"You sit on the chair," my assistant asked me to enter the consultation room and pointed to the yellow chair when I arrived at around 10 am at Toa Payoh Vets. Mr Saw was busy cleaning up the kennels but he asked me to enter the consultation room before him.
"Why?" I asked. He just repeated "Sit on the chair."
So I sat on the chair as I thought he wanted to discuss something with me since April 5 was his last day at work. He would be back in Yangon tomorrow.
I was so surprised that he knelt down, bent his head and touched my shoes three times before he stood up. "This is Buddhist culture," he was thanking me for the past 3 years of mentorship. I hope he would do well in Yangon in private practice. He had been through 3 tough years under me and learnt much more since he was willing to learn. Veterinary practice is not just treating the dog. It involves communicating with the pet owner to create confidence and a lot of administration work. In a small practice like mine, he learnt all the tricks of the trade - to build up a practice with integrity and a high standard of service, not by under-pricing the competitors. A practice must be profitable, I said to Mr Saw many times. No point being the most well equipped practice in Singapore and being the best vet when the practice loses money every day. He understood what I meant after 3 years with me. There were offers from competitors to get him. This is Ok with me, I had said to him. "That means you are good and hard working. So, you have my blessings to get a better future."
Mr Saw can start his own surgery in Yangon without any worries of technical competency in small animal practice. But he knows it needs customers and money and that it will never be as easy as ABC.
Wednesday, April 6, 2011
Tuesday, April 5, 2011
388. Antisedan effects after waking up the dog
Injectable anaesthesia in the healthy dog and cat
in one syringe. Calculated dosage for healthy animals
Weight
Domitor
Ketamine
10kg healthy
0.4 ml IV
0.5 ml IV
Domitor 5-40ug/kg = 0.005mg/kg-0.04mg/kg
Ketamine 2-5mg/kg
Heart-diseased dogs - Do not use domitor+ketamine
Old dog - Use less domitor
Injectable anaesthesia in the healthy dog and cat
in one syringe. Calculated dosage for healthy animals
Weight
Diazepam
Ketamine
10kg healthy
0.8 ml* IV
0.5 ml IV
Diazepam 0.1-0.4 mg/kg.
* is based on maximal dose
Ketamine 2-5mg/kg
Heart-diseased dogs - give 50% + isoflurane gas top up
Spay healthy dogs - give higher dose in the higher range. No need isoflurane gas top up.
Rabbit & Guinea Pig. Use Subcutaneous inj only
in one syringe
Weight
Domitor
Ketamine
1kg healthy
0.2 ml SC
0.1 ml SC
Domitor 0.02 -0.25 mg/kg
Ketamine 10 -15mg/kg
DETAILS:
Domitor 1mg/ml = 1,000ug/ml
Ketamine 100mg/ml
Diazepam 5mg/ml
CASE STUDIES OF 3 DOGS USING DOMITOR+KETAMINE
Weight
Domitor
Calculated
Ketamine
Calculated
Domitor Given
Ketamine Given
10kg healthy
0.4 ml IV
0.5 ml IV
Case 1
Fox Terrier, 1 year, 9.3kg spay
0.37 ml IV
0.47 ml IV
0.2 ml IV
0.3 ml IV
Young, healthy
Needs isoflurane maintenance as dosage is below calculated dose. No problems. When antisedan 0.2 ml IM is given, wakes up alert but limbs are rigid. Can't stand up till atropine 0.1 ml IV is given.
Case 2
Shih Tzu, F, 7 years, 8.1 kg
0.32 ml IV
0.41 ml IV
0.1 ml IV
0.4ml IV
Old age, be careful
Needs isoflurane maintenance as dosage is below calculated dose. No problems. Dental scaling. When antisedan 0.1 ml IV is given, no cries. Just wakes up as if from a nap.
Case 3
Maltese, F, 8 years, 4.3 kg
0.17 ml IV
0.22 ml IV
0.1ml IV
0.2ml IV
Old age, be careful
No need isoflurane gas as dosage is close to calculated dose. 6 teeth extracted. No problem. When antisedan 0.1 ml IV is given, cries in pain. Given tolfedine injection. Stops crying.
Dosage for the two old dogs - shih tzu and maltese
Fox Terrier, 1 year, Spayed. Rigid limbs after giving antisedan
to wake up the dog early
In conclusion, domitor and ketamine are synergistic and their combined use will be safer if injectable anaesthetics are required and no isoflurane gas is available. For healthy dogs, use the calculated dosage given above. For heart-diseased dogs, use diazepam + ketamine at 50% of calculated dose and give isoflurane gas top up. Do NOT use domitor + ketamine is heart-diseased dogs.
As google does not permit proper table to be set up or I don't know how to do it, see Toa Payoh Vets webpage at:
http://www.kongyuensing.com/folder5/20110326injectable-anaesthesia-dogs-cats-rabbits-guinea-pigs-toapayohvets.htm
for an easier to read tabulated pres
entation of the 3 cases.
in one syringe. Calculated dosage for healthy animals
Weight
Domitor
Ketamine
10kg healthy
0.4 ml IV
0.5 ml IV
Domitor 5-40ug/kg = 0.005mg/kg-0.04mg/kg
Ketamine 2-5mg/kg
Heart-diseased dogs - Do not use domitor+ketamine
Old dog - Use less domitor
Injectable anaesthesia in the healthy dog and cat
in one syringe. Calculated dosage for healthy animals
Weight
Diazepam
Ketamine
10kg healthy
0.8 ml* IV
0.5 ml IV
Diazepam 0.1-0.4 mg/kg.
* is based on maximal dose
Ketamine 2-5mg/kg
Heart-diseased dogs - give 50% + isoflurane gas top up
Spay healthy dogs - give higher dose in the higher range. No need isoflurane gas top up.
Rabbit & Guinea Pig. Use Subcutaneous inj only
in one syringe
Weight
Domitor
Ketamine
1kg healthy
0.2 ml SC
0.1 ml SC
Domitor 0.02 -0.25 mg/kg
Ketamine 10 -15mg/kg
DETAILS:
Domitor 1mg/ml = 1,000ug/ml
Ketamine 100mg/ml
Diazepam 5mg/ml
CASE STUDIES OF 3 DOGS USING DOMITOR+KETAMINE
Weight
Domitor
Calculated
Ketamine
Calculated
Domitor Given
Ketamine Given
10kg healthy
0.4 ml IV
0.5 ml IV
Case 1
Fox Terrier, 1 year, 9.3kg spay
0.37 ml IV
0.47 ml IV
0.2 ml IV
0.3 ml IV
Young, healthy
Needs isoflurane maintenance as dosage is below calculated dose. No problems. When antisedan 0.2 ml IM is given, wakes up alert but limbs are rigid. Can't stand up till atropine 0.1 ml IV is given.
Case 2
Shih Tzu, F, 7 years, 8.1 kg
0.32 ml IV
0.41 ml IV
0.1 ml IV
0.4ml IV
Old age, be careful
Needs isoflurane maintenance as dosage is below calculated dose. No problems. Dental scaling. When antisedan 0.1 ml IV is given, no cries. Just wakes up as if from a nap.
Case 3
Maltese, F, 8 years, 4.3 kg
0.17 ml IV
0.22 ml IV
0.1ml IV
0.2ml IV
Old age, be careful
No need isoflurane gas as dosage is close to calculated dose. 6 teeth extracted. No problem. When antisedan 0.1 ml IV is given, cries in pain. Given tolfedine injection. Stops crying.
Dosage for the two old dogs - shih tzu and maltese
Fox Terrier, 1 year, Spayed. Rigid limbs after giving antisedan
to wake up the dog early
In conclusion, domitor and ketamine are synergistic and their combined use will be safer if injectable anaesthetics are required and no isoflurane gas is available. For healthy dogs, use the calculated dosage given above. For heart-diseased dogs, use diazepam + ketamine at 50% of calculated dose and give isoflurane gas top up. Do NOT use domitor + ketamine is heart-diseased dogs.
As google does not permit proper table to be set up or I don't know how to do it, see Toa Payoh Vets webpage at:
http://www.kongyuensing.com/folder5/20110326injectable-anaesthesia-dogs-cats-rabbits-guinea-pigs-toapayohvets.htm
for an easier to read tabulated pres
entation of the 3 cases.
The case of the skin and bone poodle. No more daily vomiting. Shall I cut to 3 meals a day?
"No more daily vomiting. Shall I cut down to 3 meals a day?" the wife asked.
"My dog only vomits when he is let free and he rushes out to eat the grass or late at night. I leash him and stop all feeds after 7 pm. So, my dog does not vomit at other times and is putting on weight. Shall I cut down to 3 meals a day instead of 2-3 hour daily from 9 am to 7 pm?"
"No," I said. "Your dog has a megaoesophagus condition and can't eat in large amounts." The lady probably could not understand what I was saying. Mega what?
I explained again: "Your dog's gullet near the stomach area is paralysed and enlarged. So food is trapped in that area instead of going straight into the stomach like normal dogs. The food accumulates and if in large amounts, together with drinking water, can get 'vomited' out."
Actually the dog regurgitates but it is hard to explain this to the elderly couple. If they feed 3x/day, the poodle would not put on weight. Now, she is still skin and bones but feel heavier.
The owner has to feed small amounts more than 3 times a day if she wants the dog to live. There is no surgical to resolve the problem now. In any case, there is a need for more investigation but the elderly couple needs to save up for their daily expenses. The money they spent on educating two children overseas to become high earners in society have been losses since now they have to be frugal.
Many middle-income parents do sacrifice so much that they start counting pennies when their pets need treatment. It can't be helped as they don't like to ask their children for money. Even though such children earn 10 times more than what they earn!
http://www.sinpets.com/dogs/20110215megaoesophagus-follow-up-toapayohvets-singapore.htm
has the previous case reports
386. "Your intern has run away!" my assistant said.
"Your intern has run away!" my assistant Mr Saw said to me on Monday when I came back from my RES course of 3 hours in the morning on Monday, Wednesday and Friday for 2 months. Mr Saw considers interns as pests wasting his time to teach them but he obliges when I ask him.
The young bespectacled short lady from Tampenis Junior College had phoned me for an internship as she was offered a place in the BioMedical course in Murdoch University on the introduction of Mr David Teo, a campus recruitment agency.
I told her to come on Sunday April 4, 2011 at 10am to try out one day and to be interviewed. Her father dutifully drove her to the Surgery at 9.30 am.
Her A level results did not qualify her to study veterinary medicine at Murdoch University. "3 As are needed," she said. "If I do very well in the BioMedical Course, I can join the 2nd year of Veterinary Medicine."
I reviewed her background. She had done some voluntary work at the SPCA cleaning the kennels and handling dogs. However, there was no documentary proof. "Are you sure you want to study Veterinary Medicine? You will need to study very hard and be top in the Bio-Medical course to get into the 2nd year. Nothing less than that." I asked her again. "Can your family afford to pay $300,000 for the course?"
She had better O level results than her A level. Something happened during her 2nd year of Junior College adversely affecting her academic performance. There are many young ladies from brand-name schools with unbelievable straight As. The last lady I spoke to had 6As and would have qualified to study veterinary medicine. If only her parents have the money. Yet this girl said her father could support her.
Well, I gave her an opportunity to work as an intern. She worked with Dr Vanessa on a busy Sunday afternoon. The next day, she did not turn up. Nor did she phone to thank me or said goodbye.
Sometimes I wonder why I should bother with giving 2nd chance to young people who don't make the grade to study veterinary medicine overseas?
The young bespectacled short lady from Tampenis Junior College had phoned me for an internship as she was offered a place in the BioMedical course in Murdoch University on the introduction of Mr David Teo, a campus recruitment agency.
I told her to come on Sunday April 4, 2011 at 10am to try out one day and to be interviewed. Her father dutifully drove her to the Surgery at 9.30 am.
Her A level results did not qualify her to study veterinary medicine at Murdoch University. "3 As are needed," she said. "If I do very well in the BioMedical Course, I can join the 2nd year of Veterinary Medicine."
I reviewed her background. She had done some voluntary work at the SPCA cleaning the kennels and handling dogs. However, there was no documentary proof. "Are you sure you want to study Veterinary Medicine? You will need to study very hard and be top in the Bio-Medical course to get into the 2nd year. Nothing less than that." I asked her again. "Can your family afford to pay $300,000 for the course?"
She had better O level results than her A level. Something happened during her 2nd year of Junior College adversely affecting her academic performance. There are many young ladies from brand-name schools with unbelievable straight As. The last lady I spoke to had 6As and would have qualified to study veterinary medicine. If only her parents have the money. Yet this girl said her father could support her.
Well, I gave her an opportunity to work as an intern. She worked with Dr Vanessa on a busy Sunday afternoon. The next day, she did not turn up. Nor did she phone to thank me or said goodbye.
Sometimes I wonder why I should bother with giving 2nd chance to young people who don't make the grade to study veterinary medicine overseas?
385. Post-neuter complication - dog traumatises scrotal area
385. Post-neuter complication - dog traumatises scrotal area
Feedback from a client improves the standard of care
E-MAIL FROM DR SING DATED APRIL 5, 2011 4,52 am
I am Dr Sing from Toa Payoh Vets. We spoke by phone yesterday afternoon. Give the 3 tolfedine tablets before midnight and observe. It is easier to communicate by phone than by texting a reply to your iphone.
I saw your picture of the dog's scrotal bruising in my phone but since we had just spoken by phone, I did not text a reply back. The dog has been traumatising its scrotal area using the e-collar.
This self-inflicted bruising is one of the post-operation complications seen in a one or two male dogs out of 100. In your dog, the traumatised scrotal skin is not serious presently as it is just 24 hours post-neuter.
Your dog had been given tolfedine pain-killer injection after surgery yesterday morning (Apr 3, 2011). You gave the tolfedine tablets at 4.30 pm on Apr 4, 2011 and noted the redness in the scrotal area. It is good that you e-mail the picture of the site as I thought it was the operation area (which is covered by the plaster) that was bleeding.
As advised, please give 3 tolfedine tablets orally 8 hours after 4.30 pm (your first dose).
Normally, the pain killer should be sufficient but your dog needs twice a day instead of once. Please let me know if your dog needs more pain-killers as normally, I prescribe for around 3 days including the injection post-surgery. Your dog may need an injection if he further traumatise his scrotal area. If not, the redness will fade over 2 weeks. Pl phone me when you have queries as it is much easier to talk than to thumb.
Best wishes.
REVIEW
A small number of male dogs of around 1 in a hundred traumatise their scrotal area after neuter despite being given pain-killer injection post-neuter and oral tablets at home.
In this case, the owner gave the tablets at 4.30 pm, around 24 hours post-surgery. In future, all pets should be given the pain-killers in the morning, ie. 12 hours post-surgery twice a day. Tolfedine is recommended by the manufacturer to be given once a day for a maximum of 4 days. 4 days on, 3 days off schedule. Some vets prefer other brands of pain-killers.
E-MAIL TO DR SING DATED APRIL 6, 2011
Dear Dr Sing
Thank you for your note. We'll continue to observe XXX's conditions over the next few days and contact you again when necessary.
I would also like to highlight that we're very disappointed and frustrated over all the unclear and confusing verbal communications.
When we first pick up XXX post his op, I asked your clinic assistant specifically "when should we feed the medication - morning, afternoon or night? before or after meal?" He said "doesn't matter, just feed once a day."
When we spoke with you last evening, you said specifically "2 tablets 10pm+ or before midnight and 2 tablets again next day morning." which I did feed him 2 tablets at 10pm last night and 2 tablets again this morning. I've 2 tablets left which I'll feed him again tonight.
I believe if XXX is traumatising its scrotal area, its due to itch from the stitches or plasters (which was already loosely attached when we pick up XXX post op). Again, I asked your clinic assistant "when should we remove the plasters or do we need to change to a new one and do we need to bring XXX back to remove stitches or is it the dissolve-able type?" He said "leave the plasters on for next 1-2 days before removing it and don't really need to remove stitches but should bring XXX back to see you in 2 weeks time." which you advised last evening when we spoke "to change a new plaster and leave it on."
Hence, I've a few questions to re-clarify:
1. are the stitches dissolve-able type? if so, is there still a need to see you in 2 weeks time?
2. or if its not, is there any additional charges to remove the stitches on top of the premium price that we've already paid?
3. do we continue to change the plasters when it come loose and leave it on till we see you in 2 weeks time?
4. or can we remove it totally in the next few days?
5. the collar can be removed in 2 weeks time right?
6. both the yellow and pink medication bottles must be fed completely right?
When we first called to inquire about the price, we're advised its $150+ which the final bill came up to a shocking $350+ before you kindly removed the blood test charge of $100 (originally $150 before discount as advised by your clinic assistant) as we did not ask to conduct a blood test. We also found out the general clinics' market rate is $80-$100 for blood test and $5 for the collar which we've been charged $20. I can only hope that the premium price we've paid for is for return of high quality products and professional services to make this whole process most comfortable for XXX's well being.
Appreciate if you can revert on our queries above.
Regards
E-MAIL REPLY FROM DR SING DATED APRIL 6, 2011
It is best to talk directly if you need clarification, whether over the phone or in person. However, I will try and reply to your email queries as detailed as possible below in CAPITAL LETTERS.
On Tue, Apr 5, 2011 at 3:13 PM, ...gmail.com> wrote:
Dear Dr Sing
Thank you for your note. We'll continue to observe XXX's conditions over the next few days and contact you again when necessary.
I would also like to highlight that we're very disappointed and frustrated over all the unclear and confusing verbal communications.
I HAVE SPOKEN TO MY STAFF MR SAW.
When we first pick up XXX post his op, I asked your clinic assistant specifically "when should we feed the medication - morning, afternoon or night? before or after meal?" He said "doesn't matter, just feed once a day."
IN MOST CASES, ONCE A DAY IS THE CORRECT ANSWER AS I HAVE HAD GIVEN THE ANTIBIOTICS AND PAINKILLERS THE AFTERNOON BEFORE. THE NEXT TIMING SHOULD BE 24 HOURS LATER.
I HAVE TOLD MY STAFF TO BE MORE SPECIFIC AND SAY IN THE MORNING.
When we spoke with you last evening, you said specifically "2 tablets 10pm+ or before midnight and 2 tablets again next day morning." which I did feed him 2 tablets at 10pm last night and 2 tablets again this morning. I've 2 tablets left which I'll feed him again tonight.
I believe if XXX is traumatising its scrotal area, its due to itch from the stitches or plasters (which was already loosely attached when we pick up XXX post op). Again, I asked your clinic assistant "when should we remove the plasters or do we need to change to a new one and do we need to bring XXX back to remove stitches or is it the dissolve-able type?" He said "leave the plasters on for next 1-2 days before removing it and don't really need to remove stitches but should bring XXX back to see you in 2 weeks time." which you advised last evening when we spoke "to change a new plaster and leave it on."
IF PLASTER IS LOOSE, IT NEEDS TO BE CHANGED. THE PLASTER IS TO FURTHER PREVENT THE DOG FROM LICKING THE WOUND AND STITCHES
Hence, I've a few questions to re-clarify:
1. are the stitches dissolve-able type? if so, is there still a need to see you in 2 weeks time?
NO NEED TO SEE ME TO REMOVE THE STITCHES AS THEY ARE ABSORBABLE. STITCHES WILL DISSOLVE IN 14-28 DAYS TIME. BUT IN SOME CASES, THE STITCHES DO NOT DISSOLVE IN 14 DAYS' TIME AND THE DOG IS IRRITATED BY ITS PRESENCE, I ASK THE OWNER TO COME AND GET THEM REMOVED FREE OF CHARGE.
2. or if its not, is there any additional charges to remove the stitches on top of the premium price that we've already paid?
NO ADDITIONAL CHARGES
3. do we continue to change the plasters when it come loose and leave it on till we see you in 2 weeks time?
CHANGE THE PLASTER WHEN IT IS LOOSE OR DIRTIED
4. or can we remove it totally in the next few days?
IN SOME CASES, YES. MUCH DEPENDS ON THE DOG'S SENSITIVITY TO HAVING A PLASTER ON. I CANNOT BE SPECIFIC AS EACH DOG BEHAVES DIFFERENTLY AFTER SURGERY, TOWARDS THE PAIN AND IRRITATION OF WOUND HEALING
5. the collar can be removed in 2 weeks time right?
PREFERRED BUT IN SOME CASES, 1 WEEK WILL DO. MUCH DEPENDS ON THE DOG'S BEHAVIOUR TOWARDS WOUND HEALING. SOME DOGS ARE VERY SENSITIVE AS WOUND HEALING AREA IS IRRITATING BUT SOME DON'T BOTHER.
6. both the yellow and pink medication bottles must be fed completely right?
YES
When we first called to inquire about the price, we're advised its $150+ which the final bill came up to a shocking $350+ before you kindly removed the blood test charge of $100 (originally $150 before discount as advised by your clinic assistant) as we did not ask to conduct a blood test.
AS YOU DID NOT WANT THE BLOOD TEST TO BE DONE, MY ASSISTANT SHOULD DEDUCT $150. IF NOT, I WILL REFUND YOU BACK BY CHEQUE $50. I WILL ASK HIM TODAY.
We also found out the general clinics' market rate is $80-$100 for blood test and $5 for the collar which we've been charged $20. I can only hope that the premium price we've paid for is for return of high quality products and professional services to make this whole process most comfortable for XXX's well being.
MARKET RATE FOR BLOOD TEST VARIES. YOUR BLOOD TEST IS A COMPLETE BLOOD TEST WHICH INCLUDES HAEMATOLOGY AND TESTS INCLUDING THE FUNCTIONS OF LIVER, KIDNEY, BONES AND JOINTS, GLUCOSE LEVEL. IT IS NOT POSSIBLE TO COMMENT FURTHER BASED ON PRICES OF COMPETITORS. AS FOR THE E-COLLAR, PRICES VARY AND IT IS BEST YOU PHONE ME IF YOU WISH TO DISCUSS FURTHER THE PRICING.
YOUR DOG'S REACTION TO NEUTER IS NOT COMMON BUT DOES HAPPEN IN 1 OUT OF 100 CASES. IT IS NOT SERIOUS AS HE HAS THE PAIN-KILLER TOLFEDINE. TOLFEDINE IS RECOMMENDED TO BE GIVEN ONCE A DAY FOR 4 DAYS ON, 3 DAYS OFF. SINCE YOUR DOG HAS SENSISTIVITY TO PAIN, I ADVISED TWICE A DAY ON THE DAY YOU PHONED.
I HOPE ALL ARE WELL WITH HIM NOW. PL PHONE RATHER THAN TEXT AS IT IS MUCH CLEARER TO TALK THAN TO WRITE AS MISUNDERSTANDINGS ARE LIKELY TO OCCUR DURING WRITING.
E-MAIL TO DR SING DATED APRIL 7, 2011
Thanks for your notes. It's very helpful info and clarifies. There's no need for refund of blood test as all blood test charges has been taken out at point of payment.
E-MAIL FROM DR SING DATED APR 6, 2011
I spoke to my assistant whose last day is today. He said that it was $100 which was charged in the bill but had been taken out.
I appreciate your feedback as that is the most important way to improve my standard of management and service. There is no other way as the practice learns from experience and mistakes made. The best feedback are those that I have made mistakes. Will update instructions post-surgery to all my vets with a standard form now. Pl accept my thanks.
E-MAIL TO DR SING DATED APR 6, 2011
I hope my feedback didn't cause Mr Saw his job, that will be too harsh.
Good thinking, I'm sure your clients will appreciate a standard FAQ surgery fact sheet for their reference. This should save you answering repetitive queries and able you to focus on other matters.
Regards
We will continue to observe XXX's recovery from here.
E-MAIL FROM DR SING DATED APRIL 7, 2011
Thanks for your feedback. Mr Saw completed his 3-year contract. He has better prospects of starting his own practice in Yangon. He has had done an excellent job during his employment and left on very good terms with his employer. I will be doing the surgery fact sheet with my two other associate vets as all 3 of us have different post-operation nursing care and advices. For example, I use plaster to cover the surgical wound to prevent it from being contaminated by the environment and licking by the dog or cat. My associate vets do not but use the e-collar.
I hope your dog is OK now. Thank you.
CONCLUSION
The vet usually explains the risks and post-operation complications. The owner is also asked to sign the Toa Payoh Vets' Informed Consent Form to confirm he or she has been informed of the risks and complications.
Risks refer to the anaesthetic risks. Therefore a blood test is advised to confirm that the dog is healthy. Post-operation complications are pain, bleeding and infection and are listed in the Informed Consent Form.
In 99% of the neuter and spay cases in my 30 years of small animal practice in Toa Payoh Vets, there have rarely been complaints of post-op complications at Toa Payoh Vets as I prescribe antibiotics and pain killers post-surgery. I do have a post-surgical information fact sheet but it has not been given as a routine.
A very small number of dogs have low tolerance to pain after neuter or spay. Some vets even give pain-killer injections before surgery as well as after. A post-surgical advice sheet will be best.
I will get this post-operation complication advices information incorporated in the spay or neuter certificate to be printed officially and signed by the owner so that the information has been read and is always available for family members.
Phoning the vet at Toa Payoh Vets is still the best way to get answers to queries of post-op complications although text messages and e-mails to me are very common with the younger generation.
THE WEBPAGE IS ALSO AT:
http://www.kongyuensing.com/folder5/20110325Trauma_self-inflicted-scrotal-post-neuter-dogs-surgery-toapayohvets.htm
Feedback from a client improves the standard of care
E-MAIL FROM DR SING DATED APRIL 5, 2011 4,52 am
I am Dr Sing from Toa Payoh Vets. We spoke by phone yesterday afternoon. Give the 3 tolfedine tablets before midnight and observe. It is easier to communicate by phone than by texting a reply to your iphone.
I saw your picture of the dog's scrotal bruising in my phone but since we had just spoken by phone, I did not text a reply back. The dog has been traumatising its scrotal area using the e-collar.
This self-inflicted bruising is one of the post-operation complications seen in a one or two male dogs out of 100. In your dog, the traumatised scrotal skin is not serious presently as it is just 24 hours post-neuter.
Your dog had been given tolfedine pain-killer injection after surgery yesterday morning (Apr 3, 2011). You gave the tolfedine tablets at 4.30 pm on Apr 4, 2011 and noted the redness in the scrotal area. It is good that you e-mail the picture of the site as I thought it was the operation area (which is covered by the plaster) that was bleeding.
As advised, please give 3 tolfedine tablets orally 8 hours after 4.30 pm (your first dose).
Normally, the pain killer should be sufficient but your dog needs twice a day instead of once. Please let me know if your dog needs more pain-killers as normally, I prescribe for around 3 days including the injection post-surgery. Your dog may need an injection if he further traumatise his scrotal area. If not, the redness will fade over 2 weeks. Pl phone me when you have queries as it is much easier to talk than to thumb.
Best wishes.
REVIEW
A small number of male dogs of around 1 in a hundred traumatise their scrotal area after neuter despite being given pain-killer injection post-neuter and oral tablets at home.
In this case, the owner gave the tablets at 4.30 pm, around 24 hours post-surgery. In future, all pets should be given the pain-killers in the morning, ie. 12 hours post-surgery twice a day. Tolfedine is recommended by the manufacturer to be given once a day for a maximum of 4 days. 4 days on, 3 days off schedule. Some vets prefer other brands of pain-killers.
E-MAIL TO DR SING DATED APRIL 6, 2011
Dear Dr Sing
Thank you for your note. We'll continue to observe XXX's conditions over the next few days and contact you again when necessary.
I would also like to highlight that we're very disappointed and frustrated over all the unclear and confusing verbal communications.
When we first pick up XXX post his op, I asked your clinic assistant specifically "when should we feed the medication - morning, afternoon or night? before or after meal?" He said "doesn't matter, just feed once a day."
When we spoke with you last evening, you said specifically "2 tablets 10pm+ or before midnight and 2 tablets again next day morning." which I did feed him 2 tablets at 10pm last night and 2 tablets again this morning. I've 2 tablets left which I'll feed him again tonight.
I believe if XXX is traumatising its scrotal area, its due to itch from the stitches or plasters (which was already loosely attached when we pick up XXX post op). Again, I asked your clinic assistant "when should we remove the plasters or do we need to change to a new one and do we need to bring XXX back to remove stitches or is it the dissolve-able type?" He said "leave the plasters on for next 1-2 days before removing it and don't really need to remove stitches but should bring XXX back to see you in 2 weeks time." which you advised last evening when we spoke "to change a new plaster and leave it on."
Hence, I've a few questions to re-clarify:
1. are the stitches dissolve-able type? if so, is there still a need to see you in 2 weeks time?
2. or if its not, is there any additional charges to remove the stitches on top of the premium price that we've already paid?
3. do we continue to change the plasters when it come loose and leave it on till we see you in 2 weeks time?
4. or can we remove it totally in the next few days?
5. the collar can be removed in 2 weeks time right?
6. both the yellow and pink medication bottles must be fed completely right?
When we first called to inquire about the price, we're advised its $150+ which the final bill came up to a shocking $350+ before you kindly removed the blood test charge of $100 (originally $150 before discount as advised by your clinic assistant) as we did not ask to conduct a blood test. We also found out the general clinics' market rate is $80-$100 for blood test and $5 for the collar which we've been charged $20. I can only hope that the premium price we've paid for is for return of high quality products and professional services to make this whole process most comfortable for XXX's well being.
Appreciate if you can revert on our queries above.
Regards
E-MAIL REPLY FROM DR SING DATED APRIL 6, 2011
It is best to talk directly if you need clarification, whether over the phone or in person. However, I will try and reply to your email queries as detailed as possible below in CAPITAL LETTERS.
On Tue, Apr 5, 2011 at 3:13 PM, ...gmail.com> wrote:
Dear Dr Sing
Thank you for your note. We'll continue to observe XXX's conditions over the next few days and contact you again when necessary.
I would also like to highlight that we're very disappointed and frustrated over all the unclear and confusing verbal communications.
I HAVE SPOKEN TO MY STAFF MR SAW.
When we first pick up XXX post his op, I asked your clinic assistant specifically "when should we feed the medication - morning, afternoon or night? before or after meal?" He said "doesn't matter, just feed once a day."
IN MOST CASES, ONCE A DAY IS THE CORRECT ANSWER AS I HAVE HAD GIVEN THE ANTIBIOTICS AND PAINKILLERS THE AFTERNOON BEFORE. THE NEXT TIMING SHOULD BE 24 HOURS LATER.
I HAVE TOLD MY STAFF TO BE MORE SPECIFIC AND SAY IN THE MORNING.
When we spoke with you last evening, you said specifically "2 tablets 10pm+ or before midnight and 2 tablets again next day morning." which I did feed him 2 tablets at 10pm last night and 2 tablets again this morning. I've 2 tablets left which I'll feed him again tonight.
I believe if XXX is traumatising its scrotal area, its due to itch from the stitches or plasters (which was already loosely attached when we pick up XXX post op). Again, I asked your clinic assistant "when should we remove the plasters or do we need to change to a new one and do we need to bring XXX back to remove stitches or is it the dissolve-able type?" He said "leave the plasters on for next 1-2 days before removing it and don't really need to remove stitches but should bring XXX back to see you in 2 weeks time." which you advised last evening when we spoke "to change a new plaster and leave it on."
IF PLASTER IS LOOSE, IT NEEDS TO BE CHANGED. THE PLASTER IS TO FURTHER PREVENT THE DOG FROM LICKING THE WOUND AND STITCHES
Hence, I've a few questions to re-clarify:
1. are the stitches dissolve-able type? if so, is there still a need to see you in 2 weeks time?
NO NEED TO SEE ME TO REMOVE THE STITCHES AS THEY ARE ABSORBABLE. STITCHES WILL DISSOLVE IN 14-28 DAYS TIME. BUT IN SOME CASES, THE STITCHES DO NOT DISSOLVE IN 14 DAYS' TIME AND THE DOG IS IRRITATED BY ITS PRESENCE, I ASK THE OWNER TO COME AND GET THEM REMOVED FREE OF CHARGE.
2. or if its not, is there any additional charges to remove the stitches on top of the premium price that we've already paid?
NO ADDITIONAL CHARGES
3. do we continue to change the plasters when it come loose and leave it on till we see you in 2 weeks time?
CHANGE THE PLASTER WHEN IT IS LOOSE OR DIRTIED
4. or can we remove it totally in the next few days?
IN SOME CASES, YES. MUCH DEPENDS ON THE DOG'S SENSITIVITY TO HAVING A PLASTER ON. I CANNOT BE SPECIFIC AS EACH DOG BEHAVES DIFFERENTLY AFTER SURGERY, TOWARDS THE PAIN AND IRRITATION OF WOUND HEALING
5. the collar can be removed in 2 weeks time right?
PREFERRED BUT IN SOME CASES, 1 WEEK WILL DO. MUCH DEPENDS ON THE DOG'S BEHAVIOUR TOWARDS WOUND HEALING. SOME DOGS ARE VERY SENSITIVE AS WOUND HEALING AREA IS IRRITATING BUT SOME DON'T BOTHER.
6. both the yellow and pink medication bottles must be fed completely right?
YES
When we first called to inquire about the price, we're advised its $150+ which the final bill came up to a shocking $350+ before you kindly removed the blood test charge of $100 (originally $150 before discount as advised by your clinic assistant) as we did not ask to conduct a blood test.
AS YOU DID NOT WANT THE BLOOD TEST TO BE DONE, MY ASSISTANT SHOULD DEDUCT $150. IF NOT, I WILL REFUND YOU BACK BY CHEQUE $50. I WILL ASK HIM TODAY.
We also found out the general clinics' market rate is $80-$100 for blood test and $5 for the collar which we've been charged $20. I can only hope that the premium price we've paid for is for return of high quality products and professional services to make this whole process most comfortable for XXX's well being.
MARKET RATE FOR BLOOD TEST VARIES. YOUR BLOOD TEST IS A COMPLETE BLOOD TEST WHICH INCLUDES HAEMATOLOGY AND TESTS INCLUDING THE FUNCTIONS OF LIVER, KIDNEY, BONES AND JOINTS, GLUCOSE LEVEL. IT IS NOT POSSIBLE TO COMMENT FURTHER BASED ON PRICES OF COMPETITORS. AS FOR THE E-COLLAR, PRICES VARY AND IT IS BEST YOU PHONE ME IF YOU WISH TO DISCUSS FURTHER THE PRICING.
YOUR DOG'S REACTION TO NEUTER IS NOT COMMON BUT DOES HAPPEN IN 1 OUT OF 100 CASES. IT IS NOT SERIOUS AS HE HAS THE PAIN-KILLER TOLFEDINE. TOLFEDINE IS RECOMMENDED TO BE GIVEN ONCE A DAY FOR 4 DAYS ON, 3 DAYS OFF. SINCE YOUR DOG HAS SENSISTIVITY TO PAIN, I ADVISED TWICE A DAY ON THE DAY YOU PHONED.
I HOPE ALL ARE WELL WITH HIM NOW. PL PHONE RATHER THAN TEXT AS IT IS MUCH CLEARER TO TALK THAN TO WRITE AS MISUNDERSTANDINGS ARE LIKELY TO OCCUR DURING WRITING.
E-MAIL TO DR SING DATED APRIL 7, 2011
Thanks for your notes. It's very helpful info and clarifies. There's no need for refund of blood test as all blood test charges has been taken out at point of payment.
E-MAIL FROM DR SING DATED APR 6, 2011
I spoke to my assistant whose last day is today. He said that it was $100 which was charged in the bill but had been taken out.
I appreciate your feedback as that is the most important way to improve my standard of management and service. There is no other way as the practice learns from experience and mistakes made. The best feedback are those that I have made mistakes. Will update instructions post-surgery to all my vets with a standard form now. Pl accept my thanks.
E-MAIL TO DR SING DATED APR 6, 2011
I hope my feedback didn't cause Mr Saw his job, that will be too harsh.
Good thinking, I'm sure your clients will appreciate a standard FAQ surgery fact sheet for their reference. This should save you answering repetitive queries and able you to focus on other matters.
Regards
We will continue to observe XXX's recovery from here.
E-MAIL FROM DR SING DATED APRIL 7, 2011
Thanks for your feedback. Mr Saw completed his 3-year contract. He has better prospects of starting his own practice in Yangon. He has had done an excellent job during his employment and left on very good terms with his employer. I will be doing the surgery fact sheet with my two other associate vets as all 3 of us have different post-operation nursing care and advices. For example, I use plaster to cover the surgical wound to prevent it from being contaminated by the environment and licking by the dog or cat. My associate vets do not but use the e-collar.
I hope your dog is OK now. Thank you.
CONCLUSION
The vet usually explains the risks and post-operation complications. The owner is also asked to sign the Toa Payoh Vets' Informed Consent Form to confirm he or she has been informed of the risks and complications.
Risks refer to the anaesthetic risks. Therefore a blood test is advised to confirm that the dog is healthy. Post-operation complications are pain, bleeding and infection and are listed in the Informed Consent Form.
In 99% of the neuter and spay cases in my 30 years of small animal practice in Toa Payoh Vets, there have rarely been complaints of post-op complications at Toa Payoh Vets as I prescribe antibiotics and pain killers post-surgery. I do have a post-surgical information fact sheet but it has not been given as a routine.
A very small number of dogs have low tolerance to pain after neuter or spay. Some vets even give pain-killer injections before surgery as well as after. A post-surgical advice sheet will be best.
I will get this post-operation complication advices information incorporated in the spay or neuter certificate to be printed officially and signed by the owner so that the information has been read and is always available for family members.
Phoning the vet at Toa Payoh Vets is still the best way to get answers to queries of post-op complications although text messages and e-mails to me are very common with the younger generation.
THE WEBPAGE IS ALSO AT:
http://www.kongyuensing.com/folder5/20110325Trauma_self-inflicted-scrotal-post-neuter-dogs-surgery-toapayohvets.htm
Saturday, April 2, 2011
384. Dental Scaling E-mails to Toa Payoh Vets
E-MAIL TO DR SING DATED MAR 26, 2011
Subject: Scaling for dogs
To: judy@toapayohvets.com
Received: Friday, 25 March, 2011, 2:00 PM
Hi,
I am looking for a trusted vet and doctor who can perform scaling on my 2 year old Chihuahua. I am interested upon sending her to Toa Payoh Vets. I would like to know how much it would cost and what I should do to prepare her for the day of her visit.
Thank you,
Name given
E-MAIL REPLY TO DR SING
DATED MAR 28, 2011
Thank you so much.
E-MAIL REPLY FROM DR SING DATED MAR 26, 2011
Hi
I am Dr Sing from Toa Payoh Vets. Thank you for your email to Judy.
The dental scaling plus anaesthesia cost is around $250 normally. Decayed tooth extraction will be around $10-$20 per tooth extracted. Medication of antibiotics and pain-killer is estimated at around $20 if necessary. Blood test for pre-anaesthesia risk checking will not be done in normal healthy dogs and will cost $150 if it is needed but you will be informed first.
Do not feed or give water to your dog after 10 pm the night before the dental work. Bring your dog to Toa Payoh Vets at 10 a.m. The dog will go home around 5pm usually, after rest and recovery from general anaesthesia.
Please make an appointment at 6254 3326. Please indicate which vet you prefer. These are Dr Sing, Dr Vanessa Lin and Dr Jason Teo.
Subject: Scaling for dogs
To: judy@toapayohvets.com
Received: Friday, 25 March, 2011, 2:00 PM
Hi,
I am looking for a trusted vet and doctor who can perform scaling on my 2 year old Chihuahua. I am interested upon sending her to Toa Payoh Vets. I would like to know how much it would cost and what I should do to prepare her for the day of her visit.
Thank you,
Name given
E-MAIL REPLY TO DR SING
DATED MAR 28, 2011
Thank you so much.
E-MAIL REPLY FROM DR SING DATED MAR 26, 2011
Hi
I am Dr Sing from Toa Payoh Vets. Thank you for your email to Judy.
The dental scaling plus anaesthesia cost is around $250 normally. Decayed tooth extraction will be around $10-$20 per tooth extracted. Medication of antibiotics and pain-killer is estimated at around $20 if necessary. Blood test for pre-anaesthesia risk checking will not be done in normal healthy dogs and will cost $150 if it is needed but you will be informed first.
Do not feed or give water to your dog after 10 pm the night before the dental work. Bring your dog to Toa Payoh Vets at 10 a.m. The dog will go home around 5pm usually, after rest and recovery from general anaesthesia.
Please make an appointment at 6254 3326. Please indicate which vet you prefer. These are Dr Sing, Dr Vanessa Lin and Dr Jason Teo.
Fools rush in where angels fear to tread - A hamster's large neck tumour
SURGICAL AREA
A big soft lump from below one ear to another and dangling under the neck in an old Syrian hamster (female, 20 months). This is the type of surgical condition I dread most. Performing this type of surgery is "fools rush in where angels fear to tread". The neck area has many important nerves, arteries and veins and it is not a very dangerous area to remove tumours especially in a hamster. That area below the throat is so small (less than 1 cm) compared to a dog or cat. A few thousand times smaller. There is no luxury of using an operating microscope and in any case, the surgery must be short as the hamster can't survive long anaesthesias of more than 1 minute, in my experience. You can't top up anaesthesia as in the dog and cat. Any more anaesthesia, the hamster just dies.
ANAESTHESIA
Very risky in a lethargic hamster. That means the hamster is not normal and healthy. The owner of this case waited till the neck tumour becomes very large. Is it inoperable? In any case, the chances of the old and lethargic hamster surviving are much lower. Less than 10%. So why take the case and risk damaging one's hard-built reputation as a "killer" of hamsters when this Syrian hamster dies on the operating table? Why not pass the buck to other vets?
DOSAGE OF INJECTABLE ANAESTHESIA IS HARD TO CALCULATE
"How much to give?" I asked my assistant Mr Saw (as part of my training of the past 3 years with me). He will be going to greener pastures in 2 weeks' time. "One drop of Zoletil will do," Mr Saw said. The owner had already said the hamster was lethargic for the past 2 weeks and the lump had exploded to big size during this time. Therefore, minimal dose as recommended by Mr Saw was the correct thing to do.
I gave one drop of Zoletil by injection IM into the left backside muscle. Waited for 5 minutes. The hamster looked at me and behaved normally, walking around inside the plastic container. She ought to be sleepy but she was much wide awake.
I waited another 5 minutes. She was active and had produced more faecal pellets. So, this dosage given was not effective. "In Syrian hamsters (160g), you need to give 4 times the dosage of a dwarf hamster (40 g)," I said to Mr Saw. But how do you calculate the dosage? It is easy in dogs and cats because they weight in kg when adult. But in this adult old hamster, she was 160 g.
"Give 2 drops," I asked Mr Saw to prepare the Zoletil. He filled up Zoletil 100 in one one-ml syringe and then push out one drop from its tips. Then I should use another one-ml syringe with a fine needle to aspirate the two drops.
"Hey, it is better you rest your elbows on top of the operating table," I said as it is hard to be precise in the present set up. "I also put my hands on top of the table." I then used the tip of my 25G needle attached to my one-ml syringe and aspirated two full drops from Mr Saw's one-ml syringe tip.
I injected into the right backside muscle. Within one minute, the hamster was lying down on his back.
So far, the Providence had been kind to me. The hamster was down but not out. Not dead I mean.
IV DRIPS
Impossible to do in a hamster. The veins are too small. SC injection of up to 3 ml dextrose saline is possible and was done in this case post-op.
SURGERY
After being sedated with the correct, safe and effective amount of Zoletil 100, the hamster went down sideways. There was a window of analgesia for around 1 minute to get the lump excised and the skin sutured.
I incised the skin 1 cm. A glistening membrane of the lump appeared under the skin. It seemed to be cyst but it was not 100% fluid filled lump. I saw a large vein from the lump (see illustration). "Is it the jugular vein?" I asked Mr Saw to make him think. He kept quiet. We had never seen jugular veins in hamsters in previous surgeries. Well, this location of the tumour was the second one I encountered during the past years of practice.
Know your anatomy well. It was not the jugular vein. I was just making my assistant think about hamster anatomy. He photocopied many veterinary notes and illustrations to prepare himself for the setting up of a private practice in Yangon later in the year. But nothing beats photocopies like seeing the real thing.
"Is it the jugular?" I asked my assistant again. He did not reply. It certainly was the biggest widest blue vein we had seen under the neck but it was connected to the tumour some below the tumour mass. It was unlikely to be a jugular but since the neck area is so small in size compared to that of a dog or cat, it would be hard to discount its presence. As a guideline, any large vein connected to a big tumour would be a feeder vein and the artery would be next to it. The tumour needed more nutrients and the blood vessels seem to enlarge to supply the ravenous growth.
I clamped the tumour and excised. Immediately blue blood spilled out. This vein was hard to ligate initially as it was very close to the pharynx. I dared not ligate as the needle might perforate the pharynx. So I excised the tumour first. Around 3 ml of blood splashed out. "Swabs," I said. Mr Saw provided the 3 swabs I needed to clear the bloodied area. I could see the bleeding vein. Ligated it. Then another big spurt appeared. It was probably the artery injured during the first ligation. I ligated this second bleeder. No more bleeding.
"Stretch the 2 cm skin wound by putting your thumb and index finger on either side," I said to my assistant. In this way, the skin wound is stretched out and I could appose the cut skin with 3 horizontal mattress sutures quickly. The hamster's neck was not straight in this type of surgery. No luxury of tying up 4 legs and positioning the head on a pillow as in the dog surgery. The hamster was just too small to do all these. Time is of the essence. Surgery must be short.
My assistant said as I cut out the bits and pieces of this mixed tumour and started wiping off the large amount of blood from below the eyes to shoulder: "Stop, I can clean the blood off later. The hamster is going into shock soon. Stop and wait. Do not stress the hamster."
I tried to clean up as much blood as possible as bacteria from the surrounding will infect the hamster via this outside blood.
The hamster started panting. Breathing at more than 100x/minute. Why? Stress had set in. Was she going to die?
My 2nd assistant took out a hair dryer, set to lowest warmth and warm up the hamster. "Give 3 ml of dextrose saline SC," I asked Mr Saw to stop as he started to get normal saline. It was not possible to give an IV catheter as in the dog because it is practically impossible to get a hamster's vein and I doubt if anybody can do it. The hamster is just so small and everything is miniaturised. So subcutaneous fluid was OK. But it must be dextrose saline in my opinion and this can be given by SC. Glucose itself cannot be given SC.
As everything was so tense, the vet must have a clear mind and ensure that proper drugs and saline are given by being observant.
After an eternity of more than 30 minutes of being kept in a warm room, the hamster breathed normally. I took a photo of her trying to stand up. It was a good sign. In 24 hours, I took her photograph and was glad that she was alive. Not all stories end happily all the time for all vets. It is best for owners to check their older hamster early for small tumours. These are easier to remove and take a much shorter time.
More pictures are at www.toapayohvets.com. Click HAMSTERS
For more pictures of the surgery: goto
http://www.sinpets.com/F6/20110323massive-neck-tumour-syrian-hamster-surgery-toapayohvets.htm
A big soft lump from below one ear to another and dangling under the neck in an old Syrian hamster (female, 20 months). This is the type of surgical condition I dread most. Performing this type of surgery is "fools rush in where angels fear to tread". The neck area has many important nerves, arteries and veins and it is not a very dangerous area to remove tumours especially in a hamster. That area below the throat is so small (less than 1 cm) compared to a dog or cat. A few thousand times smaller. There is no luxury of using an operating microscope and in any case, the surgery must be short as the hamster can't survive long anaesthesias of more than 1 minute, in my experience. You can't top up anaesthesia as in the dog and cat. Any more anaesthesia, the hamster just dies.
ANAESTHESIA
Very risky in a lethargic hamster. That means the hamster is not normal and healthy. The owner of this case waited till the neck tumour becomes very large. Is it inoperable? In any case, the chances of the old and lethargic hamster surviving are much lower. Less than 10%. So why take the case and risk damaging one's hard-built reputation as a "killer" of hamsters when this Syrian hamster dies on the operating table? Why not pass the buck to other vets?
DOSAGE OF INJECTABLE ANAESTHESIA IS HARD TO CALCULATE
"How much to give?" I asked my assistant Mr Saw (as part of my training of the past 3 years with me). He will be going to greener pastures in 2 weeks' time. "One drop of Zoletil will do," Mr Saw said. The owner had already said the hamster was lethargic for the past 2 weeks and the lump had exploded to big size during this time. Therefore, minimal dose as recommended by Mr Saw was the correct thing to do.
I gave one drop of Zoletil by injection IM into the left backside muscle. Waited for 5 minutes. The hamster looked at me and behaved normally, walking around inside the plastic container. She ought to be sleepy but she was much wide awake.
I waited another 5 minutes. She was active and had produced more faecal pellets. So, this dosage given was not effective. "In Syrian hamsters (160g), you need to give 4 times the dosage of a dwarf hamster (40 g)," I said to Mr Saw. But how do you calculate the dosage? It is easy in dogs and cats because they weight in kg when adult. But in this adult old hamster, she was 160 g.
"Give 2 drops," I asked Mr Saw to prepare the Zoletil. He filled up Zoletil 100 in one one-ml syringe and then push out one drop from its tips. Then I should use another one-ml syringe with a fine needle to aspirate the two drops.
"Hey, it is better you rest your elbows on top of the operating table," I said as it is hard to be precise in the present set up. "I also put my hands on top of the table." I then used the tip of my 25G needle attached to my one-ml syringe and aspirated two full drops from Mr Saw's one-ml syringe tip.
I injected into the right backside muscle. Within one minute, the hamster was lying down on his back.
So far, the Providence had been kind to me. The hamster was down but not out. Not dead I mean.
IV DRIPS
Impossible to do in a hamster. The veins are too small. SC injection of up to 3 ml dextrose saline is possible and was done in this case post-op.
SURGERY
After being sedated with the correct, safe and effective amount of Zoletil 100, the hamster went down sideways. There was a window of analgesia for around 1 minute to get the lump excised and the skin sutured.
I incised the skin 1 cm. A glistening membrane of the lump appeared under the skin. It seemed to be cyst but it was not 100% fluid filled lump. I saw a large vein from the lump (see illustration). "Is it the jugular vein?" I asked Mr Saw to make him think. He kept quiet. We had never seen jugular veins in hamsters in previous surgeries. Well, this location of the tumour was the second one I encountered during the past years of practice.
Know your anatomy well. It was not the jugular vein. I was just making my assistant think about hamster anatomy. He photocopied many veterinary notes and illustrations to prepare himself for the setting up of a private practice in Yangon later in the year. But nothing beats photocopies like seeing the real thing.
"Is it the jugular?" I asked my assistant again. He did not reply. It certainly was the biggest widest blue vein we had seen under the neck but it was connected to the tumour some below the tumour mass. It was unlikely to be a jugular but since the neck area is so small in size compared to that of a dog or cat, it would be hard to discount its presence. As a guideline, any large vein connected to a big tumour would be a feeder vein and the artery would be next to it. The tumour needed more nutrients and the blood vessels seem to enlarge to supply the ravenous growth.
I clamped the tumour and excised. Immediately blue blood spilled out. This vein was hard to ligate initially as it was very close to the pharynx. I dared not ligate as the needle might perforate the pharynx. So I excised the tumour first. Around 3 ml of blood splashed out. "Swabs," I said. Mr Saw provided the 3 swabs I needed to clear the bloodied area. I could see the bleeding vein. Ligated it. Then another big spurt appeared. It was probably the artery injured during the first ligation. I ligated this second bleeder. No more bleeding.
"Stretch the 2 cm skin wound by putting your thumb and index finger on either side," I said to my assistant. In this way, the skin wound is stretched out and I could appose the cut skin with 3 horizontal mattress sutures quickly. The hamster's neck was not straight in this type of surgery. No luxury of tying up 4 legs and positioning the head on a pillow as in the dog surgery. The hamster was just too small to do all these. Time is of the essence. Surgery must be short.
My assistant said as I cut out the bits and pieces of this mixed tumour and started wiping off the large amount of blood from below the eyes to shoulder: "Stop, I can clean the blood off later. The hamster is going into shock soon. Stop and wait. Do not stress the hamster."
I tried to clean up as much blood as possible as bacteria from the surrounding will infect the hamster via this outside blood.
The hamster started panting. Breathing at more than 100x/minute. Why? Stress had set in. Was she going to die?
My 2nd assistant took out a hair dryer, set to lowest warmth and warm up the hamster. "Give 3 ml of dextrose saline SC," I asked Mr Saw to stop as he started to get normal saline. It was not possible to give an IV catheter as in the dog because it is practically impossible to get a hamster's vein and I doubt if anybody can do it. The hamster is just so small and everything is miniaturised. So subcutaneous fluid was OK. But it must be dextrose saline in my opinion and this can be given by SC. Glucose itself cannot be given SC.
As everything was so tense, the vet must have a clear mind and ensure that proper drugs and saline are given by being observant.
After an eternity of more than 30 minutes of being kept in a warm room, the hamster breathed normally. I took a photo of her trying to stand up. It was a good sign. In 24 hours, I took her photograph and was glad that she was alive. Not all stories end happily all the time for all vets. It is best for owners to check their older hamster early for small tumours. These are easier to remove and take a much shorter time.
More pictures are at www.toapayohvets.com. Click HAMSTERS
For more pictures of the surgery: goto
http://www.sinpets.com/F6/20110323massive-neck-tumour-syrian-hamster-surgery-toapayohvets.htm
Spay guinea pigs
REPLY TO AN E-MAIL QUERY
We do sterilise female guinea pig. Cost is from $250 - $300. Pl make appointment with Dr Sing at 6254 3326. The guinea pig must be at least 6 months old and be healthy. Pl note that there is always a risk of death from anaesthesia in any surgery in guinea pigs and other animals.
We do sterilise female guinea pig. Cost is from $250 - $300. Pl make appointment with Dr Sing at 6254 3326. The guinea pig must be at least 6 months old and be healthy. Pl note that there is always a risk of death from anaesthesia in any surgery in guinea pigs and other animals.
381. Hamster injuries can be infected
E-MAIL TO DR SING DATED MAR 31, 2011
2011/3/31 ...@hotmail.com>
Hi there,
I own a hamster which was previously owned by two different owners. When the hamster was taken care by the 1st owner, she placed him with another hamster which bit him. He was then given to the 2nd owner, whose mother didn't want her to keep him, so she gave him to me.
The problem is that he has bumps on his ear and around his eye. Over time his eye got worse and it covered his whole eye thus, now he is blind in one eye.
Should I bring him for a check up?
Name of owner
E-MAIL FROM DR SING DATED MAR 31, 2011
Date: Fri, 1 Apr 2011 07:43:21 +0800
Subject: Re: About my hamster
From: 99pups@gmail.com
To: ,,,@hotmail.com
Yes. Pl make an appointment at 6254 3326 to see Dr Sing at 9.30 am or let the receptionist know.
Friday, April 1, 2011
380. Keratoconjunctivitis sicca in old Shih Tzus - Duty of care
Many times, an owner of old Shih Tzus would consult the vet for some problems that are not related to the eyes, such as diarrhoea. Many times, the vet will see dry eyes as shown in the image.
Since the owner has not complained about the keratoconjunctivitis sicca, the vet would just treat the diarrhoea, ear infections or skin disease and that would all.
Has the vet a duty of care to educate the owner that she needs to use eyedrops to relieve the dog's discomfort & pain in dry eyes when the consultation is not related to the eyes?
What is a duty of care of a veterinarian when the dog is presented for diarrhoea? It is to correctly treat the diarrhoea. Therefore, the vet needs not bother with the dry eyes.
However, many Singapore pet owners are unaware that they can relieve the old Shih Tzu's dry eye discomfort and pain. The owner attributes dry eyes to old age and so what? The old dog rubs his ulcerated eyes daily. It is due to old age!
Once a vet bothers to educate the owner, she usually takes the time and trouble to ensure that the eyes are wetted and lubricated.
I usually advise clipping away the hairs around the eyes so that the facial area can be well cleaned and applying eye drops minimum twice a day. I was manning the counter to get a feel of the front-line veterinary matters.
Recently, an older woman phoned to get the eye drops prescribed by my associate vet. "I have to give you another brand," I said. "It is from the same company. The brand you want is being ordered."
"Please get for me ....eye drops next time," the woman in her 50s said. "The dog's eyes are now much cleaner with that brand."
P.S
Reference: http://www.businessdictionary.com/definition/duty-of-care.html
DUTY OF CARE
A responsibility or a legal obligation of a person or organization to avoid acts or omissions (which can be reasonably foreseen) to be likely to cause harm to others.
Duty of care is owed by an accountant in correctly preparing a firm's accounts, by an auditor in confirming an firm's financial statements correctly present its financial position, by a director to shareholders in husbanding the enterprise's resources, by a manufacturer to consumers for the safety of product, and by every party to a contract to the other contracting parties.
Since the owner has not complained about the keratoconjunctivitis sicca, the vet would just treat the diarrhoea, ear infections or skin disease and that would all.
Has the vet a duty of care to educate the owner that she needs to use eyedrops to relieve the dog's discomfort & pain in dry eyes when the consultation is not related to the eyes?
What is a duty of care of a veterinarian when the dog is presented for diarrhoea? It is to correctly treat the diarrhoea. Therefore, the vet needs not bother with the dry eyes.
However, many Singapore pet owners are unaware that they can relieve the old Shih Tzu's dry eye discomfort and pain. The owner attributes dry eyes to old age and so what? The old dog rubs his ulcerated eyes daily. It is due to old age!
Once a vet bothers to educate the owner, she usually takes the time and trouble to ensure that the eyes are wetted and lubricated.
I usually advise clipping away the hairs around the eyes so that the facial area can be well cleaned and applying eye drops minimum twice a day. I was manning the counter to get a feel of the front-line veterinary matters.
Recently, an older woman phoned to get the eye drops prescribed by my associate vet. "I have to give you another brand," I said. "It is from the same company. The brand you want is being ordered."
"Please get for me ....eye drops next time," the woman in her 50s said. "The dog's eyes are now much cleaner with that brand."
P.S
Reference: http://www.businessdictionary.com/definition/duty-of-care.html
DUTY OF CARE
A responsibility or a legal obligation of a person or organization to avoid acts or omissions (which can be reasonably foreseen) to be likely to cause harm to others.
Duty of care is owed by an accountant in correctly preparing a firm's accounts, by an auditor in confirming an firm's financial statements correctly present its financial position, by a director to shareholders in husbanding the enterprise's resources, by a manufacturer to consumers for the safety of product, and by every party to a contract to the other contracting parties.
Thursday, March 31, 2011
379. A scholarship in Political Science and Veterinary Science
E-MAIL TO DR SING DATED MAR 30, 2011 FROM AN AMERICAN VOLUNTEER
FOR HIS OLD UNIVERSITY FOR SCHOLARSHIP SELECTION OF ONE SINGAPOREAN
Thanks so much for taking the time to talk to .... yesterday. You gave her a great deal of good information. I support your advice to her to think carefully about her career choices. A clever interviewer will be alert to people who are not serious and are simply fishing for some way to pay their university tuition.
MY COMMENTS
The girl from a brand-name school, Raffles Institution could easily get into the top colleges in the U.S, U.K or Australia. A great number of her cohort of 1000 would probably get 3As but she has 6As. That was an excellent academic achievement.
It opens doors to any scholarship but she was the only candidate with Science and Maths amongst seven short-listed for a US scholarship interview. The scholarship was for a liberal arts degree in a US university which the volunteer told me is a sister school of Williams College attended by Senior Minister Goh Chok Tong. When well known names are thrown in, it gets attention of the other party
So this girl attended would have got Wesleyan Freeman Asian Scholarship if she would study Political Science, according to the volunteer whom I shall call Mr Baker.
Mr Baker was a volunteer but not an interviewer for his University which would offer 1 scholarship for each of the 11 Asian countries. I believed that this girl was top choice but she wanted to study Veterinary Science. Mr Baker said: "Political science is not veterinary science". He emailed to me to ask me if I would advise this girl by phone. Instead I advised meeting as phone calls were a waste of time if one is to advise a bright young lady on her career (as a volunteer).
Mr Baker arrived early by cycling from Clementi to Toa Payoh as I discovered later. I was surprised. "You must be one of those crazy and eccentric Ang Mos (Caucasians)," I was wondering how he could arrive at Toa Payoh Vets without sweat and how dangerous it was to cycle so far. I must say he was lean and fit at the age of 50 and could put many a younger 40-year-old man to shame in fitness.
The young lady arrived in a taxi on time. As my surgery was small in space, I suggested we had a talk at the coffee shop behind. A bespectacled fair lady with long bronze gold hair and of pleasant first impressions. We sat and Mr Baker offered to buy drinks though initially he planned to introduce us and go home. I insisted that he stay to "chaperone" me, not that I need one as it was a public place. Mr Baker with his receding forehead and baldness presents an energetic intelligent appearance and is the type who does not want to take up too much of my time.
Our talk lasted around 2 hours as Mr Baker offered to buy lunch too. We ate at the coffeeshop. So was this scholarly lady passionate about veterinary medicine? She has a dog. But not one substantial piece of evidence that she had cared for animals at the SPCA, veterinary surgeries or animal welfare groups or any activity related to animals in Singapore.
Her parents wanted her to study medicine or law as they considered veterinary medicine dirty. In any case, they can't support her to study veterinary medicine overseas and therefore she has to get a scholarship. In this modern age and in a developed modern Singapore, there are still Singapore parents who want their progeny to fulfill their dreams of not being able to become a doctor or lawyer! And to consider veterinary medicine as dirty! In the UK where I studied some 40 years ago, the demand for veterinary studies far exceed the demand to study medicine and I believe this is the situation in the U.S! Here, we have Singaporean parents looking down at a superstar academic who wants to study veterinary medicine.
Will she get the AVA veterinary scholarship? The 6As will get her into past the door into the interview room as this was what must have happened at the US university interview she attended recently. Academic excellence still give the best cherries despite some Singapore parents talking about over-stressing their children and asking for less pressure of homework in the Singapore tuition and education hot bed.
"But the AVA is looking for regulators and enforcers to check on far away farms in China and other countries to accredit them for export of meat to Singapore," I said to this girl. "SVA is not looking for practitioners in small or large animal medicine. You look kind of delicate," I said. She had said she was interested in farm practice with the large animals. Most vets have run away from rural veterinary practice and here she wanted to do that.
Typically and stereotypically, most bright Singaporean lady scholars completing their A levels spend most time studying very hard and therefore they are fair and delicate looking. At least those few ladies who applied for internship with me gave me this impression.
Will she get the AVA scholarship? She had to write 2 articles. What was her most important achievement and why she wanted to study vet medicine? Without supporting evidence, I wonder how she wrote about in the 2nd article required by AVA?
We hope she will get the scholarship. The kind gentleman aged 50 gave some advices like student loans, working for a few years first. He got a scholarship from the GI bill which provides scholarship for Americans who had served in the US Army. I thought he was the average man as he had retired and had said during our meeting: "I have one foot in the grave". Men who are past 50 and who tells me they have one foot in the grave don't impress me.
I said to this kind gentleman who is actually a top scholar at Harvard or some top US university and an inventor in military engineering after I asked him more about his background: "If you have one foot in the grave at the age of 50 years, I must be having one and a half foot in the grave as I am 60 years old!" Men who are in their 50s do think that way. I wonder if women of similar age do think similarly?
I say he is a kind man because he spent time to help this stranger, a girl with 6As to know more about veterinary science by contacting me. He was not happy with the interviewers of his old school wanting to direct this girl to study political science and thereby giving her the scholarship. Americans are always brutally honest and into your face if they like some behaviour?
In the end, the scholarship went to another girl and from what I know, this girl had the passion for the arts which included writing, literature and education as I was told that this girl with fuzzy hair (I think it was fuzzy hair) gave education classes at the School of Thought. Have you ever heard of such a school or have I got the wrong name?
Political science is far removed from veterinary science. But I would take the political science scholarship if I have 6As and study in the US. Excel in this scholarship and then get a scholarship to become a veterinarian if my parents have no money to sponsor me. After all, how many young Singaporeans can have a chance to study in a top liberal arts school in the US?
If a young adult has passion in veterinary medicine and the parents don't have the S$300,000 to pay the tuition fees, taking this US scholarship will broaden her mind and make him a better all rounded veterinarian if she studies vet medicine as a mature student.
But a lady with 6 straight As can have her pick of scholarships. So what if she can't get the AVA scholarship? She has others. So, does she have the passion for veterinary medicine or not? Was she fishing for the best scholarship? Most of her 100 friends in Raffles Institution want to be doctors and so I expect lesser competition for her.
Based on her lack of animal activism veterinary and welfare work in her past years at Raffles Institution, it would be hard for her to get the AVA scholarship if there are others with track records.
P.S
1. According to the kind gentleman, the Wesleyan Freeman Asian Scholarship Program provides expenses for a 4-year course to study "Political Science", not "Veterinary Science" for one exceptionally able Asian student annually from one Asian country. So, he was quite pissed off when the interviewers asked this girl to study Political Science instead, did some research and e-mailed to me to advise her about veterinary medicine.
In any case, the Wesleyan University, Middletown, Connecticut provides a liberal arts education. The Freeman Foundation provides the scholarship. Sadly, he told me that Mr Freeman, an original founder of AIG group has just passed away.
Selection criteria included academic achievement, intellectual curiosity, a high level of discipline and commitment, strong personal qualities, extracurricular involvement especially community service and English language ability.
2. Williams College, a highly selective private liberal arts college, Massachusetts.
3. Volunteerism is human kindness. Mr Baker is not paid by his University. In fact, he paid for the drinks and lunch. Volunteerism also open doors to meet other people when you help somebody.
4. Mr Baker appeared fresh and clean after cycling from Clementi to Toa Payoh because he changed his clothes at the Toa Payoh Swimming Pool. He has 3 engineering inventions of great interest. He must have graduated from a top engineering University in the US when I implied that in some unknown manner that he graduated from some average university after studying at Wesleyan University. Never judge a book by its cover! His inventions were in military engineering and quite impressive to me as a veterinarian. Actually if you think of it, his inventions to protect naval ships from small terrorist ships ramming with explosives are the equivalent of antibodies (with spiked attachments) fighting against antigens (foreign invaders like bacteria or terrorist)!
FOR HIS OLD UNIVERSITY FOR SCHOLARSHIP SELECTION OF ONE SINGAPOREAN
Thanks so much for taking the time to talk to .... yesterday. You gave her a great deal of good information. I support your advice to her to think carefully about her career choices. A clever interviewer will be alert to people who are not serious and are simply fishing for some way to pay their university tuition.
MY COMMENTS
The girl from a brand-name school, Raffles Institution could easily get into the top colleges in the U.S, U.K or Australia. A great number of her cohort of 1000 would probably get 3As but she has 6As. That was an excellent academic achievement.
It opens doors to any scholarship but she was the only candidate with Science and Maths amongst seven short-listed for a US scholarship interview. The scholarship was for a liberal arts degree in a US university which the volunteer told me is a sister school of Williams College attended by Senior Minister Goh Chok Tong. When well known names are thrown in, it gets attention of the other party
So this girl attended would have got Wesleyan Freeman Asian Scholarship if she would study Political Science, according to the volunteer whom I shall call Mr Baker.
Mr Baker was a volunteer but not an interviewer for his University which would offer 1 scholarship for each of the 11 Asian countries. I believed that this girl was top choice but she wanted to study Veterinary Science. Mr Baker said: "Political science is not veterinary science". He emailed to me to ask me if I would advise this girl by phone. Instead I advised meeting as phone calls were a waste of time if one is to advise a bright young lady on her career (as a volunteer).
Mr Baker arrived early by cycling from Clementi to Toa Payoh as I discovered later. I was surprised. "You must be one of those crazy and eccentric Ang Mos (Caucasians)," I was wondering how he could arrive at Toa Payoh Vets without sweat and how dangerous it was to cycle so far. I must say he was lean and fit at the age of 50 and could put many a younger 40-year-old man to shame in fitness.
The young lady arrived in a taxi on time. As my surgery was small in space, I suggested we had a talk at the coffee shop behind. A bespectacled fair lady with long bronze gold hair and of pleasant first impressions. We sat and Mr Baker offered to buy drinks though initially he planned to introduce us and go home. I insisted that he stay to "chaperone" me, not that I need one as it was a public place. Mr Baker with his receding forehead and baldness presents an energetic intelligent appearance and is the type who does not want to take up too much of my time.
Our talk lasted around 2 hours as Mr Baker offered to buy lunch too. We ate at the coffeeshop. So was this scholarly lady passionate about veterinary medicine? She has a dog. But not one substantial piece of evidence that she had cared for animals at the SPCA, veterinary surgeries or animal welfare groups or any activity related to animals in Singapore.
Her parents wanted her to study medicine or law as they considered veterinary medicine dirty. In any case, they can't support her to study veterinary medicine overseas and therefore she has to get a scholarship. In this modern age and in a developed modern Singapore, there are still Singapore parents who want their progeny to fulfill their dreams of not being able to become a doctor or lawyer! And to consider veterinary medicine as dirty! In the UK where I studied some 40 years ago, the demand for veterinary studies far exceed the demand to study medicine and I believe this is the situation in the U.S! Here, we have Singaporean parents looking down at a superstar academic who wants to study veterinary medicine.
Will she get the AVA veterinary scholarship? The 6As will get her into past the door into the interview room as this was what must have happened at the US university interview she attended recently. Academic excellence still give the best cherries despite some Singapore parents talking about over-stressing their children and asking for less pressure of homework in the Singapore tuition and education hot bed.
"But the AVA is looking for regulators and enforcers to check on far away farms in China and other countries to accredit them for export of meat to Singapore," I said to this girl. "SVA is not looking for practitioners in small or large animal medicine. You look kind of delicate," I said. She had said she was interested in farm practice with the large animals. Most vets have run away from rural veterinary practice and here she wanted to do that.
Typically and stereotypically, most bright Singaporean lady scholars completing their A levels spend most time studying very hard and therefore they are fair and delicate looking. At least those few ladies who applied for internship with me gave me this impression.
Will she get the AVA scholarship? She had to write 2 articles. What was her most important achievement and why she wanted to study vet medicine? Without supporting evidence, I wonder how she wrote about in the 2nd article required by AVA?
We hope she will get the scholarship. The kind gentleman aged 50 gave some advices like student loans, working for a few years first. He got a scholarship from the GI bill which provides scholarship for Americans who had served in the US Army. I thought he was the average man as he had retired and had said during our meeting: "I have one foot in the grave". Men who are past 50 and who tells me they have one foot in the grave don't impress me.
I said to this kind gentleman who is actually a top scholar at Harvard or some top US university and an inventor in military engineering after I asked him more about his background: "If you have one foot in the grave at the age of 50 years, I must be having one and a half foot in the grave as I am 60 years old!" Men who are in their 50s do think that way. I wonder if women of similar age do think similarly?
I say he is a kind man because he spent time to help this stranger, a girl with 6As to know more about veterinary science by contacting me. He was not happy with the interviewers of his old school wanting to direct this girl to study political science and thereby giving her the scholarship. Americans are always brutally honest and into your face if they like some behaviour?
In the end, the scholarship went to another girl and from what I know, this girl had the passion for the arts which included writing, literature and education as I was told that this girl with fuzzy hair (I think it was fuzzy hair) gave education classes at the School of Thought. Have you ever heard of such a school or have I got the wrong name?
Political science is far removed from veterinary science. But I would take the political science scholarship if I have 6As and study in the US. Excel in this scholarship and then get a scholarship to become a veterinarian if my parents have no money to sponsor me. After all, how many young Singaporeans can have a chance to study in a top liberal arts school in the US?
If a young adult has passion in veterinary medicine and the parents don't have the S$300,000 to pay the tuition fees, taking this US scholarship will broaden her mind and make him a better all rounded veterinarian if she studies vet medicine as a mature student.
But a lady with 6 straight As can have her pick of scholarships. So what if she can't get the AVA scholarship? She has others. So, does she have the passion for veterinary medicine or not? Was she fishing for the best scholarship? Most of her 100 friends in Raffles Institution want to be doctors and so I expect lesser competition for her.
Based on her lack of animal activism veterinary and welfare work in her past years at Raffles Institution, it would be hard for her to get the AVA scholarship if there are others with track records.
P.S
1. According to the kind gentleman, the Wesleyan Freeman Asian Scholarship Program provides expenses for a 4-year course to study "Political Science", not "Veterinary Science" for one exceptionally able Asian student annually from one Asian country. So, he was quite pissed off when the interviewers asked this girl to study Political Science instead, did some research and e-mailed to me to advise her about veterinary medicine.
In any case, the Wesleyan University, Middletown, Connecticut provides a liberal arts education. The Freeman Foundation provides the scholarship. Sadly, he told me that Mr Freeman, an original founder of AIG group has just passed away.
Selection criteria included academic achievement, intellectual curiosity, a high level of discipline and commitment, strong personal qualities, extracurricular involvement especially community service and English language ability.
2. Williams College, a highly selective private liberal arts college, Massachusetts.
3. Volunteerism is human kindness. Mr Baker is not paid by his University. In fact, he paid for the drinks and lunch. Volunteerism also open doors to meet other people when you help somebody.
4. Mr Baker appeared fresh and clean after cycling from Clementi to Toa Payoh because he changed his clothes at the Toa Payoh Swimming Pool. He has 3 engineering inventions of great interest. He must have graduated from a top engineering University in the US when I implied that in some unknown manner that he graduated from some average university after studying at Wesleyan University. Never judge a book by its cover! His inventions were in military engineering and quite impressive to me as a veterinarian. Actually if you think of it, his inventions to protect naval ships from small terrorist ships ramming with explosives are the equivalent of antibodies (with spiked attachments) fighting against antigens (foreign invaders like bacteria or terrorist)!
Tuesday, March 29, 2011
378. Why can't my Silkie pee normally after urinary stone removal?
DRAFT CASE REPORT
11 DAYS AFTER URINARY STONE REMOVAL CONSULTATION
A puzzling case of the male neutered Silkie, 6 years old who can't pee normally after urinary stone removal by an experienced vet. Around 11 days after surgery, the owner consulted me.
OWNER COMPLAINS ON DAY 11 AFTER SURGERY BY VET 1 THAT THE DOG HAD DIFFICULTY URINATING URINATE WHEN HE DRANK WATER. THIS HAPPENED >12 TIMES/DAY. WHY?
HE IS SUPPOSED TO BE ABLE TO PEE NORMALLY AFTER REMOVAL OF THE URINARY STONES BY VET 1. WHAT SHOULD I DO?
I palpated the bladder. It was empty. Therefore, there was no urethral obstruction in the sense of blockage of urine flow by the stones at behind the os penis (see X-ray of original condition before operation by Vet 1. Vet 1 had given the X-ray to the owner and I asked her to e-mail to me and this was done on Mar 27, 2011 for me to review.
I told the owner that there was no problem. If a vet wants to prove that there was no obstruction by catheterising the bladder in the presence of the owner, that does not prove anything as palpation had already revealed an emptied bladder and therefore no urethral obstruction.
Bladder palpation would have told the vet that there was no obstruction at that point of time. The dog did not have urethral obstruction generally. So what was the cause of this puzzling behaviour? Cystitis is a possibility. UTI possible. A small stone from the bladder obstructing the urethra? Possible as the X-ray would not take the kidney area traditionally.
(Tip: For good practice in veterinary medicine, it is best to keep an X-ray record if the vet wants to give away the X-ray or record that the owner has it).
As the owner is living far away from Toa Payoh and not to incur more veterinary costs for her, I advised observation on the initial complaint around 12 days post-stone removal by Vet 1. I had the nylon-like stitches in front of the prepuce removed at the same time and gave an anti-inflammatory and antibiotics. Then I prescribed antibiotics, SD diet x12 and asked for urine sample. X-ray of the bladder will be an option if necessary.
Some confusion from the owner's description of the dog's behaviour. Was the dog having difficulty peeing or starting to urine-mark when he was about to drink or he had some bladder infection or urinary stone stuck behind the os penis?
All stones had been taken out by Vet 1 in my opinion as I did not observe the surgery. It is possible that there is urethral obstruction from a stone or two from the bladder. However, economics deter more X-rays and tests for the time being and I did conservative treatment to "dissolve" the remaining stones (probably very small if present and from the kidneys) using S/D diet and monitoring of the urine.
Instead of another X-ray which would cause the owner stress and money, the owner was asked to monitor the dog's peeing behaviour and given S/D diet to dissolve the remaining stones. Vet 1 had not got the results of the crystals of the stones removed. The owner's e-mail report is as follows:
E-MAIL TO DR SING DATED MARCH 21, 2011
14 DAYS AFTER SURGERY TO REMOVE URINARY STONES BY VET 1
Subject: Dog X-Ray ID: 2496 Dog with urinal stones
Date: Mon, 21 Mar 2011 02:33:44 +0000
Dear Dr Sing,
As per your request, herewith my dog's x-ray given by (name given) Vet 1, there is only 1 photo of x-ray. i will be bringing his urine sample down on this Thursday 24/03/2011, around 7pm. Had spoken to you on Sunday 20th March morning, about my dog's urine behaviour after the urinal stones removal.
Duration Monitored: 30-45mins
Dogs behaviour:
- dog frequently try to pee especially after drinking water.
- out of 12 attempts, 1 attempt is successful*
- the one successful attempt is normal passing of urine
- the other 11 fail attempt: sometimes there is no urine at all, sometimes a little.
Other Conditions:
- Dog is eating normally
- Drinking not as much as before; Drunk half a bottle in 3days. In the past, dog drink half a bottle in 1day.
(Water bottle size is L12cm x W8cm x B8cm)
- Dog is playing and active as usual
- Currently on Dr Sing prescribe diet started 20/03/2011
- Previous Diet: brown rice with white rice, carrots, peas, tofu, a bit of garlic, salt and olive oil.
E-MAIL TO DR SING DATED MAR 29, 2011
22 DAYS AFTER SURGERY TO REMOVE URINARY STONES BY VET 1
Dear Dr Sing,
Updates of my dog condition after urinal stones removal operation since 7 march 2011.
Duration monitored: 30-45mins
Dog Behavior:
1) his attempts to urine has cut down from 12times to 4-5times
2) 1 successful attempts out of the 4-5 tries*
3) other attempts, urine amount is less than 3ml or no urine at all.
Other Conditions:
- Dog is eating normally
- Dog is starting to drink more; like his usual amount of intake before operation.
- Dog is playing and active as usual
- Currently on Dr Sing prescribe diet started 20/03/2011
- Previous Diet: brown rice with white rice, carrots, peas, tofu, a bit of garlic, salt and olive oil.
He is also on an eye drop, because he has ulcer in his right eye. It is improving, not as red as before.
I have not brought his urine sample down, because his condition is improving. Thus, i would like to monitor for a few more days.
Dr Sing, I truly appreciate your help in giving me advise on my dog's condition. I had brought my 1st pet, a cat, to you since 1990.
You are a good vet, please do not lose hope even when you have encounter more demanding pet's owners.
MARCH 29, 2011
I phoned the owner as e-mail writing can be misleading compared to personal conversation. She complains about a hard lump at the stitched area. Vet 1 had stitched with the absorbable nylon-like stitches in the muscle and the skin area after stone removal.
I had already got the skin stitches removed during the first complaint around 12 days of what I considered a successful surgery by Vet 1. This opinion is subject to an X-ray post-op but I did not consider the X-ray necessary at that point of time as it is likely to show no urethral obstruction based on my bladder palpation. The bladder was empty and so it would be morally unethical to advise another X-ray immediately. In any case, the original stones were removed as Vet 1 is an experienced vet and therefore I recommended conservative treatment.
Vet 1 should have got a urine sample for urinary stone crystal analysis to the Singapore laboratory pre-surgery in hind-sight. Vet 1 had sent the stones to the US lab for analysis. This would take some time but now ... I have a problem! And the owner had got her X-ray at home. So, I asked her to e-mail to me the X-ray which my Adobe Photoshop refused to download. I cropped and converted the X-ray to .tiff. This time Adobe Photoshop obliged and therefore I had the X-ray image cleaned up and presented in this report.
CONCLUSION
Post-operation complications do happen after surgeries for all vets. The owner must be informed before surgery but sometimes we are too busy to go into details of the risk of pain, infection and bleeding of surgery. Many times I don't inform the owner too as the consent form for surgery would have been signed by the owner. During my past 20 years, I seldom ask the owner to sign the consent form (for informed consent) but now I better be careful of possible litigation for "failure to provide informed consent."
It is hard to pin-point the cause of the dysuria in this dog. Certainly it is not the typical urethral obstruction at the os penis, in my experience and observation.
Dogs can't talk. That's the challenge of being a veterinarian. It takes a lot of time and patience to know what is going on in this case. From the owner's phone conversation and observation, I conclude that this dog might have some pain due to the muscle stitching and so he tried not to pee during the first 14 days post-op. As I know Vet 1 used those absorbable "nylon-like" stitches to suture, I infer that the stitches were irritating the dog at that critical area in front and below the prepuce. I had removed the skin sutures but below, there was another layer of muscle suture at the linea alba. This would be the area of pain which lessened with time and medication. So the dog now has much lesser frequency of urination pain and has improved considerably according to the owner's diligent monitoring of urination.
In conclusion, one main cause of the post-surgical dysuria is the pain at the stitched abdominal muscle area below the penis (to close up the operation after urinary stone removal).
My tip to vets will be to use the 3/0 absorbable non-nylon like sutures. There is no need to stitch the muscles at 0.5 mm apart resulting in many stitches. I stitch at 1 cm intervals. Also, I find that subcuticular stitches are not necessary but many vets do that. This means a lot of stitches (subcuticular and muscle) and this would result in stitch irritation especially when the vet uses the "nylon-like" absorbable stitches. This is probably what is happening to the dog in this case. Every time he pees, the heavily stitched muscle and subcuticular area causes pain.
So when he wants to drink water, he tries to pee first but feels the pain. At other times, he pees onto the pee tray with difficulty. The owner disputed my opinion of the male dog urine-marking as the dog has no such habit.
*So as at March 30, 2011 as I close this case, I have only this hypothesis of pain due to stitches, not urethral obstruction by urinary stones behind the os penis. 22 days after surgery, the dog has fewer episodes of dysuria (see owner's e-mails above) . If only dogs can talk! And if only we vets have more time to analyse the cases but we don't have the luxury of time! And Singaporean pet owners want instant answers!
I don't have any complaint in my urinary stone removal surgeries using such the 3/0 non-nylon suture type for closure of the bladder, abdominal muscle and skin . It dissolves usually in 28 days and that is more than sufficient time for healing of the operated wounds. I don't use subcuticular sutures as I found them unnecessary in these cases. The University professors in Australia (from my observation of some graduates' need to do subcuticular suturing) still teach the students the need to eliminate dead space under the skin and therefore subcuticular sutures are used by many fresh graduates.
"Nylon" type absorbable sutures will take a much longer time to dissolve. The owner can "feel" the "lump" for some time. In veterinary practice, perception is sometimes as important as competence. Why use nylon-like stitches to create "lumps" under the skin worrying the dog owner and risking loss of owner's confidence in the vet when good alternatives are available? As each vet has his own preference, it will be hard to convince such vets to switch suture types!
I may be fortunate in my cases of no complaints of post-operation dysuria. Or the owner might have gone to another vet for a second opinion as in this case!
FOR BLOG READERS, the Toa Payoh Vets website article is at:
http://www.sinpets.com/F5/20110320stones-post-op-dysuria-unhappy-owner-complains-toapayohvets.htm
11 DAYS AFTER URINARY STONE REMOVAL CONSULTATION
A puzzling case of the male neutered Silkie, 6 years old who can't pee normally after urinary stone removal by an experienced vet. Around 11 days after surgery, the owner consulted me.
OWNER COMPLAINS ON DAY 11 AFTER SURGERY BY VET 1 THAT THE DOG HAD DIFFICULTY URINATING URINATE WHEN HE DRANK WATER. THIS HAPPENED >12 TIMES/DAY. WHY?
HE IS SUPPOSED TO BE ABLE TO PEE NORMALLY AFTER REMOVAL OF THE URINARY STONES BY VET 1. WHAT SHOULD I DO?
I palpated the bladder. It was empty. Therefore, there was no urethral obstruction in the sense of blockage of urine flow by the stones at behind the os penis (see X-ray of original condition before operation by Vet 1. Vet 1 had given the X-ray to the owner and I asked her to e-mail to me and this was done on Mar 27, 2011 for me to review.
I told the owner that there was no problem. If a vet wants to prove that there was no obstruction by catheterising the bladder in the presence of the owner, that does not prove anything as palpation had already revealed an emptied bladder and therefore no urethral obstruction.
Bladder palpation would have told the vet that there was no obstruction at that point of time. The dog did not have urethral obstruction generally. So what was the cause of this puzzling behaviour? Cystitis is a possibility. UTI possible. A small stone from the bladder obstructing the urethra? Possible as the X-ray would not take the kidney area traditionally.
(Tip: For good practice in veterinary medicine, it is best to keep an X-ray record if the vet wants to give away the X-ray or record that the owner has it).
As the owner is living far away from Toa Payoh and not to incur more veterinary costs for her, I advised observation on the initial complaint around 12 days post-stone removal by Vet 1. I had the nylon-like stitches in front of the prepuce removed at the same time and gave an anti-inflammatory and antibiotics. Then I prescribed antibiotics, SD diet x12 and asked for urine sample. X-ray of the bladder will be an option if necessary.
Some confusion from the owner's description of the dog's behaviour. Was the dog having difficulty peeing or starting to urine-mark when he was about to drink or he had some bladder infection or urinary stone stuck behind the os penis?
All stones had been taken out by Vet 1 in my opinion as I did not observe the surgery. It is possible that there is urethral obstruction from a stone or two from the bladder. However, economics deter more X-rays and tests for the time being and I did conservative treatment to "dissolve" the remaining stones (probably very small if present and from the kidneys) using S/D diet and monitoring of the urine.
Instead of another X-ray which would cause the owner stress and money, the owner was asked to monitor the dog's peeing behaviour and given S/D diet to dissolve the remaining stones. Vet 1 had not got the results of the crystals of the stones removed. The owner's e-mail report is as follows:
E-MAIL TO DR SING DATED MARCH 21, 2011
14 DAYS AFTER SURGERY TO REMOVE URINARY STONES BY VET 1
Subject: Dog X-Ray ID: 2496 Dog with urinal stones
Date: Mon, 21 Mar 2011 02:33:44 +0000
Dear Dr Sing,
As per your request, herewith my dog's x-ray given by (name given) Vet 1, there is only 1 photo of x-ray. i will be bringing his urine sample down on this Thursday 24/03/2011, around 7pm. Had spoken to you on Sunday 20th March morning, about my dog's urine behaviour after the urinal stones removal.
Duration Monitored: 30-45mins
Dogs behaviour:
- dog frequently try to pee especially after drinking water.
- out of 12 attempts, 1 attempt is successful*
- the one successful attempt is normal passing of urine
- the other 11 fail attempt: sometimes there is no urine at all, sometimes a little.
Other Conditions:
- Dog is eating normally
- Drinking not as much as before; Drunk half a bottle in 3days. In the past, dog drink half a bottle in 1day.
(Water bottle size is L12cm x W8cm x B8cm)
- Dog is playing and active as usual
- Currently on Dr Sing prescribe diet started 20/03/2011
- Previous Diet: brown rice with white rice, carrots, peas, tofu, a bit of garlic, salt and olive oil.
E-MAIL TO DR SING DATED MAR 29, 2011
22 DAYS AFTER SURGERY TO REMOVE URINARY STONES BY VET 1
Dear Dr Sing,
Updates of my dog condition after urinal stones removal operation since 7 march 2011.
Duration monitored: 30-45mins
Dog Behavior:
1) his attempts to urine has cut down from 12times to 4-5times
2) 1 successful attempts out of the 4-5 tries*
3) other attempts, urine amount is less than 3ml or no urine at all.
Other Conditions:
- Dog is eating normally
- Dog is starting to drink more; like his usual amount of intake before operation.
- Dog is playing and active as usual
- Currently on Dr Sing prescribe diet started 20/03/2011
- Previous Diet: brown rice with white rice, carrots, peas, tofu, a bit of garlic, salt and olive oil.
He is also on an eye drop, because he has ulcer in his right eye. It is improving, not as red as before.
I have not brought his urine sample down, because his condition is improving. Thus, i would like to monitor for a few more days.
Dr Sing, I truly appreciate your help in giving me advise on my dog's condition. I had brought my 1st pet, a cat, to you since 1990.
You are a good vet, please do not lose hope even when you have encounter more demanding pet's owners.
MARCH 29, 2011
I phoned the owner as e-mail writing can be misleading compared to personal conversation. She complains about a hard lump at the stitched area. Vet 1 had stitched with the absorbable nylon-like stitches in the muscle and the skin area after stone removal.
I had already got the skin stitches removed during the first complaint around 12 days of what I considered a successful surgery by Vet 1. This opinion is subject to an X-ray post-op but I did not consider the X-ray necessary at that point of time as it is likely to show no urethral obstruction based on my bladder palpation. The bladder was empty and so it would be morally unethical to advise another X-ray immediately. In any case, the original stones were removed as Vet 1 is an experienced vet and therefore I recommended conservative treatment.
Vet 1 should have got a urine sample for urinary stone crystal analysis to the Singapore laboratory pre-surgery in hind-sight. Vet 1 had sent the stones to the US lab for analysis. This would take some time but now ... I have a problem! And the owner had got her X-ray at home. So, I asked her to e-mail to me the X-ray which my Adobe Photoshop refused to download. I cropped and converted the X-ray to .tiff. This time Adobe Photoshop obliged and therefore I had the X-ray image cleaned up and presented in this report.
CONCLUSION
Post-operation complications do happen after surgeries for all vets. The owner must be informed before surgery but sometimes we are too busy to go into details of the risk of pain, infection and bleeding of surgery. Many times I don't inform the owner too as the consent form for surgery would have been signed by the owner. During my past 20 years, I seldom ask the owner to sign the consent form (for informed consent) but now I better be careful of possible litigation for "failure to provide informed consent."
It is hard to pin-point the cause of the dysuria in this dog. Certainly it is not the typical urethral obstruction at the os penis, in my experience and observation.
Dogs can't talk. That's the challenge of being a veterinarian. It takes a lot of time and patience to know what is going on in this case. From the owner's phone conversation and observation, I conclude that this dog might have some pain due to the muscle stitching and so he tried not to pee during the first 14 days post-op. As I know Vet 1 used those absorbable "nylon-like" stitches to suture, I infer that the stitches were irritating the dog at that critical area in front and below the prepuce. I had removed the skin sutures but below, there was another layer of muscle suture at the linea alba. This would be the area of pain which lessened with time and medication. So the dog now has much lesser frequency of urination pain and has improved considerably according to the owner's diligent monitoring of urination.
In conclusion, one main cause of the post-surgical dysuria is the pain at the stitched abdominal muscle area below the penis (to close up the operation after urinary stone removal).
My tip to vets will be to use the 3/0 absorbable non-nylon like sutures. There is no need to stitch the muscles at 0.5 mm apart resulting in many stitches. I stitch at 1 cm intervals. Also, I find that subcuticular stitches are not necessary but many vets do that. This means a lot of stitches (subcuticular and muscle) and this would result in stitch irritation especially when the vet uses the "nylon-like" absorbable stitches. This is probably what is happening to the dog in this case. Every time he pees, the heavily stitched muscle and subcuticular area causes pain.
So when he wants to drink water, he tries to pee first but feels the pain. At other times, he pees onto the pee tray with difficulty. The owner disputed my opinion of the male dog urine-marking as the dog has no such habit.
*So as at March 30, 2011 as I close this case, I have only this hypothesis of pain due to stitches, not urethral obstruction by urinary stones behind the os penis. 22 days after surgery, the dog has fewer episodes of dysuria (see owner's e-mails above) . If only dogs can talk! And if only we vets have more time to analyse the cases but we don't have the luxury of time! And Singaporean pet owners want instant answers!
I don't have any complaint in my urinary stone removal surgeries using such the 3/0 non-nylon suture type for closure of the bladder, abdominal muscle and skin . It dissolves usually in 28 days and that is more than sufficient time for healing of the operated wounds. I don't use subcuticular sutures as I found them unnecessary in these cases. The University professors in Australia (from my observation of some graduates' need to do subcuticular suturing) still teach the students the need to eliminate dead space under the skin and therefore subcuticular sutures are used by many fresh graduates.
"Nylon" type absorbable sutures will take a much longer time to dissolve. The owner can "feel" the "lump" for some time. In veterinary practice, perception is sometimes as important as competence. Why use nylon-like stitches to create "lumps" under the skin worrying the dog owner and risking loss of owner's confidence in the vet when good alternatives are available? As each vet has his own preference, it will be hard to convince such vets to switch suture types!
I may be fortunate in my cases of no complaints of post-operation dysuria. Or the owner might have gone to another vet for a second opinion as in this case!
FOR BLOG READERS, the Toa Payoh Vets website article is at:
http://www.sinpets.com/F5/20110320stones-post-op-dysuria-unhappy-owner-complains-toapayohvets.htm
378. Sunday Case. "My Jack Russell suddenly can't see"
I HOPE THIS REAL CASE WILL HELP THE 5TH YEAR VET STUDENT WITH THOUSANDS OF SUBJECTS TO REMEMBER AND BE EXAMINED BEFORE GRADUATION!
One look from my reception counter and I could see that this Jack Russell was suffering from Canine Lymphosarcoma. Some vets prefer to call it Canine Lymphoma. The two lumps of the size of ping-pong balls on the right and left lower jaws were too obvious to miss.
The owners were a young couple in their early 30s and an older woman and there was great emotions involved. The mum was distressed that the 8-year-old male Jack Russell walked into chairs and just could not see on this fine Sunday morning. Only the day before, the dog was zipping here and there when exercised outdoors. No accidents. No falls. No injuries. The dog just couldn't see! Why? What happened?
I decided to handle this case as the leading vet responsible for the outcome and together with my associate vet. Working as a team is a pleasure of veterinary medicine as we share our workload. I asked if she objected as she was on duty, but this was not her client. My associate said: "I am OK."
HISTORY
"What did Vet 1 say?" I asked when the owner showed me the report of a pre-scapular lymph node biopsy sent to the AVA lab.
"Vet 1 said that the AVA lab cannot confirm that the dog is suffering from lymphoma."
I read the report. It stated that it needed at least 2 biopsies from 2 lymph nodes and to relate to clinical signs. The presented biopsy cells could not confirm lymphoma.
So the owners must have concluded that the dog was not suffering from lymphoma!
No further treatment.
EYES
Blood inside both eyes preventing vision.
Note: In canine lymphoma, eye involved in 25% of cases). This can lead to bleeding within the eye, uveitis, glaucoma, retinal detachment and blindness.)
BLOOD TEST RESULTS OF DOG WITH LYMPHOMA OVER AT LEAST 1 MONTH
I was checking for infection (high WCC) or immune suppression (low WCC and platelets) or cancer (e.g. leukaemia with very high WCC), liver and kidney disorder.
Results are as follows:
Haemoglobin 13.9 (12-18)
Total WCC 11.8 (6-17)
Neutrophils 70.51 Abs 8.32
Lymphocytes 16.44 Abs 1.94
Monocytes 11.19 Abs 1.32
Eosinophils 0.09 Abs 0.01
Basophils 1.95 Abs 0.23
Red cell count 5.5 (5.5-8.5)
PCV 0.38 (0.37-0.55)
MCV 69 (60-77)
MCH 25 (20-25)
MCHC 36 (32-36)
RDW 14.1%
Platelets 90* (200-500). No platelet clumps seen.
LIVER PROFILE
ALT/SGPT 169 (<59) AST/SGOT 138 (<81) BONE/JOINT FUNCTION Calcium 2.58 (1.5 -3.6) Uric Acid 0.05 (<0.13) KIDNEY PROFILE Urea 8.3 (4.2 - 6.3) Creatinine 54 (89-177) WHAT STAGE OF LYMPHOMA IS THE DOG IN? I palpated the abdomen. There was mild anterior abdominal pain as the dog hunched but did not bite me. The liver and spleen were enlarged. The dog was eating and active. This is now Stage 4a (generalised lymph node involvement with liver or spleen involvement). It is developing into Stage 5a (Stage 4a with blood or bone marrow involvement - see low platelet counts in blood test but no anaemia or low white blood cells yet). Central nervous system involvement (bleeding in two eyes) but no seizures Guideline. Stage 5a means the dog is eating normally. Stage 5b means the dog is not eating. 4047 - 4049. Bleeding inside the eye in canine lymphoma. Blood test shows low platelet count WHAT THE OWNER ASKED ME 1. How long will the dog live without chemotherapy treatment? I said it would depend on which stage and infections. 2 months had been quoted in some reports. 2. How long will the dog live with chemotherapy? It depends on the disease and drugs. Remission (no enlarged lymph nodes) may be present for several months, prolonging the life of the dog. 3. Is there a permanent cure? No. 4. What's the cost? Varies with the type of treatment. Cost of blood monitoring. WHAT HAPPENED ON SUNDAY? There were free blood inside both eyes. The sclera were very red and from my experience the dog had rubbed his eyes vigorously due to pain in the abdomen. (From my cases of acute pancreatitis and reading other vet reports, the dog rubs his eyes to relieve his intense abdominal pain) causing bleeding. HOW DID I SOLVE THIS PROBLEM OF BLEEDING EYES AFFECTING VISION? 7 kg. BW. Domitor 0.1 ml, Ketamine 0.2 ml in one syringe IV. Dog stopped pacing and slept. Eye sclera became normal white (the owners could see this and were quite impressed). It is highly risky to give sedation in this situation. Give the lowest dose. Next day, the owner said the dog could see. The owner has to decide on whether to do chemotherapy.
One look from my reception counter and I could see that this Jack Russell was suffering from Canine Lymphosarcoma. Some vets prefer to call it Canine Lymphoma. The two lumps of the size of ping-pong balls on the right and left lower jaws were too obvious to miss.
The owners were a young couple in their early 30s and an older woman and there was great emotions involved. The mum was distressed that the 8-year-old male Jack Russell walked into chairs and just could not see on this fine Sunday morning. Only the day before, the dog was zipping here and there when exercised outdoors. No accidents. No falls. No injuries. The dog just couldn't see! Why? What happened?
I decided to handle this case as the leading vet responsible for the outcome and together with my associate vet. Working as a team is a pleasure of veterinary medicine as we share our workload. I asked if she objected as she was on duty, but this was not her client. My associate said: "I am OK."
HISTORY
"What did Vet 1 say?" I asked when the owner showed me the report of a pre-scapular lymph node biopsy sent to the AVA lab.
"Vet 1 said that the AVA lab cannot confirm that the dog is suffering from lymphoma."
I read the report. It stated that it needed at least 2 biopsies from 2 lymph nodes and to relate to clinical signs. The presented biopsy cells could not confirm lymphoma.
So the owners must have concluded that the dog was not suffering from lymphoma!
No further treatment.
EYES
Blood inside both eyes preventing vision.
Note: In canine lymphoma, eye involved in 25% of cases). This can lead to bleeding within the eye, uveitis, glaucoma, retinal detachment and blindness.)
BLOOD TEST RESULTS OF DOG WITH LYMPHOMA OVER AT LEAST 1 MONTH
I was checking for infection (high WCC) or immune suppression (low WCC and platelets) or cancer (e.g. leukaemia with very high WCC), liver and kidney disorder.
Results are as follows:
Haemoglobin 13.9 (12-18)
Total WCC 11.8 (6-17)
Neutrophils 70.51 Abs 8.32
Lymphocytes 16.44 Abs 1.94
Monocytes 11.19 Abs 1.32
Eosinophils 0.09 Abs 0.01
Basophils 1.95 Abs 0.23
Red cell count 5.5 (5.5-8.5)
PCV 0.38 (0.37-0.55)
MCV 69 (60-77)
MCH 25 (20-25)
MCHC 36 (32-36)
RDW 14.1%
Platelets 90* (200-500). No platelet clumps seen.
LIVER PROFILE
ALT/SGPT 169 (<59) AST/SGOT 138 (<81) BONE/JOINT FUNCTION Calcium 2.58 (1.5 -3.6) Uric Acid 0.05 (<0.13) KIDNEY PROFILE Urea 8.3 (4.2 - 6.3) Creatinine 54 (89-177) WHAT STAGE OF LYMPHOMA IS THE DOG IN? I palpated the abdomen. There was mild anterior abdominal pain as the dog hunched but did not bite me. The liver and spleen were enlarged. The dog was eating and active. This is now Stage 4a (generalised lymph node involvement with liver or spleen involvement). It is developing into Stage 5a (Stage 4a with blood or bone marrow involvement - see low platelet counts in blood test but no anaemia or low white blood cells yet). Central nervous system involvement (bleeding in two eyes) but no seizures Guideline. Stage 5a means the dog is eating normally. Stage 5b means the dog is not eating. 4047 - 4049. Bleeding inside the eye in canine lymphoma. Blood test shows low platelet count WHAT THE OWNER ASKED ME 1. How long will the dog live without chemotherapy treatment? I said it would depend on which stage and infections. 2 months had been quoted in some reports. 2. How long will the dog live with chemotherapy? It depends on the disease and drugs. Remission (no enlarged lymph nodes) may be present for several months, prolonging the life of the dog. 3. Is there a permanent cure? No. 4. What's the cost? Varies with the type of treatment. Cost of blood monitoring. WHAT HAPPENED ON SUNDAY? There were free blood inside both eyes. The sclera were very red and from my experience the dog had rubbed his eyes vigorously due to pain in the abdomen. (From my cases of acute pancreatitis and reading other vet reports, the dog rubs his eyes to relieve his intense abdominal pain) causing bleeding. HOW DID I SOLVE THIS PROBLEM OF BLEEDING EYES AFFECTING VISION? 7 kg. BW. Domitor 0.1 ml, Ketamine 0.2 ml in one syringe IV. Dog stopped pacing and slept. Eye sclera became normal white (the owners could see this and were quite impressed). It is highly risky to give sedation in this situation. Give the lowest dose. Next day, the owner said the dog could see. The owner has to decide on whether to do chemotherapy.
376. Sunday case. No ringworm on post-purchase health check 3 weeks ago
INTERESTING CASES ON A SUNDAY
Sunday Mar 27, 2011
"My Jack Russell runs into chairs. He can't see today," I answered a phone call from a young lady on this unusually busy Sunday afternoon. "I wish to make an appointment." I usually don't work on Sunday afternoons and this was a bright sunshine day for photography. I have an associate vet on duty and that gives me time to smell the roses.
For some reasons, I decided to work this Sunday afternoon. The appointment system does not work in practice when patients bunch up their visits on Sunday afternoons. Some cases take longer (e.g minor surgery) and some patients don't come on time. The delays make several Singapore pet owners who come on time for their appointment very unhappy. The human medical hospitals have the same problem too. It is just not possible for the vet to see every patient punctually at the appointment time.
The best is no appointment. First come first served. But I prefer the appointment system as Toa Payoh Vets do perform surgeries even on Sundays.
So, on this particular Sunday afternoon, I skipped lunch and manned the reception counter to get a feel of the front-line phone calls and assess the waiting times. If my associate vet has to take some time in a case, I would step in. Otherwise, she would handle the cases as part of her working hours.
I usually arrive at 9.30 am on Sunday and weekday mornings to handle some cases while my associate comes at around 11 am. Sunday mornings seem to be quieter and I presume most Singaporeans are sleeping late or doing their own things.
At 10 am, a Caucasian couple in their late 30s came in with a cat. "My cat has ringworm and I also had ringworm," the lady said that she had her newly purchased cat examined 3 weeks ago by Vet 1 and was given a clear bill of health. Now she had ringworm and she diagnosed her cat with having ringworm.
I reviewed the medical record of Vet 1. I said: "There was a microscopic examination of the hairs and nothing abnormal was seen. It is possible that the ringworm takes time to develop and now 3 weeks later, the signs can be seen. The armpit and groin are big red circular patches of ringworm measuring at least 1 cm in diameter."
This is one of those post-purchase health-check for situations all vets will encounter. The animal is healthy at the time of examination to be free from signs and symptoms of contagious and infectious diseases. This must be stated in the form. In addition, I always draw the locations of the skin disease areas in the dog illustration in my case sheet and this is good practice so that the clients do not dispute that I have not checked the area and in cases of litigation.
As for Vet 1, the owner had complained to her about a small scab in the right armpit during her post-purchase examination 3 weeks ago. Vet 1 had checked it out by doing a microscopic examination of the hairs. No ringworm was reported by her.
Now, this is obviously a case of ringworm in the right armpit and groin area. The owner had now done her own diagnosis and she was spot on. "Ringworm can be transmitted from people to cats," I said. "It is not possible. I don't have ringworm before I purchased this cat 3 weeks ago. My kitten had a scab in the right armpit 3 weeks ago when I bought the cat to Vet 1."
The complainant was a lawyer by profession and it seemed she had evidence in her favour if this case goes to court. After all, she was a lawyer in a high flying firm and she can sue for failure to diagnose ringworm. The case for the defendant vet would be that she had done a competent job as what had been reasonably expected from a vet. This was the microscopic examination of the scab in the right armpit.
As Vet 1 did not record the location of the hairs she had taken for microscopic examination, I asked the lady owner.
When I asked the lady where the vet had plucked hairs for microscopic examination, she lifted the hairs from the spinal area indicating this area. This area was free from any skin disease!
Yet she told me she had complained about the scab in the right armpit area to Vet 1. So this would naturally be the area the vet had checked.
It is important for the vet to record in writing or by illustration or both locations of skin diseases.
As for this case, the treatment was the standard. I advised clipping of all hairs from the cat as there seems to be a generalised ringworm of the ventral part.
The lady did not want it and this was OK with me. If I had not advised and ringworm grows in the upper part of the body later (due to vigorous brushing and contamination of the upper body), I would suffer the same unhappiness of the owner.
"It is not nice to see a bald cat. I advise that the lower body of the cat be clipped bald so that you can apply the anti-fungal wash directly and then rinse off that infected skin area. The cat dislikes the whole body shampooing of the anti-fungal wash as there is a strong medicine smell."
The lady agreed to the lower body clipping and bathing and I advised her how to give the oral anti-fungal medication and to let me know if the cat had reactions to the drug.
One consultation would make an owner very happy as owners don't like repeat visits for ringworm! Happy owners usually are loyal clients. Therefore, be vigilant of a small scab in the armpit of the kitten, cat, puppy or dog during post-purchase examinations!
TIPS
POST-PURCHASE HEALTH CHECK
Ringworm may appear as a scab of 2 mm. I would advise that the area be thoroughly clipped and exposed. Then give it a wash and prescribe anti-ringworm wash. A microscopic examination negative for ringworm does NOT mean there is no ringworm. Veterinary medicine is always full of surprises.
PS
As for the Jack Russell that suddenly can't see, I will write the story in another report as it is 6.31 am on this Tuesday morning and I need to do other things.
Sunday Mar 27, 2011
"My Jack Russell runs into chairs. He can't see today," I answered a phone call from a young lady on this unusually busy Sunday afternoon. "I wish to make an appointment." I usually don't work on Sunday afternoons and this was a bright sunshine day for photography. I have an associate vet on duty and that gives me time to smell the roses.
For some reasons, I decided to work this Sunday afternoon. The appointment system does not work in practice when patients bunch up their visits on Sunday afternoons. Some cases take longer (e.g minor surgery) and some patients don't come on time. The delays make several Singapore pet owners who come on time for their appointment very unhappy. The human medical hospitals have the same problem too. It is just not possible for the vet to see every patient punctually at the appointment time.
The best is no appointment. First come first served. But I prefer the appointment system as Toa Payoh Vets do perform surgeries even on Sundays.
So, on this particular Sunday afternoon, I skipped lunch and manned the reception counter to get a feel of the front-line phone calls and assess the waiting times. If my associate vet has to take some time in a case, I would step in. Otherwise, she would handle the cases as part of her working hours.
I usually arrive at 9.30 am on Sunday and weekday mornings to handle some cases while my associate comes at around 11 am. Sunday mornings seem to be quieter and I presume most Singaporeans are sleeping late or doing their own things.
At 10 am, a Caucasian couple in their late 30s came in with a cat. "My cat has ringworm and I also had ringworm," the lady said that she had her newly purchased cat examined 3 weeks ago by Vet 1 and was given a clear bill of health. Now she had ringworm and she diagnosed her cat with having ringworm.
I reviewed the medical record of Vet 1. I said: "There was a microscopic examination of the hairs and nothing abnormal was seen. It is possible that the ringworm takes time to develop and now 3 weeks later, the signs can be seen. The armpit and groin are big red circular patches of ringworm measuring at least 1 cm in diameter."
This is one of those post-purchase health-check for situations all vets will encounter. The animal is healthy at the time of examination to be free from signs and symptoms of contagious and infectious diseases. This must be stated in the form. In addition, I always draw the locations of the skin disease areas in the dog illustration in my case sheet and this is good practice so that the clients do not dispute that I have not checked the area and in cases of litigation.
As for Vet 1, the owner had complained to her about a small scab in the right armpit during her post-purchase examination 3 weeks ago. Vet 1 had checked it out by doing a microscopic examination of the hairs. No ringworm was reported by her.
Now, this is obviously a case of ringworm in the right armpit and groin area. The owner had now done her own diagnosis and she was spot on. "Ringworm can be transmitted from people to cats," I said. "It is not possible. I don't have ringworm before I purchased this cat 3 weeks ago. My kitten had a scab in the right armpit 3 weeks ago when I bought the cat to Vet 1."
The complainant was a lawyer by profession and it seemed she had evidence in her favour if this case goes to court. After all, she was a lawyer in a high flying firm and she can sue for failure to diagnose ringworm. The case for the defendant vet would be that she had done a competent job as what had been reasonably expected from a vet. This was the microscopic examination of the scab in the right armpit.
As Vet 1 did not record the location of the hairs she had taken for microscopic examination, I asked the lady owner.
When I asked the lady where the vet had plucked hairs for microscopic examination, she lifted the hairs from the spinal area indicating this area. This area was free from any skin disease!
Yet she told me she had complained about the scab in the right armpit area to Vet 1. So this would naturally be the area the vet had checked.
It is important for the vet to record in writing or by illustration or both locations of skin diseases.
As for this case, the treatment was the standard. I advised clipping of all hairs from the cat as there seems to be a generalised ringworm of the ventral part.
The lady did not want it and this was OK with me. If I had not advised and ringworm grows in the upper part of the body later (due to vigorous brushing and contamination of the upper body), I would suffer the same unhappiness of the owner.
"It is not nice to see a bald cat. I advise that the lower body of the cat be clipped bald so that you can apply the anti-fungal wash directly and then rinse off that infected skin area. The cat dislikes the whole body shampooing of the anti-fungal wash as there is a strong medicine smell."
The lady agreed to the lower body clipping and bathing and I advised her how to give the oral anti-fungal medication and to let me know if the cat had reactions to the drug.
One consultation would make an owner very happy as owners don't like repeat visits for ringworm! Happy owners usually are loyal clients. Therefore, be vigilant of a small scab in the armpit of the kitten, cat, puppy or dog during post-purchase examinations!
TIPS
POST-PURCHASE HEALTH CHECK
Ringworm may appear as a scab of 2 mm. I would advise that the area be thoroughly clipped and exposed. Then give it a wash and prescribe anti-ringworm wash. A microscopic examination negative for ringworm does NOT mean there is no ringworm. Veterinary medicine is always full of surprises.
PS
As for the Jack Russell that suddenly can't see, I will write the story in another report as it is 6.31 am on this Tuesday morning and I need to do other things.
Monday, March 28, 2011
375. Sunday Case. Informed Decisions in veterinary medicine compared to real estate
Yesterday, Sunday, Mar 28, 2011, I saw the owner of the one-nose sneezing Miniature Schnauzer with his dog coming in for consultation with Dr Vanessa. I was present at Toa Payoh Vets from 9.30 am to 5.30 pm to help out and ensure that clients don't have to wait too long to consult Dr Vanessa who handles almost 100% of the caseload daily during her work hours. I would handle a case to shorten the waiting time on Sunday or if the client insists on seeing me.
The appointment system in human or veterinary medicine is not really efficient as clients don't come on time and vets can't complete cases on time too. Clients who make appointments and come on time may need to wait and they get angry.
I can't help them. Much depends on the complexity of the case and the number of clients and the need to force those without appointments to wait till the end of the day or to get lost as was a complaint to me by one client who went to a Chua Chu Kang practice without appointment! That is also not good for new clientele.
Now that I was stationed at the reception counter, I could see that some clients were quite annoyed at coming on time but having to wait. Yesterday was a busy Sunday for some reasons and I skipped lunch. My assistant Mr Saw needs to go out for lunch as his stomach cannot skip meals and so I manned the receptionist counter when he went for lunch. I would still be at the receptionist counter but Mr Saw would handle the payment if he was around. In this way, I could feel the pulse of the waiting room and supervise the associate vet as a licensee responsible for my licence to operate a veterinary clinic.
Some vets issue a ticket number and make sure that clients with no appointments are attended to last. But this is not practical as there are clients with appointments coming late.
3 incidents on this Sunday were memorable. I shall mention one here as I have not much time this Monday morning 7.28 am.
This was a matter related to INFORMED DECISIONS as related to real estate and veterinary medicine and I shall show the comparisons. I am studying the REA course (minimum 75% attendance at class of 12 weeks, 3x/week) which, if I pass will license me to be a KEO (Key Executive Officer) of www.asiahomes.com. In other words, a licensee to operate a real estate agency. Presently all vets with over a year of practice experience (supervision) can become a KEO or licensee when they want to open their own veterinary clinic or hospital. No exams are required. To be a KEO of a housing agency, the person must have 3 years of experience and handles at least 30 real estate cases. If not, he just become a salesperson after passing the RES examinations.
INFORMED DECISIONS IN REAL ESTATE
In real estate, the URA has mandated that the developers do the following:
1. Developers to issue price listings 2 days before a property launch. A price list 2 days before a property launch.
2. Developers to issue transacted prices weekly (compared to 2-6 weeks previously). Weekly transacted price list.
3. Developers to give accurate depictions of show flats (compared to fanciful and incorrect floor areas, knocked down walls to con the buyers).
4. URA extends control over web advertisements of developers.
I may get an exam question about the above in the REA exam in late May 2011!
INFORMED DECISIONS IN VETERINARY MEDICINE
1. Vets to issue a price list of common operations and procedures. This is mandated by the AVA. A list is displayed on the reception area. But no need to issue price list 2 days before the operation or consultation!
2. Vets don't have to show a price list weekly as regards new operations! A quotation is usually given by me.
3. Vets don't have to give accurate depictions of surgeries to be done! I do some illustrations and drawings of certain operations or refer some clients to my www.toapayohvets.com webpages for those operations so as to give them INFORMED DECISIONS.
4. Web advertisements by vets? This is a matter that is being studied by the AVA to the best of my knowledge. There is the code of ethics which the AVA may adopt from the SVA but I don't have the full details yet.
CONCLUSION
Informed decisions are the best way to build up the trust of the client. In the case of the one-nose sneezing Schnauzer, the owner first consulted me in Nov 2009 after he had been to a brand-name vet practice which had been too expensive for him. He had been to Toa Payoh Vets around once in 2 months to treat the sneezing or runny nose (one-sided).
I said to him yesterday again: "You know, a surgery to remove the infected fungal lump at the back of the nose will most likely resolve your dog's problem." He and his wife did not want the operation and after some days of anti-fungal drugs, the dog would recover. Then the dog would sneeze and a one-side runny nostril would be present. The brand name vet had quoted $4,000 for the surgery. In any case, his wife did not want the surgery and so, the dog comes in every 2 months from November 2009 to yesterday Mar 28, 2011.
I had given him an informed decision. It is up to the owners to decide. There is danger of the dog dying or getting infected from the surgery to open up the back of the nose and extract the fungal lump (seen on the X-ray from the brand-name Vet practice in Nov 2009) in one nostril.
Since he was well informed about the outcome without surgery, there would be no animosity or complaint should the dog fail to recover after some time on medical treatment as the fungal or nasal growth becomes enlarged. So far, he is satisfied and happy with treatment from my associate vet. I am happy for him too. For best practice, I ought to write down in the case sheet that I had spoken to him about the prognosis and surgical treatment.
.
The appointment system in human or veterinary medicine is not really efficient as clients don't come on time and vets can't complete cases on time too. Clients who make appointments and come on time may need to wait and they get angry.
I can't help them. Much depends on the complexity of the case and the number of clients and the need to force those without appointments to wait till the end of the day or to get lost as was a complaint to me by one client who went to a Chua Chu Kang practice without appointment! That is also not good for new clientele.
Now that I was stationed at the reception counter, I could see that some clients were quite annoyed at coming on time but having to wait. Yesterday was a busy Sunday for some reasons and I skipped lunch. My assistant Mr Saw needs to go out for lunch as his stomach cannot skip meals and so I manned the receptionist counter when he went for lunch. I would still be at the receptionist counter but Mr Saw would handle the payment if he was around. In this way, I could feel the pulse of the waiting room and supervise the associate vet as a licensee responsible for my licence to operate a veterinary clinic.
Some vets issue a ticket number and make sure that clients with no appointments are attended to last. But this is not practical as there are clients with appointments coming late.
3 incidents on this Sunday were memorable. I shall mention one here as I have not much time this Monday morning 7.28 am.
This was a matter related to INFORMED DECISIONS as related to real estate and veterinary medicine and I shall show the comparisons. I am studying the REA course (minimum 75% attendance at class of 12 weeks, 3x/week) which, if I pass will license me to be a KEO (Key Executive Officer) of www.asiahomes.com. In other words, a licensee to operate a real estate agency. Presently all vets with over a year of practice experience (supervision) can become a KEO or licensee when they want to open their own veterinary clinic or hospital. No exams are required. To be a KEO of a housing agency, the person must have 3 years of experience and handles at least 30 real estate cases. If not, he just become a salesperson after passing the RES examinations.
INFORMED DECISIONS IN REAL ESTATE
In real estate, the URA has mandated that the developers do the following:
1. Developers to issue price listings 2 days before a property launch. A price list 2 days before a property launch.
2. Developers to issue transacted prices weekly (compared to 2-6 weeks previously). Weekly transacted price list.
3. Developers to give accurate depictions of show flats (compared to fanciful and incorrect floor areas, knocked down walls to con the buyers).
4. URA extends control over web advertisements of developers.
I may get an exam question about the above in the REA exam in late May 2011!
INFORMED DECISIONS IN VETERINARY MEDICINE
1. Vets to issue a price list of common operations and procedures. This is mandated by the AVA. A list is displayed on the reception area. But no need to issue price list 2 days before the operation or consultation!
2. Vets don't have to show a price list weekly as regards new operations! A quotation is usually given by me.
3. Vets don't have to give accurate depictions of surgeries to be done! I do some illustrations and drawings of certain operations or refer some clients to my www.toapayohvets.com webpages for those operations so as to give them INFORMED DECISIONS.
4. Web advertisements by vets? This is a matter that is being studied by the AVA to the best of my knowledge. There is the code of ethics which the AVA may adopt from the SVA but I don't have the full details yet.
CONCLUSION
Informed decisions are the best way to build up the trust of the client. In the case of the one-nose sneezing Schnauzer, the owner first consulted me in Nov 2009 after he had been to a brand-name vet practice which had been too expensive for him. He had been to Toa Payoh Vets around once in 2 months to treat the sneezing or runny nose (one-sided).
I said to him yesterday again: "You know, a surgery to remove the infected fungal lump at the back of the nose will most likely resolve your dog's problem." He and his wife did not want the operation and after some days of anti-fungal drugs, the dog would recover. Then the dog would sneeze and a one-side runny nostril would be present. The brand name vet had quoted $4,000 for the surgery. In any case, his wife did not want the surgery and so, the dog comes in every 2 months from November 2009 to yesterday Mar 28, 2011.
I had given him an informed decision. It is up to the owners to decide. There is danger of the dog dying or getting infected from the surgery to open up the back of the nose and extract the fungal lump (seen on the X-ray from the brand-name Vet practice in Nov 2009) in one nostril.
Since he was well informed about the outcome without surgery, there would be no animosity or complaint should the dog fail to recover after some time on medical treatment as the fungal or nasal growth becomes enlarged. So far, he is satisfied and happy with treatment from my associate vet. I am happy for him too. For best practice, I ought to write down in the case sheet that I had spoken to him about the prognosis and surgical treatment.
.
Consumer rights websites in Singapore
Straits Times Mar 20, 2011
"Click and gripe" Hot 5
All Deals Leak, Redress.me and Boo-n-Bouquet (blog) champion Singapore's consumer rights. The Consumer Association of Singapore CASE is the main official channel for Singaporean complaints but it is quite a hassle to write to them. Now with these online service and product consumer rights websites that are not worried about being sued by the affected parties as they permit two sides of the story and also it is costly and impossible to get adverse posts removed, many service providers will receive bad publicity for services not up to expectations.
IMPLICATIONS FOR VETERINARIANS
I don't go around reading such websites and blogs although I have had seen one or two bad reviews of services of Toa Payoh Vets in a pet website called www.petschannel.com
This pet website just publishes all complaints and ratings. Competitors could just publish with impunity. The website just publish "Any opinions expressed are those of the individual reviewers. See disclaimer statement."
RIGHT OF REPLY
However one of the 3 above online posts say they e-mail the affected party and publish their replies.
PREVENTION
Prevention is best and as a licensee of Toa Payoh Vets, I have to ensure and check that my associate vets provide the standard of services expected from a "reasonable" man. It is just too much time consuming to surf the internet to read about complaints although they are excellent feedback to improve my veterinary services and care.
ANONYMOUS POSTINGS. There is much more power to the consumer since the one posting the complaints usually are anonymous.
One brand name vet practice had postings saying that their vets are bad and that their dogs die during treatment or anaesthesia there. Another reader would write to say he or she has better not go to this practice. "What is the name of the vet or the practice?" another writer would ask.
Sometimes I wonder whether it is the work of the competitors to run down the other party.
UPDATES AS AT MAR 28, 2011
I just log onto www.petschannel.com now at 3.46 am since I am writing this article on consumer rights online. I had not been to this website for several months. Some years ago, it publishes the good and bad comments of going to various vet clinics listed in this website. Now, it wants money from vet owners to write about the business and publish all members' reviews without limit.
I don't subscribe to this service and I note most of my competitors don't bother to do so.
As at Mar 28, 2011, Toa Payoh Vets has 15 reviews written.
I was surprised to read the latest two reviews (part published) by jologflg on Jan 10, 2011 and by samanthayap on Nov 10, 2010.
1. For jologflg, I can see his photo and he is a genuine client. He published in Jan 10, 2011 in Shoppe Place reviews as follows:
5 stars shown. Jan 10, 2011. Toa Payoh Vets>>Dr Sing-experienced, treats disease ot symptoms, good surgeon (2 ne...
If you click on the hyperlink above, you will get no more info as I don't pay to this website to get full reviews!
2. For samanthayap, there is a graphic photo of a young lady. In the Shoppe Place reviews, she wrote as follows:
4 stars shown. Nov 10, 2010. Toa Payoh Vets >>Dr Vanessa attended to me today and I would say, she's friendly and ca...
Well, since I didn't pay up, I can't read what the lady who has a picture of Hammie born Oct 2010 say about Dr Vanessa!
It is just like reading the opening paragraph of a page-turning novel. You got to buy it to know what is going to happen next! Well, I don't know as I don't subscribe to this website to get the good and the bad reviews!
The website used to give marks using a formula for reliability, frequency of postings etc. Since I don't pay, I don't get the grades. It is just too time-consuming to surf to consumer rights websites unless one has a lot of staff but they exist and so the vets must provide the best service and be street-wise as well. You don't want to end up with one comment about a competitor in this website. The comment is as follows:
2.5 stars. Mar 2, 2011>>XXX (name listed)>>I urge all of you not to go to thi...
CONCLUSION
The above can be a lesson in good writing. When you write a resume or look for a publisher, your cover letter should have a good "hook" to catch the reader's attention and consider reading your letter or buy your book.
"Click and gripe" Hot 5
All Deals Leak, Redress.me and Boo-n-Bouquet (blog) champion Singapore's consumer rights. The Consumer Association of Singapore CASE is the main official channel for Singaporean complaints but it is quite a hassle to write to them. Now with these online service and product consumer rights websites that are not worried about being sued by the affected parties as they permit two sides of the story and also it is costly and impossible to get adverse posts removed, many service providers will receive bad publicity for services not up to expectations.
IMPLICATIONS FOR VETERINARIANS
I don't go around reading such websites and blogs although I have had seen one or two bad reviews of services of Toa Payoh Vets in a pet website called www.petschannel.com
This pet website just publishes all complaints and ratings. Competitors could just publish with impunity. The website just publish "Any opinions expressed are those of the individual reviewers. See disclaimer statement."
RIGHT OF REPLY
However one of the 3 above online posts say they e-mail the affected party and publish their replies.
PREVENTION
Prevention is best and as a licensee of Toa Payoh Vets, I have to ensure and check that my associate vets provide the standard of services expected from a "reasonable" man. It is just too much time consuming to surf the internet to read about complaints although they are excellent feedback to improve my veterinary services and care.
ANONYMOUS POSTINGS. There is much more power to the consumer since the one posting the complaints usually are anonymous.
One brand name vet practice had postings saying that their vets are bad and that their dogs die during treatment or anaesthesia there. Another reader would write to say he or she has better not go to this practice. "What is the name of the vet or the practice?" another writer would ask.
Sometimes I wonder whether it is the work of the competitors to run down the other party.
UPDATES AS AT MAR 28, 2011
I just log onto www.petschannel.com now at 3.46 am since I am writing this article on consumer rights online. I had not been to this website for several months. Some years ago, it publishes the good and bad comments of going to various vet clinics listed in this website. Now, it wants money from vet owners to write about the business and publish all members' reviews without limit.
I don't subscribe to this service and I note most of my competitors don't bother to do so.
As at Mar 28, 2011, Toa Payoh Vets has 15 reviews written.
I was surprised to read the latest two reviews (part published) by jologflg on Jan 10, 2011 and by samanthayap on Nov 10, 2010.
1. For jologflg, I can see his photo and he is a genuine client. He published in Jan 10, 2011 in Shoppe Place reviews as follows:
5 stars shown. Jan 10, 2011. Toa Payoh Vets>>Dr Sing-experienced, treats disease ot symptoms, good surgeon (2 ne...
If you click on the hyperlink above, you will get no more info as I don't pay to this website to get full reviews!
2. For samanthayap, there is a graphic photo of a young lady. In the Shoppe Place reviews, she wrote as follows:
4 stars shown. Nov 10, 2010. Toa Payoh Vets >>Dr Vanessa attended to me today and I would say, she's friendly and ca...
Well, since I didn't pay up, I can't read what the lady who has a picture of Hammie born Oct 2010 say about Dr Vanessa!
It is just like reading the opening paragraph of a page-turning novel. You got to buy it to know what is going to happen next! Well, I don't know as I don't subscribe to this website to get the good and the bad reviews!
The website used to give marks using a formula for reliability, frequency of postings etc. Since I don't pay, I don't get the grades. It is just too time-consuming to surf to consumer rights websites unless one has a lot of staff but they exist and so the vets must provide the best service and be street-wise as well. You don't want to end up with one comment about a competitor in this website. The comment is as follows:
2.5 stars. Mar 2, 2011>>XXX (name listed)>>I urge all of you not to go to thi...
CONCLUSION
The above can be a lesson in good writing. When you write a resume or look for a publisher, your cover letter should have a good "hook" to catch the reader's attention and consider reading your letter or buy your book.
Sunday, March 27, 2011
373. Continuing education - Veterinary Anaesthesia - sharing tips
The following tips from fellow vets were given to me at the Veterinary anaesthesia continuing education of Mar 26, 2011 by Dr Kieren Maddern, European Specialist in Veterinary Anaesthesia:
1. INJECTABLE ANAESTHESIA from a practice in Malacca.
According to the vet who runs a practice in Malacca, the UPM professors had been using the following formula safely and effectively for the past 15 years. He had been using it for the past 10 years.
1.1
Zoletil 100 (don't use the diluent provided).
Add in the bottle 8 ml of ketamine
Add in the bottle 2 ml of xylazine
Dose: 0.04ml/kg IM. 0.03ml/kg very slow IV.
Use isoflurane gas if needed or top up 1/2 to 1/3 dose IM when the dog wakes up.
1.2
Zoletil 50 (don't use the diluent provided).
Add in the bottle 4 ml of ketamine
Add in the bottle 1 ml of xylazine
Dose: 0.04ml/kg IM. 0.03ml/kg very slow IV.
Use isoflurane gas if needed or top up 1/2 to 1/3 dose IM when the dog wakes up.
1.3 For CATS
Be careful. Use the IV dosage for IM injection. That is 0.093 ml/kg for IM.
Top up if necessary.
Zoletil is an expensive drug and therefore the above combinations is less expensive and effective and safer.
2. Lecturer's tips
Ketamine & ACP - excellent for cats. Ketamine alone makes the cat's body
rigid. Seldom use atropine (makes throat dry).
3. A Singapore's vet's tips
Xyalzine + Atropine + Ketamine. Then use isoflurane gas.
Each vet has is own method. If he uses new drugs e.g. N2O, the dog may die.
1. INJECTABLE ANAESTHESIA from a practice in Malacca.
According to the vet who runs a practice in Malacca, the UPM professors had been using the following formula safely and effectively for the past 15 years. He had been using it for the past 10 years.
1.1
Zoletil 100 (don't use the diluent provided).
Add in the bottle 8 ml of ketamine
Add in the bottle 2 ml of xylazine
Dose: 0.04ml/kg IM. 0.03ml/kg very slow IV.
Use isoflurane gas if needed or top up 1/2 to 1/3 dose IM when the dog wakes up.
1.2
Zoletil 50 (don't use the diluent provided).
Add in the bottle 4 ml of ketamine
Add in the bottle 1 ml of xylazine
Dose: 0.04ml/kg IM. 0.03ml/kg very slow IV.
Use isoflurane gas if needed or top up 1/2 to 1/3 dose IM when the dog wakes up.
1.3 For CATS
Be careful. Use the IV dosage for IM injection. That is 0.093 ml/kg for IM.
Top up if necessary.
Zoletil is an expensive drug and therefore the above combinations is less expensive and effective and safer.
2. Lecturer's tips
Ketamine & ACP - excellent for cats. Ketamine alone makes the cat's body
rigid. Seldom use atropine (makes throat dry).
3. A Singapore's vet's tips
Xyalzine + Atropine + Ketamine. Then use isoflurane gas.
Each vet has is own method. If he uses new drugs e.g. N2O, the dog may die.
372. Continuing education - Veterinary Anaesthesia & tarsorrhapy advice
Yesterday, Saturday March 27, 2011, I attended a continuing education lecture by a veterinary anaesthesia specialist, Dr Kieren Maddern, BVSc (Hons), MACVSc, Dip ECVAA, European Specialist in Veterinary Anaesthesia. The topic was "Overcoming the odds - Anaesthesia for difficult situations."
It was a very well attended lecture - some 70 people there. An excellent lecture. I caught up with a senior vet who has done a few thousand dog and cat surgeries over the last 40 years and asked his advices about young vets referring corneal ulcer cases to other practices.
He said: "The young vet may find that it is a difficult case or that the owners are the type liable to sue. So, just refer the case out. Or the young vet thinks that you can't do the surgery! He or she does not usually ask for advice but just refer!
"When the case goes from Toa Payoh Vets to the other vet, the other vet will just laugh and say 'Dr Sing does not even know how to operate a simple corneal ulcer case! What's wrong with him?' Maybe you should give instructions that all cases that your younger vets want to refer to others should go through you!"
I was not alone in having this problem of the younger vets doing their own thing without consulting the senior vets in the practice.
The senior vet told me: "Tarsorrhapy is very effective in corneal ulcer cases. Even in cases where the eyeball collapses. Just sew up the two eyelids and the outcome is usually very good. I find that the eyeball is seldom infected even with perforated ulcers."
I listened attentively for the free advice. The senior vet is 5 years older than me just in case but he puts in the very long hours and do the after hours emergencies. High energy and therefore he has more caseload experiences.
"By the way, how do you treat corneal ulcers in the dog?" my mentor asked.
"I am more kiasu," I said. "I do the 3rd eyelid flap and tarsorrhapy." Not all the time, but sometimes.
The pictures of my case in a Jack Russell are shown below.
It was a very well attended lecture - some 70 people there. An excellent lecture. I caught up with a senior vet who has done a few thousand dog and cat surgeries over the last 40 years and asked his advices about young vets referring corneal ulcer cases to other practices.
He said: "The young vet may find that it is a difficult case or that the owners are the type liable to sue. So, just refer the case out. Or the young vet thinks that you can't do the surgery! He or she does not usually ask for advice but just refer!
"When the case goes from Toa Payoh Vets to the other vet, the other vet will just laugh and say 'Dr Sing does not even know how to operate a simple corneal ulcer case! What's wrong with him?' Maybe you should give instructions that all cases that your younger vets want to refer to others should go through you!"
I was not alone in having this problem of the younger vets doing their own thing without consulting the senior vets in the practice.
The senior vet told me: "Tarsorrhapy is very effective in corneal ulcer cases. Even in cases where the eyeball collapses. Just sew up the two eyelids and the outcome is usually very good. I find that the eyeball is seldom infected even with perforated ulcers."
I listened attentively for the free advice. The senior vet is 5 years older than me just in case but he puts in the very long hours and do the after hours emergencies. High energy and therefore he has more caseload experiences.
"By the way, how do you treat corneal ulcers in the dog?" my mentor asked.
"I am more kiasu," I said. "I do the 3rd eyelid flap and tarsorrhapy." Not all the time, but sometimes.
The pictures of my case in a Jack Russell are shown below.
Saturday, March 26, 2011
371. Studying vet in the USA after A levels? Not possible?
Dr Sing Kong Yuen
Dear Sir,
I am involved with recruitment for the Freeman Scholarship Program at Wesleyan University in Middletown, Connecticut in the US. We did a recruitment session recently for our finalists. One is a lady with a strong interest in becoming a veterinarian.
I believe we are badly-positioned to help her realize her dreams. Specifically, vet schools in the US are graduate programs, requiring the applicant first complete four years of undergraduate study …. Then take the MCAT exams and go through the entire school admissions process again!
I suggested to her school systems that work on the British system, such as Glasgow. I also suggested the AVA scholarship program. I noted from your website that you attended Glasgow on the Colombo Plan, served with the SAF Provost Dog Unit, tended race horses for the Bukit Timah Club, started your own clinic, and are now headed into happy retirement.
You have walked the path that she is considering. Might you have a moment to take a call from her and give her the wisdom that comes from real experience?
I am an ex-infantry officer who spent his life as a civil engineer building prisons, police compounds and the coastal barrier for the Singapore government. My ability to guide her is terribly limited.
Thank you so much for any help you can give.
With best regards,
Name given
REPLY FROM DR SING DATED MAR 24, 2011
Hi
Thank you for your email. I can always spare more than a few minutes to meet one-on-one to the young lady who wants to be a veterinarian. Phone calls are a waste of time if the persons are sincerely interested in knowing more about veterinary medicine and surgery. During the meeting, I can assess whether the young lady is really passionate about veterinary medicine and surgery. Phone calls and text messages and emails are preferred by the younger generation who don't have the real interests or passion and merely wants to go fishing.
Let me know as soon as possible. I don't know where you get the impression that I am into "happy retirement". I have an associate veterinarian who is younger and takes care of many of my old clientele as there is insufficient rooms for 2 vets at any one time. I still consult and yesterday I spayed a Fox Terrier as the owner wanted me to do it. I am even busier than before in veterinary medicine, travel and real estate.
I hope we can meet one day and not just e-mail. Best wishes.
E-MAIL FROM DR SING DATED MAR 25, 2011
To: ....
Sent: Friday, March 25, 2011 12:44 AM
Subject: Re: Fw: For Dr Sing Kong Yuen
Hi
Yesterday, I told a prospective intern who had straight As (except one B) in her A levels to go home since she could not work the hours required of an intern. Her father had objected to her working "long hours" and she had phoned me yesterday wanting to negotiate to shorter hours. This young lady, about to venture overseas to study in the U.S and accepted by US vet school is still tied to the apron's strings. Can excellent "A" level results open a place to study vet medicine in US universities as apparently is the case in this lady.
REPLY TO DR SING DATED MAR 26, 2011
Dear Dr. Sing,
Thank you very much for taking so much time with me.
What that perspective/rejected intern told you does not make sense to me. I pulled the below off the Veterinary Medical College Application Service website:
Major- Choose a major in an area that interests you. You do not have to be a science major to go to osteopathic medical school. However, you must complete certain course requirements. Most osteopathic medical schools require the same courses as allopathic medical schools, listed below:
1 year of physics with lab
1 year of general chemistry with lab
1 year of organic chemistry with lab
1 year of biology with lab
1 year of english
Requirements do vary between schools. Many schools require biochemistry and genetics in addition .
As you can see, the American system requires one to take a four year undergraduate liberal arts curriculum before they even apply to vet school.
Might that prospective intern have been mistaken in her assumption she could apply directly to an American vet school?
P.S
On your second query: No I have never met Gerald of .... Properties! I train with a guy named Gerald at the NUSS gym, but I believe he is a teacher.
I am actually ex-US Army and ex-civil engineer (retired).
I was involved in a recruitment exercise for my old university held down in the (location given).
We got the usual collection of arts-stream types who all want to be writers or artists. But we got one applicant who stood out; this lady was math/science, wanted to be a vet, and seemed to have her priorities straight.
Our admissions officer made some ... comments about this student's career plans (apparently they wanted her to study political science!).
I had an ugly confrontation with the admissions officer after the meeting, then I went on the computer and started googling information on proper vet programs and veterinary career paths.
Your name stuck with me because you had been commander & veterinary officer of guard & tracker dogs with the Provost Guard Dog Unit. I also noted you had worked with race horses at Bukit Timah and now had your own clinic. You had been a government scholar.
I wrote you because you had the right background. I can tell this student not to waste her time with political science. But only you can set her on the right path.
If you have a moment, I can bring her by your clinic. She wrote me asking whether next Tuesday would be okay. If that day is convenient, I will bring her to:
Block 1002, Toa Payoh Lorong 8
#01-1477
Just let me know what time is convenient.
I will disappear during the meeting and you will be free to give her the good, the bad, and the ugly of her career choice.
Thanks so much.
Name given
-----------------
UPDATE MAR 27, 2011 FROM Dr Sing
Will meet prospective vet student on next Tues Mar 29, 2011 11 am at Toa Payoh Vets
Dear Sir,
I am involved with recruitment for the Freeman Scholarship Program at Wesleyan University in Middletown, Connecticut in the US. We did a recruitment session recently for our finalists. One is a lady with a strong interest in becoming a veterinarian.
I believe we are badly-positioned to help her realize her dreams. Specifically, vet schools in the US are graduate programs, requiring the applicant first complete four years of undergraduate study …. Then take the MCAT exams and go through the entire school admissions process again!
I suggested to her school systems that work on the British system, such as Glasgow. I also suggested the AVA scholarship program. I noted from your website that you attended Glasgow on the Colombo Plan, served with the SAF Provost Dog Unit, tended race horses for the Bukit Timah Club, started your own clinic, and are now headed into happy retirement.
You have walked the path that she is considering. Might you have a moment to take a call from her and give her the wisdom that comes from real experience?
I am an ex-infantry officer who spent his life as a civil engineer building prisons, police compounds and the coastal barrier for the Singapore government. My ability to guide her is terribly limited.
Thank you so much for any help you can give.
With best regards,
Name given
REPLY FROM DR SING DATED MAR 24, 2011
Hi
Thank you for your email. I can always spare more than a few minutes to meet one-on-one to the young lady who wants to be a veterinarian. Phone calls are a waste of time if the persons are sincerely interested in knowing more about veterinary medicine and surgery. During the meeting, I can assess whether the young lady is really passionate about veterinary medicine and surgery. Phone calls and text messages and emails are preferred by the younger generation who don't have the real interests or passion and merely wants to go fishing.
Let me know as soon as possible. I don't know where you get the impression that I am into "happy retirement". I have an associate veterinarian who is younger and takes care of many of my old clientele as there is insufficient rooms for 2 vets at any one time. I still consult and yesterday I spayed a Fox Terrier as the owner wanted me to do it. I am even busier than before in veterinary medicine, travel and real estate.
I hope we can meet one day and not just e-mail. Best wishes.
E-MAIL FROM DR SING DATED MAR 25, 2011
To: ....
Sent: Friday, March 25, 2011 12:44 AM
Subject: Re: Fw: For Dr Sing Kong Yuen
Hi
Yesterday, I told a prospective intern who had straight As (except one B) in her A levels to go home since she could not work the hours required of an intern. Her father had objected to her working "long hours" and she had phoned me yesterday wanting to negotiate to shorter hours. This young lady, about to venture overseas to study in the U.S and accepted by US vet school is still tied to the apron's strings. Can excellent "A" level results open a place to study vet medicine in US universities as apparently is the case in this lady.
REPLY TO DR SING DATED MAR 26, 2011
Dear Dr. Sing,
Thank you very much for taking so much time with me.
What that perspective/rejected intern told you does not make sense to me. I pulled the below off the Veterinary Medical College Application Service website:
Major- Choose a major in an area that interests you. You do not have to be a science major to go to osteopathic medical school. However, you must complete certain course requirements. Most osteopathic medical schools require the same courses as allopathic medical schools, listed below:
1 year of physics with lab
1 year of general chemistry with lab
1 year of organic chemistry with lab
1 year of biology with lab
1 year of english
Requirements do vary between schools. Many schools require biochemistry and genetics in addition .
As you can see, the American system requires one to take a four year undergraduate liberal arts curriculum before they even apply to vet school.
Might that prospective intern have been mistaken in her assumption she could apply directly to an American vet school?
P.S
On your second query: No I have never met Gerald of .... Properties! I train with a guy named Gerald at the NUSS gym, but I believe he is a teacher.
I am actually ex-US Army and ex-civil engineer (retired).
I was involved in a recruitment exercise for my old university held down in the (location given).
We got the usual collection of arts-stream types who all want to be writers or artists. But we got one applicant who stood out; this lady was math/science, wanted to be a vet, and seemed to have her priorities straight.
Our admissions officer made some ... comments about this student's career plans (apparently they wanted her to study political science!).
I had an ugly confrontation with the admissions officer after the meeting, then I went on the computer and started googling information on proper vet programs and veterinary career paths.
Your name stuck with me because you had been commander & veterinary officer of guard & tracker dogs with the Provost Guard Dog Unit. I also noted you had worked with race horses at Bukit Timah and now had your own clinic. You had been a government scholar.
I wrote you because you had the right background. I can tell this student not to waste her time with political science. But only you can set her on the right path.
If you have a moment, I can bring her by your clinic. She wrote me asking whether next Tuesday would be okay. If that day is convenient, I will bring her to:
Block 1002, Toa Payoh Lorong 8
#01-1477
Just let me know what time is convenient.
I will disappear during the meeting and you will be free to give her the good, the bad, and the ugly of her career choice.
Thanks so much.
Name given
-----------------
UPDATE MAR 27, 2011 FROM Dr Sing
Will meet prospective vet student on next Tues Mar 29, 2011 11 am at Toa Payoh Vets
370. Procedure and costs of dental scaling at Toa Payoh Vets in 2011
E-MAIL TO DR SING DATED MAR 25, 2011
--- On Fri, 25/3/11, ...@hotmail.com> wrote:
Subject: Scaling for dogs
To: judy@toapayohvets.com
Received: Friday, 25 March, 2011, 2:00 PM
Hi,
I am looking for a trusted vet and doctor who can perform scaling on my 2 year old chihuahua. I am interested upon sending her to Toa Payoh Vets. I would like to know how much it would cost and what I should do to prepare her for the day of her visit.
Thank you,
Name given
E-MAIL REPLY FROM DR SING DATED MAR 26, 2011
Hi
I am Dr Sing from Toa Payoh Vets. Thank you for your email to Judy.
The dental scaling plus anaesthesia cost is around $250 normally. Decayed tooth extraction will be around $10-$20 per tooth extracted. Medication of antibiotics and pain-killer is estimated at around $20 if necessary. Blood test for pre-anaesthesia risk checking will not be done in normal healthy dogs and will cost $150 if it is needed but you will be informed first.
Do not feed or give water to your dog after 10 pm the night before the dental work. Bring your dog to Toa Payoh Vets are 10 a.m. The dog will go home around 5pm usually after rest and recovery from general anaesthesia.
Pl make an appointment at 6254 3326. Pl indicate which vet you will prefer. These are Dr Sing, Dr Vanessa Lin and Dr Jason Teo.
--- On Fri, 25/3/11, ...@hotmail.com> wrote:
Subject: Scaling for dogs
To: judy@toapayohvets.com
Received: Friday, 25 March, 2011, 2:00 PM
Hi,
I am looking for a trusted vet and doctor who can perform scaling on my 2 year old chihuahua. I am interested upon sending her to Toa Payoh Vets. I would like to know how much it would cost and what I should do to prepare her for the day of her visit.
Thank you,
Name given
E-MAIL REPLY FROM DR SING DATED MAR 26, 2011
Hi
I am Dr Sing from Toa Payoh Vets. Thank you for your email to Judy.
The dental scaling plus anaesthesia cost is around $250 normally. Decayed tooth extraction will be around $10-$20 per tooth extracted. Medication of antibiotics and pain-killer is estimated at around $20 if necessary. Blood test for pre-anaesthesia risk checking will not be done in normal healthy dogs and will cost $150 if it is needed but you will be informed first.
Do not feed or give water to your dog after 10 pm the night before the dental work. Bring your dog to Toa Payoh Vets are 10 a.m. The dog will go home around 5pm usually after rest and recovery from general anaesthesia.
Pl make an appointment at 6254 3326. Pl indicate which vet you will prefer. These are Dr Sing, Dr Vanessa Lin and Dr Jason Teo.
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