Saturday, September 3, 2011

Euthanasia #2, CPR #1

My daytime Urgent Care rotation ended with a bang. We were far busier on Friday than any other day last week. We saw probably 15 patients in the first 4 hours of the day -- which is probably more patients than we saw total during any 10 hour shift on any of the other days. It was crazy -- about every 10-15 minutes we'd get a page that a new patient was here, along with pages about phone calls from clients or rDVMs every 5-10 minutes. It was kind of a lot of fun, in a strange way -- it's more exciting and invigorating to be busy like that than to be sitting around all day waiting for patients to show up, and it gave us students a real chance to learn how to triage patients. We also got practice explaining to owners that they are here to see an Urgent Care service, which means that some of the stable patients will be sitting around and waiting for awhile while we stabilize the more critical patients.

I primarily ended up with 2 patients, after most of my other ones were transferred to different services (neurology and internal medicine). My saddest patient was Joey, a middle-aged Labrador retriever who presented as a transfer from his rDVM with a complete urinary obstruction.

Joey was neutered only 1 month ago, when his owners noticed he was intermittently straining to urinate and his rDVM diagnosed an enlarged prostate (very common in intact adult male dogs). Testosterone causes the prostate to grow in size, consequently compressing the urethra and sometimes the rectum, resulting in difficulty urinating and/or defecating. The treatment is generally castration, and although the body's testosterone levels subside fairly quickly after the testicles are removed, it can take several weeks or months for the prostate to shrink back down to a more manageable size.

Since his castration, Joey had been able to urinate and defecate, but had still had some intermittent straining, which Joey's owners were told to expect. However, two days ago Joey became completely unable to urinate. His owners brought him to their rDVM, who felt that Joey's prostate was still somewhat enlarged but not enough to be causing his inability to urinate. Joey's rDVM took radiographs, which showed small stones in Joey's bladder, and a stone lodged in his urethra. The rDVM tried several times to place a urinary catheter (we are unsure if this was successful or not, or if the rDVM drained Joey's bladder by placing a needle through his abdominal wall), and eventually recommended that Joey head to the teaching hospital for treatment.

Upon arrival, Joey was happy and wagging his tail, but was clearly experiencing quite a bit of discomfort from his by-now distended bladder. Joey's owners were quite conflicted about how to proceed with his treatment. Our initial stabilization (about $500) would include the Urgent Care exam fee, pain meds, ensuring the rDVM's IV catheter was patent, starting IV fluids, running some bloodwork and a urinalysis, and attempting to place an indwelling urinary catheter. Long-term, Joey's owners would be looking at anesthesia and surgery for stone removal from Joey's bladder, as well as possible surgery to remove the stone from Joey's urethra if it could not be moved, and maybe even a perineal urethrostomy (crudely, a surgery that would make Joey pee like a girl) if Joey's urethra had been too badly damaged from the stone sitting in it and the repeated attempts to pass a urinary catheter.

As you can imagine, the financial estimate for these surgeries was pretty staggering, especially given the fact that, not knowing why Joey's urinary stones had formed in the first place, we could give no 100% guarantee that we would be able to prevent them from ever returning in the future. Sure, depending on the type of stones, there are medical things that could be done to decrease the likelihood of recurrence, but we couldn't say that they would never return. And Joey's owners knew that although they might be able to scrape together the funds for his initial surgery, it really wasn't in their budget, much less a second surgery.

In the end, Joey's owners permitted his initial stabilization to allow themselves time to make a decision about how to proceed with Joey's care. With sedation and multiple attempts, we managed to place a small-bore urinary catheter to drain Joey's bladder and keep him comfortable. However, the fact that his penis was dripping frank blood on presentation and throughout the day was a sign that his urinary tract was very unhappy.

Toward the end of the day, Joey's owners made the decision to euthanize him. They wanted to spend a few minutes with him outside the hospital in the garden area, then to put him to sleep out there. The intern on duty and I brought Joey to his mom and dad, and they said tearful goodbyes. Once we had Joey settled on some nice cushy blankets in the grass, his owners decided they couldn't stay until the very end, so the intern and I talked to Joey and rubbed his belly as he watched his owners walk away for the last time. Then we anesthetized and euthanized him. He went peacefully, with lots of petting and us telling him how much his owners loved him, the sun shining down through the tree above and a breeze in the air, but it broke my heart a little bit.

We made a clay paw print for Joey's owners to have, and clipped some of his fur for them to keep along with his collar and tags. His owners consented to a necropsy, so we'll be able to find out how severely damaged his urinary tract really was. (His owners didn't want to know the results of his necropsy, and I wouldn't have either.)

It was about 6 pm by the time I had prepared those mementos for Joey's owners, delivered his body to necropsy, and started a sympathy card to send to his mom and dad. After 7 nights in a row last week of 10-12 hour overnight shifts, followed by 4 days this week of 12-14 hour Urgent Care daytime shifts, and almost 12 hours into my 5th day on Urgent Care, I was emotionally and physically exhausted.

However, about 10 minutes after sitting down to complete the day's paperwork, I got quite the adrenaline boost when another student rushed down the hall toward the Urgent Care room yelling, "Get ready, we need CPR!"

The patient was a small elderly mixed breed dog, whose owners had rushed him in after he had developed acute respiratory distress as they were driving out of town for a Labor Day weekend camping trip. The dog appeared not to be breathing on presentation at the VTH, so he was immediately rushed back for CPR.

Other than walking into a patient undergoing CPR during one of my last overnight shifts (the CPR in that case was well underway by the time I arrived, and all I did was write down the drugs that were given as the rest of the team did compressions, etc.), yesterday's CPR situation was the first in which I've really been involved.

Fortunately, we had "CPR rounds" two days prior, in which a critical care clinician reviewed with us in detail the steps to perform CPR. I'm so very glad we had those rounds, because it allowed me to stay somewhat calmer in this situation.

One of the nurses immediately started chest compressions on the little dog (which is the most important thing to do), and another nurse and doctor got to work intubating the dog. A student and another doctor started placing an IV catheter, while another nurse placed an intraosseous catheter (directly into the cavity within one of the dog's bones) then hooked up an EKG. A second student went to get more help; a third student started recording what we were doing; and I headed to the crash cart to start pulling up doses of atropine and epinephrine.

We performed chest compressions, mechanical ventilation, monitored EKG, and gave 3 rounds of drugs within about 10 minutes, but with no change in the dog's condition, he was pronounced dead shortly thereafter. It was a sad situation for the family, who'd been told previously the little guy had a heart murmur but that there was nothing they could do about it (which may not have been true). Given the vast amount of fluid coming up from his lungs, it's possible he had acutely gone into heart failure. The family was shocked at his sudden death.

However, it was oddly rewarding to see how well everyone worked as a team. The goal of CPR rounds and "practice" CPR situations is to remind everybody how things are done so that nobody panics and everyone can play a useful role when a CPR situation arises. As you might expect, studies have shown that medical and veterinary teams that practice CPR regularly are more likely to have a successful outcome (although the reality is that, in CPR situations overall, there's only about a 5% chance of getting an animal 'back').

As the clinicians ever-so-helpfully remind us, in a matter of months we students will be the ones to whom the rest of the veterinary care teams look to as leaders in a time of crisis, and we'll need to be able to stay calm, give directions, and make decisions about things like CPR. That's a really scary thought, but CPR rounds and CPR practice make me feel the tiniest bit like I might actually be ready someday.

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