Status quo

I haven't blogged because I've been off work for 9 days (delightful), and my first 2 nights back were very dull. I think that's a good thing honestly. Every time I start wishing for a difficult case that requires intensive management, I remember my first week back to work and the 3 incredibly challenging and scary surgeries I did. Then I'm thankful that winter is slow and that I can get 6-7 hours of sleep per night at work. At least for now. Work is the only time I get much sleep!

Christmas was lovely. We spent a week with our families. I feel particularly lucky to not only have a wonderful family of my own, but for the fact that I love my in-laws so much and get along with them so well. Evaline was spoiled by constant loving attention. I think she has been somewhat dissatisfied with the relatively lower level of attention she's been getting since we came back (fear not, she gets PLENTY of attention).

My metastatic cancer patient (the partial liver lobectomy, etc) is doing very well at home. The owners are pleased that we bought him some time, and so am I. I questioned myself heavily on whether I had done the right thing for the dog and owner. Knowing he made it through the holidays with his family - and made it through happy and bouncy - was a great relief.

Today is my husband's birthday, but we have no exciting plans other than a nice dinner at home (chicken pot pie, his favorite) and spending time with the butterbean. Life is pretty awesome right now.

Another rock and hard place story

I was confronted with a very difficult situation recently. It was difficult on many levels and forced me to make some hard decisions. One of the major ones was finances, as it always tends to be.

I was presented with a less than 1 year old, female Labrador retriever. This Labrador was DEPRESSED. She could barely lift her head, and she noticeably winced when I palpated her abdomen. She'd been vomiting for 24 hours, unable to hold anything down. On a rectal exam, there were absolutely no feces in her colon. She was extremely dehydrated. Everything told me that she had a foreign body. Xrays confirmed it. Not only was it a foreign body, it was the nastiest of the nasty: a linear foreign body. Her intestines were bunched tightly on each other - like a tightened drawstring.

Sighing, I went to deliver my recommendation for surgery to the distraught owners. They'd come through the doors with zero finances and had applied for CareCredit right away. They were really nice people, and they owned a really nice dog. That automatically equals a bad scenario...it's one of those stereotypes of ER medicine. Nice owner, nice pet = bad disease.

At any rate, given how sick the dog was, I suspected that the linear foreign body might have already poked a hole in his intestines. Surgery was indicated right away. I made up an estimate - being as conservative as I could (no pre-operative bloodwork, etc). The low end was $1600. The high end was $1700. This was being CONSERVATIVE, mind you. Really and truthfully, the estimate should have been at least $2100-2500.

They were approved for $1500 only with CareCredit.

My options? 1) Doing the surgery knowing that it would cost more, charging them full price, and billing them 2) Doing the surgery and discounting the bill steeply 3) recommending that they wait until the next day to see their regular veterinarian so that they could have the surgery done cheaper (but risking the dog dying and/or the internal scenario worsening significantly overnight) or 4) euthanasia.

These people were nice. They applied for credit, as we'd requested. They got a stout $1500 approval. It still wasn't enough. If they waited on surgery, the dog would either die or be in a much, much worse situation by the time surgery was conducted. If they did surgery with me, it would be much more expensive than $1500. Further, it would leave them NO funds for transfer to the day veterinarian. The dog would not be able to go home in the morning; it would have to go to a day veterinarian, which would also cost money (all of which I would've spent).

What to do?

What I did was gave them the $1600-1700 estimate, deciding to roll with whatever happened. Of course, it was the worst it could possibly be. There was a small hole in the intestines. There was string/fabric throughout the small intestine. It was a long, frustrating surgery. I had to make 5 enterotomies (openings in the intestines), cut out about 3 inches of intestine, and open the stomach. Instead of taking me the projected 1 hour it generally takes me, it took me a full 2 hours. I knew this dog would have a long and rough recovery with a high chance of dehiscence at one of the sites, at least.

The final bill was $2300. I deducted that down to the high end of the estimate - meaning I knocked off $600+. Further, I stayed after my shift by about 3.5 hours to do this difficult surgery. Time I could've spent with my daughter, who I'd barely seen over the last few days due to my work schedule. Lastly, I made no money on that surgery. Deducting the $600 meant that I deducted off my production. Thus, I spent 3.5 hours of my own time on that dog.

And yet, people call vets money-grubbing.

The patient had a rough recovery and spent 9 additional days in the hospital with his veterinarian. I called to apologize for sending a new patient (the owners had just moved into town) to this clinic with no money. I'd spent it all. I had to. I had to cover the expense of surgery (i.e. doing it at cost), since I was not free to give away clinic supplies.

It was a very difficult and frustrating scenario, but the dog is alive and home with the owners' young daughter for the holidays. That's what matters to me.

Wowza

My first "rotation" back has been a combination of insanity and utter boredom. This weekend has been dreadfully slow, but the past week was full of crazy surgeries and sick patients. Balancing motherhood and work is difficult, as I expected. What is not difficult is pumping milk. I thought that I would have a hard time, but that part of the transition is going very smoothly. Evaline has also graduated to sleeping in her rock-n-play, a small, cradle-type bassinet. Of course, when I'm home, she sleeps in bed with me. I have to take advantage of all the snuggly baby time I can get!

On the work front, I was faced with 2 very difficult scenarios this week, both placing me between a rock and a hard place. Having been away from work for 2 months, my decision-making skills were a bit rusty. I also find myself equivocating more. Decision making has been become very difficult. I don't know if this is sleep-deprivation or something else.

In one case, I was faced with a very elderly (15 years old) large breed dog with an abdomen full of blood. Common sense told me that this was in all likelihood a ruptured abdominal tumor - likely splenic or liver. I expected the owner to choose euthanasia, but he opted for surgery instead. Despite finding that the dog was suffering a coagulopathy (difficulty clotting his blood), the fact that he was very old, and likely suffering a seriously malignant cancer, the owner wanted to give him the chance for some more time at home.

I offered referral to a specialist for the surgery, as I was unsure what I would find surgically. A ruptured splenic mass is no problem. A ruptured liver tumor is another story altogether. The owner debated for a while, but he eventually elected for me to do the surgery.

To my dismay, it was a ruptured liver tumor. Large, necrotic, and friable, it was growing on the right caudal liver lobe. Thankfully, it was easy to expose that part of the liver. Unfortunately, it had metastasized throughout the mesentery (fat cushioning the intestines and providing blood flow), and the spleen had several large nodules. I wrestled with the decision of whether to recommend euthanasia for metastatic cancer or to do what I could.

The dilemma here is that all hemangiosarcomas (the most likely tumor type) have metastasized by the time of discovery. They are incredibly aggressive tumors. In some cases, the metastasis are microscopic, and in some cases, they are macroscopic/grossly apparent. Most people will recommend euthanasia for grossly metastatic cancer. In this case, I was really conflicted. The owner wanted more time with the dog. He wasn't under any illusions that the dog would survive long, but he wasn't ready to say goodbye.

With that in mind, I set to work removing part of the liver. That in itself was a challenge, as I'd never done a partial liver lobectomy before. Once the tumor was out, I removed the spleen too. Finally, I went through the mesentery and removed the small nodules, as well as one very large (lemon-sized) tumor. I flushed his abdomen, said a little prayer, and closed him up.

He woke up very slowly. Blood started to ooze from his incision (not surprising, given his high clotting times). It took him a long time to even lift his head up. I was not optimistic. That morning, my technician and I transferred him to a nearby day clinic. He spent the day getting blood/plasma transfusions, then was transferred to the specialty clinic the next day.

The amazing part? Yesterday, he was barking, whining, eating, and acting like a totally normal dog. He went home with his owners to spend whatever time he has left at home. As usual, I question whether I did the right thing. Should I have woken this dog with obviously metastatic cancer from surgery? Should I have euthanized him on the table? Should I ever have done surgery in the first place?

Right now, I feel good with what we did. He's home with his owners, eating and acting like a normal dog. He probably doesn't have long to live, but he's home for the holidays, and that's what matters.

First nights back

My first night back was lovely and quiet - easing me back into work. My second night? Not so much. Within an hour of my arrival, we had a possible esophageal foreign body puppy, a chocolate toxicity, a Labrador with a GDV (bloat), a Weimaraner with a possible GDV (that's a whole 'nother story), and various other patients floating around. I ran around like a crazy person and then had to go to surgery, which turned into a total nightmare.

I was finally able to lie down around 5am for a couple of hours. My head was throbbing and I was borderline hallucinating from exhaustion. This working mom/ER veterinarian gig is going to be harder than I even anticipated. My mother is here this week, and she has been helping my husband take care of the baby while he adjusts and gets some work done. It's a huge relief to have her here. The only problem? She can't stay forever.

Once I've gotten some sleep and the weekend shifts are over, I'll blog about the FB puppy and the "bloated" Weimaraner. It will have to wait, alas.

Surprise shift

I am utterly exhausted. Evaline has decided to feed pretty much every 2 hours round the clock lately. She must be going through a growth spurt. I was sitting in a stupor in the glider yesterday afternoon, feeding her, when my cell range. The caller ID identified it as work. My husband answered it only to find my colleague on the other end, begging me to come in and help her. It was Sunday afternoon, she had no back-up vet, and she had 3 surgeries to do - a pyometra and 2 traumatic abdominal hernias (both cats). Patients were still filing in.

I agreed to come and help (again, building that good will). I figured it would be a good way to test the waters before plunging back in on Wednesday night.

It was a busy Sunday, and the cases were interesting. I saw a stable, hit-by-car English setter with a dislocated elbow, a cat with a high fever and labored breathing that turned out to have a pyothorax, a laterally recumbent, comatose Boston terrier with likely parvovirus, and a host of other cases large and small.

Truthfully, I absolutely relished being back at work. It felt great to be using my brain again and to be doing something! On the other hand, I missed my daughter pretty soon after arriving. When I arrived home, it turned out that she was rejecting my stored milk (a long story - google excess lipase in breast milk if you are interested). She'd been fussy and unhappy since I'd left, escalating to purple faced crying for about 25 minutes.

So, it's back to work officially on Wednesday night. I go with very mixed emotions. I love my job, and I look forward to being in the land of adults. I really relish the idea of using my brain! On the other hand, I missed Evaline terribly after six hours, and my heart melted with happiness when I got home to her after a short shift. The whole pumping and working thing has me worried, especially with the fact that my breastmilk has such a complicated problem (excess lipase) that must be managed. Further, Evaline isn't on any kind of a schedule at all. She eats and sleeps whenever she wants to. She doesn't "go down for the night" till about 2:30am, although "down for the night" usually means a consecutive 3 hours - 4 if I'm REALLY lucky. Further, she is highly attached and wants/needs to be held a great deal of the time. Lastly, she is used to sleeping in the bed with me, but she can't do this with my husband. She absolutely will not sleep in her bassinet or crib.

To sum it up, there are going to be many, many adjustments for her, for me, and for my husband. I am apprehensive about all these changes and how they will affect her. I know it will be fine in the long run, but I can't help but worry!

1 week left

My maternity leave ends on Wednesday, Dec 7, and I descend into the fray of veterinary emergency medicine once again. Currently, I am having very mixed feelings about this.

During my 3rd trimester, I was absolutely positive that I wanted to become a stay-at-home mother. The thought made me inexpressibly happy. Now, almost 9 weeks on the other side of my time at home, I realize that I would probably go mad without the challenge of my job. I love what I do quite sincerely. I also love being domestic - cleaning the house, fixing dinner, and the like. It is quite satisfying. I also cherish being home with my beautiful, sweet daughter.

Since I enjoy both things so much, I think being a working mom will be the best option for me.

ER medicine is a mixed bag for motherhood. While offering intense, long hours - ER medicine also offers long stretches of time off to enjoy with my family. I make more money than my GP counterparts, leading to less stress related to financial burdens. Further, despite some shortcomings that I have elucidated here, I have a great job in a bad economy. I'm thankful for that every day.

It's going to be a big adjustment. I know I'm probably going to miss things with my daughter. On the other hand, I hope to be a strong role model for her. I want her to grow up knowing that she can be anything she wants to be and still make time for a family. I also want her to grow up financially secure and to never have to worry about our finances. Growing up with 5 siblings, money was always tight for us, and early on, I worried a great deal about my parents' financial situation. I have carried this stress with me ever since childhood, and I will likely die with it. Hopefully, careful planning and saving will prevent Evaline (and our future children) from facing these worries.

T minus 7 days!

How we differ from Dr Pol

So, I thought since Dr Pol is setting the perception of veterinary medicine back about 50+ years, I would explain how I am a different sort of veterinarian and how the clinic where I work is progressive instead of backwards.

Patients during surgery are availed of the following:

1) An IV catheter and IV fluids to help control and maintain blood pressure, as well as to administer pain medications, blood or plasma transfusions, and life-saving medications such as atropine and epinephrine.

2) Full anesthetic monitoring including oxygen saturation measurements, end-tidal carbon dioxide (very important), heart rate and rhythm, and blood pressure. Patients are monitored by expensive equipment but also by a technician that is making sure that the machine readings are believable. The technician assesses pulse quality, gum color, and heart rate and rhythm periodically by actually laying hands on the patient. This ensures that we know how are patient is REALLY doing - at all times.

3) Our surgery table is heated to ensure that patients do not lose too much heat during surgery. Anesthestic gases causes vasodilation and a drop in blood pressure. As a result, body temperature drops. Opening up the body cavities exacerbates this. The technician monitors body temperature and measures are taken when necessary to keep the patient warm.

4)Sterile technique is always observed. All surgical instruments are cleaned and steam autoclaved (sterilized) between patients. All patients are fully draped, and the surgeon wears a cap over the hair, a face mask, booties, and a sterile surgical gown. The technician wears a mask, cap, and booties unless assisting. The surgical room is used for NO other reason than invasive surgery (opening the thoracic or abdominal cavities).

5) All patients are intubated and hooked up to an anesthetic machine and ventilator. This way, respiration can be closely monitored and supplemented as needed.

These are just some of the ways we protect our patients surgically. Outside of surgery, we are just as meticulous. Patients receiving IV fluids are on IV pumps that control fluid rate. These are in turn monitored by the technicians to ensure that they are working correctly. That way no patient receives an overload of fluids, which can be fatal.

Patients with infectious diseases such as parvovirus or feline respiratory tract disease are isolated from the ICU in a separate ward. This is to prevent nosocomial infection, as well as to protect animals with compromised immune systems (as in parvovirus).

If a patient presents injured and in shock, permission to administer (cheap!) pain medications is obtained right away. Pain medications indicated for severe trauma and shock, such as a mauling, are opioids. NSAIDs or steroids are not proper medication for a patien in this condition. They are not potent enough, quick acting enough, and have side effects that can be greatly worsened by shock. Patients are also started immediately on IV fluids to stabilize blood pressure. Oxygen is administered as needed either via face mask or incubator/oxygen cage.

If a patient comes in with severe neurological deficits or other problems that cannot be addressed at our clinic, referral to the nearby specialty practice is immediately offered. If referral is declined, discussion of the options is initiated, and an informed decision made with the client's help.

Patients are never sent home in a state of heavy sedation or anesthesia. All patients are fully recovered and monitored before they are sent home with their owners.

There are a thousand ways I could compare us to show that we practice up-to-date, forward thinking medication. We use constant rate infusions of narcotics to keep our post-operative patients and very sick, painful patients comfortable. We utilize the most recently recommended treatments for a variety of conditions - including choosing our antibiotics wisely and carefully rather than placing all patients on them. Steroids are avoided in cases of shock and head trauma and used judiciously where indicated. We have an ultrasound machine, digital radiology (many human clinics do not even possess this technology), and a radiologist on call who can review difficult to interpret xrays. Our technicians are highly skilled and dedicated to patient care.

As a clinic, we work hard to offer our clients the most current and best diagnostics and treatments we can. We do not cut corners to save money. Yes, we're in it because we love animals. We're also in it because we want a job that matters, and we care about what we do on every level.

We're not all Dr Pol.

The Incredible (?) Dr Pol

Since I haven't seen a patient in weeks, I have no exciting stories to relay. On the other hand, I am curious as to how many of you guys are watching this National Geographic show? It is causing an uproar in the veterinary community.

If you follow my blog at all, you know I have a passion for high quality medicine, staying updated on current diagnostics and treatments, and generally practicing with compassion and integrity. I am passionate about being the best vet I can possibly be. I am also passionate about spreading the word regarding what veterinarians really do, how much training we undergo, how expensive our education is, and how important GOOD, competent health care is for your pets.

Thus, I am a little dismayed by the way the new National Geographic show portrays veterinarians. Don't get me wrong - Dr Pol seems like a compassionate, good man. He has been doing his job a long time. I am not bad-mouthing him. What bothers me is that he is very outdated in his methods.

Granted, this is a reality TV show. It is being twisted to portray things exactly as NatGeo wants them portrayed. I understand that. But when I see Dr Pol doing an orthopedic surgery (in this case, a femoral head osteotomy) without a cap, mask, or gown on, and minimal sterile surgical technique, I cringe inside. This is a major surgery in which the head of the femur is cut off. Infection is a very, very big concern. Further, this dog - undergoing painful, major surgery - was not even intubated or on anesthesia of any sort. Had this dog arrested during surgery, saving him would have been difficult to impossible without control of his airway and an IV catheter. There was also no evidence of any pain medication being administered.

This way of doing things is very, very out-dated and considered well below the standard of care.

So far, the show presents veterinarians in a very dismal light. In our clinic, patients undergoing surgery are on IV fluids, intubated so that we can breathe for them as necessary, provided with adequate analgesia, and absolute sterile technique is maintained at all times. Yet, Joe Average Pet Owner is unaware of this. Many owners see all veterinary care as equal. Dr Pol's show reinforces the idea that veterinary medicine hasn't advanced since the days of James Herriot and that we all do things in this "old school" fashion. The opposite is true.

Further, it reinforces the idea that all vets are in veterinary medicine strictly for the love of animals, that we practice substandard medicine that puts patients at risk, and that there have been no improvements in veterinary anesthesia and analgesia in the last dedcade. It's setting the perception of veterinary medicine back 50 years or more. There is no discussion of proper sterile technique, referral for complex cases, chemotherapy, digital xray, constant rate infusions (CRIs) for pain control, or any of the many, many advancements that have been made in all areas. We can do amazing things for animals, yet this show reflects none of that. For Pete's sake, I watched in amazement as he amputated a dog's tail in an exam room with minimal pain medication, no anesthesia, and NO sterile technique.

It's disheartening. Everyone loves "Good 'ole Doc." He's cheap, he's quick, and he's "old school." Unfortunately, old school doesn't usually benefit critically ill or injured animals. This was evidenced when he gave a nauled puppy a shot of steroid (absolutely NOT indicated in trauma anymore - in human or animal medicine) and left it in a cage. He described the dog as "in shock" - yet he provided no pain medications, IV fluids, or oxygen to stabilize the shock. He placed the puppy in a cage where it died. I treat this kind of thing on a daily basis, and a shot of steroids isn't going to fix a badly mauled animal. It was heartbreaking.

Anyone watching it? What do you think?

Important points

I thought this was a thoughtful article highlighting some of the things good veterinarians do.

http://www.vetlive.com/2010/11/14/10-things-a-great-vet-does-without-credit-that-you-never-know-about/

We're all still alive!

Being a new mom is exhausting, I'm not going to lie. Our daughter is going through a high need stage right now; she needs to be held constantly. She won't even sleep unless she is being held by me or beside me in the bed. The other option is being carried by my husband in our Moby wrap.

T minus 20 days until I return to work. I have some apprehensions about it, I won't lie. Thankfully, my husband will be home for the next few months. Hopefully that will make this transition easier. We shall see. Pumping breast milk at work is going to be interesting - given that my job is a lot of feast or famine.

In the meantime, I have Thanksgiving to look forward to - lots of family time with our new addition. The definite upside is that her grandparents always want to hold her, giving me a much needed break!

The skinny on chocolate (toxicity)

This is my favorite time of year, hands down. I love the holidays - especially Thanksgiving and Christmas. For the first time in more than 5 years, I have both major holidays off of work and will be spending them with my family! I am very excited about this. It will be unlikely to occur again for many years. Well, unless I get pregnant again soon and go on maternity leave that happens to correspond with the holidays.

One of the small things I love about the holidays is the abundance of candy. Starting at Halloween and continuing through the end of the year, chocolate treats abound. I'm trying to be **more** careful about these sweet treats due to my gestational diabetes and predisposition for Type 2 diabetes, but it's hard. Imagine then how hard it must be for a dog! They have no sense of "good idea or bad idea" - they only know that chocolate smells (and tastes) delicious.

Chocolate ingestion is something I see all the time in the ER. The numbers certainly go up around the major fall holidays. Thus, I thought we could talk frankly about chocolate toxicity here.

My take on it? Chocolate toxicity does not exist.

I say that slightly tongue in cheek. But not really. Let's first talk about why chocolate causes problems for dogs (and people who eat too much of it). Chocolate contains 2 important substances : theobromine and caffeine.

Theobromine is an alkaloid found in chocolate. It is a fascinating compound that has medicinal effects. One of these is the treatment of asthma, as it relaxes the smooth muscles in the bronchi, allowing bronchodilation. Caffeine is actually metabolized into theobromide within the human body. Theobromide leads to increased heart rate and vasodilation leading to decreased blood pressure. It can also lead to tremors, nervousness/excitability, and seizures at higher amounts.

In small quantities, theobromide is not toxic. This is why we can all enjoy chocolate deliciousness. However, in large quantities in people and in dogs (who metabolize chocolate more slowly), toxicity CAN occur.

The early signs of chocolate OD in dogs are vomiting, diarrhea, and increased urination (diuresis). As the amount of exposure increases, the clinical signs worsen leading to tremoring and possibly seizures. Death can occur.

Still, I have only seen a couple of severe cases - dogs with heart rates of 190-250. They responded well to fluid diuresis, mild sedation, and beta blockers to slow the heart rate. And I have seen one dog that presented for chocolate intoxication die. His death was sudden and inexplicable. It was a small chihuahua. His heart rate was very high, but he was alert and active. He had no other health problems. He was in his kennel, receiving fluids, barking his head off, and about to be sedated, when he suddenly and unexpectedly dropped dead. Resuscitation was not successful. I still have no idea to this day if this was really a chocolate related death or some other problem (underlying heart disease).

The vast majority of the dogs that eat chocolate do just fine with no treatment. It is massive ingestion that is worrisome. Also, the darker the chocolate, the more concerning. Pure cocoa is bad! Milk and white chocolates are barely worth concerning oneself over.

Rule of thumb? Apply common sense. If your 70 pound Labrador ate 1 snack size KitKat, he is not going to die. If your 70 pound Lab ate an entire bag of dark baking chocolate, a trip to the ER is warranted. The reason I say that chocolate toxicity "does not exist" is because it is very, very, very rare to see serious consequences as a result of chocolate ingestion. Most dogs just don't eat enough or the right kind (dark) of chocolate to have any problems other than mild hyperexcitability.

When in doubt, call your local veterinary ER - we are happy to talk to owners about quantity and toxicity. We do it ALL the time.

The curse of being a veterinarian

It's kind of a joke in my field (and probably every field has their variation of this) - but veterinarians ALWAYS get the animals with the rare diseases, the congenital abnormalities, or the undiagnosable illnesses. Apparently, this extends to family members, as well.

A day or 2 after Evaline was born, my aunt called me about her 10+ year old Labrador/Great Dane mix. He was severely lethargic to the point where he would not rise. His breathing was labored, his gums were pale, he had severe bruising on his abdomen, and his extremities were cold. My aunt also noticed that his abdomen looked distended.

Any other Labrador with these symptoms would have a ruptured splenic or liver mass. It's as common as grass! I see at least 3 rupture splenic or liver tumors a month at work, and they are almost all Labradors or Golden retrievers. I recommended she get him to her veterinarian ASAP.

Dr W did a thorough exam on Flip and could not find evidence of a splenic or other abdominal mass. Flip's clotting times were abnormal, though. Given that Flip is an outdoor dog and because of the way the clotting times were elevated, the vet suspected rat poison and started treating accordingly. Initially, Flip responded and seemed to do well.

Then he started to deteriorate again and became severely, severely anemic. The veterinarian ordered packed red blood cells to give him a transfusion. When he rechecked the anemia a couple of days later, it had resolved! Flip seemed to be improving. He was discharged home, and he became lethargic again.

Further, he was now having trouble walking - as his back end was weak. He was almost walking on his elbow in one rear leg. The muscles were wasting away (atrophied), and he had developed a fever.

Last weekend, my aunt brought him to me to ultrasound his abdomen, looking for a culprit. I found nothing to explain his symptoms. He was still feverish. With no answers, I started him back on doxycycline (an antibiotic used to treat tick-borne disease such as Rocky Mountain spotted fever, Lyme, and Ehrlichia) and prednisone (a steroid).

His condition has not improved, and his atrophy has worsened in the rear limbs. I am going to euthanize him tomorrow at my aunt's house.

And still, I have no answers. I highly suspect some sort of cancer, but this could be tick-borne disease, autoimmune disease, or anything else. I am highly frustrated! I am a good veterinarian, and usually I at least have a handle on what is causing a patient's illness. In this case, I am left baffled.

Unfortunately, the veterinarian's curse strikes again - making me feel rather like a failure.

Still here and an unexpected shift at work

It's amazing how quickly large chunks of time pass without me realizing it. It must be due to the confusion my body suffers due to my wacky sleep "schedule" (which is no schedule at all). I could swear I just posted about cats and permethrins - but it has been over a week!

At any rate, guess what I did this weekend? I worked a short shift. My colleague qualified for a large regional dressage competition. She couldn't find any relief vets to work her 8am-1pm Saturday shift, despite trying for several weeks. She asked me to do it. Once I got over my initial irritation at being bothered while I am enjoying my maternity leave, I realized that I kinda wanted to do it.

Motherhood is wonderful, and I love, love, love spending time with my daughter. On the other hand, my husband is frantically working on his thesis (his defense is looming in the next few weeks), leaving me to try and manage the baby by myself. He is wonderful and steps in to help any time he thinks I need it, but I'm trying desperately not to bother him. Also, since I am exclusively breastfeeding, I am with the baby most of the day. She also sleeps with me, so I have very little time away for myself. This is the plight of all new mothers, and it's a big adjustment. My husband and I have been married for 12 years, always able to do as we please, when we please. It's been a pretty fancy free lifestyle, honestly. Having a little person to care for 24/7 is a huge change. It's like this for everybody, I realize - so nothing new there. You just don't realize HOW MUCH your life revolves around a baby until you have one. No matter what people tell you - there is no way to prepare.

At any rate, the thought of being with other adults and back at work for a few hours was really enticing, so I accepted her request. I also want to build good will at work. It was a Saturday morning, so it was slow. I saw a dog with a badly broken leg and a cat with a terribly degloved tail, and otherwise, I sat around and caught up with my technicians. Still, it was refreshing to be back at work, even for a short, boring shift.

I wonder if I could be a stay at home mom. Just a few short weeks ago, that thought was enormously appealing. Now that I've been away from work since the end of September, I realize that I really do love what I do and want to continue doing it. I also want to be an involved parent. Life to me seems to short to waste on working, no matter how much I love what I do. It's a conundrum.

Is it possible to be a great mom and still work a demanding job? I guess we'll find out. On the bright side, my job allows me large blocks of time off, which I can spend with my family.

Cats and permethrins

I can't recall if I've ever talked about this before, but I thought about it when I was doing the 5 things post. #6 would be: if a product is labeled "not for use in fill-in-the-blank species" then DON'T USE IT IN THAT SPECIES.

If you go to Wal-Mart, K-Mart, Target, and the like, you can find over-the-counter flea and tick medications for your pet. These run the gamut from what were once veterinary-only products (Frontline/fipronil, Advantage/imidacloprid, etc) to OTC products that have always been such. If you look closely at certain major brands you will see that several are prominently labeled "DO NOT USE IN CATS."

That is because these products contain pyrethrins/permethrins - chemical compounds that can lead to seizures and death in cats. For some reason however, people tend to ignore these bold warnings and use these products on cats anyway. Some cats will never have any problems, for reasons that are not clear. Other cats will have a mild, tremoring reaction. Still other cats will seizure so hard that they will appear to be levitating.

These drugs kill fleas by screwing up the sodium and potassium channels in cells. These channels are responsible for mediating conduction of impulses along nerves. When these drugs interfere with Na/K, the targeted species (for example: fleas) basically twitch to death because of interruption of normal nerve conduction. The same happens with cats when given these medications. Cat livers are not as efficient at metabolizing certain drugs (such as acetaminophen, the active ingredient in Tylenol and permethrins). As a result, clinical signs develop.

This toxicity can be treated. Unfortunately, most cats (except for the most mildly affected) will require 24-96 hours in the hospital with IV fluids, anti-seizure and muscle relaxant medications, possibly lipid therapy, and intensive care. In some cases, affected cats must be put under general anesthesia with either Propofol or inhalant anesthesia to stop the tremoring/seizuring. In some cases, it cannot be controlled at all.

It is not inexpensive to treat either - which is the saddest part. Most people put these medications on their cats to save money, not realizing that a hospital stay to treat this is going to cost in the neighborhood of $700-2000 depending on the severity (or lead to euthanasia in many cases due to financial constraints). If you break down the math ($60-90 for a 6 month supply of safe, veterinary proved product = $10-15/month) - prevention is the BEST and cheapest treatment.

Lipid therapy is a newer therapy that is very interesting to me. Permethrins are highly lipid soluble. This means that they move into the fat of the body very well. Synthetic lipid compounds are produced by pharmaceutical companies and used often for feeding patients intravenously. It has been found that if you infuse these compounds into patients with exposure to lipid soluble toxins, they form a "lipid sink" for drugs - meaning that instead of being internalized into the body's fat stores, the permethrins are bound up with the lipid we administer. As a result, they are not broken down in the body in such a way as to cause clinical signs. This is the theory anyway.

Lipids themselves are a cheap treatment option (about $20/bag - a small dog will only use about 10-20 millileters, and a bag holds about 500 milliliters). We have this in stock at our clinic, but I haven't had a permethrin case yet! I have used it on a ivermectin toxicity.

Moral of the story: the best treatment? Prevention!

Sorry for my AWOL status - new mommyhood and all. It's been wonderful and exhausting at the same time. Thankfully, my job has prepared me well for being the mother of a newborn. I don't have any trouble getting up and taking care of the baby in the middle of the night. I'm also dealing fairly well with sleep deprivation. Crazily enough, as much as I love being a mom, and as much as I never want to be away from my little butterbean, I actually miss work. We had a doctor's meeting the other day, and listening to my colleagues talk about cases made me crazy to be back in the ER. I'm not spending time dwelling on that, as these precious few weeks will fly by - and I will go back to work and miss my daughter desperately. Dec 7 is THE day...

Top 5 things I wished pet owners knew (but don't)

This was a requested post, and I thought it was a good idea. I'm sure I will expand this list one day, but for now, I am sticking with 5.

1) Aspirin, ibuprofen, Tylenol, Advil, etc. are the not the cure-all for every problem a pet suffers. I cannot tell you how many pets I see with every symptom known to man (vomiting, diarrhea, lethargy, weakness, stumbling, loss of appetite) that have received an NSAID at home. These are painkillers that help with inflammation. They are NOT going to do anything for a vomiting dog. Just like YOU wouldn't take aspirin for nausea, neither should your dog. Further, these products are dosed differently (or not at all - in the case of naproxen in dogs and Tylenol in cats). These medications can pose serious threats to your dog's health.

2) Allergic reactions to beestings, pollen, and the like that cause facial swelling, itching, and hives/wheals are not life-threatening emergencies requiring immediate care. I shouldn't complain, as this is job security for me - but if your dog breaks out in hives, his face swells, and he starts to itch like mad, give him Benadryl, and wait it out. It can take up to 24 hours for the hives and swelling to completely resolve. This cutaneous reaction is not life-threatening in any way. Now, if your dog has trouble breathing, collapse, weakness, or the like - that IS an emergency.

3) A dog or cat is not embarrassed by the words "penis" or "vagina" or "vulva." Neither am I. You can use them freely. I do NOT like the words "lipstick", "hooha", "wee-wee", or "peanut."

4) I have no control over prices, billing services, or anything else to do with the financial aspect of the pratice. I am an associate, I do not own any part of the clinic, and thus, if I give you a discount or do things for free, then I am essentially stealing from my employers. Do I sometimes do things at a discont? Yes. Should I? Probably not. Oh, and I don't drive a Porsche. I drive a 13 year old Mercedes SUV that guzzles gas, has 210k miles on it, and was a freebie hand-me-down from my generous father-in-law.

5) Lastly, I wish that pet owners knew that I love my job, take it incredibly seriously, stay up nights worrying about cases I'm managing, strive to always, always do my best for every pet
I see, and constantly berate myself when I can't save the world.

That about sums it up for me, at the moment!

For lack of words :)

The first 3 days - breastfeeding trials and tribulations

After labor, I felt fantastic. Despite being awake for about 24 hours, I felt like I could do a lap around the hospital. Eva was borderline hypoglycemic after birth, and she was having a bit of trouble with the latching/breastfeeding. I didn't want her to continue to become more hypoglycemic, and I wanted to avoid interventions like an IV catheter/dextrose, so I acquiesced to her going to the nursery for a bottle. My husband went with her. They moved me to a recovery room. After 20 minutes, I was so restless and worried about her that I trucked down to the nursery to check on her. Apparently that was a no-no for a recently delivered mommy. That's how good I felt though.

We opted for having her sleep in the room with us, as I couldn't stand the thought of her going to a nursery and being away from us. We plan on "attachment parenting." Basically, keeping her with us at all times. This includes co-sleeping (or "sleep sharing") which is controversial. I will say that the first night, she would not settle in her bassinet. I did not sleep the entire night. Doctors, nurses, dietitians, and everyone else came traipsing in and out from 8am-1pm. Then lunch, etc. So I didn't sleep again. The second night was agony. My nipples hurt from breastfeeding, I didn't feel like I was getting a good latch, she was frustrated, I was frustrated, and totally, utterly exhausted.

By the second morning, I had been up for 50+ hours. I was so tired that I was borderline hallucinating. I burst into tears when breastfeeding because it hurt so much, and we were both frustrated. She wouldn't sleep in the bassinet. So, I moved her into the bed with me, and we both finally, finally slept (around 6am). It was very restful. It solidified my position on co-sleeping with her.

When we were finally discharged on the 2nd day, after her PKU test, a tetanus/diphtheria/pertussis vaccine and an MMR for me (turns out I am not immune to rubella), and the other formalities, she began to cry right before we left. I knew she was hungry, but it was only a 30 minute drive home. Of course, we got stuck in crawling (but moving) traffic. She wailed and wailed like her heart was breaking. I was able to stand it for ... oh, about 5 minutes, then I burst into exhausted tears too.

Now, we're home. My mom is here and has been taking care of whatever we ask her to do. As a result, I have been able to sleep some, although I am still very tired. Breastfeeding is still a challenge - it hurts much more than I expected.

I will say that my job has prepared me well for the waking on command and being able to be coherent (at least, coherent enough to change a diaper and feed the bebe).

So, what have I learned in the first 3 days of motherhood? Sleep when you can (not good at this yet). Comfortable, easy clothes for nursing are a must. Having a stay at home dad to help makes being a new mommy 10,000 times easier on you. And finally - it is absolutely amazing how much you can love someone you have known for only 3 days. It is also absolutely terrifying.

Baby posts?

So, I know you guys read my blog for the veterinary stories - as it IS a veterinary blog. In the last 3 days, I have already learned so much I didn't know about being a mommy. I want to chronicle this, all of it. For her and for me, so that next time we have a baby, I will be able to read and remember. I also want her to have it for the day long in the future (only relatively) when she has her first baby and has a thousand questions like I do. My mom, God love her, had 5 natural childbirths, but she says she can't remember stuff anymore about the labor/delivery/post-partum period. Hopefully, if I record it all, I won't have to remember exactly!

At any rate, are you guys interested in these posts - or would you rather I start a separate mommy blog and keep this strictly vet medicine related? I do plan on talking about being a vet and being a mommy when I go back to work, but I'm asking more about the early day aspects. Would it bore you and drive you away from my blog? Please let me know!

She's here!

Due to my gestational diabetes, the midwives were pushing for induction next week. I opted to have my membranes stripped on Tuesday afternoon. I started spotting and cramping afterwards. I woke up Wednesday morning at 6am with what I thought were fairly regular contractions. We went to the midwife/OB office to find I was only 3cm dilated :( Sent us home to continue laboring.

After an hour in the tub, I was having contractions right on top of one another. We walked out to the car to go to the hospital, and my water broke. When we arrived, I was only 4cm! I climbed into the Jacuzzi tub and labored for 5 hours in the tub - alternating between hot water and cold water. My husband was my coach and drizzled me intermittently with cool water and placed cold wash cloths on my shoulders and head.

After 5 hours, I felt ready to move to the bed. I was checked and found to be 9cm. I had the strong urge to push - and the MW gave me the go ahead. I pushed for an hour, and she was born! Pushing was the most physically demanding thing I have ever done. Toward the end, I started to panic a little - fearing she would get stuck. Even when I could feel her head, I was scared! I started to hyperventilate a little, but thanks to an amazing nurse, midwife, my mom, and my husband, I was able to calm down. I pushed in the side position with my right leg in the air and pulled back to my chest, and the left leg bent at the knee and pulled toward my chest. It was very, very hard for me to relax my legs and not push against the midwife/nurses/husband. Truthfully, it was the hardest part of relaxing.

Pushing scared me, I won't lie. It's incredibly intense. It wasn't painful in the way that I expected really (certainly not like transition). It was more intense pressure and kind of a burning at the end when her head came out. But I was truly frightened I would be too tired to do it. Toward the end, it got very, very hard - but you CAN DO it. Pushing felt so good compared to transition and hard labor.

With the side position and perineal massage by the MW, I did not tear. The placenta passed about 15 minutes post partum. It required a little it of pushing, but it wasn't bad - similar to a moderate menstrual cramp.

At 10:21pm 9/28, Evaline Adelle joined the world at 7lb 2oz. She is beautiful and latched with some help after about an hour.

I hope this helps those of you out there considering a natural birth. This was my first child, and I was very, very scared. I kept telling my husband how scared I was. I tried very hard to rest the night before, but I was unable to do so between the cramping and the contractions starting at 6am.

Now, 4.5 hours after the fact, I feel great. I can walk around, I feel strong and healthy, and nothing hurts anywhere. I didn't tear, I don't feel swollen, and I'm very, very happy! She was borderline hypoglycemic after birth, but we're working on fixing that. Keep us in your thoughts!

My mind is currently blank

I want to do a veterinary related post, but I cannot - for the life of me - come up with anything to talk about. I can't even think of an educational post! So, I'm opening the floor: what do you guys want to hear about? Any special requests? PLEASE?

Dogs and babies

I'm going a bit stir crazy here, I won't lie. Maybe NOT working isn't so stellar either! I have nothing to post about as far as veterinary stories. It's just a waiting game now. The baby could come at any time. While I sit here on the couch, I've been thinking about dogs and babies. Dogs of any breed can pose a risk to children, but it's certainly the case when you own a big dog.

At our shower a couple of weekends ago, after everyone had mostly left - a few of us were sitting around watching UT football. Everyone was halfway paying attention to our 8 month old cousin and halfway paying attention to the game. Suddenly, there was a yelp from my BF's dog, and the baby started to cry. I saw the whole thing happen - but it was so fast that I was unable to intervene. The baby is learning to walk and is very grabby. He grabbed onto the dog, and the dog, startled, snapped at his face. He did not break the skin (called an "inhibited bite") - but he did leave a perfect red ring of teeth marks and some bruising. The baby was more scared than anything, but we were all very, very upset.

It was an excellent reminder of how important it is to train dogs to be around babies, as well as to always, always, always monitor dogs and babies together. All of these tragic children/baby accidents that you read about are usually the result of unsupervised children and unsupervised dogs. Any dog will bite, given the right provocation. It doesn't mean the dog is inherently mean or aggressive. It is rare that a dog will bite without some sort of warning sign.

In reference to the bite to my cousin, we were all being too lax. Watching football, assuming someone else was watching the baby. While it was awful, we were all lucky it wasn't worse. And it was an important wake-up call/reminder of our responsibilities as caretakers (of both dogs and children). We have to create a safe environment for our pets and children.

We're currently discussing in our family what to do as far as training with Heidi goes. She is a very timid, docile and easily trained dog, but she is also very, very anxious. She also weighs 70+ pounds and could hurt a baby without even trying. We are going to work very hard to make sure that she feels safe/protected and that our child is safe and well-monitored. This may include crating her at some times. I'll keep you posted on how it goes.

Last day for 2.5 months today!

Yeesh. I think it's good that I decided to take time off when I did. Saturday was a blurry day that I can hardly recall. The clinic wasn't super busy, but there was a steady flow of clients all day. I slept terribly Friday night, as getting up to pee every hour is not conducive to restfulness. Thus, I spent most of Saturday in a foggy daze. The theme of the day was low finances, sick animals, do what you can for X amount of money, Doc. So I did.

I saw a very nice large breed dog that was sprayed with bird (or buck) shot. I'm by no means a rifleman, so I can't tell you which it was - but the poor dog was peppered with it from scrotum, prepuce, rear limbs, to abdomen. I was concerned that some of the pellets penetrated the abdomen, but the owner did not have the finances to proceed with hospitalization and monitoring. Thus, we compromised with pain medications and antibiotics. He was counseled to bring the dog back in ASAP if he exhibited vomiting, diarrhea, loss of appetite, fever, or other signs of systemic illness.

Then there was the "stray kitten." She was being taken care of by some Good Samaritans that had been feeding her. She had acutely become depressed, anorexic, and had a 105 fever. Having never had vaccines, I was worried about feline leukemia and feline AIDs. These tests were negative. I recommended further diagnostics, but the owners declined due to finances. I gave them antibiotics, pumped some SQ fluids into the kitty, and crossed my fingers. Miraculously, the owners called today to report that she is already back to normal kittenhood. Go figure.

On the heels of this followed a shepherd dog that was very lethargic and vomiting. Her abdomen was tense, and she had a fever. I was very concerned, but her owners were financially strapped and declined everything but symptomatic treatment. A shot of anti-emetic, SQ fluids, and out the door. I'm hoping she didn't/doesn't have a foreign body.

Lastly, there was the small Poodle that was mauled by another dog (unknown size/type). He suffered puncture wounds to his abdomen, neck, and chest. Remarkably, he was stable. After clipping, cleaning, and exploring the wounds, I recommended that he stay overnight for close monitoring. The owners declined and took him home. Hopefully, he is doing well.

I dragged myself home, realized my ankles were swollen to the size of elephant ankles, and laid on the couch like a sloth. My mind was so fuzzy that as I thought back over the day, I could barely recall the patients I had seen. I drifted off to sleep after dinner (around 9pm!). Thank god for my husband. He rubbed my feet, got me a heating pad for my aching hips, and looked after my general well-being. I'm a very lucky girl.

Today was my last day of work. I am now on maternity leave until Dec 7. It's hard to imagine not working for so long, but I'm looking forward to it!

Once more into the breach

Tomorrow and Sunday are my last 2 days of work before official maternity leave. The OB and endocrinologist were worried about the funky night schedule messing with my insulin dosing and blood sugar, so I haven't worked nights, but I can still work days. This weekend is my last. There are 22 hours of work (give or take, depending on how busy we are) between me and maternity leave! I'm on an alarmingly normal sleep schedule - I've been going to bed between 12am-1am and getting up at 9:30. It feels very strange. Mostly I'm doing this so that I can space my meals and snacks out regularly, as well as take insulin when I'm supposed to. It's been much, much easier to manage the GD this way. I kind of regret not doing it sooner. On the other hand, we couldn't do without the income!

I'm conflicted about whether or not I'm looking forward to work. I really do love my job, and I miss it when I'm not doing it. I'm excited about seeing cases tomorrow. On the other hand, my hips have hurt a great deal this week, so I'm concerned about my ability to be mobile tomorrow. I'm keeping my fingers crossed that no major surgeries come in, or else I might be calling for back-up. I limped a great deal of today. Only 18 more days - give or take.

In other news - one of my foster kittens was returned to me yesterday. This is Fish Kitty - a beautiful, DMH tuxedo kitten that I fostered several months ago. The girl turned out to be rather irresponsible, and she is moving back to Pennsylvania. Her mother would not allow her to bring the cat with her. Thankfully, she called me. Fish Kitty has been reinstalled as a foster at this time. She is one of the sweetest kittens I've met in a while - but she is CRAZY. She's about 8 months old, and she is into everything. I haven't had this age of kitten in the house for a while, so it's an adventure. Fortunately, Fish Kitty is very, very sweet. We're leaning towards keeping her, believe it or not. Nuts, I know. That will bring the cat total up to 6!

I will hopefully have some interesting cases to post from this weekend - 'cuz it's gonna have to do ya'll for a while. Shortly, my mind will be occupied with everything BUT veterinary medicine.

Baby stuff

I know ya'll read this mostly to hear about my exploits as a veterinarian - but right now, my brain is totally occupied by baby. I am full-term now, so she could come at any time. We rather hope she does, so that we can avoid the whole induction dilemma presented by gestational diabetes.

The nursery is more or less finished (waiting on the crib mattress), the hospital bag is packed (my part of it, the husband's - not so much), I have washed all the new baby clothes, folded them, and stashed them away. We even have diapers. It's getting close now!

Unbelievable

Sorry for my absence. This weekend was our baby shower in Knoxville, and it was great. It also wore me out physically and mentally. We had a great time, saw a lot of family and friends, and received a lot of amazing gifts. The nursery is finished now, for the most part. The first few loads of new baby laundry have been completed and sorted and put in the dresser, and we are ready. (I hope).

I thought I would share this anecdote with you guys - because I'm still - a day after hearing about it - stunned that it actually occurred.

An owner showed up to our ER (my colleague was working) with a stuporous and laterally recumbent puppy. The puppy's heart rate was very high, it's temperature was very low, and it was essentially dying. The owner was convinced that the dog was dying from rat poison that it ate THAT day. The puppy had NO previous exposure to rat bait except for that day. Rat baits take 3 days to work at minimum. It is not physically possible to be exposed to rat poison and several hours later die as a result, no matter how much bait is ingested.

The owner had no finances and a dying puppy. My colleague offered free, humane euthanasia. The owner declined and elected to leave with the puppy, despite being counseled that it was suffering.

30 minutes later, Walgreens across the street called. The pharmacist reported that the woman was present, demanding a prescription for vitamin K (the treatment for rat poisoning). She (the pharmacist) wanted to know if vitamin K would help the puppy. My colleague explained the situation carefully. Then there was a pause. Then THE PHARMACIST, a fellow medical professional, said, "What you people charge over there is criminal. You are all criminals." And she hung up on my colleague.

Needless to say, the doctor was LIVID with this unprofessionalism and immediately called back. The pharmacist initially apologized, then tried to defend her position by stating that she had brought HER personal pet to the ER clinic, and we had gouged her. My colleague asked to speak with the manager, who was not happy and apologized.

We send a great deal of business to that Walgreens - as it is directly across the street from us, as well as 24 hours. I think however, that I will now be sending my clients to CVS Pharmacy, down the road about 1 mile, without reservation.

What is wrong with people?

Follow-up

As to what I decided to do:

Tomorrow, I plan on calling the owner at home and discussing his concerns with him. I have done extensive reading on this subject, reviewed the surgical technique in multiple texts, as well as communicated with an ophthalmologist about possible causes of the drainage. Keep in mind that I have not seen this patient, so I have no idea of the character of the drainage. This could be my fault, or it may have nothing to do with anything that I did surgically. The ophthalmologist gave me several possible causes for the vague sign of drainage. I will share all of these with the owner, discuss his concerns, and recommend follow-up with his rDVM. I will make sure he is aware of all the possible causes - including the surgical problem (which the ophthalmologist said IS a surgical "mistake" - but one everyone will make at some time in their career, if they do enough of these surgeries). I will then leave it up to the owner to continue seeing the rDVM - hopefully with my concerns/recommendations in hand. Then, I will wait for either the letter from the rDVM complaining/throwing me under the bus or hearing back from the owner.

I'll keep ya'll posted.

Post-op complications and dilemmas

I have a dilemma, and I would like the opinions of those reading - vets, vet students, and pet owners alike.

About 3.5 weeks ago, I saw a small breed dog with a traumatically proptosed eye. The eye was not salvageable, in fact it was mangled. I told the owners that removal was the only option for this eye, and after much arguing, debating, and scrounging to afford it, they came up with the money for an enucleation.

Fast forward to today. The owner calls because the empty, closed eye socket has been having drainage since the surgery 3.5 weeks ago. He has been to his referring veterinarian with the dog, a culture of the drainage has been submitted, and the dog was placed on appropriate antibiotics. Once the antibiotics were stopped, the drainage came back.

Initially, I thought this was likely an infection - probably from the initial trauma to the eye. I did a quick VIN search though, and apparently, a not uncommon complication of enucleation is that some fluid producing tissue (conjunctiva or lacrimal tissue) may get left behind. If this is the case, re-exploration of the socket and removal of this tissue is necessary. In other words, the dog MIGHT need another surgery.

Here are my dilemmas:

1) First, as an ER clinic, we are not supposed to recheck clients. This is done by the general practitioner that normally sees the pet. So, I have not seen the dog and have no knowledge of the character of the discharge, where it's coming from, or any other detailed knowledge of it. I have no idea if this is a surgical complication or a consequence of the dog having been bitten across the eye and deep infection introduced into the socket. The pet HAS been seen by the regular veterinarian, and he is handling follow-up. Thus, I should not offer to recheck the dog. I think. We ER vets have to tread cautiously here.

2) If this is a post-op complication - do I refund the money for the original surgery? Offer to re-explore the eye socket for free (I'm not sure I would know what I'm looking for and thus, would likely have a more experienced surgeon present)? At this point, I have no idea if I have ANY culpability in this outcome. Post-op complications DO happen.

3) Do I call the referring vet and alert him to what I have found in my literature search? The biggest problem here is that the referring vet is none other than the one that was fired from my position years ago. He hates our clinic and takes any opportunity to throw us under the bus. Any other clinic, any other veterinarian, and I would already be on the phone - but I am so hesitant to call this vet. No matter what happens or what the case, he will try to blame me. That's not a good reason not to call, I realize.

I talked this over with our office manager and my husband, and I will tell you what they recommended, but I would like to hear opinions from you guys first.

To clarify

I've had several constructive insights into how I could do better at work, but one thing I want to clarify:

I do not yell or lose my temper. I am not a bear to work with in that respect at all. Maintaining composure under stress is something I pride myself on. I think my problems are more personality-oriented - my lack of interaction, the fact that I'm not very talkative, that sort of thing.

Well, it has happened.

No more nights for me until my maternity leave ends. My blood sugar - while not terrible - was not stable and happy this weekend. Part of that is because of the incredibly convoluted schedule of eating/sleeping that I keep when I'm working the night shift on weekends. Part of the problem is the fact that I can sleep for a while, but I inevitably get woken up by a random 3am seizuring dog or 5am euthanasia. If I've taken my overnight insulin, I don't feel like I should eat, but then the nurse practitioner told me that if I'm up working, I should be grazing. It's all very confusing. The OB I saw last time offered to write me out of working nights because of the effect it was having, but I declined.

No longer. Instead of 9 days of work left, I have 2 day shifts the weekend after this. I would have worked the day shifts this weekend, but alas, our big baby shower is occurring.

I won't lie. There is a huge amount of guilt involved in this. There shouldn't be, I know. It's all about taking care of our little girl. Still, given the nature of our small clinic, if I'm not there, one of my colleagues has to pick up the slack. In the reverse situation, I would be totally willing to do the same, yes. I hope they realize that. It's only 7 days that I am missing. So that's not all that bad, right?

The hardest part of my job?

You would think that the hardest part of being an ER veterinarian would be say...the hours. Or maybe the working holidays and weekends. Or perhaps the dealing with gravely injured and ill animals and their distraught owners. Sure, all of that is challenging. But those things seem like a cake walk to me compared to the real challenge - interpersonal work relationships.

I am a difficult person. I am Type A+. My job is something I take very, very seriously. I pay close attention to my patients and try to always, always do the right thing - whether that be easy or exceedingly difficult. I demand perfection from myself and never achieve it, of course. My expectations for those I work with are very high. And in one area, I constantly find myself lacking - I am terrible at managing interpersonal relationships.

First of all, I am not a warm and friendly person. I try to keep my personal life to myself for the most part. I don't like to talk about personal problems at work, and I don't seek the advice of other people regarding personal unhappiness/problems. As a result, I don't like to hear about other people's problems. My approach to work is to go to work, do my job to the best of my ability, and go home at the end of the day. This aloofness never wins any popularity points. When I first found out about my gestational diabetes, I had no intention of sharing that with anyone at work. Only when insulin became a necessity did that information come out.

Secondly, I abhor gossip. As a result, I do not engage in it at work, and I expect my coworkers and colleagues not to engage in it around me. You'd think it would garner respect, but actually, it probably sets me further at odds.

Lastly, I am very blunt. I say what comes to mind, and while I never intend to hurt people, I've been told my forthcomingness can be hurtful. It is never intentional, but it's there.

There is no single aspect of my job that I struggle with as much as dealing with my technicians. I hear again and again from them that I am a great doctor, that I would be the first one to whom they brought their personal pets. Then I hear again and again how difficult I am to work with.

It has truly become a source of frustration for me in that I cannot get a straight answer on how to improve this. The technicians seem unable to clearly voice a reason, so I am left with vague answers and no real way to improve. I WANT to improve. I WANT to be a good doctor to work with and for. I don't want to be difficult. If only I knew how...?

The weekend was a very busy one, as holiday weekends are prone to being. My technicians were tired and cranky and over it. I was tired and cranky and over it. My blood sugar has not been cooperating so well this weekend, and I can't help but think that the stress, late nights, and sporadic eating have had something to do with it. I'm also having a hard time telling when to take insulin (on the very bright side, my recent growth ultrasound estimated the baby in the 47th percentile for weight, i.e. perfect, and all of my non-stress tests have been great - so everything is perfect at the moment).

At any rate, one of my techs and I sort of snapped last night and had words.I had to force her to go outside to calm down and talk about it rationally. It was a productive conversation in that she told me useful ways that she perceived I could improve. Some of the points were valid, some were not. In the end, I hope it smoothed things out, but I suppose we'll see.

Honestly, I sometimes think I will have to give up clinical medicine and become a teacher. I love teaching, and I wouldn't have to interact on a boss/subordinate level. I could just do my thing and go home at the end of the day.

**Sigh**

It's Friday!

Actually, it's Sunday - but it's Friday to me. I could not be more ready to be finished with work. After tonight, I only have 9 days of work left until I go on maternity leave. I am really ready for it. Obviously, I'm ready for the baby to get here, but I need some time off from work too.

On my actual Friday night, I hit the door at 5:30, and I already had 2 patients waiting to see me and 2 on the way. Busy nights in the ER never bother me, they make the night pass faster. Unfortunately, hitting the ground running like that always leaves me vaguely discombobulated. I feel like I don't have time to gather my thoughts and prepare for the evening. Waiting for me were a very, very sick parvo dog and a heat stroke transfer. Both were intensive care cases that required a lot - and both are doing well as of this morning when I left. The night continued with a limping dog, a coughing dog, a lethargic, febrile cat, and the like.

I haven't been having trouble staying up late to see patients. What I'm having trouble doing is getting up when I've laid down to sleep. Usually, I bounce out of bed almost immediately upon being summoned, and I can think clearly. Lately, when I've been forced to get up at 3 or 4 in the morning, I've been very groggy and out of sorts. It's not pleasant, and it's getting harder. Only 8 more nights between me and maternity leave, though.

One more night is all I have to drag myself through until I can retire to the couch and become a vegetable for a few days. It's hard to express how much I am looking forward to it.

Frustrations and bad decisions

Monday night was my first night back at work. It was fairly busy for a Monday - rather against my wishes, as I had hoped for a quiet night so that I could recuperate from our trip to Florida. No such luck. I plan on sleeping very, very late tomorrow to make up for my lack of good rest lately.

Unfortunately, Monday brought a bad case that I would handle completely differently, if I had a time machine. A woman presented her 15 year old Chihuahua for "worsening since yesterday." She was seen by our relief veterinarian for back pain. At that time, no other abnormalities were noted. The dog (Daisy) was discharged on pain medications. Her owner reported that she wasn't doing any better.

Daisy was brought straight to the back, and it became apparent that she was having very labored breathing. When I listened to her heart, she had a severe heart murmur that wasn't present the day before. She was also cyanotic and having serious difficulty breathing. We placed her in oxygen and I went to talk to her owner.

Unfortunately, her owner was very mentally handicapped. She could not drive, and she had been dropped off by a friend. She could not give me any information on her dog. She failed to grasp the severity of Daisy's condition. I tried to explain, but all she wanted to do was hold Daisy. No matter what I said, I could not make her understand how ill her dog was. Further, she was severely financially limited. She was on disability and had about $395 in Care Credit.

Daisy would need at least 2-3 days hospitalization, maybe more - depending on her underlying disease condition. She would likely need lifetime medications and diligent care. I tried to convey this and kept failing. I asked her who her regular veterinarian was, and it turned out to be one of our shareholders. In this particular case, the shareholder has a history of helping out with difficult financial cases (for established clients). I crossed my fingers that she was an established client and proceeded to treat the dog with the limited money she had.

Daisy's xrays were puzzling. I expected to find heart failure, but I was not convinced of this on the xrays. She had a severe interstitial pattern in her lungs, but it wasn't the typical heart failure appearance. It could've been pneumonia too, but she wasn't coughing, and she didn't have a fever. I really wasn't sure what I was dealing with, so I treated what I could and kept my fingers crossed.

Shortly after Daisy's owner left, she called back sobbing hysterically. Her father, who cares for her, refused to drive her back in the morning to pick up her dog. Instead, he had told her that she needed to bring the dog home and "let it die." She was beside herself. Feeling terrible, I volunteered to drive the dog to the clinic myself (nearby, thankfully). The morning rolls around, and we run her Care Credit to pay for the night's care. It was declined. Stellar. I call the shareholder clinic to get information on the client. Turns out that she is NOT established and is considered an inactive client. Daisy was unvaccinated, not on heartworm preventative, and had only been seen a handful of time in 10 years for nail trims and the like.

In other words, not a client that the shareholder will work with financially. Great. What the hell was I going to do with the dog now? I called the owner, and we had a very frank discussion. I again explained that her dog was seriously ill, needed ongoing, expensive care, and more diagnostics. It finally seemed to get through to her. After much crying and discussion, she elected to euthanize Daisy.

An hour past closing time, she showed up (neighbor drove her), and we did the inevitable. Daisy went quietly. We fixed her Care Credit and were able to run it through for a part of the amount she owed us. In the end, I felt terrible about the situation. I spent $400 of this woman's money on a dog that needed more treatment without knowing for sure that more treatment was even feasible. As it turned out, it wasn't. If I could go back now, I would have put euthanasia on the table with that first discussion. Hindsight and all of that.

Back again

It was a fun but exhausting weekend. We left Thursday around 11am and arrived in Destin, Florida at 9pm. It was a long drive, and I think I saw the inside of every single gas station bathroom between Florida and North Carolina. All in all, the trip wasn't too bad. My wonderful husband did all the driving, so that I could sit like a lazy, pregnant sack of potatoes.

I've only been to the panhandle of Florida once before that I remember - as an 11 or 12 year old for church camp. I didn't recall how beautiful the sea is there. Destin especially was gorgeous. The sea is blue-green - like Hawaii but not quite as brilliant. The sand was like sugar.

It was a beautiful weekend, and my friend was the most gorgeous bride I have ever seen. We enjoyed time on the beach, around the pool, with good friends (including one I had only ever met on Facebook and now blogs too). There was lots of beer, champagne, and liquor. Of course, I could not imbibe - but my husband made up for both of us.

Lots of random people rubbed my belly, which didn't bother me much. Everyone loves a pregnant woman. I didn't get enough sleep, and by the time the wedding was finished, my ankles were enormous. I also burst some capillaries in my legs. So, all in all, I probably overdid it. It was all in the name of my friend's wedding though...and totally worth it.

Back to work tonight, veterinary stories to come.

It's the small things

I found curtains for the nursery - just when I was starting to despair! It seems like such a small thing, but it was really bugging me. I couldn't find anything I liked. Last night, we went to Bed, Bath, and Beyond to get a wedding present for this weekend, and I happened to swing by the curtain section and find the perfect pair!

The frames above the bed are black and white photos of Jim's grandmother - the one after which we are naming our daughter.

We leave the day after tomorrow for my vet school classmate's wedding. I am matron of honor. It's going to be a long, long drive (10.5+ hours, then add in stops for my pregnant bladder and to stretch my legs). It will be a quick weekend - what with driving all day Thurs and coming back Sunday. I'll probably be AWOL for a bit, as I have to go back to work Monday night.

Rewarding!

I love a rewarding case - looking at a patient and knowing that my intervention and the care of my technicians saved its life. It is one of the things that is most awesome about ER medicine. One of my favorite things to treat - hands down - is anaphylaxis. I see this at a minimum of once a month. I am kind of an anaphylaxis magnet at work, for some reason. Maybe I'm just good at recognizing it, who knows? It took me a long time to realize that anaphylaxis was out there and to start looking for it in my inexplicably collapsed and poorly responsive patients.

Around 6am this morning, a medium sized dog named Lily presented to us. She had been normal that evening, then jumped on her owner's bed, collapsed, defecated and urinated on herself, and then proceeded to start vomiting.

When she got to us, Lily had barely palpable pulses. Her gums were a muddy grey-pink color. Her heart rate was 240 (normal 90-120). She was breathing hard and seemed very weak. Her blood pressure would not register. She had a rash along her ventral abdomen, and her body temperature was low.

Her owner was a disabled, elderly lady with $250 to her name. This is certainly not enough to treat a nasty anaphylaxis. On a weekend, these cases run into the $1200-2000 range. I was not hopeful when she applied for CareCredit, as she was on disability. I was decidedly wrong, as she was approved for $1800. We had already started working on her dog at that point anyway.

Within an hour of administering epinephrine and Benadryl, starting aggressive fluid therapy to bring her blood pressure up, administering dextrose for her low blood sugar, and re-warming her, Lily's heart rate was down to 120, her gums were pink and moist, and she was standing in her cage and showing interest in her surroundings.

When I left her this morning, her vitals were stable, her blood pressure was 120, her blood glucose was normal, and she was maintaining her body temperature on her own.

It is always immensely satisfying to take a dying dog and raise it Lazarus style from near-death. It really makes my job worth it (despite being up all night last night due to patients and having nearly constant Braxton-Hicks contractions all morning).

Sad case

Last night, a nice country man brought in his new puppy. He had obtained this puppy about 6 hours prior, and since then, she'd been bleeding profusely from one side of her nose. I couldn't see a cut or any other explanation for the bleeding without sedating her. Unfortunately, the new owner had about $120 to his name. I recommended we spend the money wisely on sedation for a nasal and soft palate exam.

Both were unremarkable, and I could find no explanation for the bleeding. I questioned the owner at length about the new puppy - any trauma? any chance of rat poison exposure? He said no to these and then elected to take the puppy home for monitoring. The bleeding continued unabated.

Prior to leaving, he called the original owner. He casually mentioned that yes, the puppy DID have access to DCon rat poisoning. Come to think of it, the dog had been pooping green pellets for the last few days!!!

I told the owner how concerning this was and recommended running at least one clotting time test (a PT). This is the first of the 2 clotting times to become increased when an animal ingests rat poison.

Most modern rat poisons are anti-clotting drugs. They exert this effect by inhibiting an important enzyme that is responsible for the reduction of vitamin K in the body. Without this enzyme, vitamin K dependent clotting factors (clotting factors 2,7,9, and 10) do not get made. As a result, the body becomes unable to clot blood. This takes about 3-6 days to occur AFTER the rodenticide has been eaten.

At any rate, the owner agreed to run a PT. It was so high as to be out of range on our machine - indicating a severe clotting disorder. It appeared that our little puppy was suffering rat poisoning.

Unfortunately for the puppy, the new owner did not have the finances to provide treatment (fresh frozen plasma transfusion to replace the deficient clotting factors and vitamin K supplementation to provide the body with what it cannot make). Instead of doing anything, he took the puppy back to the original owner. He declined to even take vitamin K.

I can only hope that the original dimwit has the puppy treated, but I suspect it will lie in a lot somewhere and die a slow death of internal hemorrhage. It was an all around bad scenario.

More nursery stuff

I am not crafty in the slightest. My mother scrapbooks, makes handmade cards, sews, makes dolls, and the like. She often accuses me of being adopted due to my lack of interest in visiting Michael's fabric store, AC Moore, or Hancock's. So, when the creativity stirs me, and I actually create something, I get really excited. A couple of months ago, I bought some white picture box frames at Ikea, and some fabric swatches from AC Moore. The plan was to frame the fabric in the colors of the nursery. I figured it would be one of those things I never got around to - mostly because I'm not meticulous or crafty at all.

But I did it! I am so proud of my wall of art!

Nursery Stage 1

My wonderful husband painted the nursery for the past 2 days, and today, he put together the crib and "dresser" (i.e. Ikea Expedit bookcase). There's still much to do - hang artwork, get a new light fixture to replace the circa 1995 brass one, pick curtain rods and hang curtains, pick a glider, and on and on - but it's taking shape. That's exciting. I'm pleased with our Wal-Mart online Baby Mod crib. For $200, it was a good deal, it's made of wood, and it feels nice and sturdy.

Who knew that babies need so much stuff??

People make me KRAZEE

Some funsies from this weekend:

A woman who looked suspiciously like she did either crack or meth (or both) presented her very sweet, old Chihuahua for a "bleeding face." Said Chi had not been to a vet in 4+ years, was not on heartworm preventative, and had received no vaccines. The "bleeding face" was a tooth root abscess. When the base of teeth become infected - that abscess needs somewhere to expand. Sometimes it expands right through the skin of the upper or lower jaw (more frequently upper). That's what had happened to this poor dog. I sent my technician in with an estimate to sedate the dog and do an oral exam. I also was careful to make sure he explained to her that the estimate did not cover ANY treatment and that would be additional. Silly me, not putting it in writing!

I extracted 8 of the dog's remaining 10 teeth, as they were literally falling out of the dog's head. All told - the bill was $70 more than the original quote. The owner absolutely REFUSED to pay the difference, as it wasn't quoted to her.

She even went so far as to bring her skanky boyfriend in to argue with my technician. Despite explaining to her that the dental I did cost $70 extra, whereas at a day practice, it would have cost hundreds of dollars (and RIGHTFULLY so) - she would not pay.

In the end, we were stiffed the $70. On the bright side, the little dog will feel much, much better now that the rotting teeth are gone. There was that to make me feel better about the whole stupid situation.

The next was a crazy breeder and her intact 10 year old Irish setter. This dog was not vaccinated. When asked why not, the woman replied, "I'm a breeder. I don't vaccinate." Anyway - she had brought the dog in for restlessness and panting/anxiety. She was convinced the dog had a GDV ("bloat"). It was obvious from 50 yards that the dog was not bloated, and I told the owner that. On abdominal palpation, she was severely constipated, however. I recommended xrays.

At that point, the owner told me that she wanted the "upside down" xray, not the "side to side" xray - as the upside down is the only way to diagnose bloat (according to her veterinarian - which I'm highly skeptical about). I explained how to diagnose a bloat - physical exam followed by a lateral xray ("side to side") if necessary.

It didn't matter - we did both views anyway, as we always do - lateral and VD. No bloat, just a colon full of rock hard stool.

Owner went home with dog only to call back at 3am, insisting we MISSED a bloat in her dog because we didn't do the "upside down" xray.

I'm sorry, Ms Wacky Breeder - where did YOU go to medical school?? I'm an ER doctor, for God's sake. I see a bloat a week. I know how to diagnose them! Hell, my last one didn't even need xrays, we just went to friggin' surgery. And guess what? I was right - the dog was bloated.

There were other colorful characters through the weekend...but those 2 took the cake.

Whoo, it's Friday, Friday...

Not that the actual day means anything to me. I still have 2 more nights to work until I'm off. It was a busy night in the ER. We hit the ground running at 6pm and didn't stop until close to 5am. I saw many interesting cases: a proptosed eye that I removed, a dog with severely low platelets and a serious bleeding problem, a cat with an inexplicable post-mass removal anemia, a blocked kitty, a vomiting dog, a couple of euthanasias, an old dog with acute onset of vestibular disease, and on and on. It was exhausting, I won't lie. The only reason I'm still up is because I have to check my post-breakfast blood glucose before I can lie down. I won't fib - gestational diabetes is downright inconvenient. I guess that's true with any disease, so I should stop complaining - as mine is relatively mild. Despite being busy last night, I was able to keep on my eating schedule well, so that was an improvement.

Not much else to report. I'll post about some interesting cases when I'm less sleepy.

Life is not fair

So, the heat stroke Labrador that went home with the jerk owners? Doing fine - eating, drinking, and recovering from his heat stroke. The pit bull whose owners poured $2000 into trying to save him - including 2 plasma transfusions? Dead. I'm happy for the Labrador, but what lesson did the terrible owners learn from this experience? Absolutely nothing, I can rest assured.

Wow

This weekend was a busy one in the ER. 14 hours on Saturday and 13 hours today. It's very difficult to manage gestational diabetes with a schedule like I work. Saturday wasn't so bad that I couldn't eat my snacks and lunch on time. My wonderful husband got up at 7am on Saturday and fixed me breakfast to ensure that I ate prior to work. The day balanced fairly well and my numbers were ones I was happy with. Sunday was a different story. The husband made breakfast again and packed me lunch. I never got a chance to eat it, as I was running from the moment I hit the door. It was exhausting, and I never really caught myself up with the food. Hopefully, I'll do better next week.

I had a horrible case on Saturday that left me shaking in anger when all was said and done. When trying to sleep on Saturday night, it kept coming back to haunt me.

An older couple presented with their morbidly (and I mean MORBIDLY) obese Labrador (140+ pounds). He'd been locked in their car for 3 hours in the 90 degree heat. When he presented to us, he was laterally recumbent with petechiae forming on his skin. He was also having diarrhea and vomiting - all bad signs.

The owners were asked for the $500 critical care/triage deposit to get started. They flipped out - claiming that was too much money. Before things got heated, I brought the owners back to ICU - thinking that I could discuss heat stroke with them, their dog's prognosis, and give them a better idea of what to expect.

Nope, the owners were adamant - $500 was too much to treat (and that was just to start - a dog this large with a heat stroke would probably run into the $2000 range). I commiserated slightly about the cost in my best soothing doctor voice and recommended euthanasia, given the dog's dire situation.

That's when things got ugly. The female owner refused to make eye contact with me.

"I don't want him to die here!" she semi-yelled. "I want him to die on MY terms." She then said, "we're not putting him down, that's not an option." Bewildered, I tried to again explain sepsis, DIC, and acute renal failure. The owners would not listen. They wanted to take him home - to live or die there. Finally, I looked straight at the husband and said, "your dog is going to die a horrible death if you take him home in this condition."

The owner patted the dog and said, "We think he'll live."

My mouth was hanging open.It is exceedingly rare that I will tell an owner that they are being cruel, but I told these owners in no uncertain terms that what they were doing was inhumane. I almost mentioned that the dog WOULD die on "their terms" - as their terms had included leaving him in a boiling car for 3 hours.

It all fell on deaf ears. They signed an against medical advice form and left, putting their vomiting, laterally recumbent, petechiated Labrador into the back of their SUV and driving off. I felt sick. I still do. Especially because today - we saw a dog that had a heat stroke yesterday. The owners did not seek treatment and now the dog is vomiting pure blood, oozing from every venipuncture site, and dying. Just like the Labrador is probably doing in some backwoods shed someplace.