… even in Emergency Care

(It has been a while, since I have blogged. My wife (and I) birthed twins 6 1/2 months ago, which is exactly when I wrote my last blog. The twins are crawling and eating now, which does not make life any less interesting (or chaotic), but it gives us a break from holding two children all the time. At any rate, I had an interesting veterinary case recently worth sharing):

james herriot-style

It was Sunday evening. My family and I had just returned from a weekend camping trip at a local State Park. I was in the yard barefoot, in cut off jeans, stacking fire wood, when an unidentified car pulled up the driveway. The older kids were playing close by, building a cake out of grass, dirt, and white clover flowers. I was taking a break from stacking and was holding a big clump of grass in my hand, about to add to the cake. I usually have a pretty good idea of when we are expecting company – a visitor for me or my wife or maybe the UPS man. We live down a gravel drive in the very back of a shared piece of land out in the country, so we do not get many (any) accidental or surprise visitors.  The blue sedan stopped up above at the top of the driveway. The two adults got out of the car and hollered down to me, “Where’s the vet that lives back in here?” I stood there shirtless in my cutoffs, making a dirt pie, looked up the hill, and said back to them, “That’s me.” It’s always possible that a client comes to the house unexpectedly, but it rarely happens. When it does, I sense an interesting mix of duty and vulnerability.

The feeling is reminiscent of a vet school summer, working in rural Ireland. The veterinarian’s house was adjoined to his clinic. Everyone in the community knew where to find him. And they did. At any hour. His lifestyle was as close to that which James Herriot portrayed in “All Creatures Great and Small” as any I have seen.

duty calls

The couple looking for the vet, lived a mile away. Their neighbor’s 7 lb chihuahua had just been attacked by the neighborhood, 50 lb, free-ranging Australian shepherd. There was urgency in the man and woman’s voices. The little dog was dragging a rear leg and had some deep gashes in its side. I thought of a back injury and the need for suturing wounds. I dropped the clump grass, threw on a shirt, pants, and shoes, and grabbed my leather vet bag. I left my superwoman wife with the twins, two older kids, and dinner time chores and climbed into our Subaru to follow the man and woman to the injured patient.  As I was pulling out of the driveway, my dog and 6yr old son ran across the field to the car. My boy climbed in the back window to come with me. My daughter wanted to come to, but she was wearing more of the mud pie ingredients than clothes.

medical evaluation

When I arrived at the patient’s house 2 minutes later, a young woman was standing on the porch holding a small laundry basket filled with blankets. Jack the 7 lb chihuahua was nestled into them. Her 3 yo daughter was standing beside her crying about Jack’s pain. I gently stroked Jack’s head and told the young girl that I was going to take care of him. He was quiet but alert. His gums were light pink and a little tacky, meaning he was borderline shocky from the trauma an hour earlier. He was extremely guarded, yelping anxiously even when his wounds were even lightly brushed by my fingers. Nonetheless, I could see that the openings in his side were clean and not too deep, but were laying open. I also felt a very distinctive sensation around his thorax. His skin was crackling. There is a very unique sensation when air is trapped under the skin. It sounds like crinkling cellophane and feels like, well, bubbles under the skin. It is called subcutaneous emphysema. There are two major causes: One is a lung punctured from the outside. Another is gas entering a wound in the skin. Both were possibilities and one was much more serious. Fortunately, since Jack was not having breathing difficulty and his heart and lungs ausculted loudly and clearly, it was much more likely that the gas had entered as the larger dog lifted his body with his teeth. The skin would have been pulled away from his body, causing negative pressure and air suction into the wounds.

I gently lifted Jack out to examine his back leg. He decided that it was not a good idea for me to check him out any further, so he hopped away. In fact, he hobbled pretty well on all 4 legs now. He traveled up the 6 front steps that were each as tall as him and then jumped up onto his favorite chair on the front porch. That rapid recovery from the couple’s previous description of “dragging his leg” was about enough for me to surmise that his back and spinal cord were not injured. He gave me a lot of information there on his porch. It was information that would have been more elusive in a veterinary hospital, where he likely would have felt too terrified to move. Assessing his musculoskeletal system in such an environment would have required a more invasive and painful exam, radiographs, and probably analgesia/sedation. The information would have been more precise, but at a greater cost. In addition, being borderline shocky, he would have first required an iv catheter and iv fluid administration before sedation.

costly veterinary care.. or not

The owner knew all about the expense of emergency and tertiary veterinary care.  In the past, another dog had, coincidentally had it’s lung punctured and leg broken in an unfortunate automobile accident. A quick run to the local vet for a day emergency cost of $800 and the follow up surgery at the local vet school ran over $2000.

My discussion with the owner centered around wound management and overall prognosis. Suturing the wounds would look better and speed healing but would require sedation. He was not a good candidate for sedation. The wounds would heal just fine via “second intention” as long as they did not become infected. We decided to go with a course of antibiotics and time. After that, we concluded that it made the most sense to give his leg another day or two to recover. That plan would allow for some of the acute pain to resolve and for us to better assess the injuries to his musculoskeletal system. In addition to the antibiotics, I prescribed pain medicine. Jack would probably convalesce well at home, although the initial presentation could have led one to believe otherwise.

If Jack had been rushed to an emergency clinic, he probably would have received and exam, bloodwork, radiographs, iv catheter and fluid administration, possible overnight hospitalization and a second exam in the morning, in addition to meds and an emergency fee. I imagine the cost would have been $800 to $1200. The care would have been closer to a gold standard, but again, at a greater cost of stress to the patient and owner, not to mention the monetary expense. We found a solution that brought great peace of mind to the owner, did not require traveling with her upset 3 year-old daughter, and adequately met the needs of the patient for $75. In fact, the healthcare experience for Jack was probably just what he wanted. It was minimally invasive and allowed him to metaphorically lick his wounds without much of a bump in that path. ie – no procedures or hospitalization away from home in a small cage. I think emergency and tertiary care are wonderful options, but we were fortunate to have found a very sensible, less intense and viable solution in this case. It is very rewarding for me to be able to help reduce an animal’s stress and pain, and to help simplify a person’s life.

I left the prescriptions and my telephone number with Jack’s person, told her daughter that he was going to be okay, and took the 2 mile trip back home to have dinner with my family.

simple, low stress (and holistic) veterinary service

I provided personal, appropriate care at a very reasonable cost. Suitable alternative treatments would have been arnica, traumeel, reiki, yarrow, goldenseal, oregon grape root, white willow bark, acupuncture, and more. However, the fundamental holistic approach was evident in the consideration of the owner’s and patient’s needs for a simple solution for mind and body; Not just an examination of disembodied wounds and biological systems. That same type of holistic, sensible care is available to all my clients in person or via phone consultation.