"Fleas make everything worse," or "Why I hate bureaucracy"

Today I had another cardiology patient whose main problem wasn't really cardiac-related. (See: The case of Mr. Beagle.)

My patient was Rosie, a cute little fluffy 14-year-old mutt dog, a "never been here" appointment whose presenting complaint was "murmur/cough." Nothing too surprising there -- most patients who present to cardiology come in because of murmurs, and dogs with heart enlargement and/or heart failure often cough.

When discussing Rosie's history with her mom, she mentioned that Rosie's housemate was diagnosed with fleas a couple weeks ago, and both dogs were treated with Frontline. Rosie's housemate, who is much larger than Rosie, was prescribed the "large dog" size of Frontline, and Rosie's mom figured she could just use half of a tube on Rosie.

However, almost immediately after we started discussing the flea issue, a plump little flea jumped onto Rosie's chart with impeccable timing, and I promptly squished him.

Sigh.

I hate fleas.

To make a long story short, after ausculting Rosie and listening to her history (which included a cough of several years' duration), we felt she most likely had some degree of mitral valve degeneration and regurgitation (extraordinarily common in older, small breed dogs) along with probable chronic bronchitis (also very common in ancient little dogs).

In order to get a look at Rosie's heart and lungs, to make sure her heart disease was what we expected and to evaluate her lungs for a pattern supportive of bronchitis, we decided to take some chest x-rays.

And, kindly and responsible veterinary student that I am, I made a note in the "comments" section of the radiology request that Rosie may have (a contagious infection/infestation potentially dangerous to other animals and people known as) fleas. Figuring that they'd like to know that information so they could properly disinfect their radiology table, etc. And figuring that they'd be happier if I told them up front that Rosie might have fleas, rather than them figuring it out halfway through taking her radiographs.

Oh my Lord. I was so wrong.

Radiology immediately flipped out and said there was no way they could radiograph Rosie while she still had fleas.

Which greatly irritated the senior cardiologist, who said he wasn't taking his irritation out on me (but it sure didn't feel that way).

I was sent to investigate ways to rid Rosie of her fleas, so I headed to Community Practice and Dermatology, both of which recommended administering Capstar, an oral medication that kills fleas almost instantly (not quite, but close). Which was something I already knew.

So I visited Pharmacy to pick up some Capstar for Rosie, only to find that Pharmacy was out of Capstar. But, "helpfully," they offered me an expired pill and generously told me I could have it for free.

The alternative was to readminister a topical flea product like Frontline. The problem was that Rosie had already been giving Frontline a week earlier, and likely got an overdose (which is fortunately not a big issue for that product) since her owner gave half of the large dog size. And although it probably would be pretty safe to just re-apply Frontline again today, neither Merial (the company that produces Frontline), Pharmacy, or Community Practice could comment on the safety of doing so.

All of which, after much running around the hospital like a headless chicken, I conveyed to the senior cardiologist. Who marched down to Radiology with Rosie and me and instructed Radiology that they would now be taking Rosie's radiographs. Which they did. And I almost ran out of the building, screaming with frustration.

The moral(s) of this story:

1. I don't feel comfortable administering an oral medication (Capstar) to a patient when said patient's owner is out of the hospital and cannot be reached by phone. Even if it's probably an innocuous medication.

2. I especially don't feel comfortable administering an expired oral medication to a patient without the owner's informed consent, especially since I have no idea if (a) said expired medication will no longer be efficacious, or worse, if (b) said expired medication may no longer be safe.

3. I don't feel comfortable administering a topical medication (Frontline) to a patient when doing so would be against the label instructions and I've been advised against doing so by the product manufacturers and two departments within the hospital.

4. I don't think it's right or fair for clinicians and students to request for the radiology and ultrasound departments to handle our patients when we know that a patient may have an easily transmissible disease or parasite, without first letting radiology/ultrasound know about the potential hazard. Even if the risk of contagion or transmission is extremely low. How would you feel if you paid $200 for your dog to have radiographs taken at a veterinary teaching hospital and he came home with fleas?

5. However, I don't think it's fair for Radiology to totally flip out if we do the right thing and inform them about a contagious disease. It sure is good motivation for other departments not to let them know the next time. I've encountered this in other departments, particularly with my leptospirosis suspect patient -- when we let Ultrasound know that the dog might have leptospirosis, they threw a fit, so the clinician then didn't want me to tell Radiology about the disease concern. (Granted, leptospirosis is a much bigger health threat than fleas, but the principle is the same.)

6. I think the pharmacy should stock Capstar that is in date. And I am really uncomfortable with the pharmacists handing out expired drugs for us to use on patients in the hospital with the advice, "It'll probably be safe." Not cool, Pharmacy.

7. If a student advises another department about a potential health concern with a patient that that department is expected to handle (e.g. to take radiographs), it is wholly unfair for the clinician to take it out on the student when the other department throws a hissy fit about the fact that they were properly notified about a contagious disease. If there are miscommunications or disagreements between department heads, it is not my job to play monkey in the middle.

8. I am really, really ready to be done with Cardiology. It has not been a fantastic two weeks.

Incidentally, Rosie's radiographs were eventually taken. To my knowledge, nobody got fleas. Her rads showed a large tumor in one of her lung lobes. Which was not at all what we were expecting, but sure does explain her cough. Rosie got a consult with Oncology and is scheduled to come in through them next week for additional diagnostics and possibly surgery. Cancer sucks. Earlier this week we diagnosed another super-sweet dog with a giant tumor on his heart. I want some cardiology patients we can fix.