OK so I know I shouldn’t have taken this so hard but I did. A couple of weeks ago I performed a surgery that didn’t go just right. And the clients are not completely satisfied. The hyper-pleaser in me abhors this feeling. And so I went home last night feeling pretty low.
The back-story: A heavy-set (read: minimally sub-obese) Rhodesian ridgeback girl arrives with her brother for his follow-up after an ear infection. She’s not the patient. She’s just there for moral support. But she sports a tiny little lump on her rump. Let’s check that out—just in case.
After a tiny, 22-guage pinprick to extract representative material from the mass, my microscope reveals lots of ugly-looking cells spilling purple-stained granules of intracellular debris: it’s a mast cell tumor.
Mast cell tumors are notoriously nasty skin cancers found not uncommonly in certain breeds (boxers, ridgebacks, Bostons, bulldogs...), though they can afflict all dogs. They are cancerous clumps of [you guessed it] mast cells, a type of skin cell that plays a role in inflammation. Sometimes they just go a little haywire. As with most cancers, we don’t know just why they get so crazy.
The problem with mast cell tumors is not just their willingness to grow into funky-shaped lumps that can mimic the look of many benign skin bumps, they also have the ability to evolve and spread to major organ systems. Dogs die every day of mast cell cancer.
Our job? Identify them as soon as possible and remove the suckers before they get a chance to do any harm. But that’s easier said than done. Because they often look like little nothings (pimples, even) the mast cell masquerade can leave a vet in the position of looking like an ambulance-chasing alarmist for wanting to stick a needle into every little lump and bump on the surface of a dog’s skin. But I do it anyway, especially in a predisposed breed.
The other problem with mast cell tumors? Once identified they must be removed ASAP with plenty of room around the lump to spare. Since they tend to grow tendrils of cells down into the skin and away from its core, we have to cut away all the skin and underlying tissues at least two centimeters around the perimeter of the mass.
That’s also easier said than done. Even on this one-centimeter mass that means I have to cut out a hemisphere five centimeters in diameter from this dog’s fat rump (fat being the operative word). The problem with fat dogs? Their skin is stretched so tight by the underlying fat that losing a five-centimeter circle of skin can result in an unclosable wound.
But I can do this one? I asked myself. She’s not that fat, I countered. And I was right. Cutting an ellipse of skin along the lines of tension with two centimeters of butt-fat resulted in a liposucted, cavitated area with perfectly arranged sutures overlying it. She went home that day with a protective collar to keep her mouth away from the danger zone.
A week later she was back. It had opened up…on my day off, of course. My colleague closed it up nicely and initiated antibiotic therapy (she had licked it repeatedly). The owners swore up and down that she had not been responsible for the dehiscence (opening up of the suture site). In fact, she’d been so good that her collar had not even been necessary. Once opened she’d been so painful, they said, that she’d had no choice but to lick at it. (I love these wacky guys and I believed them, mostly, but [dammit!] what’s so hard about using a collar on a slothful ridgeback?)
A few days later they were back. Although the site was 95% healed closed, they insisted on a more cosmetic result. I said I’d give it a go. It came out beautiful—again. But I knew it wouldn’t last. The sutures were giving way every time she sat down in a sphinx pose. Although I closed the site while she maintained this position (hoping to manage better closure if I properly understood the maximum tension applied to the wound edges) she came back two days later (yesterday).
I know you’re frustrated but we’re going to have to leave it like this, I said firmly. It’s 95% closed. She’ll have a scar. But she’s going to be fine as long as you clean the wound twice daily, complete her course of antibiotics and [for the love of God!] leave her E-collar on! Later on we can talk about cosmetic remedies to her scar tissue if you like.
These clients were so nice but they were visibly disappointed in me. I felt terrible not being able to achieve the goals we had set on day one. I realized that I’d not managed their expectations well. So I went home feeling demoralized. And then I talked to my terminally supportive boyfriend…
As usual he supported me in every point (except for the managing expectations thing—I f----- that one up, for sure). He reminded me that 10% of mast cell tumor resections dehisce. Once he even refused to remove one on a ridgeback until she lost ten pounds—no way can you close some of these surgical sites. There’s just not enough skin in a turgidly obese dog.
And then he said one thing that really made my day: Did you tell them that you cured their dog’s cancer?
The mass I’d removed was a Grade I mast cell tumor, the lowest grade. The vast majority is graded II or III by the time we remove them. This one was removed before it had virtually any chance of spreading.
How many times can anyone say they cured a potentially deadly cancer? I did that. I made her disease go away. What does it matter whether anyone appreciates it or not? I’m still her hero and it suits me just fine that my patient will never know it.