Many years ago, when I first started working at an emergency hospital, I would chafe on Fridays whenever someone wished me a pleasant weekend. Of course, any well-meaning individual who expressed such a wish had no way of knowing that weekends are to me what Mondays and Tuesdays are to normal people. But, each time, I would silently wallow in the knowledge that I would be toiling while others would be playing.
Over time, I have gained perspective. After all, Mondays now are to me what Saturdays are to normal people. My schedule isn’t bad — it’s merely contrarian.
But then there is the matter of holidays. I no longer exactly chafe when someone wishes me a happy Labor Day, but I still feel, for just a brief moment, that my nose is being rubbed in you-know-what. Holidays, for me, mean extra work. And holidays usually are busy.
Of course, emergency work is unpredictable. Sometimes, days that should by all reasonable expectations be busy in fact are not. Suffice it to say that Labor Day was not one of those surprisingly slow days. I expected it to be busy, and it was.
It was hot in the Bay Area, and heat makes fleas active. I therefore treated a seemingly endless parade of dogs and cats with skin problems during the weekend, along with various and sundry trauma cases and the ubiquitous cases of gastrointestinal upset (Labor Day means picnics, which mean plenty of opportunities for canine dietary indiscretion).
In the middle of it all, a patient jumped the line. He was a dog who was breathing irregularly. Dogs who aren’t breathing right always get seen first.
An experienced technician triaged the patient and, fortunately, found that he was not having difficulty oxygenating himself. But something was definitely wrong. He was distressed and was snorting continuously.
She explained the situation to me, and I responded, “So he’s reverse sneezing?”
Reverse sneezing is a very strange, and, to the uninitiated, very alarming phenomenon. Reverse sneezes tend to be sudden and severe. A reverse sneeze is almost impossible to describe — it is like a combination of a sneeze, cough, gag, snort, hiccup, and yak all at once. I derive a not insignificant amount of pleasure from asking clients to impersonate their dogs’ reverse sneezing.
Anything that can cause sneezing can cause reverse sneezing. Nasal foxtails, allergic rhinitis, nasal mites, and exposure to irritants are common causes. This, I thought to myself, probably would be a simple case.
The technician burst my bubble. She replied that the dog was snorting, not reverse sneezing. And she was right. I entered the exam room and immediately noted that my patient was snorting. Continuously. Imagine a person with a runny nose, snuffling the snot back up and in. Continuously, with every breath.
Here’s the thing. Dogs don’t do that. They rarely snort even when they have runny noses, and in 15 years I had never seen a dog snort like this.
The dog, an 11-month-old Shiba Inu, had been for a walk with his owners. He stuck his nose in a bush, and he began to snort immediately thereafter. He had snorted continuously since.
If his complaint were sneezing or reverse sneezing, the immediate tentative diagnosis would have been a nasal foxtail. But this dog had not sneezed once since the onset of symptoms.
I was taken back in time to the year 2000, when I was a new grad. New graduates from veterinary school run scared most of the time. With no experience, every case is something that they have never seen. The time spent as a new grad is a stressful time, with constant fears that misdiagnosis or mistreatment will occur. One of the luxuries of experience is relief from that stress. Over time, one gains experience and can rely upon that experience to guide decisions when presented with cases. But this case was a new one to me. I had never in my life seen a dog snort like that.
My experience actually made the situation worse for me. If 15 years had gone by without anything similar passing through my office, then something really unusual had to have happened to my patient. I’ve seen hundreds or thousands of dogs with foreign objects in the nose or throat, and none of them had symptoms like this. Would I be able to find an answer, or would I wind up looking like a fool?
I tried to hide my anxiety, and began a thorough physical exam. It is a saying in medicine that a thorough and complete physical exam is the most important diagnostic tool available to clinicians, and I was hoping that this one would pay off.
It did, early on. When I opened the dog’s mouth, I saw something abnormal. There was a small speck in the very back of the mouth, on the soft palate. It looked like a bee stinger.
My patient was very cooperative for a Shiba Inu, but he was a member of a spirited breed. I got a reasonable look in the back of his mouth, but he didn’t let me see well enough to confirm my suspicion.
The dog received an immediate injection of diphenhydramine (Benadryl, which is an antihistamine — bee venom contains histamine as a major component), and the owners agreed to allow sedation for further evaluation. The dog received a short-acting deep sedative, which provided enough relaxation for me to remove the object in question and confirm that it was a bee stinger. An intravenous cortisone injection caused the symptoms to resolve by 90 percent within half an hour. Further evaluation of the oral cavity, the larynx, and the pharynx (the back of the throat) did not reveal any other abnormalities.
I have seen many dogs after they tried to eat bees. Most get stung on the lip or tongue. This dog got the bee all the way to the back of the mouth before he suffered consequences.
Things could have been much worse. The dog might have been stung on the larynx (voice box), which could have resulted in swelling that could have suffocated him. Or he could have had an allergic reaction that could have compromised his airway, resulting in suffocation.
After the procedure, the dog was kept under observation for several hours to confirm that his condition continued to improve. Happily it did, and he went home little the worse for wear. Hopefully the sting taught him to leave bees alone.
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