It's 5 o'clock somewhere!

Patient of mine with a chronic (many year) urinary tract problem (whose management I share with a University specialty team came in today for a cystocentesis). The patient was brought in by a person I have never met before. The person did not know why he was bringing the patient in, but arrived about 15 minutes before we opened and asked "do you know why I am here?" Luckily, I did! Yay, Dr. VBB. So anyway, I did the cysto and returned the patient to the owner. As I typically do, I said to the owner "Fluffy has a damp belly. Don't worry about it, she just has alcohol all over her belly." The person replied "wow, lucky her. I wish I did!"

OK! Whatever floats your boat....

Favorite Rainy Day Topic: euthanasia

A vet friend just told a story (and she might blog about it at some point) that reminded me of an experience I had several years ago.  I was working as an emergency vet at some tiny EC and a couple brought in a tiny doggie with some sort of very fixable issue.  I don't even remember the issue, just that it was a no-brainer and would be a happy end for the family.

Now, this couple was engaged and they were kind of planning to start attempting to have a baby soon after getting married.  As with all smart couples, they discussed how this addition would change their lives.  The happy, wriggling canine on the table, all 5 lbs of him, was friendly and openly interested in making new friends.  But not everyone in the house was like that.

The woman had a cat, one that she loved dearly, that was....honestly, nuts.  The cat was fine with her, but would attack the fiancee, even charging the WINDOWS and tearing up blinds if she saw him coming up the stairs, before he had even entered the house.  She had attacked him, unprovoked,  on multiple occasions, but was mostly fine for the female.  It sounded like there might be some displaced aggression issues, along with over stimulation issues, plus some other psycho babble that I will not bore you with.

It was obvious from the stricken look on the woman's face, that she loved this cat.  And the husband to be loved his wife to be.  They had talked to multiple vets and veterinary technicians about this cat and how to help her adjust.  They had done metabolic testing, tried drugs, and behavioral modification....and all had failed so far.  I mentioned referral to a veterinary behaviorist, and might have been more enthusiastic about it, save one issue:  the possible future baby.

Now, if a cat sized animal is dangerous to an adult, it usually ends up with some biting/scratching wounds for the adult and perhaps a punting injury to the animal.   If something is attacking my leg, the first thing that snaps to mind is to get that thing OFF OF ME.  I do admit to throwing a lizard into a bathtub wall as a kid when I slung my hand in an effort to GET IT OFF OF ME as it chomped down between my thumb and finger.  Around Easter, a chihuahua tried to attack my 6 year old (who loves most animals BTW), and that dog almost got punted across the yard...a well placed kick/shove and my daughter would have been safe (soccer, those skilz are useful when being attacked).  It is pretty much instinct and, while I do not agree with kicking animals, I would have to qualms about it in that situation.

Well, a cat hopped up on pure crazy could do some serious damage to a baby.  Even just infected scratches, lacerated eye balls, scaring the child so that the mere mention of "meow" sends it running and hiding under at desk at the tender age of 26....that is trauma.  And I felt like it warranted, "the talk."  Now, keep in mind, the happy dog was technically my patient, but the owners were really torn up about this cat thing.  They wanted to help her, but they also didn't want to put the future groom and risk, much less a theoretical baby.

Every vet and vet tech they had talked to made them feel guilty.  As a new mother with a timid, possible biting dog on my personal hands, I could easily place myself in their shoes.  I told them that if they were looking for permission to euthanize the cat, I gave it to them, that I would do it for them.  I said that the cat was mentally ill and perhaps years of drugs and therapy might help, but in that time, they and future fruit 'o the loins could be hurt.  If they wanted to euthanize, I would pre-medicate the cat and allow her to fall asleep before really putting a hand on her to minimize stress.  I would not make them feel guilty about it because I knew I was facing something similar at home with my dog and daughter.

I was not going to shame them into a position of attempting to "help" the cat, only to get a call in a couple of years about how it attacked their baby or a guest.  There are so few times that I will literally say, "If this was my animal, I would euthanize," but this was one of those times.  It was agonizing for the woman who loved her cat and I could see the pain in the man's eyes as he watched his future bride think about it.  I told them that they needed to go home and discuss it.  If they wanted me to euthanize, they just had to call back to the EC to make sure I was working that night and I would do it for them.

When they did come back in with the kitty, it was rough on everyone.  I sedated her until she was pretty much asleep, allowing "mom" to let the kitty fall asleep while she was petting her.  The couple chose to leave the room once the kitty was asleep, but before I actually euthanized her.  It was tough on me, on them, and on my staff, even though we all knew that it was the best decision for everyone.

The next time I saw the couple was a happy day visit at a regular clinic where I did relief.  The happy puppy had grown to 7 lbs doggie and was still as happy and wriggly.  The couple was married and the wife was pregnant.  And the relief was palpable.  The family unit was intact, and though any pet, even a well adjusted little dog, can hurt someone (especially a baby), the risk was so much lower.

Not a fun rainy day topic, but my friend's case made me think about this one.  Yes, I euthanized the cat: one that could not be re-homed due to aggression, one that might have hurt someone in the family.  But perhaps I took away that cat's mental pain and saved a child from a scar or a scare or worse.  It sounds like an unhappy thing at first: euthanizing a "healthy" animal, but I would do it if I felt like I could save a little kid in the process.  Most vets have had to face this issue on multiple occasions.  Some owners will have to face this decision.

And as someone who has been on both sides of that table, I can tell you it is hard.  But once my dog finally bit my daughter (by the time she was 3, I could no longer control all of their interactions), I knew  that it was time.  He snapped at her when she bumped into him because he was afraid...but an inch to the center and she might have lost an eye as his tooth scraped her face.  I could not deal with that.  And though I still look at my pictures of him and keep his urn on my shelf, it took about a week before I realized I was no longer worried about a bomb going off in my house and taking out my daughter.

Actual exam room interaction with actual client.

Me: So did you have any additional questions today?

Client: Yes. I seem to be allergic to her saliva. Is there anything we can do about that?

Me: Don't let her lick you.

Client: well I try not to but sometimes it gets on me and the allergy is getting worse. 

Me: What do you mean? you're not having any trouble breathing or anything are you?

Client: No, but I get hives and it's very itchy.

Me: Oh. Well, Local Reputable Allergy Medical Practice is just down the road and I highly recommend them.

Client: Can't we just give her something to make her have less saliva?

Me: No, that's not something I would do. 

Client: can't we give her something so I'm not allergic to her saliva?

Me: No, that's not possible.

Client: Oh. Well, I guess I'll keep making her miserable by not letting her lick me.

!!!

AYFKM?

After an extremely hectic morning at VBB central, during which the routine of Saturday morning appointments was disrupted by a steady stream of patients from our boarding kennel who chose today to break with some kind of gastroenteritis, I sat down at my desk to do some charting and phone calls. The constant ringing of the phone is normally annoying, but today it was helpful in keeping me awake, because I'd been up all night with a severely ill family member and come straight to work without any sleep. At one point I guess the phone got ahead of the receptionist and rang through to our answering machine (yes - we still have an answering machine. It uses a tape and everything!). I heard out outgoing message play, and then I heard the raspy whispered voice of Sumdood, offering to do an assortment of sexual things to the vet next time he comes in. I was very disappointed to find out that the whisper was apparently too soft to trigger the recording by the answering machine, so I have no chance to post an .mp3 here for your listening pleasure.

A bit of bliss...horsey style. No, not that.

I have been spending my summer living above my parents' barn.  It sounds glamorous but the situation that led me there is not so great, so I will forget that for a moment.  While the dancing horses are sometimes loud, even 3 stories above, in my bedroom, they are wonderful for the soul.  Yes, I am looking at you "Mister I Love Hugs and Peppermints."  Here is a picture from last night

My daughter, for all of the strife and pain she is feeling right now, loves these guys.  For those of you that do not know, horses are therapy.  They are like being hooked up to a biofeedback machine.  Since dogs and humans are both predators, dogs do not always react to us the way a prey animal will.  A prey animal will react to you as a predator if you approach them the wrong way.  So, they will mirror you, they can show you how you are actually acting.  They are not judging you: they merely being themselves.  So, if you are angry, they will tell you.  If you are stiff or nervous, they will tell you.  But if you learn to be comfortable and to ask and not to force (try forcing an 1,800 lb animal to do ANYTHING), you can gain a ton of ground, and learn about yourself in the process.

My summer has consisted of writing lectures, riding horses, doing yoga on stand up paddle boards, free yoga in the park, and other things.  My riding instructor is a licensed "centered riding instructor."  Sure talk therapy is great, but you usually end up crying during that.  I leave my riding lessons having learned how my breathing and relaxation effects my horse and with a smile on my face.  

I am lucky enough to ride two different 6 year olds: one is a big black Friesian and one is a dapple grey American Sport horse.  Both are goofy and test me, but I have literally found such peace riding these guys.  And since they are owned by friends, I can take lessons on them but also practice on them outside of lesson time.

I ride dressage on the Friesian (no, not like a certain person that has her "therapy horse" entered in the upcoming Olympics) but switch between dressage and hunters on the mare.  I have been riding for almost 30 years and I am re-learning some things and having to unlearn a whole bunch more.  My heels are less jacked down, I am looser, my grim look (I swear that is my look of sheer happiness and peace on a horse) has turned into laughter and smiling.  And even if I get three great steps of the horse riding up into my hands and folding into me, I have a little celebration.  

Yes, it sounds expensive, but it is cheaper than combining a therapist, anti-depressants, a physical therapist, and a personal trainer.  And getting to exercise the horses for friends and practice what I learned in my lessons is good for me and good for the youngsters I am riding.

So, here is a picture of the mare, one of the most comfortable, goofiest horses that I have ever ridden.  She is so comfy, that she makes me think that I can ride like I did when I was competing.

She is young enough and her genetics are such that she will stay dappled longer than others.  This is her, "You want to WHAT?" look.  

And this picture was on my last mare, who I retired.  She flipped over with me while cantering, not even jumping.  She was a fabulous Westphalian.

Fat kitty vet my ass.  Notice the heels jacked down and the stiff elbows.  I have lost some of that.  Now, instead of stiffening when a horse acts like an idiot, I just melt into them and go with the flow.  The youngsters have tried some stupid things, but I was loose and ready and each incident lasted less than 1.5 seconds.

So, bliss on this morning of strife.  And go pet a horse, or a dog, or a cat.  Try to avoid alligators please.

Our Failing Society

I wanted to post this video for all the people out there who think our job is easy, who think we are overpaid, who think we don't deserve what we get. 

This was a neglect case that I saw a while back.  This dog died.  It broke my heart into a zillion pieces.  This dog was entirely covered in ants and maggots when he presented, and what you are seeing is a huge hole in his back, filled with maggots.  He had wounds over most of his body that were infected, and he was septic.  But dammit he died without pain, in a world pumped full of morphine.  Thank god we were there for him.

I wish I could pump the owner full of morphine.  Too much morphine.  Oh, and she was a PA.  Yep, a physicians assistant.

What was even more sad, was that I TRIED to get this owner into trouble, to no avail. 

You can judge the quality of a society by how well it's animals are treated.  I think our society is in trouble.

Is there a big black market for replacement chinchillas?

Yet another VBB sympathizer has graciously provided this guest post for our poor, neglected blog during this long hot summer. Thank you, Dr. C. Lanigera!

My story is from several years ago when I was an intern in avian and exotic pet medicine. The background on this story: One of the boarded specialists was taking call for me one evening so I could have a much needed night off. An emergency call came in regarding a chinchilla who had gotten his leg stuck in between the bars of his cage. When he arrived at the hospital, the leg was pretty much self-amputated mid-tibia, so my boss cut off the dangly bit, bandaged the leg, and admitted the chinchilla to the hospital for surgery the next day to perform a proper amputation at the level of the knee - any lower and you risk pressure/rubbing sores. This all went down around the same time as the ACVS conference and so we only had one surgeon available at the large referral hospital where this happened. Because of this, the chinchilla's surgery didn't take place until late afternoon the next day, making it necessary for him to spend an extra night with us in the hospital to recover. So to recap: Chinchilla presents in the wee hours between Weds and Thurs. Late Thurs afternoon, the Chinchilla has his surgery, and has to stay until Fri for release. On Fri, the fiancé of the owner comes to pick up said chinchilla. He is happy, understands the discharge instructions, greets the chinchilla warmly, and takes him home to heal. On the following Monday, the owner of this chinchilla, followed by her fiancé, marches into the lobby of our hospital with the chinchilla in one of those giant exercise balls and plops him, ball and all, down on the counter... 

...This is where the story gets good. 

She asks, quite sternly and accusingly "Where is my chinchilla?! THIS is NOT my chinchilla! I DEMAND my chinchilla RIGHT NOW!!!"

She then proceeds to whip out a yellow folder full of photographs of said chinchilla, holding them up next to the chinchilla in the exercise ball, and insisting that the fur pattern on the chinchilla in the ball is different than the pattern on the one in the photo. Our poor receptionist is just baffled and trying to keep this woman calm and keep her from making a scene in the middle of our busy lobby. She went to get the client coordinator and put her in a room. Unfortunately, the doctor who had overseen the whole case was off on Mondays and was not in the hospital. Our other boarded specialist was sent in to try and smooth things over. This woman would not budge on her story. She genuinely believed we had given her a different chinchilla. I was eventually asked to come into the room to talk to her, as I was also involved in the case. The witness to her crazy was unprecedented and 4 1/2 years later, it's still one of the oddest complaints I've ever been a part of. 

"This is NOT my chinchilla! He's not the same! Before surgery he ate mostly pellets, but THIS ONE wants to eat hay!"

I countered with us offering large amounts of hay in the hospital as it is better for their digestive tracts than pellets alone - maybe he liked the taste of hay once it was offered to him.

"But he's MEAN now! He used to never bite and all weekend he was nipping at us!"

"Ma'am, Your chinchilla just had SURGERY to amputate his LEG. He's been in a strange place for 2 days and experienced a significant amount of pain. We did what we could to control their pain before, during and after surgery and sent him home with oral pain relievers, but I'm sure his surgery site is still tender and he's getting used to walking around with only 1 hind leg. All this, I'm sure, is very scary to him. I can understand if he's a little cautious or aggressive." (BECAUSE OMG HE JUST HAD HIS LEG AMPUTATED is what I wanted to say)

"Look at this picture," she said, shoving a slightly grainy photo of a chinchilla printed on a piece of inkjet paper in my face, "TELL me this is the same chinchilla, because I think their fur patterns are different - you can see stripes in the fur pattern around THIS chinchilla's leg stump! My chinchilla didn't have those! SEE?!"
I told her I thought the two looked very similar and I couldn't really tell a difference. I could neither confirm nor deny this was the same chinchilla as the one in the exercise ball. I told her she probably is seeing the stripes in the fur pattern because the fur has been shaved short enough to see the nuances in the skin. This is typical of all grey chinchillas. 

This woman legitimately thought that something had happened to her chinchilla and it had died, so to save face, we had amputated the leg of a NEW chinchilla to give to her, AS IF SHE WOULDN'T NOTICE. Yes. Seriously. That's what she thought.

Her fiancé sat in the room with all of us the whole time, eyes wide with shame and embarrassment over the whole situation. I asked him, as the one picking up the chinchilla, if he had noticed a difference then. When he tried to speak, she cut him off stating HE wasn't the owner and wasn't qualified to make that determination. 

I told the woman that I was the doctor who took over her chinchilla's case the morning following his admit to the hospital. I arrived at 7:30 that morning. He had been admitted around 3am. There  was at most a 4 hour gap, in the middle of the night, where a "switch" could've happened. We had no other chinchillas in the hospital until after this one's leg had been amputated. There were cameras all over our building for security reasons. We told the woman, if she needed more proof, we could provide camera footage tracking the chinchilla's whereabouts during his entire stay with us. We had saved the original amputated leg, which we put on hold for a while, in case she came after us legally. Maybe we could use it as DNA evidence. It was absurd. 

Her defenses weakened, she said one more time, deflated, "I still think it's a different chinchilla..." ...and with that, she picked up her chinchilla in the ball, her stack of photos in their yellow folder, and her dejected fiancé meekly followed her as she marched back out of the hospital. 

At least I got a great story out of the whole thing! You can't make this stuff up, folks!

Guest post: nursing in the ICU

You may not realize this, but your veterinarian wouldn't be able to behave nearly as badly without the dedicated support from his or her veterinary technicians. These dedicated nurses are often the ones who carry out the veterinarian's diagnostic and treatment plans for your hospitalized pet. Today, AnonyTech speaks out:

Everybody desperately wishes you could tell us what happened. After a quick stop-over at your regular vet, you’ve landed first in our emergency department and now the ICU. Glancing at your fluffy, worried face (but noting the undefeated tail, still gently thump-thump-thumping), it’s easy to see why. You’re trying hard to shed your intestinal lining. It spills out, gelatinous and threaded with crimson, around your tail. Your family agrees for you to sleep-over, but hesitates to let us uncover WHY you’re doing this, “No diagnostics, just fix him. We’ll do that lab work tomorrow, please.” The receiving doctor was worried enough to put you straight into the ICU, but nobody knew for sure until your tail stopped it’s thump-thump-thumping.

 Phone call number one: Diagnostics truly cannot wait until tomorrow. It’s diagnostics and treatment tonight, or time to stop. Permission given, your ICU sleep-over party swings into action: Lab work is ordered, and it reveals to your doctor what tricks your body has been up to. You’ve forgotten how to stop bleeding. This explains why thermoregulation and peripheral circulation are not high on your body’s priority list. Red and blue bruises spread across your soft belly and, obtunded though you are, your small body curls reflexively inward to protect itself from the pain. We can help you there, and do. Fentanyl, kissing cousin to morphine, provides some measure of relief. You breathe easier, no longer grunting with each breath. Warm air blankets provide the heat your body has disregarded. Ever determined to discharge the insult, your intestines redecorate the bedding with what could be strawberry jam. That is… not ideal.

 Textbooks say that dogs’ shock organ of choice is the gut. Insult the canine body enough, and the guts will rebel. Cats take their post-shock anger out in a much more civilized manner. You clearly have no such plans and unlike cats, your body is following the text book to the letter.  Scooping your small form in one blue gloved hand, I remove more shreds of your gut rebellion. We hope to help you through this crisis; it should be a fixable situation. Uncover the underlying problem, stop the insults, recover, and then discharge. A guarded prognosis is better than grave or poor prognosis, right?

Right. 

Tonight you have your own team, not just a doctor and a nurse. The intensivist and the hospitalist, the floor nurse and the critical care nurse. We are your entourage. I gain more experienced hands, when the critical care nurse picks up where my training leaves off. It’s apparent that peripheral access isn’t enough: Orders up, and the critical care nurse throws in a venous central line. Fresh plasma so you can keep the fluids we’re pouring into you, plus artificial colloids (fancy starches, to keep your blood where it belongs), and crystalloids to help address your lack of volume. To complete the party you bask in the heat support and ride the gentle wave of analgesia. For a few fleeting hours, you uphold your end of the contract. What we pour in? You only leak some of it back out. Blood stays where it belongs. You even wake up enough to be called “depressed but responsive” and remember how to shuffle about. You’re caught rearranging the bedding to fit your whim. We take turns cooing at you, more willing to cuddle and cradle now that life seems to be back on the map. Your body, unfortunately, has other plans.

 “The death bounce” is the morbid and offhanded way to describe the hours of calm-chaos-calm-chaos before the rest plays out. Shock already did its damage before you came through our doors, and you don’t play fair for long.  Maybe your guts didn’t approve of the blanket fort you’d burrowed into, or maybe you were just building a warm place to end it all. You could not have known that in the ICU, we only become crueler as you fall away from life.

One.

 The first time you just stop breathing, but respiratory arrest can turn into full CPA if not caught and aggressively treated. We don’t mess around here. “CODE!” and your body is literally run the short distance to the crash station. Your entourage has again grown in numbers; all available hands help run your code. Orders are automatic and fast. Tube, breathe, monitor, and hopefully labs. Somebody forces a tube into your trachea and another begins breathing for you. What feels like minutes must really only be ten or fifteen seconds. Then you remember and get on with breathing. We breathe. Fool us once, shame on you, but fool us twice? We know you’re not playing along. You’ll have to keep the new tube. The doctors do not trust your stomach-- it is snuggled right up with the traitorous intestines. Until we know, the ET tube stays. Forcing another piece of plastic into your recumbent and sedated form, the doctor pulls back on the syringe and a coffee-like liquid flows into the vacuum. Your stomach was in on the trick, churning out the dark soup for the doctor half of your entourage to frown over.

We’re all watching you even more carefully, scrutinizing your every intake and output. Our machines dwarf your small form. Your pupils constrict in reply to the light shined so rudely into their depths—somebody is still there. We pull you along slowly, nursing your prone form towards life. It is too much trouble to argue with us, and for three tenuous hours it seems you’re again convinced to stay. Even with drugs, you try to chew at the tube in your trachea, sniffle at tube in your nose, shift away from the unwanted touch of the doppler, and flinch at the sharp end of a needle. Or maybe you’re just waiting for an opportune moment to escape. Not allowed, sorry.

Two.

 It is no longer worth it to you. You’ve had a good run of it, right? There’s been too much loss, too much pain, too much unwanted interference. We refuse to let your heart give up and when you go off, we crush at your tiny rib cage and pummel you with epinephrine. Then, when your end-tidal jumps, your team holds a collective breath. Somebody works to get your family on the phone for the doctor, they’re worried and waiting. Seconds after the end-tidal spike, your heart takes notice and steps back into action. ROSC can be a very, very low bar. For now though, you are back. A half-forgotten breath escapes from the whole team. The doctor carefully talks with your family, explaining that slipping away very briefly, once, is manageable, but twice has moved you to a very grave prognosis. They desperately want to keep trying, too far in their fear of loss to hear. We frown at the clock, watching the minutes tick by without a clear decision from the phone. You’re less subtle about it this time, and we watch your blood pressure march steadily downwards, ignoring all the crystalloids, colloids, and ‘pressors we throw into you. Once you’ve made a decision like this, it’s very hard to change your mind. We try to soothe each other, “Good job, smooth response, clear communication, doing all we can…” Check and recheck orders, making sure nothing has been missed, no magic life-saving step somehow overlooked. In sixteen minutes, you’ve checked out. Your pupils give up the game-- large dark empty holes, yawning into oblivion.

Three.

 In case it wasn’t obvious where you planned to go, pinkish foam burbles up from your endotracheal tube and sputters against the ambu bag until it’s suctioned by yet another (smaller) plastic tube. Jam, coffee, and now peppermint foam. Your lungs have redoubled the escape attempt, and it’s probably a matter of seconds. I wince as your ribs crack under my hands during compressions. I’m sorry for this, so sorry. It’s not fair to you; it’s not kind. It’s certainly not an ending any of us would choose. Then my two minutes are up and I gladly count down to swap out with your next tormentor. We pump more adrenaline into you, and for five pained minutes we’re worried you’ll continue this pattern all night long. The doctor makes another phone call to your family-- The Phone Call, the one nobody wants. This time your family understands what they’re asking you to endure. They hear how you’ve tried to leave life three times already, and give the choice back to you. You’ve been rescued from our resus. You’ve become a DNR.

Four.

 We watch, silently, as your heart slows to a jog, then a walk, then a shuffle. Until finally it’s just throwing electricity around without purpose or result. Silence. We remove all the bits of plastic and metal from your limp form. The monstrous machines are pushed back, clearing space for your family to caress your face and limbs one last time. You don’t curl into yourself when I lift you in my hands, to swaddle and shroud you in clean blankets.

We did all we could for you, except give you peace sooner. We cannot brood over these cases, or we’ll all end up burned out and useless. Softly we thank each other and carefully pick up the pieces scattered around the crash station and ICU. One of the doctors orders pizza (most of us forgot to eat amidst the stress and chaos) and the gentle teasing begins. By the time the pizza has arrived, so have the morbid jokes. Warm food helps us move, and we reintegrate onto the main floor. All bleeding stops eventually, right? The ache remains for me to deal with later, after my shift. You’re one of the ones I’d hoped to see walk out of our doors. And right now? Other patients need us, and they are warm and alive.