2162. Carnaissal tooth abscess treatment in a Pomeranian - follow up 6 years later

TOA PAYOH VETS toapayohvets.com   Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074   Tel: 6254-3326, 9668-6469, 9668-6468.  judy@toapayohvets.com  
21 May, 2015   Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles & rabbits
A Facial Wound did not heal: Oro-nasal fistula follow up 6 years later
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written: November 15, 2007       Update:  21 May, 2015

"Why didn't you come for the surgery?" I admonished the lady owner of the Pomeranian. "You wasted more money buying more antibiotic powder from the pet shop to dust onto the facial wound, hoping it would heal. You can see the wet wound under the left eye in the image below. It is a classic presentation of an oro-nasal fistula, also known as malar abscess or carnaissal tooth abscess. 


"For ordinary skin wounds, the antibiotic powder would heal them, but I had already explained to you why the wound would never heal without dental extraction of the infected tooth."
Her 4-year-old Pomeranian had a weeping wound of around 0.5 cm in diameter below the left eye, above the maxillary 4th premolar tooth. It did not heal over the past weeks despite various medications and powders she had sprinkled on.
Some 14 days ago, I had patiently explained to her by illustration how the infection from the root of the maxillary 4th premolar had spread into the nose from the diseased gums to the skin below the eye.

The bacteria from the decayed roots of this premolar had dissolved the nasal bone area and made a hole. This condition is called an oro-nasal fistula. Dental surgery to remove the infected premolar would resolve her Pomeranian's non-healing wound problem once and for all.

"The vet did a slick sales presentation to make me spend money unnecessarily" the husband of the dog owner must have told her. "How can a rotten tooth inside the mouth cause a hole on the skin below the left eye. This doctor is nuts and is desperate to make money. Mouth and nose. So far apart. How can there be a connection?"
Back to the present, I said, "Surgery was to be done 7 days ago after 7 days of antibiotics. But you did not turn up till today --- 14 days later!"

The middle-aged lady shook her head.  I forgot my bedside manners by scolding her. The customer is king. The general anaesthesia and tooth surgery was affordable for her as I had discounted my fees. That savings  could buy another sari from Niven Road's sari shop.  

I was annoyed because there was an optimal time to do extraction of the infected and decayed tooth. It was after 7 days of antibiotics and she had not kept her appointment nor cancelled it. 

She just did not turn up as there was less weeping of the wound due to antibiotics. However after the course of antibiotics, the bacteria in the infected teeth had resumed their attack and the facial wound became wet and bleeding again.

The lady pulled up her fine and most colourful sari and smiled sheepishly, "My husband wanted to use the money for the dog's anaesthesia and surgery to go to India for holiday lah!"

Now that the dog is no longer on antibiotics, should I operate? There was no urgency in the sense that it was an emergency. But it would be in the best interest of this poor dog to be cured as soon as possible. 

The Pomeranian's teeth were not brushed at all as this is a common practice in Singapore. 
Initially bacteria attacking the food debris on the tooth gum line would die in 3-5 days to form a plaque on the tooth surface. As the dog's teeth were not brushed daily or at all, more plaque accumulated on the surface of the teeth.

Soon they become tartar (calculus). The gum became infected, leading to gingivitis. The root of the 4th premolar tooth of the upper jaw became abscessed due to bacterial attack. Abscess tracked upwards towards the nose and side of the face. Soon a facial wound appears to form a connection (oro-nasal fistula) between the tooth and the skin, discharging pus daily. As the pus and fluid from the mouth is discharged daily, the wound can never heal as it is always infected.
The decayed 4th premolar and lst molar became loose as their roots had been exposed as the diseased gum diseased shrivelled. The supporting structure of the teeth was weakened by the bacterial attack, leading to a loose tooth that would fall out in time to come. 

At this time, there was no choice but to extract these two loose teeth. Otherwise the Pomeranian would suffer from daily toothache as the owner's husband might thwart her from doing the right thing for her dog. I put the Pomeranian under general anaesthesia gas and got the offending teeth extracted and scaled the other good teeth to remove the tartar.

BLOOD TEST & OTHER PROCEDURES. There was no pre-anaesthetic blood tests to assess the liver and kidney functions and blood cells of this younger Pomeranian. Veterinary costs would be additional $150.
Most likely the poor Pomeranian would not receive any veterinary attention if an increase of $150 was added to the veterinary expenses.  Therefore I did not require blood tests to lower the medical costs.   

Physical examination of the Pomeranian indicated that there was no cardiac problem and there should be no death from general anaesthesia. The dog's anaesthesia was uneventful. He went home on the same day and had no more facial wound below the eye since 2007 to 2013. I was fortunate to get an image of the Pomeranian in 2013 as shown below: 

2007 image of the Pomeranian

The image below showed the Pomeranian just after removal of the bad teeth.

The facial wound closed after a few days when I phoned the lady owner to follow up after extraction of the infected teeth. "You are a good vet," the lady surprised me with her compliment especially after my admonishment. She was free from the chore of having to clean the facial wound daily. Her dog was more active and has a livelier demeanour. And what more joy could a lady have than to see her companion having a higher quality of life?

2013 image of the Pomeranian with no oro-nasal fistula

UPDATE IN FEB 2013
I have not seen the Pomeranian since 2007. He was 4 years old then. In Feb 2013, the owners came with the Pomeranian asking me where to board the dog for Chinese New Year. I took the following image of him with a face that has no more oro-nasal fistulas for the benefit of readers.

As at May 21, 2015, I have not seen this dog since Feb 2013. More interesting cases of dental problems in Singapore dogs are at:
Toa Payoh Vets Clinical Research: Mouth problems in Singapore's dogs


Yearly dental check-ups may prevent tooth decay and gum infections and painful eating for your dog and cat.  For dental check-up and scaling appointments, tel: 6254-3326, 9668-6468
e-mail judy@toapayohvets.com
.

Copyright © Asiahomes
All rights reserved. Revised: May 21, 2015
Toa Payoh Vets

2161. Teaching the child to be kind to hamsters

May 20, 2015

"My mum keeps putting eye drops," the 11-year-old girl said again when the 2nd worst case of eye abscess hamster is discharged after 4 days of in-patient treatment.

The slim little girl is bright as she topped her Science examination but she confessed she failed her Maths. The mother had told me she applied eye drops but the dwarf hamster's lower eyelid kept growing bigger and bigger. "Pus leaked out from her eyelids," she said to me. So, she texted and emailed me to get an appointment.

The little girl could not understand why the mother was doing the hamster treatment but in the real world, many mothers would do that, to save money as a family expense in Singapore is very high.

The left lower eyelid was full of bacteria and pus kept forming. On the 2nd and 3rd day and even on the 4th day, I had to lance the residual pimple on the upper right eyelid and the lower conjunctiva.

The mother brought the daughter to visit the hamster on Day 3 and decided to wait another day for the pus to go away.

The worst case was seen in 2008 documented in my webpage at:
 
http://www.bekindtopets.com/animals/20080917Hamsters_Eyelid_Abscesses_ToaPayohVets.htm

2160. Chronic kidney failure in a 12-year-old cat

May 20, 2015





"What is the stage of kidney failure in my cat?" the young lady asked when I told her that her 12-year-old cat had high serum urea 36.1 (7.2-10.8) and creatinine 423 (71-160).

The cat also had low platelets 226 (300-800). but the red blood cells were normal. Neutrophils were 97% (60-70%) with absolute 13.7 (3-11.5), but the total white cell count was normal.



Vets seldom if ever stage the stage of kidney failure, unlike in human medicine. Her cat came in last week for not eating.


The cat was very thin or emaciated. He had poor appetite for the past one year. For the past 2 days, he stopped eating. There was a bad breath which could be due to teeth and gum infections. The rectal temperature was 37.2C, below normal.


"The kidneys are enlarged but there is little pain on palpation," I said. "A blood test is the minimum to check for kidney disease." I said to the parents who came in with the young girl. "I had a case where the owners did not want the blood test to check for kidney impairment and other diseases. The cat did not recover his appetite and he went to another vet."


I gave the parents some time to think about the blood test. Many Singapore cat owners just want some antibiotic injections but are not happy when the treatment does not work.


In this case, the cat had lost weight for the past year or more. He would be suffering from chronic kidney failure. What is the cause?

He could have hyperthyroidism but my hands are tied as the owners want the least medical costs. 
I gave the cat 200 ml of Hartmann's Solution and dextrose saline with vitamin B, antibiotic and anti-inflammatory. In the afternoon, his rectal temperature had gone up to normal 38.3. He went home and it was 3 days later before he ate.

Fortunately, the parents consented to a blood test and we know that the cat has kidney failure and an impending bacterial infection (neutrophilia and low platelet count). But more tests like X-rays, more detailed blood tests and urine tests are needed in the ideal world, to check for urine proteins, blood potassium, calcium, proteins and reviews.   

UPDATE ON MAY 21, 2015
The young lady made time to buy the Prescription Diet K/D for her cat. "Measure volume of water intake per 24 hours and record in the chart," I advised. "Hand-feed the K/D mixed with 90% of original canned food first until the cat eats 100%. If you just offer the K/D immediately, the cat will not eat it."

These are the tips of changing over to a new diet. The owner must make an effort to mix the new food at 10% and coax the cat to eat it till 100%. The cat is said to be eating and active. Chronic kidney failure cannot be cured as much depends on the cause which is unknown. It could be toxicity of the environment as the platelet count was low.

Will wait and see.  

2159. Injectable anaesthestic in an animal shelter and Toa Payoh Vets

TOA PAYOH VETS
toapayohvets.com   Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074   Tel: 6254-3326, 9668-6469, 9668-6468.  judy@toapayohvets.com  
20 May, 2015   Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles & rabbits

Injectable Anaesthetic Procedures in
an animal shelter and in Toa Payoh Vets
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 8 May 2008
Updated:  20 May, 2015
PART I. Sharing Knowledge with Veterinarians
Anaesthetic Procedures in NANAS
Sunday, Apr 27, 2008
I visited NANAS (Noah's Ark and Natural Animal Sanctuary), an animal sanctuary in  Johor on a fine cloudy humid Saturday afternoon of April 26, 2008 to know more about animal shelter medicine.  I had the opportunity to study the effects of Zoletil combination being used.

To share knowledge with others working in dog and cat shelter medicine in other countries via the world wide vet, I have recorded below the following effective anaesthetic regime in NANAS. It is an alternative to gas anaesthesia and is less expensive. The dosage is as follows:
1. Zoletil 50 (Virbac) white powder is present in a bottle.
Tiletamine 125mg, Zolazepam 125 mg. I refer to this as the Zoletil bottle.

2. Xylazine 100mg/ml in a bottle.  Put 2 ml of this into the Zoletil bottle.

3. Ketamine 100mg/ml in a bottle. Put 8 ml of this into the Zoletil bottle.

4.  The bottle now contains a clear solution of 10 ml.  This combination is used as shown below:
FOR CAT SPAYS
1-2 kg.  0.15 - 0.18 ml IM
Bigger cats  0.2 ml IM.
I noted that the duration of surgical anaesthesia was more than 30 minutes in cats 1-2 kg being spayed. The tongue is pulled out as a routine to prevent food being vomited during surgery. Such food  gets into the lungs and cause death by inhalation pneumonia.  Surgical incision is midway between umbilical scar and pelvic brim in the young cats being spayed.  

FOR DOG SURGERYIn a dog of around 15kg , a 0.8 ml IM permitted surgical anaesthesia of around 30 minutes in one case of conjunctival growths being removed. As the dog showed signs of waking up (eye reflex and mouth clamping), a 0.6 ml IM was injected. The dog was under surgical anaesthesia within 1 minute.  Topping up may be required at Animal Shelters.

POST-OPERATION
In NANAS, the following were given for cats and dogs.
1. Tolfedine 4% (tolfenamique 4g) at 0.5 ml IM or SC for cats after spay and neuter. A pain-killer.
2. Amoxicillin (Longamox) at 0.5 ml SC for cats after spay. An antibiotic.  

PART II. Sharing Knowledge with Veterinarians
Anaesthetic Procedures in TOA PAYOH VETS, SINGAPORE.

Recently, some owners asked me why there were no antibiotics given after sterilisation of their male cats. Generally, no pain-killers or antibiotics are given to your male and female cats post-operation from Toa Payoh Vets for cases operated by Dr Sing as experience indicates that they are not necessary. Many owners find it hard to give oral medication to cats. 

In big dogs, non-steroidal anti-inflammatory pain-killer and antibiotics may be prescribed after spay.   Typical anaesthetic regimes for cats living and born in Singapore are shared with fellow veterinarians by Dr Sing Kong Yuen.  Some vets may seek such internet information.  They are as follows as at Feb 1, 2009:

For Dr Sing's cases at Toa Payoh Vets, the anaesthetic regime is usually:

Xylazine & Ketamine injectable anaesthesia are used for cats. Dosage is xylazine 20 mg/100 ml at 0.2 ml mixed with ketamine 100 mg/ml 0.8 ml in 1 syringe, IM injection. This dosage is most effective for a cat around 2-4 kg. Onset of anaesthesia is 2 minutes after IM injection in most cases. Duration of surgical anaesthesia is at least 30 minutes.

For fat cats or young ones less than 2 kg, half the above dose is sufficient but surgical anaesthesia is less than 10 minutes compared to 30 minutes in above full dose. If necessary, isoflurane anaesthetic gas at 5% is given by mask for one minute to effect to complete the surgery.

Xylazine & isoflurane gas anaesthesia or gas anaesthesia alone are usually used for dogs by me as I find them to be most effective. I want the patient to wake up within 1 minute at the end of surgery. For injectable anaesthetics, the patient sleeps a long time and this has advantages and disadvantages. Many owners are happy that their pets are already awake after surgery. 

Please note that the xylazine solution I used is 5X less potent than that used for the Zoletil combination at NANAS. It is 20 mg/100 ml xylazine, not 100 mg/ml which is the bottle usually used for horses

Toa Payoh Vets do use Domitor, Antisedan, Zoletil anaesthetic protocols as well.  Experiences are recorded in other webpages.

UPDATE ON MAY 20, 2015. I found that the following formula is effective and safe:
For a healthy and young dog, 10 kg. Domitor 0.4 ml + Ketamine 0.5 ml IV in one syringe.
Duration of anaesthesia is around 20 -30 minutes
Onset is 5 minutes.
No need for isoflurane and O2 gas top up if the spay can be completed within 20 minutes

For old dogs, 50% of dosage with isoflurane gas top up if necessary
For a 16-year-od sick dog, 10% of dosage for short sedation is safe generally.  

INCISION SITE.
In NANAS, I observed that the incision begins at the middle 1/3 area between the umbilical scar and the pelvic brim. Cats I observed were around 6 months of age. The cat's tongue was pulled out to one side of the mouth to prevent vomitus from being swallowed. Bladder was expressed so that the bladder would not be nicked. 

At Toa Payoh Vets, I incise at the cranial 1/3 area, at 1 cm from the umbilical scar in dogs and cats. This position enables me to easily access and ligate the swollen "on-heat" ovaries easily, especially in dogs. Palpate for the full bladder and express it free from urine before spaying. Be careful not to nick the full bladder. Seldom do I encounter a full bladder at this location but there needs to be care in incising the linear alba in case the bladder is just below. Palpate the abdomen first to check for the bladder and express the urine.

PART III. Sharing Knowledge with Veterinarians
Anaesthetic Procedures in one Singapore veterinary practice

I have insufficient experience with the following anaesthetic regimes but am recording the procedures based on information provided to me by one vet with considerable experience in the following anaesthetic protocol without the need to use gaseous anaesthesia as at Feb 2009.

1. Xylazine 20 & Ketamine 100.
1.1  For example in a Jack Russell, 5 kg dog.  1-5 years old.
Xylazine 20 at 0.4 ml IV, Ketamine 100 at 0.1 ml IV.
Separate syringes. Then top up with Zoletil IM injection if necessary
1.2  For example in a Jack Russell, 6 kg dog.  1-5 years old.Xylazine 20 at 0.4 ml IV, Ketamine 100 at 0.2 ml IV.
Separate syringes. Then top up with Zoletil IM injection if necessary
1.3  For example in a Jack Russell, 10 kg dog.  1-5 years old.Xylazine 20 at 0.8 ml IV, Ketamine 100 at 0.2 ml IV.
Separate syringes. Then top up with Zoletil IM injection if necessary

1.4  For example in a Jack Russell, 15 kg dog.  1-5 years old.Xylazine 20 at 1.3 ml IV, Ketamine 100 at 0.2 ml IV.
Separate syringes. Then top up with Zoletil IM injection if necessary

1.5  For example in a Jack Russell, 20 kg dog.  1-5 years old.Xylazine 20 at 1.6 ml IV, Ketamine 100 at 0.4 ml IV.
Separate syringes. Then top up with Zoletil IM injection if necessary

1.6  For example in a Jack Russell, 2.5 kg dog.  10 years old.
Xylazine 20 at 0.2 ml IV, Ketamine 100 at 0.05 ml IV.
Separate syringes. Then top up with Zoletil IM or IV injection if necessary

2.  TOPPING UP WITH ZOLETIL when the animal shows signs of movement and recovering from surgical anaesthesia from the xylazine/ketamine combination.
Zoletil 100 powder. Add 10 ml diluent. The solution is equivalent to Zoletil 50 now.
Use 0.1ml Zoletil 50 IM for small breeds
Use 0.2 ml Zoletil 50 IM for big breeds (20 kg) 

Topping up with Zoletil IM in the above protocols is effective. The above is useful for vet surgeries without gas anaesthesia or in field work. It is much more expensive to install gas anaesthesia in certain situations and I hope the above information will be of use for practitioners. Obviously, the older dogs and cats will need half the dose and there is a need to be very careful with injectable anaesthetics. It may be best to refer to other vets with gas anaesthesia facilities, in the best interest of the animal.

CASES IN MAY 2009 AT TOA PAYOH VETS
RABBIT INJECTABLE ANAESTHESIA
1.3 kg. Around  4-5 months old. Neuter.
0.1ml Zoletil 50 IM. Wait 5 minutes. Give 0.05ml Domitor IV ear vein, 27G needle.  Effective general anaesthesia. Rabbit takes >1 hour to wake up. No problem. No need for Antisedan. 

CATS INJECTABLE ANAESTHESIA2 kg. Around 8 months
0.1ml Ketamine 100 and 0.05ml Xylazine 20 IV in one syringe gave general anaesthesia >60 minutes for spay.

2.5 kg. Around 1 year
0.1ml Ketamine 100 and 0.1ml Xylazine 20 IV in one syringe gave general anaesthesia >60 minutes for spay. Femoral vein used. 

A beautifully designed cat house in NANAS. Waterfront views and wooden floor boards.

An open area permitted cats to get out and enjoy the views and sun.

I introduced a 2nd-year Murdoch University vet student who loves cats to visit NANAS with me so as to expose her to animal shelter medicine. Would she set up a cats only practice in Singapore? Would such a practice be feasible?

PART IV. Sharing Knowledge with Veterinarians - a Singapore PDSA?

A stray male cat after neuter by Dr Sing in 2003 using xylazine 0.2 ml IM and gas anaesthesia at that time. Clipped left ear tip in stray cats indicate they have had been sterilised. But stray dogs do not get such treatment and it is difficult to know the status of whether the female stray has been spayed or not. 
Despite a first-world country status, Singapore unfortunately does not have a charitable foundation like the People's Dispensary for Small Animals (PDSA) in the UK to cater to the treatment of sick street cats and dogs for owners who can't afford veterinary treatment.

I saw practice with a private vet in in England in the 1973 during my 4th year at Glasgow University. He spent 1 day a week at the PDSA to offer his veterinary services. What stuck in my mind was the arrival of a driver/owner of a Jaguar car. He brought in a dog for free treatment. One presumes that the Jaguar car owner does not need the help of the PDSA.    

It is hoped that one day, one of our successful entrepreneurs will set up a Singapore PDSA to help owners who can't afford veterinary attention for their pets. 

SOME CASES OF CAT SPAYS DONE BY DR SING KONG YUEN

Xylazine: ketamine injectable combination for the 2 fat cats of around 5 kg neutered by Dr Sing. Dosage was halved for cats 2-3 kg. Surgical anaesthesia was around 5 minutes as the dosage should be higher. Neutered around 5 minutes after injection. No topping up was needed in this case. If necessary, I would use gas anaesthesia for 1 minute. That would be sufficient to provide surgical anaesthesia.

For this pregnant 4-kg cat, the xylazine: ketamine at 0.2 ml:0.8 ml IM (usually given to cats 2-3 kg) permitted excellent surgical anaesthesia of around 30 minutes for spaying.

Dr Sing's incision for spaying of cats is normally 1 cm caudal to the umbilical scar. The incision length is 1 cm if the cat is not pregnant. In this case, it is longer as the womb is much larger due to the presence of foetal lumps. Ligate the uterine body in this pregnant cat two areas although there should be no slippage of sutures with one ligation.

A street cat weighing less than 2 kg. The xylazine: ketamine dosage was less than half of that used for cats 2-3 kg. The skin incision is around 1 cm. Two horizontal mattress sutures are usually given.

How young should your cat be spayed? If it is a street cat, animal activists get them spayed as young as 4 months. For your pet cat in Singapore, I would advise 6 months so that her private parts can develop into adult size. If she caterwauls (meowing loudly non-stop), wait till she stops caterwauling to get her spayed as it will be bloody doing it during this stage. The above cat in Singapore  was spayed around 5 months of age by Dr Sing Kong Yuen.

1962-67. Neutering a 2-month-old hamster at Toa Payoh Vets

FOR MORE CASES AT TOA PAYOH VETS, goto:
Cats or Dogs

Copyright © Asiahomes
All rights reserved. Revised: May 20, 2015
Toa Payoh Vets

2158. How to prevent dry eyes in your old dog

A 13-year-old Silkie has sticky right eye discharge everyday for several months.

"Dr E prescribed  eye drops and eye ointment and they were effective for some time," the wife took out the bottles from the plastic bag and put on my consultation table. "After a while, they don't work and I went to the pet shop to buy the eye drops. I don't want the same eye medication from you."
17. How to take care of your old dog's eye  (Video)



Surprisingly, the left eye cornea was as clear as a crystal but the right eye cornea was scarred with brown dots of pigments covering 80% of the surface. The eye white was reddish as compared to the normal white of the left eye.

"Has the dog been rubbing his right eye with his right hind leg daily?" I asked.
"Yes, yes," the husband said.
I applied fluorescein eye drops onto the cornea (video) and there was no ulcerations as there was no green stain.

"The brown pigments on the right eye cornea are caused by long-time scratching and now is scarred," I said. "There is no chance of reverting to the clear cornea. Now, we need to prevent the 20% of the cornea from becoming covered up with brown pigmentation."

"The possible causes could be the right ear pain as the dog wanted to snap at me when I palpated the ear. Another cause could be tooth ache as the roots of the back upper teeth are exposed and the teeth are cemened with thick tartar," I explained to the owners.

Sedation 5 kg, 13-year-old  Silkie: Domitor + Ketamine 0.05 + 0.05 ml IV 
Ear irrigation
Eye irrigation with 3rd eyelid everted to flush out debri
Optomimmune and eye drops. E-collar.
Inj. antibiotic and anti-inflam.
E-collar for 2 months.

To review in 3 weeks and dental scaling.  

CONCLUSION
Allergy to commercial ear drops, vigorous overcleaning of the right ear and periodontal diseases can cause ear scratching with collateral damage to the right eye in this case. Early dental scaling would have been preferred.

2157. The old German Shepherd is scratching furiously

Monday, March 18, 2015
After 2 days of scratching from nose to paws, the owner phoned me for help. The 2nd sister had given this dog a piece of chicken on Mother's Day and now the dog keeps scratching her body.
She was fed only meat and rice nowadays and was all right. If fed commercial dog food, she would have diarrhoea and itchy body.

This old German Shepherd has bad hips and could not stand up if the carprofen injection under the skin is not given every 2 weekly. She got this injection from another vet every 2 weeks, not wanting to bother me. Lately she had her cataract operation on one eye first. As the surgeon had been on medical leave, after operating on 150 cases in one day, she saw her relief surgeon. She was a popular in great demand surgeon and had to take leave. So she packed the previous day's cases to the next day, totalling 150 cataract operations.

The relief surgeon read her medical notes and said: "It is lucky that you had opted for the mono-foal lens instead of the multi-focal as you have scars in your retina."

However, the surgeon had actually recommended multi-focal lens and she had accepted this advice. In multi-focal lens, you don't need reading spectacles. However, 3 days before the surgery, we went to my family optician, an experienced man in his 50s. He said: "Some of the people having multi-focal lens suffered side effects of seeing flashing lights and get depressed. There is no cure for this. Taking out the multi-focal lens and replacing a mono-focal is not that easy as in the first implant. With mono-focal, you need to have prescription lenses to read but you don't have these flashing lights."

So, this owner was very unhappy with the surgeon.    





  

2156. Third opinion. The stench of covered armpit wounds in a 16-year-old dog

Sunday May 17, 2015

The 16-year-old Maltese was afraid of me examining the wound, despite being given Tramadol painkiller tablets by Vet 2, 4 days ago. I was unwrapping the elastoplast and yellow wrap around self-adhering bandages covering the long left armpit wound. As I unrolled the bandage, the smell of rotting flesh permeated the consultation room.

"Vet 2 had given an antibiotic injection guaranteed to last 2 weeks," the young lady owner said. "So, he only prescribed the Tramadol, 1/2 tablet 2 times a day."
 
"Was Tramadol effective?" I asked.
"Yes," she confirmed that the dog was walking around when given the medication.

The dark greenish stained gauze under the bandage gave off an offensive odour of dead meat. I tried to control my breath. It is an odour of decomposed egg few Singaporeans will ever smell. It glued onto my fingers and needed several hand shampoos to get rid of the smell.

Vet 1 had prescribed some antibiotics and cleanser but this did not work. The dog's armpit got infected. So Vet 2 bandaged the leg from the wrist upward and adduct the armpit closer to the body with Elastoplast. The owner must return every 3 days to get the bandage changed. The owner sought me as the 3rd opinion.     

The dog was practically screaming when I slowly unwrapped the bandage. He had a high tolerance to pain and had taken half a tablet of a 50-mg Tramadol.

"There's no choice but to sedate him to clean up the bad smelly armpit wound," I told the owners. "When a wound is covered up, it becomes smelly as a different type of bacteria thrives and grow in the flesh. It is highly risky as he may die. I will give a very low dose."

I can understand that Vet 1 and Vet 2 do not want to take risk in anaesthesizing this old dog to stitch up the wound. It is a thankless option if the dog dies. Some owners just blame the vets when the dog dies, implying negligence and incompetence.

I gave Domitor and Ketamine at 10% of the normal dosage IV. The dog slept for less than 10 minutes and the armpit wound was flushed and irrigated. The dog was shampooed. I applied KMnO4 powder, injected antibiotics and inflammatory and the dog was sent home.