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!!