Update

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

LIVE, DAMN YOU, LIVE!

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

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

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

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

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

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

This is where the story gets amazing.

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

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

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

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

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

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

+1 for the home team :)

~ERDOC

)&*&#$^&!

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


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

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

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

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

Situation #2 -

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

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

What did the client choose to do?

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

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

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

When caring hurts.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Float like a butterfly....

Last night, a 2 year old poodle was rushed into the hospital.  The client reported that "Peanut" was out on a walk, limped for only two steps, and then collapsed.  Peanut was limp, not responsive, and her client was understandably hysterical.

On physical exam, Peanut's situation was grim.  She was comatose and therefore, not responsive to external stimuli.  She was unable to move any part of her body; her heart rate was extremely low and her breaths were shallow and slow.  Her mucous membranes were gray, with a pallor that is usually only seen on a deceased patient.

We jumped in to action.  The most likely explanation for a sudden collapse in a young dog was anaphylaxis, in our area, most likely from a bee sting or insect bite.

An IV catheter was placed; I started to bolus IV fluids in attempt to restore circulation; oxygen was provided. We administered epinephrine to halt the reaction as well as improve the heart rate and blood pressure, a steroid to combat the immune response, as well as benadryl and GI protectant medications.  Over about 40 minutes, Peanut steadily improved to sit up.  When another client came to the front door, she surprised us all and started to bark!  It was an amazing change, and she was on the right track.

Over the evening, Peanut improved steadily, and was remarkably eating and drinking within 4 hours.

Despite the overwhelming positive progress, one single concern emerged.  Peanut was oozing blood from any place on her body where blood had been taken, despite adequate pressure wraps.  Clotting times were evaluated, and Peanut was suffering from a coagulopathy secondary to her near-death experience.  Fortunately, her owner allowed a plasma transfusion, and 3 hours later, Peanut appeared as normal as ever.  Her mom came to pick her up this morning, and Peanut jumped, squealed and wagged her tail in joy of seeing her.  The client was equally as happy; she thanked us for saving her precious dogs' life.

Truly, a heartwarming case!

Letting out the evil vapors

The busy weekend continued with evaluation of "Gus," a 4 year old labrador, who had been vomiting and not eating for 3 days.  He was a typical lab, with a habit of eating anything not nailed down. He had been hospitalized for 24 hours, and was not improving; he had continued to vomit despite lack of food offered to him.  Radiographs from the previous day were suspicious, but not diagnostic for an obstruction.

I assessed Gus, and took him to the ultrasound for further investigation of his abdomen.  Ultrasound was overwhelmingly abnormal.  His loops of intestine were dilated with fluid, and sharp turns were noted, indicating a possible obstruction.  The actual item could not be visualized, but based on these findings, I recommended surgical exploratory.

His electrolytes were performed, and revealed a hypokalemic, hypochloremic metabolic alkalosis; classic for upper GI obstruction, (but also can occur in patients with frequent vomiting).

In Gus' case, the suspicion for a foreign object being lodged in his intestines was increased by his breed, his age, his history and lack of improvement despite therapy, as wells asthe results of radgiographs and ultrasound.  Surgical exploratory was the only way to be sure of the cause of Gus' illness, but in his case (and most others), there is always a risk of performing surgery, only to find nothing.  No obstruction, no foreign object, and no macroscopic reason for the pet's illness.  This is unbelievably frustrating for the client, given the expense of surgery, as well as the pain and recovery time associated with it.  It is also unbelievably frustrating for the veterinarian, who obviously wishes to perform surgery on all the right animals, and not perform surgery on those who don't need it.  On the other hand, the risk of NOT performing surgery on an animal with a GI obstruction is extreme; if the object remains lodged in the intestines, in can result in damage to the intestines, requiring portions to be removed, or in the most severe case,can cause rupture of the GI tract, and an overall much worse prognosis for recovery (or even death).

With these facts in mind, I discussed the recommendations' to Gus' family.  Surgical exploratory did have the small risk of anestheia, as well as the cost and associated healing time, however doing nothing could potentially result in significant worsening of his condition.  They wished to proceed with surgery, and so Gus was prepped for his surgical procedure.

Anesthesia was uneventful, and Gus' vitals all remained normal throught the procedure.  What I found at surgery, however, was just the frustrating finding I had hoped not to see; no foreign object, a negative explore.  Gus' stomach was filled with fluid, his intestines were dilated and had no normal movement, but there was no clear macroscopic reason for his illness.

Frustration washed over me as I evaluated the entire length of his GI tract again, just to be sure. Nothing. No rock, sock, string, or nylons to take out, and no clear reason why Gus had been feeling sick for three days.  The adage you learn in veterinary school is, "If you aren't doing any negative abdominal exploratories, then you aren't doing enough abdominal explores."  This comment, while true, is not comforting when you're staring into a dog's abdomen, wondering why you cut him open.......

The meaning of this comment is based in statistics.  I'll refrain from boring you with the mathematical details, but in summary:  The goal is to never miss a true foreign body (FB), so as to avoid harming the patient (or having one die).  As every patient with a FB can look different, some patients without a FB will mimic those who have a true obstruction.  Essentially, surgical exploratory is called an "exploratory" because, in the right situation, it is not only a therapeutic procedure, but also a diagnostic one. As nobody can be 100% correct every single time, it's better to have a few "negative" explores, than a few patients with an obstruction who are missed, and subsequently die.

Often, patients without foreign objects who undergo surgery do very well afterwards; it's been jokingly referred to as a "therapeutic gut stir" or "letting out the evil vapors."  The pain of surgery typically abates in <24 hours, and they return to happy, healthy lives with their families.  As frustrating as a  negative explore can be, I'd take one every time over a dog who didn't have surgery soon enough.  It's a delicate balance and a difficult decision each and every time.

Anyway, I digress.  I biopsied Gus' intestines, in hopes of determining the cause of his GI illness, and he recovered uneventfully.  He discharged the next day, eating, no longer vomiting and back to his normal self.

a mixed bag

I arrived to work on Saturday in a great mood - ready for the day, and hopeful for a busy and rewarding shift.  Sometimes, I should be careful what I ask for!

Saturday started out with very few patients already admitted to the hospital.  Before I even had the chance to evaluate these patients, client after client started to arrive at the front door en masse.  Within the first hour, there were 5 patients waiting to be seen, with more on the way.

"Leo," a 18 year old gray tabby cat, presented for bleeding from his mouth.  He had otherwise been a previously very healthy cat. Leo was indoors only, so trauma was very unlikely.  As I to take a detailed history from his concerned owner, I began my full nose-to-tail physical exam.  My standard physical exam is performed the same way every time, in the effort to be the most efficient and to avoid forgetting any sections of the body.  I start at the patient's head, with ears, eyes, nose, throat first, then moving to an oral exam, followed by listening to the heart and lung sounds, palpating the abdomen, and finally evaluating the extremities, performing a neurologic exam, and a rectal exam.

Leo's diagnosis was visible before I even left the first segment of his exam.  An expansile, large fleshy mass was present at the base of his tongue, and clotted blood was present where he had likely bit the tumor, resulting in the symptoms noted by the owner.   Unfortunately, given the size and location of this mass, Leo's options would be limited, and the client instantly knew this when I gave him the sad news.

A 2 year old dog had arrived and was brought in on a stretcher.  The 160lb Rottweiler was stumbling, and acting bizzare, according to the owners.   Immediately on examination of "Gus," his diagnosis was unmistakable.  Gus was headshy, and when left alone, would fall alseep.  He could walk, but had a drunken, ataxic gait.  He was dribbling urine - all hallmark signs of marijuana toxicity. His clients, with red, bloodshot eyes, wearing Bob Marley apparel (I'm not exaggerating!), and smelling of Mary Jane, claimed that it was completely impossible for Gus to have had access to pot.  "No way, man," they claimed.

Sure.

I tried to explain to them that my only interest is in the health of their pet, and if there really was no access to THC, then we needed to be aggressive about determining the actual toxin or process responsible for Gus' symptoms.  I offered drug testing, antifreeze testing, and a biochemical panel to evaluate internal organ function.  After reviewing costs, the clients declined testing, and requested treatment for THC.

The next patient to require my attention was a 5 year old orange tabby who had just been closed in a garage door.  Fortunately, the friendly, fat kitty had only suffered some minor brusing and soft tissue injury of his pelvic region, and radiographs ruled out pelvic fractures.  He'd be back to chasing mice in no time.

The day rolled on, and the rest is to be continued....