To the uninitiated, the Lewis Small Animal Hospital at the University of Minnesota’s Veterinary Medical Center (VMC) is a labyrinth. Kelly Tart, DVM, DACVECC, associate professor in the College of Veterinary Medicine’s (CVM) Department of Veterinary Clinical Services, is my fearless guide. She leads me through endless hallways as we spend the day striding from case to case: Emergency Services (ER), Intensive Care Unit (ICU), repeat.

“I do a lot of walking back and forth,” she says. “On some days, I’ll easily walk ten miles a day.” It’s not a boast. The ECC typically sees the highest number of cases of all the VMC services. Tart is one of five Emergency and Critical Care (ECC) board-certified faculty members who oversee the VMC’s ICU and ER. She makes sure everything runs smoothly between the students, small animal rotating interns, ECC residents and clinical instructors.

Tart’s passion for ECC has deep roots. She worked at emergency clinics while completing her undergrad and continued to do so as a CVM student. She says the unpredictable population of patients the field provides fuels her passion. 

Tart earned her DVM in 1993, then completed an internship and residency in emergency and critical care. The CVM was looking to explore the addition of both a 24/7/365 emergency service and critical care service at the time—and Tart was just the alumna for the job. She was asked to develop these services for the VMC. 

Tart spent the next twenty-three years building these services from scratch. In 2007, with the help of her colleagues, the Emergency and Critical Care service added a specialty internship and residency program. It took trial and error to fine-tune staff, space, training, and equipment details. “But that’s what has made it so fun,” she says.

Meticulous preparation 

Residents in the VMC’s three-year program need a broad knowledge base to prepare for the variety of patients and injuries seen and managed in the ECC. “There’s a lot of training, oversight, and exposure to a variety of critical, emergent patients that needs to be done so they can take the exam,” Tart explains. The program includes training shifts with the VMC’s internal medicine service, surgery service, ophthalmology, anesthesia, cardiology, and radiology services.

“There are some other hospitals or University programs that are much smaller or less busy,” says third-year ECC resident Molly Racette, DVM. “In those programs, you may not get to see quite as many of the really critical animals that need all of the things that we can provide here.”

Along with the program’s intensity, students are drawn to the VMC’s mentorship opportunities and advanced therapy technologies. “I like being in a teaching hospital,” says second-year resident Tasia Ludwik, DVM. “We can access a lot of new and exciting things.”

A well-oiled machine

The VMC’s Urgent Care (UC) service is open part of the evening on weekdays and mid-day during the weekend and works collaboratively with the ER service. Incoming patients are triaged so the cases that do not require hospitalization can be seen by the UC service. This allows the ECC team members to focus on patients that need immediate, more intense attention. 

The ECC works closely alongside other VMC specialty services, including surgery and anesthesia. Life-threatening ECC cases take priority when surgical care is needed, explains Tart, and the surgery and anesthesia teams are always willing to adjust their schedules accordingly.

“Usually, every single anesthesia prep table down here is full during the day,” Tart says when we drop in. “We’re lucky that we’ve got a great team on board to help us out when needed.” The department is buzzing with anesthesiologists, anesthesia technicians, surgeons, surgical technicians, and surgical residents.

The ER is positioned right off the VMC’s main doorway—a quick trip for patients in distress. On the day of my visit, the team consists of three doctors and two technicians. Tart introduces me, and before she can take her next breath, the ER receives its next patient: a male cat with a urinary obstruction. After removing some urine from his enlarged bladder, the team prepares him for heavy sedation so they can remove the urinary blockage.

Anesthesia can be risky, Tart explains, but the ER’s ample number of technicians allows for thorough vitals monitoring. When we check in later, a tech updates us on the cat patient’s abnormal potassium levels. Tart reviews the bloodwork: “Oh, gosh, look at that creatinine, too. His kidneys are quite unhappy.”

Racette performs the blockage procedure. It can be a challenge, but in her efforts to return her patients to health as quickly as possible, Racette takes pride in the efficiency of her approach.

One kibble at a time

Many ECC professionals are self-described “adrenaline junkies.” Ludwik is no exception. But some of the most empowering experiences take place in the moments spent with recovering patients. “They become our entire life while they’re here,” Ludwik says.

One such patient was Frank: a two-year-old French bulldog who presented to ECC in respiratory distress with a swollen face and an inability to swallow. After emergent sedation and intubation, her team found significant swelling in his larynx and upper airway. They performed an emergency tracheostomy, which saved his life.

Later, reassessing his physical exam findings revealed symptoms of tetanus infection. Most tetanus cases are localized, but Frank’s entire body was affected. “He required very intensive supportive care,” says Ludwik. This included keeping his tracheostomy tube clean and free of obstruction.

Gradually, Frank regained the ability to eat. “We’d feed him literally one kibble at a time and watch him really closely to make sure he could tolerate it.” After two weeks in the ICU, Frank went home. It was hard to say goodbye, Ludwik admits. But helping patients return to their families “is absolutely gratifying.”

Frank is doing great at home, Ludwik reports. His tube site has healed, and he’s eating and drinking normally. “He’s back to being a normal, happy Frenchie.”

Communicate, adapt, overcome 

The VMC fosters constant communication between the ER and ICU. Patients in the ICU need IV fluids, close supervision, and specialty treatments like blood transfusions or oxygen therapy. The kennels lining the walls hold about forty patients max.

Thorough treatment sheets keep everyone on the same page. This morning’s records show that three cases were transferred to third-year ECC resident Austin Luskin from the overnight ER cases. Tart reviews all cases with Luskin directly. Each time we stop by the ICU, they update one another with brief, technical discussions. There’s the seizure patient, the testicular torsion surgery, and—most notably—the Labrador that ate 25 Cliff Bars. 

“I actually went through the entire ingredients list,” reports Luskin. Thankfully, the bars are free of xylitol and macadamia nuts, both of which can be quite poisonous to dogs. “We’re going to do [radiographs] at 3 PM. If all that checks out, he’ll go home at four or five.”

Meanwhile, infectious patients are housed in an isolation ward far from the rest of the ICU. Its nurses employ stringent infection prevention measures, like wearing full body suits and plastic boot covers. However, the long trek between wards increases cross-contamination risks and creates difficulty for staff. “The nice thing about the ICU is that our doctors are near the patients,” says Tart. “They can alter patient treatments every minute if they need to, but it’s harder to keep a close eye on patients when they’re down here.”

The current isolation ward cannot accommodate patients that need oxygen, so staff must construct a makeshift isolation area within the main ICU. Even with strict cleaning controls and infection prevention protocols in place, it’s not ideal.

Tart and colleagues meet these challenges head-on by fostering an adaptive mindset among her team and contemplating a phased renovation in the ICU. Along with isolation ward improvements, her team hopes to add separate housing for feline patients, a designated area for ventilator and dialysis treatments, and soundproof kennels. “We’re really lucky to have some amazing, dedicated donors, and we’re excited to share more of our ideas with our community of supporters,” Tart says.

Uncharted waters

The recent COVID-19 outbreak spotlights just how crucial ECC is to the community. After all, pets don’t stop needing emergency care in the middle of a pandemic. The Minnesota Veterinary Medical Association initially mandated that only essential vet services remain open for the first few months of the pandemic. At one point, ECC and Urgent Care were the only VMC services fully open. 

COVID-19 poses a plethora of new challenges that test ECC workers’ flexibility, adaptability, and problem-solving skills. “We weren’t sure how this would affect our number of patients,” Tart says. “I was worried about our team—if all these other clinics are closed down, are all of their patients going to come through our ER?” 

Overall, ER cases have increased by 50 percent during this pandemic, and as a result, the ER has had to shut down multiple times as maximum hospital patient capacity has been reached. Each morning, the hospital management team and core service leaders, composed of Tart and 20 other administrators, “huddle” virtually to discuss infection control protocols and any dynamic planning that pandemic phases may require. 

All VMC workers, including front desk and custodial staff, are wearing cloth masks, having donated a large amount of their medical-grade personal protective equipment (PPE) to colleagues in human health care. When possible, team members keep a six-foot distance from one another. The hospital is also adhering to a strict policy around disinfecting surfaces. 

The ECC has also implemented curbside drop-off and pick-up protocols to minimize hospital foot traffic. An intake team of technicians, clad in full PPE, escort patients to the ER. While waiting in their car, owners consult with the ER doctors and provide patient history over the phone. After the physical exam is complete, another phone call is made to determine next steps.

These remote conversations pose their own challenges. Empathetic communication—so crucial when delivering difficult diagnoses or discussing high treatment costs—is harder to convey over the phone or behind a mask. “These are already such stressful times,” Tart says. “Anxiety is running high on both sides. As much as owners try to be understanding, it’s hard to fathom the depth of what the ER team deals with.”

Patience, Tart says, is key for both parties. Her residents are going the extra mile to put owners’ minds at ease. Since ICU visiting hours are not currently possible, residents are sending patient updates via pictures, videos, and text messages. “I’m proud of my team. They’re really putting out great effort in a stressful, challenging time.”

Tart may have had a vision of what the ECC would look like today, but its progress continues to impress her—pandemic or no. “I am so proud of the kind of care we can provide.”