Sunday, November 15, 2009

Juggling Chainsaws

Saturdays can be a challenge for me.

For one thing, I am the solo doc that day, so there's not much in the way of backup. For another, lots of people want to get in on Saturdays, since most people have that day off. We're typically booked solid two or more days in advance. Moreover, it's a short day, so if emergent cases happen, we have only so much space to cram the extras in between the already-scheduled appointments. And, to cap it all, many people tend to sleep in a little on Saturdays, so they don't notice there IS an emergent case until, say, 11:00, when we are three hours from closing, and usually already overloaded with other must-be-seen-today cases who ALSO just got up and noticed that giant abscess on their dog's head.

Mind you, I have some advantages on Saturday. For one thing, I have the mighty SS manning the phones. SS has been in the biz for over 30 years and has worked with me for 14. She has a deep seated, near-mystical sense of the rhythm of a heavy case day, and knows how I work and where she can slip in an extra case - or two or three or eight. She knows - if it's an abscess, or porcupine quills, or a laceration - that unless the owner is insistent on seeing the doctor, she can just make an estimate, get the paperwork signed, and admit the animal, saving me a few minutes in the exam room whilst I juggle other cases. For another, while she is not a doctor, she IS extremely knowledgeable about animal medicine in general, and can often assess over the phone how immediately the animal needs to be seen (and, if she is ever in doubt, the answer to that is always "today".)

SS is backed up by KD, not so experienced yet, but smart and capable and willing to dive in and hold animals for blood draws or sedation if my tech is tied up and we are slammed. My tech is JD, who is new to the Saturday gig but who is catching the rhythm of it now and who is prone to popping up and saying things like "I can run that ear swab for you" or "There's a urinalysis on the microscope for you when you have time" (having already done the dipstick, spun it down, and stained it and put it on a slide for me.) Between the four of us we can usually shoulder a schedule that is at times double- and triple-booked, without compromising patient care. SS is adept at feeling where that break-point is and reining things in just short of that point - although I will say it is not always possible to hold back that tide, and sometimes all hell breaks loose.

This Saturday was a case in point. I saw 24 patients before we closed, 22 of whom I saw in five hours. A small number of them were (most fortunately) short appointments - rabies boosters, for instance, when the animal had had a recent physical, no new issues, and only needed the shot. But most were medicine cases: arthritic pets, sick ones, injured ones, complicated ones with intricate histories. Cases which required workup of various kinds: blood work, X-rays, cytology, aspirates... or else things that needed estimates for workup, or both. Meanwhile, SS has with her one of her Schipperkes, Wicca, a pregnant bitch who is showing signs that she is about to go into labor. Luckily, Wicca is content to stay behind the front desk under SS's watchful eye.

Still, even though I kind of felt like I was juggling chainsaws, we were keeping up with it by means of judicious delegation and stacking cases so that while that X-ray is developing I can get an ear swab which JD will stain and slap on the 'scope for me, and while she does that I can go do that second puppy booster while KD weighs the three adorable Pom puppies for me.

Eventually, though, the overflow starts. I check in three cases in short order that require procedures today - as in, ASAP, most especially in one case, a cat so rocky that even taking the extremely necessary chest film constitutes a life-threatening risk. Right about then we get a call about a vomiting dog which might have swallowed a bone and have a GI obstruction. But he's also had some rich food, so maybe it's pacreatitis, or it could be a virus.

"We can have a look and get an X-ray if the doctor thinks it needs one," SS tells the client, "but if it needs surgery, she may have to refer you. She already has three emergencies ahead of you, and she's double-booked for the rest of the day - except where she's triple-booked." The owners still want to see us - they like us, and don't want to go elsewhere, and they are, of course, hoping that surgery is not going to be needed. Okay, then. Come on down, and we'll work you in whenever we can.

It's over 30 minutes before I can see the dog, 100# of plump black husky who is petrified of our floors and highly unwilling to walk anywhere. JD and I manage to coax him to the back to radiology. We look at each other. The dog is crouched at our feet, all toes clenched against the terrors of linoleum. From experience, we all know that a dog who is this afraid of the floors is somehow magically able to magnify its weight at least 30% when we go to pick it up. I'm not sure how this alchemy takes place; it is as if their fear has a gravity of its own, drawing the dog irresistibly toward the core of the earth.

"Ready?" I ask JD, grinning as I realise that we're both instinctively hyperventilating, trying to pop a little extra oxygen into the bloodstream against the hold-your-breath, grunt-and-heave effort of getting the dog onto the X-ray table.

"Ready," she says, and we squat, scoop and stand, at least one of us cursing breathlessly as the dog grabs the table edge with his clenched toes and shoves hard, trying to return to the floor (which, while scary, is evidently less frightening than the X-ray Table of Death.) We soothe and praise and ease the dog onto his side, into position for the film. The one advantage of his trepidation is that he holds his legs as rigid as steel, so that once he is in position he lies statue-still so we can get our shot. Back to the room with him while I go see the three adorable Pom puppies, who are also hilarious. The black one keeps abruptly disappearing by dropping to all fours inside her blanket-lined box while her siblings stand on their hind legs, wagging and smiling and trying to lick me. Then she pops back up just as suddenly, an adorable jack-in-the-box move rendered even more charming by her sparkling eyes and happy grin - not to mention her wiggly attempts to climb out of the box to give me a kiss. I can't decide if she's doing this because she thinks it's funny - and we obviously do, too, praising her each time with laughter and petting - or if she's searching for cookie crumbs and, finding none, pokes her little noggin up in hopes of being handed a treat. Either way, it's a completely delightful respite from the intensity of the day, and even though I'm doing exams and vaccines the entire time, it feels like a small vacation.

Ah, well. The chainsaws await more juggling. Better get to it.

I snag my film out of the developer and hold it up, not bothering with the X-ray box yet - and there is no need to, as it's a quick and easy diagnosis: the dog has swallowed a rock. Great. Surgery #4 just walked through our doors. I calculate quickly: By the time I am done with the other procedures - all of which will have to go before this one - I won't be getting to it til about 4 p.m. at best, at which time my staff will have worked for 10 hours. By the time we're done with surgery and clean-up, that'll be more like 12 or 13. But the owners don't want to see another hospital.

Okay. Time to punt.

SS calls Drs. S and G to see if one of them wants to come in and cut the rock dog, which can be done while I finish up appointments, clearing the decks for the other three procedures. Those will still not even be started til after we close, but that will most likely put most of the staff out of the hospital after only 9 hours, and me out an hour or so later. That's manageable.... if one of them can come in to cut, that is.

Hallelujah. God smiles. They can BOTH come in - and they do, Dr G. tech'ing for his wife while she cuts - and bless them for coming in on their day off to bail us out. Meanwhile I finish my appointments and give JD an order of operations for the remaining procedures so that she can set up. By the time we send the last client out the door, Dr. S has the rock out and is closing. JD has an X-ray plate in and drugs drawn up for our anaesthetise-and-X-ray, could-be-broken-leg puppy. The pup had been trying to counter-surf and had gotten injured in the attempt, screaming and refusing to bear weight on the right hind leg thereafter. JD and I put that one on while Drs. G and S heave the sleeping rock dog onto a stretcher and take him to his run. JD develops my film while I set up the drugs for the next case. I go have a look at the film: a long oblique fracture of the tibia, and two green-stick fractures of the fibula. Well, it could be much worse: there's a reasonable chance that this can heal with a splint, although surgery would be more ideal. I call the owner, who declines surgery; she'd rather do the splint, given reasonably good odds of success and the approximately $1000 difference in cost between that and surgery. Okay, then. We'll give that a try, and hold surgical options in our back pocket as our bail-out position in case the splint fails.

The leg in question is between splint sizes, but the splints are designed to be cut down to adjust the size. I get to work trimming down a splint, which would be easier if our hack saw blade was even a little sharper. I have the feeling that a tongue depressor would work about as fast, but I persist. Meanwhile Drs. S and G have extubated the rock dog and are now - bless them - cleaning up the surgery table and entering the charges in the computer. About the time I have at last finished strapping the fractured puppy into its splint, Dr. S asks me if she can enter MY charts into the computer and get the meds up for me while her husband industriously scrubs surgical instruments. Well, yes, thanks, if you aren't in a hurry to go home. That would be just lovely. I'll just hoik this giant abscess attached to the bloodhound onto the table - nope, Dr. G is there first, and bends his muscular frame to the task without being asked. And lo and behold, there is Dr. S, shaving a spot for me to lance while I get my instruments ready. Well. That was easy.

The abscess is easy, too, and deeply satisfying. A large volume of rank red pus is soon in the bottom of the sink instead of under the dog's hide, and that's just as it should be. One injection of antibiotics later and the dog is snoring happily in his run, his giant noggin now only slightly larger than the original instructions said it should be. True, he is draining a bit from his incision, which isn't terribly aesthetically appealing, but IS an excellent and necessary component of abscess repair. We'll take it. Drs. S and G admire this happy outcome before departing. SS is close on their heels, as Wicca has started labor, and SS knows she'll do better in the comfortable surroundings of home.

Now on to the thoracocentesis cat. This it the rocky kitty, brought in for respiratory problems and weight loss. On physical I could only hear airways about half of the way down his chest. He's a bit fractious about restraint, and the instant he objects we let him up, because the slightest struggle turns him blue and makes him gape, panting with his mouth open. His X-rays show a large volume of fluid inside his chest, compressing his lungs into approximately 20% of their intended size. He has marked abdominal effort with his breathing - a restrictive pattern, which I have discussed with the owners during the physical exam. Despite this, he purrs nearly incessantly, rubbing his head affectionately against his owners, me , his carrier, my tech, my pen as I try to write in his chart, and his cage wall once we have stashed him in-hospital.

This cat is unlikely to tolerate anesthesia well; he's 13 years old, thin, and his respiratory system is very compromised. Fortunately, most cats will tolerate a chest tap while awake, because it provides nearly instantaneous relief from their respiratory distress. Even so, this is a tricky gig. If you should be careless with your needle, you can lacerate the delicate membranes of the lungs, creating a pneumothorax and an entirely new life-threatening problem to stack on top of the old one. There is an art to correct placement of the needle, and to feeling delicately with the tip of it when the lungs are expanding to the point where they are at risk of laceration.

The easiest way is to have three people: One to hold the cat, one to hold the butterfly catheter in place and draw the fluid off with a giant syringe, and one to operate the three-way stopcock that allows you, with the turn of a lever, to squirt the fluid out into a bowl, rather than back into the cat, all without having to move your needle. However, with two people you can manage, assuming reasonable dexterity and a cooperative patient - and two people is all we have now, as the rest of the staff has gone home (late, but without complaint, and not before making sure we've got things under control).

This kitty isn't best pleased with being restrained even a little, but consents to have me shave and surgically prep his sides with minimal struggle. He even allows me to pop my butterfly needle into his chest without more than a little protest. Once I begin drawing fluid off his chest he's a little happier, almost as if he's thinking: Hmmm. This might be a good idea, this whole needle thing. After we are 180 milliliters to the good, he pinks up a little, essaying a deeper breath now. I have my needle angled steeply down toward his sternum, as far away as I can get it from his gratefully expanding lung tissue. Still, I am feeling for the delicate grating tick of lung tissue across the tip of the needle; this, or blood, are both warnings to stop now.

Suddenly I feel a vibration in my left hand, the one holding the butterfly in place. My heart takes a leap; this is a much coarser, harder vibrato than the usual delicate tremor that warns me to back my needle out right this instant. It takes me a half a second - and my needle halfway out - before I realise that it's not the shudder of a torn lung I'm feeling: My patient is purring. Bless his pointy little heart. This is the sweetest cat I've seen all week, purring and bumping his head affectionately against JD while we hold him still and stick a needle in his chest.

Still, the better he feels, the less inclined he is to sit around while I re-inflate his lungs. He still can't tolerate much respiratory stress, and when I try tapping his left side I get blood right away, which means I have to stop this instant. I take him back to his cage; we've gotten 400 mls of a clear, light-golden fluid off his chest, and he feels lots better now. Unfortunately, it's likely he will recur with this problem within a week. The owners, who are stretching their resources to manage what we've done so far, elect not to go after further workup today, but instead to treat as best we can and watch for results.

I send JD home after her long efforts today, telling her to pray I don't have to section Wicca. She gives me a thumbs-up. Shortly thereafter I release the cat, now getting briskly to his feet and pacing his cage, mrrowing happily, to his owners. The other two cases have their releases scheduled and I am sitting down for the first time all day, calling owners with blood work results. I have stashed the clinic's on-call cell in my bag in case SS needs help with Wicca, but as it turns out, that was an unnecessary precaution - because I am still at the clinic when SS calls me to tell me Wicca has had a gestational sac bulging at her vulva for 45 minutes and isn't progressing. SS will try one injection of oxytocin to see if she can get Wicca going, but if not, I tell her, come back: I'm still at the clinic. Better now than after I go home.

I release my abscess dog and drink a little eggnog and a lot of water. My back has been hurting all day, and since noon I've been feeling slightly flu-ish, just a hint shaky and cold. Both the water and the eggnog help. I'm still a little bit off, but I can feel a little energy, a little heat, trickling through my veins. It hasn't helped that we've been hellishly busy all day, with no time to eat or drink or sit down, nor that everyone in the clinic seems to have been down with one virus or another for the last 3 weeks - except me, for which Hygiea (or whatever deity is in charge of virus resistance) be thanked. Hey, maybe it's the Kefir. You never know.

SS calls me back about then; Wicca hasn't responded to the oxytocin, and they'll be back in 20 minutes. Okay, then. Thank God I had eggnog at the clinic.

On the heels of that call, in comes my fractured puppy owners. Perfect. I'll get my last release done before SS is in with her laboring Schipp. In fact, SS is back just before that, and she calls Em, our head tech, who (bless her, now, too) agrees to zoom on in and tech for me as I cut Wicca. Meanwhile Wicca wails and squeals piteously at every contraction, and immediately stops pushing. She does extrude a little more membrane, but even with pressure on her belly and traction on the membranes, I can't shift the puppy. I can, however, tear the membranes - dang it - which takes the choice off the table: we're going to C-section land now.

Em has Wicca induced and intubated in no time. I am shaving Wicca's enormously distended belly while Em sets a catheter; as soon as she has it taped in, she takes over shaving and I scrub in.

The trick with C-sections is to get the puppies out as fast as possible. Accordingly, as soon as the bulging dome of Wicca's belly is draped in, I make a long, swift incision. Because SS keeps her dogs trim, there is little subcutaneous fat, and a small miracle occurs: Wicca has a gorgeous linea alba, the thin tendinous band that connects the two sides of the belly muscles to each other down the midline of the dog. This is the best place to cut, as it doesn't bleed and it heals strongly, and Wicca has provided me a lovely one. I am though it in seconds, exteriorising her enormous uterus not more than 5 minutes after she was induced. It takes no more than 90 seconds to get three puppies out of the first uterine horn. I can see the strong pink muscle contracting already, a good sign, as it minimizes bleeding. It's the work of another minute to get the last two pups out of the other horn, and now I can suture the uterus up. I can go a little slower now, but I'm still going as fast as I can and still do it right: I want the bitch awake as fast as possible too, so she can recover from her anesthetic enough to try to care for her babies.

I am not through suturing the first uterine horn before I hear the first warbling cries of the pup that was stuck in the birth canal. I take a deep breath, feeling the tension drain out of my shoulders. That was the pup I was worried about, the one whose membranes I tore. I was concerned about having abrupted the placenta, diconnecting the pup from his oxygen supply, but he is wailing lustily away. I am smiling a little as I surure the other horn, checking my inverting patterns, looking for bleeding. Wicca's uterus is contracting beautifully, firm and pink under my gloved fingers. I am humming a little as I start in on her linea.

SS and Em have all the puppies singing now, three boys and two girls, as I set my skin sutures. It's been a reasonably fast C-section, maybe 30 minutes skin to skin. I barely have my sharps off the surgery tray before Em is bustling into surgery, collecting my drape and gown. I scrub out, draping a towel over Wicca's much-deflated frame. I am starting to feel slightly hollow, hungry and tired as I am. But I am also feeling warm and relaxed, becuase we managed, somehow, to get everything done today - everything and then some - and lost not a single patient. There are five chubby, vigorous Schipps and a live, healthy bitch all stirring drowsily under their blankets, and I can't resist stroking the fine glossy coats of the new babies. There's something luxurious about this, this little pause to savor the fruits of all our labors, while around me bustle SS and Em, cleaning up. I wallow a little in the warm pleasure of new life, smiling to myself. Besides, I'm leaving the hospital only a little more than 11 hours after I got there. If not for Dr. S and Dr. G, that would have been a lot more like 14 or 15. I'm feeling pretty lucky, right about now.

Days like this, it doesn't matter how many chainsaws you have to juggle: Totally worth it.


Dragon43 said...

A wonderful day... Just hope you don't have that particular kind very often. Too much of a good thing and all that. LOL

AKDD said...

Snerk! It WAS too much of a good thing, in its way... although all's well that ends well and all that. At least there's that "good thing" part and not just that "too much" part!

Holly said...

as I began to read this post ...this little bit caught my eye: "if emergent cases happen"

If?! When is more likely than if, in your bitness isn't it?

I remember the joy of hearing puppies squeak and cry in their warming box after a section. Vigorous healthy babies are a tonic to soothe a long day aren't they? There is nothing quite so soft, quite so sweet as a newborn animal that hasn't had time to grind dirt into their coats yet. Almost like soft, plush animals...but better!

Handhills Border Collies said...

Love your blog, just discovered it, its fabulous reading.I am from Alaska as well......

MaskedMan said...

Ah, but for days like that, you'd never properly appreciate the routine weekday loads... ;-)

Barb said...

Oh man, does this bring back memories!! Like getting in the car to drive home after a 10 or 12 hour day and realizing that it is the first chance you've had to sit down all day. My record (I was a tech, not a vet) was staying till 4 am helping with a tricky colic surgery on a horse. And then having to be back at work at 7:30 that same morning. The horse lived and it was SO worth it!!
Although I sure couldn't do that now...

Poquita95 said...

I printed out your 11/16 post to share with my DVM owner who was today expressing frustration about HIS 11/16 "disaster Saturday." I teased him to put it in perspective. *grin*

Thank you so much for sharing your experiences. It's so nice to read about your adventures. I am an RVT and now manage a veterinary clinic, which has unfortunately taken me away from the medicine. :( I live somewhat vicariously through your writings ... LOL! Keep it up! :)

amyinbc said...

As an animal lover and one owned by two of them I really enjoy reading of your adventures as a vet.

So interesting to read of your life and what extraordinary things you do.

samuel said...

We just discovered your website and blog. And we would love to add a link on our website. Would that be ok? You can see the company you would be keeping at:

From Samuel.

AKDD said...

Holly: Fair point. It pretty much IS "when", not "if". And too true about babies... there's something about the inert, warm weight of them, bursting with vitality yet somehow contained inside that small, plump, somnolent package... very satisfying. An hour holding a newborn anything is way better than a whole pharmacy full of antidepressants.

MM: Fair point to you, too. It does make a regular day seem kind of smooth and easy by contrast... plus, when you finish a day like that, there's real satisfaction in looking back at it, seeing what you got done. You may be completely beset in the midst of it, but when you're done... Ahhhh. That was good.

Handhills, welcome aboard! Where in AK are you?

Barb - thanks for reminding me why I elected not to do equine medicine! I well remember getting called in as a student for colic surgeries in the wee hours. Somehow, getting out of bed at 4 a.m. and 40 below zero to go shiver in a frigid barn to attend a colic horse in Alaska in January JUST didn't seem like fun. But I applaud you - and all who, like you, have sacrificed their own rest to go to the aid of one in need. That is walking on the side of the Angels.

Poquita, I'm glad your DVM has a sense of humor! That'll spare him and you and everyone around you a lot of wear and tear. ANd thanks for telling me he had a disaster day, too... it's kind of soothing in a way knowing that there are others out there in the trenches, fighting their own good fights. It makes me feel less beset to be reminded that it isn't just ME who is being innundated, but that there are others, too, who are holding up their end of the bargain.

Amy, glad you're enjoying the blog (is the "bc" part of your name for Brittish Columbia? That's some pretty country....)

Samuel, by all means, link away. And BTW, may I say: What an ADORABLE little dog! I love the photo of the leaf litter all over that pristine white coat, while those little shiny brown eyes look up with a combination of innocence and mischief.

samuel said...

Thank you! Samuel just added the link to your blog on his website:

baseball1637 said...

As always... loved it.