Wednesday, July 29, 2009

Shake and Bake

Well, you knew it had to happen. The little vacation I've been having in my head, writing about the San Juan, just came to a screeching halt, courtesy of being on call. Been doing a lot of that lately; one of the other local clinics - with whom we share our on-call duties - is having construction in front of their clinic. The access road is closed nightly from 7 p.m. to 5 a.m. Call me crazy, but that doesn't seem especially conducive to emergency calls. "Yes, the road is closed in front of the clinic, so park as near as you can - in a ditch somewhere if you have to - and carry your pet the last mile to the clinic. If it's a dog over 40#, you might want to bring a friend." I can't blame them for wanting to trade on-call days... but due to the unavailability of any of the other doctors at my clinic to take some of the overflow, it has meant that I've been on call three times in the last week. Nowadays that seems like a lot. It used to be (back in the dark ages) that I was on call a week at a time, every third week - and how I survived that, I'll never know, since that means essentially that you could end up working 24 hours a day, if you have a rough week on call. In real life, if something like that happened for more than 2 days, another doc would spell you so you could sleep at least one night... but it DID make for some pretty gruelling weeks. My worst stretch was when both my bosses were out of town for 12 days in a row, leaving ALL the on-call in my lap. For a few days we had a relief vet, but the one boss was stranded in Dutch Harbor - weathered in - and was many days overdue. The relief vet had another gig (and did no on-call in any case), so from then on I was flying solo, 24/7. I was pretty tired by the end of that. In light of that, three days in a week seems paltry - but it's more than I'm used to, any more.



Tonight I get a call from one of our own clients. She has a dog who has been pawing at and foaming at the mouth, and is holding her neck stiffly. She has puppies that are 4 weeks old, but they seem fine, and she's had diarrhea for the last 2 or 3 days.



Hm. Pawing at the mouth (and foaming) are sometimes signs of having a foreign body lodged between the teeth (although there are many other possible causes); has the owner looked in the dog's mouth? Nope, but she can do it right now.... no, nothing wedged between the teeth.

"Do you think she'd be all right til morning?" the owner asks me.

"I can't say," I tell her. "There are too many possible causes of her signs to guess. I'd have to have a look at her to know."

"Okay... we'll bring her in, then," the client decides, telling me she can be at the clinic in 40 minutes. I put on shoes and go out into the cool, rainy evening. As I drive to the clinic, I sift through the possibilities.... meningitis, toxins, rabies, chemical irritation, electrical cord bites - the list is extensive. Rabies is the least likely, since (apart from one recent imported case in Anchorage) there has not been a case of terrestrial rabies in South Central Alaska for over 35 years. I'm not sure how much over 35 years, but at least that long. The one Anchorage case was in a dog that was shipped (by a rescue group) to Anchorage from a village out in the bush. The dog came from a dog yard that had been afflicted with rabies. Now, I understand wanting to get a dog out of that situation, but really: Given that it came from a group of dogs in which rabies had already killed several dogs, doesn't it make sense to quarantine the dog and ascertain that it does not itself have rabies, before you decide to ship it to a highly populated city? Seven people were exposed and required treatment. Luckily there were no bite incidents - just contact events - and no other animals were exposed to this dog. But still... imagine the disaster that MIGHT have been, had they adopted the dog out - or had it broken with transmissible virus while in flight on a commercial airline. At any rate, while that is WAY too close for comfort, given the fatal nature of the disease, it is unlikely in this particular emergency case: the owner is a musher, and her dogs do not roam loose. Apart from that, they're all current on rabies vaccine, as required in order to race. Not only would she have to have had a vaccine break, but something rabid would also have to have come on her property to make that a possibility, and given the dearth of rabies in the area, I'm back-burnering that.

I beat the owner to the clinic, and wait for her to arrive. Meanwhile two more calls come in simultaneously; I am calling the first one back (a chicken with diarrhea) when the owner of the drooling dog comes in. Her husband, a strapping young man, is carrying the dog, who is unable to walk on her own. I motion him to deposit the dog on the treatment table, still telling the chicken owner what to do for nursing care (as I don't treat chickens, and can't see this one right now in any case, having a more pressing emergency right in front of me.) The dog is tremoring, her muscles bouncing and jittering in a fine, continuous fasiculation, something the owner did not mention on the phone. My suspicions immediately veer into a new channel. While detailing quarantine instructions to the chicken owner, phone pinched between ear and shoulder, I take the dog's temp: 105.9 F, and the dog is hot as a just-fired pistol under my hands.

"I'm sorry, but I'm going to have to see this emergency now," I tell the chicken owner.

"BUT - should I give coccidia medication?" she says, ignoring that.

"You certainly can, as the chicken's symptoms are consistent with that as a possible cause - and it's not going to do any harm. But I'd advise you see someone in the morning who DOES treat birds. I really have to go treat this dog now," I say again.

"Well, I wanted to ask more about the nursing care," says the owner.

"I'd be happy to call you back, but I need to go to this dog right now," I say. "She needs my help right this second, so I'm going to have to end this call. Shall I call you back when I'm done?"

"No... don't bother," says the chicken owner, evidently put out that I am more willing to focus on a dog who is at imminent risk of death and is right in front of me, than a chicken who I would not normally treat in any case, who I can't physically see, and who is not dying right this minute. Okay, then.

I snap the cell shut and say to the owner, "How many puppies does she have?"

"Twelve," the owner says.

Yikes. "Okay. She looks like she has eclampsia," I tell her. I'd love to check her calcium levels to be sure, but there isn't time; that will take over an hour and in that time the dog will have overheated to the point of permanent brain damage or fatality.

Eclampsia is a low-calcium state encountered primarily in lactating animals. The most usual causes are inadequate nutrition (not in this case, as the bitch has been on a growth and lactation diet for 2 months and is being given extra calcium supplements as well); short-legged dogs with smaller body-wide calcium stores, consequent to not really having any long bones to draw from; and excessive litter size. Left untreated, this is a fatal condition, and even with treatment there are risks: heat stroke, emboli, cardiac arrest, DIC. I see no reason to frighten the owner with all this, and in any case, time is of the essence here, so I cut to the chase. "We need to get some calcium into her, " I tell the owners. "Fastest route is IV, but since we need about 5 more hands than I have, I'll need you to help me." The owners nod, both of them squaring their shoulders and looking alert and focused, ready to leap into the fray in whatever manner I dictate. We get a body weight and I calculate her calcium dose: somewhere between 2400 and 3200 milligrams is our target range, although if we can control her tremors before that level, we'll stop at a lower dose. Too high is as dangerous as too low when it comes to calcium, especially if we're mainlining it IV.

Back in the treatment area the husband deposits our patient on the table, where she is unable even to recline on her chest, but lays flat out, shaking and panting. I hunt up our calcium. Well, crap. It's 5 milligrams per ml, which means I'll need.... way the hell more than I have. I have about half of a 100 ml bottle, which means I have maybe 300 milligrams.

Damn.

Well, some is better than none, so I set a butterfly catheter, tape it in and draw up 20 cc's. With one hand I push the meds, using the other to hold a stethoscope to the dog's quivering chest, trying to sort her heartbeat out of all the juddering noise of her twitching muscles. One owner is keeping the dog from shuddering herself over the edge of the table while the other is bathing the dog's feet with alcohol to bring her temperature down. I am racking my brains about where I might lay my hands on some more calcium; I have some at the farm, I recall; if worse comes to worst I can zoom out there, maybe, and get it back to the clinic in 35 minutes or so.... but first I should see if I need it. When I have to refill my syringe I have the dog-holding owner pinch off my butterfly line so that we neither exsanguinate the dog all over the table nor get air in the line, and I draw up more calcium, and more again. Well, that's the last of the bottle, and we're nowhere near done.

Luckily my boss is in the clinic, getting packed for Kotzebue (where he flies three or four times a year to do a remote clinic), and he knows where a secret stash of calcium gluconate is. Hallelujah. We're back in business.

I get an ice pack for the dog's belly (as we're still at 104.5 degrees from the intense, unremitting muscle contractions) and we keep on with the slow IV push. If I run the calcium too fast I'll stop her heart; if I run it too slow I risk hyperthermia and stress arrhythmias, strokes and DIC, a severe and life-threatening coagulation disorder. So I push it slow, and listen and push more. Suddenly her pounding heart takes a stuttering beat and I stop my push, my own heart leaping on the spur of adrenaline.

"I have to wait a minute," I tell the owner. "Her heart is reacting." We wait, using the interval to slide the dog toward the faucet on the treatment table and run cool water over her flanks and belly, inside her thighs where the big vessels run near the surface of the skin, on her feet. Inside my head I also take advantage of the pause to second-guess myself; the dog is tremoring as hard as ever and I've just caused an arrhythmia with my treatment; have I misdiagnosed her? I was sure of my diagnosis when I made it, but I'm not seeing any positive response, only side effects. If I keep going will I kill her? But the part of me that believes in my medical skill is stronger than the part that second-guesses. I can't make another disease make sense with her presentation - in another climate, snail-bait poisoning would be a real possibility, but no one up here has any need to have that around. If I chicken out I could kill her as well - and there still isn't time to take an hour to run blood work. I have to make a decision. I go with my well-educated gut which knows I am right, and says: push more calcium. I'll just slow it down, so that I can stop the second I hear anything I don't like.

This all whips through my brain in about 2 seconds, in the usual manner of adrenaline-driven thinking: from certainty to doubt and back in no time flat, spurred on by the pressing need to act now. I listen again; she's steady on now, her big strong sled dog heart rallying and picking up its rhythm once more. I fill another syringe and resume my push, slower now, because we're over 700 mg to the good and I don't want to overshoot. Then, a gift from my patient: I think it's my imagination at first, but no - the muscle fasiculations are decreasing now, and I can hear her heart more easily amongst the jumbled noises of her chest. I ease it off, pushing slower still.

Her heart takes and abrupt dive in rate, bradying down by a third in a matter of a few seconds and developing a marked irregularity. I stop my push, waiting her out; it's hot in the treatment area, and the surgery light is shining on my head, and I am sweating both actually and metaphorically. (This is not helped by the fact that my boss is standing at the head of the treatment table, silently watching.) But after a minute she picks up her rhythm again, and I breathe.

Gotta love those sled dog hearts.

Still, I'm done pushing this one. The rest will have to go intraperitoneal. Meanwhile I recheck her temp: 102.8. My own heart rate starts to level out now. I give a big injection into the abdomen (carefully palpating to be sure I'm not hitting her spleen when I go in). We wait a minute, two, five. The powerful muscles in her thighs are quiet now, and the fine tremors in her shoulders and face are smoothing out.

"Looks like you've got it under control; I'm going to go," says my boss.

"Okay - and thanks for finding the extra calcium stash," I tell him. "This would really have sucked if we didn't have the reserve bottle."

"Yeah - that's something that maybe should go on the ordering list," he agrees.

Our patient is starting to look around her now for the first time. I sponge her tongue - hanging out of the side of her panting mouth for the at least the last hour, and who knows how long before then - and she pulls it back between her teeth in surprise and sits up sternal. Well, alrighty, then. We are now on the winning team.


I pull up two further 20-cc syringes of calcium for the owners to take home, just in case she has a recurrence. I tell them that they need to wean the puppies - a little premature, but the bitch's life depends on it. Because she is a devoted mother, she will try to let them nurse again, so I advise them either separately penning the bitch from the pups, or completely covering her mammary chain so that the pups can't nurse, but can still socialize with her; some of their most important early training is gained from the mother's corrections and examples, so if they can provide the social time without the nursing time, the pups will benefit without harming the mother. I am explaining all of this to one owner, and I glance over at the other to include him in, and realize that my patient is now on her feet having a good look around and making a bid to come off the table.


Well. Isn't THAT a pretty sight. Just a few minutes ago she was trying to die, and now she wants to hop off the table and have a look around.


The owners thank me profusely for coming in. "I was afraid she wasn't even going to make it to the clinic," the wife tells me. "We thought she might die on the way in."


"Well, not to be scary," I tell her, "but that was a real risk - and if you hadn't been willing to bring her in tonight, she WOULD have died. So I'm glad you decided to let me have a look at her."

We detail after-care instructions - I tell the owner to keep the calcium supplementation going until after the bitch dries up, and to allow the litter to interact with, but not nurse off of, their mother. I instruct them on how and when (and whether) to give the other calcium injections, and tell her to call me back if she is in doubt. The owners, relieved, are bubbly and cheerful now. I thank them for being my extra hands and commend them on their good teamwork. They nod earnestly, solemn in the awareness that without all three of us taking appropriate action, the dog would most certainly be dead. I watch the dog trot out at their side, her easy, mile-eating gait restored - a different dog than the collapsing, quivering, overheated train wreck that was carried in an hour or so ago.

I love it when a plan comes together.

16 comments:

MaskedMan said...

And that is why I hold you in awe: Balancing training and experience against doubt and fear, and having the skill, courage, and deft touch to carry though to life.

Do see about that reserve bottle of calcium, though.

Pat said...

Wow!

Penny said...

Lovely story. I lost my Samoyed to an anesthesia problem, last year, and we were in the operating room with her trying to bring her back. The way you discussed what you were thinking while you were working on the musher actually gave me a sense of comfort as to what sort of thoughts were probably going on in our vet's mind when we lost our girl.

I'm so glad it had a happy ending - for the owners and for you.

ellipsisknits said...

Wow, you really know how to write drama. That honestly had me on the edge of my seat waiting to find out if it was going to work or not, and I do not ruffle easily!

It's great when things have happy endings. I hope mom and puppies are doing well, and I hope you have quieter nights coming up for you!

Out of curiosity, how far would the next option be in an emergency situation? I agree that having people walk a mile though road construction with a sick pet does not sound like any sort of good idea!

Holly said...

My heart was in my throat. Do you have any idea what a hero you are? If you don't, just take my word for it.

I have lots of friends who are dairy farmers so I know a little about eclampsia, tho they call it milk fever. Apparently this is pretty common among them. When I had my bitch bred, she had 4 very vigourous puppies and the vet who did the section warned me about it, including a list of symptoms to watch for and emphasized that if I had any inkling to *get her in quick*. That put me on edge a bit while they were still nursing.

For your second career, my suggestion would be AUTHOR!

Colleen said...

I was really on the edge of my seat on that one! I always like to hear your happy-ending stories.

AKDD said...

MM - well, thanks. That's me: cleaning litter boxes and saving lives. :-D And too right about the extra calcium gluconate. We rarely need it, but when we do, we need it NOW - and lots of it.

Penny, I'm so sorry to hear about your Sammy. I imagine that must have been very hard for you, and I'm sure it was hard for the vet as well; you always have so much flying through your head in such situations, taking in all the information you can and making every adjustment you have within your power, trying to pull it out. But we don't always win, no matter how good we are at what we do. Even doing everything perfectly is not a guarantee that it will go how we want. But sometimes the gods of medicine smile upon us and the patient walks away to fight another day.

Ellipsis, to answer your question about the next nearest option on call: we share our on-call between five hospitals scattered over two adjacent towns, and we rotate who is taking calls for all five. If you drew a circle around those five clinics, the next nearest clinic would be 20 miles from that circle; and the nearest after that about 30, and after that about 50 or 60. Depending on where the client originates, they may have even further to go. Anyway, I'm glad you enjoyed the story! It was fairly dramatic (at least for me!) while it was happening, let me tell you. :-p

Holly, you and MM are going to give me a swelled head! :-D (But that doesn't mean I don't sincerely - very sincerely -appreciate the kudos!) :-)

For some reason, my main reaction to the win is relief; I rarely feel heroic. I'm just glad I have a live patient and a happy client. I guess it's kind of like that jet pilot who landed the airliner in the Hudson. There's no doubt he saved many lives that day, but I kind of get what he meant when he said he was just doing his job. He was, and he did it well, to the everlasting gratitude of a gerat many people. OTOH, I think he deserves full credit that he kept his head and did what he was trained to do, and that he gave his judgement and his knowledge full rein, letting them control his actions instead of giving in to panic or fear. Heroism, though...? For me, at least, in the heat of the moment it just feels like digging in and doing my job. Not that I don't feel proud of myself later, if it goes right!

Milk fever is one reason I'm glad I'm not a dairy vet. It's actually a fair bit more common in dairy cattle than it is in dogs, due to the massive milk production they have. Just for fun, they also get something called grass tetany, which is a magnesium disturbance. At least I don't typically have to treat THAT amongst my patients!

Colleen, I'm glad you like the happy endings - I'm pretty into them myself! Evidently I'm an incurable optimist, because as a rule I gravitate more to these stories than the sad ones.... although there are plenty of those as well in vet med, unfortunately. Maybe that's why I wallow so in the wins!

MaskedMan said...

Well, few heros actually feel that they're heroes. Almost every last one of them feel that someone else is a hero; they were only doing what needed to be done.

I think, perhaps, the defining characteristic of a 'hero' is the courage to not surrender in the face of fear and doubt; to keep functioning effectively despite the terrible odds opposing.

So - Take a look in the mirror. If it fits, well, there you are. For the record, I think it does. :-)

Holly said...

AKDD, what do you think a hero is? Someone with a cape and a telephone booth? A true hero, in my eyes is the one who has the skills and training that can pull someone/something through when it's a true emergency.

that's you.

Dragon43 said...

And that is why you are going direct to heaven in your time.

They are so lucky in your area to have you........

Della said...

Definitely an edge of the seat story! I remember vividly how quickly a cow would recover when she got the calcium she needed. Like a miracle cure.

Black Jack's Carol said...

Absolutely fascinating to follow your thought process through this drama. Like others, I'm very thankful for the happy ending. Thanks for taking time to share your experiences so eloquently.

AKDD said...

Well... well, thanks, guys. That's really rather touching. It's a humbling experience being a vet, and it's another humbling experience (in a good way) to look at what I do for a minute through the eyes of others.

All I can say is - thanks.

Barb said...

Being a good writer AND a good vet are a dynamite combination!! This is just wonderful.

And about being a hero? I second what Holly said.

Barkley's World said...

Wow, this was a great story and a great ending - amazing. Which got me to thinking this would make for a great tv show - kind of a Vet friendly "Northern Exposure" I bet this is just one of a few great stories. Vets sometimes don't get enough recognition and our pets are just like family and deserve the best care also.

AKDD said...

Thanks, Barb and Barkley!

Hmmm... a veterinary Northern Exposure... Interesting thought.