D. E. Larsen, DVM
Note: Continued from Della’s Mammary Tumor, Part One
I noticed Della waiting in the reception area. She was still excited to come after getting injections every couple of weeks for the last eight months. She was turning circles on Wilma’s lap, and Wilma had a frown on her face.
I motioned to Wilma into an empty exam room, thinking Della was just in for a quick injection.
“Doctor, Della has a cough this morning,” Wilma said. “I thought I heard it last night, but it is definitely there this morning. Not always, but if she has any activity, she will cough and act like it doesn’t bother her.”
I petted Della to calm her a little, then I put a little squeeze on her windpipe. She coughed.
I carefully listened to her chest, ensuring my stethoscope covered the entire lung field on both sides of the chest.
“You hear something,” Wilma said. “I can tell by the change in your expression. It’s on the left side of the chest, I can tell.”
“It is not what I expect to hear in a dog with a mammary tumor that has metastasized to the chest,” I said. “Most of her chest sounds fine, but one spot on the left side has no airway sounds. So, it’s been eight months since the surgery. I think it is time we get that x-ray.”
“What do you expect to hear in a dog like Della?” Wilma asked.
“Most of the time, the lungs are showered with tumor cells, and there are thousands of small tumors throughout the entire lung field,” I said. “By the time the cough develops, there is a lot of fluid in the chest. I would hear muffled breath sounds everywhere.”
We took Della back and snapped a couple of x-rays of her chest. I rushed the films through the developer and fixer so I wouldn’t keep Wilma waiting. We brought Wilma back to the x-ray room to view the films.
It was still in its hangar when I held the lateral view up in front of the viewer. I was amazed at what I was looking at. There was a single large mass in the central lung lobe. It was about three centimeters in diameter.
I remember back in my school days when Dr. Hall came and got Jim Logan and me so we could look at a tumor in a dog’s chest.
“This is an adenocarcinoma that has metastasized from a mammary tumor,” she said. “You probably won’t see this type of tumor in practice. This is sort of how it looks in people. We can remove this tumor. It doesn’t solve the problem, but it will buy a significant amount of time for the dog.”
The tumor in Della’s chest stood out like a white ball against the normal dark lung field. I didn’t have to point it out to Wilma.
“That is what you heard,” Wilma said. “I am amazed that you could tell what it was with just your stethoscope.”
“We can thank Doctor Pierson for teaching that skill,” I said. “He was a wizard with his stethoscope. I will never match his skill.”
“What can we do about this tumor?” Wilma asked as she pointed to the spot on the x-ray.
“It is removable, but I don’t know that I can do it here,” I said. “This is a complex surgery, and with only one pair of hands, it may be more than I should tackle.”
“I could help you, Doctor,” Wilma said. “I routinely assist in surgery, and I have seen your incisions. I think you could do this with my help.”
I had just recently upgraded my anesthesia equipment. I was now using Halothane gas, and I had purchased a respirator. That would make open chest surgery much more manageable. Maybe Wilma was right. Perhaps I could do this with her help.
“I have a saying, you know,” I said. “Doctors make the worse veterinarians.”
“Why on earth would you feel that way?” Wilma said.
“They think they know everything, but they have no understanding of the challenges of veterinary medicine,” I said. “We deal with species variations daily. Our surgical patients get up after surgery and return to their daily routine rather than lie in bed for five days. When I spent a day with the staff veterinarian at the University of Colorado Medical school, he said his hardest job was teaching medical students to do secure closures on their patients when doing surgeries on dogs. Plus, they are often arrogant. I had a surgeon call me at two in the morning, seeking advice on doing a C-section on a ewe. He was the most arrogant bastard I have talked with. He just wanted to know a couple of things, not the whole procedure. My guess is he would not even have talked with me had I called him at two in the morning.”
“I have to agree with you on some of the surgeons,” Wilma said.
“I only mention it because you need to understand that we are doing surgery in a veterinary clinic,” I said. “It might look like battlefield conditions compared to your surgery rooms. And I have seen professional people have difficulty with a surgical emergency when it is their pet.”
“I can deal with your situation,” Wilma said. “I trust you completely. Regardless of what happens on the surgery table, I won’t become a problem. And I am hoping we will do this surgery yesterday.”
“Yes, we will do this surgery yesterday,” I said. “I see you learn fast. You have Della here at eight in the morning, and wear scrubs. We will schedule her surgery first thing in the morning. There will be a chest drain following surgery, and I usually like to keep those patients in the clinic while the drain is in place. With Della, I could probably let her go home as long as you have a kennel that you can keep her in at all times that she is not closely attended to.”
“How long will you leave the drain in the chest?” Wilma asked.
“If everything goes well and we have a good seal on the chest, inside and outside, maybe just overnight,” I said. “Since we will be doing surgery early in the morning, I could even consider removing it in the evening following surgery.”
“That would be nice,” Wilma said. “Della and I will be hopeful for that. We will be here at eight in the morning, ready for surgery.”
Wilma was waiting at the front door when I arrived in the morning. She was in surgical scrubs and holding an excited Della. It always amazed me how a few dogs loved coming to the clinic despite some painful procedures they would endure. While others hated it, even though they had never had a bad experience.
“I see you’re ready to get to work,” I said as I unlocked the front door.
“I think I am as excited as Della this morning,” Wilma said.
We went right to work, getting the surgery room set up and Della under anesthesia. I gave Dixie some last-minute instructions on running the respirator. This was a new piece of equipment for the clinic, and we had only used it a time or two.
Finally, with Della positioned on the table for a left thoracotomy, we were ready to go. We had more people in the surgery room than I was used to, but this was a major surgery for this clinic, and everyone wanted to be a part of it. I had three high school seniors working this summer, and Elaine McCollum was interested in veterinary medicine. She was excited to watch this surgery.
I opened the chest between the fourth and fifth ribs, checking the respirator before making the final entry into the chest. With the chest open, I spread the ribs.
There it was, in the middle of the surgical field, one large solitary tumor in the central lung lobe. I was amazed at how it looked exactly like the tumor that Doctor Hall had me look at while I was in school. I carefully palpated the other lung lobes and found no additional tumors.
“So pause the respirator and give me thirty-second reports,” I instructed Dixie.
I worked fast, isolating the bronchus and vessels to the central lobe. I was able to get a clamp across the vessels. Wilma was an excellent assistant. She had clamps waiting to hand to me without my asking.
“Breathe,” I said as Dixie restarted the respirator.
After a few breaths, we paused the respirator again, and I ligated the vessels.
“Breathe,” I said again.
We paused the respirator, and I clamped the bronchus as close to the lung lobe as possible. Then I severed the bronchus on the lung side of the clamp and handed the lung lobe back to Elaine.
“Breathe,” I said.
With the lung lobe removed, I had an excellent view of the surgical field.
“I can probably close the bronchus with the respirator functioning normally,” I said as I looked at Wilma finally. “This is the important part of the surgery. I must get a seal on this bronchus, or we lose the ball game.”
“You are doing fine, Doctor,” Wilma said. “You work so fast. I am not used to that speed.”
I placed a second clamp behind the first clamp on the bronchus. After removing the first clamp, I had ample bronchus to make a solid closure.
Once the bronchus was closed, we expanded the lungs and held them under pressure while I checked for leaks in the closure. When I was satisfied that I had a good seal, I placed a tube for the chest drain and attached a Heimlich one-way flutter valve to the tube.
I explored the chest to make sure we didn’t leave a sponge, then we removed the retractors.
I positioned the ribs to their normal position with a couple of cerclage sutures that encircled both ribs. Then I closed the soft tissues, expanding the lungs to expel the excess air in the chest before pulling the last suture tight.
Once I was sure that the chest wall was sealed, I did a nerve blog for the spinal nerves running down the posterior side of both ribs. Then I closed the skin incision and wrapped the chest to secure the chest tube and flutter valve.
“Looks like we are done,” I said to Wilma. “You did great. I’m not used to having a surgical assistant. We will give Della a dose of Innovar for pain and get her in a kennel for recovery. I will decide on the chest tube at about four this afternoon. The way things closed up, I will bet that I can pull it at that time.”
“That will be nice,” Wilma said. “That way, Della won’t have to be in a kennel tonight.”
Della recovered with no problems, and I removed the chest tube at four that afternoon, and both Wilma and Della were happy to be going home.
I submitted the lung lobe to the lab, and Doctor Albright was excited when he called me the results.
“This is remarkable to see just a single tumor in the lung,” Doctor Albright said. “I am sure you know that the lungs are usually showered with tumor cells. I also think the interval between removing the mammary tumor and this lung tumor is remarkable, considering how aggressive this tumor appeared. Your levamisole must have done its job. I am impressed.”
“What kind of a prognosis do you think I can give the owner at this point?” I asked.
“I think every week is a gift at this point,” Doctor Albright said. “I would be surprised if this tumor doesn’t raise its head again somewhere. About twenty-five percent of lung tumors, like this one, will move to the brain. I wouldn’t even venture a guess on the timeline.”
Della fully recovered from her surgery for the lung tumor and lived disease-free for the following fourteen months. We continued the levamisole injections during that time.
True to Doctor Albright’s words, Della’s final visit was for a sudden neurological collapse from a presumed brain tumor.
Wilma made the decision to put Della to sleep at that time. Both Wilma and I were pleased with the nearly two years of added life that our treatments had provided Della.
As an added benefit, years later, Elaine McCollum, DVM, told me that it was Della’s lung surgery that cemented her decision to become a veterinarian.
Photo by Luis Alberto Cardenas Otaya on Pexels.