Friday, August 29, 2008

it's a heartache tonight...

i was standing around (yeah, right) on friday night when the techs came rushing back with a dog in severe respiratory distress. it was a 1.5 year old springer spaniel mix. she was open-mouthed breathing, gasping for air. the way she sounded, i suspected an upper respiratory obstruction. the owners knew of no recent traumatic injury.

my attending clinician was gloved in on a laceration repair, and the extern was busy suturing up something else, so the case was all mine. while the techs got a catheter in and administered intra-nasal oxygen, i pried the dog's jaws open and peered down her throat. nothing. na-da. zilch. i grabbed my stethoscope and placed the bell on the dog's left chest. nothing. no heart sounds, no lungs, nothing. (the heart should be loudest on the left). i listened on the right and nearly went deaf. the heart was banging so desperately hard on the right side, it felt like it was trying to escape the cage of the ribs.

i looked at the attending (working on the laceration nearby). "i think she has a diaphragmatic hernia" i told him matter-of-factly.

"tap her," was his reply.

while i grabbed clippers, the techs got me guaze and a butterfly catheter. i shaved a big spot on her right chest, sterilely prepped it, and tried to suck air out. i got blood. not enough to indicate blood in the chest, though. i tried again and again, but each time - the tap was negative. something was blocking the tip of my needle.

"lateral xray," i snapped - and the technicians rushed her to the table. sure enough, the diaphragm was blown - the liver and some of the stomach were in the chest, crushing the lungs and heart.

while they held the dog and gave oxygen, i went to tell the owner's the dire news. $1500-2000 for surgery, a 50/50 shot at success. the owner looked at me and informed me matter-of-factly that the dog belonged to her husband...with cancer. she had to try. after gaining her signature and talking to her briefly, i rushed back to get the dog prepped.

when we opened the abdomen, the hole in the diaphragm was enormous. through it, we could clearly see the beating heart and the poor, collapsed lungs. "bag her!" barked the senior clinician. it was amazing to watch the poor little teeny lungs become bright pink and fluffy as the technician vigorously pumped iso and oxygen into them.

as i retracted the liver, the clinician carefully sutured up the diaphragm. about halfway through, he commented to me, "what's that awful smell?" i didn't know, but i had noticed it as well. we continued on and finished closing the diaphragm. we then started removing all of the bowel from the abdomen and examining it. alas, the source of the smell was revealed. far down in the small intestine was a section of bowel perhaps 5 inches long that was dead. not only dead, but it had rotted enough that feces were spilling into the abdomen. great news.

the clinician didn't blink but examined the bowel, looking for areas that still had pulses. we discussed the viability of the sections above and below the dead area, and then we cut it out and anastamosed the ends together. in the meantime, a technician was using a 3 way stop cock and a 60 cc syringe to evacuate the air of the chest cavity. each time we achieved negative pressure, the chest would inevitably fill up with air again. it would take a few minutes, but the diaphragm was not holding negative pressure. the clinician returned to his sutures and added some more. yet the chest continued to leak somewhere.

after checking the diaphragm yet again, the senior decided that a lung lobe had been traumatized and was leaking air into the chest. the solution? a thoracotomy (open the chest) and lung lobectomy. i was advised to glove out and call the owners before entering the chest, as the likelihood of recovery kept declining (the dog had a septic abdomen from the ruptured bowel and now need for an open chest surgery). when i spoke to them...i had only grave news.

they elected (wisely in all likelihood) to stop. after all that work, we euthanized on the table.

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