Thursday, May 31, 2012

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!

Tuesday, May 29, 2012

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.

Thursday, May 10, 2012

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.

Friday, May 4, 2012

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!?