Sunday Feb 5, 2012
Bright sunshine. Dr Daniel Sing started his first Sunday of working life after graduation. As a mentor of my associate vets, I was present in this case as in other cases of associate vets. Trust and audit are my management style to ensure a high standard of veterinary care at Toa Payoh Vets and that is why I do intrude into the consultation of my associate vets now and then and review their case sheets. There is no short cuts to be successful in work and life. "Associate vets in Toa Payoh Vets must adopt a consistency in the treatment of similar processes and system to ensure good clinical outcomes," I said to Dr Daniel Sing and Dr Vanessa Lin.
Without a system or standard operating procedure, each vet does his own treatment and may miss out on certain steps. For example, in urolithiasis, a failure to send urine for analysis or stone for analysis unless the client objects to this steps due to economic reasons. So, this is why I am around in some consultations of associate vets.
On this fine Sunday, Dr Daniel had a rabbit which had tearing eyes. A large bald area below the weepy eye. He touched the lower part of this hairless area. I did so too. The rabbit reacted by moving away its face. Abscess or tooth pain?
I got a fluorescein strip from the box and Dr Daniel stained the cornea. Show, not tell is the best in veterinary practice. The rabbit had an eye corneal ulcer as evident by the green 11 o'clock to 2 o'clock stain. So there is an ulcer? What next? New vets tend to relate a list of differential diagnosis to the client, as this is what the vet professors teach them.
5008 - 5009. Corneal ulceration in a rabbit. What is the cure? This is more important than why? The primary cause was two ingrowing cheek teeth on the right side. Isoflurane anaesthesia was necessary to open the mouth as the rabbit was very nervous when the vet tried to open its mouth.
To me, this is OK but some clients just have little time and just want to know what's wrong and the solution. Since this rabbit had an "on-off" eye tearing in the past few weeks and felt pain at the lower maxillary cheek area, Dr Daniel diagnosed teeth problem.
I advised warding the rabbit for one or two days. On the next day, to get the rabbit anaesthesized to check the mouth.
Monday, Jan 6, 2012
Dr Daniel used isoflurane gas mask to anaesthesize the rabbit. Min helped. I was around to pull out the tongue. Inside the left cheek, food and two long curved teeth of around 1.5 cm long were stuck and causing pain. Dr Daniel used the forceps to pull out the two teeth and two broken fragments. I took some images. I quickly irrigate below the 3rd eyelid with 5 ml of clean water as Dr Daniel everted the 3rd eyelid, just in case debris had gone inside it.
The rabbit should feel better now. Will observe on Tuesday and update. Rabbit should be able to go home. "This rabbit eats only pellets", said the gentleman owner. "No hay." He had gone home to bring the rabbit pellets.
Show not tell is the best advice for a vet in private practice. In this case, it was not possible to show the anaesthesia but there were two bone fragments and images to show the owner to give him evidence of what happened and what was done to ensure a good clinical outcome. I don't expect any tearing. On the surface, this appears to be a case of eye corneal injury as there is green fluorescein staining. Veterinary medicine can be challenging. Rabbits can't talk and owners can't tell what's wrong. Therefore, it is up to the vet to palpate (pain in the teeth area) thoroughly and in this case, the primary diagnosis would be ingrowing cheek teeth causing facial pain and irritation and eye rubbing to relieve the pain. A hypothesis. If the rabbit has recovered within 2 weeks, then my hypothesis is correct.
No need to spend money X-raying as visual inspection under anaesthesia using gas mask and isoflurane and oxygen is the method of choice and cheaper. "SC anaesthetic drug injection can be used but not necessary as the gas method is safer and the rabbit wakes up fast," I said.
The cause of tearing of the eye would be due to the rabbit rubbing its facial area to relieve tooth pain of the right teeth cutting into its right cheek, not corneal injury. "This rabbit has to be separated from the other rabbit for some time," I advised the owner. "This is to prevent the other rabbit from grooming or licking its eye." The owner said: "It is difficult to do so." Well, vets should advise but it is up to the owner to accept it.
Updates and more images at: