At a point in my career, I was not the wry, light-hearted veterinary columnist I am today. I was grumpy, tired, and burnt out. I would have welcomed a mid-clinic, Oscar the Grouch–inspired trash can into which I could intermittently retreat. During this time, on a particularly busy ER shift, a recent graduate approached me, and as I impatiently waited for her to complete her case presentation, I interrupted her, “What is the first rule of emergency medicine?” With a slightly panicked look, she stuttered out, “Give fluids?” (Not a bad answer, to be honest!) I snapped back, “No, the client is lying. The dog ate something and needs radiographs.” A nearby colleague scoffed, “OK, Dr. House!” citing the then-famous, distrusting, cynical television doctor. As it happened, I wasn’t wrong. The client was “lying,” and the dog’s radiographs revealed it had ingested a foreign body. At the same time, I was sort of wrong because the client sort of wasn’t “lying.”
The owner of that dog had expressed that they were confident that their young, lab-mix puppy had absolutely not eaten anything unusual and nothing was missing or destroyed. Well, nothing they could remember. After the radiographs, they miraculously recalled that there was an incident in which they recovered a sock from the dog, and now that we mentioned it … the second sock … where was that? (Spoiler alert: We found the missing sock!)
Now, in my much more reflective and introspective years, that interaction still stands out to me. First, it was the earliest strong sign I had a bad case of burnout. Second, I realized what I was trying to convey was the importance of a good investigative case history—both what the owner can say and what they can’t or won’t.
Truthfully, I don’t think the client intentionally lied to us. Maybe by the strictest definition, it was a “lie,” but it certainly wasn’t as nefarious as I made it out to be. They just didn’t mention what they had dismissed as an inconsequential event.
Once again, veterinary medicine and psychology have an overlapping Venn diagram. We wade through what the owner tells us, listening carefully, taking notes, reading between the lines, and asking pointed questions. We do this to get owners to recall timelines, admit things that may be embarrassing, or even remember events their brain and emotions buried deep.
So, what is the real first rule of ER medicine—or any medicine for that matter? Dr. House actually got this one right. The most important rule is that the end is often just the start, or in medicine, the diagnosis is often in the history.