Psychopaths

Several weeks ago, the police department brought in a kitten who had been smashed on the head by a 17 year old.  This was witnessed by another person, who had called 911.

The 1.5 pound, 8 week old kitten was critical at arrival, with pinpoint pupils, minimally responsive, and clear evidence of brain swelling secondary to his known head trauma.  We quickly placed an IV catheter, administered fluids and mannitol, and kept very close watch of him in the initial hours.  He struggled through the first hours of therapy.

The next day, the kitten was significantly improved, but still having neurologic issues; he pressed his head against the cage door, and constantly circled toward the side of the head that had been injured.  He was unable to eat or drink, and only time would tell if he would continue to improve to a functional pet.

Several days later, our cute little kitten is a bundle of joy!  He's eating, drinking (although sometimes, he just steps in the water and spreads it around his kennel), and he is starting to play.  He's gaining weight well.  Now he just needs a home. Another live saved, and a heartwarming turn of terrible events for everyone here at the hospital.

Unfortunately, no charge were filed against the individual who performed this heinous act.  The even sadder part of the story is that so many adults who perform violent acts against animals will either repeat their acts, or increase their violence to then be against humans.  It boggles my mind that someone would willingly and purposefully inflict damage to such an innocent, sweet, pure life.

In any case, he's nearly better now.  Until he finds a home, it sure is nice to have a kitten around!

Little man syndrome

Last night, a couple arrived with their cat.  Unfortunately, they had run over their 2 year old cat.  The kitty was severely injured, and had no ability to move or feel his hind legs.  He was paralyzed, among other injuries, and there was no way we could fix him.

The clients had zero dollars to contribute to care, which actually didn't change the outcome for their poor little kitty as there was no way we could fix him.

The client acted like a fool.  He walked in with his chest puffed up as if he was a cartoon character, and his shoulders back, storming around our lobby.  He screamed at the receptionist, and made irrational requests.  We triaged the cat, discovered the extent of injuries, and I discussed the sad news with him.  I hoped the exam findings would give them some small amount of relief, at least to know that it wasn't a financial decision.

 "GIVE MY CAT THE F***** INJECTION ALREADY!" the man screamed as he stormed around our treatment room, threatening both me and my staff.  "F***** DO IT ALREADY!"

The man acted as if he was on a 'roid rage.  I stated over and over how sad I was for his loss, and how sorry I was that he was losing his kitty.  I asked him to step away so I could give an intraperitoneal injection, as there was no possible way to hit a vein on his shocky, dying, painful cat (IP injections are non painful, but take about 5-10 minutes for effect and are used in patients like this, when venepuncture is not possible).  He screamed at me again, and finally, I had to raise my voice.  I told him that he needed to calm down, and leave the room, or I would call the police.  He finally stepped away.  I didn't trust this man to be around a needle and controlled medications, and I had to trust my instincts.  I also didn't trust him not to flip out as I gave the injection.

After I gave the injection, I asked him if he wished to come back to be with his kitty.  He continued to scream obscenities, and act as if he wanted to pick a fight.

"I don't understand why you are upset with us," I told him. "We're just trying to help relieve your kitty's suffering.  He has a non-repairable condition, and there's no way for him to ever walk again.  I'm sorry he got hit, and I know this must be hard.  You have to realize that we're here to help you and your cat."

"I'm F***** PISSED!!! I AM SO ANGRY!" He screamed, over and over again.  I re-stated the above.

His kitty passed peacefully, and I stayed with him the entire time, as much as I hated the way he was treating us.

Finally after his cat passed away, he apologized briefly for his attitude, and quickly said that he was just mad at the situation.

Mad at the situation doesn't give you the justification to act like a fool and threaten our staff.  What a moron.

Update

Dudley, the patient from my previous post (the precordial thump) is doing very well!  Just thought you all would like to hear the great news!

LIVE, DAMN YOU, LIVE!

Had an amazing, busy, hectic weekend at work.  The first case I’d like to share, and the most dramatic of my life is “Dudley,” a 3 year old black lab mix.  I met him 3 days after he had been admitted to the hospital. On July 3rd, Dudley was tied in the back of his family’s pickup (always a bad idea), and he jumped out of the moving vehicle,  As a result, he was hit by the car, as well as dragged for a distance until the driver realized and stopped the car.

At his initial admission to my colleagues, he was a severe multi-trauma patient; he had blood in his chest (hemothorax), air leaking from his lungs (pneumothorax), broken ribs, severe road rash, a large laceration in his left axilla (armpit region).  He was not able to stand, but had been stabilizing over the first 72 hours in the hospital.  Just prior to my arrival, Dudley had received a blood transfusion due to ongoing mild bleeding, probably due to a low platelet count, and potentially the start of DIC (disseminated intravascular coagulation; see previous posts).

This is when I met Dudley for the first time (my first shift back to the hospital).  My colleague and I discussed his case in rounds, and I performed my initial physical exam.   Although Dudley’s red blood cell level was improved with the blood transfusion, he looked shockingly worse; his gums were pale, his breathing was labored, and his urine began to discolor.  Dudley’s bruising was more than expected for a patient in his condition.  

I went to work.  SPO2 revealed that Dudley was hypoxic on room air; I provided him with supplemental oxygen and rechecked his labs.  Something wasn’t right; although his electrolytes were normal, his arterial oxygen saturation was way, way too low.  I rechecked chest radiographs looking for ongoing bleeding or leakage of air.  The radiographs were identical to those taken 24 hours previously, ruling out this as a cause of his deterioration.  I tried to contact his owners, but was unable to reach them.  

A dedicated assistant was assigned to monitor Dudley closely, as I was concerned for his imminent arrest.  His respiratory rate and effort worsened, and about 2 hours after I had examined Dudley for the first time, it happened.  His heart rate shot up to 220 beats per minute.  We raced to administer lidocaine, an anti-arrhythmic drug, and applied an ECG.  As I applied the ECG clips, we noted that the lidocaine had made no change in his rate or rhythm.  Just as I pushed more lidocaine into his IV line, the ECG revealed the most serious of all cardiac arrythmias :  ventricular fibrillation.

Ventricular fibrillation is a terminal rhythm if it is not corrected immediately.  V-fib basically means that instead of working as a functional pump, the heart was fibrillating, or twitching, without actually moving any blood forward.  The electrical activity of the heart needed to be reset to provide a chance for the muscle cells of the heart to work together once again.

This is where the story gets amazing.

With only seconds to spare, I performed a precordial thump on Dudley.  (This is like in ER, when the doctor pounds on a dead patient’s chest screaming, “LIVE, DAMN YOU, LIVE!” and the patient miraculously is revived.  Only it usually fails.)  The precordial thump, or a strong well placed strike of the heart, can sometimes provide enough energy to reset the electrical currents.  I’ve perfomed this twice before, and had never seen it work.

This time, it worked.   (I can’t quite put into words how unbelievably amazing this is!)

Dudley’s rhythm converted back to a life-sustaining rhythm.  I’m pretty sure I screamed, “OH MY GOD, IT WORKED!”  High - fives all around the hospital, and then back to work - as you can imagine, post arrest patients are among the most fragile, and a high percentage of them crash and arrest again within minutes or hours.

I continued to try contact the family; and was still unable to reach them.  3 hours later,  despite his death, and despite the seemingly insurmountable odds, Dudley’s family finally received my voice mails, returned my calls, and shed tears of fear, joy, fear and then joy again.  He had survived ventricular fibrillation.

Sparing the medical details and lots more hard work, 2 days later, Dudley is eating.  He’s off all heart medications, has normal blood pressure, improved bloodwork, his platelets have rebounded, and is still recovering.  He has a ways to go, including healing his wounds and a possible limb amputation, but he is expected to survive. 

This will truly be one of the most memorable cases of my life.    I can’t wait for the next one.

+1 for the home team :)

~ERDOC

)&*&#$^&!

I'm frustrated and irritated about my last 24 hours at work. Here's just two of the reasons why.


Situation #1
Pet owner calls and states that their dog just ingested rat bait, a poison that results in bleeding.  We let them know that this is an emergency, and they should come in immediately so we can induce vomiting, give charcoal and likely prescribe the antidote for this type of ingestion, vitamin K.   Seems pretty straight forward, right? A problem that we can fix.  A GREAT prognosis, if we act quickly.

You can read the specifics about the disease here, if you like.  The basic principle is this - rat bait is a POISON that works by making rats bleed to death.  It can do the same thing to dogs and cats, if they eat enough.  After ingestion, prevention of toxicity is by decontamination (as above - removal from the body with vomiting, and charcoal to prevent absorption).  If you do nothing, your pet is at risk for life-threatening bleeding.  Once bleeding occurs, the treatment is plasma, and vitamin K, which carries a significantly higher cost and chance of death than dealing with the problem right away.  ESPECIALLY if you watched them eat it.  WHY would you take the chance?

This particular person did not seem to agree with the above.  The man argued with my staff on the phone, and after several calls and two or three hours later, he finally arrived.  He was rude, insulting, and an all-around jerk with my staff and myself. He reluctantly agreed to let us induce vomiting on his dog, and when we he finally did, unfortunately, no rat bait came up.  He waited too long for successful vomiting.  This person continued to do nothing, except for  insult me, my staff, and complain about our prices. "HIGHWAY ROBBERY!" He screamed, "It's not even an EMERGENCY!" (Yes, sir, it actually is.)  Complaining about prices to me at my ER is like complaining to the checker at the grocery store.  The cashier scanning your items has exactly as much control over the price of bread as I do over the price of the exam, or the cost of inducing vomiting -- that is, ZERO control.  Mr. My-dog-ate-rat-bait-for-the-second-time-and-it's-your fault bitched, moaned, screamed and stomped his feet.  He yelled that his daytime doctor would have charged half of our fees.  I tried to help him understand that keeping the pet ER open is expensive (see a very well written post by Homeless Parrot, here), but it didn't matter.

I really don't like getting yelled at for trying to do the right thing.  It's not my fault you didn't pick up the poison.

Situation #2 -

Client arrives because her very small dog just ingested a whole, very large rib bone.  I performed and exam and discussed options with her; essentially 1)endoscopy to attempt retrieval without surgery 2)try to induce vomiting, with the known risks of this sharp bony item 3) surgical removal, or the least safe option, 4)wait and see what happens.  The bone was very large compared to the 15# dog, and had an extremely high probability of becoming obstructive, or causing damage to the intestines.

Fortunately, her pet was stable.  Unfortunately, we were very busy and the client had to wait about 30 minutes for x-rays as there were several pets to have exams, images taken, or procedures performed before it would be her pet's turn (including a dog that was laterally recumbent and unresponsive, a cat having difficulty breathing, and a dog who couldn't urinate.  All obviously much more emergent and therefore, triaged ahead of her dog, who wasn't yet vomiting or painful).

What did the client choose to do?

She left in a huff.   Now that's really going to help her pet, isn't it?

It's not my fault your dog ate the bone.  I'm just trying to help fix it.  It's not my fault that there are other animals here who are more sick than yours, increasing your wait time.  If your pet was dying, you'd want us to see it first, too.

I'm a people pleaser, a hard worker, and I'm dedicated to fixing pets.  It frustrates me when clients don't believe that we work long shifts and stay up all night to HELP, when they assume that we have bad intentions, when they are unkind, and when they don't let me help their pets.

When caring hurts.

I apologize for my long absence - the last two weeks at work have been insane.  I'll try to re-cap the interesting details over the next few days. 

Several days ago, I was presented a 14 year old, laterally recumbent akita mix who had been in a state of seizure for over an hour.  Her owner, Lila, was hysterical. She called us about 2 hours prior to arriving, and we urged her to come in as soon as possible. When she arrived 2 hours later, her dog was in critical condition.  "Pep" was unable to rise, or even lift his head; his gums were gray and his blood pressure was dismal. His pupils barely responded to light.  It was clear to all of us who were there that Pep was dying, and his chances of survival, even with optimum care, were very poor.

Lila was an emotional wreck.  I explained to her the physical exam findings, the possible causes, and the consequences on the body of having prolonged seizures, as well as sustained hypotension.  I offered to her a treatment plan, but explained my concerns that it was unlikely to be successful, and that I was worried his chances of returning to a normal life were very poor. 

So far, a normal story.  This is where a sad story and a loss of a beloved family member becomes an enraging, nightmarish case that makes us all want to run screaming from the building.

After the first 30 minutes, we had gone over the history, my findings, and my recommendations two or three times - pretty standard for someone who is upset over their very ill pet. I'm used to explaining things several times, in different ways, and I definitely realize that the general public does not understand how the body works - that's my job.  This case, however, was not a normal one.  It went something like this:

Client: "If I could just get him home, I only have to wait 5 more hours to get him to the vet."

Me: "I understand and respect that you trust your general practitioner very much, and I'm sorry that they're not available right now.  I'm a licensed veterinarian, and we're capable of providing treatments here, right away, until your doctor is open.  Pep is critically ill, and he will die if we do nothing.  We need to help him now, or we need to end his suffering.  Without treatment, he'll die."

Client: "Can't you just give him some medicine? Like a shot of antibiotics or something?"

Me: "There's not one drug that is going to fix Pep; we need to start with testing, IV fluids, and getting his blood pressure back up, and monitor his progress.  He's in critical condition, a shot of antibiotics is not going to fix him."

Remember, the dog is comatose, and doesn't even respond to light in his eyes.  He's this way for about 2 hours, and we go over the recommendations literally 20 times.  The client does not authorize any treatments- she allows an IV catheter to be placed, but does not allow bloodwork or IV fluids.  At the 2nd hour, her level of emotion raises to hysteria.  She wails and cries, and screams that she will die without her dog, and that she has no reason to live.  Her friend tries to console her, but nothing he says provides comfort.

At the third hour, watching Pep gasp for breath, agonal, and dying in front of our eyes while we stand by and do nothing, Lila finally signs the consent forms for euthanasia, but it doesn't end there.  She calls me in to the room, and then screams and sends me back out 3 times; her friend had given up on her and went outside the building (he couldn't take it any more).

I find it difficult to quite explain the details of this situation without sounding callous, uncaring, and unsympathetic.  I've been through a lot of very sad, emotional euthanasia with families and their pets, and I can guarantee that this one is the outlier.  Most clients are understandably very sad, and I always take the time to give my deepest sympathies, to let them greive as long as the need, and to make them comfortable with every step of the process, including ensuring that they feel 100% comfortable with their decision.   I've lost pets in my lifetime, and I love my furry family members like family.  I've shed tears over particularly sad cases, and always feel empathy for the loss of love and life that accompanies every single euthanasia, regardless of the circumstances.

The type of situation above is a client with severe emotional disturbences or personality problems.  I'm (obviously) not a trained psychologist, and veterinary school does not begin to teach us how to handle these types of people.  Dealing with this case for 3+ hours, while watching the patient suffer is one of the most awful parts of my job in the ER. There's nothing more emotionally draining than a hysterical, screaming, emotionally unstable person.  Cases like this are the fast track to compassion fatigue, which is rampant in the medical community.

A concurrent problem with a case like this is the client's pathologic attachment to a pet (which, in general, means an excessive, harmful dependency on the pet).  The human-animal bond is an extremely important part of society, and in the veterinary profession, the key ingredient that allows people to care for their pets.  A serious problem arises, however, when the attachment to the pet is above and beyond a healthy bond; for example, when the client threatens to harm themselves if the pet dies, claims that they cannot go on in life without their pet, or similar.  Obviously, no cat or dog can live the lifespan of a human, and unfortunately even with every advance in medicine (veterinary AND human), death is a part of life.  Clients like the one above need a trained psychological professional to guide them through understanding and healing - a position which I am clearly not qualified to fill.