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1
2:47 A.M.
WAKE-UP CALL
This might seem strange, coming from an Englishman, but sometimes emergency surgery in the middle of the night can play out like a synopsis of a perfect season for the Boston Red Sox. The beginning may be predictably crappy, slow, and discombobulated until a rhythm develops and momentum builds leaving you stricken with that familiar glimmer of hope. When it comes to the final stretch, everyone accepts that there may be failure, there may be disappointment, but the struggle is always gritty and memorable, and occasionally, if you are really lucky, something magical will happen.
My beginning came half an hour earlier with a phone call reeling me in from a cozy dreamless void.
"Hello," I said, two disjointed syllables caught in a sticky web at the back of my throat.
"This is Dr. Keene, one of the new surgical residents. We haven't met but I've got a dog, a ten-year-old spayed female German shepherd; she's bloated and . . . like . . . well . . . I need you to come in for the surgery. Sorry."
All I heard was sound, not words I could interpret, my brain dormant on my pillow.
"Hello, are you still there?"
"Yeah, sure, I'm listening," I croaked, wiping a palm across my face. "What time is it?"
She told me and dove into her apology.
"I really hate to disturb you but, like, my backup's not answering his pager and, like, I didn't know what else to do." Her words surfed through me—a Valley Girl inflection—and sluggish gray matter dug out a memory of a recent departmental memo—"Be sure to welcome our first-year surgery resident, Dr. Sarah Keene, from the University of California, Davis."
I came awake, sat up in bed, and told my wife to go back to sleep.
"No problem, Dr. Keene. Tell me about your GDV."
As a new surgery resident, Dr. Keene may know all about GDV, an acronym that stands for gastric dilatation and volvulus, commonly referred to, with a satisfying rustic flavor, as "bloat." But more than likely, at this stage in her training, her understanding is primarily academic, words and phrases in a textbook, disease as bullets of information in shocking fluorescent pink highlights. She will be a year out from veterinary school, a year in which she will probably have diagnosed and managed several cases of GDV. She knows all about this bizarre anatomical aberration and the inevitable, rampant pathology it will incite. She even knows exactly what needs to be done. But, until now, until tonight, she has never been the one who actually picks up a scalpel and makes the cure happen. Tonight, for the first time in her professional career, she is the surgeon on call, and not surprisingly, she is in need of some help.
GDV is a true veterinary surgical emergency. It typically occurs in deep-chested dogs like German shepherds, Great Danes, and standard poodles but, on occasion, I've even seen it in breeds as small as dachshunds. No one is entirely sure why it happens, but oftentimes the animal eats a large meal, gets some exercise, and an hour or so later the problems begin. Fermented gas starts to accumulate in the distended stomach, and for whatever reason the entire organ twists around and flips over on its long axis. The effect is catastrophic. The twist blocks off the esophagus so despite the poor creature's desire to throw up and rid itself of all that food and gas, nothing will budge. The stomach expands unchecked, destroying its own blood supply, driving into the chest and squashing the lungs and the blood flow back to the heart. There is no absolute timetable for how long an animal can survive in this state, but dogs can die in a matter of hours. As soon as the diagnosis is made, the clock is ticking.
"She got into a full bag of kibble around seven. Owner took her for a walk before bed. He could hear the dog trying to vomit unsuccessfully around midnight and drove her all the way up from the Cape. She looks ready to explode. Classic double-bubble on abdominal X-rays."
I had been waiting for this description, the twisted, distended stomach looking like the silhouette of a giant heavyweight's boxing glove on an X-ray. It tells me her diagnosis is correct.
"Is she stable?" I asked.
"Not really," said Dr. Keene. "Her pressures are through the floor and we're having a hell of a time just finding a decent vein, let alone placing a catheter."
My feet were swinging out of the bed and I began to fumble for clean clothes.
"Do your best. Try to pass a stomach tube. I'll be there as fast as I can."
Angell Animal Medical Center, part of the Massachusetts Society for the Prevention of Cruelty to Animals, is located in the eclectic and increasingly gentrified Boston neighborhood of Jamaica Plain. There are no world rankings of veterinary hospital size, but at 185,000 square feet I imagine Angell is one of the larger ones, with over seventy veterinarians serving nearly fifty thousand dogs, cats, and exotic pets every year.
After ten years on staff as a surgeon, I know that those nasty rumors about Boston traffic are all subterfuge because at three in the morning, an easy commute is rewarded with my pick from one of the primo parking spots close to the front door.
It is January in New England. There are a couple of inches of snow on the ground, a miniature version of the Andes has been plowed against the perimeter wall, and today's high will be only ten below. I walk across the salted asphalt like a geriatric with a bad case of hemorrhoids, poised to slip on the black ice. Despite the hour, my sleepiness is starting to burn off like fog on an imaginary sunny morning as I enter this five-story brick building and head toward the nonsterile surgical prep area. The corridors are empty, floors polished, phones silent, and pagers dead. I have entered an antiseptic ghost town and I like the way it feels. It reminds me of being a kid again, of breaking into the neighbor's backyard in order to steal the ripe apples taunting me from their tree. The mission is covert, even risky—all but guaranteeing the rewards will make it worthwhile.
Cutting through the radiology department, I catch a glimpse of my reflection in the glass window outside the MRI unit. The man I see looks unfamiliar. He has piggy eyes, a pillow-crease scar across his left cheek, and a jaunty case of bed head. Thank goodness my patients never judge me on my appearance.
My patient lies splayed across a large gurney, nervous nails clawing for purchase on the stainless steel surface. She is a big girl, obviously not lacking for love in the calorie department. Her darting chocolate eyes scream in fear of her strange situation and the changes taking place in her body, but as I enter the room and approach, her broad and bushy tail offers me a couple of friendly beats. I like German shepherds. I grew up with one as a kid, but this gesture strikes me as both uncharacteristic and, at the same time, utterly endearing. Until this moment I have been dealing with an anonymous and remote animal reduced to a list of diseases, conditions, problems, and deformities. Suddenly everything has changed. This animal has a name and a personality. This animal has become my patient. This is the moment when I begin to care.
I pat her head and run my hand across a soft velvety ear, over her chest and down to the enormous, unyielding abnormality that is her drum-tight abdomen.
"Hi, sweetheart. You hanging in there?"
For me, all my patients are "sweethearts" until proven otherwise, whether they are male or female, cute and cuddly Himalayan kittens or slobbering and stoic 250 pounds of bullmastiff.
Holding a needle and syringe, Dr. Keene, a short, shiny-faced woman with blond hair in a ponytail, turns to me. She can be no more than twenty-five. I wonder if at forty-three I'm getting a little long in the tooth for this game. She glares through sparkly green contacts as though she thought I had been addressing her. I introduce myself, offer my hand, and assure her that I was speaking to our patient.
"This is Sage," she says, trying to apply an oxygen mask to the dog's snout. "I'm Sarah, and this is Dan." She gestures to a technician I have never met before, although this is not surprising given the hour. For most of us working in a busy animal hospital, being on call for surgical emergencies every other night, every other weekend, is simply not sustainable for more than a couple of years. Nocturnal surgical emergencies are a rite of passage, an inherent requisite in any decent residency program, a privilege to be endured and enjoyed. But now, nearly fifteen years after the completion of my training, my midnight forays into the OR are limited to the one week in every month that I am available as backup to the residents.
Dan juts a square chin in my direction and gives me a casual " 'sup." He has a pierced right eyebrow and lower lip with colorful sleeves of tattoos running down his arms in perfect contrast to the sallow vampire skin of his face. In different surroundings he might attract attention, but here, working the overnight, he can relax, setting up the EKG leads, sorting out the pulse oximeter, and adjusting the intravenous fluids with an experienced hand.
There is a small shaved square on Sage's flank where an attempt has been made to release the trapped and expanding gas in the dog's stomach by directly puncturing the organ with a large bore needle. I touch the small red bull's-eye in the center of the bald spot. The skin is impossibly taut. Clearly the attempt failed.
"No luck with a tube?" I ask, although I know the question is redundant. If they had successfully passed a stomach tube, the preferred method of decompression, there would have been no need to try to use a needle.
Dr. Keene shakes her head.
"I'm afraid not," she says. "She's in bad shape. Heart rate's two twenty with occasional VPCs. Her color looks like shit."
I'm not surprised. The shock to Sage's circulation has convinced her heart that she is running an endless sprint. This effect combined with the absorption of toxic by-products via the damaged stomach can produce runs of abnormal and ineffective heartbeats called VPCs or ventricular premature contractions. Heard over a heart monitor, VPCs make the beat of a frenetic African tribal dance sound like the cord changes of a funeral march. They can be disastrous in their own right.
Sage's tail beats a message of thanks as I relieve her of the oxygen mask and lift an upper lip to inspect her gums. Healthy, vibrant pink tissue signifying normal peripheral blood flow has been replaced by an ugly, muddy purple.
"How much intravenous fluid has she had?"
"This is her fourth liter," says Dr. Keene. "It took forever to find a vein. Isn't that right, Dan?"
Dan nods.
Sage's color looks awful. I imagine someone shoving an overinflated beach ball under my rib cage. I know I wouldn't be faring as well.
"You're absolutely right," I say. "She looks like crap. You're certain Sage got into the kibble around seven?"
"According to the owner she did. Why?"
"Because she's acting like she's near the end, like her stomach has been distended for so long it's going to die. It's all very well trying to get her stable for surgery, but if her stomach dies, she dies. I don't think we have any more time to dick around. Start a lidocaine drip, give her some intravenous antibiotics, and knock her down. The faster we get this thing untwisted the better. I'm going to get changed into scrubs."
"Before I forget," says Dr. Keene, "the owner is waiting up front. He insisted on meeting with you before you get started."
Inwardly I groan. Don't get me wrong, good client communication lies at the heart of great veterinary care. There is enormous satisfaction in getting pet owners involved, explaining exactly what it is we are doing, why we are doing it, and making sure they are part of the decision-making process. But right now, with Sage fading fast, every minute lost is a minute closer to a patient who never wakes up from anesthesia. I just want to get going, to give this dog a measure of relief. Perhaps Sage's owner doesn't understand the gravity of the situation. I imagine myself walking into a time trap, forced to engage in idle banter with a belligerent owner about whether I really know what I am doing, how many of these things I have done before, committing to verbal assurances that I will be the one performing the operation and not my resident.
"Okay," I say, "if I'm not back in five minutes get scrubbed in, drape her off, and start setting up. If I'm not back in ten, page me to the OR, stat."
I hand comb my hair on the way to the vast waiting room, preparing myself for combat with some sort of aggressive middle aged lawyer type, who, despite the hour, has turned up perfectly coiffed in an immaculate pinstriped suit. But the only person I see is an old man of at least seventy, sitting in a corner, head slightly bowed with one liver-spotted hand tightly clasped in the other. He is bundled up like a snowman, frail skin swaddled in a cap, scarf, and overcoat.
"Mr. Hartman?" My mind and body rapidly decelerate as I approach.
The old man looks up, offering an apologetic expression that changes into a wince as he gets to his feet with difficulty. My nose detects the faint, menthol aroma of Bengay.
"Hi, Mr. Hartman, please don't get up on my account. I understand Dr. Keene has explained that your dog is seriously ill and in need of emergency surgery, so I thought I should introduce myself. I'm Sage's surgeon. I will be the one operating on her this morning."
Tired, frightened eyes search mine as he extends a cold hand.
"I'm so very sorry getting you out of bed," he says. "It was my daughter, you see. She's a doctor." I assume he means a doctor of humans. I am pleased to hear him refrain from saying a "real" doctor. MDs appreciate better than most that a hierarchy exists in a referral hospital—student, intern, resident, attending. She probably provoked this insight.
"She said to make sure to get a surgeon who is on staff, someone with more experience. Not a resident, she said. To be honest, it doesn't bother me. I just don't want to lose her, that's all. Sage is all I've got."
