Wednesday, April 6, 2011

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.

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