Friendships built over a life-time, like reputations, can be destroyed in one incident over the death of a beloved Toy Poodle. So, it was prudent for the first vet to avoid treating this 15-year-old for constipation.
Mrs Lee lamented: "The second vet charged the consultation fee and sent her home. She still has constipation. Do you make a house-call or should I bring the dog to your surgery?"
An old dog that can die anytime from a severe heart disease is a challenging case. To be frank, it is a nightmarish case in a litigious society that Singapore has become. It was therefore prudent that the second vet sent the dog home without doing "anything" according to Mrs Lee.
I presumed the 2nd vet wanted to avoid writs and complaints to the veterinary authorities or press from disgruntled owners should the dog die during treatment.
The background picture gets complicated as I asked more about this dog before treatment. A lean Toy Poodle with bluish tongue tip hanging out of his lips. I put her on the table. Her temperature was normal. Her heart was very bad as the machinery heart murmurs bounced off my stethoscope. She was on heart drugs prescribed by the first and second veterinary practice.
"The drugs made her drink a lot of water," the owner said over the telephone in between serving customers. It is best to phone the owner for the history of the case.
If the dog was drinking water, she should not be constipated. When I palpated her abdomen, she had a big soft mass of around 10 cm x 10 cm in the large intestine not too near the anus. Constipation stools are usually hard as stone normally.
So, how did this senior constipation?
A prescription diet for heart disease, prescribed by the second vet practice was not eaten by the dog. The owner accepted the advice to discontinue the feeding of the usual brand of dog food. Unfortunately, the dog disliked the taste of the prescription diet and would not eat. So, the owner fed her pieces of chicken meat instead. The dog urinated a lot but did not pass any stools for 6 days.
"Why did the locum not treat this dog for constipation?" I asked Mrs Lee as the first vet who was overseas and had engaged a locum.
This case appeared convoluted.
Fools rush in where angels fear to tread. If the locum vet of the first practice and also, the vet of the second practice, did not want to treat this constipation case, there must be something that needed to be known.
Was this owner a potential litigant or had shown litigious behaviour? If there was a possibility, it would be prudent to pass the buck to another practice.
I did not ask Mrs Lee about this aspect of the owner. Instead I asked: "Why did the locum not treat this case?"
Mrs Lee's bright eyes set against a chocolate brown face lit up as she said: "At one time, the locum expressed the anal glands of this Toy Poodle. No anal oil came out. The owner remarked that the first vet who engaged this locum could express the glands."
Mrs Lee still had not answered my question as to why the locum did not want to handle the case of constipation. I thought, "Well, if the dog did not have anal gland impaction, no oil would come out. What is the big deal?"
Mrs Lee was matter of fact as she shook her curly haired head: "The locum was angry with this comparison remark and henceforth refused to handle the dog of this owner."
This was understandable and right for the locum not to take up this case. If the owner has no respect, it would be best not to handle the case.
But why should the second vet at the referred practice not handle the case? Had the owner's infamy preceded her to the second practice?
Can there be no smoke without fire? I was apprehensive. If the dog dies during treatment, reputations built over a life-time get destroyed in one reckless acceptance of a case in which the owner is likely to sue for negligence. Bad press publicity is not good even if the vet is found not guilty.
As if to answer my question, Mrs Lee said, "The younger vet rejected this case after charging $25.00 for consultation. The older vet who sees this dog was on leave at that time."
So, what should I do now since the dog is in my surgery. I had the impression this was a simple case of constipation and had asked Mrs Lee to come to the Surgery.
Not a conflict canine constipation. This dog could die anytime as her tongue was moderately cyanotic. Tongues should be pink. Her nose had lung water bubbling out. The heart drugs were doing a good job. The owner and Mrs Lee could not give me the names of the 2 out of 3 drugs being taken by this dog.
This was a risky case of possible sudden death from heart failure. Any restraint of the dog for treatment would precipitate heart failure and then death. A decision had to be made as Mrs Lee and her husband had taken so much trouble and a taxi to come to the Surgery.
"Let my husband hold the dog as she is familiar with him," Mrs Lee said as she did not want to be present in the treatment room. The stools were quite deep inside the large intestine and around 25 cm away from the rectum as I pass the catheter into the colon over 15 cm deep till I met the obstructed stools.
I pumped in 10 ml of soapy enema water from the syringe after mixing the soapy liquid and water in a bowl.
Mr Lee held the dog on the table. He was a man of few words unlike Mrs Lee. The room was deafeningly silent as we waited for instant results. No stools came out of the anus onto the newspapers on the table. The dog was all right. Not panting excessively or collapsing. He just would not poop.
Was there a hope of her passing out the stools at all? This was a case where performance counts. Action speaks louder than words. If no stools come out, it was a failure of the vet to perform.
Somehow I envisaged the owner saying to me as she did to the locum: "The first vet will be able to do it. Why can't you?"
Mrs Lee stated that the first vet refers old dog with heart disease to the second vet. Heart disease, old age and constipation --- this case would be referred to the second vet practice. So the question of the first vet treating this case is moot.
Have I rushed in where angels fear to tread? The Toy Poodle looked at us in apprehension, shivering a bit as her legs trembled. She did not pass out stools. Neither did she die of heart failure.
Should I give a second dose or not take the risk? I waited 5 minutes. No poop. This time, I withdrew the catheter slowly as I pumped in 2 ml of the 10 ml of soapy enema. I had increased the concentration of the soap by adding more soap. This is no formula to share with you readers as this was not a commercial enema.
Commercial enemas come in a tube for one to insert inside the rectum of constipated babies. These are handy. They may not work in this case as the stools are deep away from the rectum. I was doing a type of colonic irrigation and had to be careful in case I perforated the colon with the catether.
The Toy Poodle still would not pass stools for the next 5 minutes. She evoked a soft cry as she strained her anus slightly. No stools came out. From my experience, I ought to wait a while.
I put the Toy Poodle inside the crate and talked to Mrs Lee about her son. Mrs Lee was in her fifties and would only work part-time at night. Her husband who looked as slim as a teenager had recently retired.
I asked: "Any grandchildren to look after?"
"No, my son presented me 2 cats from Australia," she sighed as she told me about the cat's health. Her son was doing a Ph.D and had been a small property developer in Australia. He would build 4 houses and sell them.
This was an unusual son. I would say that 99% of Singaporean parents had sons and daughters going to Australia just to study and enjoy life. Consume, not create wealth. And here, a Singapore boy who made his own money.
"Has he got any housing agents in Singapore?" I asked Mrs Lee. "I would like to meet him and talk about being his agent." Of course, I would learn more by meeting this man.
This constipated Toy Poodle brought me an opportunity to meet Mrs Lee who had a son who set an excellent example of what I mean by "Create, not consume" when I advise the youths of today that venture overseas to study. But many will not know how and will be consumers.
We were in the waiting room and there was no clients. So we could talk. After some 15 minutes of conversation, we went to the holding area to check out the Toy Poodle. She had passed a big piece of soft stools onto the newspapers and had gone to the other side to avoid stepping on the stools, well formed of around 6 cm in 2 pieces each.
She went home to Mrs Lee's house first before handing over to the owner. I advised the owner to give the old dog food that the dog was used to as it had fibre. The heart disease prescription diet could be given if the owner started with small amounts.
As the Toy Poodle had lost considerable weight, according to Mrs Lee and would not eat the prescription heart diet, it would be pragmatic to feed her the old dog food rather than pure chicken meat. The dry dog food had fibre but chicken meat had no fibres to stimulate the large intestine to move the stools.
"It is possible that the large intestines are not good at peristalsis or moving the stools out of the body despite the presence of lots of water being drunk," I explained to Mrs Lee. "The cause of partial paralysis of the intestines could be due to the old age as this dog is as old as a 100-year-old person if you use 15 years of the dog x7. This is equal to 105 human years."
The dog has not long to live in view of her serious heart murmurs. Maybe 1 or 2 years more but I may be mistaken.
For some reason, her intestine was not so active as to pass out stools after eating chicken meat. If she did not have fibre, she would get constipation again. And so, it would be best to feed her what she wanted to eat and relieve the owner of her worries.
Many Singapore owners are not aware of the need to feed the prescription diet in small amounts, adding more and more over a period of weeks.
They give the dog large amounts to replace existing formula food. Obviously, the dog does not want to eat the new food especially when he is used to table or people food. The prescription diet is abandoned and deemed no good.
Much education needs to be done to follow up with her in the use of the heart dieseaseprescription diet. It is difficult for the vet to do so. So chicken meat was substituted for the previous dry dog food or other food as the dog would eat the meat.
I never met the owner as she was busy working. I just hope that her dog would not get constipation again. I may not be second time lucky if I rush in where angels fear to tread and get slapped with litigation and demands for explanations from irate family members if the old dog's heart stopped beating during the treatment. The probabiity of this happening is very high and it would be prudent not to handle such cases.
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