Sunday, September 19, 2010

How to learn how to (not) spay a dog, Part 3: Surgery

Surgery day. This was one of the most emotionally (and physically) challenging days I’ve had in vet school, which has made it hard to write about. However, the dog did not die, and I did not faint, so let us say that overall it was a success.

The previous day, I had performed anesthesia while Lily spayed “her” dog. Today, she would perform anesthesia for me while I did surgery on mine. My dog was a very nice adult, much calmer than the puppy assigned to Lily, and giving her the premedication was a lot easier. We left her alone to let the sedative take effect while we got our operating table ready and made sure we had all our equipment set out.

I should have known that my luck was going to be bad this day when I looked outside and realized it was bucketing down rain, and that I had left my car doors open. I was already in full operating room gear, with booties and mask and head covering, but Lily (bless her) ran out in the pouring rain to close my car’s windows.

We walked my dog in to the operating room, lifted her on to the table, and Lily put in an intravenous catheter and induced general anesthesia, then intubated her. While Lily was setting up all the monitoring equipment, I shaved the dog’s belly and scrubbed it clean with disinfectant. I checked one more time for a spay scar; we had no history on this dog, who was a stray, but she did not appear to have been already spayed.

During this time, the dog was failing to breathe on her own, and Lily was using the anesthesia machine to give her breaths with the breathing bag. The intern who was helping out explained that it would not at all be unusual for a dog to never breathe on her own for the entire surgery. Thankfully for Lily’s sanity, this dog did start breathing on her own eventually, so Lily could concentrate on learning how to monitor her properly.

I left the room, scrubbed in (hand washing! putting on gown and gloves without touching anything! getting yelled at for getting too close to various unsterile items!), returned, and it was time. I put the scalpel on the dog’s abdomen and pressed down.

Opening the dog was disturbing in a very different way from dissecting a cadaver, which I did a great deal of during my first year of school. Cadavers are cold and sort of sad. Live dogs are warm and not sad, but scarier: I kept worrying that I would hurt her, even though I knew she didn’t feel what I was doing.

The initial incision went smoothly (skin; clean the subcutaneous tissue with scissors; then cut into the body wall, along the fibrous white linea alba, careful not to cut too deep so that you hit organs). I got my spay hook ready to go fish for her uterus, but the intern hollered “Put that away!” and had me stick my bare hand down into the dog’s abdomen.

I pulled out a ureter (cutting the ureter is contraindicated, though it does happen, and I can now verify that it does look like a uterine horn), some jejunum, even some colon. The intern hunted as well. Eventually I asked “Is it supposed to be this hard?” Other classmates had reported failing to find the uterine horn on their own, but I figured the intern should be able to do it. The intern called over the surgery resident and explained that this dog had already probably been spayed, and we needed to be sure. And then the surgery resident had a go.

Eventually the resident doubled the size of the dog’s incision and put in a Balfour retractor to hold the sides of the abdomen open so that she could better look around. I got a nice tour of the inside of a living abdomen. And finally she found it: the little uterine stump. The dog had been spayed previously, and I had just performed my first abdominal explore. But I would not be spaying a dog that day.

So I had to close the dog up. The incision looked huge to me. Closing this sort of incision is done in three steps: first you close the body wall, then the subcutaneous tissue (“the subcu”), then the skin. I sewed the body wall. And sewed and sewed. Sometimes I would realize I had gotten off the fibrous linea alba onto muscle (painful for the dog after she wakes up), and would pull out some stitches and back up. Sometimes the intern would point out I had gotten some subcu, and I would pull out the stitches and back up. Finally the body wall was closed, and I called the resident over. She took a look, declared my stitches too loose, and pulled them all out, every one.

I started over (and she helped). It felt as though I had been sewing linea alba for an hour. I was becoming frustrated, and my initial adrenaline rush was fading. As a result, I was starting to become aware of my body again: I was hypoglycemic, dehydrated, exhausted, and my back was spasming from the hours on my feet leaning over a table. When I am that hungry and tired, I am usually careful not to make important decisions or to do anything requiring manual dexterity until I have eaten and rested, yet here I was placing stitches in the body wall of a dog of whom I had become somewhat fond.

I wondered if this experience was showing me that I was not physically up to the demands of a veterinary internship. Maybe I was only good for research and never meant to practice. I was so hungry. I was so tired. I was so depressed at the idea that this was all for nothing: the dog didn’t need the surgery, and I wasn’t going to get class credit for it, because I wasn’t doing an actual spay. We sewed and sewed, and then I did the next two layers, and finally the surgery was done. All that was left was a pile of paperwork, four hours of lecture, and continued care of my dog until she was discharged 25 hours later.

A few days after the experience, I feel a lot better about it, but it was an emotionally rough day. I felt very bad for the dog. She had a much larger incision than she would have if she had been spayed, because we had to be sure that there was no uterus before we closed her up. And she had incompetently performed sutures, which I am sure are more painful than they would have been if someone who knew what they were doing had put them in. And she didn’t need the surgery in the first place.

So do I now think that it is a bad idea for veterinary students to do their first spays on shelter dogs? Absolutely not. These things happen. This dog would have received an unnecessary surgery no matter what, since the standard of care does not dictate waiting for a dog to go into heat before spaying her. It was inconvenient for me, but the inconvenience is worth it. The program is a good one, and no one did anything wrong.

I did not actually spay a dog, but I did learn a great deal about anesthesia and about surgical procedures. I did open and close a dog, which was very important experience. All students at my school are required to complete two spays during their third year, so I will go through this lab two more times. That won’t leave me an expert on spaying a dog, but there will be lots of other opportunities to practice during my clinical year. I can’t quite say that this particular lab was a good experience for me, but I can say that the program is well designed, finding a good balance between students’ needs for experience and ethical issues.

[How to learn how to spay a dog, Part 1: Basic skills]
[How to learn how to spay a dog, Part 2: Anesthesia]
[How to learn how to spay a dog, addendum: uterus removal]

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