Even When You Do Things Right, You Are Wrong!
Filed Under: Dogs
On certain days you can do no wrong, while on other days it seems you can’t do anything right. Today would be one of those days. No matter what happened I just couldn’t seem to get a break - at least where one case was concerned.
Ralph was a good client, a nice country guy who seemed conjenial on the surface at least, but never the type you would want to cross. His understanding of the world was all black or white: there were no shades of gray. He always paid his bills on time but only and always expected a positive outcome. Nothing less than complete perfection meant the pet was not treated correctly. Any complications indicated that for one, you did not know what the hell you were doing, or two, that your skills were substandard in performance.
I have always heard that medicine is an art as well as a science. There are also no absolutes when dealing with living systems. No two pets' bodies react in quite the same way, for we are all living systems not mechanized beings. Clients may think otherwise however, and Ralph was no exception.
Jake was his 5 year-old Doberman pinscher. Although the breed is described as medium-sized, Jake was over the breed standard. He was a well-muscled, deep-chested, black and tan, intact male. His older brother was an 8 year-old pit bull named Buddy. Although Jake outweighed Buddy by around 25 pounds he had come out worse when the testerone started flying. Apparently Ralph’s female German shepherd was coming into heat and the boys were arguing about breeding rights. Unfortunately for the boys, Ralph had a male German shepherd in mind so both male dogs were left to find an outlet for their raging hormones. They found an alternative for their sexual frustration, and unfortunately, it was in fighting each other.
If I was a betting person I would have lost badly on that fight as did Jake. He had multiple puncture wounds at various locations and a large gash that required sutures along the side of his abdomen. I was actually a little worried that there might be additional damage below the more obvious superficial wounds. Canine teeth from a large dog can do a lot of damage underneath the skin and may just be apparent as a puncture wound on the surface. On more than one occasion I have had to repair a chest wall with the lungs expanding between the ribs on every breath, while on other occasions I have dealt with herniated intestines from a canine tooth ripping the body wall.
Regardless, anesthetic release in hand, Jake and I were headed for surgery. Using a cocktail of valium and ketamine, Jake was safely sedated and placed on gas anesthesia. After surgically prepping the wound I was able to assess the damage completely. There were some deep pockets in the surrounding muscle layers, but thankfully there was no communication to the chest. This suture job would be fairly routine and I could get back to our already-scheduled surgeries. It was a fresh wound so I did not have to debride it. After cleaning all the pockets thoroughly I closed the muscle layers carefully with absorbable suture, (trying to put back anything that the sutures would hold.) Finally the subcutaneous layers were closed with a fine layer of additional sutures, followed by the cutaneous layer with non-absorbable stitches that would be removed in 10 days.
Jake was back together. He was a little sore but none the worse for wear. I had suggested that neutering might be a solution but was immediately shot down by the owner before the surgery had begun. It was a guy thing. I suspected they would both be back when the hormones started flying again. Maybe the next heat cycle.
Jake woke very quickly, being well-muscled and having very little body fat. Since he was so bright and alert I sent him home that evening with strict instructions to keep the two separate and him quiet. Antibiotics were dispensed and I did not expect to hear from Jake or his owner for another 10 days.
Well, so much for planning. Jake was back the next day. The skin over the surgery site was swollen to about the size of a grapefruit. “Did you keep the big guy quiet?” I inquired. “Sure did!" Ralph answered emphatically. The grapefruit-sized mass was rather pliable so I suspected we were dealing with a large seroma. A seroma is a pocket of serum or fluid that is released from the surrounding damaged tissues. A seroma often develops after the removal of large tumors, for you suddenly have a large "dead space" once a mass is removed. Seromas will also develop when all tissue layers are not sutured closed following surgery or when there has been severe damage to muscle layers. In Jake’s situation I had been careful to close all damaged areas in order to prevent a complication such as this.
Some surgeons will insert a drain to prevent the formation of a seroma. Over the years I have learned that most owners cannot handle the aftercare with a drain, so I try whenever possible not to use them. Owners just don’t appreciate a section of plastic tubing inserted through a wound that is left to drain to the outside of the skin. There is something not too endearing about a blood-tinged sticky fluid oozing along the coat that will bother some sensitive individuals. Then there is the issue of staining the furniture or carpets from the discharge. The dogs themselves are sometimes not all that helpful when they try to rip the tubing out. Elizabethan collars, which resemble a giant pizza pie plate around the neck, will sometimes prevent a dog from pulling out a drain, but here again, most owners do not appreciate a satellite dish around the dog’s neck.
Regardless, the seroma was not a big deal and could be easily drained. I borrowed Jake, and with my technician, headed for the treatment area to drain the seroma. After about 15 minutes and around 500 cc of fluid being drawn off, Jake no longer had a mass on his side. I gave Ralph strict instructions for warm compresses and cage rest.
The second day following surgery Jake was back. The seroma was as large if not larger than the day before. Ralph was not at all happy: his voice was testy as he continued to inquire as to why this seroma thing was not going away. You could just tell from the tone of his voice how much he appreciated seeing us daily for a problem he thought we were kind enough to create.
“Well, Jake is a Doberman.” I answered. "What do you mean by that?" his owner snapped back. "The Doberman breed is quite prone to von Willebrand’s Disease, and I suspect that is the cause of our problem." “What in the hell is von Willebrand’s Disease (vWD) and why weren’t we informed about it earlier?” he demanded. I could tell from the inflection in Ralph’s voice that he thought I was making up a disease to defend why I was having surgical complications with his dog.
The most commonly inherited bleeding disorder in dogs is von Willebrand’s Disease. It is a defect in the production of a glycoprotein produced by the body that is necessary for blood clotting. In Dobermans it is suspected that a defect in one gene will result in the genetic defect. The more I discussed the potential problem with Ralph, the less he appeared to understand or believe me. Thank goodness his girlfriend had come with him this time and was not only a calming voice -- she, at least on the surface, appeared to believe and understand what I was saying. This was not a run of the mill, surgical complication. Instead we were seeing complications from a heritable disorder.
“Why were we not informed about this condition sooner!” Ralph demanded. We don’t routinely test for vWD unless we have problems, and even then we tend to treat rather than test, especially in an emergency situation. We had never needed to perform surgery on Jake previously, and now we knew or at least suspected the condition. Privately I was thankfull that Ralph had not decided to neuter Jake. I could see myself explaining a second grapefruit-sized seroma over the scrotal area.
“How do we go about testing Jake for this von Willebrand’s crap?” Ralph's booming voice resonated in the exam room. There are only a couple of special labs running vWB testing and the only one I can remember off-hand is Cornell. We needed to contact them concerning special blood tubes and would need to send the samples in a styrofoam freezer with dry ice. Not being able to get immediate results left Ralph just a bit disgusted and perturbed. Nonetheless he brought Jake in on a daily basis for the next several day to drain the subsequent seromas.
Finally the seromas were becoming substantially smaller and we were able to take out the stitches. With the final sutures being removed, Ralph's girlfriend informed me that they wanted to test Jake for von Willebrand’s Disease. She was to get the dry ice together as well as a styrofoam ice chest. I was to contact Cornell and get the blood tubes necessary for testing. Together we planned to send the test off on the next Monday so the blood would not get caught over a weekend in the mail and become unusable.
A few weeks later the results were in and my surgical skills were vindicated. Yes, Jake was suffering from von Willebrand’s Disease and not post-surgical stress related to the surgeon’s medical skills.
Six months later the boys were again in an argument. Guess why? and who lost? This time Buddy needed some sutures in addition to Jake's and this time the owner approved surgery for at least Buddy to be neutered. Jake, the favorite son, was sutured as before with plenty of extra suture, necessatating an elevated price for surgery. Just in case, we had a blood donor available should Jake require a transfusion as a result of surgery. As was with the last surgery all went routinely, but we were again dealing with a seroma after surgery. This one was, thankfully, not as large or quite as obstinate, and the situation cleared up in a fraction of the time.
Another 6 months passed and Jake was back. This time the boys were again fighting but neither was wounded, at least not yet. The fights were becoming routine, i.e. every time the German shepherd came into heat, and now the owner had had enough. You guessed it. It was no longer a guy thing. This time Jake was coming back to be neutered. Even one male dog with raging hormones was one too many.
Now I was in a panic. This was no longer a routine surgery for a dog with a heritable bleeding problem. We would again have a blood donor on hand at the clinic, or even better yet, blood on hand. I did not want to do this surgery and informed the owner of any and all complications I could think of, at least twice. Knowing how much Ralph appreciated complications, I was not looking forward to doing the surgery. By this time I had done thousands of neuters but not one on a diagnosed vWD sufferer.
Thankfully the surgery was uneventful. Being the paranoid individual I am, all blood vessels were ligated at least four times. I had enough suture in his wound to remove a spleen. This time there were no surgical complications. I guess you could say that at least for that day I could do no wrong. It is nice when you come across such a day, especially following some of those "Oh, Sh—" days!
Never again would we have to suture the boys, for the female German shepherd was brought in to be spayed the following month. No more sexual frustration from the kids and no lectures from Ralph. Life was good.