Today is one of those days I want to remember. And due to the requests that I keep blogging - I thought this venue would do just fine for recording today's events. Actually, today started yesterday....
I saw a patient named Emma - she's an 8 year old female chocolate lab. She was injured in an accident (HBC - Hit By Car) the last week of January. She had some bumps and bruises, but recovered fine. But over the last 2 weeks or so, she's been losing weight, losing her energy, not eating with Gusto. According to her owner: "she's just not Emma." I examined her yesterday and knew pretty quickly what was going on. When she was bumped back in January - it was most likely with some force. Sometimes, a large amount of force in the abdominal cavity can cause a rip to occur in the diaphragm. This poses no immediate risk (usually) but over time things start to migrate into the chest that don't belong there. When I took an x-ray of her yesterday, I could see that her liver and a good portion of her small intestines were in fact in her chest. The liver gets mad being out of place like that, and oozes lots of fluid. This fluid eventually leads to the lungs not having enough room to expand - hence why Emma didn't feel up to snuff. This can be surgically corrected - but it is a risky surgery. Dr. Woolsey - the vet I worked for during high school and college did several while I worked with him. The prognosis was always 50/50. Dr. Bowman has done two in his career - one lived, one died - again, 50/50. I, of course, have not done a procedure like this before - and I really wanted to send Emma to a board certified surgeon in Richmond to provide her the best chance possible. I gave the options to the owner - and he said that he'd talk to his wife and call me back. I ended up calling him back, and when he answered the phone he said: "Doc, I have one question for you - are you a believer in Jesus Christ?" I answered, "of course!" - he said "then you are doing the surgery. We know this is new for you - and we know it's risky - but we trust God for the results." wow. So, ok, here I go. Try to prepare as much as possible. Read all my books. Call Dr. Woolsey - he gave me great advice! Talked with my tech who would be doing anesthesia - we both knew that this was going to be a large endeavor. It was that, indeed.
Dr. Bowman had today off - so I had arranged it so that Dr. Nice would be assisting me in the surgery. (He's never done one of these either....) Both of my tech's and both of us docs were very somber as we got started - but I told them I had been praying for Emma all morning (and most of the night, as I didn't sleep all that well!) We got started and there was so much fluid everywhere! (Dr. Woolsey warned me of that!) We couldn't see a thing. We suctioned and suctioned and I was finally able to see where the hole in the diaphragm was - we actually had to make the hole larger in order to get the liver back through it. Once the hole was unplugged, things started getting tense. She stopped breathing - but this is normal and expected as the normal negative pressure zone of the chest is now open to the world (no more negative pressure.) No prob - my tech was breathing for her (bagging her.) But then the heart started getting mad because I had disrupted it - no prob - "Jenny, give the lidocaine." This made it not so angry - but it still decided to give us probs and beat really, really slow. "Jenny - give the epinephrine." I placed my hand on her heart (THAT is a really STRANGE feeling!) and I immediately felt: thump.... thump..... thump, thump, thump, thump - all was well. Now, back to our hole. Dr. Nice had the better angle for making the first, very difficult, suture placement. Unfortunately, he nicked the vena cava with the needle (this is a large blood vessel going straight to the heart, just so you know) as he made his first pass. Lots of blood. No worries, deep breath, put a clamp on it. No more blood. Go Dr. Brown. I tried to put a suture over it, but Emma was trying so hard to breathe that there was too much motion for me to tie anything. Ok, leave clamp on, close hole, then come back to the vena cava. Dr. Nice did a great job of closing it up - I added a few stitches to close a few gaps - then we had Jenny bag her - no leaks. "Ok, Jenny, give the Dopram and let's see if she breathes on her own." This is where she lives or dies - this is where it's out of my hands. We wait. It seems like a long time. The carbon dioxide has to build up in her blood to signal to her brain to breathe. We wait. She starts breathing. We start breathing again. :)
So we use a syringe and needle to suck as much air as we can out of the chest to create the happy negative pressure zone again. Now, back to the hole in the very large blood vessel. I place an 'x' type suture over my clamp and as I tighten it, I ask Dr. Nice to remove the clamp. I tell him that whatever oozing we are left with - we are left with - I don't think I can place another suture. (This was VERY difficult!) As he pulls out the clamp, I see a stream of blood about the size of a coffee stirrer shooting out of the vessel (which is the diameter of a hot dog) - before I can even get my needle back into position to make another pass, the front part of the abdomen is full of blood. I can't see anything. I can't see where to clamp. Dr. Nice tried to swab away the blood but it was coming out too fast for me to have a visible window. I make a blind stick into the puddle and pull tight - we both watch - the puddle isn't growing. (!) We swab out the blood and look - a little bit of oozing - but nothing more! Oh, my goodness, I just closed a hole I could not see! WOO HOOO!!! Quit celebrating! Get out of there! We look through all the intestines to make sure everyone is happy, then we stitch her up. Dr. Nice starts on one end - I on the other. We meet in the middle and we are done. She's breathing! She's alive!
Then we hear a very sobering question. "Dr. Brown, I only have 5 lap sponges (large cotton sponges for wiping up blood, fluid, etc.) - how many did you start with?" I look at Jenny - "6." "Are you sure?" "Maybe." We look everywhere. No way - we did NOT leave one in her. No way. We take an x-ray of a sponge to see if it shows up - it does. Fortunately, M.D.'s have been sued many times for leaving sponges in people - so they added a little metal material to them so they show up on x-ray. We took an x-ray of Emma - there it was - glaring at me as if to say "you didn't think it would be THAT easy, did you?" Back to the table - open her up - take out the sponge - close her back up. She was still under anesthesia during all this - no worries. It's so fortunate that we found this now, and not 3 days from now. It would have been better, of course, to have found it was missing BEFORE we closed her up - but this is what we call a learning curve. :)
2 hours later Emma is up and wagging her tail. I tear up. She's alive. She got heads when the world called tails. God was involved - and he decided that Emma needed to be around for a few more years.
And I am overwhelmed that I got to be the instrument by which that happened. wow.
She's not out of the woods yet - but hopefully over the next 24-48 hours she'll continue her recovery. Stay tuned....
