Farewell to Maxie

TL;DR – Dogs get better right away or not at all. There was a small study done on dogs that determined if the glucose level in peritoneal fluid is lower than the glucose level in blood by over 20 mg/dL, it is 100% indicative of sepsis.   

I have lost a second dog, Max, to post-operative complications after a foreign body was removed from his intestine.

Our family lost our first dog, Johnny, just over 2 ½ years ago.  He was young and an avid chewer. I had bought him toys, including rope toys for Christmas.  At the time I didn’t know obstruction is a leading cause of accidental death of dogs. I thought it was a rare freak accident. I thought Johnny was good about spitting everything he chewed out. The combination of some plastic pieces from toys and string from the rope toy was fatal.  The string became entangled with a couple of plastic pieces that stayed stuck in his stomach as his intestines stretched and pleated to try to move the string through and Johnny’s intestine tore. Johnny’s symptoms were vomiting, being less energetic, and decreased appetite. At times he shook.  In retrospect, I remember him stretching his abdomen. He continued to defecate. He was sent home from the veterinarians multiple times. Johnny had surgery, but he succumbed to septic shock 17 hours later. I learned too late that continued vomiting, especially in young dogs, is indicative of obstruction. The veterinarians involved didn’t educate me until it was too late.When Johnny passed away, all I could think to do was educate and warn other families so that they would never experience what we experienced, and yet here we are, experiencing it again.

Unlike Johnny, Max was an older dog and he was not healthy. He was diagnosed with Lupus when he was six. Max was trustworthy before Lupus. He didn’t chew on shoes, he didn’t get into the trash, he didn’t eat socks, and he hardly played with toys. After Lupus, however, Max became compelled to have something, anything, in his stomach.  I don’t remember if we discovered he was eating socks or shoes first, but we realized we had to take the unmatched sock basket from under the settee in our living room and secure it in a bedroom. We realized we could not leave shoes by the door. Max had his first obstruction November 2016. I came home from work to find several spots of bile on the floor and Max lying down without greeting me at the door.  I immediately brought him to the emergency hospital where he had X-Rays showing folds of fabric. Max had his first surgery to remove a sock.

Because Max had Lupus and was on a pretty significant dose of steroids, the veterinarian obtained special suture material from another veterinary hospital to increase Max’s odds he didn’t leak.  Up to 15% of intestinal surgeries will leak. With Max’s weakened immune system, she went the extra mile to try to protect him from that devastating complication. Luckily, Max recovered without any complications, or so we thought.

After Max returned home, I put up a baby gate in front of the boys’ room to make sure Max wouldn’t go in there anymore.  When we left the home, we secured our other dog in my bedroom with the hamper, closed the bathroom door, and Max stayed out in the living room/kitchen area after we surveyed and removed anything we thought he might decide to chew on and swallow.

Over Christmas 2017, I returned home and saw Max had gotten into the trash. Max had never got into the trash can before. If I threw out anything that would be particularly tempting, I took it to the outside bin to reduce temptation. I had company over and the lid wasn’t secured and Max could not resist the opportunity. I saw cut food bags, paper towels, and a plastic shopping bag with a hole in the bottom. The bag was dry; I was sure he must have ate the contents, but I couldn’t think of what was once there.  A few days later, Max began vomiting. We went back and forth to the veterinarians a few times and eventually Max passed a sock. I wondered if the plastic bag that had a hole was a dirty clothes bag from our guest and didn’t come from the trash at all. Socks come in pairs, and Max only passed one.

A couple of months later, I recall coming home and finding Max had broken through the baby gate and was in the boys’ room while I was gone.  I added an ex-pen outside the baby gate. Another time, I went out to shovel snow and when I returned I saw Max had broken through the ex-pen and baby gate and was in the middle of the living room, eating a sock. I reasoned he broke into the room because I was outside in that area and Max has severe separation anxiety.  But after that I came home from work another time and found he had knocked over the ex-pen and the baby gate yet again. We adopted a new rule that the boys’ room door was to be shut at all times so there were always three barriers between Max and the room.

Max began to vomit again in May 2018. He had lost significant weight in the preceding months. Foreign objects can sit in the stomach for months before causing issues. I wondered about that missing sock from Christmas.  I also had no idea what he may have eaten when he broke into the boys’ room those times. When the X-Ray was inconclusive and Max refused food, we got an ultrasound. The ultrasound revealed Max had something(s) in his stomach which could have been scoped out, but of greater concern, it appeared Max had a hernia and severe inflammation at the previous surgical site.  Max had a second emergency surgery. The surgeon called me in the middle of the procedure to tell me Max had severe adhesions. Some of them could be broken down, but a lot of them would need to stay for risk of damaging Max’s intestines. Max did not have a hernia; he had a major abscess and a chronic inflammation. The veterinarian speculated Max had a reaction to the suture material used during the first surgery and she said she removed the prior suture material and used a different kind. She removed socks from Max’s stomach.  The discharge papers were clear the adhesions were of great concern. They may strangulate the bowels at any time and Max could obstruct very easily.

Max gained weight back and recovered without incident. I am clear with guests no suitcases, bags, or dirty clothes can be accessible, no shoes can be left out.   I heard noises coming from the kitchen area in the middle of the night over Christmas 2018. I got up to check on Max and found my son. I commented I came out to make sure Max wasn’t getting into the trash or anything.  I saw the lid of the trash was ajar, but Max never got into anything when we were home, only when we left. I didn’t grab the trash and put it outside. Previously I did do that once, and Max ripped it apart when he was let out. I trusted Max didn’t get into things when we were home and went back to bed. Except this time he did. When I woke in the morning, I saw he had pulled a few items out of the trash.

Max began vomiting on the overnight of December 30th. He vomited several times in less than an hour and then stopped.  He appeared to have trouble defecating on the 31st. He was drinking water, but was reluctant to eat. We took him for a couple of walks to see if that would help him poop, but it didn’t. We went back to the emergency hospital.

The X-Ray was suggestive Max had ingested fabric. His blood work was good. Max had slightly elevated liver values, but at his age, it wasn’t concerning.  The recommendation was for Max to have another surgery. The good news was Max’s clinical symptoms had only been exhibiting for one day. On New Year’s Eve, Max had his third surgery. A piece of fabric (a small dishcloth I had thrown out) was removed.  The veterinarian said Max’s intestines looked healthy aside from the adhesions. He said if he was concerned if he tried to break the adhesions down, they would grow back twice as bad. Max was discharged the following day. He was eating, drinking, alert, and doing well.

Max continued to recover the next couple of days.  The redness and swelling of his abdomen went down significantly.  His incision was healing beautifully. I was impressed with the workmanship this latest veterinarian had done. The staples were evenly spaced and close together.  It was clear this veterinarian was meticulous. Max defecated. I was over the moon that Max was sailing through this latest episode.

Max asked to go outside on the morning of the 4th.  He peed like usual. He appeared to try to defecate but wasn’t able to.  I noticed he didn’t seem very excited to eat and he was shivering. I put a blanket on him and I gave him his pain medication and antibiotics. He stopped shivering. It could have been from the cold or pain.  I tried to feed him again in a couple of hours and he wasn’t interested. I called the veterinarian. I was told Max was at the early stages of healing from major surgery and I had only just fed him a couple of hours before and he could be full and I should wait a couple more hours and try again.  He ate a couple of hours later. He drank. He followed me around the house wherever I went. He looked comfortable most of the time. He defecated in the afternoon. His stool was very loose, but he was defecating and he wasn’t having explosive or uncontrollable diarrhea.

Max would eat when food was offered but he still wasn’t very excited about it and he continued to drink.  He continued to have diarrhea, but not a lot of volume. When my son fed him his afternoon meal, I asked him to feed Max a little bit more than what we had been.  Max ate it. Max rolled over on his back with his legs in the air asking for a belly rub and I was encouraged he was feeling better. Shortly thereafter, Max came over to me and I began to pet him.  I realized he looked off and then he vomited. Inappetance, diarrhea, vomiting… these are all signs that something is seriously wrong. We went back to the emergency veterinarian. My sister gave us a ride and commented how perky Max looked to her as Max climbed up the ramp into her vehicle.

The veterinarian examined Max. She took his temperature, normal.  She checked his heart rate, normal. She checked his respiration, normal.  She inspected the incision, which was healing beautifully. It was remarkable how nicely Max’s incision was healing. She listened to his abdomen and could hear bowel sounds. She did a flash ultrasound and nothing appeared to be out of the ordinary, there did not appear to be any obstructions. She could see solid fecal matter, she said she thought he would not have diarrhea the next time he defecated. Max was responsive and did not appear to be in distress. She commented that he still had food in his stomach. She noted there was a small amount of fluid in his abdomen, but that could have been attributed to the suction not getting all of the fluid out when he was lavaged. She thought perhaps he was having a side effect to gabapentin and we stopped it. She gave him alternate pain meds, cerenia, and stomach protectant. I was to give him his dose of antibiotics when I got home. She was confident Max was not leaking. He would be much sicker if he were. His abdomen would be hot and irritated. He would have a fever. When we returned home, Max refused his antibiotics.

I called the veterinarian again the following morning.  I let them know that Max had refused his antibiotic the night before and he was refusing to eat again and I was concerned he was missing his antibiotics. I was told to try again in a couple of hours.  When I attempted, Max ate and took his medication. However, a saying I’ve heard once began to echo in my mind, “Dogs get better right away or not at all.” I called the veterinarian again. I let them know that Max wasn’t recovering like he should and he needed to be seen again.

Max and I were in the waiting room when the veterinarian called to check on him. She saw us and did another examination. Temperature, normal. Heart rate, normal. Respiration, normal. Max was responsive. She was concerned. She said Max would need to be hospitalized and given intravenous antibiotics. We would take another full panel of blood work, we would do another ultrasound, we would take a sample of the fluid from the abdomen. She reviewed his blood work taken before and after surgery. Maybe this was related to his slightly elevated liver and gallbladder values he had prior to surgery. He was anemic, probably due to the Lupus, but not to the level where he required a transfusion. There is something is definitely wrong, but we don’t want to open him up again without justification. She listened to his abdomen again. She listened where she had seen the fluid the prior night and Max slightly vocalized. Pain. She listened again, he slightly vocalized again. I heard her say she wasn’t hearing anything. Dread. Pain and she didn’t hear noise where she should be hearing his bowels. I asked her to measure Max’s glucose as she was about to take him out back.  She looked at me strangely and asked why. I said it will tell us if he is septic, right? I remember this from Johnny’s ordeal. Johnny’s glucose level dropped because he was septic. She agreed it would and she told me that the blood work we were already planning to do would show it. She took Max with her and he trotted along side her to the back room.

A little while later a technician brought Max out to me in the waiting room.  After a bit, the technician came out again with an alcohol bottle and needle and said she needed to take blood.  I was surprised and asked hadn’t they already taken his blood. “Yes,” she said, “We need more blood to measure his glucose and compare that to the glucose in the fluid taken from his abdomen.”  After she left, a man in the waiting room commented on how good Max looked, how responsive and intelligent he seemed.

The veterinarian returned and we went into an examination room. She let me know one of her colleagues had come across a white paper describing if a comparison is done between the glucose level in the blood and the abdominal fluid and if there is a difference of over 20 mg/dL, the abdominal fluid being lower, then it is 100% indicative of septic peritoneal effusion. They measured Max’s levels twice.  His blood glucose level was 105/106, the fluid was 77. Max was septic. She said it was strange, she had spun the fluid, smeared it under a microscope, looked for pathogens and didn’t see them. The volume of the fluid didn’t look like it had increased from the prior day. However, the study said it was 100% sensitive and 100% diagnostic. Hospitalizing Max with IV antibiotics was off the table, he needed to be explored again.  I consented.

I am an over-thinker.  While I was sick with worry waiting for a call, I vacillated between positive and negative thoughts.  Max’s blood glucose was normal and Max’s vitals were normal. Max had a history of chronic abdominal inflammation. Maybe the infection was localized. Peritonitis has a significant mortality rate. Max’s immune system was compromised. The most likely source of infection was a leak. Sepsis killed Johnny. The veterinarian said she wasn’t hearing bowel sounds in one area, which could mean the intestine was dead. The phone rang around 10:45 pm and I pleaded for it to be good news before I answered.  She told me Max was in surgery and she removed some pus. On top of the infection, Max’s adhesions had strangulated part of his intestines and the tissue was not healthy. It was dark purple instead of rosy pink. When she was trying to break down the adhesions to find any more unhealthy tissue and potential sources of infection, she was damaging his intestines. The adhesions were so severe, she couldn’t ensure the tissue underneath them was healthy. She couldn’t see. She said she could spend another couple of hours trying to detangle everything, but she didn’t see a happy ending. She said in her nearly 40 years of performing surgeries, she had never seen intestines that looked like Max’s before. She said she consulted with two other veterinarians at the hospital and they both agreed surgery was futile. I asked her for odds. She said that she thought there was a less than 10% chance Max would survive and if he did survive, his quality of life would be negatively impacted. She recommended, as did the other two veterinarians, to stop the procedure and to euthanize him. She spoke to my son and explained this to him as well. He agreed it would be kinder to stop. We wanted to cling to that 10% chance of hope, but that meant there was a 90% chance we would cause Max to end up suffering a horrific and painful death because we weren’t willing to let him go. We agreed to euthanize him.

My intuition that Max was not recovering was spot on. The expectation is animals should consistently improve after surgery.  Setbacks, even those that seem minor or temporary can be indicative of major complications. Both Max and Johnny did not appear to be as sick as they really were. The study on comparing glucose levels between blood and fluid was able to give us the justification to open Max up again. When peritonitis/sepsis is involved, early diagnosis and treatment is often the difference between life and death. I would have requested the test earlier if I had known about the study. I’m confident the veterinarian would have done it earlier if she had known too.

We are heartbroken. This was a bad outcome. With that being said, it is important for me to share the experience we had with Max’s veterinarians was very different than the experience we had with Johnny’s. Even in Johnny’s case, I have different feelings about each veterinarian that was involved. Max’s regular veterinarians as well as his emergency veterinarians were responsive, compassionate, patient, thorough, kind, and gentle. I recall one of his regular veterinarians telling me after Max was diagnosed with Lupus that the idea wasn’t to prolong Max’s life, but to give him the best quality of life possible while he lives. He did that for Max. Max survived two obstruction surgeries because two veterinarians at two emergency hospitals helped him. Two veterinarians attempted to save him this last time. They weren’t successful, but they tried. Even though I had consented to spend thousands of dollars on Max’s last surgery, we were given the choice to stop when it made sense to stop.

Ever since Johnny died, I’ve educated families about obstruction and how it is a leading cause of accidental death of dogs.  The most common symptom is vomiting, other symptoms can be diarrhea, difficulty defecating, painful abdomen, shaking, and lessened energy.  Some dogs will stretch their abdomen, and sometimes bowels will be loud – I recall hearing both Johnny’s and Maxie’s bowels. The outcome of surgical intervention is very good if obstruction is diagnosed early.  X-rays, followed by ultrasound should be taken if the X-rays are inconclusive. Sometimes X-rays can show soft material like fabric or plastic, however, X-rays cannot be relied on to rule obstruction out as they do not show less dense material like these very well. About 5-15% of dogs will develop leakage after surgery. Early detection and intervention is key to having a good outcome should leakage occur.  Comparing the glucose in blood and peritoneal fluid is a diagnostic tool that may allow prompt diagnosis of peritonitis, which may allow sepsis to be addressed in its early stages, giving patients a chance at the best possible outcome.

I have also been educating families about the lack of accountability within the veterinary profession.  I have advocated for families to be diligent in selecting veterinary care, to not only be confident with the skill their regular veterinarian has, but to also be confident where emergency care may need to be rendered. Families should have this plan in place prior to any emergency as not all animal hospitals are equal. Having competent care doesn’t guarantee there will be a good outcome, but it gives our pets a fighting chance.

Fly free Maxie. <3  We love and miss you beautiful boy.  :’(