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.