Tuesday, January 12, 2010

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!


Elizabeth said...

You have every right to feel great about the saves!

If you hadn't gone in and the dog bled out you would feel worse. No matter what you do in these situations you will question what you did or didn't do.

Hermit Thrush said...

I think it is good to mentally review cases that don't have good outcomes so you can learn from your mistakes. However, many times you will not have made any clear mistakes. I strongly suspect that this case falls into that category.
I don't think pressure wraps on the abdomen would have stopped the bleeding or slowed it enough to make a difference. I think going to surgery was the right decision. And perhaps no matter whose hands this dog was in, there would have been a bad outcome. The trouble is, you'll never know because there is no way of ever knowing what would have happened in an alternate universe that doesn't exist.
Thinking about these 'what if' scenarios can drive you crazy. It can shake your confidence and make you doubt yourself. I know it's hard, but I try not to dwell on the 'what ifs.' It's not your fault this patient died. You are practicing high level medicine and you made your best judgments on treatment. Sometimes that's not enough. And it really doesn't have to reflect a failing on your part.

Amy said...

C you are a wonderful vet and I love you... but you are not God. You will never be able to always save every animal no matter how perfectly you suture a liver or set a hip. I honestly feel that no doc could do a better job, and sometimes the animal will die no matter what you do for it.
Review the procedure and look at the "what if"s, but only to better yourself as a vet doc and to better understand your own reasoning. Just remember you ARE a good doc, and though it feels like it you don't always hold the ultimate power of life and death in your hands.

Nicki said...

I don't think a pressure wrap would have been enough in this case. Doesn't it suck that one bad case makes you forget all the good ones. I neutered an older large breed dog for a friend this week and of course got a scrotal hematoma. I know it's just because he's a 6 year old 100 lb dog but it still makes me feel bad. Last scrotal hematoma I dog was also on another large breed older dog for a friend. Ugh! I have a huge respect for ER vets. It's not something I'd want to do, even when vax and anal glands get boring!