Tales From the Trenches: When The Patient is the Healer

I woke up with a start, my eyes flying open.

"Chewy," I whispered into the darkness.

He had been my patient the day prior. I fumbled in the darkness for my phone so I could see the time.

It was 4:00 am.

I lay back down, staring at the ceiling and trying to shake the unwavering certainty that he had just died. It was that knowledge, that feeling of his passing, that had woken me up from a deep, bottomless sleep. "But he was doing so well," I thought. He had finally eaten for his owner and he had been consistently oxygenating well by the end of my shift.

I shut the door on my work-related thoughts and turned onto my side, covering my head with a pillow as if that would keep my brain silent, sliding into a fitful sleep where I drifted in and out of vague dreams of the great Saint Bernard that I had slaved over for 13 hours on Saturday.

I finally flung the covers off 10 minutes before the alarm went off and hit the shower, still unable to shake the feeling of what I knew to be true.

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I had said I wasn't going to write any more of these but this past weekend was exhausting physically, emotionally and psychologically on all counts and this time I think writing about it will be cathartic. If only to tell the tale of sixth senses and the realities of nursing jobs, whether human or veterinary.

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Fridays are my surgery days at a hospital closer to home and it had NOT been a Good Day by any means. I'm not one to stress over Friday the 13ths, especially because my own mother was born on Friday 13: in the family we tend to consider them good luck, just like we love black cats. Which is good because my patient on this day was, actually, a black cat. So there was good luck in the sense that my patient was still alive when I left my shift, but it was bad luck due to the events that happened to her that could have been prevented. I finished the day knowing that I had done everything I could possibly do to the best of my capabilities with the information that I had and the short rein that I was given by my doctor, but sometimes that is not enough, and as a nurse I can only do that which I am given permission to do (see "short rein"). It was one of those days that I can't write about. All you need to know is that the events on this day left me questioning my career choice. I hadn't had one of those in a long time, so I guess I was overdue.

Not my patient from that day, but still an eye belonging to a mostly-black cat.
This is an awesome shot by Carlos of none other than Zombie!

I had already worked out for two hours that morning: one hour of hard-core volume leg work, and another hour on the treadmill, but the sun was shining when I left work and I decided I was going to run outside because I just needed to pound my feelings out against the pavement around downtown Frederick.

It was well worth it. The Universe gifted me with one of the most spectacular afternoons outdoors that I have experienced in a while.

I clocked in another 3 miles before deciding I should probably stop before I wore myself completely out. It was hard to leave the sunlight and the Friday afternoon crowds ready for a night on the town to go hole up at home in preparation for a working weekend. I felt alive again driving home.

But I still did not sleep well that night.

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I walked into my ICU job the next morning, Saturday, already feeling wiped out. I usually know what kind of day we're going to have by the general vibe when I walk in, and it was not the best: everyone was flustered, moving hurriedly. The two baby doctors (as we call our interns. They are full-fledged DVMs, usually recently out of school (but not always), that choose to do rotating internships (unlike in the medical field, internships are NOT a requirement in vet med) at specialty hospitals in order to gain more knowledge so they can move on into residencies in the specialty of their choice or just be above-average general practitioners) that had worked that night were frowning at their computers, their shoulders tense lines as they typed up their notes in a hurry before the senior doctors arrived for rounds. I got smiles hello from the overnight techs I made eye contact with, but I saw the strain behind the smiles.

Usually the ICU is neat and tidy when we arrive in the mornings on the weekends, because the evening rush is normally limited to the hours between 11:00 pm and 1:00 am, so the night techs have time to get caught up on treatments, admits and diagnostics, clean up the area, and relax before their shift ends. This had not been one of those nights.

Not my hospital. This is actually the University of Pennsylvania's Ryan hospital, which was the first university-based animal hospital to receive the Level 1 designation. Our layout is different but a busy shift can look just like this.

I walked into the little break "room" (" " because it's more like a nook off of the ICU) to put away my stuff, glancing at the board where Annie was finishing assigning patients: there is a large dry-erase board where she writes all of the techs' names and underneath them, the patients that we would each be in charge of. We have been short-staffed for a really long time now, with Annie and I being the only constants (and sometimes the only techs) on the weekend daytime shifts to five doctors. We finally, finally have five techs on the team. ICU veterinary work is the absolute most demanding of all of the veterinary branches: it takes all of your skill, all of your strength, all of your will, all of your knowledge and all of your intuition. It can be the most heartbreaking but it can be the most rewarding, even more so than strict emergency work, because you get to develop relationships with the patients and their owners. But it can easily suck the life out of you if you're not careful, and it takes a very special kind of person to be able to do it long-term. Stress levels can be elevated throughout the team, especially when the case volume and patient acuity are both high, and redirected aggression amongst the staff as a result of stress is a real side effect. Burnout happens all the time in both vets and techs, and it is not uncommon for new techs to run away screaming when they realize just how intense the environment can really be.

We each had three patients, which is a reasonable caseload. We rounded with the overnight technicians that had had our patients. Since I was the most experienced tech on this shift, it meant I also had the most critical case in the hospital, which is absolutely 100% fair: I like the critical cases. The more complicated, the better. It's why I do this.

His name was Chewy. He was a two-year old 180 lb Saint Bernard that, at the moment, could not really walk. The dog was bigger than me, with massive paws larger than my hands, and a 45 lb advantage on me weight-wise as well. He was also having trouble with that most basic of things you need to be able to do in order to stay alive: oxygenate. The biggest concern with him right now (among many others) was that he had horrible, horrible pneumonia. He was too big to fit in our oxygen cages so at the moment he was sporting the latest trend in our ICU: bilateral nasal cannulas that delivered the oxygen straight into his nose. In his case, this also meant he was head-shy for administering oral medications, which was not surprising. We have the oxygen cages so that we can avoid this type of situation because the cannulas can be so annoying for the patients, but the largest dog they'll accomodate is maybe 90 lbs. Chewy would have been scrunched in there so tight, we wouldn't have been able to get the cage doors closed.

Nasal cannula for delivering oxygen in a dog. The cone (E-collar) is a must to keep them from pawing/rubbing the cannulas off. Less sick patients can often get away with just one cannula in one nostril. Chewy was not one of those patients. Photo from here. <- That article explains how it's done. At my hospital it's usually us techs placing these.

My other two patients had simple treatments so I got them out of the way first so I could dedicate time to Chewy's battery of required therapies.

I took all of his vital signs, including his blood pressure: all were normal. The most daunting thing that needed to be done was to get his weight: one of his many complications was edema, so he had to be weighed every 12 hours to keep tabs on if/how much more fluid weight he was gaining.

He had a special double harness with a handle above his shoulders and another above his hips (it's called a Help 'Em Up Harness) that allowed me to help hoist him out of his run. He was able to help, placing his feet while I lifted the brunt of his weight, as we made our way to the scale. Remember that he weighed 180 lbs. I weigh 135. Deadlifting 180 lbs of static iron in the gym is a lot easier than a living, breathing, moving animal of the same weight.

We made it to the scale (thankfully less than 10 steps away), where he lay down with a sigh. His weight remained unchanged.

Now we had to make it back to his run.

I literally deadlifted him by the handles on his harness, hoping that he would place his feet so we could get going, but it was not happening. He didn't even try: he was done. One of the other techs helped me carry him back to his run, where he was promptly hooked back up to his oxygen.

His next treatment was nebulization, which involves placing a vaporizer near the patient's face that emits steam from either water or saline to help loosen the phlegm in his lungs. He was not too keen on the steam, which I had been warned about in rounds, but if I held the vaporizer attachment about a foot from his nose, it still wafted in the general direction it needed to go without bothering him. After 10 minutes of nebulizing, I coupaged him, which involved standing above him and thumping his ribcage on both sides firmly but gently with cupped palms: this is to help continue loosening up the phlegm in this chest in the hopes that he will be able to cough it up. He didn't cough.

Next up was checking his oxygenation with a device called a pulse oximeter.

Pulse oximetry is probably one of the things that I hate the absolute most to do on awake patients. Why? Because most of these devices are meant for people, whom are hairless and tend to have lighter skin on their fingers, which is where pulse oximeter probes are usually attached. There are veterinary-specific ones, of course, but they still don't work well on fur. They are excellent for anesthetized patients, who are not moving and on whom you can just attach the probe to their tongue.

Pulse oximetry on an anesthetized dog. The 96 indicates the % of oxygen in the dog's hemoglobin. The 102 in this case corresponds to the dog's pulse. Photo from here. 

On an awake patient, however, you have to attach it to their lip. Dog lips can still be quite hairy and are often pigmented black. Other alternatives are ears (if the dog is very fine-haired), or the webbing between their toes, or their prepuce or vulvas (the probe does not pinch; you would be surprised by how well they usually tolerate this.)

Pulse oximetry options for awake patients. Photo from here. 

Movement of any sort will affect the reading, and these devices aren't very quick: it can take them at least a minute to get a correct reading. When you have an awake patient trying to chew on the probe or wiggling their lip to make it fall off, or moving their head to keep you from attaching the probe to begin with, it can turn into a half hour ordeal. I usually end up training my patients to let me do this by using pressure-release techniques like you would with a horse.

It takes a crazy amount of patience and begging to get a patient to be this tolerant of the pulse ox probe. Some patients are just this good to begin with, but it is rare! Photo from here. <- That article has a great explanation of how pulse oximetry works.

Chewy would be no different. He was already head shy to begin with, but I convinced him to lie down somewhat on his side, which was different from the position he would be in for oral medications. Once he was able to understand that I was not trying to touch his face in order to give him medicines, he let me attach the pulse ox probe to the corner of his lips and he was quite cooperative for it. I obtained a normal reading (98%, which we were really excited about because it was the first normal reading in days) and re-positioned him so that he was lying on his sternum again: lying in sternal recumbency makes it easier for them to breathe.

An adorable puppy demonstrating sternal recumbency. <3

He was my most critical patient that day, and anytime I walked into his run was with the understanding that I would not be available on the ICU floor for at least half an hour, but despite having a reputation for being inordinately stubborn, Chewy really gave me no trouble. Halfway through the day I found myself actually looking forward to sitting in his run with his enormous hairy self lying down next to me, while doing his treatments and gently stroking the white stripe between his eyes until his third eyelids peeked out and he fell asleep.

He had been in the hospital for almost two weeks, with one thing after another, his problems compounding themselves and snowballing into the avalanche that he had become. He had never really been comfortable during his entire stay with us, no matter what the techs and doctors did for him, no matter how the bedding was padded or accommodated for him, no matter how he was positioned, no matter the sedatives or pain medications that were given to him in the hopes that he would finally sleep. Just sleep. Instead he would be awake, panting, shifting uncomfortably, sometimes sitting up for hours at a time unable to find peace.

During my watch, he finally slept. He finally stopped panting all the time.

His owners came to visit, a lovely couple that adored their dog. One of the biggest challenges with him had been getting him to eat: he would not eat and up until he had required intranasal oxygen, he had been receiving a liquid diet through a tube that had been placed through his nose and into his esophagus. His need for oxygen had become greater, so the feeding tube had been removed in order to accommodate the two nasal cannulas for oxygen.

On this day, his owners brought him chicken that they had cooked for him at home. And he ate. He ate for the first time since he had been admitted.

I think that was the moment when I subconsciously stopped worrying about him. When you have a critical case in your care, you move around the hospital but the back of your mind is always tuned into that patient (or patients...sometimes ALL of them are that sick!) You find yourself drifting towards their cage when you're not thinking about it, or looking in their general direction if you realize you've been focused on something else for too long. One of the eeriest things you get to experience as a critical care nurse is when your patient suddenly tanks across the room and you feel it. You know something happened without seeing it, because you felt the change from the other side of the ICU. I can't explain it, but it is the kind of thing that forces you to believe in the unexplainable. It is something that I have seen happen over and over and over again throughout the years, to other techs and to doctors too, and that I have experienced myself with my own patients.

Chewy was still cruising towards the end of the day. I rounded him to Manuel, the overnight technician that had been taking care of him the previous night as well. The giant dog had been sleeping when we walked into the kennel area off of the ICU but he slowly woke up while we were talking. I looked at him and he looked the same as he had all day, but I got a distinct subtle feeling of unease that I couldn't place. His respiratory effort had never been easy, but it had not increased, and just 15 minutes earlier I had checked his vital signs: everything had been fine (for him, given the circumstances). His lungs sounded no worse and he had continued oxygenating great all day as well.

I shook off the feeling and finished rounding my patients. It had been a hectic day, just like I had figured, and we still had a million chores to get done before we could leave. My 13-hour shift turned into 14 hours before I could walk into the break room to grab my stuff to go home.

Walking through the ICU on the way out, I glanced at Chewy one last time in passing, almost as an afterthought. He was sleeping peacefully, his breathing still the same.

I don't remember the drive home, nor showering when I arrived at the apartment, nor feeding the cats nor what I scarfed for dinner. I just remember falling into this deep black bottomless pit of sleep.

And then five hours later being woken up by the knowledge that Chewy was gone.

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The ICU was a disheveled chaos when I walked in on Sunday morning. Only one of the overnight techs was around; everyone else was elsewhere. It was that calm that settles in after a disaster.

I glanced at Chewy's run and saw it empty, the bedding soaked, the fluid lines that had been attached to him scattered across the floor as if removed in a hurry. Annie had already assigned the cases and I looked at the board, searching for Chewy's name. It wasn't there.

I put my belongings away in the break room and walked back out just as Manuel and two of the other overnight techs walked back into the ICU from the exam rooms. They all looked like they were still in shock.

"Chewy died, didn't he?" I asked Manuel.

"I'm so sorry," he said. He was so upset.

It had been horrible, a story that I don't care to repeat in detail. Around 11:00 pm Chewy had suddenly taken a turn for the worse, into what turned into an hours-long ordeal of trying to reach his owners to let them know what was going on in the hopes that they would give permission to stop because he was not going to get better, while the dog suffered hopelessly. (Guys, if you have a pet hospitalized in the ICU, you MUST keep your phone close to you!!)

He had finally been put to rest at...you guessed it: 4:00 am, right when I woke up. The owners had just finished visiting with his remains in the room when I arrived at 7:00 am.

Manuel needed to talk and I let him. He needed to tell someone in detail about what had happened, to rehash what he had done and what he had seen. He needed to hear that he had done everything right, which he had. We always blame ourselves, we always wonder if we missed something or if we could have/should have done anything differently, if the outcome would have been different. Manuel and I ultimately stood in the middle of the ICU talking about supernatural experiences and sixth senses and all those things that you know when your job involves constantly walking the line between life and death. Eventually he was called over by another tech for help, and I wandered off to receive rounds on my other patients.

In a funny twist of fate, my most critical patient on this Sunday would be a black cat named Magpie. A black cat, like my patient on Friday. Magpie had a horrific infection that required my wearing gloves in order to touch her, and was one of those cats with Opinions. Like Victoria, that I had told you guys about before.

Magpie was very, very, very sick. And her blood pressure was low when I did her first round of vital signs, which then involved a rush of stabilizing treatments to bring her back up to normal. But that tough little girl rallied like a trooper during her 13 hours with me. It was an especially chaotic Sunday, with stress levels running higher than normal, but that little cat was the one thing that without fail brought a smile to my face throughout the day. First, when she ate for me: she had not eaten for a week at home and it was one of the primary reasons that had led to her ER visit. The doctor had already discussed having me place a feeding tube later that day. But Magpie ate. She ate all the food that I offered her by hand and then almost ate my fingers too! Her doctor's jaw dropped when I told him. So we held off on placing the tube and I was given the go-ahead to offer her small amounts of food every few hours.

The way she felt was cyclical: she would have moments where she was lethargic and would curl up at the back of her cage, sleeping. Eventually she would wake up and would start howling until I showed up. Sometimes I couldn't get to her immediately so I would call back at her from wherever I was in the ICU, "Magpie!" And her howls would change to meows, "Meow!"
"Magpie!"
"Meow!"
"Magpie!"
"Meow!"
And so on and so forth.

If I stopped talking to her, she would howl again. Until I finally reached her cage, at which time the howls would change to mews once more. Her demands were compounded when she figured out that every time she did this and I was able to make it to her, I would offer food. It became our agreement: if Magpie asked, she received. And every single time that she received, she ate.

This is not common.

Because her blood pressure had been so low that morning and because she was so sick, I had to check her blood pressure every other hour. Normally if they climb up firmly to within normal parameters, we space out the blood pressure checks more, but she was so close to borderline that I kept checking to make sure she wouldn't tank again. Cats aren't normally huge fans of having their blood pressures checked because it involves gently pressing the Doppler probe smeared in cold, wet ultrasound gel against a shaved spot on their legs, close to their large paw pad. Cats don't like cold, wet slimy things against their skin.

Blood pressure check on a kitty, using her front paw. The tech is holding the Doppler probe against the cat's paw (black cable across right palm.) Photo from here. 

Magpie was very patient for her initial reading...until she was not, because her pressure was low and I was having a hard time finding it. I had her out on the treatment table, lying on her side with minimal restraint, and she quite literally turned her head so that she was making eye contact and very deliberately yelled, "MEEEAAAAAAAAOOOOO!" "Why are you taking so damn long?"

I later figured out that what bothered her the most about the whole blood pressure ordeal was having the tiny cuff wrapped around her leg. She wasn't moving a whole lot in her cage, so I just left it on given how often we were using it, which she did not mind at all. Once we had that sorted out, she would just lie down for me to get her blood pressure readings, patiently waiting for me to find her pulse with the Doppler probe and talking to me with soft meows.

My favorite moment of the entire day was when I was sitting on the floor across from her cage while I helped one of the other techs with her patient, and Magpie started howling at me:

"There you are, slave! Why are you sitting on the floor with that stinky dog? I'm hungry! Feed me nao!"

I laughed and laughed. I was welcomed with purrs when I was finally able to bring her food.

She was still far from being in the clear by the end of the day, but she was better. Even her bloodwork, which had been horrible the day prior when she had been admitted, was significantly better. It was almost magical, what happened with her that day.

I loved that little black cat because she healed me. She settled what had been unsettled by the near loss of my black feline patient on Friday. She was a gift, a confirmation that I am doing what I am supposed to be doing.

I finally slept on Sunday night.

And that is the true beauty of ICU work:  we fix a lot of cats and dogs, we bring them back from death's door, and sometimes we send them through peacefully. We buy owners time, we put their pets back together, and we heal them...the pets, and sometimes the owners too.

But so many times, it is the patients that heal us.

Tales From the Trenches: Christmas Eve in the ICU

*Warning: you will want tissues handy.*


His name was Jerry.

He was one of those cats that arrives at the hospital a terrified spitfire: screaming, yowling, and doing his best to try to kill anyone that touched him. Cats are unique creatures in that they are prey animals first, predators second, and thus when trapped, cornered or restrained, their first instinct is flight. Like a horse. Except that if they are unable to fly, then often have no qualms about resorting to fighting. It is essential that you understand this about cats when handling them in the veterinary hospital, because it is the only way you will keep yourself from getting hurt and will also prepare you to handle the cat in such a way that prevents him from becoming permanently traumatized by the hospital experience. You should never manhandle a cat.

Our shift leader and weekend head tech, Annie, is in charge of directing the chaos that would otherwise reign in our world of emergency and critical care. I live for the critical care aspect, Annie lives for the emergency side of the equation: she loves the adrenaline rush of triages and stabilizing our incoming cases, while I am usually assigned the most critical of our inpatients because I am one of the more experienced ICU techs on the day shift...but also because I adore the intricacy and attention to detail required in keeping alive the patients that are at death's door. I've been told I'm good at it. All that I know is that it is rare for a patient to die on my watch. That's all I care about.

On this particular day, Annie had brought back to the treatment area a carrier full of hissing stripey brown cat. She was able to get Linda, one of our other techs, to help her get an IV catheter in this kitty so that he could be admitted for supportive care. I had my hands full with my hospitalized patients at that moment, so I let Annie and Linda handle the small fierce tiger: Annie is an even bigger diehard cat lover than I am and is one of the best in the hospital at handling fractious cats with minimal stress: she had effectively and carefully wrapped the cat in a thick towel to form a kitty burrito so that Linda could quickly place the IV. Kitty held still, but loudly shouted the equivalent of obscenities across the ICU, letting the world know exactly what he thought about being held against his will. However, in no time the girls were done. He was placed in a cage and started on IV fluids.

I later walked by his cage and there was something about him made me stop. He was totally chill, lying comfortably on the bedding with his front legs with their white toes extended out in front of him like a sphynx, while he calmly stared at the back wall of the cage.

I didn't know his name yet, so I looked at his cage card.

"Jerry," I said softly in a singsong voice.

One ear twitched ever so slightly as he turned his head around and looked at me with widening pupils, "You know my name!" It's cute how patients always seem initially surprised when we call them by name. It's kind of like in their minds it means we can speak their language: their name is their link back to home, to their families, to a world that is predictable and familiar.

"Hi Jerry," I said with a grin, and opened the cage door. The fighting striped fireball from earlier was gone. I introduced myself, giving him the option of sniffing my fingers. He didn't. He just bumped his forehead against my palm. "Awwww..." I thought. I ran my hands along his small thin body and the rumble of his purr immediately reverberated against the cage walls. He flexed his little white toes against the bedding, kneading. Every time I stopped petting him, he'd bump my arm with his head for more, and his purr would rev up louder and louder with each stroke of my hand. I couldn't help grinning. It was hard to tear myself away.

We admitted 4 patients within the next hour. Annie came up to me, "Do you want anyone in particular?" she asked with a grin. Most of the time we don't get to choose our patients; they are assigned based on our skill level as technicians and who has the least patients at a given time, but on this day I was getting to choose.

"I want Jerry," I said without a second thought.

And so he became my fifth patient on that shift. And he rapidly became my favorite: the formerly untouchable cat let me do everything that I needed to do to him by myself. Auscultating his chest, obtaining his blood pressure with the Doppler and its cold wet goo on the probe against his foot, rectal temperatures, checking his gum color: none of it was an issue. He purred throughout his treatments. His one request was that I continue petting him while I did everything: he would bump his head against my arm insistently if I didn't.

He was hanging in there, stable, when I rounded him to the overnight technician. I told her about his medical history but also about his awesomeness so that she would know to look for it in him: when you expect patients to be good, they usually are.

The next morning he looked so much better! His head was up, his eyes were bright, and his overnight tech had fallen as madly in love with him as I had. More patients had been admitted overnight and I now had 6 to call my own, with Jerry being the most stable of them. I kept stopping by his cage whenever I had a spare moment to hang out with him.

Annie helped me get a blood sample from him around noon that day. He was so good for it; didn't even say a peep about being held for the blood draw nor about the quick poke with the tiniest needle I could find. I ran the bloodwork and handed it to his doctor without looking at it: we were slammed with incoming emergencies and I was moving as fast as I could so that I could pitch in and help. I had no reason to think it was worse based on Jerry's appearance and behavior.

A cat carrier was rushed back by one of the receptionists while I was setting up a fluid bolus on one of my other patients who was tachycardic. What is up with all of the sick cats these last two weekends? I wondered, as I heard something about "not sure if he's breathing" and "what do we have permission for?" Normally when you walk into a veterinary ICU, 75% of patients are dogs. Sometimes 100% of them are canine. Cats can get very very sick from an assortment of maladies that are any internist's wet dream to work up, but they tend to happen when cats are ancient. The question of quality of life crops up then, and it is not uncommon for clients to elect to stop. Because how much longer do you expect to prolong a 16-year old kitty's life? Cats are tough, hardy creatures, and you can tell when you look around the ICU and notice their absence. Not on these last two weeks, though: 50% of our patient population last weekend and this one was feline.

I finished setting up my patient's bolus and ran over to the wet table where we run codes as Annie pulled a very limp cat out of the carrier. Two doctors had rushed over as well. I started setting up for an IV catheter while someone else started setting up an endotracheal tube so we could be ready to initiate CPR. One of the doctors found a heart beat. It was confirmed with the EKG. We got an IV catheter into the kitty...his blood pressure was nonexistent, as no blood flashed back from the stylet, but correct venous placement was confirmed by flushing the catheter. Fluids were started. Annie was able to get the tiniest blood sample to check kitty's blood glucose...it ended up being too low to read on the glucometer! IV dextrose was given. By then there were enough people around the cat that I was able to step away when my patient's fluid pump beeped, indicating that the bolus was done. I confirmed that my help wasn't needed anymore and returned to my patients.

Under the head attending doctor's orders, Annie was able to get the kitty reasonably stabilized but stayed with him, because his condition could change at any time.

She later asked me if I could watch him for a minute so she could run to the restroom, and so I did. I leaned against the wet table and watched the kitty's EKG on the monitor across from me: his heart rate was slow for a cat's but the rhythm was normal. I looked down at the small patient. His eyes were open, with golden irises. I had applied ophthalmic lubricant earlier because he wasn't blinking. He still wasn't really blinking, but I saw his eyes moving around, watching the goings-on of the ICU. And for a second, I saw the world as he did: the beeping of the EKG unrecognizable and far, far away, as if heard through a tunnel. A dog whining in a cage in the distance. The people moving around blurry and unfamiliar, in this strange room of bright lights and medical smells. And the question of, "Where am I?" but being too weak to really care.

I slid my hand under the heated Bair Hugger blanket that covered him, my fingers running along his surprisingly soft fur. I could feel every bone, every rib. He was old and guessing by his condition, had been sick for a long time. And he was purring ever so softly: the death purr. Cats will purr when they are happy, but the really, really sick ones will also purr to comfort themselves.

Kitty's expression relaxed and he half closed his eyes as I continued petting him. He stopped purring: since he was being comforted from the outside now, he had no need to continue comforting himself.

His doctor came back from the exam room, where she had been talking to the cat's owners, at the same time as Annie returned.

"They are going to euthanize," Dr. E explained. Kitty had indeed been sick for a very long time. He had seen multiple vets and had had diagnostics performed within reason, but he had continued to deteriorate. It was a fair decision.

Annie took my place so she could scoop the cat up into her arms to take him in to the exam room to spend time with his owners. Kitty looked up right then, turning his head, and making full eye contact with me. His eyes were clear for the first time, focusing. I reached out and stroked his head one last time, and he blinked slowly at me, "Thank you."

I wish more people saw cats the way we do.

At that moment, Dr. S, Jerry's doctor, called me over to her desk. She was very serious.

"Jerry's owners are going to be here in an hour," she said. She had just gotten off of the phone with them. "There is a 50% chance that they are going to choose to stop."

I felt my face fall. I had not been expecting that. "But he looks so good!" I said quietly.

"I know," Dr. S said, "but his bloodwork is worse. And I'm afraid there is something else really wrong with him that we are missing." We went over his long list of undiagnosed problems. The chances of any of it being curable, even if diagnosable, were slim when you took into account that Jerry was also 17 years old. Again, it was fair.

I went back to his cage and ran my hands over him. He nudged them eagerly, and his purr filled the cage once more.

His owners showed up at exactly the time they had said they would arrive. Dr. S went in to speak with them first, and came back to let me know so I could take Jerry into the exam room to visit with his people. They were going to stop.

I looked for a pretty towel in our clean laundry shelves. Jerry let me scoop him out of his cage and curled up against my chest. I wrapped him up in the towel and walked out of the ICU. He was looking straight ahead, the back of his little striped head to me. I could feel his purr soft against my heart. Walking down the hallway to the exam room, I kissed the back of his head and nuzzled him, choking up for just a second. And then pushing it away so I could walk into the room where his family was waiting for him. Dr. S was in there too, talking to them again. I hadn't realized she had returned to the room. I looked around questioningly, wondering whom I should pass him to, and one of the women in the room stood up. Her eyes and nose were red. I passed Jerry to her and she held him against her chest, just like I had, as she sat back down in her chair. Everyone was talking around us, but I heard nothing: I just saw Jerry lay his stripey head against his owner, who kissed him between the ears as he closed his eyes happily.

I walked back to the ICU to continue with my other patients' treatments.

Dr. S brought Jerry back later. Except he wasn't there anymore, it was just his small thin brown and black striped body, the fighting soul gone. Usually Annie or one of the assistants takes care of the bodies: the more experienced techs on the floor often have our hands too full with the more critical inpatients. But all of my patients were stable at that time and so I dropped everything I was doing so I could take him from Dr. S to take care of his remains myself: attaching a label to his paw, to his body bag, filling out his information in the record book in the morgue.

I want to believe that there is some magikal subconscious reason why I decided to choose him, but the truth is that I chose him because he purred when I touched him. It was that simple. I had just wanted to guarantee he would continue to feel that comfortable around the veterinary staff during his hospital stay. That was all. And I had succeeded. He had left this world still purring a real purr of happiness. And that is, ultimately, the best happy ending that one could ask for for a cat.

I furiously wiped my eyes, took a deep breath and walked back to the ICU. There were more happy endings that I needed to guarantee.

The rest of my patients did well. My youngest even went home to spend Christmas with her family, happily wagging her tail at her owners. One client brought us freshly made poptarts from Ted's Bulletin. Others brought us cookies, brownies and cupcakes. Dr. S thanked me for my hard work on her other most critical patient. The doctors had gotten together to get us all cards and gift cards to thank us for our hard work, out of their own pockets. They didn't have to do that, but they did. One of the receptionists squeezed my shoulder lovingly as she walked by, which was unexpected but somehow made my day. We giggled over off-color jokes. I made my favorite doctor laugh. Clients smiled and said "Merry Christmas" and "Happy holidays!" as they took their pets home. The colored lights strung around the ICU glowed brightly, warming up the space we all coexisted in. And we sent another 8 of our 18 inpatients home to spend the holiday with their families. Many of the others would go home on Tuesday, when their owners returned to town after the holiday.

I rounded my patients to the overnight techs that would be taking over their care, and then rushed to help complete our list of shift change chores.

"Go home!" Annie finally said with a grin. "We're good." She just had to finish tying up some loose ends and she would be leaving too.

"Merry Christmas, Annie!" I said, "I hope you get to sleep in tomorrow!" She laughed. She was on call for today, the 25th.

As I walked out with my bags slung over my shoulder, I looked around at this amazing team of people that I have the privilege of working with and thought about how it takes a special kind of person to not just do this job but to stick with it for the long haul. "We are all magical here," I thought with a smile, "And not just because it's a holiday."

TOO Blog Hop: A Day in the Life

Tracy started her Day in the Life of an Adult Ammy blog hop and I couldn't resist participating mainly because I don't have a traditional job.

As most regular readers know, I'm an emergency and critical care veterinary technician. I have a BFA and an A.S. in Veterinary Technology and have been working in the field for almost 8 years now. I worked in general practice for one year while in school then decided that vaccines and wellness exams were boring...so I plunged head-first into the unpredictable world of emergency work at 24 hour veterinary hospitals and have never looked back. 

I currently work in the emergency room of a 30,000 square foot specialty veterinary hospital in Montgomery County, MD with an established reputation in the region. The hospital has been around for almost 40 years. We get clients all the way from DE and PA who come specifically to see our specialists. The medicine and patient care are excellent. 

Because of the 24-hour nature of my hospital, I have a really weird work schedule. On Tuesdays I work 6:00 am to 6:00 pm (yes, I WALK INTO work at 6:00 am. I wake up at 4:45 am), on Wednesdays and Thursdays I work from 2:00 pm to 2:00 am, which invariably means I go to bed ridiculously late (usually around 4:00 am) and wake up late in the day the next day. It's not as luxurious as it sounds. 12 hour work days means there is not much time to do anything else other than sleep or maybe squeeze in a quick workout before work on your other 12 hours off each work day, though I LOVE me my 4 days off! :) Barn time during the work week usually happens on Tuesdays after 6:00 pm when it stays light out longer. If Charles is off on a Tuesday we might go out in the evening instead. It's tougher to get to the barn on Wednesdays, mainly because of the 1 hour round-trip I need to get to the barn. It's impossible on Thursdays. And yes, this is a full time work schedule: I work 36 hours a week, which can easily turn into more on nightmarishly busy weeks. Overtime over 40 hours is frowned upon though, unless our supervisors announce extra shifts that need coverage. Then we are welcome to sign up for extra hours.

Each day is different. Some days are very slow and the entire hospital is quiet, which means these end up being days for "conserving energy", as I like to call it: we stock and clean the ER and exam rooms, we help ICU and the Intermediate Care Ward if they have patients and then we kind of just sit around waiting for phone calls to come in or emergencies to materialize. During down time we'll catch up on work e-mail, and/or do online continued education (it is required if you are a credentialed vet tech like I am.)

Tuesdays during the day tend to be quiet. I'm the only ER tech on duty from 6:00 am to noon, which invariably means we'll have emergencies coming in, but it's usually quite manageable for one ER tech and a floater tech (we have a technician that "floats" throughout the hospital departments to help out from 6:00 am to 6:00 pm, and another floater from 6:00 pm to 6:00 am). It usually peters out around 12:30 pm, after help arrives (Murphy's Law is so so evident in veterinary medicine!), and will stay fairly slow until I leave for the day. Wednesdays are often quiet when I walk in at 2:00 pm but start to pick up around 5:00 pm, remaining steady until around 11:00 pm, with another small rush of emergencies around 1:00 am. A 1:00 am rush means I'm going to be leaving work at least an hour late. Thursdays are often absolute chaos from the moment I walk in the door until around 11:00 pm.

These are the current trends, but they will change entirely as we go into spring and summer. The full moon and barometric changes really do create more emergencies than usual. It is steadily busier in the warmer months, while in the colder months our "busyness" is dictated by the weather forecast: if it is going to snow, we get a huge rush of emergencies during the 24 hours prior to a snowstorm, dead quiet except for life-or-death emergencies during the snowstorm itself (and phone calls. So many phone calls), and then another big rush the second it stops snowing and the roads are cleared. Warmer days in winter tend to be busy with lacerations and dog bites, as these are the days that people tend to let their dogs run around more on their acreage or take them to the dog park. (If you take your friendly dog to the dog park, do be careful on busy days: not everyone that takes their dog there has a well-mannered dog, and we have encountered clients that know their dog is dog-aggressive and STILL take it to the dog park!)

This is a typical steady Wednesday ER day for me:

I'm choosing a Wednesay because I'm usually working with my favorite people. :) 

10:30 am: Wake up before the alarm sounds. Try to fall asleep again for 30 minutes because I know if I get up too early, I'll be wiped out by 2:00 am. Fail at sleeping. Check my phone for text messages and e-mail (mainly to make sure all is well at the barn, as the horses are the first thing I think of when I open my eyes in the morning). If I'm feeling extra-lazy, I might read a blog or two or check Facebook while still in bed. I don't post a lot on Facebook myself, but I keep up with friends and family through there.

11:30 am: Turn off the air filter I use for white noise but leave the fan on for Charles. We are islanders: we slept with fans on. Even in the dead of winter when it's freezing cold out, we still sleep with the thermostat at 65 (the bare minimum to keep our pipes from freezing) and a fan on...under a sheet, a blanket and two comforters. I also routinely sleep with an extra pillow over my head. It's kind of ridiculous. I get up, shivering. Peek outside through the curtains. No snow. Not that that means anything, as neither Charles nor I get to stay home if it snows; it just changes the nature of the emergencies we see at work (Charles is an ER pediatric registered nurse) and it means I have to factor in an extra 10 minutes to remove snow from the car. I open the bedroom door. Assault by the 3 cats, who pour into the bedroom around my legs like a gray, black and orange liquid. (They get locked out of the bedroom because otherwise they would wake me up at 6:00 am for breakfast. Or because Astarte thinks I've slept enough. You think mares are opinionated? You should meet calico and tortoiseshell cats...hahaha...) I crank up the apartment heater to 75, pick up the cat food dishes and go to the kitchen to split up their cans of food. All 3 cats follow me meowing happily. Astarte gets half a can of Friskies because in her old age she refuses to eat healthy food so we give her whatever she wants (she likes Friskies and Fancy Feast), and Aengus and Zombie each get 1/3 of a can of Fromm's chicken cat food (those two will eat anything so I take advantage of that by feeding them the healthiest cat food possible!). Zombie gets fed in the kitchen, Aengus chirps and leads me to the bathroom, where he gets fed behind a closed door. I have to call Astarte, who trots over to the bedroom, where she too gets fed behind a closed door. I scratch her hips while she's munching (she loves to be petted while eating) and check her water bowl. It's full. I re-fill her dry food bowl: she likes to graze throughout the day, which is why she gets separated from the boys when we're not home. So she can eat as much as she wants whenever she wants. She loses weight otherwise.

11:40 am: Sit in front of computer with coffee (I drink lattes made on an inexpensive espresso machine with 2% milk with a tablespoon of honey, or soy milk or almond milk, depending on the mood) checking e-mail, paying bills, commenting on blogs or working on a post. Finish first cup of coffee, make myself a second one.

12:15 pm: Turn the heat back down to 65. Do leg exercises with kettlebells and free weights. Ab exercises on my balance ball.

12:45 pm: Shower. Blow dry hair because it's cold. Makeup because I'm Latina and even though I work as a vet tech, I still like to look good. Scrubs are wrinkled from the dryer so they get tossed into the dryer again with a dryer sheet so they can get "ironed". (This is very effective!)

1:05 pm: Scrubs "ironed"; finish getting dressed.

1:15 pm: Charles wakes up (he works 3:00 pm to 3:00 am, but often stays until 4:00 am at work because he is an emergency room RN) and makes himself a proper lunch for breakfast: Charles will eat the food that is expected for the time of day at which he is waking up. I love breakfast; it's my favorite meal of the day. Even when I worked overnights and woke up at 4:00 pm to go to work, I still had to start my day with a proper breakfast. I eat 2 hard-boiled eggs and a cup of plain Greek yogurt with 1/2 cup blackberries or 2 slices Ezekiel cinnamon raisin toast with apple butter from our farmer's market. Still typing away at computer.

1:35 pm: Release Aengus from the bathroom. Zombie pounces on his brother's empty plate to lick up any microscopic dreg of food he might have left. I pack my lunch: a frozen entree (from Safeway Selects, Eating Right, Lean Cuisine or Weight Watchers), a Chobani banana-maple + steel cut oats yogurt, a Kind bar and a large bottle of water. I may throw in a bottle of Cold Brew coffee as well for later. I go into the bedroom to brush Astarte with the Furminator. She loves this: she meows at me and makes me follow her around the bedroom while she stretches in various spots for me to brush her, purring loudly.

Astarte the queen

1:45 pm: Say good-bye to Charles. We have this funny long-standing ritual that involves kissing his whole face before I leave. :) Dash out the door to run down 4 flights of stairs to the car.

1:50 pm: Call my mom on the way to work. I talk to her pretty much every day, especially work days. I fly down the street at 50 mph, darting among law-abiding Maryland citizens. Puerto Rican driver at your service. Except when passing the speed cameras. I slow down to 30 mph then.

2:03 pm: Arrive at work. Yes, I currently have a 7 minute drive to work! (As long as I speed...) Clock in. (We have until 5 minutes after our shift starts to clock in before we are flagged by the timeclock for being late. I religiously arrive 3-4 minutes after my shift begins.)

2:04 pm: Walk down the hallway into the veterinary ER, which often means walking into a war zone: there is a cat in the oxygen cage on my left with the owner visiting, two of my coworker techs are tending to a critically ill dog on our main ER table who is hooked up to the EKG, and the internal medicine techs are using our ultrasound machine to get a urine sample via cystocentesis. There are 5 patient names and problems written up on our ER board. 2 of them are currently in the hospital. The large dog on the table is a hemoabdomen and we're waiting for the surgery department to come take him to surgery. I remove my coats, rush around putting away my food in the ER fridge, grab my work badge and a couple of pens and a Sharpie from my purse, shove my cell in a scrub pocket and snag one of our ER handheld phones that I drop in my other scrub pocket.

Looooooooong main hallway of the building. ER is the second door on the right. That's Surgery on the left. ICU is beyond the doors at the far, far end. The resident and criticalists' offices are at the very end.

Our ER. Yes, my REAL ER. Taken from our hospital's website.
I walk in through the door that the tech is walking out through. That's our main ER table in the center, the one that doubles as a scale. There is a wet table on the other side. You can see the oxygen cages in the far left. There are two large runs at the back right of the room (you can see one of them from this angle). The computers on the left are where we do billing.

2:15 pm: The hemoabdomen dog gets transferred to surgery; the kitty in the oxygen cage is admitted and the owner leaves. I clean up the ER table, replacing the towel and diaper pads for clean ones. The cat in the oxygen cage needs an IV catheter. My coworker and supervisor, Annie, and I get to work on getting it placed and doing the various treatments the cat requires. I run down to ICU to set up an oxygen cage for the cat so we can transfer him out of the ER.

2:30 pm: I help my coworker transfer the cat uneventfully to the ICU oxygen cage. Annie, who has been taking care of the cat and knows his story, stays to round the ICU tech who will be taking care of him. I walk back to the ER to disinfect the oxygen cage and set up fresh bedding in it for the next patient.

2:45 pm: The ER handheld rings. our hospital operator is calling. There is a client on the phone who might be having an emergency with their pet. As it turns out, the pet owner just has a question about the medications she is giving. Thankfully, it is a medication I know about and I'm able to answer all of her questions without having to go tracking down the patient's chart.

2:55 pm: Downtime. I check my work e-mail and catch up with my coworkers on what's been going on today.

3:15 pm: Our ER phones and handhelds call the page: "ER TECH TO THE FRONT FOR TRIAGE. ER TECH TO THE FRONT FOR TRIAGE." It's my turn. I look up at our ER monitor that has views from several of the security cameras in the hospital. One of them shows our lobby. A client has just walked in the door with a large dog on a leash who is wagging her tail. I head out the ER door. The dog is a Lab and while she has a graying muzzle, she looks to be in pretty good health: she is quite perky and friendly. I introduce myself to the client as one of the ER techs and get a quick history about the dog. She has vomited a few times today and had one bout of bloody diarrhea. I take some quick notes on the ER sheet and proceed to check the dog's respiratory rate, heart rate, gum color, and capillary refill time while the client finishes filling out paperwork. Her gums are tacky and her heart rate is a little higher than you would expect in a dog her size at 120 bpm, but she is by no means tachycardic. She has nice strong pulses on her femoral arteries. She's very sweet and tries to lick my face. I laugh and keep my face out of her reach; her breath smells of vomit. Poor girl. The client is done filling out paperwork so I have him bring her over to the scale so we can get her weight.

3:20 pm: I walk the client and the Lab into one of our ER exams. I finish getting the history on the dog and take her temperature.

3:28 pm: I walk back into the ER, add the Lab's name and problem to the list on the board, and write her information down in our ER log. Dr. M, one of my favorite residents, is already waiting. I round her on the history and vitals I obtained and she walks out of the room to go talk to the Lab's owner and do her physical exam.

Yes. Yes he can.
And we know the symptoms!

3:37 pm: Dr. M brings the Lab back into the ER for bloodwork and x-rays. I draw blood from her jugular while my coworker Leah holds her. I put the charge for the ER exam, x-rays and bloodwork into the client's bill in the computer. This automatically causes labels to be printed in the hospital laboratory. Leah walks the Lab down to Radiology to start entering her information in the computer. I run the blood down to the lab, where Rita, our lab tech, is waiting for it to go ahead and run it on the lab machines. I meet Leah in Radiology. I gown up with a 20 lb lead radiology gown and thyroid shield and we lift the dog onto the table. We take a lateral abdomen shot first, then put her in one of the Radiology V-troughs to take a ventrodorsal abdomen view: the Lab is lying on her back with the x-ray beam focused on her belly. The Lab is very good for the entire ordeal and we give her tons of praise. Large breed dogs can be handfuls on the x-ray table: they don't understand what is happening, they are large, heavy and quite strong when frightened, and I know many techs that have gotten injured while trying to wrestle large fractious dogs into position. Slipped disks to techs as a result of trying to manipulate large dogs are a real danger in this part of the job.

Radiology. That's the x-ray table. You an see a small anesthesia machine at the end; that's how we provide patients oxygen. Every once in a blue moon we have one that's fully anesthetized while taking radiographs (like when we have to take placement rads for urinary catheters on cats we've just unblocked, for example. They're sometimes anesthetized for this procedure.)

The screen where I set up the technique we're going to use. Kvp and MAS will vary depending on the size of the patient and body part being radiographed.

"I look so sexy in my lead gown and thyroid shield," said no technician ever.
But they protect us from radiation-induced cancer.

3:45 pm: We send the x-rays to our computer server so Dr. M in the ER can pull up the x-rays to see for himself. I walk the Lab back to the ER and Dr. M gives the go-ahead so I can return her to her owner. The ER handhelds ring again: this time it really is an emergency. A client whose 12 lb Chihuahua mix may have eaten 8 oz of dark chocolate sometime during the day. The dog is acting very agitated and has been vomiting dark brown, chocolate-smelling vomit since the owner got home. I tell her she needs to take the dog into a veterinarian right away, either us or her regular vet. The client says she will try her regular vet. I tell her to let us know if for whatever reason she needs to come to us instead. (Sometimes regular vets insist on an appointment and sometimes they just tell clients to go straight to the ER in this type of situation, as ideally a small dog that ate that amount of dark chocolate will need to be monitored overnight on IV fluids and a constant EKG via telemetry. Theobromine, the component of chocolate that is toxic to dogs and cats, can cause severe arrythmias that can kill a pet.)

3:55 pm: Dr. M gets the bloodwork results and goes back into the exam room to talk to the dog's owner. "ER TECH TO THE FRONT STAT! ER TECH TO THE FRONT STAT!" One of the emergencies we were expecting that was written on the board was a possible bloat, an older German Shepherd. I had already called it, "That's not going to be a bloat. That's going to be a hemoabdomen from a bleeding tumor." After 7 years doing this, you just know. Both Leah and I bolt out the ER door. Leah has a head start and I see her running out the doors of the lobby with the client. I grab the gurney and run after them.

The doors through which Leah and I exit. They lead to the lobby and our exam rooms.
Above the door, you can see the small monitor that shows the views from our security cameras.

4:00 pm: Between Leah, the client and I, we manage to pull the 100 lb German Shepherd out of the back seat of a Ford Focus and onto the gurney. I have to slide in behind the dog to lift him up from the rear while scooting forwards on my knees across the car seat, with Leah and the owner lifting and pulling from the front. (Yes, my job is a constant workout! It is imperative that you have a strong core to protect your back.) Thankfully this dog is not aggressive (it's so much fun trying to lift a painful dog that is trying to bite your face. NOT) and has not had diarrhea all over the seat or himself, like some will do. Of course neither Leah nor I grabbed jackets on the way out and it is 32 degrees outside. I can see our breath in the air. My teeth are chattering but I'm too focused on our patient on the gurney. The dog looks very dumpy, with a distended abdomen and white gums with a yellowish tinge. His pulses are thready and his heart is racing. Shit. My guess had been 100% correct and I hate it: this is not a bloat, it's some kind of cancer along with what is probably an internal bleed. The owner says he hasn't been his usual self for the past week and today she noticed his abdomen. He had collapsed at home. We run back into the hospital, wheeling the gurney. People in the lobby materialize to hold the doors open for us. I turn to the client and in the same calm tone of voice I use on frightened horses, I explain, "He's not very stable so we're going to take him back to the ER so the doctors can start taking a look at him. The front desk is going to have you fill out some paperwork and check in. Is it okay if we place an IV catheter, start IV fluids and run bloodwork?" The client hesitates. Tears are running down her face. "He's old," she says. "If this is bad...I don't know..." "That's fine," I tell her quietly, "I can have one of the doctors come out to talk to you as soon as they take a look at him." She nods as more tears overflow and turns away to fill out paperwork, and we run the gurney down the hallway, Leah and I each with an arm over the dog to keep him safely in place.

4:03 pm: We burst through the open ER room doors into a crowd of doctors and a few extra techs. Everyone knows it's bad when we have to pull a patient out of a car. Someone has tared our main ER table, which doubles as a scale, and between 3 of us we smoothly transfer the German Shepherd from the gurney onto the table. "51.3 kgs," someone calls out. "Do we have permission for anything?" Dr. T, who is already ausculting and examining the dog, asks. I tell him, "The owner isn't sure if she's going to treat and wants to talk to a doctor first." He finishes his exam in thoughtful silence. Dr. T is a quiet, calm doctor with a surprisingly snarky sense of humor, all of the reasons why he's loved by both clients and coworkers.  "Place an IV," he tells me as he heads back out the door to talk to the owner, "He's going to need it one way or another."

4:05 pm: I start clipping and prepping a front leg for an IV. All of the materials I would need: the IV catheter, a T-set, syringes and tubes for blood samples, had already been set up in advance. The dog's paw in my hand is ice cold. I know his blood pressure is going to be very low. His breathing is heavy. He is responsive to us, but barely. Leah is standing next to me writing down what we're doing, a concerned look on her face. "This dog is going to die," she says.  I nod. I have a hard time getting the vein, even though I can see it: it's flat. I get the catheter in but despite it being a large bore 18 gauge, the blood is slow to come out and is almost black in color. I ditch the attempt of obtaining a blood sample (we always get blood from catheters on patients that might get hospitalized so we don't have to poke them again later. The blood gets run if the client gives permission and is necessary; otherwise it gets placed on hold in the Laboratory fridge.)

Because you have to be able to keep your sense of humor in the most dire of circumstances sometimes.

4:10 pm: The German Shepherd suddenly stops breathing and we lose the heart rate. Leah slaps the code button on our ER phone. "CODE BLUE ER! CODE BLUE ER!" The page is heard in the entire hospital and all of the ER and in-patient doctors and interns in the building materialize along with a couple more Ward and ICU techs. The crash cart is wheeled over to the table. I start to hook up the EKG, someone is pulling out atropine and epinephrine, someone else is ripping out IV fluids. Dr. J, who had just started his shift when the STAT was called, is already in the room and starts chest compressions just as Dr. T runs through the ER room doors: "Stop! No CPR." Everyone who is not an ER tech or doctor is thanked by the ER team and they all clear out. Dr. J confirms that the German Shepherd's heart really has stopped and tells Dr. T; he steps back out. We tidy up the patient as quickly as possible: place a pillow under his head and cover his body with a blanket. He looks like he is sleeping peacefully now. Dr. T brings in the owner. She is sobbing. We step out of the room to give her privacy; only Dr. T stays with her, talking quietly to her. Leah goes down to check on ICU and I wait in the hallway so at least one ER tech is in the vicinity.

Our crash cart. You won't find anything like this at your average general practice. Yes, that's a debrillator on the top left. There is a bin with oxygen masks and another one with various sizes of ambu-bags. There is a pole with extra stethoscopes of the cheap-o variety, but they work, as well as pressure cuffs for IV bags for bolusing large volumes of fluid as fast as possible. Each drawer has different things: emergency drugs, reversal drugs, extra IV fluids, IV catheter materials, a laceration pack, rib spreaders and internal defibrillator paddles (for open chest CPR where the chest is cracked open. I've helped with one of those once so far.) Oh and the computer screen next to the crash cart? That shows the EKG from any telemetry packs in use on patients in the ICU, which is a separate department at the end of the loooooong hallway I showed you guys in the first photo of my hospital. The patient on the screen had just been discharged and not yet removed from the computer, which is why it shows a flatline in this case.

4:22 pm: The owner leaves. She has filled out the paperwork for what she would like us to do with his remains. She wants private cremation. Annie has already made up clay for a pawprint and gets it done while I remove the German Shepherd's IV catheter and tape an ID label to his leg. We slide him into a body bag, which is also labeled carefully with all of the patient's information, the client's information, and her wishes for his remains. After putting him away, I put a copy of our Euthanasia form (where the client selected that she wanted private cremation) in our Privates log. We have a separate log for Group cremations and another one for bodies that are on Hold while the owners decide what they would like to do with the remains. The morgue at this hospital is the closest I've seen to a human morgue: we have giant stainless steel freezers where the bodies are placed in their bags on shelves (rather than in drawers like in a human morgue), where our crematorium picks them up. The crematorium has staff that stops by our hospital twice a week.

Our morgue. It's a good day if I don't have to set foot in it. The wet table is for necropsies (aka autopsies), which owners request once in a blue moon when they really want to know the cause of death of their pet.

4:30 pm: The ER handhelds ring. I take the call. It's another client who might have an emergency. I talk to her while helping Annie with the German Shepherd. The client's cat is non-weight bearing on a limb and she can't get an appointment with her regular vet this late in the day. I ask her the cat's age. She is 12 years old. Does she have any known heart condition? No. I tell the client to bring her in to see us. She'll be arriving in 40 minutes to an hour because of rush hour traffic.

4:40 pm: Annie and I walk back into the ER, where Leah is finishing giving the vomiting Lab some SQ fluids (subcutaneous fluids, or fluids under the skin). I write the cat's information on the ER board and set up more IV catheter supplies on our main ER table just in case the kitty is limping due to a blood clot. This is a worst-case scenario, but it is common in older cats with undetected heart issues. Annie helps Leah finish up with the Lab's treatments. The Lab gets to go home on medication for diarrhea and further vomiting. Dr. M disappears to her office to finish up some paperwork before leaving for the day.

5:00 pm: Annie leaves the ER to do supervisor stuff. Leah and I relax for a bit before the next wave of emergencies is due to arrive. I do callbacks to check up on pets that were in our ER the previous day to get updates and then type up client communications to put in their charts. I put the charts back in the doctors' file boxes. I check the weather forecast for the weekend and groan when it looks like we're going to get more rain and 40 mph winds. Whyyyyyy. We get 3 more phone calls about emergencies: one is a referral from a general practice for overnight care, another is a client bringing their pet for an eye issue, the third is a dog that is having difficulty breathing but the owner wasn't convinced about bringing the dog in (you would be amazed by the number of people out there that think it is okay/normal for another living being to have difficulty breathing for prolonged periods of time). Leah had talked to her and pushed hard to convince her to come. They all get written on the board. I grab a cup of coffee and my Kind bar since I don't know when I'll have time to eat next if the night explodes.

6:00 pm: Annie leaves for the day and Mary arrives to start the overnight shift. Mary is one of our most experienced ER techs. She's been doing this for over 25 years.

6:05 pm: The limping kitty finally arrives. It is called as a triage but I run up in case it really is a clot, and am relieved to discover the cat is calm in her carrier. I get a quick history from the client, get her and the cat in an exam room, get a weight and vitals on the kitty, who of course is now putting weight on the leg (adrenaline rush), and walk back into the ER to update Dr. J on her. It's his turn. The ER doctors take turns seeing emergencies. Dr. T will be seeing the next one.

I've met Maine Coons this big.

6:20 pm: Dr. J brings the kitty back into the ER. We take blood pressures on both the leg on which the kitty had been limping (left hind) and the other leg. They match: not a clot. She has a heart murmur but it is a grade I/VI: very minor. We take radiographs of the leg. The kitty gets nervous about being on her back for the cranio-caudal view of her leg, but Leah and I are The Cat Team and we take it very slowly with her, being careful to not make sudden movements (sudden movements and abrupt touching are more likely to frighten an upset cat and can put them over the edge) and to not crank on the leg that has been hurting. We get the views quickly and quietly and take the kitty back to her owner.

6:30 pm: Dr. J can't see anything obvious on the x-rays; they get submitted to an outside radiologist, which is standard procedure at our hospital. We suspect a mild soft tissue injury. Dr. J prescribes pain medication for the cat: buprenorphine. I enter the charge in the computer and go down to the hospital pharmacy to fill the medication. 2 mls of buprenorphine total, but the owner is going to be giving 0.2 ml doses 3 times a day until the medication is done. 2 mls of liquid medication is a PITA to place in a vial: we don't have anything small enough that will still accommodate a prescription label (required by law), and older clients can have a hard time with the tiny numbers on tuberculine (1 ml) syringes. I pull up 2 mls of the buprenorphine and log it in the control drug book. Buprenorphine is a controlled substance so we have to keep very precise records on the amounts prescribed. Amounts left in bottles should always match what is in the log, though math mistakes are not unheard of. The hospital can get in trouble with the DEA if controlled substances go unexplainably missing. I then open 10 tuberculine syringes, fill each one to 0.2 mls, cap them, label each one individually, and place them all into a large pill vial, large enough to accommodate all of the syringes. The pill vial gets labeled with the prescription information and I hand it to Dr. J. Our billing person leaves at 5:00 pm, so I go ahead and put in charges for the ER exam and the extremity radiographs we took, then click the box on the invoice saying it has been reviewed. This way our receptionist knows it is okay for her to go ahead and check out the client.

6:45 pm: "ER TECH TO THE FRONT FOR TRIAGE. ER TECH TO THE FRONT FOR TRIAGE." Mary leaves to go triage. It is the patient with the eye problem: a Shih Tzu. Dr. T will be seeing this one. I go to our Ophthalmology room to get our transiluminator and set up saline eye drops, proparicaine numbing drops and fluorescein stain on the counter.

6:50 pm: "ER TECH TO THE FRONT FOR TRIAGE. ER TECH TO THE FRONT FOR TRIAGE." The transfer arrives. It is a cat with diabetic ketoacidosis. Leah triages and Dr. J takes over, looking over the cat's records and bloodwork. I help Leah get vitals, check the cat's IV catheter and re-tape it, get a blood pressure and start taking notes on a treatment sheet. Dr. J asks me to write up an estimate for 72 hours of hospitalization in our ICU, including IV fluids, an insulin CRI (constant rate infusion), blood glucose curves, blood gases, blood pressure monitoring, an abdominal ultrasound, a urine culture and sensitivity, and a possible central line (jugular catheter). It is expensive, but DKA in a cat this sick is expensive to treat. Dr. J leaves to go discuss with the client. Mary is helping Dr. T with the Shih Tzu, who has a nasty corneal ulcer.

This. It's the ER veterinary pet peeve with referrals. 22 gauge is the second smallest bore catheter used in small animal, with smallest being 24G (there are smaller, but they are used in birds and pocket pets). 22G is standard for cats. The smaller the catheter, the harder it can be to bolus large volumes of fluids into a critical patient. A very sick large dog can end up getting bolused up to 3 liters in quick succession. You need the largest bore IV catheter you can get into the patient.

7:00 pm: The estimate is approved by the client. Dr. J writes up an official treatment sheet and we get to work doing the treatments: obtaining a urine sample via ultrasound-guided cystocentesis (a needle is inserted directly into the bladder. Some very skilled techs can do this blind by palpating the bladder, but the only way I'll do it is if I can see the bladder with the ultrasound (aka sonogram). The aorta runs very close to the bladder and you can cause a massive bleed and even kill the animal if you make a mistake. You can see both the bladder and the pulsing aorta with ultrasound), starting IV fluids, giving IV medications. "ER TECH TO THE FRONT FOR TRIAGE. ER TECH TO THE FRONT FOR TRIAGE." Mary gets it. It turns out to be a dog with a tick. Yes, you heard that right. A dog with a tick. Mary brings the dog back, laughing, removes the tick, and takes the dog back to the owner. No charge for something that only takes a second. In the meantime, we have to give the cat a couple of fluid boluses to get her low blood pressure (80 mmHg systolic) up. She responds and perks up a bit. I help Leah transfer her to the ICU and we round the tech who will be taking care of her on her history, problems, treatments so far, and plan.

Dogs would love it if this was an acceptable treatment.

8:00 pm: A lull. Dr. T is off doing paperwork in his office where he can avoid distractions and Dr. J is typing on the ER computers. He will tell you he doesn't like people but to interact with him, you'd never know. He's cut from a similar mold as Charles, which means he's very, very fair with people, especially coworkers and especially our baby doctors (the interns), and has a fabulous sense of humor even in the middle of the most stressful situations. Dr. T is the calm in the center of the storm, Dr. J is the ray of light. We get a phone call: a dog vomited what looks and smells like poop. The dog is otherwise acting normally, so I'm guessing the dog just ate poop and then vomited it back up, but this can also be a sign of a really serious obstruction (less likely in this particular case because the dog is acting normally) but I tell them to come in to play it safe. They'll be here in 30 minutes. I write it on the board. This phone call turns the conversation into a typical one for our ER: Leah somehow heard of chocolate butthole molds (you should read the article but NOT on your work computer screen. It is hysterical. It is not graphic (though there is a video) but the title is BIG so you may want to check it out while at home or on your phone.). The conversation shifts to the turd twister. And some pills you can take to make your poop glittery...they are sold on Etsy. What??! Why?? The conversation just gets more and more ridiculous, like a snowball rolling down a hill, culminating with looking up the size of Elvis Prestley's colon. I'm laughing so hard there are tears running down my face. Of course this entire conversation happens before I go heat up and eat my Lean Cuisine frozen dinner in the tech lounge. Poop, blood and vomit, whether in conversation or in reality, have no effect on the appetites of those that work in the medical field. I check my phone, thinking of Karen. It's after 6:00 pm in Colorado. She usually texts around this time and I'm always trying to stay in front of her and text first, but I never seem to be able to. I love her texts. Of course she has beat me to the punch yet again, so I take advantage of the quiet time to respond and text back and forth with her.

9:15 pm: "ER TECH TO THE FRONT FOR TRIAGE. ER TECH TO THE FRONT FOR TRIAGE." The dog that vomited feces comes in. It's an adorable Shepherd mix. Young dog, wagging his tail in the lobby. I put him and his owners in a room and get a quick history while getting his vital signs. Everything is normal. He tries to lick my face but I duck to avoid the poop breath, laughing. His owners are awesome and also have a great sense of humor.

9:25 pm: I give Dr. J the history and he walks into the room.

9:30 pm: "ER TECH TO THE FRONT STAT. ER TECH TO THE FRONT STAT." Leah runs out before Mary or I can move. I watch the cameras to see if Leah is going to need help. No: it's a client with a carrier. Leah is talking to her. I see her take off running with the cat, back towards the ER. I hold the door open for her. The cat is having a hard time breathing and the client is signing the emergency stabilization form. Dr. T is in the room with us and he does a quick exam after we remove the kitty from his carrier. Bad heart disease. Mary already has the oxygen cage on. We don't get vitals other than a weight and a heart rate: we're working fast and stuff like getting temperatures can really stress an already stressed out cat. We place an IV catheter, get enough blood for a mini panel (our mini panel includes renal values, hematocrit, blood sugar, electrolytes and blood gases), give a dose of furosemide (Lasix) and let the kitty chill in the oxygen cage with a litter box and a bowl of water (furosemide is a diuretic. It helps pull fluid from the chest but will also make patients urinate and drink more). Mary is already starting an estimate for the clients: 48 hours of hospitalization in oxygen, bloodwork, chest x-rays, a Cardiology consult with an echogram (ultrasound or sonogram of the heart) and EKG, blood pressure monitoring, injectable meds. Dr. T goes to talk with the clients.

9:45 pm: Dr. J is typing discharge instructions for the dog that vomited feces: the dog is just starting to have diarrhea, information which was omitted when I obtained the history. Another common occurrence: clients don't always give the same information to techs and doctors. It's not deliberate; they just tend to remember things the more they talk, which is why a history is obtained by both a technician and a veterinarian. Dr. J is sure the dog just ate his own stools; he gives the owners a script for metronidazole and I fill a prescription for Cerenia, an antiemetic (to prevent vomiting). Leah stays in the ER watching the cat.

10:00 pm: Dr. R arrives on duty. She graduated from our internship program and is a kind, sweet doctor. She is working the overnight. We update her on what's going on with the kitty in the oxygen cage.

10:05 pm: Dr. T walks back into the ER. The cat is being admitted. His owner wants to say good-bye so we make sure the ER is presentable before Dr. T walks her back. Mary goes to set up the other oxygen cage in ICU while I run the blood sample for the mini panel on one of our lab machines.

Our lab

10:20 pm: The cat's owner leaves. Leah and I finish obtaining vitals, including a blood pressure, then give the cat a 15 minute break in the oxygen cage. He is a really good boy and we are extra extra gentle with him, but his respiratory rate inevitably goes up whenever we are handling him. I go set up the x-ray machine and both Leah and I gown up with the lead gowns and thyroid shields. I make sure we have oxygen ready for the cat in the room. Getting chest radiographs on an animal that is easily stressed that is having difficulty breathing and whom additional stress can kill, is incredibly stressful for the people working to get said radiographs. The cat's life is literally in our hands during these moments. I go back to ER to get the kitty. We move swiftly and quietly, doing our best to keep the cat calm as we gently stretch him out on the table for the right lateral view of his chest and the left lateral view. We place him in a V-trough for the ventrodorsal view, where he has to lie on his back with his front paws over his head. This position is the trickiest in a patient with heart disease or any chest problems, as it is when they will have the most trouble breathing. In very sick patients we will do a dorsal-ventral view instead, where they are lying sternally on the table, but this position can be a lot more difficult for manipulating the animal so that he/she is perfectly straight to obtain the best view of the chest. I hold oxygen to his face with one hand as Leah presses on the pedal that will take the x-ray. Of COURSE the machine chooses this moment to freeze, like it loves to do when we have critical patients on the table. "FUCK!" Leah and I curse in unison. With one hand still on the kitty, who is being VERY cooperative, I click back to a previous screen on the computer, then re-select the VD shot. Leah steps on the pedal. The machine bleeps. Success! The shot is perfect but the kitty's chest looks ugly. I immediately run the kitty back to the ER to place him back in the oxygen cage while Leah crops, saves and processes the digital images, sending them to the server so Dr. T can pull them up in the ER computers. I remove my lead gown and thyroid shield and hang them back up in the x-ray room.

11:00 pm: Dr. T has us give the cat another dose of Lasix. We transfer the patient down to ICU.

11:30 pm: Another lull. I restock the ER, which involves wheeling the gurney down to Central Storage to get boxes of IV fluids, gauze, syringes, alcohol, IV catheters. I wheel it back to ER and Mary helps me put stuff where it belongs.

A corner of Central Storage

11: 40 pm: I eat my yogurt. I'm exhausted and just want to sit down at this point. It's not even that busy tonight. When I worked weekends, it was common for us to see up to 30 emergencies in a 12 hour shift. I look at the clock and at Leah enviously, who gets to leave at midnight. The phones start ringing. The receptionists are able to field some of them but several get transferred back to us so we can talk to clients. A dog that ate a packet of silica: not toxic, he'll be okay. A dog that is shivering: could be pain; come in if you're concerned; owner chooses to stay home and monitor tonight. A cat that has vomited 3 times, otherwise acting 100% normally, client doesn't really want to leave the house: monitor at home; if vomiting worsens, cat becomes lethargic and/or starts having diarrhea as well, bring it in. One of these is a current client of ours so I have to go looking for the chart so I can write a client communication. The chart is NO WHERE to be found. I finally find it in the interns' office, hiding under a stack of books on one of the desks. I write the client communication and put the chart back where I found it. The dog that couldn't breathe never showed up. We assume it died and consider erasing it from the board, but I decide to leave it up until the end of my shift.

12:00 am: Leah leaves. "ER TECH TO THE FRONT STAT! ER TECH TO THE FRONT STAT!" I run up. It's an older Golden with first time seizures. He's walking but he has another seizure as I start to take the history. Mary is right there to help me lift him and carry him back to the ER. We get permission for an IV catheter and Valium as we run back to the room. 

12:05 am: Dr. T, Dr. J and Dr. R are all in the ER. Patient weighed. IV catheter placed, Valium given IV. The seizure stops. The Golden has nystagmus. Dr. J does a full physical and neurological exam. The dog's reflexes aren't quite right. Our receptionist places the client in an exam room and Dr. J goes to talk to them. 

12:15 am: "ER TECH TO THE FRONT FOR TRIAGE! ER TECH TO THE FRONT FOR TRIAGE!" Mary goes and I stay with the Golden. Dr. R tells Dr. T to go ahead and leave; he's supposed to be off at midnight. He returns to his office to finish paperwork and Dr. R stays with me. The Golden has another seizure; we repeat the Valium dose and call Dr. J to let him know. 

12:30 am: Mary returns to the ER. The patient is a Pug with vomiting and bloody diarrhea. Lots of bloody diarrhea. Dr. R goes into the exam room; Mary stays with the Golden while I work on an estimate for hospitalization with Dr. J: bloodwork, injectable meds, blood pressure monitoring, a Neurology consult the next day. He goes into the exam room to talk to the clients and gives us the ok to repeat the Valium dose if the Golden seizures again. Of course he does.

12:45 am: Dr. J comes back; we're admitting the Golden. We placed the IV catheter in such a rush that we didn't get blood samples. I get the blood from the lateral saphenous vein (on the outside of the hind leg, right above the hock) since this is easiest when the patient is in lateral recumbency. Mary stays with the Golden while I run down to the Lab to get the bloodwork done. I set up the CBC machine to run the purple top blood tube while spinning down the blood in the other tube, a serum separator tiger top. Spinning the blood takes 7 minutes, during which the CBC is completed and printed. I aspirate serum from the tiger top, syringe it into the chemistry cartridge, and set the machine to run. I grab the CBC print out and run back to the ER. It's going to take 13 minutes for the chemistry to complete.

1:00 am: Our receptionist leaves for the night. It's now the ER techs' responsibility to check clients in and out, field phone calls, and take deposits, on top of taking care of incoming emergencies, x-rays, lab work, billing and filling of medications that we normally do. Mary has gotten a blood pressure on the Golden and written down  everything we've done so far on the back of a treatment sheet. Dr. J finishes writing up treatments. No more seizures so far. Dr. R grabs the chemistry results from the Lab. Some minor abnormalities on it, but nothing remarkable. We give the dog a phenobarbital loading dose IV and wheel him down to the Intermediate Care Ward, where our overnight floater has set up a run with plenty of bedding. I start the dog's IV fluids and round the ICW techs while Mary goes back down to ER to get started on the Pug, who also needs things done. 

1:15 am: By the time I'm back in the ER, Mary has finished taking abdominal rads on the Pug by herself. I hold him while she gets blood from one of his jugular veins for a CBC/Chem and PCV/total solids. We run the PCV in our small Statspin centrifuge in ER. The PCV and TS are good indicators of how dehydrated a patient is. Mary goes down to the Lab and I read the PCV: 65% (normal for a dog is 37% to 55%) and the total solids is 5 g/dL (normal is 6 to 7.5 g/dL). Typical for hemorrhagic gastroenteritis, one of the big causes of bloody diarrhea. I tell Dr. R and start an estimate for what we've already done (c-rays, CBC/Chem, PCV/TS) plus 48 hours of hospitalization in the Ward with IV fluid fluids, blood pressure monitoring, blood gases, a repeat CBC and PCV/TS, and injectable medications. Dr. R goes to discuss with the clients.

Because Pugs are cute. :)
Even if sometimes they can't breathe because we've bred the noses out of them. :(

1:35 am: We admit the Pug. Mary goes out to get the deposit from the client and check her out. Dr. R holds the Pug while I place an IV catheter, get a blood pressure and give a couple of IV fluid boluses because the dog's heart rate is elevated, a result of dehydration. He has a huge mess of bloody diarrhea in the cage. I move him to a clean cage and clean up the diarrhea, holding my breath to keep from gagging at the awful smell.

1: 45 am: After the third bolus, his heart rate is a more reasonable 120 bpm. Dr. R finishes writing up the treatment sheet. The IV metronidazole dose she wants seems huge for the size of this dog and I double-check it with her. Yup, it was a mistake. She thanks me for noticing and corrects it. Doctors are human and they make mistakes too: this is why it's important that techs have an idea of correct doses of drugs commonly used in the hospital. Of course during this the Pug tries to eat his IV catheter. He scores an E-collar for his efforts.

1:55 am: The metronidazole is set on a syringe pump to be given over 20 minutes. Mary has already drawn up the other injectable meds. I go set up a cage in the Intermediate Care Ward, lining it with lots of diaper pads. I apologize to the Ward techs for the impending diarrhea disaster that's headed their way.

2:15 am: The metronidazole is almost done. Mary tells me to go home; she can transfer the Pug to the Ward. I gather my stuff, erase from the board the respiratory distress dog that never came in, put on my jackets, and say good night to my ER crew. I clock out.

2:20 am: There is a layer of ice on my car. I turn the car on and blast the heater while scraping as much ice as possible off the windshield.

#$@%^*!!

2:30 am: Driving home. I blast music in the car to stay awake. I sing out loud to Plain White T's Swing to the Rhythm of Love. I drive within the speed limit all the way home because I have to drive through a shady neighborhood and there are usually cop cars around in the wee hours of the morning.

2:40 am: Arrive home. Ambush by Zombie and Aengus at the door. I remove my jackets, shoes and scrubs in the foyer: there are all sorts of cooties at work like MRSI and e. Coli (they happen no matter how much we disinfect; it's just the reality of working in veterinary hospitals) that I don't want in the house. Scrubs go right into the washing machine.  Zombie and Aengus follow me around, meowing because they know they are going to get fed. I turn the light on in the bedroom, say hi to Astarte and snuggle with her for a few minutes. Then I gather all the cat dishes to take them to the kitchen. Aengus and Zombie follow.

2:55 am: Put some chicken breasts to defrost in the microwave, preheat the oven. Feed the cats in their respective spots. Scoop litter boxes. Text Charles to let him know I'm home. 

3:05 am: Chicken is seasoned and baking in the oven. I'm tired but it's that kind of exhaustion that makes it hard to fall asleep. I take a Benadryl because otherwise I'll be up for hours, and step in the shower. 

3:20 am: Sweatpants, warm socks, a T-shirt and a hoodie. Let Aengus out of the bathroom. The apartment feels cold now so I blast the heater for a bit. I sit down to write on the blog, respond to e-mail and comment on blogs.

3:35 am: Chicken is finished. I make some steamed vegetables; set half aside along with a chicken breast for Charles in a Tupperware. Sit at the computer while I eat. 

3:50 am: Charles gets home. Says hi; hugs me and tells me an ER story about a patient that wanted to bite the security guards at the hospital. I will remind you that he works with humans. Children specifically. I listen and comment, but I don't give him details about my evening. Re-hashing right after work gets me wired again; I save my stories for the weekend. I'm just glad my patients are of the non-talking furry type when I hear some of Charles's stories... He goes to take a shower. I drink some chamomile tea with honey.

4:15 am: I start to get ready for bed. Turn the heat back back down to 65. Astarte is done eating so I let her out of the bedroom. I turn on the air filter and the fan on medium. Charles tucks me in with my sheet, blanket and 2 comforters. The alarm is set for 12:30 pm the next day but I know I'll be awake before that, as always. We snuggle for a few minutes and then Charles goes back to the living room, where he'll play video games for an hour or so as he waits to be sleepy himself. I'm unconscious within 5 minutes.

I think you can understand why by the time I get home on Thursday nights, my Fridays, I'm kind of useless, both physically and mentally. It's kind of a miracle, but I manage to NOT dream about the triage and STAT pages that come through our phones all day long.

My work days are long, intense and often horse-less, but I get a long 4-day weekend every weekend to play. :) 

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