The real joy in medicine is not the repetition of doing what you already have mastered, it's the courage it takes to trudge into unchartered territory with nothing to lose and a life in the balance.
...at least that is what I am trying to convince myself to believe these days.
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| Garfield, 24 hours post op |
I get these cases more and more frequently as the garden of availability for care shrinks to a place of abysmal, if not completely absent viable options. It seems all too frequently the pool of practitioners would rather swim in the waters of comfort and ease doing vaccines and avoid the whole messy territory of risk critical care for the common people. With its potential for failure and lack of the obligatory at the ready/disposable $10k we are becoming a profession so pigeon-holed we are petrified to challenge ourselves out of our own comfort zones. Human medicine made this leap many decades ago. They parceled out the person into parts, made a specialty for each of those parts and consciously decided to ignore the whole for the rest. Those specialists now demand high dollars and police the gate of admission based on your anility to pay the entrance fee. You may hope to be seen as the sum of your parts, but in medicine you are just that piece-meal-parts. Vetmed used to do it all, and try to do it all for the sake of our patients. Now we just refer. Regardless of whether that works for anyone else but ourselves.
Yesterday was one of those days. Seems the more I call out the ER's for ditching treatable cases when they don't meet the non-negotiable deposit required, the more calls I get to take the cases with the worst traumas and the lowest budgets. Me and my big mouth.
Yesterday it was Garfield. A speck of a puff of orange fluff with his big green eyes and his cock-eyed jaw. It was obvious he had met some sort of trauma. A 2-pound kitten with a dare devil perspective and a primitive naive sense of caution. His dad cuddled him in the exam room nervously. He had come home from work last night and found him this way. Garfield would attempt to open his mouth and scream. He was in pain, his mouth wouldn't close properly, it was fairly obvious the dilemma lay here. Dad did what all of would. He headed to the ER, screaming kitten in tow.
As dad relayed the story my mind wandered off to my beloved Seraphina. The kitten who came to me so many years ago. She had been found in the middle of the road, another tiny speck, grey and mangled. Her chin hanging from her jaw bone, a pitiful meow to landmark the site. She had been the same dilemma; a very broken kitten, and no training to pull from vet school on how to treat her. She, unlike Garfield, had been a found, unwanted kitten. She was so broken that no one would have claimed her. If you don't have the love of a human who has already bonded to you it is very hard to instill a strong enough sense of empathy to pay for the couple thousand dollars a broken kitten of her magnitude that it required. With this she became ours. Our pet project to offer a chance to, fight like hell for, and find a way to solidify her perfect presence within. She remains to this day, perfect. She is the one being I find myself seeking when the Garfield days find me. As the veterinarian who never goes looking for her next companion she will remain the most beautiful, elegant, super model caliber pet I will ever call my own. She adores me as only a once-ago-lost soul can.
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| Seraphina |
Her story can be found below, just in case you don't know her already.
Seraphina, The Why In Who I Am
Garfield's dad told me that his girlfriend had gotten a kitten, but they had broken up some time ago, she took the cat and left, and he just missed the cat. So, he had found a fluffy orange tabby of his own, and named him Garfield. The two had only been together for a few days, but he was already smitten with his kitten. Garfield was loved and his dad wanted him back to better with whatever means he had to do it. For as long as I have been a veterinarian this is all it takes for me. If a pet parent wants their pet better, if they are truly willing to move mountains to get them the help I will move the mountain with them. This is where the joy lies for me. It isn't in the assets and the accolades. It isn't the work-life-balance and the easy living of being the apex edification-aficionado in a profession you will never master fully. It is the little endeavors where we all put our heart and passion together to make the meaning of life humanity. Give me this a million times over and you can keep your yacht and Birkin bag.
The ER visit was a brief one. At two pounds, and with obvious fractures/dislocation of the jaw, this kitten needed a surgeon. They, kindly, gave a free exam, a bombshell of a projected treatment plan, and sent them on their way, with a comment that "Jarrettsville Vet takes these kinds of cases if you can't get help anywhere else."
..and so the next morning, as my first emergency appointment of my already booked day, I met little Garfield and his worried dad.
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A very brief exam later and I reiterated the same advice; Garfield is really small. Our options for treating this were limited. To make the dilemma even more precarious, I had to be really certain I knew what was wrong before I go jumping in all "damn the torpedoes" to render interventional aid. I had to know whether this was a broken jaw or a dislocated jaw. To diagnose a bone problem we rely on an x-ray. To take a picture of anything in a 2 pound kitten is fraught with impossibilities, They are too small to hold still. There's that. There is no way to not have your hands in the shot.. and the bones of a kitten are more mush than formidable. We tried three times to lay him in different positions to get a head x-ray. None were diagnostic quality. I went back to the exam room to lay it all out. It went something like this;
- Garfield is really small.
- Garfield is in pain and therefore does not want anyone to hold him anywhere near his head. (Where else can I hold a two pound anything?)
- Garfield should see a surgeon for his best chance at a life long functional mouth.
- I don't think surgeons wake up in the morning and do anything for less than $2,000. If it is a fractured anything that number starts at $4,000.
- I don't think I can get a diagnosis of what exactly his problem is without sedation. I have not sedated a two pound anything, ever.
- If I can manage the sedation I will need to intubate him to take an x-ray, and figure out what to do to try to treat him. I don't know if I have a tube small enough to intubate him.
- If I can get the above done I still don't know if I can fix it.
(Way to be all Debby-downer Krista)...Want to try?
They took a few minutes to talk about it.
I returned to the exam room and they agreed the specialists were too expensive, (preach to the choir, and can I have an "amen!" brother).
"So, we would like you to try."
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I am sure I muttered something sarcastic like; "thanks" and, "if this works you owe me a big gin and tonic." I tried to keep it light and I hated myself for offering. I don't know how to fix this? I don't even know what this is.
I walked back to the treatment area with an angry, screaming in pain Garfield. I had every justifiable reason to punt this case. It was 12 pm, I was booked solid with appointments until 7 pm, and I, have I said this yet?, did not know what I was doing.
I asked the techs to help. If I never have anything more than the support and kindness of the staff I am still the luckiest veterinarian on the planet. For every crazy, sad, lacking in the hope department case I take on they always jump in to help. "Damn the torpedoes" is our company huddle song. They won't abandon me, or these patients, and we are as close as any military unit I have ever fox-holed up with. This is the marrow of veterinary team building.
I pulled up the smallest dose the smallest syringe we have and jabbed Garfield in his non-existent thigh muscle. He screamed, I was hopeful that maybe this was an indication the medication had hit its mark.
A few minutes later we masked him with a little aerosol of isoflurane to get him quiet enough to try to place a tube down his trachea. Anesthesia for neonates, sure I remember that lecture, (there is no lecture).
Tiniest tube in the rack, you know the one I have never used before. Yep, let's see how that goes. What do I do if it doesn't fit? We wing it? (We are already winging it).
2.5 endotracheal tube slips into the trachea like Cinderella's slipper. (I say a quiet prayer of gratitude).
Lowest setting for the anesthesia machine? Well, if he stays asleep we got that right. (He did).
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| Now thay the endotracheal tube in place that we saw the blood in the back of his mouth. This is the site of his fracture. This was the clue we needed to focus the x-ray on. |
Now it was time for the magic to happen. That place every veterinarian inherently learns by being a mental ninja of anatomy. Experience and the miracles our fore-parents instilled into us when there wasn't a textbook to follow. (Did I mention I had my Emergency and Critical Care Manual on the surgery table with me?).
Three technicians jumped in to help. There was a Fossi-fanfare of hands circling Garfield's little body.
Our dental expert took the time to take/retake and keep taking all of the dental x-rays until we finally got the picture we needed to confirm our diagnosis. There was a fracture in the mandible on the left side right next to the ramus, or angle of the mandible. (I know I swore here). There are ways to fix this, (did I mention I haven't done them myself), but you need bone on either side of the fracture site to stabilize it for the whatever many weeks it takes to heal a broken bone. It's also super helpful to have had 4 years of residency training in dental surgery.
Ok, check off numbers 1,2,3 we have a diagnosis.,,, and now what. A diagnosis isn't where this kitten needs to be. He needs help in the way of a treatment plan so he can get up and go live another 20 years fully and functionally.
My dear friend Dave broke his jaw playing baseball in our senior year of college. He was pitching, his face got in the way of a slugger headed low and hard for center field. His jaw cracked upon impact. We were all there. He spent the next 8 weeks with his jaw wired shut after the surgeons put the pieces if it back together. Senior year at the Academy is called our First Class year. You show up, take your exams, pass your license test and drink to oblivion in between all of it. Four years of that pressure cooker and drinking (along with swearing) is your rite of passage. Dave wasn't going to miss out on any of this. To insure his airway could remain open if he ever got sick he carried around a wire cutter necklace. "In the event of vomiting cut wire" in bold letters. Safety first. We are trained merchant mariners who live everyday knowing the sea will claim your life if it deems appropriate.
"Sure, I just wire his jaw shut."
I walked back into the exam room with the news. Want to keep going? Don't know what I'm doing but I will keep trying?
They nodded yes.
Ok, if I wire the jaw to get the bone to heal how will he eat?
Let's place a feeding tube. I have actually done this but it was in a 10 pound cat. (Size matters).
Open Emergency Care Manual and read-re-read instructions.
An 8 French red rubber was placed. Three full body x-rays later, and a few minor adjustments and it was in.
7th inning stretch and recap; pt is under general anesthesia with breathing tube in. HUGE accomplishment! Patient has feeding tube in, Second standing ovation! Patient have jaw closed with canine teeth lined up perfectly, YAY! But, how do I keep it this way?
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The dental/oral surgeons use a quick drying epoxy to lock the teeth together. I am not a surgeon therefore I do not need, or have, locking putty. I do however have suture. So I use what I have. "Damn the torpedoes!" I close Garfield's mouth with his canine teeth lined up as they should be. Put the anatomy back where it belongs and place stabilizing material to hold. I take a big bite of the inside of his upper lip with my suture and loop it down to the same place on the inside of his lower lip. Then I tie a knot. I remember Dave had just enough room to open his mouth to allow a straw. We blended every meal for him for 8 weeks. Steak, pasta, beer. Beer with NY bagels and cream cheese. Dessert, every kind of ice cream imaginable with more beer. Initially it was a great, albeit drastic, weight loss plan. It wasn't always palatable but we were young and resourceful.
..and so I used my dear friend Dave's treatment plan as I concocted Garfield's. He had just enough room to open his mouth, extend his tongue through his canine teeth, but, the canine teeth remained in their correct position because he couldn't open wide enough the unlock them.
Now, all he had to do was wake up well enough that I could remove his breathing tube. He had to be breathing, calm and stay this way, because I had just sealed our fate in NOT being able to re-intubate him. (This requires opening the mouth wide to see the hole for the trachea). This is where the courage lies. All of these things, most I had never done before had to work. They just had to.
I was not going to euthanize a kitten without throwing my butt in the very hot, very unchartered territory seat, I haven't done it in 20 years and I am not starting today.
I placed a pink turtleneck over his neck to secure the feeding tube as he was waking up.
Garfield needed to be held for the next two hours or he would caterwaul a cry that only a desperately afraid kitten can produce.
A few doses of gabapentin, buprenorphine and a Zorbium later and he was sleeping.
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After all of this, everything going so perfectly, I just didn't feel right about sending him home with two grateful parents who still had no idea of what they were doing. Can't lose the race in the last few yards.
As I carried him back to his dad I asked if he would be ok if I kept him for the next few days. The site of Garfield with a neck bandage, black suture ends sticking out his his clenched mouth, and a long orange tube extending like an antenna from between his ears did all of the persuading.
Garfield stayed with me for the next few days. In my attempts to not over fill his stomach via the syringe I forced the gruel into his stomach with I had induced a hunger strong enough to convince him to lap up the blended kitten food with vigor. In 24 hours Garfield was eating on his own feeding tube still in place, jaw sutured closed, and yet he marched on. The biggest victory for his recovery I could have hoped for.
It's smooth sailing from here kiddo! I told him at our next 4 am check in.
Never, ever, ever give up on a kitten. They are braver, fiercer, and more stubborn than even the saltiest of the most weathered magicians we call veterinarians.
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