Update Yorkshire 16 hours after breast tumour surgery

Update & Review of breast tumours removed yesterday at 4 pm. Very weak not standing when the owner visited at 7 pm. On IV drip.

Saturday May 18, 2013  9.29 am. Alert, walking. Not eating. Some swelling at right MG 2.  

CASE
Yorkshire Terrier, F, Not spayed. Mammary tumours x 4.
7 months ago, small nodules but not excised as owner was worried about anaesthesia.
Tumours in right & left MG5 are extensive.
To remove only the right chain, MG3,4,5 as there will be no skin to suture if the left MG5 is also removed with the right MG5. Ovariohysterectomy not done at same time as the dog is very old. Shorter the surgery, higher the chances of survival.

SURGERY. Dr Daniel Sing to operate and I to assist. Nai to do vet anaesthesia.
The surgery took around one hour at minimal anaesthesia isoflurane 0-3%. Dom + Ket at 50% of formula given IV. IV drip.

Blood test May 17, 2013
Only urea high at 10.7 (4.2-6.3) and creatinine low 39 (89-177), platelets very high 886 (200-500). umours have spread possibly via the blood stream --- high platelet counts?. No X-rays of lungs done owing to economic reasons.


Goes home today 10.15 am.

1423. Old female Maltese had bladder rupture and vomiting

The 13-year-old female Maltese had a much swollen abdomen. Tense. Bladder ruptured and contained green fluid. The wound was stitched up. Continued vomiting the next 2 days. Blood tests renal disorder and total WCC of 43 (7-17). The prognosis was poor. The family decided on euthanasia.  

1422. The Yorkshire is too "light-weight" for surgery

TOA PAYOH VETS toapayohvets.com Date: 17 May, 2013 Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits A Yorkshsire Terrier has 5 breast tumours Dr Sing Kong Yuen, BVMS (Glasgow), MRCVSDate: 17 May, 2013 toapayohvets.com Be Kind To Pets Veterinary Education Project 2010-0129 Thursday, May 16, 2013 1422. Yorkshire is too light-weight for breast cancer surgery "The big one grew very large only in the last 2 months," the lady owner had not wanted the 5 small breast nodules removed in July 2012 fearing that the dog might die on the operating table. The dog is now 13 years old. "Did my associate vet advise removal?" I asked. "Yes, but since the dog is old and light weight, being 2.5 kg, I did not want the surgery done. What to do now?" "Since the 5 nodules have now become large, with the biggest one growing so fast, it is likely that the nodules have had become breast cancers. Most likely the tumours may have spread to the lungs and an X-ray will be needed to find out You have two choices. To operate or not to." "What happens if I don't?" she asked. "The biggest one will keep growing. The dog is licking it now as you can see a shiny bald spot. Soon there will be skin ulcers and bacteria infection comes in. The tumour grows bigger and smelly. The dog will stop eating as she is in pain." "Spaying the dog when she is young will have reduced the chances of her getting breast cancer. It is not guaranteed but dogs spayed early seldom get breast cancers." I explained. "What is your advice?" "If you take the anaesthetic risk of the dog dying on the op table, surgery is advised. Short surgeries rather than a long one will minimise but not prevent anaesthetic deaths." The owner wants to think about it for a day. Surgery to remove the largest breast lumps first and then another surgery to spay the dog to deprive the tumours of the hormones and to remove the 3 small ones further forward. However, if the lungs have cancers, that will be a separate matter." The dog is now active and eating. If only the owner had agreed to removal of the small nodules 7 months ago and to spay the dog, this emotional situation will not happen. "It is not a matter of whether the dog is 2.15 kg or 10 kg that is important in anaesthetic risks," I said. "It is the health of the dog and the use of safe anaesthetics and the duration of surgery. If a vet takes a longer time to operate as he or she wants to remove all 5 tumours at one surgery, it will take a much longer time and this is when the dog's heart may fail. Short surgeries minimise but do not eliminate the risk." Update will be on this webpage: http://www.sinpets.com/F6/20130517yorkshire_ breast_cancer_toapayohvets.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: May 17, 2013 Toa Payoh Vets

1421. Intellectual property for a write/illustrator

Another client of mine had written 10 stories on core values for a pre-school operator. "He paid me very little as compared to another writer," she said to me. "My stories are better as I write, illustrate and translate to Chinese language."

"He asked you to sign and paid you," I said. "So he has the copyrights. But you can always write another version. After all, you can write about a cat with one black ear instead of two black ears." She had lost her motivation.

Core values are now in the school curriculum but she said there are many other authors. "Does it mean no new writers should write about the same topic just because there are thousands of writers of how to care for your cat?"

1420. Divine intervention?

Yesterday I spoke to my client whose heart had stopped beating for over one hour in 2008 when he went in for a surgery of his middle ear. Emergency resuscitation by the medical team revived him but now he feels deep chest rib pains. His heart is OK.

"My ECG reading was flat as a straight line," he said. "I was dead."
"Did you see bright lights?" I asked.
"I saw bright lights, blue skies and hear hymns."
Was it divine intervention for an athesist? Was there medical negligence as his medical form and his hand bracelet stated he was allergic to augmentin. Yet he was given augmentin prior to surgery? I am glad he is alive. His dog which was diagnosed with paraplegia by Vet 1 was massaged and managed to prevent bed sores survived to 15 years of age. He started to walk "but hopped" after home nursing. Recently he had kidney failure and I had to euthanased him. The client came for a death certificate and I asked him about his health after being "dead" on the operating table. I was most happy he was alive.

Doctors are not Gods. They make mistakes and will continue to make mistakes. Some mistakes cause deaths of patients. It is important to adopt a systematic procedure to check for drug allergies before anaesthesia and surgery and to ensure drug dosage is not above requirements.

1419. Update: Anal wound closed up by Dr Daniel

"The old dog's circum anal wound is very big," my intern Ms Toh said to me. "But I can't illustrate. It is just very big!". Sometimes I try to motivate my intern to be more interested in the various surgical conditions in dogs. After all, she will be studying vet medicine next year and internship gives her real life cases.

"Is it a 12 to 6'oclock tumour around the anus?" I persisted.
"I don't know," she said. From Dr Daniel, it was this massive size. The wound was large as a big piece of the skin with tumours was removed and stools just lodge inside this big wound.

"This wound will never close by granulation because stools keep contaminating it," I said to the owner and to Dr Daniel. "A skin flap has to be made to stitch the anal sphincter to the skin." The owner consented to the surgery and even phoned yesterday to ask whether it was done. "It is being done now," I said. The surgery was done by Dr Daniel. No more defect or gap. Wait and see.   

1418. Large wounds

In some cases, I had to intervene when surgical wounds do not close and the owner will not want to pay for wound stitching..
 
Case 1. The kitten had a big left neck abscess. The pus was cleared and the wound stitched by my associate vet. Yet the stitch broke down. The owner did not want to pay for further stitching. "The wound is 3 cm x 2 cm," I said. "A large wound exposing the neck muscles and the big neck veins. Yellow pus and scratching will persist. Smelly later due to bacteria and hair trapped inside. Very itchy for the kitten.  Stitching must be done." I offered him a below cost rate to get the kitten wound stitched up. The kitten recovered well.

 Case 2. The old cross-bred had a massive circum-anal tumour from 6 to 12 o'clock. My associate vet excised the whole tumour. Now a big hole. The anal skin was gone. The anal opening shrank inwards. So the dog pooped and the stools are entrapped in this hole. What to do?

The owners let the maid look after the dog and did not seek treatment. The lady friends of the owner came to visit the dog. The owner had denque fever and could not turn up.

"It is not as if this dog is cuddly," the lady friend explained why the circum-anal tumour was permitted to grow so big, such that there is a big hole now. "The maid did not inform us." What is the solution? Re-stitching is the answer but there is no skin.