (19:57)

No, we should stop venting.

If you have a question for me about your pet, if you'd like me to look over their records, give you my opinion about their care they're getting and the direction I think they should go, you can go to boulderholisticvet.com and then the top right corner, you can click book a consult and you can book some time with me. I'll get records, look over them and we'll meet on zoom. It'll all be recorded and I can set you on the right path and we will see you next time.

JoJo (20:29)

Bye.

Dr. Angie Krause (20:30)

Bye!