Saturday night – shrill ring of the phone shatters the concentration required to play right armchair for the Sydney Illawarra Dragons, a position I’ve held down for the past 10 years.
With only minutes until the phones are due to be switched over to the Newcastle Animal Emergency Centre this is not what I was hoping for.
I answered with the standard “Vetcare Hospitals Emergency Service, this is Paul speaking”.
On the other end of the line was Maree, a long term client of the practice. Maree explained that Cruiza, her border collie seemed to be unwell. It didn’t seem to be an emergency Maree thought, but Cruiza had been straining to pass a motion throughout the day and when she was able to produce something it had a “jelly-like” look about it. Maree thought Cruiza may be constipated.
I tended to Agree with Maree’s assessment. It didn’t sound to be too seriousa situation, especially as Cruiza was still eating and drinking and quite bright in herself. I explained that it was possible that Cruiza may well be constipated but that she may also be suffering from an inflammation of the lower bowel, or colitis, in which case the best course of action would be for her to be fasted for a period of time to allow the bowel to heal. We would make an appointment for the following morning to perform a full physical exam and check Cruiza out once she had been fasted overnight. Maree was advised also to call back if things began to deteriorate.
I return to my role for the Dragons and attempt to “get them across the line”. They’ve wilted terribly since I left the field. I suspect that treating Cruiza the following morning will be easier than getting the Saints up. Famous last words…
The following morning, a Sunday, Cruiza and Maree arrive for assessment. Maree explains that whilst Cruiza has stopped straining, she is now not interested in the food she was offered after her fasting period and she is also becoming lethargic. This is not exactly how I expected the script to run, as minor cases of colitis usually resolve in 12 or so hours.
We lift Cruiza onto the examination table and perform a thorough physical. She is found to have a mild fever, muffled breathing and heart sounds, moderate pain in the upper abdomen/lower thorax (chest) and also a very sensitive trachea (windpipe) which causes her to cough if pressure is applied to the neck. Cruiza’s respiration is also quite rapid.
Alarm bells are starting to tinkle, much like a wind chime in a gentle breeze. At least she’s not constipated!
I explain to Maree that Cruiza’s symptoms this morning are more indicative of an upper and lower respiratory tract disease whereas last night we were seeing symptoms of a minor lower bowel problem. The fact that the symptoms we were seeing had changed and that Cruiza’s condition had begun to deteriorate, were of concern.
Our next step would be to check out that chest with some x-rays as I suspected that that was where our major problem lie. However, due to the fact that Cruiza was experiencing pain at the junction of the thorax and abdomen, blood tests to explore the health of the major organs were also indicated.
Maree readily agrees to this plan and we soon have the results of both the x-rays and blood tests. These are provided by the high definition digital x-ray and blood analysis units, which both reside on-site. Expedition is a great advantage to us, especially on a weekend.
What we find allows us to take a large step towards a definitive diagnosis.
The good news is that the abdominal organs seem healthy. However the blood results indicate a high white cell count, indicating a serious infection, inflammation or tissue destruction within Cruiza’s body.
Information gained from the radiographs is not so good. It shows the chest cavity to have a lot of free fluid within it. This fluid surrounds the heart and lungs, making it very difficult for them to function anywhere near optimal efficiency. NOT a good state of affairs. The cardiac (heart) shadow is also quite misshapen.
The fluid explains why the lungs and heart sound muffled. It’s akin to listening to a radio through a wall. Cruiza’s rapid breathing and the pain in her lower chest are now making sense. But what type of fluid is this, and from where does it come? Also, does the heart appear misshapen? The alarm bells are jangling with much more intensity.
A decision, in conjunction with Cruiza’s owner, is made to do an ultrasound of the heart to determine the possible cause of its abnormal shape, and also to aspirate as much fluid from the chest as possible. The latter procedure will not only temporarily improve cardiac and respiratory function, but will also provide us with a sample so as we can attempt to determine the fluids origin.
Because Cruiza is such a cooperative and compliant patient, only a local anaesthetic is required to insert a sterile needle, which is attached to a hypodermic syringe, into the chest cavity. We remove as much fluid as possible which allows Cruiza to breathe more easily. A sample is sent to the lab to be analysed and checked for infective organisms. If an organism is discovered, it will be tested within the lab, to see which drugs are most efficient in treatment.
After a short rest Cruiza is prepared for her cardiac ultrasound (echocardiograph). Initially the examination shows that internally, the heart is fine, but when the external or pleural surface is viewed, a moderately large solid structure is found to be attached. Similar bodies are also found on the inside surface of the ribcage. These structures also seem to be a part of, or are adhered to the pleura. The pleura are a fine clear membrane (a bit like Gladwrap) which lines the inside of the ribcage and the outside of the thoracic organs, reducing friction.
Is this a neoplastic (cancerous) infection or some other type of disease? Hopefully the results of the fluid analysis will shed some light. We seem to be generating as many questions as answers…
In the meantime, the jangling of alarm bells is gaining in intensity.
Cruiza is started on some antibiotic therapy and we await the results of the fluid analysis.
Come Monday, Cruiza’s breathing has deteriorated due to the build-up of more fluid within the chest. Results of the fluid analysis are in and show a severe septic bacterial cause. Fortunately, the bacteria (E. coli in this case) are sensitive to the antibiotic we are already using. There are no cells indicating cancer, but this doesn’t completely rule it out. Other questions, such as how bacteria which resides primarily in the gut came to be in the chest remain unanswered.
Because of the persistence of the fluid build-up and the fact that the antibiotics cannot reach the bacteria through the fluid, medical treatment alone will not save Cruiza. A collective dismay pervades the clinic as during her short stay Cruiza has won over the hearts of many of the staff with her friendly and compliant nature.
Surgery is necessary to drain the fluid and to reinflate the lungs. Surgery will also allow a search to be conducted within the chest to gain more information about the solid masses attached to the heart and ribcage. During surgery it will also be necessary to insert a specialised chest drain so that during recovery it will be possible to remove any future fluid build-up. The major aim here is hopefully, to remove the offending instigator of the fluid build-up whilst supporting the patient’s cardiac and respiratory function as healing occurs.
Because it is not known what will be found, success is not guaranteed. The prognosis is guarded at best. However, the certainty is that without surgery, Cruiza will not survive.
Because of the complicated nature of the surgery and the intensive and skilled post op nursing required (24/7), these cases are usually referred to specialist centres in Sydney. In fact in recent times, two such cases have been referred, only one of which was successful. Both referrals incurred fees of over $10,000.
Cruiza's owners are informed of the new developments, along with the prognosis and possible costs. Naturally they are taken aback. Maree asks for some time to consider, but is not confident they will be able to proceed with therapy. We have a little time to consider, but not much.
Economics and prognosis (predicted outcome) are very important considerations when deciding whether or not to proceed with a treatment.
A face to face discussion is scheduled with Maree and her family for first thing the next morning. Meanwhile, a third option presents itself. But it will require a huge team effort by both veterinary and nursing staff. If we perform the surgery at our clinic, complicated anaesthetic and surgical procedures are necessary, as is 24/7 post-operative care of a chest drain.
A hastily convened team meeting is undertaken to discuss whether A) the staff are willing and B) we feel that our skill levels are up to the challenge. Question A is answered in an instant of course. The staff areready and willing; Cruiza and her family have become real favourites within the hospital. Question B is discussed a little longer, but with a 4 man veterinary team with a combined 80 years surgical and medical experience, a skilled and committed nursing staff, plus a commitment to continuing education, the task is possible. The equipment we require is easily procured.
An informal staff meeting is convened and after the specialised requirements for the anaesthetic, surgery and aftercare are discussed, we come to the conclusion that if success is possible, we have a good chance of achieving it, and whilst the specialist centres have more expertise in these cases, the costs of our treatment will be considerably less.
Cruiza’s family are called with the prospect of this additional option for which they express their gratitude, as they had, again understandably agreed that referral would place to great a financial and emotional burden on them.
A little more thinking time is required, but shortly a decision in the affirmative is reached, surgery will go ahead!
A commitment is made to contact Cruiza’s family as soon as surgery is completed. We will also keep in regular contact with the family during the post-operative phase. This will allow us to appraise everyone of not only Cruiza’s progress, but also of the ongoing costs. The two determinants as to whether treatment remains viable.
The team discuss the upcoming anaesthetic requirements, pitfalls and solutions as Cruiza is taken to be prepared for surgery. The major problem with this anaesthesia is that as soon as the chest is opened, the patient will not be able to breathe by herself and the anaesthetist will need to ventilate (take over breathing) till the chest is again closed. The lungs are also going to largely collapsed because of the surrounding fluid. These will need to be reinflated ASAP after the fluid is removed. An intravenous fluid drip will need to be in place during surgery with a high flow rate, to help prevent the patient becoming shocked and blood oxygen will be monitored throughout via a pulse oximeter, to ensure the lungs are managing to transfer oxygen to the blood.
Just as the discussion concludes, we get word that Cruiza along with the operating theatre have been prepared. An oxygen mask is put in place so that the patients’ blood is saturated with oxygen as we anaesthetise her. A short acting anaesthetic agent is then injected into the vein to facilitate the passing of an endotracheal tube into the windpipe, which will deliver the oxygen and anaesthetic gas throughout the surgery. The tube also allows us to take over breathing once the chest is opened.
Cruiza’s chest has been surgically clipped and is cleaned with various agents to sterilise the skin. Whilst this has been taking place the surgeons have scrubbed and gowned up. We are ready to proceed. Sterile cloth drapes are put in place around the surgical site to prevent contamination. An incision is made between the ribs and the thoracic cavity is entered.
Immediately, a foul smell fills the room, followed by a rush of soupy liquid from the wound in the chest. The anaesthetist takes over breathing.
The foul smell and fluid are caused by the action of the E.Coli bacterium and their toxins on the pleura. This condition is called septic pleuritis. Air is leaking from the lungs due to the damaged pleura and the lung tissue in contact with the pleura. This was unforeseen but is impossible to repair surgically. We must trust the bodies healing processes. Large clumps of fibrous material are removed from their attachments to the chest wall, pleura and pericardium (the sac which encloses and protects the heart). These are the unidentified masses seen via ultrasound. They contain, together with the fluid, vast populations of bacterium unreachable by the antibiotics. The heart itself has been well protected from infection.
We have now drained between 3 & 4 litres of septic fluid. Following this the chest is flushed and drained several times with warm sterile saline and an antibiotic infusion. At this point, the second surgeon has created a small opening between the caudal (rear) ribs, near the point of attachment to the back bone. A specially designed chest drain is passed through this hole and into the chest where the first surgeon guides it into the front of the ribcage to sit on the sternum (chest bone). This drain is essential as even though we have drained the chest of fluid, more will accumulate over the post-operative period. It will also aid in the removal of air that is leaking into the chest cavity via the damaged lungs. A vacuum in the chest (low pressure) is necessary for the lungs to remain inflated. The chest drain is designed with a 3 way valve on the outside so fluid and air can be sucked out, without allowing air from the atmosphere in. Once the drain is in place the wound is closed and the final stitch is tied with the lungs held fully inflated to force out any excess air in the thorax.
The anaesthetic, though reaching into its second hour, has been remarkably uneventful considering the severity of the disease and Head Nurse Tracey, the anaesthetist throughout, maintains her 100% record of never having lost an anaesthetic patient.
We’re off to a good start, but now another challenge presents itself. The 24 hour nursing and maintenance of the chest tube. Initially fluid will build up quickly post operatively as the antibiotics have not yet had time to take effect. Also, some air will leak into the thoracic cavity through the damaged lung. Therefore, regular monitoring and draining will be required, particularly during the 24 hours following surgery.
As the business day came to a close, Tracey transports Cruiza home with her overnight to facilitate this, as aspirations have to take place every two hours. Alarms are set and an early night is attempted so that the regular wakeups scheduled for throughout the night don’t hurt too much. Over the first 24 hour period, 1.4 litres of thick smelly fluid is removed, along with a fair amount of air. The proceeding 24 hours sees a great reduction in the amount of air removed, to the point where by 3 days post-surgery, air is no longer being aspirated. The lungs are no longer leaking. The fluid volume is also gradually reducing, but the really encouraging sign is that the fluid is becoming clearer and no longer emits a smell. It seems we are winning against the bacteria. On top of this, Cruiza’s general condition is rapidly improving and she is much brighter, occasionally managing a wander through Tracey’s house and out into the garden for some fresh air. She is now also eating well and her breathing is no longer coming in gasps, but is much more normal.
However, an unforeseen complication has arisen! Tracey’s young family has become attached to Cruiza during her stay in their home. Each day she returns to work festooned with fancy hairclips and an ever increasing pile of “artwork” drawn by Tracey’s 3 young daughters and designed to adorn Cruiza’s cage so that she knows they are thinking of her. The kids have asked mummy if they get to keep Cruiza forever. Tracey’s husband Chris has also asked the same thing.
An attempted coup is imminent on the home front.
Day 4 post surgery, because the volume and quality of the chest fluid being removed has dramatically improved, we confer with Maree and her family and the decision is made to discharge Cruiza into the care of her family. The family are shown how to manage the chest drain and a couple of practice runs are successfully and very competently completed. Cruiza goes home with continuing antibiotic cover, and with a large pile of glittery artworks, donated by Tracey’s children who were both happy and saddened to see her go home. Before leaving, a chest x-ray is taken and this shows minimal areas of collapsed lung and very little fluid accumulation.
After a week at home the volume of fluid being removed has plateaued and we feel that the presence of the chest drain is causing this continuing fluid build-up. The drain and sutures are removed and Cruiza is placed on a regime of gradually increasing exercise. We don’t want to over inflate those damaged lungs too quickly.
After a month or so, Cruiza is back to herself, back to normality and hasn’t looked back.
What caused the initial infection remains a mystery. Was it rough housing with her canine playmate at home resulting with a tooth accidently puncturing the chest wall? Did E.Coli invade the bloodstream and lodge in the thoracic pleura following the minor bout of colitis? Or was it some other cause entirely, such as a migrating grass seed?
This question remains unanswered. All we do know is that following a highly intensive and satisfying team effort, Cruiza is happy and well and back to her old self in the arms of her loving family and will hopefully remain that way for a long time to come.
Dr Paul Collard BVSc
Westlakes Vet Hospital