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....

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