Thursday, June 28, 2012

Train Wreck

There are always those cases that make you crazy...

Yesterday evening, an 11 year old neutered male cat presented to me.  He was covered in fleas, moderately dehydrated, had a huge / painful urinary bladder (blocked), and bilateral hydroneprhosis on physical exam.  His blood work showed the expected hyperkalemia, severe azotemia, and severe leukocytosis (53,000).  So, big question is are the kidney alterations just due to being blocked or did he have chronic kidney changes already??

I had to sedate the cat in order to unblock him.  He was started on IV fluids, given a light sedative and unblocked as quickly as possible.  Then I took a radiograph that shows his bladder is full of tiny little stones.  Next question is not just what type of stone in order to guide therapy but also the fact that they are just that size that miiiiigggghhhhtttt pass uneventfully but will more likely enter the urethra and cause a recurrence of the blockage.

And there is of course the need to balance the potassium which will now plummet with post-obstructive diuresis...

He survived the night which is a good sign.  We'll see where his blood values are tomorrow and decide if surgery is a good, bad, or non-option for the stones.  And, of course, this is a nice cat with nice owners and his "real" owner is a young lady who has Asperger's and this cat is her best friend.  I feel as if I'm trying to maneuver a train wreck through a field of land mines.

Tuesday, June 26, 2012

Hay is for horses

I'm not super good with kids.  Can't say that I can remember ever thinking I might want any and I'm equally as prejudiced against marriage.  Both are fine for others; just not me.

Yesterday, I went to see an old friend of mine and her three year old daughter was there.  The child was fascinated by me and kept telling me all kinds of things, many of which I had no clue what she had said.  Every time she addressed me it began with "Hey!"  She then repeated the word over and over while leaning closer and closer to my face until I acknowledged whatever it was she was saying.  I also don't deal well with people in my personal space...and I consider my personal space to be quite large!

The other thing she did was asked me to come with her so she could "show" me something.  I followed her to the kitchen where she opened the refrigerator door and pointed out the Kool Aid.  She asked if I wanted any and I told her no then she just stared at me until I asked if she wanted some.  You guessed it, that's why she wanted to show me but why not her mom, who knows?

She's not a bad kid but I have a strong feeling they will have a little fireball on their hands as she continues to grow.

On a completely unrelated note but just as an update, the cocker in the previous post passed away this morning.  At least her owners got to say goodbye.

Monday, June 25, 2012

Tales of Woe

Where to begin??? Posting has been infrequent and irregular of late primarily because I've been super busy and frustrated beyond my capacity to express. I don't know what Can't Spell's excuse is - take that up with her.

First I feel the need to complain about the employees. The two young kennel workers are wanting more hours / money but don't want to work any of the shifts where I need them. It's like they expect to be able to waltz in at their convenience or just want to be paid for nothing. Now wouldn't that be nice just to get paid... It's really difficult for me to relate to this because I've always had to work hard for anything I got and was grateful for hours regardless if they were convenient; reschedule the rest of your life if you really need the money!

Continuing on employees, why does everyone have to worry so much about what someone else is doing? I have more than enough in my life to keep me occupied for an eternity without worrying about yours. I'd blame the bickering on the atrocious heat we have right now but the bickering pre-dates it. Then there's the know it alls who still must call me on my day off to ask yet don't really want to hear what I have to say unless it agrees perfectly with their opinion. Sigh...

I am still on a death and destruction nothing will go right kick with my cases. If anyone has any bright ideas to ease my mind on these, you are more than welcome to share! First was a 9 week old small Yorki pup who presented dull and lethargic. I had examined and vaccinated it 2 weeks previously. When it arrived, its exam was unremarkable other than its dull mentation. Glucose level wouldn't read and was covered in coccidia. Owners had fed a raw egg two days previously and the pup had diarrhea. Started IV fluids plus dextrose. Administered an injection of Cerenia and several hours later, after rehydrated, gave oral dose of Ponazuril for the coccidia. The following morning, the puppy looked great and ate some canned I/D food very well. Approximately 45 minutes to an hour later the puppy was dead with an apparrent anaphylactic reaction. To what?!?!?  Maybe I'm crazy, but I'm betting it was to massive coccidia die off.  I can't really find supporting evidence other than that large numbers of mast cells have been documented in chickens with large numbers of coccidia.  It maybe makes sense??

The other very notable case was a 10 year old intact female cat who had been treated for presumptive inflammatory bowel disease that was beginning to worsen. This case haunts me because I feel as if I did it right but it still went bad. Blood work was boring other than a very mild hypercalcemia. Abdominal radiographs showed distended bowel loops throughout. I recommended an exploratory because the cat has a history of ingesting things and I figured we could get some biopsies as well to definitively determine IBD versus neoplasia. Cat was on IV fluids; no, we do not have continuous BP monitoring capability but checks were fine throughout the procedure. There were no foreign bodies so I biopsied the small intestine (grossly normal), the colon (dramatically distended with gas), and the pancreas (abnormal appearance throughout). The cat recovered fairly well, just a little slow but I felt it was due to her becoming slightly hypothermic. I also spayed her and she had multiple ovarian cysts and her uterus was segmentally distended. She went home cautiously two days post-op looking good but needing to be syringe fed. She would take food readily but wouldn't eat voluntarily which we thought might just be due to being picky and not at home. She returned the following day looking like poop and blood work showed kidney failure. She did not respond to therapy at all.  Less than 24 hours later she died.

The biopsies were very non-specific.  There were lymphocytes and some plasma cells, no clear evidence of neoplasia but I know that differentiating lymphoma from inflammatory bowel is tricky under the best circumstances and this cat had been on steroids long term.  The pancreas was odd in that it had amyloid deposition.  It was stated that this can be "normal" in older patients.  Perhaps it is just because most of the herd that lives at my house live well into their double digits but I wasn't really thinking of her as "an older patient."  And why did the kidneys shut down?  My potential explanations include that she did have lymphoma and it was also affecting the kidneys with surgery / anesthesia / medications pushing her over the edge.  Or maybe she had amyloid deposition in the kidneys and, again, all the stressors pushed her over.  Or maybe her kidneys did have chronic changes that were functioning okay until, again, all that was added.  No matter how it falls out, though, I feel like I made a horrible recommendation for surgery to be pursued.  Yes, I can look back and still agree with my recommendation but now that I know the outcome I hate that I made it.  And, yes, I know that the cat might have continued to go downhill even without the surgery but...  Can't help it - not only am I wired in such a way that I take responsibility but it has also been drummed into me all of my life - can't not blame myself.

The boss's brother-in-law's dog is being treated for lymphoma and she is over half through the protocol and has been doing well.  I've tried to stay out of the case since it's his relatives and I'm such a cancer jinx but, of course, I got dragged in Friday to feel the nodes and they are frighteningly large again.  Much bigger than when I last felt her.  The boss is hoping it's just infection; that's NOT what I think.

He dumped the weekend duty on me at 11:00a.m. Friday.  We had seven hospitalized cases.  Thanks for that advance warning.  Six of the seven are doing great.  The seventh is a 15 year old Cocker with a 53,000+ white count and a hematocrit of 13%.  He's treating her for possible tick borne disease which is valid in the South with the non-winter and crazy ticks we're seeing but I'd be looking for the tumor.  Everyone calls me Dr. C because I find so many tumors; I swear, they just jump out in my face without my even looking!!

On that note, my 16 year old Chow / Rotti has a tumor; I'm not sure where the primary is but it's likely it is in the brain or spinal cord.  He had a neurologic episode about 2 years ago which I thought was an FCE due to the rapid recovery and lack of pain.  He showed similar symptoms but seemed mildly painful so I gave him 2 doses of an NSAID in addition to his usual tramadol (for arthritis) which pushed him into kidney failure.  His kidney values were perfect, by the way, which was why I felt okay giving him the drug.  In working up the kidney failure, I took thoracic radiographs and found nodules in the lungs meaning metastatic disease.  The presence of the neurologic symptoms is why I'm thinking CNS tumor.  I'm not putting him through an MRI, anesthesia, surgery, etc. therefore he is on Prednisone now that he is over the acute kidney problem.  Right now, he's doing well although he is being extremely picky about eating.

Can't Spell always says that my having so many geriatrics at the same time is not good for my emotional health and she is correct but what can I do about it?

I tried really hard to think of a good story to tell with light and happiness I've struck out on that.  Sorry.  Guess I could relate the somewhat funny story about how I can hold grudges.  Last September, I sent a neuro referral to my alma mater that belonged to a good friend of mine.  The neurologist there is not the one that I worked with as a student and also is not the one to whom I referred my own dog a few years back.  I hated the way he handled the case.  The only thing good I can say about it was that he reached a diagnosis but, otherwise, the experience was awful.  One of our really good clients who is also one of my personal favorites needed a neuro referral and my boss had set them up for good ol' alma mater.  I asked if she minded going elsewhere and sent her to the doctor that took care of my dog that I liked very much.  Yes, I do hold a grudge if you piss me off badly enough.  Besides, I'm sick to death tired of dealing with people like that.  I've been working very hard to build myself a network of people to whom I can refer myself if the need arises for a specialist.  Yes, I will have to travel for some of them but it is worth it to feel like I'm seeing someone I can trust with my kids.  Half the reason I went to vet school was to take care of my own because I was unhappy with everyone I had used.  I'm still short on orthopedic surgeons...

That's really all that I have time to relate right now other than that I'm working on some first class pranks (stress relief) and my cartoon book isn't going so very good.  I had volume one 98-99% complete and my pesky multiple personalities kicked in with doubts as to whether I really want to share the 'toons with the general public so I started working on all five volumes at once and stopped focusing.  Not sure where that will lead.  With that, I seriously must go to bed as work calls tomorrow bright and early!

Thursday, June 21, 2012

Those Vile Vials

I'm sure that most of the veterinarians and veterinary students out there are at least somewhat familiar with the AVMA PLIT newsletters that present multiple "Dr. A, B, C, D, etc." liability cases and their outcomes.  I'm also sure that I have commented more than once about my tendencies toward being a grammar and spelling Nazi...  I don't know how many of you read the aforementioned newsletter from June but if you did and were paying attention, the case where the vet saw a sick cat after hours and had the owner hold for a blood draw which ended with the owner sustaining injury from the cat had a nice, shall we call it a typo?  It stated that the vet turned to put the "blood into the viles" and the owner got bitten or scratched or something.  Last time I checked, "vile" is an adjective meaning something repugnant...

Sunday, June 10, 2012


Imagine the ooey, gooey chocolatey loveliness that is a Devil's Food cake still in the mixing bowl filled with promise... Now imagine that same batter strewn across the floor. Some is in your shoes, on random furniture, even on you, as if it had exploded... Now imagine that it really doesn't smell at all like chocolate... Wake up, May B., it's not one of your bizarre dreams. All that ooey, gooey, chocolatey loveliness just came from your dog's rear end. And you complain about your dreams!

Thursday, June 7, 2012

His Other Office

I work at a small clinic where we all know each other way too well (and some of the clients,too!) There are two bathrooms in the clinic; one up front that has public access and one adjacent to the break room and the boss's office. For as long as I've known him, my boss has seemed to spend an excessive amount of time in the bathroom, both in frequency as well as length of time per visit. We have always called it either his other office or his second office because, inevitably, when he is needed, the door is closed and there he is. Yesterday, the truth suddenly dawned on me and I wondered why I never realized it before. Just as a woman spends longer in the shower than is strictly necessary in order to obtain a few moments of respite from her loving spouse and adorable children who never give her a moment to herself (please read Virginia Woolf's "A Room of One's Own"), my boss is going to the bathroom to obtain that same moment. It is truly the only room in the clinic where we won't bug him because his office is certainly NOT sacrosanct. It's not a bad idea and I would probably steal it except for the fact that I avoid that bathroom as much as possible because of the vertigo inducing striped wallpaper pattern and one can't go hide out in the public access bathroom very well...

Sunday, June 3, 2012

Filter Problems

Typically I have a very, very strong filter in place to guard the things that come out of my mouth.  Very rarely, in fact, does much of what goes on in the head actually come out of the mouth.  I am well aware that I have a biting, sarcastic tongue if left unfiltered and usually keep a pretty tight cap on things.    There are, however, a couple of circumstances that predictably cause filter slippage. Prescribe medication to me, even many of the blah drugs and watch out. A little antihistamine and whatever occurs in the insane head exits from the insane mouth. Make me exhausted and I become quite delirious and the results are the same. Ironically, alcohol fails to remove the filter but that may be simply because I have such a low tolerance that a very small amount sends me straight to the land of nod...

This past week has been insanely busy and, as I like to say, the lunatic was left in charge of the asylum meaning my boss has been away leaving me in charge. I think I must have committed some vile atrocity and been paid back by a week that has left me feeling as if I had been run over by a train that then repeatedly backed over me in order to run me over again. And it's not over since I don't get a work break until Monday when I'll spend my day off catching up on everything I've yet to finish plus worrying about the patients that I have left for them.  At least it's only one day to allow more to go wrong!

That said, there have been multiple instances of exhausted delirium and a few times when I had meclizine on board as well - double whammy! Result? More instances than I can relate of filter slippage.

Crazy client that drives us nuts and always sees my boss brings in her itching dog. She asks if "I'm ok" to see instead of my boss. I hear and tell her she should run while she can. She stays and we are discussing her dog; she is concerned because the shaved coat is growing back patchy. I assure her it will be okay and will fill in, citing my own cat whose coat does the same after shaving. She says I shouldn't shave my cat because they look ugly shaved, I say "And you think your dog is pretty?"

Rescue group comes in at the end of a long day Friday with a puppy mill rescue that needs emergency surgery. They ask for a rough estimate and I reply about $5600, with $5000 being for me.

And my favorite is the one that I actually stopped myself just in time. The sister of one of the employees who breeds Beagles has a litter due. She has my phone number but I clearly told her that my boss had call Tuesday night. She calls me after 9 p.m. at which time my phone is routinely cut off and plugged to charge if I'm not on call, and leaves a message. At 2:30 a.m. I'm up for a bathroom run and get my phone to take a picture of the kids who stole my spot in bed. I listen to the message and desire greatly to return her call right then... Likely the only thing that saved her was that I had not reached the point of sheer exhaustion yet.

It's just not safe for me not to have my filter in place. The other, worse, side effect of being so tired and overwhelmed is that mistakes happen.  There have been two that could have been catastrophic but, thankfully, were caught.  My previously posted diabetic cat is back with us because she is still struggling with her hepatic lipidosis and her owners are going on a vacation for 6 weeks.  They forgot to bring her insulin the first day and dropped it off on their way out of town the second day.  Someone, and I'm pretty sure it's someone who should have known better but not positive, gave her 2 units of a U-100 insulin from a U-40 syringe.  The second incident also involves insulin.  A previous employee is boarding her crew here while she is out of town a few days.  She has a diabetic cat who is gray/brown and white.  I am intimitely acquainted with him and have met 3 of her other 4 cats, 2 of which are black and the third being a tortiseshell.  Another employee who is really good friends with her agreed to be responsible for the insulin.  I was asked Friday night around 9 when I was finally nearing time to go if the cat that needed insulin was gray and white.  At least that's what my exhausted brain heard, so I said yes.  Yesterday evening, I looked in on the cats and realized that the diabetic cat is sharing a cage with the fifth cat that I have not met who is gray/black and white with more white.  The cat was sprawled out in the litter pan, responsive but very dull.  That's when it hit me that the employee had asked if it was gray with "more" white!!  She got Friday night and Saturday morning's insulin that should have gone to the other cat.

Glucose levels were low so she is currently on a dextrose infusion and being force fed and showing improvement.  I verified that I was correct with the employee.

Man, I hate weeks like this!

One last episode of sarcasm as a post-script because it just happened.  One of our kennel workers always brings either her dad or mom to help (they are divorced so usually one comes Saturday, the other Sunday).  Her dad is perfectly capable of working and is qualified in a field in which there is no job shortage but has not been employeed for quite some time and his daughter is keeping him up.  He was yacking at me and complained that his brother would drop $2000 on his dog without blinking an eye but wouldn't loan him $10.  Before I could stop myself, I said, "But the dog can't work for a living..."