2010vets

850. Minimising complaints and litigation against vets at Toa Payoh Vets

2012-01-28T20:38:00.000-08:00

Bali, Indonesia, Jan 29, 2012. 12.23 pm

In Bali, I have time to reflect on the plans to make Toa Payoh Vets one of the top 5 vet practices in Singapore. New clients have come in from other parts of Singapore probably from the internet and some old clients of 10-30 years ago have returned to consult me. "The vets are very young," one mother of two young men said to me when she saw me after an absence of 10 years. Her sons had brought the 11-year-old Jack Russell with a big swelling below the right eye and they are now in University. Of course, I did not know that the mother had brought the Jack Russell to see me 10 years ago till she told me. I was phoning her sons to bring the dog home on Day 3 and she was in the Surgery visiting the dog. The dog was barking like nothing had happened to his loss of masseter muscle tissue eaten up by bacteria. Big hole if you see the images.

The mother identified herself as the owner of the Jack Russell and said to me that for convenience, she had gone to other vets. "You still look the same," she complimented me. I was surprised and happy to see her and the two boys who have grown so tall.

I guessed the other vets closed on the 2nd day of Chinese New Year and I was on duty. So that was how we met. I said to her, "All vets started young. They have to learn from being hands on over the years and gain the experience."

COMPLAINTS AND LITIGATION AGAINST VETS
In 2011, there was no complaint or litigation against the vets of Toa Payoh Vets. This is not a given. One way to minimise complaints is for me to check all cases done by my younger vets. Sometimes I am inside the consultation room with Dr Vanessa Lyn, Dr Jason Teo or Dr Daniel Sing to assess their management of the cases. The new vets may feel uncomfortable as this may give an impression to the client that they are being supervised. They prefer to be alone with the client, thereby generating confidence. But this is not the way to increase the standard of care.

As an experienced older vet and the licensee, it is my duty to mentor the younger vets. I have explained the rationale to them. "A complaint to the AVA or litigation takes up a lot of time and will involve me as a licensee', I said to them. "My licence can be revoked for failure to ensure an expected duty of care by my vets."

So, the associate vets or new vets must tolerate my presence and intervention and be humble. There are predatory vets in the regulatory field and amongst competitors and so, it is not as simple as in the university attending lectures and passing examinations.

In the real world of private practice, there are many aspects involving the bottom-line and younger vets must adhere to

849. Owner's e-mail query about spaying a young Chihuahua

2012-01-28T20:20:00.000-08:00

Sun, Jan 29, 2012 at 10:59 AM, <...@gmail.com> wrote:

Hi,

I would like to inquire what is the cost for the above?
She 7 months old and just began her season today, 29/01.
When is a good time to have the procedure?
Will she require hospitalization?

What are the possible side-effects?

Regards,
Name given

E-MAIL REPLY FROM DR SING DATED JAN 29, 2012

Thank you for your email. I am Dr Sing from Toa Payoh Vets. The cost of the spay is around $250 depending on whether there are complications. Best time to spay her is 2 months after the end of her season ie. around April 1, 2012. She does not need hospitalisation normally. Bring the dog in at 10 am and bring her back, usually in the evening. Appointments are best.

Possible side effects of surgery are anaesthetic deaths, infection, bleeding and pain. A blood test is advised to screen the dog's health and if there are no disorders of the kidney and liver, the risks are very low. As for bleeding and pain, there are prevention of further bleeding by careful haemorrhage control and check up. There is medication to relieve pain and prevent infections post-op.

In my experience of spays over the past 30 years of small animal practice, 99% of spayed cases of young healthy dogs do NOT die from anaesthetic risk as anaesthesia is safe nowadays. They do not get bleeding to death, infections or stitch breakdown. The majority of my dog spays are done during 2-3 months after the season.

Pl make an appointment at 6254-3326 for surgery. Best wishes.

848. The dog passes gas for a long time - flatulence

2012-01-28T00:06:00.000-08:00

I followed through today by phoning the owner. Some 5 days ago, his wife brought a container of semi-wet greenish stools, a medical swab of blood-stained vomit to me.

"My dog vomited blood", she had also told me she was a nurse and her husband was a doctor. They don't self-treat their own dog. The two samples were useful. I got the stools sent to the lab and the blood tested.

That was some 5 days ago. "Farting for so many months is not a normal thing for a dog or human being," I said. "There is something wrong with the stomach and intestines. So you get gas production and then smelly stinky smell in the room. If not treated, the intestines can get much irritated leading to "telescoping of one segment into another (intussusception) or rectal prolapse,"

This appeared to be a simple case of vomiting of blood. But the main problem could be the gastrointestinal system causing flatulence for very long time.

I gave the dog a 500 ml IV drip, antibiotic and anti-spasmodic and boarded overnight. I recommended the Prescription i/d canned diets for 1 month. No treats and any other food. Just the i/d 1.5 cans per day.

Now 5 days later, the husband answered my phone at 4 pm (Air Asia plane to Bali delayed as it was to leave at 4 pm, so I typed this story).

The husband said first: "The stools are solid for the first time. Where can I buy it? It is not sold in the shops."

Performance counts. This is what I always tell my younger vets. Stop the vomiting and flatulence. I did not give anti-vomiting injection at all. Just treat for chronic enteritis. You get good clinical outcome after the visit, you get referrals. As simple as that.

The stool sample showed blood but no white cells or parasites. The blood test was not significant. I/d for one month and go on good quality food and treats. The cheap treats sold at Singapore's pet shops should not be fed to your dogs as they are cheap for one reason.

847. An 82-year-old father can't sit up at all

2012-01-27T23:53:00.000-08:00

"Why can't my father sit up for more than a minute?" Khin Khin asked me. Her father had difficulty in breathing and lower back pain on the left and she went home to Yangon to get him treated by the Specialists. I rushed down to her Peninsular Office to see if I could help as her father was 82 years old and had alertness of mind and body. "He can walk to the hospital and now he can't sit up," Khin Khin was sad.

Basically, I checked the drugs given to him asking her to google for info since a doctor in Peninsula Plaza told her that he did not know about the drugs given to her dad. Tramadol, Lyerica and celophrix (non-steroidal anti-inflam). No wonder he could not sit up as the first two cause drowsiness. Being so old, his body could not eliminate the drug fast like a young person!

With this knowledge, what did Khin Khin do? Nothing. So today, before I left for Bali on Air Asia, I followed through and phoned her to ask the father to stop taking the 3 drugs if he has no more pain (CT scan catheter in Yangon via femoral vein had hit the kidney and cause intense pain, Khin Khin said).

If pain returns, take the Tramadol first and consult the doctors for a review. For 2 weeks, the poor father could just lie down the whole day and night and had no appetite. I asked Khin Khin to speak to him over the phone. He could not answer me promptly as if his throat was choked. Most likely water in the lungs had returned. But there was some medicine to reduce the phlegm and none to remove the lung oedema. The CT scan said there was an atypical RCC which I presume to be Renal Cortical Carcinoma?

If her father can sit in the wheel chair, his daughter would spare no expense to fly him to Singapore for a second opinion. He is a very intelligent educated man, working duing the old British colonial days of Yangon in a bank. It is so sad that he could not sit up for a minute and was vomiting and drowsy and did not enjoy his life. That was why he had not wanted to go to the Hospital but his daughter got him there. Now he can't walk!

845. An unusual complaint about puppy vaccination at Toa Payoh Vets

2012-01-26T16:27:00.000-08:00

Yesterday, Jan 26, 2012, I received a phone call from a home breeder saying that her buyer had brought a 8-week-old gold/white Shih Tzu puppy to me on Jan 25, 2012 for vaccination. I had told the buyer that the puppy was 5 weeks old and therefore too young to vaccinate. "I delivered the puppies myself," the breeder said. "They are 8 weeks old but the buyer said you told her she is 5 weeks old."

I was surprised as I do not age a puppy so accurately as being 5 weeks. No vet can do this because it is not possible to pin-point the exact age just by looking at the puppy's teeth. There is a range and 8 weeks is plausible. So, I told her I would check Jan 25 cases and none of the 4 vets had such a puppy presented on that day.

The home breeder's message to me:

Dr Sing, indly assist to investigate the following:
Name and tel of buyer given

She claimed she had brought the puppy shih tzu, female, gold/white, 2 mths old to your clinic appointment on 25 Jan, for puppy's lst vaccination and microchip. However she had informed me yesterday that your vet told her the puppy is only 5 weeks old.

I suppose in that instance no vaccination or microchip done? N what is the assessment for no vaccine for the puppy? That constitutes to the buyer claiming your vet said so. If this is the case, I will make report and take action accordingly.

The puppies were born on 28 Nov 2011. I was the one who helped my dog gave birth to the puopies. I would like your assistance to investigate and clarification to this matter soonest. Thank you.

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

My reply to the breeder:

On 25 Jan 2012, none of the 4 vets including myself had a case of a female shih tzu puppy, gold and white, 8 weeks or 5 weeks for vaccination. I have checked all cases done on that day. Give me her tel number to verify with her.

-------------------------------------------
I have not contacted the buyer yet. This is quite an emotional issue and it is best not to rush into phoning the buyer since she had not come on Jan 25, 2012. How to handle this case since the buyer had stopped responding to the breeder's phone call?

Based on this case, home breeders who are concerned about their puppies sold may find it important to give a paper of birth when they sell their puppies.

844. Character and Competence of interns and new employees

2012-01-26T13:35:00.000-08:00

To: The young interns and employees

Please note that you may want to do everything in a project at once according to your "better" way and your timing with no limits. That is the mark of your internet generation. But that takes lots of times and in the end, you take so much time that "opportunity costs" (if this is the correct word) have passed you by.

What I usually suggest to my younger interns at Toa Payoh Vets is to produce results within 3 days by doing smaller segments of the project.

For example, in doing a stock inventory of drugs, I have this young man, Mr Lim who has taken 2 months and has not been able to produce the complete list of unit pricing etc. This is because he tries to do all categories at one time. I have asked him to do one category at a time e.g. "Prescription Diets", then "Eye Drops" and that should be the way to produce results to show to your boss that you have achieved some results for discussion and editing.

The google generation will always switch on their computer to do the writing. Sometimes, a piece of paper and pencil achieve faster results.

I hope you will be open to receiving instructions to adopt the existing processes and not try and do new things for the time being.

By "opportunity costs", I mean that the opportunity to make money has slipped by if a person takes a long time to produce results like trying to get every information about a big project in place.

In the commercial world, performance counts and time is money. For the youths, time is eternal and I note that many simply waste their time daily in not being productive, efficient and able to accept instructions from old fogies whom they think are outdated and close-minded.

Old fogies have learnt from the hard knocks of life and some processes and systems have been produced through trials and errors that are not explained to the interns instantly, due to lack of time, pressure of work and the need to assess of the intern's motivations and diligence.

It takes a lot of time to explain the rationale of why the processes and systems are being used and unless the intern or youth has shown character and competence, there is so much the old fogies have to perform such that there is little time to just talk about the history of why certain tasks need to be performed in the present situation.

If there are improvements and innovations, the youths can propose later. But first, the new intern or employee must learn to adopt existing processes first and become productive. Performance and prompt results count in the commercial world and this is not taught in the junior colleges and universities, in my observations of the interns and new employees.

843. Dressing casually as a vet or veterinary staff

2012-01-25T16:09:00.000-08:00

This year 2012, I will not try to be flexible as in the past years. I will not tolerate casual dressing by my vets or the staff or intern.

Sandals, T-shirts and jeans are out. Those who persists will likely get the sack as they cannot do what they like anymore. The young may think they are cool but it is just common sense. How can clients trust you when you dress as in sports shoes, sandals with your toes exposed and T-shirts with advertisements.

Dressing casually is out in 2012 and those who insists on dressing casually will need to look for another job.

842. Chinese New Year 3rd day - follow-up 3 cases

2012-01-25T04:15:00.000-08:00

National Library, Jan 25, 2012 7.42 pm
Dr Daniel Sing's first day at work

3 cases, equivalent to senior citizens in age, seen by me yesterday needed dental attention as they strongly objected to my opening their mouths. The Persian cat had saliva stains on the chin and one front paw. The Shih Tzu snapped at me when I tried to open her mouth. She was drooling. The Jack Russell's right facial swelling below the right eye had rounded up after my IV drip and medication including steroids.

That meant sedation as I suspected inflammation of the mouth. You could tell from drooling of saliva that definitely two of them had stomatitis. The third one with a facial swelling leaking plasma blood and pus could be a malar abscess. I asked Dr Daniel Sing to let me know what he thought of the facial swelling - now half a ping-pong ball size encroaching on the lower eyelid. "It could be an abscess or haematoma," he said. "How about a carnaissal tooth abscess or malar abscess?" I asked. It was too large and he did not think so. "Well, the Jack Russell catches centipedes and he could have been stung. But he never had a dental scaling for the past 12 years of his life and that is why I am more inclined to put malar abscess as my first diagnosis."

Case 1.
Jack Russell. Male, 12 years old.

After taking some images at 9.30 am with Intern Mr Lim, the swelling burst like a dam.
"Where is your ACP (acetylpromazine)?" Daniel asked me when I told him to get ready to sedate the JR. "I don't use ACP," I said. "I know ACP is popular with the Australian vets." A new vet must adapt to the work environment. "ACP is commonly used in the Murdoch Univ school and by Australian vets giving IM sedation, but there are better alternatives in real world of private practice," I said. "I give Domitor + Ketamine IV and get a better faster sedation than ACP IM." When I was a vet student in the UK from 1969-1974, ACP was also commonly used by the UK vets. So, it is not as if I don't know what is ACP. So, Daniel got to see how effective D+K was when given IV at 50% of the formula in an old JR.

The abscess had burst and he took a big bag of swabs and looked for the pink chlorhexidine to clean the big wound. "Where's the kidney dish?" he asked.

As that is what the Murdoch Univ lecturers must have taught him and all the new graduates. I did not comment as Daniel would learn the ropes.

For me, a large amount of clean water in a 20-ml syringe would flush away the debri and take 1 minute and worked effectively. Singapore's tap water can be drunk and it is therefore clean.

But Murdoch Univ professors cannot teach this simple method. No need for bags of swab. This was a dirty abscessed wound full of bacteria yesterday. My antibiotic Baytril via IV drip had killed them all.

Spending effective but short time is important. Being productive and that is what many younger vets can't understand. When a procedure can be done in 10 mintues, they take 30 minutes. For example, in this JR, a new vet would swab and swab away the discharge. Swab again. Apply the pink chlorhex from the bottle. Put the discharge in the kidney dish. This is what I would imagine them to be taught how to do.

There are other cases to do and if the vet takes 30 minutes hour to just clean the abscess, that time is gone. I put the bag of swab away from the operating table onto a side table as I knew it would be wet. Daniel wanted it on the operating table which was already wet with the JR being washed. Later I asked Min why the whole packet was wet. He said, "The water from the operating table."

I showed how Domitor + Ketamine at 50% of my calculated dose was used effectively and not to waste time. Isoflurane gas mask and intubation.

What was the cause of this abscess? Centipede sting? There was some pus when it burst. I checked whether the 4th maxillary premolar on the right upper jaw was rotten. This would be the main cause of infection to the cheek bones below the right eye. "The PM4 is strong," Min said to me. So, Daniel was correct. This was not a malar abscess since PM4 is usually implicated. I said to Min, "I will check the two molars behind the PM4." He had never seen molars causing malar abscess. So he was doubtful. Yet, the two molars were loose and rotten. They would be the cause of the infection to the cheek bones and below the eye, over time.

He was wobbly after abscess cleaning and cutting off the dead skin and cells, dental scaling and work. The whole process took one hour. The JR looked lethargic. I gave Antisedan 0.2ml IM. Within 10 minutes, he was alert. That was good. Now, what to do with such a big hole in his cheek? More than a 50-cent coin or 8 cm x 8 cm (see image).I propose stitching up 5 days later. The owner wanted to bring him home. So, it will be against medical advice (AMA) but what the owner wants, the vet has to do and record AMA. At home, the wound may become dirtied and flies may lay eggs. But in a room and a big cage, and proper nursing, this can be good for the dog too. Then 5 days later, come back for review and stitching as I doubt that such a large wound can heal well. There are many nerves in the cheek area and it would be very painful to have a big exposed cheek area. Blood tests were done but still the economics would be important.

Case 2.
Persian cat. Emaciated. 12 years old. Tongue and gum ulcers. 3 rotten teeth extracted. No blood tests were granted. See images.

Case 3.
Shih Tzu, Female, Not spayed. 13 years old. The whole mouth, gums and inner cheeks are ulcerated. Very bad. Emaciation and anaemia. I don't know whether she would survive the domitor + ketamine IV. I gave an Antisedan 0.2 ml to wake her up. This dog is so pale but blood tests were not granted by the owner.

841. Email advice about a fast-growing hamster leg tumour

2012-01-24T16:33:00.000-08:00

On Tue, Jan 24, 2012 at 4:44 PM, ...@yahoo.com> wrote:

Dear Doctor,
I need your advise regarding my daughter's winter white hamster.
It is abt 2years 2mths old and had a tumour on the right leg. We
noticed this tumour last year and its about a pea size.
Had brought her to a vet in Jan 2011 and advise against surgery due to old age.Within 2 weeks in Dec 2010 the tumor had grown very fast to a walnut size. She is eating and drink fine only her movement is rather slow and she keep bitting the tumour.
Is it too late to have the tumour remove now? If surgery is possible how much does it cost?We really love her sooo much, how do we know if she is in pain?
Would really appreciate your advise.
Thank You.
Regards
Owner's name

Thank you for your email. I am Dr Sing from Toa Payoh Vets

There is only one option to prevent death by infections and great pain from the growing tumour and that is surgical excision. Pain is shown by self-biting and being not active or eating in hamsters.

There is always an anaesthetic risk of death on the operating table for the older pet. You have to decide yourself. Cost is approximately $150-$200 for surgery and anaesthesia.

Coincidentally, I just saw a case of a dwarf hamster with a big growth on the back leg near the ankle. The lady had been advised by my associate vet Dr Vanessa to do leg amputation. But she did not want to as she did not want her hamster to be 3-legged. The tumour grew fast into a fatty ball of around 1 cm in diameter. Just as she arrived in a taxi to consult me, the hamster passed away. She could have saved this 1-year-old by permitting surgery 2 weeks earlier.

Therefore, decisions are made by the owner. The vet should give the proper advice and in your case, the advice from your vet was good. Pl make appointment at 6254 3326 if you decide on surgery. Best wishes.

840. The case of the Chattering Chihuahua - video production

2012-01-24T16:16:00.000-08:00

DRAFT

HOOK
Teeth chattering in dogs. AUDIO CLIP
Image of THE CHIHUAHUA
Snow fall --- cold winter, snow-storm, but this is sunny Singapore
Antagonist arriving? Big bear attack when walked near the forest?
Loud noise --- fall from the sky, a meteor, earthquake tremors - 6th sense
A dog catcher on the prowl with his net? Downhill wind scent
A female dog nearby? Scent

INTRODUCTION
the case of the teeth-chattering Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
25 January, 2012

What causes it? The owner with the 8-year-old Chihuahua was a fair young lady probably had done her internet research and one of the websites would be:
http://answers.yahoo.com/question/index?qid=20100126080555AAfbVSv

AN EDUCATION VIDEO FOR VET STUDENTS AND PET OWNERS
COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com

Singapore, Jan 24, 2012

MIDDLE

CAUSES OF TEETH CHATTERING

1. Behaviour? Nervous, excitement. (Video clip of chattering). Not for her dog as this teeth chattering was recent and her dog was a calm and cool canine since young. When I saw her, the Chihuahua never chattered his teeth! Cool as a cucumber, the older Englishman would say. The google generation like this owner would say: "So cool!"

2.Cold freezing weather? (Slide of winter, snow fall)
Not in Singapore. It is Summer season all year round.

3. Certain breeds suffer from nervous disorder e.g. seizures, neuronal degeneration in young Cocker Spaniels or other breeds, white dog shaker syndrome in white dog breeds such as West Highland white terriers, the Maltese and the Bichon Frise. This needs early veterinary consultation.

4. Dental pain? This would be the likely cause as the old dog had bad breath, gum infections and loose decayed teeth. So she brought her dog to her vet as she felt that the recent teeth chattering could be due to toothache. Her vet wanted her to sign an anaesthetic risk consent form and forewarned her that her dog was an older dog and might die on the operating table during dental work.

CASE OF THE TEETH-CHATTERING CHIHUAHUA
FIRST VISIT
Sunday, January 15, 2012
The young couple came with the Chihuahua after having consulted a vet earlier. Death on the operating table is the main concern with the fair lady. Vet 1 had insisted that they sign the anaesthetic consent form highlighting the risk of death in an old dog undergoing dental work. "This is the common practice," I explained. "Even the human hospitals will ask you to sign the form if you go for anaesthesia and surgery. In the Singapore General Hospital, I was even given a 10-minute talk on anaesthetic risk by a young doctor in a room as I was scheduled for surgery the next week."

Her biggest worry and that of her mum was anaesthetic death. The vet must listen to what the client has to say. How competent is the vet? She does not know.

"How many anaesthetic deaths have you encountered when you did dental scaling?" she asked my associate vet who was handling the examination together with me. This was the sort of question many internet websites have advised the dog owner to ask the doctor. My associate vet said: "I refer you to Dr Sing."
The young lady turned her head to me for an instant reply.

I said: "I can only speak for myself. In my over 30 years of dental scaling, I have not encountered any anaesthetic death. This is because dental scaling and work do not require long anaesthesia. Therefore the risk of deaths on the operating table is very low. The anaesthesia should be completed within 15 minutes. Careful monitoring of the vital signs by the vet is most important."

I don't permit idle chatter during dental surgery. Nor do I make small talk with my assistant during surgeries. A singular focus on the surgery. Speed accuracy and completeness.

"Look at the right face," I pointed to the facial swelling. "Do you see a big swelling below the eye? The bacteria from the root of the back teeth, the 4th premolar, had gone into the face, causing this swelling. It is called a malar abscess."

The lady had a second look at the right face. "Compare to the left area below the eye," I suggested. "There is no swelling there!"

The lady turned her head to inspect the left face. This new finding added to her worries. She knew a dental work under general anaesthesia was necessary. Dental gels and paste that claim to work would not be effective. The internet advertisements of pet teeth are products are many.

Warnings of high anaesthetic risks and death esp. for the older dogs flashed back into her mind. She was well educated and informed to know that such products would not work for her dog.

ALTERNATIVE TREATMENTS WITHOUT ANAESTHESIA
1. Oral care gels and paste, chew toys and kibbles?
2. No anaesthesia dog groomers. Need to hold the dog firmly and rigorously to do the scaling or extraction as most dogs fight against such dental work without sedation and are frightened of it.

3. No action from the owner. Leads to oro-nasal fistula as in another Chihuahua. Show clips from
1. Chihuahua with a non-healing facial wound - oro-nasal fistula
http://www.youtube.com/watch?v=5AWHpWYWgy4&lr=1
2. Follow up on the Chihuahua after surgery and pyometra death
http://www.youtube.com/watch?v=ExTT2a8eUCs

How about dog groomers offering dental scaling without anaesthesia? There are such services offered by some pet shops in Singapore. This was an educated owner in my assessment, probably having completed higher education level and knows the situation.

She had done her internet research and knew that her dog would need more than dental scaling. He needed to have his loose and decayed teeth extracted. And this could not be done by the dog groomer without anaesthesia.

Her vet insisted that she signed the anaesthetic form first as taught by their veterinary professors to cover their back in case of litigation.

Here, at Toa Payoh Vets, my vets do insist on the client signing the anaesthetic form too. For me, I don't insist on it after explaining in detail one-to-one the risks and benefits thoroughly. So, I seldom get the owner to sign the form as this cause considerable stress for some of the young ones over my past 40 years of practice. If the client has no confidence in me, I would suggest going to another vet.

For this case, I advised antibiotics for the next few days and getting the dental work done on Friday as Sunday would be Chinese New Year. I don't perform surgery on Chinese New Year although I am not superstitious about bad luck if the vet "cuts" on Chinese New Year.

I told my associate vet that I would be handling the case myself as there was great worries for the fair lady.

SECOND VISIT
Friday, January 20, 2012

Sunday will be Chinese New Year's Eve. So the dog was done today. Blood test taken revealed nothing abnormal. "You have checked the blood test?" the young lady asked me. "Yes, the blood test showed normal results. There is no kidney or liver disorders and the dog's heart is good. Come back 2-3 hours later." She was comforted and left with her significant other.

ISOFLURANE + OXYGEN ANAESTHESIA
Chihuahua, Male, 8 years, Severe stage 4 periodontal disease.
No sedation
Images of the process and procedures

Mask and then intubation. Many assistants don't know how to anaesthesize the dog using just isoflurane + O2 as the dog does struggle vigorously and bite at a certain stage.
The technique is to hold the dog by the scruff of the neck and to take out the mask when the dog struggles at the excitement stage. Wait a few seconds and put the mask on. Repeat again. Normally, the dog will be anaesthesized smoothly.

Ideally, the dog should be sedated, given isoflurane by mask and then intubated. This is the better restraint and saves much time as the excitement stage does not exist. Most vets use this method and this is the method taught by the veterinary professors. I don't know whether they teach the use of isoflurane solely in old dogs or not as I was a student 40 years ago.

In this case, the owner had some knowledge of the sole use of isoflurane gas done by me and asked me about it. So I took over this case from my associate vet to give her peace of mind. Usually dental scaling is a relatively easier surgery compared to others like spay.

An endotracheal tube of the appropriate size, not too small, is inserted and the dog given 1-2% isoflurane gas as maintenance. The proper sized endotracheal tube for this dog was 6.5

Only 3 teeth left. Around 16 extracted.

The dog coughed when the owners came to pick up 2 hours later.
"It is caused by throat irritation of the endotracheal tube," I explained. "I inserted the tube into the windpipe to give the anaesthetic gas. I will give an injection."

It was one of those satisfying moments to see the young lady smile and freed of worries since her Chihuahua had not died on the op table and was as alert as if he had not been under anaesthesia. Isoflurane anaesthesia effect disappears within 5 minutes and that is why this dog was as alert as normal.

However, it takes a longer time to anaesthesize the dog and there is a certain technique which I taught my assistant Min so as not to injure the dog when he is struggling before being asleep. If a sedation injection is given first, there is virtually no struggling. As I had promised the owner that I will use gas only, I kept my word.

CONCLUSION
Anaesthetic deaths during dental scaling are rare in practice. Anaesthetic consent forms worry many owners and the risk of anaesthetic deaths promote a window of opportunity for non-veterinarians to provide dental scaling services.

Regular dental check up once a year and tooth brushing would have prevented the loss of 19 teeth and much worries. Do spend time brushing your dog's teeth at least three times a week. Easier said than done. A vast majority of Singapore owners is too busy to do the dental brushing.

CREDITS

COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com

Produced by: Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Narrated, Edited and Filmed by:

Sponsored by:
Asia USA Realty (asiahomes.com) Pte Ltd --- asiahomes.com
Be Kind to Pets (bekindtopets.com) LOGOS

Singapore, Jan 24, 2012

For more info:
W: toapayohvets.com
E: judy@toapayohvets.com
T: +65 9668-6468

Webpage with pictures at:
http://www.bekindtopets.com/animals/20120124isoflurane-gas-dental-extraction_Singapore_ToaPayohVets.htm

839. Chinese New Year 2nd day - salivation - stinks the whole apartment

2012-01-23T20:14:00.000-08:00

Tuesday Jan 24, 2012
Chinese New Year 2nd day
Bright sunshine day. All neighbours closed

I came to check on my cat patient - a stray cat with badly wounded left fore paw and swollen right paw and do some stock checking and administration.

INTERESTING CASES
1. Shih Tzu, Female, 11 years. Fever. EMACIATED. Sticky salivation as gums were ulcerated as if he had licked some poison some 4 days ago.

"Whole apartment smelly," the father said. The son of 24 years was very concerned. "Yellow liquid in his mouth. What is it?" he asked me. "Could be gastric juice vomited. Did he lick any liquid like paint or tick insecticide?"

"There was anti-mosquito fogging 5 days ago," the son said.
"Yes, it is possible the dog tried to lick off the smell. A blood test is recommended. But you have to decide."

"We are poor. Don't want the blood test," the father said. The son later told me that a vet had forced his father to take various tests leading to a hefty vet bill. So, the father is angry at all vets. However, his vet is off today. Treatment. IV drip, antibiotics and anti-fever.

2. Jack Russell, Male, 11 years. High fever. Massive swelling below R eye for past 5 days. The elder brother said: "The swelling comes and goes, but today, it expands. Can't open eye.What is it?"

No dental work for past 11 years. Malar abscess? "Any bee stings?" I asked. "Centipede sting possible as there are lots of centipedes in the house." A son and mum phoned at 5pm. "Not much changes," I said. Swelling has defined to a ping-pong sized lump after IV drip and medication. Will need sedation tomorrow to see inside the mouth as the dog prohibited opening of his mouth. Could be an abscess not related to malar abscess or a haematoma. Vet medicine is full of surprises.

3. Persian cat of son who is overseas. F, 13 years, not spayed. EMACIATED. Drooling. Emaciated. Mum went on holiday past 2 weeks and now the cat had problems not eating. salivation. Two large cystic swelling below and beside the tongue. Wandered outdoors as mum was not around. Could it be ingestion of poison? IV and medication.

4. Guinea Pig. 1 year +. Not eating. EMACIATED. Drooling. Had incisors clipped 2 weeks ago by Vet 1 who did not examine further. Still not eating well. "Examine the molars," I showed the young lady the inward pointing sharp points of the lower molars. Anaesthetic isoflurane gas using mask. Clipped teeth. Advised hard pellets. "Separate from the other GP who ate faster," I advised. "He might be bullied." The girl said: "The other GP will scream if separated." I said: "Get a grated barrier to separate them. This GP eats by herself and recover. We assume there is no bullying as we don't see it."

5. Dwarf Hamster, F, 1 year+, 59g. "He had gone (to heaven)," the lady in her late 20s said to me. "I let her swim (in the basin) longer while I took care of the other 3 hamsters. When I saw her, she was gone. Drowned. Flat out. No movement. I did heart massage a long time. She finally recovered. But she has this sound (like teeth chattering) from her chest. She ate a bit. "How many stool pellets she passed?" I asked. "Only 1 or 2. Normally many as she is a fat hamster and eats a lot."
I put my stethoscope. Yes, the heart sounds were there but there was these extra loud "crackling sound". Much louder than the heart sounds. Coming from the lungs. The hamster was shaking and breathing faster than normal.

"Have you treated hamsters before?" the lady asked me when I told her that I needed to give the hamster an injection of painkiller, lung fluid-draining medication and antibiotic. If the hamster dies, it will be due to her progression of illness and not due to the injection." She was doubtful about injections. "Well, I never had a case of a hamster that had drowned and had been returned to living," I said. "Singaporeans don't bathe hamsters or I have not got such a similar case. I have done hamster injections for anaesthesia and for itchiness."

"I suppose I have no choice," she gave permission to inject her hamster. My assistant Min held the thick cloth over the first half of the body. I injected the back area under the skin of 0.01 ml. Upon removal of the cloth, the hamster was motionless. The lady was very upset, stroking the hamster's chest and calling her name. I asked her to go outside the cold aircon consult room and into the evening sunlight outdoors. She stroked her hamster. There was a flicker of movement and the hamster's eye moved. She was happy. Booked a cab and thanked me.

So, this CNY Eve 2nd day showed a representative sample of pets common in Singapore - dogs, cats, guinea pigs and hamsters. No rabbits.

838. The case of the teeth chattering Chihuahua - follow up

2012-01-23T15:00:00.000-08:00

The teeth-chattering Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
24 January, 2012
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
DRAFT

HOOK
Teeth chattering in dogs. AUDIO CLIP
Image of THE CHIHUAHUA

Snow fall --- cold winter, snow-storm, but this is sunny Singapore
Antagonist arriving? Big bear attack when walked near the forest?
Loud noise --- fall from the sky, a meteor, earthquake tremors - 6th sense
A dog catcher on the prowl with his net? Downhill wind scent
A female dog nearby? Scent

INTRODUCTION
the case of the teeth-chattering Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
24 January, 2012

What causes it? The owner with the 8-year-old Chihuahua was a fair young lady probably had done her internet research and one of the websites would be:
http://answers.yahoo.com/question/index?qid=20100126080555AAfbVSv

AN EDUCATION VIDEO FOR VET STUDENTS AND PET OWNERS
COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com

Singapore, Jan 24, 2012

MIDDLE

CAUSES OF TEETH CHATTERING

1. Behaviour? Nervous, excitement. (Video clip of chattering). Not for her dog as this teeth chattering was recent and her dog was a calm and cool canine since young. When I saw her, the Chihuahua never chattered his teeth! Cool as a cucumber, the older Englishman would say. The google generation like this owner would say: "So cool!"

2.Cold freezing weather? (Slide of winter, snow fall)
Not in Singapore. It is Summer season all year round.

3. Certain breeds suffer from nervous disorder e.g. seizures, neuronal degeneration in young Cocker Spaniels or other breeds, white dog shaker syndrome in white dog breeds such as West Highland white terriers, the Maltese and the Bichon Frise. This needs early veterinary consultation.

4. Dental pain? This would be the likely cause as the old dog had bad breath, gum infections and loose decayed teeth. So she brought her dog to her vet as she felt that the recent teeth chattering could be due to toothache. Her vet wanted her to sign an anaesthetic risk consent form and forewarned her that her dog was an older dog and might die on the operating table during dental work.

CASE OF THE TEETH-CHATTERING CHIHUAHUA
FIRST VISIT
Sunday, January 15, 2012
The young couple came with the Chihuahua after having consulted a vet earlier. Death on the operating table is the main concern with the fair lady. Vet 1 had insisted that they sign the anaesthetic consent form highlighting the risk of death in an old dog undergoing dental work. "This is the common practice," I explained. "Even the human hospitals will ask you to sign the form if you go for anaesthesia and surgery. In the Singapore General Hospital, I was even given a 10-minute talk on anaesthetic risk by a young doctor in a room as I was scheduled for surgery the next week."

Her biggest worry and that of her mum was anaesthetic death. The vet must listen to what the client has to say. How competent is the vet? She does not know.

"How many anaesthetic deaths have you encountered when you did dental scaling?" she asked my associate vet who was handling the examination together with me. This was the sort of question many internet websites have advised the dog owner to ask the doctor. My associate vet said: "I refer you to Dr Sing."
The young lady turned her head to me for an instant reply.

I said: "I can only speak for myself. In my over 30 years of dental scaling, I have not encountered any anaesthetic death. This is because dental scaling and work do not require long anaesthesia. Therefore the risk of deaths on the operating table is very low. The anaesthesia should be completed within 15 minutes. Careful monitoring of the vital signs by the vet is most important."

I don't permit idle chatter during dental surgery. Nor do I make small talk with my assistant during surgeries. A singular focus on the surgery. Speed accuracy and completeness.

"Look at the right face," I pointed to the facial swelling. "Do you see a big swelling below the eye? The bacteria from the root of the back teeth, the 4th premolar, had gone into the face, causing this swelling. It is called a malar abscess."

The lady had a second look at the right face. "Compare to the left area below the eye," I suggested. "There is no swelling there!"

The lady turned her head to inspect the left face. This new finding added to her worries. She knew a dental work under general anaesthesia was necessary. Dental gels and paste that claim to work would not be effective. The internet advertisements of pet teeth are products are many.

Warnings of high anaesthetic risks and death esp. for the older dogs flashed back into her mind. She was well educated and informed to know that such products would not work for her dog.

ALTERNATIVE TREATMENTS WITHOUT ANAESTHESIA
1. Oral care gels and paste, chew toys and kibbles?
2. No anaesthesia dog groomers. Need to hold the dog firmly and rigorously to do the scaling or extraction as most dogs fight against such dental work without sedation and are frightened of it.

3. No action from the owner. Leads to oro-nasal fistula as in another Chihuahua. Show clips from
1. Chihuahua with a non-healing facial wound - oro-nasal fistula
http://www.youtube.com/watch?v=5AWHpWYWgy4&lr=1
2. Follow up on the Chihuahua after surgery and pyometra death
http://www.youtube.com/watch?v=ExTT2a8eUCs

How about dog groomers offering dental scaling without anaesthesia? There are such services offered by some pet shops in Singapore. This was an educated owner in my assessment, probably having completed higher education level and knows the situation.

She had done her internet research and knew that her dog would need more than dental scaling. He needed to have his loose and decayed teeth extracted. And this could not be done by the dog groomer without anaesthesia.

Her vet insisted that she signed the anaesthetic form first as taught by their veterinary professors to cover their back in case of litigation.

Here, at Toa Payoh Vets, my vets do insist on the client signing the anaesthetic form too. For me, I don't insist on it after explaining in detail one-to-one the risks and benefits thoroughly. So, I seldom get the owner to sign the form as this cause considerable stress for some of the young ones over my past 40 years of practice. If the client has no confidence in me, I would suggest going to another vet.

For this case, I advised antibiotics for the next few days and getting the dental work done on Friday as Sunday would be Chinese New Year. I don't perform surgery on Chinese New Year although I am not superstitious about bad luck if the vet "cuts" on Chinese New Year.

I told my associate vet that I would be handling the case myself as there was great worries for the fair lady.

SECOND VISIT
Friday, January 20, 2012

Sunday will be Chinese New Year's Eve. So the dog was done today. Blood test taken revealed nothing abnormal. "You have checked the blood test?" the young lady asked me. "Yes, the blood test showed normal results. There is no kidney or liver disorders and the dog's heart is good. Come back 2-3 hours later." She was comforted and left with her significant other.

ISOFLURANE + OXYGEN ANAESTHESIA
Chihuahua, Male, 8 years, Severe stage 4 periodontal disease.
No sedation
Images of the process and procedures

Mask and then intubation. Many assistants don't know how to anaesthesize the dog using just isoflurane + O2 as the dog does struggle vigorously and bite at a certain stage.
The technique is to hold the dog by the scruff of the neck and to take out the mask when the dog struggles at the excitement stage. Wait a few seconds and put the mask on. Repeat again. Normally, the dog will be anaesthesized smoothly.

Ideally, the dog should be sedated, given isoflurane by mask and then intubated. This is the better restraint and saves much time as the excitement stage does not exist. Most vets use this method and this is the method taught by the veterinary professors. I don't know whether they teach the use of isoflurane solely in old dogs or not as I was a student 40 years ago.

In this case, the owner had some knowledge of the sole use of isoflurane gas done by me and asked me about it. So I took over this case from my associate vet to give her peace of mind. Usually dental scaling is a relatively easier surgery compared to others like spay.

An endotracheal tube of the appropriate size, not too small, is inserted and the dog given 1-2% isoflurane gas as maintenance. The proper sized endotracheal tube for this dog was 6.5

Only 3 teeth left. Around 16 extracted.

The dog coughed when the owners came to pick up 2 hours later.
"It is caused by throat irritation of the endotracheal tube," I explained. "I inserted the tube into the windpipe to give the anaesthetic gas. I will give an injection."

It was one of those satisfying moments to see the young lady smile and freed of worries since her Chihuahua had not died on the op table and was as alert as if he had not been under anaesthesia. Isoflurane anaesthesia effect disappears within 5 minutes and that is why this dog was as alert as normal.

However, it takes a longer time to anaesthesize the dog and there is a certain technique which I taught my assistant Min so as not to injure the dog when he is struggling before being asleep. If a sedation injection is given first, there is virtually no struggling. As I had promised the owner that I will use gas only, I kept my word.

CONCLUSION
Anaesthetic deaths during dental scaling are rare in practice. Anaesthetic consent forms worry many owners and the risk of anaesthetic deaths promote a window of opportunity for non-veterinarians to provide dental scaling services.

Regular dental check up once a year and tooth brushing would have prevented the loss of 19 teeth and much worries. Do spend time brushing your dog's teeth at least three times a week. Easier said than done. A vast majority of Singapore owners is too busy to do the dental brushing.

CREDITS

COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com

Produced by: Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Narrated, Edited and Filmed by:

Sponsored by:
Asia USA Realty (asiahomes.com) Pte Ltd --- asiahomes.com
Be Kind to Pets (bekindtopets.com) LOGOS

Singapore, Jan 24, 2012

For more info:
W: toapayohvets.com
E: judy@toapayohvets.com
T: +65 9668-6468

DRAFT FOR VIDEO PRODUCTION IS AT:
http://www.bekindtopets.com/animals/20120124isoflurane-gas-dental-extraction_Singapore_ToaPayohVets.htm

837. Singapore vet dog dental scaling - google search

2012-01-23T05:29:00.000-08:00

The following articles are from Toa Payoh Vets and associates and are found based on google search of:
"Singapore vet dog dental scaling" on Chinese New Year 2012, Jan 23, 2012 9.14 pm.

RANKING AND WEBSITES ARE:
No. 2. http://www.toapayohvets.com/surgery/050609periodontal_disease_cat_dog.htm
Toa Payoh Vets Clinical Research
Dental & Oral Care in Singapore's Dogs, Cats, Rabbits & Other Animals

No. 3. http://www.toapayohvets.com/surgery/20100618cheek_tumour_old_dog_electrosurgery_ToaPayohVets.htm
A LARGE CHEEK TUMOUR & 15 ROTTEN TEETH IN AN OLD DOG
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
20 June, 2010

No. 4.
http://www.asiahomes.com/book2/20100664dental_extraction_16-year-old-Pomeranian_dogs_singapore_ToaPayohVets.htm
DENTAL WORK WITHOUT ANAESTHESIA IN A VERY OLD POMERANIAN WITH HEART DISEASES
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Written: 04 September, 2010

No. 5.
http://www.bekindtopets.com/dogs/20080828Dog_Dental_Problems_Singapore_ToaPayohVets.htm
DENTAL HEALTH CARE OF
THE DOG IN SINGAPORE
Case written: May 5, 2009
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Update: 04 September, 2010

No. 8 (Not Toa Payoh Vets, but Singapore Veterinary Association webpage) http://ctrlaccess.info/websysdocs/218.186.8.243201011335950_SVA_Position_Paper_on_Veterinary_Dentistry.pdf
SVA Position Statement on Veterinary Dentistry by
Non-Veterinarians and Veterinary Dentistry without Anaesthesia

No. 12 PAGE 2
http://www.sinpets.com/F6/20120107vigorous-finger-tooth-brush-exposed-roots-Schnauzer-singapore_ToaPayohVets.htm
Veterinary Productivity:
A Schnauzer has two loose front teeth
and an ear lump
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
10 January, 2012

No. 13 PAGE 2
http://www.sinpets.com/F5/20110914Bad-breath-old-dog-toapayohvets-singapore_ToaPayohVets.htm
The old dog still has bad breath after dental scaling and extraction of 6 teeth
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Sep 14, 2011

No. 14 PAGE 2
http://www.toapayohvets.com/about_toapayohvets_Singapore_Apr807.htm
ABOUT US Jan 17, 2012

No. 15
http://www.toapayohvets.com/fees.htm
FEES 29 June, 2010

No. 17
http://veterinarymedicinesingapore.blogspot.com/
Sunday, April 18, 2010
485. Urine peeing anywhere. Rebellious age at 7 months

No. 18
http://www.bekindtopets.com/dogs/20080919Pyometra_heart_disease_old_dog_ToaPayohVets.htm
Open pyometra in an old Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 06 June, 2010

No. 20 PAGE 3
http://www.kongyuensing.com/animals/20110815domitor-ketamine-sedation-chinese-crested-schnauzer_ToaPayohVets.htm
Sedation worries of a daughter
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 08 September, 2011

PAGE 3
http://www.asiahomes.com/angelfire/20100657testicular_tumours_oral_old_dogs_male_singapore_ToaPayohVets.htm
Three old dogs with tumours
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 21 August, 2010 )

PAGE 3
http://www.sinpets.com/F5/20110629gum-tumour-old-dogs-singapore-ToaPayohVets.htm
Gum Tumours In Old Dogs
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case done: May 25, 2009
Date: 28 June, 2011

PAGE 3
http://2010vets.blogspot.com/
Monday, January 23, 2012
837. Singapore vet dog dental scaling - google search

PAGE 3
http://www.bekindtopets.com/animals/tpvets_Jun2910.htm

PAGE 4
http://www.sinpets.com/F6/20110819pyometra-old-female-dog-survival-anaesthesia-spay-neuter_ToaPayohVets.htm

Survival after pyometra surgery in two old dogs
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 18 August, 2011

PAGE 5
http://www.asiahomes.com/singaporeaur/0703hunting_4_5k.htm
2000 CASE: THE 6-MONTH-OLD DOG'S MOUTH IS FULL OF SALIVA
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 3 July, 2000
Updated: 21 July, 2010

PAGE 5
http://www.kongyuensing.com/animals/20090634Internet_Beagle_Sore_Hocks_Elbows_Singapore_ToaPayohVets.htm
The Internet Beagle Bites Any
Toothbrush into Two Pieces
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written: 15 June 2006
Updated: 06 July, 2009

PAGE 5
http://www.bekindtopets.com/dogs/20101025veterinary_cost_dental_oronasal-fistual-dog-toapayohvets-singapore.htm

ORONASAL FISTULA IN A DOG - ESTIMATED VETERINARY COST IN 2010
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written: November 15, 2007
Update: 25 October, 2010

PAGE 6
http://www.sinpets.com/dogs/20111044blood-urine-recurs-over10times-old-corgi-female-toapayohvets.htm
Recurrent Blood in the Urine in a Corgi - Part 1
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
11 December, 2011

835. SPCA Singapore reported parvoviral infection in its kennels

2012-01-22T22:01:00.000-08:00

Around 3 days ago, I read a Straits Times Report that SPCA Singapore will not be accepting any stray dogs as it had to clean and disinfect its kennels affecting parvoviral infections.

For some months, I have been telling my associate vets to check for parvoviral infections in older dogs that come in with blood in the watery stools. If the owner is against the test, record this in the medical case sheet. Adult dogs can also die from parvoviral infection as many are NOT vaccinated yearly. Most Singapore owners don't bother with annual vaccinations judging from my research in vaccination reminders.

Two years ago, I had an adult dog that had stayed in a boarding kennel. The owner wanted her spayed after boarding. I spayed her. She developed bloody diarrhoea 3 days after spay and was diagnosed with parvoviral infections. She died. From one of my do breeder sources, the owner had complained about me to him but the breeder tod the owner that it was not my fault. The dog was just not vaccinated and protected.

Subsequently, I had another similar request. The owner was fed up with me for asking her to wait 7-14 days before spay and so did not return to do the spay. It takes 7-14 days to know whether the dog has parvoviral infections from the boarding kennels. Many kennel operators do not bother with updated vaccinations too.

834. Perseverance v. passion to become a vet

2012-01-22T21:53:00.000-08:00

Today, Chinese New Year, I phoned Kim to thank her for her SMS "Happy New Year Dr Sing! May your business prosper."

She had quit doing Sunday vet internship in 2012 saying that she had no money to study vet medicine anyway. I said: "Kim, Nobody can predict the future. There are ups and downs in life. Who knows? You may get an inheritance or good fortune. Or a vet scholarship with your track record of internship over the years. But do you really have the passion for vet medicine? If your father is rich, there is no need to have passion as the father pays all fees and open the clinic for you as well."

Kim said: "Maybe in 4 to 5 years' time, I will do the vet internship."

"Is it your husband who is against you doing Sunday internship? It is hard for a married woman to waste a Sunday afternoon instead of spending time with the husband!"

"No," she said. Well, I wish her good luck. This passion for veterinary medicine is difficult to define and harder to find in a Singaproean as it is hard work to excell and succeed to be a good vet.

833. A dog with recurrent bladder stones - The Standard Operating Procedures (SOP)

2012-01-22T21:14:00.000-08:00

First Written: Chinese New Year Jan 23, 2012 1.06 pm
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

RECURRENT UROLITHIASIS - CALCIUM PHOSPHATE URINARY STONES

When a dog has urinary stones again, the following will be the Standard Operating Procedures (SOP) at Toa Payoh Vets to provide the highest standard of care. This SOP defends the vet during allegations of negligence litigation or complaint if the dog has another episode of recurrent urolithiasis.

1. HISTORY. Record all vaccinations done and dates and by whom. Do not forget to do so. Record your analysis of why the dog had recurrent urolithiasisa. In this case study of the Shih Tzu with 13 calcium phosphate urinary stones, the dog came to Toa Payoh Vets for recurrent urolithiasis and I took charge of this case which was operated by Vet 1.

Vet 1 had not done stone analysis, did not advise (in writing) on post-operation prevention and follow-through tests which would permit non-surgical treatment (e.g. voiding urohydropropulsion and urinary catheterisation when small stones are detected via X-rays 3-monthly). Could it also be some metabolic disorders of the parathyroid glands as calcium phosphate is quite rare in dogs?

2. GENERAL EXAMINATION. Demeanour. Weight, rectal temperature, pulse and respiratory rate. Abdominal pain, gas in the GIT and other observations.

3. DETAILED EXAMINATION. Urine test, blood test, radiography (calcium phosphate isradio-dense, check kidneys for calcium phosphate), ultrasonography (possible in calcium phosphate) and calculi analysis. There may be a case for veterinary negligence if the tests has not been advised or done. The advices must be recorded in the case sheets clearly.

4. TREATMENT. According to symptoms. IV, SC or oral fluid therapy depending on dehydration situation. Antibiotics to treat UTI. Urinary catheterisation to relieve urethral obstruction.

The vet in charge of the case is responsible for details of time, amount and other information will be recorded in the hospitalisation sheet.

5. COMMUNICATIONS WITH THE OWNER IN WRITING. A veterinary report explaining the significance of the tests and case must be given to the owner on discharge/death of the puppy. It is best to keep the owner informed daily of the health of the dog. Such phone calls must be recorded in the medical case files.

6. RECORD AMA (Against Medical Advice) the owner's rejection of advices of the test in your medical record. Failure to do so implies that the vet has not advised at all in cases of litigation/complaint. As Singapore is becoming a litigious society, I advise that the highest standard of care to be given at all times. An example of a case done by me is down shown in the images.

TOA PAYOH VETS CASE STUDY BY DR SING

Chinese New Year Eve 4.56pm
Jan 22, 2012

PATIENT: Shih Tzu, Male, 8 years, not neutered
Around 12 months ago, Vet 1 removed many "urinary stones" but no stone analysis or other tests or follow throughs were advised. I don't know the reasons and will not speculate.

It is important to confirm the nature of the stones and a stone or calculi analysis should have been done and must be done to confirm the diagnosis. This must be recorded in the case sheet and advices of prevention of recurrence be given and recorded.

The dog recently had urethral obstruction. 13 urinary stones on X-ray were removed. Stone analysis done showed pure calcium phosphate crystals and urine tests showed bacterial infection UTI.

DIAGNOSIS: Calcium phosphate urolithiasis

CASE MANAGEMENT AT TOA PAYOH VETS

14.1.12 Calculi analysis by the NUH Dept of Lab Medicine.
Calcium stone positive, phosphate stones positive. Negative for stones of oxalate, urate, magnesium, cystine, ammonia and bicarbonate.

8.2.11 Blood test. SGPT/ALT increased, SGOT/AST increased, Urea increased 8.9 (4.2-6.3). Platelet 522 (200-500)/ Blood calcium 1.99 (1.5-3.60) is normal.

13.12.12 Urine test. ph=7, SG 1.012, Protein ++, Blood ++++, WBC 468, RBC 25, Bacteria +++. There is UTI and possibly kidney involvement. X-rays - any stones in the kidneys? Not seen. No crystals seen in the urine but this does NOT mean that the dog does not have stones when urine test is negative as in this case.

Radiography at 3-monthly intervals post-op would have picked up the stones when they were small but very rarely do Singaporean owners bother to do this. When stones are small, they can be "sucked" out using the urinary catheter and voiding urohydropropulsion. That is the reason for radiography.

X-ray in this case showed 13 radiodense uroliths. Calcium phosphate stones are radiodense.

TREATMENT
1. Medical dissolution using prescription diets. This is not possible for calcium phosphate stones.

2. Surgical removal. Done.
3. Non-surgical methods like voiding urohydropropulsion and aspiration into a urinary catheter not possible. 13 big stones with 2/13 stuck in the penile urethra.

4. Non-surgical method. Lithotripsy is not available in Singapore.
5. Metabolic disorder. Correction of hyperparathyroidism or other causes of hypercalcemia should minimise further urolith formation.

HOW TO PREVENT RECURRENCE?
1. Post-op radiography every 3 monthly is the best advice.
2. Urine test monthly to check for bacterial infection (UTI).

REFERENCE: The 5-min veterinary consult - Tiley Smith

1. PURE calcium phosphate uroliths are usually associated with metabolic disorders such as primary hyperparathyroidsim, rental tubular acidosis and excessive dietary calcium and phosphorus. This dog was fed on dry dog food.

2. A higher % of calcium phosphate uroliths are found in the kidneys than in the urinary bladder

OTHER LAB TESTS
1. Calculi analysis is necessary and was done.
2. Serum concentrations of parathyroid hormone,parathyroid hormone-related peptide
and hydroxycholecalciferol may be useful.

PREVENTION/AVOIDANCE
1. Hill's Prescription Diet U/D is formulated to reduce calcium extretion, is phosphorus-restricted and reduces formation of concentrated urine.
2. Canned diets are more effective than dry diets in preventing recurrence due to high moisture content
3. Avoid excessive acidfication or alkanisation of urine.

INTERESTING INFO
Hill's book recommends treatment of bacterial UTI and then give C/D

FOLLOW UP
1. X-ray after surgery to verify complete urolith removal is essential. This was not done as surgical removal of 13 stones were presented.
2. Abdominal radiography or ultrasonography every 3 months to detect early recurrence and prevent repeat surgery (e.g. using non-surgical methods to remove easily by voiding urohydropropulsion or catheter retrieval.

TP 16915
Op Date: Jan 12, 2012
Surgeon: Associate vet

A. Sedation injection 3.11 pm
Skin prep, Isoflurane gas
B. Skin incision 3.38pm
C. Skin stitched up 4.11 pm

B-A = 27 minutes. Dog was ferocious and therefore prep had to be done after sedation
C-B = 33 minutes. This is acceptable time taken for cystotomy for an experienced vet. All 13 stones were inside the bladder and accounted for. Therefore there was no need to do urethrostomy. The stones must have been flushed back into the bladder under anaesthesia by Vet 1 during the after midnight visit.

Blood test by Vet 1 - Significant findings, 12.40am Jan 12, 2012
MCV high 79 (60-77)
WBC high 26 (5.5 -17)
NEU high 21 (2-12)
MONO high 3 (0.3-2)
BASO high 0.16 (0-1)
PLT high 660 (175-500)

BUN high 31 (7-27)
ALKP high 233 (23-212)
K high 6.5 (3.5-5.8)

Jan 23, 2012. Chinese New Year.
I am keeping an eye on the follow through of this case. So far, the owner said she is busy and had not come down to get the CD canned diet.

TOA PAYOH VETS webpage will be written later:

833. Chinese New Year's Eve Reunion Dinner stories

2012-01-22T14:26:00.000-08:00

Jan 22, 2012 Sunday was Chinese New Year's Eve Reunion Dinner. Time to catch up. My advice to the young adults would be to ask questions to sustain a conversation rather than keep looking at their smartphones and texting. Ask what your cousins or uncles and aunties have been doing and you can learn much.

There were two Chinese idioms which I can't translate into English.

1. Teochew expression of 6 words. The Teochew mother expresses herself in Teochew and has dropped hints to the late 20s son who does not contribute one cent to the household by giving a bit of his salary to the mother. The daughter gives money monthly but the son forgets about it. In Chinese custom, children should give some part of their pay to the mother as they still live with the parents. So she said the six words. Nobody could translate into English. "It means scrounger," Julia said. Well, that is a public hint to the son to part with a bit of his salary to the mum. It will be like talking to the wall as he said that he is on hard times, having to save up for his wedding and his new HDB apartment renovation. In any case, the parents don't need his money. It is just a custom of some Chinese mothers to expect children to give some token to them when they start work and still live in the parents' house. As for the father, he said to me when I asked his opinion: "If my children don't ask money from me, I am OK!"

2. Teochew expression regarding a "golden chair". This refers to a young man who should marry an older woman. After all, an older woman is secure financially (hence the golden chair) while a younger woman wants money and security from the man. So, the niece with the fairest famed complexion of the Teochew ladies advised Jason not to marry wives younger than himself. "2 years older," she gave an example of a man dating a woman 8 years older but failing in the relationship. "Why not build your own golden chair?" her brother suggested.

Conversations can be sustained if you asked about the other party's welfare. Dogs are one favourite part in conversation. "How do you know it is dangling?" I asked the brother of the fair lady who had asked Daniel some advice about the cost of removal of a lump which keeps growing bigger in a 13-year-old Cross bred of her boyfriend. This boyfriend loves animals and she related an incredible story. One day, his favourite Jack Russell escaped and was hit by a car. The dog waited for him to return home from work. Once he reached home, the dog passed away. "He was holding on to life till he had seen his owner," she said.

To return to the dangling lump, the brother of the fair lady said he had not seen the dog. Daniel presumed it to be a growth from the groin area. I asked in more detail from the fair lady: "Where is the lump? Is it in the breast area?" She said: "No, it is dangling from between the legs and keeps growing bigger fast every day."

Since this is a male old dog, I said: "It is likely to be a testicular cancer. I can arrange a transport man to bring it down for surgery. The earlier it is done, the better for the dog." I doubt that there will be any follow through action by this young lady as it is not her dog.

Sadly, many dog owners feed their dogs and do not bother when there are growths or bad breath. However, recently, it seems that there are more cases of dental work being requested on dogs.

As can be seen in a last-minute request by a mother and her two pre-teen daughters bringing a 13-year-old small breed dog today at 4pm as the dog was not eating. As the dog had eaten at 6 am, I proposed dental work after a general examination. "This dog will not bite," I said to Dr Vanessa as she tried to muzzle him and examine his mouth via the muzzle. This small breed does look ferocious and open-eyed, being a mini-pinscher cross and so I did not blame her for being careful. I lifted the side of the dog's mouth to expose the back teeth full of tartar. "Give an IV drip plus antibiotic IV before dental work," I advised. There was a need for blood test and an anaesthetic consent form. However, the blood test would add up the cost and so this was not done. A general examination would do. Domitor 0.1 ml and isoflurane gas. 3 teeth extracted by Dr Vanessa.

The dog went home to a happy mother with two daughters on Chinese New Year's eve. Many of such cases need dental work but can get frightened by warnings about deaths from anaesthesia from the vet. Obviously the vet has to cover himself by getting the consent form signed as this is an old dog and could die. Hospital doctors do the same too. In this case, no consent form was asked to be signed. Careful anaesthesia resulted in a happy outcome for this dog. Old dogs seldom die from dental work if there is careful anaesthesia and no chatting between the vet and the assistant. Focus on the patient and in my 30 years of experience, I can be confident that the old dog will not die on the operating table as the anaesthesia duration is very short if the vet prepares and knows what to do efficiently and productively.

832. Tonsillitis in an old dog

2012-01-22T13:54:00.000-08:00

E-MAIL TO DR SING DATED JAN 21, 2012

Dear Dr. Sing,

Patient Ref. No. ... (... (Silkie, 8.5 yrs old))

We were at your clinic last Sunday (15 Jan).

I'd like to have a better understanding regarding B's lump at his throat:

On 11 Dec 2011 after his dental scaling (during which you checked on his throat), we were told that the tip of his epiglottis was red. Antibiotics prescribed, to be reviewed.
15 Jan 2012 review: we were told there is a lump at his left tonsil (right tonsil could not be seen as Bowie was struggling too much). I forgot to ask, what about the redness at tip of epiglottis?

Your advice was to put him on antibiotics first and to review again in 1-2 months' time. As B is such a nervous dog, he'll be sedated for a proper diagnosis for his next review. You said that if it is indeed a lump, the tonsil/s will be removed. Is tonsil/s removal the only treatment option, even though the lump may be benign? Without tonsil/s, wouldn't he be more susceptible to virus infection in the future? What if the lump is a cyst or an abscess?

Your reply via e-mail will be greatly appreciated, Dr. Sing. Thank you!

PHONE REPLY FROM DR SING
It is best to speak by phone as email replies can be misinterpreted. Questions can be answered immediately and clarification can be made immediately too.

In this case, tonsil removal is advised in case the tonsil is a growing malignant tonsillar carcinoma as the dog is old. The red lump of the is around 0.5 cm x 0.5 cm and visible. An aspiration biopsy can also be done in this case to check whether the tonsil is an abscess, cyst or cancerous. Sedation will be needed and anaesthetic risks are always there.

It is worrisome for the owner. The vet's duty is to inform the owner of the presence of the tonsillar growth. Excision or biopsy depends on the economics and malignancy or otherwise of the growth.

I have an image of an 8-year-old Chihuahua with tonsillitis and will post it later. 13 teeth were extracted.

831. The Shih Tzu has reccurent urolithiasis. 13 calcium phosphate stones

2012-01-22T01:44:00.000-08:00

Chinese New Year Eve 4.56pm
Jan 22, 2012

PATIENT: Shih Tzu, Male, 8 years, not neutered
Around 12 months ago, Vet 1 removed many "urinary stones" but no stone analysis or other tests or follow throughs were advised. I don't know the reasons and will not speculate.

It is important to confirm the nature of the stones and a stone or calculi analysis should have been done and must be done to confirm the diagnosis. This must be recorded in the case sheet and advices of prevention of recurrence be given and recorded.

The dog recently had urethral obstruction. 13 urinary stones on X-ray were removed. Stone analysis done showed pure calcium phosphate crystals and urine tests showed bacterial infection UTI.

DIAGNOSIS: Calcium phosphate urolithiasis

CASE MANAGEMENT AT TOA PAYOH VETS

14.1.12 Calculi analysis by the NUH Dept of Lab Medicine.
Calcium stone positive, phosphate stones positive. Negative for stones of oxalate, urate, magnesium, cystine, ammonia and bicarbonate.

8.2.11 Blood test. SGPT/ALT increased, SGOT/AST increased, Urea increased 8.9 (4.2-6.3). Platelet 522 (200-500)/ Blood calcium 1.99 (1.5-3.60) is normal.

13.12.12 Urine test. ph=7, SG 1.012, Protein ++, Blood ++++, WBC 468, RBC 25, Bacteria +++. There is UTI and possibly kidney involvement. X-rays - any stones in the kidneys? Not seen. No crystals seen in the urine but this does NOT mean that the dog does not have stones when urine test is negative as in this case.

Radiography at 3-monthly intervals post-op would have picked up the stones when they were small but very rarely do Singaporean owners bother to do this. When stones are small, they can be "sucked" out using the urinary catheter and voiding urohydropropulsion. That is the reason for radiography.

X-ray in this case showed 13 radiodense uroliths. Calcium phosphate stones are radiodense.

TREATMENT
1. Medical dissolution using prescription diets. This is not possible for calcium phosphate stones.

2. Surgical removal. Done.
3. Non-surgical methods like voiding urohydropropulsion and aspiration into a urinary catheter not possible. 13 big stones with 2/13 stuck in the penile urethra.

4. Non-surgical method. Lithotripsy is not available in Singapore.
5. Metabolic disorder. Correction of hyperparathyroidism or other causes of hypercalcemia should minimise further urolith formation.

HOW TO PREVENT RECURRENCE?
1. Post-op radiography every 3 monthly is the best advice.
2. Urine test monthly to check for bacterial infection (UTI).

REFERENCE: The 5-min veterinary consult - Tiley Smith

1. PURE calcium phosphate uroliths are usually associated with metabolic disorders such as primary hyperparathyroidsim, rental tubular acidosis and excessive dietary calcium and phosphorus. This dog was fed on dry dog food.

2. A higher % of calcium phosphate uroliths are found in the kidneys than in the urinary bladder

OTHER LAB TESTS
1. Calculi analysis is necessary and was done.
2. Serum concentrations of parathyroid hormone,parathyroid hormone-related peptide
and hydroxycholecalciferol may be useful.

PREVENTION/AVOIDANCE
1. Hill's Prescription Diet U/D is formulated to reduce calcium extretion, is phosphorus-restricted and reduces formation of concentrated urine.
2. Canned diets are more effective than dry diets in preventing recurrence due to high moisture content
3. Avoid excessive acidfication or alkanisation of urine.

INTERESTING INFO
Hill's book recommends treatment of bacterial UTI and then give C/D

FOLLOW UP
1. X-ray after surgery to verify complete urolith removal is essential. This was not done as surgical removal of 13 stones were presented.
2. Abdominal radiography or ultrasonography every 3 months to detect early recurrence and prevent repeat surgery (e.g. using non-surgical methods to remove easily by voiding urohydropropulsion or catheter retrieval.

TP 16915
Op Date: Jan 12, 2012
Surgeon: Associate vet

A. Sedation injection 3.11 pm
Skin prep, Isoflurane gas
B. Skin incision 3.38pm
C. Skin stitched up 4.11 pm

B-A = 27 minutes. Dog was ferocious and therefore prep had to be done after sedation
C-B = 33 minutes. This is acceptable time taken for cystotomy for an experienced vet. All 13 stones were inside the bladder and accounted for. Therefore there was no need to do urethrostomy. The stones must have been flushed back into the bladder under anaesthesia by Vet 1 during the after midnight visit.

Blood test by Vet 1 - Significant findings, 12.40am Jan 12, 2012
MCV high 79 (60-77)
WBC high 26 (5.5 -17)
NEU high 21 (2-12)
MONO high 3 (0.3-2)
BASO high 0.16 (0-1)
PLT high 660 (175-500)

BUN high 31 (7-27)
ALKP high 233 (23-212)
K high 6.5 (3.5-5.8)

Jan 23, 2012. Chinese New Year.
I am keeping an eye on the follow through of this case. So far, the owner said she is busy and had not come down to get the CD canned diet.

830. Sunday's Jan 22, 2012 interesting case (Chinese New Year's Eve)

2012-01-21T23:03:00.000-08:00

Sunday, bright. sunny. Most vet practices close in the afternoon as there would be no clients. Toa Payoh Vets open till 5 pm. In the afternoon, no clients as at 3 pm when I am writing this report on a new client whose poodle, male, neutered, vomited blood yesterday and vomtied without blood today.

General exam was normal.
ABDOMINAL PALPATION
The dog arched his back when his ant aabdomen was palpated. "Hunched" said the lady owner. Mild pain in the liver, kidney, gastric area. The lady owner said: "Hunch back."

HISTORY
Since young, the dog had been vomiting every 1-2 months. Usually threw up without food. Vet 1 said nothing was wrong. I proposed X-ray or ultrasound after the Chinese New Year. For the time being, put on antibioitcs for 10 days.

TREATMENT
1. Dextrose saine 500 ml IV drip + anti-spasmogesic + antibiotic. Goes home later.

ADVICES
My hypothesis. Most likely the dog had been eating outside objects on the grass when walked by the domestic worker during the evening. Domestic workers meet their friends when they walk the dog and so it was possible that the dog gets fed some food or had gone onto the grass to eat anything . It is hard to say.

Blood test, X-ray and ultrasound can be done a few days later if vomiting continues. Cost is nto a problem with this owner. I said: "It is also possible that this dog has a small gastric foreign body that can't be vomited out nor passed through the intestines and so the dog vomits 1-2 monthly due to gastric inflammation and irritation by the movement of this foreign body and bacterial infection of the stomach (gastric mucosa)."

RIGHT EYE TEARING AND ITCHY
Swollen eyelids of the right eye due to rubbing. "Fluorescein eye stain is useful to check whether the eye cornea has ulcers or not," I put the fluroescein strip under the upper eyelid of both eyes. "Can you see the green stain on the cornea?" I shone the white light tangentially at the the right eye. "Yes," the lady owner said; "Green patches in the central cornea and at 12 o'clock and 2 o'clock. What is an ulcer?" she asked me as she could not understand. "It is a wound like the skin that has been cut, you will get a skin ulcer. A broken surface." She understood and translated it into Mandarin. I don't know how to translate ulcers in Mandarin. I must learn Mandarin as there are more Chinese Nationals nowadays and many Singaporeans speak Mandarin!

3 EMERGENCY CASES
1. One year old, female, Corgi, itchy back, wet areas. Their Vet is off, but the dog is still v. itchy. "Very good appetite after Shincort inj by Vet 1," the owner said. Wife and young son came. I advised clipping all bald just as Dr V wanted to clip just the back half. "There may be other areas and it is best to get hairs grow together." Owner said he saw "flea dirt," although Vet 1 saw a tick. A flea bite allergy not controlled by Vet 1's Shin cort injection?

2. Westie now not eating again. Wanted to see Dr Vanessa.

3. A dog with loose teeth or bad teeth. Made an appointment. Saw Dr Jason Teo yesterday.

829. The chattering chihuahua

2012-01-20T17:32:00.000-08:00

Jan 20, 2012 Friday

The young couple came with the Chihuahua as scheduled. Death on the operating table is the main concern with the fair lady. Vet 1 had insisted that they sign the anaesthetic consent form hihglighting the risk of death in an old dog undergoing dental work. "This is the common practice," I explained. "Even the human hospitals will ask you to sign the form if you go for anaesthesia and surgery."

I had seen the couple on last Sunday and had advised antibiotics for the next few days and getting the dental work done on Friday. I told Dr Vanessa I would be handling the case myself as there was great worries for the fair lady. Sunday will be Chinese New Year's Eve. So the dog was done today. Blood test taken revealed nothing abnormal

Chihuahua, Male, 8 years, Severe stage 4 periodontal disease.

Isoflurane + oxygen anaesthesia only.
Proper sized endotracheal tube which was 6.5
Only 3 teeth left. Around 16 extracted.

The dog coughed when the owners came to pick up 2 hours later.
"It is caused by throat irritation of the endotracheal tube," I explained. "I inserted the tube into the windpipe to give the anaesthetic gas. I will give an injection."

It was one of those satisfying moments to see the young lady smile and freed of worries since her Chihuahua had not died on the op table and was as alert as if he had not been under anaesthesia. Isoflurane anaesthesia effect disappears within 5 minutes and that is why this dog was as alert as normal.

However, it takes a longer time to anesthesize the dog and there is a certain technique which I taught my assistant Min so as not to injure the dog when he is struggling before being asleep. If a sedation injection is given first, there is virtually no struggling. As I had promised the owner that I will use gas only, I kept my word.

826. Teeth scaling an 8 year old male silkie terrier

2012-01-18T03:00:00.000-08:00

Dec 12, 2011

Nervous silkie terrier. Slight pain in larynx.

Blood test - SGPT/ALT 109 (<59) but otherwise all normal.
Urine test bacteria +++.
Surprising to find bacteria in the urine of a male dog. Licks ventral area.

Calculated dosage 10 kg young dog D=0.4 K=0.5
This is old dog, 7.4 kg. Give 50% of calculated dose

Domitor = 0.15 Ketamine = 0.18 Total 0.33 IV sufficient
Teeth still strong. So only dental scaling

Noted tip of epiglottis red but tonsils normal.

Tibetan Mastiff sedation

2012-01-18T00:22:00.003-08:00

"Do you do house-calls for a very big dog with itchy ears?" an old client and friend asked me the fees to treat a very big dog at the home of her friend.

"It will be a waste of your money," I said. "Ear disease diagnosis need a microscope and other assistants to help out."

Tibetan Mastiff, Male, 7 months, 53kg. Healthy. Ear canals with black wax seen daily. Had lots of ticks recently when walked outdoors.

EAR IRRIGATION & LICK GRANULOMA INJECTION
A gentle giant but still it is best not to traumatise him. My client said: "My friend's dog was hit by a car, bit the owner's arm later."

SEDATION
Do a proper calculation as follows:
My guideline IV anaesthesia
10 kg young dog Domitor = 0.4 ml, Ketamine = 0.5 ml combined IV
53 kg young dog D= 2.12ml K=2.65ml
I gave 40%, D=0.85 K=1.06 Total = 1.85ml IV as this would be a short anaesthesia of around 10 minutes needed for me to irrigate the ears and inject the 3 lick granulomas with prednisolone intra-lesionally.

"My dog will not get up on the table," the owner said.
"No dog will climb up a veterinary table," I explained to the gentleman. "I will carry his back half and you carry his chest. Talk to your dog while we carry or he will feel he is being murdered."
The dog was carried up on the table by the owner and my assistant Min without a protest.

Now, to find that leg vein as the coat is so thick. The foreleg was thick as this was a man-sized dog. I don't clip off the hairs to see the vein as it is not acceptable.

"Tighten the tourniquet," I said to Min who had not seen large a gigantic dog. Singapore's dogs are usually small breeds and Tibetan Mastiffs are as rare as snowfall.

I pressed the swelling and drew the blood into the syringe. I injected the 1.85 ml IV.

The dog slept at this 40% of calculated dosage. I taught the owner how to check the ear canal and insert the cotton bud, smell it and then I irrigated the ear canals.

After that I injected pred into the 3 lick granulomas. The dog did twitched a little on the 3rd lick granuloma being injected but was otherwise knocked out.

4949 - 4958. Itchy ears and three interdigital cysts/lick granulomas must be treated early - Tibetan Mastiff. If itchiness of ears and paws are not treated early by your vet, the dog self-mutilates to relieve himself of the intense itchiness. Hair loss and skin infections present themselves soon
"I need to wake up the dog," I said as I injected Antisedan 1.0 ml IM on the right hip muscles. He woke up 10 minutes later and that was great.

The above 40% dosage was sufficient for a short painless ear irrigation and lick granuloma injection of less than 10 minutes.

Know how to check the ears and prevent interdigital cysts and lick granulomas in a big furry breed as it is a high maintenance breed. Brush daily and inspect daily. Clean ears. It is extremely difficult to avoid ticks. Wear booties or check paws after a walk. "I avoid the grass," the owner just walked the dog in the evenings along the road.

The following advices to the owner who had bought a very strong hair blower for Tibetan Mastiff were:

1. Daily brushing of the coat with the slicker and another brush rather than hot air blowing everyday as the dog has some skin itchiness and eczema, probably due to the earlier tick bite infestations.
2. Daily inspection of the ears
3. No rough cotton wool to dig the ears
4. There is no need to pour his ear lotion by pumping into the ears every day if the ears are clean. He use to do it every day. Daily ear dropping had resulted in brown black wax being produced.
To check the ear canals as to whether they are clean or not, I taught him how to insert the cotton bud into the ear canal. See the colour of the tip and smell it. If the colour is clear, the ear has no dirt.
5. Washing of the paws with an anti-fungal solution and rinsing.
6. A long bath tub is needed if he wants to de-tick his dog.
7. Get a big table (as long as my surgery table) and put the dog on top of the table to do his grooming. This is easier on his back.
8. Avoid tick areas. Inspect the four paws when the dog is back from outside walks. He had used Frontline sprays and spots-on insecticides but these have become ineffective over time. Wearing of booties when going out for walks is not practical as the dog needs to wear out his nails. So, daily inspection of the paws for the smallest baby tick after exercise.

This was about the biggest dog in Singapore. As big as a young man. A very gentle giant. If he bites the vet, the vet's fingers can be crushed to pieces. So it is important that he be treated gently and to use sedation if there is pain during treatment, as there is, in the intra-lesion injection of his lick granulomas.

Overall, he was good and could walk back to the car. I helped to carry him onto the boot of the friend's SUV. The owner's BMW was probably not big enough! It was great to meet up with this old client who had consulted Dr Vanessa for the past times as I was seldom around in the afternoons. I asked her to make an appointment to let me check out her dog's skin condition when she said that "old" vets are more experienced. Every vet needs to start at the beginning but young vets need to gain the experience with time. Experience is gained not only be practising but by reading a lot of veterinary literature on relevant situations and consulting other vets for how they treat certain conditions. It may sound stupid to ask other vets but much can be learned from asking.

NINE more images are at:
http://www.sinpets.com/dogs/20120119Tibetan-Mastiff-lick-granulomas-ear-itchiness-singapore_ToaPayohVets.htm

824. Vet surgery - productivity - cat spay

2012-01-16T21:47:00.000-08:00

I am sharing my 30 years of experiences of a cat spay with others interested and to assess my timing as a guide for associate vets

Cat, 1 year +, Female, 2.6 kg
Sent in for spay toeday Jan 17, 2012
Surgeon: Dr Sing
Suture: 2-0 Polysorb braided lactomer C14 cutting 24 mm 3/8

Preparation: Cat was clipped bald before sedation. This saves a lot of time.

Sedation:
xylazine 0.1 ml + ketamine 0.4 ml IM
Wait 10 minutes. Still alert
Need top up isoflurane for few seconds - good analgesia

Timing
10.33am xylazine + ketamine IM
10.43 am Isoflurane 5% start reducing to 0.5%
10.52 am Skin incision started
10.54 am lst ovary (left) hooked
10.59 am 2nd overy (right) hooked
11.02 am uterine body ligated. 2 ligatures
11.08 am stitch linea alba 3 simple interrupted
11.11 am stitched skin 2 horizontal mattress
11.12 am skin stitched up

Sedation to skin stitched 10.33 - 11.12 am = 39 minutes

Tolfedine and baytril injection SC
One bandage on wound to be replaced on Day 3 with new one. I usually don't prescribe e-collar as cats hate them
Baytril x 1 tab 1/4 tab/day

Total cost of spay $150

Sunday Jan 15, 2012 interesting cases - tonsillar tumours

2012-01-16T16:16:00.000-08:00

Bright sunshine, blue skies, white cloud.

Case 1.
A 12-year-old well cared for female, Golden Retriever, drooling on the left side only.
Vet 1 did dental scaling and extraction. Dog then started "drooling on left side."
Vet 1 then smoothened left lower PM4 since the upper PM4 and others had been extracted. Still the drooling persisted.
Vet 2 was "thorough" according to the owner. He X-rayed and ultrasound the whole body. "How about the head and neck area?" I asked. The owner did not think this was done.

According to the owner, said a big lump was present on the left back of mouth and a spherical lump on left neck below the submandibular. He recommended steroids as an alternative to euthanasia and surgery. When the dog was on steroids, she was very hungry and drank a lot. When given Tramadol, the drooling stopped. The dog had lost a lot of weight.

The dog did not want the mouth to be opened but I managed to open it and showed the owner and her sister (anaesthetist) the large tonsillar tumour (at least 3 cm x 2 cm). Pain and ulcerations there would be the cause of drooling.

CASE 2
Surprising an 8-year-old small breed came in for review after this Golden Retriever. I had done dental scaling 4 weeks ago. The dog objected strongly to the mouth being opened, but I could see the right tonsil as reddish lump 0.5 x 0.5 cm. I had told the owner of this lump seen during dental scaling. It could be a tonsillar tumour. The owner would wait and see.

If dog owners regularly check the dog's teeth and keep it cleaned or scaled yearly or two-yearly, many oral tumours would not form. This is the same with human beings too. A poor hygiene in the mouth predisposes to oral tumours and this is commonly reported.

CASE 3
"See the lump under the right eye," I had pointed it out to her at the waiting area. Later, she gave me permission to take a photo. "That is the beginning of a malar abscess - infection from the root of the back tooth into the sinus and bulging out." She had come for advice as Vet 1 wanted her to sign an indemnity form for dental work in case the dog dies under anaesthesia.

"How many deaths were under you while you did dental scaling?" the young lady was very worried about her 8-year-old chihuahua who had Stage 4 periodontal disease (the worst stage) and asked Dr Vanessa who was handling the case together with me. She did most of the talking. Many times, I would see the case together with her and most of the time, she would be doing the talking. Some owners would think I am an assistant and know nothing and so why was I giving medical advices? I usually identify myself as a vet first.

"How many?" the young lady asked again. "Ask Dr Sing," Dr Vanessa replied.

"In my over 30 years of dental scaling and I can only speak for myself, I don't have any cases of dogs doing dental work dying on the operating table," I replied. "Dental work or scaling takes a short time of less than 15 minutes unlike long surgeries and therefore, anaesthetic deaths are uncommon in many senior dogs. A very close focus on anaethesia by the vet and his assistant is very important. In old dogs, I don't give IV sedation but just isoflurane gas only."

The young lady was already red-eyed but well read about anaesthetic deaths of dogs on the operating table. I could understand her concern for the Chihuahua which was in good bodily condition unlike those skinny ones. A bit plump is better as this indicated that this dog was well cared for and had a good appetite (meaning good health too.)

"A blood test is taken to screen the dog's health first," Dr Vanessa said as she examined the heart and lungs and found them OK.
"A 10-day course of antibiotics before dental scaling is what I recommend usually to clients," I said. "The dental scaling is done around 7-10 days later and the mouth would be free of bacteria."
The boyfriend asked the young lady (in her late 20s) to wait for the blood test. So, it was quite an emotional consultation.

This Sunday was an eventful one as my assistant Min fell sick with flu. He left at 10 am to see the doctor and had the day off. Ms Ong, a junior college student with an offer from Glasgow Univ for vet studies came for her first day and so she got to see all the cases since the other three interns (Kim quitted suddenly as she found that it was too costly to study vet medicine, Mr Lim was said to have denque fever, Grace, going to 2nd year vet student from Sydney Univ would come only on Monday.

It was a bright sunshine Sunday and we managed to close at 5.30 pm. I advised Dr Vanessa to record as she communicate to the client as this is what I do, but she had her own style of writing only after everything. So there was much delay. Record what the client said e.g. history on the spot. That would be the efficient way as many clients dislike waiting too long. Some of the clients had to wait more than an hour and from my view at the reception, many prefer short consultations and getting the problem resolved. Waiting more than 15 minutes at the doctor is not a happy event for any Singaporean on a Sunday when there are so many things to do!

822. A twitching eye. Acquired Oculomotor Nerve Palsy in a Golden Retriever

2012-01-14T16:08:00.000-08:00

"Is the right sunken eyeball present since puppyhood?" I asked the lady owner who showed me a bottle of eyedrops prescribed by Vet 1. No other medication was given by Vet 1 who diagnosed eye infection and advised review if the eye condition did not improve.

Case of the Golden Retriever with a twitching eye
Golden Retriever, Male, 8 years. Weight below normal.
Complaint: Fits 2 days ago. I advised bringing the dog to the Surgery rather than a house-call which would waste money as the dog needed more detailed examination.
History: Right eye is smaller than left eye. Vet 1 prescribed eye drops.

Right eye: Drooping eyelid, retracted eyeball, twitching uncontrollably as if blinking at me when reviewed. Occasional twitching (videoed by Nicole).
3rd eyelid covered the right eyeball partially since it has sunken in.
Hospitalised. Blood and urine tests are minimum tests done.

Lumbar puncture for cerebrospinal fluid analysis, MRI scan of the brain are not done at this stage to lower vet costs.

Oculomotor nerve palsy and brain involvement leading to ptosis & fits

OCULOMOTOR NERVE is the 3rd cranial nerve. It innervates the muscles co controlling eye movements, the upper eyelid muscle and the muscles controlling pupil constriction.

In this dog, the Oculomotor nerve and its branches had been damaged or inflamed causing the eyeball to sink inwards, the eyelid to droop. However, since the dog suffered from fits, the lesion is likely to be inside the brain e.g. brain tumour or aneurysm near the Oculomotor nerve or inflammation.

Blood test - high serum urea
Urine test - proteinuria
Brain scan and lumbar puncture are costly options which need to be discussed with the owner.

Other contributing causes
Trigeminal neuralgia involving only the ophthalmic nerve? The trigeminal nerve has 3 branches - ophthalmic nerve, maxillary nerve and mandibular nerve. There does not appear to be facial spasm or dropped jaw and so, the maxillary and mandibular nerves are not involved. The ophthalmic nerve may be involved.

Diagnosis
Brain scan and lumbar puncture are needed for a definitive diagnosis of acquired Oculomotor nerve palsy in this dog but it is costly.

Treatment
Anti-fits and review. The dog can eat and drink and has no more fits when on anti-fit medication. Steroids were not prescribed. To review.

Updates and more pictures at:
http://www.sinpets.com/dogs/20120115oculomotor-nerve-palsy-golden-retriever-fits-singapore_ToaPayohVets.htm

Educational Video from Toa Payoh Vets - Itchy joints in a dwarf hamster

2012-01-13T18:42:00.001-08:00

http://www.youtube.com/watch?v=D3yl4GmBBU4&feature=youtu.be

UTI = Urinary Tract Infection

820. E-mail case study. Basic principles in toilet training a puppy in Singapore

2012-01-13T18:35:00.000-08:00

E-MAIL TO DR SING JAN 12, 2012

Hi Dr Sing Kong Yuen,

I really need help toilet training my new puppy. We have tried different things from fencing to open roaming and back to fencing.

She is a Female Tibetan terrier

Presently (3.5-4)months old

Born 20/09/2012 In Brisbane
where had lots of space to play and was fenced up with siblings
Came to Singapore from breeder in Australia when 2.5-3 months old
Flew with brother to new home in Singapore

When she flew over, she was confined to a small cage with brother

for over 10 hours so had to pee/ poo there while travelling

We stay in a 2 story house with a garden.

We have 2 young kids who adore her and who keep going into her fenced area to play with her or taking her out to run.
Kids laughing just seems to excite her and so confuses her when being told off by me bur kids giggling.
We have an 8 year old male Tibetan terrier who is an angel ( very passive) and is toilet trained to pee outside in garden twice a day when we take him out.

Fencing and toilet- training:

We brought her home and fenced her with collapsible fence(1.8 by 1.8)m.

During the day, she stayed in the fenced area downstairs.

One side had sleeping box & toys & water bottle and food served on other side. Newspaper with pee smell on side wall of fence (for soilage)as in photo. At same time,also, tried taking her to shower cubicle to pee/poo with pee tray or newspaper. Failed miserably. Would sleep there or whine. We would wait and cajole for over (15-20) min but she would not do her business and then soon after that she would come out and she wiuld pee on toilet floor or room floor/mat.

At night, Slept upstairs in bedroom in smaller fenced area (0.6 by 0.6)m with sleeping box and water bottle. When we suspected she needed to pee/poo, she was taken to a different upstairs shower cubicle but same result of sleeping / whining in there and peeing later outside.

Feeding:

Being Fed 3x/day since she came.

(7am/12.30pm/7pm)

For first week, Food was left in pen till finished and sometimes hand fed as figured puppy was getting used to new environment and separation anxiety.

About 2 weeks later, once started eating fairly well, we picked up food after one hour whether eaten or not. Tried a bit of cajoling if not eaten much but figured will learn to eat faster when realises food not there all the time.

Also, had to get water bottle as she had tendency to jump into water bowl and splash and play with water and bowl.

We would let her run around for a while on & off around the house and with kids and other dog and then re- fence her but she would soil anytime & anywhere.

2-3 weeks into her arrival, we changed strategies. We made mistake of letting her loose in house all day and only putting newspaper on outside balcony near garden. We thought we had confused her earlier with where to pee/ poo (too many options for locations to pee/poo including upstairs bathroom cubicle and paper in fence and downstairs bathroom cubicle, so we changed it to one location near balcony with paper and put a (0.6 by 0.6)m fence around. So when saw her sniffing we would put her there. But she would go to sleep in there and pee/ poo once out.

A while later,we changed to not confining/ fencing peeing area as we thought she was confused with fence also being used to punish her. But without fence she kept running off the newspaper and then of course she peed/ pooed in wrong place. As a punishment, we would make her see/ smell the pee/ poo and at same time say 'no no' and then place her in fenced area (0.6 by 0.6)m Would say' bad girl'or 'no, no' after pointing to the wrong location for soiling.

A month after she arrived, we have started smacking her bum for:

biting/ barking/ nipping people/ nipping other dogs/eating wrong things(ie: poo/ shoes) /running out of gate/ eating leaves in garden.

We also tried the loud noise ( old empty drink can with coins) to teach her it's wrong but seems to scare her quite a bit.

Is this correct? What's your opinion on this?

We are frustrated as now:

•She pees/ poos whenever she eats & everywhere and house smelling

•She refuses to pee when take her to newspaper with pee trainer smell and instead will sleep on the paper and whine softly but no pee/poo there and soon after being 'released' she will pee/ poo somewhere else ( no fixed place). No matter how long you wait.

•She might then eat/ play with her poo

•She whines/barks when confined / alone in punishment fence

Plays with her poo/ Tries to eat poo

Seems confused about toilet place

Sleeps in toilet confined area/ in toilet cubicle/ on newspaper with pee- trainer smell

When realize she wants to poo/pee so take her to open area with newspaper to pee/ poo she runs away or sleeps on newspaper and soon after does it somewhere else on floor/ carpet

. Sometimes chews newspaper

As of today, after reading some of your cases, we have decided to refence her (1.8 by 1.8)m with toys on one side and newspaper at other side and food placed near toys at meal time. Also decided to feed her earlier 7am/ 12.30 & 5pm so that has time to empty bladder before sleeping.

For example today,

She ate at 5pm and at 7.30pm still just sleeping on the paper. Not peed/ pooed.

So at 7.30pm i decided i will get her out to exercise and run and instead she ran to kitchen and peed there. We brought her back to the newspaper in fence and she went to sleep on it.

At 8pm kids went into fence to play for 20min. Then she peed just next to paper on wooden floor.

At 8.30pm, not pooed yet.

At 10pm plan to take her to sleep in fenced area in bedroom. ( does not like to sleep alone and once upstairs she goes to bed).

What do I do if she keeps peeing in fenced area but not on newspaper?

Do dogs poo after every meal? How long do I wait for her to pee/poo before allowing her to go to bedroom?

Also, aiming to slowly move to 2 meals a day by 6 months. Is that ok?

Please please help and advice me about toilet training her.

About to pull my hair out.

This is becoming a battle of wills.

I'm also worried she might be stubborn enough to not pee/ poo in fenced area on paper and may end up with kidney/ urine infections.

How long do I just let her not pee/poo in the fenced area? Basically, how long do I wait?

What if she does not do it on newspaper and does it in other parts of fenced area? What do I do?

Do I need to cover entire fenced area with newspaper?

Every time she pees on floor in fence, I spray the smell repellant and disinfectant and wipe it off. Is that correct?

Should elimination area be in/ out of playpen?
At night, can she sleep in fenced area in bedroom?

At what age can we take puppy for walk on leash?

Eventually want him to pee outside the house once toilet -trained like my older dog.

Does paper-training confuse or hamper that?

I was hoping to take her for walks with older dog in hope that would copy older dog when peeing/pooing but she tries to bite leash and lies on floor & refuses to walk and hates collar so unable to do that.

Will send you photos of the fenced area and her sleeping fence too.

Really waiting eagerly for your wise words as really quite lost & frustrated!!!

Yours sincerely,

Name of Owner

E-MAIL REPLY FROM DR SING DATED JAN 14, 2012

Thank you for your email and details. My reply focuses on toilet training as you will need to read up or get a dog trainer to answer the other questions. Books are available at the National Library and the info is in the internet.

In this reply, I can only provide you the concept and principles of toilet training a puppy in Singapore based on success achieved by other Singaporeans in my survey of over 600 puppies.

1. It takes 2-8 weeks of confinement of a puppy to achieve success. Much depends on the intelligence of the puppy, the hard work and time spent by the owner, the distractions of family members and friends. For example, a couple living alone with the puppy will have a higher rate of success within 2-4 weeks than a big family with so many interferences and distractions affecting toilet training.

2. Patience and perseverance and research of the owner. Many owners are sabotaged by their family members giving various instructions and treats affecting the success in toilet training.

3. Focus on one method of confinement e.g playpen fencing confinement.

4. My case studies would have given you some ideas of the successes of various types of housing plans for puppies. Basically, strict confinement 2-8 weeks is the main part of toilet training. Positive or negative reinforcement training and others are needed.

It is not possible for me to advise you in detail in your case as each puppy has different management.

819. Performance of the vet surgeon: Urinary stone surgery

2012-01-12T19:49:00.000-08:00

I am collecting data to improve the processes and system and the productivity of vet surgery by an associate vets at Toa Payoh Vets. Timings depend on the complexity of the surgical case and therefore there is no fixed period of time.

Ferocious biting Shih Tzu, Male, 8 years. 13 urinary stones inside the bladder

TP 16915
Op Date: Jan 12, 2012
Surgeon: Associate vet

A. Sedation injection 3.11 pm
Skin prep, Isoflurane gas
B. Skin incision 3.38pm
C. Skin stitched up 4.11 pm

B-A = 27 minutes. Dog was ferocious and therefore prep had to be done after sedation
C-B = 33 minutes. This is acceptable for an experienced vet doing cystostomy alone. All 13 stones were inside the bladder and accounted for. Therefore there was no need to do urethrostomy. The stones must have been flushed back into the bladder under anaesthesia by Vet 1 during the after midnight visit.

Blood test by Vet 1 - Significant findings, 12.40am Jan 12, 2012
MCV high 79 (60-77)
WBC high 26 (5.5 -17)
NEU high 21 (2-12)
MONO high 3 (0.3-2)
BASO high 0.16 (0-1)
PLT high 660 (175-500)

BUN high 31 (7-27)
ALKP high 233 (23-212)
K high 6.5 (3.5-5.8)

818. How many urinary stones?

2012-01-12T16:05:00.000-08:00

An X-ray of the Shih Tzu with a recurrent urolithiasis and an X-ray. "How many stones?" I asked my assistant Min as part of my mentoring process.

"Eleven," he said. "Well there are 13," I showed him the 2 stones hidden near the pelvic bones.

"Better make sure that you don't flush the bladder or urethra too vigorously duringb cystotomy," I said to Dr Vanessa who would be operating. "13 stones are expected." She got 13 stones. Well done. All stones were inside the bladder and she had used a bigger catheter to ensure no more stones are left behind.

"The stones must be sent for analysis," I said. "The dog had a previous surgery 1 year ago and the stones had recurred."

817. The Golden Retriever has a twitching eye

2012-01-12T16:00:00.000-08:00

Vet 1 treated this 8-year-old Golden Retriever with a bottle of eye drops and asked the owner to return if the right eye infection (eyes 3/4 closed) had not cured. This was what the owner said to me. "Is the sunken eyeball normal?" I asked the owner as the right eyeball had retracted (enopthalmos), the upper eyelid had drooped (ptosis) and the nictitating membrane (3rd eyelid) had covered the eye.

"The right eyeball was of same size and position as the left," the lady said. She had phoned for a house-call but I advised her to bring the dog dog. Her dog had developed fits.

"This is not a simple case of eye infection," I said to my assistant. It appeared to be a 3rd cranial nerve or brain problem. A blood test and urine test are done. X-rays are advised but this would be costly. The fits were controlled and the dog went home after 3 days.

I had the dog bathed one day before he went home. His ear canals were irrigated (no ear infections).

I told Nicole to take a video of the right eyelid twitching. Very rare. The dog was very thin. Proteinuria and high blood urea. Could also have kidney disorder as well as 3rd cranial nerve palsy. Is there a cure?

816. First impressions of a new vet graduate

2012-01-12T15:49:00.000-08:00

POST-SURGERY COMPLICATIONS

Yesterday, Jan 12, 2012, I had a chat with a new female vet graduate from Australia about bleeding in a neuter of a Labrador Retriever. Closed technique, 2 ligatures used by her but lots of bleeding. "A transfixing ligature and open technique may be wiser in big dog neutering to prevent ligature slippage," I said. The dog was OK after a repeat surgery at this practice I visited. For new vets, the tying of the ligature and the number of throws of the knot is important. I usually knot 5 times firmly using absorbable sutures. If you knot 3 times, you may find that the stitch breaks down and then post op return of the patient.

SPAY TIPS FOR NEW VETS
Keep surgery simple. Using intradermal or subcuticular stitching impress clients as they don't see the stitches which are hidden under the skin. However, your stitching technique has not been perfected yet. It the continuous intradermal stitches break down or irritate the cat or dog, there will be intense itching and post-op infections. Therefore, I usually advise one or two horizontal mattress sutures to close the skin. In the past 30 years of spay, I rarely encountered any return for post-op stitch breakdown or infections. Remember, your reputation is on the line. Clients will seldom refer you if your surgical outcome in a spay cause the client worries and return to be re-operated on due to post-op stitch breakdown and infections.

FIRST IMPRESSIONS

First impressions count for a new vet graduate. "Dr.... wears jeans and his staff wears sneakers," said one young male vet to me. For older vets, dressing may not be so important but it is still best to create a good first impression. For the lady vet, I noted that half of her left eye is covered by her falling hair, making it distracting to talk to her. She kept sweeping her hair to uncover her eye. Best to get a good hairstyle as clients may only see half of you!

In my surgery, younger vets and interns tend to dress casually. From 2012, I have stopped staff wearing sandals, sneaker, jeans and clogs to work. For those who persists, they will need to work or intern elsewhere. First impressions still count in a professional practice. Uniforms are sometimes used to ensure that the staff dress appropriately and create a good impression in some vet practices to resolve this tendency of the young to dress casually. I may implement this dress code.

815. Follow up - The Cocker Spaniel that had tick fever

2012-01-12T10:42:00.000-08:00

In Oct 2011, the Cocker Spaniel had pale gums. Tick fever was treated and the owner was most happy.
This case is reported in:
http://www.sinpets.com/dogs/20111039tick-fever-cocker-spaniel-singapore-toapayohvets.htm

On Jan 11, the owner messaged me to get her Cocker Spaniel vaccinated and checked. The Cocker wanted to bolt out of the door as she remembered me very well. It was great seeing a patient who had recovered from tick fever and put on weight.

She had put on weight and was very active. Her gums were pinker than normal. "It is best not to give too much liver," I advised. The dog had no fever. I took a blood test to review her health. Her owner did not bring any urine sample as she said: "Every time I tried to collect urine from her, she would stop peeing!"

The blood test revealed a low white cell count and very low platelet count. "Could it be the return of tick fever or a wrong blood sample being tested?" the owner asked me when I told her to stop using the tick wash and tick top up. The dog had a tick wash 2 days before as she still had small ticks.

"It is unlikely to be tick fever," I said. "The dog is eating well and is active. The lowered platelet count could be due to toxic blood. Your dog would have licked off the tick wash and ingested the poison over a period of time." The owner did not want a repeat blood sample so soon.

She sent in the urine sample for analysis. Results would be known tomorrow. With blood test, one assume that the dog is OK and keep giving tick washes (to prevent tick fever). The area where the dog exercises has ticks and that is why this dog has small ticks now and then. The owner is specially careful that she does not get tick fever again as it can be a killer.

814. A duty to charge fairly for work done - lawyers overcharging

2012-01-12T10:30:00.000-08:00

Straits Times Jan 12, 2012 Pg B2
"Two lawyers face disciplinary court for overcharging"

Tow lawyers of more than 18 years of practice had an agreement to charge 5% of the estate when its assets were sold. The estate value went up to $9.77 million in 2004 and they were entitled to $488,500. The disciplinary tribunal said that they overcharged by around $566,000 when the fees should be $170,000.

The lawyers' defence was that this fee agreement must be set aside before they can be said to overcharge. The tribunal rejected their defence as the charges showed that the lawyers wanted to profit from the rise in the value of assets rather than get paid for work done. In addition, the tribunal questioned the contents of their bill of costs. The two lawyers spent one hour in drafting two letters. One letter consisted of one sentence and the other three sentences. So, the lawyers were referred to the Court of Three Judges for gross professional misconduct.

812. Anorexia nervosa?

2012-01-11T16:15:00.000-08:00

A quick snap of a statue in Budapest while I was in the guided tour coach. Anorexia nervosa?

811. When to vaccinate a puppy who has kennel cough?

2012-01-11T15:12:00.000-08:00

E-MAIL TO DR SING DATED JAN 11, 2012

Hi Dr Sing

Thank you for your follow up call on Pillow's recovery last Sunday. To
be quite honest, I was quite surprised to receive your call and was very
impressed with your concern and professional service :). Even my own
physician do not follow up on my visits, kudos for your kind concern
.... great customer service :)

PP was recovering quite well over the last few days and he should
finish the Antibiotics today. The 'coughing' has decreased
substantially but I still do hear him cough every now and then after
meals. Is this normal ? or should he stop coughing completely by now ?
He is eating well and playing well but breathes heavily at times when
running around.
Do I need to bring him back to you for a check up ?

The next appointment for his Vaccination is this Friday, do I proceed
with this or should I postpone till next Monday ? Appreciate your
advise, thanks

Best Regards

E-MAIL FROM DR SING DATED JAN 11, 2012

Dear ....

Thank you for your email and compliments. I try to follow up cases whenever possible to know the effectiveness of treatment and therefore acquire the knowledge that vet books and professors cannot impart.

In reply, PP is still coughing, though considerably less.

It is not possible to predict exactly when the coughing will cease after medication. The medication to treat bacterial infections of the upper respiratory tract. However, kennel cough is caused by a bacteria and a virus. There is no usual medication against viral infections and therefore the puppy needs time to recover.

Vaccination must be delayed till 7-14 days after the end of coughing as this will indicate that the puppy has fully recovered. In your case, the puppy has already got 2 vaccinations and the 3rd one has to wait 7-14 days after the date of no coughing from the puppy.

Pl let me know if you have more queries. Thank you for 3 pictures of PP. PP was my first case for 2012 and reminds me so much of my son's Bichon who is now 5 years old and is well behaved (no urine marking inside the house)

P.S
I have 2 Sec 3 students and Dr Vanessa Lin produced an educational video on kennel cough with one rehearsal only. Pl let me have your comments as to

1. whether you have a better understanding of kennel cough and
2. whether the video was fun to view or make you fall asleep and snore.

Feedback is important to improve my pet video educational work. The video is at:

http://www.youtube.com/watch?v=tmTYP8T95V4
Best wishes for the New Year

810. Hands-Feet-Must-Quick Newspaper stand

2012-01-10T18:09:00.000-08:00

Today I went to the HDB Hub newstand to buy my Straits Times. There was a queue of 4 people and so I stood at the 5th and read the papers. "You can go to the other girl if you want to pay," a kind lady told me.

I did not see the young girl as the last time, it was only Aunty working alone. Aunty is a slim Chinese lady in her 50s. She had told me that she would resign as the hours 9 am to 9 pm are too tiring for her. At that time I asked what happened to the young girls, usually in their early 20s, employed by this kiosk. They had quit.

Today, I assumed she was alone and the queue was waiting for her as she photocopied the documents. The young girl was next to her but I did not see her.
"Aunty, you still around?" I said (in Chinese translation). "Why don't you ask the young girl to do the photocopying and you collect money?"

"Hands-Feet-Must-Quick", the Aunty told me. The new girl would not be able to use the multi-function copier and she probably did not bother to teach her. This is quite a common situation in Singapore employment matters. Why teach the young ones when they don't stay long?

I paid up and left. Singapore has developed but the parents and the education system have had no time to teach the students to be able to do what the industry wants.

Chinese language usually has 4 words to express a situation and that is why I translated literally Aunty's reply to me.

809. Update Travel Stories; Young Adults Who Are Not Hungry

2012-01-09T15:36:00.000-08:00

Just update the following:

Travel Stories. Dubai - Jan 1, 2012 Winchester Hotel 12.08 am

Many young adults in a free world of abundance like Singapore, live in a virtual world of the smart phone texting and connecting with friends day to day. No responsibilities of adulthood and parenthood.

How to pretty themselves? How to look cools? There seems to be a trend in Singapore's young adults from the middle and upper class to go for Laser Surgery of two eyes.

It is cool. Their peers do it and they desire it. A 5-hour eye test free of charge. They are sold on the benefits and want to book immediately.

Go for cosmetic eye surgery since other young adults in the middle class go for it. Side effects like dry eyes that need eye drops daily after laser operation and corneal damage affecting beauty and vision due to a possible mis-positioning or inadvertent mistake by the sophisticated eye laser machines or machine operator are ignored. Such side effects will not happen to them. How about long-term effects on vision loss. Well, the young adults are invincible. They are not 30 years old. Why think longer than 1 year later? They are not aware of the other young adults who have adverse effects after the cosmetic eye surgery as they don't want to know. They think high tech eye laser machines are perfect and will not damage their cornea. $4,000 is the price. So what?
In Europe now, I read that 40,000 breast implants which leak and may cause cancer are worrying so many women who had gone for breast cosmetic surgery. The standard of care was not there as manufacturers of breast implants use poor quality material. Who suffers daily worrying about the implants rupturing and causing cancer? How many celebrities with botched cosmetic surgeries have these young adults research? There is a website devoted to such cases but why bother to read them?

The years rush by. Time flies. Those young adults who acquire specialised relevant skills after graduation, works hard and is honest, get the good jobs globally as they are useful and indispensable to the employer.

Most of the old guards or senior citizens will never be able to compete in this global world for jobs needing more than a degree from the University and work experience. There is a need for specialised relevant technical experience in many high-paying jobs globally.

Many Singaporean young adults are blessed growing up in abundance in a Singapore, free of wars, natural disasters and crime from the 1950s - 2012 and are unprepared for the shocks of the real world. There are many hungry young adults in Eastern Europe and China who value time and money, and not cosmetic surgery to pretty themselves. They know the importance of hard work (not working 5 days a week, at 9-5 am) to succeed in life. Singaporean parents try to shelter their young ones from hard work and long hours, thinking that the world owes them a living. Or the Government will provide.

Many young Singaporeans don't bother to learn how to read the financial statements but will punt or accept a friend's advice to invest in some schemes which appear to be Pansy schemes. For example, buying a gold bar and paying for 20% below market price and getting regular returns above average. Sounds too good to be true and seems to me to be another version of Madoff's US$50 billion ponzi scheme on a small scale.

2012 appears to be another recession caused by the Euro crisis but how many young Singaporean adults can discuss in depth what is the Euro crisis and how it will impact their parents' livelihood, their own job prospects and their country's economy.

Webpage at:
http://www.sinpets.com/F6/20120110eye-cosmetic-cornea-laser-surgery-singapore_ToaPayohVets.htm

808. Veterinary Surgery Productivity in Employee Vets

2012-01-09T15:08:00.000-08:00

I have just updated the report today:

Jan 4, 2012. Wednesday. 2nd day at work.

A new client is difficult to come by as there are now 47 veterinary practices in Singapore. This was revealed to me by one veteran drugs salesman who saw me yesterday. We knew each other for more than 40 years and he had become busier now, with so many new practices compared to 4 when I first started out in 1982.

A quiet slim lady brought a black-brown Miniature Schnauzer to the Surgery as the dog had two loose front teeth. From her expressions and conversations directed at me, she would prefer me to handle her case. "I will do it together with Dr Vanessa as part of my mentoring process. When did the dog eat?"

"My dog ate at 10 am. Is it OK to do anaesthesia? "
"It is ideal that the dog should not have eaten for 10 hours before anaesthesia as the dog may vomit," I said. As the owner did not have time to postpone the tooth extraction, I said, "I will do it at 5 pm which is 6 hours later. It should be OK".

5-year Min Schnauzer, Female Spayed.
Chief complaint: 2 loose front tooth with exposed roots were surprisingly seen. Other teeth in good condition.
"i used the finger brush and gel," the owner said.
"You must have been brushing too vigorously," I replied. "The gums of the two incisors are exposed. It is best not to use the finger brush. In any case, the back teeth needs scaling."
Chief Complaint - My Schnauzer has two loose front teeth

Complaint No. 2 - My Schnauzer has a big ear lump that increases in size

4886 - 4895. Electro-surgery productivity

2nd complaint: R ear inflammatory nodule, firm, 7mmx7mmx5mm with central hole.
"A bee stung her tongue sometime ago," the lady said.
"Any bees seen in the last 2 weeks?" I asked as the owner said that the lump grows bigger in the past days. The dog had been scratching the right ear.
"It is best to excise it while the dog is under General Anaesthesia (GA) for dental scaling," I advised. "If you don't want histopathology, we will not know whether it is cancerous or not. A biopsy can be done but it costs money and delays. The best is for me to excise it since it is growing bigger day by day ."

The lady agreed to dental scaling and excision of the lump but not to blood test or histopathology. I asked Dr Vanessa to check the heart and pulse as well as general examination of the lungs. All were OK. So, the GA will be at 5pm to be done jointly.

I wanted to demonstrate how to be efficient and productive in veterinary surgery to my staff as it is one thing to lecture to young ones. Show how it is done will be best.

PLANNING
Scrub & clean ear well before sedation. "Any clipping of the ear?" Min asked me. "No need," I said.
I checked that Min had prepared the setting up of the electrosurgery equipment, dental scaling equipment and covered the operating table with a towel to prevent electric shocks to the vet on contact. After all this was done, the dog's dosage of IV anaesthesia was calculated. "Give 50% of the calculated dose and you have around 10 minutes of anaesthesia," I said to Dr Vanessa.

5 min after sedation, electro-excision by Dr Vanessa was completed within 60 seconds and then dental scaling was done. As the dog had little tartar due to the teacher's vigorous finger brushing, the dental scaling of the back teeth took a very short time.

Productivity means using the correct amount of anaesthetic drugs and least time to complete surgery and dental scaling. Therefore, the dog has the best chance of survival on the operating table. Delays by not preparing the equipment at first increases the risk and that would account for some deaths on the operating table.

The following is what happened as I asked my intern, Mr Lim to do the recording. Normally Min would do it but Mr Lim needed to be hands-on to learn if he wanted to be a vet after his National Service.
5.22 pm Sedate/IV anaesthesia at 50% dosage guideline*
5.25 pm Electro-excision
5.26 pm Dental scaling
5.36 pm End of dental scaling

*IV Anaesthesia Guideline Toa Payoh Vets and Dr Sing Kong Yuen
10kg, healthy, young dog. Domitor = 0.4 ml, Ketamine = 0.5ml IV combined
Usually no top up is required in a spay if done within 20-30 minutes.

This dog - 5 years is not young. The staff is to calculate on paper the dosage
D= 0.11ml + K=0.14 ml. Total = 0.25ml. Add 0.25ml Hartmann = 0.5 ml to be given IV.

Normally, the IV anaesthesia lasts around 15 minutes. I noted a very slight reaction to electro-incision which lasted less than 10 seconds. The dog was adequately sedated for dental scaling done by Dr Vanessa. Two teeth and nodule given to owner. I demonstrated that this case did NOT need any isoflurane and O2 top up if proper pre-op preparation had been done and the vet is skilful in using the electro-surgical instruments.

USE OF ELECTRODES
"Don't bend the circular wire," I said to Dr Vanessa as she looped the nodule and the wire tilted at 45 degrees. "It is a very thin wire. It will break and it is very expensive to buy." The wire loop was originally 90 degrees to the electrode. Training a person how to use the tools of the trade correctly is important and acquiring the correct skills makes a vet more productive. The Vet School provides some knowledge of electro-surgery but I doubt every of the 60 - 80 students has the chance to handle the electro-surgical equipment. So they acquire the skills after graduation.

WART OR NODULE?
I would say it is an inflammatory nodule (with a hole in its centre, possibly bee sting). Dr V thinks it is an ear wart. "Physically, it does not look like a wart," I argued. "A wart usually is cauliflower shaped or rough, not smooth. However, veterinary medicine has exceptions and I can't say this is not an ear wart. Since the owner does not want histopathology, we can't send the lump to the laboratory for examination. Therefore, there is no definitive diagnosis."

VACCINATION AND HEARTWORM PREVENTION
"I give heartworm tablets monthly," the owner said. "The last vaccination was 2 years ago." I explained to her the difference between the usual vaccination and heartworm.

"You may be getting your priority wrong. In the countryside like England, where most dogs don't meet other dogs, some dogs may be safe without further vaccination as they don't get exposed to many other dogs as in city living." I explained. "Parvovirus is still around. Distemper is still present in unvaccinated puppies. Have you been to England?" I asked. She said she was in England for two years and understood what I said.

VETERINARY PRODUCTIVITY & EFFICIENCY
Many employee vets and doctors are not aware of the need to manage financial costs as this subject is not taught in vet school in detail if at all. So, they use materials and waste time in surgery. After all, they don't pay out of their own pockets and so do not bother with using excessive packets of sutures or finding more efficient ways to stitch up a case.

If there is no proper planning, a lot of time and material are wasted. This dog would need top up IV anaesthesia or isoflurane gas to complete the job. As demonstrated by me, the whole process after sedation took 3 minutes for electro-excision and 10 minutes for dental scaling.

An example of poor productivity and efficiency in vet surgery would be as follows:
The dog was sedated for a spay. The legs were then anchored to the op table. The vet assistant started clipping the surgical area inside the surgery room. Then the area would be cleaned. A gas mask would be given to the dog to deliver isoflurane gas and O2. The dog struggled as sedation wore off. A lot of time had been wasted.

My usual method is as follows:
To clip the dog (not ferocious) at the Preparation Room. Clean the surgical area. Sedate with Domitor and Ketamine IV. Dog goes into Operation Room. Anchor legs to table and clean surgical area again. Wait 5 minutes (time spent after sedation would take 5 minutes). Gas mask to deliver isoflurane and O2. Intubate. Spay. A lot of time is saved and the dog is exposed to much less anaesthetic in this way.
OUTCOME
The dog in this case was groggy for over 1 hour as I did not use Antisedan to reverse the Domitor as I deem it not necessary to wake the dog up so early as she might feel the pain. Pain-killer and antibiotic injections were given. The dog went home without problems as at 12 hours at the time of writing this first draft report. However, in this final copy, the owner had texted me saying that the surgical area was weepy and inflamed and what should she do?
"Hi dr Sing, I'm .....Brought ....to ur clinic for teeth extraction n ear surgery on Wed. ....ear is not doing well...Had inflammation. Can I administer iodine on her ear? What shd I do? I gv her medication as indicated, didn't bring her out. Can y kindly advise? Thanks very much
Younger people prefer texting. I phoned her and advised daily cleaning with the iodine and to let the dog wear the e-collar as she had been scratching the surgical area. She would let me know if there are problems again.

AN EXAMPLE OF POOR PRODUCTIVITY WASTING MANY HOURS HAPPENED ON THE SAME DAY

The HDB contractor came to replace the wooden bathroom door (rotten base) with a plastic one. He dismantled the door and then found that the plastic one was too narrow to fit in. 3 weeks ago, another person had come to measure the dimensions. This was really a waste of time, being unproductive. This is what I mean by productivity and efficiency.

"Please put back the old door," I asked the thin Malaysian man from Malacca with jet black hair. "I have a lady vet and you can understand that she can't use the bathroom with no doors. She works to past 8 pm at night. For men, an open door may be OK"

The contractor actually took the trouble to fix back the old door and said, "OK. I will get the new door back to the factory to replace one with correct dimensions today." He had previously said it might take 2 weeks, since Chinese New Year falls on Jan 22, 2012 and most workers had gone home. I was surprised. He even gave me two discarded wooden boards for me as shelving.

More pictures are at:
http://www.sinpets.com/F6/20120107vigorous-finger-tooth-brush-exposed-roots-Schnauzer-singapore_ToaPayohVets.htm

807. Sunday's interesting cases Jan 8, 2012

2012-01-07T23:30:00.000-08:00

Case 1. Follow up of my first case seen in 2012 - The coughing Bichon puppy
The owner was surprised and appreciative to receive my call.
He said: "More active and much less coughing now. You are correct in that the puppy looks more like a Bichon than a poodle as we had checked the dog books.

"Does he still pee a bit to get treats?" I asked.
"Yes, he is a manipulative puppy as you had said."
This is a smart puppy.

Case 2. The 13-year-old male Shih Tzu barks when touched.
"This time, I decide to bring in my dog earlier than in Nov 5, 2011 when my dog barks when my wife wanted to clean him after eating or when he lay sideways. Dr Jason Teo prescribed rimadyl 25 mg for 7 days and he was OK."

On spending time with him, he said that Dr Jason Teo had got an X-ray done and nothing abnormal was seen. He had also asked for another 7 days of rimadyl and he dog was OK till Jan 6, 2012 (2 days ago).

PRESENTING SIGNS. Hunched back.
After Dr V had examined, I did an abdominal palpation and spinal area palpation.
"A hunched back indicates pain in the abdomen," I said to the owner.
"Where?"
I put my left hand on the front part of the abdomen and pressed. There was some sweling in the liver and spleen area to the kidneys. The dog yelped in reaction.

A painful liver/spleen area. The dog coughed violently when I palpated the pharynx.

So, there was pain. What's the cause? Tumour and/or inflammation of the kidneys, stomach, liver?

Blood test and urine test doe

806. The ferocious female cat passing red blood in the urine

2012-01-06T22:15:00.000-08:00

Saturday Jan 7, 2012

I went to work although it is my day off. Checked on the cat that passed blood in the urine and under Dr V's care. The lady owner phoned: "How's Toto?" I said: "I am Dr Sing. Dr V is off today. Toto has not been passing blood in the urine since yesterday's admission to the Surgery." The cat was in a grated flooring and dark brown urine was seen, no more red blood."

"It was my grandpa who said that the cat had passed blood in the urine," the young lady said. "I don't see it."

"Well, grandpa is correct," I replied. "I saw the red blood myself when Dr V was sedating the cat. I was present and had tried to express some urine for the urine test." Around 1 ml was expressed after sedation. Bladder was empty. I did not palpate any big stone or thick wall suggstive of tumour. So this was likely an infection of the bladder, cystitis.

FLASHBACK YESTERDAY
A lady in her late 30s and her grandpa came with a brown cat to see Dr V. A vet had treated this cat, prescribed antibiotics and a Eukanaba dry food "guaranteeing" that the urination problem would be resolved if this dry food was consumed.

"This cat is fierce," the lady said. So, Dr V, Min, Nicole and Mr Lim were in the room

806.. Old mother died from post-op infections in the ward

2012-01-04T21:33:00.000-08:00

I read this somewhere in the Straits Times in Dec 2011.

The surgeon operated successfully on the heart of the old mother. She became infected in the ward and it seemed that the doctors had not attended to her. She died. Civil suit. The registrar resigned and the surgical intern gave up his surgical internship.

Post-op infections can be very serious in old people and dogs.

804. Against Hospital Advice: Biopsy and lumbar tap discouraged for 76-year-old mother diagnosed with massive stroke

2012-01-04T21:31:00.000-08:00

AGAINST HOSPITAL ADVICE

I read in www.asiaone.com.sg while in Eastern Europe last week. The writer said he sent his mum to Changi General Hospital. 2 neutosurgeons and 2 visiting ones said his mum could have brain cancer and would not do a biopsy and lumbar tap due to high risk v. benefit.

The son scoured the internet and found a specialist who treated his mother at Tan Tock Seng Hospital and did the two tests. His mother had a brain infection and had since recovered!

No comments from CGH

803. Liposuction death of Mr Heng was due to too much sedative

2012-01-04T21:27:00.000-08:00

Straits Times Prime News Jan 5, 2012 Pg A3
"Doctors gave patient too much sedative: Coroner"

Heavily sedated man eventually died from the effects of asphyxia. His tongue was said to block his breathing. The more he struggled, the more sedative of propofol was given. This lead to the possibility that the patient could have suffocated leading to cardiac arrest, tongue rolled back causing obstruction of the airway.

13 intestinal perforations during liposuction not immediate cause of death -no massive bleeding or infections do not occur so fast.

LESSONS FOR VET ANAESTHESIA

1. I don't use propofol nor IV anaesthesia. However, some practices may not have isoflurane gas machine and theefore need to top up with IV anaesthetic drugs.

2. Keeping an accurate and meticulous record of sedation
2.1 The coroner said the two doctors "tailored" the figures - titration of the propofol and the total amount of propofol administered

2.2 The monitoring of the patient under sedation was treated with caution by the coroner. Dr Zhu could recall the sequence of titration and elvel of propoful tritratred during the entire procedure (of 3 hours) when no contemporarneous record was ever made of the number of times the propoful was adjusted or the level titrated. So the coroner was incredulous that she could recall the details.

The timing in Dr Wong's notes had been amended. Although 60 ml of propofol was claimed to have been given, this was actually more than 60 ml.

2.3 Dr Wong's nurse often paused when answering straightforard questions and claimed not to remembver important facts. So the nurse's demeanour in court was less forthcoming.

CIVIL SUIT filed against the two doctors.

For vet anaesthesia, keep proper and accurate anaesthetic records that can be believed.

802. HSA laboratory error making solutions - applicable to vet anaesthesia

2012-01-04T21:10:00.000-08:00

Straits Times Review Jan 5, 2012 Pg A36
"To err is human, to confess remarkable"

Mistake: A senior lab manager misread the concentration of the reagent used for DNA tests. He made a solution 10 times as strong as it should be.
This reagent tested the DNA samples of 400 criminal cases.

How HSA prevents a similar occurrence in the future?
It had not double-checked the solutions used and none in the world does that as it is only a basic tool.

NOW every batch is checked by an independent laboratory
"Why no test was done on the solution before?" No answer to this question.

APPLICATION TO VET ANAESTHESIA - DOMITOR AND KETAMINE IV

Using IV anaesthesia, I want the vet to write down on the anaesthesia record and calculate the dosage based on weight and age and % discounted for old dogs. I do this myself and monitor my associate vets doing it.

IV sedation should not be overdosed, otherwise the dog dies. So, it is important to have a system and process of checking by the Senior Vet.

801. Shih Tzu with possible GME - follow up on Jan 4, 2012

2012-01-04T16:35:00.000-08:00

4 Jan 2012
The Shih Tzu had been treated for a fever 2 days by Dr Vanessa. I was overseas. I saw him at 7 pm when the young couple came to take him home and observed his walking. He could walk on 4 limbs but not for long. Left eye pupil had no response to light and was dilated fully. Right eye pupil reacted to the bright white light I shone on, but constricted around 70% normal.

Blood test was taken. Showed very low WCC and higher figures of elevated liver enyzmes and higher than normal platelet count. Previous blood test showed normal WCC and elevated liver enzymes.

The dog did not have much appetite but was otherwise normal.

GME - Granulo-meningo encephalitis.
Cause is unknown. Said to be an auto-immune disease.
I did advise pred 2.5mg 2x/day for 2 weeks when the owner said that the dog had panted hard but it was only today I saw the dog again.

Prognosis is usually poor and the owner must be informed. "Feed small amounts and around 6x/day with sweet multivitamins," I advised. "You have 4 weeks." The dog rejected hand feeding but this must be done. Liver Prescription Diet 2 cans and antibiotics were prescribed by Dr Vanessa

The important issues here are prognosis and feeding several times a day at home as the owner wanted the dog back.

Day 2 of work - Productivity & Efficiency in Vet Surgery - dental and electro-excision

2012-01-04T04:14:00.000-08:00

Jan 4, 2012. Wednesday. 2nd day at work.

A new client is difficult to come by as there are now 47 veterinary practices in Singapore. This was revealed to me by one veteran drugs salesman who saw me yesterday. We knew each other for more than 40 years and he had become busier now, with so many new practices compared to 4 when I first started out in 1982.

A quiet slim lady brought a black-brown Miniature Schnauzer to the Surgery as the dog had two loose front teeth. From her expressions and conversations directed at me, she would prefer me to handle her case. "I will do it together with Dr Vanessa as part of my mentoring process. When did the dog eat?"

"My dog ate at 10 am. Is it OK to do anaesthesia? "
"It is ideal that the dog should not have eaten for 10 hours before anaesthesia as the dog may vomit," I said. As the owner did not have time to postpone the tooth extraction, I said, "I will do it at 5 pm which is 6 hours later. It should be OK".

5-year Min Schnauzer, Female Spayed.
Chief complaint: 2 loose front tooth with exposed roots were surprisingly seen. Other teeth in good condition.
"i used the finger brush and gel," the owner said.
"You must have been brushing too vigorously," I replied. "The gums of the two incisors are exposed. It is best not to use the finger brush. In any case, the back teeth needs scaling."
Chief Complaint - My Schnauzer has two loose front teeth

Complaint No. 2 - My Schnauzer has a big ear lump that increases in size

4886 - 4895. Electro-surgery productivity

2nd complaint: R ear inflammatory nodule, firm, 7mmx7mmx5mm with central hole.
"A bee stung her tongue sometime ago," the lady said.
"Any bees seen in the last 2 weeks?" I asked as the owner said that the lump grows bigger in the past days. The dog had been scratching the right ear.
"It is best to excise it while the dog is under General Anaesthesia (GA) for dental scaling," I advised. "If you don't want histopathology, we will not know whether it is cancerous or not. A biopsy can be done but it costs money and delays. The best is for me to excise it since it is growing bigger day by day ."

The lady agreed to dental scaling and excision of the lump but not to blood test or histopathology. I asked Dr Vanessa to check the heart and pulse as well as general examination of the lungs. All were OK. So, the GA will be at 5pm to be done jointly.

I wanted to demonstrate how to be efficient and productive in veterinary surgery to my staff as it is one thing to lecture to young ones. Show how it is done will be best.

PLANNING
Scrub & clean ear well before sedation. "Any clipping of the ear?" Min asked me. "No need," I said.
I checked that Min had prepared the setting up of the electrosurgery equipment, dental scaling equipment and covered the operating table with a towel to prevent electric shocks to the vet on contact. After all this was done, the dog's dosage of IV anaesthesia was calculated. "Give 50% of the calculated dose and you have around 10 minutes of anaesthesia," I said to Dr Vanessa.

5 min after sedation, electro-excision by Dr Vanessa was completed within 60 seconds and then dental scaling was done. As the dog had little tartar due to the teacher's vigorous finger brushing, the dental scaling of the back teeth took a very short time.

Productivity means using the correct amount of anaesthetic drugs and least time to complete surgery and dental scaling. Therefore, the dog has the best chance of survival on the operating table. Delays by not preparing the equipment at first increases the risk and that would account for some deaths on the operating table.

The following is what happened as I asked my intern, Mr Lim to do the recording. Normally Min would do it but Mr Lim needed to be hands-on to learn if he wanted to be a vet after his National Service.

5.22 pm Sedate at 50% calculated dosage*
5.25 pm Electro-excision
5.26 pm Dental scaling
5.36 pm End of dental scaling
*10kg, healthy, young dog Domitor = 0.4 ml, Ketamine = 0.5ml IV combined

This dog - 5 years is not young. The staff is to calculate on paper the dosage
D= 0.11ml + K=0.14 ml. Total = 0.25ml. Add 0.25ml Hartmann = 0.5 ml to be given IV.

Normally, the IV anaesthesia lasts around 15-30 minutes. Very slight reaction to electro-incision but was OK for dental scaling done by Dr Vanessa. Two teeth and nodule given to owner.

USE OF ELECTRODES
"Don't bend the circular wire," I said to Dr Vanessa as she looped the nodule and the wire tilted at 45 degrees. "It is a very thin wire. It will break and it is very expensive to buy." The wire loop was originally 90 degrees to the electrode. Training a person how to use the tools of the trade correctly is important and acquiring the correct skills makes a vet more productive. The Vet School provides some knowledge of electro-surgery but I doubt every of the 60 - 80 students has the chance to handle the electro-surgical equipment. So they acquire the skills after graduation.

WART OR NODULE?
I would say it is an inflammatory nodule (with a hole in its centre, possibly bee sting). Dr V thinks it is an ear wart. "Physically, it does not look like a wart," I argued. "A wart usually is cauliflower shaped or rough, not smooth. However, veterinary medicine has exceptions and I can't say this is not an ear wart. Since the owner does not want histopathology, we can't send the lump to the laboratory for examination. Therefore, there is no definitive diagnosis."

VACCINATION AND HEARTWORM PREVENTION
"I give heartworm tablets monthly," the owner said. "The last vaccination was 2 years ago." I explained to her the difference between the usual vaccination and heartworm.

"You may be getting your priority wrong. In the countryside like England, where most dogs don't meet other dogs, some dogs may be safe without further vaccination as they don't get exposed to many other dogs as in city living." I explained. "Parvovirus is still around. Distemper is still present in unvaccinated puppies. Have you been to England?" I asked. She said she was in England for two years and understood what I said.

PRODUCTIVITY & EFFICIENCY
If there is no proper planning, a lot of time is wasted. This dog would need top up IV anaesthesia or isoflurane gas to complete the job. As demonstrated by me, the whole process after sedation took 3 minutes for electro-excision and 10 minutes for dental scaling.
OUTCOME
The dog was groggy for over 1 hour as I did not use Antisedan. Went home without problems as at 12 hours at the time of writing this first draft report. However, in this final copy, the owner had texted me saying that the surgical area was weepy and inflamed and what should she do?
"Hi dr Sing, I'm .....Brought ....to ur clinic for teeth extraction n ear surgery on Wed. ....ear is not doing well...Had inflammation. Can I administer iodine on her ear? What shd I do? I gv her medication as indicated, didn't bring her out. Can y kindly advise? Thanks very much
Younger people prefer texting. I phoned her and advised daily cleaning with the iodine and to let the dog wear the e-collar as she had been scratching the surgical area. She would let me know if there are problems again.

AN EXAMPLE OF POOR PRODUCTIVITY WASTING MANY HOURS HAPPENED ON THE SAME DAY

The HDB contractor came to replace the wooden bathroom door (rotten base) with a plastic one. He dismantled the door and then found that the plastic one was too narrow to fit in. 3 weeks ago, another person had come to measure the dimensions. This was really a waste of time, being unproductive. This is what I mean by productivity and efficiency.

"Please put back the old door," I asked the thin Malaysian man from Malacca with jet black hair. "I have a lady vet and you can understand that she can't use the bathroom with no doors. She works to past 8 pm at night. For men, an open door may be OK"

The contractor actually took the trouble to fix back the old door and said, "OK. I will get the new door back to the factory to replace one with correct dimensions today." He had previously said it might take 2 weeks, since Chinese New Year falls on Jan 22, 2012 and most workers had gone home. I was surprised. He even gave me two discarded wooden boards for me as shelving.

UPDATES AND MORE PICTURES AT:
http://www.sinpets.com/F6/20120107vigorous-finger-tooth-brush-exposed-roots-Schnauzer-singapore_ToaPayohVets.htm

799. lst case of 2012. A white puppy that coughs like an old man

2012-01-04T02:12:00.000-08:00

Jan 3, 2012 10.30 am

My first case of the year. Poodle, Male, 3 months. Bought 7 days ago. Past 3 days, cough as if choked. Some runny nose with clear discharge. Excellent appetite. Had 2 vaccinations. 1 free vaccination voucher from a vet for 3rd vaccination and therefore I don't expect the father to see me for the 3rd vaccination.

The father had phoned for check up and the time. He came in the morning before 12 noon and I was on duty. As regards toilet training, I was surprised that the puppy was so intelligent as he would wait for treats by peeing a little bit first. There was one other case of a "manipulative" puppy reported to me during my over 600 case studies of house-breaking in puppies. One particular puppy I remember well is that this puppy would pick up all the toys and put them in a box when retiring to sleep at night.

"How's the puppy toilet trained?" I asked. The puppy was confined closely for grate training (plastic grate on one half, on top of grated floor, according to the father). He was very kind as to e-mail me 3 pictures of the most handsome "Bichon" I have ever seen and I share them with my readers. The Seller said it was a poodle but I said it looked more like a Bichon.

4935. Crate training and treats for a smart puppy. He would go to the grate and pees a bit waiting for treats!

Examination as follows:
1. General exam - mouth and throat palpation - coughed
2. Detailed exam - opened mouth, puppy resisted, shone white torchlight - no tonsillitis, no ulcers
Auscultation of lungs - no lung sounds

"Overall, the puppy had kennel cough," I said. "It is not serious and he will recover in 10 days' time provided no exertion."

QUESTIONS ASKED
1. What causes kennel cough? A virus and bacteria usually from other dogs inside the breeder's premises. The breeders in Singapore do not vaccinate against kennel cough and so the kennel cough germs persist in the kennels. However they vaccinate the puppies against parvovirus as they have had suffered heavy losses for not doing it. So, most puppies sold in Singapore are immune to parvoviral infections causing severe diarrhoea and vomiting. And deaths."

2. "But the puppy had no cough when we brought her home for the first 3 days," the daughter said. "Many breeders gave the puppy cough mixtures and medication and so the cough was suppressed for the first 3 days," I said. "If the breeder said that the puppy for sale has coughing, the owner will not buy him. So, it is difficult for him to be honest. In your case, the puppy is 3 months old and is stronger and so the kennel cough should not be a big problem. Those puppies at 2 months old suffer more as their immune system may be poorer. Some of them die from pneumonia!"

"The breeder is also selling smaller puppies," the father said. "Size may not be correlated with age," I said.

3. "When should I send my puppy for the 3rd vaccination?" the father had e-mailed me later.
This depends on how fast the puppy recovers. As a guideline, 7-14 days after the puppy has stopped coughing.

Educational Video: Kennel Cough in Puppies produced by two St Andrews' Sec 3
students in collaboration with Dr Sing
I was surprised to meet a busy multinational company employee father and his daughter in junior college and her cousin. Singapore is too small for international corporations to survive if they focus on Singapore for business. Previously, Caucasian expats were employed for regional positions but now are replaced by locals. Which means a lot of travelling and less time for the family. However, children need money if they study overseas and a salaried employee working in Singapore mainly may not be able to afford overseas education for their children. I am always happy to see a busy father bringing the daughter and puppy to see the vet as the Singapore fathers are usually very busy and delegate the duty to the mother!

Webpage at:

798. Young Adults Face Intense Global Competition

2012-01-01T00:05:00.000-08:00

Dubai - Jan 1, 2012 Winchester Hotel 12.08 am

Many young adults in a free world of abundance like Singapore, live in a virtual world of the smart phone texting and connecting with friends day to day. No responsibilities of adulthood and parenthood.

The years rush by. Time flies. Those young adults who acquire specialised relevant skills after graduation, works hard and is honest, get the good jobs globally as they are useful and indispensible to the employer.

Most of the old guards or senior citizens will never be able to compete in this global world for jobs needing more than a degree from the University and work experience. There is a need for specialised relevant technical experience in many high-paying jobs globally.

Many Singaporean young adults are blessed growing up in abundance in a Singapore, free of wars, natural disasters and crime from the 1950s - 2012 and are unprepared for the shocks of the real world. Many don't bother to learn how to read the financial statements but will punt or accept a friend's advice to invest in some schemes which appear to be Ponzi schemes. For example, buying a gold bar and paying for 20% below market price and getting regular returns above average. Sounds too good to be true and seems to me to be another version of Madoff's US$50 billion ponzi scheme on a small scale.

2012 appears to be another recession caused by the Euro crisis but how many young Singaporean adults can discuss in depth what is the Euro crisis and how it will impact their parents' livelihood, their own job prospects and their country's economy.

797. Travel Stories - Dresden and Berlin

2011-12-31T22:51:00.000-08:00

As the hotels in Dresden and Berlin, Germany don't provide free internet access, I scribbled the following into my laptop and post it today at sunny hot Dubai Winchester Deluxe Hotel Apartment facing the GM on the receptionist table (only one plug here for laptop) at 10.45 am.

Overall, it had been quite a depressing tour - coldness, grey skies and the sadness of Auschwitz in Poland and the Berlin Wall in Germany. I prefer not to visit the "Killing Fields" of Cambodia, the "tunnels" of Vietnam as a person is expected to de-stress not to reflect on man's inhumanity. I had been to another Auschwitz some 40 years ago from London when I was much younger and one visit is enough. There are still atrocities and killings in some countries, even in this modern age and therefore I don't want to pay to see more historical killings.

MY SCRIBBLINGS
It is better to write drafts rather than perfect reports as I don't have much time and if I have to publish only "good English" reports of my work and travels, I will not be able to be productive and will produce 10% of what you read.
Dec 31, 2011 Hotel ABACUS Tierpark Hotel Berlin 4.48 am Singapore time 11.48am
No free wireless even in reception space. In Berlin, I believe that most shops do not provide free wireless, including McDonald's. At Starbucks, one has to go to the Starbucks page and click "connect". If not, no free wireless. It was not automatic. I believe McDonald's has same situation for one hour surfing but I could not get into it "Hotspot".
TWO TIPS. Temperature 4 degree C and lower at night
1. This hotel has steam heating radiators. Don't forget to turn the dial as some of them are switched off and you wake up in a cold room.
2. In one Czech hotel, the maid had not closed the window 100%.. As the curtains were closed, I could not understand at first why the room was cold when I woke up and the thermostat did not seem to function.

Yesterday Dec 30, 2011
Berlin Wall - Guide Yoko - Drizzling
Afternoon - Shop at De Ka Wa. LV still popular. Rarely see Chinese national tourists in Belin today but Caucasian salesgirl could speak Mandarin having been to China for study. Her own sling bag (company staff only, not for sale). .
Dinner - Ming Garden Chinese Restaurant. I slipped when my right foot turned as I stepped on a tapering step downstairs to the Ming Garden Restaurant. One in the group disputed that dinner was in the itinerary as the first night, we had no dinner. Finally, we got Ming Garden and Marcus told us his efforts. He handed us the feedback form during lunch at another Chinese Restaruant. Today Dec 31, 2011, at 5 am we would wake up and leave Berlin at 7 am to drive to the Hamburg airport. Marcus would fly back to Singapore (tiring) and we would be in Dubai for two nights (free? accommodation at hotel). Apparently, a 10-hour flight (stopover in Colombo) instead of a 7-hour flight back to Singapore via Emirates. SIA is more expensive and so Emirates with its "free" stay n Dubai had our business for this East European Tour. Global competition for SIA is increasing as for all Singapore companies. Best Chinese dinner was at Ming Garden. Sweet and sour soup, green veg, pork, tou foo with chilli sauce, fruits (grapefruits, pineapples, oranges, apples). It was quite packed. The operator has some ideas on variety and good cooking.

Be frank and proactive and ask for good grades if you want a good feedback from your customers as Marcus had done so. Also he had served his free tea and home-made chilli. He had been extremely hardworking and entertaining. Not an easy job to handle 18 Singaporeans. He is a free-lancer. I gave him a point "5".in the feedback form sealed in a blue envelope. "You can always steam the envelope and open it," I said to Marcus. "Your company would never know." He also used blue envelopes to give tips to the local guides at 2 euros per tourist. Apparently, local guides (probably Gulliver Travels) are paid 200 euros/hour and so they are employed for half a day only.
Not a Japanese car is seen in Berlin's "Orchard Road." More Mercedes. VW

Dec 29, 2011
Prague to Dresden - Guide Sylvia - great story teller, enthralled group more than other guides. Natural. Examples:
1. A stork statute. I could not take a photo fast enough as the bus drove too fast or I was too slow.
"Stocks carry babies," she asked how many of us knew this. Four hands went up. I knew it too. Sylvia said: "In one tour, a gentleman asked what gender the stocks were," she asked us. We didn't know. "The gentleman said the stock was male," Sylvia said. "Female stocks can't stop talking and talking and would have dropped the babies!" Sexist reply? Sylvia said: "I slapped him real hard on behalf of all women."

2. Audi. Sylvia said that Audi was originally named Horsch. "Nobody could pronounce Hor.." she said in a coughing voice. "I want to buy a Hor..Hor.Haw..Haw." Since it was difficult, the prospective buyer would say "Never mind, give me a Benz!". So the name was changed to Audi which is easy to pronounce.

3. "Be careful, there is a dangerous shop there. Don't let the women go in!" Sylvia said as we crossed the road to more monuments. I was wondering whether the shopkeeper was going to scam us. Some foreign exchange shops in Prague would display a good exchange rate and when you enter, the rates would be different and unfavourable. The group paid attention to a small lit jewellry shop called "Lights" or some similar sound. Sylvia said" "It is dangerous for the men's (wallets) as the women would buy all the things there."

4. One luxury VW car shown by her. I took a picture. 65% are produced and sold to China. VW was profitable in 2011. It has acquired other car brands too and Audi is one of them.

5. FEEDBACK AND COMPLAINTS. Sylvia knows how to address any potential complaints by humour. As Marcus handed over his usual blue envelope of tips to her, she pointed to a gold figure on top of a statue and said that it can hear all complaints about her and report to her as this figure is omnipresent. I doubt anyone would complain about her efforts and humour as you can see from one image I took where she captured the attention and evoked the smiles of 15/19 of the group with her pictures of the history and her condemnation of the politicians who tore down heritage buildings in the recent years. "What was not bombed had been torn down by the politicians," she said. "So Dresden looks very modern and new."

Singaporeans seem to be her group. "You may see me in Singapore if I go there,"she told us. She's an architect and had lived in various cities but lived longer in Dresden. When I asked about the horse carriage tours, she said not to take the tour as the guide will not give accurate tour info. A man and a boy was playing an instrument on the road side. "Gypsies from Romania," she told me. "European Union permits free travel for EU citizens." I asked when she said hello to a big man at a stall: "Is the man selling mineral stones a gypsy?" She said: "No."

An image of Sylvia is posted for readers. You can learn much from Sylvia in your working life.

"Be passionate in your work" by research and know how to present in an entertaining relevant manner. The customer can sense or at least smile when you lecture on the dull historical facts. For example, "Ladies will like this handsome king..." We remember her and her presentation in our images and mine and none of the historical kings of Prussia etc. We had a fun time.

You can see my tour manager Marcos also listening to her stories. I was taking pictures as there was no time and did not appear in the picture. Another couple and one other Singaporean were wandering off taking pictures. That is why there were 15/19.

An image of a tour dog. Another tour guide with Caucasian tourists. Asian and Singapore tourists seldom are interested in European history, kings and queens. More into shopping and more shopping. So, the European tour guide may need to entertain rather than inform because arts and culture is not part of the Asian culture compared to the general Europeans and Americans, in my opinion.

796. Travel Stories - First Impressions Count

2011-12-31T22:34:00.000-08:00

7am Abacus tierpark hotel to Hamburg airport to Dubai.

WHAT MAKES THIS HOTEL SUCESSFUL AS A BUSINESS?

Abascus TierPark Hotel, Berlin, Away from downtown, Near Zoo. Has theme of animals e.g. dining table has a wooden elephant. Big framed close up of a cock, fish, fruits on walls.

1. First impressions of reception and dining room shows a well managed hotel.
2. Affordable to tour agencies. Top in travel tour gp revenue in Berlin? Least costly 4-star hotel for Gulliver and other travel agencies apparently.
Rates 99e single 120e double for walk in clustomers
3. Free car parking.
Free Independent Travellers around 30% estimated. Free car parking. Weekend v high occupancy tour gp (Europeans mainly).

4. Provides 8 lots for coach parking. Max 400 tourists if all 8 coaches come. Hotel has only 300 rooms and therefore occupancy rates can be 100%.
Hard to find free car park lots in Berlin and this is probably its selling point.

5. "A" introduced. ABACUS Tierpark Hotel. I noted that the neon sign shows only Tierpark. Therefore ABACUS must be a later addition to the name. "A" is top of phone listing advantage. Has a real abascus displayed at reception but hotel owner is not Chinese. "Abascus" is just for top listing

6. Robust revenue is dependent on buoyant tourist economy. Berlin's downtown and Brandenburg gate appeared to be full of Caucasian tourists in the time I was there. Long queue outside Madam Tussard Wax Museum.

7. Privately owned

OTHERS
No free internet access Around 50% of Berlin hotels do not provide free internet access
Zoo theme
bedroom 2 single beds slide towards each other to form a double bed. One of the beds creak and squeak. No maintenance check as the Winchester Hotel in Dubai has good beds, mattresses and two solid pillows. European hotels provide one thin pillow and soft mattresses in general or is it the quality of hotels selected by EU tours? What to expect for packaged tourists on a lean budget?
Mainly Netherland tourists for this hotel.

TIPS
1. Temp around 4 deg C. Can be quite cold inside the room

Steam heating in this hotel. Must check as the setting in room and bathroom. The setting may be zero and the room is cold. Setting no. 5 means a hot room.

Ensure windows are properly shut or cold air comes in.

Berlin has >1 million tourists a day according to desk manager and low unemployment rate of 7% (Dresden 17%).

NO English brochures for guest - Not interested in English-speaking or Asian groups as Europeans form main clientele
Free n lots car park spaces unlike Berlin's other hotels

795. Putting bare feet or legs onto the coffee table

2011-12-28T23:09:00.000-08:00

When I was working for the Singapore Turf Club, there came an older Australian vet who was appointed the Chief Vet when the Club was taken over and renamed the Bukit Turf Club.

One day, we had a meeting with the young newly recruited management committee of the newly formed Bukit Turf Club to talk about the Veterinary Department. He asked us to sit down and he placed his legs onto the coffee table. The others felt uncomfotable and some commented about this unusual behaviour. Do all Australians do that? I don't know.

Is it good manners to sit around the sofa set and you, the Chief Vet put your boots and legs to rest on the coffee table? I don't do it and I don't want any of my employees to do it as I don't think it is becoming of a vet or the manager. Sometimes, the young people do it without realising that it is not good.

794. Travel Stories - Vet stories

2011-12-28T22:59:00.000-08:00

Dec 29, 2011 Hotel Duo wireless area near reception, 7.40 am
Free wireless only at the reception area, not in rooms or even dining areas on 2nd level. The past days, my 5th floor room and another one had the smell of sewerage, as if there was a leak somewhere in the toilet. The smell disappeared later. From my experience in seeing the Sewerage truck coming to Toa Payoh outside my surgery to suck out the sewerage material, the smell was almost identical. This hotel is popular with Japanese and other Asians and boast gym, bowling ally, pool and casino and so is of a higher standard. I can't understand why there is this sewerage smell inside the bedroom on a 5th floor! Luckily, today Dec 29 morning, I would be leaving for Dresden, Germany. That smell is bad.

Yesterday, the others went to another shopping mall and then another one called Venezula Square with its boutiques from 10am to 6 pm. A free and easy day and so Marcus recommended this shopping as the group was not keen on another heritage castle some 3-hour drive away. Sick of castles, church and shopping.

Fortunately for me, I went with Daniel to the Jest ski resort. He was skiing. Patches of snow below the hill, due to global warming. On driving to the top, there was a sudden blast of air or wind. Visibility was 1 metre in front. Temperature was below zero. Was this man-made machine whipping up artificial snow or was it nature? I went into the tower to hide.

The resort was not open fully. Only a small lane was open for skiers. Some bumpy areas. A snowboarder hit Daniel and broke his ski. It was not fun skiing in such an area. So, at 1.30 pm, after the ghoulash steak lunch, the guide Katrina drove us back to Prague. I asked to meet her boyfriend Dr Tomas Stastny who does voluntary cat welfare work 3 evenings a week. "His practice is a small one. Not those with lots of equipment," she said.

"It is not the practice that is full of modern equipment that I will want to see," I said. "It is to know more about how the vet works in Prague."

"There are only 5 vet surgeries in Prague," Katrina said. "It is very expensive to buy equipment to set up a practice. There are 180 vets. For 2 million people." Katrina worked with international tourist and so her conversational English is good. Daniel said: "She means that there are only 5 vet hospitals in Prague."

Her boyfriend's practice is in a farm area. The town centre with the church (see image), the big land of farms and the row of shop houses remind me of James Herriot's practice some 50 years ago. I studied in Glasgow Univ in 1969 and had visited Thirsk, a village mentioned in James Herriot's novels. Katrina and Tomas are fans of James Herriot too and his Yorkshire vet stories must have been translated to Czech. Tomas' practice is located in similar farmland countryside small village as you can see from some pictures. His 12-year-old son wants to be a journalist and he could write stories of the stray cats and patients of Tomas if this young man can be motivated to do so.

Some pictures are shown:

792. Travel Stories - Prague Castle and another Christmas Market Fair

2011-12-27T23:03:00.000-08:00

Dec 28, 2011 Hotel Duo 7.50am Singapore time 2.59pm

Yesterday, another city tour, mainly Prague Castle and the churches. Christmas Market Fair and shopping in the afternoon. I am quite sick of this itinerary of shopping. But I had a chance to do street photography of the tourists. Only 3 are interesting to viewers and are as follows:

I like the "gray" colour theme of the distinguished gentleman with his gray poodle in similar stance and profile. His lady friend is also dressed in gray coat. There is a market square tower and when the clock chimes at the hour, the two windows open and some figures can be seen. A trumpeter will blow his trumpet! This seem to attract the crowd. A concert was shown for children too. Overall, this Christmas market fair is the most varied. Horse rides, concert, vintage car rides, hop on tours and lots of stalls. It seems that the food stalls do brisk business. The others are suffering.

791. Travel Stoires - Salt mines and Death camp Auschwitz I in Poland

2011-12-27T22:50:00.000-08:00

Dec 27 2011 hotel duo Praque 3 nights 8.45am

Yesterday visited poland's salt mines n Auschwitz.

Hotel duo is busy but one male reception staff has poor service in telling me that there are 650 rooms n guests keep their laptops inside their rooms. Previous hotels permit me to accommodate my laptop with reception. Hotel Duo is near subway warm bathroom tiled floor. Surprisingly no free Internet access in rooms. Young adults congregate near reception to use their smart phones as free wi fi is only present in this small area

OBSERVATION. When a business is big and busy, service is bound to be poorer. Other hotels in Austria and Budagpest, before I came to Prague provide free wireless internet in the rooms for the smart phone and there is one desktop for free internet access.

In Hotel Duo, I have to pay for the desktop or use the free wireless only near the reception area. The staff was quite abrupt

OBSERVATION. PLAN B. After walking over 300 steps deep into the salt mine, we were told that we just needed to go back to the earth surface by the lift. The electrician was busy repairing the lifts. So, there was Plan B -the old lifts probably used by the miners. Small ones. The two doors could only open inwards and so it was fun. Emergencies do happen and Plans B and C must be in place, unlike the SMRT subway breakdown in Singapore recently. Obviously, no Plan B had been thought out and there was widespread panic.

PACKAGED TOUR'S HIDDEN COSTS
Told Marcus I do not want to pay n take 3 hours coach to the countryside to see another castle tomorrow free n easy. The ladies warmed to his new found big shopping mall to shop till they drop tomorrow.

I prefer to take a 50-min subway ride to ski resort tomorrow. Global warming may have no snow. I can't stand seeing more branded shops like Zara as I don't shop and it can be cold. Too much "free and easy" from this travel agency adds up to the hidden cost

Morning guided tour of castle church christmas market which has good ideas to make money. Vintage car rides horse n carriage children buy pellets to feed n pat goat sheep lamb kids donkey n miniature horse.
Sausage n food stalls v busy
2to5pm at this market sq then walk 30min to dinner place as coach not permitted into this area pollution

790. Travel Stories - Day 6 Kracow, Poland

2011-12-25T17:34:00.000-08:00

Dec 26, 2011 Kracow Poland 1.56 am Singapore time 8.58 am

Spent whole day in Kracow, Poland.
Gregory, a M.A degree tour guide provided a morning city tour with lots of history about Kracow and the Jews being sent away by during World War Two. Some old houses had been kept for the owners by the Polish Government are unrenovated as no owners had come to claim them. In Summer, over 20,000 tourists but now, not many. 8 Jewish synagogues, empty chairs as monuments of the War seen. In Budapest, along the Danube River bank, I saw the metallic shoes representing those Jews shot and pushed into the river during World War Two. Castles and churches again. Then to Christmas Market. Lots of history given by this guide. "Short but can really walk fast," one Singapore lady told me as this man in his 30s would walk so fast that none of us could be near him whenever he had to proceed to another spot to gather us to explain the history. I had not thought of why short people can't be fast pacers.

After lunch at the same restaurant, I asked the guide that I would prefer not to stay another 3 hours in the chilly air of zero degree C at the Christmas market. 14 Singaporeans elected to go back to the fair and then being picked up at 5 pm for dinner at China Palace. "The reason we can't have dinner at Hotel Sympozium is that the guide and driver will not be given free dinners unlike at China Palace," Marcos the tour manager told us."I hope you understand. The other group from 5-star you saw having dinner there yesterday paid themselves."

I had offered to stay in the hotel in the afternoon and pay for my dinner in this hotel. I was sick of walking around closed shops and watching another Christmas market stalls again. It is like walking around Orchard Road with shops closed for 3 hours in freezing cold. "Why not pack fried rice back for us, like you did for the driver?" the wife of the management consultant said. This middle-aged couple also did not want more wandering. For me, I had something to do - street photography. Otherwise I would be most bored to death listening to history of Poland for 4 hours.

Krakow's Market Square is the focal point for all tourists. Horse-drawn carriages, vendors of sausages, flowers etc on this Christmas Day. Mostly tourists were seen, as locals would stay at home on Christmas Day. A pigeon-feeder was seen, likely to be a local senior citizen.

I had gone to a McDonald for a warm cup of coffee at around 11.30 am with the guide and Marcos. This McDonald was the only one open (by law, only 3-employee shops and self-owned shops are allowed to open on Christmas Day. Even Tesco supermarket that opens 24 hours was closed on Christmas Eve and Day). It had a metallic gold "M" logo outside the entrance. A famous 136-year-old hotel cafe was open too. A few hundred tourists, mainly Caucasians at the Christmas Market seen. One man juggled balls with his body to get paid in coins. Another man dressed like a Ghenkis Khan statue moved when coins are dropped into his bowl in front of him. Horse and carriage for tourists seen. More famous old churches and different styles of architecture but it seemed that none of us were interested in the details.

So, my afternoon was spent in the hotel to catch up with jet lag. In this tour, the group stayed 2 nights in the same hotel. So, less rushing and packing. The group also had 18 tourists unlike last December's tour of Western Europe when there were 40 tourists crammed in tight seats of the coach. So, nowadays, many of us could sit by ourselves as there were more seats available. Four couples would sit together - a newly wed and two senior citizens.

iPhone does not seem to work in Kracow's Hotel Symposium. A free internet access is for laptops. Got a phone line from the hotel to connect. The young men Dan and Jason knew how to create a "hotspot" via Internet Explorer in the laptop and used the laptop as a router for their iPhones. Still, at certain times, they could not access the internet while the laptop was OK. "There should be no reason for this failure to access the internet," Dan told me when I said that the hotel could be using software to prevent signals going to the iPhone from the laptop so as to secure payment for wireless use by iphones. "After all, the hotspot is inside your laptop and it is accessing the internet."

I was thinking of the Allies jamming the direction of aircraft missles by releasing some bright metallic things when missles are fired at the aircraft. So, iphones could be jammed intermittently.

Now it is 2.29 am. I tapped my iphone 4 for access to www.asiaone.com.sg which I could read about the Singaporean couple being mugged in JB and the Orchard Road flooding. The "Cannot Open Page. Data Roaming is turned off" appeared on the screen. Why can't the iphone access the hotspot which was created again by the young men? I would not know. Something to do with iphone 4's technical aspects I would think. At night, I don't want to go out to Tesco even if it is opened just in case 5 men appeared suddenly to mug me, as happened to the Singaporean couple in JB. The world has become much less safe nowadays with many people preferring to rob rather than to work and the police being under-staffed while the politicians of democratic countries try to govern the country by giving goodies to the citizens to win their votes.

Enough of kings and queens, churchs, shopping malls for branded goods and Christmas Markets in Vienna, Budapest and Kracow and the cold winter air. I did not have runny nose today unlike in Budapest's Christmas Market yesterday. Why no cold air rhinitis? I do not know.

I will be visiting the salt mines today. Got to get up at 6 am and have breakfast at 6.30 am.

789. Travel Stories - 2 veterinary stories of Singapore travellers during tour

2011-12-24T22:51:00.000-08:00

Dec 25, 2011

Some travellers have dogs and so this is always an interesting topic when they meet a vet to share their stories.

STORY 1. An inexperienced or unscrupulous vet in Singapore?
"I feel that I had been taken for a ride," the 39-year-old man recently married said. "I paid $500 for 5 X-rays. After the X-rays, my dog no longer suffers from pain in his lower chest (sternum)."

"X-rays are costly," I said. "Why was there a need for 5 X-rays?"
"2 x-rays of the neck, 2 of the chest and one of the front legs."
"Why did you consult the vet?"

"The Golden Retriever cried when I carried him," he said. We brought him to X (an old practice which seems to be the first choice of first-timer dog owners).
"Where's the pain and how old is the Golden Retriever?" I asked.
"I don't know. He is one year old."
Later I asked Daniel. He said that the vet could be inexperienced rather than being unscrupulous in trying to maximise profits, this being a young vet. It is very difficult for vets. However, deep palpation and manipulation of the joints would have located the source of pain. In most cases, it would be traumatic injury on the sternal area (dog cries when lifted up by the 'chest'". The anti-inflam worked as the dog was no more painful "after the X-rays".

To this dog owner, $500 was too much to pay. All depends on communications. I had one paralysed Shih Tzu with the left eye pupils dilated and right eye pupil constricted when bright light was shone, treated by two vets (stories written earlier). "Did the vet advise X-ray of the neck and brain?" I asked the owner. "This could be a case involving the brain and neck causing the dog to be paralysed on 2 back legs and one front leg." The owners said: "The vets asked whether we wanted X-rays and MRI. How do we know as we are not vets!" In this case, X-rays of the brain and neck needed to be done. The back spinal X-rays were done too. CSF fluid could be tapped to check for meningitis but since the dog had been on painkillers and treatment by the previous 2 vets, including acupuncture and herbal drugs, I did not do it. The dog recovered by not being recumbent and was able to stand up while it was given a steroid injection. "Pug encephalitis?" or the GME? More reviews needed.

STORY 2
"My son is the real owner," the slim man in his 50s told me when he asked me where my practice was located and why his Golden Retriever had a bad smell. Marcos called him "uncle". Marcos is 45 years old and "uncle" means somebody older than him. "Don't call me uncle," he told Marcos who tended to call another woman "auntie."

"OK," he said. "Brother", he said to the man with the Golden Retriever.
"Just call her little sister (in Chinese) instead of auntie," I tried to joke. The older woman did not like to be called little sister. "Big sister (in Chinese, there is a different name for the two group" was OK with her.

"How old is the Golden Retriever and has it ever been treated for dental or ear infections?" I asked. "Not in his 7 years of living," the management consultant said to me. I asked him to make an appointment. Once I saw him writing on a pad. "Write my good ideas as they come," he said. "Good idea," I said. "Some wrirting books advise putting a writing pad and pen beside the bed when you sleep, and write down the ideas when they come forth during your sleep. I don't know if your wife will approve?"

788. Travel Stories - Day 5. Slovakia and Poland

2011-12-24T21:19:00.000-08:00

Dec 25, 2011 Sympozium Hotel, Krakrow 6.08am, Singapore time 1.09pm
Yesterday - 6-hour drive to Poland via Slovakia. White snow countryside. Cold.

Lunch at ski resort in Slovakia. Good place for overnight stay said the guide esp. for experience of snow for one afternoon, overnight and next lunch, rather than the usual shopping malls (free and easy) again and again. I had spent two afternoons on two or 3 shopping malls which is a waste of time for me except for some Singaporeans. Life is more than shopping for branded goods which are "slightly cheaper than Singapore." Just a 2-hour stop. I could see the ski schools, ski chairs, snowboarding, ski crafts and even "Husky" dog sledges for rides

Only 18 Singaporean tourists in this tour. I saw Chan Brothers and MAsia tour groups at Budapests. Around 18 people. No children. "Quite boring," said one lecturer as compared to last year 40 Singaporeans in Italy-Switzerland-France tour. One 5-star tour group arrived one day ahead of us. I saw the young man whose money was stolen in Vienna. He is OK now. He just had dinner at Hotel Sympozium and highly recommended the hotel's mushroom soup, beetroot (pinkish) and salmon. All restaurants are closed and our guide said we needed to eat 3 meals at the Chinese restaurant China Palace. The dinner in this China Palace was bad. Red snapper fish was not fresh, cooked in sauce. I avoided it. Singaporeans have a much higher standard of fresh fish.

787. Travel Stories - Day 4 Budapest

2011-12-23T21:11:00.000-08:00

Dec 24,20ll Budapest Mercure Hotel, 5.51 am Singapore time 12.51 pm

Just heard from BBC News in hotel that a British man who toured Costa Rica had been missing for months and his family could not find him. Crime against tourists seem to be common as a Singaporean also disappeared in Greece recently.

YESTERDAY'S SUMMARY
Overnight at Budapest
Chilly. Snow flakes at 7 pm but no snow.
Morning - Erica, tour guide showed us a castle, church and briefed us on one-hour Danube River cruise and another church, souvenir stall. Too many Church visits for me but inevitable when doing a packaged tour to Europe.

Lunch at a busy Taiwan-operated restaurant in a good district. Some Hungarian name and Western old British Jane Austen-type paintings on curved ceilings. Quite good food although I did not eat the 3-layered fatty pork belly meat whole at my age. Young man Dan ate two pieces. I ate the meat part and left the skin and belly fat. Different dishes from previous Chinese restaurant but Chinese cabbage (easy to store long) and oranges are common with the two restaurants. Very salty braised fish - I did not like it. More salty than salted fish but excessively salty food is a common thing in Budapest.

Cycling lane again and we were advised not to stand on the lane.

Afternoon 2.30 to 5 pm. Shopping district and Christmas market. The salt-mine was closed and therefore cancelled. I have enough of mines but Dan was looking forward to it. This showed he has interest in nature. I prefer salt mines to another round of shopping as I don't shop for designer clothes. In any case, Singapore has most of the brands. So, I walked around and see the locals. They seem to like the sausages, pork chops. I noted a senior man standing at a shop like Zara and H&M entrance looking at a monitor. He was viewing the CCTV for shop lifters. This is good practice not found in Singapore as security is hidden somewhere.

Christmas market. A few hundred stalls. Food seem to have most customers. Sales seem difficult for those selling porcelain mugs and ornamental things and some other goods.

Two "statutes" of two men. One in dark brown and one in snow white would stand like statutes and move when money is dropped onto the box. With my runny nose in this cold weather, around zero degrees C, I can't last 5 minutes but these two men can stand for at least one hour. Shoppers do drop coins. One group of youths sang choirs outside Zara for more than one hour. They get some coins from the public.

Dinner. Walk to a restaurant. Pork chops. Some of us cannot eat beef stew. Dance

786. Travel Stories - Day 3 Vienna to Budapest

2011-12-22T18:25:00.000-08:00

Friday Dec 23, 2011 1.50am Mercure Hotel, near train station, Budapest
Singapore time 8.50 am

CHURCH
Yesterday, I was in Eastern Austria and visited a church where one young monk had made a youtube of the monks' chant viral, tying up with Sony to market to the world in large numbers. Visiting Europe means visiting churches as a tourist attraction. The 18 members of my tour group in general seem more interested in photo-taking. I entered the chapel and attempted again taking photos of the Christ and chapel mosaics together, with little success. A lady in her late 50s was using her new Canon camera and did not succeed in taking any good picture. "My hands are shaking," she said. She was a novice with a 18mm to 200 mm Canon lens and did not know how to use it. It was not possible to take the whole image of the inside of the chapel by hand. I told her to rest the camera on the gate's bars. Still she had poor focussed images. The priest came to open the gate and admitted two young ladies. He smiled at us tourists. "A good picture is one with the priest and his believers as compared to an empty chapel," I said to the two Buddhists. "Frame the picture and increase the ISO to 1600 instead of using 200 in this dark place." She got some good pictures. Point and shoot cameras are easy to use but do not produce the sharpness.

The guide Gertrude was hired by the E.U. Tours for the morning only. She was excellent in relating stories of the church (majority of Austrians are Roman Catholics), later showing a church with a wall painting of a saint for travellers' safety (usually present at road junctions in Austria), the underground mines where the Red Army or Hitler used to make aircraft, Saint Barbara shrine where all miners used to light a candle before entering the dangerous mines, the horse stable where all working horses were blinded to prevent them being shocked by flashes of lighting inside the mine. The air was cool and fresh inside this mine.

LUNCH CROWD
A Chinese restaurant called Mandarin for lunch was packed unlike the Sapporo Inn and Restaurant Chinatown yesterday. Why? It is the same with some doctors' or vets' clinics being packed and the nearby competitor being empty.

DESIGNER OUTLET IN VIENNA - Lots of "brands"
After lunch, we had one hour at a Designer Outlet which was insufficient for some ladies. "All goods are made in China" one Malay tourist said. "I had to compare the prices and need time to try. The most stressful shopping I had." I spent my time taking pictures of the shoppers and the windmills as there was good sunshine. "Will there by LV?" I asked Marcus when he mentioned the brand names like Reebok and others but omitted LV which is a big thing in Paris' Galeries Lafeyette shopping mall and which I witnessed seeing the Singapore ladies of my tour group last December, queing up like pilgrims to enter the shop as prices are cheaper than in Singapore. "No,"he replied. "LV is too high class to be in this location." POSITIONING is one aspect of the 4 Ps of marketing and LV definitely wants to position itself as high class and will not be in factory outlets like Mango. There was no ZARA but a SARAH in this fully packed car park designer outlet on Dec 22, 2011. Mainly Caucasians with a few Asian Chinese but there were more empty shops than buyers at this time.

CHRISTMAS MARKET IN VIENNA
Yesterday, she was quite vocal about visiting the shopping mall instead of the Christmas market when our guide Marcus gave an option. "Why not get a vote?" she asked. The silent majority did not say anything. I said: "Why not some go shopping and some go to the Christmas market?" In the end, Marcos was just teasing and decided that it would be the Christmas market after lunch (2 pm to 5 pm) as there would be more shopping malls and outlets in the next few days. This was only Day 3 and he wanted us to experience the Christmas market which was an excellent option.

ACCIDENTS FOR SINGAPOREANS
A few flakes of snow and then all sunshine. One of us slipped and fell on her backside while walking down a slippery iced road to view the "fairy-tale" church later on. Could have died but luckily no worries. In Europe, one has to be careful of iced roads. I fell once on my back in Switzerland last year and survived. There are other who knocked their heads and die.
Last December, a young Singaporean cut his eyebrows as he fell off the sledge downhill but he was OK.

This reminded me of my early years when I permitted my son of around 8 years to ski from the mountain chalet downhill to his ski instructor at the bottom of the hill. He remembered vividly. Just step out the door early at 9 am, put on your skis and with his younger brother, paddled a bit and he was downhill. "How did you manage to get a chalet on the hill?" he asked me yesterday. He is a young adult now. "Well, in those days, I do not book hotels early till I reach the Whistler Mountains. I asked a young Caucasian how to book a hotel and he said he had a time-share. I don't know him at all. He was a stranger I met at Whistler and he booked for me."

"Since his wife was pregnant, he could not use this and asked if I wanted to buy the vacation stay for that Christmas," my wife added. I had forgotten the finer details but I was quite adamant not to book hotels in advance when I travelled in the early years. There was no internet and that would be before 1997 I recall. 1994?

Now I can't imagine Singapore parents permitting 8-year-old and a 10-year-old sons to ski downhill by themselves
as there would be padeophiles and predators. It was 6 days of going out the door and ski downhill bliss for the two young ones I guessed since he could recall vividly. It cost a bomb for the ski lessons if I remember correctly. In retrospect, I was too trusting as that Caucasian could be a con man taking my money for the time-share but he was not dishonest. Nowadays, one cannot trust strangers offering their time-shares portion for sale. More scammers have surfaced as many people prefer to earn a dishonest livelihood.

BUDA AND PEST
"Was Marcos joking about Buda and Pest being two separate cities?" one tour member asked me. "He likes to joke."

"I don't think so," I replied. I do not study the itinerary nor read up on Budapest and so was as ignorant as her. According to Marcos, the area around the Mercure hotel we stay is a safe area. "A lot of homeless people at the railway station and a bit dirty area," he said. "But you can go out at night to see the place after dinner."
In view of the young Singaporean NUS-Duke University medical student who had disappeared and not found (since some 6 months ago), in his going out to some Greek islands by himself, I did not venture into the dark of the night.

BUDA
Dinner was 3 course - salad, salty chicken with golden cheese sauce and pasta pieces and ice-cream. Marcos forgot to tell us about the 250-ml water bottle as being payable and it cost 2.50 Euros. This is poor organisation of E.U holidays as meals usually include water or tea and here, the guide did not let us know early.

HIDDEN COSTS - DANUBE RIVER CRUISE
Singapore's travel agencies try to be competitive with costs and so cut out many necessary tours. "If not, you will be charged $4,000 instead of $3,000" Marcos elaborated in anticipation of complaints. So, in Budapest, he recommended a tour of the Danube River and visit to the salt mines for 85 Euros. This was not in the travel package which just stated a city tour in the morning. If the E.U. management keeps to just a city tour at Budapest and free and easy in the afternoon, after all the way from Singapore, most sophisticated younger Singaporeans will avoid this company. There is something not right with the management. A Danube river cruise should be included as this permitted a view of the city, just as in the Seine River Cruise in Paris.

I can't remember whether E.U. also excluded the Seine River Cruise in Paris last December when I toured with this company too as I usually don't bother reading up the itinerary. It showed the majority of important buildings in Paris including Eiffel Tower and it was snowing flakes, making it a memorable Winter visit.

AGENT'S NAME CARD
In the marketing book, the author always advises to give name cards to customers. I had asked name cards from 3 tour guides recently. One was from Macau and one was from Singapore's ASA travel agency. The latter gave me the ASA calender name-card and her name. Yesterday, Gertrude the Austrian agent came to meet us at the hotel to go to the church. I spoke to her about skiing in Innsbruck and she said she could arrange for it. "Have you got a namecard?" I asked. She went back to the bus to get one. It had her photo of her. This was unusual as Singapore's tour agents don't have photos. In any case, I said to her in front of Marcus: "Singapore tour agents don't give name cards when asked. I expect Marcus to do the same." True enough, Marcus stated: "I don't have namecards." He is a free lancer and you would think that he will give namecards to market himself. But no. His customer was the travel agency bosses who phoned him to lead the tours. So the individual "cheap-skate" packaged tour travellers would have no business for him. Yet, this may be true in 99% of the cases. But that 1% may bring him referrals and businesses for his good services. A namecard costs 0.20 cents and I guess he does not want to waste money on poor prospective clientele like me. Gertrude said to me: "Travel agents who don't give namecards do not want to have to reply to too many complaints!" I said: "Complaints are part of the job in the travel industry. Singaporeans are great complainers and so this explains why Marcus avoids giving namecards! As vets, do we give namecards to every pet owners who consult us? I do not. Well, they do get it from the receptionist counter.

MARKETING TIP FOR VETS
Why not produce a bigger namecard to illustrate surgical approaches or write advices and give to clients? I do produce receipts for writing and giving advices for follow up. If used properly, it can be a great marketing tool as most clients (I presume) keep the receipts, but my associate vets do not know how to use it correctly!

It is 3.10 am now. So far, the two hotels I stayed for 2 nights each, gave free internet access. Great for the young ones with iPhones as they don't need the laptop to connect with their friends and could just thumb away their text. I write on this laptop which can be quite a heavy burden. Julia wanted me to store it inside the coach storage with other luggage. I did it last December. The computer did not malfunction although the temperature was below zero and freezing. But this December, I carry it along as I don't want to test my luck as this is my work tool to type and to store images from my camera daily via this laptop. The temperature is 4 degree C or lower.

IS IT POSSIBLE TO DOWNLOAD FROM THE CANON CAMERA DIRECT TO THE TWO PORTABLE HARD DISKS? I have not thought of this method. Lots of new things to learn and this takes so much time. There is just insufficient time in a day and I hope to focus on the important things but new technology, like the iphone demands time to learn. Now I can see why most young people cruise along in life with just their smart phone instead of using more advanced cameras. They just don't have time and patience to learn the software. Just click and shoot with the iphone and get good pictures in general.

Will sign off now at 3.25 am which is 10.25 am in Singapore. Only BBC in Buda. Must pay for English TV programmes. So, watch your movie videos on the wireless iphone, my elder son advised yesterday. I don't bother with small screens. I will read my crime story book or just do nothing till breakfast.

CYCLING AND PEDESTRIAN PAVEMENTPATHS ARE MARKED AND DIVIDED BY TWO
As there is no such demarcation in Singapore, cyclists here tend to get quite angry at our Singaporean tourists walking along the whole width of the pavement as the cyclist has to slow down or detour!

WIND MILLS and factories with pipings and hot steam or gases sprouting out of chimmneys seem to predominate in Vienna's outskirts. Greenhouses and farmland seen too. Good for picture taking.

DOG WALKING
Seen quite a few dogs being walked. A tan and black Sharpei said to be a rare colour. My best picture of a few hundred for the first 3 days in Austria and Dubai is posted here

Tip: Street photography. Focus on eyes. Zoom lens. One shot only. No second chance. Your hand must be steady.

785. Travel Stories - Day 2 - Vienna

2011-12-21T21:05:00.000-08:00

Dec 22, 2011 5.38 am Hotel Bosei Singapore time 12.38pm

Yesterday, the morning was spent touring the Summer Palace and as I had studied European history in my school days of the 1960s, I could appreciate the history of the Austrian kings and their families. After lunch at Sapporo Restaurant (run by Chinese Nationals), whole afternoon wandering around the area - market place, Parliament house. Wanted to drink coffee at 4 pm at the famous cafe where S.Freud wrote his book but it was full house. For dinner, Restaurant Chinatown. Guide Marcus could not locate the place earlier, so some walking around and losing him. "Same braised pork knuckle, vegetables and oranges as for lunch, but we had fish, prawns." The restaurant had buffet BBQ meat and oysters but not one customer while we ate. Same with the lunch at noon in Sapporo restaurant. Could it be the Euro crisis and recession?

He had initiative, bringing his home made chilli and making tea for us at his own expense. Able to joke and converse in any topic - important attributes of a guide.

Austrian guide told me that this was the warmest winter - climate change as there ought to be snow from November. Not a flake of snow. "What's the lowest temperature?" I asked. "Minus 15 deg C," she said it was some years ago after 2006 when she started work, after having been with Austrian Airlines in Singapore (office closed now).

"The snow was ankle-deep," she showed me her shoes. "The Malaysian tourists s could not walk through the snow in this garden to see this golden Mozart statute as they had no boots. They asked to buy boots but it was a Sunday and all shops were closed. So, they " In Vienna, shops close early apparently.

For this second day in Vienna, the temperature was around 5 degrees C. Bright sunshine. The bus driver was late (traffic jam) as I waited outside with a Salem-smoking couple, appreciating the chilly air. A police car arrived. Two Singapoerans from the 5-star tour had their cash stolen from their rooms at around 7 pm while they were having breakfast and they had to make a police report to claim insurance. So they would hitch a ride from us of E.U. Tours to the Summer Palace as our driver was late.

The young man with central elevated hair and two balded sides was quite mad as he had lost over 1,000 Euros, 500 US dollars and 2 Sing dollars as well as his keys to the luggage. His room was further in while mine was near the escalator. I recalled having seen a trolley used for house-keeping by maids when I left my room 406 at 7.30 am for breakfast and was puzzled. No maids around but Daniel said he saw two men, one in pony-tail. The policemen came and took some statements and left without interviewing any one of us. "It is an insider job, if you ask me," the be-spectacled young man said to me and the smoking couple outside the hotel entrance. "The receptionist would view the cameras and know I had left the room. Then the thieves would enter my room and took the cash." His credit cards and wallet were left untouched. An older Singaporean in his late 50s in another room nearby also had lost his cash and had initially not wanted to report to the police.

"Is there any CCTV in this hotel?" I could not see any bulbs or cameras in the corridors. I still don't know. I doubt it.

There was a note on the writing table informing guests not to leave valuables in the room but in the room safe or hotel safe free of charge. Singaporeans need to know that there is another world where people make a living out of stealing or scamming and therefore need not be employees even in developed countries like France and now Austria.

Will go to Budapest today. Had some phelgm of yellowish colour. Cold air affected throat and cause upper respiratory tract infection. Must keep warm or get pneumonia and die. Take health seriously.

Punctuality is not the strength in Eastern Europe apparently. Salty food and pork are the main things.

784. Dec 21, 2011 Austria

2011-12-20T20:52:00.000-08:00

Dec 20, 2011
7 hours flight from Singapore to Dubai
7 hours flight from Dubai to Vienna

Compared to Dec 2010 when I also flew Emirates to Dubai, this year, the Dubai Airport looked subdued in lighting by 50% at 6.30 am. Not so bright. The Christmas trees were not decorated or lit. Lesson to be learnt.

1. Changes is the constant in life. Last year, Dubai airport must be at its top. Then it had to cut cost.

2. Free breakfast. Big place in the upper floor last year with choices of fruits, cakes and meat. This year, coupons to 3 cafes. I went to "Thai Express" with the coupon. A plate of rice with veg curry and one fried pop piah and one bottle of water.

3. Airport crowd. Less crowded but the Emirate plane from Singapore is still full of passengers as in last year, at around 100% full in economy class.

783. 782. Last day of work - Dec 19, 2011 - Part 2

2011-12-20T20:38:00.000-08:00

"First impressions count a lot," I had gathered Dr Vanessa, Min, Intern Mr Lim and Administrative Executive Nicole at around 12 noon on Dec 19, 2011 before I went on leave this evening.

I sat on one side of the consultation table facing 4 of them and the main door. Since this was a very small room of 8 sq me, all 5 of us filled up the space. I prefer not to hold such management and performance meetings as I usually speak one-to-one but each internet employee has his own mind and personality and sometimes do not comply with instructions. Early Min was clicking his pen obsessively while I spoke one-to-one with him about his performance. "Stop clicking your pen," I said. "You may think that you can always go back to Yangon and get a job at a vet practice. Maybe US$500 a month but with not many variety and interesting cases to give you the hands-on experiences. Let's say you prefer not to work. One month finishes very fast and you get no income. If you want to start your own practice like Dr Saw who had worked for me for 3 years, you do not really have sufficient experience to be a good vet. Here, you learn from me as do teach you, especially in anaesthesia and surgery. No other vets will want to waste time teaching you.

"You also can see the cases of Dr Vanessa and Dr Jason. In a small practice like Toa Payoh Vets, you have lots to do. Unlike X (a famous practice), where you will be given one thing to do. For example, you will do ultrasound and lab test or you just do past mid-night assisting the vet. At the end of one year, you are only good in ultrasound and nothing else. Vet practice is much more than that, as you can see, if you want to open your own practice in Yangon.

"Of course, if you don't follow instructions, you get scoldings. You are not the only one 'scolded' for poor or lack of performances. When you needed a job, you phoned the agent daily enquiring about a job at Toa Payoh Vets.

"Now, you have a job but you start comparing to what others do in other clinics. Just complete the one-year contract and look for better employers," I said. "Just give me 2 months' notice like Dr Saw and we part amicably and happily." Myanmar vet graduates can't converse well in English and are seldom in demand compared to Filipinos whose command of English and service are top notch. I don't take Filipinos as this is part of my philosophy of 'making a difference' by mentoring Myanmar vets. It is a great disadvantage as regards poor service and interaction with clients as Singaporeans can't understand Myanmarese English. But this is part and parcel of my community service. Just like employing old man James till he was hunched double and could not work anymore. It is not that I can't afford to employ younger and smarter office assistants. It is part of a philosophy of giving back since I was a recipient of a Colombo Plan scholarship from the British government to study vet in Glasgow Univ. Every vet can make a small difference in this world and it is up to each vet to do what he can. For me, it is to help the Myanmar vet and Min is the 3rd one. All he needs is to stay one year and there will be other clinics who will pay him much more as Dr Saw was said to be offered $3,000 by Dr Jason Teo who had started his own practice.

Back to my meeting with all 4 today, I covered the topics of office attire, self-respect, initiative, eye contact by the vet with clients and productivity and performance expected of a vet, assistant, intern and employee. All these will make a long story and I will cover one topic - first impressions.

As regards first impressions, I looked under my table to see what footwear all four were wearing. Dr Vanessa had her clogs, a grey blouse and pants, Nicole wore slippers and no collar T-shirt, Intern Lim wore sports shoes and jeans and Min wore normal shoes and jeans.

"This is not your father's clinic," I said to all four. "Or your grandmother's office. I expect common sense as to what to wear to the office as an employee or intern, without me having to spell out the dress code. Clients who see you all dressed casually will think that their pets are also treated casually when they compare to other clinics with uniforms. This is what they think but they will not say it loud.

It has also to do with self-respect if you don't respect others. As a qualified vet, you set an example. Wearing slippers, sandals and clogs to work are not getting you the respect of others. You may not care. Self-respect is hard to define but it includes certain types of behaviour that is expected of a professional vet or employee. As for Min, he wears jeans. It may be because he has few clothing as he comes from Yangon but Mr Lim wearing jeans to the office is not acceptable.

I had to be frank with them. It is hard. "I have better and many things to do than to check on you," I said. "In 2012, I expect common sense and knowing what to do." If not, I will wield the big stick and start firing or replacing people who will not do what is right in the office. Otherwise, Toa Payoh Vets will just go down the drain and cease to exist as more than 50 vet practices will be set up in 2012. Firm leadership and good management is needed to improve business performance and sustainable profitablility. No short cuts. No casual and loose management anymore.

782. Last day of work - Dec 19, 2011 - Part 1

2011-12-20T20:02:00.000-08:00

Wed Dec 21, 2011
Vienna, Hotel Bosei, Austria Trend, Austria
4.40 am
Singapore time 11.40 am

Monday Dec 19, 2011 was a dark thunderstorm day. I was at the office at 9.30 am to review the hospitalisation cases. A tall matronly Caucasian lady in a big SUV parked outside. I had seen her before some 3 days ago as Caucasian clientele form less than 1% of Toa Payoh Vets' practice and so they are outstanding.

"Good morning. Dr Vanessa will be in only after 11.30 am," I said. "Is there anything I can help you with while you wait for her. Has your dog recovered from diarrhoea?"

"Yes," she said. "For the past 4 days, he had not pooped. Shall I use the tube which is for treating people with constipation?"

"Yes,"I said. "Use the enema tube for children. You do know how to use it?"

"Yes," she told me. "You know, after the dog went home after treatment for diarrhoea, he had to go to the toilet so many times at night and past midnight to pee. I was so worried."

"That would be due to urine produced. When Dr Vanessa gave your dog the IV drip, your dog would produce more urine as the IV drip water was filtered by the dog's kidneys."

She said: "Nobody told me to expect this. I was very worried that my dog had to go to the toilet so many times after midnight! Now I am worried that he had not pooped for the past 4 days." Later I spoke to Dr Vanessa who told me that she had received a phone call and had settled the matter with her client.

"Stop the medication that Dr Vanessa gave and the dog should poo," I advised. "What is your dog's reference number so that I can take out his medical record. It is written inside the receipt."

The lady put her handbag on the green cloth of the receptionist table. The ccloth covered a plywood counter as the glass pane had cracked and Dr Teo had got a carpenter to put on plywood. As the plywood looked bad for a vet practice, I covered it with the big green towel. Overall, it was not a good impression unlike other new practices. But I had plans to renovate the receptionist room in 2012 and so the overall impression was not too good. I mean, no receptionist counter has a big green or blue towel covering the top! The clients would not comment but the poor impression was there as you would deduce later from this Caucasian lady's comments to me.

The lady digged deep into her bag and produced two veterinary receipts of another practice. Lots of things inside a lady's big bag. "I am sorry I can't find Dr Vanessa's receipt," she said.

I don't comment on seeing receipts of other practices as doctor-hopping is not uncommon in Singapore as this would be inconsiderate. Out of the blue, the lady said: "I use to go to X (name of a famous practice) for many years. It is nicer and has many equipment and doctors. But I prefer the services of Dr Vanessa." I deduce that Toa Payoh Vets need some more painting and repair. It is just not practical to rebuild again as the Surgery has to close for 2 months. In any case, a nice veterinary clinic is like a beauty without brains. The brains are that of the veterinary surgeon who must know what to do and arrive at a correct diagnosis and good clinical outcome. The brains are more important than the physical appearance but that does not mean that tthe practice is like a bombed out dirty place. Toa Payoh Vets need another consultation room and a new receptionist area and this takes time to plan as the space of 60 sq m is very small for dogs that need hospitalisation after surgery, unlike some newer parental financed practices which renovate at over $500,000.

A famous practice with vets that cannot meet the higher expectations of some clients like this European lady would lose such clients to the newer clinics and others. However, since Singaporeans are impressed by brand name (see my conversation with the taxi driver below), a famous established practice will unlikely close down unless it is poorly managed.

In the evening, I got a cab to go to the Changi Airport for my European travel. The taxi driver of around 60 years old was quite chatty and asked Daniel what job he was doing. On hearing that Daniel had graduated as a vet, he spoke about his old dog that his daughter had adopted and now he had to care for it. "The dog is famous amongst the senior vets in X," he said. "I spent $3,000 to fix his broken jaw. Recently he went to another branch of X for passing urine many times. All tests were done. I got some medication for two weeks. But my dog still cannot control his urine. It must be old age," he concluded.

"He will need to be reviewed again," I said softly. He was not interested in listening to outside vets and so I let it be. Unlike the European lady, this taxi-driver would not seek another opinion other than the brand name and this is why I say that brand name still pulls in clientele. But performance counts in the end. A beauty without brains is no good for the dog if the owner is sophisticated to know what to do and to seek a second, third or foureth opinion rather than going for the brand name mindlessly."

781. The year 2012 will be difficult for vet practices and other businesses - Analytics

2011-12-18T17:17:00.000-08:00

Some signs of economic recession amongst the pet owners in Singapore. Vet practices are still businesses that need to be profitable despite lofty ideals of animal care and welfare. If the practice can't make money to pay its staff and renovate and buy new equipment, it just does not exist anymore. I note that young employee vets do not have basic financial knowledge and the balance sheet.

Young employee vets who don't have to worry about the bottom-line will need to be properly assessed as regards their work performance and client outcomes. If the practice's business performance in a lull period is poor, young employee vets and staff will be out of jobs too as they become a liability.

ANALYTICS
The owner of vet practice needs to use analytics to make sense of large amounts of data from customers and business partners and social media like Facebook. If he knows what to do, he can improve business performance.

1. Highlight often-used products and services
2. Identify which market segment is growing and worth focusing on sales
3. Sales and marketing department to identify new customers, imp0rove cost control and increase sales
4. Banks to identify fraudsters - Vets to identify non-paying clients
5. Brand and reputation monitoring
6. Manage risks - credit given to pet shops and breders. Below cost services given by employee vets to breeders who don't bring in any referrals. Just taking advantage of below cost discounted vet services.

As pet owners are likely to spend less in 2012 recession, vet practice owners must use analytics to improve business performance and improve future business outcomes. Not doing it will cause the practice to decline and go into bankruptcy.

780. Dr Sing's spay complications - report by Intern Kim

2011-12-18T15:37:00.000-08:00

A COACHING SPAY SURGERY FOR MY ASSISTANT MR MIN AND INTERN KIM
- CORPUS LUTEUM

On Dec 18, 2011, a fine Sunday morning, I spayed a cat. There were 2 cats that came in for spaying. Normally my cat spays without complications take less than 15 minutues but this cat had some bleeding complications, being pregnant and has the corpus luteum.

Kim, the intern was able to see her first spay done by me. She sees practice on Sundays only whenever she is free. I asked her to write a report as writing can make her learn more. Here is her report (with my amendments in CAPITAL LETTERS):

Cat early pregnancy spay

3kg

Start time: 9.45am (SEDATION GIVEN IM. XYLAZINE 0.15 + KETAMINE 0.6 ML IM)
Start of surgery = SEDATION GIVEN

9.59am
Cut the skin (FIRST INCISION SKIN)

10.02am
Left ovary hooked out

10.07am
Scapel blade was used to cut off left ovary (CUT OFF LEFT OVARIAN LIGAMENTS AFTER LIGATION OF LIGAMENTS AND BV)

10.08am
Front paws were untied and body lifted up, cat started meowing (THE CAT WAS TILTED UPWARDS TO ASSESS THE RIGHT UTERINE HORN EASIER)

10.09am
Right ovary cut out

10.10am
Scapel blade was used to cut off Right ovary

10.13am
Extend incision bleeding (COPIOUS HAEMORRHAGE OBSERVED, USUALLY OMENTAL FAT BLEEDING)

10.16am
Slow breathing observed (I CAN'T FIGURE WHY INTERN KIM WROTE THIS AS CAT WAS UNDER INJECTABLE ANAESTHESIA)

10.17am
Ligate individual uterine twine (UTERINE HORNS)

10.18am
Check breathing again
Extend incision around 5mm
Clamp Uterine body
Check bleeding

10.20am
Bleeding controlled
Suspect torn uterine blood vessel

10.23am
Transfixing ligature uterine body to control bleeding

10.27am
(Cat on heat)
Bleeding again from ovarian fat

10.28am
Swab blood
Cut off uterine body

10.30am
Simple interrupted suture
Bleeding stop
Linear alba 3 stitches 3cm (LINEA ALBA 3 SIMPLE INTERRRUPTED SUTURES. 3 CM LONG)

10.32am
Check linear alba for hole
Stitch skin using horizontal mattress 2 stitches
Skin incision estimated to be around 3cm

10.33am
End of suture

Surgical time: First skin incision –> last stitch = 9:59- 10:33= 32mins
Operation time: Sedation-> Last stitch = 9:45- 10:33= 47mins
Suture used: 3/0 (ABSORBABLE PDS)
Amount used: 1 packet
Sedation dose: Isoflurorane gas 2% (NO ISOFLURANE GAS WAS GIVEN. XYLAZINE AND KETAMINE IM).

Conclusion by Dr Sing.
A good first draft written under time pressure. Vet interns are to write on their own first draft instead of being spoon-fed and then I will amend their report.

Corpus luteum yellow seen. Also small foetal lumps of 8 mm inside the uterine horns seen (Images taken). The cat owner was adamant that her cat Manja, 6 months old, had never been out or mated with another cat!

779. Internship - Presenting sign of hyperoestrogenism in an old female Sheltie

2011-12-18T11:00:00.000-08:00

2011/12/18 lim ..@hotmail.com>

Dear Dr Sing

I have attached a document on the case studies I have seen on the 2nd day of internship, 18 December 2011. Is this what you want of the daily case studies or does it have to be more detailed?

Yours Sincerely
Name of Intern

REPLY FROM DR SING DATED DEC 19, 2011

Thanks for email. During internship, one case study per day is to be recorded for me to review and discussed with you. Otherwise, being a bystander standing around the vet will not enable you to appreciate the diverse aspects of vet medicine and surgery and its varied clinical presentations and challenges to a correct diagnosis.

Evidence-based medicine and knowing how to arrive at a correct diagnosis is not so easy in some rare cases as in this Sheltie whose condition may be mis-diagnosed as ringworm when the actual cause of the hair loss is due to hormonal factors.

One Case study should be written with the following format using the Sheltie you saw yesterday Sunday as an example. You re-write your case study with as much info of the case under the following headings:

CASE NO. 1 DATE:

1. Description of patient - breed, gender, age, colour. Not spayed.
2. Chief complaint - hair loss. Other complaints -
3. History - Hair loss for the last 5 years. Hair grows back after the heat and problem of hair loss recurs. Not fully recovered. Seen 2 vets.
4. Presenting sign: Vulval enlarged over 20X normal. Hyperpigmented black.
5. Examination and tests (blood, urine, skin etc).
6. Diagnosis
7. Treatment/Advice
8. Review/Outcome/Follow up - 2 weeks later. Date to be written on medical record.
8. Against Medical Advices - to be written down

As reviewed by me, what should have been included in this case were:
1. Where were the medical records of other vets? This should be recorded if the owner does not bring them. If owner said "Blood test of other vet is OK," the vet should not take the owner's word for it and ask for the blood test results. Some owners do NOT want to pay for another blood test and this should be recorded under "Against Medical Advices".
2. When was the last heat? This should be asked.

From my review of the above case, the main diagnosis would be a case of hyperestrogenism rather than fungal infections of the dog. Fungal infections are present but the dog's problem will not be cured even if the ringworm is eliminated. So, the owner goes to another vet later for a 4th opinion or just accept that nothing can be done. The dog was put on a hypo-allergic diet by the previous vet for one month. This would be too early to eliminate dry food allergy as a cause of the hair loss.

Now, the Presenting Sign of a swollen vulva 3 months after the end of heat and its presence for over the last 5 years point to a high probability of hyperestrogenism.

The solution for this owner is to spay his dog after the skin infections are resolved in around 4 weeks' time. However the dog is old and there are high anaesthetic risks. This case is quite rare. I had seen less than 10 cases over the past 30 years of small animal practice. So a mis-diagnosis can easily be made as the skin signs of recurring hair loss distracts from the PRESENTING SIGN. A blood test for hormonal levels should be advised in theory and as part of the practice of evidence-based medicine.

Update at:
http://www.sinpets.com/dogs/20111219hyperestrogenism-old-female-Sheltie-internship-singapore_ToaPayohVets.htm

778. Myanmar stories from Peninsula Plaza - Lost a useful contact - case study

2011-12-17T02:59:00.000-08:00

My thoughts and tips of the younger generation - the google generation.

Lady 28 years, single, Myanmar National

Had working experience of 2 years in Malaysia and 8 months in Singapore on a "S" pass. Her Singapore company was acquired and she was retrenched. She worked in the administrative side of both companies and has a good command of English and works hard. Presently she pays $500 to attend a diploma in business course but the college told her that the course would be 2 years. That is a lot of money as she is from a poor family.

My advice to her and all young people, including Singaporeans are:

1. Acquire important IT skills like a detailed knowledge of how to use Excel, Word,
video production and digital imaging. Real depth of knowledge of these software in database management and accounting. Not just superficial as many young people even from the Junior Colleges have. This makes you useful to prospective employer.

2. Willing to work hard and the longer hours. Yes, she does.

3. Can converse in English well. Yes. Written English is not so good as to be expected.

4. Positive outlook and lots of energy. Yes, as expected of a young person.

5. Get the testimonials of previous employers esp. the Singaporean company.

6. Unique Strength - Myanmar culture and language and speaking good English.

7. Be proactive. Do your own search and write to hundreds of employers (target 14 per week for example). Do not give up hope.

8. Resume must be up to standard and relevant. This needs outside professional help.

As "S" pass now require $2,000 payment by the employer, it is much more difficult to justify employing new graduates from Myanmar. But much depends on the education and skills and the demands of the relevant industry.

9. Do not job hop. Last month, I met a Filipino who switched to a Korean company for more pay. "However, I have to work on Sundays too," she told me as she visited Khin Khin Employment Agency to look for a job before her visa expires. It was too late. She had a earlier job which satisfied her work hour demands but the money was not there compared to the Korean company which told her that there would be no Sunday work. So this young lady resigned and without another employer, looked for a new employer. This is quite common. But her visa expires and her skills are common (administrative and sales). So, she had to go home.

10. Also save your network phone numbers in duplicate. This girl lost her old phone and all contact numbers esp. of the Accountant in the Singapore company. The Accountant was happy to give her and help. As is the case for young people, such contacts are not valued and phone number had disappeared. I advised her to be more proactive in searching for this mentor who could find jobs for her.

11. Many young people just do not bother with networks and people who will be of great help in their future job search. In conclusion, this case illustrates the importance of duplicating network contacts and being organised and careful. Young people with no specialised degree like accountancy will need to be more alert and pro-active in seeking work attachments and testimonials. New employers want testimonials and character references. "The Accountant told me that I can contact her anytime if I need help," she told me today as I met her at Peninsula Plaza while looking for a Myanmar travel agent. But she lost the phone.

12. Try and get along well with Singaporean colleagues of old job. Some may provide character references for you.

13. "Get married to a rich husband," I said to the young lady. Many Singapore wives stop work to look after their families if their husbands earn a good income. So this is what I advise her. "You are already 28 years old," I said. "How's your Italian boyfriend who contacts you daily from the UK?"

"It is not that easy," she told me. As I am more than twice her age, she does not feel offended in my advices. She needs to be more proactive in finding an employer who will apply for her the "S" pass.

777. Dog lame after Vet 1 injected his thigh

2011-12-17T02:32:00.000-08:00

"Whether your injection is the cause of the lameness or not is hard to say," I advised Vet 1. "The dog owner had alleged that your injection was the cause as the dog was not lame before the injection and was lame some hours after the injection! Listen to the complaint and try not to antagonise the owner!

775. No dog

2011-12-16T17:59:00.000-08:00

Friday Dec 17, 2011 was a significant day. Dr Vanessa's dog had not been brought to the surgery. On Thursday, I nearly fell as I slipped while going to a crate in the back Animal Handling Room to show a client another Shih Tzu with tarsorrhapy. Her dog peed a big puddle on the floor and did not see it. Obviously I don't look for urine in my own Surgery. This dog had a habit of letting go of large puddles of urine when let loose in the back room. My assistant Min had to clean up and that should NOT be his job. I don't see Dr Vanessa cleaning up and I had given her instruction NOT to let the dog loose anymore. The staff will inform me if she does not heed the instruction.

The dog barks at Min and at me whenever we go to the consultation room to talk to her about the cases. Dr Vanessa would just keep quiet and not discipline the dog as I had advised her. So the dog became bolder and barked to drown out any talk from me or Min. I just can't understand why she would permit such behaviour. This is just not appropriate behaviour for a vet.

The dog also barked at clients. Some Muslim clients cannot be near this dog but he was let loose and so wandered to sniff them or their cats.

It is over one year tolerating this dog's behaviour and copious urination. I hav e to decide as to whether to terminate Dr Vanessa's association with Toa Payoh Vets. Just last month, her dog charged at me when she and I were discussing a case of a dog warded. I just could not believe that she did nothing. Not even a word of scolding at this dog. She just held back the dog in time.

This story is so incredible that readers may think I have a fertile imagination.

774. Friday Dec 16, 2011. Ear canal resection in an old Cocker Spaniel

2011-12-16T17:12:00.000-08:00

Dec 16, 2011
A young man who had completed his A levels started first day as intern till his National Service in May 2012. He surprised me by turning up at 9 am today as I told him I had an ear operation on a dog and he would be welcome to see how it is done.

"This ear canal resection surgery is seldom performed as most Singapore owners don't want to do it," I told this young man. "So, a vet undergraduate who studies 5 or 6 years may not have seen such an operation performed in real life. It costs money and that is why many Singapore dog owners don't want to do it."

Since he appeared keen by being present so early, unlike most of my interns who would be clock-watching, I shared with him some tips. He recorded the following for me:

Dear Dr Sing

Sorry to have to send you an email at such a time as I only got home by 10 p.m.. I have attached a report for 16 December 2011. The following is the timeline of the dog ear electrosurgery operation.

Dog Ear Operation (Electrosurgery)
Age: 10 Years Old Weight: 9.5kg Temperature: 38.5 Degree Celsius
10.15am: Clean flush the ear
11.13am: Sedation of the dog ( D and K)
11.23am: Isoflurance
11.35am: Electro incision
11.37am: 1% isoflurance
11.46sm: Stitching Right Ear
11.47am: 1% isoflurance
11.50am: 1% isoflurance
11.55am: 1% isoflurance
12.00pm: 1% isoflurance, 30 rr per minute
12.05pm: 1% isoflurance, 24 rr per minute
12.08pm: Finish Suture
12.10pm: Weat Exercise
12.11pm: Eye Blinking
12.11pm: increase to 4% isoflurance
12.11pm: Two clamps on the left ear
12.13pm: 1% isoflurance
12.15pm: electro incision
12.17pm: 2.5% isoflurance
12.19pm: 1% isoflurance
12.20pm: First Stitch on the left ear
12.22pm: 24 rr, per minute
12.25pm: 1% isoflurance
12.30pm: 0.5% isoflurance
12.34pm: 0.25% isoflurance
12.35pm: 0% isoflurance, remove electrode
12.39pm: End of stitch, End Of Operation

I did not edit his email report. rr=respiratory rate. isoflurance = isoflurane + O2 gas. D=domitor IV K=ketamine IV

From the above, it could be seen that two-ear canal resection surgery in an old dog with skin disease started from 11.35am and ends 12.39 pm. Total is around 1 hour just for the surgery.

I will record my surgery for the benefit of others. The vet surgery textbook can only give the theory but the practice of vet surgery is so much different in old dogs with generalised skin diseases.

EAR CANAL RESECTION IN AN OLD COCKER SPANIEL
Cocker Spaniel, 9.5 kg
Generalised skin diseases for many years. Scratching whole body, neck. Dandruff. Oily skin. The busy owner would send to the vet for treatment but the skin disease re-appears again after a few months. I believe that no vets had suggested ear canal resection to him. This was the cause of the skin disease, in my opinion. Ear infection --- painful, itchy. Dog scratches ears and neck, bites flanks - skin trauma, bacterial infections, more body itchiness, more scratching --- whole body skin inflamed. Finally, left ear had a big ear wart. Dog bites. Nobody at home cleaned the ear canals. Pus, bacterial, dampness as ear flap floppy covers ear canal --- no ventilation -- dampness inside ear canals -- bacteria grows ---pain and irritation --- dog scratches ear neck and bites flank. Uses back paws to scratch flank and chest --- oily infected red skin all over the body including forehead. Will post some images later.

1. PRE-OP PREPARATION
Dog with serious skin diseases was warded for over 2 weeks for treatment and fed proper food to gain weight. Monitored. Good appetite. Skin condition less dandruff but still oily. No yeast inside ear canal (ear canal smear). Owner gave permission for ear surgery. On day of op, dog bites esp. when left ear is touched. So my assistant only bathed him.

PLANNING PRE-OP
1.1 Sedate with Domitor and Ketamine at 50% of calculated dose IV. Very weak. Sedated within 2 minutes.
1.2 Put dog on table and flush, irrigate ear canals vigorously.
1.3 I washed his outer ear skin area thoroughly with cloth and antiseptic myself.
The oily skin was scrubbed well. I did not permit my assistant Min to do it in this bad skin diseased case as I must be sure that the area is cleaned.
1.4 Dog went to surgery room. Mask with isoflurane and O2 for <2 minutes. Intubated with size 8.5 endotracheal tube. This size fitted tightly so no leakage of gas during surgery.

1.5 Ensure set up of electrosurgery machine, big towel, moist saline on swab for indifferent plate, cotton bud, marker pen and surgical equipment and suture. "Check isoflurane level inside the machine," I said to Min after checking oxygen amount. He had to top up the isoflurane liquid.

ELECTROSURGERY
1. Full power setting for electro-incision. I fitted the electrode into the handle.
2. Towel covers steel operating table to prevent electric shocks to staff and vet
3. Marker pen defined lowest level of vertical canal.
4. 2 forceps clamp either vertical side of canal.
5. Electro-incision of skin
6. Skin flap elevated and cut.
7. Arterioles shoot out blood into me. Clamped arterioles. Venous bleeding controlled by clamp.

SURGICAL PROCEDURE
Described in detail in www.toapayohvets.com, goto DOGS, goto EARS. 3/0 nylon 2 packets used in this surgery for 2 ears.

PRODUCTIVITY
How long it takes to do the surgery? Should be around 1 hour for both ears. More experience and planning carefully, less than 1 hour in younger dogs with no skin diseases. Good assistant to monitor vital signs and the vet is to keep proper anaesthetic record

POST-OP CARE
Tolfedine 1 ml + Baytril 1 ml SC
Wash ear bleeding thoroughly at end of op and not wait.
Post-op medication.

CONCLUSION
Dog OK. Woke up with no need for Antisedan reversal. Will check on Day 2 (Saturday 9.44 am as I write this report). This surgery ought to be done for dogs with recurring ear infections and floppy ears, when the dog was much younger, e.g. 3 years old but most Singapore owners will not do it. Breeds commonly affected are Cocker Spaniels and Miniature Schnauzers with hairy ears. Some Shih Tzus. Other breeds seldom have chronic otitis externa that can't be cured.

Fluorescein eye stain test - Silkie rubs its eye vigorously

2011-12-13T16:03:00.000-08:00

Generalised greenish as can be seen as follows:

772. Ward dog for 3 days after tarsorrhapy

2011-12-13T15:47:00.000-08:00

When the left eye was injured, the owner agreed to her dog being warded for 3 days at Toa Payoh Vets and the eye was well cared for. So, no complaints.

When the right eye was injured and treated by tarsorrhapy by Vet 1, the owner wanted the dog home AGAINST medical advice. On day 2, she phoned me to say that the eye was swollen and bleeding. I advised immediate bringing the dog to Toa Payoh Vets for me to check. She did not do so. Around Day 7, she said the suture had broken down and the eye was swollen and bleeding. This time she brought the dog down and was very unhappy as the first left eye with tarsorrhapy recovered without problems.

"There is no guarantee that every surgery is going to be successful everytime," I said. "I do have cases where there are similar problems. In the first case of the injured left eye, I did advise NOT taking the dog home for 3 days but you did not accept my advice."

There was a lot of unhappiness and blame onto the vet when the owner does not heed medical advice. Vet 1 is not to be blamed as the dog's eye was not well cared for post-op by the maid and mother. The dog was not confined but left to wander around the house and could have rubbed his eyes against sofa sides and beds, leading to stitch breakdown and bleeding.

I advise a repeat tarsorrhapy as the ulcers were deep and would need to be covered up to heal. Or a second opinion from another vet as to whether to leave the eye alone. If the owner has her way, she would rather not have tarsorrhapy. If the eye cornea subsequently ruptures or get pus infection, she would again blame the consulting vet for not having given proper advice! All advices must be RECORDED in the medical records nowadays although sometimes my vet just will not do it.

I will perform tarsorrhapy on Dec 14 and follow up.
More images and update will be at:
http://www.sinpets.com/dogs/20111214tarsorrhapy-stitch-breakdown-7days-dog-at-home-tips-singapore_ToaPayohVets.htm

771. SOP for eye injuries at Toa Payoh for all vets

2011-12-13T01:11:00.000-08:00

1. General examination of the dog and eyes
1. Detailed examination of the eye injury
3. Pupil examination - Pupillary light reflex - direct and consensual
4. Cornea examination - Fluorescein stain strip on both eyes and inform owner of the extent of the green stain

5. Record and illustrate extent of ulcers (green stain) and advices on treatment on the medical record.

6. Diagnosis - superficial keratitis, ulcerative keratitis, descemotocoele as shown in images below:
DESCEMETOCOELE

CORNEAL ULCER PERFORATION

7. Advices on treatment and costs
7.1 Extremely itchy eye. E-collar and eye drops. Eye irrigation of 3rd eyelid if acute conjunctivitis, under sedation is strongly advised.
7.2 Corneal ulceration surgery. Tarsorrhapy under general anaesthesia.

7.3 Corneal ulceration surgery. Tarsorrhapy and 3rd eyelid flap under general anaesthesia
7.4 Corneal ulceration surgery. Conjunctival flap. Needs 7/0 sutures under general anaesthesia

8. Digital images before & after treatment preferred or illustration to be recorded in medical record
9. Post-op warding in Toa Payoh Vets for 3 days mandatory for tarsorrhapy and conjunctival flap. Owners who insist on bringing the dog home are strongly advised not to and the "Against Medical Advice" instruction is to be clearly recorded in the medical record to avoid disputes of post-op stitch breakdown (see case study).

10. Pre-op preparation for surgery. Ensure area is shaved clean. Bigger facial area to be clipped short on both eye area. Eye-lashes to be clipped short.
11. Eye irrigation including 3rd eyelid flap wash must be done.

12. Sub-conjunctival injection of gentamycin may or may not be done.
13. Advices: Treat cause of corneal ulcerations. Protruding eyeball in the Shih Tzu, Pug, Pekinese ensures that such eye injury cases are common in the three mentioned breeds in Singapore and elsewhere. Another cause besides traumatic, is nasal fold hairs irritating the eyeball and nasal fold excision surgery is recommended.

Case studies at Toa Payoh Vets:
1. Perforated corneal ulcer in a pug
http://www.sinpets.com/dogs/20110315pug-male-7months-perforated-corneal-ulcer-deep-ulcerative-keratitis-toapayohvets.htm

2. Descemetocoele in a Shih Tzu
http://www.sinpets.com/dogs/20100660eye-injuries-rubbing-shih-tzus_dogs_singapore_ToaPayohVets.htm

3. Most of Dr Sing's case studies will be filed at:
Eye problems seen at Toa Payoh Vets:
http://www.bekindtopets.com/animals/20081201PAGE3_Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm

770. A cat with stinky right ear

2011-12-11T16:32:00.000-08:00

"The right ear is very smelly. Have you considered ear irrigation?" I asked the lady whose cat scratched her whenever she tried to put ear drops into the right ear. "The vets gave me the ear drops and asked me to do it," she said. "But I can't do it."
So she consulted me as the problem had become worse.

As vets, we often prescribe ear drops and ask the cat owner to do it herself and often they manage. Owners who consult us again when they can't do it should be advised about ear irrigation. Otherwise the owner just go to another vet for a solution to her cat's ear problem.

"If ear irrigation fails to resolve the problem, there is the ear canal opening surgery," I said. "We will try ear irrigation first and see if it works."

The 4-kg cat was given xylazine 0.1 and ketamine 0.4 ml IM in one injection. The day before, I gave him 50% of the above formula and it didn't work. Sedation was given as low as possible as this cat was not in good health due to the chronic ear infection and it is always good to be careful.

"In ear irrigation, there must be a correct way of irrigation. Otherwise, nothing would be flushed out of the ear canal," I said to my assistant Min. I demonstrated to him my technique. He could see the big brown mass appeared out of the ear canal. I took a picture in case the cat owner was interested as Min did not keep the "evidence".

When the owner took the cat home, I said: "The cat had a lot of dead cells and wax flushed out of the ear canal. You will need to use this ear ointment to continue."

An ear ointment again? From a vet again? The lady shook her head. Why can't the vet understand that her cat would scratch her. Didn't the vet listen sufficiently?

"The ear ointment is to be applied 2 weeks later," I soothed her anxieties of being scratched. "The drugs and injection would bring down the pain, swelling and infection and you should have no problem applying the ear ointment to clear any leftover infection."

She left and I had not heard from her for over one week. If I don't see her again, I presume all are OK. Unless she went for a 4th opinion. I ought to phone her to follow up.

WEBSITE AT TOA PAYOH VETS
http://www.sinpets.com/cats/20111212ear-stinky-irrigation-cat-singapore-toapayohvets.htm

769. Sunday's interesting case. Post-op spay swelling

2011-12-10T20:50:00.000-08:00

Sunday Dec 11, 2011

1. Post-spay complications do occur now and then to all vets performing spays in female dogs. It is hard to prevent every case.

Post-op 7 days later, an active Jack Russell came with swelling and inflammation at the spayed area. It looked as if the dog had irritated the spayed area due to itchiness as the owner said he had never taken out the e-collar. The dog was warded. There was no complaint till recently. The dog had pain-killers and antibiotics post-op.

2. 18-year-old cat with 2 large sores on back spinal area. "Would you advise euthanasia?" the owner asked me. "This cat was paralysed last year and treated by you," the owner said. "He could walk later."
"How long it took to walk normally?" I recorded injury T10-L3, jumped upon by the Golden Retriever. I was much surprised that he could be alive.
"A year of walking on front legs and then all 4 legs,.

"It is up to the owner to decide," I said. "Is the cat eating?"
The owner said: "Yes,".
"Many times it will be the children who are against euthanasia," I said.
"No euthanasia," the pre-teen child who listened intenly decided.
I don't advise euthanasia and it should be the owner's decision as treatment may or may not cure. But euthanasia denies a chance of living.
Gave the old cat a warm bath after Min had clipped bald. Got a kettle of water boiled and bathe this aged feline who went into fits when I touched the two big scabs on his back, somewhere on either side of the T10-L3 area Had fleas. Needed grooming and ear cleaning.

3. 4-year-old Schnauzer with globular skin tumour around 8mm x 8mm on right neck
"Any drugs to make it disappear?" the lady in her 30s asked me.
"Not advised," I said. "This is a skin growth. It may or may not be cancerous."
"How much?"
"Anaesthesia and surgery and medication estimated around $250," I said. "Do you want to know whether it is cancerous or not. If you want to know, I will send to the lab for histopathology."
"What if the growth is cancerous?" the husband asked. "Is there a cure?"
"It is not guaranteed," I said. "Depends on type of malignancy."
So, it was decided that the lump be removed and dental scaling be done at the same time to save on costs.

4. Paralysed Shih Tzu.
This Shih Tzu could lift his head but would not stand on his four legs as 2 days ago. His tongue was peculiarly a dark pinkish red. I took him outside the Surgery at 1.10 pm for review. He peed, looked at me. Later he pooped a large amount of soft brown black stools.
Same eye reflex as before when I shone the bright light on both eyes. The left one was dilated while the other constricted on light shone on the pupils. The left one dilated lesser amount than 2 days ago. I asked Dr Vanessa to pinch the front toes of both front paws. Both paws showed withdrawal reflex.

Blood sample taken to check for infection. Glucose, duphalyte and IV drip given. "It takes a long time to recover," I said to Dr Vanessa. "It is not going to be so soon."

768. Dietary management to dissolve struvite stones in the dog - no surgery

2011-12-10T16:10:00.000-08:00

Below is an update of what I wrote from Perth in Sep 2010 when I was there on holiday and sat down to read the very thick book "Small Animal Clinical Nutrition" far away from the distractions of practice in Singapore.

The website is at:
http://www.sinpets.com/F5/20100697struvite-dietary-management-voiding-urohydropropulsion_ToaPayohVets.htm

The following is copied from the website:

After the surgical removal of the struvite urinary stones or for medical and dietary treatment, how much of the prescription diet should the owner give the dog/day?

I took some time just to read about Canine Struvite Urolithiasis case studies in the sleep-inducing thick book "Small Animal Clinical Nutrition" by Hand et. al, 5th Edition while on holiday in Perth, Australia. The following is some general guideline for Toa Payoh Vets in advising on Prescription Diet s/d to dogs based on 3 case studies in the book.

How much of the s/d diet to be given?
1. Puppy X-breed, 9 weeks,
5 kg.
700kcal (2.83MJ)
1/2 can 3x/day
2. Rottweiler, 5 years, 41 kg
1,800kcal (7.5MJ)
1.5 cans 2x/day
3. German Shepherd, 12 years, 27 kg
1,150kcal (4.8MJ)
1 can 2x/day
Other procedures to ensure compliance from the owner:
1. Antibiotics from 14-30 days and review using urine cultures
2. Monthly urine analysis (check for UTI) and blood tests (esp. serum urea nitrogen, magnesium, phosphorus and calcium and alkaline phosphatese)
3. Monthly x-rays of kidney (V/D view), bladder (lateral views).

Back to normal commercial food for the puppy as soon as X-rays show no stones. For adult dogs, give prescription food for one more month after negative X-ray results. No commercial dog treats or snacks during the period of treatment. In practice, I advise initially 3 months of the S/D diet and get urine tests done monthly in most cases. The Singapore dog owner seldom complies with the above-mentioned procedures or with monthly urine tests! Till blood in the urine returns!

RECURRENT UTI
Specialised tests like double-contrast cystography (to check out anatomic abnormalities of the bladder, obstruction of urine flow from kidneys), retrograde positive-contrast urethrocystography (to check out anatomical abnormalities of the urinary tract to the prostate gland area, bladder tumours) if there is recurrent uroliths or UTI (see case study of the old Corgi with recurrent UTI.

Recurrent UTI in an old Corgi - Part 1 http://www.sinpets.com/dogs/20111044blood-urine-recurs-over10times-old-corgi-female-toapayohvets.htm

http://www.sinpets.com/F6/20111210recurrent-urinary-tract-infection-old-female-spayed-corgi-singapore-toapayohvets.htm

Voiding urohydropropulsion is used in cases where the uroliths are small. The owner must be informed that it takes 2-4 months or longer to get all struvite stones dissolved. The owner must be aware of the need for reviews and to note the costs involved in the dietary management to dissolve struvite urinary stones.
VETERINARY SURGERY --- VOIDING UROHYDROPROPULSION IN DOGS AND CATS

What is urohydropropulsion? Basically it means pumping saline into the bladder (3ml/kg) and suck out the fluid together with the small uroliths (urinary stones) with a catheter. The stones in the bladder are too small and therefore no surgical removal is needed.

ANAESTHESIA. May or may not be need.
APPROACHES. Two methods described in Small Animal Clinical Nutrition 5th edition.

POSITION 1. Hold the dog or cat upright so that the vertebral column is upright. The urine and stones will be at the bottom (neck) of the bladder.
POSITION 2. Lateral recumbency.

In both positions, catheterise, irrigate with saline (3ml/kg), massage or press bladder to shake up the stones, suck out the saline + stones with a syringe. X-rays to check if all are taken out but not all small ones can be seen.

Dietary and medical treatment.
More information is at: Small Animal Clinical Nutrition" by Hand et. al, 5th Edition

This webpage:
http://www.sinpets.com/F5/20100697struvite-dietary-management-voiding-urohydropropulsion_ToaPayohVets.htm

767. No more smelly urine after the end of antibiotics for an old corgi

2011-12-09T18:09:00.000-08:00

On Friday Dec 9, 2011, at 11.40 am, I was in the consultation room facing Dr Vanessa and Mr Min on the other side of the consultation table. I conducted a meeting regarding work performance to ensure that the quality of veterinary service is up to my standard and to be free of clientele complaints.

"In many companies, there is a monthly meeting to discuss work matters like problems and solutions," I said to both of them. "I don't do it monthly as I expect both of you to do your part and to adopt my advices for changes. However, I have to discuss with both of you work matters today."

One of the topics I spoke about was the need for direct eye-contact with clients to connect well.

"When a client comes into the consultation room, stand up and greet him, rather than sit down and look up to him," I said. "You may be tired but still this is the proper way to do. You may get a chair and ask the client to sit down if you wish to sit down to discuss the dog's health. I always stand up to greet the client throughout my years of practice or invite them to sit. There was a complaint of one unfriendly vet who sat down and looked up at the client...."

I illustrated with my personal anecdotes and gave my tips as how to handle several cases by Dr Vanessa and Min who is a vet from Myanmar.

As regards examination of the severely "paralysed" recumbent panting dog that came in yesterday as a second opinion, the important things to do would be to collect blood and urine samples first, before any treatment like IV drip. If the owner objected to it due to the fact that Vet 1 had just done the blood test, record this objection, time and name of the owner. "The dog was diagnosed as having spinal injuries by Vet 1. How do you know whether the dog at the time of arrival half dead and panting and unable to stand up was also suffering from hypoglycaemia which would be obvious from a simple blood test?" This morning, I took the dog outside for a review and he was walking unsteadily as he had been given IV drip, painkillers and frequent feeding.

I said: "A quadriplegic dog with a cervical fracture or dislocation would not be able to walk at all. In addition, there is no rush to do an X-ray which was done yesterday as the dog's head was twisted and the X-ray views were not so good," I said. "Go back to basics of neurology. A quadriplegic dog cannot normally be having spinal problems in the lumbo-sacral area as the brain stem and cervical spinal area would be the likely area of traumatic injury. It is possible that there is injury in the tail spinal area as evident by the presence of pain on palpation, but the primary diagnosis should be the brain stem and cervical area.

"Stabilise the dog, give the IV and medication and take the neck X-ray later in cases where the dog had a twisted neck on admission." We all learn by experiences of handling a case and that include me even though I have practised for over 40 years. This was an unusual case. The dog could put weight on the right fore but limped on the other 3 legs. What was he suffering from? Was it head concussion, bleeding and traumatic injury as I suspected? A kick to the side of the head. So, the right eye pupil constricts on direct light but the left eye pupil does not constrict and is dilated even this morning. Yet he can stand up on his own on the right fore limb and walk a distance like a drunken. I am still suspecting a brain stem injury and am reviewing this mysterious case.

P.S. In the evening, the lady and her husband who read on the internet about IVDD (intervertebral disc disease) came after work. I was still around as I booked in a 6-week-old male guinea pig for neutering and showed another Shih Tzu with eye injury in to Dr Vanessa's room for her to treat.

As for the couple, I placed their Shih Tzu on the table and shone bright lights onto each eye. The left eye pupil was dilated despite the bright light. The right eye pupil was constricted. I said to the couple: "This showed that the left eye does not have a direct pupillary response to light." As for consensual pupillary response, the left eye does not constrict even when the bright light was shone onto the right eye.

So, the left eye also did not have consensual pupillary response. The neurological explanation will sound too technical to the owners and so I did not want to confuse them by elaborating.

"Basically, I would say that the traumatic injury is around the brain stem," I said. "The X-rays showed two microchips. One was on top of the cervical spinal bone. Whether this would cause the present problem, I do not know. The other one was in the armpit area.

However, the dog could put weight on the right fore limb and this morning, he could walk upright or limped a distance of over 5 metres before collapsing," I said. I pinched the toes of all 4 limbs in front of the couple. Only the left fore limb had no withdrawal to pinching reflex pain sensation. In veterinary practice, showing is communication to the owner as nowadays, the young Singaporeans are so much more sophisticated.

"There is some improvement," I said and the couple could see it too. "We feed the dog around 4 times a day and give the necessary vitamins. He can't eat on his own. He has got the energy and alertness now. But he needs complete rest and so please do not stay long." The couple adjusted the water bottle height and reluctantly left at 7.30 pm.

A HAPPY LADY IN RED CAME TO THE SURGERY

A fair lady in red sheath dress, with black eyeliner suddenly came into the waiting room and waved at me from the outside. My consultation room's door has a glass window on the top half and so I could see who was coming into the waiting area. This lady, in her prime at around early 30s, looked quite familiar and since she waved to me, she must have met me. I had to stop the meeting which had taken over 30 minutes as I guess my assistants had enough of my reiterations of things to do, government and legal processes to be complied with and records to be written meticulously. Reminders to staff appear to be part of a manager's job and it is a role I rather not be involved in. But I was the licensee and the ultimate responsibility of any clientele complaint, investigation and litigation is with the licensee.

I said hi to the lady in red. Fairness and bright red always demand attention. The lady in red said: "Do you remember the Corgi? I am coming for the S/D diet."

"I am sorry I can't recognise you," I said. "But I do remember Oreo. She had seen a few vets and always passed smelly urine after a course of antibiotics. For at least 2 years or so. Is she OK now?" I had thought of following up but had not done so and now one month had flown by. Just like that.

"Well," the lady beamed. "She is no longer passing smelly urine after one month of treatment. Your medication has been taken and is no more. Her urine is clearer. Best of all, I don't have any smelly urine in the apartment after the end of antibiotics as in the past."

"How many times does Oreo pee and how much does she drink per day?" I asked. "Did you measure the amount of water she drinks a day?" It was difficult for her to answer precisely as she did not take note. She said: "I can't measure the amount because Oreo drinks only fresh water and so the bowl of left over water has to be replaced."

I was surprised that her female spayed dog peed all over the apartment at such an old age. "An adult dog usually pees twice a day, in most cases," I said. "The fault lies with the owner if she pees many times a day," I said. "The owner has no properly house-training the dog as a puppy." This frankness was not good bedside manners.

"Well, I did," she said. "She would hold her urine and then let go a lot." She spread her arms wide. "Is it common for dogs to pass a vast amount of urine every day"

"A dog would pass a lot of urine in the morning for one time," I said. "But not several times. Your dog has been withholding the urine until she can't stand it anymore. You must be beating her up when she had peed all over the apartment when she was younger," I said. "Holding urine leads to bladder infection and the smelly urine that the various vets you consulted before could not cure. Your dog is not fully cured yet. It is only one month.

"You need 3 months of S/D diet to know whether she will be free of urinary tract infection as the S/D diet acidifies the urine and prevents bacteria forming struvite sand in the bladder, leading to bad smelly urine. No other food, dog treats or any other pills."

"My dog loves apples," she said. "Can I give her apples? She looks at me appealingly for apples when I eat one."

"It is best not to," I said. "You had suffered over 2 years of this problem of smelly urine after antibiotics after seeing a vet. Now, her urine is not smelly without antibiotics. Why take risks? Let her urinary tract system stabilise over 3 months of eating S/D diet and drinking plain water. Then you may give her apples."

As regards whether the Corgi was harshly disciplined when she was younger, the lady in red said: "Yes, she got spanked when she peed everywhere." the lady said. "This may be why she withholds her urine till the last moment and urinated a very large puddle of urine onto the floor. What do you suggest I do now?"

At first I advised confinement and removing the urine smell in the floor apartments using white vinegar + water at 1 part to 3 parts water.

As she was moving to a new apartment away from Woodlands soon, I advised: "Complete confinement for 24 hours in a room, with a baby gate, for 4-6 weeks. Newspapers with her urine smell on one side and bed on the other. Confinement is the key to success. Let the dog out when you are at home and pick her up when she is about to pee on the floor and put her into the confined area. Say in a firm tone 'Pee here.' Give a treat if she does that or a praise. Persevere. Old dogs can learn new tricks too especially when you start from a new house."

This case of recurrent UTI seems to be successful but urine monitoring per month should be done. I gave her a urine collection bottle and asked her to know volume of water drank per 24 hours. I hope the new apartment will be free of dog urine smells as friends can smell it but owners who live there will not smell it as their noses are used to it.

Will wait and see. The "living happily ever after" story has not concluded but it seems that there is a good clinical outcome of my recommendations and that is what the lady in red wanted and what all owners whose pets have long suffering diseases demanded.

PREVIOUS REPORT
Written in Oct 31, 2011 (>1 month ago), Recurrent UTI in an old Corgi is at:
http://www.sinpets.com/dogs/20111044blood-urine-recurs-over10times-old-corgi-female-toapayohvets.htm

The blog has brief version:
http://2010vets.blogspot.com/2011/10/717-recurrent-uti-in-old-corgi-is-hard.html

THE WEBSITE FOR THIS FOLLOW UP REPORT WRITTEN DEC 10, 2011 IS AT:
http://www.sinpets.com/F6/20111210recurrent-urinary-tract-infection-old-female-spayed-corgi-singapore-toapayohvets.htm

766. A happy lady in red

2011-12-09T00:39:00.000-08:00

Friday Dec 9, 2011
I was in the consultation room facing Dr Vanessa and Mr Min as I conducted a meeting regarding work performance. "In many companies, there is a monthly meeting to discuss work matters like problems and solutions," I said to both of them. "I don't do it as I expect both of you to do your part and to adopt my advices for changes."

One of the topics I spoke about was the need for direct eye-contact with clients to connect well.

"When a client comes into the consultation room, stand up and greet him, rather than sit down and look up to him," I said. "You may be tired but still this is the proper way to do. You may get a chair and ask the client to sit down if you wish to sit down to discuss the dog's health. I always stand up to greet the client throughout my years of practice or invite them to sit. There was a complaint of one unfriendly vet who sat down and looked up at the client...."

I illustrated with my personal anecdotes and gave my tips as how to handle several cases by Dr Vanessa and Min who is a vet from Myanmar.

As regards examination of the severely "paralysed" recumbent panting dog that came in yesterday as a second opinion, the important things to do would be to collect blood and urine samples first, before any treatment like IV drip. If the owner objected to it due to the fact that Vet 1 had just done the blood test, record this objection, time and name of the owner. "The dog was diagnosed as having spinal injuries by Vet 1. How do you know whether the dog at the time of arrival half dead and panting and unable to stand up was also suffering from hypoglycaemia which would be obvious from a simple blood test?" This morning, I took the dog outside for a review and he was walking unsteadily as he had been given IV drip, painkillers and frequent feeding.

I said: "A quadraplegic dog with a cervical fracture or dislocation would not be able to walk at all. In addition, there is no rush to do an X-ray which was done yesterday as the dog's head was twisted and the X-ray views were not so good," I said. "Go back to basics of neurology. A quadraplegic dog cannot normally be having spinal problems in the lumbo-sacral area as the brain stem and cervical spinal area would be the likely area of traumatic injury. It is possible that there is injury in the tail spinal area as evident by the presence of pain on palpation, but the primary diagnosis should be the brain stem and cervical area.

"Stabilise the dog, give the IV and medication and take the neck X-ray later in cases where the dog had a twisted neck on admission." We all learn by experiences of handling a case and that include me even though I have practised for over 40 years. This was an unusual case. The dog could put weight on the right fore but limped on the other 3 legs. What was he suffering from? Was it head concussion, bleeding and traumatic injury as I suspected? A kick to the side of the head. So, the right eye pupil constricts on direct light but the left eye pupil does not constrict and is dilated even this morning. Yet he can stand up on his own on the right fore limb and walk a distance like a drunken. I am still suspecting a brain stem injury and am reviewing this mysterious case.

A fair lady in red with black eyeliner suddenly came into the waiting room and waved at me. I had to stop the meeting which had taken over 30 minutes as I guess my assistants had enough of me.

The lady in red said: "Do you remember the Corgi? I am coming for the S/D diet."
"I am sorry I can't recognise you," I said. "But I do remember (name of dog). He had seen a few vets and always passes smelly urine after antibiotics. For at least 2 years or so."

"Well," the lady beamed. "She is no longer passing smelly urine after one month of treatment. Your medication has been taken. Her urine is clearer. Best of all, I don't have any smelly urine in the apartment."

I was surprised that her female spayed dog peed all over the apartment. "The fault lies with the owner," I said. "For not properly house-training the dog as a puppy."

"Well, I did," she said. "She would hold her urine and then let go a lot." She spread her arms wide. "Is it common for dogs to pass a vast amount of urine every day"

"A dog would pass a lot of urine in the morning for one time," I said. "But not several times. Your dog has been withholding the urine until she can't stand it anymore. You must be beating her up when she had peed all over the apartment when she was younger," I said. "Holding urine leads to bladder infection and the smelly urine that the various vets you consulted before could not cure. Your dog is not fully cured yet. It is only one month. You need 3 months of S/D diet to know whether she will be free of urinary tract infection as the S/D diet acidifies the urine and prevents bacteria forming struvite sand in the bladder, leading to bad smelly urine."

"Yes, she got spanked" the lady said. "What do you suggest I do now?"
As she was moving to a new apartment away from Woodlands, I advised complete confinement for 24 hours in a room for 4-6 weeks. Newspapers with her urine smell on one side and bed on the other. Confinement is the key to success.

This case seems to be successful but urine monitoring per month should be done. I gave her a urine collection bottle and asked her to know volume of water drank per 24 hours. I hope the new apartment will be free of dog urine smells as friends can smell it but owners who live there will not smell it as their noses are used to it.

Will wait and see.

4.40 pm. Back to work. A shih tzu with central eye ulcer.

765. Adopt sick or old dogs

2011-12-09T00:04:00.000-08:00

Today I had a woman in her late 40s bringing in a 9-year-old male and a very thin 5-year-old pregnant female cocker spaniel for examination as she had adopted them. The dogs needed dental cleaning but she would not want to pay for the services. She went to get something from her van.

Suddenly she rushed back to say that a gasping puppy was present on the floor of her front van seat. I got the puppy which was attached to the placenta out and tried to revive it. Her teenaged daughter was not afraid of the smell and I taught her how to clean the puppy. The dam had little milk and so I asked them to buy milk powder.

Below is another example of adoption of sick dogs

EMAIL Dec 5 (4 days ago)
to drsing

I have an enquiry to make and would really appreciate if you could help. I have decided to adopt a 6 months old Shetland sheepdog and border collie mix, but the breeder told me that he has skin problems, (he thinks it is fungus) on his back. I would like to know if I should wait for the wounds to heal before adopting it or i can adopt it and bring it to the vet for a check. If I were to bring the dog for a check at your veterinary, how much would it cost, ad how long would it take for the skin problem to recover?

Thank you,

Name given

EMAIL Reply
Kong Yuen Sing

Dec 5 (4 days ago)
I am Dr Sing. It is best to adopt a dog with no skin disease. As for vet costs, it depends on what is the cause of the skin disease and prices vary from $60 to over $200 for complicated skin disease cases.

EMAIL TO DR SING DEC 7, 2011 (2 days ago)
to me

Thank you for the reply. I have decided to get a healthy 3 months old Sheltie. May I know how much will it cost for the third vaccination and microchip at your veterinary?

Thank you,

Name given

EMAIL FROM DR SING On Dec 9, 2011, at 1:40 PM, Kong Yuen Sing <99pups@gmail.com> wrote:
Vaccination is around S$40 and microchip $50. Pl phone 6254 3326 for appointment. Thank you.

New graduates of Murdoch Univ - Dec 2, 2011

2011-12-08T16:12:00.000-08:00

On Dec 2, 2011, the 5th year Murdoch Univ vet students were informed of their exam results in a graduation dinner. I had met some of the Singaporeans last year and there was one I was particularly concerned. Did this person pass or not? Has this person wasted 5 years studying a most-sought after profession? I was glad this person had passed and has become a vet.

Apparently, according to this person, in Australia, a new vet earns around A$3,500 per month while a dentist earns A$10,000 a month and a doctor earns A$500/day. I don't know why as vet undergraduates are straight As or are top in their cohort during 'A' levels. In Singapore, a new vet earns around S$3000 - $4,000 a month generally.

Those Singaporeans with rich parents open their own practice after one year of experience as the regulatory authorities permit this. That is why we have around 50 vet clinics in 2011. Flyers are distributed into letterboxes by some of the new practices to announce their presence. This practice had been done by some of the previous vets too. Some did it by proxies using the groomer.

Will a vet earn more when they start their own practices? Maybe in the long term for many of them and if they are much less "expensive" than the older vets. But there are vets who have had closed their practices.

Good communication with the owners is usually lacking, according to this new vet I spoke to yesterday. It is very important in private practice but seldom taught in vet school. Technical skills can be picked up from books. "Doesn't Murdoch Univ teach communications with clients?" I asked. "There is a video presentation of consultation with clients and feedback."

Communications with clients is easily taught. It is part of the personality. Some do it very well. Some can't do it. I said to the new vet: "But at the end of the day, it is still a correct diagnosis." When a diagnosis is correct, the dog gets well and the owner returns or refers.

Academic results at Murdoch Univ batch in 2011
Probably 60 students in the 5th year
9 get high distinctions (HD) (over 80% in Year 3,4 and 5).
1 failed
Distinctions (70% - 79%)
From what I know, two ladies in the HD are from Singapore. One of them got 79.5% and I am glad that she got the award as the professors recognised her hard work and efforts. "What if she got 79.4%?" I wondered.

Being top in academic performance in vet school is great. It can lead to great arrogance that the world is their oyster. To succeed in private practice, academic excellence with arrogance leads to disaster for the practice and possible sacking as clients provide adverse feedback to the principal.

763. Pupillary light refex - A paralysed Shih Tzu

2011-12-08T15:51:00.000-08:00

Yesterday, Dec 8, 2011, I was consulted about a Shih Tzu that was "paralysed". The sister had phoned me on Dec 7 for a 3rd opinion and I had asked her to send the dog in for examination as it is difficult to know what is going on by phone diagnosis.

The dog was treated by Dr Vanessa on Dec 7 and so I asked her where was the area of pain. I had seen the dog lying sideways in the crate. My assistant Min said Dr Vanessa had treated the dog. She came in around 11.30 am. I was about to talk to Dr Vanessa when the brother came in. This was the best time as it is always good for the owner to be involved in the examination.

AREA OF SPINAL PAIN
The dog had been treated by Vets 1 and 2 with steroids and so the area of spinal pain was not specifically known to Dr Vanessa when she received the dog. "Which area of the spine is painful?" I asked her since she had given a steroid injection and any pain would be masked.

The dog was able to lift his head but was unable to stand on four legs and that was definitely injury to the central nervous system. "Slight pain is further to the back area," Dr Vanessa said. It would be difficult to diagnose pain in the spinal area when the dog had been treated with pain-killers by Vets 1 and 2. Their medical records were brief. Acupuncture was done by Vet 2. But both of them had not done any X-ray. Later in the evening, the sister who had taken the dog to the vet spoke to me and said that she was given the choice of "X-ray" and/or "MRI."

There seemed to be some miscommunication here. Since I did not speak to Vets 1 and 2, I would presume that they had advised X-ray and the owners had opted out but the owner had said she was not a professional and should not be given a choice. It is extremely difficult nowadays. I usually advise X-ray in such traumatic cases and if the owner declines, I will record it down in my medical record. This is to avoid this type of "mis-communication".

For this report, I would focus on the pupillary light reflex done on the Shih Tzu in the presence of the brother. A bright light was shone directly on each eye to check the consensual and direct pupillary light reflex

DIRECT EYE REFLEX
Left eye - pupil does not constrict
Right eye - pupil constricts
So, what is the problem?

See notes from Wikipedia below.

Clinical significance

In addition to controlling the amount of light that enters the eye, the pupillary light reflex provides a useful diagnostic tool. It allows for testing the integrity of the sensory and motor functions of the eye.[1]

Under normal conditions, the pupils of both eyes respond identically to a light stimulus, regardless of which eye is being stimulated. Light entering one eye produces a constriction of the pupil of that eye, the direct response, as well as a constriction of the pupil of the unstimulated eye, the consensual response. Comparing these two responses in both eyes is helpful in locating a lesion.[1][5]

For example, a direct response in the right pupil without a consensual response in the left pupil suggests a problem with the motor connection to the left pupil (perhaps as a result of damage to the oculomotor nerve or Edinger-Westphal nucleus of the brain stem). Lack of response to light stimulation of the right eye if both eyes respond normally to stimulation of the left eye indicates damage to the sensory input from the right eye (perhaps to the right retina or optic nerve).[1]

Emergency room physicians routinely assess the pupillary reflex because it is useful for gauging brain stem function. Normally, pupils react (i.e. constrict) equally. Lack of the pupillary reflex or an abnormal pupillary reflex can be caused by optic nerve damage, oculomotor nerve damage, brain stem death and depressant drugs, such as barbiturates.

Normally, both pupils should constrict with light shone into either eye alone. On testing each reflex for each eye, several patterns are possible.[6]

Optic nerve damage on one side: (Example in parens.: Left optic nerve lesion)
The ipsilateral direct reflex is lost (Example: when the left eye is stimulated, neither pupil constricts, as no signals reach the brain from the left eye due to its damaged optic nerve)
The ipsilateral consensual reflex is INTACT (because light shone into the right eye can signal to the brain, causing constriction of both pupils via the normal oculomotor nerves)
The contralateral direct reflex is intact (because light shone into the right eye can signal to the brain, causing constriction of both pupils via the normal oculomotor nerves)
The contralateral consensual reflex is lost (because light shone into the eye on the damaged side cannot signal to the brain; therefore, despite the right eye's motor pathway (oculomotor nerve) being intact, no signals from the left eye are able to stimulate it due to the damage to the sensory pathway (optic nerve) of the left eye)

Oculomotor nerve damage on one side: (Example in parens: Left oculomotor lesion)
The ipsilateral direct reflex is lost (Example: when the left eye is stimulated, only the right pupil constricts)
The ipsilateral consensual reflex is lost (Example: when the right eye is stimulated, only the right pupil constricts)
The contralateral direct reflex is intact (because light shone into both eyes can still signal to the brain, and the pupil on the undamaged side will still be able to constrict via its normal oculomotor nerve)
The contralateral consensual reflex is intact (because light shone into the left eye can still signal to the brain via the normal optic nerve, causing attempted constriction of both pupils; the contralateral pupil constricts via its normal oculomotor nerve, but the ipsilateral pupil is unable to constrict due to its damaged oculomotor nerve)

I will write more later

782. The cat with foul-smelling ears claws the owner ferociously

2011-12-07T00:31:00.000-08:00

"My cat cannot walk properly, hunching her back and not walking normally with the hind body upright. What is the problem?"

The cat walked with hind limbs low on the floor as if stalking a prey. Hind limb lameness. Why?

As I did a full body check, the cat's ears were strongly smelling of bad rotten flesh. "Did you get the ears treated?" I asked the lady.

"I consulted the vets (at another practice) twice," the woman said to me. "They give me ear drops. The cat scratches me when I tried applying the ear drops. I gave up."

On the surface, it seems that ear infections and lameness are not related. Yet if you think about being a cat. What would you do if you have such painful smelly ears over the last few months? You would try to relieve your itchy ears with your back paws. Both ears. Both paws. You do it so often and over the months. Would you not strain your hind limbs and joints? Ear drops were not applied. You claw your owners for doing it. So, in time, you feel the back pain in trying to relieve your ear itchiness and hurt your back muscles. So you slink when you walk. Can't walk upright. A hypothesis.

That's my theory. "I will sedate the cat after a day of antibiotics and anti-mite injection," I said to the owner. It was a surprise to her that I had proposed this approach as she expected me to prescribe "ear drops".

Today, 2nd day. The ear stench was much reduced. The cat still clawed but much less. The right ear had lots of wax and debris. Will irrigate the ears under anaesthesia and hope that this will help the cat not to sufer any more pain. The last option would be surgery to open up the vertical ear canal. But not now. Wait and see after ear irrigation and painkiller/antibioitc medication which is a simple way.

781. The father's day present

2011-12-07T00:21:00.000-08:00

Yesterday, Tuesday, I worked past 7.30 pm and at 5 pm, I met a senior citizen who brought in a gold and white Shih Tzu of around 8 months old, with a bleeding toe nail. Dr Vanessa had treated it and bandaged the left hind foot.

"I better not do it myself next time," the taxi driver told me.
"Why did you buy this gold and white shih Tzu?" I asked.
"My son bought it for me," he said. "A present on Father's Day. From his friend."
I was surprised that the undergraduate with a scholarship would buy such a big responsibility for his father.
It was a good gift since the father loved the dog. "My wife used to dislike dogs," he told me. "But after getting this one, she loves dogs."
"That is great news," I said. "How is his toilet training?"

"I put his urine on the newspapers and he just go to the papers every time he needs to pee and poop," the father held on tightly to this high-maintenance dog.
"This is an intelligent dog," I said. "However, he is very thin. Feel the sharp spines," I showed the father. The thick luxuriant coat had covered up the thinness of the body.
I advised adding dry dog food to the usual canned food, at 80% dry food and the dog would put on weight. The son is good as now his parents have some company in an empty nest. Aged parents become "children" nowadays and so it is good that the dog keeps them company.

780. The 1.5-year-old cat started spraying his urine is under the scalpel today

2011-12-07T00:12:00.000-08:00

Wednesday morning.

A mother and her teenaged daughter rushed in with an older male cat for neuter. An "orange" cat that resembled the other one I wrote about last time. The same colour. That one bit the mother's hand while the mother was preventing him from the stray cat.

As time is precious to Singaporeans, I told the mum to go to Toa Payoh Hub with her daughter (school holidays) for one hour and come back instead of going home and come back again. She lived in Simei which is around a 30-minute drive away. "There are other clinics nearby your condo," I said. For some reason, she preferred Toa Payoh Vets and I was quite surprised.

"319074" was the postal code I had given to her when her daughter phoned the Surgery for the "pin number" as her driver mother could not locate my surgery. Nowadays, it is so easy if you have the GPS to locate places.

ANAESTHESIA
Weight: 5 kg
Xylazine 0.15ml + Ketamine 0.6 ml = 0.7 ml IM in one syringe.
Waited 10 minutes. Needed isoflurane gas 5% top up for less than 30 seconds. This shows that the dosage is a bit low for 5-kg cat. Should be xylazine 0.2 ml + Ketamine 0.8 ml without the need of topping up with isoflurane gas.

I ensured that whole scrotal and surrounding area has been plucked clean by Min and showed him how it could be done. Cleaned up scrotal area. Horizontal cut exposed two testicles. Removed them. Washed away the blood. When the owner came 2 hours later, the horizontal would appears to close together, so no bleeding or wound is seen. I asked Nicole to take a video and to record oral instructions of post-neuter care for video production. Hope this will turn out very interesting.

I asked my assistant Nicole to take some pictures to prepare a video on how to care for the cat after neutering. I had a rare case of a male cat's scrotal wound not healing some 14 days after neuter by Vet 1. So, these two cases would be able to illustrate the educational video on "post op care after neutering."

"You need to be a good story teller to connect with the audience viewing your video," I said to Nicole. "A good story is usually one where the viewer wants to know what's happen to the protagonist. For example, the video of FIV in a stray cat done by the two Temasek Polytechnic Vet Tech students. Do you find it engaging?"

"Yes," she said.
"Now, if you produce a video of 100 FIV cats with all their diseases, would that make it an interesting education video on FIV in cats?"
"No," she agreed.
"Similarly for the video on Caesarean sections produced by you for the 'Responsible Pet Ownership' video. There is no connection showing many picures of the dog and puppies after Caesarean section in the video. I would have shown the Maltese about to go under the Caesarean section. What happened to her. Did she give birth or not? Were all puppies alive? What happened next? Instead, several images of other dams and puppies after Caesarean sections were in the video."

I give free rein to the young ones to be hands on in producing the videos and that is how they learn. If I spoon-feed, they learn nothing.

759. Health screening for an 8-year-old Silkie

2011-12-06T23:29:00.000-08:00

"You have got your money's worth today," I said to the strict-looking wife as my assistant expressed more than 5 ml of road-tarry grey granular oil from the 8-year-old solid body male neutered Silkie Terrier. "For the past 8 years, no groomer or vet had expressed his anal glands and the normally light yellow oil had turned grey. I am surprised that the dog had not bitten his tail or his backside."

Showing what is wrong is important in vet practice. The woman in her late 30s and her taciturn husband smiled a bit. Humour is sometimes important in connecting with new clients. They were from Woodlands. The wife wanted a health check up from me and had made the appointment the day before. Vet 1 had told her that her dog suffers from Grade 1/2 heart murmurs and so she would want me to give a complete check. "The heart murmurs are confirmed," I said. "But it is not serious since your dog has no coughing or loss of energy." That was good news. "If you want X-ray to see whether the heart is enlarged and the lungs are normal, let me know." The left femoral pulse was of poor quality but I have to check again this Sunday.

"Is it necessary?" she asked.
"No," I said. "It is advised as there are no signs of heart disease.

"There are so many new practices with beautiful furnishings and furniture," I compared my older premises to such new practices and asked where she would come quite far to consult me. Many Singapoean pet owners are impressed by new clinics with their shine. "New furnishings are not important," the wife said to me. "It is the vet's experience."

PHYSICAL EXAM - normal despite complaint of the dog turning his neck to the side sometimes. A painful throat but the dog disallowed mouth opening. He would twist and turn whenever I tried to pry open his mouth. "I will check for infection or tumours of the tonsils and the back of the throat during dental next week," I recorded this finding.

BLOOD TEST - ALT increase double the higher range. Liver or muscle damage but this will need another test.

URINE TEST - "Not a chance that my dog had peed this morning," the wife said to me. "We watched him closely and brought him straight to you from Woodlands." Yet when I passed a urinary cathether into the small bladder, I could get around 10 ml of urine. Why?

Results - Bacteria 3+, protein trace, bilirubin +, SG high, pH 6.5, casts but no urinary crystals. Only the bacteria count was considered significant.

"Your dog may have cystitis - a bladder infection," I said to the wife by phone. The dog was neutered very young at 8 months and his belly and neck were pigmented due to scratching. As to the cause of this black skin pigmentation, it is hard to say but it resulted from skin scratching over a long time of years.

"Does he need antibiotics?" she asked.
"I did give you some baytril tablets 2 days ago for dental scaling, to kill off bacteria in the mouth 7 days before dental scaling," I said.

"Is my dog fit for anaesthesia since he has liver disorder?" she asked.
"The ALT enzymes are not very high and the dog has good appetite. He should be OK for anaesthesia this Sunday."

Today is Wednesday. I will do the dental scaling this Sunday. Overall, the dog has passed his health screening.

758. A dog owner asked about post-op spay care from Dr Sing

2011-12-06T16:10:00.000-08:00

Pre-Operation Guidelines for Spaying your Dog.

. The best time to spay your female dog is 2 months after her heat and at an age over 6 months

• Schedule an appointment with your vet. A blood test to screen your dog's health is advised one day before surgery.
• Make sure your dog is healthy, eating & drinking well for the past 3 days before surgery
• Give your dog a good bath, and wash the surgery area well the day before surgery

• Your dog should not eat or drink after 10pm the day before surgery, or 12 hours before surgery to prevent vomiting and choking during anaesthesia
• Bring your dog to the vet in the morning so that you can collect it in the evening after the day surgery.

Operation Procedure

• Your dog will be weighed and examined before surgery.
Isoflurane gas anaesthesia and/or an injectable anaesthesia will be given according to your dog’s health and temperament.
• The spay operation take about 30 minutes if there are no complications like bleeding

Post-Operation Guidelines for Spaying you Dog.

Frequently Asked Questions

1. What kind of food do I give, and when can I start feeding her?
If you take your dog home on the evening of the operation, it’s best to feed your dog the next day as there will be a possibility of vomiting due to the anaesthesia.

2. When can I bathe her?
Wait at least three days before bathing your dog. Cover up the wound with a water-proof plaster before bathing.

3. When do we remove the stitches?
Some vets use dissolvable stitches which will dissolve on its own, however, the vet may instruct you to return after 14 days to remove any remaining stitches.

4. What do I do in an emergency, or if the stitches break down?
If there is minor bleeding after a stitch tears apart, bandage the wound and bring your dog back to the vet as soon as you can. In case of emergency when the intestines can be seen or there is heavy bleeding, call your vet immediately.

5. When can I take off the Elizabeth Collar?
The E-Collar must be worn for 24 hours for 10-14 days, or until the stitches are completely removed.

6. Change the plaster protecting the wound on Day 2 if the vet has used a plaster.

7. Give pain relief and other medication as advised.

4-month-old red poodle scratches his ears vigorously

2011-12-05T21:52:00.000-08:00

Today, Tue Dec 6, 2011, I was surprised to see a trim couple in their late 20s all the way from Sengkang wanting to vaccinate their puppy (3rd vaccination). The puppy was bought from a groomer in Pasir Ris with scales like dandruff in the legs and ears and ear edges.

"My puppy keeps scratching her ears vigorously," the wife said. The edges of both ears had fine scales. The ear pinnae, the four legs also had lots of scales. What's the cause?

SKIN SCRAPINGS 3 AREAS
I suspect scabies. I used a new scalpel blade and scrape the skin of ear edges and the paw. No ringworm. No mites seen under the microscope.
"No mites can be seen as it is possible that the experienced groomer-breeder has had treated this puppy," I said. "The mites are deep under the skin and that is why they are so irritating as they tunnel under the skin and breed."

No proof of mites but I could demonstrate the ear scratch reflex. I rubbed the edge of the right ear and the right hind limb starts to wriggle and ready to scratch the flank and chest.

GRATE + PEN TRAINING.
The puppy was paper-trained in a confined area for the first 5 days but started accidents as the wife decided to widen the space for the puppy. "It should take 14 days of close confinement to succeed in paper training," I said. "The puppy can go inside the crate (grate+pee pan) as a toilet or living den. However, the couple bought a grate + pee pan. It worked. So good.

756. Adopting dog with skin disease - vet cost

2011-12-05T21:42:00.000-08:00

I am Dr Sing. It is best to adopt a dog with no skin disease. As for vet costs, it depends on what is the cause of the skin disease and prices vary from $60 to over $200 for complicated skin disease cases.

On Mon, Dec 5, 2011 at 6:08 PM, ...@gmail.com> wrote:

I have an enquiry to make and would really appreciate if you could help. I have decided to adopt a 6 months old Shetland sheepdog and border collie mix, but the breeder told me that he has skin problems, (he thinks it is fungus) on his back. I would like to know if I should wait for the wounds to heal before adopting it or i can adopt it and bring it to the vet for a check. If I were to bring the dog for a check at your veterinary, how much would it cost, ad how long would it take for the skin problem to recover?

Thank you,

E-MAIL REPLY FROM DR SING DATED DEC 6, 2011
I am Dr Sing. It is best to adopt a dog with no skin disease. As for vet costs, it depends on what is the cause of the skin disease and prices vary from $60 to over $200 for complicated skin disease cases.

755. Sunday's interesting cases. The male cat bit the mother is neutered

2011-12-04T01:40:00.000-08:00

Sunday's interesting cases of two male cats that got neutered

CAT NEUTER NO. 1
I was on duty in the morning of Dec 4, 2011. Bright sunshine although showers come in the afternoon. My first case was a Malay family bringing in a muscular male yellow cat with brown dots of 10 months for neuter. "I phoned yesterday for appointment at 10 am," she said. "This cat bit my mother and so I want him neutered!"

"Cats in Singapore apartments don't bite people, unlike dogs," I said. "Why would he bite your mother?"

"He was chasing away a stray cat that came to our apartment door," the lady said. "My mother grabbed him to stop him. He bit my mother's hand!"

Never interfere in fighting cats or dogs - that is the morale of the story.

NEUTER
5.5 kg. My formula is xylazine 0.1 ml + ketamine 0.4 ml IM for cats <4 kg for a female cat spay. In this male cat, the above dosage was given. It was effective even after a delay of 15 minutes as I had to vaccinate the Chihuahua who had bitten me when I visited the apartment some years ago. He was neutered and adopted by Theresa and daughter, a Myanmar family in Toa Payoh, that loves him very much. This dog was given up by another family in Mandarin Gardens as he was a handful, peeing and pooping everywhere. "Does he pee all over the apartment?" I asked. "No," the mother and daughter said. "He just goes to the toilet." This was a good ending for this naughty male dog who had put on considerable weight. As I had injected the above-mentioned cat, I informed Theresa that I had to rush and it was OK with her as she had to go to the market. She had started her employment agency business. "How's your business?" I asked her. "Not good," she said. "The MOM (Ministry of Manpower) keeps rejecting every application nowadays." There is a political shift of not granting work visas for foreigners as liberally as before since the locals are not too happy as these foreigners affected their salaries.CAT NEUTER NO. 2
A woman with a son with dark blue pierced ear studs on his left ear came with 2 cats that had been neutered and spayed 9 days ago by Vet 1. "The female cat is OK," I said. "The stitches will dissolve soon. There is one small hole due to stitch coming out but it is not a problem." She asked: "Can I bathe her? She is so smelly!". "Yes," I said. "Just put a plaster onto the wound and bathe her."

As for the male cat, there was an open hole in the right scrotal area with reddish discharge coming out. "This is very rare," I said. "I have not encountered such a case in my more than 30 years of practice." Vet surgery is always full of surprises. I said: "It could be something stuck inside the wound and that is why it is not closing. There is no pain at all when I press it. Still the cat must be sedated and the open wound examined."

"I have asked my friends and they say that cat neuter wounds usually close within a few days."

All surgeries do give rise to complications of one kind or another in some cases for all vets including some of my cases. Like infection, bleeding, pain. In this case, there was yellowish nodules coming out as I pressed the 5 mm vertical hole in the right scrotal area.

I gave the cat a very low dosage of xylazine 0.05 ml + ketamine 0.2 ml combined IM and collaborated with
Dr Vanessa to handle this case as part of my coaching program. "Put the artery forcep into the gap at 12, 3, 6 and 9 o'clock and pull out any strands of tissues." Systematically. She flushed with normal saline. I wanted the cat to go home as the owner mentioned about loose stools in both cases, since the two cats was given Clavulox for the past 9 days and I am worried that the cat would develop full diarrhoea in the Surgery. But Dr Vanessa advised keeping the cat in for observation and I was OK with it. From my experience, this wound would close after removal of debris inside. But it is wise to listen to other vets.

I phoned the owner who was at the back coffee-shop that the male cat remained in for observation. "This is my first cat," she said. "It is like first love," I said. "It is always remembered. Usually it is puppy love as we usually don't marry our first love! Have you got a first love, young man?"

The pre-teen boy who love jazz music seemed to nod his head. "But mum, you are a doggy person," the pre-teen son said to the hard-working mum who had much conferences to organise. I had more time to talk to them as Dr Vanessa handle the majority of Sunday's cases after 12 noon. It was good to see mother and the music son being close.

EYE ULCER IN THE SHIH TZU AGAIN
"The previous Shih Tzu had no eye problem," the lady in her late 30s brought back a young Shih Tzu with the right eye white red and tearing. The left eye had a central white scar but the eye white was not reddish.

I had not seen the other Shih Tzu but from what I had seen from other owners, the Shih Tzu could have less protruding eyeballs and its corneas would be pigmented and black due to irritation over time. "It is hard to say that your old Shih Tzu had no problem," I said. "Many Singapore Shih Tzu owners, in the old days, just ignored the eye problems as the Shih Tzu scratches to relieve its eye itch and pain. I would expect your Shih Tzu to have black or brown corneas unless its eyeballs were less protruding."

"You did stitch up the eyelids of both eyes some weeks ago," the lady told me. "Yes," I referred to my medical record where I illustrated two eyes. The left eye had a central ulcer which is now healed white spot of 3 mm with some blood vessels. The right eye cornea was written as "cloudy," but not ulcerated and would have healed.

Dr Vanessa put in the fluorescein strip and flushed off the green dye with a syringe of saline. There were 3 corneal opacities seen. At 3 o'clock, central and 9 o'clock but they were not stained green at all after flushing off the green dye by Dr Vanessa. "It is surprising," I said. "These ulcers are over 3 mm in diameter and yet they don't stain green as expected." The dog had been rubbing his right eye despite an e-collar of size 12. I recommended size 15 and eyelid stitching up again for 14 days. The owner wanted the dog home on the same day although I advised retaining him for a day or two.

"The solution to this case is to get the facial fold cut off by the vet," I advised. I took out the Canine Opthalmology book and showed her the operation and the illustratons in this old book.

"Your dog goes to the groomer regularly to get the fold hairs snipped but the hairs grow fast and irritate the cornea causing ulcerations. You also snip the hairs but it is not easy to do it frequently. The hair grows and the water and liquid is trapped in between the facial fold and the lower eyelid leading to itchiness."

The owner was not in favour of surgical resection of the facial fold as it cost money. It is important that the vet informs the owner of a long-term solution to the problem for Shih Tzus and Pekineses as many owners are not aware of such a solution.

755. Ten ivermectin injections for a hamster with skin disease

2011-12-01T13:16:00.000-08:00

Many lady hamster owners in Singapore are sophisticated and well educated. A lady asked if I had ivermectin for her hamster who has hair loss on the back and has been "cured" by Vet 1 near her residence with injections. Ten injections over the past few months but the problem came back. I had just performed a haemangiosarcoma surgery on her old white dwarf hamster which did not survive the surgery. The tumours were large and the cells were breaking down. Full of blood. The spinal area was invaded by the tumours. The dwarf hamster could not survive the surgery. The lady was understanding as I showed her the tumour cells and pieces taken out.

"It is ivermectin," she had the info from Vet 1. "A small drop". I don't give ivermectin by 10 injections to dwarf hamsters as I believe it is harmful as hamsters are so small. She said she would revert to her vet and asked for her hamster to be cremated.

754. SOP - Old cocker spaniel with skin disease

2011-12-01T13:08:00.000-08:00

Cocker Spaniel. Head wounds, whole body skin infected. Saw the vet many times. Recovered, then skin disease again. Now over 12 years old. Eye pus.

SOP
1. History. Ear canals full of pus.
2. Blood test - Total WBC high.
3. Skin checked for ringworm, mites
4. Advise ear canal surgery when the dog has recovered. But the owner usually forgets about it.

In this case, I told the owner that the originating problem was the chronic ear infections and that an ear surgery when the dog was young would have resolved much of the scratching of the neck and flanks. Floppy ears. Covered up ear canal. No ventilation. Dampness. Bacterial growth. Pus form. Ulcers inside ear canal. Very painful. Head shaking. Hind leg scratching. But no hope from medication and groomer as problem recurs.

It is hard to persuade the Singapore Cocker Spaniel owner to do ear surgery.

753. SOP - Gangrene in an old dog's tail

2011-12-01T13:01:00.000-08:00

The dog cut his tail spirally with a wound of 10 cm long. There was a lot of bleeding. Vet 1 stitched up and the dog went home after 4 days of being warded and cared for at Toa Payoh Vets. Gangrene developed lower down the tail. The dog had fever. The owner phoned me. What to do?

1. General examination
2. Complete blood test
3. At least 2 days of antibiotics and NSAID
4. Observe dog's appetite
5. Blood test before surgery is advised to check total WBC.
6. Isoflurane gas + O2 only at 1-2% intubated. IV drip.
7. Use electro-surgery
8. Amputate higher up to avoid gangrenous toxic tissues.
9. Post-op to stay in Toa Payoh Vets unless the owner insists on going home.

TIP. Many Singaporean dog owners have no time or are bitten when they try to clean the wound post-stitching. The e-collar worn did not prevent the dog from traumatising the tail due to pain. A long black area of the tail of more than 10 cm long developed. Gangrene. Dog had high total WBC when I admitted it. Best advice is to amputate the tail at the first instance as the owners just can't manage to nurse. Pain-killers with NSAID are not very effective in tail wound injuries for some reasons. So, I do advise tail amputation and have never received any unhappiness. In private practice, a good clinical outcome is what the owner wants. No repeat visits as this means spending more money at the vet.

752. SOP for hind lameness for an adult dog

2011-12-01T12:50:00.000-08:00

Yesterday, Dec 1, 2011 at 7 pm, a lady in her late 20s came with a 13-year-old Jack Russell. "He is better today," she said to me as I was at the reception counter. I could see the unique make up of a certain airline cabin crew and enquired whether she was from the airline. I said: "Hair in a bun and clipped, as slim as can be, a gait with confidence and a type of facial make up that never fails to attract attention."

"It is called ghost make-up," she was surprised that I could guess correctly her profession. Well, I do to see these slim and pale-looking ladies with blue eye shadows at the Singapore Changi Airport going to work or coming home. I did not realise that they look like "ghosts" until she told me.

In the consultation room, I did the examination with Dr Vanessa. A right hind lameness was the presenting sign. The dog's right paw was barely touching the floor. "This lameness has been going on for many years," she said. Other vets had examined it. I asked Dr Vanessa to do first and then I demonstrated my approach.

The Standard Operating Procedure.
1. History of lameness & general examination including teeth.
2. Observation of gait on the floor
3. Put the dog on the examination table. Muzzle the dog.
4. Palpation of spinal column. No pain/painful? Where?
5. Manipulations - dog standing (extend both hind legs and compare the length*). Put dog on side (left, right, upside down).

This is where I have to demonstrate. Basically, it is palpation, extension, flexion, abduction and adduction. Check patellar luxation.

*Put thumb on hip joint, extend hip, and knee of both limb while the dog stands on front legs. Show the owner the unequal length of the hind limb (if there is subluxation).

6. X-rays (2 views) if necessary. Arthritis, Legg-Perthe Disease, Subluxation, luxation of the right hind compared to the left hind hip.

7. Complete blood test to check for liver or kidney disease is recommended as lameness in 13-year-old Jack Russells may be caused by other reasons.

8. Costs to be made known to the owner.

750. SOP - Post-purchase exam of a mini-Maltese

2011-12-01T12:22:00.000-08:00

Yesterday, Dec 1, 2011, a mother and young daughter came specifically to see me with a newly purchased mini-Maltese. She was given 24 hours for vet examination of this Maltese which cost $1,500.

I did the case with Dr Vanessa as I want to standardise the procedures in the post-purchase examination at Toa Payoh Vets to ensure a high standard of care and medical recording. Basically to be able to defend the practice in the event of litigation and complaint investigation.

As in the medical profession, each doctor has his or her own approach to post-purchase exam of a puppy. I want to make sure that Toa Payoh Vets' approach cover the bases and be able to be defended in the event of litigation and this is where I have to implement the Standard Operating Procedures (SOP). In equine medicine pre-purchase examination, the SOP is quite well defined but I don't find them commonly available in canine medicine.

The SOP is as follows:

1. Use the General Examination form and fill up the details of examination of the major body systems. Dates of the 3 vaccinations to be recorded. The vet is to be meticulous in doing the examination and recording all questions asked in the form and write remarks/comments. He or she is to sign and date the form. One copy for the owner and one copy to be kept at Toa Payoh Vets in the medical case file.

2. Do a Parvoviral test. This is mandatory for Toa Payoh Vets as parvoviral infections are common in breeders and pet shops.

3. Other tests are optional and must be explained to the owner. This includes complete blood tests, urine test, faecal test, ultrasound and X-rays whenever necessary.

4. Record house-training technique of new puppy - paper-training or grate training. The vet is to advise if he or she is able to do so. Most first-time owners appreciate this advice but not all vets can advise as it is a more complicated subject and needs reading up first.

5. Inform the owner that the Seller may have given medication to the puppy to suppress coughing (Kennel cough) and it will take at least 7 days to know if the puppy has viral and bacterial infections acquired at the Seller's premises.

749. Cataract surgery in undeveloped countries

2011-12-01T12:09:00.000-08:00

This is the operation performed by Dr Sanduk Ruit.
http://www.youtube.com/watch?v=5nnQDscK7SI

Can this be done on dogs as presently it costs over S$3000 to do a cataract removal in an aged dog in Singapore?

748. Verrucca

2011-11-28T03:42:00.000-08:00

There was a suspicious growing brown growth on my left chest. It was around 0.5 x0.5 cm x 0.2cm. As I do advise pet owners to get growths removed when they are small, esp. for older pets, I practise what I preach. So, today, Monday, Nov 28, 2011, at 7.15 am, I was at the Ambulatory Surgical Centre of the Singapore General Hospital to remove "verrucca" as stated by my surgeon. Last week, I saw a nurse from China googling when I was sent to the room to receive financial conselling. This is compulsory for all. "What are you googling?" I asked the friendly nurse who had seen me before for a synovial cyst excision on my right thumb. "Just to check the spelling of verrucca what Dr Foo wrote," she said. I was impressed with the thirst for knowledge imparted to the nurses.

On the surgical table, I asked Dr Foo whether he could remove the many red growths, as if blood vessels had burst. One young nurse told me: "In China, your many red spots on the man's skin are signs of good fortune." No wonder I am still alive.

I had a blood pressure monitoring arm band on my left forearm which expanded at regular intervals, giving readings in red.Another nurse who monitored my blood pressure asked if I have been active exercising. "Low pulse rate? Is it good or bad?" I asked the nurse. Low heart rate seems to be uncommon for senior citizens as I had been asked this question in another surgery. "I don't think Dr Sing exercises at all," Dr Foo commented correctly.

The carbon dioxide laser machine came into the room. I had multiple warts on my upper chest and so this machine would be useful. The nurse swabbed my upper chest with some liquid. Then Dr Foo got a purple marker pen to circle the verrucca or warts. "How many warts do you mark?" I asked Dr Foo. "Eleven. I am injecting local anaesthetic," he said. "It may be painful."

My eyes were covered by a piece of wet swab to prevent the bright operating lights blinding me. So I could not see what was going on as the laser buzzed. I could feel slight pain in some and none in other wart removal areas. A whiff of BBQ smoke pased my nostril. Soon, it was over. 3 samples of growths were taken for histopathology. The red one which was said to be a haemangioma and would recur when removed. A brown wart. Dr Foo said to the two young cheerful nurses from China: "Take the one rounded brown growth Dr Sing was worried about for the lab." I thanked him. "It could be an accessory nipple," he said of the brown growth near my armpit. "It is on the line," Dogs do have 5 pairs of nipples and well I knew what he was talking about.

Overall, it was a pleasant and enjoyable experience at the operating theatre. The bright yellow Crocs clogs were outstanding in two nurses. The others wore blue, green and black coloured ones. One man wore white boots. The cream0white vinyl tiled floor with red square patterns was very clean and shiny. There were 6 operating theatres. I could not understand why the large word "WASH" was pasted on the stainless steel sink where the surgeons scrubbed up and washed their hands pre-surgery. I saw one surgeon putting on a cloth glove and two more pairs of latex surgical gloves. "Some surgeons are allergic," the kind nurse explained to me.