22. Electrosurgery in hamster wart removal

The hamster's nose wart had a stalk made up of normal skin. If I used the scalpel to cut off the stalk, there would be a lot of bleeding. Shooting blood spurting all over her face. If the hamster was a dog or had a longer stalk, I could ligate the stalk. The stalk was the passage for large blood vessels to supply nutrients to the fast-growing wart. A wart bigger than the hamster's eyes.

"She rubbed off the wart previously," the teenaged girl who was accompanied by her concerned parents told me. "But the wart came back." Now, I had to decide whether to do electrosurgery on this hamster or not.

Could the hamster survive electric currents coursing through her body? What happens if the electrical circuit did not close completely. Would this old hamster be burnt or die out of shock? I doubt many vets will perform electrosurgery on hamsters to remove a wart. It sounded too risky.

In theory, the hamster should not get electrical burns if the circuit was well connected. The electric current would flow from one electrode out of the machine, pass the hamster's stalk, incising and coagulating the tumour and back to the machine.

To ensure the smooth flow of electric current without burning harming the patient or doctor, the following must be done:
1. A plastic sheet on the operating table which is metallic.
2. Normal saline on the gauze which is then placed on top of the pad of the indifferent (neutral) electrode. Saline, unlike water, conducts electricity well so that the current goes home via the indifferent elctrode back to the machine.
3. The hamster's lower body must be in full contact with the gauze.
4. No saline should be present outside the indifferent electrode.
5. No explosive anaesthetic gas to be used.
6. The hamster must be fully anaesthesized, otherwise she would move about.
7. No sparks should be seen if the procedure is well done as there would then be no resistance to the current flow.
8. The lowest intensity should be used for electroincision and electrocoagulation modes. I intended to incise and then coagulate the wound.
9. An alternative is the use of the blending mode (known as "coagulation 2" in my machine). In the blending mode, the wart is incised and coagulated at the same time. It would be ideal in this case.

Anaesthesia
The hamster was given isoflurane gas in a container for a few seconds. When she was observed to be "sleepy", she was taken out, put on the saline-wetted guaze on top of the indifferent plate.

Surgery
I used forceps to lift up the nose wart. The electroincision wire cut the stalk. There was resistance to the cutting. So I had to increase the intensity of the current. The hamster woke up suddenly and seemed shell shocked just after the passage of the electric current.

That is the problem with using gas isoflurane. It enabled rapid recovery. I had cut 80% of the stalk. There was no return. Quickly I stepped on the foot switch and lanced off the last piece of skin attachment.

There was no bleeding. That was excellent. Previously, I had bloodied noses after excision of the wart with scalpel. This was great. I took the hamster to the consultation room and handed her over to the teenaged girl. She was very happy to see the wart gone.

The hamster was much awakened now. Suddenly the girl said, "My hamster rubbed her nose. It is bleeding a lot." This bleeding was profuse. As if a dam had burst. I took a piece of tissue and put pressure on the nose to stop the bleeding. I wiped the blood away with another tissue. Still there was bleeding.

The hamster moved away from my fingers. Suddenly she squeaked as I pressed the tissue paper in an attempt to stem the flood of bright red blood spurting all over the hamster's face.







"I have never heard my hamster squeak before," the girl sounded distressed. I realise that I had to take the hamster away from the girl, back into the operating room to treat the bleeding. This bleeding was not life-threatening but it was very traumatic for the owner to watch and hard to explain to the owner. "I will use potassium permanganate powder to cauterise the wound," I said to the teenaged girl. "Have you studied this chemical in your class?" She shook her head. Probably she was in Secondary Two and had not studied chemistry. So she had not heard of this chemical.

In the silence and peace of the operating room, I wiped off the blood from the hamster's nose, applied potassium permanganate powder. There was no bleeding. Now, the hamster had a purplish black nose. Later one, she would have her normal coloured nose.

In this case, the alternative blending or "coagulation 2" mode might be more useful in the electrosurgical excision of the big hamster wart. As very few hamster surgeries are done, I would have to wait for the next case. Not many hamster owners have problems with warts.

Life is a continuous learning and hands-on experience is the only way for the vet to hone his skills in electrosurgery of the hamster.

Full report is at www.toapayohvets.com

21. Mission Impossible in 16-year-old canine pyometra

"The surgery must be completed in 15 minutes if the dog is to survive," I said to my two assistants. They looked at each other with a grin. It was just not possible.

This 16-year-old dog had not been eating for 5 days. Dark coloured vaginal discharge in large amounts. Was this the end of her life? Without emergency surgery to remove her infected womb, she would die. She might die if she was operated.

"Please wait," the best friend said to me as the lady owner made some phone calls outside the surgery. Her eyes were red. 16 years in a dog would be equivalent to over 100 years old in a person. Too old to survive an operation. The lady finally consented to the surgery and knew that it could be the last goodbye when I asked her to go home.

However, if the operation could be performed in 5 minutes, she might survive. But pyometra surgery would take more than 5 minutes. The shorter the anaesthesia, the higher the chances of survival. The following were done:

Pre-operation
1. 20 ml dextrose saline with baytril, lasix and spasmogesic injections were given 1 hour ago. Her temperature was 39.5 degrees C, pulse was strong and respiratory rate was normal.

2. I/V dextrose saline drip given.

Anaesthesia
Isoflurane gas by mask, intubate, gas at 0.5 to 1% to effect. My assistant, Mr Saw was now much more experienced in assessing the depth of anaesthesia. I noted that the blood during my surgery was bright red instead of bluish and so I knew he was doing a good job. It was great surgical anaesthesia. "Keep lowering the % till the dog react" I advised him to check for pedal pain and eye blinking reflexes. Only during the end of surgery did the dog move a bit. Mr Saw increased the % to 5% but I told him that 2% would do.

Surgery
"More haste less speed" seemed to be presented when I incised the linea alba, the midline fibrous tissue connecting two halves of the abdominal muscles. I incised but found that the muscles did not separate. I saw the brown muscle fibres instead. The linea alba was faint in this region and my incision missed it by 4 mm. "Look further cranial," my second assistant advised me as he saw me looking for the linea alba which was faint at this area, around 6 cm from the umbilical area. I checked anteriorly and followed the direction of the linea alba backwards. Got it.

The muscles separated. I put my gloved finger into the abdomen. The small and large intestines were blocking my view. A few seconds passed. I hooked out the swollen uterine tubes.

Ligated the ovarian tissues. Then the uterine body. Time was passing by fast. The dog had not given me cause to worry as the bright red blood indicated that she had sufficient oxygenated blood and her heart was beating normally under general anaesthesia. Still I could not be complacent or slow. Anytime the heart could just stop beating and a dead dog would be presented.





After getting rid of the uterus, I quickly put 3 simple interrupted sutures at 0.8 cm apart to close the muscles. No fanciful subcutaneous sutures as this would take more time. I just stitched up the skin with 3 horizontal mattress sutures.

"Switch off the anaesthesia," I said to Mr Saw. He had already reduced the gas to 0.5% and the dog was still anaesthesized. This showed that the dog was very weak as normal dogs would need 2% to be knocked out. "Switch off," I said as I tied the 2nd of 3 skin stitches. Mr Saw did it. I completed the 3rd stitch. The dog just woke up suddenly.

"Take out the endotracheal tube," I said to Mr Saw who had by then, untied the four legs. "Put the dog's head to the side in case she vomits."

The dog just looked as if she had a nap. She wailed and wailed. This happened sometimes after isoflurane gas anaesthesia without any other tranquilisation or sedation. Why would a 16-year-old dog wail and wail, I cannot say. Neither do I many case of such old dogs with pyometra. I thought the old dogs had menopaused and would never get pyometra. This case proved me to be mistaken.

But such loud wailings are good signs of a dog being much alive at the end of surgery and were a joy to hear. I don't want to see a dog knocked out and still sleeping when the last stitch is completed as there is a risk that the dog may die
later.

"What time is it?" I asked Mr Saw as I completed my last stitch. "4.55 pm," he said. He was at the far end to my left and opposite me at the other side of the operating table, nearer to the isoflurane vaporiser. I looked at the clock, just above the door of the operating room and to my right. "It is 4.53 pm" I said. So, I had used up 18 minutes to perform the surgery. It was really Mission Impossible.

The naughty senior citizen was alert but refused to eat. Well, what do I expect? She had just completed a major surgery. Her temperature dropped to 36 deg C 30 minutes after surgery. She had the IV drip but I was worried. I phoned her owner. She could still die despite a successful surgery.

I phoned the lady owner to get the dog home to nurse. This would be a finicky dog and would not eat unless hand fed. The best friend had a car and the dog went home. Some one hour later, the lady phoned, "My dog passed blood. Is it normal?"

"Yes," I said. "The blood is from the vestibule of the vagina." I doubted that the lady knew what vestibule was about. In any case, she said that the dog ate and everything was OK.

20. Electro-cautery in a Jack Russell

Will electro-surgery kill the old Jack Russell who has a weak heart?

The Jack Russell needed to be unconscious so that the gigantic mouth tumour could be excised using electricity. Yet he had a weak heart. Anytime his heart could fail and he would be gone from this world. Therefore, general anaesthesia using isoflurane gas was kept to the minimum.

The gas was like the force shield in Star Trek's Enterprise, protecting the starship from powerful killing forces.

As the electricity shot through the electro-cutting bladder to slice off the tumour at the edges of the gum, the dog started to jerk. The protective force shield was insufficient to protect the dog's systems.

His tongue moved and he opened his mouth. His heart stopped pumping blood. I could see that his tongue changed from pink to purplish in colour.

"Increase the dose to 5%," I stopped the electro-surgery. The dog was feeling the pain. The force shield needed to be at its maximum. However, it could overload the dog's heart and kill him. There was a need to know how long the 5% had to be given. One minute or more? There was no formula. The longer, the higher the risk of death on the operating table.

The dog started to slip into unconsciousness. The electro-cutting blade transferred electric current into the tumour. Zap, zap, zap... the electric sparks flew.

"Smells like burnt meat," Intern 1 who had never seen electro-surgery probably thought of her barbecue parties. The 9-sq m operating room with 2 interns, 2 assistants and myself was packed.

The faster the operation was done, the better chances of survival it was for this old dog. 15 minutes had passed. Now the dog was unconscious at 1% gas anaesthesia. The 2nd tumour in the hard palate was zapped and removed. Now, the electro-cautery electrode was used. The blood flew profusely from the gum after the tumour had been cutting. The red light at the end of the electrode blinked indicating that electricity was coursing through. However, the bleeding continued.

"Turn the dial to higher intensity," I said. The assistant turned the knob to No. 3. I put the electrode onto the bleeding point. The steam rose as the electricity burned the blood vessel as I stepped onto the foot-switch. The surgical area was now dried. No more bleeding.

The dog moved suddenly and darted his tongue in and out of his mouth. His tongue changed to a deep purple.

I looked at Intern 2. "Is the indifferent plate still in contact with the dog?" She was to ensure that the dog's abdomen was in contact with the "indifferent plate" which had been moistened with a wet gauze swab in normal saline. This plate conducted the electricity away from the dog to the machine. A complete circuit.

"Yes," Intern 2 said. I checked. The interns were inexperienced students from the Junior College waiting to study veterinary medicine. They had never seen electro-surgery in their 18 years of living. Neither did the two Myanmar assistants. Electro-surgery is seldom performed as there are not many indications requiring this machine.

Therefore, I had to be extra vigilant and yet needed to educate the younger ones on the application of electro-surgery. Seeing is believing for them.

"OK," I said to my assistant. "Take out the endo-tracheal tube now. The operation is completed." There was not a single drop of bleeding from the gum. The dog got up as if he had a short nap. It took team-work to complete the surgery in 18 minutes.

The Jack Russell wagged her tail. She was a most friendly dog and would never threaten people unlike some crazy Jack Russells I had encountered. She was not able to communicate as a human being. But she appeared quite happy as the she could now close her right upper lip normally.








NOTE: Oral tumours form when there is poor dental hygiene in dogs. In old dogs, it would be best not to attempt surgical removal of the oral tumour and dental scaling and extraction at the same time. This increased anaesthetic time considerably and the risk of anaesthetic death. Therefore, do the surgery and forget about the dental for the time being if you want a positive and happy outcome.

19. Focal dystonia in a veterinary surgeon

FOCAL DYSTONIA IN A VETERINARY SURGEON



For the past year, sometimes, the 4th finger of my left hand curls inwards involuntarily and I have to uncurl it with my right hand to continue surgery. What's the cause of this sporadic problem?

I presume it was due to aging. After all, I am no spring chicken, being 58 years old.

Could this be carpal tunnel syndrome which is commonly diagnosed in people such as mothers holding babies?

This problem does not happen all the time and has never happened while I do typing or writing. I do use the keyboard a lot to write and create pictures for the "Be Kind To Pets" (www.bekindtopets.com) educational website everyday.

Today, I read in the Straits Times, March 12, 2009, Pg C6 "Back with two hands" that the famous Ameican pianist Leon Fleisher could not uncurl the last 2 fingers of his right hand for 30 years. So he could not play the piano with his right hand. His condition was correctly diagnosed in the late 1990s as "focal dystonia". This is a neurological disorder originating in the brain. Wrong impulses from the brain cause the muscle of the finger to contract and twist involuntarily inwards.

Apparently, focal dystonia affects musicians, writers and surgeons. I had found the correct diagnosis for my problem. Botox injections and regular hand exercises can treat the problem but there is no permanent cure as at 2009.

Or is there? More research needs to be done by me. Maybe I will be forced to stop doing surgery later. A new career as a licensed travel agent?

1. Post-spay complications - The "surgical signature" of a vet

The surgical signature

"Everything was OK for the past 2 weeks after spay," the cat owner I had not met before brought in a black cat with yellow pus in her spay wound matching the colour of her yellow eyes.

As I did spay a black cat with yellow eyes recently, I assumed that this was the cat I had spayed and there was the post-spay complications of wound breakdown or infection which do happen in rare cases.

In the black cat I spayed recently, the owner pressured me to charge him $35 for spaying as it was the fee offered by some vets. Spaying of a cat is a commoditised such that the lowest priced vet gets the most business (my presumption).

"The reason I do not pay $35 to the vet who charges much lower than you is that my cat's left ear tip must be snipped off after the spay."

It is difficult to sustain the profitability and upgrading of a veterinary practice if I compete on "lowest spay price". So I was prepared to let the case go as I don't want to lose money doing a surgery. I will become bankrupt providing loss-making services in time to come.

Unlike a human general practitioner, a veterinary practice has surgical and anaesthetic equipment to buy and maintain. The rentals and staff overheads are high. Therefore, going down the path of the being the lowest priced vet is not sustainable for profitability in the long term.



Back to the black cat on my consultation table, the owner said he did not know who had spayed his cat as he was not the one who brought the cat to the vet. One look at the cat's incision wound told me that my "surgical signature" would be around 1 cm from the umbilical scar. This cat's wound was at least 2 cm away. Therefore it was not me who had spayed the cat.

In any case, the owner said that there was no problem for the past 14 days. The cat I spayed was 7 days ago and I had never heard from the other owner with the black cat.

I noted some brown stains of an iodine-like antiseptic further away encircling the wound. I did not ask the owner whether he applied antiseptic which had been licked off. How could his black cat do it when she had worn an Elizabeth collar?

"Do you have another cat in the house?" I asked him.
"Yes,"
"It is likely that the other cat cleaned up the wound for this black cat," I said. The owner nodded his head.

So, what's the solution? The cat had a fever. It would cost the owner more money to get her treated. In times of recession, this post-surgical treatment is not kindly accepted by a pet owner.

I removed the stitches, warded the cat and gave antibiotic injections for 3 days at minimal cost of $50.00. For the last 7 days, I did not hear from the owner and presumed that the cat had resumed a normal life.



Other pets licking the wound of the spayed cat or dog are unexpected causes of post-spay complications. Vets seldom if ever ask the owner to separate the spayed pet from another as we never think of such situations.

Chicken bone was neither here nor there

Sunday Nov 16, 2008

A bright sunshine day. The Maltese had survived day 6 of the surgery and should be OK. So she was going home.



VETERINARY SURGERY TO REMOVE A CHICKEN BONE BETWEEN THE OESOPHAGUS AND THE STOMACH

This was a rare case of a chicken humurus bone trapped between the gullet and the stomach. Neither here nor there. I mean, if it was in the stomach it would be an easy surgery. But it was 3/4 in the gullet and 1/4 in the stomach as shown in the X-ray taken by Vet 1.







The major problem was before induction of anaesthesia. The dog had already vomited twice over 40 ml of white bubbly saliva onto the consultation table. Frothy white saliva covered the front of the epiglottis - obstructing any view of the epiglottis opening. So this was a difficulty airway and aspiration risk case. No intubation should be done as the opening of the epiglottis was masked by foamy white saliva.

Should I use injectable anaesthetic? Well, if this old dog did not have heart disease, topping up injectable anaesthetics should do. But gas anaesthesia is the safest method in old dogs with heart disease. I had never done surgery using topping up of injectable anaesthesia as I feel that this was not the safest way to do it. Yet, in this situation, there seems to be no choice.

15. Ear gangrene in a Maltese

"Bluish black ear tips. What did you do to Gom's ears?" I asked the well groomed young Korean lady. Her English was excellent and so it was easy to communicate.

"I tied her ear tips with a rubber band," she had watched and adopted the same procedures done in a Korean TV program on Malteses. Shih Tzus do get their long hair tied up above their forehead so that they can see and look pretty.

"The blood supply to the ear tips is no more," I explained. "The ear tips have no blood supply due to the rubber band cutting off the flow of blood. Now the tissues are dying. This is called gangrene. Did you use a groomer's rubber band for Shih Tzus?"

"No," the lady showed me a red rubber band normally used for tying things.

What to do with these two dying ear tips? Nothing much could be done to reverse the cell death. 3 days later, the young lady came as the left ear tip had become black and hard. I asked Groomer Aung to clean it.

"The ear tip dropped off," Groomer Aung showed to the dead triangular piece to me and the lady owner. She cupped her hands to cover her eyes. It was too much for her to see.

I took away the gangrenous ear tip. What to do now?

"The right ear tip is becoming black," I showed the owner. "It will also drop off in a few days' time. I advise cutting it off now."

"How much it will cost me?" the lady had a tight budget as she was studying in Singapore. Many foreign students in Singapore and I am sure, even in Australia and other countries survive on a tight budget as their parents skim and save to pay for their expensive undergraduate fees and accommodation.

In theory, such students ought not keep any dogs to minimise expenses. But they are not from the frugal baby-boomer generations that have had experienced the deprivations of World War Two. So, some of these Internet Generation do buy puppies and if they do make great companions in a foreign land. If they don't fall sick, expenses are affordable.

"$60.00 to cut off the gangrenous right ear tip," I said. It was take less than 10 minutes of anesthesia and cutting off the tip would be two seconds. Potassium permanganate powder applied on the wound would stop bleeding. Hence the quotation was low.

"Can you make both ears of the same size?" the fair lady assumed that cutting off a larger piece of the right ear tip instead of the small gangrenous tip would be the same effort.

To the owner, aesthetics are important. Which owner wants to see her companion with uneven sized ears every morning? Friends would ask awkward questions too.

I thought of a Singapore boy with a Bichon Frise studying in Murdoch University. He was on a tight budget as his parents had to pay for his high undergraduate fees and accommodation of at around $50,000 a year.

So I understood the financial situation of this fair Korean lady. It is expensive living in Singapore. Fortunately she did not buy a car but taxi fares add to the veterinarian add up. Pet dogs are not permitted on buses and the subway in Singapore and so taxis are the sole transportation.

I did not explain that it takes 10 times longer to give Gom ears of equal sizes and therefore the veterinary fees would be much more than $60.00.

Gom was a happy puppy. I masked him and tubed him to give him the isoflurane gas anaesthesia. He did not sleep well under intubation and was gagging as if he did not like the endotracheal tube.

The anaesthesia was uneven and delayed my surgery. I had to worry whether he would die on the operating table since he could not get to the surgical stage of anaesthesia unlike other puppies.

When I took out the endotracheal tube and just gave him gas via the mask, he slept like a baby. The gangrenous left ear tip was placed against Gom's right ear to get the area to be cut. I drew the incision line with a marker pain. Pulled back some skin so that I could suture over the cut cartilage. It was not possible in Gom as her skin was taut. A curved artery forceps was clamped below the black marker line and the cartilage was covered with an inverting 5/0 absorbable suture, as in stitching the uterus during Caesarean sections.






The left ear tip was clamped and similarly cut to remove the gangrenous edges and dead cells. There was much less bleeding and the suturing stopped the bleeding. The right ear tip area bled a lot as it was normal tissues cut by me to ensure that both ear had equal sizes. The bleeding was not serious, so I did not bandage up the right ear to stop the bleeding. I would have had done in a Doberman after ear cropping.

Ear cropping by vets for cosmetic reasons is prohibited in Singapore in the past decade or so. However, it was not prohibited when I started practice some 25 years ago.

Gom had to stay one night for observation. Early the next morning, her owner came to take her home. The bleeding had stopped. Everything should be all right for Gom (Bear in Korean language).