Wednesday, January 25, 2012

842. Chinese New Year 3rd day - follow-up 3 cases

National Library, Jan 25, 2012 7.42 pm
Dr Daniel Sing's first day at work

3 cases, equivalent to senior citizens in age, seen by me yesterday needed dental attention as they strongly objected to my opening their mouths. The Persian cat had saliva stains on the chin and one front paw. The Shih Tzu snapped at me when I tried to open her mouth. She was drooling. The Jack Russell's right facial swelling below the right eye had rounded up after my IV drip and medication including steroids.

That meant sedation as I suspected inflammation of the mouth. You could tell from drooling of saliva that definitely two of them had stomatitis. The third one with a facial swelling leaking plasma blood and pus could be a malar abscess. I asked Dr Daniel Sing to let me know what he thought of the facial swelling - now half a ping-pong ball size encroaching on the lower eyelid. "It could be an abscess or haematoma," he said. "How about a carnaissal tooth abscess or malar abscess?" I asked. It was too large and he did not think so. "Well, the Jack Russell catches centipedes and he could have been stung. But he never had a dental scaling for the past 12 years of his life and that is why I am more inclined to put malar abscess as my first diagnosis."

Case 1.
Jack Russell. Male, 12 years old.

After taking some images at 9.30 am with Intern Mr Lim, the swelling burst like a dam.
"Where is your ACP (acetylpromazine)?" Daniel asked me when I told him to get ready to sedate the JR. "I don't use ACP," I said. "I know ACP is popular with the Australian vets." A new vet must adapt to the work environment. "ACP is commonly used in the Murdoch Univ school and by Australian vets giving IM sedation, but there are better alternatives in real world of private practice," I said. "I give Domitor + Ketamine IV and get a better faster sedation than ACP IM." When I was a vet student in the UK from 1969-1974, ACP was also commonly used by the UK vets. So, it is not as if I don't know what is ACP. So, Daniel got to see how effective D+K was when given IV at 50% of the formula in an old JR.

The abscess had burst and he took a big bag of swabs and looked for the pink chlorhexidine to clean the big wound. "Where's the kidney dish?" he asked.

As that is what the Murdoch Univ lecturers must have taught him and all the new graduates. I did not comment as Daniel would learn the ropes.

For me, a large amount of clean water in a 20-ml syringe would flush away the debri and take 1 minute and worked effectively. Singapore's tap water can be drunk and it is therefore clean.

But Murdoch Univ professors cannot teach this simple method. No need for bags of swab. This was a dirty abscessed wound full of bacteria yesterday. My antibiotic Baytril via IV drip had killed them all.

Spending effective but short time is important. Being productive and that is what many younger vets can't understand. When a procedure can be done in 10 mintues, they take 30 minutes. For example, in this JR, a new vet would swab and swab away the discharge. Swab again. Apply the pink chlorhex from the bottle. Put the discharge in the kidney dish. This is what I would imagine them to be taught how to do.

There are other cases to do and if the vet takes 30 minutes hour to just clean the abscess, that time is gone. I put the bag of swab away from the operating table onto a side table as I knew it would be wet. Daniel wanted it on the operating table which was already wet with the JR being washed. Later I asked Min why the whole packet was wet. He said, "The water from the operating table."

I showed how Domitor + Ketamine at 50% of my calculated dose was used effectively and not to waste time. Isoflurane gas mask and intubation.

What was the cause of this abscess? Centipede sting? There was some pus when it burst. I checked whether the 4th maxillary premolar on the right upper jaw was rotten. This would be the main cause of infection to the cheek bones below the right eye. "The PM4 is strong," Min said to me. So, Daniel was correct. This was not a malar abscess since PM4 is usually implicated. I said to Min, "I will check the two molars behind the PM4." He had never seen molars causing malar abscess. So he was doubtful. Yet, the two molars were loose and rotten. They would be the cause of the infection to the cheek bones and below the eye, over time.

He was wobbly after abscess cleaning and cutting off the dead skin and cells, dental scaling and work. The whole process took one hour. The JR looked lethargic. I gave Antisedan 0.2ml IM. Within 10 minutes, he was alert. That was good. Now, what to do with such a big hole in his cheek? More than a 50-cent coin or 8 cm x 8 cm (see image).I propose stitching up 5 days later. The owner wanted to bring him home. So, it will be against medical advice (AMA) but what the owner wants, the vet has to do and record AMA. At home, the wound may become dirtied and flies may lay eggs. But in a room and a big cage, and proper nursing, this can be good for the dog too. Then 5 days later, come back for review and stitching as I doubt that such a large wound can heal well. There are many nerves in the cheek area and it would be very painful to have a big exposed cheek area. Blood tests were done but still the economics would be important.

Case 2.
Persian cat. Emaciated. 12 years old. Tongue and gum ulcers. 3 rotten teeth extracted. No blood tests were granted. See images.

Case 3.
Shih Tzu, Female, Not spayed. 13 years old. The whole mouth, gums and inner cheeks are ulcerated. Very bad. Emaciation and anaemia. I don't know whether she would survive the domitor + ketamine IV. I gave an Antisedan 0.2 ml to wake her up. This dog is so pale but blood tests were not granted by the owner.

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