Dr Nick Trout - Tell Me Where It Hurts

CONTENTS

FOR KATHY, WHITNEY, EMILY,
AND ALL WHO BATTLE CYSTIC FIBROSIS

AUTHORS NOTE

The tales you are about to read are the truth, practically the truth, and nothing less than a half-truth, sifted from recollections of thousands of animal encounters over the course of the last twenty-five years.

The vast majority of these stories happened to me and where possible I have turned to the patients medical record for accuracy and specifics. In many instances I have gone back and interviewed the owners, filling in the gaps, getting at overlooked and unspoken perspectives that I missed when working the clinical aspects of the case. Frequently I alter names and identifying traits, occasionally preserving a memorable and characteristic idiosyncrasy by trading it among pets and owners to maintain anonymity, except where certain individuals have insisted their identity be revealed.

There are a few anecdotes that have been narrated to me by my colleagues. I have taken copious notes, attempted to rein in my imagination (sometimes with limited success), and endeavored to preserve the essence of their messages.

Finally, in an attempt to capture the pace, the rush, and the intensity of all that is new in twenty-first-century veterinary medicine, I have squeezed everything into a single day. Please think of it as nothing more than the vehicle that takes you on this journey. I could have opted for a sleepy ride across the state of Kansas in the back of a chauffeur-driven limo. I hope you prefer a buzz across Boston on the back of a moped at rush hour!

2:47 A.M.

WAKE-UP CALL

T his might seem strange, coming from an Englishman, but sometimes emergency surgery in the middle of the night can play out like a synopsis of a perfect season for the Boston Red Sox. The beginning may be predictably crappy, slow, and discombobulated until a rhythm develops and momentum builds leaving you stricken with that familiar glimmer of hope. When it comes to the final stretch, everyone accepts that there may be failure, there may be disappointment, but the struggle is always gritty and memorable, and occasionally, if you are really lucky, something magical will happen.

My beginning came half an hour earlier with a phone call reeling me in from a cozy dreamless void.

Hello, I said, two disjointed syllables caught in a sticky web at the back of my throat.

This is Dr. Keene, one of the new surgical residents. We havent met but Ive got a dog, a ten-year-old spayed female German shepherd; shes bloated andlikewellI need you to come in for the surgery. Sorry.

All I heard was sound, not words I could interpret, my brain dormant on my pillow.

Hello, are you still there?

Yeah, sure, Im listening, I croaked, wiping a palm across my face. What time is it?

She told me and dove into her apology.

I really hate to disturb you but, like, my backups not answering his pager and, like, I didnt know what else to do. Her words surfed through mea Valley Girl inflectionand sluggish gray matter dug out a memory of a recent departmental memoBe sure to welcome our first-year surgery resident, Dr. Sarah Keene, from the University of California, Davis.

I came awake, sat up in bed, and told my wife to go back to sleep.

No problem, Dr. Keene. Tell me about your GDV.

As a new surgery resident, Dr. Keene may know all about GDV, an acronym that stands for gastric dilatation and volvulus, commonly referred to, with a satisfying rustic flavor, as bloat. But more than likely, at this stage in her training, her understanding is primarily academic, words and phrases in a textbook, disease as bullets of information in shocking fluorescent pink highlights. She will be a year out from veterinary school, a year in which she will probably have diagnosed and managed several cases of GDV. She knows all about this bizarre anatomical aberration and the inevitable, rampant pathology it will incite. She even knows exactly what needs to be done. But, until now, until tonight, she has never been the one who actually picks up a scalpel and makes the cure happen. Tonight, for the first time in her professional career, she is the surgeon on call, and not surprisingly, she is in need of some help.

GDV is a true veterinary surgical emergency. It typically occurs in deep-chested dogs like German shepherds, Great Danes, and standard poodles but, on occasion, Ive even seen it in breeds as small as dachshunds. No one is entirely sure why it happens, but oftentimes the animal eats a large meal, gets some exercise, and an hour or so later the problems begin. Fermented gas starts to accumulate in the distended stomach, and for whatever reason the entire organ twists around and flips over on its long axis. The effect is catastrophic. The twist blocks off the esophagus, so despite the poor creatures desire to throw up and rid itself of all that food and gas, nothing will budge. The stomach expands unchecked, destroying its own blood supply, driving into the chest and squashing the lungs and the blood flow back to the heart. There is no absolute timetable for how long an animal can survive in this state, but dogs can die in a matter of hours. As soon as the diagnosis is made, the clock is ticking.

She got into a full bag of kibble around seven. Owner took her for a walk before bed. He could hear the dog trying to vomit unsuccessfully around midnight and drove her all the way up from the Cape. She looks ready to explode. Classic double-bubble on abdominal X-rays.

I had been waiting for this description, the twisted, distended stomach looking like the silhouette of a giant heavyweights boxing glove on an X-ray. It tells me her diagnosis is correct.

Is she stable? I asked.

Not really, said Dr. Keene. Her pressures are through the floor and were having a hell of a time just finding a decent vein, let alone placing a catheter.

My feet were swinging out of the bed and I began to fumble for clean clothes.

Do your best. Try to pass a stomach tube. Ill be there as fast as I can.

A ngell Animal Medical Center, part of the Massachusetts Society for the Prevention of Cruelty to Animals, is located in the eclectic and increasingly gentrified Boston neighborhood of Jamaica Plain. There are no world rankings of veterinary hospital size, but at 185,000 square feet I imagine Angell is one of the larger ones, with over seventy veterinarians serving nearly fifty thousand dogs, cats, and exotic pets every year.

After ten years on staff as a surgeon, I know that those nasty rumors about Boston traffic are all subterfuge because at three in the morning, an easy commute is rewarded with my pick from one of the primo parking spots close to the front door.

It is January in New England. There are a couple of inches of snow on the ground, a miniature version of the Andes has been plowed against the perimeter wall, and todays high will be only ten below. I walk across the salted asphalt like a geriatric with a bad case of hemorrhoids, poised to slip on the black ice. Despite the hour, my sleepiness is starting to burn off like fog on an imaginary sunny morning as I enter this five-story brick building and head toward the nonsterile surgical prep area. The corridors are empty, floors polished, phones silent, and pagers dead. I have entered an antiseptic ghost town and I like the way it feels. It reminds me of being a kid again, of breaking into the neighbors backyard in order to steal the ripe apples taunting me from their tree. The mission is covert, even riskyall but guaranteeing the rewards will make it worthwhile.