Sunday May 13, 2012

I was at the Surgery in the morning and saw a large amount of reddish brown urine drops in the waiting and consultation room. Dr Daniel was consulting with the owners and Mr Min was mopping the floor a few times. If I were Dr Daniel, I would restrain the dog on the consultation table but each vet does his own thing and so this situation led to bloody urine every where. I mean, if the waiting room was full, the other clients would be most unhappy trying to avoid stepping on bloodied urine on the floor as they waited in a small waiting room of Toa Payoh Vets.

This is what I mean by "common sense" in a vet who handles a case.  Restrict the dog's movement or crate him. I did my trust and audit in this case handled by Dr Daniel to improve the process of consultation and consistency of practice.

The X-ray showed around "6 small radio-opaque stones" of around 4 mm x 6 mm and other sizes. Dr Daniel said were unlikely to cause so much bladder bleeding and suspected a bladder tumour. Each vet has his own opinion and so that is life. As I did not examine the case which was Dr Daniel's, I did not palpate the bladder.

I disagreed with him as there was one stone with a sharp edge, like a dagger.  This sharp stone swished about inside the bladder would have stabbed the bladder mucosa and cause bleeding. "This is not chronic cystitis," Dr Daniel disagreed with me. "The blood in the urine occurred only 2 weeks ago." There was a difference of opinion.

(May 19, 2012 - RETROSPECTIVE REVIEW - The dog had been operated by me and had a large adenocarcinoma of the bladder. The blood clots were dark red black and green and were from the degenerating cancerous cells of the adenocarcinoma). 

An old Beagle. Likely to be a bladder carcinoma as well.  Dr Daniel advised ultrasound and surgery with high anaesthetic risks of death on the op table. Since the dog's red blood cells were low, his opinion was that this dog would not survive the operation. So what to do? The consultation took more than 30 minutes and he was still talking.

(May 19, 2012 review. In my opinion, ultrasound adds to cost and will not help to resolve this dog's problem. The newly graduated vet has been taught by the professors to go for more and more tests to confirm a diagnosis of cancer. In practice, he must know what to do in an old dog with cancer, not asking for more tests as many owners prefer to have lower veterinary costs. In this case, blood and urine tests and an X-ray of one view had been done. The X-ray was of average quality and an air-contrast X-ray of the bladder would be preferred)  

I intervened as the consultation was getting too long and there were others waiting. It is not good to make clients wait 2 hours when the vet does not know how to manage the time and be concise in their advices. 

I entered the consultation room which had a bloodied floor now as the Beagle wandered around. I said to the couple in their 40s: "Basically, you have two options. Consent to an operation and know the high risks and get the stones removed. If there is cancer of the bladder, give us consent to euthanase the dog during surgery if the tumour is inoperable. The other option is to medicate and euthanase the dog when the drugs don't work as she is suffering from pain, blood loss and incontinence."

In the meantime, get the dog on the IV drip, painkillers and antibiotics for at least one day and before surgery."

Vets can't afford the luxury of time on a busy Sunday morning to handle a case for more than 30 minutes unless it is necessary. Other clients have to wait a longer time. Owners of hospitalised dogs need to be called. The sick dogs need to be checked and there are many things to do. So, it is not possible to keep on talking while the old Beagle keeps on dripping.

In any case, the pressures of having to provide affordable veterinary costs v. high overheads of operating expenses and increase government regulatory payments mean that not much time can be spent on having long consultations per owner. All employee and associate vets have to be aware of the high financial aspects of running a veterinary surgery and not just how much they get paid.

SURGERY DONE BY ME
The longer the surgical procedure, the higher the possibility of complications of death on the operating table. I told Dr Daniel and the owner that I would be operating on this high-risk old dog with seizures. The wife did not want euthanasia even if an inoperable cancer was found. I incise the bladder from the apex and removed the greenish and blackish red clots.

There was an inoperable cancer in the bladder as it was large, had white stony specks and had infiltrated the tissues near the neck of the bladder (image on left). The neck of the bladder has the sphincter muscles which controls urine outflow and the cancer had spread to this critical area.

The neck of the bladder is a narrow area where the final path of the urine flows out of the body. Excising the large tumour near the neck in total means that the whole bladder would be "decapitated" and the dog would have no bladder. With no bladder to hold the urine, it was as good as being dead.

So, should I close up the bladder? "Why not excise the tumour?" Dr Daniel suggested.  I excised as much as I could of the cancer.

As at May 18, 2012, the dog was eating and had peed clearer urine. I had not expected this old dog with seizures to survive a 2-hour surgery. Dr Daniel was collaborating with me while I operated to excise the tumour near the neck of the bladder. There was no way I could complete such a bladder cancer excision in 30 minutes. The couple took the high risks to consent to an operation. It was a surprise to me that this dog survived.

DETAILS OF SURGICAL PROCEDURES ARE BELOW:

Proper pre-surgical treatment and planning gave this old dog the best chance of survival on the operating table. It is not a given that all old dogs will survive as many of them have poor health.

UPDATE ON MAY 31, 2012: The dog was normal, still incontinent but not peeing blood. The wife did not mind cleaning up the urinary spots but too much bleeding had led to blood loss and anaemia. So, the decision was to operate but not to euthanase if the tumour was inoperable. In this case, the anaesthetic risk was great and the chances of survival on the operating table were slim. Yet the dog lived when the vet expected him not to make it. Veterinary anaesthesia and surgery are full of unknown surprises.