Saturday, March 31, 2012

927. E-mail from Kuala Lumpur hamster owner

Claire ...@gmail.com

April 1, 2012 12:23 AM (7 hours ago)


Hi Dr Sing,

I do not know if you will get this mail 'in time' or that I may be too late already.
Either way I feel that I would try anything right now to save my beloved hamster.
I am in Kuala Lumpur, Malaysia.

Ham is 25 months old, very ripe old age.
Started in Nov last year (he was about 18-19 months old), his health started to decline, I presumed due to old age. He suffered some fur loss, his skin had some small black spots and definitely a decline in activities. I did bring him to our local vet here, who did a skin scraping on the black spots to determine if mites or not, and nothing came about. Ham was then diagnosed with a mild Cushing disease, but was advise to just leave him as he is, since he had no problems living his life.

Fast forward to couple of weeks ago, I noticed Ham had some sores/wound on his belly. Large gaping sores, I brought him to a vet again, and was given an antiseptic cleaning lotion and antibiotics. I faithfully cleaned his wounds twice a day and fed him the antibiotics once a day as instructed by the vet. I noticed the sores healed, but not long after, another one popped up.

Early this week, his health took a rapid decline. I thought things were better since the antibiotics was working. But then I noticed he started to sleep daily, did not eat much and lost his eyesight. He became very weak, and frail, and when picked up, he weight very light and was very limp. He does not eat much and I feed him baby food as it is easy to swallow. He still pees, but have not seen him poo. I thought it was his time to come, as he is an old hamster.
What I did not know, I found out today. And I don;t know if I am too late already. I found he had a lump at his neck (throat area)

The thing was when he started to grow older, he developed loose skins around his neck. It was nothing alarming as it was expected when the hamster gets older, but it might have been these loose skin 'masking' the lump until it is affecting him.
The lump us not very large but visible.

My Q is - is it possible for operations? I am asking because I have been googling and found this site: http://www.sinpets.com/F6/20110323massive-neck-tumour-syrian-hamster-surgery-toapayohvets.htm












But I am in KL Malaysia, my Ham is weak and not as alert as this ham in the picture.
Please can you advise if surgery is even something to attempt in Ham especially in his condition right now. So far I have yet to properly find any vet here reliable and as caring as I have read in that article above..

If you have advise please help, I am willing to take opportunity if there is, to save him. Many thanks!

E-MAIL REPLY FROM DR SING

I am Dr Sing from Toa Payoh Vets. Thank you for your e-mail. It is very difficult to diagnose by e-mail as NOT all hamster lumps are the same.

In reply, from your description, your hamster is lethargic, not eating and has several skin infected areas (most likely owing to a poor immune system). He unfit for anaesthesia and is very likely to die on the operating table. Definitely he is much older than the Syrian hamster with the neck tumour operated by me.

In conclusion, hamster owners do need to check their hamster for skin lumps daily, even under loose skin or hairless skin. Weigh the hamster weekly to ensure no weight loss. Tumours that are small are easily excised.

However, you may need to find a vet who does operations on hamsters as some vets do NOT perform surgeries, but simply prescribe some medications in the hope that the "lumps" will disappear. Some hamster owners consult the pet shop operators who will sell a "cream" to "shrink" the tumours. Both practices usually do not work unless the lump is a small skin abscess.

Best wishes.


MOST OLDER HAMSTER TUMOURS CAN BE EASILY EXCISED IF THEY ARE SMALL BUT MOST HAMSTER OWNERS WAIT AND SEE OR USE PET SHOP MEDICATION.

Friday, March 30, 2012

926. Follow-up - The guinea pig that squirted white cloudy urine

http://www.sinpets.com/F6/20120329guinea-pig-websites-singapore_ToaPayohVets.htm
is the website as the following copied report from the above-mentioned website below cannot show the images.


Friday, March 16, 2012
909. Two guinea pigs not eating - white viscous urine, blood in the urine
Yesterday Mar 16, 2012 (Friday), I saw 2 cases of guinea pigs with urinary problems and reviewed the case with Dr Daniel as part of my mentorship program.

We had met an interesting and friendly experienced Australian banker who had travelled to all over the world to work, at Liang Seah Street at 11 am today. "How old are you?" he asked Daniel. He then told Dr Daniel that 20% of the young men of his age and new graduates are jobless in Ireland. He told me that my handshake was weak, compared to Dr Daniel. "Have you been to Timbuktu?" I asked him. "No," he said. "But I have been to various places in Africa. I was sad to see so many homeless children and the poverty."

P.S
I used to study English phases in primary school in the 1960s and there is a phase referring a distant place as Timbuktu which is actually present in Africa. I doubt I have a chance to visit it. One of the guinea pig cases is written and followed up below:

Case of the Guinea Pig squirting out white cloudy urine

March 16, 2012
Not eating. Abdominal swelling obvious. The owner had seen me some months ago. "No more skin infection," she said. "My guinea pig is not eating."
Dr Daniel palpated the swollen abdomen. I did that after him. The swelling covered almost 90% of the abdomen. Soft distended bladder, in my opinion. I don't know what Dr Daniel thought. Was he thinking of ascites? Definitely, ascites present this pendulous abdomen.

Before I could speak further, the guinea pig squirted out white cloudy urine onto the stainless steel consultation table top. "The urine is not normal," I said. "I would take some for urine test." I took a new syringe to suck up some urine. The guinea pig voided much more urine. Thick cloudy liquid. As if the bladder had lots of white sand.

"Is it possible that my guinea pig has bladder stones?" the lady asked. "My other guinea pig had bladder stones. The vet removed it but then said another surgery had to be done."

"Why was there a need for a second surgery?" I asked.
"The first one was not done well," she said. "So, another one had to be done."
"What happened to the guinea pig after bladder surgery?" I asked.
"She lived for a few days and then died."
"In this case, the guinea pig might have or might not have bladder stones. We will wait for a few days and get the urinary tract infection treated first."

A follow up the next 2 - 7 days would be needed. X-rays would be needed to confirm bladder stones.
March 19, 2012
This Guinea Pig was not eating and had a grossly swollen bladder. Dr Daniel and I palpated the abdomen. Looked so much like ascites although I could feel the faint outlines of a very full bladder as big as an orange. Suddenly whitish cloudy urine dribbled out. More and more urine was released like a storm flood. I got the urine inside a syringe and sent to the lab.
Lab Results: Amorphous phosphate crystals +++, bacteria + and urine pH = 9.0.

Evidence of urinary tract infection caused by amorphous phosphate +++. So what to do now?
"In dogs, amorphous phosphate is also known as struvites. Acidify the urine or give S/D diet," I said to Dr Daniel and Dr Vanessa. "What to do for a GP with struvites in the bladder?"

The lady owner returned my text message this morning. She had left all medication to the sister who stays at home. After 3 days, the sister stopped the antibiotics as the GP was eating and drinking.

"But he sits in a corner," the young busy career lady said. "When can I send him down for another check up?" I scheduled next week. She has only one GP and believed that her sister had increased the intake of Vit C tablets to 1.5 tab/day causing the GP to stop eating.

Overdosage of Vit C can lead to kidney stones in people. In this case, the GP had a UTI. Medication was not given for a sufficient number of days.
March 26, 2012
Now, the guinea pig is crated in the Toa Payoh Vets for urine collection (see images below). The urine has been collected and tested again to check for bacterial infection. Bacteria ++ were present. No more amorphous phosphate crystals. I advised oral antibiotics again for 3 days first. The guinea pig was eating normally now.







5153 - 5159. It is good practice to follow up on guinea pigs with urinary tract infections (UTI) as bladder stones could be the cause. Also some owners don't comply with the 7-day instruction to give antibiotics.

Weigh the guinea pig during veterinary consultation. In Singapore, in 2012, the plain-looking guinea pigs are no longer so popular with pet owners!

Thursday, March 29, 2012

Bladder stones in a guinea pig - follow-up





Early treatment may or may not save its life. It is hard to guarantee. At this stage, it was unfit for anaesthesia and surgery. I asked the owner to nurse it to good health first. It died the next day, at home.

924. Follow-up: The Guinea Pig that passed fresh blood in the urine

Yesterday, Mar 29, 2012, the lady brought her guinea pig to Dr Daniel at 1pm for consultation as he had passed blood. This guinea pig had been to other vets and we at Toa Payoh Vets was seeing him for the 3rd time today.

First time, I had collected urine for analysis and X-rays.
See case at:
http://www.sinpets.com/F6/20120238guinea-pig-haematuria-singapore_ToaPayohVets.htm


"But no blood in the urine was seen," Dr Daniel told me in the evening when I asked him.
"Did you collect urine and send for analysis?" I asked.
"Yes," he said. "The urine is clear. Collected 6 times."
"What could be the cause of this blood in the urine?" I asked.
"5 possibilities," Dr Daniel said. "Trauma, infection, tumour, coagulopathy and toxins. The owner realised that the guinea pig had been given a shower a day before and blood came out in the urine. As in previous times."
"Was the guinea pig bathed before this, in the past 2 weeks since the last complaint?" I asked.
"No," he said.

So, was it the shampoo? The guinea pig started eating hungrily yesterday but was off food 2 days ago.

"Has he lost weight?" I asked.
"50 grams," he said.

"Tumour was diagnosed by one vet," Dr Daniel said. "Since he is one year old, it is unlikely."
"But it is possible," I said. However, the last 2 times the GP came, no blood was present in the urine. So, it is a mystery.

So, we wait for the urine test result. It is a puzzling case.

Wednesday, March 28, 2012

Sunday's Mar 25, 2012 interesting cases

Today is Thursday. Before I forget, I record Sunday's interesting cases.

1. ADOPTED YOUNG FEMALE CAT. The couple had decided to spay their cat adopted from the Cat Welfare Society on Sunday. However, I found that this cat was small in size and advised waiting one month since she was not caterwauling and had just stayed with the couple for 2 weeks. She looked healthy and her full set of permanent teeth had some plaque.

I estimated her age to be around 6-7 months. In the interest of the cat, spay should not be done. However, some owners do go to other vets later and so there is this need to do what the customer wants.



In spaying young cats less than 6 months, the uterine tubes are usually very thin since the cat has not matured, as narrow as 3 mm in diameter. Spaying can still be done as some humane shelters overseas do it even at <5 months of age. Since this is a well cared for cat, spaying is best done at an older age of 7-8 months. Case written at: http://www.sinpets.com/cats/20120328adopted-young-cat-kitten-singapore_ToaPayohVets.htm 2. RUPTURED EPIDERMAL CYST IN AN OLDER MINATURE SCHNAUZER "What to do now with the big hole," I asked Dr Daniel who was assisting me with this surgery. A big hole after excision using electro-surgery of a skin lump 1.5 X 2 cm x 1 cm above the neck, behind and between the shoulders. "Just stitch up?" I asked. Actually, the best way is to use Z-plasty. This is described in http://www.sinpets.com/F6/20120247z-plasty-pyometra-cat-singapore_ToaPayohVets.htm





CASE 3. Beagle with itchy lower body.
"Did you express the anal sacs?" I asked Dr Daniel who disagreed that itchy lower body would be related to any anal sac. The dog's backside was not itchy, so no anal sac problem.

"It is not as clear cut as that," I said to him. Sometimes, the itchiness is not related directly to the itchy area.

He expressed the anal sacs from the older Beagle put on the table in the waiting room. The whole waiting room filled with a pungent smell for several mintues while his hands were full of >20 ml of dark brown oil. This was really revolting. I had to open the door. The other vets had not been able to resolve the skin problem and so the owners brought it to Toa Payoh Vets. This was a case of ventral contact dermatitis with infection. A blood test would be useful. The owner had said: "The other vets did everything, so no need to do it."

"If you let the owner dictate to what you can or cannot do," I told Dr Daniel and Vanessa in the meeting on chronic skin diseases, how are you going to diagnose the problem? What had been done by other vets would not be linked to what is present now although it is still skin disease. You need to educate the owner. At least, you have to record AMD (against medical advice).

Got to rush off now.

Standard Operating Procedures at Toa Payoh Vets: Chronic skin diseases in dogs

I had a meeting with Dr Vanessa and Dr Daniel to discuss standard operating procedures in the treatment of skin diseases in dogs yesterday, Mar 29, 2012.

"In many cases, the owner had gone to at least one vet or two when they come to Toa Payoh Vets," I said. "Steroids and all medication had not worked. They had spent a lot of money. Yet their dog still scratches and bleed. If the vet at Toa Payoh Vets can't solve their problem, then there will be no referral from them. Successful outcome bring referrals. Steroids is only a short-term answer to the dog scratching."

THE STANDARD OPERATING PROCEDURES:

1. A detailed history and record of past treatments at various vets. Onset of skin diseasse. Get an overall summary if history is given orally. Pay attention and listen carefully. This takes a lot of time. Food types eaten. Treats given, shampoos used etc.

2. General and detailed examination. Location of all skin disease areas to be mapped out and written down. No general statement of "generalised dermatitis".
3. Blood test is mandatory
4. Skin test including 5 scrapings of skin for mites (not just one) and microscopic examinations. These must be recorded in writing meticulously.
5. Bacterial, fungal and yeast cultures to be advised. Sensistivity tests for bacteria.
6. Clipping of coat and bathing in an anti-mite wash is mandatory.
7. Cleaning of ears and expression of anal sacs. If otitis externa is chronic, advise ear ablation surgery.
8. Treatment may need hospitalisation for 3-7 days. Anti-mite treatments, no steroids to be given. Monitor progress of skin healing.
9. AMD. Against Medical Advices to be written down.
10. Food allergy test for 3 months. No treats or other food. This is usually not complied with.
11. Follow up by phone 2-weekly.

I will audit all chronic skin cases done by the vets.

Friday, March 23, 2012

920. Pyometra in a one-year-old cat

Yesterday I was at Toa Payoh Vets in the evening. Usually I am not present as Dr Vanessa is the vet on duty. Interns Jed and Mr Lim and my assistant Min were working hard helping Dr Vanessa. Jed was bathing the Golden Retriever with the right knee tumour wound. Mr Lim was changing to a new e-collar for him before the dog goes home. This dog had a big wound defect after excision of the large knee tumour. The high-tension area of the knee area led to stitch breakdown. The wife wanted the dog back after surgery and had slapped purple solution onto the wound which had started to break down 3 days after surgery. I asked her to bring the dog back and saw that the stitches were not holding.

When I informed the husband, he threatened to report me to CASE (consumer body) and then legal action. "If you can't do the surgery, you should not have accepted the surgery."

His opinion was that there should be no wound breakdown and if there was, I should rectify and ensure that the wound healed without charging him any money for further surgery.

"I am suing one vet as my dog had died under his treatment. My dog better not die in your Surgery." The dog was hospitalised for over 20 days to get the wound dressed daily. Stitching was not possible in this high-tension area. The dog tended to lick the wound if the e-collar was not worn. The wound had closed 20% but would need another month to granulate. It was time for the dog to go home with medication and I phoned the husband who said he would come.

CASE 1. Big tumour behind neck

Suddenly at around 6.30 pm, three young ladies came with a growling Miniature Schnauzer and I was at the reception doing some administration work and answering the phone calls while the others were doing kennel work. Dr Vanessa was consulting with another owner.

"What's happened to your dog?" I asked one lady. This was a 7-year-old male Schnauzer who warned vets off. "Are you waiting to consult Dr Vanessa?"

"I want to consult you," the lady pointed to a hard lump of 3 cm x 3 cm in the neck skin, midline, between and slightly behind the ears. "It could be a microchip inflamed lump," I said. "When did you microchip the dog?"

"He was microchipped when young."
"Did any vet inject him in this shoulder area?"
"No," she said.
I pointed the microchip scanner at this lump and it beeped showing the microchip number.

"It could also be a fast growing tumour," I said since the young lady mentioned that she only discovered the lump recently. She held the dog firmly while I examined the hard lump again.

"Tumours are what I am worried about," she said. Nowadays, many young ones read about their dog healthcare in the internet unlike the old days when many were quite ignorant.

"If it is a tumour, I would need to make a big cut to take out as much of the mass as possible and send the tumour to the laboratory for histopathology to check whether it is cancerous."
She made an appointment for this Sunday morning operation. Not all lumps are due to microchip or injections and if the vet thinks only these two possibilities, he might be in for a rude shock if the lump was cancerous.

So, it was best to excise it as early as possible and certify that the microchip had been excised, so that the owner had proof in case the regulatory AVA made a surprise check for microchip.


CASE 2. The one-year-old female cat passes pus copiously.
Another lady phone call was answered by me. "My cat passes white yellow thick discharge from her vagina non-stop. Drip, drip, drip everywhere for one month. At first, it was a little bit. Now, the cat is not eating. When do you close?"

"We close at 8 pm. It is better you get the cat treated early as it is a womb infection. It is called pyometra."

After asking about the cost of surgery, the lady came with the cat.
"Can you feel the swollen uterus?" I asked Dr Vanessa. I could feel a swollen lump like a bladder swelling of a golf-ball size and two long tubes around 1 cm in diameter. No specific hard uterine bodies. Dr Vanessa shook her had. "However, it is pyometra," I said as more yellowish-white vaginal discharge fell in patches on the consultation table.

"Now, what anaesthetic to sedate?" I asked Min. "This cat is not in good health."
"Xylazine and ketamine IM," Min said.
"That is what we usually do. Zoletil is safer."
We rarely use Zoletil on cats and so Min did not mention this.

I weighed the cat. She was 3 kg.
Zoletil 100 = 100 mg/ml. The dosage for IM was 10-15mg/kg and I decided on 12mg/ml.

I asked intern Jed to calculate so as to give him some hands-on experience. His calculator showed 2.7 ml.

"Cannot be so much," I said.
The correct calculation was 0.36 ml of Zoletil 100.
I gave 0.3 ml IM. Then I gave 0.4 ml atropine IM to prevent salivation and head twisting - side effects of Zoletil.

Dr Vanessa operated. Isoflurane at 5% for a short while by mask and then minimal 0.5%. The large womb was taken out. Dr Vanessa decided on using horizontal mattress this time as she was set in her ways, always using simple interrupted. I had advised her to practise on using horizontal mattress which is a stronger suture but she would always do her own thing. Each young vet has his or her own mindset and so I do not bother as long as the stiches heal the wound.

Dr Vanessa believed in subcutaneous sutures despite my advice not to do it as it would irritate the cat or dog during healing. Well, each young vet has his or her own mindset that would take time to change, with adverse side effect experience encountered. All vet professors lecture on the need to close up dead space using subcuticular sutures and all young vets graduate with this concept that they must do it after a simple spay. Till they realise from intense itching in a few cases of wound breakdown and unhappy owners that they need not do it for spays and Caesarean sections. It is hard to change a young vet's mindset since they believe that their professors of surgery had to be a better teacher than an old vet like me.

"For aesthetics, all sutures should be horizontal mattresses", I believed in presenting a neat surgical stitching pattern. Owners do peruse the
wound as the pet is a young family member and some do compare the competence of the vet by comparing his stitching (read one story later).
Dr Vanessa had put in two horizontal mattresses at one cm in length but felt that there was a small gap of 0.5 cm at the end of the skin. She wanted to put in a simple interrupted. "If you have to stitch that area, use a shorter horizontal mattress," I said. In total she had 4 horizontal mattresses done. Actually two would do. But it takes time to change mindsets of young vets as most have a mind of their own as regards suture patterns.

921. The vet's suture protruded the skin - Good stitching patterns count.

921. The vet's suture protruded the skin - Good stitching patterns count.

Two days ago, two ladies and their father brought a 17-year-old cat to the Surgery. The cat had been pawing her neck trying to get rid of a nodule 1 cm x 1 cm. Dr Daniel handled the case. The over 70-year-old slim built father was at the waiting room and I was at the reception and since he was chatty, I had an interesting conversation with him.

"Why do you not go to the vet nearby your house?" the father mentioned that he lived near a vet. However, his daughter did not want to consult this vet.

"The vet spayed this cat. But the cut was very long," he said. "The skin protruded from the stitches. So my daughter did not want to go there."

"Standard spay wounds are around 2 cm long," I said. "Unless there are complications of bleeding or other reasons such as pyometra."

In this case, I did not know what had happened. This is one of the times that a neat and good stitching pattern does impress and count in retaining client loyalty. And this was 17 years ago when the daughter would be in her teens. This daughter-in-charge looked to be in her earlier 30s and was in the IT field, according to the father. So, the internet brought her to Toa Payoh Vets, according to the father. The internet is a double-edged sword and could drive clients away when there are bad reviews from one or two vocal unhappy owners or competitors.

Well, the 17-year-old cat had this irritating neck nodule (1 cm x 1 cm) that she scratched. Dr Daniel's advice of a blood test prior to surgery was accepted by the IT daughter. Serum urea and creatinine levels were above normal and though the cat was normal, the daughter was not in favour of surgery.

"This cat has white strong teeth," Dr Daniel told me. "Can this cat be younger?"
"Very rare for a 17-year-old cat to have good teeth," I said. "But many cat owners do know the age of their cats."

As the father was complaining about a specialist earlier, I asked him what was the problem. "The specialist told me what was the big fuss I was making about my health since the brain scan showed no brain tumours? Why would I pay for a brain scan?"

Sometimes, it is best for a doctor or vet not to comment on personal behaviour but stick to the medical facts.

"What's exactly happened to your father's eye?" I asked the IT daughter later as her father did not speak English but the Hokkien dialect. The daughter put her fore-finger on the lateral side of her left eye and pulled up the eyelid at 45 degrees. "His eyelid flicked sideways and upwards now and then."

"The specialist said he had no problem in the brain MRI," I said. "That may be because the problem could be somewhere between the eyeball and the brain!"

"We are not refined cultured people like the specialist," the father was still mad about the poor bedside manners of this specialist.

Yet he does have a real medical problem. Earlier he had a hard lump below his left eye but this lump had disappeared.

So, what was he suffering from? He had no diabetes, no hypertension and was not obese.

"He does have a medical problem," I told the IT daughter to do an internet search of nerve pathways between the eyeball and the brain. "It is likely that a small tumour had impinged onto the nerve in this pathway. It irritates the nerve and the left eye's upper eyelid twitches suddenly, pulling up the eyelid."

It must be embarrassing for the father when that happened.

"It is best to consult a good neurologist or eye specialist." I said. "The problem is to find that particular one in Singapore. It is extremely hard to find one with the experience with this problem."

I had a similar sudden flicking up of my middle finger of my left hand two years ago. It would flick up now and then. Finally I had a non-malignant nerve tumour behind my wrist excised and the problem disappeared. So, I could empathise with this senior citizen. It was no laughing matter for him. And he does have a medical problem. "Only that the particular specialist he consulted could not diagnose this problem!"

Life is hard for senior citizens when twitches and spasms of eyelids are not diagnosed and removed. A trigger finger is not so obvious to outsiders but a twitching upper eyelid could be most embarrassing when it occurs during a conversation with somebody. I hope this IT daughter will find the correct specialist - neurologist or Ear Nose and Throat surgeon probably, I advised her. If anybody can do it, it will be this IT daughter, but would she have the time to do it? I had pointed the direction to her. It is up to her to be diligent to find out the correct specialist to pin-point the tumour affecting the father's eyelid before it grows immensely.

919. Follow up on 48-hour panting dog

Visited Clare in her new grooming shop today with Dr Daniel. Just started 2 days on her own. "How's the dog?" I asked. "No serious panting yesterday," she said.
"That's good," I said as it is bad for the dog to die while being boarded in a groomer's apartment. Some do die, from heart failures.

"This dog would have died if you had delayed vet treatment," I was told that the owner would only be back from overseas on Wednesday (today being Friday). "The blood was bluish. Her tongue was cyanotic."

So, it was good news. She started her own shop and already had clients as she had been in the grooming business for over 15 years. "This Shih Tzu was groomed by me when she was a puppy," she showed me a black and white Shih Tzu with white scars on the left eyeball protruding. "Dr Jason Teo stitched up the eyelid one time when it was bleeding."

"You can remember every dog?" I asked. "Yes," she said. "I remember all my grooming dogs." In grooming, the owner sees the groomer often. "Contact is by telephone,"Clare told me. "So, shifting to new address will not be a problem." This is unlike a vet who moved out from old positions to start up a new place. Unless the vet sends cards; if not, it is hard to find them unless the owner is persevering.

Went to see a run down building near Singapore Zoo for the pet trade today with another groomer. "It is to be tendered for the pet-trade," he said. I told Dr Daniel that the government authorities have all their nonsenses rules and regulations and by the time this dilapidated building is fixed up, at least $200,000 will be spent and unless one is in contact with contractors, the amount will be astronomical to do "pet trade."

"Only a casket company came to see this month," the officer told us.

Wednesday, March 21, 2012

The dog died after the operation by the vet

This is quite a typical remark from 3rd parties and from owners.
This 50-year-old lady told me about a 12-year-old dog that no vets would want to operate

917. Follow up on 48-hour panting dog 7 years old

Today Mar 22, 2012, I follow up with care-giver groomer.


19.3.12 Emergency 11 pm came in with panting non-stop. Case written earlier.

20.3.12 Groomer came to pick up dog at 7pm from Toa Payoh Vets. Dog was OK then. At 11 pm, was the worst. At 11 pm, panted and tongue came out like shortage of breath. Gave medicine fortekor half tab. Dog OK after 1 am.
Not panting badly. In morning, still pant but not badly.

21.3.12 Groomer gave the following:
9am Fortekor first, 1/2 tab
9.10 am Lasix 1/2 tab
9.20 am Vetmedin cap

Came home. 8 pm. Only gave Lasix 1/2.


21.3.12 Last night 11 pm , did not pant. Heavy breathing. Does not put out tongue

22.3.12 Repeat the same as morning of 21.3.12. The dog was normal. Appetite OK, eat Caesar canned food at 1/2 can. Normally 1/2 can 2X/day as instructed by owner. Urinated a lot.
11.31 am I spoke to groomer. Dog OK now.

INTERESTING ASPECT OF THIS CASE - In my observations and findings.
1. Heart sounds muffled on ausculation compared to normal dogs with heart disease or CCF (congestive cardiac failure). A case of hydro-pericardium?
(X-ray showed enlarged heart).

2. Heart murmurs - slight or absent
3. Tongue cyanotic during emergency admission on 19.3.12 and blood collected were bluish
4. Blood test - ALT high, serum urea and creatinine very low. Yet WBC and RBC within normal limits.
5. Heartworm test not done.

A "sudden onset" and persistent panting case. So what is the actual cause? Congestive cardiac failure? Overweight? Heat stress? Bacterial or viral infections starting? Dog eats well and is active. Puzzling?

916. Follow up: Guinea Pig with right ear tumour

Thursday Mar 22, 2012 11 am Toa Payoh Vets recording

The case of the big ear tumour

Yesterday I text messaged the owner of the GP with right ear tumour electro-excised some days ago to tell him the good news that the tumour was not cancerous. The lab report stated trichoepithelioma. The message could not be sent. So I phoned him at 10.30 am today. He was pleased with the good news. This guinea pig did not like the miniature tomatoes as much as the companion who is one-year old. "The other GP eats 3 a day," the gentleman whom I had not met, said. "He stops eating tomatoes and I gave him cucumber slices which he eats all. Also, he likes timothy hay."

The guinea pig was well cared for and loved.
"How did he get such a big ear lump?" I asked as the vet he consulted was Dr Jason Teo who worked on Saturday when he came. I took over the surgery and anaesthesia which is quite risky for GP compared to the bigger dog or cat of similar age.

"I noticed hair loss around his right ear one month ago. Then a white swelling."

"Did the other GP bite the lump since there was bleeding and ulcers when you brought him in for treatment on Saturday?" I asked.

"I don't know but he did have bite marks on his body. So he could have been bitten by the other GP."

"He could have scratched the big lump," I said. "It could be irritating as it was heavy. Is he normal now?"

"He is OK. He eats well, drinks and is active. No blood in the urine. Clear coloured urine peed. However, sometimes he shakes his head."

This case illustrates the importance of following up post-op. The owner did not call me to report on head shaking as it was not causing the guinea pig to stop eating.

"There is something inside the ear," I said. "Some blood from the bleeding and some powder from the purple permanganate applied to the wound to stop bleeding."

"What shall I do?" he asked.
"Buy a new syringe. Fill with boiled water. Squirt a few drops into the ear ear canal 3X/day. Massage the ear canal to clear the blood clots and chemicals for the next 5 days. Phone me after that."

Timely treatment of the ear canal by removing the debris will prevent infection. It must be done at home a few days. But in the dog and cat, I have to do it at the Surgery if the owner can't do it well. In this GP, it is best that the owner who cares much for the GP is assessed and can do it.

Always follow up esp. on ear surgery, if possible, in this hectic paced working llife in Singapore. The owner would not know about otitis externa aand this would worsen in time.

Monday, March 19, 2012

Follow up on the two guinea pigs with urinary problems.

Further to my earlier case study of 2 GP with urinary tract problems, the results are as follows:

1. GP with blood in the urine for 2 weeks. X-ray by Vet 2 showed several bladder stones and advice given was euthanasia. When the GP came to me, he was very thin and weak. The young lady got permission from her mum to get the bladder surgery done by me.

I advised against immediate surgery as the GP was not fit to be under anaesthesia. He would just die on the op table. The owner was to hand feed and make him well first. On the 2nd day at home, he passed away. In this type of case, the interest of the GP is paramount rather than the bottom line of the surgery, since the GP practically had no chance of survival on the op table.


2. GP not eating, had a grossly swollen bladder. Dr Daniel and I palpated the abdomen. Looked so much like ascites although I could feel the faint outlines of a very full bladder as big as an orange. Suddenly whitish cloudy urine dribbled out. More and more urine was released like a storm flood. I got the urine inside a syringe and sent to the lab. Came back with struvite crystals +++, bacteria + and urine pH = 9.0. Evidence of urinary tract infection caused by amorphous phospate or struvites +++. So what to do now?

"In dogs, acidify the urine or give S/D diet," I said to Dr Daniel and Dr Vanessa. "What to do for a GP with struvites in the bladder?"

The lady owner returned my text message this morning. She had left all medication to the sister who stays at home. After 3 days, the sister stopped the antibiotics and the pain-killer as the GP was eating and drinking.

"But he sits in a corner," the young busy career lady said. "When can I send him down for another check up?" I scheduled next week. She has only one GP and believed that her sister had increased the intake of Vit C tablets to 1.5 tab/day causing the GP to stop eating.

Overdosage of Vit C can lead to kidney stones in people. In this case, the GP had a UTI

Follow-up on the 48-hour panting dog

At 10 am, the 7-year-old Maltese dog that panted non-stop for 48 hours behaved as normal as any other dog. Groomer Clare was relieved of worries. I was happy for this now energetic companion of somebody. He ate a little and is as active as a puppy.

As to the cause of his medical problem, it is hard to say exactly.
"Don't need X-ray now that the dog has recovered," Clare said over the phone.
"As long as the owner has been advised that an X-ray is recommended," I said. "If the dog should die the next few days, the owner will demand to know why the vet did not recommend a simple chest X-ray."

Clare phoned the owner who is overseas and got the permission to X-ray. I told Dr Daniel and intern Mr Lim to get it done. The blood test result will come in soon.

The clinical outcome is what the owner wanted. Diazepam via a rectal tube did enable this dog to sleep and the other drugs helped her to recover. But what was the original cause of this sudden onset of continuous panting? Viral infection? Unlikely. I suspect it may be an allergic hypersensitivity reaction in the groomer's apartment affecting her. But this is pure speculation. Wait for blood test result.

913. Electro-surgery to excise the guinea pig's ear tumour

Will a guinea pig die or electrocuted when electro-excision of his ear tumour is being done? After all, he is only 800 grams and is small compared to dogs and cats where electro-surgery is well established as a procedure.

The critical point is the anaesthesia. Too Little, the GP may wake up and die of fright and pain when electrodes are applied. Too much, the GP may die. Just sufficient, the GP does not feel the pain and the surgery goes smoothly.

So what anaesthesia is to be used?

In this case study with Dr Daniel, I demonstrated the electro-surgical excision of the 3-year-old male GP with a large ear tumour. This would probably be one of those rare occasions to see such an electro-surgery for him as there are few cases in GP requiring such a method. I said that scalpel cutting would not make for a clean cut, unlike electro-surgery. Talk must be shown by action and so I did it today.

3 days of antibiotics and cleaning first. Today is operation day.

ANAESTHESIA
Zoletil 100. 800 g GP.
I drew 0.05 ml Zoletil 100. Added 0.05 ml normal saline. Injected 0.1 ml IM muscle backside.
Less than 5 minutes, the GP was done. He could still feel pain (forcep onto ear edge) and so isoflurane gas was given carefully for a few seconds. The trick her is to give not too much and yet not too little by mask. I checked the eye blinking reflex. Just at the point of no blinking and blinking. A twilight zone.

Isoflurane gas at 2% given to effect.
The electro-excision began. Some little noises from the GP when electro-surgery was applied but no waking up. All done within 2 minutes.

GP woke up after 30 minutes and was OK to go home to a happy gentleman owner who had brought him to Toa Payoh Vets on Saturday to see Dr Jason Teo, saying that the GP had a bite wound. It was not a bite wound but an infected ulcerated tumour.

Electrosurgery in GP and dwarf hamsters. I worry that insufficient analgesia may cause fright and heart attack. So I seldom use it too. But, in theory, the GP and dwarf hamster will not be electrocuted or die of heart attack if proper procedures and analgesia are adopted. The vet must know how to use the tools of his trade!

912. An old dog panted non-stop for 48 hours. Why?

Yesterday, Monday, Mar 19, 2012, at 10pm, I received a phone call from Clare who had cared for a Maltese, Female, spayed, 5 kg, 7 years old, in her apartment. The dog was Ok but started to pant non-stop for the past 48 hours. The owner was overseas and she had to get veterinary attention.

"The dog may be having a heart attack," she said to me. I drove down with Dr Daniel who had just completed his REA lecture on advertising at Toa Payoh Hub. We waited some time for Clare to come.

After the physical examination by Dr Daniel, I examined the dog and asked Dr Daniel: "What is the cause of this continuous panting? Is it a heart attack?" My assistant Min was helpful in suggesting that the dog's mouth be closed while his heart was being auscultated. An old dog like Min and I would know that.

"No," he said. I agreed with him. "So, what is the problem?"
"Pneumonia," he said. "Yes, the right lung sounds were harsh."
"What to do?" I asked.
ABC is the usual standard operating procedure taught by the vet professors.
A=Airway
B=Breathing
C=Circulation

The dog's tongue was cyanotic. "Check the rectal temperature again," I asked Min when he showed a 39.4 deg C in the thermometer. It was again 39.4 deg C. A dog that had panted non-stop for 48 hours should show a much higher temperature. Yet, she did not. She could eat. "Drank lots of water," Clare said. "But otherwise, passed normal stools and had appetite."

So, what causes the sudden-onset pneumonia?
"Kennel cough," Dr Daniel had elicited cough reflexes from the throat.
"It is possible," I said since this dog was boarded by the busy groomer who would have such viruses. "But the dog has regular vaccination," Clare said. But what type of vaccination? She did not know. Kennel cough vaccination is usually not done.

"It is possible that the virus has attacked the lungs," I said. "I need the blood test and the X-rays."

In the meantime, what to do?
"Oxygen therapy. That is for "A" of the ABC for respiratory distress lecture by the professors. Did the dog need oxygen now? I didn't agree.

"It would be better to reduce this incessant panting as the heart will fail if it continues," I said. Sedative diazepam rectal tube was given. Lasix was injected IM. A drip was given. Tolfedine and baytril with pred.

The dog's panting rate reduced by 50% after half an hour. The groomer went home quite relieved. At 8.20 am today, I checked the dog. She was panting much less. More observations needed to be done and the blood results should be known.

Friday, March 16, 2012

A Myanmar fortune teller's accurate prediction

On Mar 15, 2012, I visited Khin Khin who operates the Khin Khin Employment Agency in Singapore. A fair lady in black with silky see-through on upper part was in sitting on a chair behind me in her room. "Can you remember her?" Khin Khin pointed her to me.

"Well, I do," I said. "She was the one working for an interior design company and wanted to quit within a few days of starting work because she had a hard time from the boss and her country-woman who did not want to teach her how to use the Auto-cad software."

Khin Khin always emphasized to employers the attractiveness of a prospective candidate looking for a job in Singapore. As if the physical appearance of a female job candidate counts and she considered this girl "pretty".

I had met this Myanmar girl in her office some weeks ago. She wanted to quit and I had advised her not to. "It is not easy getting an employer in Singapore," I said to her. Just wait. Your country-woman is going back for a holiday soon. Wait."

After that I did not see her till today.

As a picture is worth a thousand words, I have uploaded a picture of another lady whose facial features and fairness in complexion resembled this lady. A rectangular-shaped face, big eyes, porcelain complexion, beauty enhanced by a knowledge of how to use make up effectively to highlight the features. A black number of good quality dress material. Well groomed.




Khin Khin continued: "Her boss forced her to write a resignation letter. She cried in buckets of tears after that. Her mother took her to a fortune teller in Yangon. The fortune teller said that she would get a job in Singapore soon. She attended an interview. The new employer keyed in her details to MOM and she got the reply the next day. She got an S Pass within 24 hours."

I was much surprised as MOM does reject and delay applications for S Pass for many employers whose applications Khin Khin had submitted. Maybe these were "not strong" employers, according to Khin Khin.

I was more surprised that the fortune teller could predict so accurately.
"Well, she went to see Kuan Yin (Goddess of Mercy) in a temple in Bugis," Khin Khin said. "She promised to make an offer of $200 if she gets a job in Singapore."

"So was it the prediction of the fortune teller or the power of Kuan Yin?" I asked.
"Or both?"

Khin Khin is a Buddhist and does not believe in Kuan Yin's power. But she said: "It must be Kuan Yin."

The fair lady did not comment as I did not talk to her and she was in a hurry to go for another appointment. It was good news as it was practically impossible for her to work in the first employer's place without the depth of knowledge of Auto-cad and thereby needing the help of the incumbent. I could see that the incumbent would not teach her as that would mean being replaced by a lovely lady. Why should she? The working place is a ferocious jungle where good looks do count. So this young girl had no chance at all.

The boss forced her to resign possibly because the incumbent had threatened to quit. And it is not easy to find Singaporeans who can work in AutoCAD as employment is quite full in Singapore. Most young Singaporeans can find a job if they will work.

The next day, I phoned Khin Khin about other matters. She said: "The little girl asked me to accompany her to Bugis as she would be offering $200 to Kuan Yin. I went to pick up a stick from the container. Devotees throng this temple to ask the Kuan Yin for better business and health and would pick up a stick from the temple's container after praying.

The temple person said that it was "bad". What is "bad"?
"I don't know," I dared not say as I don't know the significance.
Khin Khin said: "I was asking for good reincarnation for my father." Her father of 82 years of age passed away last month.

"Since you don't believe in Kuan Yin," I said. "You don't have to worry about "badness" forecasted in the stick. Khin Khin had got a piece of paper from the temple and burnt it (to ward off the bad spirits?).

In any case, the story of this lovely girl getting an S Pass to work for another employer within the predictions of the fortune teller is true. If that fortune teller is so accurate, I should be flying to Yangon to consult him. But I rather not do that in case he predicted a bad future for me.

This is the 2nd incident I heard about an accurate prediction from a Yangon fortune-teller. The first involved a person having great difficulty in collecting a business debt in Singapore. He consulted the fortune teller who predicted that he would get his money back. When he came back to Singapore, the debtor agreed to pay him, by instalments.

In conclusion, is there any scientific explanations or do some Yangon fortune tellers have powers of predicting and changing the future?

910. Guinea pig websites

http://www.theguineapigforum.co.uk/

http://www.guinealynx.info/

http://www.rngp.org/ Rabbit and guinea pig welfare


http://www.catandrabbit.co.uk/html/guinea_pigs.html

909. Two guinea pigs not eating - white viscous urine, blood in the urine

Yesterday Mar 16, 2012 (Friday), I saw 2 cases of guinea pigs with urinary problems and reviewed the case with Dr Daniel as part of my mentorship program.

We had met an interesting and friendly experienced Australian banker who had travelled to all over the world to work, at Liang Seah Street at 11 am today. "How old are you?" he asked Daniel. He then told Dr Daniel that 20% of the young men of his age and new graduates are jobless in Ireland. He told me that my handshake was weak, compared to Dr Daniel. "Have you been to Timbuktu?" I asked him. "No," he said. "But I have been to various places in Africa. I was sad to see so many homeless children and the poverty."

P.S
I used to study English phases in primary school in the 1960s and there is a phase referring a distant place as Timbuktu which is actually present in Africa. I doubt I have a chance to visit it.

Case 1.
Not eating. Abdominal swelling obvious. The owner had seen me some months ago. "No more skin infection," she said. "My guinea pig is not eating."
Dr Daniel palpated the swollen abdomen. I did that after him. The swelling covered almost 90% of the abdomen. Soft distended bladder, in my opinion. I don't know what Dr Daniel thought. Was he thinking of ascites? Definitely, ascites present this pendulous abdomen.

Before I could speak further, the guinea pig squirted out white cloudy urine onto the stainless steel consultation table top. "The urine is not normal," I said. "I would take some for urine test." I took a new syringe to suck up some urine. The guinea pig voided much more urine. Thick cloudy liquid. As if the bladder had lots of white sand.

"Is it possible that my guinea pig has bladder stones?" the lady asked. "My other guinea pig had bladder stones. The vet removed it but then said another surgery had to be done."

"Why was there a need for a second surgery?" I asked.
"The first one was not done well," she said. "So, another one had to be done."
"What happened to the guinea pig after bladder surgery?" I asked.
"She lived for a few days and then died."
"In this case, the guinea pig might have or might not have bladder stones. We will wait for a few days and get the urinary tract infection treated first."

A follow up the next 2 - 7 days would be needed. X-rays would be needed to confirm bladder stones.


Case 2.
Not eating. Weight loss for 2 weeks. The owner had phoned me about bladder stone surgery. She had consulted Vet 2 recently and an X-ray had been taken. But two weeks ago, she consulted Vet 1 who gave a different diagnosis. Today she came with the X-ray as I had advised her to get it from Vet 2 to save her cost of the need to have another X-ray taken. Vet 2 had told her that the medical notes would be sent to me. "It is not the medical notes that is important," I said to the young lady. "It is the X-ray of the bladder stones and to see if there are other locations like kidneys and urethra where stones are lodged."

"The vet gave antibiotics for a gastric infection," the lady said. "But the guinea pig did not recover and was not eating. So I went to Vet 2 who took an X-ray and said there were bladder stones. She advised euthanasia."

"What was the original problem with your guinea pig when you saw Vet 1 as you said that your guinea pig was treated for stomach infection?" I asked.

"My guinea pig had passed blood in the urine."
"What did Vet 2 advise?" I asked. The lady was not so clear about this but she said: "I don't want the guinea pig to be put to sleep. She could not pee for the past few days and did not poop."

Smaller than normal 1-cm long faecal pellets were passed on the consultation table. I palpated the abdomen. "No swollen bladder," I said. "The guinea pig had passed urine and you might not have seen it."
"I saw a brown spot," the lady said. "Just that brown spot on the paper. I have separated her from the other guinea pigs"

"It is possible that you did not see the other spots if they are not coloured," I said. "Since I can't feel a swollen bladder despite you saying that the guinea pig had not peed, I would say that presently, the guinea pig had no urinary problem."

She phoned her mother regarding surgery to remove the bladder stones (> six of them). It was the cost of surgery quoted as $300. I advised against immediate surgery as the guinea pig was very thin and dehydrated. I asked her to syringe feed with the pink syrup, food and emergency care 6 times per day, as prescribed by Vet 2 for the next 2 days.

Doing bladder surgery today would have killed this poor-conditioned guinea pig. The antibiotics from Vet 1 and Vet 2 were working to clear the urinary tract infection for the time being. "Let her be much stronger to take surgery by nursing her the next 2 days," I said to her.

"In such cases," I said to Dr Daniel. "Immediate surgery is most likely to lead to death on the operating table." Sometimes, the guinea pig dies the next 2 days. So, it is better to get the pet stronger first.

A follow up 2-7 days is needed.

P.S. In Case 2, the worried owner did not say that the guinea pig had runny nose. I saw yellow fluid from the left nostril. "Your guinea pig has an upper respiratory infection and anaesthesia would be very risky. The guinea pig needs to recover from the infection." As you can see, an immediate operation would not be in the interest of the patient.

"Any death on the operating table is a very emotional affair for the owner and the operating vet," I said to Dr Daniel. "So, it is best to get the patient in the best possible health before any operation. Unless it is an emergency."

Wednesday, March 14, 2012

908. Rimadyrl for an 18-year-old Chihuahua with pain in the hips?

Yesterday I saw one case with Dr Daniel. The owner had been my old client for at least 18 years since his chihuahua is 18 years old.

WHAT IS WORRYING THE CLIENT?
This is the crux of the matter. I spoke to him. He said: "My dog was whining and crying the whole night. She couldn't sleep and therefore I couldn't sleep. She had constipation."

The dog was limping and had pain on the right limb. During X-rays, on extension of the limb, the dog bit the handlers. So, there was no problem with the cause of pain.

Now, prescribing Rimadyrl tablets. This is standard practice. "But this is an 18-year old dog," I said to Dr Daniel. "She is equivalent to a 100-year-old man. Rimadyrl has side effects on kidneys."

"Side effects of Rimadyrl occur only after taking the medication for some time," Dr Daniel said. "Not overnight."

"In Australia, the dog owners you saw practice with other vets, usually bring in their dogs for Rimadyrl earlier than 18 years old and so the side effects of long-term medication can be seen over time. This Chihuahua is 18 years old and has come in for the first time. In Singapore, many owners don't see the vet till a crisis happens. In fact, the owner said that the dog had no problems other than constipation. What if the dog dies when the owner gives Rimadyrl over the next 3 days? His kidneys and livers may not be that great at 18 years of age. Blood tests would show but why take the risk?"

I said: "What if the dog has an adverse reaction to Rimadyrl and die soon after consultation at Toa Payoh Vets? You will be accountable for the death from oral Rimadryl as this will be what the owner will say."

It is best not to prescribe NSAID orally for hip arthritis till the blood test results come in. Even then, pred would be safer.

Many new graduates think that pred should be avoided in all situations. So NSAIDs but in this case, it is better to be safe than have a dead dog dying of kidney failure due to Rimadyrl. Each vet has his or her own prescriptions and if you consult 3 vets, you may get 3 ways to treat your dog for "constipation:.

907. The veterinary prediction was inaccurate

One day in March 2012, I received a text saying that the rabbit was not eating or drinking. So I texted back that it needed to be examined. I thought it was a rabbit owner who had consulted Dr Daniel and me earlier. See the case of The Rabbit With A Tearing Eye at:
http://www.sinpets.com/F6/20120217cheek-teeth-ingrown-rabbit-eye-tearing-toa-payoh-vets_Singapore_ToaPayohVets.htm

She made an appointment via text. I confirmed similarly. A slim young lady in her early 20s came with a 5-month-old dwarf rabbit. She was a new client. "My rabbit is not eating and drinking. Could she be suffering from hairball? Could she be pregnant?"

Dr Daniel would be treating the case with me as the mentor. He palpated the abdomen. "Pregnant, with one (kit)," he declared. I palpated the abdomen and felt the soft 4x3 cm mass in the lower third of the abdomen. "Only an X-ray would tell how many kits there are," I said. "In an X-ray, you can see the number of foetal skeletons." And therefore the number of kits.

"When was the rabbit mated?" I asked the young lady who had said that there was a 6-month-old male rabbit living together with this rabbit. "Around 2 weeks ago," she said. "How long is the pregnancy?"

"Around 28 days," I said. In this case, the rabbit would be only 14 days pregnant.

"Should I get the rabbit X-rayed?" she asked me.
"No need to do it," I said. "Just wait for a few days. In the meantime, remove the male rabbit. Keep her in a quiet dark place by herself and give her newspaper pieces to make a nest."

"We still have to check the teeth," I said to the lady and Dr Daniel.
"Scruff the neck," he said. That is the usual method of restraint of a rabbit.
"No," I noted that the young lady was particularly concerned about her rabbit and would misconstrue that the vet was rough handling her dwarf rabbit. If you think about it, a dwarf rabbit is very small. Her mouth is also very small. Scruffing the neck with a man's hand would practically cover most of the forehead, leaving little space to open the mouth.

I imagine that this might not be the most appropriate method to open the mouth for the dwarf rabbit but it would be for the cat or dog.

"Just wrap the rabbit inside a towel, like wrapping a present," I said. The young lady was watching apprehensively and this method would be more gentle. Perceptions of a client as regards the vet's "rough handling of their pets" are made and remembered when the rabbit struggles or squeals during scruffing. Sedation was not necessary in this case and in this situation of a pregnant rabbit.

It was obvious that the cause of not eating and drinking could be due to pregnancy. But the teeth must be checked for malocclusion or overgrown as this is a most common problem in the rabbit when it does not eat.

So, I wrapped the rabbit in a soft white towel with the head showing. The lady was watching quietly. Then I got the artery forceps to open the rabbit's mouth. I asked Dr Daniel or the owner to shine the white light as the rabbit resisted the mouth opening. "See the back teeth," I said. "Are they overgrown or short?". It took some time and patience but the lady was able to see that the teeth on both sides of the cheek were short and trimmed. The rabbit was not co-operating but could not move much. She did not squeal.

I thought the rabbit was around 14 days pregnant since the lady said the mating was seen around 14 days ago. Life is full of surprises as you can see from the text message of thanks I got from her 3 days later when I texted her as a follow up. In fact, the rabbit stopped eating and drinking because she was about to give birth!


Dr Daniel predicted one kit on abdominal palpation. I was very cautious and said that only an X-ray would tell how many kits were there from the number of foetal skeletons visible in an X-ray.

Well, veterinary medicine is always full of surprises. In this case, the rabbit gave birth to two kits. So, you know why I never predict the number of kits, puppies or kittens just on an abdominal palpation! It is just unpredictable usually. Unless it is a "single pup" syndrome in a chihuahua!

Tuesday, March 13, 2012

906. Starting a pet grooming business in Singapore - my observations

THE SINGAPORE PET GROOMING BUSINESS


It is relatively cheaper to start a pet grooming shop in Singapore as compared to a veterinary clinic. Still the following factors contribute to success or failure based on my observations of many groomers opening and closing shop in Singapore every year, for the past 30 years:

1. Location - convenient, easy to park

2. Capital - need a few thousand dollars to last one year to pay the high rentals.
Landlords have no mercy on tenants and will want more and more rentals esp. if the business is good. Assuming a small shop in a poor location rents around $3,000/month, the rental per year is already $36,000.

3. Clientele - new grooming graduate. No clientele of significant numbers to sustain the operations.

4. Marketing - not guaranteed but must be done. Cost money and time.

5. Pricing - cheap, will get many cases but can't make much. Market rates can be as low as $40 with transport and grooming/dog. Therefore, estimate maximum of 30 dogs, the maximum gross income per day is $1,200.

For new groomers without solid clientele, average 3 dogs per day, no dog transport provided, the income of $120/day x 25days worked = $3,000. This amount can't even pay the rent and utilities. Sales of dog food and puppies may attract walk-in but there is the additional cost and the need to go for a course and be certified by the AVA to sell puppies.

6. Skills - unproven for a new graduate. Therefore, no referrals of significance. Pet owners may have to try their luck.

7. Free Transport - Some groomers need to transport dog home as they can't afford drivers. Many competitors provide transport-grooming package.

8. Wrist pain. Limited number of pets to be groomed. I estimate that 20-30 dogs groomed will be the limit for each groomer. Hand sprain, tendinitis, back ache unless the groomer gets a proper table.

9. Administration. Make appointments, get payments, send dogs home etc. That means hiring one assistant whose pay is around S$1,500/month.

10. Intense competition. Many groomers have set up shop as Singapore develops. How many of those who opened 10 years ago are still around?

11. Work-life balance. Is the young groomer prepared to work the long hours and weekends?

Relationships, motherhood, financial strength, high energy levels and hard work and long hours. How many of the google generation Singaporeans can sustain through the years and be focused to build up a solid reputation and be able to survive when landlords start increasing rentals again and again? Singapore rentals just keep increasing because commercial shop spaces are seldom built and therefore in short supply, unlike in countries like Australia.

Monday, March 12, 2012

904. Sunday's interesting cases. Mar 11, 2012 - Sedation to last stitch

Sunday, Mar 11, 2012

Sunday's interesting cases.
Sunday Mar 11, 2012

Singaporeans hate long waiting times at clinics to see a doctor and so I have started procedures to ensure that the waiting times should be less than 15 minutes. Many vets don't realise that clients hate to wait too long on Sundays.

For example, a neuter case on a Sunday can take up longer than 30 minutes (from sedation to last stitch) if the younger vet has no sense of time management. Or it could be done in 15 minutes with planning and pre-op preparation. Now I monitor the younger vets' efficiency in veterinary surgery by using time of sedation to last stitch and review the outcome of their surgeries (repeat stitching, stitch breakdown, infections etc).

Vets who don't make the mark will be asked to go. There is no other way because a higher standard of care must be achieved if Toa Payoh Vets is to be ranked by clients as the top 5 in Singapore. There are SOPs (Standard Operating Procedures) to be adopted and stuck to and I don't tolerate any lapse. AMA (Against Medical Advices) have to be recorded and medical records are to be written in greater detail than in the past.

A pug came in for neuter. I assigned the surgery to Dr Daniel and monitored the time he took. I ensured pre-op planning and preparation. Domitor and Ketamine at 50% and isoflurane gas. The sedation time to last stitch was around 30 minutes. It was OK but I said it could be shorter.

A dwarf hamster came in for left eye discharge and reddened left ear. Dr Vanessa was assigned the case. Not just some ear drops as the owner had been given such ear drops by the pet shop or Vet 1. Dr Vanessa scoped the ear. "A general anaesthesia had to be done to irrigate the ear," I said. The owner gave his consent. I asked Dr Vanessa to do a proper time management as she had other cases. In the end, I did the hamster myself with Dr Daniel as she other cases to attend to on this busy Sunday afternoon when clients came all together around 1-3 pm. I will have to follow up on this hamster.

A Schnauzer came in for a routine vaccination. Dr Daniel did it and told me that the dog had a black lump on the right of the backside and he had advised the owner to get it excised. It was good that he did a general examination and detected this lump. Some vets would just advise "wait till it grows bigger" but many tumours, if cancerous, grow bigger without the owner being aware of it, till it is too big.

The owner declined and wanted to wait and see. "The black lump is a melanoma," I said to the middle-aged couple with a teenaged daughter. "It has grown big but not that big yet. It is very black. Our advice to you is to remove it while it is easy to do so. And less expensive. You need not accept the advice. However, you cannot not say that the vets did not advise you during vaccination. When it grows bigger or spread to other parts of the body, you cannot blame the vets for not giving proper advice. Big tumours need big cuts and longer stitching. You have to pay much more. Older dogs like older people get tumours and it is better to get them cut away when they are small. Saves money and less worries of the tumours being cancerous and spreading later."

The couple was vacillating for some reasons. After all, they came to vaccinate their 5-year-old female Schnauzer. They were worried about the dog biting the wound and the lack of care-givers and wanted to wait later.

The vet's duty is to advise properly. "How much it will cost?" the father asked me. "$150 as it is a small tumour as anaesthesia will not be long and therefore the charges are less," I said. "Can surgery be done today?" he asked. "Yes," I said.

SURGERY
"This is a simple surgery," I said to Dr Daniel." It takes 5 minutes (from sedation to last stitch) to do the whole process." Dr Daniel looked at me incredulously. I was sure that he would adopt what the professors had taught him but that would be the traditional way. Sedate, intubate, use scalpel to make an elliptical incision with a wide margin. Undermine with scissors. Stitch up the two ends. How could the whole procedure take 5 minutes? I must be getting senile?

The dog was given Domitor and Ketamine at 50% IV. Isoflurane gas by mask was given though I would say it was unnecessary as you would see what I mean. From my experience, this dosage would be sufficient for a snip and a stitch.

"Pull up the elongated melanoma (1.5 cm x 0.5 cm, with a stalk) with forceps," I said to Dr Daniel. Snip it off with scissors around 3 mm away." Dr Daniel took a pair of curved scissors and snipped off the melanoma as advised.

The melanoma came off with about 50% of the dermis intact. There was the grey dermis but no subcutaneous tissues seen. "No need to stitch," I said as small bleeders ooze blood. "Just potassium permanganate powder to stop the bleeding. Cover the wound with plaster."

Dr Daniel had not seen such wounds being covered with plaster. This was the bulging backside area. Wouldn't the plaster just drop off, he must have wondered but did not speak his mind. I got two sticky plasters and covered the wound. The type you used when you cut your finger. They did not drop off.

This was one of those easiest surgeries in the world. Snip and stitch. But no need to stitch as the melanoma had a stalk and the skin was clear of melanomas by 3 mm. The owner did not want histopathology as they were also cost-conscious. So, none was done.

Veterinary surgeries present many variations. It is up to the vet to know what to do and how to do it efficiently. The surgery text book offers the standard method but there are better ways not described in the text book, as in this case.

904. DRAFT REPORT - The cat with the FLUTD - The beginning of the case

I will need time to review this case. Below is my earlier correspondence with the owners - after treatment of Tobi in April 2011.




Tobi's not peeing again ?!
2010emailsx


E-mails_Jun6,2009x


You Tubex


Owner
8/9/11

to me


Hi Dr Sing,

It's been a few months since i updated you about Tobi.
He was doing fine, up till 2 days ago.
Straining to pee and now vomitting after straining.
Some fur in his vomit too.
Very limited appetite too, as if he's scared to eat lest he throws it up.

I'll bring him to the clinic tomorrow morning.
Hope you can see him and advise what's troubling him.

Happy National Day !

J & S

-------------------------------------------------------------
Reply Forward


Owner S
8/10/11

to me


thanks. will try to be there by 1030. he managed to pee this morning!


On 9 Aug 2011 20:50, <99pups@gmail.com> wrote:
>
> Ok. 10am best
>
>
> Sent from my iPhone

>
> On Aug 9, 2011, at 6:02 PM, ...@gmail.com> wrote:
>
> > Hi Dr Sing,
> >
> > It's been a few months since i updated you about Tobi.
> > He was doing fine, up till 2 days ago.
> > Straining to pee and now vomitting after straining.
> > Some fur in his vomit too.
> > Very limited appetite too, as if he's scared to eat lest he throws it up.
> >
> > I'll bring him to the clinic tomorrow morning.
> > Hope you can see him and advise what's troubling him.
> >
> > Happy National Day !
> >
> > J & S
> >
> >
--------------------------------------------------
Reply Forward


Owner S
8/12/11

to me


Hi Dr Sing,

Tobi's much more alert and not hazy-dazy anymore.
Pee's ok although i didn't get to see it.
Taken his meds too.
Up till now, he's been confined to a room.

Thanks so much for ur treatment and advice.
Will keep him indoors and deny entry to the garden and car porch.

:) suzy



On Fri, Aug 12, 2011 at 7:14 AM, Kong Yuen Sing <99pups@gmail.com> wrote:

I spoke to your husband and fax copies of blood and urine test results to him yesterday.

1. Significant finding of the blood test is the low platelet count and the high glucose level. The low platelet count is probably due to the cat ingesting some toxic chemicals via grooming his coat. There was some "fur vomited" too. Abdominal pain was present.

2. For the urine test, there are bacteria, epithelial cells, white cells and red blood cells and a trace of protein present. This indicated a urinary tract infection involving primarily the bladder. A trace of protein may not be serious at this stage.

3. There is no kidney disease based on the blood and urine tests. No urinary crystals are detected. As for the high glucose level, a 2nd test is needed in 2 months' time to assess whether he has diabetes.

4. A test 2 months later is advised.

5 Advice: Keep the cat indoors and away from eating grass and soil. He has lost weight and this may be due to the ingestion of toxic chemicals tainting his coat and paws when he plays in the garden outdoors. Toxic chemicals may include insecticide and fertilisers and mosquito fogging chemicals. Some cats love to nap under the car, staining themselves with engine oil etc. So, it is best to keep this cat indoors all the time.

------------------------------------------

On Wed, Aug 10, 2011 at 9:49 AM, Owner S...@gmail.com> wrote:
thanks. will try to be there by 1030. he managed to pee this morning!

On 9 Aug 2011 20:50, <99pups@gmail.com> wrote:
>
> Ok. 10am best
>
>
> Sent from my iPhone
>----------------------------------------
> On Aug 9, 2011, at 6:02 PM, Owner S...@gmail.com> wrote:
>
> > Hi Dr Sing,
> >
> > It's been a few months since i updated you about Tobi.
> > He was doing fine, up till 2 days ago.
> > Straining to pee and now vomitting after straining.
> > Some fur in his vomit too.
> > Very limited appetite too, as if he's scared to eat lest he throws it up.
> >
> > I'll bring him to the clinic tomorrow morning.
> > Hope you can see him and advise what's troubling him.
> >
> > Happy National Day !
J & S
> >
>
-----------------------------------------------------------------
Owner S to me
8/13/11




yes, he does spend a good amt of time lying under the car.
he's more alert yesterday.
has started consuming more fluids and eating a little.
Pees fine too.
On 13 Aug 2011 07:35, "Kong Yuen Sing" <99pups@gmail.com> wrote:
> Did he go under the car to seek refuge in the past 2 months?

>
> On Fri, Aug 12, 2011 at 11:08 AM, Owner S...@gmail.com> wrote:
>
>> Hi Dr Sing,
>>
>> Tobi's much more alert and not hazy-dazy anymore.
>> Pee's ok although i didn't get to see it.
>> Taken his meds too.
>> Up till now, he's been confined to a room.
>>
>> Thanks so much for ur treatment and advice.
>> Will keep him indoors and deny entry to the garden and car porch.
>>
>> :) S
>>
>>
>>-------------------------------------------------
>> On Fri, Aug 12, 2011 at 7:14 AM, Kong Yuen Sing <99pups@gmail.com> wrote:
>>
>>> I spoke to your husband and fax copies of blood and urine test results to
>>> him yesterday.
>>>
>>> 1. Significant finding of the blood test is the low platelet count and the
>>> high glucose level. The low platelet count is probably due to the cat
>>> ingesting some toxic chemicals via grooming his coat. There was some "fur
>>> vomited" too. Abdominal pain was present.
>>>
>>> 2. For the urine test, there are bacteria, epithelial cells, white cells
>>> and red blood cells and a trace of protein present. This indicated a urinary
>>> tract infection involving primarily the bladder. A trace of protein may not
>>> be serious at this stage.
>>>
>>> 3. There is no kidney disease based on the blood and urine tests. No
>>> urinary crystals are detected. As for the high glucose level, a 2nd test is
>>> needed in 2 months' time to assess whether he has diabetes.
>>>
>>> 4. A test 2 months later is advised.
>>>
>>> 5 Advice: Keep the cat indoors and away from eating grass and soil. He
>>> has lost weight and this may be due to the ingestion of toxic chemicals
>>> tainting his coat and paws when he plays in the garden outdoors. Toxic
>>> chemicals may include insecticide and fertilisers and mosquito fogging
>>> chemicals. Some cats love to nap under the car, staining themselves with
>>> engine oil etc. So, it is best to keep this cat indoors all the time.
>>>
>>> On Wed, Aug 10, 2011 at 9:49 AM, suzy lau wrote:
>>>
>>>> thanks. will try to be there by 1030. he managed to pee this morning!
>>>>
>>>> On 9 Aug 2011 20:50, <99pups@gmail.com> wrote:
>>>> >
>>>> > Ok. 10am best
>>>> >
>>>> >
>>>> > Sent from my iPhone
>>>> >
>>>> > On Aug 9, 2011, at 6:02 PM, suzy lau wrote:
>>>> >
>>>> > > Hi Dr Sing,
>>>> > >
>>>> > > It's been a few months since i updated you about Tobi.
>>>> > > He was doing fine, up till 2 days ago.
>>>> > > Straining to pee and now vomitting after straining.
>>>> > > Some fur in his vomit too.
>>>> > > Very limited appetite too, as if he's scared to eat lest he throws it
>>>> up.
>>>> > >
>>>> > > I'll bring him to the clinic tomorrow morning.
>>>> > > Hope you can see him and advise what's troubling him.
>>>> > >
>>>> > > Happy National Day !
>>>> > >
>>>> > > J & S
>>>> > >
>>>> > >
>>>>
>>>
>>>
>>

Reply Forward


Kong Yuen Sing
8/15/11

to S


What is he eating now?


On Sat, Aug 13, 2011 at 10:09 AM, Owner S...@gmail.com> wrote:
yes, he does spend a good amt of time lying under the car.he's more alert yesterday.
has started consuming more fluids and eating a little.
Pees fine too.On 13 Aug 2011 07:35, "Kong Yuen Sing" <99pups@gmail.com> wrote:
> Did he go under the car to seek refuge in the past 2 months?
>
> On Fri, Aug 12, 2011 at 11:08 AM, suzy lau wrote:
>
>> Hi Dr Sing,
>>
>> Tobi's much more alert and not hazy-dazy anymore.
>> Pee's ok although i didn't get to see it.
>> Taken his meds too.
>> Up till now, he's been confined to a room.
>>
>> Thanks so much for ur treatment and advice.
>> Will keep him indoors and deny entry to the garden and car porch.
>>
>> :) S>>
>>
>>
>> On Fri, Aug 12, 2011 at 7:14 AM, Kong Yuen Sing <99pups@gmail.com> wrote:
>>
>>> I spoke to your husband and fax copies of blood and urine test results to
>>> him yesterday.
>>>
>>> 1. Significant finding of the blood test is the low platelet count and the
>>> high glucose level. The low platelet count is probably due to the cat
>>> ingesting some toxic chemicals via grooming his coat. There was some "fur
>>> vomited" too. Abdominal pain was present.
>>>
>>> 2. For the urine test, there are bacteria, epithelial cells, white cells
>>> and red blood cells and a trace of protein present. This indicated a urinary
>>> tract infection involving primarily the bladder. A trace of protein may not
>>> be serious at this stage.
>>>
>>> 3. There is no kidney disease based on the blood and urine tests. No
>>> urinary crystals are detected. As for the high glucose level, a 2nd test is
>>> needed in 2 months' time to assess whether he has diabetes.
>>>
>>> 4. A test 2 months later is advised.
>>>
>>> 5 Advice: Keep the cat indoors and away from eating grass and soil. He
>>> has lost weight and this may be due to the ingestion of toxic chemicals
>>> tainting his coat and paws when he plays in the garden outdoors. Toxic
>>> chemicals may include insecticide and fertilisers and mosquito fogging
>>> chemicals. Some cats love to nap under the car, staining themselves with
>>> engine oil etc. So, it is best to keep this cat indoors all the time.
>>>
>>> On Wed, Aug 10, 2011 at 9:49 AM, Owner S...@gmail.com> wrote:
>>>
>>>> thanks. will try to be there by 1030. he managed to pee this morning!
>>>>
>>>> On 9 Aug 2011 20:50, <99pups@gmail.com> wrote:
>>>> >
>>>> > Ok. 10am best
>>>> >
>>>> >
>>>> > Sent from my iPhone
>>>> >
>>>> > On Aug 9, 2011, at 6:02 PM, Owner S...@gmail.com> wrote:
>>>> >
>>>> > > Hi Dr Sing,
>>>> > >
>>>> > > It's been a few months since i updated you about Tobi.
>>>> > > He was doing fine, up till 2 days ago.
>>>> > > Straining to pee and now vomitting after straining.
>>>> > > Some fur in his vomit too.
>>>> > > Very limited appetite too, as if he's scared to eat lest he throws it
>>>> up.
>>>> > >
>>>> > > I'll bring him to the clinic tomorrow morning.
>>>> > > Hope you can see him and advise what's troubling him.
>>>> > >
>>>> > > Happy National Day !
>>>> > >
>>>> > > jeffrey & suzy
>>>> > >
>>>> > >
>>>>
>>>
>>>
>>


Reply Forward


suzy lau
8/15/11

to me


SD canned food.
becos he doesn't drink fresh water from bowl nor pet fountain, i add water to his food.
he laps up the soup but leaves the harder meat bits alone.
he can pee in a stream but only for a few seconds, then stops and come out of tray to lick his penis.
then he goes back again into the tray.
in out 4 or 5 times like that, then goes off elsewhere to lay down.
his antibiotic of half a tablet of baytril finishes today.
should i still continue his quarter tablet of prednisolone?
thank u so much for advice.

903. DRAFT - Searching for answers - The cat with the FLUTD - partial report

I am writing a draft of searching for answers in the case of the cat with the FLUTD that died after 5 days of hospitalisation at Vet 2. It is quite an emotional case for the young couple and for me too as the cat had been my patient too in April 2011 and I had written a case report to bring veterinary medicine alive for the poor vet students who are studying so hard to pass their examinations. Case studies will help them learn better than thick notes from their lecturers.

Tobi was one of those cats who hates vets and was outstanding for his hissing behaviour to warn vets and assistants not to touch him. See my report at:
http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm

Suddenly I received an email from the owners that the cat had died and the email is as follows:

E-MAIL FROM OWNER DATED FEB 9, 2012

On Thu, Feb 9, 2012 at 4:12 PM, ...@yahoo.com.sg> wrote:
Dear Dr Sing A belated Happy Lunar New Year to you. I trust this email finds you in good health and standing. Its been quite some time since our male cat Tobi was treated at your wonderful practice. Unfortunately our beloved Tobi has passed away on Saturday, 4 February 2012. Just a bit of history. Tobi was admitted to your care on 24 April 2011. His case is listed in your website under cat cases-UTI -1st FLUTD.The cat can't pee again dated 12 June 2011. Shortly after his discharge, we moved into our new home. Tobi recovered well as there were no territorial cats and stress was kept to a minimum. He was maintained strictly on Hill's C/D wet food. However, sometime from October 2011, he seemed to be licking his private area again though not as frequently as when he had UTI , he was also peeing normally with good volume. His disposition and general health was very good. This continued until February 2012 when we noticed his urine volume seemed to have lessened somewhat and his penis appeared to be inflamed. We brought him to a vet(shall not mention the company name) who gave him an injection of antibiotics and anti-inflammation and discharged. Two days later, it did not seem to get better, we brought him back to the vet again, a blood test was performed with several struvite crystals detected. The vet advised us that a similar injection could be given or a catheter could be inserted. We chose the injections as we were trying to avoid Tobi being warded as it may be more stressful. In order to give the injections, Tobi had to be put under G.A. as he was putting up such a struggle.

Anyway it was done and he went home. Yet again two days he was still having difficulty peeing, this time we opted to bring him to another branch (this branch was 24 hrs with larger facilities). Tobi was sedated, warded with a catheter inserted and put on a drip via a Y-site. He was also given daily IV feeds with Cephalexin and calcium, diazepam amongst others. He seemed fairly alright the first two days, it was only on the 3rd day that we noticed he appeared rather "subdued", quiet, not he's normal fiesty self. By the 4th day ,he was lying down the whole time and didnt seemed to respond to us. We attributed this to possible lethargy and medication. The next day, his blood tests were normal and after a cursory examination he was declared fit for discharge despite the fact that by now he could not even stand up or move, we bascially had to carry him into his carrier to be brought home. We reached home in the mid afternoon and put him in the room, again we had to carry him out of the carrier.

From the time we reached home right until 10 pm, Tobi condition just deteriorated, once in while he would sort of jerk himself to another area in the room, Im not sure how he did this as he was immobile from the front quarters, his eyes could not track movement, he was drooling brown liquid and had raspy breathing. We took him back to the 24 hr branch at around 10.30 and the vet on duty arrived about 15 mins later,another blood test was conducted plus a chest x-ray, all looked normal, tests for leukemia and FIV was also done, clear as well. At about 11.30am, Tobi convulsed, expelled fluid and stopped breathing, we had opted for DNR.

An immediate autospy was done, organs again were all fine. Nobody seems to have an answer for his death. Needless to say, we are extremely saddened as well as puzzled by his sudden demise, more so when he was brought in for what ought to be a routine treatment for am inflamed penis. Instead five days later, we are having to cremate him. We have since search everywhere for anything information that might explain his sudden death. From what we found, we suspect, of course this may speculative at best, but it appears to be anaphylactic shock ( the question is what was the cause). Again we suspect it could he may have been allergic to one or more of the medications prescibed via the IV drip. Admittedly there could be numerous other possible causes. However we feel it seems to fit the symptoms Tobi displayed - pale gums, immobility, drooling, low temperature, increased heart rate. We are not ones to assign blame or find fault. Nonetheless, suffice to say we are disappointed with the level of monitoring at the vetirinarian branch Tobi was in. We are well aware that cats are notorious for masking pain and discomfort but honestly to discharge a cat that can't even stand on its feet! It would be like a doctor discharging a patient who can't walk and asking him to go home. While Tobi's blood tests looked fine, a more thorougly physical examination would have raised one or more red flags. From the time of his passing, not one person from the vet had called to offer their condolences or at least offer some theory as to Tobi's death. It's as if that there was no obvious cause, so nobody can be bothered about it. My wife and I are still coping with his passing but we are doing well. I just thought that since you treated Tobi twice and did such a wonderful job each time, we would like to let you know what has happened since then. Thank you for taking time to read this long email. Meanwhile, we wish you all the best in your practice and your great care towards all animals, big and small. P.S. we would have like to gone back to you but the distance was a bit prohibitive. Anyway we thought it would be just a routine treatment but...... Best Wishes & Regards J & S



E-MAIL TO OWNER DATED FEB 10, 2012

Further to my email,
1. was there an X-ray of the kidney and bladder done?
2. I can review, free of charge, the treatment records and procedures done on Tobi for you and your wife to understand more of what had been done and to learn from the case. I do not do it for litigation or complaint to AVA purpose. If you want the review, you will need to get the vets to give you a detailed report and they should have no problems doing it.





Dear Dr Sing

Our profound appreciation and thanks for your condolences and offer to review the case.

In response to your first email,

1. Yes it was a urine test that showed the struvite crystals.
2. DNR - do not resuscitate
3. Two X-rays done on Sat (approximately an hour before he died)
4. Urine test - Sorry I'm not sure at which point in time you may be referring to. When he was warded or on the day of his passing?
Even though we are still coming to terms with Tobi's death, we are at peace. Our intention to learn what happened was never about assigning blame or instituting litigation. If there is an practice that could perhaps be improved or certain medications that may cause potential complications, we would like to highlight to the veterinarian concerned so that it may something they could look out for in the future that may help prevent another unfortunate outcome. Tobi's death, tragic as it is, may perhaps prove beneficial in providing valuable lessons so that a similiar result can be avoided in the future. We would like to think that a vet practice or any business for that matter would welcome feedback for the betterment of their business and ultimately better care and results for their patients.

We had already obtained most of the work that was done except for the X-rays shortly after Tobi's passing. We have also scheduled an appointment with the owner of the practice this coming Tuesday. Again, we are meeting him not to lay blame but to gain a better understanding of why certain things were done and to address certain issues which we feel could be improved on. We hope that by doing so, all of us can learn from this experience and hopefully make a difference in the quality and care for all animals.

I will discuss with my wife to arrange a time to meet you. We hope we are not putting you throught too much trouble in reviewing this case as I know you are very busy and what little spare time you have is limited.

Best Regards
J & S




E-MAIL FROM DR SING Friday, 10 February 2012, 7:32
Subject:Re: UPDATE ON TOBI


Further to my email,
1. was there an X-ray of the kidney and bladder done?
2. I can review, free of charge, the treatment records and procedures done on Tobi for you and your wife to understand more of what had been done and to learn from the case. I do not do it for litigation or complaint to AVA purpose. If you want the review, you will need to get the vets to give you a detailed report and they should have no problems doing it.




E-MAIL FROM DR SING DATED Feb 10 2012




All vets learn from experience including me. I am most interested in reviewing your case for my own learning and to make improvements in the processes of FLUTD.

Presently, I am writing SOPs (standard operating procedure) for some procedures like urinary stones in dogs to ensure a consistent practice amongst the younger Toa Payoh Vets' vets as I cannot live forever.

Urine tests and X-rays (2 views) on the day of consultation or next day will be most useful. Urine bacterial culture and antibiotic sensisitivity tests as well.

Best wishes.

DRAFT REPORT - NEEDS TIME TO REVIEW AND COME TO A CONCLUSION.
TODAY'S MARCH 13, 2012 FINDINGS BY ME ARE:

On 4.2.12, on emergency admission and around 45 minutes before the death of Tobi,

1. the blood test did show an abnormally low platelet count. This may be a cause internal bleeding or may lead to internal bleeding, gasping for air and death. Lymphocytes % was below normal (immuno-suppression?) but total WCC was normal. RBC was normal. FeLV and FIV tests were negative. So, was there a starting viral infection acquired? Hard to say.

2. The BUN and CRE values were still normal but trending towards the higher end of the range of values just before death.

3. The necropsy result stated that the cause of death was unknown. However, necropsy should be done by an outside party to avoid conflict of interest. There were interesting necropsy findings such as patches of atelectasis in lungs, haemorrhages in the bladder (indwelling catheter? intra-bladder injection of baytril and Vit C?).

4. Intra-bladder injections of baytril and Vitamin C on the first day of admission. As each vet has his or her own method of treatment, I would only say that I do not practise such procedures and cannot comment further.

5. Salivation in the cat on the 5th day of hospitalisation was recorded in the case report. As to its significance, it is hard to say.

6. Sedation was given several times via the IV during the first 4 days of hospitalisation to control the "fiesty kitty". This leads to a loss of control of the reflexes leading to asphyxiation?

A combination of the above factors could contribute to death.

902. Searching for answers for a FLUTD cat that died after 5 days at Vet 1

It had been more than a week since I met the couple who was searching for answers to their cat's death and had written a report at:
http://www.sinpets.com/F5/20120235FLUTD-cat-died-searching-answers-Singapore_ToaPayohVets.htm


It was an emotional meeting for all of us as I did know Tobi too.
After some time to let sadness go away, today, at 5.30 am, I spared some time to review the case to find some more answers.


The cat was hospitalised by Vet 1 for 5 days to treat what the owner had diagnosed was a FLUTD recurrence. The cat was sent home on day 5 and he died at home. I am reviewing the case to search for the answers as to why he died. Experiences are learnt from failures or a death in this case. Every vet will have deaths and many times, the answers are not present.







Toa Payoh Vets webpages in chronological order

1. http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm

2. http://www.sinpets.com/F5/20120235FLUTD-cat-died-searching-answers-Singapore_ToaPayohVets.htm

A review may give some answers and to prevent other deaths. Unfortunately, vets are not Gods and deaths will occur for various reasons.

HISTORY:

1. April 2010. The owners referred the cat to me for treatment after being treated by Vet 1. The cat recovered from the FLUTD. I treated the cat a second time in Nov 2010 and did not see the cat anymore. The case is recorded at:
http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm

2. Feb 2011. The owners brought the cat to Vet 1 who then referred the cat to the main surgery and there the cat was treated by various vets (collectively called "Vet 2"). The cat was "fiesty" according to the medical reports of Vet 1 and was given sedatives IV and an indwelling catheter over the 5 days of hospitalisation. The cat was discharged on Day 5. He went home, had breathing difficulty and was sent back to Vet 2 for an emergency treatment. The cat was X-rayed to find out whether the chest had any problems causing respiratory distress. The X-rays were done around 45 minutes before the cat passed away.

The husband e-mailed to me about the cat's death and since the couple was not going to litigate, I volunteered to help to search for answers as to why a cat with a simple medical condition called FLUTD (Feline Lower Urinary Tract Disease) could just die and to give advises as to how to prevent a similar occurrence should they get another cat. The wife must have loved the cat a lot and that was 7 years of companionship. The husband was sad too as he just could not understand why the cat would die. I spared some time to meet and talk to them. This was the least I could do for a nice couple who cared very well for this hissing cat.

SOME E-MAIL CORRESPONDENCES
Fw: tobi's 11 page report + 2 x-rays
E-MAIL TO DR SING FEB 27, 2012


Dear Dr Sing

Please find attached copies of Tobi's reports and X-Rays (X-Rays were taken apprx 45 mins before his death)

Additiional information and our observations that are not in the attached reports


27/1/2012 - Tobi was given Convenia & Dexaason injections & injectable sedative29/1/2012 - Tobi was given Dexaason & Diazepam injections & Anaesthesia (Gaseous)
31/1/2012 - Tobi was Anaesthesia (Gaseous) - in attached report

31/1/2012 - ate a little, never ate again after this, behavior still normal
31/1 to 1/2/2012 - behavior still normal
2/2/2012 - lethargic, unusually calm
3/2/2012 - lethargic, urine scalding, disinterested,lying down the whole time
4/2/2012 - before discharge - could barely move, nose & ears cold, dried drool (brown colour), breathing slightly shallow
4/2/2012 - at home after discharge - hind limb paralysis, laboured breathing, eyes could not track movement
4/2/2012 - few minutes before his death at the hospital- somehow struggled out of his bed, gave a slight meow, convulsed, threw up and shortly after passed away

Thank you once again for sparing the time from your busy schedule to review. Even now, we are still coming to terms with the suddeness of it. I will call you tomorrow and perhaps we can arrange a time to meet at your convenience.

Best Regards
Name of husband




E-MAIL FROM DR SING DATED FEB 28, 2012




Please accept my condolences again.
1. I cannot understand why the X-rays are taken
2. Why were X-rays not taken earlier during admission?
3. Any urine analysis report?
4. How about the preceding vet's treatment report?

Were X-rays taken of the bladder area or not? There seems to be a big abdominal swelling in one X-ray. I will talk to you when we meet. Pl bring printed out copies.


SUMMARY OF SIGNIFICANT FINDINGS ON MEDICAL RECORDS
Cat admitted: 31.1.12. Owner complaint: Keeps licking on his penis.
Cat discharged: 4.2.12
Cat re-admitted: 4.2.12 after hours emergency. Died.


Cat behaviour: Hissing, fiesty, growls when approached from 31.1.12 to 4.2.12.

Sedatives given, mainly via IV:
31.1.12 Ketamine 0.2 ml, Valium 0.2 ml, Atropine 0.1 ml IV. Isoflurane gas to induce, local anaesthesia for urinary catheterisation, PDS 3/0 stitching catheter
Torbugeic 10 mg 0.5 ml IV

1.2.12 Valium 0.2 ml IV twice a day

2.2.12 Valium 0.2 ml IV 6 am and 0.3 ml at 11 pm. connect tom catheter to urinary bag.

3.2.12 Removed cathether.
4.2.12 Not as fiesty as first day. Salivation seen. Able to urinate normally.
Blood test significant findings: BUN 27 (10-30), CRE 2.1 (0.3 - 2.1)

4.2.12 After hours emergency. 36.2C . Very lethargic. FIV/FeLv test negative. X-ray lungs. Blood test significant findings: Lymphocytes % 9.6 (20-55), Neutrophils 79% (35-80), Eosinophils 10.4% (0-10). Platelets 140 (300-800)

Necropsy as requested by the owner:
Cause of death: unknown
All NAD except bladder wall thickened, slightly haemorrhagic.
Lungs with patches of atalectasis - PM change or secondary to dyspnoea towards the end??

Drugs used:
31.1.12 Inject baytril 0.3 ml intrabladder,Vit C 3m intrabladder. torbugesic 10 mg 0.5 ml IV.

Vit C 1000mg + 0.5 ml cefaxone IV BID, Ornipural 1 ml, Vibion l ml IV BID for first 2 or 3 days of hospitalisation.