And then there are those days...

I worked the 2p-2a shift yesterday, have today off, then am on again for 4 days straight before I get my big 13 day vacation...can't wait. Last night was hectic, and I made a lot of angels. My fist case was an 8yo male neutered Airedale Terrier who was laterally recumbent...at first I wondered if he was neurologic (aka - spinal disease) but after completing my neurological exam, he could stand and walk but was just really weak...so I was like uh oh...he was screaming metabolic disease. Plus heart rate was really high and I assumed that blood pressure was abnormal. He was also pretty painful in the abdomen. So, I talked with owner about running full bloodwork, getting set up with IV fluids, and doing abdominal radiographs. Got an estimate of $1000-1200 and got started. First blood pressure was high and heart rate was high so I bolused some fluids and rechecked, both still high so I bolused again...heart rate came down but blood pressure didn't. So I thought about it...hmmm...maybe painful...gave a fentanyl bolus and started a CRI of fentanyl...the result...normal heart rate and blood pressure - ok problem one solved. Next, the bloodwork comes back and dog is in acute renal failure...severe!!! So, I get set up with all the necessary meds to treat that...(fluids, phosphate binder, GI protectant)...meanwhile though dog is still laterally recumbant and very weak...odd...so I am thinking what has caused this renal failure...there is an infection (leptospirosis) that can cause this... and anti-freeze toxicity...even though owner states dog what not around any toxins and doesnt even have any anti-freeze herself, but being thorough I draw titers for the leptospirosis (to send out) and run an in-house ethylene glycol test (for anti-freeze). Meanwhile, we do the abdominal ultrasound,,,find not much...cysts in kidneys which is common for Airedale breed (they can get polycystic kidney disease)...so it is possible this dog had some underlying renal issues, but still what caused this acute episode. Then tech comes over and says ethylene glycol test is positive...so dog is dying of antifreeze toxicity. Great...call owner to discuss options which are peritoneal dialysis (placing tubes in abdomen and flushing to remove metabolites) and ethanol (yes we keep a bottle of vodka in the clinic for treatment!!!)...other treatment is just ethanol by itself without the dialysis...both options about 2-5000 uncomplicated...dog may not recover because is very sick at this point and may have renal failure that he cannot overcome...owner decided to euthanize...and then find out later she thinks one of the builders that worked on her house may have poisoned the dog because she had taken him to court...sad story. On to disaster #2 of the night. Enter Milo, a 2yo male neutered cat who was recumbent, not responsive, and gasping for breath. I mistakenly focus on the breathing, think the cat has an obstruction...it is the friends who are watching the cat for the owner who are on their honeymoon...great...so I have to call them to get ok to intubate cat and take over airway, talk about possible tracheostomy...surgery etc...they are pissed off about the estimate I give of 800-1000 but ok that. So, I go back, intubate which goes very easily and then happen to feel abdomen and bladder is rock hard...at that point I go sh--!!!! So here I have to go explain to owners that cat doesnt' have respiratory obstruction but instead is a blocked cat who is dying...but first hook up EKG...abnormal rhythm indicative of high potassium (which we see in blocked cats)...administer IV calcium gluconate, insulin, and dextrose and start a 1.25% dextrose drip in my fluids (all this helps to shift calcium intracellularly)...unblocked the cat...then the call to owners...of course they are confused because now I totally shifted focus of what is wrong with cat....basically thought boils down to fact that they are pissed off because the money is so high...becuase this cat just went up to a 2000-2500 cat....and they are on honeymoon and so worried because can't be here....so they say they need to talk about it and not to do anything more...so I said we would just do supportive care for now...then I get a call from another sister who yells at me over the phone about cost and ruining their honeymoon and that she should have been called first...I explain legally I have to contact owners...tell her she needs to talk with them...I think I calmed her down but she made me really mad!!! Meanwhile the whole family proceeds to call in and tell me what they think about the price and the way case is being handled and how the owners honeymoon is ruined...I feel like saying I don't give a shi-...the cat is alive, I have saved it,,,now what do you want me to do from here...they ask if it hadn't been brought in how long it would have survived....I said maybe one more hour...but cat was dying....well basically it was back and forth all night and finally, sadly they decided to euthanize him...the sister came in for it (the one who yelled at me earlier) and she took one look at the cat who was still lateral and not responsive at this time and says..'oh my god he is sick..proceeds to call owner on phone and say how sick he is'...at this point I am biting back my I Told You So....and just nod and say yes he is...of course they want to save cat but I can't give prognosis until we re-check bloodwork and see...I have never seen renal values as high as they were in this cat (BUN-498 normal is 7-27) (phos 16.1)(K 9.8!!!!!!!) and still having abnormal rhythm. I would really have liked to try and see how the cat did...cats are pretty amazing....but... I understand it is a lot of money for a cat...so we euthanized...and as I am giving the injection sister says to me...he proposed with this cat, with ring around its neck...final knife twist in my heart...now I kinda understand the family's anger...but damn (sorry for the language) the cat was dying and I saved it, I am sorry this clinic is so expensive...not my fault. So, those were my two angels I made last night. Then of couse around 11pm when it is just me on the floor, the whole city of Milwaukee decides to bring in their sick pets...and as always no one has any money so it is basically a lot of time spent giving sq fluids and dispensing pain meds or antibiotics or giving anti-emetic shots...but hey...since I euthanized all my patients...I had no inpatients...second time this internship...got out of there around 4:30pm by time I finished with all outpatients because I stayed and took a few extra cases after my shift to helo out...I have to stop being so nice...but oh well I figure I am learning at least and it is all over in July so do it while I can...Well, would love to write more but time to head in to rounds...even on my day off cannot get away from that place...