« February 2011 | Main | April 2011 »
Back in the fall I posted a series of photos, sort of a "diary" of the healing of a bad crushing injury. The last picture in the series looked pretty good, but this most recent picture is really gratifying.
This is the underside of the chest of Hercules, a big old Labrador retriever. On the left is the "before", a few days after the injury, when the crushed and dying tissue had sloughed out. On the right is the "after", how his chest looks today.
Man, I love a happy ending.
This really super-nice dog is thirteen years old. You can see that his beautiful chocolate coat is nicely accented by a lot of gray around the muzzle. Despite his gray hairs, he appears to be in very good physical condition generally. His coat is sleek, he is well muscled, eyes are clear, teeth are good, and he has lots of energy.
He also has this mongo-huge tumor on his paw. It has been rather slow growing, starting out no bigger than a marble around eighteen months ago. It's pretty big now, though -- 3.5 cm by 7.5 cm. The owner has been putting off doing anything to it for two reasons.
One, it hasn't seemed to bother the dog. In fact, it still doesn't. Old Fido isn't the least bit lame or tender on the foot. Two, the dog is thirteen years old. He figured this was something the dog would die with, rather than die from. That is to say, it just seemed to be more of a cosmetic problem than a medical problem.
But, it just kept getting bigger... and bigger. Now he is getting a little worried about it. What if it "popped"? What if it's malignant (cancerous)? Those are real concerns. "What should I do?"
The first thing was to try to get an idea of what the mass is. I pierced it with a needle to try to aspirate some cells that I could examine under a microscope. Unfortunately, all I could come up with was red blood cells. This could mean that I just kept getting unlucky and nicking a capillary blood vessel instead of hitting solid tumor mass. I recall a case where this happened because it was a hemangioma - a tumor made up of abnormal blood vessel growth. You get a lot of blood out of those.
So, that was pretty much a bust. I could tell the owner that it's not a lipoma (a benign fatty lump), and it's not a fluid-filled cyst. The only way to tell what it is would be to take a piece of it (or all of it) and let a pathologist examine it microscopically.
Here's where we stand. Before we consider surgery, we need to find out if there are any deal-breakers. Step one is chest X-rays. If the dog has lungs full of lumps like this, we're not going to be accomplishing much by operating on his paw. Step two would be pre-operative risk factor assessment. Along with the chest X-rays (heart okay? lungs okay?), some bloodwork to evaluate liver and kidney function and to look for any evidence of tumor spread to other organs. At thirteen years old, I'd like to have an ECG also.
Surgery in this area is a little tricky. Ordinarily, there's not much loose skin to play with when you're that low on the limb. It can be difficult to close your incision and you can wind up with a long-term project getting the surgical wound to heal.
We might be able to use a lot of that skin that has been stretched by the tumor, providing that the tumor just "shells out" like the meat of a pecan. If we need to lose that skin along with the mass, then we will certainly have more problems. Lots of bandaging could be required.
So, should we or shouldn't we? Well, if his pre-op risk factor assessment looks okay, I'd say we should. Why is that? Am I a typical surgeon? "A chance to cut is a chance to cure". Do I just need the money? No doubt I do. But those aren't the reasons.
This thing just keeps growing. Sooner or later it is going to get traumatized or it's going to outgrow its blood supply. It's going to be open and draining and then we'll HAVE to do something. We're not going to just let it slop around bleeding and draining all over the house and getting infected and painful. We'll either have to fix it or euthanize the dog.
If we don't want to euthanize the dog (and we don't), then we're going to fix it. If we're going to fix it, then we should fix it now while the dog feels good and before it gets any bigger and harder to fix.
So, it's time for tumor removal.
I just got an email from the Animal Poison Control Center. Here's a link to a page on their site listing some of the most common problems. It's always good to take a quick look and and get a reminder about things to avoid.
Five weeks, and Dizzy ate on his own for the first time. When he continued to do so for a few days, it was time to pull the feeding tube.
I've unwrapped the bandage (we've changed it weekly) and you can see the tube going into the side of his neck, into his esophagus, and going almost down to his stomach. The hole where it was sutured in looks great -- no evidence of infection. These usually do okay, though a patient with other disease processes affecting their healing can have a disaster here. I once lost a patient and a client because of that. The cat was doomed from the start, but that didn't make it look any better when his neck disintegrated.
We clipped a couple of stitches and slid it right out. The tube doesn't go all the way into the stomach, as that would cause gastric reflux. You have to measure carefully when you insert it and sew it in place.
Here is the hole in Dizzy's neck. It will heal rapidly. When his hair grows back, you won't be able to tell it was ever there.
Our only problem now is the partial facial paralysis. When the left side of his skull was gull-winged away from the rest of it, it did some considerable nerve damage. His left upper lip is paralyzed and his left eyelids don't work so well, and his eye looks a little funky.
And this is where Dizzy's story came in on the KVC Facebook page. Dr. Carol is still working with acupuncture and electro-acupuncture to try to rehabilitate some of that nerve function.
When she feels like Dizzy has come as far as he can, he'll be heading home. I'm not too sure how long that will be, so the next installment of Dizzy's story will be in the indefinite future.
He feels good, he eats well, he has eight lives left... seven, anyway.
Two more weeks of nursing care (four weeks total so far), and it looks like the infection is all under control. I'm thinking it's time to try to repair that upper jaw, and try again to re-attach the inner cheek surfaces to the gums and cover up that naked mandible bone. So, it's sleepy-time for Dizzy.
Here's where we get into that nine lives thing. That red line in the roof of his mouth is all that's left of our horrendous open fracture line. The maxilla has healed together. No more "gull-wing". No surgery, just tincture of time, the cat's remarkable healing ability, and the fact that we were giving him huge amounts of nursing care -- esophagostomy tube feeding three times a day, plus his meds.
The granulation tissue was nearly covering the naked bone, too. So, now we've just got to keep supporting him until he is ready to start eating on his own. The bones are healed together, and his lip is stuck back on. No reason he couldn't eat, but he's probably still too sore.
He could eat that soft A/D food and swallow it on his own, even though he still has his feeding tube in his esophagus. The soft food would just flow around it. Of course, if his mouth is still too sore, then it's still too sore. So, we keep feeding him with his tube, three times a day. His stomach will only hold so much, so you can't put a day's worth of food and water in one feeding.
It looks like we can see the light at the end of the tunnel, but we're not out of the woods tunnel yet.
To Be Continued...
So now we're a couple of weeks into this mess. In this picture, you can see that his tongue is healing well. Some of the stitches have already dissolved, but a couple of them are still hanging in there (the purple things). You can also see the wire that is holding his mandibles together, and that was also used to help sling his lip back up on to his chin. We are definitely making progress here. Unfortunately, we do have some problems.
There's that upper jaw that I didn't even want to think about. Then we have the outer sides of his jawbones. This isn't in focus very well (sorry), but that white stuff in front of my thumb, and between the red gum-line and lower lip, is bare bone. On day #1 when I cleaned this up and sewed his cheek lining to what was left of his gums, it just didn't hold. I can't say that I'm terribly surprised by this, since it was full of black sand. I can say that I was disappointed.
I called the University of Missouri and talked to Dr. Meadows again. "Well, it may granulate in [fill in from side to side on its own], or you could try surgically reattaching things, now that the infection is controlled. I'm worried that the bone might just be dead from the trauma. Then nothing will work." Now there's a little ray of sunshine after all my hard work.
Speaking of all my hard work, there's another problem. We still have a long way to go, and we have exceeded the owner's top-dollar budget. Time to quit... but he's getting better! I can't quit now. I mean I could, but I don't want to. I want to see how this turns out.
So we made a deal with the owner. She paid her top-dollar estimate, and Dizzy becomes our hobby. When he gets well she can still have him back.
With weeks to go before he's well (if he does get well), I can't afford too many hobbies like this one.
To Be Continued...
Dizzy would rather sleep in his litter-box and eliminate on a towel, so that's what we did. You can see his feeding tube hanging out of the bandage. He never bothered it. Three times a day we mixed prescription diet A/D with water, and pain medicine. Morning and evening, we added antibiotics. At noon we added Forti-Flora, a probiotic to help keep his gut working in the face of all his other troubles.
I spoke with Dr. Meadows at the University of Missouri about how to proceed next. He does all their dental stuff, plus he's the head of the Clinical Practice (i.e. "real world" medicine) faculty. He told me that when the infection seemed under control, we might wire that upper jaw back in place. We might even be able to just sew the soft tissues together to hold the bones in place.
That left upper jaw would just swing out like a gull-wing door on the DeLorean from "Back to the Future". Not good for the eye and other structures in the neighborhood. On the other hand, as long as he lay quietly and we were feeding him through the tube, it didn't seem to be going anywhere. So, we started in on the long haul of nursing care.
We talked with the owner (who had just inherited him with the house) and she was concerned about costs. We were already way over budget. She said she really would like to keep it to no more than twice what we had already spent (which was a lot). I said I would try, and we would keep her posted.
To be continued...
Warning: Gross pictures below
You may have seen Dizzy's picture with a face full of acupuncture needles. That's pretty much an "after" picture. We are definitely getting a happy ending. This is about the "before", when a good outcome didn't look too certain.
One of our great clients moved into a new (for her) house that came with some outside cats as a bonus feature. Some were more friendly than others, but she took them all on as family, more or less. Around January 23, she could tell something was wrong with Dizzy, but she couldn't catch him.
By January 26, he wasn't moving around much, and he was perched in a tree, huddled up. You could tell that there was something wrong with his face. Our client is not much for climbing trees. Fortunately, he wasn't up very high, as my helper, Shannon, isn't all that enthusiastic about climbing trees, even to rescue a cat for a friend.
You've heard it said that cats have nine lives. This stems from the fact that they have incredible healing powers. They recover from some injuries that just look devastating. I don't believe that Dizzy could have recovered from this one without some help, though. In fact, it's taken weeks even with all the help we could give him.
We sedated him for a good look, but it surely didn't look good. Here you can see that his lower lip and skin under the jaw are avulsed - torn loose and hanging down like an apron. What's not so noticeable in this picture is that the flesh is stripped from the sides of his jawbones (mandibles). Naked bone showing on the outside of both jaws. Also, the mandibular symphisis (where the two halves of the jaw join in front) is not joined very well any more. Also, it was crammed full of dirt, actual sand.
In this picture, you can see that his tongue is cut more than halfway in two, more like 3/4. What you can't really see is that his left upper jaw is split from front to back, and the split is full of sand and pus. It took over an hour to gently clean as much dirt and debris as possible from the wounds. When I gently flushed the upper jaw split with saline, it made his eye bulge, and fluid came out his nose. I took out a couple of teeth, too.
I spent over an hour suturing the tongue, wiring the lower jaw, and reattaching the lower lip. Then we put in an esophagostomy tube to feed him (the feeding tube is implanted through a hole in his neck) , because he sure as heck couldn't do anything with his mouth... except hurt.
I left the upper jaw alone for the moment, mostly because I really didn't know what to do with it. He'd been out for two hours, and it was 8:00 at night, so tough to get hold of a specialist.
We filled him full of antibiotics and pain medicine and waited to see how he responded.
To be continued...
Abi is a beautiful, good-natured dog who got a little too close to a horse's hoof. Actually, she got kicked in the head. It turns out to be not as cool as when Dean Martin sang about it. Incredibly, she is walking around like nothing much happened.
When you look at a close-up of the cut, you might say that it doesn't look too bad, and it doesn't. What you can't see is that every time she breathes, the skin on top of her head puffs up like a balloon. She also has some bloody nasal discharge. In fact, there is a hole in her lateral frontal sinus.
Part of the skull is a double-wall construction. If the hoof impact had been farther back, it would have hit the brain-case. In this case, it broke through into the space outlined in green on this diagram. [This is from The Viscera of the Domestic Mammals. It's not computer-generated, but is old-school -- they injected the sinuses with different colors of plastic and dissolved away the bone to make this image.]
We watched Abi for a couple of hours, and she never showed any signs of central nervous system depression or shock, so we went ahead and anesthetized her for surgery. We also gave her a lot of pain medicine. Despite her chipper disposition on presentation, she has GOT to have a headache.
We had called the Veterinary Medical Teaching Hospital at the University of Missouri to ask for advice. Apparently this is a pretty uncommon injury. The resident had to call the surgeon, who had to call some other surgeons. Dr. Carol made at least four phone calls before we ever did much of anything besides monitor the dog and give pain medicine. Here is my finger showing where the hole in her skull is.
Here is one of the fragments I fished out of the sinus before we wired it all back together. Unfortunately, the top of her sinus resembled the end of Bad Leroy Brown -- it looked like a jigsaw puzzle with a couple of pieces gone. It took me about an hour to get things cleaned up, drilled, wired, and closed up.
Here she is, all closed up. She went home with a lot of pain medicine and we'll be following up. I'm worried about the crushing done to her skin and muscle above the broken bone.
