I'm officially back to a daytime schedule now, following Saturday night's final overnight shift.
I arrived at 9:50 pm for my 10 pm shift start, and walked into CPR. One of the patients who'd had GI surgery several days prior had suddenly arrested. I assisted for about 10 minutes, at which time they called it off and pronounced the poor guy deceased. It was a surprising turn, since this particular patient had seemed to be improving quite steadily since his surgery. Everyone was, understandably, upset. Losing a patient really sets a gloomy tone for the rest of the night.
Other than the CPR, my shift was an uneventful one, with a mere 3 inpatients and no outpatients for which I was responsible. My 3 were familiar ones:
1. Mr. Presa Canario post-op Wobbler's surgery, here since Tuesday (Wobbler's patients typically stay 5-7 days in the hospital because they have a hugely extensive surgery on the vertebrae in their neck, and must be kept totally quiet for at least that period of time, which means we dope them up pretty heavily with IV pain meds and don't let them leave their cage for anything until at least 3-4 days post-op). Mr. Presa Canario is in need of an attitude adjustment (or maybe a breed adjustment) -- since he's started feeling better, he's become much grumpier and consequently more terrifying -- so his urinary catheter and IV lines were removed so we don't have to deal with those, and we pretty much do nothing with him other than feed him. He will have gone home yesterday or today.
2. Mr. Dachshund post-op hemilaminectomy, here since Tuesday. Poor Mr. Dachshund. Hemilaminectomy patients typically stay in the hospital about 2-3 nights after surgery -- 2 nights if they do exceptionally well after surgery, and 3+ nights if they are a little slower to recover. Most of them are still partially paralyzed when they are discharged (it can take up to 6 months to make a full recovery), but that's manageable for owners at home as long as the dog can urinate and defecate on its own. The problem with Mr. Dachshund is that he's had ongoing bladder issues since his surgery. Immediately post-op with all of these patients, we place a urinary catheter because we don't want to have to take them outside and we don't want them peeing all over themselves. Then a day or two post-op, we remove the u-cath and see if they can urinate on their own. If they can't, we see if their bladder can be easily expressed manually by placing pressure on their abdomen. If the dog is peeing on his own or can be easily expressed, he can go home. Unfortunately, neither is the case for Mr. Dachshund, requiring us to place a temporary urinary catheter several times a day to help him empty his bladder. I'm really hoping he improves in this area soon because he's going nuts in the hospital from boredom, and consequently driving everybody else insane with his whining and barking!
3. The older German Shepherd post-op hemoabdomen and splenectomy (patient #4 from Friday night). He's been doing somewhat poorly. His lidocaine infusion, meant to help control his cardiac arrhythmias, was making him terribly nauseated so we had to stop it. That meant that for the first 6 hours of my shift, his heart was all over the place -- his heart rate would rapidly jump from a resting rate of 55 beats per minute up to 150-200, all while he was sleeping -- and he had almost entirely ventricular-origin beats, meaning the electrical current controlling his heart was originating from the ventricles (bottom chambers) instead of near the atria (top chambers). At about 4 am, we started him on magnesium chloride, which seemed to help somewhat to increase the number of normal beats he had. Unfortunately, his arterial blood gas analysis in the morning showed that he was oxygenating more poorly in the morning than he had the night before, suggesting incipient pneumonia or something else happening in his lungs. He's such a sweet guy; I hope he improves soon.
We had a couple outpatients come in, but my rotation-mate happened to deal with both of them: a rat with a probable brain tumor that we ended up euthanizing, and a cat post-declaw whose owner felt she was very painful.
It appears that the weekend is the time for a lot of phone calls, which makes sense if you think about it -- on a Thursday night, people are probably more likely to decide on their own that something can wait till their regular vet opens at 7 or 8 am the next day, whereas an ill pet on Saturday night may not be able to see its regular vet until Monday morning.
My favorite call was a hoarse woman who sounded like a 60-year-old lady who'd smoked for 50 years. She called around 5 am to say that her toy breed dog had seemed fine on Saturday, then had bloody diarrhea late on Saturday evening, tried to drink some water afterward and vomited it right back up, and seemed lethargic when she went to bed. When she awoke on Sunday morning, she observed him having a seizure-type episode, and at the time she called, the dog couldn't really walk, was "breathin' pretty hard," and had blood coming out of his mouth.
My response was, "It sounds like your dog may be very sick and we'd recommend that you bring him in right away." (Note: for anything that may not be emergent, I get the caller's name and number, check with the intern on duty, and give them a call back with advice [which is pretty much always "Bring your pet in"]. This was one case where I felt pretty darn sure what the intern's advice would be!)
The caller's response was, "Well, I got some things ta do this mornin' but I'll try an' bringim in in a coupla hours." I reiterated that it sounded like it shouldn't wait, and she said she'd be in when she had time. (The little dog arrived just as I was walking out at the end of my shift, and fortunately looked to be in decent shape, just based on my cursory glance.)
My challenge yesterday was to figure out how to get from a daytime sleeping schedule to a nighttime sleeping schedule in the course of 24 hours. What I ended up doing was heading to church in the morning, then coming home and napping from about noon till 4 (though I'd set my alarms for 2 pm, but don't remember hearing them or turning them off, which I apparently did). Several hours of wakeful grogginess ensued, then I headed to bed for the night around 9:15 pm -- only to awake at 4:30 am feeling quite well-rested and ready to start my day, so here I am!
I can imagine getting used to a regular schedule of working overnight hours, as long as you didn't have to do much switching back to daytime shifts. By the end of the week, when I had gotten into a routine (you all know I love my routine!), I felt pretty human for most of the day. I'm fortunate that I can sleep easily during the day, so that helped me adjust more quickly at the beginning of the week. However, I have a feeling that today is going to be a long day, and that it'll take me a couple more days to fully switch back to regular hours. Luckily, I may get all of Labor Day weekend off, so I anticipate some serious sleeping in and napping to fill up the Sleep Bank before I head into what may be an exhausting 2-week oncology rotation.
Urgent Care (7 am-6 pmish?) starts today. Hope I like it!
Monday, August 29, 2011
Saturday, August 27, 2011
One more overnight
I'm down to my final overnight shift, which will start in ~2 hours.
The last couple nights have been manageable. We've not had any emergencies come in either evening, but there have been quite a few inpatients, some requiring a good deal of care.
Thursday night:
1. The young Presa Canario post-op Wobbler's surgery, still here since Tuesday (he's Tuesday's patient #1 here)
2. The middle-aged Dachshund post-op hemilaminectomy, still here since Tuesday (he's Tuesday's patient #3 here)
3. A youngish Yorkie, post-op tibia-fibula fracture repair after acting like a little nutcase when her owners took her out for a brief leash walk 3 weeks after bilateral patella repairs
4. A youngish Great Dane, post-op forelimb amputation after a presumed hit-by-car and severely damaged hock joint (tibiotarsal luxation with complete collateral ligament rupture)
5. An elderly Beagle, 1 month post-op from a partial maxillectomy for a fibrosarcoma, with waxing and waning lethargy/anorexia since his surgery, and an acute onset of hypotension, respiratory distress, and vomiting; suspected Addison's disease
6. An 8 week old kitten from the humane society, post-op from a PDA ligation (congenital heart defect requiring open-heart surgery); was so hyper and active after surgery that he removed his own chest tubes and IV line, and wanted nothing more than to make biscuits and suckle on your shirt all night; SO CUTE
Wednesday night's patients #2, 4, and 5 were discharged on Thursday. Unfortunately, Wednesday night's patient #6 (the very sick border collie mix) continued to decline and was euthanized during the day on Thursday.
I've not heard anything on how Boxer Puppy (suspected parvo) from Wednesday night is doing, but Golden Puppy from the same shift was hospitalized for about 12 hours on fluids, did very well, and was eventually diagnosed with a load of GI parasites (cryptosporidium, giardia, and roundworms) likely responsible for her GI upset.
Last night (Friday night), my 7 inpatients were:
1. Our friend the Presa Canario, post-op Wobbler's surgery on 8/23
2. Our friend the middle-aged Dachshund, post-op hemilaminectomy on 8/23
3. The elderly beagle with probable Addison's, patient #5 above (doing much better last night -- feeling well enough to be annoying)
4. An older German shepherd with acute hemoabdomen (belly full of blood) and a very low PCV of 18, who went for exploratory surgery where they removed his abnormal looking spleen, and biopsied lymph nodes, GI tract, and liver as well; he had several transfusions during surgery and did okay in recovery except for a common post-op splenectomy cardiac arrhythmia called VPCs/v-tach, which was managed fairly adequately with a lidocaine infusion
5. An 8 week old Pit mix puppy from the humane society, whose foster parents suspected he had eaten a sock or a piece of a soft toy when he started vomiting; he was taken to surgery last night and had an entire sock removed from his small intestine; did well post-op after getting out of surgery around midnight
6. An elderly Shiba Inu mix, post-op forelimb amputation for a soft tissue sarcoma; was doing pretty well with pain management and actually ambulated quite well for his first 12 hours post-op
7. A 1 year old mix dog who got loose from her owners, ran into a street, and was hit by a car, sustaining multiple pelvic fractures, the most severe of which were repaired surgically yesterday
The only patient who gave me any trouble was, unfortunately, patient #1, our dear darling Presa Canario. Though he entered CCU with a reputation for aggressive behavior and about a zillion caution signs on his cage and chart, he'd been nothing but a big sweetheart until my shift started last night. Yes, he was fearful and easily startled, and yes, we went slowly when approaching or handling him, but he had previously let me do all of his treatments (including unpleasant things like rectal temperatures and inspecting his urinary catheter) by myself.
Last night, though, he started growling at one of the CCU nurses (who has been caring for him all week) any time she would stand outside his cage and look at him. He was fine for his 11 pm and 1 am treatments (in fact, I did all of his 1 am treatments by myself) but started growling and curling his lips at me when I attempted to do his 7 am treatments.
Sigh.
With a smaller dog of a different breed, I'd push the issue a little more or not hesitate to muzzle the dog for whatever I needed to do. However, although this guy is still somewhat dopey on drugs, and is restricted in how quickly and in what direction he can move because of the surgery on his neck, he can sure whip his head around quickly if you're up within biting range, so I'm not going to push my luck. I did what I could do, and left the rest for the neuro department when they came in late morning to assess and walk him.
Hoping he'll have gone home today, but I'm guessing I'll see the bad guy again tonight!
The last couple nights have been manageable. We've not had any emergencies come in either evening, but there have been quite a few inpatients, some requiring a good deal of care.
Thursday night:
1. The young Presa Canario post-op Wobbler's surgery, still here since Tuesday (he's Tuesday's patient #1 here)
2. The middle-aged Dachshund post-op hemilaminectomy, still here since Tuesday (he's Tuesday's patient #3 here)
3. A youngish Yorkie, post-op tibia-fibula fracture repair after acting like a little nutcase when her owners took her out for a brief leash walk 3 weeks after bilateral patella repairs
4. A youngish Great Dane, post-op forelimb amputation after a presumed hit-by-car and severely damaged hock joint (tibiotarsal luxation with complete collateral ligament rupture)
5. An elderly Beagle, 1 month post-op from a partial maxillectomy for a fibrosarcoma, with waxing and waning lethargy/anorexia since his surgery, and an acute onset of hypotension, respiratory distress, and vomiting; suspected Addison's disease
6. An 8 week old kitten from the humane society, post-op from a PDA ligation (congenital heart defect requiring open-heart surgery); was so hyper and active after surgery that he removed his own chest tubes and IV line, and wanted nothing more than to make biscuits and suckle on your shirt all night; SO CUTE
Wednesday night's patients #2, 4, and 5 were discharged on Thursday. Unfortunately, Wednesday night's patient #6 (the very sick border collie mix) continued to decline and was euthanized during the day on Thursday.
I've not heard anything on how Boxer Puppy (suspected parvo) from Wednesday night is doing, but Golden Puppy from the same shift was hospitalized for about 12 hours on fluids, did very well, and was eventually diagnosed with a load of GI parasites (cryptosporidium, giardia, and roundworms) likely responsible for her GI upset.
Last night (Friday night), my 7 inpatients were:
1. Our friend the Presa Canario, post-op Wobbler's surgery on 8/23
2. Our friend the middle-aged Dachshund, post-op hemilaminectomy on 8/23
3. The elderly beagle with probable Addison's, patient #5 above (doing much better last night -- feeling well enough to be annoying)
4. An older German shepherd with acute hemoabdomen (belly full of blood) and a very low PCV of 18, who went for exploratory surgery where they removed his abnormal looking spleen, and biopsied lymph nodes, GI tract, and liver as well; he had several transfusions during surgery and did okay in recovery except for a common post-op splenectomy cardiac arrhythmia called VPCs/v-tach, which was managed fairly adequately with a lidocaine infusion
5. An 8 week old Pit mix puppy from the humane society, whose foster parents suspected he had eaten a sock or a piece of a soft toy when he started vomiting; he was taken to surgery last night and had an entire sock removed from his small intestine; did well post-op after getting out of surgery around midnight
6. An elderly Shiba Inu mix, post-op forelimb amputation for a soft tissue sarcoma; was doing pretty well with pain management and actually ambulated quite well for his first 12 hours post-op
7. A 1 year old mix dog who got loose from her owners, ran into a street, and was hit by a car, sustaining multiple pelvic fractures, the most severe of which were repaired surgically yesterday
The only patient who gave me any trouble was, unfortunately, patient #1, our dear darling Presa Canario. Though he entered CCU with a reputation for aggressive behavior and about a zillion caution signs on his cage and chart, he'd been nothing but a big sweetheart until my shift started last night. Yes, he was fearful and easily startled, and yes, we went slowly when approaching or handling him, but he had previously let me do all of his treatments (including unpleasant things like rectal temperatures and inspecting his urinary catheter) by myself.
Last night, though, he started growling at one of the CCU nurses (who has been caring for him all week) any time she would stand outside his cage and look at him. He was fine for his 11 pm and 1 am treatments (in fact, I did all of his 1 am treatments by myself) but started growling and curling his lips at me when I attempted to do his 7 am treatments.
Sigh.
With a smaller dog of a different breed, I'd push the issue a little more or not hesitate to muzzle the dog for whatever I needed to do. However, although this guy is still somewhat dopey on drugs, and is restricted in how quickly and in what direction he can move because of the surgery on his neck, he can sure whip his head around quickly if you're up within biting range, so I'm not going to push my luck. I did what I could do, and left the rest for the neuro department when they came in late morning to assess and walk him.
Hoping he'll have gone home today, but I'm guessing I'll see the bad guy again tonight!
Thursday, August 25, 2011
The parvo puppies who weren't
CCU overnight shift #4 was a busy one. I started with 6 inpatients:
1. The Presa Canario post-op Wobbler's surgery from yesterday (doing well, hasn't bitten anybody yet)
2. The adolescent shepherd mix from yesterday who ate a bunch of Rimadyl (doing fantastically well, no bad changes on bloodwork, still a 7 month old nutcase puppy going insane from being caged for 2 days)
3. The middle-aged Dachshund post-op hemilaminectomy from yesterday (also doing well, has motor function and deep pain sensation in his hindlimbs, was going to have his urinary catheter pulled today)
4. The senior coonhound post-op partial mandibulectomy and post-op second surgery for hemorrhage from yesterday (doing much better today, with no more bleeding from her incision, and less painful today)
5. The young Lab post-op enterotomy for rock foreign body from yesterday (still doing quite well today, transitioned from IV to oral pain meds and slated to go home today)
And my new inpatient:
6. A middle-aged border collie mix (who, incidentally, I saw last month on Derm for chronic management of a severe autoimmune disease, but who was doing quite well at that point) who presented with an acute onset of regurgitation, vomiting, diarrhea, anorexia, nosebleeds, prostatitis and fever, and who was subsequently diagnosed with DKA (diabetic ketoacidosis, or a "diabetic crisis"). His blood glucose was between 400 and 600 all night (normal for dogs is up to about 130-140). He was febrile with a rectal temperature that peaked around 105.5 and was finally down to 103-something by morning (normal 99.5-102.5). He kept regurgitating brownish bloody fluid intermittently. He was dribbling bloody urine, so we placed a urinary catheter (the second one I've gotten to do! fun!). Not sure what the plan for him was today since I didn't get to chat with his medicine clinician, but I'm guessing I'll be seeing him again tonight (as long as he's still alive).
(Sadly, patient #6 in yesterday's post was euthanized intra-operatively yesterday when they found that his bladder and urethra were very necrotic (dead tissue), probably from chronic distention of his bladder over the last few days as well as stones lodged in his urethra next to his u-cath. My understanding is that he had been blocked for a really long time by the time he got to his rDVM several days ago, so that probably didn't help either. Poor guy; he was such a sweetheart, even with what had to have been an ouchy bladder that we kept feeling, but at least I know that he was kept comfortable and happy with tons of petting during his last night with us.)
Last night we had 3 patients present on "emergency" (though none were truly critical patients). One was an adult dog with acute onset bloody diarrhea, who was handled by my rotation-mate.
My first emergency patient was an 8 week old Boxer puppy who presented for suspected parvovirus. Another dog in the household was treated at the VTH for parvo last week and just released 3 days ago; this puppy saw her rDVM 3 days ago for her first distemper-parvo vaccine but was in contact with the other dog and broke with diarrhea later that day. She started vomiting yesterday morning, and was lethargic and inappetant for about 24 hours before presentation as well.
Boxer Puppy's owners drove her to the VTH from about 2 hours away, passing multiple other daytime and ER vets, because they hoped to enter her in a parvo clinical trial that is being done at the VTH. The only problem was that her bedside parvo test last night was negative, which excludes her from the study. Most likely, she truly does have parvo and is just in an early stage of infection and not yet shedding the virus where it can be detected in the feces.
Unfortunately, Boxer Puppy's owners drove all that way because, if she had parvo, they really couldn't afford to treat it without financial assistance from a clinical trial. With her history and clinical signs, even with the negative test, we had to still assume she had parvo, recommended treating her as such, with hospitalization and IV fluids. However, due to financial restrictions we ended up sending her home on an oral antibiotic, an oral antiemetic, and instructing the owners on how to administer twice-daily subQ fluids. I'm hoping she does well; she wasn't clinically dehydrated yet on presentation, but being so young, it will be very easy for her hydration to fall behind.
About 15 minutes after Boxer Puppy left, I headed up to meet a second puppy and owner, this time a 4 month old golden retriever who was SO ADORABLE. This puppy had a similar-ish but more acute history -- she arrived at 2:45 am, having been completely fine until 6:30 pm the prior evening, when she began having softened stool that quickly progressed to watery diarrhea. Her attitude and appetite were a little off, and she started vomiting around 2 am. She had vomited pretty much nonstop since her vomiting began, and continued retching, vomiting, and passing liquid stool during our physical exam.
Despite her GI ailments, Golden Puppy was a happy little girl who just wanted to wag her tail and convince us to pet her belly. She was indeed somewhat sedate on exam, but did not yet appear dehydrated or otherwise ill. Her abdomen was soft and nonpainful, suggesting that a GI foreign body was slightly lower on our list of differentials, but still entirely possible.
Golden Puppy's mom works at the VTH as a receptionist and used to work elsewhere as a vet tech; she is super-nice, knowledgeable, and understanding of everything we wanted to do for hrer baby. Though Golden Puppy had had a normal series of puppy vaccines, and had already had her final distemper-parvo vaccine, we still had to consider parvovirus infection. Her bedside test was fortunately negative. A fecal cytology showed a massive overgrowth of cocci (which is bizarre, because bacterial overgrowth is almost always of rods). A venous blood gas showed low normal electrolytes.
Mom consented to hospitalize Golden Puppy on IV fluids for the rest of the morning (it was 4:30 am or so by the time she left) so we placed an IV catheter and started fluids. (Incidentally, I have failed miserably at the 2 IV catheters I've tried to place so far this week [Sunday night's Rottie with terrible veins from chemo, and Tuesday night's blocked tomcat who was really not interested in me shoving an 18g catheter into his leg] so it was quite a relief for me to finally have an IV placement that actually went well!)
Not knowing for sure if Golden Puppy might have an infectious/contagious disease, and preferring to be safe rather than sorry, we elected to place her in the isolation room in the back of CCU, with special nursing precautions including wearing a gown and gloves at all times when handling her.
Golden Puppy got a SQ injection of an antiemetic, an IV injection of Pepcid, and was started on oral antibiotics and an oral dewormer. By the time I left, she had not vomited or had diarrhea since her IV catheter was placed. Being a 4 month old puppy, she was not given the benefit of the doubt and had an e-collar placed immediately so that we didn't end up with a blood-covered puppy who had chewed out her IV catheter -- but she looked SO forlorn and mopey with the cone of shame! We submitted a fecal sample to the D-Lab for full screen, as well as bloodwork for CBC/chemistry. I'm hoping she continued to do well throughout the day -- guess we'll see tonight!
After rounds finished at 7:30 am, I ended up sticking around for a couple more hours to do paperwork on my emergency patients -- history and physical exam forms and RTG for Boxer Puppy, and history/physical exam/start an RTG for Golden Puppy. Not my preferred way to spend my morning, but I still got home by 9:45 or so and was asleep about an hour later. 4 nights down, 3 to go!
1. The Presa Canario post-op Wobbler's surgery from yesterday (doing well, hasn't bitten anybody yet)
2. The adolescent shepherd mix from yesterday who ate a bunch of Rimadyl (doing fantastically well, no bad changes on bloodwork, still a 7 month old nutcase puppy going insane from being caged for 2 days)
3. The middle-aged Dachshund post-op hemilaminectomy from yesterday (also doing well, has motor function and deep pain sensation in his hindlimbs, was going to have his urinary catheter pulled today)
4. The senior coonhound post-op partial mandibulectomy and post-op second surgery for hemorrhage from yesterday (doing much better today, with no more bleeding from her incision, and less painful today)
5. The young Lab post-op enterotomy for rock foreign body from yesterday (still doing quite well today, transitioned from IV to oral pain meds and slated to go home today)
And my new inpatient:
6. A middle-aged border collie mix (who, incidentally, I saw last month on Derm for chronic management of a severe autoimmune disease, but who was doing quite well at that point) who presented with an acute onset of regurgitation, vomiting, diarrhea, anorexia, nosebleeds, prostatitis and fever, and who was subsequently diagnosed with DKA (diabetic ketoacidosis, or a "diabetic crisis"). His blood glucose was between 400 and 600 all night (normal for dogs is up to about 130-140). He was febrile with a rectal temperature that peaked around 105.5 and was finally down to 103-something by morning (normal 99.5-102.5). He kept regurgitating brownish bloody fluid intermittently. He was dribbling bloody urine, so we placed a urinary catheter (the second one I've gotten to do! fun!). Not sure what the plan for him was today since I didn't get to chat with his medicine clinician, but I'm guessing I'll be seeing him again tonight (as long as he's still alive).
(Sadly, patient #6 in yesterday's post was euthanized intra-operatively yesterday when they found that his bladder and urethra were very necrotic (dead tissue), probably from chronic distention of his bladder over the last few days as well as stones lodged in his urethra next to his u-cath. My understanding is that he had been blocked for a really long time by the time he got to his rDVM several days ago, so that probably didn't help either. Poor guy; he was such a sweetheart, even with what had to have been an ouchy bladder that we kept feeling, but at least I know that he was kept comfortable and happy with tons of petting during his last night with us.)
Last night we had 3 patients present on "emergency" (though none were truly critical patients). One was an adult dog with acute onset bloody diarrhea, who was handled by my rotation-mate.
My first emergency patient was an 8 week old Boxer puppy who presented for suspected parvovirus. Another dog in the household was treated at the VTH for parvo last week and just released 3 days ago; this puppy saw her rDVM 3 days ago for her first distemper-parvo vaccine but was in contact with the other dog and broke with diarrhea later that day. She started vomiting yesterday morning, and was lethargic and inappetant for about 24 hours before presentation as well.
Boxer Puppy's owners drove her to the VTH from about 2 hours away, passing multiple other daytime and ER vets, because they hoped to enter her in a parvo clinical trial that is being done at the VTH. The only problem was that her bedside parvo test last night was negative, which excludes her from the study. Most likely, she truly does have parvo and is just in an early stage of infection and not yet shedding the virus where it can be detected in the feces.
Unfortunately, Boxer Puppy's owners drove all that way because, if she had parvo, they really couldn't afford to treat it without financial assistance from a clinical trial. With her history and clinical signs, even with the negative test, we had to still assume she had parvo, recommended treating her as such, with hospitalization and IV fluids. However, due to financial restrictions we ended up sending her home on an oral antibiotic, an oral antiemetic, and instructing the owners on how to administer twice-daily subQ fluids. I'm hoping she does well; she wasn't clinically dehydrated yet on presentation, but being so young, it will be very easy for her hydration to fall behind.
About 15 minutes after Boxer Puppy left, I headed up to meet a second puppy and owner, this time a 4 month old golden retriever who was SO ADORABLE. This puppy had a similar-ish but more acute history -- she arrived at 2:45 am, having been completely fine until 6:30 pm the prior evening, when she began having softened stool that quickly progressed to watery diarrhea. Her attitude and appetite were a little off, and she started vomiting around 2 am. She had vomited pretty much nonstop since her vomiting began, and continued retching, vomiting, and passing liquid stool during our physical exam.
Despite her GI ailments, Golden Puppy was a happy little girl who just wanted to wag her tail and convince us to pet her belly. She was indeed somewhat sedate on exam, but did not yet appear dehydrated or otherwise ill. Her abdomen was soft and nonpainful, suggesting that a GI foreign body was slightly lower on our list of differentials, but still entirely possible.
Golden Puppy's mom works at the VTH as a receptionist and used to work elsewhere as a vet tech; she is super-nice, knowledgeable, and understanding of everything we wanted to do for hrer baby. Though Golden Puppy had had a normal series of puppy vaccines, and had already had her final distemper-parvo vaccine, we still had to consider parvovirus infection. Her bedside test was fortunately negative. A fecal cytology showed a massive overgrowth of cocci (which is bizarre, because bacterial overgrowth is almost always of rods). A venous blood gas showed low normal electrolytes.
Mom consented to hospitalize Golden Puppy on IV fluids for the rest of the morning (it was 4:30 am or so by the time she left) so we placed an IV catheter and started fluids. (Incidentally, I have failed miserably at the 2 IV catheters I've tried to place so far this week [Sunday night's Rottie with terrible veins from chemo, and Tuesday night's blocked tomcat who was really not interested in me shoving an 18g catheter into his leg] so it was quite a relief for me to finally have an IV placement that actually went well!)
Not knowing for sure if Golden Puppy might have an infectious/contagious disease, and preferring to be safe rather than sorry, we elected to place her in the isolation room in the back of CCU, with special nursing precautions including wearing a gown and gloves at all times when handling her.
Golden Puppy got a SQ injection of an antiemetic, an IV injection of Pepcid, and was started on oral antibiotics and an oral dewormer. By the time I left, she had not vomited or had diarrhea since her IV catheter was placed. Being a 4 month old puppy, she was not given the benefit of the doubt and had an e-collar placed immediately so that we didn't end up with a blood-covered puppy who had chewed out her IV catheter -- but she looked SO forlorn and mopey with the cone of shame! We submitted a fecal sample to the D-Lab for full screen, as well as bloodwork for CBC/chemistry. I'm hoping she continued to do well throughout the day -- guess we'll see tonight!
After rounds finished at 7:30 am, I ended up sticking around for a couple more hours to do paperwork on my emergency patients -- history and physical exam forms and RTG for Boxer Puppy, and history/physical exam/start an RTG for Golden Puppy. Not my preferred way to spend my morning, but I still got home by 9:45 or so and was asleep about an hour later. 4 nights down, 3 to go!
Wednesday, August 24, 2011
Overnights: 3 down, 4 to go
I'm almost halfway through my week of CCU overnights, and it's been going well.
Sunday night was about the right amount of busy -- not too many patients, which was good because I was still learning how to do everything, and no emergencies came in.
Monday night was slower than Sunday, with only 4 patients for me and 5 for my rotation-mate. Mine were:
1. The middle-aged Shih Tzu from Sunday night, who for some reason ended up scheduled for his surgery on Tuesday instead of Monday so spent another night with us
2. An adult Lab who ate grapes
3. An elderly Lab post-op following a partial mandibulectomy for a recurrent aggressive melanoma
4. An elderly shepherd cross presented with anorexia, vomiting, and lethargy, and just diagnosed with GI lymphoma and slated to start chemo the next day
No emergencies again on Monday night.
Last night (Tuesday night) was a bit more hectic. I started out with 5 patients, then gained a sixth early on in the overnight shift:
1. A young Presa Canario (the dogs that kill people) post-op following a 12-hour-long surgery for Wobbler's (a vertebral malformation in the neck); thanks to ongoing infusions of happy drugs, he neither bit me nor made any attempt to do so
2. An adolescent shepherd cross who ate a bunch of Rimadyl (an NSAID) and a loaf of bread
3. A middle-aged Dachshund post-op following a hemilaminectomy for an acute disc herniation
4. A senior coonhound post-op following a partial mandibulectomy for a squamous cell carcinoma
5. A young Lab post-op following an enterotomy for a rock foreign body
6. A middle-aged cat who was seen by his rDVM 2 days prior for urinary obstruction; the rDVM placed a u-cath but sent him to us last night after being unable to remove the u-cath (he was headed for surgery today to remove his bladder stones, urethral stones, u-cath, and for a perineal urethrostomy to avoid re-blocking in the future)
We had no new emergency patients come in, but patient #4 above (the coonhound with the mandibulectomy) gave us an adrenaline rush. She was housed in ICW (intermediate care ward, a room across the hall from CCU that is usually used for stable post-op patients who just need IV fluids and IV pain meds overnight, then go home the next day -- ICW is staffed by a CCU nurse who is in there pretty much constantly supervising the patients, but does sometimes leave for a couple minutes at a time if everyone is doing well).
The CCU nurse left ICW for less than 60 seconds, and when she came back, the coonhound was covered in blood and there was blood gushing (like, literally gushing) from her mouth. This is a dog who, while not a total nutjob, did get removed from her baby-gated area in the corner of the room after trying to jump the gate, was wearing an e-collar after trying to chew out her IV catheter, and had been banging said e-collar around on the walls and doors of her cage.
The nurse rushed the dog across the hall to CCU where we immediately applied pressure and ice to the bleeding incision. However, the dog kept bleeding, and rapidly transitioned from her previously very alert state to basically passed out on the table in front of us. We bolused IV fluids and checked a blood pressure -- her systolic bp, previously normal, had dropped to between 50 and 60 -- low normal is 90-100. Her heart rate was dropping and her pulses were weak. We put her on an EKG and flow-by oxygen. Another nurse placed a second IV catheter. They called the doctor who had performed her surgery earlier that day, and the doctor rushed right in. Only 5-10 minutes after the dog's bleeding initially started, it was apparent that she had lost a massive amount of blood, so we started a transfusion. As soon as the surgeon arrived, back to surgery she went.
All in all, it was a definite spot of excitement in what was otherwise a pretty routine evening. It was crazy how much and how quickly the dog bled -- if she had been unsupervised for, say, 5 or 10 minutes, she could easily have bled to death. It was lucky that her bleeding was noticed immediately, which is why these patients are kept so closely supervised after surgery. I passed her rolling out of surgery this morning as I was leaving, and she seemed to be doing well (at least she was no longer bleeding, and they had washed her off -- she was a mostly white dog, of course).
Schedule-wise, I feel like I've adapted pretty well to overnight shifts. The first 2 nights and days were a little rough, but last night I really felt awake and almost normal throughout the entire overnight shift. Yesterday I slept for about 3 hours in the morning, then got up and had some lunch (dinner? breakfast? Chinese food, at any rate) and went back to sleep from noon till 5. Today I slept pretty much from 10 am-5 pm with minimal interruptions. It's nice to be able to sleep during the day -- I've heard horror stories from classmates who have had 5 or 6 of their overnight shifts before they can finally get on a sleeping schedule and sleep for more than just a couple hours in any 24 hour period.
Last night during some downtime, I was chatting with the intern and she asked me if I like emergency medicine. I replied that while the idea of seeing truly emergent patients makes me very nervous and a little panicky, I haven't been on CCU rotations long enough to know how well I actually handle it. Sure, it's fine to help care for and monitor the sick and post-op patients that are in CCU all night, but other than the coonhound episode last night, we haven't really had emergencies yet. The hours are not as bad as I expected -- I'm hopeful that I'll be able to keep up this eating and sleeping schedule for the rest of the week -- and it's certainly nice to do shift-style work, where whatever isn't done by the time the next shift arrives at 7 am, I can pass off to them and just leave when rounds are done between 7:30-8 am. The CCU nurses are really great -- they are fantastic at teaching technical procedures like placing IV lines, urinary catheters, blood draws, injections, etc. -- and they stay extraordinarily calm when things go wrong or it gets hectic. I guess I might like CCU/emergency work more than I thought I would, but at this point I can't really picture myself going for employment at an emergency clinic or anything like that after graduation. Maybe that will change; who knows.
Sunday night was about the right amount of busy -- not too many patients, which was good because I was still learning how to do everything, and no emergencies came in.
Monday night was slower than Sunday, with only 4 patients for me and 5 for my rotation-mate. Mine were:
1. The middle-aged Shih Tzu from Sunday night, who for some reason ended up scheduled for his surgery on Tuesday instead of Monday so spent another night with us
2. An adult Lab who ate grapes
3. An elderly Lab post-op following a partial mandibulectomy for a recurrent aggressive melanoma
4. An elderly shepherd cross presented with anorexia, vomiting, and lethargy, and just diagnosed with GI lymphoma and slated to start chemo the next day
No emergencies again on Monday night.
Last night (Tuesday night) was a bit more hectic. I started out with 5 patients, then gained a sixth early on in the overnight shift:
1. A young Presa Canario (the dogs that kill people) post-op following a 12-hour-long surgery for Wobbler's (a vertebral malformation in the neck); thanks to ongoing infusions of happy drugs, he neither bit me nor made any attempt to do so
2. An adolescent shepherd cross who ate a bunch of Rimadyl (an NSAID) and a loaf of bread
3. A middle-aged Dachshund post-op following a hemilaminectomy for an acute disc herniation
4. A senior coonhound post-op following a partial mandibulectomy for a squamous cell carcinoma
5. A young Lab post-op following an enterotomy for a rock foreign body
6. A middle-aged cat who was seen by his rDVM 2 days prior for urinary obstruction; the rDVM placed a u-cath but sent him to us last night after being unable to remove the u-cath (he was headed for surgery today to remove his bladder stones, urethral stones, u-cath, and for a perineal urethrostomy to avoid re-blocking in the future)
We had no new emergency patients come in, but patient #4 above (the coonhound with the mandibulectomy) gave us an adrenaline rush. She was housed in ICW (intermediate care ward, a room across the hall from CCU that is usually used for stable post-op patients who just need IV fluids and IV pain meds overnight, then go home the next day -- ICW is staffed by a CCU nurse who is in there pretty much constantly supervising the patients, but does sometimes leave for a couple minutes at a time if everyone is doing well).
The CCU nurse left ICW for less than 60 seconds, and when she came back, the coonhound was covered in blood and there was blood gushing (like, literally gushing) from her mouth. This is a dog who, while not a total nutjob, did get removed from her baby-gated area in the corner of the room after trying to jump the gate, was wearing an e-collar after trying to chew out her IV catheter, and had been banging said e-collar around on the walls and doors of her cage.
The nurse rushed the dog across the hall to CCU where we immediately applied pressure and ice to the bleeding incision. However, the dog kept bleeding, and rapidly transitioned from her previously very alert state to basically passed out on the table in front of us. We bolused IV fluids and checked a blood pressure -- her systolic bp, previously normal, had dropped to between 50 and 60 -- low normal is 90-100. Her heart rate was dropping and her pulses were weak. We put her on an EKG and flow-by oxygen. Another nurse placed a second IV catheter. They called the doctor who had performed her surgery earlier that day, and the doctor rushed right in. Only 5-10 minutes after the dog's bleeding initially started, it was apparent that she had lost a massive amount of blood, so we started a transfusion. As soon as the surgeon arrived, back to surgery she went.
All in all, it was a definite spot of excitement in what was otherwise a pretty routine evening. It was crazy how much and how quickly the dog bled -- if she had been unsupervised for, say, 5 or 10 minutes, she could easily have bled to death. It was lucky that her bleeding was noticed immediately, which is why these patients are kept so closely supervised after surgery. I passed her rolling out of surgery this morning as I was leaving, and she seemed to be doing well (at least she was no longer bleeding, and they had washed her off -- she was a mostly white dog, of course).
Schedule-wise, I feel like I've adapted pretty well to overnight shifts. The first 2 nights and days were a little rough, but last night I really felt awake and almost normal throughout the entire overnight shift. Yesterday I slept for about 3 hours in the morning, then got up and had some lunch (dinner? breakfast? Chinese food, at any rate) and went back to sleep from noon till 5. Today I slept pretty much from 10 am-5 pm with minimal interruptions. It's nice to be able to sleep during the day -- I've heard horror stories from classmates who have had 5 or 6 of their overnight shifts before they can finally get on a sleeping schedule and sleep for more than just a couple hours in any 24 hour period.
Last night during some downtime, I was chatting with the intern and she asked me if I like emergency medicine. I replied that while the idea of seeing truly emergent patients makes me very nervous and a little panicky, I haven't been on CCU rotations long enough to know how well I actually handle it. Sure, it's fine to help care for and monitor the sick and post-op patients that are in CCU all night, but other than the coonhound episode last night, we haven't really had emergencies yet. The hours are not as bad as I expected -- I'm hopeful that I'll be able to keep up this eating and sleeping schedule for the rest of the week -- and it's certainly nice to do shift-style work, where whatever isn't done by the time the next shift arrives at 7 am, I can pass off to them and just leave when rounds are done between 7:30-8 am. The CCU nurses are really great -- they are fantastic at teaching technical procedures like placing IV lines, urinary catheters, blood draws, injections, etc. -- and they stay extraordinarily calm when things go wrong or it gets hectic. I guess I might like CCU/emergency work more than I thought I would, but at this point I can't really picture myself going for employment at an emergency clinic or anything like that after graduation. Maybe that will change; who knows.
Monday, August 22, 2011
Goodbye vacation, hello CCU overnights
My first 2 weeks of vacation ended yesterday, and I had a heck of a good time. We spent most of the first week in Minnesota visiting family, including a trip up to the lake where we went fishing 4 times in 24 hours and I caught an awesome 14-inch largemouth bass. This is not my fish, but it looked just like this: 
Week 2 of vacation involved sleeping in (a lot), a full day of doctor's appointments (all annual check ups), camping in Estes Park, and a trip to the water park (where it did not rain and nothing of ours was stolen -- there had to be a first time for that!).
I am so glad that we are given 2 weeks of vacation at a time. Although I was quite refreshed after the first week, the 27 hours of driving over the span of 2 days kind of sucked up 29% of my vacation that week, and it was really nice to have a second week to just chill out and get stuff done. It's hard to have doctor appointments, etc. during rotations when I'm at school from 6:30-7:30 am until late in the evening.
I'm also glad that we get 8 weeks of vacation built into our senior year rotation schedule, and Lord knows we need it. On orthopedics, we had a visiting senior student from NC State who informed us that they get 2 weeks -- TOTAL -- of vacation time during their senior year. Of course, they also have special time set aside in their schedules for externships, whereas we small animal trackers pretty much have to do any desired externships during our vacation time, but still. Two weeks? All year? I am already dreading how drained I'm going to be by the time my next vacation rolls around in January. By then I'll have completed 4 weeks on CCU, 2 weeks each on oncology, necropsy, cardiology, and 3 weeks each on anesthesia and radiology -- plus my grand rounds will be over (September 16, how I dread you).
But anyway, this round of vacation officially ended at 9:45 pm yesterday when I reported to CCU for orientation. Step 1 of CCU orientation was a visit to the night receptionist (who is around till 10 pm every day) to learn how to have emergency clients complete new client paperwork and how to take deposits and payments. Little did I know that I was going to get to play receptionist while on CCU overnights -- "lucky" me.
Then we had case transfer rounds, where the after-hours students passed on their hospitalized cases to us. That was followed by an orientation to the CCU room itself. Fortunately, the night nurse didn't seem bothered by the fact that I didn't know where anything was or how to do anything CCU-style, since my single rotation-mate had already had her first 2 weeks of CCU earlier this summer.
My 5 cases were as follows:
1. Middle-aged Chow with megaesophagus and a newly placed feeding tube
2. Middle-aged Shih Tzu with kidney and bladder stones
3. Middle-aged cat with possibly lily ingestion the day before
4. Middle-aged Rottweiler with previously diagnosed osteosarcoma treated with a hindlimb amputation, and acute inability to ambulate (suspected spinal cord lesion)
5. Middle-aged Lab that ate 30 Adderall pills (amphetamine used to treat ADHD in people)
As you can see, it was a night for the middle-aged, with all of my patients between 6 and 8 years of age. The Shih Tzu, kitty, and Lab were all super-sweet and happy with whatever I had to do to them. The Chow was a bit cranky, but couldn't do much to get around his e-collar at me. The Rottweiler bit another student badly before I arrived, but the consensus was that he had been painful and was startled -- nonetheless, I muzzled him any time I had to touch him in any way (especially when I tried [and failed] to place an IV catheter [his veins were totally shot from months of chemo], and when I placed a urinary catheter [much more successfully than the IV!]).
CCU overnights, as I understand them, mainly involve caring for the hospitalized patients, as well as dealing with any emergencies that come in between 11 pm and 7 am. Fortunately, we didn't have any emergencies last night, which was just fine with me since I was plenty busy harassing the poor lone night nurse to show me how to do things and where things were kept.
Treatment times in CCU are on a q24h (once daily), BID (twice daily), TID (three times daily), and QID (four times daily) schedule.
q24h treatments are done at 7 am.
BID treatments are at 7 am and 7 pm.
TID treatments are at 7 am, 3 pm, and 11 pm.
QID treatments are at 7 am, 1 pm, 7 pm, and 1 am.
As overnight students on from 10 pm-8 am, we were responsible for helping finish the 11 pms, doing the 1 ams, and doing the 7 ams. The 7 ams are the hardest because all treatments occur at 7 am.
I made it home around 8:30 am and went to bed at 10. I woke up every couple hours but did manage to sleep until almost 5 pm, so I'm hopeful that that will tide me over until tomorrow's daytime sleepfest. I made it through last night with just a 90 minute nap yesterday afternoon and was still functional by the time I got home this morning, so I hope I'll be able to get enough sleep during the days to be cogent and collected overnight.
Either way, it's going to be interesting. One down, six more to go.
Week 2 of vacation involved sleeping in (a lot), a full day of doctor's appointments (all annual check ups), camping in Estes Park, and a trip to the water park (where it did not rain and nothing of ours was stolen -- there had to be a first time for that!).
I am so glad that we are given 2 weeks of vacation at a time. Although I was quite refreshed after the first week, the 27 hours of driving over the span of 2 days kind of sucked up 29% of my vacation that week, and it was really nice to have a second week to just chill out and get stuff done. It's hard to have doctor appointments, etc. during rotations when I'm at school from 6:30-7:30 am until late in the evening.
I'm also glad that we get 8 weeks of vacation built into our senior year rotation schedule, and Lord knows we need it. On orthopedics, we had a visiting senior student from NC State who informed us that they get 2 weeks -- TOTAL -- of vacation time during their senior year. Of course, they also have special time set aside in their schedules for externships, whereas we small animal trackers pretty much have to do any desired externships during our vacation time, but still. Two weeks? All year? I am already dreading how drained I'm going to be by the time my next vacation rolls around in January. By then I'll have completed 4 weeks on CCU, 2 weeks each on oncology, necropsy, cardiology, and 3 weeks each on anesthesia and radiology -- plus my grand rounds will be over (September 16, how I dread you).
But anyway, this round of vacation officially ended at 9:45 pm yesterday when I reported to CCU for orientation. Step 1 of CCU orientation was a visit to the night receptionist (who is around till 10 pm every day) to learn how to have emergency clients complete new client paperwork and how to take deposits and payments. Little did I know that I was going to get to play receptionist while on CCU overnights -- "lucky" me.
Then we had case transfer rounds, where the after-hours students passed on their hospitalized cases to us. That was followed by an orientation to the CCU room itself. Fortunately, the night nurse didn't seem bothered by the fact that I didn't know where anything was or how to do anything CCU-style, since my single rotation-mate had already had her first 2 weeks of CCU earlier this summer.
My 5 cases were as follows:
1. Middle-aged Chow with megaesophagus and a newly placed feeding tube
2. Middle-aged Shih Tzu with kidney and bladder stones
3. Middle-aged cat with possibly lily ingestion the day before
4. Middle-aged Rottweiler with previously diagnosed osteosarcoma treated with a hindlimb amputation, and acute inability to ambulate (suspected spinal cord lesion)
5. Middle-aged Lab that ate 30 Adderall pills (amphetamine used to treat ADHD in people)
As you can see, it was a night for the middle-aged, with all of my patients between 6 and 8 years of age. The Shih Tzu, kitty, and Lab were all super-sweet and happy with whatever I had to do to them. The Chow was a bit cranky, but couldn't do much to get around his e-collar at me. The Rottweiler bit another student badly before I arrived, but the consensus was that he had been painful and was startled -- nonetheless, I muzzled him any time I had to touch him in any way (especially when I tried [and failed] to place an IV catheter [his veins were totally shot from months of chemo], and when I placed a urinary catheter [much more successfully than the IV!]).
CCU overnights, as I understand them, mainly involve caring for the hospitalized patients, as well as dealing with any emergencies that come in between 11 pm and 7 am. Fortunately, we didn't have any emergencies last night, which was just fine with me since I was plenty busy harassing the poor lone night nurse to show me how to do things and where things were kept.
Treatment times in CCU are on a q24h (once daily), BID (twice daily), TID (three times daily), and QID (four times daily) schedule.
q24h treatments are done at 7 am.
BID treatments are at 7 am and 7 pm.
TID treatments are at 7 am, 3 pm, and 11 pm.
QID treatments are at 7 am, 1 pm, 7 pm, and 1 am.
As overnight students on from 10 pm-8 am, we were responsible for helping finish the 11 pms, doing the 1 ams, and doing the 7 ams. The 7 ams are the hardest because all treatments occur at 7 am.
I made it home around 8:30 am and went to bed at 10. I woke up every couple hours but did manage to sleep until almost 5 pm, so I'm hopeful that that will tide me over until tomorrow's daytime sleepfest. I made it through last night with just a 90 minute nap yesterday afternoon and was still functional by the time I got home this morning, so I hope I'll be able to get enough sleep during the days to be cogent and collected overnight.
Either way, it's going to be interesting. One down, six more to go.
Sunday, August 7, 2011
My weekend
Friday:
3 am -- called in for emergency surgery
4 am -- started hemilaminectomy
6:30 am -- hemi done; ran to grocery store for breakfast
7 am -- check on inpatients
7:45 am -- rounds
8:30 am -- appointments, rechecks, regularly scheduled surgeries, paperwork
5 pm -- home
6 pm -- nap on couch
7:30 pm -- wake up; eat dinner
10:30 pm -- bed
Saturday:
6:45 am -- wake up
7:15 am -- check on inpatients; paperwork
9 am -- visit with inpatient's owner
10:15 am -- home
10:30 am -- run errands; lunch
1 pm -- nap
2:45 pm -- wake up
3:10 pm -- movie at dollar theater
5:10 pm -- called in for emergency surgery
6:30 pm -- start abdominal explore/gastrotomy to remove foreign body
8:45 pm -- abd explore done
9:15 pm -- home; shower; dinner
11:15 pm -- bed
11:30 pm -- called in for emergency surgery
Sunday:
12:30 am -- start pyometra surgery
2 am -- pyo surgery done; grab a snack; paperwork
3 am -- start abdominal explore for foreign body
5 am -- abd explore done; paperwork; snack
5:30 am -- nap in VTH locker room
7 am -- wake up; check on inpatients; paperwork
9:30 am -- visit with inpatient's owner
10:30 am -- home; shower; meal (lunch? breakfast?)
12 pm -- bed
4:15 pm -- called in for discharge of pyo patient
4:40 pm -- back at VTH; paperwork
5 pm -- discharge pyo patient
5:45 pm -- home
Not sure how I am still awake and coherent, but there you go. Anticipating lots of sleep on the 13 hour drive to MN tomorrow. At least my pyo patient went home tonight so I don't have to go check on her before we leave tomorrow. Huzzah!
3 am -- called in for emergency surgery
4 am -- started hemilaminectomy
6:30 am -- hemi done; ran to grocery store for breakfast
7 am -- check on inpatients
7:45 am -- rounds
8:30 am -- appointments, rechecks, regularly scheduled surgeries, paperwork
5 pm -- home
6 pm -- nap on couch
7:30 pm -- wake up; eat dinner
10:30 pm -- bed
Saturday:
6:45 am -- wake up
7:15 am -- check on inpatients; paperwork
9 am -- visit with inpatient's owner
10:15 am -- home
10:30 am -- run errands; lunch
1 pm -- nap
2:45 pm -- wake up
3:10 pm -- movie at dollar theater
5:10 pm -- called in for emergency surgery
6:30 pm -- start abdominal explore/gastrotomy to remove foreign body
8:45 pm -- abd explore done
9:15 pm -- home; shower; dinner
11:15 pm -- bed
11:30 pm -- called in for emergency surgery
Sunday:
12:30 am -- start pyometra surgery
2 am -- pyo surgery done; grab a snack; paperwork
3 am -- start abdominal explore for foreign body
5 am -- abd explore done; paperwork; snack
5:30 am -- nap in VTH locker room
7 am -- wake up; check on inpatients; paperwork
9:30 am -- visit with inpatient's owner
10:30 am -- home; shower; meal (lunch? breakfast?)
12 pm -- bed
4:15 pm -- called in for discharge of pyo patient
4:40 pm -- back at VTH; paperwork
5 pm -- discharge pyo patient
5:45 pm -- home
Not sure how I am still awake and coherent, but there you go. Anticipating lots of sleep on the 13 hour drive to MN tomorrow. At least my pyo patient went home tonight so I don't have to go check on her before we leave tomorrow. Huzzah!
Friday, August 5, 2011
3 am hemilaminectomy? Yes, please
My day started when I was startled from a deep sleep at 3 am by a phone call from the on-call surgeon, informing me my presence was required at the VTH to assist with an emergency back surgery.
This being my first opportunity to test my ability to get to the VTH within the requisite 20-minute time limit for on-call shifts, I was pleased to find myself somehow stumbling in the door a mere 17 minutes after being called.
The patient was, predictably, a middle-aged Dachshund with a sudden onset of hindlimb paralysis. Myelogram (injection of contrast material into the spinal canal, followed by x-rays of the spinal column) showed what was almost certainly a disc herniation in the caudal thoracic spine.
We started cutting on the little guy at 4 am, along with the on-call surgeon and the neurologist who offered to come help. Both of them were (not unreasonably) just a tad crabby. Everything went well (pulled out a huge bulging disc) and they let us loose at 6:30 am.
Which left just enough time to run to the nearby grocery store to pick up The Breakfast of Champions: a banana, a Snickers bar, a bag of Monterey Jack & Cheddar cheese cubes, and some harvest cheddar Sun Chips. That combination'll wake you right up.
I was back at the VTH by 7 am, to take a look at my poor hospitalized Westie (who took a turn for the worse yesterday but seems to have improved today). After doing a physical exam, helping with her treatments, running her blood down to the lab, and calling her mom with an update, it was time for 7:45 am case rounds.
I had a brief break from 8:45-9:30 to catch up on some paperwork, then headed up to the lobby to meet my drop-off appointment, an older lab mix who we'd seen the previous day for a workup of right hindlimb lameness. On physical and orthopedic exam yesterday, it was readily apparent that this guy's lameness had a neurologic basis, since he was pretty orthopedically sound. He had a neuro consult and the neurologists concurred, suspecting a lesion affecting his lumbosacral spinal cord.
We discussed the findings with the dog's owners, as well as the neurologists' recommendation of bloodwork, urinalysis, chest xrays, abdominal ultrasound, MRI, +/- CSF tap and surgery if indicated (e.g. for a chronic disc protrusion). We gave them costs as well as pros and cons of the neuro workup versus conservative/palliative management. They didn't seem entirely game for the full neuro workup (which, with surgery, would put them at a cost of $5-6K for their 10-year-old dog) but agreed to bloodwork, chest rads, and abdominal ultrasound as an initial step while they thought more about it. Bloodwork and chest rads yesterday were clean, and abdominal ultrasound was scheduled for today.
When I went up to get the dog from his dad in the lobby, I confirmed the plan as I understood it (drop off for ultrasound). Dad replied, "Yes, and if his ultrasound is okay, then we'd like to do the MRI and surgery if he needs it." I was mildly surprised since the orthopedic doctor who saw the dog yesterday felt the owners were probably not interested in workup (though I got a vibe that they could go either way).
This led to a frantic race around the hospital, discussing the case with neurology, MRI, anesthesia, and ultrasound to see if everything could be coordinated to take place yet today (since it was already after 9:30 am at this point). Fortunately, I'd had the foresight to ask the owners to fast the dog (yay, me!) so he was on an empty tummy and set for anesthesia.
His ultrasound came back pretty normal (some nodules in the spleen and liver which could very possibly be just old-dog aging changes, though cancer couldn't be ruled out), and he was officially transferred to neuro. I touched base with them later in the day, and they'd found a large tumor compressing his sciatic nerve on one side, and had plans to biopsy it to see if it could be safely resected or if he might need a limb amputation.
By the time that was all straightened out, it was time to watch one of the ortho surgeries -- a young dog with infraspinatus contracture, in for an infraspinatus tenotomy (a pretty easy and cool surgery). I had originally planned to scrub in, but it was a tiny surgical field and there were already 3 doctors and 1 other student scrubbed in, so I was glad to just sit it out.
After that surgery, I assisted with a consult on a lame dog that presented through Urgent Care. We didn't really find anything orthopedically abnormal with him, other than some serious edema around one of his tarsi, which didn't even really seem to be affecting the tarsus itself, just the tissue around it. Oddly, this dog had a lot of facial asymmetry, one bulging eye, a nose that deviated to one side, and strange mentation -- he just didn't seem very "with it," would periodically stare off into space and be pretty nonresponsive, and had these bizarre episodes of a repetitive chewing/licking motion that we suspected might be focal seizures.
Then it was time for afternoon rounds (doctors bought us pizza!) around 4 pm, then tidying up some loose ends, finishing paperwork, calling my Westie's owners for an evening update, and heading home.
I guess if I had to get called in during my 5 pm-8 am on call shift last night, 3 am wasn't a bad time for it to happen. It still allowed me 4+ hours of sleep, and was perfectly timed so that I didn't have much time to kill between the end of the surgery at 6:30 and the time I'd planned to come in (7 am). The oddest thing was just that my day felt shifted around by 4 hours all day -- by the time we had morning rounds at 8 am, I was ready for lunch. By the time actual lunchtime rolled around, it felt like time to have afternoon rounds and wrap things up for the day. Once I got through that, it was just like having a second entire afternoon. But I sure was beat by the end of it -- not falling asleep, but just having trouble paying attention during rounds discussions that weren't all that interesting to me (and wouldn't have been even if I'd had a full night's sleep). I'll also point out that I continued to exercise good judgment even at 4:30 pm by abstaining from the alcoholic beverages being passed around ("It's a Friday afternoon tradition!") at the end of rounds -- that is, until the hospital director came by and expressed his absolute disapproval (no disagreement from me). It was definitely an awkward end to the day!
This being my first opportunity to test my ability to get to the VTH within the requisite 20-minute time limit for on-call shifts, I was pleased to find myself somehow stumbling in the door a mere 17 minutes after being called.
The patient was, predictably, a middle-aged Dachshund with a sudden onset of hindlimb paralysis. Myelogram (injection of contrast material into the spinal canal, followed by x-rays of the spinal column) showed what was almost certainly a disc herniation in the caudal thoracic spine.
We started cutting on the little guy at 4 am, along with the on-call surgeon and the neurologist who offered to come help. Both of them were (not unreasonably) just a tad crabby. Everything went well (pulled out a huge bulging disc) and they let us loose at 6:30 am.
Which left just enough time to run to the nearby grocery store to pick up The Breakfast of Champions: a banana, a Snickers bar, a bag of Monterey Jack & Cheddar cheese cubes, and some harvest cheddar Sun Chips. That combination'll wake you right up.
I was back at the VTH by 7 am, to take a look at my poor hospitalized Westie (who took a turn for the worse yesterday but seems to have improved today). After doing a physical exam, helping with her treatments, running her blood down to the lab, and calling her mom with an update, it was time for 7:45 am case rounds.
I had a brief break from 8:45-9:30 to catch up on some paperwork, then headed up to the lobby to meet my drop-off appointment, an older lab mix who we'd seen the previous day for a workup of right hindlimb lameness. On physical and orthopedic exam yesterday, it was readily apparent that this guy's lameness had a neurologic basis, since he was pretty orthopedically sound. He had a neuro consult and the neurologists concurred, suspecting a lesion affecting his lumbosacral spinal cord.
We discussed the findings with the dog's owners, as well as the neurologists' recommendation of bloodwork, urinalysis, chest xrays, abdominal ultrasound, MRI, +/- CSF tap and surgery if indicated (e.g. for a chronic disc protrusion). We gave them costs as well as pros and cons of the neuro workup versus conservative/palliative management. They didn't seem entirely game for the full neuro workup (which, with surgery, would put them at a cost of $5-6K for their 10-year-old dog) but agreed to bloodwork, chest rads, and abdominal ultrasound as an initial step while they thought more about it. Bloodwork and chest rads yesterday were clean, and abdominal ultrasound was scheduled for today.
When I went up to get the dog from his dad in the lobby, I confirmed the plan as I understood it (drop off for ultrasound). Dad replied, "Yes, and if his ultrasound is okay, then we'd like to do the MRI and surgery if he needs it." I was mildly surprised since the orthopedic doctor who saw the dog yesterday felt the owners were probably not interested in workup (though I got a vibe that they could go either way).
This led to a frantic race around the hospital, discussing the case with neurology, MRI, anesthesia, and ultrasound to see if everything could be coordinated to take place yet today (since it was already after 9:30 am at this point). Fortunately, I'd had the foresight to ask the owners to fast the dog (yay, me!) so he was on an empty tummy and set for anesthesia.
His ultrasound came back pretty normal (some nodules in the spleen and liver which could very possibly be just old-dog aging changes, though cancer couldn't be ruled out), and he was officially transferred to neuro. I touched base with them later in the day, and they'd found a large tumor compressing his sciatic nerve on one side, and had plans to biopsy it to see if it could be safely resected or if he might need a limb amputation.
By the time that was all straightened out, it was time to watch one of the ortho surgeries -- a young dog with infraspinatus contracture, in for an infraspinatus tenotomy (a pretty easy and cool surgery). I had originally planned to scrub in, but it was a tiny surgical field and there were already 3 doctors and 1 other student scrubbed in, so I was glad to just sit it out.
After that surgery, I assisted with a consult on a lame dog that presented through Urgent Care. We didn't really find anything orthopedically abnormal with him, other than some serious edema around one of his tarsi, which didn't even really seem to be affecting the tarsus itself, just the tissue around it. Oddly, this dog had a lot of facial asymmetry, one bulging eye, a nose that deviated to one side, and strange mentation -- he just didn't seem very "with it," would periodically stare off into space and be pretty nonresponsive, and had these bizarre episodes of a repetitive chewing/licking motion that we suspected might be focal seizures.
Then it was time for afternoon rounds (doctors bought us pizza!) around 4 pm, then tidying up some loose ends, finishing paperwork, calling my Westie's owners for an evening update, and heading home.
I guess if I had to get called in during my 5 pm-8 am on call shift last night, 3 am wasn't a bad time for it to happen. It still allowed me 4+ hours of sleep, and was perfectly timed so that I didn't have much time to kill between the end of the surgery at 6:30 and the time I'd planned to come in (7 am). The oddest thing was just that my day felt shifted around by 4 hours all day -- by the time we had morning rounds at 8 am, I was ready for lunch. By the time actual lunchtime rolled around, it felt like time to have afternoon rounds and wrap things up for the day. Once I got through that, it was just like having a second entire afternoon. But I sure was beat by the end of it -- not falling asleep, but just having trouble paying attention during rounds discussions that weren't all that interesting to me (and wouldn't have been even if I'd had a full night's sleep). I'll also point out that I continued to exercise good judgment even at 4:30 pm by abstaining from the alcoholic beverages being passed around ("It's a Friday afternoon tradition!") at the end of rounds -- that is, until the hospital director came by and expressed his absolute disapproval (no disagreement from me). It was definitely an awkward end to the day!
Wednesday, August 3, 2011
I pride myself on good judgment
Following Lilly's amputation today, I was tasked with bringing her amputated leg down to the necropsy department for disposal.
I'd hate for you not to have an accurate visual, so let me explain that this involves carrying a bloody severed limb in a translucent plastic bag through most of the hallways of the VTH, down to the necropsy cooler.
As I turned a corner to head down the final hallway toward the lab, I caught glimpse of the hospital director walking my way, followed by a gaggle of well-dressed people who were evidently getting a hospital tour.
In what I consider a moment of good judgment, I pivoted and headed back the other direction, opting to take the long way 'round rather than ambling through a group of hospital donors, gaily swinging a severed limb to and fro.
Yes, vet school beats a lot of the common sense out of you, but evidently not all of it.
I'd hate for you not to have an accurate visual, so let me explain that this involves carrying a bloody severed limb in a translucent plastic bag through most of the hallways of the VTH, down to the necropsy cooler.
As I turned a corner to head down the final hallway toward the lab, I caught glimpse of the hospital director walking my way, followed by a gaggle of well-dressed people who were evidently getting a hospital tour.
In what I consider a moment of good judgment, I pivoted and headed back the other direction, opting to take the long way 'round rather than ambling through a group of hospital donors, gaily swinging a severed limb to and fro.
Yes, vet school beats a lot of the common sense out of you, but evidently not all of it.
Pit bull attack!
There! Are you all frenzied up? Ready to frantically call the local news and demand a ban on those vicious, evil dogs?
Just kidding. Kind of.
My orthopedics patient today was Lilly, a middle-aged Westie who had the misfortune to be attacked by a larger dog while out for a bedtime walk last night.
Lilly's mom fended off the attacker, sustaining some bites to her own hands and arms in the process, then rushed Lilly to her regular vet. Lilly's rDVM briefly anesthetized her, just long enough to clip and clean the deep puncture wounds on her left hind leg, diagnose a dislocated hip, and place a bandage to keep the areas as clean as possible.
Immediately following the visit to the rDVM, Lilly's mom drove the 1 hour to the VTH, arriving with Lilly at 2:30 am. Lilly stayed in CCU on IV fluids and pain meds until she was transferred to Orthopedics when we arrived for rounds at 8:30.
Long story short, radiographs and palpation showed some serious subluxation of Lilly's left hip, with deep puncture wounds all around her left thigh. After briefly discussing the possibility of attempting a (not-very-likely-to-be-successful) salvage of Lilly's hip, everyone agreed amputation was the best option for little Lilly. So amputate we did.
My frustration with this case lies in the fact that, from the time I first heard about Lilly during rounds this morning, the phrase "pit bull attack" has been repeated about a thousand and one times.
Now, don't get me wrong, if Lilly was truly attacked by a pit bull, I have no problem saying so. If she had been attacked by a lab or a golden retriever or a Husky, I'd also have no problem saying so. No, I don't think the breed of dog that attacked Lilly is medically relevant (only the fact that she was bitten by a larger dog), but if you're sure of the breed, then go ahead and say it.
However, Lilly's presenting complaint (what the receptionists put on the appointment schedule as the reason a dog is coming for a visit) was listed as "pit bull attack." If there had been knowledge that any breed other than a pit bull had attacked Lilly, I can in no way imagine her presenting complaint being listed as "lab mix attack" or "German shepherd attack" or "Chow attack." It would just be listed as "dog attack," "dog bites," or "bite wounds."
I think the vilification of pit bulls implicit in the specification of breed in Lilly's case is unnecessary and damaging. Sure, I've met a good many pits who would indeed not hesitate to attack a cute little white dog walking down the street. But I've met a far greater number of pitties who would just as soon play bow or ignore another dog.
As Lilly's primary student, I traveled around the hospital with her to various departments today and ended up explaining her history to multiple people. My explanation went like this: "At 10 o'clock last night, Lilly was out walking with her owner when she was attacked by a larger dog. She went to her rDVM (etc.)...." Invariably, someone would ask me what kind of dog attacked Lilly, as if it would make any difference in how we would treat her or what her prognosis would be. I don't care if Lilly was attacked by a Boxer, a standard poodle, a Samoyed, a Chihuahua, or a potbellied pig, and I don't understand some people's need to hear that it was a pit bull so they can nod knowingly and look at Lilly with a greater degree of pity than if she had been attacked by another "less dangerous" breed. Even if I had personally witnessed the attack myself, and had 100% confidence that the attacker was indeed a pit bull, I still don't see the relevance to including the breed in every description of Lilly's injury. And we, as veterinary medical professionals, should know better.
And.... off the soapbox. The "good" news for Lilly is that, based on how severe her injuries were at surgery (her quadriceps were completed shredded and ripped from their bony attachments, with her patella hanging in the breeze and punctures through her skin that went all the way into her hip joint), there was zero question that amputation was the right move. And based on seeing Lilly before and after surgery, she already seemed more comfortable a couple hours post-op -- less painful and able to comfortably lie down and sleep. I've no doubt she'll be up and walking well on her 3 good legs tomorrow or the next day. Fortunately her injuries were basically limited to her left hindlimb (and her left groin region), so she's got a good prognosis as long as we can avoid infection.
Just kidding. Kind of.
My orthopedics patient today was Lilly, a middle-aged Westie who had the misfortune to be attacked by a larger dog while out for a bedtime walk last night.
Lilly's mom fended off the attacker, sustaining some bites to her own hands and arms in the process, then rushed Lilly to her regular vet. Lilly's rDVM briefly anesthetized her, just long enough to clip and clean the deep puncture wounds on her left hind leg, diagnose a dislocated hip, and place a bandage to keep the areas as clean as possible.
Immediately following the visit to the rDVM, Lilly's mom drove the 1 hour to the VTH, arriving with Lilly at 2:30 am. Lilly stayed in CCU on IV fluids and pain meds until she was transferred to Orthopedics when we arrived for rounds at 8:30.
Long story short, radiographs and palpation showed some serious subluxation of Lilly's left hip, with deep puncture wounds all around her left thigh. After briefly discussing the possibility of attempting a (not-very-likely-to-be-successful) salvage of Lilly's hip, everyone agreed amputation was the best option for little Lilly. So amputate we did.
My frustration with this case lies in the fact that, from the time I first heard about Lilly during rounds this morning, the phrase "pit bull attack" has been repeated about a thousand and one times.
Now, don't get me wrong, if Lilly was truly attacked by a pit bull, I have no problem saying so. If she had been attacked by a lab or a golden retriever or a Husky, I'd also have no problem saying so. No, I don't think the breed of dog that attacked Lilly is medically relevant (only the fact that she was bitten by a larger dog), but if you're sure of the breed, then go ahead and say it.
However, Lilly's presenting complaint (what the receptionists put on the appointment schedule as the reason a dog is coming for a visit) was listed as "pit bull attack." If there had been knowledge that any breed other than a pit bull had attacked Lilly, I can in no way imagine her presenting complaint being listed as "lab mix attack" or "German shepherd attack" or "Chow attack." It would just be listed as "dog attack," "dog bites," or "bite wounds."
I think the vilification of pit bulls implicit in the specification of breed in Lilly's case is unnecessary and damaging. Sure, I've met a good many pits who would indeed not hesitate to attack a cute little white dog walking down the street. But I've met a far greater number of pitties who would just as soon play bow or ignore another dog.
As Lilly's primary student, I traveled around the hospital with her to various departments today and ended up explaining her history to multiple people. My explanation went like this: "At 10 o'clock last night, Lilly was out walking with her owner when she was attacked by a larger dog. She went to her rDVM (etc.)...." Invariably, someone would ask me what kind of dog attacked Lilly, as if it would make any difference in how we would treat her or what her prognosis would be. I don't care if Lilly was attacked by a Boxer, a standard poodle, a Samoyed, a Chihuahua, or a potbellied pig, and I don't understand some people's need to hear that it was a pit bull so they can nod knowingly and look at Lilly with a greater degree of pity than if she had been attacked by another "less dangerous" breed. Even if I had personally witnessed the attack myself, and had 100% confidence that the attacker was indeed a pit bull, I still don't see the relevance to including the breed in every description of Lilly's injury. And we, as veterinary medical professionals, should know better.
And.... off the soapbox. The "good" news for Lilly is that, based on how severe her injuries were at surgery (her quadriceps were completed shredded and ripped from their bony attachments, with her patella hanging in the breeze and punctures through her skin that went all the way into her hip joint), there was zero question that amputation was the right move. And based on seeing Lilly before and after surgery, she already seemed more comfortable a couple hours post-op -- less painful and able to comfortably lie down and sleep. I've no doubt she'll be up and walking well on her 3 good legs tomorrow or the next day. Fortunately her injuries were basically limited to her left hindlimb (and her left groin region), so she's got a good prognosis as long as we can avoid infection.
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