it's the little things.

I came to work today with dread.  I've been off for a week, enjoying my life and feeling like a normal person... (awake during the day? Sleep at night! Preposterous!).  needless to say, working all night was not on my wish list for the day.  Unfortunately, we don't always get what we want.

Several hours in to the shift, we received a call from a small "rescue" organization that one of their recently acquired stray cats was currently in labor, and they believed that she was having difficulty. 

Immediately, I expected the worst.  It's a sad truth that being an ER doctor can turn even the most optimistic person into a hard-edged skeptic.  In my mind, if this cat was truly having difficulty with labor, a c-section was a possibility - and knowing the history of this "rescue," we'd be lucky if they had funds for the exam fee.  I imagined all the hateful comments when I denied the cat a free c-section, and all the disappointment in my heart and in my staff's eyes when I was forced to euthanize the imaginary cat.

15 minutes spent waiting for the arrival of these clients felt like a lifetime. 

The clients arrived.  My technician took a history, and to our surprise, things weren't as they had seemed.  So far, our queen, "Misty" had delivered three kittens in under 3 hours, and the last was 10 minutes prior to arrival.   Two were already nursing.

I performed my physical exam, followed by a sterile vaginal exam.  A kitten was at the tip of the birth canal, and I could feel it suckling on my finger, indicating that it is (obviously) alive.

All seemed normal - Misty was not having any difficulty with labor, in fact, she was purring, sweet, and caring for her new babies.  I educated her owners a bit on feline parturition.  While I was speaking with them, Misty delivered another normal kitten.

I spent a little extra time petting Misty before she discharged.  Misty purring vigorously and her brand new, minutes old kitten crawled around, experiencing the world for the first time. I remembered that sometimes my job is great.  Sometimes, things just work out.  The feeling of dread prior to my shift -- is gone.

This case reminded me that it's the little things that we have to enjoy to make life meaningful.  I can't make every client happy, I can't fix every pet's disease, and I certainly can't know everything -- but I can definitely be happy when things go well.

dumbest call of the day

Caller: "Hi, I have a question...."

Tech: "Sure, go ahead!"

Caller "My cat got neutered today, and they said to keep him quiet and not let him run around."

<long pause>

Tech: "And..? What's your question?"

Caller "Well, he's running around the house."

Tech: "Okay, well I'd recommend you follow your vet's instructions - keep him in a small bathroom or a dog crate so he can't go crazy -- you really want him to rest."

Caller "Oh!!"

<even longer silence>

Tech: "Is there anything else?"

Caller "No." Hangs up.

---
So you didn't know that  don't let him run around means don't let him run around? I'm so glad we could help you with that.

TRIAGE, STAT!

Here's a story from the vault of my life that I'm excited to share.

I was working a typical afternoon in a busy referral hospital. The large facility employs many veterinarians, including general practitioners, specialists, and emergency doctors, plus support staff, receptionists, administration, etc.  Many clients (probably about 20) are waiting in the lobby for their regular appointments, follow up exams, or specialist consultations.

I walked into the lobby to receive my next appointment.  As I call out the pet's name, the overhead speaker announces "ER TRIAGE ROOM 5!"

This announcement means that a critical (usually dying or dead) patient has just arrived and needs to be seen by the ER service NOW.  Etiquette is that all doctors who are able drop their current task and immediately respond.  As I was in the front of the hospital, I was easily the closest.

I ran into the noted exam room to find a hysterical client and her 50 pound, 4 year old pit mix.  "SHE'S CHOKING!" the client screams, "I CAN'T GET THE BALL OUT!"

The dog has her head and neck extended, she's drooling and gagging.  Her gums are purple and she can barely stand.  It's obvious that this dog is in immediate distress.  The client relays to me that they were playing fetch in the park only minutes prior; all was well until the dog swallowed the ball and immediately started choking.

I grabbed the dog, quickly gained permission from the client for sedation, IV catheter access, and to remove the ball.  We needed to act fast -- we only had minutes to intervene before it would be too late. A general rule of thumb is "3 minutes, 3 days, 3 weeks," in general, you can live 3 minutes without oxygen, 3 days without water, and 3 weeks without food.  This dog was already on borrowed time.

I ran to the ICU, carrying the dog and called for assistance.  Technicians placed an IV catheter, administered a sedative and prepared an oxygen mask and endotracheal tubes.  I reached my bare hand into the dogs throat and found the object; a spiky, hard plastic ball made of rubber, similar to "Kong" type material.  The ball was firmly lodged in the back of my patient's throat, and the spikes served as anchors, which in addition to the slippery saliva, prevented my initial attempts at removal with my hands.  Hindsight is 20/20; but this ball was way too small for this size of dog - larger dogs need larger balls so that they can't swallow them.

My patient continued to become purple and was gasping for air.  Thankfully, the ball had a small hole in the center which was providing a small amount of airflow (probably the only reason she wasn't dead upon arrival to the hospital).

Several of my colleagues ran to the OR to grab surgical instruments; it was nearly time for a tracheotomy.  Then, I had a great idea -- I grabbed towel clamps, an instrument used to attach a sterile drape along a surgical field.  Towel clamps have sharp points, meant to pierce the skin, and a very firm grip.  I attached the towel clamps to the rubber ball, which was just the traction I needed.  The ball came out, and my patient's upper airway obstruction was relieved!  An exhilarating, amazing feeling.  We all celebrated, especially me - this was the first case like this I'd ever seen, and I'd been the one to remove the object.  I saved a life. It felt great!

I went up to talk to the client, expecting tears of joy, hugs, and gratitude for saving her dog.  I never would have guessed, in a million years, her reaction.

"We got the ball out!  Your dog is now more stable.  She'll need to stay with us at least for a few hours so we can make sure she recovers; she was hypoxic and may have some complications from her choking episode.  You can come visit with her in just a few minutes."

"HOW MUCH IS THIS GOING TO COST ME!? You're all money grubbing assholes, and you don't care about animals!" The client screamed at me, in front of a full lobby of (stunned) clients.  The onlookers had seen me take the dog from her, and had heard that we'd saved it.  Many of them were just as shocked at her reaction as I was.

 I almost didn't even know how to respond.  "....Ma'am -- I just saved your dog's life, and I didn't even talk about money when time was of the essence -- how can you even say that we don't care about pets?"

"GIVE ME MY DOG!  I WILL NOT PAY ANYTHING FOR HER TO STAY!"

At this point, I was done dealing with her garbage.  "I'm sorry you're upset.  I want you to know that we just saved your dog's life.  I'm not really sure what I could have done differently to make you happy.  All I can do now is make you an estimate for the care we recommend, and the care that was ALREADY provided."

I sent the client to the financial office, where she continued to be the most ungrateful, rude, heinous person I could imagine.  She didn't pay one cent for the care we provided, and as a result, did nothing to support the salaries of the four doctors who were involved in the care, did nothing to help pay the technician's wages (many of whom haven't had raises in 3 years), and paid nothing for the supplies that the hospital has to buy (oxygen, IV catheters, fluids, medications, DEA licensing, surgical instruments....) to be able to provide this level of care, not to even mention electricity, rent, janitorial services... the list goes on and on.

This is one example of why I'm glad I'm not a human physician -- at least we saved her dog.  Her dog was an innocent party to the nonsense that occurred aftewards, and we can still feel great about saving the young, innocent, sweet dog.

On a side note -- if you play fetch with your dog, make sure the ball is wider than the space between their canines (the large teeth in front).  A properly sized ball will help to prevent an emergency like this one.

YES.

Cat presented to me laterally recumbent, with muddy, gray mucous membranes and unable to stand.  He was as limp as a dishrag, his body temperature was low, and his heart rate was slowing.

We immediately asked the family for permission to place an IV catheter and start initial blood testing.  At first, they said no.  Their kitty, Jerry, was almost 19 years old, and they weren't sure they wanted to treat.  They revealed that he had been a diabetic for many years, and had been receiving insulin for some time.  I asked them to allow just a blood glucose to give us a possible idea of why he was nearly comatose.

They agreed.  His blood glucose was 23, which is low enough to cause seizures in dogs and cats.  The clients had a change of heart and allowed us to place an IV catheter to give dextrose in order to raise his critically low blood glucose.

We gave the medication, and started IV fluids.  Within 5 minutes, Jerry was standing up, meowing, and trying to get us to pet him.  He looked like a normal cat -- truly amazing.

Jerry was hospitalized, and his family came back later to visit.  With tears in their eyes, they thanked me for saving his life.  They told me about his personality, how he liked to be brushed, how he would follow his owner around the house.  Jerry's family thanked me over and over -- although they know he's a geriatric cat, they couldn't be happier that they didn't have to say goodbye today.

Testing and follow up is still necessary to figure out exactly what made Jerry so hypoglycemic, but for now, we can bask in the feeling of another life saved.

Driving drunk

Don't show up to my ER drunk, especially when you drove yourself here. 

Clients arrived last night after running over their own cat.  The kitty, a 6 year old long haired female, had a broken femur, a broken pelvis, and was in shock.  She was extremely painful, as you can imagine.  We attempted to ask the clients for permission for pain medication and to start treatment on their kitty.  Unfortunately,  the clients spent the first 30 minutes outside in our parking lot, yelling at each other in a saddening display of drunken-white-trash-COPS-style fighting. 

My technician gave them the ultimatum -- start being adults, come inside, and deal with their sick kitty, or leave. 

They came inside, and unfortunately, we were forced to provide them with a free euthanasia instead of trying to fix their cat as they did not wish to pay for any services.  I guess they prefer to spend their money on alcohol and DUI tickets.

As they drove away, I contacted the non-emergency police to inform them of the situation.  I have zero tolerance for this sort of behavior - if they already hit a cat, what's next? A child? Someone else's car? 

People are so different....

Two cases, two clients.  Two extreme examples of people which illustrate one of the many factors that makes the ER an interesting and difficult place.

Client #1:

The phone rings.  My technician answers with the standard greeting, and before he can get the words out, the client is screaming. 
"MY DOG IS DYING!!!  YOU HAVE TO HELP ME!  OH MY GOD SHE'S .....OH MY GOD!"

The staff member urges the client, Sandra, a 40-something married lady traveling with her husband and adult children, to calm down and speak clearly so he can assist her.  It finally becomes clear that her dog, "Sissy" a 2 year old miniature pincher, is panting in the car.  Sandra let her dog outside at rest stop, and Sissy urinated and appeared normal.  When they got back in the car, the panting resumed.  Sandra is beside herself with emotion, fear, and on the phone is inconsolable.  She's on her way, and she'll be here within minutes.



Client 2:

The phone rings.  My technician answers with the standard greeting.  The client, Beth, very calmly states that her puppy was in a little dog fight, and has a few bite wounds.  She'll be on her way shortly. 


---------------
What do you think is wrong with each pet?  Which one is more critical? 


It's not what you'd think.

Client 1 arrives, and after triage, appears normal.  Due to Sissy's normal appearance and lack of panting in our office, the clients were given the opportunity to leave, before paying for an exam, and monitor for any change in symptoms.  The clients, hysterical by this time, elected to proceed with an exam, despite the cost, as they were fully convinced their dog was dying in front of them.  (Keep in mind, this young dog is bouncing around the lobby, looking for anything he can eat, sniffing, and acting like a totally normal dog).  A full physical exam is normal.  Panting comes and goes, but there is NO evidence of respiratory difficulty. "Sissy" is eating and drinking normally, and has pink, moist mucous membranes.  She urinated normally at the rest stop, and defecated normally outside our office. No other symptoms are present.  The clients express their new concern -- Sissy was "jumping up and down from the back seat to the floor more than usual."

It literally took me an hour to convince Sandra that Sissy's physical exam was normal.  I tried to explain that while I understood their concerns, she was absolutely not having difficulty breathing, and that "jumping up and down from the back seat" was not a sign or symptom of a specific disease.  I offered, to further prove her normal status, that we could pursue further diagnostics, if the client wished.....


Client 2 arrives, carrying a laterally recumbent 5 month old puppy.  The puppy, "Sid"  had gray mucous membranes, shallow respirations, and very poor pulses.  Immediately, the receptionist recognized that this was NOT a "few lacerations" and that this dog was much, much sicker than the clients led us to believe.  The clients described that they had returned home to find Sid in this condition; he was with 3 other dogs and they had never had any problems previously, however today obviously was a different story.

An IV catheter was placed, oxygen was provided, antibiotics and pain medications were given.  Severe bite wounds were present over the throat and neck, involving the trachea and larnyx.  Sid also had multiple bite wounds over his hind legs and groin.  Clearly, he had been viciously attacked by a group of dogs, and was suffering from severe shock.  Sid required emergency action to prevent his imminent death.  We worked quickly, however after radigoraphs and initial stabilization it became clear that Sid's chances of recovery were quite poor.  The family elected euthanasia due to concern for suffering.


This is why I can't tell you what's going on over the phone.  I have countless examples of this, however these two occurred in rapid succession and illustrate the point perfectly.  I can't see your pet, I have no idea how good you are at describing the situation, and most importantly you aren't trained to diagnose -- that's my job, and I need my eyes, hands, and ears to do it properly.

now that's a bloody mess.

Last night, I had an adult yellow labrador, "Tucker" present for symptoms of lethargy and abdominal discomfort. His owners knew he just wasn't feeling well.  They had just fed him a meal, and were worried about GDV, so they brought him in immediately.

Tucker arrived and had a semi-painful abdomen, but it was not visibly bloated.  His mucous membranes were pink and his pulses were fair.  Something was definitely going on, but it didn't look like GDV.  The owners approved radiographs (x-rays) to investigate the source of his abdominal pain. 

Radiographs revealed a food-filled, but not enlarged stomach.  The x-rays had a haziness which my technician noticed right away - and I noticed the mass.  I ultrasound to confirm a large splenic mass, which was bleeding right now, and the source of his symptoms.

Fortunately, his owners had caught the symptoms early, and he was not yet anemic.  We discussed the most likely diagnosis - cancer - and the possibility of benign disease.  The family elected to proceed with exploratory surgery and splenectomy to stop the bleeding.  This is a difficult decision for any family who faces it: Take the higher likelihood of a cancerous mass and elect euthanasia?  Go forward with an expensive and potentially risky surgery to stop the bleeding, and potentially only palliate the macroscopic cancer? Ultimately, there is no right answer since in each case, we can't know if it's cancerous until 3-5 days after surgery, when the biopsy results return.  I'm not even sure what I'd do with my dog if I was in this situation.

Anyway, Tucker's family authorized surgery.  We  performed bloodwork, provided him with fluids, pain medications, and anesthetized him.  We prepared him for a sterile surgery and moved him into the operating room.  Surgery went quite well; and the spleen was removed with relative ease.  Darwin recovered well, and is now awaiting the pathologist's decision regarding his fate.

Not to be forgotten -- there was one casualty -- me.  By the end of the surgery, my scrubs, socks, shoes, surgical gown and even my underwear were soaked thru, to my skin, with blood and bloody fluid.  Our suction unit hadn't been able to keep up with the speed at which fluid poured from his belly, and a large amount of it ended up on me, or on the floor. 

Sticky, icky, itchy, blood. Blech. All over.  Fortunately, I always keep extra scrubs and socks at work, but now I guess I should start keeping extra underwear?!!

Rage, for no reason

Actual phone call received by our hospital:

Caller: "I just gave my dog a handful of cat treats and now he's drooling. What should I do?"

Technician: "Well, what was the brand of treat? Has your dog vomited? How is he otherwise acting? And why did you give your dog a cat treat?"

Caller: "He vomited an hour after we gave it to him; and otherwise he appears a little less active than usual.  We just thought he would like the cat's treats......(gives us the brand name)."

Technician: "It's a product that's meant to be ingested, so it's highly unlikely to be toxic; if you're concerned, you're welcome to come in and have our doctor take a look. Somtimes, too many treats can cause GI upset, especially if he hasn't had them before.  Otherwise, you can monitor at home, and if the vomiting does not continue, you may not need to rush in."

Caller: "YOU DON"T F-ING CARE ABOUT ANIMALS! YOU JUST WANT TO PAD YOUR POCKETS!" (We could also hear a second voice in the background, swearing, yelling, and carrying on)

Technician: "I'm not sure why you're upset -I've tried to be as helpful as possible. I can't see your dog from here --  and we always recommend that if you're worried, come in and have an exam.  It may provide peace of mind.  If finances are a concern, you can watch your pet at home, or try CareCredit if you want to be seen."

Caller: Hangs up.

30 minutes later: (keep in mind the volume of calls we receive in a daily basis, and that there are multiple staff members answering the phones...)

Caller: <doesn't say hello, introduce himself, or offer any back-information>  "My dog is still drooling."

Tech 2: "I'm sorry, I don't know who you are - can you tell me what's going on with your pet? Is it a cat or a dog?"

Caller: Angrily repeats the story.  Throughout the story, interjects various comments about how we are "money grubbers" and "don't give a f- about animals" that we're committing "highway robbery" and that we're "just in this business to rape the f- out of people" like him.

 Yeah, buddy.  That's why we do this job.  We LOVE being verbally abused by you after giving telephone advice at ANY HOUR OF THE DAY for NO FEE. (Oh, wait, your daytime clinic isn't open? That's because it's TWO IN THE MORNING)

Tech 2: Gives similar advice as Tech1.  Second voice in the background is going CRAZY with rage. The caller hangs up again.

Repeat this process two more times, with increasing fury coming from the other side of the phone call.  Each time we picked up the phone, the caller expected that we'd know who they were based on voice recognition alone, and were mad at us when we didn't.  I'm not sure why they were so full of rage, especially given that we didn't charge them anything for the advice, we didn't demand that their pet be seen, and told them that we expected the ingestion to be non-toxic, but potentially irritating to the GI.....

People still confuse me.

A bad one -- **graphic post**

A few nights ago, we received a memorable call from a concerned pet-owner.  The caller stated that they had just arrived home, and found their cat (who was reported to be 100% normal when they left only an hour ago) to be suddenly "missing a leg and his tail."  The caller stated that he wasn't bleeding, at all.

We urged them to come in ASAP and we'd take a look.  We were all extremely skeptical as to what the truth would end up being, as the story was bizzare, to say the least.  It's impossible to have a severed limb, with no bleeding -- right?

The cat arrived, and to our amazement, the clients were right (at least in part).  The beautiful cat had a completely macerated hind limb, and a severed tail.  This was one of the most gruesome injuries I've seen so far; second only to the dog who had been hit by a train.  He immediately received pain medications, and I further inspected the wounds.  Remarkably, the kitty seemed quite stable, especially given the extent of his injuries. (Stop reading now if you're not interested in the details of the injury).

The cat's leg was unbelievable.  Distal to the stifle (knee), there was nothing..... except a foot, hanging by a single tendon. With each step, the cat would drag the nearly severed foot behind him. The leg was cold, dirty, and dry.  The remaining thigh muscles were severely damaged, and shards of bone were hanging from the remaining stump.  The family WAS right that the cat was missing a leg and a tail, however one part of their story didn't fit: this injury wasn't new. 

It appeared that a lawn mower was the cause of the injury, although I couldn't rule out attack by a large wildlife animal.  It had probably happened the night before, and the owners hadn't noticed until they arrived home that afternoon. 

I really wanted the opportunity to fix this kitty; all he needed was an amputation, antibiotics, fluids, and a little TLC, and he would have been back to a perfect family feline in a few days.  Unfortunately, while discussing treatment options, the family became very angry and combative.  It was realized that they had less than $5 to contribute to care, which was clearly not sufficient to provide intensive care and surgery.  The poor kitty was euthanized, and at least we could take comfort in knowing that we finally relieved many hours of pain and suffering that this cute kitty had to endure before his injuries had been realized.

Idiocracy

Client arrives with her kitten, who had a surgery 10 days ago.  The incision was healing well, until the client started to notice red, milky discharge coming from the surgical site.

Client has an e-collar with her, but it's not on her cat.

Me: "Did your veterinarian tell you that the e-collar should be on your kitty?"

Client: "Yes, but they said it didn't have to be when I'm supervising her."

Me: "Okay, so what about at night? Do you put it on her at night?"

Client: "No, because she sleeps with us!"

Me: "...... but you're sleeping, right?  So you can't be supervising her while you're sleeping.  She could be licking and chewing at the incision."

Client: "Ohhhhhhhhh....... I never thought of that."


I'm dumbfounded!! How can you be an adult, yet be incapable of thinking logically??!!


Next one:

Client arrives with a Chihuahua who seems to be painful.  Physical exam determines that "Chia" has pain in her neck.  The client doesn't know of any trauma; Chia is never outside alone, she's always supervised.  We treat for suspected disc disease, and Chia leaves the hospital.

Two days later, Chia returns because the client notices "red eyes."  Typically, this complaint from a client means that the pet has very slight reddening of the eyes, like conjunctivitis, for example.  Not this time --  Chia has scleral hemorrhage on both eyes -- this means that the whites of her eyes are red (it's actually quite creepy looking -- if you can handle it, go to google images and type in 'scleral hemorrhage.')

So, Chia now has neck pain, and bleeding in the whites of her eyes.  The most likely diagnoses are either trauma, strangulation injury, or a clotting problem (for example, rat bait, or platelet problems).

I asked the client again about trauma, explaining that this could explain both the neck pain, and the red eyes.  No, no, no way this could have happened.  Chia's feet almost never touch the floor -- she's a typical "purse" Chihuahua.  Testing for bleeding disorders commences.

PT/PTT were performed, and both were normal.  Platelet count was normal.  Chia's laboratory testing demonstrated that she was clotting her blood normally.

My colleague asked the client again about trauma.   The client FINALLY revealed the truth.

3 days ago, before her initial visit, Chia had been out for a walk with the client.  Two large dogs came up to them, and in fear, the client pulled Chia back by her leash.  The client then pulled Chia off the ground with her neck leash, and up into her arms.  This resulted in a temporary strangulation, and then the subsequent clinical signs -- neck pain and scleral hemorrhage.

Maybe the client could have just told us this the very first day!