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Saturday, October 8, 2011
669. Ultrasound or x-ray of the stomach for foreign bodies?
Stomach ache suspected - ultrasound or X-ray? Record AMA.
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
10 October, 2011
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
A young beagle puppy became lethargic. What's wrong?
I put her on the consultation table and put my left hand to palpate the abdomen. pain. She yelped when I palpated the anterior abdomen in front of the two women, one of whom was the owner. "Your puppy had stomach ache," I said. "You can see the and hear her discomfort crying. I advise an X-ray as puppies do swallow pebbles and other foreign bodies when they go outdoors."
This was a case I collaborated with Dr Vanessa on the management of the case. Sometimes I do intervene as part of quality control and mentorship of my associate vets. Dr Vanessa later spoke to me as she wanted an ultra-sound.
"I don't think ultrasound will be good in this case," I said.
She had shown me an ultrasound of a pyometra case. The ultrasound scan showed an increase in thickness of the endometrium. So it was pyometra and the surgery proved it.
"Speak to Vet 1," I said. "He has experience in ultrasound and X-ray." As vets have their own preferences and judgment, it would be a matter of decision and so I did not object when Dr Vanessa to favour ultra-sound. There are more than one way to handle a case of anterior acute abdomen. I decided to phone Vet 1. However, it was difficult to contact Vet 1 as he was busy in his practice. I left a message with Vet 1's staff to call me back.
Vet 1 phoned me when the Beagle arrived at his Surgery. I asked him whether ultrasound would be useful or an X-ray in the Beagle suspected of having foreign bodies (bones, stones and others) in his stomach.
"If you are looking for foreign bodies in the stomach, an X-ray is better," he advised me. "Why scan for the other organs like kidneys and liver when you suspect foreign bodies in the stomach?"
"Go ahead with the X-ray, 2 views," I thanked him. I told Dr Vanessa the switch to X-rays while she was consulting.
Acute anterior Abdominal Pain in a Beagle. I put the dog on the consultation table. Then I palpated a swollen stomach with my good left hand. The dog arched her back high and gave a whimpering cry. The lady owner heard the cry.
RECORD ANY AMD (AGAINST MEDICAL ADVICE)
If the owner does not want to have X-rays taken, this ought to be recorded in the case sheet. "If the dog dies a few days later," the family members who are not present during consultation will bad-mouth the vet as not even competent as he has not taken any X-ray!
No two vets will have the same method of using ancillary aids to diagnosis, but it is best to consult another vet who has more experience in practice and in doing ultrasound and X-rays on certain conditions, as in this case.
To excel in veterinary science, a small animal vet in private practice needs to open his or her mouth to seek advices as veterinary medicine is extremely diverse as vets are anesthetists surgeons and general practitioners unlike human medicine where there is specialisation. Usually they are given as this case illustrates. Experience comes with time and cases handled.
One needs to be humble to ask for veterinary advices from others. There is no way a vet can know everything as interpretation and when to use veterinary radiology and ultrasound is again another big specialised field that will take years to master.
Case at:
http://www.sinpets.com/dogs/20111018ultrasound-x-ray-suspect-foreign-bodies-stomach-singapore_ToaPayohVets.htm
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
10 October, 2011
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
A young beagle puppy became lethargic. What's wrong?
I put her on the consultation table and put my left hand to palpate the abdomen. pain. She yelped when I palpated the anterior abdomen in front of the two women, one of whom was the owner. "Your puppy had stomach ache," I said. "You can see the and hear her discomfort crying. I advise an X-ray as puppies do swallow pebbles and other foreign bodies when they go outdoors."
This was a case I collaborated with Dr Vanessa on the management of the case. Sometimes I do intervene as part of quality control and mentorship of my associate vets. Dr Vanessa later spoke to me as she wanted an ultra-sound.
"I don't think ultrasound will be good in this case," I said.
She had shown me an ultrasound of a pyometra case. The ultrasound scan showed an increase in thickness of the endometrium. So it was pyometra and the surgery proved it.
"Speak to Vet 1," I said. "He has experience in ultrasound and X-ray." As vets have their own preferences and judgment, it would be a matter of decision and so I did not object when Dr Vanessa to favour ultra-sound. There are more than one way to handle a case of anterior acute abdomen. I decided to phone Vet 1. However, it was difficult to contact Vet 1 as he was busy in his practice. I left a message with Vet 1's staff to call me back.
Vet 1 phoned me when the Beagle arrived at his Surgery. I asked him whether ultrasound would be useful or an X-ray in the Beagle suspected of having foreign bodies (bones, stones and others) in his stomach.
"If you are looking for foreign bodies in the stomach, an X-ray is better," he advised me. "Why scan for the other organs like kidneys and liver when you suspect foreign bodies in the stomach?"
"Go ahead with the X-ray, 2 views," I thanked him. I told Dr Vanessa the switch to X-rays while she was consulting.
Acute anterior Abdominal Pain in a Beagle. I put the dog on the consultation table. Then I palpated a swollen stomach with my good left hand. The dog arched her back high and gave a whimpering cry. The lady owner heard the cry.
RECORD ANY AMD (AGAINST MEDICAL ADVICE)
If the owner does not want to have X-rays taken, this ought to be recorded in the case sheet. "If the dog dies a few days later," the family members who are not present during consultation will bad-mouth the vet as not even competent as he has not taken any X-ray!
No two vets will have the same method of using ancillary aids to diagnosis, but it is best to consult another vet who has more experience in practice and in doing ultrasound and X-rays on certain conditions, as in this case.
To excel in veterinary science, a small animal vet in private practice needs to open his or her mouth to seek advices as veterinary medicine is extremely diverse as vets are anesthetists surgeons and general practitioners unlike human medicine where there is specialisation. Usually they are given as this case illustrates. Experience comes with time and cases handled.
One needs to be humble to ask for veterinary advices from others. There is no way a vet can know everything as interpretation and when to use veterinary radiology and ultrasound is again another big specialised field that will take years to master.
Case at:
http://www.sinpets.com/dogs/20111018ultrasound-x-ray-suspect-foreign-bodies-stomach-singapore_ToaPayohVets.htm
668. Sunday Oct 3, 2011. Veterinarian rage
Sunday Oct 3, 2011 is a very important day for Dr Jason Teo as he celebrated the opening of his own vet clinic and had asked me to join him at 12.30 pm. 
So I worked in the morning trying to clear the cases as fast as possible.
Many clients had made black faces when Dr Vanessa took some time in certain case handling on Sundays. My target for waiting times to be less than 15 minutes/person on busy weekends. Singaporeans don't like to wait a long time to see the doctor or vet.
So, on this Sunday morning, I asked one client to enter the consultation room while she was doing some minor op in the Surgery Room.
The man and his tall son got his dog into the consultation room. I had not asked him whether he wanted Dr Vanessa before he entered the room. In the room, I asked him and he said he was waiting for Dr Vanessa. So, I asked him to wait a while. I asked the second client and she said the same. So I asked the 3rd client with the Shih Tzu eye ulcer to come into the room since she was seen by me earlier.
Soon, Dr Vanessa was free, after taking blood samples in a dog and I got her client into the room. But I noted that he was bad-mouthing Toa Payoh Vets as not having a process to the 2nd client. I asked him what did he mean after identifying myself as the Principal of the practice. He started shouting: "I don't care whether you are the Principal. Dr Vanessa is a very good vet. I came to see her. You want to know what's wrong? Pay me and I will tell you! I know Dr Thiru...Dr Vanessa is a very good vet!!!"
This was the first time I encountered a dog owner's rage. I did not pursue the matter and kept my temper. Something was wrong with his behaviour and I left him alone while I took the 3rd client and her dog to the Surgery room to check on the eye.
"What's wrong with him?" the 3rd client asked me. "Is it because I jump queue?"
"I don't know," I said. "He wanted Dr Vanessa to treat his dog and so he had to wait because she was treating another dog."
I thought all was over as the angry man was with Dr Vanessa.
Suddenly, he barged into the Surgery room and shouted at me: "Go to the back of the Surgery and I will tell you what's wrong with you!"
I remained cool. What was wrong with him? He was actually being abusive. I looked at him with sad eyes. At 61 years of age, I have learnt to stay cool in such a provocative situation. His son pulled him out from the room.
Later I spoke to Dr Vanessa. "What is your relationship to this client? He even started to barge into the Surgery room after the end of your consultation. He praised you a lot and at the same time he showed disrespect to me. There is something not right here!"
Dr Vanessa said she did not know. I reviewed his case. There were contributing elements of unhappiness in the management of his case by Dr Vanessa and I advised her accordingly.
Such outburst and uncontrolled anger from a mature man in his 50s is very rare. We have road rage and educational notices on public hospitals and the National Library against abusing the staff. I don't see the need for one in Toa Payoh Vets as this is a very rare thing in my 40 years of practice.
I guess if the vet works long enough, he will encounter at least one case of veterinarian rage.
I will monitor his case and if he continues to be abusive to any staff in Toa Payoh Vets, it is best he go to another vet for his dog treatment. In the handling of veterinarian rage, just do not provoke by shouting back at the abuser. Keep cool. There are always some other causes that initiate the rage.
So I worked in the morning trying to clear the cases as fast as possible.
Many clients had made black faces when Dr Vanessa took some time in certain case handling on Sundays. My target for waiting times to be less than 15 minutes/person on busy weekends. Singaporeans don't like to wait a long time to see the doctor or vet.
So, on this Sunday morning, I asked one client to enter the consultation room while she was doing some minor op in the Surgery Room.
The man and his tall son got his dog into the consultation room. I had not asked him whether he wanted Dr Vanessa before he entered the room. In the room, I asked him and he said he was waiting for Dr Vanessa. So, I asked him to wait a while. I asked the second client and she said the same. So I asked the 3rd client with the Shih Tzu eye ulcer to come into the room since she was seen by me earlier.
Soon, Dr Vanessa was free, after taking blood samples in a dog and I got her client into the room. But I noted that he was bad-mouthing Toa Payoh Vets as not having a process to the 2nd client. I asked him what did he mean after identifying myself as the Principal of the practice. He started shouting: "I don't care whether you are the Principal. Dr Vanessa is a very good vet. I came to see her. You want to know what's wrong? Pay me and I will tell you! I know Dr Thiru...Dr Vanessa is a very good vet!!!"
This was the first time I encountered a dog owner's rage. I did not pursue the matter and kept my temper. Something was wrong with his behaviour and I left him alone while I took the 3rd client and her dog to the Surgery room to check on the eye.
"What's wrong with him?" the 3rd client asked me. "Is it because I jump queue?"
"I don't know," I said. "He wanted Dr Vanessa to treat his dog and so he had to wait because she was treating another dog."
I thought all was over as the angry man was with Dr Vanessa.
Suddenly, he barged into the Surgery room and shouted at me: "Go to the back of the Surgery and I will tell you what's wrong with you!"
I remained cool. What was wrong with him? He was actually being abusive. I looked at him with sad eyes. At 61 years of age, I have learnt to stay cool in such a provocative situation. His son pulled him out from the room.
Later I spoke to Dr Vanessa. "What is your relationship to this client? He even started to barge into the Surgery room after the end of your consultation. He praised you a lot and at the same time he showed disrespect to me. There is something not right here!"
Dr Vanessa said she did not know. I reviewed his case. There were contributing elements of unhappiness in the management of his case by Dr Vanessa and I advised her accordingly.
Such outburst and uncontrolled anger from a mature man in his 50s is very rare. We have road rage and educational notices on public hospitals and the National Library against abusing the staff. I don't see the need for one in Toa Payoh Vets as this is a very rare thing in my 40 years of practice.
I guess if the vet works long enough, he will encounter at least one case of veterinarian rage.
I will monitor his case and if he continues to be abusive to any staff in Toa Payoh Vets, it is best he go to another vet for his dog treatment. In the handling of veterinarian rage, just do not provoke by shouting back at the abuser. Keep cool. There are always some other causes that initiate the rage.
667. Follow up: The sibling hamster with the amutated leg had left ear itch
"Remember? She was 19kg when you amputated her leg?" the slim writer asked me. "Now she is 31 g. I had fed her well."
"How can I ever forget her?" I was impressed with the care given as I thought this hamster would never live after such a drastic surgery. Being amputated at the knee and being such a tiny creature. And the delay in seeking surgery due to Vet 1's advice. The suspected bone cancer had not spread since the leg was cut away. That is why she is alive now. 31 g from 19 g. What an achievement.
"There are some dwarf hamsters that stand out." The other vet had delayed her operation and the tumour exploded in size to a 10-cent disc coin mass stuck to the knee and nearby areas.
Furthermore her sibling had this smelly ear and had died, at the weight of 19g, after 4 operations.
"This sibling had no ear problem at all," the lady said. "She has been scratching her left ear."
"Was she housed together with the sibling?"
"No, she lives alone all the while," she said.
"How come she got her ear infected?" I asked. She shook her head. The hamster squeaked loudly when touched.
"There is only one common connection between the two siblings," I said. "And that is you, the owner".
The writer smiled. Themes are relevant to a writer and there is a theme in "ear infections and hamster owner".
"She is hard to handle," the lady said when I suggested some ear drops.
I put the hamster under isoflurane gas and showed 1 polytechnic student who turned up by himself how the hamster's ear is irrigated.
The next day, the hamster was not scratching her left ear. But she started scratching her right ear. I phoned the owner to take her home and observe. "If it is ear tumour," I assumed due to the age, the non-use of hamster sand bath, the fact that the sibling had died from ear infection and cyst and probably tumour, "I may need to remove the ear canal early. Wait for 2 weeks and see what happens."
"How can I ever forget her?" I was impressed with the care given as I thought this hamster would never live after such a drastic surgery. Being amputated at the knee and being such a tiny creature. And the delay in seeking surgery due to Vet 1's advice. The suspected bone cancer had not spread since the leg was cut away. That is why she is alive now. 31 g from 19 g. What an achievement.
"There are some dwarf hamsters that stand out." The other vet had delayed her operation and the tumour exploded in size to a 10-cent disc coin mass stuck to the knee and nearby areas.
Furthermore her sibling had this smelly ear and had died, at the weight of 19g, after 4 operations.
"This sibling had no ear problem at all," the lady said. "She has been scratching her left ear."
"Was she housed together with the sibling?"
"No, she lives alone all the while," she said.
"How come she got her ear infected?" I asked. She shook her head. The hamster squeaked loudly when touched.
"There is only one common connection between the two siblings," I said. "And that is you, the owner".
The writer smiled. Themes are relevant to a writer and there is a theme in "ear infections and hamster owner".
"She is hard to handle," the lady said when I suggested some ear drops.
I put the hamster under isoflurane gas and showed 1 polytechnic student who turned up by himself how the hamster's ear is irrigated.
The next day, the hamster was not scratching her left ear. But she started scratching her right ear. I phoned the owner to take her home and observe. "If it is ear tumour," I assumed due to the age, the non-use of hamster sand bath, the fact that the sibling had died from ear infection and cyst and probably tumour, "I may need to remove the ear canal early. Wait for 2 weeks and see what happens."
665. Follow up on the stray cat with FIV
"Do you know how to open the cat's mouth to check the gum ulcers?" I asked the Temasek Poly lady who was volunteering and had chosen "pneumonia" as her first case study. This was the stray cat with the FIV and she had to write a report and produce a video. No point just see like a tourist. Writing will bring vet medicine alive to a student and so I do insist on such recording. Her writing was excellent as I admire good handwriting. She had not come for the past 2 days and in that time, the stray cat made excellent progress.
I got the 3 students together. Got the cat out and demonstrated how to open a cat's mouth. The student tried while her male classmate was positioned to video the mouth. The cat swung out her right hand and claws came out. She withdrew to prevent scratching. "This is a gentle cat," I said. "Try again." She did not succeed 100%. The cat swung out her left hand and claws came out.
"Lift the upper lip at the side," I said. "You will see that the gum ulcers have healed a lot."
The cat should go home on Oct 10, 2011 i.e. at the 7th day after hospitalisation. Blood tests were normal. No immuno-suppression. The 2 months of yellow nasal discharge was gone. The two teenaged daughters visited this cat daily, brought the canned food.
This was an excellent case study for the lady student from the Poly. Learning is best when real cases are studied in detail and written up. Being an observer leads to superficial knowledge. I will see how she produces the video.
I got the 3 students together. Got the cat out and demonstrated how to open a cat's mouth. The student tried while her male classmate was positioned to video the mouth. The cat swung out her right hand and claws came out. She withdrew to prevent scratching. "This is a gentle cat," I said. "Try again." She did not succeed 100%. The cat swung out her left hand and claws came out.
"Lift the upper lip at the side," I said. "You will see that the gum ulcers have healed a lot."
The cat should go home on Oct 10, 2011 i.e. at the 7th day after hospitalisation. Blood tests were normal. No immuno-suppression. The 2 months of yellow nasal discharge was gone. The two teenaged daughters visited this cat daily, brought the canned food.
This was an excellent case study for the lady student from the Poly. Learning is best when real cases are studied in detail and written up. Being an observer leads to superficial knowledge. I will see how she produces the video.
664. Follow up: Good practice to phone the owner after surgery
"What is happening mum? What's happening?..." I heard a distant voice as I spoke to the mother one hour after the surgical excision of the hamster.
This was the hamster that Vet 1 had said would die under anaesthesia and had given unacceptable advices to cause distress to the daughter. The Vet 1's advice was to wait till the tumour bleeds. Then bring the hamster to Vet 1 to be put to sleep.
The right thing to do would be to refer the mother and daughter to another vet or just ask them to seek their own vets. Unacceptable advices greatly distress the owners as the young girl wept for the past 3 days thinking about the impending horrible painful bleeding of the tumour. And she had examinations to be done during this period of time. The poor mum was really stressed out by such advices too as she contacted me by phone.
In pragmatic terms, get the daughter's hamster put to sleep immediately so that she would focus on her examinations. Is it as easy as that? No. There must be another solution as it was Friday and the coming Monday would be examination day.
Well, Dr Vanessa had excised the tumour. There was no death and the hamster started to jump onto the exercise wheel around one hour post-op. She was unsteady for around 15 minutes after the end of surgery.
I phoned the mother to let her know the good outcome and to confirm that she did not want histopathology of the tumour done. "How much?" she asked. "$150," I said. I guessed the daughter must be in her study room and had overhead bits of the mother's hamster conversation and was worried that something had gone wrong. Perhaps her hamster had died post-op and therefore called out to her mum.
Well, the hamster was OK. The bleeding was cleaned off. "The hamster can go home today," I said to the mother. "Just clean up her wound."
The mother would take back on Tuesday. That would give time and space for the young girl to study for her Monday exams. As for histopathology, it is good practice to ask the owner and record this. Histopathology adds to the cost and previously, I assume the owner would not want it done and therefore had not asked them. However, in defensive medicine to be practised nowadays in a litigious society, it is best to cover all bases and record down advices like histopathology and laboratory tests suggested.
This was the hamster that Vet 1 had said would die under anaesthesia and had given unacceptable advices to cause distress to the daughter. The Vet 1's advice was to wait till the tumour bleeds. Then bring the hamster to Vet 1 to be put to sleep.
The right thing to do would be to refer the mother and daughter to another vet or just ask them to seek their own vets. Unacceptable advices greatly distress the owners as the young girl wept for the past 3 days thinking about the impending horrible painful bleeding of the tumour. And she had examinations to be done during this period of time. The poor mum was really stressed out by such advices too as she contacted me by phone.
In pragmatic terms, get the daughter's hamster put to sleep immediately so that she would focus on her examinations. Is it as easy as that? No. There must be another solution as it was Friday and the coming Monday would be examination day.
Well, Dr Vanessa had excised the tumour. There was no death and the hamster started to jump onto the exercise wheel around one hour post-op. She was unsteady for around 15 minutes after the end of surgery.
I phoned the mother to let her know the good outcome and to confirm that she did not want histopathology of the tumour done. "How much?" she asked. "$150," I said. I guessed the daughter must be in her study room and had overhead bits of the mother's hamster conversation and was worried that something had gone wrong. Perhaps her hamster had died post-op and therefore called out to her mum.
Well, the hamster was OK. The bleeding was cleaned off. "The hamster can go home today," I said to the mother. "Just clean up her wound."
The mother would take back on Tuesday. That would give time and space for the young girl to study for her Monday exams. As for histopathology, it is good practice to ask the owner and record this. Histopathology adds to the cost and previously, I assume the owner would not want it done and therefore had not asked them. However, in defensive medicine to be practised nowadays in a litigious society, it is best to cover all bases and record down advices like histopathology and laboratory tests suggested.
663. Follow up on hamster with itchy elbows and knees - Oct 7, 2011
"Is your hamster still licking her elbows and knees?" I phoned the young lady on Oct 7, 2011, around 3 days after I had given an anti-inflam injection and prescribed medication, advised change of diet.
"Much better. Slightly itchy though. Some hairs are growing."
"It will take some time to be free of itchiness," I said. "Did you feed sunflower seeds?"
"No," she believed that sunflower seeds cause obesity. The dwarf hamster weighed 91 g 4 weeks ago when she came in for the first consultation. 3 days ago, she weighed 86 g.
"What food do you feed?" I asked.
"Pumpkin seeds," she said. "I could not find melon seeds for sale." I did advise buying the dried melon seeds from some provision shops, shelling them and feeding to the hamster since she did not want to feed sunflower seeds which are the usual component of a hamster's ration in Singapore.
It would need another 4 weeks for the hamster to recover.
"Much better. Slightly itchy though. Some hairs are growing."
"It will take some time to be free of itchiness," I said. "Did you feed sunflower seeds?"
"No," she believed that sunflower seeds cause obesity. The dwarf hamster weighed 91 g 4 weeks ago when she came in for the first consultation. 3 days ago, she weighed 86 g.
"What food do you feed?" I asked.
"Pumpkin seeds," she said. "I could not find melon seeds for sale." I did advise buying the dried melon seeds from some provision shops, shelling them and feeding to the hamster since she did not want to feed sunflower seeds which are the usual component of a hamster's ration in Singapore.
It would need another 4 weeks for the hamster to recover.
663. Switching to become a small animal vet
E-MAIL TO DR SING DATED OCT 7, 2011
Dear Dr Sing,
I chanced upon your blog when I was looking up some vet related blogs. I read that you completed your bond with the PPD, then started up toapayoh vet clinic. Was it difficult to transition from a government vet to a small animal vet? How do you keep the knowledge learnt for small animals fresh in your mind as being a PPD government vet requires a completely different set of skills? Would be great if you could provide me with some advice on this issue. I've been pondering on career pathways recently and I need guidance.
Regards,
XXX
E-MAIL REPLY FROM DR SING DATED OCT 8, 2011
Thank you for your email. In reply to your questions:
1. It is not difficult to change to small animal practice from regulatory practice for me as I had a mentor (an experienced senior vet) whom I spent time in the evenings (closing my practice) learning from him, assisting him, working as locum and doing house-calls.
2. Lots of reading on small animal vet journals. In 1982, when I started Toa Payoh Vets, there was no such thing as the world wide web. So, lots of reading vet articles and journals and subscription to the British and American vet journals. The PPD had a small vet library at 40 Kampong Java Road, now the K.K. Hospital.
3. For your situation, be an employee in one of the 46 vet practices in Singapore for at least two years. Choose a busy one, otherwise you would have not sufficient variety of cases. Work the night shifts and really attend to each emergency as if it was your own pet instead of being a "lazy" vet, letting the vet technicians do the hands-on blood collection, urine collection and X-rays.
Give practically free services to the dog breeders and animal activists. So much small animal veterinary work to do nowadays. Read up and discuss with mentors. Review cases done and see if there are better and more efficient and cost-effective ways to handling the case.
Add value to your employer. For example, I note that some young employee vets use more than necessary (increasing expenses to the practice and reducing the bottom-line) the sutures and materials used in surgery and treatment. This may not endear yourself to the Principal of the practice as it shows you don't care about the bottom-line. In private practice, the costs are high and you need to be aware of the economics of practice, other than the salary and benefits you are getting.
In conclusion, venturing to a new field requires a new mindset to work the long hours to achieve competence and success. Small animal private practice hours are longer and will not be similar to the regular hours of civil service as most clients are free during weekends and public holidays when the civil service vet is having time off.
Passion is required if you wish to excel. Competition is great nowadays as I expect more than 50 small animal practices to be set up in the next 5 years if you intend to open your own practice. Know the economics of practice. Add value to your employer or principal. Continuing education. Network. Be proactive in vet matters.
Phone me if you need more advice as writing advices are not as good as one-to-one talk.
- Show quoted text -
Dear Dr Sing,
I chanced upon your blog when I was looking up some vet related blogs. I read that you completed your bond with the PPD, then started up toapayoh vet clinic. Was it difficult to transition from a government vet to a small animal vet? How do you keep the knowledge learnt for small animals fresh in your mind as being a PPD government vet requires a completely different set of skills? Would be great if you could provide me with some advice on this issue. I've been pondering on career pathways recently and I need guidance.
Regards,
XXX
E-MAIL REPLY FROM DR SING DATED OCT 8, 2011
Thank you for your email. In reply to your questions:
1. It is not difficult to change to small animal practice from regulatory practice for me as I had a mentor (an experienced senior vet) whom I spent time in the evenings (closing my practice) learning from him, assisting him, working as locum and doing house-calls.
2. Lots of reading on small animal vet journals. In 1982, when I started Toa Payoh Vets, there was no such thing as the world wide web. So, lots of reading vet articles and journals and subscription to the British and American vet journals. The PPD had a small vet library at 40 Kampong Java Road, now the K.K. Hospital.
3. For your situation, be an employee in one of the 46 vet practices in Singapore for at least two years. Choose a busy one, otherwise you would have not sufficient variety of cases. Work the night shifts and really attend to each emergency as if it was your own pet instead of being a "lazy" vet, letting the vet technicians do the hands-on blood collection, urine collection and X-rays.
Give practically free services to the dog breeders and animal activists. So much small animal veterinary work to do nowadays. Read up and discuss with mentors. Review cases done and see if there are better and more efficient and cost-effective ways to handling the case.
Add value to your employer. For example, I note that some young employee vets use more than necessary (increasing expenses to the practice and reducing the bottom-line) the sutures and materials used in surgery and treatment. This may not endear yourself to the Principal of the practice as it shows you don't care about the bottom-line. In private practice, the costs are high and you need to be aware of the economics of practice, other than the salary and benefits you are getting.
In conclusion, venturing to a new field requires a new mindset to work the long hours to achieve competence and success. Small animal private practice hours are longer and will not be similar to the regular hours of civil service as most clients are free during weekends and public holidays when the civil service vet is having time off.
Passion is required if you wish to excel. Competition is great nowadays as I expect more than 50 small animal practices to be set up in the next 5 years if you intend to open your own practice. Know the economics of practice. Add value to your employer or principal. Continuing education. Network. Be proactive in vet matters.
Phone me if you need more advice as writing advices are not as good as one-to-one talk.
- Show quoted text -
Friday, October 7, 2011
662. The vet's unacceptable advice - when the hamster's tumour bleeds, come put to sleep
"When the hamster's tumour starts to bleed, bring her to me and I will put her to sleep, Vet 1 advised us," the mother brought her teenaged daughter and her hamster to me today 11.30 am, Friday Oct 7, 2011. "I consulted Vet 3 days ago and my daughter has been crying since."
Vet 1 had said that the dwarf hamster, being 2 years old, would die under anaesthesia and surgery. Therefore, wait till her abdominal tumour bleeds, to bring the hamster in to be euthanased. The mother could have surfed the internet and phoned me.
"It is not a guarantee that all dwarf hamsters with tumours will die under general anaesthesia," I don't understand why Vet 1 would not have asked the owner to see other vets if Vet 1 would not perform surgery. I just rejected a koi owner who phoned up to ask if I treat kois. It is the right thing to doand is in the interest of the animal. Not to advise waiting till the tumour bleeds and bring the hamster down for euthanasia.
"Much depends on the health of the hamster, the size of the tumour and the duration of anaesthesia," I happened to pick up the phone today as I was in the Surgery to interview a job applicant and teach 3 Temasek Polytechnic volunteers on cases involving an old Maltese with cystitis, a stray cat with FIV and a puppy on an IV drip, amongst other pets.
"How big is the tumour and is it a breast tumour?" I asked. The mum did not know and spoke to the daughter. "It is best I examine the hamster."
"How much is the consultation fee?"
"$30.00," I said. "But you already had consulted Vet 1. The decision should be whether you would want to take the risk of this old hamster being operated and pay the operation and anaesthetic fee.
"If the hamster survives the operation, she lives another 6 months as dwarf hamsters live up to 2.5 years of age. If she is not operated, the tumour gets infected and bleeds as the hamster keeps nibbling it. Lots of blood stains and great distress for your daughter in the next few days, leading ultimately to death by lethal injection. In such cases, your daughter would be much traumatised after seeing the hamster suffer from bleeding all day long!"
It is extremely difficult to be a mother of young teenagers nowadays. I could see that the slim fair 14-year-old was from an elite school. The cream of the crop, now much distracted by her hamster's poor health. She did not know when the tumour developed and so whether it was fast-growing or not, it was difficult to say .
"My daughter has her examinations till Monday," the mother said. I could sympathise with her as she wanted her daughter to excel in the highly competitive academic environment. How could she revise her lessons when she cried daily as her beloved hamster had no hope of survival?
As a veterinarian, the best interest of the pet must be priority. If the vet cannot handle a case, refer to other vets or ask the owner to find another vet. I don't treat birds and fishes and I don't accept such pets in the first place.
The dwarf hamster is old at 2 years of age, but she is full of energy. Weighed 36 gram and has an excellent appetite. Trying to escape when the cage door is lifted up.
"The chances of surviving anaesthesia are 70%," I said to the mother who had asked if I provided services to euthanase the hamster to prevent pain and suffering.
"Did you hear that?" the mum asked the quiet girl.
"Quite a good chance of survival," I said.
"You had operated on hamster tumours?" she asked.
"Yes," I said.
The 3 Temasek Poly students, Dr Vanessa, Mr Min and I attended to the dwarf hamster. "This is a case where Zoletil sedation is needed as isoflurane + oxygen gas will not give you sufficient time to excise and stitch up in less than 5 minutes."
I said to Dr Vanessa, "With Zoletil sedation, you have around 5 minutes of surgical anaesthesia to complete the surgery. But you can top up with isoflurane gas." I told Mr Min to switch on the gas, just in case.
"All the theories of dosage per kg in vet books are not applicable usually in the real practice," I said to the 3 students - a young man and two young ladies. "This dwarf hamster weighs 36 g. How many ml of Zoletil to give without killing her? This is why many vets all over the world do not like to anaesthesize hamsters. The safety range is very narrow."
I got the Zoletil ready. Two one-ml syringe was placed on the table. Mr Min got me a 23G needle which I told him was inappropriate. Dr Vanessa got the 25G needle.
A person learns by doing and making mistakes. No other way. I asked Dr Vanessa to get 2 drops of Zoletil from the first syringe of Zoeltil held by Mr Min. She got 2 drops. This would not even fill up 0.01 ml of the syringe. "Add normal saline 0.05 ml," I said. "Just a little bit."
She did it. Overall, the amount was less than 0.05 ml.
The students watched in silence as Dr Vanessa adjusted the drug inside the syringe. She pushed up the plunger up a bit. Suddenly a spray of anaesthetic shot out from the needle as she had not contained all at one lower end, if you know what I am talking about.
The students kept silent. Nobody dared to laugh as I am the serious type when it comes to training. I guessed the students were astonished.
"We have to start all over again," I said to Dr Vanessa. "Use a new syringe." This time I adjusted the drug content inside the syringe and then asked Dr Vanessa to inject the hamster IM.
"Inject IM?," Dr Vanessa said I should do it. I understand. This dwarf hamster has no bulky backside muscles like the dog or cat or even a rabbit.
I stretched out the hamster's left hind leg while Min held the front body. I pointed the 25G needle at the appropriate backside and injected. I have a big bandaged right hand but I could still do the injection.
"If the hamster does not go groggy within 1 minute of injection," I said to the students, "It means the dosage was insufficient or that I had not injected directly into the muscle."
The students were very silent. Within 60 seconds, the dwarf hamster went down on her side. "You have less than 5 minutes to complete the excision of the tumour without isoflurane gas," I said to Dr Vanessa. Everything has been prepared for her.
I handed her the scalpel. She knicked the tumour for 0.8 mm long, undermined, clamped and used the scalpel to excise off the lump. The hamster moved a bit as the anaesthesia was lighter.
It is extremely difficult to get the ideal dosage without causing death as the hamster is so small," I said to one student who later commented that the hamster had moved during the stitching up. "This high anaesthetic risk is the reason why many vets do not want to do surgery to remove big tumours."
The 3 students had a rare opportunity to see the whole process from pre-op to post-op
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Above took 57 minutes to create. National Library Victoria Street, 5.12 pm, Oct 7, 2011
Something wrong with the computer. The text automatically became so small as to be unreadable. So, had to stop writing.
Vet 1 had said that the dwarf hamster, being 2 years old, would die under anaesthesia and surgery. Therefore, wait till her abdominal tumour bleeds, to bring the hamster in to be euthanased. The mother could have surfed the internet and phoned me.
"It is not a guarantee that all dwarf hamsters with tumours will die under general anaesthesia," I don't understand why Vet 1 would not have asked the owner to see other vets if Vet 1 would not perform surgery. I just rejected a koi owner who phoned up to ask if I treat kois. It is the right thing to doand is in the interest of the animal. Not to advise waiting till the tumour bleeds and bring the hamster down for euthanasia.
"Much depends on the health of the hamster, the size of the tumour and the duration of anaesthesia," I happened to pick up the phone today as I was in the Surgery to interview a job applicant and teach 3 Temasek Polytechnic volunteers on cases involving an old Maltese with cystitis, a stray cat with FIV and a puppy on an IV drip, amongst other pets.
"How big is the tumour and is it a breast tumour?" I asked. The mum did not know and spoke to the daughter. "It is best I examine the hamster."
"How much is the consultation fee?"
"$30.00," I said. "But you already had consulted Vet 1. The decision should be whether you would want to take the risk of this old hamster being operated and pay the operation and anaesthetic fee.
"If the hamster survives the operation, she lives another 6 months as dwarf hamsters live up to 2.5 years of age. If she is not operated, the tumour gets infected and bleeds as the hamster keeps nibbling it. Lots of blood stains and great distress for your daughter in the next few days, leading ultimately to death by lethal injection. In such cases, your daughter would be much traumatised after seeing the hamster suffer from bleeding all day long!"
It is extremely difficult to be a mother of young teenagers nowadays. I could see that the slim fair 14-year-old was from an elite school. The cream of the crop, now much distracted by her hamster's poor health. She did not know when the tumour developed and so whether it was fast-growing or not, it was difficult to say .
"My daughter has her examinations till Monday," the mother said. I could sympathise with her as she wanted her daughter to excel in the highly competitive academic environment. How could she revise her lessons when she cried daily as her beloved hamster had no hope of survival?
As a veterinarian, the best interest of the pet must be priority. If the vet cannot handle a case, refer to other vets or ask the owner to find another vet. I don't treat birds and fishes and I don't accept such pets in the first place.
The dwarf hamster is old at 2 years of age, but she is full of energy. Weighed 36 gram and has an excellent appetite. Trying to escape when the cage door is lifted up.
"The chances of surviving anaesthesia are 70%," I said to the mother who had asked if I provided services to euthanase the hamster to prevent pain and suffering.
"Did you hear that?" the mum asked the quiet girl.
"Quite a good chance of survival," I said.
"You had operated on hamster tumours?" she asked.
"Yes," I said.
The 3 Temasek Poly students, Dr Vanessa, Mr Min and I attended to the dwarf hamster. "This is a case where Zoletil sedation is needed as isoflurane + oxygen gas will not give you sufficient time to excise and stitch up in less than 5 minutes."
I said to Dr Vanessa, "With Zoletil sedation, you have around 5 minutes of surgical anaesthesia to complete the surgery. But you can top up with isoflurane gas." I told Mr Min to switch on the gas, just in case.
"All the theories of dosage per kg in vet books are not applicable usually in the real practice," I said to the 3 students - a young man and two young ladies. "This dwarf hamster weighs 36 g. How many ml of Zoletil to give without killing her? This is why many vets all over the world do not like to anaesthesize hamsters. The safety range is very narrow."
I got the Zoletil ready. Two one-ml syringe was placed on the table. Mr Min got me a 23G needle which I told him was inappropriate. Dr Vanessa got the 25G needle.
A person learns by doing and making mistakes. No other way. I asked Dr Vanessa to get 2 drops of Zoletil from the first syringe of Zoeltil held by Mr Min. She got 2 drops. This would not even fill up 0.01 ml of the syringe. "Add normal saline 0.05 ml," I said. "Just a little bit."
She did it. Overall, the amount was less than 0.05 ml.
The students watched in silence as Dr Vanessa adjusted the drug inside the syringe. She pushed up the plunger up a bit. Suddenly a spray of anaesthetic shot out from the needle as she had not contained all at one lower end, if you know what I am talking about.
The students kept silent. Nobody dared to laugh as I am the serious type when it comes to training. I guessed the students were astonished.
"We have to start all over again," I said to Dr Vanessa. "Use a new syringe." This time I adjusted the drug content inside the syringe and then asked Dr Vanessa to inject the hamster IM.
"Inject IM?," Dr Vanessa said I should do it. I understand. This dwarf hamster has no bulky backside muscles like the dog or cat or even a rabbit.
I stretched out the hamster's left hind leg while Min held the front body. I pointed the 25G needle at the appropriate backside and injected. I have a big bandaged right hand but I could still do the injection.
"If the hamster does not go groggy within 1 minute of injection," I said to the students, "It means the dosage was insufficient or that I had not injected directly into the muscle."
The students were very silent. Within 60 seconds, the dwarf hamster went down on her side. "You have less than 5 minutes to complete the excision of the tumour without isoflurane gas," I said to Dr Vanessa. Everything has been prepared for her.
I handed her the scalpel. She knicked the tumour for 0.8 mm long, undermined, clamped and used the scalpel to excise off the lump. The hamster moved a bit as the anaesthesia was lighter.
It is extremely difficult to get the ideal dosage without causing death as the hamster is so small," I said to one student who later commented that the hamster had moved during the stitching up. "This high anaesthetic risk is the reason why many vets do not want to do surgery to remove big tumours."
The 3 students had a rare opportunity to see the whole process from pre-op to post-op
--------------------------------------------------------------------
Above took 57 minutes to create. National Library Victoria Street, 5.12 pm, Oct 7, 2011
Something wrong with the computer. The text automatically became so small as to be unreadable. So, had to stop writing.
661. Teaching 2 Temasek Polytechnic students how to write a script
"The usual scientific report and writing as taught in the schools will put the audience to sleep," I referred to a report on "urinary tract infection in an old dog" written by a student volunteering at Toa Payoh Vets. He started "An 8-year-old Maltese was brought by his owner to see the vet .........."
The following are my points for producing a more interesting video.
1. The hook
2. Introduction
3. Middle (5 important messages or points). One point is as follows:
Bacterial infection of the joints follow if you don't have time to get your vet to treat your hamster early.
The thick yellow pus forms. The skin infections spreads all over the hamster's body. The hamster stops eating. Dies of generalised bacterial infections
4. Conclusion
5. Credits
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
More info and details are at:
http://www.sinpets.com/F6/20111004Four-itchy-joints-dwarf-hamster-singapore_ToaPayohVets.htm
The following are my points for producing a more interesting video.
1. The hook
2. Introduction
3. Middle (5 important messages or points). One point is as follows:
Bacterial infection of the joints follow if you don't have time to get your vet to treat your hamster early.
The thick yellow pus forms. The skin infections spreads all over the hamster's body. The hamster stops eating. Dies of generalised bacterial infections
4. Conclusion
5. Credits
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
More info and details are at:
http://www.sinpets.com/F6/20111004Four-itchy-joints-dwarf-hamster-singapore_ToaPayohVets.htm
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