End of life…

emergency-vet-center

As I walked out of clinic at 1am on Monday morning a family were arriving to say goodbye to their pet having been summoned by phone just 15 minutes before when he started to deteriorate so rapidly that it was obvious he only had minutes to live. They made it in time to say bye thanks to the Vets Now ECC nurse recognising what was happening early and allowing them to be summoned.

Through the weekend we’d helped countless animals who left the clinic to go home with their parents, yet there was a high proportion that was never going be leaving, whether or not their pet parents realised it when they arrived. Unfortunately our pets can never tell us how sick they are, how much pain they are in, and that they want to go on over the rainbow bridge.

This is worse as often it is not just that they are seriously ill (and sometimes even dying painfully), but is also so sudden that their parents may not have had time to come to terms with this and accept it. It is not human nature to give up and sometimes when it comes to the decision to end life it can feel this way even though it is really not.

The weekend was a mix of those that came to ask us to help them send their loved pets on over Rainbow Bridge – the request of one parent that nearly made me cry was that someone would cuddle them as they moved on. Then there were those that hadn’t realised how bad the condition was and how much pain their pet was in that let them go on pain free when realising. There were also those that just refused to give up even though it could be considered to be  the kindest thing for their pets.

Vets are legally entitled to euthanise an animal on welfare grounds if they believe the welfare is compromised and the animal is suffering. However , we realise the importance of the bond parents make with their pet and that doing so will not be easy on the parents – in fact it would be very traumatic for the parents which is something we never want.

Instead we rely on our ability to communicate with pet parents. Sometimes it is very obvious to us how bad an animal is because of our experience and training whilst it may not be to their parents. We release that the animal is never going to be able to leave alive, and whilst we may attempt to make the animal comfortable with very strong pain medications, it is the owner that we need to treat.

Euthanasia is one of the most powerful tools that a vet has – read about how it really works here.

The emergency patient…

a-day-of-maggot-emergencies

Arriving to Vets Now with a quick tour of the practice and introduction to the team I changed and it was time to see my first consult with head vet Rebecca. It was not the bleeding dying dog or cat that I expected but a rabbit with early gastrointestinal stasis that had stopped eating – giving medication against pain and to encourage gut movement we hope that we had caught it early and that the rabbit would be fine.

One of the attractions of emergency and critical care is that you never really know what is going to come through the door. Most patients will go through telephone triage so we may get a little notice to prepare if necessary; however there is always the chance that someone will run a dying pet straight in. If you have time to telephone (or can get someone else to telephone) before you come then it is better because it allows preparation of anything necessary before you arrive. This can be even more important if there are already critical patients as it may be necessary to triage the least critical to a secondary area so we have a table to work on or a connector for oxygen.

The uncertainty of what is next is also one of the challenges of  emergency medicine; you need to be very confident in your ability to deal with whatever comes in. And you have to be able to cope well under pressure  – especially when multiple emergency patients arrive at the same time.

Whilst able to send some patients home, there were unfortunately a few where euthanasia was the best option – either because they were not treatable or because they lacked any quality of life. I’ve written an entire post on euthanasia that will follow in the next couple of days.

The day quickly became one of maggots with what felt like an endless supply of the wriggly white flesh eaters being found on a cat, pigeon and a rabbit. It is amazing how quickly with the summer heat that flies will take advantage of any moist fur to lay their eggs. The eggs tend to hatch rather quickly so within 24 hours there can be a serious problem if not treated so these were emergencies. Fortunately shaving half the cat managed to remove all the maggots and only the top layer of skin was damaged, however the pigeon and rabbit had much more extensive wounds and had to be euthanised on welfare grounds.

For my first day however it was a rather relaxed introduction to emergency practice – I had time to learn how things worked – and to pick the brains of the vets and vet nurses I was working with to get a better understanding of how it worked with Vets Now. It also gave me some time to practice some of the clinical skills such as manual PCV (blood cell counts) that I’d not done for several years.

Over the rainbow bridge…

Euthanasia - Crossing the rainbow bridge

As the vet reaches for the cats leg to give the final injection the cat lies alone on the table. She has had trauma and is not in good way, and her parents cannot stand to see her in this way. I reach out to do nothing more than stroke her as she starts her onward journey over the rainbow bridge.

As the injection goes in I see her laboured breathing stop, she looks calm and relaxed as I stroke her and wish her a safe onward journey. The injection is in and the vet removes the needle before reaching out and stroking her as well briefly before they listen for a heartbeat. I’m sure she’s gone but it is important to check, sometimes it can be difficult to tell with all the noises that occur after death so sometimes can feel like you are listening a long time.

I’m sad this cat I knew only for a short while at what is probably the worst point in her life couldn’t be saved, yet I take comfort in the fact she now gets to run free. We gently remove her IV cannula to go to the clinical waste, clean her, and then wrap her in her blanket to go home with her parents for burial.

She is not the first, and will not be the last; however she did not go alone. Even for those few minutes she took a piece of my heart with her, and she went on her final journey across the rainbow bridge loved and cared for. This is something her parents never saw and something maybe one day they will wonder about, however they should not worry. They have the memories of her running around the house not struggling to breathe unable to lift her head.

I will never judge a parent that cannot be there at the end, it’s one of those choices that is so difficult to make. There is rarely a right answer, and sometimes there is not even any time to even think about it properly. Yet these parents may say their goodbyes when it is time to bury her, I will never know. It is a choice that can only be made by you. Sometimes after trauma we will explain to parents what to expect to see as sometimes injuries look much worse after being shaved and cleaned so that the parent can make a choice.

Personally I believe saying goodbye is important, some vet practices even have rooms just for this so we can give as much time as parents need. Sometimes in a busy practice we do not have enough of these rooms so we make do with what we have. We will explain what will happen to you, and tell you what we are doing. We’ll never try to rush you, we’ll try to keep noise outside to the minimum, and we will all feel your pain.

EDIT
If you have lost a pet and are struggling with the loss then please do call the Blue Cross Pet Bereavement Helpline – 0800 096 6606 (UK Only) – or visit their website for more information at  https://www.bluecross.org.uk/pet-loss. It is a traumatic experience, and there are people that have experienced it themselves who want to listen to you.

Death, the good, bad and ugly…

An exhausted vet student

Death is one of those bad words, that we try to avoid talking about, that we ignore and hope we never have to face.

Yesterday I read a blog post called “The dirty secret about CPR in this Hospital (That Doctors Desperately Want You To Know)”. For me it was nothing new, however it made it easy to understand and got the point across in a way I never could so I would highly recommend checking it out.

Since reading this it has remained stuck in my mind throughout the day, I think being in the veterinary profession gives me the other side of the picture. Unfortunately I have been in the position of watching someone I loved die slowly in a hospital bed – it was never what I expected – I expected to turn up one day and find them in their garden or home after a heart attack. It took several days for the die under the Liverpool Pathway (since then I am much more clued up as to why this may not always be the right thing) however the alternative was open heart surgery with very very very small odds of a meaningful recoveryEven at that point in time, without realising I was thinking about the quality of life and not the quantity – the chance of them doing what they loved and leaving the hospital after this surgery was near zero. The quality of life would be zero, even though the quantity would be increased (if you can consider it as life).

Whenever this person had spoken about death to me I had tried to change the subject as I was scared to think about it. I was scared of losing them. I didn’t want to think about it.

So moving forward 5 years with a lot more education and experience I am writing this. Over the past two years I’ve been seeing practice I have been around death, caused death, and prevented death. Some days it seems to be all I deal with, last Tuesday by the last patient I’d seen so many patients die or euthanized that I was no longer surprised when I confirmed another death.

Let’s talk about some death – from the perspective of a vet student… These have all happened to me…

It is 1am, my phone goes, one word – “torsion” – and I am out of bed and running for the door, 10 minutes after this phone call I am scrubbing into surgery. A torsion (GDV or bloat where the stomach swells up with gas) is a surgical emergency. The dog will die without a vet and surgery. An hour or so later the dog is in recovery, and a few days later it goes home.

Last Tuesday at 6:45pm when I was walking out the door to go to lunch a call came in… “torsion”… the owners were on their way about 20 minutes out. That’s 20 minutes for me to prepare. Operating Theatre set up, preparation for stabilisation, emergency fluids, decompression. Car drives up to the door, owner says I think he’s dead… I’m in the back of the car listening to nothing, feeling no pulse, no breathing. This dog didn’t even make it in the doors.

Is a torsion painful? Yes. Can it be fixed with surgery? Sometimes. Will the dog have quality of life after surgery? Yes. Is it a painful way to die? I would not like to die like this.

I am in surgery, normally opening the abdomen is pretty routine, however this time we are struggling. If I hadn’t opened the scalpel blade myself I would have thought it was blunt and old. Opening the abdomen finally it is like all the organs have melted together… There is nothing there, and nothing that is possible, I am wondering how the dog was still alive. We were not sure what we were going find, however I would have never expected this… The owners chose never to allow this dog to wake up.

We’ve got what is expected to be a pyometra – however there is a large mass in the abdomen along with lots of fluid. The owners know that it may be bad – and are waiting by the phone. I am running anaesthesia, the patient is having some problems to breathe so I have placed them onto a ventilator to help them. The abdomen is opened and the right liver lobe the size of the dogs head is removed from the abdomen – the breathing becomes easier. There are changes to other organs as well – it is not a pyometra however there are tumours on the uterus. We call the owners, and they give permission to euthanise on the table. I administer the drugs that will end this life – and relieve the suffering.

In human medicine – these patients would be closed and taken to recovery – they would be given drugs for pain and potentially kept sedated until they die. There is no guarantee of when this would be, they’d be trapped there in a hospital bed hooked up to machines.

A horse – unable to stand, with fluid on its lungs, anemia. The condition is getting worse… There is no quality of life, and the chance of recovery is very slim. We make the decision to euthanise and administer the drugs to do so. The horse is peaceful, out of pain, and no longer drowning inside out.

In human medicine this patient would be treated – humans are lighter than horses, the anatomy is different, and the lungs are like bags of crisps instead of sacks of potatoes. Its treatable – and there is a chance of recovery to a quality of life.

I will end on a puppy, this puppy had a deformity in its leg that was surgically correctable – however it was not showable and not breeding material. I cuddled this puppy on my lap when it was sedated, and held it when it was given the final injection. Not to relieve its suffering, simply because it was unwanted. We tried to encourage the owners to sign it over to be rehomed, tried to talk about the surgical options. That is the danger of euthanasia – that it can be used for ends other than relieving suffering.

We may not be able to pick when, however you can choose how you want to die. Where you want to die. It’s a conversation that should be had, and you can even find online guides like the Five Wishes (https://agingwithdignity.org/docs/default-source/default-document-library/product-samples/fwsample.pdf?sfvrsn=2 ) to help you.

Holding that little life in my hand…

Cow for emergency slaughter

Something that they don’t tell you when you start on the road to become a vet is the amount of death that you will see. This week I have seen everything from the euthanasia of a 1 hour old puppy, through to the emergency slaughter of a cow that could not stand.

This morning started with an owner and a fellow student carrying in the limp body of their dog, this is where you go from 0 to 60 in seconds. I was sat with 3 doctors talking about eyes, yet within seconds eyes were forgotten. One was taking care of getting an airway into place with intubation, another worked to get a IV cannula into the dog, another started chest compressions and I prepped emergency drugs. Unfortunately today we had an unsuccessful outcome.

Here in clinic we do not have a defibrillator, and sometimes I wonder if we did would we see better outcomes in resuscitation attempts… There are not really any real statistics in veterinary medicine on the survival with defibrillation. However in human heart attacks where CPR is given using a defibrillator within the first minute gives a 90% chance of survival with this decreasing by 10% every minute after. If defibrillation is not performed within 10 minutes of the cardiac arrest then the survival becomes just a measly 2%.

With this knowledge from the human field you can understand why I wonder about our veterinary patients. Is it the same?

A vets gift of euthanasia and great sadness…

Drugs for stopping the heart

Today’s Diary Entry is sponsored by Pet Webinars

As vets we are given a great gift to be used with great responsibility. We are given the right to euthanise animals in order to alleviate pain and suffering. Translated to English the word euthanasia means good death, and when used by a vet it generally is. It is painless, and for the animal just like going to sleep. For some animals that are sick and suffering it cannot be done fast enough – and though the vet may wish there was more that they could do to make the animal better it can be justified.

Now what I have noticed is that the techniques and methods for euthanasia are not covered in most of my textbooks. Instead my textbooks even with chapters on euthanasia tend to focus this towards dealing with the owner and how to prepare them for this instead of how to make this good death happen. Generally though for euthanasia an animal is sedated or given an anaesthetic drug to make them sleep, and then a different drug is injected into the animal to stop the heartbeat.

So there were two dog euthanasia’s today but they couldn’t be more different in how they made me feel.

I arrived this morning to a road traffic accident with a large dog, once we got this patient stabilised and completed the initial exam we rushed them into xray to get a better assessment. Waiting for the images to come up on screen I was slightly excited about the surgery to repair the damage, however when the images came up a deathly silence feel among us. It was not good. It was very very bad. Now you see with a large dog there is a lot of weight that needs to be supported, this is a lot of force on the legs, and so even one leg compromised can be disastrous. However this dog had 3 legs that had been damaged. We anaesthetised at this point so that a full physical exam of the injuries could be performed, after assessment and after discussion with the owner elected that it was kinder not to allow this dog to wake up. This dog was in great pain and suffering, and so the ability to deliver the gift of a painless death was a privilege.

Throughout the day there was an 8 week old puppy in for assessment of a congenital deformity to one of the front legs. Being a puppy this was a very cute dog, bouncing around wagging its tail and being very happy whilst receiving a lot of attention from everyone passing. Now after xrays and exam at the end of the day a discussion with the owner took place. The owner left without the puppy, and it was here that I realised something was up. The puppy was to be euthanized. Not because it was in pain or suffering. But because of a choice. There were surgical options available. The puppy could be fixed. However for whatever reason the owner elected not to. So it was us with this great responsibility that cuddled the puppy as it fell asleep. It was me that listened to the chest to make sure the heart had stopped. This puppy that had tried to soak me with water from its water bowl just hours before was gone. The tail wasn’t wagging.

Now you can probably guess the one that kept me awake that night… Not that I didn’t wish that there were surgical options for the big dog and was frustrated with our lack of ability to do anything… The one that kept me awake was the puppy that was happy and had good surgical options for a good life. Sure we shouldn’t get attached to patients, but there is just something about animals that makes you love them.

Sometimes euthanasia is necessary, however I believe it is a gift to be used to relieve pain or suffering. I realise that the world is largely based around consumerism now, and I hate the thought that by setting out on my quest to help animals that I may become a way to “return” a dog or other animal… As vets we are there to save as many as we can, I hate that sometimes money gets in the way, but until we have a better system I will advocate for every single pet out there being insured to remove this money factor from what is often the hardest decision pet owners have to make. Euthanasia is and should be about the animal.

What they really mean when they say vet school is tough… (Day 628)

Becoming a second year vet student photo

Today’s Diary Entry is sponsored by Best Rabbit Food

Vet school has always been called tough, maybe its because so few get in from the thousands that apply each year. Or maybe because its so much to learn. Personally I think it is the emotional rollercoaster that does it.

I study. Sometimes it is a mountain of books, sometimes it is more complex, at the moment I have to memorise the name, location, function and path of every single blood vessel in animals… Not just one species, but all the differences between them. The way that blood vessels differ between an animal with just 1 toe, to an animal with 2 toes, or maybe 4 or 5 toes. Sometimes I can sit for days on end just studying, reading stuff, making notes, eating, sleeping, reading. Sometimes I feel guilty for sleeping or eating, sometimes no matter how much I read there is always more.

I like to think I am a responsible student; I drink very rarely, I like to celebrate passing my exams by seeing practice – it is what gives me energy… Knowing that the hours I have spent reading and studying is taking me one step closer to being able to do something I love. It sounds corny saying you want to help animals, to be honest I enjoy solving the problem, pushing my limits and coming up with a solution to give something defencless a chance.

Sometimes animals die, sometimes you have to euthanise them… Sometimes you may spend hours or days or weeks or even months treating an animal – you spend more time with them than the owner, than the dr’s, than anyone else. You push your limits, you study more, things you do not know, plugging gaps in your knowledge as you go, sometimes pushing a new idea from a research paper just published. And then the animal dies. Each time a patient dies I try to learn something, that patient could not be saved then but maybe if we see it again it will be different.

Vet school is a emotional rollercoaster, sometimes it doesn’t go well but the ones you can save, the patients where you make a difference give you your energy to keep going. You are not dealing with just an animal, its someones friend, a companion, its got a name. Sometimes you get to see the them again, know that they are still there because of you, its an amazing feeling.

For me I have around 700 days of vet school left until I am released onto the world, a new graduate, I get given a license to learn, but more scarily I am responsible. Them 700 days are going be spent learning, so that when they are up I am the best vet I can be…

IMPORTANT: If you are struggling please speak up, Vet Helpline is a free 24h support service for vets, vet nurses, students and any family or colleagues who are concerned about someone in the veterinary community.CLICK HERE TO BE TAKEN TO VET HELPLINE

My first day in the Small Animal Clinic…

First Day In the Small Animal Clinic

Today’s Diary Entry is sponsored by Pet Hooligans

Well today I ventured into the Small Animal Clinic here on campus for the first time with no expectations and was pleasantly surprised (the small animal surgical unit is separate to the clinic which is a medical unit). I was lucky to be paired with a friend who is close to graduating and can understand Slovak whilst speaking English so can fill me in on what is going on. Most of the doctors here can speak at least some English however a lot of the clients cannot so again this is a motivator for me to learn Slovak faster (I’m picking up a few words now).

So I cannot say much on individual patients for the obvious reasons, however in terms of skills I picked up I can say much! 😀 So this morning started at 8am getting permission from the Dr’s to be in the clinic, I then started with observing vaccinations (and how the records are managed here in the vaccine book). An interesting case of canine otitis with a bacteria known as Malassezia dermatitis which is a yeast which is usually commensal (aka lives in harmony with the host on the skin). This means that the small amount present is usually not able to cause disease, however when there is a disease or the animal is stressed this microorganism can take advantage of the weakened immune system and grow.

I also got to observe an euthanasia and was asked to help restrain a particularly fractious cat on another. Many vets say that when you do not feel any more with euthanasia’s it is time to leave the profession, and though many times a brave face is put on in front of clients it is hard every time. Personally for me I feel that being able to relieve suffering is a great gift, however its also important to use it at the right time which is a great responsibility. I do however agree that if I couldn’t feel then I definitely shouldn’t be here!

Some of my time went to cleaning, something that is never ending! I lost count of how many times I washed my hands today! We have had a few cats in for rehoming including two little kittens who are very cute with their circus act. The rest of my time went to checking IV’s, giving a dog water by syringe and learning how to look after a recombinant patient.

I guess today’s highlight was actually being shown how to do sub cutaneous injections during a quite period, and actually injecting my first patient this evening. I finally managed to leave the clinic at 8:30pm… Not bad for my first day!

First Day In the Small Animal Clinic

Knowing when the time is right, pets and euthansia (Day 128)

Masik R.I.P.

One of the greatest responsibilities of a vet is to be an advocate  for a voiceless animal, to be able to speak for the animal and push for what it is best for that animal. With all the technology and medicine available it is not a case of keeping the animal alive, but one of trying to balance the quality of life. Every vet student wonders how they are going to have that conversation, if they are going to get it right, and if they are going be able to do it. There is no exact science here, experience – which vet students lack – does help however it is still a guessing game, one where the doubts of if it is the right time find their way into the mind.

Euthanasia… The word actually is from the Greek language and means good death. Being able to relieve suffering is one of the vets greatest tools, yet is the one I feel that has most responsibility. Here you are not just a voice for the animal, you are a counsellor for the client who is saying goodbye to their best friend. This isn’t always easy, especially if it is an animal that you liked or a friend or family.

Over the weekend I gave a voice to a friends cat who had deteriorated again, its wasn’t a easy decision to make to raise this option. Not only because I knew how much the cat meant to her, but because I was not sure it was the right time. Clinically it was possible to keep him alive, it wouldn’t have been a good life though as I suspected he had entered end stage renal failure with the toxins in the blood attacking the digestive tract. I took a chance and spoke through this with her, not an easy conversation but one that was essential for my other friend, her cat Masik.

Taking Masik to the vets it was confirmed as renal disease, the kidneys not working, now clinical signs of renal disease do not appear until 75% of the kidney is diseased. Talking with her family my friend decided that it was time and today took Masik to the vets for the last time. Before the final euthanasia drug is administered it is common to administer a sedative and painkiller to ensure a comfortable passing. One of the side effects of this drug is vomiting, and this Masik did showing my friend how it contained blood, his last gift to her saying that it really was the right time.

Masik R.I.P.Rest In Peace Masik my friend.