And then you save one...

All is restored in the veterinary career of Ang...why??...because I recently had a great success story, a case I handled all on my own...made the correct diagnosis, set up treatments, and really did save a life!! Here's my story. It was during my am shift last week...got a call from a referring veterinarian about a cat that they were sending over that was in respiratory distress - immediately flags went off in my head and I was thinking lung or heart disease. rDVM says they saw the cat a couple days earlier and took rads that were normal but thought hairball and so gave some anti-inflammatories...I can't say anything but am banging my head against the wall on the other end of the line. Why? Well if it is heart failure then the kidneys already are not perfused and are not getting the blood they need - add on an anti-inflammatory (Meloxicam) and poof..goodbye kidneys! Oh crap! So anyhow...cat comes over...beautiful male neurtered rusty orange Himalayan named Meiko!! Ok..first look and I fall in love with this cat who is open-mouth breathing yet still purring and trying to rub on me. I listen quick and confirm my thoughts...harsh lung sounds, gallop rhythm on heart auscultation, poor pulses, open mouth breathing...I place cat into oxygen cage and go to break the news to the owner....So your cat is in heart failure...no it's not a hairball...here's what we need to do...$1200-1500. They take a minute to discuss and decide they want to at least confirm heart failure - if it is they say they will likely euthanize...sign estimate...ok start diagnostics. Full blood work looks beautiful...good it is not due to other underlying disease but damn this just supports heart failure. I look at radiographs that rDVM called normal - NOT NORMAL!!! Lungs look horrible - large amount of pulmonary edema, heart enlarged -- shoot! Get catheter placed and get cat started onto lasix (diuretic), nitroglycerin (venodilator), and torb to calm. Later able to get a VD radiograph of lungs - yup--still fluid in lungs, still huge heart, huge cardiac veins. Ok...echocardiogram confirms cat has hypertrophic cardiomyopathy. Start benazepril and later atenolol because HR elevated. End up placing onto lasix CRI. Call owners and convince them to give cat overnight to see how he responds to the lasix - owners agree to this. So I hand cat over to Dr. Green for overnight care. I come in am, cat is out of oxygen and breathing normally, lungs sound great!! Yay!!!! I check bloodwork and as expected electrolytes are up and BUN (kidney value) is up - likely due to the diuretic. I start a maintenance rate of fluids and tell owner I would like to keep overnight again - they ok. They come in to visit and are so happy...they thank-me so many times...then comes the question I knew was coming...owner says " so I think our vet may have misdiagnosed the cat and we are thinking we should get all our money back from them" I think quick knowing I want to say - yay they did!! almost killed your cat by telling you it had a hairball and that was why it was breathing heaviy...come on even I didn't have to go to school to know that sounds like quakery. But instead...as I have to keep up good relations and not get others into trouble..say the following : "I cannot say what Meiko looked like when your vet examined him 3 days ago. We are sending over records of his visit here so your vet will have them. What I would do is just go in or call your vet and discuss it". The bad thing for that vet is their physical exam that is written in the record practically screams heart failure along with the radiographs they took!!! Good luck with that one! SO...that was my happy case. For one it was a cat and I love love love them...for two he was the friendliest smoosh faced Himalayan around...and I saved his life...so that his people can enjoy him...even if it is only for a few more months. Maybe I do like this job!

I can't think of a title for this one...

Oh where to start back up again...I have not been writing as much I know I think because my job is getting to me and so ends up not as exciting anymore. But hey...time is slowly coming to an end. I finally got the last July schedule where I see finally in print my last day of July 8 2008. Cannot wait!!! Ok, well I guess I can talk about a few interesting cases I recently saw. It was a referral I saw the other day...came over for anemia but has had nasal congestion for a couple months. So when it came over he was all gurgly and very pale. He was coughing up blood and dripping blood from his nose (epistaxis). So, my thought was something going on in the nose, now is bleeding acutely and causing the anemia. Top differentials: cancer, cancer, cancer, fungal infection, foreign body, cancer. Did I say cancer? So, I got him stabilized, gave him a blood transfusion. The next day he had a CT scan and rhinoscopy procedure....final diagnosis? Yup you guess it...cancer. He went home, probably to pass away as in dogs with nasal tumors, radiation therapy is the top choice - has to be done at UW Madison - of course is wicked expensive...and had very bad side effects on other tissues surrounding the nose (they slough the skin in their mouths=mucositis; their get dry eyes=keratoconjunctivitis sicca; the brain is affected) all of this is because in dogs, we do not yet have the tomotherapy like in humans where you can concentrate the beam on a very small piece of tissue. Sad case. My second case of that same night...a 3 year old (keep in mind the young age) black lab. Has had chronic GI issues for the past month, weight loss, and now she came in flat out, in shock, very dehydrated, pouring liquid bloody diarrhea out of her rear end. I palpate her abdomen and it is very painful and I feel a mass-like lesion mid-abdomen. My first thougth was an intussusception (when one piece of intestine gets sucked into another), cancer was further down on my list. Got her started on fluids and she starts having ventricular tachycardia - converts with lidocaine so I place her on a CRI but she is still throwing fairly consistent VPCs (ventricular premature beats) - is this due to her GI disease or does she now have heart injury as well? Who knows, never got to figure that out...why?...because ultrasound showed a large abdominal mass. We recommend surgery, owners think about it but in the end decide for euthanasia as it is likely not anything good. They allow necropsy so I go ahead and do the autopsy...final? Giant mass encompassing entire root of mesentery and all intestines, then another mass actually surrounding the jejunum (intestine) and obliterating the lumen (opening) - the remainder of the intestine distal to the mass was black...yes, black dead necrotic. Sad...most likely diagnosis....Cancer again. Sad story number two of the night. But at least my next case I saved, for now...it was a ferret that came in non-responsive....checked his glucose and it was only 32----yikes!! So I got him some insta-glucose and rubbed it on his gums and....insta-pet again!! So we hospitalized him on IV fluids with dextrose supplementation. Diagnosis...insulinoma - very common in ferrets - its tumor of the pancreas that secretes insulin thus causing hypoglycemia. In younger ferrets, can sometimes do surgery...usually managed medically with steroids. Anyhow, prognosis is about 6mos to 1 year but still. Ok, that was pretty much my Monday...I have had the last couple days off, luckily did not get called in...now spending my last day off trying not to think about going back!!

Happy Cinco de Mayo!!

Well, ok here I am back again mom!! I know I have been away, like I've said previously I have found this profession suddenly...challenging for me...but alas I think that it may be just this internship and once that is over (in 1 month and 3 days!!!) I will be ok again...I hope because not sure what else I would be very good at. Hmmm, so what have I been up to at work?? Fun stuff...went in on a splenectomy today with our surgeon - sad though because it was cancer and had spread throughout the whole abdomen...so we actually euthanized on the table. Saw a Rottweiler the other day that had gotten hit in the head with a baseball and had bit through its tongue - was bleeding all over the place and had to sedate it quick and suture up the tongue - pretty cool thing!!! What else have I seen...placed a cast on a cat with a broken leg, repaired some bite wounds, saved some, lost some...can't think of anything cool now but I will try and write more later and try better to keep up with the blog. Exciting thing though is it looks like we will be warm weather bound soon...can't wait...I am tired, have been working all day so am going to head to bed.

Sometimes it's the things that don't go right that end up making life perfect in the end...

Well, I know I haven't written in a while... I could make excuses and say I have been busy, which would be true but that is not the whole reason I have not written. I started this blog excited about my profession, fresh out of school, interested in everything that I was doing. Then afer a while things happen that make you open your eyes and look around and you realize you've ended up somewhere that really isn't what you thought it would be and the little string that you were holding on to that was getting you through ends up breaking...then you are falling and you see all these loose strings hanging around that you could grab to stop the fall...only you have no idea which one to grab because what if you end up unhappy again....so you keep falling and hoping that the right string will just wrap itself around your wrist and catch you. Yeah...life just doesn't happen like that. I should explain. By now you all know I didn't match for a residency position. So for me...I have spent this year in an internship I really do not like and for what?...nothing because the whole reason of it was so that I could end up in a residency position. So, now it is making it really hard for me....even though I only have 3 months and 1 day until I am done here. And so now I think..."now what?" I know I don't like ER med....don't want to do general practice...have been offered an advanced internship in Critical Care with a residency guarantee the next year in Tampa, Florida...and am waiting on an internal medicine residency position in LA which more than likely I will not get...arghhh!!! Honestly...I feel right now like I could walk away from this field and not care...and that is scary because it is really all I have ever wanted to do (minus a short stint where I thought I might want to do Marine Biology)...I am hoping it is just frustration and it will pass once I am done with my internship here. I had so many goals, dreams and now it doesn't seem like they will happen....which I know is life...it just takes a while to get used to. SO...I apologize but with thinking about all of this and putting all my effort into getting through each shift and each day... I really have not felt like writing about things. BUT alas...the warm weather is near...my time here is ticking...and I am getting more used to the fact that a normal job with normal hours may not be such a bad thing...so here I am back again...sharing my stories...and trying to get back to making it about the animals and not about what I want...because if I do that then I can't hate my job...because really... how can you not want to help the little furry beasts!! Especially since at the end of every day...no matter how horrible my day was... I open my apartment door and my two little burdocks are there waiting to stick to my leg and follow me wherever I decide to take them...

Three days and counting...

Ahh finally finished with another shift and onto my days off. Want some updates? Ok...Des, my big fatty liver cat...ended up transfering to his rDVM for continued supportive care...understandable as the bill was pushing $3000. I am really afraid that his underlying cause is probably intestinal lymphoma...it just fits him exactly with his clinical signs. Poor guy. He was so cute, every morning I would make him a new little kitty bed and he would snuggle in there... I would love to know what happens with him but as it is...he is what we call "lost to follow-up"...in other words...he went to his vet for the care and I will never know what happens...you see why I want to go into internal medicine?? Because then he would be coming to ME for the care... It's really frustrating because he was my patient the entire 4 days in the hospital, I diagnosed the hepatic lipidosis, got the feeding tube in, discussed needing biopsies of intestines for final diagnosis, set up his medications and treatments...and then he transfers away and someone else will continue my plan and I don't know what happened? Did my plan work? Was I right, did he indeed have underlying intestinal disease? I would have started steroids...will they? There is so much more that can be done...will they do it? When he recovers and is doing great I will never know. If he ends up having lymphoma or IBD...will they give him the benefit of steroids? Because amazingly cats can do very well with this...or will they euthanize without knowing this? Arghhhh!! I think the frustrating thing is that there is so much more we could have done to figure out what was going on and then when we did there are treatments that really could have helped him. Oh Des...I'll pray for ya buddy. You need to know him...he was a very cool, very LARGE cat...his real name...December...Des for short. What he looked like...hmmm...picture Jen's cat Inda...only 3 times that size and FRIENDLY!!! He was, is a very handsome cat. OK, I know...I need to be happy that I did what I could and helped him for the short time that I did but it is frustrating knowing all we could still do....3 days and hopefully I will be on my way to getting to do that! My next patient...Zippy the dachsund who ate the feet off of his martian toy and they unfortunately walked themselves into his intestines and could go no further so they stuck....so he vomits, has diarrhea, ends up getting surgerized....and there they were, the little feet....stuck right in the center of his intestines. Unfortunately though...they must have tried to kick their way out because the intestines were black (aka...DEAD!!!) and so he had a resection and anastamosis (that whole section of bowel taken out...then match the ends back together and sew them back on). He was doing good, now is vomiting again so I am really concerned he may have dehisced (leaking at the sites of anastamosis)...so he was getting an ultrasound when I left last night to take a look at the sites. In talking with the owner...poor girl she was all stressed out studying for her pharmacology final....she is in pharmacy school...crying...about my age....pregnant....I felt so bad so spent a lot of time talking with her. She said he ate the toy in January....ouch...it is almost March!!! Ummm...yeah...not good for our little Zippy friend...that means intestines were probably a lot more angry than they really looked. I fear for leakage however did talk with her about that fact that it could be severe ileus (intestines not moving/contracting) because they are so pissed off from being obstructed for 2 months....in that case...it may take a while for them to start moving again....so we will keep our fingers crossed that that is what is going on...especially since bill was at 3500 as of last night!!! I had another seizure dog last night....a Scottie named Shadow...9 years old and first time seizures...yeah....you are thinking brain tumor right? Me too...epileptics in dogs are usually under 5 years of age at onset of seizures. Mom and Dad...very nice, retired old couple...this dog is their life....the kicker? They have a daughter with epilepsy who is still struggling to get seizures under control!! So they are pretty scared. Did MRI yesterday and....drum roll....ABSOLUTELY NORMAL!!!! Yay Shadow dog!!! Breath a sigh of relief and consider yourselves lucky that you have an epileptic dog who just happened to be out of the normal mold and develop it at an older age. (Most likely if he is truly an epilectic he has had seizures previously that owners either have not witnessed or they have been silent (no outward signs)). Of course, he could still have inflammatory disease (remember the granulomatous meningoencephalitis) or infection. But for now, he got started onto phenobarbital and we will see how he does. This case makes you realize how important it is to always have hope..some would have said why waste the money on MRI (2500)..old dog...first time seizures...brain tumor most likely...should just euthanize...but hey...no tumor...happy dog who is still alive...sometimes hope (oh yeah and of course a little bit of money) can go a long way!!! Here's an interesting case for you...Foster is a 7 yo male neutered Australian Shepherd. He was living a happy life, got up yesterday morning around 5am and said hey...let me outside...ran outside, did his thing...comes back to the door with blood all down the front of himself...lays on the floor and seems kinda lethargic. Refuses breakfast which is abnormal. Owner brings dog to rDVM - blood work shows some mild anemia, mild thrombocytopenia (decreased platelets), elevated BUN (but normal creatinine). Someone looks under dog's tongue, sees some mass or something, says that is what caused all this bleeding, sends dog to AEC for biopsy of the mass, possible blood transfusion. OK, enter Ang. Dog is bounding around the room, gums are pink, physical examination pretty normal...except for black stool on rectal exam (yep you are thinking what I am thinking...blood!!!!) Oh yeah...nothing under the tongue but this tiny small grey mass...not currently bleeding...no blood in mouth...I think tongue mass....NOT the cause here. But, owner is convinced of course because rDVM said this. So, I say the following. I understand your concern over the tongue mass...it is very small and I am not convinced this is the cause of the bleeding. But, I will definitely get a sample of it and we can send it out and see what it is. However, ( I show him the black stool)..I am more concerned about this. This tells me he is bleeding in his GI tract somewhere. I ask about any toxins, rat poisons, NSAIDS...no exposure to anything. I say, with the elevated BUN, which is a kidney value but also can indicate hemorrhage...and with his creatinine values being normal...this tells me that he has GI bleeding somewhere. I am concerned. The blood work, I say his anemia is mild right now (32%) normal is above 38%. His platelets (189,000) normal is above 200,000. I say we need to get him admitted, get him on fluids, run coagulation profile to check to make sure he does not have a clotting disorder, and peform an ultrasound to look for cause. I discuss coagulopathy, gastroenteritis, infection, inflammation, cancer, pancreatitis, toxins, GI obstruction. Owner is a little financially constrained so I say lets do this...We will admit him for the day, run a coagulation profile and electrolyte panel, aspirate the tiny tongue mass (VERY VERY important as this is the owner's main concern even after hearing all I have just told him -- forget to do this and he will complain to AEC for sure), and perform an ultrasound ...$400-600. IF we find something and he needs to stay, we make a decision at that time and need to increase estimate. Owner agrees, I get dog admitted. He leaves but not before reminding me one more time about the damn tongue mass!!! Honestly, the tongue mass is likely a red heron (incidental finding that is not the problem but has actually brought him to AEC and now has helped to find the real larger problem). So, his coagulation times are normal...good. His electrolytes, concerning as his lactate is 6.3 (normal is under 2.2). What does this mean? Liver failure, severe sepsis (systemic infection), decreased tissue perfusion, extreme tissue necrosis. Most likely cause in this dog? Decreased tissue perfusion or tissue necrosis. And then my shift was done....I do not know what they will find...whatever it is...is not going to be good at all!!! That is it...there were a lot more smaller cases but these are the most interesting. Then my 4 days end...I turn over my patients...and I leave...and I am not sure what happens next. Yes it is good to get time off...but I hate leaving cases unanswered...I hate not being the one to find out what is going on (maybe that is OCD, maybe it is snobbish...) but it bothers me...you spend all day figuring things out and then....you leave...and maybe you never think about the case again...me, I wonder if my treatments worked, I wonder if my diagnosis were right, I wonder if my patients will recover...I am a perfectionist when it comes to my work, I am obsessive compulsive over my cases, I become way too attached to my patients (every cat becomes Web and Patch, every dog is Cosmo)...maybe I should lighten up, not care so much...but isn't that when it becomes time to find another job...I would like to think that is what makes me a good Vet...and THAT is what keeps me going on at his job and looking forward to 3 more years of hell...I may hate the people I work with or the place where I work...but I could never hate my patients or the concerned owners attached to them (yes, even the crazy ones)...my life is helping them, whether that means I cure them or I give them their halos...

Cancer...Unescapable

Well, I have had some sad cases as of late...lots ending in cancer which is sad. Today I had a little Italian Greyhound patient who came in initially to our oncologist and was diagnosed with a lung carcinoma. I unfortunately had to give the owners that news and then set up a CT scan of his chest and abdomen to better define the nodule...in the hopes that it was a solitary nodule and may be operable. He came in today...cute little guy...CT scan unfortunately revealed that the cancer had metastasized not only to all of the lymph nodes in the chest but also to the chest wall...very sad...I had to tell the owners that and they were very sad on the phone - as unfortunately surgery will not remove the disease...you wanna know the little dog's name? Happy...his cute little Italian Greyhound name was Happy...ironically sad. My other patient who I had operated on for 5 hours this past week - to remove a mass from his back - removed half of his back....it ended up to be a mess of a case in more ways than one but I refuse to go in to that...let's just say for those who kno what I am talking about...I did get an apology from my boss regarding the whole case!! So anyhow...his mass came back as extremely aggressive skin carcinoma!!! Not good! Means ultimately he needs another surgery to remove the skin, his scapulas (yes!!) and the spinous processes of his vertebrae (!!) -- No I do not think they will choose to do that. All right, that must be it right? Nope...this morning around 4am I saw an old dog with vestibular disease (think of vertigo in humans)...he had a right head tilt and his eyes were moving very fast in a vertical direction (this is called vertical nystagmus) - and usually is indicative of central vestibular disease...what does this mean??? It means the brain is involved! Discussed with owners MRI/CSF, infectious titers, and imaging of chest and abdomen to r/o other causes, tumors, vascular events (stroke, hemorrhage), etc. Owner declined, did allow full blood work and I started empirically onto steroids (in case of inflammatory disease - such as granulomatous menigoencephalitis which is an inflammatory disease seen in animals) and started antibiotics (TMS - as this crosses the blood brain barrier (meaning it gets into the CSF fluid) and also it is efficacious against many of the infectious agents we may see causing neurological disease). So, I get blood work back and liver enzymes are elevated so I call owner and reccomend ultrasound as I am worried about liver disease. I also discuss cushing's disease, diabetes, hypothyroidism (as these can cause elevated liver enzymes and may predispose to forming clots that may lead to stroke). Later in the afternoon...neurological signs are completely gone...hmmmm. So ultrasound shows large liver mass!! Oh no...so here is most likely what is going on...that is likely neoplastic and yep, probably has spread to the brain. So I discuss with owners that surgery is only option...discuss liver biopsy to find out and then CT scan to define mass and allow for surgeon to evaluate how best to remove. Owner is hesitant so I suggest we do a liver biopsy - which we can do through the skin (percutaneous) with the ultrasound machine...these will take 3-5 days to return and will give them time to spend with her at home and talk about wether or not surgery is an option. If it is, we go on...if not then at least they have a confirmation of cancer and maybe this makes euthanasia an easier, less guilt-ridden choice. So that is what he decided to do. Cancer 3, Ang 0. Ok, moving away from that horrible disease, I am currently taking care of this large cat name Des...he has hepatic lipidosis (fatty liver) from not eating (liver metabolized its stored triglycerides and these end up circulating and back in liver causing accumulation of fat). Kitty is glowing yellow (jaundiced...we call it icteric). We placed a feeding tube in him last night...he is not doing so well, very lethargic, not moving around much. I made him a bed today because he was curled into his litter box with litter stuck in his mouth...so I got him a little cat bed and some blankets and he snuggled right in. We still do not know what caused him to have this episode...I am suspecting GI disease like lymphoma (yes cancer again) or IBD. Biospies of the intestines will probably be needed next...unfortunately bill is already over $2000...but owners are willing to keep going...and hey, this is a bad disease but with appropriate supportive care and the funds to do it they can do well... and I must say....this is totally an internal medicine case and I am loving it!!! I also was taking care of a seizure pet the last couple days...Huskey (of course they are bred for seizures for some reason!!!) and he paced for 2 days straight in his cage, rubbed his nose raw, and finally fell fast asleep right before his owners came to visit...goofy anxious huskey dogs!!! I had a cat the other day Boomer...he was to put it nicely...a bastard!!! Had to knock his butt out just to open his cage door....he has diabetes and accidentally got overdosed by his owner on insulin...so he came in flat out and with glucose supplementation...bounced right up...did fine...sent him home. So..patients aside...only 6 days until I find out the rest of my life...it is scarey but exciting as well...east coast, west coast, midwest??...will I be a resident or not? Hmmmm.... stay tuned. I find out on Monday March 3...unfortunately I will be working, but I check at 7am and I will definitely email and write a blog to let everyone know the results....

Renal Failure Claims 2 More of My Patients...

I do not know why I claim to like this disease...it is brutal, it takes lives of innocent little kitties and doggies who have done nothing but try to drink enough to satisfy the kidney beast's thirst!!! Why do I end up with all of these patients? Ok so I guess I do preferentially select to take on those cases...additionally everyone knows how much I like a good poor prognosis kidney case...so I end up with them that way as well. So, I lost another little female kitty to renal failure today...granted she was 18 years old and so had lived a pretty good long life!! But, she just had used up all of her 9 lives on her kidneys and so had no more to give today. Her name, Gabby...what did she look like? Apache minus 20 pounds...yes she was skeletoneske...and she was laying in lateral recumbancy...not able to get up...not able to move around much. Her BUN was 312 when I met her and 314 when she left this world (yea that is after a day of IV fluids and yea that is even more elevated). Unfortunately her old little kidneys had lived their 18 years and just could no longer give any more. Owner decided to let her go, I discussed peritoneal dialysis but with a poor prognosis that function would return..the owner elected to let her go. As I was waiting for the owner, I was called in to the ICU by the technician because she was breathing really heavily...she then gets up and walks to the water dish, sits down, and starts slowly drinking...then when all her energy was gone she collapsed...face first into the water dish...so I had to reach in a pull her little head out. It was very sad. Mom then came in and we spent some time petting her and talking about her life...then, with one injection mom said goodbye to her friend of 18years and Gabby Kitty got her halo. Ok, deep breath, and on to my next renal failure...a Sharpei dog. He most likely has amyloidosis (it is genetic for these breeds)...and so really likely not a chance. I talked a lot with the owners because he was not urinating all day - over 12 hours...discussed placement of a central line to monitor his pressures, discussed urinary catheter placement to monitor urination. Owners were really money constricted but really did not want to give up if there was any chance. I discussed placement of a urinary catheter because at least then we would be able to see if he was making any urine and that might help with prognosis. Owners agreed and I placed one around 2pm....after 21 hours of high fluid rates...and urine slowly dripped out the end of the catheter...not good...all in all, he ended up not producing as much urine as he should, got a little marshmallowish, and started to vomited profusely. Owners elected to take him home and will euthanize tomorrow with their vet...so, he too will get his halo. On the positive side... I did send home a working dog (owner is deaf). Her name was Peaches and she was a Golden Retriever who had exploratory surgery to break down adhesions that had formed within her GI tract...not good because since we are not sure how they formed, they may likely form again. But, she did go home for a little while...to help her owner...painful from surgery but willing and eager to be united with the human she do fiercely protects and leads safely through life...for a little while longer... And then there is Zach, my African Grey patient...he cares for his owner in a more unusual way...by giving her a reason to smile despite the fact that life has been unfair and taken away her ability to walk...Zach does not see this though as he sits lovingly upon her shoulder and she wheels him around with her in her wheelchair...he knows that they reason she wakes up every day is to listen to him and his 4 other bird friends he lives with (a parrotlette, a macaw, a cockatoo, and an amazon parrot)...and so he strongly fights to live, despite the fact he has a bad fungal disease taking over his body. And there is Hazel Pabst...yes that is Pabst Beer...she is indeed a heir to the Blue Ribbon!!! Sweet little Corgi...had a cervical disk compression and so needed neuro surgery to fix it and was touch and go for a couple days but is now doing great. She is only boarding with us because Mr Pabst is on a business trip...and this dog, funnily enough...is his life. He used to drive in with his Mercedes Benz and expenxive clothes and...yes...lay on the dirty ICU floor next to her cage for hours!!! It is so amazing how much our animals come to mean to us. I may hate the hours, and I may hate the work...but never in an million years could I hate the pets I take care of....I love them all...sick, healthy, big, small, friendly, and mean...and so it is because of this that I gladly put on my white coat and hang my stethoscope around my neck. Like I said, if it means someone will get to enjoy one more meow or another tail wag...then it is ALL worth it.

Long Hours

Did I mention that Sunday's are horrible? I was the 8am to 8pm and I did not get out of there until 1am again. We were absolutely swamped all day!!! I admitted 4 again!! 2 goofs who ate chocolate and had tachycardia and vomiting and diarrhea. Chocolate as we all know has methylxanthines -which cause cardiac and neurological stimulation - leads to tachycardia, sometimes arrhythmias, GI signs, tremors, muscle twitches, seizures. So I had the dogs on fluids and continuous ECG monitoring...they were doing fine. Then I admitted a renal failure cat..Maya...she has bilateral ureteral stones...but they are not fully blocking the ureters. She is maintained at home with sq fluids, benazepril for hypertension (renal disease causes high blood pressure), and low dose Clavamox to ward off infection as the stones can serve as a nidus for infection. She had been vomiting at home and owners thought she was constipated. I did not feel stool in her colon on my physical exam. I recommended blood work and offered a radiograph (mostly so that I could prove that her straining was not from constipation). Radiographs showed the ureteral stones and surprise...no stool in the colon. Blood work showed elevations (above her normally high values) in her kidney enzymes so I recommended hospitalization and a recheck ultrasound, thinking this is either an infection she has and will just need stronger antibiotics, or she now has a full obstruction from the stones and will need surgery to remove the kidney or stones. Ultrasound showed the stones and also showed some dilation in the L renal pelvis (this is the ureter with all the stones)...it may have always been like this, but this could also be a sign of obstruction and urine backing up into the kidney. I talked with owners and we are sending out a urine culture to check for infection. I said that she will either improve and it is just an infection or she will continue to worsen and then it is prob. an obstruction. Recommended a recheck ultrasound in 1 week to compare the dilation...unless she continues to worse and doesn't leave the hospital. Hopefully she does good...she is a horribly mean patient to work with (have to knock her out!!) but her owners lover her and come on....you know I want the renal failures to make it through!! Speaking of Renal Failure...god I hope I get into either Davis or MN where they are top of the top in renal research because in the past two days I have lost 4 patients to renal failure!!! 2 due to money...1 due to other complications...1 due to complete anuric renal failure (this means the kidneys completely shut down and were not making any urine at all!!) That was a sad case...dad tried to give her such a chance...her name was tabby cat....but in the end I dumped a total of 800L into her and she did not make one drop of urine...after many long conversations with dad and many tears...he finally agreed to let her go about the time she was starting to look like the state puff marshmallow man....very sad case...but unfortunately in that case there is nothing to do at all. I tried giving diuretics and she had absolutely no response!!! Necropsy showed polycystic kidney disease. Sad case! My other one was another cat who the owners couldn't afford to treat at all...they euthanized right after I diagnosed it off of blood work...his name was 'Bug'...he unfortunately didn't get a chance...not sure what he would have done...would have really liked to see!! The other one was a dog with what we thought was Leptospirosis (infection, causes renal/liver failure)...owners gave him a good chance but in the end treatment became too expensive after his renal enzymes had started to creep up again and he was not able to tolerate any fluids...he too looked like a marshmallow. The last one was another cat...only 7months old..ended up having lymphoma in the kidneys...yes, cancer at 7months....very sad!! Then last night I admitted another dog, 11months old, with renal failure. Came in with no blood pressure..had to bolus both crystalloid and colloids - then it was up to 65mmHg. Then bolused dextrose and he bounced right up!! but sadly his renal enzymes were up. Ultrasound didn't show much. Submitted Lepto titers on him too, I am concerned in him that it might be this. My other suspicion was ethylene glycol (antifreeze)...but owner swears there is no chance and would not allow me to do the testing. He was doing ok when I left...hopefully he makes it. Hopefully it is just a pyelonephritis (kidney infection). So, my big ole sheepdog Moose is still in the hospital. He is doing great and is basically here because his owners are in Mexico. He will hopefully go home when they come back and do great!!! I love him, he is the sweetest dog in the whole world!!!! And his bill...a mere $20,000 and counting!!! Yeah so he damn well better make it!!!! I think the whole hospital would cry if he didn't! He's like a celebrity at AEC now. Saw a couple other lamenesses, a cat with an abcess on his foot, euthanized 5 which was very sad. Did CPR on one but unfortunately he did not make it. One other one came in dead after a patellar luxation - yeah I know, I am not quite sure if the owner are telling me exactly everything that was going on as I find it hard to believe that popping your knee out can kill you but hey...what do I know...knees are not my thing...give me the internal organs please...I don't care if ya can't walk!!! Well, I am on call now and I think I am going to see if something is on tv..don't feel like studying tonight. I might meet Rachel - our ex-intern - for dinner. She is back and working at a small clinic in Brown Deer WI...she loves it and says it is way more relaxed than AEC...except that now she refers to us... I don't know how she can do that...that would bother me knowing I know how exactly to treat the case but don't have the possibility...frustrating!!! THAT is why I have opted to give up the next 3 years of my life as well!!

Moose

So, Moose, the big sheepdog I had told you about before who I admitted and was waiting to undergo surgery...he did and our surgeon did find an obstructed bile duct...so she canulated it with a red rubber catheter and we will see how he does...when I left sunday he was still doing well. So sunday I was the 8am to 8pm person...and I got out of there at 1am!!!! I admitted 5 inpatients. I hate Sundays!! I had two surgeries...one dog had a laceration and it ended up lacerating an artery and tendon...so had to take her right away as blood was pulsating out!!! I ligated the vessels and then did a Bunell stitch on the tendon and topped it off with a spoon splint. She should do ok, but I am not sure about function from that tendon. The other surgery was a mastiff who had chewed open his own knee...he was a post of TPLO (cruciate repair) and the owners took the cone off his head for 5 mintues and he completely chewed his knee open...so I had to fix that back up. Then I admitted a G shepherd with a fractured femur...placed a splint and then he was getting a surgical consult and repair monday. I saw another kitten with a fractured femur as well but they had no money so sent him home with pain meds and the number of the low income clinic in the area...they will likely have to amputate the limb...which is sad but at least they will still have their kitten...'Chuck the kitten'. Then I admitted two cats, one kitten with a fever who wasn't eating, bloodwork and ultrasound were normal and as soon as I got him rehydrated and the fever down he ate like a champ. Started antibiotics because of high WBC - he likely went home the next day. The other cat was Moe, a big black 12yo MN DSH who wasn't eating and was vomiting. Bloodwork all normal. Radiographs showed no obstruction, gall stone. Ultrasound confirmed gallstone, thickened intestines. Discussed intestinal biopsies with owners if re-feeding did not work. I placed nasogasrtic tube to feed him as well as he was a big fat anorexic cat and I did not want him to develop hepatic lipidosis on top of whatever else he has going on. I am conerned about a diffuse gi neoplasia or IBD. Not sure what happened with him. I saw some other outpatient things too but I cannot remember then now as I was so tired that night. Now I am writing my paper so that I can start the long process of trying to get it published before I am done with this internship. 5 months left!!!! Yay!!!!

One more down...

Almost done with this month. Just got home a little while ago, have to be back at 4am. Had journal club today...my group presented...it went well. It was on renal failure which of course I think is great...but is not such an easy disease to understand. All in all though, it went good. Had some different cases today...one dog with hypoglycemia of 42!!! (normal is above 100!!). Was having continuous seizures - of course because of the low glucose, however the constant seizuring set up a seizure focus in the brain, causing the metabolic activity to rise...thus continuous complete generalized seizures (or status epilepticus to the rest of the world...but hey at AEC they call it complete generalized so that is what I will call it...for another 5 months!!). So he got loaded onto phenobarbital which ceased the seizures, however blood glucose was still in the 40's. Why? Well there is likely an insulin secreting tumor somewhere (less likely decreased production as bloodwork is normal; less likely increased demand). Owners are financially restricted so an ultrasound was performed which of course wasted $200 but didn't locate anything - rarely would - usually need CT or surgical explore. But they cannot and/or will not afford this. So, started on prednisone to try to increase glucose, maintained on phenobarb to try to keep seizures in check, and wanted to start another medication which decreases insulin secretion but the drug is $90/month and so owners declined. I sent him home this afternoon, probably things will not improve, medical management rarely works in these types of tumors and they are alos very aggressive...but I did my part...I laid options on the table and in the end made a treatment plan out of what I could. Have another cat who had a surgical exploratory because of anorexia and suspect foreign body...explore was negative (meaning no foreign body ostruction), but did get good full thickness biopsies of GI tract which is important in diagnosing GI disease...also biopsied liver and pancreas. But now cat is doing worse, still not eating, we are feeding it through the nasogastric tube...and owners are getting to the end of the financial limits...so plan to send home tomorrow prob with NGT in place and await biopsy results...what do I think it is? Maybe IBD, neoplasia (lymphoma), infectious. What else did I have? Another seizuring dog - first time 3yo Male intact (!!!) Rottweiler (yes he bites!!)...just monitored, since it was his first seizure did not phenoload - will if he has another...likely is epilepsy as all bloodwork was normal. I saw this big Portugese Sheepdog named Moose - he had a pyloric (region of stomach just before intestine) perforation, likely due to NSAID use (Deramaxx) , huge abdominal infection..had to place drains and flush abdomen daily- that was fixed by one of our ER docs...biopsies were sent in and came back as ulceration with intact duct material (possibly common bile duct)...BIG OOPS!!!! So, of course we worry about bile peritonitis..leakage...it was discussed on weather or not to go back in to surgery immediately..consesus was to monitor liver values and bilirubin as Moose was continuing to do well at that time...so he does well, is discharged on the 22nd...at that time T billi is high but we hope it will go down. He comes back today and I recheck liver values and I know they will be high as he is yellow on physical exam (jaundice or icteric as we call it)...and they are...se I recheck ultrasound...gall bladder is distended but scarey part is the free fluid... I collect some and run a T bili on it and it is 4.4 (higher than peripheral) and cytology reveals marked neutrophils, some degenerate but no bacteria....discuss with owners and decide to go back to surgery to see what can be done..if all looks normal then will take biopsies...because of the possibility of biliary tract involvement he went to surgery under the capable hands of our board certified surgeon...so I will find out results when I go back in a few hours!! What else..oh yeah two chronically boarding birds...parrots..who are doing fine but owner is a bit off her rocker and will not take them home...my management of them includes looking at them in the am and seeing that they are indeed still alive and sitting on their perches...and that is the extent of my bird doctoring skills...breathing -check, perching check, eating - check. Well, I am getting tired and it is time to transfer my white coats into the dryer and hit the sac. Webster is currently sitting on my lap and Patch is beside me...I swear they are like little burdoks...they stick to me...except that they are soft and the type of burr that you hope sticks with you through all the wash cycles of your life!!!

Tough Days at Work

We got dumped on with snow last night...the roads were horrible. I had went over to one of the residents houses with a bunch of the other residents and she cooked food and then we watched a movie...driving home then at night was trecherous. So, I am finally on my days off...had some really busy days at work with some pretty cool cases. One was a German Shepherd that came in for epistaxis (nose hemorrhage). Reg vet had referred over because they had taken blood the day before but didn't have any results back yet...why they did not at least check a PCV/TS in house I do not know but anyway...they dii take an xray and thought they saw a cranial abdominal mass (I know..we are all thinking hemangiosarcoma right? I was). However on my PE I did not appreciate any cranial abdominal enlargement or organomegally, he was slightly uncomfortable but otherwise PE was fairly normal...minus the gigantic pool of blood from his nose!! So I knocked him out (I did not plan to but oops) with some butorphanol and acempromazine, and placed some epinephrine in his nose to stop the bleeding. At that time I was able to see that the bleeding was unilateral from the R nostril (hmmm....I am thinking nasal infection, tumor...). Blood was drawn and showed thrombocytopenia (low platelets), anemia, hyperlactatemia (likely due to decreased tissue perfusion and oxygenation from the anemia, also may be sepsis or if it was a tumor - necrosis), severely elevated total proteins (9.2!!!!!!!), especially the globulins (7.8!!!!!! yikes!!!!)...so now I am thinking infectious vs neoplastic (multiple myeloma??). He is getting ready to go to ultrasound and he vomits a gigantic pile of digested blood. Yuck...ultrasound shows a distended stomach and can't see much else. So I placed a nasogastric tube and pulled about 2 liters of bloody fluid from the stomach (more likely post nasal drip than actually stomach bleeding). Lungs no signs of nodules, bones have no signs of lytic lesions (less likely multiple myeloma). Did another ultrasound after decompressing stomach and saw no mass. Hmmm, at this time I am thinking what is going on in this dog...either cancer I am not finding or infectious. So, I sent out tick titers to test for tick borne disease, clotting times were normal but buccal mucosal bleeding time was prolonged (this indicates some platelet abnormalities). Hmmm....Rechecked PCV'/Ts and he is even more anemic but weird thing is that his proteins have actually increased. Ok, so I check an in-house 4-Dx snap test that tests for some of the infectious disease (lymes, ehrlichia)....and surprise surprise he tests a whopping positive for the Ehrlichia canis (a tick disease)....this can explain all of his clinical signs and blood work...I had already started antibiotics to cover for this (of course...I was thinking see I kinda know what I am doing here!!!) and then gastric protectants, fluids. I went in yesterday and he is still alive and hopefully with the antibiotics will continue to do ok. I had a fun case the other night as well....a kitty with an aural hematoma (big swollen ear filled with blood)...I got to anesthetize her and lance the ear and then place full thickness sutures through to close up the dead space...she has allergies so I told them to follow-up with rDVM to try to get those under better control otherwise she will likely continue to develop these hematomas. Had a dog come in the other morning early...standard poodle...in respiratory distress...had to sedate and intubate her and start breathing for her...talked to owner and she had been sick for 2 days and then this am couldn't get up and having trouble breathing. He was a go for ventilator so I placed her on a ventilator for 12hrs. In the meantime she got chest rads which should horrbile pneumonia and lung consolidation, abdominal ultrasound was boring, bloodwork showed renal disease and liver failure!!! The renal disease cleared with oxygen,,,I think it was hypoxic damage. Now, liver enzymes continue to rise, she is icteric (jaundice). I sent out a toxicology screen and leptospirosis (infectious)to the wisconsin vet diagnostic lab. This could be a result of liver hypoxia as well, but fits most with a liver toxin. So hopefully the screen will show something. She got started on liver protectants and N-aceytlcystine. They did a liver biopsy the other night...and of course she started bleeding from that....so she got her belly wrapped and I believe the bleeding did finally stop. She is still in ICU,, her bill must be around $5000 by this time...but hopefully the liver biopsy will also give us a clue as to what is going on in the liver. She is a very nice dog though...I hope she makes it. Had another dog come in with gun shot wounds...this was at 4am...the owners were getting robbed and the dog and the owners were shot. The owners died and unfortunately I had to euthanize the dog as well because the bullet had went through abdomen and out the side of the chest...pieces of lung tissue were sticking out through the exit wound...and I am sure the GI tract was perforated as well...and since the owners were deceased, MADACC took control and obviously cannot afford a $5000+ surgery so she was euthanized. She had a puppy that apparently was ok. Sad case...it was all over the news that day. Then we had this cold snap and we had a dog brought in to us that had been left outside overnight with no shelter and had frozen to death!!! No comment. I had a small little poodle in heart failure, his second or third episode and so owners elected to euthanize...that was really sad! I am finding even more at this job that the more I seen, the more scared I am when I come home...I am so happy to see both Web and Apache greeting me at the door each night...healthy and happy! I know they are getting older, but I have not stuck my stethoscope on them to listen to hearts or lungs....funny thing is if you ask around the clinic a lot of us vets say the same thing...we don't examine our own animals because we don't want to know!! The day will come but why worry about the future...there is so much to do in the present. My kitties are soaking up the sunshine right now...Ahh to be a cat and not worry about anything...

I'm Back

Well, I know I haven't written in a while because I have been really busy. Let's see, in the past week I have flown to California and drove up to Minneapolis for interviews. Both places were nice...if I had to choose...I can't right now. Today was my first day back, I am still on the 4am to 4pm shifts..I love them...they are more about medicine and taking care of the patients after the stabilization has happened. Today however, I had some interesting outpatient cases that came in on ER...I had two pregnancies walk in within 30minutes of each other...so I had two rooms full of puppies being born!! It was pretty cool...one room was a black lab and the other was a golden retriever. The black lab was actually having a normal birth...it was her second, the owner just got nervous..I took some radiographs and saw about 8 puppies..she delivered 4 in the room and then the owner left to deliver the rest at home. The golden retriever it was her first time so I took radiographs and saw 5 puppies. On my vaginal exam the cervix was open and I could feel a tail of a pup. Checked her calcium levels - normal. So adminsitered oxytocin and she delivered 3 pups. Then stopped and was pushing hard...vaginal exam felt nothing. Administered another unit of oxytocin. Still no pup. Could feel a tail on vaginal exam. Administered another oxytocin injection. Heavy pushing but no pup. Discussed C-section, had estimate all ready, left the room, and she delivered a dead pup and then another live. Took radiographs to confirm all pups were out and they were. So she went home. So, it was a day of life for me instead of killing...although I started the day out with a euthanasia...GI disease dog who had went to surgery...about $5000 dollars later they left with his collar and that was it...sad! What else? Taking care of the pneumothorax that I admitted on Sunday (this means air between the lungs and chest wall - not normal!!) I did thoracocentesis (tapped the air off) and got 2 Liters off!!! Owners are not sure what happens but the dog is a "fly ball" player so this could have caused a spontaneous pneumothorax. Other causes are lung disease, infections, trauma. A CT scan was performed and there may be a bulla (pocket in teh lung that can burst)...recommended surgery or at least chest tube, owners declined and want to try medical management for a while....this is only successful in about 20% of the cases so I am skeptical, but I talked with the rDVM and set up a management plan so we will see. Tomorrow we will see what I have to take care of. I am sorr that my notes are so short, I am scared about the rank for my residency choices...my final rank is due in 1 day!! and I am torn about what to rank...I really don't care, I just want a residency, but if I had the option to care....there may be a certain place I would put first...hmmmm....stay posted. Smiles ;o)

Happy New Year!!!

Wow...one more year down...man they go by fast don't they!! Hope everyone had a good and safe New Year's Eve...hope no one is feeling too hung over today!! I was lucky enough to spend the New Year's Moment in the clinic...how fitting for this year!! Yep that's right...I got called in to do a foreign body explore surgery at 7pm and ended up there until 1AM!! The dog had eated a rug...and lots of it...so had to make gastrotomy (incision into the stomach) and a couple enterotomies (incisions into intestines) and then remove a small piece of intestine that was dead!! Then I placed two abdominal drains. Also took some biopsies of liver, intestines, and some fatty masses on the kidneys while I was in there. Had planned to have some shrimp, chips and salsa, guacamole, taco dip; and fruits & champagne with Kevin but no such luck...ended up at work of course. Wanted to say that it was great to see everyone over christmas time...I was so happy to be able to have come home, even if it was only for a couple days. I have posted a few of the christmas pics below...