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



Wednesday, February 5, 2014

Tales From The Trenches: HBC

In most veterinary ERs you will find a large dry-erase board where expected emergencies are written down, along with patients currently being worked up, and if the ICU is part of the ER, hospitalized patients with their problem lists might be included on that board too.

Like in any other part of the medical field, we have acronyms to describe common problems: BDLD (big dog/little dog, referring to a dog fight), PTS (put to sleep), ADR (ain't doin' right, often used as a collective term for vague symptoms that could be anything, including the owner's Munchausen's), V+/D+ (vomiting & diarrhea), and HBC.

HBC = hit by car. This is one of those acronyms that carries with it all sorts of suspense and dread because you really never know in what condition these patients are going to arrive. We've had HBC dogs come into the lobby bouncing at the end of their leash with a tiny scrape on an elbow, while we've had others that we've had to wheel into the hospital on a gurney at a dead run so we can immediately initiate CPR. (Yup, just like something out of a Grey's Anatomy episode. We do that too.)

The worst ones are the ones that arrive bouncing at the end of that leash, high on adrenaline, and then wind up crashing 30 minutes later when the adrenaline wears off and they go into shock. For example, the spleen is a wonderful organ. When there is acute (sudden) hemorrhage somewhere in the body, the spleen will contract in an effort to grab as much blood as it can to protect the body. It can only do this for so long. If the hemorrhage continues, the spleen has to let go of the blood it has been holding, and that's when the patient will start to really show he's in trouble as his blood volume continues to drop.

Sometimes the triage tech will catch these kinds of cases in time: on presentation they will have something like an inordinately high heart rate or increased respiratory effort or rapidly paling gums. But sometimes even on physical exam they will seem normal initially, before their body starts to decompensate. Sometimes the patient looks so stable that the client declines diagnostics and takes the dog home, only to bring it back a week later half dead from sepsis.

You really never know what to expect.

Thus, when "HBC" gets written on our board, we prepare for the worst: the crash cart is moved over next to the ER table, we'll set up for an IV catheter placement, and have fluids ready to go.

Typical veterinary ER/ICU chaos during a busy shift
(not my hospital)
Last night, "HBC" got written on the board after the patient had arrived. She was a large overweight Lab; my coworker Millie triaged her while I was working on another critical patient. After a thorough physical exam, it was confirmed that the Lab was perfectly fine. She was never even brought back into the ER, which I thought was odd. I was so involved with my case that I didn't get to hear her full story until after she had left, when her name was erased from our board. I asked her doctor what had happened. The doctor laughed in relief, saying, "She was fine! She hit the car, not viceversa." The car had been at a standstill when the Lab had slammed full-force into it while trying to catch a ball!

This reminded me of another case that I participated in many, many moons ago, back when I was just starting tech school.

It was the first 24-hour specialty hospital I'd ever worked at. During the week, I worked a mid-shift or "swing shift" similar to what I work now - going into work in the afternoon and leaving between midnight and 2:00 am - which was perfect for my class schedule, and pulling an additional full overnight shift on Saturday evenings. That overnight was a killer, but it was also the shift where I learned the most and where we saw the most interesting cases.

On one of these Saturdays in the middle of the night, we had a client bring in their bull terrier. He had escaped his collar and run into the street, where he'd been hit by a car.

You know the Tonka trucks?


In the '80's they had a popular commercial where they showed a full-size truck falling down a rocky cliff and breaking into smithereens at the bottom. They then showed the Tonka truck falling down the same cliff and making it in one piece. Like most little boys (and some girls - I was one of them...) growing up in the '80's, Charles had one of these trucks. He saw that commercial (you can watch it here!) and decided to test it out.

He dropped the truck from the balcony of his parents' 10th floor apartment.

The truck landed on the sidewalk below.

The thing actually survived the impact. (Thankfully, no one was walking by at that point, or they certainly would not have survived the plummeting metal toy truck!)

The commercials were true. Those trucks really were indestructible.

Well, bull terriers are the Tonka trucks of the canine world.

"I am indestructible!"
This patient's owner described his dog getting hit on the side and rolling across the asphalt...right under the car. There was a question about whether one of the car's tires had literally gone over the dog. We were expecting the worst.

That dog, whom I shall call Buddy, strutted into our ER wagging his tail, completely calm and relaxed, with some dirt and black scuff marks on his white fur. One of his ears had been partially torn off at the base but other than that, he was unscathed. Radiographs of his chest and abdomen were clean, and his bloodwork was completely normal. It was nothing short of a miracle.

All we had to do was fix his ear.

His dad had been able to do all of the recommended diagnostics to make sure that his dog was okay. However, by the time all was said and done, he could not afford much else. He wanted Buddy's ear repaired, but he asked that it be done without sedation or a local anesthetic to save money. I winced when the intern in charge of his case told me what we were going to do. Guess who would be holding the bull terrier for this procedure? Moi, of course.

The laceration was about 2" long, a clean, straight cut partially severing the ear from the bull terrier's head. Buddy had been absolutely fantastic for everything we'd done so far, but what we were about to do next was going to be painful. We muzzled him for our own protection, just in case; we couldn't foresee how much or how little this would hurt. We clipped and cleaned the area round the laceration to remove all the hair and dry blood prior to repairing it. Buddy was absolutely fine with all of this, requiring no restraint whatsoever.

The intern chose surgical staples to re-attach the lacerated portion of ear. Much quicker than sutures.

I held Buddy by hugging him to steady his head so the intern could do her job.

Basic head restraint of a dog. You do not put pressure on the throat. (This was sadly the best photo I could find; this example could be made even better if the tech aligned her forearm with the dog's lower jaw; this way you guarantee that you won't put accidental pressure on the throat if the dog struggles.) The sole purpose of this type of restraint is to keep the dog from turning his head. You can steady him further by placing your cheek against the top of his head, which a lot of dogs actually like because it's very similar to being hugged by a loved one.
4 staples and less than 5 minutes later, we were done.

That dog didn't even flinch throughout the whole procedure! We promptly removed his muzzle as soon as that last staple was in, and he received tons of pets and "Good boy"s from our team for being such a brave man. He grinned and happily wagged his tail at us.

He was the first bull terrier patient I'd ever worked with. Afterwards, the other more experienced techs on our team were commenting on the stoic, solid nature of bull terriers. Katie, our senior tech, said, "They are like tanks! I'm sure the car that hit Buddy sustained a lot more damage than Buddy himself. That car probably has a big ole dent in the front."

We imagined the car being taken to the mechanic the next day. Problem? "HBD" 

Hit by dog!












10 comments:

  1. I've been patiently awaiting this next installment!

    What an awesome dog...staples without sedation makes me cringe just thinking about it...

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    1. Me too!!

      I'm glad everyone is liking this series so much! I guess I should have started it sooner! :D

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  2. I once got stitches in my face without a local. The trauma to the location does limit the amount of pain the stitches cause, that said, however, it's still not a pleasant thing.

    I love hearing about your work. Great series.

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    1. Oh lord. I don't take local anesthetics well - for whatever reason, they wear off SUPER fast. The two times I've had sutures taken on my face, the local wore off and the doctor just decided to finish without re-blocking. It was faster. OW that hurt!!! I felt so for this dog! He was such a trooper! It's been almost 7 years since I met him, and I still remember him.

      I never cease to be amazed by how much dogs and cats cooperate with the stuff we have to do to them. We can't explain to them, "This is just going to hurt for a second and that will be it." Or, "I just need you to hold really still on your back so we can take this x-ray; just one 'beep' and you're done!" They don't know when it's going to end nor what's coming next. They are in the moment, and sometimes that moment is awful. If I were them, I would be such a *horrible* patient. The hardest thing for me to learn was to get blood from their jugular vein. It's a large vein and is very easy to find on dogs, which makes the process so much faster when you have to pull a larger amount of blood. Dogs tend to be really good about it. It was a good two years before I stopped flinching every time I got a blood sample from a jug. If someone came at me with a needle intending to stick it in my neck, I'd be crawling up a wall trying to get away from them...

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  3. I knew what would happen as soon as you said it was a bully -- they are such accommodating critters. :) HBD is hilarious!

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    1. I LOVE all bullies! They are my absolute favorites! Especially the pitties and the bull terriers. They tend to be the best patients and the most fun to work with. We had a young pittie mix last night that came in with some horrible cardiac arrythmias. We had to rig him up with a telemetry pack for a constant EKG and he tried to eat his IV, which meant giving him a Cone of Shame. He sat when we asked him to and tried to give us kisses when we leaned in close to him. He received lots of kisses in return. He was practically smiling. Best. Dog. Ever.

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  4. OMG, I have SO much to say about this post... bear with me! Where should I start, hmm.

    I well-remember using HBC, PTS and V/D on the cage cards at the vet hospital where I worked, but I've never heard ADR before. That's a riot! Very "country" of you guys.

    My two younger brothers had a fleet of Tonka vehicles and believe it or not, one of them was somewhat responsible for ME needing stitches! :) I leapt over their crane on the way to the kitchen to turn off an oven timer (being a crazy horse nut/rider, I was always jumping over stuff instead of going around it), and my foot got caught on the rigging strings. I went crashing down and my knee landed on the edge of the sheet metal tray underneath our guinea pig cage. His cage had wire sides and the tray was there to catch stray shavings. Split my knee wide open, requiring three or four stitches.

    Oddly, I don't recall ever seeing that Tonka commercial. I do know that I was bitterly disappointed when I went to buy my son a Tonka and discovered they are now made out of plastic. What?? No painted metal, that rusted when left outdoors (as my brothers frequently learned)? It was just as well because my little guy was much more interested in fire engines than construction vehicles and never played much with the dump truck I bought him.

    Bull terriers: yes, definitely some unusual dogs! I had never so much as seen one (never had one appear in any vet hospital I worked at in NJ) until I met one that belonged to a friend. She told us how after his neuter, he was so incredibly determined to get to THAT AREA with his tongue, despite his e-collar, that he circled and circled and circled until he literally wore his foot pads down until they bled on one side. Apparently they just Do. Not. Stop. when they are fixated on something. I also loved how when Bob stretched out on his side, his upper legs stuck straight out. I guess they're just so muscular they don't "flop" like a normal dog! He was quite a character and while I don't think I'd want to own one, they are really neat animals.

    Stitches without anesthesia: Yup, BTDT. It was after the birth of Child 1. The epidural had worn off and nobody realized that until they went to repair my episiotomy and I could feel the needle going in and thread being pulled tight. Uh, yeah, ya might want to hit me with something Down There, folks, before you start with the suturing! Yikes.

    On the other hand, I have suffered through four or five biopsies on my face now for potential skin cancer. I can't tell you how much I HATE/LOATHE/DREAD Lidocaine needles in the face. They suck so bad, in fact, that I keep saying I'm going to just tell the doc to slice/punch away without anaesthetic the next time. The worst one ever was in the tip of my nose. DAMN! One of the biopsies turned out to Basal Cell, so I had to go back in for surgery, done with about four Lido shots. Good times.

    So maybe your Bully there wasn't missing anything getting his ear stapled sans Lido... ;) Although, I have to say I'm a bit shocked that the owner cheaped out on a lousy shot of local. It would hardly have been the most expensive thing on his bill. I guess he had faith that his tough-as-nails doggie could handle it!

    Having said that, when I was in 4th grade I was trying to load staples into a stapler and accidentally stapled my thumb, right on the pad. I remember exactly how much that hurt. Accordingly I do think I feel pretty bad for the dog!







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    1. I loved reading your stories! Bull terriers really don't stop. I love them, but like you said, I could never own one! They are terrible at getting into trouble, and I've met some that had some truly OCD behaviors that were impossible to curb. I have friends who endured episiotomies with no lidocaine...I can't imagine. Owwwww.... And totally hear ya on lidocaine injections to the face. I had my forehead split open by a previous horse's shoe (long story), requiring 6 stitches (I currently have a Harry Potter scar, seriously). It took a couple of lidocaine shots to finish it. I still think I prefer the sting of the lidocaine to the sensation of that suture needle poking skin that already hurts and the suture pulling through though!

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  5. Wait - I wasn't done! I forgot that I was going to tell you the last time I took my doggie in, they had to draw blood and they did it in the jugular. Eeek! They've never done that before so it was a slight shock to me. I found out in a hurry why they had wanted to take her in the back instead of doing it in the exam room. Apparently she has very "rolly" veins on her arms so this is just easier for them... she wanted no part of going in the back so they let me hold her, knowing I wouldn't be horrified like other owners might be. But they didn't TELL me what they had planned, they just did it so I was kinda like, "OH. Well, I wish I'd known..." Anyway, this has reminded me that I need to schedule her in this week for a thyroid re-check, so thanks!

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    1. I hate doing jugular blood draws in front of pet owners. I know exactly what will go through their heads if they are not familiar with this: "You're going to draw blood from WHERE?" I was horrified when I had to learn this skill. I actually have a story in my drafts about jugular blood draws and how hard it was for me to learn because I just kept imagining that needle going into my own neck. Surprisingly the vast majority of dogs are MUCH more tolerant of jug sticks than having their leg veins poked. Can't say the same for cats, though. I'd personally much rather use a hind leg vein for blood draws on kitties than their jugulars; their necks are so short, they are so sensitive, and I've seen some of them react exactly as you'd expect to having a needle in their neck. I can't fault them for that. :/

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