Overmedication Or Something Else?

[Guest beejdas]

Hello all,

 

My mom and I have been distraught over the sudden passing of our nine year old greyhound, Samantha, who was hospitalized, released, hospitalized again and then shortly thereafter, died. After she was hospitalized the second time, we were told by the vet that she would be ok. Two hours later, Samantha was dead. I have asked the vet to detail the medicines Sammy was given and for what reason. I have copied my email to the vet and her response below. Could anyone on the list with any knowledge of the painkillers and other drugs prescribed be able to comment whether any alone of the drugs or all together could cause the kind of bleeding that ultimately killed our pup. We would really appreciate any insight. This has been a very tough two weeks.

 

Thanks,

Beej

 

MY EMAIL

 

Dr.Removed,

 

First of all, I would like to express our gratitude to you for

treating our beloved dog. When I adopted Samantha early in 2002, I

had no idea that I would fall in love with a greyhound. I knew very

little about greys at the time, and had actually been looking for a

lab. To my surprise, Samantha walked over to me and wouldn't leave my

side. At the time, her name was her body color (Brindel), because she

had not been given a name after her racing career had ended.

 

From the day I adopted her, to the day she died, Sammy has been my

baby. She, like many dogs, offers the kind of love and support that

only a loving four legged friend can. In my career and personal life,

I experienced many trials and tribulations and she was there by my

side every moment. It is therefore my duty to better understand the

circumstances behind her passing. I am sending you an email because I

am out of the country, and the time difference may be difficult to

bridge with both of our schedules.

 

From what I understand, when Sammy was discharged after her initial

hospitalization, the hospital indicated to mom that Sammy had some

form of neck injury which might be treated using accupuncture, or if

that failed, through a surgical solution. When she was discharged, no

other reason was given to us regarding her blood pressure, difficulty

breathing, or fever, for which she was initially admitted. When she

was admitted the first time, she exhibited none of the symptoms that

she later displayed: vomiting and bloody diarrhea.

 

Given that Sammy eventually expired from what we were told was shock

from acute bacterial infection of her GI tract, I am curious whether

her actual condition was (a) misdiagnosed and missed when she was

initially brought to the hospital, or ( caused by the medication she

was prescribed. I am aware, as you surely are, that greyhounds are

very sensitive to medications, especially pain killers. What I can't

seem to reconcile is that when she was initially discharged, she did

not have any of the symptoms for which she later was admitted and

later died from. What then caused the sudden bacterial infection that

killed her?

 

Could you also let me know what medicines you administered and

prescribed to her? I want to bring closure in my head to what happened

-- and what happened so quickly. I feel that a better understanding

of what you as a hospital did will at least give me some solace and

let me rest knowing that we did all that we could do to preserve the

life of a creature that was our precious loved one.

 

Thanks in advance for your help and time.

 

Regards,

Beej

 

 

VET'S RESPONSE

 

Beej--

I'm more than happy to answer any and all questions you have regarding your sweetie Samantha. As I said to your mom, I'm so heartbroken about her death.

Sammy was initially hospitalized on suspicion of neck injury (most likely a ruptured disk, which is something that also happens in humans). At that time, according to the records (I was not the doctor to see her), she did have a fever, high blood pressure, and excessive panting. These are extremely common in cases of neck pain, largely because the pain itself causes the elevated temperature, blood pressure, and breathing. I do believe that at that time, she was not suffering from any hint of the disease process that ultimately took her life. She was sent home on Robaxin, Rimadyl, and Tramadol, all of which are for pain. Her bloodwork was also completely normal, again suggesting that she was not suffering from any other disease. These medications did make her feel better, according to your mother.

When she came to see me on Sunday, she was having bloody diarrhea and was a little quiet, but otherwise seemed very stable. She had a slightly low blood pressure, which we treated, but was walking and active. She deteriorated very quickly and unexpectedly, however; I can honestly say that I can't remember another dog passing away that quickly. What I believe happened with her is that the inflammation in her gastrointestinal tract was so severe that it set off a cascade of inflammation, overwhelming her ability to handle it. Bacteria migrating from the intestines out into the rest of her body may also have been a factor. This condition is called "systemic inflammatory response syndrome" or SIRS. It occurs in pets almost with any history: animals with any severe disease can develop this unpredictably. There are some known conditions that are predisposing factors: emergency surgeries like bloat or splenectomy, heat stroke, intestinal foreign bodies. She did not, I believe, truly have an infection OF her GI tract, but she had a compromised GI tract which allowed the bacteria to go from her intestines out into the rest of the body. Some animals can compensate for this but others cannot, and it's difficult to predict who can't.

I don't believe that Sammy was initially misdiagnosed (during the neck pain episode). She really did display pretty classic neck pain and her bloodwork was normal. She was also not showing any vomiting or diarrhea at that time.

In regards to the medications, no one can say for sure whether they might have caused this. My gut feeling based upon everything I know about the medications and all the side effects I have seen is that they likely were not the cause. Each of the medications she went home on lists vomiting and diarrhea as a possible side effect, and this is because almost any medication can cause this. They don't cause the severe bloody diarrhea like Sammy had. The sensitivity that greyhounds can have to pain killers usually results in simply being a bit more lethargic than we would prefer, not in this type of acute decompensation. I will never be a doctor that completely rules out things unless I'm 100% sure, but I'm doubtful that the medications caused this.

What I believe happened to cause the gastrointestinal signs that ultimately led to her death may have been stress. That sounds like it couldn't possibly cause this, but another thing I have found to be true of greyhounds is that they do not tolerate disease very well, especially as they get older. The type of diarrhea and vomiting that she developed that day are typical of something called "hemorrhagic gastroenteritis", which can be caused by stress, diet changes, eating something unusual for them, and bacterial infections. This causes bloody diarrhea and vomiting; most dogs recover well from this with supportive care. It seems in Sammy's case, the inflammation was so severe that it overwhelmed her ability to compensate, she went into shock, and died despite our best efforts.

 

Here, she was treated with:

1) Intravenous fluids: they were given rapidly initially (to improve her blood pressure) and then at a high maintenance rate to restore fluids lost through the diarrhea and vomiting.

2) Antibiotics: to try to prevent bacterial invasion of the body from the gastrointestinal tract (she received one dose during the time she was here)

3) Pepcid: to reduce the acidity of her stomach, which we do in nearly all patients with vomiting, because it usually helps to settle their stomach a bit and prevent vomiting.

4) Buprenex: an injectable pain medication, which was given at a low dose, to reduce the discomfort associated with the severe cramping they usually have with diarrhea. This seemed to help her out tremendously while she was here.

 

She received nursing care (keeping her clean, monitoring her vital signs, taking her outside, keeping her comfortable), blood pressure, and a small amount of bloodwork monitoring while she was here as well.

When I look back at her case, Sammy very much upsets me simply because none of us can think of anything more we could have done to save her life. I hope, though, that this makes you feel a bit better. She ultimately died so quickly that it seemed everything we did couldn't stop the inflammation that had been set in motion.

I can say that she was kept comfortable and did not suffer in death. I do very much regret that it was not more clear how bad she was so that I could at least have better prepared your mother before she left or been able to get her back here before she died. Everything unfortunately happened so quickly that we could not.

I hope this e-mail is not too long, I just figured more information is always better. Please feel free to contact me to go over anything that's unclear. I very much understand your need for as much closure as possible. Sammy was such a special dog, and I sincerely wish I could have saved her. Please know that my thoughts are with your family; having lost dear pets I know how close you were to her and how difficult her death must be for you.

 

--REMOVED

Edited September 2, 2009 by Trudy
Removed Vet's name and contact info

[macoduck]

It sounds like your vet really cared about her. There is no way that my vet would ever give me such a detailed explanation in writing.

Regarding the medications, think of all the times you see advertisements on TV - all those disclaimers for potential side effects sound scarier than the condition being treated. The medications dispensed sound reasonable.

Many things are not easy to diagnose. My Thane had bloody urine one day and neither the emergency vet nor my regular vet could figure out why. Lab tests showed nothing. Yet when I took him to a specialist for an ultrasound, his kidney cancer was massive.

None of the first two vets were at fault. It was what it was.

Don't second guess yourself over Samantha's treatment and the trust you put in our vet.

Cherish your good memories.

[retiredracers]

Beej,

 

I am very sorry about Sammy's passing. I read through the emails and I agree with macoduck... your vet sounds very caring and knowledgable (sp?) and I don't think anything was done incorrectly. Don't beat yourself (or your vet) up. You did what you know was right and Sammy loved you for it.

 

Hugs,

 

Sheila

[Guest SueG201]

Has she given Previcox at all? These are classic signs of a reaction to Previcox. I am so sorry for your loss

[Guest 3greysinPA]

I have nothing to add regarding the overmedication or the emails, except that it does sound as if your Vet truly did do what she could.. sounds like she does care and still does care about your beloved Sammy.

 

My deepest sympathy in the passing of Sammy

 

GodSpeed to the Bridge Sammy

Edited September 2, 2009 by 3greysinPA

[Guest Energy11]

I, too, am very sorry for your loss. I do not think it was over medication. The meds prescribed were correct for the situation.

 

Humans get something called Sepsis, It is usually caused by a very bad bacterial infection, which gets worse, causing low blood pressure and shock. By the sound of what you vet said, it was a similar thing with your Mom's hound.

 

I, also feel the vet sounded very knowledgable and compassionate, but, it still does not bring back you Mom's baby, Sammy . We are sorry you all had to go through this.

 

 

[Anne]

I think you are very lucky to have a vet who cares enough not only about the dogs she treats, but the humans who love those dogs, to give you such a great explaination of your dogs treatment at her clinic. From what your vet wrote, I think they did everything they could for your dog. I know how much my vet hates to lose a dog, I've been there when it happened, and the entire office was devistated. Back east I was at the clinic when a cat went into cardiac arrest after waking up from surgery and I watched two vets try to save that kitty, they failed and they were very upset.

 

No matter how much it hurts when we lose pets, the majority of us do it all over again... why, because they give us such wonderful unconditional love, and it's obvious to me, that you and your Mom adored your greyhound. And while her time with you wasn't as long as you would have wanted, how lucky both of you were to find each other.

I'm so very sorry for your loss. I know how much it hurts to lose one without warning.

[Houndtime]

Sometimes when we lose a pet so suddenly, we look for an explanation, a reason, a hint as to what it was that we missed.

 

When we lost our first two, they had been going back and forth to our vet on a regular basis averaging every three weeks. They had blood work, dentals (to see if that was the reason that Brandy wasn't eating), acupuncture, chiropractor and they both died inexplicably and suddenly when they left. The best assessment is that they both had "a cancer" which was undefined until it killed them. Especially John E's death was most painful to us as he was fine in the morning and gone by lunchtime. He just filled up with blood as he bled out somewhere in his body.

 

Your vet seems very caring and concerned about your pet and your family as well. We just always don't know the reasons our greys have to leave us. I like to think that G-d wanted our beloved pets for a more special purpose.

 

Take care.

[greysmom]

I am so sorry for your loss. It's truly heartbreaking to go through the death of a beloved companion, especially under such circumstances.

 

None of what your vet did or how your grey was treated seems to be the cause. Unless an autopsy was done, there's no real way to know the actual cause of death. It's also possible that the two incidents are not related. She was treated appropriately for her neck pain, and was beginning to feel better, and then had an acute onset of an internal emergency. She could have ruptured her spleen, kidney or intestinal wall allowing the bacteria to spread. She could have had an undiscovered tumor as described above. There are so many ways our pets can become sick, and we don't know them all.

 

Sometimes, everyone can do everything exactly right, and it's still not enough.

 

Again, my sincere condolences to you and your Mother.

greysmom

[ahicks51]

Sounds like your vet cared a great deal. Sorry to hear of your loss.

 

I'll take a stab at it: the gastrointestinal problems are not unheard of with NSAIDs, as SueG201 notes with Previcox, and your hound was given Rimadyl. There are at least a couple of people on this board that will have some unpleasant things to say about Rimadyl; as with any drug, there are the effects you want, and the side-effects. The same way that some of the human NSAIDs were pulled because of bad side effects (Vioxx, Bextra, and Celebrex was given a stronger warning label), sometimes the problems with Previcox and Rimadyl can be catastrophic. This is not the fault of your vet; there is no way to predict this sort of thing in advance. It's a matter of appreciating that with great pain and inflammation comes the need for strong meds; for whatever reason, dogs sometimes don't respond well to "their" NSAIDs. We wouldn't expect a human to die from taking "Aleve" or whatever, but sometimes- unfortunately- it can happen with dogs, even with drugs prescribed as often as Rimadyl.

 

From this comes severe gastrointestinal problems; in humans, this can lead to sepsis- an infection of the bloodstream. If not managed aggressively, this sort of thing can rapidly degenerate, and even with the strongest management, humans with sepsis run the risk of death; an entire class of drugs (not available for veterinary use, and even then they run several thousand dollars per dose) called tumor necrosis factor inhibitors were created just to deal with sepsis. This may or may not be the same thing your vet refers to as SIRS in her letter.

 

Please note I am not saying with any authority that this was caused by Rimadyl; I have no particular inside knowledge, but it would be one suspect. However, with a death like this, several things probably went wrong in sequence, perhaps like this: gastrointestinal sensitivity to Rimadyl, in conjunction with a pre-existing injury or GI damage, resulting in a damaged gut, followed by sepsis and, quickly, shock with systemic collapse and death.

 

Again- very sorry for your loss.

[NeylasMom]

I'm so sorry for your loss.

 

I agree with what others have said, you seem to have an incredibly caring vet. I'm amazed by her detailed response! I can't say too much about what happened medically, except to say that nothing that was done sounds out of the ordinary to me. I don't know much about Robaxin, but Rimadyl and Tramadol are extremely common pain relievers and can be safely used together. The only thing I can think is that she was a dog who couldn't handle NSAIDs (non-steroidal anti-inflammatories, which is what Rimadyl is). I've learned that Neyla cannot take them - she starts to get bruises on her body when she does. But to have that strong of a reaction that quickly seems unlikely to me.

 

What happened to lead up to the neck injury? If she fell or was running when she did it, maybe she had an internal injury that slowly got worse?

 

Regardless, it sounds like there is nothing you, your mom, or your vet could have done to prevent this. I hope your grief soon turns to only fond memories of your precious girl.

[brandimom]

I don't have any advice but it does sound like your vet really cared about Sammy. I am so sorry!!!!!!!!!!

[Guest kydie]

Sammy is already waiting at the bridge! Your post of care sounds reasonable, I am so sorry for your loss Edited September 2, 2009 by kydie

[crazygang]

So sorry you lost your precious Samantha very suddenly......it seems your vet is genuinely very caring and sympathetic

[Guest lynne893]

I am so sorry you lost your poor Sammy, and so suddenly.

 

I haven't read anyone else's responses yet, but I do want to commend your vet for such a thorough, compassionate response to your message. It sounds like you have a WONDERFUL vet.

 

Hugs to you as you heal.

 

Lynne

[silverfish]

First let me say how sorry I am to hear of the tragic passing of your beloved Sammy. What a horrible experience for everyone. I'm so sorry.

 

 

I agree with everyone who said you are lucky to have such a caring vet, who obviously feels very deeply for his/her patients, and their owners. Clearly, they did their very best for your Sammy, and were distressed by losing her.

 

I'm so sorry for your loss.

 

I agree with what others have said, you seem to have an incredibly caring vet. I'm amazed by her detailed response! I can't say too much about what happened medically, except to say that nothing that was done sounds out of the ordinary to me. I don't know much about Robaxin, but Rimadyl and Tramadol are extremely common pain relievers and can be safely used together. The only thing I can think is that she was a dog who couldn't handle NSAIDs (non-steroidal anti-inflammatories, which is what Rimadyl is). I've learned that Neyla cannot take them - she starts to get bruises on her body when she does. But to have that strong of a reaction that quickly seems unlikely to me.

 

What happened to lead up to the neck injury? If she fell or was running when she did it, maybe she had an internal injury that slowly got worse?

 

Regardless, it sounds like there is nothing you, your mom, or your vet could have done to prevent this. I hope your grief soon turns to only fond memories of your precious girl.

 

I agree with much of what everyone has said, but this post says more or less what I'd have said myself. And what you do have to remember is that even if the Rimadyl was responsible, we ALL have to take the risk whenever our doctors prescribe something new for us. As someone who is allergic to many medicines, I feel I take my life in my hands every time I have to try a new one, but if I didn't try, I would probably be dead by now from high blood pressure, infection, etc, or too stupid to type because of my severely underactive thyroid. My mother is in worse case because she is having to take drugs which are so toxic that they will probably shorten her life, but without them, she'd have so little quality of life it wouldn't be worth living anyway.

 

What I'm saying is that we have to take that risk for ourselves, and on behalf of our dogs. If a reaction is severe enough to endanger life, well sometimes you can't know that in advance and to put it bluntly, it's the price we pay for modern medicine - which improves all our lives enormously, on the whole.

 

You wouldn't have chosen to leave Sammy in pain. You (quite rightly) wanted to help her. I'd have done the same - in fact, I have done the same. My poor little Jack suffered high stomach acid as a result of the NSAID painkillers he was on, but without them he'd have been in so much pain, all day, every day, that he'd have been able to do very little and wouldn't have enjoyed life. We dealt with it with acid reducing drugs so that he could continue having NSAIDs but I wasn't happy about it. We were just lucky that he wasn't one of the dogs who are so sensitive to NSAIDs that they can't take them at all.

 

And just to add to what Neyla's Mom says about the neck injury, we lost our beautiful Renie just after Christmas. It started as a simple neck injury, which we were treating .. but it got worse and worse. She had a horrendous time over Christmas when the vets were closed and I couldnt' get to see a specialist. When she did, it turned out that the 'neck injury' was actually a secondary tumour in her spine. It was inoperable. The primary tumour was deep in the soft tissue of her neck and was causing no problems. It hadn't been detected until her neck hurt. It is quite possible that Sammy had something like that.

 

Hugs to you. I know how hard it is to lose a dog without a proper diagnosis.

[Guest greytexplorer]

 

~Pat

[Batmom]

When I look back at her case, Sammy very much upsets me simply because none of us can think of anything more we could have done to save her life. I hope, though, that this makes you feel a bit better. She ultimately died so quickly that it seemed everything we did couldn't stop the inflammation that had been set in motion.

I can say that she was kept comfortable and did not suffer in death. I do very much regret that it was not more clear how bad she was so that I could at least have better prepared your mother before she left or been able to get her back here before she died. Everything unfortunately happened so quickly that we could not.

I hope this e-mail is not too long, I just figured more information is always better. Please feel free to contact me to go over anything that's unclear. I very much understand your need for as much closure as possible. Sammy was such a special dog, and I sincerely wish I could have saved her. Please know that my thoughts are with your family; having lost dear pets I know how close you were to her and how difficult her death must be for you.

 

Your vet is a treasure who obviously cared about Sammy and gave her the best treatment possible.

 

I know how hard it is not to have an answer to that horrible "why?" question. Sometimes there just is no answer.

 

Sending hugs for you and your mom.

[Guest arlosmom]

All I can say is that I am so sorry for your loss and that if I had a veterinarian who was as kind and informative as yours I would never use anyone else. It truly sounds like she had your baby's best interest at heart and tried her very best to treat her. With many thoughts and prayers.