D. E. Larsen, DVM

Raymond came through the door with little Sophie cradled in the crook of his arm. Sophie was a really small Chihuahua, and Raymond, her owner, was a large man. It was one of the things that I always found a little odd. Some of the largest men were attached to these tiny dogs.

After he stretched a towel out on the exam table, Raymond placed Sophie in the middle of the towel. Sophie, at four and a half pounds, was overweight. Her spindly legs looked undersized for her round body.

“She has blood in her urine, Doc,” Raymond said. “And she pees a little puddle every 5 or 10 minutes. The wife is getting upset with all the cleaning up after her.”

I looked at Sophie, her gray muzzle told she was past middle age. She should probably weigh two and a half pounds, not four and a half. Her membranes were normal, with normal capillary refill time. Heavy tartar on her teeth and some chronic periodontal disease suggested that she was a good candidate for a heart murmur. That was confirmed when I placed the stethoscope on her chest.

Chronic periodontal disease leaks bacteria into the bloodstream. These circulating bacteria take up residence on the heart valves, in the kidneys, and the liver. Poor dental hygiene, most common in small dogs on pampered diets, leads to all sorts of significant health complications.

She was heavy enough that it was difficult to palpate her abdomen accurately. But when my fingers reached the posterior abdomen, I bumped a hard firm bladder. Sophie immediately squatted and peed a small puddle of bloody urine onto the towel.

“Raymond, we are going to have to pick up the towel so I can get some urine off the tabletop,” I said as I lifted Sophie up so Raymond could remove the towel.

I sat Sophie down and felt her bladder again, more carefully this time. There was a large stone in the bladder. I could feel some movement in the stone, probably a couple of stones. They were large, making the bladder feel full, but there was little room for urine. Sophie squatted again, depositing a small puddle of bloody urine on the exam table.

I drew the urine into a syringe and placed a small drop on a microscope slide. A quick look at the slide under the microscope showed the blood but also many bacteria and struvite crystals.

Struvite stones were the most common type of bladder stones in the dog at that time. Struvite stones in the dog are caused by a urinary tract infection that leads to acidity changes in the urine, crystal formation, and then the development of stones. These stones grow with time. In male dogs, they often cause urinary tract obstruction as the small stones try to pass down the urethra. That seldom happens in the female.

Today there are diets that can dissolve struvite stones in the bladder. That was not the case in the 1970s and 80s. Stones as large as Sophie’s, are best removed by surgery, even today.

“Raymond, Sophie has a large stone, or more likely 2 or 3 large stones in her bladder,” I said. “These are caused by an infection in the urinary tract. She has a lot of bacteria in her urine. We need to do several things. We need to do a culture on her urine, and while we are waiting for the culture results, we will get her started on a good broad-spectrum antibiotic. We need to get an x-ray, so we can see how many stones we are dealing with, if there are stones in the kidneys, or a bunch of little stones also. We need to do some blood work to make sure Sophie’s kidney function is normal. These stones are going to have to be removed with surgery.”

“Doc, you sound like you are talking about a lot of money,” Raymond said. “I don’t have a lot of money. Are there some short cuts we can take.”

“We can shortcut some of the things if that is what you want to do,” I said. “You need to understand, shortcuts are great if everything works out fine. But if things don’t go just right, we end up spending more money than we would have doing things right in the first place.”

“What kind of things are you talking about, Doc?” Raymond asked.

“Looking at her urine, her kidney function is probably okay,” I said. But if it isn’t, and a random urine sample is not the best indicator of kidney function, we might be delayed in finding that out, and we could lose her. If she happens to have an infection that requires a particular antibiotic, we might not know that without a culture. If we have a bunch of little stones along with the big ones I can feel, we could leave a stone behind and have to do a second surgery.”

“She is sort of long in the tooth, Doc,” Raymond said. “Let’s put her on some antibiotics and do the surgery. If things don’t work out, at least we tried.”

“That is fine, just as long as you remember this conversation,” I said as I shook Raymond’s hand.

“Will I be able to take her home tonight?” Raymond asked.

“We are early enough that she should be able to go home tonight,” I said. “We will have her on c/d diet for a time. That will be important, nothing else.”

“You are going to ruin her life and make mine miserable,” Raymond said.

“You know, you are killing her slowly with kindness, don’t you,” I said.

“What do you mean, Doc?” Raymond asked.

“Look at her, Raymond,” I said. “She weighs twice what she should, her teeth are a mess. She should have those cleaned, and there will be many teeth that are not savable. The infection in that mouth could have been what started this bladder thing, and her heart valves are leaking a little. She needs to be eating dog food, period. But we can work on those things after we get this bladder thing fixed.”

I gave Sophie an injection of Amoxicillin and Gentocin. I planned to send her home on Clavamox. We gave her 80 ccs of fluids by subcutaneous injection and placed her in a kennel while we got the surgery room ready. Sophie was unhappy in the kennel, how dare we treat her like a dog.

After anesthesia was induced and the abdomen was prepped for the last time, I draped the incision site, first with towels and then a surgery drape. I made a short incision over the bulge in the posterior abdomen caused by the large stones in the bladder. I was able to squeeze the bladder out of the incision. It was the size of a full bladder but hard as a rock. 

I placed a couple of stay sutures to hold the bladder in position when I incised it and removed the stones. Then I made an incision into the bladder. The bladder wall was thickened from the chronic infection and the mechanical damage from the stones.

I popped the first stone out, then the next. Amazingly large stones for such a small dog. The bladder lining was burgundy red and almost bubbly from the chronic inflammation. I flushed the urethra in both directions and carefully explored the bladder to make sure no small stones were hiding.

Then I closed the bladder in two layers with Maxon and returned it to normal position. I was careful to remove a couple of drops of urine from the incision and flushed the area liberally. Then the abdomen was closed with a standard 3 layer closure.

Sophie recovered quickly and was probably more comfortable than she had been in months. Raymond was pleased with how lively she was when he picked her up.

“I want to see her in a couple of days, just to check the incision and feel her bladder,” I said. “If you get a chance, try to get a look at her urine in the morning. Mainly to see is the blood is cleared up. And Raymond, you have to be strong, c/d diet only for 3 weeks. No bacon off the breakfast table. You understand, we have come this far, don’t ruin it by being weak when she begs.”

“I will do my very best, Doc,” Raymond said.

“I can guarantee you, Doc,” Sue, Raymond’s wife, said. “He has spent our summer trip to the coast, and he will finish the job if he knows what is good for him.”

Photo Credit: D. E, Larsen, DVM

Prologue: First published January 11, 2021. coupled with last week’s story, this gives a good illustration of a veterinarian’s variety of work and skills.

D. E. Larsen, DVM

I pushed my left arm deeper into the birth canal of the young heifer, sweeping my hand left to right, trying to decide what was wrong here. 

Then I encountered intestines, this was not good. They were too large to be from the calf. This uterus was ruptured. I shoved my arm up to my shoulder. Finally, there was the calf. The calf was in a breech position. I stuck my finger into its rectum. A contraction, this calf was still alive.

I pulled my arm out and washed. “Sue, someone must have tried to pull this calf,” I said.

“Yes, my son Joe was here a bit ago, and he tried to work on it but said that he couldn’t get anywhere.”

“This heifer has a ruptured uterus. The calf is still alive. If we do a C-section, I can save the calf. I don’t know if I can fix the uterus or not.”

“Okay, do what you can,” Sue said. “This is Sam’s favorite heifer. She is kind of small, but he treats her like a pet. I hope you can save her also.”

The heifer was lying on her left side. This was probably good. A right flank incision might give me the best access to repair the uterus.

For me, c-sections on cows were a chore. But most of the work was closing things up. This one would depend on what kind of damage had been done to this uterus.

We clipped and prepped the right flank, and I did an inverted L block with Lidocaine. It did not take long, and we had the calf out, and she was shaking her head as she looked around at her surroundings in this small barn.

The uterus was mostly torn off the cervix. It was held by a narrow strip of tissue. There was no way to repair this.

“Sue, this uterus is almost completely amputated from the cervix. I don’t think that I can repair it,” I said.

“You spay dogs and cats all the time. Can you just remove it,” Sue asked?

The question stunned me for a moment. I looked at the torn mass of uterus and pondered the situation. 

The largest dog has a uterus with a diameter less than my index finger. By comparison, this was a massive uterus. But it was worth a try. Otherwise, we shoot the heifer. If the surgery doesn’t work, at least we tried before shooting the heifer.

“I hadn’t given that any thought, Sue,” I said. “I guess it is worth a try.”

I had difficulty reaching the left ovary. With that problem solved, I placed a transfixed ligature on each ovarian pedicle. After severing the pedicles above the ovaries, I hung the uterus out of the incision. Severing the remaining attachment at the cervix was no problem. I placed a couple of stay sutures in the cervix to keep it close to the incision when I removed the uterus.

With a good twenty pounds of uterus laying in the straw, now all I needed was to close the cervix and ligate a couple of bleeding vessels. Then it was a standard closure of the external incisions. This probably all took less time than a typical c-section.

After giving the heifer some antibiotics and a Dexamethasone dose, I let her up to tend the calf.

“What do you think,” Sue asked?

“Ask me in the morning,” I said. “If she survives the night, I would guess we are good to go. But don’t expect her to have a calf next year.”

“Is she going to be able to raise this calf,” Sue asked?

“That should be no problem. The uterus and the ovaries are not necessary for milk production.”

“Mom and calf were doing well,” Sue said when she called the following morning. 

When I was out to take the sutures out of the heifer, the incision had healed well. The calf was bouncing around, happy to be in this land of the living. 

“When you sell her, make sure you are honest,” I said. “Some poor guy will go nuts trying to get her pregnant.”

“My guess is Sam will make a pet out of her. She will probably never leave the farm.”

It was not long after this event when Pat called. Pat was the elementary teacher with a bunch of classroom pets. It had not been too long ago that I had repaired a fracture on a hamster’s leg for one of her pets.

“It’s Sally, Doc,” Pat said. “She has to be days overdue for delivering babies. And now she is not feeling well. The kids think she has a problem.”

“Tell me more about Sally,” I said.

“Sally is a mouse. They have a gestation for something like 20 days,” Pat said. “We have been watching for babies for over a week now. I am certain that she has to be 4 – 5 days overdue. I can get away for a few minutes shortly, can a drop her off for you to look over?”

“Does she bite,” I asked?

“Sally is the sweetest little mouse,” Pat said. “She loves to be petted and handled, and all the kids love her. That is why everyone is so upset.”

Sally was just as Pat described, sweet as could be. I rolled her onto her back and rubbed her belly in a manner that became palpation. Sure enough, Sally was pregnant with what felt like 8 babies. They were hard as marbles with no feeling of fluid in the uterus. These babies were dead.

I called and talked with Pat. 

“Pat, her babies are dead, and there is a bunch of them,” I said.

“What can we do,” Pat asked?

“If we don’t get them out of there, Sally is going to die,” I said. “She is already dehydrated. I think I should try to do a spay on her. If, by chance, there are any live babies, we could save them. But I don’t think there is anything alive in her uterus.”

“You do what you think is best. The kids and I trust your skills,” Pat said.

We gave Sally a dose of Ketamine for anesthesia and some subcutaneous fluids for her dehydration. I used a razor to shave her belly, and with a surgical prep completed, she was ready for surgery.

With her fur gone from her belly, you could see the lumps in the uterus through the belly wall. 

“I think I am going to need some magnification,” I said as I put on my loupes. “Things are going to be pretty small in there.”

I opened the abdomen and externalized the uterus, two horns of the uterus, one on each side, with 4 hard nodules in each horn, each about the peanut size. The babies were long dead, and all the fluid had been resorbed from the uterus.

The anatomy was the same as a dog or cat, just a lot smaller. I Iigated the ovarian vessels and the uterine body and removed the uterus with the dead babies.  

Closing the abdomen required only a couple of sutures. Sally recovered slowly from the Ketamine, but she was up and eating when I checked her in the morning.

Pat and her class were happy with the results, and we were paid with twenty-some pages of hand-drawn pictures with thank you notes. 

The entire class brought Sally in for suture removal. Typical of classrooms that visited the clinic, some students struggled to be as close to the action as possible. Then some sought the comfort of the reception area.

Sally enjoyed the attention. And she managed to live a year or two longer than a mouse in the wild.

Photo by Colin Davis on Unsplash

Prologue:  It has been a rough week for me. I have been having daily infusions of IVIG for my Myasthenia Gravis. The infusions take three or four hours, and the come in a set of five. Friday is my last one. This story is from the archives. First published December 16, 2019 and it fits the season.

D. E. Larsen,DVM

The barn was cold, but there was steam rising from the back of young heifer. A dusting of snow on her back was melting fast.  Bill and Connie Wolfenbarger had called with a heifer in labor.  They were not regular large animal clients but did visit the clinic with their small dogs.  I had been to their place several times to treat cows belonging to the Gilbert’s.

When they discovered a tail hanging from the heifer’s vulva, they knew they had a problem. This meant the calf was in a true breech presentation and almost certainly dead. In a true breech position, the calf does not engage the cervix, and the cow doesn’t go into hard labor.  Most people will not notice a problem until the calf has been dead for a day or two.

Tomorrow was Thanksgiving, I would miss some of the prep for the family dinner. The evening snowfall was light but continuing. Hopefully, I could make it home before the roads became a problem. Sandy’s folks were already at the house, so we didn’t have to worry about anybody traveling tomorrow.

I tied the heifer’s tail out of the way and started to wash the her rear end. The hair on the tail came off with the slightest touch. I pulled on a plastic OB sleeve onto my left arm. With a little lube on my hand, I eased into her vulva to explore the birth canal. She strained hard when I reached the butt of the calf. No fluid was expelled with the strain. I pushed the rear of the calf with a couple of fingers. There was a spongy consistency under the skin and some crackling like I was popping air bubbles. The calf filled the entire birth canal, I could not advance my hand into the uterus, and I could not move the calf, it was wedged solidly into the birth canal.  I withdrew my hand, the sleeve was covered with hair from the calf and the odor was slightly pungent.

“This calf has been dead for over a week,” I said as I removed the sleeve. “It is emphysematous, blown up with gas, I am not sure I am going to be able to get it out of her.”

“What are our options?” Bill asked.  I knew their daughter was a small animal veterinarian, maybe in California. I did not know her, but I would assume they would be a little more knowledgeable than most clients.

“Options are not many, the calf is in a breech position. That means its’ hind legs are retained and only the rump is presented. It is blown up so much that I cannot even insert my hand into the uterus. We are not going to be able to deliver this calf vaginally. I try not to do a C-Section on a dead calf, but with all the emphysema I won’t be able to do a fetotomy.  That leaves us with two viable options. Option one is a C-Section, which will be with risk and will be difficult.”

“And the second option?” Bill asked.

“The second option is to get your rifle and shot her now. It would not be fair to her to leave her in this situation,” I said.

“Let’s do the C-Section,” Bill said.

I double checked her halter to make sure she would not be choked if she went down. Then I change the tail, tying it to the right side. I placed a rope around her neck with a bowline and ran it along her side and tied it to ally fence, holding her against the fence. With her in a reasonably secure position, I clipped a wide area on her left flank, from her dorsal midline to her bottom of her flank.

I prepped her flank with Betadine Surgical Scrub. The with 90 ccs of 2% Lidocaine, I did a large inverted ‘L’ block of her left flank. I blocked a wider area than usual because I may need to make a longer incision than is usually required. This was not going to an easy procedure. I repeated the prep after the block.

After laying out the surgical pack and supplies, I pulled on a pair of surgical gloves, more to keep my hands clean than to pretend that this was going to be a sterile procedure.

“We have a couple of major risks with this surgery,” I explained as I prepared to make my incision.  “The first one is that it is going be difficult to pull this uterus to the incision and second when I open the uterus, there is going to be no way to prevent the contamination of the incision and the abdomen. We are just going to have to depend on antibiotics.”

Bill nodded, and I made a long incision down her flank, starting a few inches below her transverse processes and extending about 15 inches down her flank. The skin and subcutaneous tissues parted easily. Then I incised the muscles of the flank, they quivered as the blade divided them.  When I incised the peritoneum, the abdominal content did not sink away from the incision with a characteristic rush of air into the abdomen. The distended uterus filled the entire abdomen. There was no trouble finding it or worry about moving the rumen to externalize the uterus. The abdomen was filled with the uterus. 

I reached into the abdomen to the tip of the uterus. Cupping my hand around the tip of the uterine horn, I pulled. The uterus did not move. I tried to rock the uterus in the abdomen. Sometimes you could swing the uterus enough to make it easier to bring it to the incision. This uterus did not budge. Again and again, I tried to bring the uterus to the incision.  I searched and found a hoof, I could not move the hoof.  

I pulled my arm out, stretched and changed gloves. It this cold barn, but I was sweating profusely.

“Do you think I could give you a hand?” Bill asked.

“We might try that, if we could both get a hand under the end of the uterus, we might be able to make it move,” I replied.

Bill stripped down to his waist and washed his hands and arms thoroughly.  I stood on the head side of the incision and ran my left hand down to the tip of the uterus. Bill on the other side of the incision inserted his right arm.  I guided his hand to the correct position.  We pulled, we pushed, we tried almost every maneuver. The uterus did not budge.

Bill and I were almost nose to nose.  Bill had sweat on his brow and sweat dripping off the tip of his nose. He looked me square in the eye.

“A woman couldn’t this,” he said.

I smiled, “If you haven’t noticed, I haven’t got it done myself, yet.”

We pulled out, and I rethought the situation.

“I am going to try one more thing,” I explained. “I am going to open the uterus up here without externalizing it. I will then try to get a hold of the calf’s hoof and turn it up to the incision.  The risks in doing this are many. I could spill content into the abdomen, I could tear the uterus, and even with a grip on a foot, I might not be able to budge this uterus.”

“And then, if this fails, we are going back to option two. We will get your rifle and put this girl out of her misery.”

That said, I incised the uterus in the middle of the flank incision. With a surgical glove and an OB sleeve on, I ran by right hand down the inside of the uterus. There was a front foot, I grabbed the leg just above the hoof and pulled as hard as I could.  The uterus rolled and the hoof popped out of the incision. With my left hand, I incised the uterus over the hoof, and then I slipped an OB strap onto the hoof.  

I handed the strap to Bill. “Keep that foot from going back into the abdomen.”

Pulling my arm out of the upper incision, I enlarged the incision over the exposed hoof. Bill was able to pull the entire front leg out of the incision.  I reached in and found the other leg. It came out quickly, and we attached it to the other end of the OB strap.

With both front legs out, I enlarged both the flank incision and the uterine incision. Now I was able to pull the head out of the incision. Then putting things down, I helped Bill put a hard pull on the calf. It was sort like pulling a basketball through a knothole but when gas-filled abdomen of the calf finally cleared the incision both Bill and I almost fell as the rest of the calf followed with a swoosh.

The membranes and the calf landed on the barn floor in a splat. Then the odor hit us. Bill and Connie both gagged and had to turn back to the side door.  When they opened that door, things were better, or maybe we were just adjusted.  Bill grabbed the OB strap and pulled the calf out the barn door, and I returned my attention back to closing up this mess.

I washed and changed gloves. I put 5 grams of Tetracycline powder into the uterus and pulled the open incision to the outside. This was a long incision in the uterus, and then there was the small incision higher on the horn.  I elected to close the upper incision first, just in case the uterus would start to involute, and I would not be able to reach this incision.  I closed It with a simple continuous suture.

The larger incision I closed with my standard Utrecht closure. After closing, I returned the uterus to the abdomen. I was concerned that there was probably a lot of leakage into the abdomen and pondered how best to deal with that event. There was no option to lavage the abdomen in the middle of this barn, so I just dumped another 5 grams of Tetracycline powder into the abdomen.

I closed the flank incision with 4 layers. I used simple continuous in the peritoneum, interrupted mattress in the muscles and simple continuous in the subcutaneous tissues. I closed the skin with an interrupted mattress pattern.  No need to spray for flies in this weather.

The heifer had to feel tremendous relief getting that mess out of her. She was going to need some additional antibiotics to keep her incision from falling apart. The easiest thing was to use some long-acting sulfa boluses.  I gave her 4 boluses of Albon SR. That would give her 5 days of protection.  

I untied her tail rope and the sideline. She was as calm as could be expected.  I loosened the halter and slipped it over her head. She turned slowly and headed to the door, sniffing the floor a little as she passed.

    “She should be okay for tomorrow, but I will check with you on Friday,” I said to Bill as I was cleaning myself up.

“She will be just fine,” Connie said.  “Our daughter will be home for a week or two.  She can check her tomorrow.  We will let you know how she is doing. You go home and rest for dinner tomorrow.”

At least I was going to have a few days to rest up with the holiday.  I stopped at the clinic and cleaned all the equipment.  It would be a real mess if I left it for the girls on Monday.  I stripped down to the waist and washed thoroughly. The one mistake I made with the clinic was not putting in a shower. I thought I would wash here and go home for a shower.  Then probably have to start working on dinner for tomorrow. 

Friday morning, Bill called. “The heifer is doing great. Our daughter is impressed with how the incision looks. We told her the story, but I don’t think she really believed us. 

Two weeks later Bill called again to say they took the sutures out and the heifer continued to do well.

Photo by Ehoarn Desmas on Unsplash