ineffectual?

i think i'm being ineffective in my methods of convincing people to hospitalize their animals tonight.

in the last 6 hours, i have sent home the following:

1) a cat with heart failure as a result of his overactive thyroid - in severe respiratory distress, requiring oxygen therapy and lasix. he was certainly NOT stable.

2) a 6 week old, laterally recumbent poodle puppy with hemorrhagic diarrhea and a blood glucose of 44 (normal 70-100). she likely had parvo, but her owner had no money, didn't qualify for care credit, and declined euthanasia.

3) a 6 year old shih-tzu with hemolytic anemia, a PCV of 10% (normal 35-45%), and copious vomiting. i was able to give her a blood transfusion, as the owners had some money, but she will be going home to TTJ at some other date likely.

4) a ferret with a likely foreign body obstruction and sepsis. owners don't have money for surgery.

the ONLY patient i've kept is a 15 year old dog on 9 different medications with no current problem that requires hospitalization. the owner just wants her here for observation. lucky for us, she has separation anxiety and pretty much spazzes out non-stop despite multiple doses of torb, ace, and valium.

YAY !

this is where it hurts.

if our hospital were the land of oz, and my internmates the group that went in search of it, i would undoubtedly be cast as the tinman. in need of a heart. this isn't strictly true, i have a huge heart. on the other hand, i am extremely pragmatic about the way the world works, and sometimes others mistake this for not caring. i think those of you who read my blog would know that's not true.

the last 2 nights, my heart has been a major stumbling block - not allowing me to do my job effectively. i saw 2 cases this evening - and i had to euthanize them both. and it killed me to do so.

in the 2nd case, the dog was suffering from likely either rat poisoning or severe heartworm disease/caval syndrome. it was difficult to tell which. the owners had no money at all, and they didn't qualify for care credit. they asked me if the dog would live till the morning to see their veterinarian. and i conceded that it might. on the other hand - to what end? to see their vet with the same terrible disease process and no funds on hand? the end result is the same.

still, as i looked into those sweet, expressive brown eyes and injected the fatal pink solution, i felt a little less human.

when do you stop feeling D-U-M-B??

i am taking care of a 14 week old puppy whose head was crunched by a much larger dog. it's pretty terrible. the puppy is disoriented, vocalizes constantly, has a severe head turn (torticollis), rolls like an alligator, and is generally effed up pretty bad.

at the owner's request, i took xrays of the skull. for what it's worth - xray is a crappy way to look for skull fractures. unless it's a humongous, depressed fracture - it isn't going to show up on a plain film. ct scan is much, much better. but much, much more expensive, too.

so anyway, xrays show a "fracture" in the middle of the skull - which would be consistent with all the signs i am seeing in this dog. i diagnose a fracture of the calvarium.

i worked on her all day, and despite that, she is doing horribly. the cherry on the sundae is that tonight - after reviewing stuff on VIN (veterinary inter-network) and in my diagnostic radiology book - it turns out that the "fracture" i saw is really an open suture line (growth plate in the skull). so this fracture isn't really a fracture.

in my defense - the suture line is much too wide - likely due to significant swelling of the brain. it's possible that there is a fracture there too.

when will i start knowing EVERYTHING so i won't feel so stupid all of the time?

oh, right. NEVER.

on the bright side - skull fracture or not - management of head trauma is the same. so my "misdiagnosis" doesn't affect the patient. unfortunately, she's in bad shape. i don't expect her to survive much longer.

the heart of medicine

i am reading a fascinating book that was written in the 70s called 'the house of god'. it's "fictional" but was written by an MD at harvard and follows the internship year of 5 medical students. it's riveting, horrifying, disgusting, disturbing, compelling, and utterly familiar - the human aspect aside.

a particular passage stood out to me - after the intern has aggressively treated a fellow doctor's cancer, everything has failed, and the doctor is dying - he sits with him. and the doctor explains to the intern the heart of medicine.

"no, we don't cure. i never bought that either. i went through the same cynicism - all that training, and then this helplessness. and yet, in spite of all our doubt, we can give something. not cure, no. what sustains us is when we find a way to be compassionate, to love. and the most loving thing we do is to be with a patient..."

i like to think that i see through to the heart of my profession - that i understand my place and my function. i've seen others that don't -who keep hanging on -forcing their patients to hang on - for just one more day - for a cure that is never coming. who confuse optimism with refusal to accept that we are just human - not gods. not capable of fixing everything, every ill, every wronged organ.

i am reminded of an intensive care patient that i handled for 4 days. he was diagnosed with hepatitis and had lived TWO years with this condition (most dogs are dead within 6 months). at the end, his liver completely and predictably failed. he couldn't make clotting factors, he couldn't make proteins, and his glucose was low without constant supplementation. his owners refused to euthanize him, and i had to be party to his slow torturous decline. he was admitted for frank hemorrhage from his rectum. my attending thought he had a coagulation problem or a GI bleed. i wasn't so sure. further, he couldn't have ANY pain medications because his liver couldn't metabolize them. giving a small dose of sedative knocked him out for 12 hours at a time. his owners latched onto the idea that a novel therapy would save him, and the doctor working with me fed this idea. i was party to his demise, and it made me sick - to see this loyal, sweet dog forced to lie in a cage with tubes coming out of him, hooked up to machines, with no hope of ever being normal again. when his owners FINALLY assented to his euthanasia, we found on necropsy that an 8 inch section of his GI tract was dead (leading to the bleeding). he had lain, in a cage, without pain medications, for 5 days like that. with a dead, rotting piece of intestine probably hurting like nothing you or i could imagine.

but it isn't always that cut and dried. and reading that story makes me sound judgmental and harsh. the doctor i worked with loved that dog, and she wanted the best for him. it's not always easy to know when to stop, to say enough is enough, and to let our pets go. there are times when i honestly don't know if one more day will make the difference. that is what makes my job the hardest. looking at a patient and knowing it is time. sometimes it is easy, and sometimes, i have no idea, and i still have to help the owners make that decision. while it is a hard one, i still feel it is a gift that i - as an animal doctor - can give my patients. human doctors (and patients) aren't so lucky.

in the end, medicine isn't just knowing what to treat and how to treat it, but when to stop treating and allow our patients a measure of peace at the end.

on complications

one of the most difficult parts of my job is figuring out when i did something wrong versus when i did everything i could and the inevitable just happened.

on sunday last week, i was presented with a dog that had a possible foreign body. her owner - we'll call her ms smith - was very good friends with a veterinarian (also a shareholder in our clinic). dr X saw the pet on saturday for lethargy, diarrhea, and anorexia of 2 days duration. no diagnostics were done, although the owner reported that "pup" had a bad habit of eating things he shouldn't. dr X prescribed an anti-emetic and sent the dog home. on sunday, she saw the dog again and noted cranial abdominal pain. the dog was sent to me.

xrays revealed at least 3 foreign bodies in the stomach and small intestines - hair elastics.

foreign bodies in dogs can run the gamut from bad to really, really bad. in this dog's case, we were dealing with a linear FB (the worst). your intestines are always gently (and sometimes not so gently) squeezing in a direction away from your stomach. this is called peristalsis and it moves in waves through the intestines. if a dog eats a string that gets partially hung in the stomach, but much of it passes through into the intestines, the intestines will continue to squeeze along. however, they won't be able to move that string, so they will bunch up on the string (just like the drawstring on your pants will do). eventually that string will saw right through the delicate gastrointestinal tissue, leading to spillage of feces into the abdomen. linear foreign bodies are BADNESS - especially when they've been present for THREE WHOLE DAYS.

i took the dog to surgery and removed 2 hair elastics from the stomach, as well as a mass of carpet like material. one of the hair elastics passed into the intestines, and due to the damage done, i had to cut out about 2 inches of small intestine.

24 hours post-operatively, the dog became horribly depressed and began vomiting. the owners refused to go back to surgery to let us find out what was going on. they elected to euthanize and take the body home.

i am left with the following options:

1) my surgical site failed and leaked into the abdomen
2) contamination of the abdomen during surgery led to peritonitis
3) the bowel that i thought appeared still viable was in fact too damaged to survive

the real kicker?

the vet that referred this dog is throwing a fit that i (yes, ME) did the surgery. supposedly i'm not supposed to do surgery - since i'm JUST an intern. no matter that i'm 1 month from the end of my internship, that i've done many of these surgeries (probably more than dr X has this year) - hell, i've done more than 50 surgeries this year, some much more complicated than that, that i've been hired as an ER doctor already to do just this kind of thing, and finally - the fact that this was a LINEAR FOREIGN BODY THAT HAD BEEN SITTING THERE FOR 3 DAYS! i'm being raked over the coals for a complication that has been reported to occur in up to 16% of these patients post-operatively.

in this situation, i'm left wondering: was it something i did wrong surgically? did i make a mistake and leave bowel that i should have taken out? did i ligate something that i shouldn't have? i'll never know for sure. i do know that every time i do surgery, i learn something new, i also look for my culpability, and i always take a failure (surgical or otherwise) to heart. it's hard enough to learn and forgive yourself without other vets ganging up on you!

but i'm a big girl, and i can handle it.

surgery and the contradictions contained therein

i did 3 surgeries in my 5 nights on emergency duty.

the first was a 3am arrival - a bitch having her first litter. a puppy was stuck in the birth canal. on pelvic exam, i could feel the puppy stuck in the cervix (which was fully dilated). xray confirmed that the puppy's head was far too big to come through. i had to do a c-section. the owner refused to let me spay the dog - which was extremely upsetting - given that the dog will likely continue to need c-sections every time she is bred. i tried to talk the owner into it, but she wasn't having it. it was a particularly gruesome surgery. i was forced to decapitate the fetus in utero, push the body through the birth canal, and take the head out through my uterine incision. the mom recovered well but had no puppies to show for it (the other could not be resuscitated).

day 2 was another cystotomy. this little guy had about 18 stones in his urethra blocking urine outflow. he did not feel well at all. his owner was a pediatrician, and i really liked her.

day 3 brought the badness. a little yorkie showed up. she belonged to a woman who was good friends with the vet that had sent the dog over. this was sunday night. on thursday, the dog became lethargic, had diarrhea, and stopped eating. she saw her vet on saturday and was prescribed cerenia (an anti-emetic). no xrays or bloodwork were done. on sunday, she saw that vet again at home, and the vet noted abdominal pain. she was turfed to me. xrays revealed 3 foreign bodies - all appearing to be hair elastics. the kicker? this owner KNEW the dog ate things ALL THE FRIGGIN' TIME that she shouldn't. the vet that sent her to me knew it too. at any rate, we went to surgery, and i had to remove about 2.5 inches of small intestine, as well as do a gastrotomy (incision in the stomach) to remove the hair elastics.

linear foreign bodies are really bad. they get hung in the stomach or upper small intestine, and then the intestines try to move around them (peristalsis). since they can't move the rope/string through, they bunch up around the string. as a result, the intestines essentially get terrible rope burn, and often, the string will chew right through the intestines. having that going on for 3 days isn't good. it's very very bad.

yesterday, she developed post-operative peritonitis and was euthanized. i don't know why exactly. it's possible that i misjudged the viability of some of the gut and left stuff that should have come out. it's possible that the anastamosis site (the area i sewed back together) leaked. it possible that she developed a post-operative infection from bowel contents getting into the abdomen. the owners wouldn't let us go back in and try to fix the problem, so i'll never know if it's something that i did or something that would have happened secondary to all the damage that was done by the string.

and the second kicker? since these people were friends with the vet that sent the dog over (coincidentally the founders of our clinic and presidents of the board), i'm being held over the coals because i'm an intern - and i'm not supposed to be doing surgery alone! i almost fell over laughing when i heard that statement. i've done more than 50 surgeries this year - almost every single one alone. and i have a very good success rate. i've lost 3 prior to this - and all have had terrible, terrible diseases and/or injuries and would have died regardless. also - consider that i am no longer an intern in 1 month and that i have been hired to be an ER doctor for a large salary!

the whole thing is stupid and overblown. the dehiscence rate for GI anastamosis and resection is reported as high as 16%! it's not an easy surgery, it's not always a successful surgery, and this dog had a LINEAR FOREIGN BODY FOR 3 FULL DAYS before it came to me.

all of that seems irrelevant to the fact that i'm just an intern.

is it possible that i messed up? yes. is it possible that i left tissue that i should have taken out? yes. but it's very, very hard to know - ask anyone who has ever done GI surgery. i worked very hard on that dog. i was absolutely attentive and spent a great deal of time trying to make the decisions as far as bowel viablity went. will i ever know for sure? no. will i learn from this? yes.

on a more positive note, i did have a good week at work. i'm really excited about my new job, and in general, life is good. i just need sleep. very, very badly.