3 am hemilaminectomy? Yes, please

My day started when I was startled from a deep sleep at 3 am by a phone call from the on-call surgeon, informing me my presence was required at the VTH to assist with an emergency back surgery.

This being my first opportunity to test my ability to get to the VTH within the requisite 20-minute time limit for on-call shifts, I was pleased to find myself somehow stumbling in the door a mere 17 minutes after being called.

The patient was, predictably, a middle-aged Dachshund with a sudden onset of hindlimb paralysis. Myelogram (injection of contrast material into the spinal canal, followed by x-rays of the spinal column) showed what was almost certainly a disc herniation in the caudal thoracic spine.

We started cutting on the little guy at 4 am, along with the on-call surgeon and the neurologist who offered to come help. Both of them were (not unreasonably) just a tad crabby. Everything went well (pulled out a huge bulging disc) and they let us loose at 6:30 am.

Which left just enough time to run to the nearby grocery store to pick up The Breakfast of Champions: a banana, a Snickers bar, a bag of Monterey Jack & Cheddar cheese cubes, and some harvest cheddar Sun Chips. That combination'll wake you right up.

I was back at the VTH by 7 am, to take a look at my poor hospitalized Westie (who took a turn for the worse yesterday but seems to have improved today). After doing a physical exam, helping with her treatments, running her blood down to the lab, and calling her mom with an update, it was time for 7:45 am case rounds.

I had a brief break from 8:45-9:30 to catch up on some paperwork, then headed up to the lobby to meet my drop-off appointment, an older lab mix who we'd seen the previous day for a workup of right hindlimb lameness. On physical and orthopedic exam yesterday, it was readily apparent that this guy's lameness had a neurologic basis, since he was pretty orthopedically sound. He had a neuro consult and the neurologists concurred, suspecting a lesion affecting his lumbosacral spinal cord.

We discussed the findings with the dog's owners, as well as the neurologists' recommendation of bloodwork, urinalysis, chest xrays, abdominal ultrasound, MRI, +/- CSF tap and surgery if indicated (e.g. for a chronic disc protrusion). We gave them costs as well as pros and cons of the neuro workup versus conservative/palliative management. They didn't seem entirely game for the full neuro workup (which, with surgery, would put them at a cost of $5-6K for their 10-year-old dog) but agreed to bloodwork, chest rads, and abdominal ultrasound as an initial step while they thought more about it. Bloodwork and chest rads yesterday were clean, and abdominal ultrasound was scheduled for today.

When I went up to get the dog from his dad in the lobby, I confirmed the plan as I understood it (drop off for ultrasound). Dad replied, "Yes, and if his ultrasound is okay, then we'd like to do the MRI and surgery if he needs it." I was mildly surprised since the orthopedic doctor who saw the dog yesterday felt the owners were probably not interested in workup (though I got a vibe that they could go either way).

This led to a frantic race around the hospital, discussing the case with neurology, MRI, anesthesia, and ultrasound to see if everything could be coordinated to take place yet today (since it was already after 9:30 am at this point). Fortunately, I'd had the foresight to ask the owners to fast the dog (yay, me!) so he was on an empty tummy and set for anesthesia.

His ultrasound came back pretty normal (some nodules in the spleen and liver which could very possibly be just old-dog aging changes, though cancer couldn't be ruled out), and he was officially transferred to neuro. I touched base with them later in the day, and they'd found a large tumor compressing his sciatic nerve on one side, and had plans to biopsy it to see if it could be safely resected or if he might need a limb amputation.

By the time that was all straightened out, it was time to watch one of the ortho surgeries -- a young dog with infraspinatus contracture, in for an infraspinatus tenotomy (a pretty easy and cool surgery). I had originally planned to scrub in, but it was a tiny surgical field and there were already 3 doctors and 1 other student scrubbed in, so I was glad to just sit it out.

After that surgery, I assisted with a consult on a lame dog that presented through Urgent Care. We didn't really find anything orthopedically abnormal with him, other than some serious edema around one of his tarsi, which didn't even really seem to be affecting the tarsus itself, just the tissue around it. Oddly, this dog had a lot of facial asymmetry, one bulging eye, a nose that deviated to one side, and strange mentation -- he just didn't seem very "with it," would periodically stare off into space and be pretty nonresponsive, and had these bizarre episodes of a repetitive chewing/licking motion that we suspected might be focal seizures.

Then it was time for afternoon rounds (doctors bought us pizza!) around 4 pm, then tidying up some loose ends, finishing paperwork, calling my Westie's owners for an evening update, and heading home.

I guess if I had to get called in during my 5 pm-8 am on call shift last night, 3 am wasn't a bad time for it to happen. It still allowed me 4+ hours of sleep, and was perfectly timed so that I didn't have much time to kill between the end of the surgery at 6:30 and the time I'd planned to come in (7 am). The oddest thing was just that my day felt shifted around by 4 hours all day -- by the time we had morning rounds at 8 am, I was ready for lunch. By the time actual lunchtime rolled around, it felt like time to have afternoon rounds and wrap things up for the day. Once I got through that, it was just like having a second entire afternoon. But I sure was beat by the end of it -- not falling asleep, but just having trouble paying attention during rounds discussions that weren't all that interesting to me (and wouldn't have been even if I'd had a full night's sleep). I'll also point out that I continued to exercise good judgment even at 4:30 pm by abstaining from the alcoholic beverages being passed around ("It's a Friday afternoon tradition!") at the end of rounds -- that is, until the hospital director came by and expressed his absolute disapproval (no disagreement from me). It was definitely an awkward end to the day!