Damage Control

I figure that I will continue the theme from my prior post, and offer my veterinary perspective regarding another topic discussed in the book Better, by Atul Gawande. I would also like to mention that I am trying my hand at Twitter…so feel free to check out my updates at www.twitter.com/williamsburgvet. I am also occasionally posting photos on our facebook page. Anyway, enjoy the post…albeit a month late.

Casualties of War – Pages 51 - 69

The chapter entitled Casualties of War discusses the remarkable success that physicians have recently achieved in reducing the lethality of battle wounds over the past decade. Dr. Gawande notes that this has essentially occurred despite virtually no increase in technology from that which was available during the Persian Gulf War. The primary concept involved with the improved casualty results, centers around the Forward Surgical Team approach (FST’s). These small medical teams consist of just a handful of medical personnel that travel with the troops onto the battlefields. Basically, they carry tents with them that can become a shelter for a temporary hospital, as well as the basic supplies (sterile instruments, anesthesia, handheld lab machines, monitors, oxygen, blood products, etc.). They are without many of the instruments and diagnostics found in just about any hospital in the United States. So, even though these units, using only bare essentials, deal with the “worst of the worst” kinds of trauma, they still save a remarkable percentage of lives. The secret is that they focus on “damage control.” Their limited supplies, diagnostics, and time to deal with such devastating injuries only allows them to focus on avoiding death and minimizing injury, i.e. “damage control” - you stop/minimize hemorrhage, pack/clean open abdominal wounds, obtain an airway, etc. Once death has initially been avoided, and the patient is at least somewhat stable, they are transported to another facility with the equipment and expertise to pursue repair and treatment. This concept of “damage control” in a war zone had me thinking about some analogous situations in veterinary medicine.

Veterinarians do not always have the luxury to go past the “damage control” step. I personally feel it is our duty to do our very best to stabilize and give any critical patient that walks through our door a chance - a philosophy that I am proud to say was learned by watching my dad practice veterinary medicine. However, once we go through the initial steps - physical exam/CPR/injections/IV fluids/oxygen - there does come that point when you have to look reality in the face…and halt treatment. Medications, oxygen, time, etc. all cost quite a bit of money these days. Damage control for the veterinarian can cost hundreds of dollars. However, I feel like I have fulfilled my duty as a veterinarian by at least giving the patient a chance at recovery. The fact of the matter is that I have sent many “damage control” patients home that otherwise would not be alive.

Like humans in a war zone, there are unfortunately pets that deal with their own battlefields. This is sort of our veterinary version of Casualties of War. After reading this chapter, I started thinking about some of my past experiences performing “damage control” for these pets. While we were building Anderson’s Corner Animal Hospital, I worked three day shifts at one of the busiest veterinary emergency hospitals in the country, which allowed for experiencing some of the “worst of the worst” trauma cases. This is when my passion for emergency medicine began. This chapter has its graphic moments, going into detail about the types of trauma our soldier’s deal with on a daily basis, which got me to thinking about similar injuries that I have treated in pets. I will tell you this, nothing good happens when a bullet finds its way into flesh. So here again is the dilemma for the veterinarian. What do you do when presented with a dog with numerous deep lacerations, shot with a nail gun, having a bullet lodged in the chest, knife stuck in their eye, fractured back, etc.? I will tell you - even if this patient is trying to “eat you” (I guess this would be the critical, belligerent drunk in the human field) you say to yourself that this dog, cat, horse, etc. deserves a chance – and you then perform “damage control.” In our field, this may have to involve the difficult decision to euthanize if you feel there is no chance to stabilize the patient. However, if you feel they may have a chance after initial stabilization and treatment, you do what you can to get them through this initial insult/trauma. The body is built for survival, and you would be amazed with how pets can heal with minimal treatment. For the life threatening and/or debilitating injuries, you never know if some of our wonderful rescue groups or a good samaritan will be able to help… and this pet that is staring at you with a look of, “Why did you stop?” will be fortunate enough to get past “damage control.”