Tuesday, July 24, 2007

In a Deep Sleep

Greetings and salutations, I hope all is well for everyone. My block of performing anesthesia is coming to an end. Overall, the block has been a fantastic review of previous material and a great beginning to see what we learned about drugs in effect. In just a short three weeks, I've seen a great selection of cases, many of which were orthopedic procedures. I've done anesthesia on dogs getting hip replacements, cruciate repairs (the equivalent to when people tear their "ACL"), luxating kneecap repairs, and more. One case in particular was very unique. A dog was brought in as an emergency because it was hit by a boat. To explain in more detail, the dog was riding on its owners boat at one of the many lakes near here and jumped off the front of the boat while it was in motion, went under the boat, and got caught in the propellers. It was quite a horrifying site to see the dog so mangled when it came to the vet school. After the dog was systemically stabilized, it was taken to surgery. It had to first have some skin damage along its chest treated, then have one of its hind limbs entirely amputated (no joking, the leg was hanging by a thread), and the other hind limb was horribly broken, so it had an external fixator placed. This is where you place pins through the limb and bones so that they come out each side of the leg by a few inches, then secure the pins on each end to a metal piece going perpendicular to them (i.e. in the direction of the limb), so that in the end it kinda looks like a ladder, if that makes any sense. The dog is actually recovering well, but needless to say, it's not going to be able to walk for another couple of weeks.

Another fascinating case assigned to me was that of a small mixed breed dog that required a "balloon valvoplasty" procedure. This is the exact same procedure that is done in people where a very long catheter is placed into the jugular vein and/or up through the femoral vein (in the leg) all the way into the heart. Animals (and people) who need this procedure have a heart valve that is not opening up enough to allow proper flow through the heart, therefore, the end of the long catheter has a balloon on it which is inflated to allow stretching of that narrow passageway. While this may sound fascinating, it is an extremely dangerous procedure. I was told prior to inducing my patient that its likely for the dog to just die on the table and there's nothing I could do about it (i.e. it's a dog with heart disease to begin with, and if the balloon is inflated even slightly too much, the valve can tear, leading to almost instant death. The good news about this case was that the dog did fine with the procedure and anesthesia, the bad news is that they couldn't fix the dogs problem. Not all hearts are amenable to these procedures and you can only hope that you can resolve the issue.

Sadly, I must tell of my case from yesterday, as I had my very first ever anesthetic death :(. My case was a 15 year old dog that was presented for an anal sacculectomy....and yes, its as gross as it sounds. The dog was going to have an anal gland removed because there was a tumor growing in it. Geriatric dogs like this one are always a challenge for anesthesia for a lot of reasons that I can explain in detail if you'd like, but this one also had diabetes, and while undiagnosed, we felt it had the beginnings of Cushing's disease (where your body makes too many steroids). I induced the dog and for the most part his induction went smoothly. At the beginning, he was having trouble getting enough oxygen, but we realized that because this dog was really, really, obese, it had difficulty expanding its chest enough to inflate all of its lungs. I caught onto this quickly enough and began to breath for him with big breaths and he maintained oxygen levels perfectly. The techicians then began to prep the dog for surgery (clipping hair, sterilizing the surgery site, etc) and about 30 minutes later I noticed his heart rate going 120......110....100....95.....90..... I then proceeded to ask the anesthesiologist on duty for some glycopyrrolate, a drug that can stimulate a low heart rate. She said ok, and came over with some to draw up into a syringe. Next, I said to the technicians, "Ummm......can you guys check to see if his ECG leads were on correctly?" because there was a flatline. The anesthesiologist saw this and immediately listened to his chest, then shouted out "We have an arrest! Someone get me the crash cart!" Thankfully, people came from everywhere and immediately we had around 15 people there to help out. Since I was already giving him breaths before going into cardiac arrest, I was in charge for breathing for him while the doctors performed CPR and gave drugs like epinephrine. Much to our surprise, we brought him back to life within a minute; he was breathing on his own, he started to get reflexes back, etc. We all stayed with him to the point where he sat up and practically kicked out his endotracheal tube.

The doctors wanted to get some blood gas values on him, so they started to pull some blood, then he started doing what they call "the kick of death" which is a spasmodic twitching of the limbs before going to arrest, then fell over, and went back into cardiac and respiratory arrest. Again, thanks to all of the help, we resuscitated him back to life. Unfortunately, I don't think his heart fully recovered and would repeatedly go back into arrest whenever the epinephrine we gave him wore off. We were going to put him on a constant epinephrine drip, but by that point the owners of the dog arrived and awaited their decision whie we had him stable.

My classmates today pointed out to me how amazed they are at how unphasable I am in the face of stressful situations such as that. However, I told them about how that was the case until the clients arrived. Just as I explained in my previous post about performing euthanasia for the first time, the dealing with the dog itself should not get to me, in fact, it would hinder my ability to save the dog. However, when those owners arrived bawling their eyes out, calling to the dog even though by that point he was likely brain dead, it became very difficult for me to do anything. That is by far and away the hardest aspect of the job, not performing euthanasia, or rectal palpation of cattle. What made matters much, much worse was that the dog went into arrest while the owners were in the room with the dog. We had to be sympathetic to the owners and escorted them out of the room while we performed CPR again.

In the end, we resuscitated the dog 7 times before the owners decided to call it quits and I completely felt their pain. Noone should have to go through such pain, but its an inevitability when one decides to own a pet. The amount of love and companionship they give us more than outweighs having to deal with such pain. We discussed the case and I was told I did everything perfectly, gave the dog much smaller doses of anesthetic than a young, healthy dog, kept breathing for him etc, but anesthesia is always a risk for patients like this one. The owners made the right decision when they decided to stop performing CPR and I completely feel for their loss.

Sorry for the sad news, but my next block starts on Monday and I get to go to the other end of the surgery table as my next block is on orthopedic surgery, which I find super fascinating. Thanks to all for reading!


Sara Conrad said...

Great blog. Sorry to hear about dog. It must have been tramatic for all involved. Sad.
My dad went to Virginia Tech and I went there for sports camp years ago when we lived in Reston.
I found your blog cause I was googling "morbidily obese and limping" cause my almost 3 year old GSD is both of those.
sigh. Back to the search for info.

The Foodist said...


I dont know if this helps but look into possible Severe Hip Displacia (sp). Im no vet but those are the symptoms my dog just recently had. He must have gained 50 or so pounds in a matter of 2-3 months.

Its a thought and I hope it helps

The O said...

Hi Sara,

Thank you for checking out my blog, and I'm glad you enjoyed it. While there are many possible etiologies for your dog's limping, but The Foodist is correct, hip dysplasia is the first one that comes to my mind with a German Shephard. I know it's not always easy, but in dogs predisposed to orthopedic disease, keeping them at an ideal weight is a top priority. All that extra weight is adding stress to their joints. I hope all goes well with your dog and your vet is able to help you out.

Sara Conrad said...

Thanks for your replies!

I my pup (he's still so young and puppyish) to the vet, he got xrays and he doesn't have arthritis or anything. He is still limping. I'm calling them back today. I'm thinking he has acl or something wrong. His x-rays are fine. Oh, and he has lost a lot of weight! I am starting to see a shape to him again. It's just his front leg.

Sara Conrad said...

Just to let you know, 5 months after my dog started limping, after spending over $3000 on him for arthroscopic surgery and x-rays etc, etc... He just got diagnosed with cancer. My vet thinks it is either osteosarcoma and/or hermangiosarcoma. He just turned 3. I'm the only one that thought something was "really" wrong with him and I'm devasted. Please please please check everything you can when you get "out in the real world", maybe if they had run a blood test they would have found elevated calcium levels or something and I could have started something before it was too late.
I'm soooooo sad.

Sara Conrad said...

He died on Saturday. At home by himself, I was at work and my son was in a different room. I took his body up to CSU vet school so they can necoprsy him. I miss him so much and I'm soooooo sad. Why didn't the vets find this or test for it or look for in in JULY when I took him?

Barry said...

just trawling around trying to take it easy and found your blog.
Thankfully my old fellow (GSD) is gone to Rainbow Bridge.
He had to have anal glands removed when he was twelve and had cardiac arrest while under surgery, and thankfully recovered to go on for a further 6 years of happy life before having to be P.T.S.
Sorry you had to go through this stress while training but hopefully it will make you stronger as it is almost sure to happen again in the future in your chosen career.
Good Luck with the rest of the time you have left and all the best then with your chosen Life which I envy.