Monday, March 21, 2011

A Soapbox in Answer to a Question

So I'm using the excuse of answering the question posed about my strange case to jump on a soapbox of mine:)

Yes, it was definitely cancer although I couldn't actually send out anything for histopath (no money from the client and I am currently a poor part-time vet who has a lot of debt so I can't afford to send out for my own curiosity.) Most probably, it started with the retained testicle then spread to the urinary system via the lymph nodes and possibly to other organs that appeared grossly normal but may have had microscopic changes.


Retained testicles are dramatically more likely to develop cancer than normal testicles that are in the scrotum. We don't completely understand why but part of the theory revolves around temperature since testicles should be at a lower temperature than the core body temperature, hence being outside the abdomen in the scrotal sac. Neutering completely eliminates the possibility of testicular cancer in normal pets and especially in cryptorchid pets.

There are several types of tumors that affect testicles. In this dog's case, I didn't take time to mention the other clinical signs with the point of my story being that the big picture can be misleading. He also had bilateral hair loss, evidence of feminization (i.e. large nipples, small prepuce), and the retained testicle. The tumors that cause feminization release estrogen creating these effects and also affecting the bone marrow resulting in severe anemia and panleukopenia (both also exhibited by this patient.) The bone marrow effects are yet another potential avenue for spread. The other possibility is that he had two separate tumors - one of the testicle affecting the bone marrow and the other affecting the urinary system. This would not be abnormal, especially with my history as I have actually in the past had a dog with 3 separate tumors detected on necropsy.

The saddest part of this tale is that had he been neutered as I am sure was recommended, it would have been avoided. The other sad part is that most testicular tumors have good outcomes if treated early, prior to spread but, like all too many of my patients, he did not present until he was literally on death's doorstep.

Now that I've screamed from my soapbox, I'll address the other part of the question. You are correct, if an animal becomes obstructed, it leads to death. Typically this is because of the severe electrolyte imbalances caused by obstruction in combination with kidney failure. Potassium cannot be excreted and as it rises causes the heart rate to slow then arrest (most common cause of death). In this case, I presume that it had not happened yet because he was only partially obstructed. When I expressed his bladder, I could create a thin stream of urine but not a normal stream. The urinary catheter would not pass from outside but after opening the bladder, I could pass it from inside and pushed out blood clots. Eventually, it would likely have resulted in bladder rupture or complete obstruction if his other disease(s) failed to kill him first. And lastly, often they really surprise us at how much they can go through and still be alive. Anyone who thinks medicine is an exact science is insane!

Saturday, March 19, 2011

Strange Case Tales

Thought I'd take a moment to share one of my recent strange cases. Unfortunately, I don't have cool pictures to post but this was a doozy.

A client told me the other day that she didn't believe in all the fancy diagnostic tests that we often recommend because we should be able to see and feel a patient and thereby formulate a diagnosis. She further indicated that she thought things like bloodwork, x-rays, etc. were simply a means to generate more revenue. The case I'm about to relate is an excellent illustration of the inadequacy of that viewpoint...

I had a large breed dog present to me partially for a second opinion and partially because our clinic is less expensive than the first clinic that was visited. The previous veterinarian had run a CBC and chemistry panel and things had stopped there. It was a combination of money (as previously stated) and communication issues. Either the first vet did not explain well or the clients just chose not to hear the bitter truth.

On examining the dog, I saw pale pink, tacky mucous membranes and a distended, fluid-filled abdomen. Nothing else was extremely remarkable but when combined with the previously run bloodwork showing a hematocrit of 8.6% and panleukopenia, cancer was definitely screaming out as the most likely diagnosis. I added the exam and the anemia and figured that the dog was bleeding into its abdomen and probably had been for a while.

The owners and I had a long, very serious discussion about the limited options and poor prognosis facing their dog. They opted to give surgery a chance even though there was a good chance the dog would not survive. Further diagnostics were declined so that the little money available could be put into treatment.

I stabilized the dog as much as possible then began an exploratory fully expecting explosive bloody fluid from the abdomen as soon as I entered the cavity. This failed to materialize surprising me immensely. Instead, I found the urinary bladder distended all the way forward to the liver. I actually double checked the site of my initial incision thinking I had to be insane but, no, the bladder truly was that large and did not want to express. Additionally, a urinary catheter would not pass. Hmmmmm.....

The following summarizes my findings: Left kidney approximately 5 times normal size with irregular margins, blood clots within bladder lumen and presumptively within urethra creating obstruction (one was larger than my fist), retained right testicle within the abdominal cavity also having irregular margins, colon distended with fluid fecal material and bruised where in contact with the urinary bladder, multiple enlarged mesenteric lymph nodes.

The dog did not survive surgery....

Monday, March 14, 2011

Crazy Gracie

I have a cat that I routinely refer to as "Crazy Gracie" although her real name is simply Grace. This cat just ain't right but, as most folks who know me often point out, if she were right she probably wouldn't live with me. I don't think that any of my four-legged, furry children are quite right. In fact, we typically refer to our place as the home for misfits, unemployables, and geriatrics.

Grace is insane because she never seems to learn from her mistakes. She jumps onto the couch right next to the little old arthritic dog who can't hear well and only has one eye (and that one has a small cataract) and seems stunned each time when he gets startled and snaps, growls, or otherwise acts unwelcoming to her sudden appearance. She also just sits there when he does it as if he won't accidentally hurt her.

Today, she walked into the living room where I sat on the couch and had a completely forlorn look on her face. She then let out an unearthly wail worthy of a Hank Williams song as if she were left alone and had no friend left on earth. I spoke to her and she looked relieved then jumped onto the arm of the couch where she proceeded to sit for about an hour and periodically rub her face on mine as if reassuring herself she was not alone.

Now I call that crazy.

On Southern drawls, crazy clients, and my nasty sense of humor

As I've indicated in the past, I do have a nasty sense of humor at times. Just can't help myself when it happens; something sets me off and away I go completely unable to check myself. The title ties it all in together you see...

Last Friday, one of our crazies came in wanting to see me. Now this is a novelty as most folks come demanding to see "Doc," not me. Turns out she had seen Doc about 2 weeks prior with her dog that she had suddenly taken on a 2 mile hike after not exercising at all for 2 months then was concerned when he became lame. Hmmmm. Genius, figure that one out. Apparently the current unrest was due to the fact that Doc failed to x-ray the leg on that visit but indicated that if the dog failed to improve that would be the next step. Enter crazy client wanting to see the other doctor!

My exam showed the same things Doc had found but I went ahead and did x-rays since there was no ethical reason not to do so and it was what the client wanted. Surprise, surprise, there were no major findings on the films. I had a blast explaining all of this to the client who fits the stereotypical Yankee know-it-all type we ignorant Southerners dread. Since the client clearly knew everything, I started tossing out "doctor words" and using correct anatomical terminology just to make her squirm and have to ask what it meant. The crowning moment was when I said "stifle" and between my drawl and her confusion she thought I said "stafle."

That incident made me remember another time that my drawl caused confusion to a poor Yankee soul. I was instructing an owner in another state north of the Mason-Dixon line to cook boiled chicken and rice to feed their dog who had stomach issues. The owner asked me what that was. Admittedly, I was very confused wondering who on earth had failed to hear of boiled chicken and rice so I rather hesitantly replied, "You put chicken in water in a boiler and boil it on the stove and you do the same to the rice just adding no seasoning to either..." Perhaps all y'all that have heard my drawl or a similar one have already figured out the key but it took the owner explaining to me that they thought I had said "bald chicken."

Having a Southern drawl is certainly fun and I'm quite proud of it. I can also make it worse when I feel like it; particularly when my sense of humor gets out of control and I decide to really put on the ignorant Southern act in order to take someone out. At certain places that I have worked I really believe that people asked me questions simply to hear me speak. There were certainly times that I've been requested to say certain words like dog or walk. As I told one person I knew, though, at least we in the South know that "drawer" has an "-er" on the end unlike the person with whom I was conversing who said it "draw." Now it really gets funny when I take my Southern accent and imitate Brooklyn...

The problem is the heat, you understand. In the South it gets so hot and humid that we have to speak slowly and let our words kinda lean on one another for moral support or we'd never say anything at all!

Another incident of Friday was also very satisfying (I was really on the roll once I got started!) About 3 weeks ago, I pinned a femur fracture on a little dog then received a call from the owner who had seen another vet for the recheck on day 12 that it was not healing, the pin was placed wrong, and the leg needed to be plated immediately. Side note, there are definitely some of our colleagues that need to learn the art of client communication and how to respectfully disagree with your colleague rather than running them in the ground. The owner had a hard time getting the dog to us (long story) but e-mailed the films which did show no evidence of healing and the pin being apparently in the joint. I had the owner get the dog to us (no one there wanted to touch it since they had not started it) and leave it since travel was a problem, at no charge for the boarding. Rechecked the film and saw that the pin was fine - my colleague failed to get a perfect lateral view therefore the pin placement appeared questionable. Additionally, the leg is healing nicely. I think I shall e-mail those films to a certain veterinarian with a very nicely sarcastic comment on tangential x-ray beam artifact.....