Noblevet

Posts Tagged ‘Medical’

Death is Coming

In Veterinary Myths on June 18, 2011 at 4:54 pm

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.

Advertisement

Ouch

In Veterinary PSA on June 5, 2011 at 6:34 am

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

 

Casual Aside

In Veterinary on May 22, 2011 at 10:32 pm

There are things we say that get us in trouble. We often don’t think anything of them, just mention them in passing, often something stated as a way to relieve stress or take a stab at humor or to provide perspective on something.

As a afterthought I can think of 3 times that this has been an issue in veterinary medicine for me and others. One that came home to me was when I had an afterthought interaction with a very sick cat where I attempted to examine a wound in its mouth and when it practically passed out due to basic manipulation I stopped and called its caretaker to discuss the situation. While it was happening, one of the other veterinarians I was working with commented in a dry joking manner “I see you are doing non-anesthesia dentistry there.” And as I was on the phone with my client I had to take the phone into another room because of a sudden burst of noise that occurred.

As it turned out (the cat had to be euthanized due to a not yet determined significant occult illness) over a month later I was called on the carpet by not only our hospital medical director but the regional manager as well about the “cat who I killed” seemingly inadvertently. They had taken the word of a suspicious staff member having misinterpreted my colleagues words and thought I was hiding my discussion with the client to make it look like I had not caused its distress. And took it upon themselves to review the record (nothing was there) and interview the employee and finally ask for my side MUCH later. The whole time I had no idea. If they had asked me right off I can only imagine it wouldn’t or at least shouldn’t have been a big deal.

The other two situations had to do with overheard stressed frustrated vet comments overheard by staff, I am going to imagine. Only they know how truthful the situations were, but my role led me to believe there wasn’t much merit to the allegations made. In one case a veterinarian was thought to have a special “PIA” (pain in the ass) fee for certain clients and in the other the doctor had significant medical needs and was believed to be taking narcotics which were effecting her ability to perform her job duties. On closer inspection that didn’t appear to be the case, though an employee did say that they had been heard to say “It’s 5 o’clock, almost time for my vicodin” which was damning.

Ultimately, though we are people too and in stressful jobs, we as veterinary professionals need to remember that ALL of our actions are taken very seriously by those around us and we have to keep our actions above reproach at all times.

Otherwise …

WIHCTU

Keep your manners and wits about you at all times and you won’t have any ‘splainin to do (remember I Love Lucy?)

“Patient is odd”

In Veterinary Quotes on April 30, 2011 at 5:52 pm

“The cat is acting odd which my daughter and I disagree about and we wanted to know what you thought of this.”

This is all I was told, no further information was forthcoming without my prodding, 3 sets of expectant eyes gazing upon me waiting for me to work my magic (client and daughter, both older than I, and cat).

I elucidated that the “odd” behavior which this middle age indoor cat had never displayed before consisted of avoiding the floor in the bedroom, staring under the door entering the room, trying to get up to high places and vocalizing. Otherwise perfectly healthy. Then I asked the key question = any fleas? “No, but I did get bitten by one recently.” Aha!

Sure enough fleas were found on the cat which I showed to all and flea preventative medication was administered as well as dispensed and I’m pretty sure the odd behavior will now subside.

It is always interesting to me that people are so impressed that veterinarians can figure out what is wrong with animals, as “they can’t talk.” But they certainly exhibit some kind of changed activity which their owner caretakers pick up on and through the process of history, physical exam, testing and/or treatment/medication trials we can usually figure out what is happening or at least make them better.

Often is takes just the right query or use of the proper instrument (in this case a quick sweep of a flea comb) and away we go. From a starting point of “odd”, which may have been conjecture or strictly behavioral and I might have had to conjure up a presumption of the presence of roof rats in this case to mild or significant medical distress – it all starts as a mystery but definitely requires the client appreciating that something is amiss. I just help them focus to the best of our ability on what the problem is at hand.

This is a close cousin to our vague friend: “Ain’t Doing Right” abbreviated (unfortunately) ADR in medical records.

WIHCTU

Even though subtle, our pets give us clues to their state of health if we pay close enough attention

CS

Surgery went “well”

In Veterinary on April 28, 2011 at 3:32 am

All things medical can be a dicey proposition. As a professional I can not ethically make any guarantees of the outcome of any test or procedure. We discuss liklihoods. Based on the knowledge we currently have or experience that has been brought to bear. Surgery is where this comes true more than any other area.

Buzz words abound: routine, as expected, nothing out of the ordinary occurred. But there are so many ways that the surgical process can go awry, and clients/patients are understandably wary. And they don’t know all there is to know about these things. They rely on the medical people to do what they say they will (and what was that exactly?) and hope for the best possible outcome. On the medical side we do things so often we don’t think much about the bad possibilities, often not fear what can go wrong.

What I have come up with, having worked with animals for going on 30 years over half of them as a veterinarian, is that equal parts to how a patient does medically/surgically is shared 3 ways: me (the hospital experience, my surgical skill, our team etc.), the patients inherent ability to heal not to mention deal with the process including anesthesia, and the client who plays a key role in following instructions and administering medications and being watchful for things going awry. If things don’t go well we all have different psychological mechanisms that drive our behavior.

Some vets assume it was all their fault, others don’t imagine that anything they did could have been a problem. I personally feel you should learn from each circumstance in order to help that patient and others that follow. There is a fair amount of soul searching involved – “could I have caused that pets injury or demise?” It can be a sobering process.

The reason this comes up at this time is a patient that has had 4 surgeries at this point we are currently treating. The first surgery did not go well and ever since we have been fighting the results. There are $ considerations and every time the client states that she will have to euthanize her pet friend “next time” but has ended up not being able to do so. Most recently a specialist surgeon did some of the work. Hopefully for the final time (hope, hope, hope!!!). According to this client I can do no wrong. To myself I wonder if I haven’t terribly failed and put the patient through a horrible experience that is all my fault not to mention spent a bunch of my clients money that she didn’t have. Sigh.

WIHCTU

A little bit of fear can be a very educating thing

CS

Bunny MRI

In Veterinary Best Of on April 14, 2011 at 9:16 am

One of the more remarkable stories of pet dedication to me involved a rabbit with a particularly daunting medical problem. One of which I had been unable to resolve on my own. Many people don’t get what can be special about a bunny, how interactive they can be or how much one can bond with them. This rabbit was especially well loved and his caretaker was going to spare no expense or effort to get him well.

Specialists were involved. A MRI was recommended to further suss out his condition. The place to do MRIs was conveniently located. Much to my chagrin, however, is when called the imaging center claimed “we have never done a rabbit MRI before.” To the caregiver! Now I happen to know that they do zoo animals so the fact that this wasn’t a cat or dog shouldn’t have phased them. And in my mind you NEVER admit to the potentially upset “parent” of a sick pet your limitations in this manner. This is a vet to vet conversation to be had behind the scenes.

Luckily said rabbit Mom decided to proceed and everything went fine (whew!) and the information necessary was gleaned. I ended up on the phone with the radiologist who read the MRI to discuss a fine point in the interpretation. He claimed to have personally reviewed 70,000 scans in his career and only 3 were for rabbits!!!

All ended up well. The procedure performed subsequent to the MRI was a success and the rabbit is currently doing quite well. I always appreciate it when my clients trust the process enough to invest financially and otherwise to do things that may not work but are our best chance and when things turn out for the best, that is one of the greatest feelings in the world.

WIHCTU

Never underestimate a clients desire to do the best possible thing for their pet

CS

Emesis

In Veterinary Best Of on March 23, 2011 at 3:12 am

Emesis is the medical term for vomiting. One of the more common reasons I see a patient. Dogs that vomit are unusual. Often they are sick. Because they ate something or their food disagrees with them or something internally has caught up with them. For many dogs even missing a meal is a cause for alarm.

Cats on the other hand are self cleansing. They are born to vomit, as the last lecturer opened his talk with that I went to about gastrointestinal disease in cats. The question with them is when is the vomiting too much? Are they sick, is it a problem?

The other reason emesis comes up in a veterinary setting is making a pet vomit. Because of exposure to a poison or ingestion of an expensive object, for example. We veterinarians have chemical means to make an animal lose their lunch, so to speak. I always found it somewhat paradoxical that we make pets vomit to keep them from vomiting (from the eaten bad thing).

When asked my most memorable emesis story it comes easily and immediately to mind. I was presented by an Animal Control Officer (ACO) a friendly appearing Pit Bull on the end of a rabies pole. A request was made to retrieve the dogs owners nose. It was not made apparent how said appendage ended up in said Pit Bull. Seemingly, the ACO was expecting me to cut open the dog right there and then, anesthetics optional.

I elected to make the dog vomit which was effective. Mixed in with kibble and stomach juices was the end of a nose. I wouldn’t have known it was a nose without being told, but I could tell you its owners nationality. The nose was cleaned up, packed away in ice and flown to LA for a successful re-unification I later found out.

WIHCTU

Biting off ones nose does spite ones face

CS