(This article originally appeared in the Spring 2024 edition of West Coast Veterinarian magazine. We have reprinted the article here with their permission.)
There is nothing that will keep you awake at night like an animal whose life needs saving. As a criticalist at Boundary Bay Veterinary Specialty Hospital’s Emergency & Critical Care department, I know this intimately.
Meet Eden, the most beautiful middle-aged Leonberger dog you have ever seen. Over the course of a few days, Eden developed a cough and suddenly could barely get out of bed. Eden is seen first by her family practitioner who deems her to be in respiratory distress and advises she is taken to a specialty ER centre like ours. “STAT triage” is paged by reception, and the ER triage team gets to work. A skilled triage nurse receives her before the ER veterinarian performs a physical examination, takes a history, makes an assessment, and plans for initial diagnostics and treatments. First steps include bloodwork and chest x-rays, the latter showing shocking results. The astute ER veterinarian walks up to the criticalist attempting to leave for the day (me) and asks for advice on this case that is becoming more critical by the minute. Eden has a fever, and her breathing rate and effort are steadily increasing, to the point that respiratory fatigue appears inevitable. I have a look at the x-rays—showing severe diffuse interstitial to alveolar pattern—and am likewise concerned. I advise we perform an arterial blood gas that gives us a true measure of the oxygen and carbon dioxide levels getting to and leaving Eden’s tissues. Unfortunately, Eden’s values are incompatible with life, but thanks to veterinary training and modern science, this is not the end. It is, however, time for life support in the form of a ventilator, the same type used during COVID-19 but which, due to a criticalist’s specialized training, allows us to save dogs and cats of all sizes. This day shift has become a night shift.
As I examine Eden, my veterinary technician specialist in emergency and critical care, Jo (a specialist nurse), prepares the sedatives that allow us to place Eden in a medically induced coma. These medications are critical to provide comfort, amnesia, and facilitate acceptance of our ventilator settings. Eden’s owner, Jane, is brought back to our ventilation room to get a few precious moments with her girl before we induce Eden’s coma. Together with Jane, my technicians and I embark on the emotional rollercoaster that is life support, fraught with moments of positivity and disappointment, in hopes we can get Eden through this crisis. There is often a bond that develops between an owner and the team in critical care cases, as we all fight and hope with our whole hearts to get a patient home.
As we insert the endotracheal tube, we are able to collect thick respiratory secretions for cytological evaluation, crucial to obtaining a diagnosis. The results come back showing Eden has a highly inflammatory lung disease called eosinophilic bronchopneumopathy. The great news is that this disease is treatable with steroids to quell the inflammation. As the response time to steroids is often one-to-two days, we place her on our Draeger V500 critical care ventilator, “Pegasus”, to breathe for her while we wait for the treatment to work. Given my additional years of training and board certification, I often work during the day to support the ER veterinarians and help other specialists get their patients through challenging moments such as high-risk surgeries. But, if I stay overnight, it is often because a patient needs to be put on life support, like Eden was.
To help explain how the roles of an ER veterinarian and criticalist (i.e. board-certified specialist in emergency and critical care) may differ at night, I thought I would share an explanation of the difference between both parts of the accreditation. For one, the day-to-day job is different. The ER veterinarian is your first-line doctor who is there to provide patients the care they need, day or night. It’s our ER doctors’ jobs to assess patients, create plans on behalf of the correct specialty, and admit animals for those workups the next day. . . tasks done in between repairing a laceration, getting a dog to vomit up a sock, and helping a pregnant animal give birth. What does board-certified mean then? And what do I do?
To be board-certified or board-eligible, a veterinarian has undergone an additional three or more years of training, exclusively in their field of medicine. After this, we must pass an epic two-day marathon of an examination to prove that we were fully trained and can recall the information from our training. Really, tests don’t determine if a clinician is good at their job, but the additional three years of residency training in that field are essential to becoming a specialist. The grand total for me was 11 years: Bachelor of Science (three years), Doctor of Veterinary Medicine (four years), internship in medicine/surgery/emergency (one year), and residency in emergency/critical care (three years), concurrent with a graduate degree where I investigated ways to help animals breathe better.
So what do I do on a night in emerg? Circle back to Eden—here I am, in my passion, with my team, and with an owner who is emotionally and financially committed to the journey. Fortunately, Eden has been insured since she was a puppy, giving her owner the option to press forward without bearing a large financial burden.
I ensure my settings and alarms are correct, double check the math, coordinate the settings with the disease process, and off we go—life support in action. Eden is not only on the ventilator; she also has a urinary catheter, a sampling catheter, an arterial catheter for blood pressure monitoring, her body positioned specifically to avoid pressure sores and limit regurgitation, an ECG, a thermometer probe, and more. We monitor every vital sign multiple times an hour, take frequent blood oxygen levels to titrate the ventilator settings, and administer the treatments she needs to be comfortable and reduce the disease in her lungs. It’s now 2:00 am and I am usually up at 5:30, but this is nowhere near the longest I have been at the hospital. While we have been working away on Eden, the overnight ER veterinarian has been managing all the ICU patients and incoming emergencies to ensure everyone gets through the night.
Do I eat? Do I take a break? The answer is yes and then no, in that order. There is never a good time to step away from a patient who is critical, but if you’ve ever met me, you know I will be having a snack every other hour, and a coffee too. (Insider tip: if you have to visit us at BBVSH, the best coffee is “Portside blend” from the machine in front reception.) Jo and I take turns making our fifth coffee of the day and standing outside the ventilation room to take a sip. That is all there is time for as we alternate monitoring Eden and her ventilation settings. The overnight ER veterinarian soon comes up to me and asks for my opinion on an abnormal electrolyte value in another one of the ICU patients as I take a second sip—this is another part of my job; I collaborate on other clinicians’ cases to ensure they have optimized supportive care in the ICU. As an ICU specialist, we fine-tune treatment plans to give the patients the best chance of recovery, so even though your dog had a surgery with one of our fantastic surgeons, I will have spent at least part of my day assessing the dog’s fluids and pain medications, and ensuring they can breathe calmly.
There’s rarely a case in this hospital that my hands or thoughts haven’t touched.
Pegasus suddenly beeps excessively loudly—something is wrong. The ventilator screen flips between various concerning alarms: HIGH PRESSURE, OBSTRUCTION. Jo checks over the ventilator connections for kinks, as I look at the graphs on the screen and determine there is likely a mucus plug blocking her breathing tube. We try to quickly suction the plug, but the secretions are too thick—we have to exchange the tube. This process is often high-risk, as we are removing her breathing support all at once. Jo and I call the ICU team to be on standby, and we use our preset intubation tray. Jo removes the tube, I prepare to replace it, and suddenly Eden’s heart rate drops—103-94-68-39 beats per minute. . . “Atropine, give the atropine,” I say. Atropine is a medication used during CPR to help block the vagus nerve that is responsible for this bradycardia. I replace the breathing tube, restart the ventilator, the atropine kicks in, and Eden just barely avoids death. This moment is only one example of many that can happen over 24 hours with a ventilated patient. For the team and myself to think and act under high pressure, work together, and debrief from these events is, of course, emotionally demanding. To then have to notify Jane of her dear pet’s recent brush with fate is so disappointing for us, as we have been trying our best all night.
Jane comes back to see Eden after this event, and Eden’s heart rate and spontaneous breathing rate increase when her mom talks to her. This is a common finding, even in our ventilated patients. We don’t know exactly what it means, but it is repeated across so many patients that I believe they can hear their families. It’s 8:00 am, and Jo has arranged a team of senior ICU/anesthesia technicians and my co-criticalists to take over Eden’s care. This team is equally trained and better rested—Eden deserves fresh minds to take her through the next 12 hours. Jo and I will be back tonight.
As I am walking out the doors, I see Jane, who tells me how grateful she is that we are able to offer her sweet dog the care she needs, offering respite for worries of inadequacy I may be feeling. Despite years of experience, papers published, articles reviewed, and veterinarians I have trained, there is always a feeling of wishing you could control the outcome for every patient. Life and science do not allow for that, but this simple act of humanity from Jane made every bit of exhaustion worth it.
After Eden’s 36 hours on the ventilator, we are able to wake her and get her off the ventilator. I still have the video of her walking out of our building, tail wagging. I love working nights in emerg because we can make a difference, as we did with Eden.
– Dr. Tiffany Jagodich, DVM, DVSc, DACVECC