I don't often speak ill of other veterinarians. At least not publicly, and never, ever, ever, ever, EVER to the client. If you send us a patient, or if a patient transfers to us, in general, I've got your back. (Instances of gross misconduct nonwithstanding...) Cuz, you know what, we all make mistakes. I'm sure some day I will, and I hope that whomever sees the pet next won't throw me under the bus.
But this one, I've gotta get this off my chest.
An extremely overweight, 11 year old Aussie-type dog, owned by a long time client, presented to us on a Monday morning as a transfer from an ER/Fancy-pants clinic. Not a referral clinic, as its not staffed with specialists, however they like to consider themselves a referral center. They're not. But they think they are. Not the hugest fan of this facility...but I digress. Anyway, the dog presented to the ER and was eventually diagnosed with severe pancreatitis, so severe, in fact, that this dog's glucose was the highest reading I've ever seen...4 figures. WOW!
Extensive workup and supportive care ensued in the form of bloodwork, IVs, ultrasound, antibiotics, double run of 5% dextrose and IV insulin and extensive analgesia because they just could not get the dog comfortable, based on her panting. Despite excessive doses of opioids, the dog continued to pant. Was almost comatose, but continued to pant. And because she continued to pant, they continued to dose her with fentanyl.
When she arrived at our clinic, happily her glucose was in an acceptable range - that appeared to have been stabilized. The owner was concerned, however, because it seemed to her that they could not get her pain under control despite the excessive amounts of fentanyl and the dog was getting worse, not better. In her words, "You guys have never had problems making my animals comfortable." So, despite dire warnings from the ER facility (which had clearly wanted to transfer this patient to their in-house day service) that the dog was too unstable to transport, the owner brought her in.
She presented depressed and panting. I'm reading the discharge paperwork and I come across the line at the top: Suspect diabetic ketoACIDOSIS secondary to severe pancreatitis [my emphasis]. Then I quickly flip through the rest of the paperwork and note two very striking omissions in the pet's treatment at the ER. First, no one performed a blood gas to CONFIRM the acidosis and, second, no one treated said acidosis.
Now, I get that acid/base work is not for everyone. The mere mention of Henderson/Hasselbalch can still give some vets seizures with flashbacks to horrific fluid therapy lectures. But, guess what folks, its important.
Sadly, I've yet to convince my boss I need an iStat machine (I desperately wish for one about 4 times a year). But, drawing on my work with dairy calves with diarrhea, I made a base deficit estimate for this dog, immediately started her on bicarb containing fluids and - guess what - within 2 hours the panting had stopped and she was alert. Still sick, yes, but no longer panting and no longer obtunded. Although I probably can't take too much credit for the later - the fentanyl had likely finally metabolized out of her system.
Seriously though - you tell me you think the dog has acidosis, but you do nothing to address the acidosis? Do you not remember that carbon dioxide is an acid and animals will increase respiration in an attempt to compensate for a metabolic acidosis? I have never worked emergency medicine (outside of my time as an intern and a resident) but I really feel like this is something that ER clinicians should be aware of. Am I wrong?
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