ER Doc I'm Not: A Veterinarian's Brush with Sheer Terror
Blogging is about to get a little more difficult in my world. The kids are home from school. This means that the precious uninterrupted hour that I spent doing this while they were in school on my day off is a thing of the past. I’m currently blogging while sitting on the patio, passively making sure the kids don’t drown in the pool. We’ll see how this goes.
I had one of the most exhilarating experiences of my career this week. Oops, hold on — inflatable toy emergency.
Anyhow, it was a heady mixture of terror and, well, sheer terror.
If I recall correctly, I was sitting at my desk, checking out the "clinic" Facebook page (I may occasionally check my personal page while I’m at it), when one of my technicians ran in and proclaimed, "We have an emergency!"
Last time this particular tech made a proclamation it was because post-surgery dog 'X' was "bleeding a lot." I figured she was exaggerating; she is sometimes prone to hyperbole. But when I sauntered to the back I found the dog covered in blood, looking like a fresh murder victim.
Thus, from now on, when she says, "we have an emergency," I'll know she’s serious. I looked over at my associate, who thrives on this stuff. She was embroiled in a lengthy phone call. My boss was in with an appointment.
Crap, I think. I have to deal with this.
I work at a day practice; in reality we don’t see a ton of true "emergencies." Those always seem to happen at night and weekends. To date, I’ve never seen an actual "bloat" case. (Of course, now that I’ve said that, one will come in very soon.)
I’m more of an appointment, "know what you’re getting" kind of girl.
This was not that kind of thing. This dog was an emergency in true ER form.
She was a 10-year-old Yorkie named "Misty." All I got was "she fell." She was completely limp, her tongue was blue. Her heart rate was around 60 (normal is around 120). I’m thinking she fell off a 3-plus story balcony.
We start her on oxygen and one of my techs places an IV catheter to start fluids. I then go to talk to the hysterical owner.
She explains that it was a totally freak thing. She teaches piano. The dog likes to sit on her lap or her student's lap during lessons. The dog attempted to jump on the student’s lap and missed. The owner said she either hit her head on the corner of the piano or on the pedals. (I would have thought she was full of crap, but I’ve known her for years. She was telling the truth.)
With that, I go back to the patient. In true emergencies, I invariably grab Plunkett’s Emergency Procedures for the Small Animal Veterinarian. Vet students take note: it is an excellent resource! It has step-by-step, concise instructions on how to deal with emergencies.
I go to the "head trauma" section, because that is my best guess as to what is going on. This was like no head trauma case I’ve ever seen, though. They usually come in breathing and with fast heart rates.
Here’s the thing, this dog is dying. I have zero time to think. I have to act on gut feeling only. My gut says "head trauma," so I start following those steps. Meanwhile my brain is going: Really? Are you sure?
I am just a little freaked out, to say the least.
While doing the head trauma stuff, my brain chimes in again: "There is no way this happened from falling two feet off a piano stool. Maybe she had a heart attack or something."
I order a super-stat ECG to rule out cardiac disease. That comes back "neurocardiogenic bradycardia." Basically she got popped in the head so hard, it stimulated her vagus nerve and made her heart slow down abnormally and her blood pressure plummet.
Meanwhile, she’s having intermittent seizures. She did pink right up on the oxygen, though (meaning the oxygen is helping), so I continue to follow the book steps. I give her hypertonic saline and hetastarch to try and reduce the swelling in her brain. Then valium for the seizures.
She’s been breathing slowly during this time. However, suddenly she stops breathing all together. Let me tell you, by this time I’m positively bathing in adrenaline. I might mention, though, that I have not said the "F" word once, which is very good for me.
Let me also interject that I love, love, LOVE my staff, especially during these times. We all work together like a well oiled machine and they help keep me sane.
My other DVM counterpart was also an invaluable source of help and information (she did finally get off the phone; my boss even wandered in to provide sage "old school" advice). The whole teamwork thing is beautiful.
Anyhow, she has stopped breathing, so we place a trach tube and ventilate her manually. In my experience, when I can put a tube in a dog without anesthesia: they’re going to die. I go prep the client for the possibility that Misty won’t make it.
I give her furosemide (a diuretic) and mannitol (basically also a diuretic) to suck more swelling out of her brain.
Miraculously, she starts breathing on her own. Over the next 15 minutes or so, she eventually regains her gag reflex and starts complaining about the tube. I pull the tube and she breathes on her own. She’s still pretty out of it.
At this point, it’s about a half-hour past closing time. We’ve got to get her to an overnight care facility. I call the boarded veterinary criticalist to get her opinion on the owners driving the dog over there.
"No way," she informs me. I’ve got to get a tech to go with me and drive her over there with stuff in case we need to do roadside CPR.
Well, that’s a first for me. Thankfully, nothing bad happened and she got to the ER. She was actually trying to sit up when we got there. As of last week she was slowly improving, but still at risk of complications. Nevertheless, the vet was very pleased with her progress. (Boarded ER vet said I did a very, very good job stabilizing the patient … yay me!)
I can’t tell you how much of a huge learning experience this was. I imagine it may be another 13 years before I see another head trauma case this bad, but I’ll be ready.
Dr. Vivian Cardoso-Carroll