Sunday, March 6, 2011

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.

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