1013. Travels broaden your mind if you know how

1013. Travels broaden your mind if you know how


It is 8.42 am May 30, 2012. I have just returned from a 5day-4night packaged tour to Hong Kong, Shenzhen and Macau on May 29, 2012. Packaged tours are the least expensive way to travel and if you know how, the best way to broaden your mind if you know how to do it.



Shopping till you drop in air-conditioned comfort is a favourite of the Singaporean traveller. I will not be commenting on this retail therapy as I prefer not to visit the shopping malls of other countries if possible.



How to broaden your mind in your travels?



1. Listen more. Listen to your tour guide to gain knowledge of the world.

An experienced guide will provide much local information v. Singapore's situation. For example, my lady tour guide in Hong Kong mentioned that only 20% of the residents get public housing while 80% of Singaporeans get public housing. She was incorrect in the sense that the 20% of Hongkongers are renting public housing at very low subsidised rental rates while 80% of Singaporeans are "owners" of 99-year-leasehold HDB apartments. The statistics mean nothing to the average Singaporean but there is an economic significance. For example, the young Singaporean couple will find it better to buy the HDB flat rather than rent as rental flats, even in Hong Kong, are subject to long waiting lists and prices have had shot up recently.

2. The world is nowadays much more competitive. Speak to your tour guide and know how competitive her job and the travel industry has become over the last two years. Too many travel agencies have been set up and the more successful ones have grown big and can take away the business of the small ones. Success creates success. If you own a small business, like a solo veterinary practice you can see that you will be affected too as the bigger surgeries recruit more vet graduates and attract more Singaporean clientele. The new employees work a year or two and set up their own practices. So, there is an increase in competition for jobs, promotions and mates over the last few years, just like the travel industry has been forced to deal with direct internet bookings by prospective travellers and low budget airlines compete with established airlines like Singapore Airlines which has to compete in the premium business class with Emirates Airlines.

3. More IT-savvy younger generation. These are the ones that select their clients based on the lowest quotation and then the quality of service. In this tour, a group of "seven pretty girls" as the Macau tour guide referred to them in Cantonese, used their handphone to show the guide the itinerary. Not the usual printed paper but from the phone. When the tour guide gave her phone number to them to contact her for travel arrangements the next day, her phone rang immediately. One of the seven said she was the caller. This young generation knows what to do to verify the connection instantly.



4. Develop a sense of humour in life. Learn how the Macau tour guide has the sense of humour in reprimanding the client and yet get laughter. One example would be from paragraph 3. When the Macau tour guide answered her phone as it rang immediately when she gave her phone number, she said, "Shwai loi" in Cantonese. Ii can be translated to "naughty girl" and the group laughed. No ill feelings.



5. Be outstanding if you want attention. One of the seven ladies had a special hair cut. The Macau tour guide called her "Ma Been loi" in Cantonese. "Loi" refers to woman or lady in Cantonese.



"What is the meaning of "Ma Been"? Do you know Cantonese" I asked one of the other 7 ladies. "I am not Cantonese. It is the type of hair-style," her friend or sister said. The "seven pretty women" are sisters and cousins. 



6. Ask if you don't know. Many young ones are afraid to ask as they may reveal their inadequacies and lack of knowledge. Obviously, a young one has less knowledge as the person is young. Don't be afraid to ask. I am 62 years old and though I understand and speak Cantonese, I still asked the tour guide what is the meaning of "Ma Been"? I would guess "Ma" refers to horses. "Been" refers to tail. The Macau tour guide told me the hair-style resembles the tail of the horse. As an ex-racehorse vet, I could see some resemblances. A picture is worth a thousand words and I will show you one.

I never had a chance to talk to the "Ma Been loi" though.



7. Learn to open up by replying with a sense of humour. The Macau tour guide said, "I have 22 female tourists today. You are the only male." I had not been observant of this fact. "Men work hard to make money," I said to her. "Women work hard to spend the money made by men." So, what was I doing as a thorn amongst roses?



8. Create a lasting impression by telling stories of your personal experiences. The Hong Kong and Macau tour guides are ladies and experienced. They could communicate very well and so created a good impression. That is because they don't stop chattering. Unfortunately, they use Cantonese often and for me, it was home ground as my mum spoke Cantonese to me while I was younger.

Singaporeans seldom speak Cantonese but Mandarin nowadays and so they feel left out, in my opinion. The guides do speak English and Mandarin but most of the time, it was Cantonese. No Tagalong for the two Filipino women joining the tour in Macau. However, the younger generation of Macau and Hong Kong residents learn more Mandarin but they prefer not to be tour guides. I guess the money is not there.



9. Walk the streets to know the real life of the residents. Hot and humid. Showers. Why not just stay in air-conditioning shopping malls?

Unfortunately, you will miss much gaining knowledge if you just prefer to be in air-conditioned places as the vast majority of residents in Hong Kong, Shenzhen and Macau don't have this luxury. Too smelly in wet markets. I went to one in Hong Kong and it was a street photographer's dream site. Will show some pictures. The blood, the gore and the foul smell puts off most of the younger Singaporeans. Our wet markets are well ventilated and all pork must be sold in air-conditioned fridges in wet markets. Our enforcement officers against pork sellers in this wet market will net them a gold mine as pork sellers display their trotters and ham hanging up in open air. Our bureaucrats think of ways of making food safe for the public and drafting more regulations to control the type of trade. Then they wonder why the cost of living goes up with the years. See my pictures of the vast competition in this wet market. It was like survival in the jungle as there are more fish sellers with live fishes seen in this market than any wet market in Singapore.    



10. Don't put your backup discs in the same laptop bag.  I left my laptop in Hong Kong International Airport as I was busy taking pictures inside the airport. Practice makes perfect pictures. I put the two back up discs in my camera bag, not the laptop bag. So, I don't lose my precious memories of my travel from May 26 - 29, 2012. I phoned Hong Kong Airport at 9.30 pm. "No such laptop," the reply came and I left my phone number. So, no hope. Fortunately I had my two backup hard discs with me.



11. Excellent Service Provider from Cathay Pacific. At 10.30 pm, the Hong Kong Airport  officer phoned me to say they found it. I doubt any airport lost luggage will bother with me. On May 30, 2012, I phoned Cathay Pacific HK at 8.10 am thinking they have not started work (as like most offices in Singapore), I got a fast response from HK and I would get my laptop back from CX 739 reaching Singapore at 3 pm today. This is incredible service from Hong Kong and there is much my veterinary practice has to learn from them.  



12. Survey to get feedback from customers. The HKIA (Hongkong International Airport) girl asked me to do a survey. When she checked that my last country of travel was Cambodia which was not on his survey list, she said thanks. On Cathay Pacific CX711, an Indian steward supervisor in red silk blouse asked me if I could fill up a survey form. Survey is always good to check on staff. Overall, I rated their services as No. 1 and that was before I discovered that I had left my laptop at the HKIA. Feedback surveys are important and keeps staff on their toes. I do my own direct survey of the performance of my vets and staff by asking about the case outcome and being at the reception table and answering phone calls some days. No other way to ensure a high standard of care and service nowadays.



13. Don't complain about inconveniences or mistakes of service providers. On May 26, I checked into L'Hotel at Lina Towers and was given a beautiful room 61-12 facing the lifts. I was surprised there was a wooden bench inside the bathroom and the toilet bowl was higher than usual. The sinks were much smaller than normal. The shower rail was lower. Why is there a bench inside a bathroom? I thought it was a sauna bathroom. You just sit on the bench and sweat it out. Since I was not into sauna baths, I did not bother. Actually, this was a handicapped room. The hotel receptionist phoned later to ask if I wanted a normal room but this was OK for one night. The 4th night I returned back to the hotel, I was much surprised to be given the suite room. This room was at least three times in floor area compared to the normal room, had a bath tub, separate shower and toilet bowl. There was a marble table for four, a big dressing table, a foyer. The view of the harbour was around 180 degrees from inside the room. I would not book such a room as it would be costly.

Updates at:
http://www.designtravelpl.com/Folder_3/20120529travel-broadens-your-mind-singapore-ToaPayohVets.htm

Old dog lost 3 kg in 2 weeks.

The dog was treated by Dr V on May 1, 2012 for coughing. The cough had disappeared after 3 days of drugs and the dog stopped eating. Blood test was taken but he said that he was not told of the results. I apologised to him and reviewed his records. Liver enzymes were high and Dr V had prescribed heart medication and advised review in 14 days . However, he did not turn up and now it is May 24, 2012 and the dog is very thin and weak. A loss of 3 kg from May 1 to May 24 is too drastic.   

Now it is very thin. The 62-year-old man came with his daughter. As he had white hair, I said incorrectly that his grand-daughter was accompanying him. I asked Dr Daniel to handle this case with me. Respiratory rate and pulse were normal.

SIGNIFICANT FINDINGS 
1. Below normal rectal temp at 37.5
2. Weight loss
3. No appetite and does not drink water.
4. Periodontitis Stage 4 and painful throat area.
5. No abdominal pain or swelling of the liver which is good news.
6. Penile sheath was swollen.
7. Heart murmurs.
"This dog could be more than 15 years old," the father said. He remembered I did a tail amputation on a tail lump in 2007. "He had seizures in 2010," I saw the record but he could not remember. His daughter confirmed and said no more seizures.

What's the cause of this loss of appetite and painful throat? Blood test, urine test and IV drip done first.

Management meeting on May 23, 2012 8pm

Dr Vanessa and Mr Min were held back after the last case at 8 pm as I wanted to meet them to communicate their work performances to them. Frequent trust and audit meetings are necessary at this stage as workers and vets find it very hard to change their mindset and ways of working. This applies to all businesses.
I took out medical records done by Dr V yesterday to illustrate and to get improvements in standard of care.
Discussion centred on meticulous record keeping, evidence-based medicine to diagnose yeast infection and other skin diseases, in-patient recording to be kept for file, not just elsewhere, X-ray and other records to be kept in one file. Litigation prevention with proper records including consent forms and correct diagnosis.

Accounts to be properly filed. Interns to be guided and made sure they are gaining the experience and coming on time - a file to be started by them and Min to supervise. Min to speak out and reply when asked a question and to let me know if he has problems at work. "There are many graduates and vets in Myanmar out of job," I told Min. "Every year there are new graduates, even in Singapore. Therefore, wake up each day with happy feelings that you have a job you have been trained for as a vet in Myanmar and open your own clinic like Mr Saw at the end of the contract." Min was saying that Dr Saw in Yangon is doing very well.   

These are old issues but need communications again as it is part of management. Change management is seldom effected without communications and explanations.

1010. Westie puppy can't open his mouth - Craniomandibular Osteopathy

Yesterday, May 23, 2012, I answered a phone call. A lady wanted to speak to an experienced vet (Dr Sing) at Toa Payoh Vets. She had consulted another experienced vet (Vet 1) who had apparently diagnosed her Westie as having enlarged "lymph nodes"  and prescribed antibiotics and medication. After that, the Westie puppy again had difficulty in opening her mouth.

"I know my Westie is suffering from an inherited disease called 'lion jaw'," she could not pronounced craniomandibular osteopathy and told me to surf the internet for 'Westie, lion jaw'. She was not happy with the breeder but would not return the puppy.

I identified myself and told her that I had not come across the disease in my 40 years of practice. "Singaporean breeders seldom breed Westies," I said. "This breed is not easy to breed for some reasons. This breed has a type of skin disease." 

I advised her to go back to Vet 1 who is experienced and has X-rays facilities. Even experienced vets cannot be expected to know everything in every breed and in every system, but we are learning every day. The internet is a great help and many owners know more than the vets in specific disease conditions!

An image of a Westie with "lion jaw" is at: 
http://www.flickr.com/groups/westie/discuss/72157622728730796/

Do-it-yourself (DIY) tail docking a Schnauzer X

"My puppy's tail is swollen and Vet 1 gave him an injection yesterday," the man with three 7-week-old puppies brought one to amputate the dead swollen tail. "I brought him to see Vet 1 yesterday and was told that tail docking is illegal in Singapore. But I see many dog breeders doing it."    

"Tail docking of puppies are not banned in Singapore," I asked what material he used to do tail docking of his Schnauzer X as the puppy was already 7 weeks old and he started tying the tail at the first week of age

"I read in the internet that dental floss strings are the best," he replied.
"Most breeders either dock the tails at day 3 or use a rubber band," I said. "The rubber band strangulates the tail. The tail becomes gangrenous as it gets no blood supply and drop off after around one week. It is very painful for the puppy."

For this man, the tail was still around for the past 6 weeks. One puppy's tail had just dropped off. The other had a tail that still has feelings. Only this Schnauzer's tail was dead and swollen at the strangulated area. He wanted tail amputation.

ANAESTHESIA
Miniature Schnauzer X, 7 weeks, 1.6 kg.
What safe anaesthesia to use? The puppy is still not mature.
I used Domitor and Ketamine at 50% of the usual formula and add an equivalent 0.15 ml of saline, totalling 0.3 ml given IV by Dr Daniel

ELECTROSURGERY
"How will you amputate the tail?" I asked Dr Daniel. 
"V-shaped incision," he said as that was what his professors had lectured. I asked him to sketch his plan.

"There is a big septic dead area and the V-shaped incision will comprise some of the gangrenous area," I said. "Use my surgical approach which consisted of two horizontal skin incisions on the dorsal and ventral aspect of the tail. The dorsal incision is further away from the anal area than the ventral but as far from the gangrenous strangulated wound as possible." Then the dorsal area will flap downwards covering the whole tail, giving a good cosmetic appearance."

I have never used the "V-shaped incision" method in tail amputation but it can be one of the alternatives.    

Hypersexuality is hard to diagnose

Trust and Audit case
An interesting "skin disease" case

TP 42859
Pom White Male Born March 2012
(one year two months now as at May 22, 2012)

Born March 2011. Fluffy coat
Around 8 months, hair starts to drop from back area
1. Vet 1 in another practice attributed it to "puppy hair loss". Not much loss at that time.
2. Mar 18, 12  Vet 2. Complaint alopecia.    Licks flanks, alopecia flanks and ventrum, no crusting, erythematous scaling   Neoderm cream.
3. Apr 20, 12  Vet 3. Cream not better. Pustules. Hair around anus growing. Skin infection.
4. May 14, 2012. Vet 4. Bald, bilateral alopecia. I suspected hormonal imbalance, possibly testosterone.  History important. Humping cats and people. I diagnosed hypersexualtiy. Castration.

5. May 22, 2012. I phoned. "More calm and less sex drive since castration."
Blood test slightly elevated enzymes.
How to squeeze the anal sacs? owner asked.

1007. Final report on "No Smoke Without Fire - No scabies without mites"

Webpage:
http://www.sinpets.com/dogs/20120522scabies-hard-to-find-singapore-ToaPayohVets.htm

No Smoke Without Fire - No Scabies Without Mites?Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS21 May, 2012

toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129

FIRST CONSULTATION "My dog scratches her face vigorously, non-stop last night," the lady with red eyes showed me a young Shih Tzu with bright red cheek, ear and eye areas. "Is she suffering from an allergy?" Her friend had brought her in to Toa Payoh Vets on this fine Saturday morning, May 12, 2012. I was present from 9 am as I was conducting a "trust and audit" process on Dr Jason Teo. This is part of effective management of a licensee to ensure a high standard of veterinary care and to rectify errors and omissions of the practice. "I remember your case," I said to the lady friend as I fished out the card assuming that the affected dog belonged to the introducer. The referred lady who had red eyes said: "I just want a second opinion. For the past one and a half weeks after treatment by Vet 1, my dog is not getting better. She is still very itchy and her skin is full of red sores." I put the dog on the examination table and viewed the records and medication of Vet 1. 5306 - 5307. Itchy and crusty ears. Scabies and ringworm in a young female sibling Shih Tzu of one owner "Most likely, your dog has scabies," I pointed to the crusted lumps on the ear edges. "Just like your friend's dog I treated some 4 weeks ago." "No," the lady with the red eyes showed me a bottle of an anti-fungal liquid medication which stated "for cats",  an ear drop bottle and an enzyme-based shampoo. "Vet 1 had written in the case sheet - no sarcoptic or demodectic mites seen. She said my dog has malassezia inside the ears." Vet 1 had confirmed by staining. "It is possible that your dog has malassezia, a yeast infection." I said. "Negative skin scrapings do not mean there are no scabies. After all, your friend's dog, the sibling of this dog, had scabies." The following are the images I took of the friend's case scabies 4 weeks ago. The dog is a sibling of the presented case. 5308 - 5309. Itchy and crusty ears. Scabies in the sibling of another owner, 4 weeks ago. Now fully cured. No images available as the owner did not come back for any review since the hairs have had grown back on the ear edges and there is no more scratching "It is not possible as our dogs don't meet." the lady with the read eyes disagreed with my "instant diagnosis" and Vet 1 had stated that her dog does not suffer from mites due to one or more skin scraping done. "Scabies can be transmitted by owners' hand. Did you touch her dog earlier?" "Yes," she said. "Any kiss and hugs?" "Yes," she laughed. All puppies usually get kisses and hugs from lady owners. "So your hands could have transmitted scabies mites to your own dog. When did you touch your friend's dog?" "One to two months ago." "How is the scabies dog now?" I asked the friend who had asked me  why Dr Vanessa was not present on this second visit. She wanted Dr Vanessa as her puppy was vaccinated by her, she told me. She came again in the morning, before 12 noon and Dr V worked from 12 noon to 8 pm on weekdays and that was why she missed seeing her. I said to the friend, "Do you remember seeing one scabies mite under the microscope?" "Yes," the friend said. "My dog is fully cured now. I complied with all your instructions of cleaning." "Normally it will take 2 weeks and one injection to recover," I said. "My dog recovered in 1 week as the hair grew (back on the ear edges)." So, now I have to prove that this lady's dog has scabies. Actually Dr Jason was on duty on this Saturday. So I asked Dr Jason and Mr Min to do a few skin scrapings. "Make sure it is deeper into the skin. There is no need to use oil. A drop of water will do." So both took the dog to the back room and produced a skin scraping. I examined the skin scraping from Min and put the slide under the microscope. I scanned the hairs and cell debris. There was no scabies mites. "I can't find any mite," I said to the lady owner. "I will have to do a deeper skin scraping to look for the mites." The lady cringed at the thought of drawing more blood from the ear edge skin scraping as she could feel the pain of her young dog. She had diagnosed "allergy" as her dog had scratched herself violently. Dr Jason shook his head when I told him there was no mites seen from the ear crust. "No mites, no scabies." Simple as that. "Perhaps, the ear crusting could be ear trauma," I speculated. There was evidence and I was quite sure that the crusty ear spot was due to the burrowing of the scabies mites. However, no smoke without fire. No scabies diagnosis without scabies mites. I was at the dead end. No light at the end of the tunnel. Yet the clinical signs of intense itchiness of the face, cheeks and ears over one and a half weeks meant there were some mites burrowing deep inside the skin. The elbows and hocks were reddish and hairless. The backside had several ringworm like patches (see images above). So, there was some pathogens attacking the skin. Malassezia and ringworm medication were given for the past 10 days and yet there was no improvement in the skin disease. "Is the anti-fungal medication bottle that states 'for cats' safe for use in dogs?" the lady with red eyes asked me. "Well, the liquid medication in the bottle is not produced by the drug company for dogs. It is marketed for cats. However, the dog can take the medication if given appropriate doses." The problem is that this young female dog was still scratching intensely and was wild last night, upsetting the lady whose red eyes could be due to emotions rather than infections, in retrospect. Knowing that the lady would prefer no more skin scraping, I had  second thoughts of traumatising her. The dog is family and any deep skin scraping would be brutal in her opinion. Yet talk is cheap. Show and tell is the best policy. I reviewed the slide again instead of doing another skin scraping. Hoping against hope.  I scanned mm by mm. And suddenly, the Gods were kind to me. A fat looking squarish mite was moving his six claws under the slide! "Come and see the scabies mite," I asked the lady with the red eyes. The owner saw it under the higher power. I got the power to the lower one and the mite was distinctly seen by the lady. It was alive and punching its claws outwards. So, there was proof of scabies. No smoke with fire. No scabies without scabies mites. I could find only one. But that was sufficient evidence as it is sometimes very difficult to find them. Unless the skin scraping is deeper as the mites burrow under the skin. I did not do the skin scraping myself and this case was part of the "trust and audit" case for my staff. Once the diagnosis was there, the owner had confidence in the veterinary surgeon's competence. This is a tough world as Singaporeans are now highly educated and well informed. The treatment is a simple injection of ivermectin subcutaneous. Sometimes two injections are needed, but usually one is sufficient if the dosage is just correct. However, this sibling seemed to have some systemic disease like hormonal disorder as the whole body below the chest was affected by skin wounds and infections. "I need a blood test to check on the health of this dog," I advised. The owner consented. This may not be a simple case of scabies and malassezia. But it may be related to a poor immune system or hormonal imbalance like an early stage of "polycystic ovary syndrome (PCOS)." Many doctors will diagnose a young lady putting on weight as having eaten too much but she may be suffering from PCOS. So in this case, the dog's generalised skin disease could be due to a poor immune system as she had been on anti-ringworm medication for the past one and a half weeks with no response. It is hard to say at this stage as more tests for hormones can be expensive. Two siblings. One had scabies only on the ear edges. This one had the whole body infested with skin disease. Why?   FOLLOW-UP ON MAY 16, 2012 I phoned the owner today, May 16, 2012 to enquire about the female shih tzu, one year old with only one scabies mite shown in the microscope to her. The friend had the sibling but its ears were the only area affected. "A scratch or two, short while in the morning and evening," she said. "Not like the furious scratching earlier. Do I have to consult you 2 weeks later?" "No, if the hairs grow back," I said. "Some scabies dog need a 2nd injection 2 weeks later. Wait and see." I was glad that the ivermectin injection had worked and the owner had bathed the dog's skin lesions thoroughly. It was very stressful for her to see her young dog scratching for weeks." Blood test was taken on May 14, 2012 as the dog had generalised chronic skin infections. "Normal blood test results, except for increased liver enzymes," my associate vet told me. RESULTS are normal for the total white cell count but if you analyse the profile of the cell types, you will see that this dog has a chronic infection as evident by increase in monocytes to 11% and eosinophils to 8%. Normally the values are below 2%. Total WCC  11.9 (6-17) is normal but the monocytes and eosinophils are higher than normal   % Absolute Neutrophils  71%   8.47 Lymphocytes 10%  1.15 Monocytes    11%*    1.27 Eosinophils   8%* 0.96 Basophils      0.3%  0.04 LIVER PROFILE SGPT/ALT     95  (<59) SGOT/AST   158  (<81) Could there be other medications given by the owner's family members affecting the liver functions? Did the owner's mother use medication on the skin over the past months, affecting the liver? Overall, this was a chronic skin disease for a young dog. Was it ringworm first, yeasts inside the ears and then scabies spreading from ear edges to face and paws? Or was there scabies in the first place? It is hard to say. Blood tests can be useful and in this case, there was no bacterial infection as Vet 1 had given the antibiotics. Antibiotics don't kill scabies mites and that was why the dog kept being itchy and worrying the lady with reddened eyes. Skin diseases are hard to diagnose. Execute evidence-based medicine. Always show and tell. This provides confidence to the owner. Unfortunately, it was not possible to find more than one scabies mites in both of the dogs. Other than the possibility of re-infestation, my hypothesis is that the two dogs were treated earlier by the breeder or pet shop operator or animal shelter, as the two owners had adopted them when they are over 6 months of age. In the earlier treatment, the dosage of the anti-mite medication was insufficient to eliminate all the mites but sufficient to make skin scrapings negative.  This was a case of no smoke without fire. The fire is the "scabies mite." I was fortunate in finding only one scabies mite in each of the two siblings. Whether one or more, the clinical outcome of freedom from skin scratching is what the owner wants. Performance counts although evidence is important.

1006. Mission, Vision, Guiding Principles of Toa Payoh Vets

Blogger.com can't display the proper layout. The webpage is at:

http://www.toapayohvets.com/sinpets/guiding_principles_toapayohvets_Singapore.htm

Vision, Mission & Guiding Principles
Vision		Six Guiding Principles
A top 5 veterinary surgery in Singapore.   5297. Walk the talk to be the top 5 veterinary surgery in Singapore A veterinary surgery where it is fun to work and treat pets via a personalised veterinary services. Where pet owners and their children get good clinical outcomes for their pets and become our friends over the years. 5286. A vision for Toa Payoh Vets to be a top 5 veterinary surgery in Singapore		1. We provide a great work and learning environment for staff. 2. We provide a very clean environment for warded pets, charging affordable rates and early discharge to reduce veterinary costs for clients. 3. We contribute to the community in partnership with corporations to educate young pet owners, pet shop operators and breeders. We have been involved, since 1995 in the "Be Kind To Pets" narrative community education under the sponsorship of asiahomes.com. 4. We know that time is a valuable asset for clients. We try to keep waiting time to less than 15 minutes for customers with prior appointments.  5. We recognise that sustainable profitability is essential to our success. We need to be profitable so that we can provide a highest standard of ethical and affordable service to our customers and to upgrade our premises, equipment and services. 6. Our Veterinarians, Veterinary Technicians, Dog Groomers and Interns must find time to be self-educated continually and attempt to write their clinical research and observations for the betterment of pet care. We try to share our findings with the pet community via the internet or by publishing books ourselves and/or in collaboration with others. Draft case studies are usually first published in Draft Case Studies: 2010vets and interesting case reports are published mainly in toapayohvets.com
Mission
To establish Toa Payoh Vets as a veterinary surgery of excellence in Singapore, providing affordable veterinary health care costs without compromising our integrity and ethical behaviour. We channel efforts to address the roots of Singapore pet's problems through advocacy, prevention, education and research. These efforts are shared via the internet with pet owners at Be Kind To Pets and Toilet training your puppy in Singapore.

Give what the customer wants? Urinary stone removal + spay packaged deal

A female Miniature Schnauzer has been passing blood in the urine and an X-ray showed several large bladder stones. The couple, in their late 40s, wanted a spay and bladder stone removal packaged deal as this would be cheaper.

Sometimes it is possible to provide such a deal. For example, dental scaling and vaccination or spay and vaccination. However, in this case, it is still possible to do what the customer wants. Make a longer incision, do the spay first. Then open up the bladder and remove the stones.

However, the two surgical procedures will take a much longer time. "There may be complications of bleeding, infection and death on the operation table," I advised the owner against doing this. No news from them since two weeks ago.

Shouldn't I be more flexible and close the deal?  Give what the customer wants? In the interest of the dog, I don't do two-in-one surgeries lasting over one hour. The longer the procedure, the higher the chanes of complications like bleeding, infection and death. But other vets do not agree and some customers can be lost just by sticking to this policy. The younger generation in their 20s now may be better educated and more sophisticated to accept my advices. 

1004. Update on old Beagle with bladder cancer

DR SING'S TRUST & AUDIT PROCESS OF A BLADDER CANCER CASE AT TOA PAYOH VETS


998. Sunday's interesting case. An old Beagle drips lots of reddish brown urine



Sunday May 13, 2012



I was at the Surgery in the morning and saw a large amount of reddish brown urine drops in the waiting and consultation room. Dr Daniel was consulting with the owners and Mr Min was mopping the floor a few times. If I were Dr Daniel, I would restrain the dog on the consultation table but each vet does his own thing and so this situation led to bloody urine every where. I mean, if the waiting room was full, the other clients would be most unhappy trying to avoid stepping on bloodied urine on the floor in a small waiting room of Toa Payoh Vets.



This is what I mean by "common sense" in a vet who handles a case.  Restrict the dog's movement or crate him. I did my trust and audit in this case handled by Dr Daniel to improve the process of consultation and consistency of practice.



The X-ray showed around 6 small radio-opaque stones of around 4 mm x 6 mm and other sizes. Dr Daniel said were unlikely to cause so much bladder bleeding. Each vet has his own opinion and so that is life.



(May 19, 2012 - RETROSPECTIVE REVIEW - Dog had been operated by me and had a large adenocarcinoma of the bladder. The blood clots were dark red black and green and were from the degenerating cancerous cells of the adenocarcinoma)





I disagreed with him as there was one stone with a sharp edge, like a dagger.  This sharp stone swished about inside the bladder would have stabbed the bladder mucosa and cause bleeding. "This is not chronic cystitis," Dr Daniel disagreed with me. "The blood in the urine occurred only 2 weeks ago." This was a difference of opinion.



(May 19, 2012 - RETROSPECTIVE REVIEW - Dog had been operated by me and had a large adenocarcinoma of the bladder)



An old Beagle. Likely to be a bladder carcinoma as well.  Dr Daniel advised ultrasound and surgery with high anaesthetic risks of death on the op table. Since the dog's red blood cells were low, his opinion was that this dog would not survive the operation. So what to do? The consultation took more than 30 minutes and he was still talking.



(May 19, 2012 review. In my opinion, ultrasound adds to cost and will not help to resolve this dog's problem. The newly graduated vet has been taught by the professors to go for more and more tests to confirm a diagnosis of cancer. In practice, he must know what to do in an old dog with cancer, not asking for more tests as many owners prefer to have lower veterinary costs. In this case, blood and urine tests and an X-ray of one view had been done. The X-ray was average quality and an air-contrast X-ray of the bladder would be preferred)



I intervened by entering the consultation room which had a bloodied floor now. I said to the couple: "Basically, you have two options. Consent to an operation and know the high risks and get the stones removed. If there is cancer of the bladder, give us consent to euthanase the dog during surgery. The other option is to medicate and euthanase the dog when the drugs don't work as she is suffering from pain and incontinence. In the meantime, get the dog on the IV drip, painkillers and antibiotics for at least one day and before surgery."



Vets can't afford the luxury of time on a busy Sunday morning to handle a case for more than 30 minutes unless it is necessary. Other clients have to wait a longer time. Owners of hospitalised dogs need to be called. The sick dogs need to be checked and there are many things to do. So, it is not possible to keep on talking while the old Beagle keeps on dripping.



In any case, the pressures of having to provide affordable veterinary costs v. high overheads of operating expenses and increase government regulatory payments mean that not much time can be spent on having long consultations per owner. All employee and associate vets have to be aware of the high financial aspects of running a veterinary surgery and not just how much they get paid.



SURGERY DONE BY ME

The longer the surgical procedure, the higher the possibility of complications of death on the operating table. I told Dr Daniel and the owner that I would be operating on this high risk old dog with seizures. The wife did not want euthanasia even if an inoperable cancer was found. There was an inoperable cancer in the bladder. I excised as much as I could of the cancer.



As at May 18, 2012, the dog was eating and had peed clearer urine. I had not expected this old dog with seizures to survive a 2-hour surgery. Dr Daniel was collaborating with me while I operated to excise the tumour near the neck of the bladder. There was no way I could complete such a bladder cancer excision in 30 minutes. The couple took the high risks to consent to an operation. It was a surprise to me that this dog survived.



DETAILS OF SURGICAL PROCEDURES ARE BELOW:

5297 - 5303.

Bladder cancer surgery in an old Beagle

Proper pre-surgical treatment and planning gave this old dog the best chance of survival on the operating table. It is not a given that all old dogs will survive as many of them have poor health.


UPDATES AND MORE IMAGES ARE AT:
http://www.sinpets.com/dogs/20120440veterinary-audit-cystotomy-carcinoma-bladder-toapayohvets-singapore_ToaPayohVets.htm

Planning for the bladder cancer surgery - The Beagle

As Dr Daniel was handling the case, he had a long chat with the couple. X-ray revealed 6 small pieces of stone but the blood test showed red blood cells being low. The dog was bleeding from the bladder. He advised ultrasound.

1002. Walking the talk to be the top 5 veterinary surgery in Singapore

Walking the talk On Thursday, May 17, 2012, 12 noon, I had a meeting with Dr Vanessa and Dr Daniel, both facing me with serious faces across the consultation table. A client came but I asked her to wait.  My management meetings do get interrupted and the train of thoughts get de-railed and so I ask some clients to wait a while and keep my talk short and sharp. Walking the talk to make Toa Payoh Vets the top 5 veterinary surgery in Singapore is an uphill task, requiring frequent checks and balances on the staff performances. For this meeting, I got a big book and recorded down the meeting points. 1. Strategy.  Being the top 5 veterinary surgery in Singapore. I said: "It is easy to talk about my vision of Toa Payoh Vets being the top 5, especially in veterinary surgery. Talk is cheap. Talk is easy. I have implemented certain checks on your work and you may not like my frankness in pointing out deficiencies. But this is part of management and part of continuing education. 2. "Keeping meticulous records is part of this vision. How can Toa Payoh Vets be the top 5 if its vets don't keep meticulous records?"  I illustrated a case of a vet's sedation of a Beagle with the bladder tumour which was a "trust and audit" case done by me to check on the standard of care. The injection given was 30% of Dom and Ket as instructed by me and was injected. The dog was old, had fits, low red blood cell count and was dribbling bloodied urine. The figure written was 50% as no amendment was made.  "Meticulous records in anaesthesia and surgery provide a strong defence in the case of litigation," I said. "There will be more litigation and complaints as Singaporeans get more educated and demanding. So, meticulous recording by the vet provides a strong defence. I will be printing serial number record books soon and the operating vet will be personally responsible." 3. Keeping associate vets happy so that they will stay with Toa Payoh Vets. The vet is the prime mover but that does not mean that he or she can order any drug he or she likes and not be aware of the high costs. "Keeping the associate vet happy does not guarantee his or her loyalty to Toa Payoh Vets," I had said privately to Dr Daniel. "With sufficient clientele and easy access to money from parents or joint start ups with another vet, I don't expect associate vets to stay long and be loyal to Toa Payoh Vets. "We have a few cases where the rich parents finance the start up of new vet practices. No sweat for the younger vets as regards the need to earn sufficiently before opening because the money is already provided by the parents." 4. Leaving a legacy for the 2nd generation. I have stated to my associate vets, Dr Vanessa and Dr Jason that I do not build up Toa Payoh Vets for Dr Daniel or the second generation. I will just sell off the practice and retire when I am unable to practise. I don't worry about legacy. If the 2nd generation can't perform, so be it. In any case, the Toa Payoh Vets will just decline as there will be more intense competition over the years. The practice will die off as excellent performance counts a lot in a vet practice as referrals come in from other parts of Singapore. "The Beagle with the bladder tumour (Trust & Audit in a Case of an old dog with fits and bladder cancer) was from Pasir Ris and the Shih Tzu with the crusty scabies ears  (No Smoke Without Fire - No Scabies Without Mites) was from Jurong East. So, there must be some reasons they come to Toa Payoh Vets when there are other vet practices conveniently nearby." I said to Dr D and Dr V as these two cases were handled by me. There are around 45 vet practices in Singapore and there will be at least one near Pasir Ris and Jurong East and the majority of Singaporean pet owners will go to the vet based on proximity.  5. USP. "One Unique Selling Proposition" of Toa Payoh Vets is that there is no need to come back for stitch removal," I said. "Yet Dr Vanessa asks clients of spayed and neutered dogs to come back in 14 days' time." There is a need to be consistent in veterinary surgery amongst the vets here." I said. 6. There were other issues such as vet cost and the vets gave their feedback. "Ultimately, in a corporate world, associate vets have to take instructions from the superior or boss. If not, they better open their own practice, order expensive drugs they like and do consultations of half an hour per average case." There is a need to provide affordable vet costs and reduce waiting time. Obviously if the associate vet spends half an hour per case and keep the others waiting 2 hours, there will be much dissatisfaction in many others as Singaporeans are time-pressed. In conclusion, real world business needs to be profitable. Otherwise, associate vets will get lesser pay and will just go to another practice. As simple as that. A happy working environment with poor profits will not retain any associate vet even if the management makes them happy at work. There is the bottom line and the need to recover a decent return on investment for the founder too. Many vets don't know how to do the financial analysis. A high revenue with high expenses does not mean that the business is making money! Same for the government running a country. Webpage: http://www.bekindtopets.com/dogs/20120521walking-the-talk-to-be-top-5-vet-surgery-singapore-ToaPayohVets.htm

1001. Follow up on the "panting dog"

Update on May 18, 2012. The old dog suffered from severe ascites and was in pain. Euthanasia was the humane option and was done 4 days ago.




HISTORY

On Wed, Apr 25, 2012 at 10:31 AM, .... wrote: Dear Mdm

I would like to make an enquiry about my dog (Schnauzer-cross). She is 15 years old.
We brought her to the vet as she was panting heavily and her stomach swelled and keeps hiding in the room, away from the rest of the family.
X-ray results shows that she has an enlarged liver. Also, the blood test shows that she has high Calcium, high platelets and white blood cells.
Most likely, says the vet, my dog has cancer and recommended an ultrasound at its hospital. Meanwhile, the vet has given her some liver medication and my dog's condition has improved though the vet did share that this would be temporary.
I am worried about the costs of sending my dog to their hospital as I did some research and found that the hospital tend to order several tests and cost of the treatment usually escalates. If she is found to have cancer, it's likely that we will not opt for treatment as she is old and already her quality of life is poor, with poor eyesight etc.
Does your clinic offer ultrasound services and how much does it cost? Is ultrasound the best option for my dog now?
My family wants to see her pass on without suffering too much. What should I do to alleviate her suffering?
I would really appreciate if you could advise me. Please feel free to call me if need be.

Rgds





E-MAIL REPLY FROM DR SING DATED APR 26, 2012

26/04/12 03:35 PM

cc Subject Re: Enquiry about ultrasound costs

I am Dr Sing from Toa Payoh Vets. We spoke by phone today Apr 26, 2012, 3.31 pm and the following is my brief reply to you:

 
In my opinion, the important health care issues in your old dog are:
1. what is the cause of "panting heavily" and "swollen stomach"
2. what is the cause of the "high platelet and white blood cell count"

Is there liver cancer or not? Is there a cure?  If the cause of the illness is known and treatment can be effective, it should not be "panting heavily".


 E-MAIL TO DR SING DATED MAY 14, 2012









Hi Dr Sing

Just wanted to thank you for all your help — calling me back when I wrote to you, treating .... during her last days and calling to check on how she was doing.

Also, I didn't get to share with you that I am glad to have chanced upon your website — it's very informative and lets pet owners out there see that your practice does very good work and that you are sharing your knowledge with younger doctors.
Thanks again — I really appreciate all that you've done.


Rgds



E-MAIL REPLY FROM DR SING DATED MAY 18, 2012


Just read your email of 4 days old. Thank you very much for your kind comments.Sharing real case studies via the internet takes up a lot of time to document each case. However, real cases will benefit the animals more, as their owners become educated on real life cases. Vet students struggling in their little rooms to pass exam can remember their studies better when they see the real case pictures, bringing vet medicine and surgery alive to them.

The practice of veterinary medicine and surgery of so many animals other than dogs and cats is so large in scope unlike human medicine (one species - homo sapiens) such that it can be overwhelming and frightening to the younger vet, as the owner expects the vet to "know it all."   

Best wishes

1000. Follow up: No smoke without fire - No scabies without mite

I phoned the owner today, May 16, 2012 to enquire about the female shih tzu, one year old with only one scabies mite shown in the microscope to her. The friend had the sibling but its ears were the only area affected.

"A scratch or two, short while in the morning and evening," she said. "Not like the furious scratching earlier. Do I have to consult you 2 weeks later?"

"No, if the hairs grow back," I said. "Some scabies dog need a 2nd injection 2 weeks later. Wait and see." I was glad that the ivermectin injection had worked and the owner had bathed the dog's skin lesions thoroughly. It was very stressful for her to see her young dog scratching for weeks."


Blood test was taken on May 14, 2012 as the dog had generalised chronic skin infections.
"Normal blood test results, except for increased liver enzymes," one vet told me.

RESULTS are normal for the total white cell count but if you analyse the cell types, you will see that this dog has a chronic infection as evident by increase in monocytes to 11% and eosinophils to 8%. Normally the values are below 2%.

Total WCC  11.9 (6-17)

Neutrophils  71%      8.47 absolute
Lymphocytes 10%    1.15
Monocytes    11%    1.27
Eosinophils   8%       0.96
Basophils      0.3%    0.04

LIVER PROFILE
SGPT/ALT     95  (<59)
SGOT/AST   158  (<81)

Did the owner's mother use medication on the skin over the past months, affecting the liver?
Overall, this has been a chronic skin disease for a young puppy. Was it ringworm first, yeasts inside the ears and then scabies spreading from ear edges to face and paws? Or was there scabies in the first place? It is hard to say. Blood tests can be useful and in this case, there was no bacterial infection as Vet 1 had given the antibiotics. Antibiotics don't kill scabies mites and that was why the dog kept being itchy and worrying the lady with reddened eyes.    

999. No smoke without fire: No scabies with mites

"My dog scratches her face vigorously, non-stop last night," the lady with red eyes showed me a young Shih Tzu with bright red cheek, ear and eye areas. "Is she suffering from an allergy?" Her friend had brought her in to Toa Payoh Vets on this fine Saturday morning, May 12, 2012.

I was present from 9 am as I was conducting a "trust and audit" process on Dr Jason Teo. This is part of effective management of a licensse to ensure a high standard of veterinary care and to rectify errors and ommissions of the practice.

"I remember your case," I said to the friend as I fished out the card assuming that the affected dog belonged to the introducer. The lady with the red eyes said: "I just want a second opinion. For the past one and a half week after treatment by Vet 1, my dog is not getting better. She is still very itchy and her skin is full of red sores."

I put the dog on the examination table and viewed the records and medication of Vet 1.
"Most likely, your dog has scabies," I pointed to the crusted lumps on the ear edges. "Just like your friend's dog I treated some 4 weeks ago."
"No," the lady with the red eyes showed me a bottle of an anti-fungal liquid medication which stated "for cats",  an ear drop bottle and an enzyme-based shampoo. "Vet 1 had written in the case sheet - no sarcoptic or demodectic mite seen. She said my dog has malassezia inside the ears." Vet 1 had confirmed by staining."

"It is possible that your dog has malassezia, a yeast infection." I said. "Negative skin scrapings do not mean there are no scabies. After all, your friend's dog, the sibling of this dog, had scabies."

"It is not possible as our dogs don't meet." she said.

"Scabies can be transmitted by owners' hand. Did you touch her dog earlier?"

"Yes, kiss and hugs."

"So your hands could have transmitted scabies mites to your own dog. When did you touch your friend's dog?"

"One to two months ago."
"How is the scabies dog now?" I asked the friend. "Do you remember seeing one scabies mite under the microscope?"
"Yes," the friend said. "My dog is fully cured now. I complied with all your instructions."
"Normally it will take 2 weeks and one injection to recover," I said.
"My dog recovered in 1 week as the hair grew (back on the ear edges)."

So, now I have to prove that this lady's dog has scabies. I asked Dr Jason and Mr Min to do a few skin scrapings. "Make sure it is deeper. There is no need to use oil. A drop of water will do." So both took the dog back room and produced a skin scraping as the case was Dr Jason. 

I examined the skin scraping. There was no scabies mites.
"I can't find any mite," I said to the lady. "I will have to do a deeper skin scraping to look for the mites." The lady cringed at the thought of drawing more blood from the ear edge skin scraping as she could feel the pain of her young dog.
Dr Jason shook his head when I told him there was no mites seen from the ear crust. "No mites, no scabies." Simple as that. "It could be ear trauma."

Yet the clinical signs of intense itchiness of the face, cheeks and ears over one and a half weeks meant some mites burrowing. The elbows and hocks were reddish and hairless. The backside had several ringworm like patches. So, there was some pathogens. Malassezia and ringworm medication was given and there was no improvement.

"Is the anti-fungal medication bottle that states 'for cats' safe for use in dogs?" the lady with red eyes asked me.
"Well, the liquid medication in the bootle is not produced by the drug company for dogs. So, it is marketed for cats. However,  the dog can take the medication if given appropriate doses."

The problem is that the young female dog is still scratching intensely.

On second thoughts, I reviewed the slide again instead of doing another skin scraping. Hoping against hope.  And there, a fat looking squarish mite was moving his six claws under the slide!
The owner saw it under the higher power. I got the power to the lower one and the mite was distinctly seen.

So, there was proof of scabies.

No smoke with fire. No scabies without scabie mites. I could find only one. But that is sufficient as it is sometimes very difficult to find them. Unless the skin scraping is deeper as the mites burrow under the skin.

Once the diagnosis is there, the treatment is routine. However, this sibling seems to have some systemic disease like hormonal disorder as the whole body is affected, except for the trunk. I needed a blood test and the owner consented. This may not be a simple case of scabies and malassezia. It may be related to a poor immune system or hormonal imbalance like  an early stage of "polycystic ovary syndome."  It is hard to say at this stage as more tests can be expensive. Two siblings. One had scabies only on the ear edges. This one had the whole body infested with skin disease. Why?