I had a very busy weekend in the ER, complete with trauma, run of-the-mill bite wounds, lacerations, and plenty of vomiting and diarrhea.
The best save of the weekend was a 4 month old, adorable pit-bull puppy who had just been hit by a car. On presentation, her mucous membranes were gray and muddy, and a capillary refill time was not detectable (as in, the color never returned as it was incredibly poor to start). Her pulses were poor, and she was having difficulty breathing. Lung sounds were ausculted over her entire chest, but crackles were noted, likely due to bruising.
We immediately provided her with oxygen, placed an IV catheter, and started bloodwork. She began to breathe easier, but her blood pressure was 58mmHg. Way too low (normal systolic being at least 90-100mmHg). At a BP of <60, vital organs were being starved of oxygen, and the longer she spent at this level of hypotension, the more likelihood of irreparable damage. We had to act fast.
Her owners, a very nice young couple, authorized any and all care provided. The young man, probably in his early 20's, begged me to save his dog. He had just lost his sister at a young and unexpected age, and couldn't bear to lose his best friend, "Lucy." He requested the best care we could provide, regardless of the cost, including CPR, surgery, or anything else that would potentially become necessary. "Save my dog!" He cried. "Please! You have to save my dog!" I assured him that we would do everything in our power, but sometimes, we lose them anyway. Unfortunately, there's no guarantee in medicine, but I'd do my absolute best (as I always try to do).
We started with crystalloid fluid boluses, careful to mind her injured lungs, however at this point, hypotension was her primary danger. Her BP improved to 70 after two boluses, but this was still unacceptable for her organ function. I moved to a hetastarch bolus (a colloid fluid, which remains within the vessels longer and can provide additional BP support), which bumped the BP up to 80, and then finally, after ~45 minutes of fluid resuscitation, her BP was 110 mmHg.
Chest radiographs revealed significant intrathoracic trauma; a mild amount of free air which had escaped from her damaged lung (this is called a pneumothorax), contusions and collapse of about 1/4 of her lung lobes. The amount of air in her chest was not a sufficient volume to require thoracocentesis, as long as this air did not continue to accumulate, it would resolve with time and supportive care. Also, her diaphragm appeared to be ruptured, with a portion of her liver moving into her chest. Fortunately, no orthopedic injuries (fractures or luxations) were noted, and her urinary bladder, gall bladder and GI appeared intact. Only a scant amount of fluid was present within her abdomen (likely a mild amount of bleeding from blunt trauma, and very common with this type of injury).
The puppy was on the road to recovery. She spent the evening with the overnight veterinarian, who would provide the same expert level of care. If she became unable to breathe, emergency surgery might become necessary to repair her diaphragm. Lucy was still at risk of declining in the over night period -- I had difficulty sleeping when I arrived home, anxious to find out how my little Lucy's night would turn out.
When I returned to work the next day, I was happy to see Lucy off of oxygen. She was breathing well on room air, no longer requiring the additional supplementation of bottled oxygen. Over the course of the day, she became playful, ate vigorously, and started to act like a real puppy again. In even better news, a recheck of her radiographs revealed that the previous collapsed lung and bruising was already on the mend, and her diaphragm may not require surgery!
"Lucy" went home to her family the following day, almost as good as new. They plan to recheck the radiographs in several days to determine if a true rupture of her diaphgram is present, or if the radiographic changes were due to thoracic trauma alone.
I'm proud of this save, I'm happy that despite the severity of Lucy's injuries and her near-death experience, we were able to return her home to her family, and that for this young man, the trip to my ER was a happy one.
Monday, June 13, 2011
Saturday, June 11, 2011
People suck.
Today, I had the misfortune of meeting a heinous, evil person.
"Greg," a 40 something, normal-enough looking man, brought in his 10 month old yellow lab, "Jesse" for vomiting of 2 days duration. Jesse was not eating for 2 days, and had not produced any feces. She was known for eating objects, and yesterday had vomited up football leather and some ceramic pieces.
Her abdomen was painful, she was dehydrated, lethargic, and clearly nauseated. I recommended radiographs, and Greg agreed. Her history and exam were extremely consistent with foreign body/GI obstruction, and likely, she would require exploratory surgery. Unfortunately, Greg informed me that surgery was off the table. Initially I understood his position; exploratory surgery is expensive, and perhaps Jesse would not have an GI obstruction. If she was obstructed, surely he would change his mind. Right?
Wrong.
Jesse's radiographs were clearly obstructive; there was nothing equivocal about them. A large, jagged rock was present in the duodenum; the stomach was dilated with fluid and the remainder of the intestines appeared dilated and plicated. Surgery was clearly indicated, and the sooner, the better.
Greg coldly declared that there was no way he was going to spend the money on "this damn dog." I offered him Care Credit, our financing plan -- but he declined. Greg informed me that he already had the finances available, but had no interest in spending money on fixing his dog. "She'll just do it again, and I don't want to pay for her surgery if she's just going to eat something else."
I was taken aback by his cold, uncaring attitude. I offered him an attempt at medical management, or to contact other veterinarians in town (including his primary care veterinarian) to determine if costs might be cheaper and within his range.
"Absolutely not" Greg said. "I'll take him out back, and .... well, you know. I'll take care of it."
I've heard this before, and I wasn't surprised by a client hinting at shooting their own dog, but I still don't condone it. I expressed my concerns for this choice, however he was unwilling to change his mind.
I then offered to give his dog some pain medications in preparation for his plan to take her home. He refused. This is when I became infuriated -- an injection of a pain reliever is less than $30, and would provide his pet with some comfort in her last few hours. He declined not out of concern for finances - he explained explicitly -- but because he just didn't care.
Awful. Awful, horrible, terrible, no good human being.
Eventually, his wife convinced him to allow euthanasia. Thank goodness for her - I was able to let Jesse pass peacefully. As much as I wish I would have been able to fix her, I'm honestly thankful that this monster of a human didn't take her home.
"Greg," a 40 something, normal-enough looking man, brought in his 10 month old yellow lab, "Jesse" for vomiting of 2 days duration. Jesse was not eating for 2 days, and had not produced any feces. She was known for eating objects, and yesterday had vomited up football leather and some ceramic pieces.
Her abdomen was painful, she was dehydrated, lethargic, and clearly nauseated. I recommended radiographs, and Greg agreed. Her history and exam were extremely consistent with foreign body/GI obstruction, and likely, she would require exploratory surgery. Unfortunately, Greg informed me that surgery was off the table. Initially I understood his position; exploratory surgery is expensive, and perhaps Jesse would not have an GI obstruction. If she was obstructed, surely he would change his mind. Right?
Wrong.
Jesse's radiographs were clearly obstructive; there was nothing equivocal about them. A large, jagged rock was present in the duodenum; the stomach was dilated with fluid and the remainder of the intestines appeared dilated and plicated. Surgery was clearly indicated, and the sooner, the better.
Greg coldly declared that there was no way he was going to spend the money on "this damn dog." I offered him Care Credit, our financing plan -- but he declined. Greg informed me that he already had the finances available, but had no interest in spending money on fixing his dog. "She'll just do it again, and I don't want to pay for her surgery if she's just going to eat something else."
I was taken aback by his cold, uncaring attitude. I offered him an attempt at medical management, or to contact other veterinarians in town (including his primary care veterinarian) to determine if costs might be cheaper and within his range.
"Absolutely not" Greg said. "I'll take him out back, and .... well, you know. I'll take care of it."
I've heard this before, and I wasn't surprised by a client hinting at shooting their own dog, but I still don't condone it. I expressed my concerns for this choice, however he was unwilling to change his mind.
I then offered to give his dog some pain medications in preparation for his plan to take her home. He refused. This is when I became infuriated -- an injection of a pain reliever is less than $30, and would provide his pet with some comfort in her last few hours. He declined not out of concern for finances - he explained explicitly -- but because he just didn't care.
Awful. Awful, horrible, terrible, no good human being.
Eventually, his wife convinced him to allow euthanasia. Thank goodness for her - I was able to let Jesse pass peacefully. As much as I wish I would have been able to fix her, I'm honestly thankful that this monster of a human didn't take her home.
Wednesday, June 8, 2011
all time favs!
Thought I would share some of my all-time favorite presenting complaints -- the reason that the pet-owners have driven to the EMERGENCY ROOM.
In no particular order:
In no particular order:
- "My dog was jumping off and on the back seat of the car more than usual"
- "My dog won't look me in the eye"
- "Please remove this tick" (it was actually a skin tag, and the owner had been trying to remove it for several hours.....ouch!)
- "My dog gave my sister a weird look"
- "Has a poop-ball stuck in his fur"
- "My cat jumped on the table to get food!"
- "My cat and I both have diarrhea - can you run my fecal too?" (GROSS! NO!)
Newest additions:
- My cat is eating too much!
- My dog needs an emergency vaccination at 2am on Sunday (sorry, we don't carry vaccines!)
- My dog is depressed (emotionally, not as in lethargic)
- My dog is having an emotional difficulty with stairs
- My (female, intact) cat is meowing and trying to get my attention! (hello, heat!)
B is for bleeding
"Roscoe", a 14 year old Akita mix, presented with a sudden onset of panting. Roscoe's very attentive, loving family reported that he had been compeltely normal in the previous days and weeks; today he was suddenly different. Unwilling to rise, panting, and they just felt that he was uncomfortable.
As I started my physical exam, it was clear that they were right. His mucous membrane color was pale pink, his heart sounded muffled, and his pulses were poor. Something was causing low cardiac output, and difficulty breathing. That something was also causing me great difficulty in hearing heart sounds.
Ultrasound confirmed pericardial effusion. The heart is actually contained in a fibrous sac, which has a small amount of fluid for lubrication and during the normal motion of the cardiac cycle. This space had become over-full with fluid, therefore exceeding the normal pressures of the heart, and causing it to collapse.
We quickly prepped his chest for removal of the fluid, which I would perform by inserting a needle with catheter into this space. The procedure went very well, and immediately Roscoe felt relief.
Unfortunately, as I re-ultrasounded his heart, the reason for the effusion became very clear. Roscoe had a very gnarly looking mass on his right atrium; most likely a hemangiosarcoma. This is a tumor of blood vessels, and the space was likely to fill up again, quickly, with fluid.
His family visited, considered their options, and ultimately, elected to euthanize Roscoe while he was in relative comfort. A very sad, difficult decision for them, but they could at least take comfort in knowing his diagnosis. Death of our pets is always an awful time, but some little part of me feels just a bit better when I know, beyond a doubt, that they have a terminal disease and that there was no chance for a cure. At least we really are preventing the invetable suffering. I really do believe that dogs and cats don't understand length of life, only quality of life.
Onwards.
The next case to walk through the doors was an very sick labrador. He was unable to walk, had collapsed that morning, and was brought in on a stretcher. His clients, who were not wearing shoes, noted that he had been the picture of health only a day before.
His physical exam was a classic ER presentation; white gums, elevated heart rate, poor pulses, and a distended, fluid filled abdomen. He was bleeding into his belly, probably from a bleeding mass. Most likely, this mass was cancerous. Ultrasound and abdominocentesis confirmed my presumptions. The only way to know, definitively, would be to stabilize and proceed with exploratory surgery. Unfortunately, he was euthanized as the clients could not afford, and furthermore, did not want to put their dog through surgery with the above knowledge. I made them a clay impression of each paw, and expressed my extreme sadness for their loss.
Cancer sucks.
As I started my physical exam, it was clear that they were right. His mucous membrane color was pale pink, his heart sounded muffled, and his pulses were poor. Something was causing low cardiac output, and difficulty breathing. That something was also causing me great difficulty in hearing heart sounds.
Ultrasound confirmed pericardial effusion. The heart is actually contained in a fibrous sac, which has a small amount of fluid for lubrication and during the normal motion of the cardiac cycle. This space had become over-full with fluid, therefore exceeding the normal pressures of the heart, and causing it to collapse.
We quickly prepped his chest for removal of the fluid, which I would perform by inserting a needle with catheter into this space. The procedure went very well, and immediately Roscoe felt relief.
Unfortunately, as I re-ultrasounded his heart, the reason for the effusion became very clear. Roscoe had a very gnarly looking mass on his right atrium; most likely a hemangiosarcoma. This is a tumor of blood vessels, and the space was likely to fill up again, quickly, with fluid.
His family visited, considered their options, and ultimately, elected to euthanize Roscoe while he was in relative comfort. A very sad, difficult decision for them, but they could at least take comfort in knowing his diagnosis. Death of our pets is always an awful time, but some little part of me feels just a bit better when I know, beyond a doubt, that they have a terminal disease and that there was no chance for a cure. At least we really are preventing the invetable suffering. I really do believe that dogs and cats don't understand length of life, only quality of life.
Onwards.
The next case to walk through the doors was an very sick labrador. He was unable to walk, had collapsed that morning, and was brought in on a stretcher. His clients, who were not wearing shoes, noted that he had been the picture of health only a day before.
His physical exam was a classic ER presentation; white gums, elevated heart rate, poor pulses, and a distended, fluid filled abdomen. He was bleeding into his belly, probably from a bleeding mass. Most likely, this mass was cancerous. Ultrasound and abdominocentesis confirmed my presumptions. The only way to know, definitively, would be to stabilize and proceed with exploratory surgery. Unfortunately, he was euthanized as the clients could not afford, and furthermore, did not want to put their dog through surgery with the above knowledge. I made them a clay impression of each paw, and expressed my extreme sadness for their loss.
Cancer sucks.
Sunday, June 5, 2011
Borrowed time
My best save of the week was a 10 year old, female calico kitty. She presented in severe respiratory distress, with purple mucous membranes, gasping for air, and minutes from death. Her heart at triage was 100 beats per minute -- far to low for a cat, and as I listened, the rate was dropping dramatically. She was dying, NOW. Auscultation of her chest and her respiratory pattern were classic for pleural effusion, or fluid around the lungs. Fluid filling up in this space results in inability of the lungs to expand, and decreased area for gas exchange. When severe, as in this kitty, pleural effusion is essentially like drowning in the body's own fluid.
We provided her flow by oxygen and I shaved hair on the side of her chest. I inserted a butterfly needle into her chest and began to remove slightly white, milky fluid from her pleural space. 150ml was removed, a VERY large amount for a cat of her size (about 6#). She immediately began to breathe easier. We placed her in oxygen to let her rest, and moved on to the next case. A radiograph revealed that more fluid remained, however she was stabilized and would have to wait until the next critical patient was stable for further testing.
The next patient who had just arrived was a 15 pound beagle mix who had just been hit by a car. Her family immediately authorized any care necessary to improve her condition. An IV catheter was placed, and a fluid bolus initiated to improve her low blood pressure. Hydromorphone, a morphine derivative, was given for pain. "Suzie" was excruciatingly painful over her pelvis.
Radiographs were taken, and revealed 5 fractures in Suzie's pelvis, as well as a dislocated hip. Ultrasound and chest radiographs were clear, with no other injuries present. Her blood pressure had improved. I updated the family to the good news, and although Suzie would require surgery to repair her pelvis, she would likely survive. They were ecstatic, and hugged me and Suzie, as they left her for the evening.
Several outpatients later, I returned my attention to the kitty. Ultrasound of her chest revealed a moderate amount of fluid remaining, and I removed an additional 120ml. Chest radiographs and ultrasound revealed an enlarged heart, but Suzie was now breathing comfortably without oxygen, eating, grooming, and purring when we pet her. I saved her life, and she narrowly escaped death - a good feeling.
Suzie transferred to a surgical facility, where she did very well and went home 48 hours later. Her family called me a week later to thank me for saving their dog, for making a stressful evening a little easier, and for being compassionate.
These two cases felt really, really good. Like my header above says, it's not always this happy, as you've seen on my previous blogs, but I really love having the opportunity, knowledge, and ability to intervene and save furry, innocent lives.
We provided her flow by oxygen and I shaved hair on the side of her chest. I inserted a butterfly needle into her chest and began to remove slightly white, milky fluid from her pleural space. 150ml was removed, a VERY large amount for a cat of her size (about 6#). She immediately began to breathe easier. We placed her in oxygen to let her rest, and moved on to the next case. A radiograph revealed that more fluid remained, however she was stabilized and would have to wait until the next critical patient was stable for further testing.
The next patient who had just arrived was a 15 pound beagle mix who had just been hit by a car. Her family immediately authorized any care necessary to improve her condition. An IV catheter was placed, and a fluid bolus initiated to improve her low blood pressure. Hydromorphone, a morphine derivative, was given for pain. "Suzie" was excruciatingly painful over her pelvis.
Radiographs were taken, and revealed 5 fractures in Suzie's pelvis, as well as a dislocated hip. Ultrasound and chest radiographs were clear, with no other injuries present. Her blood pressure had improved. I updated the family to the good news, and although Suzie would require surgery to repair her pelvis, she would likely survive. They were ecstatic, and hugged me and Suzie, as they left her for the evening.
Several outpatients later, I returned my attention to the kitty. Ultrasound of her chest revealed a moderate amount of fluid remaining, and I removed an additional 120ml. Chest radiographs and ultrasound revealed an enlarged heart, but Suzie was now breathing comfortably without oxygen, eating, grooming, and purring when we pet her. I saved her life, and she narrowly escaped death - a good feeling.
Suzie transferred to a surgical facility, where she did very well and went home 48 hours later. Her family called me a week later to thank me for saving their dog, for making a stressful evening a little easier, and for being compassionate.
These two cases felt really, really good. Like my header above says, it's not always this happy, as you've seen on my previous blogs, but I really love having the opportunity, knowledge, and ability to intervene and save furry, innocent lives.
B is for BONES
The last several days at work have been jam-packed with the best of the ER. I've been too busy at work to blog, and too tired when home to write - I'll spend the next few days catching up on the action.
The first two cases I've grouped because they have a similar theme: B is for bones.
Tina, a 4 year old pit mix, presented to us early Monday with a primary complaint of "painful." Tina's owner, Sally, was a 30-something, friendly, level headed person. Upon arrival she noted that an acquaintance had given Tina rib bones, despite multiple pleas NOT to feed this to her dog. This, unfortunately, had happened before, and I had been the veterinarian to see her, so Sally was relieved to see me, a familiar face.
Tina had been vomiting bones, and was straining to defecate. She was painful. Physical exam revealed a fairly stable patient, with normal vital signs. Rectal exam, however was very abnormal. Shards of bone were present in the colon, easily within reach Tina had been straining to pass these splinters and fragments of bone, but the pain was too great for her. We administered a strong pain medication and sedative, and I removed these bones. Tina was 100% more comfortable, and radiographs revealed that no further bones remained. I sent her home with a zip-lock bag full of the bones I removed, and a letter to her friend, written in a professional tone, but with the gist being: STOP FEEDING BONES TO YOUR FRIEND'S DOG!
Chet, a 5 year old Cairn terrier, presented for abdominal pain. He was previously healthy, and had developed vomiting over the last 24 hours. His owner, David, revealed that his aunt had given Chet a knuckle bone 2 days ago.
Radiographs revealed bone shards throughout the intestinal tract, from the stomach all the way to the colon. Medical therapy was started, including IV fluids and pain control. Less than an hour after presentation, ultrasound revealed a perforation and immediate exploratory surgery was performed.
Exploratory surgery revealed a perforation at the distal ileum due to sharp fragments of bone. Surgery was difficult, and the bone was removed and the perforation repaired. Broad spectrum antibiotics, nutritional support, fluid therapy, and pain control were adjusted as needed over 3 days.
Chet discharged several days ago and is doing well. Needless to say, neither of these families will EVER feed bones to their dog(s) again!
The first two cases I've grouped because they have a similar theme: B is for bones.
Tina, a 4 year old pit mix, presented to us early Monday with a primary complaint of "painful." Tina's owner, Sally, was a 30-something, friendly, level headed person. Upon arrival she noted that an acquaintance had given Tina rib bones, despite multiple pleas NOT to feed this to her dog. This, unfortunately, had happened before, and I had been the veterinarian to see her, so Sally was relieved to see me, a familiar face.
Tina had been vomiting bones, and was straining to defecate. She was painful. Physical exam revealed a fairly stable patient, with normal vital signs. Rectal exam, however was very abnormal. Shards of bone were present in the colon, easily within reach Tina had been straining to pass these splinters and fragments of bone, but the pain was too great for her. We administered a strong pain medication and sedative, and I removed these bones. Tina was 100% more comfortable, and radiographs revealed that no further bones remained. I sent her home with a zip-lock bag full of the bones I removed, and a letter to her friend, written in a professional tone, but with the gist being: STOP FEEDING BONES TO YOUR FRIEND'S DOG!
Chet, a 5 year old Cairn terrier, presented for abdominal pain. He was previously healthy, and had developed vomiting over the last 24 hours. His owner, David, revealed that his aunt had given Chet a knuckle bone 2 days ago.
Radiographs revealed bone shards throughout the intestinal tract, from the stomach all the way to the colon. Medical therapy was started, including IV fluids and pain control. Less than an hour after presentation, ultrasound revealed a perforation and immediate exploratory surgery was performed.
Exploratory surgery revealed a perforation at the distal ileum due to sharp fragments of bone. Surgery was difficult, and the bone was removed and the perforation repaired. Broad spectrum antibiotics, nutritional support, fluid therapy, and pain control were adjusted as needed over 3 days.
Chet discharged several days ago and is doing well. Needless to say, neither of these families will EVER feed bones to their dog(s) again!
Thursday, May 26, 2011
it's the little things.
I came to work today with dread. I've been off for a week, enjoying my life and feeling like a normal person... (awake during the day? Sleep at night! Preposterous!). needless to say, working all night was not on my wish list for the day. Unfortunately, we don't always get what we want.
Several hours in to the shift, we received a call from a small "rescue" organization that one of their recently acquired stray cats was currently in labor, and they believed that she was having difficulty.
Immediately, I expected the worst. It's a sad truth that being an ER doctor can turn even the most optimistic person into a hard-edged skeptic. In my mind, if this cat was truly having difficulty with labor, a c-section was a possibility - and knowing the history of this "rescue," we'd be lucky if they had funds for the exam fee. I imagined all the hateful comments when I denied the cat a free c-section, and all the disappointment in my heart and in my staff's eyes when I was forced to euthanize the imaginary cat.
15 minutes spent waiting for the arrival of these clients felt like a lifetime.
The clients arrived. My technician took a history, and to our surprise, things weren't as they had seemed. So far, our queen, "Misty" had delivered three kittens in under 3 hours, and the last was 10 minutes prior to arrival. Two were already nursing.
I performed my physical exam, followed by a sterile vaginal exam. A kitten was at the tip of the birth canal, and I could feel it suckling on my finger, indicating that it is (obviously) alive.
All seemed normal - Misty was not having any difficulty with labor, in fact, she was purring, sweet, and caring for her new babies. I educated her owners a bit on feline parturition. While I was speaking with them, Misty delivered another normal kitten.
I spent a little extra time petting Misty before she discharged. Misty purring vigorously and her brand new, minutes old kitten crawled around, experiencing the world for the first time. I remembered that sometimes my job is great. Sometimes, things just work out. The feeling of dread prior to my shift -- is gone.
This case reminded me that it's the little things that we have to enjoy to make life meaningful. I can't make every client happy, I can't fix every pet's disease, and I certainly can't know everything -- but I can definitely be happy when things go well.
Several hours in to the shift, we received a call from a small "rescue" organization that one of their recently acquired stray cats was currently in labor, and they believed that she was having difficulty.
Immediately, I expected the worst. It's a sad truth that being an ER doctor can turn even the most optimistic person into a hard-edged skeptic. In my mind, if this cat was truly having difficulty with labor, a c-section was a possibility - and knowing the history of this "rescue," we'd be lucky if they had funds for the exam fee. I imagined all the hateful comments when I denied the cat a free c-section, and all the disappointment in my heart and in my staff's eyes when I was forced to euthanize the imaginary cat.
15 minutes spent waiting for the arrival of these clients felt like a lifetime.
The clients arrived. My technician took a history, and to our surprise, things weren't as they had seemed. So far, our queen, "Misty" had delivered three kittens in under 3 hours, and the last was 10 minutes prior to arrival. Two were already nursing.
I performed my physical exam, followed by a sterile vaginal exam. A kitten was at the tip of the birth canal, and I could feel it suckling on my finger, indicating that it is (obviously) alive.
All seemed normal - Misty was not having any difficulty with labor, in fact, she was purring, sweet, and caring for her new babies. I educated her owners a bit on feline parturition. While I was speaking with them, Misty delivered another normal kitten.
I spent a little extra time petting Misty before she discharged. Misty purring vigorously and her brand new, minutes old kitten crawled around, experiencing the world for the first time. I remembered that sometimes my job is great. Sometimes, things just work out. The feeling of dread prior to my shift -- is gone.
This case reminded me that it's the little things that we have to enjoy to make life meaningful. I can't make every client happy, I can't fix every pet's disease, and I certainly can't know everything -- but I can definitely be happy when things go well.
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