Tuesday, April 26, 2011
I'm still here!
I haven't posted in 12 days-- thankfully, because i enjoyed a week of vacation. I'm about to start up on the work week. Stay tuned for new stories -- and some great saves!
Monday, April 18, 2011
?????
I'm not sure why I'm still surprised at people's actions -- but I still am. I've been doing this a long time, and I've seen some unbelievable situations, but people like the one I'm about to describe just don't make sense.
This post isn't about the case, it's about the human interaction.
Clients arrive with their cat, who needs a blood transfusion. They had been referred by their primary veterinarian (about 50 miles away) for continued treatment of a surgical complication which had resulted in hemorrhage. The kitty was extremely critical with a PCV of 10% (prior to surgery it had been >40%), and the kitty was very weak, with white mucous membranes and a slowing heart rate.
At the front desk, the receptionist asked them to fill out the standard paperwork with their name, phone number, etc, as well as the pet's name, name of their primary veterinarian and the typical box which asks for a basic medical history, including if the pet is spayed/neutered, and if they are vaccinated. The client left these both blank.
Receptionist, doing her job in getting paperwork handled, stepped into the client's exam room (while the patient was being evaluated and treatments initiated), to ask about the status of vaccine history. The client became belligerent.
"HOW DARE YOU EVEN ASK ME THAT!" The client screamed at my staff member. "YOU F**ING ALREADY HAVE THIS INFORMATION!"
The receptionist, somehow, managed to keep her cool and told the client 1) not to speak to her in that tone and 2) that she has no knowledge of his pet's history, as she is not a veterinarian. While she realizes the doctors (myself and the referring DVM) have spoken to each other about his kitty, it is her job to make sure that the paperwork is completed. She was making no assumptions or judgements about the vaccine status of his cat, and just wanted him to reply "yes, up to date" or "no, out of date." The client backed off, for now.
I entered the room to discuss a treatment plan for his kitty, and the subsequent estimate, including 24 hours of hospitalization, blood typing, a blood transfusion, rechecking the PCV, and other supportive measures. The client then again became irate. He accused me of inflating prices to steal money from my clients, he claimed that "no other" facilities charges would even be a 1/3 of our charges, and that he just KNEW we were "screwing" him. I tried to explain to him that "no other" facilities in our area have staff (veterinarians and technicians) in the hospital overnight, no other facilities stock blood for transfusions, and his regular facility did not feel that the care of his kitty was within their abilities.
"I AM AN EMT!" He screamed at me -- "and I KNOW what these things cost. You can buy that blood for $2! and you're charging me $300 for it!" (This is obviously not true -- blood costs quite a bit more than $2 to purchase, it expires frequently and we have to stock it even if we don't use it, and the cost of the transfusion also has to include administration, transfusion monitoring, staff time, plus some small amount of the fixed costs of keeping a hospital open 24 hours a day, including electricity, phone bill, water, tech wages, equipment, etc)
I was baffled. If he actually was an emergency medical technician, then he should understand the costs of health care more than an average person ! He should realize that if this was his kid, and not his cat, the bill would be about 10 times higher than what I was presenting to him. Regardless of this, he continued to insult me, my hospital, my staff, and anyone who crossed his path. He continued to use abusive, aggressive, accusatory language, even stating that everyone in the community KNEW that we were only out for money, and that he hoped we went out of business. (I have quite a few "Thank you for saving my pet!" cards that I'd like to show him...)
The only option at this point was to reduce the estimate, and the only way to achieve this was by reducing the level of care to be provided to his cat (including returning the cat to the RDVM in the morning, and eliminating some helpful testing due to his unwillingness to let us perform them). He accepted this lower version, however had plenty more to say --
Client: "So I'm not really comfortable what happens next. I don't trust you guys. What are you going to actually DO to my cat?"
Me: "We're going to start with a blood transfusion, oxygen, etc.........<i carefully explained the treatment plan for the fourth time>"
Client: "So what if she doesn't use the whole unit of blood? Will you just give it to her anyway? And what if she needs more blood or continues bleeding?"
I explained that we typically start with a "dose" of blood, and can give more from the same unit (without additional charges) if needed, however, blood once opened, must be discarded within a certain amount of time due to risk of contamination. Additional transfusions (at additional cost) may or may not be necessary depending on the cause of hemorrhage, as well as other treatments/procedures/surgery/etc. He accused me of having a "monopoly" on blood in the area.
My colleague, arriving to the hospital to start her shift, had been listening to the majority of his tirade. Fed up, she stepped in. "Actually sir, it's impossible to have a monopoly on blood. Any veterinarian with a cat, a needle, and a syringe has access to blood. They can collect blood from a healthy cat and give it to a sick one if they wish. It's something that we actually do here from time to time if we are out of stored blood, and if you don't wish to treat your cat at our facility, you are welcome to leave, against medical advice. We're just trying to treat your cat, and I wish you could understand that we're not out to get you."
The clients left, and so did I. The cat stayed to receive the transfusions, and hopefully, the cat does well.
I don't understand why a small portion of the population is like this. It still surprises me every time just how awful some humans can be. Why does he think we want to harm him or his pet? How are we supposed to take care of pets without paying for the costs? Why does he expect us to come to work every day and not receive payment for our knowledge, skills, and services? How are we supposed to pay for our education, our equipment, or our employees? I try to express these things, politely, in situations like this one.... but usually, I get nowhere. I just don't get it.
This post isn't about the case, it's about the human interaction.
Clients arrive with their cat, who needs a blood transfusion. They had been referred by their primary veterinarian (about 50 miles away) for continued treatment of a surgical complication which had resulted in hemorrhage. The kitty was extremely critical with a PCV of 10% (prior to surgery it had been >40%), and the kitty was very weak, with white mucous membranes and a slowing heart rate.
At the front desk, the receptionist asked them to fill out the standard paperwork with their name, phone number, etc, as well as the pet's name, name of their primary veterinarian and the typical box which asks for a basic medical history, including if the pet is spayed/neutered, and if they are vaccinated. The client left these both blank.
Receptionist, doing her job in getting paperwork handled, stepped into the client's exam room (while the patient was being evaluated and treatments initiated), to ask about the status of vaccine history. The client became belligerent.
"HOW DARE YOU EVEN ASK ME THAT!" The client screamed at my staff member. "YOU F**ING ALREADY HAVE THIS INFORMATION!"
The receptionist, somehow, managed to keep her cool and told the client 1) not to speak to her in that tone and 2) that she has no knowledge of his pet's history, as she is not a veterinarian. While she realizes the doctors (myself and the referring DVM) have spoken to each other about his kitty, it is her job to make sure that the paperwork is completed. She was making no assumptions or judgements about the vaccine status of his cat, and just wanted him to reply "yes, up to date" or "no, out of date." The client backed off, for now.
I entered the room to discuss a treatment plan for his kitty, and the subsequent estimate, including 24 hours of hospitalization, blood typing, a blood transfusion, rechecking the PCV, and other supportive measures. The client then again became irate. He accused me of inflating prices to steal money from my clients, he claimed that "no other" facilities charges would even be a 1/3 of our charges, and that he just KNEW we were "screwing" him. I tried to explain to him that "no other" facilities in our area have staff (veterinarians and technicians) in the hospital overnight, no other facilities stock blood for transfusions, and his regular facility did not feel that the care of his kitty was within their abilities.
"I AM AN EMT!" He screamed at me -- "and I KNOW what these things cost. You can buy that blood for $2! and you're charging me $300 for it!" (This is obviously not true -- blood costs quite a bit more than $2 to purchase, it expires frequently and we have to stock it even if we don't use it, and the cost of the transfusion also has to include administration, transfusion monitoring, staff time, plus some small amount of the fixed costs of keeping a hospital open 24 hours a day, including electricity, phone bill, water, tech wages, equipment, etc)
I was baffled. If he actually was an emergency medical technician, then he should understand the costs of health care more than an average person ! He should realize that if this was his kid, and not his cat, the bill would be about 10 times higher than what I was presenting to him. Regardless of this, he continued to insult me, my hospital, my staff, and anyone who crossed his path. He continued to use abusive, aggressive, accusatory language, even stating that everyone in the community KNEW that we were only out for money, and that he hoped we went out of business. (I have quite a few "Thank you for saving my pet!" cards that I'd like to show him...)
The only option at this point was to reduce the estimate, and the only way to achieve this was by reducing the level of care to be provided to his cat (including returning the cat to the RDVM in the morning, and eliminating some helpful testing due to his unwillingness to let us perform them). He accepted this lower version, however had plenty more to say --
Client: "So I'm not really comfortable what happens next. I don't trust you guys. What are you going to actually DO to my cat?"
Me: "We're going to start with a blood transfusion, oxygen, etc.........<i carefully explained the treatment plan for the fourth time>"
Client: "So what if she doesn't use the whole unit of blood? Will you just give it to her anyway? And what if she needs more blood or continues bleeding?"
I explained that we typically start with a "dose" of blood, and can give more from the same unit (without additional charges) if needed, however, blood once opened, must be discarded within a certain amount of time due to risk of contamination. Additional transfusions (at additional cost) may or may not be necessary depending on the cause of hemorrhage, as well as other treatments/procedures/surgery/etc. He accused me of having a "monopoly" on blood in the area.
My colleague, arriving to the hospital to start her shift, had been listening to the majority of his tirade. Fed up, she stepped in. "Actually sir, it's impossible to have a monopoly on blood. Any veterinarian with a cat, a needle, and a syringe has access to blood. They can collect blood from a healthy cat and give it to a sick one if they wish. It's something that we actually do here from time to time if we are out of stored blood, and if you don't wish to treat your cat at our facility, you are welcome to leave, against medical advice. We're just trying to treat your cat, and I wish you could understand that we're not out to get you."
The clients left, and so did I. The cat stayed to receive the transfusions, and hopefully, the cat does well.
I don't understand why a small portion of the population is like this. It still surprises me every time just how awful some humans can be. Why does he think we want to harm him or his pet? How are we supposed to take care of pets without paying for the costs? Why does he expect us to come to work every day and not receive payment for our knowledge, skills, and services? How are we supposed to pay for our education, our equipment, or our employees? I try to express these things, politely, in situations like this one.... but usually, I get nowhere. I just don't get it.
Monday, April 11, 2011
Out of state callers
I'm not sure why, but our clinic receives a fairly high volume of calls from out of our state, and even across the country. Somehow, many of the people don't realize they're calling out of state until we try to give them directions to bring their pet in, and they don't recognize the streets, town, or highways. They usually apologize and we direct them to find a clinic in their area.
This one was a little bit different, as I'm fairly sure this caller did it on purpose:
-----
Caller: "Hi, I have a question -- my dog is not eating for the last 3 days, and I need to know what to do."
Technician: "Well, the best recommendation would be to have him seen by a veterinarian. Do you know where we're located? We're open 24 hours a day and would be happy to evaluate your dog for you."
Caller: "Oh, no I can't come in there, I'm in <a state 1500 miles away> and there's no emergency vet clinics in the entire state. You must tell me what medications I can give at home."
Technician "I'm fairly sure there's an ER somewhere in the state -- what town are you in?"
Caller <Name of town>
My technician quickly googles the town, and finds 2 ER clinics within a short distance. She notifies the caller, who was angry, and quickly ended the call.
----
This one was a little bit different, as I'm fairly sure this caller did it on purpose:
-----
Caller: "Hi, I have a question -- my dog is not eating for the last 3 days, and I need to know what to do."
Technician: "Well, the best recommendation would be to have him seen by a veterinarian. Do you know where we're located? We're open 24 hours a day and would be happy to evaluate your dog for you."
Caller: "Oh, no I can't come in there, I'm in <a state 1500 miles away> and there's no emergency vet clinics in the entire state. You must tell me what medications I can give at home."
Technician "I'm fairly sure there's an ER somewhere in the state -- what town are you in?"
Caller <Name of town>
My technician quickly googles the town, and finds 2 ER clinics within a short distance. She notifies the caller, who was angry, and quickly ended the call.
----
Thursday, April 7, 2011
A little comic (and sometimes slightly disturbing) relief
Some phone calls we receive are almost unbelievable. Trust me, I couldn't make this stuff up.
------
---
Caller: "Can I give anything at home to kill my cat? I don't want to drive all the way in to your clinic."
Technician: "I REALLY wouldn't recommend that -- it's not humane. If your kitty is sick, bring him/her in and we'll help you decide what's best."
Caller: "Can't I just overdose him on something?"
Technician: "Absolutely not."
----
Caller: "I just found a (wild) snake in my driveway. Should I run over it with my car to put it out of its misery?"
Technician: "Is it injured?"
Caller: "No, but I think it's suffering."
Technician: "I really wouldn't recommend that -- if you think the snake is suffering, bring it in and we can evaluate it. Typically, it's best to let wild animals be, however, if it's injured and you're concerned, bring it in and we can either treat or euthanize."
Caller hung up, and called us back 4 minutes later to berate the technician for "making her feel bad."
----
Caller: "Hi, my cat has the swine flu and I need some medications, but I can't afford to pay anything."
Technician: "Unfortunately, we don't do payment plans, but we can offer Care Credit... what exactly is your kitty doing?
Caller: "HOW CAN YOU NOT HELP ME!!??? WHERE DOES MY TAX MONEY GO?!?!"
Technician: "I'm sorry, sir, but we aren't government funded and receive zero tax dollars, just like the grocery store -- we're a private business. There's no public funding for pet health care. We would like to help your kitty, so if you come by, we can provide a triage exam and go from there. We'll do our best to find an affordable plan for you.
Caller: "That's BULLSHIT and you know it. You steal my tax money. Don't lie to me" *Hangs up*
-----
Caller: "My vet gave me some medication in syringes. You know, the type of medicine in syringes."
Technician: "Okay, so what is your question?"
Caller: "What should I do with it? It's the kind in syringes."
Technician: "Does it have a name of the medication on the label?"
Caller: "Well, it says my pet's name, and my name, and my phone number, and my doctor's name...."
Technician: "Ma'am, I need the name of the drug or there's no way I can help you. There are hundreds of medications that could be in a syringe, and guessing is not safe."
----
Caller: " I need directions to your location RIGHT NOW!"
Technician: "Okay, where are you coming from?"
Caller: "I don't know, I'm south of something."
Technician: "South of what city? South of what town? What highway are you on?"
Caller: " I have no idea, and also my car is broken down, so I need someone to come get me.... My dog is acting really weird."
Technician: "I'd really like to help you, but if you don't know where you are, I can't give you directions, and if you don't know where you are, how is someone going to pick you up ?? Our clinic is in <town name>, and if you figure out where you are, please call us back."
------
Caller (slurring speech): "Uhmm Hiiiiiiiiii......... uhmm. my dawwwg uhmm.. well she just you know... uhh... mmm ... I mean, uh.. what's gunna happen?
Technician: "You're going to have to give me a bit more detail -- what is your question?"
Caller: "Ok... (long pause, some snickering).... what's gunna happen if she ...(snickering) with a boy dog?
Technician: "Are you asking me what happens if she is bred by a male dog?"
Caller: ".... Yes."
Technician: "I'm pretty sure you know the answer to that question -- if they're both intact, then she may get pregnant."
Caller: "Really?"
---
Caller: "Can I give anything at home to kill my cat? I don't want to drive all the way in to your clinic."
Technician: "I REALLY wouldn't recommend that -- it's not humane. If your kitty is sick, bring him/her in and we'll help you decide what's best."
Caller: "Can't I just overdose him on something?"
Technician: "Absolutely not."
----
Caller: "I just found a (wild) snake in my driveway. Should I run over it with my car to put it out of its misery?"
Technician: "Is it injured?"
Caller: "No, but I think it's suffering."
Technician: "I really wouldn't recommend that -- if you think the snake is suffering, bring it in and we can evaluate it. Typically, it's best to let wild animals be, however, if it's injured and you're concerned, bring it in and we can either treat or euthanize."
Caller hung up, and called us back 4 minutes later to berate the technician for "making her feel bad."
----
Caller: "Hi, my cat has the swine flu and I need some medications, but I can't afford to pay anything."
Technician: "Unfortunately, we don't do payment plans, but we can offer Care Credit... what exactly is your kitty doing?
Caller: "HOW CAN YOU NOT HELP ME!!??? WHERE DOES MY TAX MONEY GO?!?!"
Technician: "I'm sorry, sir, but we aren't government funded and receive zero tax dollars, just like the grocery store -- we're a private business. There's no public funding for pet health care. We would like to help your kitty, so if you come by, we can provide a triage exam and go from there. We'll do our best to find an affordable plan for you.
Caller: "That's BULLSHIT and you know it. You steal my tax money. Don't lie to me" *Hangs up*
-----
Caller: "My vet gave me some medication in syringes. You know, the type of medicine in syringes."
Technician: "Okay, so what is your question?"
Caller: "What should I do with it? It's the kind in syringes."
Technician: "Does it have a name of the medication on the label?"
Caller: "Well, it says my pet's name, and my name, and my phone number, and my doctor's name...."
Technician: "Ma'am, I need the name of the drug or there's no way I can help you. There are hundreds of medications that could be in a syringe, and guessing is not safe."
----
Caller: " I need directions to your location RIGHT NOW!"
Technician: "Okay, where are you coming from?"
Caller: "I don't know, I'm south of something."
Technician: "South of what city? South of what town? What highway are you on?"
Caller: " I have no idea, and also my car is broken down, so I need someone to come get me.... My dog is acting really weird."
Technician: "I'd really like to help you, but if you don't know where you are, I can't give you directions, and if you don't know where you are, how is someone going to pick you up ?? Our clinic is in <town name>, and if you figure out where you are, please call us back."
Wednesday, April 6, 2011
I forgot!
I forgot my last critical patient of the last night! (can you believe there's more?!)
In the early hours of the morning, two very nice clients brought in their 3 year old, male neutered indoor-only kitty for evaluation, "Joey". He was found sleeping in the litterbox, had vomited, and was very lethargic. The also noted that he was in the litterbox most of the day prior, and it looked like he was straining.
To anyone who is in the field, these are the classic signs for a kitty with a urinary obstruction, commonly referred to as a "blocked cat" or a "blocked tom". My physical exam confirmed the above; he had a large, distended, painful, non-expressible urinary bladder. More details are available here. The kidneys function to filter blood and excrete waste products from the body, in the form of urine. (It is interesting to note that some of the waste compounds excreted are so toxic that they are diluted with a large amount of water to reduce their direct toxicity, therefore resulting in the need for urine). Urethral obstruction is the blockage of the ability of urine to escape from the body. There are multiple different reasons for the blockage to occur, including urinary crystals, bladder stones, blood clots, mucous, narrowing of the urethra, cancerous masses, or urethral spasms. Regardless of the cause, obstruction of the outflow of urine results in build-up of toxic waste products, metabolic disturbances, and elevated potassium. As potassium climbs, arrythmhias, low heart rates, and even death can occur.
The severity of each blocked kitty depends heavily on how long they have been obstructed. The first sign of urinary obstruction should prompt an immediate exam by a veterinarian, in order to prevent the sequelae of remaining obstructed for extended periods of time.
Joey had a low heart rate (100), was hypothermic at 94 degrees, and very lethargic. An IV catheter was placed, bloodwork was initiated, he was provided with gentle heat support, pain medications, and fluids were started. An ECG was placed on him, which revealed changes consistent with hyperkalemia (elevated potassium). Blood results returned and confirmed a critically high potassium, severe elevations in his kidney values, and dehydration.
I counseled the owners on the best course of action. Joey had a good chance for recovery, but also was in a critical condition, and immediate treatment was the only way to provide him with the best possible outcome. We could not be sure if he would have permanent kidney damage, or if he would have a full recovery; the only way to find out was to proceed with treatment. His owners agreed to go forward with treatment.
Joey was given calcium gluconate to combat the effects of hyperkalemia, and I started the procedure of relieving his urinary obstruction. The procedure typically requires sedation or general anesthesia, however Joey was so incredibly sick that pain medications alone were enough. I quickly relieved his obstruction, and a urethral catheter was placed, which would remain for 24 hours.
Joey had a slow, steady recovery and was eating by the end of the day. We expect him to make a full recovery. Blocked cats are one of my favorite emergencies -- usually, we're able to take a cat who is hours away from death, and pull them back to normal, potentially giving them many more years of happy, healthy life.
In the early hours of the morning, two very nice clients brought in their 3 year old, male neutered indoor-only kitty for evaluation, "Joey". He was found sleeping in the litterbox, had vomited, and was very lethargic. The also noted that he was in the litterbox most of the day prior, and it looked like he was straining.
To anyone who is in the field, these are the classic signs for a kitty with a urinary obstruction, commonly referred to as a "blocked cat" or a "blocked tom". My physical exam confirmed the above; he had a large, distended, painful, non-expressible urinary bladder. More details are available here. The kidneys function to filter blood and excrete waste products from the body, in the form of urine. (It is interesting to note that some of the waste compounds excreted are so toxic that they are diluted with a large amount of water to reduce their direct toxicity, therefore resulting in the need for urine). Urethral obstruction is the blockage of the ability of urine to escape from the body. There are multiple different reasons for the blockage to occur, including urinary crystals, bladder stones, blood clots, mucous, narrowing of the urethra, cancerous masses, or urethral spasms. Regardless of the cause, obstruction of the outflow of urine results in build-up of toxic waste products, metabolic disturbances, and elevated potassium. As potassium climbs, arrythmhias, low heart rates, and even death can occur.
The severity of each blocked kitty depends heavily on how long they have been obstructed. The first sign of urinary obstruction should prompt an immediate exam by a veterinarian, in order to prevent the sequelae of remaining obstructed for extended periods of time.
Joey had a low heart rate (100), was hypothermic at 94 degrees, and very lethargic. An IV catheter was placed, bloodwork was initiated, he was provided with gentle heat support, pain medications, and fluids were started. An ECG was placed on him, which revealed changes consistent with hyperkalemia (elevated potassium). Blood results returned and confirmed a critically high potassium, severe elevations in his kidney values, and dehydration.
I counseled the owners on the best course of action. Joey had a good chance for recovery, but also was in a critical condition, and immediate treatment was the only way to provide him with the best possible outcome. We could not be sure if he would have permanent kidney damage, or if he would have a full recovery; the only way to find out was to proceed with treatment. His owners agreed to go forward with treatment.
Joey was given calcium gluconate to combat the effects of hyperkalemia, and I started the procedure of relieving his urinary obstruction. The procedure typically requires sedation or general anesthesia, however Joey was so incredibly sick that pain medications alone were enough. I quickly relieved his obstruction, and a urethral catheter was placed, which would remain for 24 hours.
Joey had a slow, steady recovery and was eating by the end of the day. We expect him to make a full recovery. Blocked cats are one of my favorite emergencies -- usually, we're able to take a cat who is hours away from death, and pull them back to normal, potentially giving them many more years of happy, healthy life.
I think that light at the end of the tunnel is an oncoming vehicle....
I returned to work, in a relatively upbeat and cheerful mood. I love my job, and I love it even more when I'm busy, challenged, and saving pets. My last two days, despite the crazy pace, had been amazing.
Unfortunately, when I walked in to the clinic that evening, Bo was no longer in the hospital. He had declined over the day, and was euthanized by my colleague. His family had been present for the euthanasia, and they realized that they had done everything they could, and unfortunately, Bo wasn't responding well after surgery. Several days later, his biopsy did confirm a cancerous mass.
Nala, on the other hand, was moving along like a rockstar. She was already eating, bright, alert, and comfortable. The fluid draining from her abdomen was improving, and it appeared that surgery plus antibiotics (etc) was doing the trick. She was on the road to recovery, and her family couldn't be happier. I couldn't be happier, either. What an amazing save -- I was deeply proud of the work I had done for Nala. (Nala discharged home to her family 36 hours later, and is expected to make a full recovery).
It's hard to explain how this case made me feel. My whole career, and even my whole life, my friends, family, colleagues, and mentors have expected the best from me. It's as if I could never do better than they expected, because they already expected perfection. For example, after hearing this story, my closest friends and family responded with "You expect me to be surprised....?" (YES, YES I DO! That was such a hard case, and even in doing all the right things, the dog STILL could have died!!) Of course, it's amazing and flattering to be surrounded by that type of confidence, however it's a completely separate thing to have that sort of confidence in myself. Doctors (veterinarians) are people too, and although I may portray a cool, calm and collected exterior, I'm constantly self-judging, self-evaluating, and feeling inadequate. Could someone do this better than me? Would the patient have a better outcome somewhere else? Have I forgotten something important? If the treatment fails, is it my fault? This case provides me with an objective measurement to remind myself -- you did a great job. This patient is alive because of you -- and it's just the most amazing feeling. I know I'm a good veterinarian, but good isn't good enough for me -- I want to be the best I can be. Despite this positive boost for my ego and confidence, I strive to never rise completely above the level of being self-critical. This is one of my most trustworthy tools to reduce my chances of overlooking a diagnosis, missing an exam finding, or selecting the wrong treatment regimen.
If any veterinary students are reading this, definitely check out the books How Doctors Think (Jerome Groopman) and Better (Atul Gawande). These are both written by M.Ds., and definitely shine a light on the psychology of medicine. The general population expects us to be perfect, infallible, never incorrect, and somewhat omniscient. We're not. Actually, these books are great for anyone to read -- from the perspective of a patient who may someday receive a difficult diagnosis. I highly recommend them.
Anyway, I digress.
The other critical patient in the hospital was a young miniature Aussie who had been hit by a car earlier that afternoon. She had arrived unconscious, with severe head trauma, severe hypotension (her blood pressure was 30!), and severe signs of shock. She also had a large de-gloving laceration on the left side of her chest (meaning the skin was peeled back from the body), and nystagmus had been present since arrival. She was treated with IV fluids, mannitol (in attempt to reduce swelling of the brain), pain medications, oxygen, antibiotics, and intense monitoring. By the time I arrived, she was normotensive, slightly responsive, and had show some signs of improvement. We monitored her intensely over the evening, checking her vitals every 30 minutes initially. (Over the following 24 hours, her progress was positive, but the outcome is unknown to me at this time. I'll fill you in soon).
The rest of my evening was more even-keeled, and I had a chance to catch up on paperwork, make sure medical records were complete, contact owners with outpatient bloodwork results, check up on patients from days' prior and take a deep breath.
The ER is a highly stressful, emotion-filled, adrenaline roller coaster. I'm so glad that it's my job.
Now for some R & R... I'm looking forward to your comments!
Unfortunately, when I walked in to the clinic that evening, Bo was no longer in the hospital. He had declined over the day, and was euthanized by my colleague. His family had been present for the euthanasia, and they realized that they had done everything they could, and unfortunately, Bo wasn't responding well after surgery. Several days later, his biopsy did confirm a cancerous mass.
Nala, on the other hand, was moving along like a rockstar. She was already eating, bright, alert, and comfortable. The fluid draining from her abdomen was improving, and it appeared that surgery plus antibiotics (etc) was doing the trick. She was on the road to recovery, and her family couldn't be happier. I couldn't be happier, either. What an amazing save -- I was deeply proud of the work I had done for Nala. (Nala discharged home to her family 36 hours later, and is expected to make a full recovery).
It's hard to explain how this case made me feel. My whole career, and even my whole life, my friends, family, colleagues, and mentors have expected the best from me. It's as if I could never do better than they expected, because they already expected perfection. For example, after hearing this story, my closest friends and family responded with "You expect me to be surprised....?" (YES, YES I DO! That was such a hard case, and even in doing all the right things, the dog STILL could have died!!) Of course, it's amazing and flattering to be surrounded by that type of confidence, however it's a completely separate thing to have that sort of confidence in myself. Doctors (veterinarians) are people too, and although I may portray a cool, calm and collected exterior, I'm constantly self-judging, self-evaluating, and feeling inadequate. Could someone do this better than me? Would the patient have a better outcome somewhere else? Have I forgotten something important? If the treatment fails, is it my fault? This case provides me with an objective measurement to remind myself -- you did a great job. This patient is alive because of you -- and it's just the most amazing feeling. I know I'm a good veterinarian, but good isn't good enough for me -- I want to be the best I can be. Despite this positive boost for my ego and confidence, I strive to never rise completely above the level of being self-critical. This is one of my most trustworthy tools to reduce my chances of overlooking a diagnosis, missing an exam finding, or selecting the wrong treatment regimen.
If any veterinary students are reading this, definitely check out the books How Doctors Think (Jerome Groopman) and Better (Atul Gawande). These are both written by M.Ds., and definitely shine a light on the psychology of medicine. The general population expects us to be perfect, infallible, never incorrect, and somewhat omniscient. We're not. Actually, these books are great for anyone to read -- from the perspective of a patient who may someday receive a difficult diagnosis. I highly recommend them.
Anyway, I digress.
The other critical patient in the hospital was a young miniature Aussie who had been hit by a car earlier that afternoon. She had arrived unconscious, with severe head trauma, severe hypotension (her blood pressure was 30!), and severe signs of shock. She also had a large de-gloving laceration on the left side of her chest (meaning the skin was peeled back from the body), and nystagmus had been present since arrival. She was treated with IV fluids, mannitol (in attempt to reduce swelling of the brain), pain medications, oxygen, antibiotics, and intense monitoring. By the time I arrived, she was normotensive, slightly responsive, and had show some signs of improvement. We monitored her intensely over the evening, checking her vitals every 30 minutes initially. (Over the following 24 hours, her progress was positive, but the outcome is unknown to me at this time. I'll fill you in soon).
The rest of my evening was more even-keeled, and I had a chance to catch up on paperwork, make sure medical records were complete, contact owners with outpatient bloodwork results, check up on patients from days' prior and take a deep breath.
The ER is a highly stressful, emotion-filled, adrenaline roller coaster. I'm so glad that it's my job.
Now for some R & R... I'm looking forward to your comments!
Interlude
A client from a daytime clinic arrives at midnight during the madness of my previous post. We've never seen her or her pet before. The client is slightly frantic.
Client "I need some insulin syringes for my cat. I am out."
She hands my receptionist a used syringe, which is a U-30. The receptionist comes back to ask me, and we search our stock; it turns out we have nothing similar to this type. Fortunately, she can pick them up at a human pharmacy in about 8 hours, when the stores open.
Receptionist "I'm so sorry, we don't carry this type, and so we have nothing to sell to you. You can pick them up at a human pharmacy when they open in the morning. It's only about 8 hours."
Client FREAKS out. "What do you MEAN!? My cat is supposed to get her insulin at 7am and the stores don't open until 8am! WHat am I supposed to do!? How can YOU let this happen?!?!??"
(Remember, we are trying to care for critical patients, manage outpatients, answer the phones, provide excellent nursing care, and triage the patients that are still flowing in the door.)
Client continues to make a scene in the lobby. She's furious at our hospital because WE don't carry the supplies that SHE FORGOT to buy before her regular veterinarian or the pharmacy closed.
My receptionist comes back again for help. While I'm literally scrubbing in for surgery, I give her information to calm the lady down; having a single insulin injection delayed by ONE hour is not a big deal. Of course, we certainly wish we had some to help you out, but we don't use that type of insulin in our hospital, and therefore you have no other option but to wait until the morning. Maybe you should buy a few extra boxes for emergencies like this one, since after hours, there's nowhere to buy them.
Client leaves, angry. ANGRY at my hospital because we didn't have her supplies.
She calls two hours later and still wants the syringes. My technician is forced to waste 5 minutes of valuable time for treating animals, instead listening to the client's tirade and trying to be friendly and professional.
If only my magic wand was working...... *poof*! syringes!
Look, we want to help people. We do. That's our job. HOWEVER, don't come in and blame us and act like a jerk when it's 1) not an emergency and 2) your fault and 3) we can't do anything to fix it anyway. We're not retail, and we don't stock things we don't use. The same goes for pet food, flea medications, etc.
Lack of proper planning on your part does NOT constitute an emergency on my part.
Client "I need some insulin syringes for my cat. I am out."
She hands my receptionist a used syringe, which is a U-30. The receptionist comes back to ask me, and we search our stock; it turns out we have nothing similar to this type. Fortunately, she can pick them up at a human pharmacy in about 8 hours, when the stores open.
Receptionist "I'm so sorry, we don't carry this type, and so we have nothing to sell to you. You can pick them up at a human pharmacy when they open in the morning. It's only about 8 hours."
Client FREAKS out. "What do you MEAN!? My cat is supposed to get her insulin at 7am and the stores don't open until 8am! WHat am I supposed to do!? How can YOU let this happen?!?!??"
(Remember, we are trying to care for critical patients, manage outpatients, answer the phones, provide excellent nursing care, and triage the patients that are still flowing in the door.)
Client continues to make a scene in the lobby. She's furious at our hospital because WE don't carry the supplies that SHE FORGOT to buy before her regular veterinarian or the pharmacy closed.
My receptionist comes back again for help. While I'm literally scrubbing in for surgery, I give her information to calm the lady down; having a single insulin injection delayed by ONE hour is not a big deal. Of course, we certainly wish we had some to help you out, but we don't use that type of insulin in our hospital, and therefore you have no other option but to wait until the morning. Maybe you should buy a few extra boxes for emergencies like this one, since after hours, there's nowhere to buy them.
Client leaves, angry. ANGRY at my hospital because we didn't have her supplies.
She calls two hours later and still wants the syringes. My technician is forced to waste 5 minutes of valuable time for treating animals, instead listening to the client's tirade and trying to be friendly and professional.
If only my magic wand was working...... *poof*! syringes!
Look, we want to help people. We do. That's our job. HOWEVER, don't come in and blame us and act like a jerk when it's 1) not an emergency and 2) your fault and 3) we can't do anything to fix it anyway. We're not retail, and we don't stock things we don't use. The same goes for pet food, flea medications, etc.
Lack of proper planning on your part does NOT constitute an emergency on my part.
Night 2/3, the madness continues
I returned to work with serious anticipation, waiting to find out the outcome of Bo's surgical exploratory.
My colleague had pulled Bo through surgery, which was a challenge. Blood pressure dropped dangerously low despite two types of fluid support; vasopressive medications were added and the BP improved, however did not normalize. At explore, she found an abscessed, infected, ruptured mass on the cecum (part of the intestines). This portion of the intestine was removed, and sent off to the lab for evaluation. In the meantime, the abdomen was flushed well, broad spectrum antibiotics were continued, and supportive care was initiated, including pain control, attempting to get nutrition into the pet, and fluid therapy. Bo had a slow recovery from surgery, both due to his severe disease as well as his advanced age. We planned to monitor him intensely over the evening, and would be on the lookout for any deterioration.
Several other pets had been waiting to be seen, including a dog with chronic urinary tract infections. The owner had access to antibiotics through his work in the human medical field, and had been treating his own pet's symptoms off and on for the last three years. The symptoms had never resolved, and now, at 11pm, they were presenting at the ER for evaluation. I tried to explain other causes for straining to urinate (bladder stones, crystals, tumor, among others) vs an actual urinary tract infection with bacterial resistance due to the ineffective dosages and inappropriate duration of therapy given by them, without direction by a veterinarian. These clients were difficult (obviously not understanding how my 8 years of veterinary education made me better equipped to diagnose and treat than their zero years of veterinary education), and ended up leaving without letting me do anything to help them solve the problem.
Another pet, a 3 year old female Corgi (Nala), had been admitted by the daytime veterinarian with vague signs of illness, including loss of appetite, lethargy, and vomiting (once). She was spayed about 24 hours prior to the onset of her illness, and had no other known concerns. X-rays had been performed at the regular veterinarian's office, which were suggestive of excess fluid within her abdomen. Her body temperature was low, and she appeared lethargic, but otherwise her exam was unremarkable.
I performed an abdominal ultrasound, which confirmed copious amounts of free fluid in her belly. A sample of the fluid was collected, and revealed sheets and sheets of bacteria, as well as white blood cells, indicating my SECOND septic abdomen in one day. A septic abdomen is a severe, overwhelming infection that cannot be controlled with antibiotics alone; as with Bo, surgical exploratory is absolutely necessary to identify the cause, as well as to flush / clean out the abdomen and perform any other interventions based on each case. I checked Nala's blood glucose, and it was critically low, likely due to her septic status. I contacted her family, who wished to proceed despite the cost and risks of surgery.
At the time of her surgical exploratory, I expected to find a source of contamination; either a damaged intestine, a perforated foreign object, a surgical sponge left behind, or something similar. Instead, what I found was no cause of her infection, but evidence throughout her abdomen of the inflammation: her intestines were brick red, her belly was full of fluid, and otherwise, there was nothing. I flushed her abdomen out well, took a sample for culture, as well as a sample for a biopsy from an abnormal looking area of tissue, and placed a closed-suction drain. I closed her abdomen, and she woke up from anesthesia very routinely. Now, all that was left to do was provide supportive care, medications, and monitor. Nala had a definite chance for recovery, but also had the chance to succumb to her illness.
I then turned my attention to a client who had been waiting in the lobby for the last 2 hours. She was patient, friendly, and understood the reason for her wait, which was refreshing and unusual. Her dog, a 12 year old mixed breed (Sis), had been having chronic pain problems for the last 3-6 months, and despite her best attempts to control the pain, at this point, it was impacting her pet's quality of life. She had arrived to discuss euthanasia, obviously a very difficult discussion and decision. The client and I had a heart-to-heart and discussed options, including addition of other medications, acupuncture, underwater treadmills, physical therapy..... And after our long discussion, her decision was made. We placed an IV catheter, and euthanized Sis with her family present, telling her what an amazing dog she was. Ultimately, her family couldn't stand to see her in pain any longer. They poured their hearts out to me, and it really seemed like they had made the best decision. Her last 3-4 weeks had been very difficult, and they knew it was time to say goodbye.
The remainder of my night was filled with charts, contacting and updating owners of inpatients, some other boring outpatient cases, rechecking physical exams of my two critical post-op septic abdomen patients, while managing Bo's blood pressure medications and fluid rates. I ended my shift exhausted, stressed, and hopeful that I had made a life-saving difference for Nala.
My colleague had pulled Bo through surgery, which was a challenge. Blood pressure dropped dangerously low despite two types of fluid support; vasopressive medications were added and the BP improved, however did not normalize. At explore, she found an abscessed, infected, ruptured mass on the cecum (part of the intestines). This portion of the intestine was removed, and sent off to the lab for evaluation. In the meantime, the abdomen was flushed well, broad spectrum antibiotics were continued, and supportive care was initiated, including pain control, attempting to get nutrition into the pet, and fluid therapy. Bo had a slow recovery from surgery, both due to his severe disease as well as his advanced age. We planned to monitor him intensely over the evening, and would be on the lookout for any deterioration.
Several other pets had been waiting to be seen, including a dog with chronic urinary tract infections. The owner had access to antibiotics through his work in the human medical field, and had been treating his own pet's symptoms off and on for the last three years. The symptoms had never resolved, and now, at 11pm, they were presenting at the ER for evaluation. I tried to explain other causes for straining to urinate (bladder stones, crystals, tumor, among others) vs an actual urinary tract infection with bacterial resistance due to the ineffective dosages and inappropriate duration of therapy given by them, without direction by a veterinarian. These clients were difficult (obviously not understanding how my 8 years of veterinary education made me better equipped to diagnose and treat than their zero years of veterinary education), and ended up leaving without letting me do anything to help them solve the problem.
Another pet, a 3 year old female Corgi (Nala), had been admitted by the daytime veterinarian with vague signs of illness, including loss of appetite, lethargy, and vomiting (once). She was spayed about 24 hours prior to the onset of her illness, and had no other known concerns. X-rays had been performed at the regular veterinarian's office, which were suggestive of excess fluid within her abdomen. Her body temperature was low, and she appeared lethargic, but otherwise her exam was unremarkable.
I performed an abdominal ultrasound, which confirmed copious amounts of free fluid in her belly. A sample of the fluid was collected, and revealed sheets and sheets of bacteria, as well as white blood cells, indicating my SECOND septic abdomen in one day. A septic abdomen is a severe, overwhelming infection that cannot be controlled with antibiotics alone; as with Bo, surgical exploratory is absolutely necessary to identify the cause, as well as to flush / clean out the abdomen and perform any other interventions based on each case. I checked Nala's blood glucose, and it was critically low, likely due to her septic status. I contacted her family, who wished to proceed despite the cost and risks of surgery.
At the time of her surgical exploratory, I expected to find a source of contamination; either a damaged intestine, a perforated foreign object, a surgical sponge left behind, or something similar. Instead, what I found was no cause of her infection, but evidence throughout her abdomen of the inflammation: her intestines were brick red, her belly was full of fluid, and otherwise, there was nothing. I flushed her abdomen out well, took a sample for culture, as well as a sample for a biopsy from an abnormal looking area of tissue, and placed a closed-suction drain. I closed her abdomen, and she woke up from anesthesia very routinely. Now, all that was left to do was provide supportive care, medications, and monitor. Nala had a definite chance for recovery, but also had the chance to succumb to her illness.
I then turned my attention to a client who had been waiting in the lobby for the last 2 hours. She was patient, friendly, and understood the reason for her wait, which was refreshing and unusual. Her dog, a 12 year old mixed breed (Sis), had been having chronic pain problems for the last 3-6 months, and despite her best attempts to control the pain, at this point, it was impacting her pet's quality of life. She had arrived to discuss euthanasia, obviously a very difficult discussion and decision. The client and I had a heart-to-heart and discussed options, including addition of other medications, acupuncture, underwater treadmills, physical therapy..... And after our long discussion, her decision was made. We placed an IV catheter, and euthanized Sis with her family present, telling her what an amazing dog she was. Ultimately, her family couldn't stand to see her in pain any longer. They poured their hearts out to me, and it really seemed like they had made the best decision. Her last 3-4 weeks had been very difficult, and they knew it was time to say goodbye.
The remainder of my night was filled with charts, contacting and updating owners of inpatients, some other boring outpatient cases, rechecking physical exams of my two critical post-op septic abdomen patients, while managing Bo's blood pressure medications and fluid rates. I ended my shift exhausted, stressed, and hopeful that I had made a life-saving difference for Nala.
Tuesday, April 5, 2011
Start of the saga
This weekend was crazy at work. Here starts the saga, volume 1/3....
Upon arrival to my shift Thursday night, there were already 4 people waiting to be seen in the lobby.
An 8 year old beagle, "Sissy," had just transferred for overnight care as her regular veterinarian's office was closing. Instantly, as I entered the treatment area, it was apparent that Sissy was critical. She was having difficulty breathing, laterally recumbent, unable to lift her head, and vocalizing as if in pain. She was receiving oxygen, IV fluids, and pain medications, however had not improved since her arrival. She had bloodwork and radiographs performed already, which revealed severe liver dysfunction, dehydration, and evidence of a possible mass in her chest. Quickly, I evaluated Sissy and went to speak with her family. They understood that Sissy was critical, however wanted to give her the best chance. They authorized some additional testing, including ultrasound. Ultrasound confirmed a large mass in Sissy's chest, as well as some free fluid (pleural effusion). These findings were incredibly disappointing, but her family still wanted to try to make her better and seek referral to a specialist the following day.
Unfortunately, despite our best attempts, in the next 45 minutes, Sissy had a precipitous decline and became unable to breathe effectively on her own, and required intubation and mechanical ventilation to continue. Due to her decline, and the associated poor prognosis, her family elected euthanasia.
Next was a large breed, 12 year old dog named "Bo." He had a depressed appetite, seemed lethargic, and just not quite right to his family. He was admitted to the hospital prior to my arrival, started on supportive fluids and anti-nausea medications, and bloodwork was submitted. Radiographs (x-rays) was also discussed, but the owner wished to take the testing one step at a time, a very reasonable approach. Bloodwork should be returned in 3-4 hours, and we would adjust the plan as necessary.
Also in the hospital was a older kitty, "Fizzle," who had been recently found after being missing for 2 days. She had been mauled by something, and had several large wounds which needed surgical attention. She was placed on IV fluids, antibiotics, and pain medications while waiting for her time in surgery.
Last but not least was a persian kitty with a PCV (see bottom of page for definition) of 8%. She had already received TWO blood transfusions with no effect on her PCV. She was positive for FeLV (a common virus of cats), and was suspected to have myelodysplasia as a result of the viral infection. Despite her nearly non-life sustaining PCV, she was eating, drinking, and resting comfortably. She was awaiting epogen injections (a hormone medication to stimulate red blood cell production, and the offending drug in "blood doping" for athletes"). With a PCV of 8%, this kitty was actually my most stable patient, and would be discharging the following day.
I began to see the various outpatients waiting in rooms, and the details of those cases are already forgotten (a hodge-podge of vomiting, diarrhea, and other unremarkable cases). Non - critical cases in a busy emergency room can end up waiting several hours, as these cases did. Many families were gracious and understanding, with the realization that the other pets' lives were in the balance, and they understand when it does become their turn, that they will have my full and undivided attention. I make sure to apologize for the long wait, and let them know that I appreciate their patience....
However, it seems that nearly every night, there is at least one client stomping around in the lobby, protesting the long wait for their dog's ear infection to be treated (for example). From my perspective, there is nothing more frustrating than this type of personality: they feel that they are more important that any other single being, and that their schedule should be more important than a life or death situation for someone else's loved one. Equally frustrating are the clients who show up to purchase dog food, flea medications, syringes, etc, and are literally FURIOUS when we don't oblige whatever their ridiculous request is. We are NOT retail. We don't carry flea medications, we don't sell dog food.... I'm trying to save lives here, and I need my staff helping me, not dealing with BS requests. Oh, and client with no teeth, pinpoint pupils, and who didn't bring in a pet? I'm NOT selling you needles without knowing what they are going to be used for...... on second thought, I don't want to know what they're for. I'm just not selling you needles.
Bloodwork returned on Bo, and was normal, therefore not helpful in determining the cause of his illness. Due to Bo's age, and the potential for finding cancer, the owner elected to heed my recommendations and proceed with imaging of his chest and abdomen. Chest radiographs were normal. Abdominal radiographs may have appeared normal to the causal observer, however, a very important abnormal finding was present: the detail of the image was poor. This is actually not associated with technique, but with a free fluid being present within the abdominal cavity. Ultrasound was indicated to investigate.
Ultrasound was performed, and did confirm a small amount of free fluid, however the volume was insufficient to retrieve. Causes for this free fluid included cancer, pancreatitis, infection, or bleeding (other causes considered less likely due to normal bloodwork). Bo had done well over the evening, so he was monitored closely, and seemed to improve. No other significant findings were seen on ultrasound.
Surgery was performed on Fizzle, and her wounds were cleaned and repaired. She recovered uneventfully.
Bo had been stable all evening, and no vomiting, diarrhea, or other concerns had been noted. In the early hours of the morning, something changed. He had an excessively high heart rate, and refused to rise. Recheck ultrasound revealed a massive amount of fluid within his abdomen: I removed a small sample and evaluated it under the microscope. It appeared to be a massive infection, or a septic abdomen.
Immediately, Bo was given broad spectrum antibiotics. BP, ECG were monitored; Bo was provided with supplemental oxygen and electrolytes were re-evaluted. His owner was contacted and she arrived at our hospital. We discussed the precipitous decline and recommended immediate exploratory surgery, or euthanasia. Exploratory surgery was dangerous given Bo's septic shock condition, however without surgery, he would die. We suspected a perforated intestine, either due to a cancerous lesion, or due to a previously undiagnosed foreign object that he had ingested, and surgery was the only way to repair this lesion. Obviously, a cancerous lesion has a much worse prognosis than any of the other possibilities, but regardless of the etiology, surgery in a septic patient is always a complicated, risky undertaking.
Just as the hospital changed doctors for the day, Bo's family elected to proceed with surgery. My colleague prepared for the abdominal explore, and I finished up my notes on the rest of the hospital patients, and departed for the day.
To be continued....
Upon arrival to my shift Thursday night, there were already 4 people waiting to be seen in the lobby.
An 8 year old beagle, "Sissy," had just transferred for overnight care as her regular veterinarian's office was closing. Instantly, as I entered the treatment area, it was apparent that Sissy was critical. She was having difficulty breathing, laterally recumbent, unable to lift her head, and vocalizing as if in pain. She was receiving oxygen, IV fluids, and pain medications, however had not improved since her arrival. She had bloodwork and radiographs performed already, which revealed severe liver dysfunction, dehydration, and evidence of a possible mass in her chest. Quickly, I evaluated Sissy and went to speak with her family. They understood that Sissy was critical, however wanted to give her the best chance. They authorized some additional testing, including ultrasound. Ultrasound confirmed a large mass in Sissy's chest, as well as some free fluid (pleural effusion). These findings were incredibly disappointing, but her family still wanted to try to make her better and seek referral to a specialist the following day.
Unfortunately, despite our best attempts, in the next 45 minutes, Sissy had a precipitous decline and became unable to breathe effectively on her own, and required intubation and mechanical ventilation to continue. Due to her decline, and the associated poor prognosis, her family elected euthanasia.
Next was a large breed, 12 year old dog named "Bo." He had a depressed appetite, seemed lethargic, and just not quite right to his family. He was admitted to the hospital prior to my arrival, started on supportive fluids and anti-nausea medications, and bloodwork was submitted. Radiographs (x-rays) was also discussed, but the owner wished to take the testing one step at a time, a very reasonable approach. Bloodwork should be returned in 3-4 hours, and we would adjust the plan as necessary.
Also in the hospital was a older kitty, "Fizzle," who had been recently found after being missing for 2 days. She had been mauled by something, and had several large wounds which needed surgical attention. She was placed on IV fluids, antibiotics, and pain medications while waiting for her time in surgery.
Last but not least was a persian kitty with a PCV (see bottom of page for definition) of 8%. She had already received TWO blood transfusions with no effect on her PCV. She was positive for FeLV (a common virus of cats), and was suspected to have myelodysplasia as a result of the viral infection. Despite her nearly non-life sustaining PCV, she was eating, drinking, and resting comfortably. She was awaiting epogen injections (a hormone medication to stimulate red blood cell production, and the offending drug in "blood doping" for athletes"). With a PCV of 8%, this kitty was actually my most stable patient, and would be discharging the following day.
I began to see the various outpatients waiting in rooms, and the details of those cases are already forgotten (a hodge-podge of vomiting, diarrhea, and other unremarkable cases). Non - critical cases in a busy emergency room can end up waiting several hours, as these cases did. Many families were gracious and understanding, with the realization that the other pets' lives were in the balance, and they understand when it does become their turn, that they will have my full and undivided attention. I make sure to apologize for the long wait, and let them know that I appreciate their patience....
However, it seems that nearly every night, there is at least one client stomping around in the lobby, protesting the long wait for their dog's ear infection to be treated (for example). From my perspective, there is nothing more frustrating than this type of personality: they feel that they are more important that any other single being, and that their schedule should be more important than a life or death situation for someone else's loved one. Equally frustrating are the clients who show up to purchase dog food, flea medications, syringes, etc, and are literally FURIOUS when we don't oblige whatever their ridiculous request is. We are NOT retail. We don't carry flea medications, we don't sell dog food.... I'm trying to save lives here, and I need my staff helping me, not dealing with BS requests. Oh, and client with no teeth, pinpoint pupils, and who didn't bring in a pet? I'm NOT selling you needles without knowing what they are going to be used for...... on second thought, I don't want to know what they're for. I'm just not selling you needles.
Bloodwork returned on Bo, and was normal, therefore not helpful in determining the cause of his illness. Due to Bo's age, and the potential for finding cancer, the owner elected to heed my recommendations and proceed with imaging of his chest and abdomen. Chest radiographs were normal. Abdominal radiographs may have appeared normal to the causal observer, however, a very important abnormal finding was present: the detail of the image was poor. This is actually not associated with technique, but with a free fluid being present within the abdominal cavity. Ultrasound was indicated to investigate.
Ultrasound was performed, and did confirm a small amount of free fluid, however the volume was insufficient to retrieve. Causes for this free fluid included cancer, pancreatitis, infection, or bleeding (other causes considered less likely due to normal bloodwork). Bo had done well over the evening, so he was monitored closely, and seemed to improve. No other significant findings were seen on ultrasound.
Surgery was performed on Fizzle, and her wounds were cleaned and repaired. She recovered uneventfully.
Bo had been stable all evening, and no vomiting, diarrhea, or other concerns had been noted. In the early hours of the morning, something changed. He had an excessively high heart rate, and refused to rise. Recheck ultrasound revealed a massive amount of fluid within his abdomen: I removed a small sample and evaluated it under the microscope. It appeared to be a massive infection, or a septic abdomen.
Immediately, Bo was given broad spectrum antibiotics. BP, ECG were monitored; Bo was provided with supplemental oxygen and electrolytes were re-evaluted. His owner was contacted and she arrived at our hospital. We discussed the precipitous decline and recommended immediate exploratory surgery, or euthanasia. Exploratory surgery was dangerous given Bo's septic shock condition, however without surgery, he would die. We suspected a perforated intestine, either due to a cancerous lesion, or due to a previously undiagnosed foreign object that he had ingested, and surgery was the only way to repair this lesion. Obviously, a cancerous lesion has a much worse prognosis than any of the other possibilities, but regardless of the etiology, surgery in a septic patient is always a complicated, risky undertaking.
Just as the hospital changed doctors for the day, Bo's family elected to proceed with surgery. My colleague prepared for the abdominal explore, and I finished up my notes on the rest of the hospital patients, and departed for the day.
To be continued....
Sunday, April 3, 2011
Crazy, crazy work week.
I had an insane week at work. I'm too exhausted to write about all of it now, but stay tuned. There's some great cases coming. AND some crazy client stories! As for tonight, it's relaxation, TV, and my cuddly cat.
The wait will be well worth it!
The wait will be well worth it!
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