Unsupervised and furious

On a spring Saturday shift at the ER, I met a lovely family and their 7 year old German Shepard named Reggie.  Reggie had been diagnosed as an epileptic at the young age of 2 years old, but had done incredibly well over his lifetime with proper medications and monitoring.  Unfortunately, in the few hours before his arrival to my emergency room, he had experienced 20-30 seizures in rapid succession.

Reggie was admitted to the hospital for medications, monitoring and testing.  Additional anti-seizure medications were added to his therapy, and gradually, his seizures abated.  

When Monday morning arrived, Reggie's family decided it was time to head back to their primary care veterinarian -  a very common occurrence in our world.  We stabilize pets in the emergency, and then send them back to their veterinarian for ongoing care.

Later that day, after the general practice had closed, lab testing returned for Reggie.  I called his owner to give the results and check on him.

"Reggie didn't have any seizures today," the client reported. "He's there right now."

"Okay," I said. "I hope he feels better soon."

The client seemed nervous, and concerned.  "There's someone in their clinic all night, right?" she asked. "They have overnight staff, don't they?"

Our emergency room serves a large part of our community - so primary / daytime veterinarians don't have to be on call at night.  It's hard enough to work all night (just ask me!) but it'd be impossible to work all night and the next day, too.  For this reason, almost no other clinics in town have overnight techs, and none of the clinics have doctors scheduled on duty overnight.  Sometimes they make exceptions, but the vast majority of clinics transfer any unstable patient to us for monitoring overnight.

"I don't know what their staffing schedule is," I replied. "You should ask them about that tomorrow. Sometimes clinics will have a tech stay late,  but there's no way for me to know."

"WHAT THE $*#*!" The client replied. "You're saying he's there, by himself, all night?"

"I don't know."

The client thanked me for my help, and hung up.  I thought that'd be the last I heard from her - but about 45 minutes later we received another panicked phone call.   She had just driven past the clinic, looked in the windows and noticed there was no cars in the parking lot, nobody in the building and she knew her dog was in there, unobserved.  Reggie could be having any number of seizures, or stuck in constant seizure that won't end, and eventually will lead to death (called status epilepticus) and nobody would be able to help him.  The client was in tears, hysterical and upset that nobody had told her he would be alone all night - otherwise she would have just brought him back to our ER or taken him home, where at least someone would know if he was having a seizure.

I couldn't blame her for being upset.  Of course, I have no idea if she was told there was nobody in the clinic and chose to ignore it - it wouldn't be the first time a client has twisted their doctor's words - but her reaction seemed genuine.

At her request, I called her doctor at home.  He was noticeably intoxicated on the phone, but since he was at home -- there's obviously nothing wrong with a few adult beverages.  I offered to return the call for him after I noticed his state, but he unfortunately requested to do so himself.  Oh, to listen to that conversation - I can't imagine any positive outcome. 

I just hope Reggie is okay.

The lesson here:  Before you leave your pet anywhere overnight, make sure to ask if a doctor and / or technician is in the hospital all night.  Some states now require written disclosure of hours of operation and if the pet will be left unattended.  If nobody is in the clinic overnight, you should be advised of a 24 hour option and or discuss the risks of leaving your pet unattended. Some stable patients (such as orthopedic surgery, declaws, etc) are truly fine left on their own.  Although ER stays can be expensive, it's the cost of having doctors and staff up all night long to monitor and care for your pet. Many ill patients, such as those with seizure disorders, should NEVER be left in a clinic unattended.

~Erdoc

Somebody hold me back, I'm gonna punch him....

It's taken me a few shifts to gather myself to be able to write this story.  That's how angry I was.

Two clients arrived with their 10 year old pomeranian.  The presenting complaint was difficulty breathing; it was easy to see at triage that "Syclla" was breathing too quickly and too hard.  Her mucous membranes were pale, and she was definitely ill, but still able to walk and wagging her tail.  My technician asked for permission for immediate emergency treatment and diagnostics, which was declined.  We placed Syclla in an oxygen cage and I immediately went to talk to the family.

"Hi, I'm Erdoc, and I'm sorry to meet you at such a difficult time.  What's been going on with Syclla the last few hours?" I started to ask the pertinent questions that are vitally important for a patient history and to help sort out the more likely conditions.

The husband and wife (both in their late 40s) were immediately rude.  As hard as I tried to be compassionate, kind, and understanding of what is never an easy situation, they remained cool, crispy and unfriendly.  Their answers were short and their attitudes impatient.  Certainly I respect that different people grieve differently, so despite their attitudes, I moved on to my recommendations for their pet.

Just like any other case, I gave the clients the findings based upon my exam, and options for diagnostics (to figure out what's wrong) and possible treatment options (which would depend on what's wrong).

"Our dog is old. Don't you think this is a bit ridiculous? She's 10 for god's sake."

"I certainly agree that Syclla is older.   I understand if you don't think testing or treatment is in her best interest.  I meet different kinds of people all day long, and so I just want to make sure you understand the options, the risks and benefits of each option, and make a choice that's best for you and your dog.  Certainly euthanasia is something we never want to go through, but is a understandable choice in this situation, and if you felt it was right, I would support your decision."

The clients asked me to leave while they talked.  When I returned, they had made the final decision for euthanasia.  I told them that I supported their choice 100% and I was sorry for their hard day.

The euthanasia was smooth and painless; the clients held Syclla in their arms as she passed.  

After she was gone, I again expressed my sympathies for their loss.  "I'm so sorry you had to say goodbye.  Take as much time as you need, and whenever we can help you with anything just ----"

The husband stopped me in mid-sentence by putting his hand (open palmed) 1 inch from my face, effectively telling me to shut up and definitely the most disrespectful thing that any client has ever done to me.

 It took all of my professionalism, grace and restraint to walk out of that room and shut the door without saying or doing anything I would have regretted later.  I'm still angry about how much emotional energy I spent trying to be kind, caring and compassionate only to have my kindness returned with disrespect.

How dare he?

Joy and sadness.

On a busy weekend in my ER, I worked efficiently through trauma patients, removed a plastic toy from a lab's intestines, repaired lacerations, and treated this and that throughout the day.


Our lobby was a hotbed of emotions. It remained packed with waiting pet owners all day; each sharing in the joys and sadness of those around them.   One of the most memorable cases was a much loved 14 year old miniature poodle.  The parents, a husband and wife, and their children, both younger than the dog, huddled around their pet as I listened to the history, performed a physical exam, and discussed options.  Ultimately, the family decided that their beloved friend had been in failing health for too long, and euthanasia was the best answer for her.  The kids had never lived without their dog; they had no memories without her yet in their life.  This was clearly the first time they had experienced this type of grief, and it was truly heartbreaking.  I watched as the dad comforted his family, and we all shed a few tears together.  As they exited through the lobby, the entire crowd of waiting patrons was in tears.



Several hours later, after continuing with a busy shift, we were ready to discharge a patient who I had performed surgery on the day prior to remove a plastic toy he had eaten.  The dog practically ran up to his clients, tail in full wag, and licked them hello.  The clients had shared their story with those in the lobby who also shared the joy of a life saved and another pet going home to his loving family.


A roller coaster of emotions. Another day in the journey of an emergency veterinarian.

Disconnect

Last night we received a call from a frantic pet owner.  Her 4 year old dachshund was no longer able to walk.  The most likely all-to-common and devastating condition was intevertebral disc disease, and is notorious amongst the breed.

She arrived, and a physical exam confirmed my suspicions.

Tearfully, the client explained to me that her dog was "her child" and she'd do anything for him.  I explained to her that her dog needed a hemilaminectomy, a detailed and complex surgery near the spinal cord to relieve the problem and allow her pet to (most likely) recovery completely.  The surgery is typically only performed by surgical or neurological specialists, given the difficulty of operating near the spinal cord.

 Without surgery, his prognosis to walk again was significantly worse, meaning he might end up paralyzed or need a cart in the future.


"What! The surgery costs WHAT?  There's no WAY I'd spend more than $300 on this dog! It's just a dog!"


.....?


Glad I'm not your kid.

Doctor google

Today I saw a young female puppy for the symptoms of bloody urine, straining to urinate, and small frequent urinations.  In a female dog, these signs typically indicate lower urinary tract disease; such as a urinary tract infection, bladder stones, or other causes.

I recommended a urinalysis, a simple test to look at the urine under a microscope to look for bacteria, crystals, or cells indicating the cause.  The clients and I talked about the likelihood of their puppy having a recessed vulva (a poor conformation), resulting in an easier pathway for bacteria to reach the bladder.  Other possible causes included ectopic ureters, which may require surgical correction in the future. Read more about that here.

Pending test results, I recommended starting amoxicillin, the most common first line urinary tract antibiotic, as it actually is excreted in the urine, making it an exceptionally effective choice for UTIs.  A typical course of therapy for an uncomplicated UTI is 7 days. (Many other reasons may indicate longer therapy).

The clients called a technician into their room.

"We looked on google, and we read that amoxicillin is a bad choice for UTIs", they said.  "We want cephalexin for now, and a 30 day supply of baytril to go home just in case."

Oh GOOD! You read google for 5 minutes, so you are DEFINITELY more qualified to choose antibiotics than a doctor who spent 10 years training to do this job.

I tried to be patient and explain that cephalexin is typically a choice for skin, based upon the properties of the drug. Baytril is reserved for more serious or resistant infections, and is avoided in puppies because it may have a risk of cartilage damage in puppies under a specific age.

The clients didn't argue any more, but you could tell they weren't happy.  I just CAN'T understand this mentality. Of course it's not the first time this has happened - I've had people diagnose their dogs with many, many ailments based upon google, only to find out that they've diagnosed their dog with a disease that doesn't even occur in our area. (Or similar. You get my point).  Google search is an amazing tool, but is NOT even close to a substitute for medical training, testing, and experience.

whoops.

Around 2am, an older woman and her basset hound arrived.  He seemed painful, and the client was concerned.  During my examination of her sweet old dog, Fritz, the client let one rip.

"My, oh my, I don't know what I've been eating lately that's just made me a gas factory!"

It was the fart heard 'round the world; as she was still farting, she was already apologizing.  I managed to maintain my composure, and dismiss it as not a big deal, but through the doorway, I could see my staff absolutely losing it.  They turned bright red, tears of laughter, and had to go outside to avoid being offensive. 

Much needed comedic relief for a stressful shift!

Spaying saves lives.

It's incredible how much something as seemingly simple as the recommendation for spaying female dogs can become a controversial issue.  

Last night I received a patient on emergency for evaluation of difficulty breathing.  She was 12 years old, and a large mass was present in association with her mammary gland.  The clients approved radiographs (x-rays) of her chest, and unfortunately the result was catastrophic - she had widespread cancer throughout her chest.  Unfortunately, at this stage, there was no therapy that could help my patient, and her family was forced to say goodbye.

What could have prevented the development of mammary cancer? The common spay procedure (medically known as ovariohysterectomy), if performed prior to the first heat cycle, reduces the risk of mammary cancer to nearly zero percent.  Incredibly, dogs who are allowed to have more than one heat have a risk of almost 1 in 4.   Up to half of these cancers are treatable, but the other 50% may not be curable even with aggressive care.  As with any medical conditions, PREVENTION is always better than treatment.   You can read more about mammary cancer in dogs here.  Spay also prevents ovarian and uterine cancer as these organs are removed and obviously cannot develop cancer if they are no longer left in the patient.

What other reasons do you need to spay your dog? More? Sure! I have plenty more!

You may recall my post, titled "Happy Freaking Fourth of July."   Across the country, veterinarians witness thousands of cases of unwanted pregnancies in dogs and cats every year.  In the "best" case scenario, puppies are delivered easily, with no medical intervention.  These puppies add to the pet overpopulation problem and many end up in shelters, roaming, or being euthanized due to lack of a forever home.  In the worst case scenario, as in the story above, the female has difficulty delivering the puppies, requiring either emergency c-section and putting the mother's life at risk.   Each and every time I talk to a client who doesn't want to spay their dog or cat, they think they can keep their female away from a male while she is in heat - but biology is a powerful thing.  The male cat or dog's drive to find female dogs in heat and the female cat or dog's biological drive to be bred are instinctual - and the only 100% error proof way to prevent these tragic situations is by spaying your dog or cat.    

  (I've even had a client with both an unspayed female and an un-neutered male living in the SAME household tell me that she didn't think the female would get pregnant because the dogs were littermates and "they wouldn't want to do that".  Sorry, but dogs don't have social stigma or logic - they just have instincts and hormones).

Reason #3: Pyometra prevention

So, if your unspayed female dog is lucky enough that she doesn't accidentally experience pregnancy, and doesn't develop mammary cancer, what other risks of illness could she possibly have?

Another life-threatening disease of female dogs is pyometra; or infection of the entire uterus.  Each time a female dog cycles, the lining of her uterus changes. Over time, the lining can harbor bacteria, and result in a uterus that is enlarged and actually full of pus (disgusting!).  If left untreated, the bacteria spread throughout the bloodstream, causing kidney failure and severe metabolic derangments.  The only treatment for pyometra is a spay surgery; although these patients are much older, usually very sick, and with a uterus full of pus, the surgery has many more risks than a spay on a young dog.  This condition is 100% preventable.  You can read more here.

It seems pretty obvious - spay your dog (or cat) before her first heat cycle, and remove her risk of mammary cancer, ovarian cancer, uterine cancer, life threatening uterine infections, and unwanted litters, and also help prevent puppies and kittens from being euthanized or living their lives alone in a shelter.

Questions? Any theories you've heard why NOT to spay your dog? Ask me in the comments!

~Erdoc