Your Pet's Best Friend

This wound looks worse than it is.

I saw this little kitty today for a very nice lady who wanted a second opinion.  Her cat received a big wound in the left flank about six days ago.  Her regular veterinarian sutured the laceration and sent her home with antibiotics.  That seems like a good plan.

She was upset because the wound is opening up now and it just doesn't look good to her.  She was even afraid it might open up and let the cat's "guts fall out".  That would be bad, I think you'll agree.

A little questioning reveals that the kitty seems to be feeling well and eating well.  That's good.  No fever when I checked her temperature.

A closer look at the wound lets us see that while it is open, there are no pockets of fluid around it and the wound is not deep.  The exposed raw tissue looks pretty healthy.  There are a few stitches present, but many appear to be missing.  And what's that black stuff in there?

I've talked about crushing injuries time and again (here and here).  I really believe what has happened here is that the wound edges were damaged in the initial injury.  The other veterinarian sewed it together nicely, but the tissue he sewed died.  Then it started falling off (the black stuff is dead skin).  Really, for that scenario, this looks pretty good.

The owner and I discussed our options.  I could certainly have made fresh edges on the wound and scraped it out and re-sewed it.  It would look nice, and I'm pretty sure it would have healed well.

On the other hand, I'm not sure that the cat would be any more comfortable and heal any faster than if I just put a bandage on to protect the tissue from drying and other trauma.  So that's what we did.

The owner was quite convinced that the other doctor had done the worst job in the world.  She hasn't seen a gazillion wounds like I have. 

The other doctor did what was technically appropriate, but he did do a poor job in letting the owner know what to expect.  Some of these things are not going to get totally fixed on the first visit.  She could have been happy with the first doctor with a little more communication.

Don't feel bad about asking your veterinarian for more information and clarification.  They won't think you're stupid - they'll just realize that they haven't done their job of explaining as well as they need to.

Snake-bites and Facial Swelling

Most of the snakebites that I have to deal with here are from copperheads.  We do have cotton-mouth water moccasins, but most of my patients are not in the water so much.   Usually you just see some facial swelling, as dogs typically go in nose first, and the snake bites them on the lip.   You treat them for pain, for inflammation, and give antibiotics, as the puncture wounds from a snake bite can get infected, just a like a dog-bite wound.  Puncture wounds are deeper than they are wide, so you can't really wash them.  The snake's mouth is dirty, just like your own (well maybe not JUST like, but everybody's mouth is full of germs), so the bite wound can get infected.

So, you have a Pit Bull, and his face swells up until he looks like a Shar Pei (at least his upper lips do).  Use your imagination, or Google up some Shar Pei pictures.

Then there is today's case.  This is the worst case of post-snake-bite swelling I have ever seen.  The owner says that this is actually reduced from the night before when the dog grabbed the snake.  This dog usually looks like the Pit Bull on the left here.  Now he looks like a Neapolitan Mastiff.

My patient on the left, a Neapoloitan Mastiff on the right. I think he will be fine, but he has some mongo swelling.

Crushing Injury's Fabulous Follow-up

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.

Fractured Jaws - Dizzy's Story - Part Five

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.

Fractured Jaws - Dizzy's Story - Part Four

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...

Fractured Jaws - Dizzy's Story - Part Three

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...

Fractured Jaws - Dizzy's Story - Part Two

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...

Fractured Jaws - Dizzy's Story - Part One

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...

 

Sinus Fracture

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.

Crushing Injury with Bite Wounds - a diary with a happy ending.

I've talked about crushing injuries before more than once.  They are a lot worse than cuts and punctures, and initially, it's pretty hard to tell just how bad they are.

Hercules here used to be able to take on all comers.  He's a farm dog and a pretty good kind of a guy.  While he roams over the farm during the day sometimes, you can usually find him around the shop or at the house.

On August 23, at 10:00 PM, his owners found him prostrate on the patio. He had a LOT of bite-wound punctures and he wasn't moving much, being in a deep state of shock.  We started him on antibiotics and I.V. fluids with a CRI (that's a Constant Rate Infusion) of pain medications, but he looked like he wouldn't live 30 minutes.

He's a tough monkey, and he was still with us on the morning of Day 2.  The next day, he lay all day on his side, breathing heavily.  His chest X-rays looked good, but his kidney function was lousy.  So, we kept up the I.V. fluids and antibiotics and pain meds, and rolled him over every so often.

On Day 3, he had rolled up on his chest and was looking at me with some recognition.  He was able to stand, but he couldn't go far.  There was a lot of bloody goo in the floor of his cage under the grating he lay on.  I couldn't really see where it was coming from (... yet).  More fluids and medication.

Day 4: he's drinking water today, getting around a little better, but no interest in food.  My right-hand man, Greg, hand-fed him two cans of A/D.  He threw it up in a couple of hours.

Day 5: He's drinking a lot of water on his own, eating a few bites of food without prompting and getting around better.  Now it's obvious where the ooey-gooey was coming from.  While his other wounds are healing rapidly, the underside of his chest is coming apart.

The bite wounds are opening, and you can see the dying black skin that was crushed between the puncturing teeth of his attackers.  This is not pretty, and it's going to get worse.   The crushed tissue will have to finish dying and being removed before things can get better.  Of course, he's still on antibiotics and pain medicine.  We start adding Capstar to his daily regimen, just in case any flies happen to get to him and lay eggs.  I don't think maggots will help.

Day 9:  Now all the dead skin has sloughed off and there is a crater big enough to put my whole hand in and move it around.  I don't do that, though.  The wound is so big that our 5"x9" normal bandage pads are too small to cover it.  After some abortive attempts at conventional bandaging, we resort to disposable diapers taped over his trunk, and covered with a T-shirt.

Day 16:  The tissue is all looking pretty healthy now.  The infection is under control, and we start thinking about how to close the thing.  It's still a pretty big wound, but it's closing up a little already.  Considering his age (100 years old, about) and his kidney problems and his heart problems, we're not enthusiastic about a prolonged anesthetic and surgical procedure. 

After discussing it with the owner, we decide to just keep bandaging it and see how things go.

Day 28:  And they go pretty well.  Here we are closing up nicely.  Just a few more bandage changes and he'll be back out on the farm again.

 

  Day 35:  Okay, NOW it's just going to be a few more bandage changes.

Day 46:  So, I was a little optimistic, but we finally made it.  It only took seven and a half weeks.  Sure, he's got a scar, but it's on the bottom where you can't see it.  In the meantime, he got to stay indoors with the air-conditioning, eat like a prince, and wear cool T-shirts.