Saturday, September 19, 2009

A Bad Run of Bad Luck

You know, we all have our ups and downs; trials and tribulations; peaks and lows; triumphs and agonizing defeats. It's not only part and parcel of life but part and parcel of our profession. As much as it pains me to admit it, we can't save them all and we are most definatly NOT all knowing or super heroes.

That said, I've had the worst run of bad luck with my hospitilized patients I've had since school!

Over-all, I figure I probably have a little better than 65% average with my hospitilized patients walking out the door. That's probably skewed a bit because I tend to only keep the REALLY sick ones because we don't have 24 hour care here, and my philosophy tends to be I'd rather have the pet at home where at least the owner can keep and eye on it and call the emergency clinic if it looks bad then having it here by itself. (Wow, what a run on sentance!)

So I only tend to keep the really bad stuff. The stuff that's sick enough I want it on IV fluids and the owners can't afford or won't refer to the emergency clinic for 24 hour care.

So, lets see. My dog that SURVIVED organophosphate poisioning only to come down with IMHA died. My pneumonia dog died. My last blocked cat died. I did have one cat in chronic renal failure that I diuresed that survived to walk out the door, but she's not doing so hot at home. And now I have another blocked cat in the hospital.

When he came in his BUN was 194, his phospherous was 11.something and his creatinine was 11.2. Oh yeah, and his potassium was >8.5. In non-veterinary terms that means that he's really sick. Fellow medical professionals probably read those numbers and said "Ouch!"

So I got him unblocked, IV catheter in place, urinary catheter in place, e-collar on, and medicated. Than he pulled all accouterments off overnight the first night. Dumb move kitty, those things were trying to save your life. The next morning and day he looked like crap all day after said accouterments were re-placed.

I didn't think he's be alive when I walked in this morning. He was; he stared at me out of the cage like he was murdering me.

I was never so happy to see such a "pissy" stare...

I hope he makes it.

Saturday, September 5, 2009


Man am I steamed right now!!! That's the reason for a second post in so short of a time.

I'm on emergency duty for the weekend and holiday. Over the weekend, one of us covers a 33 hour shift although we are allowed to leave the building if not actively seeing clients. I feel fortunate to know that there is someone else covering the night shift Sunday so that I get a little guaranteed rest prior to coming back Monday morning. So why am I PO'd?

How dare you plan to enter vetmed with the thought of it being a 9-5 job? Or set hours at all for that matter. My emergency student's shifts are split up from 8 a.m. til 5 p.m. then from 5 p.m. til 11 p.m. then on-call until 8 a.m. We had several emergencies show up at once and were in the midst of working them up with one leaving to go to their regular veterinarian shortly after 5 p.m. and the student just left because her shift was over!!!!!!! WAY NOT COOL!!!!!!!!!

For the first time since I've been here I got really mad and called the student. I got her voice mail and left a message chewing her out for leaving. I DON'T CARE that your shift is over; you have patients for whom you are responsible and you DON'T leave until you speak to me. I don't care that you told the other student you would be back later after getting something to eat. You DON'T leave until you speak to me first. If she had asked, I likely would have kept her for about 5-10 more minutes then told her to go let pets out, eat, whatever, and we could finish paperwork later. If she had only asked...

Goes right along with all the whining. I just don't get it. Maybe I sound like the proverbial "walked 20 miles uphill in the snow both ways" story but I have to say that I worked a whole lot harder than the majority of these kids when I was in vet school and I do remember it being a bit tougher. I would have failed had I walked out at the end of my shift without checking with the doctor in charge; as is she will get chewed out (gently may I add, I'm not a harsh or screaming type of person) by me and that will be the sum total cost.

Cats for change

Animal medicine is fun. While we do still catch some of the same things that human doctors get (pun intended) such as being a psychologist and hearing all about family woes, past illnesses, and other pets, there are definite bonuses to being an animal doctor. (Oh, and as previously alluded to in another post, yes, we do get asked to diagnose people illnesses.) One of the bonuses from my perspective is the often unexpected things that these little guys will toss our way.

I have been treating a cat with a pyothorax since last Monday. For those of you non-medical types, pyothorax is the doctor word for pus in the chest. So basically, the cat had an abscess inside his chest. It was lovely. Disgusting, chunky, stinky goo that I tapped from the chest first using a needle then we placed a chest tube so that I could drain it more often and flush it out. (Yes, I do have the usual female veterinarian fascination with abscesses. Not to say that men don't ever have that fascination but it seems to usually be a female thing. I have no explanation for that...)

The most common cause of pyothorax in a cat is a fight wound. This is likely in my little guy since he is a semi-feral kitten that was outdoors and just recently has become tame enough to handle. Pyothorax can go bad (VERY BAD!!!) because cats like to wall things off with fibrin which is a tough, collagen-like material that then stops the lungs and chest from expanding normally. This can be a permanent change leaving a cat that cannot breathe normally for the rest of its life.

Typical treatment of abscesses include flushing and draining, obviously not an easy thing when dealing with the inside of the chest. This is also apparently one of those "in vogue" types of therapies, also. By this I mean that we see therapies and diagnostic modalities go in and out of favor through the years in medicine. Flushing with sterile saline +/- heparin was originally used then became less commonly accepted and is now back in favor. The use of heparin would be to try to break down and prevent the formation of the fibrin. We chose to try this therapy since after removing 160ml of fluid the x-rays looked about the same as before although he was breathing better. This made us worry that he may have had a problem before anyone realized and may have had a lot of fibrin already.

We started antibiotics and flushing/draining the chest. He began to improve almost immediately although he had a raging fever (105.7F) the first night. After that, he began to eat and feel much better quickly. My original plan was to keep him on intravenous antibiotics for a week (so that I could be certain he received a complete dose) and to leave the tube in place for a week (to allow a window for reassessment of the fluid as well as draining the fluid). It would seem that the cat had other plans...

This morning we were unable to get the fluid back that we had put in to flush (a mere 34ml). We took another x-ray (unplanned) and found that the chest looked great. Clinically, the cat looked wonderful. We then discovered that the IV catheter was blown as well meaning we could not give the antibiotics through the vein without placing a new catheter. As so often happens, we then altered our treatment plan entirely based on the whim of a cat. We pulled his chest tube and IV catheter and switched to oral antibiotics. He's a much happier kitty now without the tube and IV lines. I think he was just making the statement that he is ready to go home! So, assuming there are no complications we will send him home. His owners can't pick up until Monday (out of town tomorrow) but I think Socks will be okay with that...or he could just make change in his little world again!

Wednesday, September 2, 2009

Skewed perspective

I'm beginning to worry a bit about myself...again. I can't figure this place out. So, I'm at a university teaching hospital now for this internship and am enjoying being back in the academic atmosphere where everything becomes a chance to learn. Much improved since the other place where, while I'll admit it was not a complete waste of my time, I was very unhappy. That being clarified, I'll try to explain my dilemma.

I'm really enjoying working with the students and teaching them although I definitely defer to the senior clinicians since they know a whole lot more than I do. Thing is, though, they don't really give me much of a chance to teach. On overnights I get more opportunity but then my learning time begins to suffer (besides that I certainly wouldn't want to do continuous overnights!!! Ugggghhhhh!!!!) I also don't get much of a chance to do anything since I'm always sacrificing to let the students do then when they hand to me someone else grabs it away (i.e. the techs) almost as if they are afraid to let me do anything or I might mess it up. This is particularly difficult for a person with my completely non-traditional background. I've been out of school for 2 years, did almost a year of mixed animal private practice prior to my first internship. I am capable of pulling blood and placing IV catheters, etc. but they slap my hand away every time.

The other weird thing is that they are much more lenient on the students here than where I went to school in so many ways but the things they choose to go crazy about are just wacko. For instance: the students expect lunch every day as in to be able to go out and get something, they are given their radiology cases to work on a week in advance, they expect to leave on time every day and not be asked to stay late, they rarely have their "supplies," and the list goes on. Lunch?!?!?! IF you got it it was on the fly except on rare occasions. Our radiology cases were handed to us at 8 a.m. and we were told you have 15 minutes. Get out on time?!?!?! When did that happen? You cannot imagine the number of times I was asked "Are we stuck here until they are all done?" Whining or not having supplies??? I'm sure some people did but I would have thought you wouldn't pass the rotation. I threatened to get candy pacifiers for the last group because I was tired of telling them to stop whining.

By the way, did I mention that they get days off? Each rotation they are allowed a certain number of days off. These have to be approved, of course, but DAYS OFF!!!! I don't remember days off in vet school unless you were pretty much on death's doorstep...

I have, however, seen them go off on people about the oddest matters. Things that to me were of little or no consequence and someone is chewed out about it. An example that comes readily to mind regards myself but is very illustrative of the point. While on overnights, the rule is that you should be in ICU between 7 a.m. to 8 a.m. for case transfer matters. I stepped out one morning at 7:45 a.m. to take an emergency call (for the hospital not personal) so that I could hear better and got chewed out about it. The students get the same types of things.

Perhaps it is a type of la la land. I'm not really sure yet. Just know I feel a little as if I fell through the looking glass and am at the mad hatter's in wonderland. Still trying to figure it all out but am at least enjoying the interaction with many of the clinicians and the learning.