"Not feeling too good, are you, Jessie?" I stroked her head; it was almost totally white with age. She lifted her muzzle slightly, trying to focus her cataract-beleaguered eyes on her master, then shifted her body to find a more comfortable position.
"At first, I wondered if she was having heart trouble, but she's been looking more and more bloated over the last couple of hours."
"Has she tried to vomit?" I gently rubbed my hand over her grossly distended abdomen.
"She retched several times, but never did produce anything."
"This distention is something new, is it? She's normally quite slim through her abdomen?"
"Oh yes, I really work to keep her weight down because of her hips. If anything, I've been having difficulty keeping weight on her lately."
I lifted Jessie and cradled her against my body. She grunted dramatically as I hefted her and continued grunting with each additional breath until I put her down on the examination table.
The dog struggled to right herself, looking around desperately for her master. Dr. Walker grasped her muzzle in his hand and crooned to her in a rhythmic, comforting tone.
"That's a girl, Jessie. That's a girl. The doctor's going to get you fixed up now. That's my girl."
I slipped a thermometer into the dog's rectum and rolled back her lip to examine her colour. Her membranes were cool and so pale that I had to look closely when I pressed on her gum to see that there was any return of circulation.
"Jessie's had a rough time the last couple of years. Her hips have been giving out on her and she has a difficult time getting around. My vet has her on Butazone for the pain, but she's never been the same dog since Alice passed on."
Dr. Walker's voice trailed off for a moment then, with a far-off look, he went on. "Neither one of us has been the same since my wife died."
Jessie grunted once again as I ran my hands over her abdomen, then she released a long, agonizing groan that brought tears to her master's eyes.
"Oh, she's in such terrible pain." He looked away so that I wouldn't notice the tears. "Oh, Jessie, you poor, dear girl."
Jessie's belly was as hard as a rock. Thumping with my finger over the bulge in her abdomen, I could hear the resonant tone of a highly compressed organ. I held the thermometer up to the light and rotated it to see the mercury—almost a full degree below normal atv37.6.
"Dr. Walker, it looks as if Jessie has a torsion of her stomach. That's a grim situation for even a young dog. For a dog Jessie's age, the prognosis is very grave indeed! I know that it's my fault that we didn't see her sooner. She certainly would've been a better candidate for surgery a couple of hours ago."
With the serious nature of the old girl's condition and the fact that she had so many other problems, I was almost certain that Dr. Walker would consider euthanasia. Jessie was probably not looking at more than another year or two of life under the best of circumstances.
"You don't think her chances are very good then, Dr. Perrin?" His eyes brimmed with tears, and the corners of his mouth quivered.
"I don't like to be overly pessimistic but, with a lot of cases of gastric torsion, the spleen is involved as well; in some cases that necessitates amputation."
"And you don't think she's up to it?"
"She isn't right now. If I were to get her on intravenous fluids and treat her for shock, we may have a fighting chance. I guess you have to weigh all the odds in your own mind and determine if you think surgery is warranted."
Dr. Walker stared at his dog for several minutes, his tears flowing in a steady stream onto Jessie's coat. Finally, after what seemed an eternity, he turned to me and said in a barely audible voice, "I think I need you to put everything in perspective for me, Dr. Perrin. What would you do if she were your dog?"
"The first thing you have to consider is the quality of her life over the last few months. I notice she has cataracts and doesn't see very well. You mentioned that she has arthritis and has trouble walking. Does she mope around all the time? Does she seem able to get out and enjoy herself, or is she just hanging in there from one day to the next?
"If you're keeping her alive more for you than for her, then I think it would be best to put her to sleep. If you think she's happy, then you have to look at it from the point of view of an investment. You're obviously going to be spending money on surgery and you want to get value for your dollar. She's going to endure pain and suffering and wants to be compensated for that. The reward obviously has to be great enough for both you and Jessie in order to warrant surgery."
"Well then, I think you've answered my question! Jessie's gone downhill over the past couple of years—there's no doubt of that—but she still really enjoys life. If the truth be known, we both have our problems when we first start moving in the morning. It's certainly nothing that we can't live with. She's a very happy dog for the most part.
"As for me, Dr. Perrin, I'm an old man and living all by myself. Jessie's the only company I have. We rattle around in a big house and I've got more money left than I can possibly spend. You do the best you can for her. I know she's in good hands, and I certainly won't blame you if she doesn't pull through. I just think we have to try!"
"We better get started then." I said, with more enthusiasm than I really felt.
It was two-thirty a.m. by the time I got the intravenous started and made the call to Doris. I dialed the number, closed my eyes, and leaned back against the wall. My head was throbbing; I was not looking forward to either the surgery that I was about to tackle or the day that was sure to dawn before I was finished.
"I hate to do this to you, Doris," I began, when she finally croaked hello. "I have an old dog that needs surgery. Do you think you can come and give me a hand?"
"Okay, sure," she responded groggily. "Do I have enough time to shower?"
"We'll have to let her stabilize a bit first anyway. Unless I miss my guess, this'll be your only opportunity to have a shower before you start work in the morning."
"Oh great! And I was having such a good sleep."
Jessie's condition continued to deteriorate as I rushed around getting things laid out for the surgery. Dr. Walker stood by her. His countenance was one of dejection; his body language spelled defeat. His eyes were dull and red from crying. His shoulders were stooped and rounded; he looked very much a tired old man. He peered expectantly towards me as I checked her gums.
I looked him directly in the eyes and shook my head. "Things are not looking good. I was hoping that the fluids and steroids would improve her circulation before we put her under anesthesia."
Jessie's abdomen had become tauter over the distended stomach, but there seemed to be distention even in the distal abdomen. I began shaving the hair from her flank. She lay oblivious to the sound of the clippers.
I heard the front door open and the murmur of voices as Doris and Father exchanged greetings in the waiting room. Doris appeared, grabbed the waste basket, and began collecting Jessie's hair. Dr. Walker introduced himself and apologized profusely for getting her out of bed.
"Doris, could you scrub this area over the left flank for me? I'm going to pop a needle in here to see if we have some bleeding going on."
"What are you looking for?" Dr. Walker's face was strained as he watched me direct the needle into the peritoneal cavity.
"I'm afraid she may be bleeding internally. She's quite distended with fluid as well as gas, and her colour isn't improving the way I would expect."
I drew back on the plunger of the syringe, and the barrel quickly filled with blood.
Dr. Walker's voice wavered; his eyes were riveted on the syringe. "What does that mean?"
"It probably means that the spleen got so distended from being twisted off that it ruptured and started to leak blood into the abdomen. We have to get in there quickly; we probably need to do an amputation."
I could see that the old man had reached the limit of his endurance. His hand was trembling as it stroked Jessie's head.
"I think it would be
best if you found yourself a motel for the night, Dr. Walker." I motioned for Doris to take over his station at Jessie's head. "I think you've had enough for one day. If we need any more help, my father can come and give us a hand."
He gave Jessie a final caress, then tottered off through the waiting room.
"Give us a call as soon as you check in!" I hollered after him. "We'll want a number to contact you in case we run into more problems."
Jessie had faded so badly that she never even noticed the departure of her faithful master. Unless I was able to make some drastic changes in the dog's favour, we would all soon be able to get some sleep.
"You better get out some transfusion bags, Doris... Dad! It looks like you've inherited a job."
After another scrub, I popped the needle for the blood collection bag through the abdominal wall and watched in fascination as it filled far faster than had it been drawn from the jugular vein.
All the literature I was able to find on the correction of gastric torsion stressed the importance of decompression of the stomach as quickly as possible. As much as I wanted to relieve the pressure, I was certain that putting Jessie under anesthesia in her present state would be just another form of euthanasia.
In desperation, I decided to tap some gas. I drove a needle through Jessie's side at the point of maximum distention. Gas hissed from the hub in a torrent and, gradually, the pressure on the old dog's side lessened. Initially there was little change in her demeanour but, as the pressure diminished, her breathing became less laboured.
The blood collection bag filled as quickly as I'd ever seen one fill and, as Doris rocked it back and forth to mix in the anticoagulant, it adopted the shape of a grossly swollen tick.
"I know this may sound like a stupid question," Doris began, "but where's this blood coming from?"
"It's coming from her abdominal cavity. This is blood that has leaked from the spleen and is now lost to her as far as her circulatory system is concerned. By the feel of her abdomen, she may well be able to fill a couple more of these bags."
"Well, what good does it do to just take the blood out of there? It's still lost to her, isn't it?"
"It would be if we didn't return it, but we're going to give it back to her as a transfusion."
"You mean it's still good after being dumped out into the abdomen like that?" Doris stared in awe at the bag of blood she held in her hands.
"Sure, when it's as fresh as this blood. There's a filter in the administration set that'll remove any clots and, by using her own blood, we avoid the complications of trying to cross-match a transfusion from a donor."
"I'll be darned," Doris mused. "That's pretty neat, being able to give her back her own blood!"
Within the hour, we had obtained a second bag from Jessie's abdomen and had administered a good portion of the blood from the first transfusion. Although pressure was again building in the stomach, her colour had improved markedly, and I was feeling optimistic about her chances of handling the anesthetic.
"We don't have any more transfusion bags, Dave." Doris pulled off her glasses and polished them nervously. "Do you think we'll need to transfuse more blood?"
"The way she's leaking, we'd better see if we can get some more. Why don't you call the nurse's station and see if we can get a couple just in case. I'd hate to lose her because we couldn't give her one last transfusion."
While Doris drove to the hospital, I gave the dog atropine and Demerol as a premedication and began administering the second bag of blood. By the time Doris returned with additional bags, Dad and I had Jessie stretched out on her side with an induction mask over her muzzle. She had gone to sleep without a struggle and was now snoring deeply. We intubated the dog and connected her to the anesthetic machine.
I pushed a stomach tube over the endotracheal tube and down the esophagus. It slid easily along until it reached the cardiac sphincter, then halted as if butting into a solid object. Maintaining a steady pressure, I continued until it finally advanced and gas came gushing from the end.
"We're making the incision over here, Doris." I pointed to an imaginary line along the margins of the ribs. "We'll want both sides prepared just in case I need to make an incision down the right side too."
"That's a funny place to cut, isn't it? Why aren't you going down the middle like you usually do?"
"The textbook suggests that I'll get better exposure with the paracostal incision and, seeing as this is my first gastric torsion, I think I'll take their word for it."
"Doesn't make sense to me. You're always able to find things when you make an incision down the middle!"
Doris's words were haunting me as I applied the clamps to attach the drapes to the underlying skin. Orientation is so important when doing surgery; it's imperative to feel familiar with the area you've just invaded and know with certainty where everything should be.
The final drops of blood were running into Jessie's vein when I started a third collection. The blood flowed as freely from her abdomen as it had with the others and, by the time I completed my entry, Doris had almost finished collecting the bag.
"We know we're going to have a tummy full of blood here, Doris. Could you get me a sixty-millilitre syringe so that we can collect as much as possible without wasting it."
I soon wished that I had heeded Doris's advice. I realized before starting that the muscle layers would be much thicker here than over the midline, but hadn't given enough thought to what that would do to the abdominal access. It was after I had incised the final layer and could see nothing but an enormous pool of blood that I felt a twinge of panic. I slipped my gloved hand through the incision towards the right side. I could feel the end of the stomach tube and the huge lump that represented the engorged spleen. Putting moderate traction on the massive organ, I tried to maneuver it to the incision; it was so turgid I couldn't move it.
I repositioned the side drapes to expose the rib cage on the right side and cut there as well.
"My Lord," Doris moaned. "Will you look at that blood!"
I could see a steady flow of blood over the edge of the left incision and down the dog's side onto the floor. The front of my gown and the tops of my shoes were already soaked red.
"She's sure cranking it out!" I muttered. "She can't keep that up for long."
I quickly severed one layer after another of the abdominal muscles, then folded the whole flap back to reveal the entire anterior abdomen.
"Well, you can sure see everything now," Father pronounced sarcastically.
The peritoneal cavity was a pool of blood and the spleen, which was swollen four to five times its normal size, was split like a ripe melon down the centre of its convex surface. Blood oozed continually like a spring from the depth of the wound.
I grasped the stomach and spleen and rotated them to correct the torsion. The huge vessels that conveyed blood back and forth to the spleen throbbed with each beat of the heart. Now that I could see how much blood was leaking, getting it stopped took on a new sense of urgency. My hands were shaking as I clamped the fanlike array of vessels that proceeded from the base of the spleen and disappeared in the fatty layer surrounding the stomach.
"Open that syringe for me will you, Doris?" My voice was strained, my muscles tense. "We need to save as much of this as we possibly can."
Creating a well behind the stomach, I placed the syringe tip at the bottom and filled it time and again. Doris opened the blood pack in such a manner that she could hold the top end and still offer me access to the sterile bottom end. Each time I filled the syringe, I connected to the needle and emptied it into the blood pack. I continued until the pack looked like a gigantic engorged mosquito.
"What about all the rest of the blood that's in her tummy? Don't you have to do something with it?"
"So long as we can keep the blood flowing well enough to meet her short-term needs, she should be able to reclaim a lot of that free blood herself and get it back into circulation. Let's just keep the blood running—we sure don
't want to lose her after all this!"
Why the telephone always seems to wait until all hands are busy, I don't know—but it does. It began ringing as Doris and Father were trying to change blood bags and continued until Doris finally ran to answer it.
It was obviously Dr. Walker. Doris gave him a blow-by-blow description of what had happened. I could picture the poor old guy sitting in his motel room worrying about Jessie, but time was wasting and I needed to get on with this.
"I need some suture material, Doris!"
She quickly hung up and rushed over, fishing the packages of Dexon from her pocket. One after the other, I tied off the vessels. The size of the veins was daunting enough, especially after the swelling associated with the torsion, but there was something about the splenic artery that commanded respect. I took extra care in anchoring my suture to the surrounding tissue and placed a second ligature about a quarter of an inch below the first.
"Just look at the way that big mother pulsates." I released the vessel and watched as it throbbed with each beat of Jessie's heart.
"My lands, yes," Doris crooned in amazement.
"There must be a bag of blood left inside that spleen," Father noted, as I severed the vessels.
"Easily. The spleen's a storage vessel for blood in the body, and this one's stretched way beyond normal capacity...What's her colour like?" I separated the last of the mesenteric attachments of the spleen and carried it to the sink.
"She actually has a pinkish hue and we still have most of a bag to go with our transfusion."
"Grab one of those new disposable endotracheal tubes that came in last week and open it for me, please!" I hollered. "And open the surgery text so I can have a quick read."
Because torsions can easily recur after splenectomy, the literature stressed the need to anchor the stomach in its normal position by creating an adhesion between it and the body wall.
"What's the tube for?" Dad asked Doris in a hushed tone.
She shrugged and lifted her eyebrows.
"I'm making a hole in her stomach and blowing up the balloon on the cuff to pull it tight to the body wall. Once enough scar tissue forms around the tube, we'll deflate it and simply pull it through."
Don't Turn Your Back in the Barn (Adventures of a Country Vet) Page 14