Nicky's Story. Hemothorax and Hemangiosarcoma: When The Diagnosis is Incurable.

I wrote about Palmer a few days ago. She was brought to me for lethargy, panting, and anorexia. A week after her case Nickle arrived at the clinic with the same clinical signs.

Nickle is a five year old, mixed breed Huskie, who is under close supervision, and current on all recommended medical care, vaccines, and has no history of trauma, toxins, or illness.

Here are Nickle's presenting complaints;

• Not acting right. 
• Labored breathing.
• Not eating for 3 days,
• Weak in the back legs.
• Appears to be painful.

The list above could be many things. For all of those Pawbly questions that list these as clinical signs I always have to refer the pet to a veterinarian or emergency clinic immediately. Here's why..

His physical exam revealed the following;

• Quiet and depressed. In the hospital I expect dogs to be curious, anxious, greeting, hiding, something. Some expression of being in a foreign place. He was just there. He was too.. something? sick, tired, weak..something to act normally. LISTEN to your patient. He knew something was wrong, I needed to find it.
• Poor body condition score. He was a young dog, who was active, but now he appeared to have poor muscle mass. This is a sign that whatever is going on has been a slow and gradual process.
• He had muddy pink and tacky mucous membranes. This gives an indication of blood loss, and ability for them to circulate and dehydration. 
• Elevated heart rate. Can be stress?, can be pain?, can be fever?, but it indicates a pet in need of immediate care.
• Elevated respiratory rate. Same list as heart rate above.
• Quiet lungs.. Something is making it hard for me to hear his normal lung sounds.
• Abdomen seems normal.

He needs a chest x-ray immediately. (Just like Palmer did).

Here are his chest radiographs.

The lungs should be black and fill the whole area within the ribs.
Nicky's are being compressed and pushed to the far right,
which is the dorsal (top or towards his spine) and caudal (towards the tail).
This doesn't allow the lungs to expand or draw in air with each breath.

Compare Nickle's x-ray to Palmers here.

The radiographs show fluid, specifically blood, (although this can be hard to distinguish in some cases) in the lung space. This is making it very hard for his lungs to expand, or pull oxygen into the body and feed his muscles with the fuel they need to function. As soon as I saw his x-rays Nickle was immediately referred to an emergency clinic and specialist to further work-up his case.

Here is where Nickles case and Palmer's case has similarities;

• They are both young, active, very closely watched pets. 

Here is where they differ;

• Nickles x-rays and case were reviewed by a boarded radiologist, a neurologist, and a surgeon. He was sent for BOTH a CT and an MRI. From these he was found to have both a mass on his heart that extended up and around his spine. These were causing his neurologic (weakness in the back legs) signs, and the blood in his chest. He had an extensive, and expensive, work-up. I have to admit that in 10 years of practice I have never seen a case worked up this extensively, nor this completely, nor this complicated. Nickle had a surgery on the mass around his spine to provide a diagnosis of the mass in his chest. To provide a treatment to a condition it must be diagnosed. The best way to do this is with tissue. Nickle's surgery was performed to try to remove the mass on his spine, to help reduce the paralysis in his back legs, and tailor a treatment plan for his specific tumor. His mass came back as a hemangiosarcoma. These are aggressive, invasive and very difficult, if not impossible, to remove. Nickle's tumor was also in his chest surrounding his heart. The tumor was invading his spine and this caused his rear limb paralysis. His parents carried him or used a sling to help him walk. Although his family had provided him every diagnostic, and collected every piece of information needed to provide a prognosis, Nickle's condition was grave. His family spent the last few days with him spoiling him, doting on him, and telling him how much he was loved. 

I asked his mom if she wanted to add her thoughts to his story. This is her eulogy to her pup, Nicky.

Our Nicky –

It was August of 2012, and we were looking for the last member of our pack.  We choose our kids based on their lot in life; and that’s what connected us with “Mr. Barkley”, our Nicky.  He had been adopted out as a pup, but boomeranged   back due to some behavioral issues.  When we met, he was a long-time resident of The Jarrettsville Vet Kennel.

The intro went as well as expected, although he did take a nip at me – I explained that I would be back the following week to take him to his forever home.  Not sure the Tech believed me or not, but return I did and “Mr. Barkley”, now our Nicky and me headed home to Carroll County to meet his new family. 

Introductions were made slowly and successfully, and although he mostly kept to the edges of the pack, he seemed to be settling in.  And then it happened, every parent’s nightmare, a fully fledged dog fight in the dark.   When the blood settled, Nicky had minor injuries but our husky was seriously injured. 

We carted the husky to the vet and am embarrassed to admit - returned Nicky to Jarrettsville, he was just too dangerous.  Well it only took us one night to come to our senses, if not us, then who?  The answer was obvious, we had to go get our boy back, and that’s just what we did.  The staff was understanding and suggested a kennel to help him feel secure. 

So on the ride home, with Nicky taking what we would learn to be his customary position on Mommy’s lap in the front passenger seat; we had some shopping to do.  The kennel proved to be the difference.  We placed it in our bedroom and while the rest of the pack slept across the hall in their room, our Nicky had his own cubby. 

     

The pack sorted itself out in short order and Nicky assumed fence perimeter duties.  During his two years with us he grew to be more self-confident and out-going.  He was always very obedient and smarter than most.  Our boy loved his soccer and footballs.  And while not food motivated, he tended to save his nightly biscuits, he would occasionally pop out of his cubby in the morning grinning with one tucked into his cheek. 

He quickly became Mommy’s little helper in feeding the pond fish and remained ever vigilant for anything approaching our property; he was always first to sound the alarm.   He loved to talk back to the freight trains that rumbled by in the distance, not always in perfect pitch.

   

I could say in many ways he was just your typical boy.  But that would not be accurate, because he matured more these past two years than many folks do in a lifetime.  

I wanted to tell both stories because they both were young healthy dogs with the same presenting complaints and the same condition. Two happy, apparently healthy, pampered pups. Who both had bleeding into their chest. Two emergencies, two totally different diagnoses, and endings.

If your pet ends up at the ER with hemothorax, please look for the cause. It might be treatable!

Related blogs;

Hemoabdomen, Palmer's Story. The case of a happy ending.

Making Vet Care More Accessible

There Has To Be Mercy Before Money.

Making Vet Care More Accessible

Any pet questions? Meet me on Pawbly.com and I will answer them for free. You can also help other pet parents with their pet questions. Behavior, nutrition, homeopathy, disease, you name it we can help.

I am also available at my clinic, Jarrettsville Vet, in Jarrettsville Maryland. Or, find me on Twitter @FreePetAdvice.

Hope, Faith, and Tuckers Mom's Refusal To Give Up. WARNING GRAPHIC SURGERY PICTURES!

The stories usually start in a benign quiet fashion.

A friend of a friend calls to ask a question, seek advice, help, etc, and I find myself down another path of another patient and another story.

My dear friend had a friend who was very distraught about her older lab Tucker. He had been a lumpy bumpy boy, (as many older labs are inherently so), his whole life. But one bump in particular had been bothering him insistently for years. Appearing after festering from a quiet hibernation below the skin to breathe and burden for a little while, then disappearing again to the great delightful optimism of his family.

That story is not unique. Many pet parents opt to "monitor closely at home" instead of putting their pet through an anesthetic event or the cost of a surgery that may not be necessary. I am guilty of this approach many times over, BUT, the key to success in these cases is;

TO VERY CLEARLY EXPLAIN TO THE CLIENTS WHEN THE GAME PLAN NEEDS TO CHANGE;

Here are my ground rules for the watch and wait approach;

When the mass changes size.

OK, What size is to big? Well, I often have people use a ruler, or calipers, and a calendar. We measure it on day one and note the size on the calendar. I also tell them at what size I think it needs to be addressed. They write the day one size over the needs attention size. For instance, my friend Noodles lump was about 3/4" when I first saw it. At 2" it needed to be removed. So that's 0.75/2 inches on day 1. At every interval note both sizes. We are looking for a trend over a time period. And, remember, a small mass on the toe might need to be removed quicker than a large mass on the side of the body simply because there is not enough tissue to close the site after the mass is removed.

When the mass changes consistency. 

This is a tough one for clients to appreciate. It requires letting your hands become your eyes and it only happens with practice. So, start palpating from day 1. If the mass changes from 'soft' and 'fluctuant' to 'hard' or 'painful' it is time to go back and see the vet. 

The mass is in a place that can make it hard to ambulate or function. 

Think armpit, face, mouth, eyes, groin, etc. Even a not so big mass can make your ability to see, eat, move, and go to the bathroom difficult. We should address these masses sooner versus later.

A mass that affects your pets quality of life. 

I have seen benign cosmetic masses that were left alone and got so large that the pet couldn't physically support themselves any longer. A mass that precludes your pets ability to function affects their quality of life. Open masses are difficult to manage and affect both the client and pets quality of life. Both parties needs should be openly and honestly presented.

A mass that erodes, abrades, or eats its way through the skin.

All masses of any origin can at some point wear through the protective skin that contains them. Whether it happens due to the mass being in contact with hard surfaces, or the pet licks the skin to the point where the trauma of the tongue burnishes and erodes the surface off, or the mass eats its way out to freedom. The job of cancer, like every other living being is to proliferate until it has domination.

Once we establish the ground rules for the mass we decide on a time frame to monitor it. 

We may start with daily client re-checks, and then go to once a week, or two weeks? Month? The point is to have a scheduled time that we monitor, measure and record the findings. If at any point things change the client is instructed to either call me with updates, or return for rechecks.

Tucker is a boy whose mom cared for him. But he is also a boy who didn't have a plan. You won't be successful in any endeavor if you don't have both.

Part of the veterinarians obligation is look ahead, forecast, and provide guidance for those bumps that exist on the horizon.

I take great earnest exception to the idea of a veterinarian who doesn't foresee, forewarn, and foretell. How can we help our patients if we aren't enlightening our clients in what lies ahead?

Tucker is a 13 years old. And age was the excuse his referring vet gave his mom when it was recommended that he be put down. His mom still sees him as a happy, active, dog who still has life left to live. But, he is walking around with a chronically seeping bleeding mass about the size of your face. He has been carting it around for months. Not only is it weighing him down literally, it is stealing his red blood cell volume every minute. He can’t sit still enough to keep it from leaking, he wants to lick it incessantly, and after days, weeks, and months his body has had to work double overtime to keep him from bleeding to death. People think that you bleed to death when you lacerate a major blood vessel, (you know, like the classic science fiction jugular horror flick) where the victim grabs their throat and dies in a matter of seconds. But you can bleed to death a drop at a time over days, weeks, and months. That blood trail of Tuckers was a constant source of care for his family. His mom dressed his wound multiple times a day. She had the task down to a science. A diaper to hold the mass, a bandage to compress it, and elastic tape to hold it in place. At every diaper bandage change there was more blood to collect and a wound that was worsening and now unable to heal.

People often make assumptions. Those assumptions can steer the course to decisions that are harder and harder to resolve should your early decisions be wrong.

Tuckers family believed that the mass had healed before, and that it would heal again. Unfortunately, the mass, like most, are not made up of normal tissue. Normal tissue will heal quickly and efficiently, but neoplastic (cancer) is not able to heal. It proliferates, bubbles, erupts, bleeds, and looks grossly irregular. 

Don’t expect normalcy from cancer. It will disappoint you and cost you time.

Tucker had been to the vet multiple times. The veterinarian recommended only one option, to put him to sleep. Or, she could continue to slave to a beast that had no intention of succumbing. His mom called my friend frantic and in great despair.

My friend called me, and so Tucker’s tale began.

I met Tucker last Thursday. His mom said "Hello" in a soft, sad voice, and started her introduction with, “I mostly just want someone else to see this. I know there’s nothing we can do.”

I had to stop her there.

“Please understand, I am here to see Tucker and to try to help him. If that’s not why you are here then I don’t want to unwrap his wound and go on.” I really try to not be firm, and to be a kinder, gentler practitioner, but I get too emotionally invested, and I have to try to protect myself from cases that I just grieve with frustration over.

And so we started again.  I unwrapped the bandage and faced a new case with a bit of optimism and a new page.

Tuckers mass was necrotic and unmanageable. It was not just ugly and messy in its erupting bleeding, seeping attempts to heal, it also smelled so bad that you almost couldn't remain standing. Managing that wound is a full time job, it steals his life like grains in an hour glass, and left to attract flies and maggots.

Tucker's mass measures about 10 inches across and 8 inches wide.
His lateral thorax and abdomen measure about 24 inches.
It also weighed about three pounds.

It was time for an overdue long hard talk about treating this lesion.

Here is where I stand on masses. It is super to know what we are treating. Aspirates, biopsies, and all of the precursors to making a treatment plan are fabulous. But, there are reasons people don’t get these. 

Sometimes life is not about ideal scenarios.

Tucker had a big dilemma. It needed resolution now. There were certainly no shortage of reasons to not do it. All of those got us to this point.

“He can’t go on like this.” We all knew that already.

After blood work, (he is anemic, no surprise), and clean radiographs we decided to schedule surgery.

His mom wanted more than one terminal option, and Tucker needed to get rid of that mass..

Preparing for surgery.
Taking off that diaper and belly bandage was very rewarding.

Prepped for surgery.

Cutting to find clean margins so the tissue will heal and close normally can be difficult to do.
You need to remove the mass completely and still have enough tissue left over to close.

Using the laser to make the incision,
because, Tucker has no more blood left to lose.

It is so large I need a few extra hands.

The size of the hole the lesion leaves behind.

One hour to remove the mass,
one hour to try to close the crater it left behind.

The end result.
The middle section would not close completely,
so tension bands are placed to pull the skin together and allow the rest of the skin to stretch.
The small opening will close on it's own over time.

Immediately post-op.

Tucker spent three hours in surgery today. He did very well. And when I called his mom she was so ecstatically happy it lit my heart up.

 24 hours post op.

Don’t we all know how important hope and faith are?

One smile says it all.

Tucker is another testament to a mom who loves him, cares for him, and doesn't accept that "old dogs" aren't worth treating.

If you are ever unhappy with what one professional tells you go seek another opinion. Your pet is your responsibility and you are their best, and sometimes only, advocate.

There are sometimes happy endings..with a little bit of faith and hope..never give those away.

If you have a pet question you can ask me, and the Pawbly community, at Pawbly.com. It is free to ask, or answer, or even just share your pets happily ever after story.

Or you can find me, always in search of another story at Jarrettsville Vet. Or on Twitter, @FreePetAdvice.

Related blogs;
Butt Holes and Toes.