Miscommunication

We had a terrible mis-communication with an owner recently. She brought in her 3 year old mixed breed dog, Marti. Marti was exhibiting severe neurological signs - a head turn to the left, cervical neck pain, occasional seizure activity (per the owner, we never saw the seizures), and mild mental stupor.

Our differentials were meningitis/encephalitis of some sort - possibly GME or NME, or something like West Nile virus.

The referring veterinarian tried as hard as she could to get the owner to take Marti to a neurologist for diagnostics and treatment. The owner declined. As a result, we wound up admitting the dog one night last week to our hospital.

The treatment for NME is steroids, which we started Marti on. Her condition deteriorated over the next couple of days, but the owner still refused to take Marti to a neurologist. I took over the case on the dog's second night in the hospital.

When Marti transferred back, she was lethargic, poorly responsive, and weak. She could not lift her head. I again begged the owner to seek a neurologist's opinion. It was at about that time that my technician paged me to the ICU. I was confronted with this:





That, my dear readers, is what REAL bloody vomit looks like.

Back I went to the room. I looked at Marti's owner, a young, intelligent, well-spoken women and asked, "had you been giving anything at home prior to when we first saw Marti?" She nodded. "Baby aspirin," was her reply.

My stomach turned. "But I told the other veterinarian," she said. "At least, I thought I did. Maybe I only told her that we gave aspirin LAST time this happened." (The first episode had been about a month previously).

What happened to Marti is that she received aspirin, a non-steroidal anti-inflammatory medication (NSAID), as well as a steroid. These drugs work on the same inflammatory pathway, and using 2 at once can cause SEVERE, SEVERE damage to the GI tract. Why? NSAIDs AND steroids inhibit prostaglandins. These PGs are responsible for mediating inflammation and down-regulating them will help dampen the inflammatory response. PGs have good effects, too. They mediate blood flow to the kidneys and function in acid secretion in the stomach. When you suppress them with NSAIDs and steroids, you lose the good AND the bad. This is usually not a problem unless you 1) take massive dose of NSAIDs or 2) you MIX steroids and NSAIDs. Even though we were using a tiny dose of steroids, it was enough to cause a horrible, bleeding ulcer.

The owner finally consisted to transfer Marti to a specialist (after seeing the vomit firsthand). By the time Marti arrived at the local specialty clinic, her PCV (measure of red blood cell mass) had dropped from 46% to 32%, indicating internal bleeding. This was occurring into her stomach from her bleeding GI ulcer. After much discussion, Marti's owner elected to euthanize her.

It was a terrible, terrible thing and an important, potent reminder of why we - as veterinarians - should always, always, always ask, "Have you administered any medications to your pet lately - EITHER prescribed OR over the counter?" And that's why you, as pet owners, should always, always, always tell your veterinarian if you have given something to your pet.