Critical Care Veterinarian

https://nypost.com/2024/01/20/metro/li-animal-hospital-fired-vet-for-barking-about-dog-od-suit/amp/

LI animal hospital fired vet for barking about pet overdoses, unlicensed physicians: lawsuit A former “Best Vet of the Year” claims she was canned after exposing a Long Island animal hospital used unlicensed physicians and overdosed pets with fentanyl, a Brooklyn Federal Court lawsuit char…

https://www.law360.com/employment-authority/amp/articles/1784584

Vet Practice Fired Pregnant Doc For Raising Issues, Suit Says - Law360 Employment Authority The head of a New York veterinary practice's emergency care department told a federal court that the company's founder allowed unlicensed staff to administer fentanyl, leading to one pet's overdose, and later fired her for addressing these concerns and announcing her pregnancy.

https://www.dvm360.com/view/veterinarian-files-whistleblower-and-retaliation-lawsuit-against-former-employer

Veterinarian files whistleblower and retaliation lawsuit against former employer Mariana Pardo, BVSc, MV, DACVECC, was allegedly fired after witnessing unlawful practices and filing a complaint at the clinic

https://www.longislandpress.com/2024/01/10/animal-surgical-center-of-long-island-provided-substandard-care-veterinarian-alleges-in-lawsuit/

Animal Surgical Center of Long Island Provided Substandard Care, Veterinarian Alleges in Lawsuit Animal Surgical Center (ASC) of Long Island allegedly used unlicensed veterinary technicians for procedures, engaged in unsafe administration of controlled substances, and provided egregiously substandard medical care, a veterinarian claims in a new lawsuit.

After much consideration, I am sharing a piece of my journey. Sometimes life puts you in impossible positions, where your integrity, values and social justice are put to the test.

I am taking a stand against harrasment, retaliation and discrimination, my lawsuit against Dr. Tomas Infernuso at the Animal Surgical Center is about seeking justice and ensuring a safe environment for all.

No one should face discrimination or harassment, especially during such a significant time as pregnancy.

Your support means the world. Let's break the silence and pave the way for positive change.

Read the press release:

https://www.wigdorlaw.com/news-press/whistleblower-complaint-against-animal-surgical-center-asc-of-long-island/

Please let’s keep this space respectful – refrain from hate speech or retaliation.

This 14 year old intact female shih tzu was brought to the ER for not eating and vomiting for 5 days. She had a heat cycle a month before. She was extremely dehydrated and lethargic. We initially suspected a pyometra from the history… but diagnostics showed us something more surprising.

Holy kidney stones! Both kidneys were almost completely invaded by nephroliths. On ultrasound you can see the shadowing in the kidneys and the bladder was extremely inflamed with a thickened bladder wall. Bloodwork showed severe azotemia and urinalysis showed a severe pyuria and urinary tract infection.

We discussed options with the client:

1. Medical management, fluid therapy, antibiotics, gastric protectants, antiemetics, nutrition and hospitalization. If the patient responds then consider medical dissolution (unlikely due to the size), lithotripsy (unsure the size of these would make this successful), and nephrotomy vs nephrectomy (considering the severe bilateral involvement, this would be risky considering future renal function).

2. Euthanasia

Due to the severity, poor prognosis and financial burden of such treatments, the clients sadly decided to put her to sleep.

# shih tzu

Join me this Sunday at the Bronx Zoo!!! Free CE!

Enjoy a complementary Roo CE event at the Bronx Zoo on Sunday, November 5th!

Join Roo and Dr. Mariana A. Pardo as we discuss canine and feline ECG patterns that clinicians will most likely encounter in their ER practice while earning CE credit (RACE Approved - 1 hour for veterinarians and veterinary technicians)!

Reserve your spot today: https://hello.roo.vet/bronx-zoo-ce?utm_source=roo&utm_medium=email&utm_campaign=bronx-zoo-ce

Tranquilizer darts are designed to administer a compound from a distance, utilizing low velocities to minimize unnecessary injury to the animal by excessive pe*******on of the dart.

If an animal is shot with the incorrect amount of a drug this may lead to overdosing or injuries caused by under sedated animals fleeing with altered reflexes and/or mentation and injuring themselves. If the dart penetrates into the wrong part of the body or if projected at too close a distance, it may cause severe injuries in animals including hemorrhage, internal organ laceration and bone fractures to small animals.

When these restraint methods are used inappropriate or by inexperienced people they can be very dangerous for animals. This technique has its benefits when used appropriately. Such circumstances may include cases where the animal is in danger from traffic, where it may be hit, injured or killed, or where the dog may cause a road traffic collision where human safety is at risk. Where a dog is close to a livestock farm, then the likelihood of the dog being shot if, for example, it is seen in a field with sheep and lambs. Other cases where darting should be considered as a primary option are where the dog is aggressive, or potentially dangerous to humans.

It is unclear how this pet ended up with a tranquilizer dart, they found their pet with this hanging from him (not the least bit sedate btw!) This pet recovered well after we removed the dart and was sent home in antibiotics and pain meds.

I am so deeply humbled and grateful to have been honored with the Emergency Doctor of the Year award from . This touches me on such a profoundly personal level, and reaffirms the dedication and passion I have for emergency and critical care.

In the midst of the chaos and uncertainty that often define our field, it is moments like these that remind me of the incredible impact we can have on the lives of those in need. Every patient we treat, every life we touch, serves as a testament to the unwavering commitment we have made to this field. But it’s so much more than our patients… vet med is a team sport and every encounter we have with other colleagues, staff members, students, etc, is another opportunity to grow and to inspire.

My hope is that this recognition serves as an inspiration for others to join this noble journey, and for you to never forget that everything you do or say can have a huge impact on those around you. Let us continue to uplift and empower one another, reminding ourselves that even in the face of adversity, our work has the power to transform lives.

Thank you from the depths of my heart for this honor. Together, let us ignite a spark of inspiration that fuels our shared mission to serve, heal, and inspire.

Potassium EDTA (ethylenediaminetetraacetic acid) is the anticoagulant primarily used for hematology because it preserves the cellular components and morphology of the blood cells and hence is the recommended anticoagulant for hematology.

EDTA inhibits clotting by chelation of the divalent cations Ca++ and Mg++, which inhibits several of the divalent cation-dependent proteolytic enzymes critical to the clotting cascade.

When taking a series of blood specimens, it is essential that the samples are taken in the correct order, to not contaminate other samples with EDTA.

The correct order in which blood should be collected is:
1. Blue top/ Citrate
2. Red top/ no anticoagulant
3. Green top/ Lithium heparin
4. Purple top/ EDTA

Failure to adhere to a specific blood collection sequence will lead to contamination of blood specimens with EDTA. Significant contamination can be easily detected due to the severe hyperkalemia that would be life threatening which is also accompanied by the tell-tale signs of marked hypocalcemia and hypomagnesemia. There are frequent examples of patients being treated inappropriately and dangerously with insulin and glucose to bring down a potassium result, which was subsequently found to be normal, or even already low.

If you have any doubts about the accuracy of a potassium result (if it does not agree with the patient’s condition or with previous results), then obtain a fresh sample in which you are sure of the sample integrity, and have it analysed emergently, BEFORE you jump to conclusions and treat this normal patient.

*First bloodwork compared to second recheck on a blood gas machine with a new sample.

We don't "KILL" animals in veterinary medicine...

Words have power and using the correct words is incredibly important. Euthanasia is the practice of intentionally ending life to eliminate pain and suffering. The key here is to address pain and suffering, minimizing euthanasia and attaching it to the likes of murder is not only insensitive, but more importantly dangerous.

Studies in human doctors have shown that physicians that have performed euthanasia have a significant emotional burden and frequently have psychological repercussions that affect their clinical practices.

The emotional toll that euthanasia places on the veterinary professionals should not be overlooked, particularly as we know that su***de rates amongst veterinarians are high. Not only do vets need to manage their own emotions, but they also manage those of the grieving pet owner.

As an emergency and critical care specialist I feel that a huge portion of my job is to perform euthanasia to a variety of patients.

- Critically ill patients with a poor prognosis that will have a slow, painful death
- Patients with a poor quality of life, may not be in physical pain, but are however suffering
- Patients with a potentially treatable disease process where clients are financially limited and all financial options have been exhausted

As veterinarians we are faced with making medical decisions based on financial abilities. To be honest, this was harder for me at the beginning of my career than it is now (not to say it is easy).

I believe that euthanasia is one of the most important tools I have. I became a vet to save animals... And to me, saving doesn't always mean keeping them alive at any cost. I have the privilege to be with a patient and their family when they need me the most. I can provide peace, relief and make their final moments painless and hopefully what we all wish for our last moments... To be held by those you love the most while you drift into sleep.

Vets do not take euthanasia lightly, even when we have performed many in a day... So please be careful with the words we use, a vet's mental and emotional wellbeing is tied to this treatment that is both a blessing and a curse.

Acute blindness? Put a probe on it!

Ocular ultrasound offers several benefits in the diagnosis and management of retinal detachment and retrobulbar disease.

1. Fast and Non-invasive: It helps confirm the presence of retinal detachment and it’s extent.

2. Portable and Accesible: If you have a linear probe, you can use it to scan the eye.

3. Complementing Clinical Examination: Ocular ultrasound serves as a valuable adjunct to clinical examination in situations where direct visualization of the retina may be challenging or impossible. It aids in confirming the presence of retinal detachment when the retina is not fully visible due to opacities or poor pupil dilation.

4. Assessing Associated Pathologies: it can help detect retrobulbar and intraocular masses, hemorrhage, etc. influence treatment decisions.

5. Cost-effective Alternative: Ocular ultrasound is often a cost-effective alternative to magnetic resonance imaging (MRI) or computed tomography (CT). It provides valuable diagnostic information without the need for more expensive or time-consuming procedures (in trained hands).

It's important to note that while ocular ultrasound offers numerous benefits, it should be interpreted in conjunction with a comprehensive clinical evaluation by an ophthalmologist or a trained clinician.

Simulation-based training as a learning modality and performance-improvement tool within veterinary medicine has made huge leaps in the past decade or so.

Simulation offers scheduled, valuable learning experiences that are difficult to obtain in real life. Learners address hands-on and thinking skills, such as knowledge-in-action, procedures, decision-making, and effective communication. Because any clinical situation can be created at will, the learning opportunities can be scheduled and repeated as needed to meet the cohorts needs.

Beginners gain confidence in learning procedures and tasks, while experts strengthen communication and teamwork as well as learn new technologies and therapies.

Working in a simulated environment allows learners to make mistakes without the need for intervention by experts to stop patient harm. By seeing the outcome of their mistakes, learners gain powerful insight into the consequences of their actions and the need to “get it right.”

Simulations can be immediately followed by video recording debriefs or after-action debriefs that richly detail what happened. Physicians with major errors during simulation are offered opportunities to provide reflection, discuss feelings, and provide remediation if needed.

This week we had the most amazing CE that integrated a few formal lectures, hands on practice and integration of simulation cases to tie in everything they learned.

Loved being part of this instructor team with and

“I don’t want to do this again…”

This was the first thought that went through my head when I failed the anesthesia section of the ECFVG for the second time.

For those that don’t know, the ECFVG or Educational Committee for Foreign Veterinary Graduated exam is required to obtain your veterinary license in the United States, this is a years long (13 years in my case 😅), hands-on, expensive examination (see my Fail post for more details). I failed this time because I forgot to wipe with alcohol after each chlorhexidine scrub when prepping for my IV cath. I knew that’s what they wanted, but I’m sure between the stress and normal habits, it slipped my mind and I was asked to leave the exam.

Don’t get me wrong, I know how privileged I am to be able to have a license in the state of NY and to be able to work as a criticalist. I know many that do not have that luxury… and the big picture/silver lining/everything happens for a reason part of me is already rationalizing this failure, but yeah... the first thing that went through my mind was wanting to give up.

I felt sad, disappointed in my self, that I had let others and myself down. I completely let the feeling of defeat in and willingly sat in that feeling for a solid 30 min. Self-pity doesn’t suit me, but today I welcomed it in.

Sound familiar? Are you tired of being resilient all the time? Sometimes you just need to feel your feelings, to cry, yell, and feel bad for yourself before getting back up, taking a deep breath and doing all the inner work to build up the energy to learn and grow from yet another failure and get back on the road to a better me.

Not to worry, I’m not letting this (or ANY obstacle) get in the way of me achieving what I want, but did want to share a very real experience for those that may be going through something similar.

So, if you also failed recently, remember it’s ok to take a moment to feel it, to mourn the effort you had put into it, before brushing it off and getting back at it.

Most importantly, remember 2 things can be true at the same time… You can fail at something and still be a bad ass!

Pushing yourself and others to continue to grow and improve is a cornerstone of staying motivated at work.

I love walking into peer to peer teaching and seeing them take the initiative to train each other. Creating an environment where learning is important AND fun, is so incredibly important to me, I’m so proud of my team!

1. CRI worksheet training ( this LVT put together the handout for the team)
2. ECC jeopardy - make your own jeopardy questions on jeopardy labs.com
3. What toxin am I? game (sans alcohol 😅)
4. Classic white board downtime rounds (saddle thrombus edition)
5. Not shown here, but we also do monthly M&M rounds, journal club and lectures, presented by doctors and technicians

What educational games do you incorporate in your work day? How do you keep people engaged in learning?

This cat presented after falling 7 stories the night before. He presented in respiratory distress. Lung sounds were absent on the right side.

Thoracic ultrasound had questionable glide sign and some b-lines. Radiographs confirmed a severe right sided pneumothorax. A thoracocentesis produced around 300 ml of air and glide sign was completely recovered over the entire right side.

High-rise syndrome is defined as a fall from a height of 2 or more stories. The most common injuries are pneumothorax, fractured ribs, jaw fractures and front limb fractures. Although a vast variety of injuries may occur.

Here you can see the before and after radiographs of a thoracocentesis and how quickly you can stabilize these patients if you recognize this early on.

The patient did great thanks to the care of Dr

This is this all that’s left of this dog’s intestines, after a massive R&A from a chronic linear foreign body….

Extensive (≥ 50%) removal of the small intestine can produce small bowel syndrome, a condition characterized by malabsorption, weight loss, and fluid and electrolyte imbalances. The most common clinical signs include persistent watery diarrhea, polyphagia, weight loss, and steatorrhea. Eventually, the intestinal surface undergoes histologic and functional changes, known as intestinal adaptation, to keep the patient in nutritional balance.

The clinical manifestations of SBS in small animals depend not only on the site and the extent of the intestine removed but also on the presence of the ileocolic valve, the length and adaptive ability of the remaining absorptive intestinal surface area, and preservation of the colon.

The purpose of medical treatment of SBS is provision of adequate nutritional support, acceleration of intestinal adaptation, and control of diarrhea. During the recovery period, animals with SBS need adequate medical and nutritional support. In the early postoperative phase, treatment of most small animal patients involves intravenous fluid administration and electrolyte restoration.

Medical treatment including antidiarrheal agents (loperamide, diphenoxylate, opioids) should be initiated to increase intestinal transit time and decrease the volume of diarrhea. Gastric acid hypersecretion is controlled with proton pump inhibitors. In patients with pancreatic duct disruption may require pancreatic enzyme supplementation/ Bile-salt binding agents (cholestyramine, fiber) could be effective in animals with bile acid–related diarrhea. In cases of bacterial overgrowth, a combination of antibacterials (e.g., metronidazole, tylosin, amoxicillin, and/or tetracycline) should be effective against aerobic and anaerobic bacteria. During the management of SIBO, antibiotics should be frequently changed to prevent antibiotic resistance.

Diet-associated dilated cardiomyopathy: The cause is not yet known but it hasn’t gone away A new FDA update provides more information on diet-associated dilated cardiomyopathy (DCM). While the specific cause is not yet known, the problem hasn’t gone away

On February 3, 2023, a train derailment carrying several potentially toxic chemicals derailed in East Palestine, OH.

Several railcars burned for more than two days, and then emergency crews conducted a controlled burn of several railcars at the request of state officials, which released hydrogen chloride and phosgene into the air. As a result, residents within a 1-mile radius were evacuated, and an emergency response was initiated from agencies in Ohio, Pennsylvania, and West Virginia.

Wildlife has been seriously affected and thousands of fish have died. There is concern for local resident’s and their pets health.

The CDC has guidelines regarding the treatment of exposure to vinyl chloride and has a blog regarding some recommendations.

Please write in the comments if you have been affected or if you are currently treating pets affected by this disaster.

10 Black vet med professionals to watch in 2023 Tierra Price, DVM, MPH, founder of BlackDVM Network, introduces us to 10 Black heroes of the veterinary profession who make a difference both insid...

Patients that develop sores or ulcers in their mouth or oropharynx may benefit from compounded formulations to “coat” these ulcers. The logic behind magic mouthwash is to combine ingredients with different potential mechanisms of action to provide the greatest relief for patients.

* Diphenhydramine (Benadryl): An antihistamine or anticholinergic agent, which may help relieve pain and swelling
* Lidocaine: local anesthetic to reduce pain and discomfort
* Aluminum hydroxide (Maalox): antiacid that helps restore pH balance and to ensure that the other ingredients adequately coat the inside of the mouth

The ingredients are compounded in a 1:1:1 equal-part solution, a 120 mL solution will contain 40 mL of each ingredient. The expiration period for a 1:1:1 mixture of diphenhydramine hydrochloride, aluminum hydroxide/magnesium hydroxide, and lidocaine is 21 days.

Most formulations of magic mouthwash are intended to be used every four to six hours, and to ideally be placed topically on the ulcers or mouth lesions. It's recommended that the patient not eat or drink for 30 minutes after using magic mouthwash so that the medicine has time to produce an effect.

Although there is no evidence in support or against this treatment, it is fairly benign and may be beneficial is some patients.

This patient was brought in for concerns of lingual ulcers that had been treated with sucralfate. The patient was a geriatric dog that had a history of poorly managed Cushing’s disease, Protein losing nephropathy and recently diagnosed pancreatitis. Physical exam revealed that the tip of the tongue was necrotic, painful and there was significant sialorrhea, although the patient was still eating small amounts.

Tongue necrosis can be due to a variety of causes:

* Pine processionary caterpillar (Thaumetopoea pityocampa): these caterpillars are found in North Africa, the Middle East and Southern Europe. They have thousands of stinging hairs, like fine needles. These hairs deliver a powerful toxin known as thaumetopein. When this toxin comes into contact with mucous membranes, including the tongue, it causes tissue necrosis.

* Other toxicological causes: Industrial acids and household caustics.

* Thrombosis or thromboembolism: when a clot obstructs the lingual circulation, an area of necrosis is produced due to the lack of blood supply in the area (ischemia).

* Chronic Kidney Disease (CKD): as CKD progresses, there is an increase in the levels of urea in the blood (uremia). Bacteria present in saliva convert excess urea to ammonia, which produces uremic stomatitis with ulcers and areas of necrosis on the tongue (no specific distribution) and other structures of the oral cavity.

* Leptospirosis: is an infectious disease caused by Leptospira bacteria. In these cases, tongue necrosis can occur as a result of two factors, specifically thrombosis and/or vasculitis.

The patient had predisposing risk factors for hypercoagulability, (Cushing’s, PLN and pancreatitis), we performed viscoelastic testing which confirmed the hypercoagulability. We also performed a lingual ultrasound, although we were not able to visualize a clot, we were able to visualize the lack of blood flow to the tip of the tongue. The patient was started on Rivaroxaban 1 mg/kg PO q12hr, analgesics and topical “Magic Mouth Wash”. The next day the tip of the tongue had fallen off, the patient seemed more comfortable and was eating normally.