1206. Closed pyometra in an old Shih Tzu X

Dec 6, 2012
Ideally, it is best to use evidence-based medicine to get a diagnosis of closed pyometra. X-rays and blood tests are what the vet professors teach the new graduates.

However, in real life, there are clients who can't afford the tests. In this case, I usually get a good history and abdominal palpation of a big swollen uterus and operate to remove the uterus. There is always a possibility of no pyometra but a swollen bladder or an abdominal mass but economics prohibit more exploratory tests.

"It is how you present your case," I said to Dr Daniel. "If the owner has budget constraints, two X-rays add to the vet costs. There is a big orange-sized swelling in the abdomen. It could be the bladder but you said Mr Min had seen much urine being passed. Therefore, this globular swelling could be the uterus distended with pus."

The owner did not know when the last heat occurred. However there was vomiting yesterday and a complaint of sticky matter in the "urine." The dog was not eating much for the last 10 days. These clues point to pyometra. X-rays and blood tests will confirm.

The owner decided on X-rays.

There is closed pyometra, according to the X-rays. The uterus had swollen so much that the intestines were displaced forwards.

"Don't operate immediately," I said. "Give the IV drip and antibiotics 24 hours and operate after that. This ensures a better chance of survival, in my experience."

The owner will discuss further at around 7pm. There is no alternative but surgery to cure this dog. However, there is financial hardship for some owners and the newly graduate vet must the heartlander economics and provide the least cost surgery.


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Friday. Dec 7, 2012. The dog is better after IV drips yesterday but the rectal temp is below normal at 37.7 C.


The owner agreed to a blood test.
1. Kidney disorders. Urea 22  (4.2-6.3). Creatinine 188 (89-177).
2. Total WCC 62 (6-17) with N=98%. L=1.7%, M 0.3%. E & B =0%
3. Platelets 191 (200-500).
4.  Haemoglobin 9.9  (12-18)
5.  Red cell count 4.8  (5.5-8.5)

Surgery is necessary today but the risks are high as the dog has septicaemia and may die on the op table.

1205. Mynamar stories - An unhappy girl

On one afternoon in Dec 2012, I was at the office of Khin Khin Employment Agency. A thin fair lady in her late 20s came into the office to ask her to find an employer after working 6 months with the present employer who had told her that her services would end on Dec 15, 2012.

"Why do you want to spend more money in agency fees when you have a job now. You just put back $500 into your POSB account, apologise to your employer and complete your S pass contract," Khin Khin said loudly. "You should not have taken out the money as your boss had told you not to."

I was surprised that she could be sacked just for this $500. "Can you find the $500 to put back into the account?" I asked. "How much agency fee did you pay to get this job?" She said she had the money and had paid $4,500 agency fee.

"How much are you getting?" I asked. She said she got a good pay but she could not tolerate being scolded by her boss and colleagues.
"How many days off per month do you get?" I asked.
"4 days off," she said.
"So you have a good working condition," Khin Khin and I said. But there must be more to it than the $500 disobedience. I tried to help her by asking for her boss phone number since Khin Khin might not have the patience or ability to salvage this job loss situation with a Singapore employer.

The girl did not have the phone number. So I surfed the internet, got the company name and phoned the mobile number displayed.  It was her boss. "Who are you?" she asked me. "I am Dr Sing from Toa Payoh Vets," I said. "I am just trying to help your employee who said she would put back the $500 into the savings account and I hope she would get her job back."

"It is not the $500 which she already withdrew since the first month of work. Her agent had talked to her and I had waited for 6 months but her work attitude was bad. She swept the dirt under the table and this is 'pantung' (bad luck) to a Peranakan. She also smashed the curry puffs. I have given her Dec 15 as her last day and she has one month to look for an employer."

So this was an unhappy girl who had her first job in Singapore. A job so difficult to get nowadays as the Government clamped down on approvals even for employers who have the quota. Just a rejection letter for most employers. And there are so many young Myanmar ladies who are looking for a job in Singapore to support their families and to improve their standard of living. Yet, this unhappy girl showed her tantrums and misconduct.

She nodded her head when I told her that she had swept the dirt under the table and smashed the curry puffs in anger. "You must be from a rich Myanmar family," I said. Spending $4,500 on agency fees and more expenses just to get a job in Singapore cannot be affordable to the average Myanmar girl. "No, I am not", she said. A graduate in Myanmar with a good command of English and good looks may earn US$300-500 per month in a big company. It is just not easy to get a job in Yangon for higher pay. There are 60 million people in Myanmar and competition for jobs must be much more intense unlike the young Singaporean counterparts who can pick and choose their employer.

Poor work attitude afflicts many from the younger generation in their first job when the employment vacancies are high. As for this unhappy girl, I don't see any hope of her getting another job as there will be newer girls with no "leaving the Singapore employer before the end of contract - a red flag for employers" arriving in Khin Khin's office to look for jobs. Many of them can converse in good English and Mandarin, esp. from the Kachin State which is near to China.
P.S. According to one Myanmar lady in her 50s, she said that the Myanmar government stopped the teaching of English in primary schools in 1962. Those who studied English were ridiculed. So, the new generation of Myanmar nationals can't speak English proficiently.

1204. Integrity, meticulousness and bungling

Some young men are accident prone. I know of one young man. Whenever he plays football, he ends up with broken toe nails and lameness most of the time. I was surprised to encounter another young man in a similar predicament.This young man wanted to study vet medicine and he interned at my place. He got As for O level and is in a top Junior College and so he should be an intelligent young man.

Yet some forces affect his work as an intern.
One day, I asked him to pull out the plastic tab of the IV drip bottle as part of his hands on work. It is like pulling the metal tab of a can of Coke. I had already said he is a bungling person. He pulled the ring. The ring came off but the circular plastic cover still covers the IV drip bottle. It is like pulling out the ring of the Coke can but you can't drink because the circular piece didn't come off.

On another occasion, he showed me a video production. I encouraged interns to do it. "How come you showed the owner going away from Toa Payoh Vets when he is supposed to enter the Surgery to consult the vet?". He said: "Nobody will know. It is done in movies."

"Integrity of a production or any work process is very important," i said. "You think viewers are stupid but many will point this out. I don't want this Toa Payoh Vets video to be a multi-media class-room case study of the lack of integrity in production. In the National Service, we call bungling person cocked up." The young man laughed. Somehow fate seemed to be against him.

So he changed the scene. The video now showed the owner walking the dog into the Surgery to consult the vet. Great. "But how come the owner coming to see the vet wears a blue T-shirt and yet in the consultation room, he wears a yellow shirt?"  There is a need to be meticulous in a person's work esp. for a top school student.

After producing the video, he asked me to view it. I could see that the wording "subtitle/text" appeared again."Something wrong with the software," he said to me.

In the end, no video was produced.  A lot of time was spent by me too.

Follow up: Golf ball lump in a Golden Retriever's face

Dec 4, 2012  9.23 am

I reviewed the surgical case done on Oct 14, 2012. Not possible to talk to the busy owner for long but he said dog is OK and would check if the nylon stitches have been removed.
Golden Retriever, M, 9 years, 27kg

Blood test -  Total WCC = 5.2 (6-17) which is low. N=63% OK, L=22%, M 8%, E6%, B1%. Surprisingly in June 4, 2012, the Total WCC = 3.3 which was lower. N=55%, L 28%, M 11% E4%, B2%. Platelets 110 (200-500). The dog came in for vaccination and health check and there was no complaint of ill health. This dog is very selective in eating.

PRE-OP
24 hours before surgery, IV drip and antibiotics

ANAESTHESIA
Not a fit candidate for anaesthesia as Total WCC is low and the dog is old and thin. Short surgery, the better chance of survival.

SURGERY
Electro-surgery controls bleeding better. Still time between first skin incision and last stitch took 57 minutes and isoflurane gas time = 85 minutes. Xylazine 1.3 ml + Ketamine 0.3 ml  IV provides ineffective sedation. Needed isoflurane gas mask top up.  Nylon 2/0 x2 packets. PDS 2/0 x 1 packet used.

HISTOPATHOLOGY.  Granulation tissue either due to ulcer or wall of abscess. Had eaten chicken bones which could have pierced the cheek muscles.   

CONCLUSION
Blood test is useful in health screening pre-op. Still, there is need to be speedy, accurate and completeness in surgery.

As at Dec 5, 2012, owner said dog is OK.

   

1202. Compliance issues in bladder stone prevention in a British Bulldog

Dec 4, 2012. I phoned the owner of the British bulldog, female, 4 years today as part of follow-up.
An interesting multi-lobed large globular bladder stone was removed by Dr Daniel on Nov 26, 2012 and the stone is being analysed.

"My dog is OK but now passes stools every 2 days, as if she is constipated," the owner said. The dog used to eat like a horse.
"How many cans of S/D do you feed/day?" I asked as this 19 kg dog should be eating 1 and 1/2 to 1 and 3/4 cans per day.
"I feed 2/3 cans/day to prevent her from being fat."
"Do you feed dog treats, bread or other food?" I asked.
"Some vegetables and fruits, but only occasionally," she said.

COMPLIANCE ISSUESOwners don't comply with strictly feeding on prescription diet. They will give some treats, bread and fruits after a while.

REVIEWS FOR URINARY TRACT INFECTIONS
Owners don't do that.

1. To prevent struvites, urinary pH = 6.2 to 6.42. To prevent calcium oxalates, urinary pH = 7.1 to 7.73-weekly urine analysis is recommended but no Singapore owners do that. Breeds like Schnauzers and Shih Tzus have a tendency to get urinary stones and reviews of UTI will have prevented costly surgeries.

STRUVITES.  Use C/D after stone removal.  S/D is to dissolve the stones.
CALCIUM OXALATE.  Use U/D to prevent more calcium oxalate stone formation. U/D does not dissolve the stones.
  Check for urinary pH

CASE STUDY OF THE BRITISH BULLDOG
Nov 19, 2012. Blood in the urine for past 2-3 days. Urine analysis and X-rays (bladder stone).
Nov 26, 2012. Cystostomy to remove the stone. Bladder wall thickened. Dr Daniel put one appositional continuous suture  on submucosal layer and one inverting suture. I advised an additional layer of inverting suture as that would be what I would do. A urinary catheter could be used via urethra to pump saline into the bladder to check whether there is leakage but for 3 layers, I know that the closure is secure.

URINE ANALYSIS 2 TIMES
Nov 19, 2012.  pH 8.0, SG 1.020, Pn 2+, Blood 4+, WBC 30, RBC 720, Bacteria Nil, Crystals Nil   (history of haematuria for past 3 days only).
Nov 26, 2012. pH 8.0, SG 1.019, Pn 3+, Blood 4+, WBC >2250, RBC >2250, Bacteria 3+, Crystals triple phosphate occasional (history of haematuria for past 10 days). The dog was on trimax and medazole oral for 10 days and baytril injection. S/D X6 cans were fed.

Antibiotic sensistivity test not done.

POST OP
Stone analysis pending.
Oral Baytril 2 days, trimax bid x 10 days
S/D given but owner fed only 2/3 can per day instead of 1 and 1/2 or more.

OUTCOME
Dog active, no blood in the urine. Owner is happy.
Need to follow up to ensure compliance with C/D diet and check of urine for UTI and pH = 6.2 to 6.4.
It is time-consuming to follow up but owners don't comply and recurrence due to certain breed can recur again.

PHONED OWNER 10.35AM
1. Switch to dry C/D
2. Give 1 and 1/2 can of S/D per day for 20 kg bulldog till the switch to C/D.
2. No home-cooked rice or vegetables for at least next 6 months 
3. Urine analysis every month.

Whether she will comply is up to her.

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X-rays in the previous first report: Blog No. 1186
is at:
http://2010vets.blogspot.sg/2012/11/1186-haematuria-in-british-bulldog.html and the report is reproduced below:


Monday, November 19, 2012


1186. Haematuria in a British bulldog. Durian seed, bladder stone or a botched up spay?

"Could it be a durian seed? My dog rushed and swallowed one yesterday, before I could stop her," the be-spectacled woman in her late 40s was not fully convinced that the X-ray showed a big bladder stone in the ventral dorsal view was really a bladder stone. Her 4-year-old spayed female British bulldog had peed blood in the urine for the past 2 days.



"There is a lot of food in the stomach and intestines," I said. "It is hard to see the durian seed. Definitely, the stone is a large bladder stone. Have you been feeding dry dog food for the past 4 years?"



"No, I stopped after she was over one year old because the other vet advised me to feed home-cooked food to resolve the skin disease problem. I only gave her the dry food in the last 2 days when she passed blood in the urine. Could it be a botched spay operation done by Vet 1 when she was one year old? When she passed urine, I could see the blood in the urine."



"If the spay had not been well done, the dog would be passing blood without any urine every 6-monthly. The blood would not just be present together with the urination." I said.



"I do not see such occurrences," she said. "How about the durian seed? I forgot to tell Dr Daniel about it earlier."



"There may be a durian seed but it is not seen in the X-ray," I said. "The big mass is the bladder stone in the bladder."



I advised antibiotics for 3 days before surgery. The owner brought her trolley and dumped her Bulldog upright inside it and took her home today. The urine analysis and blood test results are pending.

SEE ABOVE CASE REPORT FOR DEC 2012 FOLLOW UP

1201. Sunday Dec 2, 2012's interesting cases

Sunday Dec 2, 2012
A bright sunny Sunday morning. Yesterday, a hamster with a "quail-egg sized" swelling in the right pouch area was admitted by Dr Jason and referred to me. Before I left the  surgery and handing over to Dr Jason, I saw a family bringing in a hamster.

I told him that tumours in hamsters should be passed to me if he does not want to operate to remove them. Giving medication would not reduce the big tumours.  Some could be abscesses but they had to be lanced. This is the correct approach.

Mr Min showed me the dwarf hamster, 2 years old, male. He had the biggest ovoid lump as hard as a hard-boiled egg.  "It could be an impacted food pouch on the right side," I said to Dr Daniel. "It is quite common. A broken seed could have lacerated the pouch and all the food got stuck inside."

We gave the hamster isoflurane gas inside a bottle. The hamster felt  sleepy. I took a pair of forceps  to evacuate the contents inside the right food pouch. Nothing came out. The hamster protested as he woke up quite easily under gas. Suddenly his eyes popped out from the sockets. "Stop every procedure,"  I said. "Let  the hamster recover. Any handling may cause death."       

After 5 minutes, Dr Daniel commenced gas anaesthesia and surgery. "Use the smallest scalpel blade and make a 0.5-cm cut on the skin," I had earlier asked Mr Min to clip off the hair and clean the area.

"It's a red tumour," I saw a bulging swelling  under the skin. "Extend the incision to 1.5cm long and shell out the tumour. There is usually a large blood vessel supplying this tumour.  Clamp "

1201. Follow up: The kidney-stone Schnauzer vomits again when at home.

"Unless the kidney is removed, it is not possible to prevent infections of the blood and urinary tract system," I said to the owner who had taken the dog back. The dog had a high total white cell count, blood and bacteria in the urine again. She was on intensive ciprobaby (twice) IV at 50ml/time (100 ml bottle) and had recovered during the past 3 days.

But she vomited again when she went home yesterday.She was active and Ok in the day time.

1199. Customised trained security dog services

Dec 3, 2012

Today, I met a 60-year-old retiree who accompanied her teenaged daughter to bring the 9-year-old Shih Tzu to me for general check up and vaccination.

"I have to ask my dad first as he is paying for the tests," the daughter said to me when I advised a blood and urine test for her old dog as part of health screening and this was not done before.

The dog had dental scaling done by Dr Vanessa last year and the teeth are OK, with some tartar formation. This dog does not permit his mouth to be opened and he showed his warning fangs when I attempted later. "He is a good natured dog as long as you don't touch his mouth," the girl told me. "He trembles and shakes when there is lightning and thunderstorm. A vet told us to ignore him but we hold him."
"You are fortunate that this dog does not pace and go into a frenzy during thunderstorms and lightning. He just shivers. Maybe de-sen. sitation using thunderstorm audio may help, by letting him listen regularly. But you may need to duplicate the change in temperature and humidity during thunderstorms and this cannot be done."

So, there was no solution.

However, the father has been working as a security consultant part-time, doing training programmes from his home. "Does he supply trained military guard dogs?" I asked her.  "In Singapore, the system is to send staff from the police and army to Europe or USA to buy puppies and train them for narcotics and other duties by the local staff. The success rate is extremely poor. The staff has to travel far distances to see one or two puppies in various parts of Europe. I doubt the breeders really sell the good ones. Then, there is the allegation of staff corruption."

So, the girl's father could provide a niche service as his contacts in China can provide trained dogs according to the buyer's requirements. For example, if the Customs want 50 sniffler dogs, he can arrange for them to be delivered fully trained and tested by the Buyer. "This is a niche market," I said to the father.

"Not much business as Singapore and Malaysia don't buy many. A dog lasts 4 years and the Police may replace less than 10 per year."

"Well, this is a niche market to be developed by you since you have the training source and dogs in China," I said. "In the past, there is no such establishment and now you have the specialised dog training school, you can supply customised-trained dogs to anybody. Not only the army or the military. For example, a rich father may wish to get a guide dog for his blind child. This will be your niche market. You need to start your own company rather than use the present security company and build up your credibility and services."
The father could see the prospects. Whether he would be able to execute my idea, that is the million-dollar question. "It is more than 50% of the problems solved," I replied when he said that he already got the source of dog training school and the good relationship with the people there. "Very few if any Singaporean or Malaysian has this type of contact."  Retirees in security business for many years have a large number of contacts if they know how to network with them to start a new business.
      

1198. A mother's sacrifice

Nov 30, 2012 was the last day of work for Dr Vanessa. I wished her well in her new venture as I had expected that she would be her own boss. She gave me a piece of chocolate cake to celebrate her birthday.

I had promised to send a Jack Russell with skin disease home at Lorong 8 Toa Payoh after treatment and clipping for skin itchiness. The domestic worker would wait at the first floor of the HDB block to take over the dog. I asked my intern (a young man in junior college year one) to put the dog in a crate. Min helped him. The owner had to go overseas and so I volunteered to send the dog back after grooming and bathing for the skin disease.

"It is the wrong dog," Dr Daniel phoned me. "There are 3 Jack Russells in the crates and you have got the one with the bladder stone."
Just a few days ago, the Kandang Kerbau Hospital had given the wrong babies to two mothers. One of the ankle name tags had fallen off and so the baby was given to the wrong mother. One of the two mothers discovered the mistake and there was needless worries and DNA checks.  The private hospitals use RFID tags and so had no problem.   

I may need to use RFID tags to identify the dogs but this would not be necessary as I don't have more than 10 dogs. Somehow, Min had given me the wrong dog. I asked the domestic worker to get permission from her employer to go back with me in the car to get the dog as the dog would bite. She got the permission via her phone and we went back to the Surgery to get the dogs.

"How long have you worked for the same employer?" I asked her.
"Twelve years," she surprised me as most workers don't stay more than 2 years.
"My employer is good," she said. "The dog is obedient too as he does not lick my face. He would look the other way. My religion does not permit me to touch dog saliva."     
She walked the dog but does not feed him medication.
"Why do you work so many years?" I asked.
"To earn money for my children's education. My daughter is now grown up and is married. She will never be working as a maid like me."
Many maids made great sacrifices being away from families and going home 4 weeks every two years.so that the progeny can have a much better life.
 
  

1197. Three teeth in a one-year-old dwarf hamster

Saturday Dec 1, 2012

The hamster with the swollen upper nose came back as she could not gnaw seeds. 4 days ago, Dr Daniel had incised the upper right area of the nose, draining the pus. Now, the lower right area of the nose below the right nostril had become more swollen. "The right nostril is bigger in diameter than the left," I said as the gentleman owner had complained that the hamster had sniffling sounds.

The hamster's upper right area was slightly swollen after drainage of the abscess. It took one month for the abscess to ripen and it was lanced 4 days ago on Nov 27, 2012. The lower right upper area had shown on pimple but was mainly hard as a rock. So, there was no point cutting it as it was not "ripe" meaning that the abscess had not come to a head.

The hamster squeaked when I tried to open the mouth with forceps but othewise was "sleepy" when hand-held by the girlfriend for me to take images of the inflamed area to document the condition. There would be another 4 days before this area would ripen and pus could be released. I scheduled Dec 4, 2012 to operate.

This hamster has only 3 teeth instead of 4. One right upper incisor and two lower incisor teeth with a gap between them.
"Was he born with 3 teeth?" I asked the gentlema as the hamster's front teeth grow continuously unlike human teeth. So a fractured one would grow back and the hamster wears out the teeth by gnawing and eating seeds..
"He had four teeth," he said.
"You dropped him when he was young," the girlfriend said.
Presently the hamster gained 5 g, from 40 g some 4 days ago after lancing the abscess. He would eat the bananna paste and loved the green jelly but could not chew on seeds or pellets for the past 4 days. So that was why the couple consulted me.
"He used to be 60 g," the man said.
"Once the abscess in the lower right area of the right nostril is soft and lanced, he will put on weight, befitting his name of "Ah Pui" (Fatty in the Hokkien dialect).