When the patient doesn’t breathe…

Inhalation anaesthesia rebreathing system

Today’s Diary Entry is sponsored by Chart Stables

 So today my patient stopped breathing…

Just like that, one minute fine, the next nothing…

I had known this patient was going be a pain as it stopped breathing during prep as well with the doctor, even though it started breathing again then I was on my toes. I’m not even sure how I ended up doing this anaesthesia, one minute there were loads of people in the room watching, the next I was alone. Anyway the surgery here was essential so had to continue, however was going be short I hoped.

Running anaesthesia is a balancing act, you need to keep the patient under deep enough to stop them feeling any pain, but you need to make sure it isn’t so deep that they are dead. Sometimes it is a fine line, and today especially it felt like a mountain ridge.

So it is going well for a while, however I did not know the induction protocol that has been used, or what has already been given so when the patient starts getting really light I am getting very little response on the inhalation anaesthesia (cold room affects the gas vaporisation) so give a little propofol as it is faster acting. Maybe not the best idea but better than the patient waking up completely during surgery I think. And propofol is really fast acting so just buys me a period of time in which to stabilise the inhalation anaesthesia.

So patient goes back to a surgical level of sleep, I start to balance my gas anaesthesia, and then the patient stops breathing.

A load of words went through my brain at this time, however randomly another doctor decides to walk into the room at this time to ask a question of the dr doing the surgery so I grab them to help me. I start manually ventilating the patient, and we try this for a minute or so to see if we can stimulate breathing like this. However it fails to start any breathing so the doctor with me vanishes and returns with a needle.

The light bulb goes on as I remember the theory of the stimulation of the nasal philtrum (groove in the middle of the nose) stimulating a breathing response. It’s some kind of acupressure point which until now I have never had to use, however using the needle to stimulate this point the patient starts breathing again. There are loads of techniques out there but sometimes it’s the simplest that are best and now I’ve seen it work I have a new tool in my anaesthesia toolkit… A simple needle. After this I managed to keep anaesthesia well balanced and the patient recovered well and went home.

After this patient was finished in surgery and had recovered we had an emergency patient in with a fracture of the mandible (lower jaw). It was a little Chihuahua who was very cute, however as it was a delicate surgery the doctor asked me to scrub in and assist in the procedure. This involved opening the skin over the fracture, drilling into the mandible, and then wiring the two halves together. This was pretty cool as it was the first time I’ve got to handle living bone myself without someone else placing the instruments for me. This surgery went well and the patient recovered very quickly and looked pretty cute once confined to the cone of shame.

When the machines don’t beep…

Vet student in surgery

Today’s Diary Entry is sponsored by Pet Webinars

Today was another spent in clinic, it’s a good balance for me as I can study when there are no patients, and then learn when there are. This morning a puppy with multiple fractures in a front leg was presented to us, the radius and ulna both were fractured however there was some callus formation here so it was healing ok alone. However the humerus was also fractured however the bone here was displaced and so it needed to be realigned and supported for healing. The doctor here decided to do surgery to insert a plate onto the fracture of the humerus.

So I actually did a lot of the prep for the surgery which was new to me so was pretty cool, and then was given the option of assisting or doing anaesthesia. As there was a final year with me I let them assist on the surgery and took on anaesthesia as I am wholly behind the philosophy of being able to do a good anaesthesia before starting to learn surgery.

Now one of the upsides of studying here in Slovakia is that we don’t have all the latest equipment, and our monitor in the main operating theatre is probably past retirement age, and about as reliable as the England football team. The reason however this is a upside is because it means I get to learn the hard way, so thanks to our broken monitor I had a working temperature probe, and a pulse oximeter that worked only some of the time.

In addition as it was a puppy the entire body was covered by the surgical drape, the surgery being on the humerus prevented me even trying to use the ECG (though it probably wouldn’t have worked anyways). So how do you monitor a patient you cannot see, with little equipment?

Well my approach today was to use the eye position and reflex, coupled with the respiration rate and mucus membranes. Generally if a patient is breathing it means the heart is still beating – though a patient can still have a heartbeat when not breathing – and the rate and depth of respiration indicate their state. Pain for example would be indicated by rapid shallow breathing, whilst deep sleep is by steady deep breathing.

The eye position is interesting as it varies within different species, in dogs however the eyes rotate down and towards the middle at surgical levels of anaesthesia, however if it goes too deep the eye will center again. There are two reflexes associated with the eye, the palpebral reflex which is from touching the corners of the eyelids and then the corneal reflex which occurs when touching the cornea. Now I used the palpebral reflex in combination with the eye position today to help keep my anaesthesia at a surgical level.

At the end as we needed to do xrays to check the position of the plate and our xray room is not equipped for gas anaesthesia I moved over to using injectable anaesthetics for this.

Now in total the anaesthesia was around 2 hours long so I managed to maintain confidence that the patient was fine, and keep the surgical levels of anaesthesia using just these parameters. It’s not the perfect way to do anaesthesia and if I could I would use a capnography and ECG however you can only use what you have. However when it came time for the patient to recover the patient was awake within 10 minutes, and alert sitting up within 30 minutes which I think is pretty impressive for this lowly vet student.

Pyometra, a very good reason to spay your bitch…

Pyometra uterus removed from boxer dog in emergency surgery

Today’s Diary Entry is sponsored by Eickemeyer

Normally I avoid graphic images here, however sometimes a picture is worth a thousand words, which is why I do not feel too bad about the photo on the right here. This is pyometra, a uterus full of pus that was removed from a dog, on the left you can see where it has ruptured and the pus is leaking out – this luckily happened after it was removed simply when we tried to move it to take the photo… If this had ruptured inside the abdomen it would have been very bad indeed.

So how did we get here? Well the 30 minutes before closing stampede happened again today, 5 patients arrived this time however unlike Christmas day which was completely crazy with just me and 1 vet there were 2 vets today.

One of the patients presented with discharge from the vagina, and abnormal findings on the palpation of the abdomen. Now this generally suggests pyometra, however we took her to ultrasound to confirm, and seeing the ultrasound image which showed the massive loops of uterus we knew the only hope for saving this dog was going be surgical.

Being an old dog, of a certain breed, and with heart problems the anaesthesia was going be very high risk. This dog had also had previous abdominal surgery for a caesarean section so it was also expected that there would be serious adhesions (where organs stick together) around the uterus. Now at this point in time we were struggling to get another doctor in, so with the 3 of us here, I was elected to assist in the surgery, I wasn’t entirely happy with this with so little experience for such a delicate operation but needs must and it was best chance for dog.

So starting prep, we get a call back from one of the other doctors that was able to come in for the surgery so I move to doing the anaesthesia. This scared me as I am just getting comfortable with running anaesthesia on healthy low-risk patients and this patient was nowhere near low-risk. At this point I was not sure what was worse doing the anaesthesia or assisting in the surgery.

Because of the high risk here I actually brought the emergency drugs with me into the operating room instead of leaving them in the prep room where they are normally kept. This was a little comfort as if I needed to I could do something, but still it didn’t make me entirely happy. Then trying to get the monitor working failed so I ended up with just pulse-ox and temperature to work with. However being abdominal surgery I could get access to the chest to listen to the heart, and actually monitor the heart rate manually.

I was just waiting for the surgery to be over so I could start waking the patient up, all my attention was on the anaesthesia however when the first uterine horn was lifted out and was the size of an salami we knew we had been right to do the surgery. The second uterine horn however had major adhesions, and when this was lifted out I was glad that I wasn’t assisting in the surgery. It was connected to the intestines and the bladder so was some very delicate work that took the attention of both doctors to remove.

Once the uterus was out the abdomen was closed, this was done with intradermal sutures so that there were no visible stitches for the dog to remove. It actually looked almost as if there had been no surgery, and then the extra doctor left and I was into recovery mode moving the patient from theatre to recovery and then starting the process of waking them up. I am not entirely sure why but recovery was very fast – I’m thinking this could be to do with the length of anaesthesia as usually procedures here are orthopaedic and very long so long recovery?

An hour later the dog walked out alive, and without the pyometra… Now when vets say pyometra is a very high risk in older bitches it really is, however vets are not always great at communicating just what a pyometra means. Hopefully as nasty as it is, this photo has giving you a very good reason to spay. This entire event (including my extra gray hairs) could all have been avoided by simply spaying the bitch when she was younger, and healthier.

EDIT: Saw patient for check up today and is doing very well, alert, urinating/defecating and walking with no signs of pain.


A Vet Students Christmas…

Puppy on oxygen

Today’s DIary is for every single person that has helped me to get here, thank you so much for your support and encouragement!

Merry Christmas everyone, it’s been a while and I have been very bad finishing my diary entries (really difficult to find time at the moment).

For some reason even though the university is not doing emergency cover over the Christmas holiday they are running reduced clinic hours with a single doctor on duty. I’ve been around the past few days as I am going be studying either way so I can sit in my room alone, or sit in clinic and study and be there to help if needed. It’s pretty difficult to do a lot of things alone so even my vet student hands can be useful.

So in the same as in the past few days I’ve gone in, most of our wound management patients are finished by 10, and so I start to study and the doctor gets on with marking exam papers. I’m finding this pretty interesting as seeing the same patients every day over a longer period I can see the daily changes in the wound healing. This is something very useful as a lot of wounds look very scary, and a lot of the time when graduating people do not have the confidence to treat these conservatively so its good experience to get.

Anyways the clocks ticking towards close when at 11:15 there is the sound of the door opening, going to the waiting room we have a collapsed dog being carried in the owners arms with blood dribbling from the mouth. We get this onto the table, and start stabilisation placing a cannula during which we notice the blood is very dark almost heading towards brown in colour.

Less than 3 minutes later there is another knock on the door, I check this whilst the doctor continues with stabilisation. My biggest problem here is still communication as my Slovak language skills are still very poor, however seeing a puppy with obvious respiratory distress I swap patients with the doctor. Now with stabilisation the basics are very important, and being basics are within my capabilities so I am dealing with shock. I get vitals measured, IV fluids running, and then as the temperature is low start warming the patient as well. Performing a clinical exam and with the blood colour in mind we are thinking it is an intoxication of some kind of poison (potentially a rodenticide), so we call internal medicine to send this patient that direction.

There is then another knock on the door with a collapsed rabbit that has had ongoing problems, on a quick exam the first thing I notice is the lack of temperature. It’s winter here and outside temperature has to be around 0-1 degrees, yet the rabbit is in an open basket with just a blanket to sit on. Sometimes I think owners are lucky I cannot speak Slovak (yet), however I set about trying to get the temperature of this rabbit up whilst knowing that being exposed to the cold like this may have killed them. (Please if bringing animals to a vet in WINTER make sure that will be kept WARM!!!)

The doctor on internal medicine duty (who is alone as well) arrives with a cat patient that needs xray for not eating for several days to rule out foreign bodies or neoplasia or torsions etc. My surgery doctor vanishes to do the xray whilst I monitor the 3 patients that have all appeared in the past 15 minutes. After this the internal doctor takes the intoxication patient back to the internal clinic, along with the cat. I take the rabbit which has really bad problems, clean the abscesses and give as much in the way of fluids, antibiotics and pain meds as possible.

This patient then leaves which means we have only the puppy left to deal with. Now this puppy is only 3 months so we are trying to avoid the radiation from x-raying it because it is still growing pretty fast which means we could cause big problems in cell replication from the xray. However we do suspect that it has a pneumothorax from listening to the chest and have it stabilised on oxygen therapy. It needs to be hospitalised in either case so the owners fill the forms and then leave. As it is so small we have a discussion about the management, and decide against the surgical draining of air from the chest with thoracocentesis due to the risks here from the size of the patient (really bad risks here especially on something so small). We choose the conservative treatment route here and reduce the respiration rate using medication, and keep the patient on 100% oxygen and warm.

It’s now 3 hours after we were supposed to close… Merry Christmas

The flying snake…

Flying snakes Chrysopelias ornata

Today’s Diary Entry is sponsored by Supreme Petfoods

So most people have heard of flying pigs before, however today I actually got to meet a flying snake, and no it wasn’t through any accidents of any kind. The snake I was looking at was the ornate flying snake, Chrysopelia ornate that is found usually in southeast Asia. There are only 5 recognised species that belong to this group of the flying snakes.

Now the flying snake can travel up to 100m in the air, and land with pinpoint accuracy using special adaptions to its body to make an aerodynamic wing. These adaptations include sucking in the stomach, and spreading out its ribs to flatten its body. Now to clarify this is more a Buzz Lightyear (Toy Story anyone) kind of flying as this snake is arboreal and lives in the trees and not on the ground. So what happens is the snake moves to the end of the branch, pulls back into a J shape, picks a landing spot and then launches itself off. During its entire journey the body keeps making its side to side movement that it would make on the ground to stabilise itself in flight.

Once in the air the ribs move up flattening the body allowing the snake to glide. Sometimes nature is pretty cool as in addition to the ability to fly the flying snakes are also venomous. Now this venom is relatively weak and will only affect small prey (such as mice), however in addition to this the fangs are at the back of the mouth and are small. This means that it would have to be something pretty small being bitten for it to fit into the mouth for the fangs to reach so most humans are relatively safe with these snakes (though getting bitten is still not a good idea because of the bacteria).

Today the flying snake was in after what we suspected to be trauma, the intestines had herniated (broken through) the circular muscles that surround the body of the snake so had to be replaced. The surgery went well, and hopefully my first snake patient that flies will make a good recovery.

Just to note though, the unique adaptations of snakes between species is one of the reasons it’s so important to research to understand the needs of pet snake before getting one as they can be so different. This snake needs to live in a tree, and needs space to exhibit natural behaviour.