Update on: Sometimes you lose... (see bottom)

I've been feeling like a rock star surgeon since I arrived at my job. I've had multiple GDVs, c-sections, exploratories, a GI intussusception, and the like. All are alive and kicking!

Last week, I saved a dog that had been hit by a car with a terrible diaphragmatic hernia. Her lungs and heart were being crushed by her spleen, stomach, and liver. Despite her unstable condition, I had to take her to surgery. 3 chest tubes and a diaphragmatic hernia repair later, she is doing great. Despite the odds, she survived!

On Saturday, I took a headless teddy bear out of patient's intestines after she'd been vomiting, lethargic, and depressed for a week. She's doing great, as well.

And finally, my liver lobectomy/giant tumor removal is 2 weeks post op. He is doing great, already feeling good again. His kidney values are improving, he is eating, and his sutures are out. He is recovered.

Those are 3 difficult surgeries. Two of them had guarded to poor prognosis...and yet, they are all alive today. I can look at them and say without a doubt that I saved them.

Yet today puts all of that to the back of my mind. You see, my patient from today is not alive. No, I do not blame myself. Her owners allowed her to roam free, and she was hit by a car. By the time she got to me, her condition was extremely, profoundly terrible. I gave her owners a less than 5% chance for survival, even with surgery. Still, for now, I'm going to sit here and review what I could have done differently for this dog and whether it would have made a difference or not.

She was a large breed puppy (less than a year). She came in after being hit by a car. Her gums were gray-purple. Her systolic blood pressure would not register. She was in profound shock. Her pelvis was broken. She had a pneumothorax. Her condition was grave.

Her owners told me to do whatever it took to save her. Money was not a concern. They plopped down $2100 without batting an eye. So, I went to work. I pumped her full of fluids - crystalloids and colloids. I tapped her chest, eventually placing a chest tube. I was aggressive.

When I checked her initial PCV (packed cell volume), it was 28%. She was losing blood somewhere. When I popped the ultrasound probe on her belly, it was abundantly clear where the blood was going -her belly. My techs wrapped her back legs and abdomen in tight bandages (shock pants). I gave the owners the bad news. We would try to stabilize her, but it was looking like surgery was in her future. When her blood pressure refused to rise above 50 despite massive fluid boluses, and her PCV plummeted to 14 with a total solids of 2.5, I knew we had to cut.

I found the bleeding within 25 minutes of getting into her belly (it took that long to suction out the 2 liters of hemorrhage). One of the liver lobes deep within her abdomen was terribly lacerated. I would either have to perform another lobectomy or find a way to suture the torn liver. Meanwhile, blood continued to pour into the abdomen. We autotransfused her, but the blood just kept pouring out of the liver, as I tried to fix it. My patient's status deteriorated rapidly. Despite the unbelievably low anesthestic level (0.2% sevo!), crystalloids, Hetastarch, and autotransfusion, she could not maintain her blood pressure. I tried everything I could to get to that liver lobe to repair or remove it. I couldn't. At least, I couldn't before she died.

Now, I sit here and question. Should I have tried to get her to the specialty hospital? Should I have hoped the shock pants and pressure wrap would stop the bleeding and held on going to surgery? Did my handling of the liver worsen the damage already done? Would she have bled to death had I waited? Could she have been saved in the first place? Had another ER doctor been there, would she still be alive?

I think I need to rest now. I've been up since 7am this morning, left work well after midnight, and have 2 more nights of work before I get a brief break.

Update: after dealing with this horrific case, I made a plea to our board members for a cautery unit. Cautery units are machines used in surgery. They are great for stopping bleeding, because they cauterize vessels. I'm not sure it would have made a difference in this patient's case, given the extent of injury, but one of the biggest difficulties with this surgery was trying to get the hemorrhage under control. Our board members approved a cautery unit, and it arrived just a few days ago! Yay for improving our standard of care. I am very happy with the hospital where I work, and I am continually pleased by their interest in doing the best we can for our patients!