Friday, July 15, 2011

Oncology- tumor biopsy

Today I got to biopsy a big subcutaneous tumor. It's probably the most hands-on I've been allowed to be in vet school!

"A" is a 12 year old labrador with a golf ball sized mass over her shoulder that seems to be causing her to limp.

We were highly suspicious that it would be a primary bone tumor called osteosarcoma. But, we took radiographs and were delighted to find out that the tumor was not affecting the bone. (Osteosarcoma generally carries a very poor prognosis.)

This leaves us with several other potential causes.

We did a fine needle aspirate of the mass and came away with a lot of blood and some maybe soft tissue tumor cells. Essentially, the fine needle aspirate wasn't diagnostic.

So, today we did a biopsy of the tumor.

We put A under general anesthesia. We then clipped the hair over the mass and did a sterile preparation. Then, Dr. Daly let me do the wedge biopsy. I took a big slice out of the tumor and Dr. Daly commented that I was not a wimpy biopsy-er. After that, the tumor bled and bled and bled. We stopped the bleeding primarily through cautery. Then, I even got to place the sutures!

The biopsy results are still pending.
But, overall a very exciting time!

Wednesday, July 13, 2011

Oncology- Today was hard

Today was hard. As much as I love Oncology- and I really do- sometimes it's just hard. Cancer isn't an easy thing. Most patients are not cured. A lot of them can be made to feel better for a while. But, there are some patients who we just really can't do anything for them.

Today was one of those days where it seems like all of the cases we see are those can't-do-anything cases.

My patient, "S", was a 5 year old orange tabby cat. He was so sweet. And his owner loves, loves, loves him. S was dumped by the owner's house as a kitten. One day, while dying of respiratory infection, S jumped up into the owner's lap and declared himself adopted. The receptionist put him in an exam room this morning and told us that she could hear him crying when she left. He cried a couple times while we gathered the history and physical exam. He also cried a little while we talked to him about our diagnostic plan.

The thing is, watching an older man cry just pulls my heart strings. As Kristen (one of my classmates) puts it, I am a co-cryer. His eyes well up and it is just totally reflexive for mine to well up too.

Even starting off in tears, it only got worse from there.

On ultrasound, S had a large mass originating from his pancreas with several other organs involved. On cytology, there was evidence of carcinoma. So, he has a pancreatic carcinoma that has already metastasized.

Even in humans, this is a bad, bad, bad tumor to have. There's no good treatment options.

We broke this news to his owner, who just sobbed. He hung his head, tugged his hair, sobbed and apologized. We told him there was nothing to apologize for.

It was heartbreaking to hear that he hates the month of July because his wife was diagnosed with cancer in July, he was diagnosed with cancer in July, and now his cat was diagnosed with cancer in July. I think we all cried a little.

Monday, July 4, 2011

Soft Tissue Surgery- compliments

True compliments in vet school are few and far between; but I got a very nice one today.

Dr Bonin, Caroline and I were leaving ICU after doing a final check in on our patients and he said "you two are the hardest workers on this rotation. You do such a good job and have such a good attitude. And you're pretty knowlegable too."

He also told us that we were going to do well this year if we keep up this attitude and work ethic.

(He also mentioned that 2 of our rotation-mates are not doing a very good job. On top of being lazy, one of them makes really stupid mistakes because he doesn't ask questions and doesn't take initiative.)

Overall, a very uplifting moment!

Friday, July 1, 2011

Soft Tissue Surgery- Electrocautery is awesome

We amputated G's leg today. We did what is called a proximal third amputation, where we left a piece of the femur. Dr. Bonin feels like this is more cosmetically appealing. Right now, that's hard to judge. I'd have to see it when it's healed better.

The amputation process was so interesting! While I'm pretty sure I won't have electrocautery in general practice, it was really awesome to use in surgery today! I even got to control it for most of the procedure. We used it to control bleeding vessels and to cut muscle bellies- simultaneously cutting and cauterizing.

The coolest part of cutting the muscles with the cautery was the way the muscle fasciculated after being cut. It looked like the muscle was boiling.

The primary surgeon found my fascination with that hilarious.

What have you found fascinating lately?

Wednesday, June 29, 2011

Soft Tissue Surgery- "G"

"G" came in early this morning on Emergency because she was hit by a car last night. As far as we can tell, she doesn't have any broken bones, but she has really significant soft tissue injuries.

She has a puncture wound over her right eye that made a pocket under her skin that goes back to the level of her ears on the top and all the way over to the left eye. We're managing that wound conservatively with bandages for a while before we really close it up in a few days.

She also had a pretty big abrasion on the front of her right front leg. We're doing the same bandage song and dance on that one.

The big story is her left hind leg which has what we call a "degloving injury." Think about when you're wearing a glove and you peel it off at the end. It's like that, except skin instead of a glove. The skin from her ankle to her toes is missing. There are exposed pieces of muscle and bone. We could manage this with bandages for 3-4 weeks and probably save the leg, but that would cost the owner $6,000-$8,000. Instead, tomorrow we're going to amputate her left hind limb.

I'm really looking forward to the surgery! And I think that she'll feel a lot better once the dead/dying foot is gone.

Monday, June 27, 2011

Soft Tissue Surgery- "J"

"J" is a 3 year old Bulldog who has had skin infections since his owner rescued him a year and a half ago. He has a severe infection underneath his tail.

The infection under J's tail, which is what he came in for, is so painful that he screams and bites when anyone tries to examine it. He also has a severe ear infection, a deep chin furunculosis (deeply infected hair follicles) and several other patches of pyoderma (skin infection.)

Overall, he is a little ball of greasy skin infection. And he REEKS. A lot. It's honestly nauseating to stand near him for too long.

Tomorrow, we're doing surgery to remove his tail, which will eliminate the fold the infection under his tail has been growing in. It will also remove the skin that is most affected. After he recovers from the pain of surgery, that should help him a lot. We already consulted Dermatology to help set up a lifelong management plan for his skin problems.

This case just re-inforces for me that Bulldogs are a breed I will never, ever own. What dog (or cat!) breeds do you never want to have?

Thursday, June 23, 2011

Soft Tissue Surgery- And the surprises keep on coming!

A's CT scan brought even more surprises to her already complicated case.

The CT scan revealed several very small nodules (in the 1-2 mm range.) Beyond that, the radiologists had a hard time agreeing on what the CT scan showed. Part of the process is using the software that comes with the CT machine to evaluate the density of the masses.

One of the radiologists got values indicating the masses were mineral density, which would likely mean that they are benign mineralizations that happen in old lungs. The other radiologist got values indicating that the masses were soft tissue density, which would likely mean that they are actually malignant. And the fact that different "windows" (ways to look at CT images) and different computers give different values indicate that the CT machine is broken in a way the radiologists can't explain.

Either way, benign or malignant, surgery is not the best option. If the masses are benign, then obviously the risks of removing a lung lobe significantly outweigh the benefits. If the masses are tumors, the fact that there are multiple ones in multiple lung lobes makes surgical resection a poor option.

The owner has a follow up appointment in a month with oncology for a repeat CT scan and further advice.

Interestingly, I'm on oncology in a month so I'll get to see how this case ends!