Wednesday, September 14, 2011

612. What is the cause of the 3rd fit?

SUNDAY'S INTERESTING CASE
Sep 11, 2011

When the urine is collected directly from a dog peeing outdoors, there is the possibility of bacterial contamination. In this case of one dog who had fits for the 3rd time 2 days ago, I reviewed the record of one urine sample collected and tested showing bacteria +++. However, no antibiotics was prescribed by Vet 1. Vet 1 received the urine sample and handled the case accordingly. I was not present when the owner came.

I know that the owner works in a human medical polyclinic and knows what to do when it comes to urine collection.

She collected the urine "mid-stream", that is, let the dog pass some urine first and then collect directly the next flow. The urine was collected in a container provided by the Lab. She sent the urine in to Toa Payoh Vets for analysis. As I was not around, Vet 1 took the responsibility of handling this urine sample.

The urine showed 3+.

Now, in veterinary medicine, each vet has his or her own interpretation of the laboratory results and come to a decision on the spot.

Vet 1 judged that the bacteria was not from the urine. Therefore no antibiotics were prescribed.

In my opinion, I would have prescribed antibiotics for a suspected urinary tract infection. A bacterial culture would have been advised too but due to financial considerations for the owners, I have not asked the owner.

I asked Vet 1 who stated that the owner did not wish to have antibiotics.
The owner came today (Sunday) to visit her dog that I had boarded for observation. He had fits 2 days ago and instead of a house-call as requested by the owner, I advised bringing the dog down. Nothing can be done during a house-call and it costs the owner money .

On this fine Sunday morning, I asked why she did not want antibiotics when her earlier urine test showed a bacteria presence of 3+. She said: "Vet 1 said that no antibiotics were necessary as the urine was contaminated."

Now there was a difference of reply from both parties. I needed to investigate what happened, being the licensee and shouldering the responsibilities of setting a good standard of care.

So, I called a meeting with Vet 1, the owner and myself present inside the consultation room to clarify the matter immediately, as to why the owner did not want antibiotics. There are some Singapore owners who don't want antibiotics nowadays and so Vet 1's explanation would be logical had I not asked the owner's side of the story. The vet on the spot has to judge. And be responsible for the judgment.

At the meeting on this busy Sunday morning, the owner denied having said she did not want antibiotics. "Why would I reject antibiotics when my dog's urine has bacteria 3+?" she protested.

Vet 1 said: "It is a mis-communication." It was an emotional meeting to clear the air as the owner was very upset over this matter. A dog with three fits is a very stressful to any owner. This dog had a sudden attack, ran to her father screaming. Foam spilled out of the dog's mouth. When the dog was calmed down, the dog started pooping and peeing all over the apartment. She phoned me for a house-call but I told her it would be better to send the dog down for my examination. She had not told me of the 2nd fit episode.

I had a blood test, urine test, X-ray of the chest and abdomen done with permission from the owner. I reviewed the urine test result done some 3 weeks ago and noted that Vet 1 had not prescribed any antibiotics. Hence, the situation arose when I found this out.

A vet has to be responsible for his judgment but sometimes it is a matter of mis-communication on the spot. The solution is simple for the vet when the owner is against medical advice. Record this advice down in the case sheet clearly and if possible, get the owner to sign: "THE OWNER HAS BEEN ADVISED BUT REFUSED ANTIBIOTICS."

Sometimes, I do not prescribe antibiotics if I deem it unnecessary. In one case, I spayed a female dog and had given an antibiotic and pain-killer injection. As the spay was a smooth short surgery, I did not deem it necessary to give antibiotics and pain-killers at home. However, the owner's wife wanted the medication. The harassed husband came for them. I prescribed the antibiotics and pain-killers for the next 4 days.

The husband came for the medication. He gave me a feedback, saying he wanted to bash Vet 2 up. "Why?" I asked. He said: "Vet 2 shouted at me from inside the consultation room when I asked a question how long the pain-killer injection lasted. Sitting on his chair and shouting from inside the room. So rude!"

I said: "From my knowledge of Vet 2 over the years, he has a gentle personality."

Later, I asked Vet 2 what had happened. Vet 2 said that he was busy consulting and therefore shouted out the reply.

Much could have been avoided had I prescribed antibiotics and pain-killers for 4 days after the operation as I usually do. You can say it was a lapse of judgment, but I find that dogs and cats who had one post-op injection of antibiotics and pain-killers do well.

Sometimes, it is best to prescribe antibiotics as it is hard to tell whether the infection will set in. In any case, a dog urine with bacteria +++ definitely requires antibiotics and failure to give them may constitute an act of negligence in a court of law if a "reasonable man" (i.e. a vet) will prescribe antibiotics in such a situation. Singapore owners are much more sophisticated. They will check the internet first to do research before consulting the vet.

In this case of the dog with the 2nd fit, the owner did not inform me about the incident till Sunday. As to the cause of the fit, most of the causes are idiopathic, i.e.. unknown.

However, based on the fact that the dog had urinary bladder stones removed and had fits just after the surgery (first episode seen at Toa Payoh Vets and the owner was informed) a few months ago, there could be a relationship to urinary stone formation. In the 3rd episode, the dog had passed blood, blood was 4+, White cells very high, the pH was 8.0 (alkaline) and struvite crystals (2+) was detected in the urine.

The owner had fed rawhide as she felt that the dog's quality of life must be poor, eating SD diet every day. She had told me that whenever she changed to other diet, the dog's urine would be cloudy. So she switched back to S/D and the urine would be clear.

Since she had deviated from the S/D diet and tried other food, would this be the cause of recurrence of urinary bladder crystals and high pH? It is hard to say. X-ray did not show any radio-opaque struvite stones.

More urine and other test need to be done monthly or 3-monthly. But few owners do bother. Till another episode of fits. In conclusion, it is best (for the owner's peace of mind) to prescribe antibiotics post-surgery or when urine samples show high bacterial count. Owners have to do their part in the management of fits in dogs. Many causes of fits are unknown.

In this case, my hypothesis was some imbalance in the urinary system and infection of the urinary tract possibly from the raw hide to the blood stream and then the urinary tract system.

"Has the dog been humping pillows?" I asked when I retracted the prepuce during my examination together with Vet 1. On the left and right lateral sides of a normal penile shaft, two bright red bleeding spots appeared like "red eyes" of a snake, if you can visualise. It was a most unusual sight as I had never seen such an appearance. If one is superstitious, one would say this was supernatural. A tall tale. Incredible. Not possible. Gone whacky. But this was a true observation.

The owner said: "His penis was hanging out yesterday." I advised neutering to stop the hypersexuality behaviour. The lady said: "Wait and see."

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