feeling bloggy...

but not particularly insightful. tomorrow heralds my departure for home!!! yay!!! i am so glad to go home. i miss my husband, my fluffy animals, my house, my town, heck - even my job a little. i've learned some while i was here, although the visit was disappointing, i have to say. my hosts were fantastic, it was more the learning aspect of it that was very disappointing. enough said on that front, i suppose.

i went out to dinner the last 2 nights in a row with one of my husband's cousins (who also lives here). she is young, unmarried, and extremely easy to get along with. it was nice to have someone with whom i felt comfortable enough to discuss my many neuroses (and no, that's not ALL we discussed). i had a lovely time both nights, which is a sound reminder to get out and do stuff on occasion. on the downside, "doing stuff" often involves spending money. jim and i are trying to cinch the old financial belt in a few notches, get really going on our savings. so part of my reluctance to get out and do stuff was financially based. on the other hand, i tend to get kind of antisocial when i'm lonely/depressed.

anyway. i have off from my real job until wednesday (or tuesday, i'm not entirely sure - depends on when the surgeons come in)...so it will be nice to have a few quiet days at home. i'll get to go visit the fat horses and ride some, as well as finally join a gym. i'm doing it when i get back, by god. i'm sick of feeling sloth-ly. i WANT to be healthy. i don't care so much about weight loss. i just don't want to have a heart attack before i'm 40. heart disease runs in my family, so i need to be super vigilant about caring for my body/heart. i'm not doing that right now, and i haven't been doing it for a long time... so... TO THE GYM. i miss running too, as i was telling jim's cousin. when i first started running, it was pure torture, and i loathed it. but then, as i ran more and more, something happened. i started to feel actually GOOD at the end of a run. i remember the first time i ran 3 miles. at the end, i still wanted to run, i felt incredibly powerful, relaxed, and energized. i do miss that. i also miss that my periods were entirely tolerable when i was running. they lasted 4-5 days (instead of 7-9), i didn't have mind-numbing cramps, and i found the depressing fog that i often suffer to be almost nil. no one has to convince me of the benefit of exercise, it was readily apparent when i began running.

i have to work for the next 2 weeks, then i have a week off. AMAZINGLY, it happens to correspond with jim's spring break. that's a virtually unheard of coincidence around our house. i booked us tickets to florida. we're going to visit my grandparents/aunts/uncles/cousins TOGETHER. we haven't been to florida together in quite some time. we'll also get to see our good friends and their adorable baby. this makes me very happy. it will be so nice to travel together for once.

i guess that's all the blathering i feel the need to do. i'm going to sleep soon, so i can get up fairly early and head for home!!!

An educational post: old age lumps and bumps (?)

So, I often talk about cases here, as well as my personal life. Yet since that MD inadvertently got under my skin by presuming that vets are ... well ... not real doctors, I've been thinking about adding educational posts to my repertoire. Today's topic will be old age lumps and bumps in cats and dogs...benign or malignant? Why should I care??

So, it is true - as dogs and cats age, they often develops lumps, warts, bumps, and soft masses - just like people. Many of these are benign growths that have no significance for the animal. Some examples of these include lipomas (benign fatty tumors that are soft and easily moveable under the skin), sebaceous adenomas (small to sometimes large, cystic masses that are particularly common in cocker spaniels), and papillomas (warts, for lack of a better word).

So, as your dog ages - should you worry about these masses? Should you bring them to the attention of your veterinarian? Moreover, should you take your veterinarians advice and have them aspirated and/or biopsied?

The short answer is YES.

The reason can be summed up fairly simply - some masses may look benign but in fact are the opposite. The following is a brief list of some lumps that should not be ignored:

1) Mast cell tumors. These are a cancerous tumor of dogs (found frequently in Boxers) that grow on the skin. They can look like just about anything - from small, red, benign-ish appearing lumps to great, big, swollen, ulcerated areas. It just depends on the mast cell. Mast cells are important in the body for mediating allergic reactions. They are full of nasty substances like heparin and histamine. Anyone with bad allergies knows what histamine can do and why antihistamines are good for allergies. When a mast cell tumor degranulates, a local allergic reaction can occur leading to redness, itching, swelling, and other general allergic signs. These tumors are often confined to the skin in dogs, but it is possible for them to metastasize to the visceral organs - especially the spleen and liver. Thus, when these are identified, it is best to have them surgically removed. Diagnosis is usually quite easy on aspiration of the mass. Surgical removal can be curative, but it is important to keep an eye out for more mast cells tumors, as some dogs have multiple tumors. A hallmark behavior of these tumors is a waxing and waning behavior - becoming large, then shrinking, then becoming large, as well as itching. Cats on the other hand, often have visceral mast cells - they start on the inside, in the spleen or liver, and then metastasize to the skin.

2) Hemangiopericytomas. These are lumps found most often on the lateral (outside) surface of the limbs, usually down toward the feet. They are tumors about which we know very little. We theorize that they come from the endothelium (lining of blood vessels), but really - we don't know for sure. They are often very soft, squishy masses that bleed easily when irritated. They don't typically metastasize, but they can be extremely locally aggressive. Radical surgical excision is the recommended treatment. This might include amputation in some cases, depending on how large/aggressive the tumor is. Getting clean margins (i.e. ALL the cancer cells with a clean rim of normal tissue) is tantamount to success.

3) Cutaneous lymphoma or hemangiosarcomas. These are skin cancers that can be isolated to the skin or that can also be found metastasized internally. Depending on which cancer you're dealing with, these can be life-threatening (if metastasis is present). I admit I know little about cutaneous hemangiosarcoma. Surgery is the treatment modality of choice - with possible chemotherapy follow up - depending on the margins and metastasis. The most common form we see is splenic (on the spleen) or atrial (found on the right atrium of the heart) and that has a horrible prognosis in dogs (6-9months). Lymphoma, on the other hand, can be very dependent on type, location, etc. It's not a very well understood entity either, but can definitely be life-threatening.

4) Liposarcomas. These are a spectrum of the benign fatty tumors. They are fatty tumors that become deeply infiltrating. They can interfere with blood vessels, nerves, and organs, if they are deep enough. While not necessarily deadly in a metastatic way, they can interfere with gait, blood flow, and the like.

There are others, but these are the big players.

Another dirty little secret of cancer? It likes to hide. Just because your dog or cat has had one fatty tumor aspirated and confirmed as a lipoma does not mean that all the other tumors that FEEL like a lipoma are in fact, lipomas! Sometimes, in the center of those lipomas...are nests of cancerous cells. Sometimes you cut open a seemingly benign lipoma and smack in the middle is a sarcoma!

So, the answer?

Monitor your dog and cat for lumps and bumps - if they appear, it is always best to see your veterinarian. They may recommend aspiration (taking a needle, sucking out cells, and looking at them on a slide) or biopsy (taking a large piece or taking off the whole mass and submitting for histopathology). The best method is biopsy and histopathology, but this is a more expensive diagnostic option - and if you have a lumpy dog, could cost in excess of $1000 (average histopath at my hospital is $180/site).

Always have the lumps and bumps checked. It is especially important to have them checked if they grow rapidly, seem deep or fixed to a layer deeper than just below the skin, bleed, ulcerate, or otherwise seem irritated. It's better to know so early treatment can be pursued!

weirdness, loneliness, and allergies

i don't do well away from home. i tend towards melancholy too much. as my grandmother likes to point out, this might be due to my propensity toward sad movies, books, and music. she might have a point. i've gotten to be rather proficient at traveling alone. last month, i went to orlando for NAVC by myself. granted, i stayed with family - but a great deal of my time was spent at NAVC, alone. prior to that, i traveled to san antonio and to baton rouge and to other places alone. when i say alone - i mean that i was not in the company of anyone with whom i was especially close. in some cases, i was actually alone.

i was once prone to panic attacks when far away from home. i learned to control those (free of pharmaceutical intervention) long ago, and it's been years (first year of vet school, actually) since i had one. once upon a time, i thought it impossible for me to ever travel alone. and yet, i've been able to do it - albeit not well. i'm always melancholy. part of it is my fault - i'm a homebody by nature. i'm also trying NOT to spend money on things i can't afford - frequent movie goings (although i love movies), frequent dinners out, etc. so that necessitates a rather home-oriented lifestyle.

since i've been here, i've only been without jim for 3 days really. he came up on friday (i arrived on tuesday). so i wasn't alone for the weekend. i took yesterday off from my rotation. i wanted to spend the day with him and given that i'm here on a strictly spectator, personal edification trip, i figured it would be okay. then i started to feel like a slacker. then i started to feel like a REAL slacker. after all, i'm here to learn, right?

no matter - back to the vet school today. only it didn't work out that way. literally halfway to the vet school, my eyes began to burn a little. no matter, i've always had overly sensitive eyes. in fact -for the past few months, i have stopped wearing contacts because they've begun to consistently bother my eyes. at any rate, they started to burn. i ignored it initially, reluctant to rub my eyes because of my makeup. within about 2 minutes, the burning escalated until tears were pouring down my face. i could feel my eyes swelling shut. i wasn't having any trouble breathing, i didn't see or feel any hives on my face or elsewhere. i didn't smell anything odd, nothing bit me, i hadn't eaten breakfast that morning, or used any new cosmetics. i was driving my car, as usual. as my eyes began to swell, i realized i was having difficulty keeping my eyes open to see and drive. i was on the beltline - which is an internal interstate of sorts with heavy traffic. slightly panicked, i looked for an exit. there was nowhere safe to pull off on the beltline itself, but i found an exit. i intended to pull off the side of the exit, but a 4 inch curb prevented this. at this point, i could barely see between the slits that had become my eyelids. i finally made it to a somewhat safe place, pulled over, threw the car into park, and sat with my eyes closed, as the tears poured down my face.

it was a good 20 minutes before i could open my eyes. i considered calling my husband's cousin to pick me up, but i hated to be an inconvenience. i was only 6 minutes or so from the house. i waited a bit longer, then i turned around and headed back. i took a benadryl (which promptly knocked me out for 6 hours) and then slept. when i woke up, the swelling had receded and my eyes felt almost normal. they feel almost normal now, except for a "phantom" burning that occurs every time i think about the incident.

i've no explanation but seeing the doctor seems pointless. the problem has resolved itself and i can see how the doctor will approach this...as i've approached many similar WTF incidents before - a thorough work-up that will - in all likelihood - not reveal a cause. i'll be sent out the door with an anti-histamine, an allergy medication, and an epi pen. knowing how medicine works can be a detriment, i must say.

so i missed work today. and now i feel like a total flake. i shouldn't have taken the day off yesterday. i should have gone and observed (for that's all i'm doing), despite my husband's presence - because today, i actually couldn't go and thus missed 2 days instead of 1. added to that the fact that my work schedule at home was messed up, so instead of arriving for the start of the rotation on monday, i had to delay until wednesday - and what does that spell: FLAKE.

i blame this all on my being away from home. i hate being away. i hate being separated from my husband (does this border on pathologic? or is it only due to the marital problems we've suffered over the last 2.5 years? i think the latter, mostly). i've worked far too much back home lately, my schedule was never-ending, my shifts often in excess of 15 hours, then i had to drive here... i realize that i need a break...and that i'm being too hard on myself. and it's not like i'm in a terrible, lonely situation. my hosts here have been gracious, welcoming, and accommodating in every way - but after a while, it's hard not to feel like an imposition. my cousin has invited me out numerous times to do things, and we actually are going out tomorrow night to do something...not sure what yet.

i'm lonely. and i want to go home. i miss my animals and my house and my "normal" job and my life.

boohoo. woe is me. i know. i must suck it up and get over it. i get to go home on saturday.

gratuitous blogging- oscar play by play.

i'm watching the oscars because i'm THAT bored. seriously. what are the oscars other than hollywood - a bunch of self-centered, narcissistic, rich, self-righteous liberals - masturbating in one grand symphony over the course of 4.5 hours? why am i watching?? i can't get myself off the couch. i just finished reading a book, and i'm not quite ready to delve into another. i'm sleepy, but i'm resisting the urge to pass out at 10pm, despite the fact that i have to "work" at 8:30 tomorrow morning.

diane lane is beautiful, i have to say. christopher walken is crazy, as well. i'm happy to see that michael shannon was nominated. he was absolutely phenomenal in 'shotgun stories' - an extremely unknown film about 3 brothers that was amazing, stark, and largely unseen. it's an excellent movie that i highly recommend.

heath ledger for best supporting actor, really? i mean - come on. the guy was absolutely FANTASTIC as the joker, but he's dead. give the oscar to someone that's alive so that they can appreciate it. heath ledger threw his life and talent away on drugs. heath ledger- everyone knew he would win it. you have to give the oscar to the dead guy. i wonder if they'll play music over the ledger family if they ramble on beyond their allotted 45 seconds? i would bet not.

i'm betting no one in the audience other than those involved have seen any of the nominated documentaries. probably a shame, many of them are probably worth seeing.

bill maher? ack. gag me with a spoon. i despise maher. 50 bucks says he has to say SOMETHING about politics. 5...4...3...2...1.... wow. he didn't say anything. i'm amazed. such restraint.

ok, this has reminded me of several movies i need to see that i've somehow missed this year (or that are coming out soon):
1) doubt
2) slumdog millionaire
3) gran torino
4) curious case of benjamin button
5) revolutionary road
6) the reader
7) watchmen (not out yet)
8) australia
9) the duchess

for what it's worth, i've heard the following:
1) that revolutionary road is overwrought melodrama and completely destroys the essence of the book (which was amazing)
2) curious case of BB was a short story taken and ruined by being made into a movie
3) australia is not a good baz luhrmann movie...which i'm going to ignore, because i love baz movies (moulin rouge, strictly ballroom, and romeo + juliet)
4) gran torino is a return to good 'ole shoot 'em up clint eastwood style

ok. i'm signing off now for real. i can't keep doing this silly non-blogging and expect people to care!

paranoia and random ramblings

sometimes i become irrationally paranoid about my house and pets. i'm terribly afraid of a fire breaking out in my house. if one ever did, i would likely lose all 8 of my animals. while they are certainly not people, i love my animals dearly and would be broken-hearted to lose any of them - let alone all of them. when i'm away from home, i have an extremely trustworthy individual pet-sit for me. she is a technician at the place i work, and she LOVES animals - more so than most people i've met in my life. having her watch my pets gives me a great deal of mental peace. sometimes though, when i'm away from home - i get so worried that one of the animals will get sick or a fire will break out in the house or something else. it's irrational, i know - but still a very real fear.

the husband is here in raleigh with me for the weekend, which is really nice. i'm staying with his cousin and her family. they have me set up like a queen in a spare bedroom in the basement, away from the main traffic of the house, with my own bathroom, TV, DVD player, and laptop. they also feed me every night. i feel rather bad that i'm not paying them something...but i guess that's what family is for, eh? i feel very welcome and comfortable. the husband came up this weekend to see me but to also visit with his family. his other cousin, as well as his aunt and uncle live here, so we all had a nice visit (and a big dinner) today.

all in all, it's been a very relaxing weekend. i slept most of the day saturday - off and on...thanks to the unfortunate monthly "illness" that is often so hard on me. i go back to NC State tomorrow for the rest of my time on cardiology. it's been going okay. not stellar. no one has really taken me under their wing. everyone has been nice, but i feel like i'm in the way oftentimes. no one has invited me out for drinks or dinner or anything like that. it's kind of an odd position to be in, but i'm hoping this next week will be better. we shall see.

that's all to say here. nothing new to report.

what to say, what to say?

the question of what to do with myself next year has again reared its ugly head. i am completely torn. i've been offered a job at my current place of work as an ER doctor. this would mean that i'd be working mostly overnights, and occasionally on the weekend days. it doesn't appeal to me. i don't think i'm cut out for ER medicine in the long run. i do enjoy it to some extent, but i also really enjoy the long-term follow up with patients, the relationships you build with owners, the feeling of getting to see an animal you've nursed back to health survive and come back to you in the future. ER medicine doesn't really allow for that very often (although on occasion, it does).

i also don't like dealing with people under an enormous amount of stress. people get too ugly and anger too easily in emergency medicine.

on the other hand, where i am now - i can practice top notch medicine 90% of the time (the other 10% of the time, we're out of really critical things ... like certain blood machine cartridges and potassium chloride and reglan...). despite myriad flaws, the place is developing, and it has massive potential. i like that i can often thoroughly work up a case instead of just prescribing antibiotics and sending a patient out the door.

i don't know where i'd work next year if not at my current location. jobs are scarce, the market in my area is not good, and i'm afraid that i won't be able to find a day job.

i go back and forth because...hey, it's just another year, right? i could work there while the husband finishes his phd, then we'd both be free to move wherever our fancy takes us.

***sighing*** i was foolish enough to delude myself into thinking that all the hard decisions would be over once i graduated vet school.

GRUMPY PANTS

sorry - that last rant about MDs was kinda grouchy - especially considering that my father-in-law is an MD. he has respect for what i do and knows that i'm not just a hack with a vaccine syringe.

ok, no time to blog now - i'm due at NC State in about 25 minutes, so i need to get motivated and moving out the door. i just hate being cold walking to my car - it makes me grumpy. do we see a theme??

some people get under my skin

sometimes MDs are so annoying. i read a great many MD and nurse blogs - just out of general medical curiosity. i love the medical field, be it animals or people, and i recognize the great challenge that medicine presents. MDs, on the other hand, seem to have a dim view of veterinarians and what we do. i get the feeling that they often view us as wielders of vaccines, heartworm preventative, flea medications, and the scalpel (but only for routine spays/neuters/declaws). while once upon a time, that might have been true - it certainly isn't any longer. i read a blog written by an MD recently, and he was amazed at the "sleuthing" their vet did to determine that their dog was suffering back pain. his description of the physical exam, diagnostics, and recommendations was completely commonplace to me - a condition we often deal with and know how to treat with a great deal of success. but this MD was absolutely impressed by his vet's ability to elucidate the problem - especially in light of the fact that our patients lack language skills and cannot tell us where it hurts.

i assume that most of you who read my blog regularly understand what vets do - especially specialists and ER docs. but just to be clear:

we treat cancer aggressively with chemotherapy, radiation, and surgical excision. we diagnose immune-mediated disorders like lupus and pemphigus and IMHA and treat with of-the-moment immunosuppressives like azathioprine and cell-cept and cyclosporine. we do organ transplants and peritoneal dialysis and bone marrow transplants. we regularly try novel surgical approaches such as urethral stent placement in cats with urethral strictures. we employ CT scanners and MRIs and PET scanners in our radiology/imaging departments. we (the veterinary field) have developed a novel vaccine for the possible treatment of melanoma. we can diagnose and aggressively treat any number of cancers. we have a myriad of treatment options for heart failure. we can repair congenital heart disorders like patent ductus arteriosus (PDA) and pulmonic stenosis. we (the vet field, again) are actively researching in every avenue of medicine.

being a vet is not just about vaccinating animals and spaying/neutering. working where i do now - as an intern - doesn't include any routine care at all. i haven't vaccinated an animal since 4th year of vet school, working at the vaccine clinic. i've only spayed animals if i was already conducting a c-section or removing a pyometra.

becoming a veterinarian requires heavy duty college coursework (organic chem I & 2, biochemistry, physics, calculus) beforehand, and then 4 years of veterinary school afterwards. 4 more years of optional learning (internship/residency) can follow that.

i am a doctor. instead of doctoring people, i doctor animals (and their people by proxy). i love my job. i considered becoming an MD, but i lack the rapport with people that i have with animals. my job can be incredibly satisfying on 2 levels - 1) i get to work with and help animals and 2) i get to help their people. if i could have stomached seeing injured people, i might have become an MD, but the sight of human blood and suffering makes me nauseated. truthfully, i'm not sorry for that. i love my profession, and i'm glad to be a member of it...whether some people see me as a real doctor or not!

i'm so tired.

after working the last 21 of 25 days, multiple shifts in excess of 14 hours, and mind-numbing exhaustion, i have today and tomorrow during which to pack, clean my disgusting house, and drive 8 hours to raleigh, NC for a rotation in cardiology. whee!!

an art, not a science

the little pomeranian i was confronted with was an unusual color. she was a merle - that blackish blue, spotted color that is usually reserved for larger breeds of dog. it was quite attractive, as was her personality as she kissed my face.

her owner reported that she'd developed a harsh cough that day. she'd been lethargic for the past 2 days, and her appetite was decreased. indeed, as i examined her, the cough became evident. it was a hacking, almost honking sound. in an older, fatter pomeranian, i likely would have instantly labeled it as a collapsing trachea. this - however - was an 8 month old puppy.

her physical exam (which i did while i listened to her history) was fairly unremarkable despite a hacking/honking cough, i couldn't hear anything worrisome in the lungs. her gums were pink, her heart rate slightly elevated (but otherwise normal), her abdomen soft and squishy. her rectal and oral exams were normal. she didn't have a fever or big lymph nodes...just a terrible sounding cough.

i turned my attention to her history, as the owner relayed it to me. previously healthy, no current medications, no prior illnesses, up to date on vaccines, never heartworm tested or placed on heartworm preventative. uh-oh.

i recommended a heartworm test. we talked about this for a bit, and then the owner (a very young girl) mentioned offhandedly that the puppy had eaten rat poison about 2 weeks ago. she'd been treated at the rDVM though - with vitamin K tablets. she'd been normal since then. i thought about it briefly, then filed it away for further consideration while we ran the heartworm test.

it was negative. the interesting point was that after drawing the blood, the venipuncture site bled. and bled. and bled. and then bled for a while longer.

in the room, i questioned the owner further about the rat poison. as it turned out, she'd only treated the dog for 7 days with vitamin K. the poison was D-con, which contains brodifacoum - a rat poison that takes 21 days to be eliminated from the body. i asked the owner, 'did you follow up with the vet 3 days after stopping the vitamin k for a clotting profile?' the owner nodded - but it was a slow, uncertain nod. i didn't press the issue, but i didn't believe her.

xrays revealed infiltrates in her lungs. her clotting times were off the chart. i explained to the owner that her dog was bleeding into her lungs, required an emergency plasma transfusion and vitamin K treatment due to rodenticide poisoning.

all went well for the puppy. her clotting times returned to normal within 24 hours of treatment, and she will live to fight another day.

you know why i love cases like these? i could identify a clear problem, and i could offer a clear solution. so often in medicine - the answer is uncertain, the treatment options varied and the research minimal. there are so many times i have told the owners, "i'm sorry, i don't know exactly what is wrong with your pet. i'm going to treat what we can, and i'm going to cross my fingers that i hit the disease process." medicine is an art, not a science. there are so few instances where i can pinpoint the exact problem and the exact treatment. when it happens though, it's reminder anew of how rewarding medicine can be.

happy V-Day!

i did a c-section tonight on a boston terrier. the owners adopted her about a month and a half ago. she must have been pregnant when they adopted her, because she had not been bred while being owned by these people. when she presented to me, she'd been in hard labor for 12 hours without producing a puppy. not good. very not good. the puppies were likely dead. on pelvic exam, i could feel a head stuck in the birth canal. we obtained approval and went straight to surgery.

5 puppies - 2 dead in utero, 1 weak and died shortly after "birth", and 2 hardy little survivors. the c-section went really well. i was finished in an hour - which considering my general abhorrence of surgery (not really) gave me a great deal of pride. that's a fast c-section from cutting to closure.

my husband - darling that he is - showed up around 3:30am with "treats" (i.e. cheese popcorn, blow pops, and a whopping huge dr pepper) as a kind of valentine's day surprise.

proud of my saving 2 puppies, i took him to the cage so he could see them. as we stood looking at the puppies - one became very rigid, stopped breathing, and died. i snatched him up, but there was no heartbeat. i called for oxygen and hot water bottles. i started chest compressions vigorously while the technician set up oxygen for the little guy. as i compressed with my index finger and thumb, i used the other hand to grab a suction bulb so that i could clear the airways. within 30 seconds, i had a heartbeat, movement, and breathing. puppy recovered and is doing okay right now.

my husband was absolutely amazed, while i was rather blase about the whole thing. i just massaged the puppy's chest, suctioned, and administered oxygen. it took about 30seconds to get puppy to come around. i actually thought it rather hilarious that the husband was so awed and excited by that relatively innocuous occurrence. it was nothing compared to my handling of the hit by train, my emergency chest tube placement - HELL, it was nothing compared to the actual c-section.

he insisted that i should post the "miraculous" puppy save on my blog. so here i am, dutiful wife - posting about my puppy save. it was rather gratifying, because my husband never gets to see me "in action." he's not really into the medicine/vet thing, and he doesn't see why i get so excited about medicine. i can't say that i understand, but i can empathize. i can't figure out for the life of me what's so intoxicating about abstract mathematics.

so that husband and wife moment brought to you by valentine's day - the lamest holiday ever.

juxtaposition

here's a little lesson in the variety of owners i see:

Case 1:
4 year old yorkie recently obtained (about 6 months prior) by the owners. said owners are obviously poor and uneducated. nevertheless, they genuinely care about their pet. unfortunately said yorkie is incredibly malnourished. she presents seizuring. according to the owner, she has been seizuring for 8 hours. all of the trouble began shortly after she ate dinner the night before. i do a quick physical exam on her and find that she is emaciated, has a palpably small liver, and is severely depressed and seizing. she also has some obvious congenital defects. the owner says that he got her from a breeder who didn't want his name mentioned when the dog was brought to us (i bet he was a scrupulous, careful breeder, eh?). he gave the dog away because of its numerous birth defects. after my physical exam, i have several differentials in mind - the most important being a congenital abnormality called a porto-systemic shunt. other things that could cause this include toxins (antifreeze notably), trauma, severe emaciation, sepsis, etc. i talk to the owner, and i explain that his dog is in very poor shape. she requires hospitalization, bloodwork, and intensive care if she is going to survive. the owner tells me that he doesn't have money for all that. i carefully explain that we are looking at spending easily $1000 or more. the owner says he doesn't have it. he explains this cautiously, and it's obvious that it hurts him to tell me this. he explains that he knew the dog was thin, but that the "breeder" recommended a certain amount so that she wouldn't get fat and have trouble walking on her gimpy leg. it is obvious he feels terrible. he calls his wife to relay the news. i can hear her crying. he hands me the phone, and i explain it all again. she thanks me for my kindness and says that we will have to euthanize the dog. no recriminations, no accusations, no insinuating or outright saying that i am a dog murderer because i can't care for their dog for free. just a thank you and an acceptance.

Case 2:
owners bring me a big 'ole dog (80lbs). he is chipper but staggering slightly, as well as vomiting. all signs point to antifreeze. i explain to them the 2 treatment options: antidote to cost $1700 for their very large dog or ethanol alcohol IV. both require hospitalization. ethanol is cheaper in the short-term but requires intensive monitoring due to the massive amount of alcohol infused into the patient (basically you get them knock-down drunk/comatose) and 2-3 days in the ICU. when i explain this to the owners, they tell me that they don't have the money. i sadly offer euthanasia. i am lambasted, told that i am a dog killer. i calmly explain that no, i am not a dog killer but antifreeze is. i explain about the overhead of running our clinic, the cost of keeping the lights on, paying technicians. i am again called heartless - a dog killer. i step out of the room to let the owners discuss their options. i go back in. the ownres tell me how very much they love this dog (i bite my tongue and do not mention the fact that 1) the dog has had heartworms because they loved it too much to give it preventative and 2) the dog has been shot because they let it roam FREELY without regard for his safety - but i WANT to say it. i want to BADLY). in the end, they coughed up enough for alcohol and hospitalization. the dog went into anuric renal failure on sunday (unable to produce ANY urine, despite massive IV fluids). guess who still hasn't finished paying the bill in full?

i try to take a deep breath and remember those that are thankful and friendly and understand that i cannot give away treatment for free. most of the time, i can remember them. sometimes, i really have to bite my tongue, because bitter words spring to my lips all too easily.

in the end, do the 2 types weigh each other out? i hope so.

back in the saddle

after a long hiatus from riding, i found myself back in the saddle today. i rode the incredibly obese draft cross belonging to the internal medicine specialist with whom i work. they live out in BFE and also own a clydesdale. both are ridden sporadically, so neither is in very good shape. that was fine by me, as it's probably been a year or more since i rode.

back in the day, i was on the equestrian team at my alma mater. i loved riding, and i loved taking lessons. i grew up riding western and tennessee walking horses. in college, i became interested in riding hunter/jumper (english). i loved the style, and the discipline and ability required to ride H/J well, so i stayed with it. vet school - however - pretty much ended any fun extracurricular activities, and riding slowly fell by the wayside.

i've always been an excellent rider (yes, modest too). my nickname in college was 'sticky butt' - i very rarely came out of the saddle, regardless of the circumstances. there were 2 notable exceptions to this - one involving a fresh, off-the-track thoroughbred and a steel fencepost...and another involving bareback riding, a lame (as it turns out) quarter horse, and very poor decision making skills.

i don't know why riding became something i did so rarely. and after today, i really want to make it part of my regular life again. i have a free pass to ride these guys, and it would be a challenge and enjoyable to be responsible for getting them into fit shape. they really need the work. it would also help me stay in shape, as well as stave off the inevitable depression that working ridiculously long hours in a often tragically depressing field causes.

so. that was all. riveting post, eh?

it's almost a full moon. (warning : profanity used)

today was unreal. at least now i know i can be a decent ER doctor - although i don't think i want the enormous responsibility of managing all of these horrible traumas/illnesses at one time. i'm just not good enough. is anyone??

today, i had the following cases present to me (all within 4 hours): 1) dog kicked in the head by a horse resulting in head trauma + broken jaw 2) different dog/same horse - kicked in the chest with horrible pulmonary contusions, hemothorax, rib fractures, and pneumothorax 3) different dog/same horse kicked in face - leaving large laceration that i had to sew up 4) dog that drank antifreeze an hour before and whose owners didn't have $$ for antidote 5) chocolate toxicity that ate 50mg/kg or some ridiculous dose AND THEN THE PIECE DE RESISTANCE: a DOG THAT WAS HIT BY A TRAIN. yes, you read that right - hit by a F*cking train. his back leg was torn off at the knee, his tail was torn off, his head was degloved, and he had schiff-sherrington posture on presentation. 2 spinal fractures were found on xrays (after we bandaged him, placed an IV cath, and gave him his fluids and pain meds). the spine was actually broken completely in half and one fragment was underneath the other by about 6 inches. it was terrible. needless to say - euthanized. the owners saw the whole terrible thing unfold before them as they tried desperately to get him off the tracks.

i had to place a chest tube in the kicked dog (ALL BY MYSELF FOR THE FIRST TIME) and auto-transfuse all the blood he had in his chest right back into him, i cared for him all day, until he succumbed to internal thoracic bleeding - despite autotransfusion, packed RBCs, and heavy duty intensive care. thoracotomy/surgery wasn't really an option, so we tried to manage him (to no avail, obviously). i admitted him at 3:00pm, stabilized him, he crashed and burned at midnight. my antifreeze dog wound up being treated with PGA due to owner financial constraints and is currently doing well, my chocolate toxicity was stable and then suddenly (totally out of nowhere) FELL OVER F*CKING DEAD at around midnight. no one has ANY clue why. he received the standard treatment for toxin - apomorphine, activated charcoal/sorbitol, IV fluid bolus. one moment, he was up and vocal, then he literally fell over and died. he couldn't be resuscitated. even the great <> had no clue as to why he died.

if i'd had 30 seconds to stop and think about what i had to do today - all the treatments i had to administer and the rapid decisions i had to make, i think i would have been completely paralyzed by fear. luckily, i didn't stop to think. and i lived. not all of my patients did.

i was there 5 hours past the end of my shift at 8pm (it's 1:15am, and i just got home). i have to be back at work in 6.5 hours, so i think i should sleep now.

**ps - explanation behind the same horse kicking 3 dogs - it was a skittish horse belonging to the owners. they took it out of the trailer and for some reason, the 11 dogs they own decided to go tearing off after it. the horse was a nut and lashed out - kicking one dog squarely (and fatally, as it turns out) in the chest, one in the head, and gave a glancing blow to a fast jack russell). seriously. i couldn't make this stuff up.

ok, now to bed.

glut

i'm swimming in a glut of new music. i joined emusic - a website that sells independent records. it's $15/month for 50 downloads. i like it better than itunes, because the music is MINE, and i don't have a finite amount of times i can burn it - and i don't have to convert it out of some stupid, special format to share with others. at any rate, i went a bit crazy today and downloaded the following:

okkervil river: the stage names (2007)
okkervil river: the stand ins (2008)
andrew bird: noble beast (2009)
bon iver: for emma, forever ago (2008)

the problem with having whole albums of new music at one time is that i don't sit at my desk and study for hours on end anymore. that was the perfect time during which to listen to new albums - savor the subtleties and complexities - revel in an album over and over until it was as familiar as my own skin.

lately, i've taken to listening to a lot of easy, trashy pop on the way to and from work (a mere 7 minute drive). this includes things like pink, britney spears, and katy perry. i feel dirty but oh so good when listening to this bubble gum pop.

on the other hand, i miss quality music. thus my quest to download all 35 of my songs left this month.

bon iver is amazing. the new andrew bird is predictably good.

unrelated - i was supposed to attend our local veterinary association monthly meeting (complete with free dinner) tonight. i elected to stay in, order pizza, and watch a movie with my better half. we watched 'michael clayton' with george clooney. it was surprisingly good. there was a great deal of character development, plot, and excellent acting. i thoroughly enjoyed the movie and highly recommend it.

i was scheduled to have today off - so i thought, but i wound up working with the soft tissue surgeon from my alma mater. the man is a phenom. he's been a vet for 35 years, is triple-boarded, and has mad surgery skills. working with him is eye-opening, so it was an excellent opportunity for me.

that's about all here...

matters of the heart

as the dog crept toward me, i started my list of physical exam findings: extremely poor body condition (ribs were prominent, vertebral spines very noticeable) but a distended/pendulous abdomen, increased respiratory rate and effort, stiff gait, and a generally unhealthy look were all too evident.

as i glanced at the record, i was stunned to see that the once beautiful male german shepherd before me was a mere 6 years old. he looked and acted at least 12.

he was a very sweet boy with big, expressive brown eyes. as i placed the nasal oxygen prongs in his nose, he gave a big sigh and laid his head on my knee.

as i examined him, i added to my physical exam list: mild heart murmur, louder on the right side of the heart, increased lung sounds, and severe abdominal distention with a fluid wave (when i briskly tapped his abdomen with a finger, fluid was felt).

everyone around me (techs, other doctors) were insisting that he had a hemoabdomen (blood in his abdomen) and a likely hemangiosarcoma (splenic tumor). looking at him, i doubted this. he was in generally poor condition.

i held off making a judgement until i could quickly tap his abdomen with a needle and remove fluid. sure enough - not blood. it was a clear, yellowish fluid with a tinge of pink. i turned to my technician. "would you please ask this owner if this dog is kept on heartworm preventative?"

the answer was really all the answer i needed. no, the dog was not on heartworm preventative. we ran the test. it was a strong positive. looking at a blood smear revealed greater than a 100 microfilariae (immature heartworms) swimming in the blood.

heartworms mature in the heart, notably the right side. that side of the heart is responsible for taking the blood back from the rest of the body and circulating it through the lungs for oxygen exchange. when the heartworms interfere with this, the heart goes into right-sided failure. fluid backs up into the body, mostly the liver, and that increased pressure causes fluid to leak out of the vessels - serum, plasma, and proteins. this fluid builds up in the belly - called ascites. there are other causes for ascites, but given that this dog was not on heartworm preventative and had respiratory signs - heartworm was number one on the list.

i talked to the owners. treatment of this dog would focus on getting him out of heart failure with lasix to decrease the ascites, heart failure medications, and supportive care. once he was out of failure, we could treat the heartworms. we were easily looking at spending $2000.

the owners didn't have that money. they had adopted the dog a mere 2 weeks beforehand from an elderly grandmother. euthanasia was their decision. they kissed him goodbye, and i took him to the back.

we gave him some yummy wet food, which he slowly ate. then, while my technician held his head and told him he was a good boy (which he most certainly was), i did that thing which i do 30 times a month but hate most.

he went with a quiet sigh, closely his doggy brown eyes and simply going to sleep.

and all of this could have been prevented with simple monthly chewable tablets.