Sunday, October 26, 2008

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:

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...

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