Mistake

I've thought about whether I wanted to post this or not for a few days. In the interest of representing what it is truly like to be an animal doctor, I think I would be heavily remiss in not sharing one of the the hardest parts of being a veterinarian (or any sort of doctor).

I made a mistake.

It's arguable whether or not it cost my patient her life.

On Sunday morning, a nice woman brought in her Golden Retriever. She had been hit by a car. Her respirations were rapid and shallow. I suspected a pneumothorax. Her gum color was not good, and her blood pressure wouldn't read.

We started stabilization: IV fluids, pain medication, and a chest tap. I removed over 3 liters of free air from her chest. At that point, I made the decision to put in a chest tube. She responded rapidly to this treatment. I discussed her condition with the owner, she left a hefty deposit and left her dog in my care.

Over the course of the day, we were slammed. I didn't eat, drink, or use the bathroom until 4:30 that afternoon. I was rushing around managing the patients pouring through the front door, as well as the 11 hospitalized patients in the back. See, we'd been open since Christmas Eve. I'd worked 14 hours on Friday, 14 hours on Saturday, and (as it turned out) 14 hours on Sunday. Further, I'd been sleeping terribly (Friday and Saturday night, I got a cumulative 6 hours of sleep). I was tired, emotional, and overwhelmed. I wasn't on my A game, or I can assure you, this never would have happened.

At any rate, over the course of the day, my patient's breathing became more and more shallow (despite the chest tube evacuating the air in her chest). Her gum color wasn't good (pale pink), and her blood pressure dropped repeatedly despite fluids.

ANY OTHER time - ANY OTHER day - I would have immediately suspected internal bleeding. The dog practically had a flashing neon light the size of a Mack truck above her head screaming HEMOABDOMEN HEMOABDOMEN HEMOABDOMEN!!!! It actually occurred to me that I should wheel the ultrasound over and check, but then something always intervened - another dying animal through the door, or something in the hospital needing my attention RIGHT THAT SECOND. I never did put the u/s on her.

As I transferred her over to the doctor on shift after me, my technician turned and said, "her blood pressure is 39 (normal systolic BP should be around 100!)." After I left, my colleague checked her belly, and sure enough: horrible internal hemorrhaging.

Surgery revealed a liver that was in multiple pieces and more than 3 liters of blood in the abdomen. My patient arrested under anesthesia.

My colleague has tried to make me feel better by telling me it wouldn't mattered had I caught it early or not, the liver was shattered. Somehow, that doesn't help. You see - somewhere in the back of my mind, I KNEW that my patient had internal bleeding, and I didn't look for it.

Why? Perhaps because I was exhausted and couldn't deal with the idea of an intensive surgery. Perhaps because I'd annoyed the techs enough that day and just couldn't stand seeing them roll their eyes when I asked that the ultrasound be wheeled over to the cage. Perhaps because my last hit by car hemoabdomen died on the table.

I'll never know the answer. I only know that I missed something that was blatantly obvious and now my patient is dead.

Christmas Eve dinner

Since I have to work tomorrow, we had Christmas early with my family (Tuesday) and Jim's family (Monday). Both were lovely, lovely days. Other than getting stranded on the interstate during the snowstorm on Friday night and having to shack up in a scary Days Inn in the wilderness of North Carolina, my break away from work was lovely.

I worked last night and have tonight off. I start days tomorrow (Fri/Sat/Sun). Jim's sister is also working tomorrow, so we had them over for dinner. It was my first real holiday meal for other people. In the past, we've always been somewhere for these types of dinners, so it was delightful for me to be able to prepare a holiday feast (how much do I love my amply sized kitchen??).


It was fairly traditional: honey glazed ham, garlic mashed potatoes, green bean casserole, corn, and yeast rolls. I made a fresh, homemade apple pie, too - using my mother in law's recipe. It was delightful. I am full and fat and happy...but I must away to bed. Work in the morning! (PS: I love having a job I look forward to going to!)

Here's a Christmas gift (begrudgingly given)

At 3am, the phone rang. A woman described her female dog's behavior: panting excessively, rigid, unable to stand, and frantic. The dog had bitten her tongue and was bleeding because she was shaking so hard. She'd given to birth to puppies 2 weeks previously. My technician explained eclampsia (low blood calcium - which is not exactly the same as eclampsia in human women, and thus, is rather confusing). At any rate, he explained that the mother dog was suffering from low blood calcium in all likelihood and should be seen. He carefully explained the cost of being seen at our clinic - $88 for the initial exam by me, followed by additional costs for diagnostics and treatment. The woman called twice, asking for other ways to treat the dog (which there are none, treatment needs to be IV calcium).

Sure enough, at 5am, they show up. They have "$20." At least, that's what they tell me at first.

I was mad. The dog was severely hyperthermic (temperature 105), laterally recumbent, with such tremoring that she couldn't even lift her head. She needed an IV catheter, IV calcium, and fluids to bring down her body temperature immediately. The owners, of course, had NO financial recourse. They didn't qualify for Care Credit (both were on disability - don't EVEN get me started there, both looked to be perfectly healthy and mobile), they didn't have a single relative that would loan them money, supposedly had no credit cards. In short, they couldn't procure even the $88 required to see me.

I was seething. I have an extremely hard time believing that they couldn't come up with EIGHTY EIGHT DOLLARS SOMEWHERE. ANYWHERE.

In the end, I treated the dog anyway. Eclampsia is extremely easy to treat in dogs. IV calcium over 20-30 minutes, some fluids for the hyperthermia, and they're usually right-as-rain. She recovered just fine, and I sent her out the door.

Her owners signed a payment agreement for the $234 they owe us. They swore they would pay us. And - mysteriously - when they got to the counter, it turned out they only had $10. How strange.

I'm not holding my breath. I'm just counting it as a Christmas good deed, even if I wasn't happy about doing it. They'll screw us, and I know it. It pisses me off, because these people - on disability - expect everything to be given to them for free. I gave in and did it, of course. Mainly because the condition is SO very easy to fix. I just couldn't put the dog down 2 days before Christmas for a problem I could fix easily in 30 minutes.

Yeah, I'm a sucker.

In memoriam

This time of year is a hard one for my family. I'm overly emotional all the time. Yesterday, at the mall, I was looking at the wishes hung on the Angel Tree and started crying. Once, I loved Christmas. Now it's a time of year during which I cry at the drop of a hat. I miss my family and wish we could be together. In 3 days, it will be the 4th anniversary. We still miss you little man.

Holy sick animals Batman!

Last night was nuts. It was a Tuesday night, and we were slammed again. We had 7 patients in the hospital this morning. For a small ER practice with 1 overnight technician and 1 overnight doctor, that's quite a bit of patients. We had 2 extremely emergent patients at once - a Labrador in terrible respiratory distress bordering on ventilatory exhaustion and a mystery case - a young (3 year old) Border collie with severe muscle tremoring. I was running between 2 sets of distraught owners and 2 critical animals. It kept me on my toes.

More to come on the mystery case.

Sunday bloody Sunday

Yesterday was (to use a very crude but very apt phrase) balls to the wall CRAZY. It reminded me of my internship. I think we did greater than $11,000 in business in 15 hours or so.

I saw (in no particular order): a severe diabetic ketoacidotic beagle (weighing in at 50#, should have weighed 25#), a cat with upper respiratory stridor and a possible polyp, a labrador retriever that ate a bag containing a bottle of acepromazine, a bottle of ibuprofen, and a bag of coffee grounds, 3 big dog / little dog attacks, a hemorrhagic gastroenteritis, a febrile, anorexic cat...and the list goes on and on.

It was busy, it was frantic, but the staff handled it well, we kept things moving, no one waited for an excessive length of time, and overall, I think we did a great job. Inpatient care suffered, but this - unfortunately - is the nature of vet ER medicine.

I didn't leave until 10:30 (my shift ended at 6pm), but it was different from my internship. I didn't get home and lie in bed, depressed and moody. Even my husband commented, in an amazed tone of voice, that I didn't have one complaint about the day. And really...I didn't.

Much better

The car situation is worked out, for the most part. We were able to sell it in about 2 hours on Craigslist. We got $1500 for it. Thanks to the generosity of a close family member, we are able to pay off the car in full and start back where we were 3 months ago - car-less. It's ok, though. The husband is working at home on his PhD dissertation anyway, and he doesn't need a car to get around.

It's the end of my 9 day stint away from work, so I'm diving back into the fray tonight. There will be more interesting stories to come, I'm sure. At some point, I'll have to talk about last Sunday and the ordeal...but not just yet.

Going through

a bit of a very rough patch here. The last weekend at work was very hard. It culminated in an exhausting (mentally, physically, and emotionally) surgical ordeal. I was thoroughly looking forward to the 9 days away from work, relaxing, spending time with my family, and recharging. Yesterday, at my uncle's cabin in the woods, we weathered a terrible windstorm. My husband's car - which we have owned for 3 months, have not paid off fully, and on which we do not carry comprehensive insurance - was crushed by a tree. It's the first car we've ever NOT bought in cash, it's the nicest car he's ever had, and it was a good deal through a friend. Now, we owe $5500 on a car that is totaled. I've been reminded to put this in perspective, but at the moment, as we're struggling to get started with savings and with my student loans coming due next month, this couldn't come at a worse, more stressful time. I am grateful no one was hurt, and my uncle's house made it through the storm unscathed, but I feel sick to my stomach all the same.

Look people, I don't care WHAT you do in your spare time...

I was sleeping quite soundly at work the other night. We've been DEAD DEAD DEAD. Dead as in NO patients in the hospital, for the last few nights, so I've been able to sleep. At 6:30am, a knock came on the door as my technician alerted me that we had a patient.

Said patient was a 2 year old dachshund. The owner thought she was having back trouble - which is a common condition in long-backed dogs.

When I first saw her, a back condition was not my biggest concern. She was exhibiting multi-focal neurological signs. This means that she had signs that pointed to different areas of the nervous system. She was ataxic (swaying when she walked), disoriented, knuckling in all 4 feet, her head was tremoring/bobbing, and she had very dilated pupils. Her temperature was 103.8.

I went to talk with her owner, a young, tattoed guy. I asked the standard questions: onset of signs, first thing you noticed, appetite, urination, defecation, other pets in the house, anything she could have gotten into, any medications in the house? His history didn't give me any clues, so back I went to stare at my patient. She looked very very sick. I pondered diffentials for multi-focal neuro disease - encephalitis? necrotizing meningoencephalitis? granulomatous meningoencephalitis? As I pondered, I idly repeated my physical exam to see if I'd missed anything. When I rolled up her eyelid, I was AMAZED at how red both of her eyes were...red like a person who had just smoked a big fat joint...

Back I went to the owner. "Do you or your wife smoke pot?" I asked in an innocent voice. The guy looked at me, smiled sheepishly, and gave me a thumbs up.

The urine drug test was positive for THC. Only after that did the owner tell me that his wife found a bud on the floor...

A bolus of fluids later, a heavy sedative, and our patient was rolling over on her back with all four legs in the air, finally able to relax. We were tempted to prop a bag of Doritos up next to her to complete the picture, but we didn't (this time).

Look folks, I don't care in the slightest if you smoke pot. A great majority of the world does. If you smoke pot, and your dog starts acting "oddly" at 6:30 in the morning, and you bring her to the ER - just save me the time, hysterics, and your money when I'm running bloodwork, and TELL ME. That way, I can give your dog a bag of Doritos and call it a night instead of going into mental hysterics over encephalitis.

Thanks!

What I did...

This is the final installment in my case study (see posts below).

In the end, I rehydrated the patient for 6 hours. He continued to be lethargic and depressed. I made the decision to go to surgery and see what we were facing.

When I opened him up, I found a massive liver tumor, as I suspected. It had not yet ruptured (as evidenced by the lack of fluid in the abdomen on ultrasound), but it was only days away from doing so. There were enormous pockets of necrosis and abscessation. As I was slowly and meticulously dissecting it away from the diaphragm (it had formed adhesions to the body wall and the diaphragm), I punctured the mass, and blood poured into the abdomen. I clamped it off and gave it time to clot, then continued working. During the surgery, my patient's blood pressure fell and fell and fell till it was in the basement. He received crystalloid boluses (NormR) followed by Hetastarch (colloid), and then a whole blood transfusion when his PCV was 14%. He also received dopamine intra-operatively to help keep his BP up.

An hour and 15 minutes later, the whole left side of the liver was out. The tumor enveloped all the lobes on the left side, and I had to remove it all. Everything else looked good, so I checked for bleeding, found none, lavaged the abdomen, and closed him up. There was no evidence of metastasis anywhere. Even the spleen looked happy.

We are 48 hours out from surgery, and he is slowly recovering. His kidney values are falling, but not as much as I would like. He is still nauseated and isn't able to eat. He is - however - able to move around his cage and go outside. His PCV is holding at around 24%.

The tumor will be sent for histopathology. In all likelihood, it will be read as a hepatocellular carcinoma - the most common malignant hepatic tumor of dogs. These are slow growing tumors that rarely metastasize and have a GREAT prognosis if not diffuse or metastatic (as this dog's wasn't). Prognosis is 4 years, and usually, the patient dies of something else unrelated to the cancer.

I am left with more questions than answers. I will never know if I did the right thing by going to immediate surgery. Should I have waited, fully rehydrated him, seen if he would stabilize more then taken him to surgery? Surgery was absolutely indicated for this little guy, otherwise, the tumor would have ruptured at some point in the near future causing a hemoabdomen. I know that. I just don't know if it should have been done that night, or if I should have treated his renal dysfunction for a week or more, than taken the tumor out.

Any thoughts?

It's that time of year.

In 2 ER shifts (roughly 24h total), I euthanized 10 animals - everything from the laterally recumbent, anemic, hypothermic, flea covered 2 month old kitten drop-off to the 14 year old, dearly loved family dog that is acutely down in the rear. I'm feeling kind of numb right now and very bummed. It's funny how that kind of stress manifests itself after the fact. I wasn't crying or upset during any of the euthanasias, but here I am...sitting here, questioning everything I do, and feeling very insecure about myself.

Time to make cheesecake.

The complexities and conundrums of medicine...

So, a little case study for my pre-vet, veterinary student, and vet readers:

My technician brings in her 12 year old, 4 kilogram, male castrated Yorkie. Two days ago, he was normal, bright, and healthy. At that time, he became slightly lethargic. It progressed to vomiting and severe depression. He has no known history of medical problems (she has owned him for 2 years, and he was a rescue), does not receive any medications other than cyclosporine (Optimmune) for his dry eye (keratoconjunctivitis sicca/KCS). He is an indoor dog, up to date on his vaccines except for leptospirosis, and he didn't ingest anything he shouldn't have. He goes outside on walks with the owner and her daughter and sometimes plays in a dirty, algae-filled pond near the house.

My physical exam findings were as follows:

1) A very depressed dog
2) 10% dehydration (eyes sunken in, skin stays tented when pinched, gums dry, capillary refill time greater than 3.5 seconds)
3) A painful, doughy feeling abdomen
4) Sparse hair growth/alopecia over the middle of his back to his tail, fleas
5) Mucopurulent eye discharge OU consistent with history of KCS
6) Very slightly icteric (yellow), very pale gums

I started with bloodwork and urine specific gravity and found the following abnormalities:

PCV/TS 30/10.5

White blood cell count of 66,000 (normal 5,000-12,000)
Blood smear confirms that this is a neutrophilic leukocytosis with a significant left shift (14% bands noted)

Blood urea nitrogen (BUN) 188 (normal 7-20)
Creatinine 6.4 (normal 0.2-1.4)
Phosphorous 20.2 (normal 2-4)

ALT 1000 (normal 20-200)
ALP 550 (normal 50-220)
GGT 35 (normal 0-7)

Bilirubin 2.0 (normal 0.2-0.7)

Cholesterol 427 (normal 50-300)

prothrombin time (PT): 10 sec (normal 3-17)

activated partial thromboplastin time (aPTT): 110 sec (normal 74-103)

Urine specific gravity: 1015 (AFTER a bolus of 100mL NormR)

Systolic BP: 70

A slide agglutination test was negative for macro or micro agglutination. No agglutination was noted in the blood tube. No spherocytes were seen on smear. Very mild anisocytosis was noted. No polychromasia was seen.

What problems do we have? What differentials would be appropriate for this dog? What diagnostics would you have done next? What treatments would you institute? What other information could be useful?

Case study continued

To approach this as I was taught in vet school, I would begin with a problem list based on my physical exam:

1) Vomiting
2) Depression
3) Severe dehydration
4) Icterus/jaundice
5) Hair loss
6) Painful abdomen
7) Pale gums

From there, I would formulate a differential list. Now, I was taught to formulate differentials for EVERY problem...but in the real world, that is rarely practical. The differentials for vomiting alone could take up 4 pages. So, I would approach this globally - look at all of my problems and then formulate a differential list.

So, my differentials for this patient based on his problems (not on his bloodwork yet):

1) Liver disease (jaundice!) - cancer would be #1, as he is 12 years old
2) Leptospirosis - a bacterial disease that can cause liver and kidney disease would be a very close #2...maybe tied for #1
3) Acute liver failure with severe dehydration and possible renal insufficiency
4) Hemolytic anemia - based on the presence of jaundice, dehydration, pale gums, and depression
5) Bile duct obstruction/rupture
6) Ingestion of toxin
7) Hypothyroidism/myxedma coma

Those were my major differentials for this case. Then I turned to my bloodwork...(to be cont'd)

Case study part 3

What did my bloodwork tell me?

1) Significant dehydration and significant anemia -a PCV of 30 with a TS of 10.5 should tell you that this patient is SEVERELY dehydrated. A normal TS is about 5.5-7.5. A normal PCV should be between 35-45. This patient has a very high TS with a normal to low normal PCV. That tells you 2 important things - the patient is severely dehydrated (TS 10.5), and the patient is VERY anemic (PCV of 30 in severe dehydration which means it's probably around 18-20 when rehydrated).

2) Severe azotemia (elevation in kidney enzymes) with a relatively dilute urine -likely representing both pre-renal and renal azotemia - urine specific gravity 1015 (although NOT isosthenuric, as one would expect in acute kidney failure AND this was after a bolus of fluids. On the other hand, this is still not appropriately high for a dog that is 10% dehydrated).

3) Significantly elevated liver enzymes - ALT 5x normal, ALP 2.5x normal, GGT 5x normal.

4) An elevated bilirubin (but not enormously).

5) Significant inflammation and/or infection is present due to a VERY elevated WBC (66,000) and the presence of 14% bands on a blood smear (a left shift indicating that the bone marrow is experiencing overwhelming demand for neutrophils and cannot keep pace with production).

6) Low systolic blood pressure (hypotension) - normal should be around 90-100.

7) Mild to moderate hypercholesterolemia

8) A very mildly increased clotting time (aPTT)

Case study part 4

Revised differential list based on findings:

1) Leptospirosis
2) Primary hepatic or renal cancer, metastatic cancer
3) Acute renal failure overlying a liver problem such as hepatitis or cancer

Hemolytic anemia is still a possibility although it is lower on the list due to the lack of agglutination noted, the lack of spherocytes, no polychromasia, and mild anisocytosis (no evidence of regeneration or ongoing hemolysis).

My plan then was as follows:

1) Correct dehydration over 6 hours with aggressive fluids: calculated deficit of a 4kg dog at 10% = 400mL. Initially bolused 250mL of NormR leaving a deficit of 150mL to correct over 6 hours = 25mL/h + maintenance at 1mL/lb/h (4mL) + ongoing losses (significant vomiting) estimated at 4mL/h = 33mL/h. That's 3.5 times maintenance - which is a HEFTY dose for such a little guy. This would be for the first 6 hours, after which we would assess his hydration status (look at gum color, CRT, blood pressure, heart rate, and skin tent) and adjust his fluids accordingly.

2) Start Ampicillin at 20mg/kg IV every 8 hours in case this is leptospirosis.

3) Start a fentanyl/lidocaine CRI (constant rate infusion) for pain control.

4) Administer Cerenia 5mg SQ for nausea, as well as metoclopramide 2mg/kg/day dose in his fluids.

5) Administer Vitamin K1 12.5mg SQ once, then start on oral tablets when tolerating food

After he received fluids for a bit, I proceeded with my next step in diagnostics. As Hermit Thrush astutely pointed out, that would be imaging. If something is wonky with the liver and/or kidneys - better go and take a peek, no?

Case study part 5

Given that my top differentials were leptospirosis and some type of cancer, I proceeded to do abdominal imaging. I started with an ultrasound of the abdomen.

On u/s, an extremely large, cavitated mass that appeared to be originating from the liver or spleen was found. The kidneys could not be visualized due to the enormous mass. The stomach was small and empty of food. No abnormalities were noted. The gallbladder was normal in size and appearance. The urinary bladder was moderately full. The intestines were displaced to the caudal abdomen due to the liver mass. The spleen was not well seen. No free fluid was noted in the abdomen.

Xrays of the abdomen confirmed an enormous abdominal mass. The kidneys could not be seen on either lateral or V/D. The intestines were displaced to the caudal abdomen. The entire cranial and mid-abdomen were filled with the mass. The head of the spleen was visible on V/D and appeared normal. The mass appeared to be originating from the liver.

I also collected a urine sample and blood sample to submit for lepto titers (BEFORE instituting antibiotic therapy).

What next?

Case study part 6

Here's where it gets sticky:

My patient was very, very sick. He had a huge, huge tumor in his belly that was cavitated and horrible looking. He also had severe azotemia (elevated kidney enzymes) and significant anemia. One of his clotting times was very slightly elevated.

I was left with these questions:

1) Was the tumor causing the clinical signs, anemia, and azotemia? Was the tumor a red herring?
2) Which came first: the tumor or the kidney disease?
3) What should I do? Stabilize the patient with the hopes that the tumor could be taken out later? Or take the tumor out now?

What would you have done?

Love it

Just call me Julia Child

The cheesecake turned out perfect - creamy, moist, smooth, not too rich. It didn't brown, and it didn't crack. Thanks to my mother-in-law for her awesome, user-friendly recipe!

Putting my time off to good use.

I love having a kitchen that begs me to cook. If I don't get in there at least once a day, I hear a little voice calling me..."cooooooome, use my oven. Turn on my buuuuuurnerrrrs. Microwave soooooooooomething..."

New recipe tonight: green pepper soup. I know - it sounds kinda yucky. The recipe was given to me by a technician at work. Since I do love peppers, I decided to give it a whirl. What a surprise! It's a very mild, light, sweet soup that would be a perfect starter course for a big meal (steak, roast, etc). We had it with a salad and crusty french bread.

The recipe is super easy, but it does call for a blender. I didn't actually own a blender until today. We went to a cooking store in the mall (not Williams Sonoma. Surprisingly our local, enormous, tourist attraction mall lacks a WS). I could have spent HOURS and HOURS in that store looking at all the cooking equipment. It was rather like a porn store for cooks.

The recipe is as follows:

1 tbsp butter
1 tbsp vegetable oil
4 large green peppers, chopped
2 large onions, chopped
1 tbsp flour
4 cups chicken broth
1 cup 1/2 and 1/2
1 tsp salt
1 tsp pepper

Sautee the peppers and onion in the butter and oil until tender in Dutch oven or soup pot (about 5-7 minutes on medium heat). Add the flour and mix until smooth. Once smooth, cook on medium high for 1 minute. Gradually stir in the chicken broth and mix well. Bring to a boil, then turn down heat and simmer for 5 minutes. Divide the soup into half and puree each half in a blender (or food processor) until smooth. Place back in soup pot (or Dutch oven). Add 1/2 and 1/2, salt, and pepper, stir over medium heat. Serve garnished with green onions.

My first cheesecake is in the oven as we speak. I'm a bit nervous, but we shall see.

On the hobby front: I've signed up for Level 1 Spanish class to commence in January. It's an "immersion" style class in which you are taught conversational Spanish. It's taught at a local language academy and the goal is teaching you to comfortably converse in Spanish. It's something I've been wanting to do for a while, but vet school and my internship made having hobbies difficult (to say the least)!

My father was a Spanish translator when he was in the Army and was a fluid Spanish speaker. He picks up languages easily, and I have inherited this trait from him, luckily. This will serve me well in life, I feel. We deal with a great deal of Hispanic people at work, and it would be enormously helpful to be able to converse with them on some level. Further, I just like languages and hope to be able to use it one day when we FINALLY travel.

Tomorrow, we leave for Knoxville to visit friends, then Saturday we drive to Nashville to see the Avett Brothers at the Ryman with other friends. I'm very excited!

Repeat after me: "I love my job. I love my job. I love my job."

Most days, this is true. However, by the time 6:00 o'clock rolled around today, I was a potato. Stick a fork in me, I was done.

The morning got off to a rollicking start with a 15 year old cat exhibiting very odd neurological signs. She had a history of severe urinary tract infection one year previously but nothing since then. She was the picture of health until that morning, at which time she became acutely unbalanced and stagger-y. When I examined her, she had blood clots around her vulva. Ultrasound of her bladder showed an incredibly thickened bladder consistent with chronic inflammation. She also had a terrible yeast infection in both her ears. I was confused. Was she showing vestibular signs (dizziness mainly) due to her inner ears? Did she have a terrible painful UTI? Was the bladder a red herring - a problem that had been around for a long time? Did it have anything to do with the neurological signs? In other words, WTF? In the end, I treated the cat with an anti-nausea/motion sickness medication for possible vertigo/vestibular disease and a pain medication, with a recommendation to see the regular veterinarian in the morning for further testing.

My next case was no better. A 120lb German shepherd acutely down in the rear limbs and in excruciating pain. He snapped at the owner while being brought into the clinic. I examined him, but it was extremely difficult, since he could not stand. It took 4 of us restraining him to get anything done. As we were lifting him to see if he could walk, my tech slipped off his muzzle so he'd stop fighting with us. Quick as a snake, he whipped his head around and bit her hand. I HEARD the crunch and almost vomited. Blood began pouring out of her hand. She held it together for about 30 seconds before the sobbing began. That patient went to see kitty Jesus shortly thereafter (because of his illness, not because of the biting).

After my tech was shipped off to the ER, the next case came rolling in: a 5 year old pregnant Doberman. She'd had "spinal trauma" more than 6 months previously. That was what the small swelling on her hip was diagnosed as then. Now, the "small swelling" was a mass that was 10 inches in diameter, so large that it was pushing her rectum and pelvic canal shut. She couldn't urinate or defecate, and she was in excruciating pain. Her bladder took up her WHOLE abdomen. Once I emptied it, I could see the puppies. On xrays, the mass was already eating away at her pelvis and femur. There wasn't much I (or anyone) could do at the point. She too went to see kitty Jesus.

Then came the puppy with the soft, fluid filled swelling taking up his whole head. A true WTF? moment if there ever was one. Of course, the owners had no money to treat or diagnose...

Today was a reminder that sometimes I hate medicine. Sometimes I hate my job. Sometimes I really really wish that I did something that didn't matter to anyone. That I could go home at the end of the day and not even think about my work day for one moment.

After all, does it really matter if I overcook someone's filet mignon? No. Does it really matter if I accidentally kill someone's beloved pet or make a mistake in my drug calculations? And how many times do I actually help animals anyway? How many times would they get over it on their own or die on their own regardless of what I did or didn't do?

Sometimes these questions keep me up at night.

Godspeed good friend, godspeed.

On Friday afternoon, a referring veterinarian called to let me know she was sending over a dog that would require oxygen therapy for the weekend. "Choco" was a 12 year old labrador mix with previously diagnosed megaesophagus, aspiration pneumonia, and possible myasthenia gravis. On top of that, he had recently been diagnosed with likely laryngeal paralysis. His owners were an elderly woman and her daughter. The mother took care of the dog while the daughter worked during the day.

The referring veterinarian confided to me that the owners just weren't ready to let the dog go, even though with the combination of a dilated esophagus and previous aspiration pneumonia, he was a very poor candidate for surgery to repair his laryngeal paralysis. Basically, Choco was going to spend the last few months of his life starving for oxygen at all times.

When the owners came in, they had many questions. We discussed Choco's condition, and I ended up spending a great deal of time with them, despite having numerous patients to care for.

I explained to them that when breathing room air, Choco's hemoglobin was only saturated with about 75% oxygen, meaning he was chronically hypoxic (oxygen-deprived). With nasal oxygen, this improved to almost 100%. Unfortunately, he couldn't live with nasal oxygen (as people can). We discussed that his problems weren't going to get any better, not unless surgery was attempted to help with his laryngeal disease.

They understood all this, cried when they left him in my care, but didn't make the decision to euthanize.

Through the night, I watched him struggle. Sometimes, he had to stand so that he could breathe. His harsh breathing reverberated throughout the clinic. My techs asked me again and again, couldn't I give him something? My answer was always the same : save sedation, not much could help him short of intubation and surgery. Finally, at 3am, I called the owners and asked them what they wanted to do. The daughter had many more questions, but the answer was always the same: prognosis very guarded to poor.

She told me that she would call back.

Three hours later, the front doorbell rang, and there they were. More questions followed, then tears. I gave them time to think about the options, as I checked on Choco - still laboring to breathe, despite intra-nasal oxygen and sedation.

When I went back out front, they told me - with tears in their eyes - that it was time to let him go. I felt a flood of relief for the poor old guy, but also sadness for his 2 obviously distraught owners.

As I sat and talked with them about the process, the older of the 2 confided in me that Choco had been a "good friend" and it was important that he didn't suffer.

In the end, he went quietly. The owners sat with him on the floor, crying quietly, and talked to him after he was gone.

It was painful to watch, even more painful to be a part of, but in the end, it was a relief to end his suffering and to let him go peacefully, surrounded by the people who loved him most in the world.

Freshly baked harvest chocolate cake

I traffic in bad smells. It's just part of the trade: male cat urine, dog poop, anal glands, impacted anal glands, abscesses, wounds, maggots...you get the idea.

So, is it any wonder then that a naughty dog who has JUST ingested a freshly bake chocolate cake is my absolute favorite emergency to see?

I saw a 100 pound black lab/great dane mix on Saturday night. He practically inhaled a fresh, 9 inch harvest chocolate cake off the counter after his owner finished baking it. She brought him right to us, a mere 10 minutes after said crime.

A large shot of apomorphine later, and practically an intact chocolate cake was lying at my feet. For the amusement of the techs, I took a plastic knife and cut into the cake, exposing the moist, fresh, almost perfectly whole inside of the cake. I could have cut a slice, put it on a plate, and no one would have been the wiser. There was still steam coming from the inside.

The whole clinic smelled of pleasant, recently baked cake. So much so that the midnight technician commented upon walking in the door, "hey, did someone bring cake?!"

(My husband implored me to post this little anecdote (if you will) on my blog...so, since he's such a RARE reader of my blog, I thought I'd oblige)

Seriously, mother.

I had my 2nd GDV in 4 days last night. It seems to happen every time I'm on my last night on before the break (Sunday) - some big surgery. The last time, it was my nasty but fun GI intussusception. The owners of that little dog brought her by to visit me on Friday night along with a thank you card. She is doing great.

My other GDV is recovering and eating well. Last night's GDV went well and recovered great...so here's hoping!

I love me some Death Cab (not Twilight)

Sad...but happy?

The Avett Brothers are finally getting the attention they deserve. They were recently signed with a major label and the latest album (I and Love and You) was produced by the mega-giant in the industry, Rick Rubin. The album is genius, beyond anything. On the other hand, I'm sad at how polished it is. Something I've always loved about the Avetts is the rawness of their sound - the absolute rough around the edges, hoedown quality. Still, they deserve this success, and the album is awesome.

"There's a darkness upon me that's flooded in light, and I'm frightened by those who don't see it. There was a dream, and one day I could see it - like a bird in a cage. I broke in and demanded that somebody free it. And there was a kid, with a head full of doubt...so I'll scream till I die and the last of those bad thoughts are finally out."

Listen here, you won't regret the time spent: NPR First Listen

Going to see them at the Ryman Auditorium in Nashville. It's going to rock my world!

MY KITTY IS HOME! She is dirty and thin and hungry and has fleas, but it's her!

Shutter Island

I like Leonardo DiCaprio. I really like Martin Scorcese. I also love good film. I was intrigued when I saw the previews for Shutter Island a couple of months ago. It wasn't until recently that I realized it was written by Dennis Lehane. I've only read one of his books - Mystic River. It was exceptionally good pop crime fiction, and I thoroughly enjoyed it (as well as the movie). So when I saw the book for Shutter Island, I decided to give it a shot.

Save your time. The plot is contrived and obvious from pretty much 30 pages in...maybe sooner if you're faster than I am. Truthfully, I had a decent handle on what was going on relatively soon...but it was so obvious that I thought to myself...SURELY that's too simple of an explanation.

It wasn't.

I'm still excited for the movie.

In other news, our beloved kitty has not returned. We have posted fliers, been on every internet site possible, including Craigslist, emailed everyone in our neighborhood, made the rounds, and called the shelters. She is really and truly gone. I've never lost a cat before, and I can't really mourn her, because I can't believe that she is dead. It's a sad state of limbo. I'm trying to focus on the hope that she found a family to love her.

Work is going well, although my sleeping schedule is abysmal. I guess that's pretty obvious, since it's 5:30am, and I have yet to go to bed tonight (my night off). Next week is my 9 day stretch without work. In that time, my parents are coming to visit (VERY excited about that), and then the husband and I are going back to the old stomping grounds to see his brother and wife, as well as watch some good 'ole college football. I'm looking forward to that time off immensely.

Last week, I rode a $50,000 dressage horse for 3 hours. My thighs still haven't recovered. More on that later.

The kitten I'm bottle-feeding is a thriving, fat as a tick, squealing monster.

That's the quick summary of my days.

Dear kitten

Dear 1 week old, blind, deaf, helpless kitten,

I find it hard to believe that you magically showed up in someone's backyard, as you seem incapable of supporting your own weight. But fine, we'll accept the impossible. We need to get a few things straight.

Yes, I am a sucker for a homeless, motherless kitten. Yes, I will bottle feed you and stimulate you to use the bathroom. BUT... and this is a BIG but...I will not pick you up every time you cry for attention. You have a perfectly nice warm box, complete with towels and a heating pad all your own. There is no reason for you to cry between feedings. Sure, I understand that you have no warm momma cat to curl up against and no littermate siblings with which to sleep...but that DOESN'T mean that you can be in my lap all the time, no matter how much you nurse on my palm and curl your warm little paws against my hand. And further, there will be no-----....

Oh fine. I give up. You can sleep in my lap.

Signed,

Dr-I-guess-I'm-unleashing-another-bottlefed-monster-on-the-world-but-really-I'm-not-since-I'll-wind-up-keeping-you-undoubtedly.

Not so amusing

I'm so depressed right now that I want to curl up into the fetal position and sleep for about 2 months. You know what makes depression better? Working in the ER on Labor Day. I can't think of anything more fun.

This weekend was supposed to be great. My best friend and her husband (coincidentally, my brother-in-law) are here for the weekend. We had planned a big trip to our local amusement park that is very similar to 6 Flags. It was part of a 30th birthday extravaganza celebration (mine in June, hers in July).

The weekend was kicked off by the realization that one of our cats - the youngest, never been outdoors, completely timid/scaredy cat, that I've had since she weighed a mere 6 oz snuck out of the house. She has been gone for 4 days. I've posted on craigslist, put fliers on every box in our neighborhood, called work several times to ensure that no one showed up with her injured, and posted fliers at our local vet clinics, and yet NO ONE has seen her. We live within about 40 yards of a busy road, which my husband and I canvass daily. I'm devastated and keep lying in bed at night thinking of terrible scenarios.

To top it off, I foolishly exposed myself quite liberally to a nasty infectious disease at work last weekend - leptospirosis. So, I'm taking antibiotics, which I think are making me sick. This isn't a precaution. I was literally covered in this dog's urine, and urine is the main method of transmission.

To top off the intermittent diarrhea and nausea, as well as the general poor-doing, today was the big amusement park day. I haven't been to an amusement park since I was 13, and our class took a trip to Opryland. At the time, I loved roller coasters. I woke up feeling very poorly this morning, but I didn't want to bail on the 30th birthday trip. Off we went. I made it onto 3 roller coasters before being overwhelmed by the MOST intense nausea, light-headednes, and vertigo that I have EVER experienced in my life. I could barely make it to the bench to lie down. Granted, it was hot today, we stood in lines (but not THAT long), and the final roller coaster had 4 or more upside down loops and went around 60 miles an hour...but still...I have been incapacitated ever since. My husband brought me home so our friends wouldn't miss out on the experience.

I think I'm going to lie in bed and cry.

Dear client redux

Dear Mr Farrier,

Thank you so much for not complaining about the $1500 you footed for your dog's care for ONE night. I am so sorry that he developed DIC (disseminated intravascular coagulation - see sidebar) and anaphylactoid shock as a result of a rattlesnake bite.

Thank you for not complaining about the money even after we had to euthanize your dog. I especially appreciate how - even though you had to wait to check out - you never once griped. Oh, and that while you quietly waited, you offered to carry a woman's cat carrier to her car for her, since it was so heavy.

I'll admit, it did make my job a little harder to do when you mentioned while we euthanized your dog that he was your 15 year old daughter's best friend and she doesn't make friends easily. It's hard to see what you're doing with a needle when you're crying yourself. I'm sorry to hear that she couldn't be there herself because she was too sad. I hope for her sake that you find her another companion very soon. Try not to worry too much about the fact that she's a loudmouth and alienates people frequently - I was (am), too - and I turned out okay.

Signed,

Dr You are one of the nicest people I have met in a very long time.

Venting

I try very hard at my new job to foster positive client relationships. I try to be a good example to technicians by not badmouthing clients or ranting about stupid/uninformed people. It's very important for me to set a positive tone. It helps the techs work better, it makes for a happier work environment. It also makes me happier because I just let it go when people are asses or have a sense of entitlement or are just plain rude. On the other hand...GOD - some of them get under my skin no matter how good my attitude is. That's what the next 2 posts are. I needed to vent. ER medicine is a hard field - people bring in severely injured and sick animals, are under a great deal of stress, and often must cough up a large chunk of money in the middle of the night. I UNDERSTAND that. I empathize. I've been in the ER myself - notably when I had a kidney stone. I was screaming and vomiting. It's stressful and scary.

BUT I AM NOT THE ENEMY!

Diabetic what?

Dear transferred for overnight care from the local rDVM client:

Thank you for bringing in your Schnauzer-Terrier cross with diabetic ketoacidosis today. No, his muffin top is not normal, and no, McDonald's chicken is not a good diet despite the fact that it is grilled chicken and you squeeze the fat out of it before feeding it to your pet. You're very lucky he doesn't also have pancreatitis with his DKA.

Thank you for reminding me seventeen times during our lengthy discussion of DKA that your other dog died here 4.5 years ago, before I even worked here. And thank you so much for explaining that it's because he didn't receive his ultrasound.

I especially appreciate how you don't make eye contact with me or respond to me when I talk to you. I liked how this morning when I cordially greeted you to give you an update on your pet's condition that you kept your back turned on me and barely answered my questions. I also especially love how you accused me of leaving your pet lying in urine through the night (he was not, my tech took EXCELLENT nursing care of him and walked him very frequently, as we do with diabetics!) and also telling me that my tech reported vomiting, when in fact - there was NO vomiting, and my tech took great pains to tell me (and you) that very fact. Thank you for also accusing me of causing his blood glucose to swing by giving him too much sugar in his fluids. The wild fluctuations couldn't be because he has a SEVERE form of diabetes that can take days to weeks to regulate!

Oh, and no - you won't be visiting him MORE often than you did last night. Every 2 hours was plenty, and I was being flexible. Friday's nights are usually pretty busy times in the clinic. Oh, and I especially appreciate how you said that you don't know us, don't trust us, your other dog died here, and basically acted like I was the enemy when - in truth - I'm NOT out to kill your dog, I actually do like animals, and actually DO care if I do a good job.

Thanks!

Dr Please take your dog to a referral practice tonight!

Stay away from sharp objects

Dear I don't have the money to spay/neuter my pets but can afford an enormous escalade with 20 inch rims and pay for very colorful tattoos covering 80% of my body client:

Thank you for bringing in your actually very sweet SharPei this evening. It's possible he's so docile because he's in shock from blood loss. Keeping your 2 intact male dogs with your intact female dog is not a good idea, despite the fact that they've lived that way for a while. Yes, not spaying/neutering them can lead to aggression - especially when a female is in heat around 2 intact male dogs.

No, it will not cost less than $300 to repair the massive wound in your SharPei's head. Threatening me by saying that you're just going to put him down if it costs that much is not an effective way to get me to help you. I WILL help your pet by giving him some pain medications and bandaging his wound. It's very considerate that you don't want him to suffer while you make a decision.

On that note, no, you should not be able to see DOWN the ear canal by looking through the hole in the neck. Further, I should not be able to put 2 hands inside your SharPei's neck. Unfortunately, he is going to need many thousands of dollars of repair, as - given his breed - sutures will be a difficulty. Oh and yes, he is going to need multiple drains, as well as probably 2 days of bandage changes BEFORE we sew him up so that we can stabilize him and prevent him from developing sepsis and SIRS secondary to his massive trauma. And yes, you have to pay for that "up front."

Truthfully, thank you for letting me put him down - as I doubt he would have received the care he needed.

Have a great night,

Sincerely, Dr this could have been easily prevented with SPAYING AND NEUTERING or at least separating your male dogs from your bitch in heat

Aye, there's the rub

I've never watched Grey's Anatomy. I have no desire to, as I abhor TV in general, stupid medical dramas specifically. So, now they have Grey's Anatomy scrubs. It costs approximately $60 for a pair. Ridiculous, right?

The problem is - they are the softest scrubs I've ever touched, they're nipped in at the waist to be flattering, and they ride low on the hips. Basically, they're the perfect scrubs.

Thankfully, one of my techs is fabulous at removing the little tag that says "Grey's Anatomy" without damaging the scrubs. I'll be damned if I wear TV doctor scrubs to work.

Imagine if you will

A perfect day in the mountains of far west North Carolina. The sky is a hard, bright blue, the clouds like gigantic fluffy sheep with light grey underbellies. You're floating in a lake of green water, where you can see to the bottom at 10 feet deep. There are no noises other than the contented chatter of friends as they fish, drink beer, and generally revel in the delights of nature.

That was how I spent my Saturday and Sunday. We went camping with Jim's kayaking buddies at Lake Santeelah. It's a stunning, secluded, enormous lake/river system in Western NC. No pollution - natural or manmade. Just absolutely clear, cold, beautiful water. Our campsite was only accessible via canoe. It was about 1.5 miles of canoeing from the place where we left the cars. At night, all you could hear was the sound of crickets and frogs.

It was a very restful trip.

Now, I'm back. The painting in the house is finished (at least, in the living room/kitchen/library/breakfast nook/great room). All of the boxes are unpacked. The house is mostly ready for guests. I still have to paint the study, spare bathroom, and guest bed, but that will have to wait until my next couple of days off. We're having a lot of company in the months of September and October. I'm looking forward to it immensely.

It's back to work tonight for me, folks.

Checkout line confessions

As I was checking out at the grocery today, my husband was making polite chitchat with the female bagger. Older, heavyset, she had the air of a crazy cat lady. When she saw the litter we were purchasing, the conversation took a turn for the slightly maddening:

"So, how many cats do you have?"
My husband, "Six."
"Me too! Well, 7, if you count the outdoor cat. My newest one, she needs to be spayed. She's about to have babies."
Husband: mumbles something politely.
Her: "I can't afford to get her spayed. It costs too much. There's some sort of low cost spay around, but they make you get some shots before they'll do it."
Husband: nodding along.
Her: "I think they should do the spays for free! They're too expensive."

What do you suppose I said in response, dear readers?

Absolutely nothing.

Exotics extravaganza (cockatoos, bunnies, reptiles oh my!)

My first weekend was a good one, but it was thoroughly exhausting. I had a surgery both nights - a c-section on the first one, an enucleation on the second. Both went well, although I was surprisingly nervous. Perhaps because it's been a while since I wielded a scalpel.

At any rate, Sunday morning, I had all my cases wrapped up, transferred to the day ER doc, and was ready to head home. An owner calls and asks if we will see his bird. Neither of the other ER docs are comfortable with birds, so that left me. I asked the technician to tell the owners to go to the nearby specialty clinic. As it turns out, however - all of the avian/exotics docs are currently out of town at the AAV (Annual Association of Avian Vets). No one else in the area was open to see the sick birdie.

I sighed and told them to come on in. I can't resist a bird in need of medical attention. Especially when there is no one else to see it.

It was an interesting case, as it turns out - a cockatoo with neurological disease. He wasn't able to grip with his feet, he kept falling, and occasionally, he was maybe having seizures. After looking him over, I explained to the anxious owners that my primary differentials were heavy metal toxicity (lead, zinc poisoning) and proventricular dilatation disease.

Birds that free roam in houses (as my patient did) often eat things they shouldn't, chew paint, chew blinds, chew windowsills - you get the picture. Any time a bird comes in with neurological signs, ingestion of a metallic object has to be high on the list of possible causes. Yet, I've never actually had one that I xrayed have actual metal in the body.

This was to be my first. Imagine my delight when I saw a small metal foreign body in the proventriculus and proventricular dilation (a common sequelae to heavy metal toxicity). Thrilled, I began treatment with calcium EDTA (to chelate the metal). My patient did very well, was able to perch and grip, before transferring away to his veterinarian on Monday.

The downside? It took me until 1:30pm Sunday to finish working him up, treating him, and getting him settled. Thus, I had exactly 4.5 hours before I had to be back for the Sunday night shift. I wound up sleeping at work. So, on my first weekend, I was there for almost 40 hours straight. Plus, we had a doctor meeting on Monday morning, after my shift ended. So I was pretty much awake from 5:30pm Saturday through 1:30pm Monday afternoon, with the exception of a 3ish hour nap on Sunday.

Don't worry, it won't become a habit. It was worth it, to fix my cockatoo patient. I also had a bunny patient (with a head tilt) that was very fun (and rewarding) to treat.

I love my new job, by the way. The people are great, the place is well-run, and I'm in charge. Maybe that's my favorite part.

Smashing pumpkins

Tonight, tonight, tooooooonight...is my first night as a solo ER doctor (well, that's not true). Really, it's just my first night solo at my new workplace. I'm actually excited about going to work. Does that make me a sad person? I love what I do.

I'm working the next 3 nights in a row, then I have off 9 days. It's a weird schedule, but I like it - especially all the time off. It's a good thing, I have many house projects.

Alrighty, back to whatever I was doing. I'll keep ya'll posted.

Here there be dragons

When I was on my ambulatory rotation in veterinary school, we'd load up the big white trucks every day and go out to visit the rural folk of Tennessee. We'd treat cows, horses, sheep, goats, pigs, and basically any other livestock floating around out in the countryside.

One particularly gloomy, wet day, we got a call to an extremely rural area, probably a good hour's drive from the vet school.

Upon arrival, we were confronted with a large, nice house on a hill - in the middle of nowhere. Deep in the valley behind it was an oddly shaped, extremely large pasture with a barn situated on the hill overlooking it. Surrounding this pasture were very deep, very dark woods. It was raining, dreary, and overcast. No living person was to be seen. The nearest other soul was probably a good 6-7 miles away. We were in the middle of nowhere. It was very Texas Chainsaw Massacre.

We drove the truck down to the pasture gate and piled out of the truck. No people to be seen, but two horses (presumably the two we were there to vaccinate) were standing in the middle of this sunken field, grazing.

As we waded through the knee high pasture grass, we all heard it simultaneously. A low, deep growl that grew into a booming roar echoed through the woods. We froze. This was no dog bark, no warning growl. This was the roar of some very large predator. We all looked around incredulously but saw nothing.

Nervous, and growing ever increasingly so, as the sky darkened and fat raindrops began to fall, we continued our trek toward the horses. Lightning cracked, as we led the horses to the makeshift shed/barn.

As we were leading the horses, the roaring came again - this time twice. Now we were all scared. We made it to the barn and started setting up. At that point, a white truck rounded the crest of the hill and started toward the barn. A normal looking woman in overalls and boots climbed out of her truck and trotted toward us.

"Wow, great, you already got-" and here, the roaring again, "started."

At this point, we were convinced that some horrible monster was going to come charging out the woods and make a meal of us all. The owner noticed our jumpiness, smiled at us, and said, "don't worry, that's just the lion sanctuary down the road. When the wind is right, you can hear them at feeding time."

Busy busy busy

Working, cleaning, buying furniture, the busy-ness here never stops.

I think I'm really going to like my new job, especially the people. My first 3 nights were relatively low key. Most of it was shadowing, although I took a few cases myself.

Otherwise, I've been putzing around doing stuff to get our house in order. We've decided to make our dining room a library/reading room. I've always thought having a dining room and another eating room was kinda silly. Also, it necessitates having 2 eating tables, and I only want to pay for one. At any rate, we're having a painter do the great room of the house, since the ceilings are very high. Also, we just HATE painting. We can't put up the bookshelves and unpack until the painting is done, so I'm at kind of a standstill with house stuff momentarily.

We have a gas grill with its own line, which I'm happy about. We'll probably be grilling every single night for the rest of the summer. Of course, we need patio furniture...

Yup, that pretty much sums up my life right now. The hunt for furniture. When I have interesting veterinarian stuff to relay, I'll post again.

The new job

I went to my first staff meeting at my new job on Saturday morning. I was thisclose to not going due to the flu bug that I seem to be carrying. I find this HIGHLY unfair. Jim and I were sick not a month ago. Jim's dad thinks it's the flu, based on a phone conversation.

At any rate, the staff meeting got me really excited to start work. Wednesday, by the way, is my first day. I have mixed feelings. If I was well and had been able to unpack my house fully, I would be thrilled. Unfortunately, I'm sick and have only unpacked about 40% of the boxes. Not my usual style, and it's driving me crazy. I also need to buy 2 bookshelves, 2 dressers, a desk, and a cat drinking fountain. Illness has rendered me incapable of making purchasing decisions, so mostly, I just sit at the computer and stare at Crate and Barrel's website without being able to do anything about it.

Ahhh...the flu.

1) Driving
1) Cleaning
2) Painting
3) Painting
4) Cleaning
5) Washing paint off self and husband
6) Being extra super crabby
7) Taking my North Carolina State board exam (yesterday, went fine)
8) Fretting about decorating a house that feels too nice for us.
9) Breaking up unhappy cat fracases...fraci?
10) Having a sore throat and wondering if I've got the swine flu!

That's what I've been doing.

The sound of echoing

The loan has been approved, the title is clear, and on Monday, we will own our first house. Wow.

Our last rental house is bare and echoing. My best friend from vet school is here and helping clean and organize. The semi is almost completely packed and will be shipped out Monday. It shall arrive (hopefully) Wednesday or Thursday. Till then, we will be sleeping on an air mattress...in our NEW HOME.

The cats and birds are completely freaked out about the absence of furniture. Despite moving 11 times in 11 years, they have never adjusted to the hullaballoo.

We go home for a family reunion on Friday/Saturday, then return to Chattanooga on Sunday to pick up the traveling zoo, and then to North Carolina and our new home! It's going to be a long and exhausting journey with 9 animals, but at the end waits our house. OUR house! It's a very, very fine house.

Moving

We're in the process of moving. The semi arrives tomorrow. In the midst, I feel sick. Not sure why. Periods of lightheadedness/weakness/no appetite/exhaustion. I want to sleep all the time. It's great! Reminds me of the time I found out (belatedly) that I had mono while we were moving. It explained a lot. Of course, I am uninsured at the moment, since I opted not to COBRA my insurance.

We close on the house Monday (if no wrenches are thrown into the works...which is a big IF). Alright, no more procrastination.

Photo Essay: Tyrolean Traverse DeSoto Falls

We had a fabulous day. My husband and I joined my aunt, uncle, and children at DeSoto Falls in Alabama for the annual Tyrolean Traverse day. Click on the pictures to see bigger versions.

Not Superman, not demi-gods, just people...

First off, let me apologize for this post. This is a subject very near and dear to my heart. I've been trying to put this post together for several days, and it keeps evading me. I finally just sat down and wrote it. It's not very good, and it jumps all over the place. Perhaps after a few days, I will attempt to re-write it into something more coherent. Until then...

I've been reading several books lately (the latest is Overtreated, others I've read include Better: A Surgeon's Notes on Performance, Complications: A Surgeon's Notes on an Imperfect Science, and How Doctors Think). They have led me to a topic very important: medicine (human and animal) and its limitations. Ever since I started actually being a veterinarian, I have been undergoing a slow and painful awakening to my misconceptions about medicine. Growing up, I invested fully in the idea that doctors are semi-gods, capable of bringing disease to its knees and helping us all. I viewed medical technology and medical research as hallowed institutions - ones not subject to market forces and the whims of the pharmaceutical industry.

Then I became a doctor myself.

Now, I see medicine for what it truly is: a wonderful but limited ART form. Medicine has created many wonder drugs and done many amazing things, BUT medicine does not cure all. Medications are not the panacea for every disease (not what the pharmaceutical companies would have you believe).

Medical journals - once the bastion of ivory tower research - have now become largely written by researchers that are funded by pharmaceutical companies. One recent estimate put the number of researchers WITH CONFLICTING FINANCIAL INTERESTS doing research and writing literature for the Journal of the American Medical Association at 80-90%! Yes, you read that right. The great majority of the medical literature that doctors rely on to make medical judgments is funded by pharmaceutical companies that want to sell a drug. Veterinary literature is NO better.

On another, completely separate subject: how many of you think that every drug we use in life has undergone rigorous, controlled, randomized, blinded clinical studies before being put on the market? How many believe that these drugs are safe because the FDA says they are? Further, who believes that they all work as they are supposed to and that each new drug is a huge advance on an older drug that does the same thing?

If you answered yes to any of those questions, check out a brief rundown of the Vioxx debacle. I realize this is a Wiki article, but this information is verifiable through the AMA. I have read several of the studies myself.

How many of you believe that if your doctor recommended high dose chemotherapy followed by bone marrow transplant for breast cancer than it must work? That this treatment would only be recommended after extensive and rigorous studies?

If you answered yes: read this brief blurb about high dose chemo and autologous bone marrow transplants. Since that blurb was published by the NCI (in 2001) - this type of chemotherapy has been discredited as being no more successful for treating breast cancer than standard chemo. It was a horrible experience in the early days - with women being isolated for up to 3 weeks while they waited for their bone marrow to recover. During this time, they were sicker than you or I could probably ever imagine. Many women died from the treatment (although this can be true of any chemotherapy).

Other examples? There are a million...but it would take pages and pages to write them all.

Ahh. To delve into this topic with any amount of clarity and determination would take hours and hours.

My message: doctors and veterinarians are humans. We are subject to the same bias as the regular public. We are ordinary people who may or may not be able to read the published literature regularly and with a very studious eye. We are not gods, and medicine doesn't fix everything. Whenever your doctor or veterinarian recommends something - TALK to them about it, ask questions, do research, and figure out for yourself (with the help of professionals) whether that recommendation is a tried and true diagnostic/therapy.

Be an informed patient/owner. Know the medications you or your pet receive. Make sure your doctor/veterinarian is aware of them.

Remember: medicine is only as good as human beings themselves can be. We're all fallible, we all make mistakes, and most importantly: MORE medicine does NOT equal good medicine. Sometimes more is just more.

As a doctor, I am rapidly learning to view treatments and diagnostics with a discriminating eye. I try to keep up on the literature, to read it with discernment (although it's difficult to read 10 article, pick them apart, then go look up the researchers and find out WHO funded them). It is something I take very seriously. Just because a new technology or new drug or new test is available doesn't mean I should or need to use it on a patient. Just because I CAN order a CT scan on a patient with suspected cranial bleeding doesn't mean I SHOULD - especially if the owner is not interested in pursuing a craniotomy.

Just one more thing that makes being a doctor such a damned challenge!

If you take nothing else from this post, take these 2 things: the pharmaceutical companies are spending millions of dollars supporting doctors that in turn do research and publish articles in respected medical journals (JAMA, JAVMA, New England Journal, JAVIM). And second: often more medicine isn't better medicine, it's just MORE.

(As a sidenote: while Overtreated is riveting reading, full of spectacular examples, it is a poorly referenced book that seems rather sensational. It does - however - point out some ideas that are important to think about in regards to the sky-rocketing cost of human medical insurance/medical care and the medicalization of the American people.)

Interesting case numero dos

So, on my last night of relief, after deciding to head to surgery on my liver laceration dog, the scene as follows:

I'm sitting up front, typing notes frantically and talking a mile a minute to 2 women about their dog that managed to ingest a large quantity of chocolate. Mid-sentence, the code alarm goes off. I bolt from my chair, leaving them staring after me.

As I barrel into ICU, I'm faced with this picture: a 120lb Bernese mountain dog, laterally recumbent, non-responsive on a gurney. Techs are scuttling in every direction, gathering monitoring equipment, a laryngoscope, and drugs.

I check for a heartbeat and find a rate of about 180 (extremely rapid for a dog this large). Her gums are tacky and bright red with a slow capillary refill time (significant dehydration/shock). Blood pressure is low at 70/40 (normal should be around 120/60). Blood glucose is also low at 45 (normal 70-100).

The owner meanwhile is rattling off the story. On Sunday, this dog was seen at our clinic. The ER doctor suspected a foreign body in the intestines. A contrast study revealed a possible obstruction. The owners wanted to wait till Monday to take the dog to their vet for surgery. On Monday, the dog transferred. For some reason, surgery was delayed until Tuesday. When the surgeon went in, she found a corn cob lodged in the intestines. After 6 hours of surgery, it was out. The intestines LOOKED viable and nothing was removed. Now, it was Tuesday night/very early Wednesday morning -and the dog was non-responsive.

With a low blood glucose, low blood pressure, and significant dehydration, I suspected that the intestines were dying post-operatively (as happened to me recently with a linear foreign body surgery). I checked a lactate (a measure of tissues being deprived of oxygen). It was 4.8 (normal up to 3). This is elevated but not terribly.

I explained all this to the owner, and she understood. We talked about intestinal necrosis (death) and sepsis (overwhelming systemic bacterial infection as a result of the dying GI tract). I explained that I suspected this was going on and that - in all likelihood - a second surgery would be required.

The owner understood, signed the hefty estimate I gave her, and left her dog in my care.

For the next few hours, I worked on stabilizing the dog. I got her blood pressure and blood glucose up, as well as her heart rate down. Her hydration status improved. I was on the fence - go to surgery now or wait? As the only doctor in the building, I had no one to bounce my question off of...so I went back and forth, back and forth. Finally, I called the big wig ER doc and asked her opinion. She told me to wait until the dog was more stable. So I waited.

The following morning, her lactate continued to climb, and her shock returned. Surgery revealed death of the great majority of her small intestine. The surgeon removed 5 FEET of her intestines. Sadly, she died later that day.

I doubt had I taken her to surgery a few hours earlier, anything would have been gained. Sometimes the intestines are insulted too much to ever recover.

With my time, with my time...

What have I been doing with my time? So, I was going to work on the 4th of July, and then again tomorrow. That was until it suddenly occurred to me that I retired my Tennessee state license. Yup, as of June 30, I am no longer licensed to practice veterinary medicine in the state of Tennessee. So my days of working relief at RIVER are over. I am officially free as a bird until I start the new job (whenever that might be).

We're in a holding pattern house-wise. We'll know about our latest offer tomorrow at 10am. If it doesn't go through, then we'll go to Plan B. Okay, forget Plan B. I think we're officially to Plan Q, at this point. Whoever said this is a "buyer's market" is severely deluded. Yes, dear readers, you sense frustration.

I can't start setting up change of address forms, calling the electric company, water company, and Comcast until I have some idea of WHERE we're moving. We're in a complete and total holding pattern, and it's starting to drive my husband and myself up a wall.

I did have a lovely 4th of July. I ended up at the lake with my husband and internmate. We swam, bathed in the sun, and engaged in generally sloth-like behavior. Afterwards, we had dinner, saw Up, and then enjoyed the fireworks show downtown. For a day with no plan other than work, it turned out great.

Also, on the bright side, my husband is finished teaching his month long summer class, so he is free as a bird for the next year. He can work on his PhD thesis and actually have something of a life. He's been so relaxed the last few days, and it's been amazing spending unfettered time together. I'm sure in 6 months, he'll wind up finding a job - but at the moment, he's all mine.

As a sidenote to prove my nerdiness, I spent several hours today perusing my new Kirk's Current Veterinary Therapy. For those of you who don't know - it's a big fat book (costing over $100) that covers current recommended therapies for just about everything. It was a gift from the head of our hospital as a thank you for our hardwork as interns. It's a great book, and I'm in love with it. How's that for nerdom??

Up

I just wanted to pop in and recommend Pixar's new movie "Up" to anyone that hasn't seen it. I'm not generally a Disney fan, but I've really enjoyed every Pixar movie I've ever seen. "Up" however was beyond anything I've seen. It was beautiful, poignant, hilarious, stunning to watch (the animators outdid themselves), with a sweet, heartwarming (and heartbreaking) message. I cried several times. Given that I weep when lettuce wilts, that's not saying much. My husband on the other hand, who has cried exactly 3 times in the 16 years I've known him, had to bite back sobs. It's a tender movie with a lovely, haunting score. I cannot recommend it enough. I've seen in twice in 3 days. The previews do not really do the film justice, and they certainly give no real hint to the underlying premise. Go see it go see it go see it go see it. I PROMISE that if you hate it, I will personally mail you the $6-15 your ticket cost you. Scout's honor!

Ode

Yesterday was mine and my husband's 10th wedding anniversary. We spent a low key day together - a movie (Pixar's Up, which I can't recommend enough) and dinner at a pricey restaurant. Gift exchange followed and was lovely for all involved.

Mostly, my blog is about myself and my exploits as an ER veterinarian. This post is about him.

We met when I was 14. We started dating when I was 17, he was 20. We married 1 week after I turned 20. After 13 years together, 10 married, I have to say that I can't imagine loving anyone more than I love my husband. The following are some of the reasons why:

He still makes me laugh - even with corny jokes.
He has an enormous soft spot for tiny kittens.
He treats me like a princess, even if I don't always act like one.
He takes his teaching position very seriously and has a staggering work ethic.
He believes it is his responsibility to take care of me and has done so for the past 10 years (as a sidenote: I'm excited about my new fancy job allowing him to take a year off to work on his PhD thesis. I can take care of him for a change!)
He spoils me rotten.
He's intelligent, interested in the world around him, and loves a good discussion.
I never get bored with him.
He's the first person I want to tell any news - good or bad.
He makes me feel beautiful.
He always drives, even though he hates driving, because I hate it more.
He puts up with the 3 parrots that take up space, poop on him, and yell at inappropriate hours.
He loves children and will be an amazing father.
He is truly the best person I know and my best friend.
Our sex life is still amazing.
I fit against his side perfectly, so sleeping together is perfect.
He always lets me pick the side of the bed I want to sleep on and takes the other.
He does dishes without complaining (and I hate dishes).
He loves his family and my family.
He doesn't criticize me, is slow to judge, and quick to forgive.
He sees the best in people.
He is my family.

To you, husband...all my love, for all time.

Not with a whimper, but a bang

My "last" night at RIVER was exactly as I imagined it would be...crazy.

I say "last" because I might be picking up relief shifts here and there during July to pad the old bank account. On the other hand, I might just decide I'm finished and give myself 2 weeks off before the moving (?) fun commences. We'll see. I have a sneaking suspicion I'll be working.

Last night was unbridled chaos. Case of the night is as follows:

A cute, 1 year old female spayed dachshund/corgi/bassett mix presents for a 1 hour history of ADR. The owners reported that she was unusually lethargic. She was outside, in a fenced yard for several hours, and when she came in, she just wasn't herself.

When I saw her, she was quiet but responsive. Her gums were pale, and her belly was mildly distended. Otherwise, she was normal. Her abdominal xrays were strange. She had a loss of detail on xray (usually meaning free fluid in the abdomen), as well as a collection of gas bubbles up near the liver/head of the spleen/stomach. The radiologist's best guess was a liver abscess. I ultrasounded her to find a moderate amount of hemorrhage in her belly but no clear source.

I was perplexed. Why was a 1 year old dog with no history of trauma bleeding into her abdomen? Clotting times were normal, so rat poison was out. I gave the owners the options: wait and monitor, if PCV starts to drop/hemorrhage worsens, go to surgery or go to surgery now. We chose the wait and see approach.

At 4am, after fluids to stabilize her and rehydrate her, as well as injectable opioids and acepromazine...her heart rate was still 180 (very high). On a whim, I checked a lactate. I was stunned to find it was 10 (normal up to 3). Lactate is an indication of anaerobic metabolism (no oxygen). When elevated, it often indicates that somewhere in the body, some unlucky organ is suffering hypoxia (lack of oxygen) and switching to anaerobic metabolism to produce energy. I called the owners and told them I was going to surgery to find out exactly what was going on in their dog's belly.

To my surprise and displeasure...my patient had somehow managed to lacerate one of her liver lobes. An enormous blood clot was sitting on top of it. After examining it, I decided a partial liver lobectomy was in order. Terror set in. I'd never done one of these before, and OF COURSE, it was the hardest liver lobe to access, as well as being closest to the vena cava. Two and a half hours later, and a massive amount of sweat, adrenaline, and near wetting myself terror later, the lobe was out, and my patient was recovering.

Today, her lactate is 1.4. She is eating, drinking, and urinating. In another 48 hours, I can call this surgery a success. Until then, I will not relax.

And I'm left with this question: how, precisely, does a dog manage to lacerate JUST its caudate liver lobe without a single bit of evidence for external trauma?

Second interesting case of the night to come later!

Sundries

I was torn between a post on my internship as a whole and a post on pediatric medicine and the unique challenge it represents to us vets.

Instead of either, I'll just give ya'll a brief update on the house-buying/moving/new job situation.

We backed out of the first contract due to the seller acting very shady and outright dishonest about the house. So, we spent Saturday night and Sunday in North Carolina AGAIN (trip 4 in 4 weeks), looking at houses. In the end, we offered on the house that was probably our second choice all along. We're in the process of negotiating, and hopefully, all will end well this time. It's getting old, I'm not gonna lie.

Tonight is the last night I will ever work as an employee at my internship. It's my last night of relief work before I say adios forever. I wish I could feel nostalgia...or something, but all I feel like is not working tonight.

My 3 days on in a row were very busy. I got to do a foreign body removal on my birthday. A young pitbull had a ... something? ... lodged in his mid-duodenum (upper small intestine). I really have no idea what it was. Some people thought brillo pad, others just called it a fecolith. At any rate, he recovered excellently and went home after 4 days in the hospital before the surgery. Long story short, he was originally treated as a renal failure until it became apparent that his azotemia (elevated kidney values) were as a direct result of his incredibly massive dehydration...as a result of the foreign body in his intestines. Ah...all is well that ends well. It was a GI surgery, and I'm happy to say that he has recovered well and went home a much happier dog. It helped restore some of the confidence I lost as a result of my last foreign body surgery.

More to come later, I'm sure.

Please read the bag...

Enter the young doctor: "Sir, Fluffy is hemorrhaging from his gums. Anywhere he could have picked up some rat poison?"

Mr Green, a mid-50s gentleman farmer, "No."

Continuing, "I'm very concerned that rat poison may be the cause of Fluffy's difficulty breathing, as well as the blood you noticed in his mouth. Are we absolutely sure Fluffy wouldn't have eaten any?"

I wait.

He clears his throat quietly and then says: "Well, I do put rat poison in his food. The damned rats kept eating his dog food! But that's for the rats. He wouldn't eat that." LONG pause. "Would he?"

And.....scene.

For giggles

It's 5am, I'm really tired, and there are 2 emergencies on their way in...so for laughs, information I gleaned from patient charts:

Reason for visit: "kidneys locking up" (Locking up for what - the night? Doors close at 5pm?)

Breed of dog: cheewawa (Hukd on fonix werks for me!)

Reason for visit to ER clinic: "emergency" (Really? I thought you came in for a pedicure!)

Name of owner: Doctor Charles X. Actual job: english professor.

Breed of dog: Daniff. This is a great dane crossed with a mastiff. We call it a mutt. Also might be known as the following: dog with 100% chance of gastric-dilatation and volvulus, dog sure to be unruly and untrained and to develop epilepsy and require frequent hospitalization for seizure monitoring...

Reason for visit: "sick" (Gee, I thought your cat just wanted to visit the vet)

And that's only a brief sample of 3 days worth of work!

No way she coulda done that...

Me: "Mrs Hillperson, your puppy seems to be bleeding internally - into both the chest cavity and the abdomen. Her clotting times are off the chart high. Could she have gotten into rat poison?"

Mrs Hillperson: "No, absolutely not."

Me: "We're sure?"

Mrs Hillperson: "Nope, no rat poison. Now, we caught her brother with a mouthful of it about a week ago, but not her - she wouldn't do that!"

Me: "You might want to bring in your other dog while we start treating the first one..."

I think I have parvo now.

Me: "I'm sorry to have to tell you this, but Mr Giggles has parvovirus. Are you familiar with this disease?"

Mr X: "Oh yeah, my last pit bull died of that."

Me: "Ummm...are you familiar with the parvo vaccine?"

Mr X: "Yeah, but that's too much money to spend. I could just buy another one for the cost of that shot. You can go ahead and put Mr Giggles down."

Mr X to son: "We'll just buy another puppy, son."

Me: Swallowing vomit.

On an empty stomach.

Mrs Green: "Jimmy has been vomiting for 2 days, and he hasn't touched any food for over 72 hours. He eats things all the time that he shouldn't. His belly really hurts him, and he cries when you touch it." (All this said of a Labrador that looks bouncy and vibrant).

My colleague: "You're sure he's eaten nothing at all? He's vomited copiously for 2 days?"

Mrs Green: "Oh yes, I just know he has something stuck."

Xrays: soft tissue density in what should be a very empty stomach

Exploratory surgery: stomach full of chicken.

Mrs Green at 3am post-operatively: "Oh well, yes, he did eat all the chicken we fed him today, but absolutely NOTHING ELSE."

My colleague: Speechless.

The Big K

Me: "Mr Brown, I'm very sorry to have to give you this news, but I suspect that your dog has a type of cancer called hemangiosarcoma. I would suggest chest xrays to check for metastatic cancer to the lungs and extensive bloodwork to evaluate the function of the kidneys, liver, bone marrow, and blood elements. Surgery would be the next step, but we need to stage Fluffy carefully before we make that decision."

Mr Brown: "Can't we just do the cancer test and skip all the other stuff?"

Me: Speechless.

blank

sorry that i haven't had much to say as of late. i know that most of you read this blog to hear about my veterinary exploits. alas, i have not worked since june 9th. my next stint of relief work dates is june 23, june 24th (my 30th birthday), and june 25th. i'm sure i'll have enough wild tales of those 3 days to fill a short novel...so hang in there.

in the meantime, i've been packing, cleaning, sorting out mortgage stuff, talking to the realtor daily, going to north carolina with the husband, spending time in ktown with the bff and her husband, attending concerts, buying tickets to new concerts (avett brothers in charlotte aug 8, neko case in nashville july 25), and generally being a sloth.

i promise veterinary posts will arrive in due time. probably after june 25th!

wow. just....wow.

so the last few days have been an emotional roller coaster. first, it's that time o'the month soon. that alone makes me a walking emotional time bomb. secondly, our offer was accepted on the dream house - only to have the mortgage people come back and say "whoops, sorry that no one mentioned this before...but since you haven't passed the NC state board yet, your job contract is revocable, and therefore - doesn't count!"

no worries. that was (in all likelihood) straightened out. it has taught me a valuable lesson though. i'm not getting excited about the dream house. i'm just going to pack and plan and not think too much about it in the concrete fashion. oh, and do the oodles of stupid paperwork required.

the husband is teaching a summer course. we needed the money to help with the moving expenses/down payment, so he took it. of course, it requires that he be in ktown 5 days a week (mon-friday). so, i'm alone during the week.

further, i'm packing like mad. i hate delaying and i hate the cleaning and sorting and throwing away stuff that comes with moving. so i get a good long head start on the actual move (our closing date is july 15. supposedly). i have one whole room completely cleaned out.

add on top of that the fact that jim and i have blazed through the final season of battlestar galactica in the last 24 hours, and i'm a crying, incoherent mess.

just in case you feel like mocking me for watching BSG (which people have) - i dare you to sit down and watch the miniseries that started it all and NOT get hooked. if you can do that, then hats off! in all likelihood, you'll find yourself devouring whole seasons in a week until you get to the final, devastatingly emotional, gut-wrenchingly sad, and yet hopeful finale.

it's good, people. but it tears your guts out first. i've never felt like characters were so real. it's the only show that's made me cry as much as band of brothers - and that WAS real.

i'm just sayin'.