How about heartworms and raw hamburger?

3-18-08 - While I was sleeping and my husband Mark was working on the other side of the county, a terribly tragic accident occurred early Tuesday morning. An SUV driven by a 23-year-old Lancaster County woman got on the highway (U.S. Route 30) on the wrong side. Unbeknownst to the passengers in the Honda Civic that was traveling the correct way on the highway, they were about to experience the last moments of their lives. The three men in their 40s riding in the Civic were on their way to work when the SUV slammed into the small car head-on, causing the death of all three passengers.

U.S. Route 30 was closed at the scene for nearly seven hours, snarling the rush-hour morning traffic. I do not have to travel on Route 30 to get to our hospital, but several of the staff members, including our practice manager, take that route. Traffic was diverted, but the slower routes were congested. Additionally, several smaller accidents occurred, which complicated things. The lower right corner of the whiteboard at the hospital was filling fast with the names of those arriving late.

When I arrived at the hospital, there were five doctors and essentially only one technician to cover the four doctors who were seeing appointments. There were two technicians in the surgery area, covering the one doctor in surgery. My first appointment, a chemotherapy patient, was only a few minutes late. My technician for the day called off sick, so I was on my own. Luckily, the night technician agreed to stay a little while longer to help. She held the Schnauzer for the injection of vincristine before going home to bed.

A short while later, I convinced a receptionist to help me hold a dog for heartworm treatment. The dog was a rescue import from one of the Carolinas. On her first visit, I gave the client my routine parasite prevention and zoonotic disease speech. Because the dog was older than 6 months, and had no previous history of parasite prevention, I recommended the heartworm/Lyme/Erlichia snap test.

In our area, we mostly see Lyme positive dogs. Seeing a heartworm or Erclichia positive test occurs much less frequently. In fact, I do not need to look at the cheat sheet of blue dots to know what a Lyme-positive test looks like; but remembering if the heartworm positive dot is on the left or the right always sends my eyes to the diagram. This time the blue dot diagram indicated that the blue dot on the test was indicative of a heartworm positive patient.

Giving the client information about heartworm disease and its treatment at her first visit seemed to overwhelm her. However, a follow-up phone call clarified the condition for the owner (who likely visited the Internet in the interim) and solidified our plan for the treatment of their new family pet. The following week, the dog came in for radiographs of her chest to assess any visible damage to the heart and lungs from the infectious disease. The board-certified radiologist reviewed the films, and finding no such visible evidence, cleared the dog for treatment.

Despite being short-staffed, we doctors and staff survived the morning. By around 10 a.m., most of the staff stuck in the traffic mess had arrived, and there seemed to be some normalcy returning to our routine.

After giving heartworm treatment to my patient, it was time to scrub in for surgery. I spayed a Westie first. It was routine; there were no complications.

My second surgery proved more involved. The dog was prepped and on the surgery table for the second time in a week.

The dog initially came to the hospital and saw one of our part-time veterinarians. It's a Chihuahua, owned by a middle-aged Amish man who said the dog had whelped one dead puppy in the early morning hours that day. Since then, the owner said the dog had intermittently been straining, but no puppy was produced. The veterinarian was able to palpate a puppy stuck in the birth canal. A caesarian section was recommended, to which the owner consented. I quickly volunteered to do the surgery because the veterinarian that examined the dog only sees appointments.

The surgery yielded no live puppies. The one in the birth canal was slightly misshapen and appeared to have been dead for some time. When the surgery was complete, I settled the little dog back into her kennel and kept her overnight for monitoring. The next day, she still did not seem to bounce back as well as I would have expected. Despite the owner's initial reluctance, I convinced him that the dog should stay in the hospital another night on IV fluids, antibiotics and pain medication.

By the second morning, the Chihuahua seemed to have improved, standing to greet staff at the front of her kennel and eating the cooked chicken that we offered her for breakfast, along with her dog food. Chihuahuas often can be little land sharks, but this dog defied stereotypes. She relished the attention, and there was no lack of it. In fact, several staff members expressed interest in her such that if the owner decided that he no longer wanted the dog, she would not be without a loving home. However, the owner did arrive, on time, to pick up his Chihuahua, and take her home (where she probably does not get cooked chicken, ever).

Less than five days after her return home, the dog was back. It began the previous morning, when one of the large-animal doctors approached me and asked if I performed the caesarian section on that particular Amish dog. Because our large-animal doctors take the phone calls in the morning between 7 a.m. and 8 a.m., he passed the message to me that Chihuahua was returning later that afternoon because she "wasn't healing right." Of course, I told the Amish owner that if there was an unusual swelling, drainage or redness to bring her right back in to the hospital. Apparently, he had listened.

When the dog arrived at the hospital later that afternoon, I was shocked to see how drastic "wasn't healing right" actually meant. Only about one-quarter of her skin sutures were intact. The upper half of the incision was open all the way down to the holding layer. She wasn't febrile, surprisingly, and still seemed very happy to see all her friends at the veterinary hospital. At the top of what used to be my pristine line of skin sutures, her skin and the subcutaneous tissue below looked like raw hamburger. She had chewed and licked an area of her skin to the right of the incision line in the process of taking out her sutures. Luckily, it appeared that she left the muscular layer intact. However, it did look like there was purulent material attached to the knots of my simple interrupted sutures. I was not looking forward to putting her back together the next day. It was definitely going to be a surgical challenge.

After admitting her to the hospital, she got a belly bandage and an e-collar for the night. I started a different antibiotic from the one I sent her home on the week prior. Despite her bad behavior post-op, it was hard not to want to give her attention and hold her. Her short little tail went back and forth non-stop when she was being given attention, making her even more adorable.

On the morning of the motor vehicle accident, the Chihuahua was anesthetized and on the surgical table. Under the drape, the only part of her body showing now was the surgical wound that needed to be debrided, cleaned and put back together. Finding that most of the subcutaneous layer was chewed out as well, I took what remained out simply by sliding my gloved finger along the original incision line. At the end of the suture line, the knot held fast. After clipping and removing the knot, I could see the muscular layer. Probing along it gently, it all appeared to be intact, but the knots did not look healthy. The surgical technician flushed the area with diluted betadine, while I gently rubbed the knots with sterile gauze, trying to free up the material stuck to the knots.

Several flushes later, I was ready to begin the repair. Cutting along the edge of my former surgical incision, I extended the width of the incision by almost one-quarter inch, debriding all of the unhealthy tissue, and creating what I thought was a bleeding mess. In this case, bleeding is good. After I cleared away the excess blood and tied off a couple persistently bleeding vessels, I decided to hedge my bets with the muscular layer and added a few extra sutures. The subcutaneous layer came together without a problem, although there was more subcutaneous tissue to bring together than I had expected.

Finally, the skin layer, too, came together. Per the advice of a senior doctor, I made the sutures very loose. I normally do keep my skin sutures loose, but these were so loose that I thought the skin would not appose well. The wisdom of experience prevailed, though, and the skin sutures were not too loose by the time I finished. I probably put in too many skin sutures, but the suture line once again looked clean and healthy. The only catch is that I'm not a plastic surgeon. After removing the towel clamps and the drape, it was apparent that two of her mammary glands now did not line up evenly. She will not be participating in any doggy beauty contestants on account of her chewing and my surgical handiwork.

The dog recovered well after her second surgery and went home to her owner the next day. When he arrived in the afternoon to pick her up, her fan club at the hospital wished her well, and although they never said it, hoped to see her back again soon -- but not before her planned suture removal in another 10 to 14 days.