Heat stroke

Following the lead of other veterinary bloggers I will share my thoughts on the very preventable heat stroke cases.  It never fails to amaze me just how downright stupid people can be.  Allowing dogs to remain in cars in the heat, or exercising them like crazy on a hot summer day. 

case one - the local animal control officer brings us a young adult dog who had been left in an unattended car at the train station.  The ACO broke the car window to retrieve this recumbent dog from the car.  The dog presents to the ER, we begin treatment as the ACO looks for the owner.  In cases like this the ACO will approve the cost of treatment, and upon finding the owner, will require that the owner pay the town back for the cost of treatment. 
This case was caught early, and we successfully turned this dog around without any life threatening complications - so we were pleased.  The ACO had made contact with the owners and they were en route to the hospital to see the dog.  Ideally we planned to keep him overnight for observation.  He had begun having some diarrhea but was otherwise looking really good. 
The owners arrived and they were irate.  The wife had left the dog in the car while she travelled to the city for a meeting, expecting to be back sooner than she actually did get back.  She thought, naturally, that her car had been broken into so she was frantic for a while.  However, the police let her know that while her car window was broken, she was not burgled and her dog was in the hospital, not running the streets (and not dead, by the way).
So husband and wife arrive and let us know in no uncertain terms that they are not paying the bill and want to take their dog home now.  Oh how I wish they could have seen their precious dog when he arrived practically non-responsive and broiling hot.  Fortunately the police and the ACO let them know that they were responsible for the bill and further, would likely be charged with animal cruelty for leaving the dog in the car alone in the heat.  Upon hearing that the sob story came out.  Wife lost her job recently, they are filing bankruptcy, and have little money, they could lose their home.  However, they paid their veterinary bill, and would have to pay to have the car window replaced, but they escaped charges of animal cruelty.  Had it not been for the local law enforcement playing a role in this, I am sure we would not have been paid.  Another life saved with no thank-you from the pet owner.

And then there is the case of the super athlete who took his dog for a 5 mile run in the heat of the day.  Another young adult male, this time a boxer.  The client called to inquire about pricing for a visit, as his dog seemed out of sorts after this run.  He was advised to bring the dog in - he opted to wait - not a smart decision.  The dog presented to us 3 hours later recumbent, pouring diarrhea from his hind end, and petechiae developing all over his body.  The owner, who always brought his dog running with him, did not believe that his dog was suffering from heat stroke (with a body temp of 106 F). 
He second guessed every treatment plan - which included blood products, serial blood work and intensive nursing care.  Eventually he agreed to treatment, but it was a hairy 36 hours for this dog.  Fortunately everything worked out - the owner paid for the care though he was extremely displeased with the cost and let everyone know about it -twice.

I just want to scream at these people - YOU caused this!  We treated it!  It's YOUR fault that you have a sick animal and a veterinary bill, not MINE!

Could I be anyone other than me?

Every so often, particularly in the summer months and around the holidays - I think to myself that I should consider leaving emergency medicine and head to "greener" pastures in general practice.  After all, they get to close their doors every day, and on some days (such as Sundays) they don't even open!  It's so alien to me, being in the ER that never closes, never sleeps, never stops.
So on Saturdays - about the time that our referring veterinary offices are closing up, our ER starts to speed up for the remainder of the weekend.  Now that it is summer it's tough especially when it is a beautiful day and I would rather be outside than at work without windows.  However, on the flip side - my technical skills wouldn't be utilized fully in GP, I would be paid less and probably have lousy benefits.  Still - what a concept to close up shop - even for those lunch time staff meetings I have heard of but never actually seen.
Yet I stick with the ER and ICU.  I can;t help it - I really love the work.  I don't always enjoy it, but I love it. 

The pharmacy is closed

Our hospital doors are open 24/7.  During the normal work week we have lots and lots of specialists that see appointments in addition to our emergency/critical care service.  These specialties have fancy medications that they keep locked up in their rooms when they leave. 

Every weekend some specialty client shows up or calls wanting a refill on some obsure medication that the specilaty technician has to order from a compounding pharmacy (takes about 1 week).  People always seem to wait until they are completely out of medication and then proceed to give us grief because they can't get a refill on a moment's notice.

I'm sorry that you spent a billion dollars to have your dog's eyeball treated, and then allowed yourself to run out of the medication that is crucial to the integrity of said eyeball on a Saturday night.  This is the ER, you didn't call before driving over here, I can do nothing for you - there are 7 clients with legitimate emergencies waiting to be seen by ER veterinarians.  Please call your specialty tech on Monday.  Ug.

Can it wait until Monday?

Our receptionists are really great at handling call but sometimes clients insist on talking to a tech or a veterinarian.  This generally occurs when people really don't want to bring their pet in but rather get advice over the phone to treat their pet at home.

"Hi this is the ER tech.  How can I help you?"

"Is this the animal hospital?"

"Yes it is, what can I do for you today?

"Well, I'm not sure.  My dog is not acting right, I think he may be sick."

"Okay.  You are welcome to bring your dog in to be seen through the emergency department.  We don't see scheduled appointments so you can come on down anytime, we are open 24/7.  Do you need our address?"

"Well...my dog was outside all day and now he is really anxious and pacing around the house.  Last week he puked all over the house.  But that only happened once - except for the day after that he puked again after he drank some water but that might have been because he drank too fast.  Do dogs throw up like that after they drink too much water?"

"It's possible, yes.  Has your dog been vomiting today?"

"Well...not really.  He acts like he has to puke but no puke comes up.  He won't lay down eaither, or eat anything."

"It certainly sounds like your dog may be sick.  I recommend that you bring him on down so our ER veterinarian can have a look at him."

"Do you think it's serious?"

"Well sir that's really difficult to say for certain but the symptoms you are describing to me can be associated with serious illness.  It's best to bring him in and have the doctor see him today."

"Really?  Do you think it can wait 2 days until my vet is back in the office?"

"I'm not comfortable telling you it's okay to wait that long.  The safest thing to do is to bring him in today."

"Is there a vet there that I can talk to right now?"

"I'm sorry the veterinarian is not available to talk on the phone.  However, when you arrive we will be sure to have a look at your dog as soon as you walk in the door.  It sounds like he may be pretty sick so he will be seen right away by the veterinarian."

"You work with animals - is there anything I can do for him at home?  He really hates riding in the car.  Plus he is so uncomfortable right now.  I gave him his heartworm pill 3 days ago.  Do you think that could be why he is not feeling well?"

"No sir - it sounds like your dog is sick and should be seen by a doctor.  There is nothing you can do for him at home.  I don't suggest you wait until Monday to see your regular vet.  No one can tell you what is wrong with your dog without actually seeing him.  What breed of dog do you have?"

"He's an Akita.  He just turned 11 years old last month.  I had him since he was a pup.  I owned his sister too but she died a couple of years ago.  Just walked in the house one day and found her dead on the kitchen floor.  Why do dogs just up and die like that, do you think?"

"I'm not sure sir.  And I am sorry but I can't really talk more right now.  Our address is 111 Main Street.  Will you be bringing in your dog soon?"

"I'll think about it.  Can I leave my number for the vet there to call me later?"

"The doctor here is very busy and won't be able to tell you much else except that your dog should be seen.  I strongly suggest that you bring in your dog as soon as possible.  The symptoms you are describing are consistent with a condition called bloat.  If your dog is bloated, it's an emergency - like life-threatening emergency.  So it would be a good idea to bring him in right away because if bloat is not treated it will lead to death."

"Oh really?  How is that?"

"We will talk all about it when you arrive.  Right now you should be focused on getting your dog here.  When you arrive the veterinarian will examine your dog."

"Okay - I'll have to call my son to help me get him in the car.  That may take a while.  How about I come in around 5pm?"

"Anytime sir.  We don't see appointments.  It's 1 o'clock now - I hate to have your dog wait until 5pm to be seen.  Can you possibly get him here sooner?"

"Well, I can try but I don't know...I'll call you back when I know what time I can come in."

"No need to call sir - just come in as soon as possible."


Ug - when I think of all the things I could have accomplished in the time it took me to talk to this guy.  Who, by the way, never did show up with his dog. 

Break on through to the other side

This week I find myself in a role that I am not entirely comfortable with - veterinary client.  And not even a client at the hospital where I am employed but rather at the local veterinary school.  My dog had total hip replacement surgery yesterday.  Suffice to say it is expensive and will require a lengthy recovery time. 

Yesterday I found myself sitting on pins and needles wiating to get the call from the surgeon affter the procedure was complete.  Thankfully there was no "oh shit" moments; everything went as it should.
I arrived at the school last night to visit and sat in the waiting room until the ward technician came to get me to bring me to see my dog.  Of course I want to explain to everyone that I'm a tech, so please everyone go about your business and allow me to sit here with my dog for hours and hours.  On the other hand, I don't want to be that irritating client that lingers for too long while the techs try to go about the business of treating their patients.  So I give my dog a pet, a kiss, thank everyone for taking care of her and head out the door.  When I got home I sent flowers to the ward technicians from my dog.  Cheesy - yes.  But she may just get a little extra attention and TLC as a result.

So now I continue to wait for daily updates from the surgeon - or more likely from the veterinary student assigned to the surgical service this week.  Luckily I do have some contacts at the school so I know someone will be looking in on my dog. 

This experience certainly gives me renewed appreciation for our clients.  I should take a little extra time with all of them to be patient and understanding.  This is a good lesson for me - and for the low low price of $6000.00!  Ug.

The waiting room waits

I have worked in emergency veterinary medicine for a number of years and I am still amazed at what exactly constitutes an emergency in the yes of pet owners (and what does not).  Every weekend there is a least one dog that presents to the ER with an ear infection.  Now, it's not that we are above provding treatment for an ear infection by any means.  I'm just surprised that pet owners will pay an emeregncy exam fee to have their pets seen for this condition.  Often it is something that can wait until their vet opens on Monday.  Still, even during the week we see these types of cases. 
I have not worked in general practice for a long time but I can't imagine that their exam fee is nearly as high as ours.  Still I think of it as a reflection of the pet owner's love for their animal that they will gladly spend the money to treat an ear infection on a Saturday night.  Of course there is the possibility that the dog's frantic ear scratching has driven them nuts enought to pay whatever it takes to stop it from happening.

Another spin on this is the pet owner that presents to the ER for something like an ear infection - totally stable patient - and then creates a scene in the waiting room because an unstable hit by car dog that arrived after them is being seen before them.  What do people not understand about being in the ER?  If it bleeds, it leads - that's all there is to it. 

Two weeks ago on a Sunday afternoon we had a waiting room full of patients waiting to be seen.  All hands in the hospital were scrambling just to keep up with our inpatients while handling the outpatient load.  The waiting room crowd was getting cranky - making frequent inquiries about how long the wait time was going to be.  Just then a car pulled up with yet another emergency and I was called to the parking lot for a triage.  In the back was a yellow lab that had just been hit by a car minutes before.  He had degloving injuries to both his front paws (in other words, the skin had been torn from his body and his muscle and bones were exposed).  There was a lot of blood, the dog was not at all stable - I carried him the building through the waiting room.  We rushed him to the treatment area so that we could begin to stabilize him.  After about 45 minues, the owners opted to euthanize this dog.  It was unfortunate because we certianly could have fixed him up though it would have cost a significant amount of money.  In the end the owners just couldn't afford treatment.

However, after seeing a dog, bloodied and in need of care being rushed through the waiting room, the rest of the clients calmed right down - realizing that all of our efforts had to be focused on this one dog.
Perhaps they realized how lucky they were to have very stable, practically healthy animals. 
Perhaps it was the tears in the eyes of the teenagers that arrived with the dog and their mother. 
Who knows? 

Triage is an art

The basic meaning of the word triage is "to sort".  Sort through stable vs. unstable patients.  Triage almost always takes place in the waiting room, though sometimes it takes place in the parking lot.  When a patient arrives at the hospital, we are called to the waiting room to triage the patient.  Because we operate as a human ER does, we do not see scheduled appoitnments (obviously the other specialty departments do not operate in this manner). 
In emeregncy/referral practice, our primary clients are the referring veterinarians.  When area animal clinics close for the day/weekend they refer their patients to us for emergencies.  We do not want to do anything that will hurt our relationship with our referring vets, so we don't provide vaccinations (except for the middle of the night bite wound of unknown origin), routine spays/neuters, or dentals.  Suffice to say a good number of the people that arrive with their pets through the ER have never been to our facility before.  That in itself is challenging, particularly if the animal is not stable.  When I arrive in the waiting room to triage an unstable pet, I have a very short amount of time to gain the pet owner's confidence.  I explain in simple terms what I am noticing about this person's pet. 
"It appears that Fluffy is working pretty hard to breathe.  Would it be okay if I took him to the treatment area to be evaluated while you fill out the paperwork?"
"I'm concerned because Rover's pulses are so weak, his heart rate is elevated and his gums are pale.  I'd like for the vet to have a look at him immediately.  Why don't you fill out some paperwork while we have a closer look at him and Dr Smith will be out to explain what's going on to you in a few minutes?"

It is not the job of a veterinary technician to diagnose, prognose, prescribe medication or perform surgery.  To that end it is crucial to not offer up any diagnosis at the time of triage.  So even though I often have a pretty decent idea of what is going on with a patient at the time of presentation, I keep my mouth shut - no matter what the clients ask me. 

When a dog presents after being hit by a car and has major injuries requiring a strecher to get from the car to the building the client generally has no problem being separated from their pet for little while.  When the patient is a cat that has been gradually declining in health for 2-3 weeks and is just being seen by a vet now - and is not stable - the owner can be surprised when I tell them my concerns and my desire to take the cat from them for a little while to be evaluated.  Couple that with an emergency consent form that, if signed, gives us permission to spend a few hundred dollars in diagnostic work on the pet right away- and it can be enough to send a client over the edge.  However, I think that, in general, people are aware of the high cost of veterinary care, and the even higher cost of emergency veterinary care.

I do empathize with clients over the amount of money that is required to fix some animals.  Sometimes the bills are astronomically high.  I could never afford to pay some of the bills I have seen.  So I really appreciate it when a client does whatever it takes to fix their pet (financially speaking).  This is, of course, when the animal can be fixed.  Clients that spend crazy amounts of money to extend the lives of pets with long term, chronic, end of life type diseases are more difficult to stomach.  However, I am not the judge, just the technician.  It's my job to do what I can for both the client and pet, make everyone as comfortable as possible, and hope for the best.  Even when the best option is euthanasia for a 2 year old dog that has been hit by a car and will require multiple days of hospitalization and surgery to fix.  Money is tight, jobs have been recently lost and a baby is on the way - we can't afford to fix our dog.  I get frustrated and feel sad for the dog - but that's the way our business goes.

Back to the actual topic - triage.  It is a skill to triage well.  I have been doing it for a number of years and I still make mistakes.  Two weeks ago I triaged a golden retriever that presented to us after having been to 3 other referral hospitals in the area.  The dog's heart rate was normal, though the pulses were not that great.  Because all of the dog's other vitals seemed okay (normal respiratory effort, sounds, pink gums), and because I knew it would not be a long wait to see the vet (about 5 minutes) AND because the owner did not really want to part with his dog, I let the dog wait with his owner.  My gut was telling me to bring the dog to the "back" (I hate that term), but I didn't go with my gut.  Fast forward 3 minutes - reception calls for a stat triage, and lo and behold, this dog has collapsed on the waiting room floor.  Come to find out he had bad heart disease - and I should have followed by instinct. 

This seems to be a lesson I have to learn over and over again.