Monday, November 15, 2010

244. At death's door - 3 cases

1. Case 1. The aggressive self-diagnosing breeder. I had stopped providing vet services to all dog breeders for the past 2 years. What most of them want was usually very cheap services.

This particular breeder brought in a Shih Tzu on Sunday at 5 pm. His vet was not available. He said he had X-rayed the dam at another practice but the X-ray showed 4 pups. He did not bring the X-ray saying he was busy. He suspected there was a 5th pup and could feel it. 4 pups were born naturally on Saturday and were OK. That was 24 hours ago.

I palpated a bony mass. "The pup is dead," I advised as it was past 24 hours from the last pup and the foetal lump felt 'bony' and that meant the water bag had broken.

"There is no point in giving oxytocin injection. Your dam needs a Caesarean section." This breeder was insistent in having an oxytocin injection. I did not throw him out as he did not accept my advice. I gave the injection. After one hour, the dog did not produce any pup. My first assistant advised a Caesarean and he accepted the need for one since no pups were produced.

The pup was smeared with dark greenish glue from the melted placenta. It had no amniotic sac and was stiff as in rigor mortis. This breeder wanted no more veterinary treatment like IV drip and antibiotics IV. He wanted to bring back the dam and wanted to pay only $250. "The new vets are charging less," he said. He became aggressive as his demands were not agreed upon. It was unpleasant. This is the reason I have had stopped dealing with dog breeders.

The next morning, the dog died. The owners were very unhappy. A dog's death is an extemely emotional experience for the owners and for the vet. This was a case where the owner entrusted this breeder to handle their dog's accidental pregnancy. He said he had X-rayed but would not produce the X-ray.

I have barred this breeder from coming to Toa Payoh Vets and told my associate vets that it would be best not to accept breeders at all. It was just not a sustainable practice to offer $250 Caesarean sections and lose money and respect from breeders who want to cut corners.


Case 2. The cat with nasal cancer. The cat went home the next day after surgery to excise most of the tumours. The owner phoned me today and said that the cat was eating. The nose bleeding on Sunday morning after I had pulled out the swab which stopped inside the nose bleeding was no more. The family had decided on no chemotherapy. "Can you do surgery when the cancer returns?" the father asked. "No," I said. "There is a big hole on the top of the nose, now covered by the skin. This malignant tumour doubles in size every 7 days and I expect that the cat will not live long." Chemotherapy is not guaranteed and may cause the cat to lose appetite. So, what's the advice?
"Try chemotherapy in low dosage first," I advised. There was nothing to lose as the wife was quite close to this cat. Chemotherapy does not cost thousands of dollars unlike the case in human cancer treatment. "Euthanasia will be the only option when the cancer recurs and bacterial infections of the right nostril causes pain and suffering," I said. This cat had no infection from this surgery because she had been on antibiotics 6 days before surgery and after surgery. So she responded well and could eat and drink normally at home post-operation, much to the happiness of the wife. But death is really at the door. If chemotherapy helps, it will be a happy ending.

FOR MY RECORD
Weight: 3.5 kg. Cat.

Anaesthesia. Domitor 0.1 ml IV. Zoletil 100 0.1 ml IV. Atropine 0.5ml SC. Intubate. Gave oxygen. Duration of anaesthesia was nearly one hour. A few seconds of isoflurane gas was given towards the end of surgery. It was taking one hour to do it. IV saline and baytril drip given 24 hours.

Post-operation.
No Antisedan antidote was given so that the cat could be sedated and wake up with less pain. The cat was observed breathing normally through its left nostril (forceps into nostril confirming no cancer cells from right nostril). He slept for many hours and was fresh as a daisy on the next morning after surgery.

Surgery on Friday at 4 pm. Incise with scalpel. Undermine skin. Nasal tumour grows from inside the nose, break through nasal bone is 2.5 cm x 1 cm long and much deeper inside the nose.

Electro-surgery separates tumour as much as possible from nasal bone. Excised. Large hole in nasal bone eaten by the tumour seen. Around 1 cm x 0.5 cm. Round fatty tumour cells seen from inside the nose and excised.

I put a gauze swab into the nasal hole and pull it out from the nostril using forceps (see picture at www.toapayohvets.com). This stops bleeding. Electro-coagulation of the tissues inside the nose helps but does not stop the bleeding.

Goes home on Sunday at 10 am after I pull out the gauze swab. I smelled the gauze swab. Not smelly and this is a good sign that there is no bacterial infection. Red blood oozed out of the nostril. Owner asked to wipe the blood off regularly. (The bleeding stopped on Monday).




Case 3. The dog with white gums
The thin, hunch-backed 10-year-old Miniature Schnauzer with white gums would not eat. She had been treated 4 times by Vet 1. ACTH tests were normal. Ultrasound indicated possible tumours of the liver, pancreas and spleen. So, the owner was very worried and wanted surgery.

"The dog is not fit for surgery," I advised. "She will just die on the operating table. Look at the white gums. She has severe anameia. I will do a blood test."

The anaemia was due to low red cell count, low haemoglobin and very low platelet count. She was attended to by Vet 1 from August to November for 4 times and was not eating when the owner consulted me, being referred to by one of my clients.

Incredibly, after an intensive IV drip of saline, glucose, protein, Vit K1, antibiotics including baytril and metronidazole, B complex and iron injections s/c, the dog that lost 1 kg (25% of her weight in the last 4 weeks) was thriving. "She ate a lot and pooped a lot for the last 2 days," the young lady said. "Today, she is not eating. Shall I give her the Re... from Vet 1? It is said to improve her appetite."

What was the cause of this severe anaemia and the low platelet count? I suspect it was either some drugs or septic infection (from virus or bacteria) when the dog was brought downstairs in recent weeks.

During the first consultation with me, the dog screamed when I pressed the very painful disc pain at T/L area and bit me when I palpated the moderately enlarged left submandibular and popliteal lymph node. Her bladder was painful on palpation. Her left kidney was slightly painful. Her left tongue had some ulcers at the back and I took digital pictures to show the owner.

So what was happening to this dog? The lady had only one wish - that this dog would not die on her as she had a recent family bereavement. Yet, the dog's gums were as white as snow when I saw her at first. I did not take a picture then but her gums became a bit pinker 24 hours after the intensive care and injections. So, this dog had come back from death's door. But she is not out of the woods yet. Only time will tell.

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