Wednesday, September 29, 2010
You know, the ones that dress their dogs. But I have a thin-coated, wimpy, shaking Doberman. And it turned downright chilly today (with rain). That's what I keep telling myself, anyway. Oh and gratuitous foster kitten cuteness (orange kitten went to his new home a few days ago...only 2 left!!!).
Last night was a potent reminder of why I love my job.
At around 7pm, we were presented with a beautiful, sweet large breed dog named Jet. He'd been outside, come back in, and the owner noticed that he was drooling heavily and had a massively swollen face. When I examined him, I saw two puncture marks on his muzzle, consistent with a snakebite. Everything else was pretty normal on him - normal bloodwork, normal blood pressure, and an unremarkable physical exam. I recommended standard snakebite treatment - hospitalization for pain medications, antibiotics for necrosis of the skin around the wound, and monitoring of blood pressure and neurological status. Everything seemed 5 by 5. The owner had no financial concerns and agreed to everything I recommended.
We placed Jet on the table for his IV catheter, and he laid on his side. Suddenly and completely without warning, he began to gasp, and his gums turned purple. We grabbed the oxygen while I quickly explored inside his mouth. Imagine my surprise (and terror) when I saw the enormous, necrotic swollen soft palate. The snake had also bitten him IN the mouth, and now his airway was rapidly swelling shut. Before it was completely shut, I was able to intubate him, which was a huge relief.
I called his owner to the ICU and informed her that given the degree of swelling and the intra-oral snakebite, Jet was going to need an emergency tracheostomy and 3-4 days in the hospital. She never hestitated.
20 minutes later, I was placing my first tracheostomy tube. It went as perfectly as can be imagined and Jet has been doing great ever since. He was transferred to our local, 24 hour emergency and specialty clinic at 7:30am, where he will remain until his trach tube can be pulled.
As I was working on him, a dog that had been hit by a car was wheeled to the back. My technician began triaging her (Sylvia) for me. She seemed stable enough, but her front leg looked broken.
After attending to Jet, I did my physical and realized that her leg was not broken. Her elbow was dislocated. I felt a cold thread of fear, as I have never reduced a dislocated elbow in a big dog. Still, that's my job, right?
Sylvia's owner also agreed to whatever I recommended. After several hours of fluids, monitoring, and stabilization, we lightly anesthetized Sylvia. After 5 minutes of sweating and pulling and twisting, the elbow suddenly and easily snapped back into place. I had done it! Xrays confirmed that her elbow was now normal again.
She also did well and went to her veterinarian this morning.
It was a fun night in the ER!
Sunday, September 26, 2010
The recession was recently declared "over." I am not seeing the effects of this in our clinic. Quite the opposite seemed to be true today. Granted, I work in a very small, very poor mill town in central NC. Many people didn't have money BEFORE the recession, and now with lay-offs and unemployment on the rise, the situation is even worse. It's a very frustrating and sad position to be in.
On the one hand, it breaks my heart to have to euthanize a 3 month old puppy for a badly, badly fractured leg. His very young parents (a married couple of 19 and 20, respectively) could barely cover the cost of coming into the ER (although I did note that the girl has a nicer smart phone than I do...). I want to help them. I want to help the dog. I want to not have to worry about the cost of the health care I'm offering their dog.
On the other hand, I look at the lack of responsibility running rampant in our country, and I am ashamed and angered. This girl had an iPhone, sleek and new. I know that the contracts on those phones run $100-250/month depending on the service. I know the phone itself runs about $200 (as I just opted to buy a smart phone recently - though I ended up with a Droid X).
That money could have been spent on a cheap cell phone and the rest put away in savings. Yet, this 20 year old is already in so much debt from making bad financial decisions that she couldn't qualify for a CareCredit card. I want to help them, but I want them to help themselves as well and take responsibility. Don't leave your young puppy outside, unsupervised. It's a simple as that. Put money aside in savings for emergencies - not just pet, but any emergency. Don't buy stuff you can't afford. Certainly don't buy stuff you can't afford with credit cards.
What is wrong with this country? Since when did owning every single gadget and fad and having everything become so important that people were willing to throw away credit for it? It is rare that I meet someone that has real savings or a plan for what happens if they need a large sum of money quickly for an emergency. Along with that, people have an enormous sense of entitlement - it's MY right to have free health care for my pets, it's my right to have everything. Our government is doing nothing to discourage this mentality either. Taking from the taxpayers more and more, spending recklessly and shadily - money going who knows where? I plan on abstaining from voting come November because ALL of the politicians are the same - Democrats, Republicans, it doesn't matter. All pay lip service to one ideal or another. What they really want is to be in power and to stay in power. Nothing else really matters.
Our government was supposed to be by the people and for the people. Now it's by the people, for the government. And what real option do we have? I'm always told that we are to blame for electing these people. What choice do we have? You can only run for president if you're independently wealthy (read: millionaire) - otherwise, your chances of a serious campaign are nil. All politicians are the same, and I think we could do without them.
Is it any wonder are country is in this mess? We elect politicians that throw our tax money away. We live in unparalleled wealth that the people in my generation never had to earn in any way, and thus value it significantly less than they should. We've never earned the wealth we have, it was earned for us by our forefathers -by those who fought in World War I and WWII. And now, this luxury is commonplace. We all expect to have 2 TVs and 2 cars and own a house by the time we're 22. It's our GOSH-DARNED RIGHT!!!!
Meanwhile, I have to keep euthanizing animals that could be saved with a minimum of effort and care...
Ok, wow. That wasn't supposed to be rant. But there it is.
Wednesday, September 22, 2010
The dog's empty scrotum was about the size of a cantaloupe or maybe a small melon. It was bruised, and blood was leaking from the incision site. This is a somewhat common post-operative complication of big dogs that are neutered later in life. It's called a scrotal hematoma - when there is marked hemorrhage at the incision site after surgery, and the scrotum fills up with blood. It looks downright horrifying but is rarely life-threatening. Treatment is usually strict cage rest, cold compresses, an e-collar to prevent self-trauma, sedation, and anti-inflammatory therapy (prednisone often).
In this case, the dog did not have a cone of shame on, and he removed his stitches for us. As a result, I had to sedate him to clean the incision site and re-suture it. She had the neuter done for $20! At our ER, sedating a big dog and sewing up an incision costs about $300. Of course, she didn't have it. After an hour of running in and out of the front doors, calling people, and applying for CareCredit, she finally procured the money. I gave her the option, since it was ALREADY 8am at this point, of waiting to see her veterinarian (who might be able to work with her financially) or going back to the spay/neuter clinic. She did not want to wait. She was very slow, and the sight of her dog bleeding sent her into near hysterics. No amount of explaining that her dog was going to be just fine could convince her to wait a half hour.
I sedated the dog, removed the chewed out sutures, placed new ones, cold compressed the scrotum, and administered anti-inflammatory medications. The dog recovered rapidly. Afterwards, I carefully went over his care with the owner - explaining that the incision would likely still ooze blood for a while, that cage rest was important, that the scrotum would remain swollen for anywhere from 5 days to 3 weeks. I also explained that RARELY, a scrotal ablation (complete removal of the scrotum) is needed if the sac becomes over-stretched. This is a last ditch approach due to the bleeding and the need for complete anesthesia again.
2 days ago, the incision was still oozing. The owner took the dog to her veterinarian. He advised her that the blood was old, the hematoma was healing, and she should go home and not fret too much. She called our office, demanding a refund yesterday because we "didn't do anything for her dog."
I didn't sedate your dog and replace all the stitches he had torn out? Must have been somebody else at another clinic. Perhaps I was sleeping and dreamed that I repaired your dog's surgical site. But that doesn't really constitute doing anything, right?
Sunday, September 19, 2010
Wednesday, September 15, 2010
When I examined him, I was confronted with a dumpy, very THIN Lab. His abdomen felt strangely doughy but was not particularly painful (a hallmark of GI foreign bodies). He was dehydrated and quiet. I asked his owner about Bing's weight. She reported that he'd been losing weight for the past 3 months. He was also vomiting at least once a day. They'd recently adopted a Labrador puppy, and she attributed his weight loss and vomiting to this puppy in the house keeping Bing active and slightly anxious. I was not convinced.
Xrays showed questionable material in the stomach. We proceeded to a barium study (a contrast study). After 14 (!) xrays and a lot of time and struggling with Bing, we had the answer from the radiologist...likely a foreign body. I called the owner and explained to her at length my recommendations: exploratory surgery with the risk of not finding a foreign body and needing to take GI biopsies. After much discussion, Bing's owner elected to proceed.
Sure enough, his duodenum (upper small intestine) was in a huge bunch - indicating the worst of the worst for foreign bodies - a linear FB that had already plicated. Luckily, the intestines were pink and healthy, hardly even angry looking. A plastic something was palpable in the stomach, with a mass of cloth material extending into the intestines, ending at a similar plastic piece in the upper jejunum. Two incisions into the intestines and one into the stomach later, and the whole wad was out.
Bing recovered rapidly from surgery. We are now almost 72 hours out. No evidence of peritonitis or surgery site leakage yet. I'm not quite relaxed, as the first 4 days are crucial post-enterotomy. Luckily for Bing, I did not have to actually remove any intestines, as everything looked healthy.
The kicker? Mom looked at the material stuck in his stomach and informed us that Bing had chewed up that particular object in JUNE! It had been stuck since then, causing his weight loss and vomiting.
I'm quite happy to think that - as long as Bing gets through the post-op period with no complications - he should begin gaining weight and feeling better soon!
Interestingly, the very same night, I had to take an eye of round bone out of another dog. It was a busy night in the OR for me.
Monday, September 13, 2010
Friday night, a family of three rolls up, all smelling vaguely of alcohol (not that I'm judging, I drink, too). They were what can only be described as a term that rhymes with "night crash." Their dog had been hit by car. It weighed >100 pounds. It could not walk, had blood draining from both nostrils, a respiratory rate of >100, and other signs of polytrauma.
That's an automatic $500 deposit to get started (a Class I form). I knew they didn't have it, but I wasn't about to watch the dog die in front of me if I could fix some of the immediate problems (shock, pneumothorax) relatively quickly.
I placed an IV catheter, administered shock fluids, tapped his chest, and gave him a dose of pain medication. Meanwhile, the owner is running in and out of our lobby, disturbing everyone else present by setting off our loud door alarm, making phone calls, and talking belligerently about the money. He was trying to find another vet to see his dog.
In the end, they took the dog to a local GP who (according to his google internet reviews) is "only in vet med for the animals, not the money." He had $100 to pay us for the $300 worth of services I rendered. He was declined for CareCredit.
Last night, he called back for a refund on my misdiagnosis. Yes, you read that right. I didn't talk to him. My tech told him to call back and speak to the office manager if he had a complaint. According to him, the dog just had a broken/dislocated elbow, nothing else. It did, however, spend the entire weekend at the other vet's office (for $250, according to the owner).
If I had talked to him, I would have said, "Sir, I did not diagnose your dog with anything other than shock after being hit by a car. I recommended pain medications, IV fluids, hospitalization, and xrays. You declined due to your financial restrictions and elected to take the dog elsewhere, leaving us with a $200 unpaid bill. That does not constitute a diagnosis. I'm glad to hear that your dog did well. Have a nice night."
I need a day off. Sometimes veterinary medicine is downright infuriating. To work the hours that I do, as hard as I do, only to be harangued and treated badly by owners, thrown under the bus by other veterinarians, and thought of as a money grubbing thief...it just makes me feel sad and helpless and hopeless for the state of humanity.
The thing is, I do love animals, and I love what I do. It's the best job in the world and can be so amazingly rewarding. Vet school was not free, however. I work for an employer that must pay the electrical bills, pay the staff, provide the medical supplies we use at great cost to us, and keep the doors to our clinic open. Where do people think that money comes from???
It only takes one bad owner to erase the memories of all the great ones, all the thank you cards, grateful smiles, hugs, and enthusiastic reviews. Why does 1 bad apple so thoroughly spoil the bunch?
Saturday, September 11, 2010
Still...occasionally, a night will just get me down, and I start to wonder, "what's the point?" What's the point in doing good medicine when I just have to ship a patient out the door to Dr St. Elsewhere so he can give it steroids to treats its massive shock (NOT good medicine, to those of you not in the medical field)? What's the point in educating clients about vaccinating the NEXT puppy for parvovirus, only to see them 3 months later, with another dying, hypoglycemic, hypothermic parvo puppy, no money, and an entitlement complex? What's the point in trying to work with clients financially only to have them turn around and accuse me of being money-grubbing and "not in it for the animals?"
I mean, REALLY. Last time I didn't have money to pay my electric bill, I called them up, and I said "hey, you must work for the electrical company because you LOVE electricity, and you want to make sure everyone has electricity. Therefore, since I can't pay for my electricity, you should give it to me for free." They laughed and turned off my power anyway. (That's a parable, in case anyone missed it, my power has not been turned off, nor ever been in danger of being so).
There are nights - I kid you not (like last night) - where I actually start to think of things from an owner's perspective. As in - what right do I have to expect payment? The animal is injured! They need help! I should help them! Forget money! I realize when I start to think like that, it's time for a break. Yes, it would be wonderful to help everyone who needs it for free. Unfortunately, I work for a business with very high overhead. Someone has to pay to keep the lights on - the clinic's lights and MY lights...
Argh. Sleep is needed in preparation for my last 2 nights before a break and a much needed mini-vacation to see my friends.
Friday, September 10, 2010
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.
Saturday, September 4, 2010
I see neglect all the time. It's part of my job. After reading about the 15 pound 4 year old found likely tied to her bed in Brooklyn yesterday, I should be completely unsurprised at the stuff I see. And yet, every time, I am still stunned, confused, and tongue-tied.
A man called and reported that his small dog, Peanut, had broken its leg again. This was the 2nd time the leg was broken. It had been surgically repaired by an orthopedic surgeon previously, and so an implant was present in the leg. This time, when it had broken, the owners didn't have the money to even see a vet. So, they splinted the leg at home. And left it splinted. I'm not really sure for how long. They were calling to let us know that the leg was swelling and smelled badly. Also Peanut had stopped eating and was lethargic.
We advised the owners to bring the dog in immediately. They had no money. We recommended applying for CareCredit. They were declined. Finally, they managed to come up with enough to at least see me.
When the dog was brought back to me, I had to resist the urge to vomit. I could SMELL the leg from across the room. When I saw it, I was even more horrified. The whole implant was exposed, and pus was oozing out of the fractured leg. It just dangled - purple, swollen, infected, re-fractured, and extremely painful. The poor dog would not even stand.
I tried not to get angry. There's no point, and it just makes my job harder. But I was angry. The leg was mangled, the dog sick - likely septic - and the owners had about $200. Had they addressed this sooner, with their veterinarian, this could have been avoided. Now I was staring at a dog, late on Saturday afternoon - all vets closed for the next 2.5 days - meaning the dog would need an emergency amputation (a rare thing) and intensive care with a guarded prognosis. $200 wouldn't even cover the first hour of care and diagnostics.
So I did what I had to do. Told the owners as gently but as bluntly as I could that they were looking at a huge financial investment, a guarded prognosis, loss of a limb or euthanasia. Going home with antibiotics, pain medications, and a bandage would not benefit this dog. I would be contributing to the cruelty.
Still, when I have to present these things to owners, I feel like the bad guy. ME. The owners have let the dog suffer through horrible neglect, and yet I wind up coming home, sitting here, thinking...gee, maybe there was SOME way?
Here are the options that existed:
1) Hospitalize the dog until a day practice vet opened on Tuesday. IV fluids, antibiotics, pain medications, bandage changes - all approximately $1500-2000.
2) Hospitalize the dog, amputate the leg (surgery), IV antibiotics, fluids, pain medications - all approximately $1900-3000.
3) Send the dog home with antibiotics, pain medications, and a bandage to protect the leg and hope to God that the owners actually take the dog to the vet on Tuesday - i.e. contributing to prolonged suffering in a dog that was already weak, unable to stand, and not eating.
Those are the real options. The owners had $200 and did not qualify for credit of any kind. I KNOW what I did was right. I KNOW that. Yet, I sit here and question...
Friday, September 3, 2010
Every time I go to work, I count myself lucky to love my job as much as I do. It affords me the opportunity to do or see something new every night while helping animals and their owners. It is always a challenge - in more ways than one - and I never get bored. On top of that, I get paid to do it! My 9 days off every 12 days affords me enough time to rest, rejuvenate, visit with friends, and family, and get ready to work again. By the time my first Wednesday rolls around, I am usually raring to get back to the ER.
Unrelated, but I am raising litter number 4 this summer. It is 3 kittens, none related to the others. I picked up the first, a gorgeous orange male tabby on my OFF week, of all times. He showed up at work, and knowing that I'm a sucker for a kitten, the techs called me. He had a nasty, necrotic wound in his armpit that healed up nicely with wound care and antibiotics. He was tiny, so obviously still on the bottle. I hate raising singleton bottle kittens. They're even MORE neurotic than your ordinary bottle babies. As a result, I was on the look-out for another bottle kitten. It was only a few days before a dilute calico with fleas showed up. She was cold and a little thin, but she started to thrive under my care. And of course, a couple of days later, 2 kittens - a boy and girl - were brought to the clinic. The little boy was too weak to save, he died shortly after arriving. The female - a "torbie" (tabby/tortoiseshell) has been growing like a weed.
Unfortunately, the little grey kitten stopped eating about 5 days ago. I couldn't figure out why, but I wound up having to supplement her with oral dextrose and subcutaneous fluids to get her over the hump. Last night, we found out why. She'd formed subcutaneous abscesses on her thorax. They all ruptured last night. I felt terrible for not seeing/feeling them before! Kittens are usually covered in poop and pee, despite diligent bathing, so I probably felt the little crusts and attributed them to kitten poop. My tech was feeding her and found some pus on her fur. Once we got to shaving her, we found 5 small abscesses. She is doing great now, eating, purring, grooming. She's on antibiotics, of course, and is wearing a teeshirt my tech fashioned for her to prevent her wounds from becoming contaminated. She's a fighter.
Bottle raising kittens is a super time-consuming endeavor, and it is expensive, as well. A flat of KMR (kitten milk replacer) costs $44. That will last me about a month. Antibiotics, guaze, dewormer, litter, kitten food...it all adds up rapidly. Thankfully, I have a husband who is patient, kind, and loves kittens. He feeds them when I am working and need to sleep, otherwise, I don't think I could do it. Thank God for good husbands!