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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. Off topicSome thanks are in order: Thanks to MSN for featuring this blog (and putting a pointer to me on their front page). I never thought anything to do with me would show up on MSN's front page!
Secondly, thanks to all for your comments. I'll try to answer what I can when I get a chance.
Third, and this is completely off topic - I'll vote for anyone who outlaws those dang political phone calls! Do they not realize some people sleep during the day? Do they not realize how much the public hates these daily, sometimes hourly intrusions in our lives? Are the horrible hate ads on TV not enough? Does anyone actually get their vote positively influenced by these calls?? Seriously, I am less likely to vote for someone who wakes me up every day (or more than once a day).
Political people - STOP CALLING! November 02 95 feetI was working on some paperwork in my office one night last week when the techs called out to me: “Hit by car is here!” This is a common call in any ER, and puts into motion a series of steps that occur automatically in any hospital.
The first step for any emergency is ‘triage.’ Triage is the process of initial evaluation when any animal walks (or is carried) through the door. The techs (or sometimes the doctor) will immediately do a basic initial assessment as to whether or not the animal is stable – this usually happens in the lobby, but may happen in the car, in the exam room, or in the treatment room. Any animal whose stability is in any question is brought, or ‘triaged,’ directly to the treatment room.
In this case, my techs triaged a big St. Bernard named Copper right in the car, hoisted him onto a gurney and wheeled him directly back to the treatment room. One of my techs, Renae, had been the one to lift this big boy out of the car almost by herself. Here is Copper, and mighty Renae.
  He probably comes close to outweighing her!
This handsome boy was in rough shape. He was breathing hard. His gums were pale, his extremities cold. His heart was beating very fast and I could not feel pulses in his legs. Copper was in shock. He did not respond to me, making me concerned for head trauma. At this point, I was not worried about broken legs, etc. In the great majority of cases, a broken leg is not going to kill my patient. Chest, head and abdominal injuries will. So that’s what I concentrated on.
Even as I was doing this initial assessment, the techs were giving him oxygen and putting an IV catheter into a vein in his front leg so we could give him fluids, and trying to measure his blood pressure. We started several different types of intravenous fluids at fast rates. This is to try to bring his blood pressure up to acceptable levels (we had a lot of trouble getting Copper’s BP to stay at acceptable levels, the reasons for which became clear later). When we did get his pressure up some, he did start responding appropriately to me calling his name, meaning that hopefully his head trauma was not too bad. We also started pain medications.
To help me figure out why he was breathing so hard, I put a large bore needle directly through his chest wall between 2 ribs and into his chest cavity. This is something called thoracocentesis, aka a chest tap. This was to see if Copper had a ‘collapsed lung’ either from air or blood buildup around his lungs. Sometimes we diagnose this with x-rays, but Copper was not stable enough to take to radiology. So we just tapped. Copper did indeed have a buildup of air. This is from his lungs being damaged when he was hit, causing them to leak air. We tapped more than a liter of air off each side of his chest.
At about this time, we noticed Copper’s abdomen looking more distended. A quick tap of his abdomen (this time by putting a needle into his abdominal cavity) revealed he was bleeding into his abdomen, most likely from his liver or spleen or both. Now, this is actually quite common for animals that have been popped by a car, and I was not surprised. But I was concerned – it is not common for the abdomen to visibly distend from the bleeding in just minutes. ‘Yikes’ is what I was thinking. We wrapped a pressure bandage around his abdomen.
I then tapped more air off his chest – this bought me some time to get set up to put a chest tube in. The chest tube was needed because Copper was building air up too fast for me to keep repeatedly drawing it off with a needle between his ribs. The larger tube allowed me to draw air or fluid from around his lungs and keep them expanded, and even allowed me to hook him up to a pump apparatus so his lungs would stay expanded without intervention from me.
You have seen a chest tube placement in people if you ever watch ‘Trauma, Life in the ER’ – the people always howl when they are getting these in – it looks really painful. Therefore, this is a procedure we like to anesthetize our patients for if possible, but Copper was not stable enough for even this short anesthetic procedure. I gave Copper some more pain medication and a sedative, put a local anesthetic in his chest wall, and placed the chest tube (this did not seem to bother him like the people on TV), then hooked him up to the suction apparatus. His breathing significantly improved.
With the chest tube in place, I could now concentrate on the rest of him.
Copper was very badly injured. I was not making much ground on his blood pressure despite giving large amounts of fluids. He had bad lung trauma and he was bleeding a lot in his belly. More than any trauma patient I’ve had in a while. Oh, and by the way, he developed a significant cardiac arrhythmia (abnormal heartbeat) from the trauma to his chest.
The bleeding in his belly was very concerning. Most of the time abdominal bleeds in HBC dogs will stop on their own. Copper’s appeared to be stopping more slowly than I was comfortable with. And this is when we have decisions to make in the ER. And it doesn’t seem to matter how many times I run up against this situation – each and every time I agonize over these decisions.
Take him to surgery to stop the abdominal bleeding? There are proponents of this course in a patient like this, and this is a common course in human trauma medicine – stop the bleeding, and breathe for his bad lungs during surgery, and hope he makes it through surgery. And hopefully his abnormal heart beats are not made worse by the anesthesia. A dicey proposition at best. The other thing to do is keep supplying him with enough fluids to keep his pressure up, meds to keep his heart arrhythmia calmed down, and we were already doing the best we could for his lungs with oxygen, the chest tube and continuous suction. (The next step for his lungs would have been to put him on the ventilator, but he did not progress to needing that.)
So I elected the second option – keep him stable without surgery. I felt it gave him the best chance. I was very worried that with his bad lungs, he would not make it through surgery. If I was wrong, he would die.
The rest of that night was a rollercoaster of high heart rates, varying IV fluid rates, dropping red blood cell count (he got a blood transfusion for this) and cardiac arrhythmias. And the constant drone of the little person in my mind: “Am I doing the right thing??”
By morning, Copper was still critical but a bit more stable – lower heart rate and acceptable BP. I transferred him to our surgeon, Barb, for continued care. He had some significant complications over the next 4 days that required multiple blood and plasma transfusions, at significant expense to his family. But he was well enough to go home on the 5th day. And the whole time, he was a great patient – he was wagging his tail when he could barely lift his head.
When Copper was well into his recovery, his mom told me he had actually been thrown 95 feet (!) by the car that hit him (and he weighs 110 lbs!). It’s amazing he even survived to get to the hospital. His family did a great job getting him to us.
It’s good to get him home. But I still wonder if I did the right thing that first night. Would his recovery course been as complicated if we had made the choice for surgery? I actually think it would have been more complicated with surgery, but I’ll never know. These decisions and cases are what keep emergency medicine so challenging for me. It just doesn’t get old.
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