Tuesday, February 11, 2014

Coco's Dystocia, Warning, graphic surgery images.

Another Friday disaster. I am 2-2 these days.

I am supposed to be off on Fridays and Saturdays. Sort of my weekend break. A chance to catch up on the rest of my life and take a day with my husband for the "to do list," or just a fun drive to check out the local activities.

Like most veterinary practice owners, we have a tough time separating "our free time" from the other responsibilities in our lives. For as few appointment hours as I currently see (about 8 a week and one day of surgery) I spend about 30 hours on the floor monitoring all of the other responsibilities that fall under my job title. I am exceedingly uncomfortable NOT knowing what cases are in the hospital, what the local gossip is, and how the staff is faring. In essence I feel compelled to have my fingers always on the pulse of the hospital. It is my obsession/compulsion and I mirror it to always having to hear an audible "beep, beep, beep" of a pulse ox if a patient is not up and alert.

Last Friday I  was mulling about the clinic and the phone rang. As is typical, the receptionist came back to me to report that "a woman who is not a client, was on the phone in hysterics, because her dog had a puppy stuck that she couldn't deliver. The emergency clinic won't take her." (She didn't need to fill in why,, they would never turn someone away because they are too busy to see them).

My receptionist looked at me with those big eyes that said "I would see them if I could do anything about it, but, since I can't, I'm pleading with you to."

Bird's eye view
Now at that moment in time. I always think the following...
"Crap, I don't want to deal with this..I don't want to try to figure out how to bleed a penny, or how to cut enough corners to write off my losses when this client walks out on her bill."

So, inevitably I internally debate sending my receptionist back to that caller to make an excuse and force her to listen to that woman in hysterics, thoughts of some poor agonal dog in their head, and get my neck out of the noose.

Quick, easy, done!

This is what everyone else does, I know it. They are better business people than I am. More steadfast in their convictions, and have learned their lessons sooner, faster, and are more able bodied than I. I would pass the buck back save for two things.

  1. I fiercely protect my staff. This job will never, ever pay them what they are worth. So I have to make this job one they want to come back to day in and day out by helping it provide them with a sense of purpose. If I am trying to foster a sense of compassion I damned well better lead by example. Ask me if I would assist in a convenience euthanasia or dismiss hysterical people for my boss for $12.00 an hour? Hell, (although the word in my head does not start with an "H") NO!
  2. There is a dog in need on the other end of that phone. And, if I say no there will likely be a dead dog on the end of that phone. It's the reason I get out of bed and come to work, and it's the reason I have a donation fund for people in need.
I picked up the phone to the wide-eyed grinning glee of my receptionists relief.

Sure enough there was a hysterical woman on the phone, a dog in desperate need of care, and another day off working on another hard case who had the cards stacked against them. My favorite.

When I answered the phone with my cursory "Hello, it's Dr. Magnifico," I was met by a swallow of  tears and a pause of disbelief. I know that most vets don't answer these calls.

"Umm, my dog has a puppy stuck in her!" sputtered almost incoherently out of her mouth. "I've called everywhere! Please help me?"

She had a hundred dollars to her name and every other clinic had told her that it wasn't enough money, she would need credit that she didn't have, and she wasn't there client." Surely we all know how easy it is to pass the buck?

I explained to her that her dog probably needed an emergency surgery, and that it would probably cost about $1,000. In truth I didn't know anything more about the case than you all do. It was a ball park, but I've been to bat enough times to know what the pitcher is throwing at me.

I explained to her that I would try to help her dog, but that she had to provide some sort of collateral to show good faith. I have tried this many times in the past, and it is always met with a sharp pause of disgust, disbelief and confusion, like I am the devil asking them to sell me their soul? 

"What kind of collateral?" she whispered softly and sheepishly.

"Well, like something of equal or greater value that I can hold to give you time to pay your bill." I replied.

I ask for collateral because although I might still be the worst veterinary business person on the planet, if I don't I end up a bitter and bad business person. She offered up a necklace and I told her to head over.

"Umm, I don't know who you are?" she said. (Always makes you feel wanted when you realize you were just a number on a list...)

"We are Jarrettsville Veterinary Center, 3961 Norrisville Rd, Jarrettsville MD."

"Oh, it will take me a little while to get there.."

When she arrived I collected a scant medical history. It went as follows;
  • two years old, female, intact (obviously), no history of...well, anything..
  • no vaccines
  • no veterinary care
  • no previous pregnancies
  • the presumed father is truly her father, and she always tried to keep them separated.
  • has been in labor for over 6 hours
  • went on the internet to learn about delivering a puppy at home.
  • owner had tried to pull puppy out (never ever something i recommend), puppy was sloughing the skin on the rear quarters (part of puppy protruding from vulva)
  • based on rear feet and legs this puppy was obviously deceased.
After a quick discussion I informed owner that I would only assist if she was to be spayed and that she needed to be updated on rabies as soon as possible. 

Coco's dilemma
Coco's exam was about par for her dilemma. She was a tiny speck of a dog. Three and a half pounds (with her puppy), skinny, weak, tired, distressed, poor hair coat, fleas, unknown everything else.

My first diagnostic was an x-ray. I wanted to be sure that she only had one puppy to deliver, and I also wanted to see how that puppy was positioned.

One puppy, stuck half in and half out.
While in the x-ray room we placed an i.v. catheter and started to rehydrate her.

I put a glove on and applied a mega amount of lube to try to unstick her puppy. Sure enough, it wasn't going to budge. I also didn't want to tear any of the dried internal tissue that was forced out of her by the friction her puppy caused. The puppy was dead, it could be manipulated any way necessary, but mom needed to be treated cautiously.

I had a flashback of large animal ambulatory service in vet school. I was called one Saturday night at midnight my senior year of vet school to assist in delivering a foal at the vet school. It was winter, the roads were bad, and it was the middle of the night. My husband offered to drive me to school, wait for me, and drive me home. He was only with me for a few short hours every weekend and it was at least a way to be together, even if he had to wait in the wings.

Lucky for him, everyone else was as tired and equally motivated to get back to bed, that he got a front row seat for the show.

The mare had a similar condition to Coco. Desperately trying to deliver a dead fetus and her life on the line to remove it.

For large animal medicine the  methods to dystocia (abnormal delivery) are a bit more archaic. Within minutes of palpating to insure the fetus was dead inside of her (involves poking eyes, poking, pinching, or otherwise trying to elicit stimuli response, and feeling for heartbeat), the chains and gigli wire come out and go inside the mare. You see, if a foal is stuck inside vets will cut them out to remove them piece by piece. For as long as I live I will never forget Joe's face. Part shock of not knowing what was going to happen next, and part shock that he was witnessing this happen at the hands of his wife. A little fear is healthy for a marriage I remind him.

Now Coco is 3-1/2 pounds. Much as it would have been quicker ans easier to do, there isn't anyway fingers and gigli wire will fit in her. Off to surgery we went.

Coco was essentially a spay with an obstruction. I entered her abdomen, relieved her enormously distended bladder, (how awful is that? You are dying to pee but you can't because that opening is corked closed by your puppy) and started to push her puppy out the direction it was already headed. With a little help from another vet her puppy was out within minutes.

Surgical prep
Dystocia can happen from a multitude of reasons. Most often I see it as one of the following;

  1. Dad is significantly larger than mom. This was the case for Coco. Never breed a small female to a larger male..the puppies will be bigger than mom can deliver.
  2. Anatomy of mom. If mom has a pelvis that won't allow passage of babies they get stuck. I have seen this in dogs with old pelvic fractures and breeds that have puppies bigger than the shoot they get delivered through, think Bulldogs.
  3. Uterine inertia. The uterus is so exhausted it just stops trying. Primary inertia can occur when a small litter size fails to deliver enough stimulation to the uterus to cause a release of the hormones that start contractions, or an overstretched uterus from a litter that is too big, stress/anxiety for first time moms, or underlying disease. Secondary inertia occurs when mom has been persistently straining to pass an obstructive fetus. In Coco's case it could be primary; first time mom, small litter, hypoglycemia, or secondary, that pup is obstructing her ability to push it out.

The rest of her spay only took a few minutes more. No bleeding, no wasted time, no internal trauma, she was at least lucky in these respects.


Post-operatively I worried about the things I always do.

  1. She is a little thin dog. After opening up her abdomen with a large enough incision to get my hands in and do all of things things I had to do she will cool off very quickly. As fast as I was in spaying her her temperature went from 102 to 95. Waking up is inextricably tied to warming up. Even though she was on a heated mat, a fluid warmer and surrounded by warmed water filled gloves she got cold fast.
  2. Her blood work was still in the blood machine. I had no idea what her electrolytes looked like, her calcium, or her glucose. All of these can be altered so significantly in a pregnant dog that they can cause death.
  3. There was the rest of her unknowns, like heartworm disease, susceptibility to infectious disease, poor body condition score, etc. etc.. I didn't know what her next stumbling block might be if it wasn't caused by her pregnancy.
Waking up
Coco woke up well. Calm, quiet, warming up, and relieved, I'm sure.

But, her blood work revealed a very low blood glucose. Correcting this should be done under close veterinary supervision. Too much glucose is just as detrimental as too little. An i.v. drip with glucose added should be delivered slowly in the hospital. Frequent blood glucose checks should be performed to insure that the blood glucose level is rising, normalizing, and not approaching hyperglycemia.

Coco was released with strict orders to return for additional treatment, monitoring and follow up. Her mom was reliant on a friend for transportation and was unable to return. Two days later Coco died. We presume it was due to complications of her condition and hypoglycemia.

I spoke to her mom after and asked for permission to write this. I told her that I was sorry for her loss, I know how much she loved Coco, and how important Coco was to her.

She thanked me for helping her and was happy that Coco passed peacefully and didn't die a terrible death from having a puppy she couldn't deliver. I offered to add any additional things to Coco's story that she wanted to mention. She said that she wanted me to say that Coco was loved by everyone, that she loved everyone in return and that she always knew she should have gotten her spayed if she had an intact male in the house. She also was worried about telling her family of Coco's passing. Her family has been through a lot and Coco was one beacon of light and love in their lives. She is in the middle of trying to assist her husband with his alcoholism and recovery, her car was repossessed, and her home is being foreclosed. She didn't need the stress and grief of losing her dear pet. Seems that life works like that sometimes, doesn't it?

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My pup Charleston


  1. I can only guess at how cases like this add to your burden of compassion fatigue. I am in awe of your commitment to animals in need. Thank you.

    1. Thanks for reading. I sometimes feel like I don't have a choice. I cant turn a blind eye, I cannot walk away, or say "no" when I know I can help. What were my options?
      I have to try, and I have to help. The rest is up to the parents and fate.

      I wish I had tried to convince Coco's mom to let her stay with us. If I had known that she wouldn't be back for her re-checks I would have offered to keep her with us for free....

      Ah, the regrets and hindsight.

      Take Care,

  2. I do not know how you do it. I would be so so angry. Whilst I am sad for Coco's mum, I just can't understand how someone can get themselves into a situation where they have 2 intact animals of opposite gender and think that isn't going to be a problem. And to not vaccinate/worm leads to so much potential disaster for the pet and the rest of the family.
    You are an exceptional human.

    1. I can't be angry. I am sad, and a bit disappointed, but anger will cause me to stop trying, to make excuses to stop caring, and turn me into something I try very hard to not be, bitter and indifferent. It is rampant in this job,,and it will kill the only things worth fighting to protect, my sense of purpose and compassion.

      I can only do the best I can,,how many others forego that? The rest is up to someone else.

      I did what I could and Coco benefited from that. Her mom really loved her, I am glad she sought help for her, she just didn't have the resources to do all that Coco needed.

      Thanks for reading.