Tuesday, November 25, 2008

kidneys on the brain...

on a terrible, crazy, non-stop, panicked sunday, a small fluffy rust colored poodle puppy came my way. he weighed a mere 4lbs 13oz. he had the great misfortune of being picked up and crunched on by a much larger dog.

when i examined him, he was quiet but alert. he even wagged his very fluffy stumplet of a tail. i'm not a poodle fan, but this guy was ridiculously cute. he looked pretty stable, was walking and alert. i found a small hernia on the left side of his body and a giant hematoma (blood clot), but it didn't feel like organs were in the hernia. i had concluded he was stable and was about to turn to a more critical case (1 of MANY MANY cases that day), when it occurred to me that i had forgotten to check his mucus membranes. i rolled back his lip and HELLO! his gums were paper-white. i checked his abdomen quickly with the ultrasound probe, and sure enough - his abdomen was full of blood. sickened, i went to deliver the news to his incredibly sweet parents who had lost their other poodle to kidney failure a mere month beforehand.

we opted for immediate surgery to identify the cause of the bleeding and to fix the hernia.

when i opened the little guy, i was prepared. this wasn't going to be like my last, god-awful hernia surgery. as soon as the abdomen was open, my assistant started removing the blood for auto-transfusion. when the abodmen was semi-cleared, i looked for the source of the bleeding. it was fairly easy to find. the left kidney was hamburger meat. the renal artery (which is a direct offshoot of the aorta) was partially torn away from the kidney and bleeding profusely into the abdomen. the kidney itself was fractured in half.

i didn't mess around but began ligating the renal artery and vein, as well as the ureter so that i could remove the kidney and stop the bleeding. when you weigh 4lbs, even a little blood loss is significant. this guy had 50 milliliters of blood in his abdomen when i started.

we fought for this guy. i tied off everything that bled that wasn't supposed to do so. i removed the kidney, i flushed the abdomen. i checked for bleeding obsessively. nothing.

we closed him, and i almost prayed.

2 hours later, he bled to death internally. likely due to the extensive amount of fluids he received to maintain his blood pressure (blood products, hetastarch, normosol-R). was it my fault?

i will never know for sure. i had my attending clinician glove in at the end and check to make sure she could find no other sources of bleeding, and she could not. she gave me the all clear, gloved out, and i closed. after surgery, his blood pressure spiked (due to the fluids/blood transfusions), and it's possible that he began to bleed from the vessels that i tied off. it's also possible that he had a tear in his aorta somewhere that i couldn't see or that i didn't completely tie off some unusual branches of the renal artery.

his parents sobbed, but they told me how grateful they were for my services. they were incredibly kind, and it broke my heart.

in the end, i know that i worked as hard as i could, was absolutely meticulous, and realize that this guy underwent a terrible trauma. i did what i could to save him.

was it enough? will it ever be enough?


jameswcalvin said...

man you have had a rough couple of days. just want to give you some encouragement and don't get downhearted. have a good vacation. sounds like you need one.

Anonymous said...

I had a day like that myself. Open for a half day before thanksgiving. Second appt. of the day is a ferret who can't breathe, crying w/ each breath, abdomen grossly distended. Quick tap - blood. There was blood from his penis, too. I wondered about a ruptured bladder post prostate enlargement from adrenal. gave the owner options - ultrasound, try to stabilize- we opted for stat exploratory lap - over 150 cc of blood in this belly . Couldn't find the bleeder. Masses in the spleen, mesentery, and liver was nasty. Still having a hard time breathing, so I tapped the chest via the diaphragm - frank blood. Stopped pulling when the 60 cc syringe was full. The ferret was white despite autotransfusion, and died shortly. Ended the day with a client who came up from Alabama for the holidays w her beloved 5 yo rabbit who was fine yesterday. 4 hours later, despite eating en route to the clinic, it had weakness, opisthotonus, seizures, death, bizarre bloodwork, normal rads.- Now both these strangers are grieving and I couldn't' save either. Sometimes this is one of the most rugged professions - and then tonight I get an email from a client just happy that I am their vet. It is a large circle. Just need to keep it in perspective, and when we agonize over the ones we lose it makes us better. It just is hard getting better.. even after 23 years...
hang in there. You did your best which was a darned sight better than many!