Sunday, December 18, 2011

Um..................... really?

Today, an older female client arrived at the front counter.  She did not have a pet with her.

"I'd like to report a lost dog," the client stated.  My receptionist gathered the form necessary to record this information and assist the woman in finding her dog.

"Okay, where did you last see him?" The receptionist asked.

"He's lost INSIDE my house," she stated plainly. "I've looked everywhere for him, and I just can't find him.  I've looked under the beds, under the couch, and he's nowhere.  I know he's in the house because I haven't left today and he slept on the bed with me."

"..... Ma'am, I'm not going to be able to help you find the dog inside your house - Lost dog reports only work if someone else finds your dog.  If your dog is in your house, nobody else is going to find him. Can you have someone come over and help you? Have you tried shaking his food dish?"


Really? You lost your dog INSIDE YOUR HOUSE and you came in to report him lost?

Monday, November 28, 2011

Trauma drama

5am, Thanksgiving morning.

A phone call comes through from a client.  "Two of my dogs were shot!  We're on the way!" She's too upset to give us any more details about their condition.

Immediately, I wonder -- how in the heck do not one but TWO of your pets get shot?

My technician and I start preparing for arrival of two potentially serious, potentially life-threatening injuries.  Gunshots can result in any bad trauma you can think of; bleeding, penetrated bowels, ruptured bladder, spinal paralysis, pneumothorax, instant death, infection....

The first pet arrives and walks into the clinic under his own power, which is a surprise. My tech receives permission for initial treatment and diagnostics.  He has two entry wounds on one side of his chest, but no exit wounds.  He is experiencing mild shock, and is exceptionally painful, but for a gunshot wound, appears moderately stable.

We start pain medications, IV fluids, oxygen, and antibiotics.  I walk up to the lobby to speak with the client who is understandably hysterical.  Hysterical, however, slows down my ability to do my job.

"Hi, I'm ERdoc.  Your pet is in fair condition, and is already receiving pain medicine, oxygen and IV fluids."


"Ma'am, I understand you're upset, this is a very scary situation.  You have to realize that we're working as fast as we can, and if you just take a deep breath and calm down a bit, we'll be able to help you more quickly.  Now is there any major medical history I should know about ?  How did this happen?"

The client calms a bit, and I get a history.  The pets had escaped out the front door, and it was suspected that a neighbor shot them for being on their property.  Cruel, but actually not illegal since the dogs were at large.

The second dog arrives and actually looks better than the first.  He has a thru and thru gunshot wound so close to his spine that it's frightening.

Amazingly, both patients recovered well and were sent home with their (very) thankful families the next day.

Despite the high stress, extreme potential for disaster, and emotionally charged situation, we were able to provide happy outcomes for both of these patients!

Thankful for the boys in blue.

What a crazy weekend.

One of my most extreme situations ever occurred this weekend, and I'm very proud of my determination in preventing animal suffering.

I arrived at work in the morning and received patient rounds from the overnight doctor.  One of the patients was a young, large beautiful cat who had arrived at 1am.   The client found this cat tragically injured after being caught in a bear trap. As the cat entered the clinic, my colleague described that he was absolutely howling in pain.  She quickly administered pain medication, despite the client's lack of ability to pay. The cat was injured nearly beyond repair.   Both hind limbs were broken, in several locations, including the feet, ankles, and tibias bilaterally.  Both hind limbs had severe degloving injuries; meaning that the skin was pulled away from the muscles, bone and tendons underneath.  Both hind legs had the pads removed, and the tissue appeared very unhealthy due to lack of blood flow and overwhelming infection setting in.   In order to try fixing this kitty's injuries, it would require far more than most veterinarians or clients are capable of - the repair would take months and months of dedicated treatment, daily bandage changes for much of that time, multiple surgeries, as well as thousands and thousands of dollars.  My heart bled for this poor, poor cat.

If the cat was a human, amputation would probably be performed, however, a human has the ability to use a wheelchair, have assistance, and understands what is happening to them.  A cat without hind limbs would be bordering on inhumane.

Unfortunately, the client was out of her mind crazy.  She also had not a penny to contribute towards any sort of care.  Let me reiterate that this was not a "give him some medicine and he'll be okay" situation.  If this cat had been my own, I don't think that even I would have chosen to try to treat him.  His injuries were massive.

The client had spent 5-6 hours trying to obtain any sort of financial assistance. By the time I arrived, the cat had been suffering for far too long.

I stepped in to her exam room.  Immediately, I knew that something was off.  The client could not sit still, could not make eye contact, and was agitated.  She did not answer any questions or respond to my comments, she instead spoke to herself and rocked back and forth.  In my experience with 'crazy' clients, she looked like a typical methamphetamine addict.

Then the unthinkable happened.  The client demanded to take her cat home, without treatment.

I was stunned.  Nobody in their right mind would think of doing that to a poor, innocent cat.  Of course, this woman was definitely NOT in her right mind.

I stated plainly - "I will not allow you to take this cat home without treatment.  This is cruel, and definitely classifies as animal neglect.  I will report you to animal control and the authorities if you try to leave the building with your cat.  I know that it is a very sad situation, but your cat is suffering and it is my job to make sure that all my patients are relieved of suffering.  Even if you had a million dollars, I honestly can't guarantee that this could be fixed. "

She didn't get it. She tried to walk out of the building with her cat, and could not listen to reason.  I had had enough and could not stand to watch the cat writhing in pain for one second more.

I contacted our local police department and asked them to assist in enforcing animal cruelty laws, as I do not have the authority to confiscate a pet.

The police arrived and dealt with the crazy woman for about an hour and a half.  She screamed, yelled, and threw things.  She lied to the police and made up a story about another clinic doing thousands of dollars of treatment "for free."  She made up crazy stories and eventually, the police told her that she could either agree to treat her cat (and present the funds necessary to do so), could agree to euthanize her cat, or she would be thrown in jail for animal cruelty.  The cops prepared for a battle as the woman kicked, screamed, spit and was a all-around psycho as they escorted her from the building.

We couldn't thank the police officers enough for helping us to prevent this poor, sweet cat from suffering for one minute more.  We pet him, told him what a good kitty he was, and teared up as I euthanized him.

For readers who have never experienced this sort of situation, I realize that it may sound odd that I fought for the ability to euthanize this cat.  If left untreated, this cat would have died after days or weeks of suffering incredible pain, being unable to move, and having massive infection take over his wounds.  The veterinary oath demands that I will use my skills for the "prevention and relief of animal suffering".  There was truly no chance for healing and I couldn't allow this crazy person to torture an innocent pet.

Tough day.  More stories to come.

Monday, November 21, 2011

Triage is the name of the game!

Last weekend was extremely busy at the ER.  Multiple critical cases,  mostly with positive outcomes, but of course some sad ones came through, too.

Out of all the chaos, the one call that I just can't understand  -

The phone rings.  My technician answers -

Caller: "Hi, I have a dog who's acting wierd.  I need you to guarantee me that if I come in right now, I will be seen immediately."

Tech: "Well, sir, we'd be happy to take a look.  We are an emergency room, and we're experiencing very high case loads right now, so a wait time does exist.  When you arrive, a technician will triage your pet, obtain vitals, and if your pet is deemed stable, they will have to wait in line.  The most critical cases have to be seen first, just like the human ER."

Caller: "NO!!!  I demand that if I come in to see you, I WILL BE SEEN RIGHT AWAY!"

Tech: "Sir, what symptoms is your dog experiencing?"

Caller: "He's just acting weird, and I... I can't explain it.  He's still eating and drinking normally."

Tech: "Has there been any vomiting or diarrhea?"

Caller: "No. But I WILL NOT WAIT!  If I come, you have to promise me I'll be seen without waiting!"

Tech: "I'm sorry sir, but there's no way I can tell you that.  Your dog sounds stable, but we are happy to take a look.  If your pet is stable, you'll have to wait your turn to see the doctor.  There are several people here waiting right now."


**Hangs up.


Thursday, October 27, 2011

Sometimes we all fall down....

Two rough shifts in a row, and minimal sleep make for one very sad and emotionally exhausted ER vet. 

Two nights ago I performed a c-section on a 12 year old pug - yes, 12 years old.  The sweet old dog had delivered one stillborn puppy, and had four remaining in her uterus when she arrived to the ER.  Fortunately, I retrieved all four puppies alive!  Unfortunately, she had a rough recovery and required more care than a typical c-section patient.  Much of that to be attributed to her age and a moderate amount of bleeding during the surgery. Thankfully, her condition was not as a result of a surgical error, but simply a complication of her age, normal surgical losses, and other clotting factors.  As of this time, she's recovering well and stabilized, but it was hairy for a few hours.  Also unfortunate is that the clients are very upset with me.  I understand the frustration of not having your pet do well after an expensive emergency procedure, however I'm not all-powerful.  I'm human, and your 12 year old dog (compare to a 80-85 year old woman) should NOT be having litters of puppies.  This was preventable. Furthermore, I saved all four of her puppies (so cute!) and she's probably going to pull through, too.  I wish that the client could understand how much I care and how hard I work on my patients.

Last night I had a beautiful young male cat arrive with an obstructed urinary bladder.  I can't remember if I've written about this topic before, so I'll be sure to scan through and if not write a full informational post...  Most of these guys I'm easily able to treat, restore urine flow, and place a urinary catheter under anesthesia.  This cat was the second one in my career (of hundreds or thousands) that I wasn't able to relieve the obstruction.  Long story short, the clients nearly didn't allow treatment to start, so with the setback, they euthanized their beautiful cat.  I cried as I administered the euthanasia.  I feel like I let him down - but there was nothing else that I could have done to change the outcome.

So, as I said, emotionally exhausted. :( Time to go snuggle my pets.

Tuesday, October 25, 2011

No, you can't have that.

A case tonight reminded me of a constant battle between me and some of my clients --

A couple presented tonight with their kitty for a primary complaint of sneezing.  He is otherwise young and healthy, eating and drinking normally, with a normal temperature.  On physical exam, he has no nasal discharge, no ocular discharge, and no evidence of substantial illness.

His most likely diagnosis is a viral upper respiratory tract infection.  Similar to the common cold in humans (although caused by different viruses), a viral URI will NOT respond to antibiotics.  Antibiotics only kill bacteria, and do nothing to affect viruses.  Most mild viral URIs will resolve without any treatment.  Some do progress to involve bacteria; these patients usually have yellow milky nasal discharge, fevers, and are not eating.  Bacterial URI does require antibiotics, however viral DOES NOT.

Most clients walk in expecting to leave with a prescription, so when I diagnose their cat with a suspected viral URI, and give them the above information, they get very angry.  "Can't you just prescribe him antibiotics or something?" They say. "It will make me feel better to give him antibiotics..." and "Please, doc, it can't hurt anything, right?" 

Wrong.  Prescirbing antibiotics in this situation (or many others where they aren't indicated) only results in development of antibiotic resistance, as well as side effects on the patient from the antibiotics (typically vomiting or diarrhea), and does nothing to hasten recovery.

Antibiotic resistance is a real concern that affects each and every one of us - since the invention of penicillin in the 1950's, increasing numbers of bacteria have developed the ability to survive its use, resulting in the formulation of more and more classes of antibiotics (cephalosporins, fluoroquinolones, tetracyclines, aminoglycosides,etc).  The reason for the development of resistance is quite simple -- evolution.  The lifespan of bacteria is in the realm of minutes; with each generation they undergo natural selection, and evolutionary pressures result in replication of ONLY the surviving population.  Simply stated: if a population of bacteria is exposed to an antibiotic, only those who are resistant will survive.  Only those who survive are able to reproduce (the resistant population) and we are left with clones of those bacteria carrying the ability to resist antibiotics. (Obviously the actual mechanisms are much more complicated than this, however that level of detail is not needed in this discussion.) 

Each and every time antibiotics are used, the likelihood of a resistant strain emerging increases.  Of course, antibiotics SHOULD be prescribed for conditions that they are needed for  - bacterial infections.  Pneumonia, urinary tract infections, bite wound/skin infections, just to name a few appropriate uses. 

Prescribing an antibiotic for conditions that they do not treat, however, is an inappropriate use of a very important class of medications.  It takes me about 3 times longer to explain to my clients why I am NOT prescribing antibiotics; honestly, it'd be easier for me to just cave in and give them the pills. 

In the words of my mother -- "just because it's the easier choice doesn't make it the right choice." Responsible antibiotic use is a ethical obligation of the prescribing community, both veterinary and human.

The silent killer

A 3 year old, female spayed poodle presented to me about 2 months ago for lethargy and weakness. Her family reported that "Tia" had been having intermittent vomiting and diarrhea over about a week, but still was willing to eat.  She was lethargic today, and had been unwilling to rise for several hours.  "Tia" had been examined in the last week by her primary care veterinarian, who had dewormed her (a possible cause of v/d).  Unfortunately, she had not improved yet.

On physical exam, Tia was extremely lethargic, unwilling to lift her head, and refused to stand.  Her gums were pale pink, and her heart rate was elevated. Her pulses were not sufficient, and she was clearly experiencing shock due to dehydration.

I recommended immediate electrolytes, IV fluids, blood pressure monitoring, and full metabolic panel to be sent to the labratory.  I discussed with the clients that there were several potential causes of the chronic vomiting, however at this time, she desperately needed IV fluids and subsequent tests to determine her diganosis.   Potential causes of her illness included inflammatory bowel disease, addison's disease, ruptured foreign object resulting in severe abdominal infection, diabetic ketoacidosis, or many others.  Many of these can be determined from simple blood tests which would be performed immediately.

The clients authorized all of our attempts to stabilize their beloved Tia.

IV catheter was placed, and blood was submitted for electrolyte panels. Urine was collected and IV fluid boluses were initiated.  Her initial blood pressure was 70mmHg, below the normal minimum of 90mmHg - meaning that her vital organs (kidneys, brain, heart) were receiving inadequate oxygen.  Shock, as you have read in my blogs before, will result in death if it is left untreated.

While her first bolus was being administered, her in-hospital electrolyte panel results completed.  Significant abnormalities were present; her sodium was very low, her potassium was life-threateningly high.  Her blood pH was abnormal due to her shock state, and she was significantly dehydrated.  Her kidney values were also elevated.  The values were so abnormal that we repeated them twice be sure that they were real and not an error on the part of our machine.

The values were consistent.

Vomiting, collapse, low sodium and high potassium point to an endocrine (hormone) disorder called hypoadrenocorticism, or Addison's disease.   Addison's disease is an interesting lesson in phsyiology - and a very rewarding disease to treat.

In a nutshell, patients with Addison's disease cannot make specific hormones, (cortisol and aldosterone) that are required for vital body processes, includign sodium and water retention, potassium excretion, response to stress, maintenence of normal blood sugar, and other processes.  Lack of the mineralocorticoid hormone aldosterone (or insufficient quantities) result in loss of sodium and build up of potassium.  Loss of sodium results in severe dehydration, and buildup of potassium results in heart irregularities, and even cardiac arrest.

Tia's blood pressure improved with administration of IV fluids.  She also received medications to reduce the effect of high potassium on her heart. After receiving her lab results, I recommended the test to confirm addison's disease, called the ACTH stimulation test. Although high potassium and low sodium are enough to suspect Addison's, several other diseases can cause these changes, and ACTH stimulation is the test necessary to confirm its presence.  A blood sample is collected, and injection of a medication to induce secretion of cortisol is administered, and a second blood sample is collected one hour later.  This test will detect the majority of addisonian patients.  This test can be inaccurate if steroids are given prior to collection of both blood samples.

Within 6 hours, Tia was standing, barking, and appeared clinically normal.  She discharged within 24 hours, after confirmation of potassium returned to normal.  Treatment was initiated pending results of her ACTH stimulation test.

Treatment of Addison's disease requires supplementation of the mineralocorticoid hormone that is absent.  This can be performed with an injection (given about once every 25 days) or an oral pill (given every day).  The specific decision about which to choose is case-dependent.  Additionally, supplementation with steroids is often needed to replace the lack of cortisol.  Prednisone is commonly utilized in a daily dose, which should be increased during times of stress (travel, vet visits, addition of new pets, etc.).  Initially, electrolytes should be monitored weekly, but over time, may only be necessary 2-3 times per year while the patient is clinically normal.

Rarely, a less common form of Addison's disease (atypical Addison's) occurs where the patient has normal electrolytes.  These patients only require supplementation with steroid hormones.  Many of them, however, progress to typical Addison's disease with time, and so they require electrolyte monitoring over their lives, espeically in times of illness.  Atypical Addison's disease is also diagnosed with an ACTH stimulation test.

Tia's test confirmed Addison's disease.  She is expected to live a long, healthy life.  With proper monitoring, careful veterinary care, and correct medications, Addison's disease does not affect the lifespan of our canine friends.

Get better care for your pets!

Longer, healthier lives - that's what we all want for ourselves, our families, and our pets.

How can we receive better care for our pets?  How can we help our veterinarian to more rapidly and accurately diagnose causes of illness in our pets?  YOU, the pet owner, are the key.  You may not realize how very important you are in helping your pet to get well, and the purpose of this post is to help you better understand how the medical decision making process works.

Veterinarians and human doctors are trained to notice abnormal.  For human doctors, this is a bit easier, as their patients can tell them - "It hurts when I do this" or "I feel nauseated and I don't want to eat" or "I don't have any energy" , etc.  Of course with sick pets, this is impossible.    The investigation into their illness starts with a history from the pet owner.  Is your pet eating? How much? Weight loss? Vomiting? Diarrhea? Are they drinking more or less than usual? Hiding more than usual? Do they seem reclusive or try to bite you when you handle them? Decreased activity? Any other abnormal behavior?

 I can't begin to tell you how many times a client brings in their sick pet, places them on the exam table, and then cannot answer a single one of these questions.  "He's just not right" is not a symptom, and could be any one of literally thousands of conditions.  The more information you can gather by monitoring your pet's normal behaviors, the more accurate your veterinarian's diagnostic and treatment plan will be. Of course we can run hundreds of tests costing thousands of dollars in lieu of a good patient history, but this is obviously not economical and a much slower way to figure out what's actually going on.  As a result, observation of your pet's normal behaviors and being able to notice variation from normal is a VERY important part of your task as a pet owner.  If you can't tell me what's wrong at home, it makes it much more difficult to know where to start looking. It also usually increases the cost of testing as we have to rule out many more types of illness.

After the veterinarian talks to you about your pet's history and your concerns, they will perform the physical exam.  This is where our trained eye will detect outward signs of disease -  pain, nausea, dehydration, fever, enlarged lymph notes, masses, swellings, etc. Although every veterinarian is specially trained to perform physical exams, there are many diseases which have vague outward signs, which look like other diseases, and/or which cannot be completely diagnosed with physical exam alone.

With these two components combined, your veterinarian will create a problem list.  The problem list will be followed by "differential diagnoses", or a list of the diseases that could be causing your pet's symptoms.  If you've ever watched House, you've seen a dramatized version of this in every episode. The differential diagnoses will help your doctor to systematically rule out specific causes of illness, narrowing the long list of possible causes.

Hopefully these comments help you to remember to observe your pet's normal behaviors, so that when they become abnormal, you'll be able to recognize it right away and get your pet the medical attention she/he needs.

~ER Doc

Monday, October 24, 2011

The mother of all emergencies !

The title can only mean one thing - Gastric dilitation and volvulus, or GDV.

GDV used to frighten me - but after my several jobs in the ER, it's now one of my favorite things to treat.  It's adrenaline inducing, requires significant technical skill, lots of medical and surgical knowledge, and has the potential to be cured.  It's a condition where I can definitely say that I saved the pets' life - without me, they would have faced certain death. I don't have a specific patient to share with you, but at the request of a reader, I wanted to provide some information about the condition and hopefully improve awareness and understanding of this condition.  Hopefully your pet never experiences GDV, but if they do, you'll be prepared.

What is GDV?
GDV is an extremely life-threatening emergency.  GDV is most common in large breed, deep chested dogs.  Great Danes, Pitbulls, Boxers, Chows, Greyhounds, and Labradors are among the most commonly affected breeds.

Typically, a GDV patient will start with initial symptoms of restlessness, a bloated or distended appearance to the abdomen, followed by unproductive retching, panting and pain.  This quickly progresses into a patient who becomes moribund; unable to walk, move, with a very high heart rate, pale gums, signs of shock, and rapidly progresses to a lethal state.

Why does it occur? 
Like so many medical conditions, the specific cause of GDV is unknown.  What is known is that the stomach fills with gas, rotates, and then leaves both the inlet (the esophagus) and the outlet (the pylorus) unable to let anything escape the stomach, including gas.  As the stomach fills like a balloon, it becomes massively stretched, compromizing blood flow to other organs, damaging the lining of the stomach and reducing much-needed blood flow to the stomach wall, and compressing large veins within the abdomen.

What can I do at home?
GET TO A VETERINARIAN IMMEDIATELY.  There is absolutely nothing you can do for your pet at home except for remain calm, place them in your vehicle, and travel to your nearest veterinary facility (this may be your general practicioner, or may be an emergency hospital).  Do not waste time at home.  Once the symptoms of bloat are noted, immediate action is imperative to recovery of your pet.

Upon arrival to the veterinary facility, your pet will be triaged.  Technicians and the veterinarian will evaluate vitals, including mucous membrane color, heart rate, pulse quality, evaluate the distention of the abdomen.  If symptoms are consistent with bloat, the veterinarian will recommend immeidate action, including an IV catheter, IV fluids for blood pressure support, pain relief, and decompression the stomach.  After your pet is receving these treatments, radiographs will be recommended for the definitive diagnosis of GDV.  A patient with GDV would have a radiograph (x-ray) that looks something like this:

Image from public domain, wikipedia commons
This image represents the stomach, filled with gas (dilitation) and twisted (volvulus).

Can my pet be saved?
 In a word, yes.  Advances in veterinary medicine over the last 20-30 years have significantly improved statistical outcomes for GDV.  Treatment however, can never guarantee a successful outcome. These are just some of the things that your veterinarian must consider when treating your pet with GDV:
  • Rapid, accurate diagnosis
  • Stabilization of obstructive shock caused by the massively dilated stomach
  • Restoration of blood flow to vital organs
  • Stabilization of blood pressure
  • Evaluation of electrolytes, lactate (an indicator of shock), and kidney values
  • Evaluation of concurrent illnesses (some pets who GDV are geriatric, with other conditions to consider) 
  • Balanced, multimodal anesthesia in a patient who is significantly compromised (very much unlike a young healthy patient for a spay or neuter)
  • Maintaining sterile surgical field
  • Abdominal exploration to untwist the stomach and asesss vital organs
  • Assessment of the stomach wall, which can become necrotic (die off) as a result of the GDV
  • Management of hemorrhage
  • Management of cardiac arrythmias which commonly occur in conjunction with GDV
  • Careful, gentle tissue handling, conscientious surgical technique
  • Attachment of the stomach to the body wall to prevent any further twisting in the future (a pexy)
  • Adequate post-operative monitoring and supportive care
This is not indented to be an all-inclusive list, but is intended to give you some idea of the degree of education needed to recover your pet when they experience GDV.  Some statistics estimate that 70-80% of GDV patients survive to discharge.

How much will it cost?
As a result of the involved care, GDV is an expensive condition to cure.  Depending on part of the country, cost of living, and your pet's specific conditions, development of complications, ets, an average GDV treatment may cost in the realm of $2500-$6000+

What will my pet's life be like afterwards?
Most pets who recover from the surgery of GDV go on to live normal, active, happy lives.  Most patients who have a pexy performed can never twist their stomach again; however, there are reports of second-time offenders.  This is fairly uncommon -- in one study, only 6% of patients treated experienced a second torsion at some time in their lives.

Is there any prevention for GDV?
Actually - YES!  At risk breeds can have a prophylactic gastropexy, which is the same as the pexy discussed above.  It prevents twisting of the stomach, and can be performed easily at the same time as a spay (for a female dog), relatively inexpensively and without the need for a second surgery.

Questions? Bring them on in the comments!

~ER Doc

Friday, October 21, 2011

Not keeping up....

Hey readers,

I'm still here -- but I've come across a month of boring cases and un-exciting clients.

Are there any diseases you want to know about?  Is there something you've always wanted to ask but were too afraid/embarrassed/timid?

Comment on this post, and I'll get to writing about it for you!

~ER doc

Saturday, October 1, 2011

Word to the wise....

Call me crazy, but.....

If you show up with bloodshot eyes, stumbling, and a giant pot-leaf tattoo on your leg with a dog who has the clinical appearance of marijuana toxicity, I'm pretty sure it's marijuana.  I'm also pretty sure it's NOT from your neighbor throwing pot over the fence.....

Then, when you try to "prove" to me that it's not marijuana by showing me the 15 $100 bills in your wallet, you've only proven that you're a dealer, too.

And after I show you the positive urine drug test for MARIJUANA, you still don't agree with my diagnosis?  Okay, cool, man. I'll trust the stoner over the veterinarian any day.  It's totally something else.

Friday, September 30, 2011

Another great fix!

A 9 week old German Shorthair puppy presented to me last weekend after ingesting a fish hook.  A fish was attached to the large fish hook, and the dog had eaten it quickly before the clients could stop him.

When they arrived, fishing line was hanging from his mouth.  We recommended anesthesia in order to remove the fish hook with endoscopy, and if we could not remove it in this manner, surgery would be necessary.

A radiograph was performed and revealed that the fish hook was in the proximal esophagus. 

Anesthesia was performed and an endoscope (a long, flexible camera utilized for visualizing the gastrointestinal system without the need for surgery) was passed into his esophagus.  The fish hook was embedded into the lining of the esophagus.

Utilizing the camera, a large stomach tube and some additional string, we were able to manipulate the fish hook into the tube, and thereby remove it from the dog's esophagus without the need for surgery, and also without causing any damage to the dog's throat. Although easy in theory, this task was a challenging one and a big cheer erupted as I removed the tube, with the hook insde, from the dog's esophagus.

He discharged later that day and is completely recovered.  Yipee!


A very happy update.  To any of you who remember the dog from post "Live, damn you, Live!".....

I just received a beautiful bouquet of flowers from his family.   He's doing well, and a recovered tripod. 

Best news of the day!

~ER doc

Tuesday, September 27, 2011

something sweet

The vast majority of pet-owners and the general population already know that chocolate is toxic to dogs.  Have you ever wondered actually why it is toxic and the mechanisms behind what can be so delightful for humans (yum!) and so poisonous to our pets?

A friend recently asked me to provide the explanation, and I thought I'd share it with you all, as well.

Chocolate contains compounds called methylxanthines, specifically theobromine and caffeine.  Dogs are believed to metabolize these compounds differently than humans, resulting in toxicity.  (Chocolate also contains high amounts of fat and sugar, which can cause GI upset even in small ingestions). The amount of methylxanthine in chocolate depends on the type of chocolate; in general, the more bitter the chocolate, the higher the methylxanthine content.  Therefore, baker's chocolate is more toxic than dark chocolate which is more toxic than milk chocolate, with white chocolate containing the least of the compound.  Baker's chocolate is estimated to contain about 7 times more theobromine than milk chocolate.

If your dog ingests chocolate (or any other toxin), it is very important to call your veterinarian or an animal poison control center (888-426-4435) for specific recommendations.  Early intervention is key to a positive outcome, and calculations based on your dog's weight, type of chocolate, and amount ingested are key in treatment recommendations.   As with most poisons/toxins, do NOT wait for symptoms to start, the time for the best outcome is BEFORE symptoms occur!

 The amount ingested and the size of the pet determines the level of toxicity. A dog ingesting enough of even just milk chocolate can develop life threatening symptoms.

The mechanisms of action of these active compounds is to inhibit a receptor in the central nervous system, resulting stimulation and tachcyardia (elevated heart rates).  Symptoms occur depending on amount ingested compared to body weight of the patient.  Lower exposures can result in vomiting and diarrhea, usually just as a result of the high sugar and fat content of most chocolates.  Vomiting and diarrhea can become quite severe and require hospitalization for fluid therapy and symptomatic treatment.  Higher exposures can result in the symptoms attributed primarily to methylxanthines; agitation, restlessness, hyperactivity, as well as tachycardia, (dangerously high heart rate), arrythmia (abnormal heart beats). Some severe exposures can result in seizures or even death, especially if untreated.

The good news is that usually, dogs respond to treatment.  The best treatment is preventing access of your pet to any compounds or foods containing chocolate. The most common times of year for our ER to see a spike in chocolate toxicity cases are the days after halloween, easter, thanksgiving and Christmas. If a dog is seen ingesting chocolate, a calculation can usually be made to determine what level of ingestion has occurred.  If the ingestion is above a toxic level, a veterinarian will usually recommend an office visit to induce vomiting.   Vomiting should never be induced at home, as complications can occur (aspiration of vomitus, choking), and medications in the hospital are much more reliable in producing productive emesis than anything given at home. Depending on the level of ingestion, activated charcoal may be given by your veterinarian.  Hospitalization for IV fluids, heart monitoring, or other medications may be necessary.

 If the patient is already experiencing vomiting and diarrhea before the exposure is known or recognized, then the treatment depends upon severity of symptoms.  Many patients improve rapidly with hospitalization for Iv fluids, treatment of nausea, diarrhea, and prevention of hyperactivity or tachycardia.  

Bottom line - save the sweets for yourself, and keep your pets safe as we approach the holiday season!  I'll highlight some more common toxins in the upcoming blog posts.  More information is available at veterinary

Thursday, September 15, 2011

A little lesson in cardiac physiology

If something doesn't seem right, trust your instincts.

A geriatric golden retriever presented to a colleague at my hospital for a sudden collapse.    Diagnostics confirmed that "Frank" was bleeding into his abdomen from an abnormal area of his spleen.  In medical terms, this condition is called hemoabdomen  About 2/3 of cases of hemoabdomen from a splenic mass are malignant, and about 1/3 can be a result of benign causes.  The most common malignancy is hemangiosarcoma, which is a very aggressive and poorly treatable form a cancer.  Read the above link if you would like more information.

My colleague and the clients discussed the only two reasonable options for Frank, which included either stabilization and emergency splenectomy (removal of the spleen to halt blood loss), or euthanasia.   His family elected to go forward with the emergency surgery.

Frank received a blood transfusion, and was stabilized for surgery.  His spleen was removed, and surgery was relatively uneventful.   After surgery, Frank transferred to the care of his primary daytime veterinarian.

Frank returned to us while I was on shift, about 36 hours later. In the interim, Frank had been sent home from the daytime clinic.  He was lethargic and refusing to eat, and his family had noted that his heart had been racing all day.  A recheck exam at his daytime clinic that same morning revealed a heart rate of 190 beats per minute.  Their primary care doctor discharged Frank, in hopes that it would 'go away,' per the clients recollection.  The family knew that something was not right, however did as they believe they were told and took Frank home.  The family monitored Frank's heart rate throughout the day, counting the number of beats in 15 seconds and multiplying by 4.  Around 2pm, they called their regular doctor with an update; the heart rate remained high.  They were instructed to wait at home.  Around 5pm, they called again and their daytime clinic recommended that they come immediately to see the emergency hospital.

As Frank entered the hospital, we immediately knew something was wrong.  His heart rate was a dangerous 220bpm, his pulses were poor, and his capillary refill time was prolonged. An IV catheter was placed, an an ECG immediately performed.  Frank was suffering from ventricular tachycardia, a dangerous rhythm which requires immediate treatment with anti-arryhthmics.  I immediately administered IV lidocaine, and consulted with the clients regarding Frank's current status.

The positive news is that ventricular beats and this type of arrhythmia is usually a transient complication of splenic surgery (in this case, ventricular tachycardia/VPCs have many, many other causes).  It is not understood why this occurs, but with treatment, ventricular rhythm disturbances commonly resolve within 24-48 hours after surgery.

One part of my job that I enjoy most is client education.  While Frank was receiving his initial lidocaine and a mini-blood panel was pending, I took the time to give the clients a brief lesson in cardiac physiology.

The heart consists of four chambers.  Two chambers are called the atria, which receive blood as it returns from the lungs and the body.  The other two chambers are the ventricules, which pump blood forward to the lungs, where oxygen is replenished, and to the body, which provides life-sustaining oxygen and removes wastes, such as carbon dioxide.  In order to organize this complicated organ, electrical activity in a normal heart starts in a specific location near the atria (called the sinoatrial node), and travels along a sophisticated pathway towards the ventricles.  This organized progression of electrical activity allows the heart to function as a unit, and for blood to move in an organized, forward fashion.  A normal ecg beat looks something like this:
wikimedia, public domain image

On the other hand, a ventricular beat originates in the ventricles, and is an unorganized, haphazard movement of electrical activity through the heart. A ventricular beat / rhythm looks something like this:
Borrowed from

Ventricular beats resulting in high heart rates become dangerous when the heart can no longer act as an effective pump, starving the body's tissues of life-sustaining oxygen.  Excessively high heart rates (>170-180bpm), poor pulses, pale gums, or weakness are all indications that anti-arrythmic therapy is needed.

The clients immediately knew that this heart rate was present 8 hours ago at their daytime clinic.  Frustrated, they asked me the question that we all were wondering --

 "Why wasn't this treated this morning? Why weren't we transferred to your care sooner?" The family looked at each other in exasperation. "We knew something wasn't right."

Unfortunately, I couldn't answer this question for them.  "I'm not sure," I said. "You'll have to talk to your veterinarian to ask them for specifics. I wasn't there, and I can't guess or assume at why specific medical decisions were made.  What I can tell you is that Frank needs to stay with us tonight for monitoring, lidocaine, and hopefully, he'll resolve this rhythm disturbance in 12-24 hours."

Morale of the story: If things don't seem right, get a second opinion.  Even the world's best doctor/veterinarian is never able to achieve 100% accuracy.  Second opinions save lives.

Tuesday, September 13, 2011

The most unbelievable story of all.

I'm so angry right now I can't even see straight.

Two weeks ago, I received a call from a daytime veterinarian.  A homeless man had arrived at her clinic, and had been hit by a car.  The dog was suffering from severe head trauma and probably had broken ribs and lung injury as well.  She had placed an IV catheter and administered dexmedetomidine, a potent sedative/anesthetic agent.

The veterinarian (we'll call her Dr. V ) was inquiring about options for this homeless man's dog.  The homeless man, with not a dime to his name, also had no means of transportation.  Dr. V called to ask me what could be done for this dog, given his critical condition.

Sadly, I reported the state of things.  As Dr. V already knew, our hospital is a small business with no outside funding and no trust fund to pay for stray/abandoned/underprivileged pets.  Any treatment that is provided at no cost directly removes money from our hospital to repair equipment, pay staff wages, provide raises, and pay our electric bill.  We simply cannot afford to provide care to patients on a pro-bono basis, especially when that care is extensive as in this case.  Providing care without payment for services WILL result in bankruptcy and closing of our doors, and therefore loss of after hours care for sick/injured pets, and job loss for all of our employees.

I apologized for the difficult situation, and informed Dr. V that all I could provide for this pet was pro-bono euthanasia, which he could obviously do at his clinic without driving the dog to our hospital.  We ended the phone call.

15 minutes later, Dr. V called me again.

"The homeless man wants to come to your hospital," she said. "I'm going to drop him off at your clinic."

Dumbfounded, I had a difficult time forming sentences in a professional manner, without screaming WHAT THE &#$*# ARE YOU THINKING??!?!?!

"Dr. V, I don't understand what this is going to accomplish," I said. "I am not able to authorize or provide any care for this pet when there is no funding to pay for charges incurred.  The only thing I can do for free is to euthanize the pet (to end suffering), and there's no reason to drive him all the way here for me to do so.  If the pet is critically injured, he should be euthanized to end suffering.  I know that none of us want to euthanize this pet, but there's no agency/group/private institution that can afford to pay for sick and injured homeless pets.  We can't even feed and house the HUMANS that are homeless."

Dr. V didn't seem to get it. "Well, the homeless man wants to come there, and what am I supposed to do? I've already placed a catheter and anesthetized his dog.  I think it has head trauma and brain swelling. "  (Those of you reading this with medical knowledge will also notice that this treatment is completely inappropriate for head trauma).

I apologized for the sad situation, but repeated the truth of the situation.  I wish the reality was different, but as our hospital (like most veterinary clinics!) has no government funding, no rich benefactors, and with the economy in a economic depression, there isn't any extra money to go around.

Dr. V ignored my replies.  "I'm bringing him over anyway.  It's 5:45 and I want to go home. Maybe he can just take his dog 'home' and see how it goes."

Never, in my career, have I witnessed such an unprofessional, rude, unfair, ridiculous decision by a supposed professional.  This is an extreme case of "passing the buck."  -- Sorry sir, I can't help you, but I'll drive you to the emergency room! They'll be sure to have everything you need to make your pet all better!!

At this point, I was furious.  If Dr. V chose to initiate therapy for a homeless man's pet out of the goodness of her heart, then she should have taken the initiative to see it to completion, or recommended euthanasia once the extent of injuries was realized.  By starting some sort of (inappropriate) treatment plan, and then driving the man to our clinic, she essentially made my clinic and me look like the heartless, money grubbing assholes who don't help out during tough times.  In addition, at this point, the client had unrealistic expectations of us providing thousands of dollars of free care for his critically injured pet.

Dr. V arrived, and refused to speak with me.  My receptionist asked her to talk with me about the case, but she ran out the door before I could see her.  "I've got to go, I just can't stay, sorry...." she said.

The homeless man was obviously and understandably distraught.  He was also carrying an 8'' knife, and a risk to myself and my mostly female staff.  His dog was critically injured, had visible signs of head trauma, difficulty breathing, and pale gums.  To allow this dog to "go home and see how it goes" would have been an inhumane decision, and I could not allow it.  We gently counseled the homeless man, and fortunately, he was a reasonable person who understood that his dog was morbidly injured.  He knew that euthanasia was the best thing for his pet.

I euthanized his dog while he cried, and I apologized for his loss.   It was the only reasonable, humane decision in the given situation.

I'm flabbergasted. How can this "colleague" think that her actions were reasonable??

Monday, September 5, 2011

Holiday weekend

I'm back from a long (much needed) break!

The holiday weekend was an expectedly busy one.

Best save of the weekend -- a 9 year old 120# mastiff presented for collapse.  He had been outside with his family, playing on a nice summer day.  All of a sudden, he fell to the side, became unconscious, and foamed at the mouth.

His family, frightened, called us immediately.  They were on their way.

When "Rufus" arrived, he was unable to walk into the hospital on his own power, and was carried in on a gurney.  His physical exam was mostly unremarkable.  The only abnormal findings included an elevated heart rate, his inability or unwillingness to walk, and an ever-so-slight paleness to his gums.

The search for cause of his collapse was on.  His BP was normal, an electrolyte panel was normal.  A scan of his abdomen revealed no free fluid. He received a bolus of fluids, and improved slightly.  An ECG was normal.  His clients expressed their concerns to me that he had eaten a large amount of clay cat litter the previous weekend, and requested abdominal radiographs.  These too, were normal (no evidence of cat litter or anything else unusual).

I recommended an ultrasound of his heart, and the clients approved.  They wished to do whatever necessary to help their beloved Rufus, who had been normal the day prior.

The ultrasound of the heart revealed the cause of his collapse -- Rufus had pericardial effusion.  This means that an abnormal collection of fluid accumulates in the pericardial sac -- a fibrous sac surrounding the heart.  When fluid accumulates in this area, pressure becomes overwhelming and the heart becomes compressed, preventing the heart from being able to fill.  This results in pericardial tamponade, and explained Rufus' clinical signs.

The treatment of pericardial effusion is to remove the fluid from the space.  The area was prepared in a sterile manner, and I utilized a large bore needle to facilitate the removal of fluid from the space.  Rufus immediately felt relief.

The ultimate cause of Rufus' pericardial effusion is pending additional testing, but for now, he's home with his family.

Tuesday, August 30, 2011


Sorry about the two week hiatus - I'm out of town - I'll be back online this weekend.

--ER doc

Monday, August 15, 2011


Today a stray dog just got hit on the highway by a semi-truck, driving about 70 miles per hour.  A onlooker who had witnessed the dog being hit brought it in to us (no collar, no microchip, no known owner).

He yelled and swore at ME because the dog was dead on arrival.  Really?
He didn't believe that there was nothing I could do. He called me a "liar." Really?
He swore at my front office staff that we were "heartless assholes." Really?

Should I have lied to you and said that we performed CPR and brought back the dog and it was going to be all better?
Should I have lied to you and said that the dog isn't injured, and it'll be home by tomorrow?

Or should we tell you the truth?  When a 40 pound dog gets hit by a semi-truck weighing somewhere in the neighborhood of 80,000lbs (2,000 times the weight of the dog), the dog loses. 

 It's sad, and I'm sorry, but I can't fix this one. Pretty sure that doesn't make me a liar.

Does Fluffy have her medical card?

Funny tidbit from my last week of working --

Very old kitty arrives with chronic, end-stage kidney failure.  The client, who is very sweet, but slightly crazy informs me that she's been feeding her cat catnip. "It's just like medicinal marijuana," she says. 

Sure. Nepeta cataria (catnip) and Cannabis sativa (marijuana).  Totally the same.  Maybe pot-heads can just start rolling catnip and save some money.

Thursday, August 4, 2011

why is it always the nice ones?

There's an expression in ER medicine - "Nice pet, nice owner = bad disease."  This saying stems from the general observation that, on average, the mean, fractious, angry feral cat can survive any diagnosis, and usually has an easily fixable condition, whereas the loved, indoor only, perfectly cared for cat with loving clients who can afford the highest quality of care will end up with a terminal disease.

This case is no exception.

"Slash," a 4 year old, mostly indoor cat presented after being hit by a car just in front of his family's home.  His clients tried to keep him indoors because they knew the risks of cars, of other animals, and were concerned about Slash eating birds and endangering songbird populations.  Slash seemed to be unhappy in the house, and after several months, despite their better judgement, they decided to give him a couple of hours during daylight, to enjoy the greater outdoors.

The client's worst fear came true last week, when Slash ran out from underneath a car, and was hit crossing the street.  He was immediately unable to walk, vocalizing and in pain.  He arrived to the ER quickly, and was in shock.  IV fluids were initiated, pain medication was started, and a neurologic exam was performed.

Slash was able to feel his hind limbs when pinched, but was unable to move.  Radiographs were the next step at determining the cause of his injury.  Pelvic fracture? Spinal trauma? Vertebral body fracture?  The other abnormality on Slash's initial physical exam is that his breathing pattern was altered.  It appeared as if when he breathed in, his entire chest was sucked in, instead of his chest expanding with every inward breath.

Radiographs revealed a very serious injury - Slash had a vertebral body fracture with compression of his spinal canal.  He would need surgery by a specialist the following day to repair the compression, and his recovery would take time.  Regardless of the cost and associated dedication to care, his family was committed to pushing forward.  No other injuries were present, and with this degree of dedication, Slash had a chance at a normal life.  Despite Slash's abnormal breathing pattern, there were no broken ribs to explain the pattern.  He was oxygenating normally at this time, and there was nothing we could do except for watch carefully for any changes.

After Slash recovered from his shock, his status improved for a few hours before they came crashing back down.  Around 3am, Slash began to have difficulty breathing and was placed on oxygen.  Recheck radiographs revealed a large amount of fluid in his lungs, and a very enlarged heart.  Despite lack of a heart murmur, Slash apparently had significant underlying heart disease, in addition to suspected bruising of his lungs from the trauma.  He continued to deteriorate quickly, even with discontinuation of intravenous fluids and addition of diuretics.  As he struggled to breathe, it became apparent that Slash was heading for disaster.

His family was contacted and wished to continue to provide every possible intervention for Slash.  Slash  was sedated in order to facilitate intubation and control his airway.  This intervention allowed sufficient oxygen to be delivered to his body's tissues (especially the brain and heart).   Fluid was dumped through his ET tube, and positive pressure ventilation was initiated.

Over the next 5 hours, we monitored Slash intensively.  Slash had a dedicated technician monitoring him, and we attempted to wean him from being intubated several times, before it became obvious this was not going to be possible at any near time frame.  Slash needed to be on a ventilator for 24-72 hours, or longer, to determine if he would ever again be able to ventilate his own body.  Our theory and the only logical cause is that ascending spinal cord inflammation, or the direct trauma and concussion of the spinal cord, resulted in paralysis of Slash's intercostal muscles and / or his diaphragm, which resulted in failure of the body's ability to effectively ventilate.  Like many neurologic injuries, there was/is no direct repair.  The only option was to support his body's vital signs, and wait to see if it would ever improve.   This time frame could literally be days, weeks, or never.

Unfortunately, his breathing pattern never improved.  Consultation with the surgeon confirmed my exam and knowledge, and we discussed the complexities of the case with the clients for hours, while they visited with their beloved Slash.

After lots of tears, much discussion, and careful consideration, the family made the difficult decision to euthanize Slash.  We were all crushed by the tragic outcome, but knew that the family had made the right decision.  Slash's chance for recovery was very small, and the cost and suffering associated with that small chance would have been astronomical.

Rest well, kitty.  You will be missed by many.

Friday, July 29, 2011


Several weeks ago, the police department brought in a kitten who had been smashed on the head by a 17 year old.  This was witnessed by another person, who had called 911.

The 1.5 pound, 8 week old kitten was critical at arrival, with pinpoint pupils, minimally responsive, and clear evidence of brain swelling secondary to his known head trauma.  We quickly placed an IV catheter, administered fluids and mannitol, and kept very close watch of him in the initial hours.  He struggled through the first hours of therapy.

The next day, the kitten was significantly improved, but still having neurologic issues; he pressed his head against the cage door, and constantly circled toward the side of the head that had been injured.  He was unable to eat or drink, and only time would tell if he would continue to improve to a functional pet.

Several days later, our cute little kitten is a bundle of joy!  He's eating, drinking (although sometimes, he just steps in the water and spreads it around his kennel), and he is starting to play.  He's gaining weight well.  Now he just needs a home. Another live saved, and a heartwarming turn of terrible events for everyone here at the hospital.

Unfortunately, no charge were filed against the individual who performed this heinous act.  The even sadder part of the story is that so many adults who perform violent acts against animals will either repeat their acts, or increase their violence to then be against humans.  It boggles my mind that someone would willingly and purposefully inflict damage to such an innocent, sweet, pure life.

In any case, he's nearly better now.  Until he finds a home, it sure is nice to have a kitten around!

Thursday, July 28, 2011

Little man syndrome

Last night, a couple arrived with their cat.  Unfortunately, they had run over their 2 year old cat.  The kitty was severely injured, and had no ability to move or feel his hind legs.  He was paralyzed, among other injuries, and there was no way we could fix him.

The clients had zero dollars to contribute to care, which actually didn't change the outcome for their poor little kitty as there was no way we could fix him.

The client acted like a fool.  He walked in with his chest puffed up as if he was a cartoon character, and his shoulders back, storming around our lobby.  He screamed at the receptionist, and made irrational requests.  We triaged the cat, discovered the extent of injuries, and I discussed the sad news with him.  I hoped the exam findings would give them some small amount of relief, at least to know that it wasn't a financial decision.

 "GIVE MY CAT THE F***** INJECTION ALREADY!" the man screamed as he stormed around our treatment room, threatening both me and my staff.  "F***** DO IT ALREADY!"

The man acted as if he was on a 'roid rage.  I stated over and over how sad I was for his loss, and how sorry I was that he was losing his kitty.  I asked him to step away so I could give an intraperitoneal injection, as there was no possible way to hit a vein on his shocky, dying, painful cat (IP injections are non painful, but take about 5-10 minutes for effect and are used in patients like this, when venepuncture is not possible).  He screamed at me again, and finally, I had to raise my voice.  I told him that he needed to calm down, and leave the room, or I would call the police.  He finally stepped away.  I didn't trust this man to be around a needle and controlled medications, and I had to trust my instincts.  I also didn't trust him not to flip out as I gave the injection.

After I gave the injection, I asked him if he wished to come back to be with his kitty.  He continued to scream obscenities, and act as if he wanted to pick a fight.

"I don't understand why you are upset with us," I told him. "We're just trying to help relieve your kitty's suffering.  He has a non-repairable condition, and there's no way for him to ever walk again.  I'm sorry he got hit, and I know this must be hard.  You have to realize that we're here to help you and your cat."

"I'm F***** PISSED!!! I AM SO ANGRY!" He screamed, over and over again.  I re-stated the above.

His kitty passed peacefully, and I stayed with him the entire time, as much as I hated the way he was treating us.

Finally after his cat passed away, he apologized briefly for his attitude, and quickly said that he was just mad at the situation.

Mad at the situation doesn't give you the justification to act like a fool and threaten our staff.  What a moron.

Wednesday, July 20, 2011


Dudley, the patient from my previous post (the precordial thump) is doing very well!  Just thought you all would like to hear the great news!

Wednesday, July 13, 2011


Had an amazing, busy, hectic weekend at work.  The first case I’d like to share, and the most dramatic of my life is “Dudley,” a 3 year old black lab mix.  I met him 3 days after he had been admitted to the hospital. On July 3rd, Dudley was tied in the back of his family’s pickup (always a bad idea), and he jumped out of the moving vehicle,  As a result, he was hit by the car, as well as dragged for a distance until the driver realized and stopped the car.
At his initial admission to my colleagues, he was a severe multi-trauma patient; he had blood in his chest (hemothorax), air leaking from his lungs (pneumothorax), broken ribs, severe road rash, a large laceration in his left axilla (armpit region).  He was not able to stand, but had been stabilizing over the first 72 hours in the hospital.  Just prior to my arrival, Dudley had received a blood transfusion due to ongoing mild bleeding, probably due to a low platelet count, and potentially the start of DIC (disseminated intravascular coagulation; see previous posts).
This is when I met Dudley for the first time (my first shift back to the hospital).  My colleague and I discussed his case in rounds, and I performed my initial physical exam.   Although Dudley’s red blood cell level was improved with the blood transfusion, he looked shockingly worse; his gums were pale, his breathing was labored, and his urine began to discolor.  Dudley’s bruising was more than expected for a patient in his condition.  
I went to work.  SPO2 revealed that Dudley was hypoxic on room air; I provided him with supplemental oxygen and rechecked his labs.  Something wasn’t right; although his electrolytes were normal, his arterial oxygen saturation was way, way too low.  I rechecked chest radiographs looking for ongoing bleeding or leakage of air.  The radiographs were identical to those taken 24 hours previously, ruling out this as a cause of his deterioration.  I tried to contact his owners, but was unable to reach them.  
A dedicated assistant was assigned to monitor Dudley closely, as I was concerned for his imminent arrest.  His respiratory rate and effort worsened, and about 2 hours after I had examined Dudley for the first time, it happened.  His heart rate shot up to 220 beats per minute.  We raced to administer lidocaine, an anti-arrhythmic drug, and applied an ECG.  As I applied the ECG clips, we noted that the lidocaine had made no change in his rate or rhythm.  Just as I pushed more lidocaine into his IV line, the ECG revealed the most serious of all cardiac arrythmias :  ventricular fibrillation.
Ventricular fibrillation is a terminal rhythm if it is not corrected immediately.  V-fib basically means that instead of working as a functional pump, the heart was fibrillating, or twitching, without actually moving any blood forward.  The electrical activity of the heart needed to be reset to provide a chance for the muscle cells of the heart to work together once again.
This is where the story gets amazing.
With only seconds to spare, I performed a precordial thump on Dudley.  (This is like in ER, when the doctor pounds on a dead patient’s chest screaming, “LIVE, DAMN YOU, LIVE!” and the patient miraculously is revived.  Only it usually fails.)  The precordial thump, or a strong well placed strike of the heart, can sometimes provide enough energy to reset the electrical currents.  I’ve perfomed this twice before, and had never seen it work.
This time, it worked.   (I can’t quite put into words how unbelievably amazing this is!)
Dudley’s rhythm converted back to a life-sustaining rhythm.  I’m pretty sure I screamed, “OH MY GOD, IT WORKED!”  High - fives all around the hospital, and then back to work - as you can imagine, post arrest patients are among the most fragile, and a high percentage of them crash and arrest again within minutes or hours.
I continued to try contact the family; and was still unable to reach them.  3 hours later,  despite his death, and despite the seemingly insurmountable odds, Dudley’s family finally received my voice mails, returned my calls, and shed tears of fear, joy, fear and then joy again.  He had survived ventricular fibrillation.
Sparing the medical details and lots more hard work, 2 days later, Dudley is eating.  He’s off all heart medications, has normal blood pressure, improved bloodwork, his platelets have rebounded, and is still recovering.  He has a ways to go, including healing his wounds and a possible limb amputation, but he is expected to survive. 
This will truly be one of the most memorable cases of my life.    I can’t wait for the next one.
+1 for the home team :)

Thursday, July 7, 2011


I'm frustrated and irritated about my last 24 hours at work. Here's just two of the reasons why.

Situation #1
Pet owner calls and states that their dog just ingested rat bait, a poison that results in bleeding.  We let them know that this is an emergency, and they should come in immediately so we can induce vomiting, give charcoal and likely prescribe the antidote for this type of ingestion, vitamin K.   Seems pretty straight forward, right? A problem that we can fix.  A GREAT prognosis, if we act quickly.

You can read the specifics about the disease here, if you like.  The basic principle is this - rat bait is a POISON that works by making rats bleed to death.  It can do the same thing to dogs and cats, if they eat enough.  After ingestion, prevention of toxicity is by decontamination (as above - removal from the body with vomiting, and charcoal to prevent absorption).  If you do nothing, your pet is at risk for life-threatening bleeding.  Once bleeding occurs, the treatment is plasma, and vitamin K, which carries a significantly higher cost and chance of death than dealing with the problem right away.  ESPECIALLY if you watched them eat it.  WHY would you take the chance?

This particular person did not seem to agree with the above.  The man argued with my staff on the phone, and after several calls and two or three hours later, he finally arrived.  He was rude, insulting, and an all-around jerk with my staff and myself. He reluctantly agreed to let us induce vomiting on his dog, and when we he finally did, unfortunately, no rat bait came up.  He waited too long for successful vomiting.  This person continued to do nothing, except for  insult me, my staff, and complain about our prices. "HIGHWAY ROBBERY!" He screamed, "It's not even an EMERGENCY!" (Yes, sir, it actually is.)  Complaining about prices to me at my ER is like complaining to the checker at the grocery store.  The cashier scanning your items has exactly as much control over the price of bread as I do over the price of the exam, or the cost of inducing vomiting -- that is, ZERO control.  Mr. My-dog-ate-rat-bait-for-the-second-time-and-it's-your fault bitched, moaned, screamed and stomped his feet.  He yelled that his daytime doctor would have charged half of our fees.  I tried to help him understand that keeping the pet ER open is expensive (see a very well written post by Homeless Parrot, here), but it didn't matter.

I really don't like getting yelled at for trying to do the right thing.  It's not my fault you didn't pick up the poison.

Situation #2 -

Client arrives because her very small dog just ingested a whole, very large rib bone.  I performed and exam and discussed options with her; essentially 1)endoscopy to attempt retrieval without surgery 2)try to induce vomiting, with the known risks of this sharp bony item 3) surgical removal, or the least safe option, 4)wait and see what happens.  The bone was very large compared to the 15# dog, and had an extremely high probability of becoming obstructive, or causing damage to the intestines.

Fortunately, her pet was stable.  Unfortunately, we were very busy and the client had to wait about 30 minutes for x-rays as there were several pets to have exams, images taken, or procedures performed before it would be her pet's turn (including a dog that was laterally recumbent and unresponsive, a cat having difficulty breathing, and a dog who couldn't urinate.  All obviously much more emergent and therefore, triaged ahead of her dog, who wasn't yet vomiting or painful).

What did the client choose to do?

She left in a huff.   Now that's really going to help her pet, isn't it?

It's not my fault your dog ate the bone.  I'm just trying to help fix it.  It's not my fault that there are other animals here who are more sick than yours, increasing your wait time.  If your pet was dying, you'd want us to see it first, too.

I'm a people pleaser, a hard worker, and I'm dedicated to fixing pets.  It frustrates me when clients don't believe that we work long shifts and stay up all night to HELP, when they assume that we have bad intentions, when they are unkind, and when they don't let me help their pets.

Tuesday, July 5, 2011

When caring hurts.

I apologize for my long absence - the last two weeks at work have been insane.  I'll try to re-cap the interesting details over the next few days. 

Several days ago, I was presented a 14 year old, laterally recumbent akita mix who had been in a state of seizure for over an hour.  Her owner, Lila, was hysterical. She called us about 2 hours prior to arriving, and we urged her to come in as soon as possible. When she arrived 2 hours later, her dog was in critical condition.  "Pep" was unable to rise, or even lift his head; his gums were gray and his blood pressure was dismal. His pupils barely responded to light.  It was clear to all of us who were there that Pep was dying, and his chances of survival, even with optimum care, were very poor.

Lila was an emotional wreck.  I explained to her the physical exam findings, the possible causes, and the consequences on the body of having prolonged seizures, as well as sustained hypotension.  I offered to her a treatment plan, but explained my concerns that it was unlikely to be successful, and that I was worried his chances of returning to a normal life were very poor. 

So far, a normal story.  This is where a sad story and a loss of a beloved family member becomes an enraging, nightmarish case that makes us all want to run screaming from the building.

After the first 30 minutes, we had gone over the history, my findings, and my recommendations two or three times - pretty standard for someone who is upset over their very ill pet. I'm used to explaining things several times, in different ways, and I definitely realize that the general public does not understand how the body works - that's my job.  This case, however, was not a normal one.  It went something like this:

Client: "If I could just get him home, I only have to wait 5 more hours to get him to the vet."

Me: "I understand and respect that you trust your general practitioner very much, and I'm sorry that they're not available right now.  I'm a licensed veterinarian, and we're capable of providing treatments here, right away, until your doctor is open.  Pep is critically ill, and he will die if we do nothing.  We need to help him now, or we need to end his suffering.  Without treatment, he'll die."

Client: "Can't you just give him some medicine? Like a shot of antibiotics or something?"

Me: "There's not one drug that is going to fix Pep; we need to start with testing, IV fluids, and getting his blood pressure back up, and monitor his progress.  He's in critical condition, a shot of antibiotics is not going to fix him."

Remember, the dog is comatose, and doesn't even respond to light in his eyes.  He's this way for about 2 hours, and we go over the recommendations literally 20 times.  The client does not authorize any treatments- she allows an IV catheter to be placed, but does not allow bloodwork or IV fluids.  At the 2nd hour, her level of emotion raises to hysteria.  She wails and cries, and screams that she will die without her dog, and that she has no reason to live.  Her friend tries to console her, but nothing he says provides comfort.

At the third hour, watching Pep gasp for breath, agonal, and dying in front of our eyes while we stand by and do nothing, Lila finally signs the consent forms for euthanasia, but it doesn't end there.  She calls me in to the room, and then screams and sends me back out 3 times; her friend had given up on her and went outside the building (he couldn't take it any more).

I find it difficult to quite explain the details of this situation without sounding callous, uncaring, and unsympathetic.  I've been through a lot of very sad, emotional euthanasia with families and their pets, and I can guarantee that this one is the outlier.  Most clients are understandably very sad, and I always take the time to give my deepest sympathies, to let them greive as long as the need, and to make them comfortable with every step of the process, including ensuring that they feel 100% comfortable with their decision.   I've lost pets in my lifetime, and I love my furry family members like family.  I've shed tears over particularly sad cases, and always feel empathy for the loss of love and life that accompanies every single euthanasia, regardless of the circumstances.

The type of situation above is a client with severe emotional disturbences or personality problems.  I'm (obviously) not a trained psychologist, and veterinary school does not begin to teach us how to handle these types of people.  Dealing with this case for 3+ hours, while watching the patient suffer is one of the most awful parts of my job in the ER. There's nothing more emotionally draining than a hysterical, screaming, emotionally unstable person.  Cases like this are the fast track to compassion fatigue, which is rampant in the medical community.

A concurrent problem with a case like this is the client's pathologic attachment to a pet (which, in general, means an excessive, harmful dependency on the pet).  The human-animal bond is an extremely important part of society, and in the veterinary profession, the key ingredient that allows people to care for their pets.  A serious problem arises, however, when the attachment to the pet is above and beyond a healthy bond; for example, when the client threatens to harm themselves if the pet dies, claims that they cannot go on in life without their pet, or similar.  Obviously, no cat or dog can live the lifespan of a human, and unfortunately even with every advance in medicine (veterinary AND human), death is a part of life.  Clients like the one above need a trained psychological professional to guide them through understanding and healing - a position which I am clearly not qualified to fill.

Friday, June 24, 2011

Float like a butterfly....

Last night, a 2 year old poodle was rushed into the hospital.  The client reported that "Peanut" was out on a walk, limped for only two steps, and then collapsed.  Peanut was limp, not responsive, and her client was understandably hysterical.

On physical exam, Peanut's situation was grim.  She was comatose and therefore, not responsive to external stimuli.  She was unable to move any part of her body; her heart rate was extremely low and her breaths were shallow and slow.  Her mucous membranes were gray, with a pallor that is usually only seen on a deceased patient.

We jumped in to action.  The most likely explanation for a sudden collapse in a young dog was anaphylaxis, in our area, most likely from a bee sting or insect bite.

An IV catheter was placed; I started to bolus IV fluids in attempt to restore circulation; oxygen was provided. We administered epinephrine to halt the reaction as well as improve the heart rate and blood pressure, a steroid to combat the immune response, as well as benadryl and GI protectant medications.  Over about 40 minutes, Peanut steadily improved to sit up.  When another client came to the front door, she surprised us all and started to bark!  It was an amazing change, and she was on the right track.

Over the evening, Peanut improved steadily, and was remarkably eating and drinking within 4 hours.

Despite the overwhelming positive progress, one single concern emerged.  Peanut was oozing blood from any place on her body where blood had been taken, despite adequate pressure wraps.  Clotting times were evaluated, and Peanut was suffering from a coagulopathy secondary to her near-death experience.  Fortunately, her owner allowed a plasma transfusion, and 3 hours later, Peanut appeared as normal as ever.  Her mom came to pick her up this morning, and Peanut jumped, squealed and wagged her tail in joy of seeing her.  The client was equally as happy; she thanked us for saving her precious dogs' life.

Truly, a heartwarming case!

Tuesday, June 21, 2011

Letting out the evil vapors

The busy weekend continued with evaluation of "Gus," a 4 year old labrador, who had been vomiting and not eating for 3 days.  He was a typical lab, with a habit of eating anything not nailed down. He had been hospitalized for 24 hours, and was not improving; he had continued to vomit despite lack of food offered to him.  Radiographs from the previous day were suspicious, but not diagnostic for an obstruction.

I assessed Gus, and took him to the ultrasound for further investigation of his abdomen.  Ultrasound was overwhelmingly abnormal.  His loops of intestine were dilated with fluid, and sharp turns were noted, indicating a possible obstruction.  The actual item could not be visualized, but based on these findings, I recommended surgical exploratory.

His electrolytes were performed, and revealed a hypokalemic, hypochloremic metabolic alkalosis; classic for upper GI obstruction, (but also can occur in patients with frequent vomiting).

In Gus' case, the suspicion for a foreign object being lodged in his intestines was increased by his breed, his age, his history and lack of improvement despite therapy, as wells asthe results of radgiographs and ultrasound.  Surgical exploratory was the only way to be sure of the cause of Gus' illness, but in his case (and most others), there is always a risk of performing surgery, only to find nothing.  No obstruction, no foreign object, and no macroscopic reason for the pet's illness.  This is unbelievably frustrating for the client, given the expense of surgery, as well as the pain and recovery time associated with it.  It is also unbelievably frustrating for the veterinarian, who obviously wishes to perform surgery on all the right animals, and not perform surgery on those who don't need it.  On the other hand, the risk of NOT performing surgery on an animal with a GI obstruction is extreme; if the object remains lodged in the intestines, in can result in damage to the intestines, requiring portions to be removed, or in the most severe case,can cause rupture of the GI tract, and an overall much worse prognosis for recovery (or even death).

With these facts in mind, I discussed the recommendations' to Gus' family.  Surgical exploratory did have the small risk of anestheia, as well as the cost and associated healing time, however doing nothing could potentially result in significant worsening of his condition.  They wished to proceed with surgery, and so Gus was prepped for his surgical procedure.

Anesthesia was uneventful, and Gus' vitals all remained normal throught the procedure.  What I found at surgery, however, was just the frustrating finding I had hoped not to see; no foreign object, a negative explore.  Gus' stomach was filled with fluid, his intestines were dilated and had no normal movement, but there was no clear macroscopic reason for his illness.

Frustration washed over me as I evaluated the entire length of his GI tract again, just to be sure. Nothing. No rock, sock, string, or nylons to take out, and no clear reason why Gus had been feeling sick for three days.  The adage you learn in veterinary school is, "If you aren't doing any negative abdominal exploratories, then you aren't doing enough abdominal explores."  This comment, while true, is not comforting when you're staring into a dog's abdomen, wondering why you cut him open.......

The meaning of this comment is based in statistics.  I'll refrain from boring you with the mathematical details, but in summary:  The goal is to never miss a true foreign body (FB), so as to avoid harming the patient (or having one die).  As every patient with a FB can look different, some patients without a FB will mimic those who have a true obstruction.  Essentially, surgical exploratory is called an "exploratory" because, in the right situation, it is not only a therapeutic procedure, but also a diagnostic one. As nobody can be 100% correct every single time, it's better to have a few "negative" explores, than a few patients with an obstruction who are missed, and subsequently die.

Often, patients without foreign objects who undergo surgery do very well afterwards; it's been jokingly referred to as a "therapeutic gut stir" or "letting out the evil vapors."  The pain of surgery typically abates in <24 hours, and they return to happy, healthy lives with their families.  As frustrating as a  negative explore can be, I'd take one every time over a dog who didn't have surgery soon enough.  It's a delicate balance and a difficult decision each and every time.

Anyway, I digress.  I biopsied Gus' intestines, in hopes of determining the cause of his GI illness, and he recovered uneventfully.  He discharged the next day, eating, no longer vomiting and back to his normal self.

Monday, June 13, 2011

a mixed bag

I arrived to work on Saturday in a great mood - ready for the day, and hopeful for a busy and rewarding shift.  Sometimes, I should be careful what I ask for!

Saturday started out with very few patients already admitted to the hospital.  Before I even had the chance to evaluate these patients, client after client started to arrive at the front door en masse.  Within the first hour, there were 5 patients waiting to be seen, with more on the way.

"Leo," a 18 year old gray tabby cat, presented for bleeding from his mouth.  He had otherwise been a previously very healthy cat. Leo was indoors only, so trauma was very unlikely.  As I to take a detailed history from his concerned owner, I began my full nose-to-tail physical exam.  My standard physical exam is performed the same way every time, in the effort to be the most efficient and to avoid forgetting any sections of the body.  I start at the patient's head, with ears, eyes, nose, throat first, then moving to an oral exam, followed by listening to the heart and lung sounds, palpating the abdomen, and finally evaluating the extremities, performing a neurologic exam, and a rectal exam.

Leo's diagnosis was visible before I even left the first segment of his exam.  An expansile, large fleshy mass was present at the base of his tongue, and clotted blood was present where he had likely bit the tumor, resulting in the symptoms noted by the owner.   Unfortunately, given the size and location of this mass, Leo's options would be limited, and the client instantly knew this when I gave him the sad news.

A 2 year old dog had arrived and was brought in on a stretcher.  The 160lb Rottweiler was stumbling, and acting bizzare, according to the owners.   Immediately on examination of "Gus," his diagnosis was unmistakable.  Gus was headshy, and when left alone, would fall alseep.  He could walk, but had a drunken, ataxic gait.  He was dribbling urine - all hallmark signs of marijuana toxicity. His clients, with red, bloodshot eyes, wearing Bob Marley apparel (I'm not exaggerating!), and smelling of Mary Jane, claimed that it was completely impossible for Gus to have had access to pot.  "No way, man," they claimed.


I tried to explain to them that my only interest is in the health of their pet, and if there really was no access to THC, then we needed to be aggressive about determining the actual toxin or process responsible for Gus' symptoms.  I offered drug testing, antifreeze testing, and a biochemical panel to evaluate internal organ function.  After reviewing costs, the clients declined testing, and requested treatment for THC.

The next patient to require my attention was a 5 year old orange tabby who had just been closed in a garage door.  Fortunately, the friendly, fat kitty had only suffered some minor brusing and soft tissue injury of his pelvic region, and radiographs ruled out pelvic fractures.  He'd be back to chasing mice in no time.

The day rolled on, and the rest is to be continued....