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!