This is right before she came in to work the overnight:
Internmate: How was it today?
Alacrity: Holy shit crazy. [The supervising criticalist] is having a rage storm.
Internmate: Awesome I'm super excited.
Alacrity: BAAAAALLS
this does not bode well:
Dr. Raeqe (criticalist): "I really hate the summer. There's far too much crying. The clients are crying because their pets are sick. We're crying because there's never enough doctors and we're all here until midnight. It's just bad."
weird emergency room skills:
1. Guessing weight.
Hey, that big dog is having a seizure! No time to get it on the scale. Instead, you guess, as in:
That looks like a 45 kilogram dog = 4.5 ml Valium (0.5 mg/kg, 5 mg/ml).
Also useful when you're tapping the sweet Golden's pericardial effusion and she goes into vtach:
That looks like a 30 kilogram Golden = 3 ml lidocaine slowly until she converts (2 mg/kg, 20 mg/ml).
You can also guess weight in multiples of cats. A medium-sized cat is 5 kilograms (12 pounds), so you go:
That dog looks like about the size of 7 cats = 35 kilograms.
2. The ghettecho.
Let's say it's the middle of the night, you have a patient with shitty cardiac output, and an ultrasound. With a little bit of knowledge, you can get yourself a lot of information:
- First, make sure your patient can breathe! Oxygen and sedation are your buddies.
- Once you've sort of stabilized and administered oxygen, Lasix, torb, or other drugs as needed, do a physical. Think about mucous membrane color, lung sounds (are there crackles? wheezes? are they...suspiciously dull or absent?), heart sounds (murmur? arrhythmia? can't hear the heart?), pulse quality (weak? thready? waterhammer? pulsus paradox?), etc.
- Chest x-rays would be pretty great, but your patient might not be stable enough for those yet. You can usually ghettecho while your patient sits or stands in a comfortable position, and you can totally do it through the oxygen cage porthole if needed.
- If your ultrasound has a cardiac preset or probe, use that.
- Figure out how to adjust your depth and gain settings.
- Find the heart with the ultrasound. Sometimes (especially if your patient is hypovolemic) this is harder than you think.
- Is the heart surrounded by a bag of fluid? Heeeey, pericardial effusion! Tap that! (caveat - sometimes you can be faked out by pleural effusion, which looks more like it has sharp corners on flash).
- Okay, next check out left atrial size. You don't need to actually measure it, but is it way bigger than the aorta? Lasix!
- Finally, find the short axis view, and look at ventricular function. The big muscular one is the left ventricle - does it look like it's adequately contracting to move the fluid inside it? If it looks like the walls move towards the center just a little bit, your patient's fractional shortening may be sub-optimal. If the right ventricle (the smaller, curved-around-the-big-muscular-ventricle one) looks really full, think about right heart failure.
- While you're there (if the patient is stable enough), check out the pleural space and the abdomen for free fluid.
The ghettecho is not as useful as a legitimate cardiologist or radiologist echo in any sense of the word, but it does have its place as a middle-of-the-night rough gander at heart function.
3. Euthanizing a wide variety of wildlife.
Ever done an intracardiac stick on a severely injured baby bunny or a tiny bird with a broken leg? It'll make you feel like a terrible person.
4. Standing high jump.
If your patient is larger than a medium-sized cat (see above) or if you are shorter than ~5'10'', you're gonna need to get on the table to do good chest compressions during CPR.
The fastest/least awkward way to do this (the CPR stool is never actually with the crash cart) is to put your hands on the table (while someone else is doing the compressions), vault onto the table in one jump, land (gently) on your knees, and take over.
5. Hitting a moving, challenging target.
You know what's fun? Intubating a healthy dog in sternal recumbency who has just gently drifted to sleep after receiving modest amounts of pre-meds and propofol.
You know what's less fun? Intubating a dog who has arrested in lateral recumbency while wedged between the crash cart and the technician placing the catheter whose head is moving because of the chest compressions while hemorrhagic fluid pours out of his mouth.
Hey, that big dog is having a seizure! No time to get it on the scale. Instead, you guess, as in:
That looks like a 45 kilogram dog = 4.5 ml Valium (0.5 mg/kg, 5 mg/ml).
Also useful when you're tapping the sweet Golden's pericardial effusion and she goes into vtach:
That looks like a 30 kilogram Golden = 3 ml lidocaine slowly until she converts (2 mg/kg, 20 mg/ml).
You can also guess weight in multiples of cats. A medium-sized cat is 5 kilograms (12 pounds), so you go:
That dog looks like about the size of 7 cats = 35 kilograms.
2. The ghettecho.
Let's say it's the middle of the night, you have a patient with shitty cardiac output, and an ultrasound. With a little bit of knowledge, you can get yourself a lot of information:
- First, make sure your patient can breathe! Oxygen and sedation are your buddies.
- Once you've sort of stabilized and administered oxygen, Lasix, torb, or other drugs as needed, do a physical. Think about mucous membrane color, lung sounds (are there crackles? wheezes? are they...suspiciously dull or absent?), heart sounds (murmur? arrhythmia? can't hear the heart?), pulse quality (weak? thready? waterhammer? pulsus paradox?), etc.
- Chest x-rays would be pretty great, but your patient might not be stable enough for those yet. You can usually ghettecho while your patient sits or stands in a comfortable position, and you can totally do it through the oxygen cage porthole if needed.
- If your ultrasound has a cardiac preset or probe, use that.
- Figure out how to adjust your depth and gain settings.
- Find the heart with the ultrasound. Sometimes (especially if your patient is hypovolemic) this is harder than you think.
- Is the heart surrounded by a bag of fluid? Heeeey, pericardial effusion! Tap that! (caveat - sometimes you can be faked out by pleural effusion, which looks more like it has sharp corners on flash).
- Okay, next check out left atrial size. You don't need to actually measure it, but is it way bigger than the aorta? Lasix!
- Finally, find the short axis view, and look at ventricular function. The big muscular one is the left ventricle - does it look like it's adequately contracting to move the fluid inside it? If it looks like the walls move towards the center just a little bit, your patient's fractional shortening may be sub-optimal. If the right ventricle (the smaller, curved-around-the-big-muscular-ventricle one) looks really full, think about right heart failure.
- While you're there (if the patient is stable enough), check out the pleural space and the abdomen for free fluid.
The ghettecho is not as useful as a legitimate cardiologist or radiologist echo in any sense of the word, but it does have its place as a middle-of-the-night rough gander at heart function.
3. Euthanizing a wide variety of wildlife.
Ever done an intracardiac stick on a severely injured baby bunny or a tiny bird with a broken leg? It'll make you feel like a terrible person.
4. Standing high jump.
If your patient is larger than a medium-sized cat (see above) or if you are shorter than ~5'10'', you're gonna need to get on the table to do good chest compressions during CPR.
The fastest/least awkward way to do this (the CPR stool is never actually with the crash cart) is to put your hands on the table (while someone else is doing the compressions), vault onto the table in one jump, land (gently) on your knees, and take over.
5. Hitting a moving, challenging target.
You know what's fun? Intubating a healthy dog in sternal recumbency who has just gently drifted to sleep after receiving modest amounts of pre-meds and propofol.
You know what's less fun? Intubating a dog who has arrested in lateral recumbency while wedged between the crash cart and the technician placing the catheter whose head is moving because of the chest compressions while hemorrhagic fluid pours out of his mouth.
so you're at the ER and your pet is really sick:
First of all, I am so sorry if you've ever been in this situation. It is amazingly panic-inducing and sad. Here are some tips on how to expedite your pet's care and how to make your day maybe a little less terrible. First, one really important point:
If your pet is having trouble breathing, unconscious, having a seizure, has been hit by a car, is bleeding profusely, has collapsed, or has classic signs of a life-threatening problem, there is a good chance that a technician will take your pet from you right away.
This is good. Your pet is going to see the doctor immediately.
You will probably be asked to approve a quick verbal estimate for stabilization. It's usually in the neighborhood of $400, and covers the ER exam, a catheter, and some basic treatments and/or bloodwork (such as pain meds and fluids).
At the place where I work, all "stats" (or legit srsly emergency cases) are brought to the ICU right away by a technician. While this happens, the front desk folks have you (the owner) sign a form where you either approve or decline this emergency stabilization.
To be honest with you, for some emergencies I do not wait for this form. If the pet is very unstable, I place a catheter, start basic treatment, and do some free/under the table tests.
For example:
- If your dog is actively having a seizure when it arrives, a catheter and some diazepam to stop the seizure are not optional.
- If your cat was hit by a car and is yowling and miserable, a catheter and some pain meds are not optional.
If at all possible (I know you are panicking at this moment), please sign the form (or verbally approve the estimate), and give the technician or receptionist a one or two sentence insight into your financial situation and goals re: your pet, as well as any known health problems:
For example:
- "Okay, I have about $300 set aside. If this is really bad, I'll probably let him go."
- "He's a diabetic. I can't spend very much but I want to do everything I can for him with what I've got."
- "She just collapsed. Money is no object - I would do anything."
I totally understand if you are completely hysterical at this moment and cannot do any of these things. Just know that it helps me help your pet if (at all possible) you can be decisive, clear and forthright.
Okay, now some general do's:
1) Be honest, as in:
- "I think he got into my stash, doc!"
- "She just ate some rat poison - here's the package."
- "I think she swallowed my brother's Adderall!"
I am not at all concerned about the existence of your stash, your rat problem, or your brother's Adderall. It helps me get the train moving in the right direction faster if you tell me what your dog ate, rather than me trying to figure it out by clinical signs and guessing.
2) Understand that care at the hospital (especially if your pet is critical) is probably going to be expensive.
There is also likely not very much that your doctor can do to influence the cost. At the place where I work, I have maybe 20% influence over the cost of care (this is by both choosing the cheapest tests/treatments I can for whatever problem, and by sneakily sneakily doing some things under the table...shhhh...).
If you're rude to me, the technicians, or the front desk staff, my desire to secretly help you with respect to the bill goes right out the window. If you crumple up the estimate and throw it at me, you're paying full price for everything. If you call me a used car salesman and swear at the emergency technician, you're getting a letter from the HR department.
You can absolutely be angry that it's expensive. It IS expensive, and it sucks. Here is how to get me, personally (other vets are different, obvs) to help you cut cost corners to the best of my ability:
"Oh wow, that's a lot. I understand that it's expensive, and I want to do what I can. I'd really appreciate anything you can do to help keep the cost down."
That sentence (combined with good manners on your part) will get me to try everything I can (as well as enlisting the help of my colleagues on your behalf) to help decrease the cost.
3) Understand that you may be in the ER for a long time.
It's like a human ER - it takes (a variable amount of) time for tests to come back and treatments to happen. Make no mistake, we will have our asses in gear if your pet is really sick, but if she is stable and can chill with her pain meds while we tend to someone sicker, that's going to happen.
We'll be as quick as we can. Sometimes there's a big lineup for radiology, or we're waiting on the on-call surgeon or technician to drive to the hospital. Or there may be four or five dogs/cats sicker than yours, and limited doctors and technicians to tend to everyone.
I try to get pets who will definitely be staying the night or the day booked in for testing so you (the owner) can go home/get some lunch/get some coffee. Please take advantage of this. I will call you with results, or if anything major happens while you're gone. "Oh, well, we'll just wait for the bloodwork/x-rays/ultrasound," often = three or four hours of sitting in the waiting room.
Unfortunately, asking the receptionists to ask me what is taking so long delays whatever you're waiting for by ~5 minutes for every ask, since the receptionist then has to page/find me, ask me what's taking so long, then I have to stop what I'm doing and explain.
I'd say it delays whatever you're waiting for by about ~10-15 minutes if you bother the receptionist enough times that they ask me to come and update you myself. Instead (and more productively for everyone), ask if you can step out for a coffee and have us call you when [tests/imaging] are done.
4) Understand that some services are not available nights and weekends.
We have one radiologist. She works daytime hours, during the week. If you come through the ER for an ultrasound at 11pm on a Friday or 4pm on a Sunday, ultrasound is not an option until the radiologist is back in the hospital.
This is okay if your dog is here with a possible intestinal obstruction, since x-rays are always available. We also have the flash ultrasound to find free fluid in places where it shouldn't be. However, if you're coming in for chronic gastrointestinal problems or because your primary care vet said, "Hey, the next step is an ultrasound," do yourself a favor and call ahead to see if that's an option today.
I have also had folks ask me in the middle of the night which internal medicine specialists are available right now for consultation. The answer is: none of them, you've got the overnight doc until the morning.
Most specialists work daytime hours, during the week. Some criticalists work on the weekends, and there's always a surgeon on call for surgery/an internist on call for emergency endoscopy, but no specialist is seeing regular appointments or doing consults at 4am.
5) Know your pet's medical history, and what medications (and doses) your pet is currently taking. You can bring the bag of drugs if you need to.
And here's some general don'ts:
1) Don't be mean.
I understand that you're very stressed +/- angry +/- sad. These are legitimate feelings. We are all trying to help make your pet well or help you let him/her go. You are welcome to be stressed/angry/sad. However, you may not abuse me, the technicians, or the front desk staff. If you need a minute to go scream or cry outside, that's totally okay.
2) Relatedly, don't accuse us of being money-hungry or only in it for the cash.
There are numerous articles on the interwebs detailing the approximate cost of a veterinary education (~$250,000-$300,000, not including undergrad). The average starting salary of a veterinarian is hilariously less than that. If you're doing an internship, your salary is likely miniscule.
We're not in it for the money. It's insulting to suggest that we are. Also (see point 3, above), it makes us less inclined to help you catch a financial break in whatever ways we can.
3) Don't freak out if we don't have the records from your primary care vet.
I once had a guy refuse to let me treat his cat (the cat was having trouble breathing) because I didn't have his vet's records. The vet had faxed over the records (but for whatever reason only the first page had arrived) and the vet's office had since closed for the day.
This is insane.
You guys, obviously it is ideal and helpful to have good records, but we operate without them all the time. Unless you brought your own copy with you, I don't get any primary care vet records when I take in cases at night or (for most clinics) on the weekends. We can get them in the morning.
Also, your ER vet is also a vet, and can probably also figure out what is wrong with your pet. Refusing to allow your pet to be treated for this reason is profoundly counterproductive and crazy. Don't be that guy.
Also, if your pet has a relatively rare condition (hemophilia, some uncommon cancers, unusual genetic problem), know the name of the condition (see point 5, above) and how (if) it's currently being treated.
4) Don't automatically reject differences in veterinary opinion.
There are about as many opinions on how to practice medicine as there are veterinarians (possibly more). If your ER doctor suggest something different than your primary care veterinarian, this does not mean that one of the two is necessarily crazy, untrustworthy, or wrong.
If you don't understand the difference, ask. We're happy to explain.
Relatedly, complementary medicine (acupuncture, herbal remedies, et cetera) is really excellent for some things. Western medicine is really excellent for some other things. Some times the circles on that Venn diagram overlap, and sometimes they don't. If your pet has a bleeding tumor in his belly, the Yunnan Bai Yao may help slow the bleed, but he likely also needs a blood transfusion and surgery to remove the mass.
5) Don't panic too much - although it's scary, your pet is in good hands.
Although this may be the first time your dog has been hit by a car, your cat has developed a urinary obstruction, or your puppy ate the entire stash of baker's chocolate, she/he is likely not your vet's first HBC, UO, or chocolate tox. And if it is (heeeeeey, new interns!), there's someone looking over her shoulder making sure she stays on track.
If your pet is having trouble breathing, unconscious, having a seizure, has been hit by a car, is bleeding profusely, has collapsed, or has classic signs of a life-threatening problem, there is a good chance that a technician will take your pet from you right away.
This is good. Your pet is going to see the doctor immediately.
You will probably be asked to approve a quick verbal estimate for stabilization. It's usually in the neighborhood of $400, and covers the ER exam, a catheter, and some basic treatments and/or bloodwork (such as pain meds and fluids).
At the place where I work, all "stats" (or legit srsly emergency cases) are brought to the ICU right away by a technician. While this happens, the front desk folks have you (the owner) sign a form where you either approve or decline this emergency stabilization.
To be honest with you, for some emergencies I do not wait for this form. If the pet is very unstable, I place a catheter, start basic treatment, and do some free/under the table tests.
For example:
- If your dog is actively having a seizure when it arrives, a catheter and some diazepam to stop the seizure are not optional.
- If your cat was hit by a car and is yowling and miserable, a catheter and some pain meds are not optional.
If at all possible (I know you are panicking at this moment), please sign the form (or verbally approve the estimate), and give the technician or receptionist a one or two sentence insight into your financial situation and goals re: your pet, as well as any known health problems:
For example:
- "Okay, I have about $300 set aside. If this is really bad, I'll probably let him go."
- "He's a diabetic. I can't spend very much but I want to do everything I can for him with what I've got."
- "She just collapsed. Money is no object - I would do anything."
I totally understand if you are completely hysterical at this moment and cannot do any of these things. Just know that it helps me help your pet if (at all possible) you can be decisive, clear and forthright.
Okay, now some general do's:
1) Be honest, as in:
- "I think he got into my stash, doc!"
- "She just ate some rat poison - here's the package."
- "I think she swallowed my brother's Adderall!"
I am not at all concerned about the existence of your stash, your rat problem, or your brother's Adderall. It helps me get the train moving in the right direction faster if you tell me what your dog ate, rather than me trying to figure it out by clinical signs and guessing.
2) Understand that care at the hospital (especially if your pet is critical) is probably going to be expensive.
There is also likely not very much that your doctor can do to influence the cost. At the place where I work, I have maybe 20% influence over the cost of care (this is by both choosing the cheapest tests/treatments I can for whatever problem, and by sneakily sneakily doing some things under the table...shhhh...).
If you're rude to me, the technicians, or the front desk staff, my desire to secretly help you with respect to the bill goes right out the window. If you crumple up the estimate and throw it at me, you're paying full price for everything. If you call me a used car salesman and swear at the emergency technician, you're getting a letter from the HR department.
You can absolutely be angry that it's expensive. It IS expensive, and it sucks. Here is how to get me, personally (other vets are different, obvs) to help you cut cost corners to the best of my ability:
"Oh wow, that's a lot. I understand that it's expensive, and I want to do what I can. I'd really appreciate anything you can do to help keep the cost down."
That sentence (combined with good manners on your part) will get me to try everything I can (as well as enlisting the help of my colleagues on your behalf) to help decrease the cost.
3) Understand that you may be in the ER for a long time.
It's like a human ER - it takes (a variable amount of) time for tests to come back and treatments to happen. Make no mistake, we will have our asses in gear if your pet is really sick, but if she is stable and can chill with her pain meds while we tend to someone sicker, that's going to happen.
We'll be as quick as we can. Sometimes there's a big lineup for radiology, or we're waiting on the on-call surgeon or technician to drive to the hospital. Or there may be four or five dogs/cats sicker than yours, and limited doctors and technicians to tend to everyone.
I try to get pets who will definitely be staying the night or the day booked in for testing so you (the owner) can go home/get some lunch/get some coffee. Please take advantage of this. I will call you with results, or if anything major happens while you're gone. "Oh, well, we'll just wait for the bloodwork/x-rays/ultrasound," often = three or four hours of sitting in the waiting room.
Unfortunately, asking the receptionists to ask me what is taking so long delays whatever you're waiting for by ~5 minutes for every ask, since the receptionist then has to page/find me, ask me what's taking so long, then I have to stop what I'm doing and explain.
I'd say it delays whatever you're waiting for by about ~10-15 minutes if you bother the receptionist enough times that they ask me to come and update you myself. Instead (and more productively for everyone), ask if you can step out for a coffee and have us call you when [tests/imaging] are done.
4) Understand that some services are not available nights and weekends.
We have one radiologist. She works daytime hours, during the week. If you come through the ER for an ultrasound at 11pm on a Friday or 4pm on a Sunday, ultrasound is not an option until the radiologist is back in the hospital.
This is okay if your dog is here with a possible intestinal obstruction, since x-rays are always available. We also have the flash ultrasound to find free fluid in places where it shouldn't be. However, if you're coming in for chronic gastrointestinal problems or because your primary care vet said, "Hey, the next step is an ultrasound," do yourself a favor and call ahead to see if that's an option today.
I have also had folks ask me in the middle of the night which internal medicine specialists are available right now for consultation. The answer is: none of them, you've got the overnight doc until the morning.
Most specialists work daytime hours, during the week. Some criticalists work on the weekends, and there's always a surgeon on call for surgery/an internist on call for emergency endoscopy, but no specialist is seeing regular appointments or doing consults at 4am.
5) Know your pet's medical history, and what medications (and doses) your pet is currently taking. You can bring the bag of drugs if you need to.
And here's some general don'ts:
1) Don't be mean.
I understand that you're very stressed +/- angry +/- sad. These are legitimate feelings. We are all trying to help make your pet well or help you let him/her go. You are welcome to be stressed/angry/sad. However, you may not abuse me, the technicians, or the front desk staff. If you need a minute to go scream or cry outside, that's totally okay.
2) Relatedly, don't accuse us of being money-hungry or only in it for the cash.
There are numerous articles on the interwebs detailing the approximate cost of a veterinary education (~$250,000-$300,000, not including undergrad). The average starting salary of a veterinarian is hilariously less than that. If you're doing an internship, your salary is likely miniscule.
We're not in it for the money. It's insulting to suggest that we are. Also (see point 3, above), it makes us less inclined to help you catch a financial break in whatever ways we can.
3) Don't freak out if we don't have the records from your primary care vet.
I once had a guy refuse to let me treat his cat (the cat was having trouble breathing) because I didn't have his vet's records. The vet had faxed over the records (but for whatever reason only the first page had arrived) and the vet's office had since closed for the day.
This is insane.
You guys, obviously it is ideal and helpful to have good records, but we operate without them all the time. Unless you brought your own copy with you, I don't get any primary care vet records when I take in cases at night or (for most clinics) on the weekends. We can get them in the morning.
Also, your ER vet is also a vet, and can probably also figure out what is wrong with your pet. Refusing to allow your pet to be treated for this reason is profoundly counterproductive and crazy. Don't be that guy.
Also, if your pet has a relatively rare condition (hemophilia, some uncommon cancers, unusual genetic problem), know the name of the condition (see point 5, above) and how (if) it's currently being treated.
4) Don't automatically reject differences in veterinary opinion.
There are about as many opinions on how to practice medicine as there are veterinarians (possibly more). If your ER doctor suggest something different than your primary care veterinarian, this does not mean that one of the two is necessarily crazy, untrustworthy, or wrong.
If you don't understand the difference, ask. We're happy to explain.
Relatedly, complementary medicine (acupuncture, herbal remedies, et cetera) is really excellent for some things. Western medicine is really excellent for some other things. Some times the circles on that Venn diagram overlap, and sometimes they don't. If your pet has a bleeding tumor in his belly, the Yunnan Bai Yao may help slow the bleed, but he likely also needs a blood transfusion and surgery to remove the mass.
5) Don't panic too much - although it's scary, your pet is in good hands.
Although this may be the first time your dog has been hit by a car, your cat has developed a urinary obstruction, or your puppy ate the entire stash of baker's chocolate, she/he is likely not your vet's first HBC, UO, or chocolate tox. And if it is (heeeeeey, new interns!), there's someone looking over her shoulder making sure she stays on track.
too many cooks in the kitchen, redux:
ER doctor: "AUUUUUUUGGGGHHH!"
Alacrity: "What?!?"
ER doctor: "It's just...every single person in this hospital is in my butthole right now, and it's kind of stressing me out."
Alacrity: "Ah."
Alacrity: "What?!?"
ER doctor: "It's just...every single person in this hospital is in my butthole right now, and it's kind of stressing me out."
Alacrity: "Ah."
on the overnight:
It's 1 in the morning. I walk into radiology, where the scrappy ER tech is wrestling with a ~75lb dog who is flailing on the table. He's holding an uncapped syringe and needle in his mouth.
Alacrity: "Hey, do you want me to take this uncapped syringe and needle out of your mouth?"
Tech: "Mrrrrmmmph!"
Alacrity: "Dude, this night is going to get way worse if you inadvertently sedate yourself."
Alacrity: "Hey, do you want me to take this uncapped syringe and needle out of your mouth?"
Tech: "Mrrrrmmmph!"
Alacrity: "Dude, this night is going to get way worse if you inadvertently sedate yourself."
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