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

Wednesday, February 12, 2014

Tales From The Trenches: Repeat Offender

In Florida there is a decorative plant called sago palm that is very common in home gardens. It is a tough plant that is beautiful and is easy to care for. It looks like this:

This palm has a center where you can find its seeds or nuts:

The nuts look like this when pulled out of the plant:

Most of you are familiar with dogs's incredible ability for eating things that you would never in a million years expect them to eat. If you don't believe me, check out the following examples. These are all canine abdominal radiograph examples taken off of Google; I have seen enough weird items in dog stomachs to believe ALL of them!:

Yes, that's a rubber ducky. I wonder if it squeaked every time the dog barked? 
A snap.
That is an ENTIRE Kong bone!

And this, my friends, is a bunch of rocks! All of those white oblong objects are rocks!
I'm sure it will come as no surprise to you when I tell you that some dogs will eat sago palm nuts. Not surprising, right? Seems like a fairly tame thing to eat in comparison with the above, right?

The problem is that sago palm nuts are lethal. The entire sago palm plant is poisonous to any animal or human attempting to eat it, but THE most poisonous part of this entire deceptively pretty plant are the nuts. Dogs that eat sago palm nuts will start showing clinical signs of toxicity as soon as 15 minutes after ingestion. These signs include drooling, vomiting, diarrhea, and decreased appetite. If the owner doesn't take their pet into the veterinary hospital for medical attention, over the next 2 to 3 days the nuts' poison will start to attack the dog's central nervous system, causing weakness, ataxia (difficulty/wobbliness when walking), tremors and/or full-blown seizures. The dog's liver will try to process and eliminate the poison, but will not be able to take a stand against this potent toxin. The liver will start to fail, causing the dog's skin, gums, and sclera (the white portion of the eyes) to turn yellow as bilirubin begins to accumulate in his tissues.

This is an extreme case of jaundice where the mucus membranes look orange! Note the dog's sclera is the same color.
This is never, EVER a normal color for your dog, your cat, your horse, or yourself.
The liver also plays a role in the blood's ability to clot. If the dog still hasn't received medical attention, the dog may start to slowly bleed out as the liver continues to go into failure. You'll see pinpoint bruising (known as petechiae) on the patient's belly, ears, and gums. The dog may die of what is called disseminated intravascular coagulation, also known as DIC (for a medical explanation go here, for a layman's terms explanation go here; DIC is an end result of different conditions; it is not limited to sago palm toxicity. It is very common in heat stroke; it's what heat stroke causes and what ultimately kills the patient). It is extremely hard to bring back a patient that is already in DIC. There is a reason why DIC is also known as "Death Is Coming." 

Unless the dog is caught in the act of ingesting the sago palm nuts and vomiting can be induced within an hour of ingestion, the prognosis is pretty bad. Even if the dog is taken into the animal hospital as soon as 24 hours after ingestion and aggressive supportive care is started immediately, the chances of the dog surviving are still only 50%.

As you can see, sago palm nut toxicity is among the nastiest you'll see in South Florida, and sadly a lot of pet owners have no idea that that pretty palm tree in their backyard is so incredibly toxic.

And now that I've driven home exactly how bad sago palm nut ingestion is, I'll proceed to my story.

I was working at that very first specialty hospital I told you guys about while in tech school. I'd been there a few months already. It was a Saturday night close to the holidays and our ER and ICU were hopping! Doctors everywhere, techs everywhere, every cage was full. We had the capacity for about 30 hospitalized patients. Todd, our ICU manager and head tech, had come in to help us out because we were drowning with incoming emergencies and treatments that needed to be done. There was an extra cage on wheels in Fluoroscopy that Todd and I ended up wheeling into the ICU because we had no more room for the patients being hospitalized!

Don't EVER say the "Q"word!!
I was just an assistant so I wasn't allowed to help with treatments, but my hands were plenty full keeping up with taking patients out for their scheduled walks and making sure every single cage was clean. Which is difficult when every other animal in the hospital is having diarrhea. That's a lot of diarrhea to clean up.

And then I got asked to help one of the techs with this one case.

She was a weird-looking puppy. A deep dark brown, almost black in color with a metallic sheen to her coat and huge floppy ears with rounded tips, set too far down on the sides of her head. She looked like a weird cross between a monkey and a German Shepherd.

A cross between this:

And this:

I'd never seen ears like that on a dog. She was a large puppy at about 35 lbs at 4 months of age and she was a typical fractious puppy: didn't want to hold still, trying to bite when poked for blood samples and to place an IV catheter. It is upsetting to work on puppies because they react so strongly to anything that hurts or that they dislike. You don't want to hurt them; you want to cuddle them and pet them and play with them, but a lot of the treatments required to save their lives require doing things that they are not going to like.

You get a lot of older patients in the veterinary ER and ICU; thankfully puppies and kittens are not as commonly seen as in general practice. You don't want to see baby animals in the ER because when you do, it's often pretty bad.

This puppy's problem?

She'd eaten a bunch of sago palm nuts.

Her owner had noticed her eating them the day before and her GI signs had started soon after. Mom had brought her in for the diarrhea and lethargy, but she had no idea that the nuts her pup had eaten were lethal.

The puppy would be on a very high rate of IV fluids to help dilute the poison in her system and in this way help her liver and kidneys flush it all out. She would also be on gastric protectants. In addition, we had to give her activated charcoal. At the time, I had no idea what activated charcoal was or why it would be administered; this was my first time having this experience.

Activated charcoal is quite literally a black liquid charcoal solution given to patients (both human and animal!) as a way to decontaminate the body against some poisons. The charcoal binds to these poisons, adsorbing them and thus preventing the body from absorbing the poisons.

This stuff. You will find it in every reputable veterinary ER and ICU.
Some goofy dogs like Labs, terriers and Beagles will often eat the charcoal all by itself straight out of the bowl. If they won't eat it by itself, you can convince about 50% of individuals to eat the charcoal when mixed with some yummy dog food like a/d. The worst ones, though, are the ones that refuse to eat the charcoal because this means you'll have to syringe it to them.

Of course this puppy decided there was no way in hell that she'd be eating the black tarry stuff on her own. (I can't say I blame her. Someone would make a lot of money if they invented dog-safe chocolate-flavored activated charcoal solution!) 

I ended up kneeling on the floor with my back against a corner, the puppy sitting in front of me between my knees, hugging her to get her to hold still long enough for the tech to carefully syringe her the charcoal.

You don't want the dog to aspirate the charcoal while you're trying to administer it, so you have to give it very slowly, a tiny bit at a time, and pause to let the dog swallow. For a dog this puppy's size, the volume of charcoal administered was quite large, over 100 mls. (I'm not posting exact doses for anything on this blog on purpose; I don't want people trying to treat at home toxicities that require veterinary attention.)

This dog is being an exemplary patient. It rarely ever goes this smoothly...
The pup kept trying to turn her head and/or spit out the charcoal. As you can imagine, by the time we were done a good 20 minutes later, there was charcoal all over me, all over the dog, all over the tech and all over the floor. It was a truly memorable first activated charcoal experience for me!

We placed an E-collar on her to keep her from potentially eating her IV in the middle of the hustle and bustle of this particular shift. I honestly don't remember anything else that happened with her that night, which means she was a good girl. It was otherwise chaotic.

I do remember overhearing the doctors and later talking to the puppy's tech about her. Since she had presented with GI signs and abnormalities in her bloodwork, her prognosis was guarded to grave. The doctors weren't expecting her to live more than 3 weeks. I remember looking at the puppy and feeling so sorry for her. I was still at that point in my career where everything was so new and death was the most tragic thing ever. (Since then I've come to accept that death is by no means the worst thing that can happen to a patient. Of course it should be avoided, but sometimes it is the right answer depending on the circumstances.)

I took her out for one last walk at the end of my shift, out in the field behind the hospital. It was 6:00 am and the sun was just starting to rise over the horizon, setting the sky afire with brilliant orange and pink. It was a gorgeous sunrise, one of those sunrises that looks more like a sunset. We took an extra-long walk so the little girl could enjoy exploring in this early morning beauty, outside of a cage and beeping fluid pumps and painful needles. I figured that she should get the opportunity to enjoy the outdoors as much as possible now that her days were numbered.

I returned to work several days later and she had been discharged and sent home. The doctors had done their best to detoxify her, but they still weren't expecting her to live more than a month.


It is 4 years later. I am working as tech team leader in a very different veterinary ICU in another part of Fort Lauderdale. The receptionist hits the triage button at the front desk. I'm busy doing treatments, but it is my turn to be the triage tech, so I stop what I'm doing, quickly tell my coworker where I'm at in case he has a chance to get to my patients, and run up to the lobby to see what is here. 

In the lobby I find a woman in her late 30's with a large chocolate brown dog that looks like some odd German Shepherd mix. The dog is here for vomiting and bloody diarrhea. I take the client and the dog back into one of our exam rooms, and find myself unable to take my eyes off of this dog. Her ears. They are large with rounded tips and set too far down on the side of her head. There is something about her ears that is tickling my brain, but I can't figure out why.

Not the dog in this story.
I take vitals on the dog and get a history from the client. According to the client, this dog has no previous history of eating foreign objects; she can't imagine what this dog might have eaten to cause her current symptoms. 

I go back to the ICU to fetch our ER doctor, Dr. Z, who also happens to be the owner of the hospital. Dr. Z is a criticalist and, to me, a god. The most awesome god with disheveled gray hair, Hawaiian shirts, colorful Crocs, and the best sense of humor. He founded the Veterinary Emergency and Critical Care Society and created the first veterinary specialty: Emergency and Critical Care. I loved working with him because there was always something to learn; despite a good 50 years of experience in the field, he was super down to earth with a great sense of humor. He loved teaching and it showed. 

As I'm going over my notes and telling him about this dog, everything suddenly clicks. 

The ears.

That puppy.

I check the dog's age. She is almost 4.5 years old. It matches. It can't be, though. She was supposed to have died. 

I tell Dr. Z about the pup I saw at my first ICU job, and he makes a point of asking very thorough questions about the dog's past history.

As a 4 month old puppy, this dog had indeed ingested sago palm nuts and been hospitalized. 

It was the same dog. She survived! Dr. Z gave me a high five when he walked back into the ICU.

Not this dog either
This was not a repeat sago palm nut ingestion as the owner had removed the palms from her yard years ago. But of course, now that we knew she indeed did have a history of eating things she shouldn't, the supportive care she received was a lot more aggressive than what we otherwise might have done for her. She was very sick which meant she was in the hospital for a little over a week. She still wasn't a particularly nice or cooperative patient, and her mom wasn't a particularly nice client, but every time I did this dog's treatments I had to smile. 

She lived. Against all odds, she had lived. 

She went home a week later, good as new, and I never saw her again. When a patient leaves the veterinary ICU, you always hope for their sake to never see them again.

And this is among my favorite and weirdest of my veterinary stories to date!



    Great story! My favorite so far.

    Saying "quiet" on the mountain has the same effect. We all yell at whoever says it and make them go be first-on to whatever incident crops up as a result. In addition to "quiet", we have certain members of patrol who are "shit magnets". The director of emergency services for my county is on our patrol and has a knack for showing up right as something serious happens. He always has to deal with it and the ambulance often requests he join them - to which he typically declines unless its super serious.

    1. Loved this anecdote! I'm always wondering if you get some of the same kind of craziness/scenarios on the mountain as we do in the ER. Charles had to learn about the "Q" word the hard way - he made the mistake of saying it out loud one night on emergency. The ER exploded with activity less than an hour later, and Charles got blamed for it allllll night long!

  2. Love this series! That seems like a terrible way to die, I'm glad she ended up pulling through against all odds. What a great feel-good story!

    1. I'm very happy that you enjoyed it! :D

  3. What an amazing story! Anyone who has had a puppy knows everything they can get in their mouths, they will try to eat. Such a fun and terrifying time dealing with pups.

    1. Oh God yes! So many people don't understand that they quite literally need to baby-proof the house before bringing a puppy home...

  4. Well, drat, it deleted my comment, too! Grrrr....

    That is a fantastic story. Too mean to die, maybe? ;-)

    I have a L/W Springer and I hope the one in the jaundice photo made it. Ugh, that was a sick puppy.

    1. Haha! I've met plenty of patients that were too mean to die! But this one was not one of them. She wasn't a mean dog at all; she was just aloof and uncooperative. Not a very emotional dog. I wondered if she might have some sort of oriental dog in her, like Chow or Shar Pei. They are great with "their" people but can be wary around strangers.

      I have no idea who the Springer in the jaundice photo is. It's just a photo from Google to illustrate the color. The ones I've seen that have been that icteric have always been very, very sick animals. There've been a few that were orange like that that we've been able to save and others whose lives we've been able to extend somewhat. It just always boils down to the individual case, the cause of the jaundice, and the clients themselves: how much can they/are they willing to pay to allow us to fix their pet. :/

  5. Such a cool story! And the info about activated charcoal is a great message. I always have some on hand with a dog and a baby in the house, and when I had my silver (e.g. mercury) dental fillings replaced with a material not likely to kill me or cause me to go insane, the dentist gave me activated charcoal to take. That stuff is awesome!

    1. It is! Charles mentioned that they have it at the hospital for kids that potentially toxic things (he's a pediatric RN) and I had to laugh...all I could picture was him trying to syringe it to a child like we do to our patients. Some things are just so much easier in the human medical field!