A little lesson in cardiac physiology

If something doesn't seem right, trust your instincts.


A geriatric golden retriever presented to a colleague at my hospital for a sudden collapse.    Diagnostics confirmed that "Frank" was bleeding into his abdomen from an abnormal area of his spleen.  In medical terms, this condition is called hemoabdomen  About 2/3 of cases of hemoabdomen from a splenic mass are malignant, and about 1/3 can be a result of benign causes.  The most common malignancy is hemangiosarcoma, which is a very aggressive and poorly treatable form a cancer.  Read the above link if you would like more information.

My colleague and the clients discussed the only two reasonable options for Frank, which included either stabilization and emergency splenectomy (removal of the spleen to halt blood loss), or euthanasia.   His family elected to go forward with the emergency surgery.

Frank received a blood transfusion, and was stabilized for surgery.  His spleen was removed, and surgery was relatively uneventful.   After surgery, Frank transferred to the care of his primary daytime veterinarian.

Frank returned to us while I was on shift, about 36 hours later. In the interim, Frank had been sent home from the daytime clinic.  He was lethargic and refusing to eat, and his family had noted that his heart had been racing all day.  A recheck exam at his daytime clinic that same morning revealed a heart rate of 190 beats per minute.  Their primary care doctor discharged Frank, in hopes that it would 'go away,' per the clients recollection.  The family knew that something was not right, however did as they believe they were told and took Frank home.  The family monitored Frank's heart rate throughout the day, counting the number of beats in 15 seconds and multiplying by 4.  Around 2pm, they called their regular doctor with an update; the heart rate remained high.  They were instructed to wait at home.  Around 5pm, they called again and their daytime clinic recommended that they come immediately to see the emergency hospital.

As Frank entered the hospital, we immediately knew something was wrong.  His heart rate was a dangerous 220bpm, his pulses were poor, and his capillary refill time was prolonged. An IV catheter was placed, an an ECG immediately performed.  Frank was suffering from ventricular tachycardia, a dangerous rhythm which requires immediate treatment with anti-arryhthmics.  I immediately administered IV lidocaine, and consulted with the clients regarding Frank's current status.

The positive news is that ventricular beats and this type of arrhythmia is usually a transient complication of splenic surgery (in this case, ventricular tachycardia/VPCs have many, many other causes).  It is not understood why this occurs, but with treatment, ventricular rhythm disturbances commonly resolve within 24-48 hours after surgery.

One part of my job that I enjoy most is client education.  While Frank was receiving his initial lidocaine and a mini-blood panel was pending, I took the time to give the clients a brief lesson in cardiac physiology.

The heart consists of four chambers.  Two chambers are called the atria, which receive blood as it returns from the lungs and the body.  The other two chambers are the ventricules, which pump blood forward to the lungs, where oxygen is replenished, and to the body, which provides life-sustaining oxygen and removes wastes, such as carbon dioxide.  In order to organize this complicated organ, electrical activity in a normal heart starts in a specific location near the atria (called the sinoatrial node), and travels along a sophisticated pathway towards the ventricles.  This organized progression of electrical activity allows the heart to function as a unit, and for blood to move in an organized, forward fashion.  A normal ecg beat looks something like this:

wikimedia, public domain image

On the other hand, a ventricular beat originates in the ventricles, and is an unorganized, haphazard movement of electrical activity through the heart. A ventricular beat / rhythm looks something like this:

Borrowed from http://www.vetgo.com/cardio/concepts/concsect.php?sectionkey=5

Ventricular beats resulting in high heart rates become dangerous when the heart can no longer act as an effective pump, starving the body's tissues of life-sustaining oxygen.  Excessively high heart rates (>170-180bpm), poor pulses, pale gums, or weakness are all indications that anti-arrythmic therapy is needed.

The clients immediately knew that this heart rate was present 8 hours ago at their daytime clinic.  Frustrated, they asked me the question that we all were wondering --

 "Why wasn't this treated this morning? Why weren't we transferred to your care sooner?" The family looked at each other in exasperation. "We knew something wasn't right."

Unfortunately, I couldn't answer this question for them.  "I'm not sure," I said. "You'll have to talk to your veterinarian to ask them for specifics. I wasn't there, and I can't guess or assume at why specific medical decisions were made.  What I can tell you is that Frank needs to stay with us tonight for monitoring, lidocaine, and hopefully, he'll resolve this rhythm disturbance in 12-24 hours."


Morale of the story: If things don't seem right, get a second opinion.  Even the world's best doctor/veterinarian is never able to achieve 100% accuracy.  Second opinions save lives.

The most unbelievable story of all.

I'm so angry right now I can't even see straight.

Two weeks ago, I received a call from a daytime veterinarian.  A homeless man had arrived at her clinic, and had been hit by a car.  The dog was suffering from severe head trauma and probably had broken ribs and lung injury as well.  She had placed an IV catheter and administered dexmedetomidine, a potent sedative/anesthetic agent.

The veterinarian (we'll call her Dr. V ) was inquiring about options for this homeless man's dog.  The homeless man, with not a dime to his name, also had no means of transportation.  Dr. V called to ask me what could be done for this dog, given his critical condition.

Sadly, I reported the state of things.  As Dr. V already knew, our hospital is a small business with no outside funding and no trust fund to pay for stray/abandoned/underprivileged pets.  Any treatment that is provided at no cost directly removes money from our hospital to repair equipment, pay staff wages, provide raises, and pay our electric bill.  We simply cannot afford to provide care to patients on a pro-bono basis, especially when that care is extensive as in this case.  Providing care without payment for services WILL result in bankruptcy and closing of our doors, and therefore loss of after hours care for sick/injured pets, and job loss for all of our employees.

I apologized for the difficult situation, and informed Dr. V that all I could provide for this pet was pro-bono euthanasia, which he could obviously do at his clinic without driving the dog to our hospital.  We ended the phone call.

15 minutes later, Dr. V called me again.

"The homeless man wants to come to your hospital," she said. "I'm going to drop him off at your clinic."

Dumbfounded, I had a difficult time forming sentences in a professional manner, without screaming WHAT THE &#$*# ARE YOU THINKING??!?!?!

"Dr. V, I don't understand what this is going to accomplish," I said. "I am not able to authorize or provide any care for this pet when there is no funding to pay for charges incurred.  The only thing I can do for free is to euthanize the pet (to end suffering), and there's no reason to drive him all the way here for me to do so.  If the pet is critically injured, he should be euthanized to end suffering.  I know that none of us want to euthanize this pet, but there's no agency/group/private institution that can afford to pay for sick and injured homeless pets.  We can't even feed and house the HUMANS that are homeless."

Dr. V didn't seem to get it. "Well, the homeless man wants to come there, and what am I supposed to do? I've already placed a catheter and anesthetized his dog.  I think it has head trauma and brain swelling. "  (Those of you reading this with medical knowledge will also notice that this treatment is completely inappropriate for head trauma).

I apologized for the sad situation, but repeated the truth of the situation.  I wish the reality was different, but as our hospital (like most veterinary clinics!) has no government funding, no rich benefactors, and with the economy in a economic depression, there isn't any extra money to go around.

Dr. V ignored my replies.  "I'm bringing him over anyway.  It's 5:45 and I want to go home. Maybe he can just take his dog 'home' and see how it goes."

Never, in my career, have I witnessed such an unprofessional, rude, unfair, ridiculous decision by a supposed professional.  This is an extreme case of "passing the buck."  -- Sorry sir, I can't help you, but I'll drive you to the emergency room! They'll be sure to have everything you need to make your pet all better!!

At this point, I was furious.  If Dr. V chose to initiate therapy for a homeless man's pet out of the goodness of her heart, then she should have taken the initiative to see it to completion, or recommended euthanasia once the extent of injuries was realized.  By starting some sort of (inappropriate) treatment plan, and then driving the man to our clinic, she essentially made my clinic and me look like the heartless, money grubbing assholes who don't help out during tough times.  In addition, at this point, the client had unrealistic expectations of us providing thousands of dollars of free care for his critically injured pet.

Dr. V arrived, and refused to speak with me.  My receptionist asked her to talk with me about the case, but she ran out the door before I could see her.  "I've got to go, I just can't stay, sorry...." she said.

The homeless man was obviously and understandably distraught.  He was also carrying an 8'' knife, and a risk to myself and my mostly female staff.  His dog was critically injured, had visible signs of head trauma, difficulty breathing, and pale gums.  To allow this dog to "go home and see how it goes" would have been an inhumane decision, and I could not allow it.  We gently counseled the homeless man, and fortunately, he was a reasonable person who understood that his dog was morbidly injured.  He knew that euthanasia was the best thing for his pet.

I euthanized his dog while he cried, and I apologized for his loss.   It was the only reasonable, humane decision in the given situation.


I'm flabbergasted. How can this "colleague" think that her actions were reasonable??

Holiday weekend

I'm back from a long (much needed) break!

The holiday weekend was an expectedly busy one.

Best save of the weekend -- a 9 year old 120# mastiff presented for collapse.  He had been outside with his family, playing on a nice summer day.  All of a sudden, he fell to the side, became unconscious, and foamed at the mouth.

His family, frightened, called us immediately.  They were on their way.

When "Rufus" arrived, he was unable to walk into the hospital on his own power, and was carried in on a gurney.  His physical exam was mostly unremarkable.  The only abnormal findings included an elevated heart rate, his inability or unwillingness to walk, and an ever-so-slight paleness to his gums.

The search for cause of his collapse was on.  His BP was normal, an electrolyte panel was normal.  A scan of his abdomen revealed no free fluid. He received a bolus of fluids, and improved slightly.  An ECG was normal.  His clients expressed their concerns to me that he had eaten a large amount of clay cat litter the previous weekend, and requested abdominal radiographs.  These too, were normal (no evidence of cat litter or anything else unusual).

I recommended an ultrasound of his heart, and the clients approved.  They wished to do whatever necessary to help their beloved Rufus, who had been normal the day prior.

The ultrasound of the heart revealed the cause of his collapse -- Rufus had pericardial effusion.  This means that an abnormal collection of fluid accumulates in the pericardial sac -- a fibrous sac surrounding the heart.  When fluid accumulates in this area, pressure becomes overwhelming and the heart becomes compressed, preventing the heart from being able to fill.  This results in pericardial tamponade, and explained Rufus' clinical signs.

The treatment of pericardial effusion is to remove the fluid from the space.  The area was prepared in a sterile manner, and I utilized a large bore needle to facilitate the removal of fluid from the space.  Rufus immediately felt relief.

The ultimate cause of Rufus' pericardial effusion is pending additional testing, but for now, he's home with his family.

MIA

Sorry about the two week hiatus - I'm out of town - I'll be back online this weekend.

--ER doc

Really?

Today a stray dog just got hit on the highway by a semi-truck, driving about 70 miles per hour.  A onlooker who had witnessed the dog being hit brought it in to us (no collar, no microchip, no known owner).

He yelled and swore at ME because the dog was dead on arrival.  Really?
He didn't believe that there was nothing I could do. He called me a "liar." Really?
He swore at my front office staff that we were "heartless assholes." Really?

Should I have lied to you and said that we performed CPR and brought back the dog and it was going to be all better?
Should I have lied to you and said that the dog isn't injured, and it'll be home by tomorrow?


Or should we tell you the truth?  When a 40 pound dog gets hit by a semi-truck weighing somewhere in the neighborhood of 80,000lbs (2,000 times the weight of the dog), the dog loses. 

 It's sad, and I'm sorry, but I can't fix this one. Pretty sure that doesn't make me a liar.

Does Fluffy have her medical card?

Funny tidbit from my last week of working --


Very old kitty arrives with chronic, end-stage kidney failure.  The client, who is very sweet, but slightly crazy informs me that she's been feeding her cat catnip. "It's just like medicinal marijuana," she says. 

Sure. Nepeta cataria (catnip) and Cannabis sativa (marijuana).  Totally the same.  Maybe pot-heads can just start rolling catnip and save some money.

why is it always the nice ones?

There's an expression in ER medicine - "Nice pet, nice owner = bad disease."  This saying stems from the general observation that, on average, the mean, fractious, angry feral cat can survive any diagnosis, and usually has an easily fixable condition, whereas the loved, indoor only, perfectly cared for cat with loving clients who can afford the highest quality of care will end up with a terminal disease.

This case is no exception.

"Slash," a 4 year old, mostly indoor cat presented after being hit by a car just in front of his family's home.  His clients tried to keep him indoors because they knew the risks of cars, of other animals, and were concerned about Slash eating birds and endangering songbird populations.  Slash seemed to be unhappy in the house, and after several months, despite their better judgement, they decided to give him a couple of hours during daylight, to enjoy the greater outdoors.

The client's worst fear came true last week, when Slash ran out from underneath a car, and was hit crossing the street.  He was immediately unable to walk, vocalizing and in pain.  He arrived to the ER quickly, and was in shock.  IV fluids were initiated, pain medication was started, and a neurologic exam was performed.

Slash was able to feel his hind limbs when pinched, but was unable to move.  Radiographs were the next step at determining the cause of his injury.  Pelvic fracture? Spinal trauma? Vertebral body fracture?  The other abnormality on Slash's initial physical exam is that his breathing pattern was altered.  It appeared as if when he breathed in, his entire chest was sucked in, instead of his chest expanding with every inward breath.

Radiographs revealed a very serious injury - Slash had a vertebral body fracture with compression of his spinal canal.  He would need surgery by a specialist the following day to repair the compression, and his recovery would take time.  Regardless of the cost and associated dedication to care, his family was committed to pushing forward.  No other injuries were present, and with this degree of dedication, Slash had a chance at a normal life.  Despite Slash's abnormal breathing pattern, there were no broken ribs to explain the pattern.  He was oxygenating normally at this time, and there was nothing we could do except for watch carefully for any changes.

After Slash recovered from his shock, his status improved for a few hours before they came crashing back down.  Around 3am, Slash began to have difficulty breathing and was placed on oxygen.  Recheck radiographs revealed a large amount of fluid in his lungs, and a very enlarged heart.  Despite lack of a heart murmur, Slash apparently had significant underlying heart disease, in addition to suspected bruising of his lungs from the trauma.  He continued to deteriorate quickly, even with discontinuation of intravenous fluids and addition of diuretics.  As he struggled to breathe, it became apparent that Slash was heading for disaster.

His family was contacted and wished to continue to provide every possible intervention for Slash.  Slash  was sedated in order to facilitate intubation and control his airway.  This intervention allowed sufficient oxygen to be delivered to his body's tissues (especially the brain and heart).   Fluid was dumped through his ET tube, and positive pressure ventilation was initiated.

Over the next 5 hours, we monitored Slash intensively.  Slash had a dedicated technician monitoring him, and we attempted to wean him from being intubated several times, before it became obvious this was not going to be possible at any near time frame.  Slash needed to be on a ventilator for 24-72 hours, or longer, to determine if he would ever again be able to ventilate his own body.  Our theory and the only logical cause is that ascending spinal cord inflammation, or the direct trauma and concussion of the spinal cord, resulted in paralysis of Slash's intercostal muscles and / or his diaphragm, which resulted in failure of the body's ability to effectively ventilate.  Like many neurologic injuries, there was/is no direct repair.  The only option was to support his body's vital signs, and wait to see if it would ever improve.   This time frame could literally be days, weeks, or never.

Unfortunately, his breathing pattern never improved.  Consultation with the surgeon confirmed my exam and knowledge, and we discussed the complexities of the case with the clients for hours, while they visited with their beloved Slash.

After lots of tears, much discussion, and careful consideration, the family made the difficult decision to euthanize Slash.  We were all crushed by the tragic outcome, but knew that the family had made the right decision.  Slash's chance for recovery was very small, and the cost and suffering associated with that small chance would have been astronomical.

Rest well, kitty.  You will be missed by many.