Death is Coming

There are some terrible diagnoses in veterinary medicine. Rabies. Bad prognosis, inevitably grave meaning fatal meaning the patient IS going to die. There is not much you can do, just try palliative measures which you know won’t do much to change anything. The *HARDEST* conversations to have with a client. Much sadness all around.

One of these is DIC = disseminated intravascular coagulation. Also known by us in vet school morbidly as “Death is Coming.” A pet simply didn’t survive this diagnosis. Basically some kind of severe disease process initiates the clotting process in the body and then all the ability to clot is overcome and worse the body is unable to clot at all, and bleeding out occurs. An irreversible process. In theory one can treat the underlying cause and replace clotting factors until the body has healed but it just doesn’t happen. A bad bad diagnosis.

I had a patient in vet school. A lovely Pit Bull mixed with Labrador came in with a woman who worked for two equine veterinarians in far northern California. The dog had been vomiting and those veterinarians were so sure there was a foreign body somewhere in the dog they went to surgery. His owner described at one point the two doctors had their fingers touching, one down the dogs throat and the other reaching through its stomach and up its esophagus, yet couldn’t find the cause of the vomiting.

As it turns out the patient had pancreatitis. An inflammation that led to an effusion in the abdomen, ascites, and ultimately DIC. And the dog just looked at us wagging its tail, asking for a meal (the therapy includes no food or water by mouth to allow the pancreas to heal). It was suggested to his owner that the dog be immediately admitted to the ICU, where he could get around the clock care from multiple caretakers who would ALL be focused on his needs and surely the only way to possibly get better. It was anticipated it would take 3 to 7 days.

“No” his owner said, basically, “I’ll take him” — and everybody was looking at me. Crickets. Not quite exactly how it happened but essentially the ICU cost a lot and to be treated otherwise meant in the wards by the student. From 8a to 8p he was mine to keep alive. In the middle of the night the evening tech took care of it, following the orders I wrote but if there was an issue I would get a phone call or have to come in. Basically we poured an unbelievable amount of fresh frozen plasma into this dog. And literally we measured his belly to determine how well he was doing.

At one point his owner took him for a walk and allowed him to eat some horse poop. I could have strangled her. I told her we are not allowed to even eat ourselves in front of a patient with pancreatitis as the digestive enzymes get started and that causes further damage. Back to the wards. But amazingly enough he got better. Gotta love a Pit. Just totally indestructible.

“Wrong diagnosis” my friends said. Patients just don’t live thru DIC. But this dog did and he had all the proper lab value changes that are consistent with the condition. And he never clotted or bled. Perhaps because we were on top of his condition. Or he had just a “touch” of DIC. Who knows. I just know I did a whole heck of a lot of work and it actually worked!

The Point:

Even when given the worst odds, if the patient has any chance at all it is still worth trying.

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It takes a lot of Heart

Sometimes we do things just because they are the right thing to do.

Orion was a young puppy German Shepherd when I met him, very sick with a huge abscess (pocket of pus) around his neck and a big fever and a substantial heart murmur which represented bad heart disease. The family that brought him in had a series of children the oldest of whom at maybe 14 was memorable because he was the only one who could speak English at all well as well as he wasn’t wearing a shirt in my examination room.

I was informed they had $50 to care for the dog. This dog had at least $5000 written all over it. The fair and easy thing would have been to put him out of his misery. But the look on the poor dogs face was pretty much mirrored in the whole families look as well. So we had them sign the dog over to our care. They don’t get to call and check on him, find out what happened. He just was to be ours to do what we will.

Part of what made this worthwhile was I had a visiting veterinary student and decided to make Orion her project. She had to sedate him and figure out what to do with the infection. There was a large hole associated with the injury and after digging around and flushing for quite awhile she said she just couldn’t find anything causing the infection. I took a long Qtip and passed it into the defect once and deftly removed a large foxtail. Definitely one of the most magical things I could have done in front of the aspiring doctor.

After the infection cleared and the dog was placed in foster care we needed to figure out to do about his heart condition. Because of the nature of the sound of the heart murmur, a so called “machinery” one (like a washing machine) it seemed likely he had a PDA which is short for a bunch of words which means that he had a communication between the large vessels outside the heart that shouldn’t be there. Most of these dogs don’t live out their first year.

The proper treatment for this condition is surgery. In fact when I was a veterinary student I had a cute fluffy shepherd mix thing that had this problem and I remembered walking around the entire hospital showing him off and sitting in the hall with him resting his head in my lap. Total trust. He bled to death during his operation. As crushing a situation as any I experienced in veterinary school.

Orion had the fortune of going up to the same veterinary school for the diagnosis and procedure. UC Davis was good enough to use teaching funds to perform the procedure which now consists of a special coil stent placed into the defect to make it scar down and is much safer. Orion had a successful recovery and ended up going home with the technician that worked in the cardiology department! One of the more satisfying experiences I have had since I left veterinary school.

The Point:

If you have faith in the process, good things can and will happen.

Ouch

Pain is not a lot of fun for anyone, especially the animals. But they are adapted to live with pain, not show that they have pain, go about their day as if nothing is wrong. So here is the problem. The people who take care of pets don’t realize they are in pain in the first place so they don’t tell their veterinarians anything is wrong and as often as not we don’t necessarily appreciate that there is something ailing our patients either.

There are some unfortunate “rules” in veterinary medicine that are still passed on, and in fact I heard this one not too many years ago from one of my favored specialists I work with: “pain is a good thing, it makes the animal stay still until they heal.” Which I think is a terrible terrible way to look at this issue. Our pets should NOT be allowed to be in pain, pain is not a beneficial thing and it is definitely stressful, and we have many ways to alleviate pain and mitigate the factors that can worsen pain.

Preventing pain in the first place, using *carefully* multimodal analgesia techniques and having a team approach where the client and doctor understand the goals of therapy is the way to go. Veterinarians are afraid to treat pain because of the medicine they use MIGHT have side effects. In the face of a very real condition! The beauty of using many (multimodal) approaches to manage the pain is that you can use less of any one given drug – they work together/synergistically to be better than they would alone and treat the cause of pain by as many ways as possible from where it comes from in the first place.

As an example: ice can be used for local anesthesia and to decrease inflammation, a NSAID (aspirin class) drug can be used as an anti-inflammatory, a narcotic can effect the way the brain perceives pain, fish oil as a natural antioxidant can be used, physical therapy helps regain function of injured body parts … the list goes on. We should ASSUME pain is going to be there for certain procedures (surgery) and processes (arthritis) not necessarily wait for the pet to whimper or limp. And treat the condition aggressively – don’t our pet friends deserve at least that much?

The Point:

Ask (yourself and your veterinarian) if your pet might be in pain and DEMAND treatment for that condition