Tuesday, 18 April 2017

In memory of a Bearded Collie called Barocca

Do you still have cases that get to you?

I had one recently, 12 years I've been nursing now. I still get cases that affect me, this one particularly in fact went home and had a little cry after my shift.

The dog in question was in for a GA to examine a mass in its mouth. I know what you're all thinking, probably an oral mass this story is only going to go one way. Except it really didn't.

On admit the owners were so upset, obviously being prepped that it could be something nasty. The dog was 8 years old, the right age group for that kind of mass and generally didn't look as healthy as it could. 

Image result for epulis in a dog
Example of Epilus in a dog. 
It was last on our list. Induction went smoothly, nothing unusual. I open the mouth for intubation and the vet has a quick examine, we tube and I get the dog connected up. I look at the vet and together we say 'this will be a quick GA' after we both spotted that the 'masses' were merely epuli. We knew that we could easily cauterise these lumps out and it should be pretty quick. However, on admit the owner did also say that the dog had been displaying some behavioural changes and itching a lot. I spotted some inflamed dry skin around the lumber spine. And the vet tracked this all down the animal's hind quarters. So could just be a skin condition, or is the animal painful somewhere? We decide to call the owners to ask permission to do some x-rays.

Meanwhile the dogs GA was smooth. HR fine, breathing fine.

We moved the dog through to x-ray, take three views. VD pelvis, Lateral lumbar and lateral thoracic spine. Easily seen was spondylosis.

We proceed to cauterise the epuli and then I proceed to turn off the gas and start the process of waking the dog up. The surgery had been a success and we couldn't wait to inform the owners of the diagnosis we had found due to the likelihood of anything being malignant quite low. The dog was recovering well, blink had returned well - normal recovery. So we turn off the oxygen and take the dog back to its kennel where the vet tells me its been a long surgery list and to go for my lunch whilst he takes over recovery. 

Image result for vet nursing cartoons

On return from my 30-minute lunch, I find the vet still recovering the patient. ET tube still present, which is a little strange. However the dog still has a blink and it is 8 years old, so perhaps it will just take a little while.

Palpebral & corneal reflex video

Almost as I'm thinking this I notice the dog's tongue has gone a purple tone and I run for the oxygen. I put the dog on oxygen, take her temperature. Although not too low I still ask for heat pads and extra blankets. Also at around this time, I notice the dogs pupils are a little enlarge, but also not bilaterally, the right was slightly more constricted than the left. I check for other signs of life, but there was no deep pain (withdrawal reflex). There was anal tone still present. I then check for pupil light reflex but this wasn't present - not a good sign at this stage.

Pupil light response video

Over the next four hours, I sit with the dog, it's heart rate remains steady and its breathing is normal. We placed it on fluids and took bloods however it shows no further signs of waking up. It never gets its gag reflex back. Eventually, the owners come down. I am now breathing for the dog as she has ceased breathing for himself, I have been doing this for 30 mins. By this point, she has lost her blink reflex and her cornea is dry and tacky. Her colour, however, has remained pink throughout other than previous attempts to remove oxygen with the pulse oximeter attached. Every time this was attempted the dogs colour changed back to purple and the O2 levels lowered to around 76% before we replaced oxygen and continued the therapy. 

The dog never woke and was put to sleep with the owners present.

This case affected me hugely and I replayed the anaesthetic over and over to work out if anything had gone wrong. There was nothing I could pinpoint, had it been an 8-year-old dog under for a 4-hour dental I could perhaps understand it better. However, this was a 30 min event. Had the dog had a stroke or another brain event that we just didn't know about? Pre-GA bloods had been normal. I guess we just won't know, perhaps the behavioural changes were an indicator? This case has really got under my skin, and I miss that dog.

Image result for upset nurse

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