Hit-By-Car

I am the queen of trauma...if your dog/cat/whatever is hit by a car, send it my way...seems like that is all I have been seeing the past few days...and not just small accidents, huge trauma!! First HBC: 8 yo f/s Rottweiler - ran over by garbage truck, truck stopped on her back leg, then backed up real quick and degloved all the skin off the foot!!! Ouch!! Yeah!! She came in to me in shock of course...started her on fluids, administered pain meds and sedatives, ran some bloodwork, after stabilization took some rads of chest (to look for contusions-bruising in lungs), rads of left shoulder, rads of left leg...the story gets more complicated and sad for this dog - she has two different types of metastatic cancer - osteosarcoma (bone cancer in the left scapula) and mast cell tumor in the left hind limb (the one run over by the truck!!) Why does this confuse things? Because the wound on her back limb is so bad - down to the bone - tendons exposed - and ultimate treatment would be amputation...not an option in this girl because of the osteosarcoma in the front limb - she would not survive as a tripod - would probably end up with a pathologic fracture of that limb. Ok, more complications, dog is supposed to go through radiation therapy for the tumors at UW-Madison...not so much gonna happen now. Well, dad is a ER doc himself...has money...keeps saying no heroic measures for the dog...however thousands of dollars for an estimate and poor prognosis is ok!!! Moving on then...radiographs of chest show a possible nodule--even more negative strikes against this poor dog!! Luckily, amazingly - no fractures in any of the limbs, not even the one the truck was on. So, we get her stabilized and then bandage her limb, plan is to do dressings on the limb because I have to wait until all the tissue declares itself dead or alive before it can be fixed....this can be a long time...So, did honey bandages...actually placing honey on the wound (has antibacterial properties and also osmotic to help pull junk out of the wound)...Dog was doing well..sitting up, alert, actually walking on that limb (I also placed a hard splint outside the honey bandage just to give her more support in the limb)...dogs are amazing...you know that has to be painful...so she got an abdominal ultrasound yesterday because it was part of staging for the cancer---strike 3 -- masses in spleen...Dad visited, cried, going to euthanize today I think...amazing dog..made it through so much...so sad...I did one more bandage change last night and wound is actually granulating in very nicely...took some pics...scroll down after reading this blog to see the images...prepare yourselves!! so that was Lily dog...great sweet girl. My other HBC came in last night...8yo f/s Pug--laceration on top of head (down to skull...yes can see the bone...I mean the whole top of the head!!!..skin is pulled away!!), right eye was proptosed (popped out of the socket!!), dog can't use limbs, breathing horribly...so I go to talk to owner and find out.....she ran over the dogs head...oh my god...so I go through my schpeel...dog is very critical...head trauma..MRI/CT and wound surgery but not for couple days until stable...thousands of dollars..possibility of no dog after all this. Women has to run to bathroom....I do not know if she vomited or what,,,but then she came back and was able to place a small deposit for the first night,,,,but only for supportive care which means I didn't get any radiographs...Just lavaged wound on head and placed skin staples to hold it together so skull wasn't exposed, took minimal bloodwork, started pain medications and minimal fluids...monitored overnight...was doing ok but early in the morning began going into respiratory distresss.....last I heard the doc I rounded to was trying to get ahold of owners, they are a money case so I am afraid she may be euthanized....hey I tried...so her pics are below too. Ok, away from head trauma...you all saw the pics of the dog that ate the rocks..my first foreign body surgery...yay me..exciting even though I do not like surgery...dog did well and went home...phew, successful surgery!!! Last night was absolutely horribly busy...horrible...what did I see...a down dog with a disk lesion that transfered to another vet at 5:30am for back surgery to remove the disk; a couple vomiting dogs that just wanted outpatient treatment; saw a dog with a laceration on his metacarpal pad -- couldn't afford surgery so I cleaned and bandaged it and told him to see his vet for follow-up; some other lame dogs; euthanized a cat with feline aortic thromboembolism (heart disease and then throw clots to legs and basically poor prognosis). The other night, saw two Boston Terriers (Zoe and Milo) brother and sister who had eaten mom's ibuprofen supply!! This causes renal toxicity and GI ulceration in dogs...activated charcoal to vomit, IV fluid diuresis, pepcid, sucralfate (GI protectant)...continued to vomit through night...transferred to rDVM in am, hope they did ok,,,cute as heck...took pics of course...they are below on the blog also.... So now I finally have 3 days off...woke up early and got ready, met Talia and her boyfriend and then Andrea (a visiting vet from Italy) for lunch...that was fun..got some pics so see below as well. It has been storming like crazy here!!! Man oh man...lost power in the clinic one night a million times...not cool...That's about it...if I think of more interesting cases I saw the past four days I'll blog them later.

My First Surgery!!!

Finally got to do a surgery last night!!! Not until midnight when my shift was over--so I was there until 5am this morning...not fun...and the power went out in the clinic multiple times...luckily right AFTER I was out of surgery!! So, I am overly tired and have to head back in to work in about an hour. So my surgery...very cool...gastrotomy (cut into stomach to remove stuff)...dog at rocks!!! Yes, that's right, rocks, 10 big ones about half the size of my palm!!! Yes big rocks...stupid black lab!! Referring vet took radiographs and there they were, filling up the stomach..dog had been vomiting and owners had seen him playing with the rocks and figured he must have eaten them...well yes he did!! So, sent to us, I did bloodwork and guess what I found, do you remember from my last obstructive case?--Hyponatremic, hypochloremic, metabolic alkalosis...remember why?...because of pyloric (region of stomach that empties into duodenum/intestine) outflow obstruction...from the rocks of course. Went to surgery with the resident Dr. Torro - he is really cool, nice, an italian/puerto rican heritage so cool accent, not so bad on the eyes!!...it was fun, he is great and I am so lucky that he went in there with me instead of someone else (I think you all know who I am talking about, no names here!!). Yeah, so the bad part was that I had to do the surgery after my shift, was going to do it during, but working with the newest intern and I love her to death, she is so nice, but multi-tasking is not her strong trait and as you can well imagine does not work out that well in this job...so needless to say she saw about 2-3 cases the entire night and I saw everything else...does make me feel kinda good when my senior is asking my help though and saying I am sorry but can you please take one more case..because they know I can handle it....I don't know guys, am getting used to the job...although ya know I think that I still might want to do an internal med residency because I just don't really want to work these hours for the remainder of my life, I would like to have a normal life at some point...hang out with my husband!!! And although the surgery was cool...if I didn't have to do another surgery in my life I wouldn't be sad...I really do'nt think I like surgery all that much...it is cool to watch and hear about what they can do...other than that I am fine with it...with internal med I wouldn't have to do surgery...besides the meat and bones of the diseases are what is interesting to me. Other cases I saw last night were a dog with melena and very lethargic but pink mm (melena is black stool = digested blood = bleeding somewhere from upper GI), this was an old Rottie so my differentials are many but included tumor, ulcer, parasites, infection, coagulopathies (bleeding disorders)...owners have no money so gave SQ fluids and sent out door with sucralfate (GI protectant) and script for famotidine...treating for ulcers..told ot follow up at rDVM because dog is really sick, they won't I know this...what can I do. Saw my repeat offender blocked cat from the other night...this is his third night in a row back..Melvin is his name, yes he is a 'stupid yellow' who is still straining at home but everytime he comes in I am able to easily manually express his bladder and get a good normal stream...I think he is just having spasms in his urethra...so placed him back on Acepromazine (tranquilizer but helps with urethral spasms as well) and phenoxybenzamine (another urethral relaxant)...hopefully this works...the girl is my age and she laughs each time because it is always me who sees him and she teases now that Melvin just wants to come here to see me...she calls me his girlfriend...I think her husband is at the end of his rope with the cat, however luckliy she loves her yellow boy and is dedicated to his care...however if this keeps up the next step is to chop his penis (perineal urethrostomy...cut and reroute it to widen urethra so it doesn't block as easily). What else did I see? Another diarrhea cat...placed on fenbendazole (dewormer) and metronidazole (antibiotic) because she also had no money. Saw a dog with renal failure who is being treated by Dr. Kaae at the UW-Madison (one of the internal medicine residents) and her renal values are through the roof but refuses to hospitalize with us for fluids...wouldn't even allow an examination...just wanted bloodwork...talked to rDVM on phone and he tried to convince her to hospitalize and she just cried and he ended up saying she could bring the dog in to him tomorrow and they would place on fluids...faxed it al away and that's it...what else can I do..I find out later though that this lady was told not to return back to AEC..she is a little off her rocker I guess and causes troubles sometimes. I'm like oh great! I can't remember any more cases. My kitties were starving yesterday... I had no food for them and no time to go get then any before heading to work...yes, things were shredded when I came home!! Luckily I found one can of canned food last night for them and then got up early this am to run to store to buy them food. Only got 2 hours of sleep last night...really tired right now, two more days of shifts left then finally have some days off...may be able to get out of town even!! I am going to head out..we have journal club today and have 3 articles to read through that I read a while ago and want to peruse through quick so I re-fresh my mind on them. I am getting pics of my rock eating dogs so I will post those hopefully at another time. Adios.

Smiles

Hey...sometime between work and sleep, I woke up and actually have started to enjoy my job!! Yikes!! The people I work with are great (with a few exceptions as is always the case)...do not get me wrong..it is still hard work and i do still hate the hours, but I do not feel as depressed as I was in the beginning...maybe I am getting used to being alone? That is probably a big part of it, I have my routine now and that makes me feel like my life once again has some purpose, I have been meeting some really great people as well that have helped me to smile through my rough times... Work on Friday was eerily slow...yes of course I got 2 traiges in with 10 minutes left of my shift, but I was ok with that because I was actually all caught up on paperwork...and it was a vomiting cat...I see this so often it is routine, either they hospitalize and I do the work-up or they take home on SQ fluids, anzemet (dolasetron)...this one hospitalized but I was still able to get out around 3:30a which is really not bad. Had a couple hit by cars...one lived and actually just had some lung contusions (bruising) so kept overnight for monitoring; other was DOA (dead on arrival) sad story, Dad was drunk and had taken dog with him to gas station to get a drink, tied him outside and he got away and ran into traffic and got killed...all he kept saying was that his wife was going to kill him...I think the relationship may suffer a little bit on that one!! What else did I see? Oh yeah..blocked cat...got to teach our extern how to unblock it...was cool... So yeah, the job is making me re-think my original plans of doing a Residency...definitely would want to do an internal medicine residency I think...but it is early and I still have a couple months to think about it...we will see. Today I had off, didn't do much...was raining all day!!! Had lunch with a friend, now hangin out and watchin 'The Hills'...some mind-dumbing tv show about rich chicks and sometimes watching it I fear I may actually become more stupid by watching the show. I do not understand those people who feel like money is everything...all money gets you are superficial objects that mean nothing (and sometimes superficial people who mean even less)...it doesn't buy happiness...it just buys things to make you even more unhappy...the richest people are those with the biggest hearts and sometimes the smallest pocketbooks..look for what's inside the heart not the wallet. Ok, stepping off my soapbox. Wait a minute, while I am on it you know what else bothers me? People who lie...really the truth hurts less in the long run...just give it to me straight the first time...besides what goes around really does come back around (to bite you in the a--). What else can I say about me, my gripes, wanna know what I like? I love hot tamales ( I am eating them right now), I love snuggling on a rainy day--if the other person likes you, otherwise it is just a waste of time, I love tacos, I love ethnic foods, I love pina coladas, I love going for a run with my headphones on and the music really loud, I love the smell and sound of the ocean, I love the first snowfall of the season, I love surprises, I love getting flowers because it makes me smile, I love dancing - I am going to start taking lessons, I love trendy stuff, I love being different than everyone else, I love thinking about what I am going to do with my life next, I love the possibility of ending up in a brand new place, I love getting emails and texts that make me smile, I love modern furniture, I love little hole in the wall eateries and bars b/c they serve the best food and drinks, I love Honey Weiss beer but am trying to beak out and try new ones, I love seafood, I love muscles, I love the song "Hey There Delilah"...i think that is it for now. I am going to head out...Starting to write too much stuff about myself...another of my gripes, I hate when people know too much about me, if you know a lot then I have let you in and you are special, if not -- sorry. Ok, seriously stepping off the soapbox now. I am off tomorrow too, perhaps I will write more then...

Your Dog Ate What???

I have about 1 hour before I head out to work again...my last day for a couple days, have the weekend off...what am I going to do? Don't know yet...got an invite to the zoo...may do that...may go hang down by the lake...not sure yet, all depends on what I feel like when I wake up on Saturday morning/afternoon. My kitties are going crazy...it is hard on them when I work so many days in a row...they count on their paws until I have days off to hang with them. Apache has developed her habit back of trying to kill me while I sleep by trying to knock the picture down from above my head. As soon as I wake up she is content and then lays down, next to my head on my pillow!!! (this is a new position for her!!) and goes to sleep. Webster just screams in my ear until I wake up, open up the covers, and let him snuggle into my left armpit...they both have their sides and Apache gets very irritated when Webster tries to sleep on her right side!!! And, they both love it when it is just me in the bed...they get me all to themselves. So my night last night was gastric foreign body night. I admitted 3 dogs..one ate a pair of black thong underwear that we fished out endoscopically, another ate a happy meal transformer figurine that we pulled out endoscopically (still intact minus one arm he had chewed off), and another ate the whole garbage which unfortunately for him contained corn cobs that he did not chew and swallowed whole...yeah those things do not pass!!! But, we are very expensive for ER surgery so she wanted me to just stabilize overnight and he was getting transferred to his rDVM this morning for likely intestinal surgery because based on Rads he looked obstructed. I also saw a little dog with a big abcess on his face, a dog with impacted anal gland, a sick cat with a fever who I just gave SQ fluids to and sent home on antibiotics (cat had painful belly, but what can you do when owner wants to spend no money??). Last patient of the night was a dog in severe respiratory distress...cyanotic mm (blue gums)...arrhythmia but couldn't really hear murmur, tachycardia...wanted to give fluids and take rads....owners say no, want to check with rDVM first..wanted me to do nothing but keep in oxygen overnight...woman is bawling the whole time...I say that I can do that but she is critical and may die without us knowing what is going on and it may be something we could have prevented...she actually sends husband home to get rDVM phone number and wake him up to ask his opinion (keep in mind it is 2am!!!!)..they come back and decide they are going to take her home and wait until can see rDVM in the morning... I am very surprised that rDVM would suggest that...I am wondering if it is because dog was seen my him a week ago and had a cough at that time and he said to just watch it, is also giving steroids for skin allergies....glucorticoids and heart failure---not good....that is maybe why...either way I send dog out door gasping for breath and blue....not without having them sign an AMA form t cover my butt (against medical advice form)...out of my hands now. I am getting more used to the job..still dread going to work...hate the long hours...always at least 18 usually 19-21hrs. I got home at 5:30a yesterday, showered, went to bed and for some reason felt like getting up at 9:30a, going for a run, and then cleaning my bathroom...now I am waiting to go back to work...it is Friday so yes it will be very busy...always is...the good thing about this job?...I have finally lost my "tweakness" (nervous, panic attacks...buh bye)...the job is tough, the hours are long, I am constantly sleep deprived, I am losing touch with everyone I once knew, but hey, what doesn't kill ya only makes ya stronger...(at least it better--sheesh!!)

Heart Failure

Well, didn' have such a bad night...it was busy but not overwhelming. Saw a Fox Terrier with an intestinal mass...had been vomiting for 3 weeks...found mass on ultrasound...placed nasogastric tube, gave anzemet (dolasetron), and scheduled for surgery today. Saw a cat with IBD and possible intestinal lymphoma...vomiting...placed on fluids, anzemet, famotidine, prednisone...will get abdominal ultrasond today. Saw a dog in for an ultrasound-guided liver biopsy...completely healthy aside from elevated liver values found on routine geriatric blood work at rDVM...kept him over night to monitor PCV/TS (monitors for bleeding from liver biopsy site)...sent in liver histopathology, anaerobic cultures, and leptospirosis titers...dog is a freak and has never stayed in a hospital so had to tranquilize him with Acepromazine throughout entire night...no evidence of bleeding...sent home today on liver protectants (Denamarin and Ursodiol)...pending results. Saw a dog with a cut above his toe, bandaged it and sent him out door on pain meds (tramadol) and clavamox antibiotics. Saw my little Puggle puppy with the pneumonia that I endotracheal washed the night before...he was doing a little coughing and owners thought he felt warm...otherwise doing great at home, eating well, good activity...PE was completely normal, no fever, harsh lung sounds still but we know he had pneumonia...they are a very young couple...high school I think...so just over-worried, assured them that he is fine and he will do some coughing, maybe for the rest of his life if it is kennel cough...so told them to continue with antibiotics, continue to nebulization, and showed them how to take a temperature. Then saw a dog came in cyanotic (blue gums), trouble breathing, lungs very wet sounding, 4/6 left systolic apical heart murmur (uh oh)...gave flow-by oxygen and he pinked up some...went out to talk with owners about treatment options which at that time included catheter placement and trying to get thoracic rads...discussed that we may need to take over airway if she goes into respiratory distress....owners agree. We start to get catheter in, dog falls on side and goes cyanotic again..I run out to owners to get ok to intubate and breath for her...woman is a mess, crying...finally get an answer...go back, sedate with Etomidate, intubate, begin manual ventilation, administer furosemide, start to think about Nitroprusside dosages...go back out to discuss heart failure with the owners and tell them we have to treat and try to pull all the fluid from the lungs as well as make it easier for the heart to pump blood through..because it is a small dog with a L systolic apical heart murmur...yep mitral valve insufficiency is what I am thinking too. So we are thinking about radiographs, Mom and Dad have left and are on their way home...then dog arrests...EKG flatlines for about 3 minutes, we are thinking she is gone (he is a no code), then all of a sudden heart starts back up again...she continued to do these cycles despite atropine...so finally called owners and said that her heart is giving out and we need to help him along..get the ok for euthanasia...very sad...owner is devastated....problem is, dog started having cough a week ago...probably had started to go into failure at that point...but we all do it, oh lets wait and see if the cough gets better before bringing in to doctor...sometimes that is our demise. Got out at about 5a last night, was done at 3:30a but had to wait around to round to other clinicians....that made me mad!! Now, I am getting ready to head back in again. I have today and Friday and then I have Sat/Sun off. I might go to Zoo on Saturday...I am excited I haven't been there in about 7 years!! Ok, well..gonna go read for a bit prior to heading back in...Thursday so I am expecting a very busy night...darn it!!!!

My last two days

Ok, I thought that the 8a-8p shift would be great because I was going to finally get off at a decent time...laugh...I should know better than that. Sunday was absolutely horrible...it was so busy and there were three of us on the floor!!! I did not get out of there until 2:30a, got 2 hours of sleep and headed back in there Monday. Not as bad but still did not get out until 2am. Damn this job and it's long hours!!! But, have to say, saw some very interesting cases. A diabetic cat with diabetic ketoacidosis (DKA)...very sick, flat out, glucose >500, glucose and ketones in urine, ketones in serum, not to mention that electrolytes and acid base was majorly messed up!!...bad, bad, bad...owners euthanized b/c cat never came out of lateral recumbancy and we are talking $2-3000 in treatment, days of hospitalization, and twice daily insulin injections for the rest of this cats life....a lot to handle...sad though because I really wanted to try to work the case...pure internal med case and I was so intrigued...god I love internal medicine!!!!!! But alas, I did not get to do that. Next comes my most favoHad a cat, flat out, hardly able to lift head, febrile...history of stone blockages in bladder and urethra, cystotomy to remove the stones, referred here from rDVM because of possible leaking of bladder from the surgery site in the bladder. Bloodwork...renal values through the roof...honestly I did not even know they could be that high!!!! (BUN>255, Creat 8.9, Phos>16.1, K6.3 -- for those of you who values mean something....for those who don't, this is a sick cat), crazy painful abdomen, of course messed up acid base and electrolytes. Started cat on fluids at high rate (75ml/hr!!!!!) and fentanyl CRI (pain med). Abdominal ultrasound later in the day showed dilated kidneys (actually dilated renal pelvices --obstruction?? or high fluid rate??), huge mass in bladder (likely blood clot) and free abdominal fluid--uh oh, tapped the abdomen and analyzed fluid for creatinine and potassium - results? Creat=14.1, K=7.0 --yup, it's urine. Phone call to owner goes: large clot in bladder that is likely causing partial if not full obstruction of urine flow from kidneys into bladder, fluid in abdomen means bladder is leaking - likely from surgery site, clot in bladder will have to be evacuated with another surgery, elevated renal values are poor prognostic indicator, cat is still laterally recumbent, explain possibilities of cardiac arrest, cost will definitely exceed $2000...owner already took out care credit to pay for this visit....final decision...euthanasia to my dismay...probably right choice but kidney are my most favoritest things!!!! I am so into renal disease especially in cats....that is what my intern paper is going to be on...lucky for me!!! I don't know why I so interested in it, but I am for some reason. So, love those kidney cases. On a side note, was talking with my resident and he was asking if I wanted to do a residency, I said I did originally and now not so sure, he asked in what and I said internal medicine....he goes you should do it, it is worth it....hmmmm, I would love to be able to do an internal med residency...I don't know why I am so interested in all the physiology of the different diseases and treatments, but I am....especially the kidneys!!! We will see. I digress...my other cases was a little Puggle with respiratory disease...likely pneumonia or really bad kennel cough (he is a pet store pup!!)...got to do an endotracheal wash last night at 1am...helped by our extern who is visiting from UW--and actually she was in my class and then entered the master's prgram so now is just finishing 4th year...cool to have her around to talk with...started talking about some of the residents at UW...Dr. Foy....we all loved him!!!! I digress again, sorry...so my little Puggle "bear"--tough guy name!! So cute, worked up whole case on my own because so busy....rounded it and got kudos from my senior on the complete work-up!! Felt good...maybe I am learning things...anyhow he doing great with my treatment so I feel good about that one!!! Also have gotten props on my records because they are so complete...my stupid, anal-retentive, obsessive-compulsive personality won't let me do anything half-a.. so that is why, but hey....whatever, at least the next doctor coming on knows exactly what I did and what I want to continue to be done....Other cases -- an IMHA (immune-mediated hemolytic anemia), IMTP (immune mediated thrombocytopenia)...blood transfusions and steroids for both; many vomiting animals, diarrhea cases (same treatment--rads, bloodwork, fluids, nasogastric tube, antibiotics and dewormers, abdominal ultrasound if not getting better, endoscopy or colonscopy if really not getting better), an intact male dog with blood dripping from penis (differentials?,,,prostatitis, prostatic hyperplasia, prostatic adenocarcinoma, urinary tract, urethral prolapse)...not urethral prolapse, rectal-feel nothing but that means prostate could be so big it is over brim of pelvis. Recommend to owner radiographs and then ultrasound of urinary tract and prostate, bloodwork, urinalysis and culture...owner doesn't want to do anything because we are too expensive - wants to take to rDVM... dog was febrile 104) so convinced him to let me hospitalize with fluids, antibiotics, and urinalysis...he ok'd and transferred to rDVM next day -- disappointed because that is a different case and I wanted to work it up but oh well. Had many other cases as well, I am definitely learning a lot...definitely stressed out. I can now drink caffeine at any time of the night...and then go straight to bed....nervous, panic attack ang is gone!!!! Awesome....!!! I am so happy about that. I am watching some TV now...it is nice because I have cable...so basically I now have a bunch of channels with nothing good on!!!! I apparently have DVR--but Dad,,,I still can not figure it out!!! I knew I wouldn't be easy...I can save things but have me figure out technology and I am like a chicken with its head cut off. Well, I am going to get going and study some on the intersting cases I had. If any of you are off and around tonight...give a call...I should be around...

Engholdt Party

Well, my day off was fun...I traveled down to the grand town on Pardeeville WI for a little Engholdt get together. Many of the Engholdt's showed up...it was really gret to see everyone that I have not seen in such a long time...and being there made me think about a lot of things...no matter how terrible life may seem, it is nice to know that family is always there on your side! Here is who was all there: Don, Jen, and the kids; Karen; Uncle Bud; Grandpa Dick and Betty; Brian and his girlfriend Jen; Jeff and his 3kids...and then Kev and I. Kev grilled burgers, brats, chicken...and then of course there was a ton of other snacky foods and salads as well. It was a great meal, and like I said really nice to see everyone. For me it was nice to get out of Milwaukee and to surround myself with others who really care and are happy to see me. The house looks really great..Kevin has his big 55gallon fish tank set up which looks really nice, and he built a pond in the back yard that looks really nice. He has a little kitty friend as well, Callie (a beautiful little calico cat) is what he calls her, she is feral to us all but friendly with him...I tell him Apache and Webbie would be jealous if she knew...but I won't tell them right now that they have been replaced...that is the worst thing in the world you can tell someone and I would never want to inflict that type of pain!! Work...My Friday shift was amazingly quiet...yes I am definitely looking forward to things slowing down over the winter time!!! I had a dog..vomiting, tachycardic, dehydrated, painful abdomen, febrile, whopping heart murmur that was brand new (hmmm...anemia? you might think but surprisingly no)...ran full bloodwork, thoracic radiographs, placed nasogastric tube, scheduled abdominal ultrasound and echocardiogram. Right away gave pain meds and anzemet (dolasetron..anti-emetic), measured blood pressure (90mmHg with HR-160bpm)...uh oh - bolused 300mls of fluids (P-lyte) and rechecked...BP 40mmHg and HR 180bpm...oh no - bolused hetastarch..brought BP up to 60 - uh oh...gave another hetastarch bolus and 300ml p-lyte bolus and started on CRI of Hetastarch. BP stayed pretty stable then at 120mmHg and heartrate at 130bpm. Ok, got that crisis taken care of. Thoracic rads showed right heart enlargement and mild interstitial pattern...not too bad, however part of abdomen I could see on those rads seemed a little hazy and loss of detail. Uh-oh. Bloodwork results - CBC shows definite inflammation with a very high mature white cell count and increasing bands. Chemistry panel shows severe elevations in liver enzymes and mild renal elevations (these prob pre-renal due to dehydration). Then comes our acid base: hypochloremic metabolic alkalosis with compensatory respiratory acidosis.....oh crap...this is classic classic classic bloodwork for pyloric outflow obstruction (obstruction in stomach not allowing emptying into intestines). Abdominal ultrasound shows mass in pylorus of stomach (that explains the obstruction), mass in the liver (explains elevated liver enzymes), and free abdominal fluid that was tapped and was bloody with a PCV/TS of 24/4.5 ---uh oh!! Dog is 14 years old, very arthritic, extremely sick and laterally recumbent...I know owner will not want surgery but that is all there is...a call to owner confirms what I thought...humane euthanasia it is. Would have been a cool surgery but she would probably have needed to have duodenum reattached to stomach and in papers dogs with this procedure performed do very poorly anyhow...so a good choice to euthanize I feel. My next case? A torn dew claw...sedated...ripped it off with hemostats, wrapped foot, and checkd a CBC because dog was febrile--but was normal so gave SQ fluids to help with the fever. My next case...a Rottweiler with a hard swelling in the tarsal region (uh-oh...if you are thinking osteosarcoma so am I)...however in meantime dog is laterally recumbent, cannot walk, has a heart rate of 210bpm which is severely tachycardic...severely dehydrated with white mucous membranes. I talk to owners and say that first thing we would need to do is some resuscitation because dog is in shock...this alone is $400-600...owners need to call their mom first, I ask if I can at least administer pain meds...they agree to that. Oh I forgot to mention, this dog is not vaccinated and despite being on the verge of death...tries to swallow my arm in the process of my physical exam...muzzle it is. Talk more with owners and osteosarcoma (a common cancer of bone seen in this breed) was already diagnosed at rDVM 2 weeks ago...they did not want biopsy or amputation at that time...decided to go with Rimadyl, even though dog could not walk... and let me tell you...this is a painful cancer...Rimadyl ain't gonna control the pain...but whatever...dog is in my care now so lets see what we can do. Mom finally arrives and I talk with owners about the cancer both osteosarcoma as well as hemangiosarcoma (as mucous membranes are white). I say we first need to stabilize the dog and pull him out of shock before we can start with any diagnostics. I say I am afraid that the cancer has taken over and that we may spend a lot of time and money on trying to stabilize and they may still walk out of the clinic without a dog. They are realistic, I talk with them about his declining quality of life...after about an hour they are finally all in tears and have decided to humanely euthanize....a good choice in this dog...he was suffereing and it would likely be very hard for us to make him comfortable if they are not willing to amputate, which they were not. So I euthanized him with all of them crying...very sad...I had to keep thinking of how sick the dog was though and that this was the best choice for him. I saw a recheck of one of my other patients from last week -- a splenectomy patient with pancreatitis...removed her j-tube (tube in intestine) today and rechecked liver values...she is doing great at home...the man is very nice...love when they come in...she is a great patient and I am really happy she is doing well. And the best thing was that after her 2 week hospital stay she was just as happy to see me and to follow me back into the treatment area...what a great patient!!! And that was my night...I was done by 11:30p but stayed until 1a to help the other clinician...however that is still the earliest time I have been out. I have to say, I was in a really sad and depressed mood going to work that day...didn't want to do anything but curl up in bed and lay there....so the slow night and getting out early really helped alot. Am I in better spirits now? I don't know. I hate the internship...dread going to work...hate that it causes me to lose touch with those I really care about... But, I am strong and I do know that life goes on. When one door closes it is usually because another is going to open up. I refuse to cry over spilled milk. It is only a year...then I can move on with my life... Please don't any more of you walk out on me though...i need your support, I need your comfort, I need to hear your voice when I am sad and need an ear to listen to...I promise to keep in touch...I promise not to lose that "Ang-ness"...and honestly I do see that little light at the end of the tunnel so please walk towards it with me...this will all be over soon and I can live normal lives with all of you...I NEED YOU FOR SUPPORT!!!! This is a very rough time for me right now....help me to smile... PS--dont forget to scroll down for some pics

I'm back

Sorry, I haven't written in a while, I have been busy...as well as sleeping after my shifts, waking up, and then doing the whole thing over again, for days in a row. My last two days have been on shift, on the floor, 12p-12a. Monday was nice and slow, got out of there I think at 1:20a or 2a. Yesterday, absolutely horrible. At one point we have 5 Triage Stats in at a time-2 on the tables and 3 laying on the floor, all trying to die!! I believe only 1 or 2 lived. We had a dacshund who had gotten stung by a nest of bees and was in anaphylaxis (tachycardia, hypotensive, v/d, hypothermic....a mess....I believe he made it) I dont know because I had a Germand Shepherd who had come in, unproductive retching - you think bloat right? Yeah well what didn't fit the picture was that the abdomen was really low slung and there was a fluid wave - although the dog was definitely unproductively retching, salivating, aspirating and basically dying in my hands. Hooked up ECG, blood pressure - tachycardia (200) and hypotension (50!!!). Bolused 1L P-lyte, HR down to 180 (still not good) and BP came up to 100 (ok). Tried to pass nasogastric tube because quick ultrasound probe did show a huge fluid filled stomach--also fluid in abdomen (uh oh...rupture??). No such luck on the NG tube....just severe epistaxis (nasal bleeding) all over. Plus dog is aspirating his own saliva at this time and crashing. So give propofol and intubate and take over breathing. Pass orogastric tube and get off large amount of yellow slimy fluid--yuck. Quick other look with ultrasound probe shows fluid in stomach and a mass attached either to stomach or intestines -- bad news -- dog needs surgery right now -- final decision - takes a while but dog is 10 years old and very unstable - owners decide to euthanize, which is not a bad choice. G shep with abdominal mass and free abdominal fluid is never a good thing!! So that was that stat. Then had a Golden come in who had collapsed and then arrested in car ride over...CPR but no luck...pronounced dead. Another golden, weak, collapsed, pale pink mucouc membranes, muffled heart sounds ... ECG shows electrical alternans (varying height of the QRS complexes) ...pericardial effusion? Why yes it is...confirmed by ultrasound probe...uh oh and a large heart base tumor as well as right atrial tumor as well as either large blood clots or tumor extension into the right ventricle....BAD NEWS!! Owner can't let go, wants us to try to stabilize so she can have at least one more day with her...knowing that we may kill her just tapping the pericardium. But, we do it, pull of 300mls of blood from pericardium and there is a lot more but can't get to it because of all the fibrin and the large mass. Bolusing P-lyte (1L) and giving pain meds but heart rate remains 180, pulses remain weak, dog is also poorly oxygenating (88% Pulse Ox). Go to have long talk with owner, dog is 14 years old, this disease has poor prognosis, with intracardiac mass, surgery not option anymore...she cries a lot and then finally decides it is the dogs time and we euthanize...with her present and hugging the dog bawling the whole time...i hate that..makes me wanna cry! Sad story... then she has to go tell me she lost her huband about a year ago and dog is all she has left both as companion and also to remind her of him....now I understand the need for us to try to stabilize the dog, however despite, sometimes it is just time and in Vet med we have the great luxury to stop the suffering which can be a great thing in certain cases. Had to pug puppies - just born - with body wall open and intestines outside body wall - yikes - would need surgery and probably wouldn't survive anyway or would likely have other genetic abnormalities as well (although did not have cleft palate or atresia ani)...euthanized both of those. Had a very sick, painful abdomen (pancreatitis???) cat...fluid, rads, abd ultrasound (which did not get done), blood work which showed sepsis...started on antibiotics...ultrasound was set up for today. Had yellow lab puppy that got bit by other dog in house...doing surgery after shift over...had to place two drains...one wound under chin - could see masseter muscle just demolished, could see salivary glands, could see nerve branches that luckily are intact!! Bad, bad wounds....he will probably be ok but jeepers...dont let the those dogs play together anymore. Had a bunch more as well but honestly cannot remember at this time. My total time for my shift last night? 21 hours....I am almost to 24hrs!!! Julio, one of the other residents...he has been away, just got married...said to me the other night "I am suprised to see you all still here, I thought for sure someone would have quit by now!!" Yep...nice internship I ended up in huh? Has a history of losing interns....WELL I CAN SEE WHY!!!!!!! If I wasn't the type of person that I am: perfectionist, afraid to disappoint anyone, determined as heck when I set my mind to something....then I would so totally bring my scrubs and coat in, drop them off, and say so long...but I can't no matter how much I dream of doing it!!! This is hard, it is hard to keep up spirits, especially coming home to no one but myself, having no one to talk to about things...basically crying by myself. I am trying to not let this job turn me into a cynical, depressed type person...I have to grab tight to that tiny light at the end of the tunnel...know that at the end of this year I can walk away from this, hopefully a better clinician, stronger person...and definitely not look back..move on with real life...get a real job and get paid...live a normal family life finally!!!...and smile!! Always smile...no matter what is going on in your life...find something every day that makes you smile. Leave work at work...work is your rubber ball...it can be dropped and not damage...so go ahead and drop it when life seems overwhelming so that you can easier hold your precious glass balls. Ok...I need to go grab some food and then head to that darn clinic again for rounds.

My First Time Alone in ICU

Well, my first shift in ICU was not too bad. I was in charge of 11 patients, which is supposedly a low number for our ICU, but good for me at least for my first night all alone in there. Let’s see, what did I have? A Great Dane who had a GDV (twisted stomach)-surgery had been performed earlier in the morning and he was in recovery. Had trouble with his blood pressure, it was consistently high, but he didn’t seem painful and really had no other reason for it to be, he was just a really anxious dog—once he settled down we finally started getting some normal readings. I almost Ace’d him (gave him some tranquilizer) to see if it would help, but he then settled down on his own and I didn’t need to. My other patient was a pancreatitis case – the one I had talked about earlier – she is still here – still jaundiced – not doing well, so they went to exploratory surgery – found masses in the spleen so did a splenectomy and removed it, liver was also grey and streaked (not normal liver color!) so that was biopsied, pancreas was very thickened (likely result of chronic pancreatitis), and the gall bladder was distended and there were multiple adhesions of omentum and mesentery to the common bile duct (that lets bile go from the gall bladder into intestine), so the common bile duct was cannulated and a stent placed (to keep it patent), a feeding tube was also placed into her jejunum (small intestine)-because in pancreatitis you want to bypass the pancreas when re-feeding them. She had a rough recovery, she is a very nervous dog any way and she kept thrashing around, so I turned down her Fentanyl CRI (pain) at first because she was very dysphoric and I thought maybe it was because of that, it didn’t help so I finally gave her some Acepromazine (tranquilizer/sedative) and she finally calmed down. Started her on feedings through both her nasogastric tube and jejunostomy tube and that was about when my shift ended. I will get her back again tonight so we will see how she is doing, hopefully better. Then had a vomiting cat with pancreatitis that had been doing very well here in the clinic with an NG tube (nasogastric) in and not had any vomiting in days…so he was set to go home, pulled NG tube and he starts vomiting all over-crap!!! So gave him a SQ injection on anzemet (dolasetron) an anti-emetic and seemed to stop it, sent him home, didn’t hear back so I hope he does well. Next step for him is an esophagostomy tube for tube feedings if he won’t eat or continues to vomit. Has an old German Shepherd with a tail mass that was removed, he did fine. Just added some pain meds no and he was ready to get discharged this morning. Had an English Setter with Parvovirus (vomiting and diarrhea) who had very low albumin (1.1) (a blood protein), we do not like to see it get under 2.0 because then you start to see effects like edema and all this nasty stuff. So, got her set up to receive a human albumin transfusion – she was still receiving that as I signed off shift…I am sure I will get her back today…hopefully the albumin helped and then hopefully she starts eating because that will both help her get albumin and will help her GI tract enterocytes to repair themselves so she is not losing the proteins through her gut (we call it protein losing enteropathy when they lose through the gut, it is because of the diarrhea and the normal GI cells get sloughed and then they start leaking good stuff out ). Had another young German Shepherd who came in with acute neurological signs, couldn’t walk in hindlimbs then couldn’t walk in front limbs. Normal cranial nerves, absent CP and reflexes both fore and hind limbs. She was very anxious also—because she keeps trying to walk and can’t. Have her on Doxycycline in case of a tick disease, also thinking coonhound paralysis (what Michelle and Dan’s first Jake dog had). So monitored her breathing really well overnight to make sure she didn’t need a ventilator if her diaphragm because paralyzed. She didn’t ever on my shift, we will see where she is tonight. I also mentioned running a tensilon test to check for Myasthenia gravis—she doesn’t have typical presentation and doesn’t have a fatigable palpebral response, but it is a cheap thing to try and rule out. Then I woke up this morning and thought..god I hope that dog doesn’t have rabies!! Other thought,,,botulism,,,kinda a stretch, but we will see how she is doing tonight. Had my hit by car in the head dog back again last night. She waxes and wanes in her mental acuity, sometimes she is up and aware and able to walk, othertimes she seems non-responsive to humans. And she has developed a wide circling to the right pattern when she walks. She finally had her CT scan yesterday of the head, good new no hemorrhage or swelling (but could have been and now went away b/c she is about 5 day s out), but multiple left maxillary (jaw) fractures, left frontal sinus fractures, left periorbital fractures (around eye). So the hard thing with her is listening when she moves her jaw, all you hear is this gross crunching sound!!! Poor girl, so she is getting a surgical consult on Thursday…but the mental aspect of her…not sure how long that will take or if it will ever fully come back. Had three post-op surgical dogs that did fine. Had to replace bandages on them a couple times. Placed two on Domitor CRI (sedatives) because they were anxious and whining and Ace did nothing for them…so that kept them nice and quiet the entire night. They will get transferred back to surgery this morning. Then at the end of the night my ternmate Katie turfed me a renal cat…possible oliguric renal failure—not good—or pyelonephritis…owners didn’t want to do much diagnostics, just wanted support and were planning to transfer to rDVM this am. Should at least do an ultrasound of the urinary tract and kidney though because one disease can be cured and the other holds a very grave prognosis!! And rDVM will just send them back to us for ultrasound anyhow!! So, that was my night. I am hoping for another slower night…as least while I am getting used to things. I am also mad because they were very slow on the floor all night…Katie was the 2p-2a person and she actually left the clinic at 1:45a…that never happens to me,,,she always lucks out with slow shifts….why can’t I ever get that? I have bad luck..I always get slammed!! Ok,,well I am going to go and work out a bit and then study some before heading back to that place.