When I was a kid there was a TV show called "Let’s Make a Deal". There were lots of appeals to greed in the program and many ways to make a fool of oneself. The BIG deal of the day always involved three doors (evoking that great short story "The Lady or the Tiger", by Frank R. Stockton). Behind one of the doors would be a terrific prize like a brand-new car! Behind another would be a pretty okay prize like a new home entertainment center (which would be a console stereo, or maybe even "hi-fi" in those days. If you were thinking home theater with surround sound, you are the age of my children). The remaining door would have something pretty useless, like a pile of popcorn or a stuffed moose-head (although, personally, I like a stuffed moose-head…maybe not as much as a new car, but better than a "hi-fi"). This was known as the "zonk". Part of the enjoyment of the show was seeing some poor devil pass up the car and choose the door with the zonk. What could be funnier than the misfortunes of others?
In real life (as opposed to game shows) the zonk is not funny. It is especially not funny when there is a zonk behind all three doors. No brand-new cars, just moose-heads. Not cool moose-heads, either — old ratty, moth-eaten moose-heads with no ears.
What, you may well ask, am I talking about? I’m talking about medical problems where I cannot offer an attractive solution: problems that are either insoluble, or where the solutions are not within the client’s reach, or where the client doesn’t consider the risk acceptable (in view of the expected benefit).
For instance, today my client brings in his ancient Labrador retriever, once black and now gray (literally). "His breath is really bad. What can we do about it?" In this case, the bad breath is not from some terrible illness; in fact, his bloodwork is good. It’s just a case of teeth that are totally encrusted with tartar (which we know to be half bacteria by weight: "the germs that cause bad breath"). The only way to make the bad breath go away is to clean the dog’s teeth. Owner hates the bad breath, but fears anesthesia for the dog. In this case, I think the risk is low, but there IS always a risk. If anesthetics were good for you, you wouldn’t lose consciousness. Two choices: accept the risk and clean the teeth, or accept the bad breath (and the health hazards associated with a nasty mouth). "What ELSE can we do?"
The little (and I do mean little) girl Boston Terrier was bred on her first heat. She’s only about 3/4 grown herself, a little young to be having babies (like a thirteen-year old girl: she can have a baby, but all concerned would probably be better off if she grew up herself before becoming a mommy). We could do a hysterectomy (Nope, they do want puppies later), hope for luck (she might not get pregnant on the first date), abort the pregnancy (yuck!), or see her through the pregnancy (and likely Caesarean section to deliver). That looks like plenty of choices, but they don’t like any of them. "What ELSE can we do?"
These may seem trivial, but how about this one (and these were all today, mind you)? Abby is a 12-years old, too fat, but very sweet Labrador Retriever. She’s had a series of episodes where she just gets weak and feels crummy, rebounding fairly quickly. After doing some pretty nifty diagnostic work, we’ve determined that her problem is most likely to be a bleeding tumor in her abdomen. We know that something in her abdomen bleeds until she’s about a quart low, then stops. This is when she’s weak and feeling crummy. She reabsorbs the blood into circulation and feels okay again. It’s probably a tumor, but it’s too small to see clearly with the ultrasound (not like some big whacking tumor on the spleen, for instance). Here are Abby’s doors, and there is no car:
Door Number One: Keep letting her have internal bleeding episodes until one kills her.
Door Number Two: Send her to the specialists for $300 to $1,000 in additional testing to see if surgery can either be avoided or more closely targeted. If they do surgery, they estimate a cost of $2,500 to $3,000.
Door Number Three: Open her up here (still several hundred dollars, but probably about $2,000 cheaper than the specialists). The incision will have to be "stem to stern" (or xyphoid to pubis, as we say in the profession, or "crown to groin" as they say in the Conan books), as you could have more than one spot bleeding, and it (or they) could be the size of a pin-head. Even if you find it (them), it could be something malignant (or inoperable) and you’ve gone to all that trouble for something that’s not going to get fixed.
I can explain it all really well, but I don’t have an attractive choice for my client.
"What ELSE can we do?" Zonks are not funny in real life.