Monday, October 25, 2010

Hawaii bound in less than 12 hours!!!!!!


Did I earn my vacation last night...?

So, husband was out of town for the football game and his grandfather's surprise 90th birthday. I slept for 3 hours on Saturday night/Sunday morning at work, came home, laid down around 10am. Various animals conspired to keep me just barely awake for 3 hours. I finally conked out, then woke up an hour before I had to get up. So... I got maybe 3 hours of sleep before my last 16 hour shift.

The night started out slow for me as far as new patients. However, we had several very sick patients in the hospital that I had to attend to (2 abdominal ultrasounds, a hepatic lipidosis kitty, etc). I hoped the night would stay quiet. It twas not to be. Cue hit-by-car #1 around 9. Followed by hit-by-car #2 at 11. Followed by hit-by-car #3 at midnight. Then came the 2 week old kitten gravely injured that I foolishly took as a Good Samaritan, thinking that I could fix it.

Then one of my two technicians received a phone call informing her that her grandmother had just died suddenly (not ill or expected, though she was elderly). She dissolved into hysterics, understandably. We all cried.

In the midst, I had to euthanize a patient. Followed shortly afterwards by euthanizing the tiny kitten that made biscuits on my thumb. (Also made me cry)

Then the ICU quieted down around 3am. I thought "FINALLY, I can get my paperwork finished and lie down for a few hours." Nope. The phone rang announcing the imminent arrival of a dog in respiratory arrest. Shortly after, it rang again, letting us know that another likely hit-by-car was coming in.

2 massive cups of coffee and 5 Dove chocolate squares later, the exhaustion was somewhat at bay, and I finished what I needed to do. Charts, notes, and phone calls kept me busy until 8am. I fell asleep standing up in the ICU briefly.

When finally released, I came home and collapsed. It is 7pm, and I have just stirred from my coma. Time to pack...because come 9:40am tomorrow morning, I will be on a plane bound for San Francisco. Catch you on the flip side - hopefully rested, rejuvenated, and slightly tanner.

Sunday, October 24, 2010

The art and the science

One of the myriad tasks a veterinarian is faced with is deciding when to try and fix a patient and when to offer euthanasia as an end to suffering. Since I am a doctor of veterinary medicine rather than a human doctor, I have the option (a blessing) of offering a humane end to pain. I rarely have to stand by and be party to endless, pointless treatment while a patient suffers. It's one of the reasons I am glad to be a DVM versus an MD. However, making this decision is an art and not a science. We're not always right. Sometimes we're very, very wrong.

Saturday night was one of those awful nights where I was faced with trying to make the best recommendation for a horrifically injured animal. "Smidge" was an 18 pound mixed breed poodle dog. He'd been used as a tug-of-war rope between 2 much larger (>60 pound) dogs. When he presented to me, a loop of intestines was hanging out of his side. He had an extremely large, palpable hernia running down his body wall. I couldn't quite tell the extent of it, but I knew it was bad.

Surprisingly, despite his grave injuries, he was fairly stable. Other than a mild blood loss anemia, his bloodwork was shockingly normal. His white blood cell count had not dropped yet, his kidneys were hanging in, and his liver and pancreas seemed to be doing ok. The loop of intestine that was hanging outside the body was still pink and actually contracting. I had high hopes for being able to save him.

I counseled his owner at length about the severity of his injuries and the need for immediate surgery. I reiterated his critical condition. They were torn. Spend $2500-3500 on emergency surgery and critical care with a 50/50 chance? Euthanize? They asked me what I would do, and I told them truthfully that I would do surgery on my pet in their situation. I was careful to explain though that I would do so knowing that death in 1-3 days after surgery was a very real possibility due to systemic inflammatory response syndrome, sepsis, acute respiratory distress syndrome, and multiple organ failure. After much discussion, they elected to proceed.

In surgery, I started by going in through the belly and enlarged the first hole I came through (the one through which the intestines were sticking). I pulled them through and looked at them. Unfortunately, they'd started to turn purple and had stopped moving. As a result, I resected (removed) about 6 inches of bowel and sewed my ends together. I then closed the part of the hernia I could get to with the dog on his back. Everything else in the abdomen looked ok. BUT...I couldn't find the right kidney. I dug and dug. I couldn't find severe hemorrhage anywhere to indicate that the kidney was avulsed. I knew it must be herniated near the dog's back. So we flushed the abdomen, and we sewed him up. Then we rolled him over to approach the rest of the hernia from the back. And that was there things went downhill.

I took my scalpel and opened up the puncture wounds on his back. My jaw nearly hit the floor. He was ripped open from his spine all the way down his body wall to the abdomen almost. How I had not seen that from inside the belly, I'm not sure. He looked like he'd been torn literally in half. The right kidney was poking up through the hole, as were the intestines. There was NOTHING left of the body wall.

I knew then that it was bad and that my patient stood less than a 5% chance of survival. Still, I gave it my best - sewing torn muscle bellies and fascia together, and poking the kidney and intestines back into the body. To orient in that picture - the dog's head is to the left. The purply thing at the top of the hole is the kidney, and next to it are loops of intestine. You're seeing basically a hole in the dog lying on its stomach/side.

In the end, he survived 2 hours post-operatively until he went in acute respiratory distress and died. The owner wisely elected not to perform CPR.

I felt terrible and moped around work the rest of the night. I felt I had wasted $2800 of the owner's money, put their dog through misery and pain, when I should have recommended euthanasia from the start. The surgery was way above my head - although, truth be told, it was far above anyone's head. There was nothing to fix. The dog had been crushed into unidentifiable fragments of meat. It was horrible.

Hindsight is always 20/20, but somehow, that is no consolation.

Thursday, October 21, 2010

I told you so...

So, I did a good deed and yet again, it was proven to me (via my colleague) that doing good things for people only gives them a sense of entitlement.

Remember this woman?

She showed up at our clinic a few days ago with a sick puppy. She agreed to pay for a physical exam and xrays. The puppy had a fixable but not cheap medical problem. My colleague elected to take the puppy on as a Good Samaritan, because the problem WAS so fixable. At the front desk, the woman became belligerent because she didn't think she had to pay the bill RIGHT THEN. She thought we could bill her.

I know that's a lie because I spent several hours with this woman helping her find financial options, discussing our payment policy (pay up front or leave). I guess she figured since we did it once, we'd always do it. That's the problem with good deeds.


So, for various reasons that I won't go into on this blog (personal family history), I am a freak about money. Constant fretter would better describe me. I'm pretty sure I fretted less when I made no money as an intern than now when I make way more than I ever dreamed I would. Dealing with finances always makes me feel stressed, worried, and overwhelmed.

Back when I started at my current job, I went to the see the financial planner that administers our office's Simple IRA. My question to him was fairly straightforward - tell me how to take charge of my money and what to do with it. He gave me some advice that I found extremely useful: first - start a savings fund with 6 months' worth of expenses. Second: get life insurance and private disability insurance (none offered through my job). Lastly: start paying off debt, starting with unsecured (my student loans) and moving to secured (the house).

A year later, I can say happily that we have a) established an emergency fund (only 3 months worth of expenses yet...but still growing), b) purchased private disability insurance, and c) bought life insurance for both myself and my husband. On top of that, I am contributing a small chunk every 2 weeks to my IRA. Both of our cars are paid off (well, the Mercedes was free), and we don't have any credit card debt.

Today, we met with our financial advisor to sign papers, and he said that we are in a great position for our age and education level - and it will only improve as my husband finishes his PhD and starts working.

I cannot reiterate to my readers that are vet students or other students or just anyone how important it is to take control of your money. I know it's probably easier for me to say that, because I am making a lot of money. But as my grandparents and aunt always said, "if you can't handle a little money, you can't handle a lot of money." Take control NOW.

I'm feeling un-frettery today for the first time in a long time. I'm also pleased to say that I can now spontaneously combust if I so choose - we are covered for that eventuality.

Ah, adult life. So dull and yet so exciting.

Wednesday, October 20, 2010

Dog versus part 2

There are 2 bread-and-butter cases we see in ER medicine - vomiting/diarrhea and lacerations. We put dogs back together from various shenanigans on a regular basis. I am not a fan of wound care. I can't really explain why, but it is something I rarely, if ever, enjoy. The machete dog was an exception. That was really fun to fix. Last night's bloodbath was most definitely not.

This was dog versus tractor hay fork tine. Luckily for the dog, the tine didn't go any farther into his body than through the skin and fatty subcutaneous tissue. Still, this mess took 3 hours to clean up - 1 hour of preparation by my technician while under anesthesia (clipping, cleaning, blunt debridement), and 2 hours by me (1 hour of sharp debridement, 1 hour of suturing).

When all is said and done, I can only hope that the flap I sewed back on remains viable. We'll see...(p.s. I forgot to take the after pics...sorry).

Friday, October 15, 2010

Dog versus machete

A while back, a very elderly, possibly legally blind man brought in his exuberant, sweet large breed dog. Said dog had been frolicking around while Mr X macheted the weeds in his yard. You can see where this is going, right?

All I had to say was, "Holy s**t, that was one sharp machete!"

Big goofy dog did fine with his rhinoplasty courtesy of moi.

Tuesday, October 12, 2010

We now return you to your irregularly programmed show...

I made stuffed mushroom appetizers tonight to take to a dinner party. They are like tiny morsels of mushroom CRACK. Super easy, as well.

12 fresh mushrooms (I bought large, stuffing, white mushrooms, I imagine any would work)
1 tbsp minced garlic
1 tbsp olive oil
1/4th cup parmesan cheese
1 package cream cheese (8oz) softened
1/4tsp ground black pepepr
1/4 tsp ground red pepper
1/4 tsp onion powder

Preheat oven to 350, coat cookie sheet/cooking pan with non-stick spray.

Wash mushrooms gently with a damp paper towel. Carefully pull stems off mushrooms (so as not to break caps).

Finely mince mushroom stems, mince garlic. Place in oil and cook until no moisture remains. Allow to cool to room temperature or slightly warmer.

Add cream cheese, parmesan, and spices. Mix. Scoop spoonfuls into mushroom caps, cook at 350 for 20 minutes (until piping hot and small puddles of liquid form under mushrooms).


A modification: I would use 1/8th tsp red pepper unless you like a little bite to your mushroom caps. Also, serve at least warm - cold mushrooms are not good.

Sad news

My recent splenectomy patient's biopsy came back as malignant (hemangiosarcoma). It's an important reminder that diagnosis can only come from histopathology! She will have 3-6 months until the lung metastasis become apparent.

Monday, October 11, 2010

Flawless fall weekend

We spent the entire weekend camping with my husband's brother and his wife (my best friend). The weather was so beyond perfect that it was almost absurd. The sky was absolutely bright blue without a cloud, the days were in the mid-70s to low 80s, and the nights were chilly enough to need to snuggle but not so chilly that we woke up shivering.

As we did last time, we took the canoe out on the lake to one of the otherwise inaccessible primitive lake campsites. We arrived Friday and came back late Sunday. No one forgot anything. There was plentiful food and beer. The dogs were in doggy heaven.

I could have stayed for another 2 days. It was blissful, relaxing, and rejuvenating. My mom and brother are here now visiting until tomorrow, then we have dinner with friends (tomorrow), and back to work on Wednesday. 15 days from now, we fly to Hawaii.


Thursday, October 7, 2010

Hard to share

There is something I have wanted to share on my blog for a long time, but I am afraid of the response it will generate. I pride myself on honesty and morality as a veterinarian. I do not believe in lying to owners to cover mistakes, and it irks me to no end to know that there are dishonest doctors out there. Recently, however, I entered a gray zone, and for the life of me, I didn't know what to do.

Several months ago, I took a dog to surgery for an abdominal exploratory. It was somewhat involved but successful. When closing a dog surgically, there are 3 layers. The first is the body wall. It is the single most important layer of all. If those sutures come out, the intestines and other organs will fall out - often under the skin, since the other sutures will stay in. One of the first things you learn in surgery is how to make sure your body wall closure is perfect. The next layer is the subcutaneous fat and tissue. This is mostly to bring the incision together so that the skin sutures (or staples) look neat, and the incision is lined up. I will reiterate - the layer that matters is the body wall.

In school, you have to close the body wall with simple interrupted sutures. This means you make a knot, then cut your suture, then make another knot, and so on. In an abdominal exploratory surgery where the incision can be a foot or more long, this can be enormously tedious and time consuming, as well as unnecessary. Once you are a confident surgeon, simple continuous (rather like a whipstitch) is perfectly acceptable.

Back to the story: I finished my body wall suture and cut the ends of my suture. I looked at them and thought, "those might be too short...they might come out." Then I mentally lambasted myself for being such a damned worrywart, checked everything, and continued. I do tend to be overly, overly careful in surgery and often fret about things that - in retrospect - were not worth fretting over. Something bothered me about this closure, though.

Longer story shorter: 3 days later, the dog came back in for dripping from his incision. His skin sutures were still in, as were his SQ. However, as I ran my hand down the external body wall, I could feel my fingers go into a cavity. The sutures had come out. I delivered the bad news to his owner. I had to go back in and fix the sutures. The owner had already spent well over $2000 on the surgery, and finances were rapidly becoming tight. They were emotionally distraught.

I asked her had she been letting the dog, Flip, jump, run, or play excessively? She turned positively green and admitted that Flip had been jumping in and out of her huge SUV for the past several days. Additionally, he had been rough-housing with the other dog in the house.

And therein lies the question: had I known that the dog was appropriately cage rested as recommended for any major abdominal surgery, I could say for sure that it was my sutures that failed. Yet, she had been letting him jump in and out of her Escalade - putting enormous strain on his abdominal incision. Further, he was wrestling with another dog 2 days post-exploratory. This is a huge no-no. Still, there was that nagging concern I'd felt when I closed the dog up that the sutures wouldn't hold for some reason. Was this me just fretting, as I always, always do, or did I have a legitimate concern? As I said, had I known that the owner had followed the post-op care instructions to the letter, I would have gladly replaced the sutures for free. Yet, I knew she had not - and I couldn't decide who was to blame - me or her, or even a combination of both.

In the end, I did not tell the owner of my concerns. Why? Because I cannot separate my natural sense of worry about any surgery I do from the reality of it. The knot was secure, but the tags were shorter than I usually cut. Had the dog been rested, though, I don't think there would ever have been a problem. I don't think. But I don't know.

Striving for an ethical compromise, I charged about 1/2 of what I would have had I know for sure that it was the owner's fault.

It still bothers me because it's such a gray area and I truly don't know the answer. The dog did wonderfully and is fully recovered. Had I overdosed him on a medication, had I cut him accidentally when taking his catheter out, had I let him fall off a table and break his leg...I would have taken full responsibility because I would have known that those things were my fault.

In this case, I have questions but no answers. Don't judge me too harshly.

Monday, October 4, 2010

You win some, you lose some.

I had a bit of both this weekend.

Saturday night, I was presented with a small breed dog in full-blown status epilepticus (non-stop seizuring). He had been seizing the entire 20 minute drive to the clinic. Due to the prolonged muscle contraction, his temperature already was too high to read on the thermometer (>108). We were able to get the seizures under control, but he rapidly began showing signs of a heat stroke (petechiae all over his body, low white blood cells, low glucose, and non-responsive hypotension). After NINE hours of pouring my soul into his care, as well as $2000 of his owners' money, fresh frozen plasma, Hetastarch, antibiotics, dopamine, and everything else under the sun, he died. His parents were devastated. I was too. I cried during the euthanasia, which is unusual for me. I'm fairly good at being able to turn that off, if you will. The difficulty of dedicated, crushed owners, an unavoidable illness (the dog was not a known seizure patient, this was his first - and last - seizure), no financial limitations, and then to lose him - it was too much for me.

Saturday mornings usually wrap up for me around 8:30 when I work the night shift. At 7:00am, a dog came in with weakness, a distended abdomen, and restlessness. Xrays showed severe abdominal effusion (fluid in the abdomen). An abdominal ultrasound showed tons of free fluid, which I sampled and found to be frank, acute hemorrhage. I suspected a mass in the spleen, but it wasn't the usual "HEY LOOK AT ME, I WEIGH EIGHT POUNDS!" tumor. This one was rather small (I thought). I'm not a radiologist, and while I am comfortable with the big things on ultrasound, this "small mass" I thought I saw could have been anything but.

I talked to the owner, ran appropriate bloodwork to rule out rat poisoning, etc. and then told her that I suspected a bleeding abdominal tumor, likely splenic in her older (7 year old) dog. I recommended surgery.

By then, it was 8am. My shift was over, and the doctor for the day offered to do the surgery. I wanted to stay though and do it myself. I love surgery, and I wanted to get the bad taste of my last patient out of my mouth - hopefully ending the day on a bright note (although a hemoabdomen probably isn't the best idea for that sort of thing).

Luckily, there was a "small" mass on the spleen (about the size of a half dollar and 3 inches thick). It had ruptured and was hemorrhaging profusely into the abdomen. With the help of my trusty and AWESOME LDS stapler, I had the spleen out in 5 minutes. She was awake from surgery within 10 minutes and looked amazing. The mass looks benign, although you really can't tell looking at them. It was well-demarcated, smooth, not necrotic or ugly. My fingers are heavily, heavily crossed for a hemangioma.

I only got 4 hours of sleep before pulling my 16 hour Sunday night shift, but it was worth ending Saturday on a good note. SO worth it. Especially when my surgery patient's owner asked if she could give me a hug this morning.

(Oh and my tracheostomy patient is home and doing great)

Friday, October 1, 2010

Save the drama for your mama...

So this lady called back several days later, after our office manager had left several messages for her. Our policy is not to offer refunds unless there is some obvious, legitimate reason to do so. This woman did not have a legitimate reason. She and the OM played phone tag for a couple of days, and in her final attempt, she called during the evening (despite my OM telling her when she would be in building), and it just so happened to be my shift. I elected to talk to her. I was surprisingly nervous. Our OM handles most of our complaints these days, because they are rarely legitimate in the slightest, and it's just easier if she handles them. It reduces our stress. She also is incredibly smart and capable and knows a great deal about medicine. Armed with our medical notes, she can usually explain the medical details to the densest client.

At any rate, I got on the phone with this owner. The conversation lasted 20 minutes. I'll hit the highlights:

Crazy lady (henceforth CL): "You did nothing for me, I want my money back."
Me: "Ma'am, I replaced the stitches that your dog had torn out. Your dog had to be sedated for this."
CL: "He didn't have stitches. The spay/neuter clinic said they used glue."
Me: "Yes ma'am, they used glue in the skin. It cannot be used in the deeper layers, as it is inflammatory. Your dog tore out his deep sutures, which I had to replace to help stop the bleeding."
CL: "I don't see how that could be true. The spay/neuter clinic said they used glue. I *guess* if you say that, then I have no choice but to believe you." Pause. "But I don't, really."
Me: Speechless.


CL: "I want to print out pictures of my dog and go stand outside the clinic to get it closed down."
Me: "Ma'am, the vets that work there are excellent vets. This is an uncommon complication of neutering OLDER dogs." (subtext that she is partially to blame for this) "They work very hard and do good work, and they do it at a significantly decreased price to help those in the community, such as yourself, that have financial constraints."
CL: "They should be closed down."
Me: "Ma'am, some of the vets that work there do relief work here, and I can assure you that they are great vets."
CL: "Ohhhhhhhh, I see." (Pause to allow me to grasp the implication of that statement) "Now, I understand..." (subtext: they screw up on purpose to generate income for the emergency clinic).


CL: "Why didn't you drain the hematoma?"
Me: "A hematoma is, by definition, a blood clot. That means that the bleeding has stopped because the blood has appropriately clotted. To go in there and remove the clot would be tantamount to ripping a band-aid off an unhealed wound. The bleeding starts all over again. Current recommended therapy is medical: cold compresses, cage rest, sedation, e-collar, and steroids."
CL: "Google says that you should have drained it."
Me: "Ma'am, where did Google go to school?" (Just kidding)


Me: "Ma'am, I am very sorry for your frustration, but I did everything in my power to help your dog. I sewed him back up, I prescribed appropriate medications for him, and recommended cage rest. We discussed that this will take a long time to heal, but this is normal and expected. I have treated 4 other dogs like this in 4 weeks, so I can assure you that I know what I'm doing. I really do care about my patients, and I was not trying to steal from you or cheat you."
CL: "Ok. I still want to get the spay/neuter place shut down."

This, coming from a woman who went to this business in the first place because she didn't have the finances to see a general practitioner. A woman for whom this business is designed to help and whose dog suffered a routine though not common complication. A woman who, if she'd spayed her dog at the appropriate age instead of waiting until he was 2 years old and 60 pounds, would never have been in this situation.

Thankfully, in the end, she seemed to at least understand that I had done everything I could have and should have. So she is satisfied with us and is no longer demanding a refund. At least...not yet. Give it a week.

Head: 0 Wall: 2