Sunday, November 27, 2011

Sunday's interesting cases - Nov 27, 2011

1. Septicaemia from gangrenous vaginal hyperplasia and prolapse
The Chihuahua passed away after heavy panting. I had a complete blood test done 2 days ago and had informed the owners that the dog had toxic blood. The total white cell count was twice as high as the higher range, the red cells were twice as low as the lower range and the platelet count was very low at 14. Urine analysis showed bacteria and blood (estrus). I noted that her tongue was purplish and that was not a good sign as it indicated some abnormality of health. The blood test was indicative of a septicaemia.

"After two days, the tip of the vagina prolapse became black," the caregiver mum told me over the phone. That was when she consulted Vet 1. The dog stopped eating and was treated but the blackness at the tip spread more. If this was a gangrenous tail tip, it could be amputated. But this was part of the vaginal mucosa. In any case, anaesthesia and surgery of a dog that is not eating and has a lower than normal rectal temperature (37.6 in the first 2 days) was highly risky. The dog was spayed and survived the operation for 4 days. The Chihuahua was 10 years old and was in good bodily condition.

It is important that a blood test is taken when necessary two days after the surgery as septicaemia is an on-going process. The earlier blood test did not show serious changes. In the event of a bad outcome, the owner and all family members will like answers as to the cause of death. Evidence-based medicine using blood test provided the answer.

2. The dog with a gangrenous tail. "It is important that the owners, you and I meet together in the consultation room to discuss about her case," I said to Dr Vanessa who had stitched up a serious profuse bleeding tail wound and had sent the dog home with an e-collar and medication 3 days after surgery. "I had spoken to the owner," Dr Vanessa said. However, I had promised the owner to have a joint meeting as it is hard for me to listen to one side of the story - her side and Dr Vanessa's side and advise. "This joint meeting in my presence is important to clear any misunderstanding," I said to Dr Vanessa. "The owners have not been happy with the dog developing a tail gangrene after surgery. This meeting is not to find blame on the vet. Such misunderstandings from the owners do happen to all vets after surgery, including myself. It is best to meet jointly and clear up all emotional unhappiness."

"I don't blame Dr Vanessa," the owner said first.

"From my experience with tail wound cases, it is usually the dog that traumatises the wound, causing it to become infected and gangrenous. That is why I normally advise tail amputation in serious wound cases as the owner does not know how to take care of it after surgery. However, some owners don't like this idea and want the tail to be saved. In your dog, the tail would be hammered by the end of the e-collar to relieve its pain and itchiness."

"The dog bites me when I try to clean the tail," the lady owner said. "Yet at Toa Payoh Vets, the dog lets the vet change bandage without biting! He uses the e-collar to scratch the tail. The wound opens up. Yellow pus is seen. I phoned Dr Vanessa but she did not answer the call. That is why I phoned you."

"I got a phone call after midnight," Dr Vanessa said.
"Was the tail gangrenous when the dog went home 3 days after surgery?" I asked.
"No," the owner said.

"Many times, the unhappiness is due to financial reasons," I shared my experiences with Dr Vanessa. "You attempted to save the severely lacerated tail by stitching and controlling the bleeding. You sent the dog home 3 days after surgery but the dog can't stand the pain and itch despite your NSAID medication. So, he bites the owner trying to change the bandage. The tail gets infected and gangrenous. Now the owner has to spend more money to get the tail amputated.

"That is why I always advise tail amputation of a seriously wounded tail as the first choice. If the owner declined and the tail becomes gangrenous, there is no unhappiness. You had done on in a cat some time ago when the owner accepted my advice. Have you seen any return of the owner?"

"No," Dr Vanessa said.
"As a vet, we try to salvage the tail. As the vast majority of owners cannot do post-op nursing, the tail becomes gangrenous and this is stressful and expensive for the owner.

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