A Toxic Sleepover

It was a Thursday morning, I was tying the last sutures of a dog neuter just a few minutes before noon.  Ingrid was answering the phone and I was only half hearing what she was saying in the hallway.   Then she walked in and turned the phone to speaker, the lady on the other end was clearly an American and from the south.  She was in the midst of spelling a word I had never heard and explaining that her dog had eaten some of this cream.  Yelling through my surgical mask in the direction of the phone I asked her a few basic questions.  She explained the cream was for her husband’s skin and now the dog had vomited three times.  Ingrid smartly asked when the dog had done this, the answer came as 7:30-8 am.  We then came to learn that by boat and then taxi they lived thirty minutes from the clinic.  Ingrid asked them to come in at 1 pm, less than an hour away, and I raced home for lunch.  Little did I know that this patient was going to stay with me forever.

I arrived back at Saga and was quickly followed by Missy and her two owners, a retired husband and wife who have lived here for many years.  She was a 2 year old, chocolate colored, female spayed spaniel mix.

Missy

missy2

Missy was fairly quiet with a normal examination.  That morning she had gotten up onto the back of the couch then on to a table to steal a tube of medical cream.  She had chewed on about 1/8 of the tube and eaten an unknown amount.  This was the very first time the owner had ever used the product. The product was Efudex (fluorouracil) 5% topical.  It is in a class of drugs called anti-metabolites.  It is a very expensive cream used topically (on the skin) for cancerous and precancerous growths in people and works by blocking the growth of abnormal cells.  I had never heard the brand name and had never had a dog eat it.  I quickly sat down to find out what it was and to search the Veterinary Information Network (VIN) to figure out what to do.

Efudex

efudex

It looked like from my research that the drug would initially cause vomiting and diarrhea, if enough was consumed (and it doesn’t take much) then next would be seizures, if the dog survived that then days later the bone marrow could be suppressed leaving the animal prone to infections.  I read a few postings that stated that if it was bad, the dog would likely be very ill within the first hour.  This gave me hope, Missy had vomited three times about three hours into the ordeal and at this point, six hours later, she had no seizures.  I quickly wrote down a treatment plan.  We started some fluids, anti-nausea medication, and stomach protectants and had her sit in another room with her owner for observation.  She sat there all afternoon and nothing happened.  Eventually I let her go home with a number of medications from antacids to antibiotics.

Minutes after leaving Missy’s owners called.  They had stopped in town and she had had a weird episode of collapse.  They came right back.  It was about 4:30 pm.  She returned to the clinic and I could tell she was off.  What they described was seizure-like and so I gave her some IV valium, which is often used to treat an active seizure.  I knew that I would not have enough of this drug for a dog with repetitive seizures.  I made a quick call to a local MD and he generously agreed to sell me some more.  I wrote down the prescription on a sticky note and sent the gentleman owner off to pick it up.

As I was preparing to put in an IV she seized.  It didn’t last long and she recovered on her own.  I gave her some more valium, but instead of becoming sedate she was hyper and whining.  This was constant.  I spoke to her owners and advised them that at this point I’d need to hospitalize Missy  overnight.  In my mind I wasn’t sure yet how I would do that, but I knew I’d just have to make it work.  I sent them to a local hotel for the night so they would be close by.  Ingrid helped me get her IV fluids going and closed up the clinic.

Missy On IV Fluids

missyandsam

My boyfriend was kind enough to bring me food and pyjamas, a dear friend Sandie came by with the fanciest air mattress I have even seen!

Getting Ready for Overnight

setup.missy

Missy continued to bark and cry, she was very upset.  I assumed this was due to being in a crate and her parents leaving.  I read up more on this toxicity.  I have limited drugs to choose from and limited equipment by which to give them.  I decided to give her just a touch of sedation so she could rest.  She slept silently for over an hour, but then it all started again.  I pilled her with oral medications, and she seized briefly each time from the stimulation, always recovering.  I realized over time that valium had no effect. Around midnight I fell asleep.  At 1 am I awoke to Missy barking/whining loudly.  I did more research.  I lacked the correct injectable medications and pumps to potentially block her seizures.  I decided to do it orally instead and gave her a high dose of phenobarbitol, with the pills she seized, then recovered.  Later in the night she seized again trying wildly to bite me in her confusion, and ruined her IV.  I decided to leave it until morning.  I sedated her once again.  I realized that the whining and barking was actually part of the poisoning, fluorouracil can cause not only seizures but hysteria as well.

At 5 am I awoke to silence.  I knew it had been long enough that the sedation would have worn off.  I prepared myself for the worst, but indeed Missy was still alive.  She was clearly looking quite drugged, as the phenobarbitol had now been digested.  But even with a little stimulation she started to cry, and then rest again.  She did not seize.  I knew from my research that it was a time game.  Most cases would have seizures for 1-3 days and then spontaneously would be ok.  Most, however, were in a drug induced coma for this duration of time and this is something I could not achieve here.  If she lived through the seizures then we could deal with the bone marrow issues if they arose.  At 7:30 am Ingrid arrived to take my place.  I gave her a briefing and then quickly took off for home to shower and eat my breakfast.  I had already updated her worried owners.  I was exhausted.

As I stood in my bedroom leaning over the dresser, trying to apply makeup and soak up the last bits of coolness from the overnight a/c the phone rang, it was Ingrid.  There it was,  twenty-five hours after she ate a small amount of Efudex cream Missy was dead.  She had seized and passed at 8:31 am.  And I did what I rarely ever allow myself to do over a patient.  I cried.  I cried because I knew how much they loved her, I cried because I tried so hard, I cried because I knew the guilt that would ensue.  I was mad because I had not yet given up, not yet decided to let her go.  I was reminded that I don’t always get to decide.

I got back on my bike and rode back to work to start the next day.

I wrote this story with Missy’s owners permission.  I did so because many people know the classic dog poisons (chocolate, rat bait, garlic, Advil, lillies) but they may not know some of the others (xylitol sweetener in gum and peanut butter, raisins, grapes) and certainly don’t often think of human topical medications as being a danger.  The drug that this dog ate is horribly dangerous if eaten/licked by a pet.  The owner was given no warning by their doctor.

Other common topicals like over the counter steroid and antibiotic creams can cause stomach upset if licked or eaten.  Prescription hormonal topicals like estrogen creams can be dangerous to pets when they eat them or even rub against the owner who is using them on their arms etc.  Pets often like the taste of things like NSAID (non steroidal anti-inflammatory) creams that owners use for pain and swelling, these include drugs like Voltaren (diclofenac) and  flurbiprofen, pets may lick them off the owner or eat the tube.  These can absolutely cause death. There are others such a zinc creams for diaper rash and vitamin D creams for psoriasis that cause severe side effects if consumed.

I realize in retrospect that once the seizures started I could never have saved Missy.  The dogs that present for eating this product die at a rate of 95-100%.  Those that live are usually in a drug induced coma for days.  Investigating this toxin and treating her, though, taught me a lot.  Missy’s case will help me in the future.  I will certainly never forget it.  I’m glad that I was naive enough to try.

Happy Missy

missy1

Please alway use caution and keep all medications far out of reach.  Do not allow dogs or cats to rub on or lick areas where you have applied a topical medication to yourself.

Advertisements

4 thoughts on “A Toxic Sleepover”

  1. Just shed a few tears with you while reading this. Losing our patients is one of the hardest things to deal with, it lingers in our hearts & minds, just as the owners will continue to grieve. Thank you, Sam, for the effort & love you put in every day. Thank you for the warnings about toxic medications. There are so many hidden dangers, your warnings will help to save numerous other pets! XOXO

    Like

  2. Dr. Sam, you are a wonderful woman and we are so lucky that your life journey brought you here to us. Missy absolutely felt your loving care and dedication in the last hours of her life and was warmed by your generosity of spirit. I believe she will be hovering around you and your clinic, returning your care.

    Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s