As I (Henri Bianucci) was completing evening rounds in our ICU, I noted that our emergency service was heating up to a low boil.
I could see the technicians move about purposively as they prepared for the impending rush. Charts were prepared, catheter sets laid out, the oxygen cage was turned on. I heard someone ask, “How many units of negative blood are in stock?” It was going to be a busy night. The case board was filling up with names and problems. My day was ending, but I was the on-call surgeon tonight, so I was not yet in the clear.
I saw a depressed looking, older golden retriever having an I.V. inserted. I scanned the board for his information, and spotted a match. There it was; Bailey, hemoabdomen. I knew then that I would not be going home anytime soon.
Bailey’s problem was that he was bleeding into his abdomen, and given that he is a golden retriever, there would be no prizes awarded for guessing why. Goldens are one of the at-risk breeds for a tumor known as hemangiosarcoma (HSA). This tumor usually grows in the spleen, and eventually ruptures, causing a massive bleeding event.
Tumors are masses of rapidly dividing cells that multiply in a haphazard way, independent of the usual signals and feedback that guide normal tissue development. Tumors often grow faster than the blood vessels, which feed them, so parts of the tumor will weaken, die and bleed.
When HSA is responsible for bleeding in the abdomen, it is most commonly coming from the spleen, then the liver, but it can be from anywhere. To determine this, prior to surgery, an ultrasound is helpful. Bailey’s owner decided that she wanted Bailey treated surgically, immediately and that an ultrasound was unlikely to change that plan.
We decided to perform an abdominal exploratory, most likely to remove the spleen. If the cancer had spread, ... well, we’d cross that bridge when we came to it.
I opened the abdomen and knew immediately that the odds were against us. The abdomen was full of blood, but the spleen was normal. That’s usually a bad sign. Sometimes a bleeding tumor on the spleen is not HSA, but a benign ruptured aneurism. When a mass is bleeding elsewhere, the news is almost always bad.
In this case, we identified a large, bleeding, mass on the liver. It was very deep, and close to the major vessels at the base of the liver. This would be difficult to excise and, unfortunately, there were multiple, smaller but similar looking nodules on the same and other lobes. This was almost a “worst case” scenario.
It was time to call the owner. To my surprise, despite my outlining a very grave situation, she wanted to press forward. I explained that given the location, excising this mass may not be possible, and that with the other masses present, the survival time may only be a month or so. She was not ready to give up. “Do what you can, please,” she said, her voice choked with emotion, “I’m just not ready to let him go.”
I gloved up again and went to work. As we were removing the mass and attached lobe, disaster struck. A massive bleeder developed. There was a tear in a major vessel. This type of bleeding only affords seconds to be brought under control before the patient succumbs.
Fortunately, the site was clamped, and the bleeding was quickly controlled. By the skin of our teeth, we got Bailey off the table and into the ICU/Recovery Unit.
If Bailey does indeed have a terminal cancer, suffered a major bleeding event and nearly died during surgery, apparently nobody has informed him. He recovered rapidly from anesthesia, and even ate dinner that same night. He went home the next day, and has reportedly gone back to work.
“Back to work?” you ask. Bailey has two jobs to which he has returned full time. You see, he lives on a golf course, and he has appointed himself as the ball-finder. He walks the rough in search of lost balls, and brings them home. He has found buckets of them over the years, and just today, 10 days after surgery he found five. He is also the family’s paperboy.
I saw Bailey today for his suture removal appointment. This big beautiful boy, blissfully unaware of his illness, greeted me with licks and excitement. He was robust, and truly back to his normal self. I have to admit, I did not feel that the best decision was to complete the surgery. I felt that the gain would be short-lived and that the discomfort he would experience would outweigh any benefit. I was wrong.
I guess I don’t know Bailey like his owner does. Bailey bounced back so quickly, that in a couple of days, they had to hold him back. Now, after 10 days, he has resumed his normal activity, and happy life. Bailey has a spirit that seems to transcend his physical state. Unburdened by thoughts of mortality, he lives in the moments, free to enjoy each one of them fully.
How much of our time is wasted worrying about, rather than enjoying, the time we have left?
Bailey may only have weeks or months, but they will be full of joy and free of worry. How many days like that do any of us have in our future?
Dr. Henri Bianucci and Dr. Perry Jameson are with Veterinary Specialty Care LLC. Send questions to email@example.com.