Friday, December 31, 2010

284. Dec 31, 2010 cases: rare puppy eyelid growths & Others

Dec 31, 2010. Last day of the year. I was on duty and finished work at 6.40 pm.
Bright sunshine and blue skies while some European and American airports are filled with snow and cold winds.

Traffic Warden. I happened to be in the waiting room and saw a parked golden car with its left side door at the side of the surgery marked: "Chubb and Enforcement". A slim bald man in his late 30s, wearing sunglasses, in white shirt and blue trousers stepped out of the car. I snapped a picture of him. He strode towards my car which was parked beside a fire hydrant as I was to go out soon and it was a shaded lot. I went out of the surgery and apologised to him. I drove my car away and put a parking coupon on my car dashboard. He drove off with his driver. So, it was all clear? Some 15 minutes later, I saw the same car in the same location (round the bend, at the side of the Surgery). The same warden was inside the car and looking at the rearview mirror. I was surprised. It seemed sneaky business. Why not use an unmarked car?

Only yesterday, 2 lady traffic wardens in similar starched white shirt and blue pants but from another private enforcement company (Certos?) were around in the afternoon. I saw them as I was in the waiting room and managed to avoid being booked. They were kind people and forgave me for not displaying a parking coupon. My parking area is one of the last rare lots in Singapore not boxed in by automated barriers and so these private wardens are employed to catch offenders.

Back to some interesting cases

Shih Tzu of 3 months old has 3 eyelid growths in the left eye. Veterinary medicine is full of surprises. I am 60 years old and have seen 30 years of small animal practice. But a puppy with 3 eyelid growths is a rare occurrence. Older dogs do have them but "never" puppies. So, this was a big surprise on the last day of the year.

"I am still searching for a vet," the mother of 4 children said. Her puppy had 3 eyelid growths of around 3 mm x 2 mm. What were they? They exploded during the last 2 weeks. She bought the puppy 4 weeks ago.

"The first vet gave me an eye ointment tube to apply," the young-looking mother in her 40s said. "The growths were still there and I consulted Vet 2. He gave me this Surolan ear drops to apply. Not effective. That is why I am still looking for a vet!"

As the puppy is young and small, weighing around 1.3 kg, the eyelid growths look prominently big. "They look like warts. Give eye drops," my assistant gave his advice to me quietly. "Eye drops will not work," I explained to him. "These are solid growths on the eyelids."

Another merry-go-around with a different brand of eye drops would not do for this first-time puppy owner. "Surgery is needed to excise the 3 growths," I said. "There are no other solutions for this problem."

I knew that the other 2 vets did not want to suggest surgery as a 3-month-old puppy is a very high anaesthetic risk. According to one vet report I read, this is because the liver of the puppy is still immature and unable to clear the anaesthetic drug normally. So, the puppy dies.

You can't excise without anaesthesia as it would be painful and impossible. My assistant produced a anaesthetic consent form as he does for my associate vets. "No need," I usually don't use this form. I usually explain clearly orally the risks involved in any anaesthesia. As the mother was quite stressed out (going to a vet the 3rd time, puppy keeps rubbing the left eye), I did not tell her it would be high risk. If anaesthesia is done carefully, the risk is minimal.

"What anaesthesia will you use?" I asked my assistant (as part of mentoring process). "Diazepam and Ketamine," he said.

"You don't use two sedatives in the puppy," I advised. "One is already risky."
My assistant said: "Domitor?"
"Zoletil will be the best as it is said to be the safest. In the past I use xylazine with no problems."

So, Zoletil 100 at 0.01 ml with saline was injected IV. Isoflurane gas by mask was given at 5% to effect. "Don't wake till the eyelid reflexes are totally absent," I advised. "The puppy may be dead!".

I used electro-surgery to excise the 3 growths. (Pictures taken). Then 5/0 absorbable sutures to close the wound. E-collar and medication. Problem solved. That is what the owner wants. This is what I learn from my 30 years of experience. The same applies to car owners or other services.

INTERESTING OBSERVATION. I noted that the puppy kept pushing its tongue out and licking its nose, as if yawning, during Zoletil and isoflurane anaesthesia. This happened a few times. Could it be the effect of Zoletil? "Shivering" was the complaint of the owner some 1 hour after surgery. She had bought a puppy coat as the whole puppy had been clipped bald (ringworm infection of one toe and right neck). "This shivering is normal after anaesthesia in some puppies," I said as we put the puppy coat on. "It will go away soon.

"I feel lucky today," the lady owner in her early 30s said when I told her that there was a small risk of bleeding in spaying a female dog in the middle of heat. Her male Jack Russell dog was pestering the female poodle and she could not sleep the whole night trying to ensure no mating. "The male dog just persists in smelling her backside," the owner explained. She had many questions to ask, like the owner of the Shih Tzu with the eyelid growths.

"No, the dog will not be pregnant after spaying," I assured her. "But the male dog will persist in wanting to mate with her for the next few days." There was no need to neuter the male dog for the time being as she was so desperate to prevent aother pregnancy. The puppies had died due to being stuck and delays in seeking a vet. They were born in Sep 2010. Now, the female had an extremely swollen vulva but no bleeding. "So was she in heat?" the lady asked. "Well, she would be in heat in July 2010. Pregnancy in September would be correct as that would be 2 months. From July, 6 months of interval between heat. Now it is nearly Jan 2011. So that is 6 months and she is definitely on heat."

The female was spayed. Domitor and isoflurane gas. I incised at MG 4 and MG 5 which was too low. I hooked up the two uterine bodies and horn from the 1-cm incision. The whole space was crowded and I had no space to pull out the ovary (which was large at 8 mm long when I saw it later). What to do?

The normal procedure is to extend the incision cranially by another 5 mm. Or I could push back the uterine bodies and hook again. Another solution was to ligate the uterine body first. The uterine blood vessels were 3 mm thick and the dog would bleed to death if they were not properly ligated. So, clamp, transfix ligature below the clamp. Unclamp and ligate again. Then excise uterine stump. Now there was space to pull out the ovaries and ligate once the cranial end by pulling the ovary out more. Check PROPERLY that the ligature was tight before putting the ovary inside the abdomen.

The dog was OK and the owner came later in the evening wanting to bring the dog home. She had no crate and reluctantly accepted my advice to hospitalise the dog for one night as the male dog would be frenzied in looking for the female. She would also have sufficient rest. All should be well by the next day.

Case 3. A cat with a badly infected left eyeball was operated. The eyeball had to be taken out.

Case 4. A woman who wore head scarf and her young adult daughter (studying political science) brought in a fat cat for spaying. She had booked an appointment for the spay at Vet 1 (who had rejected the Golden Retriever neuter case). So, she came to me. She had several stray cats neutered and ear clipped at her own expense.

"Are you sure you spayed her?" she asked me when she saw that the wound was around 8 mm in length. "One vet cut 3 cm long," she extended her thumb and forefinger. "Another did longer than yours."

I assured her that the cat was properly spayed. Each vet has his own method of incision but the owner makes comparisons.

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