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.