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

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

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

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

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

Bad, bad choices

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

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

A difficult diagnosis comes too late

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.