Thursday, October 27, 2011

Sometimes we all fall down....

Two rough shifts in a row, and minimal sleep make for one very sad and emotionally exhausted ER vet. 

Two nights ago I performed a c-section on a 12 year old pug - yes, 12 years old.  The sweet old dog had delivered one stillborn puppy, and had four remaining in her uterus when she arrived to the ER.  Fortunately, I retrieved all four puppies alive!  Unfortunately, she had a rough recovery and required more care than a typical c-section patient.  Much of that to be attributed to her age and a moderate amount of bleeding during the surgery. Thankfully, her condition was not as a result of a surgical error, but simply a complication of her age, normal surgical losses, and other clotting factors.  As of this time, she's recovering well and stabilized, but it was hairy for a few hours.  Also unfortunate is that the clients are very upset with me.  I understand the frustration of not having your pet do well after an expensive emergency procedure, however I'm not all-powerful.  I'm human, and your 12 year old dog (compare to a 80-85 year old woman) should NOT be having litters of puppies.  This was preventable. Furthermore, I saved all four of her puppies (so cute!) and she's probably going to pull through, too.  I wish that the client could understand how much I care and how hard I work on my patients.

Last night I had a beautiful young male cat arrive with an obstructed urinary bladder.  I can't remember if I've written about this topic before, so I'll be sure to scan through and if not write a full informational post...  Most of these guys I'm easily able to treat, restore urine flow, and place a urinary catheter under anesthesia.  This cat was the second one in my career (of hundreds or thousands) that I wasn't able to relieve the obstruction.  Long story short, the clients nearly didn't allow treatment to start, so with the setback, they euthanized their beautiful cat.  I cried as I administered the euthanasia.  I feel like I let him down - but there was nothing else that I could have done to change the outcome.

So, as I said, emotionally exhausted. :( Time to go snuggle my pets.

Tuesday, October 25, 2011

No, you can't have that.

A case tonight reminded me of a constant battle between me and some of my clients --

A couple presented tonight with their kitty for a primary complaint of sneezing.  He is otherwise young and healthy, eating and drinking normally, with a normal temperature.  On physical exam, he has no nasal discharge, no ocular discharge, and no evidence of substantial illness.

His most likely diagnosis is a viral upper respiratory tract infection.  Similar to the common cold in humans (although caused by different viruses), a viral URI will NOT respond to antibiotics.  Antibiotics only kill bacteria, and do nothing to affect viruses.  Most mild viral URIs will resolve without any treatment.  Some do progress to involve bacteria; these patients usually have yellow milky nasal discharge, fevers, and are not eating.  Bacterial URI does require antibiotics, however viral DOES NOT.

Most clients walk in expecting to leave with a prescription, so when I diagnose their cat with a suspected viral URI, and give them the above information, they get very angry.  "Can't you just prescribe him antibiotics or something?" They say. "It will make me feel better to give him antibiotics..." and "Please, doc, it can't hurt anything, right?" 

Wrong.  Prescirbing antibiotics in this situation (or many others where they aren't indicated) only results in development of antibiotic resistance, as well as side effects on the patient from the antibiotics (typically vomiting or diarrhea), and does nothing to hasten recovery.

Antibiotic resistance is a real concern that affects each and every one of us - since the invention of penicillin in the 1950's, increasing numbers of bacteria have developed the ability to survive its use, resulting in the formulation of more and more classes of antibiotics (cephalosporins, fluoroquinolones, tetracyclines, aminoglycosides,etc).  The reason for the development of resistance is quite simple -- evolution.  The lifespan of bacteria is in the realm of minutes; with each generation they undergo natural selection, and evolutionary pressures result in replication of ONLY the surviving population.  Simply stated: if a population of bacteria is exposed to an antibiotic, only those who are resistant will survive.  Only those who survive are able to reproduce (the resistant population) and we are left with clones of those bacteria carrying the ability to resist antibiotics. (Obviously the actual mechanisms are much more complicated than this, however that level of detail is not needed in this discussion.) 

Each and every time antibiotics are used, the likelihood of a resistant strain emerging increases.  Of course, antibiotics SHOULD be prescribed for conditions that they are needed for  - bacterial infections.  Pneumonia, urinary tract infections, bite wound/skin infections, just to name a few appropriate uses. 

Prescribing an antibiotic for conditions that they do not treat, however, is an inappropriate use of a very important class of medications.  It takes me about 3 times longer to explain to my clients why I am NOT prescribing antibiotics; honestly, it'd be easier for me to just cave in and give them the pills. 

In the words of my mother -- "just because it's the easier choice doesn't make it the right choice." Responsible antibiotic use is a ethical obligation of the prescribing community, both veterinary and human.

The silent killer

A 3 year old, female spayed poodle presented to me about 2 months ago for lethargy and weakness. Her family reported that "Tia" had been having intermittent vomiting and diarrhea over about a week, but still was willing to eat.  She was lethargic today, and had been unwilling to rise for several hours.  "Tia" had been examined in the last week by her primary care veterinarian, who had dewormed her (a possible cause of v/d).  Unfortunately, she had not improved yet.

On physical exam, Tia was extremely lethargic, unwilling to lift her head, and refused to stand.  Her gums were pale pink, and her heart rate was elevated. Her pulses were not sufficient, and she was clearly experiencing shock due to dehydration.

I recommended immediate electrolytes, IV fluids, blood pressure monitoring, and full metabolic panel to be sent to the labratory.  I discussed with the clients that there were several potential causes of the chronic vomiting, however at this time, she desperately needed IV fluids and subsequent tests to determine her diganosis.   Potential causes of her illness included inflammatory bowel disease, addison's disease, ruptured foreign object resulting in severe abdominal infection, diabetic ketoacidosis, or many others.  Many of these can be determined from simple blood tests which would be performed immediately.

The clients authorized all of our attempts to stabilize their beloved Tia.

IV catheter was placed, and blood was submitted for electrolyte panels. Urine was collected and IV fluid boluses were initiated.  Her initial blood pressure was 70mmHg, below the normal minimum of 90mmHg - meaning that her vital organs (kidneys, brain, heart) were receiving inadequate oxygen.  Shock, as you have read in my blogs before, will result in death if it is left untreated.

While her first bolus was being administered, her in-hospital electrolyte panel results completed.  Significant abnormalities were present; her sodium was very low, her potassium was life-threateningly high.  Her blood pH was abnormal due to her shock state, and she was significantly dehydrated.  Her kidney values were also elevated.  The values were so abnormal that we repeated them twice be sure that they were real and not an error on the part of our machine.

The values were consistent.

Vomiting, collapse, low sodium and high potassium point to an endocrine (hormone) disorder called hypoadrenocorticism, or Addison's disease.   Addison's disease is an interesting lesson in phsyiology - and a very rewarding disease to treat.

In a nutshell, patients with Addison's disease cannot make specific hormones, (cortisol and aldosterone) that are required for vital body processes, includign sodium and water retention, potassium excretion, response to stress, maintenence of normal blood sugar, and other processes.  Lack of the mineralocorticoid hormone aldosterone (or insufficient quantities) result in loss of sodium and build up of potassium.  Loss of sodium results in severe dehydration, and buildup of potassium results in heart irregularities, and even cardiac arrest.

Tia's blood pressure improved with administration of IV fluids.  She also received medications to reduce the effect of high potassium on her heart. After receiving her lab results, I recommended the test to confirm addison's disease, called the ACTH stimulation test. Although high potassium and low sodium are enough to suspect Addison's, several other diseases can cause these changes, and ACTH stimulation is the test necessary to confirm its presence.  A blood sample is collected, and injection of a medication to induce secretion of cortisol is administered, and a second blood sample is collected one hour later.  This test will detect the majority of addisonian patients.  This test can be inaccurate if steroids are given prior to collection of both blood samples.

Within 6 hours, Tia was standing, barking, and appeared clinically normal.  She discharged within 24 hours, after confirmation of potassium returned to normal.  Treatment was initiated pending results of her ACTH stimulation test.

Treatment of Addison's disease requires supplementation of the mineralocorticoid hormone that is absent.  This can be performed with an injection (given about once every 25 days) or an oral pill (given every day).  The specific decision about which to choose is case-dependent.  Additionally, supplementation with steroids is often needed to replace the lack of cortisol.  Prednisone is commonly utilized in a daily dose, which should be increased during times of stress (travel, vet visits, addition of new pets, etc.).  Initially, electrolytes should be monitored weekly, but over time, may only be necessary 2-3 times per year while the patient is clinically normal.

Rarely, a less common form of Addison's disease (atypical Addison's) occurs where the patient has normal electrolytes.  These patients only require supplementation with steroid hormones.  Many of them, however, progress to typical Addison's disease with time, and so they require electrolyte monitoring over their lives, espeically in times of illness.  Atypical Addison's disease is also diagnosed with an ACTH stimulation test.

Tia's test confirmed Addison's disease.  She is expected to live a long, healthy life.  With proper monitoring, careful veterinary care, and correct medications, Addison's disease does not affect the lifespan of our canine friends.

Get better care for your pets!

Longer, healthier lives - that's what we all want for ourselves, our families, and our pets.

How can we receive better care for our pets?  How can we help our veterinarian to more rapidly and accurately diagnose causes of illness in our pets?  YOU, the pet owner, are the key.  You may not realize how very important you are in helping your pet to get well, and the purpose of this post is to help you better understand how the medical decision making process works.

Veterinarians and human doctors are trained to notice abnormal.  For human doctors, this is a bit easier, as their patients can tell them - "It hurts when I do this" or "I feel nauseated and I don't want to eat" or "I don't have any energy" , etc.  Of course with sick pets, this is impossible.    The investigation into their illness starts with a history from the pet owner.  Is your pet eating? How much? Weight loss? Vomiting? Diarrhea? Are they drinking more or less than usual? Hiding more than usual? Do they seem reclusive or try to bite you when you handle them? Decreased activity? Any other abnormal behavior?

 I can't begin to tell you how many times a client brings in their sick pet, places them on the exam table, and then cannot answer a single one of these questions.  "He's just not right" is not a symptom, and could be any one of literally thousands of conditions.  The more information you can gather by monitoring your pet's normal behaviors, the more accurate your veterinarian's diagnostic and treatment plan will be. Of course we can run hundreds of tests costing thousands of dollars in lieu of a good patient history, but this is obviously not economical and a much slower way to figure out what's actually going on.  As a result, observation of your pet's normal behaviors and being able to notice variation from normal is a VERY important part of your task as a pet owner.  If you can't tell me what's wrong at home, it makes it much more difficult to know where to start looking. It also usually increases the cost of testing as we have to rule out many more types of illness.

After the veterinarian talks to you about your pet's history and your concerns, they will perform the physical exam.  This is where our trained eye will detect outward signs of disease -  pain, nausea, dehydration, fever, enlarged lymph notes, masses, swellings, etc. Although every veterinarian is specially trained to perform physical exams, there are many diseases which have vague outward signs, which look like other diseases, and/or which cannot be completely diagnosed with physical exam alone.

With these two components combined, your veterinarian will create a problem list.  The problem list will be followed by "differential diagnoses", or a list of the diseases that could be causing your pet's symptoms.  If you've ever watched House, you've seen a dramatized version of this in every episode. The differential diagnoses will help your doctor to systematically rule out specific causes of illness, narrowing the long list of possible causes.

Hopefully these comments help you to remember to observe your pet's normal behaviors, so that when they become abnormal, you'll be able to recognize it right away and get your pet the medical attention she/he needs.

~ER Doc

Monday, October 24, 2011

The mother of all emergencies !

The title can only mean one thing - Gastric dilitation and volvulus, or GDV.

GDV used to frighten me - but after my several jobs in the ER, it's now one of my favorite things to treat.  It's adrenaline inducing, requires significant technical skill, lots of medical and surgical knowledge, and has the potential to be cured.  It's a condition where I can definitely say that I saved the pets' life - without me, they would have faced certain death. I don't have a specific patient to share with you, but at the request of a reader, I wanted to provide some information about the condition and hopefully improve awareness and understanding of this condition.  Hopefully your pet never experiences GDV, but if they do, you'll be prepared.

What is GDV?
GDV is an extremely life-threatening emergency.  GDV is most common in large breed, deep chested dogs.  Great Danes, Pitbulls, Boxers, Chows, Greyhounds, and Labradors are among the most commonly affected breeds.

Typically, a GDV patient will start with initial symptoms of restlessness, a bloated or distended appearance to the abdomen, followed by unproductive retching, panting and pain.  This quickly progresses into a patient who becomes moribund; unable to walk, move, with a very high heart rate, pale gums, signs of shock, and rapidly progresses to a lethal state.

Why does it occur? 
Like so many medical conditions, the specific cause of GDV is unknown.  What is known is that the stomach fills with gas, rotates, and then leaves both the inlet (the esophagus) and the outlet (the pylorus) unable to let anything escape the stomach, including gas.  As the stomach fills like a balloon, it becomes massively stretched, compromizing blood flow to other organs, damaging the lining of the stomach and reducing much-needed blood flow to the stomach wall, and compressing large veins within the abdomen.

What can I do at home?
GET TO A VETERINARIAN IMMEDIATELY.  There is absolutely nothing you can do for your pet at home except for remain calm, place them in your vehicle, and travel to your nearest veterinary facility (this may be your general practicioner, or may be an emergency hospital).  Do not waste time at home.  Once the symptoms of bloat are noted, immediate action is imperative to recovery of your pet.

Upon arrival to the veterinary facility, your pet will be triaged.  Technicians and the veterinarian will evaluate vitals, including mucous membrane color, heart rate, pulse quality, evaluate the distention of the abdomen.  If symptoms are consistent with bloat, the veterinarian will recommend immeidate action, including an IV catheter, IV fluids for blood pressure support, pain relief, and decompression the stomach.  After your pet is receving these treatments, radiographs will be recommended for the definitive diagnosis of GDV.  A patient with GDV would have a radiograph (x-ray) that looks something like this:

Image from public domain, wikipedia commons
This image represents the stomach, filled with gas (dilitation) and twisted (volvulus).

Can my pet be saved?
 In a word, yes.  Advances in veterinary medicine over the last 20-30 years have significantly improved statistical outcomes for GDV.  Treatment however, can never guarantee a successful outcome. These are just some of the things that your veterinarian must consider when treating your pet with GDV:
  • Rapid, accurate diagnosis
  • Stabilization of obstructive shock caused by the massively dilated stomach
  • Restoration of blood flow to vital organs
  • Stabilization of blood pressure
  • Evaluation of electrolytes, lactate (an indicator of shock), and kidney values
  • Evaluation of concurrent illnesses (some pets who GDV are geriatric, with other conditions to consider) 
  • Balanced, multimodal anesthesia in a patient who is significantly compromised (very much unlike a young healthy patient for a spay or neuter)
  • Maintaining sterile surgical field
  • Abdominal exploration to untwist the stomach and asesss vital organs
  • Assessment of the stomach wall, which can become necrotic (die off) as a result of the GDV
  • Management of hemorrhage
  • Management of cardiac arrythmias which commonly occur in conjunction with GDV
  • Careful, gentle tissue handling, conscientious surgical technique
  • Attachment of the stomach to the body wall to prevent any further twisting in the future (a pexy)
  • Adequate post-operative monitoring and supportive care
This is not indented to be an all-inclusive list, but is intended to give you some idea of the degree of education needed to recover your pet when they experience GDV.  Some statistics estimate that 70-80% of GDV patients survive to discharge.

How much will it cost?
As a result of the involved care, GDV is an expensive condition to cure.  Depending on part of the country, cost of living, and your pet's specific conditions, development of complications, ets, an average GDV treatment may cost in the realm of $2500-$6000+

What will my pet's life be like afterwards?
Most pets who recover from the surgery of GDV go on to live normal, active, happy lives.  Most patients who have a pexy performed can never twist their stomach again; however, there are reports of second-time offenders.  This is fairly uncommon -- in one study, only 6% of patients treated experienced a second torsion at some time in their lives.

Is there any prevention for GDV?
Actually - YES!  At risk breeds can have a prophylactic gastropexy, which is the same as the pexy discussed above.  It prevents twisting of the stomach, and can be performed easily at the same time as a spay (for a female dog), relatively inexpensively and without the need for a second surgery.

Questions? Bring them on in the comments!

~ER Doc

Friday, October 21, 2011

Not keeping up....

Hey readers,

I'm still here -- but I've come across a month of boring cases and un-exciting clients.

Are there any diseases you want to know about?  Is there something you've always wanted to ask but were too afraid/embarrassed/timid?

Comment on this post, and I'll get to writing about it for you!

~ER doc

Saturday, October 1, 2011

Word to the wise....

Call me crazy, but.....

If you show up with bloodshot eyes, stumbling, and a giant pot-leaf tattoo on your leg with a dog who has the clinical appearance of marijuana toxicity, I'm pretty sure it's marijuana.  I'm also pretty sure it's NOT from your neighbor throwing pot over the fence.....

Then, when you try to "prove" to me that it's not marijuana by showing me the 15 $100 bills in your wallet, you've only proven that you're a dealer, too.

And after I show you the positive urine drug test for MARIJUANA, you still don't agree with my diagnosis?  Okay, cool, man. I'll trust the stoner over the veterinarian any day.  It's totally something else.