VMDiva

Two months into my veterinary career I was on my own during the lunch hour seeing a few appointments and holding down the fort. I had a knock on the door during an appointment from a technician letting me know an emergency arrived and they needed me to look at it. Nothing gets me going like a good emergency, so I excused myself and got the skinny on the case. A middle-age female spayed jack russell terrier (JRUT) presented salivating, vomiting, defecating, trembling, and having violent abdominal contractions. I knew this would be an exciting one. In questioning the owner, we discovered she had consumed the family labrador’s pyridostigmine and metronidazole earlier in the morning and the owner arrived home to find the dog in her current state. Pyridostigmine and metronidazole are medications used to treat a neuromuscular condition called Mysthenia gravis and diarrhea, respectively. Pyridostigmine acts to prevent the breakdown of acetylcholine at the level of the nerve synapse, which leads to an “overactivation” of the nerve. Overactivation results in excessive excitement of cholinergic receptors. Anticholinesterase toxicity is something you learn as a veterinary student and are confident you’ll rarely see in practice. It typically occurs from organophosphate (insecticide) toxicity. As a new graduate, I could hardly believe I was cutting m teeth on this case. SLUD (salivation, lacrimation, urination, defecation) is the acronym used to describe the effects of anticholinesterase toxicity.  Perfect presentation. And let’s not forget about that metronidazole overdose.

I began a bolus of IV fluids. With frustration, I looked up the atropine dose for this dog. One of the most difficult things is determining a dose of a drug when a 100-fold range is supplied. According to one veterinary drug handbook, the JRUT required somewhere between 1cc to 30cc’s of atropine. Huh? Convinced 30ccs of atropine would make this dog’s heart explode, I opted for 2ccs initially and increase as needed:  1/3 IV followed by 2/3 SQ. The abdominal contractions ceased nearly immediately with the IV atropine. Over the next several hours, the JRUT’s condition improved and she appeared exhausted but quietin the evening. No additional atropine treatment was required. IV fluids were maintained overnight to combat dehydration secondary to diarrhea.

Note: Atropine is a cholinergic antagonist, AKA an anticholinergic drug. It combats the effects of the cholinergic receptor overactivation by competitively binding to the cholinergic receptor site in place of acetylcholine.

After calling poison control, I discovered this dog had consumed both a lethal dose of pyridostigmine and a seizure-inducing dose of metronidazole. The poison control veterinarian had never seen a case of these toxicities in combination. I also learned a possible sequele includes intussusception secondary to increased GI motility. Intussusception is a condition where a section of intestine telescopes into another section occluding blood flow and potentially causing death of the tissue. Despite her GI upset, I astutely believed further metronidazole use was contraindicated. Luckily, she had no post toxicity complications and was discharged the following day. This is a case any vet would geek out over.

Beginning the blog with a discussion of the end. Euthanasia of family pets is certainly the greatest burden of pet ownership. Pet owners, frequently at a loss for words during the death of their animal, often utter the same simple phrases. Many thank me for compassion and helping the passing of their pet. Many more state their belief that euthanasia must be the most difficult part of my job. I often console never daring to thread my ideas into such a sensitive situation.

As a veterinarian, I have seen degrees of suffering only imaginable for most people. I provide hospice care, see neglect leading to maggot infestations, watch animals starve themselves to death over weeks, and manage cases of “just one more day”.  Death is painful for most animals burdened with chronic diseases. Euthanasia provides relief of suffering. Many owners describe it as a “peaceful” process and express relief when it’s over. Then why do we wait so long? Why too often do I see animals minutes to hours from natural death finally arrive at my practice? The answer is wrought with complexity but comes down to human nature.  The human-animal bond is evolving such that pets are now considered family members held in the same regard as a child. This makes the loss of a pet equivalent to a human for many. Pets can also represent a passed loved one or any number of personal issues. Veterinarians are always trying to be sensitive to the underlying dynamic of the family which affects the decision. We know no owner wants to see a pet die. The truth is neither does the veterinarian.

I encourage veterinarians to be sensitive to the difficult choice owners make in euthanizing a pet. The veterinary oath states “the relief of animal suffering” is one of the highest responsibilities of a veterinarian. In turn, I encourage pet owners to provide a timely gift of euthanasia to an ailing pet. In truth, euthanasia is not the most difficult part of my job. Witnessing animal suffering is.

Goodbye World.

Being admitted to the profession of veterinary medicine, I solemnly swear to use my scientific knowledge and skills for the benefit of society through the protection of animal health, the relief of animal suffering, the conservation of animal resources, the promotion of public health, and the advancement of medical knowledge.
I will practice my profession conscientiously, with dignity, and in keeping with the principles of veterinary medical ethics.
I accept as a lifelong obligation the continual improvement of my professional knowledge and competence.