Script for Intern
1. HOOK: Video: Titled
August 20, 2013,
First Consultation at Toa
Payoh Vets
A very old dog - 15 years
old, Maltese, Female
Large swollen abdomen. Not
eating.
"My dog has been gaining
weight in the past 7 days,"
the slim lady owner in her
late 50s said. "I could feel
that she is heavier than
before. After grooming, I
saw a big lump on her left
abdomen. She is not
interesting in eating.
What's wrong with her?"
Images of left & right side
views, top view
2. OBJECTIVE OF VIDEO:
A "Be Kind To Pets" Vet
educational video slide.
3. INTRODUCTION
August 20, 2013
Diagnosis:
"Is she a spayed female
dog?" I asked as many
Singapore dog owners
doctor-hop. My medical
records showed 3 incidents
of false pregnancy and
advices to spay the dog went
unheeded.
"She is my daughter's dog
but now I have taken over.
Over the years, my daughter
did not think of spaying the
dog," the mother said.
"When was the last heat?" I
noted that this dog would
have false pregnancy around
August in the previous 3
episodes in the years I saw
her during vaccination.
"None at all," the mother
said. "She is so old and
should be in menopause."
I palpated the large
abdomen. The left side
protruded a giant
"sausage-like" mass which
was painful. The dog her
head turned to bite me.
"Your dog suffers from
closed pyometra," I said
quite confidently.
"The cervix had closed and
so the pus and bacteria
accumulated inside the womb,
causing such a large
swelling. The only solution
is to operate to remove the
womb which is now swollen
with pus."
CONFLICT 1 - Highly Risky Surgery
"My dog is so old. I don't
want her to die on the
operating table. Isn't there
medication to cure her?"
"Antibiotics will give
temporary relief for a few
days," I said. "Your dog's
health will deteriorate and
she will die soon as the
toxins spread to her whole
body or the swollen uterus
ruptures spilling out pus
into her abdomen. Therefore,
you have no choice but to
get her operated."
CONFLICT 2 - Financial
costs of tests for
heartlanders
"Are you sure of your
diagnosis?" she asked.
"Nearly 100%. To save you
money, I have not
recommended an X-ray and
blood tests which will add
around $300 to the medical
costs. However, if you want
them done, I will do it."
The owner wanted the tests
done.
X-Rays images x 2. The left
swollen uterine horn can be
seen (arrows).
Blood test image. No
increase in total white cell
count but the neutrophils
have increased.
CONFLICT 3 - Chances
of Death on the operating
table.
A very old Maltese at 15
years equivalent to a
105-year-old woman. The
blood test showed a very low
creatinine level indicating
that the kidney function was
not normal. So anaesthesia
could be fatal. "Less than
50% chances," I said to the
owner.
CONFLICT 4 -
Procrastination of the
owner. The owner
is very fond of this dog and
so could not decide. The
daughter had her own family
and so this dog is her
companion. A highly risky
surgery could mean death.
She is from the baby-boomer
generation that usually does
not bother to do research on
the internet for "closed
pyometra." So she did not
know that time is of the
essence and any delay will
lead to toxic damage to the
kidneys and death from
kidney.
failure.
"My dog started eating after
your antibiotics," she said
when I followed up to ask
her to operate. It seems
like hard-sell but it is in
the interest of the dog and
the owner. When vomiting
from kidney failure starts,
the owner will ask for the
operation but then it will
be too late.
CONFLICT 5 -
Reputation of the veterinary
surgery and vet.
Deaths on the operating
table are extremely
emotional events for the
owner and the younger family
members nowadays. Some
owners post adverse comments
on the internet forum when
such incidents happen asking
others to avoid the
practice.
The owner came on August 21,
2013 for the surgery. A
bright sunny day. "This high
risky surgery is not one I
look forward to and it must
be done speedily," I told
the owner. "Ask Dr Daniel to
do it," she said. "I will do
it myself," I said to her.
Old dogs do die on the
operating table in all
veterinary practices and I
had my encounters. I hope
that this old dog will not.
A positive mental attitude
cannot overcome any weak old
canine heart that may fail
under anaesthesia..
CONFLICT 6 - A
complicated surgery prolongs
anaesthesia.
1. The left uterine horn has
twisted (uterine torsion).
ILLUSTRATIONS
2. Red blood was present in
the abdomen (haemoabdomen)
indicating rupture of blood
vessels.
ILLUSTRATIONS
3. Adhesions of the omental
fat to the left uterine horn
wrapping around the uterus
and connecting to the
spleen, stomach and kidneys.
This was unexpected as this
was my first case of uterine
torsion seen in my over 30
years of practice.
ILLUSTRATIONS
All my past cases were
over the last 30 years of
practice were just swollen
uterine bodies full of pus.
IMAGES OF 6 CASES OF CLOSED
PYOMETRA WITH NO UTERINE
TORSION IN OTHER DOGS
Reference:
http://www.bekindtopets.com/animals/20081201PG4_
Dog_Surgery_Anaesthesia_Female_Dog_Problems_
ToaPayohVets.htm
So, I expected this to be
a routine surgery. I only
had to be speedy and should
complete the surgery in less
than 30 minutes. When I
opened the abdomen, a
gigantic kidney-shaped
"sausage" - the biggest you
can find in the supermarket,
popped out.
IMAGES OF REAL GERMAN
SAUSAGES
& VIDEO CLIPS OF SURGERY
CONCLUSION
Speed, Accuracy &
Completeness are 3 important
factors in any surgery. In
old dogs, time is of the
essence as the old dog can
die of heart failure as the
anaesthesia is prolonged.
This surgery from the
inhalation of isoflurane +
oxygen gas to last stitch
took 68 minutes for a
surgeon with over 30 years
of experience.
It could be done in around
50 minutes if there were no
complications of uterine
torsion. In this rare case,
I had to figure out what to
do. The best would be to
look for the cervical area
and ligate it as the uterine
body was also twisted.
This case has a happy
ending. The dog was
hospitalised for 7 days as
requested by the owner. She
ate canned food on day 2
after surgery. Not all
similar cases end happily.
My best advice is to get
your female dog spayed when
she is young and healthy to
avoid highly emotional
stress when closed pyometra
occurs. |
TOA
PAYOH VETS
