I really don’t know what I did to deserve so many complicated bleeding cases over the past two weeks. I was starting to think that our in-house blood machine was not working because every case I handled seemed to be suffering from anaemia (low red blood cell count). I had to collect blood from a perfectly healthy patient to check that our machine was not playing games with me.
I have had to give two blood transfusions in a span of a week and recommended a few more but owners could not afford it.
Sometimes a certain vet seems to attract a specific caseload. In the past two weeks, I was destined to become the anaemic workup vet and I have learnt so much and dealt with very challenging cases. Although I looked as stunned as ‘Jessie’ below when I started getting one bleeding case after another, I managed to get into the swing of matters and focus on determining the cause as fast as possible.
It all started last week when my first afternoon consultation was Myff, this adorable four-year old labrador that had been off colour for the past couple of days. The owner said she may have had access to ratsak six days ago from the compost bin. We immediately admitted her to hospital & collected bloods and found she was only mildly anaemic. The history of access to ratsak was confusing as it usually takes 2-3 days for patients to start bleeding and I would have expected more obvious signs of bleeding (coughing or abdominal swelling due to haemorrhage or even fresh blood from the nose or covering the stools) at that stage. We proceeded with giving her the anti-dote to ratsak and started her on IV fluids.
The next day, she seemed to slightly perk up but her gum colour was paler than the day before.
We repeated her CBC (complete blood count) and found her anaemia was significantly worse. We recommended a transfusion and her owner was happy for us to do whatever we needed to help her pull through. We decided to give her caniplas (contains all the clotting factors but lacks red blood cells) transfusion over blood transfusion (blood was collected two weeks ago and so would be lacking in the clotting factors). In an ideal world, we should have collected fresh blood and transfused her with it. However, given the circumstances, the better choice seemed to be the caniplas as ratsak poisoning depletes animals of their coagulation factors and that was the process we were trying to reverse!
Over the course of the day, ‘Myff’ was closely monitored and she became more interactive and lively and even ate a little bit of chicken. I did not take any chances that night and decided to check her CBC again before we headed home. I was not happy with the results as they indicated she was still losing blood. Her abdomen seemed quite distended and I was seriously concerned about her. Even though she was heaps brighter, I proceeded with giving her a whole blood transfusion based on her blood results.
She significantly started to go downhill after that and I suspected she may have developed a blood transfusion reaction.
At that stage, I was out of ideas and seriously concerned about my patient. I called her owner and strongly recommended he took her to a specialist emergency service (about 1.25 hours away) to give her the best chance of surviving and he did. Unfortunately the referring vets did further workup and discovered she was suffering from suspect multi-organ failure and gave her a very guarded prognosis so the owner opted to put her to sleep at that stage.
Needless to say, when I found out what happened to ‘Myff’ the next day, I was simply shattered. I was hoping that the specialists would give her a fighting chance and wondered if I should have sent her down there earlier. This challenging case leaves so much room for speculation. I wonder if the outcome would have been different had she been brought in to me straight after they suspected she had ratsak poisoning or even the day she started to look unwell.
I can not stop reflecting on what I could have done better in my workup.
Did I miss something? What was the primary cause of her bleeding if not ratsak? Why didn’t she respond to all the aggressive treatment? I owe it to ‘Myff’ to learn from her tragedy and try to determine what we all could have done better in her management. I have already emailed the specialist vets and we will be discussing her case thoroughly in the next couple of weeks to see if we could piece the history and clinical findings together. We all agreed it was a very odd case in terms of presentation and how fast the patient deteriorated in spite of aggressive medical therapy.
I would like to take the opportunity to emphasize the importance of getting your pet checked out by your local vet as soon as you notice it is unwell. If you think your dog may have ingested poison, don’t sleep on it and see what happens as you may seriously regret doing that.
If you have a labrador and it’s appetite is slightly decreased and it is low on energy, then get it checked out immediately.
I have found Labradors to be such stoic dogs and they can mask serious disease. I mean ‘Myff’ ate a small amount of food and was wagging her tail just to please us. She was feeling so rotten but in all honesty, she did not look like she was shutting down.
The next few cases I will be discussing did not have such a tragic ending. Some are still not out of the woods but stabilised. Tune in tomorrow for my continued discussion of atypical bleeding cases.