Urgently Caring, one day at a time

My current CCU rotation is comprised of 2 pretty different weeks. Last week was the overnight shifts, and this week is a daytime Urgent Care shift.

Urgent Care (UC) sees patients from 7 am till 10 pm on weekdays, and more limited hours on weekends. (Emergencies during other hours go straight to CCU.)

On UC we see any patient who enters the building as a walk-in appointment, any patient who requires a same-day appointment but can't get in through the specialty service they hope to see, and any daytime emergencies like snakebites or hit-by-car cases.

It's kind of neat not to know what to expect when you get there for the day -- about 60% of the clients we see call ahead by a few minutes or hours to let us know when and why they are coming, and the other 40% just show up out of the blue. It definitely requires you to think on your feet.

I've ended up with an odd mix of patients this week. They are as follows:

1. A 6-month-old Lab puppy, presented on Monday morning for acute-onset (12-24 hour duration) vomiting and diarrhea. We hospitalized her overnight for IV fluids and supportive care. She was negative for parvo but did have coccidia and Campylobacter in her feces, which we are treating.

2. A middle-aged hound mix, presented on Monday afternoon for skin problems. He'd had an acute onset of severe generalized itching, lethargy, and inappetance 10 days prior, with some degree of improvement since then. We suspected an autoimmune dermatologic disease, so he came back on Tuesday for a dermatology consultation.

3. An older Australian shepherd, presented on Tuesday morning for a worsening head tilt and improving falling/abnormal gait of 2-3 weeks duration. She also had a 2 month history of recurrent vaginitis, and several skin masses. We worked up her vaginitis and she came back for an MRI and neurology consultation on Wednesday, which showed an inner ear inflammation.

4. A young Chihuahua, presented on Wednesday morning for neck and back pain, as well as a palmigrade stance (walking down on her wrists). Her rDVM suspected neurologic disease. We agreed but thought there may be an orthopedic component. The orthopods examined her and recommended a neuro consult. The neurologists examined her and recommended an internal medicine consult for immune-mediated polyarthritis. She had a fever, so stayed in CCU on fluids overnight and transferred to internal medicine on Thursday morning for joint taps.

5. My first euthanasia patient, presented on Thursday for euthanasia due to abject misery.

6. An elderly Doberman, presented on Thursday morning for an acute onset of steadily worsening neck pain and abnormal gait, suspected by his rDVM to be due to cervical disc disease. After seeing his bloodwork showing a lymphocyte count of 75K (normal is 1-4K) and collecting lymph node aspirates with severely abnormal cells, we diagnosed him with Stage Vb lymphoma.

The Doberman was definitely my saddest case of the week so far. He is such a nice dog with an equally nice owner, very willing to spend the money needed for an MRI and vertebral surgery (which is what his rDVM had prepared him for).

Lymphoma is a cancer of the lymphatic system, including the lymph nodes, which help drain infection and inflammation from the surrounding tissues. It's "staged" based on clinical presentation, from Stage I through Stage V. Stage I means the cancer is limited to a single lymph node or organ. Stage II means that nearby lymph nodes are involved. Stage III means that all of the lymph nodes around the body are involved. Stage IV means it has spread to the liver and/or spleen. And Stage V means that it has spread to the blood, the bone marrow, or other sites such as the brain or spinal cord.

Lymphoma is also given a "substage" of 'a' or 'b.' These are based somewhat crudely on how well the dog is doing: a substage 'a' dog is one who feels pretty good; a substage 'b' dog is one who feels poorly.

Negative prognostic factors (things that are associated with a bad outcome) for lymphoma are:

1. Stages III/IV/V are worse than Stages I/II
2. Substage 'b' is worse than 'a'
3. T-cell is worse than B-cell (Mr. Doberman is suspected to have T-cell)
4. Leukemia (cancerous cells in the blood) and spread to "protected sites" such as the spinal cord and brain are worse than lack of these factors

So poor Mr. Doberman has all of these things against him.

He became more and more painful throughout the day, eventually whining and moaning in pain even when lying in the most comfortable position he could find, and even after a whopping dose of oral pain meds. We started him on heavy doses of IV pain meds, which seemed to help somewhat, but pain meds alone would not be enough to control his discomfort, so he was anesthetized for a dose of palliative radiation in the area where his spinal cord is being disturbed, and he started on chemo.

It's so odd, because without doing bloodwork on this dog and seeing his enormously elevated lymphocyte count (which really can only be caused by leukemia or lymphoma), he probably would have headed for an MRI to see what was going on. He had otherwise been feeling well (normal appetite, energy level, etc.) and did not have any of the characteristic lymph node enlargement that is typically seen in lymphoma cases. That goes to show you why doing a step-wise work-up in these neurologic-type cases is always a good idea, starting with bloodwork/urinalysis and progressing to more advanced diagnostics one at a time.

I'm hoping for the best possible outcome for Mr. Doberman, but even that won't be all that great. If he responds well to palliative radiation, he may have 2-3 months of quality time left. However, it's possible that we will not be able to get his extreme pain under control, in which case he'll most likely end up in Doggie Heaven. The one consolation is that at least he hasn't spent a long, chronic period of time feeling miserable up to this diagnosis -- just a few days. I know his dad would love to see him get home for a few more weeks of loving.