Decision making

RE: Decision making

Robin Grimmer — Fri, 20 Nov 2015 19:30:06 GMT

[quote user="Martin Atkinson"]

[quote user="Clive Ansell"]In my first job for 5 years a colleague wore all that paraphernalia and also gave Amox LA to routines ops, where as I did neither and had fewer post op problems than she did - go figure.[/quote]I doubt we're alone, so how do reckon I deserved the red star someone gave me then Clive?

[/quote]

You've been red starred again! Not by me. I used to not wear gloves and didn't have any problems, but I've got used to gloving up now so feels strange without them. Plus you haven't got loads of blood to scrub off your hands between ops. Mind you Martin, I bet you're such a good surgeon you don't get any blood on your hands

I do remember one case years ago when an LA vet did a pinning without gloves and probably didn't scrub up very well and surprise surprise the dog got an infection.

RE: Decision making

Martin Atkinson — Fri, 20 Nov 2015 18:56:07 GMT

RE: Decision making

Clive Ansell — Fri, 20 Nov 2015 18:09:30 GMT

[quote user="Martin Atkinson"]I don't wear gloves or gown, silly hat or mask, just short sleeved non-sterile scrubs and wash my hands/wrists with chlorhexidine and get virtually no wound infections. No routine surgery gets antibiotics. That must say something. [/quote]

Me neither most of the time, although some practices prefer one to wear at least gown and gloves.

In my first job for 5 years a colleague wore all that paraphernalia and also gave Amox LA to routines ops, where as I did neither and had fewer post op problems than she did - go figure.

RE: Decision making

Martin Atkinson — Fri, 20 Nov 2015 17:51:29 GMT

[quote user="Tim Browning"]I am not trying to be picky but we were trained to put our gloves over our cuffs of long sleeved gowns to make a longer rubber barrier.[/quote]I don't wear gloves or gown, silly hat or mask, just short sleeved non-sterile scrubs and wash my hands/wrists with chlorhexidine and get virtually no wound infections. No routine surgery gets antibiotics. That must say something.

RE: Decision making

Tim Browning — Thu, 19 Nov 2015 10:37:41 GMT

I am not trying to be picky but we were trained to put our gloves over our cuffs of long sleeved gowns to make a longer rubber barrier. Is this still the case? everyone does it here at work here. One never knows if leaving the cuffs out is the latest trend suggested at CPD by some whizzkid.

RE: Decision making

ih220 — Thu, 19 Nov 2015 10:24:57 GMT

(This is my first post...)

It sounds like I might be going against the flow a bit but I would definitely have phoned both owners if I'd found something unexpected during the op which was suspicious of neoplasia. I agree that you can't make a definite diagnosis without further investigation but I think owners would appreciate being warned that there might be further complications (and expense) rather than continuing with surgery and telling them afterwards. The option of waking the dog up and seeing how it goes and then pts involves the risk that the dog is going to suffer further pain/distress before pts, and I think there is nothing wrong with the owner/vet in combination deciding not to take that risk and pts under ga. As has been mentioned, the clients may also have had a bit of time to think and actually decide they didn't really want major surgery for their dog in the first place, in which case they won't take long to make their decision. Of course there would also be clients who would want you to continue if there was the slightest chance of a reasonable recovery, but you don't know that until you talk to them. By the sound of the two dogs' history and findings at surgery I would have given the second one a better prognosis than the first one. This may not be directly relevant, but if the mass in the GDV dog was sizeable then perhaps this could have triggered the GDV in a predisposed breed whether it was benign or malignant?

RE: Decision making

Stephen Courtney — Wed, 18 Nov 2015 18:45:05 GMT

It sounds like the GDV was an unsuitable candidate for surgery in the first place, but i appreciate clients often want you to do everything you can, then have regrets or change their minds.

Once started i would have wanted to finish, and consider that consent to be already given when i start, assuming there isn't anything else wrong as well.

I don't think recovering from the splenectomy and the gastrotomy would have been any more difficult than recovering from the original insult, which is in itself a big ask for an old dog.

Regarding the other dog, i would not expect a reactive lymph node to be anywhere near that size, almost certainly it was neoplasia or something wierd like a granuloma reaction, whether clinically significant is hard to assess but probably the dog would have been OK for a while.

When clients make decisions like this I think they may well be having regrets about the initial decision, and maybe we have been too cautious in our original prognosis ( unfortunately essential to be realistic, but this can put clients off!)

RE: Decision making

Hannah Wynne Richards — Tue, 17 Nov 2015 09:53:36 GMT

Totalagreement with Micheal on the veterinary aspects. As for spelling, prople have corrected mine in the past - but - so what? My shoulders are broad enough to take it

Wynne

RE: Decision making

Arlo Guthrie — Tue, 17 Nov 2015 08:27:01 GMT

[quote user="Michael Woodhouse"]Arlo Guthrie I can't use this forum without a working spell checker. I need to use words like necessary and I have to go away and google the bloody spellings!!![/quote]

Michael Woodhouse I know, I know. Sorry. The fix has been done (along with a number of other improvements), but we're also working on a major upgrade to the jobs section, and it didn't make sense for us to do an interim release before that is complete. Expected this week now (hoping Friday).

RE: Decision making

Michael Woodhouse — Tue, 17 Nov 2015 00:20:09 GMT

[quote user="Silvia Maldonado"]Tha first one was a 13 y.o weimaraner with an already very compromised health, and when splenectomy and gastrotomy was added to the GDV plan, and owners had some time to sit and talk, they decided the recovery would be too much for him.[/quote]

If I had consent to do the GDV then I think I would have simply gotten on with the gastrotomy and splenectomy under the 'other necessary procedures' clause on the consent form. With the right technique a splenectomy doesn't take long (if you have electrosurgery and enough forceps). You could have got the job done in the time you took out of surgery to speak to the owners and give them their time to make up their mind. The biggest choice (as far as I am concerned) was to put the dog with the GDV under GA and correct that.

I'm not saying I am right. Interesting discussion.

[quote user="Silvia Maldonado"]The second one is the one that I wonder, and wonder... I do want to give the best advice, neither a catastrophic prognosis nor unrealistic hopes, with the emotional consequences for the owner in any case. In my experience, most clients choose the option I most advice, and that's why I took the pics and asks for your experiences.[/quote]

I absolutely wouldn't have suggested PTS at this point - because I don't know what I am dealing with. If the mass was unrescectable then yes, but this wasn't. Even with a tumour or mass the dog could have gone on and had many more year's life. I've not spayed that many bitches and I've seen a couple of ovarian 'tumours' - they are not that rare and surgery has always been curative. Both were opened as ?pyo. Neither had the money for histo.

Arlo Guthrie I can't use this forum without a working spell checker. I need to use words like necessary and I have to go away and google the bloody spellings!!!

RE: Decision making

Silvia Maldonado — Tue, 17 Nov 2015 00:00:22 GMT

Tha first one was a 13 y.o weimaraner with an already very compromised health, and when splenectomy and gastrotomy was added to the GDV plan, and owners had some time to sit and talk, they decided the recovery would be too much for him.

The second one is the one that I wonder, and wonder... I do want to give the best advice, neither a catastrophic prognosis nor unrealistic hopes, with the emotional consequences for the owner in any case. In my experience, most clients choose the option I most advice, and that's why I took the pics and asks for your experiences.

RE: Decision making

Michael Woodhouse — Mon, 16 Nov 2015 23:45:04 GMT

I don't understand why you put both dogs to sleep?

Both the GDV and the pyo/ovarian tumour were fixable as primary problems. I would advise sampling and histo. I think I might even whip that spleen and additional mass out, but why not recover the dogs and see what happens?

You can always PTS later if not improving.

[quote user="Stephen Courtney"]It is so easy to be wrong, and can come back to haunt you[/quote]

Not if you PTS them all................

RE: Decision making

Silvia Maldonado — Mon, 16 Nov 2015 23:43:03 GMT

Thanks for all your advice. The more I read about it the more questions that come to my head, but also, the better the advice I will be able to offer and discuss.

That comment of possibly finding a gland reaction to an infection. I'm very row at oncology, to be honest, but could you expect it to get as big as the dog's kidney? or is that too much to be a gland reaction? I cannot help thinking about the case.

RE: Decision making

Stephen Courtney — Mon, 16 Nov 2015 22:47:14 GMT

If it's worth removing,it's worth sending to a pathologist.

I would never diagnose a lump grossly ( at least out loud!) - at the very least stick a needle in and aspirate and prepare a slide.

It is so easy to be wrong, and can come back to haunt you when that lipoma etc turns out to be a mast cell tumour a year later....

RE: Decision making

Braden Collins — Mon, 16 Nov 2015 14:05:20 GMT

As Anthony says, you really need the histology. Without that, you're guessing. I've seen a lot of things that grossly looked horrible but were not neoplastic.

RE: Decision making

Anthony Dennison — Mon, 16 Nov 2015 11:52:36 GMT

Hi Silvia,

I think it's hard to give a prognosis without histopathology - the 2nd mass could have been a reactive LN from the pyo, the spleen could look like that because of the anaema and it's contracted to get more RBC's into the circulation.

I did a pyo a few months back where the dog had been having problems with seasonal flank alopecia and odd seasons and turned out to have ovarian carcinoma; whether this is the case with this dog and there is evidence of spread...

So, to answer your question, I would tell the client your findings and recommend histo to give an idea of prognosis.