How much is that doggie in the ICU?

American ER Doc Gone Walkabout Episode 011

I’ve been comparing Australian and American ER medicine a bit, perhaps a little visit to another world will be entertaining and a bit informative.

We have a nearby veterinary medical school and the veterinarians have an option to specialize in emergency and critical care veterinary medicine. During their third year, they spend a month with a human doctor and I’ve had the privilege of having 2 of the residents spend time with me. During that month, I try to make rounds with them a few times in their own ICU. I’ve also been able to exchange one of our own human residents to spend some time in the veterinary ICU.

We have our GOMER’s (Get Out of My Emergency Room), WADAO’s (Weak And Dizzy All Over). Making rounds in the ICU (cages stacked 2 high around the edges of a large room) we’re faced with the HBC (Hit By Car), ROBO (Run Over By Owner), BDLD (Big Dog Little Dog), BDLC (Big Dog Little Cat). Cute. Typically one or more of the rounding team members will have a cannula inserted because they are getting ceftriaxone for their infected cat (less commonly dog) bite. We at least don’t face being bitten by our patients too often.

Plenty of other interesting little things: Arterial lines in bassett hound ears, reusable chest and endotracheal tubes, general anesthesia for CT scans (and lots of bedside ultrasound – it’s use predates human bedside US – because the animal doesn’t have to hold still). Non-operative management of spleen injuries (in the HBC and ROBO victims) using a bolster and belly wrap to provide direct pressure – the veterinarians have been doing that a long time ago, back when the human surgeons were still taking out every little splenic laceration.

I (and our visiting human ER resident) have been given the opportunity to intubate a few cats. A valuable experience since the cat anatomy so much resembles human neonates, and we get so few chances to tube a little human. It’s nice to do something similar under calm and controlled circumstances. Great learning experience – but, you have to get used to doing it prone rather than supine (the cat, not the intubating human).

I got a chance to tube a horse, but that’s rather a life threatening experience (awake, blind nasotracheal using a tube that resembles a garden hose, in a very large and recalcitrant animal wearing steel shoes). Memorable, but not something that I can translate into human practice.

Instead of GCS they have SACS (Small Animal Coma Score). Who woulda thunk?

The vet approach to bioethics, advance directives, and end-of-life care differs somewhat from the human ER:

“If that was a dog, we’d get a lactate and if it’s over 15, just put him down.”

Or:

“Mrs Jones, your ferret is very ill (with sepsis), and we might not be able to save him. Do you want a ferret, or do you want ‘this’ ferret?”

…I’d love to paraphrase that in the ER:

“Mrs Jones your grandmother is very ill. Do you want a grandmother (we’ve got lots of unattached in the nursing home), or do you want ‘this’ grandmother?”

Since nearly all the veterinary care is paid out of pocket, we get a chance to see a bit of what medicine is like – for the well-heeled – when you have to make direct decisions as to how to spend your money. I was told that about 80% of the dogs who present with DKA – who have short term treatment and are then discharged on daily insulin – are returned for euthanasia within a couple months. Expenses and inconvenience of all the shots. Presumably an occasional dog bite from the dogs who object might be involved here.

Or, expensive advanced care vs inexpensive euthanasia plus adoption of a new dog. Hmmmmm! Which would I choose for my pet? A decision making process that we don’t ever face in the ER, at least not in places that I normally practice.

If you ever get a chance to share back and forth with some veterinarians, take the chance. There are similarities, differences, and learning opportunities in the technicalities of care. And, the decision making of the economics and the goals of care really require turning your head around a few times to think of care in a different ethical framework.Q: “Fido, Would you like us to proceed with this surgery?”
A: “Woof!”

‘Til next time.

Next time:  Overcrowded, understaffed and underfunded… It’s just not cricket