Sunday, October 24, 2010

The art and the science

One of the myriad tasks a veterinarian is faced with is deciding when to try and fix a patient and when to offer euthanasia as an end to suffering. Since I am a doctor of veterinary medicine rather than a human doctor, I have the option (a blessing) of offering a humane end to pain. I rarely have to stand by and be party to endless, pointless treatment while a patient suffers. It's one of the reasons I am glad to be a DVM versus an MD. However, making this decision is an art and not a science. We're not always right. Sometimes we're very, very wrong.

Saturday night was one of those awful nights where I was faced with trying to make the best recommendation for a horrifically injured animal. "Smidge" was an 18 pound mixed breed poodle dog. He'd been used as a tug-of-war rope between 2 much larger (>60 pound) dogs. When he presented to me, a loop of intestines was hanging out of his side. He had an extremely large, palpable hernia running down his body wall. I couldn't quite tell the extent of it, but I knew it was bad.

Surprisingly, despite his grave injuries, he was fairly stable. Other than a mild blood loss anemia, his bloodwork was shockingly normal. His white blood cell count had not dropped yet, his kidneys were hanging in, and his liver and pancreas seemed to be doing ok. The loop of intestine that was hanging outside the body was still pink and actually contracting. I had high hopes for being able to save him.

I counseled his owner at length about the severity of his injuries and the need for immediate surgery. I reiterated his critical condition. They were torn. Spend $2500-3500 on emergency surgery and critical care with a 50/50 chance? Euthanize? They asked me what I would do, and I told them truthfully that I would do surgery on my pet in their situation. I was careful to explain though that I would do so knowing that death in 1-3 days after surgery was a very real possibility due to systemic inflammatory response syndrome, sepsis, acute respiratory distress syndrome, and multiple organ failure. After much discussion, they elected to proceed.

In surgery, I started by going in through the belly and enlarged the first hole I came through (the one through which the intestines were sticking). I pulled them through and looked at them. Unfortunately, they'd started to turn purple and had stopped moving. As a result, I resected (removed) about 6 inches of bowel and sewed my ends together. I then closed the part of the hernia I could get to with the dog on his back. Everything else in the abdomen looked ok. BUT...I couldn't find the right kidney. I dug and dug. I couldn't find severe hemorrhage anywhere to indicate that the kidney was avulsed. I knew it must be herniated near the dog's back. So we flushed the abdomen, and we sewed him up. Then we rolled him over to approach the rest of the hernia from the back. And that was there things went downhill.

I took my scalpel and opened up the puncture wounds on his back. My jaw nearly hit the floor. He was ripped open from his spine all the way down his body wall to the abdomen almost. How I had not seen that from inside the belly, I'm not sure. He looked like he'd been torn literally in half. The right kidney was poking up through the hole, as were the intestines. There was NOTHING left of the body wall.

I knew then that it was bad and that my patient stood less than a 5% chance of survival. Still, I gave it my best - sewing torn muscle bellies and fascia together, and poking the kidney and intestines back into the body. To orient in that picture - the dog's head is to the left. The purply thing at the top of the hole is the kidney, and next to it are loops of intestine. You're seeing basically a hole in the dog lying on its stomach/side.

In the end, he survived 2 hours post-operatively until he went in acute respiratory distress and died. The owner wisely elected not to perform CPR.

I felt terrible and moped around work the rest of the night. I felt I had wasted $2800 of the owner's money, put their dog through misery and pain, when I should have recommended euthanasia from the start. The surgery was way above my head - although, truth be told, it was far above anyone's head. There was nothing to fix. The dog had been crushed into unidentifiable fragments of meat. It was horrible.

Hindsight is always 20/20, but somehow, that is no consolation.


Holly said...

Dear God......what a horrible horrible thing to happen to ALL of you.

I am sure that I would have elected euth had I been the owner, but then I also would have HAD to, as I don't have over $2k to invest in a dog.

As I said in another post to an MD. You will never forget this lesson. The next time a patient presents this way, you will remember this dog, and these owners. It may not happen for another 10 years, but you will use this dog and this situation next time.

I am so grateful that you post these scenerios for me. You not only helped this dog/family, but you also help me to define more clearly what factors I will use when presented with life care decisions for my pets.

Elizabeth said...

I have seen this with human medicine and they have much more equipment to use right away and still many times you do not know the extent of the damage until you start cutting.
Had I been the owner I would have wanted you to give it your best shot and that is what you did.
They knew the risks "as you saw them" at the time. You don't have a crystal ball..

Outrider said...

Wow. That's a nasty injury.

I'm an ambulatory equine veterinarian, so I don't perform either colic surgery or fracture repair. On a number of occasions, I've referred horses for surgery and the surgeon has discovered the horse was beyond repair once surgery began. Sometimes it's just not possible to see the full extent of the damage until you're in there.

In cases like that, the surgeon frequently scrubs out and discusses the revised prognosis with the owner. I don't know if that was feasible here, but it's an option to consider for future cases like this, because you will see them.

Of course, the surgeon charges for his or her time, but the cost is less than the initial estimate when the horse is euthanized on the table. Most owners appreciate the intraoperative option to proceed or euthanize when appropriate.

Holly said...

"Most owners appreciate the intraoperative option to proceed or euthanize when appropriate."

this. I *always* want to be advised of my options, even when I know what I will probably do.

The Homeless Parrot said...

Outrider: I did consider calling from surgery. I think the more optimistic side of my nature got the better of me. I really really wanted my patient to make it. Most of me knew that he stood no chance, but part of me just wanted to try. It was probably foolish, but as I said, it's part of being a doctor - deciding things like that. In retrospect, I should have called. But hindsight is flawless.

Nicki said...

You gave him a chance and did your best. It's all the owner could ask for, he didn't linger for days or die painfully in a ditch. It was just a bad case. Everyone feels bad when owners spend money on a bad outcome, but they know the odds.