What first?!

RE: What first?!

Julian Earl — Wed, 26 Jun 2019 23:09:13 GMT

[quote user="David Mills"] But to say this must always be done is an absolute clinical nonsense in the vast majority of pyometras (I'm not talking about the sick ones, the collapsed, those in septic shock etc etc), and all open pyometras where the dog is bouncing off the walls, just because, once in ?500 ?1000 cases you had one rupture overnight. [/quote]

Excuse me David, but I do not believe that I have said it MUST be done immediately. but that was indeed my choice and preference for the reasons that I thought I had explained. This routine was adopted by me, after that single rupture some years ago and have not, as far as I can recall, seen another ruptured uterus.The key for me was always electing to operate on my own case doing a procedure that I had become slick at doing and so that I could administer whatever fluids I deemed appropriate etc. Instead of off-loading the major procedure onto a colleague who might not be as happy doing the op. as I was. My job satisfaction was the reward.Then the following morning I was free to do whatever other tasks I might have line up. But nowhere did I say this pyo-spey must be done as an immediate emergency-procedure. The fluids are probably the most urgent aspect/ There are some other potential benefits in operating ASP, but not vital ones?

RE: What first?!

Anthony Todd — Mon, 24 Jun 2019 17:22:58 GMT

QUOTE:

Anthony Todd

Nobody has told me yet whether, after these modern cervix opening drugs have apparently worked, the bitch does the same thing next time??
Or whether they ever conceive???

Used it twice, worked both times. One was a youngish bitch and they successfully bred her on the next season. Don't think ever came back or was ever spayed. I can't remember the other one's fete, but remember LOTS of puss.

We don't have an evening surgery so will usually do them same day. Wouldn't do it OOH or anything. Fluids overnight and then home - usually looking like a different dog. I agree it's really a surgical condition, but can be medically managed.

This seems to me to be a valid argument for the value of one or two anecdotes as I don't think there is any other evidence, or is there??

RE: What first?!

Anthony Dennison — Mon, 24 Jun 2019 17:20:57 GMT

Not had anything die pre-op as far as I'm aware, had a couple die post-discharge from hospital. These were the sicker ones to start with, and I suspect were starting to suffer with SIRS.

RE: What first?!

Anthony Todd — Mon, 24 Jun 2019 17:15:21 GMT

[quote user="Anthony Dennison"]rare occasion something does go[/quote]

As most vets remember their bad experiences very well, we should have someone on here that has had a pyo die.

My guess is it's rather rare? Anyone done a PM and diagnosed a pyo before surgery?

RE: What first?!

Julian Earl — Mon, 24 Jun 2019 17:14:43 GMT

[quote user="Gillian Mostyn"] can't remember any dying (although I admit it is possible without my knowledge.) Whose anecdote is more valid? Neither.[/quote]

I have only had one die about three days post-operatively dueto renal failure. At this time, the poor dogs did not routinely receive NSAIDs or other post-operative analgesia so have to assume that it was the glonmerulonephritis accociated wth a pyometra.. I do not think that they routinely received drips either! So this is another anecdote that has formed the basis of my treatment regime during my career: I always give fluids, blood test all cases that do not respond dramatically within 48 hours of surgery. But does it support the idea that surgery is a better option than medical therapy by removing the source of toxins underlying the antigen/antibody complexes causing the glomerulonephritis? If Alizin or other does physically remove enough of the contents then the risk might be reduced enough but how important is the time-factor for this?

Heck I saw well over 100 cases before I even went to university and knew the relevant history: symptoms, recent season, discharge etc., etc and even the smell and in those days: the mid-seventies, the dogs were just anaesthetised with Thiopentone and maybe Halothane as well in exceptional cases, and received no fluids at all, no pre- or post-op blood tests were used and those dogs always seemed to recover within 48 hours as well! Not only that but catgut was invariably used for the linea alba, muscle, s/c fat and then nylon for the skin. I never saw a breakdown in the gut as far as I can recall either. No PDS existed in those days!

Incidentally, I worked at a small-animal vet's in Leeds for six years on Saturdays and Sundays then one year full-time before my five years a Liverpool etc. So pyometras were a regular presentation there over the years. A central part of my job was collecting history onto the record cards before the consultation. At that age I was hungry for knowledge about my dream-job so absorbed the significant aspects of histories and could eventually I could even make a stab at a diagnosis of my own as I collected the information. Likewise I saw, without exaggeration hundreds of cases of distemper at that time. To the day of my retirement, I always asked the same questions of owners abut their pets that I learnt when working in Leeds aged from 14 to 18. So that is partly why I have seen so many pyometras over the years; and have strong opinions on my best approach to cases I suppose?

RE: What first?!

Anthony Dennison — Mon, 24 Jun 2019 17:08:08 GMT

[quote user="Michael Woodhouse"]I just think it's important to be careful saying that this is better for that reason, when we don't know that. That's when someone says "never let the sun go down on a pyo" and moves on to "the VDS won't defend you if you don't operate the same day" rubbish that weeds its way into the profession.[/quote]

100% agree. If we ever have a pyo sent over early evening or come in OOH, we very rarely operate that night. Put on fluids overnight, operate in the morning when there are more people around for the rare occasion something does go tits up.

RE: What first?!

Anthony Todd — Mon, 24 Jun 2019 17:08:02 GMT

[quote user="Gillian Mostyn"]Of course they can - and you've just kneecapped your own argument. We can never think we KNOW[/quote]

So why do most on here advocate a "proper" trial after any anecdote, or opinion, and dismiss out of hand, a lot of anecdotes called "experience"?

In the absence of any stats it would be interesting to hear of the number of "pyos" that did die prior to surgery, I doubt if there are many.

But the "100% [failure] of an individual case" applies, and is hard to justify,

RE: What first?!

Gillian Mostyn — Mon, 24 Jun 2019 12:43:05 GMT

[quote user="Anthony Todd"]

Rich and Fabricant spent a lot of time and effort showing very scientifically that FUS was caused by a virus.

Peer reviewed an' all, so even the mighty, and scientists, can spout research based bollocks if they really try.

[/quote]

Of course they can - and you've just kneecapped your own argument. We can never think we KNOW.

There are opinions and theories which, sometimes, in the fullness of time, are found to be incorrect. Usually when better methods of investigation are discovered and utilised. Something that you considered right and correct 5/10/20/40 years ago WILL be contradicted eventually. Maybe some are confirmed as correct - but most are modified.

If that didn't happen, we'd all still think the earth is flat and the sun orbits us.

Oh, and I've never had a pyo rupture (20 years and counting), rarely fix them the same day and can't remember any dying (although I admit it is possible without my knowledge.) Whose anecdote is more valid? Neither.

RE: What first?!

Anthony Todd — Mon, 24 Jun 2019 00:18:20 GMT

[quote user="David Mills"]It is incumbent on the more experienced to not spout cognitive biased bollocks that in any way adds to this, if you care about the professions future in any material way as opposed to trying to desperately defend an obviously illogical position.[/quote]

It would add more weight to your sweeping statement if you would, or could, quote some examples please.

I, as a geriatric dinovet, can't correct my hard won opinions without clear, patient, direction and correction.

Rich and Fabricant spent a lot of time and effort showing very scientifically that FUS was caused by a virus.

Peer reviewed an' all, so even the mighty, and scientists, can spout research based bollocks if they really try.

RE: What first?!

David Mills — Sun, 23 Jun 2019 23:46:33 GMT

Exactly this. And then it gets jumped on by big "emergency" providers, and hey ho, it's now taught as an emergency when it isn't, new grads are terrified of them (I've seen them referred regularly), clients are charged through the nose, and there's a "gold standard" way of doing them before long. Which, if you're unlucky, you'll be judged against if it ever came to that.

It's a pernicious, creeping aspect of the profession that it is becoming obsessed with categorisation and "correct process" rather than outcome. A bland, standardisation, protocol-led profession that removes choice and, importantly for shareholders, increases fees.

It is incumbent on the more experienced to not spout cognitive biased bollocks that in any way adds to this, if you care about the professions future in any material way as opposed to trying to desperately defend an obviously illogical position.

RE: What first?!

Anthony Todd — Sun, 23 Jun 2019 18:01:01 GMT

[quote user="robloxley"]No. Anecdotes tend to be the things you remember, often the outlier cases. Building an evidence base means being more systematic, looking at all the data/cases, not just the ones that stick in your mind.[/quote]

Sure, but they are then, if remembered, [and with the same selectivity in some well-known instances] just a formal list with amplification of a series of anecdotes. Still just information.

How do you think it was discovered that ACP could cause penile paralysis in horses? One was enough, but now there could have been a few more on here, for example.

RE: What first?!

Rob Loxley — Sun, 23 Jun 2019 17:42:16 GMT

[quote user="Anthony Todd"]Given that almost all veterinary knowledge is just a dressed up series of anecdotes[/quote]

No. Anecdotes tend to be the things you remember, often the outlier cases. Building an evidence base means being more systematic, looking at all the data/cases, not just the ones that stick in your mind.

RE: What first?!

Anthony Todd — Sun, 23 Jun 2019 16:07:15 GMT

[quote user="Michael Woodhouse"]Anything could have happened and I really don't think we can or should make 'rules' from anecdote. I see that as really the point David is making, and I have to agree.[/quote]

Given that almost all veterinary knowledge is just a dressed up series of anecdotes your argument must fail in that even one anecdote has, therefore, some value.

Logic must suggest that the sooner this sort of procedure is done the better or you could just say "never" is just as good.

Add the owner's anxiety and it's even easier to justify.

RE: What first?!

Julian Earl — Sun, 23 Jun 2019 15:44:24 GMT

[quote user="Michael Woodhouse"]No one knows IF doing it the same day reduces the risk of rupture. What's to say that as you picked the dog up to anaesthetise it you caused the rupture? The uterus may have stayed intact if left and the cervix be open and draining the next morning? maybe the aggressive scrubbing by the nurse ruptured it? Anything could have happened and I really don't think we can or should make 'rules' from anecdote. I see that as really the point David is making, and I have to agree.[/quote]

Thanks again Michael,

Ihad often wondered, notabout the scrubbing up but if even my (gentle!) abdominal palpation caused the rupture! But whatever the precise cause, I am glad to have operated when I did. If ne wants to get into what-if scenarios? Then if it had died overnight before the next morning I would have needed to justify not operating that night. I could probably have done that with a certain amount of waffle and a number of "buts" In the event everything turned out okay and I am certain that my decision was correct. However, you and David are arguing that it is unnecessary to make it a general rule, if I understand you both For my own reasons that I've tried to highlight, I choose to get them done sooner rather than later. correctly? I think that is the personal choice of the surgeon. Maybe I was lucky in my decision that evening but does that matter? I suppose what I should advise to newer graduates for example is to be realistic but ruptures do occur even with open pyometras and make your decisions early if you can [ staff-permitting.] I hope that is satisfactory?

RE: What first?!

David Mills — Sun, 23 Jun 2019 15:40:28 GMT

[quote user="Anthony Todd"]

PS and I digress!!

I have a rare solicitor who answers and/or actions every communication on the same day and sends me a copy of her every action [inevitably] sent to the other side!!

[/quote]

Maybe stop at this marriage?

RE: What first?!

Michael Woodhouse — Sun, 23 Jun 2019 15:16:17 GMT

[quote user="Julian Earl"]The fact remains that occasionally they can rupture and early removal ide-steps that risk. [/quote]

I'm not arguing with you - if I have a pyo to do I will almost always do it the same day.

I just think it's important to be careful saying that this is better for that reason, when we don't know that. That's when someone says "never let the sun go down on a pyo" and moves on to "the VDS won't defend you if you don't operate the same day" rubbish that weeds its way into the profession.

No one knows IF doing it the same day reduces the risk of rupture. What's to say that as you picked the dog up to anaesthetise it you caused the rupture? The uterus may have stayed intact if left and the cervix be open and draining the next morning? maybe the aggressive scrubbing by the nurse ruptured it? Anything could have happened and I really don't think we can or should make 'rules' from anecdote. I see that as really the point David is making, and I have to agree.

RE: What first?!

Anthony Todd — Sun, 23 Jun 2019 15:07:43 GMT

I don't care! THE EAGLES are at Wembley tonight and I've just got a free ticket!!!!

RE: What first?!

Julian Earl — Sun, 23 Jun 2019 15:01:46 GMT

[quote user="Michael Woodhouse"]

his is one of those prime examples of our selective memories distorting the truth. I suspect if you did a big enough study you'd actually find that on average it was much safer for the animal to have its surgery the next day when the practice is fully staffed. You have a single memory that makes you jump to the conclusion that because something happened once, rushing in makes it safer. These views then get passed on and end up in the vet folklore.

It leads nicely to:

[quote user="Julie Innes"] I guess buscopan also works to open the cervix (and at least I had my diagnosis)[/quote]

[/quote]

Thank you Michael.

One aspect to which I have referred but have deliberately not overstated is that I personally enjoy doing pyometra op, and also prefer to deal with my own cases. So by doing it the same evening I cover all bases as it were. You might or might not be aware but I have always done mixed practice and have had many mornings occupied with routine fertility visits. Those visits left me unavailable for the surgical list on many mornings so my personal choice would be to do the procedure straightway with all the accompanying benefits: better for the dog, more satisfaction for me , a lighter case load for everyone else in the practice. okay these are non-clinical reasons but this is real life and I who knows, maybe, just maybe I'd avert another rupture by following this plan of action? Sorry, I do feel like I've cheated by introducing this reason with my argument to do the procedures the same evening but this plan has worked for me so far. The fact remains that occasionally they can rupture and early removal ide-steps that risk.

RE: What first?!

Anthony Todd — Sun, 23 Jun 2019 14:21:24 GMT

[quote user="Michael Woodhouse"]Of course, but this is one of those prime examples of our selective memories distorting the truth.[/quote]

Could be, but it's odd that dinoveteal experience is always dismissed when it conflicts with modern teaching or [usually] just dogma.

How many trials have been done on odd drugs causing cervical dilation?

When the odd pyo etc. has some calamity overnight, after the delay I've always found that saying "that's a rare unforseen event" usually unconvincing..........

RE: What first?!

Michael Woodhouse — Sun, 23 Jun 2019 14:01:39 GMT

[quote user="Julian Earl"]Surely I am entitled to pass on my [considerable] experience as long as I can justify my reasoning.[/quote]

Of course, but this is one of those prime examples of our selective memories distorting the truth. I suspect if you did a big enough study you'd actually find that on average it was much safer for the animal to have its surgery the next day when the practice is fully staffed. You have a single memory that makes you jump to the conclusion that because something happened once, rushing in makes it safer. These views then get passed on and end up in the vet folklore.

It leads nicely to:

[quote user="Julie Innes"] I guess buscopan also works to open the cervix (and at least I had my diagnosis)[/quote]

Cervix is not a smooth muscle. If you'd prescribed homeopathy and that had happened, would you be convinced that homeopathy now works? What about if you'd done some acupuncture or reflexology..........

It's no more that superstition like wearing lucky pants to help your favourite sports team win.

RE: What first?!

Anthony Todd — Sun, 23 Jun 2019 12:37:36 GMT

PS and I digress!!

I have a rare solicitor who answers and/or actions every communication on the same day and sends me a copy of her every action [inevitably] sent to the other side!!

RE: What first?!

Julian Earl — Sun, 23 Jun 2019 10:51:45 GMT

[quote user="David Mills"]

A pyometra is rarely, if ever, an emergency, and vets thinking so are simply feeding their own ego. As a charity vet for most of my working life, I suspect I've seen >300. Most that come in of an afternoon are booked for 24-48h, if they're sick then they need IV fluids overnight.

The huge majority are open, and no more an emergency than a cat bite abscess. [/quote]

Maybe this is digressing into the definition of a emergency? I would distinguish between an emergency needing immediate treatment: A stageers in a cow or milk fever etc., those can indeed be drop-everything cases. But my pyometras were not operated upon in the sense tht we need to drop everything now to save the patient. I did them the same evening because I liked doing them , it was not a hugely time-consuming procedure plus always had the nursing staff for the surgery itself and the immediate aftercare overnight. The charge would be the same as if we did it the following morning at 10am. but the dog presumably felt a lot better 24 hours sooner than if left until the following day?

An interesting comparison,David, with a cat-bite-abscess. What do other people do? No they are not usually a life-threatening emergency at all but undoubtedly can make the cat feel very sick and be in a lot of pain. I would always lance,drain and flush those immediately after an evening surgery as well. Not a complicated procedure and the advent of Domitor/Antisedan [ other brands are available!] facilitated quick treatment and recovery. Again the satisfaction n doing this straight away is immense. Not because I've had any suffer complications by not doing it, but just because it is right to do so? In fact with Dom/Ant, it is possible to do all this while the client waits as well is it not? No overnight hospitalisation is then necessary in many cases. Is there any other treatment giving such a rapid sense of satisfaction as draining a large cat abscess? Maybe just one? = A large pyometra except not quite as rapid!

Thanks for your comments.

RE: What first?!

Anthony Todd — Fri, 21 Jun 2019 09:02:42 GMT

[quote user="Julian Earl"]Surely I am entitled to pass on my [considerable] experience as long as I can I accept your argument about the low frequency of ruptures[/quote]

I remember a vet in Toorak, Melbourne pointing out that, as far as an owner was concerned, one vaccination breakdown was 100% and the same logic would apply to a pyo that ruptured overnight.....!

RE: What first?!

Iain Richards — Fri, 21 Jun 2019 08:47:47 GMT

[quote user="Julie Innes"]RE the millophylline thing[/quote]

Wow, I'd forgotten about that. Here's a really cheap way, no surgery, no ethical dilemma!

(Cheap comment I know and I burn with shame)

RE: What first?!

Julie Innes — Fri, 21 Jun 2019 08:44:29 GMT

RE the millophylline thing: years ago (first job!) I saw a big Doberman with a painful abdomen OOH. I gave her buscopan and chatted to the owners about getting her back the next day for some more investigation. As we were chatting, she suddenly flooded the floor with a sea of pus from her vulva. I guess buscopan also works to open the cervix (and at least I had my diagnosis)