Monday, November 28, 2011

747. The tu tu kueh woman's dog

Yesterday was a long day at work on a Sunday. I usually work half a day and let Dr Vanessa do the rest. I asked Mr Min to take the afternoon off and so I stayed around and stayed to do some administration. A practice needs to be administered well or it will just suffocate and wither as the world is getting complex and competitive. The clients are getting sophisticated and more demanding.

For example, one client wanted me to excise a large paw haematoma without sedatives as she was afraid that her old pug would die under sedation. That is a valid fear. To do it or not? It is up to the vet. The vet can just reject her case. What if the old pug dies under sedation? And nobody can predict this. For the sake of the old pug, I incised the haematoma and let it was OK.

The tu tu kueh woman at Bishan Shopping Mall. She asked what stall I was managing as she had seen me so many times over the years buying tu tu kueh from her and asking about her work. She had cooked soup which was shared with other woman stall holders and her brother who sold cakes under the same boss. When I told her I am a vet, she said: "I cried a long time when my dog died. Just running nose. A lot of it. My friend sent it to a vet. Some injection. Hospitalised for 2 days. My dog died. Just runny nose. Goes to the vet. Injection. Died."

"There could be many reasons," I said. "It could be a drug allergy. It could be a serious infection. How old and what breed?"

"7 years old. A Pomeranian." Her eyes teared up as she remembered her dog so well.

Now this dog was a clever dog. "My dog would jump and greet me when I unlock the apartment door. He could hear my key sound. When other family members unlock the door, my door would ignore them," she said, turning her head sideways.

"When I stayed too late watching TV, my dog would lick my ears to ask me to sleep. If I did not, he would jump to obstruct the TV screen."

"That sounds like a very intelligent dog," I was surprised. "It is as if he was a very caring human being re-incarnated as a dog." Some religions believe in re-incarnation and this canine story seems to support this.

If I can find a small breed to be rehomed, I will get one for her as she cares so much for dogs.

Sunday's interesting cases - Nov 27, 2011

1. Septicaemia from gangrenous vaginal hyperplasia and prolapse
The Chihuahua passed away after heavy panting. I had a complete blood test done 2 days ago and had informed the owners that the dog had toxic blood. The total white cell count was twice as high as the higher range, the red cells were twice as low as the lower range and the platelet count was very low at 14. Urine analysis showed bacteria and blood (estrus). I noted that her tongue was purplish and that was not a good sign as it indicated some abnormality of health. The blood test was indicative of a septicaemia.

"After two days, the tip of the vagina prolapse became black," the caregiver mum told me over the phone. That was when she consulted Vet 1. The dog stopped eating and was treated but the blackness at the tip spread more. If this was a gangrenous tail tip, it could be amputated. But this was part of the vaginal mucosa. In any case, anaesthesia and surgery of a dog that is not eating and has a lower than normal rectal temperature (37.6 in the first 2 days) was highly risky. The dog was spayed and survived the operation for 4 days. The Chihuahua was 10 years old and was in good bodily condition.

It is important that a blood test is taken when necessary two days after the surgery as septicaemia is an on-going process. The earlier blood test did not show serious changes. In the event of a bad outcome, the owner and all family members will like answers as to the cause of death. Evidence-based medicine using blood test provided the answer.

2. The dog with a gangrenous tail. "It is important that the owners, you and I meet together in the consultation room to discuss about her case," I said to Dr Vanessa who had stitched up a serious profuse bleeding tail wound and had sent the dog home with an e-collar and medication 3 days after surgery. "I had spoken to the owner," Dr Vanessa said. However, I had promised the owner to have a joint meeting as it is hard for me to listen to one side of the story - her side and Dr Vanessa's side and advise. "This joint meeting in my presence is important to clear any misunderstanding," I said to Dr Vanessa. "The owners have not been happy with the dog developing a tail gangrene after surgery. This meeting is not to find blame on the vet. Such misunderstandings from the owners do happen to all vets after surgery, including myself. It is best to meet jointly and clear up all emotional unhappiness."

"I don't blame Dr Vanessa," the owner said first.

"From my experience with tail wound cases, it is usually the dog that traumatises the wound, causing it to become infected and gangrenous. That is why I normally advise tail amputation in serious wound cases as the owner does not know how to take care of it after surgery. However, some owners don't like this idea and want the tail to be saved. In your dog, the tail would be hammered by the end of the e-collar to relieve its pain and itchiness."

"The dog bites me when I try to clean the tail," the lady owner said. "Yet at Toa Payoh Vets, the dog lets the vet change bandage without biting! He uses the e-collar to scratch the tail. The wound opens up. Yellow pus is seen. I phoned Dr Vanessa but she did not answer the call. That is why I phoned you."

"I got a phone call after midnight," Dr Vanessa said.
"Was the tail gangrenous when the dog went home 3 days after surgery?" I asked.
"No," the owner said.

"Many times, the unhappiness is due to financial reasons," I shared my experiences with Dr Vanessa. "You attempted to save the severely lacerated tail by stitching and controlling the bleeding. You sent the dog home 3 days after surgery but the dog can't stand the pain and itch despite your NSAID medication. So, he bites the owner trying to change the bandage. The tail gets infected and gangrenous. Now the owner has to spend more money to get the tail amputated.

"That is why I always advise tail amputation of a seriously wounded tail as the first choice. If the owner declined and the tail becomes gangrenous, there is no unhappiness. You had done on in a cat some time ago when the owner accepted my advice. Have you seen any return of the owner?"

"No," Dr Vanessa said.
"As a vet, we try to salvage the tail. As the vast majority of owners cannot do post-op nursing, the tail becomes gangrenous and this is stressful and expensive for the owner.

Saturday, November 26, 2011

745. The "hidden" pup in canine Caesarean sections

http://www.sinpets.com/F5/20111126hidden-pup-caesarean-section-dog-singapore-toapayohvets.htm
has the complete story.








Friday, November 25, 2011

744. Anaesthesia of old Chihuahua - vaginal hyperplasia and prolapse

Chihuahua, Female, 10 years
Active and eating well till 19.11.2011 when the owner noted a vaginal prolapsed. The dog became lethargic and did not eat. Vaginal or uterine prolapse diagnosed by Vet 1. Owner went back but the pushed back vaginal tissue came out again. Tip became black after 2 days. No e-collar worn.

22.11.11 A friend of the owner was worried and asked me to advise the owner to euthanase the Chihuahua if she was suffering from liver and kidney infections as deduced from abdominal ultrasound and blood test reports. I reviewed the case.

As the owner is not able to take care of the everted vaginal tissue and it had become necrotic, I advised spay the next day as this was the solution. But there was a high anaesthetic risk as the dog did not eat for the last 4 days and her tongue was purplish. Mild dehydration. Temperature below 38 deg C for the last 2 days.

22.11. 11 One day Pre-op IV drip and antibiotic
23.11. 11 37.6 deg, 3.5 kg.
10am
IV drip glucose 5 minutes, then dextrose saline. Tongue became pinker.
IV lasix 2 ml
Domitor 0.05 ml + Ketamine 0.05 ml IV
Isoflurane gas top up at 0.5 - 1%
I expected a 10-minute spay.
Dog vomited yellow liquid after intubation. Repeat.
Dog passed loose black stools. Cleaning up. This took time.
Opened abdomen, hooked out left ovary.
However, both the ovarian ligaments and bv ruptured when ligated. Bleeding seen. So, I had to make a large skin incision to locate the bleeder far inside, behind the kidneys. Two quail-egg sized blood clots on left and right sides were taken out. Bleeders located but bleeding was oozing now. Clamped and ligated one bleeder as the left one slipped off the kidney area. Checked and cleared all bleeding inside abdomen. Closed up 2/0 PDS sutures. Completion at 11.30 am.

743. Day 3. Vaginal hyperplasia & prolapse in the female dog - Surgical option

Day 3. The Chihuahua bites me and my assistant any time we try to catch her. She does not eat but otherwise is alert and strong. "Is the vaginal prolapse the same size?" I asked my assistant Min, as part of my coaching process. I had pushed in the prolapse yesterday morning.

"Same as before," Min said. "Come out again." He could have difficulty understanding Singapore English as he is not proficient in this language.

He tried to muzzle the dog for me to examine. The dog snapped at him. I had taught him to use a towel to cover the dog's head but he did not do it this time. It needs lots of patience to train a person. I covered the dog's head with a towel. The dog moved to a corner. "Use a leash to lasso her," I said. Otherwise it is impossible to examine her. Min held the leash and lifted up the tail. The dog moved but could not bite us.

The prolapsed vagina had decreased by 60% in size. I was not surprised as spaying removed the oestrogen causing this problem. Min saw the size and that is important. I pushed it in. The dog should be able to go home soon as she is not eating here. I did advise a 20-ml syringe to feed her. A 2-ml syringe with canned food is too short.

741. Severe tail injury - the sole option -- tail amputation

"There is only one option when the dog or cat suffers serious injury to its tail," I said to my associate vet who had stitched up the slanting tail laceration wound of more than 6 cm long and sent the dog home with e-collar and medication.

"Based on my past 30 years experience, many Singaporean dog and cat owners are not able to nurse their dog's tail wounds. Even with e-collars, the dog or cat hits the injured irritating tail, causing more damage. The tail does not heal and becomes gangrenous. The owner becomes upset as she had already spent money on this first surgical treatment. It is not working and now the owner is upset."

"In all tail injury cases, the owner must be advised firmly and in writing that tail amputation is the sole option as gangrene is likely to set in, with stitching and other bandaging. There was a case of a cat with tail injury. I advised tail amputation. We don't see any complaint post-op. Now, this case comes back with lots of unhappiness as the tail becomes blackened and the tip has become cold."

As the owner was unhappy with the outcome, I advise that she and the operating vet and myself meet at the same time to discuss the matter. It is best done that way than individuals giving their points of view to me one-on-one basis.

The outcome of a case of tail injury is very important to the owner. The owner wants just one visit and not be inconvenienced by having repeat treatment. "Even with gushing blood and copious bleeding, ligate the tail blood vessel, bandage the tail and amputate the tail 2 days later."

Thursday, November 24, 2011

741. Keratitis in pugs and people

Keratitis is an inflammation of the cornea. In people wearing soft contact lens, there are 3 types of keratitis:

1. Infective Keratitis. Cornea inflammation caused by micro-organisms like baceria, fungi and parasites. Can lose eye-sight if not treated early or by appropriate antibiotics. Cloudy scar on cornea when healed. A person can't see clearly. Same with pugs and other dogs. Big problem in pugs and shih tzus. It is called ulcerative keratitis. See one picture below:




2. Epthelial Keratitis. The top layer of the cornea is inflamed. Small holes are seen in the epithelium. It is called punctate epithelial erosions and this is also commonly seen in pugs and shih tzus. For the dogs, it is due to traumatic injury. See the green spots of one pug's eye below:
The holes may get infected by bacterial.

3. Allergic Conjunctivitis. The membrane which is below the eyelids is called conjunctiva. An allergic reaction to the contact lens or its solution leads to eyelid swelling and pain.

Chemosis - swelling of eyelids.

PUGS, SHIH TZUS AND PEKINESE
Ulcerative Keratitis is commonly seen due to injury to the protruding eyeball. Early treatment saves the eye sight.

Many Singapore owners of the pug and shih tzu and related breeds have no time to maintain the facial folds or damage the cornea during cleaning of the facial fold. Hairs get trapped inside the eyelids and as you can see from the picture below, the cornea is deprived of oxygen by the turfs of hair and get irritated and infected by bacteria found in the hairs.

My advice is to get your vet to excise both facial folds, preventing the formation of ulceratitive keratitis. But many Singapore owners do not want to accept this advice and so, as the years pass by, the cornea becomes blackened or browned by pigments (chronic irritation for many years). The dog is practicallly blind but the owner is not personally affected. It is just so sad. Keeping the eyes of pugs, shih tzus and pekineses clear and transparent to old age is a heavy responsibility. I hope the younger google generation will be more enlightened and sophisticated to prevent such problems by early treatment at the vet or by getting the facial fold excision done.


--------------------------
22 Dec 2020. The lady owner of this 10-year-old male not neutered pug contacted me via text message as her pug's right eye had some "brown" thing. It was a matted cornea with ulcers and hair glued onto the cornea, on detailed examination, under sedation, in the operation room. Images are in instagram as well.

Monday, November 21, 2011

740. SOP Dental scaling at Toa Payoh Vets

The following is advised before an old dog (>5 years old) gets dental work done under general anaesthesia

1. General and detailed examination
2. Complete blood test for health screening
3. Oral antibiotics for 7 days before dental work
4. Dental work with low sedation and use of isoflurane + O2 gas
5. Post-op antibiotic and pain-killer injection
6. Post-op pain-killer and antibiotics 5 days
7. Teeth extracted to be shown to owner
8. Dental record
9. Dental reminder 2 years later
P.S. X-rays of lungs and heart ECG may need to be done
A big thank you to the young Singaporeans who produced the following videos to educate pet owners and bring veterinary medicine and surgery alive to the vet students studying hard for their exam.

As these google-generation people are very busy and have not charged me for services, I have not asked them to edit again to make a perfect production.

The following are the videos:


http://www.youtube.com/watch?v=tmTYP8T95V4 - Kennel Cough video the Sec 3 St Andrew boys produced. The "owner" of the pug was the student but the other characters are genuine. The video producer was another student and his teacher had kindly recommended him to me to help in this production. It turned out to be quite fun to watch this video, in my opinion.

For example, locking the door of the black Mercedes car is not done nowadays but we all had great fun in producing this video. The "owner" seemed to be smiling when he came for a second vet visit with a puppy that had worsened in coughing! I mean, the real owner would be very worried!

After hospitalisation in a crate, there was a scene of the puppy on the consultation table inside the vet consultation room! This should be cut! This is the first video production and no more other versions. That is why I explained the "deficiencies" in the production!

http://www.youtube.com/watch?v=FYeG9tUXp78 - Responsible Pet Ownership video - Nicole Pereira. Excellent summary of some of the main problems seen at Toa Payoh Vets. Great work.


http://www.youtube.com/watch?v=ExTT2a8eUCs - Oronasal Fistula Follow Up - Temasek Polytechnic Vet Tech students who do not wish to be credited

http://www.youtube.com/watch?v=9vKmXgAS_SA - FIV in stray cats 2 - Temasek Polytechnic Vet Tech students who do not wish to be credited

Overall, it took a lot of time. Too much time.

734. Educational videos produced by young Singaporeans for Toa Payoh Vets

E-MAIL FROM DR SING DATED NOV 21, 2011

Thank you very much for your help in producing the Responsible Pet video meant for the AVA Responsible Dog Ownership Road show. The KC video was also good thanks to your help. The voices of the narrators were distinct and clear, to my surprise and the narrative scenes were not boring unlike a power point presentation or a professor's lecture. I hope the vet students do learn a bit about complicated kennel cough.

I gave each party general guidelines as I want other views and presentation.
Each party brings in something new (ideas and presentation and music) in video production and that is why it is so interesting to watch them. Thanks again.

I am only worried about the microchip scanning pic and some other pic you put on the Responsible Pet Ownership video as they may be copyright. Pl confirm the source as we can get sued or get a legal warning to remove it! Pl look into this matter and it is best to remove them and put in original images.

On Sun, Nov 20, 2011 at 5:06 PM, Nicole Pereira wrote:

Hi Dr Sing, here's the links to the videos i uploaded to your 99pups account-
http://www.youtube.com/watch?v=tmTYP8T95V4 - Kennel Cough video the St Andrew boys produced
http://www.youtube.com/watch?v=FYeG9tUXp78 - Responsible Pet Ownership video
http://www.youtube.com/watch?v=ExTT2a8eUCs - Oronasal Fistula Follow Up
http://www.youtube.com/watch?v=9vKmXgAS_SA - FIV in stray cats 2