“Well, the shelter needs animals neutered, and the vet school needs surgery patients,” Danielle answered. “So they give us dogs and cats to work with, and in turn we provide free sterilization services. The animals are easier to place in homes if they are already neutered. Plus it helps curb pet overpopulation.”
“It sounds like a win-win arrangement,” I said, nodding. “I don’t know if I would have thought of that.”
I also couldn’t think of anything more to say, and as the conversation died away, the suffocating silence pressed in once again around our table. I stood looking down, scalpel in hand, summoning up the nerve to make that incision. Meanwhile, my teammate Dan, the surgery note-taker, had taken notice and was obviously relishing my unease. “I’d say our surgeon is enjoying a sphincter factor of about ten,” he chuckled, adding. “Just close your eyes and make a slash! It’s not the first time you’ve handled a scalpel. We’ve all dissected our share of animals by now.”
I scowled and waved the blade in his direction. “Easy for you to say! Cadavers don’t tend to become any more dead if you slip up. Plus they don’t do disturbing things like, well, bleeding.”
There was also the little matter of performing the surgery correctly. In real-life practice, it just wouldn’t do to remove Muffy’s small bowel instead of her uterus. Her chronic obesity problem might finally be solved, but her longevity could be a bit less than desired. Long experience has shown that, oddly enough, most pet owners seem to place a fair amount of importance on the longevity issue. These were not pleasant things to contemplate on my first day as a surgeon, not at all.
Nevertheless, it was time to take the plunge. I called to mind that old surgical mantra, “Grab a Knife and Save a Life,” and lowered my blade to touch the dog’s abdomen.
I envisioned a confident stroke with the scalpel, sliding through the skin so that it would part magically, practically inviting me into the abdomen. The result would be a moderately long, three-to-four-centimeter arrow-straight line, a shining example of surgical prowess. No blood, just gleaming pink tissues glowing with health, as if they were thanking me for treating them with such professional competence. Emboldened by the image, I swept the blade down the dog’s midline, then I leaned in to view my work, and I saw…nothing.
What the…?! Puzzled, I bent to look closer, squinting. No, there was not a mark on the dog. There might have been a slight scuff line on the skin there where the blade had grazed it, but certainly no incision.
While pondering this development, I heard a muffled snort from across the table, and looked up at my assistant. Jason’s face was half hidden behind his mask, but his eyes were crinkled and his shoulders shook. It suddenly struck me that he was laughing!
Before I could think of a retort, he said, “Better watch it there, Mark: you might slice clear through her spine.” I immediately felt my face flush hot, but he had a point. Despite the razor-sharp edge of my freshly opened scalpel blade, I had managed to be so tentative with my first stroke as to avoid cutting the skin at all.
I couldn’t help it, and broke into sheepish laughter as well. “Hey, if surgery doesn’t go well, it’s always the assistant’s fault,” I retorted.
That bit of humor had a relaxing effect, and things actually became easier after that. I bore down on the blade on my second attempt, amazed at how much pressure it really did take to cut through the tough skin of a dog. The skin parted, revealing the glistening white layer of fat beneath. I used blunt forceps to push apart the soft adipose rather than cutting it, causing less bleeding that way. Finally, beneath a centimeter of fat I saw the red muscle fibers of the abdominal wall. This was the important layer, the one that held in all the organs, that provided strength to the abdomen.
Along the very midline where the left- and right-sided belly muscles meet, there is a thin line of connective tissue called the linea alba (Latin for “white line”). This was what I was looking for. An incision made there was nearly bloodless and less painful to the patient. If I missed to the left or the right, the muscles I would encounter would be much heavier, and would bleed profusely when cut.
But I was having a devil of a time seeing where the linea was. It sounded easy enough in the textbooks, a wonderfully clear white stripe against the red muscles. A heaven-sent signpost saying, “cut here!” So where was the damned thing hiding?
“Wipe that for me, will you?” I asked Jason, and he used a gauze square to dab up a bit of blood that had oozed onto the exposed abdominal wall. With a freshly cleaned surface, I finally saw it, a faint white streak running down the center of the exposed muscle layer. Hardly a signpost, but I had nothing better to aim at, so I laid the scalpel along this line and cut. I was rewarded with the gratifying sight of a dark hole leading into the dog’s abdominal cavity. With a sense of relief I quickly enlarged the slit until it was about three centimeters long. We were in!
As good as it felt, I had only accomplished the easy part of the procedure. I needed to find the uterus and ovaries and remove them. I knew in theory how to do this, and had watched the procedure performed more than once by experienced surgeons. The dog uterus was like a thick rubber band, long and narrow and flexible, shaped like a “y.” The base of the y was the uterine body which connected to the vaginal canal; in front were the two “horns” which made the arms of the y. Just off the end of each horn was an ovary.
Because the uterus was narrow and flexible, the idea was to use a long slender spay hook to catch hold of the organ, and pull it up and out through a relatively tiny skin incision. Then most of the work of suturing and cutting would be actually done outside the body. How short you could make your incision and still successfully remove uterus and ovaries was a matter of pride among many vets. More than once I had seen an experienced practitioner do a spay via an opening smaller than my fingertip. To my mind it seemed like pulling a boa constrictor through a keyhole, but somehow they did it.
Our instructors had told us to not worry about incision length if things weren’t going well. “Open them up so you can see,” they advised. “You’ll save time in the long run, and long incisions heal just as fast as short ones.” Yes, but long incisions took more time to suture closed too—hence the desire of most surgeons to make as small an incision as possible.
I had begun with a three-centimeter opening, more than enough space for anyone who knew what he was doing. The problem was, I didn’t. Theory was fine, but as I fished the steel hook into the dog’s abdomen again and again, I quickly realized how much skill was involved in making it look easy. The endless loops of small intestine seemed eager to come out and play. Sadly, the uterus had more antisocial tendencies. Time and again I pulled out a bowel loop on my hook, only to stuff it back and try again.
After about ten minutes of this, I could feel my frustration mounting. My fellow students were watching the proceedings with keen interest, and I desperately wanted to perform well in front of them. I also knew that there are limits to how long one can safely keep a dog anesthetized.
I looked around to see if a professor was handy nearby. The surgery course instructors were wandering casually here and there between the tables, observing, calmly offering advice or encouragement, and occasionally handing out a sharp word of correction when they spotted a problem. For all their relaxed demeanor, they could have been overseeing a grade school penmanship class, nodding and smiling tolerantly at each young pupil’s crude attempts to control the pencil’s trajectory. This was indeed child’s play to them. I would look like a moron if I had to call for help.
What to do? My mind began to race with dire possibilities. Perhaps I might never find the evasive uterus. Maybe the dog had been spayed already, and I would spend the entire surgery session fruitlessly searching for the missing organ. No, I was convinced the uterus was there, hiding deep inside, mocking me. I would simply miss it, again and again, until my futility caught the attention of an instructor. He would approach and say loudly (so that everyone in the room would hear), “Why is it t
aking you so long to find that uterus, Mark? Everyone else is having an easy time of it. You must be doing something wrong!”
Yes, I could see it clearly. He would stand over me as I struggled, and lecture me once again on the basics of using the spay hook, as if I had forgotten everything I had heard in class. Meanwhile, I would blush deep red and continue searching without success, until finally he would throw up his hands in exasperation and proclaim, “Oh, enough of this, let ME do it!” After quickly donning gown and gloves, he would slip the spay hook in and retrieve the uterus on his first try. A nice big mature organ, the easiest type to find. The other professors and students (who had completed their surgeries by then and were enjoying soft drinks and cookies) would applaud and laugh as they watched the whole affair.
The image made my colon twinge. But what if the instructors insisted that I complete the spay myself? I could picture the surgery extending into the late evening hours, all of the professors now crowded around my lone team in the otherwise empty room. They would glower down disapprovingly as I fished the spay hook in and out endlessly. My fellow team members would be swaying on their feet, faint from exhaustion and from missing their evening meals. It would go on and on and on.…
What would happen if I never completed a spay during veterinary school? Would they even let me graduate? Would I be expelled in shame?
My dismal musings were interrupted by a calm voice from just beyond the table. “How goes it, people?” I looked up to see Dr. Brakel, one of the course instructors, and one of the best-liked doctors in the school. He was a stocky, energetic man with a broad face and unruly blond curls. Whenever I saw him, he always had a bounce in his step and a smile on his lips, even when struggling with difficult cases that would give most surgeons ulcers. His irrepressible optimism and active sense of humor made him fun to be around, and I had taken a liking to him from the first time we met. He took in my situation in a glance, and as his eyes met mine, he winked and said, “Not finding the uterus yet, hmmm?” I shook my head silently, and he clapped his hands briskly together and said, “Well, open her up more then, don’t be proud. Let’s get in there!”
I grabbed my scalpel and dutifully extended the incisions through the skin and abdominal wall. “C’mon, a bit more, make it longer!” Dr. Brakel insisted, so I kept cutting. When at last he was satisfied, I had created a gaping hole large enough that I could have crawled into the abdominal cavity myself and looked for the uterus that way. I stared at the wound, wondering how many days it was going to take me to suture that closed again.
Dr. Brakel nodded with satisfaction. “Now you can see what you’re doing,” he proclaimed. “The uterus is located fairly dorsally, up near the spinal column, so when she’s on her back like this, it is often ‘under’ the small intestines. Move the bowel loops off to the side now, and see if you can find the uterus.” I did as he said, and there, snaking out from between the bladder and colon, was a tiny, immature-looking pink noodle that forked as it extended forward. It was hardly bigger than a cat uterus, and Dr. Brakel whistled, saying, “She must be a bit younger than we thought! It’s so small I doubt you could have stretched it up out of her even if you’d hooked it. Well, go on then, remove it.”
I grabbed the uterus and pulled it up a bit to allow easier access, and began the process of performing an ovariohysterectomy. The main attachments and blood vessels to the uterus were at its front and back ends; once these were cut, the entire organ would come free. Using absorbable suture which would later dissolve on its own, I ligated the forward blood vessels near the ovaries, and then cut the tissues to free the ovaries and adjacent uterine horns—and then to the back end of the uterus, ligating the uterine arteries and the uterine body. Once all vessels had been tied off, I severed the base of the uterus. With front and back ends now free, the skinny little organ easily came up and out in my hands.
I held it dangling for a proud moment, beaming like a fisherman with a prize catch, to a chorus of “Yeah!” “That rocks.” “Another one bites the dust!” from my surgery teammates. Finally I dropped the little strand of tissue in the medical waste can on the floor. Dr. Brakel smiled and nodded at me before heading off toward another table.
I checked for blood inside the abdomen and was gratified to see none. My vessel ligatures were holding. I sighed with relief; it was time to get this lady closed! Grabbing more absorbable suture, I began the tedious process of closing the layers of the abdominal incision. First the linea alba, then the fatty subcutaneous layer, and finally the skin. The skin sutures were external and were of monofilament nylon; they would need to be removed in ten to fourteen days when healing was complete.
The incision was long enough that I had ample opportunity to practice suturing technique, and as I worked I was gratified to find that I had a knack for instrument handling and knot-tying. It occurred to me that I might have made a good seamstress. I lost myself in the rhythm of grabbing tissue, thrusting the needle through, pulling and tying suture, holding the ends out so my assistant could cut them short, and repeating the process.
Before I knew it, the incision was closed and the dog was recovering from anesthesia, sporting a nice neat (if rather long) row of skin sutures. Equally gratifying was the realization that we had finished nearly forty minutes ahead of the other surgery teams. I was grinning like a fool as we carried our patient to the recovery room and placed her in her kennel, covered by warm blankets. She was groggy and droopy-eyed, feeling the aftereffects of anesthetic and the injection of opiate pain killer she had received. But she was conscious and her tail wagged weakly when I stroked her head.
The following day I anxiously walked (okay, it was more of a run) to the kennel to see my patient. I opened the door to her dog run, and was almost bowled over by an exuberant whirlwind of golden fur. To my delight she was bouncing and energetic, eyes alight, tongue lolling, tail lashing furiously side to side as if oblivious to what had happened to her the day before. She was a happy dog, typical of her breed, and I had to grin as I watched her.
When I checked her incision, it was clean and dry, with minimal redness and no swelling or discharge. As I crouched down examining her, I felt the hot wet slurp of a tongue across my cheek. Right then it felt incredibly good to be a veterinary student. I had survived my very first surgery. More importantly, so had my patient.
KAZAN, by James Oliver Curwood
Chapter I: The Miracle
Kazan lay mute and motionless, his gray nose between his forepaws, his eyes half closed. A rock could have appeared scarcely less lifeless than he; not a muscle twitched; not a hair moved; not an eyelid quivered. Yet every drop of the wild blood in his splendid body was racing in a ferment of excitement that Kazan had never before experienced; every nerve and fiber of his wonderful muscles was tense as steel wire. Quarter-strain wolf, three-quarters “husky,” he had lived the four years of his life in the wilderness. He had felt the pangs of starvation. He knew what it meant to freeze. He had listened to the wailing winds of the long Arctic night over the barrens. He had heard the thunder of the torrent and the cataract, and had cowered under the mighty crash of the storm. His throat and sides were scarred by battle, and his eyes were red with the blister of the snows. He was called Kazan, the Wild Dog, because he was a giant among his kind and as fearless, even, as the men who drove him through the perils of a frozen world.
He had never known fear—until now. He had never felt in him before the desire to run—not even on that terrible day in the forest when he had fought and killed the big gray lynx. He did not know what it was that frightened him, but he knew that he was in another world, and that many things in it startled and alarmed him. It was his first glimpse of civilization. He wished that his master would come back into the strange room where he had left him. It was a room filled with hideous things. There were great human faces on the wall, but they did not move or speak, but stared at him in a way he had never seen people look before. He remembered having looked on a master who lay very quiet and very
cold in the snow, and he had sat back on his haunches and wailed forth the death song; but these people on the walls looked alive, and yet seemed dead.
Suddenly Kazan lifted his ears a little. He heard steps, then low voices. One of them was his master’s voice. But the other—it sent a little tremor through him! Once, so long ago that it must have been in his puppyhood days, he seemed to have had a dream of a laugh that was like the girl’s laugh—a laugh that was all at once filled with a wonderful happiness, the thrill of a wonderful love, and a sweetness that made Kazan lift his head as they came in. He looked straight at them, his red eyes gleaming. At once he knew that she must be dear to his master, for his master’s arm was about her. In the glow of the light he saw that her hair was very bright, and that there was the color of the crimson bakneesh vine in her face and the blue of the bakneesh flower in her shining eyes. Suddenly she saw him, and with a little cry darted toward him.
“Stop!” shouted the man. “He’s dangerous! Kazan—”
She was on her knees beside him, all fluffy and sweet and beautiful, her eyes shining wonderfully, her hands about to touch him. Should he cringe back? Should he snap? Was she one of the things on the wall, and his enemy? Should he leap at her white throat? He saw the man running forward, pale as death. Then her hand fell upon his head and the touch sent a thrill through him that quivered in every nerve of his body. With both hands she turned up his head. Her face was very close, and he heard her say, almost sobbingly:
“And you are Kazan—dear old Kazan, my Kazan, my hero dog—who brought him home to me when all the others had died! My Kazan—my hero!”
And then, miracle of miracles, her face was crushed down against him, and he felt her sweet warm touch.
In those moments Kazan did not move. He scarcely breathed. It seemed a long time before the girl lifted her face from him. And when she did, there were tears in her blue eyes, and the man was standing above them, his hands gripped tight, his jaws set.
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