Sunday, November 28, 2010

258. How to succeed in business: The 72-year-old man

To succeed in life and in business, one has to know what to do and to work hard. There is no short cut to success. I will illustrate this interesting case.

Mr Oh - A prospective Buyer's Agent - The 30-year-old man
Mr Lee - A prospective Seller's Agent - The 72-year-old man
Goods in demand in Myanmar - a brand-name multi-vitamins

What Mr Oh wanted from Mr Lee was a large number of multi-vitamins without the box, an analysis certificate and quotation. He said: "I could get the vitamins from a Singapore importer but his prices are high."

What Mr Lee wanted from Mr Oh was his quoted buying price and method of payment. He did now want to waste time providing quotes so that Mr Oh can use to underprice or force another Seller to bid lower. He would not provide an analysis certificate at his own expense. He would not provide the vitamins without a box as there would be damages and then claim from Mr Oh. He wanted full payment but Mr Oh offered to pay 50% deposit and 50% on delivery.

I could see that there was no point in doing business. "It is not easy to do this business," Mr Lee reiterated to me several times. I was not doing this business as I knew that a lot of time would be wasted wheeling and dealing. So I dropped the contacts. Then Mr Oh phoned me to follow up. I arranged for a meeting with Mr Lee at the last minute and asked Mr Lee to meet at Peninsula Plaza at 4 pm.

BE FLEXIBLE
1. Last-minute meetings are irritating to my friend Khin Khin when she has better things to do. She blasted me once when I arranged for her to meet the 72-year-old man (who has extensive trading contacts in China and Indonesia). She gave me a piece of her mind. For me, this is OK if I have the time.

2. The 72-year-old man asked me to drive him to the meeting. I obliged. There is no point saying to him that "you want the business, you go yourself." This is being inflexible.

3. The old man said he had to eat something as he was diabetic. The meeting was 4 p.m and we were late by 15 minutes. So I phoned Khin Khin and her contacts to explain the situation of delay and suggested a meeting at Funan Shopping Centre Food Court which is just a 5-minute walk from Peninsula Plaza. "No," Khin Khin said. "We meet at Peninsula Plaza. How long will you and the old man take to come?"
"It will be 2 hours later," I slammed down the phone. I had driven Mr Lee all the way from Clementi and here, Khin Khin and her contacts were not keen to meet nearby and have some drinks. Making a business contact is 90% entertainment rather than just straight talking about business.

BE RESPECTFUL
1. I really dislike Khin Khin saying "old man" when she could say Mr Lee. It is disrespectful in stating the obvious. Even "young man" may be condescending to somebody who is insecure and just starting out in business. Just address the business contact by his name. It is so simple and yet Khin Khin and her friend would not do it since they are younger. But not as young as spring chickens.

BE CLEVER WHEN ENCOUNTERING OLD DOGS IN BUSINESS
1. When Mr Lee had his roti prata, he told me that since he had come all the way, he should contact Mr Oh. I said: "Phone yourself, as I don't see any future in this business with the behaviour of the Sellers' agents." He phoned Khin Khin's friend, May Thet whom I had first introduced earlier. She was the one who knew Khin Khin and Mr Oh. May Thet said OK to meet at Peninsula Plaza. When Mr Lee and I arrived, May Thet pulled up a chair and said: "Welcome boss..."

This is where I said one has to be clever when encountering old dogs in business. The 72-year-old man replied: "If I am the boss, why do I have to come all the way with my goods to see you? You even refused to meet me at Funan Centre..."

LEAVE THE MEETING WHICH WILL NOT BE SUCCESSFUL
I left Mr Lee at Peninsula Plaza with the Seller's Agent and contacts. It would be an acrimonious meeting with no results. The old man would be brutally frank to teach these young people how to do business. I went to a shop that sells paintings. The proprietor cannot converse well with me in English but she has new paintings on sale. It would be such a pleasant time to spend looking at the work of the craftsmen selling their artwork.

Later, Mr Lee told me that he told Mr Oh to put $100 cash down while he would write a cheque for $1,000 since Mr Oh said he had a Singapore importer and would not really need Mr Lee's services. Mr Lee said that the "importer" was just a distributor or post man. Mr Oh declined the bet and left in an unhappy manner. That was what I predicted. No need brains to do it. As for Mr Lee, he told me he felt invigorated sparring with the Seller's agents as they knew nothing about the vitamin business.

I learnt some business tips such as "dumping" from the 72-year-old man by being hands on and though this business meeting was acrimonious, I was not involved in the unpleasant encounters. No business university can beat being hands on and meeting a brutally frank 72-year-old general trader with considerable experience. You just need to spend time with him and if he respects you, he will share his experiences and extensive network. You just have to read the situation and act wisely.

APPLICATION TO VETERINARY MEDICINE.
"Dumping" applies to veterinary medicine too. For example, pet shops in veterinary surgeries sell a brand of food at just cost-price by ordering in large quantities.

The importer has given the seller a 40% discount and recommends a 20% discount to consumers. If the pet shop operator sells at 35% discount, he gets many sales and in theory he will ask for more supplies. However, this is dumping and the importer will never supply him more as dumping is not sustainable in business in the long term for the manufacturer and importer.

257. The dog with white gums - continued

Low red blood cells, low haemoglobin and very low platelet count are life-threatening situations to the dog with the white gums. I followed up by phone call for the next 2 weeks for 3 occasions. The owner was quite happy that the dog was eating 4 times a day and her gums were pinker and would come in for another blood test on the 14th day after the first consultation.

Then on the 14th day (Friday), the dog vomited and so the owner texted me to cancel the appointment. Vomiting is a serious sign. The owner brought in the dog on a Saturday afternoon and she was given the IV drips and treatment. Blood and urine tests were done. "The dog bites me when I carry her," the owner said. I palpated the T/L spinal area and the dog wanted to bite me. The dog had normal rectal temperature and the gums had become pale. She was not eating.

Blood tests indicated that the red cells and haemogolbin levels were back to the low range of normal but would be considered normal. The platelet count was still low but not at 1. It was 120 (normal is 200 -500). A very high white cell count of 27,000 indicated a bacterial infection. The liver enzymes were very high too indicating hepatitis. Serum urea was high but creatinine was below normal. White cells and bacteria and blood were present in the urine tests. A few crystals of calcium oxalate.

Palpation: Spleen enlarged and could be felt like a long rectangular tongue transversing the abdomen. A large painful mass on left side behind the rib, of around 10cm x 4 cm would be the left kidney. Liver enlarged.

The owner visited the dog on Saturday afternoon. The dog seemed OK. No rectal temperature increase. Then on Saturday evening, the dog just passed away quietly at 7p.m. I phoned the owner who came.

"What's the cause of death?" her 2 friends asked me. "It is likely to be septicaemia from bacterial infection. The dog could have inhaled toxic dusts from the neighbour's ongoing renovation (acid and cement dust) for the past weeks." The dog's tongue was cyanotic and white. The spleen and left kidney were enlarged.

The dog had tumours based on ultrasound and these tumours could have spread to all over the body. It is hard to say without a post mortem. Direct Coomb's test was negative but this does not rule out autoimmune haemolytic anaemia. Thyroid function tests were done.

It was hard to save this old dog when she has internal tumours and a toxic dusty environment. Both could result in an autoimmune haemolytic anaemia and thrombocytopaenia.

The owner said good bye to the dog after arranging for cremation. There was not much I could say. She shook my hands and thanked me. This was one of my saddest cases in veterinary medicine as I could not prevent a second recent bereavement in her family.

Wednesday, November 24, 2010

256. Autoimmune Haemolytic Anaemia (AIHA) in Dogs

Today, Thursday at 9.30 am, the lady owner will be bringing the Miniature Schnauzer with white gums, 2 weeks after treatment. It is 4.36 am now and I am reviewing the case of this dog. A case of the dog with white gums. The first report is at:
http://www.kongyuensing.com/folder5/201006220very-low-platelet-count-Schnauzer-10years_anorexic-ToaPayohVets.htm

So far, the lady said that the dog's gums had become pinker. The dog is eating and drinking and passes normal stools and urine. Her only complaint was that the dog had this panting throughout the day during the past 2 weeks. She said: "She may be feeling some pain."

Well, the dog did have a very painful slipped disc when I first checked her. She also had a painful bladder area on palpation.

What is the cause of this panting? Is the old dog with white gums suffering from a form of an autoimmune haemolytic anaemia (AHA)? In AHA, the dog's red blood cells are produced normally but its abnormal antibodies which are needed to destroy bacteria or viruses, start destroying the red blood cells. So, the dog has low red blood cells and suffers from anemia.

In AHA, the dog also has low numbers of platelets and suffers from thrombocytopenia. The platelets in the blood form clots when blood vessels are cut or broken. If the dog has low platelet count, there will be uncontrolled bleeding. AHA in dogs is similar to haemopilia in people.

SYMPTOMS
Anaemia. Pale or white gums, conjunctiva and later yellow instead of normal pink to red colour. So the dog is lethargic as it has low levels of oxygen in the tissues and brain.

Jaundice. The liver removes the damaged red cells. The breakdown products causes a yellow colour of gums, conjunctiva and skin.

Bleeding from the nose or blood in the stools due to low platelet count. Takes a longer time for bleeding to stop.

Heart beats faster to bring oxygen to the tissues and brain.

DIAGNOSIS
1. COOMBS TEST is used to check for antiglobulins (autoantibodies). Nearly 98% of human patients with AIHA have a positive direct Coombs test (also known as direct antiglobulin test or DAT). A positive DAT means that the red blood cells are coated with the red blood cell autoantibodies. Patients may only have a positive direct Coombs test during disease flares and not at all times. There is also the Coombs Negative AIHA as a result of vaccinations or other medical conditions and the patient is mis-diagnosed as having other types of anemia or non-immune haemolytic anemia.

2. BONE MARROW BIOPSY
AIHA may be either regenerative or non-regenerative as determined by a lab examination of a blood sample and/or bone marrow biopsy. Regenerative anaemia - increased numbers of large immature red blood cells (reticuloycytes). Non-regenerative anaemia - anaemia lasting >5 days with low reticulocytes; the immature red cells are made but are destroyed in the bone marrow by the dog's own immune system.


As Vet 1's blood results did not include platelets (IDDEX machine had advised another blood test), so there was no earlier blood test history in relation to RBC, HB and platelets.

Dogs with chronic AIHA take many weeks to show clinical signs as in this case.

A bone marrow biopsy is used to distinguished between non-regenerative AIHA and cancer or other causes of non-regenerative haemolytic anaemia. But few vets do this bone marrow biopsy and diagnose the dog with chronic non-regenerative AIHA as suffering from blood cancer.





IN THE CASE OF THE DOG WITH WHITE GUMS, it was difficult to collect the urine for analysis of the presence of haemoglobin in the urine. The dog was in great pain and I stopped catherisation of the urethra for urine. She peed the normal yellow urine instead of the dark red urine in AHA.

CAUSES
Genetic or environmental factors. The latter include infections, drugs, poisons, bee stings and vaccines. Various neoplasms, systemic lupus erythematosus and canine hypothyroidism.

The dog had not been vaccinated for the past few years and so vaccination would not be the cause. The dog was recently taken outdoors after living in the apartment for most of her life. Infections could be the cause.

Some indications of infections include ulcers at the back of the tongue on the left side. (I took a picture 24 hours after IV treatment when I examined the tongue and tonsills). At the first consultation, the dog wanted to bite me when I palpated the enlarged left submandibular and popliteal lymph nodes.

Tumours. Since the dog had been losing weight of 25% for the past 4 weeks (from 5kg to 4kg), it could be suffering from internal tumours, e.g. in the spleen, pancreas or liver as "diagnosed by ultrasound" by Vet 1 earlier.

Gender. Females of all breeds, even when spayed, have a higher risk for AHA than males.

Genetic predispostion. Some dogs have changes in their immune system, a deficiency of pyruvate kinaese enzymes or abnormal red blood cell structure.

Breeds at higher risk. American Cocker Spaniels, Beagles, Old English Sheepdog, Westies, Shih Tzus, Alaskan Malamute, Lhasa Apso, Poodles, Basenjis, Daschunds. The case being reviewed is a Miniature Schnauzer, female, spayed.


TWO BLOOD TESTS WITHIN 24 HOURS.
Low red cell counts, low haemoglobin and lower platelet count.
In theory, the haemoglobin should be high if there is AHA. This is because the destroyed red cells will lead to an increase in haemoglobin and not to a decrease.

However total white cells were in the normal range. I noted that the % of neutrophils was over 90% (normal dog is usually around 75%). The dog responded to baytril IV, metronidazole IV, Vit K1 IV and dexamethasone 0.2 ml IV, iron SC and Vit B complex SC on day 1 as the gums became pink 24 hours later.


TREATMENT
1. Most dogs with AHA respond to steroid therapy which may be required for years. Prednisolone suppresses the immune system to prevent red blood cell destruction. Bacterial, viral and fungal infections must be treated if present.
Oral prednisolone in high doses e.g. 2-4mg/kg q 24hr divided into 2X/day, starting at 2 mg and increasing dosage if response is poor. Give for 2- weeks, then gradually taper off dosage. Decrease to mg/kg/24 hours for 2-4 weeks, then 1 mg/kg/48 hours for 2-4 weeks, then taper off.

*If anaemia (one author in a dog's forum uses PCV as below 12% as unstable, PCV 35-55% as stable). If unstable, go back to previous dosage that works.

2. A gastroprotecant e.g. sucralfate (0.5-1g) given when the dog is on high doses of steroids.

3. IMMUNOSUPPRESSANT medications like cyclophosphamide together with lower dosage of steroids for severe AIHA, for several months and reassess 2-4 weekly. Most dogs respond to prednisolone and immunosuppressant. If there is a relapse, a longer course of medication may be required.

Cyclophosphamide (50mg/Ma p/o q 24 hr) or 2 mg/kg q 24hr for the first 4 days of each week for 6-8 weeks. Re-assess.

Azathioprine (50mg/Ma q 24hr) (2mg/kg p o q 24 hr) for 1-2 weeks, then every other day


Cyclosporin (15mg/kg po q 24hr) has been used to treat refractory AIHA.

Danazol (synthetic androgen, 5 mg/kg po q 12 hr). Expensive. Reserved for dogs that have are refractory to pred + cyclophosphamide or azathioprine or intolerant drug side effects. Contraindicated in dogs with heart, liver or kidney problems.


3. For severe cases, blood transfusions, splenectomy (last resort in life-threatening refractory anaemia if medical treatment is not controlling the disease after 4-6 weeks of therapy).) and intravenous immunoglubulin therapy. Blood transfusion may be needed in the very severe anaemic dog to buy time for the drugs to act.

Tuesday, November 23, 2010

The Panting Old Schnauzer with low platelet count

It is almost two weeks since I saw the dog with the low platelet count. The case is recorded at:
http://www.kongyuensing.com/folder5/201006220very-low-platelet-count-Schnauzer-10years_anorexic-ToaPayohVets.htm

Yesterday I phoned the busy young lady as there was no news from her. No news means good news. The young lady said: "My dog has pinker gums. She is eating. I have given her the prednisolone half tablet two times per day. But she pants heavily the whole day. Could it be the pain? She may need an X-ray as you had advised. Or a blood test. Should I get her examined by you?"

It is hard to diagnose over the phone. I was glad that this dog had not died from internal bleeding due to such a low platelet count. I gave her an appointment to see her dog at 9.30 am on Thursday.

A follow-up in such a case is important but some owners may not have the time to do the follow up till the dog collapses.

253. Ticks in the apartment dog

Each dog owner has his or her own favourite vet and so I did not want to interfere in this case as this 70-year-old man may view me as soliciting for business. He is a general trader by profession and yesterday he invited me to his apartment to collect some multi-vitamins and calcium which he had bought at a discount from a China trade fair last week. "The company officers at the fair did not want to take the bottles back and sold them at huge discounts on the last day of the fair. If you don't want them, I will offer them to James. He will surely buy them."

I am personally not keen on taking multivitamins and calcium from unknown drug companies as there had been horror stories from one company in Australia producing poor quality multi-vitamins marketed by health shops in Singapore some years ago. There was no quality control but a desire to make money.

I accepted his invitation to visit him as a friend. He had two dogs. One 17-year-old cross had died recently and suddenly of a bloated stomach and he was still grieving over the loss.

"He killed the dog with too much vitamins and glucosamine," the wife told me.
"Based on the history of sudden swelling of the abdomen, I think the dog had a ruptured big blood vessel due to old age. The dog's abdomen started to swell as the bleeding filled the abdomen. The dog lives to a ripe old age of 17 years and it is inevitable that the big blood vessel would break down. The only way to find the definite cause of death is a post-mortem."

"No point in having a post-mortem," the husband said that the dog had been cremated.

"When I die, I have asked my children to scatter my ashes in the sea," the wife said. "That will save them the trouble of having them to maintain my grave or urn. The later generations may forget about doing any maintenance."

The husband shocked me by saying: "Your ashes in the sea will kill all the fishes!" What a surprising thing to say. This was the first time I met the wife, a silver-haired trim lady.

"Well," I said to the husband to defuse the awkwardness of his comments, "Your ashes in the sea will kill all the whales."

The wife kept picking out the ticks from her Silkie Terrier. "The ticks keep appearing on the dog. Small dotted ones."

"Did you use spot-on insecticides like Frontline?" I asked.

"Not effective."

So this 7-year-old Silkie had been biting her back area till they were almost bald. "This could be a tick-bite allergy," I said to the wife. The dog was on prednisolone tablets and anti-ringworm tablets for many weeks.

I had to intervene for the sake of this poor dog. "I cannot guarantee, but this dog may have a full coat of hair if you can get rid of the ticks in the apartment and on this dog."

"Really?" the wife was interested as to what she should do.

"I cannot guarantee anything," I said. "The first step is to get the dog clipped bald, de-ticked and given a different type of spot-on insecticide. De-contaminate the apartment area where the dog stays usually. Best of all, after de-ticking put the dog in another part of the apartment so that the baby ticks cannot jump onto her.

"Will the dog have a full coat during Christmas?"

"I cannot guarantee it. Do you have a good groomer who can clip the dog bald and de-ticked? Ask your vet for a different spot-on insecticide."

Ticks in a dog can be difficult to be rid of due to the re-infestation from the surroundings. Apparently this dog does not go outdoors and therefore the ticks must be from inside the apartment. "My vet advised Bagon spray onto the walls," the wife said. "It does not work."

"It is hard to get rid of ticks if you don't isolate the de-ticked dog from the contaminated area," I said. "In any case, there are so many cracks in the wall and you need to do it thoroughly. Some vets and pest control companies advise 'bombs'. You close all the windows. Release the gas from the bombs to fumigate and kill all the ticks. It does not work in practice for many reasons."

"You have two dogs. Get both of them clipped bald and de-ticked by your groomer or your vet."

Many owners have their preferred vets and so I just give some free advices.

252. The itchy 15-year-old & the 10-year old female dogs

CASE 1. RINGWORM AND POSSIBLY OPEN PYOMETRA
"Can you remember this dog?" the man in his late 20s put the Maltese X with fully formed cataracts in her eyes on the consultation table.

"No," I said. "It is not easy to identify Malteses or their crosses as they look almost alike."

"In June, you extracted her right tooth which you said was infected with pus," the man said as I referred to the medical records.

"Yes," I said. "This 15-year-old must be the oldest dog in Singapore to suffer from an oro-nasal fistula. How is she now?"

"No more problem," the man showed me the right side of the face. Hair had fully grown and as I tried to open the dog's mouth, she turned her head away. The owner tried but was not successful. The old dog remembered the pain and was avoiding the pain.

"What's her problem today?" I asked.

"She is itchy and keeps rubbing her back on the floor."

The dog's back was losing hair compared to the fullness of hair on the face.

I put some of the back hairs under the microscope. "There is ringworm in the hairs," I asked the young man to view the hairs.

"Does the dog lick her private parts?" I asked. "See the vulval area. It is swollen and is 10 times larger than normal."

"I don't think so. She only licks her thighs," he said.

"To you, it appears that the thighs are itchy as well." I said. "She has some infections, either in the womb as she is not spayed or in the bladder. As she is so old, I would not advise spaying. If spaying had been done at a young age, we could be sure that the dog would not be suffering from infections of the womb or have ovarian cysts or tumours."

Due to economic reasons, I did not advocate more tests. The owner wanted to clip the dog himself as he had bought a clipper. "It is not that easy for you to shave her completely bald," I said. "You can't even open her mouth for me to examine her teeth." I had not forced this old dog to open her mouth this time as her main problem was the skin. It would be prudent to check the mouth but then she had her dental work and scaling just 6 months ago and had no bad breath. So, I spared her the agony.

What's the cause of the skin itchiness? Although ringworm is a primary cause in the back skin, there may be a more serious problem. It is likely that this 15-year-old dog has open pyometra. She keeps leaking out pus from her vagina. She licks off the discharge to be clean. So the irritated vulval lips become swollen 10X over the past few days or weeks. To the owner, she is just having itchy thighs and back area.

TIPS: Spay your female dog when she is young. If she lives to 15 years, she will not be having pyometra.

Her oro-nasal fistula case is recorded at:
http://www.bekindtopets.com/dogs/20100615oro_nasal_fistula_carnaissal_tooth_abscess_old_dog_ToaPayohVets.htm


CASE 2.
"What are those bluish lumps?" the young lady asked me. "I check my dog daily and saw them last week." The soft lumps under the skin were present between MG4 and MG5 on the left side. MG = Mammary Gland (breasts).

"They are breast tumours," I said. "The lumps may be cancerous if they grow fast."

"What to do?"

"Surgery to remove them while they are small in size," I said. "If they are cancerous, they will spread to the other breasts or grow to big sizes like ping-pong balls.

As the lady was worried about anaesthesia, she chose to have a complete blood test done to check whether her dog was healthy. "Whether she is healthy or not," I said. "Your dog needs surgery if the breast tumours grow big and fast. It will be too late if you wait another few weeks."

TIPS
Early spay will usually not result in breast tumours in the female dog in the majority of cases.

Monday, November 22, 2010

252. Misperceptions

"You must have a rich father to be able to study veterinary medicine in Scotland?" the project officer of similar age to mine, said. 30 years ago, one British pound was 8 Singapore dollars and those who studied overseas were from wealthy families.

"No," I said. "I was fortunate that the British Government gave the Colombo Plan Scholarship to enable me to study veterinary medicine in Glasgow University, Scotland. Now, Singapore has become a developed country and is in a position to offer ASEAN scholarships to students so that they can go home to help their country people."

I met him and his boss (a younger man in the family business) yesterday Nov 22, 2010 as my friend Khin Khin, asked me to be present to help her in her discussions about export Myanmar sand to Singapore. The Singapore English, thinking and culture of business is clearer to me than to her and so I was useful to her. The JTC would be tendering to buy sand on Dec 3, 2010 and Khin Khin was anxious to close a deal as an agent. If successful in getting 5 million cubic tonnes of sand for 18 months, she could get a commission of some $200,000/cubic tonne or some large figures. It sure beats spaying a dog for $200.00 as I will need to spay every dog in Singapore, probably.

Personally, I am not interested in this wheeling and dealing as it waste a lot of time. But I do attend some of Khin Khin's meetings and I do meet interesting characters for my stories. At the meeting, I will write notes for Khin Khin as she listens and learns the tricks of the commodity agency trade. For the past two years, she has not closed a deal. Well, I better stick to veterinary medicine.

After the meeting, the project officer invited us to have some coffee. Khin Khin had to go and I stayed behind to socialise with him and his boss. This boss is a young man and I said: "You must be driving a Lamborghini or a Ferrari," I had the impression that he was the type who would be doing it since his business must be successful. Supplying sand to the JTC is big business and if he can think of doing it, he must have the financial backup as there are financial performance bonds and penalties. He said that the freight cost of importing the sand from Myanmar to Singapore would cost more than the sales price of sand, which if rejected by the JTC would cost him a lot of money. That meant that he has the sufficient funds to undertake this venture.

"No, no," the young man said. "I drive a BMW."
The project officer said: "He would be buying a Lamborghini soon."
I was impressed.
"Well, I put in a bid when the LTA auctions the car," the young man said. "The LTA (Land Transport Authority) caught its senior manager milking it millions of dollars and is trying to recover some monies back by selling this senior manager's Lamborghini soon."

As a car depreciates in value, the LTA can't wait till the end of the court case to sell this car. This young man may be lucky to get a Lamborghini at below market price!

Sunday, November 21, 2010

242. Art entrepeneurship

Singapore has so many events that it is impossible to keep track of them when one is inside the surgery attending to cases. There is simply no time. Apart from veterinary medicine and surgery, I am interested in art and read many of the art magazines in the public libraries. It is just too expensive to subscribe to them.

One day, I was at the HDB Hub and there was "Global Entrepreneurship Week 2010" held by ACE - Action community for entrepreneurship and NUS - National University of Singapore.

I was surprised to see a booth about to close shop for the day. It is Artyii (www.artyii.com). The founders of this start up (incorporated in 2009) market artists and Asian art.

It helps artists to market their works online and manage framing, shipping and payment. Marketing is important as many emerging or unknown artists seldom can afford to do their own marketing and distribution. They rely on the support of art gallery owners who may not be interested in their arts. It is like new authors, e.g. Harry Potter, having great difficulty in finding a publisher when he or she is unknown.

Artyii focuses on Asian artists (not photographers, I was told). The company targets global buyers and have received strong European interest. "Do you have any marketplace art of Myanmar artists?" I asked Ms Ng Cai Lin, one of 3 founders. "No," she said. "There is a lady doing this." She was quite good in e-mailing to me some market artwork from Vietnam. Following up and keeping in contact with prospect is one of the factors of success in an enterprise.
I remember this young Myanmar lady whose concept is to market Myanmar artwork at the Art House in Singapore in 2008 and 2009. It is very expensive to do it. Now this must be the lady Ms Ng mentioned. I bought one small piece of artwork from her. I am looking for marketplace artwork but she has not many.

Being an art gallery offline is very expensive due to the high rentals in Singapore and therefore an online art gallery such as Artyii is a good concept. Ar5tyii's website was launched in August 2010 and has around 100 artists from Singapore, Vietnam, Indonesia and India showcasing over 400 original artworks.

From what I read in an Arts magazine, there is a similar concept in New York or California. It is like a co-operative for artists and helps them to sell art online. It helps them by storing some of their artwork so that they don't sell them at a great loss when they need morning. I can't remember this website.

CONCLUSION
1. Is there an online concept for photographers? I think there are but don't know any of them.
2. Is there an online concept for educational photographs in veterinary medicine and surgery? I know there a beautiful and expert textbook illustrators in medicine but am not aware of any online art gallery for this topic. Readers who know, please e-mail to me. Textbook illustrations don't reach a global audience and the beautiful textbooks are quite expensive and hard to find. I found one Singapore publisher printing such books but they are for the University and are very costly.

250. An English Literature graduate

I felt that this English literature graduate in her 30s must have loved literature in order to study this subject in her university. A vet must love veterinary medicine to study this subject and then become a real vet. However this literature graduate did not practise her craft in the sense that I would expect her to write and author books. She has no children and so would have much more time than those successful authors. I guess she has no motivation or passion.

Passion is important but will not sustain you in being successful. Without passion, you will not need be successful.

I refer to an article written by Mr Ho Kwon Ping, Executive Chairman, Banyan Tree Holdings Limited in the Straits Times, Nov 15, 2010 Page B11 - Our new generation of entrepreneurs - can they make it big?

He said that passion is necessary but will not be a sufficient attribute for success. Cash flow is the highest priority in an enterprise and that comes from long hours of hard work if the start up does not fail. If it succeeds, how do you scale up your business to become global?

FACTS OF BUSINESS
It is well known that less than 20% of start ups will succeed. This failure rate of 80% is especially true in a free and competitive economy of Singapore. Nobody can predict which start up will succeed or fail. First ventures are seldom successful and the entrepreneur needs to use this failure as a learning lesson.

SUSTAINABILITY
1. Does sustainability when successful depend on scalability? "The search for scalability is the holy grail of entrepreneurs," Mr Ho wrote. Therefore successful small business must leave Singapore which is a very small domestic market and into the streets.

2. Street-smarts - whatever they mean, is another important attribute for sustainability. IPC, a computer company and Creative Technology are 2 examples of early successes which could not be sustained overseas. Yeo Hiap Seng and Osim acquired a seafood canning company and consumer gifts chain respectively but had written off their investment. Niche markets may be successful as in Coffeemix in West Asia, Breadtalk and some foodcourt operators in China and Asian shopping malls. Olam is being a bridge using their supply chain expertise in commodity processing to bring commodities from the developing world to developed markets.

CONCLUSION
Find a niche to excel and focus on innovations as product life spans are short in information technology or consumer products which are dominated by global giants where scale is critical.

To globalise, change your mindset by not comparing things done in Singapore. Respect and promote a culture of diversity to be resilient when you manage externai businesses.

No destination but a journey. Size and success in a business can dissppear quickly due to lak of attention and hubris. One-trick companies don't succeed in the long term.

In reply to the question in the essay, Mr Ho said that our entrepreneurs can make it big but only a few of them. Practice makes perfect and failure begets sucess.

Sometimes, it may just be better to be an employee, in my opinion as enterprises have a high failure rate even though they are successful. A small number of vet surgeries have had closed down but more than 40 have been opened in recent years. It will take a long time to succeed. There is no short cut in any enterprise.

Saturday, November 20, 2010

The dog with white gums

In January 2010, I wrote an article on a case of Closed Pyometra in a female dog. The blood test shows anaemia and toxaemia in a female dog with pyometra. See the webpage at Pyometra - very low platelet count due to toxic blood.
URL is at:
http://www.bekindtopets.com/dogs/20100135Video_Education
_Closed_Pyometra_ToaPayohVets.htm


In November 2010, I had a very interesting case of a spayed female Miniature Schnauzer, 10 years old, losing 25% weight and not eating much for the last 3 months. When I saw the dog's gums, tongue and oral mucous membranes as white as snow, I predicted that this dog would not live past the next 7 days. I gave her intensive IV drip including glucose, saline, protein drip, multi-vitamins and Vit K1. An iron and Vit B complex injection SC was given. Baytril and metronidazole were given IV.



I took blood for analysis before and 24 hours after the IV and injections. The platelet count had dropped much further from 68 to 1. Yet 24 hours after the IV drip, the dog's gums and tongue were purplish pink in colour. I showed the colour to the lady owner. She was not impressed as she could not recall the snow-white colour 24 hours ago. I did not take a picture but I do remember telling her that the dog was very pale and anaemic.

She had been too stressed out by a bereavement in her family and now this dog was going to die.



Nov 11, 10 First consultation
Nov 12 24, 10 hours after IV
Ref Range
Unit
Total White Cells
12.8
6.6
6 - 17
x10>9/L
Total Red Cells
4
3.9
5.5 - 8.5
X10>12/L
Haemoglobin
9.7
9.6
12-18
g/dL
Platelets
68
1
200-500
x10>9/L
The dog survived and is well nursed by the lady owner as at Nov 21, 2010. As to the cause, I told her it was difficult to say. The cause would likely be a viral and bacterial cause. The dog had not been vaccinated since she was a puppy and was brought for walks in the past year whereas previously the dog was home most of the time.

BACKGROUND HISTORY OF THIS DOG RECORDED BY ME IN NOV 15, 2010
AT DEATH'S DOOR. THE DOG WITH WHITE GUMS
The thin, hunch-backed 10-year-old Miniature Schnauzer with white gums would not eat. She had been treated 4 times by Vet 1. ACTH tests were normal. Ultrasound indicated possible tumours of the liver, pancreas and spleen. So, the owner was very worried and wanted surgery.

"The dog is not fit for surgery," I advised. "She will just die on the operating table. Look at the white gums. She has severe anaemia. I will do a blood test."

The anaemia was due to low red cell count, low haemoglobin and very low platelet count. She was attended to by Vet 1 from August to November for 4 times and was not eating when the owner consulted me, being referred to by one of my clients.

Incredibly, after an intensive IV drip of saline, glucose, protein, Vit K1, antibiotics including baytril and metronidazole, B complex and iron injections s/c, the dog that lost 1 kg (25% of her weight in the last 4 weeks) was thriving. "She ate a lot and pooped a lot for the last 2 days," the young lady said. "Today, she is not eating. Shall I give her the Re... from Vet 1? It is said to improve her appetite."

What was the cause of this severe anaemia and the low platelet count? I suspect it was either some drugs or septic infection (from virus or bacteria) when the dog was brought downstairs in recent weeks.

During the first consultation with me, the dog screamed when I pressed the very painful disc pain at T/L area and bit me when I palpated the moderately enlarged left submandibular and popliteal lymph node. Her bladder was painful on palpation. Her left kidney was slightly painful. Her left tongue had some ulcers at the back and I took digital pictures to show the owner.

So what was happening to this dog? The lady had only one wish - that this dog would not die on her as she had a recent family bereavement. Yet, the dog's gums were as white as snow when I saw her at first. I did not take a picture then but her gums became a bit pinker 24 hours after the intensive care and injections. So, this dog had come back from death's door. But she is not out of the woods yet. Only time will tell.

UPDATE: No complaints from the young lady. I phoned her twice and the dog was getting better. Short episodes of panting which I attributed to pain in the spinal area. I asked her to give pred 2.5 mg two times per day. No more news from her. No news is good news, usually.
Miniature Schnauzer, Female, Spayed 10 years - White gums
11-Nov-10 Nov 12,10 Ref Range Unit
Total WBC 12.8 6.6 6 to 17 x10>9/L
Haemoglobin 9.7 9.6 12 to 18 g/dL
Red Cells 4 3.9 5.5 to 8.5 X10>12/L
Platelets 68 1 200 to 500 x10>9/L
No platelet clumps seen No platelet clumps seen
Few giant platelets present

Creatinine 47 62 89 to 177


Owner's complaint - poor appetite, lost weight 1 kg in 1 month lost appetite
Weight loss 25% in last month, now 4 kg
Presenting Signs: White gums and tongue
Rectal temp 38.5 C

Palpation: Enlarged left submandibular & popliteal lymph nodes 0.8 cm x 0.8 cm
Bites when left popliteal lymph node was palpated, pain in left kidney and bladder

Blood test results: Anaemia and toxaemia. Viral and/or bacterial cause likely
Platelet count dropped to 1 after 24 hours.
Any chance of survival?

Friday, November 19, 2010

Business success and worries

Yesterday, I met a young lady from Myanmar who speaks excellent English. She wants to start a dream business bringing artistes and singers from Myanmar to perform in Singapore.

"I have no contacts with the Esplanade and Integrated Resorts," she told me and I was surprised by her remarks. "It is quality of CONTENT not contacts that is important in any business", I advised her. "CONTENT means that your artistes can provide the services that the public wants so that you can make a profit," I said. "As an example, If you represent Michael Jackson, you have CONTENT and there is no shortage of venues."

I define a business as one that is for profit and for non-profit.

All business have the same worries of failures of not being able to pay the varied expenses, whether it is a veterinary practice, travel agency, real estate agency, an animal shelter, entertainment company or non-profit organisation or your own start up.

The following report applies to Travel Agencies but you can see that the factors I wrote is appropriate for the veterinary business in particular but will apply to all business start ups.

Over the last 2 years, I surveyed and observed the many interesting travel agencies in Peninsula Plaza. I also spoke to some of my interesting and successful veterinary clientele in their own and travel business and asked how they can survive the ever increasing intense competition. For the travel agencies, I enquired how they can survive in the cut-throat, price undercutting travel business with hotels and airlines provide direct internet purchase. Here are the main factors which were from an online survey I participated.

FOR THE TRAVEL AGENCY TO WIN AGAINST COMPETITORS

1. PRICES - Cheaper air tickets and hotels.
Vet example: New vet practices under price everybody. At least there are customers rather than no business. The sustainability of the business is not possible unless the vet has deep pockets and net losses are incurred per year.

2. VALUE - Better value or more interesting travel packages.
Vet example: Better equipped like CT scan, ultrasound, digital X-rays, blood testing and others.

3. SERVICES - Providing extra services such as insurance, visa application, vehicle rentals.
Vet example: Blood transfusion, acupuncture, holistic vet.

4. BRANDING - Better reputation and value.
This takes time and relies on the vet's bedside manners, ability and competence. See: A brand name vet practice opens doors...


Some agencies have loyal clientele if they provide 1 and 3 but the business may not be sustainable. The operator keeps looking for loans to cover the operating costs and this results in a bad reputation amongst the community.

FOR THE TRAVEL AGENCY TO FAIL
1. GIVE CREDIT TO CORPORATIONS AND OTHERS. One bad debt in big amount is enough to wipe out all the small margins of profit. Don't be a banker. Collect money first before starting the tour or travel.

Another factor for business success is a good updated website as a marketing and branding tool. I will tell this to the young ones who want to start a business. Many do start a website but fail to nurture and maintain it with CONTENT of relevance and interest every day. Updating of websites is time-consuming. There are better things to do in this time-pressed world of Singapore.

WEBSITE
This is important for any business. The following is my response to an online a survey I participated today.

CONCERNS WHEN STARTING A WEBSITE FOR THE COMPANY
1. High cost of starting up. The problem with the few webmasters I encountered is that the webmaster/company has no relevant experience as justified by portfolios of past clientele. I have not approached the big boys as I just can't afford their services.

2. High cost of maintenance. The webmaster disappears or his company increases fees over the years, just like accountants and auditors.

3. Lack of technical expertise. The start up business owner needs to do his own updating as it is costly to get the webmaster to do it.

4. Lack of traffic and sales from website. This is the least of the worries if the CONTENT is relevant to the prospective clients, is updated and interesting. Search engines do pick out the relevant topics. You can also pay www.google.com
and www.yahoo.com to be listed in the top 10.

Comments: In Singapore, my experience is that affordable webmasters are hard to find. Webmasters charge a lot of money due to the high cost of rentals. It is hard to locate an experienced webmaster with relevant experience. Or at affordable cost unlike in South Korea where I read that many small companies have websites due to lower costs of webmasters and broadband fees.

MY THREE MOST IMPORTANT FEATURES IN A WEBSITE
1. To be able to safely, securely and automatically accept payment online.
2. To increase sales and recognition through social marketing (like Facebook).
An interesting example is http://www.facebook.com/home.php?#!/philea.resort

I was a guest at the Philea Resort and Spa on Nov 6, 2010 and stumbled on its Facebook webpage as I submitted some photos of the Bridal Fair 2010 held at the resort to the marketing manager to forward to the models. It has a facebook page which I believe it common with all good hotels nowadays. Facebook viewing can waste a lot of time but the young generation loves it and are a source of new generation clientele.

3. To increase repeat customers with email promotions and newsletters

OTHER FEATURES
4. To increase customer conversion rate with multimedia presentations
5. To gather feedback and response from customers through company forum. This is interactive and very useful.

6. To build customer loyalty with reward points
7. To survey customers with online quiz and polls
8. To communicate with website visitor with live chat. I find this feature very useful when I had questions about my web hosting with Earthlinks.net in the USA.
9. Others - BRAND BUILDING. I will think a website builds a brand reputation.

HOW MUCH I WILL INVEST IN THE TOP 3 FEATURES
S$3,000. I doubt Singapore webmasters will take this amount. In Singapore, the Landlord keeps increasing rentals and the government agencies keep thinking of new ways to collect fees from the businesses. So, it is difficult for start ups to pay and pay.

The above replies were my participation in an online survey. It was powered by Qualtrics. www.qualtrics.com. I hope this info is useful for the young ones who want to start their dream business.

I asked the young lady who is doing her 3rd year of undergraduate studies in Economics and Finance: "Have you got a name-card?" She said: "No." Well, young lady.

A name card needs to be printed and presented if you want to start a business. This name card permits others to contact you when they need your singers and dancers or refer to the powerful ones at The Esplanade and the Integrated Resorts via networking!

Updates are at www.toapayohvets.com

245. Neutering risks for a 4-year-old male cat email

E-MAIL TO TOA PAYOH VETS DATED NOV 19, 2010

Hi Judy,

I would like to know if a cat that's 4 years old still suitable to do neutering? Will there be any risk? How's much will be the operation cost?

Regards,
Name of owner



E-MAIL FROM TOA PAYOH VETS DATED NOV 19, 2010

I am Dr Sing from Toa Payoh Vets, www.toapayohvets.com

Thank you for your email. A healthy cat at 4 years old can be neutered.

There is normally no risk if the cat is healthy (take blood test to check liver, kidney and complete blood test if you want to, before operation.The cost is around $150). In 100% of the cats neutered by me in the past 30 years (Toa Payoh Vets) was started by me in 1982, I have no male cats dying after neutering and I am quite sure this is the same with other vets in Singapore.

Prior to surgery, the cat will be examined for general health before surgery by taking a history of his past health, a general examination, palpation for abnormalities inside the cat, taking of temperature, pulse and respiratory rate and weighing him. If he fails the general examination, he will not be operated.

The main risk will be infection after surgery, from my observations of cats spayed in countries where there are no facilties for aseptic surgery and no antibiotics post-operation. Infections can kill a cat after surgery.

Surgery and anesthesia at Toa Payoh Vets for male cat neutering costs around $75.00. Add $30 for post-op antibiotic and pain-killer injection.
Estimated total will be around $105 for most clients who don't want blood test done. A pre-op blood test at this age or before anaesthesia and surgery is advised. The complete blood test costs around $150.

Please make appointment by tel 6254-3326. No food and water for the cat after 10 p.m, the night before the surgery and give the cat a good wash at the scrotal area.

Monday, November 15, 2010

244. At death's door - 3 cases

1. Case 1. The aggressive self-diagnosing breeder. I had stopped providing vet services to all dog breeders for the past 2 years. What most of them want was usually very cheap services.

This particular breeder brought in a Shih Tzu on Sunday at 5 pm. His vet was not available. He said he had X-rayed the dam at another practice but the X-ray showed 4 pups. He did not bring the X-ray saying he was busy. He suspected there was a 5th pup and could feel it. 4 pups were born naturally on Saturday and were OK. That was 24 hours ago.

I palpated a bony mass. "The pup is dead," I advised as it was past 24 hours from the last pup and the foetal lump felt 'bony' and that meant the water bag had broken.

"There is no point in giving oxytocin injection. Your dam needs a Caesarean section." This breeder was insistent in having an oxytocin injection. I did not throw him out as he did not accept my advice. I gave the injection. After one hour, the dog did not produce any pup. My first assistant advised a Caesarean and he accepted the need for one since no pups were produced.

The pup was smeared with dark greenish glue from the melted placenta. It had no amniotic sac and was stiff as in rigor mortis. This breeder wanted no more veterinary treatment like IV drip and antibiotics IV. He wanted to bring back the dam and wanted to pay only $250. "The new vets are charging less," he said. He became aggressive as his demands were not agreed upon. It was unpleasant. This is the reason I have had stopped dealing with dog breeders.

The next morning, the dog died. The owners were very unhappy. A dog's death is an extemely emotional experience for the owners and for the vet. This was a case where the owner entrusted this breeder to handle their dog's accidental pregnancy. He said he had X-rayed but would not produce the X-ray.

I have barred this breeder from coming to Toa Payoh Vets and told my associate vets that it would be best not to accept breeders at all. It was just not a sustainable practice to offer $250 Caesarean sections and lose money and respect from breeders who want to cut corners.


Case 2. The cat with nasal cancer. The cat went home the next day after surgery to excise most of the tumours. The owner phoned me today and said that the cat was eating. The nose bleeding on Sunday morning after I had pulled out the swab which stopped inside the nose bleeding was no more. The family had decided on no chemotherapy. "Can you do surgery when the cancer returns?" the father asked. "No," I said. "There is a big hole on the top of the nose, now covered by the skin. This malignant tumour doubles in size every 7 days and I expect that the cat will not live long." Chemotherapy is not guaranteed and may cause the cat to lose appetite. So, what's the advice?
"Try chemotherapy in low dosage first," I advised. There was nothing to lose as the wife was quite close to this cat. Chemotherapy does not cost thousands of dollars unlike the case in human cancer treatment. "Euthanasia will be the only option when the cancer recurs and bacterial infections of the right nostril causes pain and suffering," I said. This cat had no infection from this surgery because she had been on antibiotics 6 days before surgery and after surgery. So she responded well and could eat and drink normally at home post-operation, much to the happiness of the wife. But death is really at the door. If chemotherapy helps, it will be a happy ending.

FOR MY RECORD
Weight: 3.5 kg. Cat.

Anaesthesia. Domitor 0.1 ml IV. Zoletil 100 0.1 ml IV. Atropine 0.5ml SC. Intubate. Gave oxygen. Duration of anaesthesia was nearly one hour. A few seconds of isoflurane gas was given towards the end of surgery. It was taking one hour to do it. IV saline and baytril drip given 24 hours.

Post-operation.
No Antisedan antidote was given so that the cat could be sedated and wake up with less pain. The cat was observed breathing normally through its left nostril (forceps into nostril confirming no cancer cells from right nostril). He slept for many hours and was fresh as a daisy on the next morning after surgery.

Surgery on Friday at 4 pm. Incise with scalpel. Undermine skin. Nasal tumour grows from inside the nose, break through nasal bone is 2.5 cm x 1 cm long and much deeper inside the nose.

Electro-surgery separates tumour as much as possible from nasal bone. Excised. Large hole in nasal bone eaten by the tumour seen. Around 1 cm x 0.5 cm. Round fatty tumour cells seen from inside the nose and excised.

I put a gauze swab into the nasal hole and pull it out from the nostril using forceps (see picture at www.toapayohvets.com). This stops bleeding. Electro-coagulation of the tissues inside the nose helps but does not stop the bleeding.

Goes home on Sunday at 10 am after I pull out the gauze swab. I smelled the gauze swab. Not smelly and this is a good sign that there is no bacterial infection. Red blood oozed out of the nostril. Owner asked to wipe the blood off regularly. (The bleeding stopped on Monday).




Case 3. The dog with white gums
The thin, hunch-backed 10-year-old Miniature Schnauzer with white gums would not eat. She had been treated 4 times by Vet 1. ACTH tests were normal. Ultrasound indicated possible tumours of the liver, pancreas and spleen. So, the owner was very worried and wanted surgery.

"The dog is not fit for surgery," I advised. "She will just die on the operating table. Look at the white gums. She has severe anameia. I will do a blood test."

The anaemia was due to low red cell count, low haemoglobin and very low platelet count. She was attended to by Vet 1 from August to November for 4 times and was not eating when the owner consulted me, being referred to by one of my clients.

Incredibly, after an intensive IV drip of saline, glucose, protein, Vit K1, antibiotics including baytril and metronidazole, B complex and iron injections s/c, the dog that lost 1 kg (25% of her weight in the last 4 weeks) was thriving. "She ate a lot and pooped a lot for the last 2 days," the young lady said. "Today, she is not eating. Shall I give her the Re... from Vet 1? It is said to improve her appetite."

What was the cause of this severe anaemia and the low platelet count? I suspect it was either some drugs or septic infection (from virus or bacteria) when the dog was brought downstairs in recent weeks.

During the first consultation with me, the dog screamed when I pressed the very painful disc pain at T/L area and bit me when I palpated the moderately enlarged left submandibular and popliteal lymph node. Her bladder was painful on palpation. Her left kidney was slightly painful. Her left tongue had some ulcers at the back and I took digital pictures to show the owner.

So what was happening to this dog? The lady had only one wish - that this dog would not die on her as she had a recent family bereavement. Yet, the dog's gums were as white as snow when I saw her at first. I did not take a picture then but her gums became a bit pinker 24 hours after the intensive care and injections. So, this dog had come back from death's door. But she is not out of the woods yet. Only time will tell.

Photography tips:Bridal Models

PHOTOGRAPHY TIPS

November 6, 2010. Philea Resort & Spa, Melaka, Bridal Fair 2010 Photography Contest. I was a guest at the Philea, taking a 3-day 2-night break from my veterinary work. The pro-active marketing manager saw me at the ballroom where the Bridal Fair was held and invited me to register for the Photography Contest. The bridal models in the ballroom showed off the bridal dresses. The Contest was outdoors at 6 p.m. It started to drizzle around 6 p.m.

The evening sky was gloomy. Lighting was poor as the sky was overcast at 6 p.m. It was my first time photographing bridal models or any human models. I wanted to give up. But a Muar photographer encouraged me to get on with it.

Tips from this Muar photographer were helpful. These were "focus on the eyes" and "eye contact" to get a lively and sharp picture. "Shout 'hello' just before you click to get the model's attention and her eye contact," he advised me.

I didn't dare to shout "hello" before clicking. I waited for the eye contact to happen by chance and there were 3 below.

One photographer shouted "Marina," and the model turned her head in his direction. I learnt about the tricks of the trade in Malacca. For my animal photography, shouting at a cat or dog for eye contact photography usually does not work!

I did not submit any photo for the Contest which had the theme of "Highlight of the beauty environment and exciting premises together with beautiful model as bridal". To satisfy the theme, a close-up of the bridal models would not qualify. It would need to show the environment and premises of the Resort and the best picture I had was that of the bridal couple directed by the photographers to stand at the edge of the pool. I captured this picture as I was moving away to take pictures of other models up the hill. I quickly snapped this scene. To me, it had an excellent composition, action of the pro-active photographer risking his camera to command the hard working bridal couple to take a risk on the rocky pebbles which are meant to discourage people walking on them. The lone photographer faced the bridal couple, reminding me of the famous Tiananmen Square Protests of 1989 photo of a man facing the army tanks, as in: http://en.wikipedia.org/wiki/Tiananmen_Square_protests_of_1989.

You can see that the photographer near the model was a pro-active type. The one in orange T-shirt ventured out a bit to risk his camera falling into the pool with him should he slip and fall. The others (hidden in the right) preferred not to take risk and stayed on firm ground. This picture shows the beautiful pool and the cascading waterfall features of Philea Resort and Spa and the bridal model. It might be on the final list to win a prize, in my opinion. Maybe not. One has to be hands-on to learn a new trade as reading all the photography magazines will not be sufficient as to go to be battle-tested.

I used "P" Mode and set the ISO to 3200. I was surprised to get some "good pictures" for my readers. These were the pictures where I was at the right place at the right time and got the right point of view without obstruction from the various Malaccan photographers.




Update and more photos are at www.toapayohvets.com/philea.htm

Sunday, November 14, 2010

202. Golden Retriever with yellow discharge

"I did not want to spay her when you advised," the mother said. "I was worried about the death during anaesthesia." Now, the dog had lots of dirty vaginal discharge and I said; "She is suffering from pyometra - a womb infection." It is best to spay her as soon as possible"

The dog came in at night. My associate vet diagnosed pyometra and put her on a IV drip with antibiotics. He would operate the next day.

I had not seen this dog for some years after the initial first 3 vaccinations. The worried mum phoned me. "My associate vet is able to perform this surgery," I said. "Pyometra is one of the common surgeries."

However the mum insisted that I operate. So I took over the case from my associate vet who had no hard feelings over this as the dog was under my care since puppyhood.

PRE-OP
As the owner was very worried, I had the dog on IV drip and antibiotics for 3 days. She had an excellent appetite on 36 hours after being seen to, but still it was safer not to rush into surgery as scheduled. Total white cell count was high indicating a bacterial infection of the blood system. It would be best to kill all bacteria using antibiotics

ANAESTHESIA
Dog was 33 kg. Domitor 0.3 ml IV was given. Gas mask using isoflurane gas was inhaled for 15 minutes as this dog was now stronger now after the 3 days of IV and antibiotic. I intubated her and maintained her on isoflurane gas. In retrospect, Domitor could be given at 0.4 - 0.5 ml since no other sedatives like Zoletil were added. But isoflurane gas is the safest way.

SURGERY
A big swollen uterus, as in closed pyometra. As thick as the bigger hot dog you will see during barbecues. Some cysts appeared in one uterine horn near the ovaries. I took a picture for reference. Normally no cysts are seen but pyometra is cystic endometrial hyperplasia complex. So cysts are usually found inside the uterine tubes but these cysts were outside.

POST-OP
The dog was sent home 48 hours after surgery. She was not seen again as she had licked off her stitches on the 10th day. In any case, the stitches were self-dissolving.

CONCLUSION
Closed pyometra does present with vaginal discharge as the cervix opens during the later stages. Abdominal palpation in this dog did not reveal large uterine tubes. However the blood test with high white cell count was useful. In any case, purulent vaginal discharge in large amounts around 2 months after the heat is a quick diagnosis of pyometra. A rush into surgery is not advised as the dog is septicaemic. I would advise 3-4 days later.

ANOTHER CLOSED PYOMETRA CASE.
However, some owners want the dog operated and back home on the same day of diagnosis as they feel that the dog should not be separated even for one day. For such owners, the vet needed to use his common sense and judgment.

In this case, Vet 1 had X-rayed and took blood test and confirmed that the Maltese of 6 years had pyometra. Vet 1 phoned the next day for the dog to return for surgery. Pyometra is a much longer surgery than a normal spay and so the vet costs would exceed $1,000 with the x-rays and blood test. The surgery quoted by Vet 1 was $800 which was a reasonable cost. Unfortunately the owner felt it was too high.

"You will need to get the dog operated soon" I advised when the owner phoned me for a quotation. She wanted to wait till the weekend, 3 days later. After all, the dog looked well after Vet 1 had given antibiotics. "Delays mean more infections and complications. When the dog dies because you delay surgery, you tend to blame the vet as being incompetent in anaesthesia."


There was little difference but since I did not need to repeat the blood test nor take X-rays or ultrasound, my quote would be deemed lower.

The dog came in for surgery. An IV drip plus antibiotics was given 3 hours before surgery. Domitor 0.1 ml IV was given via the drip. The dog was masked and given isoflurane gas. She slept fast and was intubated. Isoflurane gas was given. I monitored this case very closely as it was a high risk case since the operation was done on the second day after Vet 1 had diagnosed closed pyometra. The 3rd day could be too late as the dog could die from septicaemia.

ANAESTHESIA TIP
The dog was not normal in the sense that the tongue was pale and bluish. Her re-breathing bag showed signs of very slow breathing and cessation of breathing. This was a touch and go case. The family expected 100% survival but this case could be the type of high-risk case best done by other vets. I disconnected the endotracheal tube when the dog was not breathing well and re-connected when the dog felt some painful reaction from the surgery.

OUTCOME
The dog survived and went home on the same day. She was OK.

Pictures will be at www.toapayohvets.com later.

A demanding dog breeder

Dog breeders in Singapore go for the cheapest vet and there will be new start ups that oblige. "It is better to have a case rather than have no business," this is the reality of life.

Yesterday was a Sunday. A dog breeder came in at 5pm saying that he had 4 pups born naturally from a Shih Tzu mated with a Poodle, producing "ugly crosses" that Singaporeans will not buy.

"I need an oxytocin injection for the dam. It is past 24 hours since the 4th pup was born. I could feel one pup still prsent"

I palpated a bony foetus, hard as a bone and said: "There is a pup in the right side, below the rib cage. The pup is dead as you had waited too long. Oxytocin injection may not help."

He insisted on the oxytocin injection. The dam contracted a bit and there was no puppy delivered after 30 minutes.

My first assistant was present. He told the breeder that a Caesarean section was necessary.

"I had an X-ray done at Vet 1," the breeder said. "Only 4 pups seen during the X-ray".

"Are you sure?" I had no X-ray from him since he did not bring it."Normally, at this late stage, you can see 5 foetal heads and skeletons."

I will describe the I/V anaesthesia in this case as Caesarean sections have had been written in many reports in www.toapayohvets. The black pup was smeared with dark green placenta melt-down. It was dead and stiff on taking out from the womb.


Domitor 0.1 ml. Then Zoletil 100 0.1 ml. Both were diluted with another 0.1 ml saline before IV injection via a drip line. Atropine 0.5 ml given. Dog was intubaed and given oxygen at high flow rate around 5 litres/sec.

CAESEAREAN SECTION
No pain problem. Towards the end, I increased the dosage of isoflurane for a brief few seconds. The dog woke up at the last stitch. The surgery took around 45 minutes and that was the duration of analgesia in this dam, weighting around 7kg.

The dam's tongue was initially pale but became normal pink at the completion of surgery.







ANAESTHESIA

Thursday, November 11, 2010

240. Email query about vaccination for cats

I am Dr Sing. Thank you for your email. The reply in CAPITAL LETTER is as follows:



On Thu, Nov 11, 2010 at 9:41 PM, ...@gmail.com> wrote:

Hi,

I recently took in a small black stray cat that a friend of mine had found and nursed back to health. I wanted to schedule some time to bring him in to get any required vaccinations and a general check up.

I have a few queries:

1. What vaccinations are normally required?

ALL CATS SHOULD BE VACCINATED AGAINST THE FOLLOWING FIRST 3 COMMON DISEASES IN SINGAPORE LISTED BELOW

* Panleukopenia virus (distemper)
* Feline calicvirus (FCV)
* Feline herpes virus (rhinotracheitis)

AS FOR RABIES, THERE HAVE BEEN QUERIES FROM CAT OWNERS.

* Rabies (NO NEED TO VACCINATE FOR CATS IN SINGAPORE AS THERE IS NO RABIES IN SINGAPORE)


* Panleukopenia Vuaccine (also called "Feline Distemper")
Panleukopenia is caused by a feline parvovirus (FPV), and is particularly vicious, capable of being spread rapidly, with a high mortality rate, especially in younger cats.
* Feline Calicivirus
This virus, along with the Feline Herpes virus, causes the majority of upper respiratory infections URIs in cats, and can be spread by "carrier" cats for years.
* Rhinotracheitis (Feline Herpes Virus)
Rhinotracheitis causes serious potential respiratory and neurological diseases, especially in kittens.




2. Do I need to make an appointment or can I just drop in?
Drop in is OK but sometimes the vet is operating and you need to wait a long time. It is best to make an appointment.

3. As it is a male cat I may need to consider getting it spayed. Would you recommend that?
NEUTERING IS ADVISED FOR THE MALE CAT to prevent caterwauling, wandering urges, urine marking and fighting. SUCH BEHAVIOUR IS COMMON IN MANY MALE CATS

4. What would it normally cost for all of that? VACCINATION IS $35.00 IF THERE IS NO CONSULTATION WHICH IS $35 - $40. Neutering, anaesthesia and post-op antibiotics and painkiller are estimated to be $110-$130.

Please let me know - many thanks.

Regards,
Name of Owner

Sunday, November 7, 2010

Old dog with cheek tumour

The skin wound did not close entirely. This is a complication of surgery of the cheek tumour excised from outside the cheek. The Miniature Schnauzer of 11 years of age,10 kg bodyweight drooled saliva out of two gaps in the cheek. The young lady owner wanted surgery to close the holes as the right cheek keeps getting wet.

"It is lymph," my first assistant speculated. "Do you think so?" I asked him again. "It is possible as the surrounding area had a type of wetness that looked oily. Like melted butter. However, there was saliva from inside the mouth flowing out of the two gaps.

The old dog had 3 general anaesthesias and I did not look forward to a 4th. Try not to be complacent as deaths on the operating table of an old dog are always a possibility.

INJECTABLE IV ANAESTHESIA
This time, I do not use isoflurane gas as in the previous 3 operations as the endotracheal tube would get in the way of the surgical procedure of debridement.

For 10 kg, the formula for a safe dosage of injectable IV is 0.5 ml diazepam 5 mg/ml and 0.5 ml ketamine 100 mg/ml by slow IV injection.

I used 0.4 ml + 0.4 ml respectively. It was insufficient. As the needle was in the vein in case of the need for top up, my first assistant injected 0.02 ml Zoletil 100 mg/ml diluted in 0.18 ml saline to make it 0.2 ml. The dog was sedated but his eye reflexes were present.

6 DAYS PRE-OP.
Dog was on Baytril oral for the past 6 days. The young lady remembered the appointment as I do not phone or text message unlike the Singapore General Hospital staff of some medical departments. I ought to do it and will do it.

SURGERY
Snip off granulated edges, debride. Undermine skin to separate some areas from the underlying cheek muscles. New raw bleeding edges. I used simple interrupted sutures 3/0 at 0.3 mm apart. 1.0 ml atropine SC was given to reduce salivation as Zoletil does cause salivation as a side effect. Sent dog home to reduce vet cost as this young lady had used her savings for the operations.

Only time will tell whether the old companion finally has a healed intact right side of the cheek.

OBSERVATION
It was too early to see whether the cheek tumour had recurred again. For readers, it is best to get your dog over 3 years of age, annual dental check up for mouth tumours rather than not do it. Some do develop into cheek or gum tumours as in this old Schnauzer and would then cost a lot of worries and money.

238. Integrity of the vet

"No general anaesthesia," the young man suggested local anaesthesia as he was worried that his cat might die on the operating table. His cat was weak as he had been sneezing blood and had runny noses for the past 2 months. He wanted my second opinion after Vet 1 advised a CT scan costing $1,500 excluding surgery for 2 lumps above the right nostril and below the right eye.

"Local anaesthetic cannot be applied to this area as there is not much space due to the large size of the growth," I said. "The cat would feel the pain of injections of the local anaesthetic and scratch me." I had a feeling that this cat was suffering from tumour as he had around 3 grey melanomas in the ear pinnae. Both ears and melanomas may have spread to this nose area.

The following was briefly how I handled this case with the least cost as required.

PROCEDURES
1. History & Palpation of the tumour. Firm but no pain. The cat had 10 days of vibravet 50 mg at 3/4 tablet per day from Vet 1. Now he had yellow runny nostril on the right side. "Did he get nose discharge on the left nostril?" I asked the young man. "No," he said. But I could see the brownish stain not completely wiped out, below the left nostril (see picture). His mum later confirmed that the cat had discharge of both nostrils.

2. Aspiration with 18G needle. The quiet cat was held by my assistant (without wrapping him in a towel as it should be done. My right wrist was scratched). I aspirated 0.02ml of red blood from the bigger of the two lumps.

3. Incision for biopsy. I used the scalpel to excise the lump to see what is inside. As I had promised the young man, I did not use general anaesthesia. The cat raised his front left paws weakly a few times. I got scratched once as I took out 2 pieces of the greyish maroon muscle-like mass below the skin, put in formalin and sent them to the Laboratory.

4. Anaerobic bacterial cultures and Gram stain were not done as the cat just had been on 10 days of antibiotics from Vet 1.

5. I had asked my assistant to clip the hairs of the forelegs so as to insert the IV catheter easily. This was done with no prolem. Blood test and an IV drip was done. In the IV saline drip to be given as 500 ml, I put in baytril antibiotic according to weight, a small 0.2 ml dexamethosone anti-inflammatory and metronidazole according to weight.

RESULTS
Least veterinary cost is what the young man's father wanted. With the above procedures, the cost was "affordable" as it was well below $1,000 since there was no general anaesthetic and surgery. And no possibility of death.

24 hours later, the cat had no runny left nostril. I did not expect such drastic improvement. He went home on Day 3 with Baytril antibiotics. He had no problem with runny nose and was eating well. Lab reports indicate he had cancer - malignant cellular infiltrate with a differential diagnosis including malignant melanoma. I advised surgical excision but the father wanted to wait and see.

LAB REPORT. Cat, M, 6 years. Soft tissue lesion, near muscle. MALIGNANT CELLULAR INFILTRATE. Different diagnosis includes malignant lymphoma, malignant melanoma, carcinoma or sarcoma. Immunostains needed to delineate and type the tumour.

CONCLUSION.
A biopsy is important in growths. A CT scan of $1,500 is too costly for most cat owners. In chronic sinusitis as suspected in this case, a gram stain, a fungal and anaerobic culture would be good but these were not done as the cat had been on antibiotic in the past 10 days. There was a budget from the owner.

Metronidazole IV may be effective in this case when combined with Baytril. As there was no bacterial culture done, it was hard to say what caused the blood sneezing and nose discharge. Metronidazole is effective against anaerobic bacteria (unique anaerobic bactericidal activity). It seldom cause the pseudomembranous colitis sometimes associated with the use of clindamycin. Metronidzole is said to be potentially mutagenic (likely to cause cancer), but short-term use has not been shown to cause cancer.

Dry lips

Cause varied. Sjogren's syndrome (an autoimmune disorder associated with dry mouth and dry eyes), hypothyroidsim, drugs in the treatment of hypertension, acne (Roaccutane). Most common cause is environment like cold dry weather. Allergy to metal canister. Treatment is frequent application of misturisers or lip balms containing beeswax (good moisturing properties) +/or topical steroids in allergies. More detailed medical test if problem persists.

236. Sleep bruxism

Sleep bruxism - grinds one's teeth involuntarily during sleep. One in 3 children and some adults. Causes - stress, anger, trauma, some drugs, genes. Leads to jaw pain, tense facial muscles, head and ear aches, worn out teeth.

Does this happen in dogs and rabbits during sleep? In people, treatment of underlying conditions, pain relief and mouth guard to wear during sleep.

235. Uterine Artery Embolisation (UAE) shrinks fibroids

Reference: The Straits Times Mind Your Body, Oct 21, 2010

Fibroids are benign tumours in women and affect 40% of women aged over 40. Cause pain and heavy bleeding or prevent pregnancy if inside the fallopian tubes. It will not eliminate all fibroids unlike surgical removal but does not require surgery with its complications.

UAE is a non-surgical way using a tiny catheter to block the blood flow in the artery that supplies blood to the fibroids. It is done by radiologists but Dr Bruce McLucas, an American gynaecologist wants to train gynaecologists to do it. In SGH, Prof Tan Bien Soo, senior consultant radiologist said it is team work between different specialists that matters. He says there is "continuity of care" in SGH where the procedure is currently done by radiologists who usually don't follow up on the patient, unlike the gynecologist.

Done under sedation, UAE leaves no scars and no blood loss. Outpatient procedure, less cost and recovery time. In 9/10 women, UAE shrinks the fibroid by 60% within 6 months, sufficient to stop pain and other compications. UAE is less damaging han myomectomy (surgical removal of fibroids) or hysterectomy (entire womb with or without ovaries and fallopian tubes surgically removed).

Saturday, November 6, 2010

Holiday at Philea

I had a 3-day 2-night stay at a brand new resort in Melaka and shares my experiences with readers

MARKETING INFO FOR DESIGN TRAVEL PTE LTD, www.designtravel.com.sg



1. Philea Resort & Spa, Ayer Keroh, Melaka. I arrived on Friday (Deepavali), 5 Nov 2010. There was a Bridal Fair 2010 at the Philea Ballroom which can seat a maximum of 500 people for weddings. For 200 people, the ballroom can be partitioned. There are small meeting rooms which seat around 10-20 people.

2. All info on the Philea Resort is at:
http://www.phileahotel.com/resort_melaka_malaysia/index.html

3. MARKETING SEGMENT. I believe that the type of corporate customers for this resort is:

3.1 Not those on budget like young adults who want to shop and dine till past midnight as they will need a taxi to come back to the Philea Resort & Spa which is not in the down-town location.

It will be OK for expatriates who can afford taxis and I have seen 2 older Caucasian expats in their 30s, returning by taxi at around 9pm.

3.2 Prospects with spending power including families and professional bodies. According to travel agency owner, Mr Richard Goh who picked me up from Equatorial Hotel on arrival in Melaka to send me to Philea Resort, thinks that church people may not have the spending power to host the retreat in Philea Resort & Spa.


3.3 If you send corporate customers, they will be those that appreciate the finer things in life like living in a spacious all-pinewood rooms including flooring and walls, new bathroom with long bath and showers rustic environment far from the city crowds and noises and villas instead of apartment-type or room-type hotel, low rise low density resort alternative to hotel high-rise of around 200 units or as pre-arranged.

3.4 Caucasians will definitely like this wooded villa ambience and the Russian-sourced pinewood buildings. Pictures are at the website.

3.5 Food & Beverage was generally good. During my 2 nights stay, the buffet dinner was excellent. The baby lobster was great on the first night but not so good on the second night. The satay of beef and chicken was consistently great. I like the braised beef. No pork is served. So this resort may appeal to the Singapore Muslim community for retreats.

3.6 50% F&B discount for senior citizens is a great incentive. The buffet dinner had 2 types of soups. There was a great interest in baby lobsters, prawns, shell fish, squids, Italian food, cakes, ice-cream etc was around RM26.00 per senior citizen. The breakfast coffee was bad and tasted like charcoal. Waiters' service was great. Dinner may be outdoors with no air-condition as the air conditioned cafe can seat around 100 people.

3.7. New resort. This is a selling point. Opened around June 2010.

3.8 Around 10-minute drive to the town centre. There are taxis available. For our corporate clients, you will need to provide a shuttle service and driver. I know of one operator who picked me up from Hotel Equatorial to this place. He is a travel agent and is contracted to Transtar. He has his own coaches and tour guides as well as taxis. Will give you the email later.

3.9 A Butterfly farm is just 5-10 minute walk by the back gate from Philea Resort. I will go there today, Sunday morning before I check out.

4.0 3-4 hour coach ride from Singapore to Melaka. There was an accident somewhere during my departure from Singapore to Melaka on Friday, Deepavali. The Causeway jam was from 9 am to 1.30 pm. I reached Philea Resort & Spa at around 6 pm.

4.1 The coach could have dropped me at the last toll gate which is a short walk to Philea Resort & Spa. Instead Transtar arranged for me to go to Hotel Equatorial. The taxi driver and travel agency owner, Mr Richard Goh was not around. I had to ask the Equatorial hotel receptionist to phone him. Transnational Travels had not made any arrangments for delayed arrivals nor give me instructions on what to do or tel when there is a delay in arrival. This was bad planning. Mr Richard Goh said it was unusual as most people from Singapore took 3-4 hours to reach Melaka by 3 p.m. So, he left the Equatorial Hotel which was just a drop-off point.

5. Room in the Pavillion Villa (180 units - 2 storeys bungalows, each with 4 units, upper and lower separated by a central staircase). Spacious and is bigger than some Singapore's 5-star hotel rooms like Westin. Pinewood flooring looks clean and bright. It feels great to walk upon, without the need to wear shoes. Bathroom has pinewood doors, rectangular white porcelain basin top, no-closed up screen on long bath, spacious shower area with glassed partition, big mirror and black tiled flooring giving a luxurious appearance. No adjoining room for big families but the central staircase of each level has doors facing each other and therefore the families with children can connect via the staircase landing.

6. Possibly Philea Resort & Spa has only two competitors. One in the same class will be A' Famosa Resort Malaysia, http://www.afamosa.com/main.php?m=Content&op=page&id=160. Philea Resort is not a theme-park concept unlike A'Famosa. It is said to be the only resort with pinewood logs (inter-locking, no screws and nails) with logged villa accommodation in Malaysia. There is one new development with villas built over the sea in KL I can't recall its name.

I hope the above info helps.

Best wishes.

233. Hamster vets

E-MAIL TO DR SING DATED NOV 7, 2010

I am writing to you because I have a dwarfhamster that has not emptied
his cheek pouch in two weeks not even when I gently press on the back
of his pouch. It also seems that his teeth might be too long, although
I am not quite sure how long hamster teeth should be. On your website
you have many stories about how you have treated hamsters, and it
seems that you have a lot of knowledge on this subject therefore I am
asking you for your help.
I live in the Netherlands where it is very hard to find a veterinarian
that knows how to treat small animals. I have called the vet and they
said they could not say anything without seeing the hamster first and
that they do have knowledge of hamsters. I have had several small pets
and this is their usual reply and when I bring my pet over the vet
usually knows a lot less than I do and always recommends just putting
it to sleep. The consultations are quite expensive therefore I really
would not like to go unless I would find a doctor that actually knows
something about small animals, they always say they do on the phone
but a soon as you stand in front of them they do not even know its
head from its tail.
The hamster seems to be doing fine, he does not look in distress and
he still eats and drinks. However, he seems to have slowed down.
Normally he is a very active animal that runs in his wheel for hours
and moves everything around in his cage but lately he is less active
and he seems to keep tripping and falling over when he is climbing
around on his toys, in such a manner that I have actually removed most
of his toys so that he would not be able to hurt himself. He is almost
two years old now, so maybe him slowing down is just because he is
getting older. Although my previous hamsters would remain active until
their death.
Another of my concern to bring the hamster to the vet is because he is
getting older and I am afraid that maybe the stress of being there and
maybe being handled by an inexperienced vet would make him die from
stress. Therefore, I hope you will be willing to give me advice on how
to take care of my hamster myself so I can do it in the comfort of his
own home. I would be very grateful! Could you tell me step by step how
to clean out his cheek pouch? Also how I could locate it, because when
I hold him by the scruff of his neck which makes him "smile" I cannot
see any entrance to his cheek pouch. Would you maybe be able to send
me a picture of how long the teeth of a dwarfhamster should normally
look like? I can find a lot of pictures online where the teeth are
extremely long and curled up, but my hamster does not have this. Oh I
almost forgot to say that my hamster also does not drool from the
mouth but he has not closed his mouth in a couple of days its always
just open for a little bit.
I really hope you can help me quickly before he gets sicker, I am of
course willing to pay for your consultation.

Kind regards,
Name of Owner


E-MAIL REPLY FROM DR SING

If the cheek pouch is impacted, you need to empty it. Usually I put the hamster under gas anaesthesia as it will be stressed and may die.
As for your case, your hamster may be comfortable with you. You need to restrain him and this is not easy, to empty his pouch. Use a blunt ended forceps to do it in this case. If the cheek pouch is inflamed and infected, you will need to look for an experienced hamster vet to use anaesthesia and do surgery.

I hope this advice will help. Impacted and/or infected cheek pouches are sometimes very difficult to empty as some seeds may have stuck inside and become embedded causing great pain in the mouth. If there is no anaesthesia and you try to force the hamster to empty its pouch, it may just die during your manipulation. That is why many vets don't like hamster treatment. No vets want to damage his reputation when the hamster dies during treatment. Best wishes.