I'm halfway through my necropsy rotation. I've not blogged about it yet not because I'm terribly busy (I'm not) but mostly because it's just depressing.
A necropsy is an autopsy or "post-mortem examination" on a deceased animal. Why they call it a necropsy, I have no idea.
And what we do during a necropsy is basically what they do during human autopsies: namely, cut out and examine all of the organs.
Over the last 5 days, I've necropsied dogs (young and old), cats (kittens and adults), cattle (beef and dairy, bulls/cows/aborted fetuses), horses (adults), and a koi (16 years old).
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Warning: the following information is not for the faint of heart. You've been duly advised.
Here's a sample of how we do a necropsy.
1. External examination of the animal, noting any bruising, swelling, masses, etc.
2. Lay the animal on its back (or on its side, in the case of large animals). Use a giant knife to make an incision through the skin on the underside of the animal, extending from the point of the chin down across the chest, across the abdomen, and down to the anus. Use the knife to cut the skin away from the subcutaneous tissues along either side. Cut through the muscles that bind the scapula to the thorax, so the forelimbs can be splayed flat out to the sides. Cut through the hip joints so the hindlimbs can be splayed out as well.
3. Poke a hole into the abdominal cavity. Cut the musculature along either side of the abdomen to expose the cavity. Look for any free abdominal fluid.
4. Pull back the liver so you can see the diaphragm and look for any holes. Poke a hole in the diaphragm and make sure air rushes into the chest cavity.
5. Use a knife to cut through the muscles along the ribs on either side of the chest. Then use giant garden shears to cut through each of the ribs so you can eventually pull off the underside of the rib cage to expose the thoracic cavity.
6. Use a scalpel to cut along the inside of the mandibles on either side under the jaw, so you can cut out the tongue. Disarticulate the hyoid apparatus (the tiny bones that suspend the tongue muscle). Peel the tongue back, down the neck, cutting connective tissue to free the trachea and esophagus as you go. Cut the esophagus, vena cava, and aorta where they enter the diaphragm. Remove the "pluck" in its entirety (includes the tongue, tonsils, thyroid, trachea, esophagus, thymus, heart, and lungs).
7. Flop the liver up into the now-empty thoracic cavity to get it out of your way. Cut out the omentum with the spleen attached.
8. Push the feces out of the rectum. Cut through the rectum, then cut through the connective tissue that suspends the intestines within the abdominal cavity until the intestines can be entirely removed, along with the pancreas and stomach.
9. Cut out the liver, gallbladder, and diaphragm as one unit.
10. Cut out the adrenal glands.
11. Cut out the kidneys (with ureters attached).
12. Cut into and examine the lining of the urinary bladder.
13. Examine each organ (tongue, tonsils, thyroid, trachea, esophagus, heart, lungs, lower airways, pulmonary vessels, thymus, spleen, omentum, mesentery, rectum, cecum, ileum, jejunum, duodenum, pancreas, liver, gallbaldder, diaphragm, adrenals, kidneys, urinary bladder) in detail. Take samples of most of those organs to submit for histopathology.
14. Cut out a femur or humerus and have it sliced in half so you can look at the marrow.
15. Cut open some or all of the joints (hocks, stifles, hips, elbows, carpi) to look for arthritis.
16. Cut off the head. Hack open the skull with a meat cleaver so you can remove and examine the brain.
17. Clean up.
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See why I'm not having very good dreams this week? The 'highlight' of Friday morning was cutting off a 3 week old kitten's head. The 'highlight' of Thursday morning was watching a live cow being shot then exsanguinated in the parking lot so we could necropsy it. Who knew, but it turns out that not all animals that arrive at necropsy are dead yet. Well, we fixed that.
It's heartbreaking when you let yourself realize that all of the animals (at least the small animals) were someone's pet with a name and a history and relationships. It's easy (and often helpful) to forget about that and just hack out the organs in a routine fashion, but sometimes it strikes you that this dog was only 2 years old, or look how cute this kitten was, or you think about how much pain one of the animals must have been in before it died, based on what you find on necropsy.
So, yeah, I'm ready to be done. If I'm to look on the positive side, at least I've gotten a good review of basic gross anatomy. And I'll undoubtedly need to do at least a few necropsies during my career. And I've learned an efficient way to decapitate a pet for the times when I need to submit a specimen to the public health department for rabies testing.
But that's about as positive as I can be after 5 days of eviscerating, dismembering, and decapitating dead animals, with another 5-7 days (depending on how many cases arrive next weekend) to go.
Saturday, September 24, 2011
Grand Rounds: no fun, but done
Last Friday was my day to present for Grand Rounds, and my case was, as planned, the "comedy of errors" case I wrote about previously.
As you might guess, my presentation did not include mention of any of the errors made during this case. Hope none of you were worrying about that (Dad).
The "exciting" part of that week leading up to Friday was completing my 40-slide PowerPoint presentation on Tuesday evening, and my laptop (containing my sole copy of said PowerPoint presentation) experiencing hard drive issues on Wednesday afternoon that left my laptop unable to start up completely.
No, I have not gotten it fixed yet. Yes, that did mean that I got to re-write my entire Grand Rounds presentation. Sigh.
After several hours of struggle on Wednesday evening, trying to get the laptop to work, I resigned myself to the fact that I lacked the technological savvy to fix the computer, as well as the fact that I was slated to give my presentation in less than 36 hours. Thus, I started a re-write about 9 pm on Wednesday.
Which was continued and concluded between 5:30 and 7:30 am on Thursday morning.
The re-writing of the presentation went (thankfully) much faster than the initial research and formatting. And, since I used the older desktop computer's elderly version of PowerPoint (which I actually prefer to the 2007 version), I found a format I liked better.
But I'm not going to lie -- it was no fun and made for a rough end of the week.
By the time Friday morning rolled around, though, I wasn't all that nervous. I ran through my slides once with my advisor (the surgeon for my case) on Thursday night, then made CLH listen to me talk through the presentation when I got home. I did get up a little earlier than usual on Friday morning so I could run through it about 3 times under my breath.
I was scheduled to go last out of the three presenters that morning. The first two cases were about horses (a case of nephrosplenic entrapment and a case of Neorickettsia risticii infection). When it was finally my turn, everything went very well. There were no computer or microphone malfunctions. I really didn't feel nervous and was even able to make a few jokes as I went along. It was over in about 12 minutes (we are allotted 15 minutes and are supposed to leave a little time for questions from the audience), and nobody among the roughly 100 clinicians and students in attendence asked me any questions (the part I most feared -- it's really uncomfortable to watch classmates standing in front of their peers and instructors and being asked questions they don't know how to answer).
The rest of Friday breezed by after that. One of my oncology rotation-mates brought a chocolate cake with "Congrats" written on the top to celebrate (which was really sweet of him). I ended up with just 3 radiation patients (who all left by the end of the day) and an outpatient mammary mass removal. The mammary mass was an interesting case. The mass was subcutaneous and only about an inch in diameter. The surgeon (who I'd not worked with prior to that week) basically told me what to do and then left the surgery suite. Which was admittedly terrifying, but also pretty cool.
Overall it feels great to have Grand Rounds over with. I attended Grand Rounds yesterday morning, and felt much more relaxed and at ease, and more able to enjoy the presentations than before I'd done my own. And I never have to do it again!
As you might guess, my presentation did not include mention of any of the errors made during this case. Hope none of you were worrying about that (Dad).
The "exciting" part of that week leading up to Friday was completing my 40-slide PowerPoint presentation on Tuesday evening, and my laptop (containing my sole copy of said PowerPoint presentation) experiencing hard drive issues on Wednesday afternoon that left my laptop unable to start up completely.
No, I have not gotten it fixed yet. Yes, that did mean that I got to re-write my entire Grand Rounds presentation. Sigh.
After several hours of struggle on Wednesday evening, trying to get the laptop to work, I resigned myself to the fact that I lacked the technological savvy to fix the computer, as well as the fact that I was slated to give my presentation in less than 36 hours. Thus, I started a re-write about 9 pm on Wednesday.
Which was continued and concluded between 5:30 and 7:30 am on Thursday morning.
The re-writing of the presentation went (thankfully) much faster than the initial research and formatting. And, since I used the older desktop computer's elderly version of PowerPoint (which I actually prefer to the 2007 version), I found a format I liked better.
But I'm not going to lie -- it was no fun and made for a rough end of the week.
By the time Friday morning rolled around, though, I wasn't all that nervous. I ran through my slides once with my advisor (the surgeon for my case) on Thursday night, then made CLH listen to me talk through the presentation when I got home. I did get up a little earlier than usual on Friday morning so I could run through it about 3 times under my breath.
I was scheduled to go last out of the three presenters that morning. The first two cases were about horses (a case of nephrosplenic entrapment and a case of Neorickettsia risticii infection). When it was finally my turn, everything went very well. There were no computer or microphone malfunctions. I really didn't feel nervous and was even able to make a few jokes as I went along. It was over in about 12 minutes (we are allotted 15 minutes and are supposed to leave a little time for questions from the audience), and nobody among the roughly 100 clinicians and students in attendence asked me any questions (the part I most feared -- it's really uncomfortable to watch classmates standing in front of their peers and instructors and being asked questions they don't know how to answer).
The rest of Friday breezed by after that. One of my oncology rotation-mates brought a chocolate cake with "Congrats" written on the top to celebrate (which was really sweet of him). I ended up with just 3 radiation patients (who all left by the end of the day) and an outpatient mammary mass removal. The mammary mass was an interesting case. The mass was subcutaneous and only about an inch in diameter. The surgeon (who I'd not worked with prior to that week) basically told me what to do and then left the surgery suite. Which was admittedly terrifying, but also pretty cool.
Overall it feels great to have Grand Rounds over with. I attended Grand Rounds yesterday morning, and felt much more relaxed and at ease, and more able to enjoy the presentations than before I'd done my own. And I never have to do it again!
Sunday, September 11, 2011
Bring on the juniors!
The new juniors (I call them "new" juniors because it still seems a little weird to me that we are no longer the juniors) started their morning clinical rotations 3 weeks ago.
However, since I was on CCU overnights and Urgent Care days for the first 2 weeks of the semester (and there are no juniors on those rotations), I did not get a chance to work with any of the juniors until this past week on Oncology.
And they're so cute! It almost makes me a little nostalgic for the terror of starting junior year, the wild-eyed barely-restrained panic you can see in their faces when you ask them to do something, the mostly inaudible mumbling when they give (usually correct) answers to questions during morning rounds, the silent apology in their eyes when they know something that all of us seniors have failed to remember.
The 2 juniors we had on Oncology with us this week were very enthusiastic and willing to conquer their fears and tackle appointments -- which was quite fortunate, because they didn't really have a choice. Oncology schedules a certain number of new cases every morning based on how many seniors are on the rotation that week, so that each senior has one new appointment every morning. Somehow, the schedulers got word that there were 6 seniors last week and next week, so they scheduled 6 appointments every morning. However, there are really only 3 seniors from my vet school, plus 2 students from other vet schools who are basically the equivalent of us (so we are making them take cases) -- which leaves 1 appointment every morning for the juniors to handle!
I'm having a really good time helping them out, teaching them how to fill out forms, where to drop off prescriptions, how to navigate the medical records department. It's early enough in their semester that they really don't know much about hospital procedures, and are very grateful for assistance. And it's not like they don't know enough medicine at this point in their curriculum to be able to do a physical exam and take a history from a client (though they probably doubt their abilities) -- it's more the annoying logistical stuff they need help figuring out.
And I remember being a junior myself, when so many of the seniors would rush off to their appointments without pausing to ask if you wanted to tag along. They'd hurry through online forms and completing medical records without talking you through them, or look at you like you were an idiot if you politely informed them that you didn't know how to enter a radiology request yet. It was often frustrating to feel like you were getting in their way, or interrupting them while they were busy doing important things and you had some lowly question with an easy answer (albeit one you couldn't figure out without asking).
So I'm trying not to be one of "those" seniors. I figure that investing a little extra effort in the juniors this early in the year will help them be more confident and competent as the year progresses. It'll allow them to get more out of their own junior year since they will be able to do more things for themselves, and they will be able to help us out more and more as the year progresses. And I hope that, come this time next year, they'll remember some of the nicer seniors who didn't mind showing them around and answering questions, and they'll be prepared to pass that positive attitude along to the next class. Lord knows you need all the help you can get sometimes in this fast-paced, whirlwind adventure we call vet school.
However, since I was on CCU overnights and Urgent Care days for the first 2 weeks of the semester (and there are no juniors on those rotations), I did not get a chance to work with any of the juniors until this past week on Oncology.
And they're so cute! It almost makes me a little nostalgic for the terror of starting junior year, the wild-eyed barely-restrained panic you can see in their faces when you ask them to do something, the mostly inaudible mumbling when they give (usually correct) answers to questions during morning rounds, the silent apology in their eyes when they know something that all of us seniors have failed to remember.
The 2 juniors we had on Oncology with us this week were very enthusiastic and willing to conquer their fears and tackle appointments -- which was quite fortunate, because they didn't really have a choice. Oncology schedules a certain number of new cases every morning based on how many seniors are on the rotation that week, so that each senior has one new appointment every morning. Somehow, the schedulers got word that there were 6 seniors last week and next week, so they scheduled 6 appointments every morning. However, there are really only 3 seniors from my vet school, plus 2 students from other vet schools who are basically the equivalent of us (so we are making them take cases) -- which leaves 1 appointment every morning for the juniors to handle!
I'm having a really good time helping them out, teaching them how to fill out forms, where to drop off prescriptions, how to navigate the medical records department. It's early enough in their semester that they really don't know much about hospital procedures, and are very grateful for assistance. And it's not like they don't know enough medicine at this point in their curriculum to be able to do a physical exam and take a history from a client (though they probably doubt their abilities) -- it's more the annoying logistical stuff they need help figuring out.
And I remember being a junior myself, when so many of the seniors would rush off to their appointments without pausing to ask if you wanted to tag along. They'd hurry through online forms and completing medical records without talking you through them, or look at you like you were an idiot if you politely informed them that you didn't know how to enter a radiology request yet. It was often frustrating to feel like you were getting in their way, or interrupting them while they were busy doing important things and you had some lowly question with an easy answer (albeit one you couldn't figure out without asking).
So I'm trying not to be one of "those" seniors. I figure that investing a little extra effort in the juniors this early in the year will help them be more confident and competent as the year progresses. It'll allow them to get more out of their own junior year since they will be able to do more things for themselves, and they will be able to help us out more and more as the year progresses. And I hope that, come this time next year, they'll remember some of the nicer seniors who didn't mind showing them around and answering questions, and they'll be prepared to pass that positive attitude along to the next class. Lord knows you need all the help you can get sometimes in this fast-paced, whirlwind adventure we call vet school.
Saturday, September 10, 2011
My case for Grand Rounds: a comedy of errors
I've been on Oncology this week, which has been an exhausted but informative and often fun rotation.
One storm cloud looming over my head, however, is the fact that I have my requisite Grand Rounds presentation this coming Friday.
Grand Rounds is a cruel vet school tradition wherein every senior student selects a case they've seen on clinics to present on a Friday morning sometime during the year. We are assigned a general topic for our presentation, typically the rotation that we have been on 2-4 weeks prior to our Grand Rounds date. This means that my topic is Oncology.
For Grand Rounds, you put together a 15-minute PowerPoint presentation discussing a case of interest to you. Then you get up in front of the junior lecture hall in the VTH, which is filled with other senior and junior vet students, nurses, and (most terrifyingly) clinicians.
Yes, that means that you have to give a presentation to basically the entire rest of the hospital, including the doctors who have been teaching you for the last 3+ years and working with you on clinics all year.
Okay, now that I'm done throwing up, I can finish typing.
The case I've selected for next week's Grand Rounds is a 13-year-old female Lab/Chow mix named Vega.
Vega has very dedicated, well-informed, responsible, and caring owners (no, I didn't say "obsessed," but maybe you get my drift...) who refer to her as their daughter. They have no human children or other pets, so Vega really is their only child.
On routine pre-anesthetic bloodwork prior to a dental cleaning 5 years ago, Vega's rDVM noted elevated liver enzymes. Vega had a battery of tests, including bile acids and liver biopsies, to try to discover the underlying cause of her elevated liver values, but everything came back normal. Vega's rDVM has managed her liver enzymes in the intervening period with a regimen of liver support drugs (ursodiol, SAMe, vitamin E) and a liver diet (Hill's l/d).
And Vega's done fine. She's had bloodwork monitored twice yearly, and her rDVM has noted elevations in a couple of Vega's liver values that sometimes fluctuate but have never gone back down to the normal range. Vega has never acted sick or shown any clinical signs of liver disease.
About 6 weeks ago, though, Vega went in for her 6-month geriatric wellness exam, and Vega's rDVM palpated a mass in the front part of Vega's abdomen. She repeated Vega's usual bloodwork, which was unchanged from her previous values, and recommended an abdominal ultrasound.
The ultrasound confirmed the abdominal mass and determined it to be about the size of a large orange, arising from a lobe of Vega's liver, and appearing to be solitary. Vega was referred to the vet school for an Oncology consultation and possible surgery.
Now, a lot of owners would hesitate at the thought of dropping $2-3K on anesthesia and abdominal surgery to remove a liver mass that might very well be an incidental finding in a 13 year old dog. However, Vega doesn't act her age -- if I hadn't known her age prior to meeting her, I'd have thought she was maybe 8 instead of 13. She's very fit and active, and otherwise totally healthy except for some arthritis which is under control. And though it's possible that Vega's liver tumor could be something benign that would never cause her a problem, there's also a possibility that it could be a vascular malignancy that could rupture suddenly and cause internal hemorrhaging, or some other type of malignancy that could spread elsewhere and make her sick if not excised. So, given the fact that Vega's owners didn't have much in the way of financial concerns, I can absolutely see their rationale for wanting to go to surgery.
Vega stayed in the hospital for a few hours with us on Thursday so we could repeat bloodwork and urinalysis (unchanged from her rDVM's labs a month earlier), run coagulation times (normal), check her blood type in case a transfusion was needed during or after surgery, and take chest x-rays (normal).
Vega went home on Thursday night and came back bright and early on Friday morning for surgery. She was anesthetized around 11:30 am and I was called to come shave her around noon. Given the fact that she has about 25 variably sized SQ and skin masses all over her body, and particularly on her abdomen, it was a remarkable challenge to have to try and clip her hair over and around the masses adequately to make her abdomen ready for surgery. She rolled into the OR around 12:15 pm.
Upon making our abdominal incision (difficult to find her midline due to her lumpiness!) we removed her falciform. The falciform is a very thick, fatty, gelatinous ligament that sits on the belly of the abdominal cavity and is often excised during abdominal surgery, simply because it isn't necessary to leave it in the dog and it gets in the way during surgery.
Immediately under Vega's falciform was her enormous tumor, popping right out at us. It was more grapefruit than orange-sized, and very ugly and vascular. Fortunately, it appeared to be growing on a stalk out of one of the 6 liver lobes, and the remaining liver did not appear to be involved.
Here comes Error #1: The surgeon elected to use a surgical stapler to cut off the tumor from its stalk. The way it works is that the stalk of the tumor is placed in the mouth of the stapler, the stapler is clamped down, and a double row of staggered small staples is automatically fired into the intervening tissue, effectively ligating the blood supply.
It works great.
Usually.
Unfortunately, it wasn't apparent that the stapler had misfired until the surgeon cut the tumor off of the stalk, released the stapler from the remaining stalk, and hemorrhage ensued.
In retrospect, the bleeding wasn't that bad. It certainly wasn't as bad as it would have been had none of the staples been placed as intended. But there was a heck of a lot of bleeding nonetheless, and significantly more than we'd have expected had the stapler functioned correctly.
Luckily, the surgeon remained very calm, and directed me to retract the abdominal wall and apply pressure to the hemorrhage while she obtained some additional materials to help start clotting and clamp off the bleeding vessels. There were about 10 minutes of panic, though, when multiple surgery nurses rushed in to assist us, and a flood of about 6 anesthesia personnel ran in to help the student anesthetist monitor blood pressure and heart rate, administer additional fluids, and get ready to send someone to the pharmacy to pick up some blood for a transfusion.
In the end, no transfusion was needed, and Vega'a anesthesia actually remained quite uneventful. The thing is, the liver is a very vascular organ, since its job is to filter toxins out of the blood. Tumors anywhere in the body tend to be very vascular, since they can produce factors that stimulate the growth of extra blood vessels to feed themselves; liver tumors are exceptionally vascular. Though this complication ended well, it could have been much worse and might even have led to Vega bleeding out.
Okay. Bleeding under control. Surgeons' and my heart rates were dropping back down to some semblance of normal.
Here comes Error #2: An important part of an abdominal surgery (other than something elective, like a spay) is to perform an explore of all of the abdominal organs, whether you expect them to be abnormal or not. As part of Vega's abdominal explore, we noted that one of her remaining liver lobes had a slightly abnormal appearance. The surgeon collected a biopsy sample, and placed it on a small piece of sterile paper on the instrument table. Unfortunately, she did not immediately hand the biopsy sample off to a surgery nurse to place in a formalin container, as is usually done with tissue samples, and we all forgot about the sample. It was presumably thrown away with all of the wrappers and packaging from everything needed for Vega's surgery -- but when I "got" to go hunting for it in the trash about an hour later, it was nowhere to be found. Oops.
Anyway, the rest of Vega's abdominal explore was fine. We closed her up, then transported her to CCU where she woke up slowly but normally, and proceeded to return to her usual neurotic behavior -- panting, pacing, barking, and generally trying to destroy everything in her kennel. The poor CCU staff were apparently rather irritated by this (and understandably so), since she received 5 doses of IV sedatives during the night (which reportedly did nothing to alter her behavior), and she was eventually shut up in an oxygen cage on room air, which did nothing to stop her barking but did at least dull the sound so it was almost inaudible in the room.
Vega's owners received a surgery and hospitalization estimate that included a second night's stay in the hospital if needed, since arrhythmias and pain are not uncommon complications of a surgery like this and are best dealt with in a hospitalized setting. However, Vega experienced no arrhythmias, seemed nonpainful, and clearly expressed to us that she was ready to be discharged, so we arranged a dismissal time for 9 am on Saturday.
I met with Vega's owners at 9 am and went through her dismissal instructions -- her pain medications and their side effects, how to care for and monitor her surgical incision, activity restrictions, etc. It all went well, and I advised them it would be a few minutes while I went to CCU to unplug Vega from all of her lines and monitoring, remove her IV catheters, and remove the bandage that had been placed over her incision so it would stay clean in the hospital.
Well, it turns out that the surgery nurses have gotten some new brand of extra-mega-super adhesive to get the bandages to stick onto the skin around the incisions, because Vega threw a tantrum when we tried to remove her bandage. It was really an all-out drama-queen hissy-fit, complete with howling, moaning, and thrashing, even when we were just gently restraining her and not even touching her bandage.
I should explain what the bandage looks like. It's a long, thin, flat strip of what looks like cotton padding, about 2 inches wide, laid down along the length of her abdominal incision (which goes from her sternum to her pelvis). A piece of clear plastic (which looks like plastic wrap) is placed over the cotton layer, and extends about an inch and a half onto the skin on either side of the bandage. An adhesive is sprayed onto the skin around the incision as well as onto the outside of the cotton bandage, to affix the clear plastic to the skin around the incision as well as to the outside of the bandage.
Since we couldn't easily peel or pull the plastic layer off Vega's skin (even with the help of adhesive remover wipes), the surgeon decided to very carefully cut into the cotton layer in the center of the bandage, overlying the incision. Her goal was to cut out the cotton layer (which was not affixed to the skin) and just leave the plastic layer around the edges to fall off on its own.
Error #3: Unfortunately, while cutting into the middle of the cotton layer, the surgeon accidentally cut some of the skin sutures from Vega's abdominal incision.
Luckily, not many of the sutures were lost, and we only had to replace 2 or 3 stitches in order to re-secure the suture line. But, it still meant a lot more drama from Vega, as well as more time that her poor anxious owners spent up front waiting for us to bring her out, and there's the pesky little fact that the skin likes to bleed a lot when poked with a needle, so there was still a little blood that appeared to be coming from Vega's incision (though it wasn't) by the time her owners saw her.
All in all, none of the "oops"es were major or complicated Vega's recovery. Her liver mass shows every sign of being consistent with a hepatocellular carcinoma, a tumor type for which complete surgical excision is essentially curative. We won't have biopsy results until Monday or Tuesday, but we're hopeful that it won't be something worse than that.
Now what's left for me is to put together my Grand Rounds presentation. I have some really cool pictures that were taken of Vega's abdomen and tumor during surgery. Once we have the histopath back and have confirmed that it's hepatocellular carcinoma, I'll do a little more research, but until then I'm ready to sleep for awhile!
One storm cloud looming over my head, however, is the fact that I have my requisite Grand Rounds presentation this coming Friday.
Grand Rounds is a cruel vet school tradition wherein every senior student selects a case they've seen on clinics to present on a Friday morning sometime during the year. We are assigned a general topic for our presentation, typically the rotation that we have been on 2-4 weeks prior to our Grand Rounds date. This means that my topic is Oncology.
For Grand Rounds, you put together a 15-minute PowerPoint presentation discussing a case of interest to you. Then you get up in front of the junior lecture hall in the VTH, which is filled with other senior and junior vet students, nurses, and (most terrifyingly) clinicians.
Yes, that means that you have to give a presentation to basically the entire rest of the hospital, including the doctors who have been teaching you for the last 3+ years and working with you on clinics all year.
Okay, now that I'm done throwing up, I can finish typing.
The case I've selected for next week's Grand Rounds is a 13-year-old female Lab/Chow mix named Vega.
Vega has very dedicated, well-informed, responsible, and caring owners (no, I didn't say "obsessed," but maybe you get my drift...) who refer to her as their daughter. They have no human children or other pets, so Vega really is their only child.
On routine pre-anesthetic bloodwork prior to a dental cleaning 5 years ago, Vega's rDVM noted elevated liver enzymes. Vega had a battery of tests, including bile acids and liver biopsies, to try to discover the underlying cause of her elevated liver values, but everything came back normal. Vega's rDVM has managed her liver enzymes in the intervening period with a regimen of liver support drugs (ursodiol, SAMe, vitamin E) and a liver diet (Hill's l/d).
And Vega's done fine. She's had bloodwork monitored twice yearly, and her rDVM has noted elevations in a couple of Vega's liver values that sometimes fluctuate but have never gone back down to the normal range. Vega has never acted sick or shown any clinical signs of liver disease.
About 6 weeks ago, though, Vega went in for her 6-month geriatric wellness exam, and Vega's rDVM palpated a mass in the front part of Vega's abdomen. She repeated Vega's usual bloodwork, which was unchanged from her previous values, and recommended an abdominal ultrasound.
The ultrasound confirmed the abdominal mass and determined it to be about the size of a large orange, arising from a lobe of Vega's liver, and appearing to be solitary. Vega was referred to the vet school for an Oncology consultation and possible surgery.
Now, a lot of owners would hesitate at the thought of dropping $2-3K on anesthesia and abdominal surgery to remove a liver mass that might very well be an incidental finding in a 13 year old dog. However, Vega doesn't act her age -- if I hadn't known her age prior to meeting her, I'd have thought she was maybe 8 instead of 13. She's very fit and active, and otherwise totally healthy except for some arthritis which is under control. And though it's possible that Vega's liver tumor could be something benign that would never cause her a problem, there's also a possibility that it could be a vascular malignancy that could rupture suddenly and cause internal hemorrhaging, or some other type of malignancy that could spread elsewhere and make her sick if not excised. So, given the fact that Vega's owners didn't have much in the way of financial concerns, I can absolutely see their rationale for wanting to go to surgery.
Vega stayed in the hospital for a few hours with us on Thursday so we could repeat bloodwork and urinalysis (unchanged from her rDVM's labs a month earlier), run coagulation times (normal), check her blood type in case a transfusion was needed during or after surgery, and take chest x-rays (normal).
Vega went home on Thursday night and came back bright and early on Friday morning for surgery. She was anesthetized around 11:30 am and I was called to come shave her around noon. Given the fact that she has about 25 variably sized SQ and skin masses all over her body, and particularly on her abdomen, it was a remarkable challenge to have to try and clip her hair over and around the masses adequately to make her abdomen ready for surgery. She rolled into the OR around 12:15 pm.
Upon making our abdominal incision (difficult to find her midline due to her lumpiness!) we removed her falciform. The falciform is a very thick, fatty, gelatinous ligament that sits on the belly of the abdominal cavity and is often excised during abdominal surgery, simply because it isn't necessary to leave it in the dog and it gets in the way during surgery.
Immediately under Vega's falciform was her enormous tumor, popping right out at us. It was more grapefruit than orange-sized, and very ugly and vascular. Fortunately, it appeared to be growing on a stalk out of one of the 6 liver lobes, and the remaining liver did not appear to be involved.
Here comes Error #1: The surgeon elected to use a surgical stapler to cut off the tumor from its stalk. The way it works is that the stalk of the tumor is placed in the mouth of the stapler, the stapler is clamped down, and a double row of staggered small staples is automatically fired into the intervening tissue, effectively ligating the blood supply.
It works great.
Usually.
Unfortunately, it wasn't apparent that the stapler had misfired until the surgeon cut the tumor off of the stalk, released the stapler from the remaining stalk, and hemorrhage ensued.
In retrospect, the bleeding wasn't that bad. It certainly wasn't as bad as it would have been had none of the staples been placed as intended. But there was a heck of a lot of bleeding nonetheless, and significantly more than we'd have expected had the stapler functioned correctly.
Luckily, the surgeon remained very calm, and directed me to retract the abdominal wall and apply pressure to the hemorrhage while she obtained some additional materials to help start clotting and clamp off the bleeding vessels. There were about 10 minutes of panic, though, when multiple surgery nurses rushed in to assist us, and a flood of about 6 anesthesia personnel ran in to help the student anesthetist monitor blood pressure and heart rate, administer additional fluids, and get ready to send someone to the pharmacy to pick up some blood for a transfusion.
In the end, no transfusion was needed, and Vega'a anesthesia actually remained quite uneventful. The thing is, the liver is a very vascular organ, since its job is to filter toxins out of the blood. Tumors anywhere in the body tend to be very vascular, since they can produce factors that stimulate the growth of extra blood vessels to feed themselves; liver tumors are exceptionally vascular. Though this complication ended well, it could have been much worse and might even have led to Vega bleeding out.
Okay. Bleeding under control. Surgeons' and my heart rates were dropping back down to some semblance of normal.
Here comes Error #2: An important part of an abdominal surgery (other than something elective, like a spay) is to perform an explore of all of the abdominal organs, whether you expect them to be abnormal or not. As part of Vega's abdominal explore, we noted that one of her remaining liver lobes had a slightly abnormal appearance. The surgeon collected a biopsy sample, and placed it on a small piece of sterile paper on the instrument table. Unfortunately, she did not immediately hand the biopsy sample off to a surgery nurse to place in a formalin container, as is usually done with tissue samples, and we all forgot about the sample. It was presumably thrown away with all of the wrappers and packaging from everything needed for Vega's surgery -- but when I "got" to go hunting for it in the trash about an hour later, it was nowhere to be found. Oops.
Anyway, the rest of Vega's abdominal explore was fine. We closed her up, then transported her to CCU where she woke up slowly but normally, and proceeded to return to her usual neurotic behavior -- panting, pacing, barking, and generally trying to destroy everything in her kennel. The poor CCU staff were apparently rather irritated by this (and understandably so), since she received 5 doses of IV sedatives during the night (which reportedly did nothing to alter her behavior), and she was eventually shut up in an oxygen cage on room air, which did nothing to stop her barking but did at least dull the sound so it was almost inaudible in the room.
Vega's owners received a surgery and hospitalization estimate that included a second night's stay in the hospital if needed, since arrhythmias and pain are not uncommon complications of a surgery like this and are best dealt with in a hospitalized setting. However, Vega experienced no arrhythmias, seemed nonpainful, and clearly expressed to us that she was ready to be discharged, so we arranged a dismissal time for 9 am on Saturday.
I met with Vega's owners at 9 am and went through her dismissal instructions -- her pain medications and their side effects, how to care for and monitor her surgical incision, activity restrictions, etc. It all went well, and I advised them it would be a few minutes while I went to CCU to unplug Vega from all of her lines and monitoring, remove her IV catheters, and remove the bandage that had been placed over her incision so it would stay clean in the hospital.
Well, it turns out that the surgery nurses have gotten some new brand of extra-mega-super adhesive to get the bandages to stick onto the skin around the incisions, because Vega threw a tantrum when we tried to remove her bandage. It was really an all-out drama-queen hissy-fit, complete with howling, moaning, and thrashing, even when we were just gently restraining her and not even touching her bandage.
I should explain what the bandage looks like. It's a long, thin, flat strip of what looks like cotton padding, about 2 inches wide, laid down along the length of her abdominal incision (which goes from her sternum to her pelvis). A piece of clear plastic (which looks like plastic wrap) is placed over the cotton layer, and extends about an inch and a half onto the skin on either side of the bandage. An adhesive is sprayed onto the skin around the incision as well as onto the outside of the cotton bandage, to affix the clear plastic to the skin around the incision as well as to the outside of the bandage.
Since we couldn't easily peel or pull the plastic layer off Vega's skin (even with the help of adhesive remover wipes), the surgeon decided to very carefully cut into the cotton layer in the center of the bandage, overlying the incision. Her goal was to cut out the cotton layer (which was not affixed to the skin) and just leave the plastic layer around the edges to fall off on its own.
Error #3: Unfortunately, while cutting into the middle of the cotton layer, the surgeon accidentally cut some of the skin sutures from Vega's abdominal incision.
Luckily, not many of the sutures were lost, and we only had to replace 2 or 3 stitches in order to re-secure the suture line. But, it still meant a lot more drama from Vega, as well as more time that her poor anxious owners spent up front waiting for us to bring her out, and there's the pesky little fact that the skin likes to bleed a lot when poked with a needle, so there was still a little blood that appeared to be coming from Vega's incision (though it wasn't) by the time her owners saw her.
All in all, none of the "oops"es were major or complicated Vega's recovery. Her liver mass shows every sign of being consistent with a hepatocellular carcinoma, a tumor type for which complete surgical excision is essentially curative. We won't have biopsy results until Monday or Tuesday, but we're hopeful that it won't be something worse than that.
Now what's left for me is to put together my Grand Rounds presentation. I have some really cool pictures that were taken of Vega's abdomen and tumor during surgery. Once we have the histopath back and have confirmed that it's hepatocellular carcinoma, I'll do a little more research, but until then I'm ready to sleep for awhile!
Saturday, September 3, 2011
Helpful advice for CPR
I wanted to add to my last post -- during CPR rounds, the critical care clinician told us something that I think was extremely helpful in allowing me to stay calm and not panic during last night's CPR:
"When a patient presents for CPR, they are already dead. Whatever you do, you can't make it any worse. So don't worry!"
Good point!
"When a patient presents for CPR, they are already dead. Whatever you do, you can't make it any worse. So don't worry!"
Good point!
Euthanasia #2, CPR #1
My daytime Urgent Care rotation ended with a bang. We were far busier on Friday than any other day last week. We saw probably 15 patients in the first 4 hours of the day -- which is probably more patients than we saw total during any 10 hour shift on any of the other days. It was crazy -- about every 10-15 minutes we'd get a page that a new patient was here, along with pages about phone calls from clients or rDVMs every 5-10 minutes. It was kind of a lot of fun, in a strange way -- it's more exciting and invigorating to be busy like that than to be sitting around all day waiting for patients to show up, and it gave us students a real chance to learn how to triage patients. We also got practice explaining to owners that they are here to see an Urgent Care service, which means that some of the stable patients will be sitting around and waiting for awhile while we stabilize the more critical patients.
I primarily ended up with 2 patients, after most of my other ones were transferred to different services (neurology and internal medicine). My saddest patient was Joey, a middle-aged Labrador retriever who presented as a transfer from his rDVM with a complete urinary obstruction.
Joey was neutered only 1 month ago, when his owners noticed he was intermittently straining to urinate and his rDVM diagnosed an enlarged prostate (very common in intact adult male dogs). Testosterone causes the prostate to grow in size, consequently compressing the urethra and sometimes the rectum, resulting in difficulty urinating and/or defecating. The treatment is generally castration, and although the body's testosterone levels subside fairly quickly after the testicles are removed, it can take several weeks or months for the prostate to shrink back down to a more manageable size.
Since his castration, Joey had been able to urinate and defecate, but had still had some intermittent straining, which Joey's owners were told to expect. However, two days ago Joey became completely unable to urinate. His owners brought him to their rDVM, who felt that Joey's prostate was still somewhat enlarged but not enough to be causing his inability to urinate. Joey's rDVM took radiographs, which showed small stones in Joey's bladder, and a stone lodged in his urethra. The rDVM tried several times to place a urinary catheter (we are unsure if this was successful or not, or if the rDVM drained Joey's bladder by placing a needle through his abdominal wall), and eventually recommended that Joey head to the teaching hospital for treatment.
Upon arrival, Joey was happy and wagging his tail, but was clearly experiencing quite a bit of discomfort from his by-now distended bladder. Joey's owners were quite conflicted about how to proceed with his treatment. Our initial stabilization (about $500) would include the Urgent Care exam fee, pain meds, ensuring the rDVM's IV catheter was patent, starting IV fluids, running some bloodwork and a urinalysis, and attempting to place an indwelling urinary catheter. Long-term, Joey's owners would be looking at anesthesia and surgery for stone removal from Joey's bladder, as well as possible surgery to remove the stone from Joey's urethra if it could not be moved, and maybe even a perineal urethrostomy (crudely, a surgery that would make Joey pee like a girl) if Joey's urethra had been too badly damaged from the stone sitting in it and the repeated attempts to pass a urinary catheter.
As you can imagine, the financial estimate for these surgeries was pretty staggering, especially given the fact that, not knowing why Joey's urinary stones had formed in the first place, we could give no 100% guarantee that we would be able to prevent them from ever returning in the future. Sure, depending on the type of stones, there are medical things that could be done to decrease the likelihood of recurrence, but we couldn't say that they would never return. And Joey's owners knew that although they might be able to scrape together the funds for his initial surgery, it really wasn't in their budget, much less a second surgery.
In the end, Joey's owners permitted his initial stabilization to allow themselves time to make a decision about how to proceed with Joey's care. With sedation and multiple attempts, we managed to place a small-bore urinary catheter to drain Joey's bladder and keep him comfortable. However, the fact that his penis was dripping frank blood on presentation and throughout the day was a sign that his urinary tract was very unhappy.
Toward the end of the day, Joey's owners made the decision to euthanize him. They wanted to spend a few minutes with him outside the hospital in the garden area, then to put him to sleep out there. The intern on duty and I brought Joey to his mom and dad, and they said tearful goodbyes. Once we had Joey settled on some nice cushy blankets in the grass, his owners decided they couldn't stay until the very end, so the intern and I talked to Joey and rubbed his belly as he watched his owners walk away for the last time. Then we anesthetized and euthanized him. He went peacefully, with lots of petting and us telling him how much his owners loved him, the sun shining down through the tree above and a breeze in the air, but it broke my heart a little bit.
We made a clay paw print for Joey's owners to have, and clipped some of his fur for them to keep along with his collar and tags. His owners consented to a necropsy, so we'll be able to find out how severely damaged his urinary tract really was. (His owners didn't want to know the results of his necropsy, and I wouldn't have either.)
It was about 6 pm by the time I had prepared those mementos for Joey's owners, delivered his body to necropsy, and started a sympathy card to send to his mom and dad. After 7 nights in a row last week of 10-12 hour overnight shifts, followed by 4 days this week of 12-14 hour Urgent Care daytime shifts, and almost 12 hours into my 5th day on Urgent Care, I was emotionally and physically exhausted.
However, about 10 minutes after sitting down to complete the day's paperwork, I got quite the adrenaline boost when another student rushed down the hall toward the Urgent Care room yelling, "Get ready, we need CPR!"
The patient was a small elderly mixed breed dog, whose owners had rushed him in after he had developed acute respiratory distress as they were driving out of town for a Labor Day weekend camping trip. The dog appeared not to be breathing on presentation at the VTH, so he was immediately rushed back for CPR.
Other than walking into a patient undergoing CPR during one of my last overnight shifts (the CPR in that case was well underway by the time I arrived, and all I did was write down the drugs that were given as the rest of the team did compressions, etc.), yesterday's CPR situation was the first in which I've really been involved.
Fortunately, we had "CPR rounds" two days prior, in which a critical care clinician reviewed with us in detail the steps to perform CPR. I'm so very glad we had those rounds, because it allowed me to stay somewhat calmer in this situation.
One of the nurses immediately started chest compressions on the little dog (which is the most important thing to do), and another nurse and doctor got to work intubating the dog. A student and another doctor started placing an IV catheter, while another nurse placed an intraosseous catheter (directly into the cavity within one of the dog's bones) then hooked up an EKG. A second student went to get more help; a third student started recording what we were doing; and I headed to the crash cart to start pulling up doses of atropine and epinephrine.
We performed chest compressions, mechanical ventilation, monitored EKG, and gave 3 rounds of drugs within about 10 minutes, but with no change in the dog's condition, he was pronounced dead shortly thereafter. It was a sad situation for the family, who'd been told previously the little guy had a heart murmur but that there was nothing they could do about it (which may not have been true). Given the vast amount of fluid coming up from his lungs, it's possible he had acutely gone into heart failure. The family was shocked at his sudden death.
However, it was oddly rewarding to see how well everyone worked as a team. The goal of CPR rounds and "practice" CPR situations is to remind everybody how things are done so that nobody panics and everyone can play a useful role when a CPR situation arises. As you might expect, studies have shown that medical and veterinary teams that practice CPR regularly are more likely to have a successful outcome (although the reality is that, in CPR situations overall, there's only about a 5% chance of getting an animal 'back').
As the clinicians ever-so-helpfully remind us, in a matter of months we students will be the ones to whom the rest of the veterinary care teams look to as leaders in a time of crisis, and we'll need to be able to stay calm, give directions, and make decisions about things like CPR. That's a really scary thought, but CPR rounds and CPR practice make me feel the tiniest bit like I might actually be ready someday.
I primarily ended up with 2 patients, after most of my other ones were transferred to different services (neurology and internal medicine). My saddest patient was Joey, a middle-aged Labrador retriever who presented as a transfer from his rDVM with a complete urinary obstruction.
Joey was neutered only 1 month ago, when his owners noticed he was intermittently straining to urinate and his rDVM diagnosed an enlarged prostate (very common in intact adult male dogs). Testosterone causes the prostate to grow in size, consequently compressing the urethra and sometimes the rectum, resulting in difficulty urinating and/or defecating. The treatment is generally castration, and although the body's testosterone levels subside fairly quickly after the testicles are removed, it can take several weeks or months for the prostate to shrink back down to a more manageable size.
Since his castration, Joey had been able to urinate and defecate, but had still had some intermittent straining, which Joey's owners were told to expect. However, two days ago Joey became completely unable to urinate. His owners brought him to their rDVM, who felt that Joey's prostate was still somewhat enlarged but not enough to be causing his inability to urinate. Joey's rDVM took radiographs, which showed small stones in Joey's bladder, and a stone lodged in his urethra. The rDVM tried several times to place a urinary catheter (we are unsure if this was successful or not, or if the rDVM drained Joey's bladder by placing a needle through his abdominal wall), and eventually recommended that Joey head to the teaching hospital for treatment.
Upon arrival, Joey was happy and wagging his tail, but was clearly experiencing quite a bit of discomfort from his by-now distended bladder. Joey's owners were quite conflicted about how to proceed with his treatment. Our initial stabilization (about $500) would include the Urgent Care exam fee, pain meds, ensuring the rDVM's IV catheter was patent, starting IV fluids, running some bloodwork and a urinalysis, and attempting to place an indwelling urinary catheter. Long-term, Joey's owners would be looking at anesthesia and surgery for stone removal from Joey's bladder, as well as possible surgery to remove the stone from Joey's urethra if it could not be moved, and maybe even a perineal urethrostomy (crudely, a surgery that would make Joey pee like a girl) if Joey's urethra had been too badly damaged from the stone sitting in it and the repeated attempts to pass a urinary catheter.
As you can imagine, the financial estimate for these surgeries was pretty staggering, especially given the fact that, not knowing why Joey's urinary stones had formed in the first place, we could give no 100% guarantee that we would be able to prevent them from ever returning in the future. Sure, depending on the type of stones, there are medical things that could be done to decrease the likelihood of recurrence, but we couldn't say that they would never return. And Joey's owners knew that although they might be able to scrape together the funds for his initial surgery, it really wasn't in their budget, much less a second surgery.
In the end, Joey's owners permitted his initial stabilization to allow themselves time to make a decision about how to proceed with Joey's care. With sedation and multiple attempts, we managed to place a small-bore urinary catheter to drain Joey's bladder and keep him comfortable. However, the fact that his penis was dripping frank blood on presentation and throughout the day was a sign that his urinary tract was very unhappy.
Toward the end of the day, Joey's owners made the decision to euthanize him. They wanted to spend a few minutes with him outside the hospital in the garden area, then to put him to sleep out there. The intern on duty and I brought Joey to his mom and dad, and they said tearful goodbyes. Once we had Joey settled on some nice cushy blankets in the grass, his owners decided they couldn't stay until the very end, so the intern and I talked to Joey and rubbed his belly as he watched his owners walk away for the last time. Then we anesthetized and euthanized him. He went peacefully, with lots of petting and us telling him how much his owners loved him, the sun shining down through the tree above and a breeze in the air, but it broke my heart a little bit.
We made a clay paw print for Joey's owners to have, and clipped some of his fur for them to keep along with his collar and tags. His owners consented to a necropsy, so we'll be able to find out how severely damaged his urinary tract really was. (His owners didn't want to know the results of his necropsy, and I wouldn't have either.)
It was about 6 pm by the time I had prepared those mementos for Joey's owners, delivered his body to necropsy, and started a sympathy card to send to his mom and dad. After 7 nights in a row last week of 10-12 hour overnight shifts, followed by 4 days this week of 12-14 hour Urgent Care daytime shifts, and almost 12 hours into my 5th day on Urgent Care, I was emotionally and physically exhausted.
However, about 10 minutes after sitting down to complete the day's paperwork, I got quite the adrenaline boost when another student rushed down the hall toward the Urgent Care room yelling, "Get ready, we need CPR!"
The patient was a small elderly mixed breed dog, whose owners had rushed him in after he had developed acute respiratory distress as they were driving out of town for a Labor Day weekend camping trip. The dog appeared not to be breathing on presentation at the VTH, so he was immediately rushed back for CPR.
Other than walking into a patient undergoing CPR during one of my last overnight shifts (the CPR in that case was well underway by the time I arrived, and all I did was write down the drugs that were given as the rest of the team did compressions, etc.), yesterday's CPR situation was the first in which I've really been involved.
Fortunately, we had "CPR rounds" two days prior, in which a critical care clinician reviewed with us in detail the steps to perform CPR. I'm so very glad we had those rounds, because it allowed me to stay somewhat calmer in this situation.
One of the nurses immediately started chest compressions on the little dog (which is the most important thing to do), and another nurse and doctor got to work intubating the dog. A student and another doctor started placing an IV catheter, while another nurse placed an intraosseous catheter (directly into the cavity within one of the dog's bones) then hooked up an EKG. A second student went to get more help; a third student started recording what we were doing; and I headed to the crash cart to start pulling up doses of atropine and epinephrine.
We performed chest compressions, mechanical ventilation, monitored EKG, and gave 3 rounds of drugs within about 10 minutes, but with no change in the dog's condition, he was pronounced dead shortly thereafter. It was a sad situation for the family, who'd been told previously the little guy had a heart murmur but that there was nothing they could do about it (which may not have been true). Given the vast amount of fluid coming up from his lungs, it's possible he had acutely gone into heart failure. The family was shocked at his sudden death.
However, it was oddly rewarding to see how well everyone worked as a team. The goal of CPR rounds and "practice" CPR situations is to remind everybody how things are done so that nobody panics and everyone can play a useful role when a CPR situation arises. As you might expect, studies have shown that medical and veterinary teams that practice CPR regularly are more likely to have a successful outcome (although the reality is that, in CPR situations overall, there's only about a 5% chance of getting an animal 'back').
As the clinicians ever-so-helpfully remind us, in a matter of months we students will be the ones to whom the rest of the veterinary care teams look to as leaders in a time of crisis, and we'll need to be able to stay calm, give directions, and make decisions about things like CPR. That's a really scary thought, but CPR rounds and CPR practice make me feel the tiniest bit like I might actually be ready someday.
Thursday, September 1, 2011
Urgently Caring, one day at a time
My current CCU rotation is comprised of 2 pretty different weeks. Last week was the overnight shifts, and this week is a daytime Urgent Care shift.
Urgent Care (UC) sees patients from 7 am till 10 pm on weekdays, and more limited hours on weekends. (Emergencies during other hours go straight to CCU.)
On UC we see any patient who enters the building as a walk-in appointment, any patient who requires a same-day appointment but can't get in through the specialty service they hope to see, and any daytime emergencies like snakebites or hit-by-car cases.
It's kind of neat not to know what to expect when you get there for the day -- about 60% of the clients we see call ahead by a few minutes or hours to let us know when and why they are coming, and the other 40% just show up out of the blue. It definitely requires you to think on your feet.
I've ended up with an odd mix of patients this week. They are as follows:
1. A 6-month-old Lab puppy, presented on Monday morning for acute-onset (12-24 hour duration) vomiting and diarrhea. We hospitalized her overnight for IV fluids and supportive care. She was negative for parvo but did have coccidia and Campylobacter in her feces, which we are treating.
2. A middle-aged hound mix, presented on Monday afternoon for skin problems. He'd had an acute onset of severe generalized itching, lethargy, and inappetance 10 days prior, with some degree of improvement since then. We suspected an autoimmune dermatologic disease, so he came back on Tuesday for a dermatology consultation.
3. An older Australian shepherd, presented on Tuesday morning for a worsening head tilt and improving falling/abnormal gait of 2-3 weeks duration. She also had a 2 month history of recurrent vaginitis, and several skin masses. We worked up her vaginitis and she came back for an MRI and neurology consultation on Wednesday, which showed an inner ear inflammation.
4. A young Chihuahua, presented on Wednesday morning for neck and back pain, as well as a palmigrade stance (walking down on her wrists). Her rDVM suspected neurologic disease. We agreed but thought there may be an orthopedic component. The orthopods examined her and recommended a neuro consult. The neurologists examined her and recommended an internal medicine consult for immune-mediated polyarthritis. She had a fever, so stayed in CCU on fluids overnight and transferred to internal medicine on Thursday morning for joint taps.
5. My first euthanasia patient, presented on Thursday for euthanasia due to abject misery.
6. An elderly Doberman, presented on Thursday morning for an acute onset of steadily worsening neck pain and abnormal gait, suspected by his rDVM to be due to cervical disc disease. After seeing his bloodwork showing a lymphocyte count of 75K (normal is 1-4K) and collecting lymph node aspirates with severely abnormal cells, we diagnosed him with Stage Vb lymphoma.
The Doberman was definitely my saddest case of the week so far. He is such a nice dog with an equally nice owner, very willing to spend the money needed for an MRI and vertebral surgery (which is what his rDVM had prepared him for).
Lymphoma is a cancer of the lymphatic system, including the lymph nodes, which help drain infection and inflammation from the surrounding tissues. It's "staged" based on clinical presentation, from Stage I through Stage V. Stage I means the cancer is limited to a single lymph node or organ. Stage II means that nearby lymph nodes are involved. Stage III means that all of the lymph nodes around the body are involved. Stage IV means it has spread to the liver and/or spleen. And Stage V means that it has spread to the blood, the bone marrow, or other sites such as the brain or spinal cord.
Lymphoma is also given a "substage" of 'a' or 'b.' These are based somewhat crudely on how well the dog is doing: a substage 'a' dog is one who feels pretty good; a substage 'b' dog is one who feels poorly.
Negative prognostic factors (things that are associated with a bad outcome) for lymphoma are:
1. Stages III/IV/V are worse than Stages I/II
2. Substage 'b' is worse than 'a'
3. T-cell is worse than B-cell (Mr. Doberman is suspected to have T-cell)
4. Leukemia (cancerous cells in the blood) and spread to "protected sites" such as the spinal cord and brain are worse than lack of these factors
So poor Mr. Doberman has all of these things against him.
He became more and more painful throughout the day, eventually whining and moaning in pain even when lying in the most comfortable position he could find, and even after a whopping dose of oral pain meds. We started him on heavy doses of IV pain meds, which seemed to help somewhat, but pain meds alone would not be enough to control his discomfort, so he was anesthetized for a dose of palliative radiation in the area where his spinal cord is being disturbed, and he started on chemo.
It's so odd, because without doing bloodwork on this dog and seeing his enormously elevated lymphocyte count (which really can only be caused by leukemia or lymphoma), he probably would have headed for an MRI to see what was going on. He had otherwise been feeling well (normal appetite, energy level, etc.) and did not have any of the characteristic lymph node enlargement that is typically seen in lymphoma cases. That goes to show you why doing a step-wise work-up in these neurologic-type cases is always a good idea, starting with bloodwork/urinalysis and progressing to more advanced diagnostics one at a time.
I'm hoping for the best possible outcome for Mr. Doberman, but even that won't be all that great. If he responds well to palliative radiation, he may have 2-3 months of quality time left. However, it's possible that we will not be able to get his extreme pain under control, in which case he'll most likely end up in Doggie Heaven. The one consolation is that at least he hasn't spent a long, chronic period of time feeling miserable up to this diagnosis -- just a few days. I know his dad would love to see him get home for a few more weeks of loving.
Urgent Care (UC) sees patients from 7 am till 10 pm on weekdays, and more limited hours on weekends. (Emergencies during other hours go straight to CCU.)
On UC we see any patient who enters the building as a walk-in appointment, any patient who requires a same-day appointment but can't get in through the specialty service they hope to see, and any daytime emergencies like snakebites or hit-by-car cases.
It's kind of neat not to know what to expect when you get there for the day -- about 60% of the clients we see call ahead by a few minutes or hours to let us know when and why they are coming, and the other 40% just show up out of the blue. It definitely requires you to think on your feet.
I've ended up with an odd mix of patients this week. They are as follows:
1. A 6-month-old Lab puppy, presented on Monday morning for acute-onset (12-24 hour duration) vomiting and diarrhea. We hospitalized her overnight for IV fluids and supportive care. She was negative for parvo but did have coccidia and Campylobacter in her feces, which we are treating.
2. A middle-aged hound mix, presented on Monday afternoon for skin problems. He'd had an acute onset of severe generalized itching, lethargy, and inappetance 10 days prior, with some degree of improvement since then. We suspected an autoimmune dermatologic disease, so he came back on Tuesday for a dermatology consultation.
3. An older Australian shepherd, presented on Tuesday morning for a worsening head tilt and improving falling/abnormal gait of 2-3 weeks duration. She also had a 2 month history of recurrent vaginitis, and several skin masses. We worked up her vaginitis and she came back for an MRI and neurology consultation on Wednesday, which showed an inner ear inflammation.
4. A young Chihuahua, presented on Wednesday morning for neck and back pain, as well as a palmigrade stance (walking down on her wrists). Her rDVM suspected neurologic disease. We agreed but thought there may be an orthopedic component. The orthopods examined her and recommended a neuro consult. The neurologists examined her and recommended an internal medicine consult for immune-mediated polyarthritis. She had a fever, so stayed in CCU on fluids overnight and transferred to internal medicine on Thursday morning for joint taps.
5. My first euthanasia patient, presented on Thursday for euthanasia due to abject misery.
6. An elderly Doberman, presented on Thursday morning for an acute onset of steadily worsening neck pain and abnormal gait, suspected by his rDVM to be due to cervical disc disease. After seeing his bloodwork showing a lymphocyte count of 75K (normal is 1-4K) and collecting lymph node aspirates with severely abnormal cells, we diagnosed him with Stage Vb lymphoma.
The Doberman was definitely my saddest case of the week so far. He is such a nice dog with an equally nice owner, very willing to spend the money needed for an MRI and vertebral surgery (which is what his rDVM had prepared him for).
Lymphoma is a cancer of the lymphatic system, including the lymph nodes, which help drain infection and inflammation from the surrounding tissues. It's "staged" based on clinical presentation, from Stage I through Stage V. Stage I means the cancer is limited to a single lymph node or organ. Stage II means that nearby lymph nodes are involved. Stage III means that all of the lymph nodes around the body are involved. Stage IV means it has spread to the liver and/or spleen. And Stage V means that it has spread to the blood, the bone marrow, or other sites such as the brain or spinal cord.
Lymphoma is also given a "substage" of 'a' or 'b.' These are based somewhat crudely on how well the dog is doing: a substage 'a' dog is one who feels pretty good; a substage 'b' dog is one who feels poorly.
Negative prognostic factors (things that are associated with a bad outcome) for lymphoma are:
1. Stages III/IV/V are worse than Stages I/II
2. Substage 'b' is worse than 'a'
3. T-cell is worse than B-cell (Mr. Doberman is suspected to have T-cell)
4. Leukemia (cancerous cells in the blood) and spread to "protected sites" such as the spinal cord and brain are worse than lack of these factors
So poor Mr. Doberman has all of these things against him.
He became more and more painful throughout the day, eventually whining and moaning in pain even when lying in the most comfortable position he could find, and even after a whopping dose of oral pain meds. We started him on heavy doses of IV pain meds, which seemed to help somewhat, but pain meds alone would not be enough to control his discomfort, so he was anesthetized for a dose of palliative radiation in the area where his spinal cord is being disturbed, and he started on chemo.
It's so odd, because without doing bloodwork on this dog and seeing his enormously elevated lymphocyte count (which really can only be caused by leukemia or lymphoma), he probably would have headed for an MRI to see what was going on. He had otherwise been feeling well (normal appetite, energy level, etc.) and did not have any of the characteristic lymph node enlargement that is typically seen in lymphoma cases. That goes to show you why doing a step-wise work-up in these neurologic-type cases is always a good idea, starting with bloodwork/urinalysis and progressing to more advanced diagnostics one at a time.
I'm hoping for the best possible outcome for Mr. Doberman, but even that won't be all that great. If he responds well to palliative radiation, he may have 2-3 months of quality time left. However, it's possible that we will not be able to get his extreme pain under control, in which case he'll most likely end up in Doggie Heaven. The one consolation is that at least he hasn't spent a long, chronic period of time feeling miserable up to this diagnosis -- just a few days. I know his dad would love to see him get home for a few more weeks of loving.
My first euthanasia
I had my first euthanasia case on Urgent Care today.
Oliver was an elderly long-haired terrier who had never been to the VTH before. His presenting complaint was "mass in mouth/possible euthanasia."
On presentation, he looked to be a definite euthanasia. His long tan-and-silver hair was badly matted over his entire body. His eyes were cloudy with sticky green discharge. He smelled like a sewer. He was recumbent and unwilling to move.
And, most notably, he did indeed have a mass in his mouth -- a mass that had spread from his mouth to engulf and deform his entire palate, nose, and muzzle. He was bleeding from his mouth, kept coughing and gagging, and seemed to be having a lot of trouble breathing.
Oh, and maggots were crawling in and out of his nostrils.
Oliver's owner conveyed to me that they had noticed a small oral mass about 6 months ago, and it had just kept growing since then. Over the last 3-4 days, Oliver had stopped eating, seemed to be in respiratory distress, and started to smell really bad. Her husband wasn't sure it was "time" yet, but she was pretty convinced.
Oliver's owner said, "Do you think it might be cancer?" which gave me some idea that poor Oliver had never seen a vet since developing this tumor. My reply was, "Yes, these types of things are usually cancer." I was stupefied enough not to know what else to say.
After some brief discussion, Oliver's owner elected not to be present for his euthanasia, and requested that we bring him to the back for the procedure. We obliged after she signed the consent forms to permit the euthanasia, as well as an "educational post-mortem examination" (aka necropsy). She did not want his body or ashes back, but thought a clay paw print would be nice.
We carried little Oliver to the Urgent Care treatment room, where I struggled for about 5 minutes to get the clippers through the thickly matted hair on his front leg, then placed an IV cathether (on my first try!). Oliver immediately received a heavy sedative injection IV, followed by euthanasia solution. All in all, it went quickly and peacefully. After his death, we discovered that Oliver had many other large masses over his entire body, and toenails about 2 inches long (on a 15 pound dog).
I had been quite nervous about my first euthanasia, since I know what a difficult thing it can be for owners (and for the veterinary team). I guess it turned out well that (a) Oliver's need for euthanasia was not at all ambiguous, and (b) Oliver's owner did not wish to be present when he was euthanized. That meant that I got to skip the whole part about "When Oliver's body relaxes as his heart stops, you may see some muscle twitching. He may vocalize. His eyes may not close. He may leak stool or urine," etc.
But I can't bring myself to even begin to think about what Oliver went through for the last few months, and especially the last few days. I mean, who among us can say what it feels like to have maggots crawling around inside your nose, eating bits and pieces of you? How about a huge tumor in your mouth so large that you can't even close your jaws? Spending several days gagging on the blood that is constantly running down your throat?
In the end, I feel that you can't be too hard on anyone who eventually seeks veterinary care for their pet. I don't think Oliver's owners had any idea how badly he must have been suffering. Their ignorance probably led to a lot of pain on Oliver's part, but at least they brought him to us for a peaceful ending instead of letting him die a miserable death from dehydration, suffocation, and sepsis at home. Did they wait too long? Yes. Should they have sought veterinary care long ago? Of course. But will it do Oliver or his owners any good for us to scold and shame them? Probably not. I think once they hear the results of Oliver's necropsy (which they requested we tell them), they will have a better understanding of what he went through at the end.
The power of euthanasia is one of the greatest gifts we have as veterinarians, which is lacking in human medicine. It's hard to describe the feeling I get when participating in a euthanasia that is well done and appropriately timed -- emotionally satisfying, gratifying, relieving, comforting... (I still haven't found the right words). It's a good feeling to help a well-loved pet die peacefully and painlessly when you know you've done all you can and that ending the pet's suffering is the best thing to do. My feelings are a little more mixed than that in Oliver's case. All in all, it made for an introspective, pensive sort of day.
Oliver was an elderly long-haired terrier who had never been to the VTH before. His presenting complaint was "mass in mouth/possible euthanasia."
On presentation, he looked to be a definite euthanasia. His long tan-and-silver hair was badly matted over his entire body. His eyes were cloudy with sticky green discharge. He smelled like a sewer. He was recumbent and unwilling to move.
And, most notably, he did indeed have a mass in his mouth -- a mass that had spread from his mouth to engulf and deform his entire palate, nose, and muzzle. He was bleeding from his mouth, kept coughing and gagging, and seemed to be having a lot of trouble breathing.
Oh, and maggots were crawling in and out of his nostrils.
Oliver's owner conveyed to me that they had noticed a small oral mass about 6 months ago, and it had just kept growing since then. Over the last 3-4 days, Oliver had stopped eating, seemed to be in respiratory distress, and started to smell really bad. Her husband wasn't sure it was "time" yet, but she was pretty convinced.
Oliver's owner said, "Do you think it might be cancer?" which gave me some idea that poor Oliver had never seen a vet since developing this tumor. My reply was, "Yes, these types of things are usually cancer." I was stupefied enough not to know what else to say.
After some brief discussion, Oliver's owner elected not to be present for his euthanasia, and requested that we bring him to the back for the procedure. We obliged after she signed the consent forms to permit the euthanasia, as well as an "educational post-mortem examination" (aka necropsy). She did not want his body or ashes back, but thought a clay paw print would be nice.
We carried little Oliver to the Urgent Care treatment room, where I struggled for about 5 minutes to get the clippers through the thickly matted hair on his front leg, then placed an IV cathether (on my first try!). Oliver immediately received a heavy sedative injection IV, followed by euthanasia solution. All in all, it went quickly and peacefully. After his death, we discovered that Oliver had many other large masses over his entire body, and toenails about 2 inches long (on a 15 pound dog).
I had been quite nervous about my first euthanasia, since I know what a difficult thing it can be for owners (and for the veterinary team). I guess it turned out well that (a) Oliver's need for euthanasia was not at all ambiguous, and (b) Oliver's owner did not wish to be present when he was euthanized. That meant that I got to skip the whole part about "When Oliver's body relaxes as his heart stops, you may see some muscle twitching. He may vocalize. His eyes may not close. He may leak stool or urine," etc.
But I can't bring myself to even begin to think about what Oliver went through for the last few months, and especially the last few days. I mean, who among us can say what it feels like to have maggots crawling around inside your nose, eating bits and pieces of you? How about a huge tumor in your mouth so large that you can't even close your jaws? Spending several days gagging on the blood that is constantly running down your throat?
In the end, I feel that you can't be too hard on anyone who eventually seeks veterinary care for their pet. I don't think Oliver's owners had any idea how badly he must have been suffering. Their ignorance probably led to a lot of pain on Oliver's part, but at least they brought him to us for a peaceful ending instead of letting him die a miserable death from dehydration, suffocation, and sepsis at home. Did they wait too long? Yes. Should they have sought veterinary care long ago? Of course. But will it do Oliver or his owners any good for us to scold and shame them? Probably not. I think once they hear the results of Oliver's necropsy (which they requested we tell them), they will have a better understanding of what he went through at the end.
The power of euthanasia is one of the greatest gifts we have as veterinarians, which is lacking in human medicine. It's hard to describe the feeling I get when participating in a euthanasia that is well done and appropriately timed -- emotionally satisfying, gratifying, relieving, comforting... (I still haven't found the right words). It's a good feeling to help a well-loved pet die peacefully and painlessly when you know you've done all you can and that ending the pet's suffering is the best thing to do. My feelings are a little more mixed than that in Oliver's case. All in all, it made for an introspective, pensive sort of day.
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