Saturday, February 26, 2011

349. Veterinary Nurses Wanted

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Company Description

March 1, 2011
Veterinary Nurses Wanted for dog and cat animal practice. Able to converse in Mandarin and English. Lives around Yishun to Toa Payoh area. N or O levels. Knowledge of Microsoft Word, Excel, Adobe Photoshop preferred. Able to work alternate weekends and loves dogs and cats, hamsters and rabbits. E-mail resume and two testimonials to judy@toapayohvets.com.
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Friday, February 25, 2011

Pure Stupidity

"Pure stupidity," Julia said when I asked her what she thought about the case of a Singaporean man who purchased and smuggled a Golden Retriever puppy from Malaysia to Singapore. The case was reported in the Straits Times. A Dr Boon told this man to confess to the Singapore Government in 7 days or so or else the doctor would do it. The man did not. So, the doctor did. The AVA punished him and he lost "Princess".

I wonder what happened to the Golden Retriever puppy now. It was never mentioned in the newspapers.

Some pet shops are said to sell smuggled dogs. One man told me that he could get any breed of dog I wanted from Thailand. I told him I was not interested. Smuggling of dogs is an offence as rabies may be introduced to Singapore which has been rabies free for over 50 years.

Thursday, February 24, 2011

347. A German Shepherd licks his foot pad

"He will never permit a barricade fencing to prevent the dog from leaping down to the car porch," the mother said to me. "When we put up fencing, Dad will take it down," the daughter in her undergraduate studies reinforced her mum's statement to me.

The mother phoned me because the dog had been licking his Right Fore foot pad for the past 2 days. "It is common," I said as the mum wondered whether I knew what she was talking about. She is an old friend of over 30 years but she would consult other vets as I don't charge.

"The dog will lick the big foot pad under the foot till the black covering becomes white," I replied. "Usually it is due to some wooden splinters or sand stuck inside the cut pad and the dog tries to get it out by licking vigorously."

"Yes," she confirmed that the pad was indeed white but she disputed that there were any foreign bodies inside as she could not see any.

"You can't see the small foreign body because it may be embedded horizontally or at an angle inside the pad, but the dog can feel its irritating presence."

Indeed this was the picture. "How does it happen?" the mum asked.
"Well, the dog could be pawing the garden."
"No," she replied. The domestic worker was present and she said yes, the dog did paw at certain patches of the garden.
"Maybe it is due to the dog leaping down from the higher garden to the car porch (a height of around 3 feet) and cut his pad. The bricked edge of the tiled border of the garden at the edge might have cut his pad."

There was a 0.5cm cut in the pad and this could support her hypothesis. Now, I advised fencing up this area to prevent the dog from leaping.

"Thomas will not permit it. He just takes down any raffia string fencing we put up as it makes the house looks untidy."

"Can you talk to him again?" I asked the mum and daughter. They shook their heads. It was none of my business too. I gave a steroid injection IM in the back muscles while the maid held the dog who was now muzzled and was also wearing an e-collar. "So quick?" the mum was surprised.

"I need to be fast or I will get bitten," I know of Singapore vets being badly bitten by German Shepherds during house calls.

I had this sadness in visiting this house as the eldest daughter had passed away in a car accident some months ago. She would have become a good veterinary surgeon as that was her passion. That was her dog. He had been X-rayed recently by another vet as the family had not consulted me about their dog's health care for many years as the mum would not want free veterinary services from me.

Should I phone the father to advise putting up the fencing? The wife and 3rd sister in the house had been much negative and I ought to leave family matters alone. For the sake of the dog, I phoned the father to let him know I had treated his family dog. "Your wife had spent $500 on X-rays and veterinary consultation for the dog's problem," I said to him. "If you continue to let him leap, you will need to spend thousands of dollars in veterinary fees for his injuries to his back or hips and that is a lot of money to be spent."

The father replied in a serious tone and I thought there was no hope. However, the wife happily told me that her husband had put up some fencing when I phoned the next day. I asked the wife whether the dog was still licking his right paw. She said, "No, he is wearing the e-collar."

I said, "It is not the e-collar. It is due to the steroid injection I gave. You can take away the e-collar."

Sometimes, the vet has to be proactive in contacting the other spouse to advise in the interest of the dog and this takes courage and time. In this no-hope case, the husband accepted the advice with great reluctance I am sure as he does not phone me back to let me know.

Wednesday, February 23, 2011

346. Cost of spaying a cat at Toa Payoh Vets, Singapore

On Wed, Feb 23, 2011 at 4:59 PM, ... wrote:

E-MAIL TO DR SING DATED FEB 23, 2011

Hi

I would like to enquire how much will be the cost for sterilise a cat?

COST IS AROUND S$150 WITH PAIN-KILLER AND ANTIBIOTIC MEDICATION AND E-COLLAR. LOWER FEES IF YOU DON'T WANT E-COLLAR WHICH PREVENTS LICKING.

How am i to go about it?
Do i need to make an appointment?
APPOINTMENT PREFERRED. TEL 6254-3326

Lastly where is your clinic located?
It is located at Blk 1002, Toa Payoh Lor 8, 01-1477, near the Golf Driving Range. See www.toapayohvets.com, click LOCATION or goto: Location of Toa Payoh Vets

|
http://maps.google.com/maps?f=q&source=s_q&hl=en&geocode=&q=Toa+Payoh+Vets,+Singapore&sll=1.352083,103.819836&sspn=0.631535,0.884399&ie=UTF8&ll=1.365265,103.850842&spn=0.078942,0.11055&z=13&iwloc=A

345. Teaching interns rabbit medicine

My assistant Mr Saw views interns as pests as he has to take time to teach them. He would never tell me directly but I hear this from Khin Khin. I don't blame him as not everybody cares about teaching interns as it really takes lots of time.

Being busy, he does not want to waste time on interns. Interns who are helpful will of course, be appreciated by him. However, there will be vets and vet assistants who don't want to waste their precious and busy time on interns.

Rabbit medicine - In this case of a rabbit not eating, I got the two interns to learn how to bathe a rabbit with stained feet. This thin 7-year-old rabbit had been de-matted yesterday and had some bath. However, his feet were all stained greenish-black and he tried to lick the stains off.

As the vet in charge, I inspected warded animals and checked the treatment. This rabbit's feet had not been cleaned. After bathing by the 2 interns under Mr Saw, the rabbit appeared to have excellent appetite. Intern Nathaniel Gay took 5 pictures with his latest iPhone 4 presented by his father. I showed him the craft of taking photos by zooming and using correct points of views.

He uploaded on Microsoft Silverlight and emailed to me the link to see. I thought it was youtube.com as he had given me the impression. It was a slide show and probably lasted for 5 days. Well, it was a learning experience for him.

This case of the skin-and-bone rabbit could be due to a lack of grooming care as the rabbit had excellent appetite after de-matting. Only that his feet were not washed by the groomer and I had to intervene by asking Mr Saw to show the interns how to bathe a rabbit. The intern first got the big blue tub for Golden Retriever puppies and switched on the hot water shower. Just as small plastic container sufficient to confine the rabbit and warm water from the boiling kettle would do. Sometimes, one must think about the situation and not bathe pets blindly, using big tubs and wasting lots of warm water.



Pic is shown here.

Tuesday, February 22, 2011

On Thu, Feb 17, 2011 at 11:11 PM, ... wrote:

Dear Doctor Sing,

I've previously brought 2 of my dwarf hamsters to your clinic for treatment (removal of tumor & ear growth).

I've another dwarf hamster turning 2yrs 4mths at the end of February. Just yesterday night I noticed there was some blood stain on the left side of her ear. Today, it got worst due to excessive scratching.

I've attached 2 pics for your review. As she's getting old, I wonder if there's any external medication/application that I can apply on her to stop her itch.

May I also check with you on the earliest slot that I can bring her over for your review @ your clinic.

Looking forward to hearing from you as soon as possible.

Thanks & regards,



Hi

I just came back from Myanmar. Please accept my apologies for the late reply as it is practically impossible to access the internet in Myanmar or it takes a long time. So, I did not access the internet.

Your pictures of the hamster shows an ear infection deep inside the ear canal and on the surface of the ear and may require ear irrigation and cleaning under anaesthesia.

Pl make appointment at 6254 3326 and let the receptionist know that you will be making appointment with me as there are 3 vets at Toa Payoh Vets.


BEST TO TELEPHONE 6254-3326 but young generation prefers email or text!

342. Educating and entertaining Vet Undergraduates Project

Feb 23, 2011

I am back from a trip to Myanmar to hike a trail and see the schools near Lake Inle and visit a village in the Ayeyawaddy Division to see the Future Foundation's primary school construction in progress. I met an 81-year-old artist in his Art Gallery. I was looking for an oil painting of a flower vendor in Myanmar. He did have one that was sold long ago. The next best thing was a painting of flowers and market. Will display in the Toa Payoh Vets later.

AUDIO-VIDEO veterinary education project is being done with the volunteer and help of 2nd year vet student Ms Daphne Low. This 2nd video really took me by surprise as i did not expect much from her (being a busy multi-tasking distracted young generation with many things to do). My comments are recorded as follows:



OVERVIEW. Ms Daphne Low has to create the video based on the outline. I should have said "Audio-Visual" Production as the creation had music but no voice over!

Video Production
1. Define condition
2. Diagnosis
3. Treatment

Topics
1. Anaesthesia (TPVets)
2. Surgery (what is involved)
3. Puppy Toilet Training in Singapore
4. Disease conditions
- Bladder stones
- FUS (Feline Urinary Syndrome) / CUS (Canine Urologic Syndrome)
- Ear problems
- Heartworm
- Periodental Disease
- Skin abscess: ringworm(fungal), dermatitis (bacteria), mites
5. Vomiting/Diarrhoea
6. Cesearian
7. Corneal Ulceration - esp in Shih Tzu
8. Spaying/Neutering

Vomiting/Diarrhoea
- if many times = emergency as possible death due to dehydration/bacteria intoxication
- blood test, check stools for parvovirus/foreign body, x-ray
- treatment: no food/water for intestines to recover, iv drip + medicine to control infection for 2-3days

Infection of Ear Canal
-non-stop scratching
-head scratching
-affect immune system
-groomer will treat but unsuccessful
-if unsuccessful for 2 times, lateral ear resection will be required


E-MAIL FROM MS LOW dated Feb 18, 2011


Hi Dr Sing,

Sorry i took so long to get back to you! I was so busy with cny and stuff. How was your cny? (: I just managed to do a video on cesarean which i have attached in this email. Please take a look and tell me if this is what you are looking for. I saw that you are overseas from 17feb to 22feb. Have a safe trip! I will send to you more videos once I have the time to do them!

Cheers,
Daphne




E-MAIL TO MS LOW dated Feb 23, 2011


Feb 23, 2011

Dear Daphne,

I just came back from Myanmar yesterday and expected to see a similar video production as the first video production you did for me. Thank you for spending time and effort to produce a beautiful "movie" which will help to educate and hopefully to entertain veterinary undergraduates in developing countries where there are no computers and facilities in the schools and where internet access is slow and expensive.

I just can't believe that you have had progressed to making a professional-looking video with music. Everything was well timed and clear. It is as if a rose bud has started to blossom, when I compared to your previous video production for me. Pl do not infringe on music copyright.

COMMENTS
1. No audio in this production unlike your first video you produced for me . Please make some comments about surgical techniques (the text is inside the pictures) so that the viewer does not need to strain to read the "subtitles" inside the images. Hearing is best. Reading subtitles deprives much of the fun in viewing as the viewer must focus on reading the small text. That is why foreign language non-English movies don't do well with the English-educated audience in Singapore.

2. For credits, just provide text as follows:

This is a "Be Kind To Pets" Audio-Visual Production with the objective to educate and entertain, thus making Veterinary Medicine & Surgery Alive for Veterinary Undergraduates in developing countries. This is Dr Sing Kong Yuen's Community Education Project made possible with the collaboration of veterinarians at Toa Payoh Vets. We thank the sponsors - Design Travel Pte Ltd and Asia USA Realty (S) asiahomes.com Pte Ltd, Singapore.

More information is at the respective websites:
bekindtopets.com, toapayohvets.com, designtravelpl.com and asiahomes.com.

Produced by Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Videography by: Ms Daphne Low, 2nd year, Veterinary Student, Sydney University, Australia. Feb 2011. All rights reserved.

3. Please upload this first draft to youtube.com as it is a pioneer batch.

4. I am glad that you are not wasting time on Farmville in Facebook and that it was a family member using your facebook account. Create beautiful educational "movies". Make a difference - make the world a better place for pets and children.

Wednesday, February 16, 2011

341. Follow up on the skin-and-bones megaoesophagus dog

On Feb 16 evening, I phoned the owner of the skin and bones dogs. I had proposed feeding every hourly from 7.30 am to midnight with small amounts of food (6 pellets and 1 tablespoonful of k/d diet) to get the dog to put on more weight and survive. In the past week, it was two-hourly and there was no more vomiting. Prior to consulting me, the lady owner fed small amounts of rice, cereal and other things like asparagus and multi-vitamin B's were fed by the husband 3x/day. The dog would "vomit" every day but not all the time. There was persistence in "vomiting". This was actually regurgitation of food eaten some minutes ago and finally, since the dog was depressed and unable to eat anymore and was tired out, the couple sought veterinary consultation, thinking the dog was suffering from stomach cancer.

"Didn't my wife phone you?" the husband said. "No," I said. She passed the phone to her wife. "My dog vomited at midnight after the last meal," she said. "I think every 2-hourly feeding would be fine," she suggested.

"It is a matter of trial and error in this case of megaoesophagus," I replied. "The gullet can't hold too much a large quantity of food and water and that is why I asked to feed every hourly to ensure she puts on weight."

The happy owner reiterated, "Now my dog does not have the pus discharge in her eyes every day and so I don't need to wipe off the eye discharge. She does not tire so easily and looked eagerly for her food when she hears the noise of crunching of her 6 pellets." The prescription d/d pellets are crushed into powder and mixed with the canned k/d diet so that they will not irritate the mucosa of the gullet and will pass into the stomach. 2.5 mg prednisolone was given daily too and would be stopped after 3 weeks. It reduced inflammation and promotes appetite effectively in this case. Trimaxazole antibiotics had been given and would be stopped after 3 weeks. We would wait and see.

"Is the dog putting on weight?" I asked.
"I can feel she is heavier when I carry her," the lady owner said. "She passes well-formed solid stools."
"Is she shivering?"
"No more, but she could be shivering due to your grooming clipping her bald to de-tick her last time," the lady owner was also getting the dog clothed and wrapped in a blanket at night in the air-conditioned room.
So far, no food regurgitation. The diagnosis of megaoesophagus was not a death sentence and this 8-year-old dog should live to an old age if there are no other health problems.

Earlier vet report about this "vomiting" skin-and-bone poodle is at http://www.toapayohvets.com/web1/20110204megaoesophagus-regurgitation-dog-toapayohvets-singapore.htm

This is NOT an easy case to diagnose. Regurgitation is often confused with vomiting by the owner and the owner often misled the vet by giving the incorrect complaint of "vomiting". I visited the apartment to see the dog in her natural environment and lifestyle. It is a rare case as most "vomiting" cases are really vomiting dogs!




P.S
Due to economic reasons, I did not ask the owner to X-ray the distal oesophagus with contrast medium as X-rays of the neck and abdomen had cost some money for these senior citizens. It would be good to do it, but at the owner's expense. In the X-ray, you can see that the oesophagus is dilated as gas and liquid filled up the dilated mid-oesophagus. The diagnosis is still megaoesophagus and the treatment depends on the cause. Feeding small amounts of food (powdered pellets and canned food) without regurgitation, the X-ray of mid-oesophagus and return to normal health supports the diagnosis of megaoesophagus. There appeared to be an area of granulation in the pharngeal area as the dog used to eat branches and grass for some years. It could be a granulation tissue. See the X-ray.

338. An intern flirts with the danger of being terminated from her internship

February 17, 2011

Yesterday, Feb 16, 2011 Michelle came to work late again for the 2nd time. This was despite being warned the day before! It was incredible. She behaved as if she was indispensable and was a top vet, a prima donna whom the practice revolved around. Without her, the practice would be shut down!

"Does your Victoria Junior College teachers teach you punctuality at work?" I asked her. She had been warned and yet she did it again, thereby flirting with danger of being dismissed from internship. Her mother sent her to work everyday and her father or mother picked her home unlike Nat who had to take a bus and get to work himself. Her teacher had imparted her the values of punctuality but she chose to flirt with danger. "So, what's your excuse?" I asked her as I sat down in a room to interview her. "The traffic was heavy," she said. "This is a common excuse," I said. "It is not acceptable. If you don't value your internship, don't do it. You have been warned twice now. The third time will mean termination of your internship." There are other interns whom I can't accept due to lack of space and if Michelle behaves as if her mother owns the practice, she has better go. A rotten apple spoils the whole barrel.

Nat had not been late during the past 4 days despite having to take a bus to work. He bothered to wake up early and ensure he was a bit early. In fact, Nat asked to work from 8.30 am to 10 pm. Michelle had been a clock watcher and was hoping to be just-in-time at work from 10 am to 7 pm. Both are not paid.

"Obviously, you are doing work attachment or internship because you want a testimonial," I said. "If you don't work hard, you will get a mediocre testimonial - satisfactory performance but not punctual. Is that what you want?" I do spend time teaching them some cases of veterinary medicine and if an intern persists in behaving as if the world owes her a living, she is better off staying at home.

"As for your mum driving you to work late, you will need to ensure that she wakes up early to do so," I told Michelle. In the first place, there is no need for an intelligent lady to be told in this way. Treating internship like a holiday camp or vacation or like your father's office is not tolerated. Parents who feel the need to drive their children to internship need to be alert and impart values of punctuality and be a role model for the young ones.

One more time, Michelle will be asked to go. She is setting a bad example for my staff and Nat and the rot will be like a cancer, affecting the behaviour of all employees.

I noted that the vet's dog was no longer present in the Surgery to create fears and worries in clients. There is much relief on my part. There are vets whose dogs and cats are well loved by clients if they behave responsibly. Just like interns, those who don't behave as expected will create tension and are best banned from the practice.

It is the responsibility of the Clinic Manager who is myself if there are any complaints. Every day, there are new incidents and many issues are needed to be regulated and to prevent possible litigation in this fast-paced society. Bad eggs are best asked to go. No more blind loyalty. Employees and vets that don't perform at work are best let go despite their years of work for the practice. Once they lose their interest in the practice, it is best that they work somewhere else.

I will be on leave from Feb 17 to 22, 2011 and I hope nothing unusual will happen in Toa Payoh Vets. I will be visiting a primary school built by Future Foundation and its volunteers and see whether I can be of help in the education of the children. There is a need for the building of a secondary school in this village and sponsors must be found. Some pictures of the Primary School are at:
http://www.designtravelpl.com/tours_Myanmar/20110124volunteer-tour-inn-ma-ywar-lay-primary-school-myanmar-design-travel-singapore.htm

337. An intern flirts with the danger of termination of internship

February 16, 2011

Yesterday, Michelle came to work late again for the 2nd time. "Does your Victoria Junior College teachers teach you punctuality at work?" I asked her. She had been warned and yet she did it again, thereby flirting with danger of being dismissed from internship. Her mother sent her to work everyday and her father or mother picked her home unlike Nat who had to take a bus and get to work himself. "So, what's your excuse?" I asked her. "Traffic was heavy," she said. "This is a common excuse," I said. "It is not acceptable. If you don't value your internship, don't do it. You have been warned twice now. The third time will be termination of your internship."

Nat had not been late during the past 4 days despite having to take a bus to work. He bothered to wake up early and ensure he was a bit early. Michelle had been a clock watcher and was hoping to be just-in-time.

"Obviously, you are doing work attachment or internship because you want a testimonial," I said. "If you don't work hard, you will get a mediocre testimonial - satisfactory performance but not punctual. Is that what you want?" I do spend time teaching them some cases of veterinary medicine and if an intern persists in behaving as if the world owes her a living, she is better off staying at home.

"As for your mum driving you to work late, you will need to ensure that she wakes up early to do so," I told Michelle. In the first place, there is no need for an intelligent lady to be told in this way. Treating internship like a holiday camp or vacation or like your father's office is not tolerated. Parents who feel the need to drive their children to internship need to be alert and impart values of punctuality and be a role model for the young ones.

One more time, Michelle will be asked to go. She is setting a bad example for my staff and Nat and the rot will be like a cancer, affecting the behaviour of all employees.

I noted that the vet's dog was no longer present in the Surgery to create fears and worries in clients. There is much relief on my part. There are vets whose dogs and cats are well loved by clients if they behave responsibly. Just like interns, those who don't behave as expected will create tension and are best banned from the practice.

I will be on leave from Feb 17 to 22, 2011 and I hope nothing unusual will happen in Toa Payoh Vets. It is the responsibility of the Clinic Manager who is myself if there are any complaints. Every day, there are new incidents and many issues are needed to be regulated and to prevent possible litigation in this fast-paced society. Bad eggs are best asked to go. No more blind loyalty.

Tuesday, February 15, 2011

336. The vet's dog made a lady shriek

February 15, 2011

Being the founder of Toa Payoh Vets, I do not wish the company to create unhappy customers. A Malay couple came in with their cat to see Dr Vanessa. I asked them to wait as she was busy in the operating room. I quickly cleared the laptop and other things of Nat on the table in the waiting room. I put their cat's cage and cat on the table to avoid another incident of Dr Vanessa's dog sniffing the cage and creating another unhappy customer.

I have to decide what to do with Dr Vanessa and her dog today. A good vet is no good if he or she creates unhappy customer. It is better to have a top team rather than a top vet if the practice is to survive and be around in the long term. I have made no decision yet but if there is a need, I will rather fire the top vet rather than create unhappy customers.

The dog was confined to the receptionist area when the door of the counter was closed. However, he again sneaked out. I noted that he was quiet and had not barked at anybody. He was confined by Dr Vanessa in a crate at the back yesterday for frightening the rabbit owner by sniffing the crate with the rabbit inside. I had to told Dr Vanessa to take him away from the waiting room. I had not specified banning of this dog from the Surgery yet as I would wait to see what she would do.

I presume that the Malay couple would prefer a cat's clinic but there is none in Singapore. The man went outside to answer his phone call. The lady sat at the corner of the waiting area where the table with her cat's crate is located. The cat was brought in for a spay and the couple had specified that they only wanted to consult Dr Vanessa.

Suddenly the lady shrieked. I was at the waiting room instructing my two interns what to do and teaching them some cases. I turned around and saw the dog going under the legs of this table. He did go under the table earlier when there was no people. But as Dr Vanessa opened the door to go to the back of the surgery, he followed her but now he had come out when Michelle opened the door to get to the waiting area. He must have decided to go under the table.

A few seconds more and he would have contacted the Malay lady and in her religion, this was not acceptable. As the dog wanted to bite Michelle the intern yesterday, I did not want to be heroic. I called Dr Vanessa to come out of the operating room and get the dog in. She would have heard the shrieks too.

Now, I need to decide what to do as I don't want to create unhappy customers who will go to the competitors. I will wait and see. I can see the humour of the situation but it will not be humourous to owners who are worried about their pets being "attacked" by Dr Vanessa's medium-sized dogs. Customers are what make a practice and if the founder cannot get his priority right, he deserves to lose his shirt and go bankrupt. It is not a guarantee that a veterinary surgery will be successful and be in existence if it is poorly managed and creating unhappy customers is no joke.

335. A very busy father seeks immediate treatment for his daughter's hamster

Yesterday, Feb 15, 2011, I was surprised to see a busy father rushing in with a hamster in a cage. "I am in a hurry," he said. "My daughter's hamster has broken his leg."

"Where's your daughter?" I asked. "She's in school and does not know about this yet."
It is very unusual to see a Singapore father taking time off to send the hamster to see the vet.

"Where's the vet?" he asked me.
"Dr Vanessa is in the operating room," I said. "Can you wait?"
As he was in a hurry, probably to close a real estate deal (based on he being awarded IEA Realtors Awards - lst runner up in 2008/2009 and Platinum award in 2007 and 2008, from his namecard which I got from him later), I decided to take charge of his case. Usually Dr Vanessa will handle the cases during the hours of duty.

He was hesitant as he thought I was the customer service staff.
"I am Dr Sing," I introduced myself. He smiled and said: "My daughter told me about you and your hamster cases." Since I do not know the 15-year-old daughter, I presume he was referring to my hamster case studies at www.toapayohvets.com, hamsters.

Since Dr Vanessa came in, I excused myself and let Dr Vanessa handle the case.

Monday, February 14, 2011

334. A vet's dog nearly bit the intern

February 15, 2011

Being the founder of Toa Payoh Vets, I do not wish the company to create unhappy customers. A Malay couple came in with their cat to see another vet instead of me. I asked them to wait as she was busy in the operating room. I quickly cleared the laptop and other things of Nat on the table in the waiting room. I put their cat's cage and cat on the table to avoid another incident of the vet's dog sniffing the cage and creating another unhappy customer.

I have to decide what to do with a particular Toa Payoh Vets doctor and her dog today. A good vet is no good if he or she creates unhappy customer. It is better to have a top team rather than a top vet if the practice is to survive and be around in the long term. I have made no decision yet but if there is a need, I will rather fire the top vet rather than create unhappy customers.

The dog was confined to the receptionist area when the door of the counter was closed. However, he again sneaked out. I noted that he was quiet and had not barked at anybody. He was confined by a particular Toa Payoh Vets doctor in a crate at the back yesterday for frightening the rabbit owner by sniffing the crate with the rabbit inside. I had to told a particular Toa Payoh Vets doctor to take him away from the waiting room. I had not specified banning of this dog from the Surgery yet as I would wait to see what she would do.

I presume that the Malay couple would prefer a cat's clinic but there is none in Singapore. The man went outside to answer his phone call. The lady sat at the corner of the waiting area where the table with her cat's crate is located. The cat was brought in for a spay and the couple had specified that they only wanted to consult a particular Toa Payoh Vets doctor.

Suddenly the lady shrieked. I was at the waiting room instructing my two interns what to do and teaching them some cases. I turned around and saw the dog going under the legs of this table. He did go under the table earlier when there was no people. But as a particular Toa Payoh Vets doctor opened the door to go to the back of the surgery, he followed her but now he had come out when Michelle opened the door to get to the waiting area. He must have decided to go under the table.

A few seconds more and he would have contacted the Malay lady and in her religion, this was not acceptable. As the dog wanted to bite Michelle the intern yesterday, I did not want to be heroic. I called a particular Toa Payoh Vets doctor to come out of the operating room and get the dog in. She would have heard the shrieks too.

Now, I need to decide what to do as I don't want to create unhappy customers who will go to the competitors. I will wait and see. I can see the humour of the situation but it will not be humourous to owners who are worried about their pets being "attacked" by the vet's dog medium-sized dogs. Customers are what make a practice and if the founder cannot get his priority right, he deserves to lose his shirt and go bankrupt. It is not a guarantee that a veterinary surgery will be successful and be in existence if it is poorly managed and creating unhappy customers is no joke.

Sunday, February 13, 2011

333. Employees and interns must be able to perform and blind loyalty

Yesterday, Feb 13, 2011 Sunday

I was at the Surgery at 9.30 am. Neutered a cat for one Indian lady and her friend or daughter. "Did the cat claw you?" she asked. "No," I said. "He hissed when he was held by my assistant for sedation before surgery. So, I had to be quick on the draw and injected him very fast." The older woman laughed and said: "I have two female cats. They are wild and will not permit strangers to touch them. Will you be able to spay them?"

"Yes," I said. "Provided you bring them in separate cages. I will be able to sedate and spay them." The most ferocious cat can be sedated safely for the vet and the cat if you know how to do it.

I showed Nat, the young man of 17 years in his 2nd day of internship how the cat was handled for injection. He is a lucky man as I don't accept interns who are not accepted by the Vet School as time and resources are needed to give him the veterinary experience. I told him that he had a good father who bothered to get him this attachment as that was what he wanted. His father was my wife's colleague some 20 years ago and had kept in touch with the group regularly. Otherwise I would not agree to have him. I was shocked that he did not know whether he had Microsoft Excel in his laptop as I thought all Secondary Schools in Singapore teach the students how to use Excel. "You better know," I told him off. "Or I will complain to your father. Your answer should be a yes or a no." I have no patience for young people who don't know what software they have in their laptops when they want to do internship as I am quite busy and have better things to do. I asked Michelle to check.

I asked Nat to take a dog with extensive maggot wound on the neck, treated and bandaged by Dr Vanessa Lin yesterday, for a walk outside as he had not kept any dog, being prohibited by his father from keeping dogs. The dog walked a bit and stopped. He also stopped. I checked on him standing on the grass patch with the dog. "Walk the dog a step at a time," I advised him. "He needed the exercise."

As for the other intern Michelle, I instructed her to do inventory control and database. "Being an intern does not mean that you just watch the vet and assist the vet in the treatment of animals," I told her. "Veterinary medicine is much more than that. It is a business as for all professions. Starting a vet surgery is not a guarantee of success for every surgery. It has to be properly managed and one of them is to check on stocks and costs and that must be done regularly. Otherwise medicines, microchips and sutures can get lost if there is no inventory check and over-ordering of drugs mean money spent and tied up for a long time."

I think that Michelle is getting to know more about veterinary medicine at the 4th week. "As for database management, it is good practice to keep two databases to get fastest retrieval of data. One for client particulars and one for pet particulars."

She had said that the Toa Payoh Vets database was small and in any case, the client and pet particulars were already in one file. This file was accessed easily and fast. This was a good question.

"The retrieval is fast now," I said. "However, there is a limit to the number of records being permitted by the old versions of Excel."

"But you have a newer version," Michelle speculated.
"In any case," I said. "Data will accumulate to slow down the retrieval speed over the years. Not in 2011 but 5 years from now. Also, there is a lot of wastage of hard disk space when the two databases are combined in one as not all particulars are filled up when there are absence of data from the owner or pet. These empty reserved fields take up the hard disk space and delay retrieval."

I don't know whether she understood what I was saying as this sound too technical to anyone who has no knowledge of the structure of database and database management. This was an intelligent discussion and would help Michelle, the intern in understanding more about veterinary administration.

A woman in her late 40s was sitting at the corner of the waiting room reading a textbook on childcare education. She was sneezing and had runny nose. The younger lady gripped the top of the crate which had her rabbit and pressed the crate down onto her lap and chest. I was surprised. Then I saw the associate vet's dog trying to sniff the rabbit. I had not known that this young lady was worried about the dog and now she told me why she did not place the crate on the floor. This vet's dog would try all means to get out to the waiting room when banished to the back room. Sometimes he would bark uncontrollably at me or at clients.

I ignored his barking as paying attention would encourage more barking. Barking at clients is not acceptable to me and if this dog persists, I would step in and let the vet know that her dog has to be kept away from the reception area and the consultation area. The problem was that he would sneak out from the back room whenever the door was opened by our workers.

There are some vets who have well behaved dogs and this one is definitely well known amongst clients for his barking. Some clients don't mind but as you can see from the rabbit owner, there are worries and great unhappiness. As Asian Chinese are non-confrontational by culture, there is no complaint from the rabbit owner and her mum.

The lady with the rabbit was having runny noses and red eyes. She was allergic to the rabbit but would not put the crate on the floor, holding it firmly on her lap. "Put the crate on the table," I said and asked Nat to clear the table. Her mother also had runny nose but was allergic to the air in veterinary surgeries. So, it was a surprise to me. As I did not link both together, I thought it was a coincidence that two persons were allergic to animal-related environment. I did not see both coming to the surgery together as I was busy with the administration and the two interns. Actually it was a mother and daughter suffering runny noses at a vet clinic.

It was a bright sunshine Sunday but very hot and humid in the afternoon. It was the first Sunday that was without James Ang, my 76-year-old receptionist who really could not work anymore. He had been with me for over 20 years.

Sometimes, "blind loyalty" according to the book "The Breakthrough Company" by Keith McFarland prevents small businesses from being extraordinary. Therefore, the vast majority of small businesses stay small and not by choice.

Talents and character of employees make a business expand to become large. What Mr McFarland said is that employees who are not up to scratch and don't perform are best fired and not retained for years. They drag down the company's performance and may destroy the company. Many people had asked me to retrench James as they complained about his service. I did not do so but this year, he had asked to resign and I think he would be happier enjoying the winter years.

Friday, February 11, 2011

332. Common pet shop operator's complaints about younger vets

"No need to feed chew bones, no dog treats, no need to give vitamin supplements as the dog food is complete," a few pet shop operators and breeders complained to me about some newly graduated vets. The owner whom they refer to the vet would provide feedback to the pet shop operator.

"It is best not to make any comments," I advised younger vets. "There are at least 200 brands of dog food. Can you guarantee that they are all complete and balanced nutrition? Those certified by AAFCO may claim to be complete and balanced and therefore there is no need to buy vitamin supplements."

I explained the joy of owning a puppy. The owner enjoys buying dog treats and the puppy enjoys them thoroughly. So, the puppy gets diarrhoea due to certain raw hides or treats, but this does not happen to all puppies. By saying no treats, the vet deprives the new owner of the joy of ownership. By saying all dry dog food is complete and balanced diet, the vet gets into possible litigation.

"In any case," I said. "If the puppy has diarrhoea, the owner needs to pay for veterinary treatment and learns to buy high quality puppy treats.

There is one vet on the website who says that his dog who is at his vet surgery daily never get sick and therefore does not need yearly vaccination. Based on his own dog, he concluded that no re-vaccination is necessary. This is a point of contention. However, old dogs not exposed to viral diseases may get by without booster vaccination. If the dog falls sick, it is his problem.

331. 76-year-old receptionist retires today Feb 11, 2011

My receptionist Jame retires today. He is 76 years old and has a severe hunch to 45 degrees forward. Last week, he fell off the plastic stool and fortunately landed his bum on the floor without fracturing his hip. He complained of a back pain but said it was nothing.

"My mother lived past 90 years," he said.
"How about your father?" I presumed he would live to 90 years.
"Around 50 years," he replied.

I advised him to see the Polyclinic as he had both lower limbs swollen and some non-healing wounds on his left lower leg above the ankle. "The Toa Payoh Polyclinic is closed for renovation," he said. I phoned 100 and got the Ang Mo Kio Polyclinic address for him to get a thorough check up of his hips and his hunched back. The General Practitioner prescribed tight bandages for his lower legs and advised him that he had higher than normal cholesterol after pricking his finger to test for diabetes.

No other exam. I asked him to go to Singapore General Hospital Health Screening Unit to get blood test, heart check, ultrasound and colonscopy. "How long can you live?" I asked. "Better to enjoy your life without having to work 5 days a week," I advised.

Thursday, February 10, 2011

330. Photography: a tool for better veterinary health care for pets?

From: Digital photographer Issue 97
www.dphotographer.co.uk
PHOTOGRAPHY: A TOOL FOR POLITICAL CHANGE?

Mona Miri:
Images must be visually compelling and tell a story. Photography is a very powerful tool to highlight important humanitarian and environmental issues (www.monamiri.com). When we see images of degradation, starvation, pollution or natural disasters, we want to make a difference.

www.simonnorfolk.com
Photographers need to be telling stories about their world, providing a voice for the subjects and make us think differently about conventional wisdom.

IMPACT
It must be a combination of the photos and the facts or ideas behind them that can change people's view. Not just photos alone.

An image is a very powerful weapon but a person must show the correct view instead of a distorted one.

Photo is a powerful tool that bring issues to the attention of the big decision-makers. But it is the campaign with images that makes the biggest difference

Money is influence, influence is access and that is what makes the world go round, not pictures

Wednesday, February 9, 2011

329. Modern carpark warrior

For many years, Singapore's car park wardens walk to the carparks to catch errant motorists. Before they could book one, the Toa Payoh Lor 8 industrial park tenants co-operated and warned their neighbours motorists would run to their cars to put parking coupons onto the dashboard. So, the wardens needed to sneak inspections by arriving at odd times.

Today, I noted a golden car and commercial wordings like "Chubb" parked across my car which was parked near the the fire hydrant. I was leaving and was going to politely ask the driver to make way. Inside were 2 men. One was checking his digital pad and said to me: "Somebody complained but I had not keyed in your car details yet." I thanked him and drove to the Library.

From my speculation, the HDB had outsourced to Chubb to catch errant motorists. Somebody in Chubb would check google maps at 9 am in the Chubb ofoffice and see my car parked illegally. So, it was time for enforcement.

No more walking wardens now. They sneak in by car and booked errant motorists by printing out a summons from their PDAs. No more chance for the ordinary citizen now, but most car parks are automated and only this one near my Surgery is not. So, expect driving car park wardens at any time and at any day now. Hit and run, I mean book from inside the car and drive away!

328. Fifty words to recommend a pet product

An inaugural issue of a magazine asked me to write 50 words to recommend a pet product and suggested an image of me and the product.
The images will not be of educational interest to readers. However, an X-ray of a bladder stone will have greater interest to readers (I presume).

I used Microsoft Word, "Tools" - Word Count and got the number of words as 50. Then I clicked "Spelling and Grammar. The advice was to revise the following long fragment:
I recommend Hill's® Prescription Diet® s/d® Canine pet food to dissolve struvite bladder stones in dogs that have difficulty in peeing.

Since I have a limit of 50 words, I did not revise the fragment. The 50 words are as follows:



I recommend Hill's® Prescription Diet® s/d® Canine pet food to dissolve struvite bladder stones in dogs that have difficulty in peeing. Veterinary tests are required. However, large bladder stones (X-ray) require surgical removal so that your dog does not suffer painful urination of smelly bloody urine daily for several months.


The 50 words' limit forces me to be concise and yet be able to educate pet owners.

Advice to youths.
A person must write daily to be able to write better just as exercising the muscles make one better built. There is no other way to improve one's writing.


Message from the magazine
Dear Dr Sing,

Good day! This is Michelle from the CozyCot Editorial team.

We are working on a pet story to be published in our print magazine's inaugural issue in April, and I'm hoping that with your expertise and experience, you can recommend one pet product (this can be anything and everything from pet food, to pet cages to pet toys) and tell us what's so good about it in about 50 words. It would also be great if you could accompany the text with image(s) of the product and yourself.

As we are running on a tight deadline, I would be extremely grateful if you could get back to me as soon as possible. Many thanks!

Best Regards,







Michelle Ong

Writer

michelle@cozycot.com

t: (65) 6100 2699

f: (65) 6226 3733
e: michelle@cozycot.com

CozyCot Pte. Ltd.
1 Scotts Road #26-05/07 Shaw Centre Singapore 228208



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Tuesday, February 8, 2011

Too good to be true Golden Retriever and Norwich Terrier from the SPCA, Singapore

CASE 1.
I was invited to the 2nd day of Chinese New Year dinner organised yearly by a remiser. Beautiful bungalow in a serene tranquil area of Margoulith Road. My wife and I had our food outside at the corner. I was with the owners of the skin and bone poodle with megaoesophagus (no more vomiting, a big relief to the lady owner as vomiting was presented daily for the past 3 years) and a widow in her late 60s who related an incredible tale.

"The Golden Retriever was so good looking that we adopted him even if he had no pedigree papers. My son was excited and we quickly signed the SPCA papers. This dog was recommended by my relative, a vet who helped out at the SPCA."

This vet was my intern over 20 years ago and when her name was mentioned, this woman related the incredible tale.

First the Golden Retriever chewed on plants, legs of tables and graduated to chewing metal. "The puppy chewed steel? Really?" I asked.
"Yes, it is true," the grandmother said. "The neighbour's cars parked outside the house would have no steel rims!"

"What happened to the dog after you returned him to the SPCA?" I asked.
"I don't want to know," the grandmother said. "Was there any solution to this problem? The dog trainer said no solution."

"How old is the puppy?" I presumed incorrectly.
"8 months old when I adopted him."
"Destructive chewing can be prevented when the Golden Retriever is a puppy. Put him inside the kennel when he starts to chew destructively and reward him with treats and exercise when he behaves. However this needs a lot of patience and time." The grandmother had given the dog much freedom and so he kept on destroying the garden and cars. A child not properly disciplined or trained with love will also end up being lacking in ethics and morals too. Parents need time to do the training but there will be handsome men and pretty women out to scam and con. It is best not to judge a book by its cover.

From this incident, she prohibited her grandchildren living in her house from keeping dogs! Despite the fact she enjoyed the company of dogs at a young age.


CASE 2.
I was surprised to see a Norwich Terrier puppy coming in for vaccination. This breed is expensive and rare in Singapore. It costs around $2,000 and the owners had adopted him from the SPCA Singapore. Fortunately he has no destructive chewing but he was adopted as a 4-month-old. The daughter in her pre-teens and the parents were very fond of this well behaved puppy.

326. pug with recurrent infected struvite stones - case report for vet students and owners

http://www.sinpets.com/dogs/20110207urinary-stones-pug-toapayohvets-singapore.htm
has the latest updates

Blogger can't display tables directly. The report is below:

FOR TOA PAYOH VETS VET REFERENCE BOOK FOR OWNER EDUCATION

Case study: Infection-induced struvite uroliths in the dog
Pug, Male, 2 and half years. Bladder stones removed by Vet 1 around one year ago. Dog was on Hill's SD on one month, CD for 3 months. The complaint was dysuria (straining to pee) for the past few days.

"Why?" the lady who had kept 3 pugs to an old age, had no urinary stone problems. The black pug lived up to 18 years of age. (3 pugs were fed home-cooked food by the mother but this 4th pug was given dry dog food as her mother had passed away.

However, she anticipated no problem after bladder stone removal by Vet 1. "Why did the vet not advise follow-up? I stopped giving the Hills' Prescription diet as my dog was showing allergy and feed home-cooked rice and meat." Her father asked me at another visit: "Is it because the vet (Vet 1) had not completely removed all urinary stones?" Residual stones could cause a recurrence but stones do recur even after complete stone removal.

urethral obstruction - used smaller catheter. pug drinks little. toapayohvets, singaporeA real case will interest the vet student as it can be sleep-inducing to read through the several hundreds of pages of urinary stones in dogs in various text books and the internet. The following case will help to explain to students the approach to one approach to the medical treatment of struvite uroliths in the dogs at Toa Payoh Vets.

There are 3 scenarios mentioned in the above website.
1. Medical dissolution of struvite uroliths in dogs
2. Prevention of infection-induced struvite uroliths
3. Prevention of sterile struvite uroliths in dogs

This pug has 1 and 2 and so the medical treatment (as contrasted to surgical treatment) is discussed below.
On 26.1.11, the pug strained to pass urine.
Urine Test results from lab:
Urine: amber & turbid
pH= 8.0 (5-8)
SG = 1.010 (1.005 - 1.030)
Bilirubin ++
Blood ++++
WBC 0
RBC 8
Casts Nil
Bacteria ++ Crystals
triple phosphate +,
calcium oxalate occasional, amorphous phosphate ++
Calcium oxalate crystalluria. Collect fresh urine and analyse within 30 minutes. If persistent and in breeds (Bichon Frise, Miniature Schnauzer, Yorkshire Terrier, Shih Tzu, Lhasa Apso), discontinue diets that promote formation of acidic urine and consult recommendations for Calcium oxalate prevention. Struvite crystalluria is insignificant if the dog has negative urine cultures. However this pug had bacteria in the urine. Struvite is also known as triple-phosphate, ammonium phosphate and urease stones and are invariably associated with urinary tract infections in people and dogs with alkaline urine (pH > 7.2).
Blood Test results from the lab:
% Absolute
WBC normal range. Biochemistry normal Neutrophils 71%
Lymphocytes 18%
Monocytes 9%
Eosinophils 0.2%
Basophils 1.8% 11.50
2.9
1.42
0.03
0.29
X-ray
No obvious urinary stones seen in the kidney, bladder or os penis. The alkaline pH, bacteria in the urine and struvite crystals indicated a recurrence of the urinary stone formation with urinary tract infection. The Owner wants medical (conservative) treatment. Acidifying tablets* (1 tablet 1 x/day for 10 days), canned CD diet and trimethoprim antibiotics were prescribed.
*1 tablet/5 kg twice a day is recommended by manufacturer. The pug is 9.5 kg and would be getting 2 tablets 2x/day in theory.

Feb 7, 2011. Owner is in her 30s and has good medical knowledge as she works in the medical profession. She probably does internet research on urinary stones in the dogs. She e-mailed to me the follow dipstick result I had asked her to do at home.
Feb 7, 2011

Greetings Dr Sing

Happy New Year to you, your family and your folks at Toa Payoh Vets! I had done a urine dipstix for XXX and results are as follows:
Leukocytes: Neg
Nitrate: Neg
Urobilinogen: 0.2 Protein: Neg
pH: 5.0-6.0
Blood: Neg Ketone: Neg
Bilirubin: Neg
Glucose: Neg

He's so much better with his urination though at times, his post void can be slightly delayed (meaning he puts his leg down quite some time even when there seems to be no more urine).

As I will be leaving for overseas for a week on Wed morning, do you need me to bring XXX over tomorrow?

Thanks and regards

The urine was not alkaline as on the first day of consultation. pH was 8.0 then. Dipstick results are not reliable but is easy for the owner to do. I advised a review of dog, urine bacterial culture and test 3-4 weeks after the first visit and get a urine test done (via catherisation since it is difficult for the owner to collect a mid-stream urine into the urine collection container! The pug would stop peeing when she tried to collect urine.)

On Feb 8, 2011, the lady owner came for acidurin tablets for another 20 days and said that since the dog does not have much difficulty in urination, the trimethoprim tablets must be effective and therefore there is no need for a urine antibiotic-sensistivity test.

PREVENTION OF INFECTION-INDUCED STRUVITE UROLITHS
1. Treatment: Control urinary tract infections. Select antibiotics based on urine bacterial culture and susceptibility results. Culture urine during therapy to verify effectiveness of antibiotics.

With additional recurrent infections, antibiotics for 4 weeks, then 1/2 daily doses for 9-12 months, 4-weekly urine cultures.

2. Acidify urine: medication
3. Diet which promotes acidic urine. These have reduced protein, phosphorus and magnesium.
4. Monitoring: Urine culture and urinalysis in 1 month and 3-monthly.

5. X-ray: Every 6 months or sooner if the patient has recurrent urinary tract infection symptoms*.

*excessive vulval licking, urinating in the house, pollakiuria, haematuria etc.

*identify and eradicate anatomic abnormalities (vaginourethrocystoscopy, contrast vaaginourethrocystography and ultrasonography) and functional (urine cortisol to creatinine ratio, serum biochemical and thyroid profiles and neurological exam) risk factors for recurrent infections.

Note 1: struvite crystalluria is insignificant if the dog has negative urine cultures. However this case has bacteria in the urine.

Note 2: Calcium oxalate crystalluria. Collect fresh urine and analyse within 30 minutes. If persistent and in breeds (Bichon Frise, Miniature Schnauzer, Yorkshire Terrier, Shih Tzu, Lhasa Apso), discontinue diets that promote formation of acidic urine and consult recommendations for Calcium oxalate prevention.

An American veterinary school (webpage not available to the members of the public) that does urolith analysis for Hills' samples, recorded that medical dissolution of struvite uroliths with Hills' s/d canine was 100% effective after 3-6 weeks for sterile struvite uroliths and 8-12 weeks with effective antibiotics for infection-induced struvite uroliths. It seems that this institution favours medical treatment (i.e. no surgery to remove stones).

Immature dogs should not be given low protein s/d for a long term. However, a short-term use with antibiotics has rapidly dissolved infection-induced struvite uroliths in 9-12 days without adverse events.

Owner/patient compliance when feeding s/d is easily determined with a urine SG (mean = 1.008+/-0.003) and pH (mean =6.2+/-0.7). If no urine sample, serum urea nitrogen is a reliable marker (mean 3.5+/- 2.4 mg/dl). The s/d diet is high in fat and high fat is a risk factor for pancreatitis.

Female Miniature Schnauzers and others with hyperadrenocortisicism risk pancreatitiis and UTI that includes urease-producing uropathogens. Respond by discontinuing s/d diet, maintain hydration if vomiting/pancreatitis occur. Consider alternative that also acidify urine eg. canned w/d Canine) to correct both diseases. 26% of canine nephroliths are composed of struvite. They can be dissolved medically as in bladder stones but this takes a much longer time due to reduced kidney function, reduced urine production and reduced nephrolith dwell time in therapeutically undersaturated urine.

CONCLUSION.
Approaches to treatment. Medical or surgical treatment? For large stones and urethral obstruction, I advise surgery to remove all the stones after antibiotic treatment. Stones do recur even after complete stone removal in some cases. Many Singapore owners do not comply with medical treatment and the follow-up reviews (urine tests 3-monthly, X-rays 6 monthly). I presume it is due to economics and lack of time. Surgery should be done only after effective antibiotic treatment rather than immediately.

In this case, the pug drinks little but drinks more after going outdoors for exercise. "Try adding some ice-cubes to the water," I said to the lady who loves pugs only. Regular urine monitoring will be needed for the next 6 months and no dry dog food or dog treats and biscuits must be given. The lady owner was satisfied with the outcome that the pug was no longer taking a long time to pee.

Urine-marking in male dogs may or may not lead to urinary tract infections as the male dog with-holds urine to have sufficient amount to mark the territory. The alpha male dog pees until the last drop and even tries to pee when there is no more urine in the bladder. Neutering the dog may help prevent urinary tract infection. The lady owner was not keen on neutering.
Old Golden Retriever passes smelly urine with blood. A gigantic bladder stone. toapayohvets singaporeStones submitted for analysis in one female golden retriever by Toa Payoh Vets showed magnesium ammonium phosphate (struvite) 95% in the stone and 100% in the shell with zero in the nidus and surface. Calcium phosphate carbonate was 5% inside the stone. More case studies, goto: urinary tract problems in dogs and cats

Sunday, February 6, 2011

325. Young pug has difficulty in peeing

Pug, Male, 2 and half years
Bladder stone removed by Vet 1 around one year ago
On 26.1.11, the pug strained to pass urine.


Urine Test results:

Urine: amber & turbid
pH= 8.0 (5-8)
SG = 1.010 (1.005 - 1.030)

Bilirubin ++
Blood ++++
WBC 0
RBC 8
Casts Nil
Crystals triple phosphate +, calcium oxalate occasional, amorphous phosphate ++
Bacteria ++

Blood Test results:
WBC normal range

Neutrophils 71% Abs. 11.50
Lymphocytes 18% 2.9
Monocytes 9% 1.42
Eosinophils 0.2% 0.03
Basophils 1.8% 0.29

X-ray
No obvious urinary stones
Owner wants dog home but dog still pees in small amounts. Will come for review.
Acidurin, CD diet and antibiotics

Due to economics
1. No bacterial culture of urine
2. Owner did not come for review

Saturday, February 5, 2011

324. Youths have passion but no hunger to excel

Thanks for prompt reply and good wishes. Promptness in reply tells a lot about a person's seriousness and care in doing business.

As I don't take in more than 2 interns at any one time, I hope your son is still interested in vet medicine and meet me for a discussion before I go to Myanmar on Feb 17, 2011.

Presently I have one intern. I nearly terminated one intern on 3rd day of CNY when she phoned to ask "If she has to go to work". I told her that she may as well stop coming to Toa Payoh Vets as she does not show much passion in vet medicine. Work on 3rd day of CNY?

I had an interview with her to find out whether I am wasting my resources to accept her as an intern. Her excellent academic results should get her in Vet College in Australia easily but where's that "passion"? She did not study Biology during her pre-University levels but fortunately for her, Australia accepts such prospects unlike British Universities. However, she needed to "work" in a veterinary practice.

I asked if her mum had not been happy since she was not paid and if that was the case, she had better go home. I have other applicants but I can take one at a time and usually I accept one intern who has been accepted by the University's Vet School for the first year. She had no offers and no testimonials as to her work with animals in her 12 years of Singapore education. I did have my doubts about her "passion" for veterinary medicine but did accept her.

Her mum told her that companies don't open till 5th day of CNY but she had known that she would take 1st and 2nd day of CNY off and had my permission for that 2 days off. So, I expect her and my associate vets to be "working" on the 3rd day of CNY. In fact, I was working half day on lst and 2nd day of CNY and was surprised to receive her phone call at 9.15 am asking if "she has to come to work today."

"Internship is not a summer holiday camp," I told this young lady.

From this phone call, I know she really has no passion for vet medicine. I would have terminated her internship if she had not turned up for "work" but her mother must have had quickly driven her to the surgery from Changi for "work". I had a meeting with this young lady and told her that she could stop "working" as she had done 3 weeks. I would not to waste my time and resources on a young lady who had no interest in veterinary medicine. I told her that a mother of a 5th year vet student complained to me that this daughter worked till 12 midnight in a veterinary surgery and thus was exploited as an intern. The mother just could not understand why. That this 5th year student has a passion to excel in veterinary medicine and to top the class. These are rare birds.

I hope you will explain to your son that he should be expected to put in the hours if he wants to do internship in my veterinary surgery. If he has no time and cannot do the hours, please let me know soon.

Best wishes

Thursday, February 3, 2011

324. Megaoesophagus case study report -

Chinese New Year. Feb 4, 2011.

The owner of the 8-year-old, spayed, female skin-and-bone dog phoned me to invite me to dinner of the 2nd day of Chinese New Year, tomorrow Feb 5, 2011.

"How's the poodle?" I asked. Yesterday, the wife was quite pleased that the dog did not vomit for the past 24 hours when I phoned for a feedback. I had hospitalised the emaciated dog that had refused to eat the reduced home-cooked food offered from Jan 28, 2011 to Jan 31, 2011.

"The poodle is OK," he asked his wife about the vomiting episodes while keeping me on hold. "She is playing with the Silkie in the balcony." This is where plants and grass are present, being a ground floor apartment.

"I had instructed your wife that the poodle should be separated from the Silkie (who bullies her) and not be near the plants (the poodle has a depraved appetite and would eat grass and soil, impacting the stomach and intestines).

"Don't worry," he said. "I am watching them."

"You monitor them every second?" I was incredulous. "You don't read your newspapers and do other things? All the poodle needed was access to the plants, branches and grass and take some mouthfuls and get constipation."

It was fortuitous that he had phoned me to let me know the time of dinner for tomorrow. I had expected his wife and him to be more careful and comply with the vet instructions.

The dog was emaciated and was going to die (of malnutrition) before Chinese New Year as she had lost appetite and was the thinnest dog in Singapore I had ever seen. I refer to dogs that had been well loved and cared for.

That was why the owners decided to consult me. The husband believed in giving the dog asparagus and multi-vitamins for the past 3 years but had not sought a second veterinary opinion since the first vet diagnosed stomach tumour some 3 years ago and had declared to me: "The vet predicted that this dog would not live more than 3 months and see..see...now, it is 3 years and she is still alive!" He was quite proud as he does his treatment with asparagus and multivitamins being his main methods much to the disappointment of his wife.

This foreseeing of the future continues to haunt vets who forecasted death as it is 3 years now and the emaciated poodle is still alive. "She will die before Chinese New Year," I said when I saw the dog with her pale gums on Jan 28, 2011 (6 days before CNY). Apparently his asparagus and multi-vitamin therapy and home-cooked food in small amounts must have failed after so many years.

"Unless your dog responds to the IV protein and dextrose multivitamin drips and treatment, she will not survive past the Chinese New Year." I showed the owners the pale gums. Other than pus in the eyes (a sign of poor health), the dog was looking normal if you consider a skin-and-bone dog that can stand up and walk a bit as being normal. She was still alive due to the perseverance of the wife feeding her small amounts of cereal and home-cooked food a few times a day. It was not a nice thing to say. There are other kinder ways of giving bad news, by beating around the bush. Unfortunately, owners do mis-construe and from experience, I have become frank and brutally honest about the prognosis.

As for the husband, he was introduced to me as he was in the veterinary field and so he did not object much. However he said: "Your student is not well trained by you," referring to the first vet who diagnosed stomach tumour. I had told him that this vet had interned with me some 20 years ago before she went to study "pre-vet course" in Malaysia and got admitted to am Australian Vet School. I am quite inspired by her perseverance as she did not complete her A levels and studies night classes for the A levels. Most vets get their A levels normally and go to study vet course. As a result of this remark by the husband, I should keep quiet about knowledge of my past interns in future!

Dr Vanessa got the owners to sign a hospitalisation consent form as we work as a team on this case and she was a hands-on vet. "She would be given anti-vomiting medication to prevent vomiting," she said in response to the complaint that the dog had been vomiting.

" Well, it is not as simple as that," I discussed the history of the case with her as this was the first time she saw this dog. I had visited the home of this dog and knew a bit about her life-style.

"I don't think anti-vomiting medication will work in the long term," I discussed with Dr Vanessa the history of this case. "This poodle had been 'vomiting' 1-2 hours after food per day for the past 3 years after a vet had diagnosed stomach tumour and advised against feeding dry dog food 3 years ago. She was not seen by another vet or reviewed again."

We hospitalised the dog, took blood samples, X-rays, gave the IV drips, antibiotics and Vit K1. My assistant gave her an enema and several hard stool lumps I had palpated in the abdomen passed out. No abdominal pain at all in this dog during palpation. The kidneys, liver and spleen could not be palpated. Some gas in the intestines. That was all in a shrunken abdomen with no fat.
Hospitalisation was important to observe the timing of the dog vomiting. Was vomiting just after eating and drinking or later? In this case, it does happen after and later!

However the dog did not vomit when given canned food in small amounts. The dog did vomit some hours after eating dry food I instructed to be given. She had an excellent appetite and would drink water as much as given. I deduced that the dog regurgitated rather than vomited due to retention of food in the distal oesophagus. There is a condition called megaoesophagus in dogs.

The dog is likely to suffer from megaesophagus. Earlier, I palpated her painful throat. She objected strongly, tilted her head and suddenly, around 50 ml of liquid just "spilled out of her throat." This was one sign of megaoesophagus.

My assistant Mr Saw quickly took a piece of towel to wipe off the liquid.
So this was not a vomiting case but a regurgitation case.

Other than megaoesphagus, this dog could be suffering from myasthenia gravis. The first symptom of this immune mediated disease in the older dog is due to megaoesphagus. Myasthenia occurs when nicotinic acetylcholine receptors malfunction. This leads to the muscles not contracting. The scenario would be as follows: the distal end of the oesophagus - oesophageal sphincter - not contracting and thereby accumulating food and water without being pushed them into the stomach, intestines not pushing stools out causing- constipation.

The owner's wife complained that the dog had been having constipation and passes rock-hard stools for a long time. This constipation would be due to this neuromuscular disease which is said to be an immune-mediated disease.

Yet if vets see the superficial view, this emaciated poodle was vomiting, not regurgitating based on the owner's complaint of vomiting. So, it was possible that the first vet diagnosed stomach tumour/dog food allergy, as claimed by the owner. Sometimes, the owner might have misconstrued the veterinarian's diagnosis as this was some 3 years ago.

Persistent vomiting in a dog needs reviews but the owners did not do so. Nor did they get a second opinion. It is usually a matter of economics.

"The dog could be suffering from megaoesophagus," I said to Dr Vanessa and my assistant Mr Saw who is a Myanmar vet graduate. I asked Mr Saw: "Have you heard of megaoesophagus?" Mr Saw shook his head. "This is an uncommon disease. This poodle could have acquired megaoesophagus at the age of 5 years. Now she is 8 years old."

Small animal veterinary medical cases are usually routine as in many professions. There are the usual common cases of skin problems and vomiting due to gastroenteritis. And we could get fooled by a rare case of regurgitation.

In megaoesophagus, the dog "vomits 1-2 hours" after eating. This is not vomiting but regurgitation. To the owner, it is vomiting and in many cases of foreign bodies or tumours in the distal oesophagus or stomach, it would be vomiting soon after eating.

Such cases needed more time in history taking and a house visit. The dog also ate sticks, grass and plants. So, it was possible that it had a piece of stick or branch had damaged proximal oesophagus such that it became dilated and trapped the small amounts of home-cooked food and water that the owner gave in the past 3 years (leading to emaciation). This condition could be existing at the same time as the acquired megaoesphagus.

I had 4 X-rays taken of the neck and the abdomen. "It should not be just one lateral view," I said to Dr Vanessa as we normally do that to lower veterinary costs for the owners. Was there a stomach tumour? It was possible. I had not thought of taking a chest X-ray to check aspiration pneumonia as the dog had no breathing difficulty and I had not diagnosed megaoesophagus definitely at the time of admission. I had a feeling that it could be megaoesophagus but the husband's complaint of expensive vets (vets making a lot of money, he always said to me) kept restraining me from doing the chest X-rays for this first consultation. It ought to have been done in retrospective review. I had told the owner the costs would be more than $500 and there was no guarantee that there was a cure. Yet, without the tests, the husband would save money and assumed it was stomach tumour. The dog would pass away soon and he would save money. Money was a hard fact of life and sometimes, the unwillingness of the owner to spend money affected the dog's diagnosis and treatment.

Back to the patient, I reviewed the X-rays. The poodle's abdomen was impacted with hard stools due to the lack of contraction of the muscle involving peristalsis (oesophageal sphincter and large intestines). The normal stools passed out after an enema and 3 days of hospitalisation and being fed canned food.

This "constipation" seem to support a diagnosis of megaoesphagus with myasthenia gravis. There could be an oesophageal carcinoma as a consequence of megaoesphagus.

An X-ray of the distal oesophagus with barium meal was not done. Or X-rays of the chest. The husband was frugal and so I had to be understanding. Not that he could not afford the veterinary fees but he had been cursing my mentor (another vet) regarding veterinary fees and had preferred self-treatment of his sick dogs. Times are hard and I can understand the need to be thrifty.

This case is tentatively diagnosed as megaoesophagus or megaesopohagus (in U.S spelling). The last two days had been "vomit-free" days and the wife was much relieved and happy. The dog would put on weight and if not much damage had been done to the heart or kidneys, this dog should live longer. Blood tests showed low red cells and haemoglobin. There was an unusually low level of serum urea and creatinine. This case needed further investigation for oesophageal tumours.

X-ray also revealed a dilated proximal oesphageal region. It was possible that there was a foreign body (stick or tree branch) stuck on the dorsal part of the proximal oesophagus, causing pain over the years and granulomatous tissues. Over the past 3 years of inflammation, the partially obstructed proximal oesophagus dilates to form a sac as seen by an opaque area in the cranial area of the oesopohagus distal to the epiglottis. Can you see it?

The dog is skin and bones now. If she is suffering from myasthenia gravis, anti-cholinesterase drugs will reverse the overall muscle weakness and there will be no "vomiting" and "constipation".






Veterinary medicine throws out a challenging case now and then. Red herrings like "vomiting" when they are actually "regurgitation." It is enough to make any vet go crazy. For the last 2 days, there was no regurgitation and the dog had regained pinkness in the gums and should put on weight. The wife would weigh herself and the dog and keep records of feeding. Usually it is the wife who is the care-giver and if she does comply with veterinary instructions (restricted prescription dog food canned mainly with a 3 pieces of pelleted food in small amounts and 30 ml of water each time, 6x/day every 2-hourly for the first week and reviews again) , this poodle would regain her weight and health first.

Further investigations would be needed and sometimes the owner has to be proactive and to want to spend the money on veterinary services.

I also forecasted death before the Chinese New Year since this was a dog with skin and bones. She survived past the Chinese New Year (2nd day of New Year as I write this article) but I had given her the necessary IV drips to live.

The prognosis is guarded. I don't think this poodle would live past 2 years. I dare not make a prediction as I may be proven wrong as what the first vet did. It is possible that there is a stick or branch stuck in the distal oesophagus. The dog can pass bowels normally in the last 2 days much to the delight of the wife. So, is it a case of myasthenia gravis or not? Another review if needed. The mystery has not been resolved yet.

Interesting case report written by a lady intern waiting for her 'A'-level results and before admission to vet course overseas.

Jan 31, 2011
Toy poodle “.....” with vomiting problem
Diagnosis
Dog has been vomiting regularly for 3 years
Blood test—normal, with slight anaemia; kidney tests show poor health
x-ray of stomach and neck taken
1st vet suspected problem with stomach but is likely to be in the throat—foreign body/tumour; dog has habit of eating grass and stones; 1st vet diagnosed an allergy to dog food hence home cooked food has been given to it since
2nd vet notes that dog vomits about ½ hour after eating and has advised the feeding of 1/3 portion home cooked food. Dog has become emaciated, is now unable to take anesthetic for surgery.
Treatment
Fed 5pcs of D/D and ¼ can K/D hourly; dog needs to gain weight and regain health before a surgery can be done. Antibiotics and multivitamins also given.
CONCLUSION
Megaoesophagus in the dog is a condition where there is a decreased or absent contraction of the muscles of the oesophagus. It can be congenital or acquired. Its cause may be idiopathic or it may be due to tumour (oesophageal carcinoma), vascular ring (heart blood vessels congenital) or obstruction (foreign body e.g. stick or bone inside distal oesophagus, endoscope or X-rays), neuromuscular dysfunction (myasthenia gravis).


Pic and updated webpage will be at:

http://www.toapayohvets.com/web1/20110204megaoesophagus-regurgitation-dog-toapayohvets-singapore.htm


Tuesday, February 1, 2011

322. Chinese New Year's Eve's discussion with intern - the economics of practice

Feb 2, 2011 Eve of Chinese New Year.

Old Silkie, 15 years, with two snow-white cataracts and fast-growing tumour on the neck area. Panting. The mum was much distressed. Teenaged daughter and dad were saddened. Euthanasia was the humane solution to stop the suffering and pain. It was Chinese New Year's eve and it was a joyous occasion but this had to be done.

I explained to intern Michelle (waiting for her A level results and getting to know much more about the practice of vet medicine) that a pyometra surgery could not be done for less than $1,000 - $2,000 if the surgery has lots of equipment as these assets need to be paid for. She had been impressed by one well equipped surgery in Singapore. In the end, the customer just would not want that vet to operate on her dog, due to economic reasons. I was charging $500 and that would be a lot of difference.

I don't know whether she understands. "If the surgery has a lot of clients, it will be possible to pay for more manpower," I said. "It has to charge higher fees too to pay for the expensive MRI scan equipment and others. Otherwise, there is no net profit at the end of the year and how is the owner going to earn a living? In reality, the owner may just lose the case to a more affordable vet, as in the case of pyometra in the Jack Russell you saw."


Feb 1, 2011
I visited an older vet to thank the vet for the oranges and bak kua present. The vet had just recovered from an illness. She explained to me her modus operandus when I told her that she should not reject big breeds neutering. A case from her had come to me. "No, I don't want to do it. Simple wounds and simple medical cases at the lowest cost will attract clients. I don't understand why vets would charge higher fees and get less cases."

This strategy was correct as most people prefer low fees. In Bishan, I used to see a general practitioner with a long queue compared to his competitor 4 doors away. Could be the former's low fees, I am sure.

I did not comment on her strategy as she was differentiating her services by not handling difficult surgery cases like neutering of big breed Golden Retriever or complicated ones like removal of stones in the dog's stomach. She just refers them to a big practice which calls itself the "... referral clinic" and whose staff from the Philippines run down her and others for not being so well equipped.

Besides being bad-mouthed by staff of referral clinics with their arrogant policies, if the vet charges low fees, it is hard to have sufficient savings to upgrade facilities and equipment as well as to pay staff. Many pet owners prefer to visit a "better-renovated" practice and pay a bit more as they enjoy the ambience and feel confident that the vet would do a better job. First impressions count.

321. Myanmar stories - The Psychic

Feb 1, 2011 (Monday)

"She's a very good psychic," Tun, a Myanmar businessman in his 40s and sporting a big paunch due to too many lunches and coffee meetings, related an incredible tale to me over lunch at Inle Lake Restaurant in Peninsula Plaza on Feb 1, 2011 after we had seen some office spaces for rent in Peninsula Plaza. "She goes overseas to consult. Even the top general seeks her advice (Tun mentioned his name)."

"This really happened?" I was incredulous.
"Yes," Tun said. "The used car salesman is working in Singapore. I can introduce him to you."
He had said that the used car salesman was owed a lot of money by an Indian man for a few years. So he consulted E.T who is a famous psychic in Myanmar. The debtor had said: "You can send gangsters to beat me up, the triads to kill me. I will not pay you." So, the salesman asked the psychic for help.

Tun related the following:

"E.T asked him to give me a dollar note. She then wrote 80% on the note and asked the salesman to bring it with him when he sees the debtor again. You will not get back 100% of your money but just 80%.

So the salesman left Yangon to fly back to Singapore. He saw the debtor carrying the note in his shirt pocket and asked for the return of his loan. The debtor said: "I am prepare to pay you but not every cent."

The salesman said: "Pay me 70% by September (of 2009) or 80% by December (of 2009).

The debtor said: "I will pay you 80% by December."

"Is that really true?" I asked again. "Yes," Tun said patiently. "I wanted my wife to make an appointment for me."

"Why?" I asked this congenial man.

"But my wife is overseas," he said.

There was another Myanmar couple at the lunch table but they did not doubt Tun's story. E.T charges US$40 per case and that is a lot of money for the average person in Myanmar. So, do you believe in this tale or not? Tun has no reason to tell a cock and bull story. I was talking about a Myanmar business man who was looking for old Jaguar cars from Singapore to sell in Myanmar. This was when Tun said that he knew of this large used-car company that had a lot of old Jaguars to sell. And that was then he related the story of E.T and this salesman in this company.

His friend who is an entreprenuer had said: "An old Jaguar in Yangon is half the price of a Toyota." I was surprised. He further surprised me by saying: "The housing agent in Yangon is called "worn-out sleepers and faded umbrellas. This is because he pounds the pavement till his slippers are worn out (unlike Singapore agents who drive a Mercedes) and worked under the hot afternoon sun till his umbrella colours fade away." I was surprised at such stereotypes of the realtor and did learn a bit about the culture in Myanmar. As for the psychic, I wonder whether I should make an appointment.














Psychic, clairvoyant, healer, master practitioner in the arts of black magic, tarot, numerology, palmistry and astrology.