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March 15 Cool = SadIf you have read this blog for a while, you know that our job is interesting for many reasons. One is that we have cool patients – let’s face it – I get to play with dogs and cats at work. But another reason is that we are all scientists, and the challenge of the medicine gets us going too. But a fact is that some our most interesting cases can also be some of our most challenging and also some of our saddest cases. It’s an odd feeling to feel exhilarated by making a diagnosis of something uncommon, when the outcome is not good. A case I had this weekend is an example of just that. A five year old Lab came in collapsed. He was fine with the owners left early that morning, and he had been outside in a fenced yard during the day. When they came home, they found him unable to stand, and this normally happy guy could only give a weak wag of his tail. They lifted the big boy into the car and brought him in. When he got to us, he was laying on his side, unable to get up. His limbs were cold, he was in shock. He was very painful when I felt his belly. Even though he was so tense, I thought I could feel a large mass in his abdomen. “Uh oh,” I thought. This didn’t look good. Then I noticed a couple more things on my exam. His nipples were inordinately large for a male dog. And he only had one very small testicle in his scrotum. This means he was a cryptorchid, or that only one testicle had properly descended into his scrotum during his development. The other testicle was retained in the abdomen. So I started putting the pieces together:
This dog needed aggressive stabilization, a bunch of diagnostics, then surgery to explore his abdomen to see if my guess at his problem was correct. Unfortunately, his owner just could not afford any of this, and the prognosis was up in the air until we understood the tumor’s effect on the bone marrow (if removing the tumor did not reverse the effects of the estrogen on the blood counts, he would not survive). The owner decided not to let the boy suffer, and I euthanized him. It’s hard for me to euthanize any 5 year old dog, but not as hard as the decision that owner had to make that day. The owner did let me do an autopsy (in animals we call it a necropsy). The necropsy confirmed my suspicions – a torsed, cancerous testicle was the cause of the big Lab’s problems. This is a very uncommon problem, so for me it was very interesting – ‘a cool case’. Why do the cool cases have to be so sad? PS. This is why it’s important to have a cryptorchid dog neutered. Had this Lab been neutered (which would have involved opening his abdomen to get the retained testicle), this problem could have been prevented. It’s not a common problem, but it can be devastating when it happens. March 08 Why We Do What We DoWorking in a veterinary ER can be really draining. Death, grieving owners, and financial stresses all take their toll on our emotions. Burn out is common in any ER. Amongst the hectic parts of our job are sweet patients with an amazing will to live who remind us why we do what we do. It's these patients that make our job so extraordinary. Shane, a Miniature Schnauzer puppy, was one of these patients. Here is her story.
Shane, a 3 pound, 9 week old bundle of joy, originally presented to the clinic with vomiting and diarrhea. She had recently been purchased at a pet store. Her new family had barely gotten to know her yet, but it was clear that they loved her dearly. When a puppy comes in with symptoms such as Shane's, we always recommend beginning diagnostics with a Parvo test. Shane's test resulted in a strong positive. This adorable little fluffball had a long road ahead of her.
Parvoviral enteritis (Parvo for short) is a highly infectious disease of puppies that is typically fatal if not treated. The infected dog is suspectible to secondary bacterial infections and septicemia (bacterial invasion of the blood). Puppies with Parvo have severe abdominal pain, vomiting, and diarrhea (often bloody). Parvo is a serious condition which we prefer to treat aggressively. Unfortuantely, treating Parvo is NOT an inexpensive endeavor.
We began treatment by placing an IV catheter, starting fluid therapy, and giving her antibiotics and drugs to help with the nausea and pain. Bloodwork showed us that Shane needed a blood product called plasma. This is one of the more costly aspects of Parvo treatment, but it is also very effective. Shane rested well that night. She vomited a couple times, but did not have diarrhea. In the morning, she transferred to her regular veterinarian for continued care.
36 hours later, Shane was transferred back to our clinic because she was not doing well. She needed more plasma. Shane's family brought her to us in a box, wrapped in a blanket. When I went to the exam room to retrieve her, I pulled back the blanket and thought, "Oh no, she's in bad shape." I really didn't expect her to survive long. Neither did Dr. Susan. Shane's poor little belly was extrememly painful and she groaned with nearly every breath. Her heart rate was high, her gums were pale, and she appeared to be in shock. She was in critical condition. With consent from the owners to continue her care, we worked to stabilize her and make her more comfotable. My heart broke for this tiny fighter of a puppy.
Because Parvo is so infectious, the patient must reside in isolation. Those caring for the patient must wear protective gear to prevent carrying the virus to other areas of the hospital. One technician works with the patient per shift in order to keep others "clean". Anyone who has been in contact with the Parvo puppy does not touch other puppies or unvaccinated dogs during that shift. I was the Parvo tech on this particular night. I spent a lot of time with Shane and grew quite attached. Her condition improved slightly that night, but she was still very criticial. When my shift ended, I told Shane to keep fighting, but I also did not expect to see her the next day. I'm happy to say she proved me wrong.
The next night I was surprised and thrilled to see Shane. She was still criticial and had many lines running into her, as she was receiving multiple fluids, plasma, and a continuous infusion of pain medication. I lived in Parvo Land (as we affectionately call isolation) again that night. I spent hours cleaning up diarrhea, vomit, and urine. I attempted to keep Shane as clean as possible, but this can be a fruitless effort when dealing with Parvo. I monitored her fluids and gave her the drugs she needed. Her vital signs (temperature, pulse, respiratory rate, overall condition) were closely monitored. Eventually her bum became sore from the thermometer and the diarrhea. I took it as a positive sign when she started to squeal and squirm at temperature time. At least she had the strength to do that. After this night with Shane, I had a couple nights off. Again, I felt very unsure if I would see her again. Again, she surprised me.
When I returned after my time off, Shane had improved greatly. She was eating! And keeping it down! Hooray! I was so thrilled to hear this news, and I was even more thrilled to see it with my own eyes as she happily chowed down! That night I only cleaned up urine. She did not vomit, and she did not have diarrhea. Though she was not 100% better, she was acting more like a puppy. She loved to climb on top of a blanket we had given her to cuddle. She would climb it like a mountain, curl up in the middle, and take a nap. It was adorable, and it was wonderful she had the strength to do it.
The next day, Shane went home. I was thrilled to enter the exam room this time to smiles, rather than tears. I talked to Shane's family about the at-home care they would need to provide. They listened intently; it was obvious they wanted the absolute best for their sweet Shane. Then came the golden moment, reuniting Shane with her family. Because the family had had this pup for such a short time before she became ill, I was unsure if Shane would know them. Again, Shane surprised me. She wriggled and danced in their arms. The family was bathed in grateful kisses from their loving puppy. Everyone was overjoyed. It was a moment I will carry with me for a long time. March 01 Codi the Dog VS. Corn DogDakota (Codi for short), an eight and a half year old Terrier / Doberman mix, presented to the clinic Tuesday night because she had ingested a corn dog stick. I (Renae) was spending much of my time working with a Parvo puppy that night, but, fortunately, I was able to witness most of the happenings of this case. This was a cool one that Dr. Susan and all the techs were talking about for the rest of the night.
Codi's family was eating corn dogs that night, and, apparently, Codi was patiently awaiting her share of the yummy meal. Codi must have felt it was her lucky day when the family's son dropped his corn dog on the floor. No one saw her eat the dropped goodie, but all they could find left on the floor was a small piece of the stick. Lucky for Codi, her family knew the corn dog stick could be quite dangerous if it obstructed her GI tract or if it perforated her stomach or intestines. Codi's family quickly brought her to Dr. Susan.
Dr. Susan evaluated Codi. Her exam was within normal limits. She appeared to be a healthy, vibrant dog. The technicians took an x-ray of her abdomen. As we suspected would be the case, the stick was not visible on x-ray. We were able to see that there was food in the stomach, and, at this point, her GI tract looked normal. Dr. Susan presented the options to her family. They were as follows:
The owners elected to induce vomiting. We fed Codi a can of dog food that was well smashed and crumbled. The extra food in her stomach would help cushion the stick and decrease the chances of it perforating the esophagus. Then we walked her around and around the treatment room to help mix it all up in her stomach. Codi then received an injection in her vein of a drug called Apomorphine. This is for the induction of vomiting. Within minutes she was drooling and giving us that sad look that says, "Oh my, what have you done to me?!" Shortly there after, an eruption of cheers was heard throughout the hospital as the treasure was hurled onto the floor.... the corn dog stick, complete with the WHOLE corndog (see the picture below)! (Okay, we are medical people who are fascinated by gross things, but, surely, anyone would think this was very cool... Right?!) We promptly scooped up the corn dog and ran it out to Codi's family to show them the exciting results. They were equally happy. Pictures of Codi's forbidden snack were then taken by Dr. Susan and by Codi's family with their camera phone. Never has there been so much celebration over a soggy corn dog. In the end, Codi and her family went home happy and relieved. The decision to induce vomiting was the correct one. Dr. Susan and her team have a great case story to share. Codi's family was able to quickly solve their dilemma, and they have a unique addition to their collection of camera phone photos. And Codi the Dog triumped over Corn Dog. Note from Susan: Do NOT try making your dog vomit something like this at home. There are serious risks if the stick embeds in or punctures the esophagus. Codi's family and I had a long converation about risk/benefit. It all worked out for the best in this case, but every case must be individually evaluated by your veterinarian. February 28 Beethoven[This is Susan here - I think Renae will be posting another case later today or tomorrow.] One night a few weeks ago, it was cold here. Really cold. There was a lot of snow as well. A big St. Bernard named Beethoven came in to our ER that night. Normally an outdoor dog, he had a thick, heavy coat. But it was too cold even for him that night, and his owners had brought him indoors earlier that evening. That’s when they noticed something was not right with him. He seemed agitated, and he resented his owner handling him – he even went so far as to try to bite her. This was unusual for him, as his owners described as normally a happy, friendly dog. They also noticed he seemed to have some intermittent limping, especially in his hind legs, and at times yelped as if he might be in pain. At one point he seemed disoriented and started falling into a wall. He was trembling at times too. So they brought him in to see us. On first look, Beethoven did not look that sick. He did seem a bit agitated, but sometimes it’s hard for us to tell because we don’t know an animal’s normal demeanor. Being a big boy (who outweighed most of us), he was a bit hard to handle, as he resented our manipulation of him as well. On exam, nothing really stuck out to me. His temperature was a little high, but not too bad. He was panting a lot, but dogs that don’t want to be here in our ER do that a lot. He didn’t seem to have any obvious lameness, but occasionally lifted his legs, and at one point almost seemed slightly lame on front leg. I couldn’t get him to act painful when I manipulated his joints, but he was agitated enough that it was hard to tell. Beethoven had what I jokingly refer to as a ‘nebulopathy’. Some condition that was nebulous – hard to pin down. And I hate nebulopathies. They are usually a real pain to sort out. And a nebulopathy at midnight on a busy night is always a challenge. So I talked to his mom. I didn’t have much to go on, but something was not right with him. So I suggested getting some bloodwork on him, which is usually the place we start our search for the cause of a nebulopathy. We drew the blood (a chore in itself, because he was hard to hold – he just didn’t want us handling him). I waited impatiently for the results. And there it was: the level of calcium in his blood was dangerously low (hypocalcemia). The symptoms of hypocalcemia are agitation, rapid panting, sometimes itching of the face, trouble walking and a stiff gait, tremors leading to seizures, high body temperature and death if untreated. The most common cause of hypocalcemia is eclampsia. This is a disease where a nursing mother dog loses too much calcium in her milk, and her blood calcium drops low. We see this with some frequency in the ER. But Beethoven is a 9 year old castrated male dog, so eclampsia couldn’t be his problem. There had to be another reason. Some more diagnostic tests in the next few days showed that Beethoven had an uncommon disease called primary hypoparathyroidism. This condition is caused by a malfunction of two glands in the neck called the parathyroid glands. These two glands function to keep the calium level in the blood normal. When the glands don’t do their job correctly, the blood calcium drops too low. We threw a catheter in Beethoven and gave him some intravenous calcium (this has to be done slowly and carefully, as giving it too fast can actually stop the heart). He responded nicely, and within an hour, he turned from an agitated, grumpy dog into a funny, sweet big boy. Now he is on medication to keep his calcium normal. And here’s my theory on Beethoven. The cold weather saved his life. Had he been out in his doghouse as normal, the owners wouldn’t have seen his odd behavior. If they hadn’t seen it, his calcium level could have dropped low enough to kill him that night. The signs were somewhat subtle and non-specific, and probably would not have been noticed if he was not inside with his people. (They have decided to move him inside now, even though he prefers to be outside with his dog brother.) February 15 A Technician's PerspectiveI will start by introducing myself. I am Renae, one of Dr. Susan's technicians. I've been working with her for nearly four years. My first experiences working in veterinary medicine began with Dr. Susan when I was an intern. She has taught me A LOT along the way! She's a smart cookie, and she loves to teach, so I know I will continue to learn from her. Dr. Susan and I have been through many ups and downs together during our ER adventures. We have shared many laughs over the antics of our patients and over the goofy ways we entertain ourselves on the slow nights (from Dr. Susan's previous posts: fruit wars, dressing up clinic cats, making smiley faces on other technician's rear ends when there isn't a thing that tech can do about it - that was my rear end by the way, etc.). We have shared countless tears over ill and dying pets, often crying with the owners as they say good-bye to their beloved furry friends. We have also shared in the glory of many successes with our patients. There is no greater feeling than seeing a previously seriously ill pet wag his tail as he trots out of the hospital with his family. In the animal ER, Dr. Susan and the staff experience a roller coaster of emotions. It is a tough job, one that can truly take its toll on our lives. Along with the mental stresses, the hours are far from ideal; we work nights, weekends, and holidays. We often work very long shifts, sometimes with little to no break. Ask any one of us in that ER, we wouldn't trade it. Many of us, myself included, have tried working general practice at one time or another, and we've come running back to emergency medicine. ER is in our blood. We crave it. We love it. We thrive on it.
As an ER technician, it is my job to assist the veterinarians in the patient's care. I triage incoming patients (assess the pet's medical stability and determine the urgency of the situation), monitor and treat hospitalized patients, assist with surgeries and anesthesia, perform diagnostics (such as take x-rays, pull blood, run labwork, etc.), place catheters, prepare deceased pets for viewing or cremation, handle client communications, etc. A veterinary technician's job is quite diverse and never boring. In the ER, cases are often critical, and time is of the essence. Emotions are high for the staff and the patient's owners. It is not uncommon for the doctor to shout orders at the technicians. The pet's life is in the doctor's hands, and we, the technicians, are there to help carry out the life-saving actions in a timely manner. We may hear harsh words from the pet's owners as they are extremely stressed by the condition of their pet. Of course, we also sort through client's tears and their feelings of utter shock. It is the technician's job to help the veterinarian get necessary information from the clients during this difficult time, explain the situation to the clients, and help them understand and cope.
By far, the best part of my job is spending time with the patients. We like to joke about veterinary medicine being so great because you can't get kisses and snuggles from your patients in human medicine. You also don't enter an exam room and exclaim in a silly, high-pitched voice that the patient is adorable. The satisfaction of a tail wag and a slobbery kiss from a canine patient or a head-butt and a purr from a feline patient makes veterinary medicine number one! Other advantages of working in an animal ER include the excitement and adrenaline rushes, the unusual cases, the fact that we never know what our day will hold (surprises are fun!), and the bonds we have with our co-workers.
I look forward to sharing my adventures with you from a technician's perspective. My posts will be a little different from Dr. Susan's in that there probably won't be as much medical information. Instead I will try to give you a "behind the scenes" look into the ER ... the relationships we form with our patients and clients, our daily activities, and the roles of the techicians in treating patients. Dr. Susan and all the veterinarians at our facility are incredible doctors; I feel privledged to work with them, and I feel very comfortable knowing they are there for my pets if I need them. Dr. Susan has done a great job of sharing our ups and downs with you in this blog. Personally, I find her posts quite entertaining, and I live this stuff everyday! I must admit, it was very cool for me to come home from work, read about my night on MSN, and be able to share it with my friends.... "Check out MSN, and see what I did at work last night!" I hope you find my posts as enjoyable. I have big shoes to fill! I promise, I'll keep bugging Dr. Susan to add a post here and there. She's an awfully busy lady.... February 07 Hello!!Well. as those of you who still visit, I'm sorry I haven't written in so long. So, to help remedy my lack of writing and writer's block, my tech Renae (you may remember her as 'Mighty Renae' from this post) has volunteered to blog on our ER from her point of view.
Renae has been working for us for close to 4 years, all on ER. She has seen it all here. I hope you find her posts enjoyable. I'll be getting back to posting as well.
Thanks to anyone who comes back to visit!
November 04 Ups and downsLast night was a typical night in the ER ….
I had a patient that was not doing well – he was having some severe post-operative complications. From the minute I came to work, Barb and I were working on him, trying to figure out why he was crashing on us, and trying to figure out how to reverse what was happening. We fought for more than 6 hours, but were not successful – his decline continued. His mom and dad came to visit, and made the difficult decision not to go on with treatment, as his condition was rapidly deteriorating. It was hard to lose this one, especially when this turn in his condition was not expected. And he was a really cool dog.
While this scenario was happening, another previous patient came to visit. His name is Brutus.
Brutus came in several months ago with GDV (here is a link to another post on GDV). Brutus’ surgery was relatively uneventful for a GDV, but he also developed significant post-operative complications. He developed a bad cardiac arrhythmia. Now this is pretty common for a post-op GDV, but Brutus’s arrhythmia proved much more difficult than normal to control, despite several medications. He went into heart failure from this. Over the week, his condition went up and down, and one night I was nearly sure he was not going to live through the night. But his dad, and his dad’s mom (Brutus’ ‘Grandma’) wanted to keep trying, and we did. Finally, he started doing some better after that tense night.
He would not eat for us, so we sent one of our techs to the store for ‘magic food’ – Giant Eagle deli roast beef. Arby’s roast beef will do in a pinch as well. Brutus finally started nibbling at this for us.
However, just as we thought he was out of the woods, his abdominal incision broke down and needed to be repaired (this can happen in animals with critical illness, as they don’t heal as well as normal). At this point, his heart failure was under control, but he needed to go back to surgery, and anesthesia has a tendency to make the heart arrthymias flare up. We were very worried about his ability to survive if this happened. His dad and grandma thought long and hard, and decided they could not give up. He made it through the needed repair (his arrhythmias did flare up but were more easily controlled this time), and was able to go home a couple days later. Getting him back to feeling good was a longer process.
Last night his dad brought him to see us. This is real treat for us – we rarely get to see our patients feeling better (they usually go back to their regular veterinarians, or come in during the day when we are not there). Brutus looked so good! He was bouncing around and happy and giving us kisses. We had never seen him like that. His dad was beaming – he never gave up on him.
But here we were with Brutus in the lobby and his beaming dad, laughing and admiring the handsome boy. And in the treatment room, it was an entirely different picture as we were at the same time euthanizing our patient who was not making it through his post-op complications. It was striking dichotomy of feelings.
And that is a rather typical night in the ER. |
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