When I was doing my clinical rotations as a fourth year veterinary student at Virginia-Maryland, the Internal Medicine Service admitted a very sick Golden Retriever. This poor dog was so ill he couldn’t stand and he wouldn’t eat. His abdomen was bloated. His gums, skin and the whites of his eyes were as yellow as a banana peel. This is called jaundice, and in this dog’s case, it was due to severe liver disease.
He wasn’t my patient but I heard from other students and professors that he needed a cholecystectomy – surgical removal of his gall bladder. He had a gall bladder mucocele, which is an abnormal accumulation of mucus that makes the bile thick and sludgy. The gallbladder is supposed to excrete bile into the upper small intestine where it helps digest fats. If the bile is thick and sludgy, the gall bladder can’t force it through the narrow duct leading to the small intestine. In these cases, the gall bladder itself may also be dysfunctional and unable to contract sufficiently to eject the bile. As the bile accumulates in the gall bladder, it starts to back up into the liver where it causes damage to that organ. Another complication that can occur from excess bile accumulation is rupture of the gallbladder. This causes bile to spill into the abdominal cavity causing severe, painful, intra-abdominal inflammation.
I remember hearing the professors discuss the high post-operative mortality rate in dogs who undergo cholecystectomy. They were all very worried that this poor, sick dog wouldn’t survive the post-operative period, but the owners wanted the surgeons to perform the procedure, even if only a small chance of survival existed. I remember feeling very sorry for that dog. His suffering was palpable. Sadly, his condition declined rapidly post-operatively and he died within 24 hours after the surgery. Everyone, from students to technicians to attending doctors, was emotionally devastated. It felt like a cloud of sad, self-blame and guilt had permeated the ICU, and this miasma lasted several days. I asked the professors why post-operative mortality was so high for this surgery but never got an answer that satisfied me. Maybe their answers were too technical for me to understand at that time. Maybe it was tactless for me to ask a question that poured salt on a fresh, emotional wound. But the question has remained in the back of my mind ever since.
Then one day my husband told me about a human patient he’d seen. This patient appeared perfectly healthy, had a normal physical exam and normal blood work. The patient’s only complaint was mild pain in the upper right quadrant of her abdomen (where the gall bladder lives). She told my husband that this pain only occurred after eating. Tests were run to rule out gall bladder stones and when none were found, scintigraphy was performed. (Scintigraphy involves injecting radioisotopes and using gamma cameras to capture images of how these radioisotopes are moving through the body.) In this patient’s case, scintigraphy revealed that the gall bladder was malfunctioning. It wasn’t contracting sufficiently to expel the bile. Cholecystectomy was performed and the patient did great. Of course she did. Her disease was detected and remedied before it had a chance to make her sick.
Now I understand why cholecystectomies are more dangerous in dogs. Dogs can’t tell their owners that they’re experiencing mild upper right quadrant abdominal pain immediately after eating. Owners bring their pets to us only when signs of illness have become obvious. In the case of that poor dog in the ICU at my teaching hospital, by the time he ended up at the hospital, his illness was advanced. Of course his post-operative chances for survival were low. Anyone who undergoes surgery when they’re already ill has poorer chances of surviving.
As doctors who practice veterinary medicine, we so frequently blame ourselves when our patients don’t do well. When we find ourselves unequal to the task of reversing the course of an illness, we often fail to remember that illness may have been gathering momentum for quite some time before we were given the opportunity to intervene. If a patient’s illness has progressed beyond the tipping point, even the best veterinarian will fail to cure the patient. But is it a failure? Or is it merely one of many hard truths about practicing medicine on patients who can’t talk? Veterinary doctors see patients whose illnesses have advanced beyond where they would have been detected were they able to talk, and sometimes, it’s simply too late. This is a fact of veterinary medicine. Try to remember this when you’re a veterinarian, and go easy on yourself when, despite your best efforts, you’re unable to save a patient.