Friday, December 24, 2010

You bettah sew dat up, Boy Part 2

It’s another incident from my time with Dr. Livingston…

It was a brilliant stroke of luck that the metro Atlanta practice I was working at was right next door to a Mexican restaurant.  I had just finished another delicious lunch there, heavy on the sour cream and spicy beef, and was walking back to the clinic with a lovely carbonated beverage in hand when a car tore into the parking lot and went sideways into a parking space.  The occupants of the car sprung out of both sides, grabbed a cat carrier out of the back seat, and hurried inside.

I picked up the pace and hit the side entrance to the clinic. Bob The Tech was already looking for me.  

“You gotta see this one, Doc. The owner thinks a bee did it” was all he said.

The two of us headed into the exam room, where the rattled owners pulled a cat out of the carrier sitting on the table. The problem was obvious as soon as Bob The Tech turned the cat’s head toward me. The left eye had ruptured and was shriveled up like a raisin sitting there in the eye socket.  The fluid that should have been contained inside the eye had drained down onto the cat’s cheek and dried there. I had read about these injuries before and the recommendation was always the same. General practitioners were recommended to remove the eye or refer to a specialist to see if some kind of salvage would be possible. The odds on any kind of functionality are near zero, and the odds on complications are very high.

I talked to the owners about options. Their major concern was the way that their 4 year old child would react to seeing his buddy with one eye. In fact, the cat had been playing out in the front yard with the child when the trouble began. The owners had heard the cat howl, and saw a bee buzz away from its face when they turned to see what had happened.

Even though removing the eye seemed the first choice for treatment, the clients simply weren’t ready to own a one-eyed cat.  They had turned down every other option that I had offered.  Just about that time, I heard the side door open, and knew that Dr. Livingston had just come back from his lunch. I asked the owners to excuse Bob The Tech and myself while we stepped out to clean the cat’s cheek.  This gave me a chance to get a better view of the wounded eye … and to get some advice from Dr. L.

I told him what was going on as he calmly sipped his sweet tea.  When we showed him the cat,  he looked at the eye, thought for about ten seconds, and then looked at me and said (drumroll, please) “What would happen if you just sewed dat up? You can tell ‘em dat it might not work, and they’d have to take the eye out anyway, but it would give them some time to think it over.”  What he had suggested was suturing the lids shut over the damaged eye, forming a biologic bandage, and giving Mother Nature a little time to do her thing.

Once again bowing to superior wisdom (I had been out of graduate school less than a year at this point), I went back into the room and talked to the clients. They immediately decided to give it a try. The name of this procedure is tarsorrhaphy. I have thought about nominating it for the “Most Difficult Word in the English Language to Spell” award. Pronouncing it is a lot easier: tar-sore-a-fee, if you’re from the South like me.

Bob The Tech and I sedated the cat and started prepping the eye for surgery. When we were just about ready to start suturing, I noticed something odd about the eyeball.  There was a little splinter-like structure adhered to the middle of it, just to the side of the point on the cornea where it ruptured. I looked at it under a microscope, and it was a bee stinger. The owners were right: a bee sting had been the cause of the trouble. We sutured the lids together, started the cat on antibiotics, and hoped for the best.

Ten days later, the family came back with their cat for suture removal.  I was expecting to see a ruined eye when I pulled the stitches out. Instead of seeing a shriveled raisin sitting in the socket, I uncovered a fully re-inflated eye that was apparently not painful.  The entire cornea (the part on the front of the eye that is supposed to be clear to let light through to the inside) was a milky white from being covered. I shined a light into the eye and there was no response- the pupil stayed the same size.  I told the owners that while the eye had returned to its normal shape, the vision in that eye was gone. Considering that we expected the cat to completely lose the eye, the owners were happy with the outcome, overall.  I asked them to come back in a few days for me to check things over.

Three days later, they were back in the office. My appointment notes from the receptionists said “Owner believes that cat can see.”  I was skeptical.  I went into the room and looked at the eye: almost all of the white discoloration was gone, and there was only a single small scar surrounded by clear cornea again. I shined a penlight in the eye, and the pupil constricted like a normal pupil should... the interior structures of the eye were working.  I moved my hand toward the eye to see if the cat flinched or blinked, and it did. You could have knocked me over with a feather at this point. The cat went from having a  totally wrecked eyeball with little chance of recovery to having a functional eye. It appeared that everything was going to be fine.

While I tried to recover from the astonishment, the  cat just sat on the table, angrily switching its tail from side to side, wondering why I had been so rude as to shine a penlight in its eye.

Thanks again, Dr. Livingston.

Merry Christmas, everybody!


Thursday, December 2, 2010

"You betta sew dat up, Boy..." Part 1

I’ve had the good fortune to work with some pretty sharp veterinarians over time.  If I was seeing something new or needed a fresh set of eyes to look at a problem I was having, I had some folks to lean on. One of those was a semi-retired veterinarian from South Carolina, Dr. L.  He’s a Korean War vet and has a neat Low Country accent that becomes more pronounced when he’s excited or unguarded.

Dr. L. was in his seventies when we were working together, and I was in my twenties.  He had owned a practice in Atlanta and sold it, and was working two or three days a week in retirement. He had a wealth of experience and a good way with people.  As a matter of fact, he is good people.  I learned a lot from him. Here’s an example:

A dog named Scoot came to the clinic with a lipoma on his elbow.  Lipomas are benign fatty tumors. They rarely pose any kind of health threat to a dog, but they can become so big that they have to be removed. And Scoot had a massive one.  He weighed about 42 pounds at the time of surgery, and a significant portion of that was the massive growth.  It was interfering with the range of motion of his leg and making him unable to lie down on that side… it was about the size of a child’s bowling ball. Taking the growth off was going to make his life a lot better. The growth was so huge that I debated as to what was more correct: Was I removing a tumor from the dog, or the dog from the tumor?

We got Scoot on the table and I made my incision. I started to work around the massive growth with my fingers, and it started to detach from normal tissue at the edges like these tumors usually do. As I started to work my fingers around the underside, I started putting upward compression on the rubbery mass. When I had nearly worked a full circle around the mass, the upward pressure I was putting on it overcame the strength of the tissue holding it in place. It tore away from the thin strands of connective tissue, flexed to get through the incision, and shot out of Scoot’s chest. Gravity did the rest of the work, pulling the massive clump of fat down and onto the table, tearing away the last remnants that held it inside.

Unfortunately, one of the last things holding the tumor inside was a huge blood vessel that had been hidden on the back side of the mass. The weight of the falling growth had torn it in two, and blood was spurting everywhere. It was under tension when it tore, so when I looked into the space where the tumor had been, I saw the end of the vessel slowly retract to its original position… behind a rib.  And it was bleeding heavily.  Needless to say, this was a problem.

I quickly ran out of gauze sponges in the surgery pack trying to keep things in check, but was getting nowhere- gauze was getting soaked within seconds no matter how hard I pressed. Being on the back side of the rib, there was no way to get to the vessel with a clamp without potentially puncturing into the chest. I realized that I was in trouble, and sent the tech to try to find me some help. Dr. L. came into the surgery room within seconds and looked at the mess I was in. I gave him a rundown of what was going on.

“Lemme see dat, young man,” he said in his characteristic drawl.  I took the gauze off the top, and the flood started again. Dr. L’s eyes went wide.

“Woo Hoo! You betta sew dat up, Boy!” he exclaimed.

And then he just walked out of the room with an amused grin on his face, shaking his head.

I was dumbstruck, expecting some sort of complex plan.  A plan devised from his years in practice?  Maybe from something he had seen in Korea?  … Well, no.  But his plan was better than mine, and he had been in practice for far longer than I had been alive, so I decided to go with it.  I pushed my doubts aside and began to sew like the wind. With the first layer, I pulled in all the subcutaneous tissue I could, trying to build the Great Wall of Georgia, filling the space where the tumor had been. I did more of the same with the second layer, and, to my great relief, the bleeding slowed to barely a drip. I finished the closure and monitored Scoot as he began to wake up from anesthesia.

We put a compression wrap around Scoot’s chest after surgery to help prevent any further bleeding.  Scoot went home the next day with a heads-up to the owners about bleeding from the wound.  That turned out to be pointless, because he recovered with no issues.

I learned a valuable lesson that day from a man who had seen a lot more bad situations than I ever had. When all else fails, sometimes the appropriate course of action is to “sew dat up”.

And the tumor?  We put it on the scale after we were done.  It weighed 7.3 lbs.