Memorial Day in the ER

It wasn't too bad. We were steady through the day, but most of our patients were treated on an outpatient basis. It was run-of-the-mill vomiting, diarrhea, lacerations, abscesses, and the like. Nothing that really got my heart pumping. That's not necessarily a bad thing. After my 7 day straight stint working my job AND relief, as well as the busy weekend spent with family, and an inability to sleep well...I was relieved not to be running around like a headless chicken.

I did see a kitty (and hospitalize it) that had eaten lilies the previous evening. He vomited them up in front of his owner today. Luckily, his kidney values were normal, and he was still concentrating his urine nicely when he got to us. I'm confident that with aggressive diuresis, acute renal failure can be avoided.

Relief work was interesting. The clinic is a 24 hour referral/emergency clinic. It's in a relatively affluent city, especially compared to where I work full-time. The clinic itself is beautiful - very upscale. It's a totally different working environment. In the 4 days I worked there, almost every single client took my recommendations. No one balked at finances. The vast majority of pets were vaccinated, up-to-date on heartworm preventative, and spayed or neutered. Contrast that with my job - where at least 50% of pets are not vaccinated, not spayed/neutered, and not on heartworm preventative. It's very different. Liberating and refreshing.

Still, I was relieved to be back at my job today, honestly. There's no place like home, after all...

Ugh...

The sh*t hit the fan at the ER/referral tonight. I am exhausted. This was my 7th day on in a row, and I am potato done. Thankfully, I have the next 3 days off before I have to work Memorial Day at my real job. We're going home to visit family.

My first transfer of the night was a doozy of a case. It was a 4 year old, obese, Shih-Tzu. She had a 1 month history of inspiratory wheezing. Today, it got acutely worse. Lexi couldn't breathe at all. Every time she tried, a sad little wheeze came out. Her temperature was up to 104.6 due to her obesity, the heat today (90 degrees!), and the fact that she couldn't breathe and thus thermoregulate.

We placed an IV catheter and sedated her so I could examine her upper airway. What I saw was very, very strange. A normal pharynx looks like this:

My patient's glottis (the little tongue at the bottom), as well as the cartilages, and all the area around it, were grossly thickened, misshapen/lumpy, and covered with white plaques. There were white plaques on the bottom of her tongue too. The whole area was diffusely infiltrated with disease.

I've never seen anything like this, and I have no idea what it is. My guesses currently are a yeast overgrowth (she was recently on ciprofloxacin and Simplicef antibiotics after orthopedic surgery), fungal disease (weird manifestation of histo, blasto, asper, or crypto), or cancer. Fortunately, I could help my patient in the short term without knowing exactly what the disease process was. She needed a tracheostomy tube to bypass that upper airway so that she could breathe. Luckily, her airway had just enough room to squeeze an endotracheal tube in, so we were able to control her oxygenation before placing the trach tube. She did very well through the procedure and seemed relieved to be able to breathe afterwards.

Tomorrow, she is going to be scoped and have biopsies and cultures taken of the area, so the end of the story is TBA. I'll get back to ya'll.

The rest of the night was a stream of cases: vaccine reactions, vomiting after insecticide ingestion, a terrible big dog/little dog attack, a dog that was closed in a recliner, and on and on. I ate my dinner FINALLY while standing next to a critical patient in the ICU at 11pm. It was a rough night, especially given that I am spent. Utterly spent.

Fun and easy

I worked relief again tonight. I'm filling in for my friend who is a full time ER veterinarian at this local emergency/referral center. He has pneumonia, so I've been picking up his shifts. The money is good, it's a nice break from my job, and it's not as stressful for me.

Tonight, I ran like a maniac the whole time I was there. It was fun, I'm not going to lie. One of the cases was quite enjoyable.

It was a 2 year old, Pit bull that ate his owner's fishing bait, complete with hook and fishing line. The hook was about 1 inch long, 1 barb. Xrays confirmed that it was in the stomach.

I was torn. Hooks are made to catch. That's the whole point of that extra little barb. The options were as follows from cheapest to most expensive: 1) feed him bread for the next few days to bulk up his fecal matter, hope he passes it 2) feed him bread, cotton, and w/d dog food, induce vomiting, and hope that the hook doesn't get hung 3) call in the internist to scope the dog and remove the hook, or 4) exploratory surgery and gastrotomy to remove the hook.

I gave the owner the options. He asked my opinion, and I told him truthfully that inducing vomiting would *probably* be safe. Obviously, I couldn't guarantee anything however.

He took my recommendation, so we fed his dog a delightful mix of cotton, bulky w/d, tuna juice, and bread. Two shots of apomorphine, a brisk jog around the parking lot, and 2 piles of vomit later, and we had our fish hook!

The owner was thrilled. SO WAS I! I was so worried about step 2 if the vomiting didn't work. Seeing that fish hook on the floor was a great, great relief.

That's a first...and probably a last.

I got to see a case that I will probably never see again as long as I practice.

An old (13 years old), large breed dog presented for pacing, restlessness, and vomiting this evening. He was previously healthy, just old. He wasn't on any medications, the owners monitored him closely, and he didn't get into anything. He was up to date on his preventative care and not on any medications.

Physical exam showed an elevated hart rate, very injected gums, and bounding pulses. His abdomen was not painful. Rectal exam revealed no feces in colon. Everything else was unremarkable. The dog seemed stable otherwise.

Based on the pacing, restlessness, and vomiting, we recommended that the patient have abdominal xrays. What we saw was exciting and shocking to us...the descending colon, which normally lives on the left side of the abdomen, was displaced to the right side. The cecum, which normally lives more on the midline/right side of the abdomen, was pushed over to the left. The colon was massively dilated, and the small intestine was starting to dilate, as well.

We were staring at a colonic volvulus. This is so rare that when I looked it up in the Slatter surgery textbook, only 5 cases were described (1 cat, 4 dogs). Of those cases, 3 died despite intensive care.

In this case, given the dog's age, the owners elected to euthanize. It was the right decision undoubtedly. It was disappointing in that we didn't get to go into surgery and fix it. I was dying to see what it looked like surgically. As I said, I'll probably never see another in my life. Oh well. At least I got to see the xrays and the clinical signs. In case I ever do see one again.

Amazing turnarounds

We had a couple of really rewarding cases in the ER this weekend (and it was a busy weekend, YAY). The first was a little dog that we originally saw on Friday morning, about an hour prior to closing. She presented with severely hemorrhagic diarrhea, vomiting, incredible dehydration, and a slight drop in her white blood cell count. Bloodwork was non-specific for anything, and we assumed a nasty hemorrhagic gastroenteritis. We stabilized "Angel" and sent her to her veterinarian for the day.

He monitored her through the day, and her white blood cell count continued to drop. Oddly, he decided to discharge her home, assuring the owners that she would "likely be ok." She presented to me Friday evening, flat out, with a blood pressure of 30 (normal 100!), a blood sugar of 33 (normal 80-100), terrible gum color, significant abdominal pain, and a low white blood cell count. She was suffering severe sepsis.

We started aggressive fluid therapy to get her blood pressure up, intra-nasal oxygentation to help with possible imminent ARDS (acute respiratory distress syndrome, often seen concurrently with sepsis), placed a urinary catheter to measure her urine output, started treating her with broad spectrum antibiotics, dextrose supplementation, aggressive pain medications (a fentanyl/lidocaine/ketamine CRI), and placed a nasoesophageal feeding tube so that we could start trickle feeding her.

For the first 12 hours, she stubbornly circled the drain. Her blood sugar refused to come up, her blood pressure hovered around 80 (better but not great), and she just looked bad. I gave the owners a guarded to grave prognosis, but we continued on.

Then, over the course of 72 hours, she went from flat out to sitting up to responding to us. Her WBC count started to rise. She started to show an interest in food. Her diarrhea slowed down, and she became more social, coming to the front of her cage and looking out. Her blood pressure held steady on its own, and her blood sugar came up enough to discontinue her dextrose.

This morning, I sent her for one more day of hospitalization. When her owners arrived, this previously near death dog stood up on her hind legs and danced for her owners. It was like night and day.

I was really proud of the care we provided this little dog. Without it, she would have died without a doubt. Now, because of my team, their hardwork and dedication, she lives to fight another day!

As to the other rewarding case, I'll save that for tomorrow. Technically, today is the first day of my 9 day off stint, but I am working relief at the 24 hour specialty/ER hospital tonight, so I need some sleep.

Pregnancy update

Since I've been off for the past 2 days, I'm drawing a blank on cases to post about. Instead, I'll give you a pregnancy update. I'm 21 weeks as of tomorrow. I am sporting a rather conspicuous bump these days, and I have put on around 18 pounds. It doesn't help that the baby appears to be a salt and chocolate craver (or maybe that's just my excuse!). Physically, I feel really, really good. The insomnia/anxiety has passed for now, and I'm doing very well. I started to feel the baby move about a week and a half ago. At first, I thought it was little muscle spasms, but as it continued daily, I realized what it was. There is no way to describe how odd it feels to be lightly pummeled from the inside. So far, the husband has not been able to feel the baby externally yet. There have been a few times where she kicked hard, and I was able to feel her with my hand, but by the time the husband got to me, she had subsided. So, no feeling it for him yet. It's my own little private thing for now. So far, pregnancy suits me!

SharPei shock

I ruined a very nice lady's night on Tuesday. She came in with her 3 month (!) old SharPei puppy. They are inarguably the cutest puppies in the world. The breed is also considered one of the, if not THE, most high-maintenance breeds one can own. They have myriad health problems that are guaranteed throughout life including terrible dermatological issues, entropion (rolled in eyelids), amyloidosis (deposition of abnormal protein throughout the organs), and a waxing/waning fever syndrome called familial SharPei fever.

This lady brought in "Snuggles" because he had a fever (103.6), his face and legs were swollen, and he was painful and reluctant to walk or lie down. All of these findings are very consistent with familial SharPei fever (FSF).

No one knows what causes this condition, but it leads to fever episodes throughout the dog's life. The body temperature can go as high as 106 degrees. Further the joints, particularly the hock joints, will become swollen and very painful. Treatment is non-steroidal anti-inflammatories, rest, and time. Most dogs are started on a drug called colchicine. This is used to treat familial Mediterranean fever in humans, which is similar to FSF. It is not a pain medication but does stop the formation and deposition of abnormal protein (as occurs in amyloidosis). For some reason that we don't understand, amyloidosis and FSF are linked together in this breed.

I was once listening to Click-N-Clack on NPR, and they were joking about Isuzu Troopers. They claimed that if an auto body shop had 1 or 2 Isuzu Troopers, the success of that shop was guaranteed (i.e. Troopers are high maintenance pieces of crap). Well, the SharPei is the dog equivalent of the Trooper.

The moral of this story? Do not buy SharPeis from internet breeders! Research the breed you are interested in BEFORE committing and becoming attached. It will save much heartache in the long run.

In Snuggles case, we treated with an anti-inflammatory (Metacam), fluids under the skin to bring the fever down, and a recommendation to follow up with the referring veterinarian for further treatment with colchicine. After considering her purchase for a few days, the owner had actually started to think about euthanasia. Fortunately for Snuggles, her rDVM talked her out of it and into starting the medication. Hopefully, Snuggles will have as comfortable a life as a Shar-Pei can have! Had the owner but typed in "SharPei" in Google, this could have all been avoided!

Sad kitty story #3452

Saturday, a local vet called me to let me know she was sending over a kitty for a blood transfusion. "Lucky" was a 4 year old, totally indoor male cat that had begun acting lethargic a few days prior to seeing his veterinarian. When he didn't perk up after 72 hours, the owners thought it was time to seek medical attention.

Lucky, as it turned out, was severely anemic. His white blood cell count and platelets were also low. All of these cells are produced by the bone marrow, so when all are low, it's extremely concerning. Lucky was also positive on a snap test for feline leukemia.

Feline leukemia is a weird disease that can manifest itself in many ways. One of these ways is by invading and living in the bone marrow. It's called "myeloproliferative disease." My concern was that Lucky had bone marrow involvement with his FeLV. This suspicion was fueled by the decrease in all the cell lines of his bone marrow. It would be necessary to obtain a bone marrow aspirate to confirm this.

I relayed all of this to Lucky's stunned and distraught owners. They had found Lucky and 2 other kittens in a tree stump 4 years ago. At that time, he'd been tested for FeLV and found to be negative. Since then, he'd been in the house. It was a shock to them to find out that he was suffering from feline leukemia.

Given the likely bone marrow involvement, Lucky's prognosis was extremely poor. We discussed options, including referral for bone marrow aspirate. The owners wanted to try a blood transfusion and see how Lucky did, then make a decision.

We proceeded with that, and surprisingly, Lucky responded very well. His anemia improved, the heat murmur caused by "thin blood turbulence" went away, and he started to eat and act interested in his surroundings again. Unfortunately, after much soul-searching, the owners decided the next day that they couldn't proceed with further treatment. My hope was that they would take Lucky home and keep him comfortable until he was ill, not eating, or otherwise doing poorly. Unfortunately, the owners couldn't make the decision twice. They were ready on Sunday. As much as I hated to do it (since Lucky was eating and moderately perky), euthanasia was what the owners wanted.

In the end, their decision was undoubtedly the right one. Lucky's outcome was inevitable. Still, putting down animals that are eating and purring is never easy, no matter how sick they really are.

Last night was "hey, look what I found in my yard" night.

Between 8pm-12am, I saw the following:

First, a box of baby sparrows. The nest had fallen out of the tree and was lying in the grass. The owner, in a misguided attempt at philanthropy, had placed them in a box (but at least left them under the tree). She was afraid that they weren't being fed. The nest had been on the ground since Saturday, so she brought it in. All 4 of the baby birds had crops full of food, were pooping normally, and were bright and alert. Mom had obviously been flying down to feed them. Note to readers: if you find a baby bird nest or a bunny nest or any small critter (including fawns!) - leave them alone. The parent will care for them. If they don't, there is probably a reason. Let nature takes its course.

Then came the kitten that was thrown from a car. The people behind the car saw it happen and stopped to pick up the kitten. When it got to us, it was apparent that kitten had suffered severe head trauma. I wanted to save it, as anyone who knows about my love for kittens can attest. Other than the knock to the head, the kitten seemed ok externally. Alas, it went to kitty heaven, as (at that moment), I knew I could not take another kitten.

Then came kitten #2 - 10 days old, found in a puddle of water. Other than being freezing cold, the little kitten was fine. With some warming up, kitten #2 was nursing well from the bottle and active. Guess who is raising it? Yeah, me. The pregnant girl with SUCKER written on her forehead in 10 foot tall letters. The one who - one hour before - said that she couldn't take another kitten.

Then came the decrepit old cat that someone found in their front yard. Probably thrown their by a car hitting him. He was old and had a pelvis that looked like it had been put on backwards. That's how badly it was broken. His eyes were matted shut, and he seemed barely aware of where he was. He just laid there, mewing pitifully. It was a gift to end his suffering, but it didn't make his passing any less sad.

Other than that, we saw 5 paying clients - including a dog that had been hit by a car and was dying in front of us. He had gums the color of the linoleum (gray), a respiratory rate of 100, and was breathing as if his abdominal contents might be in his chest. His dad had $100, so I was forced to deliver the grave news. All in all, not a great night in the ER.

Here is the new kitten, to lighten the mood.

P.S. Anyone want me to mail them an adorable, black and white male kitten - bottle raised, vaccinated, and dewormed? He's ready to go at a moment's notice!

Shadow

I was followed by a high school junior today who wants to be a veterinarian when she grows up. She told me that she has wanted to be a veterinarian since she was a tiny little girl, that she loves animals, and that she wants to do something to make the world a better place. She said (and I quote) that "If she could help one sick animal, it would make her worlds happier."

It broke my heart a little.

Not because veterinary medicine isn't a great thing to do, but because of her starry-eyed naivete. It's ok to be naive at 16. Who isn't?? I look back at my 16 year old self and cannot believe that we are the same person.

Still, I wanted to tell her about the realities of veterinary medicine - the financial burden of vet school loans, the horrible cases of negligence and ignorance, the difficulty of making people understand that veterinarians have to eat too, the gut-wrenching feeling when euthanizing a sick or injured animal. I wanted to tell her that to be a veterinarian, you must be a social worker, a financial counselor, a psychologist, a minister/spiritual leader, a teacher, and a doctor - all rolled into one. Oh, and by the way, you'd better like working with people, because if you can't work with people - you'll be hated by your technicians, fellow doctors, and most importantly, your clients.

Then I thought about how much I genuinely love what I do, the satisfaction I get from a day like today - steady with patients, no tragic euthanasias, and clients following my recommendations, and the rush I feel when I really, truly save a patient, and I know that there is nothing else I would rather be doing.

How do you convey that to a 16 year old?

Worst Mother's Day present ever.

I had a heart-wrenching case last night.

A fat, sleek kitty was brought into our clinic 48 hours prior. At that time, he'd eaten his owner's Mother's Day bouquet. Shortly afterwards, he started to vomit. The owners contact the florist and were told a list of flowers *possibly* in the bouquet. None of them were toxic per our consultation with Animal Poison Control. The kitty was treated for gastritis and sent home with a good prognosis.

Fast forward to this evening. Archie the cat came in for neurological abnormalities, twitching, and possible seizures. We conducted bloodwork first which showed that Archie was in severe, severe kidney failure. It was so bad that I didn't believe my initial bloodwork results. We collected fresh blood and ran it again. Still the same - severe kidney failure. It was not what I expected to find.

I went to speak with the owners about things he could have ingested in the house, since he was a totally indoor kitty. They had no ibuprofen or other medications he could have eaten. There was nothing. Just the flowers. At that point, the woman pulled out her Iphone and handed me a picture of the beautiful arrangement. Smack in the middle were 3 or 4 huge day lilies. Archie had eaten lilies.

In case not everyone knows this, lilies are incredibly toxic to feline kidneys. We don't know why, but something in the lilies leads to acute renal failure in cats. It wipes out the cells that make up the urine making part of the kidneys (called renal tubular cells). If caught early (within the first 8-12 hours), treatment can be successful. It had been 48+ hours however.

The owners were extremely dedicated to their kitty, and they wanted to try. Over the course of the next 12 hours, I pumped kitty full of fluids. It was to no avail. His kidneys refused to make urine. After 6 hours on fluids, nothing. His bladder was small and soft. His skin however, was starting to feel gelatinous. This occurs when the kidneys can't make urine. Since there is nowhere else for the fluid to go, the body starts to push the excess fluids outside of the veins - into the tissue under the skin and the lungs. It's called "3rd spacing."

I tried to force his kidneys to make urine, pumping him full of diuretics and mannitol. Nothing happened. His kidneys had officially left the building. This sad state of affairs is called anuria ("without/no urine").

The only option in the face of complete anuria is dialysis. Dialysis for a cat costs $10,000-20,000. The owner, a very sweet middle-aged guy, wanted to do everything he could for his kitty - but he didn't want Archie to suffer. He decided, after much agonizing, to let Archie go. This was the right decision given that Archie's kidneys were absolutely and completely failed. It was still heartbreaking, especially to know that had we known about the lilies on Tuesday - we might have been able to save him.

Watching a tall, tough man weep over his cat was about the most depressing thing I've seen this month. I had to step into the bathroom and compose myself at least once, or I thought that the combination of that and pregnancy hormones might push me over the edge. It's always the people with unlimited funds who haves the pets I cannot fix.

Ain't that a kick in the head?

I felt very bad for a client we saw last night. He presented to us around 8pm with his new puppy in tow. He had adopted it from a local rescue organization. Just prior to leaving the pound, the puppy vomited once. Apparently, the shelter worker were unworried by the vomiting.

At arrival, the puppy had been "owned" for approximately 3 hours. In that time with his new owner, he'd developed diarrhea, had vomited again, was not interested in food, and was just lying around. Did I mention this is a LABRADOR puppy? A breed you typically have to scrape off the ceiling due to rambunctiousness?

When I examined the puppy, he was extremely lethargic, had a temperature of 103.6, was completely dehydrated (my finger stuck to his gums, they were so dry), and he didn't wag his tail or respond much to me at all.

The parvo test was screamingly positive, and the puppy had never been vaccinated. He also had 14 littermates back at the shelter. I had to deliver the bad news to the puppy's new owner, go over parvovirus in detail, and help him decide what to do. The poor guy was torn in half. He'd already expressed regret that he couldn't adopt the whole litter! And now, here he was, trying to decide if he should treat the puppy for $800+, send him back to the shelter, or euthanize.

In the end, after much agonizing, he decided to send the puppy back to the shelter. He wasn't in a financial place to accept the burden of an expensive disease with an unknown outcome (although we do save the vast majority of these puppies). He had the money to vaccinate and give appropriate preventative care, but treating parvo was another story. The rescue actually paid for outpatient treatment (subcutaneous fluids, an injection of antibiotic, and Cerenia for nausea) with plans to take the puppy to a veterinarian this morning.

It was an unsatisfying and sad case all around. On the other hand, the rescue came through with treatment, so at least the puppy will have a fighting chance.

Moral of the story: don't adopt sick, vomiting, or lethargic puppies from rescues/pounds!

Why does a trip to the vet ER cost so darned much?

I get this question (or a snide comment) at least once a shift. It occurred to me that people genuinely don't understand why it takes more money to run an ER clinic and why the bills are often 2-3 times higher when compared to the price of a general practitioner. So, here are some of the reasons you're going to shell out more money to see an ER doctor.

1) Staff. Unlike a day practice, we do not schedule appointments and surgeries. We are walk-in service only. As a result, we must keep a certain amount of staff on hand at all times. On a regular Wednesday night, I have 2 technicians early in the evening, as well as a receptionist. A third technician comes in later to do the overnight shift. Some nights, we all sit around and stare at each other. Other nights, I need a third and fourth hand to spontaneously grow out of my chest so we have more help. There is no way to tell how any given night is going to go. As a result, we have a higher number of staff. Since they work nights, weekends, and holidays, they are also better payed (generally) then your average, day-time technician. Especially when they are working the "graveyard/overnight shift" and holidays (or overtime, as frequently happens when we are slammed with gravely ill patients).

2) Drugs. Our ER clinic stocks pretty much every drug known to man/beast. This is necessary because we see and treat a wide range of medical conditions - ranging form the not very serious to the immediately life-threatening. If we need a drug at 3am, there are no other practices we can call to obtain it. If we need red blood cells or plasma at 3am, we must procure it ourselves (and is why we keep it on hand). As a a result, we keep a very large inventory. Believe it or not, even the test cartridges for our blood machines EXPIRE. Often, these drugs and tests expire before we can use them all (MANY of then). We still need them, and so we stock them.

3) Advanced testing capabilities. Unlike many practices, we have digital xray, ultrasound, machines that can check clotting times, cortisol levels, and all manner of other bloodwork. We are often able to find a diagnosis on the spot given the on-site capabilities of our practice. Many day practices send out bloodwork, which is less expensive for the client. It also leaves the clients waiting for an answer. In GP, where animals are usually less ill, this is ok. In ER,when we often need answers NOW, this is not ok. As a result, we must keep all these machines, keep them running and healthy, too!

4) Nights, weekends, holidays. Finding veterinarians who want to give up their nights, weekends, and holidays is a challenge. ER hours are long, demanding, and frequently exhausting. Burnout is common in ER veterinarians (see recent posts). It is hard to find veterinarians to do this, and as a result, salaries must be higher. Part of the reason I do ER is the fact that I can make a great deal more money than my GP counterparts. On the other hand, I cannot count how many times I have missed family get-togethers, important milestones, or weddings because I had to work. Sure, I get 9 days off every 12, which is great. Yet, everyone else is working normal hours, so I entertain myself much of that time.

5) Overhead is extremely high. Drugs and machines/diagnostics, as I've mentioned - but also supplies, building space, heating and air. Since we are ER, we need a minimum amount of cage space, working space. There's no way to tell how many clients we could have at any given time, and having room for all of them, as well as AC and heat to keep them comfortable (and us) is part of the expense.

6) Our clinic is small but currently provides us with a generous continuing education allowance per year. This is crucial for veterinarians who wish to keep up with current diagnostic and treatment options. Further, the clinic pays for health insurance out of pocket. We are a small clinic (less than 20 employees), and as a result, we don't get any great discounts on health care. Some people may complain that this shouldn't be part of the cost of seeing an ER veterinarian, but it IS the cost of running a business.

When it comes down to it, would I like to treat every animal I see with no restrictions? Absolutely, yes. My job would probably be a great deal more emotionally satisfying if I could help every pet I see. But it all boils down to the fact that, like it or not, a veterinary hospital is a BUSINESS. It must be run like a business, and it must be self-sustaining, like any business. If we aren't, the doors are closed, the drugs are gone, the veterinarians leave, and no animal gets help.

Does that mean that we are not compassionate? That we don't love animals or want to help? No, it means that I do what I can within the means owners give me, while trying to do my best for the pet. And sometimes doing the best I can for the pet is realizing that I've done what I can and I have to be satisfied with that. Just like everyone else out there who goes to work, I go to work to bring home a paycheck, to feed my growing family, and to make sure that I have a car that runs. Happily, I am also passionate about what I do and have a great moral obligation to do it well...

No, seriously.

We frequently (as in more than once a night) receive phone calls from owners wanting to know if they can give their pet any of a myriad of drugs: Benadryl, Tylenol, aspirin, and the like. Our standard reply is that we do not recommend giving anything over the counter and that if the owner is concerned enough about it that they are considering medications, the pet should probably be seen.

Why is that the party line, you probably wonder?

Because owners are often totally clueless as to what is going on. For instance, "my dog's face is swollen. Can I give him some Benadryl?" Said dog's face COULD be swollen due to an allergic reaction, but it could also be a snake bite (been there, seen that). Or the dog that was in a "little fight" (see below) that needs pain medications. Turns out the dog is laterally recumbent and non-responsive when the owner decides to bring it in.

This post at my friend's blog is an excellent tale that highlights WHY we don't like to give out advice over the phone to patients we have never seen. If you're worried enough to want to medicate, why not have the pet checked out - just to be safe??

For my mom

As usual, this blog is mostly about me and my job/life. I thought I'd take a moment on my first Mother's Day as a soon to be mother and write about my mom.

Growing up, it's easy to judge your parents and their flaws. It takes time, maturity, and a little bit of living to really see your parents clearly (if that's possible) and to appreciate them and all that they did in raising you.

I've been really lucky in life in so many ways. One of those ways is my family. Ever since I was born, they have formed a strong, sometimes invisible safety net around me. It's easy to forget how important family is until you need something, so I try to remind myself daily.

My mother was a stay-at-home mom to 5 kids, all born before she was 30. When you're young, you don't realize that being a SAH mom IS a job, just like any other. Growing up, we didn't eat out much. Mom always cooked dinner for us, and much of my childhood, we were required to all eat dinner together. We frequently had snacks waiting for us after school - our favorite, "bad" treats like chips and cookies. Mom liked to teach us about her favorite movies (on VHS, no less), so I grew up watching "Can't Buy Me Love" and "Ladyhawke" - movies I will one day probably force my daughter to watch.

When I went through middle school and high school, an extremely trying time for me, my mother was always empathetic and willing to end an ear. She's always been a peacemaker, always been supportive, and always told me that I could do whatever I wanted with myself. She never takes sides in an argument, instead seeing the good in people - no matter how faint. When us kids are fighting amongst each other, she is non-judgmental and forgiving.

I know that if I ever need support, even at 3 in the morning, I can call my mom.

I'm very lucky to have her, as well as the rest of my family. It's nice to take a few moments and think about why.

Insidious

That is the perfect word to describe compassion fatigue and burn-out. They creep up on you, and you never realize that you are suffering from them until someone else points it out to you. Then, it's as if a light bulb has suddenly illuminated. All of your recent unhappiness becomes clear.

I have been very unhappy at work the past several months. We have been slow at work, dreadfully slow. Euthanasias for financial reasons seem to be on the rise. More and more clients complain of cost, price-gouging, money-grubbing. Animals I could save are euthanized due to owners' inability to pay.

One day, you stop and realize that you've been working in an ER environment for almost 3 years. It's tiring, it's disheartening, and it just builds and builds. You realize your attitude has been terrible over the past several months (and yes, I'm sure pregnancy hormones play a part). You look at your technicians and fellow doctors and realize that your unhappiness is completely apparent to everyone around you.

Then someone says the words "boredom" and "burnout" - and that light bulb flickers on.

Veterinary work is hard - GP, ER, specialty practice. It doesn't matter. It's all challenging and emotionally, physically, and mentally exhausting. What I have to realize is that I can't carry it all around with me. I can't let the cases I could've fixed but euthanized instead eat at me. I have to accept that my job sometimes is to end suffering and that's ok. I need to go to work, do the best I can do, maintain a positive attitude, and leave knowing that every day, I do the absolute best I can. Otherwise, in 2 years, I'll be working as a librarian in a small town.

Spring is in full flower here in the South

Meaning that my allergies are, as well. Couple that with the pregnancy rhinitis, and it sounds like a TB ward in my house. There are scattered Kleenex everywhere, Neti pots, and Benadryl tablets abound. Attending a rugby game today (my SIL's), as well as playing in my vegetable garden, did not help. Itchy eyes, alternately stuffy and dripping nose, and a mild headache have been the norm for DAYS.

On the bright side, I did finally get my vegetables in the ground! A couple of weeks later this year than I wanted to, but at least it is done. I added another raised bed this year, so I have two. One has my tomato plants and red bell peppers, and the other has squash, cucumbers, okra, and string beans. The okra and beans are a new addition. I thought about eggplant, but I had limited room - and when it comes down to it, the husband loves eggplant, but I'm ambivalent. I'd much rather have beans. Since he likes beans too, I thought it a good compromise.

My mom came and spent the first 3 days of this week with me. I wasn't much fun, physically and mentally exhausted from work. Still, we contrived to at least hang out on the couch together, in between attempts to nap/sleep. Thursday, I saw Water for Elephants with a friend. If you've read the book, I would save your money. The movie didn't really add anything new or exciting. Reese Witherspoon is kinda annoying, as well. At least, to me. Christoper Waltz was probably the best thing about the movie, as he channels insanity terrifyingly well.

Otherwise, it's been a rather low-key week - something I desperately needed!

Random good deed brought to you courtesy of pregnancy hormones

It probably goes without saying that I have been very emotional lately for a wide variety of reasons.

Last Sunday night, we were swamped. I didn't eat dinner until almost midnight, because I didn't have 5 seconds to stop and stuff something in my face. In the midst of this, a couple with very little finances showed up with a tiny (less than 1 pound) kitten. I glanced at the kitten, saw the MASSIVE abdominal hernia and told my receptionist to relay that the kitten needed surgery. The owners decided to euthanize and signed all the appropriate paperwork. Kitten was placed in a cage with a bowl of food until I could attend to her.

6 hours later, I went to examine little kitten more closely. She was tiny and absolutely adorable. A little gray tiger striped kitty with a very large personality. It felt like her bladder and some intestines were trapped in the hernia. She was too cute for me to euthanize, and she seemed to feel fine (other than the inability to urinate). I couldn't stand the thought of putting her down. I literally did not have it in me.

So, I fixed hernia kitten. Without the owner's permission. It was 3am in the morning, and I didn't want to call and wake them. Kitten recovered very slowly from surgery. At first, I didn't think that she would survive, being as tiny as she was. The first 24 hours, she laid in her kitty carrier (at my house), on her heating pad, and didn't move much. I gave her subcutaneous fluids, pain medications, and waited. I thought about euthanizing. Perhaps it was just too much for the teeny kitten.

24 hours later, said kitten was bouncing around, pooping, peeing, eating, and trying to beat down my other foster kitten (who outweighs her by a good pound). I called the owners and let them know that they could come and pick her up, no charge. I did explain that given her small size, another hernia repair might be necessary down the line (the hernia was HUGE), but it wasn't immediately needed and may never be so.

The owners thanked me profusely, and little kitten went back home with her owners (after 4 days post-op at my house). Thank you, pregnancy hormones.

Strange case

I saw something this weekend that I have not seen before. A mixed breed, 50ish pound dog presented to me for a "swollen leg." When my tech brought the dog, "Frisco" back to the ICU, I noted that indeed, the leg was massively, massively swollen. It was approximately 4 times the size of the other leg. It was also hot but not particularly painful to touch.

Frisco was a total freakazoid - growling, snapping, and defecating, so he wasn't easy to examine. I couldn't get a peek at his gum color without sacrificing a few fingers, something I am generally unwilling to do. When restrained, he urinated on my technician in defiance and fear. He was not a nice dog.

When I went to talk to the owners, they explained that Frisco had been diagnosed with hemophilia 2-3 years ago. The same problem had occurred. His leg was became massively swollen, and he started limping. The owners waited 3 days to see their veterinarian, and by then, Frisco was weak, lethargic, and had labored breathing. Turns out, he had lost a massive quantity of blood into the tissues of his leg. A blood transfusion and supportive care later, he was normal.

The same thing was happening now. From the quick glance I got at his gums (under the muzzle), he was paler than I would like. A PCV measured at 24%. Certainly not life-threatening anemia. Not yet, anyway. He didn't need a blood transfusion, but he did need a fresh frozen plasma transfusion. This would provide his body with the clotting factors that he was naturally lacking.

Unfortunately, the owners had severe financial limitations and could not afford our estimate. On the bright side, it was late Sunday evening (11pm). They planned on being at their vet's doorstep at 8am sharp. I explained that I could not guarantee that their dog wouldn't bleed to death during the next 9 hours. They understood and took the risk. I'll let you know what happened when I find out...

My grandfather taught me well

I always think of my grandfather when I'm forced to do something I'm not necessarily sure is in my best happiness interest but in the best interest of my family and my current situation.

Hypothetical person dealt with the situation very poorly when she finally confronted the colleague. Later on, she apologized for her unprofessional response, ignoring the un-professionalism inherent in the original action.

Hypothetical person has decided that being pregnant, being the sole source of income, and needing to provide a stable home, while building savings for maternity leave are the most important things right now. Said person can get what she needs to done at work and done well. She has decided winning popularity contests is not what work is about - its about doing your job, doing it well, and letting the rest go. It may not be pleasant for a while, but everything blows over. Some new drama always rears its head.

Our hypothetical friend has found a great deal of peace. It helps that she is off work for the next 9 days, she had an ultrasound today and everything looks great with her little girl, and her mother is visiting for the next 3 days. There are more important things in life than work, right?

Treading cautiously

Though my grandmother frequently warns me to be careful about what I post on this blog, when it comes down to it, my blog is anonymous. I have been careful that no one at work knows about it. It's never been opened at work on any computer. Still, I guess there's always some slim chance that someone knows about it. At this point, who gives a ?

At any rate, I'm going to tell this story anyway - as a hypothetical story.

Hypothetically, someone has been unhappy in her job in the past few months. There are a variety of reasons, but she has been trying to work through them. Unfortunately, things came to a desperate, furious head this weekend.

This hypothetical person was AT home, on her off night. She was talking to her close friend that lives 3000 miles away about her frustrations at work. Said person was discussing her complaints and worries as a way of working through them. Mind you, this was a private conversation. AT HOME. On her OFF NIGHT from work, from the comfort and supposed privacy of her own home. Her friend, we'll call her Jessica, had some good advice, and by the end of the this conversation, our hypothetical person was feeling much better about things. She resolved to get up early the next day, bake cookies for everyone at work, and try to start fresh.

This PRIVATE conversation took place on Facebook chat (not on the wall - which is totally different). Imagine our hypothetical person's shock, dismay, and anger when it became clear that her COLLEAGUE - another DOCTOR in the hospital - opened Facebook at work, accidentally logged in as our hypothetical person, and then preceded to read the entire conversation. Not only did the DOCTOR read the conversation, she allowed the technicians - with whom our hypothetical person already has a respect problem - to read it over her shoulder.

Hypothetical person is still reeling after finding this out 3 days later. Being pregnant, as our hypothetical person is, and being the sole source of income in the household, as our pregnant hypothetical person is, options at this point are limited. Hypothetical person is beyond devastated, feels violated, and is unsure how to proceed at this point.

I really feel like if hypothetical person were male, there would be no problem. Flame me for thinking that if you will.

More to come later.