Skeeter’s Vomiting

This story refers back to a previous post “Quality over Quantity”. In that story, my own dog, Skeeter, was going through chemotherapy for stage 3 hemangiosarcoma. You can read the full post here: https://drbrunke.wordpress.com/2015/10/27/quality-over-quantity/

During the chemotherapy she developed a slight cough and began having intermittent vomiting. Prior to starting chemo, we had established (via x-rays and ultrasound) that there was no cancer in her lungs, stomach, or the rest of her GI tract.

In some cases, coughing can be associated with cancer that spreads into the lung known as a lung metastases. Metastases will be solid and not allow air to move in that part of the lung .In some cases vomiting can be associated with different types of chemotherapy. However, in Skeeter’s case this wasn’t true. We took special precautions around the one drug in her regiment that could possibly cause vomiting and she never vomited during that medication. This would be random vomiting weeks after that drug was given.

Disclosure: During this time I was not completely objective. As a veterinarian, I wanted to know what was causing the problems. As a caregiver, I didn’t. I wanted to ignore it because I didn’t want to have to face the possibility that this was a possible sign that her cancer was spreading elsewhere.

During her follow-up ultrasound exams (looking at the cancer in her liver as it shrunk from chemo) we did not see any problems with her stomach. This was an appeasement to myself, I had looked (a bit) and that sufficed for now.

One Friday, while working at the emergency room, Skeeter’s coughing got worse. At that point, I took x-rays of her chest. I stared over them and peered from different angles trying to find a reason for her cough. I didn’t see anything obviously wrong with her lungs or heart.

I’m lucky to have great friends. My classmates and I keep in touch via smart phone and social media. We all bounce cases off of each other looking for ideas and insights to problems that baffle us. I sent out photos of Skeeter’s x-rays to the group and asked for opinions.

Amy wrote back a moment later, “Yeah, lungs look ok, but what’s that in her stomach?” Then, two other classmates chimed in and said the same thing. I took another look. Just at the edge of the x-rays was part of Skeeter’s stomach. And sure enough it looked like something was in there. (She had not eaten yet that morning) I took another set of x-rays, focusing on her abdomen. And sure enough it looked like there was a foreign object in her stomach.

I sent all the radiographs to another friend for verification. Sean, a boarded veterinary radiologist, took a closer look as I needed to be as close to 100% sure that this was an actual problem in her stomach. Being on chemotherapy and therefore suppressing her immune system did not make her a fantastic candidate for surgery and anesthesia.

Sean wrote back saying that he didn’t know what it was exactly, but it definitely did not belong there. I explained to him her current condition but his thoughts didn’t change: Whatever it was, it needed to come out.

I had two options here: The first was that I could get Skeeter to a specialist to try and remove this via endoscopy. This is where they put the animal under anesthesia and pass a scope down their esophagus with a mini-grappling hook to grab the object and pull them back out. This is called minimally invasive since it doesn’t require surgery and having to heal from an incision. In some cases it is very successful. Sometimes it does not work (object too big, can’t latch on, etc.).

Since it was a Friday, I would have to drive to Cornell for this procedure, unless I wanted to wait until Monday. At the time there was no weekend option for endoscopy in our region.

The second choice was to go in surgically myself and check it out. Anesthesia is a minimal risk for both cases. The hesitation I had was being wrong and not actually having an object to remove as well as having Skeeter need to heal from two incisions: one in her stomach, the other her abdominal wall.

Second disclaimer: Skeeter had never been a chewer and never really played with toys. So, there wasn’t anything that I knew of that could cause the obstruction. This fact contributed to my hesitation. But there was definitely something there. I just didn’t know what it was.

Ultimately, with support from Sean, Amy, and others, I went forward with surgery that afternoon. Skeeter did great through anesthesia and I found a small “U” shaped piece of flexible rubber in her stomach.

She recovered very well and didn’t have any further vomiting, coughing (likely the rubber getting stuck in her esophagus) or other problems during her chemotherapy.

I have no idea where the piece of rubber came from, or why she chose to eat it.

It can be daunting to face your fears. I was scared of what I would find with Skeeter’s vomiting and coughing. Facing my fear and finding the support of good friends helped me get through a difficult time and I am lucky that it had a good outcome.

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Riding for Diabetes

This June 5th I will be cycling 100 miles for the Tour de Cure to raise awareness and funds to cure diabetes in people. It is a great event and I am lucky to be part of a great team the Davidson Brothers Drafters.

Awareness and research in human diabetes would of course have a great impact on our canine and feline friends as well. If you would like to donate please click on the link below. If you are interested in riding yourself please message me for details.

Thank you!

http://main.diabetes.org/site/TR/TourdeCure/TourAdmin?px=11130114&pg=personal&fr_id=11095

Getting to the core of the problem

May is a 3-year-old spayed, female Chihuahua mix. She had surgery at our hospital this past November for a luxating patella (sliding kneecap). While this is a common issue in small dogs (they can be born with it), this was not the case with May. She had normal knees until she had an accident while playing with another dog.

 

At the time of surgery, radiographs were taken and she actually had slight abnormalities in her knees that predisposed her to patella luxation. The groove that the patella sits in was very shallow and the point where the patella tendon inserts onto the tibia was medial (closer to the groin side of the leg) than it should have been. Normally the patella tendon inserts on the tibial tuberosity on the very cranial or “front” of the tibia. These two, mild malformations did not provide enough tension on the tendon and therefore the patella luxated out of place. This will often happen when a pet is running and you will see them skip on that leg. Then, by extending their knee, the patella will slide or pop back into place.

 

The more severe the malformations the more they will slide in and out. Very mild problems may not be noticed or may just need rehabilitation and joint protectants. More severe cases will put strain on the cartilage that lines the patella and the femur which will lead to arthritis. It can also cause discomfort and pain and not allow dogs to be active and happy. In the most severe cases, it can cause them not to use the leg at all (if the kneecap is permanently out of place) or will cause such tension on the knee that other structures (most commonly the cruciate ligament) will tear.

 

Back to May. Her luxation was moderate and there was a traumatic component. This meant that part of the supporting joint capsule, fascia (connective tissue), and muscles had been stretched. Therefore, she needed surgery. During surgery, three things were done to correct her luxation: First, the trochlear groove was deepened using a drill and burr. This allows her kneecap to be seated better in the femur. Second, the stretched and partially torn supporting tissues were repaired to provide tension and hold the kneecap in place. And finally, a tibial tuberosity transposition (TTT) was done. Here the tibia (shin bone) where the patella tendon inserts was elevated slightly and rotated from the side of the bone to the front. A small orthopedic wire was placed to hold the bone in its new location as it healed and would then be permanently attached there.

 

Surgery and anesthesia went very well with May and she was sent home the next day. It is common that they will not use the leg for a few weeks. The dynamics have changed and they need to adjust to that. During this time they are on pain relieving medications and have exercise restrictions since the bone needs to heal.

 

Two weeks after surgery, May returned to have her skin sutures removed. At that point, she was using the leg well and was full of energy. It can be challenging to keep them restricted after surgery. The owner was doing range of motion exercises and slow leash walks to encourage weight bearing.

 

I first met May ten days after suture removal. She was sore and was limping on her operated leg. The knee felt fine but her muscles in the thigh and lower back were uncomfortable. She tried to bite me a few times. I wasn’t sure if this was her nature or because she was in pain. I started her on muscle relaxants and added back her anti-inflammatory medication. She felt better a few days later and I didn’t see her for three weeks. At that point, she was using the leg better, but not as well as I had anticipated. The owner reported she was hard to keep quiet and was jumping on and off furniture. I advised against this and we planned to sedate her in two weeks to see if the bone had completely healed. May tried to bite me again that visit.

 

Two months after surgery, May was sedated and radiographs were taken of her right knee. It showed that the pins and her kneecap were in place. It also showed that the tibial tuberosity (part that during surgery had been elevated and moved) had partially healed but also partially fractured. However, it was still in place, which was good. I always examine my patient’s when they are sedated it allows me to feel them while they are not guarding a painful area. In comparing the radiographs with my exam I knew that no other damage had been done to her knee and the fracture was not moving, so that no revision surgery had to be done.

 

I discussed the situation with her owner. We had a very young, active dog that was having issues with exercise restriction. My suspicion was that while she was jumping on and off the furniture she had snapped that tiny part of her tibia. Even though the rest of it was healing well, if she continued to do high impact exercise, the bone would not heal and the pins holding it in place would start to vibrate and move. If this happened, she would need surgery to correct the problem and remove the pins.

 

We had a dilemma. May clearly felt well, but being overly active was part of her problem. We needed an environment where May could be active but not do further damage. Putting her in a splint or cast at this point was not needed, and being overly confined can, in some cases, reduce bone healing. We needed to promote bone healing, but safely.

 

I suggested that May come twice a week for outpatient rehab sessions. They would include underwater treadmill, cavaletti rails, and balance/core exercises. We could use the cold laser on her muscles and back but had to be cautious around the tibia. While the laser can promote bone healing it can also heat the metal pins and cause damage to the bone. This would only happen if the laser was left in one particular spot for prolonged periods of time but it was something we had to be aware of.

 

Mom was on board with this idea and we started later that week. May wore a life jacket and did fantastic in the underwater treadmill. The jacket has a handle and this helped us to balance her on the TotoFit equipment to work on core exercises. May didn’t like to be touched directly, but with the handle of the life jacket we could shift her weight slightly and help to strengthen her postural muscles by having her shift against us.

 

The handle also facilitated a great approach to having her walk through the cavaletti rails. She got this exercise done nearly instantly and would change direction on her own at the end of each pass to head back the other way. May also did great during her laser treatments.

 

With each passing session, May became more acclimated and energetic about her session. She readily ran up the ramp into the treadmill and wagged her tail. She would bounce on the TotoFit core disk and wait for us to challenge her balance. Her tail constantly wagged. May had fun with her rehab.

 

Over the course of six weeks, May progressed from 20 minute walks to 60 minute walks. She went from 1-2 minutes on the balance work to 5-10 minute sessions. We incorporated different exercises with the infinity, pawds, disk, and cavalettis to give her a bit of an obstacle course. She did great through six weeks of rehab (12 sessions total) and today we took new radiographs and her bone is healed! Her muscle mass has increased, she’s pain free, happy, and hasn’t tried to bite since we started rehab. Her nipping I associate with pain or frustration from not walking properly.

 

It takes a team approach to get success. From her surgery to her final outcome, the balance between doctors, nurses, owners, and patient has to be harmonious. Having access to the right knowledge and equipment to achieve our goals helps too!