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.

first day back

and boy was it a doozy.

when i'm on days my responsibilities generally center around being an ICU doctor/criticalist. i take over all of the ICU cases from the previous evening. i do a physical exam on each patient and write new orders for the day - medications, monitoring instructions, further diagnostics, feeding/walking instructions, etc. i also have to put daily exam notes in the computers detailing my physical exam findings, my assessment of the patient, and the plan for the day. further, i have to contact owners, write discharge instructions for those leaving the hospital, contact referring vets about their patients that are with us, and spend oodles of time on VIN (veterinary internet) looking up diagnostic options, treatment recommendations, and drug doses on the cases i am overseeing. on top of that, i am technically the internal medicine bitch - meaning that i help with internal medicine cases (which i really do enjoy doing - when i have the time).

i am the only ICU doc for the day. the nice thing is that often maybe 1/4-1/2 of the patients will transfer to the care of the internal medicine service. on a typical monday, i'll probably have 5-7 patients under my direct care.

depending on the weekend - monday can either be a relaxed(ish) day or a day from hell. i've had as few as 2 patients in my care. today was the latter, unfortunately. when i walked in there were approximately 20 cages occupied. of those - only ONE was due to transfer over to the care of the internist. unfortunately, as i was discussing the case with the overnight clinician in front of the cage, the dog died. resuscitation efforts were unsuccessful.

the rest of the 19 cages were my patients. from the moment i breached the threshold of the door at 8am till well after 1pm, i was bombarded with questions about every patient present, owners calling for updates and discharge times, questions from the pharmacy, reports that my previously stable patient was now vomiting, bloodwork results...blah blah blah...

still - by 1pm, i had examined all of my patients, written treatment orders, and started my paperwork.

it was busy, but the day flew by. i like days in the ICU - it helps me hone my skills in case management. nights and weekends are fun, challenging, stressful, depressing, and everything in between - but one thing they are short on is the long(ish) term management of cases. i'm learning to triage like a madwoman. i'm learning to really figure out who is critical and who can wait for further diagnostics the following day (at the cheaper regular vet). i'm starting to trust the clinical judgement i am developing. the only thing i don't learn on strictly emergency duty is how to manage and monitor long term cases. that's why days are such an important part of this experience. i can manage cases while bouncing my ideas off the internal medicine specialist on duty with me.

in other, somewhat related news: i received a fairly firm offer from the hospital administrator/head doctor today for a job next year. as in this conversation: "you know what i said the other day about working with us next year? i really meant it. it's something you should be thinking about. the money is good, it would help you pay off your loans. we would really like to have you here with us."

food for further thought. but i am lonely here. i don't know how a nearly 30 year old person who works insanely long and erratic hours makes friends. my hobbies (reading, writing) are mostly solitary. i want to branch out and meet people, but i don't know how. and i miss my best friends terribly (2 in our hometown, 2 in florida, 2 up north - NYC and jersey). i miss my family too. **Sigh**

money...it's a gas...grab that cash with both hands...

i guess that first line should really be money! it's FOR gas. that will be the extent of my commentary on the current gas prices. i watched the VP debate with the husband and my intern-mate of like-minded political persuasion. if i could be said to have a political persuasion. and that will be the extent of my commentary on the political landscape. i might abstain from voting this year (taking stick, stirring family pot).

i worked from 8am-5:30 on friday and 10am-4:30 on saturday at one of the local clinics. i made $630 for that work. it was the easiest work i have done since graduating. allergies (flea, food, seasonal) and vaccines. ok, it wasn't all that...i did have an 11 year old boxer with ginormous lymph nodes (probable lymphoma, waiting on diagnostics), a 17 year old kitty with a ginormous mass in the area of the thryoid and a heart murmur (hello thyroid carcinoma), and an ACTUAL emergency show up on saturday (cat in respiratory distress with likely pulmonary metastases - although not sure where the primary cancer was located). i figured euthanasia would be a rare(r) occurrence in GP work, but i did 3 in 2 days. a bit surprising. all in all - a different experience (save the euthanasias, which were rather similar). the technicians were different - very, very helpful, very respectful, and i didn't feel like a stupid intern - which was nice (and a new feeling).
and i have almost $650 lining my pocket. ok, not lining my pocket, but lining our bank account momentarily until we apply it to the credit card. i'm really excited because we'll have the credit card paid off early (this month) - and then we can start saving for a house.

our current financial plan is to have 2 funds - one for general savings and one for a house. the really nice thing about our marriage is that we live fairly simply. i've said it before, and i'll say it again: we don't own expensive stuff we can't afford (cars, etc), we don't take pricey vacations, and other than frequent eating out, we do pretty well with money. now that i'm the primary breadwinner (i can't believe that is finally the case!) - and we both have an income, things are looking much better. i try not to think about the massive debt i accumulated to get my DVM (and jim his phD). there was no other way. and once we take care of this small credit card debt ($600 left to go - $400 of which i will make in 10 days working another 8 hours at a different day practice) - our only debt will be school loans. woohoo.

now for the real discussion-- school debt. making plans, i realize - is fairly useless. something always interferes with your plans. and maybe i'm just being incredibly naive in thinking that we can keep our cost of living low -BUT...i think that if i want to stay in my current position post internship (and that's a BIG if), i can (i was told this by the hospital administrator a couple of days ago). i would probably make around $80k starting out. if we were to stay here, with the low cost of living and our fairly minimal needs - AND not start having kids until i was about 33-34, then we could maybe pay the loans off in 3.5 years. those are all huge IFs, i realize - and i doubt that all of them will be realized. but my discipline with money has improved immensely - the more i realize how important it is, the more i realize how being in debt adds enormous stress to your life and the lives of others ... the more committed i become to getting rid of those debts.

on the other hand, i don't want to delay having a life in the interest of paying off debt. i want to have children. i want to have a house. i want to move forward with an adult life.

so...my conclusions? i have none. but i'm optimistic.

the choices we make will haunt us...

i was sitting at the receptionists' desk, doing paperwork, while the receptionist talked on the phone to a distraught owner. i could hear her voice - though not the words - clearly through the receiver. the receptionist, obviously disturbed, covered the mouthpiece with her hand and gestured to me.
"this woman says that while she was at work, her boyfriend smacked the cat, and now it's nose won't stop bleeding. it's been bleeding for an hour." i suppressed the gag reflex about to overwhelm me, and i suggested that she bring the cat in for an exam.

an hour later, i had mostly forgotten about that phone call. regrettably, we get many such phone calls, and we never see the animals. lo and behold, a couple hours later, a technician walked past me to the back. she was carrying a wicker basket. curled in it was a soft, light grey tabby cat - maybe 9 months old.

i followed her, because it was obviously a "tech to the front" (code for get your ass up here now, we've got a real emergency). removing the kitty from the basket, i felt sick. he was stuporous, barely responsive to my touch. both pupils were tiny (miotic) - what we call "snake pupil" in the vet world. the 3rd eyelids were raised partially over both eyes. blood was caked underneath both nostrils. i gently palpated the skull, and to my relief, i couldn't find any obvious fractures.

the cat had obviously suffered massive head trauma of some sort. i realized that this was the kitty that had been called about earlier when the tech recited the history to me. as i looked at this cat, at what a human had done to it in a rage, i felt my heart break a little bit.

the owners were put in an exam room, waiting to see me. i paced back and forth for a while, as the techs placed the kitty in an oxygen chamber (oxygen is extremely important in head trauma patients) on a soft bed. when i felt calm enough, i went into the room. i was confronted with a young couple - a girl in her early 20s, sobbing quietly, and her boyfriend - a very tall, imposing figure. to my surprise (and confusion), he was crying, too. later, as i discussed these events with several colleagues and technicians, i came to understand that abusive people - whether towards animals or people - are typically very remorseful of what they did. having never been in a relationship or even known anyone abusive - physically, verbally, or otherwise - i had no experience with this - and was thus surprised to see the pentinent boyfriend shedding real tears.

as the story went, the cat had been on the couch. the boyfriend was annoyed by something it did and he "lightly" smacked the cat. he fell to the (carpeted) floor, a few feet at most, and that was how the damage had been done. now, i wasn't there. and i'm not a judge or a jury or omnipresent. i have no way of knowing if what he told me was true. i just know that the cat i had just examined had suffered massive head trauma. more massive than thwacking his head on a carpeted floor should have inflicted.

i discussed his grave condition with the owners, his poor prognosis given the likely seriousness of his head trauma, and the cost of hospitalizing him for the night. the owners had no money. the girlfriend sobbed and cried and begged me to think of some way to help her kitty. i felt even sicker. in the end, the girl surrendered the cat to me - signed it over. i was relieved. the cat was being removed from what was - in all likelihood - an abusive, dangerous situation. still, i felt terrible for the girl. it was her cat - and her boyfriend had done this to it while she was away at work.

they visited the kitty one more time, and then they left him in my care. one of the technicians - being soft-hearted - as most of us in the vet world tend to be - offered to use her "pet bucks" to pay for his care - if i thought he had a chance. i was skeptical, but i recommended that we give him at least 24 hours to see if he responded to medical treatment of head trauma (oxygen, mannitol, pain control, etc).

a few hours later, the receptionist found me and told me that cat's owner (the girl) was on the phone, that she had found money, and that she wanted to know if she could have the kitty back. i was stuck. on the one hand, the cat had obviously been hurt badly by the girl's boyfriend. on the the other hand, i couldn't imagine if someone i loved hurt one of my animals and then i had to give that animal up because i couldn't afford $600-800 to treat it. i felt sick having to make this decision. keep the cat? give him back to his obviously loving owner (not counting the boyfriend)?

in the end, i returned the cat to its owner - rationalizing that due to its head trauma, it probably only had a few days left of life anyway. they came and picked up the cat so that they could transfer it to a (cheaper) nearby clinic. i called the doctor a few days later to check on what had happened to kitty. to my surprise, kitty recovered - albeit not completely, he still stumbled when walking - in a few days and went home.

i can only hope that i made the right decision in the end. the hardest part is that i will never know.

i'm baaaaaaaaaaaaaaaack!

so, in the interest in paying off the small credit card debt that we have from moving - i'm working at a day clinic tomorrow and saturday and then again on october 14. i'm getting paid $50 an hour. i'm looking forward to it, because it'll be a totally new experience for me. stressful - i'm sure - but in a totally different way than emergency medicine.

i have to bone up on dermatology tonight because 1) i rarely see much derm in the ER line of work and 2) i freakin' hate dermatology and could care less about mange, fleas, and pyoderma. unfortunately, dermatology accounts for a large percentage of general practice. that and dentistry. bleh. two things i hate more than anything else in this world.

i saw some interesting cases this week, as well as some downright depressing ones...i guess i'll post a selection here shortly. right now, i need to hit the bank, clean my house, and make a chicken pot pie for dinner.

*as a weird sidenote: there was a head technician meeting at work yesterday while i was there for journal club rounds. afterwards, the hospital administrator/criticalist came up to me and told me that i am the technicians favorite intern to work with. WTF? one of the technicians told me the same thing after the meeting. how's that for news of the weird?