1098. Dicom software to read certain digital X-Ray images & 2 tips

TOA PAYOH VETS toapayohvets.com Date:   27 August, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits   Two tips for urinary stone X-rays of dogs   Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   27 August, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129   Blood in the urine may be a sign of bladder stones. A urine test and X-rays of the bladder and kidneys should be advised and this was done by the other vet. A good practice is to use air-contrast X-ray of the bladder as it is more troublesome, esp. in the female dog as she has to be catheterized. The bladder needed to be emptied via the urinary catheter.   6339-6340. Struvites stones in a Golden Retriever. 3 X-rays were taken - 2 lateral views and one ventro-dorsal view. This lateral view (left) shows the stones inside the bladder.    In this young Golden Retriever , urine tests show lots of struvite crystals were performed by another practice. The owner was given the CD containing 3 X-rays. The CD does not have the specific software to automatically download the images. There are two ways of sourcing this software. Downloaded one from the internet or get it from the supplier of the machine. The software is at: http://www.microdicom.com/ I noted that 3 X-rays were needed to be taken as the struvite bladder stones can be seen in only one of the two lateral views.  Another good tip is to palpate the bladder before X-rays. If the bladder is full, get the dog out to the grass to pee. Or catheterise the dog to empty the bladder to get good views of bladder stones. Otherwise, there is a need to take another X-ray if the full bladder obstructs any views of smaller stones. FOR THE BENEFIT OF OTHER VETS WHO MAY ENCOUNTER PROBLEMS DOWNLOADING DIGITAL IMAGES OF THE DICOM-TYPE , THE FOLLOWING INFO IS PROVIDED: http://2010vets.blogspot.sg/2013/08/medical-imaging-software.html   Updates will be on this webpage: www.sinpets.com/F6/20130827dicom_X_rays.htm   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: August 27, 2013 Toa Payoh Vets

Medical imaging software

Clients are given a CD of the digital X-rays. However, some cannot read the X-rays as there is a need to get a specific software to be downloaded. There are free software to do this. However, the supplier has the links and one of them is as follows:

Kind Attn : Dr. Sing Kong Yuen

Dear Sir,

Please click on this link :  http://www.microdicom.com/

Once you are on this site, you can download the MicroDICOM software for free.

When this software is installed on your computer, whenever you open any DICOM file, it will open with this software automatically.

If not, you will be prompted with a message like the one below , at that time select MicroDICOM

On this screen you can check the box at the bottom which says “Always use the selected program to open this kind of file” and in future all DICOM files will be opened automatically with this program

When a DICOM image is opened with this program, you will see a screen like the example below (this is for an MRI image) and you can use the tools shown on the screen.

Please feel free to call me if you need any further assistance

Assuring you of our best attention at all times.

1097. Script for intern - closed pyometra & uterine torsion in a very old Maltese

TOA PAYOH VETS toapayohvets.com Date:   26 August, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits   A Risky Surgery - Closed Pyometra & Uterine Torsion in a very old Maltese   Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   26 August, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129   Script for Intern 1.  HOOK: Video: Titled August 20, 2013, First Consultation at Toa Payoh Vets A very old dog - 15 years old, Maltese, Female                           Large swollen abdomen. Not eating. "My dog has been gaining weight in the past 7 days," the slim lady owner in her late 50s said. "I could feel that she is heavier than before. After grooming, I saw a big lump on her left abdomen. She is not interesting in eating. What's wrong with her?" Images of left & right side views, top view 2. OBJECTIVE OF VIDEO:  A "Be Kind To Pets" Vet educational video slide. 3. INTRODUCTION   August 20, 2013 Diagnosis: "Is she a spayed female dog?" I asked as many Singapore dog owners doctor-hop. My medical records showed 3 incidents of false pregnancy and advices to spay the dog went unheeded. "She is my daughter's dog but now I have taken over. Over the years, my daughter did not think of spaying the dog," the mother said. "When was the last heat?" I noted that this dog would have false pregnancy around August in the previous 3 episodes in the years I saw her during vaccination. "None at all," the mother said. "She is so old and should be in menopause." I palpated the large abdomen. The left side protruded a giant "sausage-like" mass which was painful. The dog her head turned to bite me. "Your dog suffers from closed pyometra," I said quite confidently.  "The cervix had closed and so the pus and bacteria accumulated inside the womb, causing such a large swelling. The only solution is to operate to remove the womb which is now swollen with pus."  CONFLICT 1 - Highly Risky Surgery "My dog is so old. I don't want her to die on the operating table. Isn't there medication to cure her?" "Antibiotics will give temporary relief for a few days," I said. "Your dog's health will deteriorate and she will die soon as the toxins spread to her whole body or the swollen uterus ruptures spilling out pus into her abdomen. Therefore, you have no choice but to get her operated." CONFLICT 2 - Financial costs of tests for heartlanders "Are you sure of your diagnosis?" she asked. "Nearly 100%. To save you money, I have not recommended an X-ray and blood tests which will add around $300 to the medical costs. However, if you want them done, I will do it." The owner wanted the tests done. X-Rays images x 2. The left swollen uterine horn can be seen (arrows). Blood test image. No increase in total white cell count but the neutrophils have increased. CONFLICT 3 - Chances of Death on the operating table. A very old Maltese at 15 years equivalent to a 105-year-old woman. The blood test showed a very low creatinine level indicating that the kidney function was not normal. So anaesthesia could be fatal. "Less than 50% chances," I said to the owner.  CONFLICT 4 - Procrastination of the owner. The owner is very fond of this dog and so could not decide. The daughter had her own family and so this dog is her companion. A highly risky surgery could mean death.  She is from the baby-boomer generation that usually does not bother to do research on the internet for "closed pyometra." So she did not know that time is of the essence and any delay will lead to toxic damage to the kidneys and death from kidney. failure. "My dog started eating after your antibiotics," she said when I followed up to ask her to operate. It seems like hard-sell but it is in the interest of the dog and the owner. When vomiting from kidney failure starts, the owner will ask for the operation but then it will be too late. CONFLICT 5 - Reputation of the veterinary surgery and vet.  Deaths on the operating table are extremely emotional events for the owner and the younger family members nowadays. Some owners post adverse comments on the internet forum when such incidents happen asking others to avoid the practice. The owner came on August 21, 2013 for the surgery. A bright sunny day. "This high risky surgery is not one I look forward to and it must be done speedily," I told the owner. "Ask Dr Daniel to do it," she said. "I will do it myself," I said to her. Old dogs do die on the operating table in all veterinary practices and I had my encounters. I hope that this old dog will not.  A positive mental attitude cannot overcome any weak old canine heart that may fail under anaesthesia..  CONFLICT 6 - A complicated surgery prolongs anaesthesia. 1. The left uterine horn has twisted (uterine torsion). ILLUSTRATIONS 2. Red blood was present in the abdomen (haemoabdomen) indicating rupture of blood vessels. ILLUSTRATIONS 3. Adhesions of the omental fat to the left uterine horn wrapping around the uterus and connecting to the spleen, stomach and kidneys. This was unexpected as this was my first case of uterine torsion seen in my over 30 years of practice.  ILLUSTRATIONS   All my past cases were over the last 30 years of practice were just swollen uterine bodies full of pus. IMAGES OF 6 CASES OF CLOSED PYOMETRA WITH NO UTERINE TORSION IN OTHER DOGS Reference: http://www.bekindtopets.com/animals/20081201PG4_ Dog_Surgery_Anaesthesia_Female_Dog_Problems_ ToaPayohVets.htm So, I expected this to be a routine surgery. I only had to be speedy and should complete the surgery in less than 30 minutes. When I opened the abdomen, a gigantic kidney-shaped "sausage" - the biggest you can find in the supermarket, popped out. IMAGES OF REAL GERMAN SAUSAGES & VIDEO CLIPS OF SURGERY CONCLUSION Speed, Accuracy & Completeness are 3 important factors in any surgery. In old dogs, time is of the essence as the old dog can die of heart failure as the anaesthesia is prolonged. This surgery from the inhalation of isoflurane + oxygen gas to last stitch took 68 minutes for a surgeon with over 30 years of experience. It could be done in around 50 minutes if there were no complications of uterine torsion. In this rare case, I had to figure out what to do. The best would be to look for the cervical area and ligate it as the uterine body was also twisted.  This case has a happy ending. The dog was hospitalised for 7 days as requested by the owner. She ate canned food on day 2 after surgery. Not all similar cases end happily. My best advice is to get your female dog spayed when she is young and healthy to avoid highly emotional stress when closed pyometra occurs.          First consultation X-ray X-ray confirms Blood test & uterine torsion illustration Gigantic kidney-shaped twisted left uterine horn  View of left uterine horn torsion Omental fat adhered to left uterus proves torsion A heavy weight of toxic pus is removed IV drip video Post-op video of dog on Aug 26, 2013 Illustrations of haemoabdomen Surgery stitches image Updates will be on this webpage: www.sinpets.com/F5/20130826closed_pyometra _uterine_torsion_old_Maltese.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: August 26, 2013 Toa Payoh Vets

Uterine torsion & closed pyometra - images

1095. A clean slate - What makes a good intern

TOA PAYOH VETS toapayohvets.com Date:   24 August, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits   What makes a good intern   Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   24 August, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129   DRAFT Be prepared to change your mindset from academia to industry's expectations Time is precious Do research on the company and its internship work. See past videos done by previous interns and improve on them kongyuensing.com/animals/20100609Educational _Vet_Videos_ToaPayohVets.htm Reasons for making veterinary educational videos kongyuensing.com/animals/20130621educational_vet_video.htm Learn how to be a follower before you can become a leader. The younger generation of Singaporeans like to do it "their way" by ignoring instructions from the mentor. For example, in this case, I asked the intern not to use any material or images from the first video done (Ear abscess in the terrapin). He had forgotten to insert the abscess image. "Start on a fresh page, do not use any of the clips of the first video." When I followed up with his second video, he said he used part of the clips. This was time wasted. "How would I be able to trust you to do a good job if I have to worry about you ignoring instructions?" Be proactive. Can introduce new ideas on video production by speaking to the mentor. Copyright of images and work to be respected. Use pen and paper to discuss with your mentor. Time of mentor is short as the mentor has lots of things to do. Amendments to be written in the notebook. The two young men loved the google docs software to write the script but this is not practical for the mentor to wait while they make amendments.  The mentor has to wait. A print-out will enable the mentor to scribble amendments and discuss further. "The mentor keeps changing the script" was the complaint by the one intern. "This is because you are unable to grasp the essence of the topic and so cannot crystallise the mentor's thoughts directions into video production. In real life, you need to accept and adopt the senior's work instructions. This is good for your future career, promotions and other relationships. If you cannot be trusted to do what is legally required, you cannot be a productive team member. In the end, the mentor is responsible for the output."   Maximise the 8 hours to learn as much as possible. The interns must deliver results Make a small difference. Educational vet video helps to save lives of pets as You Tube permits those vets or pet owners less fortunate to be educated. Ignoring instructions from the teacher affects future internships Not bringing your own laptop to work. "A laptop's battery not functioning is a lame excuse. You can always plug direct to the electrical point at the Surgery." . Taking long dinners with friends is what some other interns did. Taking hours off to do other matters Industry experience broadens the mind  Self-motivated to excel in any project you do. Be meticulous about records and Credits. Be a "Tan Chia". This is Hokkien slang for being "on the ball. Bring your tools to work and that means the laptops." The 4 RI interns from Sec 4 did not bring laptops to the Surgery. The reason was that the laptops were heavy. This is despite being told to do so by their teachers. It seems they want to test the boundaries.  Save a copy as you work. No excuses. The revised ear abscess in the terrapin video could not be viewed by me as there were some technical faults according to the intern. "Did you do a back up copy?" I asked. He did not. So, the time for me to review it was wasted. Internship tips How to be an effective intern? In real life, give what the mentor/supervisor wants for work performance. Deliver results whether for promotion or other bigger bonus or for personal satisfaction of doing your best.  CASE STUDY 1. An example of a good video. Like a good novel, page turner.http://www.youtube.com/watch?v=tmTYP8T95V4 Kennel cough in a puppy. 3-day internship by 2 Sec 3 St Andrew's students. I gave them the script in a draft and left the clinic for them to produce the video. Dialogue. Diagnosis & Treatment. Prevention. Acting is natural. Good editing is the key to success. Using the key to lock the Mercedes car - not done nowadays.     Updates will be on this webpage: www.sinpets.com/F6/ 20130824internship_requirements.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: August 24, 2013 Toa Payoh Vets

1094. An X-ray salesman

Aug 20, 2013

The vet had booked an X-ray unit from a competitor at $80,000 with lots of freebies like 3 computers and printers. This vet drove a hard bargain. Then another firm came with better quality equipment from the USA. I was X-raying a cat at this practice and had a presentation. The equipment was better according to the salesperson. But this is one side of the story, the buyer vet said.

This case showed that the sales person must make visits to prospective clinics in a systematic way. 

1093. Script for intern: Abscess: Closed pyometra & uterine torsion in an old Maltese

Wednesday August 21, 2013 was a bright sunny morning with blue skies and white clouds unlike yesterday when there was haze from the burning and slashing smoke in the forests of Sumatra. (Video). 

The lady owner brought the 15-year-old Maltese with a large left abdominal swelling for around 7 days to Toa Payoh Vets for surgery.

She had wanted to wait till tomorrow as she was busy. "Any further delay will result in the Maltese being toxic and decreasing her chance of survival on the operating table. Your dog had started eating yesterday because she was given antibiotic injection on Monday and is on antibiotic medication. So she felt better but this is only a respite from a painful death from septicaemia and toxaemia

"Her health will deteriorate as the left swollen uterine body is over-distended with pus and is going to burst like a swollen dam if you procrastinate. It may rupture and spill toxic contents into the abdomen, killing the dog painfully (Video of dog at first consultation at Toa Payoh Vets on Monday August 20, 2013. Subtitled "First consultation on Monday Aug 20, 2013").

During the first consultation, the lady asked about the chances of survival during the anaesthesia and surgery. "Less than 50%," I estimated. "The dog may just die on the operating table. The blood test showed a very low creatinine level which means that the kidneys are not functioning normally (image blood collection and blood tubes). The dog is very old and the heart and blood vessels may be weak due to old age.

This informed consent of risks of anaesthesia caused the owner much concern for some reasons. "What am I supposed to do?" she asked me. "What will you advise? Your professional advice."

"You have no choice but to take the risk and operate. I had advise you to spay her when she was younger and had false pregnancy, this situation would not occur."
"She is my daughter's dog and so there was no decision to spay her. Now I am taking care of her."

The elderly slim lady had wanted proof that the dog was correctly diagnosed as closed pyometra and so I got X-rays done. These confirmed a large left uterine swelling (X-ray images) in addition to the blood test. The blood test did not show an abnormal increase in total white cell count as is common in pyometra but the neutrophils were higher (image of blood test report)), showing that the body was mobilising the anti-bacterial cells. 

The cervix had closed and so the pus was not discharged from the vagina (illustration). So the left uterine horn accumulated more and more pus, swelling to a formidable size of the largest sausage ever seen in the supermarket.  This is a case of closed pyometra and surgery to remove it is the only chance for her to recover." It seems like hard sell as I followed up with this owner whose dog had come for vaccination and dental work since 2005 (image of treatment).

Video of Singapore scenes as 2 days passed (Monday to Wednesday) as the owner could not decide.
The owner arrived at 11 am.
"To be frank with you, I don't like to do such surgeries," I said to the owner as I re-examined the dog. The dog wanted to bite when her abdomen was touched. This was very painful.
"It is such a high anaesthetic risk. The dog may just die in the middle of surgery possibly due to heart failure as she is equivalent to 105 years old person and the heart will not be that strong as a younger dog."

"This surgery needs to be completed very fast." I implied that a faster surgery would reduce the aneasthetic exposure duration and therefore lowering the risk of death. 

"Let Dr Daniel do it," the owner probably misconstrued that a fast operating surgeon is not good for her dog as surgery would not be complete. Speed, Accuracy & Completeness are essential for good surgery. But in this very old dog, speed is predominant. Of course, Accuracy & Completeness are also important. For a speedy surgery, an older vet will be speedier owing to more years of experience. So, I decided to do it.

SURGERY AND ANAESTHESIA
The old dog was an IV drip. Then she was given isoflurane + oxygen gas by mask. She was intubated. The surgery threw up some surprises as this was a case of closed pyometra and uterine torsion of the left uterine body. Images.

Haemoabdomen - This case - Red blood >300 ml was seen inside the abdomen when I made an insicion into the linea alba. Where's the source of bleeding?  "Peritonitis?" Dr Daniel said.

A brown kidney shaped structure 50% as big as a man's clenched fist was first seen. Monstrous size.   "Could this be a kidney with a large tumour?" I asked. Yet it was loose and free to move about unlike the usual fixed kidney. "It is uterine torsion," Dr Daniel said.

Omental sealed structure. The omental fat wrapped around this structure making it difficult to isolate it and take it out.  The fat seemed to have glued to this structure. What to do? I clamped with 2 artery forceps and cut in between. This separated the structure from other organs like spleen and stomach.

Spleen has splenic abscess (see video).

UPDATE ON AUG 24, 2013
3rd day. OK as she is eating all food. Owner came with adult daughter yesterday to visit as I had complained that the daughter did not visit the rabbit which was originally her pet.Will stay for 7 days as she will jump at home, causing stitch breakdown.

 

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