Tag Archives: surgery

Nothing is ever as simple as it first seems

Today served up one of those true examples of something not quite being as simple as one might initially have expected, this time in the form of a tricky case of hide and seek. Clinical hide and seek that is.

The afternoon saw a stray cat presented with a history of a swollen paw, with the concern being that it was broken. The fact that the cat was weight bearing and had a discharging wound on the front of the paw did make me doubt whether we were dealing with a fracture or, as I suspected, simply a bad case of infection on account of a cat fight. Anyway, the cat was duly tested for FeLV and FIV, both unfortunately common among the stray cat population, and was thankfully found to be negative for both. Examination of the paw under anaesthetic (it was too painful to examine thoroughly conscious) resulted in pus being expressed – so clearly an abscess was present – but there was something about the level of swelling that didn’t quite fit with a simple cat bite abscess. As such, x-

paw, cat, foreign body
You can see the object between the bones clearly on this view of the paw

rays were taken after all and the cause of the swelling and discharging tract soon identified: a small radio-opaque foreign body present in the paw, sitting, based on the views taken, right in between the metacarpal bones, the equivalent in humans being the bones in the main body of the hand. The object was suspected to be a tooth and was, according to the images, in line with the open puncture wound on the paw.

Consent was received from the owners to take the cat to surgery in order to remove the mystery item; a simple procedure that I would be able to complete within thirty minutes before my afternoon consults. Or so I thought. As is often the case in all walks of life, from professional veterinary practice to business, and life in general, the initial simple imagined scenario – ie, I open the wound a little, find said object quickly and heroically remove it from the paw thus effecting a rapid resolution of the cat’s problems – ended up being anything but. Do you think we could find the mystery object? No. No we could not! For what felt like ages I found myself frustratingly exploring the area, having to extend my initial incisions to open the region up more and all the while wondering why on earth I was not able to locate the offending article. Further radiography, this time making use of needles and the mobile dental x-ray unit in order to more accurately ascertain the precise coordinates of the object, which was very clearly visible on the films, eventually led me to see what ended up being the tiniest of pieces of tooth lodged firmly between the two middle metacarpal bones and virtually imperceptible to the naked eye. With the tip of what was clearly a cat canine tooth finally extracated from our patient’s paw, I was able to finally close the area, dress it and let the owner know the result.

My team of nurses were, as ever, superb and the entire operation ended up being a lot more challenging that any of us had initially imagined it would be. Thankfully the fact that the surgery took longer than anticipated was not a major issue as my colleague was able to handle consults whilst I rooted around delicately but purposefully in search of a biological needle in a fleshy haystack.

The main lessons that I took away from the experience include the fact that apparently simple situations can sometimes become more complicated or time consuming than first imagined and being prepared to cope with and adapt to changing circumstances is vital. Everyone on my team remained calm and acted in a really smooth and professional manner during the entire process and it ended up being a great example of effective teamwork. Remaining calm in a stressful situation is so vital as you need to be able to think clearly and make decisions, actions which are difficult if stress is at high levels. Trusting the evidence gathered is also important as in this case I knew that there had to be something to be found, due to the unequivocal radiographic evidence, meaning that persistence was simpler to adopt than if doubt had been allowed to creep into the scenario.

All in all, a testing afternoon but ultimately a triumph of appropriate clinical process, access to decent, reliable diagnostic equipment, trust in one’s own ‘gut instinct, and the superb dynamics of a great team. A great result all round, with a more comfortable and happy patient as a result.

Mountains & Milestones

Hatta mountains, DubaiMountains & Milestones

How’s your week been? My third week in Dubai has proven to be one of professional milestones in addition to some real life mountains. The week started fairly uneventfully with work as usual on Sunday – the new Mondays – and was, as is commonplace with Monday’s back in the UK, a pretty hectic one. I am really feeling more and more settled in the new job and kind of feel as though I have been here longer than just a couple of weeks, which I am taking as a good thing. One thing that is clear from working so far is that the hours I worked in the UK didn’t really have much on those that I am working here. It seems that you are actually expected to earn your money here! We are, in principle, supposed to be able to have about two hours off for lunch, assuming we finish everything by 1pm, which given how busy the clinic is and how long our surgical list can, and has, been often isn’t the case. An hour and a half is more like it on a good day, with less if it’s been especially mental, before starting consults again at 3pm. Consults end at 7pm, although we often get extras or late arrivals, meaning that a finish closer to 7.30pm is more the norm. All in all, that’s nearly 12 hours at, or near, work and at least 10 hours per day, or 50 hours per week – not quite the 38 hours a week that many are used to. Still, the perks are there, with year long sunshine and views of the iconic Burj al Arab to enjoy as I eat my lunch 🙂

I have, save for one unfortunate occurence on Tuesday, been much better at arriving on time, or actually early, for work, which is so much more professional than walking into the clinic with the clients, as seemed to be the case previously. The unfortunate morning I refer to was one in which I ended up taking a different road out of The Springs, the area of Dubai where I live, and which ended up taking me further and further AWAY from Dubai instead of closer and closer to work. I have a sat-nav so rather naievely assumed that I could rely on it to get me out of the fix that I had found myself in. Well, it did eventually get me to work but the problem was that the route it appeared to favour involved taking me, what seemed like, half way to Al Ain, with the Burj Khalifa becoming a distant point on the horizon. At the last minute it seemed to sense my panic, as the ‘estimated time of arrival at destination’ changed progressively from pre-8am (ie no worries – you’re safe) to after 8am, or “yep, you’re so going to be late!” I am rapidly coming to the realisation that sat-navs out here should only ever be considered a fall-back, safety option, for those times when you really just need to get close to a vague area or hit the ‘get me home’ option, and not the accurate, reliable guides as I have previously considered and found them to be. As I say, the device eventually seemed to take pity on me and prompted me in that rather patronising tone that sat-navs the world over seem to have been programmed with, back towards Dubai, with the chosen route taking me directly past Downtown and the Dubai Mall, into Jumeira – basically, the opposite side of town to which I would normally approach work. No wonders I was late! All I could do was make the grovelling, apology call that we all hate having to dial in and accept the looks of quiet disappointment and ribbing about alarms not going off that were clearly inevitable. Grr. Still, the rest of the day went fine, especially as I was on surgery that morning, which meant I got to flex my scalpel skills for a decent period of time, something I had been yet to do so far.

If I were pressed for a preferred discipline between medicine and surgery, I would say that my leaning is definitely towards surgery. I just like the ‘see it, fix it’ air that surgery has compared to the hidden mysteries of medicine and the reliance on tests, medicines and ‘monitoring responses’ that comes with the discipline. It was somewhat frustrating, therefore, that my first few ops were just that: frustrating. I was advised at my practical interview back in November that my cat spay incisions were too big, something that I hadn’t been aware of really until then, as a) I had always managed to remove the ovaries and uterus quite soundly, and b) all my patients had, as far as I was aware, made a speedy and uncomplicated recovery. Still, in the interests of self improvement and towing the party line I was happy to try and downsize my window into cats. The theory is sound: make a tiny little stab incision in the left flank, as normal, in the correct place (this, as it turns out is most definitely the KEY), use a spay hook (something I have rarely reached for in the past, preferring to visualise the uterus) to exteriorise the organ blind and crack on with the neutering as per normal. Spay one: frustrating! Malcolm had to scrub in to find the uterus and get me started, which considering I have done this procedure umpteen times before made me feel a little impotent. Spay two: no less frustrating, although the fact the cat turned out to be pregnant and Scott had to enlarge the incision to exteriorise the uterus did make me feel a little less like a tit. Spay three: I reverted to making (slightly) larger incisions, as I normally would have done in the past, and found my mojo again. Although I had vowed to ‘spay my way’ at that point, I did perform one under Monique’s watch and with her instruction on hook use actually managed the blind exteriorisation and so was able to perform the op through a teeny tiny little hole. It did make for a much faster closure and an almost imperceptible closed incision, so I daresay I shall be converted after all.

Surgery wise, this week was a bit of a milestone moment, as Thursday saw my first case of the afternoon being a young cat who had become acutely off colour and had been vomiting. Although the cat was apparently not normally happy about trips to see us, the fact he kicked off so wildly at any attempt to palpate his abdomen, coupled with his history of vomiting and pyrexia (temperature of 40 Celcius), made the only sensible option to gas him down, run bloods, including Felv/FIV as he was a confirmed fighter, and have a good old feel of him under GA, with radiography an option depending on what we then thought. Thankfully the owners were fully on board and just wanted the best for their cat, so with the cat asleep we set to work. Our concerns were compounded by the fact that even under GA he reacted noticeably to palpation of his cranial abdomen, and when we X-rayed him we saw that he had a lot of small intestinal distension. A further palpation revealed a firm palpable mass, or certainly a mass effect, exactly where he had been reacting and so a call was made to the owner to advise exploratory surgery that same afternoon. With the risks and estimate (4500 – 6000 AED, or roughly £800-1200) understood and accepted, time was blocked out and I set about finding out what was going on with our little feline friend. This was the first non-routine surgery that I had done since starting with Al Safa and so the pressure, it seemed, was on, not that I necessarily felt it though. After all, a clinical decision had been made, with the considerable assistance of Anni, who was brilliantly supportive and happy to do the surgery herself, and I had performed just this same procedure previously back in the UK. As such, the training kicks in and you just go through the motions. So, abdomen entered, it was time to do some exploring. All in all it was somewhat less exciting than we had expected, which is sometimes how these kind of cases pan out. The swelling we had felt was either the firm, reactive mesenteric lymph node we found and which was biopsied, or the area of distal jejunum-ilium that appeared distended and contained what appeared to be firm material. A decision was made to perform an enterectomy, with the subsequent release of gas instantly improving the appearance of the local intestinal tissue, and the palpable material rather disappointingly proving to be nothing more than faecal. Still, we removed it as it was pretty firm and I would have felt uneasy leaving it in place, especially considering that the rest of the intestinal tract, including liver etc, all appeared normal. So, with single enterectomy performed, lymph node biopsy taken and the cat closed up, it was now time to basically wait and see how our patient fared. I won’t know until I go back to work on Sunday but fingers crossed that it was nothing more than a particularly nasty and acute viral enteritis, or something similar. We will see I guess.

One thing that I was reminded of with that case was the fact that we don’t have the option of reaching for the good old opioid analgesics, instead having to rely on a combination of torbugesic and low dose petcam, a non-steroidal, which would never normally be my first choice in a gastrointestinal case. Still, with options limited and the cat in need of pain relief, all we could do was prescribe gut protectants and keep the cat comfortable as best as we could.

Whilst we’re on the theme of the clinic, we had our newest recruit start today: Scott, or Aussie Scott as I think he will probably have to be known, owing to the fact that we already have a Scott and so it is likely to get very confusing without the use of a prefix of some sort. As he is from Australia then I reckon the prefix ‘Aussie’ seems ok. He seems like he’s going to be a great addition to the team and it has been fun to be able to pass on some of the pearls of wisdom that I have managed to glean from my three weeks here already, such as advice on driving and places to consider getting an apartment. We both headed down to Knowledge Village on Thursday to get our Emirates ID card biometrics done, following my wasted attempt earlier in the week at the ID Authority building, and it seemed like we both had the same initial concerns, questions and excitement about making the big move to a completely new, and in many respects, different country. As such, it should be good fun a) having another new recruit along for the ride and at a similar level of experience as me, and b) another bloke, as veterinary is obviously very weighted towards the fairer sex so its never a bad thing to have a few more guys around for some banter and just to avoid overdosing on oestrogen, which is an occupational hazard!

Other notable cases of the week included the following:
1. Two kittens that were presented for toxoplasmosis blood testing as their owners were concerned about the risks owing to the fact that the lady was pregnant. They were advised that there was, in all reality, more risk of contracting it from unwashed vegetables and the fact that her husband had already assumed kitty litter duties was the best step to take. They did, however, duly receive their full check-ups and restarted their vaccinations, including rabies.

2. A stray cat, that had been presented by the lady who regularly fed him, due to the fact that his tail was basically black, necrotic and essentially in need of chopping off. The issue with this particular case was the fact that there was marked swelling and fluid right at the base of the tail, meaning that the surgery, which was most certainly needed, would have carried significant extra risk of post-operative complications and wound breakdown. As such, it was near on impossible to give a realistic ‘final cost’ for the case. Thankfully, the initial couple of days of antibiotic and anti-inflammatory that was given seemed to make a marked difference and at the recheck the ‘owner’ was feeling much happier about proceeding to surgery, even with the same concerns and risks present. As such, the cat is scheduled for admit on Sunday.

3. A really sad case of a young (10 month) old dog that came in for further investigation of persistent vomiting and weight loss. The same dog had previously undergone exploratory abdominal surgery and was discovered to have a pyloric stenosis, which it was initially assumed may have progressed. However, on running the bloods – which we routinely run on all patients scheduled to have anaesthesia, unless the owners specifically ask for them not to be run – it was clear that the dog had severe renal pathology. In spite of checking for possible Addison’s disease (the great pretender), the diagnosis of renal dysplasia and failure was made and the very upsetting, but correct, decision to euthanase was taken, something the owners were understandably devastated about. No one ever expected that a dog of such a young age, and who was outwardly still bright, would have kidney disease and so it really came as a shock.

Apparently, according to both Malcolm and Monique, I have thus far managed to handle a few of the clinic’s known ‘difficult’ clients well, in as much as they actually allowed me to see their animals, listened to me and responded positively. Being informed of this was obviously quite gratifying and I just hope that if I can manage to ‘win over’ the challenging clients then the others should prove to be less of a concern. I daresay the very fact that I have even mentioned it here will mean that next week I get a client that kicks off and ends up hating my guts. Lets hope I am wrong, eh?

Cycling & Pushing the Boundaries

Socially, the week has been a busy one with another trip to the Nad Al Sheba cycle track on Monday evening, although that looked like it might have been in jeopardy as Monique, and most of the nursing team, ended up in theatre that evening with a Great Dane GDV. Thankfully, I was not actually needed and so was able to drive up there to meet Kevin and another Dubai Tri Pirate member, Hassan, who had completed the Abu Dhabi Long Course Triathlon, in spite of suffering three punctures on the cycle leg, which is super unlucky. I cycled well and must be getting fitter as four laps, for a total of 32km, felt good. We even ended the evening with a short run, just to help loosen the legs. Who knows, maybe the prospect of signing up for an Ironman in the near future isn’t such a ridiculous notion.

There had been plans to head to the auto track on Wednesday in order to take advantage of the fact that they open the racetrack to cyclists but Kevin had to cancel and as my hire car has proven to be unsuitable for transporting my bike (the back seats don’t fold down!) it meant that I didn’t even have my bike with me. Still, it did mean that I had the chance to head out for my first proper run since arriving, and I managed a good 10km around the area in which I live, taking me very close to the marina area. I had been concerned that the heat would considerably affect my ability to run but I posted a pretty respectable time so I can only assume that my heat tolerance must be improving.

Today was the big test as far as cycle fitness went as I joined Kevin, his girlfriend Adriana and three other Pirates – Tyrone, Reggie and Hassan, all of whom are currently in training for imminent Ironman races – for a ride through the mountains near Hatta. I had, initially, hesitated in accepting the invite to join them as I wasn’t sure if I was actually fit enough, but was reassured that there was going to be a support car with us so that if I wasn’t able to finish then I had the option of jumping in. The start was a rather unsociable 5am pickup from the house, followed by an hour’s drive out to the desert, with a couple of coffee stops en route, before arriving at our rendezvous point as the sun was coming up. Simply knowing that we were about to start cycling whilst most people were still tucked up in bed and hours from hauling themselves up was quite satisfying, and I felt really pleased that I easily kept up with them all for the first 80km, only finally accepting my limitations as we started the seriously big climbs that my legs simply were not going to get me up. I did, however, hop back on the bike on the return but did finally have to tap out for good about 15km from the end as my legs simply were not going to give any more. In light of what happened on the drive back to meet the remaining cyclists on the road I am quite glad I had been in the car.

Adriana had also had enough before the end and so we were both in the support car as we we were signaled by Kevin to slow right down. The issue, as became clearly apparent, was that there had been a really bad accident on the highway in front of us in which a jeep had hit the central barrier and flipped. There was a moment of real concern as we approached due to the fact that we couldn’t see Hassan and so thought that he might have been involved. Thankfully he came into view and was unharmed but was looking after the driver, who was sitting by the side of the road clearly shaken and with a nasty cut to his head. Apparently the driver had, for whatever reason, swerved into the outside barrier before then swerving back into the central reservation, having lost control, which then flipped the car. This had apparently happened mere metres from Hassan himself, meaning that by sheer good fortune he had been unscathed. Given the shite luck Hassan had already had that day, with two punctures, the second of which pretty much exploded his tyre on a speedy hill descent, it was almost as if some higher force was trying to really screw his day up. Thankfully he made it back to the car safely and two punctures were the worst of it.

The accident did highlight some rather unfortunate facts about the Emirates and driving. The first is that many people choose not to wear seatbelts, refusing, it seems, to believe that they actually do save lives, and the second being that lots of people drive way too fast and way too erratically. There really was no good reason why the car in question should have swerved, lost control and crashed the way it did, and with no other vehicles involved, it seemed to be purely down to driver error and excessive speed. I am not sure I am ever going to get completely used to the style of driving here, with a much higher level of aggression and recklessness displayed, but one thing is for sure and that is it does make you become a more defensive driver, with the general rule being that it is sensible to just assume that everyone around you is about to do something stupid and make the necessary moves to counter the risk.

The cycling itself was brilliant and although I didn’t complete the entire route I feel chuffed to bits that I got out there and rode well for 90km – considerably more cycling than I have even done in the last year. And in mountains too! In the heat! Not too shabby even if I do say so myself 🙂 The mountains themselves make for quite a stark, barren landscape, made up of crumbling, jagged rock, with very little in the way of vegetation, like we are more used to seeing in the UK and Europe. The addition of wild donkeys, goats and camels along the way just added to the unmistakable fact that we were very much cycling in the Middle East and not Surrey! I am currently writing this bit sat in front of the Burj Khalifa and the Downtown fountains, and was fully expecting to be walking really stiffly but have thus far been pleasantly surprised by how good my legs feel. We shall see if I still feel the same tomorrow, although I hope so as I have a kitesurfing lesson booked and really want to be in top form to get up on the board.

Family Meetup

This week saw me finally meet my 2nd cousin in law (I think I have that correct), Eyad, who I had been in touch with prior to heading out to Dubai. We had not managed to meet up until this week and so it was a really pleasant surprise to receive a message from him asking if I wished to join him and some friends at one of their houses for dinner, also meaning that I would get to meet his vet friend (Jayna) whom he had been telling me about. It rather helpfully transpired that the friends in question (Richard and Alia) lived literally around the corner from the clinic, on Al Manara Road, and so a short drive later found me parked outside their stunning villa, complete with amazing flowering frontage, and I met everyone before Eyad actually arrived. The food that Jayna prepared was incredible and a great example of her Greek origins, with amazing stuffed peppers, lamb, sweet potatoes and some really incredible courgette fritters. Unfortunately I cannot for the life of me recall the actual Greek names of the dishes but suffice to say they were delicious. I felt very welcomed by everyone and by the time Eyad arrived I had already had a chance to chat with Richard, who is currently recovering from a knee op, his fiance, Alia, Jayna, who is having a bit of mission getting all of her veterinary registration documents sorted, and Bakh, who, according to one observation, could have been my brother. I think the fact he has dark hair, was wearing glasses and was slim were the only features that warranted this comparison but as a brother from another mother he was cool.

One of the great things about the climate here in the Middle East is that it lends itself perfectly to social gatherings in the garden, and we sat outside both before and after dinner just enjoying the stunning garden that Richard and Alia have developed over the past year, and just chatting. Its been marked how little TV I have actually watched since moving here, with most evenings either being spent out doing something physically active, such as cycling, or hanging out with friends, such as that evening. The only things I have spent time viewing on a screen have been the occasional film or trip to the cinema, and I must admit that I am really enjoying the shift away from just spending dead time staring at a TV screen.

On talking with Jayna, it became clear just how helpful it has been having my registration and visa dealt with by the clinic, and the fact that much of it was able to be done whilst I was still back in the UK was a very good thing. Unfortunately, and rather unfairly, for her she had been told by her clinic to move over to Dubai and basically go through the whole process herself, which has meant at least two months of treading the often frustrating and drawn-out path of trips to various Ministry departments and not really being able to work. It would have been a mission if I had been expected to do the same and, besides, it seems really unfair for an employer to expect their brand new employee to know what to do, especially if they’re not originally from the UAE. Still, she seems happy and is now, by her own admission, rather an expert on the whole process. We joked that she could hire herself out to other new vets to help them get registered!

Bakh, I discovered, lives in Oman and was talking about the diving opportunities over on the east coast, which are apparently plentiful and stunning. You can dive off the coast of Dubai in the Arabian Gulf, but in the summer the water becomes uncomfortably warm whereas, due to the ocean swells that pass Oman, the water remains comfortable for diving in the summer. Apparently you can routinely see turtles, sharks and a whole host of other marine species, which I definitely plan to check out at some point. There really is so much to do outdoors here that it seems you could easily fill an entire year with different sporting activities each weekend. Although it would be easy to become unfit and overweight here if you chose to simply indulge in the plethora of food options and remain completely sedentary, especially given how easy it is to drive everywhere, I can’t imagine not being even slightly more active here than you would be back home, given how plentiful the activity options are and how incredible the weather is.

Talking of activities, I was supposed to be having another kitesurfing lesson today but as is the way when relying on Mother Nature, there appears to be no wind (although there was plenty yesterday, which was definitely apparent on the bikes) and so plans have changed. It has meant that I have been able to catch up, however, on CPD and editing the new book, and also just relax, something that it is important to remember to do. We’re heading out later for afternoon tea at one of the fancy hotels down in the Marina and plan to check out the sheesha cafes at the same time, which should be good fun and a great way to end the weekend. Talking of recreation, I purchased a copy of Time Out magazine earlier in the week and picked out a new cafe that they had reviewed to go and grab some dinner in before heading along to the cinema at Dubai Mall, as they were showing a final screening of Silver Linings Playbook, an awesome film by the way.

It was really nice being able to just cruise along to hang out at a beachside cafe in the late afternoon and then make a very short trip to the breathtaking scale and visual feast of Downtown and Burj Khalifa for the evening. Its always easy to become blasse to your immediate surroundings when you live somewhere but it is good every now and again to sit back and really appreciate the fact that you have the good fortune to actually live somewhere as incredible as Dubai. The hour or so that I spent before the film screening was such a moment for me, as I watched the crowds of tourists and Dubai residents all enjoying the amazing views and thrills of the fountains and the mall. In fact, I am gravitating more and more towards the option of renting in Downtown instead of the Marina, for a number of reasons. I think many of the decisions we have to make in life start life based on assessment of facts and research but ultimately the final say comes down to gut feelings, and for me Downtown is ticking more boxes on a visceral level at present. It just feels a little closer to ‘real’ Dubai compared to Marina, although quite what is meant by the phrase ‘real Dubai’ is difficult to pinpoint. I have a couple of months to decide anyway so we’ll see – maybe I’ll change my mind completely and find myself in another villa someplace.

Right, afternoon tea is calling so I should answer. Laters….