Sunday, September 29, 2013


I'm sure at some point in vet school everyone has a case that just takes them on an emotional rollercoaster, makes them exhausted and grumpy at times, and elated and walking on clouds at others. I just had my first one.

On Tuesday at around 3:30pm we got a call that a 4-day-old downer calf was coming in. When he arrived he was "flat out" meaning on his side, unresponsive, kind of comatose but awake. The history I got from the owner was that the calf had been at the teat constantly, and crying through the night. It sounded like he wasn't getting enough to eat. My top differential was failure of passive transfer. Either mom wasn't producing enough milk or her teats were blocked or something was causing this calf to not get enough colostrum in his first day of life and he wound up immune compromised.

His serum total protein was 5.0g/dL, which was a good indicator of inadequate maternal immunity transfer. A value of 5.5 or above indicates adequate transfer. Normal serum total protein is around 7.0 with half being albumin and half being globulin (antibodies). 5.0 - 3.5 = 1.5. So he got something, just not enough. Unfortunately his blood glucose was 38 and he had a fever of 103.7. So that steered my differentials away from purely failure of passive transfer and into FPT and a secondary septicemia. He had an expiratory grunt and when I listened to his lung sounds they were harsh on expiration, leading me to believe he had a lung infection. We stuck an ultrasound probe on his chest and saw thickening of his pleural membranes and some consolidation.

So at that point my problem list was:
- Hypoproteinemia
- Hypoglycemia
- High lactate (4.9 yikes!)
- pleuritis
- dull mentation/weakness/ataxia

We gave him a fluid bolus of 1L of saline and then started him on an 8% dextrose drip to help with the lactate and hypoglycemia. We gave him some anti-inflammatories and antibiotics for the infection. And we gave him a unit of plasma for the low protein and lowered immunity.

Over the next two days he got a little bit better, started drinking from a bottle again. Then on Friday he crashed and burned. We'd corrected his lactate and his glucose, both were within normal range again. But his ataxia suddenly got worse, his mentation plummeted, and he started head pressing. So what had originally been our secondary neurological signs became suspected primary. We did a CSF tap and sent it to clinical pathology. I was sitting in the breakroom typing my SOAP when I saw the clin path people walking down the hallway toward the in house large animal ward and I thought, "Oh no..." Because clin path people don't belong down there. They stay in their offices and lab upstairs. If they came down for this, it's bad. I ran out the door to catch up with them.

Sure enough, Dr. Russell greeted me with a print out and he said, "This should make your skin crawl." The protein in his cerebrospinal fluid was 5.2g/dL. That's higher than in his blood. Normal CSF has a total protein of around 0.5g/dL. The total white cell count was 113,000/mL. Normal is 10-20/mL. Translation: Calf has an infection in his brain. The fluid was analyzed and showed high numbers of intracellular and free short, thick rods. So we added bacterial meningitis to the problem list.

We switched his antibiotic, since clearly the first one was not working, and over the next 48 hours changed his fluid rate, dextrose concentration, and fluid type half a dozen times based on seesawing blood work results. We added a nasogastric tube and feedings every 4 hours. And we also administered mannitol three times, which has to be given slowly over a period of hours and the patient has to be monitored the entire time for respiratory distress because if it's given too fast it can cause pulmonary edema. Basically, I lived at the clinic Friday and Saturday. And Saturday I was on call for ambulatory service and had to go on three farm calls as well as keeping up with his treatments. Thankfully another Rossie was on RAHMs with me who was helping me out with the calf when I was away on a call.

It was very touch and go, but then I got news that he had finally passed some feces. I came in and he was standing, alert, and hungry! He sucked down a bottle last night on his own and again three times for the overnight students. He ate very well this morning and is much more "with it" mentally. Things are looking very optimistic for him.

This is the first time I have personally been responsible for the care of a patient who has gone from completely unresponsive and mere hours from death, to making a full recovery (almost there, give it another couple of days). I did that. And it feels incredible. Pulling 12-14 hour days five days in a row, sitting in a stall with a comatose calf for hours at a time, not seeing sunlight because I'm there before it comes up and leave after it goes down.

When I was serving tables as a waitress, if I had a long night or a bad night, I hated the world. I was miserable. Even at my most exhausted and sore and disappointed this week, I was never in a foul mood. I guess that's how you know you're in the right field.

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