Mindless

Recently I had a conversation with my current boss (I have known him for a long time) who I will refer to as "Doc" and our receptionist who I will call "Calamity Jane" that I think is amusing. There's a cartoon version of the interaction but my cartoons don't post well on the blog so I didn't try...

Doc: I'm losing my mind lately!

Me: That's impossible. You lost your mind a long time ago therefore you cannot possibly be losing something you don't have.

Calamity Jane: Well I've sure been losing mine, too!

Me: That's also impossible since you never had one to lose in the first place.

Doc: Well, I sure would like to find mine.

Calamity Jane: Me too!!

Me: I wouldn't care to find mine; I'd prefer to have a new one...

Doh!

As I previously reported in a long ago post, I now work for the USDA. However, I still do a little (government approved) practicing on the side at my old place of employment. The other day the following conversation ensued:

Can't Spell, DVM: Hi Mrs. Wacky, how are you today?

Mrs. Wacky: Oh hi Dr. Can't Spell, I thought you left us?

Can't Spell: Yes, I now work full time for the USDA but also do this sometimes.

Mrs. Wacky: Who is the USDA?

Can't Spell: The Department of Agraculture.

Mrs. Wacky: I thought you were a veterinarian, not an accoutant?

Can't Spell: *I favor her with a blank stare*

Mrs. Wacky: Well, do you audit people now?

I really wanted to hand her a sign....

World's Smallest Violin Playing the Longest Saddest Song...

Yes, sarcasm is definitely intended!

On rare occasions, an odd little feeling crops up in my mind that is very atypical of my usual easy-going, laid-back, mostly reasonable, free-spirited self. I've never been sure what prompts the little grumblings but, when they occur, reason and logic go away for a little while then my sarcastic sense of humor kicks in and I give myself a good, swift kick to the rear and move on with life.

I'm having one of those moments right now. In this case, it's a good old pity party. Yesterday, June 30, was the official last day of the internship. I'm here a little longer for two reasons: 1) I drew the lovely overnights to finish out and 2) I started slightly late due to an overlap with my previous internship. So, yesterday, my three intern-mates left and not one even took the time to say "Goodbye."

Not that I expected them to go extremely out of their way to do so but I would have thought they might catch me in the morning before I left to sleep for the day or at 5 p.m. when I came in for the last night shift. Or, if they left early, a text....

In addition, one of the senior clinicians likes to bake and she brought goodies as a congratulations to all of us for finishing. When I arrived this evening it was empty, just the note left.

Yes, I know, poor, pitiful me. Waaaaahhhhh. Now it's time to start playing the world's smallest violin playing the longest, saddest song or to bake me a cardboard cookie or something to convey the message of "just get over it!"

Last overnight tonight - I'm playing supervisor and letting the new intern do it all unless he has questions. It's hard being that hand's off for me but I'm literally forcing myself because he won't benefit from my doing things for him when he won't have me here at all tomorrow night. I then have Friday and Tuesday with the exotics service then I'm outta here!!! Will spend my fourth of July weekend packing and roll out on Wednesday the 7th unless anything changes...

"So long, it's been good to know ya...etc."

Puppy Sitting

About a month ago, I spent a weekend puppy-sitting for one of the animal caretakers here. I had been contemplating fostering a puppy for the sake of my geriatric Bichon who is developing cognitive dysfunction syndrome and needs an "interactive toy." He has always loved puppies so I thought it might be a good idea although I was far from ready to commit to a puppy given that I'm not that fond of the little ones and prefer to adopt troubled adults or even geriatrics with multiple health problems.

Daphne is a 4 week old Bassett Hound / Rat Terrier mix who was orphaned and bottle raised from about 2 weeks of age. She is eating on her own and already learning the house-training skills. In short, she was really adorable and fun. She reminded me very quickly, however, why I don't like puppies. The quote from Shrek about babies pooping and crying, etc. then comparing to an ogre baby is very appropriate.

I took her to the apartment with me on Friday evening. My dogs loved her (except one who wanted nothing to do with her) and she was doing well. The cats mostly ignored her except Pistol who thought she was really cool. On Saturday, the entire outlook changed. My Bichon, the primary reason for her being there, decided he wanted no part of her and got angry every time she came near or dared to touch him at all. On Sunday, the wind had shifted again and he liked her again. Go figure - I have no rational explanation.

This experience made me appreciate the grandparents' house idea; it was a lot of fun to spoil the puppy then send it back home and shuck the responsibility entirely. The pictures show Daphne napping then, on Sunday, napping with the boys. Too bad the interactive toy idea was a little bit of a bust. I tried to include a video of Pistol playing with Daphne but couldn't get it to work right. At least he enjoyed her visit!

Addendum

I forgot to mention the other highlights of the drive. Speeding. Those of you who do not listen to classical music probably will not completely appreciate the mesmerizing affect it has on one and how quickly one discovers that the car is now moving at 90mph (just an example...)! Then one sees the pretty blue lights in the rearview mirror and thinks, "Oh, how pretty, flashing lights..."

I get too distracted way too easily! No, the flashing lights were not for me even though I was speeding. When I quit being distracted, I finally pulled to the right lane and slowed down just in time for the pretty flashing lights to pass.

Just thought I'd add those things for your entertainment.

We are now playing the theme from Twilight Zone...

Well all, I've done it. I've finally gone over the deep end, joined the loony bin, and gone over to the dark side. What I've done is analogous to Benedict Arnold (BTW, that was a special reference for M.B. Insane...), that spy plane pilot in the 50's, and Brutus all rolled into one big hairy ball...

I've decided to stop working full time in private practice and start practicing regulatory medicine... I have decided to start working for the USDA.

There, I've said it. I've left my job in private practice and tomorrow I report for orientation with the USDA. I've always said I wouldn't do it. The reasons were manifold- boring, routine, too much paperwork, not practicing medicine... Sadly, in the last year or so, the stresses not of practicing medicine but working for my boss have forced me to admit to myself that I'm burned out.

I was reaching the point where the intricacies of a nice complicated medicine case were more annoying than interesting. A lot of this was due to the fact that my boss wouldn't order me the drugs I needed to treat it... But, I digress.

I will still be keeping my license current, and still practice occasional relief work on the weekends to keep my skill set current. But I will no longer be doing the private practice thing day-to-day. I'll let you all know in the next few weeks whether this is a good thing or not...

Insanity

I get very scary, even to myself, when I'm really tired; I've always wondered what other people, even people who know me really well, would think if they had the experience of being around when I'm that loopy. I hope I can blame all of my recent behavior on exhaustion - otherwise, I'm really worried about what is happening to my brain!

I've also determined that I am psychic in some way, shape, or form. I have known this for quite some time but unfortunately, the ability is not reliable at best. (And, no, for those of you who know me, I did not mean to say "psycho;" I know that I am both but in this case I'm talking about the ability to sense things before they happen.)

Those comments are intended to act as a segue into my story. I received a telephone call from my mother last Wednesday night after I got off work with some bad news that necessitated my leaving and going home immediately. Home is a 13-14 hour drive from where I'm at right now and I had been up since 5 that morning then worked all day. Since I'm almost done here, I opted to catch the herd of cats and take them home to leave with my mother for the remaining few weeks prior to my move. By the time I had hurriedly packed, caught cats, loaded all the critters and all the necessities, and actually hit the road it was 11:30. I drove...and drove...and drove. Around 3:30a.m. I pulled off for a quick nap in the truck then was on the road again at 4.

By the time I was within 2-3 hours of home, I was way out there. I decided that I didn't like anyone except my mother and that I would divorce all of my friends since I don't want to have anyone that I need to care about. I was talking to myself (not that this is completely abnormal for me but the conversations were frightening, even to me!) and answering, of course, singing, having discussions with nearby drivers (they were too rude to answer), reviewing bug anatomy (exoskeleton, hemolymph, etc.) as they hit my windshield, talking to roadsigns and billboards, and...I think you should get the picture from that.

The next thing that happened was that I missed my final exit. Things like this do NOT usually happen to me. The road was under construction at that area and I should like to blame that but if I were to be honest with myself and y'all, I would confess that I just missed it. The north bound lane was rerouted alongside the south bound therefore the next exit was closed from the north bound side. I drove 24 miles to reach the next available exit then had to turn around and drive back 24 miles in order to get off the stupid interstate and make it home. One hour later than I should have been, I arrived home at last!

It is now 2:30p.m. CST and I have to face the reasons why I went home. Finally, around 7p.m. I was allowed to fall asleep but only after having an apparently nonsensical conversation with my mother in my sleep of which I remember nothing other than her saying, "What are you talking about?" and my responding, "I don't know, what were we talking about?" to which she answered, "Nothing."

My visit was soon over and I found myself back on the road for this place late Sunday morning. Guess what? I did it again! I missed an exit and went 10 miles (one way) out of the way because I was looking for the wrong road name in association with the highway. Found myself driving along thinking that nothing looked familiar then realizing I should have taken exit 123 but was all the way to 113. More time lost. One would think that might be the end but no, it happened one last time when I hit the next junction and took the east bound highway rather than the west bound... Once again, about 10 miles one way down the drain before I think, "Wow, this doesn't look familiar either..." followed by looking at my compass and seeing that I was heading back east.

Due to extreme forced concentration, I managed not to miss the remaining junctions and exits but it took A LOT of effort - much more effort than it should have required. I found myself looking longingly at motel signs somewhere around 6p.m. but forced myself to finish the trip and arrived back around midnight just to get the critters that returned with me in order, wash clothes for the workday ahead, and fall into bed. I allowed myself to sleep in until 6 instead of rising at 5 as per usual. It didn't help much since I've spent the entire day garbling my words and not feeling that I can truly trust anything that exits my mouth. Even simple facts should be questioned; I stated the concentration of meloxicam, which I've known simply for ages, then second-guessed my accuracy. I told the kids (read students) that they should not take anything I say today at face value but double check it first.

I've managed to explain the scariness of myself but forgot about the psychic thing. That was really brought to mind because over the past 2-3 weeks I have been exceptionally sad and found myself getting a knot in my stomach any time my mother phoned that was an unusual time of day. Receiving the call was unexpectedly expected somehow.

Which brings to mind a totally unrelated comment that I cannot stop (see how frightening the workings of my mind can be?). We use the term "regularly irregular" in an attempt to describe what is heard with atrial fibrillation. One of my friends has dubbed me "predictably unpredictable" for my typical behavior - I like it!

I think that is all I have to say at the moment. Just thought y'all might enjoy the stories of my insanity at least a little bit. Oh, and I have changed my mind for now about divorcing my friends since I am in a slightly more stable frame of mind...

Cats

I've often been asked if I'm a "cat or dog person" but I always find that difficult to answer. I have both and enjoy both. Had horses prior to vet school but they died due to old age and I haven't had an appropriate opportunity since to get more. Really, I enjoy them all. If pressed, I would probably admit, however, that I have a tendency towards cats. Likely, it's my personality speaking since I would definitely be a cat if I were an animal...

Usually, I chunk all of my important junk in my purse at night and it sits on the counter often partially unzipped. I must remember to zip it completely or put it away where the cats cannot get it from now on.

Last night one of the cats raided and pilfered from my purse! She (I guess I should say allegedly since I can't really prove who the culprit is) stole both sets of keys, my watch, and a pen. I thought that was all and had recovered them this morning prior to going to work to check on my hospitalized patient. Only now did I discover differently. I got called about my patient and had to go back to get some anti-nausea medication for him only to discover no ID badge to get in to pharmacy. I frantically searched for several minutes before the truth dawned. Fortunately, one of my colleagues was there and loaned me their badge to get the drug. I came back to the apartment and demanded that the loot be handed over. Took me a little while to find the stash...there was another pen hiding too!

Cats! Gotta love 'em....

Sarcasm Rules the Day

Sometimes, my sarcastic sense of humor takes over and crushes the filter down with the end result being that I say things I probably shouldn't. The bad part about the big one today is that I'm now going to repeat it on this blog. Can't seem to help myself. It's probably a product of the fact that I've been very bored today and looking for ways to cause trouble. Planning some great pranks for tomorrow...

Hopefully, not everyone out there is as illiterate as most of the students that I've been working with lately and are at least somewhat familiar with the classic Dickens' novel A Christmas Carol. There are many movie versions of the book and one of my favorites is the old version starring Alastair Sim in which he dances and jumps on the bed and sings "I don't know anything..." at the end. Prior to his redemption, he makes the comment to someone who is soliciting donations for the poor that "they had best die, then, and thus decrease the surplus population."

That lengthy intro to explain what came out of my mouth completely unpremeditated today.

One of my intern-mates was telling me the story of a former classmate of his who was instrumental in changing the school policy to surgery only on cadavers. After graduation, he talked to the person from whom she obtained a job who reported to him that the girl was incapable of performing a routine spay or neuter because her ligatures were not secure and all the patients then began to bleed, she freaked out and had to scrub out of surgery leaving someone else to stop the hemorrhage. She now plans to open a low cost mobile spay / neuter clinic. He very kindly put it that she was "misguided." What do I say? "I guess she's doing her part to decrease the surplus population!"

It took him a minute to realize what I implied and then I had to explain the reference so that he didn't revise his opinion of me to think that I'm a total monster...

Yep, that horrible sense of humor is going to be the death of me one day!

Sometimes it's all in the delivery...

Ah, another grump. Really, all too often things that make one mad could be not a problem at all if the delivery were only different. Think about it - there are so many different ways to say things and you can make almost anything sound better or be less abrasive if you only take a moment to think about it before you say it and try. To quote a couple of old sayings, "My mother told me if I couldn't say anything nice not to say anything at all." and "You catch more flies with honey than vinegar."

That lovely intro to complain about negativity. Honestly, I don't mind receiving constructive criticism and bouncing around ideas on how to do my job better. I'm actually my own worst critic by far. The problem is that people come in and criticize without bothering to find out the whole story and without ever offering a word of praise or considering the situation.

Two stories to illustrate the point. One relates to me, the other to one of my intern mates.

My intern mate is currently on emergency overnights. One of the critical patients in ICU went into respiratory arrest early one morning because it developed a tension pneumothorax (known pneumothorax, had been stable and suddenly deteriorated). He treated the patient and kept it alive allowing it to be rushed to emergency surgery. (The patient, by the way, is doing great.) What do the surgeons do? Do they say anything like, "Hey, good job. We can talk about other things you could do, etc.?" or "Thanks for keeping the dog alive; we know you work under difficult circumstances..." (I'm sure most of you are laughing your heads off at the moment - so my sarcasm is blatantly obvious.) Of course not. Instead, they take the dog to surgery then when he comes back in for his next shift (did I mention he stayed late helping after a 16 hour shift by the way?) they pull him aside to point out all the things he had done wrong and how he could have "treated the case more aggressively."

For me, on my ER shift this weekend, I admitted a cat that escaped the owner's house sometime during the night and got mauled by a dog or coyote or something. On presentation, his temperature was so low it would not read and his veins were so constricted that they looked like a line drawn on paper. We could not gain IV access for quite some time and started warming him aggressively as well as "bolusing" warm SQ fluids. I finally got an IV catheter in him when his temperature reached 89. The owner didn't have a lot of funds so we threw that into therapy rather than diagnostics and managed to have an alive as well as much improved cat the following morning. With what was I greeted? Why didn't you get thoracic radiographs and full bloodwork? Well, first because it took so long to warm him that I didn't want to freeze him again in radiology, not to mention that I did not feel that he was stable enough to go to radiology. Also, the price limit given to me by the owner basically covered stabilization and one 24 hour period in ICU - what good is a thoracic radiograph if you then have to euthanize due to lack of funds? There was (of course) never a "good job on keeping the cat alive, now that he's more stable we should talk to the owner about further diagnostics." (Would have been that simple to make the statement inoffensive - after all, I know that the recommendation is to obtain thoracic radiographs on trauma patients, it's not like it was ignorance factor.)

I don't know; there's always room for improvement but it is just so discouraging when negativity is all that ever spews forth. They also never seem to consider that on ER shifts we are lucky to have one technician on with us;not like the gaggle that they have following them around during the day. Yes, there are students but they cannot be depended upon to have the level of experience needed for an extremely critical case - besides, they aren't technicians and can hardly be expected to have the technical skills needed.

While I'm complaining, I also get really tired of the negativity between technicians. In the ICU here, it seems that they have chosen sides as if in a feud. Monday morning, I'm bombarded by criticism of the tech on over the weekend for not putting in charges, etc. without ever a question of "how was the weekend" because, you never know, there might be a good reason that charges were not put in. In this case, it had to do with the cat previously mentioned that was followed by one of our critical cases (septic abdomen) arresting and receiving CPR for a prolonged period (we got him back twice but failed the third time), etc., etc.

The old adage about walking a mile in my shoes before criticizing is really true but so few people do it. I wish I could just make people pause just for a moment before opening their mouths and consider what they are about to say. If they would, I think they would often either rephrase or just not say it at all.

On Fridays, Being Thrown Under the Bus, and Other Odds and Ends

It is absolutely amazing, the difference in the hospital on a Friday evening in comparison to any other day. While most things move at the speed of molasses in the winter, on Friday, suddenly, it's as if a new life is infused. Let a back dog come in at 4 and it's guaranteed that the imaging, including CT scan, will be done by 5 and the dog will be well on its way to surgery. Any other time, the molasses would slowly move and it would take hours to be done.

The other amazing thing about Friday is how quickly everyone hits the door. Better not count on someone being there at all late 'cause it ain't happening. By 5:00:01 they are gone. WHOOSH!! The gust from their leaving could knock you down and you'd better get out of the way.

And, in the vetmed world, Friday is often "dump day." All the nearby rDVM's decide that they should unload the challenging cases in their hospital that they don't want to deal with over the weekend. I've never quite understood this since most of the time further work-up won't be possible until Monday anyway, even in the referral hospital. It's even worse when the dumping "rDVM" is the in university hospital community practice (CP) service. There were at least 2 cases sent home abruptly today that I doubt were really sent home for the well-being of the patient. No, I would distinctly say that it had to do with the convenience of the clinician... To explore the motives can sometimes be a frightening prospect (even your own motives at times).

Interestingly, I have only gotten one "dump case" tonight; or, to put it better, this one is what I sometimes refer to as a "prefergency." It is a not extremely critical patient that needs further diagnostics and it was "easier" to come tonight rather than wait until Monday. Guess they have the financial means to pay for the preference as well.

Yesterday, on the other hand, was an entirely different ballgame. Yesterday, though, was more of a "thrown under the bus" type of day. Sadly, not by outside sources but by people working side by side as colleagues. Not that the occurrence is abnormal in this place. It is actually quite commonplace and you feel more surprised when it fails to occur.

A snake bite case showed up at quarter til 5, the ER overnight shift starts at 5. Guess upon whom it was dumped. I think that the icing was when the CP clinician then tried to dump callbacks for their cases on us and later called to ask about the snake bite and criticize the planned treatment regimen. Out of last night was born the repeated quote (and very atypical attitude for me) of "Not my problem!" I guess there comes a point for all of us at which we are tired of lying down and saying here, why don't you wipe your poop covered shoes all over me as you walk across my prostrate form.

This particular rotation, or I guess I should just say the last few weeks, has been particularly bad. It's easy enough to deal with small problems but when they mount up to an enormous pile they become overwhelming and that is when tempers flare and patience becomes frayed. In fact, it is usually the pile of small things that make me break much faster than the big issues - those I just take in stride. And no matter what anyone says, it always seems that if a shift begins one way, it just can't seem to be turned around and made better!

So much for Fridays...When you hear the ka-thump, just look for the big yellow bus that ran me over then backed up for a second chance.

Money

I'm going to tackle a tough subject that comes up all too often, particularly these days with the current economic situation.

It's 2:16a.m., I receive a call that wakens me from my catnap stolen on the recliner in the faculty lounge. "We have a 6 week old puppy that got stepped on and has blood coming from its nose. What should we do?"

I ask the usual questions that I use primarily to get the owner to calm down a little and also to ascertain how bad of a situation we have. I advise the owner that the puppy should be seen then advise them of the emergency fee and payment policy. We are supposed to do this with every call unless they indicate the pet is actively dying and I have learned to do so anyway in order to save grief when clients arrive with no money.

"Do we have to pay it all now?"

How often do I get asked this question. "Yes, you do or if the pet stays in the hospital you would leave a deposit of half the high end of the estimate."

"Oh."

"Are you coming in?"

"I'll call you back."

Translation = No, not spending the money.

Why do people seem to believe that veterinarians should not charge for their services? "But I thought you loved animals!!!" Like any other professional, we deserve to be paid for the things that we do as well as the materials that we use. And how many other professions allow you not to pay up front? I've always wondered why people look at us differently in that aspect.

I should point out while I'm saying this that I tend to be one of the worst when it comes to letting things slide. I've been in trouble with my boss at every place that I have worked thus far for not charging for some things. I immensely dislike "nickle and diming" people. Really, you want me to charge for the 3 staples I used on that laceration separately? Yes, I know that realistically, it all adds up to a far larger sum than I realize but sometimes it just seems unfair.

One of the worst is when a very critical patient arrives and you still have to charge the ER fee just to euthanize. It's hard enough trying to get money from people when they have nothing much less from people whose pet you just killed.

And I know that one of the arguments is not to have pets if you haven't the money but I'm not sure that I consider that particularly fair either. I couldn't have pets right now if that were the rule 'cause I sure can't afford them. If I didn't have them, though, I would truly be pushed over the edge; they allow me to maintain what little sanity I have left.

Tonight, I got a call from a guy who has $100 total and his dog just did something to hurt its nose. Sounds like the dog will survive the night and I bluntly told him that he will be able to stretch that money farther by waiting until morning and seeing a local vet sans emergency fee. People have a hard time swallowing that information but I'm nothing if not honest. That then becomes difficult when people get angry saying you are refusing to see them and don't care about their pet. The bottom line is that in the situation I'm in currently, there's really nothing I can do about the financial policy and if I were to admit the pet to the hospital, they would just rack up a lot of cost which they cannot afford then get sent to collections. Unfortunately, they are usually too upset to see that I'm trying to make my best judgment call decision for their pet's welfare.

Sticky situations always seem to revolve around money. And they wonder why veterinarians seem to feel as if they don't deserve to get paid for their knowledge....

To Dr. May B. Insane

Don't you know? When people own dogs, common sense flies out the window! Kind of like the owner I see constantly who "breeds" blue heelers... he *never* brings his puppies in for taildock and dewclaw removal in the established 3-5 day old window as "ideal" for doing this procedure. Instead, he brings them in usually from 8-14 days old... the then require local anesthesia to do the procedure... even though I've told him fifteen million flippin' times to bring them in 3-5 days of age... People are STUPID!!!

Dear Stupid Client from the Insane One

I fail to comprehend people and have determined that common sense does not exist!

Last night at 8:30, I received a call from a client whose cat has a chylothorax and has chest tubes in place. They reported that the cat had been open mouth breathing although it was resting comfortably at the time of the call. They live 3+ hours away.

I advised the clients that they should ideally find a local ER clinic and have the cat evaluated immediately. The alternative plans I offered if a local ER clinic could not be found were as follows: If the cat remained stable, have him evaluated by the regular vet first thing in the morning or head in this direction.

I heard no more from them until 4:20a.m. at which time they called, in a panic and in tears, to report that the cat was "still" open mouth breathing and no one would see them without their being an established client.

Need I point out that they could have been here hours ago had they listened to my advice...

Display of my Insanity

Really hit me again tonight, something I've thought often about since making the decision to come here for a year. Prior to coming, I was aware that a certain person that I had known when I was a fourth year student and she was an intern was here in a medicine residency. Still, yet, I chose to come.... What the heck was I thinking???

Misinformation - Ignorance is NOT bliss!

I've decided to come briefly out of hibernation to relate a story of a recent case that I saw.

The radiographic images that follow have only been altered to remove the names and other identifying features.

Received a call the other night from a rDVM (referring vet) regarding a dog with caval syndrome that he wanted to send this way. The confusing part of the story is that the description I was receiving of the case and the classification of caval syndrome did not really fit.

Caval syndrome is when heartworm disease becomes so severe that there are adult worms present in the right atrium of the heart. For those unfamiliar, calling it heartworm disease is a bit of a misnomer anyway since the adult worms are typically found in the pulmonary artery, not in the actual heart. When caval syndrome occurs, the affected dog is in right heart failure with all the bells and whistles including peritoneal effusion, pulmonary hypertension, congestion of the liver, etc. etc. etc. Often these patients are also in DIC (disseminated intravascular coagulation aka dog in cooler if you have the morbid sense of humor that most in our profession do) and are at high risk for thromboembolic events such as pulmonary thromboembolism (PTE) which is most often fatal. In other words, you have a really sick patient who is not a good candidate for anesthesia. What is the treatment? Anesthetize the animal and surgically remove the adult worms from the heart.

In addition to the above listed problems, dogs with heartworms often get a secondary pneumonitis or severe inflammatory response in the lungs. There is no such thing as waiting to make these patients more stable and a better candidate for the surgery.

Back to the patient at hand. She was described as an approximately 8 year old, spayed female, Basset Hound who had a bicavitary ultrasound showing adult worms in the right atrium, only mild changes to the heart, no evidence of failure including no peritoneal effusion or changes in the liver. I was also told that the dog was bright, alert, and responsive and that the worms had been visualized approximately 48 hours previously. What part of this description makes no sense to you???

Recommended that the dog be sent immediately. As a side note, they were supposed to arrive around 11pm but got lost and rolled in around 1am. The dog was BAR with nothing to indicate to me that it was a caval syndrome dog. We obtained some baseline data including CBC, Chemistry panel, PT/PTT, and d-dimers. Nothing particularly exciting on the bloodwork other than mildly elevated liver enzymes. We then obtained thoracic radiographs. Four views to follow:

Ventro-dorsal thorax

Dorso-ventral thorax


Right lateral thorax


Left lateral thorax

So the obvious is the large heart with a "reverse D" appearance that is oh so typical of heartworm disease. The interesting part to me is the suggestive appearance of pulmonary edema consistent with left heart failure that is not really pulmonary edema. What you see, particularly in the DV and right lateral views, is an extremely huge, tortuous pulmonary artery (I would put in an arrow or outline it but couldn't figure out how - hmmmmm.....). Pretty impressive isn't it?

Blood pressure was normal, ECG was normal. Called in the cardiologist who did an echocardiogram and determined that there were no worms in the right atrium. We then looked at the echo video sent by the rDVM and there were indeed worms present two days prior. She apparently "resolved" her own caval syndrome so to speak. Clearly, she did not develop severe symptoms therefore the worms must not have been present for long. I find it extremely amazing the things that our patients can deal with and still be okay.

In talking to the dog's owners, I found them to be extremely concerned and caring people. The dog had been diagnosed with heartworms a minimum of 3 years previously because she was positive at the time when they adopted her. So why didn't they do anything?!? Misinformation. Either through their misunderstanding or incorrect information given by someone (could have been rDVM or other vet or some random person since I have learned people often listen better to what "Aunt Polly" found off the internet than they do to trained veterinarians) they were under the impression that heartworm disease is incurable.

We opted to treat for presumptive pneumonitis and use a medication to decrease the risk of thromboembolic events then begin a two stage adulticidal therapy with required hospitalization during each stage of the therapy. The prognosis is still guarded since the same risk factors enumerated earlier still apply but it's probably better than having to go to surgery (although surgery would have been way more cool!) With some luck, this very sweet dog will get treated, do well, and still have some really good years ahead.

Duh!

Soooo...... saw a dog today for our grooming day. It was black. It had dreadlocks kind of like a Komondor (http://www.akc.org/breeds/komondor/). Except it was a Cocker Spaniel. We couldn't even get a needle through the mats to get a blood sample for a heartworm test. It had the nastiest, ickiest ears I've ever seen with all sorts of rods on the stain...

After it was shaved and had a bath it lost 10 pounds... Actually looked sort of like a Cocker Spaniel.

Some people need an instruction manual and a license to own a dog...

Dear Stupid Client vol 1

I've decided to make this long-overdue edition of this blog to air a list if things that are pet-peeves about what client's say. In no particular order...

1) "My dog's been sick for a week, you think I should bring him/her in?"
2) "Will my dog get sick from eating a whole ham bone?" Well, wouldn't you???
3) As they leave their sick/dehydrated/vomiting/not eating/insert deathly illness here dog to you for treatment, they ask "Can you trim his nails too?"
4) Same scenario as above, but they ask if the dog/cat's shots can be updated.
5) Stupid client asks over the phone what caused their dog to die even though we've never seen the dog. Let me get out my magic crystal ball...
6) No Mr. Stupid Client, I cannot tell you if your dog has diabetes just by looking at it.
7) The cat has an arm that is clearly broken and facing the other way- "He doesn't act like he's in pain..."
8) "Can I give my dog aspirin/Tylenol/ibuprofen?"
9) "I have given my dog 15 aspirin/Tylenol/ibuprofen."
10) "Why does this cost so much?"
11) "My last vet didn't charge this much!"

More to follow as I encounter them...

Letter of Resignation

To Whom It May Concern:

Please consider this my letter of resignation from your program, from veterinary medicine, and, perhaps, from adulthood in general. I am thoroughly disgusted and fed up with the politics of the profession. I want to be completely clear in the statement that this decision has nothing whatsoever to do with the medicine. Yes, there are times in which the medicine can be frustrating and cases are lost that are difficult to swallow but it is the politics that are killing me.

Nasty politics that range from making decisions based on convenience rather than what is best for the patient. Politics that involve feeling as if proving yourself smarter or better than others dictates what decisions you make for your patient. Politics that require people to dance around the boss in worship rather than consider the needs of the patient. Politics that necessitate genuflection and kissing derriere or other methods in order to advance in your career. These politics are the source of the death of my professional career.

When did veterinary medicine become a study of "me"? At what point did we relinquish our devotion to our patients' needs in favor of our own petty whims? Do not misunderstand; I am not advocating having no life of your own or being a selfless martyr. I simply do not understand what happened to our priorities.

Initially I questioned whether I was asking too much of this institution and found myself comparing it to my alma mater. I tried to be reasonable and figured that since I have been out of school for quite some time it was likely that I was viewing my time as a student with "rose-colored glasses." Recently I visited again, this time in the role of a doctor, and found that I was not disappointed. It truly does work better there. So what has happened here???

I was asked if I was burned out from working such long hard hours and the simple answer is no. Burned out is not the word I would use to describe myself. I am disappointed and depressed. I feel as one would feel when their absolute idol has crumbled and fallen to the ground in front of them, proving to be merely human after all. Perhaps I have asked of and expected too much from my profession and am now witnessing the fall of unsustainable expectations. Perhaps there really is an idealist beneath my cynical facade that is being forced to face the reality that nothing is as it should be. I don't know exactly how to explain what is going on right now other than to say that I feel suddenly, devastatingly, completely depressed and disappointed.

Unfortunately, this is not the only place in which I've witnessed this phenomenon. Since graduation, I have worked in three different places, three different settings. First in mixed animal private practice, second in specialty private practice, and lastly in a university setting; in each of these I have witnessed this disturbing tendency. I have now reached the end of my tolerance and I quit. I do not quit the patients - it is not their fault that this idiocy reigns - but I quit the situation. No residency for me; I don't even want it anymore because at this point I cannot imagine that it could possibly be any better. Veterinary medicine adieu. It is time to find a new means of making a living as I cannot tolerate this blasphemy any longer.

So anyone want to buy a cookie?

Hopeless

It seems as if all of my ER shifts go in themes. You know, I'll see a ton of GDV's or hemoabdomens or something just keeps recurring. This time it is the rotation o' death.

I started out with a bang the first night I was back with a severe pancreatitis that seemed reasonably stable all night until 6:30a.m. when he apparently had a pulmonary thromboembolism, started breathing heavily and expired within about 15-20 minutes. This has continued with nasty cases throughout the week. On Friday morning, I got to spend 1.5 hours talking to a lady about letting go and considering euthanasia for a dog that we've been seeing here for years (I'm always lucky to catch those.) It didn't help that the dog reminded me immensely of my little Choo who died last December shortly before Christmas.

I finished the week with a sigh of relief and a lot of chocolate support thinking, "Finally, the week is over; surely things will get better next week." For those astute readers, I'm sure you are just expecting the other shoe to drop and you would be correct.

Tonight, I admitted a very sad case whose ultimate outcome I am completely certain of but whose owners want to try everything possible. The dog was completely normal until after the owners had been away for 2 hours at church at which time they found him staggering and acting drunken. He had been outside on a tie out while they were gone. He drank a whole bowl of water then promptly threw up. They brought him in to me and my first thought was ethylene glycol toxicity until proven otherwise.

With questioning, the owners stated that, yes, they had changed the antifreeze in their car the day before but they didn't think he had gotten any although a small amount spilled. I told them that was my top concern and that we would run some tests to try to find an answer. Being past the probable window of getting good results for the specific test I ran a baseline CBC/Chemistry and discovered the dog was in renal failure although he was also extremely concentrated at a PCV of 72% so he had some pre-renal component. I had started shock therapy and he received a full 3 liters of fluid bolus before he seemed to stabilize at all. We attempted to get a urine sample and found that he had approximately 0.5ml in the bladder. For those medical types I'm certain the warning bells are screaming. Further confirmation of my diagnosis came from the presence of too numerous to count calcium oxalate monohydrate crystals in the sediment.

At this point, he is rehydrated and back to normal temperature (he was severely hypothermic on presentation). We administered fomepizole, the antidote for ethylene glycol. We have tried a 20% dextrose CRI in an attempt to induce osmotic diuresis without a drop of urine produced. We are now adding furosemide (lasix) and a dopamine CRI to see if that will work. If it doesn't, I have no more choices and the dog has no more chances. I'm not holding out much hope.

Antifreeze is a deadly toxin for all animals. Apparently it has a sweet taste and is attractive to pets to drink and it only requires a very small amount to induce renal failure. When you reach the point where the kidneys have stopped producing urine, particularly in the face of the volumes of fluid we are pouring into this dog, it is extremely bad juju. Our best chance of survival post-antifreeze ingestion is if the event was witnessed and medical attention sought immediately. When it has been long enough to see crystals, we are already starting out behind the eight ball. Realistically, this dog will not walk out of the hospital and it's only a matter of either time till he dies or his owners making the decision to quit. I have already had the serious talk with them and if he fails to make urine with the addition of furosemide and dopamine there is really nothing else to do and I will recommend that they choose humane euthanasia. At least that is an option that we have in vetmed...

We Wear the Mask

Paul Laurence Dunbar (1872-1906)

We Wear the Mask

WE wear the mask that grins and lies,
It hides our cheeks and shades our eyes,—
This debt we pay to human guile;
With torn and bleeding hearts we smile,
And mouth with myriad subtleties.

Why should the world be over-wise,
In counting all our tears and sighs?
Nay, let them only see us, while
We wear the mask.

We smile, but, O great Christ, our cries
To thee from tortured souls arise.
We sing, but oh the clay is vile
Beneath our feet, and long the mile;
But let the world dream otherwise,
We wear the mask!