Judgement Call

I am not a surgeon. I am not a radiologist. I am not an internist. I am a general practitioner, which means that, for better or worse, I know a little about a lot. This can sometimes get me into uncomfortable situations.

Last Friday a patient of mine came in for vomiting. The poor dog was vomiting large volumes of bright yellow fluid several times an hour, and had been doing so (off and on) for about a day. Other than him being a little dehydrated, I couldn't find anything wrong when I examined him. His belly didn't even hurt. I admitted him to the hospital for some diagnostic testing and IV fluids. His abdominal x-rays showed a very distended stomach - filled with some gas and a lot of liquid. I didn't see any foreign object or other evidence of obstruction, although the dog did have a tendancy to "eat anything and everything". His labwork was normal. I got a couple of second opinions (I took a digital photograph of the x-rays and texted them to Lisa, and also a friend of mine, who is a veterinary internist, was at my clinic with her kitten and I showed them to her as well). Well, you do what you have to when you're in general pactice by yourself! There was no consensus on whether the dog had an obstruction, so I elected to re-take the x-rays in a few hours. That led to a contrast dye study of his GI tract at 6 pm Friday. The dye started to leave his stomach pretty quickly, but then it kind of just petered out. But not in the typical "gee there's something stuck in your gut" pattern. It could be an obstruction. Or maybe just ileus, where the GI tract just decides not to move things through.

Hmmm... Now what? The dog was looking better and hadn't vomited in a few hours, so I sent him home with instructions to bring him back the next morning for a follow-up x-ray. The owner came in at 10:45 am as instructed. The dog had done great all night, but vomited a little just before coming to the clinic. I took an x-ray and it looked exactly the same as the last one we had taken the night before. The stomach was still filled with barium (the dye that we used). Crap.

At least it was now a no-brainer. I make some quick mental calculations. It was 11 am. I needed to be at a doctor's appointment 15 miles away at 1 pm. Could my two techinicians and I prep, anesthetize, operate, and recover the dog in 90 minutes? Of course I offered to just send the dog to an emergency clinic (E clinic) for the surgery, but the owner really trusted us and wanted us to do it. And it was sort of a win-win for both parties. Our surgery fees are much less than an E clinic's fees. And in the slow winter months, my clinic could really use the added income that an emergency surgery brings. I figured it would be a quick incision into the stomach to remove the offending object, then wake him up and send him to the E clinic for post-op care.

Well, you know I wouldn't be writing about this if it was that simple, right? First, when I had one of my techs pass a stomach tube in order to empty the stomach of all of that barium, most of the stomach contents (ie barium and bile) started to come out if his mouth rather than the stomach tube, putting him at risk for aspirating the liquid. As you probably don't know, barium in the lungs is a very bad thing. However, the dog was anesthetized and had a tracheal tube in place, which hopefully would keep the liquid from entering his airways.

THEN, the damned foreign body wasn't in his stomach after all, but his small intestine! A more difficult surgery, but also one that gave me a dilemma. The piece of plastic or whatever it was (the owner couldn't figure it out when we showed it to her either) was probably sitting happily in his stomach for quite some time, But then it decided to make its way into his duodenum, which had to stretch in order to accomodate said object. The 10 or so inches of intestine that the plastic has thus far passed through was very dilated and had a red/purple/black splotchy color. It was angry. But was it damaged beyond repair?

That is the million dollar question. That is when I wish I was a surgical specialist who has done hundreds of these surgeries, rather than a GP who does maybe one or two intestinal surgeries a year. Then I would maybe know if it was ok to leave the mad intestines in, or if they required surgical removal (intestinal resection and anastomosis). Guessing wrong could have dire consequences. Three years ago, almost to the day, I did a FB surgery on a dog who had decided to eat her blanket. I removed the blanket pieces, but not any intestine. Her whole small intestinal tract was damaged, and I really didn't want to remove all of it (because as you can imagine, that would also cause problems), so not knowing what parts would be ok and what wouldn't, I left it all in. And crossed my fingers that it would all be work out. In this case, it didn't. The next day her intestines started to leak in 3 areas, requiring a second surgery. But because she was now septic, she couldn't heal well, so I sent her to the U of M for a 3rd surgery, which she did not recover from. She died on Christmas Eve.

So fast forward back to Saturday. I'm stadning there with an open abdomen and a decision needs to be made. Leaving the damaged intestine in would be quicker (selfishly allowing me to make it to my own appointment on time). Taking it out would be safer. Well, sort of. Because the part that I would have to remove would be the most difficult portion of the GI tract to do surgery on. It is adhered to the abdominal wall near the spine by a large ligament, making it difficult to isolate and operate on. There is also the pancreas that empties into that part of the intestines, and you really don't want to mess with the pancreas. Because I am not a surgeon, the only other time I attempted surgical removal of that part of the GI tract was the second surgery in the dog I just described. And we know how that went.

So I left it in.

And called the E clinic 3 times in the next 24 hours to get an update. Did he have aspiration pneumonia from the barium? Did he have a septic abdomen from a leaking gut? When could I sleep at night knowing that he was finally out of the woods??

Today is Monday, 48 hours after surgery. The dog was doing great yesterday and was discharged from the E clinic. He was doing great at home today. I figure one more day and I can breathe a sigh of relief. I would hate to have to re-visit the Christmas of 2008 again.

I'll let you know tomorrow.