The Choking Doberman

So this weekend was the Alaska State Veterinary Meeting. This means I spent the entire weekend improving my mind by learning new things about veterinary medicine from those who stand at the cutting edge of it, getting up WAY too early for a weekend morning, eating convention food, and trick-or-treating in the exhibit hall (where all the reps bring little goodies to entice you over to their tables so hear about their latest products.) They know their audience, so someone always has at least one of the following items:
Coffee mugs (metal travel mugs preferred)
Leashes
Frisbees
Stuffed animals
Pens
Post-it notes
Free product samples (Hint: go back to the tables you like best on the last day. They don't want to cart their samples home, so you can have as much as you want.)
Chocolate (and other candy, but there'd better be at least SOME chocolate in the bowl, or else)
Tote bags of various descriptions
Magnets

There were no cool T-shirts this year, but I DID get an ice-scraper and a gym bag and some vet-wrap and some suture and a travel sewing kit and a mini-first-aid kit and a mini-Tabasco sauce (okay, that was from the breakfast buffet) and a mouse pad and various cool little client-education devices (no, this does NOT mean a baseball bat. It means a little laminated book with pictures of the stages of dental disease, or a diet-comparison card, or a body-condition scoring chart, or something like that.)

Meanwhile, there were some excellent lectures (toxicology, oncology, dentistry, respiratory emergency, emergency resuscitation, etc.) The emergency medicine lecture reminded me of this, from my internship.

I walk into an exam room to see a Doberman who is vomiting blood, choking and coughing for the last three days. The client seems just slightly manic, and loses focus easily, but for the most part I can keep her on track as long as I am asking her questions. If I lapse into silence for any length of time, however, she tends to ask me abrupt non-sequiter sorts of questions unrelated to the case at hand. I find this slightly distracting, but am able to get a history from her without too much difficulty. Unfortunately, she (like many people) is not 100% clear on the difference between coughing and gagging, nor between vomiting and regurgitation, and she sometimes says the dog is choking, sometimes regurgitating, sometimes retching, etc. Also unfortunately, the client reports that in the last 48 hours the dog has eaten a fair quantity of chicken bones and a skein of yarn, not all of which she ingested - but either of which ingestions could potentially lead to vomiting blood (at the very least). As I am trying to elicit from her whether or not the dog has done anything else untoward, the owner details a number of other indiscretions, winding it up with, "She's always into something. The other day she escaped from the yard and ran around loose all day, and that night she threw up tin foil. But it's okay. Nothing ever makes her sick. She ate rat poison once and she was just fine."

Rat poison? My little ears prick up.

"When was that?" I ask her.

"Oh, a long time. Like a month ago. Maybe two months. Well, it might've been six weeks. But a long time."

Hmm.

My physical isn't revealing the cause of the problem - belly is benign, color is good, eyes are clear and bright, she has no fever, heart sounds great. She does have a moderate increase in her respiratory noises, but the dog is coughing, so that isn't a surprise. Since the owner isn't certain if the dog is vomiting blood, regurgitating it or gagging it out of her mouth (and the physical didn't shake that out) I ask her if I can X-ray the dog's chest in search of the respiratory problem, and to look for esophageal foreign bodies, since the dog has had both yarn (which can saw through the esophagus or intestines, producing bleeding) and chicken bones (which can traumatize every tissue they pass, depending on the kind and size of fragments the dog swallowed.) The client agrees to this, and I take the dog to X-ray, where a chest film is taken with dispatch. As I am standing there holding the dog, waiting for the film to come out, the dog leans hard on the leash, sniffing at something, and then (not surprisingly) coughs. Blood. She's coughing the blood, not vomiting it, not regurgitating it, not gagging it up. Not choking on it - yet.

Right about now my chest film comes up. The lung fields are white. The entire chest is white. White is the color of fluid. The liver should be white on X-rays. The lungs should be black, with white structures (like the heart and the aorta and so on) arrayed in a predictable pattern on a dark field.

Now I'm thinking: This is a D-con dog. That month or two months or six weeks is probably a lot more like one or two weeks. I'm also thinking: This dog is damn lucky to be alive, with lungs that look like that. But there she is, looking brightly around, walking around under her own power. She has nary a petechiation or hemorrhage to be seen on her gums, her eyes, her skin. She has not urinated the faintest hint of blood. But her lungs are full of it.

I go back and quiz the owner. Well, hmm, maybe it WAS only two weeks ago. No, wait, it was at So-and-so's birthday last week, wasn't it? Or was it? (I am less than helpful in this regard, since I do not know her social calendar.) I manage to interrupt her musings to tell her we need to put the dog on massive doses of vitamin K, and Right Now, and she needs to give them for at least a month, and then we need to do a re-check for clotting time. I also advise her that the vitamin K we carry is a little bit expensive, and her meds may cost around $250 for the month.

"For vitamin K!?" exclaims the owner. "Can't I just get that in a grocery store?"

"Yes, if you'd like to give her 19 pills twice a day," I say, reasonably. "The veterinary form would be four pills twice a day." The client thinks this over for a bit, and decides that four pills twice a day might be a better choice. She's also reluctant to spring for the vitamin K injection to get things started, until the dog gives a great croupy cough and spatters blood all over the side of the exam table. Maybe, she decides, that injection really isn't THAT expensive.

I give my injection (gently, subcutaneously, so as to minimize the hematoma potential from the shot) and am writing the chart up when the owner asks me, abruptly: "How do you get a cat?"

"Eh?" I say, not very helpfully.
"How do you get a cat?" she repeats.
"You mean, how do you find a pet cat?" I ask, still confused.
"No. My neighbor has these cats and he keeps them in an outdoor cage without any shade. I went over there twice last week and they didn't have any water, and I don't think he feeds them very often. I've tried everything. I asked him for them, I offered him money, I offered him drugs, but he just won't give them to me."

She offered him drugs? Yikes. I guess I'm not in Kansas anymore. I have sudden suspicions about that whole manic/easily distractable/non-sequiter thing.

"Maybe you should try calling Animal Control," I tell her.
"I thought about just going over there and stealing them," she says.
"You should definitely call Animal Control," I tell her, and spend a few minutes talking her into this.

My nurse comes in with the prescription meds, and I go over instructions and after care and advise the owner to call immediately if anything bad happens (as she has declined the hospitalization I advised, this is the best I can do for the dog.) To everyone's relief and good fortune, this was sufficient, and the dog's clotting times were normal in 30 days. Although she had eaten half a batch of corn bread the night before. (Sigh.)

So this was my choking Doberman story. Not the same as the one of urban legend, in which some people come home to find their Dobe choking on something, and rush him to the hospital only to find that the obstruction is two human fingers (or three, depending on who tells it). The horrified owners run home to find a thief cowering in their linen closet, variously passed out, dead, or merely shocky, but in all cases there is blood galore in the story.

Well, mine was pretty bloody, too. But there was a complete dearth of severed human fingers and lurking criminals.

I'm so boring.