Friday, December 31, 2010

284. Dec 31, 2010 cases: rare puppy eyelid growths & Others

Dec 31, 2010. Last day of the year. I was on duty and finished work at 6.40 pm.
Bright sunshine and blue skies while some European and American airports are filled with snow and cold winds.

Traffic Warden. I happened to be in the waiting room and saw a parked golden car with its left side door at the side of the surgery marked: "Chubb and Enforcement". A slim bald man in his late 30s, wearing sunglasses, in white shirt and blue trousers stepped out of the car. I snapped a picture of him. He strode towards my car which was parked beside a fire hydrant as I was to go out soon and it was a shaded lot. I went out of the surgery and apologised to him. I drove my car away and put a parking coupon on my car dashboard. He drove off with his driver. So, it was all clear? Some 15 minutes later, I saw the same car in the same location (round the bend, at the side of the Surgery). The same warden was inside the car and looking at the rearview mirror. I was surprised. It seemed sneaky business. Why not use an unmarked car?

Only yesterday, 2 lady traffic wardens in similar starched white shirt and blue pants but from another private enforcement company (Certos?) were around in the afternoon. I saw them as I was in the waiting room and managed to avoid being booked. They were kind people and forgave me for not displaying a parking coupon. My parking area is one of the last rare lots in Singapore not boxed in by automated barriers and so these private wardens are employed to catch offenders.

Back to some interesting cases

Case 1. PROBLEM SOLVING IS WHAT THE OWNER WANTS
Shih Tzu of 3 months old has 3 eyelid growths in the left eye. Veterinary medicine is full of surprises. I am 60 years old and have seen 30 years of small animal practice. But a puppy with 3 eyelid growths is a rare occurrence. Older dogs do have them but "never" puppies. So, this was a big surprise on the last day of the year.

"I am still searching for a vet," the mother of 4 children said. Her puppy had 3 eyelid growths of around 3 mm x 2 mm. What were they? They exploded during the last 2 weeks. She bought the puppy 4 weeks ago.

"The first vet gave me an eye ointment tube to apply," the young-looking mother in her 40s said. "The growths were still there and I consulted Vet 2. He gave me this Surolan ear drops to apply. Not effective. That is why I am still looking for a vet!"

As the puppy is young and small, weighing around 1.3 kg, the eyelid growths look prominently big. "They look like warts. Give eye drops," my assistant gave his advice to me quietly. "Eye drops will not work," I explained to him. "These are solid growths on the eyelids."

Another merry-go-around with a different brand of eye drops would not do for this first-time puppy owner. "Surgery is needed to excise the 3 growths," I said. "There are no other solutions for this problem."

I knew that the other 2 vets did not want to suggest surgery as a 3-month-old puppy is a very high anaesthetic risk. According to one vet report I read, this is because the liver of the puppy is still immature and unable to clear the anaesthetic drug normally. So, the puppy dies.

You can't excise without anaesthesia as it would be painful and impossible. My assistant produced a anaesthetic consent form as he does for my associate vets. "No need," I usually don't use this form. I usually explain clearly orally the risks involved in any anaesthesia. As the mother was quite stressed out (going to a vet the 3rd time, puppy keeps rubbing the left eye), I did not tell her it would be high risk. If anaesthesia is done carefully, the risk is minimal.

ANAESTHESIA
"What anaesthesia will you use?" I asked my assistant (as part of mentoring process). "Diazepam and Ketamine," he said.

"You don't use two sedatives in the puppy," I advised. "One is already risky."
My assistant said: "Domitor?"
"Zoletil will be the best as it is said to be the safest. In the past I use xylazine with no problems."

So, Zoletil 100 at 0.01 ml with saline was injected IV. Isoflurane gas by mask was given at 5% to effect. "Don't wake till the eyelid reflexes are totally absent," I advised. "The puppy may be dead!".

I used electro-surgery to excise the 3 growths. (Pictures taken). Then 5/0 absorbable sutures to close the wound. E-collar and medication. Problem solved. That is what the owner wants. This is what I learn from my 30 years of experience. The same applies to car owners or other services.

INTERESTING OBSERVATION. I noted that the puppy kept pushing its tongue out and licking its nose, as if yawning, during Zoletil and isoflurane anaesthesia. This happened a few times. Could it be the effect of Zoletil? "Shivering" was the complaint of the owner some 1 hour after surgery. She had bought a puppy coat as the whole puppy had been clipped bald (ringworm infection of one toe and right neck). "This shivering is normal after anaesthesia in some puppies," I said as we put the puppy coat on. "It will go away soon.

Case 2. WILL MY FEMALE DOG BE PREGNANT AFTER SPAYING?
"I feel lucky today," the lady owner in her early 30s said when I told her that there was a small risk of bleeding in spaying a female dog in the middle of heat. Her male Jack Russell dog was pestering the female poodle and she could not sleep the whole night trying to ensure no mating. "The male dog just persists in smelling her backside," the owner explained. She had many questions to ask, like the owner of the Shih Tzu with the eyelid growths.

"No, the dog will not be pregnant after spaying," I assured her. "But the male dog will persist in wanting to mate with her for the next few days." There was no need to neuter the male dog for the time being as she was so desperate to prevent aother pregnancy. The puppies had died due to being stuck and delays in seeking a vet. They were born in Sep 2010. Now, the female had an extremely swollen vulva but no bleeding. "So was she in heat?" the lady asked. "Well, she would be in heat in July 2010. Pregnancy in September would be correct as that would be 2 months. From July, 6 months of interval between heat. Now it is nearly Jan 2011. So that is 6 months and she is definitely on heat."

The female was spayed. Domitor and isoflurane gas. I incised at MG 4 and MG 5 which was too low. I hooked up the two uterine bodies and horn from the 1-cm incision. The whole space was crowded and I had no space to pull out the ovary (which was large at 8 mm long when I saw it later). What to do?

The normal procedure is to extend the incision cranially by another 5 mm. Or I could push back the uterine bodies and hook again. Another solution was to ligate the uterine body first. The uterine blood vessels were 3 mm thick and the dog would bleed to death if they were not properly ligated. So, clamp, transfix ligature below the clamp. Unclamp and ligate again. Then excise uterine stump. Now there was space to pull out the ovaries and ligate once the cranial end by pulling the ovary out more. Check PROPERLY that the ligature was tight before putting the ovary inside the abdomen.

The dog was OK and the owner came later in the evening wanting to bring the dog home. She had no crate and reluctantly accepted my advice to hospitalise the dog for one night as the male dog would be frenzied in looking for the female. She would also have sufficient rest. All should be well by the next day.

Case 3. A cat with a badly infected left eyeball was operated. The eyeball had to be taken out.

Case 4. A woman who wore head scarf and her young adult daughter (studying political science) brought in a fat cat for spaying. She had booked an appointment for the spay at Vet 1 (who had rejected the Golden Retriever neuter case). So, she came to me. She had several stray cats neutered and ear clipped at her own expense.

"Are you sure you spayed her?" she asked me when she saw that the wound was around 8 mm in length. "One vet cut 3 cm long," she extended her thumb and forefinger. "Another did longer than yours."

I assured her that the cat was properly spayed. Each vet has his own method of incision but the owner makes comparisons.

Thursday, December 30, 2010

283. Common problems of the first-time Singapore Landlord

COMMON PROBLEMS OF THE FIRST-TIME SINGAPORE LANDLORD

E-MAIL TO DR SING DEC 31, 2010

Hi Dr Sing,

Thanks for the advice given on your web page (www.asiahomes.com), I am sure it has benefited a lot of people. I hope you can help advise me on my situation.

I am a first time landlord. My agent just told me that my new tenant has decided to break the lease barely 1 month into the contract. The reason being his company is not properly registered here hence he has to return to his home country.

Pls advise:
1. I have already paid the 1 month commission to the agent. Should the agent return me the pro rata commission since the lease has not been fulfilled to 2 years

2. The co-broke agent has been demanding his share of the commission, saying that I have already forfeited the tenant's 2 month's deposit, so he is entitled to it. I feel he does not deserve to be paid since he did not conduct his due diligence on the tenant hence causing unnecessary inconvenience to me.

3. My own agent took the full month's commission and said that I still need to pay commission if she finds me another tenant. All in I have to pay 2 month's commission through no fault of mine. Is this the norm or am I taken for a ride?

4. How do I recover compensation from the tenant? My agent advise me against it citing that it is difficult to do so since the tenant can easily return to his home country. She advises that u let things be and just pay up the commission and look for another tenant and thus incur another commission. I feel she is not acting in my interest.

5. The co broke agent refused to return me the keys, access cards and transponder unless he gets his commission. Does he have a right to? What recourse do I have.

Thank you so much for your time and I hope to hear from you soon.

Regards,
Ms Ang

Sent from my iPhone




In reply, see CAPITAL LETTERS BELOW

On Thu, Dec 30, 2010 at 7:59 PM, Orange Whale wrote:

Hi Dr Sing,

Thanks for the advice given on your web page, I am sure it has benefited a lot of people. I hope you can help advise me on my situation.

I am a first time landlord. My agent just told me that my new tenant has decided to break the lease barely 1 month into the contract. The reason being his company is not properly registered here hence he has to return to his home country.

Pls advise:
1. I have already paid the 1 month commission to the agent. Should the agent return me the pro rata commission since the lease has not been fulfilled to 2 years


THIS DEPENDS ON THE TERMS AND CONDITIONS OF THE COMMISSION AGREEMENT. I PRESUME YOU HAVE ONE. IF NOT, MUCH DEPENDS ON NEGOTIATION.


2. The co-broke agent has been demanding his share of the commission, saying that I have already forfeited the tenant's 2 month's deposit, so he is entitled to it. I feel he does not deserve to be paid since he did not conduct his due diligence on the tenant hence causing unnecessary inconvenience to me.



CO-BROKE AGENT? IS HE YOUR AGENT OR NOT? NORMALLY A LANDLORD HAS ONLY ONE AGENT TO ACT FOR HIM.


3. My own agent took the full month's commission and said that I still need to pay commission if she finds me another tenant. All in I have to pay 2 month's commission through no fault of mine. Is this the norm or am I taken for a ride?


IN REAL ESTATE, MUCH DEPENDS ON THE WRITTEN COMMISSION AGREEMENT OR CONTRACT OF REAL ESTATE. IN SOME AGREEMENTS, THE LANDLORD GETS BACK THE AGENCY COMMISSION PRO-RATED IF THE TENANCY IS TERMINATED PREMATURELY. IN OTHERS, NOTHING IS STATED AND THIS IS WHERE THE LANDLORD HAS PROBLEMS.


4. How do I recover compensation from the tenant? My agent advise me against it citing that it is difficult to do so since the tenant can easily return to his home country.


YOU NEED A GOOD LAWYER TO ACT FOR YOU FOR BREACH OF TENANCY AGREEMENT. IF THE TENANT RETURNS HOME, YOUR LAWYER CAN STILL SUE HIM ON YOUR BEHALF VIA THE COUNTRY'S LAWYER.

IF THE TENANT IS LEAVING THE COUNTRY, HE CAN PROVIDE DOCUMENTARY PROOF.


She advises that u let things be and just pay up the commission and look for another tenant and thus incur another commission. I feel she is not acting in my interest.


THE CEA (COUNCIL OF ESTATE AGENTS) HAS JUST BEEN FORMED IN NOV 2010 TO ADDRESS YOUR CONCERNS AND COMPLAINTS AGAINST THE PRACTICE OF HOUSING AGENTS. YOU MAY WISH TO CONTACT CEA AT 5TH FLOOR HDB HUB.


5. The co broke agent refused to return me the keys, access cards and transponder unless he gets his commission. Does he have a right to? What recourse do I have.


IS THERE A COMMISSION AGREEMENT YOU SIGNED WITH THE CO-BROKE AGENT? HAVE YOU BREACHED THE TERMS AND CONDITIONS OF THIS AGREEMENT? YOU CAN SEEK ADVICE FROM HIS HOUSING AGENCY AND/OR CONTACT THE CEA.


Thank you so much for your time and I hope to hear from you soon.


IN YOUR SITUATION, THE TENANCY AGREEMENT HAS BEEN SIGNED AND THEREFORE THE AGENTS HAVE COMPLETED THEIR TASKS. AS TO THE RETURN OF AGENCY COMMISSION ON A PRO-RATED BASIS, MUCH DEPENDS ON THE TERMS AND CONDITIONS OF THE COMMISSION AGREEMENT.

YOUR RECOVERY OF 2 MONTHS' RENTAL DEPOSIT FROM THE TENANT IS FOR BREACH OF TENANCY AGREEMENT.

THEREFORE THIS MATTER OF LOSS OF RENTAL INCOME AS CONTRASTED TO NOT PAYING THE CO-BROKE AGENT AND RECOVERY OF PRO-RATED COMMISSION FROM THE MAIN AGENT IS A SEPARATE ISSUE AS THERE ARE TWO SEPARATE CONTRACTS (tenancy agreement and commission payment agreement). If you agree to pay commission on securing of the tenancy (signing of the tenancy agreement) and have not stated on return of pro-rated commission on premature termination of the tenancy agreement, you will need to consider whether you need a lawyer to act for you. I am not a lawyer and so the above is free advice. I will advise you consult a good lawyer to act for you. Best wishes.

The written contract is usually the main document which the lawyers and judges will refer to.

282. Neutering big breeds and fluroescein dye in eye ulcers

Dec 30, 2010

INTERESTING CASES

2nd last day of 2010. Today was the low season (as in tourism) as I had only a handful of cases. But I could spend more time with each individual and this is the best part of veterinary medicine. If the vet has 40 cases a day, it is not possible to get to know the clients well since the waiting queues and dogs barking at each other in the very small reception room would be harassing.

Case 1. Neutering of big breeds
A young man in his 30s came with a big breed for neutering. He had been to the Surgery before. Since there are now over 40 veterinary practices in Singapore and the practice of vet-hopping is common and he lived in Changi which is a 30-minute drive to Toa Payoh Vets, I expected him to choose a vet based on proximity, not on reputation or skills. Therefore asked him: "You have several practices closer to your residence. Why do you come so far away to neuter your Golden Retriever?"

"Actually I phoned up Vet 1 (which is an established practice nearer to his residence than mine). The girl said that the practice does not neuter big breeds. So I come here."

I was surprised as I thought all vets in Singapore neuter all dogs irrespective of size. Neutering is a most common surgery in veterinary practices all over the world. Well, life is full of surprises and changes.

As to why Vet 1 does not neuter big dogs, I can only hazard a guess based on my observations and said to the young entrepreneur: "In big dogs, the bleeding complications after surgery can be very distressing. The scrotal sac swells to as big as a tennis ball if there is bleeding. Some dogs bite and lick the operation area vigorously and this is one cause of bleeding. The profuse bleeding leads to a lot of blood inside the scrotum and the owner becomes worried when they see it becoming a huge tennis ball." Big dogs seldom wear e-collars to prevent licking as some owners don't want it. E-collars should be worn for the first 48 hours but big dogs and owners don't like it. The dog finds it difficult to eat and drink properly. However, I have cases where e-collars do not prevent self-trauma licking and injury of the operation site. In such cases, pain-killers may not be effective or the dog is highly sensitive and clean.

In this case, I share with the vet students my surgical approach to get a good outcome of no post-operation trauma of the surgical site after neutering.

ANAESTHESIA. Golden Retriever, Male, 3 years
Domitor 0.3 ml IV. Wait 5 minutes. Isoflurane gas 2-3% maintenance. Intubated. Excellent surgical anaesthesia.

SURGERY. 2-cm incision in skin above scrotal area. (Some vets in Singapore incise the scrotal area apparently according to one of my clients). I took out one testicle. Then I clamp the tunica as a whole sheath enclosing the spermatic cord and blood vessels. 3 forceps are used to clamp.

TRANSFIXING LIGATURE. Below the lowest clamp (3rd forceps), I inserted the suture needle (2/0 absorbable) into the sheath away from the blood vessels. Then I ligate the blood vessel end. After that I ligate the opposite end.

DOUBLE LIGATURE. Then I release the clamp. I wrap one suture round the clamped area of the sheath and ligate. In this area, the suture is unlikely to slip. In any case, I knot on one side. Then I knot again on the other side.

I cut off the sheath between the lst and 2nd forceps. Push back the sheath into the inguinal canal. Checked for bleeding. There was none. I repeated the procedure on the other testicle.

SKIN INCISION. I put in 2 horizontal mattress sutures using the same 2/0 absorbable suture. There was profuse bleeding from the skin. This is quite common and not serious. I put on plaster to stop the bleeding which will be obvious.

POST-OP PAIN-KILLERS AND ANTIBIOTICS. Tolfedine and Baytril are given SC based on 10 kg post-surgery. The dog was OK. There was no need to give Anti-sedan to reverse the Domitor as the dog woke up after 10 minutes since I had reduced isoflurane gas go zero in the last 3 minutes before completion.

5 HOURS AFTER SURGERY. INSPECTION BEFORE GOING HOME. The owner and his wife came. The dog wagged his tail. There was no pain and he did not lick the area since tolfedine was effective. The owner rejected the e-collar. So I advised him to give tolfedine tablets 12 hours later (the next morning) and therefore for 7 days at one dosage per day. Antibiotics were prescribed. There ought to be no problem.

STITCH REMOVAL 10 DAYS LATER ADVISED. The owner was advised to wash the operation area and thigh with warm water as there was some blood stains.

TEETH SCALING AFTER NEUTERING. Some tartar in the back teeth. Teeth scaling was $100. This was a big discount to $250 since the dog was already under anaesthesia for neutering. Tooth brushing will prevent tartar formation.

This was a very friendly Golden Retriever. I took some pictures of him and tried a close up picture of his eye with my 18-55 mm lens. It was a most happy outcome for everybody as the dog appeared normal and happy.

Case 2. Shih Tzu with left eye corneal ulcer (generalised superficial keratitis).
"Vet 1 said that my dog must use artificial tears as my dog has dry eyes. She used a green dye on the eye and said it had dry eyes and conjunctivitis," two young ladies presented their Shih Tzu with a red left eye. Her father was present with her. The left eye was cloudy while the sclera was intensely red. It is unusual for a young dog to have dry eyes as this was what the young ladies reported as to what Vet 1 had said. However they had no medical report from Vet 1 with them and I did not want to go into the hassle of phoning Vet 1 to ask for medical records. Some vets would do it.

A simple eye examination would be practical and even if the dog had dry eyes, it would be possible and that would be some time ago. In any case, it had no dry eyes now. I asked: "How long has this left eye been so red?"

"Only 1 week." the older sister said.
I shone the torchlight on the eye. The cornea was cloudy for around 70% of the area esp. on the top half. I asked my assistant Mr Saw to put the fluorescein strip into the eye as part of my mentorship. He would be returning to Myanmar in 2011 to be involved in a new practice and as he has been working for me for 3 years, I wish him well and am sure he would be a better vet in Yangon after 3 hard years in Toa Payoh Vets.

Mr Saw came into the room and went to take a syringe, filled it with saline and squirted some onto the eye. Then he applied the fluorescein strip onto the eye. I was puzzled as why he did it this way. He had seen me doing it the direct way and here, he did it another way*.

The fluorescein strip started to disperse green dye onto the eye. However, the greenish was not so obvious as the saline squirted onto the eye was making the stain less green. In any case, the owners could see that the top half of the cornea was greenish, indicating ulcerations. I advised stitching up the eyelid for 7-10 days to enable ease of healing of the cornea which had been exposed to sunlight and wind and caused the dog to rub the left eye till it was red.

Domitor 0.1 ml IV was given. Isoflurane gas. The eyelids were stitched up. The dog went home. Eye ointment to be applied. Stitches should come out by itself in 7-14 days and there ought to be a good outcome. "Eye injuries are emergencies," I advised. "They should be treated within 24 hours of injury. The Shih Tzu commonly gets eye injuries. Sometimes it is the prominent nasal fold's hairs irritating the eyes," I said as I showed the illustration from the Ophthalmology book. "How much it costs for the surgery?" the father asked about the stitching of the eyelids. "Around $250." He was agreeable.

P.S. *I asked Mr Saw later as I showed him the direct way. He said this was what my associate vet did and therefore he did it. Mr Saw's friend came to visit, saw the faint green dye and said: "Nothing serious with the eye ulcer, no need to do surgery to stitch up the eye lids." This was his opinion as he clipped the dog bald including the eye area for my surgery.

During anaesthesia, I re-applied the strip directly onto the eye and this time, Mr Saw could see the intense green covering more than 50%of the cornea. The ulcers were obvious now since the green dye sticks onto the pitted cornea from 9 o'clock to 4 o'clock of the cornea mainly. I took a picture for record and educational purposes. "Show rather than tell" is the most effective way to mentor a person.

Life is full of surprises and changes. I told Mr Saw that the best way is to apply the fluorescein strip under the upper eye lid and there was no need of saline flushing first. I don't know whether he will remember but hands-on experience is the best way to learn. Nobody is perfect but sometimes I expect perfection in my veterinary assistants of procedures they have had seen done successfully. However, there are other ways to do a procedure in veterinary surgery and sometimes a new way is much better. So, it is hard to say that my way is the correct way and be narrow-minded.

Wednesday, December 29, 2010

281. Ear problems and Injectable anaesthesia - xylazine & diazepam IV

Dec 29, 2010

I was on duty as Dr Vanessa Lin went on leave for the next 10 days. This was the 2nd day of work since I came back from the holidays. I thought it would be a quiet Wednesday and brought my laptop to do some writing and scheduled a house-call to micro-chip and vaccinate some dogs at Pets Zone in Dunearn Road at 4 pm. But it was a hectic day from 10 am to 8 p.m, with one-hour break at lunch-time. The cases were the usual ones of neutering and spaying, dental scaling, skin diseases, ear problems, eye infections in two stray kittens. Some interesting cases are as follows:

1. Animal activism in Singapore. A young lady wanted to know how much it would cost to hospitalise two stray kittens with flu for a few days while she looked for new homes for them. Her father would kill her if she brought these kittens home as she already had several. She was looking for the least cost veterinary care and dictating that the kittens should not be given antibiotics. This is a common situation encountered at all vet clinics. There is insufficient space at Toa Payoh Vets which is a small surgery of 60 sq metres. I do help a few stray cat cases but there is a limit in charitable work. A practice has high overheads although it does not look obvious to the average pet owner in Singapore. In this case of cat flu, home nursing would be best. I advised her to nurse the kittens herself as it would be better for the kittens.

2. Animal activism in Yangon. An old friend started to help homeless dogs and cats in a place in Yangon. This is his personal thing as he could better spend his time and skill earning more money in the IT field. However, the residents there wanted US$20,000 from him if he wanted to continue his mission. I had advised him of the risks of doing animal activism overseas as politics would become dominant. This happens even in Singapore, as cat welfare people tried in vain to get the Singapore Government to permit cat ownership for the average person living in HDB apartments.

From this incident, you can see that it is difficult for a Singaporean animal activist going across borders to help change the world unless he has powerful political connections. Politics and economics interact in animal activism and business. Such are the facts of life.

3. Ear problems. One dog had red ear flaps for many weeks. I did a microscopic examination of the hairs. It was ringworm. "A follow-up one month later is important," I said to the owner. Some owners blame the vet for not resolving their problem when they don't follow up but went to another vet.

4. Injectable anaesthesia. The following is one of many metods of injectable anaesthesia used safely in practices and countries with no access to isoflurane gas anaesthesia, unlike fortunate Singaporean pet owners where the best anaesthetic drugs are available for pets.

I am sharing this knowledge with vets working in such locations. The above dosage is a general guideline. An IV catheter is inserted so that top up injections can be given IV should the dog need more anaesthesia. For a 10-kg dog, the dosage of diazepam and ketamine in one syringe are respectively 0.4 ml + 0.4 ml IV.

Case 1. At 50% of the above dosage, ie. 0.2 ml diazepam + 0.2 ml ketamine in one syringe IV for a 10-kg mixed breed dog, the dog shows signs of head shaking sideways and salivation. It was not under surgical anaesthesia. I top up with 5% isoflurane gas by mask for a minute or two to effect and this provided excellent anaesthesia for neutering.

Case 2. At 100% of the above dosage, the dog's body muscles were tense. The dog's neck and legs were flexed. The eyes were open and the pupils dilated. However, dental scaling was done without pain or the need for top up.

CONCLUSION. Each vet has his own preferences in anaesthesia. As long as it is safe for the dog, injectable anaesthesia offers a cheaper alternative to isoflurane gas. The anaesthetic machine and isoflurance are expensive compared to the injectable anaesthetics. In an effort to lower veterinary costs, injectable anaesthetics are used. As for me, I prefer to use xylazine (or domitor) sedation and isoflurane gas anaesthesia as I find that the dog sleeps relaxed (not with tense muscles as in the diazepam and ketamine injectable anaesthesia) and surgery can be done smoothly without the need for topping up as the dog struggles when pain is experienced.

ECONOMICS OF PRACTICE. Each vet does what he prefers as long as the dog is safe and alive at the end of the day. I am just sharing my observations to benefit vets who may not have access to isoflurane facilities as not the isoflurane gas machine purchase cost and maintenance are very expensive. There are more less sophisticated pet owners who just want "cheap" veterinary anaesthesia and surgery and a veterinary practice needs to sustain its profitability to be around the next year. So, there is a need to reduce veterinary costs, sometimes performing loss-making surgeries!

INTERESTING CASE OF BLACK EAR DISCHARGE
"The (pet shop owner's son) was not in a good mood and so I talked to the counter staff," the matronly woman had brought the 7-month-old female salt and pepper Miniature Schnauzer in for his 3rd vaccination. Toa Payoh Vets had given the puppy 2 vaccinations earlier. She paid $350 for the dog which I thought was too cheap as it had such good physical characteristics. But older dogs are difficult to sell and only puppies fetch a premium price in Singapore.

"The young man may be having some personal problem," I said as the husband wanted the wife to complain that she was sold a dog with black ear discharge. "His father had died while delivering dog food and crashing his van. The hospital doctor did not diagnose that he had a head injury and sent him home. What ear drops have you been using to clean the dog's ears?"

"I use eucalyptus oil for the past few days," the lady said. "The next day, the black ear discharge appears again."

"This is is a good looking dog and you had got it at a cheap price," I could appreciate a Schnauzer with good conformation. A good sized head, proportionate body length and not too long legs. Not too bulky as Singaporeans prefer this type of size although dog show people will consider this dog under-sized. Female dogs of this size and shape are more valuable for breeders as there is a demand for "miniature" Miniature Schnauzers.

I took a cotton bud and spread some ear discharge on a slide and put it under the microscope but saw no mites. "You must have drowned all mites with oil," I said. "Not a mite can be seen."

What caused the blackness and the black particles inside the two ears? As black as black shoe polish. Ear discharge comes in all colours but pure black is rarely seen by me in practice over 40 years. It was as if the ear drops of oil were black in colour. I did not ask the owner the colour of the ear drops as it was an extremely hectic day and I still had not done the 3rd spay of the 3rd stray cat.

The owner who loves his 3 stray cats had brought in the 3rd one for spaying today. Yesterday, he got two in and I had neutered and spayed them. The 3rd one was "fierce" and was put inside a cardboard box, taped up but with gaps for the cat to breathe. It was as if he had a tiger inside the box and so we did not dare open the box and transfer the cat to the crate for the time being. The minutes ticked by and the whole afternoon had gone and still I had no time to spay this cat.

Spending time with the owner is essential in practice building but the other owners at the waiting room disliked waiting too long unfortunately. Some owners want fast service. I could see that the Schnauzer lady's husband was all ready to go to work. But he was the patient type who would wait for his wife to get the dog vaccinated. That was all she came for and vaccination should be fast. But for the black ear discharge, the dog would leave in 5 minutes.

I got the ears irrigated and taught the owner how to use the medicated ear drops. The best would be another ear irrigation the next day but I could sense that the husband was an extremely busy man but his wife mentioned about him working in an important post in a volunteer organisation. "You work for the famous Red Cross," I said to him as I was thinking of the excellent volunteerism and time it had done for so many unfortunate people in countries all over the world.

"The infamous Red Cross," he laughed. Yes, there was a newspaper report about some loss of money taken by a staff in the Singapore branch but I was not thinking of this matter. There will always be staff who steals money from the organisation all over the world.

In one case of a famous cosmetic surgeon in Singapore, I was shocked to read in the newspaper that he did not print his own receipt books. He bought commercial ones. So, he had 3 copies. The white for the client, the blue for audit and the yellow for the case file. Now, his billing staff found a way to milk him of over $100,000. She would buy another set of books. When she billed the client, she would give the client the white copy with say $1,000 and collected $1,000. Then she would write, say $500 on the blue and yellow copy from her own purchased set and discard the original blue and yellow copies of the surgeon's book. She could also under-declare the income by replacing the yellow or blue copies.

"How was she caught?" my wife asked me yesterday when I told her that the famous surgeon did not print his own receipt books which I found it hard to believe if not for this case in court.

"Well, another staff discovered that the blueness of the blue receipt was not similar to the blueness of the other receipts." But over $100,000 had been misappropriated and this sacked staff complained that the surgeon had not granted her medical leave.

I digressed. Back to the Schnauzer's black ears. The husband seemed appreciative when I asked the wife to use the medicated ear drops herself to clean the ears for the next 7 days and if the black discharge disappear, then there was no need to consult me.

This was one of the 4 interesting ear problems. The other one was the fiery red inside ear flap caused by ringworm infestation in both ears mentioned above. The 3rd one in a young cat with thick reddish black waxy ear discharge was even more interesting in the sense that I managed to find one dead ear mite under the microscope when I did an ear discharge examination.

"See the mite," I asked the young lady to peer into the microscope. "There is only one." The mite with a round body and six short legs in the front half was clearly visible and sharp under my newly purchased microscope. "Where's the mite," the lady asked. She was not into biology I presumed. I took out the Hill's Atlas of Clinical History and showed her the drawings. Maybe I should produce one myself. "See the book drawing of the mite," I showed her the cat and ear mite drawings inside the book. "What's the name of this ear mite in the cat?" I asked Mr Saw, my assistant who is qualified as a vet in Myanmar and would be returning home in April 2011. The book did not mention any name. Mr Saw shook his head. "It would be Otodectes cyanotis," I said. It was Greek to him and to all vet students. I got the ears irrigated and gave an anti-mite ivermectin injection. Follow up would be good.

It is 7.25 am and I have to get ready for work. The 4th ear case was one in which the young man's cotton tip fell into the dog's right ear canal while cleaning. The Pomeranian would bite when he tried to retrieve it deep inside the ear canal. "Surprisingly my dog did not shake his head. I would rather get it removed before it infects the ear. How long will it take?"

"That depends on whether the dog needs to be sedated," I said. I got the dog inside the surgery, muzzled it and Mr Saw held the dog properly. Mr Saw had wanted the ear scope to check out the ears. "No point in doing it," I said. "The ear scope will push the cotton bud deeper into the ear." Sometimes we have to visualise the impact of a particular procedure.

In theory, all ear examinations must be scoped. Sometimes it could even be considered negligent not to scope the ears as a routine. In practice, the dog owner had already given us the history that his cotton tip had dropped inside the right ear. Using an ear scope would push the cotton into the horizontal canal and that would be very difficult to extract.

I inserted a slim curved artery forceps into the right ear vertical canal to the base, open and clamp. Fortunately I got the cotton bud out at the first clamp. I showed the bud to the owner who was quite pleased. "It's time I buy good quality cotton buds to clean my dog's ears," he laughed.

So, in one day on Dec 29, 2010, I got at least 4 different causes of ear problems in 3 dogs and 1 cat. There was a 5th in a Westie. In this case, the Westie had itchy ears, paws and body. It could be a Westie-related genetic disease or allergy. So, there were actually 5 cases of variations of ear problems in dogs and cats in one day. And I thought this was going to be a laid-back day and smell the roses. At 8 pm, I completed my house-call vaccination and microchip at Pet's Zone in Dunearn Road apologising for the late arrival.

It was an unusual day of ears to remember. I record it to remember it when the years go by. I hope you did enjoy reading the report.

Tuesday, December 28, 2010

280. Two para-police guards at the CEA office

I was surprised to see two senior para-police guards outside the CEA office as there were none two weeks ago. "We are protecting the CEA directors inside the offices. Many housing agents had their licences revoked and we have much experience handling such riotous people."

The CEA is set up to regulate the housing agents and started in Nov 2010. "There is a Chinese syndicate conning the people," the guard told me. I was surprised to know that. The world has changed and there may be more cunning scam and con men and women who want to make fast bucks without having to work.

279. The man who loved 3 stray cats

Yesterday, Dec 28, 2010 was my first day back to work, after a 14-day packaged tour to Europe (Italy, Switzerland and France) and a subsidised stay in Dubai from Emirates Air and the Tourism Board.

It was extremely tiring as the tour leader had to rush us from one place to another. There was a group of 49 Singaporeans and a few would not be punctual throughout this packaged tour as they took their time to take photographs and eat their meals belatedly, making the majority wait for them.

Surprisingly, the Divine Powers had been kind to us as there were no major traffic jams from Rome to Turin to Switzerland and Paris. Nor were there delays in flights back from Paris to Singapore. Yet the the heavy snow falls affected road traffic and flights in London, the US and Europe at around this time (Dec 13 - 27, 2010). One Singapore Tour Group had to spend the night inside the coach from Milan to Rome as snowfall had caused traffic slowdown. We were clear all the way.
The only thing we missed was seeing The Colosseum in Rome. The students protested violently against Prime Minister's Belusconi's decision to cut funding for University research and expenditure and increased fees. So they burnt cars and caused closure of the Colosseum. The Eiffel Tower in Paris was closed before we arrived as there was strong winds or something but when we arrived, we could visit the 2nd floor. Strong winds did close the railway service to the top of Europe - the Jungfrau mountain or Matterhorn in Lake Interlaken, Switzerland. We went snow sledging. I did not want to risk my life as any mistake in rounding corners on the right could fling me down the ravine. I was no spring chicken and wanted to back out as the younger ones and some older folks took the risk of sitting on the snow sledge downhill.

I was the last one left holding the snow sledge as the others who did not want to do snow sledging were holed up in a cafe. Well, I took the risk. It could be death if I fell into the steep slope on the right and knocked my head.

The snow sledge's downhill slide was to be stopped by putting two heels down onto the snow as if braking a car. My heels were not deep into the snow and so the snow sledge continued to slip downhill increasing momentum as the gradient was steep, at around 45 degrees. I banged into the left side (of the hill) and slightly bruised my left shin. I did crash onto the right edge and quickly hopped off to avoid falling into the ravine below as my sledge could not turn left for two times. Midway down, I nearly crashed into a group standing around. There, the tour leader was phoning for ski patrol for help. A Singaporean was really flung down a bit of the ravine. A tree stopped his tumble further down and he received 4 stitches above his right eye-brow. That was the main excitement of the packaged tour. Fresh snow had just fallen a few days ago.

After snowsledging, we went to Lucerne for the night. The tour guide took the group there from Lucerne the next day and it was clear. I did not bother to take another 1.5-hour coach ride and explored the Lucerne town and its inhabitants and tourists. The two sons went skiing nearby.

Back to my first day at work. A family was too early and was waiting for Dr Vanessa to do dental scaling. An old client came with two stray cats. "The vet would only sterilise them at 6 months of age," he said. "However, these two cats were meowing and behaving like adults at 5 months of age. I want to sterilise them. There is a 3rd cat somewhere. I will get him later."

I examined the cats. The male was 2.8 kg. The female was 2.4 kg. Both could be sterilised and so I booked them in. I am teaching my veterinary staff to be efficient and not to waste material unnecessarily. I pointed out to them that the new $7,000 surgical operating table of two weeks had more than 30 scratches. "So, at the end of two months, the whole surface would be all scratched," I said. "This should not be the case. You need to put a tower on the table to protect it until the dog is under anaesthesia and surgery." The seller had delivered the table without informing me when I was on holiday. Sometimes it is common sense. Stainless steel surfaces should not be clawed by dogs as the scratches would rust later. So, use towels to protect the surface when a dog is awake and not fully sedated.

The examination table of over 10 years and sourced from the same U.S. manufacturer was hardier and did not suffer any serious scratches.

"Gauze?" my assistant got the gauze ready. "There is no need to use gauze," I said to him again. "There is little bleeding during a cat spay." That is the situation I encounter when I spay a cat.

"The start and end of the surgery must be recorded," I told my assistant. This will enable me to audit my surgery as well as those of my associates and learn from the situations needing unusual lengthy surgeries. An animal has a better survival rate if the surgery is as short as possible.

ANAESTHESIA
2.4 kg stray cat. Xylazine 0.1 ml and ketamine 0.4 ml in one syringe IM. Effective. There was no need for an assistant to hang around. I took around 25 minutes for the surgery doing it at a leisuredly pace. It could be done in 15 minutes.

VET-HOPPING
This is common in Singapore. Proximity and pricing would be the attracting factors. 6 months of age is the common recommendation for spay of dogs and cats. In this female cat, at 5 months, the ovaries and uterine bodies were enlarged with thick red blood vessles. Therefore the cat was on heat at 5 months.

2nd VACCINATION AND EAR CLIPPING. The gentleman in his late 50s said: "Clip the left ear so that the AVA would not grab the cat and kill it. My family is attached to these stray cats and that is why I want to sterilise them." He wanted to hospitalise them for a few days although I said it would not be necessary.

Monday, December 27, 2010

278. Myanmar travel and tour travel agency

In December 2010, I have started Design Travel Pte Ltd, a travel agency focused on Myanamar travel and tours. The previous licence from the Singapore Tourism Board was for Asia USA Realty (S) asiahomes.com Pte Ltd in 2009. This was returned to the STB and replaced by a new licence for Design Travel Pte Ltd which is more appropriately named as a travel agency whereas the previous licence was part of a real estate agency.

My blog on my 2008 tours are at:
http://myanmar-singapore.blogspot.com/2009/03/asiahomes-start-up-travel-agency.html

Thursday, December 23, 2010

277. Christmas in North Myanmar

DRAFT TO SUBMIT TO TRAVEL STORY CONTEST

PERSONAL SAFETY
"Is it safe to tour Myanmar?" many Singaporean friends thought I was insane when I made arrangements to visit Central and North Myanmar in late 2008. The local newspapers seldom market or advertise tours to Myanmar in the past 10 years and so most Singaporeans do not visit this country of 50 million people. "The planes there are not safe," one veterinarian's wife surprised me with her comment on air safety. Yet there have been no news of airplane crashing in Myanmar for at least 10 years.

When a bomb exploded in a tour bus in Israel some 15 years ago, a few of the Singaporean pilgrims backed out of the Bible Land tour organised by my ex-National Service officer who became a pastor. I was a non-believer but I toured with him to visit Bethlehem's Church of Nativity where Jesus was said to be born in a stable surrounded by farm animals and related Christian sites, making my Sunday School lessons of some 50 years ago alive.

So, should I go to Myanmar with my family during the Christmas holidays and endanger the safety of everyone? Fools rush in where angels fear to tread? An old Myanmarese friend assured me: "Myanmar is a safe country for tourists. The government prohibits tourists from visiting certain regions which are deemed not safe for foreigners." After talking to other Myanmar nationals, I decided that there was no concern and embarked on an unforgettable journey whom I got to know more about my family members as well as the culture of the Myanmar nationals, one of whom was my veterinary assistant.

BEST SEASON TO VISIT MYANMAR & TOURIST ATTRACTIONS
October to April is considered the best period of time to tour Myanmar as it is the dry season and the tourist does not get drenched and travel on muddy track roads in visiting rural areas.

TWO TOURS IN 2008
From Singapore, we boarded a Silk Air plane to Yangon in September for an 8-day travel to Central Myanmar. A tour guide met us at Yangon and we toured using local airplanes and a tour bus to visit Mandalay, Pyin Oo Lwin, Lake Inle and Kyaikhtiyo before going back to Singapore via Yangon. In December for 14 days, from Yangon, a tour guide went with us. We took internal flights to North Myanmar's city of Myitkyina. Then we took two cars to travel over 7 hours on bumpy roads and broken bridges to Lake Indawygyi. Then we drove back to Myitkyina and took a plane to Bagan, by coach to Mount Poppa and then Pyin Oo Lwin before going back to Singapore.

LUXURY ACCOMMODATION
"The Racing Manager must be corrupted. He and his family stayed in Mandarin Oriental Hotel in Bangkok for their holidays," one strictly religious Turf Club Security Manager remarked to me when I was a racehorse veterinarian some 30 years ago. Staying in a 5-star hotel in Singapore is still very expensive but the rates would be much lower in Bangkok, Thailand and affordable for many Singaporeans. In Myanmar, we could afford to stay one night each at the luxurious Strand Hotel, Myanmar and the Governor's House (rebuilt) in Pyin Oo Lwin to experience the ambience and the history of the British colonialists who designed and built both buildings.

KILL ALL SPIDERS AT GOLDEN ISLAND COTTAGES HOTELS, INLE LAKE
On checking in at the Golden Island Cottages villa built of bamboos over the Inle Lake, spider cobwebs lined the walls and several spiders scattered on top of the mosquito nets over the beds. My wife was not happy. The hotel staff rushed in with Bayon spray cans. "No need to kill the spiders," I stopped the staff from blasting the rooms with insecticide spray. "Just catch the spiders and put them outside. Sweep away the cobwebs with a brush and broom."

Arachnophobia from a veterinarian's wife? Well, one James Bond's movies had shown a tarantula crawling onto a sleeping person and killing him with painful bites and this could have caused arachnophobia in city dwellers like my wife. Now, I had a problem. How to resolve this? The tour guide had already booked the hotel. Yet, the fear of spiders should not be dismissed away. We went on the boat ride to visit a hut where local women weaved lotus fabric and on the way, I saw Myanmar Treasure Resort Hotel and got the guide to book the rooms for us. It was a luxury hotel type. There was not a cobweb in sight in the bedroom. This solved my problem!

EXPOSURE TO LIGHTNING, THUNDER AND STRONG WINDS, KYAIKHTIYO
"I don't want to be electrocuted by lightning," I said to myself as four men carried me on a palanquin 11 km up the steep hill from Kinpun base camp to the mountain top where the Golden Rock Pagoda and Hotel were located. Heavy showers erupted just as we reached Kyaikhtiyp by coach. I remembered that a golfer was killed by lightning in a Singapore golf course and the advice was to stay away from open areas during thunderstorms. Here I was, fully vulnerable, damp and exposed to the elements. The four men on each end of the pole walked in tandem, switched positions of the pole swishing their slippers as they carried the tourists past boulders, shrubs and trees. Black skies flashed yellow as if I was in a air bombing battlefield. It was too risky to drive up the mountain and the accommodation was booked at the top. So all of us had to pay to be carried uphill like what British officers were during the colonial period. It seemed like an eternity. I was more worried that my camera and shoes would get wet as I wrapped them with plastic bags. It must be one of those unforgettable moments for my family as the fear of being killed by an act of God was too real and time to reach our destination was an eternity.

At the hotel, we no dry clothes as the guide had left our luggage at the bottom of the Mountain. So we purchased some sarong. I thought it was fun. But not for the others. The manager told us that electricity would be switched off after midnight as there was this thunderstorm. At 4 am, the bedroom was as dark as hell. I could not even see my finger. Where was the bathroom? "Grope the bedside," I said to my wife. "Feel the wall edges and then slowly glide your hand towards the direction of the bathroom door." This was worse than my national service military exercise past midnight. At least I could see the starlight then. Here, I was blind as a bat. The next morning, I discovered that the hotel had torch-lights hanging on the wall. Well, the manager or hotel notices did not inform inexperienced travellers like us about the presence of torches in hotel rooms.

HARDSHIP ACCOMMODATION AT LAKE INDAWGYI
Cracked WCs, no hot water at the Lakeside Guest House in Lake Indawgyi in North Myanmar. "This is acceptable to the backpacker," my wife declared to me two years later as she recalled the visit to Lake Indawgyi. She was no more the young spirit who would sacrifice comfort to see the world. No electricity at dinner too? This was upsetting. Candle-light for dinner at Lake Indawgyi's small restaurant was romantic, I thought. This was hardship dinner. I appreciated the boat tour of this clear and beautiful lake and the pagoda where pilgrims walked to pray during the season when there was no water. "The fish was good," my second son recalled. "As for the rough bathroom amenities, the national service training had accustomed us to such situations."

TOILETS BEHIND THE BUSHES ON THE WAY FROM MYITKYINA TO LAKE INDAWGYI
The 7-hour car ride from Myitkyina to Lake Indawgyi was hard on the backside of city dwellers. It was worse when it came to bathroom facilities. Once my wife had to go behind some low shrubs while her sons stood guard as she had to pee. On the visit to the gold-mining area 2 hours's drive from Myitkyina, she could not stand the stench of the public toilets. My guide had the brains to persuade a monk to let her use the bathroom of the monastery. Well, no more Myanmar rural tours for her if there are no good bathrooms with fresh air.

COMMUNITY TOURISM
I would like to see the how the six bigger groups of ethinic minorities live in their communities. These are the Shan, the Karen, the Kachin, the Mon, the Rakhine and the Chin. Tourism revenue helps to improve the standards of living of a community and my travel may make a very small difference to the local people as it provides some employment for the hospitality staff. Bagan with its archealogical and historical heritage was busy with Caucasian and Asian tourists during my visit there. There were worries that the pagoda floors would be worn out by the footsteps of such large numbers of tourists.

ECONOMICS
Stunning beauty of the interior, cultural heritage, gentle people
Oil, minerals and natural gas resources are abundant. Myanmar is of vital strategic value for its rich resources. Between two emerging giants, China and India. I would like to visit the jade mining areas of North Myanmar but my guide said it was not possible at that time.

STREET PHOTOGRAPHY, MILITARY & PROVINCIAL CHECK POINT

BACK-UP CAMERA, CAMERA SHAKE AND RAIN

CULTURE
Novice monks and nuns, ear boring.

FESTIVALS

WET MARKET

ART AND THE FLOWER GIRL


POLITICS AND TOURISM
INDEPENDENCE HERO, General Aung San founded the Burmese army. His daughter, Aung San Suu Kyi (pronounced as "Awn Sun Sue Chee") was under house arrest in 2008 and was released in late 2010. Now she is said to support tourism.

1962 coup by army. Burma is called the Union of Myanmar.
1988 Demonstrators fought the military.
1990 NLD won national elections. Aung San Suu Kyi under house arrest for 15 out of past 21 years in Rangoon (Yangon).
1990s Western government imposed economic sanctions on Burma. Suu Kyi supported the sanctions by discouraging tourism.
2007 Saffron revolution by monks.
2009 An American Vietnam War veteran said he was on a mission from God swam to her lakeside home, thereby extending her house arrest
2010 Elections held and Aung San Suu Kyi is free from house arrest after the elections.


BUDDHISM
Over 85% of the population are Buddhists. Philosophy of nonviolence.

INTERNET ACCESS in hotels - None or poor connections in 2008 except for top hotels in Yangon.

BROWN OUTS. Power failures do happen in shops and small hotels in bigger towns and cities but generators are available to restore the electricity in 2008.

ART - Art galleries yes. I bought a painting at the Bagoyoke market for my surgery.

VET HOSPITAL - none in Yangon in 2008.

Wednesday, December 22, 2010

Travel stories - Dog catches snowball?

Dec 23, 2010

Yesterday morning, while waiting to leave the Postillon Hotel in Lucern (Day 2 of 2-night stay), an elderly couple in a car let out two cross-bred dogs. Slim and active. One went towards the 2 single ladies in our group. They shrank in fear. So I presume these two Singapore ladies do not have experience with dogs. On the other hand, the 9-year-old Chinese girl who has a Maltese and rabbit at home, could not resist patting dogs she met.

The elderly gentleman made a snowball and threw it further away into the snowed field. The dog rushed forward but the snowball split and so it was a waste of time as the dog could not find it. It was a futile task for the canine companion but he barked for the owner to throw another ball. The other dog could not be bothered.

Paris today is 0 degrees C. Wake up call at 6 am automated. Will stop now to get ready to eat the bacon as I expect it to be of highest quality as in the Novotel hotel in Venice. I have stopped eating bacon for many years as it is not part of breakfast for the Singaporean Chinese family.

275. Travel stories - Paris

Thurs, Dec 23, 2010
Novotel Paris Est
6.34am (Paris), 1.22 pm (Singapore)

I left Singapore on Dec 14, 2010 on a 13-day Switzerland-Italy-France tour. Stayed in hotels in Rome, Milan, Turin, Interlaken, Lucerne (2 nights) and now Paris (lst of 2 nights).

COACH.
1. Leg space practically nil for most seats in European coaches provided by a European company. Stop-over at 2-3 hours enables one to walk stiffly. Free and easy tours will be better but will cost more. Less hectic and see more.

HOTEL QUALITY. Mainly 4-stars but quality of heating and bathroom vary considerably.
Novotel Hotel chain sets a very high standard. So far, stayed in two of the Novotel chain. Excellent variety and quality of breakfast in the first Novotel in Venice. Now in Novotel Paris, the hotel provides a long writing table.

KETTLE
On the table, you get a kettle, tea and coffee bags, and two convenient power points in the two Novotel chain I stayed. A kettle is much appreciated by guests. According to the tour manager, some tourists boil their socks in the kettle. This should not be done.

COMPUTER KEYBOARD
In Paris and Switzerland, the computer keyboard of Apple does not use the same letter layout as those in Singapore and UK. This means you waste several minutes correcting your typing and soon your time is up. It costs 5 Euros or S$6.30 for 30 minutes in Italy. So, you have to be fast.

FREE INTERNET ACCESS FOR 6 HOURS. This is really generous of Novotel Paris. The one in Venice gives free access for 20 minutes. It will be difficult for the other hotels to match this offer and also provides a variety and good breakfast, a kettle and warmth in the room when the guest opens the door.

BACON
As I had studied bacon production as a vet student in Glasgow Univ and stayed there for 5 years, the quality of bacon is defined as less fat. This will be more expensive. So far, only the Novotel chain in Venice passed my test. I expect Novotel Paris Est when I go down for breakfast at 7 am will pass the test too. Fatty oily bacon strips indicate that the hotel management is cutting down costs by buying the fatty streaky ones. I asked a Chinese student what "bacon" is in Mandarin Language. His mum who is a Chinese National says it is "the 3-layered pork belly meat." Bacon is essentially part of British breakfast. Maybe the French, Italians and Swiss do not eat it?

CLEANLINESS APPEARANCE.
Both Novotel chains in Venice and Paris are around 4 years old and have the high standards of cleanliness and pastel colours of curtains and white wall paint.

EAT
It is risky for health to travel in a packaged tour in Europe. I tend to eat more hamburgers, sausages, scrambled egg and fatty bacon. Sphaggeti in tomato sauce is my choice as I deem it less high-cholesterol filling. Salad and fruits. It seems most Singaporean tourists in my 50-person tour group shun them. They dislike eating European cornflakes, bread, milk and the same scrambled eggs, canned fruits and salami for breakfast every morning.

Tuesday, December 14, 2010

273. Travel Tips: Europe & Winter

Dec 14, 2010
Hotel Papillo, Rome
11.56am
7 hours' difference from Singapore as it is 4.56 am. Tour group of around 49 people from Singapore are sleeping. Left Singapore's messy renovating and dark Terminal 3 Changi Airport, Dec 14, 2010 at 2am. Reached Dubai at 4am (Dubai time), said to be 6 hours' of travel by plane. Waited >4 hours. Boarded Emirates Air again to Rome for another 6 hours. 3 pm bright and sunny blue skies at an old dark airport at Rome (could be a minor airport as there were 2 or 3 small Alitalia planes?).

I took a vacation break from Singapore from Dec 13 to 27, 2010 to refresh my mind and gain a different perspective in my veterinary practice and life. Travel does broaden your mind if you are receptive and alert to differences in people and places seen.

For some Singapore ladies, it is the inexpensive branded handbag and fashion shopping. Nothing matters. "I bought an LV handbag at $1,800," the single office girl in her late 20s declared: "It is cheap compared to Singapore where it sells for $2,400."

Here are some travellers' tips applicable to veterinary practice business and life.

1. TRAFFIC COUNTS
Dubai Airport Terminal 3, at 4 - 6 am is a very busy place unlike Singapore's Changi Airport at this time (I was at Terminal 3 on Dec 13). Planeloads of tourists or people keep the shops very busy. With high traffic, money is generated. More profits are ploughed to renovate and beat the competition by upgrading and providing more vendors and shops. In veterinary practice, this traffic does matter too.

2. NEW ARCHITECTURE AND DESIGN IMPRESS CLIENTS. Both Terminal 3 airports can compete in architectural impression as both were big, bright and newer. Rome's airport where I landed looks dated and gloomy. The circular design of the celing lights on arrival are attractive and brightens the place (see picture later).

3. FREE BREAKFAST FOR TRANSIT PASSENGERS OVER 4 HOURS. I discovered this by accident when I asked a lady who was soliciting breakfast clients for her restaurant as to why there was a long queue opposite her restaurant. My family had filled their stomachs with deep fried chips and onion rings and burgers at this Cosy and Burger Restaurant just below this free breakfast. Our transit was more than 4 hours. I went up to inspect as I try to refrain from fried fast food or eat little. The queue was due to one man verifying the 4-hour rule. His lady colleague just stamp and issue receipts with no verification to reduce the long waiting time.

Breakfast menu: Fruit juices, canned drinks, sausages, fried rice, canned beans, hard boiled eggs, scrambled eggs, buns, apples, bannanas. Certainly healthier than fried chips and onion rings which the young adults of Singapore are prone to eat.

4. PORTABLE HARD DISC (IOMEGA). In Singapore, I rushed to Harvey Norman at Yishun's Northpoint at the last minute to buy Toshiba hard disc. Since it does not sell Toshiba which I like for its design, I bought the Iomega 500GB. I thought its cable to transfer my pic from camera to hard disc was the same as Toshiba and so did not bring the Iomega's cable. I bought a different cable which could not fit into IOMEGA's input as it was much smaller in size. Always bring the same cable from the hard disc supplier. Fortunately I had one cable for the Canon camera but this meant that I had to download pic to computer hard disc from camera using this sole cable. Then disconnect the camera, take out the camera and connect the Iomega drive to computer to download the folder now saved in the laptop.

5. TWO-PIN mulitple plug for Europe. I bought one. So, now I connect to the laptop but cannot charge my handphone since I don't have another. Always bring 2 or 3.

6. ACCESS CODE FOR INTERNET CONNECT AT HOTEL PAPILLO. I went down to see the young man at 11 am to get the code to exercise a bit. Wet cold outside the hotel which is clean and white (marbled flooring is white) and carpets are pale brown green colours making the hotel look clean and bigger.

He gave me in CAPITAL letter of 6 alphabets. I keyed in the first two codes as instructed. No connection. Then I phoned him to get another code. CAPITAL LETTERS AGAIN from him over the phone. Can't connect. "Is it in capital letters?" Julia asked. "Yes," I said. I thought maybe, should use non-capital letters. It connected me.

7. ENQUIRE INTERNET COSTS. According to the receptionist, it is free for 10 hours of operating time. High speed broadband laptop connection is available in this hotel.

8. SPILLAGE OF ORANGE JUICE onto my camera. I sat on the aisle seat of 3. The Emirates Airplane has 3-4-3 seating arrangement. Very cramped. I like the touch-screen viewing. As I handed the drinks to Julia and Jason from the stewardess holding a tray of drinks in cups, I accidentally knocked one. Orange juice spilled out onto my trousers and camera. Only one SLR which I depend on for its sharpness and zoon and now, wet with sweet orange juice. My pants wetted but I was worried that the camera was disabled by orange juice. Nothing happened.

9. STANDBY SMALL CAMERA. Unlike my Myanmar trip, this time I am wise enough to carry a small Limux camera. It is not great in taking close ups and its auto features are ok in daylight. I should have another SLR back up. Hope this SLR Camera EOS 550 does not malfunction as the previous Camera EOS 50D I bought to Mynamar tour in 2008 failed me at the crucial last 3 days of the trip.

10. STUDENTS' POWER. On arrival at Rome yesterday, the tour guide said the students blocked downtown and therefore the Colosseum and downtown would be risky for tourists. The Italian tour guide took us to the Vatican which had no student demonstrations. "The students demonstrated against the Prime Minister, some 50,000 of them," the guide said to me. "But the Prime Minister won. By two votes." Political power is still the controlling factor.

11. BROADEN YOUR MIND BY KNOWING MORE ABOUT THE VATICAN CITY AND CHRISTIAN EMPERORS AND WARS. We had more time at the Vatican and I would say that it takes more than 3 hours to appreciate the beauty of Mary and Christ on her lap sculpture by Michaelangelo, the various mosaic altars of Christianity. The tour group was not that keen into Catholcisim and the Pope and so the guide was not keen to talk much as the group scattered to take pictures.

If you watch movies (I can't remember the thriller name), you would see as the guide pointed out, the central of 3 balconies where the Pope would stand out to bless the crowd on Christmas Day. Also the second room from the right of a building near the St Peterburg's church which is the Pope's office. Took some pictures. I don't think my tour companions care two hoots about catholicism and the history of Christianity.
Probably more interested in fashion and shopping in Milan. Since the colesseum was closed, the tour leader took us there at night when the students had left. It was very cold and we could view the outside only. The tour leader said we could see the colosseum at Verona where Juliet lived and where she declared her love for Romeo. "Must pay to see the inside of the house," he said. "Outside, see the balcony, it is free." I doubt there are any romantics in the tour group although we have two newly married. I used to see Shakespeare's house and bedroom at Stratford upon Avon when I was an undergraduate in Glasgow some 50 years ago. I really paid to see the room and the short bed he slept on. Shakespeare was taught in literature in Singapore schools. Now, the schools have thrown out literature for most junior college students. So, Romeo and Juliet's play and Verona means nothing to the younger Singaporeans. "Anybody watch the 'LETTERS TO JULIET' movie in the Emirates Airplane?" the guide asked. Julia did. I did not. Guess I am not a romantic. I enjoyed watching "THE GOOD, THE BAD AND THE UGLY" Western which I watched some 40 years ago. The plot is still riveting. I also watched "ROMANCING THE STONE" which has young Mike Douglas as an adventurer. It is a sob romantic story with rapid action scenes of life in Colombia. The young Singaporeans will never watch such movies in my opinion. It is a pity as they are "evergreens". What are evergreens? They are interesting good movies for all generations to come as they have excellent plots, pacing and character. But Avatar and new movies beat them in design and impressive visuals on the younger generation.

12. NO AIR COND. VERY HOT INSIDE BUS. One complaint from a big-sized Singaporean lady. The outside air is 10 degrees C. The driver switched on the ventilator or something.

Saturday, December 11, 2010

272. Know what to do in seeking employment

Related themes or events happen in threes within a short time in this case when I encountered 3 ladies with BSc (Chemistry) degrees from Myanmar universities.


I was at Peninsula Plaza to visit Khin Khin who had rented a table space to start up her employment agency focused on Myanmar nationals (except maids) looking for jobs in Singapore. I congratulate her on finally doing her own business as she had passed the examinations to be licensed as an employment agency (except maids in the first year of operation).

LADY NO. 1. She was in her 50s and had submitted her papers to Khin Khin to look for an employer to do research in the chemistry field. Khin Khin asked me to read the papers. She was a Chinese and spoke the Hokkien dialect to me. Her English was not so good. I noted that she took 7 years to get her PhD degree and asked her why. She said she had to raise 2 daughters and therefore she took a long time while working for the government. It would be very difficult for her to get a job as she did not have proper documentation of her work experience or testimonials from previous employers. She said: "The government (of Myanmar) does not give testimonials to employees." Her daughter came to Peninsula Plaza later. She studied in Singapore and the father was working in Singapore on a "S" pass. She said: "Looking for job is her 2nd priority. Mum comes to visit the family in Singapore." Yet to me, Mum's first priority seemed to be looking for a job and be able to stay with the family in Singapore. Without a job, she could stay in Singapore for 2 months on a visitor visa
and then must go home.

LADY NO. 2. While talking to Lady No. 1, there was a young lady doing typing on a table near Khin Khin. Khin Khin said: "This lady has a BSc (Chemistry) degree too and her S pass had been rejected. So she is asking me to help her apply for an Employment Pass."

This lady is in her late 20s or early 30s, I can't really tell. Her oral English was good as she could communicate with me just like a Singaporean. She had worked 18 months in Singapore for an expatriate company under an S pass. But now, the MOM (Ministry of Manpower) said that her company did not have 4 Singaporeans to qualify for an S pass for one foreigner. So, her manager wrote a few sentences in a letter to apply for an Employment Pass. The MOM officer rejected this application saying she was not qualified.

So, she looked for an employment agency to help her do a proper job and that was where Khin Khin's employment agency was involved. I was just visiting her but Khin Khin wanted me to help her review her client's case. If I can help somebody to get a job, I will be most happy to do it.

Khin Khin's one-table desk was insufficient to provide the administrative support. So the young lady had to go out to another office to get her documents printed. Two and a half hours passed by so quickly and still she could not finish her paper work. I could now see why it is so difficult for a person just to apply for an S or E pass from the MOM as there are at least 6 procedures to be adopted and presented in writing.

One of them is testimonials from the previous employers and the other is a list of duties and responsibilities from the new employer. Now, she has the excellent testimonials from her previous two employers in writing. One was from a Myanmar hospital expatriate who wrote a good testimonial for her to get her job in Singapore. Then she got the S pass from this second Singapore employer 18 months ago but now her S pass would not be renewed by the MOM. It must be very stressful for her.

I advised her to get all the writing done as required by the MOM as updated details of her work, her promotion to assistant manager to qualify for the Employment Pass and testimonials, employment contract, details of her company's activities, recent invoices and contracts were required. Surprisingly, she has all these documents as her expatriate boss trusted her to do all the operations. So, she has a 50:50 chance of success to apply for an E pass, I told Khin Khin. So much more documentation needed to be done. Khin Khin wanted me to help and another 2 hours were spent. Still we had not completed the paper work as I had to ask her to edit and I had to proof read.

This case has all the supporting documents MOM wanted but it takes so much time to justify in English. I had to help as the written English of this young lady and Khin Khin would understandably be not be up to the MOM's standard of English to support the case. I hope this young lady will be successful as I discovered that she is energetic and has good communication skills as well as experience. This expatriate company with head offices in Hong Kong has the potential to create more jobs for Singaporeans but it needs the time to do it. It does not have 4 Singaporean employees as its jobs are highly specialised and professional engineers from overseas are used to do the technical work for the time being.

LADY NO. 3. She stays in Myanmar with her parents who run an electronic trading company. She asked me whether there are jobs in Singapore for her. She has a BSc (Chemistry). I advised her that she has to have a good command of English and the best way is to study English in Singapore seriously and get the certificates. At the same time, she may speak English better while in Singapore. Her parents would need to pay for her tuition and boarding expenses. But I guess this is difficult for her. She can work for a foreign company in Myanmar if she has good skills just like Lady No. 2 who worked in a Myanmar hospital in administration and IT and got her first testimonial from an expatriate there to get a job in Singapore. I advised this young lady to acquire IT skills in Myanmar and tourism skills if she is really interested. She would be around the same age as Lady No. 2 but Lady No. 2 was already working in Singapore for at least 2 years and getting more experiences.

In the end, much depends on the mindset and drive of young Myanmar single ladies with graduate degrees being proactive in seeking employment in a foreign company in Yangon first. The pay may be very low but it is a stepping stone to a better tomorrow.

271. 4th surgery to remove cheek tumour in an old dog

Report is written by a 4th year vet student from Murdoch Univ doing internship at Toa Payoh Vets. I welcome different perspectives from interns.


Surgery Report for XXX (11 Y/O mixed breed male dog)
PRE-OP
History:
XXX was presented with a malignant tumour on the Right cheek. Tumour was persistent, with ill-defined margins and had a rough 7cm circumference. It also had a history of dermatitis with multi-focal exudative pustules and papules located primarily on the proximal fore and hindlimbs, with severe scaly and crusted regions of epidermis on the caudal elbow and knee joints. XXX was otherwise eating normally.

Physical Exam (PRE-OP):
On physical examination, XXX displayed an obdunted attitude. Heart, respiratory rate and temperature were within normal limits at 102 bpm, 30bpm and 39.2degrees Celsius respectively. Peripheral perfusion seemed normal with mucous membranes being moist and pink and CRT < 2 secs. Breath was malodorous (possibility of bacterial / fungal overgrowth inside the mouth).

Treatment Plan:
Palliative and curative.
To surgically excise the malignant cheek tumour via electrocautery and check for observable metastasis to regional lymph nodes under general anaesthesia.

OPERATION
Surgical and Anaesthetic details:
XXX was not sedated prior to anaesthetic induction as there was sufficient restraint to hold him down.
Catheterization was performed via a 22G needle into his left cephalic vein for easy intravenous (IV) access before anaesthetic induction with Diazepam (0.4ml) and Ketamine (0.4ml) totaling 0.8ml IV. Roy was deemed sufficiently induced after 10minutes and surgery proceeded. Surgical site was prepped with chlorhexidine and alcohol and a transverse incision across the tumour was made via electrocautery.
The epidermis above the tumour site was undermined to relieve skin tension and provide easier excision of the tumour itself. Roy was also given an IV drip of 5% dextrose wit 0.45% NaCl to compensate for electrolyte losses and to prevent dehydration and hypovolaemia.
Care was taken not to sever the facial nerve although part of it might have been as the tumour margins were large and irregular and the base of the tumour was located deep within the facial cavity, thus requiring aggressive surgical therapy. Upon tumour excision, tumour was found to have metastasized to the bone as well as the upper gingiva. As the effects of the induction drugs weared off, gaseous anaesthesia for maintenance was administered. 5% isoflurane was administered initially and slowly decreased over the course of the surgery up to 0.2% during the muscle, subcutaneous and skin closure at the excision site. 0.1% zoletil was also administered IV during the course of the surgery as Roy was still deemed too light. After 40 minutes, tumour was partially resected and wound closure commenced so as to decrease anaesthetic risk and toxicity. Muscle, subcutaneous and skin closure was performed using 2-0 synthetic polysorb, absorbable suture for all layers. Muscle and subcutaneous layers were closed using a simple interrupted pattern while the skin layer was closed using a mattress suture pattern.

POST-OPERATION
Surgical site was washed and swiped clean with sterile saline to reduce risk of sepsis and 1ml of Tolfenamic Acid (Tolfedine) was administered IV as post-op analgesia. XXX was then placed back in his cage and equipped with an E-collar while he continued to receive the remainder of the 5% dextrose and 0.45% NaCl at maintenance rates followed by another 500ml of Hartmann’s after, also at maintenance flow rates to prevent dehydration, hypovolaemia and to maintain electrolyte balance. Blood sample was taken for CBC and biochemistry while a tumour sample was also submitted to QuestLabs for histopathology.

DRUGS USED AND PRECAUTIONS
Ketamine:
- Mode of action: Acts at the N-methyl-D-Aspartic (NMDA) receptors and blocks central sensitization. It is useful for patients with chronic pains and patients that fail to respond to conventional analgesic therapy. Can also be used (mostly in combination with other drugs such as Xylazine and Diazepam) for sedation and anaesthetic induction.
- Precautions: AVOID the use of ketamine in patients with traumatic head injury as it increases cerebral blood flow and may increase intra-cranial pressure.
Diazepam:
- Mode of action: Diazepam is a benzodiazepine that binds to a specific subunit on the gamma-aminobutyric acid (GABA) receptor at a site distinct from the binding site of the endogenous GABA molecule. Therefore it works as an allosteric modulator of GABA, enhancing its effects and provides good anxiolytic, anti-convulsant, hypnotic and amnestic properties. Used especially in the management of seizure cases.
- Precautions: IV administration of diazepam should be performed slowly, particularly when injected into the smaller veins such as the cephalic vein because of the potential of thrombophlebitis and cardiotoxicity due to the propylene glycol base.
Diazepam may cause weakness, drowsiness and loss of motor coordination. In rare cases, it may result in paradoxical excitement, unexpected aggression or unusual behavourial changes.
Zoletil
- Mode of action: Combination of 2 drugs, tiletamine and zolazepam. Tiletamine’s mode of action is similar to that of ketamine as it is a NMDA receptor antagonist and blocks central sensitization as well. Zolazepam’s mode of action is similar to diazepam as it is a pyrazolodiazepinone derivative that is structurally similar to the benzodiazepine drugs.
- Precautions: Contraindicated in animals with CNS signs, hyperthyroidism, cardiac disease, pancreatic or renal disease, pregnancy, glaucoma or penetrating eye injuries.

REFLECTIONS
As tumour was incompletely resected, the chance of recurrence is very high. Prognosis of this dog is very poor as well as it is old and there has already been evident local metastasis to bone and gingival. Distant metastasis has not been diagnosed but is possible, which will further decrease its prognosis for survival.
In my opinion, if cost is not an issue for the client, I would recommend palliative treatment with NSAIDs such as acetaminophen, aspirin, meloxicam as well as prophylactic broad spectrum antibiotics such as Trimethoprim Sulphate (TMS) or Amoxicillin Clavulanate (Amoxy-clav) along with neoplasia excision again when the tumour grows again to a clinically significant size.
As the surgery had to be aggressive, part of the facial nerve might have been severed in the process which might have resulted in the post-op excessive salivation, drooping of the lip and ear on the ipsilateral side of the lesion. Dog should also be examined for signs of nystagmus, head tilt, asymmetrical pupil size dropping of food and ataxia to further confirm the suspicion of facial nerve paresis or paralysis. Part of the sublingual and mandibular salivary glands and/or their ducts might have also been severed in the process, resulting in excessive salivation. Due to traumatic injury to the glands and/or ducts, in my opinion, I would expect the dog to develop a sialocele which would then require further surgical intervention. Diagosis of this could be confirmed with fine needle aspirate should a SOFT, palpable mass develop near the mouth region. Needle aspirate can also help differentiate a sialocele from a neoplastic process.
On a separate note, the dermatological processes should also be looked into if the client is willing. Punch biopsies should be done on the pustules and papules, centered in the middle of the biopsy specimen. Punch biopsies should also be obtained from the scaly and crusted areas AS WELL AS from the normal skin. This is to allow comparisons of the epidermis and stratum corneum of the 2 sites by the pathologist. This is done to diagnose the nature of the skin lesions and to determine an appropriate treatment plan for XXX with systemic treatment such as injectable or oral cephalosporins, enrofloxacin etc. Adjunctive therapy could include topical treatments such as Chlorhexidine gluconate (Pyohex Dermcare) shampoos as well as benzoyl peroxide (Pyoben Virbac)


Done by:
Name of student

270. Immunosuppressive drugs, oxalate urinary stones, cheek tumour dog cases

3 reports are written by the vet intern. They are:
immunosuppressive drugs, oxalate urinary stone management and 24-hour follow up on a surgery to excise the recurred right cheek tumour in a dog for the 4th time.


DRUG DETAILS:
Atopica® (Cyclosporine-systemic) 50mg soft caps
INDICATIONS: Normally indicated for perianal fistula, atopic dermatitis, feline necrotizing gingivitis, renal transplantation and other immune-suppressive purposes.

Dose rate (CANINE): 2-5mg/kg PO q12h OR 2-5mg/kg PO q24h if concurrent ketoconazole administration*
PRECAUTIONS: Ensure to adjust dose to attain good clinical response. Overdose or excessive use may cause nephrotoxicity (protein-losing nephropathy), gingival hyperplasia, anaphylaxis (type 1 hypersensitivity reaction) possibility with IV administration.
DO NOT use in dogs aged less than 6 months or weighing less than 2kg as efficacy and safety has NOT been assessed for the above-mentioned parameters.
Occasionally, Atopica may cause gastrointestinal disburbances such as vomiting, mucoid or soft stool and diarrhoea as well.

Imuran® (Azathioprine) 50mg tablets
INDICATIONS: This is an immunosuppressive agent, normally indicated for use in autoimmune diseases such as Rheumatoid Arthritis, immune mediated hepatopathies, pemphigus, polymyositis, myasthenia gravis, atopic dermatitis, Idiopathic thrombocytopenic purpura (ITP) etc.
PRECAUTIONS: DO NOT USE IN CATS as it is TOXIC. Ensure to monitor CBC, bone marrow suppression and biochemistry (to ensure that leukopenia and thrombocytopenia does not occur). Although incidence rate is rare, use of Imuran may occasionally result in hepatotoxicity.
NOTE recommended dose rates for Diazepam + Ketamine drug combinations for anaesthetic induction is 0.25mg/kg IV for Diazepam and 5.0mg/kg IV for ketamine

CASE STUDY 1)
UROLITHIASIS: This is essentially aggregates of crystalline and occasionally non-crystalline solid substances that form in one or more locations within the urinary tract
CLINICAL SIGNS: Signs normally vary according to the locations of the uroliths and normally include cystitis, stranguria, dysuria, haematuria and Urinary Tract Infection (UTI). Acute urethral obstruction may also occur. Hydronephrosis and sometimes renal failure also occur with nephroliths. Ureteroliths are normally accompanied by intense pain.
DIAGNOSIS: Based on clinical signs, palpation and diagnostic imaging.
UROLITH TYPES: There are generally 6 types of uroliths, which is basically made up of a central Nidus, coated with stone, followed by a shell and surface crystals

DIAGRAM NOT ABLE TO DISPLAY FROM WORD TO BLOGGER.COM





The types include:
Struvite
Calcium Oxalate
Ammonium Urate (Urates)
Cystine
Silica
Xanthine
Only Calcium Oxalate uroliths shall be discussed
CALCIUM OXALATE:
RISK FACTORS: Increased urinary calcium excretion DUE TO
- Increased GI calcium absorption (absorptive hypercalciuria)
- Renal-leak hypercalciuria (a tubular defect)
- Hypercalcaemia (of any cause, usually chronic)
- Hyperadrenocorticism (Cushings)
TREATMENT: Medical dissolution of calcium calculi is NOT possible so the only treatment is surgical removal, lithotripsy or hydropropulsion.
PREVENTION:
- Correction of hypercalcaemia if present
- A reduced protein, calcium and oxylate diet for absorptive hypercalciuria
- Urinary alkalisation with potassium citrate
- Consider thiazide diuretics in dogs with highly recurrent disease (eg. Hydropchlorothiazide at 2mg/kg q12h PO)
- Recurrence is common.
- THERE IS NO TREATMENT FOR RENAL-LEAK HYPERCALCIURIA



POST OPERATIVE Subjective, Objective, Assessment and Plan (SOAP) for XXX, 11 Y/O mixed breed male dog
Subjective: XXX was eating and drinking normally. No observed signs of anorexia, dysphagia or dysuria. His attitude was BAR (Bright alert and responsive).
Objective: On physical examination, XXX’s heart rate and respiratory rate were within normal limits at 72bpm and 30bpm respectively. Weight remained relatively constant at 9.5kg. Rectal temperature was at 38.8 degrees Celsius, mucous membranes were pink and moist with CRT <2s, displaying no abnormalities in peripheral perfusion.
Assessment: XXX was given 1 tablet Imuran (Azathioprine) 50mg PO and antibiotic and antifungal coverage with metronidazole* 10mg/kg IV slowly via fluid bag.
*Side effects of metronidazole may include vomiting, hepatotoxicity and skin hypersensitivity so use with caution and keep under close observation.
Roy was also given 500ml of 5% Dextrose, 0.45% NaCl fluid therapy overnight at maintenance flow rates to maintain electrolyte balance, prevent hypovolaemia and dehydration.
Plan: To assess again in the morning and to administer another dose of metronidazole given at 10mg/kg IV q8h. Ensure vitals, temperature and peripheral perfusion are within normal limits.



Done by
Name of student


4th year vet student, Murdoch Univ
Seeing vet internship practice at Toa Payoh Vets
Dec 6-10, 2010. One of the few interns who was hardworking to write up case studies seen. Most observe and do not write. University professors do require report writing from students seeing practice in some instances but this is not a consistent policy.


UPDATE ON SUN DEC 12,2010
4th year exam results are out for Murdoch Vet students. I hope this intern has good news.
XXX went home on Day 2. Imuran tablets will be given 1/4 tab/day. Antibiotics Baytril and multivitamins are given. Need to follow up. Prognosis very poor as this is the 4th recurrence of tumour. Tumour has spread to bones and gums.

Thursday, December 9, 2010

Acute vomiting and bloody diarrhoea

"It is better to get an X-ray done," I advised the owner who brought back the dog after he was discharged. My associate vet deemed it not necessary to X-ray and sent the dog home after 3 days of hospitalisation and IV drip and treatment. His judgment was that the dog did not have foreign bodies and was in no need to have an X-ray, to save money for the owner. Unfortunately, the dog vomited at home and the young lady was not too pleased.

To prevent negligence complaint, I advised my associate vet to get an X-ray done. There was no "sausage roll" palpated to indicate an intussception which causes acute bloody diarrhoea.

IV drips and treatment drugs were given. The dog was hospitalised for 2 more days. X-ray showed lots of gas in the intestines. Some opaque grains which may be remnants of bones but the owner insisted that the dog did not eat any bones. Blood test showed low platelet count. A possibility of toxaemia from acute food poisoning.

This appeared to be a case of acute food poisoning. The dog recovered and there was no complaint after going home again. The owner was worried about vet expenses and many times, we try to save them some money. In the end, we may get sued or complained for incompetence and failure to take X-rays if the dog dies. Therefore, I have a system of requiring X-rays when the vomiting persisted more than 2 days or even earlier if abdominal palpation revealed foreign bodies. Negligence and incompetence rear their ugly heads when the dog dies. Therefore, preventive medicine is sometimes necessary.

268. A very painful encapsulated abscess in the neck

CHUBBY – DOG – Shih Tzu
9 Y/O Male

CBC interpretation:
Haematology Profile:
Description:
The CBC is commonly performed on an automated haematology analyzer using well mixed whole blood that is added to a chemical (EDTA – Ethylenediaminetetraacetic Acid) to prevent clotting. A CBC is a group of tests used to quantify the number of RBCs, WBCs and platelets, provide information about their size and shape, measure the haemoglobin content of RBCs, determine the percentage and absolute number of the five white blood cell types, and identify early and abnormal blood cells. These tests are performed simultaneously.
Analysis (Haematology):
Haematology Result Unit Ref. Range
Haemoglobin 18.4 g/dL 12.0 – 18.0
Red Cell Count 7.7 X10^12 / L 5.5-8.5
Total White cell count 8.3 X10^9 / L 6.0 – 17.0
Differential Count % Absolute V. Unit
Neutrophils 68.19 5.66 X10^9 / L
Lymphocytes 21.08 1.75 X10^9 / L
Monocytes 6.14 0.51 X10^9 / L
Eosinophils 3.49 0.29 X10^9 / L
Basophils 0.96 0.08 X10^9 / L
PCV 0.48 0.37 – 0.55
MCV 63 fL 60 – 77
MCH 24 Pg 20 – 25
MCHC 38 g / dL 32 - 36
RDW 15.7 %
Platelets 491 X10^9 / L 200 - 500

Haemoglobin: 18.4 g/dL
• This value is lightly above reference range but it should not be of much significance as the red blood cell count, PCV, MCV, MCH, RDW are all within normal limits.
• Haemoglobin concentration is normally used to diagnose anaemia, which can be caused by microcytic RBCs, which are smaller than usual in size and unable to carry sufficient Oxygen. Macrocytic anaemia usually occurs when the division of RBC precursor cells in the bone marrow is impaired. The most common cause of macrocytic anaemia are vitamin B12 deficiency, folate deficiency and liver disease.
Normocytic anaemia may be caused by decreased production of RBCs (any cause of bone marrow failure), increased destruction of RBCs (haemolytic anaemia) or loss of blood.
Total White Cell Count: 8.3 x 10^9 / L (within normal limits)
• Normal white cell count usually indicates that the animal is not in any threat of infectious diseases and foreign bodies.
• An elevated white cell count usually occurs in infection, allergy, systemic illness, inflammation, tissue injury and leukemia.
• A depressed white cell count may occur in some viral infections, immunodeficiency states and bone marrow failure.
• The white blood cell differential count will reveal which WBCs are affected the most
• Neutrophils are the most abundant granulocytic cells and are phagocytic cells that aid in the removal of bacteria and antibody-coated antigens
• Lymphocytes are the 2nd most abundant monocytic WBCs and originate from the lymphoid tissues and are NOT phagocytic. They are responsible for initiating and regulating the immune response by the production of antibodies and cytokines.
• Monocytes are the largest monocytic WBCs and are phagocytic cells that process and present antigens to lymphocytes, an event required for lymphocyte activation
• Eosinophils are granulocytic WBCs that have cytoplasms filled with granules that contain peroxidise, hydrolases and basic proteins that aid in the destruction of phagocytised cells. They are increased in allergic and parasitic infections
• Basophils are granulocytic WBCs that contain large amounts of histamine, heparin and acid mucopolysaccharides. They mediate the allergic response by releasing histamine.
Platelets: 149 x 10^9 / L (Below reference range of 200-500)
• Platelets are disc-shaped structures formed from the detachment of cytoplasm from megakaryocytes. They aid in the coagulation process by attaching or adhering to the walls of injured blood vessels, where they stick together to form the initial platelet plug.
• A low platelet count may occur in patients with viral infections, lymphoma or animals taking certain drugs such as quinine and quinidine.
• Decreased platelet production is also a cause of thrombocytopenia, and may be due to aplastic anaemia, leukemia, lymphoma or bone marrow fibrosis.
• A low platelet count can occur due to increased destruction and can result in antibody production that is often drug-induced (heparin treatment being a prominent cause)
• In relation to this case, Chubby’s decreased platelet count might be auto-immune, resulting in platelet destruction and decreasing his ability to clot blood and predisposing him to conditions such as TTP (Thrombotic thrombocytopenic purpura) and DIC (Disseminated intravascular coagulation).





BIOCHEMISTRY RESULTS:
BIOCHEMISTRY RESULT UNIT REF. RANGE
Total Cholesterol 4.75 Mmol / L
HDL Cholesterol 3.72 Mmol / L
LDL Cholesterol 0.20 Mmol / L
Cholesterol / HDL Ratio 1.28 Mmol / L
Triglycerides 1.83 Mmol / L
Glucose 4.1 Mmol / L 3.9 – 6.0
SGPT / ALT 59 U / L < 59
SGOT / AST 41 U / L < 81
Calcium 2.06 Mmol / L 1.50 – 3.60
Uric acid 0.01 Mmol / L <0.13
Urea 11.6 Mmol / L 4.2 – 6.3
Creatinine 77 Mmol / L 89 - 177

Result Interpretation:
Glucose 4.1 mmol / L (within normal limits):
• Serum glucose tests are generally used to diagnose diabetes mellitus and monitor its treatment. It can also diagnose hypoglycaemia.
ALT / AST (within normal limits):
• In Chubby’s case, the results are not too diagnostic of liver disease as serum ALT is at a border line 59 while AST is well within the reference range. However this is not definitive as in liver disease, ALT and AST levels generally rise and plateau for a period of time before decreasing back to normal values. Therefore DO NOT RULE OUT liver failure or complete cirrhosis if ALT / AST values are within normal limits. I would not fret too much about the ALT values in this case but it is best to take an x-ray or ultrasound of the liver to check if the size has been altered.
• ALT (Alanine Aminotransferase) is found in large amounts in the liver, and small amounf os this enzyme are also found in the heart, muscle and kidney. When the liver is injured or inflamed, the levels of ALT in the blood usually rise (a few fold). Therefore this test is performed to check for signs of liver disease
• AST (Aspartate Aminotransferase) is found in many body tissues including the heart, muscle, kidney, brain and lung. When body tissue or an organ such as the heart or liver is damaged, additional AST is released into the bloodstream. The amount of AST in the blood is directly related to the extent of the tissue damage.
Calcium and Uric Acid (within normal limits):
• In Chubby’s case, calcium and uric acid levels are within normal limits, thus indicating a low probability in bone / joint function or diseases such as osteomyelitis, osteoarthritis.

Urea (11.6 mmol / L) Mildly elevated:
• Urea is produced as a break down product of protein and it is usually completely filtered by the kidney while some of it is reabsorbed.
• It is important to note that the amount of urea reabsorbed increases with dehydration, therefore, in Chubby’s case, it is important to assess the hydration state of Chubby first to ensure that he was not dehydration prior to the blood test.
• Mildly elevated BUN may also be a result of an increased protein diet, resulting in increase urea formation.
• It may also result a physiological response to a relative decrease of blood flow to the kidney as seen in heart failure along with dehydration.

Creatinine (77 umol / L) Slightly below reference range:
• Creatinine is a break-down product of creatine phosphate in muscle, and is usually produced at a fairly constant rate by the body.
• A marked increase in serum creatinine levels (normally with a marked increase in BUN – termed azotemia) generally indicates kidney disease.
• In Chubby’s case, his creatinine levels is decreased slightly below reference range which I wouldn’t be too worried about. It is probably due to a decrease in muscle mass due to low protein diets or lack of exercise.
• Rise in blood creatinine levels is generally observed only with marked damage to functioning nephrons



Above report written by a 4th year Murdoch Univ vet student during internship. He saw the encapsulated abscess being operated. Old dog is OK. It was surprising that the abscess erupted like a volcano as it "swelled and subsidied" over the past 2 years and the lady owner thought it was normal. Till 2 weeks ago. The dog just couldn't stop scratching till he got a bloodied bruised neck. (Picture in www.toapayohvets.com).