|Fluffy - The Miracle Dog|
One of the greatest challenges in having a pet like Fluffy is the fact that any potential medical problem is complicated by his hemophilia. The most serious of his many brushes with death didn’t even seem vaguely related, at first…
It was a Friday afternoon, and I was at work with Fluffy. He wasn’t acting right – laying about and trying to hide. Since he’s usually quite social, this concerned everyone. We examined him, ran a few tests, and shot an x-ray. Nothing looked unusual. As the evening wore on, he appeared not to get any worse, so I took him home for the night, knowing I was going back to work in the morning. At home, he refused food. This was the first time in his life he’d ever done so. I was concerned but assumed he had a sick tummy. I watched him and waited; he seemed worse but I still didn’t know what was wrong with him.
2:30 AM – “Come here – Fluffy’s vomited up some blood!” I rushed him to the clinic and shot another x-ray. The lung borders looked a bit funny, but I was focused on the abdomen, looking for signs he’d swallowed something. I called Dr. Glass at 3:00 AM. ”Hmmm…” says Dr. Glass. “I’ll be in in a couple of hours if he’s stable. Stay with him and call me if anything changes.” He retched some more and vomited up small amounts of blood. This was enough to cause concern, especially for a hemophiliac.
5:30 AM – Dr. Glass came in early. “Let’s have a look at that x-ray.” “OK. As you can see, the abdomen looks pretty benign.” “Yeah, but look at the lungs. He’s bleeding into his chest. Let’s get a chest x-ray, re-run his blood work, and transfuse him right away.”
By 7:30 AM when everyone else started to arrive, we’d already had two large-bore IV lines started. One was running in blood products in an attempt to stop the bleeding, and a second was giving him artificial blood to help keep him from damaging his organs. The staff at the clinic thought he was sedated. My usually boisterous companion lay so still that it was clear even he was beginning to grasp just how sick he was.
The x-rays showed us that he did, in fact, have a major bleed into his chest. Blood was trapped in the cavities on both sides surrounding his lungs, pushing them upward. We debated all of his options. In a trauma case with a healthy dog the option would have been clear-cut – insert a chest tube and evacuate the blood. But what if he had clotted? What if by disturbing a clot he bled more? But what if we left it in place and it permanently impaired his lung function? This was uncharted territory for us and any sort of intervention required anesthesia.
In a human trauma setting, chest tubes can often be placed using only local anesthesia. The procedure is very uncomfortable and painful, but you can explain to a human why you’re doing a procedure. For a dog, general anesthesia is required which has its risks in the best of circumstances. His compromised lung function just made things more difficult.
We all said our good-lucks and sedated him. Fortunately, he was a champ. A needle decompression did no good – whatever was in there was organized. He sat asleep, breathing nicely, as we debated about what to do next. We agonized and decided on conservative therapy. We would not insert a chest tube. He had survived the first of several ordeals over the next two weeks. A good lung exam revealed the sounds of a minor lung puncture – not unexpected with this procedure, but just one more difficulty for him.
I stayed with him that night, and into the next day. In fact, I would live in the animal hospital 24-hours a day for the next two weeks. But it was the kindness, not only of Dr. Glass, but of so many other people as well who helped us get through that extremely difficult time. The next player was my good friend and fellow medical student, Melissa Burger.
Dr. Glass and I had been in the clinic all day Sunday. She went home exhausted at the end of the day, then I called Melissa to update her on things. As we talked about some of the difficulty Fluffy was having with his breathing and the way his exam had changed, Melissa made some very prescient observations. Fluffy was, in fact, going into what is known as “volume overload.” It was Melissa’s observation that a phenomenon called ‘pulsus paradoxus’ – when the pulse disappears on inspiration – can be a sign of early volume overload. The balancing act became more delicate; we had to restrict his fluids.
He still needed to be transfused with whole blood. He had lost a lot of blood; his hematocrit level went from 40 -> 20 -> 10 over the course of two days. We were able to give him fluids, but IV fluids don’t replace the lost red blood cells. He needed a whole blood transfusion, or maybe two. Enter Fluffy’s sister, Bella. I met Bella (and her mom) by accident in the pet store. I was buying a harness for Fluffy, and asked a woman with a dog about his size what size harness her dog wore. I was thunderstruck – she was Fluffy’s twin. After a bit of questioning back and forth I realized the two dogs must have been from the same litter. She said she’d always help me out with him anytime - and now it was time. Bella came in and donated a unit of blood for Fluffy, which we duly transfused into him.
But Fluffy couldn’t eat
After a few days he was beginning to show an interest in food, anything he tried to eat made him retch. We started feeding him a little at a time with a syringe. It was slow, but he liked it. We gave him some milk. He liked that, too. I gave him more than he could handle, then he vomited and may have aspirated some, too. Things were about to get much worse.
I took him home for a night. I had not been out of the hospital in the past several days and needed to spend time outside of the clinic with my family. I packed up his medicines, his IV pump, his fluids, and everything else I thought I might need and decided to give him an 8-hour furlough. It was strange … the routine of the hospital – medications every 2 - 3 hours, constantly checking IV pumps, responding to every little noise – while routine at the hospital was much more difficult at home. It was not a restful night for me or Fluffy. When morning broke, I took him for a walk. He was so short of breath he couldn’t get much beyond the corner without resting. I took him back to the hospital a short time later.
Fluffy sat on his favorite bed in the middle of clinic while we tried to go about our normal day, treating other patients. But something was wrong. Amanda (one of our techs) went over to him. “Come here and feel him. He feels hot.” I grabbed a thermometer… 102… 103… 104… 105… 105.2… 105.6.
“What do we do when his temperature is 105.6?” We immediately began cooling him with cold compresses and shot a chest x-ray. Not only did it show the bilateral lung collapse we’d known about, but now there was a new finding – pneumonia in the right middle-lobe. We reviewed his antibiotic coverage – he was already being covered prophylactically for a blood parasite that had recently made several dogs very sick at our clinic and may have been the precipitating factor in his current bleed. We hit him with the broadest spectrum of drugs we could – the most powerful antibiotics we had. We hooked him up to the electronic temperature probe… and waited. His temperature didn’t go up at least… and slowly it came down… 105.4… 104.8… 103.7. Very good. After an hour we were encouraged. He seemed to be getting better. Then… 101… 98… 95…, huh? In a rare moment of levity, he had squirmed and knocked off his temperature probe. We got a much-needed laugh, and then replaced it.
He made it through the day, but he still couldn’t eat. And his breathing was worse. The volume overload had left him with fluid in his lungs. The pneumonia found this a fertile ground. He still had the lung puncture and he still had the clot in his chest. It was getting more difficult for him to breathe. We started him on supplemental oxygen, which helped. He would sit up rigid and bolt upright. Late Saturday night I thought he was finally going into respiratory failure. He couldn’t stay up, he was just getting so tired trying to breathe. We had no ventilator. Maybe it was time; we just didn’t know. Unable to do anything else, we sat with him and held him. I felt him slowly go limp in my arms, over maybe half an hour, as he struggled to keep his eyes open. He fought, but the fatigue was too much for him, and he was finally overtaken. By death? I thought so for a minute. But then I realized it was sleep… much-needed sleep. He slept quietly and peacefully for a few hours.
Fluffy still can't eat
We were watching him waste away, hungry, cachectic, and losing weight. We debated about starting IV nutrition, but all of his transfusions meant he had fragile peripheral veins. We were more nervous about losing out last IV access. We gave him IV medications to protect his stomach from ulcers. But his urinary output decreased to almost nothing, and what fluid there was was root-beer black. Our next concern was kidney failure. We watched him very closely; if we gave him too much fluid, his lungs would fill up, too little and his kidneys would shut down. We gave him some medications to help his kidneys along, and watched his kidney function with blood and urine tests. He didn’t make much urine, but at least things didn’t decline much further.
Why wouldn’t Fluffy eat, indeed? We gave him a bit of barium, and we finally had an answer. There was something occluding his esophagus - a bit of a toy ... a sock that he may have have chewed on, perhaps? Who knew? Barium could get past it, but it took a LONG time. This also explained why he kept vomiting up nothing solid. We arranged for the endoscopist to come visit and run a scope on Fluffy.
Delays, delays. A broken endoscope; replacement parts had to be ordered. Dr. Hayes would be there as soon as he could, but maybe it would be better to take him over to St. Elsewhere if this was urgent? They had all the equipment in-house.
So we packed Fluffy up and went to St. Elsewhere, late in the evening. Dr. Glass ferried everyone about after a full day of work of her own. We stayed at this hospital till 2 AM. They felt Fluffy should stay overnight and be transfused by their staff first. We were reluctant to leave him, and ended up going home $250 poorer with only a clotting profile showing us nothing we didn’t already know. Now it was 2:30 AM. Dr. Glass dropped Fluffy and I back at the clinic, and went home to close her eyes for just a couple of hours before seeing her next full day of clients.
Dr. Hayes, the endoscopist, came later in the afternoon. We had a pool at the hospital to see what might be found in Fluffy's esophagus. A bag of Fluffy’s toys and chewed up shoes were some of the things we all placed bets on. We were convinced that just as soon as we plucked the offending item from his gullet, he’d be able to eat. He NEEDED to eat. He’d lost almost 7 pounds by this point. He was increasingly cachectic. He was also developing peripheral edema (swelling); so he was thin and bloated at the same time.
Everyone said their good-lucks and we sedated him again for his endoscopic procedure. They always have a breathing tube for a procedure like this, even though they generally breathe on their own. Dr. Hayes put the other tube down his esophagus, and we all watched the monitor expectantly. We saw the occlusion and found the mysterious object was – NOTHING. Everyone’s hearts sank. The pressure holding his esophagus shut was from the outside - from the clot. We all knew what that meant and silently considered the possibilities.
Again, we had the problem of his hemophilia complicating the picture. In an otherwise healthy dog, the answer was simple – dilate the esophagus. But the dilatation on Fluffy might start bleeding which would kill him. We could evacuate the chest which might start him bleeding again. We debated, talked, and considered every option available to us at this point. He wasn’t tolerating this anesthesia as well as he did the last time and his lung function was worse. We decided to wake him up.
Fluffy stopped breathing
Before I knew it we were running a code on him as I watched his heart rate plummet on the monitor. Automatically I began bagging him by hand, filling his lungs full of oxygenated air. Dr. Glass gave him an IV drug to stimulate his breathing. The heart rate began to come up, he got more oxygen in his blood, his tone improved, and he began to have some color. He started breathing on his own.
Now we were desperate… what do we do? He NEEDED to eat. He wouldn’t get better without eating. We knew liquids would pass, but what if he aspirated again? He couldn’t handle real solids but simply did not know what else to do.
Melissa came to the rescue again. She suggested that we give him thickened liquids – we often give them to human patients who have strokes because they sometimes have swallowing difficulties. Would Fluffy respond to this? We tried a compromise - a small little meatball made of a little bit of very moist cat food, some oatmeal, a little bit of water, some liquid vitamin, and just a touch of barium so we could x-ray how far it got and what happened to the meatball when it got past his occlusion. One hour and four x-rays together, we saw that it got down, got past the stricture in his esophagus, and stayed down. So Fluffy ate Barium Meatball Surprise under fluoroscopic guidance for the next few hours. Once we were comfortable that we had the timing down we stopped the x-rays. We gradually increased the amount of food he was getting and he gradually responded to his food intake.
Fluffy’s meatballs were the turning point. He needed to get better to eat, but he needed to eat to get better. And we’d finally found a way to break the cycle.
Fluffy improved rapidly over the next several days. As his oral intake improved we weaned him off of IV fluids. We gave him a raised bowl to eat from. After six units of cryoprecipitate (a concentrated type of plasma that contains clotting factors), two units of whole blood, and two units of synthetic blood we finally got the bleeding under control and stopped. Finally, he would start to heal. His lungs started to improve slowly; it was a process that continued over the next several months.
And now, several months later…
Fluffy has regained all the lost weight (and more!). His lung function returned to normal – he’s able to play and do all of his normal dog-ly activities without any difficulty. He’s stronger than he was before his admission, and his hemophilia is better controlled.
He has finally recovered the use of his voice! The blood tracked up from his chest into his neck, and the pressure of the clot had caused a temporary nerve paralysis. For about three months Fluffy was unable to bark or make any noise at all. Over the last couple of months he gradually regained the ability to make sound – first some barks, then full barking, and finally the many small little vocalizations that he made almost constantly before his bleed. It’s wonderful to hear him fully vocal again (except at 3 AM when the cat next door is in the yard).
It’s been quite a roller-coaster ride… one I never hope to go on again. Two weeks in the hospital; two weeks of round-the-clock care. Anesthesia. Pneumonia. Renal failure. GI obstruction. Antibiotics. Endoscopy. IV’s. Transfusions. And the generosity of so many people – all of whom helped Fluffy recover.