Thursday, June 19, 2008

holy first two days, batman!

i walked in at 6:30 tuesday evening and was handed a file. "patient in room 4," i was informed, "chewed and swallowed LARGE pill-cutter, complete with 2 razor blades sometime 12 hours ago." i looked at the radiographs from the referring veterinarian. uh-oh. 2 blades in the massively distended stomach.

the owner, a kindly, late 40s man, grasped my hand and admonished me to save his dog. said dog was a 9 year old (friendly - believe it or not) cocker spaniel with the most disgusting skin that i have ever seen (which is saying a lot for a cocker spaniel - they all come complete with gross skin, ears, and eyes). pimples, yeast, short - your average cocker. said cocker appeared to be feeling fine. i triaged - got her back to the techs to start getting in a catheter, drawing blood, and prepping for surgery.

i tried to find a quiet closet in which to hyperventilate. i was about to do an abdominal surgery. a REAL abdominal surgery. and that wasn't all. while that patient was being prepared, i was to see other patients. while she was in preparation, i took in a german shepherd with an extremely odd presentation (more on that later), a dog in respiratory distress with a heart murmur, a stepped-on puppy, a seizuring cat (definitely more on that later), a straining to urinate female cat, a humane society hit by car...and more.

meanwhile, the extremely talented technicians were battling to place a catheter in the disgusting, thick, mucoid skin of my cocker spaniel. surgery was supposed to be around 8pm. however - by the time the catheter was in, pre-anesthetic bloodwork was conducted, and we were ready to go, it was 11:30. my other patients were settled, and so in i went.

i was supervised by my attending clinician - but the surgery was up to me. and of course it couldn't be a simple foreign body removal. nope - not my first. it had to be spectacular. i exteriorized the stomach, gently palpating the bloated sac. i instructed an orogastric tube to be placed so that the material in the stomach could be removed. gentle palpation revealed masses of plastic. good - i knew where some of the pill-cutter was. i moved down the GI tract, softly squeezing and slipping the intestines through my hand. at the junction between the ileum and cecum (small intestine), i hit pay dirt. a huge wad of plastic - jagged and sharp - lodged there. i continued to palpate and to my immense dismay also found plastic in the colon. the colon is a nasty organ. surgery is absolutely avoided in that area whenever possible because of the poor healing associated with that part of the intestines.

sighing, i returned to the stomach. i made a small incision in the middle of the body and went to work removing the incredibly jagged plastic. but i couldn't find the razor blades. after suctioning and lavaging the stomach and feeling around more and having dr G feel around more, we decided they must have passed into the intestines. we closed the stomach and moved to the intestines. the mass located at the cecum was absolutely torturous. after incising the small bowel, i spent 20 minutes removing all of the plastic. the good news was that the bowel was healthy and pink - no sign of devitalized tissue. yet. and razor blades.

and then the colon. dr G suggested an ingenious idea. we used extremely long forceps (with an equally extremely long name that i have since forgotten) and had an unlucky extern remove the plastic rectally. and razor blades.

we were at a loss. it seemed unlikely the dog had passed the blades. the referring vet had taken the xrays a mere 1 hour before we saw the dog. the owner was very vigilant. so - by all appearances - the blades were still in the dog. dr G whipstitched the linea for me, and we took our patient to radiology. xrays revealed the razor blades.......................still sitting in the stomach. sighing with frustration - at hour 2 of surgery - back i went. i re-opened the linea, stared at the stomach for a moment, and then make an executive decision. my incision this time was 10cm. lavaging lavaging lavaging - and then - the razor blades made their much longed for appearance.

i closed the gastrotomy site and sighed with relief. 45 minutes later, the patient was recovering. and then...badness. her abdomen started to swell. i took a sample, and it was bloody fluid. ack. fearful that she had perforated a gut or that one of the enterotomy sites was leaking, i looked at the sample under the microscope. no bacteria. whew. over the last day and a half, she has been slowly improving. this morning, we offered her a tiny bit of bland stomach diet. and she wolfed it down. when i relayed this information to her extremely worried owner, i was engulfed in a minute and a half long, very soggy (as he was crying) hug.

and that - folks - was ONE of the myriad cases i handled on tuesday night - my first night as a veterinarian. more to come later on the other interesting cases i saw.

No comments: