1056. Update on Westie with bladder stones: KPI for removal of 4 bladder stones from a male dog - The invisible 4th stone

The male dog's anatomy is more complicated than a female as there is the penis obstructing the incision. A skin incision is cut beside the penis between mammary gland 5 and 4. Other than that the surgery is the same.


Westie, M, 9 years, bladder stones x 4. The case is introduced at:
http://2010vets.blogspot.sg/2013/08/1054-westie-passes-blood-in-urine-since.html

I did the surgery today Aug 5, 2013 to record my KPI for a male dog. The previous report was the KPI for a female dog. The case is at:
http://www.sinpets.com/F5/20130615stones_urinary_poodle.htm



A: Injection of Induction Drugs  1.12 pm
B: Isoflurane gas first given: 1.16 pm
C: Isoflurane gas stopped:      2.15 pm
D: First skin incision:             1.30 pm
E:  Completion of skin stitching  2.16 pm

E-A = 1 hour & 4 minutes
E-D = 46 minutes
C-B = 59 minutes

The surgery took 46 minutes. The 4 stones were spiked and it took some time to grasp them out from the neck of the bladder.  The bladder was severely inflamed and the wall was thick at 5 mm wide. Two layers of 3/0 absorbable sutures closed the 1-cm cut at the apex of the bladder. The overall operation including induction took around 1 hour as done by me. I had done several bladder stone cases over the 30 years of practice and so I can perform shorter surgery and risk doing a KPI for Toa Payoh Vets. To set a benchmark to measure performance of speed, accuracy and correctness.

As this is an old dog, the speedier the surgery, the lower the risk of anaesthetic death.  The dog was barking furiously within 4 hours after recovery from anaesthesia, ready to charge out. I noted he has passed urine, at first yellowish and later bloody. This is to be expected and means no leakage from the bladder after stitching.  A video is being produced.

This case is rather tricky. According to the X-ray taken by Vet 2, there are 3 bladder stones. I was most glad to grasp 3 stones out and was satisfied. However, I inserted the forceps into the bladder to make three 360-degree sweep of the mucosa from the neck to the apex and sideways. I felt a gritty stone and was most surprised to find a 4th stone of similar size! Always perform this procedure. I did flush normal saline into the bladder via the catheter and also inserted a cathether via the inside of the bladder to flush any stones out of the urethra. Never in my imagination would I imagine a 4th invisible stone as the X-rays showed 3.




This illustrated that the vet must be meticulous to thoroughly sweep the inside of the bladder. The 4th stone was also spiked at the neck of the bladder. And I had thought I had completed my task after getting out 3 big stones.
As I can't take another bladder X-ray after surgery owing to financial constraints as some vets do. Failure to remove any big stones would result in haematuria again and unhappiness from the owner. Therefore, do the forceps sweep of the interior of the bladder as palpation did not reveal any since the bladder wall was 5 mm thick. The stones were around 5 mm across and hard to feel though I did palpate the bladder directly.

These are not the usual rounded ones. They were stuck at the neck of the bladder as they were spiked. Calcium oxalate crystals were found in the urine and presently I will presume they are calcium oxalate. The stones are sent for lab analysis.

Not all old dogs survive the anaesthesia. Therefore, the vet must be speedy as well as be accurate in his surgical performance. As to the factor of "correctness", this case illustrated that 4 bladder stones were the correct number. If I had closed the bladder after removal of 3 bladder stones as shown in the X-ray, my surgery would be deemed "incorrectly" done.

I did a retrospective review of the X-ray and cropped it. There appeared to be 4 stones as shown below:

------------------------

Extract of KPI from female poodle with bladder stone removal

KPI FOR SURGERY
How long it takes to remove one bladder stone from a poodle?

Poodle, 10 years, 4.1 kg 38.8 C. Dog was panting but owner said this was normal behaviour of excitement. Urinated blood yesterday, incontinent and now had abdominal distension the size of a small mango, indicating a much swollen bladder with difficulty in peeing.

Had antibiotics for past 7 days. Blood in urine. Dark red cloudy urine. Dog's abdomen distended on arrival. Anti-spasomodic injection and antibiotics enabled dog to pee and on surgery, bladder was empty but swollen with 8 mm wall (normal bladder is around 3 mm)

2 packets of sutures 3/0 absorbable Polysorb, 3/0 nylon for skin

A: Injection of Induction Drugs 2.50 pm
B: Isoflurane gas first given: 2.55 pm
C: Isoflurane gas stopped: 3.39 pm
D: First skin incision: 3.11 pm
E: Completion of skin stitching 3.41 pm

E-D = 30 minutes for a vet with 40 years of experience.
E-A = 51 minutes
C-B = 44 minutes of isoflurane gas + oxygen used.

The female poodle surgery took a much shorter time  of 30 minutes as there is no need to reflect the penis to access the bladder and the stones were rounded struvites unlike the male Westie which took 46 minutes as the stones were spikey and stuck to the mucosal wall at the neck of the bladder and was difficult to pop out. I had to use forceps to fish them out. This took time.

1055. Sunday's interesting case. A 7-year-old female cat pees fresh blood on the floor

The 7-year-old cat pees blood in the urine on the floor as she was confined inside the room. The couple showed the bright red puddle on the wooden floor of the bedroom in the handphone.

"Our vet is fully booked on Sunday and so we came to see you," the husband explained.

1054. A Westie passes blood in the urine since July 2011

Haematuria - Blood in the urine in a dog. Every vet has his or her own way of diagnosis and treatment as illustrated in the case of this 9-year-old male Westie.

July 27, 2011. Vet 1 took a blood test which was quite normal and prescribed antibiotics. No more blood in the urine for 2 weeks. Haematuria recurred on and off for the next year. More incidents in 2013.

Around December 2012. Vet 2 consulted. X-rays showed bladder stones. "No need urine test as surgery will be done to remove the stones."

Dec 27, 2012. Vet 3 (Dr Daniel) at  Toa Payoh Vets was consulted with Vet 2's X-rays for a "second opinion". Bladder stones - one big and two small. The dog was given an injection.

Aug 1, 2013. I was consulted as the dog had haematuria today. The owner did not want a urine test. I palpated a "fish-ball" sized bladder stone. The owner consented to a blood test for health screening as the couple was worried about anaesthetic death. Except for a rise in SGOT/AST to 229 (normal <81 br="" nbsp="" normal.="" results="" the="" were="">
The dog was given antibiotics and would be operated by me today Monday at 1 pm. The owner wanted the dog home after surgery. There will be owners who want the dog back immediately as they feel that the dog would be home-sick. "Is it a major surgery?" she asked me. "Yes," I said.

It seemed that the owner was worried about anaesthetic deaths in old dogs and financial considerations resulting in delays getting treatment.

The couple preferred an older vet to operate on their dog when I asked her whether she would mind Dr Daniel operating on her dog. She did object but said that an older vet ought to be more experienced. So I would be doing the surgery.

The two Sec 4 interns from RI should be around today to video the surgery. Urine crystals were calcium oxalate but it is best to get the stones analysed.

-------------------------------
After surgery review of X-rays again to determine the number of stones thought to be 3 prior to surgerty. The view was cropped. It appeared there were 4 stones

Never trust the X-rays. Use the artery forceps to palpate systematically 360-degree sweep of the interior of the bladder. If 3 stones were taken out, the 4th stone would cause haematuria and the vet would be deemed incompetent. 

1053. Sunday Jul 31, 2013 Interesting Cases: Abuse of veterinarian

TOA PAYOH VETS toapayohvets.com Date:   05 August, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits Continuing education in digital photography    Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   05 August, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Sunday, August 4, 2013 1053. Sunday Jul 29, 2013 Interesting Cases: Abuse of veterinarian   Sunday, July 29, 2013 "I don't like your attitude," the man in his 30s, heavy built and has some tattoos in his left arm pointed his forefinger to within 10 cm of my spectacles. He shouted again. It was 11 am on this bright sunny Sunday morning. He came with his elder sister to view his dog that had passed away after 3 days of treatment. I had phoned him and texted him at 9 am to inform him that his dog had passed away. He phoned and said he would be coming. At the Surgery, his sister had asked: "Why did the dog die? Is it because we sent the dog late for treatment?"  "The dog is 9 years old," I said. "He is old. He is also very thin and had anaemia and kidney disease. His total white cell count had gone up a lot indicating a bacterial infection." For this comment, the brother blasted me. On the day before, I was working and had checked on his sick dog. The rectal temperature had dropped to below 37.6 C. The dog had no appetite. I had phoned and texted him to let him know that his dog was seriously ill. He had come in the afternoon to see the dog. As for me, I am aware of abuse of service personnel as there were many notices put up in the Singapore General Hospital warning clients to treat the service staff with respect. Some veterinary practices have such notices too. So, I did not engage him with replies to provoke him. It seemed he was ready to assault me giving his lack of anger management control. All he needed was provocation. I said: "This dog is treated by Dr Daniel who will be working in the afternoon. He will talk to you as regards any queries on why your dog died." The elder sister said: "Let the dog's death be peaceful. We will bring him to Pasir Ris to cremate. The next day, he texted wanting to speak to the vet who treated his dog. Dr Daniel spoke to him and said all was resolved. He had been very busy and had not sent the dog down for treatment for the past two weeks of vomiting. As for me, I had my man to "WhatsApp" the haematology results and comments to him and had phoned him on Saturday morning to let him know that his dog's health had deteriorated and blood test had shown kidney disease too. He denied I had told him about the kidney disease on Saturday morning. From this experience, it is best to write down every communication with the owner in the medical records and blood test reports. Usually I ask my assistant to What's App the blood test to the owners and in this case, the attending vet was Dr Daniel and not me. I was covering his morning duties and so got the brunt of the anger. Vomiting dogs might need prompt veterinary attention. I think of installing closed-circuit TV. Abuse of vets is rare but seem to be common in the last 5 years. This may have to do with the highly stressful lives of some Singaporeans. As for such cases, it is best not to provoke further with words. He had the hematology results in his handphone and he showed me. I had WhatsApp the results to him on Friday, but I did not WhatsApp the kidney results to him since I had spoken to him on Saturday morning by phone. I was not in the Surgery in the afternoon when he came to visit his dog as I was off        In such cases, I should be hands off this case and leave it to the attending vet. Vets who are off-duty should be "on duty" to communicate with the clients whose dogs are ill but this is expecting too much of the younger or older generation who values "work-life" balance. Last year, I was verbally abused by a client of Dr Vanessa and I had written about it in an article. In that situation, the son pulled the father away as the irate man kept shouting at me that I should pay him so that he can educate me about his dog case. There was something abnormal about the man as he was asking for a fight. I just kept quiet to prevent further provocation. As the senior vet, I do participate in case consultation of the associate vets to uphold a consistent standard of performance and care at Toa Payoh Vets and verbal abuses by clients are very rare. I take such abuses are part of the diversity of human behaviour and so do not get upset over the unusual shouting. Maybe I should have some tattoos on my right arm. A fiery dragon perhaps.   Updates will be on this webpage: www.sinpets.com/F5/20130805vomiting_death_dog.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: August 05, 2013 Toa Payoh Vets

Rabbit neuter video - post-op

On Aug 31, 2013, the owner WhatsApp me an image of severely inflamed and swollen scrotal sacs after neuter by Dr Daniel on Aug 29, 2013. So I asked her to bring the rabbit down as the image looked serious.

"The scrotal sac does not look so red or swollen as in the image," I said to the maid.
"The image was taken last night," she replied.
"Did you feed the antibiotics and painkiller medication witht the syringe?" I asked.
"Not possible. The rabbit keeps moving his head sideways."
"So you didn't give any?" I asked.
"I put it into the water for her to drink. I put a bit of water. She drinks it and then I give more water."
Quite a good idea.

I hospitalised the rabbit for 2 days. On Aug 2, 2013, the scrotal sac was no longer swollen. The rabbit ate ravenously and pooped and peed a lot. I asked the two interns to take the video regarding rabbit neuter and post-op complications and nursing.


CASE
Male rabbit, 14 months, 1.4kg, 38.7C
Had sired 5 litters but all of them died. So the owner decided to neuter him.

Post op meloxicam and baytril were given twice a day and this was found to be effective. Images were taken

1051. Distemper in a Golden Retriever in Yangon

Saturday Aug 3, 2013
Today I got a call from a young Yangon lady regarding a cure for distemper in a Golden Retriever puppy, 3 months, 9 kg. Her vet had asked her to get the antiserum which is not available in Myanmar. I told her that Singapore does not have the antiserum too as it is too expensive to produce. The young lady emailed to me a link which says that the antiserum can be produced and used for treatment. The link is at:
http://blog.chron.com/fromunderthebridge/2012/10/canine-distemper-there-is-a-cure-if/ 

My reply to her:

photo.PNG 1169K View Share Download

Reply

Reply to all

Forward

Kong Yuen Sing <99pups gmail.com="">	4:28 PM (1 minute ago)
to daniel, michelle

I have got your 3 emails. Thank you.
Once the distemper virus has infected the puppy and spread to the
nervous system, there is no cure. There is said to be antiserum
produced but this is not commonly available. Your article mentioned
that some vets do produce the antiserum from dogs which have been
vaccinated or infected but such antiserum is not available commonly
and the quality of online sale of such serum is in doubt. .

Antibiotics for a long time, anti-fever and pain-killers, rehydration
and other supportive treatment for difficulty in breathing and
diarrhoea need to be done with the help of your vet as the treatment
takes many weeks. It is very difficult for an owner to do it herself.

Recovery depends on the dog's immune system and past vaccination. The
majority of puppies with distemper infections die. I hope you will
work closely with your vet in Yangon.

----------------------

Around 3 weeks ago, a Myanmar man came to me to ask for the antibody treatment for his boss' Golden Retriever that has distemper. I told both of them that there is no specific antiserum for distemper in dogs. The Myanmar man messaged to me an image of "interferon" bottle available from Bangkok and asked my advice. I said it would not be effective.

1050. KPI - How long it takes to remove a big bladder stone?

SCRIPT FOR INTERN




1. HOOK

2. OBJECTIVE

3. INTRODUCTION - SAC (Speed, Accuracy, Completeness).  Speed is especially important in the old dog as the heart may fail when surgery is prolonged. This video is to share my surgical experience and process in removing a big bladder stone in a 10-year-old poodle. I have had been in small animal practice for around 30 years and therefore the surgical time taken would be shorter.  

4. Systematic Process & meticulous records
    Examination - Palpation of bladder. Risks and complications esp. in old dogs to be discussed. Economics to be discussed. Dog on antibiotics for 7 days prior to surgery by Dr Sing Kong Yuen.
    Medical advices of 4 test given to be recorded to prevent misunderstandings as the family members may not communicate with each other after visiting the vet.  These tests are:
    4.1  Urine test. Absence of urinary crystals do not mean no stones are present.
    4.2  X-ray. The owner said he was not told about X-rays in this case. I advise an air-contrast radiography by injecting 30 ml of air into the bladder prior to X-ray. (X-ray image). The female dog should be catherised for the catheterrisation.
    4.3  Blood test for health screening pre-op.
    4.4  Stone analysis is important for prevention.


5. Videos x2  by one intern. Extract relevant clips.
5.1
http://www.youtube.com/watch?v=bvku1Ix4Bxc&feature=youtu.be
Case of Kerri.


5.2

http://www.youtube.com/watch?v=27CezPtvRTk&feature=youtu.be
X-ray of urinary stones


6. Illustrations of vet surgery to be done to reinforce the surgical techniques or pull out clips from the video and write subtitles.
Reference to X-ray (image) pre-op
Tools needed.
Sterile swabs isolates the bladder
Incision to be as small as possible
Irrigation of bladder to flush out smaller stones
Catheter into female urethra to dislodge any stone if present
First layer. 2 anchor sutures with artery forceps.
Second layer.

Post-op complications
Bleeding -
Infection
Pain
Death of old dogs in poor health. IV drips. 

CONCLUSION
Performance indicators. How long it takes for an experienced vet to remove a bladder stone from a female dog.



TEXT

http://www.sinpets.com/F5/20130615stones_urinary_poodle.htm. See below

TOA PAYOH VETS toapayohvets.com Date:   19 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits KPI - How long it takes me to remove a bladder stone in a poodle  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVSDate:   19 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Friday, June 14, 2013 1460. Update: KPI - How long it takes to remove one bladder stone from a poodle? Friday June 14, 2013 I share my surgical experience with regards to the removal of a bladder stone from an old poodle and to provide a benchmark to enhance the standard of care by younger vets at Toa Payoh Vets. KPI FOR SURGERY How long it takes to remove one bladder stone from a poodle? Poodle, 10 years, 4.1 kg 38.8 C. Dog was panting but owner said this was normal behaviour of excitement. Urinated blood yesterday, incontinent and now had abdominal distension the size of a small mango, indicating a much swollen bladder with difficulty in peeing. Had antibiotics for past 7 days. Blood in urine. Dark red cloudy urine. Dog's abdomen distended on arrival. Anti-spasomodic injection and antibiotics enabled dog to pee and on surgery, bladder was empty but swollen with 8 mm wall (normal bladder is around 3 mm)   2 packets of sutures 3/0 absorbable Polysorb, 3/0 nylon for skin A: Injection of Induction Drugs  2.50 pm B:  Isoflurane gas first given:     2.55 pm C: Isoflurane gas stopped:         3.39 pm D: First skin incision:                3.11 pm E: Completion of skin stitching   3.41 pm E-D = 30 minutes for a vet with 40 years of experience.  E-A = 51 minutes C-B = 44 minutes of isoflurane gas + oxygen used. ANAESTHESIA 1. Domitor + Ketamine 0.1 + 0.11 ml IV in 3 ml of saline 2. Dog intubated 5 minutes after Dom + Ketamine IV. She was intubated a few times but seemed not to be breathing the isoflurane. Barked twice. Eyes blinking. I did not want to waste time to mask and intubate as this is an old dog and every second counts towards her survival rate. I decided to use gas mask which was excellent anaesthesia from 3% maximum for maintenance. SURGERY 1. I palpated the empty bladder with stone. In female dog, I do not catherise unless necessary. 2. I incised where the bladder was located. Spread out the SC fat, linea alba cut and pop out the empty bladder. 3. I turned the bladder backwards, exposing the dorsal part of the apex. 4. Incised 1 cm. Popped out the stone which would be slightly >1 cm across. 5. My assistant flushed bladder with saline. I squeezed out any remaining debris or crystals, known to be struvites. 6. A urinary catheter passed from inside bladder to outside the vulva to dislodge any stones if present in the urethra. 7. I suture the 8-mm thick submucosa first with a layer of inverting sutures, parallel to incision. 8. At one end, I anchored the artery forceps and proceeded to suture a similar continuous inverting suture layer to the other end from bladder serosa and mucosa. "Suturing is similar to Caesarean section uterus," I said to Dr Daniel. I used 3/0 Polysorb sutures and throw 5 knots/tie. 9. "Some vets inject saline into the bladder of the female dog after suturing to see if there is a leak," I said to Dr Daniel. "I don't do it as the closure is tight with two layers." He took a video. 10. Closure of the linea alba (simple interrupted & continuous overlay). 11. Skin - horizontal mattress x 3 with 3/0 nylon. 12. There was some profuse bleeding post -op.  "Probably the bigger artery from the caudal epigastric blood vessel," I said. After bandaging, the bleeding stopped. POST OP The dog vomited twice, yellow gastric juice some 15 minutes after surgery, but seemed OK. "Barking non-stop before surgery," I said to the owner who visited. The dog sprang onto him as if she did not have any major op. Still barking non-stop as at 7.35 pm when I recorded this case. Incredible. The owner is advised to give the S/D diet but the dog did not like it. There are still small stones inside the left kidney and S/D may dissolve them. But the dog would not eat the S/D. "Give 10% mixed with home-cooked food and increase daily," I said. "It is important to avoid kidney stone operation!"   An unusual old dog so active 2 hours post op. Compared to the overweight Jack Russell who is drinking lots of water and depressed, lying down 2 days after 10 small bladder stone removal surgery. He would stand up when the owner came. UPDATE ON THE ABOVE-MENTIONED POODLE WITH BLADDER & KIDNEY STONES ON JUN 18, 2013 I phoned the owner. He said the poodle had started to eat more and was more active. The bruised redness of the belly area had moved to the thigh. I asked him to WhatsApp the images to me. The advantage of the patient going home on the 2nd day of surgery is home nursing and lower medical costs. The disadvantage is the dog cannot be crated and running around at home movement causes wound breakdown or infection ---------------------------------------------------------------------- UPDATE ON THE JACK RUSSELL WITH 10 SMALL BLADDER STONES ON SUNDAY JUNE 16, 2013 The dog returned to Toa Payoh Vets on Saturday June 15, 2013, on the 2nd day after surgery as she was fit. The other Jack Russell, on 3 bottles of IV drip was more active and barked on Saturday, much to the joy of the owners. He was drinking and drinking a lot of water of Friday lying on his chest and looking lethargic. He would walk when taken out but preferred to lie down for the last two days.. Updates will be on this webpage: www.sinpets.com/F5/20130615stones_urinary_poodle.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: June 19, 2013 Toa Payoh Vets

Video clips to be edited by interns:

MVI 
497 & 504. Location of Toa Payoh Vets in 2013. Industrial Park. Lorong 8 Toa Payoh. Near a Hindu Temple off Lorong 8 and Golf driving range from Toa Payoh East.

457 & 450. Patient before surgery. June 2013. Abdominal swelling is not ascites. It is a swollen bladder as big as a mango. Edit clip to show swelling. Not eating. Passing blood in the urine. Dribbling urine.
X-ray (image), catheterisation of female urethra to empty bladder and pump in 30 ml of air into bladder for contrast radiography. (image).

460. IV sedation given by Dr Daniel Sing.

465.Surgery by Dr Sing Kong Yuen. Bladder pushed out. Incise bladder as small an incision as possible. Stone taken out. Irrigate bladder with normal saline to flush out other smaller stones. Catheter inserted from bladder into female urethra to dislodge any stones stuck inside.

3/0 absorbable sutures used.
First of 2 rows of inverting sutures to close the bladder incision in this image. The submucosa is stitched in the first row in this video.
Clip of forceps anchoring suture at two ends of the knots. (Edit clip and highlight or illustration).



483. Submucosa stitched. Knot at one end. 2nd artery forceps anchor it. (Edi clip and highlight or illustration). 2nd row of sutures being placed.


484. Bladder incison fully closed. Some vets inject saline to check for leakage. Not necessary in this case as the two rows are tight.

485. 30 minutes after surgery.

490. Post-op bleeding seen. Back area bandaged. Subcutaneous blood vessel bleeding likely.
Dog vomited twice. Bladder stone (image). Struvite from stone analysis.

492. 3 hours after surgery. Barking loudly. Goes home. Dr Sing's comments on this old dog's barking as a good sign of health.

UPDATE IN AUGUST 2013. Dog recovers at home. Refused to eat the Prescription S/D diet which is recommended to dissolve the struvite stones in the kidney. X-ray shows stones in kidneys (image of X-ray).