Xylitol and its associated nastiness

Many of you pet owners out there have probably peripherally heard that xylitol, a sugar substitute, can be deadly to dogs. Xylitol is an interesting compound. It is a sugar alcohol that has numerous benefits. The first and most important is that it doesn't stimulate the release of insulin in humas. Thus, it is a good "sugar" for diabetics. It also has benefits in the dental world ("tooth friendly sugar").

So, why is it bad in dogs? Sounds like a safe sugar for them to consume, right? Well, as I frequently have to remind my clients, dogs and cats are not people. The metabolism of the canine body is not the same. For some reason that we don't understand well, xylitol causes massive insulin release in the dog. When this occurs, the blood sugar (glucose) drops precipitously leading to seizures, coma, and death.

Additionally, in some dogs, for reasons we REALLY don't understand, xylitol causes terrible liver damage (hepatic necrosis). As a result, these dogs go into liver failure, complete with vomiting, diarrhea, lethargy, jaundice, abdominal pain, and clotting problems (since most of your clotting factors are made in the liver). Electrolyte imbalances can also occur, as a spike in insulin can lead to low blood potassium. This is because one of insulin's functions is to "push" potassium into cells.

So, when an owner calls and tells us that the family dog has just ingested sugarless gum flavored with xylitol, we rush the pet in. Inducing vomiting is a mainstay of treating this toxicity. Interestingly enough, gum in particular can hang around in the stomach for days. I read about a case recently in which a dog ingested a massive amount of gum. The dog was in the hospital for 4 days with a blood glucose that would not stay stable without supplementation. On the fourth day, the dog suddenly vomited up a huge, huge wad of gum! It recovered soon after.

Usually, inducing vomiting is only helpful in the first 1-1.5 hours, but in this case, we do it regardless. Once that is finished, the patient's blood glucose is checked, as well as liver values and clotting times. Depending on how much was ingested, I usually recommend hospitalization for at least 24 hours to monitor blood glucose and liver enzymes.

Activated charcoal is commonly used in dogs that have ingested something toxic. It coats the stomach and prevents absorption of toxins. There is a great deal of debate as to whether this works with xylitol at all. There is no evidence that it hurts (other than it can cause extremely high blood sodium levels, so it should be used with care), so I generally administer it.

So far, I haven't seen a particularly nasty case, but I've read about and been tangentially involved with a couple of liver failures. They are very, very bad, but dogs can survive this. The liver is an amazing organ, capable of significant regeneration.

Sugars/sweeteners that are not toxic include sorbitol, sucrose, and aspartame. Still, you should probably avoid giving your dog (and cats) sugary treats. Xylitol is not known to cause the same syndrome in cats.

Devastation back home

The tornadoes hit my home county pretty hard. Luckily, my parents and in-laws came through relatively unscathed. The flashing on my parents' house was peeled off, and the neighbors shed is now residing in the front yard (after being thrown there), but no one was injured! My in-laws fared even better. Unfortunately, there are 10+ dead in the county, which is unheard of. Greene County is in the foothills of the Appalachians. It's a hilly, rugged place, and tornadoes just aren't the norm!

Read the story here.

My friends in Chattanooga also all came through unscathed, thankfully.

The storm hit us about 5am this morning, but I think its fury was spent prior to arriving here.

Adjustments

An anonymous blogger asked me to comment on any adjustments I've had to make at work. Honestly, at the moment, there have been practically zero. My techs take all the xrays, so I haven't had to set foot in there since announcing my pregnancy. We are progressive about anesthesia in that we don't box or mask animals down. I'm careful in anesthesia to not be around the patients when they are recovering, which is when the most dangerous of the sevoflurane is exhaled.

So far, the schedule has not been too difficult/challenging. The hardest part has been my non-stop insomnia. For the past 2 weeks, I have been unable to sleep for more than 1-2 hours at a time. I wake up after this time period and just lie in bed. I'm not stressing about the baby or how much there is to do, but the insomnia just seems to worsen. It's very frustrating. Sometimes I have to work when I haven't been sleeping at all.

As you can imagine, this makes me not the super friendliest person in the world. I'm not nasty or mean, just quiet and uninvolved in what is occurring around me.
I guess this makes me seem standoffish or aloof, but it really has nothing to do with work. It's just me, tired and hormonal.

Other than this insomnia, my pregnancy is going well. Work adjustments have been minuscule so far. I guess we'll see how it is once my belly is too big for me to reach the surgery table...

How not to win friends and influence people

I'm not an easy person to get along with, and I never have been. Sometime several years ago, I accepted this fact about myself and moved on. When I started my internship, it took me a bit to figure out that I was in a position of authority (although at an internship, that is debatable). Since then, I frequently remind myself that I am "the boss" at work, even if I don't feel like it. My goal at work is not to be friends with people but to make sure the work gets done, that our work environment is professional, and that we provide excellent customer service. This often makes me unpopular. For the most part, I don't really care about my popularity. I am who I am, I have high expectations of myself and those who work with me, and I expect people to come to work with a strong work ethic.

This morning my hormones got the better of me. I've worked really hard to learn NOT to say things out loud that I'm thinking. When someone goes on and on about their allergies, pneumonia, and bronchitis while smoking the fifteenth cigarette of the day, I DO NOT point out the logical fallacy, for instance - no matter how much I'm dying to do so. Apparently, this morning my filter was turned off.

I was coughing and sneezing, as I am wont to do these days - a combination of allergies (raging) and rhinitis of pregnancy (a condition I was previously unaware of). Someone said to me, "Dr Blank, you'd better not get me sick."

For a moment, I was quiet. Then I said, "I hate when people say that. First off, I'm not sick. Second off, I would never deliberately make anyone else sick. And lastly, if I WAS sick, I'd still have to come to work, as we're not really able to call in."

That reply did not make me popular. In fact, the commenter flew off the handle at me. I didn't think it was that bad of a comment. Apparently, I was wrong.

Why can't I just keep my mouth shut?

How not to break up a dog fight

This past weekend, I was presented with a 3 year old Boston Terrier named Penny. Outwardly, she looked just fine. Her owner however, relayed that Penny had had 2 seizures in the past hour. Penny had no history of seizures, so this was a new development. When I delved into the history, it got interesting.

Apparently, Penny had been picked up by her housemate (a larger dog) and slung roughly to the ground by her neck. The owners were unable to break up the fight, so the male owner put HIS FOOT on Penny's head to hold her down. After they were able to peel the other dog off of Penny, she laid there, sluggish and poorly responsive. Slowly, she came around. Shortly afterwards, she had a 30 second, tonic-clonic ("grand mal") seizure. She recovered quickly, but then had another about 20 minutes later.

Her physical exam was normal, and Penny seemed alert and responsive. Still, I recommended we treat her for traumatic brain injury with mannitol, oxygen, and monitoring. The owner elected to proceed with that.

We sent Penny home the next morning having had no more seizures. Yet, she had another about 1 hour after getting home. We re-admitted her to the hospital and started phenobarbital for the short-term (a week or so) to see if this would get her over the brain injury. The owner declined follow up with a neurologist to determine if there was anything intracranial that we should be seriously worried about. Other than the seizures, Penny was acting like a normal dog.

Moral of the story? Standing on your dog's head to break up a fight might not be the BEST idea ever.

Interesting veterinary reading

While I make it a policy not to get riled up by stuff I read on the internet, see on the news, or generally hear from any media outlet, this article almost made my blood boil:

http://www.yumasun.com/opinion/chickens-67648-horses-cows.html

Thankfully, a local veterinarian wrote a thoughtful rebuttal. Still, this article explains the mentality of many people I see...

http://www.yumasun.com/opinion/yuma-69331-care-ford.html

Bad blogger

My apologies against for the sparsity of my presence this week. Work has been dreadfully, dreadfully slow. I am starting to really fear for our solvency in this economic climate. To keep the lights on, the technicians employed, and drugs stocked on the shelves, we must average around $2000/night during the week and $20,000 for the weekend. When I left work about an hour ago, we had barely made $7000 this weekend. Dismal doesn't even describe this. Of course, I work on production, so this is affecting me and my salary as well. With the baby on the way, it's very stressful. The bright light at the end of the tunnel is that my husband will soon be employable. That and we'd already gotten a good start on our emergency savings fund prior to Eva's conception, so we theoretically have enough to get us through my maternity leave with room to spare. Couple that with a lack of car payments and no credit card debt, and it's not that we're struggling. It's just stressful at this time! Also, my SUV is acting funny and is out of commission while my husband works on it.

I wish I had something veterinary related to talk about, but I haven't really seen any interesting cases this weekend. I'll try to come up with something interesting to talk about! I won't let ya'll down forever!

Sorry that I've been inexplicably AWOL

We went to Knoxville for the past 2 days so that my husband could meet his thesis advisor to discuss defending (this summer/early fall - YEAH), and I tagged along so I could see my BFF and Jim's brother. It was a nice 2 day mini-vacation. My mom drove up and spent the day with me, which was lovely. We went and saw Jane Eyre, which - for whatever reason - is not playing in our BIG city! We also went clothes shopping for light summer dresses that I can live in while I get big and had lunch.

In veterinary news, my blog was featured on this website. I was very, very excited about this news.

http://www.rncentral.com/nursing-library/careplans/50-Best-Blogs-for-Veterinary-Students

More veterinary stuff to come soon, I promise. This weekend, I am working the day shift, so I should have something to talk about.

It's a girl!

We had the anatomy ultrasound today. For some reason, the OB scheduled it a bit earlier than normal (16 weeks when usually it is 18-20 weeks). Everything looked normal and healthy, although I found out that I have a huge fibroid tumor in my uterus. Not shocking, since they run in the family. The OB did not seem concerned about it crowding the baby, though. Interestingly enough, I saw it myself this morning at work when ultrasounding the baby. I just wasn't sure what it was. I'm proud that I noticed something abnormal though!

So, it is a girl, as I suspected. Evaline (Eva) Catherine will be her name. We're tossing around Evaline Robin too, after Jim's grandmother and my mother. Mostly because I think that naming your kids after yourself is kinda narcissistic. Jim does not agree. So, we'll see. Eva is pretty set in stone, at least.

In other small critter news, our first kitten of the season is thriving. He is fat as a tick and sincerely confused as to his species (or ours). He thinks either that he is a small, furry person or that we are large, hairless cats. Ah, the downside of bottle-raising singleton kittens. Alas, I could not find him a buddy. He will need a home soon though!

Spring is in the air...and in the flesh, too *Warning: Graphic Post*

Last night, I got to see one of my least favorite things as a veterinarian...and that's saying a lot! There are tons of things I hate to see. This was a case of neglect, but it was difficult to tell how to classify it. The owners certainly loved their pet and were devastated by her condition. On the other hand, this condition had been present for several days.

Around 9pm, we were presented with a laterally recumbent English sheep dog. She was breathing rapidly, barely responsive, and her temperature was 105 degrees. Her heart thudded along at 200 beats per minute (normal 100-120). Her gums were injected and dry. Attending her was a smell that I am all to familiar with (as are all my technicians). The smell of an open dumpster in the dead of July.

She'd been down and unable to rise for an unknown number of days. The owners claimed she was normal until that day, but we knew better. Her rear end was caked with fecal matter, her vulva was swollen and matted, and she was splinting her abdomen as hard as if she was trying to push out a baby (she was spayed). She was in agony. Maggots were caked around her rear end. There weren't enough there to explain the smell, and her bad condition. So, we shaved her and found the problem.

On her back, directly above her tail, were two gaping holes. The tissue was dead, and there was a clearly demarcated area extending halfway up her back of totally dead skin. There were thousands and thousands of maggots in these holes. A seething, boiling mass of maggots. Thousands upon thousands, ranging in size from 1cm to 2 inches (days old).

Her owner was stunned. "But I pet her back there!" he said. "I never felt anything." My skin crawled (pun not intended) at the thought, but I tried as gently as possible to explain to him that his dog was likely septic, was dying in front of us, and unless he had several thousands of dollars and weeks to invest in healing - with a 50/50 prognosis AT BEST - then he needed to euthanize his dog. Privately, I thought the dog's chances (given that she was trying to die in front of us), were way less than 50%.

After much discussion, the owner decided - wisely - to let her go. I tried to explain to him how vulnerable dogs are to maggots in the spring, especially if they get down but can't get up. Lying in feces and urine is a magnet for these disgusting little buggers. It's unfortunately something we see a fair amount of in the summer.

Wowza

My pregnancy has been relatively smooth sailing until this point - no real bumps to complain about. That ended last night. Back when I was in my early 20s, I started to have panic attacks. These were mind-numbing, wipe my brain clean of logic, meltdowns. Over the years, I learned to control them without medical intervention - a combination of deep-breathing, hot baths, distractions, etc. I haven't had a real panic attack again since early in vet school. I thought they were a thing of the past.

Last night, I went to bed around 3:45am (the usual when I have to work, as I am in this weekend starting Friday). I laid down and felt fine. Closed my eyes, drifted off to sleep fairly quickly (within minutes). About 40 minutes later, I shot out of bed, wide awake, a worm of panic burrowing into my chest. Calming myself, I got out of bed, stepped outside for some fresh air, watched some TV. Within about 30 minutes, it felt under control. So I laid back down, drifted off. 45 minutes later, the same - only this time the panic was worse. So, I got up again and did the routine - including a hot soak in the tub, more TV, and the like.

Sometimes my panic attacks wouldn't subside until the sun came up. So, I laid on the couch, patiently waiting for the sun. Once it was up, I curled up in bed with no concerns. 45 minutes later, I was awake, panic threading through my chest like a snake. I rose, starting to feel the flutters of uncontrollable panic. Shortly afterwards, the tears came - and I cried hysterically for about 20 minutes.

This continued through 1:00pm this afternoon, and I had been up for now 24 hours. My hysteria and depression mounted, and I cried constantly between attempting to sleep. Each time, the period of "sleep" was shorter. It was now lasting 20 minutes, before I snapped awake, oriented and panicked.

I finally succumbed and called the doctor/midwife. The sense of panic and despair was becoming overwhelming, and I was starting to fear that something was very, very wrong with me. None of my usual tricks for controlling panic were effective. I had tried them all. I'd even called my mom at the ungodly hour of 8:30am (knowing she would not be up).

After talking to the midwife at length, she gave me a prescription for Ambien to help me sleep. There are no good, safe anti-anxiety medications during pregnancy, so she could not give me anything to help cope with that. However, I knew that just getting some sound sleep would help break the cycle of panic. I was loathe - absolutely LOATHE - to take the Ambien. The thought of any medication affecting the baby worries me terribly. On the other hand, I HAVE to work this weekend - there's no option, since our other doctor is out of town. As a result, some sleep is an absolute must.

She also listened to the baby's heartbeat with the fetal monitor, and everything sounded normal. My blood pressure was 110/70, when it usually runs 95/60 - so a little stress was obviously compounding the panic. The Ambien is not for daily or even weekly usage. It's for desperate situations, which I currently found myself in. With serious trepidation, I took the pill.

Thank God, I was able to sleep from about 4pm-11pm. The panic is gone now, and I am more tired than anything. Hopefully, sleep will not again elude me tonight. I did not enjoy the feeling of the Ambien in my body - I was confused. When I tried to walk (to the bathroom), I was ataxic, almost as if drunk. It was not a pleasant, fuzzy, sleepy feeling (like Benadryl). It is not something that I plan on taking again unless absolutely necessary, it distresses me to have to put anything in my body that baby gets as well.

Ah, hopefully this will not be a repeat performance. We'll see.

Fun parts of being pregnant

So, there are all kinds of little "perks" to being pregnant. I say "perks" because they are anything but. I've always been a bit moody, this is true. It's definitely worsened by the pregnancy though. Today, we went to get groceries at Target. Since we were already there, we took a spin down the baby aisle. It was very exciting to look at bassinets and cribs. Then we got in line. We managed to get behind a (surprisingly calm-looking) mother of 4, including a tiny newborn. Said newborn's face was all scrunched up, and he was wailing as if the world was ending. I kid you not when I say that my eyes actually welled up with tears. I HATE crying, especially!!!! in public!!! Luckily, I was able to bite the inside of my cheek really hard and stop the tears from flowing. Yet still, every time I think back on that little baby's pitiful wails, I could cry again!

Last night, my husband and I got into an argument about our dog. I have legitimate feelings I was trying to express, but it quickly degenerated into me losing it entirely and screaming/crying at him. It was not my calmest moment.

At work, my fuse seems to be shorter. That may have to do with how sluggish we've been. We were busy all weekend, but despite the physical exhaustion, mentally, I felt good. My techs might disagree with this assessment.

Overall, I feel like I am fairly level, but my husband may disagree with this, as well. Physically, I feel good - so that's definitely on the plus side of things!

Happy old cat

Last weekend, I was presented with a 17 year old, female spayed kitty. She weighed in at a whopping 4.7 pounds! Her coat was greasy and unkempt. Her heart rate was very high. Worse, she was extremely ataxic (staggering) and unable to lift her head. Her head pointed straight at the ground, and she could not lift it.

Previously, this thin kitty (Ms Kitty) was diagnosed with hyperthyroidism. This is a fairly common condition in older cats in which the thyroid gland becomes overactive. As a result, excessive amounts of thyroid hormone are produced in the body. This causes a sharp increase in metabolism - leading to a cat with a sky-high metabolism: ravenous appetite but constant weight loss (due to the extremely high demands of the body for energy). The heart rate speeds up - sometimes to 250-300 beats per minute. As a result, the heart muscle thickens significantly, and the cat develops a secondary heart problem (hypertrophic cardiomyopathy). It's a very treatable condition - either with oral medications to down regulate the thyroid hormone, surgery to remove the thyroid glands, or radiation therapy to the glands to destroy them.

This cat was diagnosed with hyperthyroidism a year ago. She'd been on medications for a while, but the owner had stopped due to the side effects. She was supposed to see her veterinarian and start them back 4 months ago. She never did. Now, I was staring at the typical emaciated, weak hyperthyroid cat. She was worse than the usual though.

"Thyroid storm" is a well-described condition in humans. The thyroid hormones can spike and bring on an extremely high heart rate, a high body temperature (again, due to the high metabolic rate), increased respiratory rate, irregular behavior (aggression, hyperactivity), and weakness. Until recently, this condition was not really described in animals. It was then realized that this may indeed happen in animals - especially old cats with uncontrolled thyroid disease.

The syndrome is described as causing profound weakness, ataxia, cervical ventroflexion (inability to hold the head/neck up), high heart rate, respiratory distress, and changes in behavior (in cats). So...I was faced with a kitty possibly having a thyroid storm. On the other hand, cervical ventroflexion and weakness can arise secondary to changes in electrolyte status - specifically low potassium. Ms Kitty's potassium was indeed low. On the OTHER hand, hypokalemia can occur with hyperthyroidism...so - was it related to the thyroid problem? Was she hypokalemic for some other reason? Her urine was dilute, although her kidney values were normal, so I also suspected early renal insufficiency. There were many pieces to this puzzle, and I couldn't make them all fit.

So, I was left guessing. The test for hyperthyroidism must be sent to an outside laboratory. There is nothing I could do in-house to confirm my suspicion. I was left with treating the kitty with an anti-thyroid medication, potassium supplementation in her fluids, a beta blocker to slow down her heart rate some (as well as to interfere with the body's usage of all that extra thyroid hormone), and CROSSING MY FINGERS that I was doing the right thing.

When she left on Monday morning, she was purring, eating, and soliciting attention. Her potassium was in the normal range, finally. Hopefully, her owner will take her thyroid disease seriously, and she will live a few more happy, healthy kitty years.

Miracles can happen, folks

First off, this was a great weekend. We were busy, clients were compliant, and we were able to do good medicine. Further, we saved a patient that had absolutely no business living - none whatsoever.

On Saturday night, we were presented with an older cat in severe respiratory distress. As Alyssa the cat sat there, her abdomen puffed in and out as she tried to breathe. She was demonstrating a "restrictive" breathing pattern, indicating to the naked eye that she had something in her chest, compressing her lungs. Given her age, I suspected heart failure and pleural effusion (fluid around her lungs). We gave her a dose of Lasix (a diuretic) to promote urination (although this arguably does not help with pleural effusion) and a mild sedative of fentanyl and midazolam. We placed her in oxygen and waited. Trying intervention with this cat would have likely lead to her death. After about 20 minutes, she seemed improved. We took her to xray (a mistake, I later decided) for a quick snap of her chest. Really, what I should have done was tapped her chest to remove the fluid. At any rate, she did fine with the xray, we placed her back in oxygen, and then she died.

Her gums turned blue, she stopped breathing, and her heart rate dropped to 20. We snatched her out of the cage, intubated her, and started breathing for her. Bloody fluid from her lungs (pulmonary edema) came frothing out of the tube. Her pupils became fixed and dilated. She lost all responsiveness to us. She was a dead cat other than a slow heartbeat. The owner was there for this, and she begged us to do everything and not to give up on her cat. Privately, I thought this was insanity. The cat was dead for pete's sake, but we went at it with the fervor of the optimistic.

We gave her atropine and epinephrine to stimulate her heart beat, we manually ventilated her to supply her brain with oxygen. I grabbed 2 large bore chest tubes and punched them through into her chest cavity, removing 1/4th of a liter of fluid from around Alyssa's lungs. The owner was standing by for all of this, alternately praying and asking questions - which I mostly ignored.
She wanted us to do anything, and she didn't want us to give up, no matter what. I'll admit, I thought the cat was a goner, but we persevered.

After 30 minutes of emptying her chest, breathing for her, administering drugs to stimulate her heart, careful fluids to get her blood pressure up some, and hoping, Alyssa amazingly began to breathe on her own! Her pupils remained fixed and dilated, but she was breathing. I still thought there was no way this cat could possibly pull through, but at the owners request, we continued.

After an hour of supplemental manual ventilation, 2 chest tubes, and a polypharmacy of drugs, the cat was breathing steadily and normally on her own. The bloody froth from her lungs had stopped. She was still absolutely neurologically absent, but she was breathing, her heart rate was normal, and her blood pressure was hanging close enough to normal for me.

We moved her to the oxygen cage (still intubated) and waited for her to die. I told the owner the chances of this cat surviving were last than 5%. 2 hours later, we pulled her endotracheal tube and moved her to a sternal position. Her pupils were still fixed and dilated, but she began to make noises - muted meows.

3 hours later, she was able to hold herself upright and meow, although she was blind. 8 hours later, she was visual again. Her respiratory rate was almost normal, and her breathing was no longer labored. I started her on pimobendan (the cardiac wonder drug of dogs, while tested extensively in them, has never been tested in cats - but many cardiologists are recommending trying it). We continued her Lasix to remove any pulmonary edema and started enalapril.

After 12 hours, we removed her chest tubes due to discomfort and the likelihood that we would not need them again (heart failure fluid tends to accumulate very slowly).

This morning, when I sent her to the cardiologist for her echocardiogram, she was a "normal" cat - eating, drinking, meowing, and soliciting head rubs in the oxygen cage. She was 100% neurologically normal, no residual effects from her near death experience. If you saw this cat on the street, you'd think nothing was wrong with her (well, other than her shaved chest and stitches from her chest tubes).

It's rare that I can look at an animal and say that I saved it for sure. In this case, if we hadn't intervened, the cat would have undoubtedly died. My team did an excellent job getting this cat back - unparalleled in my 3 years of experience. It was one of the most satisfying experiences of my veterinary career thus far.

On top of that, we had a cat with a pyothorax ("pus chest") - and the owner elected to treat instead of euthanasia. We saved a kitty that was dying from severe electrolyte imbalances and sent her home a happy, healthier, eating kitty. We took a 2 year old parvo dog with a 106 temperature and turned him into an eating, tail wagging machine. It was a great, great weekend with many successes to make it memorable. It restored my faith in my ability to love my job.

What is wrong with people?

This case was particularly heartbreaking and tragic. It took me 3 hours to figure out what was going on with the patient, and by then, it was too late. It was likely too late from the moment the dog walked (or rather, was carried) through our doors.

She was presented to me, a 27 pound, morbidly obese small breed dog named "Small Fry". Her history was odd. Her owner had let her outside before leaving for lunch. It was 80 degrees today, and she was a brachycephalic breed (like Pugs, Boston terriers, Shih-Tzus, and bulldogs) with a weight problem. That was a recipe for a heat stroke. At any rate, the owner - a small, frail, elderly woman - was gone for an hour. When she came home, the dog was in the house, let inside by the workers that were fixing the siding on the house. The owner was concerned that "Small Fry" had either suffered a heat stroke or that someone had deliberately hurt her.

She found Small Fry on the floor, extremely lethargic with bloody diarrhea. The owner decided to wait to see if her condition improved. Over the next 4 hours, it deteriorated. So, the owner brought her to us.

Small Fry was extremely lethargic, cold (temperature was 94 degrees!), her blood pressure was too low to read, and her gums were grayish white - all signs of a dog in profound shock. My initial thoughts were a heat stroke, anaphylaxis of some sort, a toxin in the yard, or a pyometra (she was not spayed). My bloodwork did not support any of those suspicions very specifically, so I was left treating aggressively with IV fluids and monitoring.

Over the next 2 hours, her condition would improve with aggressive fluids given IV. As soon as we backed off however, her blood pressure dropped, her heart rate sky-rocketed, and her gum color became grayish again. She also developed a heart murmur. I began to suspect heavily that she was bleeding somewhere internally. But where? And WHY?

At that point, we rolled her onto her back for an abdominal ultrasound and that is when the clue hit us smack in the face. Along her belly were 2 horrific, very large hemorrhagic bruises. There were also scrapes and scratches. It looked like something might have hit her in the abdomen - extremely hard. Xrays confirmed free blood in her abdomen, concentrated on the right side of the body (where the worst bruising was located).

A growing suspicion nagged at me, but I didn't have time to gnaw much at it. Small Fry started to demonstrate signs of impending cardiac arrest. We called the owner, who rushed to be by her side. Moments later, she died. The owner did not want resuscitation, but she did want a post-mortem exam.

We opened her up to find horrific hemorrhage and bruising under the skin, an abdomen full of blood, and a kidney that had been bluntly traumatized. The kidney itself was normal, but it had hemorrhaged severely. There was no tumor, no nothing to explain why the sudden bleeding. Coupled with the presence of the external bruising, it seems all too obvious that a blunt force trauma was applied to the abdomen. It looked - for all the world - like she had taken a kick to the abdomen. A very, very hard kick.

We documented everything with pictures, should the owners decide to proceed with legal action. I am not a pathologist, but I am fairly certain given the external bruising, the bruising in the subcutaneous fat, and the hemoabdomen that this was blunt force trauma. The only likely explanation is that someone kicked this poor little dog. Such a sad case with such a sad outcome.

Amazing

We had a lull at work the other night, and during it, we decided that it would be a good idea to ultrasound the baby. It's weird to be at this stage. I am now 14 weeks along. I've gained weight, and I'm showing - but I can' feel the baby. Every day, I wonder if he/she is ok. The last ultrasound I had was at 6.5 weeks, and the baby looked like a tadpole and/or gummi bear. Thus, I didn't expect much this time. Boy, did I get a shock! Our baby has hands and feet and is moving! We watched him move around for 5 minutes on the ultrasound. He was very active. At one point, it looked like he was contentedly sucking his thumb. (I have no idea why I've taken to referring to the baby as a he...I'm no ultrasonographer, so I certainly couldn't tell.)

Seeing that for the first time caused indescribable feelings - fierce protectiveness, love, awe, and excitement would be some words that might come close. Really, it was a feeling of being full till near bursting. The techs commented on my chipper mood for the rest of the night.

Incidentally, we've picked out names: for a girl, Evaline Catherine (with plans to call her Eva after my husband's grandmother), and for a boy, Lane Russell (after my grandfather, and my husband's mother's maiden name). We're pretty happy with those, and likely to stick with them...but things could always change.

Really??

There is a clinic in our area that hates us. I'm not sure why, but they refuse to refer their patients to us for overnight care, instead choosing to send them to the farther away specialty clinic. SO, when we received a call from them a few days ago, letting us know they were transferring us a blocked cat, I went on high alert. The receptionist casually mentioned to our receptionist that they'd contacted "big specialty referral clinic" - but the owner wasn't going there. No mention was made of why, but I knew immediately this would be a money problem.

The owner showed up shortly thereafter with a laterally recumbent, shocky cat (body temperature was 93 degrees, heart rate was 120 beats per minute - normal being 180-200), and NO WALLET. He had no ID (required to fill out paperwork to ensure against identity theft), no finances, and no way of getting any. His cat was in extremely critical condition, essentially trying to die in front of us.

The owner was a jovial, big man - very friendly. First, he wanted to post date a check. Then he wanted to make payments. The receptionist explained that this was not possible. Meanwhile, I stood in ICU and stared at the cat, waiting for permission to proceed. We'd already put in an IV catheter and started IV fluids, in the interest of being humane. We'd also emptied his bladder.

After 45 minutes of extended discussion of his cat's life-threatening illness, the prognosis, the possibility for recurrence of the obstruction, and how severely his cat was affected, I thought we would be euthanizing him. To my surprise and delight, he finally contacted his mother, who agreed to pay the bill. We successfully unblocked his kitty and were able to keep him in the hospital for the night. In the morning, the owner gave me a high-five because he was so pleased with his cat's progress. We'd deliberately done "minimal" testing and just spent money on the treatment. Normally, a blocked cat runs about $800-1200, but we did this kitty for $500 (no bells and whistles).

Cases like that have been rare lately, but it was very, very satisfying. I saved a patient, I made an owner happy, and I was able to do it without much stress. My hope is that his kitty will continue to improve. He went to a different veterinary clinic in the morning, and I can't say I'm sorry. The vet clinic that sent him to us knew full well of his financial situation, but obviously didn't bother to appraise us of the situation. I can't say I'm surprised.

Options...

So, my assumption prior to becoming pregnant was always that I would go straight back into ER medicine at my job. My maternity leave is 2 months. Now that my husband has reported that he thinks he can defend this summer, the possibility that he may be employed come fall raises some interesting possibilities.

With everything that has been going on lately and my general state of mind, I am tempted to not go back right away after the baby is born. Of course, this all hinges on my husband finding a job come fall, which is not a guarantee. If he does however, I could take my time, maybe give up ER medicine for a while, stay home, then work part-time at a GP practice (or full time). There are options, right?

These thoughts perk me up and make me feel much better about the current situation. All is not hopeless. I have a DVM, I can do so much. I won't lie, the thought of having my weekends free (like a normal person) is very appealing to me. So is the thought of having a "regular" job.

I don't know, but my previously firmly entrenched priorities are shifting around underneath me like quicksand. I never saw myself as a stay-at-home or even predominantly stay-at-home mother. My job has always been rewarding and challenging. Now I am faced with the prospect of a new job and a new challenge, and everything is changing in focus.

These are interesting times indeed.

At the risk of alienating my readers...

I am rapidly approaching a burnt out point. This scares me, as I've only been practicing 3 years. Granted, it's been an intense 3 years - with the internship from hell and now, working ER. On top of that the economy has taken such a huge nosedive that clients' financial situations are just getting worse and worse. Veterinarians are really bearing the brunt of many of these financial situations, and nowhere is worse than ER. It's exhausting and demoralizing to spend the majority of the day seeing critically ill and injured animals only to turn around and euthanize them. By the end of today, my head was pounding, my heart was sore and bitter, and I just wanted to quit veterinary medicine forever.

It's not the cases that I can't fix for any amount of money - those don't eat at me so much. It's the ones that I CAN fix and that have a great prognosis that break my heart. My first one of the day was a blocked cat. He'd been blocked for at least a couple of days, given his condition - but he would have responded well to treatment. The owners came with $100 (our exam fee is $92). They both sobbed as I euthanized him.

Then, the small dog that was picked up and ripped to shreds by a CANE CORSO - a whopping 36 hours before the owners decided to bring him in. He was covered with rotting wounds, couldn't walk, and was likely septic. Had the owners brought him in when it happened - a day and a half prior - than I might have been able to fix him for a reasonable cost. Now, he was trying to die and needed serious intervention to the tune of at least $1500-3000. No can do, said the owner.

I know that pregnancy hormones are worsening my feelings, but it doesn't help. I feel so bad right now that going to work is a chore. Leaving the house is a chore. I want to hide somewhere. Facing these owners, in this economic climate, with their animals that need medical care, I am starting to FEEL like a moneygrubber. I hate going into a room and telling someone that we cannot continue care for their pet because the care will cost $1500 or more. LOATHE it. I would fix them all for free with my expertise if I could, but I have to eat too and feed my family. Just like everyone, we have a mortgage, electricity bills, phone bills. Yet still, lately, the guilt is overwhelming. The blocked cat was especially hard because it was one of the rare cases where the owners did nothing wrong. The cat was vaccinated, indoors, and well-loved. Fate dealt him a crappy, crappy hand.

On top of the stress of my job in general, there is the financial stress. We are trying to carefully save for my unpaid maternity leave, but I am paid on production. And our numbers have been way, way off compared to last year. My pay has dived down about $2200/month, adding stress to the burn out. At this point, I'm looking at doing relief shifts to help build up the savings for baby Homeless Parrot. My husband has offered to find a job, but his thesis is finally in the writing stages and may be undergoing defense THIS SUMMER, so I want nothing to interrupt his continued work. Once he's finished, a massive amount of stress will magically be lifted.

Sorry for the tirade...but it's one reason I blog. Therapy. Catharsis. Release.

Uncomfortable euthanasia

Every veterinarian is faced with 1 or more euthanasias that are really, really questionable. In those situations, we all have to think long and hard about what our obligations are to the client AND the patient. I have refused to do a euthanasia before and incurred the wrath of a client. It was not pleasant, but I felt that I was doing the right thing. Recently, I had a euthanasia that was just...difficult and left me questioning whether I'd done the right thing.

An older lady came in with her elderly small breed dog (14 years old). The dog, Katie, was bright, alert, and affectionate. She was a bit fat with a potbelly, some dark pigmentation on her belly, and a history of increased drinking and urinating for the past several months. That day, her owner claimed she'd begun having seizures - 3 to be exact.

On physical exam, Katie appeared to be Cushingnoid - an endocrine disease in which the body produces too much steroids. She had a muffin top, but she was otherwise pretty normal. No other significant abnormalities. She was very affectionate, and she ate readily when we offered her food.

I went to talk to her owner, and things went downhill from there. As I stepped into the room, the owner told me that she bringing Katie in for euthanasia. "Her kidneys are failing," she informed me. "That's why she has so much edema." I stopped for a moment. "What?" I finally replied.

The owner went on to inform me that she was a nurse and had been for many years. Several months prior, Katie had become acutely lethargic. The owner - instead of taking her to the vet - elected to start injecting her at home with penicillin. She claimed that Katie improved. A few weeks later, she developed "edema." Since then, the owner was convinced that her dog was dying of kidney failure. And now, Katie had developed seizure activity. From the owners description, they were tonic-clonic ("grand mal") seizures.

I tried to gently explained that her dog was not edematous, but rather fat and possibly Cushingnoid or hypothyroid. She argued with me, telling me that she was a nurse. Uncharacteristically, I argued back - telling her that I was an ANIMAL doctor.

We talked about seizures, we talked about endocrine abnormalities, and we talked about diagnostic and treatment options. In the end, the owner told me that she was away from home too often to take care of Katie, that she had financial limitations and couldn't do endocrine testing or afford anti-epileptics (although I explained they were relatively cheap), and that she had come to terms with the euthanasia of her pet. She cried when she said it and assured me it was not a decision she had come to easily.

It was obvious she loved her dog very much. These were no crocodile tears. Katie was old, but she was still wagging her nub, and she was still eating. Still, she was suffering seizures at home. Her owner wouldn't be there to care for her, and I didn't want Katie to suffer. Still, as she wagged her nub at me, I felt terrible.

I talked with her owner extensively, and it was clear that she was not going to change her mind. In the end, I don't think it was a wrong decision, but I'm not sure it was right either. Part of my job is balancing what is right for the pet with what is right for the owner. Sometimes knowing the answer to that is very hard. It is rare that I have to make this assessment, because most of the cases I see are pretty obviously suffering. In this case, the owner knew that she could not care for her dog as she needed to, could not afford the necessary testing and treatment, and was away from home much of the time. On the other hand, staring at me was a nub-wagging, happy old dog.

Though this has been several weeks ago, I question whether I made the right decision even now.

Warning: extremely graphic post

This brought tears to my eyes - first because of the depravity of humans, and second, because the outcome was happy.

These pictures are graphic and heartbreaking - so be prepared.

Patrick the Pit Bull, thrown down a garbage chute:

http://www.ahscares.org/showarchive.asp?id=772

Cats and Tylenol

It annoys me no end when I hear my technicians on the phone telling people that all over-the- counter medications are deadly to pets. They do this because we are not allowed to dispense medication advice over the phone. If someone calls wanting a dose of medication for a limping pet, we do not give that information. If we are busy, and I field the call (as sometimes happens), I simply say, "without evaluating your pet, it is not possible to determine the cause of the problem. Many OTC medications are not safe or buffered for pets, so we recommend that you have your pet seen by a veterinarian so that an appropriate medication can be chosen."

Drugs that can be used in dogs include aspirin (though not buffered for the GI tract) and acetaminophen (used in Tylenol-3 for oncology patients). Drugs that are not safe include ibuprofen and naproxen. Naproxen in particular is a nasty, nasty drug with a very low level needed for toxic events. I once lost a patient to that particular drug, and it was terrible.

Cats, on the other hand, are very intolerant of most OTC medications. Aspirin, ibuprofen, and naproxen are not safe for them, although not always fatal. Acetaminophen (Tylenol) is an exception to this. It is fatal to cats and should never, under any circumstances, be administered to them!

Tylenol has always been an interesting drug to me. Unlike the NSAIDs (aspirin, ibuprofen, naproxen, etc), which work by inhibiting inflammatory pathways, Tylenol's mechanism of action is not completely known. Some argue that it works on the same pathways as NSAIDs (and thus, classify it with aspirin and the like), and some argue that it does not (and classify it as not an NSAID). It was discovered sometime in the last 1800s but did not find wide marketing until the 1950s. It is associated with liver failure in humans, especially when combined with alcohol (sometimes even small amounts).

The body (human and cat) metabolizes Tylenol in the liver. This is primarily through glucuronidation. Glucuronic acid is a chain of carbohydrates that link to the molecule and render it more water soluble. Thus, it can be excreted in urine or feces. There are other pathways through which it is metabolized, but this is the most significant. The problem for cats is that they lack an important enzyme called glucuronyl transferase, which catalyzes this reaction. Without it, the Tylenol does not get metabolized. Without going into too much biochemical detail, the Tylenol is eventually partially metabolized by other pathways, producing some nasty byproducts. These byproducts damage red blood cells, making it difficult for them to release oxygen to tissues. This is called methemoglobinemia.

The hallmark of this is chocolate brown mucus membranes. Roll up a cat's lip with this toxicity, and you will see dark brown gums. The cat will often have trouble breathing due to the red blood cells holding tightly to their oxygen and not releasing it. They sometimes vomit and have a swollen face as well.Further, as in people, Tylenol damages the liver of the cat (although less so than in dogs that have received an overdose).

Therapy is aimed at helping the body metabolize the Tylenol. This is achieved with a drug called Mucomyst (N-acetylcysteine). Other therapy is mainly supportive: oxygen, sometimes blood transfusions, Vitamin C, and other treatments. The prognosis can be good to very grave - depending on how long it has been since ingestion of the toxin (and how much).

Personally, I have yet to treat one of these, but almost every older ER doctor I know has, so it's coming. And when it does, I shall be ready!! The moral of this story: no Tylenol in cats! Consult your veterinarian before administering anything OTC. Dogs and cats are not small people. The doses and safe ranges are very different, and no OTC medications should be administered until you have consulted a vet!