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Monday, January 5, 2015

Low Risk Doesn't Mean No Risk

Jessica emailed me this recently and I thought it was a good way to open up to a larger topic of discussion.
I came across your blog posts on tail amputation while doing some research. My 3 year old bulldog had her tail amputated yesterday after a year and a half of trying to manage her chronic infections and skin irritation conservatively. I got more than 1 opinion and I really thought we were doing the right thing. It was obvious that her tail was sore more often than not and she hated having it cleaned. I was told of the risk of incontinence postoperatively but was unable to find anyone who actually experienced this. Our surgeon assured the risk was very, very low.
Well now 2 days after surgery, we are at home and our poor girl has been unable to control her bowels. At first I hoped it was just diarrhea from anesthesia & antibiotics, but twice now she has passed 2 small formed stools while sleeping. Otherwise it has just been constant small dribbles.
She has gotten in the poo position twice outside but only a very tiny bit came out.
I did speak with our surgeon who said he was confident that there was no damage to surrounding nerves or muscles but that it was a known risk of this procedure. He said that her whole backside is sore and irritated. She also had an anal purse string suture to prevent her from having a bowel movement during surgery which could be causing additional pain for her. He said to keep her on a bland diet and wait it out.
Have you ever seen this before in your practice? Is there a chance it could be temporary?
Let begin by addressing the specific condition.  I've performed several tail amputations in bulldogs as well as other breeds.  The closer you are to the rectum during the surgery, the higher the likelihood of damaging important nerves or muscles.  Tail amputations in bulldogs are normally done because of deep folds that lead to significant irritation and infection, and with their short tails you're very close to the rectal area.  Even though the risk is low, damage can happen despite the best surgical skills, and there is no way that even the most experienced surgeon can 100% predict every outcome. 
There is also the consideration of temporary post-operative trauma.  Sometimes damage is transient due to localized inflammation of the nerves or muscles.  You can have short-term problems that will resolve with a bit of time and rest.  If this dog had significant irritation there could be a situation where the tissues will heal and return to normal.
How do you determine which outcome will happen?  Time.  Really, that's it.  Temporary "damage" due to surgery should resolve within 1-2 weeks, if not sooner.  If it goes on longer than this there may be permanent damage.  Once initial healing has taken place (usually 10-14 days) your vet can check some of the reflexes and nerve responses around the anal area to see if there is a concern.  You can also consider taking her to another vet for a second opinion, though I would give the doctor who performed the surgery the first opportunity to assess her since he is most familiar with the case.
This topic brings up a bigger issue that I also want to touch on.  "Low risk" never means "NO risk".  No matter what the procedure or treatment is, there is always some degree of risk involved.  I've done several thousand spays and neuters so far during my career.  Once I had a puppy die due to problems with the anesthesia equipment, and once I had sutures slip internally during the night after surgery, requiring a trip to the ER and emergency surgery.  But those are the only serious complications I've had in thousands of cases, which are pretty darn good statistics.  Most vets consider routine spays, neuters, and dental cleanings to carry very little risk, especially with proper monitoring, pre-anesthestic blood tests, and modern anesthetics.  Even so, there is always the risk that a pet will have an unexpected reaction to a medication or something else will go wrong.  There will NEVER be a way to reduce the risk to 0%, just due to the nature of how surgery and anesthesia affect the body.
Sometimes complications happen that are beyond a doctor's control.  A pet has an unexpected allergic reaction to a drug.  Suture material fails.  The pet's body reacts severely to the sutures.  The anesthesia equipment malfunctions.  There are hidden health problems with the pet that we don't notice on our initial work-up.  I could go on and on but you get the point.  There are situations that even the best doctor and best preparation can't prevent.
Sometimes complications happen because of the fault of the doctor or technician.  Maybe a suture wasn't tied properly.  The tech may not have been monitoring properly to catch the arrhythmia.  A drug may have been overdosed.  The surgeon may have cut a little too far in one direction.  Yes, these are things that shouldn't have happened.  I hate to break it to you, but doctors and technicians are human, and we can make mistakes.  I've said it before and will say it until my dying day.  If a doctor tells you they've never made a mistake or missed a diagnosis, they are lying to you.  It is simply impossible for any human to be 100% perfect at our job 100% of the time.  If anyone challenges this idea, I will ask you to do some serious reflection on your own life and career and honestly tell me that you've never made a mistake that somehow could have been prevented. 
Let me also be clear in saying that "we're only human" doesn't excuse mistakes.  If a serious mistake happens, that professional is certainly held liable, as is proper.  We're going to make mistakes, but they should be rare and we should face the consequences and try to make ammends.  There is a difference between a rare mistake and repeated mistakes of the same kind.  The former will happen and the latter needs to be investiaged and handled differently.
Now that I've said all of this I need to go back and reassure everyone, as I know that there are people reading who have been freaked out and won't have surgery done on their pet, even routine procedures.  Don't let my comments scare you.  Every day of our lives we take risks, and usually don't even realize it.  The National Safety Council produced a nice little graphic that gives the odds of dying from various causes.  Here are a few choice bits of that data.
Motor vehicle incident:  1 in 112
Falling:  1 in 152
Assault by firearm:  1 in 356
Car occupant:  1 in 492
Exposure to fire, flames, or smoke:  1 in 1,418
Choking from inhalation and ingestion of food:  1 in 3,649
Air and space transport incidents:  1 in 8,357
I've seen data that shows that surgical risks are about 1 in 10,000 if proper pre-anesthestic work-up, monitoring, and drugs are used.  This means that your dog or cat is far more likely to die as a passenger in a car accident on the way to the vet than they are while undergoing a routine anesthetic procedure!
Worry sometimes is misplaced.  The average American is 3 times more likely to be killed in a car accident than by being shot with a gun, yet we casually get in our cars and drive every day without worrying much.  We hear so much about plane crashes around the world, yet we're about twice as likely to die by choking on our dinner than in such a situation.  Pet owners routinely fear anesthesia for their pets, yet the risk is low.
So what does all of this mean????
First, there is minimal risk of your pet undergoing an average anesthetic procedure and the huge majority of the time it is safe and uneventful.  The risks of complications with surgery are highly dependent on the kind of surgery, with some carrying far greater risk than others.  Whenever a pet (or person!) is undergoing surgery the doctor should make you aware of the potential risks and how likely they may be.  If they don't come out and tell you, be sure to ask!  But also be aware that if the complications you were warned about do happen, sometimes everything can be done right and the outcome is still not what you wanted.
Remember....low risk doesn't mean no risk, but low risk does mean complications are rare.