"And, when you want something, the entire Universe conspires in helping you to achieve it." -The Alchemist, by Paulo Coehlo



Thursday, January 30, 2014

Tales from the Trenches: Veterinary ER Stories

I started this blog with the intention of also sharing stories from my job as a vet tech. Most people don't know what exactly a tech does unless they've been techs themselves. I have a pretty freaking awesome job, and I'm always meaning to write more about work but I'm always second-guessing myself when I do because there is a confidentiality and privacy issue; I don't want to say too much nor do I want to get in trouble. There have been several posts that I've published and then gone back and removed or completely re-vamped due to these non-disclosure rules. 

All that said, I am going to start a new series called Tales From the Trenches, which I hope to post randomly at least once a week. Patient names and problems will be changed to protect patient privacy, and I may change the patient's breed or species to further protect their privacy. The spirit of the story and the events which occur and the way in which doctors and techs handle the problem at hand will remain as they happened in real life. If I post photos from work, they will be of staff, as I am not allowed to post photos of patients on virtual media. If you see a photo of a patient of a cat or a dog on here, it is going to be a photo obtained from Google so as to help illustrate the story. I will explain things that I think you might not be familiar with. Most stories will be funny. Some will be sad. Some will just be great stories with a happy ending. There often will be sarcasm, as sarcasm and a big sense of humor are vital to surviving in any type of job that involves saving lives. 

Let us start!

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It snowed the other night while at work.

Usually things like polar vortexes and snow mean that people stay home with their pets. This night was the exception: it was unusually steady, especially after 10:00 pm, which is usually the time when things start to slow down.

We had one particularly memorable case, a 2 year old Great Dane mix named Odie that had been referred to our hospital by the client's regular vet to monitor for bloat. Bloat, aka GDV (gastric dilatation & volvulus) is a problem that is common in large breed dogs (and can also happen in horses!) and is a life-threatening emergency because it involves the stomach becoming full of air and flipping over on itself, effectively cutting off circulation to the stomach, liver, spleen and the entire hind end of the dog. It is either surgery or die. Symptoms are simple: non-productive retching, lethargy and a distended abdomen.

When Odie arrived with his owner in our lobby, he was bright, alert and bouncing around, almost pulling his owner to the ground as he tried to fill out his paperwork. The dog's abdomen was not distended, and he was not in danger of bloating at the moment; he was having bloody diarrhea and productive vomiting. He was panting excitedly when he arrived at our hospital. His regular vet had taken radiographs that showed a normal stomach with a moderate amount of air, most likely a result of his overzealous panting. His abdomen was normal on palpation but he was pretty dehydrated, which was confirmed with bloodwork.

Our intern who was overseeing the case recommended hospitalization and the owner agreed. So Odie got to spend the night with us.

He was one of those incredibly frustrating dogs that is large, strong, and goofy enough to have an uncanny ability for moving and doing things at exactly the worst possible moment.

Our intern wanted a blood pressure and an IV catheter placed so we could bolus Odie a large volume of IV fluids. Dehydrated patients can be tachycardic (have an accelerated heart rate) as a result of the thickened consistency of their blood: the heart has to work harder to pump that blood through the patient's veins. Odie's heart rate was almost 200 beats per minute on presentation; the normal heart rate of a dog his size is closer to 90!!

My coworker Janice and I decided to get the blood pressure first, as the stress of clipping the patient's leg, scrubbing and placing the IV catheter can cause enough anxiety to falsely elevate the blood pressure.

Obtaining a blood pressure on a dog, using a Doppler, a blood pressure cuff and a sphygnomanometer. (Bet you can't say that word quickly! I have coworkers that don't even bother. They just call it the "spaghettimometer" Hahaha...)
Odie did not like his paws touched. He did not like the sound of the Doppler. He did not like the cold ultrasound gel on his paw. Every time I started to hear his pulse through the Doppler, he'd yank his enormous paw out of my hand, despite Janice's awesome restraint skills and my firm hand around his toes. I'd have to start all over again trying to find his pulse with the Doppler so I could get his blood pressure. After the 5th attempt, Janice and I gave up and decided to just place his IV catheter.

Odie's IV placement was quite an ordeal in itself because of his uncanny ability for doing exactly the opposite of what you needed him to do at the worst possible time. I was able to get the catheter in his cephalic (front leg) vein, but then he somehow managed to remove the T-set (adapter for connecting an IV line to the IV catheter) with his other leg before I was able to tape it in. This involved a lot of gushing blood while trying to get Odie to hold still long enough to replace the T-set. Since we were sitting on the floor in the middle of the ER, I could not reach where we had our T-set stock up on the counter! Janice and I were able to get him to hold still long enough for us to occlude his vein with our hands and clean up his leg (you do NOT want blood smeared all over an IV catheter site, as blood is the perfect breeding ground for bacteria!), while one of the doctors passed me a fresh sterile T-set. Odie then kept randomly jerking his leg as I was trying to change the catheter tape, despite Janice's best efforts at holding him still. There is only so much you can do when the patient you are trying to restrain weighs more than you do!

Flushing a cephalic vein IV catheter on a dog.
The little cable-like looking thing attached to the IV is a T-set.

By this point, both Janice and I were laughing uncontrollably.

Then there was still the matter of obtaining Odie's blood pressure.

With a big sassy grin, I told our intern that based on how Odie's blood had gushed out through that 18 gauge IV, I determined his blood pressure to be 150. (This is a high normal value for a dog's systolic blood pressure. In veterinary, we just focus on the systolic pressure, and it is what we are able to obtain with the Doppler. If we have the patient connected to a multiparameter monitoring device, we'll focus on the Mean Arterial Pressure (MAP))

The intern laughed at me and said that, while she would gladly take my word for it, we still had to obtain a real blood pressure.

We started his fluids just letting him hang out in the middle of the ER. Since he was being a really good boy and just standing still, while Janice was squeezing the fluid bag (you can give a bolus on an IV fluid pump but the doctor wanted us to give almost a full liter as quickly as possible; it was faster to just squeeze the bag and let the fluids pour into him), I prepped a hind leg for Odie's blood pressure, thinking that maybe he'd be more tolerant of having this hind feet touched. (Some dogs really are better about their hind feet than their front feet.) The minute I put the Doppler probe to his foot, he kicked out like a horse and leaped forward. Janice ended up holding him for me while squeezing his fluid bag at the same time. Wouldn't you know: his blood pressure really was 150!

The intern high-fived me when I told her.

I got mad skillz yo. :D

Odie decided that that IV catheter in his leg sure looked yummy and tried to go for it with his teeth. "ODIE NO!!!" both Janice and I exclaimed. Thankfully, this was the one time he obeyed. Millie, the third tech working with us that night, grabbed an E-collar (aka Elizabethan collar, aka Cone of Shame) and slid it over Odie's head while Janice and I distracted him. Sorry Odie, we really don't want to have to go through that whole IV catheter ordeal again.

He now had a weapon on his head with which to knock us over like bowling pins.

Not Odie
His heart rate after his fluid bolus dropped to a much more normal rate of 120 beats per minute. Janice and I transferred Odie to our hospital's intermediate care ward and rounded the ward techs on him. Rounds include going over the patient's problem, symptoms, diagnostics run and treatments already performed, plan for the patient during his/her stay in the hospital, and a brief explanation of the patient's attitude and personality (if they get nippy about temperatures, if they need to be muzzled, diet preferences or restrictions, the best way to get that patient to calm down, any special handling required, etc.) We warned the ward techs that Odie had a knack for doing exactly the opposite of what you wanted him to do.

While rounding, he had been standing up in his run, head cocked, seeming to be listening attentively to everything we were saying about him. Katherine, the head ward tech, turned to Odie and told him, "Odie, you need to stand up."

Odie sat down.

Not Odie. But you get the idea!
The ward techs loved him. :)

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In the veterinary ER, we get cases in series. Example: we'll have weeks where on every shift we'll see at least one cat with a urinary obstruction. On another month, we'll get multiple hemoabdomens. For a week, we'll get emergency ear infections. There's always one specific problem that we will see in a series. It's weird. Sometimes it's borderline creepy, like the night where we had two different dogs come in that had run away from their homes. Both dogs had been found moments later with bites from another unknown animal; both dogs were brought into our ER minutes apart for laceration repairs. Both dogs each had a "cauliflower ear" (crinkly ear from a past ear hematoma.) Both dogs were from very different areas. Neither dog owner knew the other. That's just plain weird, guys.

This week, it was anemic cats. Of course, this had to happen when we had run out of cat blood for transfusions in our hospital.

Most specialty hospitals store canine and cat blood for possible transfusions. Most specialty hospitals will just order their blood from an animal blood bank. Some hospitals keep a couple of donors at the hospital. The canine blood donors of choice are greyhounds, as they naturally have a higher packed cell volume (PCV) than the average dog (this means they have more red cells circulating in their blood than the average dog.) The first specialty hospital I worked at had 5 greyhounds that lived at the hospital as blood donors.

My current hospital buys blood from the blood bank, but they also have the capacity to obtain and process blood from donors. We have a huge centrifuge for this purpose only (I could sit down in the centrifuge; it's that big!) , and all of the special equipment, blood bags, anticoagulants, and preservatives required for this job. The centrifuge is used to separate whole blood into units of packed RBCs (concentrated red cells) and plasma. (Plasma is the fluid portion of the blood; you can give a transfusion of just plasma to a patient with low blood proteins or one that needs coagulation factors.) Our donors don't live in the hospital; they are employee or client pets. Blood donors must meet certain health, weight and age criteria, and  have extensive blood work done once a year along with a very thorough physical exam to make sure everything is in order. They have another physical exam done at the time of donation - if anything is amiss, they are not donated. Donors must be absolutely 100% healthy animals.

Our centrifuge for donated blood looks very much like this one, except it's even bigger.

We have several techs that are specially trained to be able to prepare donated blood for storage. I have received this training but have not practiced it enough to feel confident donating an animal by myself and preparing the blood as required.

We had 3 anemic cats referred to us on this day that we had no cat blood, so we had to scramble to have employees bring their donor cats in for us to collect blood for transfusions.

Donor cats are always sedated for donation, as they must hold absolutely still while drawing that larger-than-average volume of blood. One of our main donor cats is named Peter. He is so feisty that his owner is unable to handle him when he is in the hospital. It is just fear on his part that makes him like this, so we try to get him sedated as quickly as possible because this often calms him down enough to actually make him a really nice cat to work with.

The day Peter was donated, he saved the life of an adorable young kitty who arrived at our hospital severely anemic.

Peter, however, let us know afterwards that he would gladly accept human sacrifices in exchange for his blood.

This really is Peter.
My coworkers Janice and Leah did this work of art in Peter's tribute with medical tape, and the photo was shared by all of us on Facebook. His owner loved it! (Unlike clients, employees at my hospital sign a waiver stating that photos of ourselves and our pets can be shared on the internet.)

The kitty felt so much better after her transfusion with Peter blood that she started channeling Peter himself. To everyone's relief, she was discharged to go home today. 





26 comments:

  1. Yay stories!! Bahaha lol at Peter's "kill zone"!

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    1. It was the comic relief of the day! Hahahaha...

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  2. I giggled a lot when I saw that photo on FB earlier this week. Cats...love them. Hate them. Live with them. Haha

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    1. I love cats so so so hard. They can be THE most challenging patients, but it makes it all the more rewarding when you turn into the single person they decide to trust during their hospital stay. :)

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  3. I kill you.

    Have you seen that video. So funny and exactly what I thought when I saw the photo on FB earlier.

    Pretty cool idea for sharing work stories. Can't wait to read another one. I think it takes a very big heart to be able to tend the sick and dying.

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    1. The video I ask about is one with two cats and a guy doing the voice over for the cats. An older black cat is introduced to a kitten. The last comment by the black cat is shot over his shoulder in a snarl, "I kill you." It's hilarious. And it's what I thought about when I saw the drawing on the floor.

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    2. Do you remember the name of the video? I haven't seen this one and I'd love to look it up! :)

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    3. This video is one of my all-time favorite cat videos. I never get tired of it! "An Engineers Guide to Cats"
      https://www.youtube.com/watch?v=mHXBL6bzAR4

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    4. I love that video! Especially where the cats just fall over in their costumes.

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  4. Great story! Brings back memories of when I was a tech, many, many years ago.

    I love Peter's tribute, too funny! The hospital I worked in kept donor animals, but (fortunately) our cats were all very sweet. They were mostly surrendered for urine marking issues. Our donor dogs were all Pitbulls, we were located outside Philadelphia so there were a lot of surrendered Pitbulls! We didn't store blood, but this was over a decade ago. A lot of things have changed since then, I'm sure!

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    1. I did some of my tech school rotations at hospitals that kept blood donor cats, and they were all very, very sweet too! It's so much easier for them if they think of the hospital as their home, not as a place where they go to be poked and prodded. And how wonderful that your hospital kept Pitbulls! Brilliant! In FL we had a lot of greyhound donors, and I know part of it was simply because the greyhound racing industry is huge down there: there are always retired greys looking for homes. We have several pitbulls in our current donor program. A lot of vets and techs at our hospital have pitties. :)

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  5. Yay! I love these stories! Can we ask questions? Not about the paitent, but more of a general sense.

    I am just wanting to know if dogs and cats have blood types, like humans, and if so do blood types need to match for reciving donations? Do they have a Rh factor?

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    1. Yes, questions are welcome! :) Cats and dogs do have blood types. Cats have three: A, B, and AB. A is found in maybe 85% of the population; we'll get type B cats, but they are much more rare and it is a type limited to certain breeds like British Shorthairs, Exotics and Cornish and Devon Rex. AB is extremely rare; I've never seen or heard of one in almost 7 years in the field. They are, however, universal recipients.

      There are 8 canine blood types which can potentially make canine transfusion medicine very complicated, but for transfusion purposes we focus mainly on blood type DEA 1.1 and its antigens: DEA 1.1+ and DEA 1.1-. DEA 1.1+ is the canine universal recipient; DEA 1.1- is the universal donor. I'd say the frequency of both types of blood in dogs is about 50/50, with DEA 1.1+ being slightly more common than DEA 1.1-. Being universal donors, we prefer to have negative type blood donors in our program, but we'll still accept positive type donors; there's always a couple of positive type blood units in our blood bank fridge. They will get used if a positive type canine patient needs a transfusion.

      This was a really cool question because I did not know what a Rh factor is, so I had to look it up. :)

      The Rh factor is unique to humans (and apparently the Rhesus monkey, the species where it was originally discovered). However, in cats and horses especially you can sometimes see an event very similar to Rh disease in humans. It is called neonatal isoerythrolysis.

      Type A cats have antibodies against type B blood and viceversa. These antibodies are always there; the individual cat does not need exposure to another cat's opposite blood type to mount an immune defense against that blood type. Type A is dominant, so if a type B female cat mates with a type A male cat, the kittens will be type A. The problem occurs when those kittens start to nurse: they obtain their mother's antibodies from her colostrum. Including the type A antibodies found in her blood. These antibodies start to destroy the red cells in the kittens' bodies. The best way to prevent this from happening is to blood type the cats in a breeding program. Otherwise, it can be prevented by keeping the kittens from drinking their mother's colostrum. They can be placed with a surrogate mother cat with type A blood or bottle fed for the first 12 to 24 hours after birth. After that time, colostrum production has stopped and they can be returned to their mother. What happens in horses is very similar to what happens in cats.

      As a very interesting side note, feline and equine blood have more in common than feline and canine blood. Canine blood shares several similarities to our own blood in both appearance under the microscope and behavior (lack of rouleaux formation, presence of area of central pallor in the red cells, etc.) I know several medical technicians in the human field that have found it easy to cross over into the animal lab field because of these similarities in ours and our dog's blood.

      I used to be so squeamish about blood before I started in this field, but I find it to be such a fascinating thing now!

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    2. Cool! It is very interesting that cats are more similar to horses then dogs. And that dogs have so many blood types.

      I never had a interest in blood until I was pregnant with my son and found out I am Rh- so I needed the rhogam shot to protect me from the babies antibodies in the event that it mixed during birth/trauma. Similar to the cats in a way, if I was to be sensitized and then our next baby was rh+, I would more then likely miscarry. Because my blood would attack the babies blood. There are ways, now, to carry a pregnancy with that situation, but the baby is not normally compleatly healthy at birth, mainly anemic. This is partly why so many women had miscarriages in the past, they where - (+ husband), got senstized by a + babies blood and then when got pregnant with another + baby...miscarried...over and over again until they got a - baby. Very interesting to me!

      My husband is O+, I am A-. The funny thing is, both my kids ended up O- (the blood banks will like them, like they like my double donation dad who is also O-). So I didn't really need the shot, to begin with, and didn't get the 2nd after birth since they test the baby before (you have 48 hours after birth to get it if needed). Is there something like that for cats to block antibodie production in the colostrum if knowen before birth? Although I guess it wouldn't be a common need. I believe 85% of humans are rh+, so similar rate to cats A blood type.

      Now I find blood pretty interesting! This was furthered because of some health problems I have been having and I went to a hematologist a couple times to rule things out. I also think the genetic component is cool because my kids both somehow got the recessive O (A would be dominent), and they got the recessive - (+ is dominent). So that means I am A(O)- and my husband must have some RH negitive stuff in his family. They have some blood disorders, so my kids will be tested for that as well. More fun with blood! Haha!

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  6. Love these! Sounds like an exciting job :)

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  7. Great post, and I am looking forward to more like it. It was like a modern day James Herriott story!

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    1. Thanks Judi! I love James Herriott; I'm tremendously flattered by your comment!

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  8. Keep these up! I enjoyed reading:)

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  9. The first clinic I worked at had three cats on site to be donors. ..But they all actually failed as donors and became purely clinic companions. My big kitty, Lizzie, has donated twice (once just a little to a couple kittens that didn't require sedation and once to an adult suffering flea anemia) and Savannah, my big dog, has done it a few times, too. Savannah didn't appreciate the process, but did appreciate the canned food afterwards. Ironically, her last donation was to a basset named Savannah right before we moved to Savannah.

    And I completely get the confidentiality thing. One of my friends, and the head ER vet tech at the hospital, was term'd for posting photos of a neuter repair we did.

    Because I saw so many bloats in ER ("Oh, vomiting and restless? Is he getting anything up when he vomits? No? What breed? BRING IN IMMEDIATELY!" while simultaneously paging the techs to prep.), I was excited to learn that the most recent clinic offered laparoscopic gastropexy. I've always been deathly afraid of bloat with Savannah - to the point that she has only ever eaten out of a "slow down" food dish and I restrict activity when the hammock is full.

    I'm living vicariously through you. :)

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    1. Yay for vicarious living! ;) That's really weird about Savannah's blood saving another dog named Savannah before you moved to Savannah. You could say that's another example of the odd series we get in ER.

      I'm always surprised veterinary surgeons don't do laparascopic procedures more often.

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  10. Oh, yippee! I am just tickled that you're doing this series. I love hearing "True Stories of the ER" for animals and absorbing all the medical details. You did a good job of keeping things confidential, too. Can't wait for more!

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    1. Haha I figured you in particular would enjoy these too! :D

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  11. I didn't know you were a tech too! I don't talk about my tech job much on here for the exact reasons you listed. LOVE your new series though :)

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  12. I have no idea if you'll see this response, but one of the reasons why I started reading your blog is because you're a tech. ;) Regarding me being a tech...it's on my bio on the blog's front page! Lol I went to school for this and am both licensed in VA and certified in FL. Been working as a critical care tech for almost 7 years now. :) I hope to complete my specialty in Emergency and Critical Care this year. These stories are my practice runs for the case studies I have to do for the specialty.

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