978. Follow up Roborovski - scent gland infection?

May 7, 2012 I phoned the owner regarding the scent gland inflammation. The wife answered," Seems to be OK. The left hip area is drying up." That meant there was no more exudate and the two hamsters were separated.

"Can the hamster eat, exercise on the wheel and groom herself?" I asked.
"Yes," she said. "I restrict cycling to 10 minutes as she panted. It could be due to the medication."

The wound drying up. No squeezing by the owner. Good sign of recovery.

977. Bench-marking of a spay procedure at Toa Payoh

Today May 9, 2012, I phoned the father and daughter of the Chihuahua 8 months, Female, I spayed as a benchmark and example to Dr Daniel on May 6, 2012. It is very useful to know the effect of pain-killers and compliance by the owners. On May 6, 2012, Sunday, I spayed Chihuahua, Female, born June 18, 2011, said to be 10 months old. She was 1.7 kg, good bodily condition,38.7 deg C. Vulva slightly enlarged. Bleeding heat said to be 2 months ago. Health check by Dr Daniel, . Hx:. Ab  E/D/T Well. No V+/D+/C/S. PE: BAR, active. heart/lungs normal. GIT normal (abdo palp - no pain). menses 2 months ago. Does not want blood test screening of health. Dom and Ket Sedation at 50% and isoflurane gas maintenance and the dog woke up at the end of last stitch. Ovaries and uterine bodies enlarged and congested as if on heat/infected (see images)/0 absorbable suture x 1 Post op tolfedine + baytril injection SC Home medication 1. tolfedine painkillers x 3 tablets (not given at all). Now Day 3. Advised owner to give. Owner will give crushed tab in banana. 2.  trimeth x 1 bottle, multi-vit x 1 bottle. Owner had given. "Almost all medicine is taken," the father said there was no problem and so did not give the 3 tolfedine pain-killer tablets. Post-op observations by the owner (father) is as follows: Day 1 and Day 2 after op. Not active but can walk to pee and poop as normal. Will eat dry food if the owner added chicken wing meat Day 3 - Not eating since chicken wing meat not added. I advised the owner to continue with chicken wing meat as an eating dog recovers faster. Will give crushed tolfedine powder with bananas as dog like bananas Bandage changes advised but father is afraid the stitches will come off. "No problem with the stitches as they are quite tight," I said. "Wash away the dried blood clots and replace with new bandage on Day 4 or 5. It seems like this spay has no post-op complication despite the owner not giving the tolfedine tablets. But there was a tolfedine and baytril injection post-op. CONCLUSION  Liquid medicine is easier to give in this case. Crushed painkiller tolfedine tablet within meat ball may be advised. The owner said bananas can be used as the dog loves bananas. A follow-up is important after spay but vets usually don't have time to do it and 99% of the cases have no post-op problem anyway. So we don't do it. Bandage changing may be difficult for the owner. lst day is always the inactive day. By Day 3, the female spayed dog should be eating normally. In this case, she was eating when chicken wing meat was added, even on Day 1.The father thought of stopping the chicken wing meat on Day 3 to prevent the Chihuahua from being picky but I advised him not to, till the dog has recovered from surgery, in around 14 days. There is no need for stitch removal in spays done by me and so I doubt I will see this dog from Rivervale in North Singapore again.  Vets veterinary surgery performance. Case study of a Chihuahua spayed by Dr Sing K Y   Sunday May 6, 2012 New client. A young lady with her parents from North Singapore had booked me to spay their Chihuahua. Female, 8 months. Said to have heat 2 months ago. I noted that the vulva was still swollen. I used this case to mentor Dr Daniel so that he could see how an experienced vet would handle a case in the fastest, safest and most efficient way. Veterinary surgery text on spays don't reveal the practical aspects of the real life and death situation.  He was to ask questions about the spay.   1. PRE-OP. 1.1 Inpatient record. General health check up by Dr Daniel. Weight of dog: 1.7kg 1.2 The owner did not want blood test. 1.3 Clipping the surgical area outside the Surgery Room. 1.4 Anaesthesia & surgical record. Dr Daniel to calculate sedation dosage at 50% of the formula for Domitor (0.034 ml) + Ketamine (0.043) IV and add equivalent amount of 0.07 ml normal saline to make it 0.14 ml to be given IV by me. 1.5 Absorbable suture packet 3/0 x 1 was prepared. However, I used 2/0.   2. SURGERY ROOM. 2.1 Sedation by Dr Sing.  Mr Min would hold the dog and distended the left foreleg cephalic vein. He was still not good at this despite his at least one year of experience. Somehow,  he did not press the right elbow skin area and so the cephalic vein was not distended. I tried the IV but found no blood drawn out. I asked him to twist the skin to the side and the cepahlic vein was visible. For some reasons, Mr Min can't distend the cepahlic vein in some dogs but could do in others and today was his bad day.   I knew the dog would not stay still long. So, once I injected and saw the blood gushing inside the syringe, the dog started withdrawing her left foreleg. I injected immediately instead of waiting. There was no time to waste as the full dosage to be given was just 50% of the calculated dose. "The whole dosage might not be injected," I said to Dr Daniel as the dog had withdrawn her leg as I completed the injection. It was a wink of the eye. However, the dog quietened and dropped her head. She was sedated within 60 seconds.   2.2 As 50%* of the formula is insufficient sedation for intubation, I asked Mr Min to give isoflurane gas at 5% for less than 60 seconds. It was around 40 seconds. I intubated the dog. There was slight coughing but soon the dog was anaesthesized and maintained on isoflurane at around 1%. Mr Min was to record the % at 5-minute intervals.   (*At 100% of the formula, no isoflurane gas would be necessary but I seldom use 100% as isoflurane gas is much safer and the dog wakes up at the end of spay. Giving 100% would delay waking up. Each procedure has its pros and cons).   2.3 Dog's belly shaved and cleaned.   2.4 Skin and linea alba incision. In this dog, the umbilical scar was not distinct. So I made the incision a bit further than the usual 1 cm from the scar. I showed how I blunt dissected the subcutaneous fat in less than 2 seconds to show the white fibrous linea alba. Many new vets took longer to find the linea alba due to slow dissection and separation of the fat. Sometimes, the new vet could not see the linea alba due to the cloudiness of the SC fat masking the white line. A piece of SC fat could be cut off if the dog was fat so that the linea alba can be seen..   Then I had to extend cranially to expose the left ovary as the ovary was leaning very close to the cranial edge of the incision without giving me access to the ovarian ligament. "The left ovary is more cranial than the left," I said to Dr Daniel. "I have to extend the incision to expose the whole ovary and the ovarian ligament."     QUESTION. "You didn't break the ovarian ligament of the left ovary," Dr Daniel said as I extended the incision of the linea alba cranially by 3 mm and could ligate the ligament. REPLY. "There is no need to break the ovarian ligament in the Chihuahua if the left ovary is well exposed," I said. "You will note that the right ovary is easily exposed as it is more caudal and I did not need to cut or rupture the ovarian ligament. However, in larger breeds and with small incision, the ovarian ligament can be stretched and cut before ligation of the liagment."   3. The uterine body was ligated once.  4. Linea alba closed with 3 interrupted sutures. 5. Skin incison  (2 cm long) was closed with 2 horizontal mattress sutures. 6. No bleeding but the ovaries and uterine bodies were swollen and red, indicating heat was still present. There was some bleeding of the surrounding tissues due to the dog being on heat. 7. Post-op tolfedine and baytril SC. 4 days of tolfedine. One bottle of trimethoprim and one bottle of multi-vitamin. E-collar and bandage of wound. 8. Dog woke up just as I completed the last stitch as I had asked Mr Min to switch off the isoflurane 1 minute as I stitched the skin.   SUGGESTION. "It is better not to switch off the isoflurane and disconnect in case of emergency," Dr Daniel suggested. ANSWER. "Based on the smooth anaesthesia, such happening is unlikely. However, the endotracheal tube is still inside the dog if there is an emergency." In any emergency, there will be cardiac massage first, in my experience, rather than oxygen.   POST-OP.  The Chihuahua got up without crying within 2 minutes of completion of stitching. This meant I don't need to give Antisedan antidote to reverse Domitor. The surgery took a longer time as I had to extend the cut cranially and to hook out the left uterine horn. In this case, after 6 tries and hooking up the small intestine, I switched to hooking out the right uterine horn and was successful. This delay added up to several seconds. Normally, I could hook out the left uterine horn in 3 attempts. But veterinary surgery is full of surprises. THE ANAESTHESIA AND SURGICAL RECORD                   Weight             Domitor           Ketamine Healthy, young, 10kg        0.4 ml               0.5 ml Healthy, young, 1.7kg       0.068 ml           0.085 ml *Give 50%                           0.034 ml           0.043 ml Actual given  0.03 ml + 0.04 ml = 0.07 ml. Add 0.07 ml normal saline. Total IV = 0.14 ml. A: Injection of induction drugs: 10.45 am B: Isoflurane first given: 10.46 am. Intubated. C: Isoflurane gas stopped: 11.15 am D: First skin incision: 10.54am E: Skin stitching completed: 11.17 am   E-A = 33 minutes E-D = 23 minutes C-B = 29 minutes BENCHMARKING SPAY PROCEDURE The Chihuahua spay surgery by an experienced vet with 40 years of spay experience like me took around 23 minutes in this Chihhuahua. It could be as short as 15 minutes but I don't expect younger vets to achieve this benchmark. However, one hour is too long. TIP:  "The hydraulic operating table must be adjusted to the proper height for the vet to operate comfortably and efficiently," I said to Dr Daniel. Each vet has his or her own height and so it is best not to bend double by not making full use of the hydraulics of Toa Payoh Vets' operating table in long surgeries like spay. QUESTION:  "How is it possible for a spayed dog to bleed on heat when she is spayed?" Dr Daniel asked me when I said that there are complaints of dogs and cats still cycling with heat when they have been spayed. "Usually there is a bit of ovarian tissue left behind," I explained that the left ovary is more cranial. So, a vet may incise a bit of ovarian tissue after ligation of the ovarian ligament. The prevention is to make a bigger linea alba incision to expose the whole ovary and ligament. This means making a big skin cut which cannot be helped. Owners are unhappy when spayed dogs and cats come on heat staining the floor with blood and with cats, continuous caterwauling can drive the owner crazy as evident in one case of a spayed cat. A spay is not that simple after all. Besides being on heat, there are reported cases of stump pyometra. I encountered one such case of a dog spayed by Vet 1, in the last 40 years of practice and that would be due to remnant of ovarian tissues left during spays. All veterinary surgeries will adopt a consistent process and approach as described in this case study. I will be doing my trust and audit of some veterinary surgeries done by my associate vets. In the April 20, 2012, AVA Veterinary Clinic inspection of Toa Payoh Vets, the letter of the annual renewal of the licence mentioned that the clinic was well managed. I intend to ensure that it will be well managed with the trust and audit procedures. It will always be difficult to effect changes for the better and this needs time and explanation.

  

976.  Hamster's neck swelling may or may not be cancerous - E-mail query from Malaysia 

E-MAIL TO DR SING DATED MAY 4, 2012

Dear doctor,

My sister's Syrian hamster (about 2 yr old) is having a neck tumour and both the vets that we consulted advised that it is cancer, and there is nothing that they can do about it. Is there anything that we can do to reduce her suffering to the minimal? For example special diet or anything to watch out. I saw from your blog that you had performed surgery for similar cases too, unfortunately my sister and the hamster reside in Malaysia so we are unable (prohibited) to bring the hamster oversea for your consultation.

Thank you very much

Regards,
X

Sent from my iPad

E-MAIL FROM R SING DATED MAY 4, 2012

If possible, send 2 images if possible. There are no drugs that are effective...

May 5 (2 days ago)

If possible, send 2 images if possible. There are no drugs that are effective against tumours.

E-MAIL TO DR SING DATED MAY 6, 2012

On Sat, May 5, 2012 at 12:22 PM, ...@hotmail.com> wrote:

Dear doc,
I'm X's sister, the owner of the hamster. Attached herewith the pictures of my hamster who suffers from cancer

E-MAIL REPLY FROM DR SING DATED MAY 6, 2012

Thank you for 3 images. Neck swelling is large. Is it hard and firm or soft and cystic? Have you got the vet's report.

It may or may not be cancerous as it is hard to diagnose just by size. In some cases, it may be a haematoma, an abscess or soft tissue growth under the skin. As the hamster is old, cancer is likely but not definitely.

To confirm whether it is cancerous, the swelling has to be sent to the lab for histopathology. Therefore, the diagnosis is based on FNA (fine needle aspiration) of the swelling to be sent to the lab for histopathology.

Surgery by excision is the only option but the anaesthetic risk is much higher. Any medication like pain-killers and antibiotics from your vet can be given but will not resolve the problem.

975. Testicular tumours in old Papillon

This Saturday, May 5, 2012, I worked as Dr Jason Teo is off in Batam.  Dr Vanessa covers him.

Papillon with big testicular cancer (more than 10 cm). Not eating 2 days.
"Yesterday, Dr Daniel gave an injection. I noted some improvement. My dog ate the chicken later. I gave another piece. He ate all overnight."
"Dr Daniel is not working today," I said.
"You have seen my Papillon before," she replied. "What is the cost as I can't afford $3K to $4K for the surgery. My niece's Jack Russell went for an operation at a vet and was charged $3k to $4K."
"Where did she go?" I asked. She mentioned a name of an old practice.

"Each practice charges differently. If she preferred a brand-name like being treated at Mount Elizabeth Hospital as a patient, she would have to pay top dollars. Your dog's operation to remove testicular tumour is probably around $300 - $400. Don't take the blood test as suggested by Dr Daniel to assess the risk of anaesthesia, to save some money. In any case, you have to decide to take the high anaesthestic risk of the dog dying on the op table as you don't have a choice of whether to operate or not. If the dog survives the anaesthesia, he can live a normal pain-free life, provided the cancer has not spread to the lungs and elsewhere."

"I am very close to my dog," she said. "I don't know what to do."
"Now the dog eats as the bacteria inside the tumour cells is gone and the dog feels better," I said. "But the pain and infecton will come back as the cancer cells are rotting."

So, the lady decided to wait one more day as I could operate on Sunday morning tomorrow. I have 2 spays lined up tomorrow Sunday.

P.S Neutering the male dog early would have removed all worries and frustrations of testicular cancer in an old age. Blood test for health screening is good but in this case, the dog has to be operated to remove the disease cancerous cells. It should be a simple short operation but the risks are still there. The shorter the anaesthesia, the lesser the risk. But the vet must know what to do.

In this case, no other way to help this dog but removal of the enlarged testicular tumours.  So blood test results indicating poor health is not going to be useful.     

974. Veterinary audit of one case TP 43569

TRUST & AUDIT PROCESS AT TOA PAYOH VETS

Saturday, May 5, 2012
10.25 am
I did a veterinary audit of one surgical case done at Toa Payoh Vets as part of my management of the practice to make it as one of the top 5 vet practices in Singapore. This is to ensure a high standard of veterinary care from vets at all times especially in veterinary surgery.

TP ...569
Chihuahua, Male, 10 years
Complaint: Blood in the urine.
Blood in the urine. X-rays and blood tests done by another practice (Vet 1) on Mar 31, 2012

Admitted: April 16, 2012.
Cystotomy: Bladder stones removed by Dr XXX: April 18, 2012
Neuter by Dr XXX: April 18, 2012
Sent home: Apr 18, 2012
Owner returned dog for hospitalisation as the dog screamed when touched or given medication:
Apr 19 - May 3, 2012.

AUDIT PROCESS - LIST OF RECORDS MAINTAINED
Veterinary Surgeon - Dr XXX
1. Follow up. I phoned owner today to find out about the present situation. No response on this Saturday morning.
2. Outpatient record  - Yes.
3. Anaesthetic and surgical record - Yes.
Anaesthetic dosage recorded. Number of packetes used and type of sutures not recorded. 3 packets were used.
4. Inpatient record - Yes.  2 days. Apr 16-18, 2012
5. Hospitalisation record - Yes.  Apr 19 to May 3, 2012
100g dry food given and consumed per day. I checked on weight of food given by Mr Min.

TESTS DONE AS AIDS TO DIAGNOSIS
6. Blood test - done by Vet 1. Nothing abnormal discovered.
7. Urine test - not done by Dr XXX. Reason being that there was urethral obstruction. In this "audit and trust" procedure, I informed the vet that urine test should be done in all cases and could be collected during cystotomy. This is to enable us to know the pH of the urine and whether there is bacterial infection.
8. X-ray of bladder - done by Vet 1  - 6 small stones seen on hard copy kept by the owner.
9. Bladder stone analysis done by Dr XXX - Yes. Mainly calcium oxalate with trace of phosphate and magnesium.

CONCLUSIONIt is extremely difficult to effect changes as each vet has his or her own mindset and way of practising veterinary medicine and surgery. The Domitor and Ketamine IV sedation formula, much discussed in my case reports, is now accepted by Dr XXX after many months as being scientific, effective and safe. Formerly Dr XXX would use Domitor in low dosages irrespective of weight of the dog.   

973. The circling dog (clouds)

I seldom travel by plane, but in the many years, I had not seen such beautiful clouds from a plane. I was on the way to Phomn Penh from Singapore on April 30, 2012.

The image of one cloud reminds me of my patient - a 12-year old Miniature Schnauzer whose head tilted left and who circled anti-clockwise for the past 2 weeks. I wonder how the dog was as the chances of recovery to normal are very slim. Would he still be circling anti-clockwise? Or would the drug be temporarily effective? 

P.S. google and the mobile phone tends to display a portrait image sideways for some unknown technical reasons. Probably some software bug.

972. Make money from google and youtube - create niche info

May 4, 2012




To: Two young men of less than 30 years old



REF: Make money from your pictures - google ad sense and youtube



You are living in a golden age and in a country where peace has been present for over 70 years allowing you to grow up in an era of abundance, consumption, no worries about hunger and much comfort. Your parents work very hard to get you educated at great expenses which they will never recover.



Generally, I notice that many of your peers trend towards more consumption and pleasure rather than suffer the pain in the creation of artwork, products and services to better yourself and your community.

However, only in recent years, can you actually create and make money from the internet from google and youtube. But you need to put in the effort and hard work and learn a new skill (video production, digital photography and writing). If you want to be rich as well as be smarter than the 80% of your peers, start spending time creating niche and interesting webpages with videos and images.



1. google ads pay you money when viewers click on your webpages.

2. youtube may pay you for good videos



For point no. 1, goto

https://mail.google.com/mail/?shva=1#inbox/13713f5ac6042ab5



Spend much less time watching videos and TV. Produce niche interesting videos and be "rich" in time to come. Wealth comes from knowledge gained, positive results and community education and services rather than just making money. Best wishes.

971. The circling dog

"Though glucocorticoid works in enabling the circling dog to straighten its neck and look left and right, it is not easy for any vet just to prescribe such medication," I explain to Dr Daniel Sing when I asked him to handle any query from the owner of the circling Schnauzer while I was away in Phnom Penh.

"In this case, there was marked improvement as the dog had been circling anti-clockwise in tighter and tighter circles for 2 weeks," I said. "I gave dexamethasone IV twice. If given orally, it may not work effectively. Therefore, the dosage must be not too little nor too much. To the owner, the clinical outcome is whether the dog still circles and in this aspect, performance counts.

Two vets may prescribe the same medication but the dog may not respond to the medication or respond to one vet's medication. Therefore, follow up to know and adjust the dose-response effect is so important. Many owners don't provide feedback as the dog is old. 

The increase in eosinophil count is mentioned in the following relevant article:
http://ezinearticles.com/?Vestibular-Disease-in-Dogs-and-Cats&id=494854
In the above-mentioned article, circling in tighter circle (vestibular disease?) v. wider circles (brain disease?). This dog circled in wider circles initially. So, was the brain area involved originally?

970. Travel Stories - Phnom Penh Apr 29-May 2, 12

This is my first time to visit Phnom Penh, Cambodia. I am not keen in visiting the "Killing Fields" or the temples as I had seen the best ones at Angkor Wat in Siem Reap. Street photography is my hobby and Phnom Penh with 80% of its 16.5 million inhabitants should have much more interesting scenes than sterile Singapore. I was not disappointed.

Sisowath Quay in Phnom Penh reminds me of the Esplanade of some 40 years ago where young couples meet for a date and view the lappng sea waves and see the ships. Maybe ordered some satay to eat. It is not the present day "Esplanade Theatre". I did invite my pen pal to walk along that Esplanade and we were so young then. Sisowath Quay so much reminded me of those days gone by.

My impression of Phnom Penh is a city of high competitivenss. I met a very old white-haired gaunt-looking sharp faced woman and her thin grand-daughter at "The Central Market" and she asked for some money. "Give her some money," I said to Julia as we boarded the tuk-tuk to go to Nagaworld for lunch. "No," she said. "If I give her, many beggars would rush forward." Actually, I don't see any beggars. In any case, she handed her a note and the woman clasped her hands in grateful thanks. Beggars are rare in Singapore too but they do exist. Recently, one older woman asked me for some money to buy food when I had lunch in the coffee shop near Courts Furniture in Toa Payoh. I did not encounter other beggar in Phnom Penh during my 4days/3nights' stay and I would say they are rare too.

As for competitiveness, I note that Nagaworld is probably No. 1 in earnings power as it has a casino and many food outlets compared to Phnom Penh Hotel where I stayed since Nagaworld's rooms were fully booked. I booked the land tour package at the last minute as I don't believe in early bookings. So, I had to pay more for Phnom Penh Hotel which is 4-star compared to my desired Nagaworld which is 5-star and cheaper. But, like any professional, what is the point of being cheaper when one is unavailable?

Soliciting for business is important for tuk-tuk transportation, boat cruise operators, small boys and girls who sell Lotus fruits, drinks, magazines. I saw one teenaged boy still at the roadside selling Lotus fruits at 9 pm
yesterday (May 2, 12). It was so dark on the distant Sisowath Quay area but he was still around. 

A Lotus fruit vendor is shown in the images below.

Will upload more pic when I am back in Singapore.

969. Best time to spay a Mini-Maltese 2 kg

On Mon, Apr 30, 2012 at 1:38 PM, ...> wrote:

Dear Dr Sing,

I’m considering spaying my female Maltese when she is 6 months old. Her birthday is 29 Nov 2011 and will be six month old on 29 May 2011.

She just reached five month but she is small in size, weighing around 2kg. Will it be advisable to spay her sometime around 1st week of June given her size?

Kind regards


E-MAIL REPLY FROM DR SING DATED MAY 2, 2012 (from Phnom Penh Hotel, 11. 23am)

Hi


Thank you for your email. If you are not in a hurry to spay your Maltese, wait till she is mature. The ideal time will be 3 months after her first estrus so that her private parts (e.g. urethra) are fully developed. This may be around 8-9 months of age, assuming first bleeding is 6 months. Some Maltese start having heat at 8 months.
The period between two heats (bleeding) is 6 months, so in theory, you can get her spayed 4-5 months after the first heat and she will have matured and put on more weight. And will be much stronger too.
However, 6 months is the earliest age to spay a female dog kept at home and not in animal shelters.
Pl email me if you have more queries. Best wishes.