Saturday, January 8, 2011

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............

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