So glad my week is over, I am exhausted and not quite recovered!

I might be on a bit of a hiatus, as it looks like I'll be traveling to Florida unexpectedly for a funeral. We haven't quite decided when/if we are going, but it looks like it will be the case. Unfortunately, flights are exorbitantly expensive, so we'll likely be driving.

If you don't hear from me for a few days, don't fret. I'm alive and well - if saddened by a loss to our family.

Oh, what a night.

I feel like the walking dead, and I still have 1 more night to go before I am released from my exhaustion.

I walked into an ER of chaos with 2 patients waiting for surgery and a possible 3rd. The first was a cat that had been diagnosed by his vet with a metal "foreign body" and obstruction of his GI tract. Kitty was feverish and extremely painful in his abdomen. When we looked at the xrays, we all agreed that it wasn't a foreign body that the cat had swallowed but a BB. We shaved the cat's side and found an entry hole. On the other side of the body, we could feel the BB moving around under the skin. Under exploratory surgery, it became evident that the BB had poked holes in the colon. The colon is a nasty organ, and when it leaks, sepsis sets in rapidly. I had to debride the necrotic holes and close them up. I am very, very worried about kitty.

Then there was the dog with a 104 fever, vomiting, and abdominal pain. 6 days prior, I removed a foreign body from his intestines. He had recovered well from surgery, but now he was back. My gut feeling was that he was leaking from his surgery site, so back to surgery we went. I could not find any leakage, but the surgery site did not look healthy. I removed the tissue (resected and anastamosed), patched it, and now I am crossing my fingers for the dog. I'm really really worried about him too. His owners are now $5000 into his care and becoming irate.

Follow that with a host of other patients...the big dog little dog attack victim, the coughing dog, the dog with a limp after jumping off the couch, the malnourished, starving dog, and many, many others. Then the piece de resistance. After running like a headless chicken all night, starting to feel the pangs of exhaustion, we got a call from the police department. A drunk driver had wrapped his car around a telephone pole. His dog had become wedged under the dashboard after being thrown into it. It was on the way.

Said dog was exhibiting severe Schiff-Sherrington posture, was mentally dull, and in a great deal of pain. Otherwise, she seemed fairly stable. I was afraid her back was broken, but it was surprisingly not the case. She either suffered severe blunt trauma to her neck and head leading to spinal inflammation or a disc had popped out of place. She will likely be going to the referral hospital tonight for advanced spinal imaging.

One more night! One more night! Then I can catch up on some much, much needed sleep.

Worst euthanasia ever

ER work necessitates a lot of euthanasia. It just goes with the territory - very ill and injured animals, staggeringly high bills, financially strapped owners in a bad economy - all contribute to the high number of euthanasias I do. I can't really estimate how many I've done in the past 12 months, but I would say at least 200+. That would likely be a good estimate. Only two of them have stuck out as unpleasant, and last night was sure one of them.

A couple and their daughter brought in a cat. She was lying on her side, barely responsive to us. Her temperature was too low to read, her heart rate was extremely slow, and her blood pressure was negligible - all signs of a cat in shock.

She'd been seen at her veterinarian and then sent to a specialist for pleural effusion (see sidebar). Despite an exhaustive work-up, the cause of the fluid in her chest could not be determined. She'd had ultrasounds of her abdomen, her chest, her heart. The fluid had been sent to a pathologist for examination, and yet there was no diagnosis. In 1 week, her chest had been tapped 3 times to remove the fluid accumulating there.

The owners had had enough of watching her struggle and suffer, so they brought her in for me to euthanize.

My standard approach to euthanasia is to place a catheter, let the owner spend time visiting with the pet, then go in, administer a strong sedative (usually Telazol or Propofol), wait for the pet to go to sleep, then follow up with Euthasol.

Euthasol solution is usually made up of pentobarbital (a potent barbiturate), potassium chloride, and lidocaine. Thus, it is a very strong depressant of the respiratory and cardiac systems - causing the heart and breathing to stop. It is generally a very peaceful death. As I explain to the owners, it's like kitty is going to sleep to have his teeth cleaned, only he doesn't wake up. No pain, just peaceful sleep, followed by death.

In this case, I did not use my standard initial sedation because the cat was so out of it. Usually if the patient is severely compromised, sedation beforehand is not necessary.

I went through my standard spiel with the owners, flushed the catheter with saline to ensure it was patent, and then started to inject the Euthasol. For a moment, the cat seemed fine. Then her respiratory rate began to speed up, she attempted to sit up, and she started to groan. Her front legs became rigid, and she threw her head back, groaning and gasping for air. She twisted to one side, legs still rigidly extended.

Her parents seemed to take it in stride, while internally, I was freaking out. I'd never had a pet do this - whether they got pre-euthanasia sedation or not. NEVER. It seemed to last an eternity but really only probably lasted about 30 seconds, and then the cat was gone.

My theory on what happened is that she'd had fluid in her chest for so long that her body had adjusted to low oxygen levels by cranking up her respiratory rate. When I gave her pentobarbital, her breathing naturally became slower because of the drug. She then began to experience severe air hunger, which in turn caused a panicked state.

I felt and still feel terrible about it. The owners seemed unperturbed, but I was a mess (again, internally). No one wants to see a patient struggle like that and then die. I prefer the peaceful, gentle death that Euthasol provides 99% of the time. Seeing an animal thrash and cry out before death makes me feel like I have gravely under-served them at the most critical juncture of my job for them. It made me feel ill and sad for the sweet kitty that had already endured so much.

New ER vet blogger

My friend has joined the ER vet blogging world - go, read, and follow if you like:

http://journeyofanerveterinarian.blogspot.com/

Sometimes, there's nothing I can do...

A couple of weekends ago, our front door burst open, and a young girl came barreling through, sobbing hysterically. She was clutching a small breed dog in her arms. Blood oozed from the obvious wounds, and the dog struggled to breathe.

My technician took the dog and brought her straight to the back while the receptionist received approval for Class I triage.

The patient was obviously in shock. She was on her side, unable to stand. Her front limbs were rigidly extended, while her back legs were flaccid. This position is called Schiff-Sherrington posture. When you see this position in an animal, it means that severe trauma has occurred to the thoracolumbar ("middle") of the spinal column. It often means the back is broken, although I have seen cases where the spine was intact but the spinal cord suffered a great shock (hit-by-car cases, etc).

As we placed face mask oxygen, placed an IV catheter, obtained vitals, and started fluids, I examined my patient carefully. She had a huge wound on one side of her chest wall. Out of the hole was hanging fatty tissue but no lung, thankfully. On the other side, she had penetrating wounds into her abdomen. We quickly shaved the wounds and wrapped her chest and abdomen in bandages, then tapped her chest to remove any free air.

Her back legs had no sensation, her tail was flaccid, and she had no anal tone. She seemed to feel nothing from about mid-abdomen down. I knew it was bad, but I couldn't risk moving my patient to xray yet to confirm what I suspected - not until she was more stable.

After 45 minutes of aggressive fluids, pain medications, and oxygen, her blood pressure was stable, her gum color had improved, and she was more alert. Carefully, we moved her to xray. Unfortunately, my suspicion proved correct. Her spine was broken in half. The cranial portion was overriding the caudal portion. It was a severe spinal fracture, likely representing spinal cord transection. The prognosis is unbelievably grim for that type of injury.

Add to that - thoracic trauma and abdominal trauma - one and/or both requiring exploratory surgery.

The owners were dumbfounded. They had adopted a large breed dog a mere 1 day before, doing a good deed for a dog that needed a home. Unfortunately, the dog proved aggressive, bit their small terrier across the back (the dog only weighed 12 pounds), and shook it.

The damage was too grave, and I was left to do nothing but deliver the sad news. The hardest part was the 15 year old girl. She had owned the little terrier for 11 years, since she was 4 years old. Sobbing, she held the little dog and begged me to do something. I gently explained that there was nothing I could do for her companion, that she had suffered too much trauma. Her mother struggled to make a decision, asking over and over, "isn't there something you can do?" I said that we could stabilize the dog and refer it to the university for neurology consultation, but I explained that her chances for survival, at 12 years old, and quality of life, were very slim.

In the end, the owners made the decision to let her go. My heart went out to that little 15 year old girl, losing her lifelong companion. It was likely her first experience with death, and it made me very sad. Trying to do a good deed, her parents had invited into their home a dog who took away her companion. I can only hope that - for the big dog's sake - they didn't go home and shoot it, as they said they would.

My technician rescues that particular breed of dog, and she offered to help them place it safely...but they were very angry. I shudder to think of what might have happened when they got home.

It's an important reminder to think very carefully before introducing new, unknown pets into the household, especially when they are significantly larger or smaller than your other pets.

Bad blogger

Sorry I've been AWOL for a few days. I was doing really good at the blogging every day there for a bit. This weekend was long at work. 8am-7pm on Saturday, 8am-1am on Sunday. Sunday ran so late because a vomiting dog with a suspected foreign body showed up at the end of my shift. The relief veterinarian who was working overnight offered to cut the dog for me, but I opted to stay and do it. It was worth it, as I removed a chunk of rubber from the dog's intestines that had been present for 10+ days. He was much happier after surgery.

So far, pregnancy seems to be agreeing with me (knock on wood). I expected to be flattened after the 17 hour shift, but I was actually fine. Tired, yes - but no more than the usual 17 hour shift would have caused. No real morning sickness yet. Bouts of mild nausea here and there, but nothing I can't handle. Hopefully, I will inherit my mother's ability to have peaceful, easy pregnancies. She had 5 kids, and all of her pregnancies were easy. She also had precipitous labor with all 5...which I'm also hoping to have inherited. 3 hours, and you're finished! My official due date is Oct 5.

The pregnancy motivated me into hiring a painter to come and finish painting the house (spare bed/bath), and we bought new fixtures, mirrors, and lights for the bathroom. It's going to look great when it's finished. Unfortunately, my husband is going on day 6 of mystery illness. It's likely the flu, as he was febrile, achy, coughing, and lethargic for the first 3 days. He has recovered from most of that, but he is still exhausted and has to sleep all day. Hopefully, he'll rebound in the next few days. I have not contracted this illness yet, but when I found out I was pregnant, the OB gave me a flu shot...

Off to work I go.

A question of ethics and professional responsibility.

So, if you read my last post, then you have been introduced to the concept of caval syndrome - a massive overload of heartworms found in the right heart leading to right heart failure. As I outlined, there is only one way to treat it - extract the heartworms manually from the heart. This is done by isolating the jugular vein, cutting into it, and placing a long, long pair of forceps into the heart. The worms are grasped and removed via the hole. It is a bloody, messy procedure, and it has a 50/50 shot at working. Further, I have never done the procedure.

Here is my question for you, readers. If a patient comes through the door suffering caval syndrome, the owners are appraised of the risks, outcome, my inexperience with the procedure, and the prognosis, and they want me to TRY to remove the worms, should I attempt to do it?

My colleagues and I recently got into a heated debate about this. I have seen 3 caval syndromes in 18 months. Two of them have died within 30 minutes, the last was euthanized. None of them would have survived to go to a referral facility where the worms could be removed by specialists. It was me or nobody. If the owners had wanted me to try, I would have done it - as I see no other option for the pet, save rapid death or euthanasia. My colleagues say that I shouldn't be doing something like that without experience. I argue that I am the pet's only chance for survival, and it is my job to intervene if I can.

If we, as veterinarians, didn't do things outside our comfort level, no GDV would ever be fixed, no pericardium would ever be tapped, no foreign body would ever be removed. I still remember vividly every time I did all 3 of those things for the first time. It was nerve-wracking, but it was necessary. If I could refer these cases to a specialist, I would do so. However, as I said, all 3 lived less than 30 minutes from the moment they arrived on our doorstep.

So, what do you guys think? Intervene or push euthanasia?

Now, don't fixate too much on one diagnosis, doctor.

About a month or two ago, I was presented with a case that initially threw me for a loop. We were somewhat busy on a Sunday afternoon when a medium sized Shepherd mix was carried in by her owners. She was in obvious respiratory distress - her breathing was labored, her gums were cyanotic (blue-tinged) and pale, and she could not stand. Her condition was so poor, that our receptionist requested that the owners allow me to proceed with Class 1 triage (I start life-saving intervention on the pet before speaking with the owners). They consented to this immediately.

We placed oxygen by face mask initially, placed an IV catheter, and administered a mild sedative to help with the dog's obvious panic. Once she had calmed some, we started our testing. The first thing I wanted was a blood pressure. Given her bluish-white gums, I was worried about anemia, hypoxia, low blood pressure, and a host of other problems. Imagine my shock when her systolic blood pressure was over 300!! My technician was so convinced that our system had a leak or some other problem that she got a new cuff, new sphygmomanometer, and did it again. Still the same, >300.

Scratching my head, I started to mentally go over differentials for profound hypertension in our patients. Unlike people, dogs and cats very, very, very rarely (if ever) have primary hypertension. Humans have it all the time. In a dog or cat, there is an underlying cause - a tumor of some sort, heart disease, renal failure, or something else.

As I was thinking, my technician shaved the jugular to collect blood samples, and I was floored again. My patient had a pounding jugular pulse. To those not in the medical field - it is not normal in any way to see a pet's jugular pulse. You might feel it, you can certainly make the jugular stand up by applying pressure to it, but to see it actually beating like a drum in the neck is absolutely, 100% abnormal. It is a sign of right sided heart failure. Since the right side of the heart is responsible for taking blood that has been used by the body, pumping it through the heart, and into the lungs, it is a low pressure system. If that part of the heart starts to fail, blood starts to back up. It backs up into the vena cavas - one of which becomes the jugular vein. Hence, the jugular pulse. The right heart was failing, and blood was backing up into the jugular.

At that point, I suspected my diagnosis. Respiratory distress, jugular pulses, and severe hypertension in an obviously (from her appearance) outdoor, poorly cared for dog. I summoned the owners to the back at that point to discuss with them the dog's condition.

They were convinced she had been poisoned. Everyone always is. I pointedly asked them immediately if she was on heartworm preventative. Well, no, they said. That stuff doesn't work anyway, right doc?
I carefully explained that their pet appeared to be suffering from caval syndrome. Caval syndrome occurs when the burden of heartworms in the heart becomes so large that the worms start to cause occlusion of the vena cavas. In these cases, there are often >50 adult heartworms living in the heart. The heart begins to fail, and since the right side is such a low pressure system, it happens very, very rapidly.

The owners looked very skeptical. "Now, doc," they said, "we don't want you to fixate on just heartworms. We think she was poisoned."

I sighed, as we started the heartworm snap test running and moved the patient (carefully) into radiology for chest films. Her xrays were classic. Torturous, enlarged pulmonary vessels. Her caudal vena cava (taking blood to the heart form the abdomen) was 3 times the size of her aorta (extremely abnormal). I'd never seen anything like it. Shortly after moving her back to ICU, she urinated a massive amount of dark red urine. This was the final nail in the caval syndrome coffin (once the heartworm test showed up positive). The worm clot in the heart causes a secondary hemolytic anemia - the fragile red blood cells circulating through the bloodstream bump into and break up when encountering this clot. As a result, the patient develops what is called "port-wine hemoglobinuria." The hemoglobin released from the damaged red blood cells is cleared by the kidneys into the urine.

The owners were finally convinced. Due to their financial situation, and the grave prognosis associated with caval syndrome, they elected euthanasia. There IS a treatment for caval syndrome, however. It is radical, dangerous, and can be fatal in and of itself. The only way to stop the process is to physically remove the worms from the heart. This is done by actually making a hole in the patient's jugular, taking a long, long pair of special forceps, and inserting them into the dog's heart, then pulling out clots of heartworms. It is a procedure that few people do, as it is dangerous and has a guarded prognosis. Had the owners the finances and had they wanted me to try, I might have done it - as the dog was going to die anyway, but they did not.

She actually passed away before we were able to euthanize her. It was a very sad case but another excellent reminder of why heartworm prophylaxis is so absolutely crucial, especially in the SOUTH!

The antibiotic war

If you read the newspaper or watch the news at all, then you've likely heard about the problem of antibiotic resistance. Bacteria are nasty little boogers in that once exposed to an antibiotic, they like to evolve to become resistant to that particular drug. There are many, many ways that bacteria can do this, and it is leading to big problems in human medicine. Drugs that once worked miracles (such as penicillin) now only work for very selected problems. We are having to rely more and more on "big-gun antibiotics" to clear infections. Eventually, we may run out of antibiotics altogether.

Reasons for this resistance include over-prescribing of antibiotics to patients that do not have a documented bacterial infection, patients not taking the antibiotics for the full-course but instead stopping when they feel better (and selecting for resistant bacteria), and prescribing of the wrong antibiotic for the bacteria involved. All of these lead to bacterial resistance and are bad news for us.

As a result, doctors are trying collectively to be more responsible with antibiotics so that we don't run out of them. After all, we need them to treat so many terrible bacterial infections.

The same is occurring in veterinary medicine. Some are leading the way for all. And we're still not doing good enough. Antibiotics are the back-up, default treatment for a variety of conditions. It's a knee jerk reaction when we as veterinarians don't understand what's going on. Why not try a course of antibiotics? It can't hurt, right?

The truth is that it can! Animals are starting to have resistant infections, too. As people have MRSA (methicillin resistant staphylococcus aureus), dogs and cats are now coming down with MRSI (methicillin resistant staphylococcus intermedius). I saw it numerous times during my internship. The same causes are present: over-prescribing of antibiotics, inappropriate dosing schedules, and the wrong antibiotic for the bacteria.

What can we do about this? Veterinarians need to step up to the challenge and really start thinking before we prescribe antibiotics. This sounds simple, but it is very, very challenging. Many owners come into the veterinary hospital asking for antibiotics. Many veterinarians think, why not try them? They're cheap and often we are faced with clients who refuse to let us do any diagnostic testing for financial reasons, thus we are left "shot-gunning" treatment as best we can. Further, owners will frequently get mad when they are NOT given antibiotics, even though they don't really understand why they need/want them in the first place.

It is our place as veterinarians to understand when "shot-gun" therapy is appropriate and when it is not. It is our place to tell our clients "no, more testing is needed before therapy can begin", and it is our place to understand when we are contributing to the problem and not helping.

Here is a list of diseases in which I think antibiotics are over-used and contribute to resistance (these are my opinion, of course. Gleaned from schooling, my internship, and VIN -but still, my opinion).

1) Cat bite abscesses: this is an incredibly common presentation in both ER and GP. A cat comes in with a big, pus draining abscess somewhere on the body. It is very likely the result of another cat bite. The cats usually have a high fever (103-105), are lethargic, and don't want to eat. Most veterinarians either prescribe oral antibiotics or give a shot of Convenia, a long-acting antibiotic. The problem? Once the abscess is open and draining, the infection is leaving the body. Antibiotics are not warranted. I stopped treating cat bite abscesses with antibiotics after my cat, Boo, got outside and developed a giant one himself. 2 doses of clindamycin, and he started vomiting all over my house. After thinking through the process of abscess formation and doing some reading on VIN, I stopped the antibiotics, gave him fluids under the skin to bring his fever down and hydrate him, drained and flushed the abscess, and waited. Three days later, he was good as new. Since then, I have stopped treating cats with these abscesses with antibiotics. They get well just as fast in my experience. (The same is true with horses and strangles - an abscessation of the lymph nodes in the neck - once open and draining, antibiotics are no longer used because they select for resistant bacteria while adding nothing to treatment). I'm not using my n=1 case of Boo to back this up, but thoughtful, careful research on abscesses, how they form, and the like.

2) Pancreatitis: as discussed in my last post, pancreatitis has historically been treated (in dogs) with antibiotics. Recent literature has demonstrated that >95% of pancreatitis cases are inflammatory but not infectious. Thus, antibiotics do not help with recovery. I no longer treat my uncomplicated pancreatitis cases with antibiotics. If they develop abdominal effusion (fluid in the abdomen) or other signs of systemic disease, they are started on broad spectrum antibiotics. Cats are different. They have shown to often have a bacterial infection related to pancreatitis, and if pancreatitis is suspected, they should be on specific antibiotics.

3) GI surgery: this is a knee-jerk reaction of veterinarians, as well. If we have to cut into the stomach or small intestines, antibiotics MUST be warranted for at least a week, right? WRONG. In a patient undergoing GI surgery, as long as no peritonitis (inflammation of the abdominal cavity, usually manifested by free fluid in the abdomen) is present prior to surgery, antibiotics should only be used peri-operatively - meaning at induction of anesthesia and 90 minutes into surgery. Afterwards, they should be discontinued. If they are used, and the patient has a failure of the surgical site after surgery (the sutures come loose and start leaking), inappropriate antibiotic administration can mask the signs of sepsis until the patient is severely compromised. I learned this recently at a conference, as well as at the specialty/referral hospital where I sometimes do relief work. I was shocked, but as I thought through it and did some reading, I came to realize that it makes sense.

4) Cats between 1-10 years with bloody urine/straining: it is very rare for a cat between the ages of 1 and 10 years old to have a true urinary tract infection. It is much more common for them to have a condition called FLUTD/idiopathic cystitis. This condition, like pancreatitis, is not infectious but inflammatory. Antibiotics often appear to help, as the condition naturally runs its course in 3-5 days. Thus, for many years, antibiotics were prescribed. It is realized now that this condition is extremely rarely bacterial in nature (unless the cat is older than 10 years) and antibiotics are not warranted. If your veterinarian suspects a UTI, a culture - either in-house or sent out to a laboratory - to confirm this should be submitted. This will identify if bacteria are present, WHAT bacteria are present, and WHICH antibiotic should be used.

5) Vomiting and diarrhea: many owners come in with a dog that has vomiting and diarrhea. They decline all tests (bloodwork, xrays, etc). The veterinarian tries to cover all bases and prescribes a round of antibiotics - frequently Clavamox (amoxicillin that has special anti-bacterial properties). The problem with this? So many v/d cases are not bacterial in nature. They are often related to getting into the trash, eating a toy and having it stuck, or just run-of-the-mill gastroenteritis. Antibiotics are not warranted in any of those cases. Time, anti-emetic therapy, SQ fluids, and nursing will usually help these diseases run their course (an exception to this is metronidazole. Metronidazole is an antibiotic with unique anti-inflammatory properties in the large intestine. As a result, it can help significantly with diarrhea. The dose for this is much, much lower than the antibiotic dose at 7.5mg/kg.)

6) Trauma: I cannot tell you how many patients I've seen on antibiotics that were just hit-by-a-car and have only the most minor road rash or skin abrasions. Again, it's a knee-jerk reaction with little basis. How many times have you scraped yourself on concrete, barked your shin, or cut yourself in the kitchen? How many times were you on antibiotics for that? Trauma alone is not an indication for antibiotics unless severe or contaminated lacerations are present.

7) HGE (hemorrhagic gastroenteritis): this condition is also not likely bacterial in nature. I do tend to put my cases on the low-dose/anti-inflammatory metronidazole dose to help with the large intestine inflammation (7.5mg/kg), but otherwise - fluid therapy is the mainstay of treatment.

8) Kennel cough/Bordatella of dogs and feline upper respiratory tract infection: these are common respiratory diseases of cats and dogs that are almost always caused by viral infections. Antibiotics are very rarely warranted, and I never use them. Dogs usually respond well to rest and an anti-tussive such as butorphanol. Cats do well with home nebulization, warmed, foul-smelling, wet cat foods (when cats can't smell, they can't identify food), and SQ fluids to help maintain hydration. In rare cases, these upper respiratory tract infections can move into the lungs and cause pneumonia, at which point, antibiotics are ABSOLUTELY indicated - but as I said, this is rare. Cats can be a little tricky in that some can develop chronic upper respiratory tract infection that does respond to a short-course of antibiotics and steroids, but this shouldn't be the default treatment. In my limited experience, some small kittens with URT infection respond well to Clavamox, too. This might be because they are young, have incompetent immune systems, and have secondary bacterial infections too.

So, there you have some common conditions that are frequently, inappropriately treated with antibiotics. Remember, antibiotics are not benign - they can cause GI upset with vomiting, diarrhea, and appetite loss, and some have been linked to pancreatitis (such as sulfa drugs). On top of that, over-use has lead to antibiotic resistance, a very serious problem for MDs and veterinarians alike.

The moral of the story: think carefully before you accept antibiotics from your veterinarian. Read up on the condition that your pet has been diagnosed with, make sure you are familiar with the indications for antibiotic therapy. Veterinarians and veterinary students: really ask yourself if antibiotics are warranted, or if they are making you (and the owner) feel better. We live in a litigious society. We are frequently faced with clients that tie our hands diagnostically and therapeutically. Still, we are the guardians of both animal AND human health, so we have a strong responsibility to be responsible with the medications we have. I remind myself of that every day.

The controversy of pancreatitis

Chances are that some of you readers out there have had a pet diagnosed with pancreatitis in the past. Typically, the initial clinical signs are a combination of lethargy, vomiting, diarrhea with or without blood, and loss of appetite. Outward signs of pain (groaning, difficulty resting comfortably, and frequent stretching of the hind or forelimbs) are also possible. Your veterinarian may have diagnosed pancreatitis and either sent you home with antibiotics and GI protectants or recommended hospitalization for your pet. Your pet likely recovered, although some cases take a turn for the worse. This is the usual arc of a "pancreatitis" case - lasting anywhere from 48 hours to a week or more. So, what's the real story?

That's the trouble. The "real" story is much, much more complicated.

Pancreatitis is a simple word - pancrea: referring to the pancreas and itis: referring to inflammation. Simply put, pancreatitis means an inflamed pancreas. The pancreas is a crucial organ that lies snugly along the greater curvature of the stomach and along the upper duodenum. It secretes many enzymes that are crucial for food digestion. Without a properly functioning pancreas, dogs, cats, and people cannot digest their food, develop diarrhea, and lose significant amounts of weight (a disease called pancreatic insufficiency). Your pancreas can also be the enemy, as when it becomes extremely inflamed, starts leaking digestive enzymes, and then starts to digest itself and nearby fat (the mesentery that cushions and nourishes the small intestines).

No one really knows what triggers pancreatitis. For many years, it has been associated with dietary indiscretion in dogs - Fluffy got into the trash, or Fluffy was fed a giant, bloody ribeye, or a large, greasy meal from McDonald's. There is also thought to be a hereditary component in Schnauzers, as they are particularly prone to this disease. No direct, causal link has ever been established to prove that these things cause pancreatitis, but we do see many dogs that have gone dumpster diving or been fed possibly offensive foods with suspected pancreatitis. Medications have also been implicated including the diuretic furosemide (Lasix), the immunosuppressant drug azathioprine, sulfa antibiotics, and others. Steroids are a controversial possible cause.

For whatever reason, the pancreas becomes very inflamed. This happens because the digestive enzymes, which are normally secreted into the intestines before activation, become activated within the pancreas and start to autodigest it. As a result, significant inflammation of the pancreas begins. The inflamed pancreas pushes on the stomach and small intestine, causing pain both by the pressure and due to autodigestion. Furthermore, nausea and vomiting occur, followed by diarrhea as a result of the dysfunctional organ.

Many patients present lethargic, with a fever (although fever is not always present), vomiting, diarrhea, and abdominal pain. They are often dehydrated from vomiting and diarrhea. Some present in septic shock, as pancreatitis can be very severe and even life-threatening.

The trick is diagnosing pancreatitis and distinguishing it from other diseases. This might seem like it should be very simple. It is however, the crux of our problem. Pancreatitis is an elusive disease to diagnose with any surety. Therefore, it is often over-diagnosed. Many dogs with vomiting and diarrhea have gastroenteritis, GI foreign bodies, dietary indiscretion unrelated to pancreatitis, or cancer, yet pancreatitis is frequently the diagnosis. It has become a catch-all term for vomiting and diarrhea and seems to be one of the most over-diagnosed diseases I have seen.

So, how is it diagnosed and why is it so tricky? For years, veterinarians looked at the values of amylase and lipase on a chemistry panel. These are enzymes secreted by the pancreas. The problem is, as it turns out, these enzymes are also secreted by the small intestines, kidneys, and other organs. As a result, where once it was thought that elevated amylase/lipase = pancreatitis, now it is understood that this is not necessarily the case. These values can be elevated in other disease processes, and they can also be NORMAL in dogs that have pancreatitis. Other bloodwork findings are very non-specific to pancreatitis and are not helpful in distinguishing.

A test was recently developed called the cPLi (canine pancreatic lipase immunoassay). This test purportedly measures the lipase that is released from the pancreas only, and not the other organs. As a result, if it is elevated, pancreatitis is present. The problem with this test is that there are many false positives, for a variety of reasons. It is useful in that if the test is negative, pancreatitis can likely be ruled out (although not with 100% confidence). It is a good screening test only. If it is negative, you should probably be looking for other causes of vomiting and diarrhea. If it's positive...well, is it a true positive or a false positive?

There is also a test that can be sent out to measure the level of canine pancreatic enzyme. This is the best test we have at the moment, but it has limitations as well. If your veterinarian is very suspicious of pancreatitis, a spec cPLi should be sent to an outside laboratory to measure the value. These can be more helpful in making a definitive diagnosis. Unfortunately, this test is not available at 3am on a Sunday night to us ER veterinarians. This makes our job in differentiating even more difficult.

Xrays can provide clues, but again, a definitive diagnosis cannot be made from just xrays. In suspected cases of pancreatitis, abdominal xrays should ALWAYS be done to rule out some causes of secondary pancreatitis. Since the pancreas is so closely associated with the stomach and small intestines, insults to these organs can cause secondary pancreatic inflammation. Foreign objects stuck in the intestines can cause this, as can cancer and other such diseases. Xrays of classic pancreatitis usually show a loss of detail in the area of the pancreas, mild upper duodenal dilation, and sometimes a mass like effect in the area of the pancreas (right cranial quadrant). These findings are inconsistent and not very specific, unfortunately.

Where does that leave us? There is ultrasound, which - IN THE RIGHT HANDS - can be a very good indicator of pancreatitis. The problem with this is that the everyday practitioner is usually not good enough at ultrasound to see the pancreas. This includes myself. It is an elusive organ, and unless it is really, really enlarged, I can't usually find it. Thus a specialist (i.e. a radiologist) is usually required for that diagnosis. Again, something many owners cannot afford or that is not available to us ER people in the real world (we have an ultrasound, but I am not comfortable finding the pancreas!).

So, where does that leave us? On the bright side, it might be strictly academic. The most important piece of the puzzle is ruling out OTHER, potentially life-threatening problems such as a foreign body in the intestines or cancer. True pancreatitis should be treated like any severe gastroenteritis. IV fluids should be administered. Perfusing the pancreas is crucial to allow it to heal. Anti-emetics such as Cerenia (maropitant) and Zofran (ondansetron) should be used for nausea/vomiting. Metoclopramide (a drug called Reglan that helps promote intestinal motility and stop vomiting) is currently controversial, as it has some negative effects on blood flow to the pancreas. Pain medications should be used in all cases, as some animals are stoic enough that pain can be very hard to detect. These run the gamut from the more minor opioids such as Buprenex to pure mu-agonists such as morphine, hydromorphone, and fentanyl. Patients should have serial blood glucose, electrolyte, and other parameters monitored to make sure they are not worsening.

In some cases, true pancreatitis can progress rapidly to sepsis, DIC, and acute multi-systemic organ failure. It is crucial to treat these cases early and aggressively. Antibiotics were once thought to be warranted, but it has been realized recently that the vast majority of pancreatitis cases are inflammatory but not infectious. No bacterial or viruses are involved. Thus, antibiotics are no longer recommended. I do not use them in my pancreatitis cases, and I have a very high positive outcome.

So, if your vet diagnoses pancreatitis, what should happen? Full bloodwork (a complete blood count/CBC and chemistry panel including amylase/lipase) should be conducted. A spec cPLi should be submitted to an outside laboratory, your pet should undergo xrays of the abdomen to rule out other possible causes of pancreatitis, and an ultrasound referral should be offered (although many owners do not go this route). Early, aggressive intervention in all but the most stable patients should be undertaken to prevent the disease from worsening. IV fluids, anti-emetics, pain control, +/- antibiotics should be administered, and the patient monitored closely. Feeding should be withheld for a period of time (again - clinician preference) to prevent worsening of vomiting.

In most cases, complete recovery will occur, although some cases can become extremely severe and wind up fatal. This is not the majority of cases, thankfully. Possible triggering causes should be identified and avoided in the future (less table scraps, more dog food). Schnauzers should be monitored closely throughout the course of their lives, as they can have low-grade, chronic pancreatitis with occasional flare-ups of more acute disease. Working closely with your veterinarian in cases of pancreatitis is crucial, as well as being an informed, involved owner. Asking questions, doing research, and following veterinarian recommendations can help your pet enormously!

Sundries

I'm off work and at the moment, I don't feel like doing any veterinary related posts. Sorry I'm being such a slacker.

Expecting a child has had an unexpected side effect. We bought our house about a year and 7 1/2 months ago. It's a nice house, but it was built in 1994, and it has many small things we want to change. Light fixtures are a good example. The house has the typical brass gold light fixtures that are really ugly. We've slowly been replacing them, but we haven't quite finished yet. The bathrooms need to be updated. The kitchen had white appliances and white countertops. We've replaced all the appliances with stainless steel, but the countertops (Formica) still need to go.

Ever since I found out we're having a baby, I've been low grade stressed about getting these small projects done. It feels like this stuff has to be done before the baby comes. I don't know why I feel so rushed - perhaps because I feel like this stuff won't get finished once we have a baby to care for. The spare bathroom needs painting, as well as the spare bedroom.

Ok, I have lists to make.

Pregnancy update

We went to the OB today for an ultrasound. We actually saw the heartbeat which was amazing. I didn't cry, but it was pretty cool. My due date is October 5th give or take 2 days. It works out well because I'm matron of honor in a wedding in late August, and I was afraid I'd have to back out. Thankfully not! Although, being a matron of honor on the beach in Florida in August might be a bit trying at 8 months pregnant!

Food for thought

Today, this comment was left on one of my previous posts (the dog with severe, generalized demodectic mange for the 3rd time):

"I just stumbled across this blog - and while I agree on many points you make, I wonder...is it wise to post commentary on the referring veterinarians? From a business standpoint, it seems like bad form to post your opinion in a public forum like this. What is your practice owner read it? What if one of your referring DVMs read it? Are you comfortable with that even if it means potentially losing your job?"

On top of that, I recently read this post on a fellow veterinarian blogger's website: Professional Disagreement.

It got me to thinking and going back to read my old posts. My blog is anonymous, of course. I don't give specifics about where I live. I realized I had - in the past, so I edited out those details.

All of that is irrelevant to the fact that really, I shouldn't criticize other veterinarians on my blog. There are several reasons. First and foremost, I wasn't there when the patient was initially seen, thus I do not know what physical symptoms were present and which weren't. I remember a recent case that came to me one night. It was a dog that had gotten into rat poison. She'd been seen at her vet that morning for generalized lethargy, but she had no other symptoms. The rDVM drew blood and submitted it for testing. By the time I saw the dog, her breathing was mildly labored, and she had a huge hematoma on her neck. It didn't taken long to figure out rat poison. The owner was furious that the other veterinarian had missed it, but I kept explaining to her that her dog's symptoms had worsened through the day, and many of the symptoms/clues I was seeing (the hematoma, the heavy breathing) likely hadn't been present that morning.

I need to remind myself of that in all cases. As with the recent Demodex case, the owner told me her vet didn't recommend any testing. Was that true? How am I to know? This woman medicates her own pets and thought she knew more than I did about everything because she was a breeder. Isn't it likely that she treats her own veterinarian the same way? Without direct, tangible proof that the veterinarian had done something wrong, who was I to judge?

Sometimes I forget, and my mouth *or rather my hands* get away from me. My blog is extremely cathartic, and I come here to vent about my frustrations. There are things I don't talk about on this blog because they are unprofessional, but sometimes, it gets out anyway. I'm going to work hard not to do this anymore. I'll probably slip up sometimes...but I'm going to work on it anyway. And in my defense, it is rare that I post critique of other veterinarian's case management. I went back and re-read my posts all the way through to the beginning of this job over a year and a half ago, and I only had to edit 5 or 6 of them. I try to maintain professionalism as much as possible, but I am going to try even harder from now on out.

Lots and lots o' blood.

About a month ago, I was presented with an intriguing case. It was 6:30am, and I was soundly asleep in the doctor's bedroom. We'd had an uneventful night in the ER, and I did not expect the last couple hours to be any different. At 6:30am, my technician woke me up to let me know that a patient with bloody diarrhea was waiting to see me. I inwardly rolled my eyes and sighed. 6:30am? Bloody diarrhea? It couldn't wait a mere 1 hour to see the regular veterinarian?

I dragged myself from the dark, cold cocoon of the bedroom to see my patient. Waiting for me was a shepherd mix dog. I bent down to begin my physical exam. Upon rolling up her lip, I was confronted with almost grey, cold gums. I felt her femoral pulses and was startled to feel how weak they were. Her heart rate was thudding along at 150bpm. More worrisome still, frank blood was running out of her rectum. I'm not talking bloody diarrhea, I'm talking straight blood pouring from her.

Summoning my tech, we quickly placed an IV catheter and started bolusing her fluids. Her blood pressure was a measly 60 systolic (normal 100). As the fluids ran, we drew blood from her jugular to look at her blood values. About 15 minutes later, while the blood was running, she vomited on the floor. It was PURE blood.

As I waited for the bloodwork, I quizzed the owner. Was there rat poison in the house? Was the pet receiving steroids or NSAIDs such as Rimadyl or aspirin? Could she have gotten into any medications? The answer to all these questions was a resounding no. This was a responsible foster parent who took excellent care of her pets. At 3:15am that morning, the dog had been fine, baby-gated in the kitchen. We the owner got up at 5:15am, the kitchen was splattered with blood.

My patient responded somewhat to her fluids. Her bloodwork showed a low white blood cell count (all white blood cells), a low platelet count, and a low red blood cell count. Her total protein was also low. The numbers were only moderately decreased, and all of it pointed toward acute onset of severe bleeding. Her clotting times were elevated too. The odd thing was that her PT was elevated less so than her aPTT. That pretty much rules out rat poison, as in rat poisoning cases, the PT goes up first. That left me with maybe DIC (see sidebar), but from what?

I started thawing fresh frozen plasma for the patient, knowing she needed the clotting factors that plasma would provide her. Meanwhile, I told her mother that barring any toxins or medications that the dog had ingested, I was suspicious of peracute hemorrhagic gastroenteritis.

Hemorrhagic gastroenteritis is a poorly understood clinical entity that is seen in dogs frequently. It is characterized by rapid onset of extremely bloody diarrhea, vomiting, lethargy, and severe dehydration. Some cases can be severe enough to be life-threatening in a matter of hours. Or so I had read. I have seen tons of HGE, but I had never actually seen this sudden onset myself. The cause of this disease process (known as HGE) is widely debated but not known. Some veterinarians think E. coli, Clostridium, or Salmonella may be the root cause, but the answer remains unknown.

Fast-forward to my patient. She was discharged to her general practice veterinarian at 8am with a double unit of plasma. Miraculously, she responded to her plasma and fluids and was able to go home that night with no ill effects. Her presentation and bloodwork was not classic for HGE, but in the face of her presentation, I had no real answer for the owner. The good news is that regardless, she responded well to plasma and is alive today. It makes the point that sometimes knowing "the answer" is not the most important thing - sometimes just knowing what to do is enough. My patient lives to fight another day.

(There are other possible differentials for her condition but none of them really fit either, so the real answer remains at large - medication ingestion? toxin? HGE? weird Addisonian crisis? rat poisoning?)

Just call me the Grim Reaper

Saturday night brought a plague of euthanasias.

First through the door was a tiny terrier type dog, about 10 months old. She was outdoors only, had never been to a veterinarian, was unvaccinated, and emaciated. The owners had found her that day with bite marks on her sides. They had cleaned the wounds as best they could, bandaged her chest, and given her aspirin for pain. Several hours later, they found her unable to move, breathing heavily. When she got to us, I unwrapped her chest to find a huge thoracic bite wound. One side of her chest was caved in, and her breathing was extremely labored. Sighing, I knew what the verdict would be. Owners without the finances to vaccinate, spay, or deworm a pet would not have the finances to repair this kind of thoracic trauma. I dispatched the cute little terrier shortly afterwards.

Quick on the heels of that was an 11 year old Great Dane with acute onset of non-productive retching for the last 20 minutes. Great, I thought. A GDV in an ANCIENT Great Dane. After talking to his distraught owners, the decision was made to euthanize him. I cannot fault that decision given the dog's advanced age.

In the midst of that, I was presented with a cat in acute, severe respiratory distress. This kitty was also of an advanced age (15 years old). His lungs sounded like Rice Krispies, making me immediately suspicious of heart failure +/- pleural effusion (fluid around the lungs). I gave him a dose of Lasix to help pull the fluid out of his lungs, then popped him in the oxygen tank. His owner was also financially limited and concerned about the age of her cat. He went to heaven shortly thereafter as well.

Finally, at the end of all this, came an ancient miniature Poodle. She was acutely unable to use her hind limbs at all. Given her age, I was concerned about a spinal tumor of some sort, although an extruded disc pressing on her spinal cord certainly could have caused her signs. I gave her owner the option of referral to the neurologist nearby, but due to finances and (again), her dog's age, euthanasia was the final decision.

You would think all of this would depress me no end, however it didn't. With the exception of the small terrier, the animals were all old and had very grave illnesses. In these cases, it was a privilege to be able to relieve suffering and be with owners as they said good-bye to their pets. It's one reason my job is better than a human MDs. I don't have to stand by often and be party to mindless suffering, I can help alleviate it.

The rest of the night was sprinkled with the usual vomiting, diarrhea, lethargy, bloody urine type cases. Nothing too exciting, no major surgeries. I have to say, I kinda like it that way. Other than very mild bouts of nausea, some tiredness, and mild abdominal cramping, the pregnancy is not making itself too known yet. I go for an OB visit on Friday, at which time I'm supposed to be able to see the heart on U/S. We'll keep you posted!

Addended: Parrots and food - what's the "right" answer?

**My addendum to this post comes after another DVM posted about his Eclectus patient. While I do find that working with your bird on diet for a good fit is the ideal approach, I will add some caveats:

1) I feed my birds a predominantly pelleted diet supplemented with table food. They are in excellent health, have beautiful plumage, and seem generally to be happy/healthy birds. Since this works for us, I adhere to the 80/20 rule (or 70/30) - 80% pellets/20% regular food. This is what is currently touted by avian veterinarians. It changes...

2) Monitoring your pet for signs of ill health are crucial and can be an indicator that the diet is not appropriate: signs include picking and feather destruction, dark colored, brittle feathers, overgrowth or very rapid growth of the beak and nails, and being overweight. A healthy bird in good weight should have an easily palpable keel (the "chest bone" that runs down the middl). There should not be plump, round muscle on the side. The muscle should drop away smoothly. Weighing your bird at least once weekly can alert you quickly to illness, as birds will frequently start to lose weight before any other signs of illness are evident. Here is a good place to look at some average weights for different species. Birds, as people, will fluctuate a few grams in their weight, but a loss of 5% or more of body weight is concerning and should warrant a trip to the veterinarian.

3) Read up about the species you choose to own! It is important to know the particulars of each species and dietary recommendations. As I said before, they vary enormously between species. Research research research!

4) Feather picking is not always a sign of boredom. It can also be the first indicator of illness/poor diet. If your bird begins to pick, a trip to the avian veterinarian for a full check-up is in order. If nothing turns up, a behavioral cause should be sought.

I had a request (thank you, Elizabeth) for a post on parrot nutrition. As many of my readers have wound up here due to my title, which isn't really that descriptive, I thought I would oblige my parrot fans. After all, 3 of them run my life.

The question of diet in parrots is an enormously tricky one. The problem arises in that each type of bird whether it be macaw, caique, or African grey represents a different species of psittacine. Where all dogs are dogs regardless of breed, all parrots are not the same. Even within species (like between the Cockatoos), diet requirements can vary enormously.

For instance, macaws need higher fat diets than other parrots. In the wild, they subsist on largely nut based diets. This is especially true for the larger macaws such as Hyacinths. On the other hand, cockatiels in the wild are seed and crop eaters (and can be quite destructive to crops). Some types of Amazons subsist almost entirely on fruit diets. Lorikeets are nectar-drinking birds and require a nectar diet.

With all the diversity, it is no wonder that parrot diet is such a hot topic of debate. The endless argument between seeds, pellets, and table food is an old one in psittacine aviculture. Many believe that seeds are evil and should never be fed to captive parrots. They have a high fat content, some say "empty calories," and overeating of seeds can contribute to severe liver disease, hardening of the arteries, and countless other health problems.

On the other hand, there are pellets. A formulated, pelleted diet dyed with colors (or not, depending on the brand) that is supposed to be good for every type of bird on the bag. My personal bag of Zupreem has an African grey, a conure, and a Macaw depicted on the front. Many believe that pellets are absolutely the right answer.

What it boils down to is that it is very unlikely that a strictly pelleted diet is good for any species of bird. The food companies have produced a mass market product that is probably aimed at somewhere in the middle of most pet bird species. The fat content is probably not enough for macaws, whereas it might be too much for a cockatiel or a budgie. On that same note, it is highly unlikely that an all seed diet is good for any bird (although budgies, parrotlets, and cockatiels seem to do fine on it).

The answer I think lies in common sense and balance, just as it does for human diets. Moderation in all things. It is important to consider first the lifestyle difference between a captive parrot (very sedentary) and a wild parrot (spending > 80% of the day flying, scavenging, and foraging for food). Captive parrots have food presented to them in a bowl and have access at all times. Wild parrots spend most of the day finding food.

One suggestion to increase your parrots activity level, increase his interest in his surroundings, and encourage natural behaviors is to hide the food. This involves simply wrapping pellets and other food items (seeds, Nutriberries, etc) in newspaper, paper towels, or other easily shredded material, and hiding it around the bird's cage. This stimulates natural foraging instincts, cuts down significantly on self-mutilation due to boredom, and encourages your parrot to work for his food.

The next suggestion is variety, variety, variety. Instead of feeding just pellets or just seeds, a mixture of both, offered at different times throughout the day can keep your parrot interested and healthy. A small bowl of healthy seed "treats" at night can become something to which they look forward (because they will learn and start to expect it!). Safflower seeds, hulled peanuts, almonds, and cashews can all make up this "treat" bowl.

Finally, add "people" food, lots of it. Stay away from the big no-nos such as avocado, chocolate, caffeine, and alcohol (although I will say that with the exception of avocado, my birds have had all of those at one time or another) and choose healthily - dark, leafy greens like kale and broccoli, deep orange and red vegetables, noodles, eggs (cooked only), and the like. It amps up your bird's interest and quality of life if they can eat when you are eating and encourages flock behavior.

What it boils down to is that no one knows the "right" answer to parrot diets, just like no one knows the "right" answer totally to dog, cat, or human diets. Do what works for you and your bird! No 2 birds, even within the same species, are alike. Finding the right balance between pellets, seeds, and table food can be difficult, but it can be done.

Anaphylaxis

Remember this patient? After spending a couple of days at the referral hospital, undergoing numerous diagnostic tests including clotting times and an abdominal ultrasound, no underlying cause for her collapse was found. The presumptive diagnosis was as I had originally thought: anaphylaxis.

It occurred to me a moment ago that everyone might not be exactly familiar with the term or what it means.

Anaphylaxis is an acute, severe allergic reaction. If you've ever known someone with a life-threatening peanut or penicillin allergy, you are probably familiar with its effects. The onset is extremely rapid. A dog is exposed to something to which he is allergic. This could be a food substance, an insect bite, or something as innocuous as grass. In most cases, we never know the trigger. Mast cells and basophils (blood cells) release massive quantities of histamine. Histamine is a nasty substance and it is what ANTI-histamines like Benadryl, Zyrtec, and Allegra combat.

Histamine in large quantities causes the veins of the body to dilate, decreasing return of blood flow to the heart and causing a drop in blood pressure. Also, the small arteries of the body (arterioles) dilate, causing a further drop in blood pressure. Lastly, the smallest vessels in the body (the capillaries) become very permeable, and fluids and proteins move out of the cells and into the tissues of the body. This loss of protein into tissue also worsens the hypotension. Blood pressure plummets, heart rate sky rockets. The patient collapses, often developing diarrhea and vomiting.

The diarrhea and vomiting occur because the shock organ in the dog is the gut. It is the first place to suffer severe damage from decreased blood flow/blood pressure. Diarrhea and vomiting result. The diarrhea is often extremely thick and whitish, representing death of the lining of the intestines and sloughing of the cells.

Other substances elicited from the basophils and the mast cells called leukotrienes can cause spasms in the small airways (bronchioles). As a result, rapid, asthma-like symptoms and suffocation can occur.

Death can occur in a matter of minutes if a patient (human or animal) is not treated immediately with epinephrine. Epinephrine opposes the effects of histamine rapidly.

A dog that has suffered anaphylaxis usually presents very classically. They were totally normal, went outside, came back in, vomited, collapsed, and began to have labored breathing and/or diarrhea. Most dogs present in shock, but it is usually rapidly reversible with epinephrine and IV fluids to restore blood pressure.

As in the case of the unfortunate patient above, I believe if the owners had found her 10 minutes later, she would have been dead. Thankfully, she lives to fight another day!

Why I do ER medicine

The question of why I do ER medicine was brought up in one of my recent, frustration venting posts. So, I will attempt to answer that here.

First and foremost, I really do love the challenge that ER medicine presents. Every day, I see cases running the gamut from totally mundane (a broken toenail) to immediately life-threatening (my recent anaphylaxis patient) and everything in between. ER is rarely boring. This couples well with my desire to be challenged, to be forced to think on my feet, multi-task, and stay on top of current medical diagnostics, treatments, and new diseases.

Secondly, I absolutely hate dermatology. Unfortunately, the vast majority of day practice is dermatology. There is no expressing how much I loathed that rotation in school. I loathe it still. The minute that something presents for "itching," I want to run out the back door. We were told as veterinary students that 80% of our cases as GPs would be for skin issues. That in and of itself is enough of a deterrent.

Thirdly, ER medicine has significant benefits including significantly higher pay than my GP counterparts and long stretches of time off.

Does it have its downsides? Oh yes. Angry clients with no money, injured and ill animals that no amount of money and trying can fix, long, long hours, not sleeping in my own bed with my husband several nights a week, and having to answer to referring veterinarians who weren't there and didn't see/treat the patient.

My personal satisfaction with the job currently outweighs my frustrations. Will that always be so? I'm not sure. It's possible that I will always love and stay in ER medicine. It is equally possible that one day, I will move onto something else. Teaching is in my blood. My father, grandmother, grandfather, husband, aunts, uncles, and even cousins are all teachers - so one day, perhaps I will teach, too.

My rule is this: the minute I stop being truly happy doing what I'm doing, it's time to move on - either to a new job, a new career, or a new place. Making that promise to myself keeps me sane.

More on pregnancy

I know ya'll read this blog for veterinary related stuff, but honestly - the baby is taking up all of my spare brain space lately. I laid down to sleep around 3am last night, after watching Center Stage (possibly one of the stupidest, yet most addicting dance movies EVER), and I COULD NOT sleep.

Through my head went everything - finances, stress, lack of sleep, change in schedule, followed by sweet thoughts of a tiny little baby. I keep thinking of it as a her already. My husband scoffs at the idea that I might know already...but hey, I have a 50/50 shot, right?

Everyone at work is sick. One of my technicians has confirmed H1N1 flu, so my OB vaccinated me against it on Tuesday. Hopefully, I wasn't already incubating it! I have been somewhat snotty/congested lately, but I'm told that it's normal to be like that during pregnancy.

So far, no hard-core nausea. Small, brief bouts of it here and there, especially when I don't eat frequently enough - but otherwise, I'm ok. I'm suffering a wee bit of anxiety - because I'm still so early in the pregnancy that I'm worried about miscarrying and that sort of stuff. It's morbid and pointless to worry about, but it's at the back of my mind.

Seems like being at work and busy would be helpful for me at this point, as I'm feeling a bit fragile. The distraction would probably be excellent for me!

Due date

I am 6 weeks along. That puts my due date around the end of Sept/beginning of October. After seeing the ultrasound yesterday at the OB, it has really started to sink in. There are moments when everything seems totally surreal, but I think we're handling it well. It's constantly at the back of my mind, and the thought "I'm pregnant" never really goes out of my head. It has driven all veterinary related posts to the back of my brain, though. That, and I saw exactly ZERO patients last night. Talk about a slow winter!