Mind over matter, and test results

The next morning started as all those before it, with my cell phone ringing to inform me it was time to get out of bed. The unwelcome sound is the single part of my day that I never look forward to, even if it could be signaling that this is the day my husband and I will become homeowners. An hour and a few minutes later, I realized that shortly after my alarm went off, as I padded along the carpet to the shower, my phone had signaled again. It was a missed call from the overnight technician, reporting that Pugsley was not improving and had begun odd behavior after vomiting. Could this odd behavior be my worst fear: hepatic encephalopathy?

After ending the call with the technician, I tried to focus on something else for the nearly 30-minute drive to the hospital. Passing no less than five Amish buggies, all on their way to someplace in the general direction of the hospital, it took all of those 30 minutes, and maybe a little more, to arrive in the hospital parking lot. It may not sound like a task worth stressing over, but in morning traffic on curvy country roads painted with double yellow lines, it was enough to sour my morning. (Note -- it is presumably legal, as everyone does it, to pass a buggy with a "slow moving vehicle" emblem, despite the double yellow line. It's just potentially more hazardous.)

When I arrived, the first thing that I did was check on Pugsley in the ICU area, where his mom, my technician, was already waiting just outside his kennel. Although his eyes were bright and he seemed to revel at the attention he was getting, the jaundiced color belied any improvement. The yellowing had spread to his inner lips, and what I had seen the day before in his sclera and inner pinna had increased in pigment intensity. Despite the abnormal appearance, the rest of his physical exam remained normal, and he still had a spunky attitude around his mom, giving her Pug kisses of reassurance.

Still wanting to find a way to get doxycycline into him, my technician asked if there was some type of transdermal form, knowing that her dog was still marked NPO. I had never heard of a transdermal, and even if such a form was available, I suspected it would have questionable metabolism. Despite my doubts, I agreed to call the compounding pharmacy, and they were able to get injectable doxycycline from the local human hospital. The unfortunate part was that it cost several hundred dollars. Considering the options, the inventory manager agreed to call a local veterinary supplier stationed less than a mile from the hospital. Finding injectable doxycycline in stock, a technician left the building to pick it up almost immediately. Perhaps this would be the saving grace for Pugsley.

When the drug arrived back at the hospital, I already had his dosage calculated and had spoken with a pharmacist regarding its dilution and slow IV-drip administration. I was prepared to give Pugsley what I wished would help him turn the corner. I hoped beyond all hope that it was not too late for this to be effective. As it stood, I was treating the unknown, and frustration at my inability to find the "silver bullet" was settling in my mind.

The afternoon proceeded, and finally, a few minutes before 4 p.m., I was paged to take a call from our client/realtor. My heart seemed to miss a beat as I answered, waiting to hear the news and thinking it would be something to celebrate. I never expected to hear anything less -- this is a buyer's market and my husband and I offered the asking price for the house. What I heard made my heart sink; she could not tell me any information over the phone. Rather, she was on her way to get the answer from the selling agent and would be dropping by the hospital in the next hour or so.

In the meantime, I occupied myself by picking up dinner with a technician and her sister, a receptionist. By the time we returned with our sub sandwiches, I could see the client/realtor exiting her red car. I ordered the car I was riding in to stop immediately. I needed to hear "the news." I walked with her to the doctors' office, asking for the bottom line.

Her answer: "There's good news and bad news." That there was even a small amount of bad news was not what I wanted to hear at that moment.

The good news was that the sellers had accepted our offer. The bad news: They did not accept our request in its entirety for the sellers' assistance with closing costs. My brain immediately started churning the numbers, transferring those in an exploding fashion onto paper. Could we do this? Could Mark and I come up with another several thousand dollars upfront?

Disappointingly, it did not seem that would be the case. Now, with tears in my eyes, I delivered the news to my husband over the speaker phone. We had already made some plans in our minds for the space over the garage. We had visions of the future dog and children playing in the enormous backyard. In short, we had gotten our hopes up way too soon, and now the reality was that it simply would not work for us.

I had little time to mull over the disappointment. A receptionist informed me that a transfer from one of our satellite offices was on the way in, and that it was a vicious dog, yet one in pain. As the appointment schedule bore out, I only had 20 minutes to see the dog and figure out the problem.I wiped my tears, but they started all over again when I saw the surgeon in the hallway before my first appointment. She knew of our house saga, and I told her of the disappointing news. After telling the story again, I took several deep breaths and straightened out my lab coat. I had appointments to see, and I could not waste precious moments worrying about what would not be. I whispered to myself before entering the exam room, "If it was meant to be, it would be."

Indeed, the dog that was first on my appointment schedule was vicious, snarling when I walked in the exam room, with a stance suggesting she might lunge at me if I moved an eyebrow in the wrong direction. Away from her owners, the evening technician (not Pugsley's owner) and I were able to muzzle her. I did a physical exam to the best of my ability and could not illicit where the pain was coming from; everything I touched made her growl. There was something about her stance, however, that made me think of the acute abdomen patient.

Back in the exam room, the owners, an older couple, were hungry. Before I suggested they take the path across the parking lot to the Smoketown Diner, I questioned them again about anything the patient could have eaten that she should not have, anything from toys to human food. I continued to get negative responses. I suggested sedated radiographs and after receiving consent, sent the owners on their way for dinner.

Looking at the digital films in between other appointments I was convinced that there was something unusual just beyond the stomach. While the irritated patient was sedated, I decided it would be a good idea to send down some barium. To protect the trachea, the plan was to intubate her and then pass a gastric tube to deliver the barium. Of course, as per usual, the plan was not going to happen ideally. The sedation was wearing off, and she had enough jaw tone to attempt to clamp her teeth down on my hand. As I am particularly fond of my fingers, we opted to give her some isoflurane by mask first.

After the now-anesthetized patient allowed intubation, I lubed up the gastric tube and measured for its placement. With the dim lights in the radiology room, it was a blind push into the esophagus, but fairly easy. I held the gastric tube as far above my head as I could, while still pouring in the barium, letting gravity drive it downward. The radiographs over the next hour and a half were concerning, as the barium seemed to simply stop just past the stomach. Looking at the digital films taken in a series, I could have thought I was looking at the same film.

Finding that the owners had returned from dinner, I took them to the ultrasound room to look at the radiographs on a large monitor. I explained that I was still very suspicious their dog had eaten something that was stuck in the intestine, thus not allowing the barium to pass. Then, as if a light bulb clicked on in her head, the female owner stated, "Well, I did give her a bone last week, but I try to buy all 'Made in America' bones, not made in China. And with natural ingredients." Chinese- or American-made, that might have been the answer to her pain.

Unfortunately for the night technician, we could not keep the dog anesthetized all night, and the decision was made to schedule her for surgery in the morning, on my day off. I would have jumped at the chance to do an exploratory that evening but stabilizing her overnight with pain medications, fluids and pre-operative antibiotics was the plan. Calculating a CRI of pain medications was a snap this time; not because I had learned something magical with the metoclopramide CRI earlier, but rather because there was a cheat sheet with drug doses calculated per liter and hanging outside the surgery suites.

The only way to handle the painful patient later in the evening was with an e-collar, cautious handling and a little bit of luck. The e-collar served the dual purpose of keeping her IV catheter in place and giving the night technician a few inches of distance away from her teeth and lips that were snarling again as soon as she woke up. When I left that evening, it did not seem as though the pain medications in the IV drip were offering as much comfort as I had hoped, but tomorrow I anticipated she would feel much better after surgery.

Pugsley had remained status quo throughout the latter half of the day. When I left that evening, he had moved to the right side of his kennel, off his bed. It was unusual for him not to curl up in his bed, even when he was away from home and his owner. He continued to vomit intermittently, despite all of my efforts. His coloration had not changed, in fact perhaps worsened, but I did not want to see it. I mentally willed him to get better. I hoped that by the time I returned on Friday, he would have turned the corner. Yet, despite my desires, the repeat chemistry and complete blood count were not showing positive improvement. As I left the hospital late in the evening, the science behind veterinary medicine weighed down on my optimism; but for my technician's sake, I would not give up on Pugsley.