Musings from Dr. Knox
Houston Veterinary Clinic
109 Avalon Circle Warner Robins, GA 31093
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A day in the life...a blog presented by Dr. Knox Hilliard on topics from preventative veterinary care, cool cases and sometimes just plain sarcastic humor. 

Musings from Dr. Knox

Yesterday was terrible. I hope today isn't.

by Knox Hilliard, DVM on 01/06/17

So despite my month long hiatus from the blogosphere, I am in fact still alive and functioning like a semi-responsible adult. I can begin to list the excuses here for why I've not posted but they're really probably the same as why a lot of people get busy and put things on the back burner: work, family, and lack of sleep. The holidays are always in theory a celebratory time (meaning they really haven't been since we were all around 12 years old, let's be honest) but can also be quite stressful, what with all those burdensome one click shopping outings on Amazon.com and the catching up with old great Aunts and second cousins- at least that's how you think you're related to these people? 


Well combine all that fun with what has been an unbelievable atypically busy couple of months for us at Houston Veterinary Clinic (which makes the boss happy, and when the boss is happy, we're all happy), plus I've had some trouble sleeping lately, and the last thing on my mind has been writing on my blog about educating clients and others on the web. But I'd be lying if I said I haven't missed it, because it's quite cathartic making corny joke and mocking things. Though I'll go ahead and let you know, today won't be one of those posts. 

But alas, another early morning where sleep has been an adventure so I figured it's time to let the rambling begin. Only this time I'm pretty sure I know why sleep was an adventure this evening. Yesterday was one of the most difficult days I've had since I've returned to private practice. No puppy or kitten vaccines. All medical cases (which I love by the way, but puppy and kitten visits are always a nice pick me up) and a surgery case that I will not soon forget. 

As many of you know, we have a very close relationship with the local rescue group Critical Care for Animal Angels. They take in your "atypical" rescue cases- those that most groups wouldn't have the time, money, resources or sheer desire to save. A lot of their rescues are in bad shape. A lot of their rescues (realistically most of their rescues) have been abused in the prior life and present in various poor conditions, both physically and psychologically. We've had animals come in emaciated to the point of near death, animals with motor oil burns, animals used as bait dogs for dog fighting, and on and on. It makes you lose hope in humanity seeing what some people are capable of doing to the helpless. 

But CCAA helps restore that faith in humanity by taking these animals in from certain death or euthanasia, and in conjunction with our medical efforts at Houston Veterinary Clinic, we've had a lot of success getting what may have seemed like a hopeless or impossible case and nursing them back to health to ultimately find adoption. I can't speak enough of the great work this group does. 

I have the easy part. The medical workup, surgeries, treatments, etc. are fun and challenging, but ultimately it comes down to the caretakers of these animals to make sure they get their medications, care for their wounds where appropriate, and most importantly help to regain these animals's trust in humans. That's not easy.

One such case was adopted by an absolutely incredible family a few months ago. I'll not mention her real name out of privacy and respect to her grieving family, but she was an approximately four year old pit bull who had been clearly used as a bait dog for dog fighting. The only problem was she hadn't a mean or aggressive bone in her body so she was quickly abandoned by those cowardly people with significant wounds and unquestionable emotional trauma. CCAA bounced right on her and from the get go everyone at our office fell in love with her. She was truly one of a kind in both her physical appearance from her scars and in her personality, as she was nervous but loving, never aggressive. She was easy to become attached to. After a period of time rehabbing and having all the necessary vetting done, she found her "forever home."

About one month ago she came back in with her new owners for some mild gastrointestinal signs, which we chalked up to a mild GI bug and she resolved with non-invasive symptomatic care. A week later, same story, though a little more serious. Again, she resolved with the same care. Her x-rays at that time were unremarkable as we were concerned about a foreign body obstruction. I've seen dogs that ate something several months before  showing signs that stayed in the stomach and didn't become a clinical problem for months, so it wasn't out of the realm of possibility that this could be the case with her. However, pictures don't lie and they looked clear. 

Well I corresponded with her owners over the holidays and they reported she began to eat grass almost obsessively, which in my experience often times means nothing. Some veterinarians will tell you its a signs of gastroenteritis or early pancreatitis or nutritional deficiency. But my own dogs do it and they have none of the above. Ditto with several of my other patients, so I've always filed that notion along with the "wet nose/dry nose theory of sickness" in dogs. 

Well our rescue dog returned on Wednesday in poor condition. She had been vomiting profusely, had diarrhea, and was feeling very lethargic. She wasn't the same girl we had come to known and love. We took some x-rays and the alarm was quickly sounded. You can check out the pictures of the abdominal x-rays here and here. Note the severe gas distended small intestine and the mineral opacity (bone like granular foreign material) in the bottom of the first picture. 

All signs pointed to this being a severe foreign body obstruction and surgery was a must. However given her poor condition it was important that we stabilize her first so we started aggressive IV fluids to correct her fluid deficits and get her blood pressure to a satisfactory level for surgery We also started injectable analgesic therapy and peri-operative antibiotics for the pending exploratory surgery.

Keep in mind this sweet girl was a four year old dog. Upon opening her abdomen, I quickly realized things weren't good. In addition to a severe foreign body intestinal obstruction in the mid-jejunum (small intestine) which turned out to be a baseball sized pack of grass, just distal there was a large, infiltrative small intestinal tumor. Within one foot of small intestine, she had the foreign body and an even larger tumor. 

Something I had never in my life witnessed before, the tumor had blood vessels growing into it from the spleen, stomach and normal mesenteric arteries so it was exceptionally vascularized and thus had grown exceptionally fast. In fact, the tumor had caused nearly complete collapse of the small intestinal lumen so that no food or ingesta could pass beyond it. It was a miracle she was even was alive for surgery given the extent of the lesions.

So after surveying the damage, it was apparent that several undesirable procedures would be necessary. The first and easiest was to perform a gastronomy to drain the stomach of its contents and remove and foreign material which had backed up into it. This was done rather easily. The next was to remove the spleen which required tremendous care and precision because the spleen is one of the most vascular organs in the body and because of its close, almost intertwined relationship with the tumor. The blood vessels (aka "neovascularization") from the spleen and stomach towards the tumor had to be carefully ligated and incised, the spleen had to be removed, and the mass was now fully visualized. 

Because of the damage to the small intestine from the grass impaction and obstruction, the intestine was unhealthy from that point to the area beyond the tumor and required removal of approximately 1.5 feet of small intestine, which included the terrible tumor and the area of obstruction prior to it. If you have a strong stomach, the picture of what was removed can be seen here as well as a picture of the tumor and luminal obstruction here. **Graphic**

At the moment the intestine was removed, she underwent cardiovascular collapse. Had it not been for the incredible and outstanding job of our anesthesia technician Tammy and the speed in which she realized the problem, Jenny would have died right then and there. But Tammy realized it, we immediately called for all hands on deck and our entire staff rushed to help. CPR was started with chest compressions, and vasopressors and inotropic drugs were given IV and shock fluid boluses were administered aggressively for over 30 minutes and we were able to successfully bring her back. I am always proud of my coworkers, but I've never been so proud as I was yesterday. They all came together, worked as a team and kept complete composure to do every action that absolutely had to be done or else our patient would have been lost. Tammy, Kori, Courtney, and my dad (yes, I'm giving public credit to my old man) all performed flawlessly and phenomenally well. It's one thing practicing on a dummy, it's another thing in real life.

Once we stabilized her, I scrubbed back in and finished the surgery. She was closed and the whole team stayed to help recover her over the next hour. Her body temperature despite our active warming during surgery was down to 93F, so we had to get her warm quickly but not too quickly. This was a success, her heart rate and blood pressure and respiratory rate remained strong and she became lucid enough to look around and even wag her tail prior to extubation. We sat with her in recovery in her kennel and she did well for 30 minutes, opened eyes, breathing normally, looking around. We thought we were out of the woods.

And then it stopped. Suddenly. I was immediately called from my office and sprinted to assess and we intubated her to obtain a patent airway and provide oxygen. Her heart rate was totally normal but she wouldn't breath on her own. I assessed her cranial nerves which were absolutely normal thirty minutes prior, and they were completely absent. She had developed a post-operative thromboemolism and lost brain function. Her owner arrived immediately and based on my recommendation, we proceeded to euthanize, the only fair thing for her. She was a fighter her whole life, and fought until the end. 

Part of being a veterinarian is frequently delivering bad and painful news to people. I have to do it so much that admittedly I almost become numb to it, as a way of coping. All animals and their owners are of utmost importance to me, but this case hit me harder than most. And it certainly did the same for our whole staff. We loved her as a dog and friend, and we all adored her owners. The mood at the clinic yesterday evening can only be described as somber. It was as if each of us had lost one of our own. 

We were talking afterwards about how unfair the world is, that a dog that had literally been through hell in life finally gets adopted and treated to the life she deserves, only to get a rare tumor that takes her life at 3.5 years old. How is that fair? It's because it's not fair. It was said best that cancer takes the young because Heaven wouldn't be as enjoyable without them, and I think that's the truth. I hope that's the truth. Because Earth certainly isn't as enjoyable without them.

Hug your companions harder tonight than usual, including your humans. Because you truly never know when the last time you'll get to do so could be. Our hearts and prayers go out to her family and all of those associated with CCAA. I thought it was an unbelievable gesture and almost gave me chills that when her owner arrived, all of the members of CCAA who do the heavy work were there right along with him to offer their support. 

It's been a tough week at the clinic. We lost another patient to another freak anomaly entirely too young last week that really got to us all. One case in a year like that is too many. Two in a week is nearly impossible. But still, we have a job to do and a commitment to all our patients and clients to keep working hard and fighting for their well being and health. But as we do that, I can tell you all of us have scars on our heart that weren't there a week ago. I promise my next writing will include jokes and sarcasm and will leave you laughing. But as important as laughter is in life, so are sadness, tears and mourning. 



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