Thursday, June 30, 2011

485. A Schnauzer pooping 6x/day now poops 3-4X/day after 7 days

The Miniature Schnauzer came yesterday Jun 30, 2011 for her 3rd vaccination. 7 days ago, the young lady owner with 2 small boys asked me whether it was normal for her 3-month-old puppy to poop 6x/day of 24 hours? What would be my advice since I said it was not normal?

Following my advice she reported that the puppy now poops 3-4X/day on 2 meals (breakfast and dinner as is customary in Singapore but puppy books recommend many more times for 3-month-olds).

"How did you do it" I asked for her secret.
"I did what you advise," she laughed.
I did advise a few things.
"Well," she said. "No distractions. That means my two boys and I don't bother with the puppy before and after meals. So she can poop all as you said."

That was good news.
"Furthermore," she said. "The puppy now does not pee on the side of the tiled area (left side). Just the newspapers. But she still pees onto the kitchen floor when let out although I remove the baby gate as advised by you."

"You ought to let her out an additional 50% of her present tiled area," I said. "Not the whole kitchen floor. Then increase the tiled area. She would then be able to remember to go to the papered area in the store room."

I forgot to tell her to neutralise the urine smell on the kitchen floor. The puppy still had dark brown anal sac oil expressed and I was surprised. I taught her how to do the anal sac expression. It was overall a happy encounter.

Tuesday, June 28, 2011

484. E-mail query on toilet training behaviour

Hi Dr Sing,

I am having some paper training problem with my 4mth male Golden Retriever puppy and hope to get some advice from you.

My puppy is call .... and he had been with me since 2.5mths.
It took us 2 weeks plus to paper trained him to pee n poo on newspaper which we placed in the kitchen area.
He had been doing so for abt a mth.

However recently, he begin to sometimes pee in the living area and other areas.
Which means, sometimes he will pee on the newspaper (n tats usually in the morning) but other times he will pee elsewhere.
He still poo on the newspaper thou despite his peeing problem.

Another thing we notice is that he tends to 'leak' pee when we touch him.
There is even once he pee out when we are giving him belly rub (ya he pee when he is on his back like a fountain)

Is it because he tend to hold his bladder till very full and is unable to control till he reach the newspaper? There are a couple of times i saw him running into the kitchen n just pee half way before he can reach the newspaper at the corner.

Wang wang knew he had done wrong by peeing elsewhere other than the destinated place because everytime he mis-pee, he will quickly hide under the chair.

Is he getting restless thus the misbehavior or is there anything wrong with his bladder?
I will really appreciate your advice in Wangwang's change of peeing habit.

Thank you so much

Best regards,
Name of Owner


E-MAIL REPLY FROM DR SING DATED JUNE 29, 2011


I am Dr Sing from www.toapayohvets.com. Thank you for your e-mail.
There are at least 3 possibilities for your dog's actions
1. A urinary tract infection. Get your vet to have his urine analysed.

2. Submissive urination. Pees when his belly is rubbed. Don't continue with your rubbing. Don't greet him with a loud tone when he sees you. Build up his confidence. More socialising and outdoor experience. Read books on submissive/excitation uirnation.

3. Unknown causes arising from your management and housing.

In any case, a veterinary examination soon is advised.

Sunday, June 26, 2011

Finding the diagram in the Murdoch Vet Library

Singapore does not have a Veterinary University and all its vets are graduates from overseas universities. So, it can be difficult to get the latest periodicals and books.

In October 2011, I went to Murdoch University. There was a big sadness as my god-daughter who was 5 weeks from graduation to be a vet from this University had died in a car accident one month earlier. I had seen her as a baby, baptised and grown up. Why did this happen? Nobody has the answer.

I have been searching long for some notes on catheterisation of the urethra of the female dog and spent half a day at the Veterinary library of Murdoch Vet School. Unlike Singapore's Universities which restrict or ban access from members of the public, I find that Murdoch University libraries permit access.

I found my information and drew out the sketch for the benefit of vets who may need such information.

The details are at www.toapayohvets.com, DOGS - URINARY TRACT PROBLEMS.


Or goto http://www.bekindtopets.com/animals/20081201PG7_Dog_Surgery_Anaesthesia_Urinary_Tract_Problems_ToaPayohVets.htm
if you want more case studies. The diagram is given below:


Tumours in a very old Chihuahua - benign adenomas

Old dogs with growing subcutaneous tumours may die under anaesthesia. Tumours keep growing to irritate the dog as they become infected. It is very difficult for the owner to take the risk as deaths on the operating table do occur in old dogs.

Different vets and doctors have different approaches to the treatment of tumours.
1. One approach is to do a fine needle aspiration and then a surgical biopsy of the tumour to be sent to the histopathologist to determine if the growth is cancerous or not.
If it is not cancerous, everyone is happy.

Unfortunately, the histopathologist takes time to reply the findings. In some cases, the fine needle aspiration is not useful. So, the histopathologist asks for a surgical biopsy. Time is needed and it may take two weeks to get the reply.

If the tumour is malignant but has not metastasized (spread to other parts of the body), the time taken by the histopathologist permits the tumour to spread.

2. Another approach is to excise the lump including a wide margin in case the lump is cancerous. This is known as radical excision. After surgical removal, the lump is sent to the histopathologist for a report as to whether it is benign, malignant or just an infection.

I prefer this method and have used it in this old Pomeranian. Fortunately she has a benign adenoma.

481. Sunday cases : Malignant fibrosarcoma in a 2-year-old cat

Sunday June 26, 2011. I was on duty the whole day as Dr Vanessa Lin was on leave. Usually I work from 9.30 am to 11 am on Sundays and Dr Vanessa Lin starts from 11 am to 5 pm.

BE KIND TO PETS
TIPS TO OWNERS

1. Malignant fibrosarcomas in a 2-year-old cat. The young couple came for a 2nd opinion as the cat came a few months ago for a right eye injury. Now the cat had multiple large firm hard lumps on the right side of the body mainly and the right eye is a white cloudy mass. The first lump appeared above the right shoulder blade. Then another one grew behind it. Today, the right front leg had a chicken egg's lump under the armpit (axillary lymph node metastasis). There were two smaller lumps to the left side of the midline near the left shoulder blade.

The owner had consulted Vet 1 who did the following:
1. Fine needle aspiration sent to the histopathology lab.
2. Surgical biopsy sent to the histopathology lab as the fine needle aspirate was not useful. Malignant fibrosarcoma was diagnosed.
3. Complete blood cell count indicated a high white cell count initially. X-rays were done.

MY ADVICE
The fibrosarcomas are malignant and grow aggressively to massive sizes. Surgical excision of the axillary lymph node is highly risky as the cat is not in good health (very thin now) and the tumour has spread to the muscles. The tumour will recur after surgery.

Chemotherapy is not well tolerated by the cat. Radiation therapy is not available for cats in Singapore. Therefore, it would be best to let the cat enjoy the expected one month of his life before the tumour ruptures causing infection and pain and requiring euthanasia. Also, the right front paw shows signs of swelling due to venous obstruction. The cat is thin and has difficulty walking on the right front leg.

CAUSES
A malignant fibrosarcoma is a cancerous growth of the fibrous connective tissue. It is one of the most common musculoskeletal cancers found in cats.

There are four possible causes of fibrosarcoma.

1. Older cats with usually a single, irregularly shaped mass found on the trunk, legs & ears.

2. Rare cases said to be vaccine induced sarcoma.

3. A mutant form of FeLV known as 'feline sarcoma virus' (FeSV). Usually happen in younger cats & occurs as multiple tumour masses.

4. Genetics? This has not been confirmed.

This young cat had the first lump appearing to the right of the midline, between the shoulder blades and had been vaccinated. It is possible that he could be suffering from a vaccine induced sarcoma. Could it be due to genetics? His right eye ball is no longer normal. Could it be the original site of the sarcoma inside the eyeball ? Could he be having FeLV too as this was not tested. It is hard to say.

RETROSPECTIVE

Cat owners with very small fast-growing lumps on the vaccination site or in any area may need to find a vet that will remove the lump immediately rather than do fine needle aspiration and surgical biopsy as these test takes time.

By fast-growing lumps, I mean that the lump "suddenly appears" or double in size every week.

Although malignant fibrosarcomas do recur in cats after surgery, early radical surgical excision with a wide margin and repeat surgeries when the lumps recur and are small may lead to an extension of more than one year of life.

By small lumps, I mean those that are less than 1 cm in diameter. Surgical plus chemotherapy prolong lives but chemotherapy is not well accepted by the cat. Radiation therapy has side effects too and is not available for cats and dogs in Singapore. Once the fibrosarcoma has spread, surgery is not advised as fibrosarcomas grow very big very fast and do spread elsewhere in the body.

Prognosis, cost and the welfare of the cat are important considerations in the treatment of fibrosarcomas in the cat. In this case, the owner opted for no treatment and asked me how long the cat would live. I expected one month of good quality life before the armpit tumour ruptures and become infected and painful.

In this young cat, early radical excision of the sarcoma and sending the tumour for histopathology would be my approach to the treatment of this case. This approach is to minimise the chances of metastasis (spread of the tumour).

The client would be advised that the fibrosarcoma will recur and repeat surgeries will be needed. There have been a report by a vet of success using this approach but not much details have been given as she only encountered 3 cases in 26 years and was successful in treating 2/3 cases with repeat surgical excisions.

From my experience, most pet owners in Singapore have a wait-and- see attitude. Only when the tumour is large will they seek veterinary advices. By then, the fibrosarcomas have spread and become inoperable.



Any updates will be at www.toapayohvets.com, goto Cats - Tumours in Cats

Thursday, June 23, 2011

480. Finding a good family for a young timid chihuahua

It is hard to find a good family for an adult dog. I had given up hope of finding a very good family for this timid Chihuahua who had been staying with an experienced and famous Chihuahua breeder for the last 8 months. The breeder gave the dog to me to find a good home as he did not want to breed a monorchid (one testes). I thought he would be giving me a puppy as he had done before but this was an 8-month-old handsome Chihuahua.

On July 22, 2011, a client phoned me to make an appointment the next day as her female Chihuahua had an "ant bite" in the backside. I happened to be taking phone calls like the receptionist. "Come before 11 am if you specifically want to consult me," I said. I am usually on duty before 11 am and after that my clients would be consulting Dr Vanessa Lin who works from 11 am to 7 pm usually.

So, time and space connected. The timid Chihuahua found a very good family and I am very happy for him. He needs a teenager who will have time for him and another Chihuahua who will be his playmate and make him grow up to be more confident. It was a coincidence as my client could have not be free to consult me before 11 am and therefore, would not be offered this Chihuahua by Dr Vanessa as the dog had nothing to do with her and I had not thought of asking her to look out for a family to adopt this dog. She had an older Shih Tzu whom she had found a new family to adopt and it took some time too. Mine took over 2 months.

It is just tough to find a family to adopt a dog unless one is the SPCA.



Wednesday, June 22, 2011

479. Dachshund neck abscess - microscopic exam

Dachshund Male Neutered 10 years had a large golf-ball swelling on the neck above and between the shoulders. What was it?

SURGICAL DRAINAGE
Blood aspirated and drained (see syringe).
Wound closed and healed in 2 days.
On day 3, a golf-ball swelling appeared.

SURGICAL DRAINAGE
I snipped off the stitches and opened up the wound.
Clear yellow plasma-like fluid flowed out, around 10 ml. What was it?
On day 2, reddish brown fluid seeped out. This continued for next 3 days.
Some yellow pus-like tissues.

MICROBIOLOGICAL EXAM. TISSUE FROM NECK
June 9, 2011, I did a bacterial culture. Results: Moderate growth of coagulase-negative Staphylococcus, sensitive to amoxycillin/clavulan, ceftriaxone, vancomycine, oxacillin.
Resistant to chloramphenicol, erythromycin, penicillin, bactrim, tetracycline and ampicillin.

I gave baytril for 3 days and metonidazole for 6 days. Irrigated the wound with hydrogen peroxide. The 71-year-old mum took back the dog on Day 3. Wound was left open. On Jun 22, 2011, I phoned the owner. All OK.


The owner was in Japan and was most worried. We communicated by phone. As to the cause, it was hard to say. Was it due to the tight bandaging or SC baytril injection? The sibling was given similar drugs SC below the neck and was OK, but he did not have tight bandaging.

Bacterial culture was needed in this case.

Tuesday, June 21, 2011

478. Sharpei websites

http://sharpeiforums.com/viewtopic.php?f=2&t=816

http://www.kavishi.freeserve.co.uk/

Dr Sing,

Thank you for treating (name of Sharpei).
The above are the two sites I frequently go to.
There are a few more which I have yet to locate.
Can you send me a photo or two of the photo you took of my dog

Sharpei could not see clearly as he did not respond promptly to objects as before.
So the owner consulted me.

The dog had lower eyelid medial entropion. His upper eyelids' entropion was well done by the UK vet and had everted the upper eyelid. I noted generalised superficial ulcerative keratitis (cloudy cornea over 80% in both eyes). This explained why he could not focus as sharply as before.

What caused this superficial keratitits? Eye rubbing + ear rubbing over several weeks. His left ear was infected as he growled to warn me not to continue touching his ear. So, there was a problem. His neck skin was infected as signs of scratching were seen.

Skin scrapings by Dr Vanessa - no demodectic mites seen. "This negative finding does not mean he is not suffering from demodectic mange," I said. The owner said he was molting and therefore had those bare moth-bitten patches in his body.

477. Training a 5-month-old puppy advices

E-MAIL TO DR SING DATED JUN 20, 2011

Hi Dr Sing,

I was surfing the net searching for solution to train my puppy and I found your blog.

I have a terripoo puppy which is now 5 months old. When he was young, around 2months old, we used to buy the pee pan for him but he will not stop biting the wee wee pad. Therefore, we tried to lock him in the crane when all of us went out to work but it creates another nightmare by non stop barking. This has caused inconvenience to my neighbours and some of them had complainted about it. Due to this, my mom has decided to let him out from his crane and he is allowed to walk around in the house even none of us are home.

When he is out and no supervision, he will bite our furnitures and also pee pee anywhere he likes. My mom and I used vinegar to clean but still, useless. Can you please advise what should we do?


Best regards,
Name of owner



E-MAIL FROM DR SING DATED JUN 22, 2011


I am Dr Sing from www.toapayohvets.com. Thank you for your email.
It is difficult to advise on what you should do as each puppy or dog has a unique personality. Below are my general guidelines.

1. Confine the puppy to a room e.g. kitchen instead of a crate when he is home alone. A baby gate is placed at the door entrance so that the dog will not feel isolated. Confinement to a small area (crate, room, leashed area) is the basic factor to success of all puppy training programmes for most puppies.

He will bark at the beginning and possibly neighbours will complain. Give him chew toys that contain food inside (ask pet shops). Such chew toys with his favourite food occupy his time to try and get the food out. This may or may not work with your dog.

2. Develop a Routine. Morning and evening exercise outdoors daily for more than 15 minutes after meals and pooping in the designated confinement room. Do not interact with him while he is eating. After exercise, put him in the room as part of the routine.

3. Somebody must be the "boss" in the family. Firm voice of "No barking" and rewards for performance of no barking (go out, treats). Read your dog obedience books to know what I mean.

4. Neuter him at 6 months of age.

5. Supervise him when he is let out to roam free in the apartment and use the firm voice to train him as mentioned in paragraph 3 for barking, chewing, indiscriminate peeing and pooping.

6. I have heard of cases of success (barking and obedience training) when the puppy is boarded at a trainer's place for two weeks or more. Consult a good dog trainer.

I hope the above tips will help. Best wishes.

Sunday, June 19, 2011

476. Turtle rectal prolapse - purse string suture

Sunday's Interesting Case
Jun 19, 2011. Bright sunshine day.
A turtle owner had made an appointment to see me at 9.30 am on Sunday.

5-year-old red-eared slider
"How long has the rectum come out?" I asked the owner.
"7 days," he said. "It happened some weeks ago and a vet had stitched up the rectum. After 7 days, he took the stitch out and there was no problem. What is the cause?"

"Something irritating the rectal area," I said. "Usually it is diarrhoea for many days in dogs."

"It was due to constipation," the gentleman said he kept the slider in a tank with dry and wet areas and fed her pork meat, chicken meat and the green sticks of commercial turtle food. "I will stop feeding the green sticks," he thought these were the ones causing constipation.

"If it was constipation," I said. "The turtle may not be drinking water although water is present. Is the water dirty and contaminated?"

"I change water every day," the man said.

So it is hard to know what causes this rectal prolapse as he seemed to have maintained the terrapin well for the last 5 years. The shell was in good condition with no cracks or abrasions on the shell and of good normal size. No peeling or discoloration. Active. She looked healthy.

ANAESTHESIA
Gas mask. Isoflurane gas at 5% in short duration to effect. There was some "clicking" noises of less than a second during anaesthesia. The turtle was anaesthesized just sufficient to put a purse-string suture to close up the anus after pushing back the rectum inside the anus.

PROCEDURE

1. An assistant puts the gas mask onto the turtles head and focus on her reaction.
2. A 2nd assistant holds the turtle upright but NOT upside down on her back, as the turtle will suffocate.
3. I push the rectum in. Then insert a 2.5 ml syringe into the rectum to prevent prolapse. The 2nd assistant held the syringe inwards as the turtle would strain to cause prolapse
4. Stitch 3/0 nylon.

DURATION OF STITCHING
7-10 days. The cause of the rectal prolapse must be known otherwise it will be difficult to prevent another episode.

I advised clean water (water left overnight to get rid of the chlorine and asked the owner to check whether the turtle actually drinks by giving her the clean water directly.)

Antibiotics and anti-inflam oral for 7 days.

Not many cases seen in Singapore as there is not a large number of red-eared sliders kept as pets at home.

Saturday, June 18, 2011

475. Rare case of pyometra in a young female dog

After over 30 years in small animal practice, I thought I have seen all pyometras. Pyometra is an infection of the womb in the female dog, mostly in dogs over 5 years old.

Yet, this female dog just had her first heat 2 months ago. I checked her before spay and saw mucoid yellow vaginal discharge. "Is she really 10 months old?" I asked Mr Min, my assistant. She was as her teeth were all white as snow and her puppy canine tooth was still present and white.

I am happy to say she is OK after spay. Small animal veterinary medicine is full of surprises every day.




Friday, June 17, 2011

474. Watery pus in shar pei's eyes - entropion?

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.


E-MAIL REPLY BY DR SING
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.


Costs include all fees and medication.
Blood test to check whether the dog is healthy is not included and is advised. Cost is $150. However, this depends on the owner as to whether he wants the blood test or not.

E-MAIL TO DR SING DATED JUN 16, 2011
Can I make a appointment to consult Dr. Sing tregarding my dog's eye and to advise
if he needs entropion surgery.
Mon.11.30am or Wednesday, or Thursday 11.30am or but not Tuesday.
Please call me to confirm the appointment.
Thanks !

Ande Lai h/p  xxxx



- Show quoted text -

Thursday, June 16, 2011

473. Deep eye ulcer in a 3-month-old Shih Tzu puppy

Yesterday, Jun 16, 2011, I operated on a 3-month-old Shih Tzu with corneal ulcers on both eyes. The owner was referred to me by the sister who had sent the hamster with the large cauliflower ear wart to me 3 days ago.

I am still much worried about anaesthesia of 3-month-old puppies as they are not strong enough.

"No injection?" Mr Min asked me as he has been used to vets giving sedation and then gas anaesthetic for the last 2 months or so. He had replaced Mr Saw and was new to the small animal veterinary world although he had some experience in Malaysia and had graduated some 10 years ago in Myanmar.

"Only isoflurane gas," I replied. "If you know how to do it." I showed him how to hold the puppy and give anaesthesia gas via the mask. "Hold the scruff of the neck, angle the head at 45 degrees and give the mask," I said. Yet he did it his way and when I corrected him, he said "I don't want the mask to touch the corneal ulcer!"

It needs a lot of impatience to teach the young ones and sometimes I feel that they just want to do it their own way. I said: "At 45 degrees, the puppy can breathe normally. At 90 degrees (to the mask), it is unnatural and the gas cannot flow through smoothly!". Teaching Min is important as he assists my two other associate vets who have their own styles. But there must be one standard operating procedure which is safe, efficient and least costly (wasting of the very expensive isoflurance gas).

My previous technician, Mr Saw had learnt what to do after 3 years of working with me, but he had decided to retire to greener pastures in Yangon where he was promised a "partnership" in a practice. So, a new technician had to be supervised and mentored again.

For this puppy, the owner is very worried, as do all owners of puppies and parents of babies. The anaesthetic risk is so much higher and it was no surprise that the vet near her apartment had prescribed just antibiotics eye drops and atropine eye drops and vibravet oral tablets. Then she was referred to the parent company's vet who was unfortunately fully booked. So, that was how the case came to me from my successful handling of the hamster with the large ear wart with Dr Vanessa 3 days ago. Well, if the hamster had died under anaesthesia, I doubt this referral would come. So much depends on the anaesthetic outcome in veterinary anaesthesia.

HOW THIS CASE WAS DONE
1. Isoflurane gas by mask at 5%. Observe signs of surgical anaesthesia by me. Don't depend on inexperienced vet technician Min. Proper angle of the neck and nose at 45 degrees.

2. Intubate just when the puppy was not fully anaesthesized. Be alert. There was a "vomiting" sound. I quickly pulled out the endo-tracheal tube but there was no vomiting. If negligent, the vomitus goes into the lungs.

3. Give 2% isoflurane. The temptation of the technician or vet is to give 5% via the tube as the puppy moves. Close the mouth with hands and be patient. It takes time for the puppy to be under surgical anaesthesia.

4. Flush hairs and debris off the eye thoroughly. Ensure the 3rd eyelid is opened up and irrigate all hairs trapped inside.

5. Check eye is clear of debri. I put in terramycin eye ointment and the atropine drops.

5.1 In infected eyes, I do inject subconjunctival gentamycin but not in this case as it was 4 days old.

6. A horizontal mattress suture, 3/0 absorbable sews up lower and upper eyelids. Eye-lashes must be completely shaved off.

7. E-collar. The puppy wakes up fast as if she has a short nap.

DISCUSSION WITH A 5TH YEAR VET STUDENT FROM MURDOCH UNIV
Each vet has his own approach. The student, Daniel said he would swab the ulcer, get a bacterial culture. Give appropriate eye drop antibiotics, atropine, e-collar and let the ulcer heal. NSAID pain-killers. Perhaps an eye patch.

IN REALITY
The first vet had essentially prescribed what Daniel had proposed except for NSAID. The owner had great difficulty putting eye drops on the puppy as the naughty one shifts right and left. Both corneas were ulcerated (will show images later). Puppy's sclera gets redder by the day. Itchy, rubbing eyes.

LEFT EYE
Deep ulcerative keratitis. The cornea ulcer of the left eye was deep. A red blood vessel forms at 11 to 2 o'clock above this ulcer.

RIGHT EYE
Superficial ulcerative keratitis from 6 o'clock to 11 o'clock.

So, the owner is worried that the puppy will become blind.

Friday, June 10, 2011

472. Sharing knowledge of veterinary anaesthesia from Malaysia

Many Malaysian vets I meet during continuing education talks have found the following effective for injectable general anaesthesia. Here is one from a helpful vet in Johor Bahru.

Hi there Dr. Sing,

For me, in terms of injectable zoletil most of us vets here uses the TKX mixture. here is how you do it:

1. take zoletil 100
2. discard the water diluent
3. mix 2 ml of xylazine 100mg/ml
4. mix 8 ml of ketamine 100mg/ml

then you will have 10ml of TKX (zoletil plus ket plus xylazine) where 0.1ml of this tkx should knock down an animal about 3kg for a decent 15-20 minutes. very good for short procedures and also the muscles are quite relaxed unlike those if you use in pure zoletil.

i personally use my own concoction of 3ml xylazine and 7 ml ketamine and i find that this mixture gives me a knock down of 20-25 minutes and the animal 'sleeps' longer. i maintain my animals on gas if the procedure takes any longer than 15 minutes. the only worry is the chance of hypotension (due to xylazine) and we should be mindful of older animals or those with cardiac insufficiency.

COMMENTS
I have seen the above TKX used effectively in cat spays in NANAS, an animal shelter in Johor some 2 years ago. It is said to be safe.

Thursday, June 9, 2011

471. AMA (Against Medical Advice) Form

Vomiting and diarrhoea in a dog, several times a day and over 2 days.

TREATMENT
1. Don't just give an injection and some antibiotics as this may be what the pet owner wants. The owner wants the pet to go home, but in such severe cases, it is best to hospitalise the dog, get IV fluids.

2. Check potassium levels. If it is low, the dog can get hypokalemic which can lead to life-threatening cardiac arrhythmias and death.

ONE CASE
The owner insisted on antibiotic injection and oral antibiotics first. If the dog still has vomiting and diarrhoea, she would bring it back. But the dog could not stop vomiting and passed watery stools past midnight. The next day, the angry son came with the owner (the mother) and verbally abused me.

A written form of discharge stating that IV fluids and hospitalisation is advised but the dog owner wants the dog back AMA (Against Medical Advice) would be best. In this case, the mum was rather embarrassed at the son's wanting the money back. I request him to send the dog to another vet for treatment. When the trust is not there and oral allegations of negligence set in, it is best not to continue with the case.

The AMA form is used in human medicine and this may be adapted for use in veterinary medicine as family members who are not present during consultation may start to get litigious when the clinical outcome is not to their favour, due to restrictions imposed or AMA behaviour of the primary caregiver who is present during consultation.

Wednesday, June 8, 2011

470. Continuing Education: Adverse Reactions to food in the dog and cat

On Jun 7, 2011, I attended this seminar and was surprised to see most of the participants are young people of around 20-30 years of age. Probably from Malaysia and Indonesia.

I met Dr Lee who has a surgery in Johor Bahru's industrial area (small breeds 20% compared to my practice which is 95%; large breeds and mixed breeds 80%). He says there are around 15 vet clinics in JB. I said there are around 50 in Singapore. He mentioned about a very good 3-in-one sedation. "Just 0.1 ml IV and you can intubate the dog of 30 kg."

He said that he had attended a teaching seminar conducted by some European Vet Association in China (no Singapore vets were there). The European vets just use one layer of continuous appositional suture to close the bladder or intestinal incisions, unlike the American textbook recommendations of 2 layers of inverting sutures. He also said that in gastric torsion, the European vet just tears off the falciform ligament from the dog, exposing the twisted stomach for correction. No ill effect. Excellent teaching of ultrasound interpretation. He was generous as to share vet knowledge as most vets would just keep silent.

469. Continuing Education - SAP Summit 2011 - The Future State - Engaging the customer

On Jun 8, 2011, I attended the SAP Summit 2011 - The Future State. The 9.10 am topic for the panelists was "The Secrets of Making A Best-Run Government Run Better; The Changing Mandate; The Shocking Disasters; The Future State

The Panelists were: Dr Anthony M Cresswell, Deputy Director, Center for Technology in Government, University at Albany, NY, USA; Zaqy Mohamad, Member of Parliament, Choa Chu Kang GRC, Singapore and Adaire Fox-Martin, SVP, Industry Business Solutions, SAP Asia Pacific Japan.

Mr Zaqy spoke about the better use of social media by politicians to engage the segment of the public. Apparently this had not been done effectively in the recent General Elections in Singapore if I heard Mr Zaqy Mohamad correctly.


The other panelist, Dr Anthony Cresswell talked about President Obama's Open Government's initiatives in the US and the difficulty of evaluating the key performance indicators of the services provided. It was an eye-opener for me when he said that over 80% of government computerisation projects fail.

What is the relevance of social media to veterinary surgeons in practice? There is a segment of the pet owners who are younger and would only be engaged through the use of social media. They will search for topics of relevance to their pet's illness and want to know which vet has the ability and experience to treat their beloved pets. Their own vet may not provide such a service.

Social media using webpages or blog requires the content to be created daily. There is now the twitter novel (short novels of 140 words are popular with netizens of China). Whatever the form, the contents must be updated daily or weekly to get a stream of "fans". Writing is very hard work for those who prefer not to touch a pen as there need to be research to produce a useful article. There are so many distractions and better things to do than to create good content after a hard day's work at the Surgery!

To illustrate the amount of work involved to produce a useful article, I will let readers know how I produced the article, "What Makes A Horse Racing Club Profitable?" This article was written in 1989 and the scanned pages are at Horses, starting with the first page at: http://www.asiahomes.com/dev/Stc1.JPG

On a recent encounter, 2 days ago on Jun 9, 2011, I met an aunty and her niece who brought a hamster with a large dangling ear wart to Toa Payoh Vets. This wart was initially very small but her vet said she would not operate due to the high anaesthetic risks. As the wart grew bigger over the last 4-5 months, her vet referred her to another vet whose location was quite far to her residence. So this aunty googled for "hamster, warts" and an asiahomes webpage, probably similar http://www.asiahomes.com/singaporetpvet/ popped out.
I was at the Surgery at that time and so I got the above-mentioned feedback from her. This episode demonstrated the culture and lifestyle of the younger generation. The aunty was around 30-40 years old. The niece was a teenager. I paid special attention to this case as I collaborated with Dr Vanessa to ensure that the outcome of anaesthesia was what the aunty hoped for. Signing an informed anaesthesia consent form is one thing. I don't usually request it but Dr Vanessa does.

What was important was that the hamster come out of the surgery room alive and biting (this hamster bites, the aunty had said). Obviously, I would bite if anybody messes around with my wart. The hamster was anaesthesized under isoflurane gas.

I kept a close eye on my assistant Mr Min telling him not to be distracted by looking for sutures etc while anaesthesizing the hamster. At one time, his eyes and one hand were on a drawer to take out a packet of suture for Dr Vanessa.

I told him off not to do it. "Hamsters die because there is no 100% focus on anaesthesia by one person or the vet." Unfortunately, new vet assistants and new vets need to be mentored closely. There is no other way to prevent anaesthetic deaths in hamsters. Deaths on the operating table damages the reputation of Toa Payoh Vets and I am very strict on anaesthetic training and procedures to ensure that no healthy pets should die on the operating table at all times.

Dr Vanessa excised the wart and sutured the wound. I proposed no suturing as the wound in the ear was so small and that bleeding would stop with pressure. As each vet has his or her own ideas, I will not interfere whenever an associate vet operates in most cases but I do monitor the handwork - the post-operation complications and the complaints. This is my duty of care for Toa Payoh Vets clientele.

Dr Vanessa decided to stitch up the wound. I recommended potassium permanganate to stop the bleeding. Each vet has his or her approach to a surgical case and there are several satisfactory outcomes on any approach. Bleeding still came back as I had predicted in this case. This bleeding was not life-threatening.

The hamster was now free of "shouldering" a burden. Actually, the wart of 1.5 cm x 1.2 cm x 0.5 cm looked so much like one of those big dangling ear rings worn by some ladies. The hamster scratched his left ear where the wound was. The aunty was concerned. So I proposed a paper e-collar. "The hamster hates it very much," I said to the aunty as she put the e-collar on. The hamster used all his two hands to pull out the hamster. Vigorously and angrily I think. So, no more e-collar. "Just use the clean tissue to wipe off the blood," I advised the aunty. "And take the medication." The niece did not say a word but I presumed she was the real owner of this beloved hamster and was happy.

P.S. What are the Secrets of Making A Best-Run Government Run Better? There were no clear list of secrets enumerated as far as I know. The political party who knows how to engage the Generation Y effectively will be the one to win their votes and get the increased mandate to govern if the Generation Y is the vote swinger. The Government is now said to be a business. So, the Government who provides "public value" to the citizens will be a better-run government.

468. What Makes A Horse Racing Club Profitable? Dr Goh Keng Swee's few good men and women

Dr Goh Keng Swee's few good men and women tasked to reverse the horse racing decline - Part 1

"Dr Goh Keng Swee's men will assess your performance. They use financial ratios," Mr Ismail, the Personnel Manager said to me, a Junior Veterinary Surgeon of the Singapore Turf Club in 1988.

The Singapore Turf Club prior to 1988 was a private club registered with the Registrar of Societies. I heard that "black balls" were shown when any proposed member is rejected by the Management Committee. Some time around 1986 or earlier, a newspaper report mentioned that the $286 million in the 1986 bank deposits could be shared by the 580 members if the Club was dissolved as it was a private club.

On Jan 1, 1988, the Singapore Totalisator Board (STB) was set up. It appointed the newly formed Bukit Turf Club as an agent to run the racing and 4-D operations in Singapore. The Singapore Turf Club was a private club and now would be "dormant" with the formation of the Bukit Turf Club.

So, my 6th year of employment contract was now assigned to the Bukit Turf Club in the sense that I was not asked to new a new contract which would be unfavourable to me as compared to the old contract.

Dr Goh Keng Swee who had retired from politics was the man in charge of the new changes. The "decision-maker" would be Mr Quek Chee Hoon, an accountant resigned from Temasek Holdings and was appointed as the General Manager of the STB. Mr Yu Pan Fey, an accountant from the Big Four (auditing firms) would be the General Manager of the Bukit Turf Club. The Senior Veterinary Surgeon was no longer my immediate boss as I had my performance assessed by the Chief Stipendiary Steward who was answerable to the Racing Manager who reported to another Head of Racing Department.

1988 - 1999 was a time of great changes for the Singapore horse racing industry and the people involved. A newspaper report said that the racing industry would benefit from the progressive management of the STB and would turn around the decline in the horse racing industry.

As a racehorse veterinarian working for the last 5 years with the horse trainers and jockeys, I talked to them. I could sense their hope and aspirations for a better future with the formation of the STB.

The trainers and jockeys are said to be the prime movers of the racing industry and they were not earning sufficiently from their hard work and getting into debts from bad horse owners, there was something wrong in the horse racing industry at that time.

Therefore, they looked to the leadership of Dr Goh Keng Swee and his few good men and women to do the right thing. Just as Dr Goh had done to revamp the Ministry of Education, as reported in the newspapers.

What was the right thing to do to reverse the decline in racing? The STB's leadership had pin-pointed the problem - a trend of decline in racing profitability. In 1988, almost all of the STB members had no horse racing proficiency, judgment or training in the business of horse racing.

In fact, the majority of top civil servants and politicians did not want to be seen inside the premises of the Singapore Turf Club unlike in countries like the U.K and Australia. The ex-Prime Minister Lee Kuan Yew first visited the Singapore Turf Club officially only sometime in 1987 and that was the first time I saw him at the Paddocks where horses were checked prior to going out on parade.

I was only an equine veterinary surgeon with 5 years of employment at the Singapore Turf Club. No track record or qualifications in business management. Around 8 years of veterinary service in the Primary Production Department dealing with pigs and chickens. Then another 5 years dealing with horses.

The reverse in racing decline was a management problem. It was not a veterinary problem overall. It was none of my business. I treated equine problems, not human ones. Yet much could be improved in the lives of the trainers, jockeys and the racehorses if I would not be selfish and know what to do.

Knowing what to do in a time of crisis and great upheavals of the workplace is the most difficult thing for most people. I could complete my last year of employment contract as it was most unlikely that the new management would want to terminate my services or the services of the racing and betting managers as they were well chosen to be Dr Goh Keng Swee's team. It seemed to me that they were mostly trained in accountancy.

So the financial ratios that the Personnel Manager spoke to me about made sense. What financial ratios would be applicable to monitor the performance of the Veterinary Department of the Turf Club? I had no clue as I had not been interested in business or financial management in general.

Updates later. See www.toapayohvets.com, goto HORSES

Monday, June 6, 2011

467. Seeing is believing

"Doc, my Dachshund has a big lump behind his neck?" the lady owner phoned me regarding a big lump in her Dachshund. "It appears in the last 2 days. I think it is due to the tight bandage. What shall I do?"

"Is it as large as a ping pong ball?" I asked.
"Yes."
"It may be an abscess (pus inside) or a haematoma (blood inside)," I said. "It is hard to diagnose without examination."

She brought the dog in on Friday evening. "Well, there is no pain in this lump," I said as I pressed it. Firm and tense, around the 3/4 of the size of a table-tennis ball. I scheduled for surgery on Saturday, forgetting I had my day off on Saturday.

"I can't come on Sunday," the owner phoned me. "I have to travel overseas on Sunday. Can the lump wait till I come back 10 days later?"

"It is best not to wait. The lump could harden or the bacteria inside could spread to the muscles, making it very painful and hard to operate. Can you ask your husband to bring the dog in on Sunday at 9.30am so that I can operate first thing in the morning?"

I was surprised she was single as she had that essence of a combination of inner and outer beauty. "Well, I can arrange for a dog taxi man to bring the dog to the Surgery."

She said she would phone me and later made an appointment for Sunday morning 9.30 am. She was very punctual.

"There is no electricity," my assistant Min suddenly told me. The HDB management had given prior notice of no electricity supply till 9 am on Sunday morning but my staff did not inform me.

"What to do?" the lady owner asked me pleasantly. That is her personality. Not to get angry over unexpected circumstances beyond her control.

"Don't worry," I said. "The dog will go home at 11.00 am". My operation room has glass walls on one side facing the back door which brings in the morning light and a glass screen between it and the consultation room, bringing in daylight from the consultation room. It is not a windowless operating room as in most surgeries. We have torch-lights too.

I told Mr Min to clip as I had sedated it with 0.3% xylazine IM. Min said, "No electricity. You cannot use the gas anaesthetic machine."

I shook my head. "Do anaesthetic machine need electricity?" I asked Min shaking my head. Sometimes I can get very impatient with such feedback with no basis.

This was the Dachshund's 3rd anaesthesia and though nothing ought to go wrong, I did not want to tempt fate as old dogs are high anaesthetic risk. On the other hand, I could just sedate the dog and drain the abscess and cut off the hock melanoma spotted by the owner. It could be painful. A higher dose of sedation may also kill the dog.

Therefore a light sedation of xylazine and isoflurane gas is the best safest method of general anaesthesia. This was done and the dog was as awake as a normal dog when the happy owner came in a taxi to pick him up to go home.

"A lot of gas and blood with pus," I said to the owner.
"Really?" she replied.
"Min, take out the syringe with the blood and pus," I said.
I forgot to present the syringe but I did stick the melanoma from the hock to show her.
Min took out the syringe and the lady was convinced. Seeing is believing in veterinary medicine. I do not know why I had not shown the syringe earlier.

Emergency surgery lights can be installed. However, these must be maintained and tested weekly as they do fail if they are not tested.

This is the Dachshund's 3rd anaesthesia in 2 months. It is best not to tempt fate anymore.



http://www.sinpets.com/F5/201006252abscess-haematoma-Dachshund-old-ToaPayohVets.htm
has all the pictures. One of them is shown here.

Saturday, June 4, 2011

466. Family firms must plan their succession well & UVP

The founder of a family business must be able to plan his succession well. Otherwise, family feuds ruin the business. There will be no business continuity during the critical period after the founder dies.

What can be done?

1. Systematic and organised handing of control to the next generation to prevent family feuds.

2. The founder has to resolve some conflicts. One big conflict is between the family's welfare and the company's value. The patriarch is responsible for finding a job for the adult children of the family. If they are capable, they will grow the business. If they are not capable, they are going to hurt the business. If the patriarch does not put the son in the company, the wife will not be happy. So, there are dilemmas for the founder.

3. If the company has a lack of talent, it can trust outsiders to hold the fort before the children can take over. But it has to offer good pay and an equal chance for promotion to attract talent. This may not mean that "loyalty can be bought" as good talent may set up a competitive firm.

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Enterprises must be more innovative and continuously offer a strong and unique value proposition (UVP) to their clients to stay ahead of competition. How to do it? That is the question hard to answer.

465. Real estate: REA examination question

In May 2011, I attempted to answer a main question on REIT and another one on one part question on REIT. It is a tough question to answer as I don't know what the examiner wants.

Some detailed report is presented in The Business Times Weekend, Apr 30-May 1, 2011 Pg 30 Smart Money. This is for the benefit of future students of REA and in case I fail this exam.

Its topic is "Reit or business trust?" and has a detailed technical report comparing listed companies, business trust and reits.

1. Vehicle
2. Corporate Governance
3. Gearing limit
4. Dividend distribution


Reits - Unit holders --- Manager -- Trustee

I guess I would not get good marks as I didn't write about the above.

464. What is effective leadership?

Managing a veterinary premises require excellent leadership. Otherwise, the business may close down. What is effective leadership?

I read The Business Times, May 14-15, 2011, Pg 8-9, Raffles Conversation. Robert Hogan, president and founder of Hogan Assessment Systems.

Briefly, Mr Hogan said that leaders are made, not born. A good leader is one where employees will work for him on their own free will. The leader's performance is assessed on his ability to build and maintain a team. Employees evaluate the leader under 4 aspects:

1. Integerity. Whether the leader is honest and can be trusted not to play them out.

2. Judgement. He said that 50% of business decisions are made by bad judgement. A good leader is one who is able to repair the bad judgement rather than know how to make a good judgement.

3. Competence. Know about the business. I often call that "Know what to do" in your profession. Not a "blur" king.

4. Vision. Able to explain, justify and convince the employees that what they do is worth their while.

Therefore a good manager makes money. A poor one incurs unnecessary costs and is unable to maintain the good talent. A good one creates high turnover, low absenteesim, high productivity and high customer satisfaction.

It is difficult to be a leader when you are not fit to be one as the business just will not succeed as there are high overheads and low turnover, making the company bankrupt. That is why it is extremely difficult to invest in a veterinary premises and expect to employee vets to make money for the investors. It seldom works.

Friday, June 3, 2011

463. USP - A Timberland boy of Lake Indein, Myanmar

A USP (unique selling proposition) is very important for a person or for any business to have a chance to succeed. It positions the person or business foremost in the mind of the other friend or client respectively. In a photo contest, a USP of a picture is also needed as I will illustrate below.

Three days ago, I read the Digital Life magazine and saw a photo contest sponsored by Timberland whose products I have never bought. The photo contest is at: http://www.earthkeepers2011.com/sg/home.aspx.

The prize is a chance to be part of our Timberland® Earthkeepers™ reforestation activity in Horqin Desert, Inner Mongolia, and a nature appreciation trip to Jiuzhaigou Valley.

It is the category of travel I love very much as I get to see raw nature and it will be too expensive to go to such places.

However, I need to be realistic as my digital photography is not up to competition standards. Should I give up?

The theme was to tell a story in a picture with the theme:
What is your relationship with the outdoors?

I viewed my various images and came across the following. It is just an ordinary image of two boys standing on the banks of Lake Indein in February 2011 when my wife and I visited Myanmar. Nothing unique about two boys trekking along the bank of a stream of Lake Indein. The photograph was not of a high quality.

Then I saw the Timberland logo on the boy's shirt. The Timberland logo is the USP (unique selling proposition). This photo definitely will catch the eyes of Timberland judges owing to the logo unless they are blind.

It opens the door to a rare opportunity for a winner to participate in a reforestation project of a desert in Inner Mongolia.

So, how should I go about using this picture to show that "nature subtly connects our lives with meaningful relationships" as required in this contest?

I don't know exactly but the following image is my first draft, taking me over one hour to create the image. There are grammatical mistakes which I could not see yesterday.

What's the big deal about a boy wearing a Timberland shirt in Lake Indein, Myanmar?

Well, it is rare to spot a Timberland T-shirt in Yangon and Lake Indein is considered a remote area of Myanmar. I was in the boat much appreciative of being alive and healthy. I was able to see the willowy grass, hear birds chirping and smell clean unpolluted air and befar away from the urban jungles of Singapore.

For that brief instant when I clicked my camera, I realise that I was once like this Timberland boy. At his age, I was living with my grandparents in Bentong, a village in Pahang, Malaysia. Every morning, I would cycle with another boy to a stream to swim and to appreciate nature. Now, Singapore's children don't get this opportunity and to most Singaporeans, especially the females, a good travel itinerary is shopping. Not nature.

Try to enter photo contest and even if you don't win, you have educated yourself in being hands on, in creating a picture and writing text that would be much improved when you practise for many times. Just do it and you will find that your ability to take pictures and write better will come to you naturally.

Wednesday, June 1, 2011

462. Poor administration of a top Junior College in veterinary internship

Today is the 3rd day of her 10-day internship and she asked: "My mum asks if I have to work on weekends."

"Didn't your XXX (a top Junior College in Singapore) teacher tell you about the terms and conditions of internship at Toa Payoh Vets?" I am surprised that there was no disclosure from a top school. It speaks poorly of the administration. Students who want to study vets do e-mail me direct. I just interviewed one from ACS (Independent) 2 weeks ago. She could come for only 3 days. Straight As in her "O" levels and two testimonials from her teacher as required. For XXX, it seemed that the administrator does the match-making and there was something inherently defective in its system of not disclosing what is required for the intern who came to Toa Payoh Vets.

"Well," I said. "You don't have to come to work if you think that vets only work during office hours and not on weekends. Some interns work even after midnight but you are exempted. What did your teacher say about weekend work to you?"

"She said to inform her if I am required to work weekends." There was something not right somewhere.

"Vets in small animal practice work very long hours," I said. "Some emergency cases of Caesarean sections require 3 am surgeries and the next day, I walk like a zombie. If you want a 5-day week, don't become a vet."

XXX may be a premier school but it is not doing its students a service by providing a poor quality of administration. XXX e-mailed to me asking whether I would accept interns for the June holidays. I told the administrator that two testimonials are needed and the working hours are long. If the prospective student has no interest in veterinary medicine, don't even recommend him or her.