Sunday, April 10, 2011

396. Sunday Apr 10, 2011 - Interesting cases

396. Sunday Apr 10, 2011 - Interesting cases
April 10, 2011. Sunny in the morning. Downpour in the afternoon. Steady stream of clients from 9.30 am to 6.30pm. I did not break for lunch. However, I insisted that my new assistant, Mr Min who replaced Mr Saw recently, to go out for lunch at 3 pm. It is best to pack a lunch box on weekends as it may be too disruptive to close for lunch as cases don't complete on schedule.

CASE 1. Cat Neuter
For example, a mother and her adult son wanted me to neuter the cat. I could not do it till 4 pm when they came for the cat. The cat was said to be fierce and so he was injected IM inside the carrying trolley cage. I tilted the cage downwards waved a piece of paper in front of him while Dr Vanessa injected him IM back muscles.

"He looks OK," Dr Vanessa said to me. The cat certainly did not show claws or aggressive behaviour. He just sat still and looked serene. "Well, the owner had already forewarned me about his aggression when handled. Looks can be deceiving. I had a cat who was taken out of the cage to be injected on the table. Before I could complete the injection, it sprung up, climbed up the vertical pipe and into a gap in the false ceiling. Fortunately, it was half sedated and I could get it down from high up in the false ceiling. You don't want to suffer this type of experience! It will even be worse if that cat had not got the tranquiliser IM and hides up the false ceiling forever." Dr Vanessa looked at the false ceiling I had pointed. "The false ceiling gap in which the vertical pipe from the 2nd floor passed down to my unit had been covered up." Wisdom can only be learnt from experience and I was not taking any chances. "Once the cat is angry and frightened, it is extremely hard to catch it."

Cat, Male, 4.9 kg.
I used xylazine 0.1 ml + zoletil 100 0.1 ml in one syringe IM. The cat looked calmly and was not on the side after 15 minutes. I asked Mr Min to get him out and gave Zoletil 0.05 ml in 0.1 ml saline IV, femoral vein. The cephalic vein just could not be seen due to probably hypotension of the earlier injection. The cat was sufficiently sedated and did not experience any pain in neutering. See guidelines: Injectable anaesthetics in dogs & cats
CASE 2. Cat with urethral obstruction goes home in a cat carrier bag.
A young lady in her 20s came with a small fabric carrier bag. The type used for holding books. She was taking the cat back after 2 days of hospitalisation. Dr Vanessa had successfully cleared his urethral obstruction and flushed out the bright red blood in the bladder 2 days ago. The cat could not urinate for the past 2 weeks. Vet 1 had prescribed antibiotics but the lady said to me: "The cat became worse. He drips urine all over the apartment!"

So, Dr Vanessa had to clear the obstruction once and for all and to ask the young lady to switch to canned food.
Now, she was here to get the cat home. I was helping out as Dr Vanessa was very busy consulting. The lady was to put the cat inside her small bag, walk out to get a taxi to go back to Bishan. The cat resisted being put inside the bag. I could see the problem as the bag was small. The lady insisted she could do it. "The cat has some pain in the penile area now," I said. "He is not fully cured. Go buy a cat carrier bag as once he escapes, he will be lost forever in most cases." However, the young lady did not believe this would happen. I went to the back and found her a carrier bag with a zip and got the cat in backside in. It was more comfortable and most important secure as I zipped 90% of the bag. This cat would not escape.

CASE 3. Tumours in old Dachshunds
An Indonesian family brought 2 Dachshunds and a terrapin for treatment. One of the two old male Dachshund had 3 subcutaneous tumours and 1 small skin tumours. The owner was worried about one SC tumour to the right and below the anal sac as it was around 3 cm x1 cm. "It is possible to operate on a Sunday," I said. "However, it is best not to ask any vet to operate on a Sunday as it is a busy day." The Dachshunds will be operated on Tuesday and will be starved on Monday night after 10 pm. For old dogs, a short anaesthesia of less than 15 minutes will be safer and one Dachshund may need two short anaesthesia rather than be a hero and excise all 4 tumours for expediency. But with a dead dog on the operating table.

CASE 4. Cocker Spaniel with an ear flap tumour
Dr Vanessa had a case of an ear wart of around 1 cm x 0.5 cm on the inside of the ear pinnae. It looked very much like a wart with no stalk and 2 nodules. However the owner did not want laboratory histopathology and had phoned. I told Dr Vanessa her request as it was not possible for Dr Vanessa to answer phone queries during a busy consultation Sunday. It would be best for her to focus and shorten the waiting time to around 15 minutes/normal case, otherwise there will be unhappiness. Case management is important on a Sunday and I had to train Mr Min who is not experienced in small animal practice yet. This was a simple surgical case but I provided some inputs to my surgical approach to this case. There is more than one surgical approach to remove a wart in the medial aspect of the ear flap.

CASE 5. Lymphoma with blood clotted inside the eye in a Jack Russell.
The mother wanted the blood clots inside the eye to be removed. 14 days ago, she came with her daughter and son-in-law to consult me because the Jack Russell suddenly could not see and bumped into furniture. He had swirling blood inside both eyes as bleeding had just started. So I sedated him and the next day, he was able to see. I advised chemotherapy but the mother was against it as she knew the bad side effects in other people undergoing chemotherapy. "Ok, I respect the mother's wishes," I said to the daughter. "Eye bleeding will return again and again till the dog becomes blind as this occurs in around 25% of canine lymphoma cases. The cause is internal bleeding due to lowered platelet count." The dog's eye whites or scleras were very red and inside both eyes, I showed that the lower 20% of the eye had a red crescent of clotted blood. "This is hyphaema," I said but I doubted the owners understood. What to do now? An ultrasound had been done by the owner to find out if the tumour had spread. "The dog is in Stage 5a which means the dog's condition had spread to other systems and is still eating," I had told the daughter before. "Chemotherapy is not a guarantee of complete cure but would buy time. In some cases, the tumours become smaller."

The tumours esp. the prescapular lymph nodes had shrunk a bit and was not so hard due to my initial treatment with dexamethasone and NSAID but it was not a cure. "The dog eats a lot and is very active," the mother had said. This is "a false dawn". It was the eye bleeding and intense eye pain that would cause the problem as well. "The dog never rubbed his eyes," the daughter said. I don't want to argue further as the dog would seldom rub his eyes in front of the owners and in any case, no owner can monitor the dog 24 hours a day. If only the dog could talk.

Now, the mother decided to have chemotherapy. Dr Vanessa and I worked together on this case. "According to some reports, chemotherapy can be effective even at late stages unlike other cancer cases," I said. "Lymphoma does not mean cancer." The laboratory report from a biopsy by Vet 1 some 3 weeks ago was inconclusive and the owner had not wanted a piece of tumour to be excised for histopathology as advised by me. Get a piece of the lymph node for histopathology instead of syringing for the cells for the lab to check, as done earlier by Vet 1.

It required anaesthesia and was too risky in case the dog dies. So, the owner had an ultrasound which indicated that the tumours had spread internally but there was no veterinary report from another vet who did the ultrasound. This is a highly emotional case to be handled with care and requires follow up. The dog had this eye bleeding for the past 7 days before the mother decided that the sedative and other injections which I did 2 weeks ago would do the trick. I told them it would not work now as the blood had clotted.

But I sedated the hyperactive dog with domitor 0.1 ml IM and after 15 minutes diazepam 0.6 ml IM to let the dog have a long rest. It was hope against hope that the clots would be removed by the body when the dog is sedated and the owners had been told of the prognosis. I will have to wait and see if the clot goes off with some sedation medication and chemotherapy. There is a need to follow up weekly but it is difficult to get the owners to comply.

CASE 6. Duty of Care.
"Dr Teo gave the cat an enema," the man in his 30s said to me at the counter. "I wish to have one as the cat can't poop." I took out his case record. There was no mention of treatment by Dr Teo who could not be contacted by phone. "Well, he referred the cat to the hospital. The cat is better but my other two cats cannot poop. Is it due to sympathy with the sick cat?" I said: "It is hard to tell. It could be the litter box and its contents or change of brand." The owner said: "I have placed more litter boxes but the contents and food remain the same." I said: "I can't really say. Try the hair ball paste commonly available in the pet shop. In any case, I can't prescribe as I have not seen the cat. Should it die due to my prescription without a proper examination, I could be subject to legal action." He understood and left amicably.

These are some cases and situations I encountered at the receptionist table. I took phone calls and appointments on this Sunday. It gave me a pulse on the standard of care provided by Toa Payoh Vets. There is no other way as in the past years, I was always inside the consultation room. Being a licensee of Toa Payoh Vets, I have to be very careful that the standard of care is up to what a "reasonable man" expects. A practice can wither away instead of flourishing if the management is very poor. It does not mean that the vet opens a clinic and people will come to make the business sustainable over the years.

CASE 7. Leaking eye plugged 14 days later. The young couple came for the stitch removal and was asking me about a red spot by phone earlier. It is hard to know what the wife was talking about. After the stitches are removed, I could show her the plugged perforated corneal spot which she referred to as a red spot. This case is recorded separately.

PERFORMANCE COUNTS IN THE FINAL ANALYSIS
An older couple came with a 13-year old Silkie that could not recognise her yesterday but could do so today. She asked whether it was a CCD as she had read somewhere in the internet. A canine cognitive disorder? In other words, an old dog's brain malfunction.

She said to me: "My friend refers you to me. Her cat could not eat despite treatment from a vet. You said it was tooth decay. After your removal of the tooth, the cat ate." I said: "It must be 10 years ago. Is the cat still alive?" She said: "The cat is much alive and well. It was around 3 years ago." Veterinary medicine and surgery is a diverse complex subject as vets are expected to know from head to toe. It is a mission impossible and needs many years to encounter the various cases. A systematic approach to medicine and surgery will help but in the end, performance counts as you can see in this case. As this owner knew Dr Vanessa from some common friends, I did not participate in this case.

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