Sunday, July 29, 2012

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.


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.


Wednesday, July 4, 2012

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.


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.