My holiday

so far has been lovely, absolutely lovely. Two Christmas dinners - one with my family and one with my husband's, some very thoughtful gifts, and relaxation and sleep! Lots of sleep. Tonight, we are going to watch the UT bowl game with my husband's grandfather (as well as celebrate my husband's 35th birthday!), and tomorrow night, we are seeing the Avett Brothers in Asheville to ring in the New Year (with friends).

I can't wait!

The happy Christmas story!

MTWaggin - I HAVE IT! A happy Christmas story!

On Christmas Eve, a very nice woman and her daughter showed up at our clinic. In tow, they brought a yellow labrador. Based on his teeth, he appeared to be about 1-2 years old. He should have weighed a good 60 pounds. Instead, he weighed in at 31.7 pounds. He'd been outside a trailer and left to die without food. The lady that brought him in had thought he was being fed, but she kept noticing him outside the trailer without food, no cars in the driveway. Finally, one day as she drove by, the Lab happened to stand up, and she saw how shockingly thin he was. She banged on the trailer door and realized it was empty. She took the dog then and there (Christmas Eve).

For being half-starved, he was remarkably chipper. I was assuming the lady had come to turn him over to our clinic (and I likely would have been forced to euthanize him...). Instead, she wanted to take financial responsibility. I explained how expensive it could be, especially given that he was completely starved. He would have to be fed VERY carefully to avoid refeeding syndrome (a killer of concentration camp victims, first recognized in WWII). We would have to monitor his electrolytes and hydration status.

Further, as it turned out, he was heartworm positive.

I was sure he would be euthanized.

Nope. The lady wanted to do what he needed, regardless. And despite his starving, the Lab was in good spirits and relatively healthy condition. We started treatment for his starvation and he did amazingly through the weekend. She picked him up this morning, did not complain about the $850 bill (I knocked off $200 due to my cheery Christmas spirit), and is taking him to a day veterinarian to discuss heartworm treatment, vaccinations, and other preventative care.

My good cheer is fully restored this morning. I've been cooking in preparation to go home for Christmas dinner (one with my family, one with my husbands), although me + punch drunk/slap happy + knives and hot cooking oil...maybe not such a good idea. Only one small bleeder so far and that came from a sharp can.

Snow...and idiot awards

It snowed in earnest here last night, necessitating that I stay 2.5 hours beyond the end of my shift. Really I should be sleeping, not blogging. Our night was steady but not crazy. The morning, on the other hand, was turning into a CRAZY day. I'm glad I left when I did. I'd just admitted a female dog with a urinary obstruction, an older dog with abdominal pain and free abdominal fluid, and euthanized a laterally recumbent, severely hypoglycemic cat. There were 3 or 4 patients waiting to be seen by the day doctor when I evacuated.

There was about 4 inches of snow on the windshield of my car, so I turned it on to warm it up. I also flipped on the windshield wipers, not thinking anything of it. I came back out about 15 minutes later to find the windshield wipers not moving. When I got in the car, the overwhelming smell of burning plastic/melting car parts almost made me vomit. It was then that I realized that I'd burned the motor out on my windshield wipers.

I win the idiot award for the week - as in retrospect, DUH!!!!!

It's a Mercedes SUV (my freebie, hand-me-down), and I love that car...but fixing anything costs a fortune! Plus, it's the day after Christmas, it's Sunday, and it's snowing. There is no way in Hades it's getting fixed by a mechanic. Luckily, my husband is quite talented with automobile repair. The Mercedes always presents a special challenge, but I'm confident in his capabilities.

Here's hoping desperately, as we are supposed to leave and go home for Christmas with the families tomorrow. We likely can't make the drive without windshield wipers...(although there are other options - rent a car, fly, etc).

On a brighter note, my wonderful husband surprised me at work last night. He brought me a roasted and stuffed duck (he made himself), homemade mashed potatoes, dressing, gravy, broccoli, hot rolls, and sweet tea. He also brought me a few, smaller presents. How wonderful is that? I didn't even feel sad to be working on Christmas.

Ok, to bed with my tired self.

Merry Christmas (Eve)

My night consisted of the following:

Arriving at 5:30pm to a mostly quiet ER with some inpatients but nothing waiting to be seen.

Within 30 minutes, I had 7 rooms waiting on me as follows:

1) A 1 year old Shepherd mix with a swollen eye (turned out to be conjunctivitis of unknown cause)

2) A dog that had been (likely) attacked by another dog, non-weightbearing on one leg, with puncture wounds.

3) Another dog that tussled with the neighbor's dog and now had a flap of skin dangling that needed to be cleaned and sutured up.

4) A hit by car Labrador puppy that wouldn't walk (nasty femoral fracture)

5) An emaciated (30 pounds at 1.5 years old) Yellow labrador that had been tied outside an abandoned house for 2 weeks without food, brought in by Good Samaritans that wanted to take responsibility for him (he has heartworms and is starved - but is in good cheer - currently refeeding him slowly to make sure he doesn't die from refeeding syndrome).

6) A Shih-Tzu with severe back pain.

7) A dog that ate a large quantity of semi-sweet, milk, and white chocolate.

The night continued to be interesting from there on...3 euthanasias (an ancient Great Dane with dilated cardiomyopathy that chose to BLOAT, of all things), a HBC Boxer with the worst pulmonary contusions I've seen in a long, long time, and a 7 year old mixed breed dog with a history of seizures that presented in status epilepticus (owner had not a SINGLE penny to his name - but it being Christmas, we did some treatments until he could make a decision).

I should rest now...because there are 2 more nights of holiday madness to come...then 9 days off to rest, recuperate, have Christmas with the husband's family, then my family, then celebrate his birthday, then see the Avett Brothers in concert on NYE.

Merry Christmas everyone!

Thank you for all the thoughts. It has made me feel a lot better. That and the final cessation of a 72 hour headache, some sleep, and the presence of my husband back from meeting his PhD advisor. It is a beautiful, though chilly day here. We're going to have dinner and see a movie together, and I'm going to remember all the good things I have to be thankful for. I'm also going to re-read my stack of thank you cards one more time.

Angry kitten gods

I must have angered the kitten gods. A nice young man showed up yesterday morning at work, holding a little black fuzz ball to his chest. It was a beautiful black kitten (with silver frosted fur). His eyes were caked shut with snot, and so was his poor little nose. He was about 8 weeks old. Both eyes were ulcerated, but as soon as you cuddled him under your chin, he made biscuits on your face and cheeks, and purred.

So...guess where he now resides? Yes. Yes. Yes. The bathroom. At least this one is not a bottle baby. He's big enough to eat kitten food. He's also very sick, so I'm not sure if he's going to pull through, although he does purr and make biscuits.

Worse yet, a woman brought in her puggle puppy tonight (pug/beagle cross). It's so ugly, it's adorable. He was picked up by his nose and shaken by a much larger dog. As a result, he developed some serious pulmonary bruising. The owner had not a single cent to her name, not even the money to come into the ER. I offered CareCredit, she did not want to apply. She called people. No money. Finally, I confided to her that I was fairly sure the puppy would pull through. I told her that I thought if she took the dog home and kept him quiet and calm for the night, he would likely survive. No, she didn't want to do that. She couldn't stand the thought of waking up and finding him dead. They just wanted him euthanized!

Exasperated, I went back to this cute little 5 month old puggle (who has a great prognosis). I couldn't stand the thought of euthanizing him. So now courtesy of some quick paperwork, he belongs to the clinic (i.e. me). Anybody want the world's cutest puggle??

Want some wine with that cheese?

The last 2 nights have been significantly less than stellar. SIGNIFICANTLY.

7:00pm Wednesday night, an owner calls. Her large breed dog has had 2 puppies, both dead. The third one was born alive, but the bitch accidentally eviscerated the puppy while chewing the umbilical cord. Further, the bitch has stopped pushing and produced no more puppies in over 8 hours.

My technician recommends bringing BOTH mom and the eviscerated puppy in ASAP. The owner declines to do so and hangs up. At 11:30pm, she calls back. The puppy with its intestines hanging out is dead (there's a real shocker), and the bitch has not been pushing. Should she bring her in? My technician counsels her AGAIN that bringing in the dog is imperative. The owner demures.

1:15am, I am dog tired. Owner shows up with a ONE HUNDRED AND TWO POUND dog in tow. No puppies. Owner doesn't have finances...but she's been breeding for 20 years, and she knows all about it. She coughs up the money for xrays and an ultrasound. I see 5 puppies, 3 definitely alive on ultrasound. There is no obvious cause of fetal obstruction, so I recommend trying oxytocin to stimulate labor.

It starts to go downhill at that point. The owner complains that she doesn't want to sit around for 3 hours and wait to see if numerous doses of oxytocin work. She has to be up at 5am. However, she doesn't have money for c-section. She's not worried about live puppies. She asks me if she can get one shot of oxytocin and take the dog home. I tell her she can do that, however I would strongly advise against it. She whines some more, then she asks me what I would do.

I was thisclose to saying a) I WOULD HAVE BROUGHT THE DOG IN EITHER OF THE FIRST TWO TIMES YOU CALLED and b) I DON'T BREED SO I WOULD NEVER BE IN THIS POSITION!

It takes her an hour of more wasted time to decide to try oxytocin. Another puppy is born, but it is dead. I call to give her the news. She suddenly becomes extremely worried about the other puppies (previously she said she was not concerned with live puppies). I recommend c-section if she wants any live puppies (although I tell her that the chances of any surviving at this point are slim). She wants another ultrasound to see if any are still alive.

I'm rapidly losing my patience. Another u/s reveals live puppies still. Mom suddenly comes up with enough money to do a c-section, so to surgery we go. It is now 4:30am. Surgery is bloody, as all c-sections are. It is not routine in any fashion. The puppies are absolutely enormous. There are 4 left. The owner - OF COURSE - did not want the dog spayed, despite the fact that she was SIX YEARS old and well past good breeding age. Unfortunately, I had to make 4 uterine incisions (when normally I make ONE). The uterus was friable and tore. In the end, I had my technician call and tell her that the uterus needed to come out. I was afraid to leave it in, as I was seriously concerned about healing.

Then it got really interesting. For no discernible reason (and believe me, we exhausted the possibilities), the dog went into complete cardiac arrest. We started CPR in the operating room. Her heartbeat came back. I continued surgery. She died again. We got her back. I continued surgery. Repeat 2 more times.

Yes, she died 4 times in surgery. Amazingly, she pulled through and recovered from anesthesia. I suspect occult heart disease contributed to her cardiac arrest. We removed four puppies from the uterus, 2 alive, 2 dead. One was so huge that I realized surgery was necessitated from the start. There was no way that puppy was coming out.

I didn't leave work until well past 9am, collapsed into bed around 10am, only to get up and do it all over again last night. Last night was also a nightmare. One of my techs called in sick; the receptionist called in sick, too. So we were staffed with 2 techs and myself. Further, Everyone had a problem with money last night.

We had one couple who signed an estimate for their very ill cat, agreed to payment, then threw a fit at the register when they realized that we run our checks electronically. They accused our technician of lying to them over the phone about taking checks. It got ugly. Then there was the young, well-to-do looking lady with her 2 little dogs that ate a bottle of Rimadyl. We decontaminated them, treated them with activated charcoal. Then the perfectly nice looking young lady threw a fit (literal) that her bill was $300. She protested that she was quoted $92 for the first dog and $46 for the second (our exam fees). When we explained (again) that those were the exam room fees, she stated that since she was not told the price for treatment, she should have to pay nothing. I didn't let her get away with that.

Then there was the nice young guy with his beautiful dog that somehow managed to badly break its leg in the backyard. He had the $92 to be seen and nothing else. We discussed options: amputation, orthopedic surgery, or long-term cage rest and pain medications with questionable return of function to the leg. He could do NONE of those things. His wife hated the dog and wanted him to get rid of it. The dog was euthanized while the man held it in his arms and sobbed.

After all this, one of the only 2 technicians I had melted down in the ICU. She had been in surgery with me the night before, dealt with the stupid, thoughtless owners who were only concerned with breeding and producing puppies to sell, she'd dealt with the owners that night complaining about money, and then had to assist with euthanizing the dog with the broken leg. So, she lost it in the middle of the ICU - sobbing hysterically, asking me "why, why?? Why are people such idiots? Why do people breed? Why is it our fault that we can't fix them for free?" - tears streaming down her face.

I had to resist the urge to run screaming and crying from the building myself, but I kept it together. Thank god I have the night off.

PUHLEEZ

Can we go the park and throw my tennis ball?? I know it's 20 degrees outside, but I love my tennis ball!!




It's back to work tonight for me, and I'm sure I'll have many tales to regale you with come my next posting. I am trying to be vigilant and post once a day, but once works starts again...I'll probably start to slip.

Reproductive emergencies - dystocia

I don't know how many of you guys are breeders, but if you are, or if you know someone who is, this post is for you.

There are several different types of reproductive emergencies that I see. The four most common are (in order of most prevalent) - dystocia, eclampsia, pyometra, and mastitis. There are others such as uterine or vaginal prolapse, metritis, mammary tumors, etc, but those are less common.

This post will cover dystocia (slow or difficult labor). It is a fairly in-depth post, as this is a fairly in-depth problem!

There are several important steps that need to be taken during pregnancy that are often overlooked.

First, the bitch should be up to date on her vaccines before she is impregnated. She should also be current on heartworm preventative and flea/tick preventative. I can't tell you how many puppies/kittens I see (and treat) suffering severe flea infestation and/or hookworm infestation leading to life-threatening anemia.

Second, from about the mid-period of pregnancy onward, the bitch should be on a high density food (make sure it is formulated for pregnancy/lactation). Small meals fed frequently will help, as the puppies cause a great deal of press on the stomach/diaphragm, making the stomach (in effect) smaller. A bitch should gain weight, she should NOT lose weight, become thin/emaciated looking, or maintain the same weight.

Deworming at least 3 days in a row with fenbendazole is also crucial. During pregnancy, latent GI parasites (hookworms/roundworms predominantly) come out of muscle hibernation and are passed to the puppies. Thus, careful deworming is essential.

At 45+ days of gestation, xrays should be conducted at your veterinarian so that puppies can be counted. This way, it is easy to tell when the bitch is finished having puppies. It is rarely done by hobby breeders, and it is usually the FIRST thing I do as an ER veterinarian faced with a dystocia.

I see at least one dystocia case a week, and bar none, it is always dogs. Cats very, very, very rarely suffer a dystocia. I have never performed a cat c-section. They are their own species and can actually take days to deliver a whole litter - without any adverse side effects. Dogs, on the other hand, cannot.

Labor proceeds through three phases - stage I labor is exhibited by nesting behavior/hiding, restlessness, and some anxiety. It usually lasts about 12-24 hours. At that time, rectal temperature will usually drop to under 100 degrees. We recommend that people monitor rectal temperature when expecting puppies.

Stage II is active expulsion of the puppy. Normal expulsion with active contractions should take less than 20 minutes. If a bitch is pushing for more than 20 minutes and not producing a puppy, this is a sign of trouble. If anything is noted hanging out (head, feet, etc), and after 20 minutes of CONTINUOUS pushing, nothing comes out; the bitch is having problems. It is normal for a dog (especially with her first litter) to push a bit, then rest, then push some more. 20 minutes of non-stop pushing without a puppy is usually a sign of dystocia.

It is important to note that a dog can go hours between puppies. The bitch may expel a puppy, then sleep for several hours before having another. This is normal. We start to worry if no puppy has been produced beyond 4-5 hours, and at that point, a trip to vet might be in order to check heartbeats via ultrasound.

Stage III is placenta expulsion. Since there are multiple puppies, there are also multiple placentas. They do not come out sequentially - not one puppy/one placenta - it can be three puppies, one placenta, another puppy, 2 more placentas. I also recommend that owners count placentas (the bitch will often eat them, so counting and keeping a close eye on mom is crucial!). Retained placentas are not common in dogs, but they can occur and cause a problem.

If your dog exhibits difficulty, the flow of your ER visit will go something like this: the bitch will be taken to the doctor and examined. A thorough physical exam and cervical exam will be conducted. At that time, the veterinarian will likely recommend checking calcium, blood glucose, and conducting xrays of the abdomen to count puppies.

Once the puppies are counted, an abdominal ultrasound should be conducted to assess fetal heartbeats. They should be at least two times as high as that of mom. If they are slow or absent, a c-section is immediately indicated, as this indicates fetal distress.

If everything looks normal on the xray and ultrasound(i.e. no evidence of fetal death, no puppies blocking the birth canal, puppies look small enough to pass, and heartbeats are normal), the veterinarian will likely offer trying oxytocin. This is a labor-inducing drug (the same that is used in humane females) that stimulates uterine contraction. It is used in very, very small doses intramuscularly to stimulate labor. It was once thought that large doses were appropriate, however recent literature has demonstrated that large doses cause uterine tetany (ineffective contractions) and smaller doses are better. Make sure your veterinarian is aware of this recent research if you are having this problem! Many veterinarians are not and still use whopping doses of oxytocin, which are not indicated, may cause decreased oxygen supply to the puppies, and may make uterine contractions disorganized and ineffective! (Normal doses should be 0.25 units for a small dog, 0.5-1 unit for a medium or large dog). Doses may need to be increased if contractions do not occur.

At the same time the oxytocin is administered, calcium will also likely be given under the skin to help improve uterine contraction.

Usually, I will try oxytocin 3 times. After each shot, the bitch is relegated to a dark, private cage at the back of the ICU with a towel over it. She is left alone for at least 45 minutes. If no puppies are produced after the 3rd shot, I recommend c-section.

There are times when I skip the oxytocin route. It all depends on the owner. Some owners are only concerned about the bitch and do not care if the puppies survive. I will try oxytocin in that case to prevent c-section. In other cases, the owners want the puppies all alive and well. If that is the case, I tell them that c-section is the fastest way to get all the puppies out immediately (though not necessarily alive).

C-section is a risk to the mother and puppies. Pre-anesthetic agents such as opioids can depress fetal oxygen supply, and anesthesia itself is hard on immature body systems. Thus, we avoid this route unless necessary. Unfortunately, it is frequently necessary.

Once the c-section is performed, if there are live puppies, the veterinarian will likely send the bitch home as soon as she is recovered. This is because the puppies have very immature immune systems and are prone to picking up disease. Getting them out of the hospital ASAP is important. If no puppies survived, the bitch will often stay in the hospital for around 24 hours.

Another consideration hobby breeders (and sometimes "professional" breeders) rarely take into account is the myriad number of things that can go wrong and the cost involved if that happens. Breeding well and carefully is an expensive process. The excellent breeders I know rarely make any money off of their pups, despite selling some for around $1000 each. This is because they spend money on appropriate pre-natal care, make sure the pups are appropriately dewormed, vaccinated, and certified in whatever way that particular breed needs to be certified.

A c-section at our hospital runs from $1000-2500 (depending on size of the patient). The majority that I do are small breed dogs (Yorkshire terriers, chihuahuas, and the like). I do get stuck with big dogs sometimes (recently a pit bull and a Boerboel).
It is all too common for me to see a dystocia (or an eclampsia, metritis, mastitis), and the owner whines that they can't afford to pay for it.

My gut reaction (which I rarely voice) is that breeding is expensive. Even if everything goes perfectly, responsible breeding costs money! Most people think they'll just pop out a few, really cute puppies, they'll sell like hotcakes on Craigslist, and they'll make a few bucks.

In reality, "breeders" often get stuck with big medical bills when their pet suffers a dystocia or eclampsia or mastitis. That or they wind up euthanizing an otherwise healthy pet for a totally preventable problem. In addition, I frequently see puppies with parvovirus that the misinformed buyers/owners had been told were vaccinated, only to find out that the breeder administered the vaccines themselves (not to say that responsible, educated breeders can't administer vaccines, they certainly can - but that's not the majority of breeders).

Reproductive emergencies are some of the absolute easiest to prevent by simple spaying/neutering, and yet, they are one of the MOST common things we deal with in the ER. Just another of the myriad ways in which being a veterinarian can confound and frustrate!

The cougar story

This was told to us by our surgery professor during our 2nd or 3rd year of veterinary school. It should have been an early hint about what we would deal with as veterinarians.

The surgery service at our school was presented with a privately owned pet adolescent female cougar (about 1 year old). She had suffered severe burns to her gums and mouth - so bad that they required surgical intervention. The wounds appeared to have been caused by a caustic substance, so the surgeon sat down to chat with the owners.

The story unfolded as follows: the cougar had become "mouthy" as she aged. She had started "teething" on the ONE YEAR OLD child in the house, gnawing on his arms and such. The owners decided, in their infinite wisdom, to stop this behavior. They applied Icy-Hot to their arms and encouraged the cougar to bite them. If you have ever used Icy-Hot on your skin, you can imagine how it would feel on your mucus membranes. It burns. Hence, the burns in the cougar's mouth.

You might think they couldn't get stupider, but there's more.

The surgery department went in and fixed the damage, doing skin grafts around the lips, debriding the necrotic oral tissue, etc. The cougar recovered normally, but when all was said and done, the owners were not pleased. They complained that the repair was not cosmetically appealing. The surgeon was dumbfounded. Why did it matter if it was perfect cosmetically?

"Well," the owner replied, "we have a male in the house too, and we're going to breed them and sell the cubs. If people see the female cougar, they might think she was born that way."

My surgeon professor said that she offered to adopt the ONE YEAR OLD CHILD out of the house, so that it wouldn't be killed in the near future.

Talk about stupid.

How far my dog has come...

So, my park story. I took Heidi to the park yesterday. As long as there is no one on the tennis courts, I close the gates and throw the ball for her. Yesterday, an older man (mid-60s) comes up to the fence with his young dog. It was a 10 month old Golden Retriever mix, neutered male. He asks if he can come in, and I acquiesce. Heidi has been really good with other dogs thus far, although she is very timid. I am conscious of this and am careful with her in unknown situations. She weighs 75 pounds, so I am cognizant of her ability to do damage. While well trained and obedient, she has sort of a "SQUIRREL!" mentality, so I have to keep her very focused.

At any rate, said bouncy 10 month old puppy comes in and promptly tries to mount Heidi. This proceeded to continue for a few minutes. Heidi was becoming highly agitated, and I was very uncomfortable. The guy kept saying, "oh, it's ok, she can teach him some manners." Meanwhile, my dog is trying everything she can to get away from the puppy. He is tormenting her and trying to mount her - and I couldn't catch her, because she was terrified. She starts snapping at the puppy, trying to get him off. She's running from him, and I'm running after her - without much success. The owner keeps saying, "oh, it's ok, she won't bite." I'm pretty damned sure she will. Immediately after he said that, Heidi came away with a mouth full of golden fur - but no punctures.

I finally catch her, and while I'm holding her to put her leash on, the puppy mounts her again. The owners is meanwhile explaining how SUBMISSIVE his puppy is. THE PUPPY THAT IS ATTEMPTING TO MOUNT MY DOG is submissive.

I held my tongue, got my dog on her leash, and left the park. I was shaking I was so angry. Heidi was remarkably good. While she snapped, she only made contact once, and she only got fur. It was clear she was warning the other dog off. In retrospect, I can't believe that I said nothing to this clearly clueless owner.

Lack of training infuriates me. That dog will grow up to be 60+ pounds and capable of knocking children over.

I am so anal retentive about training that my husband gets annoyed. For instance, I take Heidi to PetSmart so that she can be around other dogs and people. She is not allowed to solicit interaction from people. She is also not allowed to approach other dogs unless I give her permission to do so.

Further, she's not allowed to beg. If we are eating, whether in the kitchen, dining room, or on the couch, she is not allowed to be nearby staring at us. I also don't let her eat her food without express permission or go out the door ahead of me. She knows "wait" and obeys well.

Training a dog - especially a large breed - is so crucial to their well-being and safety. A big dog, no matter how mild tempered, can do a lot of damage without even trying. Heidi isn't perfect and neither is my training, but she's come a long, long way from the timid creature she was when we adopted her.

While we're on rants - it drives me crazy when I verbally reprimand my dog for doing something she shouldn't, and people say, "oh, it's ok, she's not bothering me." And the dirty looks you get in PetSmart when you verbally reprimand your dog! It's like people think I beat her because I take a sharp tone when she is doing something she knows better than to do.

Dogs need training. They need to know where they stand in the order of the household. It should be BELOW the people, otherwise all sorts of problem behaviors come out - housesoiling, destructive behaviors, separation anxiety. Having a dog that is stable and mentally appropriate involves some work, but it is doing a disservice to your dog (and to the world that has to deal with it), if you don't.

The mother of all emergencies

That's the universal nickname for a "bloat". I don't know if that's necessarily true, given some of the emergencies I've seen, but let's not split hairs.

Bloat is actually a misnomer. The correct term for the condition of the stomach filling with gas and rotating on its axis is called a gastric dilatation and volvulus (GDV). A gastric dilatation without volvulus (twisting) is technically a bloat. Dogs food bloat all the time - they get into the bag of cat food and eat all 20 pounds, and then they lie around and groan. That is a bloat. It is rarely life-threatening (although occasionally it can be). Somehow, the term bloat was applied to a GDV many years ago, and it has stuck. Most vets call a GDV a bloat, but at universities, you'll likely find sticklers who only say GDV.

At any rate, GDV occurs in large breed dogs such as Great Danes, Weimaraners, St Bernards, Doberman Pinschers, German shepherds, Labradors, and the like. No studies have been able to consistently identify a cause of bloating. There are many theories. Some believe that thin, nervous dogs that are fast eaters and gulp down a lot of air while eating are more prone to GDV. There has been no proof that this is the case. Others think it is strictly conformational - big, deep chested dogs. The truth is that no one knows what causes it. Some of the risk factors that have been identified are:

* Feeding only one meal a day
* Having closely related family members with a history of bloat
* Eating rapidly
* Being thin or underweight
* Moistening dry foods (particularly if citric acid is listed as a preservative)
* Feeding from an elevated bowl
* Restricting water before and after meals
* Feeding a dry diet with animal fat listed in the first four ingredients
* Fearful or anxious temperament
* History of aggression towards people or other dogs
* Male dogs are more likely to bloat than females
* Older dogs (7 - 12 years) were the highest risk group

The onset of a GDV is rapid, and a patient's condition can deteriorate in a matter of an hour. Once the stomach flips itself, gas, food, and fluid can no longer exit. The stomach rapidly dilates, leading to pressure on blood vessels that return blood from the rest of the body to the heart. Furthermore, the blood supply to the stomach is cut off, rapidly resulting in necrosis (death) of the stomach tissue. Shock rapidly sets in.








The signs of GDV are restlessness/pacing and discomfort, retching but not producing anything (or only producing a small amount of white foam), and a distended abdomen that sounds like a drum when you tap on it. These come on rapidly, and if noted, the patient should be taken to the ER immediately! In this case, minutes count!

Once you arrive at the ER, the technicians will likely whisk your pet away to the back immediately. Initial triage is the placement of an IV catheter, rapid infusion of large amounts of IV fluids to combat the shock, pain medications, and initial bloodwork. Once the patient is as stabilized as possible, a lateral xray of the abdomen will be taken. A GDV looks like this:



Surgery is absolutely the BEST treatment for a GDV. And FAST. Some veterinarians will pass a tube and can de-rotate the stomach that way. This method is fraught with problems. First, placing a tube into a twisted stomach is risky. If there is damage/death to the neck of the stomach (cardia), it is easier to accidentally puncture that neck. Further, if surgery is not conducted, it is impossible to tell how much damage has been done to the stomach. Lastly, if a patient does not undergo surgery and have the stomach de-rotated, a GDV is highly likely to happen again. In one study, at least 25% of dogs that did not have surgery were euthanized within 48 hours because of poor response to treatment.

As a sidenote, I recently saw a Great Dane that had a GDV. He presented to us, collapsed in the lobby, and proceeded to die. We were able to successfully resuscitate him, but after all that, his owners elected euthanasia. Afterwards, they casually mentioned to me that the dog had bloated before! but had not had surgery to correct it. The vet had passed a stomach tube and that was that. Had this dog had surgery, it is likely that I would never have seen him, and he would still be alive.

Surgery consists of de-rotating the stomach, passing a stomach tube and emptying out the contents, and then tacking the stomach to the body wall (gastropexy). If the stomach has suffered irreversible damage, then some of it might have to be removed.

Many people have the mistaken impression that a GDV cannot be fixed. This is not so! While it is a life-threatening emergency, rapid intervention and surgical repair can fix it. Rapid identification of the problem and surgery are absolutely imperative. Waiting 6 hours before deciding that a vet should be consulted is not a good idea.

Hospitalization after GDV repair can last for as little as 24 hours to as much as a week. My last 2 have spent about 36 hours hospitalized, then went home to live normal, happy lives. Complications can arise post-operatively, necessitating longer stays in the hospital. The whole process is also very expensive. Most dogs that we treat for GDV are 90 pounds or heavier. As a result, everything is more expensive. For surgery and post-operative care (in our hospital), a GDV will not run less than $1800-2500. As a result, we see many financial euthanasias. It's always sad, because a GDV is such a fixable problem.

*A special note about Great Danes. Some research indicates that as many as 1 in 4 Danes will bloat at some time in life. I highly recommend that all Great Danes undergo gastropexy (stomach tacking) as puppies. Especially females! It can be done while they are under anesthesia for a spay. It is important to remember that even though your dog has a pexy, it is possible that a GDV could still occur. Occasionally, these pexies break down! If a dog is pexied and exhibits signs of a GDV, it should be seen ASAP.

In the spirit of giving

and since several of you made interesting suggestions for future posts (I am working on a bloat post specifically, as well as one on reproductive emergencies), how about you guys tell me what you would like to read about on my blog? I'm interested in whatever ya'll want to hear about - more blood and guts stories? More client financial nightmares? More great saves? Let me know and I'll try to come up with a post for you.

I'm also going to have a contest soon with a nice prize...I just haven't figured out what it will be yet (the contest OR the prize).

Ok, someone remind me to tell you about my terrible experience in the park today at a later date. I have to get ready for a Thanksmas party!

How to know if you need to visit the vet ER

My best friend made a suggestion for this post, and I thought it was a GREAT idea.

So, we've all been faced with the question: Do I take Fluffy to the ER, or can I wait until tomorrow? Here are some reasons why you should go, as well as some reasons that can wait.

1) Allergic reaction to shots (or other causes): these occur fairly frequently, especially in small breed dogs like Boston Terriers, dachshunds, chihuahuas, and the like. The most common reaction is swelling around the eyes, lips, and muzzles (urticaria). Hives all over the body might also be present. They can be very subtle or extremely severe. Your dog will likely itch all over and frantically rub him/herself all over the carpet, walls, and scratch vigorously. The reaction is called a hypersensitivity type I reaction. If your dog is suffering from hives, itching, and swelling, a trip to the ER is NOT necessary. Benadryl can combat the effects. I usually use 1-2mg per pound (so for a 25 pound dog, one adult Benadryl-25mg should be sufficient - up to 50mg if needed). Make sure that the Benadryl has no other ingredients in it other than diphenhydramine. Pseudephedrine, etc can kill dogs!

On the flip side, dogs can develop anaphylaxis - a life-threatening manifestation of a type I hypersensitivity. This is typified by very sudden onset of vomiting, diarrhea/defecation, collapse, pale gums, and labored breathing. Immediate treatment is warranted for this type of allergic reaction, as it can cause swelling shut of the airways.

Rarely do both occur together. Dogs suffering cutaneous (skin) hypersensitivity reactions rarely have any problems. Dogs suffering anaphylaxis rarely have any skin manifestation.

2) Ingestion of chocolate, antifreeze, rat bait, sugar-free gums containing xylitol, raisins, grapes, any over the counter medications such as ibuprofen, tylenol, aspirin, or prescribed medications: these do necessitate a trip to the ER. Many owners try to induce vomiting at home with hydrogen peroxide. That stuff is incredibly caustic and can cause esophageal and stomach burns/ulcers. If your pet has eaten something it should not have, the safest route is to have a veterinarian induce vomiting with an injectable drug called apomorphine. Afterwards, activated charcoal is often administered to coat the stomach and prevent further toxin absorption.

A sidenote about rat poison: most of them (with the exception of bromethalin) are drugs that inhibit clotting in the body. It takes a minimum of 48 hours for those drugs to take effect (usually closer to 72 hours). So, if your pet ingests rat poison in the wee hours of the morning, or you can't get to the ER vet immediately, as long as you see a vet within 24-36 hours, you're fine. It's ideal to get there sooner, so that vomiting can be induced, but it's not going to kill your pet if you have to wait a bit.

Also a note about bones: bones will digest in stomach acid. However, I do not recommend feeding them, because large bones can become lodged in the pylorus of the stomach, causing pain and/or damage to that area. I recently had to take the eye of round bone out of dog's stomach. Also, sometimes bone dissolve so slowly that they wind up in the colon, causing massive discomfort and very bloody diarrhea.

Another important thing: moldy food. It often contains mycotoxins - which lead to tremoring. This can be very mild or so severe as to be life-threatening.

3) Limping: this can be very hard to sort out. A good general rule of thumb is this: if the pet REFUSES to put the leg down AT ALL, it is likely broken and should be addressed. If a patient will walk on the leg occasionally but prefers to hold it up, a muscle sprain or other soft tissue damage is much more likely. Obviously, if the leg is dangling/limp or there is any blood involved, it should be seen immediately.

4) Vomiting and diarrhea: not every case of v/d is an emergency. I tell owners to apply common sense to this. How many times have you personally been to an ER for v/d? I can answer that question with a never. If your pet is vomiting or having diarrhea, but otherwise seems bright, alert, and happy, take up his/her food for 12 hours. Offer nothing by mouth (even water) for that period. After 12 hours, you can offer very bland food such as unseasoned white chicken (boiled) and white rice. If the vomiting continues, it would be a good idea at that point to have your pet checked.

Continuous vomiting that goes on for more than an hour or having the knowledge that your pet likes to chew/eat things such as socks, towels, or toys necessitates a trip to the ER.

As for diarrhea, it just depends. If the pet is otherwise happy, eating, and drinking, it can wait. A little bit of blood in the stool is not necessarily an emergency. If your pet is lethargic, passing LARGE amounts of blood in the stool, or has other systemic signs (vomiting, weakness, etc), he/she should be seen. If the pet is a puppy (<1 year old), has vomiting and bloody diarrhea, parvo needs to be ruled out.

5) Broken toenails: these are very rarely emergencies. Corn starch applied to the tip of the nail, along with light pressure for 5-10 minutes can usually stop even the nasty broken toenails. I hate wasting $92+ of someone's money to apply Kwik-Stop to a toenail.

6) Difficulty breathing: this is always an emergency. If your pet is having trouble breathing (coughing, rasping, wheezing), he/she should be seen. Questions your vet needs to know the answers to: up to date on heartworm preventative? history of a heart murmur or other known cardiac disease? any other pets in the household affected? history of coughing over the last few weeks/months?

7) Lacerations: if your pet has sustained an injury or a cut, they should be seen. If a wound can be addressed, cleaned, and sutured closed within 8 hours, you can prevent bacterial proliferation to the point of infection. Don't wait until the cut is dirty!

8) If you have a male cat that is suddenly lethargic, vomiting, straining in the litterbox, yowling while using the litterbox, or collapsed - to the ER immediately. Male cats frequently suffer urethral obstruction - the formation of small, crystalline plugs that block the urethra and make urinating impossible. This can be rapidly fatal due to the rising level of potassium in the body, as well as the acute renal failure that occurs due to back pressure on the kidneys.

9) Anything to do with the eye should be addressed. While fairly tough structures, any damage to the eye (scratches, trauma, etc) should be looked at immediately. Even if there is no blood, if your pet is squinting, has excessive discharge from one or both eyes, or significant redness/swelling, the eye should be checked.

10) Sneezing/ropy nasal discharge/lethargy in cats: this is not usually an emergency. Cats (esp outdoor) are very prone to picking up upper respiratory tract infections. These URIs are 99% of the time a virus (either herpes or Calicivirus). Thus, antibiotics are not warranted. Cats will feel very lethargic, may feel hot, and refuse to eat. You can care for them at home by cleaning their noses and eyes frequently, humidifying the bathroom with the shower and putting them in there for 10 minutes 4-6 times a day, offering wet, smelly, foul cat foods (like Friskies, etc), and monitoring to make sure that in 3-4 days, they feel better. Rarely, these cats will be very, very sick and require hospitalization and a feeding tube, but this is very uncommon.

For now, those are the most common things I can think of. What do you guys think? Do you have questions about things you've encountered and been unsure about?

Cont'd

11) If your large breed dog starts pacing, acting restless, non-productively retching, and exhibits a distended abdomen, have him/her seen IMMEDIATELY. Gastric dilatation and volvulus (GDV/"bloat") is rapidly life-threatening and requires immediate surgical intervention. With early intervention, many of these dogs go on to live long lives. In the past year, I have done 3 or 4, and all are still alive today. Breeds predisposed include Great Danes, Doberman Pinschers, Weimaraners, Standard Poodles.

12) Female dogs that are in the post-partum period for up to 6 weeks can exhibit eclampsia - also known as "milk fever." This is due to a sharp drop in calcium due to puppy suckling. Signs start out mild - restlessness, pacing then progress to all over body tremors, weakness, ataxia (difficulty walking), and very high body temperature as a result of the low blood calcium. Treatment is needed immediately to supplement the body's calcium.

13) Any animal that is acutely unable to use its back legs - whether cat or dog - should visit the ER immediately.

Re: the job

So, I did apply to the job. Alas, I waited too long - and someone had already been offered the position. The great sense of relief I felt when I heard that news is an excellent sign that despite my current city, I am where I belong. The husband and I have been making a concerted effort to go into the nearby, big city (that is gorgeous, clean, and interesting, btw) and spend time there. I've also been a little more aggressive about meeting people lately. So, we're here for a while. It's fine by me!

Lilly

As much as I hate to tell the ending to this story...

Lilly rallied and was doing well Monday night. Her condition continuously improved. Prospects were looking good for her survival. Then her parents decided that they no longer had the finances to pursue treatment. They euthanized her.

I was stunned and crushed. To drag her through all of that, only to have her euthanized! It was such a blow.

To top it off, I feel like I wasted $5000 of their money...

I'm so sad. :(

Remember...

this teeny, pathetic little kitten from Litter #2 this summer?



This is her now. Who knew?

Weekend wars

This weekend brought unbridled chaos to the ER, including multiple traumatized and sick patients all in a 20 minute span and a man that had a stroke in our lobby in the midst of all of this. I wish I was making that up. To top it off, I managed a case that would have benefited from a university setting and the services of a criticalist.

Friday afternoon, I was transferred a post-operative case to care for. Lilly, a 7 month old shepherd cross puppy, had suffered a GI intussusception (remember the scary surgery from this post?). Her vet had gone in and was forced to remove 5 inches of colon and 6 inches of jejunum. As I've said before, cutting into the colon is a terrifying process. It doesn't heal well. It's full of nasty bacteria - even worse than the small intestines. You're taught NEVER to do it, unless there is no other choice. In Lilly's case, there was no choice. Her colon was dead.

Her first 20 hours with us were uneventful. She was bright, alert, and playful. Then, her temperature skyrocketed to 106 degrees, her blood glucose dropped, she became lethargic and painful, and I could feel a wave of fluid in her abdomen - all signs of a suture site failure. Having your intestines leak feces into your abdomen is possibly one of the worst things - sepsis rapidly sets in, followed by SIRS (systemic inflammatory response syndrome), ARDS (acute respiratory distress syndrome), and MODS (multi-organ dysfunction). Blood pressure, blood sugar plummet. Heart rate skyrockets. The patient becomes non-responsive, often starts vomiting, and eventually lapses into a coma unless the leaky bowel is fixed.

We treated her aggressively with fluids, flooding her with crystalloids and colloids. I called her owners. No answer. I called again 15 minutes later. No answer.

For the next NINE hours, we called the owners, unable to get in touch with them. Lilly needed surgery, and she needed it IMMEDIATELY. As the nine hours passed, I watched her deteriorate from stable enough to survive surgery to circling the drain. I felt a panicked, clenching sensation in my chest as the hours passed. I was helpless. Lilly needed surgery to fix her leaking bowel, but I couldn't do it without the owner's permission. So we waited.

At 4am, the phone rang, and I snatched it off the wall. I explained to the owners Lilly's condition. At this point, despite massive, massive quantities of fluids (far beyond anything I've ever administered) and vasopressors (dopamine) Lilly's blood pressure refused to rise above a mean of 40 (necessary is 60). Her white blood cell count was down to 2000. She was non-responsive, her blood glucose dropping without constant supplementation. I gave the owners a less than 5% chance with surgery.

Despite this, and the huge financial commitment that taking on a second surgery and long, long recovery (if it happened at all), the owners wanted to go for it.

To my enormous shock, in surgery, her intestines looked good. The surgery site had ripped open completely. However, Lilly hadn't eaten in several days, so there was virtually no fecal matter in the abdomen. Further, the omentum had walled it off. The rest of her bowel was pink. Inflamed, yes. Not moving, yes - but pink and NORMAL!! I cut out the surgery site and sewed the new, fresh ends together. I removed the 3 liters of fluid that had filled her belly as a result of the inflammation. I placed 2 Jackson Pratt drains in her abdomen so that we could lavage and empty her abdomen after surgery. I stapled her up.

Lilly's blood pressure was terrible during surgery. Yet, she survived. She woke up from anesthesia - much to our shock. And then she took another turn for the worse. She developed respiratory distress, which we combated with nasal oxygen. Her clotting times went off the chart - a combination of the massive doses of Hetastarch (a type of fluid) she received and disseminated intravascular coagulation (see sidebar). We poured the plasma into her. Her BP plummeted, and HR rate skyrocketed. Fluid began to pour out of her nose due to her ARDS. She regurgitated fluid constantly.

Still, she hung on.

For 2 days, a technician was by her side constantly, monitoring blood pressure, blood glucose, heart rate, rotating her, suctioning her abdominal drains, cleaning her up when she urinated, talking to her and calming her when she woke up from her intermittent sedation, cleaning her nose, adjusting her fluids for me, letting me know if she had the slightest change in her condition.

I told her owners, prepare for the worst. And yet, Lilly hung on.

This morning, we converted my Mercedes SUV to a pet ambulance complete with oxygen, a gurney, and fluid pumps. I drove her myself (with my tech riding in the back) to the 24 hour specialty clinic.

On the way, she continued to regurgitate, and she aspirated the material for the first time. On arrival, her oxygen saturation had fallen from a perfect 100% on oxygen to 80%. She began to breathe harshly, and fluid flowed from both nostrils. My heart sank.

I accompanied the ER doctor into the room to deliver the bad news to the owners - who had already poured $5000 into her care. They were distraught, but they wanted to give her a few hours to see if she would stabilize.

And again, she did. Tonight, she is at the 24 hour hospital, oxygen saturation back up to 95%. She is hanging on with everything she has, fighting for her life.

It is amazing what this dog has survived. I cannot bear the thought of her dying after all of this. Yet, we still have to wait. We have to see if her lungs can recover from ARDS, her body from sepsis, and whether or not her intestines can heal together in the face of overwhelming systemic infection.

For 3 days, I kept her alive. I am not a criticalist, I would never fool myself into thinking that I am that good - but dammit, for 3 days, I kept her alive - giving her the chance her owners wanted to. Whatever happens, I feel like a damned good doctor this weekend.

Relief

Last night, I worked relief at a local 24 hour referral and emergency center. I'll be doing the same tonight. It's good money, and it's a nice break to be working somewhere where I don't have to tell people to do stuff such as cleaning. I go, do my thing, and I come home. It's delightful. Also, since I'm not "the boss", I'm mucho laid back. I was told by almost every tech I worked with last night the following a) how fast I am for a relief vet (I did remind them that I do ER full-time) and b) how much they enjoyed working with me. It's a nice confidence booster.

I shall return tonight for more excitement, then my 3 weekend overnights at work (Fri/Sat/Sun), then 9 days of freedom before the Christmas push.