Euthanasia Nightmares

One of the toughest parts of our job as veterinarians is euthanizing pets.  Even if we know that it's the best thing for the animal and is humane, there are still a lot of emotions running through the situation.  Owners are sad that their pets are leaving them and may be questioning their decision to euthanize.  Some are bawling and breaking down in tears while others are very stoic.  Even with our experience it can also be hard on us and emotinally draining. 

That's with everything going smoothly.  And things don't always go smoothly.

On the surface it's pretty easy...you put a catheter or needle in the vein, inject the solution, and in a few seconds brain activity stops.  The huge majority of the time it really is this quick and simple and the pets fall asleep quietly, not waking up.  But when you're dealing with physiology and chemicals you can't predict every single outcome.  Every vet can tell you stories of routine euthanasias gone horribly wrong. 

Today my associate saw a cat we had been treating this week for renal failure.  She wasn't getting any better and the client elected euthanasia.  They placed the IV catheter since the owner wanted to be present, which wasn't an easy task considering that the cat was aggressive, severely dehydrated, and had poor blood circulation.  In the room she gave the injection into the catheter in front of the owner.  Nothing happened.  So she gave some more.  Still nothing.  She ended up giving enough euthanasia solution to kill a 60 pound animal, and this cat was only 8 pounds.  And it wouldn't die!  As this was happening the husband was becoming very upset and even irate that it wasn't happening quickly.  My associate came to the back to get an intramuscular sedative (not deemed necessary at first because a catheter was in place) and the husband came into the back, grabbed her arm, and said that she needed to find someone "who knows what they are doing."  I was busy so she eneded up giving the sedative and then once the cat was out giving an injection directly into the heart.  Definitely NOT a smooth procedure, and it resulted in a very mad client.

There was nothing she did wrong and this was an unusual outcome.  The catheter was placed properly, the solution didn't come out of the vein, and she used far more than is typically necessary.  She has been practicing for longer than I have, has worked at emergency clinics, and is a very skilled doctor.  We think that the cat's circulation was just so poor due to the disease that the solution was having a hard time reaching the brain.  It was tragic but not something that could be helped.

I've had similar things happen to me.  One time a cat lept into the air screaming as I gave the injection, then landed hard on the table dead.  I've had pets suddenly jerk, causing the needle or catheter to pull out, necessitating further pokes.  Sometimes the calcuated dose isn't enough and the pet doesn't pass away quickly, requiring additional dosing.  In rare cases there will be significant disorientation, causing the pet to cry out or thrash as the drug takes effect.  These situations don't mean that the doctor did anything wrong or is somehow incompetent.  They are rare and bother us as much as they bother the client.  It's also hard for us because we have both our own discomfort as well as the client's obvious sorrow to work through. 

Thankfully these "nightmares" are rare even though every vet can tell you times when they have happened.  Almost every time it will be quick, smooth, and easy with a very peaceful, painless passing.  I also don't want to discount the cases where the doctor does make a mistake or do something they shouldn't (I'm sure I'll get comments about those).  But there are times when everything is done correctly and it still goes wrong.  Those things are bad enough normally, but it's even worse of an emotional impact when someone is going through the passing of their pet.

Fragile Birds

Birds are surprisingly fragile creatures, especially when it comes to illness.  Anyone who has worked with them medically knows how quickly they can seem to be come sick and how serious that is.  That was reinforced today.

A cockatiel came in for breathing problems and bubbles from the nose.  The owners had just noticed it last night, so they didn't wait to see if it would improve.  The bird was alert when it came in, but I could hear some "clicks" when it beathed.  I started doing my exam and heard a lot of fluid in the lungs and air sacs.  It seemed to be getting stressed, so I started to put it back in its cage to prevent further handling.  As I did so it started to act strange, and in less than a minute had died in my hands.  All of this was right in front of the owner, so they know that I didn't handle him roughly, but they were also surprised.

Why did that happen so quickly?

Birds hide their symptoms better than just about any animal.  Once a bird acts sick it actually means that the illness has progressed to the point where they can no longer hide it.  "Sudden" onset of symptoms is actually the last part of a bird that has been sick for at least a few days, rather than a true actue illness.  So when a bird acts sick, they should be brought in right away rather than waiting.

When a bird is this sick even gentle and appropriate handling can push them over the edge.  In this case there was so much fluid in the lungs that even mild handling caused a rapid breathing and difficulty getting enough oxygen.  The bird would probably have died in 24 hours anyway due to the fluid in the respiratory tract; the stress from handling just hastened the disorder and happened so quickly that there was no way to intervene.  This is only the second time I've had that happen to me, but I was trained that this was a possibility and am careful to always try and warn the owners about this possibility.

It's sad, but it's part of doing medicine on birds.  They are fragile little creatures and don't give us much warning before they become seriously or critically ill.  Again, the lesson here is to bring a bird to a qualified vet at the first sign of illness; but even then some patients can't be saved.

Vaccines, Side-Effects, And Brain Damage?

Here's one from Stefanie...

I just came across this blog that mentions vaccine induced meningoencephalitis.  Apparently this occurs with the rabies vaccine.  Have you ever seen this in your practice and how common is it?  

http://petblogsunited.blogspot.com/2012/09/what-would-you-do-to-save-your-dogs-life.html

Let's begin by saying that ANY medication or treatment can have complications.  Go pick up any over-the-counter medication in your medicine cabinet and read the small-print.  I'll bet you never realized how potentially dangerous aspirin and cold medicine can be.  If you want a real scare, go onto WebMD and put in any symptoms you might feel every week.  You may come out of that thinking that you need to update your will.

My point in bringing this up is that most of the anti-vaccine people quickly point to death and other serious complications of vaccines.  However, the actual incident rate of such things is very small.  On average a serious side-effect happens less than 1 in 10,000 times, so a dog or cat has less than a 0.1% chance of a significant reaction.  Can bad things happen?  Absolutely.  But they are the exception rather than the rule and vaccines are overall considered very safe for the majority of patients, as well as being far better than the diseases we're trying to prevent.

In my 15 years in practice I have given countless thousands of doses of vaccines.  Figure that I see around 100 patients per week and half or more of those receive vaccines.  A little quick math...50 work weeks in a year...2500 x 15...so I've given somewhere around at least 35-40,000 vaccines so far in my career.  Out of all of those I've seen 4-5 truly anaphylactic reactions that almost resulted in death.  More common reactions are vomiting, facial swelling, and hives, but even those happen less than 10 times per year (still great odds) and are normally just uncomfortable without being life-threatening.  Being sore, lethargic, or running a low-grade fever are all normal for a day or two after vaccines and are not considered "reactions", instead being "responses" that are normal for the immune system.  With proper precautions such as pre-treating with antihistamines or antiinflammatories, these mild reactions can be prevented.  In fact, one of my own dogs had facial swelling after her first adult vaccines, but I continue to vaccinate her with no problems by giving her diphenhydramine injections before and after the vaccines.

So what about the meningoencephalitis that Stefanine mentioned?  This is a serious inflammation of the tissues surrounding the brain and doesn't show up immediately after the vaccine.  It seems to happen more commonly in very young dogs that are given a modified-live vaccine, while rabies are killed vaccines.  In fact, in my searching it seems to be more common after a distemper vaccine than any others.  That being said, it's probably the rarest of all vaccine reactions.  I've never seen one in my career and have never talked to any colleagues who have mentioned this.  It's certainly nothing I ever worry about in my patients or my own pets.

Most of the time you'll see effects like this one and others brought up by people who are against vaccines and are into holistic or homeopathic therapies.  Yes, they can show incidents of such problems, but they are overwhelmingly the minority of cases and are statistically rare.  They are also impossible to predict ahead of time.  Make your own decisions but realize that most vets continue to use vaccines on their own pets without concern.

Do We Love It?

One of the comments on yesterday's blog was an interesting one to me.

I'm starting to question whether most vets love what they do or not. A great majority of the ones I talk to do not. 

Several years ago I saw a survey in a veterinary journal stating that around 80% of practicing veterinarians loved their job and would choose to do it again.  I had a hard time relating to that study since I was in the 20% that didn't feel the same.

I think that most professionals reach a point in their career where they question their choice.  What was once a dream and a passion becomes routine and just a job.  When I first graduated from vet school I loved my job.  I was eager to put my knowledge to use and took pleasure in going to work every day.  As I practiced longer I began to feel the stress of the duties and responsibilities.  I also kept seeing the same kinds of cases day in and day out, which was not very exciting or interesting.  Fast-forward a few more years and I hated what I did and dreaded work every day.  Now the pendulum has swung back and I don't mind work most days, even though it is still a job.

As I mentioned yesterday there are a lot of stresses that come with being a vet, especially when you start realizing how many serious decisions you have to make on a daily basis.  For the most part I would say that it is a rewarding career, and I've gotten so I actually like what I do most days.  But would I do it again?  No.

As is typical, hindsight is 20/20.  My interests have also changed over the years to where I enjoy other sciences and history more than I did when I was younger.  I also discovered a love for teaching.  So if I had to do it over again I would likely go for a PhD in history and become a college professor.  Knowing then what I know now would have completely changed my future.

Would I recommend a career in veterinary medicine to someone at this point?  Possibly, yes.  The circumstances are different than when I applied almost 20 years ago, mainly in regards to the financial picture and debt load.  I do think that someone could really enjoy themselves and it's a stable career. However, the salary and hiring prospects are the worst they've been my lifetime with no signs of getting better.

All of this being said, I doubt that veterinary medicine is alone in these feelings and outlook.  

Fatigue

Though today was busy, it wasn't the worst day I've had.  Yes, I'm tired but have been far worse in the past.  Even so, it brings to mind just how hard we work sometimes.  I think that most clients don't realize that working at a busy veterinary practice causes fatigue in different ways.

Most obvious is simple physical fatigue.  I work from 9am until 7pm and on days like today I don't stop for the entire 10 hours.  I eat lunch while I'm typing medical notes or am calling clients.  It's not uncommon for me to barely sit down all day, leading to some sore feet and legs by the time I leave work.  Constantly going and going at that pace will really wear a person out.

Next is mental fatigue.  Much of the day I'm having to juggle cases, switching from well pets to sick ones in an instant, and having to keep track of which set of lab results goes with which patient.  Then there is the challenge of difficult cases.  When symptoms don't make sense or when lab results don't give answers you really have to work the ol' brain muscle to try and figure out what's going on.  Such rapid flip-flops between cases and such continual stress can burn out brain cells.

Then there is compassion fatigue.  This is a legitimate phenomenon among many health-care professionals as we have to show caring and feeling to man different people in often difficult situations.  Just today I had to euthanize three pets and all were crying.  I have to counsel them and help them through their decision all while maintaining a professional, clinical demeanor.  I also have to work with people faced with tough financial situations and how that affects their pet care.  Then there is my staff, each of whom may be going through problems and trials on their own.

Most vets love their jobs and find them very satisfying.  But that doesn't mean we don't get worn out.  This is a very, very difficult career for many reasons.  Sometimes it's nice to help clients understand the realities of doing what we do.

Necessary Dental Work

I received this email from Barbara,

My family owns a small mix breed that needs her teeth cleaned, however the vets around my area are instantiating on extensive dental work. They are telling us that there is no point to just clean her teeth and will not do the basic care. Is it true there is no point in the basic because there is more extensive work that must be done?

Well, it's a little hard for me to give a precise opinion without knowing more details about the case, such as exactly what is meant by "extensive dental work".  However, I can imagine that there may be receeded gums, periodontal disease, loose teeth, and so on.  If such is the case, then simply cleaning the teeth isn't going to help.

Let's say that you have a car that isn't in the best of shape.  The floorboards are rusting, the tires are balding, and the bumper is hanging at an odd angle.  So you decide to spend a hundred dollars to get it professionally waxed and detailed.  Does it look better?  Sure!  Have you don't anything to fix the car?  Nope.  You may still have a bumper fall off, tires that aren't safe, and might put your foot through the bottom of the car.  So what have you really done to help your car be safer?  Nothing.  What was the purpose of spending the money merely to make it look better?

While not a perfect analogy, you can use it to describe teeth.  When there is periodontal disease, especially with loose teeth or erosion of bone, doing a basic dental cleaning isn't going to help.  That's like washing and waxing a rusting car.  In order to fix the problem you have to get below the gumline, extract infected teeth, and treat the problem.  If you merely clean the tartar away and polish the teeth you haven't actually fixed anything.  In fact, you've ignored the real problem that is brewing where you can't easily see it.  Since you're putting the patient under anesthesia with those associated risks, you are doing a procedure that doesn't really fix anything.  Sure, the teeth look a little better but that's a false sense of security.  The problem is still there and you've spent the money without truly fixing anything.

In similar situations I have also refused a basic dental cleaning.  I don't know if that's the case with your dog, Barbara, but I hope this explains it a little better.

Dragon*Con 2012

Just got back from one of the biggest multi-genre geek conventions in the US, Dragon*Con.  I'm very tired, but had a great time.  Here are a few choice pictures of me and my family in a couple of our costume sets.  All costumes were made by my wife, who runs A Touch Of Magic Costumes.

These are pictures of us as Snow White, Prince Charming, Emma, and Henry from the TV show, Once Upon A Time.

These are pictures of us as steampunk versions of the Thundercats, which I guess you can call "Steamcats".

Yes, we're a bit crazy and geeky, but at least we can do it as a family!  Not your typical family, but we have a lot of fun.