Internal Bleeding; Rodenticide Toxicity. A tale of two outcomes. Palmer's hemothorax story.

Pets With Santa at Jarrettsville Vet 2013

If you aren't getting attached to your patients I would venture to guess that it is because of two reasons.

1. You forgot why you became a veterinarian, or,
2. You are exhausted from being a veterinarian.

I get too attached. I admit it. It happens when you love something.

This is Porter. I met her two years ago when she arrived with her mom and siblings fresh off a transport vehicle from a high kill shelter in the south. She was one of the many rescue kids we see because we work so closely with Black Dogs and Company Rescue. She happened to be walking into the examination room as my friends were visiting me in the front reception area. Within about 30 minutes of arriving at our clinic she was in my friends arms and on her way to her new home.

It was impossible to not love her from the moment you saw her face. She is a timid, gentle, bundle of sweetness. She will throw herself into your lap and burrow a nuzzle that is as irresistible as it is endearing. So you can understand why and how I get attached. Once I love you I never forget you.

Palmer was in the clinic almost weekly at first as we struggled to get her up to date on her vaccines,  get her nourished, de-wormed and used to being on a leash with a family. We spayed her a short time later and she was the little black shadow who went everywhere with her busy family. I saw her, and spoke about her often.

Spay day, June 2014

There are pets who change the lives of their people. And there are pets who change the lives of their vets. Palmer is both of those. 

On Saturday November 8, 2014  I got a call from Palmer's mom. She was worried because Palmer had vomited a few times, was panting and was lethargic. I asked if she had gotten into anything? Or had been injured? They assured me that she hadn't. I was getting ready to go to a dinner party and told them that I thought she should be brought to the emergency room. They elected to continue to monitor her through the night and wanted to bring her in to see me in the morning. At 9 pm I received another call that she had worsened and they were on their way to the ER. At 11 pm I called to check on them.

Palmer was pale, dyspnic  and tachypnic (short troubled, rapid breathing). She was critical. An x-ray of her chest was taken and showed that she had blood in her chest. She was placed in an oxygen cage to help her breathe better. I spent the next hour talking to them and the ER vet. It was a clear reminder of how frightening and fragile life is. The ER gave Palmer's family a $3,000 estimate and wanted a deposit. They couldn't afford this. So Palmer's life was left hanging on an x-ray and a list of possible etiologies. Hard as we tried we couldn't get her history to fit a likely scenario. This is where an experienced ER vet, a diligent devoted and observant family, and a pet with a complete and accessible medical record make all of the difference in the world. 

Palmer's chest is full of blood causing her lungs to be squished to the back of her chest.
Therefore, they cannot expand normally,
hence her panting and lethargy.

Her family left her at midnight to see if the conservative plan of oxygen, fluids, and time would help. At 8 am Sunday morning I called back to check on Palmer. Her family was electing to euthanize her because they couldn't afford to do all of the diagnostics the ER was proposing to try to diagnose her. They wanted to bring Palmer to me at the clinic to look at her. I was sad, frustrated, and my typical stubborn obstinate self. "Please don't bring her to me so I can kill her." It was a selfish thing to say. But I meant it. I told them that I was going to do whatever I could to save her. I meant that too. I tried repeatedly to get some clue as to what had happened to her that could have caused this. They reassured me over and over that it couldn't be a toxin, or trauma. That left a few bad, and likely untreatable, scenarios left.

I called the ER again and spoke to the vet. We both knew that Palmer's family was leaning toward euthanasia. Together we talked about Palmer's case. The ER vet hadn't run any diagnostics outside of an x-ray because her family had declined them due to cost. If Palmer didn't get a diagnosis quickly AND cheaply we believed she would die. It is a terrible real-life predicament. 

"OK," I said to the ER vet. "Palmer is 3, it is probably not a tumor. And, even if it is we can't treat that. (Too expensive and very poor prognosis). There is no evidence of trauma. Just run a PCV/TP and a coag(ulation) profile. That's the only real possibility that is treatable."

Ten minutes later, and for less than $100, Palmer had a diagnosis; Rodenticide Poisoning. She was bleeding into her chest from ingesting rat poison. Her family did not use it, and she had no known access to it, but it was inside of her and killing her. She was immediately started on vitamin K. 

A few  hours  later she was still critical and still fighting for her life. Her parents called me again and I opened my big mouth, again. "She needs plasma." The ER's price for this was $600. "I'll give you mine or pay for what she needs." A day later Palmer left the ER wagging and happy. She made a full recovery in a few days.

Turns out she had gotten an animal carcass from the mulch they had delivered two days before she fell ill. (Don't use rodenticides anywhere. Please! It kills more than rats every single day. There are more humane methods to keeping pests out of your house. (My favorite.. 4 cats!)).

Two days later she came to give me a hug at the clinic. I live, and work, for those hugs.

Palmer changed the way I practice medicine. She changed the way I am accessible to my clients.

I called the two emergency clinics that we refer to and asked them to call me if one of our pets was there and was being euthanized because of cost or uncertainty. I can't change fate, disease, or the fact that medical care can be expensive, but I can change that powerless fear that many people euthanize over. Or, at least I can try.

If you have any  thoughts on Palmer's story I would like to hear them. Please leave a comment below, or you can find me on Twitter @FreePetAdvice, or at the clinic, Jarrettsville Vet, or on Pawbly.com. Pawbly is an open online comunity for pet people. Our goal is to empower you, educate, and assist you in taking the best care of your pet as possible. Pawbly is free for everyone to use and open to all pet lovers.

A tale of two outcomes..coming soon the blog on Nickle.

The Emergency Calls, The Screams In My Head, and Why Do People Still Use Rat Poison?

I had another booked Monday and my routine few ‘emergencies’ piled on top, (yes, again). Seems there are few ‘routine Mondays’ anymore. It is the nature of the veterinary beast, and in all honesty, the fun in the day. (I can’t stop the emergencies so I might as well embrace them, right?).

I had a conversation with a client the other day. He had called us two Mondays ago asking if we could do “an emergency C-section on his dog who was at the emergency clinic.” I had to ask, “Why his dog wasn’t having her C-section at the emergency clinic?” I wasn’t surprised to hear that it was because of the estimate they had provided him for the service. I then asked him if he had a “regular veterinarian?” “Yes, I do, but I called and they can’t see me today.”

Huh? I don’t get it? I don’t understand why vets turn away their clients when they are in dire need? Now I understand that there are always two sides to every story and I only heard one of them, but if you call me and your dog is in ‘DIRE’ need I am not going to have the receptionist tell you that I am too busy.

My heart went out to this owner and I couldn’t bear to hear that there was a dog sitting in an emergency clinic that needed any emergency surgery and wasn’t going to be helped. Another deep breath, a little bit of further Q and A and I was going to have a longer day than I had originally planned, but my conscious was clear. That day I performed a caesarian section on one of the sweetest Golden Retrievers I have met. She was full of infection and two dead puppies. But I know that if she hadn’t had that surgery she would have died a terrible death within a day.

Since that surgery I have decided that every emergency that I can do something about I am going to see. I am going to help my clients take care of their pets and I am going to move a mountain if that’s what it takes to get the care a pet needs.

This conversation reminded me of the conversation I had during today’s emergency.

I often stand there listening, taking notes in the medical record, wanting to ask a litany of questions, some for the sake of helping me identify the pets needs and some for just plain old curiosity, and some to address the inner voice in my head screaming,  “What the hell were you thinking!!!?”

The call this morning was about a puppy that needed to come in because the owner had found him eating on a rat bait package. I told the front staff to tell them “to come in as soon as possible!”

I began to re-arrange my schedule. The cat spay on the docket could afford to wait for her surgery tomorrow but that puppy needed to be seen today.

Thirty minutes later, a 3 month old puppy bounced his way into the clinic.

Little Zeus has a serious face with ears that stand straight up, bright intense eyes, a long mane of fur and all of the qualities of the German Shepherd breed  designed to impose fear onto any visitor his family will entertain. But, for now he is an adorable beautiful curious and clumsy boy of wags, and mouthy ‘hellos’.

As I met with Zeus’s mom we discussed how he had landed himself a trip into the exam room this morning.

It seems that Zeus had ‘found’ the container of D-Con under the couch. “He is at the age where everything goes in his mouth and he gets into everything” she told me.

I try very hard to just listen when I am in the exam room. It is very important to get a good detailed history and not interrupt the parents account of the patients tale. She went on to tell me that “the container had been under the couch for over a year and the blocks had started to come apart and were more of a cake-like consistency.” She went on to say that she was “also pretty sure that he hadn't eaten any of it, he was just playing with it.”

One of the ways that you can tell a seasoned veterinarian is that we learn to trust what we see, and what our gut tells us, versus what the parents tell you. We use some pretty excuse like, “It all has to fit together and make sense, or else we are missing something,” when our gut and brain are dueling with the diagnostics, history, and patients clinical signs.

It also is a true art to not let your mouth speak when your brain does. My brain is screaming, “What kind of person keeps rat poison under the couch?” 

Based on my presentation of a happy healthy puppy and a parent in denial we decided to run some blood work and start vitamin K as a precaution to the rodenticide exposure.

Along with the little pills I sent home, I did feel obligated to review basic home safety for pets.

Thankfully,  Zeus never skipped a beat. He never showed one clinical sign of having ever using the green blocks as a chew toy.

It is January. The weather remains chilly. The thermometer continues to hug the tipping point between the positive and the negative digits, and the snow bird rodents to migrate into your home. As the mice march in the house, the humans march to the “pest management” aisle at the hardware store seeking eradication mechanisms.

Now I know that no one wants vermin in their home. But when it comes to deciding what to do about them I have a few words of experience to impart. The poison you put in your home is designed to be “attractive” to all beasts. Your pets will find it (oh, gosh, please never put it under the couch), and they will eat it. Worse yet, they will eat it and you won’t know it until days to weeks later when they are bleeding out. Please never use these baits if you have pets! Glue traps, well, I think that they are just awful. Who wants to die because you are stuck in quicksand, and have to die by reason of starvation? The old quick and painless way is what I choose. You have to look your intruder in the eye, and you have to remove the carcass, but it won’t hurt your pets, well, not seriously.

I have seen countless cases of rodenticide toxicity over the years. Dogs with nosebleeds, blood just pouring out of their penis, or any orifice the blood can find to slowly drip out of. These bleeding guys are surreal, like some sort of zombie extra who lost their movie set.

Treatment for them has traditionally been to monitor red blood cell counts (or PCV’s), provide vitamin K, and maintain blood pressure by avoiding hypovolemia. But there is a new generation of poison (bromethalin is the active ingredient) that have no antidote for treating our pets against it. Unless these toxins are identified almost immediately allowing us time to induce vomiting and remove it, these pets will die if diagnosed after clinical signs of toxin exposure manifest.

For all of those dozens of dogs that have been successfully treated when they show up at the clinic dripping blood like a leaky faucet, the new generation of rat poison will kill your pet and I won’t be able to help.

As we move into the new generation of rat bait poison I fear I will see more patients who I can only wait and watch. Maybe I can buy them a little bit of time? But they will still die. 

If you have any pet questions you can ask me, and a whole bunch of pet experts, FREE, at Pawbly.com.

Or you can find me at Twitter @FreePetAdvice, or on Google+

They Should Re-name it Dogicide

Every Tuesday evening I get to meet a new set of challenges it seems. I am the late Vet and the darker it gets the crazier the scene seems to set.

Tuesday was another for the blog books. In the middle of the booked evening I had on the schdedule one of my Receptionists came to me to notify me that she had just received a call from a woman who was not a client asking if she could come in immediately because her dog was bleeding profusely from the penis.

“Sure,” I said, thinking this is probably just a urinary tract infection. (I had seen 4 that evening already). This was just going to just be another tick in the evening’s cluster of unexplainable clustering pee issues.

I continued plowing through the appointments and figured I would meet the new client as I looked over some urine the tech had caught from their dog for me before I went into the appointment. I would then begin my dialogue about the physiology and treatment options of UTI’s as I tried to endear myself to the new client in the building.

A short time later I was called by my tech to come look at the dog in Room 2. As I walked in I saw a very timid small badger looking Australian Cattle Dog crouched over a puddle of very dark bloody…. umm, well maybe? urine? I actually wasn’t sure if the puddle on the exam room floor had come from his penis. It looked a iteensy-bit more watery than arterial blood, but not watery enough for me to believe it had come from the bladder, or might be urine.

“OK, not a simple UTI, fabulous.” I thought. Time to rethink the evenings plans. I put my files down and closed the exam door behind me. It was time to meet the new clients and do some investigative work. My tech knew to go into the other rooms and start offering some excuses and apologies.

I gave JD a look over. He was slumped, head bowed, pot bellied, and looking like he really felt crummy. His gums were muddy light pink and dry. He was dehydrated, shocky, had an elevated heart rate, respiratory rate, and a belly full of fluid, (I suspected blood based on his poor mucous membrane color and blood on my exam room floor).

I then turned my attention to the new client. She was a tall woman very obviously 8 plus months pregnant. She also brought her two pre-teen children who were hungry and bored already. We had some ground to cover, lots of questions to ask, and explore, and 2 kids that had better things to do.

When I asked if there was any chance of trauma?, like being hit by a car?, JD’s mom told me that he is never out of their yard. When I asked if he could have gotten into any poisons (like rat poison), she assured me that she lives on a farm with 10 acres and they never use poisons because they raise goats.

I was coming up empty despite my persistent queries and inability to make the clinical signs of this dog fit the history she was providing.

JD’s mom told me that he had been perfectly normal the day before and had seemed a little quieter in the morning but had just started bleeding this afternoon.

I asked her if I could take an x-ray. I was concerned about there being blood in the chest and I wanted to look for radiographic evidence of trauma. She consented. Three chest views, (left and right side down, and ventral (lying on the back)), and side and ventral abdominal x-rays all showed bleeding and clusters of bleeding, but no signs of trauma (broken bones). I returned to the exam room and requested we take blood to run a CBC (complete blood count) and chemistry panel. I hoped to only find a low PCV (packed cell volume due to blood loss) because blood loss was the only clue I had so far.

As I reviewed the diagnostics we had done I again questioned her about the history of this dog. I just couldn’t believe cancer would cause him to be fine one day and then bleeding profusely the next.

JD's PCV was 31%. I was surprised a little because he looked worse than 31%, and his TP was 5. OK, he looked as bad as 5.

The bloodwork revealed anemia, (low red blood cell count), low protein, and everything else was normal. OK, now very unlikely it was cancer. It was an internal bleed, but why?

At this point I had JD’s mom in hysterics telling me that her pregnancy wasn’t going well, she loved her dog but had NO money, and she needed to know what was wrong with him and why.

My night was now significantly running late and going south, fast. Nothing beats stressed out, like stressed out, guilt ridden, and an emotional pregnant woman with a sweet dying dog who needs A LOT of emergency care, and a $2500 budget.

I told her that JD was critical. I also told her that I was not sure why he was bleeding, but if he didn't stop soon he would likely succumb to dying via exsanguination. He had to be transferred overnight to the ICU emergency room. The moment I suggested this to her sobbing turned into firm persistent unequivocal denial of transfer.

“I won’t go there! I will never go there again! They are thieves and they don’t care about us or our pets!” OK, she was adamant and I was losing any hope of this dog making it through the night.

Compromise talking time.

“What if I call the other emergency clinic and see if they can monitor him for the night for less than $200?”

She doubted my ability to negotiate and she doubted their ability to execute a plan. I re-assured her that we all wanted to try to save JD and we all understand that all of us have budgets.

I called the ER and spoke to the DVM on duty. My conversation started something like, “Boy, do I have an interesting case for you!” All I had to say was $200 bucks, 8 months pregnant, and bleeding profusely from the penis and she realized my sarcasm was understated.

JD was transferred with some diagnostics, a long list of unknown answers, and a presumption of toxicosis but nothing to prove or back it up.

Thankfully the ER has the ability to run a coagulation profile, and thankfully it was within the $200 overnight budget. JD’s coags were “off the scale.” He had been poisoned by a rodenticide (likely) and he was bleeding out of the easiest hole his body could dump out of; his bladder.

Overnight I received text messages from the ER DVM saying that "he was holding his own and they had started Vitamin K."

JD returned the next morning whiter, more depressed, and breathing even harder. He now had frank blood coming from his penis. (Frank blood means thick, red staight bleeding). It is a scary thing to witness and significantly worsened his prognosis.

I had to have a difficult discussion with a now exhausted (she was at the ER until midnight), 8 month pregnant, still 2 kids in tow (also overtired), emotionally charged owner. Yippee!

“JD looks worse this morning. I had hoped that the Vitamin K would have stopped the bleeding by now. When I saw JD last night his PCV was low at 31%, and his protein was also low because of the acute blood loss. He is now 19% and his albumin (protein) is at a very dangerous 2. He needs to be transferred to the ICU for blood transfusions and I estimate this is all treatable but will cost upwards of $2000.”

Profuse hysterics ensued.

“OK, plan B: I will do the best I can here.” Crying stopped.

She asked if she and her children could say goodbye to JD just in case he continued to decline and didn’t make it through the day.

I also had her sign a “Consent for Euthanasia” form so that if JD became agonal (started to die) I had her permission to humanely euthanize him.

At 9 am we began our low-budget, no holds barred, quest to save JD. He received 4 units of fresh frozen plasma. (I have had this one treatment save more lives in my clinic than probably anything else. I strongly recommend clinics keep a few units in the freezer. It lasts a year, is easy to give and is really very safe. It saved my own dogs life (Savannah) and it saved JD).

The magic liquid elixir worth more than gold. The life-saving miracles of plasma.

After 2 units of plasma JD started urinating almost normal looking urine. Instead of it being frank blood there were only blood specks. He also began to eat, and breathe much easier.

This is the urine JD left on the towel. We were sooo happy to see only one speck of blood.

Lots of fluids means "I gotta pee! A lot!"

BIG improvement from the night (and this morning), before!

After 4 units I called his mom and told her that I thought JD had just dodged another big bullet.

Pink mucous membranes. Also a BIG improvement from the pale muddy pink of the night before.

She had told me the day before that he had already survived a fractured skull many years ago.

JD went home last night wagging his tail and smiling, head held high.

He is a miracle and another living testament to early medical intervention and treatment.

This is what a GREAT Technician does. She sits and hand feeds the patients who need love and encouragement.

Eating only because someone will take the time to make everything less scary.

I also had a visit from the Sheriff yesterday. Seems JD’s mom now believes that the neighbors intentionally poisoned JD.

I know how terrible the effects of rodenticides can be on pets. I am not a person who wants to share my home with rats, but this is a terrible way to die and kills too many domestic pets every year. Someday this product will be banned, but until then I urge all of you animal lovers to pick another way to rid your house of unwanted visitors.

After I finished this story I posted a Twitter message stating the following;
"Saved a dog from rat poison ingestion w vit K & fresh frozen plasma transfusion. This stuff kills more than mice, pls don't use it!"

I received a reply from Vet School Style stating,
"I had a guy say he didn't realize that bc it said "rodenticide" and not "dogicide."

JD's PCV was up to 23%, and TP 7.4 the next morning. He is one lucky boy!

He will stay on oral Vitamin K for the next two weeks.

1 week update. JD came to visit and he is back to his happy, energetic, sweet self. His color looks great, and his chest sounds much better also. We put him on anothr 2 weeks of vitamin K because we don't know what kind of rodenticide he got into. Treatment for rodenticide toxicity is 2-4 weeks. We are playing it safe by supplementing him longer.

JD's family came back in with him, and the son confessed that they had done a search of their home and found a box of rat poison. JD's mom tried to convince me that she didn't think it was the poison he got into because there weren't partially eaten pieces, and JD is "too smart to do something that stupid." I told her if they found it, he got into it.

As a side note; I just went into our basement to retreive our kittens who snuck down there (because it is off limits) after my husband went down to find a can of paint. Seems