Hit by Car Horror

No one witnessed this little fella as he was rolled over by a vehicle, but he managed to walk himself home and park himself on the porch until he was brought to me.

On presentation, he was in hypovolemic shock. He received a shock dose bolus of LRS and an anti-inflammatory dose Dexamethasone SP IV. Abdominal, thoracic, and pelvic radiographs were taken to evaluate for pulmonary contusions, internal hemorrhage, bladder rupture, pelvic fracture etc. Radiographs showed minimal sacroiliac subluxation, but were otherwise normal! When I spoke with his parents about his condition, they were ready to euthanize. But when asked my opinion, I said I would give him a shot, and they agreed!! As soon as he was stable, we were going to surgery.

Remarkably, CBC/Chem showed only mild increases in liver enzymes and a stress leukogram. Of course the CPK was high, but I expected that. We moved forward with surgery.

I was extremely worried about peri-operative hypothermia. This is a typical finding in all patients undergoing anesthesia, but more worrisome in a patient whose side is filleted open! I'm certain I don't even need to go into the potential dangers of hypothermia.

The wound was flushed with a warmed dilute betadine/lidocane solution. Walking sutures were placed to re-appose the tissue and a Jackson-Pratt Drain was placed in the subcutaneous layer. The drain was removed after 72 hours, but the deadspace continued to accumulate a lot of fluid. Hopefully that will all have resorbed by his recheck!

Saying 'Yes' to Life

iCat

Scared Away

I was on a roll. Posting cases that were interesting, complicated, and most importantly.... successful I've not posted in quite some time, due to the fact that I lost some part of my confidence. This came after I lost a seemingly healthy 4 month old chihuahua while under general anesthesia for a routine spay. As a doctor, I knew this was a risk. I discuss this risk with every single owner, but do I ever think it will happen... No. But it did.

Towards the very end of my procedure, the anesthesia assistant noted that the patient was no longer breathing on her own. After a few assisted breaths of oxygen, a heart rate was no longer audible or evident on ECG. CPR was immediately started, but corneal reflex and palpebral reflexes were gone and never returned. She also began to exude copious amounts of blood-tinged fluid from her endotracheal tube. Even after numerous doses of Lasix, she continued to show signs of pulmonary edema: decreased ETCO2, decreased O2, and even radiographically.

She eventually passed around midnight that night. It was the worst day I had experienced in a loooong time. Hence my delay in posting for a while. Just didn't have much to discuss.

Necropsy Results: death caused by pulmonary edema. Not very helpful- I knew that... but what caused the edema!?

Anal About Anesthesia

iCat

Bacterial Culture Confusion

Last week I was presented with a case of an older dog, who suddenly began to grow a lump on her head. The owner noted that the growth only took 24 hours to reach the size it was at the time of her appointment. On palpation, the mass felt fluid filled, and no puncture wounds were visible. As with all masses, I suggested a fine needle aspirate (FNA) and cytology. The FNA showed that the mass was indeed fluid filled, and it was a very hemorrhagic and appeared to have a purulent component. Due to the purulent component, I also submitted for anaerobic and aerobic culture. The fluid cytology report was very unhelpful in stating that this is a marked neutrophillic fluid with mixed inflammation.... I knew that already. The aerobic culture was negative, but the anaerobic culture left me scratching my head: few colonies of Wolinella spp. were grown on the culture media. For starters, I had never heard of Wolinella spp., and secondly, I had no idea of the origin of this bacteria. Quick and easy research showed me that this is a common pathogen found in mouths of dogs with periodontitis, but I know that this pooch did not bite his own head.... nor did he have any history of trauma or rough play with other dogs. So how do I explain this type of bacteria in this location... ??? Any ideas?

Culture Conscious

iCat

Surgical Success

I recently had a 2 year old bulldog present with two days history of not eating, vomiting a couple times, and lethargic. He appeared to be well hydrated, and acting spunky. If this was his lethargic, I was curious as to just how spunky he could be. I recommended complete abdominal radiographs as well as blood and urine tests to rule out all possible causes for the symptoms he has.

The x-rays were taken first, and holy maloly. It was the most severe obstructive pattern I have ever seen. All loops of bowel were severely dilated with an obvious foreign body right in the center of the x-ray. I showed the owner and she couldn't put her finger on exactly what that foreign body might be, but it didn't matter. It had to come out.

Oh my gosh. This is my first big surgical case. I was nervous about how this surgery would turn out... Intestinal surgery is a bit intimidating. I had to be confident that I could do it. After all- I do want to be a surgeon. I had practiced this in school, and seen a number of the surgeries performed before, but I was hesitant to trust myself.

After a pep talk to myself, and a quick glance at the surgery procedure book I scrubbed in for surgery. Once inside the abdomen, I examined all other organs to make sure they were normal. All was good. Then I started with the stomach and traced the intestines until I found the diseased tissue at the distal jejunum. Not good. There was no question about leaving this tissue enterotomy v. resection- it was dead and had to be resected.

All in all, I removed about 6 or 7 inches of intestine. I made sure to keep the blood vessels intact that would supply my remaining intestines, and watched as everything pulsed before lavaging (rinsing with sterile staline) the abdomen and closing him up.

Now for the waiting game. There is a 3-5 day window that that intestinal tissue will either heal up or fall apart. If it falls apart that means either another surgery or euthanasia, if death didn't come first. Luckily he did not vomit anymore. He began to eat, and pass feces. His temperature stayed within normal limits, and I was more than thrilled to hear that by the end of the 5 days it was taking at least 2 or 3 technicians to do any kind of treatment on this guy! He was ready to go home!

Two days after sending him home, I called to check in. He was doing absolutely perfect. Success!!!

Surgeon to Be ;)

iCat

What's This? Glossotrichia

While intubating a dog for a routine neuter today, I was quite shocked to discover this streak of hair coming from the center of his tongue. I was puzzled... was this dog grooming too much? The owner didn't mention that, nor was he missing any patches of hair.... so of course... I head to my trusty http://www.vin.com/ (veterinary information network), only to discover that this is a common finding, and it's completely normal! The hair actually originates from the tongue, and some veterinarians find that the hairy-tongue hair will actually shed right along with the rest of the hair coat. With that taken care of, the neuter proceeded as planned and without any complications.

Avoiding Hairy Situations

iCat

string-toy CAT-astrophe

Two days ago, a previously frisky 1 year old cat came into the hospital acting very depressed and looking like it was on the brink of death. While taking the history, I discover that the indoor-only cat recently escaped and spent a day or three outside. Upon his return, the owner realized the cat was very ill, as evidenced by the every-hour-for-48-hours vomiting pattern. The owner readily consented to admit the cat to the hospital for further work-up, but it only took a quick look at the radiographs to show us that we were dealing with the dreaded linear foreign body. The owner was able to tell us exactly which toy she believed to be the problem. Surgery was the only option.

Once in the abdomen, a large portion of the toy could be felt in the stomach. The long string-y portion was traceable throughout all loops of bowl with a portion even felt in the colon. A gastrotomy incision was made, which revealed a large (2cm) rubber square with a string attached. An incision was also made in the distal jejunum so that the string could be grasped and cut at that site. With careful milking of the string, and gentle traction on the rubber part, a large part of the toy was removed via the gastrotomy incision. Considering that we were taught in school to "Never Cut The Colon," and because the rest of the toy appeared to be in the colon, it was decided the cat would likely expel the rest of the contents during defecation. The incision sites were then closed up and just as we were closing the abdominal wall, I asked my colleague to attempt to retrieve the string from the rectum. I milked the string and feces further into the colon while she reached through the rectum. Success!! The rest of the toy was out!

Two days later, the cat is acting a little depressed. He is still not eating, but he's not vomiting either. A close eye is being kept on this guy. Stay tuned for recovery updates!

Waiting and Watching

iCat

Ovariohysterectomy Hysteria

If you read my blogger bio or happen to be someone that knows me personally, you know that I am not one to fear surgery. I have a healthy respect for tissue handling and the challenges that potentially may arise from a "routine" surgery, but I don't fear those situations.

Until now.

I've recently been plagued with a number of obese dogs who, as a bonus, have all happened to be in heat. I have been elbow deep in adipose tissue (fat), which makes for a very slimy mess. Think about trying to tie a knot in fishing line after lathering soap onto your hands first. Not easy. Not to mention the vessels I'm trying to ligate (stop the flow) are the size of a water hose. A water hose whose flow I'm trying to stop with fishing line after lathering soap onto my hands first. I even have sore spots on my hands from where the suture and needle holders dig into my skin through my gloves. Just today, during a very bloody surgery, I noticed that my surgery gown was soaked in blood at the spot where I lean on the surgery table. Of course, when I de-gowned, I had a huge blood stain on my shirt. Sheesh.

Shopping for BandAids and Blouses

iCat

MCT update

The histopathology results of the mast cell tumor biopsy brought good news and bad news. Which do you want first?

Good News: The tumor was completely excised! The margins are clean by at least 2cm all the way around. Yay!!

Bad News: The grade of the biospy showed a high grade 2 tumor. Not good in a 2 year old.

I recommended that the family seek the guidance and treatment of our local oncologist. I pray they make an appointment.

Encouraging Oncology

iCat

From Gung-Ho to Takin-it-Slow

I've never been one to make decisions slowly. So it's no wonder that I when I decided I was ready for veterinary medicine to start.... that meant I was ready. Not just partially ready, but full-steam-ahead ready. My hospital has a different mindset, however. I'm advised to "take things slow," and "don't bite off more than you can chew," or "avoid becoming burnt out in 6 months..." That one I hear loud and clear. It wasn't until my boss explained the epiphany he had one day.... This was it. This day-to-day routine that he had going on, would continue to keep going on. So with that advice (and after a consultation with my mother and husband- separately- about whether or not I could slow my roll), I'm going to finally take. things. slow.

maybe.

Taking a Chill Pill

iCat

Check Lump on Side

Yesterday I began to see appointments. It was only Day 2 on the job, but I felt confident enough to begin to see my own appointments and hopefully start building clientèle. It started out easy enough: a handful of vaccine appointments followed by a handful of dermatology appointments. Piece. Of. Cake. Then I pick up a chart that reads "Check Lump on Side." I check the age of the animal.... 2 years old. The lump is just caudal to the last rib and soft but immobile. The client informs me that this lump has been much bigger before, and today appears significantly smaller. She also tells me that another lump was seen along the dorsal midline of his back. This lump is absent.

Ok, so I begin to think of differentials: bug bite, inflammatory process, some kind of blunt tissue injury, hematoma..... and of course (although less likely due to such a young age)... neoplasia. The client consents to a fine needle aspirate, which I immediately perform. I get a surprisingly decent sample, very bloody, and smear it onto a slide and submit it to the pathologist. Without much more thought of the "Lump on Side," I go home for the evening.

First thing today, I asked a veterinarian of 10 years what he believes to be the cause of this "Lump on Side." First question he asks: "Is the dog microchipped?" hmmmmm.... I didn't even think to ask that. He begins to explain to me that the tiny, rice granule-sized microchips can occasionally migrate making a reaction similar to what I was seeing. Seemed like a no-brainer to me. That provided a very logical explanation for this type of lesion in this age of dog. So all I needed now was a cytology reading of "inflammatory cells" to make the conclusion.

WRONG.

Well differentiated mast cell tumor. I was so so so sad. I just sat and read the pathologists description over and over again. The words never changed. I couldn't believe I was going to have to call this woman and tell her that her 2 year old dog has cancer. Luckily, the call went very well. The clients were very receptive to all the information I had and opted to proceed with surgical removal of the mass tomorrow morning.

Crossing My Fingers for Clean Margins

iCat

"Hi, I'm Dr. iCat"

I cannot begin to explain how difficult it has been to remember to introduce myself as "Dr. Lastname." I am meeting so many new doctors, receptionists, technicians, and kennel workers, and I introduced myself to each and everyone as "Hi, I'm Firstname." It was only after one kennel worker asked what he should call me that I realized... I'm no longer just Firstname. I'm Dr. Lastname. Alrighty then.

My first day started out by signing all the PLIT (professional liability insurance) forms. Once that was finished, I was ready to start! As the newbie, I was thrown into the surgery suite to perform enough spays and neuters to sterilize all the animals of a small town in Nebraska. Surprisingly my right thumb and right forefinger did not swell and blister, even though it seemed as if they were actually being sawed off. I finally sat down for lunch at 3pm, which lead me to decide that I must bring lunch/snacks/survival food that can be eaten in increments.

After my 10 hour day, I am still on a high but am exhausted too. Luckily, I didn't feel overwhelmed today. I think I'll catch on quickly. This is going to be a good year.

Learning to Say Dr. iCat

iCat

13 days until DVM!

Since the last post, I've somehow managed to calm my nerves about my new job as a new veterinarian. I have a feeling this is short-lived since my tactic was simply to forget the upcoming responsibility and pretend my future days will be spent jogging and taking my energetic pooch to the dog park. Those tasks are a bit (a lot) easier to swallow.

I did, however, reach out to a colleague to ask her advice on how to make this adjustment. Her proposal was the following:

First Key: Confidence!

Second Key: Fake it till you make it!! (aka don't act as if you don't know, take a minute to refresh the mind).

Third Key: Take a DEEP breath, and lastly believe in yourself! Your school taught you well!

Luckily, I've never been one to lack confidence. I have always maintained a healthy sense of assurance, but I want to be certain that I always feel comfortable checking myself. I don't think this will be a problem considering all the heavy, expensive books that stand proudly on the shelf. They don't go without attention, that's for sure.

Breathing and Believing

iCat

Graduation is Imminent

There are only a few weeks left until my graduation from veterinary school. Days really. It has been my life-long dream to be a veterinarian, and as this day creeps closer and closer I realize how scared I am of my first day on the job. Will I see patients or just get to know the clinic and staff? Will my first client know that they are my first? Will I remember how to diagnose something that should be relatively simple? How long will it take until I am completely comfortable... if ever?

Stay tuned to see how I fair against veteran veterinarians.

Learning to Adjust

iCat