What would you do?

RE: What would you do?

Anthony Dennison — Tue, 18 Feb 2020 10:37:59 GMT

Scoping and removing a gastric FB can be a real faff. I imagine something like this would break in to lots of pieces as you try and remove it, unless you use basket forceps which are just as fiddly.

I'm another for induce vomiting. One of our new nurses looked after to dog I made vomit a glove up yesterday - hung a clinical waste bag around his neck so all the vomit was caught in the bag rather than on mats on the floor. Never thought of that before, thought it was genius.

RE: What would you do?

Lucy Fleming — Mon, 17 Feb 2020 16:52:08 GMT

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/28890/what-would-you-do/219577"]As a young graduate [BITD], I believe it was common practice to continue to use an open vial SC and it worked without problem even when it went green[/quote]

Can testify to having done this with my own dog (we too tend to keep the open vial around, and it doesn't always get binned at the end of the day once whoever opened it has forgotten about it) when the husband left her unattended near some Welsh cakes. Despite having gone distinctly yellow, it worked fine. A few years ago Forum were at BSAVA asking lots of leading questions about wastage with Apometic and I told the rep this story, don't think it fitted in with their preferred narrative They were refusing to say what they had in the works and I was hopeful it was some sort of multi-dose vial, turns out it was just the switch to Emedog which admittedly results in less waste but higher cost to the client.

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/28890/what-would-you-do/219577"]As an aside - I use whatever apomorphine is on the shelf, it's not really a phone around and see if I can find a dog branded one sort of a drug for me[/quote]

I'm not sure quite what you mean by this? I've only ever used what we had on the shelf - surely if you have nothing in stock you can't exactly help the dog given that it needs to be administered in a timely fashion. Sure, if the "branded" (or I think you mean licensed ) version was unavailable, then a human generic could be ordered in replacement, but shouldn't be kept in preference to the branded version based on cost alone (sadly).

RE: What would you do?

Beats — Sun, 16 Feb 2020 08:21:06 GMT

[quote userid="3585" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/28890/what-would-you-do/219576"]We have all seen plenty of oesophageal fbs that get stuck on the way down, but has anybody seen one that verifiably got stuck on the way back up?[/quote]

I haven't, Glen, and I'm pretty liberal with my apomorphine use.

I would add the other comment I hear on occasions: "It;s already vomiting, so there's no point giving it apomorphine". In my experience apomorphine induces a much more profound vomiting experience, and I'm pretty sure can empty out the proximal duodenum on occasions. A Case example: dog had eaten a pair of pants 2 days previously, V+ some of it, then ate normally, then started vomiting even with water this morning, admitted for xrays by colleague - I gave it apomorphine first (best done before sedating a patient!) as I usually would - £20 and a lot of vomiting later we had a pair of pants. Had it not worked, I can still continue on to other things.

I can personally attest to never having regretted an apomorphine administration - like Glen, though, I'm interested to hear stories of times people have regretted giving apomorphine to dogs. I wouldn't give for something that I thought might cause esophageal damage or perforation though.

As an aside - I use whatever apomorphine is on the shelf, it's not really a phone around and see if I can find a dog branded one sort of a drug for me - if I can't get it one day in one enquiry, then I'm not going to keep looking for a more expensive drug in a lower concentration that works slower in preference to a tried and tested drug with decades of experience of use and not a single adverse reaction ever reported to my knowledge [unless one counts vomiting]! As a young graduate [BITD], I believe it was common practice to continue to use an open vial SC and it worked without problem even when it went green (£20 was a lot of money and a bit of a rip-off for a single injection to make a dog V+); more recently freezing ampoules has become more trendy, but again I'm not going to sit defrosting a drug when I have a dog needing emesis induced. If I open a vial, I cahrge the whole vial to the client, but I give them a credit of half a vial if I use the remainder of the vial in another patient and charge them half a vial (I tend to keep it for the rest of the day).

RE: What would you do?

Glen McIntosh — Sun, 16 Feb 2020 05:13:33 GMT

Maybe, but I don’t quite see the logic. If they have referred it for scoping then they already know a scope is available should something get stuck when they induce emesis themselves. Oesophageal fb cases are eminently transportable. By inducing emesis themselves (in appropriate cases) and if it is successful, then they save clients my consultation fee and the trouble of having to drag their pet to another clinic. If it is unsuccessful then they can still refer for scoping if they want.

But I really question the validity of people’s concerns about things getting lodged in the oesophagus following emesis induction. I mean, I can understand why people might be concerned but does it ever happen in the real world? Dogs vomit up FBs spontaneously all the time, but they never seem to get stuck in the oesophagus. I have never seen it happen (with either spontaneous or induced emesis), I have never heard of it happening to somebody else, I have never read about it happening and I have never heard it discussed at any CPD events. I would genuinely be very interested to hear from anyone who has experience of this particular complication.

We have all seen plenty of oesophageal fbs that get stuck on the way down, but has anybody seen one that verifiably got stuck on the way back up?

RE: What would you do?

Liz w — Sat, 15 Feb 2020 08:47:53 GMT

Glen - maybe your referring vets are not using apomorphine in suspect cases because they don’t have access to a scope if something gets stuck, rather than not thinking that it may not work.

RE: What would you do?

Rob Loxley — Sat, 15 Feb 2020 08:03:06 GMT

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/28890/what-would-you-do/219548"]double discounted off a subsequent bill[/quote]

If you make an informed decision (costs, risks, benefits - percentages if you wish - explained) to go for a reasonable treatment option, why would any vet discount it if subsequently further/different treatment is needed, let alone double discount it?

RE: What would you do?

Glen McIntosh — Sat, 15 Feb 2020 04:28:20 GMT

We charge the equivalent of GBP40 per vial, entire vial charged to the client.

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/28890/what-would-you-do/219548"]No one here has talked about denying over cost. Rein in your accusations Dr McIntosh.[/quote]

But you reference the cost of apomorphine several times. If cost is not at least part of the reasoning for not recommending (offering?) emesis induction, why discuss it?

Your clinical/evidentiary stance is absolutely sound, although not one I find strong enough, given my clinical experiences, to lead me to change my approach to emesis induction. Like you say, it is guesswork - but it as much guess work for one approach as it is the other.

I also agree with your 1% statistic (although I think it is probably less than 1% and I tell clients this). But when clients are given the options and all of the factors are fully discussed including risks of emesis induction, risks of wait and see (less than 1% with problems), cost, and efficacy, then in my experience 90% of clients choose emesis induction.

Clients have two options in fb cases where emesis induction is not contraindicated:

1. Gamble a relatively small amount (cost of emesis induction) that has, say, a 50% chance of winning the big prize - ie reducing the risk if needing an enterotomy, and the attendant high costs and risks associated with that, to zero (even though the chance of the need for enterotomy is already very close to zero (<1%)).

2. Guarantee of winning the small prize (saving a comparatively small amount of money by not inducing emesis), but denying themselves the not insignificant chance (50%) of peace of mind that a successful emesis induction would bring.

It is human nature that most people chose the first.

If apomorphine was dirt cheap (as it is in Australia in the form of a tablet that you can administer transconjunctivally) would you still reccomend against emesis induction in appropriate clinical cases?

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/28890/what-would-you-do/219548"]If I was your client signing up for your approach I would want to know if I was chucking ?100 your way, that I would expect more than oh well that didn't work let's see eh, and if no t that failed attempt would be at least or if not double discounted off a subsequent bill.[/quote]

If you were my client, then I would be telling you that if that is your expectation then your expectations are unrealistic, and if you are unable to adjust your expectations based on the information I have given you then emesis induction is definitely not an appropriate treatment choice for your pet and we should look at other options.

RE: What would you do?

David Mills — Sat, 15 Feb 2020 02:12:20 GMT

How much do you charge for apo? Post it up. Per vial. Thanks.

No one here has talked about denying over cost. Rein in your accusations Dr McIntosh.

If I was your client signing up for your approach I would want to know if I was chucking ?100 your way, that I would expect more than oh well that didn't work let's see eh, and if no t that failed attempt would be at least or if not double discounted off a subsequent bill.

After all, it was nothing more than guesswork. See above.

RE: What would you do?

Glen McIntosh — Sat, 15 Feb 2020 01:39:10 GMT

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/28890/what-would-you-do/219525"]Blaming clients because they don't want to throw about quite a bit of money for a therapy that may not work (and who no-one can put any sort of chances of working on) - suspect in my book.[/quote]

Not offering clients a potentially definitive treatment that is generally quite safe and a lot less expensive (and a long long way from being prohibitively expensive - I simply don’t buy that you shouldn’t be offering apomorphine because of cost - it is a choice that should be made available to clients in the right clinical circumstances) compared to the alternatives should problems develop, is even more suspect in my book.

Nobody is blaming clients if they can’t or don’t want to spend a bit extra to try apomorphine, but in my experience this is unusual.

The number of cases that I have had referred to me for scoping that I have been able to resolve in 10 minutes with apomorphine is quite large. Doesn’t always work, but it is worth a punt in most cases.

Having said that, depending on the fb, waiting and seeing is also an option that is on the table, and if a client chooses that, fine by me.

RE: What would you do?

Neil Wheadon — Fri, 14 Feb 2020 19:01:22 GMT

Called the owner this afternoon

Has vomitted once this morning,

I can see it now in front of the RCVS, 'well I took the advise of my fellow members on Vetsurgeon'

Result

Foreign Body 1, Emedog 0

Yes folks I feel slightly vindicated in that it was too big to come back up again

Waiting and seeing

Neil

RE: What would you do?

David Mills — Fri, 14 Feb 2020 17:11:10 GMT

Emedog is only licensed sq. Single use, so any remaining in the vial should be discarded.

Cost price per vial is around £15-20, mark up to allow for wastage (most places around here I've seen priced at around £60/ml).

Blaming clients because they don't want to throw about quite a bit of money for a therapy that may not work (and who no-one can put any sort of chances of working on) - suspect in my book.

RE: What would you do?

Rob Loxley — Fri, 14 Feb 2020 16:20:14 GMT

[quote userid="3585" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/28890/what-would-you-do/219513"]In terms of cost - benefit wrt to using apomorphine,[/quote]

also if giving apomorphine iv rather than sc you can get away with a much lower amount

RE: What would you do?

Glen McIntosh — Fri, 14 Feb 2020 15:08:06 GMT

Yes, I would also be one for recommending trying to make the dog vomit in this case. There is almost no downside (assuming the dog is otherwise healthy and not neurologically impaired in any way).

If dog vomits it up, great, job done, nothing more to worry about.

If it doesn’t come up then we wait and see, but chance of problems are very low.

I think the chance of this fb lodging in the oesophagus is also very very low. And what’s the worst case even if it did? Well it went down no problem the first time, so it would almost certainly spontaneously return to the stomach. If not, then a small meal or a drink if water will push it back in the stomach. Worst case is you scope (if the dog shows clinical signs of oesophageal fb obstruction - eg regurgitation etc).

In terms of cost - benefit wrt to using apomorphine, only the most cost concerned of clients would baulk at paying the extra cost of apomorphine that could well provide a definitive resolution and priceless peace of mind. I am talking about private clients of course, for charity cases there may be a valid argument for not inducing vomiting with apomorphine.

If it didn’t come up with emesis induction then I would also discuss and offer endoscopy, but the risk/benefit and cost/benefit is far less clear cut in comparison to emesis induction, so I would be more likely to recommend wait and see.

RE: What would you do?

Kate Richardson — Fri, 14 Feb 2020 12:32:24 GMT

Surely if the dog could swallow it, it could vomit it up?

RE: What would you do?

Nicola Cole — Thu, 13 Feb 2020 20:34:54 GMT

Obviously past the decision making stage now as dog has gone home but I’d be another wait and see (obviously after discussing options/ pros/cons etc).

RE: What would you do?

Neil Wheadon — Thu, 13 Feb 2020 18:26:19 GMT

I've left it in situ,.

The one brought in can be pulled apart with my fingers so it's not solid, let the stomach acids do their job. Like the 1% stat

If you can scope it and pull it out then if soft it will vomit out

They are calling back tomorrow, i'm here the next week, so will get follow up

Neil

RE: What would you do?

David Mills — Thu, 13 Feb 2020 17:44:19 GMT

Wait and see. It looks a benign object and may well pass through. If it starts to show signs, then operate.

Never been a fan of scope removal of these as it becomes a self-selecting population. Those scoped and removed will definitely not cause a problem, but that is not to say that those not scoped and removed would definitely have caused a problem. The cost of apomorphine is very high and may not work - same applies to this population as the scoping ones.

We see things like this relatively commonly and only around 1% need subsequent surgery. The risks of breakdown of any GI wound are higher than this. First do no harm etc. There was a RCVS DC around glass that the anointed expert said similar.

RE: What would you do?

Beats — Thu, 13 Feb 2020 17:42:56 GMT

apomorphine injection.

RE: What would you do?

Anthony Todd — Thu, 13 Feb 2020 17:32:32 GMT

I think it's a Boots product so undoubtedly little money for referral [JOKE]

Seriously though, I'd wait for signs of obstruction then explore. [ if you grab it via the oesophagus it will break up.]

RE: What would you do?

Dagmar Steele — Thu, 13 Feb 2020 16:18:21 GMT

I actually know the object in question, it's soft but very dense. I don't think vomiting would work, and I also think it won't pass in a dog that small if swallowed in whole. So, I'd refer for scope as I don't have one.

RE: What would you do?

Lucy Fleming — Thu, 13 Feb 2020 16:10:04 GMT

I would probably apogo (well, expensive emedog, nowadays) or leave. If I was more adept with a scope I might offer that, but I'm not convinced I would definitely manage to see it or grab it. (Obviously usual caveats apply about discussing relative risks/ benefits with owners).

As it's soft, will it actually get truly stuck in the oesophagus? Would expect the next heave to dislodge it, or worse case scenario the dog be able to swallow it back down again. Though if it really is quite wide perhaps it won't make it through the lower oesophageal sphincter?

RE: What would you do?

Neil Wheadon — Thu, 13 Feb 2020 15:49:53 GMT

If you screw it tight, it's quite wide., so i'm not sure if it would actually come up. I'm slightly fearful it would get stuck in the oesophagus. I usually reach for the Apo go in the beat of a heart, but in this case i'm not sure.

Neil

RE: What would you do?

sbird — Thu, 13 Feb 2020 15:45:46 GMT

Probably apogo. If he vomits it then brilliant. If not I’d probably monitor unless o keen for ga and scope. Might suggest potatoes for dinner to help move it through

RE: What would you do?

Neil Wheadon — Thu, 13 Feb 2020 15:45:16 GMT

Swallowed it (the edit doesn’t seem to work on an iPhone)

Neil