Tuesday, December 18, 2012

Building trust - an old poodle snored loudly making mum's sleep impossible.

Dear Gina

Narrate this case study - Building trust and use the video you had done for me so beautifully. Many thanks.  Let Vannessa know and edit this article as I have no time and have to rush to the airport today Dec 24.  Have a good holiday. It is very rare to have two interns who are so diligent and interested in veterinary medicine. Best wishes.

REVIEW -  A loud snoring old poodle affects working mum's sleep. What to do?

The Patient
Male poodle, 14 years old, sneezing, snoring and difficulty in breathing
1. Jul 29, 2012. Toa Payoh Vets, associate vet reported glaucoma and cataract. Right canine tooth root abscess extracted under general anaesthesia.  Most decayed teeth had dropped out. (In Dec 18, 2012, the mum said to me there was a smaller swelling below the left eyelid at this time).

2. Nov 2012. Consulted another vet at another practrice. He accepted medication but not advices on surgery and other tests.

3. Dec 15, 2012. The son consulted me. Blood from nose as he fell yesterday. Sneezing, snoring, breathing difficulty. Heart and lung sounds normal. Surgery advised but worried about risks.

"What are the chances of surviving the anaesthesia?" the young undergraduate was told it was slightly more than 50% after I examined the heart of his mum's very old poodle and found it to be in good state. He said: "50% is not good enough. The poodle could just die on the operating table. Would you say 20%? I have not got the dog operated because the other vet said the same 50% as you. My mum's dog is here today and gone tomorrow if he dies on the operating table! How about some medication?"

"As your dog has normal heart sounds, I assessed his survival as more than 50% but I can't say it is 80% as he is very old. He is blind and has fully developed cataracts in both eyes.

I believe that your dog's snoring is due to an infection of the sinuses near the left eye. Your dog has a large 'eye-bag' below the length of the lower eyelid. It is around 3 cm in lenght. It is most likely an infected tumour. An abscess in this left eye. It spreads the bacteria from there to the sinuses and to the back of the nostrils. The sinuses will be the maxillary sinuses which get infected and blocked as well." I said. "This obstruction and inflammation causes pain and snoring."

"How can that be?" the young man questioned my hypothesis. "The nose is quite far from the left eye!"

"The maxillary sinuses are connected to the nostrils. The inner side of the left eye connects to the nostrils through the lacrimal or tear gland ducts. Any bacteria from the left eye's lower eyelid will spread from there to the tear gland ducts and into the maxillary sinuses and into the back of the nostril. This causes sneezing and painful breathing difficulties."

The young man was not convinced. So I advised a blood test to screen the health of the old dog and if the dog is healthy, the blood test will show it. Then he can decide whether to permit anaesthesia or not.

"The dog did survive one anaethesia in July 2012 to extract the rotten right canine tooth," I said.
"I don't think he will survive another anaesthesia," he said.
"Surgery is the solution. I can give you the medication which would just be a waste of money." A vet can't build trust if he milks the patient just to make his money. But here, the issue is of anaesthetic risk and veterinary competence. Every vet will say this is extremely risky and so most owners will procrastinate till they can't wait any longer.

The blood test showed normal results and the dog was operated on Dec 18, 2012. The dog now objected strongly to direct isoflurane gas by mask before intubation. What to do? I decided on 25% of the dosage for domitor and ketamine IV. The dog needed just less than 5 minutes of isoflurane gas and he was knocked out. Electro-surgery acrosss the lower abscess shot out lots of yellow pus. I used the electrode to cut off as much of the tumour under the skin as possible. The tumour had 4 holes with pus leaking outwards. Pus also leaked out from inside the eye at the medial canthus but this was  going on for some days (the owner wiped it off every day, she told me after my surgery but more pus oozed out again). The old dog did not wake up despite me switching off the isoflurane gas for some 5 minutes as I electro-excised the tumour. A spurting arteriole on the lateral canthus area sprayed me like a machine gun. I used the electrode to coagulate and quickly stitched up the cut with 3/0 absorbable sutures interrupted.

The tip for success in old dog surgery is to operate in as short a time as possible. In this case, the time had stretched to over 15 minutes. If more time is spent, the heart may fail as this is an old dog and other blood vessels may not be as strong as a young dog. Rupture of arteries may happen. The dog may die. So, surgery must be very fast. Bleeding was profuse. There was not much time to be wasted on catching all the bleeders. I closed the wound. As the dog could not get up, I gave 0.1 ml of the Antisedan antidote IM. He got up within 2 minutes with a profusely bleeding eye. I used a bandage to cover the wound. Still the bleeding continued. I used cold compress. However, such bleeding would be controlled by the closure of the wound and so I was not worried. 

Today was a bright sunny morning of Dec 19, 2012. I phoned the mum. She sounded quite happy when I asked about the dog's snoring. "Will you say the snoring is less than 50% as compared to the night before surgery?" I asked. "Yes, yes," she said that the profuse bleeding had stopped, the dog had eaten and thanked me.

In private practice, building trust is important. But good surgical outcome and performance are still very important.

In old dogs, the client considers only one matter. His or her old companion is alive at the end of surgery. No excuses. There was no point doing a perfect surgery removing all bleeders and presenting a dead old dog with no post-op bleeding due to meticulous ligation and coagulation. In this case, the bleeding would stop by pressure control after stitching and it did so by the next morning when I phoned the owner to check on the bleeding status. I told the owner that it was not possible to remove 100% of the tumours and that only 80% of the tumours were electro-excised. As to whether the tumour below the eyelid was malignant or not, I advised sending the tumour to the laboratory as this is part of professionalism. The owner did not want histopathology but she had been informed and that is important for the veterinary surgeon.  

Speed, accuracy and completedness are hall-marks of a good surgeon. In this case, speed is most important.

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