Monday, August 22, 2011

"All Fed Up With Stupid" & Other Complaints

One of the employees pulls out that quote along with "Put your big girl panties on and deal with it" on an almost daily basis with good reason. Right now I am very much "all fed up with stupid." Couple of composite stories to give you an idea:

Lady with a Pekingese with atopy comes in and wants to euthanize the dog stating "I've tried everything and she's no better!!!" I look in the chart and see that the first time we evaluated the dog was 3 months prior at which time the dog was in really bad shape; I examine the dog and see that the skin is dramatically improved with new, healthy hair growth and no active lesions. I question the owner who states the dog had "chewed herself raw and made a hot spot the night before." Really? Where? She can't show me. I ask if she has tried antihistamines, omega fatty acid supplementation, flea prevention, medicated baths, hypoallergenic diet...etc. The answer to everything is no yet she wails again, "I've tried everything!!!" Check.

Enter another lady who actually volunteered at the clinic for a short time when she was going through the online vet tech course and trying to do her clinical hours with us until she dropped out of the course, "My old dog can't move one of his hind legs!! What do I do???" Side note, I examined the dog about 2 months ago and found that he had back pain and an old CCL rupture evidenced by a huge medial buttress; at the time, I talked to her about pain control, massage, exercise recommendations, etc. and had prescribed Tramadol as a daily medication and, reluctantly, allowed her to continue using aspirin instead of sending a different NSAID for bad days. When she arrived with the dog, he was significantly lame on the hind leg with the buttressing but could move the leg. Because of it, it was difficult for him to rise, particularly on a slick floor. She finally admitted the dog had played rougher than usual 2 days before and that she had not been giving the tramadol as directed, only giving a 50mg tablet once daily because "I've been prescribed it before and 1 tablet knocks me out; I couldn't give him as much as you recommended!" (He's a 75 pound dog, by the way.) I read her the riot act. She was considering euthanasia because "there was nothing else to do." In less than 5 minutes, I had listed over 20 alternatives to make the dog more comfortable. I advised that ultimately, yes, it would be up to her what was acceptable and what not but that there were many alternatives at this stage to help the dog depending on how much she was willing to do...

People!! It brings me back to a personality trait of mine that makes me crazy most of the time. Responsibility is an interesting concept. I think there are 3 basic levels. 1) The crazy hyper-responsible people like me who take blame for things that cannot possibly be their fault, 2) the mid-range people who are probably the most healthy of the groups taking responsibility when it is theirs but not accepting blame for things that are not their fault or beyond their control, and 3) those that shirk all responsibility, blaming everyone else for their decisions and mistakes.

I don't know why I'm so hyper-responsible. Most of the people that have that trait that I have met were tossed heaping helpings of responsibility at a very young age. Maybe that is the reason; we started being responsible so young it is hard not to take it for everything... I don't know, I just know it contributes highly to my general insanity and is one of the major reasons that I can be manipulated by guilt. I was worse before but have at least learned to recognize the manipulation better now and can force myself to stand against it but it is really difficult because the whole time a war rages within over what I know is right and my guilt / responsibility hang-ups.

Yet another reason I second guess myself so much about the Rusty-dog. I keep wondering if I was wrong about pneumonia and maybe it was neurogenic pulmonary edema and maybe I made it worse with fluids... I still don't understand what happened and why it progressed so quickly. The Holter didn't really give answers although I'd like to discuss a couple of the strips with a cardiologist. Apparently the tech that read the thing didn't understand the approximation of some of the times such as the small seizure around 3:30 a.m. where the strip is normal at that time but not normal 5-10 minutes prior, hence approximately... No, I did not opt to have a necropsy which may have settled some of my questions and self-doubt; I couldn't deal with the thoughts of having it done. Besides, I'm sure I would have found some way to blame myself anyway. Rest of the herd doing okay, Buddy grieves a lot still and is more clingy to me than he was before. I worry a lot about Sam and Chief, my other 2 old guys (15 & 16), especially Sam since he has more medical problems but, to be honest, I thought he would go before Rusty...shows how much I know, right?

At work, cancer has been the theme as usual except for one other case that I'll relate shortly just for the irony of the situation. Let's see, first there was the German Shepherd who presented for a possible foreign body because it chewed up a toy and now had a distended abdomen. I wondered first about a GDV but walked in to see a calm, quiet, somewhat depressed dog with an easily observed distended abdomen. On palpation he had a fluid wave and a cranial mass. His belly was full of blood on abdominocentesis and I did a radiograph just to prove to the owner that there was no foreign body, a hope she clung to until the end of the visit. They opted to take the dog home and spend a little time with him rather than go to surgery, etc. so I can't totally prove that it was a tumor but what do you think given he was 9 years old? Then the axillary mass that I talked about before, histopath identified it as a "high grade soft tissue sarcoma" and they could not definitively determine the tissue of origin... And the cat that presented for "some blood in his stool and can he get his vaccines too?" There was a mass in the caudal abdomen easily palpated. The owner actually wanted to try surgery but the cat became stressed in the process of attempting to place an IV catheter then started breathing heavily and bleeding more from the rectum. We wound up euthanizing and the owner allowed me to open the belly. There was a golf ball sized lymph node that was necrotic and hemorrhagic. We had not done thoracic radiographs yet but I'm making bets on Lymphoma. And the list goes on, and on, and on....

The ironic case needs 2 preludes. First, I am good at critical cases. I'm actually probably better at those than I am at surgery, which is my first love. I don't particularly like them but I am good at them and the last few years experience in primarily ER / Critical Care has only served to hone these skills. Perfect? Certainly not, but definitely a strong area. My boss is not. He doesn't think outside the box and doesn't push fluids when needed and so on. Second, for those of you who remember, the dog and person involved is the one I spoke of several months ago that came in wanting "the same shot that the boss always gave" and after getting it the dog tried to die because his blood pressure plummeted. The one that I said would be a "Doc only" client from then on. Right... Doc had to go out of town unexpectedly last Monday because his mom was in the hospital therefore I worked on my usual day off. Lady shows up with her dog; she had talked to Doc and finally been convinced he should be seen and not wait. She had called the week before to pick up dewormer because she thought he had worms again but refused to be seen until Friday when Doc was in (he was out most of that week on vacation) at which time the dog was given a small dose of Gentocin, amongst other things.

When I saw the dog last Monday, he had a necrotic area on the tip of his tongue, uremic breath, increased respiratory rate and effort, focal crackles in the left cranial area, a low grade heart murmur, and was very dehydrated. CBC / Chem showed a white count of 34,000 (it was 13,000 on Friday), BUN unreadable (means it has to be over 200 on my machine), Creatinine of 8.8, Phosphorus over 20, some elevation of ALP and ALT, to name the highlights. Urinalysis showed a low specific gravity, glucose, protein, and blood in the urine with white blood cell and red blood cell casts. Thoracic radiographs showed an alveolar pattern in the left cranial region, possible aspiration pneumonia was the working diagnosis. I spoke to the owner and explained the poor prognosis and that the only chance was aggressive fluid therapy and antibiotics, etc. She asked what I would do if he were mine; I told her bluntly that I'd at least give a chance but that not doing so was not a wrong decision. She decided to let me try. I hit him hard with fluids, antibiotics, coupage, sucralfate, etc. I pulled out the tea trick for the tongue discomfort, something I had practically forgotten from onco in school. 48 hours later, there was a small downward trend in the recheck bloodwork but I also felt we had only really just begun true diuresis given the in's and out's. Additionally, he was coughing more and producing with decreased crackles auscultated. He had also eaten a small amount where he had previously shown no interest at all. In my opinion, far from out of the woods but at least taking baby steps in the right direction. (By the way, to remind you, the owner is a nurse so should at least have some grasp of the situation. I know it's her own dog and that clouds thinking but she should understand a little more than a lay person.) The next day, I was off. As usual, I briefed my boss very thoroughly on the situation. When I returned the following day, it was to find that the dog had been euthanized. I was told that although the kidney values had fallen some more (why were they even checked only 24 hours later?) the liver values had climbed and he was breathing more heavily.

Now, I don't know, maybe he was way worse than before. Maybe it was the right decision. I really don't know. I do know, however, that it is not the first time by far that my boss has done something entirely different than my plan for a patient on my day off. I also know it is not the first time that one of my cases has "gone downhill" while I was off and when I returned it was because of something done or not done according to what I had planned. The most memorable was the pylonephritis dog that was given lasix on my day off because he had some SQ edema. REALLY PEOPLE??? He did not have a heart murmur or crackles or fluid dripping from his nose or any other signs of fluid overload. There are other reasons for SQ edema such as, oh I don't know, MAYBE THE FACT THAT HIS PROTEIN LEVEL WAS AT ROCK BOTTOM. Remember Starling's Law and the relationship between proteins, etc., osmotic pressure and fluid being held inside the blood vessels??? Can't help but wonder if the decision was a bit precipitate but I'm also the only one at the clinic that will really push the envelope on critical cases. And I have as yet to work in a place where I haven't had an argument about pushing fluids in which some know-it-all tech or other vet thinks I'm giving too much, too fast. I know about overload but most people that I've worked with don't push hard enough and freak out way too soon or about things that don't really indicate overload. That's one of the reasons that I became a veterinarian; so that I can make those decisions on my own pets rather than being trapped into either stopping sooner than I want because no one will put in the effort or going too far because of the attitude of some vets that cannot determine what is truly humane. I certainly don't claim to always make the right decisions and know what is best to do but I don't, as one of the AVMA speakers so beautifully described it, "roll over and pee on myself" when given a difficult / critical case and just decide to euthanize. One statement that always comes to mind is that euthanasia is permanent.

Besides cancer and the crazy client's and the critical cases, I've seen some great abscesses lately. Mammary gland abscesses, fight wounds, an eyeball, etc. There is something deeply gratifying about abscesses although I have often wondered if this is more of a female thing than male because it seems that more females enjoy them than males. Hmmmmm..... I'm sure there is some deep dark meaning in that.

I believe that covers most of my complaints for now. As for my mental health, well that is probably beyond help even in the best of times... If it were not for the necessity of being at home right now I would be looking elsewhere for another job. Speaking of mom, I finally forced myself into the conversation I've been putting off for a while. As of right now, she is agreeable to getting an appointment with a lawyer and updating her will as well as stating that I will have power of attorney when the need arises. Hate to think about it but it is a necessary step. I remember when I took care of my grandmother with Alzheimer's right after I graduated from high school. The family fights were horrendous with no one being willing to help at all, ever to give me a break even when I exceeded the breaking point, fighting over her stuff even though there was no money to speak of, complaining about what was spent on her, etc. Then I think about the fact that I'm pretty sure my mom is already showing early symptoms of the disease and I think about how my brother is, much as I hate to admit it. The only conclusion I can reach is that I need to make sure that mom's home is protected which probably means it needs to be in trust for me to care for and that, since I'll be the caregiver, I can make decisions regarding what is spent on her care, etc. when the time comes. Not that I want my brother to have nothing but I really don't want to face having to sell the home and property without even a chance to go through things as soon as mom passes because he insists on splitting all assets immediately. Guess I sound really cynical and all but, much as I love him, I know my brother and, for that matter, my family. Nice morbid thoughts I've been having lately, aren't they? Really miss Rusty for someone to discuss these things with and just to hold when I need a hug...


Anonymous said...

I'm not Rusty, but . . . {{{hugs}}}

Purple Stinky Onion said...

I love the name of your post-lol.....That pretty much wraps up every night I work too........

One day many, many moons ago I had a really crappy night at work and posted something NASTY about some of the mormons I work with, and later that day, Dr. Can't Spell DVM wrote that she was sorry about how my night had gone and could tell how upset I was feeling...and thought I could use a Big Cup- somehow I must of posted how much I love them- I sat back and thought about it and drove to the local store and purchased a Big Cup, okay maybe it was two of them, but it really helped:-)

Our black lab, Jameson died passed away almost 10 years ago, I would talk to him all the time after work, and I still miss him, so I'm sending happy words, thoughts and wishes of chocolate your way!!

{{Hugs too}}