Tuesday, April 27, 2010


A few pictures...Heidi, wonder-dog, my vegetable garden (which is doing well), and the back flower bed. I should have taken before pictures. It doesn't look that exciting now, but it was full of dead crab grass, dead hydrangeas, and out of control vine until I took it in hand today. I weeded, cut back the crab grass, pruned the hydrangeas, and put down new mulch. I also push mowed the entire lawn (and it's NOT a self-propelled mower). I followed that up by making ginger soy chicken and broccoli for dinner, then reading some. All in all, a productive day.

Sunday, April 25, 2010

Update on the H-bomb

So, she has improved markedly. The urine overflows at night are down to smaller spots...but she is still losing control of her bladder.

A repeat urinalysis tonight did not show any bacteria or white blood cells - so that's encouraging. It doesn't mean that she doesn't have an upper urinary tract infection like pyelonephritis, but it's encouraging all the same. Her urine specific gravity has improved from the hyposthenuric 1.005 to an isosthenuric 1.016. It's still not good...her urine should be more concentrated. We'll probably be seeing the IM specialist soon.

I collected more urine to send out for culture, so we'll see if e.coli still grows. I switched her antibiotic, as well - to cephalexin. It's a pain in the arse, as it has to be given every 8 hours, but it's a heckuva lot cheaper than Clavamox...and she doesn't seem to be 100% on the mend yet.

We shall see, we shall see.

In other news, went out of town this weekend to visit the in-laws. It was a great time with fantastic food involved (my MIL is a gifted cook). We also stopped in Asheville on the way back to visit with friends, have beers, and dinner. Now, we're back, and I'm very, very tired...

Saturday, April 24, 2010

Veterinarian, heal thy pet...

I am about to lose my sanity.

Heidi is a great dog. She is obedient, trainable, smart, calm, and everything else I always wanted in dog - including housebroken. That is, until recently.

Her urine culture grew e .coli - A TON of e.coli. This is the most common bacterial isolate of dog and cat urinary tracts, likely due to contamination of the vulva with fecal matter and bacterial migration up the urethra. This was probably especially true in Heidi. She's been in heat for the last week, and her vulva was enormously swollen. It is likely that fecal matter caused a UTI.

The sensitivity showed that luckily, the e. coli was sensitive to pretty much every antibiotic. I started her on Clavamox - a penicillin (amoxicillin) that has been clavulanated to improve its efficacy against nasty little microbes. Within 2 days, Heidi should have been on the mend.

She's not. She's still urinating and drinking massive quantities, going out every 3 hours, and still losing control in the house. It's not small accidents, either - we're talking 2 liters of dilute urine. Oddly enough, it seems to only happen when she sleeps. She always wakes up in a pool of urine. She was spayed on Tuesday, and the vet that did it mentioned that her bladder was massively distended in surgery. I noted the same thing when I ultrasounded her to obtain a urine sample. Despite having just urinated about 2 gallons in my car, she had a huge bladder.

I'm starting to REALLY worry that the urinary tract infection was a symptom of a larger problem. Pyelonephritis? Cushing's disease? A urine retention problem? I have no anwers at the moment, only frustrations. And dog beds soaked in urine.

Tuesday, April 20, 2010

When it rains...

I love my animals. They enrich my life in untold ways. So far, I've been very lucky and had healthy pets. I attribute this to a combination of things: luck, having "mutt" cats and no purebred dogs (until now), minimalist vaccinations, and benign neglect. Some of my cats are getting old, however. Two of the current 5 indoor cats are pushing 12 or 13 years old. That's not ancient by any means, I've seen many, many cat patients in their mid to late teens. Still, they are now geriatric. My birds are still young in bird years. Heidi is middle-aged for a Doberman.

I love my pets, love love love them. I love animals, obviously...but tonight...ahh, tonight.

The kittens are old enough to urinate on their own. And they did, on the couch after being fed. My fault, I should have put them back with their towels and "litterbox" (actually just newspaper). I cleaned that up.

I went to do laundry and found cat urine in the laundry room. This is unusual. Although I have 3 male cats, I have NEVER had an outside the litterbox peer - thankfully. I've been fortunate. Apparently, someone was stressed and/or unhappy about the litterbox being not pristine and/or locked in the laundry room and/or angry about the dog, and decided to urinate in the laundry room on the dirty laundry (thankfully) AND on the expensive vacuum cleaner (!!!!!). I cleaned that up.

Heidi, who is being spayed tomorrow, walked into the living room, paced around (after having been out a mere 3 hours previously), squatted, and urinated on the rug. The second the smell hit me, I knew I needed to take her to work for a urinalysis. Sure enough - raging urinary tract infection. The signs have been there for 3 days, but I've been wrapped up with work and I missed/semi-ignored them. Now I feel terrible, of course. She must've been very uncomfortable. She was drinking massive quantities of water, urinating every 2-3 hours, and urinating large amounts frequently. She also peed on the rug. All signs pointing to lower urinary tract disease. My fault. She's at work now, on IV fluids and antibiotics in preparation for her spay tomorrow. Her urine culture is pending. I'll let you know what it grows.

I came home with medications for her and also for my old fat white cat. He's 13 years old and has a recurring, nasty rhinosinusitis (basically recrudescence of his Calici and herpes virus - he was infected when I adopted him at 1 year of age). I was afraid it was cancer a while back, but biopsies confirmed a raging lymphoplasmacytic inflammation. When it flares up, he gets all watery eyed, drooping, and sneezes ropes of snot. So, now he's taking prednisolone and azithromycin (Z-pack). Pilling him usually ends up being an exercise in torture (and claw marks) for both of us. Usually, it only takes a couple of days of meds before he's on the mend completely.

My 12 year old tabby barn cat Zeppelin continues to lose weight...and I know it's time to start her on prednisolone and Leukeran for presumed inflammatory bowel disease and/or GI lymphoma. I just don't want to put her under the knife to get a diagnosis when I'm pretty sure I know what I'm dealing with...

All of this makes it sound like my house must be disgusting - what with cat pee, dog pee, cat snot, etc EVERYWHERE, but really, I'm a neat freak. I've been cleaning and scrubbing since I got home, and the house smells nice and fresh. You'd never know that 3 animals have had accidents in the house.

But STILL. GEEZ. When we have kids, I'm going to have to hire someone to take care of the pets.

Monday, April 19, 2010

I need my head examined

Look what I took on last night...like a moron.

What a crapola way to end this shift

At 7am this morning, 1 hour before my shift ended and I began my 9 days off, our front doors blew open. In staggered a man carrying a dog that looks EXACTLY like my dog (except for the testicles). The Doberman was rigid and dying. His abdomen was so massively distended, he looked like someone had inflated him.

The hysterical owner laid him down on the triage table and exited stage left while we tried to work a miracle. As my excellent technicians got a large bore IV catheter in the front leg and intubated the dog (not breathing) - I rapidly stabbed 4 large bore catheters into the massively distended abdomen. Gas in huge quantities came pouring out. We poured the fluids into him, but he was already in ventricular fibrillation. Since we didn't have a defibrillator, I had my burly, 6"3 male technician hit the dog as hard as he could on the chest - hoping to help the heart re-start itself. Nothing - just disorganized fibrillating.

The Doberman had suffered a GDV ("bloat"). He had been in this condition for possibly hours and hours. He was an outdoor dog, and the owners had gone to bed around 11pm and found him lateral and groaning this morning.

We did what we could, but he was too far gone.

It reminded me that when Heidi is spayed tomorrow (and no, I'm not touching that with a 10 foot pole) that she also needs to have a gastropexy. I never want to have to go through that.

Thursday, April 15, 2010

And now for something entirely different

I have never had much of a green thumb. On the other hand, I despise buying terrible tomatoes and other produce at the grocery store. I got ambitious today. Let's be honest...I am not handy. My wonderful husband is, however he is currently out of commission due to a broken rib he sustained whitewater kayaking last weekend. Thus, it was up to me. I did some reading and decided that the easiest way to grow my own vegetables was to try a raised garden bed.

This would normally involve building said garden. Thankfully, Lowe's has these:

They're great for the non-handy!

3 hours and 2 trips to Lowe's later, I have this:

I've planted tomatoes, cucumbers, yellow squash, red peppers, and parsley. I'd like
to plant some lettuces, but I couldn't find any.

This was under a tree...it made me sad. No baby robin will be coming out of it.

Sunday, April 11, 2010

I'm not God.

I'm feeling like a bad vet today...Monday morning quarterbacking myself and whatnot. I lost some critical cases this weekend, and I am searching for what could have been done better. VIN (Veterinary Information Network) has been instrumental in helping me become a better, more informed veterinarian. Yet...I will always make mistakes. EVERY single doctor - human or animal - will. It's part of being human. Still, when I lose, my frustration can be overwhelming. I look back and think - had I done this, had I done that - would I have saved the patient? Dammit. I need a Benadryl and a good night's sleep.

Friday, April 9, 2010

Dr. heal thyself (NOT thy dog)

A while back, I was presented with an interesting and sad scenario.

The story was muddled from the start. We'd received a call notifying us that a client was bringing in a dog for euthanasia.

From the beginning, this went south. The dog was down in the rear. He had a history of severe hip dysplasia and had received intermittent treatment for this from (I assumed, and you know what they say about assume) a veterinarian. Apparently, his condition had recently deteriorated, and his owner was ready from euthanasia.

When the owner arrived, he summoned us to help him. The dog could not get out of the car. My tech went to help and was bitten (rather badly - 2 deep puncture wounds) in the process. When she came back in crying, I helped her clean up the wound and then went to assist the owner in getting the dog into the hospital.

By the time everything was settled (paperwork filled out, cremation selected), I had done a quick assessment of the dog - namely that he was panting extremely hard and could not walk. He was 13 years old and obviously uncomfortable, so I felt no qualms about euthanasia. I didn't do a full exam on him (listen to his heart, check his gums), as he was obviously suffering. I also didn't look at the intake form where the owner writes what they brought the dog in for. Usually, it's something stupid like "sick" or "emergency" - so I rarely glean much info from that.

As I was preparing everything for euthanasia, I got to talking to the dog's owner. Turns out that he was a human ER doctor. As I was slowly injecting the Euthasol solution, he was telling me that HE'D been the one treating his dog for his hip dysplasia. What had he been treating with? Non-steroidal antiinflammatory drugs AND steroids. Without even thinking, I said to him, "but not together, right? Don't want to cause GI ulceration."

When I looked up and caught the stricken, stunned look in his eyes, it dawned on me that yes, he had been treating his dog with both at the same time. Apparently, this is ok in humans.

The kicker? When I went to look at the dog's intake form, the reason for the visit was "euthanasia for melena."

Melena is a term for digested blood in the feces. It's a sign of upper GI ulceration and damage. And then it hit me. The dog wasn't down from his arthritis. He was likely down and dying from a perforated intestinal tract. As I was thinking this, pure blood diarrhea began pouring of the (now) deceased patient. I now realized why the owner's eyes had looked so stricken. He'd realized that the bloody diarrhea and weakness were a result of his medicating the dog himself. It was his fault the dog was down and weak and possibly dying.

Meanwhile, the dog's owner is up front, sobbing to my receptionist about how he "killed his dog." And while that is - in the strictest sense - true, I felt terrible that I had made him realize this. It was not my intent. I had misunderstood why the dog was there (for euthanasia, yes. For the problem I thought, no) - due to a combination of factors - the stress of getting the very large, very aggressive dog out of the car, my technician getting bitten, etc. Had I slowed down and done my full exam, I would have realized it was likely a GI perforation.

Would the outcome have been the same? Undoubtedly...dad was ready for euthanasia. On the other hand, I could have spared his feelings somewhat and broken the news to him gently. He DID need to know that NSAIDs and steroids don't go together - as he had another dog at home. I just would have presented it more delicately.

This is why MDs shouldn't doctor their own pets. The same goes for veterinarians. We shouldn't doctor ourselves (unless this involves sewing up a minor laceration or an xray of a sore foot or something)...that's why MDs went to med school and we went to vet school. Sure, there's a great deal of overlap - but it's not the same - as this case evidenced. That's why - when someone asks me something about human medicine - I just demur and say, "you'd better call your doctor. I'm an ANIMAL doctor."

Thursday, April 8, 2010

Why I love and (simultaneously) hate ER medicine.

This was my Tuesday night:

First, a cat was presented to me after being hit by a car. The car apparently missed his body and just hit his head. Either that or his head was run over. Blood poured from his nose, mouth, and eyes. His head was the size of a pumpkin. Other than obvious multiple jaw fractures and head trauma, he didn't look too bad. After talking to the owners at length about the amazing regenerative abilities of cats, they decided to treat him and cross their fingers. He actually did pretty well through the night, although he is facing lots of surgery, a feeding tube, and slow convalescence at our local specialty clinic.

Two dogs both shot with a .22 (my guess based on entry/exit wound size). The first was a smaller breed dog (around 35 pounds). The bullet had entered the back of the thigh and come out the front. While excruciatingly painful, he was not in immediate life-threatening danger. He was shocky and painful...but this was quickly rectified with IV fluids and aggressive pain medications.

His housemate was not so lucky. A much bigger dog (75 pounds), she had sustained a bullet through the thorax and out the abdomen. For the severity of the wound, she was more stable than I would expect. We worked on her for hours (fluids - crystalloids and colloids, pain medications, other stabilization efforts) before xraying her. I was not happy with what I saw - free gas in the abdomen, as well as mucho fluid and a very unhappy looking (aka ruptured) GI tract. Sadly, she died while being induced for surgery. Post-mortem exam revealed 2 holes in her stomach, 2 ruptured areas of small intestines, a badly lacerated liver, a hole in the diaphragm, and an abdomen full of feces and gastric contents (including whole kibble). Her death was likely a good thing. Some things are just too broke to fix. Her owner is a lovely man - a military medic and veteran who thanked me profusely for my work and actually came in person the next morning to thank me.

A small dog with a lacerated pad and very nice owners.

Two dogs with mild diarrhea.

A puppy that had been run-over by a car and picked up by a very Good Samaritan who wanted to pay for his care. Unfortunately, the puppy had a severe body wall abdominal hernia. I could feel intestines and bladder in the hernia. He needed surgery, and the $600 the poor "owner" had borrowed wouldn't even begin to cover the care this puppy would have needed. He was TTJ'd after much discussion with the distraught Good Sam.

A dog with a torn and bloody toenail and a ***bleep*** owner who couldn't understand why he would have to wait to have his dog's toenail addressed - despite being told repeatedly about the dying gunshot wound in the back.

A cat with bloody nasal discharge, a respiratory rate of 72, a heart murmur, and a body temperature of 94. I suspected congestive heart failure secondary to occult (until that point anyway) hypertrophic cardiomyopathy (HCM), but the owner did not have the finances to proceed with treatment. Even if she had, the cat's prognosis was guarded at best.

It was a loooooong, depressing, tiring night. My colleague has been very ill (doctors are suspicious of mono). I was supposed to be off Monday and Tuesday (the end of my 9 day off stint), but she was so sick, I worked for her. She's offered to work my next 2 shifts (Wed/Thurs), and as long as she feels up to it, I'm taking her up on it. I need a break after the last 2 nights!

Wednesday, April 7, 2010

Why do I NEVER learn??

I worked 15.5 hours on Monday night. That's a regular shift for overnights, but it's tiring nonetheless. Moreover, it was a busy night. The last case of the night was the one involving the cut artery and duct tape bandage. I felt good about the night - having wrapped it up with a charitable deed.

Fast forward to 8 hours later. I awoke - semi-refreshed after having slept all day. It was 4:15pm, and I had to get ready for work. About 4:50pm, my phone rings. It's our office manager, whom I love.

She had called to inform me of an irate phone call she received at 12pm that day (while I was peacefully sleeping).

Apparently, the dog with the lacerated artery and duct tape bandage had NOT been to his vet. The owners could not come up with any money (according to them). The girl - YES, THE VERY SAME GIRL to whom I extended some freebies - called and DEMANDED - no, SCREAMED at my office manager that I needed to be woken up and brought to office so that I could treat her dog.

Yes, folks. I wish I was making this up, but I'm not. She kept our OM on the phone for 50 minutes telling her to wake me up and get me to the office so I could take care of her dog. I believe that her very words were, "I don't care if she's only been asleep for 30 minutes, you need to get her up and get her to the office."

Our OM is the patron saint of patience. Really - the stuff she puts up with makes me angry. And she tolerated this girl's screaming and demanding, all the while trying to explain that 1) we weren't open currently - as we work nights and weekends 2) we don't make payment arrangements / do billing and 3) I was AT HOME SLEEPING AFTER A 15.5 HOUR SHIFT. I would have hung up on this girl much sooner after making it abundantly clear that I could not help her any further.

She finished her conversation by telling our OM that - if the dog lived - she would be at the door at 5:30, waiting for me. It's 12 hours later, Wednesday morning, and she has not appeared. Big surprise.

That was it for me. No more good deeds...I'm officially cynical and hard-hearted.

Tuesday, April 6, 2010

What they say is true.

Duct tape does fix everything.

At least, temporarily.

This was evidenced by the poor patient I saw this morning around 4am. Said patient was a large, mixed breed dog of approximately 70 pounds. He'd been running outside the previous evening and cut his foot badly. He starting bleeding, and it had continued unabated for 3 hours. According to the "owner" (more on that later), it was massive volumes of blood. The "owner's" boyfriend (actually the dog's true owner) had fashioned a tourniquet of his own for the foot.

The tourniquet consisted of an elastic hair tie double-wrapped around mid-forearm, pillow material ripped into shreds wrapped around the wound, and a forearm to just-above-the-paw "cast" of duct tape. This was placed at 11pm and left until I saw the dog at 4am. Actually, had this been placed as a temporary measure (say: 1 hour or less), it would have been pretty good!

By the time I saw the poor dog, the paw was 5 times the size of the normal foot. Circulation was beyond cut off. The dog wouldn't even put his foot down. His femoral pulses were rip-roaring bounding (likely a combination of pain and blood loss), his color was poor, his blood pressure was none-too great (systolic BP 85, should be around 95-100), and his heart rate was a whopping 250 beats per minute (normal for a dog his size should have been around 90-120). He was NOT bleeding anymore, however.

I went to talk to the "owner." Turns out this was the owner's (barely 18 years old) girlfriend. The boyfriend (he the fashioner of the duct tape bandage) had placed the bandage and gone to bed. When the GF got up and saw the swelling around 4am, she was so horrified, that she woke her BF and demanded a trip to the vet. He refused to get up, so she dragged the dog in. This was no mean feat, considering she weighed all of 100lbs.

I gave her my recommendations - sedation, pain medication, acepromazine to help with hemorrhage control, wound care, check PCV/TS to assess blood loss, possibly clotting times, possibly a packed red blood cell transfusion. She had $150, given to her by the BF's father.

She didn't whine, she didn't complain, she acquiesced to the treatment she could afford (sedation, removal of tourniquet for examination of the wound, placement of a proper bandage) and thanked us for our care. She didn't ask for a payment option or expect special treatment.

When I removed the duct tape bandage, nothing happened for about 3 minutes. I was able to examine the wound. It was about nickel sized and located just below the carpal pad - circular and rather unremarkable. It took all of those 3 minutes for circulation to return to the arm. When it did - WHOO-WHEE! The severed artery started pumping like mad! We quickly placed a stack of guaze over the wound and re-wrapped it with cast padding and VetWrap.

The owner's girlfriend was stuck in an unfortunate situation - trying to care for - let's admit, if you won't get out of bed to care for your hemorrhaging dog because you want to sleep, you're a douchebag- a douchebag's dog. I felt for her, and she expected no charity.

I placed a 16 guage catheter in the back leg - no tape, no nothing, and ran a liter of fluids into the dog to boost the blood pressure and help improve perfusion. I checked a PCV/TS (measure of anemia/hemorrhage) and found it wasn't that bad. I also checked a blood pressure. All for no charge.

It was my good deed for the week. When they left, it was 5:45am. Their general practitioner opened in less than 2 hours. I told her I thought the dog would make it till then, but that he still needed treatment and monitoring. I'm sure she'll get it for him.

Must be the spring fever that's making me a giver this week...

Sunday, April 4, 2010

Lovely Easter

We took a trip back to Tennessee for Easter this weekend. It was lovely. We had dinner with my brother and the rest of my family on Friday night, spent Saturday with the husband's grandfather, had dinner out at a BBQ place with my siblings and mom on Saturday night, and Easter dinner with my parents today. We also squeezed in an all too brief trip to see the husband's parents, as well.

It was overwhelming for Heidi, but she did well. She's a great traveler in the car (sleeps the whole way). She did get anxious being around new dogs and lots of people and children, but she was very good. She did have an accident the minute we walked into my in-laws house, on the rug no less, but it was my fault. I hadn't realized that we hadn't actually let her out to use the bathroom in several hours. Otherwise, she did well.

Back home now, enjoying the gorgeous spring weather. All the windows are open, the fans are on, and temperature is perfect.

Other new things: I got my latest bonus check from work (quite large, given the slow economy and generally slow season), as well as our tax return (quite large thanks to the contribution of the $8000 tax credit for buying a house). With that, we were able to firmly establish our emergency living fund, buy Jim a car (in cash), and buy a new stainless steel fridge and microwave for the kitchen (appliances are phase 1 of the kitchen remodel).

All in all, it's been a nice week off from work.

Thursday, April 1, 2010

(Almost) Tricked

A few weeks ago, I was presented with a 9 year old dog with acute onset of seizuring and stumbling. He was a well-cared for dog, outdoor only in a fenced in yard, with several other dogs. He was up to date on his vaccines, heartworm preventative, and Vectra flea control. The owners kept no toxins around the yard, no antifreeze, and nothing else that he could have gotten into. The owners mentioned offhandedly that 12 hours before the stumbling and seizuring began, the dog had also been vomiting all over the house. Warning bells started going off.

On presentation, the dog was depressed but aware of his surroundings. He was very dehydrated (about 9%). Physical exam was pretty much unremarkable otherwise.

Bloodwork showed significant azotemia (elevated kidney enzymes), a high white blood cell count (35,000), and significant dehydration. Otherwise, it was unremarkable. About half an hour after arrival, he suffered an incredibly violent seizure.

I couldn't get a urinalysis from the dog, because he was extremely dehydrated and had no urine.

In any other case, antifreeze would have been my first differential. After all, seizures and renal failure together usually only have a handful of differentials - especially when proceeded by prolonged, copious vomiting. I longed for a urine sample. Why?

In dogs that have ingested antifreeze, there are often very specific crystals in the urine (calcium monohydrate). These aren't always present and depend on several factors including time since ingestion, but IF present - they are pretty damn incriminating. Combined with clinical signs and other bloodwork changes, you pretty much have a diagnosis.

Antifreeze wasn't my first differential because exposure seemed impossible in this dog. He was well cared for, kept in a fenced yard with 3 other dogs, none of whom were showing any signs. The owners had NO antifreeze on the premises. The dog never left the fenced in yard and was not unsupervised. Also, his WBC count was very elevated (35,000 is a respectable white blood cell count), and this is not the norm in antifreeze.

I had no urine to look at, and that left me with two diagnostics: blood gases and the commercially available antifreeze test.

Blood gases measure several things: blood pH (which is severely low in antifreeze patients, called acidosis), blood saturation with oxygen and carbon dioxide, and some other parameters. Unfortunately, I blanked on the blood gas for some reason (it'd been a while since I'd had an antifreeze).

So, why not run the antifreeze test, you're probably wondering? After all, if it's positive, then you have your answer, right? Wrong. Recently, the old school antifreeze test went off the market and was replaced by a new, more "user-friendly" test that was good for both dogs AND cats (the previous test didn't always pick up exposure in cats, because they need to ingest only a fraction of what a dog does to die, and the test didn't test for levels that low).

The new test, however, has been rife with problems. Some of my colleagues at other clinics have tested normal, healthy pets and had positive results - even when following all instructions to the letter. This has been seen again and again. I was afraid to run the test in this dog and get a positive, because what would that tell me? It would be a death sentence for this dog, since he'd been sick for > 12 hours (antifreeze needs to be treated within 6-8hrs of ingestion, or it is uniformly fatal).

So, I started aggressive fluid therapy, anti-seizure medications, anti-emetics for nausea, and waited. Two hours later, he had a bladder. We got our urinalysis.

Guess what we found? Calcium monohydrate crystals. I called the owners who elected to euthanize instead of attempting treatment with the VERY expensive antidote (an excellent decision, as he was already severely affected).

In the end, we still have no idea where or how the exposure occurred. None of the other dogs have ever shown signs of toxicity. It's a mystery that will never be solved. I've since decided that the elevated WBC count was due to renal failure and renal inflammation...but that's just another guess in a series of guesses.