This seems to be a recurring theme. Maybe, if I can do it without getting too gross, I’ll continue to post cool little bits like this now and then. I’ll attempt to not break down into ranting either. Andrew knows all too well how often my days at work degenerate into ranting. I’ll try not to rant.
I mentioned during my last post that I’d get back to how I knew that it was spring. I’m a soothsayer.
Well, not really. But I do practice visceral diviniation. See, cats are long day breeders. This means that female cats start going into heat when the day period starts to lengthen. If a female cat is in heat, you can most certainly tell when you spay her. Every she-cat that I’ve spayed since the first part of February has been in heat, therefore, it’s spring. The cats’ uteruses tell me so. 😀
Back to why veterinary medicine is uber cool.
Two Wednesdays ago I was looking over my schedule for the day. I do surgery on Tuesday and Wednesday mornings from 0700 until I finish in the early afternoon. My first appointment of the day isn’t until 2p.m.
That Wednesday I saw that my 330 appointment was scheduled as: “Alex, 10 year old Siamese, dragging his back end”.
That got my alarm bells ringing. Cats almost never have the slipped intervertebral disc problems that affect some dogs and make them drag their hind ends. It’s rare for a cat, especially a 10 year old cat, to break a leg unless he does something like fall off a roof. Cats just generally do not drag their hind ends unless there’s something catastrophic happening. The most common catastrophe that will cause a cat to drag his hind end is what’s called a saddle thrombus.
*pause for medical stuff*
The aorta leaves the heart and travels along the midline of the body supplying major arteries to the thoracic and abdominal organs. Just below the pubic bone the aorta terminates, forking into the two femoral arteries which supply the major blood vessels for the back legs.
I don’t know whether or not this happens in people, it almost never happens in dogs. Under the right conditions, usually massive underlying heart disease (for instance, the first cat in which I saw a saddle thrombus had seven chambers to his heart), a clot will form that travels to the terminal aorta and blocks the blood flow to the femoral arteries. Bad news. Way bad news. Uber bad news.
Generally cats that present because of a saddle thrombus are screaming, literally, painful. Aortic thromboemboli (ATE) cats can usually be diagnosed when they are carried into the hospital.
The appointment book didn’t say anything about Alex crying and dragging his hind end, but still….
I asked the receptionist if Alex’s people WANTED the 330 appointment or if they had taken it just because it was the first appointment available. It was the latter, so I had the receptionist call them back and bring the cat in so they could drop him off and I could look at him while I was in between surgical procedures.
Reception called them, the mister brought the cat in about half an hour later.
I wasn’t in the middle of something when Alex came through the door so I had the reception people tell Alex’s dad to wait while I took a preliminary look at him.
Alex most certainly was dragging his left rear leg. While the nail beds of both rear legs were still pink (with a saddle thrombus the nail beds will be blue), the pads of both rear feet were cooler than those of the front feet which could possibly indicate poor circulation in the femoral arteries. Alex didn’t seem to have any notable orthopedic pain, in fact he didn’t seem to be painful at all, he was just lying on his towel purring and making happy feet with his front feet.
Then I put my stethoscope in my ears.
*a second pause for medical stuff*
Normal resting heart rate on a cat is in the 120-150 beats/minute range. A cat that is stressed out by having been shoved in a traveling crate, by having been shoved into the car, and by having a stranger poke and prod at them will have a heart rate in the 180-250 beats/minute range. I’m never even really concerned when they hit 280, although that does generally indicate a pretty freaked out cat.
Alex’s heart rate was in the 420-450 range. 😯
According to my assistant, my eyes went really wide, I checked the clock, checked my stethoscope and then, having put the stethoscope back on the cat again, my eyes went even wider.
My assistant is fairly used to me by now. Unlike most of the other staff at this hospital (including, to a certain extent, the other two doctors) I’m used enough to crashing emergencies not to get too ruffled by much. When my eyes started popping and I asked her, with the stethoscope still in my ears, to get the other on duty doctor, she BOLTED.
My boss came, I stepped back, and gestured for her to have a listen. She put her stethoscope in her ears and put the bell on Alex’s chest. Her eyes went wide, she checked the clock she checked her stethoscope, and then went back to listening to the cat.
This is what is known in medical slang as a “don’t die on my shift” moment. Depending on one’s particular brand of medicine it can also be “don’t die on my floor/don’t die in my bus/don’t die in my hospital”, but the underlying sentiment is the same.
I am rarely certain about anything in medicine, I’m too cautious to be so, but I can be certain when I say that that cat would have died within the next 12 hours if something hadn’t been done.
The only thing I could focus on at that moment was getting that cat out of the building and somewhere that he could be helped before he died. The subtlety of medicine, however, is to be able to convey that urgency to a lay person, without getting them so freaked out over how freaked out you are that they are incapable of making any rational decisions.
When I went to talk to Alex’s dad I was cool, I was collected, and I was rational. I was not, in fact, subtle.
I told him the cat was going to die, I told him there wasn’t anything useful that I could do to stop it. I told him the cat had a chance at living if he’d get the hell out of my lobby and take Alex to the specialty center where the critical care doctors could put him on medications that would slow his heart down before he blew another clot to something more vital than his left femoral artery.
To his credit, Alex’s dad didn’t freak out at my freaking out.
More to his credit, he actually was willing to do something useful for his cat instead of opting to try the band aid approach which my hospital was equipped to offer. Which would have been rather like trying to repair a decapitation with a butterfly bandage.
I have to stop here and note that I mean no disrespect to my hospital by describing our capabilities to treat such crashing emergencies. The honest truth is that we are simply not equipped, not staffed, and not scheduled, to deal with critical patients. Our mission is not to be an ICU, our mission is to be more like your GP’s office. We’re able to deal with the day to day medical stuff that our patients require, and anything more complicated than that generally gets referred somewhere where they are equipped for the complicated stuff.
I loaded Alex up with some *really good* pain medication, bundled him back into his carrier and told his dad to get OUT!
To my knowledge Mr. Alex didn’t break any laws in getting from Renton to Kirkland with his scary ass ticking time bomb cat in his car. I did, however, send them out the door at 0830, and got notification from the specialty center at 0930 that the cat had been admitted. For a weekday morning from Renton to Kirkland on SR 405, that’s an admirably short period of time.
Alex saw the cardiologist that day and had an ultrasound exam of his heart. Alex also had a full blood chemistry workup. Cardiology found that the walls of Alex’s heart had thickened to the point that his heart chambers were too small (a condition called hypertrophic cardiomyopathy which I won’t define any further). Blood chemistries showed that Alex’s total serum thryoid hormone levels were at 17.6. Normal for a cat is 1.5-4.5. The combination of the underlying heart disease and the cardiovascular effects of too much thyroid hormone (hypertension and elevated heart rate) had caused an electrical short in Alex’s heart.
Last Monday I got the final records from the specialty center for Alex’s stay. Alex had been hospitalized for two days during which time his heart rate and rhythm were converted to something more approaching normal. Alex was discharged with a pile of cardiovascular and anti-thyroid medications.
I saw Alex last Wednesday for a recheck.
The quiet, purring cat whose heart rate I’d not been able to count had turned into a bright, active, vocal cat with a heart rate of just under 200 beats per minute. The rhythm ain’t normal yet, but we haven’t gotten Alex’s thyroid levels back inside the normal range either.
Veterinary medicine is so cool!