What am I, a magnet??

I seem to attract 2 cases consistently: diabetic ketoacidotic patients and foreign bodies. Yup, I had one of each this weekend.

The DKA was frustrating. I wasn't as able to stay on top of her fluids as I should have been. Diabetics are generally dehydrated as a rule. This is 1000 times truer for a DKA patient. As my internal medicine specialist mentor told me, "it often takes incredible quantities of fluids to keep up." After 2 days of managing her, I am not happy with where we are. On the bright side, while her numbers aren't improving, her clinical condition seemed to be...maybe. It's really hard to tell. I'm still obsessing about it, and I've been off work for 3+ hours.

My other magnetism...foreign bodies! A nice lady brought in her 3 year old small breed dog. He had a history of a foreign body 1 year previously that our clinic also fixed. She was pretty sure he had something else stuck. After my physical exam, I was 80% sure she was right...A few hours on fluids with no improvement in dehydration, abdominal palpation that caused regurgitation of foul, dark brown liquid, and a palpable something in the middle of his abdomen, and to surgery we went. I removed a rubber stopper of some sort from his mid-intestines. Currently, he's doing well...but we're still in the iffy period of 24-72 hours. I didn't have to cut out any intestines, so that's encouraging. We shall see. I never count on these until they're at least 3 days out.

We were pretty busy on Saturday, not as busy today. I saw 2 heartworm cases -both in bad shape today - one coughing up blood (hemoptysis) and another in post-caval syndrome. Post-caval syndrome is when the heartworm burden has gotten so heavy that worms are backing up into the vena cava and portal vein. It's a bad, bad thing. The only "cure" for that form of heartworm infection is to make a cut in the JUGULAR vein and take a HUGE pair of forceps, stick them down in the jugular, and start pulling out heartworms. I know...crazy, right? I euthanized that dog, as you can imagine. I also euthanized the one coughing up blood. Both were sad because heartworms are SO completely preventable. Ah, human folly. Both dogs enjoyed Hershey's chocolate beforehand...it eased their passing, and my acceptance of it.

I also saw a SIXTY POUND MINIATURE SCHNAUZER. SIXTY POUNDS. The poor dog was in to see me because she couldn't walk. The owner thought her anal glands needed to be stressed. I can only assume he meant EXPRESSED. I had to try and explain to him that his dog should weight twenty pounds at the most, and the reason she couldn't walk and was covered with URINE scald was because of her morbid, morbid obesity. He didn't believe me, refused xrays to confirm her horrible, palpable arthritis, and took her home with pain medications. I almost lost my cool with him. Not solely because of the dogs condition but because he 1) told me he didn't know me and that his vet was GREAT 2) how expensive we were and 3) how educated he was about dogs.

I had to step out back after that last one.

Sundries

I've been on my 9 day off stretch.

Over the past weekend, my BF from Knoxville came and spent the weekend. We had a delightful time together - mindless shopping excursion on Saturday, dinner with Jim's sister, our nephew, and BIL on Saturday night, then out to see a live show later in a small, intimate local venue. It seats about 75 at maximum. We saw Cary Ann Hearst - whom I absolutely adore musically and personally. She's obscenely talented. We also saw a band called Red Shepherd (very good) and another localish band called Raised by Wolves. Due to the amount of alcohol imbibed, Sunday was spent sleeping VERY late, eating VERY greasy food to recover, and a late start home for her.

I had my 6 month job review with our office manager and 2 of our shareholders. All around excellent. I was very, very pleased. Here's one comment from my review: "X has been an excellent addition to our team. She came with a great knowledge base, brings new ideas to the team on a regular basis, and promotes the growth of our business. She has an exceptional amount of knowledge regarding her profession. She genuinely exhibits care and compassion for her clients, patients, and staff. She prides herself on client communications both while the patient is in our care and after." Pretty nice, huh?

We had a doctor's meeting yesterday to discuss work stuff, and we have a staff meeting tomorrow to translate the doctor's meeting to the staff.

I've been an utter sloth. I don't even have any bread to show for my time off. It's pretty sad. On the bright side, there are many things that I am looking forward to coming up:

Rogue Wave, March 8th in Atlanta - chance to see a great band in concert and spend the night with my internmate and classmate from vet school

Band of Horses, April 23 or 24th in Raleigh

My Morning Jacket, April 30 in Cary

A visit from Jim's cousin in mid-March for the weekend

A possible visit from my parents (fingers crossed) in mid-March

I'm sure there is more to report, but I'm already bored with myself.

Update

My Dachshund patient turned out to have a rather large gastric mass. He was scoped, and his stomach found to be full of blood with 2 actively bleeding sites. Endoscopically obtained biopsies were inconclusive. He would not survive surgery, because he was very, very ill, and he had few platelets to clot with. The owners elected to euthanize.

I feel like a moron moron moron. An older (7) dog with vomiting, melena, and thrombocytopenia - I should have had gastric cancer on my list. It occurred to me, but I didn't put it on my "official" differential list in the chart. I'm not sure why, entirely. It was an odd case, and now, we'll never know the answer. Was the mass cancer? Was it something else - something infectious like pythiosis? Was it an embedded foreign body that had set off a systemic DIC?

What I found interesting and confusing was the low platelets with a NORMAL PCV (measure of red blood cells in circulation). The internal medicine specialist attributed the low platelet count to ongoing bleeding in the stomach, however the dog wasn't anemic. We had no explanation for that other than perhaps a "consumptive coagulopathy" - the platelets were just being used up too fast.

Guess we'll never know. It was however, an excellent reminder of why we should refer. When something is above us...get help from the specialists! I never, ever hesitate to refer.

Mystery case...

At 2am last night, a small family walks in, a young couple (early 30s/my age). Both are polite, well-spoken, and obviously educated. The woman is very, very pregnant. They toted along with them a very sick small breed dog.

For 2 days, he had been progressively more lethargic, had begun vomiting, and having black, tarry diarrhea. They had at first assumed a nasty bout of gastroenteritis (vomiting and diarrhea due to non-specific GI upset). He wasn't getting better, though. They brought him to me.

I did my physical exam and found a depressed, dehydrated dog with melena (digested blood diarrhea). I figured we were dealing with something relatively run-of-the-mill: a nasty pancreatitis case, perhaps a raging hemorrhagic gastroenteritis (HGE), or a foreign body lodged somewhere, since he was a little Hoover dog (ate anything from the floor).

Imagine my surprise and confusion when I saw the labwork: marked thrombocytopenia (low platelets). The normal range is 175-250,000. This dog had 53,000 platelets. On top of that, he was very dehydrated and possibly suffering renal insufficiency (kidney values were elevated, he was very dehydrated, yet his urine was very dilute). He also had mild liver enzyme elevations. A canine pancreatic lipase assay to test for the presence of pancreatitis was normal - much to my surprise.

I was left with a very ill dog that was inexplicably thrombocytopenic, depressed, with vomiting and diarrhea.

My differentials? possibly tick-borne illness of some flavor, early immune-mediated thrombocytopenia (body destroying its own platelets), perhaps leptospirosis, a foreign body that had been present for a while, and now the dog in early/low-grade DIC? I ran clotting times to determine if DIC was present, and the clotting times were elevated (aPTT) and high end normal (PT). WTF? Xrays of the abdomen were non-specific.

In the end, I gave the dog a plasma transfusion to help in case this was early DIC, started IV fluids, pain medications, anti-emetics, and an antibiotic. I felt like an idiot, and I was very stressed about the case. I was tired, and I was afraid there was something huge and obvious that I was missing. The owners were flabbergasted. They had expected to find out that something simple was wrong with the little guy - like I had. When I told them that I didn't know what it was but that it was serious, they were just not prepared. I spent probably 2 hours talking to them and trying to explain my various differentials, but in the end, I was left with more questions than answers.

I sent him to the internal medicine specialist the next day. Last I heard, they have no clue what is wrong with him either...and are doing a barium study to rule out a foreign body -- even though I saw nothing on xrays to indicate a foreign body.

It made me feel a lot better that the specialists are currently stumped. Not for the dog, but at least I don't feel like I failed my clients...

Yeah, I know

that most of you don't read this blog to hear about food. Really, work has been work lately, and I haven't felt like typing about it. Not because I'm unhappy or because work hasn't been going well - quite the opposite. Other than a run of cases determined to remind me of my own fallibility, work has been great. I just haven't seen anything lately that blew me away (other than some referring veterinarian incompetence...which shall make another post).

Tonight, I made THE cookies. If you aren't familiar with THE cookies - they are supposedly the best chocolate chip cookies ever. This is according to the NY Times, a questionable source, admittedly. Anyway, the cookies are chock full of specialty items (cake flour, bittersweet chocolate feves or discs, and SEA salt), and they cost a fortune to make ($19 for all the ingredients).

On the other hand, they are truly beautiful to behold and might just be the best cookies ever. The sea salt sprinkled over the dough adds a great hint of tang to the sweet.




I finally bought a cast iron skillet to make breakfasts upon. I've been doing pancakes and eggs a lot, and a frying pan is just a pain the ass. The 15 pound skillet I bought works much, much better. Damn, is it a beast though! We made thick cut, boneless pork chops (from our local meat market) with dry rub and caramelized onions on it tonight. Quite tasty with garlic mashed potatoes and a fresh salad.

Is it sad that I get this much pleasure from food?

I've recently realized that I really identify more with the Paula Deen school of cooking than with the **insert some famous French chef's name here.** I like comfort foods, rich, delicious, unhealthy. I don't like raw fish or strange concoctions that would fit in the palm of my hand. I like big, hearty meals. What's wrong with that, I ask? I will try anything once. Heck, I tried sushi 3 times. It just doesn't work for me...

P.S. : Quality control in the kitchen is crucial

Bread and frustrations

The early reviews are out on the bread, and they are favorable. It does taste good, but it really, really gave me a further and deepened appreciate of my mother-in-law's talents. Her bread is light, soft, consistent, and absolutely amazing. It's handmade too - no bread maker. You don't realize how difficult getting bread to be perfect is until you make it yourself. My MIL is incredibly talented in the kitchen. At any rate, my bread was tasty and well-received at work and by the husband. I was not thrilled with consistency, I thought it was too dense...I've attached pictures. Don't laugh at the oversized, irregular shapes! It wasn't until 3 hours into the process that I realized that I don't have any true bread loaf pans. I wound up using a sort of bread loaf pan and a casserole dish. It worked out okay.






Yesterday, we watched our nephew (15 months). He is such a fun little guy. It was beautiful outside, so we spent the majority of the morning/early afternoon enjoying the sun and blue sky and relatively warm weather (50s). We also enjoyed the company of Porch Kitty quite a bit.





Last night was my first night back at work. We were steady but not busy. One woman brought her dog in for an emergency ear infection. She got to check-out and claimed to have left her purse at home, but she said she would call when she got home and give us her card number. Guess what? No phone call, no answer to OUR calls. Who does that?? Who walks in, receives services of any sort, and just ditches on the bill?? I would never go get my eyes examined, order new glasses, and then just say..."oopsy, I forgot my wallet," and then stiff the person that provided services. How is that ok? The dog didn't even have a critical problem, it was just a yeast ear infection.

On another work note, work was kind of a downer last night. I usually do relatively good on my follow-ups. I don't have suture dehiscences often (unless the dog removes the sutures) and otherwise, my patients (surgical and otherwise) do fine. I got to work and started checking follow-ups and found that 3 of my patients had complications.

One was a laceration repair that was easy to fix. I didn't start antibiotics because I was able to convert the wound to a very clean, surgical one. It got infected and had to have a drain placed, as well as more sutures. I fixed a proptosed eye (hanging out of socket), and the sutures loosened on it, leading to a corneal ulcer. Thirdly, I saw a kennel cough dog that was bright, alert, and healthy with just a mild cough. He had no fever and no other signs of pneumonia. I don't start these guys on antibiotics, because the kennel cough rarely progresses to pneumonia. I told the owners if the dog became depressed, lethargic, coughing worsened, etc to bring him in. Sure 'nuff - he developed pneumonia. He's doing great - no worries, and all of the others are also doing fine...but still.

I cut the tip of my thumb off with a butcher knife last week. It was a large, large piece, and I had a significant defect in my thumb. It also bled on and off almost constantly for 2 days and was very painful. I fixed the eye and the laceration the first day I had that problem, and it made wielding surgical instruments very, very difficult. I'm wondering if that contributed.

Eh, it wasn't my finest week as a veterinarian...but on the bright side, all 3 of my abdominal surgeries are doing great.

What I've been doing (and my husband too)

I've had the last 4 days off , and it's been delightful - utterly lazy. My handy husband installed new track lighting above our sink. It replaced the ugly, ugly white lights that were up there.




I'm in the process of making my first round of homemade bread today. It is rising as we speak...so we shall see. I'm skeptical.




I wanted to volunteer at Big Brothers/Big Sisters. As it turns out, they are in desperate need of male volunteers (as my husband is), but they don't need females. So, I was shot down there.

Last night, we met a fellow veterinarian (the one I ran into at NAVC) and her SO for dinner at our favorite greasy spoon. It was a nice, low key evening. It was nice to get out to dinner with other people. Jim and I tend to be our own little group and we fail to branch out enough.

I've also been doing a fair amount of bird wrangling. I haven't clipped wings in a while, and everyone is fully flighted. My African grey demonstrates this in the picture below.






My mom is coming to spend the night with us Saturday night on her way to Florida to see family. I'm very much looking forward to it, although I have to work all day Sat/Sun.

Not much else to report here.