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...
4 days ago