Tuesday, March 29, 2011

A chance to cut is a chance to cure.

Another happy ending !

A friendly, very chill cat presented to us several months ago with a broken leg.  She was quite obese, and otherwise had relatively few other injuries. Her biggest problem was that she had arrived to us with a good-samaratin, who had found her outside and brought her to us for care.

She wiggled her way into our hearts with her affectionate, friendly attitude, so rarely seen from cats in the hospital.  She was nearly 20lbs of purring, friendly feline love.

So, our hospital took on her care, of course, hoping to find her owner (as clearly she had not been wanting for food!), but also realizing that if they could not be located, we could save her life and find her a new family.  Her leg was splinted, and we monitored healing of her fracture over the following weeks.  (Ideally, surgical repair of the fracture would provide for the best outcome, however this was not feasible due to a variety of factors, including her status as a stray kitty and the unknown whereabouts of her original family).

Despite our best efforts, her leg did not heal.  Nevertheless, she remained friendly, happy, and never grouchy.  She purred and kneaded during her bandage changes, rolling on to her back and begging for belly rubs.  She loved anyone who was willing to stop by for a few minutes and pet her.  She was truly the ideal feline companion.  With a soul as precious as hers, we marched forward providing the best we could for her, although still, no family had come forward to claim her.  Our hospital absorbed the cost of her care, and honestly, even in these tough economic times, we were happy to do it.  This kitty reminded us why we continue to pour our blood, sweat, tears, and sleepless nights into this profession -- to save pets.

About 10 weeks after her initial injury, it was determined that without surgical intervention, her leg would not be functional and would be a constant source of pain.  Amputation of the broken, non healing leg was a means to provide her with comfort and an excellent quality of life.  Three-legged animals are happy, ambulate well, and have no long term problems associated with the loss of their limb (regardless if the affected limb is either a forelimb or a hindlimb).

With our sweet kitty's best interests in mind, I prepared to remove her broken leg.  I reviewed my anatomy, brushed up on the extrinsic muscles of the forelimb, and noted pertinent vessels and nervous structures in the path of surgery.  Interestingly, the cat's forelimb is only attached to their body by muscles, ligaments, and tendons.  Many cats actually have a clavicle, however it is considered "floating" and a non-functional vestige of a previous evolutionary structure.   Amputation surgery requires careful pain control, balanced anesthesia, ligation of large vessels, and blocking nerve pain with local anesthetic while in surgery.

She was anesthetized, given pain medications, and her vitals monitored carefully.  My staff watched eagerly as I removed her entire limb, including the scapula, and handed off the offending leg. The surgery was uneventful, and our sweet friend woke up and recovered routinely.  Her scar is currently prominent, but as the incision heals and her hair grows back, it will be completely hidden from the untrained eye. She's already a pro at walking on her three limbs (she's been mostly unable to use the injured limb for the majority of the last 10 weeks, so that's actually no surprise).

Unfortunately, we have not yet located our tripod's original family.  Despite this, she is on her way to being a normal kitty, and will most definitely find a new, loving household to share in her chubby happiness!

As an aside: if your pet ever has a condition requiring them to lose a limb, fear not.  In the hands of a skilled surgeon, with aggressive pain control, amputation is a chance to provide pain relief, a good quality of life, and in cases like this one, a cure.

Sunday, March 27, 2011

I'm sad.

I actually cried tonight at work -- the first time in a long time.  Of course, I've been sad, I've grieved with owners, but I don't usually cry. 

A one-year old beautiful cat presented laterally recumbent, weak, cold, and with a low heart rate.  I couldn't palpate femoral pulses, suggesting that her blood pressure was critically low.  As I examined her, it became apparent that she had been hit by a car. An area of swelling was present over her abdomen, she was bruised, painful over her back and neck, and her nails were frayed.

Initially, she responded to stabilization with IV fluids, pain medications, and oxygen. The family allowed us to continue care and monitor her for progress, knowing the variety of possible outcomes for pets that have suffered trauma. She rallied, and became able to stand, vocalizing and resisting our attempts to take her temperature.  I celebrated a bit as she had made significant strides in the correct direction.

And then, she crashed and burned.  Her swelling had increased, and now, visible on x-rays, there was air accumulating under her skin and in her abdomen.  Her effort of breathing worsened, and her mental status declined.  She became minimally responsive.

I watched her deteriorate (and tried to intervene) over the following hour.  We discussed treatment options, and ultimately, her family elected euthanasia.  I cried as I gave her the injection, and although I knew that I was preventing suffering, I wished that I could save her.

I still do.

Tuesday, March 22, 2011

sometimes, things go well

Today was a great day -- which had the potential to be a disaster.

A 13 year old chow mix presented today with signs consistent with GDV - which is actually considered "the mother of all emergencies."  The dog, "Tuscon" was extremely weak, unable to walk, tachycardic, and had poor pulse quality, as well as classic severe distention of his abdomen.  He had been retching unproductively at home and had been worsening over the last 30 minutes.

A blood pressure was measured at 60mmHg, a critically low level, resulting in poor perfusion of internal organs, development of metabolic derangements, and if left untreated, potential for death.

Immediately, an IVC catheter was placed and bolus fluids were initiated. He was provided with pain medication and oxygen, and blood samples were collected for analysis.  I spoke with the family and recommended emergency treatment, including stabilization, fluid therapy, confirmation of my diagnosis (with a radiograph), and then emergency surgery to decompress, derotate, and pexy the stomach to the body wall.

Initially, the owners were reluctant to allow treatments as they had no ability to finance care.  They wanted surgery to be performed, however a GDV surgery typically costs between $2000 and $4000 depending upon patient factors, recovery time, etc.  This is obviously a huge financial investment and difficult for many of us to come up with on the spot. (Yet another reason to start that pet savings account I discussed previously)

Also contributing to the potential for a bad outcome in Tucson's case was his advanced age, his poor blood pressure, and the potential for concurrent age-related diseases.  His family and I discussed the risks of surgery, and that without immediate treatment, Tucson would succumb to his illness.  The only option other than surgery for Tucson was, unfortunately, euthanasia.

Tucson was a very well loved dog, and he had a dedicated family - they were able to quickly reach a friend who could help them finance Tucson's care.  Tucson received hetastarch, his stomach was decompressed by trocharization, and his blood pressure improved.  He was anesthetized and prepared for surgery.

Tucson's family and I had discussed the increased risks of anesthesia and surgery in his case; however due to our treatment interventions, careful monitoring, proper drug selection and just a little bit of luck, Tucson performed very well under anesthesia.  His stomach was easily replaced back to its normal position, and had little evidence of damage from the previous severe dilation.  Tucson did suffer from one additional complication of GDV: his spleen had torn, resulting in hemorrhage.  The tear could not be repaired, and his spleen was removed.    His family was ecstatic to hear his progress after surgery; despite his advanced age, critical condition, and all the potential complications, he had done very well.  

Sometimes, things just go well.  Thank goodness for that!

It's like a real ER

Yesterday, we had one of the most critical patients I've ever seen arrive at our clinic.

An adult terrier mix had been attacked by a housemate.  The victim had a gaping hole in his chest, and with each breath, air was flowing in to the wound.   His mucous membranes were gray to purple, and he was gasping for air. 

Open chest wounds are imminently life threatening, based upon the mechanics and physiology of breathing.  The chest cavity maintains a pressure which is actually slightly lower than atmospheric pressure; therefore, breathing in is actually a passive process.  If the chest wall integrity is lost (such as in a trauma case), the pressure equilibrates, and breathing in becomes a much more difficult task.  In addition, if air is sucked into the chest cavity, the pressure inside the chest can actually become higher than the environment, resulting in what is called a tension pneumothorax.  (If you've seen House, this is when he dramatically stabs someone's chest with a sharp, hollow object to relieve the pressure.  DO NOT try that at home!).  The ability to exchange oxygen and carbon dioxide in the lungs is one of the  most critical processes in the body, and without this process, life ends within minutes.

Thankfully, both myself and the overnight doctor were in the building, as well as ample nursing staff.  Immediately, we placed an IV catheter, provided him with oxygen supplementation, and covered the wound.  A thoracocentesis was performed to remove excess air from his chest cavity (relieving the tension pneumothorax), and pain medications were given.    Fluid support was initiated, a chest tube was inserted, and a technician focused on continuing to remove air from around his lungs.  The other veterinarian and myself worked quickly to provide closure of the open chest wound, in an attempt to save the little dog's life.  All of this happened in a matter of less than 15 minutes.  The 10# dog had between 5-8 hands on him at any one time, trying to save his life.

We were successful in closing his wound, in providing him with rapid, life saving intervention, and although still critical and requiring much care, our little patient was in a bit of a better place.  

Despite our best effort, effective teamwork, and our initial successes', the family ultimately decided that they couldn't continue treatment.  He was euthanized, and passed peacefully with his family. 

Monday, March 21, 2011

the (not so) immaculate conception

Clients present with a 4 year old, intact, unvaccinated female cat who is STRICTLY indoor only, and lives with no other adult cats. The queen has been in labor for >48 hours, and has a fetus currently stuck in the vaginal canal. So far, the clients note that she's delivered 5 kittens alive.  (In actuality, she has 8 newborn kittens in her box at presentation).

In the exam room, the clients, who are reluctant to pay for services, note that they just can't believe she got outside that ONE time, and got pregnant. 

Me: "So this is her first litter?"

Client:  "No, this is her third litter."

Personally, I'm pretty amazed that getting out one time results in three separate pregnancies!

Fortunately, I was able to remove the last fetus from the birth canal manually, and no other fetuses remained.  The clients grumbled about now having to find homes for 8 kittens -- I gently, but firmly, urged them to have their cat spayed, thus AVOIDING the problem.

Client: "That's a great idea!"

......I'm again, puzzled.  You couldn't think of that on your own?

Sunday, March 20, 2011

Not your average laceration.

Client arrived for me to evaluate a wound on her cat's neck, which occurred just prior to arrival.  A tech gathered vitals and a brief history in the exam room, as is typical for any patient who presents at our hospital.  The patient (Reeba) was 2 years old, and the client did not note any other health concerns.    When I entered the exam room, I was not expecting this case: Reeba weighed about 4 lbs, was emaciated, very weak, and icteric (a yellow tint to the skin).

I started to ask questions to figure out the real story with Reeba; her appearance suggested a very chronic, long term illness that the client did not seem to recognize.  The client reported that her kitty was totally normal prior to this wound, did not go outside, and was not any medications.  I asked specifically what Reeba had been eating and commented on her emaciated figure.  The client paused for a minute ....  and finally admited that maybe Reeba hadn't been eating well for a few weeks.  The client had been out of town for 2 weeks, and she thought maybe the other cat in the household ate ALL the food.

Me: "Are you sure it's only been a few weeks?  She's extremely thin.  Do you know how much weighed before she started to look thin?"

Client: "About 16 pounds.  She was obese and my vet told me to help her to lose weight at her last checkup."

Me: "When was that, specifically? Did you have her seen by your veterinarian, so perhaps you have an exam date or some records? A few weeks seems like too short of a time to lose 75% of her mass."

The client shuffled through her paperwork, and found the exam dated THREE MONTHS prior.   Reeba's mom reflected on the history, and realized maybe it had been more like 2-3 months that her appetite had seemed poor.   While the client was out of town, Reeba had eaten NOTHING.  The client returned home about a week ago, and started syringe feeding Reeba several days ago.  The wound happened today, accidentally, when she tried to hold on to Reeba for a feeding.

Regardless of the initial cause of Reeba's illness, at this point, she was likely suffering from hepatic lipidosis, or accumulation of fat into the liver during starvation. Very simply stated, hepatic lipidosis causes kitties who were already sick to have a worsened appetite, causes nausea, and also results in liver dysfunction and icterus, as in Reeba's case.  She was a very sick cat, and having lost nearly 75% of her body weight, required intensive care and diagnostics.

The client authorized bloodwork and hospitalization, which provided further evidence for severe liver dysfunction.  Over the next 5 days, Reeba stayed in the hospital for rehydration, placement of a feeding tube, and careful monitoring.  Reeba suffered from multiple complications of starvation, including re-feeding syndrome and skin fragility syndrome.  Re-feeding syndrome is a potential consequence of eating after long periods of starvation.  Reinitiating normal nutrition results in massive electrolyte changes, which can be life threatening and severe, including hypophosphatemia, hypokalemia, and hypomagnesemia resulting in weakeness, cardiac arrythmias, destruction of red blood cells, or death.

Unfortunately, due to Reeba's starved condition, she also suffered from acquired skin fragility syndrome -- which caused the initial wound and the original presenting complaint.  Her skin tore with normal activity, resulting in wounds over large portions of her body.  Despite careful handling, Reeba acquired new open wounds almost daily.

Reeba was discharged after about a week from our hospital, and over the following month, continued to suffer from complications related to her starvation.  Eventually we lost contact with Reeba's owner.  I hope Reeba had a full recovery, but I believe it is more likely that she eventually succumbed to her illness.

All of this could have been avoided if the owner had not waited THREE months to see a veterinarian about her cat's lack of appetite.  I still can't grasp what she was thinking -- watching each day, as her cat skipped meal after meal and lost every ounce of muscle on her body.   Imagine an average, physically fit, six-foot adult male going from 180lbs to 72 lbs over several months, and not consulting a physician.   To this day, I still just don't understand if she wasn't smart enough, was in denial, was concerned about finding out bad news, or.... ?????  It's beyond my comprehension.

Friday, March 18, 2011

Did anyone see the train that hit me?

Sometimes, it's just chaos.  This morning, I am exhausted, have a pounding headache, and feel like I got hit by a train.  Honestly, I had some great cases and it was worth it. (Sorry folks, this post is a long one)

I arrived to the ER last night with four patients waiting to be seen because one trauma case had been taking precedence - as with any ER, the most critical patients are seen first.

The victim was a 2 year old golden retriever mix named Cashew who was hit by a car earlier in the day.  His family did not bring him in immediately (I never understand why YOUR DOG GOT HIT BY A CAR is not an emergency, but c' la vie), they actually decided to come in because he had been vomiting blood for the last hour.

Vehicular trauma cases can vary immensely; some are killed instantly.  Other cases don't even have a scratch on them -- and everything in between. Fortunately for this guy, he was on the side of not-so-bad.  Chest radiographs were performed and revealed a mild pneumothorax; mild contusions were also evident.  He continued to vomit blood, and when asked, the owners were unsure if there was any rat-bait on the property.  Cashew appeared very stable, and had a great chance to have a full recovery and go back to his family within 24-48 hours.  Unfortunately, due to the nature of car-trauma, Cashew also had the potential to worsen over the next day and require oxygen or other treatments.

His family dug in their heels.  We presented them with several different estimates for care; starting with the ideal plan, and going all the way down to nothing additional to what they had already spent.  They wanted to euthanize Cashew, and they told me having the potential for a sick dog was "too stressful."  They'd rather euthanize.

The technician told me of the family's decision.  Typically, I do not question an owner's wishes for euthanasia, however, this case was different.  Cashew was bouncing in his kennel, barking, bright and happy, wagging his tail.  I couldn't stomach putting him to sleep.  It seemed as if his family just no longer wanted him, and therefore, the only solution was to find him a new home.  We offered to take ownership of Cashew, and if he continued to do well, to find him a forever home.  His family hugged me, thanked me, and had tears in their eyes as they signed the paperwork and left him with us forever.  Although they didn't want Cashew any more, the silver lining is that I was able to offer them a great chance at a long healthy life with a new family. (Update; Cashew is doing amazing!)

At the same time, I had a patient who presented with vomiting and lethargy.  Xrays were performed and revealed a massive amount of foreign material.  After additional views and introducing some air into the patient's colon, the foreign material was confirmed to be within the large intestine -- and had a high likelihood of making it all the way out without surgery.   She went home the next morning after defecating out the foreign material -- we still don't know what it was.

Various other outpatients later, and fast-forward to 4am.  Two clients arrived at once; a cat who was vomiting, and a dog in labor.

The vomiting kitty was relatively stable, however dehydrated, cold, and nauseated.  Her owner (Tim) was friendly, however extremely difficult.  I took a look at the kitty, assessed her as ill, but stable, and stepped in to talk to the dystocia's family (a more urgent condition).

The pregnant female, TJ was in active labor.  She was brought in by pet-sitters, who had been watching her all night. They had been calling our hospital for about 6 hours, completely clueless about what to watch for during whelping.  A puppy had been stuck in the birth canal for about 4 hours before they finally brought her in for examination (FYI; a puppy stuck in the birth canal for > 10 minutes is an EMERGENCY).   They had initially refused to pay the exam fee to have her seen.

While in the exam room speaking with TJ's agents, the owner of the cat starting ringing the bell at the front desk.  OVER. and OVER. and OVER.  She had seen the pregnant dog in the lobby, had exchanged some pleasantries with the other family, and knew what was going on.  She had talked my assistant and knew that we were dealing with a situation, and that there was just the two of us in the building at this hour. My assistant was collecting vitals and monitoring TJ and unable to come to the lobby.  Tim's cat was in the back with my assistant as well, and very stable. I opened the exam room door and asked Tim if I could help him with anything.

Tim: ".....Is there another vet here?"

Me:  "No, I'm sorry.  It's 4am.  I am the only veterinarian in the building, and I have to evaluate the most critical situation first.  I've looked at your kitty and she is sick, but stable.  I'll be with you as soon as I can."

Tim: *HUGE SIGH*. "Fine.  How long do I have to wait? This isn't fair."

Me:  "I'm really sorry, but I am required to see the most critical, life threatening emergencies first.  We'll be with you as soon as we can.  I know it's very late in the night and I'm sure you are tired."

Tim was visibly irritated, but I had to return to TJ.

TJ was a sweet staffordshire mix, and was straining and straining trying to deliver her puppies.  She had been in labor for about 6-7 hours and was becoming tired.  Ultrasound confirmed that the 2 remaining live fetuses were in distress with low heart rates; the puppy in the canal was dead and unable to pass vaginally.  A c-section was recommended, and fortunately TJs family allowed her to go to surgery.

While paperwork and getting TJ started on fluids, I returned my attention to Tim's cat.  I offered outpatient therapy or hospitalization, and Tim did not seem to be able to follow a linear conversation. Example:

Me: "I can offer you some testing and hospitalization to try to figure out what's making your kitty sick, or we can just do outpatient therapy, including SQ fluids (explaining that this will help her restore hydration) and anti-nausea medications and you can see your veterinarian when they open in 3 hours."

Tim: "I want her to get nausea medication."

Repeat the above 6 times, while trying to move things along to save TJ's puppies.... the clock is ticking and each second counts....

Finally, Me: "Tim, do you understand what I am telling you?

Tim: "I want her to get nausea medication."

Me: "That's exactly what I just said.  She'll get that.  I need to know if you want her to stay here, with us, or go home with you and see your vet.  Your kitty is very sick and really needs some testing.  You need to make a decision so we can try to make her feel better. "

Tim: "She can't stay."  *some mumbling about something at the regular vet that was mostly incoherent*

FINALLY. We treated the kitty as an outpatient and away she went.  Her vet called me later that morning, so I know she was seen and receiving the additional care that she required.

  After a lot of hard work and a few tense moments, both live puppies were retrieved during a c-section, and after a few minutes of resuscitation by my assistant, I could hear them screaming like newborns.  There is nothing that can describe my joy of hearing that sound during a dystocia surgery. TJ recovered well from surgery and went home later that day.

Unfortunately, TJ will probably be in the same situation in the future as the owner refused to allow her to be spayed.  Overpopulation of pets is a larger-than-life problem in the US and around the world.  Of course, it's amazing to be able to provide TJ with relief from her long, difficult labor and to watch the first breaths of a newborn.  It's amazing to know that we saved three lives just in that single case.  As I've previously written, c-sections and delivering puppies is one of my very favorite emergencies.  In this situation, it's a bit bittersweet, however, knowing that there will be more and more unwanted puppies brought into the world.

Please, please spay and neuter your pets (shout out to Bob Barker!).  There's hundreds and thousands of unwanted pets living in shelters, humane societies, and rescues around the country who need homes.

Tuesday, March 15, 2011

Doc, my wolf-mix is sick....

I'm not sure why there is a small population of people who want to believe they own "wolf" hybrids; especially because the majority of them are actually just husky mixes, and not "WOLVES." Wolves are wild animals - and do NOT make for good house pets!  Would these people want a lion mix or a bobcat mix in their house?  NO!  

Below is a word for word copy of a handout given to a client (and then eventually to us, when the dog was sick) who adopted a "wolf" from a breeder. This is not made up -- I don't think I could make it this good.  It's not my bad grammar, incomplete sentences, and complete lack of understanding of biology and the natural world.

I have so many problems with the things written in this handout, starting with the fact that these dogs are NOT wolf hybrids, but that fact put aside, other important points to note: The breeder states that dogs are part of the feline family (the same as lions, tigers and BEARS), have 1 inch thick skin, that they cannot catch parvovirus, and while they must drink filtered water, they also must eat their food on dirt.  They tell their adopting owners to give their dogs CAT vaccines.  I also like the part where it states that "cannot digest fruits and vegetables; can rake the colon and make them bleed."  WHAT???!!!!



Here are some helpful tips when one of our clients brings in their wolves for check ups or with problems: 

They have a very high metabolism. 
Parvo shots could kill them or make them ill. 
Wolves are prone to have diarrhea because of their metabolism. 
Can be caused by drinking too much water or not getting filtered water (as we always recommend) 
Too much moisture in their system. Wolves absorb moisture through their skin. 
Too much food, they should be eating one time per day. 
Eating the wrong types of food. They need a high protein diet, 27% or higher. Should not be eating any fruits or vegetables, can not digest them, it make rake the colon and make them bleed. 
Require dirt in their diet. This comes from years of eating a kill that gets dirty on the ground. It makes their stool solid. Food should be fed on the ground or a small amount of dirt/pebbles added to it. 

They do not get parvo or heartworm. 
Diarrhea is more than likely caused by the above mentioned items. 

No flea products. These products are made for hair not fur. It can burn the fur and cause their skin to be irritated. 

They are from the feline family, non the canine as taught. This is why they have a high metabolism. the same as lions, bears and tigers.    So no dog shots, feline shots only. 

The skin is about 1 inch thick and so a mosquito can not lay larva under the skin so they do not get heartworm. Because of this they also do not get fleas or ticks because they can not penetrate it. Meds for heartworm could cause them to become sick. 
Because of their fur coats they tend to get hotter faster than dogs. They can easily get heat stroke so if it is hot outside they need a cool area they can get to. 

Please feel free to contact us with any questions. 


I'd like to contact them with some questions. WOW.  Where did these people become so backwards?  When did a wolf or dog with the genus Canis become a FELINE?  It's so incredibly unbelievable; I'm just not sure how any person can trust a "breeder" who writes something like the above.  

Monday, March 14, 2011

The customer is NOT always right

One evening, at about 2 am, an older gentleman arrived with his geriatric cat, "Nutty" who was having open mouth breathing.  His request, however was not for treatment, and his complaint was not to address the respiratory difficulty; he wanted us to bathe his cat.  He refused to let my staff get vital signs on his cat, refused to let them take the cat to be seen immediately by me, and refused to let us provide the cat with oxygen.  I let my staff know that we would not be bathing his cat under any circumstance; any stress in a dyspneic patient can result in death, in addition to the fact that we are not a grooming service and do not provide outpatient baths.  The client became very angry and started yelling at my assistants to bathe his cat, and continued to refuse an exam by a doctor (me), or any treatments.  The client was nearly asked to leave due to his inappropriate behavior and aggression.

He had been a previous client of our hospital and I quickly read through his chart.  The more I read, the more incredulous I became; his cat had 1) a brain tumor, diagnosed with a CT scan, 2) nasal cancer 3) a liver tumor 4) mammary cancer, 5)spread of cancer to the lungs, and 6) kidney failure.  Nutty had not eaten in weeks, and had been failing multiple chemotherapy protocols.  Nutty was clearly suffering, and unfortunately due to grief or mental dysfunction, the client could not recognize this.

I went in to speak with the client; and was even more appalled at what I saw; Nutty was gasping for air,  too weak to even lift her head, was critically dehydrated, had crusted food on her face (her owner had been trying to syringe feed her but she would not swallow the food), she was emaciated, and had a low body temperature. She had no teeth, and a nasal tumor was occluding the left nostril. Due to her severe weakness and lethargy, she had been urinating and defecating on herself, and was covered in urine and feces. I begged with the client to allow me to provide her some relief with oxygen, and he finally gave in.  I offered to clean the urine and feces from her coat with a waterless shampoo, and the client refused, stating that he did not want any sort of chemicals placed on her.  We removed as much as possible with a wet washcloth; feces and urine on the skin for extended periods can result in fecal or urine scald and a skin infection.

Mr. client and I spoke for about 15 minutes; I tried to explain to him that she was suffering, starving herself, and at risk of dying, with or without any therapy.  I tried to convey my empathy for his situation, and I could see how much he loved her, but at this point, there was literally nothing that could be done to fix her.  I talked to him about her prognosis (grave), that even one type of cancer is a difficult prognosis, and his kitty had at least 5 types of cancer.  She had already tried chemotherapy and failed to improve.  She had been sick for weeks; declining each and every day. When I mentioned humane euthanasia, the client became IRATE.  How dare I even bring up this subject?  He would absolutely NOT consider euthanasia, under any circumstances.

The client did not allow any testing or treatments that night except for providing Nutty with oxygen.  He came in the morning and picked her up; she had really little improvement in her status.  He refused pain medications.  She died sometime that week, at home, after struggling to breathe and starving for an untold amount of time.  I can't imagine a worse way to feel.

Even more unbelievable -- after the ER visit, the client called the clinic every day for a week to complain about me.  He told anyone who would listen that I was "hostile" and each time, went on and on about how angry he was that I had mentioned euthanasia.

I still remember how sad I felt just looking at Nutty that evening.  Her image is burned in my memory forever.   Most of my patients never have to suffer through the bitter end like Nutty, because in veterinary medicine, unlike human medicine, euthanasia is a viable option.   I'd prefer to fix every pet forever, but obviously, death is a fact of life.

Crazy day!

This weekend was a first for me -- we had to call 911 for a client.

On a busy weekend shift, a client arrived with her pet who had been attacked by a larger dog.  Unfortunately, her cute little toy breed dog, "Teddy" was critically injured and had open sucking chest wounds on both sides of his body.  He was declining rapidly after arrival, and due to his severe injuries and the chance of recovery, the family elected to let him pass.

While grieving outside, the client disappeared from view of our window.  Her family knocked on the door frantically, and my assistant at the front counter dialed 911.  She was suffering a seizure, and had collapsed onto the sidewalk in front of our hospital.

Fortunately, the ambulance arrived within 2 minutes and her seizure resolved as they arrived.  The paramedics spoke with her, and she was not transported to the hospital.  It was a tense two minutes, knowing that none of us could provide any assistance to the one species I can't treat.

Saturday, March 12, 2011

Good day, good times

Today was one of those days where I really, really love my job.

The morning started out with a dog who ate a BUNCH of food last night; he was seen by the overnight doctor and they elected outpatient therapy.   Eating WAY more than your stomach can handle can just result in abdominal pain, but can cause more serious problems with the stomach lining or even shock-symptoms if the stomach is large enough.  Unfortunately for the dog, he was in the latter category; and he returned this morning with severe gastric dilation.  Due to his history of previous GDV surgery and a gastropexy, there was no risk of torsion, however his dilation was serious enough that I recommended decompression.  The owners allowed us to treat, without too much difficulty.

I anesthetized him, placed a secure tube in his trachea to protect his airway and continue the anesthesia, and then passed an orogastric tube.  We flushed his stomach with water and emptied it.  When he woke up, he was good as new and went home wagging his little tail by the end of the day.

I also saw a particularly courteous client who came in because he thought his cute little 10# maltese mix was painful.  The case wasn't interesting in the slightest, however the owner thanked everyone for their time, was patient, thanked us for being available on the weekend, and appreciated our concern and care.  He genuinely loved his dog and wanted to make sure to do the right thing.  That's my ideal type of client.  Thank goodness for people like him.

I also got a thank you card and cupcakes delivered to the hospital today from one of my previous patients, who I'll write about soon.  She had a severe condition ( a pyothorax) and is now back to normal, happy and healthy as can be! That story will come sometime soon --

Thank goodness for days like this -- I love my job!

Sunday, March 6, 2011

Try to save $3, spent hundreds to save your kitty

Last night, we received a phone call from a concerned owner.  Their cat, Princess, a 2 year old cat, was acting very bizarre; the owners were concerned that she was experiencing seizures.  She was indoor only, lived with two other cats, and had not been sick before.  The technician inquired as to if there was any medications or products that had been given or applied to Princess.  The family remembered that earlier that morning they had applied an over the counter flea product not recommended by their veterinarian.   My technician recommended that the come in immediately and bring the packaging from the applied product with them.

Upon arrival, Princess was experiencing generalized muscle twitching and tremors.  She was not seizing, as she was conscious, but was instead unable to control her muscle activity.  Her eyes blinked uncontrollably, her ears flicked, and her body twitched rhythmically.  I suspected flea product toxicity, and the packaging confirmed my suspicion; a permethin based over-the-counter product.  Permethrin products are an older generation of flea control; they are typically a few dollars cheaper than currently recommended and approved products.  Permethrin can have serious, even deadly, results when applied to cats.  Cats can also experience toxicity if products are applied to dogs in their household (especially if the cats and dogs sleep in the same locations, or spend a lot of time in contact with each other).

We bathed Princess to remove the offending product; we placed an intravenous catheter and started muscle-relaxant medication.  She improved, but the tremors did not resolve completely and she was hospitalized for monitoring.  Over the next 12 hours, her tremors were difficult to control and her owners considered euthanasia.  I asked them for permission to treat her with administration of intravenous lipids; a recent advance in human and veterinary medicine; this treatment has been life-saving in overdosages of certain medications and ingestion of toxins.  The owners reluctantly agreed, as their budget for her care was nearly gone.

I started the intravenous lipids; and within minutes, the results were amazing.  She was able to stand, her tremors nearly resolved, and she began to purr and beg for food.  As the infusion continued, she continued to resolve her symptoms.  Several hours later, she was normal.

Her ecstatic family came and took her home that evening.  She's never looked back!  I'm sure that Princess will enjoy many more years with her people and they'll never apply a cheap product -- this time, trying to save a few dollars actually cost them hundreds, and almost killed their kitty.

This case highlights the importance of talking to your veterinarian before giving ANY medications or applying any sort of product to your pet.  Just because a pet-store employee or your friend tells you a product is okay to use does not mean that they know what they are talking about.  "Natural" does not mean that the product is non-toxic (for example, several types of lilies, an all "natural" flowering plant, are fatal to cats if any portion of the plant is ingested.  There are hundreds of other examples of so-called natural products that are toxic, or even fatal to humans and animals). Veterinary approved flea products have been proven safe in clinical studies, have a track record of effective prevention and treatment of pests, and furthermore, have very, very little risk of adverse reaction.  In my opinion, products which contain permethrins should never be used on cats, or even in households that contain cats.


Nice dog, nice family.... bad disease.

10 year old labrador patient, "Theo," arrives with a history of vomiting.  He's been previously in good health, but the last 2-3 days he had been lethargic, less willing to walk around, not interested in eating, and every time he tries to drink, he vomites shortly afterwards. 

On physical exam, Theo was very depressed, dehydrated, and appeared nauseated.  His bladder felt small on palpation of his abdomen, and otherwise, his physical was unremarkable.  Being an ill geriatric large breed dog, I recommended some in-house blood testing to rule in or out serious illness.  Unfortunately, we were just about to find out how serious of an illness he indeed had been hiding.

Theo's kidney values were sky-high.  His potassium was elevated.  His ionized calcium off the charts.  All signs pointing to severe kidney failure, severe enough to be decreasing the amount of urine being produced by Theo's kidneys.  

Theo's loving family and I discussed the lab findings; discussed the potential causes of his symptoms.  I considered the following diagnoses; cancer (lymphoma most likely, but many other types also possible), acute kidney failure from a toxin (many plants, human drugs, and poisons can be directly toxic to the kidneys), a severe kidney infection, or less likely hypertension, or kidney stones.

Theo's family wished to start treatment, and continue the search for the original cause of his symptoms, even with the knowledge that his disease may have a poor prognosis.  A urinary catheter was placed to monitor his urine output.  He was started on IV fluids, to improve his hydration and provide improved circulation to the kidneys.  Anti-emetics and anti-acid medications were started to relieve his nausea. After several hours and several liters of fluid, Theo failed to produce more than a few drops of urine.  

A diuretic medication was initiated in hopes of restoring urine production; a common saying in the treatment of  kidney failure is "where there's pee, there's hope."  Theo did start producing urine, and the diuretic treatment also brought his calcium down to a more normal level.  He stopped vomiting, but still didn't choose to eat.

After Theo's metabolic condition was stabilized, the owners and I discussed again his progress.  It was important to get to the bottom of his illness, to find the original culprit of the elevated calcium. 

The hunt for cancer was on.

Chest radiographs were performed initially as a screening tool for metastatic neoplasia.  To all of our suprise, a very large mass occupied >60% of Theo's chest.  Theo had no symptoms associated with difficulty breathing, coughing, and no abnormal breath sounds were present.  In dogs and cats, who can't tell us the details of how they're feeling, imaging often is a very important tool to look inside of their body cavities and find out what may be hiding underneath. This often includes chest radiographs (x-rays), abdominal ultrasound, and sometimes more advanced testing such as bone marrow aspirates, aspirates of abdominal organs, or imaging of the brain (CT scan or MRI).

Unfortunately for Theo, the whole picture was complete.  His tumor had caused an elevation in the blood levels of calcium, which in turn had caused his kidney failure and then his resulting symptoms; lethargy, vomiting, inappetence, and malaise.  His loving owners were grateful to know that they gave him every chance, that his diagnosis was certain, and they spent quality time with him before later that weekend, they helped Theo pass over the "rainbow bridge."

I can treat all species.... except for one.

I had a very sad situation that I was reminded of this evening.  Veterinarians often joke that we can treat all species except for one: humans.

A client brought her dog, Skittles, to our hospital for evaluation of vomiting, red/bloody urine, weakness, and decreased appetite for about 24 to 36 hours.  Skittles was relatively young, and had no prior health problems.  She did not have access to any known toxins, including rat bait.  

 Physical exam revealed a very icteric patient (also known as jaundice; a yellow tint to the skin and mucous membranes).  Her mucous membranes were also pale, dry, and her circulation poor.  Her limbs felt cool to the touch and her heart was racing.  Initial blood testing confirmed a severe anemia of 9% (you may remember that normal is somewhere between 30 and 45%). Blood analysis also revealed a severely elevated bilirubin; one of the breakdown products of red blood cells.  In this case, excessive amounts of bilirubin cause the skin to be tinted yellow.  (Similarly, local breakdown products of red blood cells cause the discoloration of bruises as they go through various phases of healing). The question to be answered -- where did the blood go?

Previous blog posts have discussed external hemorrhage,  as well as internal hemorrhage.  A third type of anemia was present in Skittles' case; hemolysis, or destruction of her red blood cells within her body.  Mechanisms of destruction of cells include abnormal immune system reaction against normal healthy tissue (also occurs in diseases such as Rheumatoid arthritis, multiple sclerosis, etc), blood parasites, tick borne disease, or cancer.  In Skittles' case, lab testing, her age, and the symptoms suggested that immune mediated hemolytic anemia was the most likely culprit.

I discussed this finding with her owner, "Sue".  We discussed the test and treatments necessary to stabilize Skittles and allow for a more sure diagnosis.  We discussed the associated prognosis - IMHA is treatable, but not all dogs make it through the initial crisis.  Skittles was in very critical condition, and I asked Sue if we could start treatment.  This is when things began to go very, very wrong.

Sue started a downward spiral of hysterically crying, being unable to speak, and threatening self-injury.  She started ingesting pills out several prescription bottles in her bag.  She told me that if her dog didn't live, she was afraid she would hurt herself.  She said again that if her dog didn't live, she had no reason to live.  I've seen hundreds, if not thousands, of very upset, emotionally wrecked people in the most difficult of situations.  99.5% of the time, they don't threaten suicide.

I tried to comfort Sue, and we talked more about her dog's care and her own well-being.  I spent what felt like several hours talking with her, discussing her own situation and Skittles' situation.  I tried to initiate treatment (most importantly, a blood transfusion) for Skittles several times, but unfortunately, it became clear that Sue was in need of emergent care herself and had no means to provide care for her beloved pet.

I asked Sue if I could call someone to come and help her.  She initially refused, but a short time later agreed that she did need help.  I called our local police station, who sent an officer to talk with Sue.  Apparently, she had been previously treated as an in-patient for several suicide attempts.  He took Sue to a crisis counselor, and I really do hope that she gets the help she needs.  I'm so glad I followed my instinct and took her threats seriously.  I'm not trained to diagnose or treat humans, and I certainly don't have any psychiatry education in my background -- but thankfully, this time, I may have helped avoid a crisis.

Friday, March 4, 2011

Don't you love animals?

Perhaps one of the most difficult aspects of my job is angry clients.  Clients arrive and are already defensive - for some reason they have it in their minds that we're only here for the money.  It's so far from the truth that it's insulting - for the same amount of time I spent in school and amount money I spent on my education, I could have five to ten times the salary if I had chosen human medicine, pharmacy, etc.  As we all know, money does not equal happiness, and I chose veterinary medicine over all those other more lucrative careers because it is my passion.

Of course, those facts make it even harder to have a client yell at me, "DON'T YOU EVEN LOVE PETS!?" or "YOU'RE JUST GOING TO LET MY LITTLE FLUFFY DIE??!!!" Often times, it's because they're grieving for the difficult loss (or illness) of their pet; many visits to the ER are unexpected, and as a result, families have not had time to cope.

The other common reason for an irate client is that they can't pay for the care their pet needs.  The majority of veterinary hospitals accross the country are small businesses, with a small operating budget and as a result, are unable to offer payment plans or extend credit to clients.   The costs associated with running a 24 hour facility result in higher costs to our patrons in comparison to daytime only general practice.  Humans are used to going into their M.D., paying a $20 copay, and having a bill sent later for whatever insurance doesn't cover.  People don't realize that their cost of treatment, before insurance and write-offs, is at a minimum, 5-10 times the cost of veterinary care.  Case and point: recently, a good friend of mine had a routine cesearean section without complications; her bill was $40,000 (not including the infant's care!).  An average c-section in an emergency veterinary facility, including care of the puppies, is going to cost between $1000-$2500 depending upon patient factors and local cost of living factors.  That's 16x less than a human's procedure!

Obviously, I do love pets, and so do my co-workers and collegues across the country (and world) who study and live to fix sick animals.  Unfortunately, our education was far from free, we have to pay our rent and utilities just like everyone else, and our support staff needs to be paid, too.  I know it's hard to be faced with an estimate for hundreds of dollars, especially in this economy.  I know it's even harder during an emotionally stressful time.  I want to help -- but I can't do it for free, or I wouldn't have a job, and our facility wouldn't be able to keep the lights on and the doors open for the next patient that needs our help.  Every case is different, and I always try to find the best plan for the patient's needs and the client's pocketbook, but it's not free.  I could go on and on, but I think you all get the point I'm trying to make.

My best recommendation for all of you to avoid this problem: AVOID pet insurance, instead, make a savings account for your pets.  Put in $10 or $20 dollars per month, whatever small amount you can afford.  Over time, you'll have your own "insurance," and you'll be able to decide what YOU want to cover, instead of letting a company decide what and when they want to give you back.

Hold on, I've got to call my psychic first....

One very busy evening, a seemingly normal family came in to the ER for help with their geriatric lab mix, Teddy.  He was about 13 years old, had lost weight over the last several months, unable to stand, and had been vomiting for several days.  I could palpate a suspicious mass in his abdomen.  He hadn't eaten normally in weeks. He had a long history of osteoarthritis, and his joints were stiff and painful despite daily pain medications. I talked to the family, and they noted a change in his demeanor over the last few days as he had become more and more weak and ill. 

After discussing my physical exam findings, options, and tests to determine the underlying cause(s), the options for treatment, and thinking about her quality of life and age, they elected to consider euthanasia.   I was surprised when they told me that they would have to get in touch with their animal communicator/pet psychic before proceeding to make sure that Teddy was okay with the decision.

I was stunned for a few seconds.  I'd just spent > 30 minutes talking to them about the concrete, visible exam findings, medical conditions common to cause these findings, treatment options, and recommendations based on my 8 years of higher education as well as my years of hands-on experience and clinical judgement skills....but yet, they preferred to consult with an unlicensed, uneducated, unverifiable self-proclaimed "pet psychic" who would render her opnion over the phone and without being able to see or touch the pet.  I should have skipped veterinary school (and the associated debt!) and gone straight for the big $$!!  (Clearly, I'm kidding.  I could never do something that I consider so wholly unethical.)

I took a deep breath, and as kindly as I could muster, reiterated what we had already talked about.  Teddy's health was failing, he wasn't eating, he was dehydrated and weak, and our only options at this point were either perform basic testing and start treatment to help him feel better, or allow relief of suffering.  Doing neither of these things was not a favorable option, in my opinion, despite what the pet-psychic may think.

Fortunately for Teddy, his family could not get ahold of their "psychic" and weren't able to ignore his current situation.  He passed peacefully, with his loving family surrounding him.

Thursday, March 3, 2011

Wrong time for alternative medicine.

Recently, I had a patient come in with a hemoabdomen, or free blood in the belly.  In veterinary medicine, this is typically the result of a bleeding tumor (malignant or benign), trauma, or ingestion of rat bait.  Other causes definitely exist, but are not the point of this post, and so I'm going to leave them out.  Unfortunately for this patient, there was no history of trauma and no possible exposure to rat bait.

At arrival, my patient was unable to stand, tachycardic, had pale gums, and a visibly distended abdomen.  Classic findings for a hemoabdomen.  Classic findings for hemorrhagic shock and a very unstable patient requiring aggressive intervention, otherwise death is soon to follow.

The even more unfortunate thing is that the owner came with records from her regular clinic from several hours prior to her arrival here. They diagnosed the hemoabdomen (imaging was performed, followed by removing a small amount of fluid with a needle, or an abdominocentesis), diagnosed a developing anemia (low red blood cell count, secondary to blood loss), and then, for me, they did the unthinkable.  They sent the patient home with an herbal medication.  An actively bleeding patient. Home.  The plan was to pursue surgery the following day if the bleeding did not stop.  Anyone with any medical training will realize how crazy this is, and those of you who are not hopefully will realize that this is not a typical recommendation.

I don't even know what to say.  I'm frustrated.  Bleeding is one of the most emergent emergencies.  Bleeding of this sort of severity doesn't stop without treatment.  There's definitely a place for alternative medicine, chiropractic, accupuncture, herbs, supplements.... but it's hard for me to understand its use in this situation.