Anaemic JRT from stomach ulcer, but then... Surprise!

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Francisco Gomez — Tue, 26 May 2015 21:12:30 GMT

I didn't have the guts to ask. I'm sorry :'-/

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Robin Grimmer — Tue, 26 May 2015 20:40:32 GMT

[quote user="Francisco Gomez"]

Thank you for all your help.

Unfortunately Mac continued to deteriorate and found his PCV to be 21% this morning. I went through the options of what to do next. His owners were always reluctant to 'ex-lap' him for further info (even when he was better and his PCV wnl). Eventually they requested to euthanase him but thanked everyone involved in his case.

It is quite possible that this wasn't an ulcer but a tumoural lesion and he could have more in his intestines, this was discussed with his owners at the time, but they were never keen to investigate further.

Again, thank you all for your input in this case.

[/quote]

Post Mortem?

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Francisco Gomez — Tue, 26 May 2015 18:03:19 GMT

Thank you for all your help.

Again, thank you all for your input in this case.

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Kara Gibson — Tue, 26 May 2015 08:59:31 GMT

Any possibility of rodenticide ingestion? I think it is worth ensuring the clotting times are not drastically lengthened and giving some vitamin K and if his PCV continues to drop I would be worried about gastric neoplasia causing the ongoing GI bleeding. Ex-lap to evaluate the stomach is a reasonable choice and at the very least you can resect the ulcerated area to prevent ongoing bleeding and send off for histopathology. Surgery is indicated if he hasn't responded to medical treatment after 5-7 days.

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Francisco Gomez — Mon, 25 May 2015 08:02:59 GMT

Ok guys, remember Mac? Yep, the dog this thread's was about

Well, I managed to dig up one of the images I got from our endoscope. Sorry about the resolution but it is an old one and that's as far as it goes.

His PCV was returning to normal and he was doing much better. His faeces were still dark but I wasn't worried because he stopped vomiting completely and his stools were normal in consistency. His apetite was also back to normal.

The owner is super-happy with the progress, but I've told them than I'm not that thrilled. His PCV was 31% when I checked on Friday and his got a high reticulocyte count. He's currently on omeprazole and ranitidine. There isn't any other bleeding site as far as I'm aware.

Tomorrow, I will try and convince his owner to let me check clotting factors (although if they've been used and there's no other bleeding site, I will expect some degree of abnormality and I don't think it will give me much more extra information), check his biochemistry (how are ALB/TP... etc), recheck PCV and repeat is abdominal ultrasound.

My hypothesis is that there is something else bleeding and it is not in the stomach (unless I'm missing something else here)... how far would you go? If I don't find anything conclusive, Is there enough indication to open him up or should you continue with conservative treatment and repeat his transfusion if it came to it? [I worry his owners will be emotionally and economically drained by it and will advise pts ]

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Utlendigur — Mon, 18 May 2015 12:56:45 GMT

[quote user="John Flynn"] I suggested that the solution was not to hire more staff, but to remove the bureacracy that had grown up around her.[/quote]

But that is the new cash cow in business. Just look at the volume of regulation, inspection, assessment, assessment of assessors, etc that has grown up in

Waste disposal

Nurse training

Medicines regulations

Health and Safety

OVS training/registration

What would all these people do for a living without the endless creation of new regulation for them to police? And once in place they then have to justify their existence by creating more and more nit-picking rules, inspectors to check we are implementing the rules and fines and fees for being regulated to the nth degree. Cynical, moi?

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

John Flynn — Mon, 18 May 2015 12:47:25 GMT

[quote user="Francisco Gomez"]If we are obliged to do this and the time available is not there, aren't we all failing our patients?[/quote]

The time is not there to convert the pet-owner in front of you into a highly trained professional capable of making independent treatment decisions based on full knowledge and understanding of issues ranging from statistics to pharmacology, so you request they sign their name on some random uncertainty-disclaimer that barely covers your trouser-seat. Heck, I'd need to go away for a few days to inwardly digest the available data on the potential adverse outcomes myself first to be able to perform such a thorough education, then take a further sabbatical to consider the risk-based questionnaires I'd need the owners to complete - I'd never have thought of the cost of their car!

A dog gets a metoclopramide injection and eats a car --> solution = more paperwork required when dispensing drugs?? Really??? So you think that a form saying there may be undesirable side effects, but not specifying that a 9K car may be damaged by the dog on the way home, would have saved you from a hot-shot barrister? He must have been pretty good as otherwise he would have been shot down in flames for not having his dog safely secured in a vehicle.

I personally hate paperwork and consider that it generally detracts from doing an efficient and decent job. I spoke to a lady who was a paediatric physio in the UK recently, she moaned that they were only 30% staffed (whatever that means) due to budget-constraints. I asked how much time she actually spent doing physio on an appointment and the answer was 30-40mins max. I asked how many children she saw in an 8 hour day, she answered 2 to 4. I suggested that the solution was not to hire more staff, but to remove the bureacracy that had grown up around her. We started to talk about what else she did during the day, and were these activities (while hugely meritorious no doubt in a society with endless resources) actually worth prioritising over simply seeing children for physio appointments.

I would suggest that if you have a 10min appointment it is highly unlikley that form-filling is likely to be a more meritorious use of your time than some of the other things you could be doing - if you're brave, then video a couple of random consults and we can discuss what might have been a preferable use of time than form-filling. Indeed, I would suggest that if you have 10mins appointments and are dedicating 5-10% of that time on form-filling (this assumes a very efficient form-filling system in place, otherwise it is likely to be a considerably higher percentage) then you are more likely to be failing your patients.

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

John Flynn — Mon, 18 May 2015 12:47:05 GMT

[quote user="Francisco Gomez"]If we are obliged to do this and the time available is not there, aren't we all failing our patients?[/quote]

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Francisco Gomez — Mon, 18 May 2015 12:16:21 GMT

Rephrasing the question: If we are obliged to do this and the time available is not there, aren't we all failing our patients?

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Francisco Gomez — Mon, 18 May 2015 12:12:21 GMT

[quote user="bob lehner"]

I often site this case when advising people that they really should get informed consent and give details of any possible side effects when using unlicensed meds (and indeed licensed ones).

[/quote]

I don't disagree here.

Unfortunately, we're reaching the point where a single case can have up to 10-12 different (often all licensed) drugs, each with a full A4 sheet of potential side effects. Is it fair/unfair to the pet and the owner, and by extension to the vet, to report /list or not all of them in our 10min slots for consultations?

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Robin Grimmer — Mon, 18 May 2015 10:44:21 GMT

[quote user="Martin Atkinson"]

[quote user="bob lehner"]I often site this case when advising people that they really should get informed consent and give details of any possible side effects when using unlicensed meds (and indeed licensed ones).[/quote]I've never had any nasty side effects in dogs with metoclopramide, just the odd cat going a bit weird. However, I had a vomiting dog in Friday and found some wally (me unfortunately as I'm sole charge) had put the Cerenia bottle back with 0.1ml left in it and not ordered a new one. The dog got that even though it was 1/4 the correct dose. I contemplated giving it some metoclopramide but resisted - glad I didn't now! It didn't come back so I guess it worked or more likely got better despite it.

[/quote]

I agree with Bob. I refer you to a recent case where a dog had an expensive neuro referral, but the cause was given as side effect of metronidazole, which the referring practice had supplied. No informed consent was given so they had to settle the referral costs.

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Anthony Todd — Mon, 18 May 2015 10:38:33 GMT

[quote user="Martin Atkinson"]1/4 the correct dose.[/quote]

How was the "correct dose" determined I wonder?

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Martin Atkinson — Mon, 18 May 2015 10:25:16 GMT

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

John Flynn — Sat, 16 May 2015 22:02:27 GMT

I don't often say this, but that is SUCH a cute video

Glad to hear he's on the mend - you;ve done a cracker job on this one Fran and thanks for posting the interesting case with follow up for us all to chew the fat on. Oh, and special thanks to Jane for her helpful and enlightening post re transfusions.

it's a full and otherwise unremarkable recovery from here on in.

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

John Flynn — Sat, 16 May 2015 22:02:21 GMT

I don't often say this, but that is SUCH a cute video

it's a full and otherwise unremarkable recovery from here on in.

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Francisco Gomez — Sat, 16 May 2015 14:05:45 GMT

and please, let's not talk about his tail... I don't know if his owners had anything to do with that...

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Francisco Gomez — Sat, 16 May 2015 14:03:56 GMT

[quote user="Francisco Gomez"]

3.) Francisco... you're missing something really obvious today, we'll forgive you coz you're a good guy but don't do it again..

[/quote]

Let's be honest. There are some threads in this forum that worth their weight in gold http://www.vetsurgeon.org/forums/t/22546.aspx A better monitoring of the blood transfusion might have saved me lots of headaches.

Anyway in his way to recovery and thanks to all the people who had help me...

Ladies and gentlemen, with the permision of their owners to publish his story, behold the 'Stoic' Mac.

Click here for 19sec video: www.vetsurgeon.org/.../8838.mac2.mp4

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Anthony Todd — Sat, 16 May 2015 00:54:52 GMT

[quote user="Chris Barker"]Agree with Jo and Bob - we had the dog eat the seatbelts of the car (within 15 mins of injection)[/quote]

I wonder if we were using it at lower dose rates; 'cos there were none published before it was licensed?

I always gave it sub.cut too so slower absorption?

This from NOAH.

Overdose: Most of the clinical signs reported after an overdosage are well known extrapyramidal side effects. [Emeprid]

In some very rare cases, extrapyramidal effects (agitation, ataxia, abnormal positions and/or movements, prostration, tremors and aggression, vocalisation) have been observed after treatment of dogs and cats. [Vomend]

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Michael Woodhouse — Fri, 15 May 2015 21:53:53 GMT

[quote user="Francisco Gomez"]

[quote user="Michael Woodhouse"]

Hypocalcaemia from the transfusion?

[/quote]

Nah, thanks Michael, but low Ca was there before the transfusion.

[/quote]

And you've just given a shitload of anticoagulated blood with extra calcium binding properties.

I'd be more worried because it was low first.

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

ruths — Fri, 15 May 2015 20:03:49 GMT

I'd forgotten about that. My fave FB was a chop bone that a westie ate as it dropped off the table. The dog wasn't a natural scavenger but was on immune surpressive steroids for IMHA. It was obviously a s/e of the trestment

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Luca Poddighe — Fri, 15 May 2015 16:05:24 GMT

[quote user="bob lehner"]VDS paid out c £9k to re-furbish the car.[/quote]

And luckily he didn't get a FB.

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Hannah Wynne Richards — Fri, 15 May 2015 16:01:22 GMT

Bob Ouch

Wynne

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Wren — Fri, 15 May 2015 16:00:17 GMT

[quote user="Jo Dyer"]

when using metoclop I occasionally used to get feedback from the clients about an hour after the injection, the most memorable one being: 'my (normally very good-natured) dog has gone mad and won't let me back in the car!'

[/quote]

Ditto this!

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

Chris Barker — Fri, 15 May 2015 15:44:24 GMT

Agree with Jo and Bob - we had the dog eat the seatbelts of the car (within 15 mins of injection) and the dog that by the time it has reached the end of the road had become so aggressive we had to go and rescue the owner and dog . Seat belts were paid out by Smith/Kleine who made Emequell at the time and we always wondered if the side effects claims were part of the reason the drug was discontinued. We got to the stage that any dog getting the injection had to stay in the building for at least 15 mins to be monitored!

Re: Anaemic JRT from stomach ulcer, but then... Surprise!

bob lehner — Fri, 15 May 2015 15:37:49 GMT

[quote user="Jo Dyer"]Many years ago when using metoclop I occasionally used to get feedback from the clients about an hour after the injection, the most memorable one being: 'my (normally very good-natured) dog has gone mad and won't let me back in the car![/quote]

When metoclop was first used in dogs (human prep only available) one of our vets injected a westie for vomitting - owner left the surgery and drove down to Waitrose - went in to do her shopping - when she emerged the dear little dog had gone quite mad and totally destroyed the inside of her very expensive car. Husband unfortunately turns out to be a hot-shot lawyer - looks at all paper work and sees metoclop is not a vet licensed drug and no warnings had been given to the owner re poss side effects etc. VDS paid out c £9k to re-furbish the car.

I often site this case when advising people that they really should get informed consent and give details of any possible side effects when using unlicensed meds (and indeed licensed ones).