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Category: Opinion

How to anaesthetise a reindeer

I’ve written before about omnicompetency, but the word is mostly used in the sense of vets being able to work in mixed practice and tackle the veterinary care of horses, dogs, cats and farm animals in the same day – certainly, the first thing to come to mind would not be a reindeer.

However, on my recent equine placement, the staff were met with quite the challenge when a reindeer was referred in.

“Reindeer aren’t something you’d expect to see every day in practice,” says Jordan.

With a history of acute coughing/regurgitation, the reindeer in question had a suspected food impaction in the cranial oesophagus. Conscious radiographs and an ultrasound scan (he was a very well-behaved reindeer) confirmed suspicions of foodstuff, but it didn’t seem to be in the oesophagus.

Collaborative anaesthesia

The equine team – with help from one of the farm vets and some phone calls to other colleagues and practices that had dealt with reindeer before – came up with an anaesthetic protocol and proceeded to surgery.

The reindeer was induced with ketamine and xylazine before a gastroscope was used to try to visualise the larynx and trachea.

There appeared to be a diverticulum or outpouching from the oesophagus at the level of the larynx, which is where the food impaction had settled.

This discovery triggered a discussion as to whether our findings could be normal in some reindeer – similar to the Zenker’s diverticulum in people – since its appearance suggested a congenital, rather than acquired, defect.

A gastroscope was used to aid placement of an endotracheal tube and the reindeer was, subsequently, maintained under anaesthesia with isoflurane. He was positioned carefully in consideration of the rumen and ventilated throughout the procedure, which was to incise into the pouch using a lateral approach and remove the impacted food material.

Back to his reindeer games

He recovered well from the anaesthesia and was happily bounding around a paddock before long, eating some specially imported moss provided by his owner.

Reindeer aren’t something you’d expect to see every day in practice, but it was a great example of how veterinary knowledge can be adapted and applied to new situations, with the added benefit of working together with others with varying levels of experience to come up with a solution.

June 30, 2016
Needle aspirate subcutaneous masses

Cytology of a mast cell tumor from a Labrador retriever at a magnification of 1,000x. Image by Joel Mills [GFDL, CC-BY-SA-3.0 or CC-BY-SA-2.5-2.0-1.0], via Wikimedia Commons.
Fine needle aspiration (FNA) is a valuable tool in subcutaneous skin masses.

We have all had those lumps that, on palpation, you are sure are lipomas (being soft, freely mobile and slow growing). Indeed, the vast majority are just such benign problems – however, it is worth aspirating them to be sure.

Felt like lipoma

We recently had a case in a nine-year-old Labrador with a soft subcutaneous mass the owner had been aware of for a month. It felt just like a lipoma.

On checking the lump again two weeks later, this had got noticeably bigger. FNAs of the mass revealed the presence of a mast cell tumour.

Following excision with good 3cm margins, the Lab went on to make a full recovery.

June 20, 2016
Standing surgery

On my latest EMS placement at an equine hospital, I’ve seen a number of surgeries – some done under general anaesthesia (GA) and others under standing sedation.

After getting over the fact a horse can stand half asleep while having its face drilled into and not really seem to care, I started wondering about the pros and cons of both approaches.

“Sinus surgery to remove a bony mass – that is me in the pink scrubs holding the head,” says Jordan.

Generally, standing sedation is accompanied by less haemorrhage and, therefore, increased visibility – in sinus surgery, for example. It also eliminates many risks associated with general anaesthesia. However, asepsis may be harder to maintain (for example, if the horse moves and the surgical site comes into contact with something that isn’t sterile, such as the stocks).

Lower costs

For the client, procedures conducted under standing sedation would be much cheaper than the costs incurred from general anaesthesia.

During general anaesthesia, atelectasis contributes to the risks from an intraoperative point of view, as well as myositis and cardiac concerns (of which the risk can be considerably reduced by the use of acepromazine in the premedication protocol).

A risk of injury also exists during recovery and knockdown, such as worsening incomplete fractures or other self-inflicted wounds, which can, to some degree, be prevented by carefully assisted knockdown and paying careful attention during recovery with the use of ropes.

Achieving optimal sedation for standing surgery can, in some cases, be difficult. For example, the horse must be adequately sedated, but not so much it is swaying; this can be an issue for intricate surgeries, but may be more of a problem for diagnostic imaging (such as MRI or bone scintigraphy).

In these cases, I have seen morphine used – opposed to the usual sedative culprits, such as detomidine, butorphanol and xylazine – and it seems to achieve sedation without so much swaying.

Choosing correct method

The choice of standing sedation versus GA depends on the type of surgery required, but a number of procedures can be done using either method.

Last week, I saw tie-back surgeries (prosthetic laryngoplasties to correct laryngeal hemiplegia) done both ways, which made for an interesting comparison. The standing tie-back was considerably quicker, taking into account the time for knockdown and recovery, as well as surgical time.

Both tie-backs were followed by a laser hobday procedure (ventriculoectomy), meaning both procedures were conducted under the same sedation in the standing horse, whereas the tie-back performed after GA had to be followed later the same day, after the horse had recovered sufficiently to undergo standing sedation for the laser.

The second tie-back was a repeat of a previously failed procedure, hence GA was chosen to allow removal of the first prosthesis.

The standing technique is still being tweaked, but, despite reports of postoperative infection in more cases than ideal, the easier access to the laryngeal cartilages while standing – and the avoidance of further risks associated with GA – contribute to continued work to perfect this method.

Some surgeries, however, can still only be done properly via GA. Colic surgery, for example, requires significant abdominal access and, often, examination of the gastrointestinal tract. It is also highly recommended septic joint surgery and lavage is conducted under GA to ensure optimal sterility on closure of the joint.

Conclusion

Having now seen both types of surgery in the horse, it’s astonishing how quick standing surgery can be, and how much goes into the preparation and recovery for GA – even for the shortest of procedures. In one surgery, division of the aryepiglottic fold, causing epiglottic entrapment, took a matter of minutes – if you didn’t count the couple of hours total taken for premedication, knockdown and recovery from GA.

The choice very much depends on the procedure, and is assessed for each case. I do, however, think the advantages to standing surgery are significant and look forward to seeing more standing techniques developed in the future.

June 13, 2016
Don’t forget cytology and Malassezia dermatitis

Tape cytology from dog with Malassezia dermatitis (Dif-Quik stain) – note the “peanut-shaped guys”. Image: Wikimedia Commons

Ever had one of those cases, which seem to typically occur around this time of year, that you think must be the start of an allergic dermatitis?

These present with pruritus, erythema and sometimes a yellowish/grey, greasy feel to the skin and hair coat.

The dog is already on a regular POM-V broad-spectrum antiparasiticide.

Initial thoughts

Pyoderma immediately springs to mind – it’s 6.55pm on a Friday, you skip the cytology and start on an appropriate antibiotic; maybe even a short course of prednisolone.

A week later and the dog has not really improved, so it’s a great time for some cytology. There is a good chance we have got a Malassezia dermatitis, and hey presto – the peanut-shaped guys are visible on microscopy. A couple of Malaseb shampoos later and we are rocking.

Then the fun really starts as we try to determine the underlying cause…

June 13, 2016
The beginning of the end of vet school

Exams passed, Jordan can walk the halls of Glasgow’s small animal hospital without feeling like an imposter.

As regular readers of this blog may have noticed, I was a little apprehensive about starting my final year at veterinary school…

Having already been in the small animal hospital for two days, we finally received our results – confirming I and many of my fellow classmates had passed our exams and could now wear our final year jackets without guilt and walk around the hospital without feeling like imposters.

However, despite now knowing we had qualified to be in the hospital, it still felt like we had been thrown in the deep end.

In at the deep end

My first rotation was emergency and critical care, with the first part being internal medicine. The first couple of days were spent frantically researching the background of patients coming in for appointments, bumbling through clinical exams and brushing up on my rusty practical skills.

It was my first time taking consults alone and, after missing out key questions the first few times, I eventually got into the swing of things and made fewer mistakes.

Image: seregraff / Fotolia.

Despite feeling like I didn’t know anything to begin with, I at least managed to scrape together a few sensible ideas when clinicians tried to worm differentials out of us. It has been a steep learning curve, changing the way of thinking entirely to apply things to a real patient in front of you, which usually has not read the textbook.

OOH my goodness

Just as I was beginning to feel comfortable with medicine, we swapped to out of hours – which, against my presumptions, turned out to be a really enjoyable week.

I adjusted to nights far easier than I expected and was powering through until one particularly long night when a bulldog came in with a suspected gastric dilatation volvulus (GDV).

This was the first genuine emergency we’d been involved in and stress levels were running high. Having rapidly set up fluid boluses, taken radiographs to confirm our suspicions, checked lactate levels and run in-house bloods, we went through to theatre. After a very long night of surgery and having warned the owner of an extremely grave prognosis, we were delighted to see said bulldog looking bright and happy the following evening, eating and pulling us down the corridors to the runs outside.

Not all GDVs end with such a happy ending, as we had learned earlier in the week – a dog that underwent the surgery at its own vets came to us for overnight care in ICU and, after a rocky night of a supraventricular tachycardia that we struggled to keep under control, crashed the following morning, was resuscitated successfully once, but could not be saved when it crashed again minutes later.

Hearts, not brains

Coming from nights straight back into days, however, was much harder and I felt like a zombie for the first day of my cardiology week.

On the subsequent days, when my brain was working again, I was able to make a bit more sense of echocardiography and gain a better understanding of some conditions and the tray menu options available.

I also learned a bit more about the genetics of Bengal cats and found trying to heart scan a cat that’s only two generations away from a leopard cat can be quite challenging (and may involve chasing said cat around the ultrasound room for some time, following an artful escape act).

This year isn’t going to be a picnic, but, although I already feel exhausted, if last month is anything to go by, it will be an enjoyable one.

May 17, 2016
Behind the scenes at Fitzpatrick Referrals

Two years ago, I received an email to confirm an EMS placement at a certain well-known veterinary practice in the south of England.

Fitzpatrick Referrals: arguably one of the most recognisable practice premises in the UK. Image taken from the VBJ Practice Profile.

In my head, the placement remained far off until – three days after one set of exams ended and four weeks before another set – it seemed to sneak up on me far quicker than expected.

Brain slightly frazzled from exams, but orthopaedics (hopefully) fresh in my mind, I found myself pulling into the car park of Fitzpatrick Referrals.

Making sense of things

Being such a large and busy hospital, the first few days were a bit manic, with lots of new faces and protocols to get used to. To be honest, just finding my way back to the staff room was quite a challenge.

As my first time in a referral hospital, there were notable differences from first opinion practice, and the sheer number of surgeries the vets would get through in one day was impressive.

I was able to see a lot of surgery, which helped make sense of the numerous abbreviations our orthopaedic lectures presented, for both the conditions and procedures – an FCP corrected by PUO or the options of TPLO or TTA for CrCLR meant very little until I was able to see the procedures and understand a little more why they helped correct the particular conditions.

(If you’re still wondering: FCP = fractured coronoid process; PUO = proximal ulnar osteotomy; TPLO = tibial plateau levelling osteotomy; TTA = tibial tuberosity advancement; CrCLR = cranial cruciate ligament rupture).

Standard versus innovative

Noel Fitzpatrick: veterinary visionary? You be the judge.

The above are among many other “standard” referral procedures carried out at other referral orthopaedic hospitals throughout the country. There are, of course (as seen on television), other surgeries Noel carries out. Whether these are considered groundbreaking, experimental or too much is open to interpretation, but they are certainly unique to the “Supervet”.

Noel himself is clearly very passionate and believes wholeheartedly his innovations provide the best options in the world for his patients.

Many other vets would disagree. Many believe he goes too far; that the prolonged recovery and rehabilitation time for heroic procedures are not justified in patients that live in the moment and cannot perceive the future advantages temporary discomfort may bring.

Having been “behind the scenes”, I’m still not sure where I stand on these heroic procedures, but am certain the ethics must be considered on an individual case basis, as is done at Fitzpatrick’s – for example, limb-sparing surgery was decided against in a case of osteosarcoma in which survey chest radiographs showed metastasis.

Camera shy

Undoubtedly, Noel is an extremely clever bloke who has dedicated his life to providing animals with the best orthopaedic technology possible, but his methods will always remain controversial.

The placement was certainly a worthwhile and very different experience. The stationary cameras around the practice were easy to ignore, but observing a surgery that was being filmed, with the surgeon re-explaining the procedure for the third time at a different angle, not so much.

A very definite highlight was scrubbing into a TPLO and being handed the bone drill, to my utter terror and delight at the same time. I’m not sure the novelty of putting a screw into a dog’s leg will ever wear off.

May 16, 2016
Moulting chickens
Image ©iStockphoto.com/ZannaDemcenko

Mature chickens normally undergo one complete moult a year, usually in autumn. However, this can depend on the time of the year the bird started laying.

Natural moulting usually begins sometime during March or April, and should be finished by July, when egg production recommences.

The three main factors that bring about moulting are:
- physical exhaustion and fatigue
- completion of the laying cycle (usually 11 months)
- reduction of the day length, resulting in reduced feeding time and consequent loss of body weight
Natural moults can occur any time of year if chickens are subjected to stress. Common stress factors that can induce moulting include disease, temperature extremes, poor nutrition, predators and poor management.
May 16, 2016
Don’t talk to clients about free T4 evaluations

Free, not gratis – image ©iStock.com/Aquir

We recently had an elderly cat that presented with typical signs of hyperthyroidism.

However, as is sometimes the case, total T4 proved stubbornly normal on two estimations a couple of weeks apart.

So we suggested it would be a good idea to send a blood to the lab for free T4 estimation – and you may be able to guess what’s coming next…

But, you said…

Yes, you’re right – the client then complained profusely that they had to pay for the test, because (and I quote): “You said it was free!”

We now call this an “unbound” thyroid blood test – it just makes life simpler.

May 9, 2016
An irrational fear of the final year

Having averaged four hours’ sleep a night for a couple of weeks, I came out of fourth year exams alive… just.

Poster image created online with the Keep Calm-o-Matic.

Sleeping pattern ruined, and a number of family and friends to see in quick succession (seeing as the next time I’ll be “home home” will be in five months or so), the four-day “summer holiday” we were given was anything but restful.

Midway through a week of induction lectures and “how to cope with real life” talks, the prospect of final year rotations beginning in five days’ time is becoming very real.

However, I think the induction week has had the opposite of the desired effect and, subsequently, I am anticipating my first week in the hospital with utter terror.

Panic mode

In theory, we should have the knowledge base to cope with whatever they throw at us in final year. However, in my panic-stricken state, I can only imagine drawing a blank at the first case I’m given and already feel sick at the thought of looking like the idiot I’m almost certain I am.

I feel under-prepared and tired from the last few weeks, not to mention the fact I don’t know if I’ve passed the exams and deserve to be in the hospital in the first place.

Several family members have asked me if it feels like my time at vet school has gone quickly, to which I can only answer “yes and no” – on one hand, it feels like I’ve always been at vet school; on the other, final year has sprung suddenly out of nowhere.

Time flies

Sound familiar?

More relaxed times seem a long way off, such as soaking up the German sun at a yearling auction, or paddling waist-deep through a swamp to care for a puma. Even scrubbing into orthopaedic surgery a month ago seems much more distant. Time flies when you’re having fun… or are kept stupendously busy by the various aspects of vet school.

While this transition feels tough, I’m sure tougher ones are ahead (such as this time next year, when we’re all about to enter the real world of work), but I’ll worry about those closer to the time.

I can only hope students in the year above (those finishing final year), who claim they felt the same way when starting rotations, were speaking the truth and, somehow, as unlikely as it seems right now, we’ll come out the other side as qualified, competent vets.

The question now is whether to spend the next few days – between the remaining induction lectures – catching up on sleep or frantically trying to relearn everything I’m supposed to already know…

May 4, 2016
Check bile acid values in lethargic puppies

He might look cute asleep, but lethargy and exercise intolerance aren’t a particularly good sign in a puppy. Image ©iStockphoto.com/feedough.

Have you ever had a puppy that just presents with lethargy, exercise intolerance and sleeps all the time?

This is normal for my teenage daughters, but not so for a young Lhasa apso that presented to my surgery. Physical exam was unremarkable, but the dog was so sleepy we administered IV fluids to perk it up.

Routine biochemistry revealed a low blood urea nitrogen (BUN), and a urine sample demonstrated the presence of urate crystals.

This triggered a request for a bile acid stimulation test, which showed markedly abnormal elevation postprandial levels.

Our diagnosis of hepatic portosystemic shunt was confirmed at Davies Veterinary Specialists and luckily this was shown to be extra hepatic. So, after some very smart surgery, the dog went on to live an energetic life.

May 2, 2016