Thursday, May 14, 2009

surgery and the contradictions contained therein

i did 3 surgeries in my 5 nights on emergency duty.

the first was a 3am arrival - a bitch having her first litter. a puppy was stuck in the birth canal. on pelvic exam, i could feel the puppy stuck in the cervix (which was fully dilated). xray confirmed that the puppy's head was far too big to come through. i had to do a c-section. the owner refused to let me spay the dog - which was extremely upsetting - given that the dog will likely continue to need c-sections every time she is bred. i tried to talk the owner into it, but she wasn't having it. it was a particularly gruesome surgery. i was forced to decapitate the fetus in utero, push the body through the birth canal, and take the head out through my uterine incision. the mom recovered well but had no puppies to show for it (the other could not be resuscitated).

day 2 was another cystotomy. this little guy had about 18 stones in his urethra blocking urine outflow. he did not feel well at all. his owner was a pediatrician, and i really liked her.

day 3 brought the badness. a little yorkie showed up. she belonged to a woman who was good friends with the vet that had sent the dog over. this was sunday night. on thursday, the dog became lethargic, had diarrhea, and stopped eating. she saw her vet on saturday and was prescribed cerenia (an anti-emetic). no xrays or bloodwork were done. on sunday, she saw that vet again at home, and the vet noted abdominal pain. she was turfed to me. xrays revealed 3 foreign bodies - all appearing to be hair elastics. the kicker? this owner KNEW the dog ate things ALL THE FRIGGIN' TIME that she shouldn't. the vet that sent her to me knew it too. at any rate, we went to surgery, and i had to remove about 2.5 inches of small intestine, as well as do a gastrotomy (incision in the stomach) to remove the hair elastics.

linear foreign bodies are really bad. they get hung in the stomach or upper small intestine, and then the intestines try to move around them (peristalsis). since they can't move the rope/string through, they bunch up around the string. as a result, the intestines essentially get terrible rope burn, and often, the string will chew right through the intestines. having that going on for 3 days isn't good. it's very very bad.

yesterday, she developed post-operative peritonitis and was euthanized. i don't know why exactly. it's possible that i misjudged the viability of some of the gut and left stuff that should have come out. it's possible that the anastamosis site (the area i sewed back together) leaked. it possible that she developed a post-operative infection from bowel contents getting into the abdomen. the owners wouldn't let us go back in and try to fix the problem, so i'll never know if it's something that i did or something that would have happened secondary to all the damage that was done by the string.

and the second kicker? since these people were friends with the vet that sent the dog over (coincidentally the founders of our clinic and presidents of the board), i'm being held over the coals because i'm an intern - and i'm not supposed to be doing surgery alone! i almost fell over laughing when i heard that statement. i've done more than 50 surgeries this year - almost every single one alone. and i have a very good success rate. i've lost 3 prior to this - and all have had terrible, terrible diseases and/or injuries and would have died regardless. also - consider that i am no longer an intern in 1 month and that i have been hired to be an ER doctor for a large salary!

the whole thing is stupid and overblown. the dehiscence rate for GI anastamosis and resection is reported as high as 16%! it's not an easy surgery, it's not always a successful surgery, and this dog had a LINEAR FOREIGN BODY FOR 3 FULL DAYS before it came to me.

all of that seems irrelevant to the fact that i'm just an intern.

is it possible that i messed up? yes. is it possible that i left tissue that i should have taken out? yes. but it's very, very hard to know - ask anyone who has ever done GI surgery. i worked very hard on that dog. i was absolutely attentive and spent a great deal of time trying to make the decisions as far as bowel viablity went. will i ever know for sure? no. will i learn from this? yes.

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