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.

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