Posted on September 1, 2013
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.
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?
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
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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.