KPI - neutering a normal poodle using IV anaesthesia Dom + Ket

May 31, 2013

"Double ligation is better," I said to my assistant Naing. "Sometimes the ligature slips and the dog bleeds leading to a much swollen scrotal sac. But most vets will ligate once." I was giving Naing, a young vet graduate from Myanmar some tips.

KPI
How long it takes me to neuter a poodle? For knowledge gathering purposes, I record the times.

Poodle, M, 1 year, two normal descended testicles, 4.85 kg.
Anaesthesia - Domitor + Ketamine 0.2 + 0.25 ml IV, one syringe.
"No need to prepare isoflurane," I said to Naing who was getting ready to switch on the oxygen and isoflurane. "The dosage is sufficient if the vet is fast."


1.47 pm Injection IV Dom + Ket
1.56 pm First skin incision. 2 testicles removed, double ligation per testicle into grooved clamped area
2.12 pm  Skin stitched. Dog started to move legs at this time.

Surgery time -  2.12 - 1.56 = 16 minutes
Duration of surgical anaesthesia without isoflurane top up 2.12 - 1.47 = 25 minutes.
Dog is young and healthy but thin.  

Goes home at 4 pm, no problem.
"What's the black area?" the man asked.
"Actually it is part of the scrotal sac. The other part is not black due to continuous licking. It becomes pink and hairless.

A little girl came. "This poodle is her dog," the mum said. "The old Schnauzer with heart disease you put to sleep on Vesak Day is my dog."
"How old is she?" I asked as she had cried that day when she was not allowed to see the dog after euthanasia. Fair complexion, big eyes and bright.
"3 years old," she said.
"I thought she is 6 years old," I replied. 

1440. Ascites

Yesterday, the 6-year-old Jack Russell came in with a huge tense abdominal swelling. "He still runs and eats," the owner and a young man said. "What is the problem?"

I examined it. Percussion. An abdominal exudate needs to be collected and examined.. Will do the basic tests of blood and urine as the owner has a budget.

1439. NIMBY Syndrome - A polluting generator with an exhaust pipe at the back of Toa Payoh Vets

Friday
March 31, 2013

After assuring me that the company would relocate this generator with a blue-smoke exhaust pipe away from the space between the back of my surgery and the restaurant's cooking area, the Filipino staff installed a 10-foot high pipe to re-direct the smoke upwards to the 2nd floor.

"This should be OK," he said.
The smoke is now more visible and the air blew it into the units in floor one.
"I was told that the unit will be relocated just yesterday by the managing agent but obviously, this company has no intention of doing it."

The smoke had drifted into the back of the surgery and into the kitchen of the restaurant. I do eat in this restaurant. But nobody cares about eating polluted food. 20-30 years many Singapore cars and lorries emit such blue smoke from the exhaust pipes but now you seldom see any. But this generator does it. It would be at least 2 months of smoke. Imagine yourself breathing such smoke from the vehicle's exhaust pipe for a few hours a day.

The managing agent, the contractor and the supplier of this generator would be the parties involved.They did not see the effects of the smoke on the kitchen cooking, poisoning the staff and food for the workers.

I followed up again and again. The supplier wanted to meet me at 11 am today to "seek my solution" but was tardy. I had to postpone one surgery to wait for him. The Filipino man said that he would get a crane and relocate the generator by Monday 12 noon. The long black pipe to re-direct the smoke was not long enough and in any case, the smoke just settled downwards again.

NIMBY means "not in my backyard" happens to everybody. If the company can erect a pipe 10 stories high, it may be possible to resolve this problem, not just 10 feet high. Electricity generators are smoky but are there ones with no smoke? Just like the cars, buses and lorries in Singapore nowadays?

  

1438. A well loved dog passed away

TOA PAYOH VETS toapayohvets.com Date:   30 May, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits A well loved dog passed away Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   30 May, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 1438. A well loved dog passed away I received an email dated May 27, 2013 from a lady who loves her dog very much. I always feel the loss of my client's older dog from illness or cancer at nearly 14 years of age. The dog was said to have suffered from lymphoma. At 9 years of age, I spayed her as she was suffering from open pyometra and being old, some vets would not operate on her.  She survived the anaesthesia and the surgery in 2008. She thrived due to the high quality of care from the couple.      May 27, 2013 Dear Dr. Sing, It has been a long time since we last communicated.  I hope you have been well.  I see you have been busy traveling now that you have more or less retired from running your clinic full time. I do see from your website that you still work at Toa Payoh Vets part-time. CC passed away last month on 22 April 2013, just a week short of her 14th birthday.  She had been diagnosed with chronic kidney failure for a couple of years and in May 2012 she collapsed and was very lethargic.  She spent 4 nights at the vet on IV drip and that hospital stay restarted her kidneys. Since she came home on 17 May 2012 to the last day of her life, I had been giving her daily subcutaneous fluid injections at home.  As you know, this was only to maintain her quality of life, and not a form of treatment. CC had always been patient and brave with the daily jabs.  In the end it was not the kidney failure that took away her life, but an undiagnosed gastro-intestinal tumor that grew so aggressively.  In the last one week of her life, she was in and out of hospital 3 times, staying around 2 nights each time.  On her last night at home, she pooed blood, had 4 seizures and was just so weak.  She passed away on Monday morning 22 April at the vet clinic on the operating table after the vet Dr. XXX opened her up and found the cancer was too big and deep. I thought I should write to let you know.  As you know, CC has always been very precious to R and me.  I tried my best as long as I could and poor CC hung on to stay with me too, but it was just too tough for her physically.  I always remember you as her first vet and look upon you with utmost respect because you were the one who operated on her when she was 9 years old when no other vet in Singapore would.  It was after that surgery you performed when I nursed her back to health that our bond deepened.  I still keep digital and printed records of that spay surgery as well as the dental scaling you performed for her. Thank you very much for your kindness to my beloved CC. Best regards, L   EMAIL REPLY FROM DR SING dated May 28, 2013 Thank you for updating me about CC and please accept my condolences. Do let me know if I can be of any help or to talk to. She lived to a ripe old age of 14 years and I am most happy that she has been well cared for, judging from the images I see from your blog which I visited now and then. P.S. I phoned the owner as emails are very impersonal and it would be too much grief for her to phone me. Old dogs are a high risk anaesthetic case and it is not surprising that the other vet did not want to do it as death on the operating table ruins the vet's reputation since some owners will post on internet forums, Facebook and blogs publicising his name, practice and the dog's death for the whole world to know. No explanation is acceptable when a beloved dog dies on the operating table. I could consider myself lucky in this case. The case study of this Lhasa Apso at: http://www.bekindtopets.com/dogs/20080912Complications _bleeding_pyometra_ToaPayohVets.htm   Updates will be on this webpage: http://www.sinpets.com/F6/20130530pyometra_old_dog _toapayohvets.htm   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: May 30, 2013 Toa Payoh Vets

1439. A 10-year-old Schnauzer has fits and collapses suddenly

TOA PAYOH VETS toapayohvets.com Date:   31 May, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits Fits in a Schnauzer  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   31 May, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 1439. A 10-year-old Schnauzer has fits and collapses suddenly   May 29, 2013 "Do you remember you operated on his ears?" the mother and daughter brought in a white Schnauzer that had fits and collapsed just over one hour ago. The dog had white and cyanotic tongue and was breathing fast. I put him on oxygen therapy first as he had insufficient oxygen for his red blood cells, leading to purplish tongue and mucous membranes. I reviewed the medical records and said: "Yes, he had very painful and itchy right ear and his ear canal was opened up. How's the ear?" "No more problem," the mother said. "Could the dog be suffering from a stroke?" "Hard to say at the moment, I need a blood test and examination. It is possible there is a brain abnormality e.g. tumours, infection or bleeding or a systemic infection. I advised a brain scan but that would be costly and so the owners wanted the basic treatment to be done. That included a blood and urine test.   The veins were collapsed too. Dr Daniel had to collect blood from the jugular vein. It was not a good sign. Despite intensive treatment, the dog passed away 2 hours later.  BLOOD TEST Significant findings are: 1. Total white cell count 18.3 (6-17). N 90% Absolute 16. L 9% Absolute 1.7 2. Red cell count 5 (5.5 - 8.5) 3. Haemoglobin 11 (12-18). 4. Platelets 108 (200-500). Few giant platelets present. No platelet clumps. 5. Uric acid  0.27 (<0 .13="" br=""> 6. SGOT/AST 129 (<81 br=""> 7. Urea 3.4 (4.2 - 6.3). Creatinine levels were normal.  The blood was taken from the jugular vein. The dog had around 30 minutes of oxygen therapy by mask before the blood and urine were collected. URINE TEST pH 5.0 (5-8), SG 1.020 (1.005-1.030), urobilinogen +, blood 4+, bacteria 3+, white blood cells >2250, red blood cells 315. It is important to practise evidence-based medicine. In this case, the dog could have a septicaemia. There could be a pathogenic type of bacteria picked from sniffing the grass or consuming some poisonous food or treats. The onset was "sudden" fits and recumbency. There could also be an internal bleeding and breakdown of capillaries. A post-mortem may give a definitive diagnosis as to the cause of death. As it would be costly, this was not advocated by me. A simple blood and urine test provide some clues of illness at the most economic rates as compared to brain scanning and more tests. In any case, the dog was breathing fast and had white and purplish tongue, indicating a very poor prognosis. However, other tests like brain scan needs to be advised. This Schnauzer has been well cared for as evident by his good size and body condition as so the death was a "sudden" loss to the family. No poisonous food or drink was consumed according to the mother.   The dog's ears were normal after the surgery as there was no more intense and continuous ear scratching. The case study and lateral ear canal resection surgery is at: http://www.asiahomes.com/singaporetpvet/dogs/ 0750Schnauzer_lateral_ear_resection_Singapore.htm   Updates will be on this webpage: http://www.sinpets.com/F6/20130531 fits_Schnauzer_toapayohvets.htm   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: May 31, 2013 Toa Payoh Vets

1441. Facebook condemns a vet in Myanmar - vomiting pug with blood in the urine. UTI or urinary stones?

May 29, 2013

A Myanmar vet was condemned by the Facebook posting as the pug he treated for urinary tract infection died. I saw the image of the pug although I could not read the Myanmar postings.  According to my assistant Naing, the vet said there was just urinary tract infection and no bladder stones. The owner had consulted Vet 1 who diagnosed bladder stones from ultra sound and so the owner brought the dog to Vet 1.

When a dog dies, the postings can be very sharp. The dog had been vomiting. So was there bladder stones or not?

"It is possible there is renal failure causing vomiting, but blood tests were not done to show the health of the kidneys. An X-ray could have been done to confirm the bladder or kidney stones."

Based on urine microscopy of "no crystals," the vet came to a conclusion there was no stones despite Vet 1's ultrasound stating there were stones.

Although no autopsy was done to find out the cause of death, the Facebook posting would be harmful to the reputation of the vet practice as the postings spread around the world. .

It is best that a process is used whenever a vomiting dog with haematuria is presented. Blood tests, urine tests and X-rays are mandatory unless the owner declines them. Practise defensive medicine but be compassionate if the owner has financial difficulties.   

1440. Anal sac swelling in a 3-year-old Pom

May 30, 2013

The accountant had to rush here at 7.30 pm after work to get her Pom treated.
"Dr Daniel is in Bangkok today Friday," I said as she asked for him. Dr Daniel had expressed the anal sac in February and she had instructed the dog groomer to do so soon after. Now the dog was not happy with his backside.

"Is there tail chasing or biting?" I asked. "You can consult Dr Daniel as he will be back on Sunday."
However she could not wait and asked me to teach her how to express the anal sacs. They were swollen at around 1 cm x 1 cm but quite deep inside and so I asked her to feel the swelling with her fingers. "At 4 and 8 o'clock deeper in. Pinch the area outwards. Don't let the anal sac oil splatter onto your face or dress as this had happened to my assistant Niang and myself."

So, she had to be careful as this lady in her late 20s had a blue office dress and wanted to know how to do it.

My assistant was present to help hold the dog which is muzzled. After confirming she is right-handed, I said: "Lift up the tail with your left hand, place the tissue to cover the anal opening and press with you right hand's thumb and forefinger."

It was easier said than done. She could not do it.
"You use your fingers to feel the swelling and press while I cover the anal opening with the tissue paper," I said. "Hold the tail upright."

She pressed the anal swellings. The male not neutered Pom growled. He had been patient for some minutes and this was painful.

She squeezed the area.
"The tissue paper has 6 x 6 mm of brown oil contrasted on the white surface. You had success but you took out less than 1%. Let me do it."
The Pom was getting fed up with being a guinea pig.
I expressed an impressive amount of grey granules spreading an area of 5 cm x 4 cm.
"Did Dr Daniel express this much in February when he vaccinated your Pom?" I asked.
"Much more but blacker in colour."
"The anal sacs are still inflamed and the oil still solidifies," I said. I gave a course of medication and asked her to express the sac with her bare fingers to massage it, during the weekly bath.

Education of the client is important but takes a lot of time. Many vets don't have the patience to do it and it is not so easy for a dog owner to do the anal sac expression as in theory.

1437. Caesarean section tips for vets

1436. How to close a large peri-anal wound after a massive circum-anal tumour surgery

TOA PAYOH VETS toapayohvets.com Date:   02 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits How to close a large peri-anal wound  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   02 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 1436. How to close a large peri-anal wound after a massive circum-anal tumour surgery Male Cross-bred, 10 years, not neutered, has several tumours. But circum-anal tumours were massive and extended around the anus from 12 to 6 o'clock. A cluster of tumours appeared at 10 to 11 o'clock. May 1, 2013 Tumour excision was done by Dr Daniel but the skin was under high tension after stitching as there was insufficient nearby skin to close the wound. After 7 days, the stitches broke down. The anal opening shrank deep into the big wound caused by the breakdown. Stools clogged inside the skin folds of the large wound. Flies appeared from nowhere and settled on the wound. I got the dog washed twice daily to clear the stools and keep the wound clean.  "This wound will never heal by secondary intention as the stools keep falling into the wound, contaminating it," I said to Dr Daniel. "There is a need for another operation to close it. The retained stools keep contaminating the wound. The owner's permission must be given." Dr Daniel said: "The dog is old and had difficulty in surviving the long anaesthesia. So I did not create a flap to close up." "In old dogs, to ensure survival from anaesthesia on the operating table, it is best to do a 2-stage surgery. Stage 1 to excise the wound. Stage 2 to create a skin flap to close the wound. However, the owner must be informed early and told of the financial costs in 2 operations."    I sketched two surgical plans for Dr Daniel to consider.  I phoned the owner who asked about the costs and gave permission to close up the big wound. May 17, 2013 The dog had been cleaned twice daily for the past 16 days. There was diarrhoea earlier and the wound would not heal.  Creating a flap to cover the wound was done by Dr Daniel on May 17, 2013. On the 3rd day, the dog went home as the wound was healing well.       6158 - 6164.  Massive circum-anal tumours in old dogs - 2-stage surgery advised UPDATE As at Jun 2, 2013, no complaints about the wound from the owner. I text-message her on May 28, 2013 and did not get a reply. Will follow up again.  Owing to financial constraints of the owner, some large wounds can be left to heal by secondary intention rather than using a skin flap. For example, large umbilical or sternal area tumours. Financial costs are much higher when tumours are massive and two-stage surgeries are advised in dogs over 7 years old to minimise anaesthetic deaths.    Updates will be on this webpage: http://www.sinpets.com/F6/20130602circum_anal _wound_closure_toapayohvets.htm   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: June 02, 2013 Toa Payoh Vets

1435. Myanmar stories - Same name but different destinies

Yesterday May 27, 2013, I visited Khin Khin's office. There was a plump Myanmar lady asking her to find her a better job earning more than the $500 per month she was paid for the last 4 years working as a nursing aide for the intellectually disabled. She loved her job as she showed me her mobile phone pictures of her favourite patient and of her cooking for over 200 people in the home and in the monastery.

It is very difficult for Khin Khin to get to know all prospective job applicants as several come in per day. I noted that this lady has exactly the same name as Khin Khin. Many Myanmar nationals seem to have same names but this was the first time I noticed the exactly identical names.

"Try and help her find a better job," I said to Khin Khin. "She has the same name as you and has a degree in Geography from the East Yangon University. She needs to support her family. If she has a better fate like you, she will not be earning so little. "

"She is too fat," Khin Khin was surprised that this lady has a similar name as hers. "Employers will think she is lazy and will not accept her."
The lady was not offended by this stereotyping of fat being lazy.    
"Where is your home in Myanmar?" I asked.
"In China-town in Yangon. My parents live there."
"Yes, I had been there. Are the people there speaking Mandarin?" I asked.
"No, they speak Hokkien," she enlightened me that the "Little India" street where vendors sell nuts I visited when I was in Yangon was Muslims from Blangladesh, not Indian nationals.
"Why don't you work in Yangon now that Myanmar is booming?" I asked.
"I like Singapore," she could converse in English well. She would prefer a job where she could earn $1,000 and stay out of the employment area.
"Will you get a good testimonial from the employer? You have worked for 4 years to the expiry of your contract."
"My officer is hospitalised with some shoulder pain," she replied. "They will give me the air ticket and testimonial at the Changi Airport tomorrow when I have to go back."
This was a lady who was mature in that she did not jump ship when a prospective agent offered her a $1,000 job and freedom to live away from the employer's premises as her contract had not expired.
"How old are you?" I asked.
"I am 38 years old." Certainly age and experience makes her responsible to complete her contract. But there are others who don't care and will job hop at any moment for a better pay. Now she is free to go to interview for the $1,000 job but will need to go home first.
As she left she asked Khin Khin in Myanmar language and Khin Khin told me: "What weight should I lose?"
"10 kg will be good," I replied. "You can always go jogging early morning as I see many Yangon people doing it near the lake.  Don't eat the fatty oily food. Just chicken, fish, vegetables and rice mainly."

It is very difficult to reduce weight on Myanmar cooking which is extremely oily in my observation. Oily food tastes good. In Singapore, the numerous slimming saloons ensure that our young ladies keep slim before marriage.

1434. Two cases of undescended testicular tumours in old dogs.

TOA PAYOH VETS toapayohvets.com Date:   28 May, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits High anaesthetic risks in surgery  of undescended testicular tumours in old dogs Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   28 May, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 1434. Two cases of undescended testicular tumours in old dogs May 27, 2013 Case 1.  Anaesthetic risks are very high when an old dog is operated and all vets will have encountered deaths on the operating table. This case was one of them. A woman adopted a bigger Papillion cross-bred that has a left undescended testicle larger than the biggest hen's egg you will ever see in a supermarket. That was some weeks ago when she asked me to examine the dog and to age  him. I estimated the age to be over 6 years as the teeth were in good condition. She did not want any surgery to remove the large left undescended testicular tumour.   2 days ago, the lady brought in the dog as there was a few new lumps growing beside this tense skin testicular tumour, irritating the dog causing him to lick it. I warned the owner of the very high risk. The tumour was massive and the cancer cells would have destroyed much of the testicle based on this large size. "I met his ex-owner who came to me when I was walking the dog a few days ago. The person asked why I was so stupid to adopt a 12-year-old dog but did not acknowledge she was the owner."  The tumour and the cysts were removed. It was quite a bloody surgery. The dog survived the surgery but passed away probably from heart failure around 12 hours later as her tongue and gums were cyanotic.  The woman was understanding. Dogs over 7 years old are considered high anaesthetic risks and most owners and vets prefer not to operate on such categories of dogs as so much risks and emotions are involved when a dog dies on the operating table. Case 2. One day before this case, there was the 13-year-old Shih Tzu with the recurring ringworm in his belly. He had an undescended left testicle 3 x larger than the descended one and is much firmer. The dog came in for the generalised ringworm in April and had recovered in her face, legs and body. But the belly was itchy and red rings appeared. It was a new case of ringworm again.     Left undescended testicular tumour has been removed together with the descended right normal testicle in this 13-year-old Shih Tzu "Why didn't you tell me that my dog had testicular tumour the last time you saw her for ringworm?" the woman in her 50s asked me. She had brought in the dog for an itchy body which did not respond to anti-ringworm drugs prescribed by two vets consulted and by her self-treatment of over-the-counter lotion.  "At that time, the undescended tumour was not so big and hard," I advised neutering. This was done under general anaesthesia with little bleeding unlike case 1. The tumour had not grown fast and large yet. The dog is of a similar age as Case 1 but survived the anaesthesia and is well as at today (3 days after surgery).  Conclusion Annual health examination of your older male dog by your vet will have been best if you don't want him neutered. It is best to neuter dogs with undescended testicles as there is a high probability of them becoming cancerous. Although anaesthesia is safe nowadays, old dogs are always a high anaesthetic risk.    Updates will be on this webpage: http://www.sinpets.com/F6/20130528 undescended_testicular_tumours_toapayohvets.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: May 28, 2013 Toa Payoh Vets