1260. Video production at Toa Payoh Vets

TOA PAYOH VETS toapayohvets.com       Date:   25 January, 2013

Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits

Squamous papilloma in an older Cavalier King Charles - How does a vet diagnose & treat such a case? Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS First written:  26 October 201.  Updated: 25 January, 2013 toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 The following is my script for the video production 1.  THEME Be Kind To Pets - Oral tumours in A Dog   This video describes the processes of how  a vet diagnoses & treats a case of squamous cell papilloma in an older Cavalier King Charles. These processes form part of the Standard Operating Procedures at Toa Payoh Vets 2.  HOOK A large strawberry-like lump is spotted by the young lady owner one day. She informed her father and brought the dog to Toa Payoh Vets The Patient: Cavalier King Charles, Male, 10 years. Singapore History: Dog was not active, had difficulty eating. Excessive salivation. Sometimes, blood seen dripping from the mouth. What is the problem with this old dog?   Music & Insert the image into the video:  3.  INTRODUCTION An old dog is like part of the house furniture.  Family members, especially children who grow up with him love him very much. But they have not much time for him unlike the time when he was a new puppy (video of Cavalier King Charles puppies at the pet shop being sold).The older dog is a family member for most Singaporeans nowadays. Visits to groomers regularly, good food, dog treats of various brands and plenty of water available at all times. (video of regular visits to groomers) The dog's mouth is seldom examined by most dog owners and bad breath is usually tolerated by many Singaporean dog owners. Dental check ups are not usually done and the rotten teeth drop out. Many owners are not bothered when they see their old dogs dropping teeth. Oral tumours develop in some of these dogs. Their health is no longer a priority as they age.  The older dog is always happy to greet the owner and is a good companion to the senior citizen parents and retirees but many dog owners in Singapore do not have time to send the older dog for dental check up or annual health screening.  (video of dogs in apartments, being walked in Singapore). In 2010-2011, I note an increase in the number of younger Singaporeans seeking dental treatment for their older dogs. The younger generation of Singaporeans is better educated and more concerned about the welfare of the old pets and this is good news for the four-legged companions. Back to my case. One sunny day in August 2012, the owners of a male, 10-year-old Cavalier King Charles saw a pinkish lump appearing on the front of the lower jaw covering two of the front teeth. It grew bigger and bigger. The father and his daughter consulted me. Video of Singapore's blue skies and sunshine, families at the Pasir Ris beach and Toa Payoh Vets At Toa Payoh Vets, Dr Daniel Sing was on duty. I was present.  "Is it cancerous?" the owners asked Dr Daniel and me.  "If it doubles in size within a week, it is likely to be cancerous," I  said. 4.  BODY 4.1  Problem -- Is the dog suffering from a cancerous gum tumour or not?  "How to find out whether it is cancerous? What can I do to resolve the dog's oral tumour problem?" the father asked. The financial costs must be explained fully before any operation is done. There are several processes to be addressed to ensure a high standard of veterinary care and as a defence against negligence litigation. (Video of lawyers and subordinate court) But the owner must give his consent and that is where personality and financial conflicts come in. CONFLICT NO.1  Biopsy   as recommended by the vet professors during undergraduate studies will be adopted by most vets especially the recent graduates. This is the standard practice as taught in the University. A small piece of the oral tumour is cut out and send to the laboratory for analysis of its type - cancerous or benign? If the biopsy shows that it is not cancerous, then, there is "no" need to do any surgery. But biopsy takes time and involves anaesthesia. Sometimes as long as 7 - 14 days. Not much time is available in this case as the tumour was said to be fast growing. It may be malignant and must be excised within 24 hours.   Some vets do biopsy and find the tumour non cancerous. Some tell the owner there is no need for surgery. Some owners decide that they don't want surgery to remove the tumour since it is not cancerous. (Video of consequences of not early removal of an oral tumour - images of oral tumours in other dogs) As the weeks pass by, the tumour grows bigger. Excessive salivation, blood in the mouth, bad breath and difficulty in eating. Bacterial infection. By then, the owner has no choice but to get the gum tumour excised.     CONFLICT NO.2 X-RAYS should be done to find out whether the tumour has invaded the jaw bone and below the gums. Due to economic reasons, this was not done in this case as vet costs needed to be as low a possible.   CONFLICT NO.3 BLOOD TESTS Health screening is strongly advised before anaesthesia and surgery for all patients, esp. in the older dog. Anaesthetic risks are much higher in old dogs. There is always the possibility that the older dog may die on the operating table. When the owner hears that the dog may die on the operating table, he may decide not to get the surgery done. Some deem the vet incompetent and consulted another vet. A health screening should be suggested by the vet to let the owner knows whether the risks are high or not. "I advise a blood test to screen the health of the Cavalier King Charles," Dr Daniel said.  The owners must consent to take the anaesthetic risk if they give permission for the surgery as in this case. No surgeon can guarantee no risk in any anaesthesia, whether in people or animal.      The total WCC  17.8 (Normal  is 6-17) Neutrophils 81%, Lymphocytes 15%, Monocytes 3.2%, Eosinophils 0%, Basophils 0.4%. The platelets were below normal. This blood test indicates a bacterial infection. The liver and kidneys were functioning normally. "OK," the patriarch consented to the surgery. Antibiotics were given to the dog.     CONFLICT NO.4 IV Anaesthesia No  Intubation Anaesthesia. What type? IV anaesthesia, gas anaesthesia or both? IV anaesthesia is shorter acting than gas anaesthesia. Intubation (a breathing tube connects anaesthetic gas and oxygen to the dog) is usually done in dental scaling which will be performed after oral tumour removal surgery.   (Insert above images of a dog intubated, left and dental scaling, right) But this dog had a big oral tumour in the front of the mouth, obstructing the insertion of the endotracheal tube. "No intubation, as we need good access to the gingival tumour and to excise all, if possible. It is growing fast."    Domitor + Ketamine IV at 25% of calculated dosage for a young healthy dog was sufficient for electro-surgical excision. Dental scaling was done after that. The old dog survived the anaesthesia and that was what mattered most for the owners. It is not always possible for every old dog to survive anaesthesia during surgery. Therefore it is wiser to remove the tumour when it is smaller and when the dog is younger.    Informed consent form "This is an old dog. Explain in detail the anaesthetic risks of death on the operating table and operation and post-op complications. An informed consent needed. The form is to be signed by the owner. In any case, the vet must delivers a dog alive at the end of surgery but no vet can guarantee. Therefore assess the risk and get the informed consent.   CONFLICT NO.5 Gas Anaesthesia The teeth need to be extracted. Dental scaling need to be done. That means surgery will take longer than normal. Isoflurane gas top up anaesthesia to be delivered by an endotracheal tube is needed.  But this endotracheal tube blocks the operating view. "IV Anaesthesia is the best," I said to Dr Daniel. Will this be effective? Yes if you know how to use the appropriate drugs. The dosage must be just sufficient for surgery but safe for the older dog.  50% of the Domitor & Ketamine IV formula was used in this case. It was effective. No need topping with isoflurane gas in this case.    CONFLICT NO.6 Histology "Is the oral tumour cancerous or not?" the father asked. "Nobody can tell from the physical appearance," I said. "The tumour needs to be analysed by the laboratory and the tumour cells can be seen under the microscope if there are any. This is the process of histology.  Do you wish to get the tumour sent for histology?" It is best to get the owner's permission to send the tumour for histology to check whether it is cancerous or not, as some owners may have a budget or do not wish to spend more money.   Write "AMA" (Against Medical Advice) in the medical report if the owner is not in favour of histology, blood tests or any process advised by the vet. This record serves as evidence to protect the vet in the event of negligence litigation.   4.2  SOLUTION Electro-surgery, not medication   It is unprofessional to give medication to the owner to treat the oral tumour as some owners may insist on having them as an alternative to the high risk of anaesthesia during surgery. It will not disappear. Electro-surgical excision including extraction of 3 incisor teeth enclosed by the papilloma. Electro-surgery by Dr Daniel. "Transect at least 2 mm from the tumour and remove the entombed incisors," I said. "However this is not possible in this case. X-rays are not done to see whether the bone is involved to lower veterinary costs for the owner at this time."     Histology - a microscopic examination of the tumour to check its cells as to whether the tumour is cancerous or not. The owner consented for the gum tumour to be sent to lab for histopathology  (Image of microscope)   Squamous papilloma with reactive atypia and chronic inflammation. No definite dysplasia or malignancy. (Video of a microscope) Good news for the owner. However, the papilloma may return as it is extremely difficult to completely excise it. Lab Report:  Squamous papilloma. So it is not an epulis as I thought it would be except that it had various finger-like projections as in a wart. The owner was happy with the good news. Not cancerous.   5.  CONCLUSION Final Diagnosis from histology The diagnosis is squamous cell papilloma. The dog goes home 24 hours after surgery. There was no more gum bleeding.  BE KIND TO YOUR OLDER DOG.  EXAMINE YOUR OLDER DOG'S MOUTH WEEKLY FOR ORAL TUMOURS. SMALL TUMOURS ARE EASIER TO REMOVE AND THERE IS A MUCH LOWER ANAESTHETIC RISK.   6.  ADVICES & TIPS Post surgical management 1. POST-OP REVIEWS. THREE-MONTHLY NEXT 12 MONTHS. Owner need to be advised and reminded by the vet but this is seldom done by me. Dog has not returned as at Jan 4, 2013. 2.  Older dogs must be checked by the owner daily and any mouth tumour be removed when it is small. In this case, the tongue covered the papilloma till it became chronically infected and swollen. It could have existed for some weeks without the owner seeing it. 3. TIPS. Old and unhealthy dogs (>5 years) must be given 25-50% of the calculated dosage of IV anaesthesia for younger dogs to lessen risks of heart failure. CREDITS     Toa Payoh Vets' Be Kind To Pets video Veterinary Education for vet students and pet owners   Concept by: Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Video and narration by: Video is at: (Insert the name of the URL): Date of video production: For more information: toapayohvets.com +65 9668-6468, 6254-3326, e-mail judy@toapayohvets.com The video produced by a vet intern is at: Video: Oral tumour electro-excision in a Cavalier King Charles Toa Payoh Vets Clinical Research   Copyright © Asiahomes All rights reserved. Revised: January 25, 2013 Toa Payoh Vets

eyeball prolapse in a dog with itchy eyes

http://www.kongyuensing.com/laws/20130188eyeball_prolapse_dog_itchy_eyes_toapayohvets.jpg

1258. Follow-up hamster eyeball enucelation & eye salvage alternatives

TOA PAYOH VETS toapayohvets.com Date:   24 January, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits The hamster has a popped out eyeball  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS First written: 22 January, 2013 Date:   24 January, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 1256. Hamster with a popped out eyeball. Follow-up update and surgical procedures info.   Jan 22, 2013 "She is going to die," the young lady wiped her tears as her 2-year-old female dwarf hamster was sleepy unlike others. The hamster just would not move when held on the palm of her hands. She took her out several times and this would stress out the sleepy hamster which had not eaten and drunk water in the past 2 days and was in great pain. "Two days ago, the right eyeball just popped out," she said. "Before that there was a white spot in her right eye. I thought it was a cataract." The hamster's shoulder skin stood up when pulled indicating severe dehydration. The protruded eyeball must be very painful as the hamster can't talk. She just sat still most of the time. The owner was quoted $400 by another vet to do surgery. "I don't have that much money," the student said. "Normally I charge $100-$250" for hamster surgery depending on how complicated it is and the time it takes.   Eyeball prolapse   After eyeball removal PRE-OP DEXTROSE SALINE "What are you injecting?" Dr Daniel saw me preparing a small injection of 0.05 ml in a 1-ml syringe and thought I was overdosing this hamster. "It is dextrose saline as he is so lethargic and weak." ANAESTHESIA "This is a very sick hamster," I said to Dr Daniel when we discussed anaesthesia. He proposed 1 drop of Zoletil IM. "The safest is just isoflurane gas," I said. "The vet needs to be very observant as it is hard to tell when the hamster is fully anaesthesized. We put the hamster inside a plastic container infused with 5% isoflurane gas. "Count up to 10 and take out. Repeat," I said. Dr Daniel did say 1,2,3...10!" once. The dosage was not enough. He tried again. "Use the mask," I said. But the mask was not effective as it was too big. OK for the baby rabbit. SURGERY Basically enucleation of the eyeball is similar to that for the dog. I incise 4 mm on the lateral canthus. Then I clamp the base of the eyeball with forceps. The normal eyeball suddenly popped out and the hamster squeaked. I ceased the procedure and gave the hamster more case. I scrutinised the hamster inside the plastic container. Once he could not move, I quickly took him out within a second. Clamped the eyeball, excised the base with scalpel. Unlike the dog, it was not possible to ligate the optic stalk and blood vessels. Profuse bleeding. I swabbed. Then I cut off the upper and lower eyelids to create two wounds which I sutured with 6/0. The hamster wriggled and I stitched fast 3 interrupted sutures. "Hold on to his front paws, the scruff of his neck," I said to him. The dwarf hamster is so small that there is no space for both of us. Finally, I sutured the eyelids. It was too cramped for the intern to take a video of the surgery. However she videoed 30 minutes post op and the hamster was busy cleaning himself. Surprisingly, the hamster became much more energetic after removal of the eyeball. It would be attribute to removal of pain and the dextrose saline. So, the owner was glad to see him as she took him home in the afternoon. 1 DAY AFTER SURGERY On Tuesday, Jan 22, 2013,  I phoned the young lady. She was most happy. "The hamster drinks a lot," she said. "She is much more alive." It was good news. 2 DAYS AFTER SURGERY Yesterday, Wednesday, Jan 23, 2013, the owner phoned me to say that there is a big hole. "Is it normal for hamster in such operations to have a big hole in the eye? What should I do? Can I send you the images of the eye by iPhone?" I said it was difficult to know what she meant and it is best to examine it as she thought there was a stitch breakdown exposing the eye wound. She brought the hamster to the surgery in the afternoon. I was out and some driver had suddenly swerved into my parked car opposite the church and public library, damaging the right fore lamp area. So Dr Daniel examined this hamster. "What happened?" I asked Dr Daniel. "The swelling was due to the bleeding after removal of the eyeball. It has become a clot. The owner did not give the pain killer and the hamster scratches the eye area. But the hamster is normal, very active, eating and running. Is it possible that you did not snip off the eyelids but had just stitched up the eyelids?" Dr Daniel was assisting me in this surgery to remove the eyeball but he was on the other side of the op table holding on to the hamster while I stitched up the "eyelids". As the hamster was a dwarf, he could not see me using a pair of scissors to snip off the upper and lower eyelids, as per standard operating procedure in eyeball removal surgery. In fact, it would be professionally incompetent not to do. SNIPPING OFF THE UPPER AND LOWER EYELIDS His palm is 4X in area compared to this dwarf and unlike the surgery in the dog or cat, he could not see much. He saw me using the scissors to cut off the 6/0 sutures after stitching the "eyelids". Actually, I had trimmed off the eyelids before putting in 3 stitches to close the eye. "I had cut off the eyelids, otherwise the eye would not seal off when the stitches dissolve," I said to him patiently.   EYEBALL REMOVAL SURGERY COMPARED TO THE DOG AND CATG The surgery to remove the eyeball in the hamster can be completed in less than 5 minutes unlike in the dog or cat owing to the small size of the eyeball. The same principles of surgery apply to the hamster as to the dog and cat, only that the operation is on a miniature scale and the anaesthetic risk of death from isoflurane gas is 10x higher as it is difficult to monitor the depths of anaesthesia.    SAVING THE EYE This hamster had a "white spot" in the right eye earlier. The owner thought it was a cataract. This would be a corneal ulcer. The hamster would have scratched so hard that her right eyeball popped out permanently and caused great pain. In the dog and cat, it is possible to "save the eye" if it is not badly damaged or infect. This is done by doing lateral canthotomy (which I did in this hamster) to enlarge the ocular space, push back the eyeball, give antibiotics and anti-inflammatory, stitch up the upper and lower eyelids (tarsorrhaphy) and in 14-21 days review the eyeball and remove the stitches. In this case, the eyelids are not snipped off. An e-collar is then worn. All these are not possible for the hamster esp. the post-op care as the hamster hates the e-collar and will get rid of it in no time. The hamster may not eat after such a drastic surgery. So, removing the popped out eyeball is the practical option.     Eye Injuries Are Emergencies in Hamsters. Consult Your Vet Immediately       3785 - 3791. Enucleation of the eye in a Syrian hamster at Toa Payoh Vets performed by me. The 3rd eyelid is not so prominent in the hamster unlike in the dog. This webpage is: http://kongyuensing.com/folder7/201301123hamster_eyeball_enucleation_toapayohvets.htm     More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: January 24, 2013 Toa Payoh Vets

1257. Amputation of leg saved the rabbit's life, prevents septicaemia in a guinea pig.

Why amputate if fractures are multiple fragments?  Not possible to pin or screw. Economics.

Two case studies will give you the answers.

1. Recent fracture. GP. Big swollen swelling at fractured region.
Reasons:     

    1. Pain. Guinea pig feels the pain and licks the region to alleviate its pain
    2, Pressure sores due to dragging of foot, friction from floor, continual licking of area    
  3. Infection of the inner tissues including muscles over time - localized infection - generalized infection = septicaemia  ---> multiple organ failure ---> shock ---> death.

 4. Emaciation. Not eating much owing to daily pain of fractured area.  

Case 1. Amputation of the leg prevents septicaemia in the guinea pig in later months
Narrate slides. Include how it is anaesthesized and surgery briefly

Post op complications - infection- stitch abscess.

Include some video footage. Overall video should be around 5 minutes. Ask owner to send video footage of latest updae in Mar 18, 2020 to close the case. 

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What happens if you don't operate but seek TCM? 

Case 2.  Amputation of the leg saved the rabbit from dying of septicaemia

narrate text

Amputation of leg saved the rabbit's life, prevents septicaemia in a guinea pig.

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Old images. Do not use for video production.