Thursday, January 20, 2011


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!

1 comment:

Anonymous said...

About the cat who may have had an anaphylactic reaction to the hetastarch... Yeah, some of us thought of that. BUT it's a whole lot easier to sit here and second-guess when there's no pressure, no other cases to worry about, and no consequences to being wrong. Sometimes things just go wrong no matter what we've done (or not done), and sometimes we miss things. (I say "we" even though I'm not a veterinarian myself; we're all human.)

If you were my vet and it'd been my cat, well, I would have grieved for my little friend, but would have had to admit that sh*t happens. I've been blessed with some damned fine veterinarians over the years, ones who have pulled elderly cats out of kidney failure and have kept cancer patients and a diabetic (7 years on insulin BID!) going long after they should have been dead, but even they've missed something on occasion. Didn't make me think any less of them because they were honest about the situation and learned something from it.