Even though I've been a veterinarian for almost 16 years, I still have cases where I am surprised, or get bit in the ass, or both. Last week I saw one of them.
"Mac" (not his real name) was a middle aged large breed dog, a long-time patient of ours. He had been seen a couple of times recently for intermittent vomiting and lethargy. My associate vet saw him both times, and the second time (after x-rays were taken), we jointly diagnosed free fluid in his abdomen. Abdominal fluid is never a good thing. It could be blood (indicating internal bleeding), pus (indicating bacteria in the abdomen, or septic peritonitis), fluid containing cancer cells, or a clear serum-type fluid (most commonly seen with liver or heart disease). Anyway, I called the owner and even though the dog was feeling better, I told him to come in so we could work the problem up further. The dog had a 1:30 pm appointment.
On exam, Mac was fairly bright, but his gums were pale and his heartrate was elevated. I tapped his abdomen (basically a quick procedure where I poked his belly with a needle and syringe) and easily pulled out a syringeful of blood. In a dog of his age and breed, a bleeding tumor was most likely. I discussed Mac's condition at length. Statistically, most of these tumors are on the spleen and successfully removing the spleen can solve the problem. At least temporarily. A large percentage of these tumors are malignant and will come back. However, unless we see evidence of metastases during surgery, we cannot tell a malignant tumor from a benign tumor without sending it in to the lab. In addition, I told the owner that if he wanted to do surgery, today was the day. Mac could crash and bleed out at any time and now he was about as stable a surgery patient as he could be. We discussed doing an abdominal ultrasound to make sure the tumor was in fact on the spleen, but I didn't think I could get one done that day. His chest x-rays were clear and his bloodwork showed only mild anemia. So we took our chances and headed for surgery.
As I opened his abdomen, I was stuck by how much blood there was. In fact, I was a bit surprised that he was as stable as he was! I suctioned out at least a liter of blood from his abdomen, and there was plenty more in there. I had a hard time visualizing anything, but my heart sunk when I pulled out the spleen. No tumor. Damn! Where is it??? Finally, deep in the right side of his abdomen, I felt it. an orange-side mass on his liver. LIVER! Not a common area for this type of tumor, but I have seen it before. Once. That dog did not make it. You see, removing the spleen is one thing. Just tie off a bunch of vessels and you're done. The liver lobe, especially the right caudate lobe, is best left to a specialist. In fact, should only be left to a specialist. I pulled out all of my surgery books and none of them had very good instructions on how to remove this liver lobe. In fact, one book only said that it was rarely performed. Thanks. So helpful. In the region is the pancreas, the portal vein, the vena cava, and the gallbladder, among other things. And in this case a mess of blood made it even more difficult to see everything. Plus, it's all deep in the abdomen and cannot be pulled out for better visualization.
And, from what I did see of this tumor, it had started bleeding again. Alot. Perhaps I dislodged a clot when I was suctioning the abdomen or feeling around. Who knows. But the blood! So much bleeding! I had to do something so I placed a big clamp right at the base of the lobe. The bleeding stopped but I was certain that my clamp contained many delicate things that were not supposed to be clamped. Plus, now what was I going to do? I had no idea. So I scrubbed out and called a surgeon. Can I send the dog to you with the clamp inside the abdomen, so you can clean up my mess? Or can you talk me through the surgery here? Hmmm. He said. The surgery is too difficult for me to be able to explain. You could send the dog to me, but it is very risky (duh!).
So I called the owner and explained everything. It didn't take long for them to make their decision. Euthanize Mac on the table. I admit that even after hearing those words I did try to remove the liver lobe. Well, for about 30 seconds. But then he started to bleed so profusely that I just slammed the euthanasia solution into his IV line. Nobody wants to see an animal bleed to death, even if they are under anesthesia.
We all want to be heroes. And in this profession, I am sometimes given the opportunity to be just that. However, this profession is also very humbling and often reminds me that there are problems bigger than I can fix.
A week later, I am still a little upset about the outcome. However, today I called the owners to see how they were doing and they were actually doing pretty good. They figured that it was meant to be. And they are getting another puppy this weekend! Nothing like a puppy to heal the soul, right? After last week, maybe I need a puppy too...
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