Sunday, February 27, 2011

don't do it yourself

Last night, a very nice couple came into the ER with their cute young labrador.  She had a freshly acquired skin laceration, which was relatively small.  These are the fun, easily fixable cases that (nearly) always have a good outcome.

All seemed normal, until the client reveals to me that they had tried to "sew it up" themselves at home.  They had applied some topical anesthetic and used a needle and some suture (acquired from his workplace, a human medical facility), but his cute, wiggly dog wouldn't hold still.  Not to mention the fact that he had not cleaned out the wound or removed any of the contaminating hair from the area, did not have sterile instruments, or any sort of surgical training.

Thankfully they allowed me to sedate their dog, provide pain control, and close the wound surgically and appropriately.  They didn't seem to realize that next time, they should skip the do-it-yourself routine and just come straight to a veterinarian.

Another client, whom I had never met previously, requested several times for me to let them treat their dog at home with IV fluids and IV medications.  As much as I want to help my clients and make them happy, my job is to be the pet's advocate, and as the veterinary oath states, "above all, do no harm."  Most of the medications, even simple intravenous fluids, that I provide on a daily basis can be harmful, even deadly, if used inappropriately.  The wrong rate of administration, lack of careful monitoring, giving the wrong dose of a drug or hundreds of other mistakes are the potential pitfalls of an inexperienced person trying to do my job at home.  That's not a standard of care I'm willing to participate in.  (Veterinarians who take their patients home at night is a completely different situation and my previous comments are in regards to laypersons or those without veterinary medical education).

Dogs are not small humans in fur coats.  There's hundreds of stories of well-meaning humans, especially in the medical field, trying to treat their pets at home and failing miserably.  Just because you've watched someone else do it, you've seen it on TV, or you do it on a different species, doesn't mean you should try this at home.

Saturday, February 26, 2011


One evening, about a year ago, we received a phone call from the fire department.  A pet store was on fire, and they needed help transporting the evacuated animals.  Two of my assistants jumped in their vehicles and raced to help.  Fifteen minutes later, ambulances and trucks filled to the brim with caged animals started to arrive at the clinic.

It was a sight unlike anything I ever anticipated; cages full of mice and rats (who were giving birth due to the stress of the experience), to a Gila monster (a poisonous reptile), a wallaby, African Grey parrots, budgies, cockatiels, snakes, ferrets, rabbits, a few puppies, desert tortoises, two cats, lizards, leopard geckos, chinchillas, and even a tarantula or two.  The number of animals (including the mice) clearly exceeded any reasonable expectations for one human to be able to evaluate and treat. We estimated approximately 300 animals were brought to our hospital, with about 100 of those being mice and rats.

Special attention was given to the birds, who are as a species, very sensitive to the effects of smoke inhalation.  All of our available oxygen outlets were utilized.  Animals in their cages filled our lobby, all of our exam rooms, spilled into the treatment areas, and the smell of smoke overtook our clinic. That overnight felt like one of the longest of my career, and dawn was a welcome sight.  The pet-shop owner came by to thank us for our assistance in their time of need, and began to move the animals from our hospital to foster homes.

It was later determined that the cause of the fire was a faulty heating pad at the pet store.  Due to the quick actions of the firefighters and my staff, a majority of animals were rescued and survived. 

Wednesday, February 23, 2011

Even more blood

The last story was one of internal hemorrhage.  This following one is a story of external hemorrhage.

A geriatric 40# mixed breed dog presented two weeks ago for severe blood loss.  The owner noted that there was a great deal of blood in the yard, and that the dog was covered in blood.  She was in a fenced yard, with no other dogs, and no history of trauma. Typically, calls about "severe blood loss" are minimal amounts of bloody diarrhea or the like that scare owners, and not actually a severe amount.  This was different.

When our patient, Mickey, arrived, her pelvic limbs were literally soaked red with blood.  Overall, her general appearance was poor, with matted fur all over her body, feces caked into her feet and toenails curling and overgrown nearly into her pads.  She had not seen a veterinarian for at least 8 years, they family reported, because she had been "so healthy."  Her teeth were nearly falling out of her head with a smell that could knock you over from two rooms away. The smell of blood, her breath, and feces was overwhelming, even for ER veterans like myself.

We jumped into action; her gums were still pink, but locating the source of the hemorrhage and stopping it was the first priority.  I gently rolled her onto her side, and started clipping away matted, blood soaked fur, until finally, I saw it -- a 4 inch, circular, necrotic mass in her groin that was gushing blood.  Not just gushing, but actually shooting blood up to 3 feet (hitting my technicians shoulder when she was at arms length).  This only occurs when an artery is the source of bleeding.  The arterial blood vessels are a high-pressure system powered by the strength of the heart's contractions.  Arterial bleeds are severe, and can result in death from blood loss quite quickly.  My staff applied direct pressure while I went to speak to the client and explain the situation.

Unfortunately, the mass was quite large and in a difficult area with many important structures; the chance of a cure with surgical removal alone was poor.  If left alone, the mass would begin to bleed when bumped even slightly; and due to the arterial nature of the bleeding, could quickly result in death.  Along with her other age-related illnesses and changes, her owners ultimately elected euthanasia.  Despite her outward appearance, they loved her very much and were grateful to have spent the last ~10 years with her as a part of their family.

(In order to help other pets, it is important to note that this tragedy could have been potentially avoided with annual or semi-annual complete physical exams by a veterinarian.  Physical exams are important in our veterinary patients as they obviously do not have the capability to tell their family member or neighbor, "hey, look at this mass growing here!  What do you think that is?" By performing an exam, a veterinarian would have had a chance to identify the mass when it was small and surgically removable, also allowing time for the family to discuss options, prepare for outcomes and make decisions in a less critical situation.)

Blood, blood everywhere....

Hemorrhage.  We've all seen it in the movies, we've seen it on TV, but have you seen it in a real-life emergency?  Depending on the patient's age, exposure, clinical signs, history, medications and other factors, the list of causes for bleeding can be quite extensive.  These critical patients require the efficiency, expertise, and dedication of the emergency veterinarians around the country who work around the clock, just in case they're needed.  And they often are.

I've still never forgotten the story of Sheeba, a sheltie who presented to me about one year ago.  She was about 3 years old, in great health previously, but had been lethargic and having increasing difficulty breathing for the last 1-2 days.  Her breathing was labored, and her gums were pale.  She had no history of trauma, and they did not witness her ingesting anything recently. No other symptoms had been noted, including no vomiting, diarrhea, or anything else unusual.

Immediately, a triage physical exam was performed.  Auscultation of her lungs suggested fluid in her chest cavity, or pleural effusion.   Pleural effusion is a build up of fluid between the surface of the lungs, and the body wall; typically there is only a very slight amount of fluid in this space which serves to lubricate the lungs as they move to and fro during the motion of breathing.

Oxygen was provided and a minimum database was collected to rule out causes of her symptoms.  (For those not familiar with medicine, a minimum database typically includes the quick, in-house, rapid testing that provides the attending with critical information to help make diagnostic and treatment decisions).  An IV catheter was placed.  Initial testing indicated blood loss was occurring, and in conjunction with her symptoms, the most likely location was her chest cavity.  Radiographs confirmed a severe amount of fluid within her chest.

Additional tests were performed to attempt to determine why Sheeba had been bleeding into her chest; in a young patient without a history of trauma, the most treatable (and arguably most common) cause of this is exposure to anticoagulant rat bait.  Testing, called PT (prothrombin time) and PTT (partial thromboplastin time), were performed, and both were severely elevated, indicating a deficiency in the clotting factors necessary to maintain hemostasis.   After talking to the family about her symptoms, signs, and test results, they remembered that rat bait was indeed placed under their house last week, and she was able to access this location.  Rat bait toxicity was our most likely culprit.

Anticoagulant rat bait works by inhibiting the enzyme vitamin k epoxide reductase, leading to a vitamin K deficiency in the body.  Vitamin K is a necessary factor for the production of clotting factors (II, VII, IX and X) in the liver.  As these factors are depleted, the body is unable to clot blood, and life-threatening hemorrhage occurs.  Unfortunately, the same pathway that is intended for pests is also the method of toxicity in our companion animals.  Bleeding can occur anywhere in the body; externally or internally, and symptoms vary widely as a result (bloody diarrhea, vomiting blood, difficulty breathing due to bleeding into the chest, bleeding from the nose or mouth, or death if bleeding occurs into the brain).

If you see your animal ingest anything unusual, especially a known toxin, the best course of action is to contact a veterinarian.  If caught quickly enough, they may induce vomiting to remove the toxin from the animal's system, potentially preventing toxicity.  Unfortunately, our pets are often able to ingest these types of things without our immediate knowledge, as in Sheeba's case. 

Sheeba was hospitalized, and fresh frozen plasma was administered in order to restore her body's missing clotting factors.  She was started on the antidote for this type of poisoning, vitamin K1.  Initially, she improved and her clotting times reduced towards normal values.  However, after the first 12 hours of hospitalization, her breathing worsened.  The amount of fluid within her chest cavity was overwhelming her lungs' ability to exchange life-sustaining oxygen for the waste product carbon dioxide.  She was near death, and her best chance of survival was to remove the fluid from around her lungs (called thoracocentesis). Doing so was not without risk, as removing this fluid required placing a needle into her chest cavity, a moderately dangerous procedure in a patient with a bleeding disorder. Her clinical status continued to deteriorate, and cautious thoracocentesis was her only chance for survival.  Her family agreed to allow the removal of just enough fluid to improve her respiratory rate, mentioning to me that they were strongly considering euthanasia, due to her disappointing progress and concern for the financial burden associated with treatment.  Her family visited with her, sobbing together, just prior to the procedure, just in case it was their last time.

I removed about 75ml of frank blood from Sheeba's chest while she lied laterally recumbent, gasping for breath, unable to do anything but focus on the effort of breathing.  After the fluid was removed, I monitored her closely. With almost instantaneous results, she sat up, looked around, stood up, and began to bark and wag her tail.  It was one of the most dramatic recoveries I have ever seen.  With tears in my eyes, I ran up to the lobby, called for her family, and brought them to Sheeba's kennel.  They hugged each other, they hugged me, and they celebrated.  The joy of this moment is forever frozen in my mind.

Sheeba never looked back.  The bleeding halted (thanks to plasma and vitamin K), the blood within her pleural space was reabsorbed back into her body (which normally occurs over about 48 hours once hemostasis is restored), and she went home 24 hours later, wagging her tail and into the arms of her thankful family.  

I heard from the family about 1 week later, and she was as good as new.  That's why I love the ER.

Tuesday, February 22, 2011

Everybody loves puppies!

One of the most stressful, and also most rewarding, emergencies is a dystocia.  Dystocia literally means "difficult birth," and occur for a variety of reasons, including large fetuses, small pelvic diameter of the bitch, malpositioned fetuses, inadequate uterine contractions, etc.  The end result is that a pregnant female is unable to successfully provide vaginal birth without assistance.

Signs and symptoms of dystocia include active contractions without production of a puppy, green vaginal discharge, excessive delay between puppies, ineffective contractions, or a puppy visibly stuck in the vaginal opening. Any of these problems should alert an owner to contact a veterinarian for an exam.

My patient, Fergie, was a 4 year old corgi currently pregnant with her second, unplanned litter.  She had delivered no puppies yet at home, and had been straining for several hours.  Her family, Dan and Stephanie, brought her to my hospital at about about 1am.  Dan and Stephanie had not intended for Fergie to become pregnant, however they had not prevented this by the most simple method, ovariohysterectomy, commonly referred to as a 'spay'.  Spay surgery is an incredibly important part of preventative care for companion animals; spaying females helps to reduce the dramatic pet overpopulation problem, and prevents development of ovarian or uterine cancer.  Spaying a female before the development of her first heat also dramatically reduces the probability for mammary cancer.  The Humane Society of the United states estimates that 5 million dogs and cats are euthanized every year due to overpopulation.  Spaying (and neutering) is one tool to help reduce this horrible statistic.  Spaying also prevents pyometra, which I will cover in a later discussion.

  I performed an exam on Fergie, and performed ultrasound to detect fetal heart rates.  Her fetuses were in distress, with heart rates dropping to critical levels; it was now or never to try and save these babies.  5 puppies were in Fergie's uterus, and it was our job to get them out safely as well as provide a safe, sterile surgery for Fergie.  Various drugs can be tried prior to surgery, however in Fergie's case, delaying surgery was a more risky option, and fortunately, the family wished to proceed with surgery immediately.  Emergency cesarean surgeries can be expensive, due to the expertise and training required to perform a safe, sterile, surgical procedure.

A cesarean section was performed, and we successfully removed and resuscitated 5 healthy puppies (three boys, two girls).   For me, watching a newborn take his or her first breath, and knowing that I am the one who provided this life with a chance to be lived is an incredible experience.  The joy of seeing the puppies latch on and nurse for the first time while their mom licks them clean, is an experience unlike any other.

Monday, February 21, 2011

Flea anemia

Sam, a 40-something single man, brought in his cat, Percy, a 3 year old persian.  On presentation, she was as limp as a dishrag, barely breathing, with her heart rate falling, and her gums nearly white.  She was also covered in fleas.

Percy was provided with oxygen and initial bloodwork was started as well as placement of an intravenous catheter.  Her blood pressure was so low, that only one drop of blood could be obtained.  A packed cell volume, or PCV was performed and was 8%.  Normal PCV for a cat is approximately 35-40%; the red blood cells are responsible for carrying oxygen from the lungs to all the tissues of the body, and without them, life cannot be sustained.

I quickly relayed this information to the owner.  In young, small animals, or those with severe infestations of fleas, these blood-sucking parasites can be the cause of death.  Percy was not far from this fate.  She immediately required an IV catheter for a life-saving blood transfusion from one of our generous feline blood donors.  Our feline blood donation program utilizes employee pets who are healthy, young, indoors, and free of illnesses to provide this life saving medical treatment.

Fleas are blood-sucking insects, and can easily exsanguinate a small cat or dog if no flea prevention is utilized. There are many other causes of anemia, however in this case (and so many sad others) that I have seen, a simple treatment with a veterinarian recommended product can prevent a life-threatening illness.

Unfortunately, many people are fooled by cheaper-priced, "naturally" labeled, ineffective or dangerous products.  Many over the counter products are toxic to cats, and others are purely ineffective.  Flea prevention is safely and easily achieved by following a veterinarian's recommendations (typically Frontline, Revolution, Advantage or others are recommended .  Speak to your veterinarian about your specific pet's needs.)

Why can't you ask the pet-store employee? Veterinarians are trained in prevention, diagnosis, treatment, and control of internal and external parasites.  Veterinarians spend a minimum of 8 years of their life in training to help keep your pet healthy, as well as treat them when they are ill.   It is actually more difficult to gain admission to veterinary school that it is to become a human physician!  (This is because there are only 28 veterinary schools in the US, while there are literally hundreds of M.D and D.O. programs).  On average, veterinarians make a fraction of the salary of a human physician, and undergo nearly the same training as a family practice M.D.  We're not in this for the money.  We're in this because we love pets, just like you.

Luckily for Percy, we were able to locate a compatible donor and provide her with the blood she needed to survive, as well as eliminated the fleas who were stealing this oxygen providing fluid.  She was discharged 36 hours later, and her owner was as happy as we were to have saved her life.  He'll never miss a dose of flea prevention again..... A mere $8 tube of Frontline could have avoided an almost-tragedy, as well as nearly $1200 in emergency veterinary bills.

Read more about flea anemia.  While the internet is a useful tool for learning, always check your source. is a legitimate, veterinarian supported tool for basic information about various conditions.  It is not a replacement for a visit to your veterinarian.

Monday, February 14, 2011

Slander (Actually, Libel)

Working in the ER means that I'm often required to provide people with bad news.  Most of the time, it doesn't go this badly.

Sarah presents at 2am during one overnight shift with a wretchedly thin boxer-cross, Tank.  Tank is extremely painful, Sarah says, and not able to use his leg.  She's driven a long way to get help from the doctors at my hospital.
"How long has this been a problem?" I inquired.

"At least a month." Sarah replied.  She told me the long story; she'd spoken to 'doctors' at 'universities' across the country who'd recommended multiple diagnostic tests that she hadn't yet been able to perform.    Tank, an adult boxer cross, was emaciated, in excruciating pain, and not able to bear any weight on his front left leg.  A hard, bony swelling was present near the shoulder.  His nearby lymph nodes were severely enlarged. Immediately I suspected osteosarcoma, an aggressive bone tumor, and the most common cause of these symptoms.  Our geographic location did not make fungal infection likely, although certainly tests would be performed to rule out other causes before any treatment would be started.

I recommended the tests needed to definitively diagnose his symptoms; starting with limb radiographs and likely including chest radiographs, to start the search for spread of suspected cancer. I also recommended pain relief medications, as his posture and inability to use his limb appeared excruciating. I explained treatment for that likely diagnosis; although we wouldn't be able to start treatment until the diagnosis was confirmed. (The most common course of treatment includes amputation of the limb for pain control, followed by chemotherapy.  Other therapies include limb-spare surgeries or radiation).

"It can't be cancer.  My dog's dam is still alive, and she doesn't have cancer.  They eat an organic diet.  There's no way it's cancer. You're wrong."  Sarah refused to believe my medical opinion, and started to become angry, aggressive, and argumentative.

Her response was a common feeling among many who receive a devastating diagnosis; denial.  However, for this client, it was different.  She refused to accept pain control medication for her dog, and she could not afford the thousands of dollars needed for diagnostics, surgery and chemotherapy.   She expected that our facility could provide her with over $4000 of free services, and demanded that we do so immediately, at 2 in the morning.  While I wish that this was the case, unfortunately veterinary hospitals, like the one where I was employed, are privately owned businesses and have to make a profit to stay open and serve clients.  Fortunately, our hospital did have grants for patients who had a good chance of a full recovery, however bone cancer did not fit the requirements for a good prognosis.

I again asked if I could give her dog something for pain, but she refused.  Sarah did not believe that her dog was in pain.  My supervisor that evening also examined the dog, and came to the same conclusion; he again tried to reason with her to let us provide pain relief for her dog, but she refused.  Furious, she stayed in our lobby all night in order to speak with administration when the offices opened at 8am.

During the next several weeks, despite their better judgement, the hospital ended up providing Sarah and her dog Tank with grant funds to see two groups of specialists, who did confirm definitively my suspected diagnosis based on radiographs and fine needle aspirate.  A pathologist evaluated cells from the tumor under a microscope, and an unequivocal diagnosis of osteosarcoma was given.  Tank was prescribed three types of pain medications, and Sarah refused to give any of them based on her own uneducated, misguided attempt at 'holistic' medicine.  The tumor had already spread to the chest and lymph nodes; eliminating any chance for a cure.  We never heard directly from Sarah again, and I only hope that Tank did not suffer too much in the last months of his life.

Several months later, on a public review website, Sarah accused me of not offering pain relief, of making the wrong diagnosis, and of malpractice.  She used my full name and stated that I should be removed from the profession.  The posting was vicious and one of the most difficult things I've ever had to read.  Fortunately, not only was her post completely false, it was also against the terms of use of the web host, and was removed almost immediately.

Tuesday, February 8, 2011

A new day, a new journey

You have to start somewhere...

Many years ago, when I started veterinary school, my mother told me - "You should write down your stories and cases, so that someday you can write a book like James Harriot".  Of course, being a 20-something, I disagreed -- MOTHER, nobody wants to hear those stories.

She was right.  Several years later, here I am, wishing I had chronicled my cases and stories of human life, grief, happiness, and success for my own reading, and for others to understand the inside of the mind of a dedicated emergency veterinarian.  

You have to start somewhere.  Today is the day.  I hope that someone, somewhere, understands the dedication, sacrifice, investment, and heart it takes to do my job.

Onward, ho!