Saturday, April 30, 2011

421. Twelve Golden Rules

Friday, April 29, 20911
REAL ESTATE AGENCY (REA) PAPER 3. Real Estate Agency Practice & Regulations
Ethics & Client Care

I remembered this lecture more than the 12 Golden Rules of the CEA (Council for Estate Agencies). The lecturer was showing a power point presentation slide to illustrate Rule No. 8 which is Ethics & Client Care - Advertisement.

The slide showed two advertisements of an agent before and one week after the CEA was formed. The advertisement showed the agent's photo on the left and her viewings of the HDB flat.

The lecturer said: "This is a top agent. Every 15 minutes from 5pm to 7.15pm, she had an apartment for sale viewing. There were 10 viewings every 15 minutes on one Saturday afternoon."

The mature students would have been exhausted by this 3-hour-long lecture of power point slides and after slides did not comment. 7 Golden Rules had been preached and must be memorised for the dreaded examinations. We had several housing and property rules to remember too.

To lighten the solemn mood, I asked: "Is she good-looking?". What I meant to communicate to the class was that this was a well posed professionally taken photograph (angle of body slightly tilted unlike most agents' face-direct photography), long hair to below the shoulders and a comely smile.

"What do you mean," the lecturer turned and looked at me with atomic eyes that could annihilate me. "I am already so old! She can be my daughter!"

I was shocked at his response. Had I implied that he was having some hanky panky? Or was there a clash of cultures, he being nearly 7 decades old and deadly serious in affairs of the heart?

I kept silent but it seemed the classmates paid more attention.

The lecturer said: "See the heading of the first advertisement. It says 'XXX International Top All Around No. 1 Achiever For Year 2009 - XXX USA.'"

We focus on this impressive claim. In the second advertisement one week later, the heading was not presented. What was the reason? I checked my lecture notes of Estate Agency Act & Practice, Ethics & Client Care, 8/12 Rule:

CEA Regulation of Rule 8:
"ALL FORMS of an advertisement must be supported by proof".

Then the lecturer pointed to the bottom of the first advertisement which stated:
"Senior Marketing Director" and then to the second advertisement which stated: "Senior Team Director". Why?

CEA Regulation of Rule 8:
ALL FORMS of an advertisement must be supported by proof
If necessary, VETTED/APPROVED by the Estate Agent.
I would infer that the Estate Agent did not now approve of the position of "Senior Marketing Director".

The 3rd change he showed was "Just Sold by ..." in the first advertisement was replaced by "My Achievement for the Year 2010". Why?

CEA Regulation of Rule 8:
All advertisements to be REMOVED if withdrawn/sold/rented e.g. website. The lecturer's notes did not give newspapers as an example but this type of trumpet-blowing advertisements of past properties that had been sold had been a common practice by the more successful agents.

Going into more details as I write this report to attempt to retain some knowledge for the exam, there is another CEA Regulation of Rule 8 which states:
Advertising/Promotion/Letter MATERIALS must have
1. Name/Contact number same as in the CEA Register
2. Registration/Licence NUMBERS
3. If necessary VETTED/APPROVED by estate agent.

The 2nd advertisement did not show the Registration/Licence Numbers. So, is the R and L numbers compulsory in every advertisement?

If we cannot remember all the 12 Golden Rules, I hope my classmates can at least remember Rule No. 8 due to the reaction of the serious lecturer who would be their father for many of them, due to the age gap.

To summarise for my revision for the May 2011 exam, here are the 12 Golden Rules:

1. Knowledge of and compliance with applicable laws, practice, circulars and guidelines (laws of agency, contract, tort).
2. Due diligence and compliance with law and statutory requirements.
3. General duty to clients and public (mislead, misrepresent, lack of integrity and honesty, unethical practices).
4. Not to bring discredit or disrepute to real estate industry (I will write on an case of touting in a lawyer setting up a real estate referral company, as reported recently in the Straits Times)
5. Duty to clients in relation to signing of documents (explain meaning and consequences, seek professional advice).
6. Obligations in respect of agreements (all in writing, no blank spaces and accurate recording).
7. Conveying offers, counter offers etc. (Counter offer is not legally an offer or part of a contract).
8. Advertisement
9. Interpretation or translation if necessary (record interpreted by...).
10. Duty to avoid conflict of interests
11. Recommending professional advice where appropriate.
12. Safeguarding confidential information (e.g. distress sales).

Many of the rules of ethics and client care can be applied to the veterinary practices too. For the real estate agent, he or she must be careful of mis-communication between clients and agent (all relevant contracts and services to be in writing- Rule 6). In particular, regarding Rule No.8, there should be no misleading advertisements (property not accurately described), misrepresentation (impersonating as buyer in flyers and newspapers) or advertise without proof (e.g. claiming to be a HDB specialist).

Friday, April 29, 2011

421. Put Non-Profits on the road to sustainability

Sat Apr 30, 2011 National Library Victoria St

I spend some time to read the book "ROI for Nonprofits" by Tom Ralser, 2007 as I am interested in non-profit organisation.

I don't have much time to read nowadays, due to my having to study for the CEA REA real estate course exam in May 25, 2011 (3 evenings, 2 hours, 5/8 questions, passing the exam does not mean getting the licence according to my lecturer).

Tom Ralser is a Chartered Financial Analyst (CFA) and taught finance and investments to college seniors for 7 years.

ROI (return on investment).

Tuesday, April 26, 2011

420. The hissing cat has difficulty in urination. Initiating cause due to amitriptyline?

Sunday, April 24, 2010. Bright sunshine, blue skies. Should be outdoors. I was at work at 9.30 am. 3 clients came in but they were my associate vet's clients and so I told him they had to wait as she comes in at 11 am. Suddenly a couple with a cat carrier came in at 10.15 am. They would be 4th in the queue and by the time, they get attended by my associate, it would be past 12.30 pm which meant a 2-hour wait. As they have no preference, I took over the case, thinking it was a simple case of a cat that can't pee. A commonly presented case, usually of an older male cat fed on dry food.

HISTORY. Cat, Male, Neutered, 7 years old. Could not pee 2 weeks ago. Vet 1 relieved urethral obstruction, gave one "2-week-lasting" SC injection. Cat went home. OK for first 2 days. Then difficulty in peeing. Squatted but no urine. After for around 2 weeks, the couple in their 30s consulted me for a second opinion on Sunday April 24, 2011, 10 am. "Be careful," the husband warned. "The cat is very ferocious since the visit to Vet 1." According to the wife, Vet 1 had used anaesthesia to catherised the cat at the first time. However, the second and third bladder irrigation via the catheter was done without sedation as witnessed by the wife who was called to help. The wife was unhappy at seeing her cat traumatised. "Now the cat hisses whenever he is taken to the vet," the wife said. "The vet may think that it is risky to give sedation/anaesthesia again," I said. "The cat may die from the sedation and that would be disastrous." I don't do repeat bladder irrigation but each vet has his own ideas.
Now the cat warned me with a loud hiss as I examined his backside and palpated his abdomen. There was no point traumatising the cat. So, I gave a sedation and asked the owner to wait. Was this a recurrence of the urethral obstruction?
SEDATION & EXAMINATION Weight: 6kg, xylazine 0.15ml ketamine 0.5ml. Catheter passed in smoothly. No obstruction. But the unusual problem was that the penis of the cat could not be extended. The prepuce had swollen to a ball-shaped lump. An unusual case. I took a picture.

After some massage, it was possible to extend the cat's penis and insert the catheter. There was no penile inflammation. Bladder palpation. Bladder was swollen to twice the ping pong ball size. Urine collected for analysis. No crystals. Blood, white cells and red cells, bacteria + present.
DIAGNOSIS. Feline Lower Urinary Tract Disease (FLUTD).
The owner was not prescribed oral antibiotics by Vet 1 but the wife said to me: "The cat had been given a "2-week-lasting antibiotic injection". Therefore, there was no need for oral antibiotics. However, Vet 1 prescribed an anti-depression oral medication which the cat objected forcefully. So the owners did not give him the amitriptyline after two tablets. This drug licensed use in people is for depressive illness, bedwetting (nocturnal enuresis) in children aged 6 years and over.


Vet 1's X-ray show that the bladder is large and distended. No urinary stones seen, according to the owner.




4109 - 4111. The cat can't pee again. He hisses at the owners and at me (the 2nd vet). Why? Is there a permanent cure for feline lower urinary tract disease (FLUTD)? The hissing cat has difficulty peeing again
One of the adverse side effects of amitriptyline is "difficulty in passing urine" and this is reasonable since it is used to prevent bedwetting in children. I don't use it in cats or dogs and so I have no experience with this drug. But after two tablets, the owner observed that the cat had difficulty peeing! So was this the effect of amitriptyline or not? The cat continued to have dysuria for the next 10 days and that was when on this bright sunshine Sunday morning, I encountered this interesting case. Interesting only to veterinary knowledge on the use of amitriptyline, not to the owners as it had been traumatising for them and their cat.

To make a long story short, the cat did not have urethral obstruction as the catheter went into the bladder smoothly. He was warded for 2 days. The diagnosis was feline lower urinary tract disease confirmed by urine analysis. This was an intelligent cat as he sat on the litter box all the time while warded for 2 days in the surgery. If you understand that a cat wants to be clean, he is leaking urine via the catheter and so, by sitting on top of the litter box, he does not mess up the surrounding area. Even after removal of the catheter, he still sat on top of the litter on day 3 when the owner came to take him home.

When the owner came to take him home, he hissed at the owner! So, the couple patiently took time to get him to relax and put him inside the crate. In the morning I had sedated him (xylazine 0.1 ml + ketamine 0.4 ml IM) to remove the 6/0 stitches tying his catheter to his prepuce in 4 places and take rectal temperature (fever 39.8 deg C) and to weigh him. I treated his fever with baytril and tolfedine injections SC.

According to the wife, at Vet 1, the e-collar had been taken out once and the cat pulled off his catheter but with the sutures still knotting one end to the prepuce. Therefore, she asked whether I had put an e-collar all the time. Better to use oral pain-killers for cats post-treatment as the cat is very difficult to medicate and will claw you.

In any case, I don't usually put catheters in cats after bladder irrigation, except in some cases such as this case and only for 1-2 days. I don't bladder irrigation more than once but some vets do, without sedation.

The cat will be on oral antibiotics for 12 days. I don't believe in giving one single injection lasting "2 weeks" as Vet 1 did, but if the owner can't medicate at home, this may be the alternative. Pound medicine into powder and add to sugary paste. Spread on cat's body or paws without the cat knowing it. But cats may be too smart and flick away the medicated sugar.

Close monitoring of water intake and canned food, urine analysis in 2 weeks. Change to sand litter. Continue canned SD diet for 1-3 months and urine test monthly for 1-3 months. Then canned food. No shampoo for the first week. The cat is shampooed once a month as the owners find its coat oily. "Cats seldom get bathed in Singapore," I said. I did not take blood test so as to lower the veterinary costs.

However, urine tests are important for diagnosis of FLUTD and this was done in this case as the owner wants to know what is happening. Bacterial antibiotic sensistivity tests of the urine was not done in this case but would be done if there is another episode, so as to save the owners some money as they had spent quite a large sum at Vet 1.

P.S.
1. Cause of the FLUTD
I said to the owner on the second day: "You must have given dry food after treatment by Vet 1, thus leading to difficulty in urination."
"No, I did not," the husband said.
Then he remembered that Vet 1 had given him the dry food of Hills' Prescription SD as canned ones were out of stock. So, there was a dry food involved. Could it be the dry food? Could it be the action of amitriptyline retaining the urine in the bladder and permitting bacterial infection? Could it be the sharp pelleted litter injuring the prepuce and causing it to swell and prevent ease of urination? Could it be the re-infection of the bladder after going home? Was Vet 1's "long-term guaranteed to last 2-week" antibiotic injection of Synulox (clavulanic acid and amoxicillin) ineffective since it was apparently given once only? There are so many factors causing the urinary tract infection presented to me now and so it is hard to specify one causative factor.

It is a mystery but a urine analysis is important and must be done as part of the vet's duty of care. Certainly there was bacteria and white cells in the urine, indicating urine retention had led to cystitis or was a cause of cystitis. The SD diet had acidfied the urine apparently as the urine pH was 6.5 in the test.

It is quite painful for the couple to see their cat going to the litter box many times, tried to pee and not able to do so on the 3rd day after going home from Vet 1's treatment. They decided to seek another opinion and I was present on this bright sunshine blue-skies Sunday that I would like to spend at the Botanic Gardens.

2. Follow-up 24 hours after going home on Tuesday, April 26, 2011. I phoned at around 4 pm on April 27, 2011 as the cat had a fever of 39.8 deg C on Tuesday morning (when I took out the catheter and checked the rectal temperature under sedation). I had informed the husband of the fever and asked him to observe the cat closely. I had given tolfedine injection which would reduce the fever.

The husband said: "Everything is OK. The cat ate a lot and drank a lot on reaching home. Then he became quiet and not moving much. My wife smeared the baytril antibiotic in brown sugar onto his body and he licked it off."

This was one of the tips of medication I had given to the handsome couple in their 30s.
I replied: "It is possible that she is very tired after spending two stressful nights at Toa Payoh Vets which is a new environment for her.

"She is also not hungry after eating a lot. Check whether she has fever by feeling her lower abdomen with the hand but this is not accurate. Let me know if the cat is not eating. You have the anti-fever tolfedine tablets ready. Have you bought the sand litter?"

The owner had not and would do so. I expect this case to stabilise and that the emotional coaster-ride of the couple would fade away. The veterinary costs of two vets would be over a thousand dollars but this could not be avoided since there were so many procedures and tests.

The management at home is most important as there are many causes involved in the development of FLUTD (Feline Lower Urinary Tract Infection). The causes include uroliths (stones), urethral obstruction (plugged-penis syndrome and blocked cat syndrome), infectious causes and others (unknown causes in about 60% of the cases, physical trauma to penile area, tumours of the urinary tract, congenital abnormalities, neurological problems and intentional urinary retention (common behaviour seen in cats not given a litterbox or dirty litterbox).

In this case, the sophisticated owners told me the cat was shifted to a new house and that would be the cause.

The risk factors would be

1.1. Age. Uncommon in cats less than one year old but most common in cats 2-5 years old. This cat is 7 years old).
1.2 Sex. Male and neutered cats are at greater risk of urethral obstruction as their urethra is longer and narrower.
1.3 Neutering.
1.4 Dehydration.
1.5 Dry food high in magnesium or other minerals and high in pH.
1.6 Obesity.

All the above factors are present in this case. Dehydration could be due to the lack of adequate water intake as the cat was adjusting to the new house environment. Most cats on dry cat food do NOT get FLUTD. The causes are many and therefore, amitriptyline was not the only cause of the recurrence of the dysuria. Good management at home and regular veterinary check ups are very important to prevent recurrence of the dreaded Feline Lower Urinary Tract Disease (FLUTD).

Updates and more pictures of this webpage for my blog readers:
http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm











Monday, April 25, 2011

My 3 Ninja turtles

"Eat your vegetables!" the mum would command and the child would clamp his mouth shut. All children hate vegetables, I believe. So, the same with this 8-year-old red-eared slider turtle. He would clamp his mouth shut very tightly as I tried to dose him with medication from a dropper and a syringe. I tickled his nostrils expecting him to open his mouth. No way.

Then I covered his nostril for a few seconds so that he would open his mouth to breathe and then I would drop his medication into his mouth as I did with the smaller red-eared glider I treated last week. But this 7-inchx5-inch slider held his breath and I did not want to suffocate him.

There was no way to open his mouth unlike dogs and cats whom I could grip the upper jaws and prise the mouth open. Maybe I don't have the technique as turtles are rarely treated by me since most Singaporean owners do-it-yourself treatments. In any case, I had 3 sliders in a short time.

Remember my comments about things happening in threes? I had 3 gliders with eye problems in a short time and for the past year, not a turtle or tortoise seen. It was like famine and feast in the biblical sense.

The first one was a very young one with eyes closed for a day or two and came to see Dr Vanessa. I took over the case and I treated its eyes with eye drops since Dr Vanessa was busy and from her expressions, turtles are not one of her favourite things. After that, I the young lady owner to keep the water clean.

The second one was another small one, a week before this big boy came in. It was around 4-inch by 3-inch and the owner failed to open its eyes for the last two months and so sent to me for treatment. The owner had bought eye drops from the pet shop but since the eyes would not open, how to apply the eye drops? The glider's dried prawn and commercial food and eye drops arrived with it as advised by me.






No hope, I thought. Two months and the mucous membranes of the mouth of this turtle was deadly bluish maroon. A cyanosis as if from cyanmide poisoning.

It needed antibiotics and vitamins. I opened its mouth when I pressed my finger against its nostrils and got its medicine. It opened its eyes partially on the 6th day and I sent it home for nursing. Now, this big boy just would not open his mouth despite me doing the same nostril tickling and covering as in turtle No. 2.

His owner sent him down to me for treatment as the glider's eyes remained tightly shut and swollen for the past two weeks. Dr Jason Teo received the turtle at night and left the treatment to me. I guess he's not into turtles as many vets don't really like treating this species.

"Is it Vitamin A deficiency?" the gentleman asked over the phone.

I said: "I don't know. Do you just feed the commercial turtle sticks?"
The owner said: "Usually. My mum will give some meat. I brought this turtle back from the U.S."

The turtle shell looked quite dirty and so I had the turtle four baths. Dirty cellular debris floated off the water. On Good Friday morning, I had this turtle in a blue bath tub meant for babies and let him have some morning sun for 10 minutes. I had to keep an eye on him in case stray dogs come and grab him. This time the bath water was cleaner and not polluted with brown stuff. My assistant complained to me about the turtle not co-operating in opening his mouth. We did manage to give some medication and I put him inside the crate. My assistant Mr Min advised me: "Put him in the baby bath tub with water." I said: "No, he may not be safe. What if he can climb over and fall down? Or horrors and nightmares! What if Dr Vanessa's dog eats him should he fall out of the bath tub while we are busy?

"Rule No. 1. It is always best to crate the turtle." I teach this young man who is qualified as a veterinarian in Myanmar and now works for me. I like feedback from staff as there may be new angles and perspectives. But no turtle is going to run away or be eaten while under my care.

Then on the 4th day, on a bright sunshine Sunday morning, I got the turtle out for another bath. Wow, his eyes were opened. That was great. "Should he stay one or two days longer?" the owner asked me as the turtle had just opened his eyes. "No need to," my policy is to get the animals home as soon as possible to their well loved home to recuperate. Yet, around 4 hours later, the owner texted me to say that the turtle had closed his eyes. Why? I don't know but I presumed that given the freedom of the whole apartment to wander, this turtle must have been exhausted. I advised observation. Then the owner texted to say that the turtle did open his eyes for a while. "Confine to small space," I texted back. The turtle needed rest and two changes of clean water a day and good food. No more news from the owner and I presume all are well. The owner could not be contacted by phone once and I let sleeping dogs lie.





This ends my story of my 3 Ninja turtles and I hope you enjoy reading them. I got pictures of two of them for you to appreciate.

418. Sudden onset "Shortness of breath and panting" & toilet-training a puppy

E-MAIL TO DR SING DATED APRIL 26, 2011

On Mon, Apr 25, 2011 at 1:03 PM, ...@yahoo.com.sg> wrote:

Hi Dr Sing,

it's me again. Actually I've a question in mind and was wondering if you're able to advise me. My Cookie has just turned 1 yr old 2 months ago. Every 2-3 months, he would pant very hard and gasping for breath for about 1 - 2 mins, so far I've seen him like that for about 3 times, however after every incident, he'll return to normal again like nothing has happened.

Is this common? Does dog gets asthma as well? We often bring him for long walks and he seems to enjoy and doesn't pant at all. I'm getting very worried, should I bring him to the vet asap?

Thanks & Regards,
XXX

E-MAIL REPLY FROM DR SING DATED APR 26, 2011

Hi

I thank you for the email. Cookie's condition is not common. It is hard to diagnose what is the problem without examination and X-rays (pharyngeal area, heart, lungs). Consult your vet asap if the problem persists as it is not easy to diagnose.

UPDATE: APRIL 26, 2011. It was one year ago that I got the following e-mail from Cookie's owner. Toilet-training queries by e-mail from her and my reply in CAPITAL LETTERS. It is rare to get the owner's point of views and problems as regards toilet-training so well written. As the situation for each owner, the puppy and living space is unique, affecting the toilet-training success, there is no one-stop solution but the basic principles of confinement, perseverance and positive reinforcement training are necessary for success.


On Tue, Apr 27, 2010 at 5:36 PM, ...@yahoo.com.sg> wrote:

Hi Dr Sing,

I’ve been reading up your toilet training blog and find it very useful when toilet training my puppy. However, I still have a few queries. I’m a first timer raising up a puppy and hence has been quite stress up. I’ve accompanied my puppy for the first 3 days (almost keeping him within my sight) and observed the following:

My puppy is a mix breed of Chihuahua and Pomeranian, 3 months named Cookie. He was with us since 24 Apr 10.

The pet shop owner came with a crate with wire flooring and a pee pan below. Initially I try to carry Cookie to the bathroom after nap/food with newspapers laid on the floor but was unsuccessful. Cookie usually poos twice a day, 1 in the early morning and another one in weird timing. I realized that he only pees in the middle of the crate; I supposed it’s due to the urine smell. He pooed everywhere though.

COOKIE IS USED TO THIS WIRE FLOOR SYSTEM. HE WAS IN THE PET SHOP WITH SUCH A SYSTEM. AS TO POOPING EVERYWHERE, ARE YOU SURE? Where is his sleeping area? Is the crate too small?

XXX: So far we've not really let him outta his crate for too long, only wanted him to get some exercise and will put him back aft 10 - 15 mins. We try to bring him outta his crate at least 3 times a day. He drinks a lot too esp aft play outside the crate. As for the crate size, please advise if it's too small or too big based on the attached pictures.

CRATE SIZE OK

QUESTION 1: Do you think Cookie will poo in the middle like where he used to pee if I spray those anti-pee/anti-poo spray (given by my friend) on those area that I don’t want him to do pee/poo? The spray has a strong smell and I'm contemplating to use it.

YOU CAN TRY. THE BEST IS TO ENSURE THAT HIS SLEEPING AND EATING AREAS ARE FURTHEST AWAY FROM THE POOPING AREA AND

THE MIDDLE OF THE CRATE.

XXX: I tried spraying on the red rubber mat and Cookie refused to eat after that. I guess its due to the pungent smell. He continues his eating after I wiped the mat.

SPRAY IS NOT VERY USEFUL IN MANY CASES

QUESTION 2: It seems like he’s trained to pee/poo in the crate. Is that a good idea? It’s ideal for us since we are working. However, if we bring Cookie out eg. to a friend’s place, will he pee/poo everywhere since there’s no crate?

YOU MAY NEED TO BRING YOUR CRATE ALONG. COOKIE WILL PEE AND POOP ANYWHERE IF LET ALONE FOR THE FIRST 2-4 WEEKS as he is not fully house broken.

XXX: how do we determine if a puppy is fully house broken?

WHEN THE PUPPY KNOWS WHERE TO PEE AND POOP IN AREA REQUIRED BY THE OWNER. E.G. PAPER TRAINED PUPPY WILL ELIMINATE ON PAPERS ONLY AT ALL TIMES, UNLESS THERE IS NO PAPER. OR HOP INTO CRATE WHEN HE NEEDS TO ELIMINATE AND NOWHERE ELSE. OR TO A SPOT IN THE GARDEN.

QUESTION 3: Cookie seems to be stepping hard on his own poo when all of us are asleep. He’s also seems to be shifting them around. I can see portions of it at different areas of the crate. We also caught him eating his own poo once. How do we prevent such action from happening especially when we are all asleep?

EATING STOOLS IS A COMMON COMPLAINT. YOU MAY NEED TO REMOVE STOOLS PROMPTLY. IF NOT PRACTICAL, YOU MAY NEED OTHER METHODS I had mentioned in my blog. These are not guaranteed to succeed.

XXX: Will try a few of the methods and update you on the improvement.

QUESTION 4: When I let him out to play in the living room, will it be better to leave the crate door open and let him run to the crate to pee/poo? YES. HOWEVER, MONITOR HIM CLOSELY SO THAT HE DOES NOT PEE/POOP OUTSIDE THE CRATE. KEEP ALL DOORS OF BEDROOMS CLOSED.

XXX: So far he hasn't poo outside but has an accidental pee just outside the toilet.
Or will it be better to lay newspapers on a pee pan (given by my friend) with Cookie’s urine smell at a corner so he can pee/poo when he’s out playing and need not rush back to the crate? DECIDE ON ONE METHOD - CRATE WITH WIRE FLOORING OR NEWSPAPERS FOR THE NEXT 2-4 WEEKS IF YOU WANT EARLY SUCCESS. In the Crate method, your dog will then use the Crate as the toilet area and outside as his den in 2-4 weeks, in most cases. So, you just clean the crate. Later, you can buy the GRATE + PEE PAN which is actually the same as the lower half of your present crate, without the enclosed vertical walls.

XXX: "In the Crate method, your dog will then use the Crate as the toilet area and outside as his den in 2-4 weeks, in most cases. So, you just clean the crate." When you said "outside as his den in 2 - 4 weeks", are you saying that Cookie will want to sleep outside of his crate in 2 - 4 weeks?

DEPENDS ON THE TYPE OF TOILET TRAINING PROVIDED BY THE OWNER IN THE FIRST 2-4 WEEKS.

MOST PUPPIES WILL SLEEP OUTSIDE THE CRATE AS THERE IS FREEDOM. JUST GOES INTO THE CRATE'S WIRE FLOORING TO PEE AND POOP. OTHER SMALL BREEDS WILL SLEEP INSIDE THE CRATE AND ELIMINATE OUTSIDE (ON NEWSPAPERS).

As for Grate & Pee Pan, can I just used the current pee tray and removed the vertical walls since it's similar to the one you recommended?

OK

I've let him out of the crate twice on 26 Apr and surprisingly, he climbs back to his crate when he's thirsty after running a few rounds. I see that as a good sign of recognising his own den?

FOCUS ON CRATE TRAINING FOR THE NEXT 2-4 WEEKS, SINCE YOU ARE WORKING AND HAVE NO TIME. IF YOU START PAPER-TRAINING, YOU WILL NEED TO FOCUS ON PAPER TRAINING. The puppy gets confused as to what you want.

XXX: Will heed your advice and focus on crate training for the next 2 - 4 weeks.

YOUR PICTURE SOLVES THE MYSTERY OF WHY YOUR PUPPY PEES EXACTLY IN THE CENTRE. THE PUPPY 'FEELS' THE FLOORING AND IS USED TO THE WIRED FLOORING OF THE PET SHOP. SO HE PEES IN THE CENTRE SINCE YOUR LEFT 1/3 AND RIGHT 1/3 HAS RUBBER MATS WITH A DIFFERENT FEELING.

IN THEORY, YOU SHOULD HAVE ONLY RUBBER MATS ON THE RIGHT 1/3, THE WATER BOTTLE ON THE RIGHT 1/3 FRONT PART AND FEEDING NEAR THE WATER BOTTLE.

SO THE LEFT 2/3 IS THE WIRE FLOORING INTENDED TO BE A TOILET AREA. WIRE FLOOR GRATING. THIS WILL NOT CONFUSE THE PUPPY AS IT DOES "FEEL" THE FLOORING AS WELL AS DETECT THE URINE SMELL IN THE NEWSPAPERS BELOW FOR PEEING AND POOPING.

I HOPE YOU KNOW WHAT I AM WRITING ABOUT.

Sorry for the long post and thank you for the time to read my email, I would be very much delighted to receive your reply J

Regards,

XXX

--------------------------------------------------------------------------------------------------------
On Wed, Apr 28, 2010 at 10:42 PM, ........@yahoo.com.sg> wrote:

Hi Dr Sing,
as promised, I've attached 2 pictures of Cookie's crate & pee pan. By the way my mum is a housewife but she goes out like 2 - 3 days a week and hence Cookie is not under full supervision on these days. I'll have to follow the way a working adult trains his/her puppy.

Hope it helps. I've also added further comments in my email to you (her comments are in the above email).
From: Kong Yuen Sing <99pups@gmail.com>
To: ...@yahoo.com.sg>
Sent: Thursday, 29 April 2010 05:34:35
Subject: Re: Toilet Training My lovely darling Cookie(Chihuahua x Pom)

SAW ONE PICTURE.

FORTUNATELY, YOU EMAIL PICTURES AS I WAS WONDERING WHY YOUR PUPPY PEES IN THE CENTRE ALL THE TIME. FROM YOUR PICTURE, YOU HAVE RUBBER MATS WITH HOLES ON THE LEFT 1/3 AND RIGHT 1/3 WITH THE MIDDLE BEING THE ORIGINAL WIRE FLOORING OF THE GRATE. IN THE LEFT 1/3,

THE BACK HALF OF THE LEFT IS THE POOPING AREA, THE FRONT PART IS THE FEEDING AND WATER AREA.

THE BACK HALF OF THE RIGHT IS THE SLEEPING CLEAN AREA.

THE RIGHT 1/3 IS THE CLEAN AREA AND SO HE DOES NOT PEE AND POOP THERE. HOWEVER THE LEFT 1/3 IS ALSO THE DRINKING BOTTLE AND FEEDING AREA. SO THE POOR PUPPY HAS TO WALK DIAGONALLY PAST THE SOILED CENTRE (WHERE HE PEES) TO GOTO THE WATER BOTTLE ON THE FRONT RIGHT.

I WILL RECOMMEND THAT THE FRONT OF THE RIGHT 1/3 AREA BE THE AREA WHERE THE PUPPY EATS AND DRINKS. THAT MEANS THE WATER BOTTLE SHOULD BE ON THE RIGHT, NOT ON THE LEFT.

IF YOU CAN, SEND ME 2 PICTURES IN .JPG FOR MY RECORDING PURPOSES.

E-MAIL REPLY FROM DR SING DATED SEP 23, 2010

From your email, I have the following observations:

1. Cookie is an adult dog now. He can be neutered anytime.
2. As an adult male dog, he wants to keep his den (crate) clean and so he waits till you let him out to eliminate.
3. As a male dog, he wants to urine-mark his territory (natural instinct). So he pees everywhere. It is not that he "forgets" but that when you are around, he has to behave himself otherwise he may get punishment.
4. As a male dog, he may want to mark his territory with poop although most male dogs mark with urine.

5. Solutions:
5.1. Neutering as early as 6 months may reduce his urine-poop marking but you have delayed this. Still it is not too late although it may not be as effective.

5.2  Neutralise your flooring with white vinegar: water in 3 parts to 1 part respectively.

5.3  Confine the dog to his crate or to a small toilet area for the next 264 weeks after neutering.

5.4 Every day, twice a day, after meals, bring him outdoors to eliminate. Praise and reward with dog treat when he eliminates outdoors in an area not used by members of the public.

5.4.1  Pick up the poop with papers and dispose properly. Going outdoors is a positive "reward" and he will learn not to dirty the whole apartment which is his "den". This takes patience and time. Many owners find the above-mentioned tips to be useful.  

6. Adult dogs are harder to toilet-train but you need to have a routine for him now. He must have realised that you are his "subordinate" and this is natural for dogs. Dogs need a firm leader and I believe you are gentle towards him when he is growing up. Now, he thinks you are his follower. Therefore, you need to be a leader and start with him going outdoors at least once a day (morning and/or evening). 

As blogger.com can't do proper tabulations, goto:
http://www.bekindtopets.com/stories/20110434chihuahuaxpom-toilet-training-emails-drsing-toapayohvets-singapore.htm

to read in proper layout.

Friday, April 22, 2011

417. Negligence lawsuit

I just read a Straits Times' report on a negligence suit against the doctors of Kandang Kerbau Hospital. The plaintiffs were the parents of a child who is not normal now since the doctors were alleged to have shifted the position of the endotracheal tube during the movement of the child. The endotracheal tube brings oxygen from the machine to the lungs. By shifting the position of the endotracheal tube, the oxygen was not delivered to the child and the child's brain was damaged, making her now unable to look after herself.

Was there medical negligence? Was there a lack of care by the doctors?

I refer to my real estate REA notes to pass my examinations in late May, some 6 weeks later by reviewing this real case.

1. WAS THERE MEDICAL NEGLIGENCE?
LAW OF TORT - NEGLIGENCE
To succeed in an action for negligence, the plaintiff must show that:
- the defendant owes him a duty of care - YES
- the defendant has beached that duty of care - NOT ADMITTED
- his breach causes damage/loss to the plaintiff - YES
- the damage/loss is not too remote (not controllable, not foreseeable, not an expert on a particular subject matter) - YES. THE DOCTORS WERE EXPERTS IN CARDIO-RESPIRATORY FIELD


2. WAS THERE A LACK OF CARE?
LAW OF TORT - DUTY OF CARE - TEST
Duty of Care - "But For" Test
A test of duty of care is: "You must take reasonable care to avoid acts and omissions that you can reasonably foresee, would be likely to injure your neighbour"

The cause of damage is established by the "but for" test:
The court will ask - would the plaintiff (patient, buyer, tenant, owner) has suffered the injury but for the defendant's (doctor's, agent's) negligence?

LAW OF TORT - DUTY OF CARE - BREACH
Standard of Care - Breach.

More important in professions requiring special skill or expertise, the person must exercise a reasonable standard of care that must be measured.

The standard of care is measured by the "reasonable man" test:
Whether the defendant's conduct fall below the standard of care which is expected of the reasonable man.


CONCLUSION
The Kandang Kerbau Hospital settled out of court (High Court's claim for damages must be above $250,000) without admitting liability and this was accepted by the parents. Otherwise, legal fees would be much more and the parents may win or lose the case.

P.S
The above incident reminds me of one case some 30 years ago. A vet spayed a dog. The dog became comatose during surgery, according to the operating vet who was not in private practice at that time.

The owner (a leading flight stewardess) was asked to take the dog home as the vet could not do anymore. I saw the dog. It was paddling and not able to live normally. So, was this a case of deprivation of oxygen during the spay or some reactions? I don't know. Many complications can occur during anaesthesia, in medicine and surgery and the only advice I can give is that one must not be complacent.


An endotracheal tube in veterinary medicine is shown below:




something wrong with blogger's layout: The picture is at:
http://www.sinpets.com/dogpix/20081124Tooth_ache_Old_Dalmatian_Bites_People_Singapore_ToaPayohVets.jpg

416. Good Friday's "Source Code"

Good Friday, April 22, 2011

A bright sunshine blue-sky day. The lady with the 2nd Dachshund was at Toa Payoh Vets when I arrived at 9.30 am to operate on her 2nd Dachshund (10-year-old male neutered) with two growths on the right side of the body. One appeared to be a large lipoma similar but 10% smaller as in the first Dachshund sibling I operated successfully on Tuesday.

Somehow, I felt that I was repeating a scenario as if I was going back in time and improving myself with this second repeat electro-surgery to remove a lipoma and another tumour from the Dachshund.

As if there was a Divine Power presenting me a repeat of my first surgery - report in "A fast-growing tumour in an old Dachshund - a lipoma or liposarcoma?" with website at:

http://kongyuensing.com/folder5/20110338lipoma-liposarcoma-old-dachshund-singapore-toapayohvets.htm

- which was done on the same breed (sibling Dachshund) at the same time (around 10 am), in the same place (Toa Payoh Vets operating room) and with the same procedure (xylazine 0.2 IM and isoflurane gas, then electro-surgical excision to excise the big lipoma out to show the owner, no bleeding during the operation due to electro-surgery). But the dog had dental scaling as requested by the owner. The dog worked up uneventfully as if from a nap and the happy owner took him back around 2 hours later (same time in going home and same happy ending).

However this time, I had the big lipoma to show to the owner as in the previous case, the Laboratory courier came to take it to the lab before the owner came 2 hours after surgery as she did for the Good Friday operation.

In the afternoon, I took time off to watch the movie "Source Code" which is a science fiction which reminds me of my above-mentioned Dachshund surgeries. As if I had experienced "Source Code" in the canine version. I will elaborate further below.

In the Source Code movie, Captain Colter Stevens is a decorated army helicopter pilot has had died. His body is kept alive and a source code (computer software) is inserted into his brain. The scientist sends him back to the past by activating the source code. He then appears as a teacher (another person) inside a moving train where the bomber is present but he has to find out the identity of the bomber and where the bomb is to prevent a second explosion which will follow this explosion. The first time he is sent back to the past, he cannot find the bomb or the bomber and the train explodes killing everybody including the teacher and a pretty girl who secretly loves this teacher.

At another time, he finds the bomb and takes the handphone attached to the bomb. But the train still explodes killing everybody. He is sent back to the past again. After a few times of going back to the past, he learns what to do and identifies the bomber. The story has a happy ending as he lives in the alternate universe with this girl he appears opposite her on the train and saves her from death. He gets to live and fall in love with this girl in an alternate world since he has prevented the first explosion.

P.S. My repeat surgery is a short canine version of the Source Code. It is not as thrilling as this popular move and will never be made into a film. There is only one repeat of the surgery for me, unlike Stevens but there is the happy ending. The dog owner as both Dachshunds are alive at the end of the surgery and she may have prevented nasty large liposarcomas from forming if she has had delayed surgery by a few years as the big lipomas were growing fast. As the outcome was great, I am also very happy as old dogs are very high anaesthetic risks and many vets will prefer not to operate.

P.S. The smaller tumour of around 3 cm x 3cm under the skin and near the breast looked yellowish. It could be a mammary tumour. I made a large excision and removed the nipple as well. I could see a small yellow spot of less than 2 mm x 2mm in the muscle area beneath this skin tumour. This was excised. Male dogs do get breast cancer but rarely. I did not send this small tumour for histopathology to save the owner some money as the lump was really small. Only this woman could detect it. It was "nodular" and present in the mammary area, like those of firm small starting breast tumours in the female dog.

I advised Hills' R/D diet for the two dogs and if that prevents lipoma formation by slimming the dogs down, I will let readers know in 2 years' time. These two dogs should live past 18 years of age as they are healthy at 10 years of age based on health screening of their blood and general physical examination.

I don't look forward to doing surgery of old dogs as it is not worth taking anaesthetic risks. These are high stress surgeries and I don't tempt fate. It is just too emotional for the owner, her family members, myself and my staff whenever a dog dies on the operating table.

The owner did bring her other dog to enquire about the backside bleeding. "It is not a problem," I said. The wound had closed and the bleeding was minor but present.

E-mail Research on a poop collector

E-MAIL TO DR SING DATED APR 22, 2011

2011/4/22 ...@hotmail.com>

Hi,
I would like to collect some data for my DnT research for 'o' levels. I am making a poop collector for my 'o' levels. It is mostly about dogs and their poop.


- What are the more common breed found in Singapore?
- What is it's size?
- What is their poop size?


Thank you for your valuable information :)



E-MAIL REPLY FROM DR SING DATED APR 23, 2011

I am Dr Sing from Toa Payoh Vets.

More common breeds found in Singapore in 2010 are the small canine breeds. These include Shih Tzus, Malteses, Miniature Schnauzers, Poodles, Silkie Terriers and Jack Russells and their crosses.

Sizes of small breeds - Usually weigh 10 - 30 kg. Height is usually around 14 inches.

Poop size - If you refer to one well formed faecal lump passed intact, I will say that the size is around half the size of a ping pong ball of around 3 cm x 2 cm x 2 cm. However, the small breed dog passes more than one lump at any one time.

It is best you get your hands dirtied and really measure yourself as this is the correct approach to research. Some commercial poop collectors are just too small to collect all the poop at one go. You really need to be hands-on to be a good researcher.

414. Ear haematoma?

EMAIL TO DR SING DATED APR 21, 2011

Hi there

I've never been to your clinic. However, I would like to enquire if you all do dispense oral medication for ear infection/hematomas-related illness. My cross-breed dog (quite similar to the Miniature Pinscher) is 13 years old and she is quite aggressive towards strangers. She had been having her ear infection for some time, and recently there's been a lump growth just at the bottom of the infected ear, which I suspected is hematomas.

I was wondering if it would be possible to obtain oral medication for this illness without having to bring my dog in, as she is quite averse to travelling and towards strangers.

Please advise. Thanks!


E-MAIL REPLY FROM DR SING DATED APR 21, 2011
I am Dr Sing from Toa Payoh Vets. It is best to check what the problem is. An ear haematoma is a swelling with blood inside the ear flap. Send two images by email as soon as possible.


E-MAIL TO DR SING DATED APR 23, 2011
Dear Dr Sing

Thank you for your prompt response!

I will try to describe her condition as best as I can. Thus far, her ear has been giving out smelly discharge, which are slightly brownish/reddish in colour. The discharge is usually in liquid form. She tends to whine as she try to scratch her affected ear. Recently I've noticed that the discharge is not as much as before, in fact, I do believe that there hasn't been any discharge these two days and that her ears are relatively dry. Though however, the smell still persist. Admittedly, it is not as strong a smell as before.

Only quite recently did I notice the lump just below/behind her ear. It was quite "hard" when I touched it and it does not seem to cause her any kind of pain when I touched it. She does not have floppy ears.

I have also attached some photos of my dog for your preliminary viewing. The lump is on her right side, just below/behind her ear. I've also taken close up pictures of her affected ear. Pictures taken from behind makes the "lump" appear slightly bigger than it really is as her hair was sort of sticking out in the area.

Thank you
(Name of Owner)


E-MAIL REPLY FROM DR SING DATED APRIL 23, 2011

Thank you for your pictures. From your images, the lump at the bottom and back of the right ear appears to be

1. a haematoma due to the dog pawing his ears to relieve himself of the intense pain
2. an abscess due to infection by bacteria of the haematoma
3. a fast-growing malignant tumour since you describe it as "hard" and not painful and the dog is at the age when tumours are common.

Ideally, large haematomas and abscesses should be incised and drained to prevent infection by bacteria and pain which you believe is not painful to your dog but it actually is. Malignant tumours are best resected (removed) when they are smaller in size. In brief, surgery is advised.



Ferocious dogs can still be sedated and anaesthesized for the surgeries. A dog transport man can bring your dog to the vet for surgery. There are anaesthetic risks (of death) involved in sedation and anaesthesia of an old dog. An aggressive old dog poses higher risks. The alternative is to wait for the lump to subside if it is a haematoma and not causing pain. You will have to decide yourself as to what to do as the anaesthetic risks of death are higher in old dogs. Pl phone me at 6254 3326 for appointment or for more queries.

Thursday, April 21, 2011

413. Bitten by a tranquilised dog

I took my assistant Mr Min to a Toa Payoh General Practitioner on Thursday Apr 22, 2011. He was bitten twice by a sedated dog while helping Dr Jason Teo to remove maggots from it yesterday evening.

He showed me his two palms with dog bite wounds. One was bandaged. In my car, he recounted that he was once bitten in his finger by a turtle while working for a vet in Malaysia. "This turtle is not seen in Myanmar," he said. "Its mouth was very low and when I held it, it bit my finger."

"Next time, put a towel over the dog's head instead of trying to muzzle him," I advised as he got bitten while trying to muzzle the sedated dog.

412. Puffy and closed eyes for 2 months in a red-eared slider

Many vets prefer not to treat the puffy & closed eyes red-eared sliders. In Singapore and all over the world, this condition is most common. It is said to be due to insufficient Vit A. In my observation, it is the poor quality of water.

For bad cases, I advise in-patient treatment. It takes over 2 weeks to get the eyes open if the case is moderately serious. See one case below:






Tuesday, April 19, 2011

411. A fast-growing backside tumour in an old Dachshund - a lipoma or liposarcoma?

"The lump on the right backside grows quite fast," the lady owner pointed to a 1.5 x 2 cm globular swelling to the right of the anus. "There are 4 other smaller lumps."
She was concerned about the large lump as it grows bigger every day. Could this be a liposarcoma (malignant growth) instead of a lipoma? Although middle-aged and old dogs, overweight female dogs do develop lipomas which are benign, I don't ask the owner to wait and see approach.

In one instance, Vet 1 had asked the owner of a Labrador Retriever to wait and see when the owner complained about a small globular growth above the neck of the dog. As typical of the busy Singapore owners, the owners waited till the lump becomes half the size of a tennis ball. When I saw it, it was a malignant tumour as it recurs after excision. "Well, Vet 1 had said that there was no need to remove the tumour when it was small," the owners said. Eventually, the dog had to be euthanased. From this experience, it is best NOT to advise the owner to wait and see. Give the owner the option to get the tumour resected and let her decide. The vet should not assume that every tumour under the skin is a lipoma and is benign.

In this female spayed Dachshund of 8.5kg, the owner had knowledge and asked me to operate. She was worried about the anaesthetic risk. A blood test showed the dog to be healthy for anaesthesia. Still the risks of death on the operating table are made known to her. She accepted the risks.

"Don't ask the vet to perform surgery during weekends or public holidays as the vet is busy and may need to rush through the surgery," I advised her and most clients that any rushed anaesthesia and surgery will not be in the interest of the patient.

I operated on April 19, 2011, a Tuesday morning at 10 am as scheduled and the owner arrived early. No food and water from 10 pm the night before. She used a marker pen to ink the 5 lumps as instructed by me. I still took one hour in total just to remove 5 fatty tumours and that included preparation, IV drip and surgery. The electro-surgery took around 30 minutes. Can't be shorter.

SEDATION
0.2 ml xylazine IM. My new assistant Mr Min asked if I wanted to give xylazine IV as I sometimes do. "No," I said. Isoflurane gas by mask was smooth and uneventful. The dog slept like a log. Intubated the dog to get oxygen and gas in. The anaesthetic machine was not leaking gas after industrial glue was applied to the hairline crack in the base tubing 2 days ago. 0.5 - 2% isoflurane gas was sufficient. "Keep to 0.5% and not less," I said to my assistant as he knew that the less the safer for the patient. But too little may lead to the dog waking up and delaying my surgery! A good assistant during anaesthesia is worth his or her weight in gold as vets don't have the luxury of the tax-payer's money to have an anaesthetist and the best equipment like the Singapore General Hospital.

ELECTRO-RESECTION
I like electro-surgery for such cases. No bleeding at all when I cut the skin of over 3 cm long to expose the pure white globular fatty tumour of 1.5 x 2 cm in size. Not one drop of blood. If you use scissors, you need to undermine the skin. The fine wire electrode just skim below the skin and the fatty tumour parted. I excised the base of this tumour attached to the muscle layer. I could see small red blood vessels of around 2 mm supplying this tumour with nutrients. This could be a liposarcoma as it grows fast.

Still no bleeding after I excised from the base of the skin to the top of the muscle layer and brought out the whole tumour intact. That is the usefulness of electro-surgical electrode (see image). There is no need to use scissors to undermine the skin and damage this fragile fatty tumour, pure white like snow and fragile too.

The owner came at around 11.30 am. The courier man had just taken the tumour inside the formalin bottle to bike back to the laboratory. So I could not show her but I have the image to show her. The other 4 small pieces of 3mm x 5mm were discarded as I did not keep them. However, she could see the stitched areas (3/0 absorbable sutures, horizontal mattress for the backside and simple interrupted for the others)

DOG POOPS
Unfortunately the dog started pooping. Brown solid stools started coming out from the anus. Surgery stopped and stools removed. Should have asked the owner to bring the dog to the toilet at home or plug the rectum.

"Is the dog awake?" the owner came at 11.30 am expecting a drowsy old dog. Well, this was the first time I met her and so she would have known about dog anaesthesia done in other clinics that use injectable IV anaesthesia. Isoflurane gas always allow the normal healthy dog to wake up within 10 minutes after completion of the surgery. As if it had a good nap. The surgery was not particularly painful but I gave the painkiller tolfedine SC and oral for the home.

"Yes," I said. "She woke up very fast after the end of anaesthesia." Xylazine 0.2 ml IM is a very low dose for a 10-year-old overweight Dachshund of 8.5 kg. I did not use xylazine IV this time as IM would be safer in an old dog, in my opinion.

"I had excised the 4 smaller tumours completely with their skins," I explained to the owner. "The backside tumour is large and if I removed it with the skin, there will be a big hole and the hole may not heal. So, I removed as much as possible under the skin and above the muscle. If it is malignant, it may recur." It is best to communicate this to the owner. The skin wound was over 5 cm long just to expose this 2x1.5x1.0 cm tumour and so there would not be enough skin to close the wound properly. I don't want a dog with a big gap in the backside due to the non-healing of the wound as this area is a high-tension area making wound healing difficult.

"Can you operate the other Dachshund? He has only 2 tumours similar to this dog?" the lady in her 40s asked. Red blood had oozed out from the dog's backside now despite the two horizontal mattress stitches closing the wound. "Your blouse and your handbag is stained with blood," I told her. "It does not matter," she said. The dog was alive and that was what mattered in her world.

She had earlier wanted two dogs done at one day. There are pros and cons for the vet. Pros - revenue comes in and client may go to the competitor if there is a delay. Cons - rushed job, not in the interest of the dog as mistakes in anaesthesia can result in the dog's death.

"It is always best not to stretch the vet as he has other surgeries and things to do in a day," I tried to educate this lady. I had asked her to bring just one dog today for the simple reason that I could focus on this dog alone and not be distracted.

I also did not want her to be waiting outside the reception room while I operated as to maintain a peace of mind during operation and not having a worried owner pacing outside the operating room.

"Well, it is best not to tempt fate," I told this personable lady. "Your operated dog is alive and well. It is not a guarantee that old dogs undergoing anaesthesia will survive and so it is best not to do another one on the same day. I am actually worried when I operate on old dogs! I don't even look forward to any old dog surgery." It is not that I am superstitious or can't do the 2nd surgery. There was no emergency for the 2nd dog to be operated on the same day and I do have a lot of things to do.

"Thursday will do," I said. Well, the lady was busy on Thursday. "How about Friday?" she asked. "If you come early on Good Friday at 9.30 am, I will operate as most clients don't come so early." However, I can understand that the owner is worried about the tumours in the sibling Dachshund becoming malignant through delay in surgery and she preferred me to operate. I had assigned Dr Vanessa to operate as this is a simple surgery. It is the anaesthestic death that the owner is very worried about and this must be understood.

Although there will be just 2 small fatty-like tumours, the whole procedure of preparation before op, sedating and giving the isoflurane gas and the IV drip and surgery can take 45 minutes in the 2nd dog.

No wonder, many vets just give injectable anaesthesia. No need to "waste time". I prefer isoflurane gas as it is much safer and the dog wakes up fast. But it sure takes 4 times as long. But in the end, the owner just wants a live dog and giving the owner a living dog is what she wants. Isoflurane gas gives a high safety margin and so I seldom use injectable anaesthesia in old dogs or young ones.

Injectable anaesthesia is also safe but it needs topping up in small amounts if the surgery takes longer than expected. A higher risk is involved in using injectable compared to isoflurane gas but usually a very small amount is injected and that is quite safe.

Well, each vet has his own choice but deaths on the operating table simply ruins a vet's reputation as owners spread the word and so, over the years, I rarely use injectable anaesthesia. It is preferred that other vets do the old-dog anaesthesia and surgery!








P.S LIPOSARCOMAS are uncommon malignant tumours of the fatty tissue. As this lump grew fast, the owner agreed to the histopathology to be done by the Lab.
Classified as low, intermediate or high-grade liposarcomas. With low and intermediate grade, the risk of spread to other parts of the body is low. With high-grade, the risk is much greater.

UPDATE APRIL 22, 2011
Histopathology results: A lipoma with no malignant cells seen. This is good news for the old Dachshund.

410. Vicarious liability & Duty of Care

Vicarious liability is a doctrine of English tort law. Employers will be held liable for the wrongdoings of their employees while the employee is conducting his duty. Intentional wrongdoings not in the course of ordinary employment were historically not the employer's liability.

But now, the employer is vicariously liable if the employee's intentional wrongdoings (e.g. deceit, fraud or sexual assault) is closely connected with the employee's duties.

EMPLOYER'S LIABILITY
Employers are vicariously liable for negligent acts or omissions by their employees in the course of EMPLOYMENT. For an act to be considered within the course of employment, it must either be authorised or be connected with an authorised act such that it can be considered a mode, though an improper mode, of performing it.

COURTS will sometimes distinguish between an employee's "detour" or "frolic". For example, an employer is vicariously liable if the employee had gone on a mere detour in carrying out his duties. If an employee acts in his own right rather than on employer's business, the employer is not liable for the employee's frolic.

Generally, an employer will not be liable for assault or battery committed by employees unless the use of force is part of their employment (e.g. police officers).

However, the employer of an INDEPENDENT CONTRACTOR is not held vicariously liable for the tortious acts of the contractor, except where the contractor injures someone to whom the employer owes a non-delegable DUTY OF CARE such as where the employer is a school authority and the injured party is a pupil (e.g. principal abusing the child on a field trip).



DUTY OF CARE
is a legal obligation for an individual to conform to a standard of REASONABLE care
while performing any act that could foreseeably harm others.

THERE ARE 4 ELEMENTS - LAW OF TORT - NEGLIGENCE
To succeed in an action for negligence, the plaintiff must show that:
1. the defendant owes him a duty of care.
2. the defendant has breached that duty of care
3. the breach causes damage/loss to the plaintiff
4. the damage/loss is not too remote (not controllable, not foreseeable, not an expert on the particular subject matter).


It is the first element (defendant owes him a duty of care) that must be established to proceed in an action of NEGLIGENCE. The plaintiff must BE ABLE TO SHOW a duty of care imposed by the law which the defendant has breached.



THE STANDARD BY WHICH DUTY IS MEASURED
Once a duty exists, the plaintiff must show that the defendant has BREACHED IT.
This is the 2nd element of negligence. Breach involves testing the defendant's actions against the standard of REASONABLE PERSON. This varies depending on the facts of the case. For example, doctors will be held to reasonable standards for members of his profession rather than the GENERAL PUBLIC, in negligence actions for MEDICAL MALPRACTICE.

Once the appropriate STANDARD has been found, the BREACH is proven when the plaintiff shows that the defendant's conduct fell below or did not reach the relevant STANDARD OF REASONABLE CARE.

However, if the defendant took every possible precaution and exceeded what would have been done by an REASONABLE PERSON, yet the plaintiff was injured, the plaintiff cannot recover in negligence.

Monday, April 18, 2011

Sunday April 17th - interesting cases

Bright sunshine and blue skies. Sunday morning April 17th, 2011

Started work at 9.30 am and finished at 6.00pm with Dr Vanessa.

1. Shih Tzu bites till the paws and feet bleeds. Very distressed to see a dog going at its body and feet. E-collar helped but bleeding stains apartment. Couple saw Vet 1 twice but no resoltion. Expat husband phoned Vet 1 today (Sunday) but no response. "When Vet 1 returns call," the husband said to me, "I had already phoned Toa Payoh Vets for an appointment."

"Skin diseases are not easy to cure in many cases," I said. I handled this case as the leading vet with Dr Vanessa as it would be an emotional case and I prefer to take the lead. Dr Vanessa was OK with this approach.

2. Rabbit with big jaw abscess. I asked my vet whether she would operate. She passed. So I did it the next day.

3. Three female SPAYED dogs with skin disease.
1. Low platelet. Lots of yellow pus in vulva. Why?
2. Bites flanks both sides. Alopecia. Endocrine? Vulva very small (spayed very young). Reddish.
3. Old dog. Health screening. Blood test. Vulva normal pink and size.

409. Entropion in the Sharpei can be cured if the owner knows

EMAIL TO DR SING DATED APR 19, 2011
Hi Judy,

I have a 6 years old male Shar Pei and have been having watery
eyes and yellow sticky discharge.
I am cleaning him a few times a day with eye wash and the problem
keep coming back.
I understand that surgery on the eye lid is necessary to stop this problem.
Can I know what will be the total cost for this surgery. And how long do I
have to leave him there.

Thanks



EMAIL FROM DR SING DATED APR 19, 2011

I am Dr Sing from Toa Payoh Vets. Thank you for your email. Estimated costs are around $600 - $700 for both eyes as general anaesthetic gas is used. Bring the dog in at 9.30 am and bring home in the evening. No food and water the night before after 10 pm. Phone 9668 6468 or 254 3326 for appointment.

Saturday, April 16, 2011

A love child

"Where are your front teeth?" I asked a little girl sitting on the left side of the van which had parked to pick up her mother who had brought in the old Pomeranian for oxygen therapy (gasping for breath and coughing earlier and was treated by Dr Vanessa). "How many teeth have you lost?"

The little girl smiled when I said "hello" and so I could see that she had lost 2 front teeth upper and lower. She also had two backward aligned corner incisors. The mother came and I asked: "Is this your daughter? How old is she?"

I couldn't believe that 6 years had passed. The mother was a single mother working for a dog breeder and running his pet shop in Marine Parade and then in MacPherson Road. The breeder had packed his bags and left the industry. Wow, the baby is a very happy 6-year-old girl.

"You will have to spend around $3,000 to align your daughter's teeth when she is older," I said to the happy mum. I am glad she is still a groomer and making ends meet. I don't know much about her love child and did not intrude on her privacy. She takes so much trouble to come to Toa Payoh Vets when there are over 45 vet clinics and some nearer to Pasir Ris.

Dr Vanessa gave her dog the necessary treatment and the oxygen therapy. This was her sister's dog. I said to her: "This dog will not live past one week. If you give the medication for the heart problems, give 3 to 4 times a day according to her panting."

She had brought her sister's dog for treatment and since I was not available, my associate treated the dog. She said: "I was told to give two times a day."

"Yes, that is the standard recommendation. Giving to effect will let this Pomeranian live a bit longer. In the end, the heart fails and the dog passes away peacefully."

I heard a hissing sound when I was in the room where the dog had the oxygen therapy by mask and the necessary injections. I noted that Dr Vanessa had pressed the red button a few times to flush out any isoflurane gas before giving the oxygen. The anaesthetic man had replaced my "faulty" vaporiser 3 days earlier as there was a leakage of oxygen. But all was well since.

Now, I could hear a faint hissing sound. Was there another leak in the piping? I phoned the anaesthetic man who was busy and wanted the whole set back to his factory. "Is there some elephant glue to seal the hairline crack in the piping under the vaporiser?" I asked him. "We need to operate and can't afford to wait a few days."

Dr Vanessa was going to postpone surgeries but I stopped her. The anaesthetic man came and saw the crack. His girl had placed some soapy water and I could see the bubbles from the blue tubing. So, there was a crack here too or was it there earlier? Was it due to the pressing of the red button repeatedly? Well, equipment piping do wear and tear.

Surprisingly, my old car had this ping message "Add one litre of engine oil when you next fill up." I had the car repaired by the mechanic when this message appeared earlier. Still now, the problem showed itself. Wear and tear or an inability of the mechanic to diagnose and treat? I top up the engine oil and the message disappeared. There must be a hairline crack somewhere. Should I sell off the car? But COE prices had shot up and 2nd hand cars fetch a good value. But it is much more expensive and stupid to buy a new car now. So, I have two identical problems of hairline cracks - in a car engine oil system and in my veterinary anaestethic gas system. Both need management and assessment of risks.

406. I want to sue the vet

"I want to sue Dr ...!" the employment agent who could never control her demons in her brain shouted over the phone. I had her to get a replacement for Mr Saw who left at the expiry of his lease on amicable terms last week. Mr Min started work for less than a week and here I had this threat to sue my associate vet because Mr Min could not get his regular break for dinner during some busy days.

I had known her for more than 15 years and know that she bears grudges and will tell me off whenever the anger demons dominate her brain. She would rattle off her anger over the handphone though I had told her to call me back later. Her loud voice could be heard distinctly by my friends in a car in Penang and during other inappropriate occasions when she aired her complaints about work-related problems. I could switch off the handphone as she would not let me speak but I consider it better that her demons get out of her brain through her big mouth and cool down.

However a threat to sue any my associate vets is not tolerated by me at all. I said to Mr Min and the associate vet at a meeting I convened: "When Khin Khin wants to sue Dr ..., she is suing me as I own the practice. Dr ...has no share in this practice. I will engage a lawyer to defend any associate vet who is sued. Has she got a lot of money to sue? Don't threaten to sue. Just sue."

I had advised my vet to ensure that Mr Min, the vet assistant get his meal breaks. I said to Mr Min: "Khin Khin does not respect older people. Maybe she thinks I am old and stupid and therefore can shout at me. You have to think for yourself as to what is good for you. If you don't want to work at Toa Payoh Vets, have you got another offer from another vet?

"Old people have gone through the life of war, meeting all sort of nonsenses and people and suffering losses while gaining experiences and wisdom," I said to both parties who are at least 30 years younger than me. "They are a valuable source of knowledge and I always respect people older than me so that they can share their experiences with me. Obviously if you have no respect for the seniors, you can't expect them to share their experiences with you so that you don't suffer losses.

"You will have to think for yourself as regards your need to respect your employment agent. You had paid her the money for her services. Do you want this job or not? Do you have another employer waiting for you now? I have many applicants from the Philippines asking for your job."

Mr Min wanted this job as he was practically unemployed in Myanmar and earned very little. In Myanmar, the vets don't earn more than S$500 a month, I believe.

I told Mr Min and my associate vet a bit of my philosophy and why I employ Myanmar vets as vet technicians.

"I employed my first Vet Technician many years ago. She was a Myanmar Vet working for Dr XXX. Dr... did not want to continue employing her because she was slow in her work. She also could not speak English well, just like you now. So, it was very difficult for her.

"I employed her and she completed her year of employment and wanted to go home to see her sick father. An army officer, I believe. Around 2 years later, she visited me and gave me a present. I was much surprised. You can check her out as she is in Yangon and Khin Khin knows her.

"In your first week here, I have complaints from a pet shop owner that her referred customers cannot understand what you are talking about over the phone. This is a common complaint of Myanmar vet technicians as their standard of conversational English is not good. You just start your job in Singapore. Over time, like your friend, Mr Saw, your English will be good. This is one reason why most vet technicians employed in Singapore are Filipinos as they speak very good English and can start work without the employer worrying about client services being downgraded.

"You may be able to get a job at one of the 45 vet clinics in Singapore, but do you want to work in a clinic where there are no cases during some days? Just sit and go for your scheduled lunch and dinner times waiting for cases? You learn nothing because there are no cases over the year of employment. Or you work in a very big practice in a small area like Haematology. You can't do other aspects of vet medicine as there are other vet technicians assigned.

"So you can't start your own practice confidently because you have no cases in the new clinics. Do you want that?

Mr Min did not want to work in such a situation. All employees have this "what's in it for me" attitude and I accept that they are in a job for themselves. Times have changed.

I can easily employ a Filipino vet and grow my practice very fast due to good service as Filipinos are culturally excellent in English language communications and services.

However, making a small difference to the disadvantaged and the underdog have always been my philosophy as others had made a difference to me by awarding my a scholarship to study vet medicine in Glasgow in 1969.

It is very difficult for most of the younger vets in Singapore to understand my philosophy when their parents pay and pay for their vet studies. Pay and Pay? PAP? Elections in May 2011? Some distraction here.

In any case, I had instructed the associates to ensure that Mr Min get his meal breaks and I am personally checking on this. Time management is important for a vet and also for the employee.

I don't want the demons to re-appear again in Khin Khin's brains and there have been so many incidents from her such that I can write a novel of some interest to human relationship readers.

This incident is just one of the chapters of this novel. I said to Mr Min: "If you want to sue, don't threaten. Just do it. Pay the lawyer and sue the pants off the vet!"

I told Mr Min and the vet: "When I started Toa Payoh Vets, there were around 4 competitors. During the first few years, there were few customers. Just sit down and wait as vets cannot advertise. Now that Toa Payoh Vets is busier, I cannot be taking it easy. There are now at least 45 competitors and I know some of them have not sufficient number of customers to make ends meet."

Mr Min is a gentle person in his early 30s. He does not lose his cool and that is a good trait. I also advised Mr Min to buy some food during busy times when he can't go for the break as scheduled. In the end, he has to decide. Does he want the job or not? He is slow in his work but this will change with my training. He is not indispensible and there are so many stronger and better qualified Filipino vet technicians. Hire the best talent if you want your business to grow in this competitive world, the business management books will teach us. Why care about the disadvantaged with no experience or a good command of the English language. Why care for the underdog in this world? Why bother with employment agents who can't exorcise their demons? Why patronise a small businessman in a niche in veterinary anaesthesia when you can get business from an established corporation? All these encounters make life stressful. However, make a small difference to change the world if you are blessed with health and can do it. That is my philosophy.

405. BARF/raw food diet query to Dr Sing

On Sat, Apr 16, 2011 at 9:35 AM, ...@uqconnect.edu.au> wrote:

Dear Mdm Judy,

I have a question for Dr Sing which I hope you can pass on to him. I am interested to know about Dr Sing's position on feeding a BARF/raw food diet for small animals.

Thank you,
(Name given)


Kong Yuen Sing to Mr,

Thank you for your email. I am Dr Sing from Toa Payoh Vets, www.toapayohvets.com. The answer to your question can be several pages an even be a book as there are many pros and cons. There are various formulas recommended by various proponents for the BARF/raw food diet.

Briefly, I am not recommending the BARF/raw food diet to my Singapore clients for the simple reason that most of them have no time to educate themselves on what makes a balanced diet for their dogs. My clients will also not be able to provide the necessary supplements to make sure that the diet is balanced during the different stages of life in a dog. Feeding such a diet to puppies, for example, will not be good for the puppies.

Best wishes.

Thursday, April 14, 2011

404. Follow-up on the itchy and scootering DachshundXJR

This is a follow up to a very interesting perplexing case I saw 2 days ago. My tentative diagnosis was allergy to the environment or dog food. The owner was more worried that the dog still scootered despite consulting Vet 1 earlier. Scootering was just continuous.

"My dog is calmer now. No more scootering and I don't scratch her anymore," the owner could not hear me distinctly as she was at the mall.

"What do you mean when you say you scratch the dog?" I asked the caregiver. "Well, I had to pet her and she would want more petting before I consulted you!". English is a hard language to understand. I was wondering why she would scratch her dog who was already itchy all over the body.

"How much hair loss?" I asked. She was not able to confirm as she was busy.

So far so good. I called to ask her to pick up the Hills' Canine d/d Potato and Salmon formula. It is a single animal protein source for allergic pets. The dog is not permitted to eat treats and any home-cooked or other food for the next 3 months. Then the owner can introduce treats and see if the body itch occur.

Painful ears with no infection, biting all four paws, whole body itch without skin diseases and hair falling out. These are one of the possible signs of dog food allergy. The dog just arrived from the USA. There could be multiple causes like heat, humidity, shampoos, stress and so many others.

We will have to wait and see. It is important that the dog does not scooter anymoe as that seems to be the main issue of the owner. She was very observant and said that I squeezed the anal sacs from quite deeply into the anal region. Of course, I did produce the grey particles and anal fluid. Evidence is important in veterinary medicine. The proof of the eating is in the pudding if there is such an English expression?



TODAY'S CASE
Old Jack Russell. Female, 8 years old said to be spayed 8 years ago and had no heat period.

Lost 2 kg from Oct 2010 (fat as a pig) to April 2011. Lethargy. Not eating much during past 3 weeks. Dried purulent eye discharge in both eyes suggested a serious systemic illness as in the hamster. Examine the whole body from mouth to private parts.

Dehydrated. Left gum ulcerated around Left Upper PM4. Yellow pus in swollen vagina (I showed to the busy lady owner's mother who brought the dog in). I suspected stump pyometra if the dog had not been properly sterilised but it could be UTI with pus inside the bladder and kidneys. No signs of vomiting. The dog just wanted to sleep and die.

BLOOD TEST. Low blood pressure and so I taught Min to use the tubing around the elbow and clamp with forceps just to collect 2 ml of blood successfully. Min is not inexperienced but he tended to do blood collection from the forelimbs and then the hind limbs but was unsuccessful today with both legs. So, I taught him how to fish rather than give him fish.

BLOOD TEST RESULTS

Very low platelets = 40 (normal 200-500). No platelet clumps. Large platelets present.
Liver enzymes elevated. Urea 15.6 (normal 4.2 - 6.3.
Red cell and haemoglobin below normal.
Total White Cell Count normal.

So what is the cause of the low platelets? I phoned the young lady. She said no Chinese medicine was given but the dog had the chicken flavouring or some powder added to the chicken meat for some weeks. Could this be the toxic substance depleting platelets? Would the dog live? Hard to say.

Wednesday, April 13, 2011

403. New anaesthetic gas machine

April 13, 2011.
I got a new anaesthetic machine vaporiser as the old one had leaked at the bottom. There is a hole on the lower right, hissing oxygen and depleting my oxygen tank. This vaporiser is only 3 years old. But I don't want it repaired. I bought a new one as gas anaesthesia is very useful and very safe, esp. for old dogs.

The vaporiser started hissing oxygen 3 days ago on a Saturday. All gas operations ceased and I had to get the experienced man to service but Mr Goh was in Malaysia doing some vet clinics set up there. So, on Wednesday (yesterday), I told him to treat urgently as I did not want to buy a vaporiser from his competitor. I support Mr Goh as he needs the help. If one does not support the small technical person who specialises in vet machines, he will go out of business and the vet community will be much worse. The big boys are not interested in vet machines anyway. Sales persons can't service.

"It is only $8,000," my Myanmar friend James said. "Throw away the old one. Even if you give to me, I don't want it. It is hard to repair in Myanmar." James is starting his clinic in Yangon soon. A few weeks ago, I offered him my old Shoreline veterinary surgery table which costs $7,000 to purchase as I bought a new one. He said no but his wife later said yes. So, there was much unhappiness with the

Tuesday, April 12, 2011

iPhone 4 or an Android phone

2 weeks ago, I decided to upgrade myself from the conventional mobile phone which was good for nothing but useful to send and receive calls. I could not surf.

iPhone 4 is already one year old. The Samsung was a new model. So, brand-name or the latest technology? iPhone 5 may come soon but maybe not.

I was much tempted to take the brand-name. But it is never good to do it when the brand name does not bother to upgrade and lose to its competitors. So, I took the Samsung. The HTC was sexy but it had caused me loss as it malfunctioned some 3 years ago when I first got one (I could write instead of thumb). The company took months to repair and the problem of hanging came back again. As you can see, good performance counts even in mobile phone sales and service.

Same tough competitions exist for the 45 vet clinics now existing in Singapore. Brand name clinics definitely lose out in numbers to the new ones with sexy renovations and frills. And that attract many younger pet owners.

401. Give what the owner wants

April 12, 2011

9.30am. 1-year-old JackRussellXDachshund spayed dog was itchy all over. She arrived from US one month ago, quarantined at Sembawang for 10 days and had been boarded at a Pasir Ris boarding place where there were numerous rescued dogs.

"My dog is itchy all over the body and scoots her backside," the slim European lady said. She had consulted another surgery and the vet did press some tissue around the anal area. She was not shown what was expressed from the anal area.

I put the dog on he exam table and pressed the anal sacs. I showed her the greyish particles in the anal sacs to the owner. "The normal colour is like cooking oil - light yellow," I said and explained what the anal sac oil was used for by the dog. She was quite happy.

As for the ears, I palpated the ears. The dog yelped in pain at the horizontal and vertical canal junction. I scoped the ear but found no mites. A cotton bud tip showed light brown discharge. No smell. So what was the pain? "I am no ear-person," the woman in her 40s said to me when I asked if she knows the structure of the dog's ears. I remained professional by not cracking jokes about anatomy which may be offensive since I met her the first time. Some men are said to be attracted by certain anatomy of the female and therefore, cracking such jokes as a "butt" person may not be welcome unless the client has a sense of humour.

As for the itchy body, the lady said: "My friends asked me to examine the body for skin infections but there are none. Yet the dog keeps losing hairs eve1y day. What is the problem? Also she chews her 4 paws "

I examined the dog's skin. Good coat. Strands of brown hair fall out. The lady said: "She is also developing those long harder coarse hairs. Could it be the weather in Singapore being so hot?"

"There is no skin problem," I confirmed. "Those coarse hairs could be the result of the dog's parents being wire-haired Jack Russell. Now she is one year old, her adult coat is being formed."

It sounded logical to her. As for the cause of generalised body itch, it was hard to tell what was the cause. "It is most likely allergy from the food or environment. A skin patch test may not give you the answers but costs you some money." I advised her to get the ears and paws cleaned regularly and to go on a low-allergic prescription diet for 3 months. "No treats or other foods", I said. "After 3 months, you can test her with dog treats or your food and see whether the dog itches."

I said: "It is extremely difficult to let you know what is the exact cause of the dog itching all over and so we do the food trial first. In some cases, it could be due to the loss of hormones due to spaying but these are rare cases. Hot weather and stress can cause the dog to shed hairs too as the dog came from the US."

This dog has no skin or ear problems and so a dog food or human shampoo allergy is suspected at this stage. The dog uses her human shampoo. There are so many factors and so it is best to take time to explain and illustrations of the ear canal and anal sacs to show the anatomy.

In this dog, the owner even remarked that I could have gone deeper to express the anal sacs than Vet 1 who did not show her any oil (probably).

Nowadays, it is hard to be a vet. See the following case 2.

Case 2. "Has my dog got CCD?"
This was the 2nd case in the last 3 days that a client who had researched the internet asked me about the dog having CCD.

"My dog could not recognise me and knocked onto furniture," the man in his late 50s said to me. His dog had been examined by a vet and had blood and urine tests done. "Nothing wrong with the blood and urine tests, the vet said. Can you prescribe a drug so that my dog can be alert and active?"

I was on counter receptionist duty and so got this feedback. I was surprised that another dog owner had researched the internet and diagnosed CCD again and asked for the drug.

I said: "Nowadays, owners research the internet. Sometimes, they are better informed than the vet. There is a drug but are you sure that the dog has no other health problems?"

I continued: "Many cases, the old dog has painful mouth due to teeth decay. Poison from the bacteria goes to the surrounding areas including the eyes and brain. So, the owner diagnoses CCD and asks for the drug. In the end, the dog is still suffering from pain."

"My dog eats the same amount of food every day," the man said when I asked why the dog had dropped 1.5kg in weight when it had the same appetite and was less active, esp. for the last 2 weeks. He was positive that his dog ate the same amount and had no vomiting or diarrhoea.

So I asked to check the blood and urine test results. The significant finding was a high blood urea (12 instead of the maximun value of 6). So, there was an abnormality but his vet said it was normal as the creatinine was low, meaning the dog does not have kidney disease.

It is not normal to have high blood urea, I said to the owner. As to the cause, the vet said it could be due to disorders in the muscles and internal organs and possibly cancer but since an X-ray would be useless, an ultrasound was proposed. Multivitamins were prescribed for the time being.

As the owner stated that he was referred to me by his friend, I handled his case and asked the dog to be admitted for an examination as he did not bring his dog when he came to see me.

Old dogs that have not been given dental checkup for the last 5 years (his vet did not want to do it since the dog was 8 years old) would have bad breath and oral infections. These problems needed dentistry and not a drug for CCD. Then there is the ear problems as many of the old dogs are neglected. They just get fed.

Much will depend on what I find but dentistry under general anaesthesia is needed. I strongly advised the high risks and he ought to tell his wife. His wife phoned me and I explained the possibility that her dog could just die on the operating table. That is the reason why most vets don't want to do the dentistry. "How about half dose?" the man asked me. "I use gas only and it should be quite safe if given over a short time of less than 15 minutes, but no guarantees."

"How about no anaesthetic?" the man asked. I said: "It is extremely painful to extract decayed teeth. I had only done once in dental extraction of a 16-year-old Pomeranian. It survived. However, some dogs may die of fright. Did you read the Straits Times forum letter where the writer's dog was lost and found by the AVA? The AVA micro-chipped the dog but it died. What did it die of? The AVA is doing an autopsy to ascertain the cause of death." From this incident, I prefer not to do any dentistry without anaesthesia.

Case 3.
A Chinese National sought my advice about her Silkie puppy that had fractured his right fore leg. "What can be done?" she asked me as I was on counter duty. The dog's legs were cast by Plaster of Paris and the dog had come in for a change of the Plaster. I asked Dr Vanessa what was the outcome. She showed me the X-rays before and after the cast. The tranverse fractures of the radius and ulna had closed and the fragments were aligned. So, there was good news. I told the lady that the progress was good. She had phoned me earlier wanting no invasive surgery for the fracture as proposed by another vet and Dr Vanessa had done a good job. A second opinion would be better service for the client and I was glad that she appeared satisfied.

She was from Yunnan. I had seen paintings by Chinese painters of Yunnan and read about the refugee problems from Myanmar to Yunnan which is part of China. I would like to visit this place as it appeared to be the equivalent "wild wild West" of the USA after reading about drug lords and other news.

"The travel agent in Yunnan cannot be trusted. Contact your travel agent. Many Singaporean businessmen go to Yunnan for gold," she said to me.

I asked her about the presence of elephants in the Yunnan mountains after hearing a story of a Myanmar businessman whose truck driver impatiently sound the horn to quicken the mother elephant and baby to walk past faster along the mountain road. The dam rushed onto the truck and this businesman was flung deep into the ravine. A tree broke his fall and he was hospitalised for 3 months. When he went home after that, he said to me: "My family members sprinted fast and ran away as they thought I was a ghost." In the old days before the mobile phone, he could not inform his family and they thought the elephant had killed him.

So I asked this Yuannan lady about the wandering wild elephants which I could not imagine, being a frog in the well in the small island of Singapore.

It is just too expensive to travel and I prefer the off-the-tourist places which can be more expensive and dangerous.

"There are wild elephants in the mountains. Tourists can view the mountains from the tree top."

"How do I do it?" I asked. "Just sit on the tree?"
The young lady in the IT field said: "I will not advise you to watch the wild elephants. It is very dangerous. The elephants may bang the tree and knock you down!"