My first "rotation" back has been a combination of insanity and utter boredom. This weekend has been dreadfully slow, but the past week was full of crazy surgeries and sick patients. Balancing motherhood and work is difficult, as I expected. What is not difficult is pumping milk. I thought that I would have a hard time, but that part of the transition is going very smoothly. Evaline has also graduated to sleeping in her rock-n-play, a small, cradle-type bassinet. Of course, when I'm home, she sleeps in bed with me. I have to take advantage of all the snuggly baby time I can get!
On the work front, I was faced with 2 very difficult scenarios this week, both placing me between a rock and a hard place. Having been away from work for 2 months, my decision-making skills were a bit rusty. I also find myself equivocating more. Decision making has been become very difficult. I don't know if this is sleep-deprivation or something else.
In one case, I was faced with a very elderly (15 years old) large breed dog with an abdomen full of blood. Common sense told me that this was in all likelihood a ruptured abdominal tumor - likely splenic or liver. I expected the owner to choose euthanasia, but he opted for surgery instead. Despite finding that the dog was suffering a coagulopathy (difficulty clotting his blood), the fact that he was very old, and likely suffering a seriously malignant cancer, the owner wanted to give him the chance for some more time at home.
I offered referral to a specialist for the surgery, as I was unsure what I would find surgically. A ruptured splenic mass is no problem. A ruptured liver tumor is another story altogether. The owner debated for a while, but he eventually elected for me to do the surgery.
To my dismay, it was a ruptured liver tumor. Large, necrotic, and friable, it was growing on the right caudal liver lobe. Thankfully, it was easy to expose that part of the liver. Unfortunately, it had metastasized throughout the mesentery (fat cushioning the intestines and providing blood flow), and the spleen had several large nodules. I wrestled with the decision of whether to recommend euthanasia for metastatic cancer or to do what I could.
The dilemma here is that all hemangiosarcomas (the most likely tumor type) have metastasized by the time of discovery. They are incredibly aggressive tumors. In some cases, the metastasis are microscopic, and in some cases, they are macroscopic/grossly apparent. Most people will recommend euthanasia for grossly metastatic cancer. In this case, I was really conflicted. The owner wanted more time with the dog. He wasn't under any illusions that the dog would survive long, but he wasn't ready to say goodbye.
With that in mind, I set to work removing part of the liver. That in itself was a challenge, as I'd never done a partial liver lobectomy before. Once the tumor was out, I removed the spleen too. Finally, I went through the mesentery and removed the small nodules, as well as one very large (lemon-sized) tumor. I flushed his abdomen, said a little prayer, and closed him up.
He woke up very slowly. Blood started to ooze from his incision (not surprising, given his high clotting times). It took him a long time to even lift his head up. I was not optimistic. That morning, my technician and I transferred him to a nearby day clinic. He spent the day getting blood/plasma transfusions, then was transferred to the specialty clinic the next day.
The amazing part? Yesterday, he was barking, whining, eating, and acting like a totally normal dog. He went home with his owners to spend whatever time he has left at home. As usual, I question whether I did the right thing. Should I have woken this dog with obviously metastatic cancer from surgery? Should I have euthanized him on the table? Should I ever have done surgery in the first place?
Right now, I feel good with what we did. He's home with his owners, eating and acting like a normal dog. He probably doesn't have long to live, but he's home for the holidays, and that's what matters.
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