30-Day ICU Externship

Spending 30 days at a specialty referral centre is a completely different world compared to a general practice or even university rotations. You don't see healthy animals getting vaccinations. Everything that walks through the door is already complicated — chronic, referral, or emergency. You adapt fast or you fall behind.

These are my notes from the rotation. Some are proper case write-ups, some are quick bullets I wrote between cases. All of it is things I didn't want to forget.

Clinical Cases

Case 1

Geriatric · Female intact · Toy-breed terrier · <2 kg

This one had been in and out of the clinic over several weeks. Chronic diarrhoea, anorexia, getting weaker. When you look at her you already know she's not doing well — she's tiny, obviously underweight, and just looks exhausted.

Diagnosis: Protein-losing enteropathy (PLE) secondary to chronic inflammatory enteropathy with lymphangiectasia. Confirmed by endoscopic biopsies. There's also pancreatitis, and small cell lymphoma is on the differential.

Why she's crashing: Massive hypoalbuminaemia (albumin running at 1.2–2.2 g/dL), anaemia (haematocrit as low as 16%), and intermittent hypoglycaemia. Free fluid in the abdomen and thorax. The intestinal loops are thickened. Histopath confirmed lymphangiectasia + crypt abscesses.

Treatment:

• Prednisolone ½ tablet (5mg) SID — anti-inflammatory / immunosuppression
• Co-amoxiclav + Metronidazole — antibiotics pending biopsy results
• Omeprazole — gastric protection
• Cerenia — nausea
• Ursodeoxycholic acid — bile flow support
• Mirtazapine topical — appetite stimulation (love this one, just rub it on the ear)
• Vitamin B12 injections — weekly
• Vitamin K — given during hospitalisation for coagulation support

Diet: Hill's I/D low fat + hypoallergenic options. Low fat is key with lymphangiectasia — fat absorption drives the lymphatic overload.

Complications to watch for:

• Thromboembolic events — hypoproteinaemia + inflammation = pro-thrombotic state
• UTI and pyometra — intact AND immunosuppressed from steroids. That's a bad combo.
• The feeding tube was accidentally dislodged at one point and had to be replaced

Clinical note: This case really highlighted how much of medicine is actually owner communication and managing expectations. The dog is sick and the prognosis is guarded — being honest about that while keeping the owner motivated to continue treatment is harder than it sounds.

Low fat diet · B12 · Steroids → the PLE with lymphangiectasia triad to remember

Case 2

Middle-aged · Male neutered · Small-breed dog · ~3 kg

Came in with a history of seizures, chronic intermittent diarrhoea, and progressive weight loss. Initial presentation was scary — abnormal bloodwork, suspected seizures, clearly losing protein fast.

Diagnoses: PLE (protein-losing enteropathy) + PLN (protein-losing nephropathy) — losing protein from both ends. Suspected lymphangiectasia + IBD. The seizures turned out to be secondary to electrolyte imbalances (hypocalcaemia) rather than primary epilepsy.

Bloodwork on admission: Marked hypoproteinaemia, hypoalbuminaemia, hypocalcaemia, hypokalaemia, hypophosphataemia, leukocytosis with neutrophilia, thrombocytopenia. Elevated PLI initially but imaging didn't confirm active pancreatitis. Urinalysis: UPC >2 — that's significant protein loss through the kidneys.

Medications:

• Cyclosporine 0.15ml BID (later tapered)
• Prednisone — tapered from 5mg/day down to 1mg every other day
• Spironolactone — diuretic, later discontinued
• Rivaroxaban — anticoagulant (again, thromboembolism risk with PLE)
• Omeprazole
• Mirtazapine PRN
• B12 + folic acid — oral + injection
• Doxycycline — discontinued after negative parasitic panel

Procedures: Plasma transfusions, IV fluids + electrolyte correction, Keppra for seizures, endoscopy with GI biopsies under GA, PARR testing (excluded lymphoma).

Note on Cyclosporin: It's a calcineurin inhibitor. Inhibits T-cell activation. Side effects to know: GI upset, gingival hyperplasia, nephrotoxicity, hepatotoxicity, alopecia. Important drug for immune-mediated diseases in small animals.

Seizures in a hypoalbuminaemic dog → think electrolytes before epilepsy. Check calcium.

Case 3 — Idiopathic Lymphoplasmacytic Rhinitis

Presented with continuous nasal discharge + reverse sneezing. Diagnosis by exclusion after ruling out fungal, bacterial, neoplastic causes. Lymphoplasmacytic rhinitis is frustrating because there's no definitive test — you diagnose it when everything else comes back negative and biopsy shows lymphoplasmacytic inflammation.

Snake Bite — Common Viper (Tzefa Matzui)

The Common Viper (Tzefa) is the main culprit in Israel. Bites are more common in summer, often on the face or limbs, and owners frequently don't witness the actual bite — they just notice sudden swelling. Common in this setting because it's a referral/emergency centre.

What you'll see: Rapid local oedema (usually dramatic and obvious), tachycardia, tachypnoea, lethargy, drooling. The scary part is the coagulopathy — check PT/aPTT early because DIC can develop fast.

Protocol:

• Stabilise first — IV access, crystalloid fluids for hypotension/shock. Keep the animal calm and minimise movement (movement spreads venom faster)
• Monitoring — minimum 24h hospitalisation. CBC, biochem, coag panel (PT/aPTT), blood pressure, ECG, repeat every few hours
• Analgesia — bites are painful
• Antihistamines — sometimes used (diphenhydramine), though evidence is limited
• Antibiotics — controversial, used in some protocols for secondary infection risk
• Antivenom — the only specific treatment. Give when: shock, severe/rapidly progressing oedema, coagulopathy, haemorrhage. Dose is titrated to effect — not a fixed amount. Watch for anaphylaxis during infusion (give slowly, have epinephrine ready)

⚠️ Steroids are contraindicated — retrospective studies link steroid use to increased mortality in common viper envenomation. Don't give them.

First aid don'ts (tell owners): no incision of the bite site, no ice, no tourniquet. Just keep the animal calm and get to a clinic fast.

Dehydration & Heat Exhaustion / Heat Stroke

Israel in summer. Heat stroke is a constant risk. Cases here were more often from being left on balconies or walked during the afternoon heat than from being left in a car. Heat stroke kills fast — by the time you see organ failure signs it's already bad.

Heat exhaustion vs heat stroke — know the difference:

Cooling protocol (start before full workup):

• Cool (NOT ice cold) water — wet the body, focus on neck, axillae, groin, paw pads
• Fan over wet skin — evaporative cooling is the most efficient method
• Stop active cooling when rectal temp reaches ~39.5°C — don't overshoot or you'll cause hypothermia
• Never submerge an unconscious or seizing patient
• IV fluids — cool fluids actively help lower core temp AND treat hypovolaemia
• Oxygen supplementation

Monitoring: Rectal temp every 5–10 mins during cooling. Then: blood pressure, ECG (arrhythmias), blood glucose (hypoglycaemia is common), coag panel (DIC risk), renal and hepatic values. AKI is a common and serious complication — watch urine output.

Dogs cool via panting, not sweating. When it's 38°C outside and the air they're panting is 38°C — the system fails. Brachycephalic breeds are the worst.

GD / GDV — Gastric Dilatation (±Volvulus)

GD = stomach fills with gas and dilates. GDV = stomach fills, then rotates on its axis. GDV is the emergency. Without surgery, mortality is ~100%. With surgery, survival is 70–90% — but time matters hugely.

Who gets it: Large/giant deep-chested breeds — Great Danes, German Shepherds, Irish Setters, Weimaraners. Often after a large meal + exercise. But it can happen in any dog.

Signs: Non-productive retching (trying to vomit but nothing comes up), rapidly distending abdomen, hypersalivation, restlessness, weak/rapid pulse, pale MMs. The retching with nothing coming up is the most telling sign.

Emergency protocol:

• 1 — IV access + fluid resuscitation immediately — two large-bore IVs if possible. Aggressive crystalloids ±colloids for shock. These dogs are haemodynamically compromised from the dilated stomach compressing the caudal vena cava
• 2 — Analgesia
• 3 — Gastric decompression — attempt orogastric tube. If tube won't pass (volvulus), trocarise (large-bore needle through the abdominal wall into the stomach to release gas). This buys time
• 4 — Confirm with X-ray — classic "double bubble" or "Popeye arm" sign on lateral view indicates volvulus
• 5 — Emergency surgery — derotate, assess stomach/spleen viability, resect necrotic tissue if needed, perform gastropexy to prevent recurrence

Post-op monitoring: Cardiac arrhythmias in 40–70% of cases in the first 24–48h (ventricular premature contractions are classic) — have lidocaine ready. Also watch for DIC, electrolyte imbalances, and hypotension.

Gastropexy types (from the surgery section): incisional, belt-loop, circumcostal, gastrocolopexy, laparoscopic. Incisional is the most commonly performed open technique.

GD ≠ GDV. A dog with simple GD can often be decompressed and managed without surgery. The moment it twists, surgery is the only option.

Surgery Cases / Observations

• Gastropexy — 5 types (incisional, belt-loop, circumcostal, gastrocolopexy, laparoscopic). Performed prophylactically in large/giant breeds or at time of GDV correction.
• PLO — Patellar Luxation Osteotomy
• CCWO — Closing Cranial Wedge Osteotomy
• TTA — Tibial Tuberosity Advancement (for cranial cruciate)
• TPLO — Tibial Plateau Levelling Osteotomy
• Hemivertebrae — can be seen on X-ray, especially in screw-tailed breeds (Bulldogs, Pugs). Causes spinal cord compression.
• TECABO — Total Ear Canal Ablation + Bulla Osteotomy. Need to read more on this one.
• HBC (Hit by Car) — a pelvic fracture case. Pelvic fractures are often managed conservatively unless neurological signs or inability to urinate.

Clinical Pearls — Random but Important

Drugs

• Why Zofran (ondansetron) and not metoclopramide or maropitant? — Maropitant (Cerenia) cannot be given to puppies under 16 weeks. Metoclopramide is a dopamine antagonist — fine but has CNS side effects. Zofran is a 5-HT3 antagonist, often preferred in vomiting with CNS involvement.
• Amlodipine — treat systemic hypertension in cats and dogs (calcium channel blocker)
• Weight to Body Surface Area conversion for dogs — important for chemo dosing. BSA = (kg^0.667) × 0.101 (or use a chart)
• Pimobendan + Furosemide + ACE inhibitor — the classic CHF triad

Lab / Diagnostics

• PCV/TS — quick bedside test. PCV tells you red cell mass, TS (total solids) tells you protein. Low TS with normal PCV = protein loss, not blood loss.
• CPL (Canine Pancreatic Lipase) — more specific than lipase for pancreatitis in dogs
• CK (Creatine Kinase) — marker for skeletal muscle, cardiac muscle, and brain damage. Elevated after trauma, seizures, prolonged recumbency.
• SDMA — detects CKD earlier than creatinine. Rises when ~40% of nephrons are lost vs creatinine which rises at ~75% nephron loss.
• US: A lines vs B lines — A lines = normal (air), B lines = fluid in alveoli (pulmonary oedema, pneumonia)

Conditions I Saw or Heard About

• Slipped capital femoral epiphysis — different presentation in dogs vs cats. Cats: obese neutered male, no trauma needed. Dogs: usually trauma-related.
• Multiple Myeloma — need 2 out of 4: monoclonal gammopathy, Bence Jones proteins (light chains in urine), bone lesions (punched-out lytic lesions), bone marrow plasmacytosis (>10%)
• Hepatocutaneous syndrome — superficial necrolytic dermatitis, liver disease + skin lesions (especially footpads). Seen in older dogs with liver disease.
• FUO (Fever of Unknown Origin) — work up: CBC, biochem, urinalysis, cultures, imaging, +/- bone marrow. Think: infection, immune-mediated, neoplasia.
• Hyperkalemia + hypothermia — affects the ALDOSTERONE receptor (increasing sensitivity). Urinary obstruction is a classic cause of hyperkalemia.
• Mucocele — salivary gland problem. Accumulation of saliva in surrounding tissue. Surgery is the fix.
• Bronchomalacia — collapse of airway during expiration. Chronic cough, especially small breeds.
• Intussusception — telescoping of bowel. Usually young dogs/cats. Emergency.
• Protothecosis — algal infection. Rare — first time seeing it. Affects the eye, skin, GI, CNS. Treatment is very difficult, prognosis guarded.

Open Questions I'm Still Working Through

• Recurring disk herniation — how do you manage a dog that's had multiple IVDD episodes? At what point do you recommend surgery vs conservative?
• If a patient is on steroids and develops CNS signs — do you stop steroids? (Answer: depends. If it's steroid-induced myopathy vs if steroids are treating the CNS condition — you don't just stop.)
• Will CNS inflammation always cause systemic fever? → No, not necessarily. MUE (Meningoencephalomyelitis of Unknown Etiology) can present without fever.
• Reflexes: Vagal response when taking urine sample → basically a vaso-vagal faint from bladder stimulation. Seen in cats more.

Oncology — CHOP vs COP

Lymphoma is the most common haematopoietic tumour in dogs. These are the main protocols:

• Histiocytic Sarcoma (HS) — from dendritic cells. Breed predisposed (Bernese Mountain Dog, Rottweiler, Flat-Coated Retriever). Can look like hemangioma or lymphoma on imaging — tricky.
• Furosemide in oncology? — to prevent/manage hypercalcaemia-associated issues and to force diuresis with some nephrotoxic chemo agents

Neurology Notes

• SCRUBS - FIGGS — neurological exam acronym (need to flesh this out more)
• Hemiparesis + truncal sway + CP deficits → localise before everything else
• MUE (Meningoencephalomyelitis of Unknown Etiology) — umbrella term for immune-mediated CNS inflammation. GME, NME, NLE all fall under this. Treated with immunosuppression.
• Nerve compression is more common than blood vessel compression as a cause of lameness. Remember that when doing your differentials.

Dermatology / Eyes

• Pruritus: Steroids first. If long-term → anti-histamines. Note: steroids take months (not just a few days) to fully suppress the immune system — manage expectations.
• Corneal ulcer → uveitis → IOP decrease. This is the chain. Uveitis will always drop IOP (unlike glaucoma which raises it).
• M. Retractor bulbi — retracts the eye back into the socket. Blepharospasm = eye squinting due to pain.
• Long-term steroids → GI ulcers. Always protect the stomach (omeprazole/misoprostol) if steroids are going for more than a few weeks.

ICU Flow Sheets

The centre uses a digital flow sheet system for ICU patient monitoring — vitals, medications, and treatments tracked in real time. Highly recommend learning one of these tools if you're going into emergency/critical care.

More Cases & Notes

Surgical Techniques — Gastropexy & GDV

Gastropexy is a surgical procedure performed to prevent Gastric Dilatation-Volvulus (GDV), a life-threatening condition primarily in large, deep-chested dog breeds. The goal is to create a permanent adhesion between the stomach and the body wall.

1. Midline Gastropexy (99%): involves closing the ventral midline incision together with the seromuscular layer of the stomach to the suture line (external rectus sheath).
2. Incisional Gastropexy: a 2-3 cm incision is made on the pyloric antrum and a partial-thickness incision on the transverse abdominal wall. The edge of the stomach is sutured directly to the body wall using a continuous suture pattern.
3. Preventative Gastropexy (Incisional): can be video-assisted laparoscopic. The stomach wall is grabbed and pulled through a 3-4 cm incision behind the costal arch.
4. Tube Gastropexy: a feeding tube is placed through the body wall into the stomach. When the catheter is removed, scar tissue forms, creating a permanent adhesion between the stomach and the abdominal wall.
5. Belt-Loop Gastropexy: a seromuscular flap is created in the pyloric antrum. A loop is made between the parietal peritoneum and the transverse abdominal muscle. The stomach flap is passed through this tunnel and sutured back to itself.
6. Circumcostal Gastropexy: similar to the belt-loop gastropexy, but instead of a soft tissue belt loop, the stomach flap is passed around a rib to anchor it. Noted as having limited advantage over simpler methods given the increased risk of complications like pneumothorax or rib fracture.

Feline Case — Purebred Cat

Feline pica and anemia with a gallop rhythm strongly suggest underlying cardiac disease (like Hypertrophic Cardiomyopathy - HCM) or infectious causes (Mycoplasma haemofelis, which causes regenerative anemia). The biochemical profile indicates renal or pre-renal azotemia and possible gastrointestinal involvement.

• Signalment/History: young adult castrated male cat. Presented with weakness, anorexia (not eating for several days), and dehydration. Significant body weight loss. Tick-borne evaluation was done. Antibiotics were stopped a couple of days prior.
• Clinical Signs: Pica, anemia (pale gums), gallop heart sound. Intestines and stomach appeared enlarged (likely on imaging).
• Diagnostics: Suspect HCM (Hypertrophic Cardiomyopathy)? Aorta/left atrium ratio evaluated at the apex? NMB (New Methylene Blue) stain showed regenerative anemia, suspecting Mycoplasma (feline infectious anemia). Bloodwork: BUN increased (122), Phosphorus increased (8.9), Total Protein increased (10), Globulins increased (6.3), ALT increased (104). Decreased Chloride (Cl-) and Bicarbonate (HCO3-).

Canine and Feline Cases

The canine case involves GI signs with thrombocytopenia, prompting consideration of tick-borne disease, severe gastroenteritis, or neoplasia. The feline case describes severe systemic illness with immune-mediated components (Evans syndrome).

Case: Canine, senior small-breed dog
Clinical signs: diarrhea, tenesmus, dehydration.
Diagnostics/differentials: thrombocytopenia, gastroenteritis. Differential diagnoses included transitional cell carcinoma (TCC) or prostate carcinoma.

Case: Feline, senior
Clinical signs: vomiting/diarrhea, anorexia, dehydrated.
Diagnostics/findings: thrombocytopenia and neutropenia. Ultrasound showed a solitary kidney, ascites, and ileus. Enlarged lumbosacral (LS) lymph node.
Diagnosis: suspect Evans Syndrome (concurrent Immune-Mediated Thrombocytopenia [IMTP] and Immune-Mediated Hemolytic Anemia [IMHA]).

Dermatology — Pyoderma

Canine pyoderma is primarily caused by Staphylococcus pseudintermedius. Classification into surface, superficial, and deep pyoderma is crucial for determining the duration and type of antimicrobial therapy.

• Pathogens: Gram-positive (+): mostly Staphylococcus species (S. pseudintermedius, S. aureus), Streptococcus canis. Gram-negative (-): mostly E. coli.
• Surface Pyoderma: Hot Spot — acute, moist, self-inflicted pyoderma. Common in hot/humid weather and dogs with long hair. Skin-fold Pyoderma — treated with benzoyl peroxide. Common in brachycephalic breeds and Shar-Peis.
• Superficial (Spf) Pyoderma: Impetigo — juvenile pustular dermatitis, typically in dogs < 8-10 months old. Associated with ectoparasites, poor nutrition, and unhygienic conditions. Superficial Folliculitis — often secondary to atopic dermatitis, flea bites, or endocrinopathy. Presents as "moth-eaten" alopecia. Treated with chlorhexidine shampoo and systemic antibiotics (e.g., cephalexin).
• Deep Pyoderma: infection beneath the hair follicle, involving both dermal and subcutaneous tissues. Includes: canine acne, nasal pyoderma, pressure point pyoderma, lick granuloma, and generalized deep folliculitis.

Neurology — Feline and Canine Cases

Neurological presentations can vary widely. Seizures in young cats can be due to congenital issues (like portosystemic shunts), infectious diseases, or metabolic derangements like diabetic ketoacidosis (DKA). A "horse-walk" gait in a dog might suggest a proprioceptive deficit or a specific spinal/neuromuscular lesion. The use of diazepam (Assival) is standard for acute seizure management, while pregabalin is used for neuropathic pain or as an adjunctive anticonvulsant.

Case: Feline, a few months old
Clinical signs: episodes lasting ~1 min to ~45 sec. Foaming, disorientation, running, and seizures. Described as "drunks".
Diagnostics/differentials: suspect diabetic ketoacidosis (DKA)?

Case: Canine, small-breed
Clinical signs: hindlimbs exhibiting a "horse-walk" gait.
Treatments: Optalgin (Metamizole/Dipyrone) — analgesic/antipyretic; Pregabalin — neuropathic pain/anticonvulsant; Assival (Diazepam) — muscle relaxant/anticonvulsant.

Canine GI Presentation

Acute vomiting and inability to stand in a young dog can point to acute intoxication (e.g., saltwater toxicity from the ocean), severe gastroenteritis, or acute abdominal emergency.

Case: Canine, young adult, intact
Diet: dry kibble and food.
History/clinical signs: went to the ocean in the morning, started vomiting, and within an hour couldn't stand. No vomiting at home prior.

Systemic and GI Cases

Icterus with suspected toxin exposure and fever in a dog strongly raises the index of suspicion for Leptospirosis, an important zoonotic disease affecting the liver and kidneys. Aggressive hepatoprotective therapy (SAMe, NAC) and fluid therapy are appropriate. The feline case involves routine follow-up with recent minor GI signs.

Case: Canine
Clinical signs: might have eaten a toxin. Icterus (yellow mucous membranes observed on examination), fever (temperature 38.7°C), but general condition fair.
Diagnostics/differentials: suspect Leptospirosis. Recommendation for hospitalization.
Treatments (liver protectants & supportive care): SAMe (S-adenosylmethionine) 20 mg/kg SID; NAC (N-acetylcysteine) 140 mg/kg, then reduced to 70 mg/kg; Vitamin E; FFA (Free Fatty Acids / Omega-3); Coenzyme Q10 30-100 mg/dog/day; isotonic crystalloid fluids.

Case: Feline, juvenile
History/clinical signs: recently acquired. Had first vaccine and deworming. Had a period of vomiting a month prior that resolved on its own.
Examination: physical examination normal (follow-up examination, doing well).

General Reflection

The pace is relentless. By week two you start to get a rhythm, but week one is overwhelming. The specialists here are exceptional and genuinely want to teach — if you ask questions, they'll stop what they're doing to explain. If you don't ask, they assume you know.

What I'd do differently next time: review the specialty of the week in advance. If I know it's neurology week, re-read the neuro exam the night before. And talk to the department heads at the start of the week — they'll tell you what cases are coming in and what to expect.

The professional network I built here — residents, specialists, students from other schools — is something I'll carry forward. Medicine in a referral setting is genuinely collaborative.