Sunday bloody Sunday

Yesterday was (to use a very crude but very apt phrase) balls to the wall CRAZY. It reminded me of my internship. I think we did greater than $11,000 in business in 15 hours or so.

I saw (in no particular order): a severe diabetic ketoacidotic beagle (weighing in at 50#, should have weighed 25#), a cat with upper respiratory stridor and a possible polyp, a labrador retriever that ate a bag containing a bottle of acepromazine, a bottle of ibuprofen, and a bag of coffee grounds, 3 big dog / little dog attacks, a hemorrhagic gastroenteritis, a febrile, anorexic cat...and the list goes on and on.

It was busy, it was frantic, but the staff handled it well, we kept things moving, no one waited for an excessive length of time, and overall, I think we did a great job. Inpatient care suffered, but this - unfortunately - is the nature of vet ER medicine.

I didn't leave until 10:30 (my shift ended at 6pm), but it was different from my internship. I didn't get home and lie in bed, depressed and moody. Even my husband commented, in an amazed tone of voice, that I didn't have one complaint about the day. And really...I didn't.

Much better

The car situation is worked out, for the most part. We were able to sell it in about 2 hours on Craigslist. We got $1500 for it. Thanks to the generosity of a close family member, we are able to pay off the car in full and start back where we were 3 months ago - car-less. It's ok, though. The husband is working at home on his PhD dissertation anyway, and he doesn't need a car to get around.

It's the end of my 9 day stint away from work, so I'm diving back into the fray tonight. There will be more interesting stories to come, I'm sure. At some point, I'll have to talk about last Sunday and the ordeal...but not just yet.

Going through

a bit of a very rough patch here. The last weekend at work was very hard. It culminated in an exhausting (mentally, physically, and emotionally) surgical ordeal. I was thoroughly looking forward to the 9 days away from work, relaxing, spending time with my family, and recharging. Yesterday, at my uncle's cabin in the woods, we weathered a terrible windstorm. My husband's car - which we have owned for 3 months, have not paid off fully, and on which we do not carry comprehensive insurance - was crushed by a tree. It's the first car we've ever NOT bought in cash, it's the nicest car he's ever had, and it was a good deal through a friend. Now, we owe $5500 on a car that is totaled. I've been reminded to put this in perspective, but at the moment, as we're struggling to get started with savings and with my student loans coming due next month, this couldn't come at a worse, more stressful time. I am grateful no one was hurt, and my uncle's house made it through the storm unscathed, but I feel sick to my stomach all the same.

Look people, I don't care WHAT you do in your spare time...

I was sleeping quite soundly at work the other night. We've been DEAD DEAD DEAD. Dead as in NO patients in the hospital, for the last few nights, so I've been able to sleep. At 6:30am, a knock came on the door as my technician alerted me that we had a patient.

Said patient was a 2 year old dachshund. The owner thought she was having back trouble - which is a common condition in long-backed dogs.

When I first saw her, a back condition was not my biggest concern. She was exhibiting multi-focal neurological signs. This means that she had signs that pointed to different areas of the nervous system. She was ataxic (swaying when she walked), disoriented, knuckling in all 4 feet, her head was tremoring/bobbing, and she had very dilated pupils. Her temperature was 103.8.

I went to talk with her owner, a young, tattoed guy. I asked the standard questions: onset of signs, first thing you noticed, appetite, urination, defecation, other pets in the house, anything she could have gotten into, any medications in the house? His history didn't give me any clues, so back I went to stare at my patient. She looked very very sick. I pondered diffentials for multi-focal neuro disease - encephalitis? necrotizing meningoencephalitis? granulomatous meningoencephalitis? As I pondered, I idly repeated my physical exam to see if I'd missed anything. When I rolled up her eyelid, I was AMAZED at how red both of her eyes were...red like a person who had just smoked a big fat joint...

Back I went to the owner. "Do you or your wife smoke pot?" I asked in an innocent voice. The guy looked at me, smiled sheepishly, and gave me a thumbs up.

The urine drug test was positive for THC. Only after that did the owner tell me that his wife found a bud on the floor...

A bolus of fluids later, a heavy sedative, and our patient was rolling over on her back with all four legs in the air, finally able to relax. We were tempted to prop a bag of Doritos up next to her to complete the picture, but we didn't (this time).

Look folks, I don't care in the slightest if you smoke pot. A great majority of the world does. If you smoke pot, and your dog starts acting "oddly" at 6:30 in the morning, and you bring her to the ER - just save me the time, hysterics, and your money when I'm running bloodwork, and TELL ME. That way, I can give your dog a bag of Doritos and call it a night instead of going into mental hysterics over encephalitis.

Thanks!

Sometimes you lose...

I've been feeling like a rock star surgeon since I arrived at my job. I've had multiple GDVs, c-sections, exploratories, a GI intussusception, and the like. All are alive and kicking!

Last week, I saved a dog that had been hit by a car with a terrible diaphragmatic hernia. Her lungs and heart were being crushed by her spleen, stomach, and liver. Despite her unstable condition, I had to take her to surgery. 3 chest tubes and a diaphragmatic hernia repair later, she is doing great. Despite the odds, she survived!

On Saturday, I took a headless teddy bear out of patient's intestines after she'd been vomiting, lethargic, and depressed for a week. She's doing great, as well.

And finally, my liver lobectomy/giant tumor removal is 2 weeks post op. He is doing great, already feeling good again. His kidney values are improving, he is eating, and his sutures are out. He is recovered.

Those are 3 difficult surgeries. Two of them had guarded to poor prognosis...and yet, they are all alive today. I can look at them and say without a doubt that I saved them.

Yet today puts all of that to the back of my mind. You see, my patient from today is not alive. And yes, I blame myself. I'm sure I'll get over it by Wednesday (when I finally have a break from work). For now, I'm going to sit here and review what I could have done differently for this dog and whether it would have made a difference or not.

She was a large breed puppy (less than a year). She came in after being hit by a car. Her gums were gray-purple. Her systolic blood pressure would not register. She was in profound shock. Her pelvis was broken. She had a pneumothorax. Her condition was grave.

Her owners told me to do whatever it took to save her. Money was not a concern. They plopped down $2100 without batting an eye. So, I went to work. I pumped her full of fluids - crystalloids and colloids. I tapped her chest, eventually placing a chest tube. I was aggressive.

When I checked her initial PCV (packed cell volume), it was 28%. She was losing blood somewhere. When I popped the ultrasound probe on her belly, it was abundantly clear where the blood was going -her belly. My techs wrapped her back legs and abdomen in tight bandages (shock pants). I gave the owners the bad news. We would try to stabilize her, but it was looking like surgery was in her future. When her blood pressure refused to rise above 50 despite massive fluid boluses, and her PCV plummeted to 14 with a total solids of 2.5, I knew we had to cut.

I found the bleeding within 25 minutes of getting into her belly (it took that long to suction out the 2 liters of hemorrhage). One of the liver lobes deep within her abdomen was terribly lacerated. I would either have to perform another lobectomy or find a way to suture the torn liver. Meanwhile, blood continued to pour into the abdomen. We autotransfused her, but the blood just kept pouring out of the liver, as I tried to fix it. My patient's status deteriorated rapidly. Despite the unbelievably low anesthestic level (0.2% sevo!), crystalloids, Hetastarch, and autotransfusion, she could not maintain her blood pressure. I tried everything I could to get to that liver lobe to repair or remove it. I couldn't. At least, I couldn't before she died.

Now, I sit here and question. Should I have tried to get her to the specialty hospital? Should I have hoped the shock pants and pressure wrap would stop the bleeding and held on going to surgery? Did my handling of the liver worsen the damage already done? Would she have bled to death had I waited? Could she have been saved in the first place? Had another ER doctor been there, would she still be alive?

I think I need to rest now. I've been up since 7am this morning, left work well after midnight, and have 2 more nights of work before I get a brief break.

What I did...

This is the final installment in my case study (see posts below).

In the end, I rehydrated the patient for 6 hours. He continued to be lethargic and depressed. I made the decision to go to surgery and see what we were facing.

When I opened him up, I found a massive liver tumor, as I suspected. It had not yet ruptured (as evidenced by the lack of fluid in the abdomen on ultrasound), but it was only days away from doing so. There were enormous pockets of necrosis and abscessation. As I was slowly and meticulously dissecting it away from the diaphragm (it had formed adhesions to the body wall and the diaphragm), I punctured the mass, and blood poured into the abdomen. I clamped it off and gave it time to clot, then continued working. During the surgery, my patient's blood pressure fell and fell and fell till it was in the basement. He received crystalloid boluses (NormR) followed by Hetastarch (colloid), and then a whole blood transfusion when his PCV was 14%. He also received dopamine intra-operatively to help keep his BP up.

An hour and 15 minutes later, the whole left side of the liver was out. The tumor enveloped all the lobes on the left side, and I had to remove it all. Everything else looked good, so I checked for bleeding, found none, lavaged the abdomen, and closed him up. There was no evidence of metastasis anywhere. Even the spleen looked happy.

We are 48 hours out from surgery, and he is slowly recovering. His kidney values are falling, but not as much as I would like. He is still nauseated and isn't able to eat. He is - however - able to move around his cage and go outside. His PCV is holding at around 24%.

The tumor will be sent for histopathology. In all likelihood, it will be read as a hepatocellular carcinoma - the most common malignant hepatic tumor of dogs. These are slow growing tumors that rarely metastasize and have a GREAT prognosis if not diffuse or metastatic (as this dog's wasn't). Prognosis is 4 years, and usually, the patient dies of something else unrelated to the cancer.

I am left with more questions than answers. I will never know if I did the right thing by going to immediate surgery. Should I have waited, fully rehydrated him, seen if he would stabilize more then taken him to surgery? Surgery was absolutely indicated for this little guy, otherwise, the tumor would have ruptured at some point in the near future causing a hemoabdomen. I know that. I just don't know if it should have been done that night, or if I should have treated his renal dysfunction for a week or more, than taken the tumor out.

Any thoughts?

It's that time of year.

In 2 ER shifts (roughly 24h total), I euthanized 10 animals - everything from the laterally recumbent, anemic, hypothermic, flea covered 2 month old kitten drop-off to the 14 year old, dearly loved family dog that is acutely down in the rear. I'm feeling kind of numb right now and very bummed. It's funny how that kind of stress manifests itself after the fact. I wasn't crying or upset during any of the euthanasias, but here I am...sitting here, questioning everything I do, and feeling very insecure about myself.

Time to make cheesecake.