Sunday, September 29, 2013

1170. Update on 2nd cat not eating. Blood test

2nd cat, boarded for 2 weeks with a friend, was eating and went home yesterday sunday.


Blood test results:

High urea and creatinine, low platelet count.
Neutrophils high % but total white cell count normal.
A kidney infection.

1169. Incredible Singapore stories - "Ah Pek"

Monday Sep 30, 2013

This is the 2nd incredible story I hear from one of my clients. The first was regarding drops of blood appeared out of thin air onto the glass table top, fore-head and clothing when one of my clients, a successful businesswoman asked me to help her in the placement of design for her new company logo. 

Today, my client in his 40s, of medium height and solid build works in a logistic firm. He came to buy medication for his old dog having serious coughing. The dog would not cough if he was given this medication.  This Indian man was an excellent story teller spinning an incredible tale of "Ah Pek" which I saw on the dashboard of his 5-year-old shiny Subaru sportscar, immaculate polished shiny with wheel rims very clean, just like a new car.  

"How come you have the figures of two "Ah Peks" glued onto your dashboard?" I noted one Ah Pek wore white and one wore black robes. Both had long black beards and wore hats. The colours had faded to silvery and blue respectively. I must confess ignorance of this Chinese belief of "Ah Peks". According to him, "Ah Peks" ranked 2nd and below were 5 dieties including the monkey god. Above them was another level and the 4th tier was the Judge.  


BIKE ACCIDENT
The client said: "On a rainy day, a lady dashed across the road. I braked my bike and my whole face hit the road as I swerved to avoid this lady. I was in intensive care with tubes into my mouth. I had head and facial fractures. I vomited blood daily as I had internal injuries. The doctor said that he needed to open my skull to operate and remove my injured left eye.

"Those are serious injuries," I said. "Yet you look normal today."
"I was lying in the hospital bed and I asked my friend to ask 'Ah Pek' to help me before the operation.

He gave me a piece of paper blessed by the Ah Pek to put under my pillow.
 I did not interrupt his narrative but I had no reason to doubt his integrity of the events happening to him personally. He was seriously ill and the doctor had given him a poor prognosis for recovery.

He continued: "At night, 'Ah Pek' came to the hospital."
"You really saw him?"
"No, at night,  I heard the dragging of chains of somebody walking into my room. The next day, when I came out from the operating table, there was no skull operation. Two titanium plates are now fixed on either side of my nose but you don't see it. My left eye was OK as I have normal vision."

Certainly this was a tall tale.

"I offered my thanks to Ah Peks via my friend at a medium's house."

"Where's the house? Is it an HDB apartment as I had seen some of such places of worship."
"In Woodlands," he mentioned a place which believers would know.
"Did you have to pay money to the medium?"
"No, just two bottles of beer and fruits," he replied. "The lady who dashed across the road had only a small wound on her right arm. She was quite plump and I guessed she had been cushioned."

DRIVING TEST
He had another tall tale. After the bike accident which nearly snuffed out his life, he decided to drive a car.  He failed his driving test for 6 times. So he sought the help of "Ah Peks" via his Chinese friend who translated the "Hokkien" speech from the medium. "The Hokkien is too cheem (of a high standard) for me."

"I was given a green piece of paper which I had to drink part of it and to smear on my face." 
"Just a green piece of paper? What type of paper is it?" I asked.
"The green paper had signature and chop on it" he said. "One has to believe and I did accordingly. The driving test was in Circuit One at Ubi."

To me, I do not know why Circut One is so fearsome as I took my driving test in the UK. "What's so fearsome about Circuit One?" I wondered but did not interrupt his story telling.
"I hit the kerb during the test," he told me. "The tester would usually fail the driver. Hitting the kerb is like hitting a person's leg. So, I should fail. But the tester did not inform me immediately. He was having a discussion with somebody. I was waiting nervously. Just tell me I had failed so that I can book for another test. The waiting was terrible."

"Why did you hit the kerb?" I asked.
"Circuit One has a road full of bends and if the driver hits the kerb, he or she fails. No mercy from the tester."I was thinking that "Ah Peks" had failed him this time. According to him, the Ah Pek in white extends life and the one in black takes away a person's life.

"After some time, the tester told me I had passed!"
It is hard for me to believe that this is because of "Ah Pek's" blessings.

SPEED TRAPS
Another story he told me as that he had been advised to "Ah Pek" to drive fast as he tended to be collided often when he drove slowly. 
"Once I sped along the straight stretch of Mandai Road. At one end, I saw a motorist being booked before me. Then I sped back to the other end. Another motorist was booked before me."
This sounded too hard to believe. Twice not being caught as if he had a protective order. He had a mat blessed by Ah Pek inside his car to protect him when he drove in Malaysia.
"Speeding can kill people," I said to him.
"I don't do it often."

PEEING ON BROKEN GODS
This was the most incredible of his stories. "During my brash younger days, I purposely peed onto the broken idols discarded near a tree," he told me. "The next day, my right arm burst out with big swellings as big as a 5-cent coin. All over the arm. No itchiness. No pain. The doctors could not diagnose what's wrong and hence they could not prescribe a cure."

I thought it was urticarial weals but it happened only on his right arm and no other parts of his body.
"Well, I asked my friend for help. He consulted the medium. I went to the idols to ask for forgiveness and offer them some fruits and food. The next day, all my skin swellings disappear. My experience illustrates than we must respect the religions of others."

"What type of Gods were they?" I had to ask as I had read of a similar incident in a book called "32 true stories of Ghosts and Spirits & Gods Plus Questions & Answers on the paranormal" by Andrew Tan Chee Khoon, born in 1939.

"Guan Yin (The Goddess of Mercy), the Judge and others, like those you see under a tree in some places."

"Yes, I have seen them and  I don't disturb them."


FACE IS ALL BLACK
He narrated an incident which I cannot recall when the cleaner told him that his face is all black.
"What do you mean 'black'?" I asked him. He has dark complexion because he is Indian, more towards dark brown.
"Very black, the colour of black"
"Like Kiwi black shoe polish?" I asked.
"Yes. Yes."
After he made some apologies to the dieties, the cleaner said his face was back to normal colour.

A clientj with a Yorkshire Terrier had come to the clinic and so I could not talk further.













1168. Update on large abdominal mass in an old Malese

tpvets_logo.jpg (2726 bytes)TOA PAYOH VETS
toapayohvets.com

Date:   30 September, 2013  
 
Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits
The old Maltese with breathing difficulty has 7 days to live    
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date:   30 September, 2013  
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129

Thursday, September 26, 2013

1160. Seven days for the Maltese to live

On Wed, Sep 25, 2013 I received a phone call from a young lady for a 2nd opinion. Her 14-year-old male Maltese had breathing difficulties and was not eating. Vet 1 diagnosed anaemia and a big abdominal mass. She advised surgery but the owner did not want it. So the lady searched the internet forums and there were some recommendations for her to phone for Dr Jason Teo at Toa Payoh Vets. 

"Dr Teo works at Toa Payoh Vets on Saturdays only," I said.
"Another vet at Toa Payoh Vets will be OK," she replied. 
"What's the name of Vet 1 whom you first consulted?"
"I do not wish to disclose her name."
"Did she have X-rays and blood test results for your dog?" I asked as she was telling me the findings without the documentary evidence.
"Yes," she said.
"You can ask Vet 1 to fax or email to me at Toa Payoh Vets," I said.
"I don't think it is possible," she replied.
"Why not? Are the documents illegal?" I asked. "Vets do pass clinical records to each other when the owner seeks a 2nd opinion. I have done it before and other vets have done it. You just have to phone them and ask for the medical records."

She phoned later to say that Vet 1 would want her to go to the practice to take over the records and so would be late for the appointment. This was OK with me.  Around 3 pm she came and saw Dr Daniel first. He had recorded "4 days of changed behaviour, increased breathing, decreased appetite and cannot walk. No vomiting, diarrhoea and no change in diet. Cheese treat for one week and polyuria and polydipsia.

Blood test from Vet 1. No abnormalities in the liver and kidneys or total white cell count. But RBC 3.37 (5.5 - 5.8), HGB 8.4 (12-18) and HCT 23.9 (37-55) were very low. I told the owner that the gums were purplish and the tongue was pale. This was not good.
The mid-abdominal lump was solid, painless and half the size of an orange. What is it?

Vet 1 was consulted for a "breathing problem". She had taken a lateral X-ray showing much fluid inside the swollen abdomen. A large opaque areas obscured the views of intestines. Vet 1 recorded that the heart was enlarged.  An abdominal mass pushed guts up and above. She recorded that the owner was not keen on surgery. Dog was anaemic and lung sounds were dry. She proposed pain relief since surgery was not acceptable.

Overall, Vet 1 was spot on in her diagnosis but the owner was not satisfied.

"Is it because you went when the practice was going to close?" I asked.

"Yes," she said.

Sometimes it is difficult to satisfy the owner on the first consultation in a medical condition with no cure except surgery.

Yet this dog was 14 years old, very thin and I would say emaciated. Surgery would kill him. So I don't even want to propose surgery as this dog will never survive the long time needed to remove this large abdominal lump. In any case, the young couple was never in favour of it as they must have done their internet research and know the high risks involved..

But what is this large abdominal lump and what should the couple do?

"Euthanase the dog," one young lady et suggested when I spoke to her after X-raying two views of the dog's chest and abdomen at her practice. "This dog is suffering and the owner should not prolong her suffering."

"The owner does not want euthanasia," I replied.
"Why? Is it for religious reasons?"
"It is for personal reasons," I know of owners who rather not put the old companion to sleep by lethal injection at the onset of signs and symptoms of difficulty in breathing. In this case, there might be medication to alleviate such a condition.

"There was one government vet before your time," I said to this young lady vet who had worked for over a year in another practice. "He is now retired. He recommended euthanasia so many times that he has a reputation to be avoided. This is because the owners would forecast that he would advise euthanasia in many sick cases.

"His intention was to save money for the owners but he gained the reputation of being an "euthanasia" vet to be avoided at all costs by pet lovers with sick pets.

"In this case, the couple is against euthanasia. They want to know what is the nature of the abdominal tumour."  Dr Daniel had proposed ultrasound scanning. From my reading of the couple, they want an acceptable solution such that the dog would live the last few days of his life without pain."

What more can be done other than ultrasound?

Dr Daniel elaborated on the causes of the swollen abdomen - bleeding, chyle, fluid from heart failure since the liver and kidneys were OK based on blood test from Vet 1, peritonitis. He also advised surgery to remove the abdominal mass as the only option. He advised abdomino-centesis to draw out the fluid to send to the lab for examination but sedation would be required and this would be risky as it may kill the dog. So the couple did not accept his suggestion and wanted to take the dog home.

I let Dr Daniel handle the case to the conclusion but I did give my take on this medical condition.

What should be done for this dog if surgery was not an option? "There is no need for sedation," I said to the couple. "We need to draw out the abdominal fluid so that your dog can breathe easier at least for the next 2 days and start eating."  Each vet has his or her own opinion and my opinion was that abdomino-centesis could be done without much pain on this ill dog and so without any risk of death.

The only risk is in putting the needle into the abdominal mass. This was what I was concerned and so was the thinking behind the young lady vet who looked at the X-ray with me earlier after X-ray. "The needle might puncture this big lump," she said..

"Not if you slide the needle under the umbilical skin area," I did that with a 19G needle and fresh blood came out. Dr Daniel inserted a finer butterfly clip needle and withdrew another small amount of blood. Total amount was around 20 ml. The blood clotted soon indicating that bleeding was very recent.

This blood collection in a bottle was shown to the couple as they wanted to know the cause of anaemia and the nature of the abdominal tumour. No exploratory surgery but just to know what the abdominal mass is.  
 
tpvets_logo.jpg (2726 bytes)3806 - 3809. Large abdominal mass palpated and seen in the X-ray. Blood tests showed liver and kidneys were normal. The heart is enlarged and lung sounds were "dry" on auscultation. l

Friday, September 27, 2013

1164. Update on old Maltese. Abdomino-centesis shows bleeding inside the abdomen - old Maltese

Maltese, M, 14 years
Large abdominal mass 50% size of orange
Breathing difficulty around last 4 days
Abdomino-centesis drew out 20 ml of blood which clotted soon, indicating fresh blood from abdominal mass.

Probably a splenic tumour starting to bleed. The kidney and liver enzymes were normal. IV drip
with amino acids and vitamins given. Dog went home and was active pacing the next day. Surgery is too risky. Owner does not want surgery anyway. Prognosis poor if bleeding continues. Dog does eat but is emaciated.

Sep 28, 2013  Saturday 10.15 am
Spoke to the husband

Dog has much less breathing difficulty. Active. Gums pinker.
"Any abdominal swelling?" I asked. "No," he said. That means the bleeding of the tumour has stopped but in any case, the abdominal swelling was not that large since the dog was sent for treatment early..

Will not want to eat the egg yolk or chicken liver. Husband asked whether he can get repeat medication in 7 days' time.

I had advised hand-feeding of egg yolk to build up red blood cells. The lady owner asked whether liver was OK. "Chicken liver would be good," I said.  

Feeding 6x/day in small amounts and electrolytes. Heart medication given as well. For this dog, a blood transfusion would be normally advised. In this case, after the amino-acid, glucose and electrolyte drip IV, the dog was much alert and with home feeding and medication, the dog lived a comfortable life as at Sep 30, 2013. I hope the dog lives longer than 7 days.
 
Updates will be on this webpage:
www.sinpets.com/F5/
20130930abdominal_tumour.htm

More info at: Dogs or Cats
To make an appointment:
e-mail judy@toapayohvets.com
tel: +65 9668-6469, 6254-3326
tpvets_logo.jpg (2726 bytes)Toa Payoh Vets
Clinical Research
Copyright © Asiahomes
All rights reserved. Revised: September 30, 2013

Toa Payoh Vets

1167. A stray male cat smelt of urine has lots of blood inside the bladder

On Saturday, Sep 28, 2013, a woman brought in the stray male cat that would go to her house to eat only and would disappear for the whole day. She found him having blood in his backside and brought him in for treatment. The bladder was slightly swollen and urine leaked continuously.

On Sunday, Dr Daniel catheterised this cat and sent the urine for testing. "This is a case of FLUTD in a male cat and is quite common," I said to the intern Daniel. He had not seen such cases before.

For the woman, it is difficult for her to ignore the cat's plight and to pay for the veterinary treatment. After all, this is a stray cat.



 

1166. A second cat had poor appetite.

Sunday Sep 29, 2013

Yesterday, I had another cat not eating. The first cat was the one-eyed cat that did not eat for 5 days and recovered after treatment for a kidney infection as shown by blood tests and palpation of swollen kidneys. The kidneys were 3x the normal ones.

Now this 2nd cat had poor appetite for the last 3 days after being boarded for 2 weeks with a friend as the owner was overseas. What's the problem? The rectal temperature was 36.6 C and the cat was dehydrated. Her right eye was tearing but the left was OK. So, what's the problem?

It is hard to say. I asked Dr Daniel to come in to take blood and gave the IV drip. The cat clawed anyone and so needed to be given anaesthesia gas. She recovered the next day. When the Caucasian couple who boarded this cat came to take her home today, the cat was eating the A/D canned food and this was the best evidence of recovery. 

1165. Sunday Sep 29, 2013's interesting cases

1.  I was surprised to see the young couple from Tampines as they had brought in their rabbit for treatment of scabies after purchase and I did not expect to see them again since many Singapore pet owners go for proximity and Tampines is a 20-minute drive to Toa Payoh. 

"How long did it take the rabbit to recover from the scabies and ear mites after the injection?" I could see that the rabbit is fully cured. They had bought the rabbit with scabies in the ears, nose and paws and had consulted me some weeks ago. The rabbit seemed to have changed coat colour as I remembered he was grey and not brown. I wondered if it is a replacement rabbit. I have a video of it as it was used as a case study of the Lemon Law by Intern Terrence. The video is "Lemon Law for diseased/defective pets in Singapore" and is at:

 http://www.youtube.com/watch?v=uHXcYlGmvOI&feature=youtu.be



"We complained to the Seller. He sent the rabbit back to the breeder who kept him for 3 weeks before returning to us!" the slim young lady said.  

"Did you use a pee grate and tray for this rabbit's toilet?" I noted that the rabbit has urine-stained fur in the lower part of the four feet. 

"No," the slim young man said. "We used one but it was so small in area that the rabbit stepped on it and peed outside the tray!  So we put the brown cat litter pellets at one corner of the playpen and he would go above the cat litter to pee and poop."

"That explains why he has four paws urine stained. There should be a larger grate like the plastic one in your rabbit carrier you are carrying your rabbit to the vet. In this way, the urine can flow through onto the cat litter which would be enclosed by the tray. Go to the pet shop to buy one pee tray + grate for puppy toilet training. "

"The reason for the urine stain could be that we have not placed sufficient litter and so he stepped on the urine. We find it very difficult to wash off the urine stains."

"I will get the yellow urine-stained hairs cut off. Also the matted hair near the scrotum. It is important that your rabbit be free of urine and matted hairs, otherwise he may become sick."

The couple purchased a puppy grate + pen when they come to collect the rabbit at 4 pm. I asked Dr Daniel to hold the rabbit for them to check the absorbable stitches after neutering by Dr Daniel to make sure there is no bleeding. They were quite happy.

"Place urine-stained litter inside the tray and smear some smell at the corner of the grate," I advised. "Usually the owner will spread all litter covering 100% of the tray. You may find that the rabbit pees out of the tray as he has no clearance of the non-urine-stained area."  The couple wanted to cover the whole tray with cat litter but this may not work as the rabbit may pee outside the tray owing to his positioning.

It was great to see this rabbit again and I did take some images. Certainly he looks like the same rabbit that had gone to live with the breeder for 3 weeks to get cured but it is hard to tell since there is no micro-chipping in rabbits! The couple was inexperienced in rabbits and so a replacement rabbit will be the same as the other one.   

Friday, September 27, 2013

1164. Update on old Maltese. Abdomino-centesis shows bleeding inside the abdomen - old Maltese

Maltese, M, 14 years
Large abdominal mass 50% size of orange
Breathing difficulty around last 4 days
Abdominocentesis drew out 20 ml of blood which clotted soon, indicating fresh blood from abdominal mass.





Probably a splenic tumour starting to bleed. The kidney and liver enzymes were normal. IV drip
with amino acids and vitamins given. Dog went home and was active pacing the next day. Surgery is too risky. Owner does not want surgery anyway. Prognosis poor if bleeding continues.



 Dog does eat but is emaciated.

Sep 28, 2013  Saturday 10.15 am
Spoke to husband

Dog has much less breathing difficulty. Active. Gums pinker.
"Any abdominal swelling?" I asked.
"No," he said. That means the bleeding of the tumour has stopped.

Will not want to eat the egg yolk or chicken liver. Husband asked whether he can get repeat medication in 7 days' time.

Advised hand-feeding of egg yolk and liver to build up red blood cells. Feeding 6x/day in small amounts and electrolytes. Heart medication given as well.

Thursday, September 26, 2013

1163. Update on cerebellar ataxia dog

On Sep 25, 2013

"What's the cause and what more medication is needed?" the lady owner asked me again when she came in late for some repeat medication and consultation after 8 pm. "It is hard to say," I told her. She showed me a short handphone clip of her 6-year-old female poodle taken the day before. The head and body tremors were not so pronounced as when I first saw it. The dog could amble for a short distance.

"In some nervous disease cases, more money has to be spent on tests like CT Scan, MRI, CSF fluid and more blood tests and other X-rays. But I know there is a financial limit and so the one blood test done was not sufficient. There is a possibility of a liver disorder and the causes can be infectious, toxic or other unknown causes 


"Furthermore, each vet has his or her own way of treatment of this disease which is a rare disease," I said. "The first vet gave glucosamine.The 2nd vet referred you for a CT scan and prescribed no tests but the scans costs from $1500 - 2,000 and so your husband contacted me as the 3rd vet."

So far, with my medication, the dog can eat and that is what the owner wants.
"However, the cure is not available for cerebellar ataxia," I said. "Unless the cause is known or can be treated."

1162. Being organised and systematic

Today I asked my assistant Niang to sit down and have a chat with him as regards adding value to his employer. Management requires many re-education of the employees.

"A man must be able to control his temper," I said. "Especially with his employer. Later, when you want to find another better job, you don't expect your old employer to support you if you don't care about his business by not being organised,"

I gave him two examples of vets not being organised.

"Yesterday, you heard the owner of 2 dogs complaining that she had asked this vet who has set up her own practice that she wanted dental scaling in addition to neuter of 2 dogs. The vet did not do any dental scaling. I have a system where any job to be done on the pet to be written down, but many younger vets  or their assistants don't do it. So, the practice loses income as the dental scaling of 2 dogs would have been additional income. Also, now the owner thinks badly of this vet who had been referred to her by her brother."

In another example today, the lady owner of the pug brought in the dog for me to examine the lameness in the left fore paw. I reviewed the medical records and there was a blood test done on this pug previously. 

As I studied the blood test result report with this pug's name on it, she said of the vet who was not meticulous. "The name is incorrect. It is the  name of my other pug."

She has 2 pugs and the young vet incorrectly labelled the blood tubes as belonging to the other pug.

"It is hard to teach young ones to be meticulous and organised and systematic if they don't want to be," I said to my assistant. "You just ruin your reputation if you are not meticulous as the owners will not want you to treat their dogs!"

Earlier in the morning, I was speaking to Julia, a manager of more than 20 staff and at one time more than 200 staff, about the younger generation. "The young ones have their ways of doing work and may not want to do it your way as your way is 'Old School'"

I replied: "Whether it is Old or New School, certain tasks must be done in an organised and systematic way. To be efficient and productive. If a surgery can be completed in 10 minutes, why take 30 minutes to do so? That has nothing to do with Old School of thoughts. It is the personality and character of the younger generation. "

"Unfortunately, the younger generation of Singaporeans behave "lassia faire" and in my organisation, we have to put up a "step by step" process of doing tasks too. You only manage so few younger staff."

I guess this problem of the younger generation born to an affluent period is common in all organisations.

      

1161. Practising evidence-based medicine for an anorexic cat

On Sep 29, 2013, a cat owner said that his one-eyed cat has not been eating for the past 5 days. This is said to be a British Shorthair and Dr Daniel had remoed an ingrown toe-nail Right Digit 3 on Sep 11, 2013.

"My cat has not been eating after the ingrown toe nail surgery," he said to me.
"How long has the cat not been eating?" I palpated a bigger than golf-ball size firm lump in the mid-abdomen, similar in location to the 14-year-old Maltese case I wrote about recently.

"Past 5 days."
"There is a big spherical lump inside the abdomen," I had palpated a painless mass the size of a bigger golf ball. "It could be an enlarged kidney, bladder or hair ball in this young cat. X-rays and blood tests are needed."



It is extremely difficult to diagnose without lab evidence like X-ray and blood test.
Blood test results showed kidney disorder likely to be an infection as the neutrophils was over 90%. The cat was given an IV drip and medication to remove lots of gas inside the intestines as seen in the X-rays and ate nearly one can of K/D diet and drank water overnight at the surgery. Will be going home today.

Heartlander clientele wants the least medical cost but what to know the cause of the disease. So, in this case, the owner had to give permission for the test and get a diagnosis.







Update: Sebaceous adenoma in the old Husky's right eye

Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits
Anaesthetic death worries for an old Siberian Husky     Dr Sing Kong Yuen, BVMS (Glasgow), MRCVSDate:   27 September, 2013   toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129
 
Sep 15, 2013
Dear Dr Sing Kong Yuen 
We – my wife Pri and I - have been at your clinic half a year ago with our two Huskies. Cleo - 6 years old, the male Husky, had strained his back legs muscles, but slowly he can run again after you had advised us what to do and how to treat him. It is still not perfect, but we get him there.
Our female Husky Al, now 9 years old,  has at her right upper eye-lid an abscess since some years (please see image), but we get the impression it is growing and causes her some problems, because sometimes she is scratching it and the eye ball is inflamed.
We hope it is not malignant. Nonetheless we think it must be removed now somehow.
Therefore we are asking you to get us an appointment for Friday, 20th September, at any time, but best would be in the morning. We are prepared to take all the time it would need to stay with Al at your clinic. Please get us your answer by email.
Thank you for your attention and I am looking forward to hear from you soon.
With warm regards
EMAIL FROM DR SING DATED SEP 16, 2013

Thank you for your email. Pl bring Al in at around 11am on Friday.
Surgery and anaesthesia will be done using electro-surgery in the afternoon. She goes home at around 6 pm after recovery from anaesthesia. No food and water after 10 pm the night before.
Please note that old dogs undergoing anaesthesia are at risk of death from anaesthesia. In most cases, there are no deaths if the dog is healthy and the surgery is short duration as in this case. The dog will be examined before surgery as there is inflammation and infection in the eye.  Pl give antibiotic eye drops for at least 3 days before surgery as I don't advise operating on an infected area.
 
 
REPLY TO EMAIL FOR SURGERY APPOINTMENT
 
Sep 16, 2013
Hi
Thank you for your email. Pl bring the Husky  in at around 11am on Friday Sep 20, 2013.
Surgery and anaesthesia will be done using electro-surgery in the afternoon. She goes home at around 6 pm after recovery from anaesthesia. No food and water after 10 pm the night before.
Please note that old dogs undergoing anaesthesia are at risk of death from anaesthesia. In most cases, there are no deaths if the dog is healthy and the surgery is short duration as in this case. The dog will be examined before surgery as there is inflammation and infection in the eye.  Pl give antibiotic eye drops for at least 3 days before surgery as I don't advise operating on an infected area.


EMAIL REPLY TO OWNER DATED SEP 16, 2013

Thank you for your energetic response. I am sorry that I do not permit all clients to be present at the surgery as I need to focus 100% on the anaesthesia of old dogs and thereby not getting anaesthetic deaths due to distractions or conversations.

In addition, the surgery room is small and you are welcome to inspect it.

The whole process takes around 30 minutes including pre-op preparation. It may take longer if there are complications like cardiac emergencies in which I have to revive the patient. With the owner present, there will be much emotional distress when such emergencies occur and distract me from my resuscitation of the patient. No vet can assume that the old dog will not have any cardiac or respiratory emergencies during anaesthesia and surgery and so it is best that the owner not be present.

In my younger days, I permited one lady to watch her hamster being operated for a small tumour as she requested. She fainted at the sight of blood when I excised the tumour. From that experience, I do not permit any owner to be present at surgery. Pl accept my apologies.

The dog needs to recover fully from anaesthesia and this takes around 2-4 hours for old dogs. That is why you pick the dog at around 6 pm.  

Sep 19, 2013

Dear Dr Sing
This afternoon we have been at your clinic and discussed with Dr Daniel the operation of Al’s eye lid tumour, he took a blood sample and checked her general health which should be OK.

 
Everything is clear and we fully trust to be in good hands due to your experience. However, having in mind yours and Dr Daniel's repeatedly mentioned remarks that Al could die due to the anaesthesia, even afterwards, you may understand that we are still concerned that the worst could happen to our precious dog Al.

Both our dogs are like children to us. That’s why we are still reading everything about this surgery and found the below article of a dog clinic from Washington D.C.

May we ask you, what is your opinion regarding  local anaesthesia after drug sedation and the described “freezing” of the wound? Please forgive us our nervousness.

QUOTE
:

2.   EYELID TUMORS. Older dogs commonly develop eyelid tumours (cancer). As in humans, cancer can be either benign or malignant. Fortunately, eyelid tumours in dogs are usually benign and do not spread to distant tissues. However, eyelid tumours do slowly or quickly grow, and can destroy the structure of the eyelid, in addition to rubbing on the eye. It is usually best to remove them when they are still small.
Eyelid tumours are treated by surgical removal. While there are many different surgical procedures possible, most eyelid tumours in old dogs can be removed at Animal Eye Care without requiring general anaesthesia. The patient is given a sedative, and then a local eyelid anaesthetic is given to numb the eyelid. The tumour is removed and the site frozen with liquid nitrogen (cryosurgery) to kill any remaining tumour cells. Tumour cells are usually very sensitive to freezing, and normal eyelid tissue is more resistant. After surgery, the eyelid margin turns pink (de-pigmentation), but usually re-pigments within 4 months.
EMAIL REPLY FROM DR SING DATED SEP 19, 2013
I can understand your concerns as the dog is old and thank you for your research in the article on eyelid tumour removal by one vet practice which claims that general anaesthesia is risky and the practices claims that it uses sedation and local anaesthesia to avoid the risks. Sedation is used at that practice and it does carry risks too. Even local anaesthesia has risks of adverse reactions.  

As the surgery, sedation and general anaesthesia with isoflurane gas is very short (<5 30="" and="" are="" at="" based="" be="" blood="" br="" case="" chances="" death="" dog="" dogs="" don="" dying="" electro-surgical="" examination="" excision="" experience="" general="" have="" he="" healthy="" i="" if="" in="" is="" low.="" minute.="" minutes.="" minutes="" my="" not="" of="" old="" on="" operating="" over="" procedure="" risk="" short..="" since="" so="" surgical="" t="" table="" test="" the="" this="" tumour="" very="" when="" will="" years="">
Sedation and local anaesthesia can be used as an alternative to remove the eyelid tumour. It is hard to achieve full pain relief if sedation is not given at full dose.

In my case, sedation is given at 50% of the dose and the isoflurane gas given for <5 3="" achieves="" analgesia.="" and="" br="" complete="" completely="" dog="" excised="" eyelid="" in="" is="" less="" minutes="" movement="" no="" pain="" properly="" s="" seconds.="" than="" the="" tumour="" with="">
Isoflurane gas is very safe and many times, I have used it solely for over 100 Caesarean sections of dogs stressed out by the breeder's delay in seeking prompt surgery. Those dogs were operated WITHOUT sedation using just isoflurane gas anaesthesia. None died from the anaesthesia.

Of course they were younger dogs but they were under considerable stress. In brief, old dogs with very short surgical procedures and anaesthesia ,<15 30="" died="" experience="" have="" in="" minutes="" my="" not="" of="" on="" operating="" over="" p="" past="" practice.="" table="" the="" years="">
I hope the above provides a satisfactory explanation. It is best not to research too much the technical aspects of anaesthesia to get worried. Chances of your dog surviving are excellent as your dog is eating normally and is active. The surgery to remove the eyelid tumour will be over in 3 seconds and I normally don't even inform some owners about anaesthetic risks as the risks are minimal if I assess they are worried.        
Best wishes. 
Dear Dr Sing 
Thank you so much for your comprehensive answer to our concerns! Appreciated. 
Now we feel much more calm and relaxed and can sleep better.
Finally, we do hope that the tumour is not malignant which the analysis will show later. 
Good night, and see you tomorrow.
With warm regards
UPDATE AS AT SEP 25, 2013

I operated on the husky on Sep 20, 2013 with Dr Daniel doing the anaesthesia and Niang assisting. The wife was present during IV sedation as this dog was "nervous" if the wife was not around during sedation. I asked my assistant Niang to tie a tourniquet using the infusion drip tubing looped over the elbow. However, the cephalic vein could not be seen as the dog was quite plump. "Clip the hair around the cephalic vein to see it," suggested Niang. "No," I said as that would not be good for the dog's appearance.

"You didn't tighten the tourniquet sufficiently," I lifted up the tubing. "I can put two fingers under it."

Niang said: "You do it yourself." This behaviour was not good for a young man and I had counselled him before as other employers would have terminated his services if he cannot control his mood when his job incompetencies are pointed out on the spot.

Dr Daniel palpated for the cephalic vein with his finger while Niang still gripped the elbow area of the right leg. The wife was present all the while. Dr Daniel inserted the needle in the region of the cephalic vein and drew blood into the syringe at the first prick. He injected the sedative of Domitor + Ketamine according to my formula and at 50%. I told the wife that it was OK for her to leave her dog now.

She left the room and the driver drove the couple home. The couple  had been waiting since 11 am for Dr Daniel who started work at 12.30 pm. They had first consulted Dr Daniel and so they just would not want to leave the dog alone till it was time to operate and so waited patiently in the waiting room. Usually I ask the owner to bring in the dog at 11 am so that the dog would settle down but this couple wanted to wait.
The eyelid tumour was large and I made a large electro-excision so as to have a wider margin in case it is a malignant tumour. "You are cutting off too big an area," Dr Daniel commented as I took a pair of blunt-edge scissors to trim off the jagged edge and undermine the  skin before stitching with 3 interrupted sutures of 3/0 absorbable sutures. The wound was large, around 2 cm at the base of the triangle  (see image below) and Dr Daniel must be wondering how I would be able to stitch up the wound.

Overall, the isoflurane gas + O2 was given for 24 minutes. This was not a 5-minute surgery as the tumour had expanded as you can see in the images. The dog survived and that was what the owner wished for. So it was a happy ending.

A vet in another practice had told the owners earlier that there was no need to operate such a small eyelid tumour. But it grew bigger and bigger and the dog started scratching the eyelid. So, the owner decided to operate. However, I had to get "informed consent" which meant letting them be aware of the anaesthetic risk of dying and this just was worrisome to the couple. "Eyelid tumours are best removed when they are very small," I said. "Your first vet may not like surgery and so advised to leave it alone. Some vets just don't like to perform surgery and prefer medical cases. You probably encountered one such personality."
It was great that there was a happy ending and the dog would be on a diet. "No more beef jerkys from Italy," I saw the owner eating such treats (air-dried) that were a specialty in the province of Italy and sharing with his Huskies. His wife said it was too salty.
 
Another surgical approach is such that the apex of the triangle is uppermost as contrasted to this approach where the apex was at the eyelid margin
     
UPDATE ON SEP 27, 2013

Histology reports indicated that this eyelid tumour is a sebaceous adenoma. I phoned the owner on Sep 26, 2013. He is happy that it is not malignant and asked me to email to him the lab report. The dog is still wearing the e-collar and is normal and I presume, eating jerkys from Italy.

Many Singaporean pet owners are worried about anaesthetic deaths and so small tumours get ignored till they become massive and irritating the dog, causing bleeding with blood soiling the floors and painful cries and infections.

As this dog's eyelid tumour was large, it took around 24 minutes of general anaesthesia to complete the surgery.  The dog was not given Antisedan reversal as the owner wanted her to wake up slowly. Usually I gave the antidote to get the dog to wake up early so as to restore the body systems to normal earlier.  

Surgery with general anaesthesia causing death on the operating table frightens away many owners from treating their dogs. The risk is there but is very low if the old dog is healthy. See video of a 15-year-old Maltese operated at
https://www.youtube.com/watch?v=7c_QNAHP3wY
https://www.youtube.com/watch?v=P54Q6NZgK7w

 
Updates will be on this webpage:
www.sinpets.com/F6/20130920
anaesthetic_risk_old_Husky.htm

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