whoops.

Around 2am, an older woman and her basset hound arrived.  He seemed painful, and the client was concerned.  During my examination of her sweet old dog, Fritz, the client let one rip.

"My, oh my, I don't know what I've been eating lately that's just made me a gas factory!"

It was the fart heard 'round the world; as she was still farting, she was already apologizing.  I managed to maintain my composure, and dismiss it as not a big deal, but through the doorway, I could see my staff absolutely losing it.  They turned bright red, tears of laughter, and had to go outside to avoid being offensive. 

Much needed comedic relief for a stressful shift!

Spaying saves lives.

It's incredible how much something as seemingly simple as the recommendation for spaying female dogs can become a controversial issue.  

Last night I received a patient on emergency for evaluation of difficulty breathing.  She was 12 years old, and a large mass was present in association with her mammary gland.  The clients approved radiographs (x-rays) of her chest, and unfortunately the result was catastrophic - she had widespread cancer throughout her chest.  Unfortunately, at this stage, there was no therapy that could help my patient, and her family was forced to say goodbye.

What could have prevented the development of mammary cancer? The common spay procedure (medically known as ovariohysterectomy), if performed prior to the first heat cycle, reduces the risk of mammary cancer to nearly zero percent.  Incredibly, dogs who are allowed to have more than one heat have a risk of almost 1 in 4.   Up to half of these cancers are treatable, but the other 50% may not be curable even with aggressive care.  As with any medical conditions, PREVENTION is always better than treatment.   You can read more about mammary cancer in dogs here.  Spay also prevents ovarian and uterine cancer as these organs are removed and obviously cannot develop cancer if they are no longer left in the patient.

What other reasons do you need to spay your dog? More? Sure! I have plenty more!

You may recall my post, titled "Happy Freaking Fourth of July."   Across the country, veterinarians witness thousands of cases of unwanted pregnancies in dogs and cats every year.  In the "best" case scenario, puppies are delivered easily, with no medical intervention.  These puppies add to the pet overpopulation problem and many end up in shelters, roaming, or being euthanized due to lack of a forever home.  In the worst case scenario, as in the story above, the female has difficulty delivering the puppies, requiring either emergency c-section and putting the mother's life at risk.   Each and every time I talk to a client who doesn't want to spay their dog or cat, they think they can keep their female away from a male while she is in heat - but biology is a powerful thing.  The male cat or dog's drive to find female dogs in heat and the female cat or dog's biological drive to be bred are instinctual - and the only 100% error proof way to prevent these tragic situations is by spaying your dog or cat.    

  (I've even had a client with both an unspayed female and an un-neutered male living in the SAME household tell me that she didn't think the female would get pregnant because the dogs were littermates and "they wouldn't want to do that".  Sorry, but dogs don't have social stigma or logic - they just have instincts and hormones).

Reason #3: Pyometra prevention

So, if your unspayed female dog is lucky enough that she doesn't accidentally experience pregnancy, and doesn't develop mammary cancer, what other risks of illness could she possibly have?

Another life-threatening disease of female dogs is pyometra; or infection of the entire uterus.  Each time a female dog cycles, the lining of her uterus changes. Over time, the lining can harbor bacteria, and result in a uterus that is enlarged and actually full of pus (disgusting!).  If left untreated, the bacteria spread throughout the bloodstream, causing kidney failure and severe metabolic derangments.  The only treatment for pyometra is a spay surgery; although these patients are much older, usually very sick, and with a uterus full of pus, the surgery has many more risks than a spay on a young dog.  This condition is 100% preventable.  You can read more here.

It seems pretty obvious - spay your dog (or cat) before her first heat cycle, and remove her risk of mammary cancer, ovarian cancer, uterine cancer, life threatening uterine infections, and unwanted litters, and also help prevent puppies and kittens from being euthanized or living their lives alone in a shelter.

Questions? Any theories you've heard why NOT to spay your dog? Ask me in the comments!

~Erdoc

This is what makes me tick

On a quiet, rainy weeknight shift, the doorbell rings at 1030pm.  Even after all this time in the ER, my heart still flutters a little each time - what will it be? Will the client be friendly? Will they be able to treat their pet? Will I be able to fix it?

An older gentleman approaches the receptionist.

"My dog had a c-section here about 4 months ago, and I was sort of wondering if the doctor who did the surgery is here, and... " he trails off.

I panic a little inside. Instantly, I focus on the worst things --  Was it me? Is something wrong? Is he angry? Did the puppies die? Is he here to demand a refund, or complain about care?

The receptionist types in his information and brings up the chart.  I review it  -- and it WAS me who did the c-section, but I retrieved 100% of the puppies alive, and they all went home doing well.  What does he want?

I nervously head up to the lobby - and and amazed by the truth.

"I just wanted to know if you wanted to see the puppies you saved" he said.  "I also wanted you to know how thankful I am, and I just wanted to come by - I don't mean to impose, but if you want to see them, they're in my car."

"OF COURSE I want to see them!" I exclaim (Fortunately, we're not that busy at the time). "Please, please bring them in!"

The gentleman brings in two beautiful, bouncy, playful, healthy, well cared for puppies.  They bounce around the lobby and are truly a joy to behold.

A simple act of thank you renews my passion for the profession.  Invigorates my empathy, inspires me to be a better doctor, and compels me to always give people the benefit of the doubt and not to anticipate the worst.  Thank you, kind client, for reminding me why I love my job.

~ERdoc

Stupid client phone call of the day AWARD!

Today was an insanely busy day in our emergency room, full of very sick pets, trauma, and animals who truly required our attention.  In the midst of our hectic day, trying to efficiently manage multiple emergencies at once, I happened to have the misfortune of answering this phone call:

SCOTD: (Stupid client of the day)

"Hi, my dog has some sort of swelling on his butt, and I didn't know what it was, so I cut it open, and now it's bleeding and I can't get it to stop.  He doesn't seem to be in pain or anything, but it's bleeding a lot."

Me: "Well, I'd definitely recommend you bring him on in so we can take a look; apply pressure and head on in. If your dog is bleeding then we want to get that stopped right away"

SCOTD: "Well, just tell me what you guys would do and I'll do it at home."

Me: ".... You want me to tell you what I would do on a bleeding area of your dog that I can't see over the phone? We might do surgery, we might need to ligate something, we might need cautery. You expect me to tell you how to do that over the phone?

SCOTD: "Ya, just tell me what you'd do and I'll do it myself."

Me: "That's just impossible.  If your dog is bleeding, bring him in right away."

SCOTD:  "Right, fine"

-They never showed up.  Do people call their human physician and act like this?

She's not your "sweetie"

I'd sat around for the first 13 hours of my 14 hour shift, anxiously watching the clock and waiting for the time to go home.  Having no patients for an entire day renders me a little stir-crazy.
And then it happened, 45 minutes before the end of my shift.  Doorbell rings, technician greets a new client at the door. Dog is a 7 year old, muzzled, growling Sharpei.  The client is bleeding from her face, hands and both legs. We all don gloves and start to ask for details of the situation.

"My dog got attacked by a pit-pull!" she screams. "You know how them pit-pulls are!" (no, that is not a typo.  She wrote and pronounced it in this manner).

My technician answered "yes, I do know how they are. I have one, and she's the sweetest dog on earth.
....
Now, why are you bleeding?"

The woman replies that her OWN "sweetie" bit her on the face, legs and hands. She baby talks her dog as it snarls, growls and snaps at her and everyone who approaches it.  From a distance, I can see he has multiple bites and lacerations over his back and neck, which require flushing and surgery, as well as probably drains and closure.  These are big wounds - but I can't get near enough to actually see the extent of the injuries.

I've dealt with a lot of scared pets over my years in the ER.  I know how to read them, approach them, and when to give them space. This dog wasn't simply scared, this dog was unsocialized, aggressive, fearful AND dangerous.  In order to be able to even get within 4 feet of her, we had to find some way to protect ourselves from the client's fate. I wish I had a dart gun (like they use on wild animals), but alas, we don't keep those lying around since 99% of our patients are friendly (or at least approachable!).  We sent the client to the human ER to get her wounds addressed while we took care of her dog.  As she left, she didn't seem to understand the gravity of the situation.

"Bye sweetie, mommy loves you" she cooed, as the dog growled and snarled AT HER. "Mommy will be right back to take you home."  I was dumbfounded - how do you get bitten in the face, and not realize that your dog is a terror, a danger to society, and could someday kill a child, someone's pet, or at least seriously maim an adult!?

Unfortunately, this patient was so nasty that it took all of my staff's strength, a rabies pole, three broken leashes, a broken muzzle (meaning she could now bite us un-hindered), three doses of drugs and 45 minutes to be able to get this dog even close to a handleable state. Once an adequate level of sedation was finally achieved, I took care of her gnarly wounds and recovered her, carefully.  The great news was that none of my staff or myself got injured - but the bad news is this dangerous dog is back out in the world, with no hope of training, rehabilitation, or any sort of behavioral therapy to help treat her obvious anxiety, fear, and socialization issues.  Regardless of the fact that we risked injury to ourselves, had to clean up the poop and urine sprayed around the clinic for hours, and cared for this woman's dog, she still would complain about the fact that my record indicated that her dog "had bitten."  You know what? I'm here to tell the truth, not the truth as you see it.

I ended up leaving work 2 hours late that night, exhausted, frustrated and with no real reward.  Usually I'm happy to have fixed an animal, even if the owner is awful, but this time, I worry that fixing the animal could result in future harm for some other creature. Euthanize? I think it probably would have been the right thing to do, but there's no way that this client could see her "sweetie" for what she truly was - anything but.

~Er doc

Kudos

"Do you have an internet survey?"  my client asks, after receiving my update on her pet this morning.

"Not a specific one, but we do have paper surveys in the clinic. Why?" I replied.

"Because you were fantastic!" She said. "And everyone should know you are terrific!"

Positive feedback is amazing!

~ERdoc

Ouch.

Clients rushed in the front door, carrying their 60#, 2 year old German shorthair pointer.  "He's been shot!"

I quickly assessed the patient, "Theo."  An entry gunshot wound was present on his flank, and an exit wound on the other side.  His mucous membranes were gray, and he was unable to stand.  Theo was suffering extreme shock, and likely bleeding internally from the gunshot wound.

His family immediately approved triage care, and an IV catheter was placed.  IV fluids were started, initial labs collected, and pain relief medication started.

"Do you know what happened?" I asked the family.

Through tears, the family explained what had occurred. "We let him out to pee..... We heard a gunshot and ran outside, and found out that he had jumped over the fence.  The neighbor shot him just because he could....." The story broke away as the clients sobbed and hugged each other.

I returned to assess Theo.  Therapy managed to improve his vitals, but he was still in a critical condition, likely due to internal injuries, bleeding and possible rupture of vital organs.  His abdomen was becoming visibly more distended by the minute.

The only option for Theo was an immediate abdominal exploratory surgery to assess and attempt to repair damage.  His family and I discussed risks and benefits of surgery, with ultimately no other way to try to save his life. It was surgery, or euthanasia.

The clients elected to proceed with surgery, with the clear instructions given to me that if it didn't look like a good chance at survival, then euthanasia would be their choice while Theo was under anesthesia.  As we prepared Theo for anesthesia, blood started to pour out of his gunshot wounds.  Pressure was applied, a unit of blood prepared for transfusion, and he was prepped for surgery.

Within minutes I was in his abdomen.  My assistant applied pressure to bleeding vessels and held the body wall out of my way while I quickly assessed for injuries.  One puncture to his bowel was found.  Then another. And another.  Ultimately, I located 9 perforations, 2 places were the intestines were nearly severed, and his major blood supply to the intestines was severed in multiple locations. Feces and tapeworms oozed out of the open intestines, and blood was everywhere.

I made the call.  There was nothing left to sew together, and, in reality, no chance for Theo to recover from this injury.  The clients and I made the difficult decision to let him go.

Theo's family returned to say goodbye.  I grieved with them, and they shared memories with me of his life.  The family thanked me for trying, and thanked me for being their in their time of need.

For the rest of the evening, my staff and I tried to understand the mentality of the person who shot at this kind, young, great looking dog.  I understand if the person's life, children, or pets had been in danger...... but out of spite? Because your neighbor's dog jumped the fence and *gasp* stepped on your property? I just can't understand.

I'll be thinking about that family and their loss for a long time.  I know we did everything we could - I just wish the injuries had been repairable.

~Erdoc

But it doesn't hurt...

A frantic lady arrived, screaming "He's choking, he's choking! My baby is choking!"

The technician who answered the door quickly took at look at the 3lb hairless chihuahua who was clearly not choking.  He growled as she approached him to look at his mucous membrane color.  His vitals were normal, and he and his family were placed in an exam room so I could come take a look.

I entered the room, introduced myself as usual, and asked the client what she'd been seeing at home. Clutching the dog to her chest, she told me that the dog had eaten some cat food and suddenly started choking so she rushed right in.

I tried to get a look at her dog, but she clutched him closer, burying him in between her breasts.  Without touching something inappropriately (which I was obviously not willing to do), there was no way for me to access even one square inch of her 3 pound dog.

"You're going to have to put Zorro on the table so I can take a look at him," I said.  "I can't see him when you've got him held that tightly to your body."

She set Zorro on the exam table, and then leaned over, burying him again in her generous bosom.

"Ma'am, I am really sorry, but I need you to allow me to see your dog and get my hands on him so I can help you figure out what the problem is.  You can hold on to him with your hands, but you'll have to take a step back from the table so he's not buried in your ..... body."

Finally, she complied.  At this point, Zorro started to show his true colors.  He growled, snapped and snarled when I even attempted to place a stethoscope on his chest.  He refused to allow me to look at his face, and forget thinking about approaching his mouth.

The client picked Zorro up and clutched him desperately, as if I'd beat him with a bat.

"I'm sorry, I'm not going to be able to look in Zorro's mouth," I said.  "He's too scared and aggressive, and if I get near his face, he's going to bite me."

"He doesn't BITE!" the client shrieked, and at the exact time, Zorro proceeded to bite her hands and fingers 5-10 times, repeatedly.  "HE DOES NOT BITE!"

"Ma'am...... he's biting you right now....." I said, incredulous that I was having this conversation with an adult.

"Well, it doesn't HURT.  You just need to stick your finger down his throat! He's choking!"

"It's irrelevant how much it hurts if he bites me; I can't have your dog biting me at all.  First of all, I don't think he's choking based upon his physical appearance, but if you still want me to be able to look in his mouth, he'll need to be sedated. My hands are vital to me being able to do my job, and I can't be bitten by my patients; not to mention the risk of infection....." (Really?!? Do I really need to explain why I can't be bitten by a dog?)

The client refused to have her dog sedated, and I offered him some food, which he ate.  Pets who are choking can't and don't eat, so I tried to explain to her, again, that he doesn't appear to be choking and she can watch him at home for any problems.

As medical records must be complete and accurate, I filled in the section for oral cavity exam, truthfully: "not able to examine, patient will bite."

The client was furious, and demanded I retype the medical record, because of course...... her dog doesn't bite!

Of course I refused to falsify my medical record, and the client stormed out.  Really?!?

fuzzy thinking

Few things frustrate me more than lack of a proper diagnosis.  Certainly, there are some cases where a diagnosis isn't attainable for financial, logistical, or medical reasons, but a lot of times, it's a failure on the part of the doctor.


A 10 year old great dane presented to me for a 5 week history of dribbling urine, which had progressed to not really being able to pee a full stream.  He wasn't straining, the urine was clear (not bloody) and he was otherwise acting normally.  His regular veterinarian had prescribed antibiotics 5 weeks ago, without any testing, and when those didn't help, prescribed a second antibiotic. The first error in logic is in this decision. Dribbling urine is not a common symptom of a urinary tract infection.  Antibiotics only help if a UTI is present and won't help a long list of other problems.  Signs of a urinary tract infection include frequent small urination, bloody urine, or straining to urinate.  Furthermore, male dogs are very unlikely to get a urinary tract infection without a mitigating factor, primarily due to the length of their urethra.  If a male dog indeed does have a UTI (confirmed with a urinalysis or culture), a search is indicated to look for the underlying cause (such as bladder stones, diabetes, etc.)


Medical training teaches the new doctor to start with a history (to gather a list of symptoms) and physical exam (to look for abnormalities), and then create a list of medical problems, followed by a list of most likely causes (differential diagnoses in medical terminology), which should each be ruled in or ruled out with testing.  This dog's problem list consists of dribbling urine, which could be a result of urinary incontinence, inability to empty his bladder (due to obstruction, bladder stones, mass, or spinal cord problems), or a long list of other possibilities.  The job of the clinician is to determine the cause of the symptoms, and most of the time, that requires testing.  I can't (nor can any human) be 100% sure if there's bladder stones, or bacteria, or a mass in the bladder without imaging (such as ultrasound). The treatment for each of these is very different, and so a diagnosis must be achieved to select the proper course of therapy.

Unfortunately, the regular vet did not recommend nor offer any testing, such as a urinalysis or imaging to the clients.  When their dog didn't improve after the antibiotics, the vet added pain medications to "relax" the dog's muscles, which also didn't provide any relief or ability to urinate.  When the patient still didn't get better, referral was not offered or any sort of diagnosis as to the cause of his symptoms.  The clients didn't know to ask for any other testing (as most laypeople have no way of guessing at the proper tests, and trust their doctor implicitly to do the right thing). When the clients felt their dog was simply too uncomfortable, they showed up at the ER for evaluation.

Immediately upon hearing the history I knew that this dog never had a urinary tract infection.  As I mentioned above, UTIs are rare in male dogs.  More likely, the cause of an adult/geriatric male dog to be dribbling urine is a bladder mass or bladder stones. I recommended an ultrasound, which was immediately authorized, and found the large mass with ease.

Breaking the sad news to the clients was beyond devastating.  I am frustrated at the poor diagnostic process and lack of options the clients were given; perhaps 5 weeks ago, the tumor would have been operable.

Sometimes the minutes DO count

Heartbreaking case today - if only we'd had a few extra hours, the ending might have been drastically different.

"Lucy," a 3 year old westie, presented to her regular veterinarian for not eating the last 3-4 days.  The clients weren't concerned until she collapsed today.  Her regular veterinarian's office took one look at her, noticed her white-as-a-sheet mucous membranes and recommended transfer to our emergency room.  Unfortunately, the clients were a 2 hour drive away from our office.

When they arrived, Lucy was like a rag-doll.  Floppy, listless and mucous membranes white as can be.  The family noted that she did have access to rat bait, but had been abnormal for 3-4 days.  She had no signs of trauma and no evdidence of bleeding, but instantly upon placing an IV catheter and pulling a small sample, it was clear that she was critically anemic.  Her PCV was just 8%; barely enough red blood cells to provide her with the oxygen that her tissues so desperately need.

Given all this information, oxygen and supportive care were initiated.  A unit of packed red cells was warmed and I looked at some in-house testing to determine the cause of her symptoms.  A blood smear was evaluated under the microscope and confirmed the most likely diagnosis; immune mediated hemolytic anemia, or IMHA.  IMHA is a condition where the body's own defenses, the immune system, attack and destroy the red blood cells, which carry oxygen.  The causes of IMHA are unknown, and can include drugs, certain types of infections, rare reactions to vaccines or medications, but most commonly IMHA has no identifiable cause.  More information can be obtained here.

The client gave permission for treatment, despite the risks and guarded prognosis. Just as the blood was nearing room temperature and ready for transfusion, Lucy became agonal; she vomited, stretched out, and started gasping (all typical reactions just before a pet dies).  We worked hard to ger her stabilized; she was intubated, I gave atropine and epinephrine and started bolusing red blood cells in an attempt to pull her back from the brink of death.  Unfortuantely, it was all for naught.  Despite every medication and intervention I could give her, it was simply too late.  The family had waited too long, her body couldn't take it any more and she had nothing left to fight with.  She was gone. If we had only had 30 minutes or more to get her blood transfusion started before she went agonal, she just may have survived.

After several minutes of CPR, the clients and I decided that there was nothing left to do but to say goodbye to Lucy.  With tears in our eyes, we made an impression of Lucy's paw and gave our heartfelt condolences for their loss.  I still am racking my brain to see if I could have done anything differently, but there's just... nothing.  The only way we could have saved her was to have her brought to us sooner.

If your pet isn't feeling well, 3-4 days is much too long to wait.  If you notice your pet isn't acting right, isn't eating, or has any symptoms of illness, call and get advice from your local veterinary office immediately or bring them by for an exam.  It could save your pet's life.


~ERdoc

What would you do?

Pretty much on a daily basis, a client asks me "What would you do?!" in their given situation.


While this may seem like a simple question, it's impossible to answer and loaded with problems.

One busy evening, a 2 year old beautiful pit bull mix arrived after being accidentally hit by a car on a busy highway.  "Toby" had been playing outside on the client's rural property when he unfortunately chased a squirrel into the road, and was hit by a car who had no chance to slow down.

Toby's owner was a kind young man who rushed his dog in to our ER immediately.

I assessed Toby, and at my direction, the staff started emergency triage and care; providing oxygen, placing an IV catheter, start fluid therapy, and providing pain medications.

Toby's injuries were severe.  He had two obviously broken hind legs, a possibly broken pelvis, and even more substatially, his tail was torn from it's attachment at the base, his rectum was torn and he had no sphincter remaining.  Besides attempt at trauma resussitation, Toby's wound was very dirty and required immediate surgery, attempt at reconstruction, and possibly a tail amputation. With the injury to his rectum, Toby may never be able to control defecation and may develop permenant incontinence.  Furthermore, after stabilization and initial wound management were complete, Toby had two broken legs that would likely require additional surgery.  Needless to say, Toby's wounds were extensive, severe and would require a long hospital stay, likely several surgeries and a massive financial investment.

Could Toby be saved? Yes. 

Should Toby be saved?   That's the part I can't answer.  Every individual person that walks through our doors has a different set of beliefs, values, religious affiliations, attachment to their pet, life experiences and financial abilities.  As I'm sure the reader is aware, some people choose not to have blood transfusions or transplants for their own healthcare based upon their religious beliefs; others decline to have CPR or life saving care based upon their moral / ethical concerns.  Some clients have been through chemotherapy themselves and would never want that thrust upon their pet.  Some people have been through a trauma with their pet by their side, and would give anything to save their companion.  The experience of each human being that I meet is drastically different, and there's no way for me, meeting them in a a time of extreme need, to determine what's right for them. I've met all types of clients; quite literally, from those who refused to even have their pet evaluated by a vet because it's "just a dog," to those who elect to try treatment despite an extremely low chance of a positive outcome.

Financially, Toby's care could easily cost over $5000, based upon the extreme nature of his injuires.  Finances aside, he may need a week or longer of intensive care, several surgeries, and would have to endure excruciating pain in the interim.  Some people feel that this duration of pain and suffering is not in Toby's best interest.  The nature of his injuries also may make him unable to control his feces; resulting in a problem for any pet owner who wants to keep a clean and sanitary household, or relegating Toby to be an outside dog. Unlike human healthcare, euthanasia IS an option for our pets - and when it is appropriate to do so is dependent upon all the above factors. 

So what would I do?  You and I are very different people, and that's why I can't actually answer that question when you come into my ER.  It's not fair if I tell you that I would treat, and make it seem like you're heartless for not doing so. On the other side of the coin, it's not fair if I tell you I would euthanize, making it seem like there's no hope for survival.   My task is to assess your pet and provide objective medical information, to help you to understand your pet's condition, to understand the possible outcomes and prognosis, the chance for success, and the possible time to recovery and cost.  (Obviously, if the pet has zero chance of recovery, I tell the clients that as well).  As the pet owner, it's your job to do what you think is right for your pet and your family.  I'm just here to help you along the way.

Afer a lot of discussion and thought, Toby's family decided that due to his extensive injuries, euthanasia was the kind decision.  We tearfully said good-bye, and I gave them my heartfelt sympathies for their tragic and unexpected loss.

~ERDoc

The things clients say...

Late one night, in the middle of a holiday weekend, a husband and wife arrive with their 13 year old poodle. 

I enter the exam, room, gather a history and presenting complaints, perform a physical exam, and recommend very urgent, important tests for the 13 year old poodle.

Before I can even finish, the husband says, in an aggressive tone, "Fluffy has been seening Dr. RegularVet for her whole life, and I've been using him for the last 30 years.  I don't want anyone other that Dr. RegularVet to treat my dog."

(Keep in mind that the client has driven himself to the ER, where Dr. RegularVet has never worked, in the middle of the night, for an emergent problem.)

My desired response: ......Then why in the hell did you drive here, fill out paperwork, waste your time giving me a history, allow me to perform an exam and give you my recommendations?

Instead of that, of course,  I gently tried to explain to the husband that Fluffy could have a number of conditions that couldn't wait 2 days for the holiday weekend to end.   I again discussed why these simple tests were important, and if he declined them, that Fluffy was basically at risk for getting worse until Dr. RegularVet opened again.

"Nobody touches Fluffy other than Dr. RegularVet.".

"You realize he doesn't work here, right? And I'm here to help you and Fluffy the best I can?!"

"My wife made me come, and I don't think we should be here.  We're going."  The wife interjects, concerned about the dog and wanting to approve the simple, non invasive testing.

Husband and wife argue, and I excuse myself from the room.  Since when did I become a marriage counselor?

Happy freaking fourth of july....

Oh, fourth of July.  A very exciting day for beer and sun, and a not so fun day for pets.

But this isn't a story about fireworks, phobia, lost dogs or hit by cars - the classic fourth of July ER stories.


This is a story about clients with no sense.


Clients arrived to our hospital, reporting that their 8 year old German Shepard dog was having difficulty giving birth. (Yes, you read that right.  EIGHT year old LARGE breed dog). The dog has no socialization, has not been trained at all, cannot be restrained, does not use a leash and alligator rolls if we try to handle her, even to listen to her heart or try to look at her mucous membrane color.

Already frustrated, a technician quickly gathers some information from the client.

Tech: Is the female vaccinated?
 Client: Well, I do them myself.  How often does that usually happen?

Tech: 1-3 years, it depends on your dog and the vaccines.
 Client: Oh, yes, definitely I do them in that time. Oh, yes, I definitely gave them.

Tech: What about rabies vaccine?
  Client: Oh, yes I definitely gave that one too.

Tech: You realize that you can't legally purchase a rabies vaccine and therefore it can only be given by a veterinarian according to many regulations and laws?
  Client:<Stammers> uhhh, I guess she doesn't have that one.

Tech: Was this an intentional breeding?
  Client: Yes.  She's eight years old and I wanted her to have her first litter.

Tech: Did she have any pre-natal preventative care, deworming, or x-rays to see how many? Do you understand how to whelp puppies?
  Client: No.

<SIGH>.

The client reports that the bitch had one puppy at home, about 4 hours prior to arrival, and immediately bit the entire back leg off.  They have the puppy in the hospital for an evaluation, but don't want to have to pay for an exam.  I look at the puppy anyway, and it's grave.  Two legs and a tail are missing; this poor newborn has pretty much no chance at a normal life.

I return my attention to the female.  On exam, another puppy is in the birth canal.  I assist delivery of this puppy and it resuscitates easily.  And that's the very last thing that goes right.

The clients admit they also have no funds to pay for any sort of care for the female or her litter.  As in, absolutely zero dollars and zero cents. It quickly becomes apparent that these "owners" were trying to make some quick money by breeding their geriatric dog, and it has gone terribly, terribly wrong.

For better or worse, they were able to come up with $200 total.  Imaging confirms 2 more puppies, one in the birth canal, and one behind it.  Another exam reveals the next puppy is in the canal, but is not making progress. As time passes, medications given to try and assist labor have no effect. Manipulation to try and move the puppy forward has no effect.  The puppy is too large, and the female needs an immediate c-section.

I discussed with the clients the unfortunate situation and recommend the only next steps to get the puppies out - surgery.  The clients re-iterate that they cannot agree to proceed with surgery and after arguing with me, take her home against medical advice, with the puppies still stuck and her unable to make progress.

I try my best to helpfully explain the situation, monitoring at home, and some low-cost options for spay the following morning, as the clients are out of options for middle-of-the-night care.  As they leave, I ask them if they have any questions.  Snarkily, the man replies,

"I'm just worried about my dog. I don't think you get that."

Seriously? It's MY fault that you didn't spay your dog, bred her on purpose too late in life, didn't educate yourself on the birthing process, didn't save or plan for possible complications and now she's in dire straits?

Instead of that reply, I actually said, "I'm sorry, sir, that you're in this tough situation.  However, it is completely preventable with spaying to prevent pregnancy, and if you did really want a litter, education and financial planning for emergencies, as well as realizing that allowing an 8 year old large breed dog to have a litter is comparable to a 60-70 year old woman.  I am very sorry that you have to leave without surgery this evening, but you have to understand that there's no way we can provide free several thousand dollars of care and still manage to pay our bills and keep our doors open.  We wish you the best, and I hope you find a solution in the morning when the low cost clinics open up for the day.

An awful, frustrating situation.  As much as I did not approve of the client's attitude and treatment of their pet, I was highly concerned worried for her welfare.  I called to check on her the next day.  The clients reported that they were forced to surrender her as no clinic could provide low cost options due to her very risky status.  She was no doubt turned over to a family that will provide far superior care -any care is superior to level of these lamewads.

update!

Great news -

The post-arrest patient (after her spay) lived and is doing great at home! Yippee!

Kind words

In the middle of a very busy shift this weekend, a client took the time to thank me for my exceptional knowledge, straightforward communication, and to let me know they appreciated my kind demeanor and gentle bedside manner.  They told me I was the best doctor they'd ever met, and asked if they could continue all their pets' care through me. I thanked them for their amazing compliment, and told them no --  I only practice emergency medicine, and cannot take on routine clients. One of the definite downsides to being an ER doctor, but the benefits of saving lives when it really counts makes up for it (for me, anyway)

Those simple, kind words helped carry me through a long day of difficulties.  Remember to thank the people in your life when they do something well, even if it's their job.  It means a lot.

~ER doc

Cheaper does not equal better

"Patient presents for a routine spay."  -- This might seem like an simple, straightforward statement, but it couldn't be more of a complicated issue.

There is no such thing as a routine spay - each and every ovariohysterectomy (the medical term for removal of the ovaries and uterus) is a complicated, in depth surgical procedure requiring vast knowledge of anatomy, surgical skills, anesthetic monitoring, and careful tissue handling.  Most daytime veterinarians (at regular veterinary clinics, not emergency clinics) perform thousands of these procedures every year, making the procedure itself seem benign - but buyer beware - sometimes you get what you pay for.

Last week, a patient presented to me after experiencing an arrest under anesthesia during a spay.  The patient was a previously healthy, 5 year old miniature pincher named Suzie.  Suzie had been spayed at a local low cost clinic.

Before we discuss Suzie's case  -- what are low cost clinics?
 Low cost clinics are of several varieties; they can either be privately owned and for profit, or run by a government organization such as animal control or a humane society.  Each low cost clinic is different, but in general, they attempt to serve the same purpose - providing spay and neuter surgeries at a deeply discounted price.  This is with the goal of preventing the overpopulation and subsequent euthanasia of unwanted pets. In general, in order to keep overhead at a minimum, these low cost clinics do not have equivalent monitoring equipment, facilities, or staff of a fully modern hospital (of course, this depends on the specific location).  In order to remain "low cost" and charge clients significantly less than the market rate of this major abdominal surgery (the spay), these facilities either have outside funding (eg., governmental grants, private donors, or trust funds), or they are forced to cut corners to save money and pass the savings on to their clients.  Sometimes this means choosing the least expensive (not necessarily the best or safest) form of anesthesia, and sometimes this means that pets receive little to no anesthetic monitoring during their procedure.


Low cost clinics have an important place in our society to help control the pet population.  The vast majority of these facilities are run by truly wonderful people who honestly DO care about doing the right thing for pets.  The problem for me is when the client doesn't know the differences between a 'low cost' spay and a spay at their regular veterinarian - or when they believe the only difference is the dollars and cents.  This isn't the case.  Modern, up to date facilities provide clients with the option of pre-anesthetic blood testing, IV fluids, IV catheter (for emergency use), blood pressure monitoring, ECG, and other vital parameters.  Up-to-date facilities typically have a dedicated assistant or licensed technician who has the exclusive job of monitoring patient parameters and notifying the veterinarian if anything is amiss.  Even without 'fancy' equipment, just a human with training monitoring simple vitals such as heart rate, mucous membrane color, respiratory rate can go a long way in preventing tragedy.   Low cost clinics typically have the pressure of performing as many procedures as possible in a day, as their profit margin is exceptionally low per case. 

Back to Suzie.

Suzie was anesthetized with medications commonly used in low cost facilities, and she received appropriate dosages.  She was intubated and at the time of opening her abdomen, the veterinarian noticed that her heartbeat had stopped.  She was given emergency drugs (atropine and epinephrine), but as no IV catheter was placed, these were given via other less immediately effective routes.  The veterinarian continued the spay, and no IV fluids were given -also due to lack of prior IV catheter placement.

Upon finishing anesthesia, Suzie suffered several seizures, likely from cerebral edema (swelling of her brain) and anoxia (lack of oxygen) during her arrest.  She was transferred, comatose, to our intensive care unit, where she is making a slow, but steady improvement after receiving medications for cerebral edema.  Her prognosis is uncertain, but with time, she may experience a full recovery, at the cost of several thousand dollars and days in the hospital.

How could this have been prevented?
  This is a very difficult question, as the cause of the arrest was not made certain (due to lack of monitoring, trends could not be observed to determine the cause).  Absolutely, an inexpensive safety measure is placing IV catheters in any patient undergoing general anesthesia; if an adverse event does occur, intravenous access is immediately available for life saving fluids and medications. Better yet, monitoring of blood pressure and depth of anesthesia can help the veterinarian and medical team to realize problems BEFORE they result in an arrest, which has a significantly improved prognosis for survival.

Please realize that complications are a part of any surgical procedure (yes, even in human medicine!), and even with perfect technique, monitoring and surgical skills, there is still a small percentage of patients who will experience some problem (ranging from very minor to very serious). The majority of patients do well during spay/neuter procedures despite the lack of cutting edge medicine. In no way do I mean to disparage low cost facilities - they serve a very important purpose - I only wish for the client (and my readers) to have the opportunity to be educated about the differences and make an informed decision. Additionally, pet-owners should feel adequately informed about ANY medical procedure, regardless of the status of the clinic. Ask questions!

Always be 100% sure.

One area where there should NEVER be a mistake is in declaring a pet deceased.  100% is the only option.

In the wee hours of the night, a small chihuahua was hit by a car.  The driver of the car stopped, looked at the tags, and took the pet to the family's home.  He rang the the doorbell, and the family answered.  He told them the accident had happened, and he was so sorry.  The family quickly looked at their pet, and presumed she was dead.  They left her on the doorstep to bury the next morning.

The next morning, when the family went outside to bury her, the found the unimaginable.  She was still BREATHING.

They rushed her to our facility, and she is currently being treated for severe head trauma, shock, exposure and her prognosis is uncertain. 

It's almost too sad to believe.

A comedy of errors

Thursday night, 8pm.

"Tia", a 5 year old Chihuahua, eats two dark chocolate marijuana cookies while her mom, Susan, is at work.  The ingestion is witnessed by Susan's roommates.  Fearful, the roommates quickly run to grab something to make the dog vomit.  Instead of hydrogen peroxide, they accidentally grab rubbing alcohol and quickly shove 1/4 cup of the toxic liquid down the dog's mouth.  Realizing their mistake, they call the dog's owner (who is on her way home from work), then grab the actual hydrogen peroxide, and pour it down Tia's throat.

The dog does not vomit and starts to cough.  Susan returns home from work, and calls the clinic. We urgently recommend she bring Tia to us for evaluation.


Tia arrived, and immediately she was given an injection of a drug, apomorphine, which reliably produces vomiting in dogs (but not in cats).  She vomited up a large amount of chocolate-y-pot-smelling-goo.  Unfortunately she was also coughing, and I suspected that instead of swallowing all the hydrogen peroxide, she had breathed some of it into her lungs.

Her client was a friendly, reasonable person, and let us treat her dog as necessary.  She avoided any serious side effects from the marijuana, chocolate and alcohol toxicities, but now has a mild case of aspiration pneumonia.


This is one of MANY reasons why I never recommend a pet owner attempting to make their dog vomit at home.  First of all, hydrogen peroxide is not a reliable emetic, and secondly, if the peroxide is inhaled, it is very dangerous (as Tia did -- and realize, it's an easy mistake to make for anyone, especially with a struggling, panting, frantic pet).  Even if actually ingested and not inhaled, hydrogen peroxide is very irritating to the stomach lining and can result in bleeding stomach ulcers which actually can be fatal, especially in cats.  Furthermore, since emesis (vomiting) is not always achieved, valuable time is wasted before arriving at a veterinary clinic for induction of actual vomiting. If your dog or cat eats a poisonous substance, please contact a veterinarian IMMEDIATELY.  There are no safe, reliable at-home ways to make your pet vomit, and all of the other ways you'll find on the internet are even more dangerous or ineffective.    We don't recommend you come to us for any reason other than your pet's safety - that's our primary goal.

I love my job!

As you probably have seen from reading my blog, my job can be very stressful, sometimes infuriating, and often exhausting.  Working overnights, 15+ hours at a time, and in emotionally charged situations is exceptionally difficult.  It takes a specific personality, and a specific person to be able to work this job in the long term.

Despite all this, I love my job.  I have the best employers anyone could ask for.  I work with amazing colleagues and support staff.  I have the equipment, tests, drugs, and supplies that I need to do my job every day.  This all may seem like no big deal, but I can tell you that a great portion of my classmates, friends and colleagues struggle with the above on a daily basis.  Furthermore, I have worked hard throughout veterinary school and my internship that I truly feel that I am good at what I do. Of course, I don't know everything - but I know enough to realize that I'm in the right career as an emergency doctor.

A case this week reminded me of how amazing my job really is.

"Glenda," a 5 year old great dane, presented to my hospital for bloat. (See previous posts for a description of bloat, or read here).  Her family had come home to find her in this condition, so she had been bloated for an unknown portion of time.  They gave permission to treat aggressively and proceed with surgery.  She was stabilized with fluids, give pain medications, antibiotics, and we prepared to place her under general anesthesia.

Glenda's vitals, BP, ECG, and all other parameters remained stable and normal under anesthesia.  Despite this, she suffered from several complications of GDV surgery; she refluxed gastrointestinal contents (unfortunately, the dilated stomach contents can spill into the esophagus and possibly be aspirated despite precautions of a tube in the trachea), and she seemed to ooze blood excessively. I untwisted her stomach, performed a gastropexy so she could not suffer a GDV in the future, and also removed a large piece of bone from her stomach.  When her laboratory values returned, I noted that her platelet count was low, as well as her albumin, a very important protein involved in healing.  She also had a low white blood cell count, probably due to bacteria spreading into her blood stream from the compromise tissues (known as bacterial translocation).  

Over the next day, Glenda also suffered from ventricular arrhythmias, a common complication associated with surgery of this type.  In total, Glenda was probably suffering from SIRS - or systemic inflammatory response syndrome.  This is poorly characterized in veterinary medicine, but results in patients with systemic illness, such as GDV, and sends whole cascades of inflammatory mediators, cell signals, and clotting cascades on a crash course towards disaster.  There is no specific therapy for SIRS, other than supportive care, nutrition, and correction of the underlying cause (which I had done in surgery).

Over the next few days, Glenda was treated with lidocaine (to stop her cardiac arrhythmias), IV fluids, hetastarch (to support her low proteins), antibiotics (to treat the suspected sepsis, or blood infection), pain medication, and she was provided nutrition through a tube into her esophagus.  Her blood pressure, ECG, vitals, comfort, attitude, appetite and physical exam were rechecked constantly.  She improved gradually and by the second day, she was significantly stronger and eating on her own.  

With careful attention to detail, constant observation, expert technicians, and knowledge of complicated physiology and pathology of Glenda's condition, we were able to pull her back from the brink of death.  She went home to her happy family 3 days after surgery, and is expected to make a full recovery!

Easy isn't always easy....

A client came in last week with her 8 year old chihuahua, who was experiencing tremors, panting, and unable to stand for the last 24 hours.  The chihuahua was an intact female who had just delivered puppies three weeks prior.  History and physical exam confirmed the most likely diagnosis; eclampsia (also called post-parturient hypocalcemia).

This condition results when the body stores are insufficient, or when the bitch's metabolism is not prepared to deliver the high loads of calcium into the breast milk, and as a result, the blood levels dip dangerously low, and muscles can no longer work appropriately. (The physiology is really quite fascinating, but I'm sure my readers would prefer that I skip the nitty-gritty cell and channel physiology!)

The condition is easily treated (injections of calcium, and oral supplementation), and the female goes home the same afternoon. We recommend separating the puppies from the female, and providing them with milk replacer.  If they nurse on the mom, they will continue to deplete her stores, and she is at high risk for a relapse.

Why is an 8 year old dog having puppies?  It was her 7th litter, and her client excused the situation by stating that she "meant" to get her spayed, but it just didn't fit into the schedule.  She also owned an intact male dog, and one might ask - why didn't she separate them?  The answer, as dumb as always, was that she thought he'd leave the female alone, since she was "older."  No.  Dogs don't have social stigmas.


Anyway, the client called later that day to inform us that the puppies weren't nursing, and she also thought that bitch was acting weird.  We asked if the formula was warmed, if the nipples had appropriate openings, and she assured us that wasn't the problem. We urged her to return with the puppies, and to bring the mom at the same time so we could examine her. "I don't think the puppies will use the bottle," she said.  "They are trying to crawl down my cleavage to get at my boobs, but I keep telling them those don't work."

(I tried to refrain from vomiting).

When she arrived, the adorable puppies were strong, bright, and alert with great suckle reflexes.  She handed us the bottles she had been using - and there was absolutely NO opening in the nipples.  We made a hole, and the puppies nursed as if they had been starved all day (they had!)  For some reason, she left the mother at home instead of bringing her in so I could take a look.

I went to talk to the client and give her the great news - the puppies are not sick, just needed to open up the nipples so milk could come out.  She then argued with me for 10 minutes about the seemingly obvious situation.... asking me questions, then interrupting before I could answer.  Exasperated, I excused myself from the conversation.  I encouraged her to get the female spayed, and soon.

Why did such an easy fix have to be so complicated!?

I wouldn't believe this one myself if it wasn't true

This one's a doozy --


A few months ago, during a busy weekend night shift, a man arrived, clutching a blanket to his chest.  The blanket was wrapped around something, which my technician assumed was a sick or injured pet. (Good assumption, right?)

Tech: "Hello sir, how can I help you?"

The man whispered, almost inaudibly. "I need some medicine."

Tech: "What's wrong with your pet?"

Man:  "I have a sick mouse.  I rescued him from a trap 7 days ago, and I've been feeding him, and caring for him, but I need some medicine."

Tech: "Okay, let me see him - I need to get an idea how sick he is, and gather some vitals, and then I'll go get the doctor."  The technician escorts the man and his blanket into an exam room, and asks him to get the mouse out for a triage evaluation.

The man starts to unwrap the blanket.  After he removes the first layer, he pats a clearly empty section over and over, as if he can't locate the mouse.  Meanwhile, a lump clearly is present in the remaining part of the folded blanket.

Man: "You're scaring my mouse, he won't come out unless you leave the room. We're usually in tune and right now I just can't find him."

Tech: "Okay, but I'll need to evaluate him when I come back."

The man finally pats the obvious lump on the table. "Oh, wait, I found him!"  He unwraps the blanket further, which reveals a hamburger take out box, tied shut with a sock.  He carefully and slowly unties the sock, and opens the box.

The technician peers inside the box, and sees a mouse, lying on its side, motionless, not breathing, cold, stiff, and clearly dead.  It appears to be a field mouse that was killed by whatever trap the man "rescued" the poor thing from a week ago.

"Sir, I'm really sorry, but your mouse isn't alive."

Man: "Yes, yes he is!  I know he is, and you are wrong.  I am a healer, and I have healing hands, but this time I just need the medicine too.  I just fed him before we got here and I saw him move yesterday."

"Sir, your mouse does not have a heart beat, and I don't think he's been alive for some time.  He's not moving, he's not breathing, and he's in a really awkward position."

"No, you're WRONG! I just need the medicine!"

My tech listens for a heartbeat for the man's benefit - nothing.  At this point, it becomes pretty obvious that this man is bat-shit-crazy, and she needs to get out of the closed exam room before something freaky or dangerous happens.

The tech tells the man that she's going to go ask the doctor if there's any medication that can be dispensed, in order to remove herself from the exam room.

She relays the story to me, and we realize the entire lobby had heard the conversation through the exam room door.  The other clients are concerned for my technicians safety, and ask her if she is okay.  Of course, we have nothing to help this dead mouse be less dead, so the technician returns to the man, and talks to him in the doorway, where she is in view of the other clients.

She informs him that there's nothing we can do.   He argues with her for some time, and finally gets ready to leave.  He wraps his dead mouse back up in the hamburger box and blanket.

Just before he leaves, he says, "I'll come back, when my mouse is better, and I'll make you believe me!"

Anger.

Apologies for the long delay, readers.  This blog is a work of passion for me, so when I'm not inspired to write a post, I can't force it.  I've been outrageously busy at work, and taking care of lots of duties outside of work. Forgive me for the absence  - I try to only write when I have something to say!


This last few days has brought me many clients who are just downright angry. I actually wish I understood human psychology a bit better in order to understand this phenomenon.  Clients angry, even  furious at me and my staff for things we couldn't possibly be responsible for - but yet, they perceive us as the bad guys.

Example #1 -

A woman brought her cat to me who had been a cat fight the day prior.  He was painful over his left side, and on initial exam, I shaved some hair and found puncture wounds as well as swelling over his belly.  The wounds were in a precarious location, and possibly penetrating the abdomen, causing an abdominal hernia.  I gave the kitty pain relief medications, and spoke to the client.

I recommended radiographs to evaluate for possible body wall damage from the bite, and to look for entrapped bowel or dangerous fluid within the belly, as a result of the bite.  These conditions could be quickly fatal if not addressed immediately.

"YOU PEOPLE!!.......!!" The client screeched. "I CAN'T PAY FOR THIS!"
I tried to calmly explain to the client that we did offer a payment plan in the form of CareCredit, a third party credit system which allows interest -free payment periods, and can provide instant approval for credit.

"YOUR PRICE FOR X-RAYS IS TOO HIGH! HOW DARE YOU CHARGE THAT MUCH!"

Again, I tried to calmly explain to the client that our prices are set by our fixed costs, costs of the machinery, repair costs, maintenance, etc and that I understand her dilemma, however I cannot change the prices.  I asked her if she wanted to apply for care credit- she replied, "I DON'T CARE."

Finally, we convinced her to fill out the paperwork and, alas, she was approve for credit (and thus, a payment plan through CareCredit) and her kitty was well taken care of.  She suddenly acted polite and friendly.

Example #2
Clients found a stray, sick looking Shepard cross dog on the side of the road in their small town.  They called us and described that the pet was sickly and appeared to be dying.  We offered for them to bring it in, and we would evaluate it on a stray - pet basis, and they would have no financial responsibility.

 (This is a LUXURY - almost every other clinic in our area refuses to provide any similar service.  We provide this at no charge to the public to prevent animal suffering, because we really do care.  When the found pets are un-injured, we send them to the shelter to be found by their owners, and when they are minimally injured, we provide emergency care.  When they are critically injured, and no owner can be found (no collar, no chip, etc), then unfortunately some times, we do have to provide euthanasia to prevent suffering. All pets who are brought in and treated through this program are signed over to the hospital until their true families come forward; if none is found, we then transfer them to the local shelter for adoption.  We cannot return them to the finders directly due to legal concerns and the importance of giving the true family a chance to find their pet.)

The clients brought us the found Shepard cross, and he was emaciated.  His skin was jaundice, and he appeared to be truly near death. He appeared to have a fluid filled, distended abdomen. Due to his extremely ill nature, euthanasia was provided to prevent suffering.  This was the right decision for this poor, neglected dog who had clearly suffered too much already.

Hours later, a friend of the finders of the dog called and requested information on adoption.  We told them that unfortunately, the found pet was not adoptable, and we thanked them for taking the time to bring the poor guy in and prevent suffering.

The caller became LIVID.  Screaming profanities at my technician, yelling that we don't care about animals, and demanding to speak with the owner of the business.  She went on for several minutes before my tech could no longer handle the verbal abuse and was forced to end the phone call.

Why so angry at us? We provided relief of suffering, at no cost, to an stray animal who was clearly in a critical condition.  I can only guess that the "Finders" were truly the owners of the "stray" dog, and thought that we would provide care for free, and that they could pick up their dog under the guise of adoption.

 It's people who abuse the system like this that ruin it for everyone else!  WE are here to do the right thing for the PET, and unfortunately, some clients will never understand what we really go through to help pets 24/7.

Compassion fatigue - and then the remedy.

Earlier this week, I was suffering from a pretty stiff case of compassion fatigue, mostly as a result of mean, downright awful clients, and several cases with sad outcomes.  Compassion fatigue is a known occurrence among medical professionals who experience sadness, high emotional cases and drama on a daily basis. Experiencing these negative feelings over and over again results in a numbness or a lack of compassion for the suffering of others; usually this is temporary. Read more about it here.

After several prior days of bad cases, mean people, and frustrating situations, last night was long-awaited.  All evening, we had friendly, reasonable, logical clients who spoke to us like normal human beings, who asked smart questions, who treated us with the respect that we afford to them, and who all truly cared about their pets.  Not once yesterday was I called a name or screamed at; not once did I have to explain to an angry client that I'm not a millionaire.  This might not seem so shocking to those who are not in the field; unfortunately ER medicine has a propensity for the absurd.  I'm sure those of you who have worked with the general public (retail, customer service, etc.) have seen some idea of the ridiculous actions of people; mix in with that the high drama of an ill or injured pet and the odd hours of the day that we are working, and an explosive mix results.

The pinnacle of the evening was a 13 year old Basset hound, "Eva," who presented for a distended abdomen.  Eva was owned by a lovely older woman.  At first glance, Eva had a rough hair coat and a moderate amount of flea dirt; her client was quiet but kind.  Initial diagnostics confirmed that Eva indeed had a bloat, or gastric dilatation and volvulus (see several previous entries about this condition).  Given her condition, she was relatively stable, thanks to her very observant client noticing symptoms almost immediately and quickly responding by bringing Eva to us.

Immediate surgery was required; unfortunately, I was suspicious that instead of treatment, Eva would be euthanized due to her advanced age and the cost of surgery.  Definitely an understandable decision in this situation - however, after discussing the risks of anesthesia, surgery, as well as an honest discussion about a typical lifespan for a dog of Eva's breed, I was excited and surprised at the client's decision.

"She's my family" the client said. "Do whatever you need to do.  I know she's an old girl, but I want to give her a chance, even if she only has a few more months or years to live. I know we can't pinpoint how long she'll live, but I want to give her a chance."

YES.  This is why I do my job. I hurriedly prepared Eva for the procedure; it would be a challenge to get her safely through anesthesia and surgery.  Amazingly, she performed exceptionally well under anesthesia, and surgery was a success.  She recovered well.

My favorite part of the day was reuniting Eva and her mom.  Truly, a heartwarming moment that for me, melted away the crusty shell of compassion fatigue.

down with the man!

Client had seen us a few days ago because his cat had been attacked by another animal and developed an abscess. The wound was treated, and his cat was sent home with a liquid antibiotic.  This medication must be kept in the refigerator, and the client was informed of this.  We even put a "keep refrigerated" sticker on the box as a reminder.


The client called today because he left the antibiotic out on the counter for 2 days, and could no longer use it.  He needed to replace the bottle.  No problem, come right on down and pick it up!

But there was a problem.

My technician fielded the call.
Client: "I shouldn't have to pay for this second bottle of antibiotics" he claimed.  "I already payed the mark-up on the first one, and the second one should be at cost.  You know, those pharmaceutical companies are just taking over the world, man, and it isn't fair."

 "..... But we told you to keep in the fridge?"

"Yeah, you did. And I forgot."

".... and so you admit that it's your fault the antibiotic can't be used?"

"Yeah. I'm not arguing that.  I'm arguing that since I already paid the mark up, I shouldn't have to pay again. The government, man, they're taking over.  And it's guys like you, the bureaucracy, man, that's making this country bad. I've got to stand, up, man, and take a stand."

"Okay, so I understand your frustration, however I'm not able to change the prices; our prices reflect the cost of keeping our doors open.  If you've ever taken economics, you'd understand the importance of fixed costs, which have to be distrubted over the entire business.  For example, we don't charge you for the water or electricity you use while you're here - and those costs, among all the other things we have to pay for, are spread out over everything we do.  Secondly, you admit that it was your error that resulted in the mistake.  We can't be responsible to pay the mistakes of all our clients.  Third, we have nothing to do with the government, or pharmaceutical companies, other than we need drugs to treat our patients. You are welcome to come down and pick up your medicine, but it will be $X.xx, just like last time."

"Well, I'm standing up for myself and I'll tell anyone who will listen.  This country is unjust and the government is takin--

"I'm sorry sir, I'm hanging up now.  I can't debate politics with you, and I have patients and emergencies to tend to.  If you want to pay for the medication, you can come get it anytime."

Balancing act, continued

Whereas the previous story was a very gray zone, the following story is a little more black and white.

A 12 year old, male neutered lab presented to a colleague of mine for a second opinion.  Gus, a family pet, had experienced a sudden onset collapse, pale gums, and a distended abdomen.  I'd venture that the vast majority of veterinarians would start by looking for the most obvious condition; a hemoabdomen.  And they'd be right.  Hemoabdomen is when a large amount of blood pools in the belly; typically from a ruptured tumor (spleen is the most common culprit; it can also be a tumor on the liver).  (Hemoabdomen can also be caused by trauma, such as being hit by a car, but typically this sort of history is known, as well as there are other signs of injury on the pet which lead towards a trauma diagnosis).  This is a condition that must be treated quickly, or the pet will die from blood loss.  Unfortuantely, often the underlying cause is cancer, so many of these patients are euthanized as the prognosis is not very good. Regardless, some clients choose to proceed with therapy, which includes surgery (to remove the bleeding tumor), blood transfusion, supportive care, followed by chemotherapy once the specific type of tumor is known.

Gus presented for a second opinion because the first veterinarian who saw the case told the clients gave them no options; offered no diagnostics, and no therapy plan.  The vet gave them a bottle of prednisone (a steroid anti-inflammatory medication), sent them home, and told them that "he won't make it long enough to finish the bottle."

Again, I don't want to speak ill of others, but this is just plain wrong. There's nothing wrong with not knowing, but if you don't know, REFER. 

This didn't feel right to the clients. They left this office; presented to my friend and got the real diagnosis, treatment plan, and proceeded with care.

The bottom line; there's good and bad in every profession, including medicine.

Balancing act

On a weekly basis, I struggle with the balance between being a good colleague, and being honest with clients.  Veterinary medicine has grown so much in the last 20-30 years that some older standby "treatments" are simply outdated and no longer recommended, and in some cases downright harmful.  Further complicating the situation is that, in the exam room, it's impossible to know if what I'm being told by the client is the actual truth, or just their interpretation/memory of the truth. As a result, I try really hard not to judge the medical decision made by others, until I see the medical record and/or speak with them about the case.  Unfortunately, sometimes, it's impossible to sort out why things happen the way the do.

Case and point -
A 6 year old Chesepeke bay retriever, "Grizly" presented as a transfer to me one afternoon.  The dog had started to have hematemesis, or bloody vomiting.  3 weeks prior, the dog had been lethargic, vomiting and not eating.  Blood testing had showed very severe liver disease; this was confirmed with abdominal ultrasound.  The dog was not placed on any medications, and was basically sent home for "observation" with re-testing of labs to occur weeks later.  Unfortunately, Grizly didn't make it to that recheck.

On presentation Grizly was weak, pale and listless.  He was thin, having lost 6lbs in the last 2 weeks.  He hadn't eaten or held down a full meal in weeks. His clients wanted every possible intervention for Grizly, and agreed to aggressive supportive care, with the eventual goal for liver biopsy to gain a definitive diagnosis and plan the perfect treatment strategy.  Unlike many cases, cost was no object; they only wanted to give their dog a chance to recover.

Unfortunately, by the time I saw Grizly, it was much too late.  He was debilitated, and having severe GI bleeding; we could not stop this bleeding and he quickly progressed to a comatose state.   In the last few minutes before he died from his disease, his clients were with him and allowed euthanasia to ease the passing.

A post-mortem exam was performed, and confirmed a bleeding stomach ulcer, which ultimately lead to his death.  His liver was also diseased, and the original source of his illness.  I am left to wonder - if he had been placed on the appropriate GI protection, liver supportive, and proper medications weeks earlier, could he have survived? If referral to a 24 hour care facility like ours had been offered originally, would he have had a recovery and normal life span?  Had the clients given some indication to the original doctor that they did not want these things and only changed their minds once he fell more seriously ill?

I'll never know.

Saved two birds with one stone

It's not every day that my diagnosis saves TWO lives.


Last weekend, a 15 year old cat arrived at the clinic for evaluation.  His clients rushed in the front door, stating that he had been attacked by their 2 year old boxer. 

The patient, "Stewart" was tilted to the right, with frequent eye movements (nystagmus) and meowing.  He could not stand, but could move all four of his legs.  We placed an IV catheter, and gave him oxygen.  I looked over his entire body, and I found dirty ear canals, dental disease, and a cat who could not stand, but nothing to support a trauma event.  No saliva, no open wounds, no fractured legs, no blood, nothing.

I went into the exam room to discuss the history in more detail. 

"What happened tonight?" I asked. "Did you see Stewart get attacked by your dog?"

"No," the clients said. "We heard no scuffle, no indication of a fight, but all of a sudden, while Stewart was in the other room, we heard him start meowing loudly.  When we went to go see what was going on, he was like this."

I smiled, realizing that this was a case of a wrongly accused boxer.

Stewart's clinical signs included brown foul smelling discharge in both ears, a head tilt, inability to stand, especially falling to one side, and nystagmus.  These symptoms point to dysfunction of the vestibular system, which is the part of the brain responsible for balance.  Common causes of this include stroke, inner ear infection, blood clot, or brain tumor.  Trauma is a possible, but much less likely cause, given the cat's indoor only status and the specific nature of the symptoms.

I discussed with the clients these facts.  They simply could not believe that the boxer was not responsible.  Apparently, he had been known for rough play, and was responsible for an accidental broken limb of their other pet about 6 months prior.  Again, I poured over the cat, looking for any evidence of injury. I found nothing.  I looked at his ear debris under the microscope, and found a raging infection.  I took radiographs and found again, nothing.

The clients started to take a deep sign of relief. Inner ear disease is treatable, and the most likely cause of the symptoms for Stewart that evening.

 With tears in their eyes, they earnestly told me, "Doc, you've just saved a boxer's life tonight. We didn't want to have to put him down for his behavior, and now you've helped to prove that he probably wasn't responsible for Stewart's illness.  Thank you so, so much."

Emotionally drained.

This week was long and frustrating.  Case after case came in with $20 or less available to fix life threatening illnesses.  As you all know, veterinary care isn't free; in fact, nothing in life is free.  I can't count the number of times I've been called names, yelled at, or told that I don't even care about animals, and the reality is that those statements couldn't be further from the truth.  It hurts each and every time I have to deny an animal care it needs - because it's never the animal's fault.  We do what we can to provide affordable care, but unfortunately like any small business, we have to be able to pay our employees, pay for our equipment, electricity, water, rent, restock our shelves, and at the end of the day, be able to pay our own personal mortgages, school loans, and afford food.  There's a very, very small limit to what we can do without payment.  This isn't a matter of loving animals enough - it's a matter of the costs of keeping a business running.

Unfortunately, when faced with this, some of my clients turn into an extra-special form of nasty.  Personal choice involving money are a complicated and emotionally charged issue, and I am definitely no expert in sociology or economics, however I can point out a few especially frustrating observations:

1.  Don't call me a money-grubbing asshole if you are driving a new Lexus SUV (Mercedes, BMW, etc), wearing more diamonds on your hands than a small country's worth, and carrying a Prada bag. You  have chosen to spend money on other (ridiculously unnecessary!) things, and it is NOT MY FAULT that now you have terrible credit.

2.  If you think of your dog/cat as "your child," and you then why did you notice that it stopped eating and started vomiting TWO WEEKS ago, and do nothing about it until 2am tonight, when your dog/cat is unable to move, and in critical condition?

3.  Don't try to guilt me into treating your pet for free because you paid your taxes this year! (Someone actually stormed into my office and demanded care with the statement "Where does my f***** tax money go, anyway"!!!) Veterinary hospitals are not owned, operated, or supported by government funds!

4.  If your friends, family members, neighbors, and multi-million dollar credit card companies refuse to let you borrow money, then how can you possibly expect my clinic to take on that risk?

5.  If you choose to do drugs, whatever.  If you choose to drive yourself to our clinic, high on heroin, and demand free care, whatever.  HOWEVER, if you do these above two things and bring a CHILD with you.... you can bet your ass I'll be calling the police to pick you up and take that kid away from you, you sick evil bastard.

6. (Unrelated to #5) I'm sorry, I can't hold your child (yes, adult human child) for collateral.  Don't even bring it up again, or I'm calling the police.

7. Furthermore, no, I can't pawn your clothes and jewelry.  I'm a doctor, not a pawn-shop owner or a consignment shop.


These are just a few examples of the depths to which people can sink when they feel trapped.  Don't get me wrong, I empathize with anyone who is in a crisis with limited resources, however as the recipient of the nastiness, it gets really hard not to take it personally.  There's only so much a person can take, and in the ER, we get way more than our fair share.

It's been a full week filled with this emotionally draining, burn-out producing crap, and I'm ready for a new leaf.  Here's hoping for a good weekend at work.

~ERDoc

IMPORTANT.

Everyone, spread the word.  Bloat kills. Any owner of a deep-chested at-risk breed should know the signs and symptoms.

Tonight, a young, intelligent client called.  "My dog has a distended abdomen, and he's trying to vomit.  This has been going on for three hours.  What can I give him?"

My tech immediately, and directly informed the man that this is a critical emergency, and that his dog required IMMEDIATE medical attention. 

The client arrived, and his dog was already deceased.  We attempted CPR, to no avail. 

His dog was only 9 months old, and if he had come in when he first noticed the problem, we could have saved her. The saddest part is that I saved her after being hit by a car only 4 months ago, and now this.

I know I've posted on GDV before, and I know that sometimes, if you aren't home, there's nothing you can do.  But if you ARE home, don't wait.  These symptoms require IMMEDIATE action, or it's quickly too late.

Spread the word, save a life.

The things we do....

A few days ago, I saw a 2 year old male cat for straining to urinate. After a physical exam, he was quickly diagnosed with urethral obstruction, a life-threatening emergency and a common problem in emergency medicine.  I spoke with the client, a woman in her 50's who was acompanied by a child.  At first, I thought the kid was poorly behaved; he beat on the doors, screamed, slammed the chair into the walls, and made it nearly impossible for me to speak to the client.  His yelling was louder than I am capable of speaking, and many times I stopped, waited for a pause in the yelling, and then would continue.  After a few minutes, I realized the child likely was autistic, not poorly behaved.  I tried to be as understanding as possible however his activity made discussing the situation with the client very, very difficult.

Urethral obstruction in male cats is a complex process.  Many times, urethral obstruction is due to a build up of crystals in the urinary bladder, urethral spasm, and blood clots that form a plug in the urethra.  Inability to urinate quickly results in pressure on the kidneys, causing build up of dangerous toxins, electrolytes, and eventually, if left untreated, kidney failure and death.  More information is available at veterinary partner.

The treatment for urethral obstruction is pain control, resolution of electrolyte abnormalities, and anesthesia in order to pass a urinary catheter and relieve the obstruction.  Cats should remain hospitalized for 24-48 hours, depending on the duration and severity of their condition to allow urine to be flushed, kidneys to be healed, and to decrease probability of a second obstruction.  Urethral obstruction can reoccur, and often cats who experience this condition will be placed on a prescription diet, or a canned food-only diet.  Some cats experience multiple obstruction episodes and require surgery to enlarge their urethral opening.

The client began to cry, and her autistic son began to scream.  "I don't have any way to pay for this" she said.  "The cat helps my son, and I just don't know what to do. There's nobody who can help me. I just can't let him go."

The preferred medical treatment was out.  I had to find a way to help this kitty with a budget that could barely cover the exam fee.

I gave the kitty pain medication, and emptied his bladder with a small needle and syringe to relieve the pressure.  I applied a local numbing agent to his penis, and then attempted the impossible- catheterizing an awake cat.  This method is not recommended, as it is painful and usually unsuccessful.  I'm sure most of you can imagine trying to even touch a cat when they don't want you to.... add on top of that, trying to insert a catheter into a cat's penis!  Nevertheless, I had to give it a try, for if I couldn't find a way to unblock this kitty, he would face certain euthanasia. 

I discussed with her the risks of this, and we discussed euthanasia as well.  While her autistic child screamed, she cried, explaining to me how this cat helped her son cope with his disability. I couldn't bear not giving the cat a chance.

We attempted the procedure, and fortunately, were successful.  I sent them on their way with medications, instructions, and strict monitoring parameters.  She called me 3 weeks later to let me know that despite the odds, her kitty had not required further care, and our willness to help her had saved her cat's life.  She thanked me, and I knew we had done something very important for her family.

The true meaning of irony.

These two cases still make me giggle. You'll soon see why.



A client called, screaming into the phone. " I'm coming with my dog, RIGHT NOW!" Before my technician could ask her what was wrong, she hung up.

20 minutes later, a car comes tearing into our parking lot, headlights flashing, brights on, honking her horn like a crazy person. My techs are already on their way outside when the client flings open her door, screamng hysterically. In the process, she manages to scratch the bejesus out of the car next to her. "He's dying, he's dying!!!" She screams.

My tech takes a look, obviously concerned that this pet might be critically injured. While performing a brief evaluation and carrying the pet inside, my tech starts to get a patient history. "What happened? Did he get by a car, or...?"

The dog cannot walk well, is ataxic (means literally 'without axis,' or off balance), stumbling, and hypersensitive to noise and sound. He overreacts with any sort of stimulus. His mucous membranes are pink, his pulses are strong and his heart rate and body temperature are slight slowed. He's also dribbling urine.

It becomes clear that this dog is definitely not dying..... He's stoned.... and so is his owner.

We notify the owner of the other car, and I talk to the client about her pet. Shockingly, it is revealed that marijuana is in the household. I offer testing to confirm my suspicions, but also let her know that her dog is likely to be fine by the morning.

Even she laughs a little about the way she arrived, and the other car she scratched

Case number two:

A 3 year old, otherwise healthy doberman presents for suddenly being unable to walk. She was fine when the family left for work, and upon arriving home, was in this state. The dog, "Lizzy" was brought in on a stretcher. Her heart rate was slow, about 60 beats per minute, but her pulses were strong. Her body temperature was low, and she was mostly non-responsive, however if startled, would completely over-react, flail and panic, then return to her near coma state.

Lizzy had been in a kennel all day, but prior to the clients leaving for work, she had been outside, out of sight. No known toxins were available, but based upon her history, some sort of toxicity was still the most likely diagnosis. Her family authorized all testing, including antifreeze testing (negative) electrolytes, blood sugar ( normal) and urine drug screening.

Can you guess what she got into?

Yes, that's right. Marijuana. I had a suspicion from the inital symptoms, however her family swore up and down that couldn't be possible. They also didn't seem like 'the type,' but you just never know.

I saved the drug test cartridge and took it with me as proof to show the clients. This was good news, as marijuana poisoning, even severe exposures, are very treatable.

The clients looked at me and listened. When I showed them the positive drug test, they laughed incredulously.

"Do you know who I am or what I do for a living?" The female client asked.

"No, I'm sorry, I have no idea. Should I know?"

"I'm the chief of police!" She laughed, almost too hard. "And I have a stoned dog!!!!!"

Grief

Unfortunately, in my line of work, I see a lot of grieving people from all different causes; unexpected tragic losses to expected but not quite ready long term cancer patients.  I am extremely sympathetic, as I love my own pets dearly and know what it feels like to be on the other side of the exam table.

I am no psychologist, but from experience, I can tell you that there are many variations of normal grief.  Some people hide their tears and break down once they walk out of the room, others cry openly and accept my condolences and even a hug after their pet has passed. Others do not talk, and some are even slightly rude with the reception staff at the counter.  99% of my clients grieving, even given the most extreme circumstances, thank me for helping their pet at their final minutes, and are courteous and kind.

Yesterday, I had the misfortune of dealing with someone who could not control herself, and took it out on me and my staff.

"Sissy" was her cat, a 14 year old domestic longhaired cat with extreme difficulty breathing.  At triage, my technicians immediately recognized the urgency and placed Sissy on oxygen.  The client had stated that an asthma attack was the cat's presenting complaint, that she had had this before, and she had been trying to wait for her veterinarian to open (in another 24 hours).   Sissy was cyanotic (blue gums), and very pale.  She was open mouth breathing and fluid was coming from her nose, and she had a low body temperature.  When I listened to her chest,  I heart a high heart rate and moist lung sounds, or "crackles" that often occur when fluid builds up.  The most likely causes of these findings is congestive heart failure, however other possible diagnoses (or 'differential diagnoses' in medical terminology) include pneumonia, neoplasia, or asthma.  These differentials were much less likely given the picture as a whole, but none of the possibilities can be completely ruled out without testing, like chest radiographs (x-rays) or an echocardiogram (ultrasound of the heart).

I went into the exam room.  I inquired further about the history; it turns out that Sissy had never had any testing to confirm asthma, furthermore she had not had any treatment or flare-ups in 4 years.  This is not consistent with asthma, and certainly my physical exam findings were not consistent with asthma as the  most likely diagnosis.  I recommended oxygen, chest radiographs, and hospitalization with medications to be determined based on imaging.  The client refused any testing and screamed at me.  "JUST GIVE HER A STEROID SHOT! ALL SHE NEEDS IS A STEROID SHOT!!"

Steroids are a prime treatment for asthma, however can worsen heart failure.  I explained this to the client, as well as the findings that did not go along with asthma.  I discussed that we could try medications alone, but that Sissy might decline.  I also discussed that given her critical condition, even with all diagnostics and no limitations, she was at risk for sudden death or respiratory failure.  I have pulled cats back from this condition before, but there are no guarantees in medicine.  Further complicating the issue was that the client did not want to spend any of her own money on her cat.

The client screamed at me again.   She then put her hand up in my face, dialed her phone, and called someone.  I excused myself to go check on her cat, as well as to give her time to make her call, despite her rude behavior.

Five minutes later, I came back into the room.  Her sister had joined her and was also hysterical. "CAN'T YOU JUST FIX HER? FIX HER! WHY CAN'T YOU JUST FIX HER?!"  Calmly, I explained the medical situation again, and that I could definitely try to fix their cat, but ultimately, the clients decided upon euthanasia.

"NOW what's going to happen!?" She screamed.  "I want my cat right now!"

Sissy had been resting in our oxygen-enriched incubator, where she was still struggling to breathe, but had more comfort than the room air environment.   I explained this to the client.  I offered for her to come sit with Sissy while we provided oxygen via a face mask to help her stay comfortable.

I brought the client to the treatment area, and an assistant placed Sissy in her arms with a blanket.  I brought over an oxygen mask, and told the client "This oxygen will help Sissy to breathe easier while you spend time with her."  I slowly moved the mask into place, and the client screamed at the top of her lungs in a tone that could have fightened a demon;

"WHAT IS THAT!!!!!!!!!!!!!!!!!! WHAT ARE YOU GIVING HER?!?!?!??!!!!!!"

Somewhat dumbfounded, I replied "Ma'am, this is OXYGEN to help Sissy breathe while you hold her." (What did she think it was? Poisonous gas we were going to make her and her cat breathe?)

When the clients were ready, and amongst screaming, yelling, and swearing, I administered the euthanasia solution.  Sissy stopped struggling to breathe, and passed peacefully.  I knew we had done the right thing, despite the drama associated with the decision.

As sad as the loss of a pet is, there's no reason to treat the veterinarian like an enemy!

The full moon.

Wow.

I woke up this morning after finally getting a night of sleep.  Work this week has been outrageous, and actually this entire winter has been busier than usual.  To give you some idea of my schedule this week, it went something like this:

Wake up in the afternoon/early evening, shower, get ready for work.  Feed my pets.  Stumble around the house for awhile, trying to figure out what day it is and get rid of my sleep-deprivation headache.  Leave for work, drive somewhere to find food (since there's no groceries or time to go to the store while on 15 hour shifts), arrive at work.  Eat my dinner at the staff break table.  Clock in, put on lab coat and stethoscope.  Run around like a mad-woman for 14-15 hours dealing with situations like the one below.  Try to maintain patience, poise, and make sound medical judgements.   Finish shift, clock out. Drive home (trying not to fall asleep at the wheel), crash into bed, try to sleep (it's been sunnier than usual this winter, so I've been having a hard time with the sleep part, and additionally, we just moved, so it's even more difficult with everything askew).  Repeat.  No time for household tasks, cooking, eating, or other such silly things.  Needless to say, I'm exhausted.




So after arriving at work one night this week, it was blessedly quiet.  Nothing hospitalized, no patients waiting to be seen when I arrived.  I got a few things done that have been waiting for weeks, and enjoyed a few hours of peace and quiet.  We took a few phone calls, but none of the callers would agree to come in.

The night looked golden - usually after about midnight, the caseload drops off as most people are asleep and not able to know what their pet is or isn't doing. Unfortunately, that wasn't the case this night.

Four clients, three of them disasters, all arrived within 15 minutes of each other.

Client #1 - Young, otherwise healthy dog who had had his first seizure.  Fortunately, this patient was stable.  Unfortunately, the clients were ridiculous.  I spent about 20 minutes talking to them about the most likely diagnosis, epilepsy, and the usual therapy for their pet.  As their cute young dog tried to get me to throw his toy so he could fetch it, these clients actually asked me to euthanize their dog. Again, I explained that their pet was stable, that he may never seizure again, and even if he did, it was (usually) manageable with medications.  In the middle of my third go-around explaining, I was pulled away for the next client.

Client #2 - 1 year old pomeranian, Sid, presenting for "just not being himself." She stated that this had just happened in the last hour or so. "Just not himself" was a ridiculous understatement - Sid was laterally recumbent and nearly comatose, dripping blood from his penis and definitely critical.  The client was acting bizarre, attempted to leave several times, and stated that she had no money to spend to help Sid.  

She refused to apply for CareCredit to help herself help Sid.  She contacted 3 or 4 relatives, who then each separately called our hospital multiple times.

While I waited for the client to sort out her drama, I tried to help Sid, regardless of the fact that she couldn't pay for services.  I passed a urinary catheter, and found that he had multiple bladder stones, including some stuck in his urethra.  My technician inquired again about symptoms, and the client changed her story - now stating that she had been holding him all day and that the bloody urine had started that morning.  In truth, poor Sid probably had been unable to urinate for several days, and probably had kidney damage as a result.

I went in to speak with her.  Any normal human could see that this dog was suffering.  It didn't take doctor status to be able to look at the poor thing, unable to move, body temperature falling, dribbling bloody urine and nearly in a coma to make that decision.  I gently explained the situation to her.  She made multiple more phone calls, gave me way too much information regarding her multiple estranged husbands/baby's daddy/boyfriends, and finally agreed to euthanasia, TWO HOURS after her arrival.  She refused treatment for Sid, and without treatment, she knew, even in her drug-altered state, that he would continue to suffer and eventually die.  I thought we had resolution of this awful situation.

Client #3 had been waiting in an exam room for much of this time.  This client had been calling our office multiple times with a 1 year old chihuahua having difficulty with labor.  The dog had one stillborn puppy, and 8 hours had gone by with no further puppies.  Green discharge was now coming from her vulva.  This is BAD - the remaining fetuses are probably either near dead or already dead, and if the fetuses aren't removed from the uterus, they can decompose and make the bitch very, very sick.

Unfortunately, these clients were complete morons. (You may think I'm being harsh, but just wait and see for yourself).  They refused an exam by a doctor (so why did they come in?), they refused to apply for CareCredit (the only payment plan that is available).  My technician got vitals on the bitch, who thankfully appeared stable at this time, and recommended they see a low - cost spay/neuter clinic as soon as they opened in the morning, about 7 hours' wait.  He explained to them that the wait was not ideal, and she could be very, very sick quickly based on their poor decisions.  We gave them contact information for the most affordable low-income spay clinic in our area.  The next day, they continued to call, had NOT taken the bitch to be spayed, and her symptoms were worsening.  By 5pm, when the spay clinic closes for the day, they never made any sort of arrangements for her care and continued to call us.  The spay clinic is subsidized by donors and local government and is able to perform spays well below cost, therefore the cost of a spay at this clinic is actually LESS than our exam fee ALONE.  We gave them the tools to save their dog at a VERY low price (we're talking less than $100), and they did nothing.  I feel bad for their poor, poor dog, but I feel nothing but contempt for the humans.

Client #4 had also been waiting a very long time to speak with me.  I was so happy to walk into the exam room and find a normal person, a friendly dog, and a minor problem which I remedied quickly.  The client was friendly, asked good questions, and genuinely loved her pet.  I apologized for her long wait and she thanked me for my care of her pet.

Back to client #2
Despite signing the paperwork for euthanasia, which we were performing for free, and was the only right thing to do for her poor dog, the client continued to call family members.  Her estranged baby's-daddy-creepy-douchbag-ex-husband came down to the clinic after hour number two of this drama, and refused to let us euthanize the dog.

I argued with him for an hour, but he was completely irrational (and probably on drugs).  He said really smart things, including that he had a dog with this problem before who he had fixed by giving it yogurt.  Oh, right, yogurt totally clears up KIDNEY FAILURE and bladder stones.  Sorry, I forgot when they taught that in EIGHT YEARS of school.  My bad.

After the fourth hour of this saga, my patience was completely gone.  I informed this man that he needed to put his feelings aside and do the right thing for his pet.  He refused.  I then told him that he either needed to authorize treatment, to euthanize his dog, or he needed to leave.  If he chose to leave, it would be against medical advice and I would contact the animal control authorities and report him for cruelty.

He chose to leave, and signed against medical advice paperwork.

So incredibly infuriating.  I contacted the authorities the next morning, and they will be doing a full investigation.  I hope they throw the book at him.