Wednesday, June 8, 2011

The negative exploratory

There are few things that make me as mad (at myself) as a negative exploratory surgery. How does a negative exploratory happen, you might wonder.

My patient last night was a Dachshund mix. On Monday, she stopped eating. She also became lethargic and started to act painful/tremble. This continued through Tuesday, and the owners brought her to see me early Wednesday morning. Layla had not vomited, but at home that night, she had gagged/retched numerous times.

On physical exam, Layla was a quiet but alert puppy. Her abdomen was a bit distended, and I could easily palpate a fluid-filled stomach. Xrays showed dilation of her stomach with fluid and gas. There was also a very odd appearance to the material inside the stomach. It looked like there was something in it, despite the fact that she hadn't eaten in well over 36 hours. Her intestines were normal.

I sent her xrays to a radiology reading service, and they agreed that a partial obstruction was an important consideration in Layla.

I talked to the owners about her condition and recommended exploratory laparatomy. My first mistake was not giving them option #2 clearly. Option #2 would have been IV fluids, monitoring, and transfer to her regular veterinarian in a few hours for re-evaluation. There was nothing in Layal's physical exam that made me think she COULDN'T wait. It was already 4am. Yet I more or less told the owners that ex lap was warranted. I believed it too. I had no doubt I would open up that abdomen and out would pop an obstructed stomach or upper duodenal foreign body.

Prior to surgery, we ran bloodwork. In a dog with an upper GI obstruction, there will often be a metabolic alkalosis - the pH of the blood will be high, with a concurrent drop in potassium and chloride (from vomiting usually). Most GI obstructions will also show a significant amount of dehydration. This is determined with a PCV/TS.

Layla's pH was normal, as was her PCV/TS. Alarm bells rang faintly in the back of my head. Mistake #2 - not listening to the alarm bells.

I went back to the xrays. Highly suspicious. Layla was lightly sedated for her xrays, so I palpated her abdomen again. Fluid in the stomach, possible obstruction high up under the ribcage. I felt confident.

What did I find in surgery? Nothing. Zilch. Nada. The material seen on xray of the stomach was a mass of bubbles and frothy fluid. No foreign object. The intestines were not moving, but they were not obstructed.

I was furious with myself. The owners had plunked down $1400 for an exploratory surgery, and what had I done? Put their dog through a needless surgery. I had neglected to offer option 1 and ignored the alarm bells when they rang. Granted, it was 4am, I was tired, and it had been a long night - but still, no excuses.

We were taught in vet school that if you aren't doing negative exploratory surgery, you aren't doing enough explores...but it's no consolation when you're staring into a perfectly normal abdomen, beating yourself up for making the wrong call.

On the bright side, Layla's owners were lovely people and pleased to find out that there was no obstruction that needed to be removed.


Elizabeth said...

So did you find out what was wrong?

Anonymous said...

Oh heavens! I think you were RIGHT to explore! Can you imagine if you offered to let them wait and there WAS something in there? As a client, I'd be absolutely thrilled to have a negative exploratory on one of my pets. It's one more thing that can absolutely be ruled out.

IMHO, you did everything right. It's just hard not to second-guess yourself. You're an awesome vet, give yourself some credit, ok?

--faithful reader, vet assistant and pet owner

The Homeless Parrot said...

Elizabeth: No, I did not. I recommended that the owners follow up with their veterinarian for testing to r/o Addison's disease - since the dog was a young, spayed female. I'll let you know how she does.

Elizabeth said...

Anonymous, you are so right, I have seen several dogs die having been sent home to wait it out. By the time surgery was done it was too late. I know it is frustrating not to have an answer but better to have things ruled out then to be sent home and die from an obstruction..

Elizabeth said...

HP- well there are much worse things than Addison's :) I am grateful that is what my boy has and it is easily treated unlike many other things.

ERDOC said...

HP, you have no idea how much i needed this post. Just went through the same thing today, just about to write about the same thing. Negative explore today, and I was pretty sure that the rads AND ultrasound were obstructed. Biopsy pending, dog doing well. bummer anyway.