By: Dr. Amy Plankenhorn
It was an ordinary busy Wednesday afternoon in October when a phone call from the Asheville Humane Society introduced a miracle into the Animal Hospital of North Asheville family. The medical coordinator at AHS was sending a little dog named Ella to us because she was suddenly having a lot of trouble breathing. Ella had been at the AHS adoption center for about a week with no problems, but that day she went outside and came in gasping for air.
Ella is a cute little brindle mix with lopsided ears and a crooked underbite. When she arrived at the hospital, she was breathing with a great deal of effort. The effort was so great that we had to take an x-ray with extreme care, as the needed position caused her to panic and made her breathing worse. The xray showed that her pleural space, which is the area between the lungs and the ribcage, was full of fluid causing her lungs to collapse. We sedated her, and drew nearly half a liter of fluid out of her pleural space. That’s a regular sized water bottle full of fluid filling the space around her lungs and preventing her from taking a breath! Using ultrasound, we examined her chest after the fluid was removed. We were concerned that she might have a diaphragmatic hernia, which is a tear in the diaphragm. This type of tear allows abdominal organs to move from the abdomen into the chest. Ella’s ultrasound showed an area that looked suspiciously like a portion of her liver was in her chest cavity. AHS approved exploratory surgery for the next day, and Ella was carefully cared for by our overnight staff throughout the night. In appreciation for the wonderful work Asheville Humane Society does to help all needy, homeless animals in Buncombe County, Animal Hospital of North Asheville donates the care we give to dogs and cats presented by Asheville Humane Society rather than accept the funds that AHS uses for medical and surgical care by local veterinarians.
Ella’s breathing was better after the large amount of fluid was removed on Wednesday night, but by mid morning on Thursday, she was having trouble again. A repeat ultrasound confirmed that the fluid was back and that there was definitely a liver lobe in her chest. Surgery was her only option for survival, so we got the team together. Kelly Brown volunteered to come in on her day off to assist with the anesthesia, as she has years of experience anesthetizing diaphragmatic hernia patients. Jen Watson provided additional support in surgery and with anesthesia. I performed the surgery.
Unless injured, the diaphragm muscle provides a barrier between the chest and the abdomen. This barrier actually creates a vacuum in the chest cavity which helps the lungs to expand normally. When the barrier is torn or when there is fluid in the chest, the lungs can’t expand normally. However, when the abdomen is opened up for surgery, air enters the chest cavity and the lungs can’t expand at all unless assisted. The anesthetist must assist breathing the entire time that the diaphragm is open. This means that the surgeon must work quickly and efficiently to find the tear, bring all of the organs back into the abdomen, and repair the tear completely. In Ella’s case, the tear was on the right side and appeared to be have been caused by an old injury. There was scar tissue attaching the diaphragm to the normal liver lobes, and the liver lobe in the chest was swollen and difficult to bring back into the abdomen. This scarring confirmed that the injury happened before Ella arrived at the Humane Society. Poor Ella! To add to the challenge, her heart rate started dropping as I was performing the needed surgery. Kelly responded quickly with a dose of epinephrine, and Ella’s condition stabilized. Fortunately, I was able to put the liver back in its correct place and close the tear.
The next critical period in a diaphragmatic hernia repair is after the diaphragm is closed. The chest cavity is full of air that has to be removed immediately or the lungs will collapse despite the assisted breathing. Jen started aspirating the air from the chest while I quickly closed Ella’s abdominal incision. Despite these efforts, Ella’s heart rate started dropping again and her heart stopped! We gave more drugs and started CPR, hoping and praying that we could restart her heart and that the chest compressions wouldn’t tear her diaphragm again. Just when we thought the battle might be lost, Ella took a breath on her own… then another and another. Her heartbeat came back. She was alive! She woke up from surgery like nothing had ever happened, with pain control from a continuous IV narcotic drip and a lot of attention from the nursing staff all afternoon and overnight.
In the short time that Ella had been in the hospital, she had captured the attention and the heart of everyone, but especially our certified veterinary technician Kelly Carter, who decided that she would like to foster Ella during her recovery. Ella recovered beautifully from her surgery, breathing normally, eating and showing no ill effects on Friday. Saturday morning she had a slight cough, which we hoped was due to irritation caused by the endotracheal tube during the surgery and the CPR that was performed. Kelly took her home with pain medicines and antibiotics on Saturday afternoon, but was watching her very closely. She called me on Saturday night with concerns that the cough was getting worse. We started her on a cough medication, but at about 1:00 Sunday morning, Kelly took Ella to REACH because her breathing was becoming labored. X-rays at REACH showed that she was developing pneumonia and that she had pneumothorax. Instead of fluid in the pleural space, Ella had accumulated air in the space. The veterinarian at REACH removed the air and started her on IV fluids. She stayed at REACH until Monday morning, when she transferred back to AHNA for further intensive care. Dr. Dennis Golden put her on IV pain medication to help make her comfortable, and IV antibiotics for the pneumonia. We also placed a nasal oxygen tube, which provided continuous oxygen to help her breathe better.
Luella out with friends!
Poor little Ella could breathe better with the air out of her chest cavity and with the oxygen therapy, but she was burping and regurgitating any time she was offered water or food. Dr. Golden suspected that she had regurgitated and aspirated her stomach fluid, causing the pneumonia. During his time teaching at Auburn University, he had seen a number of patients who developed severe stomach acid reflux after abdominal trauma, sometimes to the point of causing scarring and narrowing of the esophagus. On Tuesday, Dr. Golden, Kelly and I discussed what to do, and we decided to give Ella one more day of medical treatment including adding an anti-nausea medication to her fluids. Thankfully, she stopped regurgitating and by Thursday was able to eat and drink and take oral medications. She had survived another scare! Her chest x-rays showed daily improvement in her pneumonia, and once again, Kelly took her home. She was skinny and weak, but she had a fighting spirit that wouldn’t let her give up – or let us give up on her. She has been eating like crazy, and has gained almost four pounds since her lowest point. She has met Kelly’s other dog Juno, and they are getting along great. Her name has also evolved from Ella to Luella. To see her now, you would never know that she had gone through any of these experiences. She is sweet, loving, active and completely charming. We look forward to loving Luella for a very long time!