Working Emergency Over The Holidays

Above: That's how I felt at the end of three shifts in a row at the emergency clinic!

I worked Wednesday, Christmas Eve and Christmas. Although everyone has been complaining that business has been slow this year, it was pretty busy. I had a hard time keeping up with the pace-- it's been a year since I've worked as a technician and to top that off everything had moved (those of you who have worked emergency know that there is nothing more frustrating than not being able to find what you need quickly-- I couldn't even find the muzzles as they were in a completely different place than last time I had worked there!)

We saw a lot of chocolate toxicities, which is typical of this time of year. Giving charcoal or UAA gel to animals is one of my least favorite things to do as a technician. Not because it is messy but because I am terrified of my patients aspirating. I've seen a few charcoal aspiration pneumonias that have been referred to us for overnight care and none of them have lived. I especially dislike giving charcoal when my patient is still heavily sedated from the drugs used to induce emesis or is struggling with me fiercely. In fact, I had one very stubborn (but otherwise totally sweet) chihuahua fight me so much that I told the veterinarian I could not get the full dose into her patient. She then came over to help me and found the same thing to be true with both of us working on getting the charcoal into this dog. She commented that one way to get veterinarians to realize that what they are asking is impossible is to make them help. I know that I am just working relief and so I don't really have the doctors' trust the way a regular employee would... but still I hope that if/when someday I am a veterinarian that I trust my technicians' judgment and don't push them to do things that might jeopardize my patients' health.

I also saw one marijuana toxicity. Classic signs-- ataxic, acting as if it is reacting to something when there is no stimuli, low heart rate, peeing all over the floor. The receptionist asked me to triage the dog and after doing a quick once over (pink mm, normal capillary refill time, low heart rate, acted like it had neurological disease and/or was hallucinating) I asked the owners point blank, "Do you have any marijuana in your house?" I think my bluntness caught one of the teenagers off guard and she nodded. Mom was ready to kill. I felt badly and explained we had no interest in the legality of the matter but that it would be much easier to treat her dog if we knew what it had eaten.

What I enjoyed the most on my shifts was the two things I've always liked best as a technician-- lab work and anesthesia. It was rewarding to find that after not working for so long I still knew what I was seeing under a microscope. I found tons of giardia on a direct fecal smear from a puppy that had projectile, watery diarrhea and had just been treated (suprise, surprise) for giardia. It's been a long time since I've seen that alien face-like trophozoite staring back at me through the microscope, flagella undulating wildly. I also found schistocytes on a blood smear from another patient when doing a differential-- I called out from lab to the vet, "Hey, has this dog had a splenectomy?" To which she replied from her desk, "No, why?" Well, it turns out the dog had splenomegaly. Hmm...

I had a cat with rouleaux on the blood smear, differential was a classic stress leukogram. Nothing too remarkable in my book as far as blood work goes in an emergency clinic. The vet later told me she suspected FIP based on a constellation of signs-- uveitis, high globulins, not responding to treatment. When I showed her the lab work she noted that rouleaux is often found in cats with FIP, has something to do with the elevated globulins. I thought that was interesting.

I also got to be the anesthetist for two difficult anesthesias. The first was a geriatric dog, which made me nervous as after not doing any anesthesia for a full year the last thing I wanted was for my first patient to be old and sick! And it was not a smooth anesthesia-- the dog was too light once the vet started doing something painful, and when I deepened the anesthesia the dog got too deep and so we partially reversed its premed dose of hydromorphone. The vet joked, "This dog either wants to walk off the table or die." No fun. But the veterinarian got her job done in a hurry and I turned off the anesthetic gas expecting a fast recovery. Twenty-five minutes later I was still monitoring an intubated patient on oxygen. Realizing that the patient was not going to wake up on its own, I asked the veterinarian if we could reverse the rest of the hydromorphone. She agreed. About one minute after I gave the naloxone to the dog intraveneously, it woke up. Amazing. In all the years I've worked emergency this is the _only_ case where I've ever had to reverse a premedication.

My other anesthesia was a c-section. I had trouble intubating (super elongated soft palate!) and was nervous because there were no premedications on board and a masked induction, which can make for a rocky anesthesia. Plus, I wanted to keep my patient as light as possible so that the puppies would not be too anesthetized themselves when delivered. My patient's blood pressure tanked and wouldn't come back up no matter what I did-- lighten the anesthesia, bolus fluids, give hetastach... you name it. So finally, once all the puppies were out, the veterinarian had me give a dose of hydromorphone to see if that would help. As soon as I had injected the hydro IV, the dog began to tremor violently. I don't know what was going on. I've never seen anything quite like it (although I did once have a dog seize on a propofol induction). My first panicked thought was that my patient was going agonal, but the continuous, steady heart rate and regular, spontaneous respirations did not support that. Eventually she stopped shaking. (Of course then I was shaking from the adrenaline rush that came from thinking my patient was dying). She had a smooth recovery and went home with her pups the next morning.

I went home at 4:30 am Christmas morning after being on since 5:30 pm Christmas eve. That's emergency. And I came back the same day at noon. Now you know why I konked out like the puppy in the picture after I was done working!