It's not all death and destruction in the ER...

Even though sometimes, it seems like it is. The last 2 nights have been very, very slow. Dismally so. On the bright side, I got to help a patient feel much, much better!

"Molly" came in because she'd been outside, racing around the yard with her best friend, a much larger dog. The owners heard her cry out, and then she came back into the house limping. When the owners investigated, they found a sharp point sticking out just above Molly's knee. A large foreign body had rammed through her skin, tunneled through the subcutaneous tissue, and was buried there, under the skin. Only the tip was sticking out.

The weekend

Sorry for not posting this weekend - I worked 2 14 hour shifts, and I am exhausted. We were busy all weekend. It wasn't crazy busy, but steady enough and with enough complicated patients that I didn't have much time to eat or sit down.

We had a really fun, rewarding case come in yesterday afternoon, in the midst of all of the clamor. A man called to tell us that his dog had swallowed a fishing hook. This in and of itself isn't all that exciting - puppies get hooks embedded in their lips or swallow them all the time. My colleague took a 3 pronged, barbed hook out of a Labrador puppy's stomach just this weekend.

When this dog came in however, it was a new wrinkle on an old problem. Fishing line with a weight was hanging out of the dog's mouth. The dog was vomiting copiously and repeatedly, making me suspicious that the hook wasn't in the stomach at all. We sedated her and xrayed her head and neck. Sure enough, the hook was in the back of her oropharynx. Two of the barbs had engaged the soft palate and the other was through the glottis. The hook was effectually holding the airway partly closed. This was not a large dog (22.5 pounds), so getting back there to get that hook out was going to be a huge challenge.

If you're not a fisherman or if you've never looked at hooks closely - they are barbed in such a manner that once engaged, they will not back out of the tissue. This assures that your fish does not get away. The hook had done its job well...there was no way it was going to be backed out of the flesh.

We knocked the unlucky pup out with Propofol and intubated her, then examined our problem. It would take two people - one to push the barbs through and hold the tips with hemostats (to prevent the barbs from falling down the esophagus) - and one to clip with the wire cutters.

It took an incredible amount of finesse and finagling, but 20 minutes later, I held the fish hook in my hand. The puppy recovered well and went home no worse for the wear (although probably with a bit of a sore throat).

An odd frustrating case...

Last night, I saw a case that totally stumped me.

The patient was an old (>13 years), small breed dog. He presented for acute onset of vomiting and lethargy. Before I saw the dog, I was thinking pancreatitis, gastroenteritis, cancer, and the like. When I saw the dog though, I was unsure. He was incredibly weak, swaying on his feet, and he was very mentally dull. There were no signs of pancreatitis really (no abdominal pain, no diarrhea, no fever, no other real abnormalities). Further, his blood pressure was 200! This likely explained why he was mentally not so with it.

Further investigation revealed a dog with severe, severe dehydration - far in excess of what I expected from 4 bouts of vomiting. Oddly though, his heart rate, which should have been sky-high to compensate for the dehydration, was actually rather low.

The combination of severe hypertension and a slow heart rate (bradycardia) is often a good indicator of cerebral edema ("swelling in the brain"). Initially, I was so fixated on the vomiting that I didn't make this obvious connection. I was so focused on the vomiting - trying to figure out where that came in...and thinking that was the primary symptom. Eventually, it dawned on me that there was something going on in this poor dog's brain.

Xrays showed an enlarged heart but no evidence of heart failure. Due to the severe dehydration, I started the patient on aggressive fluids, keeping a close eye on breathing. I also started an anti-hypertensive. I wanted to give mannitol, an intense diuretic that will decrease pressure within the brain. Given the dog's enlarged heart and significant dehydration, mannitol was a risky proposition. It would further dehydrate the patient and possibly push him into heart failure. On the other hand, his brain was obviously not functioning well and could have used the mannitol.

Urinalysis showed that the patient was dumping a massive quantity of protein into his urine.

So I was dealing with a myriad of different problems, unsure which was the primary one...

The patient continued to spiral down through the night. Despite treatment, his blood pressure never came down and his heart rate never came up. By the time morning came, I knew it was either referral time or heaven time.

The owners were distraught, and they elected euthanasia. It wasn't a bad decision. The dog obviously had something going on in its brain (tumor?), as well as a disease called protein losing nephropathy (the kidneys start to be unable to retain protein), and toward the end of the morning, he developed pulmonary edema from the large amount of fluids I gave him.

It was a terrible case, and I wish I had managed it better. Honestly though, I doubt it would have made any difference....

First night back ...

It was a busy and pleasing one...nothing too "omigod, it's going to die RIGHT now if I don't intervene." I treated a puppy with pneumonia, a Schnauzer with severely abnormal liver enzymes and a history of phenobarbital administration, 2 cats from the same household - one with a non-healing abscess and one with an enlarged prescapular lymph node, a dog with seizures, etc. etc.

It kept me busy until well after 2am, at which point, I was able to lie down for a bit. I've been a tad tired these last fews days. I'm not sure if it's pregnancy or just emotional distress or the combination of the two...but I've really been dragging. I'm also cutting my sugary drink intake way down, and I've only had caffeine once in 2 days...which precipitated a massive headache.

Otherwise, good first night back at work.

Porch Kitty

We miss her around here. She really was a sweet kitty.

Not much to blog about

Having been off of work for 2 weeks does not make for exciting blogging.

After consulting with the cardiothoracic surgeon, my father is seriously considering the bypass surgery. He has three vessel disease - atherosclerosis of the 3 main vessels of the heart. This type of disease responds well to treatment with a coronary artery bypass. The surgeon made a strong case for my father. He's still deciding.

We're home again. I go back to work tomorrow night, and I'm afraid I'll have forgotten how to be a doctor!

In garden news, my squash are doing well. I also picked about 0.75# of snap beans from the garden. The tomatoes are growing, but they are still green. My peppers STILL aren't doing anything - which is a huge source of frustration. I have no idea why. I might need to cross pollinate them - because they are growing but not fruiting.

At any rate...not much else to say...sorry.

My dad

We are faced with a tough decision right now. My father has severe coronary artery disease and critical obstruction of many, many arteries. He is not a good candidate for stenting - and from what limited reading I've done, the bypass procedure is superior anyway. In all the reading I've been able to do - both refereed literature and Dr Google - it has been repeatedly stated that there is no difference in outcome between surgical and medical management. Further, my father is 74 - and this alone doubles his chances of mortality. Thankfully, he does not smoke, does not have diabetes, or renal disease, and is otherwise fairly healthy.

The bypass surgery is incredibly invasive - the chest is cracked down the sternum, and the patient's heart is stopped. They are then placed on a heart-lung bypass machine to pump blood while the veins are moved to the heart. Strokes and heart attacks are common peri-operative compliations (about 10% from what I've read).

My father is home and now that I can see him standing up - he is incredibly gaunt - down from around 190# to 168#.

Nothing I've read or heard from the cardiologist makes me think that my dad should undergo this surgery - and yet...how to know?? If he should have a heart attack, he will be a much, much poorer candidate for surgery, should he need it.

Lastly, overhearing him and my mother discussing what she will do when my dad is gone...well, that doesn't help much either (my dad is 21 years older than my mom).

I'll keep ya'll posted on what he decides to do.

Rest in peace, Porch Kitty

Porch Kitty briefly rallied after her blood transfusion, and my hope was that she was suffering internal trauma. The fact that she'd been losing weight for the past couple of weeks/month didn't really fit, but I chose to ignore that. Unfortunately, her condition began to deteriorate again last night, and it became apparent that she was hemorrhaging into her abdomen still.

My colleague took her to surgery and found what appeared to be diffuse intestinal cancer. The bleeding was from multiple, eroded mesenteric vessels. There was nothing to be done. She was not woken up from surgery.

She will be very, very missed. She was an extremely sweet cat, and she spent her days keeping our neighbor's very ill (terminally) mother company. She was also a favorite of my husband - who worried about her incessantly when she disappeared on her 2 day jaunts.

Rest in peace, sweet kitty.

It's pouring again.

I'm sitting in the hospital in my hometown next to my father's bed. Ya'll might remember that he had a heart attack in 2008, during my internship. Thursday night, he started having severe chest pain that worsened to the point of inability to walk or talk. He was taken to the hospital and diagnosed with worsening coronary artery disease. He did not have a heart attack per se but a serious attack of angina. A cardiac angiogram showed significant worsening of his heart disease. His right main coronary artery is 99% occluded. He also has significant occlusion of other vessels throughout the heart.

The cardiologist is recommending a quintuple bypass surgery. From what I can tell in a brief literature search (and from what the cardiologist himself said) - outcome between more aggressive medical management (i.e. increasing his current Plavix, aspirin regimen and adding on nitrates) and surgical management is the same. The difference is in quality of life.

I'm trying to do a good literature search on Pubmed, but I haven't been able to narrow my search efficiently enough.

At any rate, my dad is stable and watching Quantum of Solace in the hospital as we speak.

To make matters more stressful, about 2 hours after we left home to drive here, our neighbor called to let us know that our outdoor kitty (Porch Kitty) was lying in her backyard, extremely lethargic and weak. She's been AWOL for 5 days or more. This isn't surprising - she often goes off for short periods of time, then reappears. She adopted us in Chattanooga, and she's been our cat ever since. We tried to make her an indoor kitty, but she was having none of that - hating our other cats, hiding in the bathroom sink, and generally being miserable. So we gave her back her outdoor life (although I do not like outdoor cats).

At any rate, my wonderful office manager went and looked her over - finding a cat with white gums, labored breathing, and abdominal distention. She took her straight to our local excellent referral hospital where she was diagnosed with severe, severe anemia and a belly full of blood. All other testing was totally normal. She wasn't having trouble clotting her blood, all of her bloodwork was normal, and she didn't have external signs of trauma. So, WTH??

She is now at my ER getting a blood transfusion, and we're hoping for the best. She is a sweet kitty who lives on the lap of the 85 year old neighbor who is dying from kidney failure. She will sit there for hours with this lady, and I would hate for her to lose her companion. Keep you fingers crossed that Porch Kitty will fight the good fight.

And keep my dad in your thoughts, please. My mom is under a lot of stress right now, as we all are.

Some thoughts on disillusionment

Last night, I had a visit from a fellow blogger, Hermit Thrush. She just finished her 2nd year of veterinary school at Cornell, and naturally, we fell to discussing what she would do when she graduated. Our discussion got me to thinking long and hard about why so many veterinarians I know are unhappy in their jobs - nay, in the career of veterinary medicine itself. After talking about it with her, I came up with some reasons so many young vets are rapidly disillusioned (and better clarified some of the reasons I was so burnt out recently).

First, we are taught excellent medicine in veterinary school. We learn chemotherapy, MRI and CT scan, how to do biopsies correctly, how to submit histopathology, and every other advanced diagnostic technique that exists. What we don't learn? How to unblock a cat. How to deal with a flea toxicity patient. How to approach stabilization and surgery on a GDV. How to treat a simple cat bite abscess or laceration. How to triage ER patients in a busy ER. How to manage client communications. How to discuss money and how to handle patients with very limited (or no) funds. There is a huge, huge disconnect between academia and the real world.

We are taught black and white: for instance, NO STEROIDS for ANYTHING EVER without a clear diagnosis. Every suspected foreign body MUST have 3 view abdominal xrays. Well, what do you do when the owners won't LET you do any work-up? When they have $200 and an ill pet? Are steroids and/or antibiotics "wrong" then? Does every patient with a possible foreign body require 3 view abdominal xrays (at 2x the cost of just one xray)?

Much of the initial disillusionment comes from the initial realization that vet school is nothing like the real world. It has taken me the better part of the last 3 years to come out of the Ivory Tower mentality. To realize that there are multiple ways to do something, multiple right answers, and rarely wrong ones (although there ARE wrong ones). It was a shock and has lead to some of my greatest disappointments and unhappinesses. When people come to the vet school, they are there to spend a great deal of money, at whatever outcome. Not so in general practice and general emergency. Often, owners just want a pill to fix their pet. Sometimes I can provide it, sometimes not. But learning to accept the REAL world for what it is and not try to force it to conform to my ideas of perfect medicine has been an important step forward in my personal happiness.

I've also had to come to the realization that general practitioners have it hard, too. They work very long hours, are often astonishingly busy, and it can be very, very difficult for them to manage a complicated case like a DKA or IMHA. Learning not to judge the general practitioners so harshly, but instead being grateful that the patient is able to transfer for further care, has helped enormously. I used to get very angry at some of the stuff I saw done, but then realized these GPs are dealing with the real world too, trying to be realistic and do what they can for their clients. Does that mean there isn't true negligence or malpractice? No, but it means that I don't need to look so hard at the wrong things -but focus on the right things that were done and what I can do to improve the patient's care.

Secondly, we are never taught how to be good employees. How to work well with our colleagues, how to manage staff and technicians. We are taught no workplace skills at all. So we graduate, full of ourselves, our vast knowledge, and then go out into the real world with no idea how to function. Most of us suffer a great deal of friction in the first few years - dealing with clients, dealing with office managers, dealing with our colleagues and technicians. Learning how to manage people and how to be good to work with without being a push-over is a huge challenge. It is something that some veterinarians will never learn.

Lastly, and this is nebulous I realize, but I think with myself in particular, personal life satisfaction stems from work satisfaction. When I'm not happy at work, I'm not happy anywhere. It has taken a bit of attitude re-adjustment to realize that while I LOVE being a veterinarian, it is still a job. It is a special job with unique requirements, unique stressors, yes. It is still a job. Being pregnant has helped me to realize that I can leave my job AT my job and still be an excellent veterinarian. There is more to life than work.

Just some nuggets of un-wisdom from someone emerging from a period of very bad burn-out.

Breedism

So, we went out for a lovely brunch with an old, good friend from vet school and her fiance, as well as with my husband's 2 brothers and my BF. Downtown Knoxville has a place called Market Square - full of little trendy shops and restaurants, and we frequent The Tomato Head for Sunday brunch. Afterwards, we hung round in the sun and people watched until Super 8 started playing. Sitting there, on a hot, gorgeous summer day, I watched the many, many people and dogs go by, and all I could think about were which diseases the specific breeds would get.

Cute little fat dachshund: start saving up for that slipped disc surgery.

Middle-aged German shepherd: hemoabdomen secondary to splenic tumor just waiting to happen...or really bad hip arthritis secondary to dysplasia. OR BOTH.

Fat Boston terrier panting frantically: imminent heat stroke.

Lovely Doberman: needs a savings account for a ventral slot surgery when Wobbler's sets in...either before of after you become hypothyroid.

Kinda ruins dog ownership. Still, the day was lovely, the dogs were amusing, and life is good.

Wedding bells

We're in Knoxville for the weekend. One of my best friends from veterinary school is getting married. It's great to be away from home, visiting my best friend and her husband (my brother-in-law). I'm off work for the next 2 weeks - so veterinary posts will likely be scarce. I'll do my best though, I promise.

Good Sam kittens again

So, I have 2 Good Sam kittens under my care. One is a beautiful lilac Siamese with incredibly blue eyes. The other is a gimpy little tabby. One of the local veterinarians did an amputation on the kitten's bad back leg today. I stood around and watched as he worked magic! The kitten only weighs 0.9 pounds! It was a challenge anesthetically, but everything went beautifully. Now all I need is a home for said 3-legged tabby.

The negative exploratory

There are few things that make me as mad (at myself) as a negative exploratory surgery. How does a negative exploratory happen, you might wonder.

My patient last night was a Dachshund mix. On Monday, she stopped eating. She also became lethargic and started to act painful/tremble. This continued through Tuesday, and the owners brought her to see me early Wednesday morning. Layla had not vomited, but at home that night, she had gagged/retched numerous times.

On physical exam, Layla was a quiet but alert puppy. Her abdomen was a bit distended, and I could easily palpate a fluid-filled stomach. Xrays showed dilation of her stomach with fluid and gas. There was also a very odd appearance to the material inside the stomach. It looked like there was something in it, despite the fact that she hadn't eaten in well over 36 hours. Her intestines were normal.

I sent her xrays to a radiology reading service, and they agreed that a partial obstruction was an important consideration in Layla.

I talked to the owners about her condition and recommended exploratory laparatomy. My first mistake was not giving them option #2 clearly. Option #2 would have been IV fluids, monitoring, and transfer to her regular veterinarian in a few hours for re-evaluation. There was nothing in Layal's physical exam that made me think she COULDN'T wait. It was already 4am. Yet I more or less told the owners that ex lap was warranted. I believed it too. I had no doubt I would open up that abdomen and out would pop an obstructed stomach or upper duodenal foreign body.

Prior to surgery, we ran bloodwork. In a dog with an upper GI obstruction, there will often be a metabolic alkalosis - the pH of the blood will be high, with a concurrent drop in potassium and chloride (from vomiting usually). Most GI obstructions will also show a significant amount of dehydration. This is determined with a PCV/TS.

Layla's pH was normal, as was her PCV/TS. Alarm bells rang faintly in the back of my head. Mistake #2 - not listening to the alarm bells.

I went back to the xrays. Highly suspicious. Layla was lightly sedated for her xrays, so I palpated her abdomen again. Fluid in the stomach, possible obstruction high up under the ribcage. I felt confident.

What did I find in surgery? Nothing. Zilch. Nada. The material seen on xray of the stomach was a mass of bubbles and frothy fluid. No foreign object. The intestines were not moving, but they were not obstructed.

I was furious with myself. The owners had plunked down $1400 for an exploratory surgery, and what had I done? Put their dog through a needless surgery. I had neglected to offer option 1 and ignored the alarm bells when they rang. Granted, it was 4am, I was tired, and it had been a long night - but still, no excuses.

We were taught in vet school that if you aren't doing negative exploratory surgery, you aren't doing enough explores...but it's no consolation when you're staring into a perfectly normal abdomen, beating yourself up for making the wrong call.

On the bright side, Layla's owners were lovely people and pleased to find out that there was no obstruction that needed to be removed.

Snake update

My poor little Yorkie patient with the horrible oral snakebite recovered slowly over 3 days at the referral hospital, and she is now home and back to normal! That's my first rattlesnake bite to survive!!

The kitten with the snakebite to the eye was discharged the next morning with marked improvement in swelling.

Summer is watermelon, lemonade, corn on the cob...

I had a rewarding case on Sunday night. A nice, middle-aged couple brought in their Labrador for vomiting and loss of appetite. Before it even arrived, my receptionist jokingly asked me what I thought was stuck in the Lab's intestines, as Labradors are notorious for 2 things: ravenous appetite and eating stuff they shouldn't. The combination of a Labrador that wasn't eating with vomiting was a big clue to the underlying diagnosis.

Said Labrador (Daisy) was indeed very ill. She barely managed a tail wag when I examined her.Her abdomen was tense but not especially painful, she had no poop in her colon on rectal exam, and she was very, very dehydrated. Otherwise, her physical exam was normal.

I wanted to start with xrays. Especially after the owners mentioned that she had vomited up something "foreign" the previous day. When quizzed about what it was, the male owner shrugged and said, "it looked like corn on the cob. But we didn't give her corn on the cob, and she's in a fenced in yard."

Xrays showed a very suspicious but not definitive looking abdomen. About midway through the abdomen was an abnormal, "bubbly" looking thing. It looked remarkably similar to other corn cob foreign bodies I have seen. The owners SWORE no corn cob! Daisy's bloodwork was totally normal, giving no explanation for her vomiting and loss of appetite.

Based on the xrays, her clinical signs, and the fact that Daisy often ate socks and vomited them back up, I recommended abdominal exploratory. The owners were very worried and took my recommendation. They left Daisy in our care, and we set about rehydrating her and prepping her for surgery.

About 30 minutes after they left, the owner called back and casually mentioned that, "Oh, by the way, we had corn on the cob with dinner the other night, and Daisy DID get into the trash that night." DOH!

Sure enough, the butt end of a corn cob was lodged halfway down Daisy's intestines. Luckily, her intestines were still pretty healthy and happy looking. 50 minutes and a simple enterotomy later, and Daisy was awake and recovered.

Keep your fingers crossed that her intestines heal well!

Well, ain't that a kick (bite) in the head...?

This afternoon, I was presented with a fiesty little ball of fur. "Macy" is a 3 month old kitten. She was outside with her owners this afternoon on the back deck. She disappeared for about 20 minutes, and the owners had no idea where she'd gone. When she came back, her right eye was swollen shut, she had massive swelling around the eye, and there was blood dripping from it. Macy was crouched, painful, and meowing loudly. They rushed her to us.

When she initially presented, I suspected some sort of blunt trauma - hit by a car, picked up by a dog, dropped from a decent height, or the like. Still, the eye looked suspicious - unusual.

Macy was a handful, and it took some sedation before we could clip around her eye. What I found surprised me. She appeared to have puncture wounds over her eye. As in - snakebite fang puncture wounds. I wasn't convinced. Cats are usually smarter than that and won't play with snakes. We see snakebites in dogs ALL the time, but in cats, it's a rarity.

We drew blood for a sample and examined it under the microscope. Sure enough, almost of her red blood cells were irregular and spiky. This is called echinocytosis and is a result of the snake's venom on the cells. They change shape from smooth and oval to round and "spiky." It's a classic sign of envenomation. Still, I was NOT convinced. A cat snakebite to the EYE? And the cat wasn't dead? It seemed unlikely.

So, we made an official blood smear to count kitty's platelets. Snake venom can and often does cause a profound thrombocytopenia (decreased platelet count). Macy had 14,000 platelets to her name. She should have had 200,000-500,000. The evidence was mounting. It was clinched when within 1 hour of presentation, Macy's face had swollen to 3 times the size it was when she came in. There was moderate bruising and necrosis of the skin around the eye.

I spoke with the owner, giving her a very guarded prognosis for Macy's recovery. Such a small animal with such a serious bite...it could not end happily. Kittens are not meant to withstand snake venom! That's the whole point.

Macy however seemed determined to prove me wrong. When I left this evening, she was rolling around her cage, trying to play with her IV line, purring, and eating her face off. That was one happy kitten on narcotics! I'm hoping she continues to do so well. Keep your fingers crossed for 2.5 pound Macy kitten.

Lawnmowers: 2, dogs of the world: 0

I don't know what it is with dogs and lawnmowers in this neck of the woods. For some reason, dogs in this area like to play with lawnmowers.

This week, I was presented with a dog that had its foot run over by a lawnmower. When he came in, he was wagging his tail, but blood was splattered all over him, his owner, his owner's car, the walls, and shortly, the ICU. His foot, from the carpus down, was dangling by about 3 shreds of skin and tendon.

We gave him a dose of fentanyl IV for pain and relaxation, then placed an extremely, extremely tight bandage and tourniquet to control the hemorrhage. Once we had addressed the bleeding, I went to speak to his owner.

She was distraught and moderately intoxicated. I explained to her that we would need to stabilize her dog, Dudley, with IV fluids, pain medications, antibiotics, and possibly a blood transfusion. Once he was stable, we would amputate his leg at likely the elbow joint.

Unfortunately, Dudley's owner had $100 to her name. She begged me to "work with her." I had to gently explain that the bill would be $1500-2500 for the night and surgery. She did not qualify for CareCredit. My hands were tied. In the end, she was forced to make the right decision for her dog.

By the time she had made the decision, Dudley was weak, his gums were pale, and he was weak. He did not resist as we gently injected him with the euthanasia solution.

Awesome night

Last night was an awesome reminder of why I do ER medicine. We've been slow lately, and frankly, I've been a bit bored at work. Most people are financially strapped in our area, and they can't afford work-ups for illness. If I see a seriously injured or critically ill pet, euthanasia is highly likely. While these are important parts of my job, it gets old when all I feel like I'm doing is shotgun medicine and euthanizing things.

Last night, the night got off to a rollicking start. There were 3 rooms waiting to be seen simultaneously. In one of them were 2 dogs, both bitten by a rattlesnake several hours before. I was initially skeptical - rattler bites in this area are much, much less common than copperheads. The owners had brought the snake with them, and sure enough, it was a rattler. Not only was it a rattler, it was a very young one. This is, probably surprisingly, worse than an adult. Young snakes cannot control the amount of venom they inject and usually inject it all at once.

One patient was a 7.5# dog named Sunny. She sustained a bite to the inside of her mouth, in a highly vascular area. When she presented, she was laterally recumbent, oozing pure blood from her rectum, had a very low blood pressure, and blood sugar. Her condition was terrible. Her housemate, a 70# dog, sustained a bite to the leg. While swollen, Lena was in much better condition. It appeared that the baby snake had likely expended all his venom on Sunny.

I expected to be euthanizing Sunny, as her care with antivenin (which she needed), would run in the high $1800-2000 range. Add in hospitalization and monitoring for Lena, and the bill would likely be around $3000 just for the night.

To my enormous delight, the owner consented to treatment. I was able to give anti-venin. My patient went from laterally recumbent and shocky to responsive and able to walk outside this morning. Her blood glucose and blood pressure stabilized, and she looked 1000 times better this morning when she transferred.

In the midst of dealing with an extremely unstable Sunny, the doors opened to allow in a dog thats foot had just been almost completely severed by a lawnmower. Shortly behind came a Great Dane with a suspected GDV, a dog with a vaccine reaction, and the like. We had to call in an extra technician to help us with the craziness - as we had one dog bleeding all over our ICU, Sunny trying to die after being bitten, a Great Dane with a distended abdomen, and all kinds of other fun stuff.

It was a great, great night. Does that make me twisted?

And we all fall down...

It seems like when it rains, it pours.

My dog has decided to develop intermittent vomiting, diarrhea, loss of appetite, lethargy, and abdominal pain. It started about a month ago, and she's just having this periodically. Initial bloodwork and xrays have been boring. Thus, I am now left to rule out Addison's disease, inflammatory bowel disease, whipworm infestation, food sensitivity, some weird manifestation of hypothyroidism (she IS a Doberman, after all), chronic pancreatitis, and a host of other problems. It's making me empathize enormously with my financially strapped clients. Though I get a discount at work, it really sucks, and my bill is already up to $550 again! All of this testing will be expensive. For the time being, I am switching her to a low-residue/bland diet and deworming her in the hopes that this is something fairly benign and easily treatable.

My old kitty Archie, who is around 13 years old, has a raging lymphocytic-plasmacytic rhinitis. It was diagnosed via biopsy about 2 years ago, and it flares up intermittently. No cause has ever been found. Usually, it responds beautifully to a round of antibiotics and steroids. Not so this time, and it's getting worse. With the chronic inflammation in his nasal passage (the left side), I am afraid this is turning into something more malignant (e.g. cancer).

Titus, my African grey, has a small, slightly picked area in the center of his chest. This concerns me because I think he might be picking his feathers. This might be just behavioral, but I need to rule out underlying disease first, before I assume that.

Another cat has randomly adopted us, and she needs feline leukemia/AIDs testing, as well as some vaccines - if nothing else. I'm not sure if she's spayed or not. So far, she's been hanging around 2+ months, so if she were pregnant, I'd have expected it to manifest itself by now. Let's just hope she is spayed.

I *think* the rest of my animals are doing fine.