Investing Too Much. When, and Where Do You Draw The Line?

Perhaps I went into this for all of the wrong reason(s)?

Maybe not the wrong reasons, but, perhaps the expectations were unrealistic? Maybe there was too much of me in this endeavor for others? Maybe it's the other way around?

These are the questions I ask myself as I muck through the maze of my daily life as a veterinarian in general practice.

One of the many delightful faces of my vet life day

Yesterday I spent a long time, (to be honest 20-30 minutes), with a sobbing client as she dropped off her dog, Brunswick, for a forelimb amputation. She was, (as every single other amputation pet parent has ever been), reluctant to consent to this surgery. Of all the procedures that we do, and, for all of the many indications this procedure is recommend for, there is no other life-saving, pain alleviating surgery that is met with such pet parent reluctance and resistance. In my clinic over the last 15 years that I have been practicing, I would say that only about 1/4 of the pets who need this procedure, and, I believe would benefit immensely from, actually get it. Most pet parents will sacrifice the pet to spare the removal of a limb. There is this incredibly difficult and deeply rooted mental block on consenting to limb removal as a treatment option. We were at this place; sitting in the front office, debating whether to consent to cutting off the leg of her otherwise perfectly healthy and happy pup.

Brunswick is a timid 7 year old, 50 pound, mixed breed dog. She is a tawny brown with big erect triangular ears, a wide faced and her soft white body is liver spotted from neck to tail. She has a history of a mass removal from this leg that yielded a diagnosis of "lipoma" many years ago. That mass has returned, slowly growing within the armpit of her front leg. It is now pushing the limb out and away from her torso. It has gotten so large that it has exceeded her skins ability to further contain it. The underside of the arm was red, raw and ulcerating. The mass that has been slowly growing for years now is outgrowing her. The cold cruel eventuality of Brunswick's leg was lose the leg or lose her as she would soon have an open wound that would never heal but instead continue to erode her leg, cause her increasing pain, and chew its way up her neck and across her sternum. 

Brunswick walks front legged short stepped, cowboy style. It manifests as a limp. The mass is hidden from obvious view by her bushy hair. The dappled coat hides the magnitude of the mass until you pet her. The diameter of the upper part of her left front leg is easily twice that of her slender athletic right leg. Her demeanor is always stand-offish for a few moments, but, if you are patient, quiet, and gentle in allowing those few moments to pass she will warm up to you to flounder flop on her "good" side for a full belly reveal. It is her not so subtle invitation to focus your affectionate rubs on the tender fleshy part of her belly. She is easy to fall in love with. Her handicap simply reinforces her charm. Her mom adores her. She will tell you that "Brunswick is her first child." 

And, now,,, here we are. Sobbing. Crippled with fear and doubt, and stuck about what to do with it all.

Many conversations get to this point. That critical pivot point where biology, disease and prognosis has met the timetable of limited options. That juncture in a pets life where you have to choose? Are you a proactive parent seeking to gain as much time with your pet as medicine is able to provide? Or, do belong to the crowd that does not believe in surgical procedures for pets? Do you choose to invest multiple thousands of dollars, hours, and caregiving requirements to gain the precious commodity of more time with your companion. Do you value your pet as a member of your family? Are they one of your kids? Can anyone possibly speculate all of the twists and turns that lie ahead if you do, or don't, take action? 

Most pre-op surgical discussions go like this. 

In Brunswick's case we had already done multiple examinations. Two with me, one with the surgeon. At each time we (the "professionals") agreed the best resolution to this tumor was to remove the leg. There were about a dozen emails back and forth to discuss every possible question and concern. And,, yet,, here we were, crying at drop off. 

I sat with her and said; "I know how hard this is. Please do what you think is right. Not what anyone else tells you to do." I firmly believe that this needs to be said to every parent. The road ahead is too full of twists, turns, and potentially even life-threatening landmines. I should add the cost of care, but, for me it is not a part of the equation I will let decide options. If we believe a treatment option is needed we will find a way to make it accessible. (Note: we use multiple payment plan options to help people not let the financial burden be the deciding factor).

I try to ask myself who will benefit from these decisions? Who am I looking after? These are huge weighty decisions with dire consequences. I try to be unbiased, neutral, indifferent. I try to present facts, argue all sides. I soo often feel that I fail miserably at this. I am not ever able to remain indifferent. I am not on anyone's team outside of my patients and their family. It is the dark force that grips my soul surrenders my conscious heart at midnight.

Brunswick post op

Here's where the muck meets the sole. Brunswick needs this operation. She will die within a year from the mass if she doesn't have it. How do I advocate for that? A: I just have to be honest. Then I have to accept the consequences. But, I know Brunswick is loved and I know her mom is making this decision based on that. Seems silly to some, maybe? But that is always enough for me. I am not the vet for indifferent people who don't value pets. That I cannot do. That would kill me.

My pups; Frippie and Storm

These are the elephants I carry on my back all day every day. They remain cumbersome, consuming and catabolic even after I get home at night.

I didn't sleep much after midnight. That mystical witching hour.  My typical work day has me arriving home after 9 pm, a 12 hour day of work without breaks, meals or niceties logged in the record books.  My shear exhaustion leads me to literally passing out on a pillow having foregone the obligatory teeth brushing, face washing, moisturizing and evening medical supplement regimen. They are all tossed out the window for the sake of sparing my legs the 80 paces they would require. There are loads of nights like this. Wrung out dry. I enter home as this zombie-eyed shell. I sleep for 3 hours and the death cipher lets go her grip for the anxiety ridden stressed-out-Suzie to take claim. Its always this exchange of custody each night between the hours of midnight and 2 am. A shared custody battle as the sun sleeps. 

My Frippie always brings me a gift

Why does the day weigh so hard? Brunswick is one example.. this is another. This one happens too often these days. COVID has created a huge demand for puppies. None of them are being socialized appropriately and for some (often breed specific) it is causing potentially disastrous consequences.

The other emotional dilemma of my day was an 11 month old German Shepherd, (let's call her GS), who visited for a pre-spay exam with bloodwork. Her mom had brought her inside the clinic vestibule on a one foot leash to a tight prong collar. Even with moms double fisted grip she could not get GS to remain with four feet on the floor nor have any kind of focus. She had no control of her adolescent puppy, and, she knew it. She told me that she "doubted I would be able to get her blood." She passed my technician the one foot lead and watched us all as we struggled to lead her to the treatment area. All GS needed was a 5 minute physical exam and 30 seconds to pull a blood sample. These appointments are not charged for as they should only take 6 minutes to complete. That didn't happen.

GS was a happy, outgoing 75 pound determined to party firecracker. She was elated to be around people, and in absolute resolve in not sitting for longer than one split second for anything. She knew commands, and she knew how to decide to avoid them. She surged, jumped, boxed, and thrashed. She twisted arms, crashed heads, and started to lunge and bite to have her demands heard.

Our dinnertime excitement

I always stop here...... The three of us; myself, my technician, and GS. We all looked at each other. What to do now? Take a breath? Try a different tactic? All of the above? We took breaks. We tried treats. We tried calm quietness. I tried a large muzzle, just to see if that would settle her. Fifteen minutes into the endeavor and one thing was clear; Nothing worked. We were at the place where one of three things was going to happen;

    1. I lose my patience and I hog tie, muzzle and we pig-pile on her to attempt to bruticaine (brute-force-paralysis vet lingo), and see if she is so shocked by this she gives in.  I just turn into a cold hearted drill sergeant. Bark orders. Intimidate. Force her to be what I want her to be. Force her to hold this command until I feel she has learned who is in charge. Quickly restrain GS and get it done. Get the blood. Skip the exam. Smile and return her to mom. After all what she doesn't know isn't my problem. She can't claim naivete when she already admitted unruliness. Make friends with the owners, even if it  is at the patients expense. A lot of vets have learned this trick. Two faced. Sweet to people, not so much to patients. A bite will likely follow at some point. What the real consequence of this is; To hell with the next guy who has to deal with her.  Might work for some dogs, never works for shepherds. Shepherds are too intelligent, they cement resentment like dolphins. If I do this to her she will never again come happily into our doors.. She will start every future interaction with fear and aggression. A bite will follow at some point soon.

    2. I give up knowing the short game loss is worth the long term gain and we have a family meeting to try to find a way to make her appointments more enjoyable and productive. Her mom had already expected that today wouldn't go well. We come up with a plan for next time. This should include training at home with the family to allow others to handle her. Working with a trainer to help her focus on commands and execution of them with focus and safety. And medications to help bridge the gap as we work on training. 

    3. I just get bitten. No chance to compromise, or convince her that we are not trying to hurt her. She just explodes and bites as fast as she  can. She is done with us and she will remind us she is in charge. 

What happens when a "bite" happens? Paperwork, fear, and almost always the pet parents compounds the tragedy by isolating their dogs in an attempt to avoid future potential bite provocations. Muzzles, prong collars, yelling, over protecting orders and mounting anxiety across all fronts. It's a snowball. Attempt to avoid situations leads to a lowering of estimation of the pets perceived threats. They used to like everyone. They were puppies meeting a world of new sights, sounds and smells. Now they are guardians that bark at the door knocking, or, strangers. You can't take them out in public anymore because now they bark at everyone. Everyone is a perceived threat. They are 100 pounds and you cannot restrain that amount of determined muscle. They become isolated. We reinforce the idea that everyone is a stranger. I used to see them every two to three weeks. We had fun visits. Now I am the stranger. I ask for unreasonable acts of discipline and focus. They don't know me and they certainly can't see a reason to obey me. Hence the bruticaine and indifference. 

Buster

Who's fault is a bite? Well, for the huge majority of clients vets see daily they would say it is our fault. For every time I have handed back a shepherd to say "we need a different plan to make this visit enjoyable." I almost always get, "well, you don't know how to hold her. She is fine with me." Oh, how I long to reply; "Ok then you do the bloodwork and  the spay. I like my fingers and face." Or, "she would never bite me, therefore, you are the problem." 

Here's my advice; it is the advice that every seasoned pet care professional will give you. Train your dog to accept a muzzle. It is NOT a reflection of a persons failure. Nor the pets. It is a tool to provide assistance as we transition out of anxiety based fear laden actions and reactions. Every pet parent should openly and provide permission for a muzzle to be used if deemed necessary. Man-handling, bruticaine, that is not permissible.. ever (unless a pet is endangering another's life). How do we insure this? Trust. If you don't trust your pet care professionals ask to be present for all possible procedures. Ask, demand, insist that pre-anxiety medications be given. Set ground rules for care. Resistance is a flag for scrutiny. Leaving a practice because a person intervenes on your pets behalf is only going to hurt your pet. 

About 30 minutes after I aborted pushing GS any further I sent her home with a training plan and sedatives to try at the next vet visit. I chose to not push her, not exacerbate a bite, and not make it impossible for the next time. Here's what I got for that, a call from the husband saying "they had a bad experience with us and they are going elsewhere." I doubt I will ever see GS again. There is pride before a fall. There are Shepherds relinquished everyday because no one intervened on their behalf at this critical development time. And, worst of fall there are vets who get court orders to put animals down after a "bite" history deems them a danger to the public. Will the next vet push her so hard she bites? Or becomes passive aggressive? Or fears people so much she reacts with defensive aggression to everyone outside of her family? In my opinion she needs help. Will she  get it? It's one of the reasons I awaken at midnight with elephants.

Tex. His first puppy visit. My goal is to have every patients visit look like this.

The truth is that people pine as much as I do, if not more, on what to do for their companions. What is the right/best/safest/compassionate course of action to take? What will consequences for that looks like? Will I hate/berate/beat up/chastise myself for the action, or lack there of, I take? I have been in these shoes. At every moment of my professional life I remind myself that I am still that devoted pet parent who is in turmoil about what to do? Do I trust my own judgement? Do I have enough pertinent information to base my judgements upon? Is there trust here. Maybe GS's parents lack that? They just don't trust my call? The reality is that she is being set up to fail, not flourish, and her "bite" won't be on my account of failing her. 

Brunswick. One week post-op forelimb amputation

What these two cases have in common is that I did my best to make decisions, present options that were in the  best interest of my patients. period. I can fall asleep knowing that. The rest, the worry, the grief, the elephant on my shoulders that I failed them, their parents, or the relationships we have is the midnight hour that clutches my throat and drags me into the abyss of self-doubt of avenues from that first decision to "do no harm."

Magpie helps me motivate for another morning.

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The Bump That Gets Too Big. (Warning; Surgery Scenes). Why a team approach will always tilt the odds in your favor.

This is Cody's story.

He is an older Springer Spaniel who has been visiting me for the last four years. He came to me seeking a second opinion because his primary veterinarian had given him a very poor prognosis and no plan.

Now, I am a realist. Medicine is about statistics... (by the way, I loathe statistics, numbers; boring, scenarios; boring, population studies; boring, math..well, you get the picture), but as much as it is boring it is a factor in guiding our decisions and our recommendations. Veterinarians look at the physical exam findings, lab work, and then decide which diagnosis fits your pets billet. From there we discuss treatment options and  their corresponding most likely prognosis. To many clients it is a difficult wad of information to chew on and digest, never mind to try to make a decision upon.

My job, as your vet, is to help you all understand your pets ailments, options, and decide where to go with them.

Some vets do this better than others. If your vet, (who I will almost guarantee is one smart cookie), cannot adequately articulate and help you understand which direction to head in, or even worse, if they cannot give you any options, or sign of hope, it's time to rethink the value they add to that relationship.

Soapbox Time: WE HAVE AN OBLIGATION TO HELP YOU NEVER LOSE HOPE, OR AT LEAST PROVIDE YOU WITH AN OPTION TO HELP END SUFFERING! If your vet doesn't give you this find one who will.

Cody's parents did not want to give up on him. At eight years old he was their kid and they felt he had a few years left ahead of him. They came to visit me and we laid out a plan this included a change in diet, a nutritional supplement, carefully planned scheduled monitoring (which includes a plan for Best AND Worst case scenarios), and access to me, or any of the other veterinarians at the clinic to help when the plan changed, as it inevitably will.

Cody has a plan, a clear written list of items for his family to do at home, a schedule to follow and a support network to utilize if anything comes up along the way that his family needs assistance with.

That was over four years ago.

Over those four years Cody has blown two cruciates, had them surgically corrected. He has beaten the odds at every challenge. He has an army fighting for him, and we all know that the odds always shift in your favor when you have a team approach to your problems.

Cody was visiting this time because one of his many bumps had gotten rather large and worrisome.

Like many dogs Cody has gotten a little lumpy as he aged. We have kept track of all of them, monitored them closely and none have changed size, shape, or texture. Well, that was until this one. Cody's previously thought to be a lipoma (benign fatty tumor) had all of the sudden gotten much bigger. It had evolved from golf ball sized to bigger than softball.

Cody's mass is on his lower neck/upper chest area. It is firm, round, and felt as if it was adherent to the underlying tissues (in other words I was not able to get my fingers underneath it and pull it away from the muscle). The skin covering the mass was very red, had visible blood vessels and the hair was beginning to wear off. This is a sign of the mass being either abraded by the surfaces that he is laying on (thereby wearing off of the hair and causing the skin to thin), and/or the skin is being stretched to the point of beginning to tear). Either scenario is a problem.

We discussed Cody's current predicament.

His family had come in because they understood that something had to be done.

Their options were;
1. Do nothing. Not a good one, because unless we thought Cody had only a few weeks left that mass was going to open and we would have a heck of a time (I used the word "impossible") keeping it from bleeding continuously, and/or it could become a source of infection. It is impossible to keep these kinds of masses bandaged, and even keeping as bandage on does not prevent infection. Chronic bleeding will lead to anemia and there is no permanent way to treat this without stopping the source of the bleed. You will end up with your back against a wall deciding whether to euthanize your pet because you cannot manage an open and non-healable mass. Don't wait for this. don't euthanize your pet without trying to heal them.
2. Take it off, cross your fingers that you can close your incision and remove the cancer in total just in case it is a tumor that can spread. to other parts of the body. Plan and hope for excision to be curative.
3. Perform a fine needle aspirate and/or biopsy.  We do these to try to identify what the mass is before deciding which step to take next. Sometimes we classify this as "de-bulking" because we feel that we cannot get the whole mass removed cleanly.

Cody's family opted to take off the mass before it opened up and became a big messy problem.

That same evening in addition to Cody's physical examination we checked a CBC, full chemistry, urinalysis, and three view chest x-rays. 

Thankfully, everything was normal. Cody was scheduled for surgery the following week.

I have to admit that I was pretty nervous. None of us want to admit to being paranoid, but I was afraid that I had pushed my luck too far with Cody already. This was the sixth "older dog not really sure what I am going to find mass removal surgery" in about as many weeks. Could I really be so lucky to not have one of these guys NOT make it through surgery?  And, damn it, I liked these clients a lot,, we had been through too much together already.. weight of the world on my shoulders we went into surgery.

They always look waay more ominous when they are shaved.

The first big sigh of relief. The preliminary exploration of the mass and it all appears to be fat!

Now all I have to do is get my fingers all the way around the big ball of fat, hope that they don't encounter any big angry blood vessels and get this thing off.

The lipoma is off, and I have enough skin (always think about this before you place scalpel to skin) to close the incision. Almost nothing is worse than having a bigger problem after surgery than you did before because there is too much tension, or, it takes months and months to heal because you didn't have a good exit strategy.

A big mass always leaves you a big hole.

Starting to close is more technically challenging than any other part of this surgery..

In the end there is a large incision. It always looks worse after than it does before,prepare your clients for this.

TAH-DAH!

A closed incision must be able to maintain function. Expect some pocketing, some bruising, and monitor very closely for any signs of infection. Some pets need to be hobbled. We bandage the front legs together so they cannot splay open accidentally, or otherwise, and put excessive stress on the incision.

Cody recovered well and seems to have once again proven that if you have a team behind you, and you face the challenges life throws you head on with them, anything is possible!

Related Blogs;

Charlie's Life Saving Lipoma Surgery.

When a Bump Causes You Concern Slay it with a Diagnosis!

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This is my team.. resting for the challenges life might throw them..later.

When a "Bump" Causes You Concern; You Slay It With A Diagnosis!

Lexi

This is Lexi. She is a  sweet, docile, lovable 5 year old spayed female dachshund. She is is an integral part of her family and is usually found snuggled up under their wings.

Can't you see the happiness in her eyes?

Her parents, being the devoted doting people that they are, noticed a few days ago that a round bump had appeared on her side They called me and rushed her right in for an examination.

When it comes to bumps there are a few guidelines that we use to help us identify which are worrisome and which are most likely  to be simply benign and/or just cosmetically unpleasing. Learning which is which takes both practice and an in person hands on examination.

I am asked frequently to diagnose and provide guidance based on a picture alone and I always hedge my skepticism on being concerned versus trying to reassure a client that they are "probably OK."

Lexi's bump was firm, round, about 6 cm in diameter and directly behind her right armpit. It also seemed to appear quickly over the last week. There are a few things in this list that caused me concern; I am worried about the size, the area, and the quick appearance. Because of these we decided we needed to do something more than just watch it.

There are a few options when we talk about lumps and bumps on pets. you can;

1. Watch and wait and see approach. This should only be done after your vet has examined it and agreed that it is most likely a cosmetic benign mass. This takes years of practice and is still at best an educated guess. There should be some take-home instructions if this approach is chosen. Here are mine; The mass is measured (a ruler r calipers on a scheduled basis. Record measurements in a journal. Have a "size to return to the vet" rule. I.e. if it grows by 20%, or gets this big.. we return. Don't wait until it is so big we can't safely remove it.) Here is a good example, Charlie's story.
2. Fine Needle Aspirate option. This is performed with a large bore needle (I prefer a 16 or 18 gauge needle) being placed into the mass to collect cells. This is a cheap, quick diagnostic tool. It doesn't require anesthesia, (I have never sedated a pet for it either), and within a few minutes a sample of the mass can be collected and submitted on slides for cytology. The cost at my clinic for this is about $40 for the aspirate, and $140 for the slides to be submitted to the lab for analysis. The disadvantage is that you have to be very careful that the needle is in the mass, not in the surrounding fat, or tissue, and that you can get a good sample. Occasionally, I have had difficulty in getting a good sample due to excessive bleeding.. and sometimes you aspirate a terrible tumor that bleeds and gets soo angry that you make the tumor bigger and scarier. Also, the more tissue you collect the better the pathologists ability to diagnose correctly.. FNA is about 70-95% accurately diagnostic. In the world of human medicine biopsies are the tissue sample size of choice and treatment plans are rarely decided on aspirates.
3. Biopsy. This is the best way to make a decision about a mass.. More tissue allows for more information to be collected for the pathologist. It also allows the surgeon to see what they are collecting. More tissue allows for more accurate diagnosing, which allows for a more successful treatment plan. This requires general anesthesia and hence is more costly. I would like to add that this also allows for a chance at excision being curative. In other words I approach every biopsy as an opportunity to remove something that I hope will not ever have to deal with again. A biopsy is accurate about 90-99 % of the time.

I should add that in some cases my clients elect to take the quicker, cheaper, and less invasive approach by having a fine needle aspirate done, but later need a biopsy and or mass removal after the FNA is done. This can be more expensive in the long run, (about $150 at my clinic).

In Lexi's case they elected for a FNA.

I prefer to used an 18 gauge needle on a syringe. I isolate the mass in one hand and pierce the mass with the needle while pulling back on the plunger of the syringe. We call it the "woodpecker" technique because we stab the mass multiple times to pull as many cells into the syringe as possible.

After the sample is collected we examine them on a slide and submit the slides to the lab for a pathologist to analyze. I usually get an answer on a FNA in a day or two, versus a biopsy which usually takes about 4-6 days.

Luckily for Lexi, her FNA sample was all fat cells. We decided that as long as it didn't change too significantly that we would just keep an eye on it. Why did it appear to have grown so quickly? Well, Lexi's diet had actually begun to work, and now her new waistline was revealing a lipoma. The fat cells will grow bigger or smaller with weight changes to some extent, but fat cells only disappear with liposuction, or surgical excision.

Here is how I recommend that you monitor a mass;

1. Measure the mass using either a ruler or calipers.
2. Record the size in either your pets file, on your yearly refrigerator calender or ask your vet to help you by adding it to the pet record.
3. Have a plan for action. Know what size is the time to go back and go to plan B. 
4. If the mass becomes too big for your pet to haul around go to plan B.
5. If the skin covering the mass starts to tear, thin, or weaken, or if the mass ruptures go to plan B.

Identify plan B.. In almost all cases plan B indicates that it is time to stop watching the mass from the couch.. it is time to slay it with a scalpel and bid farewell to it forever.

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Charlie's Life Saving Lipoma Surgery. (Warning graphic surgery photos.)

Helplessness is despair with a straight jacket on.

When you are in this place mercy is your only prayer.

We saw it four times in four separate patients two weeks ago.

People can call me a "sucker", a "bleeding heart", a million other things, and yet, each case was a miracle disguised as a pathetic plea, and every case walked out of Jarrettsville Vet's door with a second chance and a grateful parent. It is what we do here. It is who we are, and it is part of the reason people drive from far and wide to get to us. Am I tooting my own horn, absolutely! Why?, well because I believe that there is always hope and always a chance, IF you try. I believe that part of my job is to help people, remind myself that I am just an interpreter of disease, and that the biggest failing I can ever have is to remove hope.

This is the story of Charlie. He arrived two weeks ago to be euthanized. But, I just didn't feel right about it. My gut couldn't accept that his only option was death. That story here.

I stuck my neck out, I donated my skills, and together the staff at JVC saved Charlie's life.

Before Charlie came to us he had been to three other vets. They were correct in warning his family about all of the possible outcomes of his condition. There were a ton of unknowns. That's what life and medicine is. That's why medical advances and the luxury of diagnostics came into existence. On the human side doctors have been beaten by angry, bitter, entitled, victims who have sued or harassed enough doctors that they now will only make a decision after appropriately covering their butts by performing every diagnostic possible to be able to proceed with a clear defined treatment option. It is certainly the ideal way to practice and save lives. But, this has come as a terrible trade-off. We get so frightened to allow ourselves to be vulnerable that other patients suffer. There are now well documented "minimal standards of care" for everything. These are the protocols and practices we are required to recommend. These also give us the protective excuse to dodge our clients ability to pay for treatment. We have yet another convenient excuse to remove ourselves from the case. No dirty hands, no weighty guilty conscious, move on to another paying customer. The reality is that most people cannot afford all of the diagnostics we want to do before we assist a patient. The other reality is that many treatable patients suffer or die because of this.

The decisions made from this point separate the mavericks from the meek, and save lives. It is that simple.

Have we lost the ability to practice the kind of medicine our forefathers did decades ago? When diagnostics were a rumored luxury, when medicine was half gut guesses, half attempts at swinging the bat to try to hit one out of the park, and attempts to help without all of these was the norm?

Charlie was a risk on almost every front. There were no funds to run diagnostics, (every vet before me had drawn their line here and walked away with a clear conscious). The imaging that he had done years ago was not available for me to reference. He had an ENORMOUS mass in his leg and I had to go by my gut and my skill set to determine if this surgery was likely to allow a possible improvement in his ability to function. But, then again,,

He was at the clinic to be euthanized. His parents believed there was no hope and he was losing his ability to walk, urinate, and defecate.

When it comes to basic life functions my list includes;

1. Ambulate. A pet must be able to ambulate, with or without assistance. Few pets are happy or content to simply remain paralyzed and lie in their own excrement.
2. Eat and Drink. 
3. Pee and Poop. 

If you can't do these the question of quality of life needs to be discussed.

For all the money that they had spent previously they had been filled with words of discouragement, too many worst case scenarios, and believed that their only options were to perform more expensive diagnostics which they could not afford. So, here they were at my door in deep despair feeling like there weren't any options available, and that he would be better off dead.

Except for the fact that running around the room wagging was Charlie. Charlie wasn't anywhere near ready to die. I wasn't ready to abandon one of my primary veterinary guidelines, "The pet always decides. They always tell you the answer if you listen."

I called my surgery specialist friends for advice. What I got was a list of diagnostics to do, information to gather, and a pep talk about how to proceed based on a every possible scenario. They were incredibly helpful, supportive, and a bit envious that I could try to help when the facilities that they work for would never allow them to.

I had many conversations with Charlie's owners. They understood what might happen  and they were willing to try. It all starts with that. You have to care enough to try.

Charlie's grossly abnormal leg, camouflaged in a wiry coat.

Last Tuesday morning we tried. Charlie had the most successful outcome imaginable. His surgery was relatively easy and any first year grad could have successfully cured Charlie with his lipoma removal.

As the hair is shaved off the leg reveals itself.. and no one is left to wonder why he was having such a hard time walking, peeing, and pooping.

Shaved of his wiry hair, you can now see what Charlie had to deal with. His leg is about four times the size it is supposed to be. To the touch this is firm and solid. 

Veterinarians use their hands as we do our eyes. Your hands can feel size, texture, and tell your brain what your eyes can't see. To the normal by stander Charlie looked normal. If he was standing still there was a mildly detectable abduction (away from the body) of his back right leg. At a walk there was also a mild limp. Not until you put your hands on his thigh could you understand the magnitude of his dilemma. When I was palpating his leg my hands couldn't tell my brain what was under this pups skin. Clients often don't understand why the vet wants to run so many diagnostic tests, but it is a guessing game without them. Charlie was a whole bunch of unknowns for every single step we took with him..until we got him to surgery.

There has to be a plan for every treatment strategy. It should be discussed as best case AND worst case scenario. Everyone should understand the consequences, even the most remote, and the plan should always be agreed upon before the first swipe of the scalpel. 

Charlie's surgery contained too many unknowns, (based on a lack of resources to run diagnostics, and the position of the husband), therefore, his pre-op plan was even more difficult to  address.

I knew that Charlie likely had one shot. One attempt to go under the knife, one chance for this dilemma to be resolved or he would be euthanized. I also knew that if this was NOT a simply removable lipoma that the next best option for palliative relief would be an amputation.

Amputations are fraught with emotionally charged discussions. Of all of the treatment options that I discuss with people this is by far the most reluctantly agreed upon option. Most clients will drag their feet, procrastinate this decision until the pet is about to be put to sleep. It is also my least favorite surgery to do. I hate them. They are long, exhausting, and cumbersome. 

Charlie's mom did not want to talk about this, but I needed her to. I needed to hear that she understood the case  had possible unforeseeable unwanted outcomes. I also told her that for me to try, on this first surgery was me getting myself emotionally invested. I did not care to stick my neck out to be told that there were no future options. I understand that this is a selfish thing to say, but I had to say it in the beginning. I had to be honest. 

Charlie, like every case, was hope for the best, but plan for the worst.

This is what best case scenario looks like;

Using my fingers to probe from a small incision under the most superficial muscle lay... a soft squishy mass.

The emergence of a large fat pad.

In the hopes that the entire mass is a fatty tumor I probe the mass all the way around the leg.

Four large fatty tumors (lipomas) merge to form one large circumferential mass that has been growing for years. Because they lay under the muscle they did not feel as if they were the normal soft fluctuant superficial mass that most of them are.

The immense size of these space occupying lesions is evident as they lie on the surgery table.

Even with the fat being consolidated there are still numerous vital structures that reside deep in the thigh. Dissecting these out (think blood supply and nerve function to the foot) requires careful finger tips, (nothing sharp belongs in here!). I had warned Charlie's mom that there might be some decreased nerve function (often manifests in the form of dragging the foot, or not righting it normally to place the toes at the step/walk), but as long as you don't sever the nerve they often improve with time to a normal walk. 

The large pocket the fat left behind. The muscles of the leg are small, flaccid, and not in their correct anatomical position.

There is also a large pocket of dead space left behind.

I can remove the extra stretched skin, but the rest of the leg will heal and re-find its normal position with time and resolution of normal range of motion and ambulation.

Lots of extra stretched skin.

The extra skin removed so the incision closes normally and the leg retains its shape.

The leg profile after.

Almost 4 pounds of fat were removed from Charlie's (pre-op) 24 pound body.

Charlie at his 3 day post-op check. He has exceeded all recovery expectations. I feared he would have difficulty remembering how to use a leg that had encumbered his ability to move for almost a year. I also worried that there would be nerve damage to the nerves that tell the foot and brain how to walk because I had mucked around the area they reside in as I peeled the fat out of the muscles that protect the arteries, veins, and nerves. But there he was walking around perfectly.

At two weeks post-op Charlie's body perfectly reflects the demeanor he has never flickered from. He is a beaming bubbly boy with a long happy life left to live.

Some stories do have a "Happily Ever After," 

I wish Charlie and his family many happy wagging days to come.

Here is Charlie in 2018;
Still the same happy, unstoppable boy he always has been;

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You can also find me at the clinic, Jarrettsville Vet, or on Twitter @FreePetAdvice.