St. Elsewhere Veterinary School
10:30 a.m. Monday
Dr. Janet Miller sits and nervously listens to rounds moderated by her senior professor.
She half-listens as she thinks about the morning disaster.
Dr. Miller had admitted an animal named "Pete" with liver problems the night before. The referring veterinarian had sent the animal up with a continuous IV in place and the owner had dutifully hung the fluid container from the coat hangers in the back of their new SUV. A complete report accompanied the admission.
It seems that liver failure secondary to drug interaction was the tentative diagnosis by the referring vet, Dr. Jim Blount. Dr. Miller had decided that general anesthetic might have been too risky but Pete still died during a liver biopsy done under light sedation and a local. What killed Pete?
Entering spin zone
Preliminary blood tests indicated high white cell count and various elevated liver tests; Dr. Miller now faces talking to the owners in an exam room momentarily. What she told the owners was right out the "spin zone".
"Hello, Mrs. Wheeler, I am afraid we lost Pete." (A description of the ensuing scene is unnecessary for our readers.)
Finally, after several minutes, Mrs. Wheeler composed herself enough to ask what he died from. "Well, Mrs. Wheeler, it appears that there must have been some septic shock likely induced by the IV."
Mrs. Wheeler asks for a clearer explanation.
"Well, your doctor left the IV catheter in too long, and by the time we got around to helping Pete, it was too late. Dr. Blount should have placed another catheter Sunday morning. The catheter had been in since Saturday noon and this is Monday. My personal limit is 24 hours max for each catheter," she pronounced with granite-eyed authority.
"What about the liver like Dr. Blount was talking about?"
"We went ahead with the biops,y but I'm positive that we are dealing with a septic shock from the IV."
"Must be Elsewhere" Animal Clinic
9:30 a.m. Monday
In central New England Dr. Blount just finished telling Mrs. Smith that her cat must have died from a stroke or heart attack. Mrs. Smith did not want an autopsy but did want to know the likely cause of death-Dr. Blount gave her one. A few minutes later Dr. Blount opened the exam room door and was presented with a serious abdominal distention in "Rufus," an obese German Shepherd, owned by Bucky Shannon.
Dr. Blount ordered X-rays, and the results were inconclusive. To Dr. Blount there appeared to be gas distension and a small radio-dense shadow in the anterior abdomen.
"Mr. Shannon," Dr. Blount intoned, "Rufus has something going on in the abdomen at this time. This almost always requires surgery. Rufus has eaten something, and it is likely caught in the stomach. This shadow could be a piece of metal." Mr. Shannon was impressed by the serious tone of Dr. Blount's pronouncements and authorized surgery that morning.
While making a midline incision in Rufus, the fatty omentum and falciform ligament boiled out onto the surgical drapes. As Dr. Blount continued the incision, it became quite apparent that Rufus was filled with an enormous amount of abdominal fat. The exploration continued. Nothing was found in the stomach but a small amount of food. The rest of the celiotomy was without any significant findings save the intestines that were a bit reddened.
In his mind Dr. Blount was quick to note this as a potential "cause" for what must be going on. He had to find causation beyond the mountain of adipose tissue lying in front of him.
After surgery he called Mr. Shannon.
"Mr. Shannon, Rufus did fine. What we found was an inflamed gut that was giving him all the trouble. I found something in the stomach that probably was the object. It could be metal, but I think that if it is metal it will pass through with no problems.
"Dr. Blount, what was causing all the swelling in the abdomen then?"
"Oh, the inflamed intestines for sure were a good part of it," the doctor replied.
"Did you do anything that will help him?" queried Mr. Shannon.
"Oh, yes, we'll put him on antibiotics and keep him on fluids through the night. Oh, and by the way, we ought to look at putting him on a diet."
Dr. Blount added this as if it was an "afterthought".
Just then an assistant named Mary opened the door and said that the university was on the phone. Dr. Blount excused himself and put the receiver to his ear.
"Dr. Blount, this is Dr. Miller. Your patient expired this morning. It appears that a septicemia developed before we could ascertain the cause of death. We started stupendo-flutixicin ASAP but it was too late. I see that you had the patient on a 4th generation cephalosporin developed a few years ago. We feel at the university that the brand new stupendo-flutixicin is a better choice for these septic situations. I also noticed that the catheter was placed Saturday noon and Pete arrived Sunday evening without a new IV placed on Sunday. The newest protocols call for every 24 hours in potential septic situations. I feel that without a sterile dressing and antibiotic ointment on the IV site during transit that the IV was contributory to the patient's death."
Dr. Blount was confused.
"Dr. Miller, was a blood culture done?"
"Yes, it came back negative, but I feel that there are many false negatives," she said evenly.
"Didn't you do a biopsy? What was the result?"
"The preliminary report shows acute hepatitis, but this could be from the septicemia."
"But all my tests showed liver problems Saturday morning."
"We can't rule it completely out, but septicemia is our best definitive diagnosis."
"Did you notice that I had taken Pete in on Saturday from another veterinary hospital and that he had been on 'stupendo-flutixicin'* prior to his liver enzymes skyrocketing?"
"Yes, doctor," she intoned condescendingly, "but we really can't make the correlation can we now? Besides, the manufacturer has never reported any liver problems."
Dr. Blount hung-up the phone and was depressed. He had tried his best, and the university wasn't really helping much.
"Must be Elsewhere" Animal Clinic
1:30 p.m. Monday
Mary was at the door again. She came over and whispered that an attorney was on the phone and that she was representing Mr. and Mrs. Wheeler. A lump formed in Dr. Blount's throat.
St. Elsewhere Veterinary School
4:00 p.m. Monday
Janet Miller was wondering about her car that she dropped off at the dealership earlier in the morning. Her car just hadn't been running right. As if the shop was communicating by telepathy, the mechanic called as she completed her last thought.
Shoe on other foot
"Doc, this is Jimmy Adams down at the dealership. Your car needs a complete overhaul plus some of the other maintenance items are overdue."
"Can I get my car back tonight?" she naively replied.
Jimmy laughed under his breath-(she didn't realize that Jimmy was on commission.)
"No, doctor, your car will be in the shop for about two weeks and the cost will be over $2,000."
Dr. Miller felt her temperature rise very quickly.
"What on earth do you mean? What could have caused such a big issue with my car?" she fumed.
"Well, Doc, my best guess is that your last mechanic sold you the wrong motor oil. Ya should'a come to the dealership in the first place."
Dr. Miller unknowingly had just entered someone else's spin zone.
*Author's note: This story and the antibiotics described here are fictitious. It does not imply a problem with a particular drug from any real pharmaceutical company. This story is partially autobiographical. In my case, the director of clinics at the university later apologized.