AVMA Atlanta

I'm heading to Atlanta Sunday night for the Monday and Tuesday ER lectures at AVMA. See you Wednesday...

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3 months...and YES, I am counting down.

My heat stroke patient made a full recovery and went home. I am thrilled. One for the home team. Victories like that make me love my job!

The Southern heat

The dog before me looked bad. He was laterally recumbent and poorly responsive. He would respond to his name by opening his eyes, but otherwise, he didn't move. Light brown diarrhea oozed from his rectum as a result of injury to his GI tract (mucosal sloughing). Bright red blooms of blood (petechia) were present all over his abdomen and gums. He was suffering a heat stroke.

His owners had recently moved here from cooler climes and had left him outside today. They found him, collapsed and barely responsive. They immediately began cooling him off with a hose, as well as trying to get him to drink water. By the time he got to us, his temperature was only 102 degrees.

My techs leapt into action. IV catheter, fluids (Normosol-R and Hetastarch), mannitol for suspected heat injury to the brain, fresh frozen plasma to stop the inevitable DIC, heparin to help ward it off, and antibiotics to combat bacterial translocation from his intestines. We placed nasal oxygen, as well as a urinary catheter. Often, dogs that suffer heat injury will develop renal failure as a result. Monitoring urine output is an important part of therapy.

For the first 2 hours, he looked like death on wheat toast. Then, he started to lift his head. It progressed to sitting sternal, then sitting up on his front legs. By 4 am, he was wagging his tail, giving kisses, and wiggling irrepressibly in his cage.

He's not out of the woods yet. His platelet count dropped this morning a bit, and he has extremely bloody urine, but he looks far better than any other heat stroke I've ever treated at this stage.

Keep your fingers crossed for him. So far, he's made a miraculous recovery.

Ugh. Food. poisoning. sucks. Especially when you have to work.

FAIL.

Aloha...

I finally did it. After untold years of school, work, and no real vacation...I booked tickets to Hawaii for 6 days in October! My intern-mate and good friend lives on Oahu, and she has graciously offered (begged) me to come visit. So, we'll be heading down there in October. I'm so excited!

Boiling point

Sorry I've been such a slacker about posting lately. Work has gotten on my nerves to the point that when I'm off (as I have been for the past 8 days), I don't really want to talk about it. This anecdote, however, is too good to not tell. I found my boiling point...

A couple of Saturdays ago, I was presented with a 13 year old German shepherd. She had suddenly begun urinating blood. Not just blood but blood clots. That's usually not good. My top differentials would be urinary tract infection, bladder stones, bladder cancer (usually transitional cell carcinoma), maybe renal failure, or less likely, a clotting problem or heartworm disease (caval syndrome). I went over these with the elderly, male owner and recommended diagnostics. He couldn't answer my questions well, and he kept stammering over things - such as - "is Fluffy on monthly heartworm prevention?" Finally, tired of my questions, he summoned his wife - who, as it turns out - was sitting in the car.

She comes in, sits down. I start with my spiel again - differentials, recommended diagnostics, treatment options (hospitalization versus outpatient and follow-up with regular veterinarian). When I say "regular veterinarian" she pins me with a steely gaze.

"I don't speak to my vet anymore." She said.
Uh-oh, I thought. I deliberately DID NOT ask what her beef was and continued. She interrupted me and said, "They did not acknowledge that I administered my own vaccines. I am a NURSE. I KNOW how to give a subcutaneous injection."

I shrugged and said, "I'm sorry, ma'am, but I cannot help you with that. So back to Fluffy's bloody uri--", and here, she interrupted me.

"They wanted to charge me $200 for vaccines. That's rape. She was RAPING me. YOU ALL-" and here, I got a pointed, nasty look, "are raping us."

My temperature started to elevate. I could feel my face growing hot and flushed.

"Ma'am, I am not here to discuss your previous veterinarian and your complaints. I am concerned about Fluffy's bloody urine."

She glares at me. "I am a NURSE. What you said about kidney failure was contradictory."

I am speechless momentarily. Finally, I say, "what exactly was contradictory??"

She says, "She just started having bloody urine, how could she be in renal failure already? That's contradictory."

So then, I explain my concerns again and tell her that renal failure is LOW on my list, but that it needs to be ruled out. I explain that we will check her kidney enzymes on bloodwork and this, combined with her urine specific gravity, will give us an idea of the status of her kidneys. She interrupts and says, "Do the renal failure test. If it's positive, what then?" I then have to explain that it's not positive/negative test - it's measuring enzymes and comparing them to her urinalysis. This goes in one ear and out the other.

Then she REALLY throws me for a loop.

"Why are you recommending treatment for a terminal condition?"

I am speechless AGAIN.

"Ma'am, I do not know WHAT is wrong with your dog yet. I have given you a list of POSSIBLE causes, but I cannot rule them in or out without TESTING."

She continues to glare at me.

"I want her placed on APPROPRIATEpain medication, do you understand?"

At this point, I can barely control my rage. I take the file, the dog's leash, and leave the room before my head explodes, thus spraying her with gore.

Diagnostics found no bladder stone, no urinary tract infection, no giant tumor. Something was amiss here.

The owner, of course declined hospitalization, taking the dog home on cephalexin and tramadol. I managed to mostly hold my tongue, although I found myself explaining to her, in no uncertain terms, how very many pets we see in our ER that have been vaccinated by their owners and now have the disease which they were supposedly vaccinated against. She didn't care.

The absolute ICING ON THE CAKE?? Today, I spoke with our office manager, who did a callback to check on the dog. Three days after I saw it, the dog started dragging both its rear legs. The owner called because she thought it was the CEPHALEXIN that caused it. Our OM carefully explained that it was not the antibiotic and that a dog dragging both rear legs should be seen for emergency care immediately.

The dog did not show up at work. The owner called 2 days later, saying that the dog was now completely paralyzed in the rear limbs. She refused to bring it back in because she did not want it "poked and prodded" and "stressed by the car ride." She would let her die PEACEFULLYat home. I wasn't there for this, or there would have been words. The woman was a grade A bitch. Sorry, no other way to say it.

I'm working on getting Animal Control involved, because at this point, I have no idea if the dog is alive, dead, or lying in its own feces somewhere, dying a slow death.

Look, I understand if you don't want to subject your 13 year old, large breed dog to a bunch of diagnostics tests only to euthanize it. I don't have a problem with that. If you're ready, and you think your pet is ready, then I'm ready, too. Bring them to me, and together, we will ease their suffering. BUT AT LEAST GIVE ME THE CHANCE TO DO THAT INSTEAD OF LETTING YOUR DOG DIE A LINGERING DEATH.

Sometimes, I really hate people.

The PhD thesis

My husband has been working on his PhD thesis for a while. It's been quite a job for him, owing to some problems with his there, then not there, thesis advisor. It's been very frustrating for him in many ways. He's 3 years into the program.

I finally solved the mystery of why he can't get any work done. Behold.

Feeling very bummed

I'm quite down in the mouth right now. There's some stuff going on at work - my previously perfect job (for a whole year!) - that I'm really unhappy about. In the interest of being anonymous, I can't say what exactly. It's also really hard being away from family and friends. As much as we've settled into our house, we still haven't really put down any permanent roots here. As much as I hate it, this all feels very temporary. The older I get, the more I realize that I don't want to be far away from my family and the friends that really matter to me. Isn't life about the ones you love?
Thankfully, my best friend and brother-in-law are coming to spend a 3 day weekend with us in a few days. I'm so excited about it I can't express it.

In the meantime, this was the thank you card I received from the people whose son died (and whose cat I had to euthanize):

Dear Dr Homeless Parrot:

I just wanted to thank you for your kindness last Saturday in taking care of me, my husband, and our cat. I've found a thousand ways to blame myself for what happened, and I guess my consolation was your tenderness and kindness in how you handled it. I keep telling myself that he's hanging out with Eric (their son), purring away, eating salmon and chasing moles every day. It's hard being the one left behind, but people like you make the world a better place.

Sincerely, X

Those owners made me cry twice in 2 weeks. That's all you get!

Seriously, people?

The whiteboard read as follows:

Patient: Missy
Room #2
Complaint: draining mass

What I actually found was an intact, unvaccinated, 7 year old female German Shepherd. Draining mass didn't prepare me much for what I saw. The dog was wearing a teeshirt. The teeshirt was soaked with fluid - pus, blood, serum...it was a rank mess. Underneath it was a mass that was - conservatively - the size of a basketball. It smelled pretty bad.

I recommended sedation so I could remove the teeshirt from the (very sweet) GSD and examine the mass. The owner agreed.

When the teeshirt came off, my stomach contents almost came up. The poor dog had a giant, basketball-sized, infected, necrotic mammary mass. It was oozing pus and blood. It was horrifying.

Mom reported that the mass had been present for a year, and it never bothered her. It had only gotten really bad recently.

I didn't know what to say. My options were 2: get infuriated that this poor, sweet dog had never had good preventative health care (spaying would have prevented this) such as vaccines and a spay or just give her my recommendations and let it go.

I chose the latter. Surprisingly, the dog is now at our hospital after having a radical mastectomy today. She's not doing well, from what I understand. Shocking.

This post brought you to by the Coalition for Damned Cute Kittens

Antidote to sadness

Since my last post was so damned depressing, some levity. Thank god for teeny little kittens and fresh tomatoes and cucumbers. Nothing is ever as bad as it seems.

All around sad

This weekend was too, too sad for me.

On Saturday, a very nice mid-40s woman brought me her purring, fluffy, EIGHT YEAR OLD white cat. With a giant abdominal mass. That wasn't eating. Hadn't been for 2 days. That equals NOT GOOD.

She apologized in advance if she seemed "over-emotional" - her 20 year old son had been killed in a car crash a mere 3 weeks before.

You can see where this is going. Her cat had a GIGANTIC kidney...and was in renal failure. After much discussion, she and her husband elected euthanasia. They were kind people and so sad. As I was injecting the euthanasia, the cat's owner kissed his (still purring) head and said, "give eric a big kiss when you get to heaven." Eric was their deceased son. I almost lost it at that point. Then the lady - totally out of nowhere - reached out, clasped my cheek with one hand, and said, "you are so sweet." I had to go out behind the building and cry for a few minutes.

Then back into the fray I went.

Today, I euthanized my technician's dog. I diagnosed her with sudden onset of megaesophagus (12 year old dog) and severe aspiration pneumonia three weeks ago. Since then, she's been to an internal medicine specialist for scoping, biopsies, the whole work-up. To no avail. Her condition continued to deteriorate, and she had lost 15 pounds. She regurgitated constantly, no matter what medications we gave, no matter how we thickened her water. She probably hadn't eaten in well over 2.5 weeks. It was time.

My technician only has the one dog. Her fiancee works in the Middle East as a private contractor 10 months out of the year, so she is alone the majority of the time. Her dog was her best friend.

We took her out into the grass behind the clinic and made her a bed in the shade. About an hour later, we said goodbye. My technician lost it - as we all expected.

So I had another good cry behind work today.

I'm glad the weekend is over. Hopefully, tomorrow night won't be so sad.

Holy fabulous food, Batman.

Growing up, I was a meat and potatoes girl. My father is phenomenally choosy (read: picky) about his food, and my mom usually cooked to accomodate him - as good wives should. As a result, food experiences were limited in my house as a child. I still have an amazing aversion to seafood that no amount of willpower will overcome. I love tuna, and I relish Szechuan tuna above all - nice and raw - but otherwise, I don't do it. Growing up, I also didn't eat much in the way of vegetables. A salad in my house was iceberg lettuce, some carrots, and toast croutons.

My husband, on the other hand, will eat ANYTHING. So, over the past 13 years that we have been together (married 11), I have slowly come out of my shell. Once upon a time, I would not have touched mushrooms, raw onions, or tomatoes with a 10 foot pole. Nor would I have eaten spinach, broccoli, or anything resembling those foods.

This all builds up to our anniversary dinner at an amazing, local establishment.

I made the reservations on OpenTable.com. When we arrived, the host wished us a happy anniversary (I noted this on the website under special considerations) and led us to our table. It had been decorated with confetti of hearts, champagne glasses, and bottles. A nice touch, I thought. Our waitress also immediately wished us a happy anniversary.

We started with a cremini mushroom tart. This was a flaky pastry filled with sauteed cremini mushrooms and red onions, garnished with goat cheese. On the side was a cake of roasted red and golden beets in a walnut vinaigrette. It was absolutely delicious.

We followed that by splitting the day's salad special - the chef's take on a caprese salad: heirloom tomatoes under a bed of basil with a molasses balsamic reduction vinagairette and candied walnuts. The combination of the perfectly ripe tomatoes and the tiny, sweet bursts of candied, spiced walnut with the basil was about more than I could stand. Delicious doesn't even describe it.

For dinner, I went with a safe bet - fried chicken. Yes, fried chicken, something this gourmet, expensive restaurant is known for. They fry 2 plump, juicy breasts, then lightly coat them with a gravy of black pepper and cream (scrumptious), and place it on a bed of spinach and Yukon gold mashed potatoes. It was absolutely comfort food, and absolutely delicious.

My husband chose the evening special: Cornish game hen on a bed of forbidden rice and broccoli rabe. His was very good, mine was perfection.

We finished off dinner with a chocolate ganache torte on a pecan crust with caramel and raspberry sauces. It wasn't inspired, but it certainly tasted delightful. Coffee finished off this excellent meal.

It was an amazing dinner. If any of you, readers, are ever in my area of NC...let me know, I can't recommend this place enough!

Turn the needle on myself...

I'm becoming a halfway house for wayward kittens. It's summer, so there are a bunch of kittens out there. They keep getting my name and number somehow.

So, I have litter number 3 of the summer (not too bad considering), one of which I lost to an unknown cause. The other 2 are thriving. On Wednesday night, a tiny little calico with goopy eyes (read: super contagious upper respiratory tract infection - probably herpesvirus or Calicivirus) was brought in. She was absolutely tiny - maybe 1/2 pound at the most. Her head was too big for her body. I really felt that I couldn't take another kitten (she had infectious disease - mainly), and no one else wanted to foster her. I made the decision to euthanize her.

When euthanizing kittens this tiny, I always anesthetize them first. Often they are so small, they require a cardiac injection, and this MUST be done under complete anesthesia, so that they feel nothing.

I set up the anesthesia machine, wrapped her in a comfy blanket, and put her under the big mask. I left to attend other stuff, giving her a full 20 minutes to go to sleep. When I came back, heavy-hearted, holding the pink solution in my hand, I felt sick. It's part of the job, I know that, but I hate it. I lifted the mask. Lo and behold, kitten was purring and looking around, completely alert. I glanced at the anesthesia mean and realized I had forgotten to turn on the oxygen - the CARRIER gas for the anesthesia. Sighing, I realized it was too late. It took all of my strength to put her in the mask the first time. I couldn't do it a second.

She is now residing in my bathtub, getting her antibiotic eye drops (the goo has cleared up), and eating her body weight in kitten food.

In my defense, when my husband first saw her, he said that if he'd been in my position, he would have had to turn the needle on himself rather than harm the tiny, bobble-headed kitten.

It's now taking me an hour before I can get into bed after work to care for the menagerie: I have to walk the dog, feed/water the dog, water the flowers, water the vegetables, check on the bird's food and water, stimulate/bathe the small kittens, feed the small kittens, check food on the housecats, check food on the back porch cat, start kitten laundry (twice a day!), and now put eyedrops in and feed the small, pathetic calico. *Sigh* I have a problem.

Happy 11th Anniversary to my wonderful, sweet, tender-hearted, kind, and absolutely one-of-a-kind husband!