Willow

 D. E. Larsen, DVM

 I could see Willow sitting in the reception area. As always, she was aloft to all that was happening around her. Willow was a natural hunting dog, a Drahthear, a German wirehaired pointer. She was getting older now and had mellowed with age. She was very self-confident, like all the larger dogs who had a mission in life.

Today she was holding up her right front foot, which must be why she was here. I stepped out to the reception door and motioned Howard to come on back. I took him to the treatment room, bypassing the backlog and the reception desk. Willow followed on three legs.

“Thanks, Doc,” Howard said. “I thought we would be hung up there for an hour, and Willow here has a pretty sore foot.”

“I could see her hold it up,” I said. “What has she done to it?”

“I don’t rightly know, Doc,” Howard said. “She has been gone for a couple of days and just came home this afternoon carrying that foot.”

“A couple of days sounds like a long time, Howard,” I said. “Were you looking for her?”

“No, that is not unusual for her,” Howard said. “I someone is going to take her hunting, she just goes herself.”

I lifted Willow onto the treatment table and laid her down on her left side. I grabbed her sore foot, and Willow just sort of looked away. She was either trusting me or maybe just resigned to her fate.

Looking at the foot, there was a significant wound on the top and bottom of her two central toes. I could see some bone exposed. I leaned down and took a whiff. 

“Wow! This is a rotten wound,” I said. “It looks like Willow was caught in a foothold trap.”

“I was wondering about that,” Howard said. “But how would she have gotten loose?”

“Anyone setting traps is supposed to check them every 24 hours,” I said. “It is likely she was released by the trapper.”

“What do you think is going to happen to her foot?” Howard asked.

“I think she will lose at one of these two toes,” I said. “It is going to take a few days before we will know for sure. I think we will clean this wound and put it in a wrap for a few days. We will have Willow on some antibiotics, but we are going to allow nature to decide what stays and what goes.”

“You mean you are going to let these toes rot off?” Howard asked with a bit of concern in his voice.

“No, not rot off, but we are going to give enough time for nature to show us what would rot off if we did nothing,” I said. “If I take this foot to surgery today, I will be making decisions about what tissue stays and what tissue goes based on several factors. If we wait a couple of days, it will be obvious what tissue is alive and what is dead. Then, when I go to surgery, I can easily save as much tissue as possible. Either way, Willow will lose one or two toes, but when everything is healed, it won’t slow her down much.”

“Okay, that makes me feel better,” Howard said. “What do we do now?”

“Let’s leave her for a few hours,” I said. “I will sedate her, get this wound cleaned up, and trim some obviously dead tissue. Then we will send her home with a wrap on that foot and with antibiotics. We will schedule her for surgery on Friday. At that time, I will do the final removal of all dead tissue and probably a toe or toe. We will keep this foot wrapped for a couple of weeks.”

We put Willow in a kennel and took care of the backup in the reception area. As soon as I could squeeze in a few minutes, we sedated Willow and started cleaning the wound. 

The main thing about cleaning an animal’s wounds is getting all the hair away from the injury. On this foot, that was a challenge. The new clippers do a pretty good job, but I  found that using a straight-edge razor was necessary.

When I removed the hair and some of the rotten tissue, it was obvious that the timeline I discussed with Howard was not going to be necessary. There was no way I could save either one of the two central toes.

“Ruth, would you have Sandy call Howard and tell him that I am going to remove these two toes today,” I said. “Tell him the toes are beyond saving, and removing them now will speed up the healing process and be more comfortable for Willow.”

While Ruth was gone for a few minutes, I finished removing a few bits of dead tissue from the wound.

“Sandy can’t get Howard on the phone,” Ruth said. “What are you going to do now?”

“I will go ahead and take the toes,” I said. “Howard will understand. We will still put a wrap on this foot and bring Willow back on Friday and see if we can do a delayed closure. Willow will be better off this way.”

I removed the two central toes, digits III and IV, by disarticulating their joints with the metacarpal bones. There was no bleeding. I packed the wound with nitrofurantoin ointment and placed a well-padded wrap on the foot. I gave a large dose of cephalosporin by intramuscular injection. Then we moved Willow to a kennel for recovery.

Willow was bouncing around the kennel when Howard returned later in the afternoon.

“She looks a lot better,” Howard said as we let Willow out of the kennel.

“Yes, this wound cleaned up pretty well,” I said. “I did go ahead and remove those two middle toes. There was no saving them, and this foot will be more comfortable for Willow without them. We will still need to bring her back on Friday. I will do a final wound cleaning and remove any dead tissue. I think there will be ample skin surviving, so I can do a complete closure on this wound.” 

***

Willow came through the clinic door on Friday morning with a smile on her face. There were a few dogs, not many, who seemed to be able to equate a clinic visit with their feeling better. Willow was one of those few. She was walking on the wrapped foot, almost normally.

We sedated Willow and removed the wrap from her foot. The wound looked great. I had to trim very little tissue, and I removed the skin edge to make a fresh edge to suture. 

The wound closed up better than I expected. I did go ahead and applied a light wrap to the foot. I figured Howard would be unable to keep Willow in the house through the healing process.

“You need to bring Willow in on Wednesday next week, and we will change the wrap,” I said when Howard came to pick her up. “And one thing I forgot to mention, I have to report this wound to the Dean of the Vet School at Oregon State. It’s a new state law. I doubt they do anything with the information, but just so you know if they give you a call someday.”

“Are you just trying to run up the bill, Doc, or does she really need the wrap?” Howard asked.

“Howard, you should know by now that I don’t charge for surgical follow-ups,” I said. “If you could keep her in the house for the entire healing process, we could probably get by without a wrap. This wound closed up pretty well. But, the wrap is just insurance. This wound will heal much nicer if the sutures hold, and the wrap helps that happen.”

“I was just pulling your leg a little, Doc,” Howard said as he and Willow headed out the door.

I watched as Willow followed behind Howard. She was walking on the wrapped foot. I could see a slight limp, but I’m not sure that Howard’s neighbor would be able to notice the limp.

***

Willow’s foot healed, and she walked normally on that foot. It probably did slow her down a bit when she was hunting and working hard, but she let anyone know.

The one thing that changed with her was summed up by Howard on a visit a year or two later.

“The one thing I have noticed, Doc,” Howard said. “Willow stays pretty close to home these days. She has given up on those hunting trips by herself.”

If only people could learn from experience like a good hunting dog.

Image by EM80 from Pixabay

Della’s Mammary Tumor, Part Two 

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.

A Gift for Dad

D. E. Larsen, DVM

For everyone looking for the perfect gift for Dad, especially those who may be a bit pinched for funds, all four of my books are free this weekend on Amazon Kindle. Running Saturday through Sunday, all my Kindle books are available for immediate delivery at no charge.

Autographed paperbacks are available for sale at Lilies and Lovelies at 1141 Long St., Sweet Home, or by contacting me via email at d.e.larsen.dvm@peak.org.

Links to these books are also on my home page at docsmemoirs.com. They can be previewed at this link. Scroll down the page. The books are near the bottom.

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