odds and ends and where did you get your veterinary medical training??

so, since i got so many interested commenters on the whole lymphoma saga - here's the REST of the story:

i worked sunday with 2 vets pulling relef shifts for us. one of them was THE referring vet for that case. the boxer is still doing well. we are both perplexed and highly skeptical of the cytology report. if it is lymphoma, we'll know in about 1.5 months. not that spectacular of an ending, but so goes medicine.

in other news, i did an exploratory surgery on a 120lb dog that came into work on sunday collapsed with a PCV of 23 (packed cell volume = what percent of blood is cells versus plasma - normal is 35-45), and white gums. he was bleeding into his abdomen. i talked to the owners about the likelihood that he had a bleeding splenic tumor. we talked about prognosis for this, and they decided to do initial staging of the possible cancer (bloodwork and xrays), then if everything was clear - take him to surgery. the chest xrays were pristine, especially for an old dog. the bloodwork revealed dehydration and a VERY MILD elevation in ONE liver enzyme. all other liver enzymes, as well as liver function values were normal. the one enzyme that was elevated was about 1.5 times normal - which can be secondary to old age, dehydration, mild inflammation. it wasn't a value that i even glanced at twice. it was that benign and non-specific of a finding.

so to surgery we went. i suctioned about 4.5 liters of hemorrhage out of this dog. that's a MASSIVE amount of fluid. when i could finally see the liver, i was saddened to see that - despite normal testing - it was covered in metastatic cancer. the bleeding was coming from an angry looking mass on the caudate lobe. the spleen itself did not have a bleeding mass, but it did have masses all over it (benign or malignant could not be determined by looking). we euthanized on the table per the owners' decision.

i was satisfied with the job i had done. i knew i had gone to surgery and given the dog a chance. the outcome sucked, but i was happy with my performance. apparently, the owners were not. they called disputing their surgery bill, claiming that they shouldn't have to pay because the dog was no longer alive. they also claimed that i should have KNOWN that the liver was covered with metastatic cancer because of the EXTRAORDINARILY mild elevation in a liver enzyme (ALT - the value was 156 - the reference range is 0-80). despite the fact that all other liver enzymes and function was normal (even the clotting times were normal!), i should have intuitively KNOWN that the cancer was in the liver.

i spent 20 minutes on the phone with the female owner explaining as patiently as possible that despite the fact that her dog was euthanized, i still took 2 hours to do surgery, used THREE technicians to do it due to the extensive suctioning and bleeding, used suture, anesthesia, injectable medications, etc. i also tried to point out as tactfully as possible that if you go to the ER, receive emergency treatment, and die - then you're still responsible for the bill. surgery in a human hospital is no different. the expertise, materials, time, and staffing are the same - regardless the outcome. i also spent 10 minutes explaining bloodwork values to her, liver function versus liver damage, and what exactly ALT means and what such a minor elevation could indicate. i had to repeatedly resist the urge to ask her where she received her medical training?

she told me that she thought i "downplayed" the changes in the bloodwork and that they would have euthanized if they'd known what they knew now (AS WOULD I HAVE...OBVIOUSLY - HINDSIGHT IS FLAWLESS, but alas, my crystal ball and xray vision were on the fritz this week). she said that she felt that they were pressured to go to surgery.

the kicker?? she actually admitted to me the following piece of information: "maybe i watch too much grey's anatomy. you know - they're always dying to go to surgery on that show."

i almost screamed when i heard that. i resisted the urge and calmly informed her that i have NO financial or personal incentive to go to surgery, that i avoid surgery unless it is absolutely necessary, and that her dog had lost about 1/2 of his blood into his belly, and would have died on his own had we not done something (either surgery or euthanasia).

in the end, the owners were nice to me. unfortunately, i have the feeling i haven't heard the last of them.

we'll see.

hold on to your hats people...

i usually work 3 sundays out of 4 in a month. on those 3 sundays, i always wake up about an hour and a half before work. i lie in bed, and i think to myself how - at that moment, in that time - i don't hate my job, i don't hate myself, i don't hate people and the universe at large. i lie there and revel in that feeling - there in the pre-sunday calm.

sundays are unabashedly nighmare-ish at our clinic. we are the only ER clinic in this area, and we see a massive influx of animals in dire need of medical attention on sundays. i HATE sundays. i dread going to work on sundays and sundays alone.

today was .... hang on to your hats people ... NOT BAD.

i had a good day at work, despite 2 euthanasias. i was chipper, upbeat, and relaxed - in spite of having to go to surgery on a 120 pound dog with 4 liters (or more) of hemorrhage in his abdomen and despite putting down a small miniature pinscher that was out for his nightly walk and was mauled by a stray dog.

all that said - i still had a good day.

my last patient of the day was a bit of a mystery at first. a 7 lb mixed breed dog that presented for vomiting, lethargy, and "bruising." when i rolled his lip up, i was astounded to see that his gums were paper (and i'm talking PAPER) white. i went to get a blood sample with the tiniest needle imaginable, hit the vein on the first flawless stick, and watched in amazement as the vein began to blow and a huge hematoma spread under my needle. i took another look at the "bruising" and went to find my owners.

"any chance he got into rat poison?" i asked innocently.

the owner looked at me and with a straight face said, "oh no! absolutely not. well...now that you say it...we caught his brother with a mouth full of rat poison about a week ago and we made him throw it up...but his little guy...no, not possible."

so little puppy is getting himself a plasma transfusion (probably finishing it up as we speak), as well as some vitamin k to help him start clotting again. i hope he will do well, but we shall see. he was pretty anemic, too. thankfully, the owners gave their dog aspirin today because they thought he was painful. YES, i said ASPIRIN - as in the medication that causes "blood thinning" i.e. decreased clotting.

gotta love self-medicating owners!

the life and inanities contained therein

here are some non-veterinary tidbits...to lighten the mood a bit:

1) we dropped sprint like a hot potato. sure, i enjoy having no to 1 bars in my house at all times, as well as getting about 50% of my voicemail (where the other 50% goes is anyone's guess. the ether?)...but it was time for a switch. we are now with verizon. and yay, i got a new phone that i keep playing with (an EnV2). hopefully it'll be a few months before i drop it in a) the toilet b) a cup of coffee c) a large glass of water or d) throw it at the windshield in an absolute fit of PMS-induced rage

2) i gave up reading atlas shrugged for the time being. i'm about 250 pages in. i really like it, and i'm intrigued. i just can't bring myself to finish it. i did go back and finish reading 'the last days of dogtown' - which turned out to be fantastic and tear-inducing. i really enjoyed it. i was reminded of diamant's other book i read, 'the red tent.' it took me a bit to get into it, but it was incredibly rewarding. same with dogtown. i highly recommend it.

3) i'm a total and complete music snob. i like prog rock and obscure music. pandora.com has become my favorite internet music browser, and i buy independent music from emusic. i'm recently addicted to for against and interpol (they've been around a while). all that said, i can't help but admit that i'm totally infatuated with the new and totally idiotic britney spears song (womanizer) and pink's anti-marriage anthem (so what?). "yes, hello. my name is catherine. i have been clean and sober from terrible pop for all of 30 seconds. i'm back off the wagon." ***Sigh*** at least i own up to my problem.

4) i'm doing relief work next week at another local clinic (haven't been to this one yet). the pay is only $38/hr instead of the $45-50 i'm accustomed to...but i want to work, and i'm getting a new computer (YAY!), so i need to finance it.

5) the credit card is really and truly paid off. now our debt merely consists of student loans. merely. hahahahahahaha.

6) i've been firmly offered a position next year at my current place of work. i haven't decided what to do. one moment i'm squarely 100% committed to taking it. the next second, i'm totally against it. look for a pro/con list coming to a post near you soon.

7) the husband has been mistaken for the actor gale harold (jackson from desperate housewives) at least 3 times this week, including today at verizon. i've seen pictures, and the similarity is astounding and uncanny. we're trying to figure out how to use this to our advantage.

8) mike wasowski has become firmly entrenched in the household cat-ranking. apparently, she will be staying with us permanently. damn cute kittens. i think 5 cats borders on mentally unstable.

9) i got new perfume (in gel form) from my mom for xmas. i was thrilled, because it was the perfume i wanted. when i went to work, my boss and sometime mentor was also wearing the same perfume. thus, i used some xmas money to buy another perfume. the techs already refer to me as her "mini-me".

10) while home for xmas, i watched a BBC miniseries with my MIL called 'north & south' - it was ridiculously addictive and ridiculously good and rather like jane austen, with a twist.

i guess that's all here for the moment. look for more self-centered posts ... oh wait. they're all self-centered.

peace out, yo.

in the words of the teletubbies...BIG HUG.

as in, i need a big hug.

saturday was a nightmare from start to finish. the morning began with me oversleeping. i was rushing around, trying to put on makeup and look halfway decent when the full length mirror in the bathroom decided to fall onto my foot. it managed to hit the joint between my big toe and the rest of the tarsals. i screamed after the 10 second period of absolute numbness (that split second when you KNOW how bad it's going to hurt but it hasn't started hurting yet). i thought my foot was broken for sure. so first on the agenda at work - xray myself. thankfully, it looked ok - other than a horrible bruise and swelling. i just had to limp around all day.

it only got better from there. my 2nd case of the day was a 5lb fluffy dog that drank antifreeze. his owners' car blew its radiator. the dog was frolicking around and licked the fluid coming out from under the hood. by the time he got to us, he was already vomiting. the owners had NO money. not a single cent. they didn't even have the money to pay the $103 emergency fee. the female owner was on drugs of some sort - i'm not sure what - valium, oxycontin, some sort of downer. at any rate, we saw the dog about 4 hours after ingestion - which is still in that golden period when the antidote might work. problem? the antidote is $830 a bottle. what did i charge them in the end? $90. yup. i said $90 (the clinic pays about $300 for the bottle). i didn't even recoup expenses. i'll be interested to see how this turns out when i go back to work on thursday. maybe i won't have a job anymore. the kicker? the woman owner treated me like garbage - yelling loudly in the lobby about how unfair it was. after all, why should i expect money?

that was followed by an african grey in severe respiratory distress. she was a 21 year old bird that was well-loved by an elderly gentlemen. i worked on her like mad for 2.5 hours trying to save her, but in the end - i was no match for the disease process that had her in its grip. i had to euthanize her. it broke my heart in two pieces. mostly because i could see my own little fluffy grey bird in her.

on the heels of that came a little dog with an eye problem. i recognized the name as the dog i had done a conjunctival pedicle graft on months before (a delicate, difficult eye surgery). i was thrilled to see that when they followed up with ophthalmology - the ophthalmologists were impressed with the surgical technique. unfortunately, as i talked to the owner, it became clear that my surgery had failed, and it had been redone by another vet.

i finally made it out the door, depressed, distraught, and feeling like a failure - only to have to get up and do it all over again yesterday. sundays suck. yesterday was no exception. at the end of a 13 hour shift, i had to pack in a mad rush to drive 4 hours to our hometown so that we could celebrate christmas with my husband's family today.

the car trip was miserable. i was exhausted, had a migraine, and had to stop halfway so that i could vomit.

i have 2 more days off before i have to go back to work for 5 days - the christmas weekend. it promises to be hellish.

BLEH.

um.......quoi?

so remember how i had the patient that i "mis-diagnosed"? i sent the cytology out to the state lab, and they agreed with my diagnosis of lymphoma.

now - the answer to this question might seem easy. call the owner and tell her that her dog - in all likelihood - has cancer, right?

wrong.

i'm an emergency doctor. i don't have an established relationship with this owner. further, she doesn't like me, and she was upset that i incorrectly diagnosed her dog. she was seen by her veterinarian for follow-up care after my diagnosis. that vet - with whom she does have an established relationship - diagnosed something different and is treating accordingly.

so there's the difficulty of navigating the emergency doctor/referring vet relationship to consider. and here's the other part of the dilemma: lymphoma can be a tricky diagnosis on cytology. usually it's very straightforward. unfortunately, there are occasions where lymphoid hyperplasia (hyperactive lymph node) occurs and can mimic lymphoma. i've know cytologists to say that the two can be mistaken for one another. it's possible the cytologist is wrong. possible but likely? biopsy is the gold standard diagnosis - which is what the referring vet offered to the owners. they declined.

the dog is doing well on antibiotics appropriate to the disease the referring vet diagnosed (doxycycline for suspected tick-borne disease) and prednisone (which will TREAT AND SHRINK lymphoma, if present).

i've done my part. the owner is not going to like me, regardless of what happens. the results have been sent to the regular vet and now she can decide what to do from here on out, right? i should be out of the picture. the ball is in the rDVM's court as to how to proceed. and yet, it niggles at me. the owner of said dog was rude to me on the phone, had no faith in my abilities (this was even apparent the night i saw the dog as a patient), and it irks me - ESPECIALLY when i see that the cytologist agrees with my assessment of the cytology.

it is no matter. if it is lymphoma, and the dog is only treated with steroids - it has about 1-3 months of life left - at the very most. so i'll have the real answer, one way or another eventually.

i need to learn to swallow that desire to be right about everything, to have people know i'm right and know i'm a good doctor, learn what i can from the situation (which was still a valuable lesson, despite the fact that i turned out to be right), and MOVE ON.

ok.

moving on now.

any minute the moving on will begin.

seriously.

i'm just worried that in all this tiptoeing around the referring vets and irate owners, the animal's well-being will suffer. and that is strictly against the creed of "first, do no harm." i'm doing harm if my patient's illness is not managed accordingly.

dammit.

i lost a follower...

i hope it wasn't my story about the indecent man in new york city that sent follower #6 packing. if it was, i'm sorry to have offended. please come back and follow me again:)

bleh.

first day back...not fun. i had a really hard time getting my head straight this morning. i was foggy and kind of just...out of it. that - coupled with the fact that i'd been away from veterinary medicine for a whole week - was a bad combination.

i also found out that i likely mis-diagnosed a patient last week. i saw a 3 year old boxer with gigantic (and i'm talking lemon-sized) lymph nodes. my suspicion (given breed and history) was lymphoma. i did an aspirate (sucked cells out of the lymph nodes and made a slide) and thought it was lymphoma. i discussed sending out the slide to a cytologist for review - explaining to the owners more than once that i am NOT a cytologist and would prefer that one review the slides. they declined, because i did tell them that i was ... eh ... 90% certain of my diagnosis. we discussed further diagnostics, as well - including bloodwork and xrays. the owners declined that and took the dog home to talk about what to do.

that was the saturday before last. i called today to check on the dog because there were no notes in the computer that they scheduled for a follow-up visit. it turns out that the referring vet diagnosed the dog with tick-borne disease after conducting actual bloodwork. after treatment with appropriate antibiotics and steroids (due to the low platelets found on the bloodwork), the lymph nodes are normal in size, and the dog is back to his old self.

i feel rotten. yes, the dog is doing fine - and my mis-diagnosis was caught and no harm done. the owners were actually considering euthanizing this dog though, because he was so sick! they called their vet, and the vet recommended at least doing bloodwork and trying antibiotics.

i'm upset with myself because 1) i saw that my patient was a boxer with enlarged lymph nodes and immediately thought lymphoma (boxers are one of the most predisposed breeds) and 2) the owners might have euthanized him without doing further diagnostics based on my mis-diagnosis.

now, here's the catch. it could still be lymphoma. there's a free animal diagnostics lab in our state, so i sent the slides to them for reading, just to be sure. after spending 20 minutes talking to the (very, very nice) referring vet though, i think she was spot-on with her diagnosis.

and so i feel rotten.

on the bright side, the c-section i did on my last night before leaving for new york is doing well. the puppies are not, 2 were dead in utero and had been for a while, and the 2 live puppies were not fully developed. mama is doing fine though, despite a bloody and frightening surgery.

bleh. not a good first day back. maybe tomorrow will be better.

where does the time go?

home again. it's grey and warm here in the south. nothing like the bitterly cold but bright blue day i spent in new york yesterday. it was in the low 20s. luckily, the breeze stayed rather minor. i don't think i could have stood 24 degrees and a stiff breeze from the hudson.

my last day and a half were divine. friday night, we met up with a good friend from vet school and had dinner at a spectacular, small, cozy, and "inexpensive" (for new york) italian restaurant in the village called piadina. the food was absolutely exquisite. we began with corn polenta smothered in melted gorgonzola. i had a salad of bitter greens covered in thinly sliced pears, parmesan cheese, and almonds with a light sweet balsamic dressing. the main course was luscious. garganelli pasta in a light cream sauce of green peas and ham. dessert was the italian restaurant standby of tiramisu and espresso. for 3 of us to eat with an appetizer, 2 salads, 2 entrees, dessert, and espresso - it was $65. that's dirt cheap, by new york standards, and the food was absolutely amazing. afterwards, we visited the slaughtered lamb pub in on the corner of spring and ... some other street, and i had too many beers. we made it home around 2am. i also had a near miss on the subway. there are no public restrooms in new york city. a dangerous combination with my hamster bladder, consumption of too many beers, and being 30 some odd blocks from a bathroom i could use.

yesterday, myself and my friend roamed soho and the street markets for christmas gifts. we wound up in brooklyn momentarily, by accident (took the train the wrong way). it was a rather serendipitous accident, because the train came out on the manhattan (i think) bridge right around sunset. i got to see the brooklyn bridge and the statue of liberty and the manhattan skyline. it was a lovely sight, and a much needed rest for my feet.

we spent the whole day out and finished off by eating at the moonstruck diner - one of the many fantastic diners to be found in new york city. the food was great, as usual - but i still blanched at the $40 pricetag attached to a meal for 2 in a diner, of all places. gotta love the cost of living in NYC. we both collapsed early (9pm!!) because my flight was out of newark at 9:05, meaning my cab was coming at 6:30.

newark is about what i imagined - as is new jersey. flat, marshy, smoggy, ugly. of course, i only saw a tiny bit of NJ on my way to the airport, but it was kind of what i imagined / saw on the sopranos. my flight was excellent, surprisingly. i flew continental - which had muffins and juice and free blankets. my entire row (3 seats) was also empty on the newer jet - and so i had all the room i could want. my palms only sweated lightly on take-off, and otherwise, i felt fine.

so now i'm home and back to responsibility - starting with my animals needing various amounts of care (litterboxes, etc). tomorrow, i go back to work. i'm on days through sunday, so the 8am-6:30pm shift.

i'll be around with interesting cases to post, i'm sure.

the sun is out!!

i'll tell you what - new york city is depressing when it rains. since wednesday morning, it has steadily either drizzled or outright poured. coupled with the drop in temperature (30s), walking around can be exhausting. you've got to have gloves, a hat, a jacket, an umbrella, a purse...it's a lot of stuff to lug around and manage anytime you enter or exit a place. it was tiring! thank god the sun is out today and is supposed to remain out tomorrow for my last day here.

yesterday, i made my first foray into the subway alone. i only got on the train going the wrong way once, thankfully. otherwise, it was uneventful. i made it to soho and noho (i didn't know that existed, honestly), did some light window shopping (i haven't actually purchased anything in NYC, other than food), and got myself a huge slice of greasy new york pizza.

last night, my best friend and i elected to stay in, as the weather was bitingly cold and the rain continued to pour down. she made me dinner, we started watching tristan and isolde (a big fat thumbs down on that movie), and eventually fell asleep.

alas, the sun is shining today, and i am going to the village to do some christmas shopping for the people on my list. it's the first time since i've been alone during the day that it's not pouring, so i don't think it'll be nearly as depressing. new york city is a downright unhappy, sullen town in the rain. it's also kind of a lonely place to be without accompaniment during the daytime.

tonight, my other closest friend from vet school comes in from new jersey, and we're going out on the town. tomorrow, my friend is off work, and we're going to do the tourist-y stuff - the brooklyn bridge, coney island, hit up H&M, the empire state building, and whatnot. then i head back on sunday morning out of newark.

i love NYC, but i love home better.

how to pass for a new yorker

in my brief visit (and gleaned from my previous week here 3 years ago), i have figured out how to pass for a new yorker. here is my incomplete list (i'll add as things occur to me):

1) don't wear bright colors. black, dark brown, navy, and an angry expression are the standards for wardrobe.

2) don't smile. it automatically gives you away as a non-new yorker. strive for a look somewhere between sullen indifference and sneering cynicism. a cigarette really helps. if you don't smoke, talk angrily into your cell phone. and loudly.

3) while waiting for the walk signal at each block, DO NOT stand on the actual sidewalk. those who are not from new york stand on the sidewalk. stand about 6 inches from the sidewalk, actually in the road else you'll just look like a noob in the big city. if cars and cabs are blocking the intersection and you have the white walk signal, weave through the cars to cross. if someone inches forward as you walk in front of them, gesture angrily OR cut them down with a freezing glare. alternately, if you're feeling bold - hit the hood of the car with the palm of your hand and use an expletive such as a$@hole.

4) do not make eye contact while walking on the street. EVER. PERIOD. there is no getting around this rule.

5) this is an addendm to rule #3: while hailing a cab : stand IN the road, raise one hand, and look really impatient. when a cab with its light on drives right past you, throw your hands up in the air to exhibit your utter exasperation with the whole of new york city cab drivers.

6) walk very fast. if you see someone coming toward you, do not - under any circumstances - deviate from your path. if this involves playing chicken with the oncoming traffic, then by god - play chicken. you're not moving out of anyone's way.

7) if a cell phone is lacking, have headphones on. this way, you won't ever be mistaken for showing ANY interest in the seething mass of humanity around you.

new york is composed of the loneliest mass of humanity i have ever seen. more to come later after my dinner in chinatown and my shopping excursion for christmas gifts.

day 1 recap: chicago, giant rodents, masturbating man

yesterday was a whirlwind of activity. my plane landed (on time! and uneventfully) aorund 1:15. i took a cab to manhattan (east 53rd) and met my friend. it was as if no time at all had passed. it seems to always be that way with good friends. i was starving, because i hadn't eaten for nearly 24 hours. we picked a good little mexican diner near her house called blockheads. the food was excellent, as seems to be the case everywhere you go in NYC. i guess because the competition is so fierce? at any rate, we filled up on delicious mexican food then went to visit the famous AMC (animal medical center) where she is doing her internship.

it amazed me that after a mere oh...8 hours away from home and work, i was already yearning for the presence of a few fluffies. we visited the exotics ward, so i could get a brief birdie fix. aftewards, we roamed the city like bandits. we visited madison ave, 5th avenue, rockefeller center (the tree is amazing), stopped in at gucci and betsey johnson and nine west, and generally drank in the city and all its pulsing life.

whilst in rockefeller center, we met a handsome mounted police officer in his mid
20s who tried to pick us up. my best friend gave him her number, i demured and stood in the background, trying not to crack up. after all, shouldn't he be doing...oh, i don't know - cop stuff?? and my friend is always complaining about not being able to meet men. we met three on our stroll around the island! and we never left our side of the island!

afterwards, i told her "hey - at least you know he likes animals!" his beautiful quarter horse was impeccably kept and wonderfully fit.

we ate a very light dinner at a bar and grill (charley o's) in times square and then went to see chicago at the ambassador theater. it was not exactly what i expected. for one thing, the backdrop was the same the entire show. the actors wore the same costumes, with very mild changes (additional jewelry, different shoes), the whole show. i guess i expected crazy, flashy, incredible sets and costumes...because it is broadway, after all. it was a good play. it wasn't fabulous. i wasn't completely blown away, but i thoroughly enjoyed myself. i had a long island ice tea (which has NO tea in it) at charley o's. that, combined with my small size, general lack of drinking habits (i haven't drunk anything alcoholic in weeks), and my exhaustion at traveling and just coming off overnights, pretty much made me slightly more tipsy than i expected. it made the whole experience that much more enjoyable.

afterwards, we strolled the leisurely 11 blocks or so back to home. on the way, i wanted to stop and take a picture of radio city music hall. as i was standing in the square across the way, trying to get the light right, i felt something aggressively brush/grab my lower leg. i thought a person had grabbed me. i glanced down and to my HORROR saw a large rodent dashing for the nearby landscaping arrangement. i kid you not. a drunk (he must have been, to run into me like that) NYC rodent tried to maul me.

it only got better. as we stood on the corner of park avenue waiting to cross, a man in a dodge neon crept by us very, very slowly. i thought he must have thought we were prostitutes or something, despite our conservative garb. that was until i noticed that he was masturbating with the window down as he cruised by.

ahhhh...welcome to new york city!

in all seriousness, it's 8am, and i can't get back to sleep. the city awaits. my friend is working, but i have all day to roam around and see the place. amazingly, it's in the high 50s here, so i'm not going to have to wear 37 layers and be miserably cold. i can actually wear a light jacket and be comfortable.

i promise that there will be more to come as i commence my next 4 days in the big city.

17 hour countdown....

in 17 hours, i will do the thing that i enjoy least in the world. i will board a plane and fly.

but when i touch down (as opposed to crash and burn, i hope)...i will be in the land of the manhattanites. my favorite city in the world (thus far) - though i haven't been to paris or rome or madrid yet - will once again welcome me with open arms. this time i go sans husband, which will be a rather new experience.

my best friend got tickets to see chicago tomorrow night on broadway. yes peeps - a little later then this time tomorrow evening, i will be watching a broadway play. i'm sure you can imagine my excitement.

on friday night, i will also get to see my other closest friend from vet school. she's doing her internship across the bay in new jersey. she's coming into the city for dinner and hanging out on the town.

it's going to be so great to get away from this state for a while, to get away from pets and responsibility, litterboxes, bird cages, vacuuming, my job and thoughts of my job. i'll be away in the land of tiffany's and rockefeller center and the empire state building.

i'm sooooooo excited...so much that i'm almost not fretting about flying. almost.

FAIL

i know i said that i would try to post upbeat cases. for the life of me, i can't think of any that are interesting. i know that can't be the case, but it's the ones that you lose that tend to stick in your mind.

last night was a loser night. i saw a lovely chocolate lab / pit mix. he had been taken in by a good samaritan, as he was free-roaming and unloved. as i was listening to his heart, he nuzzled up between my cheek and shoulder and proceeded to lick my neck and head butt me (like a cat). his new owner of 1 month was a young girl (early 20s) excited for her upcoming marriage. as soon as i looked at the dog, my heart sank. he presented for staggering and swaying, as well as running into walls. he was also vomiting frequently. a free roaming dog with those signs means only one thing. start the antifreeze testing.

he was indeed, poisoned. antifreeze is a terrible thing. unless caught in the first 8 hours, treatment is pointless. even sometimes before 8 hours, they don't recover. 9 times out of 10, the animal will die. this guy was already showing elevations in his kidney values. the owner had no idea when he was exposed. treatment for a dog his size would have been very expensive - and perhaps fruitless. we euthanized him, needless to say.

on his heels followed a 13 year old blocked cat. fairly routine in emergency medicine. except that this guy had a quiet, very focal (1/6) heart murmur that i missed on my physical exam. when he received his fluid bolus prior to unblocking, he developed pulmonary edema secondary to his undiagnosed heart disease, started vomiting (a symptom of fluid overload), and collapsed. he recovered from that after 2 hours of oxygen, but the stone in his urethra could not be moved. neither myself, nor my senior clinician, nor the internal medicine specialist could budge the stone. despite repeated cysto (sticking a needle in the bladder to remove the urine), his potassium continued to climb (this leads to slowing of the heart and death, eventually). i talked to the owners about surgery, but his prognosis was guarded with his heart disease. they elected to euthanize the sweet little guy. his owner was a mother and her teenage daughter, both in tears and extremely grateful to me for my (i thought rather poor) care.

the icing on the cake? this morning before leaving, i ran into the students that come up from my alma mater every 2nd and 4th friday to do spays and neuters. one of them was a guy who ... honest to god, as evil as this sounds ... if he died, i'd probably throw a party. he did a terrible thing to me in vet school, and i've never quite gotten over it. of course, he would be there.

ok. i'm going to curl up in my warm bed with my husband and warm kitties and try to forget last night and its accompanying failures. for every animal i euthanize, there is are at least 2 to 4 that i send home with their owners for many more years of life.

tonight is another day.

oh....my....i might....faint

i have information that i cannot post on my blog about my favorite band in the world - the avett brothers. it's secret information about a possible show somewhere where i would be able to meet them, hang out with them, and sit in the front row.

i think...i might...faint.

mumblings, an impromptu trip, my itinerary

last night was my first night back on overnight emergency. we saw ONLY cats. eight of them, i think. it was a typical slow monday night during our (yes, it's apparently real) recession. i enjoyed it, because i am a fan of the kitties. not a single dog came our way. it was odd...something to do with the cold, snowy-ish weather? i don't know, just a theory.

so the holidays are always a little depressing. i'm not sure why. i'm lucky enough to have great family and friends with whom to spend it, and despite the fact that i'm working on christmas this year, i do have the 3 days off beforehand to spend with friends and family. my schedule this month is awful. i'm working 20 days of 31 - and 7 of those off days are next week! in a real job with 40 hour weeks, that would be fine. in my life, with 90-100 hour weeks...not so fine. the thought of my 5 days on starting christmas and extending through the weekend is giving me nightmares (it's going to be very, very bad- especially if thanksgiving was any indicator). ah well. i'll survive.

the point of that was that i talked to my close friend who is doing her internship in manhattan. she is lonely, recently broke up with her boyfriend, works 6-7 days a week, and is very, very depressed. she called me in tears last night while i was at work.

so...i'm a bit depressed too. holiday blues, i suppose. i have the whole next week off, and tickets to NYC are $234 round trip from atlanta (+37 for the shuttle to atlanta). so guess what? i'm going to NYC next week for a spur of the moment trip - leaving early tuesday morning and returning sunday. i'm so excited i can barely stand it! i'll get to see one of the people i love most in the world, in a city i love, for 5 days. i love NYC in the winter, even though it's cold. i find rockefeller center and the tree and all the displays in the windows to be romantic. it would be nice to someday go to NYC in the spring...but...perhaps another time.

i'm thrilled thrilled thrilled thrilled thrilled!!!

i'm also flying to orlando in january to attend the annual north atlantic veterinary conference (NAVC). i'm renting a car and staying with my grandparents for the week (it's a long commute...but i figure it's worth the family time - and my CE funds pay for everything). so i'll be gone for a week in mid/late january too. then in february, i go to north carolina state for a rotation in cardiology. i'll be driving to NC State.

i'm gallivanting all over the place, eh? it'll keep me occupied and lively, which is good. sometimes i think i'm getting into a rut.

Happy Gobble Day!!

i sincerely hope that everyone finds a happy place to be today. i am reminded how lucky i am to have not one but two families. we had 2 thanksgiving dinners, played some football, and are now spending time visiting.

i am truly lucky in my life...well...other than the fact that i have a cut in my mouth where i ran into a tree while playing football and 2 maybe broken toes where i was stepped on while playing football and a big bruise on my stomach from where my brother accidentally kicked me while playing football.......and i'm about to slip into a turkey-induced coma too...

GOBBLE TILL YOU WOBBLE!

kidneys on the brain...

on a terrible, crazy, non-stop, panicked sunday, a small fluffy rust colored poodle puppy came my way. he weighed a mere 4lbs 13oz. he had the great misfortune of being picked up and crunched on by a much larger dog.

when i examined him, he was quiet but alert. he even wagged his very fluffy stumplet of a tail. i'm not a poodle fan, but this guy was ridiculously cute. he looked pretty stable, was walking and alert. i found a small hernia on the left side of his body and a giant hematoma (blood clot), but it didn't feel like organs were in the hernia. i had concluded he was stable and was about to turn to a more critical case (1 of MANY MANY cases that day), when it occurred to me that i had forgotten to check his mucus membranes. i rolled back his lip and HELLO! his gums were paper-white. i checked his abdomen quickly with the ultrasound probe, and sure enough - his abdomen was full of blood. sickened, i went to deliver the news to his incredibly sweet parents who had lost their other poodle to kidney failure a mere month beforehand.

we opted for immediate surgery to identify the cause of the bleeding and to fix the hernia.

when i opened the little guy, i was prepared. this wasn't going to be like my last, god-awful hernia surgery. as soon as the abdomen was open, my assistant started removing the blood for auto-transfusion. when the abodmen was semi-cleared, i looked for the source of the bleeding. it was fairly easy to find. the left kidney was hamburger meat. the renal artery (which is a direct offshoot of the aorta) was partially torn away from the kidney and bleeding profusely into the abdomen. the kidney itself was fractured in half.

i didn't mess around but began ligating the renal artery and vein, as well as the ureter so that i could remove the kidney and stop the bleeding. when you weigh 4lbs, even a little blood loss is significant. this guy had 50 milliliters of blood in his abdomen when i started.

we fought for this guy. i tied off everything that bled that wasn't supposed to do so. i removed the kidney, i flushed the abdomen. i checked for bleeding obsessively. nothing.

we closed him, and i almost prayed.

2 hours later, he bled to death internally. likely due to the extensive amount of fluids he received to maintain his blood pressure (blood products, hetastarch, normosol-R). was it my fault?

i will never know for sure. i had my attending clinician glove in at the end and check to make sure she could find no other sources of bleeding, and she could not. she gave me the all clear, gloved out, and i closed. after surgery, his blood pressure spiked (due to the fluids/blood transfusions), and it's possible that he began to bleed from the vessels that i tied off. it's also possible that he had a tear in his aorta somewhere that i couldn't see or that i didn't completely tie off some unusual branches of the renal artery.

his parents sobbed, but they told me how grateful they were for my services. they were incredibly kind, and it broke my heart.

in the end, i know that i worked as hard as i could, was absolutely meticulous, and realize that this guy underwent a terrible trauma. i did what i could to save him.

was it enough? will it ever be enough?

sigh

i think i neglected to mention that both of my surgeries died in the post-operative period. not from anything i did or didn't do (that i know of) - but because the nature of their respective conditions was so severe that their chances going in were very poor.

still, it didn't make for a good weekend AT ALL.

now i'm off for 5 days, headed home for thanksgiving and the 30th wedding anniversary party i'm throwing for my parents. i'm sure i'll post more details about my surgical experiences soon.

there are no words. or at least, only a few words.

omigod. there is nothing to say about this weekend other than this:

i did my first GDV / splenectomy surgery BY MYSELF (no attending clinician) followed today by my first NEPHRECTOMY BY MYSELF. big dog little dog attack, fractured kidney, partially torn renal artery (which comes off the aorta - the biggest blood vessel in the body), tons of blood in the abdomen. it was SOOOOO much fun. and by fun, i mean awful, terrifying, and in the end, fruitless.

i will elaborate at another date, but for now...OMIGOD.

**ps: nephrectomy = kidney removal

how i became the homeless parrot redux

for beloved parrot - a repost of a previous explanation of how i became the homeless parrot (on my original part 2 blog, which i took down several months ago)


someone asked me the other day what the title of my blog means. and while i'm a total fan of individual interpretations...being a lover of novels and poetry and music and such...i thought i'd explain. however, if my explanation doesn't jibe with yours, then by all means, continue to believe what you originally thought. everything has different levels of meaning, eh?

while an undergraduate, i decided veterinary medicine was what i wanted to do with my life. to that end, i took courses designed for med/vet students. however, during my junior year, i became concerned that veterinary medicine was a selfish career choice. it would take 4 years post-graduation and eat into the time during which i could be having children and building a family -something i'd always wanted to do. vet school would also be an enormous financial and emotional burden. i decided - after lengthy consideration - vet school wasn't for me. i finished a degree in biology, but i was short a few pre-reqs for vet school (organic II and biochem, physics, notably).

after graduation, i spent a year completely lost. floating along, trying to decide where my life would lead me. nothing made me happy. i applied to various graduate programs - microbiology, evolutionary biology, even the masters in teaching. but nothing felt right. i was intensely unhappy during that year - dissatisfied with my lack of direction. after graduation, i worked as a riding instructor at a YMCA camp for a summer (which i absolutely loved) and then as a veterinary technician (which i loved, too). i moved on from that to a job in a human medical office that offered health insurance and which i absolutely and totally hated and actually wound up walking out on. i made it 6 months there before moving on to a job in the business office of a physical therapy center.

one day, i went with a friend to pick up my landlord's sick horse from the vet school. i stepped inside the building and was overwhelmed by a sudden sense of absolute belonging. of coming home. of being exactly where i was supposed to be. i cannot begin to describe it. if i believed in the divine, then i would believe that the moment was a sign from above. when i left, i knew that i had to do it. there was nothing else.

i enrolled in organic II and physics at a local community college and spent the next year working on finishing my pre-reqs and going through the rigorous process of applying to veterinary school. most candidates apply to multiple schools. i put all my eggs in one basket, mainly because hubby was already enrolled in his graduate program, and hoped against hope that i would be one of the few selected. and here i am, near the end of this leg of my journey. sometimes it all seems too surreal to be true, as if this is my dreaming life and my waking life is false.

i suppose a more appropriate name for this blog would be the homed parrot. but before i found vet school, my soul was homeless. and now i've found that thing which makes me happier than anything else. for all the toil, the sorrow, the burden, the hours and hours of work and studying, the damage it's done to my mental stability and that of my husband, i know that i am where i belong. there is nothing else that would have sufficed. my only sadness is that one day i will be too old to be a veterinarian anymore.

tired...

good times today. long though...

actually - i did have a rather good day. i was woken up at 7am (rather than 7:45) by my phone ringing. it was a neighbor 4 houses down who had maybe found my cat. despite the fact that she called me at SEVEN A.M. - i was thrilled. and it was - indeed- bruiser she had found. he'd been hanging out with a gaggle of outdoor cats in the yard next door. i was grateful - but i did NOT mention that i am a veterinarian to her, since i saw that she had a dog.

at work, we did 2 dog neuters, 1 dog spay, 1 cat spay, and a declaw (ick). it was nice working with the senior students. they all did well, were pleasant to work with and helpful. it took us all of 10 hours to do those simple surgeries, but i was okay with that...other than the fact that i didn't pee for 12 hours. and the fact that the last surgery of the day was a declaw - which i absolutely hate to do.

afterwards, i grabbed some dinner with a classmate who works at a nearby vet clinic, an extern currently at my place of employment, and the husband.

now, i'm wiped. it's time for bed, because the weekend is here. and the weekends are hell!

hi-ho hi-ho...it's off to work i go...

tomorrow, i return to work for a four day stint. our schedule is very strange. when we're on days - we typically work 7-8 days in a row. then we have 3-4 days off, then we go back and work the noon to midnight weekend shift (which is friday through monday).

i'm on the four day weekend shift this time around. tomorrow, the orthopedic service from my alma mater comes up and does orthopedic surgery and sees referral appointments. they bring along the current seniors (class of 2009) and they do spays/neuters/declaws/etc while the orthopod does surgery. the noon to midnight intern is in charge (so it's really 9am till midnight - except i think i finish when the senior students finish, so i could conceivably leave as early as 5pm).

WTF?

long story short: i brought home a black cat from work to live outdoors at my house. he was unceremoniously dumped at our clinic by his white-trash owners (sorry, but it's true). he was a GREAT cat, and i fell in love with him in a weeks' time. we were introducing him to the backyard, and he was outside, when my mom called to tell me that dad was having a heart attack. we tried to find him to no avail. rather than continuing to search, the husband and i left for our 4 hour drive to the hospital. i haven't seen the cat since, which makes me feel like a terrible vet and person. i've driven round the neighborhood, posted signs, called the shelter, checked online - nothing.

i'm not generally an advocate of outdoor cats - i've seen far too many dog maulings, hit by cars, malicious abuse, FIV + cats to ever want my cats to have to suffer something like that. yet, i didn't want this guy to go to the shelter and possibly get euthanized (and he was already an outdoor cat), so i brought him home to be outdoors (we currently have 5 indoor cats - which borders on crazy). he was bar none one of the sweetest, most pliable cats i have ever met. and he liked to hug you!

he's been gone since saturday and naturally, i feel rotten. NOT the best week ever. i posted fliers yesterday with my name (first only) and phone number. thank god, not my address- as it turns out.

my phone rang this afternoon. the conversation went something like this:

me: hello?
crazy woman: yeah, i was calling about the black cat. where did you get him??
me: umm...what?
CW: where did you get him? the cat?? where did you get him, huh??
me: i'm a vet (mistake number 1) and someone dumped him at my workplace.
CW: you're a vet? oh so somebody abandoned him?
me: yes.
CW: i just wanted to tell you that there are mean people in this neighborhood. they steal cats. of course, they steal mine because i 'm single. but they steal them and they take them to the smiths' house. only smith isn't the girl's maiden name, it's mcgammon or something.
me: ooookay.
CW: so like i said, there are mean people in this neighborhood. they collect cats. they might have stolen yours.
me: okay, so you're not calling because you found my cat?
CW: no, bvt i do have one that looks like that. he hangs out at the house behind me now though - that's the brown's house. but i know he's there. he just hangs out there. you know - there are people in this neighborhood that steal my cats because i'm single.
me: ok - will you just keep an eye out for my cat?
CW: hey, could you vaccinate my cats for free for me?
me: umm, i work in an ER clinic and don't currently have access to vaccines.
CW: oh. ok. do you know the smiths? they steal cats. i think it's because they're poor. they're not too poor, but they are a little poor.
me: umm, i have to go.
CW: hey, could you come to my house and vaccinate my cats and just send me a bill?
me: i work for an ER clinic, and we don't do vaccines.
CW: oh...so you work at the **insert the name of my workplace here**?
me: ummm yes (likely mistake number 2), ok, i have to go now.
CW: oh. ok. are you sure you can't vaccinate my cats?
me: HANGING UP.

don't worry, she called back a mere 25 minutes later. i recognized the number and didn't answer, but i had this message waiting for me on my voicemail: "hey, i was just wondering if you have any coupons for free animal food, since you're a vet - and if you maybe wanted to share them with me."

cause after all, i am a vet.

who is john galt?

so 'the last days of dogtown' has been moved to the back burner, and i'm taking another run at my personal literary everest...'atlas shrugged.' once upon a time, 'the fountainhead' was my literary everest. it took me 5 attempts - the first four, i couldn't make it past the first 30 pages or so. on the fifth try, i became totally and completely immersed and burned through the book in no time (relatively). so far, i'm riveted, naturally. ayn rand is nothing if not compelling. should i finish it this time, i will have to find another literary everest. oh wait. i already have one: the gormenghast trilogies...

insert segue here:

when we went to the avett bros concert back a bit ago (2 weeks?) - i came in at the tail end of the opening band. the bijou is the ONLY venue that runs on time, in my experience. when it says "show starts at 8pm" - well then - the opening band is on at 8pm dammit. so, we missed 98% of the opening band. i got to hear the end of the song "i will be released" by matt butcher and the revolvers. i was very sad to have missed them - because - from what i can tell, the music is great. so check them out:

http://www.myspace.com/mattbutchermusic

you can also see the stuff from knoxville on youtube, if you just type in avett brothers knoxville - it will bring up the matt butcher stuff, too.

my dad

my dad is home already and expected to make a full recovery. he is going to be on plavix and low-dose aspirin for the rest of his life, it seems. i see it as a good thing - because hopefully his life will now be much longer, since we know what his biggest health problem is. thanks for all the thoughts, prayers, emails, phone calls, and text messages. it meant a lot to me.

crushing defeat...yet again

when i came on the day shift monday, a case was transferred to me that had been hospitalized for the weekend. max was a 1 year old, beautiful boxer. he was absolutely stunningly gorgeous, and he was sweet to boot. he and his sister dog had decided it would be a good idea to raid mom and dad's medicine cabinet. during the raid - an enormous quantity of naproxen and advil was consumed. the toxic dose of naproxen in dogs is VERY low - something like 5 milligrams / kilogram. max had ingested about 50-100 times that amount.

he was treated at his veterinarian with decontamination (induced vomiting, activated charcoal to absorb toxins in the stomach, hospitalization, and monitoring). his sister did well, but he developed SEVERE bleeding in his GI tract. this isn't surprising, since NSAIDs (non-steroidal anti-inflammatory drugs) inhibit the production of prostaglandins in the body. when you have a headache or muscle ache, this is a good thing, because some prostaglandins promote inflammation. unfortunately, there are good prostaglandins, too - and these are also inhibited by NSAIDs. these good PGs help keep the gastric mucosa healthy and the acid level normal. when you inhibit them, the stomach and upper small intestine have problems with the normal coating, and GI ulcers occur. this is why you have to be cautious when taking NSAIDs. too many can lead to stomach and duodenal ulcers. the biggest concern in these severe cases is that the area of ulcerated mucosa will eventually rupture, leading to perforation of the GI and spillage of the intestinal contents into the abdomen (septic abdomen = BAD).

max started to have extremely black stools - full of digested blood from his ulcerated stomach and GI. he was depressed, and he didn't want to eat. we managed him aggressively, but his PCV (packed cell volume) continued to drop, as he lost massive quantities of blood into his intestines. his albumin (a critical protein in the body) also dropped precipitously, because - again - he was losing it in his blood through the ulcers.

we supported him with GI protectants out the wazoo (pepcid, prilosec, carafate) and misoprostol - a medication that is a mimic of prostaglandins made by the body, but his biggest problem was his falling PCV and albumin. i made the decision on wednesday to transfuse him. transfusion won't bring the proteins up much - you need massive quantities of albumin to do that, but it would help his PCV. in total, he received 1 unit of packed red blood cells, 2 units of fresh frozen plasma, and 450mL of whole blood from a donor.

and he bounced back. his appetite and attitude improved, his PCV hovered around 26% (as opposed to 15%), and he started wagging his stump again. i made plans with his owners to send him home on thursday.

and then...from the jaws of victory, defeat was snatched. he spiked a fever of 105. his PCV dropped from 26% to 18% then to 16%. he turned yellow. his liver values went off the chart high - and i mean high (for vet people - his ALT was 6500!!). 24 hours after his transfusions, he was suffering a delayed reaction to the blood products. his body started to destroy all of that blood we had pumped into him. even worse, he went into acute liver failure.

on saturday, i wasn't with him, caring for him as i was supposed to be. his PCV dropped to 12%, and he collapsed and began to have difficulty breathing.

his owners - invested emotionally and financially ($4000!) were crushed, i'm told - as the final decision to euthanize him was made. i spent a week working with this guy, loved him, saw him improve dramatically, and allowed myself to hope that we had been able to undo some of the terrible damage to his GI tract - only to watch him suffer the most severe reaction to a transfusion possible.

chalk it up to another loss for the home team.

addendum: i just noticed that all of my work posts are depressing...i promise that the next story i tell will have a happy ending. problem is - i have to come up with an interesting case that ended well. it's a dilemma - because if it's interesting enough to write about - the outcome probably wasn't good.

my dad had a heart attack this morning. he was taken to the ER about 30 minutes after the onset of the chest pain. they treated him with thrombolytic drugs to break up any clots and sent him in an ambulance to the nearest referral center. he underwent a cardiac catheterization which confirmed a blood clot in the coronary vessels (not sure if artery or vein). the thrombolytic was successful in breaking the clot down, but the degree of myocardial (heart muscle) damage is unknown at this point. he is in the ICU. we spent the day there with him. he is bright, alert, and aware of everything. we talked at length, and he is feeling okay. hopefully, he arrived at the hospital in time to absolutely minimize the damage.

he'll probably stay in ICU 1-2 days total, then maybe go home monday - depending on what they find on the echocardiogram tomorrow/monday.

it was not a good way to wake up this morning (at 6:30am to a phone call from my mom - who sounded oddly calm). this is the second time in 2.5 weeks i've had to miss work. first i was sick, now this. i'm starting to feel very unreliable.

keep my dad in your thoughts please!

ps ps

just spoke to my c-section dog's owner. all is well, and she is bouncing back amazingly.

i'm thrilled. and i'm home finally after 3 days away. i'm such a homebody that i miss my house that quickly. i love being with my best friend and her husband, but i love my house. i also miss the fluffies when i'm away.

i go back to work tomorrow, i'm on days (8am-8pm). i rather like days and can't complain.

ps

i have nothing veterinary to talk about because the last 2 nights i was working, i was in a sick, sick haze. i can't remember more than 1 patient - my c-section. i really want to find out how she did, i was terribly paranoid about her well-being post-operatively.

whoo

perhaps i will not see the avett bros when they go to my favorite venue. second best: i'll see band of horses on the husband's birthday in atlanta.

i can deal with that:)

sundries

i just attended my 4th avett brothers concert. they are so ridiculously, freakishly talented that i'm amazed anew every single time. this show was no exception. it was a bit of a departure from their other shows - they played more of their lesser known music and a great deal of newer stuff. it was also not all rompin' stompin' bluegrass like the last show. nonetheless, it was fantastic. they are becoming polished performers - but not in an obvious way.

i WAS really excited, because they're going to play one of the best venues within a 3 hour radius in december - the same place i saw them this time last year. unfortunately, i am scheduled to work.

sadness ensues.

ah well. perhaps one of my comrades will want new year's eve off work and will choose to swap a night with me...we shall see.

tomorrow is college football and homecoming. also - my sister-in-law's birthday, which we will celebrate with friends and family after our (presumed) football victory.

our head coach was fired. after 30 years at the school...he has been fired. i was all for it, until i saw the press conference and watched him visibly choked up by the loss of his job. on the other hand, he doesn't get paid millions and millions of dollars every year to lose 6 games!! still - it was bittersweet. i'm very interested to see what next season brings in terms of a new coach. i've been immersed in college football since my then boyfriend (now husband) introduced me to its previously dubious charms in 1997. ever since then, i'm a junkie.

as you might expect, this previous illness has not killed me - and i will live to see another horrendous head cold/flu bug/? the husband has the great misfortune of now being ill. i have the even greater misfortune of caring for him. (really, i'm kidding. he doesn't whine at all - not NEARLY as much as i do).

i promise to post something vaguely related to veterinary medicine again soon.

scattered, incoherent thoughts on the president elect

i'm sure everyone who follows my blog knows how depressed i am that we just elected an inexperienced senator from the chicago political machine to the highest political office in the land (a man whose idea of fixing our economic crisis is to "redistribute the wealth" b/c it worked so well for so many other socialist countries).

i was not a huge fan of bush. i was not and am still not a huge fan of mccain (he's conservative by a HAIRSBREADTH) - although i respect his experience and service to our country. i do not like obama most of all.

the election is over, and instead of looking at the bleak side of things...i am going to hope for the best. perhaps obama will choose his advisors wisely - looking to people that are in no way similar to his lifelong mentor and church leader, jeremiah wright.

i can only hope that this is the case. i want to be optimistic - and it sure beats looking ahead glumly.

this election also reminded me again that it is all a puppet show. a 2 party system in which the only candidates that could possibly afford to sustain a campaign are millionaires many times over (and consummate politicians) is no way to run a democracy dammit!! third party !! third party!! fourth party too!!

plato may have had a point with that whole republic idea.

welcome to the blogger world!

my mom has joined the blogging world:

http://redrobinlane-rgcarr.blogspot.com/

after almost a week, i'm still fairly sick and unhappy. we're still going back to the hometown for a concert on friday night (rompin' stompin' bluegrass) and homecoming football on saturday with a birthday dinner afterwards. all of these plans might go straight in the toilet because the husband woke up this morning full of snot. i coughed all night and kept both of us awake.

good times.

triple ugh.

ugh. i am sick. not the fun kind of sick where you only feel slightly bad - enough to justify lying prone on the couch and watching TV. nope, i'm the staggering around in a dayquil/nyquil induced fog cannot think straight want to sleep all the time fog. i feel awful. i would chalk this up to a bad head cold, except that both of my mandibular lymph nodes are swollen and painful. i don't think that typically goes along with your run-of-the-mill cold. but what do i know?? i'm an animal doctor. hee hee. i have lymphadenopathy. if i were a dog, i'd diagnose myself with probable lymphoma and aspirate my own lymph nodes.

ok that was the nyquil talking.

i missed friday and saturday night at work. it sucked. it made me feel like a total slacker. i never complain when i'm not at work, but i hate calling in because other people have to pick up my slack, obviously. i worked in a day clinic on saturday. i wasn't able to call in at that place, because i was the only doctor working and they were relying on me to be there. at least at my "real job" on the weekends there are 2 interns and 1 senior clinician.

i went in last night, and i was predictably miserable. plus, i had to do surgery - which super-duper sucked. i did a c-section. my first c-section, actually. i hope the dog is still doing well. i was very scared- mostly due to a) being so sick i couldn't think straight and b)the dog had HUMONGOID veins and arteries from being pregnant.

all 4 puppies survived. hooray. i laid down at 1:15am, sick, miserable, and foggy only to be awakened at 6:30am with a patient.

**sigh** i'm off tonight, for some odd reason - but i have to work tuesday night. if i haven't died.

ok, i'm going back to the couch to continue watching season 2 of gilmore girls.

part 2

the sequel to why emergency medicine is so hard:

4) euthanasia: we do so many more of these than GPs- running the gamut from tragic injuries that could have been avoided to old dogs and cats ready to die. after pulling up the pink juice for the 5th time in 8 hours, i start to become emotionally numb. sometimes i have to refuse to do a euthanasia and ask a colleague to do it (as long as they haven't done many themselves that day) for fear of becoming completely emotionally unhinged.

5) exhaustion: often our shifts run several hours over - bleeding into the wee hours of the morning or late into the night. sometimes i don't get to eat or drink or pee in a 12 hour stretch. it ain't healthy and it ain't ideal - but it's a fact. we are chronically understaffed and chronically over-stretched.

6) staffing: it is difficult to find technicians who can bear the stress and emotional burden of emergency work. see reasons 1-5 for why their jobs are just as hard as ours. on top of that, they cannot take proper care of their assigned patients because they're also responsible for diagnostics on all the emergencies that come to the ICU. on top of that, they rarely hear words like THANK YOU from anyone. i've made it my personal goal to try and tell all the techs at the end of their shifts (and often many hours afterwards) thank you. i know how much better i feel when someone takes time to thank me for caring for their pet or doing a good job.

i'm sure there are many more, but at the moment - i can't think of any.

i'm going on overnights for a week starting tonight - so again, if you pray - pray for my sanity. pray that this week isn't like last weekend at all, or i might have to find a new vocation!

Courage is going from failure to failure without losing enthusiasm

i read a blog called dolittler with a fair amount of frequency (at least 4 times a week, if not more). it's kept by a female veterinarian in miami named dr khuly. her posts run the gamut of veterinary care - from medical conditions to interpersonal relationships to finances and the frustrations of being viewed as a humanitarian, and therefore - unconcerned about money in regards to our patients. lately, there's been spirited and sometimes angry discourse about some people's perceptions of veterinarians. if you're interested - you can check out the comments sections on some of her recent posts at:

www.dolittler.com

it has brought to my awareness some of the inherent problems of being an emergency doctor. i am going to elaborate on them here:

1) trust issues: most people who show up at the emergency clinic have an animal in dire need of medical care. often they are fatally injured and all that is left for me to do is deliver the terrible news and dispense the ever present pink juice. for those that i can help, their owners are faced with emergency room expenses (by no means cheap - i'd estimate the average hospitalization runs between $450-650) and an uncertain prognosis. all of this information is delivered by a strange veterinarian they've never met and with whom they have no previously established rapport - in a time of probable duress in their lives.

2) triage: to each individual owner - their pet is the most important thing. this is understandably so. and to us - each pet is an important patient - however all of their problems are not equal in severity or relative emergence. we - as doctors - must triage. this involves often putting the less severe cases on the proverbial back burner while the more severe cases take precedence. does this suck? yes. do we sometimes inappropriately triage i.e. mistake a serious case for something more benign? yes. can we help that? that is arguable.

3) the time crunch: i would love to spend 20 minutes discussing every possible outcome of treatment with an owner, as well as every single possible complication associated with their pet's condition. i would love to endure a question and answer session spanning a half an hour. i do love to educate people - clients, our technicians, anyone who listens (part of the reason i keep this blog). unfortunately, in emergency medicine - the time is not there. often i get to run over the most likely complications, the cost of hospitalization, diagnostics, and/or surgery, discuss quickly any concerns the owners have, and then move to the next room. it's my job. and it sucks not only for the clients - who may be left with more questions than answers - it sucks for me.

i have an example of this latter case i want to share. a couple of months ago, a young woman brought her small dog to me. he had begun vomiting and having diarrhea that day. the dog - an older mixed breed terrier - was well taken care of, up to date on shots, heartworm preventative, and general healthcare. recent geriatric blood tests had been normal. the owner noted that he had seemed to slow down a lot in the last week - but the vomiting and diarrhea had just begun that day. i did my physical exam and was a bit confused. i couldn't hear the heart to save my life. it was not a physical exam finding i was expecting. i whisked him off to ultrasound quickly - just to convince myself i was hearing (or in this case - not hearing) things. but lo and behold, i was right on the money. i couldn't hear his heart because it was floating in a sac of fluid.

normally, there is a sac around the heart called the pericardium. it has a small amount of fluid (3-4mL probably) to keep the heart muscle lubricated. that fluid is not visible on an ultrasound. what i was seeing in this dog's heart sac was probably 300-500mL of fluid. what did that have to do with the vomiting and diarrhea, you're probably wondering. and i'm wondering too. still am.

i went back to the room and explained to the owner my findings. the dog was severely tachycardic (elevated heart rate) - likely due to the fluid in the sac putting too much pressure on the thin-walled right side of the heart. treatment for pericardial effusion is an immediate pericardiocentesis. this involves sticking a long needle/catheter into that sac (but trying NOT to hit the heart) and removing the fluid. i discussed this with the owner, as well as the complications associated with this kind of procedure - including sudden death from cardiac decompensation.

the owner left her dog in my hands after kissing him on the head. i tapped him twice. the first time, he developed cardiac arrhythmias which were corrected with lidocaine. i was only able to get about 60mL of fluid out before the catheter was blocked by a clot. i tapped him again and was able to remove almost 150mL of fluid successfully. i returned him to the cage and hooked him up to an ECG that i could easily monitor from across the room. as i was attending to my other patients, i watched the monitor. a hit by car came to the back, and i bent over it, checking the ECG monitor every 30 seconds. the last time i looked up, the heart rate read zero. my pericardial effusion had died. we attempted rescucitation - but we could not get him back.

what does that have to do with the time crunch? you might wonder. it centers around the fact that the owner brought her dog in with vomiting and diarrhea. these are concerning but not usually life-threatening conditions. though we found a life-threatening condition, i don't know that the owner fully grasped the seriousness of pericardial effusion. first, she wasn't expecting it and second, i didn't have 45 minutes to explain it to her. i had to explain it in brief terms and then get to tapping the chest because time is ALWAYS ALWAYS ALWAYS of the essence in emergency medicine.

in this situation, her dog received the best and most appropriate medical care it could - but does the owner know that? all she probably knows is that she brought her dog to us for V/D and it died. trying to explain this in the shock that follows the sudden death of a beloved pet is difficult. the owner is often not fully processing what you are saying - but instead mentally replaying the events of the past few weeks - trying to find clues or explanations for what happened.

to be continued...

raindrops keep fallin' on my head...

it's a rainy, dreary, cold day here in the south. i'm back at the old stomping grounds, spending the weekend with my best friend and brother-in-law. it's a perfect day for lolling around and doing exactly nothing, and i love it.

tonight, we will play poker and probably eat burritos courtesy of moi.

i am recovering from the riot that was this past weekend, but i'm still a bit too bitter and tired to write about it in its entirety.

suffice to say that i had a patient with terrible vomiting that i couldn't control with conventional anti-emetic therapy, including a drug called zofran. zofran (ondansetron) is an anti-vomiting medication used for human chemo patients. it is usually fantastic. it didn't help my patient. after 2 days, i made the call to take my patient to surgery on the off-chance that he was obstructed in a way that wasn't obvious on the xrays (which were normal) and to obtain GI biopsies. i found exactly nothing - other than a strange thing hanging off the spleen. it didn't look like cancer or a granuloma - so i had no explanation for it. i wound up doing a splenectomy, but the owner was cash-strapped - and i couldn't submit the splenic thing for pathology. afterwards, my patient didn't wake up from anesthesia. his blood pressure plummeted - and he went into respiratory arrest. we aggressively resuscitated him, but the owner elected to stop.

i should feel good. the owner didn' have enough money to keep treating. we were going to euthanize when i offered him a payment plan (which we are typically not allowed to do in emergency medicine - just the nature of our client base). he accepted this tearfully, thanking me. i had a good sense about him, i knew he would pay us and gratefully. we decided that i would do surgery - if i found an obstruction, i could remove it. if i found something else, something terrible, i would euthanize on the table.

i gave the patient a chance. we were going to euthanize him. still, i feel so bad. it was terrible. and i still don't know why. all of my testing was normal - and he still died - despite my care, despite my testing, despite finally making the call to go to surgery.

it left me feeling sad, empty, and confused. of course, his owners were lovely, lovely people with children. and of course, my patient was a lovely, young (2 years old) animal whom i wanted to spend all of my "spare" time petting.

one of the many things that made this weekend a particularly rough one. another case that reminds me that no matter how hard i work, no matter how conscientious i am - i am not god, and i cannot fix them all. it's a bitter pill to swallow, but one i must keep swallowing nonetheless.

anonymous RE:drug testing

ok, first of all - i don't even understand your comment. it seems that you think i had to do drug testing for research? what i'm talking about is being randomly selected for a drug test for myself - to see if i'm using marijuania or ketamine or cocaine. and i don't think i'm superior to people. i have no problem with people working at mcdonald's. but i DON'T think that as a doctor - i should have to go sit in a clinic with people on parole, people who were drunk or high on the job, and take a drug test just because my employer wants to claim a drug free work-place. i don't know a single other doctor - DVM or MD that has to do that. that may be elitist of me, for which i will not apologize. it's how i feel. it was insulting. i kow doctors are prone to drug use as much (if not more so) than the average person - but i still object. hell - i object on behalf of the person that works at mcdonald's too. if you show up sober, do your job, and go home -why is it your employer's business what you do at home??

thank god the weekend is over (how many people say that?)

this weekend was unbridled chaos the likes of which i haven't seen since july 4th weekend. i don't know why. the previous weekend was so slow, i went home on saturday early to watch football. this weekend - every cage was full. it was terrible.

one of the internal medicine specialists made an eloquent analogy for our job. it's like a relationship with a boyfriend that beats you. sometimes it's really great - and everything is rocking and rolling. and sometimes it beats you down.

this weekend beat me down.

ok, it's a stupid analogy. but it worked at the time.

on sunday, i arrived at noon and didn't leave until 7am monday morning. i squeezed in a 3.5 hour nap, then went back to work for the noon to midnight shift again. i was exhausted, emotional, and depressed. one of my patients died - and i still don't know if it was something that i did or not.

i saw some interesting cases that i might feel like talking about sometime soon, but for now - i want to block out the last weekend in its entirety. it was awful. finished off by my being selected for a random drug that i was supposed to go take on monday. after working for 20 hours and sleeping for 3 hours. i flatly refused. first - i think drug testing is insulting. i am a doctor. i'm not working at mcdonald's, for god's sake. at any rate, i refused to go that day, because i had a patient in dire condition. so i got to go on my day off and piss in a cup. YAY.

today, i was a naughty monkey. really naughty. i went and had my hair colored - it's a really deep purple-red now (my grandfather will have a heart attack - and i think my nanny - who reads this blog - will rat me out). and i went to clinique and got a make-up consultation and finally learned to actually apply it. it was fun. they went a little heavy on the eye makeup, but the overall effect was awesome. i bought new perfume (dior addict 2). i bought make-up. it was bad, but i feel better. drowning my sorrows in unabashed frivolity. ah...the american way.

i need to go clean litterboxes and bird cages in preparation for our trip to the hometown tomorrow.

i'm scared

very scared that by the time i die, i will be living in a socialized america - big brother will be watching me.

the wall street journal has a good article on exactly why i am fearful of an obama presidency. and i'm NOT endorsing mccain. truth be told, i don't like either of them. and i don't necessarily think if mccain does somehow pull out a win that america still won't be socialized by the time i have grandchildren.

it makes me sad.

http://online.wsj.com/article/SB122420205889842989.html?mod=rss_opinion_main

two roads diverged

i'm diverging from veterinary medicine briefly to talk about another passion of mine...

i've loved music for as long as i can remember. for the first decade of my life, i was very limited in my musical tastes. my parents raised me on "oldies" - the 40s, 50s, 60s, and 70s. johnny cash, marty robbins, elvis presley, the big bopper, chubby checker, the beatles...for the longest time, i thought that was the only music that was worth a damn. when i was 10, i started to branch out on my own and experiment with my own musical tastes. i retained a love for the oldies and that has never waned. yet at the age of 10, i was ready to forge my own way.

my tastes since then have been eclectic - to say the least. in 5th grade when i first heard '3am eternal' - i thought i was hearing genius. i worshipped KLF - a forgotten (and undeservedly so, i contend) British acid house/ambient band (according to the all-knowing wiki god), although compared to current ambient (aka boards of canada, age of rockets, explosions in the sky, M83, appogee) - it's a completely different sound. much more frantic.

i still love KLF and i think the white room is genius.

another offbeat band that i was introduced to in high school (my best friend was way more cool and way more up on the underground scene) was messiah - a techno/trance/? group that heavily sampled other songs and artists to create a frenetic album (21st century jesus) that had a huge impact on my appreciation for techno/trance/ambient/dance/house, etc. i still love it, although finding a copy of the original is a bit of a challenge - mine having gone the way of many of my CDs.

i still have a very strong taste for techno. i still, after all these years, love lords of acid - shock sex techno though they were. i'm not "up" with the underground music scene as much as i wish i was - having lately moved over to the prog rock side of things.

i think that my love of techno has kind of bled over into the ambient rock genre. appogee is one of my recent acquisitions that i'm rather fond of, as well as caterpillars.

caterpillars i cannot take credit for - my brother put them on his myspace, i merely followed my ears (and the link). i've been sucked in entirely - which - since they only have 2 songs on the web currently - is not a good thing. i need more. as yet unsigned, they are releasing their EP soon. i'm happy about that, since at the moment, i cannot tote them around with me on my ipod. that makes me sad.

the song 'bury your words' does something to me. it's dreamy, ethereal, and makes me feel a yearning i can't really describe. maybe only a yearning to strive for something better, to strive for something beyond the here and now.

i love it.

"bury your words beneath this insane earth,
in a silence found only beneath the dirt.
no i don't want to hear what i've heard before,
wanna escape this place and find something that offers more."

and the lead singer works at a vet clinic (a kindred spirit musically and with the fluffies!).

check them out: www.myspace.com/caterpillarss

if anyone has any other musical suggestions - i am ALL ears. i'm in a musical rut as of late, sadly. i'm going to see the avett brothers in november, so at least i have something to look forward to - but other than that...nada. the hellsayers are playing sporadically in asheville, but i can't get away to go see them. another unsigned band that i adore: www.myspace.com/thehellsayers.

albums everyone should own:
grandaddy: the sophtware slump, under the western freeway
the hellsayers: the lonesome sea
the avett brothers: emotionalism
rogue wave: descended like vultures
band of horses: everything all the time
cary ann hearst (still unsigned DAMMIT!): dust and bones
anything by arcade fire

i go back on emergency work tomorrow through monday - 12pm-12am shifts for 4 days. i'm sure i'll be back on tuesday with lots of stories to tell. for those that pray, pray for my sanity.

a GP's life for me?

i did relief work again - at another local clinic. i must say - it was relaxing, it was fun, it wasn't all life or death and WTF is wrong with this patient? and what fluid rate? and how much of this drug can i give with this drug...both of which have serious side effects but must be given to save this dying animal?? nope. i also didn't have a single vaccine appointment today. i had some skin (ick ! but it's becoming more tolerable). i had a mass that looked like a mast cell tumor but on cytology was not. i had a cancer staging with a boxer that had mast cell tumors (different patient)...it was an all around relaxing day. i really enjoyed it.

i got to work at 8:30am and left at 5pm. no staying after work, doing oodles of paper work and calling referring vets and checking on my terribly ill patients. i made $400. it's a pretty sweet life, i have to say. and it leaves room for things like children and a social life...and pursuits i would again like to pursue (riding, notably).

hmmmmm.

oh yes, i've already decided to forego the residency next year - for myriad reasons which i will elucidate some other time. i need a nap before the local veterinary med meeting tonight at a swanky restaurant.

is a GP's life for me??

a rare political moment.

so we sort of have cable now. i say sort of because we split our cable internet line so that we could get ESPN for football games. since it's a pain to hook it up and unhook it, the husband has left it permanently attached to the TV in the study. we used to have only 1 TV - which was more than enough. now we have 2 because the previous renters of our house left their TV behind.

today, i found myself watching 'the rachel zoe project'. before today, i had never even heard of this show. it's about a famous stylist named rachel zoe. her whole job is to run around selecting clothes and accessories for famous people to wear to their various functions. her whole life is fashion - which i admit - sounds rather glamorous and fun (after all, i love to shop as much as the next fashion oriented female).

i spent about 2 hours watching the show - stunned into silence at the sheer vapidness (vapidity?) of the people around which the show centers. i don't know why i was surprised - a quick swing through all of the other cable channels reveals shows like 'i love money' 'jerry springer' and anything on MTV (notably 'the hills').

sometimes i hate our culture. not capitalism mind you, i believe in the free market. materialism is what i hate. no, it's not even materialism. it's ok to want things. it's this sense of...self-centered narcissism and entitlement. the people in this show - all they think about is themselves, their immediate wants and desires. it was epitomized by rachel zoe herself saying something along the lines of "i buy what i want, that's what credit cards are for - it's not like i'm paying in actual cash." that statement is the acme of what is wrong with our country currently - the most succinct explanation of why freddie mac and fannie mae and all of this other financial ruin is occurring. we are a country living on easy credit - with high expectations. we think we should be able to have it all - and have it now. no one saves anymore, no one exercises good judgement (i'm making a generalization here - though not a sweeping one).

our country has a sense of entitlement - that we should all have equal wealth, equal status, equal equal equal. if you listen to obama talk about wealth redistribution, you hear it.

that's not how life works. life is not equal. life is not fair. life is not about being entitled to anything just because you exist or because you live in america.

this is a rant, and it's a poorly written one with probably little logic or explanation.

my point is that we are not entitled to anything. we are lucky to live in a nation that was made for us long before most of us were even born. we are lucky to live in a wealthy, free society where we can work for and earn anything we want - work being the operative word.

but no one sees it that way anymore. everyone gets a credit card and spends until the limit is met. then they obtain another...and do the same. they buy houses they cannot afford, cars they don't need and cannot afford, and elect politicians that promise "redistribution of wealth."

i hope by the time this becomes a totally socialist/communist society where everyone is equal and the government runs everything (because government does such a great job at the DMV) that i'm long dead.

i fear i won't be.

decisions, decisions.

i have an 11 year old kitty. he is a bit on the "fluffy/big-boned" side. ok. he weighs about 14lbs. and he should weigh about 8lbs. in my defense, when i obtained this cat, i was all of 19 years old and didn't really know any better about free feeding pets. now that i DO know better, my cats are all too old to bend to big rule changes like structured feedings. that - and i currently have 5 cats and 1.5 jobs. it's not possible to feed them all individually. it's a bad, lame excuse - because it would be better for them if they were lighter...so i have no excuse.

at any rate, my fat white kitty (fat man) started vomiting about 4 years ago - and it developed into a somewhat chronic problem. otherwise, he's stunningly healthy for being 11. bloodwork looks great, chest and abdominal xrays are normal. when he started vomiting, i took him into my vet at the time to xray his abdomen. as an aside, while telling me his guts looked normal, she pointed out his horribly arthritic hips. i promptly forgot about it.

fast forward to 3rd year of vet school when a clinical trial starts at my CVM. it was a clinical trial for a new NSAID for arthritic cats. i enrolled my fat man in the study. at his first check-up, the orthopedist - who has seen thousands of hips - turns to me and says, "your cat has the worst feline hips i've EVER seen."

fast forward to now - my beloved fat white kitty is limping a great deal on the back left leg. he's always been reluctant to jump, but he's never limped so noticeably. he's also started grooming all of the hair off his belly and rear legs. i think -given the lack of external/internal parasites (fleas, etc), any known internal disease, and a basic lack of any other cause, that he's overgrooming because he's so painful in the rear limb.

what sucks is that there are no good drugs for cat chronic pain. dogs - yeah. we've got rimadyl and deramaxx and previcox and aspirin and ketoprofen and metacam and cosequin...and on and on. cats...eh...not so much. there are no real good options. none of the NSAIDs are approved or really safe for cats- prone as they already are to renal failure (NSAIDs decrease blood flow to the kidneys and can precipitate renal failure). other medications i might try include opioids - which are expensive and leave my kitty doped up a lot of the time. gabapentin is promising - it's an anti-seizure medication that also has interesting pain control in dogs and cats. there isn't much research, so the pain control is theoretical.

the short answer for chronic pain control in cats? there is none.

i've considered these options, as well as adding an injectable polysulfated glycosaminoglycan (PSGAG - a joint supplement) to his control. but it's a lifetime (hopefully many more years) of medication. medicating cats sucks. even one as amazingly well-behaved and easy to pill as fat man (he used to take the clinical trial out of my hand).

and so i've decided. in 2 weeks, fat man will undergo a femoral head osteotomy bilaterally. what that means is that a surgeon will go into his legs and cut the head and neck off of the femur. he won't have a hip joint on either side anymore. yes. it works. i know. i can remember how i responded in ortho during 3rd year when they described the procedure.

WTF?? you can cut the head off the femur? you can destroy the hip joint?

yes. you can. it will eliminate the source of fat man's pain (the bone on bone contact between the femur and his pelvis). and yes, he'll be able to walk normally - if all goes well operatively and post-operatively. he'll be a little jacked up in the rear (as in - his rear legs will be a little taller than they were). but he'll be pain-free finally and hopefully have many more years of a pain-free existence.

it scares me a litte - despite the fact that i know anesthesia is safe. despite knowing that the majority of orthopedic surgeries are without complication. i just don't want to put my fat man under anesthesia.

but i want him to be comfortable and happy - and i can't stand to see him limp. and i don't want to force pills and liquid into him and give him once weekly intra-muscular injections for the rest of his life.

so there you have it.

uh...come again?

whilst managing and discharging my post-operative patients from "surgery" day on tuesday, as well as caring for my new emergency patients from the previous evening, and trying to be involved in internal medicine cases...i received a phone call from a local veterinarian asking if we could see an emergency of sorts. it was a geriatric dog weak in the rear limbs. i told him to send the dog.

a couple hours before the end of my shift, said patient shows up. 16 years old, emaciated, with foul breath, and significant rear limb weakness. i did a physical exam carefully and thoroughly. despite weakness/falling in the hindlimbs, a neurological exam was normal. the problem likely wasn't in the brain or nerves then. i gently palpated the dog's wasp thin waist and was dismayed to note two small kidneys. two too small kidneys. ugh.

further, the dog had gone acutely blind 2 weeks previously, had a 3 month history of vomiting and diarrhea, as well as 12 lbs of weight loss (which in a dog that should weigh 30ish pounds is a LOT).

i discussed my fears with the owner that kidney disease might be contributing to the signs i was seeing. i recommended starting with bloodwork and a urinalysis. i also checked the blood pressure, as well as examined the retinas to see if i could elucidate a reason for the acute blindness.

while the blood pressure was elevated - it wasn't "blow your retinas off high" - so the blindness remained a mystery - at least temporarily. then i saw my bloodwork. BUN and creatinine were extremely elevated (as was her phosphorous level). BUN and creatinine are 2 values that are used to assess renal disease. when elevated, they indicate a condition called azotemia. you see - your kidneys are rather important in many ways. they filter blood - yes - removing toxins that are nasty to you and getting them out of the body. they are crucial in maintaining electrolyte status (sodium, potassium, calcium, phosphorous, etc). when the kidneys start to fail - many bad things happen - nausea, vomiting, electrolyte imbalances, oral ulcers due to uremic toxins, neurologic changes, respiratory disease even. kidney disease is B-A-D.

azotemia itself can be classified as pre-renal, renal, and post-renal. pre-renal is an elevation due to dehydration usually, renal is due to primary kidney disease, and post-renal is due to something like an obstruction (bladder/kidney/urethral stones). in this case, with the history of progressive disease, emaciation, vomiting and diarrhea, i suspected chronic renal failure (or an acute episode of renal failure on top of a chronic kidney disease).

the prognosis i gave the owners was very guarded. the dog looked terrible. hospitalization with aggressive fluids and other treatments were absolutely needed to give this dog a shot. at the age of 16 and in such an advanced stage of disease - euthanasia was a very viable option. i discussed this with the understandably distraught owners at length - making sure they understood kidney failure and its attendant symptoms.

they asked me for some time to consider the options, so i stepped out of the room while they talked. after about 5 minutes, they called me back in - and i went - mentally preparing myself for a euthanasia. what happened was not what i expected.

"we want to take her home."

ok, i thought. i can deal with that.

i though that they wanted to take her home and spend some time with her than see the referring vet in the morning. but no. i had misunderstood. they wanted to take her home and bring her back to the vet when the dog got bad. i had to physically remind myself to keep my jaw closed - else it might have hit the floor.

i explained to them again in somewhat gentle terms that kidney failure is horrible horrible death. i made the point clear. treatment - ANY treatment - was better than nothing. the owners declined. they wanted to take her home until she got bad.

this dog had lost half of its body weight in 3 months. the ribs and spine were prominent. she was partially blind, limping terribly, deaf...and in severe kidney failure. also - totally anorexic with vomiting and diarrhea. BAD??

no amount of discussion would persuade these owners that their dog required intensive care.

in the end, they took the dog home after subcutaneous fluids and a shot of anti-emetic.

these weren't cruel or malicious owners. they'd owned and loved the dog for 16 years. they brought her to us hoping that the news we gave them wouldn't be terrible news - and that is precisely what i gave them. i don't think they were ready to accept what i had to tell them. i was torn. i could be harsh - explain to them in absolutely brutal terms the death that their dog would likely suffer in the next few days or i could accept that my hands were tied - that the owners loved their dog - and that there was nothing more i could do.

in the end, i chose the latter. my job sucks sometimes.