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...