Saturday, July 30, 2011

526. Four packets of stitches to spay a female dog is extravagance

Best Time To Spay Your Female Dog
- A Dream Spay
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written: 23 November, 2007
Update:  31 July, 2011

When the dog owner is well informed, a spay operation in the female dog can be a very smooth operation taking less than 30 minutes.

Today was such a day. The Miniature Schnauzer, born in Dec 3, 2005 was on heat 4 months ago. She was spayed today Nov 23, 2007 as the owner was advised to do so 3-4 months after heat and she made the appointment at the 4th month.




My assistant Mark talked to the dog as he put the face mask over her muzzle. She did not struggle and went to sleep under 8% gas anaesthesia within 10 minutes. No tranquilisation was needed. I inserted the endotracheal tube to connect her lungs to the anaesthetic machine, maintained the anaesthesia at 1.5%.

The incision was 2.5 cm from the umbilicus. A 1-cm cut into the skin and the linea alba to access the internal organs of the womb and ovaries. I inserted the spay hook into the abdomen by turning it towards my right at 45 degrees caudally.

It hooked out the left uterine horn. I pulled the left ovarian ligament. The dog started to breath much faster as she felt the pain. My assistant increased the gas to 8% for a minute so that the dog had more gas to remove the pain of surgery. The minimal amount of gas given will lead to no deaths and that was why I used 1.5%.

No more rapid breathing observed. I cut the ovarian ligament with the scalpel. Clamped the ovarian stump. Ligated the stump. Then I pulled the left uterine horn totally out of the body and saw the right uterine horn at the uterine body junction popping out. I used forceps to pull it out.

From there, I accessed the right ovarian ligament and repeated the same procedure as with the left. No bleeding. The blood was normal red with oxygen. The dog was breathing regularly. Finally, I took out the uterine body, clamped and ligated it. It was let go into the abdomen.

The skin and muscles were stitched up. The gas anaesthesia was switched off as I stitched the skin. No bleeding from the ovarian and uterine tissues at all as the dog was no longer on heat.

The dog woke up smoothly after 3 minutes. An Elizabeth collar was given to prevent licking of wound. Overall, this was a dream spay. It was the most satisfying spay I had ever done as everything proceeded smoothly, there was no bleeding and therefore the surgical time taken was less than 30 minutes. The dog woke up by the last stitch as I had the gas reduced to 0% during stitching which is usually one horizontal mattress stitch. She went home without complications post-operation as the owner did not phone me nor came for stitch removal, thus saving time for him.

QUESTIONS THE OWNER ASKED:
1. Bathe the dog? Yes, but make sure the plaster is not wet.
2. Can the dog eat any food? Yes.
3. When to come back to remove the stitches. No need. The absorbable stitches will dissolve and fall off in 14-28 days.
4. When to remove plaster? 7 days later.
5. Can give antibiotic and pain-killer tablets crushed and mixed with water inside a syringe? Yes.
UPDATE IN JULY 2011

ANAESTHESIA IN TOA PAYOH VETS
A new isoflurane vaporiser has been installed in July 2011. Maximum is 5%. The dog is usually sedated with xylazine or domitor before isoflurane gas is given by mask and then intubation.

USE OF SUTURES IN SPAYING A FEMALE DOG BY DR SING
For dogs in general, I find that one packet of 2/0 absorbable sutures is sufficient, even for big breeds like the Siberian Husky. From my over 30 years of spaying dogs, I find that there is no need to do a subcuticular sutures. One horizontal mattress suture closes the skin as shown below.

ADVICE TO NEW VETS
There are employee vets who use two packets to spay a female dog as they don't need to account for the bottom-line.

In July 2011, I discovered a vet who used 4 packets of sutures (2 packets of "0" chromic catgut and 2 packets of "3/0" absorbable monofilament) for pyometra surgery in a Maltese. This is extravagance from this vet who does not have to pay for the sutures herself. There is a need for a new vet to be prudent and to keep surgery simple and safe for the dog. In this case, 2 packets of sutures will be more than sufficient and that will be the industry's bench mark.

Keep spay simple for the dog by using minimal suturing. Less sutures mean less irritation and itchiness during healing. There is no need for subcuticular sutures. If you feel the need to impress the client by using "subcutaneous" sutures (sutures under the skin) so that the client does NOT see any sutures on the skin, you need to have excellent stitching skills. No point showing the sutures or stitching another appositional layer if you want to impress the client.






A RARE CASE OF PYOMETRA IN A VERY YOUNG FEMALE DOGPyometra in a very young female Silkie Terrier is very rare as this womb infection occurs usually in female dogs over 5 years of age. By spaying her, the owner prevents pyometra which can cause death in some female dogs.


Photos and more details at:
http://www.sinpets.com/stories/20090520Spaying_Female_Dog_ToaPayohVets.htm

Friday, July 29, 2011

524. Survey on post-op licking of wound by a male Yorkshire Terrier after neuter

Surveys are important to assess the efficacy of the pain-killer tolfedine which I usually prescribe for dogs after surgery e.g. neuter and spay. Tolfedine is a NSAID. It has anti-fever effects as well as pain-killer. Below is one survey by e-mail feedback from the owner.

E-MAIL TO DR SING DATED JUL 12, 2011
On Tue, Jul 12, 2011 at 6:39 PM,

Dear Judy,
I have a one year old Yorkie that we want to neuter. Please advise how much will the procedure be and when is the earliest time that we can bring him down. You can reach me at .... if you need any further info.

Thank you.

Best regards,
Name of owner

E-MAIL REPLY FROM DR SING DATED JUL 12, 2011

Thank you for your email I am Dr Sing from toapayohvets.com

The cost of anaesthesia, surgery and post-op pain-killer and antibiotic injection is estimated to be around $150-$200 for dog breeds less than 5 kg and without surgical complications and have two descended testicles. You have a choice of 3 vets, namely myself, Dr Vanessa Lin and Dr Jason Teo.

If you want me to neuter him, please bring him down at 9.30 am from Monday to Friday. No food and water after 10 pm the evening before surgery. Phone 6254-3326 for appointment. The dog will be operated at 10 am and goes home around 12 noon or later in the day if you are not free. The dog should preferably be vaccinated within one year and in good health. Bathe the dog first and clean up his lower area.

Best wishes.

E-MAIL TO DR SING DATED JUL 16, 2011

Hi Dr Sing,

Can I book an appointment with you this coming Thurs? I'll bring him down at 930am and pick him up later part of the day. Look forward to your confirmation.

Best regards

E-MAIL FROM DR SING DATED JULY 16, 2011

Thank you for your email. Thursday 9.30 am will be OK. Will see you this Thursday.

E-MAIL FROM DR SING DATED JULY 23, 2011

Hello
I could not contact you by phone to enquire the post-operation situation in your dog. Please let me know whether your dog is recovering well with no bruising trauma to his operation area and when you give the medication of tolfedine.

Best wishes.

E-MAIL TO DR SING DATED JULY 23, 2011

Hi Dr. Kong,

He is doing well except that he looks kind of tired which I expect from the op. Please advise when can we remove the plaster from the op area. Thanks.


Cheers.
E-MAIL FROM DR SING DATED JULY 25, 2011
Plaster can be taken out on Day 7 and clean wound. He should be OK, not tired after Day 3.

E-MAIL FROM DR SING DATED JULY 25, 2011

Further to my email, please let me know whether your dog has tried to lick his surgery area and the dosage of painkiller tolfedine and duration (at what time) you give to him as your sister was the one present at the Surgery. This is because I am gathering some info on the usefulness of tolfedine on Yorkshire terriers. If he does not lick his surgery area, then it is effective.

Best wishes

E-MAIL TO DR SING DATED JULY 25, 2011

Hi,

Even with the neck guard (not sure what is the term for it), he have managed to find ways to lick his wounds….He is recovering well but seems that the antibiotic did not work well as he does want to lick his wounds.. His plaster came off last night. Wound area seems to be quite okay.

Cheers
E-MAIL FROM DR SING DATED JULY 27, 2011

Can you let me know the estimated times per day and how long you gave him the tolfedine painkiller tablets?


E-MAIL TO DR SING DATED JULY 27, 2011

Estimated times per day in terms of licking the area? I am not too sure but based on what my maid told me… As much as possible when he can push the collar off in the position where he can lick it. The painkiller was given as instructed.


Cheers

E-MAIL FROM DR SING DATED JULY 28, 2011
Thank you for the feedback. I am glad he has no big problems.

CONCLUSION

Two Yorkshire Terriers of similar ages were neutered at around the same month. Both had normal testicles inside the scrotum. No post-operation complaint. As the dogs were given 2/0 absorbable stitches, I don't get to see them 14 days after operation as in the old days as the stitches will drop off after 21 - 28 days usually.
Tolfedine is given once a day for 4 days at 4mg/kg orally from Day 2. From Day 1, after the operation, the dog will be given a tolfedine injection as well as a baytril injection SC. In the above Yorkshire, I advised tolfedine oral twice a day for Day 2.

As for adult male dogs trying to lick the surgical area, this is a common post-operation behaviour. Tolfedine, an NSAID and anti-fever drug reduces the pain and inflammation and much less post-operation licking in most dogs, in my experience. Sometimes, the owner forgets to give on time, and this may result in vigorous licking and bleeding.

Surveys after surgery and from customers are very important for any enterprise. When I went to visit Malacca on a Saturday July 23, 2011, I noted that the tourists were given some survey forms. I post a picture of two pretty tourists writing their opinions on a form for readers to appreciate the beauty of the two English roses.


Updates and pic are at:
http://www.sinpets.com/F5/20110731survey-tolfedine-post-op-Singapore-ToaPayohVets.htm

Bilateral cryptorchidism surgery

On this bright Sunday, July 24, 2011 morning, I was preparing to operate on the Silkie Terrier with "the mother of all perineal hernias" as described in Perineal hernias in a Silkie Terrier repair pictures. Update on a Boston Terrier's perineal hernia. The dog had his hernias repaired 11 days ago. However, the skin where his herniated bladder and intestines had crushed had little blood supply and the cells started dying. This is called gangrene.

A young couple arrived promptly at 9.30 am as they had made an appointment with me. They wanted to neuter a good looking solidly built miniature 2-year-old "miniature" Bull Terrier.

A hyperexcitable dog, resisting handling and turning upside down to examine his testicles which were not present inside the scrotum as in normal male dogs.
 
"Listen to the whistling sounds," I handed the hearing piece of the stethoscope to the husband so that he could listen to the whistles. I could hear the heart sounds separately but the continuous whistling sounds blocked out the heart sounds. This sounds reminded me of a condition similar to the racehorse - laryngeal hemiplegia.

"They are heart sounds," the husband declared. I asked if he had medical training but he had none. He heard loud distinct whistles in the stethoscope and therefore deemed them to be heart sounds.

"Well, they are lung sounds," I said. The heart sounds were muffled and he could not hear them since he had no experience with dog heart auscultation.

SYNCOPE
It was in 1974 when I was in my 5th year of veterinary studies at Glasgow but I still remember the word "Syncope" mentioned in my veterinary lectures. At that time, syncope was a word meant to be remembered for the examinations. I seldom encountered this transient fainting and spontaneous recovery after a short while in dogs in my over 30 years of practice. This miniature Bull Terrier appeared to be suffering from this condition and more detailed heart examinations including the ECG will be needed.

The dog has a history of fainting when over-exerted. "When he plays vigorously with the bigger and younger 8-month-old standard Bull Terrier, he could just simply collapse, as if out of breath and lie down for a while. Then he would recover completely. As if he has caught his breath and behaves normally."

This bit of information from the husband is valuable. It indicates that this dog has a cardio-pulmonary problem. He is a highly risky candidate for anaesthesia. I checked the gums. Excellent pink colour. However, the left inside lip had a yellow ulcer and several holes. "Bitten by the other bull terrier?" I asked. "Probably," the husband said. "They bite each other."

Two undescended testicles. With the dog upside down, I could palpate the left one. The right one was barely felt as it slipped inside the body. "My advice is to prepare for general anaesthesia rather than just take out one. When the dog is down, his right testicle may just disappear inside. Under anaesthesia, I can open up the abdomen and locate and get it out. (Undescended testicle can become cancerous years later). Neutering was to reduce his hyperexcitability.

BLOOD TEST
The couple agreed to the complete blood test. The liver enzymes were high while the platelets were below normal.
"Why?" the husband asked.
"Did you feed herbal or other supplements?"
"Yes," he said. "One iodine capsule per day since he was a puppy."
"Is the dosage recommended for the dog?" I asked.
"I gave one capsule as recommended for adult people," he said.

HIGH ANAESTHETIC RISKS
Based on his history of syncope, the liver disorders and low platelet count, I advised against surgery for the time being. Another blood test can be taken 4-12 weeks later. Definitely, no more iodine or other supplements and wait one month for another blood test.

The liver could have had been damaged by the iodine and its other ingredients consumed over the past 2 years. "It is not just iodine alone inside the capsule," I said to the husband. "The manufacturer will add other substances. Over the years, the liver could have been damaged. As to why the dog was given iodine, I did not ask the owner. It was good that he agreed to a blood test.

UNDESCENDED TESTICLES if normally felt under the skin can be easily removed via skin incisions as shown in the case of the poodle below. In this miniature Bull Terrier, one testicle is barely felt.

To save on veterinary cost and the need for another operation to open up the abdomen to remove the hidden testicle, it is best to put the dog under general anaesthesia, open up the abdomen, locate and remove the abdominal testicle inside as well as to remove the inguinal testicle under the skin.

INFORMED CONSENT
If the dog is healthy, there should be no anaesthetic risk but this miniature bull terrier has some health problems. So, the owner has to take the risk and be given proper information of the risks and options (informed consent). It is best that this be recorded in the case files, in case of litigation and complaint when the dog dies on the operating table.

NEGLIGENCE AND REMOVAL OF THE HIDDEN ABDOMINAL TESTICLE NEEDS A LONGER SURGERY
In some practices, since the dog has only one undescended testicle felt under the skin, this is only one that will be removed during the traditional neuter while the abdominal one is not as that necessitates opening up the abdomen, prolonging anaesthesia and increasing the risks of dying on the operating table. This is not in the interest of the dog or owner as the hidden testicle inside the abdomen can become cancerous in old age and I had seen some cases (revealed by X-ray). A negligence litigation suit may result.

Therefore, the owner must be well advised and both testicles must be removed. Not just the one under the skin. The hidden testicle is usually seen located just below the mid-penile area and can be hooked up to be tied and taken off.

Cryptorchidism can be either bilateral or unilateral, and inguinal or abdominal (or both). This poodle has bilateral inguinal cryptorchidism. Therefore you can see both undescended testicles under the skin. In abdominal cryptorchidism, the testicles are inside and there is a need to open up the abdomen to take out the "hidden testicle."


 In the case of the miniature bull terrier, one testicle is in the inguinal and one is retracted into the abdomen when the dog is held upside down. Neutering or castration is strongly advised as there is a high chance of the undescended testicle becoming cancerous in older dogs.

Pictures of bilateral cryptorchidism are at:
http://www.sinpets.com/F5/20110730syncope-undescended-testicles-miniature-bull-terrier-Singapore-ToaPayohVets.htm

Thursday, July 28, 2011

523. Food and dog treat allergy cases in two female dogs

Friday, July 29, 2011. Half a year had flown by! I am still practising but I sometimes still do the routine cases of spay and neuter at 9.30 am and handle the complex difficult cases such as the Silkie with the big backside perineal hernias as written in: Perineal hernias in a Silkie Terrier repair pictures. Update on a Boston Terrier's perineal hernia

I narrate two recent interesting skin disease cases I chanced upon as they seem to be associated with dog treats.

CASE 1.
Yesterday, July 28, 2011, Dr Vanessa left at 6.30 pm as she had asthma the day before. Actually she had informed Min that she would be back 3 days later. I quickly informed her clients to postpone her appointments as I don't want them to be upset when they come.

Veterinary medicine at Toa Payoh Vets is much personalised and since she handles most of the day cases, most of my clients get used to consulting her since I seem to have "retired." Succession plan is taking place as I am over 60 years old and must leave space for the younger ones to bear the responsibility and learn from practising. I do intervene in my associate vets' cases when I need to.

One of her clients was looking for her today and she suddenly appeared after 11.00 am and so I passed the male cat couple whose daughter wanted her to neuter him. I was manning the reception counter while my assistant Mr Min went for dinner.

Suddenly, an old client with a 4-year-old Maltese X came in for vaccination. She was abandoned and was adopted by this man in his 40s as the 4th owner. The man reminded me that I had diagnosed some urination problem. "It is called submissive urination," I said. "She would empty her bladder when any person approaches her. Is she better now? Confidence build up will lessen her problem. Bring her out more often."

The busy printer owner said: "I only bring her out to pee and poop once a day. Then it is back to the apartment. She definitely has better control of her bladder. When she sees other dogs when we go out, she will bark loudly."

"Does she pee?"
"No, but she will run away after barking."

"You ran out of Hills' ZD diet and so I went to the pet shop to buy Hills' Skin Sensitive Diet since they can't sell Hills' ZD diet. My dog now no longer itches. Hills' brand is very good. Anyway, the ZD produces a very sticky dog poo and so it is not good for me. This Sensitive Diet produces well formed stools that do not stick to the floor as you can see!"

The dog pooped 2 lumps. I used a toilet roll tissue to pick up the two stools instead of ordering my assistant who had just come back from dinner.

"It is not any Hills' brand that resolve your dog's skin itchiness problems," I reviewed his dog medical records. I spayed the dog in June 2011 and prescribed Hills' ZD diet twice. He switched to the Hills' Sensitive Skin diet since I ran out.

Very little scratching except for some black ear wax. One of two scabs in the belly and chest sternum. He as very happy as his dog had this skin problem of itchiness and hair loss for over two years before spaying. She had received treatment for ringworm and had her shampoos.

To the owner, the dog no longer itches and he does not need to cook home-cooked food for the dog, an inconvenience. Just feed this Hills' brand.

In my experience, spaying sometimes do resolve the skin itchiness. As to why, I don't know but it has been reported by some vets and I had a small number of dogs recovering. However, this dog also is no more given the dog treats unlike last time. It is possible that she could be allergic to dog treats in the first place. Eliminating dog treats resolved the problem. Spaying to remove hormonal imbalance. Nobody knows scientifically why this dog has no more skin itchiness problem.

CASE 2.
On the previous day, that is, Wednesday, July 27, 2011, I went to the Surgery at 8 pm to do a surprise check. It is a heavy responsibility being the licensee and founder, but such audits need to be done as the Toa Payoh Vets practice I founded is still a rebellious teenager and needs my personal attention.

Around 50 vet practices have sprung up in Singapore in 2011 and the old practices can be complacent and go bankrupt if poorly managed. Success is not a given in any business or medical practice just because the practice is established as competition becomes more intensive. Success depends much on the vets or doctors but the management of the practice (quality of veterinary services, over-ordering and unnecessary use of products by associate vets, clinical outcomes by vets, economics, human resources, strategic planning, amongst others) is extremely important

Dr Jason Teo was to be on duty at night. An adult daughter and her mother with a spayed female Maltese came in. They had consulted me 3 weeks earlier about itchiness in this dog's ears, elbows, armpits, groins, paws. Just scratching and scratching and I had asked for a review 3 weeks later. They don't mind consulting Dr Teo too as they had seen him earlier.

"Well, the dog started scratching 3 days ago, when your medication was finished," the daughter said. "So we come in for a review." As Dr Teo had not arrived, I checked the medical records. I examined this dog. Eyelids rubbed red. Ear pinnae flamingly reddish pink. Four paws itchy and licked. Elbow front show reddish bloodied streaks due to licking. Groins reddish. Armpits were OK for the time being. These were signs of allergies which had been present for the last two years. What is the cause?

Dr Teo arrived soon and I asked him to come in to collaborate on this case and to do a proper recording. He would be opening his own practice and it is good that he does so since he has been with me as an associate vet for at least 4 years.

"Do you give dog treats?" I asked the mother and daughter who expected more anti-itch medication, drugs and shampoos.

"Yes, I just bought a big bag of treats."
"No treats. Just switch over to Hills' D/D diet for 2-3 months," I said. "Not even one treat."

"My dog can't survive without any treat," the mother said. "What do I do with my big bag of treats?"

"After 3 months of feeding Hills' D/D diet and if the dog does not itch anymore, you can give the treats," I said. "If the dog starts being itching again, then you know it is due to the treats. Give 90% of the old dog food and treats for the first 3 days, then slowly change to 100% of D/D in 14 days," I advised.

As to whether the owners will comply, it is hard to say. This Maltese is definitely a case of generalised allergy. It was no longer generalised ringworm as in the past. Ringworm is also a very itchy skin disease for most dogs.

As to the exact cause, it is hard to say unless the vet knows all about the dog's lifestyle and environment. For starters, I advise an anti-allergic dog food and if this works, there will be much happiness and convenience as well as money saving for the owners.

These two cases are examples of allergies with one cause being the various brands of dog treats being given. Prescription diet for dry dog food allergy may be one way to elimination of the cause. Spaying may help too.

522. A hamster's orange urine - ageing or illness?

E-MAIL REPLY TO DR SING DATED JULY 29, 2011
Hi Doctor Sing,

Hope this email finds you well.

I've another dwarf hamster (1yr 7mths old, male). Recently, i noticed that his urine turns darker in colour. Last week, it was kind of orange and this week slightly better as you can see in the attached picture.

When I flip him over, i noticed that his fur around belly & bottom area have also turned yellow/orange from the urine stains which cannot be removed with water.

Despite so, his appetite & bowel movement remains normal just that his breathing/heart beat seems a lot faster even while he's asleep.

Appreciate your advice if this is normal in aging hamster or could it be sign of any illness that requires medical treatment.

Enclosed is the picture for your review.

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

Best regards,
Name of lady owner


E-MAIL REPLY FROM DR SING DATED JULY 29, 2011
Thank you for your email. It is very difficult to know what is the cause of the urine stains or change of colour unless a urine sample can be collected for urine analysis.

Your picture of urine colour shows some orange or reddish colour of urine as well as yellowish urine but no diagnosis can be made based on colour. The urine needs to be collected and analysed by the laboratory.




A change of urine colour may be due to a kidney disorder, urinary tract infection, urinary tract tumours, food colouring, traumatic injury (falling down from climbing cage) to the bladder and kidneys or other reasons.

I advise
1. collecting a urine sample via a plastic bag or come to the Surgery for me to collect a urine sample.
2. Let me know how much water he is drinking. Is it more than normal?

With best wishes.

With best wishes.

Tuesday, July 26, 2011

Sunday's interesting cases - stitching up a big backside gap

Sunday at 9.30 am was scheduled for me to stitch up the poor Silkie's big backside holes. He had a big Taiwanese mango lump in his backside some 10 days ago. The intestines and bladder popped out from his pelvis and rubbed against the skin. He licked till the skin became paper-thin and you could see the intestines just lying under. The blood supply and the subcutaneous fat and skin dermis layers were almost wiped out. No blood flowed. So, the area became white as snow (see pictures).

After I repaired the 3 hernias, the thin skin became gangrenous. So, the skin died day by day and 3 big hole appeared. I took 1 hour to re-do and re-stitch. If not done, the stools just drop into it.

520. Sunday's interesting case. The whistling Bull Terrier

Sunday

A young couple wanted to neuter a good looking solidly built miniature 2-year-old Bull Terrier and came at 9.30 am on Sunday July 24, 2011.
A hyperexcitable dog, resisting handling and turning upside down to examine his testicles.
"Listen to the whistling sounds," I asked the husband to listen to the stethoscope. I could hear the heart sounds separately but there was a continuous whistling sound, as if the dog has a condition similar to the racehorse - laryngeal hemiplegia.

"They are heart sounds," he said. Loud distinct whistles. "Well, they are lung sounds," I said. The heart sounds were muffled. Well, the dog had a history of fainting when over-exerted. When he played vigvigorously with the bigger standard Bull Terrier, he could just run out of breath and lie down for a while, as if to catch his breath.

A highly risky candidate for anaesthesia. I checked the gums. Excellent pink colour. However, the left inside lip had a yellow ulcer and several holes. "Bitten by the other bull terrier?" I asked. "Probably," the husband said.

Two undescended testicles. With the dog upside down, I could palpate the left one. The right one was barely felt as it slipped inside the body.
"My advice is to prepare for general anaesthesia rather than just take out one. When the dog is down, his right testicle may just disappear inside. Under anaesthesia, I can open up the abdomen and locate and get it out. (Undescended testicle can become cancerous years later). Neutering was to reduce his hyperexcitability.

BLOOD TEST
The couple agreed to the complete blood test. Fortunately, this was done as the liver enzymes were high while the platelets were below normal. "Why?" the husband asked.
"Did you feed herbal or other supplements?"
"Yes," he said. "One iodine capsule per day since young."
"Is the dosage recommended for the dog?" I asked.
"One capsule is for adult people," he said.

I advised no surgery, no iodine or other supplements and wait one month for another blood test. The liver could have had been damaged by the iodine and its other ingredients. "It is not just iodine alone inside the capsule," I said to the husband. "The manufacturer will add other substances. Over the years, the liver could have been damaged.

Monday, July 25, 2011

519. Advantix spot-on for dogs only, not for cats - update

The following has been updated today as there was an error in the earlier article stating that imidacloprid is toxic to cats. Bayer Thailand pointed out this error, namely that imidacloprid is safe for use in cats but it is permethrin that is toxic in cats. Since Advantix contains imidacloprid and permethrin, it is NOT safe for use in cats e.g. in the treatment of FAD (flea bite dermatitis).

On March 13, 2010, I attended a continuing education programme "Canine Vector-Borne Diseases in Pet Practice - Focused on Singapore" conducted by Dr Susanne Siebert. The contents were mainly on diseases transmitted by ticks, fleas, mosquitoes and sand flies. Heart worms and intestinal worms were discussed too.

For 4th & 5h year students, veterinary parasitology and pharmacology can be very boring as there are so many names and drugs and their efficacy, safety, ease of application, treatment schedule and ability to only treat or treat and prevent. How is the lecture relevant to the real world? I hope the following summary of my comments on "Bayer Parasite Solutions" may make their studies more enjoyable and in case they get tested at oral examinations in their final year.

1. Drontal Plus - One-dose dewormer
2. Advantix - Kills and repels. Not to be used in Cats.
3. Kiltix collars - Long-acting specialist against ticks
4. Bayticol - Anti-tick dogwash
5. Negasunt - Anti-maggots.

1. Drontal Plus (synergistic febantel and pyrantel formulation with praziquantel). Broad spectrum against round, hook, whip and tapeworms, nematode larvae and (when given daily for 3 consecutive days) Giardia which is a zoonosis. Safe in puppies, pregnant and nursing bitches. Strategic deworming is 4x/year with one dose. It seems that puppies as young as 2 weeks old can be dewormed. Note that Giardia treatment needs 3 consecutive days instead of one dose. Puppy can be given at 2 weeks of age and 2-weekly till they are part of the strategic deworming 4X/year.

2. Advantix Spot On (synergistic imidacioprid 10% and permethrin 50%). Kills fleas/larvae, ticks, mosquitoes, lice, stable/biting flies. Repels ticks, mosquitoes, sand flies, stable/biting flies. Repellency (anti-feeding) means that the parasites do not bite or attach to the body on contact with the dog. Explain this to the owner who may see one or two ticks on the body after application. Remove all ticks.

Safe in puppies over 7 weeks old, pregnant and nursing bitches.

NOT FOR CATS (imidacioprid is safe for use in cats but it is permethrin that cannot be metabolised by cats. Therefore Advantix is contra-indicated in cats). Ensure that cats do not groom the dog's skin that have had been applied Advantix.

Do not apply earlier than 1 day after bath and do not bathe earlier than 2 days after application. This advice does not seem practical for Singapore dog owners who usually bathe their dogs more than 1X weekly). If Singapore's dogs are usually bathed >1x/week, application of Advantix every 2 weeks instead of 4 weeks is needed.

Advantix is said to have acaricidal and repellent efficacy against tick infestations (Rhipicephalus sanguineus and Ixodes ricinus for 4 weeks, and Dermacentor reticulatus for 3 weeks). It kills fleas within 1 day following treatment and prevents further flea infestations for 4 weeks and so can be used as part of a Flea Allergy Dermatitis (FAD) treatment in dogs. But it is NOT to be used for FAD in cats (due to the permethrin component being toxic in cats).

Apply in 3 or more spots along the back of the dog. 5 spots are better.

In heavily infested dogs, use Bayticol dog wash first, apply Advantix and also treat the environment to prevent reinfestation (vacuum, wash bedding, clean tiles, apply Bayticol at 1 ml per 1.5 litres of water to tiled/concrete areas, not grassy areas). Remove all ticks still attached to the dogs after the use of Bayticol dog wash.
3. Kiltix collars (2.25% flumethrin and 10% propoxur). Spectrum of activity is 6-7 months. Longest lasting tickicide. Works within 24 hours reaching even remote parts of the body like the tail of the dog. Flumethrin has some repellency efficacy. But not comparable to Advantix's repellency. So, cannot claim that ticks, if trying to attach to the treated dog, will die very soon.

Does not lose its properties when it is wet. But take off collar before bath or swimming frequently. Also, you cannot use Advantix with collar as the collar will be affected. I don't see much interest in Singapore compared to the spot-ons like Frontline being available freely in the pet shop and convenient to use. I may try Kiltix collars but they are rarely available and so inconvenient for Singaporean dog owners who are city dwellers.

4. Bayticol 6% emulsion. (flumethrin 6%). Used as dip, spray, wash, environmental treatment. Efficacy against tick (40ppm), flea, lice, mite (30ppm) and environmental control (40ppm).
Larvicidal effect, inhibits oviposition (check label claims).
Residual efficacy: 7 days after application of 30 ppm, 3 ppm are still present on the hair.
How do vets apply Bayticol 6% emulsion?  In heavily infested dogs, use this onto dog to kill ticks first. Pull out all dead attached ticks. Then give Advantix 24 hours later to dog as spot on for 5 spots. Goes home with Advantix to be given 2-weekly for 2 months. De-contaminate the environment.

In one example of 4 Siberian Huskies with heavy infestations of ticks. I got the dog's coat clipped. Then I inject 1.0 ml ivomectin SC. After 12 hours, I applied Frontline Plus spot on. The dogs were sent home. However on Day 3, the owner returned the dogs as they have "ticks". All ticks were still attached to the body but they were dead. My assistants plucked out the ticks. An anti-tick solution (e.g. Bayticol 6% or Carrington Dog Wash) may be too risky for these dogs since they have got ivomectin and Frontline Plus.

However, spot-ons should be applied 2-4 weekly. This may be costly when the owner has 4 big dogs. There was a reinfestation because the owner's workers had neglected to apply the spot-ons or check the 4 dogs in his factory. The pictures of the de-ticking of one Husky case are shown below:



De-ticking heavily infested dogs at Toa Payoh Vets
Salivation: Obviously, if the dog licks the wash before it is dry, the dog will salivate and the owner may not be happy. Salivation will also occur even when the wash is dried, as I have seen such cases. Owners are worried, although the literature in "Promeris" - a competitor's spot on product claims that there is no need to worry as the dog is not poisoned but is showing "hyper salivation". In practice, the vet or groomer has to care about the owner's worry after application of the wash. One smart groomer advised me that she gets the dog to wear an e-collar and she has no such problems after tick wash with the Carrington Dog Wash (another competitor). The amount used is 1 ml per 1.5 liters of water. Check the label.

5. Negasunt powder (coumaphos, propoxuf, sulfanilamide). Dust thinly on wounds cleaned from dirt, pus and tissue debris. Maggots will crawl out.

Protects wound against bacterial infection and infestation with fly larvae, kills flies and fly larvae (larvicidal, repellent, anti-bacterial, adhesive, dying, deodorant, scar tissue forming activities.

CONCLUSION. Indoor and outdoor dogs, use Drontal plus with Advantix, Kiltix, Negasunt and Bayticol when necessary against all ecto-parasites.

Bayticol - Heavily infested dogs. Wash dog to remove parasites. Then apply Advantix or Kiltix 24 hours later for prevention.
 
Advantix. Heavily infested dogs. Use Advantix and Kiltix 24 hours later. Next Advantix application should be 5 cm apart from the Kiltix collar as the latter is affected. Negasunt. Can be applied together with Kiltix if wounds are not too close to collar. Same as for Advantix spot-on area.

IN TOA PAYOH VETS DE-TICKING PROGRAM FOR HEAVILY INFESTED DOGS, we clip the dog's coat, apply Bayticol 6% emulsion wash. Then 24 hours later, we pluck out all ticks before sending the dog home with Advantix spots-on to be applied every 3 weekly. We check the dogs for tick-borne diseases.




P.S
Tick infested dogs can get sick with tick fever or other diseases and some do die. Owners wanting to de-tick their dogs, tel: 6254 3326, 9668-6469, e-mail judy@toapayohvets.com
for appointment.

The website with pictures are at:
http://www.bekindtopets.com/dogs/20100196ectoparasites_control_dogs_ToaPayohVets.htm

Sunday, July 24, 2011

Sunday's interesting cases

Sunday, July 24, 2011
I showed to my assistant Min the importance of proper recording for blood samples being sent to the lab from the example on this Sunday. Some assistants and employees take a much longer time to understand the significance of advices and this is the biodiversity of the human species.

A new client brought in a dog called Ted. I was going to operate on another dog called Tedi. "If you don't write the reference number, but just Ted or Tedi in the blood collection bottles of two dogs, the Lab may make mistakes in giving you the results. To them, they think Ted and Tedi are the same dog.

From now on, I told Min that he has to let the associate vets check the names and reference number before submission. The responsibility will be the vets, not his.

Baytril oral to hamsters and rabbits

Baytril comes in 10% bottle. I taught my assistant how to dilute it for hamsters and small mammals.

1 ml Baytril + 4 ml water = 2.5%
0.01 ml/25g twice a day for dwarf hamsters.
0.2ml/kg twice a day for rabbits etc.

3 hamster surgery follow up today

Surprisingly, two calls this morning Jul 25, 2011

1. Hamster 1 and 2, Female, 2 years old, lady owner phoned up. Day 3 of surgery. Hamster 2 (amputee) attempted to bite stitches. What to do? Plaster? Not practical.
Hamster 1 - Ear canal ablation. Hamster eating. Objected strongly to cleaning off blood from ear. So done once only. Advised to do more cleaning. Isolfurane gas anaesthesia only but very stressful ear canal removal. Took 2 days to recover.

Hamster 2 - Confirmed leg tumour was only 5 mm diameter 6 weeks ago but grew furiously big to 1.5 cm. Leg amputated. Starting exercise wheeling. 30 g before surgery. After surgery 19 g. Hates Biolapis.

Feedback from owner who noted the following.
1. Lowered water bottle. Can't drink as only one hind leg.
2. Food bowl too high now. Hard to climb out. Use bowl from those used in Chinese household for chilli and soya sauce. A bit of spillage but hamster could eat.
3. Tempted with favourite bean sprouts. Then give baytril oral.
This hamster needed sedation IM. First day, one drop Zoletil 50 IM. No effect. Just looked at me. So, suspend all operation till 24 hours later. 2nd day, 3 drops OK. Leg bone tumour extended to inguinal. Amputated. Quite active within 1 hour.

Advices
No exercise wheel. Stitches quite many. Blue nylon 5/0
Continue on paper litter. Not so rough. But hamsters loved to shred them.


2. Hamster 3 - 81 g - loves bread, husband rushed down. 2 5/0 nylon stitches bitten off today on Day 8. Bleeding. Wife phoned. OK at clinic. No bleeding. Cut off two entangled nylon stitches. 1 remaining. Husband did not want it cut off. To observe. To reduce weight further. 79 g.

Transparent 5/0 nylon taken out

Feedback, fully active and normal on Day 3 but would eat after operation. Daily exercise on wheel. Owner quite happy.

515. Anaesthesia & Surgery In Old Dogs - 13 years old

HIGH-RISK ANAESTHETIC CASES
AN EXAMPLE FOR VETS AT TOA PAYOH VETS

CASE STUDY FOR VERY OLD DOGS

HISTORY
On Oct 28, 2010. Not eating. Tense abdomen. Uterus thickened. High WBC count (44 compared to normal 6-17). Suspected closed pyometra. Operated by Dr Vanessa Lin. Recovered fully. Now, the owner requested dental work. Review medical history and make judgment as to the risks of another anaesthesia.


October July 25, 2011
Jack Russell, Female, Spayed, 5.6kg, 38.6 deg C. Excellent bodily condition
Today, 10 am, phoned gentleman owner to confirm request for dental checkup and extract loose teeth. 10.30 am Dental scaling & extraction of M1 (left upper, roots exposed), PM2 (left upper, roots exposed) & PM2 (right upper, roots exposed). Overall, teeth in good condition.

Last dinner at 7 pm yesterday
Sedation: Domitor 0.1 ml + Ketamine 0.2 ml IV. Shivering.
Others: Atropine 0.5ml IM. No shivering.
10 minutes: Isoflurane 0.2 - 1%

Dental scaling. 3 loose teeth with exposed roots extracted. Sleeps
Antidote: Antisedan 0.25 ml IM. Wakes up in 5 miniutes.
Antibiotic & pain-killer: Tolfedine 0.7 ml & Baytril 0.7 ml SC

Duration of anaesthesia: 15 minutes. No IV drip.
IV drip not given as the dog was eating and drinking with normal stools and urine for the past 3 days.
Dog OK. Goes home.

CONCLUSION
1. In weak and sick old dogs, IV drip should be given. Baytril via IV. Lasix IV if indicated in heart diseased dogs.
2. Blood test strongly advised. Record in case file if the owner objected to blood test.
3. Informed consent form must be filled up properly be the vet and signed by the owner. Case record should note risks and complications being explained.
4. Anti-sedan to be given to wake up the dog.
5. In dogs with heart disease, IV drip post-op.
6. Post-op pain-killer tolfedine + antibiotics SC as soon as possible after surgery

Friday, July 22, 2011

514. The "reasonable" man test

The following is related to an old dog with a chronic ear problem. An earlier e-mail was posted in Blog No. 508 at:
http://2010vets.blogspot.com/2011/07/508-ear-canal-ablation-in-dog-email.html


E-MAIL TO DR SING DATED JULY 22, 2011

Hi Dr Sing,

Thank you for your reply!
(Ear Canal Ablation surgery is the only cure in chronic otitis externa with growths)--- URL is:
http://www.sinpets.com/F5/20110722vertical-total-ear-canal-ablation-surgery-chronic-ear-infections-tumours-dog-toapayohvets-singapore.htm


I am not confident with the surgery. Although he had one last year to laser which i mentioned, the vet used gas (i think) and promised to take less than an hour to minimize the risks, (he woke up immediately on the table and stood up wagging tail) his kidney suffered about 6-8 months after that (BUN was 188+ & before surgery 38). I don't know for sure if it was related to the surgery (or chemo) but I've read that it is possible. I cannot help but wonder if your 11-yr old patient died from post surgery...

May i ask, (I've not dared to ask other vets face to face) do you think the ear tumor is going to kill my dog if i leave it as it is...? How is it going to develop...? Will it go into the brain or pressing on it?

Thanks a million.

E-MAIL FROM DR SING DATED JULY 23, 2011

Thank you for your reply. Old dogs are at the end of their life-span and therefore are very high anaesthetic risks.

Any outcome in a complaint is judged by a "reasonable" man test in a court of law. Will a "reasonable" man think that the death of my 11-year-old dog patient that had ear canal ablation and passed away in his sleep 4 months later was due to the surgery?

A reasonable man will think that the death of patient that dies during or within a day or two after surgery is due to the surgery. After 4 months, a reasonable man does not think that the death of this 11-year-old dog is due to the surgery especially when he has been eating and drinking normally after convalescence.

As every dog is an individual and the exact nature of his ear growths are not known due to no histopathology results (as to whether the growths are cancerous or not) being available from you, it will be difficult to predict what will be the final outcome of your dog.

With chronic otitis externa and ear canal growths, infections of the ear canal get more severe, leading to the rupture of the ear drum and spread of the infections to the middle and inner ear may occur. If the growths are cancerous, they may spread to other areas including the brain.

Best wishes.

Neutering a second Yorkshire Terrier, male

I had an e-mail appointment to neuter a Yorkshire Terrier, 2.7 kg only. He was so well behaved. "But in the house, he lords over us," the sister with the brownest sun tan I had even seen in a Singaporean Chinese girl. Usually this tan is for Caucasians who sunbathe for hours.

Teeth scaling needed. Two lower puppy canine teeth were extracted as they accumulated food in between the permanent and puppy canines.

Xylazine 0.15 ml IM. Then isoflurane gas by mask and intubate. Smooth surgery. I was very surprised that there was very little bleeding from inside and from the skin suture. Only one ligation of the spermatic cord using 3-forcep clamp method and closed method of neuter. This was one of those very satisfying neuters. I advised tolfedine 4mg/kg oral for first 24 hours and then once daily. Tolfedine was given by SC post-op.

The other Yorkshire Terrier owner (also a lady) did not contact me at all after neuter. Similar suture. Similar query from my assistant Mr Min again: "No subcuticular suture?" when he saw me giving one 2/0 horizontal mattress. He must have had been impressed with seeing many subcuticular sutures done by my associate vets and so he was much surprised as to why I did not do it.

Good post-op outcome (lack of complications) counts. He had not seen any skin irritation complaint from my case if you ask him. "Subcuticular sutures are not necessary if you don't traumatise the surrounding tissues and close with horizontal mattress," I told Mr Min who is a veterinarian qualified in Myanmar. Well, he is new to Singapore veterinary surgery and he can see 3 vets with 3 different styles. So, it is up to him to learn the best practices from the 3 vets. And be a better vet.

There is no need to return for stitch removal and so I don't see the Yorkshire anymore. No news is good news.

512. Auditing Veterinary Surgery - Accuracy, completeness and speed

I do a surprise audit of veterinary surgery of my associate vets now and then to ensure that the standard of care and surgery is to a high standard as I am the licensee. Besides, good surgical outcomes mean more referrals and business.

SUTURES
All young vets want to use their own sutures and drugs. However, there is a need to be sensible in a young vet's demands and to be aware of the costs of veterinary practice.

In this audit I did today, I noted that 2 packets of 0 chromic catgut and 2 packets of absorbable 3/0 monofilament have had been used during the spay of a poodle. From my experience, the most is 2 packets of sutures. Not four. There was a need for an explanation as this is just a small breed. I would have used at the most 2 packets of 2/0 absorbable sutures. With suture placements at the optimal distance and the use of 3 horizontal mattress sutures of 0.8 cm placed at 0.8 cm apart, I could use just one packet.

I was quite surprised that 4 packets were used. One explanation was the need to use subcuticular sutures to seal off dead space. Another was 3 ligations on the uterine body and 2 ligations each on the ovarian stumps, totalling 7 ligations and therefore needing more suture lengths and time.
The skin incision and linea alba were closed with interrupted sutures. Still, there was a waste of one packet.

NO SUBCUTICULAR SUTURING NECESSARY

Excessive suturing does not mean better suturing. The dog gets irritated with the numerous subcuticular sutures. I have explained this many times to my associate vets but it seems they have had great difficulty accepting my advices.

There is no need to do this line as the dog keeps licking its skin wound during healing resulting in redness. And there are a few cases despite NSAID painkillers.

On my side, I don't get any complaint over my 30 years of practice as I use just one or two horizontal mattress suture and no subcuticular. Yet the two young vets don't agree with dispensation of subcuticular sutures. So, it is up to each vet to do what they have had been taught. The Australian professors of veterinary surgery still preaches SC sutures

HORIZONTAL MATTRESS V. SIMPLE INTERRUPTED
Horizontal mattress provide stronger bonding and is less easy to lick off. Interrupted sutures placed at 0.5 mm apart are too close and unnecessary. Read surgery suturing books yourself if you don't believe my experience. In small dogs, interrupted sutures at 0.8 cm apart will be OK and ideal in neuter and spay cases. In dwarf hamsters, I stitch the skin with interrupted at 0.3 cm apart. DEFINITELY NO subcuticular sutures.

E-COLLARS
In my experience, e-collars are unnecessary after spay and neuter in most cases. I protect the wound with a plaster bandage. NSAID painkillers must be effective and given by injection post-op. Tolfedine may need to be given every 12 hours for the first 2 days. Altogether 4 days. My associates use rimadyril.

CONCLUSION
As each vet has his or her own mindset, it will be best if they read more and find out for themselves the most cost-efficient way to perform stitching. Accuracy, completeness and speed are the 3 tenets for surgery. No point doing fanciful stitching esp. concealed subcuticular sutures to impress the client as most owners just want the least cost and least need to come back for stitch removal or complaint of licking and inflammation of the skin.

511. Two squeaky sibling dwarf hamsters from the internet

The internet introduced me to two active sibling female grey dwarf hamsters on Thursday, July 21, 2011. They were no ordinary 2-year-old greyish dwarf hamsters in the sense that both gave angry squeaks whenever I tried to handle them. They would sprint away as fast as their legs would carry them. If cornered, they would stare at me ready to nip me if my finger ever touched them.

Hamster 1. Female. 28g. Her right ear was swollen and oily. As I got near her, she emitted a strong smell of rotten meat in the consultation. Body odour? Not from hamsters. Especially dwarfs as they groom themselves frequently.

"Is it your dirty glove?" I asked my assistant Mr Min. He wore a soiled cotton glove to handle the hamster to protect himself against being bitten. I had strongly advised him to change gloves when they get dirtied but he is the type that needed frequent reminders and wearing down my patience.

"No, no," the slim lady owner in black-rimmed glasses said. "She has this foul smell. My vet gave her this Panalog ear ointment to apply. But there is still the smell. Pieces of white pus comes out from the ear!"

Recently I had a hamster with a similar smell due to it being bitten. Smell of putrefying flesh. "Was this hamster bitten by the sibling?" I asked. "Well, yes," the lady said. "The sibling who is more aggressive bit her.

"Did your vet give any antibiotics?" I asked.
"No," she said. "Just the ear ointment."
This looked like a complex case. "I will have to put her under anaesthesia and check the ear," I said. "Normally, there should be no anaesthetic risk as she is very active and eating. I may have to irrigate the ear with hydrogen peroxide to get rid of the smelly bacteria and tissues."

As simple as that. Irrigate the ear under anaesthesia. What is so difficult when the hamster is not trying to bite you? Well, it was not to be. The ear was swollen with nodules piling one upon the other. Big growths. There was no time to phone the lady for permission as the hamster can't take long anaesthesia without dying off. Less than 10 minutes would be OK. I cut off the whole vertical canal with its tumours. I saw the parotid salivary gland - a small yellow white. Surgery in illustration. The hamster survived and went home the same night.

As for Hamster 2, the left leg had a big lump. "It was just a pimple, last month. I asked my vet. I was told to wait and see. Now the vet says the leg must be amputated.

It was a big bony hard tumour like a coin involving the bone from below the knee. Anaesthesia was Zoletil 50. 1 drop 1M given. The hamster was not sedated. So I phoned the owner to say I would do the next day. 3 drops IM. The hamster went down and looked quite dead. There was slow breathing. I got the tumour out. Leg had to be amputated above the knee. Stitched 5/0 nylon. Very weak. May die post-op. Tried to exercise with 3 legs still. What a strong hamster. Weighed her. Now 19 gram. And she was 30 grams befoe he surgery 2 days ago. "She drinks more, and is more aggressive," the young lady said to me. Well, 2 hamsters alive. That is what matters. The bony tumour must weigh 10 grams.

Thursday, July 21, 2011

509. Accuracy, completeness and speed in hamster surgery.

Accuracy, completeness and speed in hamster surgery. The hamster cannot survive if anaesthesized for over 5 minutes, in my experience. How to achieve this? Prepare well in advance and plan the surgery. No distraction. Very short gas anaesthesia of less than 10 seconds. Be observant and alert.

The surgeon must review his case and see what improvements can be done in future surgeries. This means that the young surgeon must do more surgeries and be humble enough to get advices from experienced surgeons. He must read more about other surgeries. Unfortunately, very few vets like hamster surgeries as these little ones are high anaesthetic risks. From what I know, the vet universities in Australia devote 0.00000001% of the time to hamsters. I was told Australians don't keep hamsters at all and so our vet graduates from Australia seldom encounter any case.

Successes in veterinary surgeries give confidence to the client who may refer their friends to you. I spoke to one of my clients, an administrator in the Kandang Kerbau Hospital. She said: "The older specialists get overworked and therefore they leave the public service for the private sector."

"Why don't they farm their surgeries to the younger ones?" I asked.
"It is not possible," she said. "The clients are referred to them."
So the overworked old surgeons leave for the private sector and there is a dearth of experienced ones to teach the younger surgeons.

I anticipate that our hospitals will eventually be staffed by younger specialists since there is an exodus of senior doubles who are offerred double and treble their pay to join the private hospitals.

Referrals are an important source of clientele as this case of the Shih Tzu puppy with a deep ulcer shows. The client was referred to me by her family member as I treated the massive cauliflower ear wart in the niece's hamster successfully.

"There is a string hanging out from the ear!" the mother told me when I enquired about the hamster. "But no more warts."

She had brought in the Shih Tzu puppy 30 days after my tarsorrhaphy surgery on the left eye as the puppy was rubbing her left ear and face.

"The eye ulcer has healed," I said. "The problem is the infected left ear, not the eye. You can remove the e-collar nowadays."
"Will the white spot disappear?" she asked.
"No," I said. "It may become much smaller when the puppy grows bigger."
I took a picture of the eye for record. I should have used reflectors but did not. So I had the eye angled facing the sunlight and got a picture for readers.

In vet surgery, two types of referrals are important to build up a practice. One is the existing client. The other is the internet. Price under-cutting can also build up a good clientele.

508. Ear Canal Ablation in the dog - email query and google search

E-MAIL TO DR SING DATED JULY 21, 2011:


From: ...@yahoo.com>
Subject: Dog ear hard mass
To: david@sinpets.com
Date: Thursday, July 21, 2011, 3:04 PM

Hi Dr Sing,

I found you online. My dog is a 14 yr old shih tzu. He started with infections in his left ear for 6 months, seen 3 different vets, put on almost all kinds of antibotics available but did not help. Till sometime last year, i felt a hard lump. Then i went to another vet who did a minor surgery to laser off some masses on the surface (was able to see cauliflower-like masses in the ear hole). He said due to my dog's age, heart problems and failing kidneys he is not going to cut deeper into the ear. About 3 months later, i can see those cauliflower-like masses in the hole again. And the ear canal starts to feel hard. The vet put him on chemo (0.03ml, very small dose) but his kidney suffered. The last chemo was administered in April this year. I have since decided not to go for the chemo. Currently, the lump is growing, probably towards the middle ear? It is visible, growing down towards the jaws. The smelly pus and bloody discharge is present for almost 1.5 years. He does not appear to be in pain to me, because he is able to sleep lying on it. May i ask what would be your treatment since he is not in a condition for surgery, and i'll not take the risk. Thank you so much!


E-MAIL REPLY FROM DR SING DATED JULY 22, 2011

Hi

Thank you for your email. It was a pure coincidence that yesterday I had operated on a 2-year-old dwarf hamster with similar cauliflower-like masses inside and pus discharging from her right ear canal. A vet had given an antibiotic ear ointment for some time. It was ineffective. The right ear continued to emit an over-powering smell like rotten meat.

Anaesthesia was very high risk as this hamster is nearing the end of her life span of 2.5 years. The lady owner accepted the risk as medical treatment was ineffective. The hamster is OK and went home to be nursed by the owner yesterday. This surgery is called total canal ablation and I believe it is very rarely is done in old dwarf hamsters (compared to old dogs) as anaesthesia is very high risk.

I just googled "ear canal ablation" for you and came out with this URL:

http://www.google.com.sg/#hl=en&sugexp=bvre&xhr=t&q=ear+canal+ablation&cp=11&pf=p&sclient=psy&source=hp&aq=0&aqi=g5&aql=f&oq=ear+canal+a&pbx=1&fp=4246f7dc13410bc6&biw=1024&bih=545

In the googled page, the ear canal ablation surgery is described in
1. A website at:
http://www.2ndchance.info/earsurg.htm

2. Another website (my surgery at Toa Payoh Vets) at:
http://www.google.com.sg/#hl=en&sugexp=bvre&xhr=t&q=ear+canal+ablation&cp=11&pf=p&sclient=psy&source=hp&aq=0&aqi=g5&aql=f&oq=ear+canal+a&pbx=1&fp=4246f7dc13410bc6&biw=1024&bih=545. The 11-year-old dog survived the surgery. He lived for another 4 months with no pain and died in his sleep.

In your dog's chronic otitis externa with no cure from other treatments, surgical removal of the ear canal is the only option. This will be my advice to dog owners with similar problems as the condition and pain just get worse over time.

However, since your dog is very old and has heart disease. You will need to make a decision as to whether you will take the high risk of your dog dying on the operating table. If the dog survives and the surgery is without complications due to belated decisions for surgery and old age's poor healing, the dog will be pain-free and infection-free normally and may live for another 6 years to the age of 20 years (from the optimistic point of view).

In conclusion, I have no other alternative effective treatment to propose to you other than ear canal ablation surgery.

Best wishes.




GOOGLE SEARCH RESULTS "ear canal ablation" dated July 22, 2011 at 4.43 am in Singapore


Search Results


Ear canal ablation - Relax. Take a deep breath. | RightHealth.com
www.righthealth.com
We have the answers you seek.


Search Results

Ear canal ablation and bulla osteotomy
www.vetsurgerycentral.com/ear_ablation.htm - Cached
Below is an illustration demonstrating total ear canal ablation; the thatched area shows the part that is surgically removed; after the ear canal has been ...
YouTube - Advanced Vetcare Total Ear Canal Ablation‏

www.youtube.com/watch?v=ertUBPvc6wk1 min - 29 Jan 2007 - Uploaded by advancedvetcare
An overview of total ear canal ablation in the dog. Posted by Advanced Veterinary Care.
More videos for ear canal ablation »
Ear Surgery In Dogs And Cats
www.2ndchance.info/earsurg.htm - Cached
Total ear canal ablation is almost always successful while less extensive types of surgery often fail. The secret of this success is in choosing surgical ...
Vertical Ear Canal Ablation - 031208ASingapore Toa Payoh ...
www.kongyuensing.com/.../20080613Vertical_Ear_Canal_Ablation... - Cached
14 Jul 2010 – Vertical Ear Canal Ablation surgery in the dog - Part 2. Chronic thrombocytopenic purpura? toapayohvets.com ...



The URL is as follows:
http://www.kongyuensing.com/animals/20080613Vertical_Ear_Canal_Ablation_ToaPayohVets_Singapore.htm



Monday, July 18, 2011

507. Giving neuter instructions by text and e-mail.

The google enables me to meet some of the interesting Y-generation I will never get to meet as there will be one of the 50 veterinary surgeries near their residences. Some 40 years ago, when I graduated, there were around 4 private practices but there was a Government Animal Infirmary doing a roaring "trade" as dog and cat owners came to consult the one or two vets employed by the Primary Production Department (now called the Agri-Food and Veterinary Authority). Usually, the X or Y-generation will e-mail to me as one example shows below:


E-MAIL TO DR SING DATED JULY 12, 2011


On Tue, Jul 12, 2011 at 6:39 PM, ....com> wrote:

Dear Judy,

I have a one year old Yorkie that we want to neuter.

Please advise how much will the procedure be and when is the earliest time that we can bring him down.

You can reach me at (phone) if you need any further info.

Thank you.


Best regards,

Name of owner



E-MAIL REPLY FROM DR SING DATED JULY 13, 2011


Hi

Thank you for your email I am Dr Sing from toapayohvets.com

The cost of anaesthesia, surgery and post-op pain-killer and antibiotic injection is estimated to be around $150-$200 for dog breeds less than 5 kg and without surgical complications and have two descended testicles. You have a choice of 3 vets, namely myself, Dr Vanessa Lin and Dr Jason Teo.

If you want me to neuter him, please bring him down at 9.30 am from Monday to Friday. No food and water after 10 pm the evening before surgery. Phone 6254-3326 for appointment. The dog will be operated at 10 am and goes home around 12 noon or later in the day if you are not free. The dog should preferably be vaccinated within one year and in good health. Bathe the dog first and clean up his lower area.

Best wishes.



E-MAIL TO DR SING DATED JULY 12, 2011



Hi Dr Sing,

Can I book an appointment with you this coming Thurs?

I'll bring him down at 930am and pick him up later part of the day.

Look forward to your confirmation.


Best regards,

Name of owner



E-MAIL TO DR SING DATED JULY 19, 2011



Thank you for your email. Thursday 9.30 am will be OK. Will see you this Thursday.

506. The cat lady comes to the rescue

In one article I read, it stated that the Y-generation is the Google generation as it searches information via googling instead of asking for advices from the seniors. . It has the following characteristics:

1. It is a generation that does not take instructions as willingly as my baby-boomer generation. When I instruct this generation to do something, it will do anything its own way and therefore I need to watch out. For example, my assistant Min. I told him how to restrain a ferocious cat in a certain way by first placing the crated cat on a table and not from the floor. By placing on a table, the human is in a better and comfortable position to handle the hissing cat. It so happened that we had two hissing cats for spay yesterday as they are stray cats. Usually, Singapore's cats are quite gentle. There is a community of cat lovers who will get stray cats sterilised and released to the wild and manage them and so Toa Payoh Vets do get some of these kind souls.

Yesterday, he would do his style and tried to get the ferocious cat (after spaying) out of the crate by bending down to the floor level where the crate was placed. He would then use a towel trying to get the cat out and risk being scratched. He tried but no way would the cat come out. He would not ask me for help or advice. Min had been bitten on both hands by a dog some months ago and had cat scratches. This is the risk of working in the small animal veterinary practice. But such risks can be dispensed with if Min knows how.

In this situation, Min had asked for the owner to take the cat out. However, the owners (a Malay mother and teenaged boy) who sent the cat for spay stood outside the Surgery as there was a big Golden Retriever in the reception room waiting to be discharged (after being clipped and de-ticked off thousands of small ticks).

The mother waved her hand at her nose indicating that the dog's tick insecticide smell was too much for her and that was why I asked her and the boy to wait outside the Surgery where the air is fresher.

After the Golden Retriever owner left, I asked the boy and later the mother to come into the Animal holding area to get the cat out. They failed to get the cat out to transfer her to their own carrier. Many minutes passed. So what should I do? Dr Vanessa came out to help after vaccinating six stray cats brought in by a lady in her 30s. This lady had specifically made an appointment to see her and I presumed this was a serious cat lady as I did not see her smiling when she came into the receptionist room.

Well, she seemed to be a cat handling expert. I asked her for help and she did. "Put some food on the floor," she said to the Malay woman. "Once the cat comes out, I will be able to catch her and put her in the carrier."

The problem was that no normal cat owner would bring the cat's favourite food with them when they come to take the cat home. Dr Vanessa came to help too as this was the cat she spayed. The dog with the bleeding nostril (now no longer bleeding) was barking till his lungs would burst and I asked Min to quieten him by being near to him and let the cat lady do her job.

No cat food. I asked Min for the cat food from the Surgery. What happened next? Well, the overweight hamster with two large tumours of over 4 cm long and 1 cm wide x 1 cm deep came to take the hamster home. This was around 5.30 pm and so I attended to him as it was I who operated the hamster. I had to advise him how to take care post-operation and to show him the tumour. "It is large," he said. "What's the cause? Is it genetic?" So, I was engaged and did not see how the cat lady take the cat out from the crate. Somewhere I heard about taking the crate up onto the table.....In any case, the cat lady succeeded where Min failed and I was grateful for her help. I will ask Min what happened later today as I was in a rush to to somewhere after spending time with the young hamster owner whose wife found me by googling "hamster tumour" or something.

I asked the husband to stop feeding the hamster too much food. "Is it the melon seeds?" I asked again.

"No," he said. "My wife gives her a lot of bread as the hamster simply loves eating bread." The dwarf hamster was 81 gram in bodyweight as I asked Min to weigh the hamster in the presence of the owner. Her belly was as rounded as a soft toy and she looked really cute. I was surprised she survived the anaesthesia and surgery. I remembered her very well as her spleen came out of the 1-mm thin abdominal wall when I removed the big tumours (likely to be mammary tumour). I had to push back the spleen and sutured the muscle defect with one 5/0 nylon suture. The suture was transparent and so it was quite difficult to see it. However, the gap was stitched up and the hamster was OK some 4 hours when the owner came. As if she had a slimming session with one of those numerous spa operators in Singapore and was active as before when the male owner came.

"No more bread. Target to reduce weight to 65 gram," I said. So I was rather busy myself while Dr Vanessa had to get the cat out of the bag, the crate, I mean. To transfer her to the carrier to go home. She did it as the Malay woman and the boy went home while I was still consulting the owner. I could see the cat lady hailing a cab and put the 4 cat crates in the taxi's boot for the short ride to a cattery. I had no time to thank her as I had to teach the hamster owner how to give antibiotics to the hamster. This hamster squeaked when handled. As I picked her up from the cage with my bare hand to demonstrate, she squeaked suddenly and instinctively I had to let go, for fear of being bitten. I got Min to give me the cotton hand glove to restrain this hamster for demonstration.

Everything ended fine with the hissing cat and the obese dwarf hamster. It was a good evening.

Saturday, July 16, 2011

505. A 2.5-hour perineal hernia repair surgery and anaesthesia

Sunday July 17, 2011

Four days ago, I did a 2.5-hour perineal hernia repair in a 10-year-old Silkie Terrier with no heart disease. I share my experience while the details are still fresh in my mind.




INFORMED CONSENT
1. The owners have been reminded many times that they may not see the dog alive as the anaesthetic risks in an old dog are extremely high. As the dog has no heart disease, the chances of survival are 40%. Usually, the owners will sign a Consent Form.

Details of benefits, risks and complications should be recorded in the case notes, just in case of litigation but few vets do it. In a recent human medical case, from what I read in the newspapers, the specialist was suspended by the 3 judges for failing to write down the risks and complications in his case notes. Therefore, he could not defend himself. He did my colonoscopy well and that is why I remember his litigation case well.

BLOOD TEST
A complete blood test was done. Only abnormal finding were low urea and creatinine.

PHYSICAL EXAMINATION
The dog was active, trim and fit in appearance. The heart and lungs were OK on routine examination.

COOLING OFF PERIOD AND OBSERVATION
I waited 3 days to perform the hernia repair surgery so that the owners and the family members have time to think about the high-risk surgery. Sometimes the owners may want to go to another vet surgeon or a brand-name practice and that will be OK with me. This surgery is the type "where fools go in where angels fear to tread" as the hernias are bilateral and incredibly massive. Clinical outcomes may not be what the owners expect. The dog may die on the operating table since it will be a long anaesthesia and the perineal hernia may recur later.

PRE-OPERATION
Sedation (domitor + ketamine IV) is required as there is a need to knock the dog out smoothly during maintenance (isoflurane gas) anaesthesia. This is to prevent the intestines and bladder from coming out during surgery and the dog pooping (atropine 0.5 ml IM given). Isoflurane gas alone without sedation is possible but is not so effective as the dog struggles during the initial stage and may be stressed out.

IV anaesthesia and topping up is NOT advised although it can be done. This is because the surgery takes a long time as there are two hernias.


SEDATION DOSAGE CALCULATION
I use the following formula as a guideline.
For a young healthy dog of 10kg bodyweight and one year old, Domitor is 0.4 ml mixed with Ketamine 0.5 ml in one syringe. This formula gives good analgesia without the need for isoflurane gas maintenance for a half-hour spay.

This case:
Old dog -10 years old, 6.5 kg bodyweight
Domitor 0.15 ml + ketamine 0.2 ml in one syringe IV
This dosage was very low but permitted the dog to be given 5% isoflurane by mask with a little struggling. Intubated and given 2-2.5% isoflurane gas maintenance. "Don't reduce to 1%," I said to my assistant Mr Min. "Even if the dog's anaesthesia is deeper as the intestines, bladder and omental fat will bulge out suddenly, disrupting my surgery."

Atropine 0.5 ml IM was given prior to mask with isoflurane. Sometimes, stool pellets keep coming out during surgery. In this case, no anal straining. The anal opening was plugged with gauze.

Isoflurane anaesthesia at 2 - 2.5% maintenance was excellent over the 2.5-hour surgery.

IV DRIP
1. I gave 5% glucose at around 50 ml. The tongue looks redder when the dog is given glucose IV. The dog was starved from 10 pm yesterday.
2. Normal saline IV drip is given after the glucose IV.

PERINEAL HERNIA REPAIR
1. The left hernia was very large and repaired first. Large intestinal coils with inflamed serosa were just under the skin. So, the vet has to be very careful.

2. The right hernia was in two holes separated by a muscular septum. Omental fat seen.

3. On first electro-incision of the thin skin which was lifted up to incise, a large quantity of light brown fluid shot out. This would be the exudate but looked so much like urine. Be careful as the bladder was also present.



4. I suture the ventral area first. Then mid or top layer. Suture from muscle to the wall of the anal sphincter. Interrupted and continuous sutures. I used 2/0 absorbable sutures in the lower layers. The topmost layer was closed with 1 Maxon absorbable monofilament.

5. According to the text books, the pudendal nerves and blood vessels are at the lower 1/3 of the hernia. In theory, this is excellent. In practice, the whole area is swollen, bloody and messy. The hole is so deep and wide.




It was not possible to identify and avoid the nerves and blood vessels in this case where the hernia was very long-standing. In fresh small perineal hernias, the nerves and blood vessels can be seen as according to the text books!

POST-OP
The dog was deep in anaesthesia even 20 minutes after the end of anaesthesia. I gave 0.25 ml Antisedan IM. He woke up within 5 minutes. It is important that the dog wakes up as he is an old dog. But sometimes, it is best for the dog to wake up gradually and I don't given Antisedan reversal.

I gave baytril and tolfedine SC. Then follow up with oral. I find that tolfedine is not very effective based on recommended dosage of once per 24 hours. Twice a day for the first 2 days may give pain relief.

E-COLLAR
My assistant did not give an e-collar. So, the dog licked the left side of the wound to relieve his pain as tolfedine in recommended dose was ineffective. My assistant changed to a much larger e-collar as the dog continued licking.

POST-OP BLEEDING
Two days of post-op bleeding. Nursing is important.




FOOD AND WATER
The dog ate canned food for the first two days. Water given freely. Passed loose stools. So far, so good as at Saturday (Day 4). Today is Sunday 6.30 am
and I will see him later.

CONCLUSION
This is the type of challenging and high risk surgery that I hope not to see as nowadays, the clients are more litigious and the vet just have to be careful and selective of customers. Not all customers are good for the vet unlike the marketing theories where all customers are welcome.

When the clinical outcome is not good, many family members who are not at the consultation start becoming abusive in some cases. This is the brave new world. Where hard-earned reputation built over the years can be destroyed by some family members who make lots of unjustified complaints of negligence and costs. The majority of my clients are happy ones fortunately for me.

Many more pictures illustrating the problems met are shown in:
http://www.sinpets.com/F5/20110714perineal_hernia_old_Silkie_Terrier_male_dysuria_painful_backside_singapore_ToaPayohVets.htm

Friday, July 15, 2011

504. Dog ticks suck plant sap?

E-MAIL TO DR SING DATED JULY 15, 2011

Dear Sir(s) and Madam(s),

We are a group of students looking for dog ticks for research purposes. The research is based on whether it is possible for dog ticks to adapt to plant sap. Hence, we kindly request for your help, and if you have any dog ticks, please contact us at zlwang916@gmail.com. If not, then kindly reply to this email at bobyu12334@yahoo.com . Any help would be greatly appreciated.

Thank you very much!

Warmest Regards,
Mr Wang Zi Liang, Zi Wei and Ace Tay


E-MAIL FROM DR SING DATED JULY 15, 2011
I am Dr Sing from Toa Payoh Vets, www.toapayohvets.com.
You can more likely to get ticks if you contact some pet groomers and be present to collect the ticks on the spot. This is because most Singapore dog owners go to the groomers for de-ticking. Or they just buy the de-ticking spot-on medication or wash and do-it-themselves. Include your phone number as I doubt anybody will e-mail to you to collect live and biting ticks for you. But there may be kind souls. Bring along your bottles.

Dog ticks have evolved to suck canine blood. I have great doubts that they will even sip one drop of plant sap but please do your research as many conventional thinking is incorrect.

Wednesday, July 13, 2011

Celebrate small successes in life - a Singapore rose

On July 13, 2011, at 1 pm, I went to lunch organised by one of my realtor classmates to celebrate our passing of the first REA (Real Estate Agency) examination conducted by the CEA (Council for Estate Agencies) and to thank our old lecturer. This class mate initiated the celebration as the rest would not be bothered to make contacts.

Yet, networking is a very important part of real estate work and in life and yet most of all are inert. It was an excellent Korean BBQ lunch at a restaurant opposite Novena Church.

"Did the prettiest girl in our class pass?" I asked my classmates.
"You can phone her," my male classmate wanted to give me her phone number.
"I better not," I said. "Her name does not seem to appear in the 41 names of persons to collect the REA certificate, in the list at Informatics. Besides, she has a Caucasian male friend. I may be bashed up! I had only spoken around 10 words to her during the whole 3 months of class."

"No, no, he is not her boyfriend," my class mate volunteered to give me her phone number and to recruit her as my salesperson.

I said to the lecturer who had told me that all ladies in the class are pretty when I enquired by e-mail whether she had passed: "You were the one who scolded her for coming to class one hour or more late."

"I did not do that," he protested. "I just said 'good morning'" He was correct. He did not really scold her or shut her out for being late at most times.

She was one of the few classmates who just sauntered into class late and interrupted his lessons. No apologies. No greeting of 'good morning to the lecturer'. In fact, all my classmates don't say that to my lecturer except for me.

All eyes had to focus on the pretty young thing as she looked for a spare seat.

Probably in her late 20s. Slim or I would say, thin. A clear fair face, bright friendly eyes that talk to you, good clothing sense, possibly high heels and a steady cat walk. She exudes confidence. A Singapore Rose. Just as Princess Diana was the English Rose.

"Who is the prettiest girl?" another male classmate asked. "Is she the one with the long hair and dresses up in designer clothes and carry designer handbags?"

"Most of the younger lady classmates have long hair," I said. It is a pity that my 40 classmates did not socialise much as we rushed back from lectures three times a week for 3 months from 10 am to 1 pm and discarded our lecture notes immediately to earn our living.

There were two lady classmates sitting opposite me and I asked them who was the prettiest girl and why. I wanted the female point of view. They gave me the same name as the one I mentioned. Why? She is young. She is good-looking.

Well, I was not the only one who spotted a pretty woman. Beauty always command attention. If beauty is combined with brains, the combination is just killing. I mentioned her as part of communications during our lunch. No ulterior motives of recruiting her as I am sure she has many offers. Of realtor jobs I mean.

It is good to celebrate small successes in life. My male classmate sitting next to me complained that the police phoned me to ask whether he had taken home the REA examination paper 1. He scolded the policeman. "The policeman is doing his job," I said. "I also got a phone call from the police and I asked the policeman why he is doing this loss of an examination paper when there are so many more important murders and cheating cases to do?"

"I know who took the paper," my lady classmate said to me.
"How do you know?" I asked.
"Well, she was sitting next to me during the examination. However, the policeman did not ask whether I know of anyone who took the paper and so I did not say."

Another classmate who was scolding the Informatics girl who would not give him any extra piece of writing paper when requested had been called up by the CEA for an interview, probably on a complaint from Informatics for swearing.

"You were the first suspect," I said. He had used the "F" word when the Informatics staff came rushing out to a group of us loitering after the end of Paper 1 examination and simply asked: "Did you take out the examination question paper 1?" So, he said: "F... you" and got to be on the top list of suspect.

"Actually two examination papers of Paper 1 were taken home," one lady classmate told me. "Informatics staff phoned everybody." The policeman phoned subsequently. However, the papers were recovered. For Paper 2 and Paper 3, no examination candidate was allowed to leave till all examination question papers were collected.

It was a time of laughter and joy for the group and the lecturer who said that the Batch 2 and 3 classes were quiet and did not ask many probing questions. My classmates were more vocal. "It is the Korean classmate," I said. "He asked too many questions about investments."

I said to the lecturer: "You did not lecture about stray cats and rats. We had a question on how he should handle a complaint of the restaurant who created smoke, had stray cats and rats. I was forced to answer this question as the other questions were harder."

"Well, you are a vet and should know," the lecturer replied.
"But what is the right answer? Just contact the AVA? The police? The NEA?"

There was another examination question which we do not know what is the right answer too. It referred to land acquisition and asked which "3 persons" are interested parties. "3 person" in quotes. Two of my male classmates at the lunch said it was the owner, landlord and somebody. My female classmate said it was government departments. I had replied: "Singapore Land Authority, HDB and National Heritage Board." Why National Heritage Board? Preservation and conservation of buildings in land being acquired.

We don't know the correct answer and I suspect our lecturer does not. We can't expect our lecturer to know everything when examination questions are so tricky. "Well, they still can pass when they write landlord, owner and tenant," my serious lady classmate who avoided this question said to me. She was sure that the "3 persons" in quotes refer to institutions rather than living souls.

It was one of those lunches full of laughter and noise for two hours and the staff must be waiting impatiently for us to get going as the place closed after lunch. It is good to celebrate little successes in life. We will have set backs in life and I hope the Singapore Rose will re-take the examination and pass.

P.S
Greeting the lecturer is good manners but this does not seem to be part of the Singaporean culture. Definitely the lecturer remembers you better when you pay respect to his position. You can't expect him to know every subject in the syllabus. You just have to do your own reading and research to pass the REA examination comfortably. There was an examination question on "Professional Etiquette" which I don't know much as it was not in the lectures. However, I had to answer this question. Maybe, "good morning" should be part of the answer.

It is best not to be rude to service staff as they are just doing their duty. Rudeness resulted in a record in the CEA files for this classmate of mine, I would think so since he was called up by the CEA.

For examiners, each examination question paper should be written with the candidate's reference number. Therefore any missing examination question paper can be traced to the candidate, my classmate who is a lecturer in China said to me. In Informatics, no candidate is allowed to leave the class till everybody has handed in their examination question papers and they are accounted for.

502. Perineal hernia in a Boston Terrier one year ago

The Boston Terrier was operated one year ago. I review this case which was operated successfully (no anaesthetic deaths or complaint of recurrence) before I operate on the "mother of all perineal hernias" of the Silkie Terrier (described below) who is 10 years old and in a more risky anaesthetic position.

The pictures and more details of this record are at:
http://www.bekindtopets.com/animals/20100625constipation_perineal_hernia_old_Boston_Terrier_male_singapore_ToaPayohVets.htm


CASE 1
This Boston Terrier case was written: 25 June, 2010
Boston Terrier, Male, Not neutered, 7 years, 12.4kg
Big swellings besides the anus, the left swelling being bigger.
Difficulty in pooping for past 3 weeks.

A knowledgeable young man who has his own views of dog care.
He presented a Boston Terrier with constipation for the past 3 weeks. He went to Vet 1 who referred him to another vet after taking a blood test as she did not want to perform the surgery. She had given him a laxative for the dog and the dog had passed loose stools instead of hard ones.




"Why don't you see the referred vet?" I asked.

"The Surgery has a bad reputation," the young man had googled the name of the practice he was referred to by Vet 1. "There is a very bad complaint about the vets from one dog owner. So I better not go there."

"All veterinary practices will have one or two nasty complaints about service," I educated this young man. "The busier the practice, the higher the chances of getting complaints. This is because the vet has no time to handle each case as thoroughly as he or she would love to. This applies to over-worked doctors in human medicine too especially in the emergency wards."

VACCINATION HISTORY MUST BE ASKED
"Has your dog been vaccinated?" I asked.
"No vaccination for the past few years. Do you have parvovirus in your Surgery?" the young man asked me.

"Fortunately for your dog, my practice does not have parvo-viral cases for many months as I seldom provide service to the dog breeders nowadays. You have taken a big risk exposing your dog the risk of parvoviral and canine distemper infections."

PRE-OP BLOOD TEST IMPORTANT FOR OLD DOGS BEFORE SURGERY
I checked Vet 1's blood test results. It is wise not to trust the blood results of other practices based on one of my experiences (see one case I had written). However, he had paid $130 for the test and I would not insist as that would increase his vet bills. Overall, the dog was examined and was healthy. So I took the chance.

ANAESTHESIA
IV saline given. Then I gave Atropine 0.4 ml IV followed by Domitor 0.2 ml IV
Waited 10 minutes. Isoflurane gas mask. Dog struggled. So, I gave Zoletil 100 @ 0.1 ml IV. This sedated the dog who was masked and given isoflurane gas at 5%. The dog slept and was intubated. Isoflurane at 1-2% maintenance was done by my experienced assistant, Mr Saw. I asked him to increase the dose when the pelvic fat kept coming out from the hernia after pushing the fat into the abdominal cavity. The dog recovered smoothly.

SURGERY
I gave him antibiotics to take and schedule perineal hernia surgery 2 days later. The surgery took nearly an hour as the hernia was large. The hernia bulge with pelvic fat is large, around 4 cm x 6 cm. An electro-incision made a big cut to the left of the anus.

It was difficult to identify the medial coccygeal and levator ani muscles in this case as there is a lot of inflammation. The internal pudendal artery and vein and the pudendal nerve on the dorsal surface of the internal obturator muscle looked compressed as I showed to my assistant Mr Saw who nodded his head. Judging from his eyes, he did not believe they were what I said.




Is there a right perineal hernia too?


Electro-incision. Big amount of pelvic fat. A retractor enabled me to have a good field of view to stitch up the defect


See the big hole through which part of the colon and pelvic fat herniated through causing a big backside swelling


Left perineal hernia repaired. Neutering in 3-4 weeks if the owner wants to do it. The right perineal hernia may need to be repaired later.
The internal obturator muscle is on the ventral aspect of the pelvic diaphragm. This was a big fatty mass horizontally covering the muscle, unlike the no-fat muscles illustrated in Small Animal Surgery, T.W. Fossum 1997, pg 354.

I used a retractor to spread open up the operating area and to see the pudendal vessels and nerve just above the obturator muscles in this case. Do not stitch these vessels or nerves.

POST-OP
Dog woke up fast. Given tolfedine painkillers.

TWO HERNIAS TO BE OPERATED AT ONE GO
I doubt that it is possible to do two hernias at one go as the muscle stitching on one side (i.e. left hernia in this case) pulled the left anal area tightly to cover the herniated hole. Therefore doing two hernia repair at the same time just is not in the interest of the dog as he will feel very uncomfortable and painful.

LOOSE STOOLS leaking out from the anus. This must be plugged. The dog had been given an oil laxative by Vet 1 for 3 days and the loose stools start to come out despite atropine injection.

CONCLUSION
The dog was OK and was warded for at least 4 days as the owner did not have a crate to prevent the dog running loose. I checked the dog every day to ensure that he had proper nursing care and pain-killers. The boy's parents came to visit the dog yesterday. The dog should be back home after 7 days. He had managed to rub his backside onto the floor of the crate despite tolfedine 60 mg at half a tablet per day for 3 days. I decided to give him 1/4 dose of a 30mg phenobarb and then Rimadryl for another 3 days to prevent pain and inflammation.

P.S
1. Yearly vaccination is important. Fortunately this dog did not get infected with parvoviral disease in the practice of Vet 1 which is a very busy practice and in my surgery. Otherwise, I end up with a dog passing blood in the stools and dying later. At the time of writing this report, it is still early at Day 5 after visiting Vet 1. Parvoviral signs come in around 10-14 days after infection.

2. "Neutering the dog when he was younger would have decreased the chances of him getting perineal hernia," I said. "Perineal hernia is more common in non-neutered dogs." The young man said: "It is cruel and that is why I don't do it." He has been advised to neuter the dog around 2-4 weeks later. As for the right perineal hernia, it is a smaller one. Wait and see. If the dog is neutered and there is
no more swelling in the backside, then there is no need to do a right perineal hernia repair.

3. High anaesthetic risks. I don't enjoy doing high anaesthetic risk surgeries as they are very stressful for me. If the dog survives, everybody is pleased. There will be deaths and the owners may be very emotional and angry. Some may post a nasty complaint in the internet. To minimise risks of deaths of old dogs on the operating table, I don't force myself to perform hernia repair and neutering at the same time. The owner has to appreciate that I don't take risks unnecessary.
UPDATE AS AT JULY 11, 2011
No news from the owner since the surgery in Jun 2010. I presume all are OK as now news is good news.

CASE 2
ANOTHER MORE CHALLENGING CASE ONE YEAR LATER
THE MALE DOG HAD A VERY LARGE BACKSIDE SWELLING - PART 1
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case: Updated: 14 July, 2011

This Silkie Terrier case was written: 24 June 2011
Silkie Terrier, Male, Not neutered, 1- years, 6.5kg
Big swellings besides the anus, the left swelling being bigger.
Difficulty in pooping for past 3 weeks.
I have not seen perineal hernias since I operated on the above-mentioned Boston Terrier one year ago. Surprisingly, on Sunday, July 10, 2011, my assistant Mr Min said that a couple insisted on seeing me. Normally, all cases go to Dr Vanessa Lin but I was around at the reception to get a pulse of the grass-roots from 9 am to 6 pm and to ensure that the waiting times are kept to the minimum. Only at the receptionist's counter can I know what is the situation of the waiting time like, rather than depend on the receptionist to enlighten me.

The couple said to me: "My vet said that no vets in Singapore would operate on my 10-year-old Silkie Terrier. He had said that the dog is old and to leave the swelling alone. But it kept growing bigger!"




He was not neutered and had a backside lump 3/4 the size of the biggest mango you can see in Singapore. The dog had difficulty in pooping and the older parents were concerned about his quality of life. The dog could eat, drink, poop and pee without difficulty and was active.

"There will be vets in Singapore that will operate on this dog," I said when the couple brought the dog in later for examination. "The main issue is that the operation will take a long time and the dog may just die on the operating table. No vets want to do a dog that dies on the operating table."
I had asked them to illustrate as they did not bring the dog down at first. A male dog, not neutered, big swelling from below the anus (in this case) instead of to the sides of the anus as in unilateral perineal hernias. The couple had actually diagnosed perineal hernias via the internet education and so they knew what was wrong with their dog. The problem was that their vet did not want to operate and put his reputation on the line when the dog dies on the operating table. What should I do?

This was the "mother" of all perineal hernias. Both left and right perineal hernias have "amalgamated" to form a large 3/4-Taiwanese mango-sized lump to the right, left and below the anus. Taiwanese mangoes are gigantic but are not sweet and they measure around 25 cm x 10 cm x 7 cm. So, you can imagine that the swelling was really gigantic.

The surgery will take over 1.5 hours and the old dog's heart may just stop beating. The dog needs to be operated as he has had been licking his skin thin. Continuous licking to relieve his pain and irritation as the intestines and omental fat prolapse through the pelvic muscular defect from both the left and right side. It was hard for him just to sit down too.

http://www.kongyuensing.com/pic/20110713perineal-hernias-bilateral-silkie-terrier-male-10-years-toapayohvets-singapore.jpg

"Do your parents know that they may not see the dog alive once he gets operated?" I asked. The aged parents are the care-givers. The couple said: "My parents say it is better to take the risk rather than let the dog suffer with such a big dangling mass. The groomer had nicked the lump earlier and discovered this hernia. Otherwise, we would not know it exists!"

The dog was in good body condition. I checked his heart. His heart was surprisingly normal. He was alive and active now. As if he has not a worry in this world while his caregivers bear the burden and surgical risks on their shoulders. Should I pass the buck? And to whom? To my two associate vets? This is the type of challenging cases that I prefer not to take on and it will be most unkind to pass the buck to my two associate vets as there is the possibility of post-surgical complications like infections, bleeding and nerve damages in addition to death on the operating table. So, I did not refer the case to them. It is a moderately difficult surgery but it will take a long time to do. The longer the time of anaesthesia and surgery, the likely that the old dog's heart will just stop and the dog dies on the operating table!

If the surgery can be completed in 15 minutes, the old dog is very likely to survive the anaesthesia. Unfortunately, this surgery will take a long time as both hernias seem to be required to be operated on at the same time since the intestines and omental fat have leaked and spread to each other's sides! That is why I say that this case is the "mother" of all perineal hernias.

The dog was operated on July 13, 2011. The whole process started from 9 am and ended at 12 noon. The surgery itself started from 9.30 am to 12 noon. It was the type of surgery that most vets would prefer not to be challenged to do as there were 3 hernias. The main one was the left perineal hernia with defect from above the anal area to the ventral most part of the backside. This would be at least 6 inches long, 3 inches wide and 5 inches deep. (1 inch = 2.5 cm). The right perineal hernia was two smaller holes separated by a band of muscle.

In the left perineal hernia, the bladder and large intestines had prolapsed. Over time, the intestines have had shifted from the left half of the backside to the right half. The dog licked the swollen area (mango-sized) over the months and the skin had become very thin and about to rupture. You can see the intestinal coils more prominent on the right side. So, I thought this was a right perineal hernia. Actually, it was a left!

Details of the surgery and anaesthesia done on June 13, 2011 will be recorded in Part 2 at:

www.sinpets.com/F5/20110714perineal_hernia_old_Silkie_Terrier_male
_dysuria_painful_backside_singapore_ToaPayohVets.htm