Monday, December 22, 2008

String Theory

I work alone on Saturdays, which can mean they get pretty crazy. Every so often there's more work than one person can do, and I have to call in another doc to handle the overflow. This last Saturday was pretty uneven; slow to the point of stagnation in the morning, it gradually got busier until noon. After that it was pretty much death, destruction, war, devastation and horror. It seemed that everything came in at once, and all of it was in need of big intervention: a cancer patient, induced into remission on meds, who had developed anorexia, a distended abdomen and bloody diarrhea; a dog in sudden collapse; a dog (most unfortunately) arriving DOA, most probably as a result of a cardiac event; a lethargic and vomiting cat which might have a urinary tract obstruction; a dachshund with a possible blown disc in its back; a lab with an ear infection whose owners had come in without an appointment, in the midst of all this, and who didn't mind waiting.

All of the above came in within two hours. The DOA was (sadly) not very time-consuming, there being exactly nothing I could do to help the dog, although I did my best to comfort the owners. The painful doxie was also pretty quick, as it had (most fortunately) no neurologic signs, and a sore hock instead of a blown disc. The ear infection, as the least critical and the only one without an appointment, had to wait til last. That left me with a collapsing dog, an ill cat and a cancer patient with a big belly and bloody stools, all at the same time.

I do my physical on the collapse first, advising bloodwork (which the owners agree to) and pulling my bloods. The owners want to wait for results, so I leave them and their recumbent Aussie mix in the exam room and go on to the bloody diarrhea. The dog's abdomen is grossly distended and soft; the dog is a bit portly to begin with, so the abdomen is always a bit indistinct, and with the added distension I am unable to distinguish structures. Additionally, the dog's respiratory pattern is a bit rapid and shallow. I take the dog back for an Xray (during which time we relieve at least some of his abdominal distension in the form of copious emissions of a paint-melting gaseous miasma emanating from the "buttockal area", as Jay Leno is inclined to call it).

Returning the dog to his owners to wait for the Xray to develop, I go on to the next room, in which the vomiting lethargic cat is waiting. When I walk into the room, the cat is lying quietly on the table, his demeanor a little withdrawn. Because SS has warned me this cat might have a bladder obstruction, I palpate his abdomen first thing, but his bladder is small and pliant. I do discover, however, that he is a little dehydrated and has some mid-abdominal discomfort. His chest sounds normal -although he is purring steadily, making it a challenge to listen to - his color is good, and he has no fever. I am discussing workup with the owners as I am doing my physical, laying out options.

"Let me just check one more thing before we decide what to do first," I say, rotating the rightward-pointing cat to the left, a move he tolerates with good grace. Grasping his head gently with my right hand, I press the pad of my left thumb between the arms of his mandible and hook the nail of my index finger over his lower incisors. I carefully pry the cat's mouth open, pressing up against the base of his tongue with my thumb to elevate it into view, and discover the one thing I was hoping not to see.

All along the root of the tongue is a knobby furl of inflamed tissue, infected and bleeding slightly. In the cleft of this, nearly buried amongst the thickened, reddened tissue, is a strait dark line.

Oh, crap. This cat has a linear foreign body. This means that he has swallowed a string, or a thread, or a bit of dental floss or tinsel, or something of a similar nature (ribbons, rubber bands - you name it). It has gotten hung up around the base of his tongue, and the ends are proceeding down into his GI tract. This is a bad situation; unfortunately, unless the string is pretty short, it works its way past the stomach and into the intestines. There the peristaltic contractions of the gut pleat the gut up on the string, the way that tightening a drawstring pleats up the fabric through which it is threaded. Because the string is anchored at the base of the tongue, the pleating tightens until the string starts to saw through the delicate inner tissues of the gut. If this is not relieved via surgery, the string will eventually cut all the way through it, leading to peritonitis and death. I have a particular "thing" for the looking for the linear foreign bodies, having been burned on one once as a freshman vet student. I've never forgotten. At that time I didn't know the trick of looking under the tongue for the string (having not yet gotten on to clinics, where the skills of physical exam are learned), and though I suspected a string, I didn't know how to find it. As a consequence of that and other circumstances, the cat ultimately died, despite surgery. In one sense, it was beyond my skill level, so it is perhaps not surprising that I didn't find it. But it bothers me to this day that I didn't know how to find it, and I'll never miss another one for want of looking.

I explain the consequences of the linear foreign body to the owners, who look grave. "How much would it cost to take him to surgery?" asks the mom. I ballpark her an estimate. Tears swim in her eyes.

"Let me talk to my husband," she says softly, in a voice husky with sorrow, "but I think he'll say no."

I step out to give them some privacy and go back to see my Xray on the cancer dog. I discover the reason for his anorexia and his abdominal distension. His stomach is so full of food that I can barely find his spleen and kidneys. His liver is mashed up against the diaphragm (gee, hmm, d'you think this could this be the cause of the rapid shallow breathing? Yikes.) In addition to which it appears the dog has swallowed two coins, most probably a quarter and a nickle, based on the size. They're small enough to pass through the gut, but there is the possibility of toxicity from the coins. This is most common in pennies, which have in more recent years been made with a high enough zinc content to be an issue. Unfortunately it's not possible to read the date on coins found on Xray, so if you suspect penny ingestion the safest thing to do is to remove them either via surgery or the induction of vomiting.

The owners are hilariously relieved that the dog isn't eating because he's obviously eaten WAY more than his usual share. I discuss the likelihood that the bloody stools are also a consequence of his dietary indiscretions, and warn them about the potential consequences of coin ingestion. The elect to observe the dog and call back if problems arise; the fact that the dog has an underlying cancer and is on borrowed time makes them understandably disinclined to put the dog through anything particularly strenuous or expensive. I release the dog to the owners' care, with some misgivings; it probably isn't a penny ingestion, but I dislike leaving the coins there. On the other hand, given the enormous amount of food present, and the fact that the stomach is so enormously distended that it overlaps the entire front half of the abdomen, it's entirely possible that inducing vomiting will be ineffective; the coins may have left the stomach and could currently be residing in a loop of gut that merely overlays the giant gastric shadow. Alternatively, even if they are in the stomach, it might not be possible to get the dog to vomit them up. I might be able to get them out via gastric lavage, but the owners don't want to anesthetize the dog. I guess we'll have to see if he can pass them safely on his own.

I go back to the recumbent dog, give them the results of the CBC (while the chem panel is still pending) and then back to the cat. The owner reports her husband has, with great reluctance, elected euthanasia. Both the owner and her teen aged son are crying, but realistically, the only possible outcomes we have are surgery, euthanasia, or a slow ugly death from peritonitis. If we can't do surgery, that means there really is only one choice.

I'm sorry, little man. But at least I can stop your suffering.

The owner signs papers and I take the cat to the treatment area where my nurse, E, and I gently and quickly euthanize him. Poor kitty. This is sad, especially so near Christmas.

While we are doing this, the receptionists are loading the ear dog into one of of the two recently-emptied exam rooms. Since my chem panel is still cooking, I go in, do my exam and collect an ear swab, while E is doing the body care for our string cat. I make a slide and am just heat fixing it when E hands me the bloods. I let her finish the stain while I go talk to the owners of the recumbent Aussie mix. The bloods show that the dog has one of two likely problems: either an infection or a tumor masquerading as infection (tumors can outstrip their blood supplies and become necrotic and infected). I can locate no primary mass, but sometimes you can't. I discuss options with the owners, who elect to have an expensive but effective injection of an antibiotic which is effective in the bloodstream for two weeks from a single injection. The dog has rallied a little, pinking up and seeming less distressed than before, so maybe all will be well.

At last I dispatch the ear infection and we close only 45 minutes late. I am sad about he string kitty, but realistically, it was either surgery or death for him. Poor little man. Any other alternative would have been a miserable suffering exit, something he never deserved.

Monday morning I come in and my nurse E tells me her cat - who had been anorexic and vomiting the day before - had defecated several lengths of thread (which, knowing better than to just pull on it, she had carefully trimmed away from his anus a bit at a time as he passed it over 12 hours). We checked under his tongue. Nothing hooked there. Big sigh of relief.

Meanwhile Dr, M brings in a cat back in a carrier.

"What's that?" I ask him.
"Vomiting cat, getting some bloodwork done," says Dr. M.
"Bet it has a string," I say sourly. "We had one in on Saturday and E had one Sunday, so we're due for our third one."

Dr. M looks startled, and I go up front to take an appointment. When I go back, the cat is being added to the surgery list. Because Dr. M looked under the cat's tongue. Guess what he found?

Sometimes things DO come in threes.


Holly said...

you didn't know this, but your post sent me right back to the barn because my fav barn cat Frosty snuck into the tack room and I forgot her. Whew, saved me you did!!!!

Anyway, that is sad about the kitty but I'm glad he did not suffer. Sometimes I wouldn't want to do your job.

SweetMotherOfMars said...

Agreed, Holly.

AKDD, it must have been even harder following your loss of Seven. I'm glad you were able to alleviate the pain for both cats.

MaskedMan said...

Christmas. Lots of string and ribbon about. Dangerous times...

And my daughter wonders why I'm such a prick about her picking up after her sewing..? I think I'll mention this to her. Again.

Juri said...

I just had to leave a comment! I am not sure how I found you blog, but I am so glad I did...what an interesting and informative blog! What animal lover wouldn't? Okay, I am going back to read more of your older posts....


AKDD said...

I'm glad to have helped - however inadvertantly!

It IS hard some days, and it's true that it was harder because of the recent loss of Seven; thoughtful of you to have noticed that. The cat in question was a red tabby variant, coloring that echoed Seven's, which called him to mind immediately. It was sad for the cat and sad for the owners - but better, in the end, that he did not suffer his way out of this life. On the plus side, the other two string cats did well.

MM, but all means, keep after the sewing clean-up; I've taken needles out of cat (and dog) mouths as well. Those are usually more of a painful hassle to the pet than life-threatening, but it's still anesthesia.

Juri, glad you're enjoying the blog!

Smart Dogs said...

I've been wondering if those rope toys for dogs that are made up of string and seem to be very easily torn apart are a problem. I don't let my dogs have them, but I'm a professional trainer and a lot of my clients get them for their dogs.


AKDD said...

Depends on the dog. Some dogs won't tear them up; some dogs will tear them up and not eat the string; some dogs will eat anything, and in large quantities, but those dogs should not be given toys OF ANY KIND and then left unattended. Also depends on the rope toy: Some of them are pretty soft/weak cotton thread, and it easily pulls apart, so that it would be unlikely for the dog to be able to ingest pieces more than two or three inches long. Those don't pleat up the gut and saw through it, although in big enough wads they could cause other GI issues. Some toys have tougher, harder fibers, which would be swallowed in longer pieces, which could be bad. Regular sewing thread is often mercerized or coated with something, or is made of a cotton/poly blend to add strength. Dental floss is likewise strong and resists tearing into shorter pieces. Cassette tapes, carpet backing fibers, tinsel, etc, are all higher on tensile strength than plain cotton fiber, but IF EVER IN DOUBT, DON'T DO IT. My Am Bulldog had a cotton rope toy for years and never tore it up (although she nearly beat herself senseless with it). My BF's BC had one she tore up but never ate any of. I think I'd just warn people that it could happen, and not let the dog have it without supervision. They're fun to play with, though, if oyu're there to keep it from being eaten.

Jenn said...

Poor kitty. I'm glad you were there to help ease him out of pain. Does the string always get caught around the tongue in those cases or is it just highly common?

It amazes me what animals will eat...they are so much like little kids. One of my dogs likes to tear the fuzzy outer covering off her tennis balls and eat it. I always find the strangest colors in her poop. Another one will eat Crayons and chalk if she finds it left lying around by my youngest. I can't even imagine those things taste good! Sheesh.

AKDD said...
This comment has been removed by the author.
AKDD said...

It's just highly common. Sometimes you get it hung up in the stomach or lower gut as well. Occasionally it will exit the GI tract without causing major harm, in which case you should carefully trim the dangling bit as it appears, and NEVER pull on it.

Crayons and chalk - could be they just smell good or have an appealing mouth-feel. Or maybe they just want more colorful poops to make the other dogs jealous.

Carole said...

Would it be possible to simply cut the string from the cat's tongue and see if it works its way through? Or is there just too much internal damage already for that?

Just came across your blog and I'm just fascinated. Thanks!

AKDD said...

Carole, glad you're enjoying the blog!

Interesting question about cutting the string. I suppose, theoretically, you could cut the string and hope for the best, but it's not medically advisable. I've heard it suggested, but not by anyone who has seen the consequneces, and certainly not by anyone I'd consider an authority. There's no way of knowing if the string would hang up later down the line again, and you're back where you started. The other problem is that, once the string is cut, the gut un-pleats, and then any holes that have been sort of purse-stringed shut by the pleating of the gut now open up and dump the gut contents into the peritoneum. This leads to a raging peritonitis, massive infection and shock. Peritonitis is a miserable, painful death. Those are animals who are suffering, and part of the job is to prevent suffering. I guess I can't say that NO animal would survive if you just cut the string, but the odds are extremely poor, IMO, and the potential consequences grim.

There's no way of knowing now how many holes were in that kitty's gut, but I'd pretty much guarantee you it was more than one. The fact that the cat was shocky already means he was in trouble. Even surgery might not have saved him at that point, but it would have been his best shot, if we were able to go there.

That said, I and other vets HAVE saved peritonitis cases - my Grand Rounds case senior year of vet school was one, in fact - but it's not easy, and may require multiple surgeries. So having peritnoitis is not a guarantee of death, but it's a damn good downpayment on it, unfortunately.

AKColleen said...

Wow! What a day! This is why I don't want to be a vet, as much as I love animals. One DOA and one euthanasia. Made me cringe just reading about it! Not wanting to be a vet might also have to do with the daunting prospect of the schooling...

AKDD said...

Well, the schooling IS a bit daunting, which is why you just have to plunge ahead without really looking at it too hard. But I will say that Vet School was a complete BLAST. I had a great time. It was a TON of work, mind you, and quite stressful, but it was really fun at the same time, and very satisfying too.

And just look! Because of all that, here I am blogging like a normal 21st century human!