The veterinary team waits for Gucci to wake up. The blue-gloved hand is slowly giving Gucci a shot of Narcan through her IV. Dr. Johnson and another team member discuss how they prefer to give Narcan. It takes a while, but wait for the excitement. Video by Dr. Tony Johnson, who can be heard cheering "hurrah!"
My otherwise peaceful Thursday ER shift was abruptly disrupted by the metallic clang of the treatment room's doors opening and the squeak of a gurney.
Heaped atop said gurney was a pile of dark grey pit bull, unresponsive and laying on her side, breathing slowly. I noticed mammary development, which probably meant she was an unspayed female, and may have given birth recently.
“OK – what do we have?” I asked the tech steering the gurney to the treatment table and oxygen.
“Intact female pit, 2-3 years old, found unresponsive at home.”
“Nothing, else, huh?” I asked.
I did a quick physical exam called the primary survey, which is just the initial things that threaten life: airway, breathing, and circulation. I found nothing but the slow breathing and a slow, but steady, heart rate.
Owners of pets brought into our ER are asked to answer two questions before anything else is done, even before registration paperwork with the pet's name, address, etc.
Can we begin treatment for pets needing immediate care?
In the event it is needed, should we begin CPR?
Both questions are accompanied by rough costs for each.
The tech's Vocera (a little Star Trek communicator gizmo that each tech wears to communicate within the hospital) made its little bloopy sound and one of the receptionists chirped “She's a yes and yes,” which was our shorthand that the owner had answered yes to both questions.
So, we started in.
We gave oxygen through a facemask and placed an IV catheter. I did a more complete physical exam and found not much more than on the primary survey. Blood was drawn for later analysis. We set about getting a few vitals, like body temperature and blood pressure. I dispatched the tech to talk to the owner, and to specifically ask about toxins and drugs, either of the prescription or recreational kind while I attended to my nonresponsive new patient.
My tech (we'll call her Laura) came back a few minutes later.
“Nothing in the house. She says she has a 4-year-old kid, her place is childproofed, and no drugs. Dog's name is Gucci.”
“Anything in the yard? Antifreeze, rat poison?” I asked.
“OK,” I said, thinking perhaps she had a uterine infection (common in unspayed females) and had become septic due to overwhelming infection.
“One more thing,” Laura said.
I had a pretty good idea what was coming.
“She has no money, no insurance.”
“OK – we'll do what we can.”
This is an every day occurrence in the veterinary ER, and I'll refer the reader to the many times we've covered this at VetzInsight. I am well-versed at working within an owner's financial constraints, and, thankfully, most of the time we can get done what needs to be done for the patient. Not every time, and there are many cases that still gnaw at me – cases I could have saved, but it was not realistic or possible for the family.
I had a sinking feeling about this one, though. If she was septic, the rule #1 of treating sepsis is “remove the septic focus,” meaning cut out (or drain) what is killing the patient. This almost always involves surgery, an extensive ICU stay, and significant cost.
At the intersection of “no money” and “septic shock,” the shops sell only sadness.
The other informal rule we have in the ER is that pets named after luxury items (Versace, Vuitton, etc.) rarely have the financial backing needed to get the job done. Perhaps the owners have already spent too much on other things to afford medical care for their pets. I don't know.
I don't judge, but I do notice.
Just about then, Laura's phone rang. We usually discourage taking calls while on the clinical floor, but she took it anyway.
And good thing she did.
After hanging up, Laura told me that (completely by chance) she and the owner of the dog on my gurney had a common friend. The friend told her that the owner was reluctant to tell us what happened to Gucci because she thought she'd get in trouble.
I asked Laura if she wanted me to go in the room, and she said, “Hold on, give me a minute with her.”
I don't know what went down in the room, but Laura came back a few minutes later and said, “She's ready to talk to you.” I didn't wait for more explanations.
Just as I got into the room, before I could extend my hand and introduce myself, the owner said “It's fentanyl.”
So much for childproof.
Fentanyl, as nearly everyone now knows, is a potent opioid. It is 50 times stronger than heroin and 100 times stronger than morphine. I use it almost every day for my patients, as it is a truly effective means of controlling pain. It is also highly addictive, and one of the main drugs that has been abused and has killed thousands of people across the U.S. and the world.
Luckily, it has an effective and cheap antidote: naloxone (trade name: Narcan). I was recently lecturing to a group of veterinarians in Kentucky and saw my first naloxone/overdose station at the lecture hall. It brought into stark relief how bad the opioid crisis has grown.
And now it's affecting pets like Gucci. Not to mention the child that also lives in that home. What if it had been her instead of Gucci? A 4-year-old little girl snuffling around on the floor and wondering if that white powder was sugar?
I told the owner I would be right back after giving Gucci the antidote, and assured her it was not my job to call the police unless the dog was intentionally poisoned, which she hadn't been. But, I said, I wanted to talk to her about safety in her home. I usually stay in my lane, but this one was just too egregious to overlook, and I have received some criticism for not notifying Child Protective Services about conditions in the home.
Since we already had an IV catheter in place, it was the simplest thing to give Gucci a dose of naloxone straight through her IV. It takes effect almost immediately, and within about a minute she popped her head up and she looked around as if to say “How did I get here? Who are you people?”
She did just fine.
Fentanyl has a short duration (usually less than an hour), but we watched Gucci for a couple of more hours to be sure. She did not need any further testing or treatment, and the owner managed to find the money to pay her bill. (If memory serves, it ended up being less than $300.)
I stepped back in to talk to the owner and basically re-stated what I said above about her daughter and the implications if she had ingested the fentanyl instead of Gucci. That would be trouble. I didn't want to see her daughter exposed to the same substance that had sickened Gucci and killed so many people; in the U.S. alone, fatal fentanyl overdoses have risen 279% since 2016. And I didn't want the state to have to take away her child.
She got the message.