You already know about the common non-liver causes of increased ALP, like bone isomers in young animals, steroid or phenobarb induced ALP in dogs, and of course those vague old-with-high-ALP-but-otherwise-healthy dogs. But here a few ALP facts that are new to me from our episode on interpreting liver bloods with the queen of clinical reasoning, Prof Jill Maddison:
Breed:
Healthy huskies can have an ALP of over a 1000 when they’re 6 months old, and still have it sitting at around 700 at 1 year old - WAY over normal young dog ALP.
Scottish Terriers can also have abnormally high ALP for no apparent reason.
Cats
The half life of ALP in dogs is 2-3 days. Cats, in contrast, get rid of it way faster, with a half-life of just 6 hours. This means that if ALP is up in a cat you should definitely take notice. It probably has a liver problem. Except if it has:
Hyperthyroidism. HyperT can increase ALP in cats. Interestingly, the suggestion is that it’s not hepatic ALP, but the bone isomer that increases. Or:
Haemolysis. which can sometimes increase ALP. (We don’t know why.)
The complexities of sodium confuse the heck out of me, and I don’t think I’m alone. I could write 30 newsletters just on what I’ve learnt about it in the past 2 years, but here are something new that I learnt this week from Prof Kate Hopper. (I’ll assume that you know that changing serum sodium levels too quickly can lead to Very Bad Things - like irreversible brain damage and death. If this is news to you then you should definitely listen to the sodium episodes we have on our clinical podcasts, which finally helped me to understood sodium.)
I knew that if my patient’s sodium levels had changed slowly (over more than 48 hours) that I need to fix it slowly. But what I didn’t know was that if your dysnatraemic patient presents symptomatically, ie with neurological signs, that you can push for a small but quick change in sodium in an attempt to get rid of the clinical signs, regardless of chronicity of the inciting cause.
Aim for a change (up or down, depending on whether your patient is hypo- or hyper) of 2-6mmol/L over 10-30 minutes.
How?
For hypernatraemia, give a 10ml/kg bolus of something like D5W (5% glucose in water - it’s not about the glucose, it’s about the lack of sodium in your fluid).
For hyponatraemia, give a 2ml/kg bolus of 3% hypertonic saline.
These recipes should shift sodium by around 2mmoles/L. Keep doing it until your patient improves, or you hit a change of 6mmol/L.
Those aspiration cases can feel so frustrating: they can be SO dyspnoeic and SO sick, but yet we’re so limited in what we can do for them: “Here’s some oxygen, and here’s an antibiotic. Now good luck to you!”
Want to hear some bad news? That antibiotic may well not be doing anything (good) for your patient, because it probably doesn't have bacterial pneumonia!
Pneumonitis from acute aspiration without bacterial infection will look for all the world like severe bacterial pneumonia. This will include all the classical diagnostic criteria for aspiration pneumonia, like pyrexia, neutrophilia, hugely increased levels of CRP, radiological evidence of aspiration, arterial hypoxaemia, and even a positive culture of the ET tube that was down their throat.
BUT
Most of them will start getting better after 12 -24 hours, and will be normal by 36 hours, WITHOUT any antibiotics.
So how do we make this practical?
There’s no need to throw a barrage of antibiotics at that patient that has just inhaled half the pond, or it’s own dinner, and now looks like it’s dying.
Treat it with all the things (oxygen, basically), minus the clav or the baytril, and monitor it closely.
Expect that they will look really bad at 1 hour post-aspiration, then get a bit better, then crash again after 4-8 hours. This is not infection - it’s inflammation.
If they don’t start improving after 12-24 hours, start considering antibiotics.
Or, if this is too scary, and you decide to start antibiotics anyway, then once your patient is clinically better, stop the antibiotics. Remember - you don’t need to ‘finish the course’ or treat suspected pneumonia with weeks of antibiotics.
“If you see through yourself, you will see through everyone. Then you will love them. Otherwise you spend the whole time grappling with your wrong notions of them, with your illusions that are constantly crashing against reality.
Understand that everyone except the very rare awakened person can be expected to be selfish and to seek his or her own self-interest, whether in coarse or in refined ways.”
“Am I being an arsehole for saying that I won’t work the extra Saturdays?”
A younger vet friend was facing a tricky situation at work: her initial terms of employment said 1 Saturday per month, but people quit or got pregnant or burnt out - you know what it’s like - and now 1 Saturday has become 2, with occasional last-minute panicked requests for an extra hand on additional days. (If you’ve run a practice you’ll have complete empathy for the people doing the panicked asking!)
It’s a great question: where IS the line between being a committed team player and a doormat? Because if you care about your workplace, your colleagues, and your patients, you’ll likely pick up the slack. But to what extent?
It’s not a black and white answer. A good working relationship definitely involves some sacrifice. You try to accommodate each other’s needs. It’s a bit like a marriage: in broad terms, you like each other. Not all the time, but your goals and values align, you respect each other, and you are willing to compromise. So sometimes you do stuff that you don’t like, because you believe that it’s worth it in the long run. Because you care. So you do the dishes and you change the nappies and you put up with hair in the shower drain. Or, in your work relationship, maybe you work that Saturday.
BUT, it HAS to be a two way street. Because if one person does all the compromising, there will likely be an eventual end to the relationship.
So how do you know when you are setting healthy boundaries, or just being selfish? I don’t have a clear answer, but I think these are some good questions to ask to help you figure it out:
Are the requests to compromise REQUESTS, or expectations?
Is it a short term thing? Are these type of requests occasional, or is it the norm? Is there a pattern of asking for a finger and then taking the hand? Watch out for the slow creep of resentment, where you say yes, and you say yes, and you say yes, and then you wake up one day and, to your disappointment, you find that you hate work.
Is it reciprocal? Is there give and take? (Remember that this goes both ways. The changing vet job market has created some tyrannical employees, which is no better than a boss who just takes and never gives.) Is there a built-in negotiation with some gesture of compensation, or at least acknowledgement of your extra effort?
Is there a long term plan? Ie, is the request a short-term solution with a clear end point, or will it just be the new normal, because now the problem is solved for one of the parties?
Can you visualise your long term ability to put up with what is being asked? If you can’t, then you might be the person who says yes, because you don’t have the courage to say no, but then quit a year or two later, vs the person who says “I can’t work as many Saturdays”, but is still there 5 years from now, doing good work.
