Wednesday, February 25, 2009

Unnatural Appetites

In vet school, there is (at least there was at my U when I was attending) an entity known as "Grand Rounds".

Regular rounds are when all the docs (and in the University setting, students, plus or minus the techs) get together (usually twice a day) and go over cases. At the University, that is in part so everyone can learn from all the cases, and in all settings it's in part so things don't fall through the cracks and we keep everything in mind and stay abreast of progress or lack thereof. It provides an opportunity to bounce cases off one another, if we're stumped, and lets us learn from each other. And of course, if I'm about to have a day off, I want someone to be up to speed on my cases so they get good care while I'm gone.

At any rate, during vet school, each senior gets a Grand Rounds case. Grand Rounds are presented once a week to the entire school - any member who cares to attend, be it doctors, techs, students, ancillary staff, what have you. Generally speaking it's seniors and some juniors (those who are not actively tied up in class or on rotations that can't spare them), plus clinicians and some technicians. However, especially in the summertime, underclassmen sometimes attend. Generally two or three students present cases each time, and all seniors have to do one in order to graduate. At the beginning of senior year you are assigned a clinician to be your Grand Rounds advisor, and you pick a case from his or her service (for instance, if you are assigned Dr. B from equine medicine as your Grand Rounds advisor, you pick a case from your equine medicine rotation, not one from your small animal dentistry rotation). Sometimes this meant that you didn't have a particularly exciting or happy case to present; there's no controlling what comes in on a given week to a given service, so you have to take what you get.

Naturally, this is cause for consternation for most of the seniors; not only can a roomful of clinicians eviscerate you in front of your peers and future colleagues if they choose - and sometimes they do, if they think you haven't done your homework - but a great many people would rather run into a burning building than get up and speak in front of a room full of people. For some reason this doesn't trouble me as much as it does many people, which has always puzzled me; on personality assessments I test as a relatively strong introvert. I should hate this. But I actually kind of like it. Go figure. That's not to say I wasn't nervous and stressed; it could, after all, affect my ability to graduate, and no matter how you slice it, it's scary to get up in front of the gauntlet, knowing they could decide to mow you down in a hail of verbal bullets.

However, I had two things going for me: One was that I had already had a trial by fire of a similar sort (although of a much smaller scale) when I passed my oral exams during my master's program. The other was that I had the good fortune to be assigned Dr. B, the head of small animal soft-tissue surgery, as my advisor. This was fortunate in part because he was easy to get along with and liked me; it was even more fortunate in that I inherited, the week I started that rotation, an excellent case that would make a very interesting Grand Rounds case. The case had actually begun the week before, but bridged a rotation switch, so the student who had started the case was on to another service, and I inherited it.

So, I did my homework and prepared intra-op and post-op slides (with the help of the excellent G, the visual aids and media expert at the teaching hospital). My Grand Rounds presentation was scheduled for the spring, several months after the case in question; as I got close to the scheduled time, I called the owner to get an update on the dog so I'd have follow-up to report. I did the best I could to have my ducks in a row, which to some degree alleviated my anxiety. Certainly I was less nervous than the other student presenting that morning, the soon-to-be-doctor S. Graves (poor man; imagine going into an exam room and having to say to a client, "Hi, I'm Dr. Graves." Too bad he didn't share my internship, when - I am not making this up - I worked with Drs. Grimm and Dier.) At any rate, on the morning of our presentation, SG was pale and clammy and more than a bit shaky-looking; when he asked me if he could go first, I wasn't inclined to argue. We'd all heard horror stories about students who got up, opened their mouths to begin, and promptly vomited all over the front row, or else been unable to force a single word from their mouths, or else pitched into the laps of the audience in a dead faint. SG was whipcord lean, but tall and broad shouldered and with a certain rawboned solidity. I didn't fancy having to try to break his fall - since, as a presenting student, I was front and center. He survived his presentation without seizure, syncope, emesis or vocal paralysis (although I believe at one point he felt cardiac arrest might be imminent). He fielded questions, concluded his presentation and sat down with an enormous sigh of relief and a rather sickly grin of encouragement for me. All right, then. I'm up.

Fortunately for me, I had as my case the aptly named Muttley G, an endearing creature, not lacking intelligence so much as being of slightly less common sense than soap. Muttley was enormously engaging, possessed of tremendous bright-eyed (albeit scruffy-faced) charm. He was an Airedale mix of indeterminate origin, having come into his owner's possession as a stray. Muttley lived peaceably with Mrs. G - a pleasant, active, 50-ish tennis matron of comfortable means and kindly demeanor - without incident, for many years. However, owing to an unfortunate inclination to ingest everything in his immediate vicinity without regard for its edibility, Muttley found himself one day at his usual vet's office, having swallowed an intact half of a tennis ball (apparently without taking the precaution of chewing it into smaller bits first). For reasons I cannot explain (although I was not there at the time and thus am in absolutely no position to criticise), the vet, on finding the tennis ball inMuttley's duodenum, decided to try to milk it down to the colon, where it could be expected to pass without further incident. I'm not clear on why this choice was made; the duodenum is pretty tolerant of surgery, and if you have to milk it somewhere, why not back into the stomach, which not only is WAY closer by, but seems to be delighted to have surgery, and tends to heal rapidly and without incident? - Well, as I say, I wasn't there, and no doubt it seemed like a good idea at the time. In any case, the hemi-tennis ball made it to the ileocecocolic junction - where the small intestine, the cecum and the colon all meet - and apparently decided to take a stand. This is a narrow spot in the gut anatomically, so it only makes sense that things might get stuck there. Unfortunately, if you're going to do gut surgery, this is a spot to avoid; it has the second highest bacterial load of the entire gut, second only to the colon, and it is also the place in the entire GI tract most likely to dehisce. So, if you add high bacterial count plus high likelihood of the incision line rupturing, and then add in maximum tissue handling during the milking and cutting procedures, which in itself increases the chances of the incision line failing... well, you get the picture.

Evidently Muttley's ileum got the picture too, and a few days after surgery he re-presented to his doctor with a painful abdomen, spiking a high fever and vomiting. He got punted to the U, where we unzipped his previous incision, only to be confronted with an entire belly full of semi-digested kibble swimming in an inflammatory soup of horror-film proportions. I don't know if you can imagine how many zillions of tiny nooks and crannies there are in an abdomen; the organs are all neatly packed in there, but with myriad folds and flexures in the intestines, long deep clefts between the lobes of the liver, channels and alleys that run along the vessels and around the bladder and spleen, small secret pockets of potential space in every possible location. Add to that the omentum, a large lacy membrane as thin and pliant as fine silk and several square feet in area, draped and folded all over everything, and the possible hiding places for tiny granules of wet kibble become astronomical. With each little speck of food go zillions of bacteria. Small wonder then that Muttley had a peritonitis of biblical proportions, and was officially In The Land Of Deep Doo Doo.

What kills these dogs is generally the infection; it's like having a biiiiig abscess where your abdominal cavity is supposed to be. This, as they like to say in the trade, is a condition Incompatible With Life. The treatment for an abscess is to drain it. How to do that in an abdomen? If you poke a big hole in it, the guts show an unfortunate penchant for falling out onto the floor, which can really mess up your carpet.... not to mention your whole day.

The solution for this is open peritoneal lavage. This means leaving a nice 10 or 12 inch incision open for 4 or 5 days, and going in once a day to rinse the cavity thoroughly. You discourage any unauthorized fraternization between abdominal contents and the outside world by loosely whip-stitching the body wall together, leaving about a one-inch gap for drainage, and then packing that gap with about an acre of lap sponges. In the skin you set a series of nylon sutures in big loose loops, like the eye part of a hook and eye fastening. Using these, you lace a length of umbilical tape over the lap sponges like you're lacing up a tennis shoe; the lap sponges are like the tongue of the shoe and the abdominal contents are like the foot in the shoe, snugly laced in place. The whole assembly gets covered with a waterproof plastic Stick-Tight drape, which serves the dual purposes of keeping fluids from seeping out, and keeping urine from seeping in (a non-issue in female dogs, but sort of an issue with males. Seeing as how Muttley could piss on his own front legs and abdomen with the best of them, this was an essential precaution for him.)

Every day Muttley got anaesthetised, un-stuck, un-laced, un-whip stitched, filled with several liters of sterile saline warmed to body temperature, agitated like a Maytag on the extra-power cycle, suctioned out, sorted through, hand-plucked of any debris, washed and suctioned at least twice more, and then re-closed. He took this all in a spirit of good fun, apparently believing that part of the game was to turn counter-clockwise in his cage at least 6 turns every hour or so, thus twisting his IV line, his EKG lines and his bedding into bizarre ropey creations which required de-tangling by harried ICU students at least 18 times a day (they got a break when he was actually in surgery and anesthesia recovery).

Five days later Muttley was well on the road to recovery and feeling fine, a fact he demonstrated by eating a student's lunch (including brown bag, baggies and napkin) while no one was looking (fortunately he declined to eat her fork - or maybe he just hadn't gotten that far when we caught him). In case he was missing anything else that was ingestible but not (strictly speaking) edible, he also spent considerable effort attempting to raid the trash at every opportunity. We took this as our cue that Muttley would like to go home now. We sent him back home with a happily smiling Mrs. G and a really big E-collar, since Muttley had thoughtfully indicated before leaving that his abdominal sutures were next on the menu.

Having detailed Muttley's adventures and itemized his final bill for the Grand Rounds audience (you don't want to know), I was fair game for questions. I tried not to look like a deer in the headlights. Luckily, everyone was charmed by Muttley's shiny brown button eyes peering out of his wiry and riotously curly face - since, in a craven (and fortunately successful) attempt to distract my inquisitors I had as my last slide a picture of his triumphal departure from the hospital, posed with me and the best-looking technician I could find - and most of the questions were either easy or ones my advisor had prepared me for. I'd taken the precaution of salting the audience with buddies who would ask easy questions if no one had any real questions (too demoralising to stand there with them all staring blankly at you after the gig, as if so stunned by your incompetence they don't know what to ask). And at last someone (I swear not one of my "plants" - actually an ICU student who had had to untwist Muttley enough times to make him regret that whole career-in-vet-med thing) gave me the one question I'd been waiting for.

"How is Muttley doing now?" he asked. In hopeful anticipation of this question I had called Mrs. G the day before to check on Muttley's progress. She had laughed merrily at this inquiry, blessed my heart for asking, expressed happiness that Muttley's case was to be presented to the entire school, and updated me on his progress.

"I spoke to Mrs. G yesterday," I replied - as if I kept up with her weekly - "and Muttley is doing fine - although apparently he learned to flop his E-collar cone-down on the ground so he could conveniently trap and eat grasshoppers, and last week he ate a dead frog and half a bar of soap." Naturally this got some laughs, although I got a sort of sour look from the girl whose lunch he'd eaten, as she hunched protectively over her morning bagel.

I sometimes wonder how he did in the long run. Mrs. G sent me some pictures of him about 6 months post-op, his hair grown back and his eyes bright and happy as ever. I imagine he's died of natural causes by now, bless his pointy little heart; he was seven or eight when I knew him and that was in 1993-94. I hope it was a peaceful end, and not precipitated by some unfortunate attempt to recycle the world's goods through his GI tract.


Holly said...

I'm on a few dog training lists and on one, there was a Sock Eating Doberman. His owner could not leave socks anywhere as he would grab them and if she attempted to retrieve them, he would swallow them whole. Since she had 3 small children at the time...this was a mostly unsuccessful endeavor.

Socks don't seem to be very digestible and this owner seemed to be a slow learner. AFTER 3 surgeries to remove socks, she finally decided to work on training him and he lived to be 10 or 11ish.

At the time I thought, thank God for vets.

Just another illustration of why you need to teach your dogs not to swallow everything they get in their mouths.

Jenn said...

I love, love, love the way you tell stories!

I can almost see Muttley's mischievous brown eyes and giggled at his penchant to eat everything within reach.

AKDD said...

Thanks, Jenn! :-)

Holly, too true... the "leave it!" command has been a lifesaver (literally) on more than one occasion...

MaskedMan said...

In Muttley's case "Died of natural causes" might well include death by consuming, say, a moderate-sized kitchen appliance...

However, there's something about the engaging, goofy manner in which most such vacuums approach life, that they're usally forgiven their dietary indescretions, no matter how bizzare. Lucky dogs. :-p

Anonymous said...

off case topic - i've been catching my dogs scrounging for bits of grain left on the floor when I miss the horses bucket. Sometimes, when opening the grain bags, those stupid strings fall on the ground and I forget to pick them up. Ever since your story about the cat with the string around its tongue I've been vigilant about keeping them off the floor and watching the dogs more closley. Hubby left one on the ground a week ago and our 12yr old GSD had it in her mouth!!

I hope they never consume a tennis ball - or half of one. I hope they just stick with the horse poop! Its also amazing how all of that could have been prevented - like you said - by taking it out in the gut. What a good sport!

AKDD said...

MM, fair point. Scarfing up inedibles WAS natural to Muttley, so a GI foreign body might in that sense be a "natural" death. And too right he was engaging. No one could stay mad at that dog for long. He was such a happy goofball.

Beth K, thanks for telling me that story - I'm glad that my little blog may have saved you and your dog from a bad episode! As for the excessive tissue-handling - well, maybe the vet that did the original surgery had a good reason for trying it the way they did. I wasn't there, so maybe the idea of working it back to the stomach and cutting there would not have worked... but it's certainly an easier job to move an object through 12 inches of gut than 3 feet of gut, and the stomach is SO forgiving of surgery that it's the best place in the entire GI tract to cut. ::shrug:: I'll never know. But alls' well that ends well, and Muttley recovered with no longterm side effects and nary a ding to his mischeivious soul.

Karl Katzke said...

One of the reasons I love large breed dogs is their goofy and somewhat indiscriminate tendency to love EVERYTHING ... including me ... although sometimes by the most ruminary of means. (I'm not sure that's a word, but it should be.)

ADKK, as was previously stated, I'm also glad to have you back in the blogging seat! One of the reasons I love your blog is that it's kind of like Popular Science (with a sense of humor) for those who don't quite have the fortitude to go through something as crazy as veterinary school, but can't help but get a very in-depth education about veterinary medicine from the simple ownership of animals that came "some assembly required"...

Linda Kaim said...

I have no less than three dogs coming for "intervention" training to teach them to not eat odd objects.

Unfortunately, two of them were due in this very afternoon when the woman called me to cancel; the older dog apparently ingested a foreign body of undisclosed nature and needed emergency surgery for it's extraction.

The other poor dog had undergone the same thing a few weeks ago which is what prompted her call to me.

It would seem that he had swallowed a piece of tubing that he had discovered in the yard from a long discarded garden hose...

I anticipate that she will be eager to at least drop off the survivor while the OTHER dog recovers.

Dragon43 said...

As a kid, I was like this dog. I ate a lot of thing that were bad... LOL

Great story...

Anonymous said...

So I'm wondering (as a veterinary student and fellow blogger) how you manage to blog about patients and not get in trouble for patient confidentiality. Do you wait a few years to release the stories? Do you change names/breeds?

I'd like to have a more open blog someday so I'm just wondering how you can do so and not get into trouble.

Also wanted to say I LOVE the blog. The stories are great, and keep me smiling and remembering that yes, I DO want to do this (even after getting dragged through the mud by midterms). Thanks for sharing!

AKDD said...

Wyld, yes, I change names and breeds - or fail to specify them in the first place - (unless I have permission to do otherwise) and most of the time the stories are some time after the fact.

Dragon, I'm afraid to ask what things you ate in your youth... I hope it was not a dead frog and half a bar of soap!

LK, YIKES! I hope the dogs in question recover and I hope you can help them to end this unfortunate quest for attention via surgery.

KK, thanks! - And it's true, if it goes wrong with your dog (or house, or car, etc), you learn a lot about it. That's how I learned to change the master cylinder in a 76 Mustang... 'cause mine went out and I helped my BF at the time change it out. Otherwise it would never have occurred to me that it would be useful to learn about!

Cavewoman said...

Love your blog! Karl had it right when he described it as similar to Popular Science.

Thus, I'm passing along a Kreativ Blogger Award. The details are in my blog.

clink said...

OMG!! I have not laughed so hard since my father past away. He, too, was a vet and told delightful stories about his adventures.

One of my favorite -- I was home from college with my best friend -- and at the dinner table Dad says........ "Cath, I had a really interesting prolapse today."

My mother quickly kicked him and crawled under the table with embarrassment.

Thanks for the story, the memories and the laughter. I'll be back to read more.

Dana - World by the Tail, Inc. said...

Hi VetOnTheEdge,

I LOVE your daily stories! My husband is a veterinarian and we own a pet hospital together in Colorado Springs, Colorado. I'm a grief counselor for pet owners so while he's caring for bodies, I'm trying to take care of hearts.

Your descriptions of certain illnesses just crack me up (from now on, I'll always think of Infectious Peritonitis as the "Land of Deep Doo Doo!"

My huband had Grand Rounds when he was in Vet school at Colorado State University. His patient had osteosarcoma and you already know how many cancer bigwigs are located there. Talk about some pressure!

Muttley sounds like a charmer. You did a great job for him and he certainly beat the odds. It's these goofy creatures who are willing to eat anything and everything that keep us in business, don't they!

I really enjoy your stuff!

friendlyf said...

What a great story ! LOL
Thanks for sharing it ! I once had one of my dogs eat 6 socks and 1 kitchen towel, when we open'd him up the socks and towel where in ONE piece ! My vet said all we had to do was give em a good wash and they'd be good as new LOL The dog was good as new too and we spent the next 6 years locking the laundry room!