During my first ER shift, an elderly German shepherd presented for increased difficulty breathing for the past 2 weeks. He had been referred by his primary veterinarian after x-rays of his chest showed pleural effusion (fluid accumulating around the lungs), which causes difficulty breathing. After completing my physical exam, I put the German shepherd into an oxygen cage so he could breathe easier and went with the intern to talk to the owners.
We discussed that drawing off the fluid in his chest and analyzing it would help us figure out the likely cause. For example, the fluid could be blood, watery fluid, pus, or chyle (a milky-white fluid containing fat droplets and lymph). If the fluid was blood, we would look for the cause: trauma, a bleeding disorder, or a bleeding mass, for example. If the fluid was watery, we would look for cancer or evidence of heart failure. If the fluid was pus, that would indicate an infection that needs drainage and antibiotics. If the fluid was chyle, we would look for evidence of cancer, heart disease, or trauma.
I was a little nervous to tap my first chest, but luckily the intern was a cheerful, solid support and coached me through it. Using a sterile catheter and stylet, I punctured through the chest wall, then withdrew the stylet and held the plastic catheter in place as the intern placed an extension line and syringe, then began drawing off blood-tinged fluid. We pulled 500 mL (half a liter!) of fluid from the left side of the chest, and 250 mL from the right side. Because the fluid was watery, we scheduled a consult with cardiology to look for signs of heart disease and discussed performing a CT scan to look for cancer.
The cardiologists found no evidence of heart disease, but during their echocardiogram (ultrasound of the heart) they found a large tumor just cranial to the heart, the likely cause of the shepherd’s pleural effusion. Without biopsying the mass, it’s impossible to give an accurate estimate of survival time or formulate a good treatment plan. I felt sorry for the owners, who were clearly surprised by such big news, and struggled to make a decision whether to pursue more tests and treatment. I crossed my fingers and assured them that no matter what decision they came to, we would support them and help make their pet as comfortable as possible. Sometimes it’s strange, dealing with the dichotomy of being excited about an interesting case, yet feeling empathy for what the owners are going through.