Wednesday Feb 20,
2013 "Can you operate today?" the owner of this 7-year-old with a
disc-shaped bladder stone of 8 mm x 8 mm and 3 smaller stones was referred to me
by his vet friend working in Biopolis. I had asked him how he came to know
about Toa Payoh Vets as presently, one salesman told me the 52nd vet clinic is
about to open in Singapore.
"I can operate today, but you may have a
dead cat at the end of surgery," I showed him the high total white cell count
and neutrophils of the cat's blood test taken earlier in the day. "These
data showed that the cat has a generalised blood infection of bacteria and is
not in a good health state to be under anaesthesia and surgery. He may die on
the operating table."
"But Vet 2 told me that my cat is suffering from a
serious kidney failure. She said I should operate soon and any delay will result
in death." Vet 2's blood test result show BUN as "---", creatinine and
phosphorus as exceedingly high. "---" denotes that the value is too high to be
read. This indicated an acute renal failure.
"It is best to stabilise
this cat first," I had read the medical reports and viewed the X-ray. "Was there
any antibiotic injection given to the cat? Any fluid therapy? Any urine test?
"I don't think so," the gentleman is typical of the
increasingly educated and well informed pet owners in Singapore putting vets on
their toes as he would have done his internet research on his pet's urolithiasis
with one click of the mouse. "Otherwise my bill will have this item charged. Vet
2 did say that the cat was slightly dehydrated."
The cat was now
furiously hissing and the owner could not handle him. I did not want to provoke
this frightened cat further as the cat would go crazy and very aggressive. I
asked the owner to hold and talk to him while I gave the Baytril antibiotic
I assessed that this cat would not need the fluid therapy
as he was drinking and peeing. Only that he was not eating for a few days and
the owner had brought him to consult his regular vet (Vet 1). Vet 1 had asked
him to return again if the cat had not recovered but Vet 1 closed on Wednesday
and so he remembered Vet 2 whom he had consulted before.
Vet 2 told him
that she was not sufficiently experienced to operate and her senior vet's
surgical bookings were full house. So he had to find another vet. He phoned his
vet friend who works at the Biopolis. She referred him to me. I don't know this
vet friend and so it was a great surprise.
The operation would be
done the next day. Weighing the cat, taking the rectal temperature and giving SC
drip would be out of question as the cat was quite fed up with Vet 2's blood
taking and X-raying. Cats are notoriously difficult to take blood and Vet 2 had
managed well. I presumed she X-rayed first, otherwise it would be very difficult
to restrain this little tiger.
2013 The main worry was the possibility of death under anaesthesia
as this cat was just not fit for surgery based on Vet 2's blood test of a severe
kidney disorder. I would say it would be acute nephritis but this cat had
no history of vomiting.
Would this cat die on the operating table? This
was one of those hot potatoes vets prefer not to handle as death may result in
bad-mouthing of the vet's incompetence. Who to pass the buck to? I decided to
operate myself under such negative conditions of impending death of a cat.
Ideally, the cat should wait 3 or more days before surgery. But the
owner was much worried and the kidney disorder may worsen to severe vomiting and
death owing to delays. The kidney enzymes were exceedingly high. To wait would
be risky as a cat in deteriorating health would die anyway.
So, I was
holding the hot potato one way or another. To operate or to wait more than one
day. What safe anaesthesia to give so that the feline patient is delivered alive
to the owner? A surgeon must deliver. A cat alive at the end of surgery. No
1394. Follow up. Sunday. Cat
with bladder stone
Before I forget, the Thursday surgery in
brief is as follows:
ANAESTHESIA 5 kg
bodyweight. I gave xylazine 0.2 and ketamine 0.8 ml IM in one
syringe. Isoflurane gas top up was necessary for a short while.
Rectal temperature was 36.8 C after sedation as the cat was angry and we could
not want to antagonise him more.
remove bladder stones seen on X-rays taken by Vet 2. 1. Catherise the
bladder 2. Withdraw urine for urine analysis 3. Inflate bladder with 40 ml
normal saline so that it is palpable. 4. Incise skin and linea alba. 5.
Press out the distended bladder. 6. Incise at apex of 8 mm as I know the
stone was around this diameter. 7. I insert an artery forceps to grab and
take out the stone without making too big a bladder incision. 8. My assistant
Min pumps in more normal saline as I closed the wound for a while. 9. 3 small
pieces of stones of around 3 mm x 2mm flowed out with the bloody mucus and
blood. 10. More irrigation of the bladder. 11. I stitched the mucosa 3/0
absorbable - inverting layer 12. I stitched the serosa similarly - another
inverting layer. 13. To check leakage, I asked Min to pump in more saline via
the catheter to inflate the bladder. No leakage. 14. I put the bladder back
into the abdomen and closed up the linea alba (2/0 absorbable) and skin (2/0
nylon). 14. I put the bladder back. 15. Post-op baytril and
tolfedine 16. Cat goes home in the evening as the cat was quite ferocious and
nursing at home would be better as the cat would be hand-fed food (K/D) and
Blood Test showed high total
white cell count. X-ray showed >1bladder stones
Friday - Day 1 after surgery. I phoned the cat
owner. "Vomiting one hour after food and medication," the owner reported as
he had given medication on the evening of the surgery. I advised not giving the
tolfedine tablets, just the Baytril tablet from Vet 2 and give honey water by
Saturday - Day 2 after surgery Vomiting once. Drinks a lot. Pees a lot. "There could be gastric ulcers due
to the high BUN kidney disorders," I said. "That would account for vomiting.
Feed less amounts."
Sunday Feb 24, 2013 - Day 3 after
6.23 pm Yishun public library to type this
report Communications post-op is most important. The cat owner phoned me
twice and left his name and phone number. My receptionist reminded me to phone
him after my consultations. I was kept busy with the owners of a cat from an
American couple regarding removal of the claws, a rat with nasal swelling on the
right and a large skin lump on its back and a rabbit from Woodlands for "spay"
from a Malay family who had stated incorrectly the gender.
terrapins came yesterday for Dr Jason Teo - one would not eat and the other one
had puffy eyes and I had them cleaned and given eye drops and bask in the bright
morning sunshine. I had to supervise a new vet technician as Mr Min would be
moving on to better future after having worked two years with me, increasing his
value to the new employer as an experienced vet technician.
Back to the
cat with the bladder stones operated 3 days ago. The owner phoned me yesterday
and today to provide me feedback and that was important.
"My cat did not
vomit after eating food. He drank a lot, around 375 ml of water and peed a lot,"
he said. "He laid on his urine and so his surgical wound is very
"It is good news that he pees a lot," I said. "This shows that his
bladder is normal." I tried not to joke that this showed that his bladder was
not leaking after my surgery.
"What should I do to the red area of his
wound?" the owner asked.
"It is very difficult for me to know what you
are describing," I said. "Was the cat licking the wound since you did mention
about taking off the e-collar?"
"No, he is still wearing the
Since the owner was working, I suggested that he changed the
plaster covering the wound and replace with a new square one. "It could be the
blood clot from the skin after stitching," I said. Will wait and see.
seems that the cat with the renal impairment based on blood tests taken by Vet 2
on Wednesday (4 days ago) is doing well. He did not vomit his food. I asked the
owner to give 2 cans 6 times/day instead of feeding him one can of the K/D diet
yesterday. He has a good maid and with home care, this cat should
Day 7 after
Feb 27, 2013 - I phoned the busy gentleman
owner of the cat with the bladder stones as I was reviewing the past few days'
cases. All cases done by associate vets and be me are reviewed by me as much can
be learned from cases done. But this takes a lot of time and time is not much
when there are many other things to do.
"My cat is back to as good as
normal," he said that the cat was jumping and his stools and urine were normal.
He had told me the day before that the cat drank less. I explained that the cat
was fed canned K/D diet and canned food has a lot of water.
"Does he eat
on his own?" I asked this important question. "He eats a bit and does not
mind spoon-feeding by my maid." This was a moment of great joy to know that a
surgical patient who was having kidney disease based on blood test by Vet 2 had
recovered almost fully. The stitched bladder with a 8-mm cut by me to extract
the 8-mm diameter stone must have healed well, otherwise this cat would be
Follow ups are much appreciated and great learning lessons for any
vet but we seldom have much time to do it. It creates an excellent customer
This owner loves his grandmother as he did bring her
to take the cat home the day after surgery. Grandmothers are most loved as they
usually spend most time with the grand children while the parents are out
working and surviving in the corporate jungle. His grandmother was over 80 years
old and her mind was sharp and alert.
"Remember the S/D can of food given
by Vet 2?" I asked the owner. "It may not be useful as the cat's urinary pH is
acidic at pH=5.0. That means that the bladder stones are unlikely to be
struvites as S/D is for prevention and dissolution of struvites stones. Most
likely, they are calcium oxalate stones but we have to wait for the results of
the stone analysis."
This info was obtained when I collected urine
before opening up the bladder for stone removal. It is important that the vet
performs this procedure as it may not be possible to collect urine from an angry
non-sedated cat earlier. That could be one reason Vet 2 did not do a urine
analysis and just prescribed S/D of one can. It is best to practise
evidence-based medicine by doing urine analysis. In this case, there were no
crystals in the urine.
A 4th year vet student from the top Portugal Vet
University was with me and I asked Catarina Mateu : "No crystals in the urine
test means no bladder stones. Many vets will come to this conclusion. What about
you?" "Yes," she replied. "I also think this way."
UPDATE ON MARCH 1, 2013. Day 9 after
surgery I phoned the owner to inform him that stone analysis
revealed calcium, oxalate and magnesium in the bladder stone. I advised canned
C/D food for at life. But it is relatively expensive compared to the usual
He said: "My cat is ok now. Only that he is inactive when
he wears the e-collar. When do I come for stitch removal?" "Your cat has
never worn e-collars before. Once the skin stitches are removed on this Sunday,
your cat will be free of the burden of this collar."
UPDATE ON MARCH 5, 2013, Day 13 after
The cat's nylon skin stitches were removed by me. The
owner said that the cat was withdrawn and quiet when he was wearing the e-collar
but would be more active when he was not wearing it. "No need to wear the collar
now since I had removed the stitches."
UPDATE ON MARCH
10, 2013. Day 18 after surgery The cat
with the bladder stone surgery came for stitch removal on Sunday, March 3, 2013.
No need to wear e-collar. The owner got 48 cans of C/D for his cat and will buy
from the vet near his apartment later. No further news from the owner. As for
the cat with urethral obstruction, no recurrence and no news from the
UPDATE ON MARCH 22, 2013, Day 22 after
surgery7.22 am from home, as I review this case to be produced as
an educational video. No news or complaint from the owner. No news is good news
in the case of the cat with the bladder stones removed. It is good to know that
the cat is back to normal. The owner will be buying his feline C/D from Vet 2 as
the surgery is across his home. UPDATE ON APRIL 21, 2013.
Day 52 after surgeryNo news is good news or phone call from the
owner. The owner complies with the medical instruction to feed the cat only C/D
and nothing else.
A CAT CANNOT PEE March 1,
The above-mentioned case of the cat with the bladder stones had a different
history from Case 2. In Case 1, the owner had complained that the cat was not
eating for 5 days, not blood or difficulty in urination. The cat could pee.
Case 2 reviewed another cat of around the same age came soon. Emergency
catherisation and treatment removed the obstruction of the urethra.
On March 1, 2013 I discharged this 8-year-old male neutered cat with a
catheter one day of hospitalisation. He was a good-natured cat. The owner had
told me that the cat could not pass urine for 2 days. I found her history
unreliable when I checked the blood test results.
Based on the blood
test results, the history of difficulty in urination for 2 days was dubious.
"The high urea and creatinine values, more than 6X the higher range of
normal and the vomiting indicated that the cat was having urination problems
more than 2 days," I said to her. "There is kidney damage and the cat may get
kidney failure now."
"He had peed blood for over a month. A 10-cent coin
of red urine appeared on the floor many times. I was too busy to bring him to
the vet. When he could not pee at all for 2 days, I knew I had no choice but to
send him to you for treatment."
Under sedation, Dr Daniel had a urinary
catheter passed into the bladder with great difficulty as the urinary sand
blocked the passage at the bend of the urethra. So the bladder started filling
to half the size of the mango and the cat could not pee at all. He had to pump
in normal saline via the catheter to dislodge the sand back into the bladder.
Then he irrigated the bladder with more saline and sucked out the blood
and sand. The urinary catheter was stitched on the prepuce and kept for 3 days.
As no X-rays were done to lower the veterinary costs and as no stones
were palpable in the bladder, I told the owner that there might be bladder
stones if the condition recurred. X-rays would have to be done. The heartlanders
have a limit as to veterinary expenditure in these times of rising costs and
"No more dry cat food or cat treats," I said to the
working lady in her 50s. "Just this can of K/D and then C/D." "What if he
eats the food from the other cats?" she asked. "Then you may get a recurrence
of the bladder blockage problem." "I know what I will do," she had a
solution. "I will feed him in another room. When he is full, he will not eat the
other cat's food." P.S I spoke to Hills' supplier. He told me
that feline S/D was no longer produced since 9 months ago. The feline C/D is
found to be effective to prevent S/D as well and so it is the only product for
kidney health for cats. He was surprised that Vet 2 still had cans of feline
Saturday, April 20, 2013 RECURRENCE 50
DAYS LATER IN APRIL 20, 2013
1378. The FLUTD cat returned
with a blocked bladder again.
With heartlanders, the least cost veterinary
medicine is practised. For one and a half months after the cat fainted from a
blocked bladder, the white grey cat now had difficulty peeing for the last 5
days. Dr Daniel handled the case and he decided to catherise the urethra to
unblock the bladder. There was great difficulty in catherisation. The cat had no
complaints but she would stop feeding the 10 cans of C/D diet and feed other
canned food since the C/D was expensive.
"Clear" urine leaked onto the
table. "He was licking his penis," the owner said. I turned the cat upside down
and noted that his penile tip was bright red. Clear urine dribbled onto the
I taught my new veterinary assistant Nai how to use
the urine dipstick to check the urine for pH, SG, blood, protein, white cells
and others. Nai is a young veterinarian graduated from Myanmar. He is new to
this job and has lots to learn. It takes great patience to train a rookie from
the internet generation. He would mumble in Myanmarese whenever I told him off
for not doing a good job after I had taught him how it should be done. Many
young people has a different mindset nowadays. They would do a task their own
way and so needed to be supervised closely as a recording system and process
must be adhered to if the practice wants consistently a high standard of care.
One day I told him that he should quit as there are others who can speak
good English. They have the advantage of being able to handle phone queries and
client discharge. If he wanted to stay, he should not grumble as nobody wants to
employ or train him if he has this attitude. "This is not your father's
office," I said to him. Other practices would have sacked him.
he understood that he had to change his mindset. Working in an
established Singapore small animal practice like mine gave him the opportunity
to see various cases and challenging surgeries as compared to working in
a Yangon practice where it is difficult to handle complex cases due to financial
constraints of the average pet owner. A cat spayed in Yangon costs S$20 which is
at least 5 times cheaper than in Singapore. In 2 years, he would have gained
much veterinary knowledge and would open his own clinic in Yangon. Presently
there are around 100 small animal veterinary practices in Yangon from one of my
sources. Singapore has more than 50.
Back to this cat. There was a need
to cut medical costs as the owner was worried about cost based on the fact that
she had waited for many weeks till her cat "fainted" and could not pee at all,
before seeking vet treatment in the first consultation one and a half months
ago. This second consultation, she came after the cat had dysuria (difficulty in
peeing) after 5 days.
In theory, this cat should be sedated and
catherised as in the earlier incident.
To save costs, I gave injections
to reduce pain and infection followed by oral antibiotics and 10 cans of C/D.
The owner had complained that the C/D was costly as compared to the commercial
It is like comparing apples to oranges. The C/D is
specially formulated to prevent FLUTD (Feline Lower Urinary Tract Disease). .
The owner swore she had not fed the cat any dry food. But only canned
food. But her other two cats were eating dry food. "Can you guarantee that this
cat has not eaten any dry food?" I asked. She was not sure. Failure to comply
with medical instructions lead to a recurrence of FLUTD.
This cat could
have bladder stones but no X-rays were done to save money. If there is a 3rd
recurrence, X-rays would have to be done.
Contrast this case to the other
cat with bladder stone removed by me in an earlier report of these 2 cats. No
news from the other cat at all. No problem. No news is good news.