Our ski terrain….
Do you need any more excuses to join us in the Dolomites in Italy in January? (I can give you 20 more, but you should just trust me) Put your hand up at vetsontour.com
From a Recent Cut Above Episode on Incontinence with Dr Bronwyn Fullagar
How many incontinent (fat) old dogs have you put onto an oestrogen supplement or phenylpropanolamine in your career? A LOT, right? Now, this is going to sound silly, but despite the fact that it’s something I’ve done thousands of times, I don’t know if I was ever exactly clear on why my patients were incontinent (I knew it was something to do with sex hormones) and what exactly the drugs were doing to fix it, or if I did know, I had long since forgotten. So I was thrilled when we revised these concepts in our episode on incontinence on our advanced surgery podcast. Here’s what you need to know to sound intelligent when you explain it to your clients:
The urethral sphincter mechanism that is supposed to stop your patients from leaking onto the couch is made up of smooth muscle (involuntary control) and striated muscle (conscious control - ie - why Bella doesn’t pee on the rug). That much I think you’d remember.
But it’s not just muscle. There’s also some collagen in that urethra, which, as Bronwyn put it, is ‘jiggly and soft.’ (More on that in a sec)
If there is a mismatch between how much pressure there is on the bladder in the abdomen, and how much pressure the ‘pinch’ of the sphincter can resist, well - then you have a wet patch. So - first few lightbulbs:
This pressure mismatch is why dogs with sphincter incontinence generally wet themselves when they are lying down. It’s simply that there’s more pressure on their bladder.
It’s also why your chubby patients with a lot of intra-abdominal fat are more likely to be incontinent - less room for a full bladder.
And why does de-sexing a female dog make them more likely to develop sphincter incontinence?
Well, it’s that jiggly, soft collagen: oestrogen increases the ratio of smooth muscle to collagen. Ie - more oestrogen, less collagen, more muscle, more pinching power, less leakage.
Which is obviously also why oestrogen supplementation like Stilboestrol or Incurin is an effective therapy for these patients.
And phenylpropanolamine (Propalin)? Well, that increases the sympathetic tone, which helps to tighten that internal sphincter just a little bit. (Bron explains it as when you get a fright and you get that feeling of ‘puckering your sphincter’ with the sympathetic surge.)
Neat, right?
By the way, we are very close to wrapping up recording of our Cut Above Advanced Surgery podcast series - aimed at anyone doing further study in surgery, as well as super enthusiastic surgeons who want to get a better foundational understanding of why we do what we do as surgeons. If that’s you, then you should sign up before we wrap up production. Once it’s a fully fledged product, we’ll put aside our ‘under-construction’ pricing, which is 25% of what will eventually be the final package price. AND… If you are seriously studying for surgery memberships, then you should consider the Sydney CVE Surgery Distance Education Course. We’ve partnered with them, so anyone who signs up for their course will get free access to Cut Above. It kicks off in February, so they’re currently still on early bird pricing. CVE members save $888 on their course fees if they enrol by 31st October.
From Episode 226 Surgery Feed, with Prof Vicky Lipscombe
You know those horrible wounds that cats get when the collar somehow slips over the front leg and then digs into their axilla? They are no fun to deal with, and in this conversation on wound management tips and tricks, surgeon professor Vicky Lipscombe used these as an example of a wound where you might want to use the omentum to assist in wound healing. Now I know what you’re thinking: ‘We’re all used to the ‘policeman’ helping with wounds inside the abdomen, but isn’t the axilla - like on the OUTside of the body?’ Yes, yes, it is.
It seems extreme… well, it is extreme, but in selected cases it might be your only or your best option.
Here’s the gist of it:
The main problems with those axilla wounds are a high degree of mobility and way too much dead space. You suture the skin beautifully, but the poor wound is about 3 cm away from the underlying body wall, so it gets no extra blood supply from below to help it heal.
So if the blood supply won’t come to the wound, then you can bring your own - using our old friend, the omentum, which not only brings a great blood supply, but also provides the surface for the wound to heal onto.
Here’s how (in broad strokes - details in the show notes/episode)
Standard ex-lap to harvest omentum
Make a new, smaller hole in the abdominal wall, paracostally, close to your wound.
Pass some grabbers through this new hole and grab the omentum, pulling it outside the body.
Create a subcutaneous tunnel from this new wound to the wound you wish to repair and feed the omentum through this tunnel into your wound.
Close the midline abdominal incision as normal, and close the skin where you harvested the omentum paracostally.
Close the wound you went in to repair over the omentum. No need to specifically tack the skin onto the omentum: the policeman will do its job.
By the way - this is Dr Vicky’s standard first-time repair technique for these axillary wounds. Who else is dying to try this?! It’s cheap and easy, and it doesn’t require any special equipment or huge costs.
From Episode 230 ECC Feed With Dr Ryan Smith
Quick one: this episode was an immense deep dive on all things canine anaphylaxis, and when we think anaphylaxis in dogs, we picture oedematous gallbladder walls, right? But I loved this little pro tip, which I reckon will help me from going down the wrong path one day:
There’s a paper that showed that dexmedetomidine (so I’m assuming also medetomidine) can cause a degree of gallbladder wall thickening and oedema.
And this means that if you sedated your patient with an alpha 2 for that scan, you should not jump to conclusions when you see a thickened gallbladder wall.
Details: In the study it happened in 24% of the dexmedetomidine sedated patients that were scanned and appeared to take somewhere between 12 and 24 hours to resolve. So also keep it in mind for the dog that was sedated on the shift before yours.
Now you know. (Told you it was a quick one!)
2 Other Things
“I believe that if, at the end of it all, according to our abilities, we have done something to make others a little happier, and something to make ourselves a little happier, that is about the best we can do...
We must try to contribute joy to the world. That is true no matter what our problems, our health, our circumstances. We must try.”
Roger Egbert
Source: Go Gentle Into That Good Night (May 2, 2009)
“Never be so focused on what you're looking for that you overlook the thing you actually find.”
Ann Patchett
My kids all play rugby. (With their South African heritage, did they ever have a choice?) Niggly aches and pains are par for the course for such a physical sport, especially as you progress through the age groups and those boy-bodies turn into manly chunks of meat, so the groin strain that my 15-year-old man-boy had been living with for a couple of weeks was no surprise.
It’s a Thursday night - just before bed. Friday morning - 5:30 am - there’s sevens training at the school - a fun side gig, but not the main event. Saturday is Game Day - the one that matters.
Son: “My leg is so annoying.”
Concerned parents: “Why don’t you skip sevens training and give it at least a 24-hour rest?” (Sensible)
Son: “Fine.” (Teenager.)
Friday 5:13 am - said son is in the kitchen having breakfast.
“I thought we’d decided that you should give the leg a rest?”
“Yeah, but then I thought - no - I want to teach my leg a lesson.”
That’s so dumb, right?
But if it’s so dumb, then why was I a little proud of him?
When I was a vet student, self-sacrificial heroic effort was not only encouraged but kind of expected: late nights, long shifts, patient-first, your needs right down at the bottom of the priority list. We’ve come a long way - thank goodness.
I worked for an emergency company that used to celebrate that sort of stupidity. Just did two or three 16-hour shifts back to back, sustained mainly by caffeine and cortisone? Well done - here’s a bonus. Keep it up, and soon you’ll be the vet manager.
Then one day some adults were employed in the leadership. Now company HR has explicit rules that prevent such foolishness - it’s not just frowned upon, there are actual repercussions. When a situation arises that requires drastic over-and-above type behaviour, the official response is ‘why did this happen in the first place?’, not ‘you’re so amazing.’ No high fives allowed. (At least not in public.)
Much better.
And yet…
And yet, my kid has slowly gone from ‘below-average space filler’ on the rugby field to a vital part of the team, and for the past 2 years, team captain. And not because of spectacular sporting talent.
Now - to be clear - the coaches would have told him to rest that naughty leg. I still think he should have rested it. I don’t want him to think that he has to play with an injured leg - to push through the pain. But rugby, like life, is full of pain, and I think that opportunities that teach you that you CAN live with a bit of pain, when you need to, aren’t all bad.
I remember a shift soon after I’d started my emergency practice. Early on in the business, so just one vet - my shift. I woke up that morning with a queasy stomach. By late afternoon - 3 hours before my shift was due to start - it was clear that we had a problem. Call around, try to swop, look for backup, try to find a locum. No luck. Guess I better go in - I’ll just lie on the couch and see the bare minimum, defer anything that can wait. Then the GDV came in. Can’t wait, couldn’t refer.
Let me tell you that it’s no fun having to run to the toilet several times during a surgery. The constant re-scrubbing alone is enough to exhaust you! Definitely not ideal for anyone - least of all the patient. But hey - there was no other option. And we all survived.
Now , would I ever want to do surgery again while suffering from gastro? Hell no. Nobody should. But I’ll tell you what, I felt like a bit of a hero. And I like the feeling - the knowledge - that if a dog ever needed life-saving surgery, a bit v and d (or a lot!) won’t stop me.
Heroic effort is not sustainable - Achilles didn’t fight the Trojans every day. (In fact, he had a major sulk about it when he didn’t like management!) And yet, many vet businesses rely on it. So let’s be clear: heroic effort is not a business model. We shouldn’t recommend it, and we certainly shouldn’t expect it. Maybe we shouldn’t even celebrate it in the veterinary context.
And yet…
When my son was little he had a rugby coach who, after half the team subbed themselves out of the game for bumps and bruises, told them: there’s a difference between hurt and injured.
My kid obviously took that lesson to heart. By the way - Saturday game day came - he showed up, groin strain and all, and did his job. And once the season was over he could rest that leg - no lasting damage. Hurt, not injured.
The only way to learn where that line is for you is to play hurt - to be a bit heroic. Sometimes because you have to, but mainly to prove to yourself that you can.
Much love,
Hugh
How to connect with us:
Comments
Nothing yet. Say the first thing.
Sign in to join the conversation.