The Shadow Knows

D.E. Larsen, DVM

I first met Dr. Al on a hillside up 50th Ave on the East side of Sweet Home. I was in the middle of doing a C-Section on a 15-month-old heifer who was stretched out on the ground. Dr. Al was visiting at a neighbor’s house and came out to watch. I think he was surprised at the surgery in the middle of a pasture.

“How does a little heifer like this get pregnant in the first place?” Al asked.

“If they cycle and are not separated from the bulls, the system is made to work,” I answered. “I have done this on heifers under 14 months of age.”

About now, I had entered the abdomen through an incision on the left flank. The inside of the abdomen of a cow is always sort of a mystery to MDs. Al looked on with interest as I pushed the rumen aside a brought the uterus up the incision.

“That looks pretty simple,” He said.

“All surgery is pretty simple as long as everything goes well,” I replied.

I incised the uterus and had both hind feet sticking out of the incision. I secured the feet with an OB strap and handed the strap to the owner standing behind me.

“Pull straight up and then let him down to the ground easily,” I instructed as I guided the calf out through the uterine incision.

The calf hit the ground, raised his head, and shook fluid out of his nose.

“He is going to be up before mom,” I said.

“Now, how do you close all of that?” Al asked.

“It won’t take long,” I said. “I use a single layer on the uterus with number 2 Dexon in a pattern developed by Utrecht University in the Netherlands. It closes the incision securely and does not leave any of the suture material exposed to the abdomen. That way, there is little chance for adhesions to form and less loss in future fertility. The rest is just routine abdominal closure.”

“You won’t have any infection problems?” Al asked. “I mean, you’re out here in the pasture, with only gloves on, instrument pack opened on the ground. In people, we would have a mess.”

“I never, knock on wood, have an incision infection on a C-Section,” I said. “Maybe your hospitals are the problem.”

“Ha, that might be,” Al said. “Thanks for letting me watch. It was fascinating.”

Following that meeting, Al’s family became regular clients. They had a Great Dane. Al always enjoyed sharing similarities in our professions and the differences. I think he envied the lack of regulatory restrictions I enjoyed. He often spoke of early days in practice in Colorado and how he enjoyed making house calls and having close relationships with his patients.

Great Danes never seem to live very long, and it wasn’t very long until they were in with their Dane with an enlarged breast. It had developed very rapidly, and chest x-rays showed tumors in the lungs and in the vertebra already. There was nothing we could do at the time except to provide comfort care for a short time.

It was not long after the loss of their Dane that Al’s wife Jane and a daughter brought in a new German Shepherd pup. They were going to try a new breed. German Shepherds were a breed that I was always cautious about. There are many super dogs, but there seemed to be an increasing number of screwballs.

“We have always had Great Danes, but they never seem to live very long,” Jane said. “A friend has a German Shepherd that seems to be a great dog. So anyway, here we are.”

“He is a pretty good looking pup and well behaved already,” I said. “What are you going to call him?”

“We haven’t made the decision just yet,” Jane said. “Al wants to call him Rudy, the girls and I are thinking Shadow is a better name.”

“We will write Shadow on the record,” I said. “That is how it usually works out.”

I lifted Shadow up on the exam table. For a young German Shepherd, he looked good. Both ears are erect, teeth are good, and he is responsive to the people around him. Ruth hands Shadow a tennis ball to chew on as I start with his exam.

I start at the nose and work toward the tail.

“Everything looks good,” I tell Jane as I put my stethoscope to my ears.

The lung sounds are healthy, and the heart sounds strong. I almost put my stethoscope down and then remembered to check the left anterior thorax, which I always try to remember on young pups.

My expression immediately changes. Jane, who worked alongside Al for many of his early practice years, instantly recognizes the concern on my face.

“What is it?” she asks.

“There is a machinery murmur in the left anterior thorax,” I said. “That almost always means there is a PDA, a patent ductus arteriosus. That is a vessel between the aorta and the pulmonary artery that normally closes at birth. In Shadow’s case, it did not close.”

“Does it need to be fixed, or can he live with it?” Jane asked.

“He can live with it for a short time, but when he starts his rapid growth phase around 4 – 5 months, it will become life-threatening,” I explain. “Virtually all of these dogs will die before they reach adult size. Some small breeds might live longer, but not the large breeds.”

“How do we fix it?” Jane asked.

“Right now, in the dog, the fix is a surgical one,” I said. “They go into the chest and ligate the vessel.”

“You say they, does that mean you don’t do that surgery?” Jane asked.

“I have never done one, but I could probably do it,” I said. “We do have a cardiologist in Portland. He would be a better choice.”

“I don’t think Al is going to be up to sending a new puppy to a specialist for surgery,” Jane said.

“Will, we don’t have to make the decision right now,” I said. “You have Al listen to this heart and give me a call this evening. We can go from there.”

It was after dinner when Al called.

“I’m not sure I hear what you heard today,” he said.

“Put your stethoscope on the left side of the chest and move it way to the front of the chest, almost under his elbow,” I instructed.

There was a pause on the phone.

“Dang, do you think that is a PDA?” Al asked.

“It is a PDA or a large defect in the ventricular septum,” I said. “In veterinary medicine at this time, a PDA can be fixed. A septal defect cannot.”

“We are not going to Portland with this pup,” Al said with a finality in his voice. “Can you do this surgery?”

“I can do the thoracotomy,” I said. “But ligating the PDA, I have never done, but it should be something that I can do. The important thing for you to remember, this is a veterinary clinic. I am the only veterinarian. If I make a mistake, if I were to tear the ductus or puncture a vessel, the ball game is over.”

“I have watched you in surgery, I don’t think you will have any problems,” Al said. “You go ahead and get set up and schedule it, we will have him there.”

Jane had Shadow in the clinic at 8:00 AM sharp on his surgery day. She was obviously worried and understood the gravity of the undertaking. She patted Shadow on the head as the girls took him into the exam room, then she shook my hand as she wiped a tear from her eye.

“We are hoping for the best,” she said.

“I think we can do this with little problem, I will call you when he is recovered,” I said.

We completed Shadow’s exam and had him under anesthesia in short order. We clipped the entire left side of his chest, laid him on the surgery table on his right side with a towel roll under his chest to facilitate spreading his ribs.

When he was prepped and draped, I made a curved incision between his 4th and 5th ribs. I continued this incision down to his intercostal muscles. Then I carefully divided these muscles and opened the chest.

My surgical philosophy was to work fast. I had sure hands and utter self-confidence, in the environment of a veterinary clinic surgery room, the longer an incision was open, the better the chance of having an infection.

We had Shadow hooked up to a ventilator with his chest open. We paused the ventilator and moved his anterior lung lobe out of the way and packed it off with a moist lap sponge. I could put my finger on the PDA, the mechanical murmur shook the whole heart. I isolated the vagus nerve and pulled it out of the way with a loop of umbilical tape.

Now I was at the most critical point. I had to bluntly dissect a pathway around the PDA so I could place the ligatures. This dissection, especially on the deep side of the short vessel, could result in a catastrophic tear in the vessel that would most likely lead to a fatal hemorrhage.

I took a deep breath and began the dissection. My inexperience made me a little more aggressive with the dissection than a surgeon who had seen a vessel rupture. It only took me a couple of minutes, and I could grasp the middle of a length of 0 silk and pull it through the open pathway around the vessel. 

I divided the silk into two ligatures.  Then I slowly tightened the ligature closest to the aorta.  I moved to the ligature on the pulmonary artery side. I slowly tightened this ligature. Then I took another deep breath.

I returned the vagus nerve to normal position and placed a couple of sutures to close the soft tissues in the area. I removed the packing from the lung lobe and allowed the ventilator to expand this lung lobe. I placed a ten french chest tube with a 3-way stopcock on the outside of the chest. 

I did a nerve block on the intercostal nerves to help control pain and closed the ribs with 4 sutures placed around the 4th and 5th ribs. After insuring an airtight closure of the chest wall, the remaining closure was routine.

After putting a light wrap on his chest, we moved Shadow to a kennel to recover, and I began to relax. Looking at the clock, surgery was less than 50 minutes. I listened to Shadow’s chest. Nothing but good heart sounds. This guy should have a long and healthy life.

“Surgery went well, we were done in less than an hour,” I told Jane.

“Oh, thank you!” she said. “I was so worried.”

“We will keep him overnight, just to make sure everything is okay. But if I can pull his chest tube in the morning, he can go home.”

Shadow went home in the morning. After his hair grew back, nobody ever knew he had had a problem. 

Some years following Shadow’s surgery, one of Al’s daughters called. She had a friend in Bend, Oregon, who had a dog with a PDA. Her friend was being referred to Portland for surgery and could not afford the fee. They were hoping I would do the surgery.

I declined. Working with an established client, who I had a good relationship, I could feel confident they understood the risks. It would be far different from someone I did not know. They would likely have a whole different set of expectations.

The last time I saw Shadow, it was almost twelve years to the day following the surgery. Like a lot of his breed, old age was not kind to his body. He was crippled with arthritis in his back and hips. His life had become a struggle. You never heard him complain, but his efforts to get up and down had become unbearable for Jane. Al had died a couple years before, and the girls had moved on with their lives.  

Shadow’s last trip to the clinic with Jane saw tears in her eyes as they were on the first trip. The clinic where we had years before given him an opportunity for a full life was where we gave him a silent and humane end to that life. Putting Shadow to sleep was one of the most challenging things I have had to do. May he rest in peace.

Photo Credit:https://www.pexels.com/@carl-adrian-barcelo-1978030