Veterinary Medicine - November 2008 - (Page 586)

Leading Off Making the most of specialty referral services Kenneth R. Harkin, DVM, DACVIM S everal years ago, I received a call from a relative living on the East Coast. He had just found out that his elderly Yorkshire terrier had kidney failure, and the dog’s primary-care veterinarian had given my relative little chance for hope. The veterinarian had told him the only option was euthanasia and hadn’t offered consultation with a specialist. Recognizing that more could be done for this dog and knowing the owner’s willingness to pursue any reasonable course, I contacted a referral hospital in that area, and an internist agreed to see the dog. My relative’s dog survived another few years after successful therapy for leptospirosis. Why did the primary-care veterinarian fail to refer in this case? The dynamics of that situation will never be known, but it is clear that neither money, distance, cataract surgery, balloon dilation of an esophageal stricture, and transvenous placement of a pacemaker are all examples of conditions that one would prefer were handled by a boardcertiﬁed specialist. Unfortunately, deciding when to refer is not always that straightforward. Specialists frequently see patients whose condition has deteriorated, sometimes to the point of becoming a terminal illness, for many reasons, including an incorrect diagnosis or suboptimal treatment. Often the primary-care veterinarian has suggested referral only to have the client decline month after month and then ﬁnally agree when it’s too late. However, sometimes a referral is never offered, even when the results of routine diagnostic tests are inconclusive and the patient’s condition declines with empirical therapy. Kenneth R. Harkin, DVM, DACVIM Department of Clinical Sciences College of Veterinary Medicine Kansas State University Manhattan, KS 66506 Although the question of when to refer a patient often has an easy answer, that is not always the case. nor client stubbornness was preventing the referral. This client wanted his dog to receive the best care possible. So what does a specialist offer? The tangibles are obvious: advanced diagnostic evaluation, such as computed tomography (CT), magnetic resonance imaging, ultrasonography, and endoscopy; technical expertise and the latest techniques, such as phacoemulsiﬁcation, total hip and knee replacement, tibial plateau leveling osteotomy, balloon valvuloplasty, TO REFER OR NOT The question of when to refer a patient to a specialist frequently has an easy answer. Complex pelvic fractures, a ruptured anterior cruciate ligament, and radiation therapy; and 24-hour care in most specialty hospitals. The intangibles are difﬁcult to quantify, however. Sometimes it just takes a different perspective to uncover a cryptic diagnosis. The following is a list of the main reasons primary-care veterinarians refer cases to specialists: • 24-hour care is needed. Patients with spontaneous or traumatic pneumothorax, diabetic ketoacidosis, acute necrotizing pancreatitis, acute renal failure, splenic hemangiosarcoma, or gastric dilatation-volvulus, for example, need round-the-clock care. For these patients, telemetric electrocardiographic monitoring, routine measurement of central venous pressure and urine production, and early intervention of complications can make the difference between life and death. • Necessary diagnostic tests are unavailable in general practice. Although this is probably the most overrated reason for referral, it is often the hook that convinces a client to pursue the referral. The client often easily accepts that his or her dog needs abdominal ultrasonography, gastroduodenoscopy, or a CT scan. However, the real value in the referral comes from the added evalua- 586 November 2008 VETERINARY MEDICINE

Table of Contents Feed for the Digital Edition of Veterinary Medicine - November 2008

Veterinary Medicine - November 2008 Contents Leading Off Editors' Guest Just Ask the Expert Letters Practice Makes Perfect Clinical Exposures Practice Matters Idea Exchange Author Guidelines A Challenging Case: Esophageal Leiomyoma in a Dog Osteoarthritis in Cats: What We Now Know About Recognition and Treatment Product Preview CE Form/Advertiser Index Marketplace/Classifieds Mind Over Miller

Veterinary Medicine - November 2008

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