Referral is best but the vet must deliver

TOA PAYOH VETS toapayohvets.com Date: 11 January, 2013 Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits Referral is best but the vet must deliver Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS First written: 9 January 2013Date: 11 January, 2013 toapayohvets.com Be Kind To Pets Veterinary Education Project 2010-0129 Wednesday, January 9, 2013 The 14-year-old Burmese has 3 large abscessed mammary glands Yesterday, Wednesday Jan 9, 2013, I phoned the gentleman to follow up on a hissing 14-year-old Burmese cat brought in on last Saturday and advised by Dr Jason Teo to operate. So on Sunday, Jan 6, 2013, I phoned the owner to tell him the high risks involved. "Your cat may just die on the operating table," I said. "She has fever and infections of the ulcerated breast lumps - half as big as fish balls and very smelly." "I will ask my mum first," he later phoned me to give consent. I decided to get the cat operated on Sunday, 24 hours after admission and after antibiotic injections given. The cat was angry and so she was still in good "health" for one with such smelly mammary ulcers. Dr Daniel would operate. This needed to be a fast operation. The problem was the dosage of anaesthesia. How much that would be effective and not kill the old dame? "Give xylazine 0.1 and ketamine 0.4 ml IM," I said to Dr Daniel. Clip the hair and bathe the cat after sedation as this is an angry cat." Dr Daniel had used electro-excision to remove the 3 tumours. I had one young lady intern with top academic results waiting to study vet in Australia. She put a finger to cover her nose. I was surprised. "My father is house-proud," she said when I asked whether she lived in a fragrant household with aromatherapy. Definitely no smells of infection and sick animals. "Not cutting well," Dr Daniel said as the long elliptical incision of the skin to remove all 3 tumours by the needle electrode did not seem to be effective. "Well, the contact with the skin of the inguinal area is not there," I pressed the soaked saline gauze and folded the return plate so as to close the circuit for the electricity to cut through and return back to the equipment. Mr Min was monitoring the gaseous anaesthesia and he was good at this. AN INTERN CAN'T STAND THE SMELLS The young intern was really feeling nauseous as the wisps of smoke on flesh and the putrefying smell of the ulcerated mammary glands filled the operating room air. "You better go outside," I wondered how she would be able to pass out as a vet. The next day she wore a mask. Another day, she wore one glove when she handled a skin-diseased dog so as not to infect her own cat. She would wash her hands after touching a dog and her mum would remind her. "I can be a hygienic vet," she said to me. Top grades from a top class in a top school and money of $300,000 or more to fund her veterinary studies- what more does a 19-year-old scholar desire? I did not expect this 14-year-old cat to survive the anaesthesia. She was thin. She was bright 12 hours after surgery after fluid therapy and antibiotics and pain-killers. I phoned the son to take her home as cats usually don't eat at the surgery. As a follow up with trepidation, expecting bad news, I phoned the owner yesterday which was Jan 8, 2013 at 5 pm. "My cat is very active. Eats a lot. Walk here and there! My mum is very happy as the cat was not eating." "Did she lick the stitches?" I asked. "She has an e-collar and could not lick." Actually it was the tolfedine pain-killers that made her so normal post op. "How did you give her the tablet medicine?" I asked. "Just crush the tablet and mix it inside her food - canned food. No problem." CATERWAULING As this cat was never spayed, I enquired how he coped with angry loud meowing which could be misconstrued as beating up the cat in some cases of caterwauling. "No problem of noise nuisance due to her being 'bising' (noisy)," he said. "Does she still do it? At this age? " "She does it 3-4 X per year. But not nosily." PRE-OP CONDITION I asked about the cat before op as this was a first-timer and Dr Teo was consulted. I worked from 9 am to 11 am on Saturdays usually and the client came later. "Day by day, she lost appetite," the son related the history of his cat during this follow-up call. "She became very weak. My mother wanted the cat to be cured but at the same time did not want to lose the cat (to death on the operating table). Yet my cat will suffer more if no operation is done." "How long were the lumps present?' "The lumps were small some weeks ago but started to grow bigger and bigger recently," the owner said. According to the operating surgeon, these could be abscesses. To save money for the owner, no lumps were sent to the laboratory for histology to check whether they were breast cancers or not. The owner confirmed that he had this cat as a kitten and therefore she was 14 years old. STITCH OUT IN 14 DAYS I advised stitch out in 14 days as most cat owners don't come and the knots get buried into the skin and cause stitch abscess and irritation to the cat some months later. The Monosyn stitches used look like nylon and are absorbable.. REFERRAL He lived in Tampines, near the Changi Airport. This is a 15-minute drive to Toa Payoh Vets and there are several vet clinics closer to him. "Why did you come to Toa Payoh Vets when there are vets nearby?" I asked this filial son. "My friends in Bedok refer you to me." I guess these friends were the two Malay ladies with cats that I had vaccinated some weeks ago as I seldom have any clients from Bedok. Proximity is the choice of pet owners as most Singaporeans are time-pressed and so the majority of clientele for me would be around a 5-minute drive to Toa Payoh Vets. Referral is best as the client trust is there. But the veterinary surgeon must deliver. Nothing less than a live 14-year-old cat at the end of surgery and being alert and hungry at home after surgery. Essentially, this means assessing the anaesthetic risks such that the minimal dose is given without killing the cat. How do you do it? This depends on the good judgment of the individual vet. In this case, Dr Daniel asked me and I judged that this 4-kg Burmese cat should be given xylazine 0.1 ml and Ketamine 0.4 ml IM and it was effective and safe. "Do a fast surgery in an old cat," I advised. "Electro-excise the 3 big lumps as fast as possible. Ligate the main vessels. There were no big blood vessels to ligate as I expected some from the caudal superficial blood vessels. Perhaps the tumours were necrotic and septic and the blood supply was being terminated or damaged. UPDATE AS AT JAN 11, 2013 As at Friday, Jan 11, 2013, no news from the owner. In this case, no news is good news.   Some problem with blogger.com's alignment of text. URL is at: http://www.kongyuensing.com/folder7/20130110burmese_cat_breast_tumours_toapayohvets.htm     A case study of recurring urolithiasis in a Miniature Schnauzer - Struvites Video: Kidney & bladder stones More info of interesting case studies at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

1236. Not recognised vet degree

Nobody can "influence" the AVA on your behalf unless you are the son of a big important person, things may be reviewed again. That is a fact of life.

I have given your resume to an employment agent. It is NOT possible for you to be a vet in Singapore due to AVA's licensing requirements of accredited vet universities for practising vets and your degree is not recognised by the AVA. .

But if you are flexible, you may get other industry jobs or even in Yangon. But the pay is not what you expected and if you are agreeable, you may get a job e.g. in a vet pharmaceutical company that is looking for a vet to provide after-sales services for its veterinary products to vets in Singapore and the region..

I am really sad that you are in this situation but life is full of ups and downs. Whether you can be resilient or not, it is up to you.

House-call to vaccinate 2 cats

On Tue, Jan 8, 2013 at 8:37 AM, Daniei@gmail.com> wrote:

Hi.  I live near Orchard and my two cats need their annual
vaccinations.  Can you tell me how much it would cost to get these
vaccinations done via a house call?

Thanks,
Dan

 Thank you for your email. House-call will be $250 and 2 vaccinations will be $70. Total $320.

1234. Anaesthetic risks for the young rabbit and the old cat

Jan 8, 2013

Recently Dr Daniel and I had 2 cases of high anaesthetic risks - the very young and the very old patient. Every vet will inform the owner of the high risks. Invariably, the owner would not want the operation. So, the disease progresses as in the following cases:

Case 1. Rabbit, F, 3.5 months
The lady bought 2 siblings at 1 month old at Farm Mart which is in Chua Chu Kang. This patient had a twisted leg but the appetite was "good." Over the next 2.5 months, her sibling doubled in size while this rabbit started to hide in a corner.

"She refused to move as she grows older," the lady had phoned me for the fees for amputation. "The two vets in the same practice wanted to charge $1,000 to cut off the leg. I have already spent over $1,000 treating this rabbit!"
"I have to examine the rabbit in order to quote you," I said. "If the surgery is short, the fees are lower."
The lady came while I was out. Dr Daniel advised amputation. "She wanted to try TCM (traditional chinese medicine)," Dr Daniel said when I asked why he had bandaged the leg.

I spoke to the owner as she was paying the bills after consultation with Dr Daniel and not accepting amputation as the medical advice. The rabbit's leg had swollen at least 3 times and multiple yellow abscesses flowered inside the leg. "Do you know that this rabbit's life is endangered as his leg will become gangrenous and septic, spreading bacteria to her whole body and killing her? I have already given you a below cost fee to amputate her twisted leg. Yet you want to try TCM."

"I tried TCM in the sibling which was similarly lame and he recovered," she said.
"The sibling did not have the same condition of fractured lowered leg that became twisted and infected," I had not seen the sibling but it is highly improbable that both siblings suffered fractured legs. The sibling was probably weak in his hind limbs but the fact is that he is a thriving rabbit, double the size now.

1232. 2 years and 2 months old hamster with breast tumour

Dec 31, 2012
Last hamster case of the year.
"I still have to pay for cremation if the hamster dies on the op table?" the mother asked me about the chances of survival if I operated on her dwarf hamster with an infected black-scabbed leaking pus breast tumour below the neck.
"Yes, you need to pay or you can bury the hamster yourself," I noted that the hamster was alert and had passed several stools indicating he was eating.

"How long more can he live?" the mother asked me.
"Normally, dwarf hamsters live up to 2.5 to 3 years," I said.
"He is now 2 years and 2 months," the mother calculated that it was not worth the $200 to operate and stitch the tumour.
"One month of the dwarf hamster's life is equivalent to 2 years of the Singaporean human life," I said. "If he survives the surgery, he could live, provided the tumour does not come back again." The mother had waited 2 months before her daughter asked her to send him to Toa Payoh Vets for surgery. She could not decide what to do now. "I phone my daughter," she said. "He is her pet.". Her daughter would not decide in view of the high risks of death on the operation table. Finally her her husband said to proceed,

HOW MUCH ANAESTHETIC TO USE?
"Isoflurane gas will not give sufficient time to operate," Dr Daniel said to me.
"This is correct," I said. "Zoletil injection by IM will give you 60 seconds of operating time if the dosage is just right."
How much to give? This is where the judgment and experience comes in. Too little, the hamster needs top up with isoflurane gas to sleep. Too much, he dies.
"This is a very old dwarf hamster," I said. "His body weight is 54 g which is good sized. He is alert and eating and that is good. But he is aged and so the Zoletil dosage should be reduced so that the hamster is alive at the end of the operation."

The theory is easy. The practice is not. How much of Zoletil 50 to give by IM?
Dr Daniel decided on 2 drops which I approved. "They must be full drops," I said as I saw Mr Min's hand trembling as he held the 1-ml syringe to draw out Zoletil drops from Dr Daniel's 1-ml syringe.
"Hey, your hands are shaking!" I said to Min. "Shaky hands cannot be a surgeon! Rest your elbows on the op table to stabilise the syringe."

Dr Daniel injected IM. The hamster has very little muscle and so the needle must just get into the muscle and this can be difficult to assess. Practice makes perfect. "There is so blood on the operating cloth," Dr Daniel said after his injection. "Unusual to see it," I had never encountered such a situation. "It could be from the muscles after injection."

Soon the hamster felt sleepy. I asked Intern Gina to video this case study. The tumour was excised. Lots of yellow pus inside the tumour which was 1.5x1x1 cm globular in size which black scabs. The skin was excised and undermined. The tumour was cut off from the clamped area. Skin was stitched with 6/0 absorable sutures.

It was most likely a malignant tumour which was put nside a plastic bag for the owner to see. The hamster went home alive and that was what the owner wanted. Now, there was another subcut lump near the left inguinal area. "Never operate on two tumours at one time," I said to Dr Daniel. "The hamster will die as op time has been too long." So we left the other tumour  of around 0.8x0.8 x 0.5 cm alone. This was New Year's eve and the famiily wanted the hamster home to celebrate life and a new year.      
  

1231. Hong Kong Dec 24-27 2012 stories & images

Hong Kong is a fascinating place to visit and for street photography if you look further than its shopping centres and its good food.

Up to Nov 2012, Hong Kong has 44 million visitors, up 16% from the same period last year, according to the Hong Kong Tourism Board. That means more revenue to Hong Kong's retailers, government and people.

Here are my observations on how Hong Kong has become more progressive:
1. Excellent communications with passengers.
Cathay Pacific Airlines staff would communicate their feedback to the passenger before the passenger leaves the plane. For some reason, I was given a feedback form and so I said that the "bacon and eggs" were of poor quality in that the bacon was not "real" bacon. It looked like ground meat with an even layer of fat in between. This roll would then be sliced to give the appearance of bacon. The English bacon and eggs will be the standard if the traveller knows it and so it was a poor quality breakfast. The manager told me she would speak to the food side. So this was immediate feedback on complaints. The overhead light was not working. One crew said I should have told her so that I could change seats or she could "reset" the light. Why not check before flying? This flight was an old Airbus (brushes like thick eyebrows seen at the emergency exit door for disarming or arming the door). The inflight stereo phone set had one plug instead of the usual two and so the adaptor for the head phone could not be used. Regional flights' passengers get poorer facilities.

2. Survey on efficiency
Wait times at the Immigration. There was a person who gave me an electronic counter at the start of the queue and at the end of the queue, I was to return the counter. There was a message saying that the waiting times are being surveyed. This would be good for feedback on management and be useful for any organisation interested in cutting down the waiting times.

3. Interest of the organisation in service staff
On Dec 25, I went to Peking Garden Restaurant for dinner. No prior booking. I was about to leave but the gentleman in charge said that I could eat if I could leave by 7 pm. It was 5.45 pm then. So, he was a flexible manager able to add revenue to his employer. I did not order the famous Peking duck as it was too big for me. The fish was great.

On Dec 27, I wanted to eat at Din Dang Fong near Regal Hotel Hong Kong. It was jammed packed with lunch people.  "It will only take a few minutes," the waitress said as I handed back the queue number. She had the interest of the organisation at heart as she could have not bothered. It seemed that F&B staff is highly motivated to increase the revenue for the company.
3. High rentals keep increasing.
Dec 24, 2012. I had dinner at the Sweet Dynasty Restaurant in Canton Street. The last day for the operator as the rentals were too high and the famous restaurant had relocated to Causeway Bay. "An Apple store" will be opening, according to one Langham Hotel staff.

Canton Street looks much like Orchard Road, only busier. It was closed to traffic on Christmas eve and there was a band playing. Crowds of few thousands stream from the subway and there was crowd control. Nothing like this in Singapore's Orchard Road on Christmas eve.

I saw some policemen towing away a scooter parked outside the shops on Haiphong Road near Canton Road at 5 pm. Serious business in crowd control. A few hundred thousands I would estimate for that Christmas Eve night.

4. Use of IT.
Hong Kong Tourism Board equips its staff with iPad at the branch outlets. More efficient as no staff can remember all info. The lady checked out opening times of Peking Garden Restaurant and location using her iPad. This was efficient and fast.

1230. Posting to facebook of Stanley Veterinary Centre

Dec 30, 2012 From Singapore to Ms Rachel Woo with thanks
I am Dr Sing Kong Yuen, a veterinary surgeon from Toa Payoh Vets, (www.toapayohvets.com) Singapore. 

1230. Posting to facebook of Stanley Veterinary Centre

On Dec 27, 2012, I took a train and taxi to visit Stanley Veterinary Centre and was most impressed with its well designed layout and facilities and the friendly staff.
I write to say thank you to Ms Rachel Woo, Clinic Manager for her time and sharing of her vast knowledge of the various aspects of  practice management and veterinary medicine and the use of MRIs in Hong Kong. Hong Kong's veterinary services including SPCA's veterinary services appear to me to be most fascinating for closet writers, and more advanced at the MRI level compared to Singapore presently from my conversations with Ms Woo.    

On the way, I was shocked to see a mini-bus advertising a veterinary clinic ("Veterinary Light??) but before I could snap an image to prove that vets are allowed to advertise on buses, my taxi driver had zoomed downhill towards Stanley Village.

Could this be the new kid in Stanley Village, Ms Woo?
In Singapore, bus adverts by vets are prohibited and so I was much surprised to see one in Hong Kong. Ms Woo says they are permitted in Hong Kong.  
I wish Ms Rachel Woo all the best in the years to come Happy New Year. Keep up your good spirits

1229. Veterinary matters in Hong Kong - visit to HK on Dec 27, 2012

Dec 28, 2012  5.50 pm

I visited Stanley Veterinary Centre yesterday 11 am to 12 noon. It is a well designed basement clinic as no space is wasted for veterinary use.

Three consultation rooms, 1 cardiology cum ultrasound room, one operating room, one dental area, one X-ray area, one laboratory, one pantry, one office cum pantry and one room for the boss. I like the elevator which is reserved only for large dogs with some diabilities. A very nice place to work. The hours are incredible good.

"No for people or dog owners? I asked the Manager Rachel who told me that Hongkongers love their pets very much.
"No, no," Rachel said.  I was most surprised. Lifts are expensive to build and to maintain and this is a good idea.

1228. Two videos produced by an intern - Urolithiasis &

By just being an observer is not good for the interns.
Interns learn better when they are hands on and do research as shown by the two videos:

Urolithiasis
http://www.youtube.com/watch?v=x6K4z3VtaXY&feature=youtu.be

Hamster tumours

http://www.youtube.com/watch?v=W4tSj8ubAyQ&feature=youtu.be


It takes a lot of time to mentor the interns and there is much editing and time of over several hours involved just to produce the two videos. The videos are not perfect but these are excellent ones produced by the young man.

Old female rabbit has "breast" tumours

	Dec 28, 2012  4.57 pm. Spoke to owner who wanted a second opinion. The vet had taken a biopsy, checked under the microscope and had diagnosed tumour. Anaesthetic consent form needed to be signed and as the rabbit is 10 years old, the owner is worried. As to the $1,000 veterinary costs, I explained that much depends on the surgery time, blood tests and histopathology tests and any other medication that the vet would do and the costs could add up. The vet had lanced the "infected tumour" and the rabbit stopped eating after being fed some medication. However, it was active and eating when medication was stopped. I advised review and if the tumours were small, the surgical costs  would be much lower. Will see him tomorrow 9.30 am. ----------- Dec 27 (1 day ago)
to me

 

Hi Doc, 3 years ago I brought my rabbit to your clinic to clear matted fur. Now I want to bring it to you for medical attention again. Rabbit was diagnosed to have 2 cancerous small breast tumours about 2 cm. I need your opinion and about how much for the surgery ? The young unexperienced vet nearby my house quoted 800 to 1k !!!! Also,when is the earliest appointment I can make with you? Regards     --- On Wed, 3/6/09, Kong Yuen Sing <99pups@gmail.com> wrote: From: Kong Yuen Sing <99pups@gmail.com> Subject: Re: Enquiry on Rabbit To: "A...> Date: Wednesday, 3 June, 2009, 6:14 PM Thank you. Will see you tomorrow. On Wed, Jun 3, 2009 at 4:10 PM, A...> wrote: I just called up your clinic to make appointment for tomorro 3pm. Thanks for your prompt reply. Kind Regards --- On Wed, 3/6/09, Kong Yuen Sing <99pups@gmail.com> wrote: From: Kong Yuen Sing <99pups@gmail.com> Subject: Re: Enquiry on Rabbit To: "A...> Date: Wednesday, 3 June, 2009, 3:06 PM Estimated cost including anaesthetic, cleaning, dematting and antibiotics, bathing and exam is around $150. Staying for 2 days is $20.00 Pl tel for appointment at 6254 3326. On Wed, Jun 3, 2009 at 2:17 PM, A...> wrote: --- Message --- I have a 4 yrs old female rabbit which has thick hardened clumps of matted furs at bottom area, may i kn do you provide shave down and checkup service? What is the approx cost and earliest appointment available? Thank you