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...