Thursday, July 2, 2009

Not with a whimper, but a bang

My "last" night at RIVER was exactly as I imagined it would be...crazy.

I say "last" because I might be picking up relief shifts here and there during July to pad the old bank account. On the other hand, I might just decide I'm finished and give myself 2 weeks off before the moving (?) fun commences. We'll see. I have a sneaking suspicion I'll be working.

Last night was unbridled chaos. Case of the night is as follows:

A cute, 1 year old female spayed dachshund/corgi/bassett mix presents for a 1 hour history of ADR. The owners reported that she was unusually lethargic. She was outside, in a fenced yard for several hours, and when she came in, she just wasn't herself.

When I saw her, she was quiet but responsive. Her gums were pale, and her belly was mildly distended. Otherwise, she was normal. Her abdominal xrays were strange. She had a loss of detail on xray (usually meaning free fluid in the abdomen), as well as a collection of gas bubbles up near the liver/head of the spleen/stomach. The radiologist's best guess was a liver abscess. I ultrasounded her to find a moderate amount of hemorrhage in her belly but no clear source.

I was perplexed. Why was a 1 year old dog with no history of trauma bleeding into her abdomen? Clotting times were normal, so rat poison was out. I gave the owners the options: wait and monitor, if PCV starts to drop/hemorrhage worsens, go to surgery or go to surgery now. We chose the wait and see approach.

At 4am, after fluids to stabilize her and rehydrate her, as well as injectable opioids and acepromazine...her heart rate was still 180 (very high). On a whim, I checked a lactate. I was stunned to find it was 10 (normal up to 3). Lactate is an indication of anaerobic metabolism (no oxygen). When elevated, it often indicates that somewhere in the body, some unlucky organ is suffering hypoxia (lack of oxygen) and switching to anaerobic metabolism to produce energy. I called the owners and told them I was going to surgery to find out exactly what was going on in their dog's belly.

To my surprise and patient had somehow managed to lacerate one of her liver lobes. An enormous blood clot was sitting on top of it. After examining it, I decided a partial liver lobectomy was in order. Terror set in. I'd never done one of these before, and OF COURSE, it was the hardest liver lobe to access, as well as being closest to the vena cava. Two and a half hours later, and a massive amount of sweat, adrenaline, and near wetting myself terror later, the lobe was out, and my patient was recovering.

Today, her lactate is 1.4. She is eating, drinking, and urinating. In another 48 hours, I can call this surgery a success. Until then, I will not relax.

And I'm left with this question: how, precisely, does a dog manage to lacerate JUST its caudate liver lobe without a single bit of evidence for external trauma?

Second interesting case of the night to come later!

1 comment:

Nicki said...

my HOUSECAT had a diaphragmatic hernia (and not a congenital one) last year. No clue.