Yesterday, Jan 26, 2012, I received a phone call from a home breeder saying that her buyer had brought a 8-week-old gold/white Shih Tzu puppy to me on Jan 25, 2012 for vaccination. I had told the buyer that the puppy was 5 weeks old and therefore too young to vaccinate. "I delivered the puppies myself," the breeder said. "They are 8 weeks old but the buyer said you told her she is 5 weeks old."
I was surprised as I do not age a puppy so accurately as being 5 weeks. No vet can do this because it is not possible to pin-point the exact age just by looking at the puppy's teeth. There is a range and 8 weeks is plausible. So, I told her I would check Jan 25 cases and none of the 4 vets had such a puppy presented on that day.
The home breeder's message to me:
Dr Sing, indly assist to investigate the following:
Name and tel of buyer given
She claimed she had brought the puppy shih tzu, female, gold/white, 2 mths old to your clinic appointment on 25 Jan, for puppy's lst vaccination and microchip. However she had informed me yesterday that your vet told her the puppy is only 5 weeks old.
I suppose in that instance no vaccination or microchip done? N what is the assessment for no vaccine for the puppy? That constitutes to the buyer claiming your vet said so. If this is the case, I will make report and take action accordingly.
The puppies were born on 28 Nov 2011. I was the one who helped my dog gave birth to the puopies. I would like your assistance to investigate and clarification to this matter soonest. Thank you.
----------------------------------------
My reply to the breeder:
On 25 Jan 2012, none of the 4 vets including myself had a case of a female shih tzu puppy, gold and white, 8 weeks or 5 weeks for vaccination. I have checked all cases done on that day. Give me her tel number to verify with her.
-------------------------------------------
I have not contacted the buyer yet. This is quite an emotional issue and it is best not to rush into phoning the buyer since she had not come on Jan 25, 2012. How to handle this case since the buyer had stopped responding to the breeder's phone call?
Based on this case, home breeders who are concerned about their puppies sold may find it important to give a paper of birth when they sell their puppies.
Friday, January 27, 2012
844. Character and Competence of interns and new employees
To: The young interns and employees
Please note that you may want to do everything in a project at once according to your "better" way and your timing with no limits. That is the mark of your internet generation. But that takes lots of times and in the end, you take so much time that "opportunity costs" (if this is the correct word) have passed you by.
What I usually suggest to my younger interns at Toa Payoh Vets is to produce results within 3 days by doing smaller segments of the project.
For example, in doing a stock inventory of drugs, I have this young man, Mr Lim who has taken 2 months and has not been able to produce the complete list of unit pricing etc. This is because he tries to do all categories at one time. I have asked him to do one category at a time e.g. "Prescription Diets", then "Eye Drops" and that should be the way to produce results to show to your boss that you have achieved some results for discussion and editing.
The google generation will always switch on their computer to do the writing. Sometimes, a piece of paper and pencil achieve faster results.
I hope you will be open to receiving instructions to adopt the existing processes and not try and do new things for the time being.
By "opportunity costs", I mean that the opportunity to make money has slipped by if a person takes a long time to produce results like trying to get every information about a big project in place.
In the commercial world, performance counts and time is money. For the youths, time is eternal and I note that many simply waste their time daily in not being productive, efficient and able to accept instructions from old fogies whom they think are outdated and close-minded.
Old fogies have learnt from the hard knocks of life and some processes and systems have been produced through trials and errors that are not explained to the interns instantly, due to lack of time, pressure of work and the need to assess of the intern's motivations and diligence.
It takes a lot of time to explain the rationale of why the processes and systems are being used and unless the intern or youth has shown character and competence, there is so much the old fogies have to perform such that there is little time to just talk about the history of why certain tasks need to be performed in the present situation.
If there are improvements and innovations, the youths can propose later. But first, the new intern or employee must learn to adopt existing processes first and become productive. Performance and prompt results count in the commercial world and this is not taught in the junior colleges and universities, in my observations of the interns and new employees.
Please note that you may want to do everything in a project at once according to your "better" way and your timing with no limits. That is the mark of your internet generation. But that takes lots of times and in the end, you take so much time that "opportunity costs" (if this is the correct word) have passed you by.
What I usually suggest to my younger interns at Toa Payoh Vets is to produce results within 3 days by doing smaller segments of the project.
For example, in doing a stock inventory of drugs, I have this young man, Mr Lim who has taken 2 months and has not been able to produce the complete list of unit pricing etc. This is because he tries to do all categories at one time. I have asked him to do one category at a time e.g. "Prescription Diets", then "Eye Drops" and that should be the way to produce results to show to your boss that you have achieved some results for discussion and editing.
The google generation will always switch on their computer to do the writing. Sometimes, a piece of paper and pencil achieve faster results.
I hope you will be open to receiving instructions to adopt the existing processes and not try and do new things for the time being.
By "opportunity costs", I mean that the opportunity to make money has slipped by if a person takes a long time to produce results like trying to get every information about a big project in place.
In the commercial world, performance counts and time is money. For the youths, time is eternal and I note that many simply waste their time daily in not being productive, efficient and able to accept instructions from old fogies whom they think are outdated and close-minded.
Old fogies have learnt from the hard knocks of life and some processes and systems have been produced through trials and errors that are not explained to the interns instantly, due to lack of time, pressure of work and the need to assess of the intern's motivations and diligence.
It takes a lot of time to explain the rationale of why the processes and systems are being used and unless the intern or youth has shown character and competence, there is so much the old fogies have to perform such that there is little time to just talk about the history of why certain tasks need to be performed in the present situation.
If there are improvements and innovations, the youths can propose later. But first, the new intern or employee must learn to adopt existing processes first and become productive. Performance and prompt results count in the commercial world and this is not taught in the junior colleges and universities, in my observations of the interns and new employees.
Thursday, January 26, 2012
843. Dressing casually as a vet or veterinary staff
This year 2012, I will not try to be flexible as in the past years. I will not tolerate casual dressing by my vets or the staff or intern.
Sandals, T-shirts and jeans are out. Those who persists will likely get the sack as they cannot do what they like anymore. The young may think they are cool but it is just common sense. How can clients trust you when you dress as in sports shoes, sandals with your toes exposed and T-shirts with advertisements.
Dressing casually is out in 2012 and those who insists on dressing casually will need to look for another job.
Sandals, T-shirts and jeans are out. Those who persists will likely get the sack as they cannot do what they like anymore. The young may think they are cool but it is just common sense. How can clients trust you when you dress as in sports shoes, sandals with your toes exposed and T-shirts with advertisements.
Dressing casually is out in 2012 and those who insists on dressing casually will need to look for another job.
Wednesday, January 25, 2012
842. Chinese New Year 3rd day - follow-up 3 cases
National Library, Jan 25, 2012 7.42 pm
Dr Daniel Sing's first day at work
3 cases, equivalent to senior citizens in age, seen by me yesterday needed dental attention as they strongly objected to my opening their mouths. The Persian cat had saliva stains on the chin and one front paw. The Shih Tzu snapped at me when I tried to open her mouth. She was drooling. The Jack Russell's right facial swelling below the right eye had rounded up after my IV drip and medication including steroids.
That meant sedation as I suspected inflammation of the mouth. You could tell from drooling of saliva that definitely two of them had stomatitis. The third one with a facial swelling leaking plasma blood and pus could be a malar abscess. I asked Dr Daniel Sing to let me know what he thought of the facial swelling - now half a ping-pong ball size encroaching on the lower eyelid. "It could be an abscess or haematoma," he said. "How about a carnaissal tooth abscess or malar abscess?" I asked. It was too large and he did not think so. "Well, the Jack Russell catches centipedes and he could have been stung. But he never had a dental scaling for the past 12 years of his life and that is why I am more inclined to put malar abscess as my first diagnosis."
Case 1.
Jack Russell. Male, 12 years old.
After taking some images at 9.30 am with Intern Mr Lim, the swelling burst like a dam.
"Where is your ACP (acetylpromazine)?" Daniel asked me when I told him to get ready to sedate the JR. "I don't use ACP," I said. "I know ACP is popular with the Australian vets." A new vet must adapt to the work environment. "ACP is commonly used in the Murdoch Univ school and by Australian vets giving IM sedation, but there are better alternatives in real world of private practice," I said. "I give Domitor + Ketamine IV and get a better faster sedation than ACP IM." When I was a vet student in the UK from 1969-1974, ACP was also commonly used by the UK vets. So, it is not as if I don't know what is ACP. So, Daniel got to see how effective D+K was when given IV at 50% of the formula in an old JR.
The abscess had burst and he took a big bag of swabs and looked for the pink chlorhexidine to clean the big wound. "Where's the kidney dish?" he asked.
As that is what the Murdoch Univ lecturers must have taught him and all the new graduates. I did not comment as Daniel would learn the ropes.
For me, a large amount of clean water in a 20-ml syringe would flush away the debri and take 1 minute and worked effectively. Singapore's tap water can be drunk and it is therefore clean.
But Murdoch Univ professors cannot teach this simple method. No need for bags of swab. This was a dirty abscessed wound full of bacteria yesterday. My antibiotic Baytril via IV drip had killed them all.
Spending effective but short time is important. Being productive and that is what many younger vets can't understand. When a procedure can be done in 10 mintues, they take 30 minutes. For example, in this JR, a new vet would swab and swab away the discharge. Swab again. Apply the pink chlorhex from the bottle. Put the discharge in the kidney dish. This is what I would imagine them to be taught how to do.
There are other cases to do and if the vet takes 30 minutes hour to just clean the abscess, that time is gone. I put the bag of swab away from the operating table onto a side table as I knew it would be wet. Daniel wanted it on the operating table which was already wet with the JR being washed. Later I asked Min why the whole packet was wet. He said, "The water from the operating table."
I showed how Domitor + Ketamine at 50% of my calculated dose was used effectively and not to waste time. Isoflurane gas mask and intubation.
What was the cause of this abscess? Centipede sting? There was some pus when it burst. I checked whether the 4th maxillary premolar on the right upper jaw was rotten. This would be the main cause of infection to the cheek bones below the right eye. "The PM4 is strong," Min said to me. So, Daniel was correct. This was not a malar abscess since PM4 is usually implicated. I said to Min, "I will check the two molars behind the PM4." He had never seen molars causing malar abscess. So he was doubtful. Yet, the two molars were loose and rotten. They would be the cause of the infection to the cheek bones and below the eye, over time.
He was wobbly after abscess cleaning and cutting off the dead skin and cells, dental scaling and work. The whole process took one hour. The JR looked lethargic. I gave Antisedan 0.2ml IM. Within 10 minutes, he was alert. That was good. Now, what to do with such a big hole in his cheek? More than a 50-cent coin or 8 cm x 8 cm (see image).I propose stitching up 5 days later. The owner wanted to bring him home. So, it will be against medical advice (AMA) but what the owner wants, the vet has to do and record AMA. At home, the wound may become dirtied and flies may lay eggs. But in a room and a big cage, and proper nursing, this can be good for the dog too. Then 5 days later, come back for review and stitching as I doubt that such a large wound can heal well. There are many nerves in the cheek area and it would be very painful to have a big exposed cheek area. Blood tests were done but still the economics would be important.
Case 2.
Persian cat. Emaciated. 12 years old. Tongue and gum ulcers. 3 rotten teeth extracted. No blood tests were granted. See images.
Case 3.
Shih Tzu, Female, Not spayed. 13 years old. The whole mouth, gums and inner cheeks are ulcerated. Very bad. Emaciation and anaemia. I don't know whether she would survive the domitor + ketamine IV. I gave an Antisedan 0.2 ml to wake her up. This dog is so pale but blood tests were not granted by the owner.
Dr Daniel Sing's first day at work
3 cases, equivalent to senior citizens in age, seen by me yesterday needed dental attention as they strongly objected to my opening their mouths. The Persian cat had saliva stains on the chin and one front paw. The Shih Tzu snapped at me when I tried to open her mouth. She was drooling. The Jack Russell's right facial swelling below the right eye had rounded up after my IV drip and medication including steroids.
That meant sedation as I suspected inflammation of the mouth. You could tell from drooling of saliva that definitely two of them had stomatitis. The third one with a facial swelling leaking plasma blood and pus could be a malar abscess. I asked Dr Daniel Sing to let me know what he thought of the facial swelling - now half a ping-pong ball size encroaching on the lower eyelid. "It could be an abscess or haematoma," he said. "How about a carnaissal tooth abscess or malar abscess?" I asked. It was too large and he did not think so. "Well, the Jack Russell catches centipedes and he could have been stung. But he never had a dental scaling for the past 12 years of his life and that is why I am more inclined to put malar abscess as my first diagnosis."
Case 1.
Jack Russell. Male, 12 years old.
After taking some images at 9.30 am with Intern Mr Lim, the swelling burst like a dam.
"Where is your ACP (acetylpromazine)?" Daniel asked me when I told him to get ready to sedate the JR. "I don't use ACP," I said. "I know ACP is popular with the Australian vets." A new vet must adapt to the work environment. "ACP is commonly used in the Murdoch Univ school and by Australian vets giving IM sedation, but there are better alternatives in real world of private practice," I said. "I give Domitor + Ketamine IV and get a better faster sedation than ACP IM." When I was a vet student in the UK from 1969-1974, ACP was also commonly used by the UK vets. So, it is not as if I don't know what is ACP. So, Daniel got to see how effective D+K was when given IV at 50% of the formula in an old JR.
The abscess had burst and he took a big bag of swabs and looked for the pink chlorhexidine to clean the big wound. "Where's the kidney dish?" he asked.
As that is what the Murdoch Univ lecturers must have taught him and all the new graduates. I did not comment as Daniel would learn the ropes.
For me, a large amount of clean water in a 20-ml syringe would flush away the debri and take 1 minute and worked effectively. Singapore's tap water can be drunk and it is therefore clean.
But Murdoch Univ professors cannot teach this simple method. No need for bags of swab. This was a dirty abscessed wound full of bacteria yesterday. My antibiotic Baytril via IV drip had killed them all.
Spending effective but short time is important. Being productive and that is what many younger vets can't understand. When a procedure can be done in 10 mintues, they take 30 minutes. For example, in this JR, a new vet would swab and swab away the discharge. Swab again. Apply the pink chlorhex from the bottle. Put the discharge in the kidney dish. This is what I would imagine them to be taught how to do.
There are other cases to do and if the vet takes 30 minutes hour to just clean the abscess, that time is gone. I put the bag of swab away from the operating table onto a side table as I knew it would be wet. Daniel wanted it on the operating table which was already wet with the JR being washed. Later I asked Min why the whole packet was wet. He said, "The water from the operating table."
I showed how Domitor + Ketamine at 50% of my calculated dose was used effectively and not to waste time. Isoflurane gas mask and intubation.
What was the cause of this abscess? Centipede sting? There was some pus when it burst. I checked whether the 4th maxillary premolar on the right upper jaw was rotten. This would be the main cause of infection to the cheek bones below the right eye. "The PM4 is strong," Min said to me. So, Daniel was correct. This was not a malar abscess since PM4 is usually implicated. I said to Min, "I will check the two molars behind the PM4." He had never seen molars causing malar abscess. So he was doubtful. Yet, the two molars were loose and rotten. They would be the cause of the infection to the cheek bones and below the eye, over time.
He was wobbly after abscess cleaning and cutting off the dead skin and cells, dental scaling and work. The whole process took one hour. The JR looked lethargic. I gave Antisedan 0.2ml IM. Within 10 minutes, he was alert. That was good. Now, what to do with such a big hole in his cheek? More than a 50-cent coin or 8 cm x 8 cm (see image).I propose stitching up 5 days later. The owner wanted to bring him home. So, it will be against medical advice (AMA) but what the owner wants, the vet has to do and record AMA. At home, the wound may become dirtied and flies may lay eggs. But in a room and a big cage, and proper nursing, this can be good for the dog too. Then 5 days later, come back for review and stitching as I doubt that such a large wound can heal well. There are many nerves in the cheek area and it would be very painful to have a big exposed cheek area. Blood tests were done but still the economics would be important.
Case 2.
Persian cat. Emaciated. 12 years old. Tongue and gum ulcers. 3 rotten teeth extracted. No blood tests were granted. See images.
Case 3.
Shih Tzu, Female, Not spayed. 13 years old. The whole mouth, gums and inner cheeks are ulcerated. Very bad. Emaciation and anaemia. I don't know whether she would survive the domitor + ketamine IV. I gave an Antisedan 0.2 ml to wake her up. This dog is so pale but blood tests were not granted by the owner.
841. Email advice about a fast-growing hamster leg tumour
On Tue, Jan 24, 2012 at 4:44 PM, ...@yahoo.com> wrote:
Dear Doctor,
I need your advise regarding my daughter's winter white hamster.
It is abt 2years 2mths old and had a tumour on the right leg. We
noticed this tumour last year and its about a pea size.
Had brought her to a vet in Jan 2011 and advise against surgery due to old age.Within 2 weeks in Dec 2010 the tumor had grown very fast to a walnut size. She is eating and drink fine only her movement is rather slow and she keep bitting the tumour.
Is it too late to have the tumour remove now? If surgery is possible how much does it cost?We really love her sooo much, how do we know if she is in pain?
Would really appreciate your advise.
Thank You.
Regards
Owner's name
Thank you for your email. I am Dr Sing from Toa Payoh Vets
There is only one option to prevent death by infections and great pain from the growing tumour and that is surgical excision. Pain is shown by self-biting and being not active or eating in hamsters.
There is always an anaesthetic risk of death on the operating table for the older pet. You have to decide yourself. Cost is approximately $150-$200 for surgery and anaesthesia.
Coincidentally, I just saw a case of a dwarf hamster with a big growth on the back leg near the ankle. The lady had been advised by my associate vet Dr Vanessa to do leg amputation. But she did not want to as she did not want her hamster to be 3-legged. The tumour grew fast into a fatty ball of around 1 cm in diameter. Just as she arrived in a taxi to consult me, the hamster passed away. She could have saved this 1-year-old by permitting surgery 2 weeks earlier.
Therefore, decisions are made by the owner. The vet should give the proper advice and in your case, the advice from your vet was good. Pl make appointment at 6254 3326 if you decide on surgery. Best wishes.
Dear Doctor,
I need your advise regarding my daughter's winter white hamster.
It is abt 2years 2mths old and had a tumour on the right leg. We
noticed this tumour last year and its about a pea size.
Had brought her to a vet in Jan 2011 and advise against surgery due to old age.Within 2 weeks in Dec 2010 the tumor had grown very fast to a walnut size. She is eating and drink fine only her movement is rather slow and she keep bitting the tumour.
Is it too late to have the tumour remove now? If surgery is possible how much does it cost?We really love her sooo much, how do we know if she is in pain?
Would really appreciate your advise.
Thank You.
Regards
Owner's name
Thank you for your email. I am Dr Sing from Toa Payoh Vets
There is only one option to prevent death by infections and great pain from the growing tumour and that is surgical excision. Pain is shown by self-biting and being not active or eating in hamsters.
There is always an anaesthetic risk of death on the operating table for the older pet. You have to decide yourself. Cost is approximately $150-$200 for surgery and anaesthesia.
Coincidentally, I just saw a case of a dwarf hamster with a big growth on the back leg near the ankle. The lady had been advised by my associate vet Dr Vanessa to do leg amputation. But she did not want to as she did not want her hamster to be 3-legged. The tumour grew fast into a fatty ball of around 1 cm in diameter. Just as she arrived in a taxi to consult me, the hamster passed away. She could have saved this 1-year-old by permitting surgery 2 weeks earlier.
Therefore, decisions are made by the owner. The vet should give the proper advice and in your case, the advice from your vet was good. Pl make appointment at 6254 3326 if you decide on surgery. Best wishes.
840. The case of the Chattering Chihuahua - video production
DRAFT
HOOK
Teeth chattering in dogs. AUDIO CLIP
Image of THE CHIHUAHUA
Snow fall --- cold winter, snow-storm, but this is sunny Singapore
Antagonist arriving? Big bear attack when walked near the forest?
Loud noise --- fall from the sky, a meteor, earthquake tremors - 6th sense
A dog catcher on the prowl with his net? Downhill wind scent
A female dog nearby? Scent
INTRODUCTION
the case of the teeth-chattering Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
25 January, 2012
What causes it? The owner with the 8-year-old Chihuahua was a fair young lady probably had done her internet research and one of the websites would be:
http://answers.yahoo.com/question/index?qid=20100126080555AAfbVSv
AN EDUCATION VIDEO FOR VET STUDENTS AND PET OWNERS
COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com
Singapore, Jan 24, 2012
MIDDLE
CAUSES OF TEETH CHATTERING
1. Behaviour? Nervous, excitement. (Video clip of chattering). Not for her dog as this teeth chattering was recent and her dog was a calm and cool canine since young. When I saw her, the Chihuahua never chattered his teeth! Cool as a cucumber, the older Englishman would say. The google generation like this owner would say: "So cool!"
2.Cold freezing weather? (Slide of winter, snow fall)
Not in Singapore. It is Summer season all year round.
3. Certain breeds suffer from nervous disorder e.g. seizures, neuronal degeneration in young Cocker Spaniels or other breeds, white dog shaker syndrome in white dog breeds such as West Highland white terriers, the Maltese and the Bichon Frise. This needs early veterinary consultation.
4. Dental pain? This would be the likely cause as the old dog had bad breath, gum infections and loose decayed teeth. So she brought her dog to her vet as she felt that the recent teeth chattering could be due to toothache. Her vet wanted her to sign an anaesthetic risk consent form and forewarned her that her dog was an older dog and might die on the operating table during dental work.
CASE OF THE TEETH-CHATTERING CHIHUAHUA
FIRST VISIT
Sunday, January 15, 2012
The young couple came with the Chihuahua after having consulted a vet earlier. Death on the operating table is the main concern with the fair lady. Vet 1 had insisted that they sign the anaesthetic consent form highlighting the risk of death in an old dog undergoing dental work. "This is the common practice," I explained. "Even the human hospitals will ask you to sign the form if you go for anaesthesia and surgery. In the Singapore General Hospital, I was even given a 10-minute talk on anaesthetic risk by a young doctor in a room as I was scheduled for surgery the next week."
Her biggest worry and that of her mum was anaesthetic death. The vet must listen to what the client has to say. How competent is the vet? She does not know.
"How many anaesthetic deaths have you encountered when you did dental scaling?" she asked my associate vet who was handling the examination together with me. This was the sort of question many internet websites have advised the dog owner to ask the doctor. My associate vet said: "I refer you to Dr Sing."
The young lady turned her head to me for an instant reply.
I said: "I can only speak for myself. In my over 30 years of dental scaling, I have not encountered any anaesthetic death. This is because dental scaling and work do not require long anaesthesia. Therefore the risk of deaths on the operating table is very low. The anaesthesia should be completed within 15 minutes. Careful monitoring of the vital signs by the vet is most important."
I don't permit idle chatter during dental surgery. Nor do I make small talk with my assistant during surgeries. A singular focus on the surgery. Speed accuracy and completeness.
"Look at the right face," I pointed to the facial swelling. "Do you see a big swelling below the eye? The bacteria from the root of the back teeth, the 4th premolar, had gone into the face, causing this swelling. It is called a malar abscess."
The lady had a second look at the right face. "Compare to the left area below the eye," I suggested. "There is no swelling there!"
The lady turned her head to inspect the left face. This new finding added to her worries. She knew a dental work under general anaesthesia was necessary. Dental gels and paste that claim to work would not be effective. The internet advertisements of pet teeth are products are many.
Warnings of high anaesthetic risks and death esp. for the older dogs flashed back into her mind. She was well educated and informed to know that such products would not work for her dog.
ALTERNATIVE TREATMENTS WITHOUT ANAESTHESIA
1. Oral care gels and paste, chew toys and kibbles?
2. No anaesthesia dog groomers. Need to hold the dog firmly and rigorously to do the scaling or extraction as most dogs fight against such dental work without sedation and are frightened of it.
3. No action from the owner. Leads to oro-nasal fistula as in another Chihuahua. Show clips from
1. Chihuahua with a non-healing facial wound - oro-nasal fistula
http://www.youtube.com/watch?v=5AWHpWYWgy4&lr=1
2. Follow up on the Chihuahua after surgery and pyometra death
http://www.youtube.com/watch?v=ExTT2a8eUCs
How about dog groomers offering dental scaling without anaesthesia? There are such services offered by some pet shops in Singapore. This was an educated owner in my assessment, probably having completed higher education level and knows the situation.
She had done her internet research and knew that her dog would need more than dental scaling. He needed to have his loose and decayed teeth extracted. And this could not be done by the dog groomer without anaesthesia.
Her vet insisted that she signed the anaesthetic form first as taught by their veterinary professors to cover their back in case of litigation.
Here, at Toa Payoh Vets, my vets do insist on the client signing the anaesthetic form too. For me, I don't insist on it after explaining in detail one-to-one the risks and benefits thoroughly. So, I seldom get the owner to sign the form as this cause considerable stress for some of the young ones over my past 40 years of practice. If the client has no confidence in me, I would suggest going to another vet.
For this case, I advised antibiotics for the next few days and getting the dental work done on Friday as Sunday would be Chinese New Year. I don't perform surgery on Chinese New Year although I am not superstitious about bad luck if the vet "cuts" on Chinese New Year.
I told my associate vet that I would be handling the case myself as there was great worries for the fair lady.
SECOND VISIT
Friday, January 20, 2012
Sunday will be Chinese New Year's Eve. So the dog was done today. Blood test taken revealed nothing abnormal. "You have checked the blood test?" the young lady asked me. "Yes, the blood test showed normal results. There is no kidney or liver disorders and the dog's heart is good. Come back 2-3 hours later." She was comforted and left with her significant other.
ISOFLURANE + OXYGEN ANAESTHESIA
Chihuahua, Male, 8 years, Severe stage 4 periodontal disease.
No sedation
Images of the process and procedures
Mask and then intubation. Many assistants don't know how to anaesthesize the dog using just isoflurane + O2 as the dog does struggle vigorously and bite at a certain stage.
The technique is to hold the dog by the scruff of the neck and to take out the mask when the dog struggles at the excitement stage. Wait a few seconds and put the mask on. Repeat again. Normally, the dog will be anaesthesized smoothly.
Ideally, the dog should be sedated, given isoflurane by mask and then intubated. This is the better restraint and saves much time as the excitement stage does not exist. Most vets use this method and this is the method taught by the veterinary professors. I don't know whether they teach the use of isoflurane solely in old dogs or not as I was a student 40 years ago.
In this case, the owner had some knowledge of the sole use of isoflurane gas done by me and asked me about it. So I took over this case from my associate vet to give her peace of mind. Usually dental scaling is a relatively easier surgery compared to others like spay.
An endotracheal tube of the appropriate size, not too small, is inserted and the dog given 1-2% isoflurane gas as maintenance. The proper sized endotracheal tube for this dog was 6.5
Only 3 teeth left. Around 16 extracted.
The dog coughed when the owners came to pick up 2 hours later.
"It is caused by throat irritation of the endotracheal tube," I explained. "I inserted the tube into the windpipe to give the anaesthetic gas. I will give an injection."
It was one of those satisfying moments to see the young lady smile and freed of worries since her Chihuahua had not died on the op table and was as alert as if he had not been under anaesthesia. Isoflurane anaesthesia effect disappears within 5 minutes and that is why this dog was as alert as normal.
However, it takes a longer time to anaesthesize the dog and there is a certain technique which I taught my assistant Min so as not to injure the dog when he is struggling before being asleep. If a sedation injection is given first, there is virtually no struggling. As I had promised the owner that I will use gas only, I kept my word.
CONCLUSION
Anaesthetic deaths during dental scaling are rare in practice. Anaesthetic consent forms worry many owners and the risk of anaesthetic deaths promote a window of opportunity for non-veterinarians to provide dental scaling services.
Regular dental check up once a year and tooth brushing would have prevented the loss of 19 teeth and much worries. Do spend time brushing your dog's teeth at least three times a week. Easier said than done. A vast majority of Singapore owners is too busy to do the dental brushing.
CREDITS
COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com
Produced by: Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Narrated, Edited and Filmed by:
Sponsored by:
Asia USA Realty (asiahomes.com) Pte Ltd --- asiahomes.com
Be Kind to Pets (bekindtopets.com) LOGOS
Singapore, Jan 24, 2012
For more info:
W: toapayohvets.com
E: judy@toapayohvets.com
T: +65 9668-6468
Webpage with pictures at:
http://www.bekindtopets.com/animals/20120124isoflurane-gas-dental-extraction_Singapore_ToaPayohVets.htm
HOOK
Teeth chattering in dogs. AUDIO CLIP
Image of THE CHIHUAHUA
Snow fall --- cold winter, snow-storm, but this is sunny Singapore
Antagonist arriving? Big bear attack when walked near the forest?
Loud noise --- fall from the sky, a meteor, earthquake tremors - 6th sense
A dog catcher on the prowl with his net? Downhill wind scent
A female dog nearby? Scent
INTRODUCTION
the case of the teeth-chattering Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
25 January, 2012
What causes it? The owner with the 8-year-old Chihuahua was a fair young lady probably had done her internet research and one of the websites would be:
http://answers.yahoo.com/question/index?qid=20100126080555AAfbVSv
AN EDUCATION VIDEO FOR VET STUDENTS AND PET OWNERS
COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com
Singapore, Jan 24, 2012
MIDDLE
CAUSES OF TEETH CHATTERING
1. Behaviour? Nervous, excitement. (Video clip of chattering). Not for her dog as this teeth chattering was recent and her dog was a calm and cool canine since young. When I saw her, the Chihuahua never chattered his teeth! Cool as a cucumber, the older Englishman would say. The google generation like this owner would say: "So cool!"
2.Cold freezing weather? (Slide of winter, snow fall)
Not in Singapore. It is Summer season all year round.
3. Certain breeds suffer from nervous disorder e.g. seizures, neuronal degeneration in young Cocker Spaniels or other breeds, white dog shaker syndrome in white dog breeds such as West Highland white terriers, the Maltese and the Bichon Frise. This needs early veterinary consultation.
4. Dental pain? This would be the likely cause as the old dog had bad breath, gum infections and loose decayed teeth. So she brought her dog to her vet as she felt that the recent teeth chattering could be due to toothache. Her vet wanted her to sign an anaesthetic risk consent form and forewarned her that her dog was an older dog and might die on the operating table during dental work.
CASE OF THE TEETH-CHATTERING CHIHUAHUA
FIRST VISIT
Sunday, January 15, 2012
The young couple came with the Chihuahua after having consulted a vet earlier. Death on the operating table is the main concern with the fair lady. Vet 1 had insisted that they sign the anaesthetic consent form highlighting the risk of death in an old dog undergoing dental work. "This is the common practice," I explained. "Even the human hospitals will ask you to sign the form if you go for anaesthesia and surgery. In the Singapore General Hospital, I was even given a 10-minute talk on anaesthetic risk by a young doctor in a room as I was scheduled for surgery the next week."
Her biggest worry and that of her mum was anaesthetic death. The vet must listen to what the client has to say. How competent is the vet? She does not know.
"How many anaesthetic deaths have you encountered when you did dental scaling?" she asked my associate vet who was handling the examination together with me. This was the sort of question many internet websites have advised the dog owner to ask the doctor. My associate vet said: "I refer you to Dr Sing."
The young lady turned her head to me for an instant reply.
I said: "I can only speak for myself. In my over 30 years of dental scaling, I have not encountered any anaesthetic death. This is because dental scaling and work do not require long anaesthesia. Therefore the risk of deaths on the operating table is very low. The anaesthesia should be completed within 15 minutes. Careful monitoring of the vital signs by the vet is most important."
I don't permit idle chatter during dental surgery. Nor do I make small talk with my assistant during surgeries. A singular focus on the surgery. Speed accuracy and completeness.
"Look at the right face," I pointed to the facial swelling. "Do you see a big swelling below the eye? The bacteria from the root of the back teeth, the 4th premolar, had gone into the face, causing this swelling. It is called a malar abscess."
The lady had a second look at the right face. "Compare to the left area below the eye," I suggested. "There is no swelling there!"
The lady turned her head to inspect the left face. This new finding added to her worries. She knew a dental work under general anaesthesia was necessary. Dental gels and paste that claim to work would not be effective. The internet advertisements of pet teeth are products are many.
Warnings of high anaesthetic risks and death esp. for the older dogs flashed back into her mind. She was well educated and informed to know that such products would not work for her dog.
ALTERNATIVE TREATMENTS WITHOUT ANAESTHESIA
1. Oral care gels and paste, chew toys and kibbles?
2. No anaesthesia dog groomers. Need to hold the dog firmly and rigorously to do the scaling or extraction as most dogs fight against such dental work without sedation and are frightened of it.
3. No action from the owner. Leads to oro-nasal fistula as in another Chihuahua. Show clips from
1. Chihuahua with a non-healing facial wound - oro-nasal fistula
http://www.youtube.com/watch?v=5AWHpWYWgy4&lr=1
2. Follow up on the Chihuahua after surgery and pyometra death
http://www.youtube.com/watch?v=ExTT2a8eUCs
How about dog groomers offering dental scaling without anaesthesia? There are such services offered by some pet shops in Singapore. This was an educated owner in my assessment, probably having completed higher education level and knows the situation.
She had done her internet research and knew that her dog would need more than dental scaling. He needed to have his loose and decayed teeth extracted. And this could not be done by the dog groomer without anaesthesia.
Her vet insisted that she signed the anaesthetic form first as taught by their veterinary professors to cover their back in case of litigation.
Here, at Toa Payoh Vets, my vets do insist on the client signing the anaesthetic form too. For me, I don't insist on it after explaining in detail one-to-one the risks and benefits thoroughly. So, I seldom get the owner to sign the form as this cause considerable stress for some of the young ones over my past 40 years of practice. If the client has no confidence in me, I would suggest going to another vet.
For this case, I advised antibiotics for the next few days and getting the dental work done on Friday as Sunday would be Chinese New Year. I don't perform surgery on Chinese New Year although I am not superstitious about bad luck if the vet "cuts" on Chinese New Year.
I told my associate vet that I would be handling the case myself as there was great worries for the fair lady.
SECOND VISIT
Friday, January 20, 2012
Sunday will be Chinese New Year's Eve. So the dog was done today. Blood test taken revealed nothing abnormal. "You have checked the blood test?" the young lady asked me. "Yes, the blood test showed normal results. There is no kidney or liver disorders and the dog's heart is good. Come back 2-3 hours later." She was comforted and left with her significant other.
ISOFLURANE + OXYGEN ANAESTHESIA
Chihuahua, Male, 8 years, Severe stage 4 periodontal disease.
No sedation
Images of the process and procedures
Mask and then intubation. Many assistants don't know how to anaesthesize the dog using just isoflurane + O2 as the dog does struggle vigorously and bite at a certain stage.
The technique is to hold the dog by the scruff of the neck and to take out the mask when the dog struggles at the excitement stage. Wait a few seconds and put the mask on. Repeat again. Normally, the dog will be anaesthesized smoothly.
Ideally, the dog should be sedated, given isoflurane by mask and then intubated. This is the better restraint and saves much time as the excitement stage does not exist. Most vets use this method and this is the method taught by the veterinary professors. I don't know whether they teach the use of isoflurane solely in old dogs or not as I was a student 40 years ago.
In this case, the owner had some knowledge of the sole use of isoflurane gas done by me and asked me about it. So I took over this case from my associate vet to give her peace of mind. Usually dental scaling is a relatively easier surgery compared to others like spay.
An endotracheal tube of the appropriate size, not too small, is inserted and the dog given 1-2% isoflurane gas as maintenance. The proper sized endotracheal tube for this dog was 6.5
Only 3 teeth left. Around 16 extracted.
The dog coughed when the owners came to pick up 2 hours later.
"It is caused by throat irritation of the endotracheal tube," I explained. "I inserted the tube into the windpipe to give the anaesthetic gas. I will give an injection."
It was one of those satisfying moments to see the young lady smile and freed of worries since her Chihuahua had not died on the op table and was as alert as if he had not been under anaesthesia. Isoflurane anaesthesia effect disappears within 5 minutes and that is why this dog was as alert as normal.
However, it takes a longer time to anaesthesize the dog and there is a certain technique which I taught my assistant Min so as not to injure the dog when he is struggling before being asleep. If a sedation injection is given first, there is virtually no struggling. As I had promised the owner that I will use gas only, I kept my word.
CONCLUSION
Anaesthetic deaths during dental scaling are rare in practice. Anaesthetic consent forms worry many owners and the risk of anaesthetic deaths promote a window of opportunity for non-veterinarians to provide dental scaling services.
Regular dental check up once a year and tooth brushing would have prevented the loss of 19 teeth and much worries. Do spend time brushing your dog's teeth at least three times a week. Easier said than done. A vast majority of Singapore owners is too busy to do the dental brushing.
CREDITS
COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com
Produced by: Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Narrated, Edited and Filmed by:
Sponsored by:
Asia USA Realty (asiahomes.com) Pte Ltd --- asiahomes.com
Be Kind to Pets (bekindtopets.com) LOGOS
Singapore, Jan 24, 2012
For more info:
W: toapayohvets.com
E: judy@toapayohvets.com
T: +65 9668-6468
Webpage with pictures at:
http://www.bekindtopets.com/animals/20120124isoflurane-gas-dental-extraction_Singapore_ToaPayohVets.htm
Tuesday, January 24, 2012
839. Chinese New Year 2nd day - salivation - stinks the whole apartment
Tuesday Jan 24, 2012
Chinese New Year 2nd day
Bright sunshine day. All neighbours closed
I came to check on my cat patient - a stray cat with badly wounded left fore paw and swollen right paw and do some stock checking and administration.
INTERESTING CASES
1. Shih Tzu, Female, 11 years. Fever. EMACIATED. Sticky salivation as gums were ulcerated as if he had licked some poison some 4 days ago.
"Whole apartment smelly," the father said. The son of 24 years was very concerned. "Yellow liquid in his mouth. What is it?" he asked me. "Could be gastric juice vomited. Did he lick any liquid like paint or tick insecticide?"
"There was anti-mosquito fogging 5 days ago," the son said.
"Yes, it is possible the dog tried to lick off the smell. A blood test is recommended. But you have to decide."
"We are poor. Don't want the blood test," the father said. The son later told me that a vet had forced his father to take various tests leading to a hefty vet bill. So, the father is angry at all vets. However, his vet is off today. Treatment. IV drip, antibiotics and anti-fever.
2. Jack Russell, Male, 11 years. High fever. Massive swelling below R eye for past 5 days. The elder brother said: "The swelling comes and goes, but today, it expands. Can't open eye.What is it?"
No dental work for past 11 years. Malar abscess? "Any bee stings?" I asked. "Centipede sting possible as there are lots of centipedes in the house." A son and mum phoned at 5pm. "Not much changes," I said. Swelling has defined to a ping-pong sized lump after IV drip and medication. Will need sedation tomorrow to see inside the mouth as the dog prohibited opening of his mouth. Could be an abscess not related to malar abscess or a haematoma. Vet medicine is full of surprises.
3. Persian cat of son who is overseas. F, 13 years, not spayed. EMACIATED. Drooling. Emaciated. Mum went on holiday past 2 weeks and now the cat had problems not eating. salivation. Two large cystic swelling below and beside the tongue. Wandered outdoors as mum was not around. Could it be ingestion of poison? IV and medication.
4. Guinea Pig. 1 year +. Not eating. EMACIATED. Drooling. Had incisors clipped 2 weeks ago by Vet 1 who did not examine further. Still not eating well. "Examine the molars," I showed the young lady the inward pointing sharp points of the lower molars. Anaesthetic isoflurane gas using mask. Clipped teeth. Advised hard pellets. "Separate from the other GP who ate faster," I advised. "He might be bullied." The girl said: "The other GP will scream if separated." I said: "Get a grated barrier to separate them. This GP eats by herself and recover. We assume there is no bullying as we don't see it."
5. Dwarf Hamster, F, 1 year+, 59g. "He had gone (to heaven)," the lady in her late 20s said to me. "I let her swim (in the basin) longer while I took care of the other 3 hamsters. When I saw her, she was gone. Drowned. Flat out. No movement. I did heart massage a long time. She finally recovered. But she has this sound (like teeth chattering) from her chest. She ate a bit. "How many stool pellets she passed?" I asked. "Only 1 or 2. Normally many as she is a fat hamster and eats a lot."
I put my stethoscope. Yes, the heart sounds were there but there was these extra loud "crackling sound". Much louder than the heart sounds. Coming from the lungs. The hamster was shaking and breathing faster than normal.
"Have you treated hamsters before?" the lady asked me when I told her that I needed to give the hamster an injection of painkiller, lung fluid-draining medication and antibiotic. If the hamster dies, it will be due to her progression of illness and not due to the injection." She was doubtful about injections. "Well, I never had a case of a hamster that had drowned and had been returned to living," I said. "Singaporeans don't bathe hamsters or I have not got such a similar case. I have done hamster injections for anaesthesia and for itchiness."
"I suppose I have no choice," she gave permission to inject her hamster. My assistant Min held the thick cloth over the first half of the body. I injected the back area under the skin of 0.01 ml. Upon removal of the cloth, the hamster was motionless. The lady was very upset, stroking the hamster's chest and calling her name. I asked her to go outside the cold aircon consult room and into the evening sunlight outdoors. She stroked her hamster. There was a flicker of movement and the hamster's eye moved. She was happy. Booked a cab and thanked me.
So, this CNY Eve 2nd day showed a representative sample of pets common in Singapore - dogs, cats, guinea pigs and hamsters. No rabbits.
Chinese New Year 2nd day
Bright sunshine day. All neighbours closed
I came to check on my cat patient - a stray cat with badly wounded left fore paw and swollen right paw and do some stock checking and administration.
INTERESTING CASES
1. Shih Tzu, Female, 11 years. Fever. EMACIATED. Sticky salivation as gums were ulcerated as if he had licked some poison some 4 days ago.
"Whole apartment smelly," the father said. The son of 24 years was very concerned. "Yellow liquid in his mouth. What is it?" he asked me. "Could be gastric juice vomited. Did he lick any liquid like paint or tick insecticide?"
"There was anti-mosquito fogging 5 days ago," the son said.
"Yes, it is possible the dog tried to lick off the smell. A blood test is recommended. But you have to decide."
"We are poor. Don't want the blood test," the father said. The son later told me that a vet had forced his father to take various tests leading to a hefty vet bill. So, the father is angry at all vets. However, his vet is off today. Treatment. IV drip, antibiotics and anti-fever.
2. Jack Russell, Male, 11 years. High fever. Massive swelling below R eye for past 5 days. The elder brother said: "The swelling comes and goes, but today, it expands. Can't open eye.What is it?"
No dental work for past 11 years. Malar abscess? "Any bee stings?" I asked. "Centipede sting possible as there are lots of centipedes in the house." A son and mum phoned at 5pm. "Not much changes," I said. Swelling has defined to a ping-pong sized lump after IV drip and medication. Will need sedation tomorrow to see inside the mouth as the dog prohibited opening of his mouth. Could be an abscess not related to malar abscess or a haematoma. Vet medicine is full of surprises.
3. Persian cat of son who is overseas. F, 13 years, not spayed. EMACIATED. Drooling. Emaciated. Mum went on holiday past 2 weeks and now the cat had problems not eating. salivation. Two large cystic swelling below and beside the tongue. Wandered outdoors as mum was not around. Could it be ingestion of poison? IV and medication.
4. Guinea Pig. 1 year +. Not eating. EMACIATED. Drooling. Had incisors clipped 2 weeks ago by Vet 1 who did not examine further. Still not eating well. "Examine the molars," I showed the young lady the inward pointing sharp points of the lower molars. Anaesthetic isoflurane gas using mask. Clipped teeth. Advised hard pellets. "Separate from the other GP who ate faster," I advised. "He might be bullied." The girl said: "The other GP will scream if separated." I said: "Get a grated barrier to separate them. This GP eats by herself and recover. We assume there is no bullying as we don't see it."
5. Dwarf Hamster, F, 1 year+, 59g. "He had gone (to heaven)," the lady in her late 20s said to me. "I let her swim (in the basin) longer while I took care of the other 3 hamsters. When I saw her, she was gone. Drowned. Flat out. No movement. I did heart massage a long time. She finally recovered. But she has this sound (like teeth chattering) from her chest. She ate a bit. "How many stool pellets she passed?" I asked. "Only 1 or 2. Normally many as she is a fat hamster and eats a lot."
I put my stethoscope. Yes, the heart sounds were there but there was these extra loud "crackling sound". Much louder than the heart sounds. Coming from the lungs. The hamster was shaking and breathing faster than normal.
"Have you treated hamsters before?" the lady asked me when I told her that I needed to give the hamster an injection of painkiller, lung fluid-draining medication and antibiotic. If the hamster dies, it will be due to her progression of illness and not due to the injection." She was doubtful about injections. "Well, I never had a case of a hamster that had drowned and had been returned to living," I said. "Singaporeans don't bathe hamsters or I have not got such a similar case. I have done hamster injections for anaesthesia and for itchiness."
"I suppose I have no choice," she gave permission to inject her hamster. My assistant Min held the thick cloth over the first half of the body. I injected the back area under the skin of 0.01 ml. Upon removal of the cloth, the hamster was motionless. The lady was very upset, stroking the hamster's chest and calling her name. I asked her to go outside the cold aircon consult room and into the evening sunlight outdoors. She stroked her hamster. There was a flicker of movement and the hamster's eye moved. She was happy. Booked a cab and thanked me.
So, this CNY Eve 2nd day showed a representative sample of pets common in Singapore - dogs, cats, guinea pigs and hamsters. No rabbits.
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