Thursday, September 26, 2013

1160. Seven days for the Maltese to live

On Wed, Sep 25, 2013 I received a phone call from a young lady for a 2nd opinion. Her 14-year-old male  Maltese had breathing difficulties and was not eating. Vet 1 diagnosed anaemia and a big abdominal mass. She advised surgery but the owner did not want it. So the lady searched the internet forums and there were some recommendations for her to phone for Dr Jason Teo at Toa Payoh Vets. 

"Dr Teo works at Toa Payoh Vets on Saturdays only," I said.
"Another vet at Toa Payoh Vets will be OK," she replied. 
"What's the name of Vet 1 whom you first consulted?"
"I do not wish to disclose her name."
"Did she have X-rays and blood test results for your dog?" I asked as she was telling me the findings without the documentary evidence.
"Yes," she said.
"You can ask Vet 1 to fax or email to me at Toa Payoh Vets," I said.
"I don't think it is possible," she replied.
"Why not? Are the documents illegal?" I asked. "Vets do pass clinical records to each other when the owner seeks a 2nd opinion. I have done it before and other vets have done it. You just have to phone them and ask for the medical records."

She phoned later to say that Vet 1 would want her to go to the practice to take over the records and so would be late for the appointment. This was OK with me.  Around 3 pm she came and saw Dr Daniel first. He had recorded "4 days of changed behaviour, increased breathing, decreased appetite and cannot walk. No vomiting, diarrhoea and no change in diet. Cheese treat for one week and polyuria and polydipsia.

Blood test from Vet 1. No abnormalities in the liver and kidneys or total white cell count. But RBC 3.37 (5.5 - 5.8), HGB 8.4 (12-18) and HCT 23.9 (37-55) were very low. I told the owner that the gums were purplish and the tongue was pale. This was not good.
The mid-abdominal lump was solid, painless and half the size of an orange. What is it?

Vet 1 was consulted for a "breathing problem". She had taken a lateral X-ray showing much fluid inside the swollen abdomen. Opaque areas obscured the views of intestines. Vet 1 said heart was enlarged.  An abdominal mass pushed guts up and above. She recorded that the owner was not keen on surgery. Dog was anaemic and lung sounds were dry. She proposed pain relief since surgery was not acceptable.

Overall, Vet 1 was spot on in her diagnosis but the owner was not satisfied.
"Is it because you went when the practice was going to close?" I asked.
"Yes," she said.
Sometimes it is difficult to satisfy the owner on the first consultation in a medical condition with no cure except surgery. Yet this dog was 14 years old, very thin and I would say emaciated. Surgery would kill him. So I don't even want to propose surgery as this dog will never survive the long time needed to remove this large abdominal lump. In any case, the couple was never in favour of it.

But what is this large abdominal lump and what should the couple do?

"Euthanase the dog," one young vet suggested when I spoke to her after X-raying two views of the dog's chest and abdomen at her practice. "This dog is suffering and should not prolong her suffering"

"There was one government vet before your time," I said to this young lady. "He recommends euthanasia so many times that he has a reputation to be avoided. This is because the owners say that he will advise euthanasia in very sick cases. His intention was to save money for the owners but he gained the reputation of being an "euthanasia" vet to be avoided.

"In this case, the couple is against euthanasia. They want to know what is the nature of the abdominal tumour."  Dr Daniel had proposed ultrasound scanning. From my reading of the couple, they want an acceptable solution such that the dog would live the last few days of his life without pain."

What more can be done other than ultrasound?
Dr Daniel elaborated on the causes of the swollen abdomen - bleeding, chyle, fluid from heart failure since the liver and kidneys were OK based on blood test from Vet 1, peritonitis. He also advised surgery to remove the abdominal mass as the only option. He advised abdomino-centesis to draw out the fluid to send to the lab for examination but sedation would be required and this would be risky as it may kill the dog. So the couple did not accept his suggestion and wanted to take the dog home.

I let Dr Daniel handle the case to the conclusion but I did give my take on this medical condition.

What should be done for this dog if surgery was not an option? "There is no need for sedation," I said to the couple. "We need to draw out the abdominal fluid so that your dog can breathe easier at least for the next 2 days and start eating."  Each vet has his or her own opinion and my opinion was that abdomino-centesis could be done without much pain on this ill dog and so without any risk of death.

The only risk is in putting the needle into the abdominal mass. This was what I was concerned and so was the thinking behind the young lady vet who looked at the X-ray with me earlier. The needle might puncture this big lump.

"Not if you slide the needle under the umbilical skin," I did that with a 19G needle and fresh blood came out. 


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