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.

Bailey's Beyond bad Belly, really it was Abominable!

I have introduced you to Bailey already, but I thought I would give you her full story.

I met Bailey on a Tuesday evening appointment. She was brought in by her owners who were in their mid-twenties and full of smiles. They told me that they had just returned from their 2 week honeymoon.  After the “congratulations” were exchanged I started to focus on Bailey. Bailey was a big (like 100 pounds) fluffy, (which makes you look even bigger) 2 year old spayed female white Husky. She had sky blue eyes, an open sweet mouth with her tongue was always hanging out. She was always engaged in her surrounding company, always very alert, and always a big cuddly, fluffy, sweet, gentle girl. She looked a little intimidating but she was as friendly as a Golden Retriever. I will say though, that for as friendly and gentle as Bailey is she also possesses that stoic, strong, impressive stance. She is definitely a big boy’s dog. Every manly man loves her. She is the dog my husband would pick if he could pick, (don’t EVER tell him he can pick, he can’t, sorry, that’s just the way it is in this household).

Bailey’s parents had left the care of her and their other dog with their parents while they were honeymooning in sunny Mexico. Their parents had called them and reported that “Bailey wasn’t acting quite herself.” Apparently everyone wrote this off as her just not used to being in a different house and missing her parents. Later their parents called them back to report that “Bailey’s gums were pale.” Now as soon as this came out of their mouths I wanted to scream! This is like telling me that you noticed that your child had had passed out, had a seizure and stopped breathing. I was waiting to hear that their parents had recognized the immense severity of this clinical sign and IMMEDIATELY brought her to the emergency clinic, but this never came. I let them continue to tell me about her, from the perspective of their parents. They went on to tell me that Bailey had seemed to wax-and-wane the whole time they were away. She wasn’t playing, or eating as well, then she would be a little better the next day and worse a day later. They also said that after their parents noted her pale gums they watched the gums very closely, and reported her gums were pale pink, then pale, then white, then got pale again.

I was writing all of this down as fast as I could, because it kept me from talking, and I was afraid my gasps and looks of horror might cause us to loose track, and Damn, I couldn’t really believe what I was hearing. After they told me about what their parents had observed I asked them what they had observed. I think that they had been pretty wrapped up in wedding plans, honeymoon plans, and each other to be too observant with Bailey. It was all very understandable. (FYI they told me that the wedding and honeymoon were fabulous!)

Bailey’s parents had just gotten back the day before and they too had realized that she just wasn’t right.

I started my examination of her. One of the things we have to “train” ourselves to do is understand what a “normal” gum color looks like in all of the different breeds of dogs. There are some breeds of dogs with very dark gums, it can be hard to tell the color pink when your background is black. And then the white dogs can have a red, pink, or pale gum. It is definitely a learned assessment. I looked at Bailey and she had what we call a “muddy pale” color. I did not like this at all. The second I see such a bad color I stand on alert and dig hard. There is NO way a pale mucous membrane pet is getting out my door without a lot of talking about my fears for their pet. AND just in case you aren’t getting my “I am really afraid” vibe yet, I will say for the record..

Every single person and pet with pale gums needs to be at the emergency room right now!

Further, if you or your pet, or anyone else, ever has a seizure you must go to the emergency room ASAP!  My dad actually came home one day and found their dog having a seizure, what did he do? He got back in his car, and drove to my mom’s work, to tell her. He left the dog at their house. He got a lecture from me later. Now I understand we don’t always respond correctly in the event of an emergency, that’s why I write this blog, and talk to my clients a lot.

Bailey’s physical exam also revealed an increased heart and respiratory rate, and a palpable mass in her belly. I discussed my exam findings with the owners. I wanted to do some blood work and take an x-ray. They told me they had a budget. I thought to myself, this was not the case to have a budget on.

The x-ray revealed an enlarged spleen, which had been what I suspected when I felt the mass in her belly, but thankfully no blood in her abdomen. I ran a PCV (packed cell volume to get a red blood cell count), because by this point it was after 7 pm and I couldn’t keep her in the hospital alone, and they told me they couldn’t afford the few thousand dollars a transfer to the ER would likely cost. Her PCV was 30, it is supposed to be mid 40’s. I told them I would have the blood work back in the morning and I wanted her back at the hospital by 9 am and left here for the day. I suspected that she would need her spleen taken out then, (splenectomy). They said “ok” left with a brochure for Care Credit. Care Credit is a credit card for those who need to pay for a medical procedure.

The next morning Bailey was dropped off with a large amount of trepidation from her parents who had been warned she would probably be having a surgery today, and a Care credit limit of $1500. Which we were pretty sure would cover her needs.

Dr. C looked at Bailey and to my surprise did not feel an abdominal mass. She did however see bailey urinate. The urine was bright orange. This is a big CLUE! I called Baileys owners immediately and told them our newest findings. We were now concerned that maybe she had Immune-Mediated Hemolytic Anemia. Which made a little more sense, because Bailey was so young and splenic tumors are much more common in older dogs. I wanted to give Bailey an ultrasound but this was going to cost $200. They couldn’t afford this. So I tried to cut a corner. Dr. C and I tried to do an ultrasound on Bailey. Neither one of us has had enough practice to be proficient at ultrasounds. I was fairly certain that there wasn’t a mass in her belly, but we don’t have eyes trained well enough to distinguish the finer details of a trained ultrasonographer.

Because there wasn’t a mass on palpation, and we couldn’t see it on the ultrasound. We defaulted to the IMHA diagnosis.  We started her on a steroid, and sent her home. I wanted to see her in 3 days to re-check her PCV and immediately if anything worsened or changed. They came in 3 days later and then 3 days after that. Bailey’s PCV never changed. Neither did her demeanor. I wasn’t settled we were right. The next Monday, 6 days later I begged them to come back and let the very very well trained ultrasonographer take a look at her. I told them we wouldn’t charge them for this.

As soon as the ultrasound probe hit Baileys belly the ultrasonographer said. “Splenic torsion!, “ “you have to cut this dog now!” I very quickly called the owners and braced them for surgery, again. I told them that if we didn’t remove her spleen she would die.

Bailey’s surgery happened a few minutes later. Thankfully there were 2 other vets in the building. For a bad splenic surgery you need a few more hands in the belly. I have done probably 20 splenectomies in the last few years. When I looked in Bailey’s belly I couldn’t believe what I was seeing. Her whole entire spleen looked like it had been tied in knots. I couldn’t even recongnize the surrounding organs. My heart sank. I had to look up, close my eyes, and take a few deep breaths. How was I going to break the news that she had an inoperable, beyond the worst thing I have ever seen abdomen, and that she was certainly going to die soon, and shouldn’t even be woken up from this surgery? I just sank.

This is what a REALLY bad spleen looks like

I asked Dr. E to help out. I needed another set of hands and eyes, and I damn well needed to be sure before I made that phone call. Dr. E scrubbed in and helped me lift out the tangled mess. She couldn’t believe what she was seeing either. That belly looked so bleak.

We looked at each other and I just said. “Let’s just start taking out what we know we need to, and let’s see what’s left.” “Okay,” she replied.

3 hours later, we had what used to be a spleen out and some completely unrecognizable structures that I think were really angry lymph nodes? Maybe? Without being able to explain it the stomach and kidney which were right up to, but not incorporated with the mass, were fine.

I closed her up, said a little prayer, and crossed my fingers. I called her parents and told them how lucky this girl was. And, how after seeing what was in her belly, how I couldn’t believe that she could walk, eat, live, not be screaming in pain, and how lucky we were that we did that ultrasound and didher surgery today.

Bailey walked out of the clinic the next day. She was actually wagging her tail, and eating. It took a week for her PCV to get back to normal. But I swear that dog is a miracle.

1 day post-op picture, going home

As a parting thought I told Bailey’s parents to RUN to the emergency room if she ever hints at not feeling well, because that girl can mask the most horrific illness. Talk about stoic, that’s an understatement!

1 week post-op

It has been about a month since Baileys surgery. She has done remarkably. And she has her sparkle and playfulness back. And her parents still have room left on their Care Credit. JIC they go away again.