The Vet Vault 3.2.1.

Some GI surgery pro tips, clarifying heart sounds in cats, and my strategies to help navigate periods of high stress.

Aug 15, 2024

3 Clinical Pearls.

1. Gastropexy pro tips

Unreleased recording from Science Week with Prof Nicole Buote.

For me, the fiddliest bit of aGDV surgery is the pexy, specifically placing the sutures between the stomach and the body wall. (Especially at 2 in the morning!) You’re working in a fairly tight space in a surgical field that’s quite far away, and kinda upside down. And once you’ve sutured one side of your pexy incision, the stomach obscures the other side, making it even trickier. These two little pearls from surgeon Nicole Buote’s session on GDV surgery should reduce the fiddling:

Go horizontal. Most of us were taught to make the incision on the body wall vertically, which means that you’re starting your suture line 4 or 5 cm’s deeper inside the abyss. Prof Nicole says that there is no reason why you can’t do a horizontal (ie cranio-caudal orientation) pexy, bringing everything closer to you.
Go knotless. It is standard procedure when performing an endoscopic gastropexy to use unidirectional knotless sutures to secure the stomach to the body wall, with good literature backing up success rates. And there’s no reason why you can’t also use it when you’re doing your pexy post-GDV. saving you the extra effort of making good knots in a tricky area. (If you haven’t come across the knotless suture material - it’s very cool. And yes, it feels very wrong to do a suture line without finishing it off with a knot!)

2. Clarifying heart sounds in cats

From a episode 165 on our ECC stream. With Dr Fiona Meyers.

More than 2 decades into my career murmurs and gallop rhythms in cats still confuse me a bit. But no more! Cardiologist Dr Fiona Meyers helped us understand exactly what we can and can’t deduce from cardiac auscultation in cats:

The two main causes of murmurs in cats are:
- 1. Dynamic right ventricular outflow tract obstruction, which is a very normal physiologic phenomenon, and not at all uncommon.
- 2. Murmurs associated with systolic anterior motion of the mitral valve and hypertrophic cardiomyopathy, which is very much not benign.
This means that
- Your non-clinical feline patient with a heart murmur either has a condition that is nothing to worry about, or one that will eventually kill it.
- Your respiratory crisis feline patient with a heart murmur might have an incidental benign murmur and not be in heart failure.
- On the flip side, up to 40% of cats with bad hypertrophic cardiomyopathy DON’T have a murmur.
So basically, the presence or absence of a murmur in cats doesn’t really tell you anything, other than that you need to have it investigated if you do hear one.
Gallop rhythms, on the other hand, are almost always cause for concern (some very old cats can have a gallop with no heart disease), so the cat with clinical signs of CHF with a gallop rhythm probably has heart disease, and the cat with no clinical signs and a gallop will probably have clinical signs in the not-too-distant future. BUT
The absence of a gallop rhythm also doesn’t rule out cardiac disease, so the cat in respiratory crisis with no gallop could very well still have heart failure.

3. GI anastomosis tip

From ep 165 on our surgery stream. With Dr Tania Banks.

What’s the trickiest bit of GI tract to suture when you’re doing an end-to-end anastamosis? It’s the mesenteric side, right? All that fat obscures your view, so you can’t be quite as accurate with your suture placement. The data backs this up, with most post-op leakage happening in this area. In this episode on pro tips for doing a subtotal colectomyDr Tania described her technique for suturing the colon (where perfect suture placement REALLY matters), but it’s a great trick for the rest of the GI tract too:

Start your sutures at the mesenteric side, placing a series of interrupted sutures.
Take full thickness bites from the serosal side, into the lumen and back out again, but visualise and confirm placement from the luminal side. I.e., you’re checking your work from inside the bowel where you can see much better.
Once you’re happy that you’ve closed this area neatly you can start zipping up the sides, where you can see much better, from the outside.

2 Other things

“I think that where it is possible to do work that is satisfactory to a man’s constructive impulses without entirely starving, he will be well advised from the point of view of his own happiness if he chooses it in preference to work much more highly paid but not seeming to him worth doing on its own account.
Without self-respect, genuine happiness is scarcely possible. And the man who is ashamed of his work can hardly achieve self-respect.”
- Bertrand Russell
“You can love your job, even if you don’t like it every day.”
(Sounds bit like children…)
- Simon Sinek

1 Thing to think about.

In last week’s post I told you about my little ‘moment’ at work, and what I think the reasons were that led to it. Let’s look at a few strategies that I’ll try to employ to avoid this in the future. Because isn’t that the point of strong negative emotions: to teach you something? But first, a few thoughts on what really helped me de-escalate in the moment:

Recognition. I think that a semi-regular meditation practice has helped me be more self-aware of my emotions by reading their physical manifestations and hearing the associated self-talk in a semi-detached way - ‘watching the dancing from up on the balcony’, like someone once told me. Being cerebrally aware of my tight chest and thumping heart was a clear signal to listen to what was going on in my head, which was something along the lines of “f…f….f…., I don’t think I can do this.” “All I wanted was a quiet shift. Why do I always get the challenging cases?!” “I just want to be at home - I don’t need this in my life.”
This step of recognition is useful for several reasons:
- It helps me remember that these are feelings, not facts.
- Now I can question that internal narrative: “Is what it’s telling you saying true? Do you REALLY ALWAYS get the hard cases? Is it true that you can’t do this?’ Of course not.
- I can provide counter-evidence. Internal dialogue: “I don’t think I can do this.” My reply: “I’ve dealt with much worse than this 500 times - I can totally do this.” (Yes, there are voices in my head. Don’t tell anyone.)
- Simply witnessing the emotions can help, even if I can’t ‘fix’ them. Like a rogue set of waves beating you up when you’re surfing, you know that they’ll pass.
- It’s a signal to tell someone. Ask for help. “Hey Colleague/ Nurse, for some reason this case is really messing with me and I’m feeling totally overwhelmed. Is there any chance that you can help me think it through/ see my next consult / make me a cup of tea / give me a hug?” If said colleague is not in physical proximity - pick up the phone. (Of course I did not do this, because, just like you, I have way to much ego. But that’s stupid.)
- Breathe. Don’t underestimate the power of a minute of box breathing or simple mindfulness. You’ve heard this before, but I bet you’re still cynical about how effective it can be. Try it next time and see.

Necessity. The reality is that there were things that needed to be done, and I was the one tasked to do them. Balancing the narrative of self-kindness, there remains a tougher voice with a very clear internal dialogue: “You ARE the adult in the room, so stop whining, put on your big boy pants and do what you can, with what you have.” I don’t think this voice should run the show, but cultivating it by doing hard things is still useful.

What will I do differently for my next shift? Well, like I said last time, we all know the answers, right? Sleep. Make time to actively unwind. Exercise. Meditate. Engage in non-work related activities that nourish and bring joy. Foster relationships. All the basic self-care stuff that we hear about all the time but don’t do, because, tbh, if we did all of this well we’d have about two hours left for work each day. So what’s the solution? For me, it’s a mix of mindset and strategy:

Accept that I’ll never do these things perfectly, but don’t give up on trying my best.
Schedule them and apply the same self-discipline to these that you apply for work. Would you skip a scheduled work shift because something else came up/ you just don’t feel like it. Give the same respect to your self-care. It’s as important.
Be prepared to disappoint others and learn to be ok with it. I should have had my nap, and I should have done a proper workout, and I should have watched a bit of TV before my shift. But this would have meant that I didn’t publish the next episode on time, or skipped a newsletter, or annoyed my wife because the gutters weren’t cleaned. Something had to give, and someone would have been disappointed in me. (Probably less than I imagine.) We hate that, right? But is it better to disappoint a little bit now, but have the capacity to keep showing up in the long term?
Debrief. I will make a point of calling someone to talk me through the cases that challenge and upset me. What can I do better next time? Maybe I did everything right, and that’s just how they go.

These are hard things, and not something any of us are likely to consistently get right. (Cue the occasional emotional episode to help you course correct!) But that, in itself, is something to be grateful for. If your life is busy and full of expectations from others with a seemingly endless to-do list, it means you are needed and not entirely useless and, most importantly, not dead yet.

Much love,

Hugh