There was a suspicious growing brown growth on my left chest. It was around 0.5 x0.5 cm x 0.2cm. As I do advise pet owners to get growths removed when they are small, esp. for older pets, I practise what I preach. So, today, Monday, Nov 28, 2011, at 7.15 am, I was at the Ambulatory Surgical Centre of the Singapore General Hospital to remove "verrucca" as stated by my surgeon. Last week, I saw a nurse from China googling when I was sent to the room to receive financial conselling. This is compulsory for all. "What are you googling?" I asked the friendly nurse who had seen me before for a synovial cyst excision on my right thumb. "Just to check the spelling of verrucca what Dr Foo wrote," she said. I was impressed with the thirst for knowledge imparted to the nurses.
On the surgical table, I asked Dr Foo whether he could remove the many red growths, as if blood vessels had burst. One young nurse told me: "In China, your many red spots on the man's skin are signs of good fortune." No wonder I am still alive.
I had a blood pressure monitoring arm band on my left forearm which expanded at regular intervals, giving readings in red.Another nurse who monitored my blood pressure asked if I have been active exercising. "Low pulse rate? Is it good or bad?" I asked the nurse. Low heart rate seems to be uncommon for senior citizens as I had been asked this question in another surgery. "I don't think Dr Sing exercises at all," Dr Foo commented correctly.
The carbon dioxide laser machine came into the room. I had multiple warts on my upper chest and so this machine would be useful. The nurse swabbed my upper chest with some liquid. Then Dr Foo got a purple marker pen to circle the verrucca or warts. "How many warts do you mark?" I asked Dr Foo. "Eleven. I am injecting local anaesthetic," he said. "It may be painful."
My eyes were covered by a piece of wet swab to prevent the bright operating lights blinding me. So I could not see what was going on as the laser buzzed. I could feel slight pain in some and none in other wart removal areas. A whiff of BBQ smoke pased my nostril. Soon, it was over. 3 samples of growths were taken for histopathology. The red one which was said to be a haemangioma and would recur when removed. A brown wart. Dr Foo said to the two young cheerful nurses from China: "Take the one rounded brown growth Dr Sing was worried about for the lab." I thanked him. "It could be an accessory nipple," he said of the brown growth near my armpit. "It is on the line," Dogs do have 5 pairs of nipples and well I knew what he was talking about.
Overall, it was a pleasant and enjoyable experience at the operating theatre. The bright yellow Crocs clogs were outstanding in two nurses. The others wore blue, green and black coloured ones. One man wore white boots. The cream0white vinyl tiled floor with red square patterns was very clean and shiny. There were 6 operating theatres. I could not understand why the large word "WASH" was pasted on the stainless steel sink where the surgeons scrubbed up and washed their hands pre-surgery. I saw one surgeon putting on a cloth glove and two more pairs of latex surgical gloves. "Some surgeons are allergic," the kind nurse explained to me.
Monday, November 28, 2011
747. The tu tu kueh woman's dog
Yesterday was a long day at work on a Sunday. I usually work half a day and let Dr Vanessa do the rest. I asked Mr Min to take the afternoon off and so I stayed around and stayed to do some administration. A practice needs to be administered well or it will just suffocate and wither as the world is getting complex and competitive. The clients are getting sophisticated and more demanding.
For example, one client wanted me to excise a large paw haematoma without sedatives as she was afraid that her old pug would die under sedation. That is a valid fear. To do it or not? It is up to the vet. The vet can just reject her case. What if the old pug dies under sedation? And nobody can predict this. For the sake of the old pug, I incised the haematoma and let it was OK.
The tu tu kueh woman at Bishan Shopping Mall. She asked what stall I was managing as she had seen me so many times over the years buying tu tu kueh from her and asking about her work. She had cooked soup which was shared with other woman stall holders and her brother who sold cakes under the same boss. When I told her I am a vet, she said: "I cried a long time when my dog died. Just running nose. A lot of it. My friend sent it to a vet. Some injection. Hospitalised for 2 days. My dog died. Just runny nose. Goes to the vet. Injection. Died."
"There could be many reasons," I said. "It could be a drug allergy. It could be a serious infection. How old and what breed?"
"7 years old. A Pomeranian." Her eyes teared up as she remembered her dog so well.
Now this dog was a clever dog. "My dog would jump and greet me when I unlock the apartment door. He could hear my key sound. When other family members unlock the door, my door would ignore them," she said, turning her head sideways.
"When I stayed too late watching TV, my dog would lick my ears to ask me to sleep. If I did not, he would jump to obstruct the TV screen."
"That sounds like a very intelligent dog," I was surprised. "It is as if he was a very caring human being re-incarnated as a dog." Some religions believe in re-incarnation and this canine story seems to support this.
If I can find a small breed to be rehomed, I will get one for her as she cares so much for dogs.
For example, one client wanted me to excise a large paw haematoma without sedatives as she was afraid that her old pug would die under sedation. That is a valid fear. To do it or not? It is up to the vet. The vet can just reject her case. What if the old pug dies under sedation? And nobody can predict this. For the sake of the old pug, I incised the haematoma and let it was OK.
The tu tu kueh woman at Bishan Shopping Mall. She asked what stall I was managing as she had seen me so many times over the years buying tu tu kueh from her and asking about her work. She had cooked soup which was shared with other woman stall holders and her brother who sold cakes under the same boss. When I told her I am a vet, she said: "I cried a long time when my dog died. Just running nose. A lot of it. My friend sent it to a vet. Some injection. Hospitalised for 2 days. My dog died. Just runny nose. Goes to the vet. Injection. Died."
"There could be many reasons," I said. "It could be a drug allergy. It could be a serious infection. How old and what breed?"
"7 years old. A Pomeranian." Her eyes teared up as she remembered her dog so well.
Now this dog was a clever dog. "My dog would jump and greet me when I unlock the apartment door. He could hear my key sound. When other family members unlock the door, my door would ignore them," she said, turning her head sideways.
"When I stayed too late watching TV, my dog would lick my ears to ask me to sleep. If I did not, he would jump to obstruct the TV screen."
"That sounds like a very intelligent dog," I was surprised. "It is as if he was a very caring human being re-incarnated as a dog." Some religions believe in re-incarnation and this canine story seems to support this.
If I can find a small breed to be rehomed, I will get one for her as she cares so much for dogs.
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.
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.
Saturday, November 26, 2011
745. The "hidden" pup in canine Caesarean sections
http://www.sinpets.com/F5/20111126hidden-pup-caesarean-section-dog-singapore-toapayohvets.htm
has the complete story.
has the complete story.
Friday, November 25, 2011
744. Anaesthesia of old Chihuahua - vaginal hyperplasia and prolapse
Chihuahua, Female, 10 years
Active and eating well till 19.11.2011 when the owner noted a vaginal prolapsed. The dog became lethargic and did not eat. Vaginal or uterine prolapse diagnosed by Vet 1. Owner went back but the pushed back vaginal tissue came out again. Tip became black after 2 days. No e-collar worn.
22.11.11 A friend of the owner was worried and asked me to advise the owner to euthanase the Chihuahua if she was suffering from liver and kidney infections as deduced from abdominal ultrasound and blood test reports. I reviewed the case.
As the owner is not able to take care of the everted vaginal tissue and it had become necrotic, I advised spay the next day as this was the solution. But there was a high anaesthetic risk as the dog did not eat for the last 4 days and her tongue was purplish. Mild dehydration. Temperature below 38 deg C for the last 2 days.
22.11. 11 One day Pre-op IV drip and antibiotic
23.11. 11 37.6 deg, 3.5 kg.
10am
IV drip glucose 5 minutes, then dextrose saline. Tongue became pinker.
IV lasix 2 ml
Domitor 0.05 ml + Ketamine 0.05 ml IV
Isoflurane gas top up at 0.5 - 1%
I expected a 10-minute spay.
Dog vomited yellow liquid after intubation. Repeat.
Dog passed loose black stools. Cleaning up. This took time.
Opened abdomen, hooked out left ovary.
However, both the ovarian ligaments and bv ruptured when ligated. Bleeding seen. So, I had to make a large skin incision to locate the bleeder far inside, behind the kidneys. Two quail-egg sized blood clots on left and right sides were taken out. Bleeders located but bleeding was oozing now. Clamped and ligated one bleeder as the left one slipped off the kidney area. Checked and cleared all bleeding inside abdomen. Closed up 2/0 PDS sutures. Completion at 11.30 am.
Active and eating well till 19.11.2011 when the owner noted a vaginal prolapsed. The dog became lethargic and did not eat. Vaginal or uterine prolapse diagnosed by Vet 1. Owner went back but the pushed back vaginal tissue came out again. Tip became black after 2 days. No e-collar worn.
22.11.11 A friend of the owner was worried and asked me to advise the owner to euthanase the Chihuahua if she was suffering from liver and kidney infections as deduced from abdominal ultrasound and blood test reports. I reviewed the case.
As the owner is not able to take care of the everted vaginal tissue and it had become necrotic, I advised spay the next day as this was the solution. But there was a high anaesthetic risk as the dog did not eat for the last 4 days and her tongue was purplish. Mild dehydration. Temperature below 38 deg C for the last 2 days.
22.11. 11 One day Pre-op IV drip and antibiotic
23.11. 11 37.6 deg, 3.5 kg.
10am
IV drip glucose 5 minutes, then dextrose saline. Tongue became pinker.
IV lasix 2 ml
Domitor 0.05 ml + Ketamine 0.05 ml IV
Isoflurane gas top up at 0.5 - 1%
I expected a 10-minute spay.
Dog vomited yellow liquid after intubation. Repeat.
Dog passed loose black stools. Cleaning up. This took time.
Opened abdomen, hooked out left ovary.
However, both the ovarian ligaments and bv ruptured when ligated. Bleeding seen. So, I had to make a large skin incision to locate the bleeder far inside, behind the kidneys. Two quail-egg sized blood clots on left and right sides were taken out. Bleeders located but bleeding was oozing now. Clamped and ligated one bleeder as the left one slipped off the kidney area. Checked and cleared all bleeding inside abdomen. Closed up 2/0 PDS sutures. Completion at 11.30 am.
743. Day 3. Vaginal hyperplasia & prolapse in the female dog - Surgical option
Day 3. The Chihuahua bites me and my assistant any time we try to catch her. She does not eat but otherwise is alert and strong. "Is the vaginal prolapse the same size?" I asked my assistant Min, as part of my coaching process. I had pushed in the prolapse yesterday morning.
"Same as before," Min said. "Come out again." He could have difficulty understanding Singapore English as he is not proficient in this language.
He tried to muzzle the dog for me to examine. The dog snapped at him. I had taught him to use a towel to cover the dog's head but he did not do it this time. It needs lots of patience to train a person. I covered the dog's head with a towel. The dog moved to a corner. "Use a leash to lasso her," I said. Otherwise it is impossible to examine her. Min held the leash and lifted up the tail. The dog moved but could not bite us.
The prolapsed vagina had decreased by 60% in size. I was not surprised as spaying removed the oestrogen causing this problem. Min saw the size and that is important. I pushed it in. The dog should be able to go home soon as she is not eating here. I did advise a 20-ml syringe to feed her. A 2-ml syringe with canned food is too short.
"Same as before," Min said. "Come out again." He could have difficulty understanding Singapore English as he is not proficient in this language.
He tried to muzzle the dog for me to examine. The dog snapped at him. I had taught him to use a towel to cover the dog's head but he did not do it this time. It needs lots of patience to train a person. I covered the dog's head with a towel. The dog moved to a corner. "Use a leash to lasso her," I said. Otherwise it is impossible to examine her. Min held the leash and lifted up the tail. The dog moved but could not bite us.
The prolapsed vagina had decreased by 60% in size. I was not surprised as spaying removed the oestrogen causing this problem. Min saw the size and that is important. I pushed it in. The dog should be able to go home soon as she is not eating here. I did advise a 20-ml syringe to feed her. A 2-ml syringe with canned food is too short.
741. Severe tail injury - the sole option -- tail amputation
"There is only one option when the dog or cat suffers serious injury to its tail," I said to my associate vet who had stitched up the slanting tail laceration wound of more than 6 cm long and sent the dog home with e-collar and medication.
"Based on my past 30 years experience, many Singaporean dog and cat owners are not able to nurse their dog's tail wounds. Even with e-collars, the dog or cat hits the injured irritating tail, causing more damage. The tail does not heal and becomes gangrenous. The owner becomes upset as she had already spent money on this first surgical treatment. It is not working and now the owner is upset."
"In all tail injury cases, the owner must be advised firmly and in writing that tail amputation is the sole option as gangrene is likely to set in, with stitching and other bandaging. There was a case of a cat with tail injury. I advised tail amputation. We don't see any complaint post-op. Now, this case comes back with lots of unhappiness as the tail becomes blackened and the tip has become cold."
As the owner was unhappy with the outcome, I advise that she and the operating vet and myself meet at the same time to discuss the matter. It is best done that way than individuals giving their points of view to me one-on-one basis.
The outcome of a case of tail injury is very important to the owner. The owner wants just one visit and not be inconvenienced by having repeat treatment. "Even with gushing blood and copious bleeding, ligate the tail blood vessel, bandage the tail and amputate the tail 2 days later."
"Based on my past 30 years experience, many Singaporean dog and cat owners are not able to nurse their dog's tail wounds. Even with e-collars, the dog or cat hits the injured irritating tail, causing more damage. The tail does not heal and becomes gangrenous. The owner becomes upset as she had already spent money on this first surgical treatment. It is not working and now the owner is upset."
"In all tail injury cases, the owner must be advised firmly and in writing that tail amputation is the sole option as gangrene is likely to set in, with stitching and other bandaging. There was a case of a cat with tail injury. I advised tail amputation. We don't see any complaint post-op. Now, this case comes back with lots of unhappiness as the tail becomes blackened and the tip has become cold."
As the owner was unhappy with the outcome, I advise that she and the operating vet and myself meet at the same time to discuss the matter. It is best done that way than individuals giving their points of view to me one-on-one basis.
The outcome of a case of tail injury is very important to the owner. The owner wants just one visit and not be inconvenienced by having repeat treatment. "Even with gushing blood and copious bleeding, ligate the tail blood vessel, bandage the tail and amputate the tail 2 days later."
Subscribe to:
Posts (Atom)