Hard Lessons Learned

Hi...first have to apologize because my computer crashed last week and so the 'Geek Squad' has been fixing it for me and luckily it is back and functional and have not lost anything that was saved....which is awesome because my paper info was all on there, pictures (which are non-replaceable). So work has been..weird..messed up...so I've come up with some lessons that I have learned these past 4 days while I was working in the ICU (which I love by the way...reinforced how much I hate the triage floor!!!). LESSON #1 : Life IS hard - deal with it...and if you must quit...don't burn bridges!!! So, we are down one intern starting next Monday...yep she is actually throwing in the towel and quitting. To be fair, she does have a couple health problems she is dealing with, however for the most part the main reason is because this internship is hard as hell, it was never what she wanted...so it seems weird that she would take it in the first place...but also, people are mean to her at the clinic, I have noticed this and it makes me really mad...she is a good friend of mine and I hate that people are always talking so bad about her...I think they are realizing now that we are friends because they say a lot less around me now about her...which is good because I don't want to hear their mean comments anyhow. I WILL still stay friends with her because she is so nice and we have a fun time when we go out. She is staying in Milwaukee to work, her boyfriend is finishing vet school at UW. BUT...despite that...I am irritated becuase the schedule is out thru Feb...and now it needs to be re-done...what that means is the rest of us will lose days off and end up working more, more on-calls....that makes me really irritated!! The schedule I have now was going to be perfect for allowing me to travel to different places to interview for residencies...oh well though...life goes on... LESSON #2: Do NOT drink and drive with your dog!!! Yeah, this is a very sad story. On my Sat. night shift in ICU, around 2:30AM we got a call from the Milwaukee Police Dept. saying they were bringing a dog in that had been involved in a car accident...hmmm...it of course was called as a stat triage...it comes back on the stretcher and it is this big, beautiful brindled bull dog...with no pulses, no heart beat, not breathing...DOA. So, I go out to talk to the Police officer...apparantly when they arrived at the scene the dog was found pinned between the front seat and the dashboard...he was breathing at that time but had blood running from his mouth, he started agonal breathing on the way to AEC and was dead by the time they arrived here. The worst part was the it was a mom's dog and her son had been driving drunk...who knows why at 2AM with a dog in the car...and crashed into a light pole. So the son was in critical condition, they did not know if he would make it...and I had to call the mom and tell her her dog was dead. That was a sad phone call - one of the hardest I have ever made... The thing that makes me cry is that the dog was probably so happy to be going for a ride in the car...and then he died because his owner that he trusts to take care of him was driving drunk!! Bad decisions, hopefully if the son makes it this will wake him up a bit... Please...don't drive drunk with your pets, and if you take them in the care...seat belt them up because they are no different than people... LESSON #3: When you leave for vacation - Hug and Kiss your pets as if you will never see them again...because you might not!! Two really bad, sad cases I have now had of owners that left on vacation and returned to find their cats dying. One was the blocked cat I discussed in an earlier blog. The other,another cute little girl kitty who the pet-watcher described as hiding alot and so she never really saw the cat alot. When the owners returned, the cat was under the bed, severely dehydrated, not eating, laying on it's side. She brought it to her vet who did some preliminary bloodwork and found severe renal elevations and so it was transferred over to AEC. My ternmate admitted the case and I inherited the disaster later that night when I came on shift in the ICU. The cat had acute renal failure...was more than 10% dehydrated (this is raisin-like for those who don't know), and had renal BUN of 386 (normal is less than ~27), Creatinine of 14 (normal less than 2.0) and Phosphorus of 27!!! (yes I kid you not!!! normal is usu less than 4-5). Oh my god...wait...it gets worse. The sodium was 190 (normal is around 140-150), chloride was 170 (normal around 120), potassium was 5 (this is high end of normal). The cat was started on rehydration fluids to try to both rehydrate and also to flush out the toxic high levels described above. It gets worse...with sodium and chloride that high, this means the blood is hyperosmolar (think of it as really salty) - what this means is that the fluid in tissues is then going to tend to go into the blood to dilute it....this is especially bad in the brain...so what the brain does (because the brain is oh so smart and really only cares about its own survival) it creates substances that make it hyperosmolar as well so that is does not lose fluid and still can get the blood supply it needs. OK, go brain...however enter me with my fluids....with a cat like this I want to push as many fluids as I can obviously because I want to flush out the toxins...but now I can't because I am adding fluids which will dilute the blood (which on one hand is good) but for the brain...now it has produced these substances that will stick around and it is matching the blood, the fluids I add then will tend to leak out in to the brain causing cerebral edema...shoot!!!...so now I have this cat who desperately needs high rate fluids, but I have to push my fluids slow because you must only lower the sodium and chloride by so much per hour to avoid fluid in the brain. So, I push fluids over ten hours, normally I would push over 4-6hrs...and recheck bloodwork shows the values are not dropping, they are in fact rising. Now I know I am not pushing fluids as fast as I would like but this cat is still on about 4x maint which is a lot...and which should still be working to bring values down. So something else is going on. I reassess the cat and find that after being on fluids now for 7hrs, the bladder is no bigger then when I first met the cat, and it has not urinate...uh oh...I told you it gets worse. The cat is not making urine. So not only does it have acute renal failure, it has anuric acute renal failure....this is bad, it means the kidneys are not working at all. There are medications we can give to see if they cause the kidneys to produce urine (diuretics) however in this severely dehydrated cat, that is not a good option at this time. We do ultrasound and kidneys have some fluid around them and some minor abnormalities, but otherwise nothing huge...the rads also show nephroliths, but this could be an insignificant find. So, I get on the phone with the owners and say that the cat is most likely going to be one that needs dialysis - thousands of dollars - owners say they will not do that... I say then we at least need to place a central line (catheter) so we can monitor pressure which will allow us to push fluids faster, and she needs a urinary catheter in so that we can monitor if she is making urine. I give them a really poor prognosis, they fight over the phone with each other and then decided to try this first and see if we can get values down. So that gets placed and another 4 hours go by and I am in with the cat as the techs have just drawn blood...I notice cat is panting so I am listening to it and HR is 110 (normal for cat is 180) so I have techs hook up an ECG and there are huge abnormalities...before bloodwork is even back I know that values have increased again just from my PE and my ECG....I am suspecting that potassium is now at such dangerous levels that it is causing abnormalities in the heart....bloodwork comes back and confirms my fears so I get on the phone with the owners and they finally decide to euthanize, they get out of bed and come in. And, that was one of the saddest euthanasias I have ever done...the woman was just bawling and wouldn't stop...sad. OK - lessons done, dont think I learned any more. Work was super busy this weekend..and of course Saturday I had the pleasure of an extra hour at work because of the time change...I ended up doing 18hrs on both Saturday and Sunday...so needless to say I just came home and crawled into bed and slept half of my first day off...now today I am on call...I try to ignore the mess in my apartment when I get home..by mess I mean things knocked off of every table and counter, napkins shredded, mail shredded, any other paper shredded...this would be courtesy of my cats who do not appreciate it when I am gone for 18 hrs in a row and they are very 'vocal' about telling me this. If not for them however, coming home wouldn't be half as great. They love me ( or at least this is how I interpret it!!!)...it is like a huge train in the house from the minute I walk in the door...me and then my two little shadows following close behind...they sit on the edge of the tub while I shower, watch me brush me teeth...webster even sits on my lap while I go to the bathroom!!! and then we all go to bed...Webster gets the left armpit and Patches the right. The funny thing is Webster has always cuddled in my arm, underneath the blanket with his head on my pillow. Now however, patchie is doing the same thing.... and they love to sit on the couch...webster will help me send emails...throwing in an occasional line of jibberish which I don't understand but which I am sure he is trying to say something important.!! OK, well, sorry I have been a way for a while as I have not had my computer. Hope everything is going well for everyone...hopefully no one has any snow yet!!! Can't believe winter is so close....smiles