Thursday, July 9, 2009

Interesting case numero dos

So, on my last night of relief, after deciding to head to surgery on my liver laceration dog, the scene as follows:

I'm sitting up front, typing notes frantically and talking a mile a minute to 2 women about their dog that managed to ingest a large quantity of chocolate. Mid-sentence, the code alarm goes off. I bolt from my chair, leaving them staring after me.

As I barrel into ICU, I'm faced with this picture: a 120lb Bernese mountain dog, laterally recumbent, non-responsive on a gurney. Techs are scuttling in every direction, gathering monitoring equipment, a laryngoscope, and drugs.

I check for a heartbeat and find a rate of about 180 (extremely rapid for a dog this large). Her gums are tacky and bright red with a slow capillary refill time (significant dehydration/shock). Blood pressure is low at 70/40 (normal should be around 120/60). Blood glucose is also low at 45 (normal 70-100).

The owner meanwhile is rattling off the story. On Sunday, this dog was seen at our clinic. The ER doctor suspected a foreign body in the intestines. A contrast study revealed a possible obstruction. The owners wanted to wait till Monday to take the dog to their vet for surgery. On Monday, the dog transferred. For some reason, surgery was delayed until Tuesday. When the surgeon went in, she found a corn cob lodged in the intestines. After 6 hours of surgery, it was out. The intestines LOOKED viable and nothing was removed. Now, it was Tuesday night/very early Wednesday morning -and the dog was non-responsive.

With a low blood glucose, low blood pressure, and significant dehydration, I suspected that the intestines were dying post-operatively (as happened to me recently with a linear foreign body surgery). I checked a lactate (a measure of tissues being deprived of oxygen). It was 4.8 (normal up to 3). This is elevated but not terribly.

I explained all this to the owner, and she understood. We talked about intestinal necrosis (death) and sepsis (overwhelming systemic bacterial infection as a result of the dying GI tract). I explained that I suspected this was going on and that - in all likelihood - a second surgery would be required.

The owner understood, signed the hefty estimate I gave her, and left her dog in my care.

For the next few hours, I worked on stabilizing the dog. I got her blood pressure and blood glucose up, as well as her heart rate down. Her hydration status improved. I was on the fence - go to surgery now or wait? As the only doctor in the building, I had no one to bounce my question off I went back and forth, back and forth. Finally, I called the big wig ER doc and asked her opinion. She told me to wait until the dog was more stable. So I waited.

The following morning, her lactate continued to climb, and her shock returned. Surgery revealed death of the great majority of her small intestine. The surgeon removed 5 FEET of her intestines. Sadly, she died later that day.

I doubt had I taken her to surgery a few hours earlier, anything would have been gained. Sometimes the intestines are insulted too much to ever recover.


Elizabeth said...

If they had only allowed the surgery to be done when the ER doc found the obstruction (sigh)...

Hermit Thrush said...

These are interesting cases. I once (as a tech) saw a similarly puzzling liver lac case. A small dog, yorkie, with no history of trauma. It was the first case of one of our new ER docs and she figured it out in no time and took the dog to surgery and it did great (we were all impressed). Also saw a very sad case like this where surgery on a FB was delayed by the RDVM and by the time we went in it was too late.