part 2

the sequel to why emergency medicine is so hard:

4) euthanasia: we do so many more of these than GPs- running the gamut from tragic injuries that could have been avoided to old dogs and cats ready to die. after pulling up the pink juice for the 5th time in 8 hours, i start to become emotionally numb. sometimes i have to refuse to do a euthanasia and ask a colleague to do it (as long as they haven't done many themselves that day) for fear of becoming completely emotionally unhinged.

5) exhaustion: often our shifts run several hours over - bleeding into the wee hours of the morning or late into the night. sometimes i don't get to eat or drink or pee in a 12 hour stretch. it ain't healthy and it ain't ideal - but it's a fact. we are chronically understaffed and chronically over-stretched.

6) staffing: it is difficult to find technicians who can bear the stress and emotional burden of emergency work. see reasons 1-5 for why their jobs are just as hard as ours. on top of that, they cannot take proper care of their assigned patients because they're also responsible for diagnostics on all the emergencies that come to the ICU. on top of that, they rarely hear words like THANK YOU from anyone. i've made it my personal goal to try and tell all the techs at the end of their shifts (and often many hours afterwards) thank you. i know how much better i feel when someone takes time to thank me for caring for their pet or doing a good job.

i'm sure there are many more, but at the moment - i can't think of any.

i'm going on overnights for a week starting tonight - so again, if you pray - pray for my sanity. pray that this week isn't like last weekend at all, or i might have to find a new vocation!

Courage is going from failure to failure without losing enthusiasm

i read a blog called dolittler with a fair amount of frequency (at least 4 times a week, if not more). it's kept by a female veterinarian in miami named dr khuly. her posts run the gamut of veterinary care - from medical conditions to interpersonal relationships to finances and the frustrations of being viewed as a humanitarian, and therefore - unconcerned about money in regards to our patients. lately, there's been spirited and sometimes angry discourse about some people's perceptions of veterinarians. if you're interested - you can check out the comments sections on some of her recent posts at:

www.dolittler.com

it has brought to my awareness some of the inherent problems of being an emergency doctor. i am going to elaborate on them here:

1) trust issues: most people who show up at the emergency clinic have an animal in dire need of medical care. often they are fatally injured and all that is left for me to do is deliver the terrible news and dispense the ever present pink juice. for those that i can help, their owners are faced with emergency room expenses (by no means cheap - i'd estimate the average hospitalization runs between $450-650) and an uncertain prognosis. all of this information is delivered by a strange veterinarian they've never met and with whom they have no previously established rapport - in a time of probable duress in their lives.

2) triage: to each individual owner - their pet is the most important thing. this is understandably so. and to us - each pet is an important patient - however all of their problems are not equal in severity or relative emergence. we - as doctors - must triage. this involves often putting the less severe cases on the proverbial back burner while the more severe cases take precedence. does this suck? yes. do we sometimes inappropriately triage i.e. mistake a serious case for something more benign? yes. can we help that? that is arguable.

3) the time crunch: i would love to spend 20 minutes discussing every possible outcome of treatment with an owner, as well as every single possible complication associated with their pet's condition. i would love to endure a question and answer session spanning a half an hour. i do love to educate people - clients, our technicians, anyone who listens (part of the reason i keep this blog). unfortunately, in emergency medicine - the time is not there. often i get to run over the most likely complications, the cost of hospitalization, diagnostics, and/or surgery, discuss quickly any concerns the owners have, and then move to the next room. it's my job. and it sucks not only for the clients - who may be left with more questions than answers - it sucks for me.

i have an example of this latter case i want to share. a couple of months ago, a young woman brought her small dog to me. he had begun vomiting and having diarrhea that day. the dog - an older mixed breed terrier - was well taken care of, up to date on shots, heartworm preventative, and general healthcare. recent geriatric blood tests had been normal. the owner noted that he had seemed to slow down a lot in the last week - but the vomiting and diarrhea had just begun that day. i did my physical exam and was a bit confused. i couldn't hear the heart to save my life. it was not a physical exam finding i was expecting. i whisked him off to ultrasound quickly - just to convince myself i was hearing (or in this case - not hearing) things. but lo and behold, i was right on the money. i couldn't hear his heart because it was floating in a sac of fluid.

normally, there is a sac around the heart called the pericardium. it has a small amount of fluid (3-4mL probably) to keep the heart muscle lubricated. that fluid is not visible on an ultrasound. what i was seeing in this dog's heart sac was probably 300-500mL of fluid. what did that have to do with the vomiting and diarrhea, you're probably wondering. and i'm wondering too. still am.

i went back to the room and explained to the owner my findings. the dog was severely tachycardic (elevated heart rate) - likely due to the fluid in the sac putting too much pressure on the thin-walled right side of the heart. treatment for pericardial effusion is an immediate pericardiocentesis. this involves sticking a long needle/catheter into that sac (but trying NOT to hit the heart) and removing the fluid. i discussed this with the owner, as well as the complications associated with this kind of procedure - including sudden death from cardiac decompensation.

the owner left her dog in my hands after kissing him on the head. i tapped him twice. the first time, he developed cardiac arrhythmias which were corrected with lidocaine. i was only able to get about 60mL of fluid out before the catheter was blocked by a clot. i tapped him again and was able to remove almost 150mL of fluid successfully. i returned him to the cage and hooked him up to an ECG that i could easily monitor from across the room. as i was attending to my other patients, i watched the monitor. a hit by car came to the back, and i bent over it, checking the ECG monitor every 30 seconds. the last time i looked up, the heart rate read zero. my pericardial effusion had died. we attempted rescucitation - but we could not get him back.

what does that have to do with the time crunch? you might wonder. it centers around the fact that the owner brought her dog in with vomiting and diarrhea. these are concerning but not usually life-threatening conditions. though we found a life-threatening condition, i don't know that the owner fully grasped the seriousness of pericardial effusion. first, she wasn't expecting it and second, i didn't have 45 minutes to explain it to her. i had to explain it in brief terms and then get to tapping the chest because time is ALWAYS ALWAYS ALWAYS of the essence in emergency medicine.

in this situation, her dog received the best and most appropriate medical care it could - but does the owner know that? all she probably knows is that she brought her dog to us for V/D and it died. trying to explain this in the shock that follows the sudden death of a beloved pet is difficult. the owner is often not fully processing what you are saying - but instead mentally replaying the events of the past few weeks - trying to find clues or explanations for what happened.

to be continued...

raindrops keep fallin' on my head...

it's a rainy, dreary, cold day here in the south. i'm back at the old stomping grounds, spending the weekend with my best friend and brother-in-law. it's a perfect day for lolling around and doing exactly nothing, and i love it.

tonight, we will play poker and probably eat burritos courtesy of moi.

i am recovering from the riot that was this past weekend, but i'm still a bit too bitter and tired to write about it in its entirety.

suffice to say that i had a patient with terrible vomiting that i couldn't control with conventional anti-emetic therapy, including a drug called zofran. zofran (ondansetron) is an anti-vomiting medication used for human chemo patients. it is usually fantastic. it didn't help my patient. after 2 days, i made the call to take my patient to surgery on the off-chance that he was obstructed in a way that wasn't obvious on the xrays (which were normal) and to obtain GI biopsies. i found exactly nothing - other than a strange thing hanging off the spleen. it didn't look like cancer or a granuloma - so i had no explanation for it. i wound up doing a splenectomy, but the owner was cash-strapped - and i couldn't submit the splenic thing for pathology. afterwards, my patient didn't wake up from anesthesia. his blood pressure plummeted - and he went into respiratory arrest. we aggressively resuscitated him, but the owner elected to stop.

i should feel good. the owner didn' have enough money to keep treating. we were going to euthanize when i offered him a payment plan (which we are typically not allowed to do in emergency medicine - just the nature of our client base). he accepted this tearfully, thanking me. i had a good sense about him, i knew he would pay us and gratefully. we decided that i would do surgery - if i found an obstruction, i could remove it. if i found something else, something terrible, i would euthanize on the table.

i gave the patient a chance. we were going to euthanize him. still, i feel so bad. it was terrible. and i still don't know why. all of my testing was normal - and he still died - despite my care, despite my testing, despite finally making the call to go to surgery.

it left me feeling sad, empty, and confused. of course, his owners were lovely, lovely people with children. and of course, my patient was a lovely, young (2 years old) animal whom i wanted to spend all of my "spare" time petting.

one of the many things that made this weekend a particularly rough one. another case that reminds me that no matter how hard i work, no matter how conscientious i am - i am not god, and i cannot fix them all. it's a bitter pill to swallow, but one i must keep swallowing nonetheless.

anonymous RE:drug testing

ok, first of all - i don't even understand your comment. it seems that you think i had to do drug testing for research? what i'm talking about is being randomly selected for a drug test for myself - to see if i'm using marijuania or ketamine or cocaine. and i don't think i'm superior to people. i have no problem with people working at mcdonald's. but i DON'T think that as a doctor - i should have to go sit in a clinic with people on parole, people who were drunk or high on the job, and take a drug test just because my employer wants to claim a drug free work-place. i don't know a single other doctor - DVM or MD that has to do that. that may be elitist of me, for which i will not apologize. it's how i feel. it was insulting. i kow doctors are prone to drug use as much (if not more so) than the average person - but i still object. hell - i object on behalf of the person that works at mcdonald's too. if you show up sober, do your job, and go home -why is it your employer's business what you do at home??

thank god the weekend is over (how many people say that?)

this weekend was unbridled chaos the likes of which i haven't seen since july 4th weekend. i don't know why. the previous weekend was so slow, i went home on saturday early to watch football. this weekend - every cage was full. it was terrible.

one of the internal medicine specialists made an eloquent analogy for our job. it's like a relationship with a boyfriend that beats you. sometimes it's really great - and everything is rocking and rolling. and sometimes it beats you down.

this weekend beat me down.

ok, it's a stupid analogy. but it worked at the time.

on sunday, i arrived at noon and didn't leave until 7am monday morning. i squeezed in a 3.5 hour nap, then went back to work for the noon to midnight shift again. i was exhausted, emotional, and depressed. one of my patients died - and i still don't know if it was something that i did or not.

i saw some interesting cases that i might feel like talking about sometime soon, but for now - i want to block out the last weekend in its entirety. it was awful. finished off by my being selected for a random drug that i was supposed to go take on monday. after working for 20 hours and sleeping for 3 hours. i flatly refused. first - i think drug testing is insulting. i am a doctor. i'm not working at mcdonald's, for god's sake. at any rate, i refused to go that day, because i had a patient in dire condition. so i got to go on my day off and piss in a cup. YAY.

today, i was a naughty monkey. really naughty. i went and had my hair colored - it's a really deep purple-red now (my grandfather will have a heart attack - and i think my nanny - who reads this blog - will rat me out). and i went to clinique and got a make-up consultation and finally learned to actually apply it. it was fun. they went a little heavy on the eye makeup, but the overall effect was awesome. i bought new perfume (dior addict 2). i bought make-up. it was bad, but i feel better. drowning my sorrows in unabashed frivolity. ah...the american way.

i need to go clean litterboxes and bird cages in preparation for our trip to the hometown tomorrow.

i'm scared

very scared that by the time i die, i will be living in a socialized america - big brother will be watching me.

the wall street journal has a good article on exactly why i am fearful of an obama presidency. and i'm NOT endorsing mccain. truth be told, i don't like either of them. and i don't necessarily think if mccain does somehow pull out a win that america still won't be socialized by the time i have grandchildren.

it makes me sad.

http://online.wsj.com/article/SB122420205889842989.html?mod=rss_opinion_main

two roads diverged

i'm diverging from veterinary medicine briefly to talk about another passion of mine...

i've loved music for as long as i can remember. for the first decade of my life, i was very limited in my musical tastes. my parents raised me on "oldies" - the 40s, 50s, 60s, and 70s. johnny cash, marty robbins, elvis presley, the big bopper, chubby checker, the beatles...for the longest time, i thought that was the only music that was worth a damn. when i was 10, i started to branch out on my own and experiment with my own musical tastes. i retained a love for the oldies and that has never waned. yet at the age of 10, i was ready to forge my own way.

my tastes since then have been eclectic - to say the least. in 5th grade when i first heard '3am eternal' - i thought i was hearing genius. i worshipped KLF - a forgotten (and undeservedly so, i contend) British acid house/ambient band (according to the all-knowing wiki god), although compared to current ambient (aka boards of canada, age of rockets, explosions in the sky, M83, appogee) - it's a completely different sound. much more frantic.

i still love KLF and i think the white room is genius.

another offbeat band that i was introduced to in high school (my best friend was way more cool and way more up on the underground scene) was messiah - a techno/trance/? group that heavily sampled other songs and artists to create a frenetic album (21st century jesus) that had a huge impact on my appreciation for techno/trance/ambient/dance/house, etc. i still love it, although finding a copy of the original is a bit of a challenge - mine having gone the way of many of my CDs.

i still have a very strong taste for techno. i still, after all these years, love lords of acid - shock sex techno though they were. i'm not "up" with the underground music scene as much as i wish i was - having lately moved over to the prog rock side of things.

i think that my love of techno has kind of bled over into the ambient rock genre. appogee is one of my recent acquisitions that i'm rather fond of, as well as caterpillars.

caterpillars i cannot take credit for - my brother put them on his myspace, i merely followed my ears (and the link). i've been sucked in entirely - which - since they only have 2 songs on the web currently - is not a good thing. i need more. as yet unsigned, they are releasing their EP soon. i'm happy about that, since at the moment, i cannot tote them around with me on my ipod. that makes me sad.

the song 'bury your words' does something to me. it's dreamy, ethereal, and makes me feel a yearning i can't really describe. maybe only a yearning to strive for something better, to strive for something beyond the here and now.

i love it.

"bury your words beneath this insane earth,
in a silence found only beneath the dirt.
no i don't want to hear what i've heard before,
wanna escape this place and find something that offers more."

and the lead singer works at a vet clinic (a kindred spirit musically and with the fluffies!).

check them out: www.myspace.com/caterpillarss

if anyone has any other musical suggestions - i am ALL ears. i'm in a musical rut as of late, sadly. i'm going to see the avett brothers in november, so at least i have something to look forward to - but other than that...nada. the hellsayers are playing sporadically in asheville, but i can't get away to go see them. another unsigned band that i adore: www.myspace.com/thehellsayers.

albums everyone should own:
grandaddy: the sophtware slump, under the western freeway
the hellsayers: the lonesome sea
the avett brothers: emotionalism
rogue wave: descended like vultures
band of horses: everything all the time
cary ann hearst (still unsigned DAMMIT!): dust and bones
anything by arcade fire

i go back on emergency work tomorrow through monday - 12pm-12am shifts for 4 days. i'm sure i'll be back on tuesday with lots of stories to tell. for those that pray, pray for my sanity.