Wednesday, November 17, 2010

Twenty Minutes Later...

We are very happy to have a guest blogger this week: our new associate, Dr. Jennifer Compton.  Dr. Compton was kind enough to share some of her experiences from vet school at Tuskegee University.   

(Dr. Compton, in the blue hoodie jacket, securing the west end of an east bound calf)
Among the most memorable experiences of my vet school career are those of our Large Animal Ambulatory rotation.  There is no better way to bond with your classmates and clinicians than by piling up in the cab of an F-150 and riding around rural Alabama smelling of cow manure.  In addition to the experience in large animal medicine, this rotation taught those special life skills you can only learn in the field….how to improvise, think on your feet, rely on your colleagues, and most importantly, how to catch and restrain a 6 month old calf running rampant around a muddy paddock.
For most large animal calls, it is customary for farmers to have their cattle in a holding pen prior to the arrival of the veterinarian.  To many farmers, this is a small gated area with a chute of some sort. To some farmers, however, a holding pen is nothing more than a half-acre paddock filled with mud and debris from old fencing material and farm equipment.  To a junior veterinary student, this kind of holding pen means herding our patient around a slick, muddy obstacle course.   It was exactly this kind of area that my classmates and I found ourselves in on one particular call.  Facing this, we all filed out out of the truck, fresh in our coveralls and rubber boots and began chasing a lame calf around the paddock. 
Twenty minutes later, we finally managed to herd the calf into a “chute” (I use that term loosely), and close it in with a gate.   During this time, our clinician simply watched from the sidelines while the owner of the calf was strangely absent.  A mere 40 seconds after entering the chute, the calf came flying out wearing the gate around his neck and shoulders.  Not ready to let our patient escape, a couple of classmates and I grabbed the gate and held it steady in an effort to keep the calf within reach.  Not successful.  Our calf kicked free and continued his tour of the muddy paddock.  It’s amazing how fast a lame calf can run. Our clinician, a seasoned large animal vet whose demeanor most closely resembles “Eeyore”, moved slowly from his position on the sidelines only to remind us “You’re not supposed to let him go, hold onto him while you’ve got him!”.  Thanks.  We hadn’t kept that in mind while being tossed around by a calf powered gate. 
Thirty minutes later, our lame calf was claiming victory in pursuit of freedom.  We had nowhere left to herd him now that we are minus a gate.  Our shame and defeat was comical at this point, but we had a job to do and continue on.  But then, out of nowhere, came our seasoned clinician and his rope.  With all the energy of a cinderblock he gave the rope a few swings over his head and effortlessly tossed it in the direction of our calf.  Moments later our patient was captured.  Our group was certainly appreciative of his valiant effort, although we would have liked it sooner.  We then began our next task: to restrain the beast.  This involved a hobble, a firm grasp of his tail (my job), and about 3 of us to hold him once he was down.  So that’s what we did, and only a few minutes later, his injured claw was inspected and cleaned and he was released back to the freedom of his muddy paddock.  Nothing to it.
Forty minutes later, we finally got our truck (not 4-wheel drive) free from the mud pit it was trapped in with minimal damage to the surrounding structures.  Then we were on our way, ready to see what was in store for our next large animal adventure.   It sure is nice to be a small animal vet now, but even better not to be the lowly student anymore!

Here are some of my other favorite quotes from the large animal ambulatory rotation:
Large Animal Vet: “When I say run, you RUN!!!!!”       

Classmate: “What do you say when we get back to school we all take a cattle prod?”
Me: “No.”
Classmate: “Why not?”

Tuesday, November 9, 2010

Gift from a Client

“We outlive them. It’s sad, but that’s how things are designed.”

I have to say this fairly often to people who are dealing with terminal diseases in pets. We deal with the same sorts of diseases in animals that humans are afflicted with-  cancer, kidney failure, and heart disease for instance. Eventually, a lot of owners are faced with the decisions of whether or not to euthanize a pet, and when is the right time to do so. Honestly, the second one is the hard one for most owners that I talk to.

There was one particular dog that I remember from a few years back. The dog, Jake, had come in for weight loss, diarrhea, and vomiting. None of these is an unusual thing in and of itself, but Mrs. Jeffries said that something was off about Jake’s behavior as well.

As I started the physical exam on Jake, I saw that there was a bulge in his belly that wasn’t supposed to be there. I felt his abdomen, and immediately bumped into a mass the size of a baseball.  Given the location, Jake’s age, and his symptoms, this was more than likely going to be cancer. I talked it over with Mrs. Jeffries and she decided to do an X-ray of his abdomen and chest to see more about what was going on. The images we got didn't hold good news- there were spots in his lungs, and it appeared that the mass had entrapped a couple of different sections of his intestines as well.

Given the prognosis, the owner decided to try to keep Jake comfortable and give her family some time to say goodbye to him. We put him on medications for nausea and any pain that he might be feeling.  We knew that most likely we didn’t have long before his quality of life declined to the point that his owners would have to let him go.  I asked Mrs. Jeffries to call me if anything new developed and she took Jake home.

A couple of days later, I got a phone call from her.  Jake had stopped eating his dog food completely.  Mrs. Jeffries had some time to come to grips with the situation, and was as upbeat as she could be about things. She knew that he didn’t have long, but she wanted to make the most of that time.

“Dr. Bean, he really seemed interested in a McDonald’s hamburger that my daughter brought home last night.  I know that people food isn’t good for them, but do you think it would be O.K?”  Mrs. Jeffries asked.

“Considering the situation, I think that whatever you want to feed him is fine. It’s more important to me that he gets some calories in and for him to be happy than anything else. When my time comes, I want to go out with an empty Snickers wrapper in my hand.”  I replied.

She chuckled a little, and we said goodbye.  A few days after that, Jake’s situation became untenable and she decided that it was time to let him go.

The next week, I came in to work on a Monday morning, and found a wrapped gift box with my name on it lying on the counter in the clinic’s pharmacy area.  I asked my boss what was happening, and he said that he didn’t know- he had found it on the doorstep that morning when he got there.

Inside the box was a thank-you note from the Jeffries family, a picture drawn and colored by their daughter…. And a Snickers bar.


Tuesday, November 2, 2010

One Tough Dog

Another recent event...
Last week, we had a young pit bull mix (we’ll call him Bullseye) come in with what we suspected were gunshot wounds in the hip and the chest. He was somewhat depressed, weak, and had lost an undeterminable amount of blood. Lungs sounded OK, so we kept him for observation overnight. The situation dictated that we not do x-rays at that time.  He was a little better the next morning on meds, so we sent him home. We asked the owner to call us if there was any more trouble, or if his recovery wasn’t steady.

You may be wondering, why not pull the bullet out?

We see a lot of animals that have bullets, airgun pellets, BB’s and lead shot from shotguns in them that the owners never knew about. It’s what we call an “incidental finding” on an x-ray: it’s there, but it’s not causing any trouble where it is because the body has usually walled it off with scar tissue. We’ll often be looking at a broken toe or an enlarged heart on an x-ray, and then have to show the owner the extra metal that their animal is carrying around. There’s normally the potential for doing more harm than good when you go after the metal, so leaving the bullets in place when they’re not a medical issue is pretty standard in animals. 

Back to the dog-
Four days later, the owner brought Bullseye back late in the afternoon for new swelling on the point of his chest about the size of a fist. Dr. Fraser opened it up, and emptied out some bloody fluid. Then she checked inside the wound with a vascular clamp and ran into something hard attached to shredded muscle in an area that was supposed to be all soft tissue. Bullseye was stable and in good spirits, so we waited to do the exploratory surgery until the next day when we would have more time to do it properly.  Anesthesia, x-ray, surgery, and recovery all take time and we prefer to have animals wake up early in the day so we can watch them closely.  So Dr. Fraser patched him up, medicated him for pain, and housed him in a quiet place to rest.

This occurred on my afternoon off, so Dr. Fraser sent me an email describing what she found (the late night email is a pretty common occurrence between doctors at Branchville). I was scratching my head after she described things… neither one of us was really sure about what was going on, but having hard things attached to muscle usually means a piece has broken off a bone.  Not good. Given the direction we thought the bullet had traveled, it was possible that it would be ribs, shoulder blade, or the top part of the humerus (the upper arm bone). I took a little solace in the fact that this dog was still –amazingly- walking around with barely a limp. It couldn’t be too bad, right?

Bright and early, a tech and I got Bullseye sedated and took an x-ray of his chest:

As you can see, there were two metal objects in the front of the chest cavity. The one that looks like a mushroom is the expanded lead core of a hollowpoint .45 bullet. The curly looking one is a side view of the bullet’s copper jacket which peeled away after traveling through the heavy muscles and tissues of the chest wall.

Most hollowpoint pistol ammunition is composed of a cup of metal that touches the barrel, and a core of softer but denser metal that expands on impact with a target. This bullet had simply split into its component pieces, as many handgun bullets do at some point after impact. We went in and removed the bullet pieces - this situation was unusual in that they couldn’t stay where they were.

Here’s what they looked like when we got them cleaned up:

There is a dent in the lead core where it skipped off the humerus and chipped a small piece of bone away, but that damage is pretty minimal.

About 30 minutes after we took the bullet out, Bullseye was walking around. He left that afternoon and has been doing well for the last week.

For all the CSI / Law & Order / Bones fans out there, here’s the technical breakdown of the bullet path and dynamics inside Bullseye: The entry wound was on the left chest wall just behind the point of the elbow traveling slightly downward. The bullet traveled forward under the skin, beneath the shoulder blade, deflected off the head of the humerus, and passed forward across the top of the sternum through the pectoral muscles. Bullet fragments came to rest in the pectoral muscles on the right side of the chest- the bullet crossed the midline of the body. The chest cavity was undamaged.

Total length of the bullet path was 9 inches. The bullet began at .45 inches in diameter, and the expansion of the bullet left it at .70 inches in diameter when it reached the end of its travel. The separated jacket is intact, but sheared into 8 roughly even “petals”.  Recovered weight was 181.1 grains. If the bullet weight started out at 230 grains, then retained weight was about 79%.

Through an incredible set of circumstances, this bullet went from one side of the dog to the other and never hit a critical structure. He was always able to walk. During the 5 days that the bullet was in him, he was never in immediate danger.

Even so, law enforcement data shows that 80-90% of humans hit with a similar handgun round either don’t make it or are too incapacitated to continue fighting (this data is usually compiled from reports of people who are in gunfights with police).

I say all of that to say this:  Bullseye is one tough dog.