What was we to do?

Sorry it has been so long since I’ve shared a story. After many encouraging emails, I finally worked up the courage to write another blog post. Here is a shortie but a goodie and a favorite of many of my friends and colleagues.

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It’s about 2pm on Sunday, and an owner calls with questions about her dog. She says her dog ate a bunch of baclofen (a human muscle relaxer) but he seems fine so far. She thinks more than half a bottle of 10mg tablets has been consumed; there were 60 tablets in the bottle when it was prescribed. She is immediately instructed to contact a pet poison helpline and bring the dog to the clinic as soon as possible. She is informed that dogs that ingest large amounts of baclofen are at risk for vomiting, ataxia (drunken gait), vocalizing / disorientation, but also increased respiratory effort, respiratory arrest, and even seizures. The owner says she will bring the dog in immediately.

Spoiler alert: The owner does NOT bring the dog in immediately.

We promptly forget about the call altogether, assuming she sought veterinary care somewhere else, and move on with the steady supply of cases at hand.

Approximately 24 hours later, it is now Monday – Memorial Day. We have seen about 30 emergencies since 8am; the day has been murderous and we are all beat. A STAT triage is called and a hound dog named Roy is brought to the treatment area on a gurney. He is disoriented, vocalizing, dehydrated, and covered in shit. His heart rate is low, his pupils are dilated, and he has muscle tremors all over. The owners signed an immediate care form, so an IV catheter is placed and a fluid bolus is performed. As I grab the chart and trot off to meet with the owners, a technician grabs my attention and says “This is the dog from yesterday! The one that ate all the baclofen!”

I am immediately floored and think to myself “How the f*** can this dog still be alive, and how the heck can these people be so stupid.”  Little did I know.

I walk up front and call out for the owners. A group of 3 people nonchalantly rise and walk over to me, and I show them into an exam room. They are dressed in farm attire – one man in Carhartt overalls with a large cowboy hat and two ladies in jeans, boots, and musty t-shirts. My nose stings with the smell of manure. These people are COUNTRY. Now country doesn’t necessarily mean stupid, but in this scenario it certainly applies.

Me: I believe you called our facility yesterday. Your dog ate baclofen?

(OK readers – It is imperative that you insert the thickest, most Southern, country accent you can muster up and then add to that accent some very poor English grammar in order to get the full experience of this story. I’m counting on you. Google “Southern accent in the Deep South” if you need help.)

Woman #1 – from here on out, we will call her Honey: Yes a Mam. Maybe half a bottle. Ain’t that right, Mama?

Woman #2 – now introduced as Mama: Yes, thas right.

Me: OK. I know we instructed you guys to come in for immediate treatment. Can you tell me what happened? How has Roy been doing overnight?

Honey: Well, we was half way here when the exhaust blew out on the truck. We was like “Dang. Oh no. What do we do now?” So we thought we betta call a tow. So the tow truck came and we had a decision to make, ya know. Do we continue on our way here or do we go on back home? So we thought, we best go home.

Mama: So we got home and it was late by then. We thought we best just ride this out. But Ol’ Roy couldn’t settle. He started pukin’ and poopin’ everywhere. Then he was actin’ stupid and having seizures and such. We just couldn’t believe how messed up he was. So by the time mornin’ came around, we was tired. You know, we’d been up with him all night.

Man (who up until this time has said nothing): Well yeah, there was no sleepin’ through all that hootin’ and hollerin’.

Me – Silent. Speechless. Telling myself over and over again in my head “Do not laugh. Do not laugh.” I am thoroughly convinced at this time that I am on an episode of Punk’d and Ashton Kutcher is going to jump out from behind the door at any moment to let me know this is a hoax.

No. Such. Luck.

Honey: So yeah, we was tired. So we thought, we betta try and get some rest before we bring him in. So we all shut our eyes for a bit. But then we woke and Roy was no betta. So yeah, here we are.

Me – Blinking. Thinking “Oh shit, it’s my turn to say something.”

Mama: Well, is he gonna be OK?

Me: Yeah, sorry. So I have a couple concerns. Roy is very dehydrated and obviously still under the influence of this muscle relaxer. It is literally a miracle he is still alive. He needs aggressive IV fluids and close monitoring. We will watch him for further seizure activity and make sure he is breathing well. Some of these dogs have to go on ventilators to help them breath until the medication is out of their system. I think that window has passed, but it is difficult to say for sure. I will get you guys an estimate.

Honey: Well I hope he is gonna be OK. I mean, what was we to do?

Me (begin embarrassing rambling / word vomit): Ummm, I mean, I’m kind of a glass half full person, so if you were half way here then it would have been just as easy for you to continue in this direction, as opposed to going half way back home. But that’s just me, and I wasn’t there. And I’m not judging, but I might have done things differently. Nevermind, I think you were asking that as a hypothetical question… I’m just going to go get the paperwork…

Insert wide eyed emoji with the blushed cheeks.

The estimate was approved, treatment was implemented, and Roy recovered well.

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Hostage Situation

It was a weeknight. I’m there for several hours seeing routine appointments when a STAT triage is called. The technicians rush the patient, Twinkles – a Chihuahua that has been hit by a car, into the treatment area. The dog has an elevated heart rate and respiratory rate and one of his eyes has some blood in it (hyphema). His jaw and teeth appear intact, his gums are nice and pink, and there are no obvious wounds.  Twinkles’ pupils are a bit small but equal in size and reactive to light.  An intravenous catheter is placed, a brief neurologic exam is performed, and an injection of pain medication is administered. I go to talk to the owner to obtain a history.

The owner is an older woman and a retired teacher.  She is obviously upset, but her demeanor doesn’t immediately scream: Beware, I’m insane.

Me: Hi, I’m Dr. Smith. Can you tell me what happened tonight?

Woman: What do you mean? I already told the girl who was in here before – my dog was obviously hit by a car.

Me: Yes, I understand that. Does your dog have any pre-existing medical conditions? Is he currently on any medications? Can you tell me how he got hit by the car? For example: Did it bump him or did it go over him completely?

Woman: I just watched my dog get hit by a car. You think I remember the details of that?! Shouldn’t you be helping him right now?!

Me: I understand, Mam. Your dog is stable. I am just trying to get some more information so that I might treat him better. I would like to take some radiographs (x-rays). After trauma, I recommend chest and abdominal views. I specifically want to make sure the diaphragm and the bladder appear intact. I would also like to perform a brief ultrasound to look for free fluid (FAST scan).

Woman: He was hit in the head. Is this all necessary?

Me (frustrated already – Insert emoji with the eye roll): Well, this is some of the pertinent information I was asking you about… He was hit in the head, you say.  Ok – so he was not run over?

Woman: I hardly see how that makes a difference.

Me: It actually makes a significant difference. I am going to go check on Twinkles, but my technician will be in with an estimate.

I leave the room. Twinkles is looking more comfortable.  A dose of mannitol is administered due to the head trauma and the mildly small pupils on initial exam.  I make an estimate for diagnostics and treatments, and I head into another appointment.  When I get out of the appointment, my technician has the signed estimate for Twinkles in her hand.  We take some radiographs, and there is concern for collapsed disc space between two cervical bodies but the radiographs are otherwise unremarkable. The patient was ambulatory (able to walk) at intake, and he had normal proprioception (meaning he knew where his feet were).

I go to talk to the owner and discuss the radiographs and offer a plan of overnight hospitalization with pain medication, intravenous fluids, and serial neurologic exams. I bring with me an updated estimate for the aforementioned plan.

Woman: This dog is my life. He has to be ok.

Me: I understand that. So far he is looking pretty lucky, but we will need to keep a close eye on him. I will likely recommend transfer to the specialty hospital in the morning for advanced imaging and consultation.

Woman: Twinkles can sing the alphabet. He is a very special dog.

Me (alarms are going off in my head – CAUTION: SHE IS NUTS):  Oh, that’s really neat. Here is the estimate for the plan I discussed with you.

Woman: Oh.  I don’t have any money.

Me (Not completely surprised but definitely not amused): Oh.  Umm… so you already signed the initial estimate, which we then performed. So at a minimum you owe us that amount of money.

Woman: Yeah, I needed you to start treating my dog. He was hit by a car.

Me (now notably pissed): Yeah, I understand that. Unfortunately, there are costs associated with treatment. And, as discussed upon presentation to the hospital, all services require payment tonight. Perhaps there is someone we can call for you. Children? Siblings? Friend?

Woman: My kids hate me! There is no one! Only Twinkles!

Me (Thinking: Oh, fuck. My boss is going to kill me!): OK. I’m so sorry, but Twinkles is going to have to go home with you tonight, and we will have to set up a payment plan for all services rendered so far.

Woman: Twinkles can’t go home with me – HE WAS HIT BY A CAR!

Me (Insert emoji with the red face and steam coming from his nostrils): I understand that. Unfortunately, Twinkles can’t stay here without payment of at least the low end of the estimate.

Woman (walks out of the exam room into the lobby): I need to leave!  I watched my dog get hit by a car tonight, and I just need to go rest.

Side note: The doors at this facility lock after 8pm for the safety of the staff in the hospital. All the employees are equipped with keys to let people in and out of the building, but, technically, the clients can’t leave on their own volition.

Me: Mam, that door is locked to keep strangers from entering the building. And I’m afraid you can’t leave until we resolve a treatment plan for your dog. Also, I would like you to join me in the exam room where we can discuss things privately.

Pan out to the lobby where people are clutching their pets closely, sensing the crazy radiating off this woman. I try to assure people with my facial expression that I have things under control. Likely my face reads more like: RUN! ALL OF YOU! SAVE YOURSELVES!

Woman: ALL YOU CARE ABOUT IS MONEY! You thoroughly explained the treatment plan. Twinkles needs to stay! HE WAS HIT BY A CAR!

At this point, I gesture to my technician to please escort the guests in the lobby to various exam rooms. I also quietly ask her to call the hospital manager.

Scenes from a lecture in veterinary school about how to deal with clients begin to run through my head. I squat on the back of my heals to try to make myself small and non-threatening.

Me: Mam, I am so sorry this happened to you and Twinkles tonight. I am sorry that you are not in a place financially where you can offer Twinkles the kind of care he unexpectedly needs this evening. However, I can’t let you leave without paying or without taking your dog with you.

Woman: OPEN THESE DOORS! I CAN’T DO THIS RIGHT NOW!

Me: Mam, please calm down. As I said, I am so sorry …

Woman: I NEED TO LEAVE!

Me: Mam, please listen to me …

The woman charges the reception desk and reaches over the counter.  She promptly picks up the phone.

Woman: I’m assuming I need to dial 9 to get out.

Without waiting for an answer, she dials 9-911.  I hear the operator answer.

Woman: I am being held hostage at the animal ER!

I can’t help it. I audibly laugh.

Me: I am actually glad you did this, Mam. We clearly need a moderator.

She provides the location of the hospital and hangs up.  She then casually makes a cup of coffee and sits in the lobby quietly while we wait for the cops to arrive.  It’s as if she has gotten a little bit of crazy energy out and now feels some momentary relief.  In the meantime, she doesn’t even think to ask for an update on her dog or ask to see him.

This hospital is in a small, safe town, so it takes the cops less than 5 minutes to arrive. I leave a technician in the lobby to babysit her, while I go speak with the other clients.  

I leave an exam room and enter the lobby just as the cops arrive. The woman begins with a rundown of her evening and the events that lead us to this moment. I explain to the officer that the pet is stable and needs to go home with the woman at this time.

Cop (to the crazy lady): Mam, try to think about it this way. If you parked your car illegally and it got towed, then you would have to pay in order to get it back.

I think: Solid scenario, kind officer, but there is no way this lady is going to appreciate this analogy.

Woman: DID YOU JUST EQUATE MY DOG TO A CAR?! TWINKLES KNOWS THE ALPHABET! TWINKLES CAN SING!

The officer and I lock eyes, and I can see that he now appreciates what I have been dealing with for the past 2 hours.

Perfect timing – my manager shows up. Brief introductions are made. Crazy lady meet hospital manager. Hospital manager meet crazy lady and the clever officer with the worthless analogies.

Cop: OK, Mam. Everyone here is sorry for what happened to your dog this evening.  With that said, you can’t act this way.  (He then looks at me). Unfortunately, you can’t hold her here.

Manager: Mam, we will treat your dog with compassionate care and we will monitor him overnight.  Please be here in the morning to get your dog.

Woman (glaring at me): That wasn’t so hard was it?!

Me: I give up.

Saturdays are for shit storms

Occasionally when I work overnight, I have the pleasure of working with one of my close friends (Dr. Z) on swing shift. This particular individual is a wonderfully chill, smart, funny veterinarian who just so happens to be a shit magnet. We all moan and groan when she says she’s stopping by the hospital because we know the minute she walks in all hell will break loose. The story I have for you today entails one such evening when I worked a shift with Dr. Z.

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I walk in and mayhem is immediately evident. There are about 20 hospitalized patients and already 6 triages waiting to be seen. We quickly round then immediately dive into the triages. After working for several hours, it is nearly time for Dr. Z to take off for the evening and leave me to work the overnight shift alone. Surprising no one, a STAT triage is called. I am already working to get an intravenous catheter and sedation into a dog with respiratory difficulty due to congestive heart failure. Dr. Z cordially agrees to stay a bit late to take this last case. The technician comes running back with a cat (Muffin) that is yowling at the top of her lungs. Muffin is tilting her head to the right, her eyes are jumping back and forth (nystagmus), and she is drooling profusely. There is a terrible malodor to Muffin that can’t be ignored, and a severe ear infection is quickly suspected.

Dr. Z goes to meet the owner and obtain a full history. The owner is a paramedic who has driven his cat to the hospital this evening in an ambulance… Because this is a normal scenario… (Insert here: Emoji with the hands on his cheeks and the white eyes of awe). Also, the owner is high. Naturally.

The history is as follows (sarcastic mental comments noted in italicized script): Muffin spends a significant amount of time outside (oh, lucky girl) and is not currently on any flea, tick, heartworm prevent (why would she be?), and she was totally fine until just now (of course she was).

Please note: It is hard not to get jaded when working emergency. I recommend dry sarcasm, a sense of humor, and wine after work, but that’s just me.

Dr. Z takes it all in stride – she doesn’t skip a beat.  She obtains a swab of the ear and looks at the material under the microscope.

All of a sudden, one of the technicians hollers my least favorite phrase: “Can I get a little HELP OVER HERE?!”

This particular phrase always sends chills down my spine because it means something terrible is afoot. There is an incline in the volume and terror in the voice that always accompanies this series of words. It screams: impending doom!!

Dr. Z runs over to Muffin, who has promptly decided to try to die. Her pupils are dilated and she is stretching out and paddling with her front legs. The technicians quickly get an intravenous catheter into the cat and provide flow-by oxygen while Dr. Z runs up to reception to speak with the owner.

Dr. Z explains that Muffin has declined rather quickly and she is about to arrest. She explains that, unfortunately, it is not clear at this time what is causing Muffin to be sick. She has an obvious ear infection, but that finding does not explain her decompensation. Dr. Z asks if the owner would like CPR performed, and the owner says “YES, of course!”

Dr. Z returns to the back/treatment area and starts to work on Muffin. She places a tube into the trachea to ensure a patent airway and provides oxygen. Muffin’s heart is beating, but she is no longer conscious.

Another triage is called, and I head over to perform a physical exam. In the background, I hear Dr. Z say: “What the fuck?!”

At this, I turn around and see the cat spewing a dark liquid substance that I can only equate to black ichor – something straight out of Lord of the Rings, this I know. The volume and force of the vomitus is like a scene from a horror film. I tell my technician to take the most recent triage to an exam room. I then start to head over to assist Dr. Z when a blur runs past my peripheral vision, and I hear a stranger shout:

“IT’S OK, I’M AN EMT!”

Muffin’s owner has snuck back to the treatment area (shoving past my poor technician who was returning to reception with the next patient) and is running to his cat who is in the process of respiratory arrest (and quite possibly some kind of exorcism). He scoops up Muffin and turns around to make a break for it. Dr. Z, being the magician she is, manages to nimbly grab the end of the endotracheal tube between her pointer and middle fingers and pulls it from the cat as the owner starts to run away.  Dr. Z and I lock eyes in a moment of shear amazement.  The owner doesn’t hesitate – he sprints out of the hospital with his cat, hops in the ambulance, and drives away.

IV catheter in place.

No payment.

No Against Medical Advice (AMA) form.

Nothing.

Gone.

A thousand thoughts run through my mind. Begin internal monologue: Did that seriously just happen? … Whelp, that cat is toast… Why does this shit always happen when I’m here?… My family is never going to believe this one… I swear, I need to write a book about this shit (Insert here: Emoji wink face).

After blacking out for an unknown amount of time, I look at Dr. Z. I half expect her to start crying or stressing about the obvious liability with regard to this case. Instead, I see her nonchalantly type a brief medical note detailing the events of the appointment. She looks up, calmly collects her things, and says: “Ok guys! It’s been a good night. See you next time.”

Toes, Teeth, and Tail

I arrive at the emergency clinic and a STAT triage is immediately called. A large shepherd is wheeled back on a gurney, as he is unable to walk.  His gums are pale and he is having a difficult time breathing.  When I try to listen to his chest, I can’t hear his heart.  I reach for the ultrasound and immediately visualize fluid around the dog’s heart (pericardial effusion).  As I head to the lobby to get the owners, a technician hands me the chart (or Bible rather; it is that thick) and says “Good luck!” I review the chart quickly.  Synopsis: Bruiser has a heart-based mass, a splenic mass, and repeat episodes of pericardial effusion; he has been diagnosed with cancer (hemangiosarcoma).  The sarcastic comment from the technician can mean several things. Top differentials include: 1. Owner is crazy, 2. Owner is mean, 3. Owner is crazy and mean.  For this case, the answer was quickly determined to be #1.

I enter the room and am greeted by 5 people: owner (Mr), owner (Mrs), owner’s mother, owner’s father, and (my personal favorite) the animal communicator/family friend.  Also present in the exam room are two other dogs because who goes to the emergency veterinary clinic without bringing all the household pets to help support the sick pet? (Answer: No one. No one brings all their pets with them to the emergency clinic). Immediate alarms sounding in my head.

Owner (Mr): Where is Bruiser? His siblings are worried.

Animal communicator offers a confirmatory nod.

I explain that he is in the treatment area getting an intravenous catheter placed, as he is at risk for impending arrest.  I explain the return of the pericardial effusion and the concerns at this time.

Owner (Mr): We need to hear the most aggressive treatment option.

Me: We can drain the fluid from around the heart.  Bruiser would then stay overnight for monitoring and supportive care. In the morning the surgeon can review the case and Bruiser would likely go to surgery to remove the affected organs (spleen, right auricle) and the sac around the heart.  

Owner (Mr) shakes his head repeatedly while I give my spiel.

Animal communicator: Bruiser is scared right now; he wants us to know that.

Owner (Mr): We would like to put Bruiser down right now.

Me (experiencing whiplash from this complete 180 in treatment discussion): Ok, I understand that this is a lot to take in right now. I definitely think humane euthanasia is a compassionate decision today with everything your pet seems to have going on. The way we do this …

Owner (Mr): We would like to do it right now. This moment. Please go get my dog.

Me (with likely a frustrated expression on my face due to being interrupted): Ummm, ok. I understand this is difficult, but there is a process here. I will need to have you guys fill out some paperwork, and I will get the medications ready.  We will move you to a more comfortable room and we will bring Bruiser on a big, comfy bed.

Owner (Mr): My dog is suffering. I would like him dead right now.

[NOTE: This is verbatim folks… (insert emoji with the teeth showing)]

Me (appalled): Sir, I understand. We will proceed with the euthanasia, but we will need to take the appropriate measures to make sure everything goes smoothly.

Owner (Mrs): We understand.

Owner (Mr): What of Bruiser can you offer me to take home today?

Me: Yes, of course. We can make you an impression of his paw in some clay.

Owner (Mr): No, I would like more than that. Please provide me with his toes, teeth, and tail.

Me (with obvious shock and disapproval on my face): Yeah, I’m so sorry, but I can’t do that.

Animal communicator: Is the concern that the tail would rot?

Me: Yes, among other concerns. Also, it is not easy to obtain the samples you are asking for, nor is it common practice. I can certainly clip some of his hair for you. Otherwise, I can only really offer the paw prints.

Owner (Mr): Oh, you can shave him for me and provide the pelt?

Me: No sir. I don’t believe that’s what I said. I can offer a small hair clipping. … You know, perhaps we should just put a hold on his body so you guys can decide what you would like to do.

Owner (Mrs): No, we will take the paw prints and hair clipping and private cremation.

Owner (Mr) showed obvious disapproval, but I elect to quickly flee the room to get some air.  

I go get the dog while the receptionist goes over the paperwork. When I enter the euthanasia/comfort room with Bruiser, the sibling dogs immediately bark.

Owner (Mr): Please! Sit down!  You are scaring them.

Animal communicator: No, they are trying to say goodbye.

The owner nods.  He then permits me to bring in the gurney and lower it to the ground so we can all surround Bruiser. The owner’s father allows the sibling dogs to sniff Bruiser and then he leaves the room.  At this point, I notice the animal communicator in the corner of the room with a phone in his hand.

Owner (Mr): We are ready to record.

Me: I’m sorry, what?

Owner (Mr): Please get started.

With some trepidation, I go ahead and administer the first injection.

Chanting from all people present (myself excluded): We love you. We love you. We love you.

This is for sure a kind sentiment, but, when chanted, it comes off pretty creepy…. I continue despite the alarms going off in my head. I can’t help but think that I need to check YouTube later and make sure this video doesn’t get published or something.  I imagine the title: Awkward veterinarian euthanizes man’s best friend. I curse myself for not putting the kibosh on the recording, but I just want to get this over with so I continue. 

Me: He is sleeping now. I am going to give the second injection.

The patient peacefully passes away.  I confirm with my stethoscope.  The owner (Mr) then starts wailing and picks up Bruiser’s legs and drops them to the ground repeatedly. He looks straight at me…

Owner (Mr): You killed my dog.

Me: Yes, I believe that was the intention… I’m so sorry for your loss. I am going to go, but you are all welcome to stay and visit and grieve.

Owner (Mr): But we haven’t gotten your photo with him yet.

I immediately imagine a photo of me holding this dog up by the ears as if I am some kind of trophy hunter.  I visibly wince.

Me: Oh, that’s very kind, but I am actually going to have to pass on that.

Owner (Mr): WAIT! Where do we stand on the toes, teeth, and tail?!

Me: I’d like to stress that our paw prints are quite good.