Keep piling it on universe. No, seriously.

Chicken Biscuit is doing ok. Despite fluids, his kidney values have not improved. At the moment, we are holding off on the surgery to remove the bladder stones. He's going to see the internal medicine specialist on Monday to have an abdominal ultrasound done. They can figure out where that ureteral stone is and whether or not surgery will be beneficial or if it will just buy him some time. I'm hoping for the former, but with my luck lately - it will be the latter.

I also just got the news that I miserably failed my glucose tolerance test. So miserably in fact - that they aren't even going to give me the next test in the process (the 3 hour glucose tolerance test). I got to skip straight to a diagnosis of gestational diabetes. My appointment with the nutritionist is on Tuesday, at which time I'll learn what I can/can't eat. In the meantime, I'm supposed to "watch my sugars and starches" per the nurse. Gee, thanks for the specifics.

We're here in Asheville at the B&B, but I can't say I'm having a great time. I'm worried about my cat, worried about being diabetic, and worried that I'm putting all the wrong foods in my mouth. Further, I've had two dizzy spells today and some nausea - which is a first. I feel weak and icky. It's not conducive to having a great time.

Stellar!

So my big fat male kitty, Chicken Biscuit, started acting strange today. Stalking around the house, mewing loudly, and acting restless. He went in and out of the cat door, laid down in various places, only to move moments later. Suspicious, I followed him to the litterbox. He got in. Then he got out. Then he got in again. Then he got out. Sighing, I had my husband restrain all 20 pounds of him and palpated his bladder. Sure enough, it was very large and firm. Stellar!

Male cats -- especially fat ones - like to develop urethral mucus plugs. These are little faux stones, made up of grit and debris. I figured I was dealing with that, as it is the more common cause of urinary obstruction.

We packed him up and took him to work. He got a urinary catheter, and we xrayed him to make sure it was in place. Imagine my surprise (and great displeasure) to see that he actually had stones! Not just bladder stones, but also kidney and ureteral stones. His kidney values were also slightly elevated - indicating either dehydration or imminent renal failure.

So, he's at work, getting IV fluids and pain medications. He has an indwelling urinary catheter. If his kidney values come down, then he will have a cystotomy to remove the bladder stones on Friday. There's nothing to be done about the ureteral and kidney stones right now. He only has one good kidney, as one of them has shrunken down - likely from a previous obstruction. It's not great news, but hopefully the good kidney is still functioning and un-obstructed. I'll let you guys know what happens.

Bang up way to end the weekend

Last night, I got to work at 7pm and hit the ground running. Within 30 minutes, I had a bloat patient, a dog in fulminant heart failure, a limping dog, a cat with a fever of unknown origin, and a dog that was down in the rear. I ran for the next 8 hours, stopping for some dinner around midnight.

My bloat patient was a surprise. It was a rickety-looking, old dog (11 years old). She didn't look particularly well cared for, and I expected to euthanize her when I gave the owners the $2000 surgery estimate. Imagine my surprise to find that she was up-to-date on her vaccines and heartworm preventative, spayed, and much loved. The owners did not balk at the financial expenditure in the least - telling us to do whatever was necessary.

Bloats can be incredibly rewarding surgeries. If the stomach hasn't started to die from twisting on itself, and the patient is otherwise fairly stable - they can do really, really well. This dog came in laterally recumbent, her sides so tight she was about to pop, breathing heavily. I stabbed 3 giant catheters into her side to relieve the gas distention, and within minutes, she was deflated and breathing easier.

Her stomach looked great in surgery, and afterwards, she was up and wagging her tail! The owners were thrilled and so thankful.

I saw 2 heat strokes this weekend as well - one came in non-responsive and blind. The owners committed to the financial expenditure, and after 2 days of intensive care, she was up, wagging her tail, eating, and could see just fine. She went home on Sunday night.

When ER work is rewarding, it is intensely rewarding. I felt like I had at least 3 solid wins this weekend, and that makes all the difference in my mental health!

Our suite

This is where we're staying...I'm very, very excited!!

2011

So, I had a little breakdown yesterday as the weight of 2011 descended on me full force prior to work. Looking back over the year, I realize that it hasn't really been a very good one in many ways.

My aunt found out about her cancer and underwent chemotherapy and shortly radiation therapy. My mother sufferd severe blood loss and was hospitalized for blood transfusions, followed by a hysterectomy. My grandmother has been hospitalized twice for either minor strokes or complex migraines (or both). My father underwent invasive cardiac surgery for his angina, and my cat was euthanized unexpectedly for cancer at the age of 3, while we were away.

Thursday night, after working a relief shift at the local 24 hour clinic, I got home to find my latest foster kitten vomiting and acting strange. We'd been calling him Grub. Someone found him by the side of the wound and brought him to work. He had a huge, infected wound on the side of his neck, and living in it was a Cuterebra ("wolf worm"). He was a terrified little thing. Every time you approached him, he hissed and spit. He was also adorable. He looked heavily Maine Coon cat - with tufted ears, giant paws, and incredibly soft fur. I took to him immediately.

He's been at our house for the last couple of weeks, and I had grown quite attached to him. He turned into the friendliest kitten. On Thursday night, he vomited twice and acted very disoriented. Over that night, he became more and more ataxic. He woke me up around 10am the next morning, staggering. I planned on taking him to work with me Friday night, so I tuckd him into our bed and went back to sleep. He woke me again at noon, this time totally blind, frantic, running into walls, and mewing.

Due to his incredibly quick decline, I euthanized him at home. It felt terrible, and I just laid in bed and cried and petted him while the Euthasol did its work (since I had no technician to hold off a vein, I injected it into his peritoneal space, which is painless but slow).

The worst of it is that I don't know what the wound on the side of his neck was. It could have been a bite from another animal. Last week, while playing roughly, he bit me on the finger and broke the skin the smallest amount (enough to draw blood but not enough to really hurt). Thus, I was forced to submit his head for rabies testing. It's not a great likelihood...but it exists, and I have to be safe.

Lately, I feel like I've been working so much. The pace at work has picked up steadily, as it does every summer. I am worn out most days, my ankles are swollen, and I have more trouble sleeping then I once did. I also picked up a relief shift at the 24 hour place this week on one of my two nights off. It was a mistake, as I am about worn to a fray.

It's just been a crappy year in so many ways. And yet, this is the year my daughter will be born. It won't be all bad.

I am working on being thankful for the things that are going well - the fact that my father is recovering very well from his CABG surgery, my mother did NOT have cancer and had everything taken care of in time, my aunt has come through chemo and is cancer free at this point, and my grandmother is still doing well. It could have been much, much worse. I need to focus on that. I also need to get some rest. Next weekend, my husband and I, as well as my best friend and Jim's brother, are going to stay in a B&B for some much needed relaxation. My BF/SIL is 8 weeks pregnant - so we're taking advantage of this and pampering ourselves. I cannot wait.

Bones cont'd (part 2)

Lori went to her veterinarian for the day come Monday morning. She reportedly did very well. Normal vitals, normal physical exam, drinking, urinating, but reluctant to eat still. At 5:30, a colleague examined her, found normal vitals and a quiet dog. She sent her back to us for overnight monitoring. That clinic is 2 miles down the road from us. The temperature was around 90 outside. When Lori arrived 10 minutes later, she was laterally recumbent, spewing projectile brown vomit, with a body temperature of 105.

My heart sank. Was her intestinal incision failing? Were her intestines leaking? Was she becoming septic? Bloodwork did not confirm this suspicion, and after treatment with an anti-nausea medication, IV fluids, and cooling, her body temperature was normal, her vitals were normal, and she completely came around. Flummoxed, I assumed I was dealing with either a heat stroke or a manifestation of malignant hyperthermia - a problem that Greyhounds are genetically prone to having.

The owners were understandably distressed about this sudden shift and elected to take her to the 24 hour clinic in the morning, so that she could finish convalescing in one place and not have to be transported back and forth.

I sent a stable, quiet, alert dog out the door. When she left, her blood sugar was stable, she was not vomiting, she did not have a fever, and her belly was not painful. Her abdomen was severely, severely bruised - secondary to surgery. Greyhounds have very thin skin, and as a result, bruise like peaches. One of her clotting times was VERY slightly elevated- and I mean very slightly (4 seconds).

When she arrived at the specialty hospital, she remained stable. The intern, a new graduate, talked to the owners and gave them the same spiel I had. Dehiscence of the surgical site could happen any time in the first 3 days, she might need a plasma transfusion if her clotting times continued to elevate, and the like. It was nothing that I hadn't told them already.

They signed the consent to treat agreement, left a deposit, and left Lori in the care of the ER doctors. Five miles down the road, they turned around, came back, and elected to euthanize her!! She was stable, through the worst of it, and recuperating/convalescing. Apparently, the owners had had too much. They were concerned about Lori's quality of life. They were done in.

I am devastated by this. What I found in surgery -was it a red herring or was it truly causing her pain? Had I not taken her to surgery, would she have recovered with IV fluids and pain medications? Had I done more harm than good? Barring finding something on histopathology like cancer or severe inflammatory bowel disease... I will never know if what I did was right or wrong.

It was such a frustrating case.

Here's a diagram of what it looked like...

Them bones, them bones...

I had an ultimately unrewarding and very sad case this past weekend/early week that has left me questioning my medical decisions and management.

Over the weekend, I was presented with a 10 year old, female spayed sighthound breed named Lori. She had been fine that morning. She ate her breakfast, went for a walk, and seemed normal. Then she became restless, needed to go outside frequently. The owners walked her and noticed that she seemed to be straining. They thought she was straining to urinate. She would not rest. So they brought her to us.

On physical exam, she was a fit dog. Vitals were totally normal. The only significant finding was a very, very painful caudal abdomen. I could not feel her bladder she was so painful and tense. My initial thoughts were urinary tract infection, bladder stones, or bladder cancer of some sort. I recommended a urinalysis and xrays of the abdomen.

Urinalysis showed absolutely nothing. Xrays, on the other hand, were quite interesting. Lori's small intestines were massively dilated. The radiologist (and I) thought she was suffering some sort of obstruction. But what? She wasn't a chewer, she had no evidence of cancer...so what was obstructing her bowel? Bloodwork and vitals were totally normal.

Based on the xrays, I recommended exploratory surgery. We discussed that we could wait, try IV fluids, pain medications, and simethicone for gas, but since Lori was currently so stable, the owners wanted to proceed with ex-lap. I agreed with this decision.

What I found was so out of the realm of my experience that I was forced to call in an older, much more experienced veterinarian. In the middle of Lori's small intestine was a 1.5 foot section of massively dilated bowel. It was healthy, it was pink, and it had normal peristalsis. It ended in a blind sac (a diverticulum)! Out of the diverticulum came normal intestines, continuing on their merry way. It all looked healthy and like it had been present Lori's whole life. I had never seen anything like it.

After much discussion with the other doctor and weighing of pros/cons and other options, I elected to remove this area of intestines and send it for histopathology. I carefully anastamosed the ends of the jejunum together and patched them with omentum.

Lori recovered well from surgery. She was awake and alert within about 40 minutes. She spent the night with us and went to her veterinarian the next morning, doing well.

The rest is to be continued...

Ugh...it's starting to wear a bit...

So, it's getting harder with work. I'm having trouble being awake and alert past 2 am. Since I often see patients at that time of morning, this can be bad. I'm also starting to really have trouble getting down on the floor with big dogs. My ankles swell like mad when I stand for too long, and I move really slowly - which makes me worried I'm going to get bitten by a quick dog that gives no warning.

Lastly, I'm starting to really lose patience with owners that act stupid or belligerent or whatever. Usually, I keep my mouth shut about stuff - but lately, it's getting harder. Take today, for instance. A woman brought in her small breed dog with bloody diarrhea and vomiting. In the midst of taking a history, a very, very unstable/critical patient presented. I had to deal with that for about 45 minutes, but we already had permission on the other patient to run bloodwork.

After reviewing the bloodwork, I went back in and spoke to the owner, recommending 12-24 hours of hospitalization for IV fluids and medications. The owner declined and wanted an outpatient estimate. I produced this in about 5 minutes, handed it to the tech, and turned to my other patients.

From arrival, filling out paperwork, technician triage, doctor exam, bloodwork results, and two estimates - the client had been at the hospital for 2 hours. That's pretty damned fast. But no. She was angry. She declined all treatment and wanted to leave. Normally, I don't argue with people like this. This time, I counseled her heavily that her dog needed treatment. She claimed she'd been sitting in the hospital for 3 hours. Luckily, we track those things (time of check-in, triage, and doctor's exam). I showed her that she had only been there for 2 hours, then implored her to wait 15-20 more minutes so that we could appropriately treat her pet.

Nope, she wasn't having it. She just wanted to complain. I shrugged my shoulders, told her that her dog was very ill, didn't apologize, and made her sign an against medical advice form for taking her dog home without treatment. When I mentioned that the dog I had stepped out to care for was now dead, I was met with a blank stare. The woman could care less. I had the overwhelming urge to slap her.

Ahh, pregnancy hormones.

In other picture news (check out my cankles below)

For some reason, my garden has taken off in the last few weeks. The tomatoes have been very sluggish to ripen, some of them rotting on the vine before they're ready to eat. I've read in many different forums that this is happening to a lot of people due to the heat/humidity this year. Today, it is 70 degrees and overcast. I can practically hear the garden growing. I went out to harvest and was amazed at the abundance. It certainly wasn't like that a couple of weeks ago. My green peppers, which were completely worthless last year (produced 1 pepper) have exploded, and now the three plants are dripping with peppers - big fat ones. The cucumber vines are even more amazing. I counted no less than 12+ rapidly growing, almost ready to pick cukes, and a whole host of baby cukes. This ... all from 2 small/medium sized garden boxes. It's really amazing what you can do in your own backyard. Now, if I could just keep chickens for eggs, and cows for milk, and learn to churn my own butter...

Holy cankles

After 2 13+ hours shifts.

How to make a night in the ER extra super fun...

My least favorite surgery is hands down a c-section. They are bloody, stressful messes without fail. The bigger the dog, the worse the c-section. So, at 9:00pm last night, in rolls a 140 pound South African mastiff (called a Boerboel). She had not produced any puppies in 8 hours, after pushing out 2 monstrous (2 pound+) puppies.

It was an instant headache, and I'm not exaggerating. My neck and back immediately became tense, and I felt a headache spread over my temples, neck, and down into my back.

The bright side to this was that we'd seen and dealt with this owner multiple times before. She always takes our recommendations, doesn't complain about cost, and pays here often very expensive bills in full. I knew we wouldn't have to mess around with xrays and ultrasound and oxytocin. If c-section was the way to go, the owner was on board.

As it turned out, c-section WAS the way to go. The dog's cervix was severely inflamed and swollen, and she had struggled mightily to squeeze out her last puppy - a 2+ pound male. After that, she had just stopped. I could palpate at least 2 more puppies in the uterus, which seemed a small litter (4 total, her last was 12!). We discussed options and decided that c-section was the way to go.

Despite hating this surgery, it went surprisingly well. I was also being shadowed last night by a very young, enthusiastic master's student at the local college (22 years old...it made me feel kinda old). She was absolutely DELIGHTED to get to see a c-section. It was rather fun to be on the teaching/explaining end and to see such delight in something I absolutely hate!

Mom recovered rapidly and well, and both of the enormous puppies we pulled out did great. All went within 4 hours of presenting to our ER - which is not the norm with c-sections. It always helps to have responsible owners who don't waste time!

Oh, and nursery/baby/dad stuff

If anyone is interested, this is the theme I'm using for the nursery. I'm going for more jewel-toned blues and greens, less pastel -but overall, the same effect.

http://www.chiccheapnursery.com/2011/real-rooms/childish-and-serene-nursery-featured-real-room/

Eva is growing amazingly fast. I am now 28.5 weeks and officially in my 3rd trimester. I can feel her roll, kick, punch, and flutter around in there most of the time now. It's a singularly odd feeling. We've started our Bradley method of natural childbirth class. It's going well, and every day that I do more reading and feel more comfortable being pregnant, I become more sure that natural is the way to go. I'm very excited about labor and delivery, instead of scared...which is something I never expected.

I am awesomely fat, having gained 34# already. It's not the target weight, but my husband has been working hard to ensure that I eat well, and the Bradley class focuses heavily on nutrition initially, so I am making much better food choices, I hope. It used to bother me a great deal and still sometimes does, but I'm letting my body take the lead here and do what it needs to do...after all, it knows better than I.

My father is home and recovering very well. He has been out of atrial fibrillation since discharge, so that's encouraging. It's been hard on my mom, and I think they are still struggling with the post-op aftermath and stress. I plan on going down there at the end of this month for a few days to provide some relief.

You're not intimidating us...sorry, sir.

Early the other evening, our doors burst open, and a huge, burly man (we're talking 6"7 or so) flew in with an ambulatory, excitable Pit bull. Said Pit bull had been hit by a car and thrown about 15 feet into a ditch. Now, he was exhibiting a head tilt and was walking in circles.

We took the dog from his owner and gave him paperwork to fill out. My receptionist went into the room and gathered up the papers, while discussing our exam room fee with the owner ($92). Sure enough, he "didn't have a cent to his name." He looked at my receptionist and said, "Surely, you ain't gonna let a dog suffer just 'cuz I don't have no money," in a deeply scornful, vaguely threatening voice.

My receptionist is about 5"2, so she was intimidated and came back to relay the problem to me (also 5"2 and noticeably pregnant). I was instantly incensed. The dog, according to the paperwork was unvaccinated and not on heartworm preventative. Further, he was not neutered and was allowed free roam. The owner had basically made the choice to let his dog roam free, intact, and be hit by a car. Now that the dog had been hit by a car, he was trying to make it our problem. In reality, it was HIS problem, since he let the dog run around in the first place (and un-neutered, free roaming pit bulls are not a good idea anyway).

Luckily, my 6"2, burly male technician was working that night. I sent him in to deal with Mr Belligerent. The conversation went like this,

"I ain't got no money, but surely you aren't going to let my dog suffer."
My technician, "Sure, we require a $92 exam fee, and then the doctor can come in and discuss the options with you."
"Well, I ain't got no hunnert dollars."
My tech, "Would you like to apply for CareCredit? Or make some phone calls?"
Sullen silence, then, "I want to talk to the doctor."
Tech, "The doctor is busy with other patients."
More silence, then, "Well, I'll leave this up to your conscience." Then he storms out of the room and sits down in the lobby.

For what it's worth, the dog appeared stable. He was walking, wagging his tail, and alert. I DID examine him, despite the lack of finances. I wouldn't let a dying dog walk out the door.

My technician gathered up the dog and took him back to his owner, handed him the leash, and said, "please let us know if we can help in any other way."

The man sneered something nasty at him, at which point my tech replied, "well, sir - you can't go to the grocery store, fill up your cart with groceries, and expect to get them for free."

"No," he replied, "But I can go down to human health services and get money for food."

Unbelievable.

Needless to say probably, but he took his dog and left. We didn't hear from him again that night.

Squirrels with harpoons

The things people say sometimes can really crack me up in the ER. Case in point last night - a youngish, normal looking guy brings in his 60+ pound mixed breed dog. This is a big dog, hefty. Said dog has a nasty sucking chest wound right in front of his shoulder. The hole is only about quarter sized, but every time the leg is moved forward - a sucking noise is heard. This indicates that the hole is much deeper and penetrating into the chest. The dog was pretty stable with only a mild pneumothorax.

After discussing the treatment plan with the owner, I casually asked what he thought had happened. Apparently, the dog loved to run in the woods full tilt after squirrels. Oh, I thought to myself, so he impaled himself on a stick or something. The owner however, looked me square in the eye and said **in all seriousness**, "I think he was attacked by a squirrel."

All I can say is that a squirrel that would attack a hefty dog like that must be either supremely confident, rabid, or armed with a grenade tipped harpoon.

Exhausted

So, after getting home at 1am on Friday night, I worked a 14 hour shift on Satuurday, and a 12 hour shift on Sunday. We were busy enough both days to keep me on my feet the majority of the time. When I got home, both ankles were swollen so badly that I could feel the edema jiggling around inside of them. Today, they hurt, and I have to work tonight. I'm hoping this doesn't get worse, but I guess we'll see.

Dad's surgery was more mentally exhausting and stressful than I thought it would be. As someone in the medical field, used to seeing very ill, injured animals, I thought I was prepared for the medical aspect of things. When my mom and I went up to the ICU to see him immediately post-operatively, still intubated and on the ventilator, I actually cried. Yes, I know I'm pregnant and all, but there's a big difference between my patients that are on ventilators and my father. The second time we visited, he had started to wake up from the anesthesia and had been extubated. He was incredibly dysphoric, trying to roll from side-to-side, and moaning. More discrete crying ensued.

The third time we visited that evening, he was awake enough to talk to us, but in a great deal of pain. Since then, he has been making a slow recovery. He was able to walk the day after surgery, and he actually walked from his bed in ICU to this bed in the step-down unit. He was coherent most of that day, but then he had a really bad day - a great deal of pain and drug fogginess. In fact, Saturday and Sunday were very rough, per my mother's report.

Today, he is eating and talking to my mom pretty normally. He's having intermittent atrial fibrillation, which isn't an uncommon consequence of invasive cardiac surgery, but otherwise, he is doing very well. I plan on going back down once I'm off come the end of the month, just to help my mom out.

And interesting and disturbing thing happened to me at work yesterday. I was so tired I couldn't see straight, and all I wanted to do was be at home with my feet propped up. It made me totally apathetic about my cases and that was a scary development. Normally, I relish the complexities of medicine, figuring out a strange case, making a pet more comfortable. Yesterday, I was just clock-watching. It wasn't a pleasant feeling, and I worried that my apathy would affect my patient care. We'll see how it goes tonight.

Dad

My dad's bypass went well. He was in surgery for about 4 hours and wound up with 3 bypasses. I will give more details for those interested in a few days. We didn't get home till close to 1am last night, I worked all day today after only 5ish hours of sleep, I've been at the hospital for 5 days straight and sleeping poorly, and I am just totally exhausted in every way. More to come later.

In one ear...

As of late, I find myself approaching client education a bit differently than I once did. When I first started out as a veterinarian, I would spend a great deal of time in a room with a client, explaining diagnostics, treatment plans, and disease processes. I fancied myself quite the communicator. Lately, I've taken the "less is more approach" - much like human MDs. Whisk in, discuss physical exam findings, recommend some tests, and whisk out. Part of this is necessity - we've been very busy in the ER, and part of this is because of the following:

Over the last 2 years, it has become readily apparent that people just don't listen. Or even if they do listen, they only hear and process about 1% of what I say. This has become obvious recently because my technicians will often go into the room after me to discuss the medical plan with the owner. My tech will then come back out and say, "Ms Smith didn't realize that you were recommending Fluffy stay the night. Could you go back in there and explain everything again?" This happens so many times in a weekend now that I'm beginning to question whether it's me or them.

I cannot decide if it's my technique, the owners unfamiliarity with medical topics, the owner's disinterest in medical topics, or the emotional distress most people are under when they visit the ER with a pet. Perhaps it's a combination of all of these things.

So, pet owners out there - answer me this: how can your veterinarian better serve you in the communications department? Currently, I give everyone an informational hand-out regarding their pet's particular disease process (as long as I have a fairly firm diagnosis and a hand-out). I also try to answer questions and pause during my explanations to ask if there are any questions. Still, people don't always seem to "get it."

What could your vet do to better communicate with you?

Developments

So, in non-veterinary news:

1) Baby is cooking along nicely. I am officially 27 weeks pregnant. Pregnancy has been pretty good thus far. I'm starting to have some intermittent hip and back pain, and it's getting much harder to get down on the floor with patients at work - especially the big dogs - but otherwise, things are going well. I did surgery sitting down for the first time - so that was new and entertaining. It actually did help with the back strain, and it wasn't as difficult as I imagined it was. Of course, this was a small dog with bladder stones...so we'll see when it's a 150 pound Great Dane GDV.

Eva is really, really active. I can sit and stare at my stomach in awe - watching her move back and forth. It's very exciting to be able to see and feel her so well. I'm getting extremely impatient to meet her...but I still have about 90 days to go! It will here in a flash, I'm sure.

2) My father is having cardiac bypass surgery on July 7th. After talking to the cardiothoracic surgeon, we elucidated that he has 3 vessel disease - disease of all the major vessels in the heart. As a result, the surgery would be of benefit to him. Since he is stable now, and his heart is in good condition, he is going to go ahead. We're heading home Wednesday night to be there.

3) Eva's nursery is going to be in the current cat/bird room. It has 3 bird cages and 3 litterboxes in the closet. We needed a place to move the litterbox, so we installed a cat door in the window to our screened porch. The cats can now go in and out. Since we put in this door, our cats have defected to the back patio. I kid you not, they spend > 85% of the day outside, lounging uselessly in the sun. Stupid cats. Well, our 3 legged cat stays indoors, since he abhors all other cats, but otherwise - all the cats are on the back porch. We haven't moved the birds yet. That's stage 2. It will be followed by stage 3 ... painting the nursery. We've already agreed that it's something my husband will do, and I will take no part in. It's better for our marriage that way. This is the color scheme I'm going for with the nursery

4) This weekend was a busy one at work, thankfully. I didn't sleep any of the 3 nights I worked. Today, I'm fairly worn out. We're missing the 4th of July with family - which is disappointing. It's always been one of my favorite holidays. Instead of being with them, we're here. Tomorrow is our first Bradley method of childbirth class, so we couldn't go home, since we're already leaving to do so on Wednesday.

I'll probably be AWOL most of this week, since we'll be out of town with my family. I'll try to post as I can, though.

Happy America's birthday everyone!

Unexpected complication

I recently saw a very sad and frustrating case. "Madeline" was a 13 year old mixed breed dog. She came in to see me one weeknight for generalized lethargy and just plain feeling bad. She wasn't energetic, she seemed kind of dazed (to the owner), and she wasn't interested in her favorite treats. This had happened rather drastically - in the span of 1 day. When I first examined her, I cringed inwardly. Her gums were a muddy, pale pink, she had a slightly increased and labored respiration pattern, her heart rate was higher than it should have been, and her pulses didn't feel great. When I palpated her abdomen, I could feel a possible mass near her rib edge, and she seemed a bit distended. My spidey sense was tingling - telling me I was dealing with the all too common hemoabdomen of large breed, older dogs.

I see this condition all the time in big, old dogs - a belly full of blood secondary to a ruptured tumor (usually spleen or liver in origin). Us ER vets develop a 6th sense for sniffing this out. Sure enough, xrays confirmed mild to moderate abdominal fluid and a big nasty tumor on the spleen. Ultrasound showed it to be growing from the spleen, and abdominal tap yielded frank blood. Luckily, Madeline was not suffering a catastrophic, life-ending hemorrhage. She was actually pretty stable, and the bleed seemed to be slow.

Her owner was not ready to commit to surgery, and he wanted to seek a second opinion (understandable, given the gravity of my diagnosis). So, we hospitalized Madeline for the night on IV fluids and monitored her. In the morning, she was slightly more anemic but otherwise stable. She went to her veterinary where I fully expected the owners to decide to euthanize her.

Imagine my surprise to come back and find her back in the hospital post-operatively. The owners had decided to remove the tumor, despite the high likelihood that it was malignant cancer (hemangiosarcoma). The prognosis post-tumor removal is only 6-12 months, depending on adjuvant chemotherapy. Still, the owners wanted to try, so to surgery they went.

I was happy for my patient. Madeline was a sweet, good dog with a waggy tail She would have a few months left with her owners until the tumor metastasized, and those would be good months. Or so I foolishly thought.

Madeline remained stable throughout the day, eating, drinking, and resting quietly. Her PCV stayed stable, indicating no significant post-operative hemorrhage. Then at 7:00pm, as my shift was ending, she suddenly developed diarrhea. She then vomited a large amount of foul-smelling liquid. Shortly afterwards, she began to sway, then she collapsed. Her gums were white, and her BP plummeted. I was flummoxed. The white gums and BP seemed to point to internal hemorrhage. But what of the vomiting and diarrhea? Where did that come from? We tried to stabilize her rapidly, but her condition continued to deteriorate. Abdominal tap yielded frank blood with a PCV very close to the PCV of Madeline's circulating blood. An internal bleed? But why?

I gave the owner a grave, grave prognosis. To my shock, he elected to re-explore Madeline's abdomen and find out why she was suddenly in such dire condition. We prepped her for surgery as fast as we could, but her condition was spiraling out of control. While we prepped the OR, we transfused her a unit of packed red blood cells as rapidly as they would go (over 20 minutes). This is certainly not the norm. Usually blood transfusions are given over 2 to 4 hours. Madeline was dying in front of us, so we didn't care. The blood was cold too, but our options for saving her pre-operatively were running out. We ran with her into surgery, and as we got her on the table, her heart stopped. We pumped her with atropine and epinephrine while breathing for her, and her heart rate came back.

I slapped some sterile towels around her incision, as there was no time for a drape. Ignoring the staples from the previous surgery ( which would have taken 10 minutes to remove), I slashed my way down her midline alongside the first incision. Opening her abdomen, blood came pouring out. We started suctioning madly and that was when I saw it. Madeline's entire GI tract - from stomach to colon - was thrombosed. Her stomach had turned a dark purple and was covered in petechiae and ecchymotic hemorrhage. Her intestines were swollen and red, and throughout her mesenteric fat, all of the vessels were engorged with blood clots. No pulses beat at all in the vessels that supplied her GI tract. I pulled out her pancreas and stared in awe at the completely engorged and thrombosed organ.

Madeline could not be saved. Her entire GI tract was full of clots, blocking blood flow to the organs. This likely happened secondary to the large tumor that was removed from her spleen. Many of those tumors are malignant hemangiosarcomas, and many of these dogs are suffering subclinical disseminated-intravascular coagulation. A post-operative complication of splenectomy can be massive thromboemoblic disease. Sadly, it was not the first dog that I've seen with this complication. She was the second. The first dog I saw developed this a week post-operatively! It's not common, but when it happens, it is massive, incredibly acute (Madeline went from normal to vomiting, diarrhea, and collapse in 30 minutes), and fatal.

I felt terrible for the owner. He had taken Madeline to surgery with the expectation of spending several more months with her. Now, he had to stand by and helplessly watch as she died. He was with her as we prepped her for surgery and transfused her, so at least her last moments conscious were with her owner but still. It was a crushing and unexpected disappointment.

How can vet school better prepare veterinarians?

This question was posed way back on a post I wrote about disillusionment with the veterinary field, and I've been meaning to get back around to it.

Here are my gripes with the veterinary curriculum as it stands:

1) Lack of tracking (at least, at my school). Everyone must take all classes - equine surgery, food animal medicine, exotics and wildlife.

2) Lack of applicable real world experience in the 3rd and 4th years.

3) Focus on extremely advanced diagnostics (MRI, CT scan) and treatments (linear accelerator, radiation therapy, ureteral stenting) instead of focus on "real-world" medicine and approaches.

4) Black and white, wrong and right answers. Shades of grey are not taught.

5) No classes on client communications, financial management, or anything to do with money.

So what are the answers to these problems?

First and foremost, I am a strong proponent of tracking. Everyone takes the same basic sciences for the first 2 years - anatomy, physiology, microbiology, clinical pathology, etc. After that, the classes become more specific. At that point, tracking should start - equine, food animal, small animal, and exotics/wildlife. Many but not all schools are starting to do this.

I cannot tell you how much I felt like 3 months of my 4th year were wasted in the barn. Everyone must rotate through 1 month of ambulatory services, 2 weeks of food animal production, 2 weeks of equine surgery, 2 weeks of overnights, and 2 weeks of equine medicine. That was 3 months that I could have been focusing on my chosen area - small animal medicine. Instead, I was a glorified technician, running around the barn on overnights, taking care of sick cows and sheep and pigs. Did it have its fun moments? Absolutely. Ambulatory was great fun, even in the dead of a Southern summer (July/August). It was still wasted time in which I could have been learning how to deal with the real world.

Secondly, there was no real world experience in 4th year. We were given 1 month to do externships. This may sound like a lot of time - but when compared with the other 14 months of rotations, it really isn't. My alma mater is trying to change this. They recently introduced a "Community Practice" to the vet school. This is staffed by students and a couple of the doctors at the school. It provides vaccines and spay/neuter services, which is excellent. It is one step towards making vet school more real world friendly.

Third, the focus on advanced diagnostics is too intense. It is great for us, as veterinarians, to know that CT scan is available, that radiation therapy can treat brain tumors and other disease. It's unlikely that most of us will have clients in this economy that will go that far for their pets. Classes and clinics should focus more on how to approach problems in a realistic and financially feasible way. Sure, it's great that my patients can have chemotherapy if they need it. Most people cannot afford $3000 to treat their pet for a benefit of 9-16 months.

This is hard for vet schools to do, admittedly. Most people coming to the vet school are there to spend any amount of money at whatever outcome. Thus, you spend a lot of time learning how to do echocardiograms, interpret CT/MRIs, and very little time learning how to administer steroids intelligently, and when to use antibiotics and when to avoid them. Part of this is unavoidable and goes back to the need for a community practice (which the school has done, admittedly).

Fourth - black and white answers. When I was in vet school, I was taught "steroids are absolutely wrong unless a definitive diagnosis is obtained." Now, steroids are massively overused and abused. I will admit that freely. Instead of teaching us to use them responsibly however, we were scared away from them altogether. Steroids are a useful tool, when used correctly. The veterinary field is full of useful tools - but they must be applied at the correct time and to the correct diagnosis (or suspected diagnosis).

At the vet school - we almost always got answers - through invasive and advanced diagnostics. In the real world, clients frequently tie our hands due to financial and personal limitations. Thus, we are left guessing at the best diagnosis and treating as best we can. Nowhere is that approach taught in veterinary school. In our case-based laboratories, we also always got an answer - usually after extensive full bloodwork, urinalysis, xrays, and a CT scan. This is not real or practical.

These laboratories should have focused more heavily on generating a problem and differential list, followed by empirical treatment based on suspected diagnosis. Then and only then should the answer have been revealed.

Lastly, we are taught no client communication skills. We are not prepared for the fact that we will act as a psychologist, financial advisor, therapist, priest, and every other niche at some point. When I first entered the real world, I had no idea how to talk to people about money. I had no idea how to ferret out what financial resources and expectations individual clients had. The first year was full of friction as I learned to deal with people, their financial and personal problems, and how to do the best I could with the least amount of resources.

This would be remedied by veterinary schools having client communication classes, simulated clients and patients, and more, more, more, more, MORE real world experience. Those 3 months I wasted in the barn could have been spent on externships at private practices - learning about the field that I was shortly to join.

These are just my thoughts. Does anyone have others?