Monday, December 6, 2010

Weekend wars

This weekend brought unbridled chaos to the ER, including multiple traumatized and sick patients all in a 20 minute span and a man that had a stroke in our lobby in the midst of all of this. I wish I was making that up. To top it off, I managed a case that would have benefited from a university setting and the services of a criticalist.

Friday afternoon, I was transferred a post-operative case to care for. Lilly, a 7 month old shepherd cross puppy, had suffered a GI intussusception (remember the scary surgery from this post?). Her vet had gone in and was forced to remove 5 inches of colon and 6 inches of jejunum. As I've said before, cutting into the colon is a terrifying process. It doesn't heal well. It's full of nasty bacteria - even worse than the small intestines. You're taught NEVER to do it, unless there is no other choice. In Lilly's case, there was no choice. Her colon was dead.

Her first 20 hours with us were uneventful. She was bright, alert, and playful. Then, her temperature skyrocketed to 106 degrees, her blood glucose dropped, she became lethargic and painful, and I could feel a wave of fluid in her abdomen - all signs of a suture site failure. Having your intestines leak feces into your abdomen is possibly one of the worst things - sepsis rapidly sets in, followed by SIRS (systemic inflammatory response syndrome), ARDS (acute respiratory distress syndrome), and MODS (multi-organ dysfunction). Blood pressure, blood sugar plummet. Heart rate skyrockets. The patient becomes non-responsive, often starts vomiting, and eventually lapses into a coma unless the leaky bowel is fixed.

We treated her aggressively with fluids, flooding her with crystalloids and colloids. I called her owners. No answer. I called again 15 minutes later. No answer.

For the next NINE hours, we called the owners, unable to get in touch with them. Lilly needed surgery, and she needed it IMMEDIATELY. As the nine hours passed, I watched her deteriorate from stable enough to survive surgery to circling the drain. I felt a panicked, clenching sensation in my chest as the hours passed. I was helpless. Lilly needed surgery to fix her leaking bowel, but I couldn't do it without the owner's permission. So we waited.

At 4am, the phone rang, and I snatched it off the wall. I explained to the owners Lilly's condition. At this point, despite massive, massive quantities of fluids (far beyond anything I've ever administered) and vasopressors (dopamine) Lilly's blood pressure refused to rise above a mean of 40 (necessary is 60). Her white blood cell count was down to 2000. She was non-responsive, her blood glucose dropping without constant supplementation. I gave the owners a less than 5% chance with surgery.

Despite this, and the huge financial commitment that taking on a second surgery and long, long recovery (if it happened at all), the owners wanted to go for it.

To my enormous shock, in surgery, her intestines looked good. The surgery site had ripped open completely. However, Lilly hadn't eaten in several days, so there was virtually no fecal matter in the abdomen. Further, the omentum had walled it off. The rest of her bowel was pink. Inflamed, yes. Not moving, yes - but pink and NORMAL!! I cut out the surgery site and sewed the new, fresh ends together. I removed the 3 liters of fluid that had filled her belly as a result of the inflammation. I placed 2 Jackson Pratt drains in her abdomen so that we could lavage and empty her abdomen after surgery. I stapled her up.

Lilly's blood pressure was terrible during surgery. Yet, she survived. She woke up from anesthesia - much to our shock. And then she took another turn for the worse. She developed respiratory distress, which we combated with nasal oxygen. Her clotting times went off the chart - a combination of the massive doses of Hetastarch (a type of fluid) she received and disseminated intravascular coagulation (see sidebar). We poured the plasma into her. Her BP plummeted, and HR rate skyrocketed. Fluid began to pour out of her nose due to her ARDS. She regurgitated fluid constantly.

Still, she hung on.

For 2 days, a technician was by her side constantly, monitoring blood pressure, blood glucose, heart rate, rotating her, suctioning her abdominal drains, cleaning her up when she urinated, talking to her and calming her when she woke up from her intermittent sedation, cleaning her nose, adjusting her fluids for me, letting me know if she had the slightest change in her condition.

I told her owners, prepare for the worst. And yet, Lilly hung on.

This morning, we converted my Mercedes SUV to a pet ambulance complete with oxygen, a gurney, and fluid pumps. I drove her myself (with my tech riding in the back) to the 24 hour specialty clinic.

On the way, she continued to regurgitate, and she aspirated the material for the first time. On arrival, her oxygen saturation had fallen from a perfect 100% on oxygen to 80%. She began to breathe harshly, and fluid flowed from both nostrils. My heart sank.

I accompanied the ER doctor into the room to deliver the bad news to the owners - who had already poured $5000 into her care. They were distraught, but they wanted to give her a few hours to see if she would stabilize.

And again, she did. Tonight, she is at the 24 hour hospital, oxygen saturation back up to 95%. She is hanging on with everything she has, fighting for her life.

It is amazing what this dog has survived. I cannot bear the thought of her dying after all of this. Yet, we still have to wait. We have to see if her lungs can recover from ARDS, her body from sepsis, and whether or not her intestines can heal together in the face of overwhelming systemic infection.

For 3 days, I kept her alive. I am not a criticalist, I would never fool myself into thinking that I am that good - but dammit, for 3 days, I kept her alive - giving her the chance her owners wanted to. Whatever happens, I feel like a damned good doctor this weekend.


Anonymous said...

I had a client have a stroke in our waiting room once! The EMTs made some clever comments about the person's "choice" of location - I was not amused.

Holly said...

Holy Moley! You just never know which animals will fight like L and which should recover and don't. Please update when you know what happened. I'm pulling for the plucky little dog! Do you know what happened in the beginning to cause this?

Karen w said...

Please keep us updated. If life were fair, a fighter like this dog would live. Hoping that's the case.

Mary said...

Great job!

voguevet said...

Wow, impressive work! I'm also impressed at your success in keeping up with your blog throughout the years. Any tips for a budding vet student blogger?


Elizabeth said...

Any news on Lilly?

The Homeless Parrot said...

Holly: no, we don't know the cause. Many dogs start out with diarrea, and the supposition is that the constant straining leads to the intussusception. It's a somewhat common occurrence in parvo puppies. As to why some dogs develop it and some do not...?