Thank you, Walt Disney et al

Have you ever stopped to think about all of the different venues that somehow contribute to our profession? Over the past few years, I have made a concerted effort to avoid the phrase "the back room" or any variation thereof.

Why?? Well, think about all the lovely movies that refer to taking the animal star to the "back room" where untold horrors will occur. Homeward Bound, Lady & the Tramp, Beethoven, just to name a few.

Yes, I love these movies and am an avid Disney fan but they do contribute to some of the negative emotions clients feel about veterinary medicine. Many times before I thought about this I would refer to taking a beloved pet "to the back," meaning of course the very plain, safe treatment area to protect both the pet and the owner while a benign procedure was performed, only to be greeted with a horrified look and extreme reluctance to relinquish said pet into my hands. It took me a little bit to connect the dots but since that time I've always imagined what horrifying images must be going through the poor owner's mind...

And so I say "Thank you" to the movie industry as a whole for adding more work for us.

Oops!

Had to share the funny. In a vet clinic when folks are restraining animals often unintentional inappropriate touch occurs. It's just a fact of the job. The tech, groomer, and assistant were behind me holding a very reluctant pooch trying to get the nails trimmed as the final touch of the groom when I hear the following exchange:

Groomer to Assistant: Okay, let go of the boob!

Tech to Assistant: Here, hold this one!

Note: The tech was referring to a dog leg which was what the assistant was trying to hold the entire time - we do not r0utinely practice boob holding.

Frustration

I'll have to give a little background here so the following makes some sense. For those who don't know me or haven't figured it out, I tend to be pretty OCD and paranoid about certain things - particularly the care of my personal kids and my patients. I also spent most of my life thinking I would hate teaching in any way, shape or form but was surprised to learn through firsthand experience that I actually enjoy it. I'm one of those weird folks who is extremely laid back and easygoing in general but have a very intense, type A, streak about certain things that seems to hit people by surprise when it arises...

All that to introduce comments on a couple of items. I get very frustrated and angry with myself when I make mistakes. If the mistake resulted in the loss of a patient or even could have possibly contributed to the loss, the anger is magnified many times. Yes, I know we are all human and no one is perfect but that isn't enough to stop my anger at myself.

I had a couple of critical patients come in on top of each other on the first day back after the snow when we were only open part of the day due to road conditions. One of those patients was a middle aged cat that was easily diagnosed as a kidney failure, apparently relatively uncomplicated. I've treated many of these guys, most successfully as long as there were no complicating factors such as owners unwillingness to try or underlying heart disease. This cat began to eat a little on the first day after just a few hours of fluid therapy so I was very encouraged.

The second day, the cat continued to look better and was eating small amounts; not ravenously but some. Around 3:30, I had her out again, re-examined her, and hung a new bag of fluids. At that time I also gave a small volume of hetastarch in addition to her crystalloids since her protein levels were going down with the fluid correction of her dehydration and the lack of significant intake. I was then busy for a time and the owner came to visit around 4:30. He asked the tech why the cat's face was swollen and they called me to look. Indeed, her face was swollen as was her tongue. It made no sense to me initially and I checked her lungs, etc. to see if I could find other signs of fluid overload but did not. I made some lame comment about protein levels being low being a cause of edema and that we would slow the rate in case she was trying to overload then the owner left.

I wound up stopping the fluids entirely and continued to monitor the cat. She was sleeping comfortably but would not eat anymore, likely because of the swelling. Around 2 a.m. I suddenly awoke from a sound sleep to remember that hetastarch can sometimes result in anaphylactic reactions. (Probably the astute reader already thought of that.) When I arrived at the clinic, she had died, apparently peacefully in her sleep since she was curled in her cat bed.

Since then I have agonized and beat up myself almost constantly wondering if she did have an anaphylactic reaction that I could have treated had I recognized it and was that the cause of her death???? Alternately, did she get fluid overloaded and should I have done something more??? I hate losing patients, especially when I know that I've done something wrong!!!

The other subject upon which I wanted to comment is our volunteers. Currently we have two volunteers. One is a recent high school graduate who has just begun taking the basic undergrad courses in preparation for applying to vet school. The other already has a degree and has decided to go back to school to become a technician. Unfortunately, my state no longer has a full time veterinary technician program and the only available program is done by correspondence with the practical portion done in private practice clinics who are willing and qualify to help train them.

The first volunteer is very nice although very young, if you know what I mean. (That's funny coming from me because I've always felt old compared to the people around me regardless of their age... In this case, she is very young!) She seems very interested, asks lots of questions, and is fun to teach; except that she talks too much when she is trying to ask something. I know, I'm probably being too witchy but it makes me crazy and I then have a hard time deciphering what she is saying because I get lost and tune out. I've often thought that one reason no one listens to me is that I pack too much information into too few sentences but I hate talking very much and try to give all the pertinent information as succinctly as possible when discussing a case. She was asking a question about her pigs and I got totally lost before she finished because she just kept going, much like the energizer bunny.

The second volunteer laughs too much and doesn't seem very dedicated. For someone to actually become a good technician through a primarily correspondence program, a lot of dedication and self-control is a necessity. I don't think this one will turn out well. I have no problem having a good time at work, enjoy a good joke, and can laugh about most anything but in a professional setting, there is a time and place for it. When I am euthanizing a long time patient in one exam room, cutting up and giggling just outside the door is highly inappropriate. This one just doesn't seem to care enough unless she wants to show off for someone. I'm getting the feeling that her primary interest is doing the "cool stuff" and that she really doesn't understand the job. The other difficulty is that she has been a client for several years and she has seen my "professional face" but not my "private face." This is very different because I'm very introverted in private but appear extroverted in professional settings.

Otherwise, things keep rolling along. I think this one is worth sharing as well for the comedy. There was a small dog that had a bladder stone that was removed by my boss the day before he left on vacation. I reluctantly sent her home on Saturday; she wasn't eating and just didn't seem to be bouncing back well but the owner was very insistent and I had nothing else to stop me. She presented again on Tuesday (first day back after snow) almost flat out, bradycardic, and with diarrhea seeping from her rear. Thought she had free fluid in the abdomen but wasn't positive until abdominocentesis found urine.

Yep, the bladder had dehisced and her abdominal cavity was filled with urine. In essence, she felt as if she were in kidney failure given the blood values (BUN >180, Phos=20, Potassium=8.5, Creat ??) but it was all due to the urine. I stabilized her with IV fluids then took her to surgery as soon as possible. Closed the bladder again and flushed the abdomen. The bladder wall was at least 1cm thick and very fragile.

Here's the comedy - I called the owner and was telling her the surgery went well but there was still danger that it could dehisce again, etc. given the state of the bladder. Explained that we may need to get her to a specialist if it happened again, that she couldn't live without a bladder and if the bladder would not heal we would be running out of good options, and that this could result in death.

The owner was slow on the uptake and responded "Do you mean we could lose her?"

Me: "Unfortunately, yes, we could."

Owner: "When will Doc be back?"

I almost laughed aloud. No, he did nothing wrong to cause the bladder to dehisce, it was a very unhealthy bladder. He is more optimistic and less cynical than I so it's very unlikely that he explained the dangers associated with the surgery. I'm sure that the owner figured I must not know what I was doing when I told her how bad it could be... Gotta love folks!

On College Football

I'm sure that anyone who has any interest in college football heard that Auburn won the championship in Arizona this time. For those of you who don't know much or anything about college football, particularly in the South dealing with the SEC and the Alabama vs Auburn rivalry, I am not going to try to explain and the following joke won't mean much to you. (I've tried explaining in the past and, unless you've seen it firsthand, I've found that you just can't grasp the extent of the insanity of football in the South.) For those of you who know, enjoy!

The Alabama folks have always said that hell would freeze over before Auburn won a championship title...

For once, it seems they are right.

Tuscaloosa was frozen.

Snow Day

I neglected to mention a couple of items in the last post so this is somewhat a continuation and somewhat a tale of today.

Forgot to tell about the lady who brought in her very overweight MinPin with a ruptured cruciate and back pain. The lady is a human drug rep but does not believe in drugs. Fortunately, I am very sold on the research and efficacy of many homeopathic type remedies so that helped. It was a very long appointment that helped to run the afternoon behind. And there was the huge mast cell tumor on the old corgi's prepuce. That would have been a fun challenge to try to resect if only they would have let me... No one ever lets me do the things I would love to do although I can see their point given his age, etc. (Sigh!!)

So Saturday improved immensely. I spoke to the crazy guy with the sick puppy again that afternoon. I had told him to meet me at 1:30 but he didn't show so I called him. He said the pup was doing fine and he wasn't bringing it after all. I told him to call if he had problems and he assured me "we would be the first to know." Right. I heard nothing but dead silence until Sunday night just before 8 p.m. when he called to say the pup had been vomiting ever since we spoke the previous evening and he needed to bring it in now.

We had a winter storm advisory out with expected ice and snow, enough to shut down roads in the south and it had already started when he called. He also caught me right in the middle of my own home duties and I couldn't drop them immediately. I told him I had to wrap things up and would call as soon as I could hit the road but that, if he was coming, we had better meet ASAP due to the weather. In less than 5 minutes he called back to say he couldn't get out of his driveway. I advised him of things to do (including stop feeding the dog for a while for heaven's sake!) and told him we would likely be opening late Monday if at all. He called back several more times to ask the same questions over and over as if I could provide a new, magic cure that I didn't have available 10 minutes before.

I expected that the winter storm would be less than predicted and we would be at work as usual, maybe an hour late this morning. Imagine my surprise when I found out that all the roads were closed and the area where the office is was very icey. At my place, we mostly got snow and very little ice but just a few miles down the road, the ice was terrible. No one could go in but the few boarding animals had been provided for the day before so we didn't worry too much - it wasn't worth risking that icey road up to mountain!

Called the crazy man and was told the pup was doing better so will keep in touch with him until we get back into the office. I then made use of my gift of snow and a day off to play. I made snow dogs modeled after the 3 small dogs in my herd and 1 snow cat, lifesized I might add, modeled after my very large white cat. I stole the idea from a friend but was very pleased with the results. Tonight, we are supposed to get some freezing rain but hopefully the roads will be opened and we can get back to business as usual. I know my boss will be a happier man if he hears we are open tomorrow!

Days that make you want to quit!

Yep, had another of those days yesterday. The boss is out of town on vacation and he has been a solo practitioner for years so many of his regular old clients are suspicious at best of the new girl even though I worked here for years before vet school.

Started out much as the other story I told with my running late which is never a good way to start the day. Arrived to find a client waiting for a glucose check. This post will unfortunately probably degenerate to some degree to a bit of criticism for the boss who has been out of school for 30+ years from the relatively new grad. The boss likes to change his insulin doses based on single spot checks which scare the bejesus out of me - I like to do curves. This particular dog has been consistently getting higher and higher doses of insulin and its BG level is consistently rising on each check. I talked the owner into leaving the dog for the day for a mini-curve (better than nothing!!).

After this, I jumped into the day which was steady but semi-boring in the morning appointments and routine junk. The only excitement was the glucose curve dog who is a very sweet little dog but suddenly vomited, sat in it, then tried to eat us immediately after the owner left. Ironically, after getting her out, cleaning her up, and continuing the plan, she decided it was all okay.

Things started to go downhill at lunch time. One of the hospitalized puppies (worms!!) was doing great so we told the owner we would try to discharge that day. The other puppy has been slowly circling the drain for days going into weeks. She was a mysterious vomiting and diarrhea pup that we were unable to definitively identify a cause and had been discharged multiple times eating, drinking, not vomiting, no diarrhea only to return within 2-3 days with a relapse. At this point, she had become septic and we were fighting the last battle for her life. The sick cat was doing great and went home a little after noon allowing us to rearrange our limited ICU capacity to a more manageable option.

I had to run a couple of errands that could not be postponed then found myself stuck in the store by the mad rush of folks panicked by the impending threat of snow and ice (they had to all go for bread and milk, you know). At first, I had no idea why the store was such a madhouse then it slowly dawned, too late alas! This made me run late in returning and, of course, the first appointment was early.

The first appointment was the highlight of the day. A small puppy, sold to the new owner as a 5 week old that is more likely 3.5 weeks old, that I saw at the first of the week. When I first saw it, I sincerely doubted it would survive. It was hypothermic, hypoglycemic, non-responsive, not eating, not pooping, covered in worms, and had purulent discharge from the eyes as well as the tail from where it had been docked. I'm pleased to report that it is doing great! Walking around, eating, pooping, discharge looks better, and acting like a puppy.

The other highlight of the day was being proved right on the glucose curve. The dog was experiencing reflex hyperglycemia. The nadir of her mini-curve was 41 (yikes!) and she had begun to go back up but was only at 50 when she went home with no apparent clinical signs which is typical when a dog has become accustomed to hypoglycemia. Needless to say, I altered her insulin regimen.

The rest of the afternoon was a rather hectic blur. We did not have that many appointments but had several walk-ins and none of the appointments were on time, being either late or early. The man picked up his puppy and was very rude to the receptionist as well as my technician even though we were sending the dog home doing well and a day early therefore saving money.

One of the walk-ins was a very old client who had called previously demanding to pick up "the shot that Doc always gives my dog when he has an upset stomach." Wth her being a retired nurse, my boss has often dispensed injections for her to give at home. My technician pulled the chart, looked at what he had given previously, and pulled up two shots for her to pick up (again, panic due to possible bad weather). When she arrived, she suddenly decided to let me check her dog over. I did an exam, checked for worms (negative) since he had some recently, and talked to her about all the possibilities for his appetite being decreased. Since he was very bright, alert, and responsive, she opted not to do further diagnostics but wanted me to go ahead and give exactly the shots that Doc always gave.

Herein I made a huge mistake because I was feeling rushed. I should have double checked but I didn't and just pulled up what he had written and gave it then sent her home. We got a call shortly afterwards saying he had a seizure in the car on the way home and she was going to watch him closely and come back if he had another. She then returned later saying he could not stand and did not act right. One of the medications I gave can have a sedative effect but when I examined him again, it was far too much! He was weak, had poor pulse quality, had pale mucous membranes, and seemed very depressed. We could not obtain a blood pressure value initially but everything in me said he was hypotensive so we started him on an IV fluid bolus.

Of course, the lady refused to leave him in the hospital but finally agreed to leave him for a little while and I would call later to let her pick him up. This was peppered with snide remarks about whether I knew what I was doing, didn't I know what was wrong, was I certain I had given the right medications, etc. My favorite was when I was trying to talk to her about leaving the dog and she misconstrued my question to say "I know you close soon and want to go home but isn't my dog's life more important!" She called back 5 minutes after leaving to ask the technician if I was really even a doctor.

The dog responded well to the treatment during which time all my staff was rushing out the door to go home and I had no place to put him due to a full ICU and the phone was ringing off the hook from other frantic owners who had not been called back yet or were convinced they had to rush in right away in case they got snowed in this weekend. After a bolus, his blood pressure returned to normal and he was responsive with normal parameters. Reluctantly choosing the lesser of two evils, I sent him home with IV catheter in place to allow him to have fluid support for the rest of the night.

During this time, I was pondering the possible causes and suddenly it made perfect sense. My boss still uses chlorpromazine a lot. I'm not particularly fond of this drug due to its tendency to cause hypotension and the fact that most cases that need an anti-nausea drug are really sick patients. I usually reach for cerenia but had given chlorpromazine at the dose written in the chart since she wanted to have exactly what he usually gave. At the time, I briefly thought it seemed to be a lot but, I don't use it enough to have been positive. After recalculating the appropriate dose, I realized he got twice what he should have hence the seizure and the hypotension. Now, whether he had truly gotten that dose in the past or not, I don't know; it certainly could be a recording error in the chart (we're all human you know).

I told my tech that this would become one of those "Doc only" clients but I didn't care too much since she was annoying anyway. My tech argued that it was his fault but I then told her of the last parting comment as the owner prepared to drive away, "This is a good lesson for you, you should always calculate your own dose."

Don't get me wrong, she is correct; the only problem is that if I had given something different than he usually did, that would have been a problem as well. Sometimes you just can't win. I am, however, immensely glad that it happened that way rather than her giving the drug at home sometime that night or something!

Finally managed to go home and watched an all time favorite movie, Bob Hope in "My Favorite Brunette," then got some rest.

Came back this moring to find the sick puppy had died (I hate not having 24 hour care but don't have an answer for the problem since I can't do it all 24/7 by myself...) Then I got a call from the boss to ask if I had heard from "that guy with the puppy." Of course I have no clue what he's talking about then discover that I have 6 (!!) missed calls and 2 messages from the man who owned the puppy we had sent home the day before. The first went something along the lines of how we didn't know what we were doing, "Doc said he was going to keep the dog for 3 days and we sent it home after 2!", etc. etc. The second only said "If you don't call me back I'm calling my lawyer!"

When I called, it turned out the dog was far from dying. Instead of listening to our instructions to feed a bland diet in small portions for a few days, he had let the pup scarf all it wanted and it threw up twice. Funniest part was that he was perfectly polite after being a complete ass in his messages. People are weird!

So, hopefully the day will end, so to speak, soon! Don't know why the bad ones always stick in your mind and the good ones fly away so fast. As of last night, I was threatening to quit and find a new profession, new job, new family, new brain, etc. In the light of day I see the difficulty in that statement but one can always wish............

The Joy of Family

I had a great reminder of the joys of my dysfunctional family the other night. A distant cousin called randomly and I answered (very unusual!) wanting to speak to my mom. Mom had her on speaker phone so I could hear everything that followed:

Cousin: Is Dr. Insane dating anyone?

Mom: No.

Cousin: I just wondered 'cause there is a friend of my son's who is looking for someone and asked if I knew anyone so I thought of her.

Mom: Oh.

Cousin: Yeah, he's a youth minister and he has 2 daughters and his wife done left him 'cause she's tired of the religious life. He works with my son and he's into animals, too, 'cause they go 'coon hunting together!

Mom: Yeah, I doubt she'd be interested right now.....

Cousin: Well, tell her about him and see!

That was apparently the whole purpose of her call. Those who read this and know me will instantly know my response. For those who don't, well, I don't want kids, I'm not good with them, and one of my dogs loathes and despises small humans who are loud and busy. Besides that, I'm way too busy for a relationship right now and am rather anti-relationship anyway being very much a loner and introvert. As to his interest in animals, hmmmm, what do you think??? Somehow, I doubt very much it would work out with my menagerie!

A Day in Private Practice

I recently experienced one of those days that illustrate the fun as well as the frustration of private practice. If you are not in the vetmed field, please excuse my morbid sense of humor at times; we can't help it, we develop it to keep ourselves sane! (Well, somewhat sane!!)

My day started with my running late. Having a menagerie at home means that there are certain things that must be done every day before leaving the house and, if any small thing goes awry, one will be late! This morning started with cat puke and the never ending race to stop the dogs from cleaning up faster than I can. This was followed by the diabetic cat not being in any of her usual spots so I had to put out an APB to find her and get her insulin administered. Finally, I frantically ran out the door to perform my last duty prior to leaving which is giving all the big dogs their morning meds. I have a few who are geriatric and don't hear well so, of course, one of those was sound asleep in his house and I had to go in and wake him after having my customary panic of whether he was still alive or had died in his sleep (yes, I know, sounds horrible but when they get to be in their late teens it is a constant worry). At last, into the truck and fly to work trying not to get a ticket.

When you start the day running late, you can never catch up. The morning was already falling in on my head by time I walked through the door. I threw my junk in the general direction of a counter top and went to work on the beagle who howls constantly that we are currently treating for lymphoma. For some reason, he tolerates certain people better than others and I am one of those so I grabbed a needle and syringe and pulled blood for a CBC quickly so we could send him out the door! Immediately, I got sucked in to taking care of the hospitalized patient that is technically my colleague's responsibility but my colleague was also running late.

No sooner had that patient been situated than we had an emergency walk through the door. Big dog little dog, my dog is dying, he's bleeding to death, etc. Yeah, two tiny puncture wounds on the shoulder, white dog so of course it looked terrible. Oh what a miracle worker (ha, ha)!!

Finally, down to the business planned for the day. I start examining all the surgery dogs and tell my tech to start pre-meds, get everything ready. Since being out of school, I've had one dropped pedicle. Two in a row that day and I'm not even sure why. The first one the suture just cut right through and, unless I'm She-Ra disguised as an ordinary person, I still can't explain it. The second one had to do with a defective hemostat that is now broken into pieces (temper, temper) and I probably shouldn't be admitting that just in case my boss sees this...

Naturally, this puts me behind in my schedule since dropped pedicles equal more time than usual to finish. The next dog just didn't want to get to a surgical plane of anesthesia. We spent far too much time fluctuating between the dog is okay, right? and could you please get her deeper so she stops spilling her guts out at me! Fortunately, we did not have a heavy surgery load for the morning but, with all the "complications," I wound up working well into lunch time to finish. I'm becoming spoiled to having lunch again after not for so long and thought I'd have 15-20 minutes to grab something and write up all the surgery charts prior to the first appointment. Alas, no, this was not meant to be.

This time, we had a real emergency. A septic puppy that probably had parvo. After spending quite a lot of time and not a small amount of money, the owners opted to euthanize and by that time the first 2 afternoon appointments were there, in rooms, and chomping at the bit. The afternoon was steady with no great mishaps until 5 p.m. We close (ha, ha) at 5:30 and the last appointment is usually kept at 4:30 to allow time to finish up and in case there is an emergency. Not this night. At 5, the guy comes in with his very large dog (90lbs) who has blood oozing from his rectum and cannot walk. 45 minutes later, he is still trying to decide if we should attempt to treat the dog or euthanize it. His wife finally came in from the car and talked to us, decided in less than 5 minutes to euthanize (I got the feeling she really didn't care) and left again. He still agonized with the decision.

After spending a little more time with his dog, he decided to euthanize but wanted to be with his dog. Don't get me wrong, typically I encourage owners to stay since I believe our pets deserve for us to be there for them when they die but I knew this one would not be good because the dog was so terribly dehydrated and debilitated. I began injecting into one vein after explaining the whole process, especially how quick and painless it was, only to see the vein blowing after about 1.5cc. Okay, I went to a different leg and had the same thing happen but at least it was enough for the dog to go to sleep. Now what? This was becoming a nightmare. I couldn't do a cardiac stick in front of the owner, besides, I didn't have a big enough needle for this dog (he was thick!) Finally, I persuade the owner to go and assured him that I would stay with his dog until it was gone (I think his wife impatiently gesturing to him was more stimulus than I, to be honest). After the owner left, in a last desperate attempt, I injected into the tongue vein (also not owner appropriate, can you imagine pulling the tongue out and sticking there while someone watched?) very slowly with strains of "This is the dog that will not die..." (Lamb Chops "Song that Doesn't End" hint, hint) running through my head. As he peacefully breathed his last, I started singing aloud much to the chagrin of my assistant who had stayed late to help.

And, no, the day still wasn't over. We had to bag the dog, avoid the diarrhea, carry him to the freezer (heavy!), and clean up the mess. Then I got to finish writing up my charts. Then I got to go home and take care of the kids (4 legged) and cook supper and.....