Monday, September 22, 2008

good night and good luck

i will bid all 3 of my readers (if that many??) a fond adieu until next monday. i am on overnights for the coming week, so you won't be hearing much - if anything - from me. i'm sure you're crushed. try to curb your disappointment and look forward to my return 7 days from hence.

Sunday, September 21, 2008

roll the credits*

instead of talking about the absolute disaster/embarrassment that constituted saturday's football game (the worst game i have attended in the last 12 years with one possible exception) - i've decided to do something new and different on this blog - talk about something besides myself/my job. i know. crazy. i just realized that those of you who read my blog that have never met me probably don't know much about the major players in my life. so i thought i'd introduce them and talk about them for a change.

the husband: i met my husband when i was 14 and he was 17. he went to the same high school and church. i had a huge crush on him, but he graduated and went off to college. he was everything in high school that i was not - well-liked, involved (he wrestled, ran cross country, and track), and cute. (ok, i was cute in high school). at any rate, i continued along the high school path, not seeing him again until i was a senior in high school (and he was 20). we hit it off and started dating shortly thereafter. we married when i was 20. he's as close to perfect as someone can be. currently, he's working on his phd dissertation in abstract mathematics. we've been married 9 years - together for 12. every day, i'm reminded of how lucky i am to have him.

the brothers: i have 4 brothers, ranging in ages from 28 to 21. they are employed in various fields and one is a father to my beautiful niece. the other 3 are not married and live too far away! i don't get to see them enough. they kind of "swim against the current" as it were. the twins are both tattoo happy and of the skater punk variety. they're also both very hard workers. the oldest of the 4 (1 year younger than me) is in college and supporting his daughter and fiancee (my future sister-in-law). the baby of the family is living in our hometown and "finding himself" - as the young are prone to doing. he's definitely the sweetest natured of all of us.

the parents: my parents have been married for 30 years this november. they married young -despite their age difference (my dad is 22 years older than my mom). growing up - i butted heads with my father frequently - likely due to our similar natures. i've been accused of being just like him. my mother and i got along better - although i was still a pain in both of their asses as a teenager. i was not well-behaved or interested in being a model high school student. later on, i shaped up - i have to say. so my parents did something right. my father started out life up north, enlisted in the army at age 18, and fought in vietnam and korea, for which he was decorated with 2 purple hearts - among other citations. he was a green beret - back when being a green beret was something exceptional. after retiring, he did many different managing jobs but found his true calling after obtaining his master's in teaching and becoming a high school teacher (my chemistry teacher). he was chosen teacher of the year in his last year of teaching. he's retired now and spends most of his time involved in the gideon order (yes - the people who leave the bibles in hotel rooms). my mom was a stay at home mom for many years but finished a bachelor's degree when i was around 14. she works in the performing arts theater in our hometown. she's much nicer than i am.

the grandparents: my father's parents died before i was born, so i never knew them. my mother's parents have been an incredibly formative part of my life. they live in florida, but i get to see them rather frequently - as they travel here on a semi-regular basis. we also go down to see them when we can. they've been married for...a long time. they had their 50th wedding anniversary some 5 years ago. my grandmother was an english teacher, and i credit her with my exceptional vocabulary and oratory skills. my grandfather was a college math professor - and very good at what he did. this comes from his students of many years - not just me - although he tutored me in calculus (and i got an A). when i was young, my grandparents used to tease me and ask me if i'd still want to come and visit them when i grew up. i said yes then and nothing has changed. their home in florida is the only place that NEVER changed as i grew up. we moved a lot when i was young - and i still move fairly frequently now - but that house is always the same - a beacon of safety and familiarity. it's still one of my favorite places to be.

the best friend: i met my best friend when i was 14 - a freshman in high school. i still remember exactly when. it was at a class "party" for a holiday (don't remember which one). i had baked a cake which turned out to be a disaster. i was in the bathroom, scrubbing the burned cake out of the pan when i introduced myself to her. we had some fallings out in high school - mostly over boys and my propensity for skipping school and indulging in extra-curricular activities of which she did not approve. in the end though, i introduced her to my husband's brother, and lo and behold - several years later - they married. she's an incredibly talented graphic designer and lives about 2 hours away from me (which makes me sad).

the husband's siblings: my husband has 4 siblings, as well - ranging in age from 22-35. they're great friends who have freely welcomed me into their lives without reservation. i'm lucky to have not one but two families that love and support me.

my vet school best friend: in vet school, i was lucky to meet a rare, generous soul whom i love as a sister. in those 4 years, she became one of my closest friends. i hate that she is now 12 hours away from me - and we're both so busy - we only get to talk on the phone about once a week - if we're lucky. it's only for a year, i keep telling myself. she's doing an internship, as well - in new york city. she's extremely kind, forgives everything, and is generous almost to a fault.

the florida friends: when i was freshman in undergrad, i met an interesting person in college (i went to fresh/soph year of undergrad in florida - at the school where my grandfather taught). she wasn't a crowd follower, and we hit it off. i took a year off from undergrad to spend in my hometown. when i went back to college the following year - we reconnected and became good friends. her boyfriend at the time met my husband and it was like gangbusters - one big fun foursome. we all got along great. they broke up and then got back together, and we've spent as much time with them as we can. they've come to see us up here twice, and we see them whenever we're in florida. we were in their wedding about 5 years ago. they're expecting their first child any day - and i love them both dearly. though we don't get to talk on the phone much and only see each other every 3-5 months, it's as if no time has passed at all. it's just that kind of friendship.

there are more - but these are the major people in my life. i am ridiculously lucky in the fact that all around me are people who love me and who pick me up when i fall. whenever life gets rough and i start to get down on myself about my job or my personality or whether people like me or not - i just stop and think about this list. i have so much. why would i need any more??

*this post brought to you by pre-menstrual syndrome.

Wednesday, September 17, 2008

learning the cost of declining

when i work days (as i did monday) - i generally take over care for the ICU cases that came in the previous night and help internal medicine see appointments. emergencies during the day shift are unusual. yet on monday, we received a call from a local vet saying that he was sending us a cat in respiratory distress.

said cat was 2 years old. about a month prior to her seeing me, she had developed open-mouthed breathing. the owner rushed her to the vet. he recommended chest xrays and a feline leukemia/feline AIDS test and bloodwork - all of which the owner declined. backed into a corner, he treated the cat with steroids and an antibiotic. the kitty responded well and was normal for a few weeks. but the respiratory distress came back. kitty was returned to the vet - and again, full diagnostics offered. the owner refused. kitty was treated with the same medications and sent home. 2 weeks later, the respiratory distress returned. the owner finally agreed to have xrays of the chest taken.

the news was not good. the chest was full of fluid. the vet treated the cat for possible pulmonary edema (fluid in the lungs) with a diuretic called lasix, gave a bronchodilator to help the cat breathe, and sent it to us for further diagnostics.

a chest full of fluid in a young cat is a very bad thing. there are 4 typical substances that can be in the chest: blood (hemothorax), chyle (which is fluid from the lymph system), pus (pyothorax), and transudate (proteins and cells that are normally confined to the bloodstream/tissues). pleural effusion (fluid in the chest cavity NOT the lungs) in a young cat can be caused by many things. none of these things are good. FIP (feline infectious peritonitis) was my first and foremost concern. this is a terrible and uniformly fatal disease of cats. it is a mutated strain of a fairly benign gastrointestinal virus called corona. there is no cure - and it is typically a disease of young cats. so i was worried about that. other causes include an overwhelming infection in the chest (bacterial usually), feline leukemia virus, feline AIDs virus (although less likely), an idiopathic condition where the chest fills up with chyle - but the reason is never understood, heart failure either primary (a condition of the heart) or secondary to something like heartworms (yes, cats get heartworms too!).

none of those are great things for a cat to have at the age of 2 (or any other age!).

when the kitty got to us, i could see immediately that she was having a great deal of difficulty breathing. she was using her abdominal muscles to pull air into her lungs. the xrays that came with her confirmed fluid in her lungs - but there was something else. the cranial (toward the head) part of her chest cavity looked awfully solid. less like fluid and more like a mass. this immediately worried me.

kitty was placed in the oxygen cage while i prepared everything to tap her chest. when all was ready, i removed kitty from the cage. that didn't go so well. kitty was apparently feral at some point - as the huge, painful scratch on my right wrist can attest. after some heavier drugs than i would normally employ in a cat with respiratory disease, she was calm enough for me to tap her chest and remove the fluid. i collected enough for a culture (for bacteria) and for a pathologist to look at the fluid and tell me if they saw cancer cells.

after the tap, i re-xrayed kitty and was dismayed to see that there was indeed a mass in the chest. it was located in the front of the chest (in an area called the cranial mediastinum). it's location made me very suspicious that the cat had a type of cancer called mediastinal lymphoma.

i went back to the record to see if the owner had ever consented to a feline leukemia test. sure enough, she had not. she had wanted to forego the $50 cost of the test. i asked my technician to run a snap test for me, while i looked at the slides i had made from the chest fluid. my heart sank, even though i was expecting it - when i looked at the slides. lymphocytes everywhere - moderate to large sized and not terribly mature. the slide was very consistent with lymphoma. at about that time, the tech tapped me on the shoulder and asked me, "guess what your results are?"

i looked at her evenly, "strong positive for feline leukemia?" she nodded.

feline leukemia is a well-known disease of cats that is transmitted through close social contact such as mutual grooming and sharing of food bowls. it can lie dormant in a cat for years before making appearance. typically the cats that we see are either very young or very old. the presence of leukemia has been linked to the development of lymphoma - a cancer of cats (and dogs) that i've talked about here before. dogs do great with chemotherapy and can usually expect another year to a year and a half of good quality life. cats - on the other hand - are all over the map when it comes to responding to chemotherapy. the fact that this cat already had fluid in her chest, a large mass making breathing even more difficult, and was feline leukemia positive did not bode well for her long term survival.

i discussed this with her owner, who elected to take kitty home on steroids (which shrink lymphoma and explain why kitty responded so well to the first 2 treatments at the referring vet) and bring her back for euthanasia when the time came to do so.

in the end, we spent $1100 to diagnose kitty's disease, tap her chest, and hospitalize her for the night in oxygen. if the owner had elected to have her feline leukemia tested prior to this - and vaccinated possibly - she would have spent $75. that doesn't make her a bad owner. don't misunderstand me. i understand the financial crunch all too well - despite my "lucrative" position as an intern. and in the end, this woman paid a great deal of money to understand exactly what was wrong with her pet and treat it as best as possible. so she was a concerned owner who wanted to do what was best for her cat.

but remember this story when you see your veterinarian and they recommend routine testing and vaccines. finding a problem early can save you a great deal of money in the long run. more importantly, it can prevent your animal from unnecessary suffering. i'm not advocating blind acceptance of whatever your veterinarian recommends - shots yearly, etc. be an informed pet owner. but if you're reluctant to do something preventative for financial reasons, just think of the financial burden if your pet actually comes down with the disease or condition you could have tested for and prevented for so much less.

not alone after all

i just spent an hour and a half talking to my best friend from vet school. she is doing a hardcore internship at a very well-known, very large, very challenging private emergency and referral hospital up north. from what i understand, it's a very coveted position.

we spent an hour talking about our similar frustrations. we're both terribly lonely. neither one of us has found an intern-mate with which we totally click. we're away from our families (although i'm much closer to mine than she is to hers) and the close friends that keep us sane (namely each other). she describes the same feelings of apathy about getting out and doing anything with her off days. and she's in new york city - for god's sake! it makes me feel better. i've been off for the past 2 days - and what have i done? slept a great deal. gone to the grocery store so that i'd stop eating greasy fast food. played guitar hero and mastered a couple of songs on expert level. watched 'the matrix', played on the internetm, printed out and read some articles from VIN on IMHA, DIC, lymphoma, and hemangiosarcoma.

the husband is gone for 3 days - staying with his brother and wife and teaching. so i'm here. alone. lonely. ever since he's started back teaching - he's gone either 3 days and 2 nights or 2 full days (sometimes he drives home on the off day - wednesday) - but mostly he stays in our hometown.

work has gotten better at least. so i can't totally blame my apathy and reluctance to leave the house on depression stemming from my work situation. i continue to educate myself by reading, and i'm happy with the job i'm doing. my marital situation has improved some. not vastly - but things are better.

i'm just...apathetic. that's the only word i can think to describe it.

maybe it'll pass soon and i'll be motivated again to have a life outside of the confines of my house. or maybe i'm just a homebody and i should embrace it. but i do feel like i wasted 2 beautiful days. the weather has been idyllic - blue skys, balmy 75 degree temperatures. i should have gotten out and done something.

friday night, we're heading back to the hometown to stay with jim's brother (and my best friend, his wife). we're having poker night (texas hold 'em) and then football saturday. i just hope it's not as scorching as last saturday's game. i really could do without the knee and sandal burn i acquired.

Tuesday, September 16, 2008

hot town...summer in the city...back of my neck gettin' dirt and gritty...isn't it a pity - doesn't seem to be a shadow in the city!

when the dog came to the back, i listened to her history while the tech recited it, and then asked for a temperature. rectal temperature was 104.5. not horrendous - certainly compatible with a fever. unfortunately - the overweight, female hunting dog had been out hunting that morning. she had hunted for about 3 hours in 90+ degree heat and >60% humidity. she was not in good conditioning. the owner - a nice man in his 30s - had taken her home and left her in the air conditioned house. several hours later, she refused to rise. concerned, he brought her to us.

i suspected that she'd had a heat stroke in the early afternoon, despite having a body temperature of less than 106. this often happens because owners don't recognize a heat stroke. they think the animal is tired, take it home, allow it to rest in the air conditioning, and then - often very belatedly - realize something is amiss. when the animal comes to us - the temperature has usually dropped to a "less than heat stroke" level.

so why did i think this dog was a heat stroke? history - first and foremost. a fat, out of condition hunting dog working for 3 hours in late august heat. secondly, she was passing mucoid, foul-smelling feces that looked suspiciously like the lining of her GI tract. her mentation was also obtunded. she wasn't very responsive to us or our ministrations.

while the techs placed an IV catheter and bolused her IV fluids, i went to talk with her distraught owner.

heat stroke is a terrible condition and one we see fairly commonly here due to our very hot summers. many people keep breeds that are poorly suited to our area - huskies, saint bernards, malamutes, chows...the list of heavy coated, winter breeds is endless, and we see them all. when these animals go outside to play, they can over-exert themselves easily and have a heatstroke as a result. it always comes as a shock to owners - generally because the dog has never had a problem before.

when the body temperature rises past a certain point - there are terrible consequences. body temperature is a closely regulated homeostasis. cells can only survive and function within a narrow range. the body keeps this range constant - or close to constant - at all times. when the temperature goes up past the body's ability to cool (dogs cannot sweat - except a small bit through their footpads, but they can pant) - cells start to die. the increased temperature causes cells to swell, eventually rupture and die. this leads to cerebral edema (one of the many consequences). cerebral edema = swelling of the cells in the brain = very very bad. this causes changes such as increased blood pressure, slowed heart rate, unequal pupil size, and stupor or coma due to brain damage.

this is only one of the unfortunate problems. when heat stroke occurs - blood sugar will often drop precipitiously (the mechanism is poorly understood). further, the delicate balance of blood will be upset. as i've said before - the body is always in homeostasis. small platelet clots are made at all times to plug tears in the vasculature - these are then broken down by the body. when heat stroke occurs, this balance is upset. the bloood begins to make inappropriate clots everywhere - millions of them. all of the clotting factors are consumed - and then the body has nothing left to make clots with - and the animal will bleed to death. this syndrome is called disseminated intravascular coagluation (DIC) - also known as consumptive coagulopathy. DIC is a very common consequence of heat stroke (and snakebites, and sepsis...etc).

it just gets worse. in the dog - the "shock" organ is the GI tract and by proxy - the liver. the cells lining the GI tract die and are sloughed into the gut so that the dog essentially defecates out the lining of its guts. this leads to extraordinarily bloody diarrhea and bloody vomiting.

heat stroke is a horrible thing to see.

my patient - while having a blood glucose 0f 35 (normal 80-120) and mucoid diarrhea - didn't look too bad. i told the owner we could try.

"trying" involves giving plasma transfusions (of questionable efficacy - the idea is to provide clotting factors that are found in plasma to slow/stop DIC), heavy duty fluid therapy, antibiotics (when the gut sloughs - bacteria in the GI system can cross straight into the bloodstream = VERY VERY bad --> sepsis), pain medications, supplementation with dextrose to keep the blood sugar up, and intensive nursing care. the prognosis is not great.

the owner elected for treatment, so we started. my patient received 2 liters of fluids, then was started on heavy duty fluids (at about three times her maintenance rate) as well as dextrose to maintain her blood sugar. i started a plasma transfusion immediately, and i selected my antibiotics (broad-spectrum!). i gave her an anti-emetic injection, as well as a constant infusion of another drug called Reglan to prevent her from throwing up. she received pain medication (i can't imagine that losing the lining of your guts is terribly comfortable). she was also treated for cerebral edema with mannitol (to draw fluid out of the brain cells). i sat with her for several hours - but she never became terribly responsive. when i left - she looked okay. not great, not horrible.

when i returned the next morning, she was still hanging in there. despite aggressive fluid therapy, she was not rehydrated - and so i increased her fluids even more - despite fear that i might overhydrate her. she began to look worse. her mentation was incredibly dull - she would only respond if her name was shouted accompanied with a brisk clap. at around noon, she suddenly sat up and spewed out a liter of blood (the lining of her stomach). she also began to pass incredibly hemorrhagic diarrhea. during all of this - she made a low, pitiful moaning sound.

i looked at her and knew that i couldn't fix the damage done to her. she had all of the factors that have been associated with a negative outcome for heat strokes (>90 minutes between stroke and presentation to a clinic, DIC, and hypoglycemia). she wasn't getting better...she was getting worse.

and that's where the question always arises. when do you stop? when do you know that your patient isn't going to get better? the truest answer is that you don't. there is no way to know. you have to make the best decision you can based on the information you have. it's unfortunate - because i'm sure that sometimes i euthanize animals that might have pulled through eventually. i'll never know i suppose.

the owner came in to talk to me, and i explained the dog's dire condition. he was visibly distraught - but insisted that he didn't want to be present when we euthanized her. in the end, alll i could do was assure him that someone would be petting her and telling her she was a good dog...and that she wouldn't hurt anymore.

no news is good news...

my schedule this week was exceedingly strange. i've been off for 6 days (during which i went home with my husband - spent 2 days with my best friend and brother-in-law and went to a scorching hot but fun home football game) - then i worked 2 days (today, yesterday)...and now i'm off again for 6 days. this is obviously not the norm. usually i work 7-8 days, have 3-6 days off, then work again. i kinda dug it. 2 days on 6 off. who can complain?

sunday was an actually slow day. sundays are usually unbridled chaos but yesterday came in small, manageable bursts. nothing that we couldn't handle. today was a typical monday (i worked the 12p-12a shift). slow during the day - i helped with internal medicine cases and busier at night.

i saw a very interesting case of a 2 year old kitty with fluid in her chest. i'll blog more about that later (case is still open, at the moment).

not much else is occurring in my life that would garner much interest. i got to see my parents and my brothers and niece for a bit on friday night. this involved my mother slaughtering the fatted calf (and fatted rotisserie chicken, too). we all had a nice dinner. it was very relaxing to go home. i wish i could have stayed longer. i might go this week sometime - but there's another home game on saturday which we are definitely attending (our biggest rival) the likelihood that i'll go home is slim.

i continue to pursue excellence in guitar hero. i can now finish a single song on expert level (the killers: when you were young). i've watched a few movies here and there. i re-watched the original batman with michael keaton. it's tim burton - which i love. the movie't love so much. certainly not as much as batman begins or the dark knight. i do have to acknowledge that it's a classic, no matter how bad.

i've been trying to read. i'm feeling very motivated, so i've picked up ayn rand's 'atlas shrugged' - i loved 'the fountainhead' - and i've heard atlas is we'll see. i'm also sort of reading gone with the wind again (a personal favorite).

at work: i'm finding an equilibrium of sorts. my perfectionist tendencies have not waned. i've had extremely positive feedback from my mentors - encouragement to do a residency (hazy on that decision). i think my working relationships are improving. all in all - i'm just less...self-conscious about everything. happier, dare we say? to sleep. i have to get up and go talk to a client tomorrow despite being off work.

Wednesday, September 10, 2008

crashing and burning

this was not a successful week for my patients - despite intensive management of them. sometimes nature wins, no matter how much we as doctors struggle against it.

i had 3 heartbreaking cases that i poured myself into - all were euthanized. a heat stroke, an IMHA (immune-mediated hemolytic anemia), and a dog with aspiration pneumonia that developed during a routine dental.

i guess i'll start with my IMHA.

julius was an older cocker spaniel that came in through the emergency service. he presented to his vet collapsed with white mucus membranes. the vet took one look at the signalment (cocker spaniel) and chief complaint (anemia/collapse) and sent him straight to us without conducting any bloodwork. he knew on presentation that in all likelihood we were dealing with primary IMHA.

IMHA is a disease in which the body decides to destroy the red blood cells. it can occur by itself or concurrently with ITP (immune-mediated thrombocytopenia). this is when the body also destroys platelets - which are crucial for clotting. the two together are called Evan's syndrome.

when IMHA happens, the body's immune system coats red blood cells with antibodies, leading to their removal from circulation. this can happen via the normal pathway of red blood cell destruction (in the spleen) which leads to extravascular hemolysis. or it can happen inside the veins (intravascular hemolysis). intravascular is usually considered worse. IMHA is fairly common in cocker spaniels. in primary IMHA, the underlying cause is never determined and is likely a genetic predisposition. in secondary IMHA, there is a known underlying cause like drugs (sulfa drugs can cause this), cancer, or tick-borne diseases like Lyme disease or Rocky Mountain spotted fever. in cockers, it's usually primary IMHA. but you always look for the other diseases - just to be sure.

treatment for this disease is to suppress the immune system. recent research suggests that the best outcome is achieved by using a combination of steroids (prednisone orally), azathioprine (a purine antagonist that interferes with DNA/RNA synthesis), and low-dose aspirin (at low doses, aspirin is not an anti-inflammatory/pain drug but inhibits platelet aggregation and prevents clots from forming). with the exception of the aspirin, neither of the other treatments are exactly benign. steroids come with a host of negative side effects, and azathioprine can cause pancreatitis and occasionally acute liver failure.

when i saw julius, i ran bloodwork - which looked surprisingly good. his PCV (packed cell volume) - a measure of what percent of his blood is actually cells - was 15% (normal in dogs 35-45%). 15% is the borderline for transfusing or not. when i put his blood on a slide, it instantly agglutinated. this isn't the same as clotting. agglutination is where all the red blood cells stick together - which REALLY - isn't what clotting is (i know it sounds the same). the red blood cells are sticking together because of all the antibodies on their surfaces, as opposed to platelets and clotting factors forming clots. see the picture for the difference. at any rate, he was obviously an IMHA. but was he primary or secondary to something else? given his older age, i was worried about cancer.

we did the IMHA "special" - tick titers, thorax and abdominal xrays, as well as full panel bloodwork. i was pleased to find that his liver, kidney, and other values were all within normal ranges.

we held off on the transfusion with strict orders to have his PCV checked every 4 hours, and if it dropped below 15% to transfuse. when i left him for the night, julius was wagging his stump of a tail, eating like crazy, and giving kisses to anyone who would tolerate him. he was a truly sweet cocker spaniel (a rarity).

i arrived the next morning to find julius still eating and chipper, but his PCV had dropped to 11%. we transfused him and he seemed to do well for a while. on the second day, he developed purulent nasal discharge and a high fever indicative of a respiratory infection like canine influenza. it was very strange and a very uncommon occurrence with IMHA.

and then on day 3, he started to turn yellow and i knew things were not going in our favor. i expected this. the drugs we started him on usually take a minimum of 2-3 days to work (sometimes up to a week) - so i knew he would get worse before he got better. it was no surprise. why yellow, perhaps you're wondering? when red blood cells are broken down, they release a substance called bilirubin as part of their metabolism. this is usually cleaned up and handled by the liver. however, in IMHA - the liver becomes overwhelmed and cannot keep up so that bilirubin builds up in the blood. it's a pigment - and it's color is....drumroll...yes, you guessed it...yellow. you can see the color in the sclera of the eye, the gums, and the skin (if it's bad enough). julius was turning highlighter yellow.

i rechecked his bilirubin and to my dismay found it to be 21.5 (normal 0.1-0.9). what did that mean to me? that julius was hemolyzing (destroying) his transfusion rapidly. i rechecked his PCV - and it was 13% (it had come up to 20% after the transfusion). on top of that, julius had started vomiting and having diarrhea, as well as abdominal pain. i was worried - because azathioprine has the side effect of causing pancreatitis (inflammation of the pancreas)- a debilitating and sometimes fatal in its own right disease. i checked his amylase and lipase - 2 questionable markers of pancreatitis. both were through the roof. i conducted a snap test for pancreatitis and it was positive (but that test has a HOST of its own problems). my clinicial suspicion was mostly based on the severe abdominal pain he demonstrated when i palpated his abdomen.

i also noted at the time that his ALT (a liver value that marks acute damage) had gone off the charts. not a good sign at all...indicating possible impending liver failure.

i stopped his azathioprine and switched him to a 2nd line immunosuppressive - cyclosporine.

he continued to decline. he went from eating and wagging his stump to laterally recumbent and barely responsive. his mother was crushed, and so was i. here, after 3 days of intensive care, he went from looking great to looking like he was dying. he just got worse and worse.

stumped at the rapid progression of his other GI diseases - i took him to ultrasound and was stunned to find his abdomen full of blood. not only was he hemolyzing his blood - he was bleeding into his abdomen. i rechecked his platelet count - which was low - but not Evan's syndrome low. it didn't explain the bleeding. acute pancreatitis didn't explain the bleeding either.

i was left full of questions with no answers. julius meanwhile was in a stupor. his mother - crying quietly - told me that she wanted to stop. i agreed that it was time, that i thought we'd lost the battle. julius went quietly, without a struggle.

in the end, i was left with more questions than answers. julius had IMHA, yes...but why did julius go into acute liver failure? was the pancreatitis really 2ndry to the azathioprine? why did he bleed into his abdomen? was there something i could have done differently? did he have cancer somewhere?

the only question to which i have an answer is did i do the best i could and did i give julius gold standard care? i can answer those both with a resounding yes. still, it hurt to tell his mother that there was nothing more that i could do for him. it hurt to give up, even though i knew it was time.

Tuesday, September 9, 2008

the residency question rears its ugly head

and here we are again - same place i was last year - albeit now an intern rather than a fourth year vet student.

to do a residency or to forego the residency?

there are many, many reasons to do one. there are many, many reasons not to do one.

reasons for:
1) i want to go 110% with my education. i want the extra letters and recognition of specializing.
2) i'm smart enough to do it and do it well (sorry, but it's true).
3) i want to be a specialist.
4) i love academia (sick as that sounds).
5) i'll be in demand (as an emergency specialist (criticalist) or an internal medicine specialist).
6) i want to do it.

reasons against:
1) i'm almost 30. i would like to have children eventually.
2) there is more to life than veterinary medicine (like seeing my siblings and parents and in-laws
3) it's 3 more years of hard, hard work (long days, long nights...)
4) i'm afraid that i'll become consumed by my job and that's never where i saw myself heading.
5) i take everything really hard a specialist - i can only see it getting worse.

any thoughts?

Monday, September 8, 2008

so much to talk uninspired to write

i've seen so many cases in the past week - fascinating stuff - but i'm soooooo....soooooo......
apathetic about writing.

on the bright side, this is the 1st sunday i've worked and NOT left hating my job and myself -
despite the fact that before leaving today, i euthanized 2 patients on which i'd exhausted my mental and physical and emotional resources (a heat stroke and an immune-mediated hemolytic anemia).

soo...where to start, where to start????

my first day back (labor day), i arrived at 8am to patients already awaiting. the first was a 10 year old golden retriever with a recent history of coughing up blood (never ever ever a good sign). the other was a 6 year old cat down in the rear limbs.

i took the golden retriever first. the owners reported that he had been coughing up spots of blood for about 2 weeks and had a fever. he saw his regular veterinarian who suspected that he had possible tick-borne disease. the xrays showed "spots" on the lungs of uncertain origin. when i examined the dog i noticed he was limping in the rear limbs. i questioned the owners about the limp and they noted that it had been ongoing for a while. i carefully palpated the area (the rear knee) and was dismayed to find a large, firm mass. i couldn't tell if it was bony - but it was very large. i discussed with them my concern that we were dealing with cancer that had metastasized to the lungs and recommended xrays of the leg and chest. the owners agreed. as i shipped that dog off to the techs, my down in the rear kitty came to the back.

off the golden went for his diagnostics while i turned to the kitty. kitty was 6 years old, previously healthy. the owner had found him down in the rear legs, dragging himself and crying. as i did my physical exam - several things stuck out immediately. kitty's rear legs were cool, the muscles firm. i exposed the nailbeds and noted that they were not pink and healthy but rather blue-ish. i could not feel femoral pulses. the clincher was when i placed my stethoscope on kitty's chest and heard a massive heart murmur. bad news for kitty. (heart murmur + down in the rear limbs = hypertrophic cardiomyopathy and a clot that lodged at the split of the aorta in the rear legs).

at about this time, my xrays were finished. the leg had incredible soft tissue swelling but no destruction of the bone. my suspicion of a soft tissue mass (sarcoma of some sort) went up. and then i looked at the lungs. nodules everywhere. whatever cancer was in the rear leg had gone to the chest and had turned the dog's lungs into swiss cheese.

here i was - fresh back from a week off with 2 cases immediately that had a less than 10% chance of living for much longer than a few weeks - at most.

armed with bad news for everyone, i double-teamed the rooms - delivering my grim reaperish news. both elected to euthanize to prevent further suffering.

as i walked back to ICU with a frown on my face and tears in my eyes, one of the techs placed her hand on my shoulder and said, "welcome back doctor."