Death, the good, bad and ugly…

An exhausted vet student

Death is one of those bad words, that we try to avoid talking about, that we ignore and hope we never have to face.

Yesterday I read a blog post called “The dirty secret about CPR in this Hospital (That Doctors Desperately Want You To Know)”. For me it was nothing new, however it made it easy to understand and got the point across in a way I never could so I would highly recommend checking it out.

Since reading this it has remained stuck in my mind throughout the day, I think being in the veterinary profession gives me the other side of the picture. Unfortunately I have been in the position of watching someone I loved die slowly in a hospital bed – it was never what I expected – I expected to turn up one day and find them in their garden or home after a heart attack. It took several days for the die under the Liverpool Pathway (since then I am much more clued up as to why this may not always be the right thing) however the alternative was open heart surgery with very very very small odds of a meaningful recoveryEven at that point in time, without realising I was thinking about the quality of life and not the quantity – the chance of them doing what they loved and leaving the hospital after this surgery was near zero. The quality of life would be zero, even though the quantity would be increased (if you can consider it as life).

Whenever this person had spoken about death to me I had tried to change the subject as I was scared to think about it. I was scared of losing them. I didn’t want to think about it.

So moving forward 5 years with a lot more education and experience I am writing this. Over the past two years I’ve been seeing practice I have been around death, caused death, and prevented death. Some days it seems to be all I deal with, last Tuesday by the last patient I’d seen so many patients die or euthanized that I was no longer surprised when I confirmed another death.

Let’s talk about some death – from the perspective of a vet student… These have all happened to me…

It is 1am, my phone goes, one word – “torsion” – and I am out of bed and running for the door, 10 minutes after this phone call I am scrubbing into surgery. A torsion (GDV or bloat where the stomach swells up with gas) is a surgical emergency. The dog will die without a vet and surgery. An hour or so later the dog is in recovery, and a few days later it goes home.

Last Tuesday at 6:45pm when I was walking out the door to go to lunch a call came in… “torsion”… the owners were on their way about 20 minutes out. That’s 20 minutes for me to prepare. Operating Theatre set up, preparation for stabilisation, emergency fluids, decompression. Car drives up to the door, owner says I think he’s dead… I’m in the back of the car listening to nothing, feeling no pulse, no breathing. This dog didn’t even make it in the doors.

Is a torsion painful? Yes. Can it be fixed with surgery? Sometimes. Will the dog have quality of life after surgery? Yes. Is it a painful way to die? I would not like to die like this.

I am in surgery, normally opening the abdomen is pretty routine, however this time we are struggling. If I hadn’t opened the scalpel blade myself I would have thought it was blunt and old. Opening the abdomen finally it is like all the organs have melted together… There is nothing there, and nothing that is possible, I am wondering how the dog was still alive. We were not sure what we were going find, however I would have never expected this… The owners chose never to allow this dog to wake up.

We’ve got what is expected to be a pyometra – however there is a large mass in the abdomen along with lots of fluid. The owners know that it may be bad – and are waiting by the phone. I am running anaesthesia, the patient is having some problems to breathe so I have placed them onto a ventilator to help them. The abdomen is opened and the right liver lobe the size of the dogs head is removed from the abdomen – the breathing becomes easier. There are changes to other organs as well – it is not a pyometra however there are tumours on the uterus. We call the owners, and they give permission to euthanise on the table. I administer the drugs that will end this life – and relieve the suffering.

In human medicine – these patients would be closed and taken to recovery – they would be given drugs for pain and potentially kept sedated until they die. There is no guarantee of when this would be, they’d be trapped there in a hospital bed hooked up to machines.

A horse – unable to stand, with fluid on its lungs, anemia. The condition is getting worse… There is no quality of life, and the chance of recovery is very slim. We make the decision to euthanise and administer the drugs to do so. The horse is peaceful, out of pain, and no longer drowning inside out.

In human medicine this patient would be treated – humans are lighter than horses, the anatomy is different, and the lungs are like bags of crisps instead of sacks of potatoes. Its treatable – and there is a chance of recovery to a quality of life.

I will end on a puppy, this puppy had a deformity in its leg that was surgically correctable – however it was not showable and not breeding material. I cuddled this puppy on my lap when it was sedated, and held it when it was given the final injection. Not to relieve its suffering, simply because it was unwanted. We tried to encourage the owners to sign it over to be rehomed, tried to talk about the surgical options. That is the danger of euthanasia – that it can be used for ends other than relieving suffering.

We may not be able to pick when, however you can choose how you want to die. Where you want to die. It’s a conversation that should be had, and you can even find online guides like the Five Wishes (https://agingwithdignity.org/docs/default-source/default-document-library/product-samples/fwsample.pdf?sfvrsn=2 ) to help you.

Poultry with a slice of emergency surgery

First GDV of 2016 xray

Thursdays for me is either protection of the environment which is about cleaning things so I am confused as to why it is in my 5th year of vet school or poultry medicine which is more what I think 5th year should be like.

This Thursday was a poultry day and spent in the exotics department learning about chickens. Something I know a little about but still have a ton to learn. The chicken industry is big business with the only economical operations being industrial – however that is a topic for another day.

After finally getting home and sitting down to read up on stuff for tomorrow my phone goes – its emergency surgery for a GDV. Now a GDV is Gastric Dilation and Volvulus – often referred to as bloat or twisted stomach in dogs. The body of the stomach twists around so that the contents are trapped in a pocket of the stomach with no entrance or exit channels. As gas is produced from the breakdown of food material this pocket then starts to swell.

The swelling stomach then starts to squash other organs within the abdomen due to its increase in size – it has nowhere else to go and the abdomen is a limited space so this can also put pressure on the diaphragm and limit the lung space. This includes the blood vessels and finally the vessels and tissues that make up the stomach wall and lining are compressed as well. This leads to what is called pressure necrosis which is where tissue doesn’t get enough blood supply because all the blood vessels inside have been squashed so the tissue starts to die and turn black.

I’ve been in surgeries where pressure necrosis has been so great that the entire stomach is black and there is no way for us to fix the patient so it can survive.

The second complication of the increased pressure inside the abdomen is for the distribution of blood in the body. When we release the pressure from the stomach we need to have fluids ready so that we can help the body rebalance its blood fluid to fill the now empty blood vessels where the stomach was compressing them.

However tonight’s patient is a weird presentation. It was referred from a private vet for a suspected GDV, however there was no dilation when it arrived – and the dog was relatively stable. However when it made it into xray it would not lie on its side so the only radiograph we could get was the one with it on its back (ventral-dorsal position) which is here.

On this xray you can see that it is like a shape of a 8 with loads of gas (dark areas) within the abdomen. This line going across splitting the image is common with GDV presentations.

Taking the dog into surgery it was a successful repair to the stomach, however we found some haemorrhage around the spleen vessels so performed a partial splenectomy as well. The dog recovered very well.

What happens when a dead animal bloats?

Zebra exploded by Leopard

So today in a quick break from revision I wanted to share this video that was sent to me earlier today as a bit of cheer.

When an animal dies, and is left in the sun the decomposition causes the release of gas within the body – especially from food that remains in the digestive tract. This can cause the body to swell whch is known as bloat.

I’ve seen it happen personally with a horse, it was very entertaining to see a friend get covered in crap but this video is from a zebra. And for it to be a hungry leopard that causes the explosion when it finds a zebra carcass in the Djuma Private Game Reserve in South Africa.

It was caught on camera too, so if you have the stomach to watch (it is bloody!) check it out here:

For anyone more curious, it takes a good few bites because the abdomen is pretty tough, there is a layer of skin, then muscle, then the peritonium as well. Muscles tend to solidify and get really touch on death because of rigor mortis. Also where the leopard was biting is around where the bladder is located so the jet could also be urine.