Hypertrophic cardiomyopathy

Cats are wonderful creatures. I've been lucky enough to populate my home with them every since I left home for college. As fantastic as they are, they have a few inherent problems which are heart-breaking. The three most common diseases I see in cats as an emergency veterinarian include 1) chronic kidney failure, feline asthma, and hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a disease where a cat's heart walls become abnormally thickened. Specifically, the wall of the ventricles, which are the parts of the heart responsible for pushing blood into the lungs or the rest of the body (depending if we're talking about the right side or the left side, respectively), become so thick that the lumen or center of the ventricle becomes so small that it can't fill up with blood. When this happens, the blood obviously can't be pushed forward. In addition, the atrium, which are the small parts of the heart which push blood into the ventricles, become very enlarged. This in turn leads to back pressure on the blood vessels which lead to the heart. And this back pressure leads to the symptoms of congestive heart failure, because the fluid from the blood vessels may leak into the lungs, or the vessels can't normally drain the lungs or abdomen the way they should.

There are unfortunately other problem associated with HCM. When you have back pressure causing distension of the atrium, the blood inside it tend to sit there, and not move forward how it should. This stagnant blood has a high chance of developing clots. Small clots can come off of these larger clots, similar to how an iceberg is calved off of a glacier, and travel throughout the body, causing havoc. These small clots may lodge in the lungs, the kidneys, the coronary vessels of the heart, or worst of all, the caudal aorta, where the arteries feeding the back legs branch off. This is called a saddle thrombus (aortic thromboembolism), and symptoms include searing pain, sudden paralysis of the the back legs, cold and blue rear legs, and respiratory distress. Occasionally, instead of the rear legs being affected (or in addition), one of the front legs is affected.

HCM is thought to be a familial trait, meaning it may be genetically linked. The underlying cause of the disease is a disorganization of the heart muscles at a microscopic level. Cats can be diagnosed with HCM from a young age until their middle age. They may have a heart murmur, or an intermittent arrhythmia, or their heart may sound completely normal. HCM can be a silent disease, only raising its head through a catastrophic decompensation such as congestive heart failure or sudden death.

HCM is diagnosed by a veterinary cardiologist following an echocardiograpm (ultrasound of the heart). It initially is treated with medication to slow the heart rate, which allows for better filling of the ventricles and decreased back-pressure to the atrium and hence to the vessels. Additional medication may include low-dose aspirin or Plavix, to prevent clot formation in the atrum.

My cat has HCM. She was diagnosed with it in November. She's on a beta blocker and low-dose aspirin. However, despite this therapy, her heart disease is rapidly progressing. She's just turned 8, and I'm not sure if she'll make it to 9. I hate HCM.

Trojan can bite my ass

So I've wanted to write numerous posts, but I did a stupid thing and got a wicked strong Trojan virus on my computer. One of the annoying effects of this virus, beyond the risk of identity theft and having my google searches misdirected every time, was that every time I tried to log onto blogger, my internet connection would crash.

I spent last night finally wrestling with the virus, and thanks to some great information I found online, I think I've managed to clear the thing. Hence, I'm finally writing. So you can expect writings to finally start appearing again.

It's good to be back.

Ship out to sea

There are times when working in veterinary medicine makes one feel very low. I, to my luck, am experiencing such a time right now. Brought on by come clients with excessive emotional needs, and worsened by one or two clients whose only goal appears to be making my heart do a little VPC dance, I am wiped out and feeling mildly hostile to the idea of treating any patients in the near future. add in the stresses of a residency, and I am officially burnt out this week.

What makes it still bearable are the nice clients I get and the most adorable puppy I admitted to the hospital the other day. Every time I see him, I want to squeeze him, put him on a cracker and gobble him up. Of course, that wouldn't help with his pneumonia, but damn if his cuteness isn't the best thing I've seen in a while.

In the midst of my ennui morphing to self-berating, I received an email from a client who I'd met the previous week. Her dog had developed acute kidney failure, and she had been referred to me as soon as the regular veterinarian got the scarily high lab values back. I spent a whole 6 hours with the dog and her owner, and my colleague spent another 5 hours, when we ended up diagnosing the dog with anuric renal failure. It was so sad, with the dog being just 4 years old, but the owner was so grateful for the care we gave, that he made sure to write to us about it. Letters like that are so powerful, providing support that we are doing the best job possible, confirming that we are making a difference.

For this past week, that letter has stayed in my pocket for me to read whenever I have a difficult case. I hope it gets me through the next 5 days.

Death midwife

Seeing either emergency patients or the sickest of the sick in our ICU, I have become nearly immured to death. And that makes me sad. I wish I had the time to truly be with each patient as they dies, pet them for a while afterward, and wish them piece. Or if I could truly be there for the clients, as they realize their beloved pet will not be coming home, helping them start the process of grieving, and ensuring that they have the support they need.

Unfortunately, there are moments where I can only start the process, perform the euthanasia, explain to the owners what they are about to witness, ensure the patient is comfortable and pain free for their last moments. Most times, that is enough. The rare times when death becomes messy leave me broken inside, wishing for a do-over, even though I know that without changing the nature of the disease, the needs of the client, or the time it takes to make a decision to euthanize, that there is nothing that would have changed for the better.

Helping people decide when to euthanize can range between ridiculously easy, or horrifyingly hard. Some clients arrive at my hospital, knowing that their cat is at the end of their life, simply wanting confirmation from me that their decision is appropriate. Other clients, due to extreme love for their pet, lack of medical knowledge, or an inability to admit that their pet is suffering, cannot make the decision to euthanize their terribly ill dog. Helping them come to terms with the fact that their pet will not be able to survive it's current condition, while trying to keep their pet comfortable, is the most difficult task I face.

I would much rather perform CPR, place a chest tube, discuss the allergic reaction, look over blood work results, suture a laceration, monitor a patient on the ventilator, or even treat a terrifying cardiac arrhythmia. 

But instead, I find myself using all my energies to ensure that the owner of this sweet, innocent animal who has severe chest injuries and is bleeding out, or cannot breath due to lungs riddled with cancer, or has severe sepsis with a blood pressure which won't respond to three different types of blood pressure medication, or any other horrific illness or injury with an extremely grave prognosis, understands what is going on with their pet. Meaning I take myself off the floor to discuss everything, repeatedly. Many want assurances that their pet is not in pain. Luckily, I'm able to control most animals' pain. But the suffering, that I rarely can fully control. And that is what breaks me.

I see animals suffering, and have tried everything possible to help them them, and still they suffer. My technicians know when I have a patient like this, suffering, with an owner who cannot yet make a decision which would end their suffering, for they see me constantly hovering over the animal, biting my thumb, rocking back and forth on my heals, wanting to do something, anything, and coming up empty handed.

It is those cases, when I am able to guide the owner to the decision, and then perform the actual euthanasia, that I know it to be the true gift which it is. Those are the times when I am most grateful to be able to midwife a patient's death, knowing that I am helping, that I am serving my patients as I swore to do upon graduation, and that I am hopefully providing some peace for my clients.

Sometimes it actually works

The other week, I did CPR on a puppy twice within 30 minutes. Successfully.

I still feel like a rock star.

Diagnostics

I know that diagnostics can cost a fair amount of money. $200 for blood work is nothing to sneeze at. But if your cat has been ill for 3 weeks, and all you've let us do is a mini blood panel, a single radiograph, and a physical exam, do not be surprised if we cannot tell you what is wrong. Please bite the bullet and go for a full lab panel, including a urinalysis. I would have liked to have diagnosed your cat with acute kidney injury 2 weeks ago when it had a much better chance of responding to IV fluids quickly. Now that it's BUN is 240, and its creatinine is 8.7, my hopes of getting your kitty healthy and home are relatively low.

Shift work

Nearly all veterinarians working in emergency medicine have worked overnights. And most of those doctors dream of being able to do their emergency medicine shifts NOT overnight. Of course, there are a few people who flourish at night. I am not one of those people.

I accept that my chosen focus requires me to be up when most sane people are sleeping. I get that I have to make my brain work more at 3 am than most people would dream (why does everything actively dying come in at 3 am, anyway?). But I would give my teeth (which I end up grinding during the day when I'm trying to sleep) to occasionally have a normal job.

Wait, I lie, I'd be boarded with a normal job. I just want normal hours. And by normal, I mean a normal 10-12 hour shift, not the 8 hour shifts found with people who are not doctors, or with people who aren't in the medical field. Or truckers, cops, fire fighters, or even factory workers. And in that last sentence, I am poorly writing how I recognize that those folks have long, shitty hours too (not that they have 8 hour long shifts).

Tonight, I am staying awake in preparation for working the holiday weekend, Friday through Sunday, for 14 hour each night, overnight. Obviously, the sleep drain is already causing me to lose portions of my functioning brain rapidly. In fact, my mentors can easily guess which day of the week it is by the number of vocabulary words that no longer make it to my mouth. (Me: the patient has that wacky heart rate thing where it's going super fast and scares the techs. My poor suffering mentor: you mean tachycardia?) It's scary, and ugly, just how quickly I revert to survival thinking when I'm on overnights: Mara sees cookies brought in by a grateful client whose pet she has never seen, mine! she thinks as she hordes a handful for later.

When I'm actively working (and not prepping like I am tonight, where I allow myself to be a dumbass because no one will die if I think the wrong thing), and busy, I do okay. My brain gets in a pattern of dredging up useful information, I am able to converse appropriately, and I spend what little downtime I have pacing back and forth in front of my patients. But if it's slow, it's as if I'm swimming through molasses. Yes, I can still catch the important stuff for the most part, but it is painful, and there is constant worry that I'm missing something. That worry stays with me when I go home for my 8-10 hour break from work, and manifests itself as horrific dreams where I'm failing my patients, or pissing off my colleagues, or getting myself sued by a client. And then I wake up refreshed (not), and go back to another 14+ hours of just barely keeping up.

Beyond the brain-numbing aspect of shift work, I find the overnights physically destructive as well. I start out the night, relatively warm, my hair combed, with clean scrubs. By the mid point, my hands are like ice, I've got both a jacket and a blanket on me as I huddle in front of the space heater. I develop bags under my eyes, my vision gets blurry, and every joint makes me feel like an arthritic grandmother in the frozen tundra cackling that snow is coming soon. By 4 am, I am shivering and nauseous, with blotchy skin and chapped lips. My skin either reeks of the hand sanitizer, or my cuticles have split and are starting to bleed. I generally have at least one bandaid on some part of my body. It's a wonder that any clients trust me with their pets when I look that beguiling.

What I'm trying to say is that I really, really, really, really, really, REALLY hope that I'll get to work days or swing shifts if I ever make it through this residency