Moment of brilliance

I try not to brag here about the things that I do that sometimes astound even myself, but I have kicked some serious a** before - surgically and medically. It's ok to pat myself on the back once in a while, right (so much for NO ego in my writing:)?

Case in point: last weekend I came in to take over the night shift from my day shift colleague. She had just admitted an 8 year old dog with vomiting, bloody diarrhea, anorexia, and severe depression. Bloodwork showed a low white blood cell count and hypoglycemia (low blood sugar) at 43 (normal 80-100). In other words, the patient was showing signs of sepsis. My colleague suspected something intra-abdominal - a foreign body, possibly a perforated GI tract. She prepared the owner for possible exploratory surgery.

When I came in, she handed me the chart and asked for my thoughts. I skimmed everything, then reviewed the xrays - which were utterly unremarkable other than mild ileus (ileus = GI tract is not moving). We discussed differentials for this case. As we stepped out of xray, I asked offhand "have you tested for parvo?" She shook her head and told me the dog was vaccinated.

There are several problems with the vaccinated response. The first is that the definition of "vaccinated" in our area is decidedly loose. Many people vaccinate their own dogs with Tractor Supply vaccines, administer them wrong or store them incorrectly, and their dogs wind up with parvo. I see it every day. Secondly, vaccines are not 100%, although we fall into the trap of thinking they are. A vaccinated dog can still - although it is VERY unlikely - contract disease.

I flipped the chart open to where the owner marks vaccine status and saw that the dog was indeed vaccinated - for RABIES. Nothing else.

The parvo test was screamingly positive. When I called the owner to relay the news, she was stunned. However, after some prodding, she told me that they'd recently adopted a puppy that had developed vomiting and diarrhea for a couple of days and then gotten better. Wanna guess where the 8 year old dog probably got the parvo? Also, the poor dog had never gotten a parvo vaccine - not once in its life. Mom was astounded and couldn't wrap her head around the fact that her adult dog had parvo.

See, we DO recommend those vaccines for a reason - and not just to make money.

Dog anecdote

Today, I went riding. Heidi had such a perfectly thrilling weekend running off leash with the pack of dogs at my in-law's family reunion and did so well, that I decided to take her. Alas, it did not go well.

Horses scare her to death. She ran off almost as soon as we got to the barn. The barn itself is set back about 100 yards from a fairly busy, high speed road. Of course, she made tracks for it. After 10 minutes of chasing her and calling her, I finally laid down on my back in the grass and rolled around giggling and talking - basically inviting her to play (not because I'd gone mad). She succumbed, and I was able to catch her.

I put her on her leash and attached her at the barn, then went to ride in the ring. 45 minutes later, I came back to the barn, only to find a chewed in half leash and no dog. Luckily, she had gone straight to my SUV and laid down in front of it, patiently waiting for me to be done with the horses. There she stayed until I came to get her.

I really need to work on recall training her. She's great at everything I've taught her so far, but I'll admit, I've lazed up on the training -and she doesn't come when called. As a lesson, I now own 2 halves of a leash...

Sad

We have had a busy few days. Yesterday, we went home to Tennessee for a birthday party (mine, on Friday night) and a family reunion (the husband's family, on Saturday). It was a busy 2 days, but we had to be back tonight, as I am going trail riding tomorrow.

Alas, I lost my first bottle raised baby. I have raised many kittens -from as young as 12 hours old to 3 weeks old. I have never had one die. The middle-sized one of this litter has been acting strange for several days - star-gazing, mentally dull, vocalizing frequently for no reason that I could determine. On the way home tonight, he just kept crying and crying, and he wouldn't settle down or eat. He also just seemed off. When we got home, he had died. It makes me very sad. I work so hard on these guys. I just hope whatever it was, it's not contagious.

I did do a post-mortem exam on the kitten, though I was loathe to cut him open. His stomach was absolutely huge, his small intestines were empty, and he had a large amount of feces in his colon. It was soft and not impacted. I'm really at a loss. There were no obvious causes of death.

Poor kitten. Poor me. Poor husband (he has a big, soft, tender heart for kittens and puppies, so he took it hard).

I gone and dun it...

I'm reaching back to my East Tennessee roots for that title :)

I finally went ahead and found horses to lease. It's a great situation - 2 horses: a quarter horse named Fish and a thoroughbred named Kit - at my disposal. They are stabled about 20 miles from my house, in the country. I have access to a very nice, large riding ring, complete with jumps, as well as a pasture. Additionally, the woman with whom I'll ride trailers the horses every weekend to trail ride. All of this for $250/month. I'm pretty excited. I've been out 3 times this week. Both horses are great, both are extremely well-trained - in hunter/jumper, dressage, foxhunting, Western, the whole nine yards. I'll ride them predominantly hunter/jumper. Showing isn't out of the question. I'm thrilled to finally be getting back into my hobbies! It only took me a year past my internship to get a life again!

Tipping point

This weekend was rough - really rough. We had many very critical patients in the hospital, several perplexing cases, just a great deal on our plates. That's ok, it's part of emergency medicine - feast or famine.

What made it particularly difficult was the absence of my husband. He was gone for a week in Knoxvegas, meeting with his thesis advisor regarding his PhD work. I was alone. I'm nursing 3 kittens. When I got them (on Monday last) - they were only 48 hours old - blind, deaf, totally helpless. Taking care of kittens that young - especially 3 of them - is a full-time job. On top of that, I have the dog, 5 indoor cats, 1 outdoor cat, and the birds. Then, I have the garden to water, as well as all of my flowers. I got a jam jar stuck in the garbage disposal, and no amount of attempting would get it out. The A/C broke on Tuesday, and it was 87 degrees in the house. The whole week, I felt like I was walking a fine, fine line of nervous exhaustion.

Come Friday night and the start of my overnight weekend shift. It's ALWAYS, ALWAYS the hardest. 16 hours (overnight) for 3 nights in a row. By the time it's over, I'm usually a blob of incoherency.

What should come in on Friday night but a cat with a pyothorax? Pyothorax translates into normal person speak as pus chest. You can read more about it here. The owner was a young guy (maybe 19), and I assumed when I told him the cost and length of treatment required (3-10 days usually, $2500-5000 and possible chest surgery) that I would be dispatching kitty to heaven.

Boy, was I wrong. The owner wanted to go for it. I had to put bilateral chest tubes in poor kitty. They are painful, scary to place, and require a great deal of management. This cat managed to have 4 chest tubes in 36 hours, which is ridiculous. They kept backing out of his chest space, which was awful, because he really needed them. I worried and worried over him all weekend (although, he is doing GREAT now - or was, as of this morning).

Then, I had a tiny little kitten - 3 weeks old - that was hypothermic, hypoglycemic, and dehydrated. His owners wanted to give him a chance, so he got a teeny tiny IV catheter, and we worked on saving him. Come Sunday morning, he looked terrible, and the owner consented to euthanasia. I had it drawn up and the needle actually inserted into the catheter, and he started to come around and make biscuits on my face with his good paw.

I dissolved into tears. The owner elected to try for another day, so we did.

Then there was the horrible heart failure on Saturday night, owned by a girl a little younger than myself, pregnant, and having recently miscarried. The dog came in blowing bloody froth out of its lungs. We hospitalized it, and he arrested shortly afterwards. No amount of CPR could bring him back. His mother melted down in the ICU (my husband was there to witness this). I almost lost it myself, I'm not going to lie.

By the time I came home Sunday morning - with one shift still to go - I couldn't stand the thought of one more living thing relying on me. I went to water my garden, saw my dead squash vines (which I haven't pulled completely yet) and burst into tears. I almost had a panic attack because of my DEAD SQUASH. I felt like a failure, desperately needed sleep, and had exactly 5 hours before I had to be back at work for another 16 hour shift.

I was actually able to lie down for 3 hours on Sunday night/Monday morning, although I had so many patients to care for, I wasn't comfortable doing it. Had I not, I think I would have fainted from exhaustion.

Alas, today, all is well. I had breakfast with my husband, our A/C is working, all 3 kittens are doing fine, I actually rode today (looking at leasing 2 horses), and now I'm ready for bed again.

By the way - all of the patients I fretted over lived to fight another day.

Weird complaint

Usually if I get a client complaint, it falls along the lines of "money grubbing," or some other such rubbish. I had a new one that just floored me.

When I got to work Wednesday night, a chart was printed and in my box. It had our OM's name on it and said, "Can you call me about this patient?" I glanced through it. Everything seemed relatively straight-forward. Back in September, a small dog presented after being hit by a car. Its gums were grey, no capillary refill time could be appreciated, and the dog had severe orthopedic injuries. The owners declined to sign a class I form and provide a $500 deposit for initial ER treatment. I talked to them and they elected euthanasia. I wrote nothing in the record to indicate that the owners gave us any problems. Truth be told, I don't even remember the patient - not even vaguely.

So, the owners called their vet a couple of weeks ago (9 months AFTER the fact) and complained that we (the clinic, myself, my techs?) were resistant to euthanizing their dog. That was their complaint - we didn't want to put down the dog.

Now, like I said, I have no memory of this patient at all - but I can tell you this, if a dog comes in traumatized, in shock, with polytrauma, and the owners can't come up with the initial $500 - I give them the options as I see them (usually either treat/find a credit card/relative/apply for CareCredit or euthanasia). I don't generally argue with people - especially in cases where euthanasia is the best option. This case was clearly that from my notes.

I still have NO idea what they were talking about. Barring any strokes of sudden "A-HA! THOSE clients..." moments, I doubt I'll ever know. People are so weird. Who wants a vet that LIKES putting down an animal?

Sundries

Just got back from a delightful weekend in old Knoxtown with the brother-in-law and his wife, my best friend. It was very relaxing. Last night, we met with a local ER vet and his wife for dinner at a swanky French cafe. Food was mediocre, company was excellent.

Tonight, I fixed veggie and cheese stuffed pork chops (disappointingly bland) and squash puppies. As you might guess, squash puppies are a cute take on hush puppies. I used the large yellow squash from my garden. Our salad had small cherry tomatoes and cucumber, also courtesy of my super-overproductive garden. The tomatoes are unreal. There are at least 3 dozen, if not more, growing. I also have 3 or more red peppers and tons of cukes. One of my tomato plants fell over, so I stopped screwing around and staked them with the only thing I had around at the time, a tall aluminum pipe that was once part of my husband's kayaking rack (before the tree smashed it). That should hold the plant up!

I've decided that I'm going to get really bold next year and plant 2 or 3 more raised beds - more vegetables and some flowers.

Back to work tomorrow night. More blood and guts to come.

Lawnmower: 1, Dog: 0

A frantic owner called last week to tell us his dog's nose was bleeding badly, and he was bringing the dog in for care. I immediately started running through differentials in my head for epistaxis (bloody nose). Rat poison is always at the top of the list, as is a thrombocytopenia (low platelets) - which can be caused by any number of diseases: tick-borne disease (Rocky Mountain Spotted fever, Lyme disease, Ehrlichia), immune-mediated thrombocytopenia, cancer, etc. etc.

The owner somehow failed to mention on the phone WHY the dog's nose was bleeding.

20 minutes later, the door to our ICU bursts open and my burly, 6"4 tech runs in carrying a large mastiff mix. Blood is pouring from the dog's nose - but not the nostrils. No, it's pouring from the 6 inch laceration across the bridge of the nose. Pouring isn't even the right word. It was spurting directly into the air, a bright red frothy fountain that told me that an artery was severed.

My enterprising tech quickly wrapped a towel tightly around the (very docile) dog's muzzle to form a temporary tourniquet while the rest of us cast around for a brilliant way to staunch the arterial bleed rapidly. It wasn't as easy as knocking the dog out and sewing it up right then and there. By the pale color of his gums, the blood covering his front legs, his sky high heart rate, and generally very docile demeanor, it was evident he'd lost a great deal of blood and would need an IV catheter and some fluids (possibly a blood transfusion) before we anesthetized him. That left us with trying to rapidly find a way to stop the bleeding.

Binder clips, as it turns out, are excellent for these sorts of linear, gushing wounds. While my tech held the (still amazingly calm) dog's head, I secured a 2 inch binder clip across the straight wound, staunching the gush of blood. Necessity is the mother...and all that.

The owners elected to proceed with my proposed plan: IV fluids, pain medications, blood pressure monitoring, a PCV/TS, and then - when his heart rate and color improved - light sedation with Propofol (yes, the drug that killed MJ) for a wound cleaning and repair.

When we finally got him sedated and got a good look at what we were dealing with, I was so stunned that I sent my tech running for the camera (pics to come when I get back home). The dog had lacerated the major artery that runs across the bridge of the nose. It was completely sliced through. A half an hour's honest work, and the wound was fixed.

When I asked dad what happened, he said that the dog had run at his very large, specialized lawnmower, grabbed the wheel, and was flipped completely over and under the fender of the the tire - resulting in the very large slice on his nose. It was at least 2 inches deep and made quite a pocket under the left eye.

I had to work really hard to restrain the laughter that came bubbling up within me when I visualized this occurring.

The moral of the story : please be specific if you call with an emergency that you are bringing in. Example: my dog is bleeding from the nose BECAUSE HE SUSTAINED A LAWNMOWER INJURY TO THE FACE would have been a lot more helpful :)

Just something to think about (and pictures of the wound coming when I get back home).

-HP

Fruits (or vegetables) of my labors...

The bread is my homemade wheat. The squash is from my garden, and the salad is garnished with fresh cucumbers, also from my garden. The meatloaf and potatoes are homemade, as well. We had an unexpected dinner party last night, and it was lovely.

Ya want fries with that?

I love my job, I really do. I feel lucky to have a job that stimulates me constantly - that allows me to stretch my thinking while helping animals and their people. Sometimes though - just sometimes - I wish the worst part of my day was screwing up someone's fry order.

On Saturday night, as I rounded with my colleague, we came to the incubator. A small dog lie within, fighting for survival. A week prior, the dog had developed nasty, horrible diarrhea. He had been to his vet, and the dog was not doing well. When it presented to us, he was septic - with a white blood cell count of 930 (normal 5000-16,000). We could not keep the dog's blood pressure up (it wouldn't read for the first 8 hours of hospitalization, despite every possible measure), and his blood glucose hovered in the 30s - despite every effort to bring it up. On top of that, the dog was excruciatingly painful in its abdomen. We suspected a foreign body or some other severe GI problem.

The owner, of course, had financial constraints. We told her quite clearly - that the dog had <1% chance of survival. We told her it would be expensive. She wanted to try. We tried, but we all agreed that the dog needed exploratory abdominal surgery. She wasn't strong enough to survive it, likely. We told the owner that too.

I took over. The dog continued to deteriorate, and then suddenly, she began to do better. She was still very ill, and she was still suffering terribly, and I (and another doctor) told the owner so. We reiterated that she needed exploratory surgery - which increased her chances (completely subjectively) from <1% to maybe 5%. The owner elected euthanasia. She came to be with the dog. After about 5 minutes, she came out of the room and asked if surgery would give her dog a chance at all. I said that the dog DID have a chance, but it was still very, very slim. I explained again that the dog might not survive surgery. She decided to try.

I gave my technician explicit instructions to have her sign a surgery estimate and acquire a surgical deposit. He didn't. I didn't find that out until halfway into surgery. Oh, and of course, I didn't find a good explanation for her illness. Her intestines were hemorrhagic and not moving at all - but there was nothing stuck. It looked for all the world like parvovirus. Two tests 24 hours apart were negative. I'm still not convinced it wasn't, though.

At that point, her bill was already $1700. With surgery, it came to just under $3000. I called her back and asked for a further deposit before I left (5 hours beyond the end of a 16 hour shift). She demured and said she would call back. Four hours later, and a helluva lot of phone tag with the owner (who, as it turns out, had to hide in the bathroom away from her husband to talk to us) - we figured out she was a nutbar.

Long story - shorter - we didn't get paid, the dog had to be euthanized, and the woman spent 15 minutes screaming at my colleague last night around 3:00 am about how I only care about money and we forced her to do surgery - just for the money. Oh, and her son called this AM - threatening to show up at the clinic and "straighten us out." The police are currently on standby, in case he actually decides to make good on that threat.

And somehow - on some level - I feel like this is my fault. Like I AM money-grubbing and evil. Why? I can't answer that, but the feeling lingers on.