Thursday, September 5, 2013

1118. HOW YOUR OLD DOG CAN LIVE LONGER? Intern uses google docs to write script for closed pyometra + uterine torsion + kidney failure

Toa Payoh Vets WAP

Script for Video on Swelling

[Opening]: Show scenes of crowds.
(N: Most Singaporeans face busy and hectic lives. How then can they look after the health of their pets?)

[1]: Abscesses in Pets
(N: A common ailment in pets is an abscess. Does your pet have visible swelling on its body? Learn how to see if your pet has an abscess!)

[2] What are Abscesses? <2> Flash pics of cats, dogs, terrapins, hamsters, humans respectively
(N: The definition of an Abscess is a localized collection of pus confined within tissues. Abscesses can be present in a wide range of animals: <2> cats, dogs, terrapins, hamsters etc. even human beings!)

[3] Causes of Abscesses? <3> Cue picture of wound oozing pus.
(N: Abscesses may be caused by a: infections or b: foreign objects stuck into our flesh. This leads the immune systems of the animals to try to fight off the infection by inducing inflammation at the infected site. Dead bacteria and white blood cells accumulate within the tissues, forming pus.

[4] Warning—Danger!!! Etc.
(N: If you suspect that your pet has an abscess, seek immediate veterinary attention immediately!

[5] Serious Consequences of Abscesses
(N: This is because abscesses may pose serious health risks for your pets, which includes….

[6] Severe Pain and Discomfort, overlaid pic of dog/cat in pain

[7] Loss of Appetite---Malnutrition and Dehydration
(N: The severe pain faced by your pet due to the abscess may cause it to refuse to eat and drink, causing it to become malnourished and dehydrated.)

[8] Skull and Crossbones
(N: and of course, Death)

[9] How to Diagnose if your Pet has an Abscess
(N: Keep in mind that an abscess is an accumulation of pus underneath the skin. This will cause visible symptoms like hardening, redness, swelling and tenderness at the infected area, fever, chills and lesions. In most cases, if your pet has a visible small swelling and is acting in discomfort, it may have an abscess)

[10] Treatment of Abscesses
(N: We shall use the case study of a terrapin, which suffered from an abscess in its ear canal)

[11] Step 1: Anaesthetization
(N: Firstly, we need to anaesthetize the animal, in this case with isoflurane gas. This is to reduce the animals’ pain and trauma during the surgery, and to make it easier to handle.)

[12] Step 2: Lancing of the Abscess
(N: Secondly, we will need to lance, or pierce the abscess with a scalpel. This will allow the toxic pus to drain out)

[13] Lancing Process: Lanced 5 mm into the abscess, pus and blood came out.
( N: A scalpel was used to pierce 5mm into the abscess. Pus and blood were drained out of the abscess. )

[14] Pic of Syringing of Abscess
(N: Following lancing, water was squirted into the wound to clean it, and to remove as much pus as possible.)

[15] Post-Operation Handling
(N: The terrapin was allowed to rest after surgery. 12 hours after operating, the swelling was reduced by 50%. The terrapin was fine)

[16] Conclusion
(N: As they say, “Early treatment saves Lives”. In the case for abscesses, while they may look small and relatively harmless, they can actually have an adverse impact on your pet’s health and veterinary assistance should be sought immediately.)

Credits etc.

Script for Video on Peppe’s case

Introduction to Pyometra -- The story of Peppe, the little maltese

[Opening]: An unexpected turn of events (street)
(N: In this video, we will explain to you the condition pyometra, bringing you through its definition, diagnosis and treatment. We will focus on the case study of a little maltese named Peppe, who was diagnosed with closed pyometra on 19th August 2013)

[1]: Definition of Pyometra
(N: So what’s the definition of Pyometra? “Pyo-” means “pus” and “-Metra” refers to the uterus---in short, pyometra is an infection of the uterus in female animals and the subsequent accumulation of pus within, causing it to swell.)

---Sub-point: Closed & Open Pyometra
(N: There are two forms of Pyometra. The first form, Open Pyometra, occurs when the cervix is open and the pus is thus able to drip out through the vagina as a smelly discharge. In the rarer second form, Closed Pyometra, the cervix is closed and the pus is thus unable to drip out. This causes more complications as the lack of definite external symptoms make it harder for a clinical diagnosis, and the animal is also sicker as the toxic ous is retained internally.)

[2]: Where? (bullet points)
(N: It is commonly present in dogs, cats and other animals such as hamsters. It is only present in female sexes as only females have uteri, and usually above 6 years of age.

[3]: Signs, the diagnosis
(N: In the case of pyometra, the following signs are usually present. Swollen, large uterus, vaginal discharge, lethargy, refusal to eat, excess urine, vomiting and abdominal swelling)

[4]: Show video of peppe (pause when narration starts, preferably on a frame directly on the face)
(N: This is Peppe, a maltese breed. She was born in the July of 1998, and hence is around 15 years of age and is not sterilized. She previously had 3 false pregnancy cases, in september 2005, August 2008 and the latest in January 2013. On the 19th of August 2013, the lady owner brought her in with a large left abdominal swelling for around 7 days.)

[5]: Signs in Peppe, show picture of swollen abdominis
(N: In the case of Peppe, she had an extremely visible swelling on the left side of her abdominis. X ray of her abdomen also showed significant swelling, with a higher than normal neutrophil percentage present blood from the blood test, signs of an infection.)

[6]: Common misconceptions
(N: Pet owners commonly treat such swelling as pregnancy or simply, weight gain, allowing the condition to exacerbate over time. Therefore, please consult a veterinarian immediately when such swelling is observed!)

[7]: Dialogue
(N: During the first consultation, the lady asked about the chances of survival for the anaesthesia and surgery. “Less than 50%”, Dr Sing replied. “The dog may just die on the operating table. The blood test showed a very low creatinine level which means that the kidneys are not functioning normally, coupled with the fact that the dog is of very old age and as a result, the heart and blood vessels may be weak.” The owner, visibly concerned, asked, “What am I suppose to do then? What is your advice as an experienced veterinarian?” To that, the Dr Sing replied, “Well, in my opinion you should take the risk and operate”

[7]: Treatment - Surgery
(N: For treatment of prometra, the only viable option is surgery.
Warning: The following video you are about to see contains graphic images)
~show video
(N: One uncommon observation was the presence of large amounts of blood due to burst blood vessels.

[8]: Unexpected turn of events. Though Peppe was in the early stages of pyometra, the more pertinent and main issue that was discovered during surgery was torsion of the uterus, or in other words, a twisted uterus.

[9]: Show video of cutting open uterus
(N: This is the uterus removed from Peppe. As you can see, it weighs 672g, around 16% of Peppe’s total weight of 4.35 kg. In the condition of a closed pyometra, white pus should flow out when uterus is sliced open. However, as you can see, the fluid flowing out is mainly red with blood. This is due to the torsion of the uterus bursting the twisted blood vessels.)

[10]: Conclusion
(N: Cases of torsion of the uterus are extremely rare, and this is the first case overseen by Dr Sing in his 40 years of practice. In this surgery we were able to extract 3 crucial factors involved in any surgery, namely, accuracy, speed and fidelity. Any surgeon has to be extremely accurate, and fast, as a matter of seconds could determine life and death. A surgeon has to also adapt accordingly to the immediate situation and practice correctly. )

(This video is based on the re-enactment of a true story)
Scene 1
Consultation room at TPY vets (can show creative things) (Video already obtained)
Owner: I’m very worried for my dog---it seems to have a large swelling on its side. Is it putting on weight or is it something else?
Vet: There may be several causes, but I’ll have to examine and check the dog’s history first. Firstly, is it eating and drinking normally?
Owner:  It’s not eating as much. Er I’m not really sure.

Vet: Are its urine and stools normal? When was its last heat?
Owner: The stool is normal...not really sure when was its last heat though.

Vet: Is there any vomiting? Vaginal discharge?
Owner: There is no vomiting or vaginal discharge. However, the swelling has been there for already 1 week.

Vet: I see. Ok based on your records, She previously had 3 false pregnancy cases, in september 2005, August 2008 and the latest in January 2013. I am suspecting a closed pyometra, but we should take an x-ray and blood test to find out.

Owner: Okay, sure.

Vet: Ok let me first do a physical examination (Flash video of physical examination)

Scene 3
Blood test
Show videos of the blood test

Scene 4
Inside consultation room
Vet: This doesn’t look good. etc.etc.etc. refer to blood test. Looking at the X-ray this furthermore confirms my diagnosis of a case of closed pyometra. The only choice left now is surgery.
Owner: What are the chances of survival for the anaesthesia and surgery?
Vet: Less than 50%, the dog may just die on the operating table. The blood test showed a very low creatinine level which means that the kidneys are not functioning normally, coupled with the fact that the dog is of very old age and as a result, the heart and blood vessels may be weak.
Owner: So, so what am I supposed to do?
Vet: I think you have no choice but to take the risk and operate. That will be your best bet.
Owner: How much will the surgery cost?
Vet: It will be above 1000, around 1100
Owner: So expensive? I am actually under financial difficulties now, could you lower the price by a bit?
Vet: Ok.. the final price I can give you is 900
Owner: Ok…
Vet: Ok, before we proceed with the surgery, you as an owner have to take full responsibility of your pet. Here, you will have to sign this piece of informed consent before we can proceed.
Owner proceeds to sign the paper.

Scene 5
Surgery videos

Scene 6
Post-op show video

Post-Surgery Update with Owner

Head:”Education of Pet-Owner”

Mrs Lim: So how is Pepe? Is she okay after the surgery?

Vet: Oh she’s actually fine. The surgery was a success and we managed to remove her infected uterus.


Vet: The infected uterus was extremely big and swollen, and weighed 672 g. Your dog only weighed 4.35 kg! You were really quite lucky: your dog was very old as it is already 15 years old---it could have died from many complications due to the surgery or the anaesthesia due to its old age. so you take very good care ah!

Owner: xiexie tyvm lol hackz.;[worried] Oh so how is it now? Is its condition stable after the surgery?

Vet: It has been 24 hours since the surgery, and Pepe is fine. She’s  eating  and drinking well and has a healthy appetite (show the empty food bowl etc.) Also she is not vomiting, which indicates she does not have serious kidney disorder, or toxaemia.

I also have her new blood test results here. Her WBC count is normal, so  she’s not  experiencing any major infection now. So she looks fine!

Owner:So what should be done now?
Vet: I recommend that you keep her here for 3 more days, so that we can continue to monitor her condition. After that, you will need to keep her confined in a cage for the next 14 days to prevent her from jumping about and causing her stitches to unravel.

Owner: Huh I don’t have a cage to confine her....Can I keep Pepe here for 7 days  instead? At least I will feel reassured that she’s in safe hands.

Vet: Ok sure. I’ll keep you informed of her condition. Come let’s go to the counter to give you the medicine.


overview of situation.
--> closed pyometra + uterus torsion is rare
--> this dog despite old age has healthy heart, kidney and liver --> This is the reason that ( praise owner abit) the dog was able to survival the 68 miniutes of anaesthesia. In this 68 minutes the heart could fail and many old dogs could have died because of poor health (closed pyometra)

In retrospect, if you had spayed your dog when she was young then you could have avoided the high medical expenses and the emotional distress of undergoing surgery

Prologue - uterine torsion + closed pyometra is a rare case --> ormental fats is wrapped around the uterus --> due to the torsion of the uterus. As you can see from the other closed pyometra cases none of them had the fat around the uterus (already in website) emphasis on the point that normal cases don’t have the fats
closed pyometra - manifested by the swollen uterine horns cause the cervix is closed so that they can’t discharge the pus

In this diagram, we can clearly see the huge layer of omental fat adhered to the left uterine horn. This confirms the diagnosis that this is a case of the torsion of the uterus, because in the case of a normal closed pyometra as shown in the picture now, there is no omental fat present on the uterus.

As shown in the video, as we carefully cut open the infected womb, a fluid consisting mainly of blood and pus squirts out. As can be inferred from the red colour of the fluid, we can conclusively propound that the dog was in its early stages of closed pyometra, as later stages of closed pyometra has a more whitish coloured fluid contained in the infected womb

Tips and Advices
TIPS & ADVICES for the Dog Owner:

1.  SEEK PROMPT VETERINARY ATTENTION when your dog does not eat around 4-8 weeks after her heat period. That is when pyometra develops. Many younger Singaporean dog owners feel that it is cruel to sterilise their dogs. As they become busy in their careers, they neglect their older dog's health. The dog is well provided for in food and there are the parents and the domestic worker to look after the dog. They don't have time to bring their dogs for walks and when their dogs are not well, they delay seeking veterinary treatment or second opinions.   

2. SPAY your female dog when she is young and healthy. Pyometra surgeries to remove the womb are high-risk anaesthestic cases since the dog is already very sick or old. Some do die during anaesthesia.

TIPS & ADVICES for the newly graduated Veterinary Surgeon:
Pyometra should top the list of differential diagnosis in female dogs presented with distended abdomen with or without vomiting. The onset of estrus should be asked and recorded in the medical case sheets. However, some owners give incorrect dates of estrus and this could lead to a mis-diagnosis of closed pyometra as gas in the stomach and intestines. In some cases, the owner's mother knows the onset but she is not present during consultation.    

Compared to a spay, pyometra surgery costs a lot more. If the owner desires the least medical costs, he will not want to pay for the blood tests and X-rays. I usually advise a spay to be done soon once the dog is fit for surgery. Evidence-based medicine should be practised but compassion will be needed for financial distressed owners.             

The vet should record "Against Medical Advices" on the medical records, if the owner declines blood tests and X-rays of the swollen abdomen. This written advice will be a defence in cases of complaints and litigation. A good vet will be meticulous in writing his case records and advices given to the owner. Write your advices as you talk rather than wait till the end of consultation as you will have omitted certain information.

Final video – owner came

Do not cause pain to the pet -  in this case gas anaesthesia is used - can be used by gas mask or container - the container was used in this case - hence in this case it is dangerous as the safety margin is not as clear as that in the case of a dog or cat - cannot observe breathing easily, the eye blinking reflex etc. that would have been possible in a dog/cat


what - instruments that are used
where - incise at the lower part of the abscess (so that can drain unlike the scenario in which the cut was done at the top, the pus cannot drain out because it is too high up) , horizontally around 5 mm in this case
who - the vet, anaesthetist must be vismoke
why - why must we treat the abscess? 1. cause alot of pain, stop eating, abscess near the mouth - stop eating will die 2. becomes lethargic due to the infection   3. infection may spread to the brain cause ear is close to the brain --> leading to death
how - post-op talk about it. vet follow up to the owner, as to date, seven days after the surgery the owner says that the terrapin has started to eat

ETSL In the case of an abscess, it is important that the pet is treated promptly to prevent further spread of bacterial infection. the longer you drag it the more it will exacerbate, the more difficult for the terrapin to recover its former full health

Unusual case as most owners do not bring terrapins to vets, but abscceses can affect almost allt ypes of pet, but common methods: treating an abscess in a terrapin is the same as cat/dog. Vets must learn to improvise and not rely on textbook procedures.

Financial implications: terrapin only 2.50, but entire surgery and anaethesia, cost 200. Issue of conflict for financially challenged owners, vets may want to take into account.



Script for Video on Colour’s case

[Opening]: The story of Colour
- Mini Schnauzer
- Old dog, kidney failure
- high creatine count
- high urea count
- previous occurrences of kidney stones
- show signs of vomiting and diarrhea
evidence-based medicine

Blood test report 22/01/13
Urea: 44.3 mmol/L  (4.2 - 6.3)
Creatinine: 449 umol/L  (89-177)

Blood test report 20/08/13
Urea: 89 mmol/L (4.2 - 6.3)
Creatinine: 1243 umol/L  (89 - 177)


Dog was fed dry food despite recurrence of kidney stones and so had 3 bladder stone operations. The owner then stopped feeding dry food. However, the dog now had kidney failure on Aug 20, 2013. He passed away 10 days later.

Miniature Schnauzers are prone to development of bladder stones. Regular urine tests (3 monthly) for crystals and feeding an appropriate diet after the first surgery would have resulted in this dog living a longer life. 

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