Thursday, 25 July 2013

The Easy Diagnosis

It's been a week of textbook bashing. Where is this oedema coming from? Why is he insulin resistant? Is the GGT value significant? The kind of cases that make me tear what little hair I have remaining out, and pray to Hippocrates for a nice, simple diagnosis.

I've forgotten a fundamental truth about the easy diagnosis, though.


'... just not been quite right for few weeks. I know it's probably the hot weather, but we thought it would be best to check.'

I'm nodding sagely as I reach into the box, and even as I'm lifting the cat out I've got alarm bells ringing; under it's long hair, it feels like a skeleton wrapped in a thin blanket. I place it on the table to see that it's lost weight everywhere - everywhere, that is, except for it's abdomen, which is incongruously swollen.

'We thought he might have lost a bit of weight?' the old lady adds. Her husband nods helpfully and smiles.

'We just wanted him checked,' he says, adding with a chuckle, 'don't know what we'd do without you, littlun.' He reaches across and tickles the cat's chin, who starts purring. I smile up at the old couple then look back down at the cat, my hands reaching down to palpate it's abdomen. It doesn't take much squeezing before I feel the large, knobbly mass just behind its liver. We're seconds into the consultation and already I have a fair idea about what is going on. There is, of course, a chance that the mass I'm feeling is nothing to do with my patient's weight loss and inappetence, but that's not too likely.

'We thought that maybe he needed worming?' the old lady says, while the cat contentedly rubs his face into the old man's hand.

Whatever happens from here, the cat is going to need blood samples, x-rays, scans, possibly exploratory surgery, and there is a fair chance that whatever we do it's not going to make it. There are going to be difficult decisions about whether it's fair to put him through any of that at all, and their are going to be tears in the night, far from my surgery, over a companion who probably isn't going to journey along with his owners for much longer. All this I know within the first sixty seconds of my consultation.

It's hard to just blurt out that I'm pretty certain that we're dealing with cancer before the old couple have realised I've started examining at all, so I continue my checks. The rest of my clinical exam ticks more worrying boxes; mild jaundice, a low-grade heat murmur, pale mucous membranes. I return my hands to the abdomen, not really because I need to feel the lump again, but because I need to owner's to see that I'm starting to get concerned. I grow quiet, my usual smiles and nods tailing off, as I feel. If I was consulting with anyone else at the moment, I would say to the couple that I just want to 'take him out the back for a moment and ask my colleague for another opinion, because I'm just wondering if I might be able to feel something unusual here'. I don't really need the second opinion - the tumour isn't subtle - but it gives the enormity of what I'm about to tell the clients a little preparation. As it happens, this afternoon I'm consulting on my own. I briefly consider saying the same and taking the cat into the prep room for a moment anyway, but it feels too much like deception. Instead, I weigh the cat, and allow a concerned look to creep across my face. I return to the abdomen, and palpate the tumour while the cat purrs for a good thirty seconds; enough time for husband and wife to grow silent, and look at each other nervously. I take my hands off the swollen belly, and open my mouth to speak...


'You tell him, Emma, he's yours, after all!'

The young girl - maybe eight? I'm never good with child's ages - lifts the wriggling white rabbit from the box, and drops him onto the table. I swiftly grab him to stop him from bouncing straight back into his box, or, even worse, several feet onto the floor.

'What... er...,' I say, trying not to show how hard I'm having to grip the rabbit, 'what can we do for Dillon today?'

The little girl goes silent, and looks shyly at her mum. The young woman rolls her eyes, grinning. 'Okay, okay, but next time you say!' The girl nods, and the young woman looks at me. 'He's fine in himself,' she says, 'but Emma found a little lump around his mouth. I thought it might be a cyst.'

While she's speaking, my hands have found the little lump. It's about eight millimetres in diameter, attached to the bone of the jaw, firm, tense and unwelcome as hell. I look at it, seeing the skin stretched taut over it, so thin as to appear transparent. The parts of it that aren't bony are filled with what appears to be a thick, white fluid. It's not a cyst. It's not a tumour. It's an abscess. It's going to mean a long, protracted course of treatment and probably multiple surgeries and if we're very, very lucky, it might just not kill Dillon. It probably will, though.

The young girl finds her voice. 'We think it's a cyst,' she says, then turns back to her mum.


'She's just been a little lame the last few weeks. I thought it was probably the hot weather, it's been hard for her, of course, at her age.'

The greyhound stands at the edge of the consulting room, looking at the door. You might think she was aloof, but I've owned greyhounds, and I know they're just nervous with new people sometimes. It's partly why I like them; they're just like me.

'I was told you know a little about greyhounds, so I wanted to come and see you,' the woman says. 'I was thinking it might be time to start on some arthritis treatment, maybe? She's already on glucoasmine, of course.'

Of course. Everyone is nowadays. I smile, and start to feel down the left fore leg. It's not far before I feel the swelling in the bone.

'I had wondered about cod liver oil too,' the woman continues, 'but I thought... oh!'

I've squeezed the lump in the bone, gently, and the greyhound has yelped and turned to her owner. Painful on palpation. Ten year old greyhound. It'll take an x-ray to confirm it, but I'm already almost certain that I'm dealing with an osteosarcoma - a bone tumour. There's something like a sixty percent chance that it's already spread to the rest of the body, but even if it hasn't, we're talking amputation plus chemotherapy, with a very low survival rate. If we don't do anything, the tumour will erode through the bone until, one day soon, it will just snap - a pathological fracture.

Standing in the consult room, I remember the sunny day when I felt that same lump in the humerus of my own dog. I remember standing by the x-ray developer with Kerry next to me, both of us hoping against hope. I remember the very next day, Kerry looking at me with tear-filled eyes, cradling her head in her lap while our colleague finished injecting, whispering the words unbelievingly, 'Beattie's dead.'
I look up at the woman, and wonder if she will the remember the words I am about to say for the rest of her life too. I take a deep breath...


Here's the truth. Sometimes the easiest diagnosis is the hardest one to make.

Tuesday, 23 July 2013

ENnie-thing goes!

Hello blog readers/spambots/ghosts in the machine

This a quick (and rather excited) post merely to mention that my book, The Express Diaries, is up for an ENnie award - so, yay, go Paul, Eric and me!

If you've read the book and enjoyed it, please consider nipping over to the voting booth and voting for us - it's in the RPG related category - and, not that I'm trying to influence your voting or anything, but '1' is for first choice etc.

Thanks for reading! New proper blog post to appear here soon, I promise. Unless you don't vote for us, I which case I'll throw my laptop out of the window in a huff. Yes, you.

Nick :)

Friday, 12 July 2013

The Bluffer's Guide to Neutering

Firstly, congratulations are in order, for today is graduation day for the veterinary students of Nottingham University - well done, new vets! Well-deserved! My lord, you all look so young. I hate you.

Ahem. Apologies. Also, I don't hate you. You have a long and likely happy career ahead of you, but you've got a bit of a learning curve ahead of you now. Well, okay, not so much a curve as an Everest.

Thinking enviously about your cheerful, fresh faces, has got me thinking about being a new graduate myself, you see, and of all the things I started worrying about the moment I realised that bloody hell, I had only bloody qualified as a bloody vet!

I'm good at worrying (and at whinging, as regular blog readers are no doubt aware). After I graduated, I was at the very height of my worrying powers, and could probably have worried for Team GB. Amongst the many, many things that I worried I wouldn't be able to do (blood sampling, consulting, driving the practice car without writing it off (it turns out I was right to worry about this one)) one that loomed very, very large in my mind was surgery - and, particularly, given my woeful experience at the time of graduation (five cat castrates and a half a dog castrate), neutering.

Neutering. The bread and butter of the general practioner's day. If you can't neuter something, you might as well hang up your stethoscope before you've even bothered to (very cooly) drape it around your neck.

I am here to tell you, new graduates, not to worry about it. Well, that's not entirely true. I'm here to tell you why it's totally pointless worrying about it (a subtle distinction), by showing it to you from my perspective as a equally fresh-faced, enthusiastic new graduate; and I'm going to do that (along with telling everyone else what neutering actually entails) that with the aid of my (please insert a fanfare mentally at this point)

BLUFFER'S GUIDE TO NEUTERING! (Or, how I stopped worrying and learned to love the ops)

(You didn't do that fanfare, did you? Tsk)

Neutering is the generic term for removal of an animal’s reproductive ability. For males, it’s castration (removing the testicles. You might think this is rather too obvious to spell out, but I have, in my career, been confronted by a furious owner demanding ‘where the fuck’ her dog’s testicles were after I had castrated him. A few awkward moments passed while I explained the procedure that she had signed for that morning. The owner had been under the impression that castrating her dog merely meant ‘giving it the snip’. She was especially annoyed because now, all the other dogs in the area would pick on him because they would spy his conspicuous lack of love spuds, and realise that he was an easy target. We sorted it all out in the end but it was, as I say, an awkward consultation). For females, it’s speying (or, if you’re American, spaying; all I’ll say on the matter is that you’re wrong about grey, and you’re wrong about this).

Castration is a relatively simple (if eye-watering, for male readers) procedure in both dogs and cats – relatively low risk exercises in ligation (tying off blood vessels) and suturing. As with all surgical procedures, there are a few variations in technique, based on personal preference, but they were good procedures for my new-graduate self to sharpen my surgical teeth on (if you’ll forgive the slightly disturbing mental image that metaphor creates). Speying... speying is a different matter. The medical term is ovariohysterectomy – the surgical removal of both the uterus and the ovaries (As opposed to the human hysterectomy – removal of just the uterus (hystera being the Greek word for uterus, and the same root word from which we derive the word hysteria – which probably tells you all you need to know about the male attitude towards women throughout history)) is much more involved surgery. The ovaries are inside the animal – just below the kidneys, to be precise – and so harder to get to. Ligation is trickier, because the blood vessels supplying the ovaries and the uterus are similarly harder to manhandle into a position where you can tie your knot (incidentally, our domestic pets don’t suffer from hormone deficiency problems in the same way that humans do, on account of having a different reproductive cycle – the oestrus cycle, as opposed to the human (and other primate) menstrual cycle. This explains both why female dogs and cats don’t go through a menopause as they age, and also why humans don’t come on heat – which is why you never see un-neutered male humans leaving their homes searching for other women. Oh, wait...)

With cat speys, the added complication, just to make things interesting, is that in the UK we have decided to make the flank approach to the uterus our approach of choice. Flank means what it sounds like – making an incision in the side of the cat’s abdomen, rather than the midline approach that we choose for every other abdominal surgery we ever do. I’m still not entirely sure of the reasoning behind this; I’ve heard arguments that it’s quicker, that you get less post-operative reactions, or that if you get a hernia it tends to be less serious in the flank – but I’m not convinced by any of them. A well-practised surgeon will be equally speedy with either technique, I’ve see my fair share of post-operative reactions with flank cat speys, and if you get a hernia then you need to surgically repair it whichever hole the internal organs happen to have popped out of. I can just about see the argument that it’s a useful technique for animals that are lactating, because your wound is further away from the teats, and so the mother is less likely to reject the kittens when they come to suckle. You’re less likely to get milk leaking into your wound and causing an infection (because if there’s one thing that bacteria love, it’s a bit of milk) – except that in lactating dogs we still operate midline and don’t seem to see any of the attendant problems.

The main problem with the flank cat spey is that if you make you incision in just the wrong place it is an absolute bugger to find that bloody uterus. In these early months of my career, I spent many, many hours peering into a cat’s abdomen, fruitlessly searching for its reproductive organs like Gollum forlornly searching for his lost ring, only to discover that I had yet again failed to penetrate the peritoneum (a thin membrane coating the abdominal organs, that shrink-wraps them away from hapless surgeons that fail to make their cut deep enough), or that my incision was to dorsal, or too ventral, or (on one occasion) so far back that I had managed to enter the poor cat’s abdomen through the muscles of its hind leg; this last individual seemed fine when it woke up but I made sure it had extra pain-relief at home. Even though my days of elusive uteri are long behind me, I have spent enough hours since helping out stressed and sweary foreign locums attempting this strange technique to wonder why it is we persist in our approach. Tradition, I suppose. I guess it's no weirder than putting trees in our houses at Christmas.

The last, and by no means at all the least of the ‘routine’ neutering procedures is the bitch spey. Ahh, bitch spey, my old nemesis. The bitch spey is the same surgery as a cat spey, in that you’re performing an ovariohysterectomy, but it’s much, much harder. I would contend, in fact, that speying a fat deep-chested dog is about the most difficult surgical procedure you’re likely to encounter before you start entering the realms of certificate-level surgery. There’s a feeling that only surgeons know – a warm, prickly, feeling, experienced during an operation that isn’t going very well; the surgeon’s sweats, we’ll call it: a terrible feeling that you want to escape, you want to be anywhere but standing here in this hot, humid operating theatre wondering what the hell you are going to do to sort this mess out. In my early years, I came to associate bitch speys with the surgeon’s sweats.

Here’s how I saw it: a bitch spey is a no-win procedure. You’re starting with a completely healthy animal who, given the choice, would probably rather not have you ferreting about in its abdomen, and you’re performing major abdominal surgery upon it. Those blood vessels of the ovaries, those difficult to get to ones up by the kidneys, are no small potatoes. If you don’t ligate them properly, the dog could bleed to death. Now, it’s worth pointing out that in my decade (and a bit mumble mumble) as a veterinary surgeon since, I have never once seen or even heard of a bitch spey bleeding to death either during the procedure or afterwards (although I have seen a handful need to be re-operated on to re-tie oozing blood vessels) but the knowledge that it was at least theoretically possible was very much on my mind as I learned my surgical skills. When abdominal fat, which obscures your vision and makes everything – including your suture material - as greasy and slippery as a bacon sandwich, is added into the mix, then you have a recipe for a young veterinary surgeon such as myself turning the air blue as he attempts to complete a procedure that he wishes he had never started, in the full blush of the surgeon sweats (although, apparently, it's not when I start swearing that my nurses get worried nowadays; it's when I stop swearing and go quiet). As well as that horrible feeling, I discovered to my surprise that during a long, hot and unpleasant surgical procedure is the time that I seem most likely to be afflicted with an ‘earworm’ – the internet term for a song repeatedly playing unasked in your head. There were many times in my younger days when I stood with my hands placed inside a still-living animal, surgical gloves covered with a slippery sheen of fat, feeling hot, stressed, sweaty and miserable, with ‘Memories are made of this’ inexplicably blaring at full volume within my skull. After several of these long, stressful and strangely lonely experiences, I started to develop something of a 'thing' about bitch speys.

Much as I started to do with consultations that I might have to see the next morning, I started to check the ops board the day before my ops day. A board that featured a bitch spey larger that fifteen kilos, or older than a couple of years (and so likely to be fatter) would mean a restless and worried night’s sleep for me. I grew to loathe them. However, I decided that the best way to deal with my ‘thing’ was to confront it full on, and do as many as possible, rather than try to avoid them (which is what I desperately wanted to do). 

I sweated and swore my way through a lot of speys. They got easier, but I never stopped worrying. what if I get a bleeder? What will I do? How will I cope?

Eventually, of course, my worst nightmare – the one that had deprived me of so many hours of sleep worrying about it- came true. During the spey of a particularly chubby Doberman, one of my ligatures slipped off an ovarian stump, and the dog’s abdomen began to fill with blood. I panicked, and called for a colleague, who very calmly scrubbed in with me, helped me find the stump, made me ligate it again, smiled, and walked back out whilst I got on with the rest of the spey. 

This was a surgical epiphany for me, because I realised that all that worry and fear over what would happen if one of my stumps wasn’t ligated properly had been for nothing, because all that actually happened was that the operation took about ten minutes longer that it otherwise would have done. That’s all. Everyone, at some point in their career, has a bleeding stump from a bitch spey, and everyone goes through that same realisation – what was all the worry about? It didn't completely cure my nervousness of bitch speys, but it was the beginning of the end of it. It took a lot more bitch speys before I began to see them in my own mind in the way we describe them - routine - but I did get there eventually.

(Having written that personal odyssey through my earliest surgical steps, it occurs to me that the conclusion that may be drawn from it is that the best way to stop worrying about a surgical procedure is to immediately cause the worst complication that you can imagine on the basis that it will all get better from there. Please don't follow that advice, or crucially, if you do, please don't mention this blog to the Royal College of Veterinary Surgeons)

So, the months passed, and the stresses of surgery began to recede. Neutering, taking bloods, hitting veins, placing catheters (intravenous and urethral), placing ET-tubes and the scores of other practical things that I had lain awake at night wondering whether I would actually be able to do became easier an easier, as things do when you’re doing them all day, every day. All that worrying, for nothing. You see what I hadn’t realised is that, in veterinary medicine, as with every other aspect of life, it’s not generally the things you worry about that end up becoming a problem. 

It’s the things that jump out upon you unexpectedly, like a phone call at three in the morning, that really cause you trouble. Err... have fun with that out of hours work.

Right, well that's all the worries of today's Nottingham graduates (well done again!) eliminated, as well as, I suspect, the worries of all future veterinary graduates from here on in. A good day's blogging, I think. Now, to relax in the sun with a drink. Oh rats, I can't, I'm on call. Can anyone hear the phone ringing?