A Surgical Disaster, and How a Veterinarian and Dog Owner Saved My Career

Audubon,  New Jersey, 1977

I had graduated from veterinary school just 3 months prior to experiencing one of the darkest moments of my career. I will never forget the little sheltie that I spayed in the small animal practice in Audubon, New Jersey that I joined right out of school. I forget her real name but lets call her “Shelly”.  It was one of the first spays I had ever done. My boss, the owner of the practice, was on vacation but I was comfortable doing the surgery on my own. Heck, I had done 2 or 3 of these before; I was an expert, right? The surgery went well; Shelly recovered without any problems and was discharged the following day. The owner, a nurse, was given the usual postop instructions.

The following Monday, about 5 days after the surgery, I arrived at the clinic and I was greeted by Shelly’s owner. She was holding a cardboard box and was crying. She opened the box and there was Shelly’s dead body inside. She had chewed out her sutures, developed an evisceration, and then chewed on her own intestine. Obviously she then went into shock and quickly died.

I was devastated. Although Shelly’s owner did not blame me, she was upset and I know that in the back of her mind she wondered if this inexperienced young doctor had done something wrong to cause this catastrophe. My confidence sunk to an all time low.  What a way to start my career. I did a limited necropsy on the body and found that several of the sutures in her incision were missing or broken. The suture used for the linea alba was catgut because that’s all we had back then. Believe it or not in those days it was the suture used by most practitioners for the linea and most animals did fine. We have so many better options now, PDS being the suture of choice for most surgeons today and the dehiscence rate is much lower.

I became afraid to do surgery. In fact I was afraid to do anything that involved technical skill. I was convinced that I had fallen short of the skills necessary to perform a routine surgery and thus could not trust myself to do anything and even questioned my career choice. This experience was worse than the near disastrous splenectomy during my student surgery lab (see post on 11/3/13).

I once read an article about “imposter syndrome”. This is the condition that many people have where, regardless of their accomplishments and recognition from others, internally they think that they do not deserve their success and that they are frauds waiting to be discovered. I think I suffered from this malady for a time as a result of this surgical episode.

As I mentioned, Shelly’s owner was a nurse. She did rehabilitation therapy for cardiac patients. One of her patients was a veterinarian, Dr. Dick Klesmer. Dick practiced in Collingswood, just a few miles from where I worked. I knew Dick pretty well; he was a nice guy and an experienced and excellent vet. As Shelly’s owner was working with Dick on one of his rehab sessions she told him the story of the spay disaster. She said she had already purchased another female sheltie puppy and wanted to have him do the surgery this time when she was old enough. He suggested a different strategy. He said that she should bring the new puppy back to me for the spay. He told her I was a good doctor and for her to come back to me would help restore my confidence (assuming this time all went well!) and send the message that she did not blame me for what happened.

Amazingly, she did just that. I was shocked when she brought the puppy in but of course I tried to mask my surprise and act normally. We didn’t talk much about Shelly; just focused on the puppy and made arrangements for her spay.

It was the most nerve-racking surgery I’ve ever done. I was careful to a fault on every aspect of the surgery, especially the closure of the abdominal incision. I closed it in about 16 layers and used bridge cable on the linea alba. Then I put her in a body cast for 6 months and kept her in the hospital. Of course that’s all an exaggeration but I was really careful and did keep her in the hospital for a few days with a belly bandage on. She healed fine and everyone was satisfied with the results. My confidence and professional life were back on track.

Dr. Klesmer’s act of kindness saved my career as a surgeon and a veterinarian. I thanked him for what he did but he passed away some years later and I wished I had thanked him more. I will never forget his unselfishness and professionalism, and I will always be grateful to him. I wonder what he would say if he learned that I became a board certified veterinary surgeon and spent 27 years a surgical instructor? I will also always be grateful to Shelly’s owner for her courage in having faith in a very young, green and shaken doctor. I learned many important lessons from this experience that helped shape my career and my actions toward my colleagues.

One of my favorite quotes is an African proverb: “Smooth seas never made a skillful mariner.” What makes us better doctors are the problem cases that challenge us to learn from our mistakes. We never want bad things to happen but they are a part of life and sometimes occur regardless of our best efforts. The best thing we can do is to try to understand why, and always strive to be better. 

STEVE! I Got a Bitch in the Truck!

His name was Ray. He was a middle-aged dog breeder; show dog handler, and boarding kennel owner.  He was a regular customer of the practice I worked in right out of veterinary school.  He was a big, tall, gruff man.  He was hard of hearing so he shouted all the time and you had to shout back. He was honest and direct and he expected the same from everyone else. His dogs were boxers; the females were “bitches” and the males were “studs”. Typical lingo in the dog-breeding world.

He always let himself in the back door of the practice. It was a courtesy granted him by the owner of the practice since he’d been a client for so many years. He never had an appointment; he didn’t need one. It was like he was a member of the staff. He came in the mornings before appointments started, usually on Mondays. He would come in the door and very loudly proclaim to my boss: “Doc, I got a bitch in the truck! I need you to look at her!” Then he would go back to the pick-up and fetch the dog.

He called me Steve, and at first he wasn’t so sure what to think of this “wet behind the ears” new graduate. My boss told him I had potential, but he had to find out for himself. He asked me to help hold a boxer while “Doc” did a rectal exam. Of course the dog started to squirm, and Ray yelled at me: “What’s the matter son, can’t restrain an animal? Didn’t they teach you that in vet school?” I was humiliated but held my tongue, and held the dog tighter. I found out later he was testing me. I guess I passed the test since I took his criticism in stride. The honest truth was, Ray knew more about dogs than I did and he and I both knew it. He intimidated me but I didn’t let him see it because I thought he wouldn’t respect me.

Ray had just enough veterinary knowledge to have a pretty good idea what the diagnosis and treatment was going to be when he brought a dog in. But, he didn’t always get the terminology quite right. If one of his dogs was lame in the rear leg, it had a rupture of the “crucial” ligament. If a puppy had a lump around the umbilicus, it had a “Biblical” hernia. I didn’t dare correct his mistakes. Ray didn’t know pathophysiology or pharmacology, but he knew dogs.

Gradually he started to trust me and let me treat his treasured boxers. He once asked me to remove a small skin mass from the head of one of his dogs. He wouldn’t let me give anything other than a local anesthetic, not even a sedative. He said: “Steve, if I tell her to stay, she won’t move a muscle.” I took the mass off with her sitting up and she didn’t budge.

We got to be friends and I developed a tremendous amount of respect for him. He even referred clients to me for veterinary care and I referred people to him for boarding.  After I moved on to Ohio State he occasionally called me for advice about his dogs. Underneath that crusty exterior was a heart of gold.  He loved his boxers more than anything. He taught me so much about dogs, things I never learned in vet school.  He also taught me about the world of dog breeding and show handling.  It's a tough way to scratch out a living, I can tell you that. He was an amazing man and I will never forget him.

My friend Ray is gone now.  I spoke with his daughter Pat today; she is 71 years young and told me that Ray passed away 7 years ago. The boxers have passed on, and the boarding kennel is closed. But Ray’s legacy and his spirit live on, and I can still hear that booming voice:

“STEVE! I got a bitch in the truck!”

The Story of Crystal, The Chicken That Ate Metal

Crystal
(This really is Crystal, not some random picture from the internet.)

I guess you could say she was into “heavy metal”, but not the musical kind. She was a pet Rhode Island Red chicken (above). The fact that she had a name was a clue that she was not just your run of the mill member of a flock. She presented to the Veterinary Hospital at Ohio State many years ago for treatment of suspected gastrointestinal foreign bodies. Our avian veterinarian, Dr. Barb Oglesbee, admitted Crystal and did a diagnostic evaluation. After determining that foreign material was present in her GI tract, she performed endoscopy under general anesthesia and removed multiple metallic foreign bodies from the crop and proventriculus.

Metallic foreign bodies removed from Crystal's crop and proventriculus
by endoscopy. The nickel is shown for sizing purposes only.

However, one piece of metal remained that could not be removed by endoscopy. Dr. Oglesbee came to me for a surgical consult. My first reaction was: “Really? You want me to do an abdominal exploratory on a chicken?” I had done surgery on birds before but never on a chicken. All veterinarians know that sometimes you have to go outside of your comfort zone and do what needs to be done.

Crystal was still under anesthesia from the endoscopy so she was transported to the surgical area and her abdomen plucked and prepped for surgery. I ran to my office to do a quick avian abdominal anatomy review, developed an impromptu plan and returned to the surgical prep area to get the surgical team ready.

Basic anatomy of the chicken. 
www.poultryhub.org

We positioned Crystal in dorsal recumbency and did a ventral abdominal midline approach. A nail was immediately found protruding from the gizzard, and black caseous debris was present around the gizzard in the peritoneal cavity. 

Nail protruding through the gizzard (arrows). Black caseous
debris is due to leakage from the gizzard.

We performed a “gizzard-otomy” to remove the nail and closed the gizzard with simple interrupted absorbable sutures. Inverting suture patterns would have been impossible on this very muscular organ.  We then flushed the peritoneal cavity and did a routine closure of the abdomen. I did not place a drain in the abdomen since bandaging the abdomen would have been difficult and removal of the drain by the patient seemed like a good possibility.

The nail and other metallic debris removed from Crystal's gizzard.
The dime is for sizing purposes only.
(Crystal did not eat money.)
(Well considering the bill for surgery maybe she did!)

One of the interesting things that occurred during the surgery on Crystal was related to the hemostasis. As is done routinely in surgery we used electrocautery to control bleeding. When we used it on Crystal, particularly in the muscle, we became aware of something. The smell of cautery on the muscle was like fried chicken! I guess that's because it was . . . fried chicken! I can honestly say it was the first time that operating on a patient stimulated my appetitie!

Amazingly, Crystal made a full recovery with no complications. This was incredible considering she had a perforated gizzard and septic peritonitis. She returned home and probably started searching for more metal. 

For so many reasons, I will never forget this patient.

Just say "There". An irreverent look at the world of surgery.

Many years ago when I was a surgical resident my advisor, Dr. Ron Bright, taught me a very important lesson. When something goes wrong in surgery, for example you accidentally cut something you should not have, there is a proper way to respond. What you do not do is say “Whoops!”, or “Oh my god!”, or scream some unprofessional expletive. (although one of my former residents claims that the “f” word has hemostatic properties.) What you do is step back from the operating table, look at the patient, and calmly say: “There”.  In this way, you maintain a stable and professional demeanor and maintain what little respect the surgical assistants may still have for you. Saying “There” makes people think you actually meant to do whatever that stupid thing was you did. Of course, after saying “There”, particularly if there is active bleeding or other potentially catastrophic event happening, quickly step back up to the operating table and correct the problem.

Surgeons are very modest people.

In the first blog we talked about Halsted’s principles of surgery. There are a few other principles that should be recognized by all surgeons:

• Do not cut blood vessels that have names.
• Especially do not cut blood vessels that have short names.
• The worst kind of bleeding is that which you can hear.
• Gelfoam is a wonderful hemostatic agent, but it will not stop hemorrhage from the aorta.
• All bleeding eventually stops.
• The incision heals from side to side, not end to end. (courtesy of Dr. George Wilson)
• Do not use retractors that are bigger than the patient. (see Figure 1)
• The only surgeons who do not have complications are those who are dead.
• The surgeon is allowed to sing in the operating room.
• Most surgery is to remove an SBI (“something bad inside”).
• Pour sugar into an open wound, but not salt.
• Do not cut something unless you know what it is.
• When operating on a chicken around lunchtime, do not use electrocautery to control bleeding in muscle tissue.

Figure 1: This chihuahua and this Balfour retractor do not make a good match.

The Halsted Chant!

When I was on the faculty of the College of Veterinary Medicine at Ohio State, I taught the "Instruments and Tissue Handling" lecture to the 2nd year veterinary students. I tried to emphasize the importance of the surgical principles developed by Dr. William Halsted, a great surgeon who is considered one of the patriarchs of modern surgical technique in humans. His principles were:

Gentle handling of tissues

Meticulous hemostasis

Close dead space

Maintain blood supply to the organs and tissues

Maintain asepsis

Do not suture tissue under tension

Accurately align the tissue layers when closing

Rather than have the students memorize that list of principles, I modified them into a silly but fun exercise we called the "Halsted Chant".  I had one member of the class stand in front of his or her fellow students and yell the first part of each line with the students responding with the second half of each line.

I have to say each time we did it I found it to be a wonderful experience. If it helps you remember the most important principles of surgery, commit the Chant to memory and say it out loud before beginning the intended surgery.

Chorus:

When in doubt . . . cut it out!

A chance to cut . . . a chance to cure!

Above all else . . . do no harm!

Verses:

Tight stitches . . . incision itches!

Unhappy tissues . . . healing issues!

Leave dead space . . .    seroma in place!

Hemostasis . . . bloodless spaces!

Handle rough . . . inflamed stuff!

Asepsis . . . no abscess!

Layers aligned . . . healing sublime!

Repeat the Chorus