The Homeless Parrot

The importance of patterns or, a treatise on how I didn't see that coming (again)

2012-01-30T07:38:00.000-05:00

Part of being a good doctor is learning to recognize patterns. This can generally be agreed upon by medical professionals. A more subtle part of being beyond good and being excellent is realizing when to ignore the patterns so that you don't miss something really important.

Examples of recognizing patterns. A 2 year old, female spayed Poodle presents for generalized lethargy, vomiting, and diarrhea. Addison's disease is an important rule out. An owner that calls and reports that his Great Dane is retching non-productively retching. Think GDV. A 7 month old Labrador comes in for vomiting and not eating, think foreign body in the stomach or small intestines.

These are the patterns that every veterinarian learns. They are important. But they are "stereotypes" as it were. And as with everyday life, these stereotypes are sometimes wrong.

This morning, my colleague saw a patient. It was a 14 year old Golden retriever. She'd been vomiting off and on for a week. She briefly responded to medications, then she started vomiting again. My colleague treated her symptomatically and sent her home.

At the beginning of my shift, the dog came back. She had deteriorated through the day. Her breathing was labored, her heart rate was sky high, and she looked generally I'll. Her case perplexed me a great deal. Her heart rate was so high that I initially thought she had a primary cardiac disease. She was also having an intermittent arrhythmia. Xrays did not support heart enlargement, heart disease, or pulmonary edema, but they were suggestive of aspiration pneumonia. This often occurs in vomiting patients.

Bloodwork was equally unrewarding, being very non-specific and unexciting. I tried a dose of a beta blocker to slow her heart rate. It was unsuccessful. Thus, I assumed that her heart rate was related to something else - pain or dehydration. I administered a dose of pain medication, and the heart rate dropped immediately.

I returned to my xrays, suspicious. Then I talked to the owner and gave her the news. In a 14 year old, vomiting dog that is not responding to therapy, cancer has to be the #1 consideration. The dog's xrays looked consistent with an upper GI obstruction. Masses of cancerous origin can cause this.

After much discussion, we decided to explore her dog's abdomen. Guess what we found? A foreign body stuck in the middle of the intestines! It was a very nasty linear foreign body, but we were able to remove it and leave all of the intestines behind.

The lesson? Don't rule out differentials just because of patterns. A 14 year old dog can eat a foreign object just as easily as a 14 month old dog. Thankfully, I knew I was missing the cause of her problems and kept looking and probing to find the answer. Had I just gone with patterns, I likely would have told the owner cancer until proven otherwise. Instead, we took her to surgery, found the problem, and fixed it.

Work and family

2012-01-25T09:48:00.001-05:00

I received this comment yesterday:

"I am a new reader to your blog and like reading about your vet work. Very interesting--but I would also love to hear how you are juggling motherhood and work. How is your family adapting --esp. your baby?"

The timing couldn't have been more perfect, as I've been meaning to do an update on the work/motherhood situation.

So far, the transition has been mostly painless. It's definitely hard being away from Evaline for long hours of work. I miss her terribly when we're slow. Being busy helps more, as I have less time to think about my darling little girl.

The transition for her has also seemed to be relatively painless. When I started back to work, I was really worried about 2 things - her lack of a schedule and her refusal to sleep well anywhere other than in the bed with me. Amazingly and luckily, those things naturally and quickly worked themselves out when I went back to work. She started to self-regulate and now has a pretty normal schedule of going down for the night at around 10:30-11:30 and sleeping till anywhere from 5:30-7:30. At that point, she wakes up and wants to eat, then sleeps again for several hours. We've had a bit of regression on the sleeping at night lately, but I've read that this is very common at 4 months.

As to sleeping in bed with me, she still does that when I am home (it's the only way I get to snuggle my sweet baby when I'm working long night shifts), but she has no trouble moving into the cosleeper bassinet next to me at night. I find the cosleeper to be helpful when I need good, deep sleep. Evaline is a wiggler and tends to kick and fidget in her sleep. If I need to get a good, restful 5 hours, I nurse her to sleep, then move her to the cosleeper. If I'm off work however, she just sleeps with me.

She does tend to get a bit more fussy with her daddy than with me, and she seems to know when I am leaving and get a tad upst. Otherwise, she is doing great at home with my husband. He is in the final death throes of his mathematics PhD. He has been working on his PhD for years, and it is almost done. Right now, he's struggling to get work finished when I am at work. The baby takes up all of his attention when I'm gone. Luckily, we have family members (my mom, his mom) who are kind enough to come down on a semi-regular basis and help with childcare so that he can prepare for his defense.

Working and pumping has also been going pretty well. There have been a couple of situations in which I've had to go too long between pumping sessions. This has lead to some very painful clogged ducts. Otherwise, I am currently able to pump enough to keep up with her, and I am able to find time to do it at work. That's the beauty of winter in the ER - we're usually slow (although that has not been the case lately).

As to the "sleep deprivation," I find it no more serious than bottle raising 3 kittens at one time. Truthfully, ER has prepared me well for this kind of sporadic sleeping schedule, and other than the first month and a half (when I wasn't even working), I haven't felt like a zombie. I feel like I'm getting enough sleep at home, and I've been able to catch a few hours of sleep every night at work (except for my last weekend on, which was hellish).

All in all, I couldn't ask for a better, smoother adjustment period. It has definitely been hard, and there are nights (like last) where I miss her so much that I call my husband 6 times in 6 hours, just to see how she is doing.

Interestingly, my approach to work is evolving rapidly. I used to be very, very serious about my work. In such a way that I was very one-dimensional in my approach to things. Having a baby and something outside my work to focus so intently on, it has helped me broaden my focus. I think it's having an effect on my medicine. It's hard to explain, but I'll work on it. I'm also not so annoyed with clients and stupid situations anymore. When it boils down to it, I do what I can within the constraints clients place on me, and there's really not much else I can do. It's strange to think that having a child would change this for me, but it really has.

Overall, I'm happier and much more well-balanced. My technicians have all commented on the change. They think I'm glowing. Motherhood does that to you. I love her so much that sometimes my heart is stilled with astonishment.

Well, that's a first

2012-01-24T14:51:00.000-05:00

I was recently presented with a bloated Great Dane. Gastric-dilatation volvulus (GDV/"bloat") is extremely common in this breed. It requires immediate surgical intervention if the patient is to live (see sidebar for more information). The first step beyond physical exam in diagnosing the GDV is a lateral xray of the abdomen. When I took the lateral xray on this patient, it wasn't the typical xray we always see (called the "double bubble"). It was definitely a torsion, but it just looked wrong for some reason. I filed that away for later consideration and went to talk to the owners about surgery. They agreed to proceed.

Now, I do GDV surgery fairly often. In fact, I did one on my last week of work. It went swimmingly - textbook, "caught it early" GDV. This one...far from textbook.

The first clue came when I opened the abdomen. In a typical GDV, the omentum is on the top, as the stomach is torsed 180 degrees, pulling that tissue up and over itself. So it **should** be the first thing you see. Instead, I was staring at a massively engorged spleen. Hemorrhage came pouring out of my incision. My heart did a little skip as my brain computed. What the heck was going on?

I lifted the spleen up as gently as I could, and as soon as I did, blood started to pour out of it. It was then that I realized I was looking at a 360 degree GDV. This is a much less common manifestation of GDV in which the stomach twists completely around. The complete torsion pulls the spleen up and over, so it is the first thing you see when exploring the abdomen. In doing so, the spleen is often torn off of its blood supply, leading to massive hemorrhage.

I'll tell you guys, that was the fastest I have EVER done a splenectomy in my life. That spleen was out in about 4 minutes. Afterwards, the surgery proceeded fairly routinely, as we passed a tube and deflated the stomach.

Our patient recovered mostly uneventfully and will hopefully go on to live a normal and long life. And now I have an explanation for the weird xray. Hopefully should I see one again, I'll be ready for it!

Oh and if you missed it on the sidebar

2012-01-19T09:51:00.001-05:00

I am now a contributor to a new blog called "Veterinarians Behaving Badly." It's hilarious. Check it out.

Bad, bad choices

2012-01-19T09:46:00.002-05:00

Few things irk me as much as people making repeatedly stupid choices when it comes to the medical care of their pets.

I was transferred a case recently that was terribly sad because it was SO avoidable. A mastiff bitch was seen at her veterinarian and underwent a c-section. 8 puppies all told were present, 5 alive, 3 dead.

The dog (Lizzy) had started passing thick, dark, foul-smelling and bloody fluid from her vulva on Thursday morning. Thursday night, she had a puppy. It was very dead. Nothing else happened for 12 more hours. Friday morning, she had another puppy, also dead. The owners still did nothing. Saturday morning, she was very lethargic and had passed no further puppies. The owners gave her a shot of "something" provided to them by a friend. It was supposed to induce labor, but the owners had no idea what the medication was called.

Late Saturday, still no puppies and a progressively more lethargic dog. Finally, the owners decided a trip to the veterinarian was in order.

A c-section was conducted on Lizzy. After surgery, she was not recovering very well. The veterinarian did some testing and discovered that Lizzy was likely suffering septicemia (systemic infection). This is not an uncommon sequelae to prolonged dystocia. He transferred the patient to me for continued care.

Unfortunately, it became apparent at presentation that the owners had spent all of their finances on the surgery. They applied for CareCredit and were granted an increase of $1200. Unfortunately, care for Lizzy for only 1 night would run in the $700-800 range.

It was time to have a frank discussion with the owners. Lizzy was likely going to need 2-5 days of hospitalization, her prognosis was very guarded, and the bill would likely become expensive rapidly. We discussed the finances involved. The owners really had the extra $1200 AT MOST and that was stretching it for them.

After much soul-searching, they decided euthanasia was the best option. When I knelt beside Lizzy, she lifted her head and looked at me, then sighed and rested her head on my knee. This was the first sign of responsiveness we'd really seen since she presented. My heart hurt a little. Her predicament was utterly preventable.

First, the owners shouldn't have bred her if they weren't prepared financially to deal with the possible ramifications, and secondly, had they taken Lizzy to see her veterinarian when the first problems were noted, the sepsis would very likely have been avoided. Now, the only one really suffering from the owner's terrible decision making was Lizzy herself.

I felt terrible euthanizing her. Hopefully, she is somewhere running through a field of green grass with puppies that have gone on before her.

Change in contact info

2012-01-16T00:15:00.001-05:00

My new email address: homelessparrot@gmail.com. I really hate hotmail.

A difficult diagnosis comes too late

2012-01-14T06:08:00.001-05:00

A few weeks ago, my diagnostic skills were really challenged, and unfortunately, I failed the test. By the time I made a diagnosis, it was far too late for the animal to be saved.

On a very busy weekend, as I was running around like a headless chicken, I was presented with an older, large breed dog named Triton. He had been normal the previous evening. When the owners came outside, they'd found him collapsed in a pool of blood. They rushed him to us quickly. The owners reported that he'd been losing weight for several weeks, but otherwise he was healthy. He was a well-cared for and well-loved dog. The night before he became sick, he had been able to get out of his enclosure at home. This was the first time he'd ever gotten out. He was gone for an hour, and the owners had no idea what happened in that hour of time.

On physical exam, I had a quiet/depressed dog with pure hemorrhage coming form his rectum. There was no history of vomiting or other GI signs. His heart rate was very high, his body temperature was slightly low, his pulses were poor, and his gums were muddy and pale.

We started shock treatment on him - fluids to help stabilize his low blood pressure, a sedative to help him calm down, re-warming, and other treatments. Bloodwork was conducted and showed significant dehydration - a PCV of 71! and a normal lactate (see sidebar). The kidney, liver, and all other values were pretty much normal.

My tentative diagnosis was hemorrhagic gastroenteritis (see sidebar) secondary to Triton getting into something the previous evening. He started to respond well to treatment. His temperature came up, his blood pressure improved enormously, and his gums became pink and moist. With this excellent response to therapy, I assumed I had my diagnosis and need look no further. Xrays were on my list of things to do as he stabilized, but since he was doing so well, I elected to wait until there were more hands on deck to do them. He was placed in his cage on a strict hourly vitals and blood pressure monitoring schedule. One of my techs watched him like a hawk, and he seemed to be doing well. Blood pressure stayed normal, temperature stayed normal, and he rested quietly.

3 hours later, my technician went to take him for a walk. He took 2 steps, urinated, and collapsed. My technician put him up on our wet table and got a round of vitals, including blood pressure. They were rapidly worsening again (the bloody diarrhea had stopped).

Perplexed, I started at him, trying to see what I was missing. I requested the ultrasound machine, which was rolled to me. Ultrasounding his abdomen, I saw a lot of free fluid - never, ever a good sign. Tapping it with a needle, I got a syringe full of foul-smelling, brown fluid. Uh-oh. It smelled like intestinal contents.

On the spot, I told the owners that surgery was needed ASAP to find out where the fluid was originating. In the meantime, we were conducting more bloodwork. Results were still fairly unremarkable, and lactate was still normal. They never hesitated, and within 20 minutes, I was opening his abdomen.

What I found devastated me. Triton had a mesenteric volvulus. This occurs when the root of the mesentery twists on itsef, often several times. As a result, most of the small intestines are deprived of their blood flow. The small intestines were completely dead. Not part of them. ALL of them. There was nothing I could do, no salvaging Triton's intestines. He had to be euthanized on the table.

So, why did I miss the diagnosis? In a dog of his breed and with his clinical signs, a mesenteric volvulus should have been on my list of differentials immediately. It wasn't. So, why?

First, the getting out for an hour and running around was a total red herring. It had likely nothing to do with the formation of the volvulus, but I was distracted by this piece of history. He had never gotten out before, so naturally I assumed it was somehow related.

Secondly, I've seen 3 other cases of mesenteric volvulus, and in none of them was the patient ever able to be stabilized well. Since Triton initially responded well to our shock therapy, I assumed we had likely identified the underlying problem and were treating appropriately.

Third, of the other 3 I have seen, all of them have had excruciating pain on abdominal palpation. One of them almost bit my face off when I touched her belly, she was in so much pain. This dog didn't seem to be painful at presentation.

Fourth, Triton's bloodwork reflected dehydration but not much else. The normal lactate threw me off. Why was lactate normal in a dog with significant oxygen deprivation to the intestines? Because they were so twisted that the blood within them with an incredibly high lactate couldn't get back into circulation. Drawing blood from the front leg did not reflect what was happening in the strangulated intestines.

Lastly, I didn't take xrays immediately. A dog with hemorrhagic diarrhea that severe, I SHOULD have taken xrays immediately. Instead, since he responded so well to treatment, I elected to wait until we were less busy, and I had a technician to do them. At the time, xrays didn't seem emergently necessary.

The one bright spot in the whole dismal case? Mesenteric volvulus has a mortality rate of almost 100%, even when caught by the very astute (obviously not me) within minutes. The small intestines cannot handle being cut off from their blood supply for even minutes. Thus, by
the time the problem is found generally, there is nothing that can be done.

It's cold comfort to me. I should have known or at least had some idea.

You can bet though that I won't miss it next time.

Frustrations and limitations

2012-01-12T22:29:00.000-05:00

As anyone who reads this blog knows, one of the more difficult aspects of my job is helping people deal with their finances. Finding ways to help people treat their pets while staying within their budgets is a crucial part of my job. It's something I do very frequently.

Yet sometimes I am faced with clients that have endless resources, and this can be just as difficult for me.

If you - as a human being - become ill and are admitted to the hospital, you will have a bevy of professionals taking care of you. This includes nurses, a specialist doctor for your particular problem, a hospitalist, a patient care advocate, and on and on. Your health insurance pays for this. Every patient gets some version of this model.

Now, say you come to the emergency clinic with your seriously ill or injured pet. You have all the money in the world to spend. You would expect that your pet will receive 100% of our attention. The problem? There are only a few of us to go around - 1 doctor and 2-3 techs in my case. We are serving multiple clients and pets with problems ranging from the mundane to the very, very serious.

Friday night, I was faced with several critically ill patients. All of them had owners willing and able to pay the expensive fees for aggressive treatment. The problem? I had 2 surgeries to conduct, as well as two circling the drain septic patients to deal with. I had 2 technicians to triage new patients, conduct bloodwork and xrays on new patients (and those in the hospital), and take care of the patients that were already in the hospital - a couple of which required significantly intensive care.

I wound up extremely frustrated with the situation. Trying to stretch my brain to manage the two septic patients (which are nightmares requiring careful monitoring of IV fluids, the additions of medications such as dopamine and the like to regulate blood pressure, and other intensive care) was draining enough. Then I was faced with the surgeries.

If I were an MD, I would be dealing with one aspect of these cases - the surgery perhaps, or the management of the septic patient.

As a veterinarian, I have to deal with them all. The limitation is obviously myself and my technicians. We can only do so much so fast. Mistakes get made when we try to handle too much. Further, I am still young in my career, and I still have a great deal of learning to do. This necessitates researching complex cases, which further takes time away from the actual care of my patients.

Sometimes, I wish I WAS an MD. I think my job would be simpler on some levels.

Holy cow

2012-01-11T13:22:00.000-05:00

It's been a week since I posted? I had promised myself to do better, then the weekend came and swept away all good intentions. It was CRAZY at work. Then, I had one day to reset before driving to Florida (Tuesday) for the North American Veterinary Conference that begins on Saturday. We combined it with a family trip, so the 3 of us drove down yesterday so that Evaline could meet her aunts, uncles, cousins, and great-grandparents. It was the most perfect trip we could have hoped for with a 3 month old baby. She slept most of the way, and she only had one 20 minute fussy spell. We made it in 10.5 hours, exactly what Google predicted!

This past weekend at work had a mix of significant highs (a GDV/"bloat" that the owner caught within 5-10 minutes of occurrence and underwent almost immediate surgery, home within 24 hours) and significant lows (3 septic patients that required incredibly intensive care). We were so busy that on none of the 3 nights (Fri-Sun) did I get to lie down even for 30 minutes to nap. It was exhausting.

A typical weeknight for us in the winter can be dreadfully slow - seeing as few as 1-2 patients the entire night. The average production for a winter weeknight is somewhere around $1000. On Friday night, we made $6000!! It was quite crazed.

The first patient of the night was a cat that had been shot through the leg with an arrow! The very large arrow head and barbs went straight through the poor cat's femur, snapping it in 2. It was a horrible injury, requiring amputation. Next through the door were 2 transfer cases from local veterinarians. Both had suffered severe, severe injuries when attacked by other dogs. They'd both undergone extensive external wound cares and were transferred to me as "stable" patients for monitoring.

Unfortunately, neither of them were stable. One I suspected was suffering severe intra-abdominal trauma, and the other I suspected was rapidly developing sepsis. I was right in both cases. The first went to surgery and was found to have a hole in his intestines, torn mesentery, and a section of jejunum about 4 inches long that was totally dead (due to trauma and damaged blood supply). The second patient was septic and circling the drain. For reasons upon which I will not elaborate, the discovery of this sepsis was so delayed that by the time we knew what was happening, treatment was likely useless.

On the heels of those nightmares came a cat with a chestful of fluid, a positive feline leukemia test, and a large mass growing in his chest. This is a clinical syndrome that we see somewhat frequently in young cats - a combination of lymphoma (cancer) and feline leukemia virus. The owner wasn't prepared for euthanasia, so she elected to palliate the cancer. In the meantime, I had to tap the chest to remove the fluid.

It got so crazy that I was forced to call in the other doctor for back-up, something I haven't done in the 2.5+ years I've been working at this clinic.

By the time Monday morning rolled around, I was thrilled to be leaving! I was exhausted - physically but also emotionally. Dealing with such difficult, complicated cases (especially sepsis) drained me to the point of near tears come Sunday.

Thankfully, there's nothing that a little R&R with my family (in the form of a car trip to Florida) and some sleep can't fix.

Happy(er) news

2012-01-04T21:59:00.000-05:00

I had a great case this weekend that turned out to be much, much more rewarding than I originally thought. I was presented with a large breed dog weighing in at a hefty 150 pounds - a mastiff breed. He'd been normal the prior today, but that morning, he'd started vomiting and acting lethargic. He'd become progressively more and more lethargic to the point where he could not rise. After some finagling, the owner was able to get him into the car and to us.

On my physical exam, I found a very quiet/depressed dog. His heart rate was very high for a dog of his size, breed, and current lethargy. His pulses were somewhat bounding. The biggest concern I had however was the mass lying along his abdominal floor. It was huge and took up most of his abdomen. Palpating it did not make him happy, as he hunched his back and hardened his abdomen in response to my touch.

I was a bit stumped, but I recommended to his owner (an MD) that we start with xrays. Xrays were a bit confusing and worrisome. The stomach was being pushed very far cranially, and there was a significant mass effect in the abdomen. My first thought was a liver tumor. Bloodwork findings did not support systemic illness though. The patient had a mild anemia, but his liver enzymes were normal.

Hmmm.

Thank god for radiologists. I sent the films off for review. While awaiting a response, I spoke to the owner and relayed my concerns (mass v. something else). She was very sad to hear that this might be a mass, but I cautioned her to not worry yet, as there were other possibilities (who says I don't learn from my mistakes?).

The radiology report came back fairly quickly. Like a typical radiologist, the answer was a list of 10 different possible things. Getting a straight answer out of a radiologist is like trying to nail jello to a wall. It didn't matter, the first differential she listed hit me like a ton of bricks. Splenic torsion.

Splenic torsion occurs for reasons that we fail to understand. In large breed dogs, the spleen will start to twist on its axis, cutting itself off from its blood supply. The spleen rapidly becomes engorged with blood that is trapped, enlarging within the abdomen.

The symptoms fit. A perfectly healthy dog the day before, now vomiting (likely from the massive spleen pushing on the stomach) and lethargic. I relayed the findings to the owners and recommended an exploratory surgery.

Two hours later, the MASSIVE 10 pound spleen was removed, and my patient was alert and recovered from surgery. He did very well post-operatively, and he is now home with his very grateful owners. It was a great end to a very, very hard day.

How doctors think

2012-01-04T21:17:00.000-05:00

One of my readers asked if I read the book "How Doctors Think." I have and that is how I recognized these thought processes and the mistakes I am prone to making. It was an enormously helpful and insightful book. I might read it again soon.

It seems to be divided 50/50 as to whether people would want to know or not. For what it's worth, the final radiologist decision was aspiration pneumonia. After reviewing the rads again, I had come to this conclusion, but I sent the xrays for professional review just to be sure. So, aspiration pneumonia and an abdominal mass. This was coupled with a pretty serious anemia. All told, in a dog that old, it wasn't good.

After much soul-searching and discussing the situation with fellow, scrupulous veterinarians, I have decided there is nothing to be gained from telling the owner. I do not want to make her question her final decision, as I still think it was the right thing. She was anguished when euthanizing the dog, and I think introducing any uncertainty into her decision would be selfish of me. I don't want to unburden my guilt onto her - relieving myself but hurting her further.

It's not an easy decision, but I hope it is the right one.

Day of the dead

2012-01-01T06:42:00.000-05:00

Atul Gawande is a human surgeon who writes fascinating books on medical errors and how they can be avoided. I have read all 3 of his books: Better, Complications, and The Checklist Manifesto. Having done so, you would think that I'd be prepared to recognize when I attempt to make them. Yet, that's not the case. Just like every doctor, there are errors in my logic/rational thought process that lead to misdiagnosis and mistakes.

I saw a case recently. It was an old dog Golden Retriever (13 years old). She came in for collapse, labored breathing, pale gums, and extreme lethargy. Based on the history and my physical exam findings, I suspected she was suffering a hemoabdomen - likely secondary to a ruptured splenic or hepatic tumor. I focused heavily on this diagnosis, although I did consider others - heart failure, rodenticide poisoning, etc. Still, in my mind, hemoabdomen until proven otherwise.

This is the first cognitive failure. Focusing too heavily on one diagnosis due to previous/recent experiences. I see these types of cases (hemoabdomens with ruptured abdominal tumors) ALL THE TIME. Thus, it is always a forefront diagnosis. This is an important step in formulating a differential list - recognizing patterns. The problem with recognizing patterns is that often we as doctors stop seeing the forest for the trees. That diagnosis pervades in our minds as THE diagnosis based on previous experience, making it difficult to see and accept any evidence that does not support that diagnosis.

On my physical exam, the patient had a significant arrhythmia - possibly consistent with hemoabdomen (very common), but also possibly primary heart disease (which can also lead to collapse, labored breathing, pale gums, and lethargy). I recommended xrays and bloodwork to the owner.

Then I went to pump while my techs took care of testing. About 30 minutes later, my technician came to me and said, "abdominal mass with metastatic cancer in the chest."

Error #2 occurred here. I went into the radiology room to review the xrays, and I already had an idea of what I was going to see. Thus, I tried to make what I saw on the xrays fit what I had already suspected (a ruptured abdominal tumor) and what my technician had diagnosed.

The dog did indeed have an abdominal mass. It was not ruptured. I recognized that immediately. The chest xrays were a little sticky. Initially, I diagnosed the dog with extremely enlarged tracheobronchial lymph nodes. I called this metastatic cancer.

The problem? The typical cancer of the spleen (hemangiosarcoma) doesn't usually show up in the lymph nodes like that when it metastasizes. The metastasis I should have seen (were this truly a metastatic hemangiosarcoma) would have been ill-defined, patchy nodules in the lungs. Instead, what I saw was likely a pneumonia/collapsed lung with retracted lung lobes (possibly a chronic lung disease). There are other cancers that this could have been that WOULD show up in the lymph nodes - like lymphoma. So it's not entirely impossible that this was metastatic cancer. It could have been pneumonia/chronic lung disease however.

I saw these things (the retracted lung lobes, the consolidation of the lung tissue) and yet, I must have subconsciously wanted a simple diagnosis to give the owner - a neat package to wrap up with a bow. So I ignored them (not deliberately, I am only understanding this in hindsight).

My next step was ultrasounding the abdomen. I did not see free fluid, so I knew that the tumor hadn't ruptured. I did find a large abdominal mass, but it didn't look like your typical malignant tumor. It wasn't cavitated and "nasty" looking - it was large but more smoothly marginated.

Bloodwork was fairly normal other than a pretty good anemia.

So, what I should have recognized was that several things were occurring here: the anemia was likely secondary to chronic disease of some sort. The lungs were probably a chronic problem, although possibly not. The splenic mass may have been an incidental finding or it may been cancer on the verge of rupturing. I **should** have recognized that this might be many different problems.

Yet my mind had decided this was metastatic cancer before seeing the xrays, and I made this fit, even though all the pieces weren't there.

In the end, the owner decided to euthanize her dog based on my diagnosis. Was it the wrong decision? Likely no. I do believe this dog had cancer. She was obviously very ill and needed a blood transfusion. I do not think my original clinical picture was correct though. In retrospect, I committed at least 2 significant cognitive errors that led to making a leap in deduction. I have to struggle to overcome this and find a way to prevent this in the future.

I've sent the xrays to a board-certified radiologist for review (professional interest). Once I have a better idea of what I was dealing with, I'll decide whether I need to contact the owner.

What do you think? If your dog was extremely ill, very elderly, and needed at least $1500 of treatment with a guarded prognosis for survival - would it matter if the doctor was right about the tentative diagnosis? If it was metastatic cancer versus some other terminal illness? If the doctor made a mistake in diagnosis and your pet was euthanized, would you want to know after the fact? Keep in mind that this dog was very ill and likely had some form of cancer - so the ultimate outcome would have likely been the same.

When I have the xrays back, I will let you know what the radiologist says. Try not to judge me too harshly.

Status quo

2011-12-30T09:44:00.001-05:00

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.

Another rock and hard place story

2011-12-21T19:28:00.000-05:00

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 scenario...it'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.

Wowza

2011-12-18T17:15:00.000-05:00

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.

First nights back

2011-12-10T06:54:00.000-05:00

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.

Surprise shift

2011-12-05T14:29:00.000-05:00

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!

1 week left

2011-11-30T00:28:00.001-05:00

My maternity leave ends on Wednesday, Dec 7, and I descend into the fray of veterinary emergency medicine once again. Currently, I am having very mixed feelings about this.

During my 3rd trimester, I was absolutely positive that I wanted to become a stay-at-home mother. The thought made me inexpressibly happy. Now, almost 9 weeks on the other side of my time at home, I realize that I would probably go mad without the challenge of my job. I love what I do quite sincerely. I also love being domestic - cleaning the house, fixing dinner, and the like. It is quite satisfying. I also cherish being home with my beautiful, sweet daughter.

Since I enjoy both things so much, I think being a working mom will be the best option for me.

ER medicine is a mixed bag for motherhood. While offering intense, long hours - ER medicine also offers long stretches of time off to enjoy with my family. I make more money than my GP counterparts, leading to less stress related to financial burdens. Further, despite some shortcomings that I have elucidated here, I have a great job in a bad economy. I'm thankful for that every day.

It's going to be a big adjustment. I know I'm probably going to miss things with my daughter. On the other hand, I hope to be a strong role model for her. I want her to grow up knowing that she can be anything she wants to be and still make time for a family. I also want her to grow up financially secure and to never have to worry about our finances. Growing up with 5 siblings, money was always tight for us, and early on, I worried a great deal about my parents' financial situation. I have carried this stress with me ever since childhood, and I will likely die with it. Hopefully, careful planning and saving will prevent Evaline (and our future children) from facing these worries.

T minus 7 days!

How we differ from Dr Pol

2011-11-26T21:33:00.000-05:00

So, I thought since Dr Pol is setting the perception of veterinary medicine back about 50+ years, I would explain how I am a different sort of veterinarian and how the clinic where I work is progressive instead of backwards.

Patients during surgery are availed of the following:

1) An IV catheter and IV fluids to help control and maintain blood pressure, as well as to administer pain medications, blood or plasma transfusions, and life-saving medications such as atropine and epinephrine.

2) Full anesthetic monitoring including oxygen saturation measurements, end-tidal carbon dioxide (very important), heart rate and rhythm, and blood pressure. Patients are monitored by expensive equipment but also by a technician that is making sure that the machine readings are believable. The technician assesses pulse quality, gum color, and heart rate and rhythm periodically by actually laying hands on the patient. This ensures that we know how are patient is REALLY doing - at all times.

3) Our surgery table is heated to ensure that patients do not lose too much heat during surgery. Anesthestic gases causes vasodilation and a drop in blood pressure. As a result, body temperature drops. Opening up the body cavities exacerbates this. The technician monitors body temperature and measures are taken when necessary to keep the patient warm.

4)Sterile technique is always observed. All surgical instruments are cleaned and steam autoclaved (sterilized) between patients. All patients are fully draped, and the surgeon wears a cap over the hair, a face mask, booties, and a sterile surgical gown. The technician wears a mask, cap, and booties unless assisting. The surgical room is used for NO other reason than invasive surgery (opening the thoracic or abdominal cavities).

5) All patients are intubated and hooked up to an anesthetic machine and ventilator. This way, respiration can be closely monitored and supplemented as needed.

These are just some of the ways we protect our patients surgically. Outside of surgery, we are just as meticulous. Patients receiving IV fluids are on IV pumps that control fluid rate. These are in turn monitored by the technicians to ensure that they are working correctly. That way no patient receives an overload of fluids, which can be fatal.

Patients with infectious diseases such as parvovirus or feline respiratory tract disease are isolated from the ICU in a separate ward. This is to prevent nosocomial infection, as well as to protect animals with compromised immune systems (as in parvovirus).

If a patient presents injured and in shock, permission to administer (cheap!) pain medications is obtained right away. Pain medications indicated for severe trauma and shock, such as a mauling, are opioids. NSAIDs or steroids are not proper medication for a patien in this condition. They are not potent enough, quick acting enough, and have side effects that can be greatly worsened by shock. Patients are also started immediately on IV fluids to stabilize blood pressure. Oxygen is administered as needed either via face mask or incubator/oxygen cage.

If a patient comes in with severe neurological deficits or other problems that cannot be addressed at our clinic, referral to the nearby specialty practice is immediately offered. If referral is declined, discussion of the options is initiated, and an informed decision made with the client's help.

Patients are never sent home in a state of heavy sedation or anesthesia. All patients are fully recovered and monitored before they are sent home with their owners.

There are a thousand ways I could compare us to show that we practice up-to-date, forward thinking medication. We use constant rate infusions of narcotics to keep our post-operative patients and very sick, painful patients comfortable. We utilize the most recently recommended treatments for a variety of conditions - including choosing our antibiotics wisely and carefully rather than placing all patients on them. Steroids are avoided in cases of shock and head trauma and used judiciously where indicated. We have an ultrasound machine, digital radiology (many human clinics do not even possess this technology), and a radiologist on call who can review difficult to interpret xrays. Our technicians are highly skilled and dedicated to patient care.

As a clinic, we work hard to offer our clients the most current and best diagnostics and treatments we can. We do not cut corners to save money. Yes, we're in it because we love animals. We're also in it because we want a job that matters, and we care about what we do on every level.

We're not all Dr Pol.

The Incredible (?) Dr Pol

2011-11-21T23:20:00.001-05:00

Since I haven't seen a patient in weeks, I have no exciting stories to relay. On the other hand, I am curious as to how many of you guys are watching this National Geographic show? It is causing an uproar in the veterinary community.

If you follow my blog at all, you know I have a passion for high quality medicine, staying updated on current diagnostics and treatments, and generally practicing with compassion and integrity. I am passionate about being the best vet I can possibly be. I am also passionate about spreading the word regarding what veterinarians really do, how much training we undergo, how expensive our education is, and how important GOOD, competent health care is for your pets.

Thus, I am a little dismayed by the way the new National Geographic show portrays veterinarians. Don't get me wrong - Dr Pol seems like a compassionate, good man. He has been doing his job a long time. I am not bad-mouthing him. What bothers me is that he is very outdated in his methods.

Granted, this is a reality TV show. It is being twisted to portray things exactly as NatGeo wants them portrayed. I understand that. But when I see Dr Pol doing an orthopedic surgery (in this case, a femoral head osteotomy) without a cap, mask, or gown on, and minimal sterile surgical technique, I cringe inside. This is a major surgery in which the head of the femur is cut off. Infection is a very, very big concern. Further, this dog - undergoing painful, major surgery - was not even intubated or on anesthesia of any sort. Had this dog arrested during surgery, saving him would have been difficult to impossible without control of his airway and an IV catheter. There was also no evidence of any pain medication being administered.

This way of doing things is very, very out-dated and considered well below the standard of care.

So far, the show presents veterinarians in a very dismal light. In our clinic, patients undergoing surgery are on IV fluids, intubated so that we can breathe for them as necessary, provided with adequate analgesia, and absolute sterile technique is maintained at all times. Yet, Joe Average Pet Owner is unaware of this. Many owners see all veterinary care as equal. Dr Pol's show reinforces the idea that veterinary medicine hasn't advanced since the days of James Herriot and that we all do things in this "old school" fashion. The opposite is true.

Further, it reinforces the idea that all vets are in veterinary medicine strictly for the love of animals, that we practice substandard medicine that puts patients at risk, and that there have been no improvements in veterinary anesthesia and analgesia in the last dedcade. It's setting the perception of veterinary medicine back 50 years or more. There is no discussion of proper sterile technique, referral for complex cases, chemotherapy, digital xray, constant rate infusions (CRIs) for pain control, or any of the many, many advancements that have been made in all areas. We can do amazing things for animals, yet this show reflects none of that. For Pete's sake, I watched in amazement as he amputated a dog's tail in an exam room with minimal pain medication, no anesthesia, and NO sterile technique.

It's disheartening. Everyone loves "Good 'ole Doc." He's cheap, he's quick, and he's "old school." Unfortunately, old school doesn't usually benefit critically ill or injured animals. This was evidenced when he gave a nauled puppy a shot of steroid (absolutely NOT indicated in trauma anymore - in human or animal medicine) and left it in a cage. He described the dog as "in shock" - yet he provided no pain medications, IV fluids, or oxygen to stabilize the shock. He placed the puppy in a cage where it died. I treat this kind of thing on a daily basis, and a shot of steroids isn't going to fix a badly mauled animal. It was heartbreaking.

Anyone watching it? What do you think?

Important points

2011-11-18T17:36:00.003-05:00

I thought this was a thoughtful article highlighting some of the things good veterinarians do.

http://www.vetlive.com/2010/11/14/10-things-a-great-vet-does-without-credit-that-you-never-know-about/

We're all still alive!

2011-11-17T15:56:00.001-05:00

Being a new mom is exhausting, I'm not going to lie. Our daughter is going through a high need stage right now; she needs to be held constantly. She won't even sleep unless she is being held by me or beside me in the bed. The other option is being carried by my husband in our Moby wrap.

T minus 20 days until I return to work. I have some apprehensions about it, I won't lie. Thankfully, my husband will be home for the next few months. Hopefully that will make this transition easier. We shall see. Pumping breast milk at work is going to be interesting - given that my job is a lot of feast or famine.

In the meantime, I have Thanksgiving to look forward to - lots of family time with our new addition. The definite upside is that her grandparents always want to hold her, giving me a much needed break!

The skinny on chocolate (toxicity)

2011-11-04T00:19:00.005-04:00

This is my favorite time of year, hands down. I love the holidays - especially Thanksgiving and Christmas. For the first time in more than 5 years, I have both major holidays off of work and will be spending them with my family! I am very excited about this. It will be unlikely to occur again for many years. Well, unless I get pregnant again soon and go on maternity leave that happens to correspond with the holidays.

One of the small things I love about the holidays is the abundance of candy. Starting at Halloween and continuing through the end of the year, chocolate treats abound. I'm trying to be **more** careful about these sweet treats due to my gestational diabetes and predisposition for Type 2 diabetes, but it's hard. Imagine then how hard it must be for a dog! They have no sense of "good idea or bad idea" - they only know that chocolate smells (and tastes) delicious.

Chocolate ingestion is something I see all the time in the ER. The numbers certainly go up around the major fall holidays. Thus, I thought we could talk frankly about chocolate toxicity here.

My take on it? Chocolate toxicity does not exist.

I say that slightly tongue in cheek. But not really. Let's first talk about why chocolate causes problems for dogs (and people who eat too much of it). Chocolate contains 2 important substances : theobromine and caffeine.

Theobromine is an alkaloid found in chocolate. It is a fascinating compound that has medicinal effects. One of these is the treatment of asthma, as it relaxes the smooth muscles in the bronchi, allowing bronchodilation. Caffeine is actually metabolized into theobromide within the human body. Theobromide leads to increased heart rate and vasodilation leading to decreased blood pressure. It can also lead to tremors, nervousness/excitability, and seizures at higher amounts.

In small quantities, theobromide is not toxic. This is why we can all enjoy chocolate deliciousness. However, in large quantities in people and in dogs (who metabolize chocolate more slowly), toxicity CAN occur.

The early signs of chocolate OD in dogs are vomiting, diarrhea, and increased urination (diuresis). As the amount of exposure increases, the clinical signs worsen leading to tremoring and possibly seizures. Death can occur.

Still, I have only seen a couple of severe cases - dogs with heart rates of 190-250. They responded well to fluid diuresis, mild sedation, and beta blockers to slow the heart rate. And I have seen one dog that presented for chocolate intoxication die. His death was sudden and inexplicable. It was a small chihuahua. His heart rate was very high, but he was alert and active. He had no other health problems. He was in his kennel, receiving fluids, barking his head off, and about to be sedated, when he suddenly and unexpectedly dropped dead. Resuscitation was not successful. I still have no idea to this day if this was really a chocolate related death or some other problem (underlying heart disease).

The vast majority of the dogs that eat chocolate do just fine with no treatment. It is massive ingestion that is worrisome. Also, the darker the chocolate, the more concerning. Pure cocoa is bad! Milk and white chocolates are barely worth concerning oneself over.

Rule of thumb? Apply common sense. If your 70 pound Labrador ate 1 snack size KitKat, he is not going to die. If your 70 pound Lab ate an entire bag of dark baking chocolate, a trip to the ER is warranted. The reason I say that chocolate toxicity "does not exist" is because it is very, very, very rare to see serious consequences as a result of chocolate ingestion. Most dogs just don't eat enough or the right kind (dark) of chocolate to have any problems other than mild hyperexcitability.

When in doubt, call your local veterinary ER - we are happy to talk to owners about quantity and toxicity. We do it ALL the time.

The curse of being a veterinarian

2011-10-29T18:51:00.000-04:00

It's kind of a joke in my field (and probably every field has their variation of this) - but veterinarians ALWAYS get the animals with the rare diseases, the congenital abnormalities, or the undiagnosable illnesses. Apparently, this extends to family members, as well.

A day or 2 after Evaline was born, my aunt called me about her 10+ year old Labrador/Great Dane mix. He was severely lethargic to the point where he would not rise. His breathing was labored, his gums were pale, he had severe bruising on his abdomen, and his extremities were cold. My aunt also noticed that his abdomen looked distended.

Any other Labrador with these symptoms would have a ruptured splenic or liver mass. It's as common as grass! I see at least 3 rupture splenic or liver tumors a month at work, and they are almost all Labradors or Golden retrievers. I recommended she get him to her veterinarian ASAP.

Dr W did a thorough exam on Flip and could not find evidence of a splenic or other abdominal mass. Flip's clotting times were abnormal, though. Given that Flip is an outdoor dog and because of the way the clotting times were elevated, the vet suspected rat poison and started treating accordingly. Initially, Flip responded and seemed to do well.

Then he started to deteriorate again and became severely, severely anemic. The veterinarian ordered packed red blood cells to give him a transfusion. When he rechecked the anemia a couple of days later, it had resolved! Flip seemed to be improving. He was discharged home, and he became lethargic again.

Further, he was now having trouble walking - as his back end was weak. He was almost walking on his elbow in one rear leg. The muscles were wasting away (atrophied), and he had developed a fever.

Last weekend, my aunt brought him to me to ultrasound his abdomen, looking for a culprit. I found nothing to explain his symptoms. He was still feverish. With no answers, I started him back on doxycycline (an antibiotic used to treat tick-borne disease such as Rocky Mountain spotted fever, Lyme, and Ehrlichia) and prednisone (a steroid).

His condition has not improved, and his atrophy has worsened in the rear limbs. I am going to euthanize him tomorrow at my aunt's house.

And still, I have no answers. I highly suspect some sort of cancer, but this could be tick-borne disease, autoimmune disease, or anything else. I am highly frustrated! I am a good veterinarian, and usually I at least have a handle on what is causing a patient's illness. In this case, I am left baffled.

Unfortunately, the veterinarian's curse strikes again - making me feel rather like a failure.

2011-10-25T02:02:00.001-04:00

Still here and an unexpected shift at work

2011-10-25T01:40:00.000-04:00

It's amazing how quickly large chunks of time pass without me realizing it. It must be due to the confusion my body suffers due to my wacky sleep "schedule" (which is no schedule at all). I could swear I just posted about cats and permethrins - but it has been over a week!

At any rate, guess what I did this weekend? I worked a short shift. My colleague qualified for a large regional dressage competition. She couldn't find any relief vets to work her 8am-1pm Saturday shift, despite trying for several weeks. She asked me to do it. Once I got over my initial irritation at being bothered while I am enjoying my maternity leave, I realized that I kinda wanted to do it.

Motherhood is wonderful, and I love, love, love spending time with my daughter. On the other hand, my husband is frantically working on his thesis (his defense is looming in the next few weeks), leaving me to try and manage the baby by myself. He is wonderful and steps in to help any time he thinks I need it, but I'm trying desperately not to bother him. Also, since I am exclusively breastfeeding, I am with the baby most of the day. She also sleeps with me, so I have very little time away for myself. This is the plight of all new mothers, and it's a big adjustment. My husband and I have been married for 12 years, always able to do as we please, when we please. It's been a pretty fancy free lifestyle, honestly. Having a little person to care for 24/7 is a huge change. It's like this for everybody, I realize - so nothing new there. You just don't realize HOW MUCH your life revolves around a baby until you have one. No matter what people tell you - there is no way to prepare.

At any rate, the thought of being with other adults and back at work for a few hours was really enticing, so I accepted her request. I also want to build good will at work. It was a Saturday morning, so it was slow. I saw a dog with a badly broken leg and a cat with a terribly degloved tail, and otherwise, I sat around and caught up with my technicians. Still, it was refreshing to be back at work, even for a short, boring shift.

I wonder if I could be a stay at home mom. Just a few short weeks ago, that thought was enormously appealing. Now that I've been away from work since the end of September, I realize that I really do love what I do and want to continue doing it. I also want to be an involved parent. Life to me seems to short to waste on working, no matter how much I love what I do. It's a conundrum.

Is it possible to be a great mom and still work a demanding job? I guess we'll find out. On the bright side, my job allows me large blocks of time off, which I can spend with my family.

Cats and permethrins

2011-10-16T00:49:00.000-04:00

I can't recall if I've ever talked about this before, but I thought about it when I was doing the 5 things post. #6 would be: if a product is labeled "not for use in fill-in-the-blank species" then DON'T USE IT IN THAT SPECIES.

If you go to Wal-Mart, K-Mart, Target, and the like, you can find over-the-counter flea and tick medications for your pet. These run the gamut from what were once veterinary-only products (Frontline/fipronil, Advantage/imidacloprid, etc) to OTC products that have always been such. If you look closely at certain major brands you will see that several are prominently labeled "DO NOT USE IN CATS."

That is because these products contain pyrethrins/permethrins - chemical compounds that can lead to seizures and death in cats. For some reason however, people tend to ignore these bold warnings and use these products on cats anyway. Some cats will never have any problems, for reasons that are not clear. Other cats will have a mild, tremoring reaction. Still other cats will seizure so hard that they will appear to be levitating.

These drugs kill fleas by screwing up the sodium and potassium channels in cells. These channels are responsible for mediating conduction of impulses along nerves. When these drugs interfere with Na/K, the targeted species (for example: fleas) basically twitch to death because of interruption of normal nerve conduction. The same happens with cats when given these medications. Cat livers are not as efficient at metabolizing certain drugs (such as acetaminophen, the active ingredient in Tylenol and permethrins). As a result, clinical signs develop.

This toxicity can be treated. Unfortunately, most cats (except for the most mildly affected) will require 24-96 hours in the hospital with IV fluids, anti-seizure and muscle relaxant medications, possibly lipid therapy, and intensive care. In some cases, affected cats must be put under general anesthesia with either Propofol or inhalant anesthesia to stop the tremoring/seizuring. In some cases, it cannot be controlled at all.

It is not inexpensive to treat either - which is the saddest part. Most people put these medications on their cats to save money, not realizing that a hospital stay to treat this is going to cost in the neighborhood of $700-2000 depending on the severity (or lead to euthanasia in many cases due to financial constraints). If you break down the math ($60-90 for a 6 month supply of safe, veterinary proved product = $10-15/month) - prevention is the BEST and cheapest treatment.

Lipid therapy is a newer therapy that is very interesting to me. Permethrins are highly lipid soluble. This means that they move into the fat of the body very well. Synthetic lipid compounds are produced by pharmaceutical companies and used often for feeding patients intravenously. It has been found that if you infuse these compounds into patients with exposure to lipid soluble toxins, they form a "lipid sink" for drugs - meaning that instead of being internalized into the body's fat stores, the permethrins are bound up with the lipid we administer. As a result, they are not broken down in the body in such a way as to cause clinical signs. This is the theory anyway.

Lipids themselves are a cheap treatment option (about $20/bag - a small dog will only use about 10-20 millileters, and a bag holds about 500 milliliters). We have this in stock at our clinic, but I haven't had a permethrin case yet! I have used it on a ivermectin toxicity.

Moral of the story: the best treatment? Prevention!

2011-10-14T17:01:00.000-04:00

Sorry for my AWOL status - new mommyhood and all. It's been wonderful and exhausting at the same time. Thankfully, my job has prepared me well for being the mother of a newborn. I don't have any trouble getting up and taking care of the baby in the middle of the night. I'm also dealing fairly well with sleep deprivation. Crazily enough, as much as I love being a mom, and as much as I never want to be away from my little butterbean, I actually miss work. We had a doctor's meeting the other day, and listening to my colleagues talk about cases made me crazy to be back in the ER. I'm not spending time dwelling on that, as these precious few weeks will fly by - and I will go back to work and miss my daughter desperately. Dec 7 is THE day...

Top 5 things I wished pet owners knew (but don't)

2011-10-06T00:12:00.001-04:00

This was a requested post, and I thought it was a good idea. I'm sure I will expand this list one day, but for now, I am sticking with 5.

1) Aspirin, ibuprofen, Tylenol, Advil, etc. are the not the cure-all for every problem a pet suffers. I cannot tell you how many pets I see with every symptom known to man (vomiting, diarrhea, lethargy, weakness, stumbling, loss of appetite) that have received an NSAID at home. These are painkillers that help with inflammation. They are NOT going to do anything for a vomiting dog. Just like YOU wouldn't take aspirin for nausea, neither should your dog. Further, these products are dosed differently (or not at all - in the case of naproxen in dogs and Tylenol in cats). These medications can pose serious threats to your dog's health.

2) Allergic reactions to beestings, pollen, and the like that cause facial swelling, itching, and hives/wheals are not life-threatening emergencies requiring immediate care. I shouldn't complain, as this is job security for me - but if your dog breaks out in hives, his face swells, and he starts to itch like mad, give him Benadryl, and wait it out. It can take up to 24 hours for the hives and swelling to completely resolve. This cutaneous reaction is not life-threatening in any way. Now, if your dog has trouble breathing, collapse, weakness, or the like - that IS an emergency.

3) A dog or cat is not embarrassed by the words "penis" or "vagina" or "vulva." Neither am I. You can use them freely. I do NOT like the words "lipstick", "hooha", "wee-wee", or "peanut."

4) I have no control over prices, billing services, or anything else to do with the financial aspect of the pratice. I am an associate, I do not own any part of the clinic, and thus, if I give you a discount or do things for free, then I am essentially stealing from my employers. Do I sometimes do things at a discont? Yes. Should I? Probably not. Oh, and I don't drive a Porsche. I drive a 13 year old Mercedes SUV that guzzles gas, has 210k miles on it, and was a freebie hand-me-down from my generous father-in-law.

5) Lastly, I wish that pet owners knew that I love my job, take it incredibly seriously, stay up nights worrying about cases I'm managing, strive to always, always do my best for every pet
I see, and constantly berate myself when I can't save the world.

That about sums it up for me, at the moment!

2011-10-04T22:51:00.001-04:00

For lack of words :)

The first 3 days - breastfeeding trials and tribulations

2011-10-02T10:56:00.000-04:00

After labor, I felt fantastic. Despite being awake for about 24 hours, I felt like I could do a lap around the hospital. Eva was borderline hypoglycemic after birth, and she was having a bit of trouble with the latching/breastfeeding. I didn't want her to continue to become more hypoglycemic, and I wanted to avoid interventions like an IV catheter/dextrose, so I acquiesced to her going to the nursery for a bottle. My husband went with her. They moved me to a recovery room. After 20 minutes, I was so restless and worried about her that I trucked down to the nursery to check on her. Apparently that was a no-no for a recently delivered mommy. That's how good I felt though.

We opted for having her sleep in the room with us, as I couldn't stand the thought of her going to a nursery and being away from us. We plan on "attachment parenting." Basically, keeping her with us at all times. This includes co-sleeping (or "sleep sharing") which is controversial. I will say that the first night, she would not settle in her bassinet. I did not sleep the entire night. Doctors, nurses, dietitians, and everyone else came traipsing in and out from 8am-1pm. Then lunch, etc. So I didn't sleep again. The second night was agony. My nipples hurt from breastfeeding, I didn't feel like I was getting a good latch, she was frustrated, I was frustrated, and totally, utterly exhausted.

By the second morning, I had been up for 50+ hours. I was so tired that I was borderline hallucinating. I burst into tears when breastfeeding because it hurt so much, and we were both frustrated. She wouldn't sleep in the bassinet. So, I moved her into the bed with me, and we both finally, finally slept (around 6am). It was very restful. It solidified my position on co-sleeping with her.

When we were finally discharged on the 2nd day, after her PKU test, a tetanus/diphtheria/pertussis vaccine and an MMR for me (turns out I am not immune to rubella), and the other formalities, she began to cry right before we left. I knew she was hungry, but it was only a 30 minute drive home. Of course, we got stuck in crawling (but moving) traffic. She wailed and wailed like her heart was breaking. I was able to stand it for ... oh, about 5 minutes, then I burst into exhausted tears too.

Now, we're home. My mom is here and has been taking care of whatever we ask her to do. As a result, I have been able to sleep some, although I am still very tired. Breastfeeding is still a challenge - it hurts much more than I expected.

I will say that my job has prepared me well for the waking on command and being able to be coherent (at least, coherent enough to change a diaper and feed the bebe).

So, what have I learned in the first 3 days of motherhood? Sleep when you can (not good at this yet). Comfortable, easy clothes for nursing are a must. Having a stay at home dad to help makes being a new mommy 10,000 times easier on you. And finally - it is absolutely amazing how much you can love someone you have known for only 3 days. It is also absolutely terrifying.

Baby posts?

2011-10-01T16:25:00.001-04:00

So, I know you guys read my blog for the veterinary stories - as it IS a veterinary blog. In the last 3 days, I have already learned so much I didn't know about being a mommy. I want to chronicle this, all of it. For her and for me, so that next time we have a baby, I will be able to read and remember. I also want her to have it for the day long in the future (only relatively) when she has her first baby and has a thousand questions like I do. My mom, God love her, had 5 natural childbirths, but she says she can't remember stuff anymore about the labor/delivery/post-partum period. Hopefully, if I record it all, I won't have to remember exactly!

At any rate, are you guys interested in these posts - or would you rather I start a separate mommy blog and keep this strictly vet medicine related? I do plan on talking about being a vet and being a mommy when I go back to work, but I'm asking more about the early day aspects. Would it bore you and drive you away from my blog? Please let me know!

She's here!

2011-09-29T03:18:00.000-04:00

Due to my gestational diabetes, the midwives were pushing for induction next week. I opted to have my membranes stripped on Tuesday afternoon. I started spotting and cramping afterwards. I woke up Wednesday morning at 6am with what I thought were fairly regular contractions. We went to the midwife/OB office to find I was only 3cm dilated :( Sent us home to continue laboring.

After an hour in the tub, I was having contractions right on top of one another. We walked out to the car to go to the hospital, and my water broke. When we arrived, I was only 4cm! I climbed into the Jacuzzi tub and labored for 5 hours in the tub - alternating between hot water and cold water. My husband was my coach and drizzled me intermittently with cool water and placed cold wash cloths on my shoulders and head.

After 5 hours, I felt ready to move to the bed. I was checked and found to be 9cm. I had the strong urge to push - and the MW gave me the go ahead. I pushed for an hour, and she was born! Pushing was the most physically demanding thing I have ever done. Toward the end, I started to panic a little - fearing she would get stuck. Even when I could feel her head, I was scared! I started to hyperventilate a little, but thanks to an amazing nurse, midwife, my mom, and my husband, I was able to calm down. I pushed in the side position with my right leg in the air and pulled back to my chest, and the left leg bent at the knee and pulled toward my chest. It was very, very hard for me to relax my legs and not push against the midwife/nurses/husband. Truthfully, it was the hardest part of relaxing.

Pushing scared me, I won't lie. It's incredibly intense. It wasn't painful in the way that I expected really (certainly not like transition). It was more intense pressure and kind of a burning at the end when her head came out. But I was truly frightened I would be too tired to do it. Toward the end, it got very, very hard - but you CAN DO it. Pushing felt so good compared to transition and hard labor.

With the side position and perineal massage by the MW, I did not tear. The placenta passed about 15 minutes post partum. It required a little it of pushing, but it wasn't bad - similar to a moderate menstrual cramp.

At 10:21pm 9/28, Evaline Adelle joined the world at 7lb 2oz. She is beautiful and latched with some help after about an hour.

I hope this helps those of you out there considering a natural birth. This was my first child, and I was very, very scared. I kept telling my husband how scared I was. I tried very hard to rest the night before, but I was unable to do so between the cramping and the contractions starting at 6am.

Now, 4.5 hours after the fact, I feel great. I can walk around, I feel strong and healthy, and nothing hurts anywhere. I didn't tear, I don't feel swollen, and I'm very, very happy! She was borderline hypoglycemic after birth, but we're working on fixing that. Keep us in your thoughts!

My mind is currently blank

2011-09-26T22:54:00.000-04:00

I want to do a veterinary related post, but I cannot - for the life of me - come up with anything to talk about. I can't even think of an educational post! So, I'm opening the floor: what do you guys want to hear about? Any special requests? PLEASE?

Dogs and babies

2011-09-23T15:12:00.000-04:00

I'm going a bit stir crazy here, I won't lie. Maybe NOT working isn't so stellar either! I have nothing to post about as far as veterinary stories. It's just a waiting game now. The baby could come at any time. While I sit here on the couch, I've been thinking about dogs and babies. Dogs of any breed can pose a risk to children, but it's certainly the case when you own a big dog.

At our shower a couple of weekends ago, after everyone had mostly left - a few of us were sitting around watching UT football. Everyone was halfway paying attention to our 8 month old cousin and halfway paying attention to the game. Suddenly, there was a yelp from my BF's dog, and the baby started to cry. I saw the whole thing happen - but it was so fast that I was unable to intervene. The baby is learning to walk and is very grabby. He grabbed onto the dog, and the dog, startled, snapped at his face. He did not break the skin (called an "inhibited bite") - but he did leave a perfect red ring of teeth marks and some bruising. The baby was more scared than anything, but we were all very, very upset.

It was an excellent reminder of how important it is to train dogs to be around babies, as well as to always, always, always monitor dogs and babies together. All of these tragic children/baby accidents that you read about are usually the result of unsupervised children and unsupervised dogs. Any dog will bite, given the right provocation. It doesn't mean the dog is inherently mean or aggressive. It is rare that a dog will bite without some sort of warning sign.

In reference to the bite to my cousin, we were all being too lax. Watching football, assuming someone else was watching the baby. While it was awful, we were all lucky it wasn't worse. And it was an important wake-up call/reminder of our responsibilities as caretakers (of both dogs and children). We have to create a safe environment for our pets and children.

We're currently discussing in our family what to do as far as training with Heidi goes. She is a very timid, docile and easily trained dog, but she is also very, very anxious. She also weighs 70+ pounds and could hurt a baby without even trying. We are going to work very hard to make sure that she feels safe/protected and that our child is safe and well-monitored. This may include crating her at some times. I'll keep you posted on how it goes.

Last day for 2.5 months today!

2011-09-18T19:38:00.001-04:00

Yeesh. I think it's good that I decided to take time off when I did. Saturday was a blurry day that I can hardly recall. The clinic wasn't super busy, but there was a steady flow of clients all day. I slept terribly Friday night, as getting up to pee every hour is not conducive to restfulness. Thus, I spent most of Saturday in a foggy daze. The theme of the day was low finances, sick animals, do what you can for X amount of money, Doc. So I did.

I saw a very nice large breed dog that was sprayed with bird (or buck) shot. I'm by no means a rifleman, so I can't tell you which it was - but the poor dog was peppered with it from scrotum, prepuce, rear limbs, to abdomen. I was concerned that some of the pellets penetrated the abdomen, but the owner did not have the finances to proceed with hospitalization and monitoring. Thus, we compromised with pain medications and antibiotics. He was counseled to bring the dog back in ASAP if he exhibited vomiting, diarrhea, loss of appetite, fever, or other signs of systemic illness.

Then there was the "stray kitten." She was being taken care of by some Good Samaritans that had been feeding her. She had acutely become depressed, anorexic, and had a 105 fever. Having never had vaccines, I was worried about feline leukemia and feline AIDs. These tests were negative. I recommended further diagnostics, but the owners declined due to finances. I gave them antibiotics, pumped some SQ fluids into the kitty, and crossed my fingers. Miraculously, the owners called today to report that she is already back to normal kittenhood. Go figure.

On the heels of this followed a shepherd dog that was very lethargic and vomiting. Her abdomen was tense, and she had a fever. I was very concerned, but her owners were financially strapped and declined everything but symptomatic treatment. A shot of anti-emetic, SQ fluids, and out the door. I'm hoping she didn't/doesn't have a foreign body.

Lastly, there was the small Poodle that was mauled by another dog (unknown size/type). He suffered puncture wounds to his abdomen, neck, and chest. Remarkably, he was stable. After clipping, cleaning, and exploring the wounds, I recommended that he stay overnight for close monitoring. The owners declined and took him home. Hopefully, he is doing well.

I dragged myself home, realized my ankles were swollen to the size of elephant ankles, and laid on the couch like a sloth. My mind was so fuzzy that as I thought back over the day, I could barely recall the patients I had seen. I drifted off to sleep after dinner (around 9pm!). Thank god for my husband. He rubbed my feet, got me a heating pad for my aching hips, and looked after my general well-being. I'm a very lucky girl.

Today was my last day of work. I am now on maternity leave until Dec 7. It's hard to imagine not working for so long, but I'm looking forward to it!

Once more into the breach

2011-09-16T22:59:00.000-04:00

Tomorrow and Sunday are my last 2 days of work before official maternity leave. The OB and endocrinologist were worried about the funky night schedule messing with my insulin dosing and blood sugar, so I haven't worked nights, but I can still work days. This weekend is my last. There are 22 hours of work (give or take, depending on how busy we are) between me and maternity leave! I'm on an alarmingly normal sleep schedule - I've been going to bed between 12am-1am and getting up at 9:30. It feels very strange. Mostly I'm doing this so that I can space my meals and snacks out regularly, as well as take insulin when I'm supposed to. It's been much, much easier to manage the GD this way. I kind of regret not doing it sooner. On the other hand, we couldn't do without the income!

I'm conflicted about whether or not I'm looking forward to work. I really do love my job, and I miss it when I'm not doing it. I'm excited about seeing cases tomorrow. On the other hand, my hips have hurt a great deal this week, so I'm concerned about my ability to be mobile tomorrow. I'm keeping my fingers crossed that no major surgeries come in, or else I might be calling for back-up. I limped a great deal of today. Only 18 more days - give or take.

In other news - one of my foster kittens was returned to me yesterday. This is Fish Kitty - a beautiful, DMH tuxedo kitten that I fostered several months ago. The girl turned out to be rather irresponsible, and she is moving back to Pennsylvania. Her mother would not allow her to bring the cat with her. Thankfully, she called me. Fish Kitty has been reinstalled as a foster at this time. She is one of the sweetest kittens I've met in a while - but she is CRAZY. She's about 8 months old, and she is into everything. I haven't had this age of kitten in the house for a while, so it's an adventure. Fortunately, Fish Kitty is very, very sweet. We're leaning towards keeping her, believe it or not. Nuts, I know. That will bring the cat total up to 6!

I will hopefully have some interesting cases to post from this weekend - 'cuz it's gonna have to do ya'll for a while. Shortly, my mind will be occupied with everything BUT veterinary medicine.

Baby stuff

2011-09-15T12:30:00.000-04:00

I know ya'll read this mostly to hear about my exploits as a veterinarian - but right now, my brain is totally occupied by baby. I am full-term now, so she could come at any time. We rather hope she does, so that we can avoid the whole induction dilemma presented by gestational diabetes.

The nursery is more or less finished (waiting on the crib mattress), the hospital bag is packed (my part of it, the husband's - not so much), I have washed all the new baby clothes, folded them, and stashed them away. We even have diapers. It's getting close now!

Unbelievable

2011-09-13T11:41:00.000-04:00

Sorry for my absence. This weekend was our baby shower in Knoxville, and it was great. It also wore me out physically and mentally. We had a great time, saw a lot of family and friends, and received a lot of amazing gifts. The nursery is finished now, for the most part. The first few loads of new baby laundry have been completed and sorted and put in the dresser, and we are ready. (I hope).

I thought I would share this anecdote with you guys - because I'm still - a day after hearing about it - stunned that it actually occurred.

An owner showed up to our ER (my colleague was working) with a stuporous and laterally recumbent puppy. The puppy's heart rate was very high, it's temperature was very low, and it was essentially dying. The owner was convinced that the dog was dying from rat poison that it ate THAT day. The puppy had NO previous exposure to rat bait except for that day. Rat baits take 3 days to work at minimum. It is not physically possible to be exposed to rat poison and several hours later die as a result, no matter how much bait is ingested.

The owner had no finances and a dying puppy. My colleague offered free, humane euthanasia. The owner declined and elected to leave with the puppy, despite being counseled that it was suffering.

30 minutes later, Walgreens across the street called. The pharmacist reported that the woman was present, demanding a prescription for vitamin K (the treatment for rat poisoning). She (the pharmacist) wanted to know if vitamin K would help the puppy. My colleague explained the situation carefully. Then there was a pause. Then THE PHARMACIST, a fellow medical professional, said, "What you people charge over there is criminal. You are all criminals." And she hung up on my colleague.

Needless to say, the doctor was LIVID with this unprofessionalism and immediately called back. The pharmacist initially apologized, then tried to defend her position by stating that she had brought HER personal pet to the ER clinic, and we had gouged her. My colleague asked to speak with the manager, who was not happy and apologized.

We send a great deal of business to that Walgreens - as it is directly across the street from us, as well as 24 hours. I think however, that I will now be sending my clients to CVS Pharmacy, down the road about 1 mile, without reservation.

What is wrong with people?

Follow-up

2011-09-08T22:38:00.000-04:00

As to what I decided to do:

Tomorrow, I plan on calling the owner at home and discussing his concerns with him. I have done extensive reading on this subject, reviewed the surgical technique in multiple texts, as well as communicated with an ophthalmologist about possible causes of the drainage. Keep in mind that I have not seen this patient, so I have no idea of the character of the drainage. This could be my fault, or it may have nothing to do with anything that I did surgically. The ophthalmologist gave me several possible causes for the vague sign of drainage. I will share all of these with the owner, discuss his concerns, and recommend follow-up with his rDVM. I will make sure he is aware of all the possible causes - including the surgical problem (which the ophthalmologist said IS a surgical "mistake" - but one everyone will make at some time in their career, if they do enough of these surgeries). I will then leave it up to the owner to continue seeing the rDVM - hopefully with my concerns/recommendations in hand. Then, I will wait for either the letter from the rDVM complaining/throwing me under the bus or hearing back from the owner.

I'll keep ya'll posted.

Post-op complications and dilemmas

2011-09-07T22:26:00.000-04:00

I have a dilemma, and I would like the opinions of those reading - vets, vet students, and pet owners alike.

About 3.5 weeks ago, I saw a small breed dog with a traumatically proptosed eye. The eye was not salvageable, in fact it was mangled. I told the owners that removal was the only option for this eye, and after much arguing, debating, and scrounging to afford it, they came up with the money for an enucleation.

Fast forward to today. The owner calls because the empty, closed eye socket has been having drainage since the surgery 3.5 weeks ago. He has been to his referring veterinarian with the dog, a culture of the drainage has been submitted, and the dog was placed on appropriate antibiotics. Once the antibiotics were stopped, the drainage came back.

Initially, I thought this was likely an infection - probably from the initial trauma to the eye. I did a quick VIN search though, and apparently, a not uncommon complication of enucleation is that some fluid producing tissue (conjunctiva or lacrimal tissue) may get left behind. If this is the case, re-exploration of the socket and removal of this tissue is necessary. In other words, the dog MIGHT need another surgery.

Here are my dilemmas:

1) First, as an ER clinic, we are not supposed to recheck clients. This is done by the general practitioner that normally sees the pet. So, I have not seen the dog and have no knowledge of the character of the discharge, where it's coming from, or any other detailed knowledge of it. I have no idea if this is a surgical complication or a consequence of the dog having been bitten across the eye and deep infection introduced into the socket. The pet HAS been seen by the regular veterinarian, and he is handling follow-up. Thus, I should not offer to recheck the dog. I think. We ER vets have to tread cautiously here.

2) If this is a post-op complication - do I refund the money for the original surgery? Offer to re-explore the eye socket for free (I'm not sure I would know what I'm looking for and thus, would likely have a more experienced surgeon present)? At this point, I have no idea if I have ANY culpability in this outcome. Post-op complications DO happen.

3) Do I call the referring vet and alert him to what I have found in my literature search? The biggest problem here is that the referring vet is none other than the one that was fired from my position years ago. He hates our clinic and takes any opportunity to throw us under the bus. Any other clinic, any other veterinarian, and I would already be on the phone - but I am so hesitant to call this vet. No matter what happens or what the case, he will try to blame me. That's not a good reason not to call, I realize.

I talked this over with our office manager and my husband, and I will tell you what they recommended, but I would like to hear opinions from you guys first.

To clarify

2011-09-07T00:38:00.002-04:00

I've had several constructive insights into how I could do better at work, but one thing I want to clarify:

I do not yell or lose my temper. I am not a bear to work with in that respect at all. Maintaining composure under stress is something I pride myself on. I think my problems are more personality-oriented - my lack of interaction, the fact that I'm not very talkative, that sort of thing.

Well, it has happened.

2011-09-06T16:05:00.000-04:00

No more nights for me until my maternity leave ends. My blood sugar - while not terrible - was not stable and happy this weekend. Part of that is because of the incredibly convoluted schedule of eating/sleeping that I keep when I'm working the night shift on weekends. Part of the problem is the fact that I can sleep for a while, but I inevitably get woken up by a random 3am seizuring dog or 5am euthanasia. If I've taken my overnight insulin, I don't feel like I should eat, but then the nurse practitioner told me that if I'm up working, I should be grazing. It's all very confusing. The OB I saw last time offered to write me out of working nights because of the effect it was having, but I declined.

No longer. Instead of 9 days of work left, I have 2 day shifts the weekend after this. I would have worked the day shifts this weekend, but alas, our big baby shower is occurring.

I won't lie. There is a huge amount of guilt involved in this. There shouldn't be, I know. It's all about taking care of our little girl. Still, given the nature of our small clinic, if I'm not there, one of my colleagues has to pick up the slack. In the reverse situation, I would be totally willing to do the same, yes. I hope they realize that. It's only 7 days that I am missing. So that's not all that bad, right?

The hardest part of my job?

2011-09-05T10:15:00.000-04:00

You would think that the hardest part of being an ER veterinarian would be say...the hours. Or maybe the working holidays and weekends. Or perhaps the dealing with gravely injured and ill animals and their distraught owners. Sure, all of that is challenging. But those things seem like a cake walk to me compared to the real challenge - interpersonal work relationships.

I am a difficult person. I am Type A+. My job is something I take very, very seriously. I pay close attention to my patients and try to always, always do the right thing - whether that be easy or exceedingly difficult. I demand perfection from myself and never achieve it, of course. My expectations for those I work with are very high. And in one area, I constantly find myself lacking - I am terrible at managing interpersonal relationships.

First of all, I am not a warm and friendly person. I try to keep my personal life to myself for the most part. I don't like to talk about personal problems at work, and I don't seek the advice of other people regarding personal unhappiness/problems. As a result, I don't like to hear about other people's problems. My approach to work is to go to work, do my job to the best of my ability, and go home at the end of the day. This aloofness never wins any popularity points. When I first found out about my gestational diabetes, I had no intention of sharing that with anyone at work. Only when insulin became a necessity did that information come out.

Secondly, I abhor gossip. As a result, I do not engage in it at work, and I expect my coworkers and colleagues not to engage in it around me. You'd think it would garner respect, but actually, it probably sets me further at odds.

Lastly, I am very blunt. I say what comes to mind, and while I never intend to hurt people, I've been told my forthcomingness can be hurtful. It is never intentional, but it's there.

There is no single aspect of my job that I struggle with as much as dealing with my technicians. I hear again and again from them that I am a great doctor, that I would be the first one to whom they brought their personal pets. Then I hear again and again how difficult I am to work with.

It has truly become a source of frustration for me in that I cannot get a straight answer on how to improve this. The technicians seem unable to clearly voice a reason, so I am left with vague answers and no real way to improve. I WANT to improve. I WANT to be a good doctor to work with and for. I don't want to be difficult. If only I knew how...?

The weekend was a very busy one, as holiday weekends are prone to being. My technicians were tired and cranky and over it. I was tired and cranky and over it. My blood sugar has not been cooperating so well this weekend, and I can't help but think that the stress, late nights, and sporadic eating have had something to do with it. I'm also having a hard time telling when to take insulin (on the very bright side, my recent growth ultrasound estimated the baby in the 47th percentile for weight, i.e. perfect, and all of my non-stress tests have been great - so everything is perfect at the moment).

At any rate, one of my techs and I sort of snapped last night and had words.I had to force her to go outside to calm down and talk about it rationally. It was a productive conversation in that she told me useful ways that she perceived I could improve. Some of the points were valid, some were not. In the end, I hope it smoothed things out, but I suppose we'll see.

Honestly, I sometimes think I will have to give up clinical medicine and become a teacher. I love teaching, and I wouldn't have to interact on a boss/subordinate level. I could just do my thing and go home at the end of the day.

**Sigh**

It's Friday!

2011-09-04T17:16:00.000-04:00

Actually, it's Sunday - but it's Friday to me. I could not be more ready to be finished with work. After tonight, I only have 9 days of work left until I go on maternity leave. I am really ready for it. Obviously, I'm ready for the baby to get here, but I need some time off from work too.

On my actual Friday night, I hit the door at 5:30, and I already had 2 patients waiting to see me and 2 on the way. Busy nights in the ER never bother me, they make the night pass faster. Unfortunately, hitting the ground running like that always leaves me vaguely discombobulated. I feel like I don't have time to gather my thoughts and prepare for the evening. Waiting for me were a very, very sick parvo dog and a heat stroke transfer. Both were intensive care cases that required a lot - and both are doing well as of this morning when I left. The night continued with a limping dog, a coughing dog, a lethargic, febrile cat, and the like.

I haven't been having trouble staying up late to see patients. What I'm having trouble doing is getting up when I've laid down to sleep. Usually, I bounce out of bed almost immediately upon being summoned, and I can think clearly. Lately, when I've been forced to get up at 3 or 4 in the morning, I've been very groggy and out of sorts. It's not pleasant, and it's getting harder. Only 8 more nights between me and maternity leave, though.

One more night is all I have to drag myself through until I can retire to the couch and become a vegetable for a few days. It's hard to express how much I am looking forward to it.

Frustrations and bad decisions

2011-09-01T18:28:00.002-04:00

Monday night was my first night back at work. It was fairly busy for a Monday - rather against my wishes, as I had hoped for a quiet night so that I could recuperate from our trip to Florida. No such luck. I plan on sleeping very, very late tomorrow to make up for my lack of good rest lately.

Unfortunately, Monday brought a bad case that I would handle completely differently, if I had a time machine. A woman presented her 15 year old Chihuahua for "worsening since yesterday." She was seen by our relief veterinarian for back pain. At that time, no other abnormalities were noted. The dog (Daisy) was discharged on pain medications. Her owner reported that she wasn't doing any better.

Daisy was brought straight to the back, and it became apparent that she was having very labored breathing. When I listened to her heart, she had a severe heart murmur that wasn't present the day before. She was also cyanotic and having serious difficulty breathing. We placed her in oxygen and I went to talk to her owner.

Unfortunately, her owner was very mentally handicapped. She could not drive, and she had been dropped off by a friend. She could not give me any information on her dog. She failed to grasp the severity of Daisy's condition. I tried to explain, but all she wanted to do was hold Daisy. No matter what I said, I could not make her understand how ill her dog was. Further, she was severely financially limited. She was on disability and had about $395 in Care Credit.

Daisy would need at least 2-3 days hospitalization, maybe more - depending on her underlying disease condition. She would likely need lifetime medications and diligent care. I tried to convey this and kept failing. I asked her who her regular veterinarian was, and it turned out to be one of our shareholders. In this particular case, the shareholder has a history of helping out with difficult financial cases (for established clients). I crossed my fingers that she was an established client and proceeded to treat the dog with the limited money she had.

Daisy's xrays were puzzling. I expected to find heart failure, but I was not convinced of this on the xrays. She had a severe interstitial pattern in her lungs, but it wasn't the typical heart failure appearance. It could've been pneumonia too, but she wasn't coughing, and she didn't have a fever. I really wasn't sure what I was dealing with, so I treated what I could and kept my fingers crossed.

Shortly after Daisy's owner left, she called back sobbing hysterically. Her father, who cares for her, refused to drive her back in the morning to pick up her dog. Instead, he had told her that she needed to bring the dog home and "let it die." She was beside herself. Feeling terrible, I volunteered to drive the dog to the clinic myself (nearby, thankfully). The morning rolls around, and we run her Care Credit to pay for the night's care. It was declined. Stellar. I call the shareholder clinic to get information on the client. Turns out that she is NOT established and is considered an inactive client. Daisy was unvaccinated, not on heartworm preventative, and had only been seen a handful of time in 10 years for nail trims and the like.

In other words, not a client that the shareholder will work with financially. Great. What the hell was I going to do with the dog now? I called the owner, and we had a very frank discussion. I again explained that her dog was seriously ill, needed ongoing, expensive care, and more diagnostics. It finally seemed to get through to her. After much crying and discussion, she elected to euthanize Daisy.

An hour past closing time, she showed up (neighbor drove her), and we did the inevitable. Daisy went quietly. We fixed her Care Credit and were able to run it through for a part of the amount she owed us. In the end, I felt terrible about the situation. I spent $400 of this woman's money on a dog that needed more treatment without knowing for sure that more treatment was even feasible. As it turned out, it wasn't. If I could go back now, I would have put euthanasia on the table with that first discussion. Hindsight and all of that.

Back again

2011-08-29T13:12:00.001-04:00

It was a fun but exhausting weekend. We left Thursday around 11am and arrived in Destin, Florida at 9pm. It was a long drive, and I think I saw the inside of every single gas station bathroom between Florida and North Carolina. All in all, the trip wasn't too bad. My wonderful husband did all the driving, so that I could sit like a lazy, pregnant sack of potatoes.

I've only been to the panhandle of Florida once before that I remember - as an 11 or 12 year old for church camp. I didn't recall how beautiful the sea is there. Destin especially was gorgeous. The sea is blue-green - like Hawaii but not quite as brilliant. The sand was like sugar.

It was a beautiful weekend, and my friend was the most gorgeous bride I have ever seen. We enjoyed time on the beach, around the pool, with good friends (including one I had only ever met on Facebook and now blogs too). There was lots of beer, champagne, and liquor. Of course, I could not imbibe - but my husband made up for both of us.

Lots of random people rubbed my belly, which didn't bother me much. Everyone loves a pregnant woman. I didn't get enough sleep, and by the time the wedding was finished, my ankles were enormous. I also burst some capillaries in my legs. So, all in all, I probably overdid it. It was all in the name of my friend's wedding though...and totally worth it.

Back to work tonight, veterinary stories to come.

It's the small things

2011-08-23T23:17:00.000-04:00

I found curtains for the nursery - just when I was starting to despair! It seems like such a small thing, but it was really bugging me. I couldn't find anything I liked. Last night, we went to Bed, Bath, and Beyond to get a wedding present for this weekend, and I happened to swing by the curtain section and find the perfect pair!

The frames above the bed are black and white photos of Jim's grandmother - the one after which we are naming our daughter.

We leave the day after tomorrow for my vet school classmate's wedding. I am matron of honor. It's going to be a long, long drive (10.5+ hours, then add in stops for my pregnant bladder and to stretch my legs). It will be a quick weekend - what with driving all day Thurs and coming back Sunday. I'll probably be AWOL for a bit, as I have to go back to work Monday night.

Rewarding!

2011-08-21T09:13:00.006-04:00

I love a rewarding case - looking at a patient and knowing that my intervention and the care of my technicians saved its life. It is one of the things that is most awesome about ER medicine. One of my favorite things to treat - hands down - is anaphylaxis. I see this at a minimum of once a month. I am kind of an anaphylaxis magnet at work, for some reason. Maybe I'm just good at recognizing it, who knows? It took me a long time to realize that anaphylaxis was out there and to start looking for it in my inexplicably collapsed and poorly responsive patients.

Around 6am this morning, a medium sized dog named Lily presented to us. She had been normal that evening, then jumped on her owner's bed, collapsed, defecated and urinated on herself, and then proceeded to start vomiting.

When she got to us, Lily had barely palpable pulses. Her gums were a muddy grey-pink color. Her heart rate was 240 (normal 90-120). She was breathing hard and seemed very weak. Her blood pressure would not register. She had a rash along her ventral abdomen, and her body temperature was low.

Her owner was a disabled, elderly lady with $250 to her name. This is certainly not enough to treat a nasty anaphylaxis. On a weekend, these cases run into the $1200-2000 range. I was not hopeful when she applied for CareCredit, as she was on disability. I was decidedly wrong, as she was approved for $1800. We had already started working on her dog at that point anyway.

Within an hour of administering epinephrine and Benadryl, starting aggressive fluid therapy to bring her blood pressure up, administering dextrose for her low blood sugar, and re-warming her, Lily's heart rate was down to 120, her gums were pink and moist, and she was standing in her cage and showing interest in her surroundings.

When I left her this morning, her vitals were stable, her blood pressure was 120, her blood glucose was normal, and she was maintaining her body temperature on her own.

It is always immensely satisfying to take a dying dog and raise it Lazarus style from near-death. It really makes my job worth it (despite being up all night last night due to patients and having nearly constant Braxton-Hicks contractions all morning).

Sad case

2011-08-20T09:25:00.000-04:00

Last night, a nice country man brought in his new puppy. He had obtained this puppy about 6 hours prior, and since then, she'd been bleeding profusely from one side of her nose. I couldn't see a cut or any other explanation for the bleeding without sedating her. Unfortunately, the new owner had about $120 to his name. I recommended we spend the money wisely on sedation for a nasal and soft palate exam.

Both were unremarkable, and I could find no explanation for the bleeding. I questioned the owner at length about the new puppy - any trauma? any chance of rat poison exposure? He said no to these and then elected to take the puppy home for monitoring. The bleeding continued unabated.

Prior to leaving, he called the original owner. He casually mentioned that yes, the puppy DID have access to DCon rat poisoning. Come to think of it, the dog had been pooping green pellets for the last few days!!!

I told the owner how concerning this was and recommended running at least one clotting time test (a PT). This is the first of the 2 clotting times to become increased when an animal ingests rat poison.

Most modern rat poisons are anti-clotting drugs. They exert this effect by inhibiting an important enzyme that is responsible for the reduction of vitamin K in the body. Without this enzyme, vitamin K dependent clotting factors (clotting factors 2,7,9, and 10) do not get made. As a result, the body becomes unable to clot blood. This takes about 3-6 days to occur AFTER the rodenticide has been eaten.

At any rate, the owner agreed to run a PT. It was so high as to be out of range on our machine - indicating a severe clotting disorder. It appeared that our little puppy was suffering rat poisoning.

Unfortunately for the puppy, the new owner did not have the finances to provide treatment (fresh frozen plasma transfusion to replace the deficient clotting factors and vitamin K supplementation to provide the body with what it cannot make). Instead of doing anything, he took the puppy back to the original owner. He declined to even take vitamin K.

I can only hope that the original dimwit has the puppy treated, but I suspect it will lie in a lot somewhere and die a slow death of internal hemorrhage. It was an all around bad scenario.

More nursery stuff

2011-08-19T01:30:00.001-04:00

I am not crafty in the slightest. My mother scrapbooks, makes handmade cards, sews, makes dolls, and the like. She often accuses me of being adopted due to my lack of interest in visiting Michael's fabric store, AC Moore, or Hancock's. So, when the creativity stirs me, and I actually create something, I get really excited. A couple of months ago, I bought some white picture box frames at Ikea, and some fabric swatches from AC Moore. The plan was to frame the fabric in the colors of the nursery. I figured it would be one of those things I never got around to - mostly because I'm not meticulous or crafty at all.

But I did it! I am so proud of my wall of art!

Nursery Stage 1

2011-08-17T03:15:00.000-04:00

My wonderful husband painted the nursery for the past 2 days, and today, he put together the crib and "dresser" (i.e. Ikea Expedit bookcase). There's still much to do - hang artwork, get a new light fixture to replace the circa 1995 brass one, pick curtain rods and hang curtains, pick a glider, and on and on - but it's taking shape. That's exciting. I'm pleased with our Wal-Mart online Baby Mod crib. For $200, it was a good deal, it's made of wood, and it feels nice and sturdy.

Who knew that babies need so much stuff??

People make me KRAZEE

2011-08-15T23:08:00.000-04:00

Some funsies from this weekend:

A woman who looked suspiciously like she did either crack or meth (or both) presented her very sweet, old Chihuahua for a "bleeding face." Said Chi had not been to a vet in 4+ years, was not on heartworm preventative, and had received no vaccines. The "bleeding face" was a tooth root abscess. When the base of teeth become infected - that abscess needs somewhere to expand. Sometimes it expands right through the skin of the upper or lower jaw (more frequently upper). That's what had happened to this poor dog. I sent my technician in with an estimate to sedate the dog and do an oral exam. I also was careful to make sure he explained to her that the estimate did not cover ANY treatment and that would be additional. Silly me, not putting it in writing!

I extracted 8 of the dog's remaining 10 teeth, as they were literally falling out of the dog's head. All told - the bill was $70 more than the original quote. The owner absolutely REFUSED to pay the difference, as it wasn't quoted to her.

She even went so far as to bring her skanky boyfriend in to argue with my technician. Despite explaining to her that the dental I did cost $70 extra, whereas at a day practice, it would have cost hundreds of dollars (and RIGHTFULLY so) - she would not pay.

In the end, we were stiffed the $70. On the bright side, the little dog will feel much, much better now that the rotting teeth are gone. There was that to make me feel better about the whole stupid situation.

The next was a crazy breeder and her intact 10 year old Irish setter. This dog was not vaccinated. When asked why not, the woman replied, "I'm a breeder. I don't vaccinate." Anyway - she had brought the dog in for restlessness and panting/anxiety. She was convinced the dog had a GDV ("bloat"). It was obvious from 50 yards that the dog was not bloated, and I told the owner that. On abdominal palpation, she was severely constipated, however. I recommended xrays.

At that point, the owner told me that she wanted the "upside down" xray, not the "side to side" xray - as the upside down is the only way to diagnose bloat (according to her veterinarian - which I'm highly skeptical about). I explained how to diagnose a bloat - physical exam followed by a lateral xray ("side to side") if necessary.

It didn't matter - we did both views anyway, as we always do - lateral and VD. No bloat, just a colon full of rock hard stool.

Owner went home with dog only to call back at 3am, insisting we MISSED a bloat in her dog because we didn't do the "upside down" xray.

I'm sorry, Ms Wacky Breeder - where did YOU go to medical school?? I'm an ER doctor, for God's sake. I see a bloat a week. I know how to diagnose them! Hell, my last one didn't even need xrays, we just went to friggin' surgery. And guess what? I was right - the dog was bloated.

There were other colorful characters through the weekend...but those 2 took the cake.

Whoo, it's Friday, Friday...

2011-08-13T09:36:00.000-04:00

Not that the actual day means anything to me. I still have 2 more nights to work until I'm off. It was a busy night in the ER. We hit the ground running at 6pm and didn't stop until close to 5am. I saw many interesting cases: a proptosed eye that I removed, a dog with severely low platelets and a serious bleeding problem, a cat with an inexplicable post-mass removal anemia, a blocked kitty, a vomiting dog, a couple of euthanasias, an old dog with acute onset of vestibular disease, and on and on. It was exhausting, I won't lie. The only reason I'm still up is because I have to check my post-breakfast blood glucose before I can lie down. I won't fib - gestational diabetes is downright inconvenient. I guess that's true with any disease, so I should stop complaining - as mine is relatively mild. Despite being busy last night, I was able to keep on my eating schedule well, so that was an improvement.

Not much else to report. I'll post about some interesting cases when I'm less sleepy.

Life is not fair

2011-08-11T00:17:00.003-04:00

So, the heat stroke Labrador that went home with the jerk owners? Doing fine - eating, drinking, and recovering from his heat stroke. The pit bull whose owners poured $2000 into trying to save him - including 2 plasma transfusions? Dead. I'm happy for the Labrador, but what lesson did the terrible owners learn from this experience? Absolutely nothing, I can rest assured.

Wow

2011-08-08T00:17:00.000-04:00

This weekend was a busy one in the ER. 14 hours on Saturday and 13 hours today. It's very difficult to manage gestational diabetes with a schedule like I work. Saturday wasn't so bad that I couldn't eat my snacks and lunch on time. My wonderful husband got up at 7am on Saturday and fixed me breakfast to ensure that I ate prior to work. The day balanced fairly well and my numbers were ones I was happy with. Sunday was a different story. The husband made breakfast again and packed me lunch. I never got a chance to eat it, as I was running from the moment I hit the door. It was exhausting, and I never really caught myself up with the food. Hopefully, I'll do better next week.

I had a horrible case on Saturday that left me shaking in anger when all was said and done. When trying to sleep on Saturday night, it kept coming back to haunt me.

An older couple presented with their morbidly (and I mean MORBIDLY) obese Labrador (140+ pounds). He'd been locked in their car for 3 hours in the 90 degree heat. When he presented to us, he was laterally recumbent with petechiae forming on his skin. He was also having diarrhea and vomiting - all bad signs.

The owners were asked for the $500 critical care/triage deposit to get started. They flipped out - claiming that was too much money. Before things got heated, I brought the owners back to ICU - thinking that I could discuss heat stroke with them, their dog's prognosis, and give them a better idea of what to expect.

Nope, the owners were adamant - $500 was too much to treat (and that was just to start - a dog this large with a heat stroke would probably run into the $2000 range). I commiserated slightly about the cost in my best soothing doctor voice and recommended euthanasia, given the dog's dire situation.

That's when things got ugly. The female owner refused to make eye contact with me.

"I don't want him to die here!" she semi-yelled. "I want him to die on MY terms." She then said, "we're not putting him down, that's not an option." Bewildered, I tried to again explain sepsis, DIC, and acute renal failure. The owners would not listen. They wanted to take him home - to live or die there. Finally, I looked straight at the husband and said, "your dog is going to die a horrible death if you take him home in this condition."

The owner patted the dog and said, "We think he'll live."

My mouth was hanging open.It is exceedingly rare that I will tell an owner that they are being cruel, but I told these owners in no uncertain terms that what they were doing was inhumane. I almost mentioned that the dog WOULD die on "their terms" - as their terms had included leaving him in a boiling car for 3 hours.

It all fell on deaf ears. They signed an against medical advice form and left, putting their vomiting, laterally recumbent, petechiated Labrador into the back of their SUV and driving off. I felt sick. I still do. Especially because today - we saw a dog that had a heat stroke yesterday. The owners did not seek treatment and now the dog is vomiting pure blood, oozing from every venipuncture site, and dying. Just like the Labrador is probably doing in some backwoods shed someplace.

Work and sundries

2011-08-05T19:31:00.000-04:00

The last 2 nights I have work have been dreadfully slow. I saw three patients on Wednesday night and three on Thursday. Other than the perforated intestines, nothing was really interesting. Run-of-the-mill stuff like ear hematomas and the like. Thus, not much to discuss re: veterinary medicine.

I started insulin yesterday - before eating and before bedtime. It's not bad, since the needles are very small - just frustrating and annoying. I continue to follow the diabetic diet. One day at a time is how I'm taking this.

The SUV will cost $1500 to fix. We haven't made any decisions about what we're going to do yet. At the moment, it resides in the garage while we decide. We're not in a place to buy a car at the moment, as most of our available funds are going to save for maternity leave. We have excellent credit, so we could buy a car on credit - but we've never had car payments before, and I see no reason to start now. At the moment, the husband is home all day working, so 2 cars is really a luxury we don't need. Thus, we aer not making any decisions at the moment. There's no super rush, although we will need a 2nd car when Evaline gets here.

No other real developments. Chicken Biscuit has been doing fine at home. He hates me and won't let me touch him or come near him, he runs in terror. He will get in bed with Jim though, so he's coming around. I haven't decided when/if we are going to do surgery to remove his bladder stones. It might permanently scar him.

$2400 later, here's your dog in a box.

2011-08-04T09:06:00.000-04:00

I simultaneously love a challenging case such as I had last night and hate it (when they end badly). At around 7pm, I was presented with a small breed dog suffering acute onset of abdominal pain, vomiting, diarrhea, lethargy, anorexia, and fever. On physical exam, the dog was very, very depressed, had extreme pain associated with abdominal palpation, and was spewing foul diarrhea from its rectum. I recommended bloodwork and xrays to the owners.

Bloodwork showed sepsis (white blood cell count was 1400, normal is 5500-16,900), slightly low platelets, borderline hypoglycemia, and dehydration. Xrays were what really concerned me. There appeared to be fluid in the abdomen. Even worse, there was a pocket of what looked like free gas sitting up next to the kidney. No animal or person should EVER have free gas floating around inside the abdomen - not unless they've recently had abdominal surgery or a penetrating abdominal wound such as a gunshot.

I was very concerned and discussed my findings at length with the owners. Surgery was definitely indicated, as this little dog had likely perforated an intestine or his stomach. After looking at a sample of the fluid in his belly, I was confident. First, there should be no fluid in your abdomen. Secondly, if there is, bacteria should not be present. This dog's abdominal fluid was loaded with tons and tons of bacteria - another sign that the GI tract was leaking.

In surgery, I found inflamed, not moving intestines. The abdomen was full of fluid and feces. Once the intestines were out, I found a large, oozing hole in the cecum - a section of intestine between the large and small bowel. I had no choice but to remove that area and anastamose the small intestines to the large intestines.

My patient was doing very poorly under anesthesia. Her blood pressure would not stabilize, no matter how aggressively we treated. Her intestines were not moving, and the fat supplying blood to the intestines (mesentery) was inflamed terribly. There were also hardly any pulses in the mesentery.

Shortly after removing the sick part of the intestines, my surgery site started to turn purple, then black,. Within five minutes, it was just lying there, flaccid and purple-black. I knew that the site was dying. So I removed it and did another anastamosis. Five minutes later, the same thing happened. At this point, I had removed >60% of the small intestine (dog only weighed 6 pounds). Every time I touched the intestines, they died.

I knew what I was looking at - sepsis, hypotension, and DIC likely secondary to the sepsis and shock. These intestines were not going to live, no matter what I did - and especially not in the face of low blood pressure and DIC.

Scrubbing out, I called the owners and gave them the grave news. They wisely elected to not wake up the small dog, as she would have suffered heinously before inevitably dying.

It was a very interesting case with a very, very sad outcome. My inability to save the patient despite my best efforts was crushingly disappointing, as usual. And the owners, of course, were the nicest people on the planet.

Welcome back to work!

Lately...

2011-08-02T22:58:00.000-04:00

I realize I haven't been talking much about veterinary medicine. This diabetes thing is dominating my mind. Eating is really difficult when you have to be so careful. Planning is required. Any interruption in the schedule throws off everything. For instance, I set an alarm this morning to get up and check my BG, then fix myself breakfast. As I was lying in bed, preparing to rise, my phone rang. It was our office manager, asking me to come in. Our receptionist's cat was dying and on the way to the clinic.

I barely had time to grab a box of Wheat Thins and run out the door. I also didn't get a protein to pair my carbs with, so another fail. After everything was said and done at the clinic, I had to meet with the dietitian for 2 hours to discuss managing the diabetes. My BG immediately beforehand was 180. Stress spike anyone? (My receptionist's cat was in fulminant heart failure likely brought on by an error made by a technician at work last night. He died before I arrived).

With the way my numbers are looking, insulin is very likely going to be added to my treatment regimen. People keep telling me that it's no big deal. It feels like a very, very big deal - twice daily injections until the baby arrives. I'm depressed and cannot stop believing that this is my fault on some level.

Someone suggested in the comments that I switch to part-time work at the clinic. This isn't feasible for the simple fact that I am our sole source of income. Since my maternity leave is unpaid, the money we have in our savings will be the money that will get us through the maternity leave. Thus, unless the doctor makes it mandatory, I have to work through to the end.

It's only 59 more days! Evaline had her first bout of hiccups that I was aware of last night. It kept me awake for a good 20 minutes, until they subsided. At first, I was a little worried, since I hadn't felt that particular movement pattern before, then I figured out what it was. Very, very weird...

Let the complaining continue

2011-08-02T00:15:00.000-04:00

My husband left town this morning to meet with his thesis advisor. I had to corral all 20 pounds of Chicken Biscuit into the cat carrier. He is so traumatized from his recent hospital stay that he won't let me touch him. I cornered him on the front porch, thinking that I had him. Until he turned and threw himself THROUGH the screen. He burst through it like the Hulk and disappeared in the direction of the busy road near our house. I spent 1+ hours on my hands and knees, trying to retrieve him from under the bushes/trees. It was to no avail. He wouldn't let me near him. Finally, in tears, I gave up. I herded the other cats into the bedroom and locked them up, then propped open the patio door in the hopes that he would let himself in. He finally did after an hour or so. We were able to get his ultrasound done thankfully - showing disease in both kidneys (as suspected). The ureteral stone is lodged in the bad kidney's ureter, so that's good news. The bad news is, he's going to have kidney disease for the rest of his life. It will eventually probably kill him unfortunately. As to when...?

With the husband gone, I'm fending for myself food-wise. Knowing what to eat is difficult. I had whole wheat bread with peanut butter and a handful of baked Cheetos for lunch. My blood glucose shot up to 180! I broke down and cried at that point. No more chips of any sort for me - baked or otherwise. Lacking anything diabetic friendly in the house, I knew I had to go to the store and buy some appropriate foods. My energy has been very low today, likely due to my low mental state and the fact that I am in my 8th month of pregnancy. It took all of my willpower to get off the couch and go to Target. I cried twice while there.

For anyone who hasn't been through this, I feel on some level that the diabetes is my fault. Despite knowing that people in excellent health develop gestational diabetes, and it was nothign I did, I still blame myself. Did I eat wrong? Should I have exercised more? I let myself gain weight too fast. And on and on. It may be irrational but the guilt that I may have somehow hurt my daughter makes me ill.

I bought myself a new notebook to keep track of my blood glucose. It has a Rainer Maria Rilke quote on the cover - "Think of the world you carry within you." I thought it was a good reminder of why I am going through all of this, so I bought it.

For dinner, I prepared chicken and white bean stuffed green peppers (peppers from my garden!) and a baked potato with sugar free popsicles for dessert. My post-dinner reading was 107. I felt a great measure of triumph, did a little Rocky dance. Maybe I can get the hang of this diabetes BS.

Also, one of my 2 friends in the area came and hung out with me for a couple of hours. We ate dinner and planned to watch a movie, but we wound up just hanging out and talking. It helped a lot.

I think I'm actually looking forward to going back to work...I can focus on something besides my stress! I can focus on job stress!

Tired and frustrated

2011-08-01T00:38:00.000-04:00

I contrived to enjoy my weekend, even though it was a challenge. Despite being with my husband, BIL, and best friend, enjoying a responsibility free weekend at a bed and breakfast, and generally relaxing, the diagnosis of gestational diabetes was always in the back of my head. I was also worried about Chicken Biscuit. Then, as we were leaving to come home today, the AC in my car died. It's a 13+ year old car, I knew it wouldn't last forever - but come on! It's 90+ every single day outside, I am now 8 months pregnant, I NEED MY AC. Unfortunately, there is no way we're blowing $1000+ to fix the AC on a 13+ year old car with 210k miles on it. I'm not sure what we're going to do yet. I'm working on keeping all of this in perspective...but sometimes I'm failing miserably. Thankfully, my husband has been solicitous and concerned and taking care of my mental health (or trying to).

So, my GD diagnosis has further instilled in me no confidence in the human medical profession. This is how it went down: I took the test on Tuesday. I was told that I would have the results on Wednesday afternoon. I double-checked with the nurse that someone would call me with the results. I was assured they would. No word on Wednesday. When I realized what time it was, it was too late to call. I assumed the results were normal. Still no word Thursday, so I finally called around 2pm. The nurse says, "oh yeah, your results were very high. We need to schedule a 3 hour test."

"WHAT?" Why had no one contacted me? It was Thursday now, with plans for us to leave town that evening. I asked if they could get me in that afternoon, as I was luckily (accidentally) fasted. No can do. We'll schedule you for Monday.

Fine, whatever.

Then, on Friday - while I'm lounging on the front patio of the B&B, relaxing, a different nurse calls me and informs me that my blood glucose was so high that I get to skip the 3 hour GTT and go straight to a diagnosis of gestational diabetes. She told me that the dietician/nutritionist would call. That was it. No information, no discussion with the doctor, no mention of re-testing to make sure the high reading wasn't an error, no confirmation with a 3 hour GTT. No "hey, in the meantime, you should do the following thing...." WTF?

In my line of work, if I get a bloodwork results that are high, unexpected, or concerning on a patient's bloodwork - my first response is to make sure that the sample was collected and run correctly. Then, if I think that was done properly, I repeat the test to make sure that the result wasn't erroneous - wrong patient, wrong blood sample, sat too long, didn't sit long enough, etc. Then and ONLY then do I believe my results. In other words - one concerning result does not = disease.

Apparently, in human medicine, a one-time high blood glucose reading is sufficient to diagnose gestational diabetes. On the one hand, I understand this. It is a cost/benefit scenario. It is better to assume that I am diabetic or borderline diabetic, and stick me in the diabetic group. This way they can monitor me closely and ensure that I have a healthy pregnancy and baby. It also decreases the liability of my doctor should there be an "adverse outcome." With the high volume of patients that my office sees, I'm sure this is the MO.

The downside is that it labels me as high risk, meaning that the medical team will want to do all kinds of interventions that may or may not be necessary in what was a previously perfectly healthy pregnancy. I am now a "high risk pregnancy" and thus, must be monitored very closely with more testing than previously. Also, I'm sure I will be counseled that my baby is going to be too big and that I should be induced and/or undergo c-section (estimates on fetal age and size can be wildly inaccurate - acknowledged by some medical texts I've read and anecdotal experiences with friends).

Today, on the way home from Asheville, I downloaded a med school textbook on managing the diabetic pregnancy and read it. Reading the laymen's book was too frustrating - as I wanted to know what was taught to OBs as far as recommendations and WHY. It was helpful, and I feel more knowledgeable now. I'm still very frustrated with the whole procedure. I plan on calling the OB tomorrow and asking that I either re-take the 1 hour or take the 3 hour. I'm not in denial and don't believe that I can't have GD - I just think the responsible thing/medically correct thing to do is confirm with another test before I get all stressed out. In the meantime, I'm keeping a food journal and checking my BG as recommended in the medical text (4 times a day - fasting/just woke up, 1 hour post-breakfast, lunch, and dinner). So far, my readings have been fine.

In Chicken Biscuit news, we are taking him to get an ultrasound tomorrow. This will help determine if he has a good kidney left. I'm hoping very much that the does, otherwise we will be managing chronic renal failure with an uncertain prognosis.

I am really, really tired right now. And really stressed. I go back to work Wednesday, and I can't tell if that's a good thing or a bad thing!

Keep piling it on universe. No, seriously.

2011-07-29T16:06:00.001-04:00

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!

2011-07-27T20:08:00.000-04:00

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

2011-07-25T23:53:00.000-04:00

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

2011-07-24T08:49:00.002-04:00

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

2011

2011-07-23T17:41:00.000-04:00

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)

2011-07-21T09:41:00.001-04:00

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...

2011-07-20T23:32:00.003-04:00

Them bones, them bones...

2011-07-20T13:03:00.000-04:00

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...

2011-07-16T23:08:00.000-04:00

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)

2011-07-15T19:46:00.002-04:00

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

2011-07-15T18:11:00.000-04:00

After 2 13+ hours shifts.

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

2011-07-14T16:23:00.000-04:00

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

2011-07-13T16:27:00.001-04:00

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.

2011-07-13T16:08:00.001-04:00

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

2011-07-12T12:32:00.000-04:00

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

2011-07-11T15:22:00.000-04:00

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

2011-07-09T23:01:00.000-04:00

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...

2011-07-07T11:13:00.002-04:00

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

2011-07-04T22:33:00.002-04:00

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

2011-07-02T17:58:00.001-04:00

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?

2011-07-01T15:48:00.003-04:00

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?

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

2011-06-29T09:03:00.003-04:00

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.

After some flushing and sutures, Molly was as good as new - and not even limping. See - there are happy endings in the ER!

(I have pictures, but the computer is not cooperating...)

The weekend

2011-06-27T14:22:00.001-04:00

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...

2011-06-24T22:48:00.000-04:00

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 ...

2011-06-23T16:25:00.000-04:00

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

2011-06-22T15:58:00.000-04:00

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

Not much to blog about

2011-06-21T20:50:00.000-04:00

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

2011-06-19T17:39:00.001-04:00

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

2011-06-19T14:57:00.002-04:00

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.

2011-06-17T21:03:00.000-04:00

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

2011-06-16T15:32:00.001-04:00

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

2011-06-12T18:11:00.001-04:00

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

2011-06-11T01:11:00.000-04:00

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

2011-06-09T14:34:00.000-04:00

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

2011-06-08T09:46:00.001-04:00

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

2011-06-07T08:50:00.002-04:00

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...

2011-06-07T08:47:00.002-04:00

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...?

2011-06-06T01:14:00.001-04:00

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

2011-06-04T22:00:00.000-04:00

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.