Yesterday was Vomit Tues, Today was Diarrhea Weds

We all know that the crazy cases come in waves.

I remember one year where we saw 12 splenectomies in 12 weeks. It was incredible, and freaky! I was really beginning to think about sending a water sample into the the health department.

Well today we had three cases of diarrhea in a row.

Case 1 was Ruby, an 8 week old, just adopted 2 days ago, Boxer puppy. Ruby is quite possibly the cutest thing with two ears. She was so shy, and so kissable! Dr. C kept kissing her and telling us that she was pretty sure she was infecting herself with round worms every time she did. (That's typical Vet hosp humor). Ruby likely had diarrhea because she had just left the only place and the only family she ever known. This would be incredibly stressful to anyone, and it is especially stressful to a baby. She also is likely eating a new food, (hopefully a high quality large breed puppy brand), and having some "stress and dietary diarrhea" because of it. Dr. C. gave Ruby an oral de-wormer, and we sent her fecal to the lab for analysis. As long as Ruby's diarrhea is not profuse, she is eating and drinking well, on a good diet, and de-wormed, and monitored closely she will likely be fine in a day or two. Any puppy with diarrhea needs to be monitored very closely and needs a Vet immediately. I have seen puppies with Parvovirus die in 2 days.

I tell every new pet owner to expect some intestinal worms. It's part of the puppy/kitten package when you get a new pet. We check a fecal first thing, (and then yearly), and de-worm appropriately when the results come back positive. It's very important to bring your new pet, (and their poop sample), to your Vet within three days of getting your new pet. And make sure that you pick- up and dispose of all poop daily so you don't get your yard contaminated with the intestinal worms that might be making a home in your puppy or kittens belly.

Also, I recommend a follow-up fecal a month or so later to re-check that all of the worms are gone. And if your pet is having chronic or recurrent diarrhea we recommend that you check 3 consecutive fecals before we call your pet "intestinal worm-free." Some of the intestinal worms that pets can acquire are what we term "intermittent shedders." This means that we won't see them in the fecal exam at every fecal test we check. Three consecutive negative fecals and we usually call you negative.

Case number 2 was Maggie. A spayed 4 year old Papillon. Maggie's mom, Mrs. Kyrie, called us today to tell us that Maggie had woken them up at 2 am with bloody watery diarrhea. Maggie continued the projectile diarrhea sporadically throughout the night, and Mrs. Kyrie was very worried. The Kyrie's are very doting, watchful owners and they called us as soon as we opened to see if they could bring her to us.

When Maggie walked in the door she had her butt tucked under her and seemed to still be straining to defecate. Many owners incorrectly assume that their pet is constipated when they see this stance but in reality it is the complete opposite. Some owners have actually gone so far as to give their pets laxatives. Can you imagine anything worse than being given a laxative when you already have bloody, watery, poop dripping out of your butt? These guys are postured to poop because their over active intestines are full of watery diarrhea and their intestines are telling their brain to poop to get rid of it.

When Maggie was seen by Dr. C she thought that she looked nice and pink, (therefore indicating good circulation, good RBC count, and not septic) and not dehydrated. Dehydration is one of the things we are worried most about in pets, (and people) with diarrhea, especially with the small breed dogs. Everything in her examination looked normal and the fecal sample Mrs. Kyrie had brought in was loose but not discolored. Our plan was to send Maggie home with some SQ fluids, an anti-diarrheal, and a diet plan. She was in her mom's arms at the check-out counter when Mrs. Kyrie put Maggie on the floor to sign her check when Maggie tucked her butt, postured and produced what we call "raspberry jam" diarrhea in a Jackson Pollack application all over the reception area. This "raspberry jam" is a classic sign for HGE. Hemorrhagic Gastro Enteritis.

We diagnose HGE by a few factors. These include raspberry jam diarrhea, and  a high PCV. Maggies PCV was 63%. The normal reference range should be around 40%. Above 50% and we start you on i.v fluids to decrease the PVC. Maggie stayed the day with us to correct her PCV, monitor her diarrhea, and start her on antibiotics and anti-diarrheals.

Case #3 was Winston. Winston is a three year old wire haired fox terrier. He is owned by a couple who monitor his every move and love him like crazy. Winston's dad is retired so they are best buds that are inseparable. Winston's dad also spoils him terribly. I am usually not a stickler for feeding your pet some table scraps but I do not want you to feed them bacon, and fried eggs.

Winston sat begging by the dinner table on Friday evening as he has been trained to do by his parents. After they had eaten their portion of their stuffed shells that they had for dinner they handed him their plates to polish off. That evening Winston woke them up to notify them that he had just vomited and pooped in their bed. He had four other episodes Friday night. Saturday morning he refused his breakfast had 4 more episodes of diarrhea and was placed on plain white rice for dinner, which he readily ate. Sunday morning he seemed to be back to his normal self and sat begging again for their breakfast. Winston ate bacon and fried eggs Sunday morning. Winston's dad did mention that this was "his favorite Sunday breakfast foods."

I examined Winston on Monday and he seemed to be within normal limits for all of his physical exam parameters. I gave him some SQ fluids to maintain his hydration throughout the day and instructed them to not feed him anything else for the rest of the day. I told them to feed him boneless skinless boiled chicken or ground beef with plain white rice starting Tuesday morning. I instructed them to feed 1/4 cup servings every  4 hours as long as he wasn't vomiting. I asked them to do this for 4 days. I also sent them home with a gastro-protectanct and probiotic. I, as always, provided a written instruction sheet for dad to take home for mom to review. (I try very hard to document everything so that owners don't go home with questions, and because I know I talk fast).

I called this morning to check on him. His dad said that he had done great on Monday and Tuesday morning, but that his wife had started to add his normal food back into his food on Tuesday night's dinner. Winston's belly was apparently not ready for this and the diarrhea resumed. WInston and his dad came back to see me this afternoon. Winston still looked fine, but we all decided to stick with the chicken and rice for 4 days. Winston's dad asked me to write "No regular food for 4 days," in bold letters on his go home sheet. He was blaming his wife, and he wanted her to know that these were "Dr.'s orders!"

I will check on him again on Thursday.

We ALL Need Options!

There are many times I see a client and their pet when I curse myself for not being able to clone myself.

How do I keep myself available to all of my clients and their pets and still try to have a life with my own pets and my own family?

I grew up in a small town with a vet who lived over his practice, (Dr. Barsanti) and was available 24/7 to his clients. Now in my own defense I will say that he didn't have the luxury of an emergency clinic for his clients and patients to go to after hours, and he didn't have as many clients as I am serving. But the point is, his clients knew he was there for them at anytime they needed him and he was able to save many pets because people called him for help as soon as they needed it. They didn't wait until Monday when their dog has been vomiting profusely since Saturday afternoon, and they didn't go to the emergency clinic to be given an estimate they couldn't afford and therefore "elected euthanasia" because they had no other options. He was an Vet, a shoulder to lean on, a friend, and always available. His clients loved him, trusted him, stayed very faithful to him, and he built a respected and cherished practice because of these.

I know that there are many vets out there who need to be able to "turn off the clinic" and focus on their family, and I have not worked for a clinic that puts you "on call" so that you never get a full nights sleep. I understand and empathize with trying to wear every hat at every minute, it is an impossible task.

But I feel incredibly guilty leaving my clients to fend for themselves and be at the mercy of a new place, a new face, and a new set of hospital policies when my door isn't open. I am lucky to have two emergency clinics available to my clients within a 20 minute drive. The problem lies in the inherent nature of an emergency clinic. In most cases the emergency clinics are going to be more expensive than your local vet, and they have to provide you with a wide ranged estimate to cover all of the possible diagnosis. This wide range estimate means that you, the client, need to be able to provide a deposit for the mid to high range of their estimate.

I have many clients go to the emergency clinic and either leave without their pet because they could not afford to treat them, or left because they could not afford the deposit. Either way those patients don't get the care they need.

I use the saying "you do the best you can in life, and that's the best you can do." But medicine needs to be about treatment options..OPTIONS, you all always have options. Here is a story of a dog who needed lots of options.

On Wednesday morning while I was back in surgery sweating nervously over Wrens eyelid surgery a very very sick young Rottie walked in. I will call her DiDi. She had a sweet gentle face and was unable to move more than just picking up her head to look around. She was what we call "flat out." You could see the misery in her young beautiful face. She remained on the surgery floor while the vet and techs on her case gathered her medical information.

She had been found by the people who brought her in 4 months ago. She had not been to the vet since they found her, and they had no history on her. This is a very tough place for the vet to try to build a case when we have a very ill patient. We have no idea of vaccine status, age, history, etc etc. It makes your possible list of diagnosis long and difficult to dissect through.

As Dr. E came back to the surgery area I asked "what the deal with DiDi was?" She filled me in on the scant history and said that the people, (I will call them her owners, because at this point they are), said that "they had brought her in because they noticed blood on her backside." Sure enough she had a butt covered in dried blood. We spent a few minutes making sure that the blood was indeed coming from the rectum and not the urinary or reproductive organs. (Very important to know where the source of your bleeding is!) A digital rectal exam revealed a gloved finger covered in frank blood. She was definitely bleeding from her butt. But why?

Our first bit of detective work told us that we had a very sick young female dog in front of us. She appeared to have lost a significant amount of blood. She was depressed, dehydrated, and had more unanswered unattainable questions than we were going to find answers. So we started collecting any information that we could. Her blood work looked terrible, (honestly it usually does if you are dehydrated and you look terrible). She had a very high PCV (packed cell volume) and TP (total protein), so, OK even her blood knew that she was dehydrated. She had elevated kidney values, (dehydrated), and her temperature was low.

We took x-rays and found no additional clues to help here. By the time we had covered our basic diagnostics it was closing time. Our presumptive diagnosis was HGE (hemorrhagic gastroenteritis) so the i.v fluids that we had started a few hours ago were hopefully going to start to treat both the dehydration and assist her body in its own healing process. Because she was still so ill, needed to stay on i.v. fluids and needed 24 care we sent her to the local emergency clinic for overnight care. Her owners came to JVC to pick her up at 7 pm and headed with her to the ER. When they arrived there the attending vet gave her an exam and repeated the x-ray. She then reported to the owners that she believed there was blood in the abdomen and told the owners they needed to put down a $1500 deposit for her overnight care JIC she needed surgery. The owners called us back immediately and said that they couldn't afford to keep her at the ER overnight. So back to JVC she came. Certainly not ideal because we are not 24 hour and she couldn't be monitored overnight. But she needed her i.v. fluids and she needed a break.

The next morning DiDi looked worse. We knew she needed immediate intervention and she couldn't wait any longer. With a sad phone call to her owners we told them that her only two options were to euthanize her or go in to her belly and take a look. 20 minutes later she was on our OR table and we saw for ourselves what had her feeling so terrible. Her intestines were black from her stomach to her anus. She had been dying from the inside for at least 3 or 4 days.

She was put to sleep on our operating table and her owners were called with the terrible news.

She is a sad story with an unhappy ending but I am glad that we could give her owners some answers even if I still don't know exactly what happened to her or why.

She could have found a poison somewhere. She could have torsed (twisted) her stomach and the rest of the intestines that follow it, or she could have had some disease that just ravaged her entire gi tract.

I think of how many owners bring their pets in to us in search of treatment and options and how many of them never get either. It is heart-breaking to think that we can't at least offer some small answers and some hand of compassion without an estimate and a deposit.