Friday, September 10, 2010

Labor day celebrated the REAL way...

by laboring. We were slammed at work. I worked the day shift on Saturday and Sunday, the night shift on Labor Day, and the night shift on Tuesday. By the time that Wednesday morning rolled around (the end of my shift for 2 days), I was a mental vegetable. It didn't help that I saw 2 cases that left me with a complete "what the ???" feeling.

The first was a 13 year old dog with a history of controlled diabetes. “Salty” presented collapsed, open-mouthed breathing, vomiting with bloody diarrhea, pale gums, weak pulses, and a blood pressure of 50. It looked like a classic hemoabdomen likely secondary to a ruptured splenic or liver tumor (other than the GI signs). The problem with that theory? There was no blood in the abdomen, no blood in the chest, and the dog’s PCV/TS (see sidebar) were normal at 38/8.6. Other differentials included pericardial effusion/cardiac tamponade, acute anaphylaxis, or DKA.

Bloodwork was boring other than mild anemia (RBC count 3.9 normal 5.50-9.5) and a lactate of 8.8 (see sidebar). Xrays showed no abnormalities other than a small heart indicating hypovolemia (decreased blood flow/shock). I started treating the hypotensive shock and discussed with the owner that I suspected anaphylaxis.

Over 3 hours, Salty's condition rapidly deteriorated. His gums turned white, he began to gasp with his mouth open. A recheck PCV/TS showed that he had dropped from 38 to 12, indicating severe, acute hemorrhage. Lactate continued to go up (9.2 at last check). His chest and abdomen were still negative for hemorrhage. I had to assume it was going into 3 places - his brain (unlikely given the quantity that he must have lost), his bladder, or his GI tract. Given the thin, watery blood leaking out of his rectum, I suspected an acute GI bleed. I had never seen this before. Salty was on Rimadyl, a non-steroidal anti-inflammatory medication similar to aspirin that can cause GI ulceration.

I called his owner, and she decided to euthanize rather than go the blood transfusion route. During the euthanasia, I felt terrible. It was a confusing case, I didn't really get a handle on it until 3 hours in, at which point, I finally figured out what I thought was going on. Was there anything else I could have done? No. I was appropriately resuscitating the patient with crystalloids and colloids, monitoring BP, gum color, mentation, and blood parameters.

Still, I felt like a failure because it took me 3 hours to figure out what was going on with this dog. I realize I am NOT a failure…but losing patients is never easy.

1 comment:

Holly said...

I know you know...but it just hasn't reached your heart yet.

Think of it this way....he would have suffered much longer, and been way more painful if you had not been able to help him. Difficult as it is....that is a gift.