Inside the dogs open chest…

Fluid therapy by cannula

I spend hours upon hours reading, studying, visualising and learning from what seems like an endless stream of knowledge. Some of it is stuff I know I will never use but must learn (such as slaughter inspection), then there is stuff that will be used commonly (such as dog vaccinations), and finally the stuff that is really interesting that I won’t use unless I end up a specialist (such as heart bypass protocols).

Now whilst a little more common in the UK, a thoracotomy is not really common here – there have only been 2 in the past 18 months and one of these was traumatic performed by a dog attack. A thoracotomy is where the chest is opened – whether that is for heart or lung surgery or something completely different. This was the first time I have assisted on a thoracotomy where it was intentional…

The case today was different; a dog had got a foreign body stuck in its esophagus. We originally tried endoscopy via the mouth as a minimally invasive approach, whilst we could visualise this foreign object in the esophagus, it was too large to be able to grab or move onwards into the stomach. Unfortunately also when an object has been in place for a while it can also weaken the wall of the esophagus around it so moving it can cause rupture so we have to be very cautious around this as well.

So we went into surgery as an emergency to remove this obstruction from the esophagus. Unfortunately the esophagus mostly lies within the thorax (chest) – it enters the stomach just a few cm’s beyond the diaphragm. This meant that to get to the foreign body meant opening the chest.

Opening the chest is not like it is on TV medical drama’s – there are numerous complications that can occur – and its technical surgery to stop the lungs inflating on the side of the surgery so that there is space to work. Also you have to open in the correct space between ribs to give you access to where you need to be. We open the tissue layers above the space we want to use to gain access to the chest, and then open the space between the ribs.

The pink of the lungs inflating is visible before we deflate them on this side to give us the space to operate. This space is still relatively small, it’s only a small dog, and the ribs will not stretch that far apart. We bring in the rib spreaders – this gives us maybe space 4cm wide to work in, though it sounds like a lot the esophagus is in the center of the chest, maybe 7cm deep. Think about having to operate on the bottom of an empty tin from the top… This is where suturing becomes more fun and demanding, or even dissection, the tip of the scalpel has to be used whilst holding the end of the handle instead of the normal curve of the blade.

Looking up the chest where the lungs are deflated I can see the beating heart – however it is the esophagus that we are interested in – we can see the bulge of the esophagus where the foreign body is. Everything is moving though, and barely seems to stay still.

We use stay sutures to hold the esophagus as close to the wall as we can whilst making an incision into it – opening the muscular layer, and the inner mucosa. We delicately manipulate the foreign object (which looks like a chicken head & neck) from the esophagus. It is larger than we expected so we have to make the incision longer to accommodate it, and then it is out. Time to close – we did this in two separate layers – one for the mucosa and then the muscular layer around this.

One of the tricky things about thoracotomy is getting the chest closed and the lung re-inflated and breathing again. A chest drain can help with this so this is placed. We then place all our sutures into the chest wall around the ribs either side and then let the lungs inflate as we close the wall together before tying these sutures. The wall muscles and skin is then closed.

We remove the excess remaining air through the chest drain to ensure the lung can inflate fully. And then move the dog over to recovery which was surprisingly uneventful.

This has taken maybe 3 hours in total, yet my study around the chest is many hundreds of hours. I know where things are – the vagus nerve runs along the esophagus which is essential we do not damage as it controls so much of the body – the heart, abdomen, throat, swallowing. The major vessels of the aorta and vena cava also run close to the esophagus here so we have to be precise. It’s also important how we open the intercostal space so we do not damage the nerve and vessels that run along the rib. The way the respiration of the animal is compromised when the chest is opened is something that needs to be dealt with – we used a ventilator to keep the patient breathing during surgery.

Now with my latest surgery high finally being beaten by tiredness I am going sleep for the new day tomorrow.

Death, the good, bad and ugly…

An exhausted vet student

Death is one of those bad words, that we try to avoid talking about, that we ignore and hope we never have to face.

Yesterday I read a blog post called “The dirty secret about CPR in this Hospital (That Doctors Desperately Want You To Know)”. For me it was nothing new, however it made it easy to understand and got the point across in a way I never could so I would highly recommend checking it out.

Since reading this it has remained stuck in my mind throughout the day, I think being in the veterinary profession gives me the other side of the picture. Unfortunately I have been in the position of watching someone I loved die slowly in a hospital bed – it was never what I expected – I expected to turn up one day and find them in their garden or home after a heart attack. It took several days for the die under the Liverpool Pathway (since then I am much more clued up as to why this may not always be the right thing) however the alternative was open heart surgery with very very very small odds of a meaningful recoveryEven at that point in time, without realising I was thinking about the quality of life and not the quantity – the chance of them doing what they loved and leaving the hospital after this surgery was near zero. The quality of life would be zero, even though the quantity would be increased (if you can consider it as life).

Whenever this person had spoken about death to me I had tried to change the subject as I was scared to think about it. I was scared of losing them. I didn’t want to think about it.

So moving forward 5 years with a lot more education and experience I am writing this. Over the past two years I’ve been seeing practice I have been around death, caused death, and prevented death. Some days it seems to be all I deal with, last Tuesday by the last patient I’d seen so many patients die or euthanized that I was no longer surprised when I confirmed another death.

Let’s talk about some death – from the perspective of a vet student… These have all happened to me…

It is 1am, my phone goes, one word – “torsion” – and I am out of bed and running for the door, 10 minutes after this phone call I am scrubbing into surgery. A torsion (GDV or bloat where the stomach swells up with gas) is a surgical emergency. The dog will die without a vet and surgery. An hour or so later the dog is in recovery, and a few days later it goes home.

Last Tuesday at 6:45pm when I was walking out the door to go to lunch a call came in… “torsion”… the owners were on their way about 20 minutes out. That’s 20 minutes for me to prepare. Operating Theatre set up, preparation for stabilisation, emergency fluids, decompression. Car drives up to the door, owner says I think he’s dead… I’m in the back of the car listening to nothing, feeling no pulse, no breathing. This dog didn’t even make it in the doors.

Is a torsion painful? Yes. Can it be fixed with surgery? Sometimes. Will the dog have quality of life after surgery? Yes. Is it a painful way to die? I would not like to die like this.

I am in surgery, normally opening the abdomen is pretty routine, however this time we are struggling. If I hadn’t opened the scalpel blade myself I would have thought it was blunt and old. Opening the abdomen finally it is like all the organs have melted together… There is nothing there, and nothing that is possible, I am wondering how the dog was still alive. We were not sure what we were going find, however I would have never expected this… The owners chose never to allow this dog to wake up.

We’ve got what is expected to be a pyometra – however there is a large mass in the abdomen along with lots of fluid. The owners know that it may be bad – and are waiting by the phone. I am running anaesthesia, the patient is having some problems to breathe so I have placed them onto a ventilator to help them. The abdomen is opened and the right liver lobe the size of the dogs head is removed from the abdomen – the breathing becomes easier. There are changes to other organs as well – it is not a pyometra however there are tumours on the uterus. We call the owners, and they give permission to euthanise on the table. I administer the drugs that will end this life – and relieve the suffering.

In human medicine – these patients would be closed and taken to recovery – they would be given drugs for pain and potentially kept sedated until they die. There is no guarantee of when this would be, they’d be trapped there in a hospital bed hooked up to machines.

A horse – unable to stand, with fluid on its lungs, anemia. The condition is getting worse… There is no quality of life, and the chance of recovery is very slim. We make the decision to euthanise and administer the drugs to do so. The horse is peaceful, out of pain, and no longer drowning inside out.

In human medicine this patient would be treated – humans are lighter than horses, the anatomy is different, and the lungs are like bags of crisps instead of sacks of potatoes. Its treatable – and there is a chance of recovery to a quality of life.

I will end on a puppy, this puppy had a deformity in its leg that was surgically correctable – however it was not showable and not breeding material. I cuddled this puppy on my lap when it was sedated, and held it when it was given the final injection. Not to relieve its suffering, simply because it was unwanted. We tried to encourage the owners to sign it over to be rehomed, tried to talk about the surgical options. That is the danger of euthanasia – that it can be used for ends other than relieving suffering.

We may not be able to pick when, however you can choose how you want to die. Where you want to die. It’s a conversation that should be had, and you can even find online guides like the Five Wishes (https://agingwithdignity.org/docs/default-source/default-document-library/product-samples/fwsample.pdf?sfvrsn=2 ) to help you.

CEVA Animal Welfare Awards 2016

CEVA Animal Welfare Awards 2016

Often when I log onto social media to a constant barrage of animals needing help, petitions to prosecute properly people slapped on the wrist for outright animal cruelty, and some horrific images. This evening however I was very excited to be invited to the Animal Welfare Awards 2016 – an evening to celebrate the people on the front-line making a difference every single day.

In the 5 years since these awards started they have become an inspiration to others that a difference can be made. And it doesn’t always take a lot of money, fancy facilities or equipment. It can be a single person with the passion to lead others towards a common goal.

It was an amazing evening celebrating amazing people that I cannot do it justice in a single post here however the use of technology has made these awards truly international with the awards being broadcast live on youtube around the world. I hope that this recording will be available and will share it with you when/if it appears.

Coming into these awards I knew very little about CEVA, however the passion through the staff right up to management for animal welfare is infectious. I will be writing up each category through the congress. I hope to track down some of the finalists later for more of a chat – there are some great tips from these awards that can be taken away to help you make a difference.

In the meantime you can check out some twitter highlights…

CEVA Animal Welfare Awards 2016 (with images, tweets) · vetschooldiary