Day in the life of a 24-hour clinic

A 24-hour clinic sees a huge variety of cases, highs and lows – and all dealt with by an extremely dedicated team with a passion for helping animals when they need it most. In this article, the clinic director of YourVets24 Coventry offers an insight into a typical day for his team.

It takes a special kind of person to work in a critical care environment; you never know what’s going to come in and the cases that do are often at risk of being seriously ill.

Here at YourVets24 Coventry we can see up to 150 patients in the day, with around 8 to 10 consultations overnight, and 20-plus hospitalisations overnight. The team is often making active decisions on the spot. It certainly has its moments, so a barrel full of chocolate biscuits and a tea break can provide a welcome respite.

A typical day at YourVets24 Coventry looks something like this:

Handover

7:30am – Saturday morning and a tired, but satisfied, night team completes its final checks on the Coventry practice’s inpatients and responds to the handful of early morning telephone calls as the day team assembles in the main prep area ready for rounds.

7:45am – Cases start being handed over to the day team. Two diabetic ketoacidotic dogs and a collapsed hypoglycaemic puppy all required hourly blood glucose readings through the night and constant adjustments to IV fluids, glucose and insulin levels.

A couple of postoperative orthopaedic patients from the day before just need pain scoring and analgesia. An anorexic cat with pancreatitis, a Jack Russell terrier – which had surgery for a pyometra late the previous evening – and a chocolate Labrador retriever that came in with dysuria complete the list of inpatients.

8:10am – Rounds complete and a flurry of early morning telephone calls occur, with most cases being deferred to 9am when the main doors open and regular consults begin. One, a worried client with a fitting elderly Staffordshire bull terrier (SBT), is advised to come straight down.

8:30am – The morning temperature, pulse, respirations (TPR) and 8am meds are all complete; the SBT is in prep having been quickly catheterised by the nursing team while awaiting the attendance of the hospital vet, who had been looking at the Labrador retriever with urinary obstruction and making a plan for the morning with the remaining nursing team.

Radiographs of a dog with an ornamental pebble in its stomach.

Swiftly, a history is relayed by the auxiliary – not good news; the patient had no previous history of seizures until last week, but has “been increasingly behaving oddly over the past few months”. The initial blood sample arrives 12 minutes after it has been taken – no significant abnormalities. An examination reveals a number of neurological symptoms consistent with a space-occupying lesion. The vet goes back to speak to the owner.

8:45am – A small queue of clients forms, waiting for the doors to open. The vet concludes the discussion with the SBT’s owner about the likely outcome of a neuro referral for advanced imaging and the regretful, but sensible, decision to euthanise is taken.

Doors open

9am – Doors open and the early walk-in clinic commences. Two vets and a nurse tackle the list while the hospital vet continues getting to grips with the inpatients. Some rapid decisions are made about who can go home, and discharge appointments are made by the nursing team. Emptying the hospital is a priority each morning as there is rarely a lack of new patients to replace them and reducing the average length of stay is a key action in remaining true to the affordable claim of YourVets24.

Prioritisation of the inpatients reveals Arthur, a dysuric Labrador retriever, is the next patient for work-up. At nine years old, he has had a worsening history of dysuria for a number of weeks. Having been seen in another YourVets clinic yesterday evening, he had been transferred by ambulance to the Coventry clinic. The night team had passed a catheter with relative ease to withdraw a large quantity of turbid, bloody urine. Blood sampling had revealed significant azotaemia, probably of post-renal origin. IV fluids overnight and pain relief had improved his demeanour, but the team remained concerned about the possible differential diagnoses, including bladder neoplasia.

9:30am – Ultrasound of Arthur revealed a generalised thickened bladder wall, but no obvious cause of obstruction. Plain radiography is unremarkable so the team moves on to positive contrast radiography, which reveals a relatively normal bladder neck. However, on repositioning the catheter to get a better view, it’s noted there is a very slight “grating” sensation. Finally, a positive contrast urethrogram reveals the culprit – a single stone wedged around the region of the pelvic brim. Between images the team makes calls to the other, less critical inpatient’s owners and has a cup of tea.

10:00am – A further inpatient is admitted – a pyrexic young cat with a significant history of anorexia. The inpatient team splits up so the cat can have blood drawn, start IV fluids and get settled in while the others tackle Arthur’s stone.

10:30am – Word comes in of an inbound pug that had 3 puppies 18 hours before, but the owner is now concerned she might have one left inside.

Meanwhile, Arthur’s stone has been retropulsed back into the bladder and, following a swift discussion with his owners, he is being prepared for a cystotomy.

11:45am – Cystotomy completed, Arthur is heading for recovery, and the pug that arrived via the walk-in clinic is being rapidly prepared for ultrasound – the nurses have already seated the somewhat exhausted patient on the x-ray table revealing a single retained puppy.

Noon – An IV catheter is placed in the pug. The hospital vet leaves Arthur to the nurses to recover, glancing satisfyingly at the stone sitting in a pot outside his recovery kennel en route to ultrasound.

12:10pm – In the imaging room the puppy is alive, but in distress, so the race is on; a quick call to the concerned owner and a C-section with spay is hastily agreed (following some careful words to ensure informed consent recorded by the in-house call recording system).

12:45pm – Successful puppy resuscitation and smiles all around the prep area.

1:30pm – The pug goes into recovery after being spayed. The team enjoys lunch and a chat.

2pm – Time to take stock of all the patients – a “mini ward round” with the lead inpatient nurse and some new priorities become apparent. Another SBT that had a mass removed from below its anus five days earlier has been admitted for assessment and possible revision surgery. The owners inadvertently allowed it to scrub its bottom along the floor – traumatising the suture line.

Meanwhile, the first of the diabetic dogs is finally ketone-negative and eating. The other diabetic continues to look even more ill with two-plus ketones in its urine. This triggers further calls to the owners to update them about the prognosis and ongoing costs. At “front of house” the appointments stop for the day and the second two-hour walk-in clinic of the day begins.

2:45pm – A collie that has caught itself over a barbed wire fence comes in via the consulting service – it’s added to the list growing of ops and procedures to be done. Time to break out the reserve pack of chocolate digestives to go with a hasty tea round made by one of the veterinary care assistants between an unending list of lab work, cleaning and packing of used kits, inpatient walking and generally trying to keep up with the trail of mess made by vets around the prep and ops areas.

3:15pm – Word comes in via reception, a cat straining to urinate is on its way. The hospital team gets stuck into afternoon checks and meds for the current inpatients in anticipation of a potential urinary emergency.

3:45pm – The cat with urinary obstruction arrives to be seen by one of the consulting vets. Word is rapidly passed to the hospital team a small bladder and history of significant stress through a house move suggests the three-year-old cat is, so far, suffering from a non-obstructive cystitis – relief all round as it goes home with meds and a dog appeasing pheromone diffuser.

Closing time

4pm – Doors close on the walk-in service and the hospital officially goes back to emergency consults only. After completing her call-backs and notes, one of the consult vets heads home leaving the hospital vet and one other to work their way through urgent consults and the growing list of inpatients

6pm – A trickle of urgent consults keeps everybody busy. It’s the typical late afternoon mix of the benign (vomiting since lunchtime and “must” be seen) and the potentially more complex (a lame retriever that’s been intermittently vomiting for the past two weeks that’s admitted for work-up). The second consulting vet stays on a while longer to complete notes and calls.

7:45pm – The night vet and nurse arrive just as the collie stitch-up is going into recovery and the handover process begins again.

8pm – The SBT with the perianal wound is settled on antibiotics and analgesics awaiting surgery. The somewhat fatigued day team starts to hand over the cases

9pm – Handover completed.

9:30pm – A handful of concerned clients call up as the last of the day team departs. The small, but highly capable, night team of vet, nurse and auxiliary are now responsible for the emergency care of all of the pets of the five large Midland’s YourVets clinics.

10:15pm – The SBT is in theatre – a large 6cm-deep defect requires some careful debriding, a drain implanting and re-suturing. Meanwhile, the collie stitch-up is returned to some grateful owners. Hooray, another kennel emptied.

11:30pm – Surgery complete, attention returns to trying to improve the stubborn ketoacidotic diabetic.

A harsh reminder

1am – Sunday, and after more than an hour of intense activity, the collapsed puppy crashes for the second time and dies – a harsh reminder of the realities of emergency and critical care medicine. A frustrated team clear up and the night vet gets the thankless task of breaking the news to the owner.

2:30am – The lame, vomiting retriever is in the imaging room being worked-up. The suspicions of cranial cruciate disease are confirmed, but also a radio-dense object is seen in the stomach. While the nurse preps theatre, the vet breaks the unfortunate news to the puppy’s owners.

4:15am – The retriever, and what turns out to be a glass ornamental pebble, are successfully separated in a gastrostomy, during which the nurse had to juggle her anaesthetic duties with giving inpatient meds and the seemingly endless blood glucose tests.

4:45am – The retriever’s owners are given the welcome news the dog is in recovery. Arthur, the other “stone dog” of the night, joins the celebration by starting to pass urine and the night team grabs a quick break.

5am – Theatre clean down is complete. Inpatient checks, more meds and more blood glucose tests will occupy the team for the next hour.

6am – The night team’s end-of-shift routine starts – everybody has a TPR, dogs are walked out, catheters flushed and rebandaged. Handover sheets are prepared ready for the 7:45am rounds. This well-rehearsed busy routine is interrupted by a call about a pregnant shih-tzu due tomorrow. She’s been vomiting for 48 hours, not eating and unable to stand. The owner is told to bring her straight in.

7:30am – The day team trickles in for 7.45am rounds. As they do so, the collapsed shih-tzu arrives and a day team vet is dispatched to triage her.

7:45am – As rounds begins again the initial results from the shih-tzu arrive: hypothermic, semi-comatose, hypocalcaemic and hypoglycaemic. Luckily, somebody thought to bring in extra biscuits – it looks like it could be a challenging start to the day, but the hard-core 24-hour YourVets team wouldn’t want it any other way.