KIM the Samoyed

a mis-diagnosis

by Dr. Scott Tillman

Kim with daughter Stephanie

Kim was not a show dog, perhaps she was not a champion as many of you know it..but she was a champion at our home....she was a family dog..a family member...and herein lies the story that some of you have suggested I tell, perhaps to help avoid similar tragedies from occurring again.... When Kim (our female Samoyed) was about 12 1/2 years old, she started to have some difficulty getting up, especially on slippery floors. Until that time, she loved to go for long walks ...and would often run as soon as she got outside, with her leash in my hand, I would have to run as fast as I could to keep up with her.

Then, one day she slipped on the kitchen floor and cried out in pain.... Following her vet's instructions, she was kept quiet, placed on anti-inflammatories, and all the battery of usual veterinary tests were run, including a full series of radiographs.(This all took place during the summer of 1996). As a result of this injury Kim was left with a unilateral neurological deficit which weakened her left leg; she had a "toe curl" also ..but in time, this improved and she was walking pretty well again. However, I never allowed her to walk steps after that injury, and carried her up and down steps just to be sure she did not injure herself again. Further, all slippery floors were carpeted (kitchen ceramic tile, foyer marble) so that she had traction...and over a period of several months, Kim seemed pretty much back to her old self. She remained on Cosequin (to help those older joints) and when the weather was bad, she was given Ascriptin for what might have ailed her. Her improvement and ability to walk distances was dramatic and by March 97, she was able to master a ramp I had built for her to go up and down backyard steps herself.   Effectively, Kim had improved about 90% and was doing fine...

During May, 97, Kim started showing signs of rear leg weakness so many you have come to recognize in Samoyeds. After examination, her vet suggested corticosteroids (prednisone or dexamethasone) for those "bad days" however the bad days seemed to come more often than the good ones..she could get up, but would eventually drag one or both of her rear legs..It was time for something to be done, so her vet suggested she be evaluated by a Diplomate of the American College of Veterinary Surgeons---someone trained at the Animal Medical Center of New York. Unfortunately, this surgeon's office was some 200 miles away but in early June, we hopped in the 4x4 and made that appointment. Using x-rays that were over a year old, this DACVS vet examined Kim, made her walk on a tile floor (where she did slip and hurt herself more) and examined her clinically. He suggested that she probably had a "class II disc lesion" or tumor, and the only way to find out was to have her undergo a myelogram which would be done under general anesthesia. The alternative was to give higher doses of corticosteroids and alternate them with Rimadyl (carprofen) which is a drug usually used for arthritis. I took the information under advisement, and decided to take Kim home and see how she did. My own vet called and just reiterated what the surgeon told me, and suggested we just see how Kim would do.

During the latter part of June 97 and early July, Kim's rear leg ataxia became worse ..She was dragging her legs, and this shortly became a case of rear leg paraparesis. She was totally unable to move her rear legs, but she was not incontinent. I would carry her outside on the lawn and Kim would eliminate.. Clearly, this was not the kind of life she deserved, but with an otherwise very healthy Samoyed, one who was so much a part of our family, another child, really...it was not Kim's time. I discussed the situation with her own vet, who suggested that since the first surgeon was so far away, another DACVS vet surgeon was nearby, and he trained under the first surgeon at the AMC. We decided that another evaluation was in order. On July 21, 97 Kim was evaluated by this second Diplomate of the American College of Veterinary Surgeons who used the same x-rays which were over a year old by now,(I suggested new ones be taken and he said it wasn't necessary) and said that Kim might have a tumor or she might have a bulging disc and only a myelogram performed under general anesthesia, with surgical decompression of her spine would be of aid at this time and that she had a 75% chance of recovery.   Of course I was very concerned that Kim would not make it through even the general anesthesia, however, this was the only option given to me other than euthanasia. Euthanasia, at this point was not an option I could consider.    I would rather Kim attempt to learn the use of a K9 cart to get around first..(One was ordered custom built, just in case it would be needed).

In the meantime, Kim's attitude psychologically was phenomenal, Her own vet said she was really more like a much younger dog. At a check up on July 26th, he drew blood for a routine CBC, which would probably have been requested by the surgeon, he said, prior to treatment there, and sent the results to the surgeon.   The appointment was set for July 31, 1997 with the surgeon. Kim was to undergo myelogram under general anesthesia in efforts to surgically decompress her spinal lesion or remove a tumor, whichever was found. These were Kim's options and something needed to be done to improve the "quality" of her life to where it was before, if possible. Cost was no object and never was an issue.

The morning of July 31st 1997 came, Kim had been deprived of food and water for at least 10 hours, and she was still in excellent "spirits." Clearly a dog doesn' know what she's in for........still the day before, we spent together, driving around going to favorite places..She even was treated to a big juicy steak from a major steak restaurant for lunch. I thought she deserved it, considering what she was about to be put her through.   I explained to my two young daughters what the doctor was going to do to Kim and that Kim would need a lot of attention and love during her recovery afterwards (That was assuming Kim made it through the anesthesia). Of course, they were upset, as I was at the prospect of anything happening to her, but the surgeon had assured us that this was routine, even in dogs of Kim's age. To say that I had a bit of trepidation, would be an understatement. Still, Kim underwent the anesthesia and myelogram that Thursday noontime; but I received a phone call from the surgeon during the time Kim was to be undergoing surgical decompression treatment. The surgeon said to me he had removed a fractured rear tooth which I told him about, and that the films from the myelogram showed the myelogram dye traversing through, with no blockages, and no tumors were found. Was that good??? Or was that bad??? The surgeon advised that with no bulging discs, and no tumors, there was nothing to decompress surgically, and that therefore, there was nothing he could do for Kim.. He added that Kim's inability to walk and her rear leg paraparesis was due to a disease called Degenerative Myelopathy, (DM) and that there was little he could do.

I took Kim home the next day; she was handed to me sopping wet at the surgeon's office. (I was told they had just cleaned her up and didn't have time to dry her). I was heartbroken, but Kim was, at least alive..and we would do everything that was humanly possible to help Kim adapt to using a K9 cart once she recovered from post anesthetic symptoms. I had been carrying her up and down stairs for almost a year anyway to avoid injury, so, it just meant we would have to be there more for her now. Our entire family was committed to making her life as normal as possibly could be under the circumstances. During the following week, the surgeon called to tell me about the interpretation of the myelogram from a group that does this from Cornell University Vet College. The interpretation suggested perhaps some infectious diseases be tested for, since there were no spinal lesions. I asked the surgeon if we were going to do this and he replied that DM was the cause of her symptoms so it didn't make sense to do any more tests. When the surgeon told me Kim had Degenerative Myelopathy (DM), I did some research on the ailment, and it seems that Samoyed are usually NOT affected with DM. So something bothered me about all this. Further, the weekend after the myelogram, I contacted the author of the articles on DM in German Shepherds, (http://kitty.vetmed.ufl.edu/neuro/dm_WEB/DMofG.htm) (I have been advised that this url has changed since Aug, 97) and was advised that Samoyed indeed do not get this disease, and that I should have the surgeon check the cerebrospinal fluid for infectious diseases, including Rocky Mountain spotted fever, Lyme Disease, Erhlichias, and others. When I picked Kim up I was shown the initial csf tap results from the lab so I had the name of the lab used, and the accession number so I called the lab directly on a Sunday, and requested the tests advised, and guaranteed payment for whatever the costs of the additional tests. The only test originally ordered by the surgeon was a usual csf screen which showed up as an inflammatory tap. The next day, the surgeon called me to tell me he was contacted by the lab, and told the lab not to run all those tests except Lyme. When I question him as to why, he answered "we can run tests to rule out space aliens but what will that prove?"

The next day (which was 5 days after the myelogram/anesthesia), I called the surgeon to advise him Kim had developed a "wheeze" during breathing...and it was more labored at night.   The surgeon advised that it was probably due to the endotracheal tube used during anesthesia and she'd be fine. As it got worse by mid to the end of the week following his treatment, I called him again, and he said that it would clear up, and that since the myelogram was negative, he suggested that we increase the prednisone dose for Kim from 5mg twice a day to 30 mg twice a day (60mg per day) to see if we could stimulate some motor function of her rear legs.. He called in the prescription and Kim was put on this for 5 days...All the time the wheeze did not sit well with me, so finally I called Kim's vet and advised him what was going on. He put Kim on Cipro (an antibiotic) and advised I call him in two days on Monday.

By Monday, (Aug 11, 1997) Kim's temperature had reached 103 degrees F, and I rushed her down to her own vet. She was diagnosed as having pneumonia, likely aspiration pneumonia, probably from aspirating bacterial contents of the tooth socket where the surgeon had extracted the fractured rear tooth. She was placed on iv fluids, doxycyline and baytril antibiotics, and given nebulizer treatment for her labored breathing. Chest x-rays were taken to confirm the diagnosis. However her vet suggested that Kim be brought home at night, leaving the catheter in her arm, so that we could give her loving care at home at night, and each morning I should bring her back to his office for more iv fluids for hydration, and antibiotics. He felt taking Kim home at night would be good for her mental attitude.   Blood tests were run every day, but Kim's fever hovered around 104F. By the third day of treatment, Kim's lungs were clearing and she was breathing easier. Her chest radiographs confirmed resolution of the pneumonia, however the fever remained.

I could not sit around and do nothing. The diagnosis of DM by the surgeon bothered me. I contacted, via email, a prominent vet; Chairman of Veterinary Neurology at a major east coast vet college. We discussed, by phone, all the results of the cerebrospinal fluid tap (I had a copy) and the myelogram report. The chairman was convinced Kim did NOT have degenerative Myelopathy as the cytology was all wrong. She advised several other tests for infectious diseases, including tests for myasthenia gravis (a muscular disease). She spoke by phone to Kim's vet, and they discussed other antibiotics to try, including Primaxin, used in pneumonia cases that were difficult to resolve. Kim cleared the pneumonia quite well, but her fever remained at between 104 and 105+ F. Kim was given antipyretics (Tylenol, etc) to try to get the fever to break, but it did not drop below 102.8 at any time.

The surgeon was contacted by Kim's vet, to advise him of Kim's condition. The surgeon had no recommendations and did not advise consultation with a neurologist, nor offer any other suggestions. (One suggestion could have been to take Kim directly to the Animal Medical center of NYC where veterinarians of all specialties evaluate complex conditions like Kim's.) Kim's own vet ran out of answers, and posted Kim's condition to the Veterinary Information Network hoping that member vets would respond with some insight. Kim's vet didn't think she was in trouble, and expected that the fever would break. However, by that time, it was pretty much too late.

In the meantime, antibiotics were again changed to Rocephin, a drug for neurological Lyme. The reason was that, throughout the battery of lab tests run on Kim, a blood Lyme titer was not run because the csf tap Lyme titer taken by the surgeon was negative. However, when it was run some three weeks later, it was significantly positive (1:256 indicates significant exposure or infection. Kim' s titer was 1:2048) Yes, Kim had Lyme disease...and no one knew it. The surgeon should have known that a csf tap titer can be negative, while a blood titer can be positive..If he did know, he told no one and made no suggestions. As a result, her own vet did not test for it for some three weeks. Doxycycline is the drug of choice for Lyme disease, and apparently all the use of prednisone, especially at such massive doses as prescribed by the surgeon had masked the developing pneumonia, and Kim became immunosuppresed as a result of the massive corticosteroid dose given two weeks before for 5 days. Kim could not fight off whatever infection she was harboring, which turned out to be Lyme disease. No one knew that is what Kim had..and the stress of general anesthesia on the organ systems allowed the infection to "come out of remission." Dogs can harbor Lyme disease with no symptomology whatsoever.

Upon seeing that Kim seemed to feel better on Aug 22, a Friday, Kim's vet suggested that she could spend the weekend home; and so Kim was taken home, and rested on a makeshift "hospital" setting, pillows and blankets, --thermometers, and Tylenol suppositories, and doses of antibiotic injectables made up for home administration.   (I am a dental surgeon and the vets taught me how to administer these injections twice a day). Kim's own vet told me twice during the two weeks, that Kim was a fighter...and said to me, "Kim does NOT want to die...dogs let you know when its their time..usually they don't eat or respond very well. Kim has had fevers as high as 106F and "wolfed" down bowls of meat and rice or Alpo...she has a good appetite and that is encouraging..she wants to live." And I agreed, Kim wanted to live. I could see it in her eyes when she looked at me....If you could only see those trusting eyes...

Early Sunday morning, August 24th, as I was getting up, I realized Kim's breathing was extremely shallow; I rushed to help her but she was unresponsive. After I unsuccessfully administered CPR to her in front of my 7 and 4 year old daughters (her fever was 107.4+F)   she closed her eyes and she passed away. Kim died in my arms.

A lot more really died.   If life were a 36 inch diameter, I had a 35 inch blown in mine that morning...We buried Kim at a nearby pet memorial park two days later; the tears still come when we least expect them, especially for me and my oldest daughter.

Having difficulty accepting the course of events, I undertook extensive research on the results of Kim's lab tests. Through the internet and other contacts, many have followed the course of treatment from Kim's rear leg weakness to paraparesis, through her DACVS surgical evaluations, myelogram, anesthesia, and follow-up treatment. The following has been realized.

Kim's myelogram under general anesthesia should never have been done, nor should it ever have been suggested without first ruling out all possible causes of her neurological motor function deficits. The surgeons never requested that any of the tests for infectious diseases be run. Both simply advised myelogram under general anesthesia. Secondly, there is a school of thought brought to my attention by a board certified internist, trained at the same center as the surgeons, that under no circumstances other than life and emergency should a myelogram ever have been undertaken on a dog of Kim's age, no matter what the situation. Thirdly, specifically because of the clinical symptoms Kim exhibited and her previous improvement during the prior year, and because of the acute onset of deficit this year, AND the location that we reside, LYME DISEASE should have been ruled out before anything else was done. Kim's' treatment by the surgeons was a deviation of standard and accepted care and protocol, given her clinical history and empirical findings..that perhaps her own vet might not have known her ultimate diagnosis given the symptoms, (as Lyme disease can mimic so many other diseases, including meningitis, etc.) but that the surgeon should have known, given his additional training and credentials. Failure to properly diagnose, failure to use the proper diagnostic tools (blood tests) and failure to refer when you cannot determine treatment is negligent treatment and grounds for malpractice.

It has been suggested that the surgeon be brought up to the American Veterinary Medical Association on ethics charges.   (These suggestions have been made by other vets). To date, I have not done this. I am not sure what it would accomplish.

Kim suffered needlessly, and her death was preventable. I believe, as others more qualified than myself do, that her myelogram was unnecessary, and the general anesthesia was likely to be a contributing if not causative factor in Kim's illness complications and subsequent death. The surgeon was remiss and neglect in pre and post treatment care due to misdiagnosis during initial clinical examination. The radiographs he viewed were over a year old at that time and a new series of films should have been recommended and taken. Remaining narrowly focused, the surgeon did not request any infectious disease blood tests. Later, when Kim was not responding to treatment, no one suggested referral to the Animal Medical Center of NYC or someplace that had the facilities to properly diagnose and administer care. As a specialist, he should have advised Kim's own vet to refer. He did not. Kim's vet is a generalist, and did not have the training and may not have had the knowledge that the specialist is expected to have.

If this specialist had a philosophy in diagnosis and treatment that were less rigid and utilized less "tunnel-vision" he might broaden his perspective of physical causes and symptomatic effects. Perhaps if he saw the look on my daughter's face when she saw Kim in her casket and the pain and tears on her face when she was asked to throw the first shovel of dirt on Kim' grave, he might realize that every time he gives treatment advice its not just another dog passing through his office...it's a family member, one who has a family history and whose health and well-being greatly impacts on those who give to it their love...and attached to it are the hearts and emotions of those families. In most cases it's someone's best friend..Kims was MY best friend. She may not have been related by blood, but in every aspect she was MY child..I got her as a pup, I saw her learn and grow. I saw her offer and surrender her territory to my children..and most of all we were honored and so very very privileged to be the ones lucky enough to receive her unconditional love and devotion.

In closing, let me apologize for the length of this.   I was asked to tell Kim's story, believing that perhaps by doing so, if you are ever in a similar situation you do not take all veterinary advice as set in concrete. If you are not sure about something, seek another opinion or go to a university veterinary facility.

Yes, we all know that God played a cruel trick on man when he only allowed man's best friend to live so short a life...And dog's do die...this we expect to occur, but hope that we can have many many wonderful years with our best friends..It is tragic when any die, but more-so when it is preventable.

There is a Chinese proverb that says "a mistake of inches at the start becomes significant on a journey of 1000 miles." There was a mistake much greater than just inches when the surgeon advised myelogram under general anesthesia that day in July.....and I made the error of listening.

To Jet, my cocker spaniel of years gone by, and my Samoyeds that have gone to that rainbow bridge.. Kippi, Shani, and now Kimmie......Thank you for your radiant smiles. Your presence brought us comfort and immeasurable happiness. Your unconditional love and devotion enriched our lives and touched our hearts like no others could. Your were our best friends and our love for you could be no greater. Our lifelong bond transcends the distance between us.....You will remain forever in our hearts a part of us, always loved, never forgotten........

To all who took the time to read this, I thank you...perhaps knowing some of what happened to Kim may help someone out there not make the same mistakes that I made...

Scott (ShaniDDS@aol.com)
Long Island, NY.. Copyright � Dr. Scott Tillman No reprint without permission.