Friday, December 30, 2011

Status quo

I haven't blogged because I've been off work for 9 days (delightful), and my first 2 nights back were very dull. I think that's a good thing honestly. Every time I start wishing for a difficult case that requires intensive management, I remember my first week back to work and the 3 incredibly challenging and scary surgeries I did. Then I'm thankful that winter is slow and that I can get 6-7 hours of sleep per night at work. At least for now. Work is the only time I get much sleep!

Christmas was lovely. We spent a week with our families. I feel particularly lucky to not only have a wonderful family of my own, but for the fact that I love my in-laws so much and get along with them so well. Evaline was spoiled by constant loving attention. I think she has been somewhat dissatisfied with the relatively lower level of attention she's been getting since we came back (fear not, she gets PLENTY of attention).

My metastatic cancer patient (the partial liver lobectomy, etc) is doing very well at home. The owners are pleased that we bought him some time, and so am I. I questioned myself heavily on whether I had done the right thing for the dog and owner. Knowing he made it through the holidays with his family - and made it through happy and bouncy - was a great relief.

Today is my husband's birthday, but we have no exciting plans other than a nice dinner at home (chicken pot pie, his favorite) and spending time with the butterbean. Life is pretty awesome right now.

Wednesday, December 21, 2011

Another rock and hard place story

I was confronted with a very difficult situation recently. It was difficult on many levels and forced me to make some hard decisions. One of the major ones was finances, as it always tends to be.

I was presented with a less than 1 year old, female Labrador retriever. This Labrador was DEPRESSED. She could barely lift her head, and she noticeably winced when I palpated her abdomen. She'd been vomiting for 24 hours, unable to hold anything down. On a rectal exam, there were absolutely no feces in her colon. She was extremely dehydrated. Everything told me that she had a foreign body. Xrays confirmed it. Not only was it a foreign body, it was the nastiest of the nasty: a linear foreign body. Her intestines were bunched tightly on each other - like a tightened drawstring.

Sighing, I went to deliver my recommendation for surgery to the distraught owners. They'd come through the doors with zero finances and had applied for CareCredit right away. They were really nice people, and they owned a really nice dog. That automatically equals a bad's one of those stereotypes of ER medicine. Nice owner, nice pet = bad disease.

At any rate, given how sick the dog was, I suspected that the linear foreign body might have already poked a hole in his intestines. Surgery was indicated right away. I made up an estimate - being as conservative as I could (no pre-operative bloodwork, etc). The low end was $1600. The high end was $1700. This was being CONSERVATIVE, mind you. Really and truthfully, the estimate should have been at least $2100-2500.

They were approved for $1500 only with CareCredit.

My options? 1) Doing the surgery knowing that it would cost more, charging them full price, and billing them 2) Doing the surgery and discounting the bill steeply 3) recommending that they wait until the next day to see their regular veterinarian so that they could have the surgery done cheaper (but risking the dog dying and/or the internal scenario worsening significantly overnight) or 4) euthanasia.

These people were nice. They applied for credit, as we'd requested. They got a stout $1500 approval. It still wasn't enough. If they waited on surgery, the dog would either die or be in a much, much worse situation by the time surgery was conducted. If they did surgery with me, it would be much more expensive than $1500. Further, it would leave them NO funds for transfer to the day veterinarian. The dog would not be able to go home in the morning; it would have to go to a day veterinarian, which would also cost money (all of which I would've spent).

What to do?

What I did was gave them the $1600-1700 estimate, deciding to roll with whatever happened. Of course, it was the worst it could possibly be. There was a small hole in the intestines. There was string/fabric throughout the small intestine. It was a long, frustrating surgery. I had to make 5 enterotomies (openings in the intestines), cut out about 3 inches of intestine, and open the stomach. Instead of taking me the projected 1 hour it generally takes me, it took me a full 2 hours. I knew this dog would have a long and rough recovery with a high chance of dehiscence at one of the sites, at least.

The final bill was $2300. I deducted that down to the high end of the estimate - meaning I knocked off $600+. Further, I stayed after my shift by about 3.5 hours to do this difficult surgery. Time I could've spent with my daughter, who I'd barely seen over the last few days due to my work schedule. Lastly, I made no money on that surgery. Deducting the $600 meant that I deducted off my production. Thus, I spent 3.5 hours of my own time on that dog.

And yet, people call vets money-grubbing.

The patient had a rough recovery and spent 9 additional days in the hospital with his veterinarian. I called to apologize for sending a new patient (the owners had just moved into town) to this clinic with no money. I'd spent it all. I had to. I had to cover the expense of surgery (i.e. doing it at cost), since I was not free to give away clinic supplies.

It was a very difficult and frustrating scenario, but the dog is alive and home with the owners' young daughter for the holidays. That's what matters to me.

Sunday, December 18, 2011


My first "rotation" back has been a combination of insanity and utter boredom. This weekend has been dreadfully slow, but the past week was full of crazy surgeries and sick patients. Balancing motherhood and work is difficult, as I expected. What is not difficult is pumping milk. I thought that I would have a hard time, but that part of the transition is going very smoothly. Evaline has also graduated to sleeping in her rock-n-play, a small, cradle-type bassinet. Of course, when I'm home, she sleeps in bed with me. I have to take advantage of all the snuggly baby time I can get!

On the work front, I was faced with 2 very difficult scenarios this week, both placing me between a rock and a hard place. Having been away from work for 2 months, my decision-making skills were a bit rusty. I also find myself equivocating more. Decision making has been become very difficult. I don't know if this is sleep-deprivation or something else.

In one case, I was faced with a very elderly (15 years old) large breed dog with an abdomen full of blood. Common sense told me that this was in all likelihood a ruptured abdominal tumor - likely splenic or liver. I expected the owner to choose euthanasia, but he opted for surgery instead. Despite finding that the dog was suffering a coagulopathy (difficulty clotting his blood), the fact that he was very old, and likely suffering a seriously malignant cancer, the owner wanted to give him the chance for some more time at home.

I offered referral to a specialist for the surgery, as I was unsure what I would find surgically. A ruptured splenic mass is no problem. A ruptured liver tumor is another story altogether. The owner debated for a while, but he eventually elected for me to do the surgery.

To my dismay, it was a ruptured liver tumor. Large, necrotic, and friable, it was growing on the right caudal liver lobe. Thankfully, it was easy to expose that part of the liver. Unfortunately, it had metastasized throughout the mesentery (fat cushioning the intestines and providing blood flow), and the spleen had several large nodules. I wrestled with the decision of whether to recommend euthanasia for metastatic cancer or to do what I could.

The dilemma here is that all hemangiosarcomas (the most likely tumor type) have metastasized by the time of discovery. They are incredibly aggressive tumors. In some cases, the metastasis are microscopic, and in some cases, they are macroscopic/grossly apparent. Most people will recommend euthanasia for grossly metastatic cancer. In this case, I was really conflicted. The owner wanted more time with the dog. He wasn't under any illusions that the dog would survive long, but he wasn't ready to say goodbye.

With that in mind, I set to work removing part of the liver. That in itself was a challenge, as I'd never done a partial liver lobectomy before. Once the tumor was out, I removed the spleen too. Finally, I went through the mesentery and removed the small nodules, as well as one very large (lemon-sized) tumor. I flushed his abdomen, said a little prayer, and closed him up.

He woke up very slowly. Blood started to ooze from his incision (not surprising, given his high clotting times). It took him a long time to even lift his head up. I was not optimistic. That morning, my technician and I transferred him to a nearby day clinic. He spent the day getting blood/plasma transfusions, then was transferred to the specialty clinic the next day.

The amazing part? Yesterday, he was barking, whining, eating, and acting like a totally normal dog. He went home with his owners to spend whatever time he has left at home. As usual, I question whether I did the right thing. Should I have woken this dog with obviously metastatic cancer from surgery? Should I have euthanized him on the table? Should I ever have done surgery in the first place?

Right now, I feel good with what we did. He's home with his owners, eating and acting like a normal dog. He probably doesn't have long to live, but he's home for the holidays, and that's what matters.

Saturday, December 10, 2011

First nights back

My first night back was lovely and quiet - easing me back into work. My second night? Not so much. Within an hour of my arrival, we had a possible esophageal foreign body puppy, a chocolate toxicity, a Labrador with a GDV (bloat), a Weimaraner with a possible GDV (that's a whole 'nother story), and various other patients floating around. I ran around like a crazy person and then had to go to surgery, which turned into a total nightmare.

I was finally able to lie down around 5am for a couple of hours. My head was throbbing and I was borderline hallucinating from exhaustion. This working mom/ER veterinarian gig is going to be harder than I even anticipated. My mother is here this week, and she has been helping my husband take care of the baby while he adjusts and gets some work done. It's a huge relief to have her here. The only problem? She can't stay forever.

Once I've gotten some sleep and the weekend shifts are over, I'll blog about the FB puppy and the "bloated" Weimaraner. It will have to wait, alas.

Monday, December 5, 2011

Surprise shift

I am utterly exhausted. Evaline has decided to feed pretty much every 2 hours round the clock lately. She must be going through a growth spurt. I was sitting in a stupor in the glider yesterday afternoon, feeding her, when my cell range. The caller ID identified it as work. My husband answered it only to find my colleague on the other end, begging me to come in and help her. It was Sunday afternoon, she had no back-up vet, and she had 3 surgeries to do - a pyometra and 2 traumatic abdominal hernias (both cats). Patients were still filing in.

I agreed to come and help (again, building that good will). I figured it would be a good way to test the waters before plunging back in on Wednesday night.

It was a busy Sunday, and the cases were interesting. I saw a stable, hit-by-car English setter with a dislocated elbow, a cat with a high fever and labored breathing that turned out to have a pyothorax, a laterally recumbent, comatose Boston terrier with likely parvovirus, and a host of other cases large and small.

Truthfully, I absolutely relished being back at work. It felt great to be using my brain again and to be doing something! On the other hand, I missed my daughter pretty soon after arriving. When I arrived home, it turned out that she was rejecting my stored milk (a long story - google excess lipase in breast milk if you are interested). She'd been fussy and unhappy since I'd left, escalating to purple faced crying for about 25 minutes.

So, it's back to work officially on Wednesday night. I go with very mixed emotions. I love my job, and I look forward to being in the land of adults. I really relish the idea of using my brain! On the other hand, I missed Evaline terribly after six hours, and my heart melted with happiness when I got home to her after a short shift. The whole pumping and working thing has me worried, especially with the fact that my breastmilk has such a complicated problem (excess lipase) that must be managed. Further, Evaline isn't on any kind of a schedule at all. She eats and sleeps whenever she wants to. She doesn't "go down for the night" till about 2:30am, although "down for the night" usually means a consecutive 3 hours - 4 if I'm REALLY lucky. Further, she is highly attached and wants/needs to be held a great deal of the time. Lastly, she is used to sleeping in the bed with me, but she can't do this with my husband. She absolutely will not sleep in her bassinet or crib.

To sum it up, there are going to be many, many adjustments for her, for me, and for my husband. I am apprehensive about all these changes and how they will affect her. I know it will be fine in the long run, but I can't help but worry!