Friday, March 23, 2012

920. Pyometra in a one-year-old cat

Yesterday I was at Toa Payoh Vets in the evening. Usually I am not present as Dr Vanessa is the vet on duty. Interns Jed and Mr Lim and my assistant Min were working hard helping Dr Vanessa. Jed was bathing the Golden Retriever with the right knee tumour wound. Mr Lim was changing to a new e-collar for him before the dog goes home. This dog had a big wound defect after excision of the large knee tumour. The high-tension area of the knee area led to stitch breakdown. The wife wanted the dog back after surgery and had slapped purple solution onto the wound which had started to break down 3 days after surgery. I asked her to bring the dog back and saw that the stitches were not holding.

When I informed the husband, he threatened to report me to CASE (consumer body) and then legal action. "If you can't do the surgery, you should not have accepted the surgery."

His opinion was that there should be no wound breakdown and if there was, I should rectify and ensure that the wound healed without charging him any money for further surgery.

"I am suing one vet as my dog had died under his treatment. My dog better not die in your Surgery." The dog was hospitalised for over 20 days to get the wound dressed daily. Stitching was not possible in this high-tension area. The dog tended to lick the wound if the e-collar was not worn. The wound had closed 20% but would need another month to granulate. It was time for the dog to go home with medication and I phoned the husband who said he would come.

CASE 1. Big tumour behind neck

Suddenly at around 6.30 pm, three young ladies came with a growling Miniature Schnauzer and I was at the reception doing some administration work and answering the phone calls while the others were doing kennel work. Dr Vanessa was consulting with another owner.

"What's happened to your dog?" I asked one lady. This was a 7-year-old male Schnauzer who warned vets off. "Are you waiting to consult Dr Vanessa?"

"I want to consult you," the lady pointed to a hard lump of 3 cm x 3 cm in the neck skin, midline, between and slightly behind the ears. "It could be a microchip inflamed lump," I said. "When did you microchip the dog?"

"He was microchipped when young."
"Did any vet inject him in this shoulder area?"
"No," she said.
I pointed the microchip scanner at this lump and it beeped showing the microchip number.

"It could also be a fast growing tumour," I said since the young lady mentioned that she only discovered the lump recently. She held the dog firmly while I examined the hard lump again.

"Tumours are what I am worried about," she said. Nowadays, many young ones read about their dog healthcare in the internet unlike the old days when many were quite ignorant.

"If it is a tumour, I would need to make a big cut to take out as much of the mass as possible and send the tumour to the laboratory for histopathology to check whether it is cancerous."
She made an appointment for this Sunday morning operation. Not all lumps are due to microchip or injections and if the vet thinks only these two possibilities, he might be in for a rude shock if the lump was cancerous.

So, it was best to excise it as early as possible and certify that the microchip had been excised, so that the owner had proof in case the regulatory AVA made a surprise check for microchip.


CASE 2. The one-year-old female cat passes pus copiously.
Another lady phone call was answered by me. "My cat passes white yellow thick discharge from her vagina non-stop. Drip, drip, drip everywhere for one month. At first, it was a little bit. Now, the cat is not eating. When do you close?"

"We close at 8 pm. It is better you get the cat treated early as it is a womb infection. It is called pyometra."

After asking about the cost of surgery, the lady came with the cat.
"Can you feel the swollen uterus?" I asked Dr Vanessa. I could feel a swollen lump like a bladder swelling of a golf-ball size and two long tubes around 1 cm in diameter. No specific hard uterine bodies. Dr Vanessa shook her had. "However, it is pyometra," I said as more yellowish-white vaginal discharge fell in patches on the consultation table.

"Now, what anaesthetic to sedate?" I asked Min. "This cat is not in good health."
"Xylazine and ketamine IM," Min said.
"That is what we usually do. Zoletil is safer."
We rarely use Zoletil on cats and so Min did not mention this.

I weighed the cat. She was 3 kg.
Zoletil 100 = 100 mg/ml. The dosage for IM was 10-15mg/kg and I decided on 12mg/ml.

I asked intern Jed to calculate so as to give him some hands-on experience. His calculator showed 2.7 ml.

"Cannot be so much," I said.
The correct calculation was 0.36 ml of Zoletil 100.
I gave 0.3 ml IM. Then I gave 0.4 ml atropine IM to prevent salivation and head twisting - side effects of Zoletil.

Dr Vanessa operated. Isoflurane at 5% for a short while by mask and then minimal 0.5%. The large womb was taken out. Dr Vanessa decided on using horizontal mattress this time as she was set in her ways, always using simple interrupted. I had advised her to practise on using horizontal mattress which is a stronger suture but she would always do her own thing. Each young vet has his or her own mindset and so I do not bother as long as the stiches heal the wound.

Dr Vanessa believed in subcutaneous sutures despite my advice not to do it as it would irritate the cat or dog during healing. Well, each young vet has his or her own mindset that would take time to change, with adverse side effect experience encountered. All vet professors lecture on the need to close up dead space using subcuticular sutures and all young vets graduate with this concept that they must do it after a simple spay. Till they realise from intense itching in a few cases of wound breakdown and unhappy owners that they need not do it for spays and Caesarean sections. It is hard to change a young vet's mindset since they believe that their professors of surgery had to be a better teacher than an old vet like me.

"For aesthetics, all sutures should be horizontal mattresses", I believed in presenting a neat surgical stitching pattern. Owners do peruse the
wound as the pet is a young family member and some do compare the competence of the vet by comparing his stitching (read one story later).
Dr Vanessa had put in two horizontal mattresses at one cm in length but felt that there was a small gap of 0.5 cm at the end of the skin. She wanted to put in a simple interrupted. "If you have to stitch that area, use a shorter horizontal mattress," I said. In total she had 4 horizontal mattresses done. Actually two would do. But it takes time to change mindsets of young vets as most have a mind of their own as regards suture patterns.

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