Blood is something we just see a lot of– blood in a tube, coming from a wound, in the urine, in vomitus, in stool, on the floor, and sometimes even on the ceiling. My father practiced for three and a half decades as a general surgeon on the human side. My brother and his wife are both kid doctors. I, on the other hand, took my first job in a veterinary practice at the age of 16. I’m akin to the black sheep of my family, in that I have chosen to treat four-legged patients rather than two. Regardless of our chosen paths, my brother and I are capable of doing our jobs, in no small part, because of our desensitization to the sight of blood at an early age. I recall my mother complaining of the blood drenched underwear on the floor after my father was on trauma call. I was much older before I realized that this was not just a complaint about his underwear on the floor.
As of late, our practice has had a bit of a run on anticoagulant rodenticide toxicosis cases. My latest one presented for a simple cough, one with a little blood in it. My client: a teenager of minority ethnicity. Her grasp of the English language was stellar but her mother, the actual owner, could communicate in my native language with less fluency and was not present for today’s visit. As my technician presented the patient to me, a walk-in on an otherwise busy day, I began to process the information and apply the relevant history in a calculated flow-chart style visualization of the potential causes for the clinical presentation. I looked up just briefly enough from my record writing tasks to see a large husky-like dog provide for me an example of this very deep chested guttural cough that he presented for. On the floor in front of his forelimbs, a perfect forty degree spray of frank ruby red blood appeared on the otherwise bright white and grey speckled floor. “CBC, Chem, PT, aPTT, and survey films of the thorax and abdomen,” I asked of my technician. Cursory physical exam accomplished. I worked on completing tasks for my scheduled cases and other emergency walk-ins as I eagerly awaited the results of my requested diagnostics.
I have become cynical over time as many of my emergency patients present with, otherwise, very mild clinical signs and turn out to be train wrecks. This husky was no exception, well except that this wasn’t during our emergency hours. This new client had waited until the daytime to come in because her perception of cost savings during the day meant that care for her beloved family member was a potentially surmountable obstacle and they knew every nickel was going to count.
Bad news! The prothrombin time: greater that thirty seconds. The activated partial thromboblastin time: greater than one hundred sixty seconds. Hematocrit: thirty. Platelets and blood chemistry panel: normal. All that jiberish boils down to bad news for this dog. Active bleeding into the lungs and laboratory findings consistent with a clotting problem, the most common cause at my practice is rodenticide (rat poison).
You see rat poison is an anticoagulant. It is designed to prevent blood from being able to clot. Without a functional coagulation cascade, we bleed to death internally. The week before one of our associates had a confirmed rodenticide case that presented with only hematuria (blood in the urine). It’s a nasty, and sometimes silent killer, but unfortunately a common one for emergency clinicians to encounter in my region. That patient lived because the perceived urinary tract infection was actually evaluated for what it really was, hematuria; a clinical sign, not a diagnosis.
As I enter the exam room I find myself face to face, for the first time, with my client. How beautiful innocence is: that look of trust that my daughter fuels me with ever time she looks up at me when faced with a physical or emotional challenge. As the “doctor in charge” (the DIC) I am faced with this look routinely, by both children and adults. This one waited eagerly as I rambled on and on about the details behind what she really wanted to know, the prognosis. I’ve found that no one hears anything after the prognosis is given so I often present the facts first and the, always subjective, prognosis last. This was a better situation than most, in that in this case I wasn’t being translated by an eight or eleven year old to her parents who don’t speak a lick of English. I’m not having to tell a small child that the short of it was that her believed dog was likely going to die and watch as she proceeded to muster the strength to tell her parents in their native tongue. At least, I had a teenager this time and fortunately we knew what was wrong.
It’s never good to have to suggest rodenticide toxicosis as a possible cause for a pet’s problem because this means that the ingestion occurred several days ago. In this case, the bait was laid out on Sunday. Today is Thursday. The best prognosis comes when a client sees the ingestion occur and comes in straight away. If caught early, there is an antidote, phylloquinone, (also known as phytomenadione, phytonadione, or simply vitamin K1) administered twice daily for many weeks.
For this little girl, her chances of survival were not very high. Not only did we have the clotting problem to contend with but we had the fact that blood, or any fluid for that matter, in the lungs presented a challenge from an oxygenation standpoint. The risk of, literally, drowning on her own blood was very real.
Ideal therapy…plan A? Not really on option for this family. How about plan B? No chance. The almighty dollar will decide the treatment protocol for this one. Fortunately, this client expected no special treatment and demanded nothing. They accepted the financial limitations of their situation and were grateful for the care that they were able for me to provide. No matter, I assured her, without transfusion therapy, the antidote is either going to work or not work. We’d have either caught it in time or not.
My client and her mother returned to take their four legged daughter home with a pharmacy full of medications towards the end of my day. She weakly staggered out the door as I watched on. The mother of my client, the owner of my patient, reassured me that they understood the implications of their action; taking the pet home AMA (against medical advice). I urged her to call immediately should they be willing or able to consider an alternative.
So where is the ethnography in this tale you ask? I’m not sure that discussing the outcome of this case relates at all to the experience of any one of our souls. Did I do all that I could do? Would the client feel regret if the case were to go wrong after getting home? Would my staff blame me if it did? Would I blame me if it did?
Somehow I came out on top, the perceived good guy in a whole mess of my client’s emotional turmoil. The ups and downs in this kind of medical case have turned my client and their family upside down. The case discussion with my peers… I presented this case’s details wrapped up in a whole mess of detached cynicism!