Who Goes First in the ER?
It may not be who you think

Despite the world going all potty of late, most of the clients I have dealt with recently in the veterinary ER have been nice folks. At the very least, they just come and go, but most have been appreciative and kind. I have even had some truly top-tier folks who I have kept in touch with and communicated with by text, phone, or email about their pet's progress. There's a lot of buzz about the wearing down of social graces, but I have been lucky enough to have avoided the worst of it.
One situation does stand out. Let's start with a scenario:
What would you think if you went into a deli and, instead of taking a number and waiting for it to be called, the person behind the counter held up a giant log of bologna and started shouting “Who needs this delicious, highly processed, lunchmeat the most? Who is just dying for this salty log of fatty nitrates?”
My guess is you'd think you stepped into an episode of Black Mirror or you would start looking for the hidden cameras. It's just not the way the deli works.
But it is the way the ER works, with one exception.
The situation goes like this: Saturday night in the ER, lobby full, staff working at max capacity.
We have advised folks that the expected wait is 3-4 hours to be seen, and most are OK with it. A few people have left, some harrumphing about how we don't care about pets (false) and some figuring they can wait until their regular vet is open (hopefully true), or maybe they can find another ER with a shorter wait time (also hopefully true, but unlikely).
One of the waiting patients is a dog with a broken toenail. This is painful, but not life-threatening, so after being given something for pain they are shuffled near the bottom of the priority list.
Doors bust open and technicians wheel in a large dog on a gurney with the panicked owners in tow. The dog is flat out and crying in pain. He is rushed to the treatment area for evaluation and stabilization.
Most of the waiting pet owners know what this means – this dog is in a crisis and will probably:

1. Need attention right away
2. Be sicker than their pet who is waiting
3. Make their wait time longer

Not Mr. Toenail, though. Even though his dog has already been triaged and given analgesics, he jumps up from his chair and accosts the receptionist.
“Hey! My dog was here first!”
I wish I was making this up – this really happens.
The ER is the anti-deli. In the ER, the delicious bologna log becomes medical care, and we give it to the worst first, not the first who show up. Sure, if it's a slower night and everyone is equally sick, we take care of the patients in the order they come in. But when it's hopping, we attend to the life-threatening stuff first, and everyone else sits (hopefully) patiently until it's their turn. It usually works just fine, until entitled Mr. Toenail shows up and must have the concept of triage (taking care of the most seriously ill first) explained to him by our patient and caring receptionist.
There is one exception, though, and this one doesn't happen in human ERs (or delis, either).
We do everything we can to move euthanasia cases to the front of the line. (If there's ever euthanasia in a deli, then you truly have entered the Black Mirror universe.)
It's not a medical priority, but it is a humane priority. People waiting for hours to have their beloved pet put to sleep just doesn't sit well with most veterinarians, and we do our level best to accommodate. Sometimes I literally can't get away, for example, if I am doing CPR or involved in a procedure, but my staff and I try to get to these cases and help the family as quickly as we can.
It usually involves multitasking, something I am good at after 30 years of ER work, and efficient staff. In some cases, if the family does not want to be with their pet when the final injection is given, it's easier to get done. But it can take time to place an IV catheter, sign the required authorization form, and time for a last visit. Time is not a commodity that is in abundant supply in the ER. But we make it work. One thing that I have recently learned is that it is legal for credentialed technicians to give the euthanasia injection (an overdose of an anesthetic, often accompanied by a sedative) and this can help streamline the process if the owners are OK with it. Most are.
So, if you are waiting in the ER, try your best not to be like Mr. Toenail. He upsets everyone: the other owners, the receptionist, and the health care team. Understand that in this world of entitlement, at this particular moment, someone else may be more entitled than you. If it's your pet who needs to be euthanized right now to eliminate suffering, you would not want a broken toenail to be seen ahead of your beloved pet in severe distress. Perhaps pop down to the deli for a delicious bologna sandwich and try and be thankful that the big, crying dog on a gurney or the red-eyed family emerging from the exam room with a blanket-draped parcel was not you and your dog.

Credit: VIN
​Published: July 07, 2023
By Tony Johnson, DVM, DACVECC

Hyperthermia may be a life-threatening condition and requires immediate treatment. 
Body temperature may be elevated because of an infection (fever), but it may also increase because of hot and/or humid conditions outside. An increased body temperature caused by environmental conditions is commonly referred to as hyperthermia, heatstroke, or heat prostration. 

Temperatures differ greatly inside vs outside of the car, and can be extremely dangerous. Copyright VIN 2023, design by Cristina Rózsa
Hyperthermia (heat stroke) is a common and preventable emergency that has the potential to be deadly.A dog’s normal body temperature is 101.5°F plus or minus 1 degree Fahrenheit, and any time the body temperature is higher than 105°F, a true emergency exists.  Heatstroke generally occurs in hot summer weather when dogs are left with inadequate ventilation in hot vehicles. However, heatstroke may also occur in other conditions, including:

• When an animal is left outdoors in hot/humid conditions without adequate shade.
• When exercised in hot/humid weather.  
• When left in a car on a relatively cool (70°F) day; a recent study from Stanford University Medical Center found the temperature within a vehicle may increase by an average of 40 degrees Fahrenheit within one (1) hour regardless of the outside temperature. 

Other predisposing factors may be obesity and/or diseases affecting a pet’s airway. Keep in mind that prolonged seizures, eclampsia (milk fever), poisonings, and many other conditions may cause hyperthermia. Also, brachycephalic (short-nosed) breeds (Pekingese, Pug, Lhasa Apso, Boston terrier, etc.) may suffer from “ineffectual panter syndrome” which results in an increased body temperature that may be fatal.
Initially, the pet appears distressed and will pant excessively and become restless. As the hyperthermia progresses, the pet may drool large amounts of saliva from the nose and/or mouth. The pet may become unsteady on his feet. You may notice the gums turning blue/purple or bright red, which is due to inadequate oxygen.
What to Do: 
Beginning the process of cooling the pet immediately is extremely important. 

• Remove your pet from the environment where the hyperthermia occurred. 
• Move your pet to a shaded and cool environment, and direct a fan on them.
• If possible, determine rectal temperature and record it.
• Place your pet in a cool or tepid water bath (or in the shower) without submerging their heads. 
• You may also wet the ear flaps and paws with cool water. Directing a fan on these wetted areas will help to speed up evaporative cooling. Transport to the closest veterinary facility immediately.

What NOT to Do:

• Do not over-cool the pet. Do not cover your pet with wet towels.
• Most pets with hyperthermia have body temperatures greater than 105°F, and a reasonable goal of cooling is to reduce your pet’s body temperature to 102.5-103°F while transporting them to the closest veterinary facility. 
• Do not attempt to force water into your pet’s mouth, but you may have fresh cool water ready to offer should your pet be alert and show an interest in drinking.
• Do not leave your pet unattended for any length of time.

Severe hyperthermia is a condition that affects nearly every system in the body. Simply lowering the body temperature fails to address the potentially catastrophic events that often accompany this disorder. A pet suffering from hyperthermia should be seen by a veterinarian as soon as possible.

Credit: VIN
Roger Gfeller, DVM, DACVECC;  Michael Thomas, DVM;  Isaac Mayo; The VIN Emergency Medicine Consultants
Revised: July 09, 2024