Thursday, May 14, 2009

on complications

one of the most difficult parts of my job is figuring out when i did something wrong versus when i did everything i could and the inevitable just happened.

on sunday last week, i was presented with a dog that had a possible foreign body. her owner - we'll call her ms smith - was very good friends with a veterinarian (also a shareholder in our clinic). dr X saw the pet on saturday for lethargy, diarrhea, and anorexia of 2 days duration. no diagnostics were done, although the owner reported that "pup" had a bad habit of eating things he shouldn't. dr X prescribed an anti-emetic and sent the dog home. on sunday, she saw the dog again and noted cranial abdominal pain. the dog was sent to me.

xrays revealed at least 3 foreign bodies in the stomach and small intestines - hair elastics.

foreign bodies in dogs can run the gamut from bad to really, really bad. in this dog's case, we were dealing with a linear FB (the worst). your intestines are always gently (and sometimes not so gently) squeezing in a direction away from your stomach. this is called peristalsis and it moves in waves through the intestines. if a dog eats a string that gets partially hung in the stomach, but much of it passes through into the intestines, the intestines will continue to squeeze along. however, they won't be able to move that string, so they will bunch up on the string (just like the drawstring on your pants will do). eventually that string will saw right through the delicate gastrointestinal tissue, leading to spillage of feces into the abdomen. linear foreign bodies are BADNESS - especially when they've been present for THREE WHOLE DAYS.

i took the dog to surgery and removed 2 hair elastics from the stomach, as well as a mass of carpet like material. one of the hair elastics passed into the intestines, and due to the damage done, i had to cut out about 2 inches of small intestine.

24 hours post-operatively, the dog became horribly depressed and began vomiting. the owners refused to go back to surgery to let us find out what was going on. they elected to euthanize and take the body home.

i am left with the following options:

1) my surgical site failed and leaked into the abdomen
2) contamination of the abdomen during surgery led to peritonitis
3) the bowel that i thought appeared still viable was in fact too damaged to survive

the real kicker?

the vet that referred this dog is throwing a fit that i (yes, ME) did the surgery. supposedly i'm not supposed to do surgery - since i'm JUST an intern. no matter that i'm 1 month from the end of my internship, that i've done many of these surgeries (probably more than dr X has this year) - hell, i've done more than 50 surgeries this year, some much more complicated than that, that i've been hired as an ER doctor already to do just this kind of thing, and finally - the fact that this was a LINEAR FOREIGN BODY THAT HAD BEEN SITTING THERE FOR 3 DAYS! i'm being raked over the coals for a complication that has been reported to occur in up to 16% of these patients post-operatively.

in this situation, i'm left wondering: was it something i did wrong surgically? did i make a mistake and leave bowel that i should have taken out? did i ligate something that i shouldn't have? i'll never know for sure. i do know that every time i do surgery, i learn something new, i also look for my culpability, and i always take a failure (surgical or otherwise) to heart. it's hard enough to learn and forgive yourself without other vets ganging up on you!

but i'm a big girl, and i can handle it.


Anonymous said...

You caught the other doc's error and he's reacting to this, therefore, the best thing for him to do is make it your fault and throw a hissy.
I'm not a vet but it sounds like you did all you could and the outcome was inevitable.

Nicki said...

Not knowing is always crappy. My hospitalized patient died unexpectedly overnight. Did I miss something, was it sicker than I thought, or was it something we really couldn't have anything about. It's still tough but you just gotta trust yourself sometimes. You can only do what the owners will let you.

alana schmidt said...

I think that you did everything that you could and things sometimes are meant to happen. I really like your web page and you are doing a wonderful job for the animals. I have always loved animals and I now have my own blog also. It is

Mara said...

Yeh, with me, interns are not allowed to see any cases directly referred over from the regular vet. Because the reg vets think that someone who is almost done with an emergency internship has no idea how to correctly treat their patient who has an emergency. Crazy.

Homeless Parrot said...

vets are not very cohesive as a group, i've noticed. it seems like vets want to tear down other vets at first opportunity. it's kind of frustrating.