Busy Days at Work

Well I have had some really busy days at work...and still have two more to go...today is Sunday and that means pure chaos at the clinic!! I have seen some interesting cases though...another dog that ate a sewing needle....got that one out with endoscopy also. The other night had an old LARGE black lab come in collapsed, I look at gums - pale white - uh oh I already know what this dog has, palpate abdomen - huge fluid wave, dog is so obese and full of fluid that I can't really palpate anything in the abdomen, talk to owner about my fears of hemangiosarcoma in spleen, bleeding out, etc...we do ultrasound and find gigantic mass on spleen, wife says euthanasia but goes to get husband..who comes in like a pistol saying absolutely that euthanasia is not an option (this is two hours later and meanwhile dog has been bleeding out...)...SO I bolus liters of cystalloids, some colloids, and a unit of blood...knock him out...scrub...and $4500 dollars later head in to surgery at 11PM!!!....Getting through the layers of fat is challenging, finally able to see abdomen and blood starts pouring out as soon as I open the peritoneum...suction on....I locate spleen...gigantic nodular mass - about the size of a softball...it has little bleeds but not huge hemorrhage...hmmmm....go to look at liver...oh shoot...riddled with small masses and then some large nodular masses that are actively hemorrhaging....contact owner...they opt for euthanasia on the table...sad story...but unfortunately this is a bad disease and why a lot of times people don't go for surgery...especially since survival after is still only 5-9months. Had a case last night...8yo male neutered Bernese Mtn Dog...came in with all peripheral lymph nodes enlarged...uh oh...I already have a diagnosis in my mind before I aspirate and plop slide under microscope...yup...sheets of round cells...lymphoma...the story gets more sad...I tell the owner and he breaks down and bawls in the room...then says his wife's father just died of cancer, his father has it, his mother is in the ICU in New Mexico for something and he is going in for surgery on Thursday...WHAM!!!...I felt really small!!...but talked a lot with him, lymphoma fortunately is a cancer that does respond well to chemo and can go into remission...he is all for chemo...so we started him on prednisone...sent out the aspirates for professional pathological review...and he is coming in today to induce with chemo...I hope he responds!!! Had a really cool cat that ended up with an abdominal mass...sad...he is still alive though, doing great, eating as soon as I placed the nasogastric tube (of course - nothing like a therapeutic tube down your nose to make you decide now you want to start eating!! oh well...if he goes to surgery he will need the tube because for sure he won't eat afterwards!!). What else...millions of ultrasounds last night...a couple masses...a couple hyperchondriac owners...but hey...I always joke with the other docs...we are always like "I can't believe that owner is spending all this money when it is hopeless"....but at the end of the day...put apache, cosmo, or webster in that position and I would drop any amount of money even if it meant I got an extra 5 minutes to spend with them...because in those 5 minutes I could hug/kiss/tell them how much I have enjoyed them/thank them for being in my life...so I try to keep that in mind when I talk to owners who just are not ready to let go because in the end...is there ever gonna be a good time to let go?? The answer sadly is no....so we do what we can in the meantime...and when the end comes... cry and mourn but don't forget to smile for the good times too!!

Let it Snow...Let it Snow...Let it Snow...

We got another snow storm here last night...and it was pretty slow at the clinic as a result. I did see a couple cases...one I admitted was a referral from another veterinary clinic...8yo MN Rhodesian Ridgeback who presented to explosive bloody diarrhea. On PE he was severely dehydrated with tachy mucous membranes but nice and pink and normal capillary refill time (push on gums and count how long it takes for the pink color to return...normal is 1-2seconds...this can give an indication of perfusion...so if they are shocky and need fluids it would be prolonged)...his was normal...rectal revealed frank blood, he splinted on abdominal palpation (was extremely painful)..remainder of exam was WNL (within normal limits). Admitted him, ran coagulation times, CBC, electryolyes (rDVM had done a chemstry that was normal) - bloodwork came back fairly normal - except PCV/TS were elevated (54/8.0), he had a L shift (immature white blood cells high), and his cPLI (canine pancreatic lipase - test for pancreatitis) was abnormal...however pancreatitis was not the first thing on my list although it could definitely be a factor as well. I was thinking more HGE (hemorrhagic gastroenteritis) - this is basically a disease where the dogs are really dehydrated, they have elevated PCV/TS, and usually are having blow-out bloody diarrhea and sometimes vomiting as well. We did abdominal ultrasound and it showed gas in stomach and intestines and decreased motility but not real other abnormalities. So I started him on rehydration rate of fluids, metronidazole (anti-diarrheal antibiotic), unasyn (another antibiotic - because of the L shift), cisapride (for intestinal motility), and fentanyl CRI for pain control. Also placed a nasogastric tube and started trickle feed of Resorb for enteral nutrition (gut nutrients to keep it from sloughing even more...keeps gut cells happy!!). He has fecal cultures pending that I submitted to check for other fecal pathogens (salmonella, campylobacter, clostridia, shigella). We will see how he does...hopefully he does well. My second case was an old hunting lab who had pain somewhere that the owner couldn't fine where...PE was fairly normal, normal neurological examination, but severe pain on dorsoflexion and L lateral flexion of the neck. Sedated, did cervical radiographs, didn't see nothing, placed him on strict cage rest, no neck leads, tramadol, and rimadyl (NSAID). I think it is just muscle pain in him because neuro was normal and the owner mentioned that the shock collar he has on for the invisible fence was malfunctioning so I think the dog got repeatedly shocked and has muscle trauma due to that...poor dog!! My next case was a pitbull who came in for a red eye....now there are about 8 causes of red eye (glaucoma, scleritis, episcleritis, keratitis, conjunctivitis, trauma...)...So I do PE - aside from the R eye (OD), normal PE. I sedated dog and then did my fundic exam (to look at retina, optic nerve), this was normal. I then checked pressures (tonometry) and they were normal (13mmHg). I then stained the eye with FES and checked for a corneal ulcer - there was none. When I was examining the globe however, there was a lot of scleral hemorrhage and bruising on the globe - looks like a traumatic, blunt hit type injury. So I prescribe steroid drops for 3-5 days (because there is no ulcer) and then when I take dog out to owner he mentions that earlier he had to tackle the dog when they were walking so the eye was probably bumped at that time. Poor dog, but should heal up just fine. My last case was a 2yo MN orange (!!!!) cat who was straining in the litter box. He came back as a stat because of possible urinary obstruction...but I palpated bladder and it was very small, soft. So I talked to owners about different causes of FLUTD (feline lower urinary tract disease)...urethral obstruction (which he still could be in the early stages of), UTI, stones, idiopathic cystitis....discussed running bloodwork, urinary ultrasound, and urinalysis....owner agreed....everything came out fairly normal...did prescribe a couple days of pain meds and antibiotics in case of infection....but he probably is one of the idiopathic cystitis cats (meaning we don't know what causes it but something causes them to get bladder irritation and they end up with these straining episodes) Discussed management as being increased water consumption and pain medications....talked about switching diets to canned urinary diet because he did have crystals on the urinalysis. He went home...but he was a really cool cat...talked and loved to be held....And that was my night. Now I am heading back in for day 2/5. It is Friday so I am sure tonight will be busier as all the regular veterinary clinics transfer their disasters over to us for the weekend. But, I am happy because after this 5 day shift I am finally on the ICU shift for basically the rest of my time here....happy times coming off the floor..yay....actually get to manage cases!!!! Alright....I have to head out to work.

Tis the Season...

Ahh, it is that time of the year...when the snow comes and Santa's workshop is in full gear...and we get to put up pretty decorations all around the house. So I did some baking the other day on my time off - some pretzels with white chocolate and some chex mix - I still have to make my puppy chow and then decide on one cookie to make. And today, I went and bought myself a little tree and decorated my apartment...and made some egg nog coffee drink...mmmm! So, make sure to scroll down below because I have posted some pics of my decorations. And may I say that the kitties love this holiday as well...Webster and I were so excited setting up the tree....he helped so much....I put the tree up, he tried to knock it down...I put the bulbs on, he batted them to the ground...oh but he was just so happy to have a tree back again!!! So I am finally on a couple days off...2 and then Wed on call. Lets see, what did I work this past shifts? I worked Wed-Fri, Sun. Wed-Fri were l-o-n-g shifts of about 19hrs each!!! I had some very cool cases though. Had a neck abcess - huge about the size of a soccer ball--had to go in and open in up surgically - I cut into it with my scalpel and pus just started pouring out!!!! It was very awesome...yet grotesque at the same time!!! So I flushed that out and debrided the tissue inside the abcess pocket....very carefully as I was looking straight down at trachea, esophagus and two pulsating jugular veins...oh yeah...and I was all by myself...I have to say though that it was great!! Placed two penrose drains on each side of the neck (so that I could close the wound yet it would still be able to drain.). What else, last night I had a dog that swallowed 2 garland strings of popcorn and fruit loops...and the needles that were attached to them....oops and ouch!! So, I took an x-ray first and the two needles were sitting right in the stomach so we did endoscopy and pulled them out that way. The stomach was pretty ulcerated afterwards so he will go home on sucralfate and pepcid!! Saw a couple vomiting diarrhea cases of course....a couple had pancreatitis so admitted, fluids, pain meds, antibiotics, NG tube for feeding. One was a hemangiosarcoma (cancer in the spleen)...sad case...owners were totally not expecting that but luckily on my PE I had felt fluid in abdomen and a huge spleen and so had talked with them about that being a possibility...and unfortunately I was right! What else did I see?? We had a lot of stats....dying cats...2 we saved with CPR!!! One went on a ventilator and then came off and is still alive, the other we saved and brought back to life and then owners couldn't afford further care and so we had to euthanize....very sad after we worked so hard to bring it back to life and actually did it!!! Saw a big parrot with a bleeding tail blood feather...so I yanked it out....crisis averted!! Saw a torn toenail...sedated, yanked it off, bandaged it, dog went home....another life saved!!! Yes, ER is exciting and you get to see a lot and maybe I will miss it a tinge but on July 8, 2008 I do not think many tears will be falling...!!