I left Guardian Animal early so I wouldn’t be too late to be at the ER. It opens at noon, but everyone understands that doctors cannot be at two places at the same time. I did stop by Tim Hortons for a dozen donuts for the staff and a sandwich and cappuccino for me. I knew I might not get anything else to eat until I got off my shift.
When I arrived at the ER, I was shocked at the presence of the new building. The shareholders had decided to purchase a larger building and move a few blocks. The brick exterior, large glass doors, and ample parking were a striking improvement. There is more room for more cages and exam rooms inside. Of course, a few things were given up. There is no shower in the doctor’s room which is in an extremely inconvenient location. Turns out I was only in the doctor’s room long enough to set down my gear. Some of the layouts are awkward.
Saturday afternoons are unique at the ER. The Friday night doctor goes off at 8:00 am, and the afternoon doctor is often not there until 1:00 pm. This means that no new patients can come in during those hours, but it also means that there is no doctor to update me on the cases. The staff and charts update me on the cases, and I start a mental list of things that need to be done, checked, or changed. Most are a continuation of the case, but there will be a few things that I tweak along the way.
Before I know it, there are three or four new cases to be seen. ER work is a fine line between keeping folks happy and triaging the worst cases to the front of the line. Triage is an art. Every owner wants to be seen first, but with a single doctor (and we sometimes have trouble even staffing one of those) and limited staffing (anyone want a night and weekend only, high-stress job for not a lot of money?), very sick and injured animals, everyone cannot be seen at once.
Yesterday I saw a lot of urgent cases and emergent cases. There were pancreatitis dogs, pneumonia cats, and broken legs and feet. There were a few ultra-critical cases: a large dog had picked up a small dog and broken five ribs and punctured the chest wall to create a sucking chest wound; an open mouth gasping pleural effusion and pneumonia cat; and a hit by car dog with a pneumothorax (ruptured lung), broken pelvis, dislocated hip and commuted, complex (more than three pieces and through the skin) fractured tibia.
Obviously, these cases took priority over the husky with a months-old cruciate ligament tear that was acting up. The saying goes something like, “you never want to be the patient that cuts the line to the first at the emergency department.” I did feel sorry for the husky’s dad. He waited a long time at the ER. Every time I would be ready to go in to talk with him, something would try to die.
It didn’t happen yesterday, but one thing that triage does not mean is that things closest to dying go first. That is not true. Things that are closes to dying that can be helped go first. This is an important distinction. The immediate category is the patients that require immediate life-saving treatment. The urgent category is the patients that require significant intervention as soon as possible. The delayed category is the patients that will require medical intervention, but not with any urgency.
The expectant category is the patients who are either dead or who have such extensive injuries that they can not be saved with the limited resources available. Another way this is said is the patients where further resuscitation is delayed because they require significantly limited resources and still have a poor chance of survival. Thankfully, this category changes as trauma and internal medicine get better and better. Many of the wounded warriors in the Middle East would have been casualties in prior conflicts.
Coincidentally, I used some of the battlefield advances in acute human wound management in my patients yesterday. There is blood clotting powder that I used in a wound before I repaired the laceration. The flail chest stabilization techniques were perfected on the battlefield. Critical care medicine has now become a specialty in veterinary medicine. Being on the cutting edge is one of the benefits of working at the ER. It is also one of the reasons that some doctors don’t want to work at the ER. Medicine and surgery can be very different than general daily practice. I have a friend who is a very smart, progressive veterinarian, and she was apprehensive about her first few
shifts at their ER. (I texted her radiographs about a case, just as she had done her first few shifts.)
Some other vets don’t like the multitasking, delegating, and oversight that is required. At one point yesterday, I looked at a stack of six to eight charts that I had not seen the patients yet. I scanned through and requested tests as I moved to the next urgency. By the time I would get back to the animals, I would have more information and prioritize my time with the patients and the owners. I will admit it can be overwhelming.
I remember three times Nikki asking me if I wanted something from Taco Bell. I had a new gift card, so I ordered and told her to put everything on my tab. There seemed to be about a dozen staff, so they took turns and got to eat, but I would only get to eat my power bowl cold an hour after I was supposed to be off. To be fair, I did eat half of one of the donuts I brought.
Long hours, fast pace, no breaks, but my relief was there before I expected her. It was also 8 pm before I expected it. I finished up my cases and got out about 9:30 pm. This might be another reason that people don’t want to work in the ER.
A huge reason vets don’t want to work in the ER is the clients that are on edge. Their family member is not well, it costs more money than usual at the veterinarian, and really tough discussions have to happen in a short amount of time. This means clients are not at their best. All of my clients yesterday were great, but it isn’t always that way. Actually, it is often not that way. We have been yelled at, cursed, attacked, threatened, and had legal action. I understand most of the time, they don’t mean it, and I have my guard up. However, I even noticed that the husky’s dad said thank you in spite of his wait; Reese’s mom said “I appreciate you” through tears as she made a very hard decision, and there were several other thank yous that were a blur among the urgencies. That makes the job easier for me and helps, but it is always waiting for someone to lash out or snap at my temporary staff or me.
I do get paid for these long days, but that is not why I work at the ER. As much as I love to be a hero and save lives, that is not it either. I volunteer at the ER because I feel it is my duty to help make sure that pets get taken care of, even on the weekends and evenings. That is why I do those long days.