Internal Medicine and Emergency Medicine: Star-Crossed Lovers

Get ready. You are about to be double teamed by a couple of veterinarians who love to blog. As specialists in emergency medicine (Dr. Tony Johnson) and internal medicine (Dr. Nancy Kay) we both do whatever is reasonable to help our patients feel better while providing emotional support to their humans. We are fascinated by the inner workings of the body: acid-base balance; blood oxygenation within the lungs; and the many marvelous functions of a liver cell are the kinds of things that make our hearts go pitter-patter.

Out of necessity, we’ve become adept at working with emotionally charged people. Our clients typically arrive at our doorsteps in a state of high anxiety, desperation, fear, frustration, worry, sadness, or all of the above. Although our patients are always our primary concern, the emotional well being of our clients runs in close second place.

Our differences

Dr. Tony: I am a Sagittarius. My favorite shark is the hammerhead. I have next to no long-term memory. As an emergency medicine/critical care specialist, my patients usually come to me very ill, and if they survive I often forget them in a few days. It’s not for lack of caring, it’s just the way my brain works. I may be very involved in a case for a few hours or a few days, speak with pet owners a dozen or so times, shed tears or laughs or high-fives of triumph over death, but then if someone asks me about the case the next week, my response is usually a dim-witted “Who??”

In emergency medicine, I often have no idea what I am treating. My team and I are usually trying our hardest to keep the patient alive until the patient is stable enough to be subjected to intense diagnostic tests.

When I have snatched the patient from the jaws of death, I usually seek out help from the internists like Dr. Nancy to try and figure out what made the patient so sick. It’s a little bit like strategic vs. tactical nuclear weapons; I’m the tactical, she is the strategic.

I work well in a stressful and uncertain environment, but I often run out of ideas for what to do for a patient that is not dying in front of my eyes. I can juggle a lot of things simultaneously for a short while and generate ideas to get oxygen into patients and keep the blood going round and round. My idea of health is “you are not currently dying.” I sometimes refer to the emergency service at Purdue, where I work, as the “keep them alive” service and the internal medicine service, where the patients are often transferred once we have stabilized them, as the “work them up” service that finds out what’s wrong, and they take the ball from us for long-term care. Of course the distinction is not that black and white, but what is?

My relationship with my patients is usually like a torrid, passionate affair: intense, emotional, brief and often with an unhappy ending.

Dr. Nancy: I am an Aquarius. Any type of shark makes me nervous, particularly when I am in the ocean. I have exceptionally good long-term memory for my patients, but not so much for the humans who accompany them into my exam room. When I encounter a client in the grocery store without their pet in hand, I am usually at a complete loss.

Most of my patients are referred to me because of medical issues that are complex or challenging. Truth be told, sometimes veterinarians refer cases to me because it is the client who is complex or challenging!

With hopes of ferreting out a complicated diagnosis, I have access to some exceptionally cool high-tech toys. Oops, did I say toys? What I meant to say was “diagnostic medical equipment.” On any given work day I spend lots of time in front of an ultrasound machine peering inside abdominal and chest cavities. The MRI and CT scan machines are always up and running, providing me with far more information than the average X-ray. When performing endoscopy, I feel like Tom Thumb on an incredible journey snooping around inside a nasal passageway, esophagus, stomach, intestine, airway, or bladder. This is the stuff internists love.

I have the luxury of hour-long first consultations. This allows plenty of time to sort through the typical stack of referral records, examine my patient, and discuss things with my client. After that hour spent in the exam room, I typically walk away with an accurate sense of what my client is going through from an emotional point of view. Most cry at some point during our initial contact: sometimes tears of sadness, sometimes relief. This first consultation sets the tone for what will often wind up becoming a long-term relationship. Depending on the underlying diagnosis, we may spend years working together to maintain a good quality of life for their beloved pet. This relationship is somewhat akin to a stable marriage: lasting, nuanced, and mutually satisfying.

A day in their lives

Dr. Tony examines a 12-year-old Miniature Poodle mix named Bugsy because of coughing and labored breathing of a few days’ duration. Today Bugsy failed to greet Susan at the door when she returned home. She found her little buddy slumped in the kitchen corner, panting heavily with a dazed expression on his face. Dr. Tony takes one look at Bugsy and immediately places him in an oxygen cage. Once his breathing has stabilized a bit, a chest x-ray is taken that reveals heart enlargement and pulmonary edema (fluid accumulation within the lungs). Blood and urine test results are unremarkable other than some indicators of mild kidney insufficiency. Bugsy’s diagnosis is heart failure. Accordingly, Dr. Tony maintains him overnight in the oxygen cage and begins treatment with a diuretic, a “water pill” to help remove excess fluid from the lungs, as well as other medications and monitoring that require an ICU setting. Within six to eight hours, Bugsy is a new man, breathing normally, barking, and wagging his tail vigorously when Susan visits. His care is transferred to a veterinary internist for further assessment. After their 12-hour relationship, Dr. Tony bids Bugsy and Susan farewell.

Dr. Nancy examines Bugsy, a 12-year-old Miniature Poodle mix, after he has spent 12 hours in an intensive care unit being treated for heart failure. Sounds like this lucky little boy was rescued from the jaws of death! Although Bugsy seems to be feeling great, he appears significantly dehydrated, a common side effect of the aggressive diuretic treatment necessary to treat his heart failure. An ultrasound evaluation of Bugsy’s heart reveals a disease process called mitral valvular endocardiosis, or degenerative changes of the mitral valve (it separates the left atrium from the left ventricle), preventing it from closing normally. Repeat blood work indicates that Bugsy’s kidney values have dramatically changed for the worse, likely a result of dehydration combined with kidney disease. Successful treatment of both heart and kidney failure is tricky business and a precarious balancing act. What’s good for his heart disease (draining as much fluid from the body as possible to lessen the workload on the heart) is bad for the kidneys.  Likewise, the supplemental fluids that are the ideal treatment for kidney failure increases the workload for the heart. Bugsy’s therapy will involve careful tweaking of his medications, fluids, and diet with hopes of keeping him nicely balanced on his rather narrow tightrope. If successful at accomplishing this feat, Dr. Nancy and Susan will spend considerable time together in the exam room and on the phone rechecking Bugsy and discussing how things are going at home. With attention to detail, medical expertise, and a little luck, the relationship between Bugsy, Susan, and Dr. Nancy can last for years.

The same coin

Those are the different sides of the same coin, both vital, in some ways similar and in other ways wildly different. Each specialty has different skill sets that complement one another. When it comes to patient care, we are like star-crossed lovers – ships in the night and all that. And that’s okay with us because we’re happy when a patient leaves the adrenalin-rushed ER alive to go into an internist’s tender loving care.

What has been your experience with veterinary specialists? Have you worked with several veterinarians at the same time who worked as a team? Did they agree with each other?

Best wishes,

Nancy Kay, DVM

Diplomate, American College of Veterinary Internal Medicine
Author of Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Author of Your Dog’s Best Health: A Dozen Reasonable Things to Expect From Your Vet
Recipient, Leo K. Bustad Companion Animal Veterinarian of the Year Award
Recipient, American Animal Hospital Association Animal Welfare and Humane Ethics Award
Recipient, Dog Writers Association of America Award for Best Blog
Recipient, Eukanuba Canine Health Award
Recipient, AKC Club Publication Excellence Award
Become a Fan of Speaking for Spot on Facebook

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot and Your Dog’s Best Health.   There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot and Your Dog’s Best Health are available at www.speakingforspot.com, Amazon.com, local bookstores, and your favorite online book seller.

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8 Responses to “Internal Medicine and Emergency Medicine: Star-Crossed Lovers”

  1. LeeAnn Brown says:

    I think I would prefer the approach that Dr. Tony takes and clear it all away a couple of days later. But either way this sounds like a pretty stressful occupation, I am just glad there are caring people like them around, it is an invaluable service.

  2. Natalie says:

    This particular case was interesting for me. Our diabetic dog Chris also suffered from heart problems (multiple ones).

    We basically could not give him the diuretic because his kidney values would go south very quickly even on a small dose. He tended to be very sensitive to some meds and incredibly tolerant of others, like NSAIDs.

    We used Vetmedin for his heart issues, which worked well for him.

    Chris required emergency care a handful of times during his senior years – he had what was suspected to be a TIA, he had what seemed to be a bad allergic reaction to something – both times he couldn’t stand up or walk. And one night well into his cardiac problems his heart rate was extremely high so we took him in that night.

    We were fortunate to have a really good 24-hour emergency hospital 20 minutes from home when those occasions arose. The same hospital also was where his dermatologist worked so they knew us, which was nice.

    I encourage folks to check out emergency hospital resources ahead of time so when you do have to go, you know them, you know what the environment is like, and you know how to get there. It’s scary enough driving to the e-vet as it is. If you’re lucky enough to have access to more than one, as we are, you can choose the one that best suits your goals and style.

    Chris was followed at various times by an ophthalmologist, a cardiologist, a neurologist, and a dermatologist – all of whom contributed greatly to his well-being and longevity despite his many health issues. I am a huge advocate of good Internal Medicine and other specialists after seeing the dramatic difference in what they and GP vets can bring to a problem.

  3. Dr. Tony Johnson says:

    Thanks for sharing your experiences, everyone and thanks for the positive comments.

    Jeanette, did the first internist only do a phone consult – no exam? That’s an interesting idea, but I can many pluses and minuses with that. It sounds like you have had many positive experiences with specialists to the benefit of your pets!

    Amy – glad to hear you had a good experience at Purdue! Sounds like everyone benefited from the high-end medical therapy, which can be a gamble. The dental experience points out that we are not always spot-on with recommendations. I have seen some cases where a dental makes a huge difference, but lots of time (maybe the majority) where it does not. Juggling heart disease and renal disease is always a balancing act – glad that went well for so long.

  4. speakingforspot says:

    Hi Cathy. The possibility of needing to show up at a veterinary emergency clinic in the middle of the night is one good reason to keep a copy of Lucy’s medical record at home with you. That way, the new doc will have access to Lucy’s medical history!

  5. Cathy Allred says:

    This was a very interesting post. As the caretaker of sweet Lucy who will be nine in a couple of months I have the most terrible feeling about needing emergency treatment. This makes me feel a little bit better. I keep thinking how difficult it is for humans to go to an emergency room; I can hardly bear to think of taking Lucy to one. They won’t know her history, she’s not at ease with her regular vet so I can’t imagine what her demeanor might be in an emergency. I can only hope the result will be as good as it was for Bugsy. Thanks for posting.

  6. Janis Dolphin says:

    That was a brilliant dual-blog that explained the different approaches of the two sorts of medicine VERY well. Thanks for the enlightenment and good writing.

  7. Amy says:

    wow my first experience with an E.R. was when my schnauzer mix collapsed on a walk. She came to as I was running to the car and by the time I got to the E.R. she was her “normal” self, but they detected heart disease. I took her home and then to a cardiologist where they diagnosed mitral valve disease on top of her kidney disease. Her cardiologist was a saint and juggled her medicines to keep her comfortable for over a year. Missy was just over 15 when she passed away.

    My sweet diabetic cocker, Karly, went to Purdue’s Internal medicine people in conjunction with breast cancer. I did a glucose reading before every meal and she had wild swings. Before her many mammary tumors had been removed, she got very easily regulated on vetsulin, which became unavailable. My theory is the cancer cells were greedily sucking up the glucose and when they were (almost!) gone, the glucose circulated in her blood. We never really got to the bottom of it, but they recommended a food that seemed to equalize her glucose a bit. And they recommended a dental, which turned out to be very expensive and not particularly helpful for her glucose. She had to be PTS after she developed a spinal inflammatory disease of some kind that looked like a tumor on MRI. Just goes to show – just because a dog has two diseases doesn’t mean she can’t develop a third! But… she didn’t die from diabetes or cancer, so her internists and oncologist can get some credit for her happy life.

  8. Jeanette says:

    Great post, Dr. Kay and Dr. Johnson. Interesting to read the two perspectives.

    My first experience with a veterinary specialist was a phone consult with an internist to help me sort out suspected IBD with my 10-year old Rotty (that was before I knew we had an internist here in the state). She was wonderful and did attempt to work with the vet where I’d been taking Lexi for years.

    By the time we really got to the bottom of everything, I’d moved to another veterinary clinic at the recommendation of a friend who also had a geriatric dog. That’s when we had our appointment with the in-state veterinary internist (who was also wonderful and thorough). Our regular vet consults with the internist whenever we’re considering a new medication or treatment that might impact Lexi’s IBD, so yes, they work very well as a team.

    My other experience with a specialist was more recent with my overly-active and energetic mixed breed. He’s been dealing with chronic lameness so an orthopedic specialist was consulted. He worked well with Boone’s regular vet (even though we haven’t yet resolved the lameness issue).

    I appreciated that in both cases my regular veterinarians (Lexi has her vet, Boone has his) recognized when it was time to consult with veterinary specialists.

    And I appreciate your insightful posts, Dr. Kay!

    Jeanette