Beating cancer one pet at a time one year on…

Arriving to Fitzpatrick Referrals Oncology and Soft Tissue Hospital

A year ago today I was invited to the grand opening of the new Fitzpatrick Referrals Oncology and Soft Tissue hospital in Surrey. On that day I made myself a promise that I would be back to learn how to fight this devastating disease so in June this year I ended up sat in a room with 3 world experts discussing the care of a single patient. It’s not about just doing the advanced procedures or having the fancy toys to play with. It is about the four legged member of the family that gets to spend more time with its parents without being in pain or suffering.

Something that I really like with the way that Fitzpatrick Referrals is run is that it is based on a massive team approach. Especially with oncology this can be extremely important – the week started with tumour rounds via video link with the Fitzpatrick Referrals orthopaedics and neurology hospital. Having two rooms full of Veterinary specialists talking about a single patient allows delivery and development of the latest cutting edge ideas. Having an orthopaedics team supporting oncologists allows for world class treatment for advanced tumours that may also involve the bone or need advanced reconstruction so that the patient has the best outcome.

Chris Fitzpatrick Referrals Oncology and Soft Tissue prep area

There is little that can prepare you for entering such a facility, and I barely slept the night before I was so excited. After rounds I changed to scrubs and entered the prep-area where I’d stood 8 months ago wishing that I was here to see practice, and let it finally sink in that I was here. As it is such a new field it is not as busy as the Fitzpatrick Referrals Orthopaedics and Soft Tissue hospital however there was still a full surgery board. Something I like is that there is a specialist anaesthesiologist Dr Diego Castineiras, for me this is amazing as there are so many things to consider with anaesthesia that there is always a ton to learn. Something I saw for the first time here was flushing the esophagus after reflux to prevent it developing strictures later.

Moving from prep to the first surgery of the day I get to really see what surgical cancer treatment looks like – tumours are removed with large margins. Removed tissue is stained and sent to pathology to make sure all the margins are free of cancer cells. And finally the most scary part – the massive wounds left behind are reconstructed so that they heal using advanced techniques when necessary.

Before this the biggest surgical wound I had seen was a strip mammectomy where all 5 of the mammary glands on one side of the body are removed. This wound basically ran the entire length of the dog and we performed this surgery in stages cutting a bit and then suturing it up as we went. This worked in that case however here the patient had tumours in multiple sites so removing them all was not going be so simple, the wound was massive and a caudal epigastric axial pattern flap created to close it. Something I really liked here was the use of towel clamps to bring the wound edges together temporarily so that you can plan your closure before placing the sutures responsible for holding the shape together.

One of the things that had a really big impact for me however was that of cytology. We were in surgery when we found another lump on a dog. The question was whether it needed to be removed or not – we could save the owner money and the risk of another anaesthetic if we removed it now however we didn’t want to remove it if it didn’t need to be. Thanks to cytology however we did not need to guess, a simple FNA biopsy, a couple of glass slides, some diff-quick stain and a microscope told us the answer accurately. This was a Mast Cell Tumour and needed to be removed. Cytology is something that is covered quickly, so now after this experience of it used properly in practice I will be doing a lot more sticking needles into things and having a look to see what is there.

The use of chemotherapy is often better tolerated in animals than it is in humans, and this is where the medical oncologists get involved. It is a tool that can be used in many different situations and can work really well with great results however the use of chemo drugs is still difficult in general practice as there is always a danger to staff working with them. I was lucky to have Dr Kelvin Kow spend time to explain drug preparation and different protocols with me as it is an area that I’ve not covered in vet school. One of the most amazing things with chemo I think is its use to shrink non-operable tumours to a size where surgery becomes an option.

The passion behind medicine

It however is not all about curing a pet of cancer – sometimes that is not possible as we just don’t know enough yet. In this case it then becomes palliative where the goal is to give a loved pet the extra time with their guardians without pain. This can be with just medical treatment, however sometimes the problem is large tumours simply taking up the space other organs need to work correctly. In this case then removing the tumour whilst not curing the disease allows the dog to eat, urinate or pass faeces and so have a relatively normal life until the disease progresses. This is where it is the experience of a oncology team that allows this ethical decision to be made – is the recovery period of surgery (which is likely to be painful) significantly shorter than the “happy” extra time the dog will spend with their guardian?

The best thing however is that whilst there is a great team based at Fitzpatrick Referrals Oncology and Soft Tissue, it is also about the teaching of other vets, and vets of the future especially with the new Fitzpatrick Learning Academy laproscopy training center. To be able to see a surgical site the best way is to scrub in, and if it is really deep then it is the only way. I was lucky to be allowed to scrub and see some really cool palliative surgery with the removal of lymph nodes from around the aorta towards the pelvis where tumour cells had spread from the initial site around the anal glands.  This is something that will give the dog months more of life to share. The sharing of knowledge and answering of questions gives me hope that we will beat cancer, with hospitals like this being the beacon of hope in the veterinary profession.

FLA Training Center

Something that I am asked a lot when people see that I’ve seen practice at Fitzpatrick Referrals is if it is as good as on TV. The truth of the matter is that it is better! There is not enough time to cover everything on TV so the other thousand things that go into giving patients the best care in the world are not shown.

Vet Festival 2016 – Day 2 Roundup

Dr Laurent Findji on skin resconstruction

Sometimes you have that feeling where you know it’s the last day and you don’t want it to end. This is how I woke up this morning, excited for what I was to learn today, yet sad that in a little over 18 hours it was all going be over. I am hungry to learn, and every single thing I learn here will help me become a better vet.

Today started again with Prof Nick Bacon talking about thoracotomies which is where the chest is opened through the space between 2 ribs. This is normally used for surgery on the heart or lungs and sometimes just to remove tumours from within this space. The amount of information shared in this session was incredible – my take home point however was to consider all information and anatomy to determine the surgical approach. Sometimes it is easier, less painful and more sensible to make an approach through the abdomen under the rib cage.

Dr Philipp Mayhew talks thoracoscopy

Philipp Mayhew then again took the stage to look at how to work on the chest using a minimally invasive approach. Unfortunately with the size of the animal you are limited in what you can do with a key hole technique as things such as surgical staplers to remove a lobe of the lung are too bulky for smaller patients. However the ability to approach the chest with this technique does reduce the post-operative pain and improves recovery immensely as you are not pulling the ribs apart. In humans doing surgery thoracoscopically instead of open thoracotomy results in less pain, drainage, sepsis, pneumonia, and death.

Dr Clare Rusbridge talks chronic pain

After this I continued with Dr Clare Rusbridge – one of the best speakers I have ever come across who makes complicated things really simple. Today it was about chronic pain, syringomyelia and chiari-like malformation. I’d tried to learn about pain myself, however it is something really difficult to wrap your head around as there are different pathways and receptors. Here Clare spoke about the pain in context of the Cavalier King Charles Spaniel which due to bad breeding often suffers from these two painful conditions which affect the brain and spinal cord causing chronic pain. Chronic pain cannot be controlled with normal medicines as these do not act on the pathways activated with chronic pain.

Dr Laurent Findji on skin resconstruction

The next lecture was especially interesting for me as I had spent a few days in practice at the Fitzpatrick Referrals Oncology and Soft Tissue Hospital with Dr Laurent Findji. Laurent now was talking about skin flaps and reconstructive surgery. This is especially important in oncology surgery where you need to have the confidence in putting it back together again to cut loads of skin and tissue away to remove the entire tumour. In some human hospitals for oncology there are separate surgical teams for the removal of the tumour and reconstruction afterwards so that fear does not prevent removal of all cancerous tissue.

Prof Noel Fitzpatrick Limb Amputation vs Limb Salvage

Prof Noel Fitzpatrick took the stage again to discuss limb amputation vs limb salvage. This is something that is very possible now, however the question has now become just because we can, should we? This is usually required as the results from trauma or bone cancer, an important point to note here is that if a suspicion of bone cancer is there and limb salvage is an option then incisional biopsies should be avoided to prevent spread of tumour cells.

Sir Christopher Evans keynote Vet Festival 2016

The conference keynote was given by Sir Christopher Evans, a scientist that has been amazingly successful in turning science to profit. Nature is amazing, and yet it is something that is not really well understood, and Sir Christopher shared his story on how he used his knowledge combined with nature to create products that were in demand. Not once, but again and again. It was an inspirational story, and left one with much to think about.

ONE Live Concert 2016

The day ended with Prof Noel Fitzpatrick inviting everyone to join him at the ONE LIVE Festival to celebrate the difference that vets, vet nurses and everyone else in practice makes to the lives of animals every day. This is a reminder for every single person in practice out there that people care about the difference that you make every single day!

The VET Festival for One Medicine – Day 2 Roundup….

Festival busker at vet festival

In his last lecture yesterday Noel said that he had txt God asking for the Sun to be turned on, and this morning it really was. For the first time all week my sunglasses came out of their bag and onto my head. However that is not what I want to write about so back to the VET Festival…

Today is day 2 (and the last day) of VET Festival 2015….

vet festival with Noels ordered sun

One of the first vets I met when I arrived at the Fitzpatrick Referrals center on Tuesday was Clare Rusbridge, one of the senior neurosurgeons at the center. On Tuesday I learnt a ton (I will write about this later!) and Wednesday even more, however today blew me away with an update on Canine Epilepsy. Pushing the limits of technology Clare used interactive txt polling to engage the audience. It was such a big topic that I will write a post just about this later, however the take home messages were that diazepam is not effective (I tested Clare’s reaction here to confirm it!) and that diagnostic tests do not exist for idiopathic epilepsy. Something else I was shocked by is that pharmaceutical companies consider a seizure drug “effective” if it reduces seizures by just 50% – personally this seems a low threshold for me…

Canine epilepsy with Clare Rusbridge

I then headed outside of the main lecture streams (they’re being recorded so I will watch every single one later!!!) however I wanted to learn some more about The Humanimal Trust. This new charity is all about vets and human doctors working together towards One Medicine – sharing expertise for the benefit of all. Even though we are both in the medicine field until today there has been little collaboration between vets and doctors. Actually when you look at the drug development cycle it takes around 13 years to get a new drug to market, and 10% of drugs do not make it on a mouse model… Yet if vets were engaged and dogs were used in the development the time and cost to develop new medicines would decrease greatly! The Humanimal Trust is all about animal and human healthcare moving forward together sharing advances.

The Humanimal Trust for one medicine

It then all became about the spine, such a small amount of time for such a big topic, and my first lecture with Noel. This was different to most with the opening words being about remembering that picking up a scalpel needs to be a carefully considered and thought out decision. It has become tradition for Noel to pick on a member of the audience to help with demonstrating different techniques, and today it was Ian Holsworth…

Noel Fitzpatrick demonstrating on Ians Holsworth

I then had the pleasure of hearing Laurent Findji talk about hepatobiliary surgery – this is surgery of the liver and gallbladder with the associated connecting duct to the intestines. Generally liver surgery is one of the more interesting parts of soft tissue surgery with some highly technical procedures. The liver is split into different lobes all connected to a central area – in terms of surgery the left liver lobe is a lot easier to remove than the right liver lobe. Also it is somewhere you need to be able to get good exposure as the liver sits right against the diaphragm at the end of the ribs.

Laurent Findji talks about hepatobiliary surgery

Something I was really interested in learning about were limb sparing surgery options where instead of amputation a bone (or part of one) may be removed and replaced with an artificial one or a part from elsewhere in the body. This was given by Will Eward from the Duke Cancer Center who is a vet and a human orthopaedic surgeon. During this I learnt loads that will be useful into my future – however the most important points were that when dealing with cancer it really is important that surgery should be planned properly, as correcting future mistakes can be devastating. Once a joint capsule is contaminated then it must be removed preventing artificial joints from being placed. The most dramatic surgery discussed here was a rotationalplasty which is where a knee joint is replaced with the ankle joint – success of this hinges on which way you rotate the foot.

Dr Jane Goodall speaking at VET Festival 2015

The last lecture of the weekend was delivered by someone that is a driver of change in the world for the better, Dr Jane Goodall. The room was packed, and this was the first speaker of the weekend to get a standing ovation from some of the smartest vets, vet nurses and vet students in the world. Dr. Goodall told her fascinating story of how she went from a little girl reading Dr. Doolittle to one of the foremost experts on chimpanzees. It is not my story to tell so I will leave it there; however it is a reminder of how one can achieve whatever they dream if they take the risk.

Dr Jane Goodall standing ovation

The VET Festival is now over; however the journey to One Medicine for One Health has only just begun and I hope that I, as well as you all will be part of it!