Thursday, August 4, 2011

$2400 later, here's your dog in a box.

I simultaneously love a challenging case such as I had last night and hate it (when they end badly). At around 7pm, I was presented with a small breed dog suffering acute onset of abdominal pain, vomiting, diarrhea, lethargy, anorexia, and fever. On physical exam, the dog was very, very depressed, had extreme pain associated with abdominal palpation, and was spewing foul diarrhea from its rectum. I recommended bloodwork and xrays to the owners.

Bloodwork showed sepsis (white blood cell count was 1400, normal is 5500-16,900), slightly low platelets, borderline hypoglycemia, and dehydration. Xrays were what really concerned me. There appeared to be fluid in the abdomen. Even worse, there was a pocket of what looked like free gas sitting up next to the kidney. No animal or person should EVER have free gas floating around inside the abdomen - not unless they've recently had abdominal surgery or a penetrating abdominal wound such as a gunshot.

I was very concerned and discussed my findings at length with the owners. Surgery was definitely indicated, as this little dog had likely perforated an intestine or his stomach. After looking at a sample of the fluid in his belly, I was confident. First, there should be no fluid in your abdomen. Secondly, if there is, bacteria should not be present. This dog's abdominal fluid was loaded with tons and tons of bacteria - another sign that the GI tract was leaking.

In surgery, I found inflamed, not moving intestines. The abdomen was full of fluid and feces. Once the intestines were out, I found a large, oozing hole in the cecum - a section of intestine between the large and small bowel. I had no choice but to remove that area and anastamose the small intestines to the large intestines.

My patient was doing very poorly under anesthesia. Her blood pressure would not stabilize, no matter how aggressively we treated. Her intestines were not moving, and the fat supplying blood to the intestines (mesentery) was inflamed terribly. There were also hardly any pulses in the mesentery.

Shortly after removing the sick part of the intestines, my surgery site started to turn purple, then black,. Within five minutes, it was just lying there, flaccid and purple-black. I knew that the site was dying. So I removed it and did another anastamosis. Five minutes later, the same thing happened. At this point, I had removed >60% of the small intestine (dog only weighed 6 pounds). Every time I touched the intestines, they died.

I knew what I was looking at - sepsis, hypotension, and DIC likely secondary to the sepsis and shock. These intestines were not going to live, no matter what I did - and especially not in the face of low blood pressure and DIC.

Scrubbing out, I called the owners and gave them the grave news. They wisely elected to not wake up the small dog, as she would have suffered heinously before inevitably dying.

It was a very interesting case with a very, very sad outcome. My inability to save the patient despite my best efforts was crushingly disappointing, as usual. And the owners, of course, were the nicest people on the planet.

Welcome back to work!

1 comment:

nagonmom said...

This happens in people as well, usually secondary to horrid blood supply to gut. You gave it your best shot, and the dog did not emerge from anesthesia to suffer.
Quit blaming yourself for your GD, you wouldn't blame your patients for their illnesses, would you? (except the ones that eat tennis balls, cat food cans, etc. As long as you aren't eating tennis balls, cut yourself some slack.)
And funny thing, I am a retired physician who likes reading the vet stuff about my animals. So it goes both ways. And yes, you have to be proactive, aggressively so, in managing your healthcare. No one else will. I enjoy your blog, but it evokes my nag reflex something fierce!