Saturday morning. My birthday. We had planned to go away for the night but not before morning chores. I walked out to feed the horses and immediately sensed something was amiss. Our 2-year-old, Duke, short for Countess’ Menacing Duke, was not menacing at the fence. Duke usually appreciates food like I do. I threw the hay over the fence and he made no move toward it. Big problem. I moved him into a stall and noted he was lethargic. I took his temperature; no fever. He was tachypneic with flaring nostrils but no cough or nasal discharge. No teeth baring, restlessness, biting at his sides, lying down or other signs of pain. Out of my league, time to call the vet.
The answering service picked up, the original transfer center. My vet’s partner was on-call and would call me back. Note to self: it sure is nice to talk directly to the doctor. He would be there as soon as he could. How many times have I said this to someone? What does it mean? Give them a number for God’s sake. But alas, the house call is magical. I suppose emergency medicine was born when the house call was dying so we never had a chance to give it a try. This was the original emergency department (ED). Or in this case, emergency stall.
The vet came, did a history and physical and drew blood. Himself. Why don’t I ever draw my own blood? It’s quick, efficient and very impressive to the patient – well, to the patient’s family at least. Duke could have cared less. Not a good sign. The vet said he wasn’t sure what it was but suspected it was gastrointestinal. He gave some analgesia and sedation and performed the disappearing arm trick in Duke’s rectum. So the vets use procedural sedation for a rectal and I still must convince doctors to do it for an LP. Things that make you say “Hmmm.” He found the colon was distended with gas.
“Isn’t there a medicine for that?” my wife asked. He stares at her with disbelief as if she had just asked if there was a cure for a cold.
“I don’t understand?” he said. Clearly he had lost the ability to think like a normal person. Why do we allow and encourage that in medicine?
“Could it be contagious to the other horses?” my wife asked next.
“I don’t think it’s infectious. I think it is mechanical.”
My wife gave him a blank stare. Apparently using English does not mean it makes sense to anyone else. As doctors we believe we have communicated successfully as long as we leave out the Latin. After being rebuffed by his first disbelieving stare, she was not about to ask any more questions. How often do I subconsciously close the door like that?
The vet left to go run the blood and promises to call in an hour. My wife launched into a tirade of really good questions. I did the best I could to answer. Note to self, make sure you answer all the questions before you leave the stall…I mean room. Impressively, the vet called in an hour. Darn, you really can get blood work in an hour.
“The blood work is very concerning. I think this is potentially more serious than we can take care of at home. Can you bring him to the office?”
An hour later we were at the vet’s office for more tests and intravenous fluids. We were standing in the treatment area while he shaved Duke’s neck and prepared to put in an IV.
“Can we stay?” I asked sheepishly.
“You can do whatever you like.” Apparently vets figured out that family in the resuscitation room is a good thing long ago. Why did it take us so long?
The vet did an ultrasound. Are we the last ones to discover the bedside ultrasound? He found some free fluid to tap. He shaved his belly, prepped, put in some local and pulled out a giant blunt-tipped needle. Blunt-tipped needle for a paracentesis. That’s brilliant! Can’t wait to try that one. A few hours and 12 liters of fluid later, Duke is looking better.
“Let’s get another CBC.” Like any self-respecting emergency physician, I was wondering if the sensitivity and specificity is any better with horses than people? But suddenly I realized why a CBC became routine in the first place. It’s about all they have, at least in the community. No CAT scan or x-rays. No lipase and LFTs. Just a CBC. Suddenly the little information you get is worth hanging your hat on. This confirms my suspicions; surgeons really are just veterinarians. At this point my wife wandered off to the restroom and the vet and I are left to chat.
“So what do you do?”
“Oh, umm, I’m one of the ER docs at the U.”
“Oh, so you understand what’s going on?”
“In theory, yes.” Then the labs and my wife came back.
“Here, look at this. The crit has come way down. The white count is still in the normal range and the total protein is quite low. Overall I think this is good news. If he had necrotic bowel I doubt our resuscitation, even 12 liters, could keep up. And he doesn’t look nearly so toxic.” Suddenly the conversation had turned to medspeak.
“So what’s wrong with him?” my wife asked with a tone between pleading and frustration.
“We don’t really know. It could be an obstruction but I would expect more signs of pain. I still think it’s gastrointestinal. Maybe it’s just inflammation of the intestine.”
“What causes that?”
“We really don’t know,” he said, turning to me as if to hand it off.
My wife is perplexed, of course, but I understood two things. First, idiopathic always wins. The belly is still a mystery to us people doctors, even with all our fancy tests. Imagine the vet. How many times have I told patients before writing “abdominal pain – unclear etiology” on the chart? “I know it’s crazy. We can put a man on the moon and we have all these fancy tests but a lot of times we still can’t figure out the belly. But it’s ok if we never know; as long as you get better and it doesn’t come back.”
The second thing I understood is the transformation that takes place when we are talking to one of our own, even a distant cousin. There is a big sigh and we revert to our native tongue. Suddenly English is the vet’s second language and I am left to translate. The same thing happened when I took my wife to the ED. Even though she was the patient and clearly all right-brained, few of the staff could talk English with me around, let alone real-person English. It was just too easy for them to say it to me in our native tongue and leave me to translate. How many times have I made that mistake?
“We’ll just have to see how it goes. I’m not inclined to give him antibiotics; just more NSAIDS.” What?!?! Rational use of antibiotics. So the vets are ahead of us on this one too?
“You can leave him here or take him home to watch him.” Ah yes, tincture of time and serial exams; been there, done that.
“We’ll take him home.” I bet half the patients in our observation unit would never have stayed if given the choice. Oh, how I hate the observation unit.
It is now Monday morning. Duke is still not his menacing self but well on the way to recovery, though it has been a long weekend for all of us. I just checked in with the vet.
“Keep doing what you’re doing and call us tomorrow morning for an update. Call anytime if he gets worse.”
We have spoken by phone no less than 5 times, he has been to the house twice and we spent half a day at the clinic; we’ve even met his wife. He has earned my respect and admiration. I felt tremendous security knowing he was available. I suppose the public feels some security in knowing the ED is always available but it’s not quite the same. This is the continuity and personal relationship all of us in emergency medicine knowingly sacrificed but can’t help but long for at times. It’s what I want for my family and my animals but am unwilling to give to others. Thanks Doc.
Postscript
The day after this was written Duke relapsed and died tragically at the vet’s office while we held him. The cause of death remains a mystery despite an autopsy. The vet and his staff have been wonderful; they even sent a sympathy card. I suppose this is what makes us old and wise rather than simply old. Funny, I just feel old.
Here’s to Duke. I sure do miss him menacing at the fence.
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