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Old June 4th, 2014, 02:16 AM
MalteseMourner MalteseMourner is offline
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Anyone with any veteranary knowledge? - warning, morbid topic

I appreciate that there are already other sites and forums for consulting vets but I wasn't able to find any that wouldn't charge for responses.

I also know that there is a rainbow bridge section on this forum but I wasn't sure if my questions would be seen if I posted there.

If anyone knows of a better place for this to be posted or some sites to contact vets that don't charge, then please, do share.

I apologise if this is a misplaced post but maybe I'll be lucky and there are some vets, vet students/nurses or someone knowledgable about canine health lurking here that may be able to field this slightly technical, overly detailed post...



I had a male, neutered, Maltese terrier; he was 14 years 7 months old when he died a couple of days ago.

I know that he died as a result of multi-organ failure and that it was just his time, but the way he died upset me and Iím not entirely convinced we and our vet didnít play a role in expediting his death or causing his suffering.

I was wondering if I gave the details of his health and death, if anyone would be able to explain what caused him to die the way that he did. It would bring us comfort to know that we didnít cause it although if it appears we did do something wrong, we would rather it was pointed out to us and not sugar coated, that way we can come to peace with our actions and know better for any future pets we may have.

Iíll provide as much detail as I can.

His medical history:
- He had poor dentition, several teeth cleanings during his lifetime and many removed.
- He had 3 subcutaneous lipomas on his abdomen. They had been there at least 5-6 years prior to his death.
- He had a haemangioma on his neck.
- He had 'benign skin growths' on his back and on his back right paw.
- Bilateral patella subluxation, since birth, worse with age and a bit arthritic.
- He had an episode of geriatric vestibular disease about 2.5 years ago from which he made a full recovery.
- He had asthma for the last 1.5 years of his life with at least 3 chest infections during this time.
- He had cataracts; he appeared to 'suddenly' lose his sight completely about 2 months ago.
- He had a corneal ulcer of the right eye that healed with a thick scar and several mild eye infections over the last 2 years.
- Despite using a 4 week flea and tick spray every month, I have removed at least 4 ticks from him in the last 2 years, one of which was very large as it was hidden in his ear - this one was about 2 months ago.
- His liver enzymes have been mildly raised for at least 3 years.
- He was diagnosed with renal failure one month ago, BUN 67, creatinine 3.8, also found to be mildly anaemic at this time.
- He had a heart murmur of unknown origin; it had been present for at least 4 years.
- All his immunisations were up to date and he was de-wormed at the vet every 3 months.
- Up until his last 2 months he had a diet of dry dog food (puppy version because the pieces were smaller and easier for him to manage with his loss of teeth), tap water, some rawhide sticks and table scraps here and there and weight 6.9Kg in good health.

His medications:
- Azodyl for his kidneys.
- Aironyl for his asthma.
- Iron supplements for his anaemia.
- Multi-vitamin syrup, the vet advised as a dietary supplement.
- Anti-diarrhoeal syrup & metronidazole he had loose stools, the vet thought this was due to the iron tablets and threw in the metronidazole in case it was an infective cause.
- Boric acid lotion used in conjunction with an antibiotic, steroid containing eye drop.

We had scheduled him for cataract surgery to restore his eyesight as he had been so down at his sudden loss/decomposition of his eye sight, he was certainly getting lost, stuck and bumping his head into things a lot (though I know this may be senility and cognitive dysfunction).

We took him for blood tests about a month ago to assess his ability to withstand the procedureís anaesthesia and found the liver enzymes mildly raised (still), renal failure, mild anaemia and were prescribed the above medications. We were told to wait one month to allow the Azodyl to do its job, reduce his creatinine and BUN and make the procedure a little safer.

The vet thought the mild rise in liver enzymes was transient and due to antibiotics he had been prescribed for a recent chest infection he had recovered from.

About 2 weeks ago his appetite began to reduce; he stopped eating his dry dog food which he had been eating for years. However, when offered our own foods, like chicken, cereals, burgers etc he would happily eat so we had thought he has just decided to be abruptly fussy.

He soon lost interest in our foods as well and just drank water. Whenever we did manage to coax him to eat, heíd vomit soon after. One time, he vomited a meal from a previous night, completely recognizable and undigested. Worried me immensely, it was as if he were obstructed or his stomach was shut down and not working at all. But he certainly ate no foreign bodies to cause obstruction.

He was soon down to just water which he was able to keep down and then soon enough, down to nothing. His weight reduced from 6.9kg to 6.45 over a week.

We took him to our vet who administered some saline and inserted a cannula. He told us that his medications (such as the iron tablets) may have caused gastroenteritis or ulceration and told us to stop all oral medications as he was no longer eating. On further probing he did admit the other possibilities could be that he were dying or a malignant obstruction considering his SC lipomas.
He prescribed us 5% glucose 50ml, saline 100ml and ringer lactate 100ml 3 times a day IV infusion.

He also prescribed 0.5ml ranitidine twice daily IV, 0.5ml anti-emetic 3 times a day (I believe it was domperidone) and 35ml amizole 3 times a day (this came as a vial so we administered it as an IV injection slowly through his cannula though we were later told it should have come as an infusion pack).

Iím a 5th year medical student with some experience of IV injections and infusions. Iím no expert certainly but Iím confident we made no major errors in administration, asepsis (I checked the cannula site after his death, no erythema or other signs of infection or inflammation), air bubbles etc.

He seemed to improve mildly over the next two days but continued to vomit, this time, it was just yellow bile, initially large amounts which reduced to just mouthfuls and then just bouts of nausea with excess salivation (though looking back on it now, perhaps the excess salivation was a sign of its own?).

Concerned that he was already on an anti-emetic but still vomiting I called the vet but he assured me to allow it 48 hours to settle and that there was no better alternative medication or dose to administer.

He continued to have apparently unproductive bouts of nausea on the third day.

In his last 24 hours, I found him blindly wandering around, rapidly, anxiously, climbing all over cushions and such in the living room (much more physical movement then he had been exhibiting in weeks) but whenever he had anxiety like that it had been prior to needing to vomit so that is what I attributed it too.

Later that day, he had another bout of sudden energy and anxietyÖwhen I watched his behaviorÖI was certain there was something wrong with his brain. He seemed confused and terrified.

At his last IV infusion session of the day, I noticed we should have finished one 500ml bag of his saline and ringer lactate as it had been more than 5 sessions (100ml each session) and that we seemed to have used too much of the glucose. The bags are a bit difficult to read, they arenít made of soft plastic but a hard plastic that gets deformed and Ďsucked iní as fluids are administered, making the fluid level on the gauge of the bags rise higher and making them inaccurate to read, we had been going by the vetís advice of rate which was 1 drop every 2 seconds for 20 mins for 100ml, 10mins for 50ml.

I disconnected the bags, allowed them to reinflate and reshape so that I could see the fluid level on the sides of the bags correctly and ensured that this dose, he got the correct 100ml saline & ringer lactate and 50ml glucose.

Shortly after this IV infusion session, he began twitching. He also seemed unable to rest his head when he laid on his right, but could when he was laid on his left, his neck was in spasm. Since that episode of confusion that afternoon, I had been concerned for him. I stayed awake with him all night, his twitching got worse but then seemed to subside by the early morning, his neck spasm had gone as well.

He urinated on himself during his sleep, common occurrence since his renal disease was causing such huge fluid intake. I went to bathe him, as I wet his fur, I could see the skin colour on his back was alarmingly dark. As routine I check inside his ears after each bath, the skin was pale, the tips of his ears were dark. I checked his tongue and gums, they seemed paler than usual too. I put the tips of the ears and mouth down to reduced peripheral circulation, perhaps the mouth was peculiar in colour due to lack of oral fluid intakeÖthe backÖhe hasnít been outside, sadly, in long time, canít be sunburn, he hasnít had trauma to the back to cause that amount of bruisingÖis it hyperpigmentation? I decided to take him to the vet in the morning when he opened, it all worried me greatly. My biggest fear was that it was a sign of internal bleeding but I kept telling myself Iím too paranoid, I know too much medically, every sign is the worst case scenario in everyone I know.

In the morning he had a small episode of what we assumed was nausea with excess salivation but no vomit produced. His twitching was gone but his neck seemed to spasm again. I noticed his eyes seems to be diverging a bit, I had noticed it the previous afternoon as well but thought I was being paranoid.

I sat him down on the bedroom floor. He began to breathe heavily and cry, he appeared to focus on something above his head, despite being blind. Whatever he focused on, terrified him, his ears went down, his tail went down and he ran full speed in the opposite direction, his head was turned back over his shoulder, still focused on whatever it was he could apparently see.
I caught him before he could run into a wall and hurt himself, as I did he collapsed to the floor and began to convulse.
I lay him on his side on the carpet and protected his head.

He convulsed for about 3 minutes but remained, I assume, unconscious with his eyes open. His eyes were moving rapidly, he began agonal breathing, his spine was going in and out of hyperextension (I believe this is a terminal spinal position seen in humans too but canít think of the name of it at the moment).

He lost bowel and bladder control which I expected but he also began to bleed from his nose which I hadnít expected to see.

He eventually passed away, fortunately, at home and with his loved ones around him until the bitter end but I hope you can appreciate how utterly destroying and heart wrenching it was to watch my little best friend of 15 years terrified in his last moments and die in such a horrible manner. I canít close my eyes without seeing him in spasm on our bedroom floor in a pool of his own blood, urine and faeces.

I know this was a long story with probably far more detail than necessary but I wanted to provide as much information as I could in the hopes that someone more educated about canine health can explain why my dog seized like that before dying, why was he twitching for 8 hours prior to his death, why the neck spasm, why did he bleed from his nose, what was the discolouration I saw, was it disseminated intravascular coagulopathy, was it thrombosis and bruising, was it hyperpigemntation Ė what from, if I had taken him to an emergency vet hospital when I saw that discolouration could he have been saved, did I wait too long, did I push him into hypernatraemia with his last IV dose despite it being the prescribed 100ml, did the excess glucose cause his confusion or attribute to his death, what about the ringer lactate Ė did I kill him with that, did the antibiotics I unknowingly gave him as an IV injection instead of an IV infusion push his liver to fail and cause internal bleeding, is it possible to go from mildly raised liver enzymes to utter liver failure with lack of clotting factors the space of 3 days worth of infusions, Ö.did we just cause all that morbidity in our dog by following our vets prescriptions, did he overprescribe, did we cause our dogs sudden blindness with medications, did that large tick I found in his ear so long ago give him a disease, wouldnít that have been picked up on his bloodwork Ė his white cells were fine and no lameness - did I miss the signs that could have saved him at a treatable stage, did our dogís SC lipomas occur internally causing GI obstruction and brain metastasisÖI have so much doubt, guilt and what ifs swirling around in my head.

The vet is a very soft vet, the kind that didnít want to mention the possibility of death or malignancy until you sharply confronted those possibilities to him yourself. Even though we spoke to him (he was surprised our dog had passed away) and he offered us reassurance that the antibiotic as injection instead of infusion wasnít ideal but didnít kill him and that even at double the dose of saline we couldnít have caused hypernatraemiaÖI canít believe him because of how reluctant he is to give us bad news.

In the end I know we did our best and had the best intentions. I know that even if the vet made a mistake that he also had the best of intentions for our dog but if anyone is able to explain the cause of death or point out any errors in our dogís management that could have set off these terminal events, id appreciate it if you could explain them to me.

Thank you in advance for your time and kindness and sorry for such a long and possibly misplaced post.

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Old June 4th, 2014, 08:22 AM
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marko marko is offline
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First I'm I'm so sorry for your loss MalteseMourner and please accept my deep condolences.

Your post was moderated, but I just clicked a setting and you should not have further problems. I'm reading through your post now and will respond shortly.
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Old June 4th, 2014, 08:35 AM
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marko marko is offline
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It's so heartbreaking to read through your story as it's SO obvious that you are a wonderful pet owner

I am not a vet or a med student but like many members on our board I've picked up a lot of knowledge. As a med student, you likely know more than I do when it comes to multi organ failure.

Your little dooger had a lot of problems at the end of its life and to me it sounds like his body just gave out as every living body does eventually. 14 years 7 months puts the dooger at over 100 in human years. We all have to go eventually and it isn't always pretty when we do. An autopsy would be the only costly and definitive way to find out what happened, but because dooger had so many issues...it's likely a combination of system stress and failure.

Please don't beat yourself up! You are a fab pet owner and imo we need more caring responsible pet owners just like you.

for your sweet Maltese

Sincerely,

Marko
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Old June 4th, 2014, 10:25 AM
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Dog Dancer Dog Dancer is offline
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I'm so sorry for your loss also. Your pup was so cute. I have to agree with Marko that he was likely just at a point where nothing was going to change the course of his life or death. If you truly feel your vet failed you then you will likely always second guess him and I would recommend changing vets in the future. I doubt there would be any way to hold him responsible even if he did make an error, but as you said you don't doubt he was trying to help your pup.

I'd try to put it behind me and know that you gave your boy the best life possible and move on. I don't mean that to sound harsh, sorry if it did. I just mean continue with your grieving and hold his memory dear. Remember all the wonderful times you had with him. He's pain free now and beating yourself up with questions isn't helping him or you. One day, another lucky pup will fill your heart again.
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Old June 4th, 2014, 08:31 PM
Digston Digston is offline
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I'm so sorry for your loss. There is nothing more difficult then being there with your pet as they pass on, especially when it's unexpected

As a vet tech student, with limited clinical experience, I can't tell you whether bringing him in would have changed the outcome. He would have been put on fluids and had a CBC/Chem run. Maybe they could have extended his life for a short while, but with everything that he had going on it may not have been for long. A lot of what we know in vet med can be directly related to human medicine. If an elderly person comes into your hospital w/ liver disease, kidney failure (75% loss of kidney fxn, is that the same in human medicine?), anorexia, vomiting, possible neurological behaviour, skin discoloration, and what appears to be decrease peripheral perfusion (possibly linked to the existing anemia), what would you think?

Your training in a medical profession will make this harder for you, but will help you at the same time. Stop doubting yourself, you didn't do this to your dog.
You did an amazing job of caring for him, and you were there with him.

As for the sudden blindness, glaucoma usually accompanies cataract so that may be a cause.

The antibiotics that are given slow iv are typically done so to prevent hypotension or anaphylaxis. The load on the liver wouldn't change as the dose is the same either way.

To end my post, again I will say, stop blaming yourself. It's not your fault.
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Old June 4th, 2014, 09:59 PM
Barkingdog Barkingdog is offline
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I am so sorry to hear of the lost of our beloved pet , he was very cute and looks a lot like my dog. I was told by a couple of vets that small white dogs have a lot health issues. Considering how old your dog was and it health history I think you get a wonderful job as pet owner. Your dog was very lucky to had you for an owner. I really feel that you should feel good knowing your dog had a very full life and was very well loved. It's so hard losing a beloved pet and I know you will grieving the lost for a long time , I hope all the wonderful memories of your dog will help eases your pain a little. My dog has health issues and I hope he'll live as long as your dog did .
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Old June 5th, 2014, 12:11 PM
MalteseMourner MalteseMourner is offline
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Thank you for allowing my post through and thank you for such kind and thoughtful responses, I appreciate it a lot. It's comforting to read posts from other people who clearly have love for animals and their own pets as much as I loved mine.

You're all right of course, I'm sure we all beat ourselves up and question every little thing after loved ones die.

@Digston, thank you for your input as well, I think humans kidneys are able to compensate function up to about 90-95% glomeruli function loss roughly. Just disturbed at the idea that he was possibly bleeding internally and perhaps into his brain causing all of those neurological signs for up to 8-12 hours prior to his death. It makes me feel stupid for not taking him in as soon as I was convinced he had something wrong with his brain, though you're right, I'm doubtful anything significant could have been done for him at that point.
We did think of glaucoma and a few other reversible causes of sudden blindness but the vet was certain he didn't have those unfortunately, would have been nice to have something more treatable to work with.

Thanks again for all of this input so far, it's helpful to hear what other pet owners think.
This seems to be a lovely forum having had a read around, I wish all of your pets good health and many happy days.
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