For bad cases, I advise in-patient treatment. It takes over 2 weeks to get the eyes open if the case is moderately serious. See one case below:
Friday, April 22, 2011
412. Puffy and closed eyes for 2 months in a red-eared slider
Many vets prefer not to treat the puffy & closed eyes red-eared sliders. In Singapore and all over the world, this condition is most common. It is said to be due to insufficient Vit A. In my observation, it is the poor quality of water.
For bad cases, I advise in-patient treatment. It takes over 2 weeks to get the eyes open if the case is moderately serious. See one case below:
For bad cases, I advise in-patient treatment. It takes over 2 weeks to get the eyes open if the case is moderately serious. See one case below:
Wednesday, April 20, 2011
411. A fast-growing backside tumour in an old Dachshund - a lipoma or liposarcoma?
"The lump on the right backside grows quite fast," the lady owner pointed to a 1.5 x 2 cm globular swelling to the right of the anus. "There are 4 other smaller lumps."
She was concerned about the large lump as it grows bigger every day. Could this be a liposarcoma (malignant growth) instead of a lipoma? Although middle-aged and old dogs, overweight female dogs do develop lipomas which are benign, I don't ask the owner to wait and see approach.
In one instance, Vet 1 had asked the owner of a Labrador Retriever to wait and see when the owner complained about a small globular growth above the neck of the dog. As typical of the busy Singapore owners, the owners waited till the lump becomes half the size of a tennis ball. When I saw it, it was a malignant tumour as it recurs after excision. "Well, Vet 1 had said that there was no need to remove the tumour when it was small," the owners said. Eventually, the dog had to be euthanased. From this experience, it is best NOT to advise the owner to wait and see. Give the owner the option to get the tumour resected and let her decide. The vet should not assume that every tumour under the skin is a lipoma and is benign.
In this female spayed Dachshund of 8.5kg, the owner had knowledge and asked me to operate. She was worried about the anaesthetic risk. A blood test showed the dog to be healthy for anaesthesia. Still the risks of death on the operating table are made known to her. She accepted the risks.
"Don't ask the vet to perform surgery during weekends or public holidays as the vet is busy and may need to rush through the surgery," I advised her and most clients that any rushed anaesthesia and surgery will not be in the interest of the patient.
I operated on April 19, 2011, a Tuesday morning at 10 am as scheduled and the owner arrived early. No food and water from 10 pm the night before. She used a marker pen to ink the 5 lumps as instructed by me. I still took one hour in total just to remove 5 fatty tumours and that included preparation, IV drip and surgery. The electro-surgery took around 30 minutes. Can't be shorter.
SEDATION
0.2 ml xylazine IM. My new assistant Mr Min asked if I wanted to give xylazine IV as I sometimes do. "No," I said. Isoflurane gas by mask was smooth and uneventful. The dog slept like a log. Intubated the dog to get oxygen and gas in. The anaesthetic machine was not leaking gas after industrial glue was applied to the hairline crack in the base tubing 2 days ago. 0.5 - 2% isoflurane gas was sufficient. "Keep to 0.5% and not less," I said to my assistant as he knew that the less the safer for the patient. But too little may lead to the dog waking up and delaying my surgery! A good assistant during anaesthesia is worth his or her weight in gold as vets don't have the luxury of the tax-payer's money to have an anaesthetist and the best equipment like the Singapore General Hospital.
ELECTRO-RESECTION
I like electro-surgery for such cases. No bleeding at all when I cut the skin of over 3 cm long to expose the pure white globular fatty tumour of 1.5 x 2 cm in size. Not one drop of blood. If you use scissors, you need to undermine the skin. The fine wire electrode just skim below the skin and the fatty tumour parted. I excised the base of this tumour attached to the muscle layer. I could see small red blood vessels of around 2 mm supplying this tumour with nutrients. This could be a liposarcoma as it grows fast.
Still no bleeding after I excised from the base of the skin to the top of the muscle layer and brought out the whole tumour intact. That is the usefulness of electro-surgical electrode (see image). There is no need to use scissors to undermine the skin and damage this fragile fatty tumour, pure white like snow and fragile too.
The owner came at around 11.30 am. The courier man had just taken the tumour inside the formalin bottle to bike back to the laboratory. So I could not show her but I have the image to show her. The other 4 small pieces of 3mm x 5mm were discarded as I did not keep them. However, she could see the stitched areas (3/0 absorbable sutures, horizontal mattress for the backside and simple interrupted for the others)
DOG POOPS
Unfortunately the dog started pooping. Brown solid stools started coming out from the anus. Surgery stopped and stools removed. Should have asked the owner to bring the dog to the toilet at home or plug the rectum.
"Is the dog awake?" the owner came at 11.30 am expecting a drowsy old dog. Well, this was the first time I met her and so she would have known about dog anaesthesia done in other clinics that use injectable IV anaesthesia. Isoflurane gas always allow the normal healthy dog to wake up within 10 minutes after completion of the surgery. As if it had a good nap. The surgery was not particularly painful but I gave the painkiller tolfedine SC and oral for the home.
"Yes," I said. "She woke up very fast after the end of anaesthesia." Xylazine 0.2 ml IM is a very low dose for a 10-year-old overweight Dachshund of 8.5 kg. I did not use xylazine IV this time as IM would be safer in an old dog, in my opinion.
"I had excised the 4 smaller tumours completely with their skins," I explained to the owner. "The backside tumour is large and if I removed it with the skin, there will be a big hole and the hole may not heal. So, I removed as much as possible under the skin and above the muscle. If it is malignant, it may recur." It is best to communicate this to the owner. The skin wound was over 5 cm long just to expose this 2x1.5x1.0 cm tumour and so there would not be enough skin to close the wound properly. I don't want a dog with a big gap in the backside due to the non-healing of the wound as this area is a high-tension area making wound healing difficult.
"Can you operate the other Dachshund? He has only 2 tumours similar to this dog?" the lady in her 40s asked. Red blood had oozed out from the dog's backside now despite the two horizontal mattress stitches closing the wound. "Your blouse and your handbag is stained with blood," I told her. "It does not matter," she said. The dog was alive and that was what mattered in her world.
She had earlier wanted two dogs done at one day. There are pros and cons for the vet. Pros - revenue comes in and client may go to the competitor if there is a delay. Cons - rushed job, not in the interest of the dog as mistakes in anaesthesia can result in the dog's death.
"It is always best not to stretch the vet as he has other surgeries and things to do in a day," I tried to educate this lady. I had asked her to bring just one dog today for the simple reason that I could focus on this dog alone and not be distracted.
I also did not want her to be waiting outside the reception room while I operated as to maintain a peace of mind during operation and not having a worried owner pacing outside the operating room.
"Well, it is best not to tempt fate," I told this personable lady. "Your operated dog is alive and well. It is not a guarantee that old dogs undergoing anaesthesia will survive and so it is best not to do another one on the same day. I am actually worried when I operate on old dogs! I don't even look forward to any old dog surgery." It is not that I am superstitious or can't do the 2nd surgery. There was no emergency for the 2nd dog to be operated on the same day and I do have a lot of things to do.
"Thursday will do," I said. Well, the lady was busy on Thursday. "How about Friday?" she asked. "If you come early on Good Friday at 9.30 am, I will operate as most clients don't come so early." However, I can understand that the owner is worried about the tumours in the sibling Dachshund becoming malignant through delay in surgery and she preferred me to operate. I had assigned Dr Vanessa to operate as this is a simple surgery. It is the anaesthestic death that the owner is very worried about and this must be understood.
Although there will be just 2 small fatty-like tumours, the whole procedure of preparation before op, sedating and giving the isoflurane gas and the IV drip and surgery can take 45 minutes in the 2nd dog.
No wonder, many vets just give injectable anaesthesia. No need to "waste time". I prefer isoflurane gas as it is much safer and the dog wakes up fast. But it sure takes 4 times as long. But in the end, the owner just wants a live dog and giving the owner a living dog is what she wants. Isoflurane gas gives a high safety margin and so I seldom use injectable anaesthesia in old dogs or young ones.
Injectable anaesthesia is also safe but it needs topping up in small amounts if the surgery takes longer than expected. A higher risk is involved in using injectable compared to isoflurane gas but usually a very small amount is injected and that is quite safe.
Well, each vet has his own choice but deaths on the operating table simply ruins a vet's reputation as owners spread the word and so, over the years, I rarely use injectable anaesthesia. It is preferred that other vets do the old-dog anaesthesia and surgery!
P.S LIPOSARCOMAS are uncommon malignant tumours of the fatty tissue. As this lump grew fast, the owner agreed to the histopathology to be done by the Lab.
Classified as low, intermediate or high-grade liposarcomas. With low and intermediate grade, the risk of spread to other parts of the body is low. With high-grade, the risk is much greater.
UPDATE APRIL 22, 2011
Histopathology results: A lipoma with no malignant cells seen. This is good news for the old Dachshund.
She was concerned about the large lump as it grows bigger every day. Could this be a liposarcoma (malignant growth) instead of a lipoma? Although middle-aged and old dogs, overweight female dogs do develop lipomas which are benign, I don't ask the owner to wait and see approach.
In one instance, Vet 1 had asked the owner of a Labrador Retriever to wait and see when the owner complained about a small globular growth above the neck of the dog. As typical of the busy Singapore owners, the owners waited till the lump becomes half the size of a tennis ball. When I saw it, it was a malignant tumour as it recurs after excision. "Well, Vet 1 had said that there was no need to remove the tumour when it was small," the owners said. Eventually, the dog had to be euthanased. From this experience, it is best NOT to advise the owner to wait and see. Give the owner the option to get the tumour resected and let her decide. The vet should not assume that every tumour under the skin is a lipoma and is benign.
In this female spayed Dachshund of 8.5kg, the owner had knowledge and asked me to operate. She was worried about the anaesthetic risk. A blood test showed the dog to be healthy for anaesthesia. Still the risks of death on the operating table are made known to her. She accepted the risks.
"Don't ask the vet to perform surgery during weekends or public holidays as the vet is busy and may need to rush through the surgery," I advised her and most clients that any rushed anaesthesia and surgery will not be in the interest of the patient.
I operated on April 19, 2011, a Tuesday morning at 10 am as scheduled and the owner arrived early. No food and water from 10 pm the night before. She used a marker pen to ink the 5 lumps as instructed by me. I still took one hour in total just to remove 5 fatty tumours and that included preparation, IV drip and surgery. The electro-surgery took around 30 minutes. Can't be shorter.
SEDATION
0.2 ml xylazine IM. My new assistant Mr Min asked if I wanted to give xylazine IV as I sometimes do. "No," I said. Isoflurane gas by mask was smooth and uneventful. The dog slept like a log. Intubated the dog to get oxygen and gas in. The anaesthetic machine was not leaking gas after industrial glue was applied to the hairline crack in the base tubing 2 days ago. 0.5 - 2% isoflurane gas was sufficient. "Keep to 0.5% and not less," I said to my assistant as he knew that the less the safer for the patient. But too little may lead to the dog waking up and delaying my surgery! A good assistant during anaesthesia is worth his or her weight in gold as vets don't have the luxury of the tax-payer's money to have an anaesthetist and the best equipment like the Singapore General Hospital.
ELECTRO-RESECTION
I like electro-surgery for such cases. No bleeding at all when I cut the skin of over 3 cm long to expose the pure white globular fatty tumour of 1.5 x 2 cm in size. Not one drop of blood. If you use scissors, you need to undermine the skin. The fine wire electrode just skim below the skin and the fatty tumour parted. I excised the base of this tumour attached to the muscle layer. I could see small red blood vessels of around 2 mm supplying this tumour with nutrients. This could be a liposarcoma as it grows fast.
Still no bleeding after I excised from the base of the skin to the top of the muscle layer and brought out the whole tumour intact. That is the usefulness of electro-surgical electrode (see image). There is no need to use scissors to undermine the skin and damage this fragile fatty tumour, pure white like snow and fragile too.
The owner came at around 11.30 am. The courier man had just taken the tumour inside the formalin bottle to bike back to the laboratory. So I could not show her but I have the image to show her. The other 4 small pieces of 3mm x 5mm were discarded as I did not keep them. However, she could see the stitched areas (3/0 absorbable sutures, horizontal mattress for the backside and simple interrupted for the others)
DOG POOPS
Unfortunately the dog started pooping. Brown solid stools started coming out from the anus. Surgery stopped and stools removed. Should have asked the owner to bring the dog to the toilet at home or plug the rectum.
"Is the dog awake?" the owner came at 11.30 am expecting a drowsy old dog. Well, this was the first time I met her and so she would have known about dog anaesthesia done in other clinics that use injectable IV anaesthesia. Isoflurane gas always allow the normal healthy dog to wake up within 10 minutes after completion of the surgery. As if it had a good nap. The surgery was not particularly painful but I gave the painkiller tolfedine SC and oral for the home.
"Yes," I said. "She woke up very fast after the end of anaesthesia." Xylazine 0.2 ml IM is a very low dose for a 10-year-old overweight Dachshund of 8.5 kg. I did not use xylazine IV this time as IM would be safer in an old dog, in my opinion.
"I had excised the 4 smaller tumours completely with their skins," I explained to the owner. "The backside tumour is large and if I removed it with the skin, there will be a big hole and the hole may not heal. So, I removed as much as possible under the skin and above the muscle. If it is malignant, it may recur." It is best to communicate this to the owner. The skin wound was over 5 cm long just to expose this 2x1.5x1.0 cm tumour and so there would not be enough skin to close the wound properly. I don't want a dog with a big gap in the backside due to the non-healing of the wound as this area is a high-tension area making wound healing difficult.
"Can you operate the other Dachshund? He has only 2 tumours similar to this dog?" the lady in her 40s asked. Red blood had oozed out from the dog's backside now despite the two horizontal mattress stitches closing the wound. "Your blouse and your handbag is stained with blood," I told her. "It does not matter," she said. The dog was alive and that was what mattered in her world.
She had earlier wanted two dogs done at one day. There are pros and cons for the vet. Pros - revenue comes in and client may go to the competitor if there is a delay. Cons - rushed job, not in the interest of the dog as mistakes in anaesthesia can result in the dog's death.
"It is always best not to stretch the vet as he has other surgeries and things to do in a day," I tried to educate this lady. I had asked her to bring just one dog today for the simple reason that I could focus on this dog alone and not be distracted.
I also did not want her to be waiting outside the reception room while I operated as to maintain a peace of mind during operation and not having a worried owner pacing outside the operating room.
"Well, it is best not to tempt fate," I told this personable lady. "Your operated dog is alive and well. It is not a guarantee that old dogs undergoing anaesthesia will survive and so it is best not to do another one on the same day. I am actually worried when I operate on old dogs! I don't even look forward to any old dog surgery." It is not that I am superstitious or can't do the 2nd surgery. There was no emergency for the 2nd dog to be operated on the same day and I do have a lot of things to do.
"Thursday will do," I said. Well, the lady was busy on Thursday. "How about Friday?" she asked. "If you come early on Good Friday at 9.30 am, I will operate as most clients don't come so early." However, I can understand that the owner is worried about the tumours in the sibling Dachshund becoming malignant through delay in surgery and she preferred me to operate. I had assigned Dr Vanessa to operate as this is a simple surgery. It is the anaesthestic death that the owner is very worried about and this must be understood.
Although there will be just 2 small fatty-like tumours, the whole procedure of preparation before op, sedating and giving the isoflurane gas and the IV drip and surgery can take 45 minutes in the 2nd dog.
No wonder, many vets just give injectable anaesthesia. No need to "waste time". I prefer isoflurane gas as it is much safer and the dog wakes up fast. But it sure takes 4 times as long. But in the end, the owner just wants a live dog and giving the owner a living dog is what she wants. Isoflurane gas gives a high safety margin and so I seldom use injectable anaesthesia in old dogs or young ones.
Injectable anaesthesia is also safe but it needs topping up in small amounts if the surgery takes longer than expected. A higher risk is involved in using injectable compared to isoflurane gas but usually a very small amount is injected and that is quite safe.
Well, each vet has his own choice but deaths on the operating table simply ruins a vet's reputation as owners spread the word and so, over the years, I rarely use injectable anaesthesia. It is preferred that other vets do the old-dog anaesthesia and surgery!
P.S LIPOSARCOMAS are uncommon malignant tumours of the fatty tissue. As this lump grew fast, the owner agreed to the histopathology to be done by the Lab.
Classified as low, intermediate or high-grade liposarcomas. With low and intermediate grade, the risk of spread to other parts of the body is low. With high-grade, the risk is much greater.
UPDATE APRIL 22, 2011
Histopathology results: A lipoma with no malignant cells seen. This is good news for the old Dachshund.
410. Vicarious liability & Duty of Care
Vicarious liability is a doctrine of English tort law. Employers will be held liable for the wrongdoings of their employees while the employee is conducting his duty. Intentional wrongdoings not in the course of ordinary employment were historically not the employer's liability.
But now, the employer is vicariously liable if the employee's intentional wrongdoings (e.g. deceit, fraud or sexual assault) is closely connected with the employee's duties.
EMPLOYER'S LIABILITY
Employers are vicariously liable for negligent acts or omissions by their employees in the course of EMPLOYMENT. For an act to be considered within the course of employment, it must either be authorised or be connected with an authorised act such that it can be considered a mode, though an improper mode, of performing it.
COURTS will sometimes distinguish between an employee's "detour" or "frolic". For example, an employer is vicariously liable if the employee had gone on a mere detour in carrying out his duties. If an employee acts in his own right rather than on employer's business, the employer is not liable for the employee's frolic.
Generally, an employer will not be liable for assault or battery committed by employees unless the use of force is part of their employment (e.g. police officers).
However, the employer of an INDEPENDENT CONTRACTOR is not held vicariously liable for the tortious acts of the contractor, except where the contractor injures someone to whom the employer owes a non-delegable DUTY OF CARE such as where the employer is a school authority and the injured party is a pupil (e.g. principal abusing the child on a field trip).
DUTY OF CARE
is a legal obligation for an individual to conform to a standard of REASONABLE care
while performing any act that could foreseeably harm others.
THERE ARE 4 ELEMENTS - LAW OF TORT - NEGLIGENCE
To succeed in an action for negligence, the plaintiff must show that:
1. the defendant owes him a duty of care.
2. the defendant has breached that duty of care
3. the breach causes damage/loss to the plaintiff
4. the damage/loss is not too remote (not controllable, not foreseeable, not an expert on the particular subject matter).
It is the first element (defendant owes him a duty of care) that must be established to proceed in an action of NEGLIGENCE. The plaintiff must BE ABLE TO SHOW a duty of care imposed by the law which the defendant has breached.
THE STANDARD BY WHICH DUTY IS MEASURED
Once a duty exists, the plaintiff must show that the defendant has BREACHED IT.
This is the 2nd element of negligence. Breach involves testing the defendant's actions against the standard of REASONABLE PERSON. This varies depending on the facts of the case. For example, doctors will be held to reasonable standards for members of his profession rather than the GENERAL PUBLIC, in negligence actions for MEDICAL MALPRACTICE.
Once the appropriate STANDARD has been found, the BREACH is proven when the plaintiff shows that the defendant's conduct fell below or did not reach the relevant STANDARD OF REASONABLE CARE.
However, if the defendant took every possible precaution and exceeded what would have been done by an REASONABLE PERSON, yet the plaintiff was injured, the plaintiff cannot recover in negligence.
But now, the employer is vicariously liable if the employee's intentional wrongdoings (e.g. deceit, fraud or sexual assault) is closely connected with the employee's duties.
EMPLOYER'S LIABILITY
Employers are vicariously liable for negligent acts or omissions by their employees in the course of EMPLOYMENT. For an act to be considered within the course of employment, it must either be authorised or be connected with an authorised act such that it can be considered a mode, though an improper mode, of performing it.
COURTS will sometimes distinguish between an employee's "detour" or "frolic". For example, an employer is vicariously liable if the employee had gone on a mere detour in carrying out his duties. If an employee acts in his own right rather than on employer's business, the employer is not liable for the employee's frolic.
Generally, an employer will not be liable for assault or battery committed by employees unless the use of force is part of their employment (e.g. police officers).
However, the employer of an INDEPENDENT CONTRACTOR is not held vicariously liable for the tortious acts of the contractor, except where the contractor injures someone to whom the employer owes a non-delegable DUTY OF CARE such as where the employer is a school authority and the injured party is a pupil (e.g. principal abusing the child on a field trip).
DUTY OF CARE
is a legal obligation for an individual to conform to a standard of REASONABLE care
while performing any act that could foreseeably harm others.
THERE ARE 4 ELEMENTS - LAW OF TORT - NEGLIGENCE
To succeed in an action for negligence, the plaintiff must show that:
1. the defendant owes him a duty of care.
2. the defendant has breached that duty of care
3. the breach causes damage/loss to the plaintiff
4. the damage/loss is not too remote (not controllable, not foreseeable, not an expert on the particular subject matter).
It is the first element (defendant owes him a duty of care) that must be established to proceed in an action of NEGLIGENCE. The plaintiff must BE ABLE TO SHOW a duty of care imposed by the law which the defendant has breached.
THE STANDARD BY WHICH DUTY IS MEASURED
Once a duty exists, the plaintiff must show that the defendant has BREACHED IT.
This is the 2nd element of negligence. Breach involves testing the defendant's actions against the standard of REASONABLE PERSON. This varies depending on the facts of the case. For example, doctors will be held to reasonable standards for members of his profession rather than the GENERAL PUBLIC, in negligence actions for MEDICAL MALPRACTICE.
Once the appropriate STANDARD has been found, the BREACH is proven when the plaintiff shows that the defendant's conduct fell below or did not reach the relevant STANDARD OF REASONABLE CARE.
However, if the defendant took every possible precaution and exceeded what would have been done by an REASONABLE PERSON, yet the plaintiff was injured, the plaintiff cannot recover in negligence.
Tuesday, April 19, 2011
Sunday April 17th - interesting cases
Bright sunshine and blue skies. Sunday morning April 17th, 2011
Started work at 9.30 am and finished at 6.00pm with Dr Vanessa.
1. Shih Tzu bites till the paws and feet bleeds. Very distressed to see a dog going at its body and feet. E-collar helped but bleeding stains apartment. Couple saw Vet 1 twice but no resoltion. Expat husband phoned Vet 1 today (Sunday) but no response. "When Vet 1 returns call," the husband said to me, "I had already phoned Toa Payoh Vets for an appointment."
"Skin diseases are not easy to cure in many cases," I said. I handled this case as the leading vet with Dr Vanessa as it would be an emotional case and I prefer to take the lead. Dr Vanessa was OK with this approach.
2. Rabbit with big jaw abscess. I asked my vet whether she would operate. She passed. So I did it the next day.
3. Three female SPAYED dogs with skin disease.
1. Low platelet. Lots of yellow pus in vulva. Why?
2. Bites flanks both sides. Alopecia. Endocrine? Vulva very small (spayed very young). Reddish.
3. Old dog. Health screening. Blood test. Vulva normal pink and size.
Started work at 9.30 am and finished at 6.00pm with Dr Vanessa.
1. Shih Tzu bites till the paws and feet bleeds. Very distressed to see a dog going at its body and feet. E-collar helped but bleeding stains apartment. Couple saw Vet 1 twice but no resoltion. Expat husband phoned Vet 1 today (Sunday) but no response. "When Vet 1 returns call," the husband said to me, "I had already phoned Toa Payoh Vets for an appointment."
"Skin diseases are not easy to cure in many cases," I said. I handled this case as the leading vet with Dr Vanessa as it would be an emotional case and I prefer to take the lead. Dr Vanessa was OK with this approach.
2. Rabbit with big jaw abscess. I asked my vet whether she would operate. She passed. So I did it the next day.
3. Three female SPAYED dogs with skin disease.
1. Low platelet. Lots of yellow pus in vulva. Why?
2. Bites flanks both sides. Alopecia. Endocrine? Vulva very small (spayed very young). Reddish.
3. Old dog. Health screening. Blood test. Vulva normal pink and size.
409. Entropion in the Sharpei can be cured if the owner knows
EMAIL TO DR SING DATED APR 19, 2011
Hi Judy,
I have a 6 years old male Shar Pei and have been having watery
eyes and yellow sticky discharge.
I am cleaning him a few times a day with eye wash and the problem
keep coming back.
I understand that surgery on the eye lid is necessary to stop this problem.
Can I know what will be the total cost for this surgery. And how long do I
have to leave him there.
Thanks
EMAIL FROM DR SING DATED APR 19, 2011
I am Dr Sing from Toa Payoh Vets. Thank you for your email. Estimated costs are around $600 - $700 for both eyes as general anaesthetic gas is used. Bring the dog in at 9.30 am and bring home in the evening. No food and water the night before after 10 pm. Phone 9668 6468 or 254 3326 for appointment.
Hi Judy,
I have a 6 years old male Shar Pei and have been having watery
eyes and yellow sticky discharge.
I am cleaning him a few times a day with eye wash and the problem
keep coming back.
I understand that surgery on the eye lid is necessary to stop this problem.
Can I know what will be the total cost for this surgery. And how long do I
have to leave him there.
Thanks
EMAIL FROM DR SING DATED APR 19, 2011
I am Dr Sing from Toa Payoh Vets. Thank you for your email. Estimated costs are around $600 - $700 for both eyes as general anaesthetic gas is used. Bring the dog in at 9.30 am and bring home in the evening. No food and water the night before after 10 pm. Phone 9668 6468 or 254 3326 for appointment.
Sunday, April 17, 2011
A love child
"Where are your front teeth?" I asked a little girl sitting on the left side of the van which had parked to pick up her mother who had brought in the old Pomeranian for oxygen therapy (gasping for breath and coughing earlier and was treated by Dr Vanessa). "How many teeth have you lost?"
The little girl smiled when I said "hello" and so I could see that she had lost 2 front teeth upper and lower. She also had two backward aligned corner incisors. The mother came and I asked: "Is this your daughter? How old is she?"
I couldn't believe that 6 years had passed. The mother was a single mother working for a dog breeder and running his pet shop in Marine Parade and then in MacPherson Road. The breeder had packed his bags and left the industry. Wow, the baby is a very happy 6-year-old girl.
"You will have to spend around $3,000 to align your daughter's teeth when she is older," I said to the happy mum. I am glad she is still a groomer and making ends meet. I don't know much about her love child and did not intrude on her privacy. She takes so much trouble to come to Toa Payoh Vets when there are over 45 vet clinics and some nearer to Pasir Ris.
Dr Vanessa gave her dog the necessary treatment and the oxygen therapy. This was her sister's dog. I said to her: "This dog will not live past one week. If you give the medication for the heart problems, give 3 to 4 times a day according to her panting."
She had brought her sister's dog for treatment and since I was not available, my associate treated the dog. She said: "I was told to give two times a day."
"Yes, that is the standard recommendation. Giving to effect will let this Pomeranian live a bit longer. In the end, the heart fails and the dog passes away peacefully."
I heard a hissing sound when I was in the room where the dog had the oxygen therapy by mask and the necessary injections. I noted that Dr Vanessa had pressed the red button a few times to flush out any isoflurane gas before giving the oxygen. The anaesthetic man had replaced my "faulty" vaporiser 3 days earlier as there was a leakage of oxygen. But all was well since.
Now, I could hear a faint hissing sound. Was there another leak in the piping? I phoned the anaesthetic man who was busy and wanted the whole set back to his factory. "Is there some elephant glue to seal the hairline crack in the piping under the vaporiser?" I asked him. "We need to operate and can't afford to wait a few days."
Dr Vanessa was going to postpone surgeries but I stopped her. The anaesthetic man came and saw the crack. His girl had placed some soapy water and I could see the bubbles from the blue tubing. So, there was a crack here too or was it there earlier? Was it due to the pressing of the red button repeatedly? Well, equipment piping do wear and tear.
Surprisingly, my old car had this ping message "Add one litre of engine oil when you next fill up." I had the car repaired by the mechanic when this message appeared earlier. Still now, the problem showed itself. Wear and tear or an inability of the mechanic to diagnose and treat? I top up the engine oil and the message disappeared. There must be a hairline crack somewhere. Should I sell off the car? But COE prices had shot up and 2nd hand cars fetch a good value. But it is much more expensive and stupid to buy a new car now. So, I have two identical problems of hairline cracks - in a car engine oil system and in my veterinary anaestethic gas system. Both need management and assessment of risks.
The little girl smiled when I said "hello" and so I could see that she had lost 2 front teeth upper and lower. She also had two backward aligned corner incisors. The mother came and I asked: "Is this your daughter? How old is she?"
I couldn't believe that 6 years had passed. The mother was a single mother working for a dog breeder and running his pet shop in Marine Parade and then in MacPherson Road. The breeder had packed his bags and left the industry. Wow, the baby is a very happy 6-year-old girl.
"You will have to spend around $3,000 to align your daughter's teeth when she is older," I said to the happy mum. I am glad she is still a groomer and making ends meet. I don't know much about her love child and did not intrude on her privacy. She takes so much trouble to come to Toa Payoh Vets when there are over 45 vet clinics and some nearer to Pasir Ris.
Dr Vanessa gave her dog the necessary treatment and the oxygen therapy. This was her sister's dog. I said to her: "This dog will not live past one week. If you give the medication for the heart problems, give 3 to 4 times a day according to her panting."
She had brought her sister's dog for treatment and since I was not available, my associate treated the dog. She said: "I was told to give two times a day."
"Yes, that is the standard recommendation. Giving to effect will let this Pomeranian live a bit longer. In the end, the heart fails and the dog passes away peacefully."
I heard a hissing sound when I was in the room where the dog had the oxygen therapy by mask and the necessary injections. I noted that Dr Vanessa had pressed the red button a few times to flush out any isoflurane gas before giving the oxygen. The anaesthetic man had replaced my "faulty" vaporiser 3 days earlier as there was a leakage of oxygen. But all was well since.
Now, I could hear a faint hissing sound. Was there another leak in the piping? I phoned the anaesthetic man who was busy and wanted the whole set back to his factory. "Is there some elephant glue to seal the hairline crack in the piping under the vaporiser?" I asked him. "We need to operate and can't afford to wait a few days."
Dr Vanessa was going to postpone surgeries but I stopped her. The anaesthetic man came and saw the crack. His girl had placed some soapy water and I could see the bubbles from the blue tubing. So, there was a crack here too or was it there earlier? Was it due to the pressing of the red button repeatedly? Well, equipment piping do wear and tear.
Surprisingly, my old car had this ping message "Add one litre of engine oil when you next fill up." I had the car repaired by the mechanic when this message appeared earlier. Still now, the problem showed itself. Wear and tear or an inability of the mechanic to diagnose and treat? I top up the engine oil and the message disappeared. There must be a hairline crack somewhere. Should I sell off the car? But COE prices had shot up and 2nd hand cars fetch a good value. But it is much more expensive and stupid to buy a new car now. So, I have two identical problems of hairline cracks - in a car engine oil system and in my veterinary anaestethic gas system. Both need management and assessment of risks.
406. I want to sue the vet
"I want to sue Dr ...!" the employment agent who could never control her demons in her brain shouted over the phone. I had her to get a replacement for Mr Saw who left at the expiry of his lease on amicable terms last week. Mr Min started work for less than a week and here I had this threat to sue my associate vet because Mr Min could not get his regular break for dinner during some busy days.
I had known her for more than 15 years and know that she bears grudges and will tell me off whenever the anger demons dominate her brain. She would rattle off her anger over the handphone though I had told her to call me back later. Her loud voice could be heard distinctly by my friends in a car in Penang and during other inappropriate occasions when she aired her complaints about work-related problems. I could switch off the handphone as she would not let me speak but I consider it better that her demons get out of her brain through her big mouth and cool down.
However a threat to sue any my associate vets is not tolerated by me at all. I said to Mr Min and the associate vet at a meeting I convened: "When Khin Khin wants to sue Dr ..., she is suing me as I own the practice. Dr ...has no share in this practice. I will engage a lawyer to defend any associate vet who is sued. Has she got a lot of money to sue? Don't threaten to sue. Just sue."
I had advised my vet to ensure that Mr Min, the vet assistant get his meal breaks. I said to Mr Min: "Khin Khin does not respect older people. Maybe she thinks I am old and stupid and therefore can shout at me. You have to think for yourself as to what is good for you. If you don't want to work at Toa Payoh Vets, have you got another offer from another vet?
"Old people have gone through the life of war, meeting all sort of nonsenses and people and suffering losses while gaining experiences and wisdom," I said to both parties who are at least 30 years younger than me. "They are a valuable source of knowledge and I always respect people older than me so that they can share their experiences with me. Obviously if you have no respect for the seniors, you can't expect them to share their experiences with you so that you don't suffer losses.
"You will have to think for yourself as regards your need to respect your employment agent. You had paid her the money for her services. Do you want this job or not? Do you have another employer waiting for you now? I have many applicants from the Philippines asking for your job."
Mr Min wanted this job as he was practically unemployed in Myanmar and earned very little. In Myanmar, the vets don't earn more than S$500 a month, I believe.
I told Mr Min and my associate vet a bit of my philosophy and why I employ Myanmar vets as vet technicians.
"I employed my first Vet Technician many years ago. She was a Myanmar Vet working for Dr XXX. Dr... did not want to continue employing her because she was slow in her work. She also could not speak English well, just like you now. So, it was very difficult for her.
"I employed her and she completed her year of employment and wanted to go home to see her sick father. An army officer, I believe. Around 2 years later, she visited me and gave me a present. I was much surprised. You can check her out as she is in Yangon and Khin Khin knows her.
"In your first week here, I have complaints from a pet shop owner that her referred customers cannot understand what you are talking about over the phone. This is a common complaint of Myanmar vet technicians as their standard of conversational English is not good. You just start your job in Singapore. Over time, like your friend, Mr Saw, your English will be good. This is one reason why most vet technicians employed in Singapore are Filipinos as they speak very good English and can start work without the employer worrying about client services being downgraded.
"You may be able to get a job at one of the 45 vet clinics in Singapore, but do you want to work in a clinic where there are no cases during some days? Just sit and go for your scheduled lunch and dinner times waiting for cases? You learn nothing because there are no cases over the year of employment. Or you work in a very big practice in a small area like Haematology. You can't do other aspects of vet medicine as there are other vet technicians assigned.
"So you can't start your own practice confidently because you have no cases in the new clinics. Do you want that?
Mr Min did not want to work in such a situation. All employees have this "what's in it for me" attitude and I accept that they are in a job for themselves. Times have changed.
I can easily employ a Filipino vet and grow my practice very fast due to good service as Filipinos are culturally excellent in English language communications and services.
However, making a small difference to the disadvantaged and the underdog have always been my philosophy as others had made a difference to me by awarding my a scholarship to study vet medicine in Glasgow in 1969.
It is very difficult for most of the younger vets in Singapore to understand my philosophy when their parents pay and pay for their vet studies. Pay and Pay? PAP? Elections in May 2011? Some distraction here.
In any case, I had instructed the associates to ensure that Mr Min get his meal breaks and I am personally checking on this. Time management is important for a vet and also for the employee.
I don't want the demons to re-appear again in Khin Khin's brains and there have been so many incidents from her such that I can write a novel of some interest to human relationship readers.
This incident is just one of the chapters of this novel. I said to Mr Min: "If you want to sue, don't threaten. Just do it. Pay the lawyer and sue the pants off the vet!"
I told Mr Min and the vet: "When I started Toa Payoh Vets, there were around 4 competitors. During the first few years, there were few customers. Just sit down and wait as vets cannot advertise. Now that Toa Payoh Vets is busier, I cannot be taking it easy. There are now at least 45 competitors and I know some of them have not sufficient number of customers to make ends meet."
Mr Min is a gentle person in his early 30s. He does not lose his cool and that is a good trait. I also advised Mr Min to buy some food during busy times when he can't go for the break as scheduled. In the end, he has to decide. Does he want the job or not? He is slow in his work but this will change with my training. He is not indispensible and there are so many stronger and better qualified Filipino vet technicians. Hire the best talent if you want your business to grow in this competitive world, the business management books will teach us. Why care about the disadvantaged with no experience or a good command of the English language. Why care for the underdog in this world? Why bother with employment agents who can't exorcise their demons? Why patronise a small businessman in a niche in veterinary anaesthesia when you can get business from an established corporation? All these encounters make life stressful. However, make a small difference to change the world if you are blessed with health and can do it. That is my philosophy.
I had known her for more than 15 years and know that she bears grudges and will tell me off whenever the anger demons dominate her brain. She would rattle off her anger over the handphone though I had told her to call me back later. Her loud voice could be heard distinctly by my friends in a car in Penang and during other inappropriate occasions when she aired her complaints about work-related problems. I could switch off the handphone as she would not let me speak but I consider it better that her demons get out of her brain through her big mouth and cool down.
However a threat to sue any my associate vets is not tolerated by me at all. I said to Mr Min and the associate vet at a meeting I convened: "When Khin Khin wants to sue Dr ..., she is suing me as I own the practice. Dr ...has no share in this practice. I will engage a lawyer to defend any associate vet who is sued. Has she got a lot of money to sue? Don't threaten to sue. Just sue."
I had advised my vet to ensure that Mr Min, the vet assistant get his meal breaks. I said to Mr Min: "Khin Khin does not respect older people. Maybe she thinks I am old and stupid and therefore can shout at me. You have to think for yourself as to what is good for you. If you don't want to work at Toa Payoh Vets, have you got another offer from another vet?
"Old people have gone through the life of war, meeting all sort of nonsenses and people and suffering losses while gaining experiences and wisdom," I said to both parties who are at least 30 years younger than me. "They are a valuable source of knowledge and I always respect people older than me so that they can share their experiences with me. Obviously if you have no respect for the seniors, you can't expect them to share their experiences with you so that you don't suffer losses.
"You will have to think for yourself as regards your need to respect your employment agent. You had paid her the money for her services. Do you want this job or not? Do you have another employer waiting for you now? I have many applicants from the Philippines asking for your job."
Mr Min wanted this job as he was practically unemployed in Myanmar and earned very little. In Myanmar, the vets don't earn more than S$500 a month, I believe.
I told Mr Min and my associate vet a bit of my philosophy and why I employ Myanmar vets as vet technicians.
"I employed my first Vet Technician many years ago. She was a Myanmar Vet working for Dr XXX. Dr... did not want to continue employing her because she was slow in her work. She also could not speak English well, just like you now. So, it was very difficult for her.
"I employed her and she completed her year of employment and wanted to go home to see her sick father. An army officer, I believe. Around 2 years later, she visited me and gave me a present. I was much surprised. You can check her out as she is in Yangon and Khin Khin knows her.
"In your first week here, I have complaints from a pet shop owner that her referred customers cannot understand what you are talking about over the phone. This is a common complaint of Myanmar vet technicians as their standard of conversational English is not good. You just start your job in Singapore. Over time, like your friend, Mr Saw, your English will be good. This is one reason why most vet technicians employed in Singapore are Filipinos as they speak very good English and can start work without the employer worrying about client services being downgraded.
"You may be able to get a job at one of the 45 vet clinics in Singapore, but do you want to work in a clinic where there are no cases during some days? Just sit and go for your scheduled lunch and dinner times waiting for cases? You learn nothing because there are no cases over the year of employment. Or you work in a very big practice in a small area like Haematology. You can't do other aspects of vet medicine as there are other vet technicians assigned.
"So you can't start your own practice confidently because you have no cases in the new clinics. Do you want that?
Mr Min did not want to work in such a situation. All employees have this "what's in it for me" attitude and I accept that they are in a job for themselves. Times have changed.
I can easily employ a Filipino vet and grow my practice very fast due to good service as Filipinos are culturally excellent in English language communications and services.
However, making a small difference to the disadvantaged and the underdog have always been my philosophy as others had made a difference to me by awarding my a scholarship to study vet medicine in Glasgow in 1969.
It is very difficult for most of the younger vets in Singapore to understand my philosophy when their parents pay and pay for their vet studies. Pay and Pay? PAP? Elections in May 2011? Some distraction here.
In any case, I had instructed the associates to ensure that Mr Min get his meal breaks and I am personally checking on this. Time management is important for a vet and also for the employee.
I don't want the demons to re-appear again in Khin Khin's brains and there have been so many incidents from her such that I can write a novel of some interest to human relationship readers.
This incident is just one of the chapters of this novel. I said to Mr Min: "If you want to sue, don't threaten. Just do it. Pay the lawyer and sue the pants off the vet!"
I told Mr Min and the vet: "When I started Toa Payoh Vets, there were around 4 competitors. During the first few years, there were few customers. Just sit down and wait as vets cannot advertise. Now that Toa Payoh Vets is busier, I cannot be taking it easy. There are now at least 45 competitors and I know some of them have not sufficient number of customers to make ends meet."
Mr Min is a gentle person in his early 30s. He does not lose his cool and that is a good trait. I also advised Mr Min to buy some food during busy times when he can't go for the break as scheduled. In the end, he has to decide. Does he want the job or not? He is slow in his work but this will change with my training. He is not indispensible and there are so many stronger and better qualified Filipino vet technicians. Hire the best talent if you want your business to grow in this competitive world, the business management books will teach us. Why care about the disadvantaged with no experience or a good command of the English language. Why care for the underdog in this world? Why bother with employment agents who can't exorcise their demons? Why patronise a small businessman in a niche in veterinary anaesthesia when you can get business from an established corporation? All these encounters make life stressful. However, make a small difference to change the world if you are blessed with health and can do it. That is my philosophy.
405. BARF/raw food diet query to Dr Sing
On Sat, Apr 16, 2011 at 9:35 AM, ...@uqconnect.edu.au> wrote:
Dear Mdm Judy,
I have a question for Dr Sing which I hope you can pass on to him. I am interested to know about Dr Sing's position on feeding a BARF/raw food diet for small animals.
Thank you,
(Name given)
Kong Yuen Sing to Mr,
Thank you for your email. I am Dr Sing from Toa Payoh Vets, www.toapayohvets.com. The answer to your question can be several pages an even be a book as there are many pros and cons. There are various formulas recommended by various proponents for the BARF/raw food diet.
Briefly, I am not recommending the BARF/raw food diet to my Singapore clients for the simple reason that most of them have no time to educate themselves on what makes a balanced diet for their dogs. My clients will also not be able to provide the necessary supplements to make sure that the diet is balanced during the different stages of life in a dog. Feeding such a diet to puppies, for example, will not be good for the puppies.
Best wishes.
Dear Mdm Judy,
I have a question for Dr Sing which I hope you can pass on to him. I am interested to know about Dr Sing's position on feeding a BARF/raw food diet for small animals.
Thank you,
(Name given)
Kong Yuen Sing to Mr,
Thank you for your email. I am Dr Sing from Toa Payoh Vets, www.toapayohvets.com. The answer to your question can be several pages an even be a book as there are many pros and cons. There are various formulas recommended by various proponents for the BARF/raw food diet.
Briefly, I am not recommending the BARF/raw food diet to my Singapore clients for the simple reason that most of them have no time to educate themselves on what makes a balanced diet for their dogs. My clients will also not be able to provide the necessary supplements to make sure that the diet is balanced during the different stages of life in a dog. Feeding such a diet to puppies, for example, will not be good for the puppies.
Best wishes.
Thursday, April 14, 2011
404. Follow-up on the itchy and scootering DachshundXJR
This is a follow up to a very interesting perplexing case I saw 2 days ago. My tentative diagnosis was allergy to the environment or dog food. The owner was more worried that the dog still scootered despite consulting Vet 1 earlier. Scootering was just continuous.
"My dog is calmer now. No more scootering and I don't scratch her anymore," the owner could not hear me distinctly as she was at the mall.
"What do you mean when you say you scratch the dog?" I asked the caregiver. "Well, I had to pet her and she would want more petting before I consulted you!". English is a hard language to understand. I was wondering why she would scratch her dog who was already itchy all over the body.
"How much hair loss?" I asked. She was not able to confirm as she was busy.
So far so good. I called to ask her to pick up the Hills' Canine d/d Potato and Salmon formula. It is a single animal protein source for allergic pets. The dog is not permitted to eat treats and any home-cooked or other food for the next 3 months. Then the owner can introduce treats and see if the body itch occur.
Painful ears with no infection, biting all four paws, whole body itch without skin diseases and hair falling out. These are one of the possible signs of dog food allergy. The dog just arrived from the USA. There could be multiple causes like heat, humidity, shampoos, stress and so many others.
We will have to wait and see. It is important that the dog does not scooter anymoe as that seems to be the main issue of the owner. She was very observant and said that I squeezed the anal sacs from quite deeply into the anal region. Of course, I did produce the grey particles and anal fluid. Evidence is important in veterinary medicine. The proof of the eating is in the pudding if there is such an English expression?
TODAY'S CASE
Old Jack Russell. Female, 8 years old said to be spayed 8 years ago and had no heat period.
Lost 2 kg from Oct 2010 (fat as a pig) to April 2011. Lethargy. Not eating much during past 3 weeks. Dried purulent eye discharge in both eyes suggested a serious systemic illness as in the hamster. Examine the whole body from mouth to private parts.
Dehydrated. Left gum ulcerated around Left Upper PM4. Yellow pus in swollen vagina (I showed to the busy lady owner's mother who brought the dog in). I suspected stump pyometra if the dog had not been properly sterilised but it could be UTI with pus inside the bladder and kidneys. No signs of vomiting. The dog just wanted to sleep and die.
BLOOD TEST. Low blood pressure and so I taught Min to use the tubing around the elbow and clamp with forceps just to collect 2 ml of blood successfully. Min is not inexperienced but he tended to do blood collection from the forelimbs and then the hind limbs but was unsuccessful today with both legs. So, I taught him how to fish rather than give him fish.
BLOOD TEST RESULTS
Very low platelets = 40 (normal 200-500). No platelet clumps. Large platelets present.
Liver enzymes elevated. Urea 15.6 (normal 4.2 - 6.3.
Red cell and haemoglobin below normal.
Total White Cell Count normal.
So what is the cause of the low platelets? I phoned the young lady. She said no Chinese medicine was given but the dog had the chicken flavouring or some powder added to the chicken meat for some weeks. Could this be the toxic substance depleting platelets? Would the dog live? Hard to say.
"My dog is calmer now. No more scootering and I don't scratch her anymore," the owner could not hear me distinctly as she was at the mall.
"What do you mean when you say you scratch the dog?" I asked the caregiver. "Well, I had to pet her and she would want more petting before I consulted you!". English is a hard language to understand. I was wondering why she would scratch her dog who was already itchy all over the body.
"How much hair loss?" I asked. She was not able to confirm as she was busy.
So far so good. I called to ask her to pick up the Hills' Canine d/d Potato and Salmon formula. It is a single animal protein source for allergic pets. The dog is not permitted to eat treats and any home-cooked or other food for the next 3 months. Then the owner can introduce treats and see if the body itch occur.
Painful ears with no infection, biting all four paws, whole body itch without skin diseases and hair falling out. These are one of the possible signs of dog food allergy. The dog just arrived from the USA. There could be multiple causes like heat, humidity, shampoos, stress and so many others.
We will have to wait and see. It is important that the dog does not scooter anymoe as that seems to be the main issue of the owner. She was very observant and said that I squeezed the anal sacs from quite deeply into the anal region. Of course, I did produce the grey particles and anal fluid. Evidence is important in veterinary medicine. The proof of the eating is in the pudding if there is such an English expression?
TODAY'S CASE
Old Jack Russell. Female, 8 years old said to be spayed 8 years ago and had no heat period.
Lost 2 kg from Oct 2010 (fat as a pig) to April 2011. Lethargy. Not eating much during past 3 weeks. Dried purulent eye discharge in both eyes suggested a serious systemic illness as in the hamster. Examine the whole body from mouth to private parts.
Dehydrated. Left gum ulcerated around Left Upper PM4. Yellow pus in swollen vagina (I showed to the busy lady owner's mother who brought the dog in). I suspected stump pyometra if the dog had not been properly sterilised but it could be UTI with pus inside the bladder and kidneys. No signs of vomiting. The dog just wanted to sleep and die.
BLOOD TEST. Low blood pressure and so I taught Min to use the tubing around the elbow and clamp with forceps just to collect 2 ml of blood successfully. Min is not inexperienced but he tended to do blood collection from the forelimbs and then the hind limbs but was unsuccessful today with both legs. So, I taught him how to fish rather than give him fish.
BLOOD TEST RESULTS
Very low platelets = 40 (normal 200-500). No platelet clumps. Large platelets present.
Liver enzymes elevated. Urea 15.6 (normal 4.2 - 6.3.
Red cell and haemoglobin below normal.
Total White Cell Count normal.
So what is the cause of the low platelets? I phoned the young lady. She said no Chinese medicine was given but the dog had the chicken flavouring or some powder added to the chicken meat for some weeks. Could this be the toxic substance depleting platelets? Would the dog live? Hard to say.
403. New anaesthetic gas machine
April 13, 2011.
I got a new anaesthetic machine vaporiser as the old one had leaked at the bottom. There is a hole on the lower right, hissing oxygen and depleting my oxygen tank. This vaporiser is only 3 years old. But I don't want it repaired. I bought a new one as gas anaesthesia is very useful and very safe, esp. for old dogs.
The vaporiser started hissing oxygen 3 days ago on a Saturday. All gas operations ceased and I had to get the experienced man to service but Mr Goh was in Malaysia doing some vet clinics set up there. So, on Wednesday (yesterday), I told him to treat urgently as I did not want to buy a vaporiser from his competitor. I support Mr Goh as he needs the help. If one does not support the small technical person who specialises in vet machines, he will go out of business and the vet community will be much worse. The big boys are not interested in vet machines anyway. Sales persons can't service.
"It is only $8,000," my Myanmar friend James said. "Throw away the old one. Even if you give to me, I don't want it. It is hard to repair in Myanmar." James is starting his clinic in Yangon soon. A few weeks ago, I offered him my old Shoreline veterinary surgery table which costs $7,000 to purchase as I bought a new one. He said no but his wife later said yes. So, there was much unhappiness with the
I got a new anaesthetic machine vaporiser as the old one had leaked at the bottom. There is a hole on the lower right, hissing oxygen and depleting my oxygen tank. This vaporiser is only 3 years old. But I don't want it repaired. I bought a new one as gas anaesthesia is very useful and very safe, esp. for old dogs.
The vaporiser started hissing oxygen 3 days ago on a Saturday. All gas operations ceased and I had to get the experienced man to service but Mr Goh was in Malaysia doing some vet clinics set up there. So, on Wednesday (yesterday), I told him to treat urgently as I did not want to buy a vaporiser from his competitor. I support Mr Goh as he needs the help. If one does not support the small technical person who specialises in vet machines, he will go out of business and the vet community will be much worse. The big boys are not interested in vet machines anyway. Sales persons can't service.
"It is only $8,000," my Myanmar friend James said. "Throw away the old one. Even if you give to me, I don't want it. It is hard to repair in Myanmar." James is starting his clinic in Yangon soon. A few weeks ago, I offered him my old Shoreline veterinary surgery table which costs $7,000 to purchase as I bought a new one. He said no but his wife later said yes. So, there was much unhappiness with the
Wednesday, April 13, 2011
iPhone 4 or an Android phone
2 weeks ago, I decided to upgrade myself from the conventional mobile phone which was good for nothing but useful to send and receive calls. I could not surf.
iPhone 4 is already one year old. The Samsung was a new model. So, brand-name or the latest technology? iPhone 5 may come soon but maybe not.
I was much tempted to take the brand-name. But it is never good to do it when the brand name does not bother to upgrade and lose to its competitors. So, I took the Samsung. The HTC was sexy but it had caused me loss as it malfunctioned some 3 years ago when I first got one (I could write instead of thumb). The company took months to repair and the problem of hanging came back again. As you can see, good performance counts even in mobile phone sales and service.
Same tough competitions exist for the 45 vet clinics now existing in Singapore. Brand name clinics definitely lose out in numbers to the new ones with sexy renovations and frills. And that attract many younger pet owners.
iPhone 4 is already one year old. The Samsung was a new model. So, brand-name or the latest technology? iPhone 5 may come soon but maybe not.
I was much tempted to take the brand-name. But it is never good to do it when the brand name does not bother to upgrade and lose to its competitors. So, I took the Samsung. The HTC was sexy but it had caused me loss as it malfunctioned some 3 years ago when I first got one (I could write instead of thumb). The company took months to repair and the problem of hanging came back again. As you can see, good performance counts even in mobile phone sales and service.
Same tough competitions exist for the 45 vet clinics now existing in Singapore. Brand name clinics definitely lose out in numbers to the new ones with sexy renovations and frills. And that attract many younger pet owners.
401. Give what the owner wants
April 12, 2011
9.30am. 1-year-old JackRussellXDachshund spayed dog was itchy all over. She arrived from US one month ago, quarantined at Sembawang for 10 days and had been boarded at a Pasir Ris boarding place where there were numerous rescued dogs.
"My dog is itchy all over the body and scoots her backside," the slim European lady said. She had consulted another surgery and the vet did press some tissue around the anal area. She was not shown what was expressed from the anal area.
I put the dog on he exam table and pressed the anal sacs. I showed her the greyish particles in the anal sacs to the owner. "The normal colour is like cooking oil - light yellow," I said and explained what the anal sac oil was used for by the dog. She was quite happy.
As for the ears, I palpated the ears. The dog yelped in pain at the horizontal and vertical canal junction. I scoped the ear but found no mites. A cotton bud tip showed light brown discharge. No smell. So what was the pain? "I am no ear-person," the woman in her 40s said to me when I asked if she knows the structure of the dog's ears. I remained professional by not cracking jokes about anatomy which may be offensive since I met her the first time. Some men are said to be attracted by certain anatomy of the female and therefore, cracking such jokes as a "butt" person may not be welcome unless the client has a sense of humour.
As for the itchy body, the lady said: "My friends asked me to examine the body for skin infections but there are none. Yet the dog keeps losing hairs eve1y day. What is the problem? Also she chews her 4 paws "
I examined the dog's skin. Good coat. Strands of brown hair fall out. The lady said: "She is also developing those long harder coarse hairs. Could it be the weather in Singapore being so hot?"
"There is no skin problem," I confirmed. "Those coarse hairs could be the result of the dog's parents being wire-haired Jack Russell. Now she is one year old, her adult coat is being formed."
It sounded logical to her. As for the cause of generalised body itch, it was hard to tell what was the cause. "It is most likely allergy from the food or environment. A skin patch test may not give you the answers but costs you some money." I advised her to get the ears and paws cleaned regularly and to go on a low-allergic prescription diet for 3 months. "No treats or other foods", I said. "After 3 months, you can test her with dog treats or your food and see whether the dog itches."
I said: "It is extremely difficult to let you know what is the exact cause of the dog itching all over and so we do the food trial first. In some cases, it could be due to the loss of hormones due to spaying but these are rare cases. Hot weather and stress can cause the dog to shed hairs too as the dog came from the US."
This dog has no skin or ear problems and so a dog food or human shampoo allergy is suspected at this stage. The dog uses her human shampoo. There are so many factors and so it is best to take time to explain and illustrations of the ear canal and anal sacs to show the anatomy.
In this dog, the owner even remarked that I could have gone deeper to express the anal sacs than Vet 1 who did not show her any oil (probably).
Nowadays, it is hard to be a vet. See the following case 2.
Case 2. "Has my dog got CCD?"
This was the 2nd case in the last 3 days that a client who had researched the internet asked me about the dog having CCD.
"My dog could not recognise me and knocked onto furniture," the man in his late 50s said to me. His dog had been examined by a vet and had blood and urine tests done. "Nothing wrong with the blood and urine tests, the vet said. Can you prescribe a drug so that my dog can be alert and active?"
I was on counter receptionist duty and so got this feedback. I was surprised that another dog owner had researched the internet and diagnosed CCD again and asked for the drug.
I said: "Nowadays, owners research the internet. Sometimes, they are better informed than the vet. There is a drug but are you sure that the dog has no other health problems?"
I continued: "Many cases, the old dog has painful mouth due to teeth decay. Poison from the bacteria goes to the surrounding areas including the eyes and brain. So, the owner diagnoses CCD and asks for the drug. In the end, the dog is still suffering from pain."
"My dog eats the same amount of food every day," the man said when I asked why the dog had dropped 1.5kg in weight when it had the same appetite and was less active, esp. for the last 2 weeks. He was positive that his dog ate the same amount and had no vomiting or diarrhoea.
So I asked to check the blood and urine test results. The significant finding was a high blood urea (12 instead of the maximun value of 6). So, there was an abnormality but his vet said it was normal as the creatinine was low, meaning the dog does not have kidney disease.
It is not normal to have high blood urea, I said to the owner. As to the cause, the vet said it could be due to disorders in the muscles and internal organs and possibly cancer but since an X-ray would be useless, an ultrasound was proposed. Multivitamins were prescribed for the time being.
As the owner stated that he was referred to me by his friend, I handled his case and asked the dog to be admitted for an examination as he did not bring his dog when he came to see me.
Old dogs that have not been given dental checkup for the last 5 years (his vet did not want to do it since the dog was 8 years old) would have bad breath and oral infections. These problems needed dentistry and not a drug for CCD. Then there is the ear problems as many of the old dogs are neglected. They just get fed.
Much will depend on what I find but dentistry under general anaesthesia is needed. I strongly advised the high risks and he ought to tell his wife. His wife phoned me and I explained the possibility that her dog could just die on the operating table. That is the reason why most vets don't want to do the dentistry. "How about half dose?" the man asked me. "I use gas only and it should be quite safe if given over a short time of less than 15 minutes, but no guarantees."
"How about no anaesthetic?" the man asked. I said: "It is extremely painful to extract decayed teeth. I had only done once in dental extraction of a 16-year-old Pomeranian. It survived. However, some dogs may die of fright. Did you read the Straits Times forum letter where the writer's dog was lost and found by the AVA? The AVA micro-chipped the dog but it died. What did it die of? The AVA is doing an autopsy to ascertain the cause of death." From this incident, I prefer not to do any dentistry without anaesthesia.
Case 3.
A Chinese National sought my advice about her Silkie puppy that had fractured his right fore leg. "What can be done?" she asked me as I was on counter duty. The dog's legs were cast by Plaster of Paris and the dog had come in for a change of the Plaster. I asked Dr Vanessa what was the outcome. She showed me the X-rays before and after the cast. The tranverse fractures of the radius and ulna had closed and the fragments were aligned. So, there was good news. I told the lady that the progress was good. She had phoned me earlier wanting no invasive surgery for the fracture as proposed by another vet and Dr Vanessa had done a good job. A second opinion would be better service for the client and I was glad that she appeared satisfied.
She was from Yunnan. I had seen paintings by Chinese painters of Yunnan and read about the refugee problems from Myanmar to Yunnan which is part of China. I would like to visit this place as it appeared to be the equivalent "wild wild West" of the USA after reading about drug lords and other news.
"The travel agent in Yunnan cannot be trusted. Contact your travel agent. Many Singaporean businessmen go to Yunnan for gold," she said to me.
I asked her about the presence of elephants in the Yunnan mountains after hearing a story of a Myanmar businessman whose truck driver impatiently sound the horn to quicken the mother elephant and baby to walk past faster along the mountain road. The dam rushed onto the truck and this businesman was flung deep into the ravine. A tree broke his fall and he was hospitalised for 3 months. When he went home after that, he said to me: "My family members sprinted fast and ran away as they thought I was a ghost." In the old days before the mobile phone, he could not inform his family and they thought the elephant had killed him.
So I asked this Yuannan lady about the wandering wild elephants which I could not imagine, being a frog in the well in the small island of Singapore.
It is just too expensive to travel and I prefer the off-the-tourist places which can be more expensive and dangerous.
"There are wild elephants in the mountains. Tourists can view the mountains from the tree top."
"How do I do it?" I asked. "Just sit on the tree?"
The young lady in the IT field said: "I will not advise you to watch the wild elephants. It is very dangerous. The elephants may bang the tree and knock you down!"
9.30am. 1-year-old JackRussellXDachshund spayed dog was itchy all over. She arrived from US one month ago, quarantined at Sembawang for 10 days and had been boarded at a Pasir Ris boarding place where there were numerous rescued dogs.
"My dog is itchy all over the body and scoots her backside," the slim European lady said. She had consulted another surgery and the vet did press some tissue around the anal area. She was not shown what was expressed from the anal area.
I put the dog on he exam table and pressed the anal sacs. I showed her the greyish particles in the anal sacs to the owner. "The normal colour is like cooking oil - light yellow," I said and explained what the anal sac oil was used for by the dog. She was quite happy.
As for the ears, I palpated the ears. The dog yelped in pain at the horizontal and vertical canal junction. I scoped the ear but found no mites. A cotton bud tip showed light brown discharge. No smell. So what was the pain? "I am no ear-person," the woman in her 40s said to me when I asked if she knows the structure of the dog's ears. I remained professional by not cracking jokes about anatomy which may be offensive since I met her the first time. Some men are said to be attracted by certain anatomy of the female and therefore, cracking such jokes as a "butt" person may not be welcome unless the client has a sense of humour.
As for the itchy body, the lady said: "My friends asked me to examine the body for skin infections but there are none. Yet the dog keeps losing hairs eve1y day. What is the problem? Also she chews her 4 paws "
I examined the dog's skin. Good coat. Strands of brown hair fall out. The lady said: "She is also developing those long harder coarse hairs. Could it be the weather in Singapore being so hot?"
"There is no skin problem," I confirmed. "Those coarse hairs could be the result of the dog's parents being wire-haired Jack Russell. Now she is one year old, her adult coat is being formed."
It sounded logical to her. As for the cause of generalised body itch, it was hard to tell what was the cause. "It is most likely allergy from the food or environment. A skin patch test may not give you the answers but costs you some money." I advised her to get the ears and paws cleaned regularly and to go on a low-allergic prescription diet for 3 months. "No treats or other foods", I said. "After 3 months, you can test her with dog treats or your food and see whether the dog itches."
I said: "It is extremely difficult to let you know what is the exact cause of the dog itching all over and so we do the food trial first. In some cases, it could be due to the loss of hormones due to spaying but these are rare cases. Hot weather and stress can cause the dog to shed hairs too as the dog came from the US."
This dog has no skin or ear problems and so a dog food or human shampoo allergy is suspected at this stage. The dog uses her human shampoo. There are so many factors and so it is best to take time to explain and illustrations of the ear canal and anal sacs to show the anatomy.
In this dog, the owner even remarked that I could have gone deeper to express the anal sacs than Vet 1 who did not show her any oil (probably).
Nowadays, it is hard to be a vet. See the following case 2.
Case 2. "Has my dog got CCD?"
This was the 2nd case in the last 3 days that a client who had researched the internet asked me about the dog having CCD.
"My dog could not recognise me and knocked onto furniture," the man in his late 50s said to me. His dog had been examined by a vet and had blood and urine tests done. "Nothing wrong with the blood and urine tests, the vet said. Can you prescribe a drug so that my dog can be alert and active?"
I was on counter receptionist duty and so got this feedback. I was surprised that another dog owner had researched the internet and diagnosed CCD again and asked for the drug.
I said: "Nowadays, owners research the internet. Sometimes, they are better informed than the vet. There is a drug but are you sure that the dog has no other health problems?"
I continued: "Many cases, the old dog has painful mouth due to teeth decay. Poison from the bacteria goes to the surrounding areas including the eyes and brain. So, the owner diagnoses CCD and asks for the drug. In the end, the dog is still suffering from pain."
"My dog eats the same amount of food every day," the man said when I asked why the dog had dropped 1.5kg in weight when it had the same appetite and was less active, esp. for the last 2 weeks. He was positive that his dog ate the same amount and had no vomiting or diarrhoea.
So I asked to check the blood and urine test results. The significant finding was a high blood urea (12 instead of the maximun value of 6). So, there was an abnormality but his vet said it was normal as the creatinine was low, meaning the dog does not have kidney disease.
It is not normal to have high blood urea, I said to the owner. As to the cause, the vet said it could be due to disorders in the muscles and internal organs and possibly cancer but since an X-ray would be useless, an ultrasound was proposed. Multivitamins were prescribed for the time being.
As the owner stated that he was referred to me by his friend, I handled his case and asked the dog to be admitted for an examination as he did not bring his dog when he came to see me.
Old dogs that have not been given dental checkup for the last 5 years (his vet did not want to do it since the dog was 8 years old) would have bad breath and oral infections. These problems needed dentistry and not a drug for CCD. Then there is the ear problems as many of the old dogs are neglected. They just get fed.
Much will depend on what I find but dentistry under general anaesthesia is needed. I strongly advised the high risks and he ought to tell his wife. His wife phoned me and I explained the possibility that her dog could just die on the operating table. That is the reason why most vets don't want to do the dentistry. "How about half dose?" the man asked me. "I use gas only and it should be quite safe if given over a short time of less than 15 minutes, but no guarantees."
"How about no anaesthetic?" the man asked. I said: "It is extremely painful to extract decayed teeth. I had only done once in dental extraction of a 16-year-old Pomeranian. It survived. However, some dogs may die of fright. Did you read the Straits Times forum letter where the writer's dog was lost and found by the AVA? The AVA micro-chipped the dog but it died. What did it die of? The AVA is doing an autopsy to ascertain the cause of death." From this incident, I prefer not to do any dentistry without anaesthesia.
Case 3.
A Chinese National sought my advice about her Silkie puppy that had fractured his right fore leg. "What can be done?" she asked me as I was on counter duty. The dog's legs were cast by Plaster of Paris and the dog had come in for a change of the Plaster. I asked Dr Vanessa what was the outcome. She showed me the X-rays before and after the cast. The tranverse fractures of the radius and ulna had closed and the fragments were aligned. So, there was good news. I told the lady that the progress was good. She had phoned me earlier wanting no invasive surgery for the fracture as proposed by another vet and Dr Vanessa had done a good job. A second opinion would be better service for the client and I was glad that she appeared satisfied.
She was from Yunnan. I had seen paintings by Chinese painters of Yunnan and read about the refugee problems from Myanmar to Yunnan which is part of China. I would like to visit this place as it appeared to be the equivalent "wild wild West" of the USA after reading about drug lords and other news.
"The travel agent in Yunnan cannot be trusted. Contact your travel agent. Many Singaporean businessmen go to Yunnan for gold," she said to me.
I asked her about the presence of elephants in the Yunnan mountains after hearing a story of a Myanmar businessman whose truck driver impatiently sound the horn to quicken the mother elephant and baby to walk past faster along the mountain road. The dam rushed onto the truck and this businesman was flung deep into the ravine. A tree broke his fall and he was hospitalised for 3 months. When he went home after that, he said to me: "My family members sprinted fast and ran away as they thought I was a ghost." In the old days before the mobile phone, he could not inform his family and they thought the elephant had killed him.
So I asked this Yuannan lady about the wandering wild elephants which I could not imagine, being a frog in the well in the small island of Singapore.
It is just too expensive to travel and I prefer the off-the-tourist places which can be more expensive and dangerous.
"There are wild elephants in the mountains. Tourists can view the mountains from the tree top."
"How do I do it?" I asked. "Just sit on the tree?"
The young lady in the IT field said: "I will not advise you to watch the wild elephants. It is very dangerous. The elephants may bang the tree and knock you down!"
Monday, April 11, 2011
400. Plug the leaking aqueous from deep inside the eye.
Sunday April 11, 2011
14 days ago, the young couple was referred by Vet 1 to another "dog's eye expert" at another vet surgery. However the "dog's eye expert" had no time for them. So my associate wanted to refer them to another vet as this was a highly charged emotional case. Some vets refer away the difficult and emotional cases to preserve their reputations. Others do their best as the vets being referred to are no better qualified in many cases, depending on their track record. It is hard to know the track record of other vets as we are all generalists and we don't publicise our clinical experiences.
Eye injuries are emergencies and should be treated within 4 hours of injury. The dog had been injured at the pet shop. Aqueous humour was licking out daily but it was hard for a layman to know what's happening. Under general anaesthesia, I could see the outflow. Like a damaged oil disaster in the Gulf Of Mexico. Instead of from deep inside the earth, the leaking was from deep inside the anterior chamber.
I took out the two stitches. The leak was sealed with a larger piece of white tissue. The eye, at 14th day, always looks horrible to the owner. A big white piece of tissue plugging the perforated cornea (I will show the image later). This case was a successful case.
However, the couple still has lots of nursing to do for the next 30 days. E-collar 24 hours/day. Medication & Eye drops and clean eyes as advised. No freedom to run around - restricted area. No sunlight and breezes and dusts. Follow up after 2 weeks. "The mass will shrink to a white spot some weeks later, if this eye is well cared for," I said. "The oil well has been plugged." I guessed the couple must be well read as they could relate this case to the Gulf Of Mexico oil spill which took several weeks or months to plug and caused environmental disaster!
It is just a pity that many Singapore pet owners of breeds with protruding eye balls do not know that eye injuries are emergencies.
14 days ago, the young couple was referred by Vet 1 to another "dog's eye expert" at another vet surgery. However the "dog's eye expert" had no time for them. So my associate wanted to refer them to another vet as this was a highly charged emotional case. Some vets refer away the difficult and emotional cases to preserve their reputations. Others do their best as the vets being referred to are no better qualified in many cases, depending on their track record. It is hard to know the track record of other vets as we are all generalists and we don't publicise our clinical experiences.
Eye injuries are emergencies and should be treated within 4 hours of injury. The dog had been injured at the pet shop. Aqueous humour was licking out daily but it was hard for a layman to know what's happening. Under general anaesthesia, I could see the outflow. Like a damaged oil disaster in the Gulf Of Mexico. Instead of from deep inside the earth, the leaking was from deep inside the anterior chamber.
I took out the two stitches. The leak was sealed with a larger piece of white tissue. The eye, at 14th day, always looks horrible to the owner. A big white piece of tissue plugging the perforated cornea (I will show the image later). This case was a successful case.
However, the couple still has lots of nursing to do for the next 30 days. E-collar 24 hours/day. Medication & Eye drops and clean eyes as advised. No freedom to run around - restricted area. No sunlight and breezes and dusts. Follow up after 2 weeks. "The mass will shrink to a white spot some weeks later, if this eye is well cared for," I said. "The oil well has been plugged." I guessed the couple must be well read as they could relate this case to the Gulf Of Mexico oil spill which took several weeks or months to plug and caused environmental disaster!
It is just a pity that many Singapore pet owners of breeds with protruding eye balls do not know that eye injuries are emergencies.
Injectable Anaesthetics For Cats
Below are guidelines for vets who don't have gas anaesthetic machines
e.g. animal shelter work in the field and cost considerations. Zoletil, Domitor and isoflurane are costly.
CATS
1. XYLAZINE + ZOLETIL ANAESTHESIA
5 kg
Xylazine 0.1 ml + Zoletil 100 0.1 ml in one syringe IM
If insufficient, top up with Zoletil 0.01 ml IV to effect.
In one case of a 5kg male
cat, I topped up with Zoletil 100 at 0.05 ml + 0.1 ml saline IV after 10 minutes of the xylazine 0.1 ml + Zoletil 0.1 ml IM combination. Effective analgesia for neuter.
2. XYLAZINE + KETAMINE
3-4 kg
Xylazine 0.1 ml + Ketamine 0.4 ml in one syringe IM. If insufficient, top up with Zoletil 0.01 ml IV to effect.
For cats 4-6 kg, double the above dosage IM.
I use this formula frequently for spay and neuter of cats without problems.
Duration of anaesthesia is half an hour.
3. DOMITOR + XYLAZINE
Domitor 0.1 ml + Xylazine 0.1 ml in one syringe IM.
If insufficient, top up with Zoletil 0.01 ml IV to effect. Domitor is expensive for stray cat spays.
I have not used this before.
4. IF USED ALONE, adverse effects are as follows:
1. Insufficient analgesia. Needs to top up IV.
2. Salivation and legs rigid (ketamine IM)
3. Wakes up fast
Combined with xylazine will make the cat sleep longer.
e.g. animal shelter work in the field and cost considerations. Zoletil, Domitor and isoflurane are costly.
CATS
1. XYLAZINE + ZOLETIL ANAESTHESIA
5 kg
Xylazine 0.1 ml + Zoletil 100 0.1 ml in one syringe IM
If insufficient, top up with Zoletil 0.01 ml IV to effect.
In one case of a 5kg male
cat, I topped up with Zoletil 100 at 0.05 ml + 0.1 ml saline IV after 10 minutes of the xylazine 0.1 ml + Zoletil 0.1 ml IM combination. Effective analgesia for neuter.
2. XYLAZINE + KETAMINE
3-4 kg
Xylazine 0.1 ml + Ketamine 0.4 ml in one syringe IM. If insufficient, top up with Zoletil 0.01 ml IV to effect.
For cats 4-6 kg, double the above dosage IM.
I use this formula frequently for spay and neuter of cats without problems.
Duration of anaesthesia is half an hour.
3. DOMITOR + XYLAZINE
Domitor 0.1 ml + Xylazine 0.1 ml in one syringe IM.
If insufficient, top up with Zoletil 0.01 ml IV to effect. Domitor is expensive for stray cat spays.
I have not used this before.
4. IF USED ALONE, adverse effects are as follows:
1. Insufficient analgesia. Needs to top up IV.
2. Salivation and legs rigid (ketamine IM)
3. Wakes up fast
Combined with xylazine will make the cat sleep longer.
Myanmar stories - Air Bagan flight stewardesses are the prettiest
I met a tall and slim fair Myanmar lady who speaks good English and is working in Singapore on an S Pass. I asked her about "Save The Children" organisation in Myanmar as I had seen some poster of this organisation at pre-schools built by the NGO. She said she had a friend working there and would provide me with some info.
"Do you know about Air Bagan, Myanmar Airways, Yangon Airways and a new airline with red black colours?" I asked. "I flew by Air Bagan from Yangon to Heho Airport recently to tour Inle Lake. In some Western-printed tourist guide books on Myanmar like some editions of The Lonely Planet, some airlines are mentioned not to be supported by the tourists. I find this strange as tourism benefits the ordinary people by providing jobs."
She said: "I was working for MAI and yes, I know about the airlines. Air Bagan employs the prettiest air stewardesses!"
"Why?" I asked.
"Air Bagan does not employ relatives unlike ...."
Well, this was a surprise comment to me as I did not expect a lady to comment on the external appearances of stewardess. Beauty in a female still matters a lot in this commercial world.
In any case, the travel agent books Air Bagan for me on the two times I visited Lake Inle and so I cannot confirm whether the other airlines have less pretty stewardess.
"Do you know about Air Bagan, Myanmar Airways, Yangon Airways and a new airline with red black colours?" I asked. "I flew by Air Bagan from Yangon to Heho Airport recently to tour Inle Lake. In some Western-printed tourist guide books on Myanmar like some editions of The Lonely Planet, some airlines are mentioned not to be supported by the tourists. I find this strange as tourism benefits the ordinary people by providing jobs."
She said: "I was working for MAI and yes, I know about the airlines. Air Bagan employs the prettiest air stewardesses!"
"Why?" I asked.
"Air Bagan does not employ relatives unlike ...."
Well, this was a surprise comment to me as I did not expect a lady to comment on the external appearances of stewardess. Beauty in a female still matters a lot in this commercial world.
In any case, the travel agent books Air Bagan for me on the two times I visited Lake Inle and so I cannot confirm whether the other airlines have less pretty stewardess.
NGOs in Myanmar
I had lunch on last Thursday with my accountant who had opened a new office in Peninsula Plaza. His friend, a businessman came for lunch. He is quite a jovial man and I always asked him about Myanmar as I employ Myanmar Vet Technicians and it would be good to understand more about their culture and way of life.
I asked him about "Save The Children" organisation whose notice board I saw in Inle Lake Primary schools and in pre-schools.
"It is an NGO," he said. "I want to start an NGO as it makes money and I have the connections. The sponsors give the NGOs money for the work done during earthquakes and typhoons. The NGOs take around 40-50% of the donation. One of the founders of the NGO has 3 cars and a house now!"
I said: "Nobody works for free. NGO members are not paid a salary and they do take risks going into disaster areas. Will you prefer the money to go the government? In Singapore, the money goes to an organisation too but for that NGO, the money did go to the affected people. Not 100% but at least 50%. What NGO you want to start?"
"Some environment. You know Lake Inle now is not so deep due to the chopping down of trees. The soil fills up the lake and it become shallow in certain areas. Last time, it took 2 hours to travel up and down the lake. Now, it takes half an hour!"
"Save the trees?" I asked. "Or clean water for the villages?"
He said: "Clean water will be very useful for the villages."
I said: "You just start an NGO and think sponsors will give you the money. It is not so simple. Sponsors from Europe are not stupid people. You need a team and credentials and track record. Those NGOs whom you said are waiting for disasters to strike Myanmar and to send in lorries of rice and food are experienced and have been trusted by the sponsors to benefit the affected people!"
I asked him about one of my clients who wanted to sell halal pancreatic enzymes made from bovine, not porcine pancreas and wanted to know how to get a halal licence to export his product. He said: "Your friend has to pay $10,000 and wait 6 months for approval. Nowadays, the government prevents unauthorised drug import. Some years ago, the poor people bought "Pannadol" from China as it was very cheap. They die and it was found out that what they bought was chalk tablets. So, the government now is very strict on this import of drugs. Give me a sample and I will ask my doctor friends to try. In Myanmar, it is the lowest price and not the halal process that counts."
Sick and poor people still buy medicine as they need to get cure. Many businessmen just peddle the fake medicine to them as in all countries, not just Myanmar.
I asked him about "Save The Children" organisation whose notice board I saw in Inle Lake Primary schools and in pre-schools.
"It is an NGO," he said. "I want to start an NGO as it makes money and I have the connections. The sponsors give the NGOs money for the work done during earthquakes and typhoons. The NGOs take around 40-50% of the donation. One of the founders of the NGO has 3 cars and a house now!"
I said: "Nobody works for free. NGO members are not paid a salary and they do take risks going into disaster areas. Will you prefer the money to go the government? In Singapore, the money goes to an organisation too but for that NGO, the money did go to the affected people. Not 100% but at least 50%. What NGO you want to start?"
"Some environment. You know Lake Inle now is not so deep due to the chopping down of trees. The soil fills up the lake and it become shallow in certain areas. Last time, it took 2 hours to travel up and down the lake. Now, it takes half an hour!"
"Save the trees?" I asked. "Or clean water for the villages?"
He said: "Clean water will be very useful for the villages."
I said: "You just start an NGO and think sponsors will give you the money. It is not so simple. Sponsors from Europe are not stupid people. You need a team and credentials and track record. Those NGOs whom you said are waiting for disasters to strike Myanmar and to send in lorries of rice and food are experienced and have been trusted by the sponsors to benefit the affected people!"
I asked him about one of my clients who wanted to sell halal pancreatic enzymes made from bovine, not porcine pancreas and wanted to know how to get a halal licence to export his product. He said: "Your friend has to pay $10,000 and wait 6 months for approval. Nowadays, the government prevents unauthorised drug import. Some years ago, the poor people bought "Pannadol" from China as it was very cheap. They die and it was found out that what they bought was chalk tablets. So, the government now is very strict on this import of drugs. Give me a sample and I will ask my doctor friends to try. In Myanmar, it is the lowest price and not the halal process that counts."
Sick and poor people still buy medicine as they need to get cure. Many businessmen just peddle the fake medicine to them as in all countries, not just Myanmar.
396. Sunday Apr 10, 2011 - Interesting cases
396. Sunday Apr 10, 2011 - Interesting cases
April 10, 2011. Sunny in the morning. Downpour in the afternoon. Steady stream of clients from 9.30 am to 6.30pm. I did not break for lunch. However, I insisted that my new assistant, Mr Min who replaced Mr Saw recently, to go out for lunch at 3 pm. It is best to pack a lunch box on weekends as it may be too disruptive to close for lunch as cases don't complete on schedule.
CASE 1. Cat Neuter
For example, a mother and her adult son wanted me to neuter the cat. I could not do it till 4 pm when they came for the cat. The cat was said to be fierce and so he was injected IM inside the carrying trolley cage. I tilted the cage downwards waved a piece of paper in front of him while I injected him IM back muscles.
"He looks OK," Dr Michael said to me. The cat certainly did not show claws or aggressive behaviour. He just sat still and looked serene. "Well, the owner had already forewarned me about his aggression when handled. Looks can be deceiving. I had a cat who was taken out of the cage to be injected on the table. Before I could complete the injection, it sprung up, climbed up the vertical pipe and into a gap in the false ceiling. Fortunately, it was half sedated and I could get it down from high up in the false ceiling. You don't want to suffer this type of experience! It will even be worse if that cat had not got the tranquiliser IM and hides up the false ceiling forever."
Dr Michael looked at the false ceiling I had pointed. "The false ceiling gap in which the vertical pipe from the 2nd floor passed down to my unit had been covered up." Wisdom can only be learnt from experience and I was not taking any chances. "Once the cat is angry and frightened, it is extremely hard to catch it."
Cat, Male, 4.9 kg.
I used xylazine 0.1 ml + zoletil 100 0.1 ml in one syringe IM. The cat looked calmly and was not on the side after 15 minutes. I asked Mr Min to get him out and gave Zoletil 0.05 ml in 0.1 ml saline IV, femoral vein. The cephalic vein just could not be seen due to probably hypotension of the earlier injection. The cat was sufficiently sedated and did not experience any pain in neutering. See guidelines: Injectable anaesthetics in dogs & cats
CASE 2. Cat with urethral obstruction goes home in a cat carrier bag.
A young lady in her 20s came with a small fabric carrier bag. The type used for holding books. She was taking the cat back after 2 days of hospitalisation. Dr Michael had successfully cleared his urethral obstruction and flushed out the bright red blood in the bladder 2 days ago. The cat could not urinate for the past 2 weeks. Vet 1 had prescribed antibiotics but the lady said to me: "The cat became worse. He drips urine all over the apartment!"
So, Dr Michael had to clear the obstruction once and for all and to ask the young lady to switch to canned food.
Now, she was here to get the cat home. I was helping out as Dr Vanessa was very busy consulting. The lady was to put the cat inside her small bag, walk out to get a taxi to go back to Bishan. The cat resisted being put inside the bag. I could see the problem as the bag was small. The lady insisted she could do it. "The cat has some pain in the penile area now," I said. "He is not fully cured. Go buy a cat carrier bag as once he escapes, he will be lost forever in most cases." However, the young lady did not believe this would happen. I went to the back and found her a carrier bag with a zip and got the cat in backside in. It was more comfortable and most important secure as I zipped 90% of the bag. This cat would not escape.
CASE 3. Tumours in old Dachshunds
An Indonesian family brought 2 Dachshunds and a terrapin for treatment. One of the two old male Dachshund had 3 subcutaneous tumours and 1 small skin tumours. The owner was worried about one SC tumour to the right and below the anal sac as it was around 3 cm x1 cm. "It is possible to operate on a Sunday," I said. "However, it is best not to ask any vet to operate on a Sunday as it is a busy day." The Dachshunds will be operated on Tuesday and will be starved on Monday night after 10 pm. For old dogs, a short anaesthesia of less than 15 minutes will be safer and one Dachshund may need two short anaesthesia rather than be a hero and excise all 4 tumours for expediency. But with a dead dog on the operating table.
CASE 4. Cocker Spaniel with an ear flap tumour
Dr Vanessa had a case of an ear wart of around 1 cm x 0.5 cm on the inside of the ear pinnae. It looked very much like a wart with no stalk and 2 nodules. However the owner did not want laboratory histopathology and had phoned. I told Dr Michael her request as it was not possible for Dr Michael to answer phone queries during a busy consultation Sunday.
It would be best for her to focus and shorten the waiting time to around 15 minutes/normal case, otherwise there will be unhappiness. Case management is important on a Sunday and I had to train Mr Min who is not experienced in small animal practice yet. This was a simple surgical case but I provided some inputs to my surgical approach to this case. There is more than one surgical approach to remove a wart in the medial aspect of the ear flap.
CASE 5. Lymphoma with blood clotted inside the eye in a Jack Russell.
The mother wanted the blood clots inside the eye to be removed. 14 days ago, she came with her daughter and son-in-law to consult me because the Jack Russell suddenly could not see and bumped into furniture. He had swirling blood inside both eyes as bleeding had just started. So I sedated him and the next day, he was able to see. I advised chemotherapy but the mother was against it as she knew the bad side effects in other people undergoing chemotherapy. "Ok, I respect the mother's wishes," I said to the daughter. "Eye bleeding will return again and again till the dog becomes blind as this occurs in around 25% of canine lymphoma cases. The cause is internal bleeding due to lowered platelet count." The dog's eye whites or scleras were very red and inside both eyes, I showed that the lower 20% of the eye had a red crescent of clotted blood. "This is hyphaema," I said but I doubted the owners understood. What to do now? An ultrasound had been done by the owner to find out if the tumour had spread. "The dog is in Stage 5a which means the dog's condition had spread to other systems and is still eating," I had told the daughter before. "Chemotherapy is not a guarantee of complete cure but would buy time. In some cases, the tumours become smaller."
The tumours esp. the prescapular lymph nodes had shrunk a bit and was not so hard due to my initial treatment with dexamethasone and NSAID but it was not a cure. "The dog eats a lot and is very active," the mother had said. This is "a false dawn". It was the eye bleeding and intense eye pain that would cause the problem as well. "The dog never rubbed his eyes," the daughter said. I don't want to argue further as the dog would seldom rub his eyes in front of the owners and in any case, no owner can monitor the dog 24 hours a day. If only the dog could talk.
Now, the mother decided to have chemotherapy. Dr Michael and I worked together on this case. "According to some reports, chemotherapy can be effective even at late stages unlike other cancer cases," I said. "Lymphoma does not mean cancer." The laboratory report from a biopsy by Vet 1 some 3 weeks ago was inconclusive and the owner had not wanted a piece of tumour to be excised for histopathology as advised by me. Get a piece of the lymph node for histopathology instead of syringing for the cells for the lab to check, as done earlier by Vet 1.
It required anaesthesia and was too risky in case the dog dies. So, the owner had an ultrasound which indicated that the tumours had spread internally but there was no veterinary report from another vet who did the ultrasound. This is a highly emotional case to be handled with care and requires follow up. The dog had this eye bleeding for the past 7 days before the mother decided that the sedative and other injections which I did 2 weeks ago would do the trick. I told them it would not work now as the blood had clotted.
But I sedated the hyperactive dog with domitor 0.1 ml IM and after 15 minutes diazepam 0.6 ml IM to let the dog have a long rest. It was hope against hope that the clots would be removed by the body when the dog is sedated and the owners had been told of the prognosis. I will have to wait and see if the clot goes off with some sedation medication and chemotherapy. There is a need to follow up weekly but it is difficult to get the owners to comply.
CASE 6. Duty of Care.
"Dr Nelson gave the cat an enema," the man in his 30s said to me at the counter. "I wish to have one as the cat can't poop." I took out his case record. There was no mention of treatment by Dr Nelson who could not be contacted by phone. "Well, he referred the cat to the hospital. The cat is better but my other two cats cannot poop. Is it due to sympathy with the sick cat?" I said: "It is hard to tell. It could be the litter box and its contents or change of brand." The owner said: "I have placed more litter boxes but the contents and food remain the same." I said: "I can't really say. Try the hair ball paste commonly available in the pet shop. In any case, I can't prescribe as I have not seen the cat. Should it die due to my prescription without a proper examination, I could be subject to legal action." He understood and left amicably.
These are some cases and situations I encountered at the receptionist table. I took phone calls and appointments on this Sunday. It gave me a pulse on the standard of care provided by Toa Payoh Vets. There is no other way as in the past years, I was always inside the consultation room.
Being a licensee of Toa Payoh Vets, I have to be very careful that the standard of care is up to what a "reasonable man" expects. A practice can wither away instead of flourishing if the management is very poor. It does not mean that the vet opens a clinic and people will come to make the business sustainable over the years.
CASE 7. Leaking eye plugged 14 days later. The young couple came for the stitch removal and was asking me about a red spot by phone earlier. It is hard to know what the wife was talking about. After the stitches are removed, I could show her the plugged perforated corneal spot which she referred to as a red spot. This case is recorded separately.
PERFORMANCE COUNTS IN THE FINAL ANALYSIS
An older couple came with a 13-year old Silkie that could not recognise her yesterday but could do so today. She asked whether it was a CCD as she had read somewhere in the internet. A canine cognitive disorder? In other words, an old dog's brain malfunction.
She said to me: "My friend refers you to me. Her cat could not eat despite treatment from a vet. You said it was tooth decay. After your removal of the tooth, the cat ate." I said: "It must be 10 years ago. Is the cat still alive?" She said: "The cat is much alive and well. It was around 3 years ago." Veterinary medicine and surgery is a diverse complex subject as vets are expected to know from head to toe. It is a mission impossible and needs many years to encounter the various cases. A systematic approach to medicine and surgery will help but in the end, performance counts as you can see in this case. As this owner knew Dr Michael from some common friends, I did not participate in this case.
Friday, April 8, 2011
395. Do Skin Warts recur after excision? A case is reviewed 8 months later
Do Skin Warts recur after excision? A case is reviewed 8 months later
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 09 April, 2011
http://www.kongyuensing.com/folder5/20110330generalised-infected-warts-old-shih-tzu-singapore-toapayohvets.htm
has the pictures and updates.
April 8, 2011
"My uncle was so surprised and said: 'Your dog is so young and active," the wife said to me over the phone today when I asked what happened since 76 warts were excised by me 8 months ago. See: http://www.asiahomes.com/real_estate_tips/0816bluff.htm
"He is like a brand new dog a few days after the surgery. He behaved as if he was 6 years younger. Full of energy! It was not just my uncle who commented. Many friends were so surprised that my dog had become energised after the wart surgery!"
Today, the husband made an appointment specifically to consult me about the dog's right ear.
His first remark was that the 13-year-old male neutered Shih Tzu was a new dog after the warts were removed. I expected a half-dead lethargic old Shih Tzu but I was also surprised at the full coat and alertness.
The old Shih Tzu has been stressed by the painful eyes and right ear canal (filled with stinking pus) for at least 8 months. 10 viral skin warts came back and were frozen.
The couple will need to be diligent and educated to eliminate the stresses if his old companion is to live to a ripe old age in comfort and free from pain and itchiness. Follow up with the vet is advised after one month and subsequently.
The dog came in for a smelly right ear. I put a cotton bud and got a smear of dark brown pus at one end. The Shih Tzu winced in pain when the cotton bud touched the junction of the horizontal and vertical canal. He did not bite me. I smelt the brownish-yellow tip to check what type of bacteria or yeast infection it could be. This is not scientific as an ear discharge smear to check for yeast and bacteria would be done soon.
The smell was like some rotten flesh kept for some time. I asked my assistant and the owner to smell the tip as I waved it in front of their nose. The left ear was perfectly normal. "I ran out of your ear drops," the husband said.
There were 10 warts on the back spinal area (after I had the dog clipped bald. We thought it was 3 warts before clipping). 10/76 warts. Yet Vet 1 had told the owner: "The dog is old already. The warts are not serious. No point removing the warts. They will return back." I did say there is a possibility of recurrence too. The dog was 12 years old and a very high anaesthetic risk.
WHY DID THE OWNER SEEK A SECOND OPINION?
I asked the wife over the phone as Vet 1 had been their regular vet and they were a loyal client. "The dog was bleeding every day," the wife said. "A lot of blood. The dog was in pain. He was sleepy most of the day. I had to do something." In other words, the wife was very concerned and went into the internet to do research. Then the couple came to consult me.
WHAT DID I DO 8 MONTHS AGO?
Admitted: August 8, 2011, 2011, 9.3 kg, 38.1 C.
76 warts from head to toe literally.
R ear - rotten smelly skin. L eye - dry eye.
8 months ago, 76 warts were electro-excised under general anaesthesia
HIGH ANAESTHETIC RISK
It is not surprising that the family vet (Vet 1) did not want to perform surgery to excise the warts. He probably did not relish the blame and hassles if the old dog died on the operating table. So, over the 5- 6 years, the warts multiplied to number 76! The dog was lethargic most of the day. "What do you expect?" you would say. "He is an old dog!"
Anaesthesia & Surgery on Day 1 - August 11, 2011 and goes home on Day 2.
IV saline drip with Baytril 0.5 ml and Tolfedine 0.5 ml IV
Domitor 0.1 ml IV. Isoflurane gas maintenance. Electro-surgery. Excised 76 warts (a packet of warts given to the owner is still remembered).
2/0 absorbable stitches.
Baytril x 3 tablets, Trimethoprim and multivitamin for home.
The owner came 2 weeks later for antibiotics and no more news from the owner till today to consult about the smelly right ear. The wife was knowledgeable and had agreed that it was too risky to get the lateral ear canal resection surgery done. This surgery would have eliminated this recurring right ear infection (since 8 months ago, if you referred to my notes dated August 2010 (image below).
Procedures used to excise 76 warts
BLOOD TEST ON AUGUST 11, 2011
Liver enzymes high, urea high, creatinine low.
White Cell Count 19.8 (6-17)
Neutrophils 88% Abs 17.55
Lymphocytes 9.6% 1.90
Monocytes 1.1% 0.22
Eosinophils 0.71% 0.14
Basophils 0% 0
PCV, platelets, haemoglobin and RC etc - normal.
URINE TEST ON AUGUST 11, 2011
pH 6.5 (5-8)
SG 1.038 (1.005-1.030)
Protein trace
Blood negative
White blood cells 8
Bacteria Occasional
Crystal Calcium oxalate+
TODAY'S TREATMENT
Clipped bald. 10 warts. 2 most prominent between eyes and behind midline of eyes.
1. Right ear discharge sample. Stained exudate (fixative, air dry, S1, air dry, S2, air dry) to check for yeast and bacteria. Bacteria present. The owner had been giving his own ear drops for the past 8 months from some sources.
2. Irrigated the ear and bathed the dog after clipping the coat.
3. Froze 10 warts seen after clipping coat, 1 minute. Prominent one between eye. biggest cauliflower shaped at 4 mm x 4 mm. Others were much smaller appearing as small lumps under the skin. No need for sedative or anaesthesia.
PERFORMANCE COUNTS
This is a rare case of generalised warts in Singapore. The warts multiplied and spread over a period of 5-6 years. Why?
Food fed - home-cooked chicken and dog treats and canned Caesar. Sometimes diarrhoea, the wife said.
Given k/d canned and dry (last 2 months). Stools well formed and no diarrhoea.
OVERALL
Need to treat right ear infection and dry eyes if the dog is going to live longer with no pain and discomfort. Warts must be frozen when they are small. 10 very small warts were frozen without the need for anaesthetic and sedative as this dog was OK with the freezing. The biggest one was around 4mm x 5 mm between and above the eyes in the midline as shown below.
8 months ago. Under general anaesthesia and for around one hour, the 76 warts were excised by electro-surgery!
8 months later. The wart above and between the eye has recurred but was hidden by the hairs. Clipping exposed this wart. This was deep frozen.
Small warts <4mm x 4mm can be frozen and usually they will disappear 7-14 days later. Note that the large wart above the left ear (as in 8 months ago) has not recurred! So, the owner was happy with the outcome. But the war can be lost if one battle is won if the owner is not vigilant to get small warts excised.
PHONE ADVICE TO THE WIFE - REDUCE STRESS AS WARTS ARE SAID TO BE VIRAL AND GROW WHEN IMMUNE SYSTEM IS DONE.
A very busy working couple. I told them I do consult on Sundays and other days by appointment only. Fortunately, the dog's 10 warts discovered early - can be frozen. Only 10 small ones. The husband did not want a blood test as advised. Here are instructions given for this dog:
1. EYE CARE TO BE DONE DAILY (2 types of eye drops and Atopica) to prevent dog going blind with dry eyes 2 years later. Put dog on table. Teach mum how to do it if couple goes overseas for 2 weeks.
2. NO DIRECT WIPING OF EYEBALL by husband to clear pus around eyelids. Close the eyelids first after applying eye drops, I advised.
3. RIGHT EAR INFECTION MUST BE DILIGENTLY CONTROLLED AND FOLLOWED UP WITH THE VET. Rotten flesh smelly pus. Should be able to cure this one soon. Should review with the vet (me) 4 weeks later.
Warts do come back and can be frozen if detected early. Warts had caused pain and infection if left for several years (WCC high in Day 1). Owners are happy with the outcome. If the dog had died under anaesthesia, it would be bad for the vet. So, it is understandable that Vet 1 was reluctant to do surgery. Too many large warts, deep freezing is impractical.
A rare case in Singapore. Many older dogs have a few skin warts but this old Shih Tzu had 76 warts. The warts started with a few over the back area some 5 years ago, according to the wife. Then more and more appeared. The family vet would not want to excise them saying that the warts would come back again. So, no point removing them. The dog started rubbing his infected warts onto the floor and bloodied the apartment. "The Shih Tzu just could not stop scratching the large wart above his left ear. I have to do something," the wife checked the internet and contacted me.
What causes these warts? They are believed to be caused by papilloma viruses. Poor immune system in very young and old dogs lead to wart formation. What is the cure? Reduce the stresses.
PERFORMANCE counts in the veterinary practice. This case needs the owner to take care and follow up with the vet monthly or regularly. It had been 8 months since I saw the dog. I said diplomatically to the wife that an old dog needs more care than a young one and that stress due to pain and infection must be reduced considerably to prevent wart formation in old age. Also, good nutrition and no dry feed (urine crystals). The dog has a very good coat and skin and I presume k/d diet and some home-cooked food were sufficient.
RETROSPECTIVE REVIEW. In hindsight, I should have operated the dog after 24 hours as he was lethargic. Sometimes I want to save the owner some money by doing a same-day operation as in closed pyometra and urinary stone cases. It may not be wise to take such a risk as many dog owners never really forgive and never forget if the dog passes away on the operating table. Deaths of pets on the operating table are very highly emotional events even for the vet and his or her staff.
GET YOUR DOG WARTS EXCISED BY YOUR VET WHEN THE WARTS ARE SMALLER.
This case has a happy ending but owners are advised that skin warts in their dogs are best removed when they are few in number and are smaller. Happy endings are not always the case in high anaesthetic risky old and sick dogs with warts!
A YOUNG MAN WITH FOOT WARTS
Skin warts occur mainly in very young and old dogs as both groups have a much lower immune system. What about young people?
Do people get the cauliflower skin warts? I remember this young man in his early 20s in National Service. His shoes were damp from military training.
At first he had one and then more foot warts presented below his feet as he had to wear his boots for military service. Moe warts kept appearing on his hand as well. I can't remember how many he had. I advised him to see the doctor who made him an appointment with the surgeon as these warts seem to thrive and spread.
Like many young Singaporean males hooked onto the online gaming, he did not have sufficient rest. He would go online gaming till past 3 am every day.
He ate noodles most of the time. He saw the doctor who removed some warts. He reduced his online gaming of WOW II and other games. Slept more hours and earlier. I got him a freezing solution. He applied on the remaining two warts. Now he has no warts recurring. It seems that the warts are best excised early as they seem to spread to nearby skin areas. How he got the skin warts, I don't know. Now he has no warts at all and that is a relief for him as such warts can be quite painful.
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 09 April, 2011
http://www.kongyuensing.com/folder5/20110330generalised-infected-warts-old-shih-tzu-singapore-toapayohvets.htm
has the pictures and updates.
April 8, 2011
"My uncle was so surprised and said: 'Your dog is so young and active," the wife said to me over the phone today when I asked what happened since 76 warts were excised by me 8 months ago. See: http://www.asiahomes.com/real_estate_tips/0816bluff.htm
"He is like a brand new dog a few days after the surgery. He behaved as if he was 6 years younger. Full of energy! It was not just my uncle who commented. Many friends were so surprised that my dog had become energised after the wart surgery!"
Today, the husband made an appointment specifically to consult me about the dog's right ear.
His first remark was that the 13-year-old male neutered Shih Tzu was a new dog after the warts were removed. I expected a half-dead lethargic old Shih Tzu but I was also surprised at the full coat and alertness.
The old Shih Tzu has been stressed by the painful eyes and right ear canal (filled with stinking pus) for at least 8 months. 10 viral skin warts came back and were frozen.
The couple will need to be diligent and educated to eliminate the stresses if his old companion is to live to a ripe old age in comfort and free from pain and itchiness. Follow up with the vet is advised after one month and subsequently.
The dog came in for a smelly right ear. I put a cotton bud and got a smear of dark brown pus at one end. The Shih Tzu winced in pain when the cotton bud touched the junction of the horizontal and vertical canal. He did not bite me. I smelt the brownish-yellow tip to check what type of bacteria or yeast infection it could be. This is not scientific as an ear discharge smear to check for yeast and bacteria would be done soon.
The smell was like some rotten flesh kept for some time. I asked my assistant and the owner to smell the tip as I waved it in front of their nose. The left ear was perfectly normal. "I ran out of your ear drops," the husband said.
There were 10 warts on the back spinal area (after I had the dog clipped bald. We thought it was 3 warts before clipping). 10/76 warts. Yet Vet 1 had told the owner: "The dog is old already. The warts are not serious. No point removing the warts. They will return back." I did say there is a possibility of recurrence too. The dog was 12 years old and a very high anaesthetic risk.
WHY DID THE OWNER SEEK A SECOND OPINION?
I asked the wife over the phone as Vet 1 had been their regular vet and they were a loyal client. "The dog was bleeding every day," the wife said. "A lot of blood. The dog was in pain. He was sleepy most of the day. I had to do something." In other words, the wife was very concerned and went into the internet to do research. Then the couple came to consult me.
WHAT DID I DO 8 MONTHS AGO?
Admitted: August 8, 2011, 2011, 9.3 kg, 38.1 C.
76 warts from head to toe literally.
R ear - rotten smelly skin. L eye - dry eye.
8 months ago, 76 warts were electro-excised under general anaesthesia
HIGH ANAESTHETIC RISK
It is not surprising that the family vet (Vet 1) did not want to perform surgery to excise the warts. He probably did not relish the blame and hassles if the old dog died on the operating table. So, over the 5- 6 years, the warts multiplied to number 76! The dog was lethargic most of the day. "What do you expect?" you would say. "He is an old dog!"
Anaesthesia & Surgery on Day 1 - August 11, 2011 and goes home on Day 2.
IV saline drip with Baytril 0.5 ml and Tolfedine 0.5 ml IV
Domitor 0.1 ml IV. Isoflurane gas maintenance. Electro-surgery. Excised 76 warts (a packet of warts given to the owner is still remembered).
2/0 absorbable stitches.
Baytril x 3 tablets, Trimethoprim and multivitamin for home.
The owner came 2 weeks later for antibiotics and no more news from the owner till today to consult about the smelly right ear. The wife was knowledgeable and had agreed that it was too risky to get the lateral ear canal resection surgery done. This surgery would have eliminated this recurring right ear infection (since 8 months ago, if you referred to my notes dated August 2010 (image below).
Procedures used to excise 76 warts
BLOOD TEST ON AUGUST 11, 2011
Liver enzymes high, urea high, creatinine low.
White Cell Count 19.8 (6-17)
Neutrophils 88% Abs 17.55
Lymphocytes 9.6% 1.90
Monocytes 1.1% 0.22
Eosinophils 0.71% 0.14
Basophils 0% 0
PCV, platelets, haemoglobin and RC etc - normal.
URINE TEST ON AUGUST 11, 2011
pH 6.5 (5-8)
SG 1.038 (1.005-1.030)
Protein trace
Blood negative
White blood cells 8
Bacteria Occasional
Crystal Calcium oxalate+
TODAY'S TREATMENT
Clipped bald. 10 warts. 2 most prominent between eyes and behind midline of eyes.
1. Right ear discharge sample. Stained exudate (fixative, air dry, S1, air dry, S2, air dry) to check for yeast and bacteria. Bacteria present. The owner had been giving his own ear drops for the past 8 months from some sources.
2. Irrigated the ear and bathed the dog after clipping the coat.
3. Froze 10 warts seen after clipping coat, 1 minute. Prominent one between eye. biggest cauliflower shaped at 4 mm x 4 mm. Others were much smaller appearing as small lumps under the skin. No need for sedative or anaesthesia.
PERFORMANCE COUNTS
This is a rare case of generalised warts in Singapore. The warts multiplied and spread over a period of 5-6 years. Why?
Food fed - home-cooked chicken and dog treats and canned Caesar. Sometimes diarrhoea, the wife said.
Given k/d canned and dry (last 2 months). Stools well formed and no diarrhoea.
OVERALL
Need to treat right ear infection and dry eyes if the dog is going to live longer with no pain and discomfort. Warts must be frozen when they are small. 10 very small warts were frozen without the need for anaesthetic and sedative as this dog was OK with the freezing. The biggest one was around 4mm x 5 mm between and above the eyes in the midline as shown below.
8 months ago. Under general anaesthesia and for around one hour, the 76 warts were excised by electro-surgery!
8 months later. The wart above and between the eye has recurred but was hidden by the hairs. Clipping exposed this wart. This was deep frozen.
Small warts <4mm x 4mm can be frozen and usually they will disappear 7-14 days later. Note that the large wart above the left ear (as in 8 months ago) has not recurred! So, the owner was happy with the outcome. But the war can be lost if one battle is won if the owner is not vigilant to get small warts excised.
PHONE ADVICE TO THE WIFE - REDUCE STRESS AS WARTS ARE SAID TO BE VIRAL AND GROW WHEN IMMUNE SYSTEM IS DONE.
A very busy working couple. I told them I do consult on Sundays and other days by appointment only. Fortunately, the dog's 10 warts discovered early - can be frozen. Only 10 small ones. The husband did not want a blood test as advised. Here are instructions given for this dog:
1. EYE CARE TO BE DONE DAILY (2 types of eye drops and Atopica) to prevent dog going blind with dry eyes 2 years later. Put dog on table. Teach mum how to do it if couple goes overseas for 2 weeks.
2. NO DIRECT WIPING OF EYEBALL by husband to clear pus around eyelids. Close the eyelids first after applying eye drops, I advised.
3. RIGHT EAR INFECTION MUST BE DILIGENTLY CONTROLLED AND FOLLOWED UP WITH THE VET. Rotten flesh smelly pus. Should be able to cure this one soon. Should review with the vet (me) 4 weeks later.
Warts do come back and can be frozen if detected early. Warts had caused pain and infection if left for several years (WCC high in Day 1). Owners are happy with the outcome. If the dog had died under anaesthesia, it would be bad for the vet. So, it is understandable that Vet 1 was reluctant to do surgery. Too many large warts, deep freezing is impractical.
A rare case in Singapore. Many older dogs have a few skin warts but this old Shih Tzu had 76 warts. The warts started with a few over the back area some 5 years ago, according to the wife. Then more and more appeared. The family vet would not want to excise them saying that the warts would come back again. So, no point removing them. The dog started rubbing his infected warts onto the floor and bloodied the apartment. "The Shih Tzu just could not stop scratching the large wart above his left ear. I have to do something," the wife checked the internet and contacted me.
What causes these warts? They are believed to be caused by papilloma viruses. Poor immune system in very young and old dogs lead to wart formation. What is the cure? Reduce the stresses.
PERFORMANCE counts in the veterinary practice. This case needs the owner to take care and follow up with the vet monthly or regularly. It had been 8 months since I saw the dog. I said diplomatically to the wife that an old dog needs more care than a young one and that stress due to pain and infection must be reduced considerably to prevent wart formation in old age. Also, good nutrition and no dry feed (urine crystals). The dog has a very good coat and skin and I presume k/d diet and some home-cooked food were sufficient.
RETROSPECTIVE REVIEW. In hindsight, I should have operated the dog after 24 hours as he was lethargic. Sometimes I want to save the owner some money by doing a same-day operation as in closed pyometra and urinary stone cases. It may not be wise to take such a risk as many dog owners never really forgive and never forget if the dog passes away on the operating table. Deaths of pets on the operating table are very highly emotional events even for the vet and his or her staff.
GET YOUR DOG WARTS EXCISED BY YOUR VET WHEN THE WARTS ARE SMALLER.
This case has a happy ending but owners are advised that skin warts in their dogs are best removed when they are few in number and are smaller. Happy endings are not always the case in high anaesthetic risky old and sick dogs with warts!
A YOUNG MAN WITH FOOT WARTS
Skin warts occur mainly in very young and old dogs as both groups have a much lower immune system. What about young people?
Do people get the cauliflower skin warts? I remember this young man in his early 20s in National Service. His shoes were damp from military training.
At first he had one and then more foot warts presented below his feet as he had to wear his boots for military service. Moe warts kept appearing on his hand as well. I can't remember how many he had. I advised him to see the doctor who made him an appointment with the surgeon as these warts seem to thrive and spread.
Like many young Singaporean males hooked onto the online gaming, he did not have sufficient rest. He would go online gaming till past 3 am every day.
He ate noodles most of the time. He saw the doctor who removed some warts. He reduced his online gaming of WOW II and other games. Slept more hours and earlier. I got him a freezing solution. He applied on the remaining two warts. Now he has no warts recurring. It seems that the warts are best excised early as they seem to spread to nearby skin areas. How he got the skin warts, I don't know. Now he has no warts at all and that is a relief for him as such warts can be quite painful.
Thursday, April 7, 2011
394. Real Estate : Collective Sale - A good question without an answer
April 6, 2011
"What is the point of a 2-year restriction when the sales committee (SC) can be formed again within the 2-year restriction period to get enbloc sales going?" I asked the lecturer during the class on April 6, 2011.
The lecturer had stated that the SC will cease to exist if the enbloc sale is not successful after one year from the first signature done on the CSA (collective sales agreement). Therefore, he had answered my question as to what happened if the SC cannot get the 80% or 90% and therefore is unable to offer the property for sale. In the previous lecture, he had said that the "failed attempt" meant that the SC fails to find a buyer for the enbloc property after one year from the first signing of the CSA. If the SC gets 80% or 90% within that one year, the SC had a "failed attempt".
OK. He has answered my pestering question which had confused some of my classmates.
THE FOLLOWING IS WHAT I RECORDED IN MY BOOK
The lecturer wrote on the white board an illustration as follows:
--------------------------------------------------------->
Talk a lot
No action SC formed Year 1 Year 2 Year 3
Either AGM or EGM to form a SC
Quorum - 20% of SV (share value) or 25% of owners present
One-hour waiting time, no quorum, meeting cancelled.
Quorum = 30% of SV. SC is then formed. One year must do it. If nothing happens after one year, "failed attempt", SC ceases to exist.
Starting point of enbloc is the formation of the SC
Once SC is formed, within one year must obtain the CSA's first signature or face automatic termination.
The one-year period begins when the SC is elected at the AGM/EGM.
There is a (2-year restriction period?) after a potential collective sales fall through.
Within 2-year restriction, lst repeated attempt for enbloc sales by SC must get 50% SV or number of owners. 2nd and subsequent repeated attempts must get 80% will be needed.
WHAT PUZZLED ME WAS HIS INTERPRETATION OF THE 2-YEAR PERIOD
So I asked since nobody did it:
"What is the point of having the 2-year restriction when the SC can be formed within the 2 years to attempt another enbloc sale?"
The lecturer looked at me and said: "That is a good question!"
So what is the answer? He would not give me the answer and he insisted that his interpretation that the first attempt after the failed attempt is to be done within the 2-year restriction.
So, why the 2-year restriction rule is made? Does not make sense to me and to many of my classmates. The lecturer stuck to his gun.
So this is a good question without an answer.
I said: "Maybe the STB (strata title board) should be be asked?"
He said: "Who do you think is in charge of the enbloc sale? Ask that authority."
"It is the URA".
I said: "The STB is the regulatory body."
So, all students get confused since none of us are experts in collective sales!
One classmate said to me: "Since the collective sales question was just asked in the recent examination, it will never be asked again".
I told my classmate: "The collective sale is an important issue and has many parts. The question can still be asked again!"
I still can't understand why this lecturer is so sure that the first attempt must be within the 2-year restriction period. There are so many facts and figures to memorise but at least this lecture was lively. Two of my classmates chatted by themselves prompting the displeasure of the lecturer and I told them to be quiet, diplomatically. Then another student with grey hair said: "Please don't point the laser at me," as the lecturer was so active moving his hand and his laser beams shot at various angles. Sometimes the beam shot to my eye but I was too polite to tell him about the safety.
Is the lecturer committing a breach of duty of care to his student by pointing his laser beam anywhere and every direction when he lectured?
Law of Tort: Duty of Care - Test - Breach
Standard of Care, vicarious liability, Negligence, Negligence Defence - contributory negligence and consent negligence (volenti Non Fit Injuria), Disclaimer, Dangerous Premises (laser pointer?).
The lecturer apologised and said that he could not switch on the laser promptly if he switches it off. I asked the complainant classmate: "Perhaps we should chip in the money and buy him a good laser pointer."
This course is very tough as we will get over 1000 pages of paper to study. Some humour is necessary during lectures.
"What is the point of a 2-year restriction when the sales committee (SC) can be formed again within the 2-year restriction period to get enbloc sales going?" I asked the lecturer during the class on April 6, 2011.
The lecturer had stated that the SC will cease to exist if the enbloc sale is not successful after one year from the first signature done on the CSA (collective sales agreement). Therefore, he had answered my question as to what happened if the SC cannot get the 80% or 90% and therefore is unable to offer the property for sale. In the previous lecture, he had said that the "failed attempt" meant that the SC fails to find a buyer for the enbloc property after one year from the first signing of the CSA. If the SC gets 80% or 90% within that one year, the SC had a "failed attempt".
OK. He has answered my pestering question which had confused some of my classmates.
THE FOLLOWING IS WHAT I RECORDED IN MY BOOK
The lecturer wrote on the white board an illustration as follows:
--------------------------------------------------------->
Talk a lot
No action SC formed Year 1 Year 2 Year 3
Either AGM or EGM to form a SC
Quorum - 20% of SV (share value) or 25% of owners present
One-hour waiting time, no quorum, meeting cancelled.
Quorum = 30% of SV. SC is then formed. One year must do it. If nothing happens after one year, "failed attempt", SC ceases to exist.
Starting point of enbloc is the formation of the SC
Once SC is formed, within one year must obtain the CSA's first signature or face automatic termination.
The one-year period begins when the SC is elected at the AGM/EGM.
There is a (2-year restriction period?) after a potential collective sales fall through.
Within 2-year restriction, lst repeated attempt for enbloc sales by SC must get 50% SV or number of owners. 2nd and subsequent repeated attempts must get 80% will be needed.
WHAT PUZZLED ME WAS HIS INTERPRETATION OF THE 2-YEAR PERIOD
So I asked since nobody did it:
"What is the point of having the 2-year restriction when the SC can be formed within the 2 years to attempt another enbloc sale?"
The lecturer looked at me and said: "That is a good question!"
So what is the answer? He would not give me the answer and he insisted that his interpretation that the first attempt after the failed attempt is to be done within the 2-year restriction.
So, why the 2-year restriction rule is made? Does not make sense to me and to many of my classmates. The lecturer stuck to his gun.
So this is a good question without an answer.
I said: "Maybe the STB (strata title board) should be be asked?"
He said: "Who do you think is in charge of the enbloc sale? Ask that authority."
"It is the URA".
I said: "The STB is the regulatory body."
So, all students get confused since none of us are experts in collective sales!
One classmate said to me: "Since the collective sales question was just asked in the recent examination, it will never be asked again".
I told my classmate: "The collective sale is an important issue and has many parts. The question can still be asked again!"
I still can't understand why this lecturer is so sure that the first attempt must be within the 2-year restriction period. There are so many facts and figures to memorise but at least this lecture was lively. Two of my classmates chatted by themselves prompting the displeasure of the lecturer and I told them to be quiet, diplomatically. Then another student with grey hair said: "Please don't point the laser at me," as the lecturer was so active moving his hand and his laser beams shot at various angles. Sometimes the beam shot to my eye but I was too polite to tell him about the safety.
Is the lecturer committing a breach of duty of care to his student by pointing his laser beam anywhere and every direction when he lectured?
Law of Tort: Duty of Care - Test - Breach
Standard of Care, vicarious liability, Negligence, Negligence Defence - contributory negligence and consent negligence (volenti Non Fit Injuria), Disclaimer, Dangerous Premises (laser pointer?).
The lecturer apologised and said that he could not switch on the laser promptly if he switches it off. I asked the complainant classmate: "Perhaps we should chip in the money and buy him a good laser pointer."
This course is very tough as we will get over 1000 pages of paper to study. Some humour is necessary during lectures.
Law of Tort - Negligence - Duty & Standard of Care
The Straits Times April 6, 2011 "Patient's wife sues top heart surgeon".
The husband had a bypass surgery in Texas in Jan 17, 2007 but suffered a heart attack on March 9, 2007. The heart surgeon performed a re-do coronary artery bypass graft surgery 3 days later. The patient died 43 days after the heart surgery. Autopsy report said that death resulted from complications arising from the surgery. A coroner's inquest stated a verdict of misadventure.
The wife alleged that the surgeon was liable for the death and seeks damages. Her case was that the treatment was inappropriate, risks were understated and the husband was inadequately briefed on the options available. The surgeon, amongst other things, said that the patient had agreed to the operation after being advised about the options and thinking over.
The High Court hearing is in progress. What is the standard of care expected from a heart surgeon? Experts are being called to testify.
NOTES COMPARING REAL ESTATE TO MEDICAL PROFESSIONS
Comparing the disclaimer clause and the informed consent form
1. LAW OF TORT - DEFINITION
Definition: Tort is a breach of duty imposed by law, making the offender (defendant) liable to action for causing damage or injury to the plaintiff.
It is a body of law that addresses and provides remedies for civil wrongs not arising out of contractual obligation acts.
2. LAW OF TORT - DUTY OF CARE - TEST
Duty of Care - "But For" Test
A test of duty of care is: "You must take reasonable care to avoid acts and omissions that you can reasonably foresee, would be likely to injure your neighbour"
The cause of damage is established by the "but for" test:
The court will ask - would the plaintiff (patient, buyer, tenant, owner) has suffered the injury but for the defendant's (doctor's, agent's) negligence?
3. LAW OF TORT - DUTY OF CARE - BREACH
Standard of Care - Breach.
More important in professions requiring special skill or expertise, the person must exercise a reasonable standard of care that must be measured.
The standard of care is measured by the "reasonable man" test:
Whether the defendant's conduct fall below the standard of care which is expected of the reasonable man.
4. LAW OF TORT - NEGLIGENCE
To succeed in an action for negligence, the plaintiff must show that:
- the defendant owes him a duty of care
- the defendant has beached that duty of care
- his breach causes damage/loss to the plaintiff
- the damage/loss is not too remote (not controllable, not foreseeable, not an expert on a particular subject matter).
5. LAW OF TORT - DISCLAIMER
1. A disclaimer (e.g in veterinary medicine, an informed consent form signed by the pet owner or patient) may prevent an agent (doctor) being held liable to a 3rd party in tort arising from fiduciary duty.
2. A disclaimer does not automatically protect an agent (doctor) from any liability to the 3rd party.
3. For a disclaimer to be effective, it must be firmly incorporated into the contract and must be done at the time the contract was made.
4. Whether the disclaimer will be effective or not depends on the court's interpretation of the "reasonableness" test and the facts of each case.
A common disclaimer clause is as follows:
The vendor does not make or give and neither the agent nor any of his employee has the authority to make or give any representation or warranty whatever in relation to the property.
The husband had a bypass surgery in Texas in Jan 17, 2007 but suffered a heart attack on March 9, 2007. The heart surgeon performed a re-do coronary artery bypass graft surgery 3 days later. The patient died 43 days after the heart surgery. Autopsy report said that death resulted from complications arising from the surgery. A coroner's inquest stated a verdict of misadventure.
The wife alleged that the surgeon was liable for the death and seeks damages. Her case was that the treatment was inappropriate, risks were understated and the husband was inadequately briefed on the options available. The surgeon, amongst other things, said that the patient had agreed to the operation after being advised about the options and thinking over.
The High Court hearing is in progress. What is the standard of care expected from a heart surgeon? Experts are being called to testify.
NOTES COMPARING REAL ESTATE TO MEDICAL PROFESSIONS
Comparing the disclaimer clause and the informed consent form
1. LAW OF TORT - DEFINITION
Definition: Tort is a breach of duty imposed by law, making the offender (defendant) liable to action for causing damage or injury to the plaintiff.
It is a body of law that addresses and provides remedies for civil wrongs not arising out of contractual obligation acts.
2. LAW OF TORT - DUTY OF CARE - TEST
Duty of Care - "But For" Test
A test of duty of care is: "You must take reasonable care to avoid acts and omissions that you can reasonably foresee, would be likely to injure your neighbour"
The cause of damage is established by the "but for" test:
The court will ask - would the plaintiff (patient, buyer, tenant, owner) has suffered the injury but for the defendant's (doctor's, agent's) negligence?
3. LAW OF TORT - DUTY OF CARE - BREACH
Standard of Care - Breach.
More important in professions requiring special skill or expertise, the person must exercise a reasonable standard of care that must be measured.
The standard of care is measured by the "reasonable man" test:
Whether the defendant's conduct fall below the standard of care which is expected of the reasonable man.
4. LAW OF TORT - NEGLIGENCE
To succeed in an action for negligence, the plaintiff must show that:
- the defendant owes him a duty of care
- the defendant has beached that duty of care
- his breach causes damage/loss to the plaintiff
- the damage/loss is not too remote (not controllable, not foreseeable, not an expert on a particular subject matter).
5. LAW OF TORT - DISCLAIMER
1. A disclaimer (e.g in veterinary medicine, an informed consent form signed by the pet owner or patient) may prevent an agent (doctor) being held liable to a 3rd party in tort arising from fiduciary duty.
2. A disclaimer does not automatically protect an agent (doctor) from any liability to the 3rd party.
3. For a disclaimer to be effective, it must be firmly incorporated into the contract and must be done at the time the contract was made.
4. Whether the disclaimer will be effective or not depends on the court's interpretation of the "reasonableness" test and the facts of each case.
A common disclaimer clause is as follows:
The vendor does not make or give and neither the agent nor any of his employee has the authority to make or give any representation or warranty whatever in relation to the property.
Top 10 Canine conditions in the USA from an Insurance Company & Prostatitis in an old male dog
Top 10 medical insurance claims for dogs in 2009
Veterinary Pet Insurance Co (VPI), the oldest and largest pet health insurance in the USA received >1 million claims from pet owners each year. For 2009, the top 10 canine conditions are:
1. Ear infection
2. Skin allergy
3. Skin infection/hot spot
4. Gastritis/vomiting
5. Intestinal inflammation/diarrhoea
6. Bladder infection
7. Arthritis
8. Soft tissue trauma
9. Non-cancerous tumour
10. Eye infection
Most of the conditions affect all dogs, regardless of age.
At Toa Payoh Vets, Skin infection is the top canine condition in 2009 and 2010 seen by me. The others mentioned by VPI above are commonly seen but I don't have the statistics. As I have been in practice for over 30 years, many of my cases are old dogs as the children of my baby-boomer generation clientele have had grown up and become young adults taking over the care of their aged dogs.
An interesting case study of an old male dog problem is mentioned below.
Prostatitis in the old male dog
"I thought he had died," the mum said. The Shih Tzu, male, neutered, 8 years old was motionless. He had a right perineal hernia repair and then neutering 2 weeks ago and was Ok for a few days. Then he stopped eating for a few days and collapsed as if he had died.
23.8.10
On examination, he on 23.8.10, I found that he had a high fever and was pale.
1. Palpation: Bladder felt firm and enlarged. Urine by catherisation.
Urine test: Urinary Tract Infection. The dog went home the next day. 3 days later, he came back as he was licking his private parts and urine kept leaking out. Cloudy urine.
Palpation: Bladder felt firm and painful. It could be an enlarged bladder wall, bladder tumour or prostrate enlargement.
2. Empty bladder using cathether. 15 ml of urine came out. Palpated the bladder. A little amount of urine came out but a rounded lump of 3 cm x 3 cm. This was the enlarged prostate.
3. Rectal digital palpation when the bladder is emptied. This confirmed that the prostate was enlarged.
To check the prostate:
1. Palpation. There was painful reaction. I diagnosed this as prostatitis and enlargement. Also epithelial cells seen in urine test.
BLOOD TEST
23.8.10 Creatinine was below normal. Red cell below normal. Total White Cell Count above normal. Neutrophils 97% (Absolute 17.2 x 10^9/L), Lymphocytes 2.5% (Absolute 0.45X 10^9/L).
URINE TEST
Colourless, slightly turbid. pH 6.5 (5-8), SG 1.005 (1.005 - 1.030). Protein - trace. Blood 4+, White blood cells >2250, Red blood cells 20, epithelial cells 0, Mucus Threads Occasional, Bacterial Occasional. Possible haemolysis of RBC in urine.
24.8.10
Vomited white froth overnight
"Tongue colour pinker," the mother told me. "At 7 pm yesterday when I saw him, his tongue was very pale."
Another urine test was taken. Owner was advised that an X-ray or ultrasound scan might be required. "The dog had never been sick for the last 7 years," she said. Now there were some veterinary expenses and worries. The dog is still incontinent and more work need to be done.
CONCLUSION
"Can a dog die of UTI?" the mother asked me.
"A dog can die of UTI or any infection if he is not treated," I replied. "Older dogs are more likely to die when they are sick as they have lower immune system. Your dog is 8 years old and is considered an old dog."
Neutering the dog when he was young would have prevented the worries but many owners feel it cruel to sterilise dogs. Annual vet examination and health check may be advised. Statistically, male dogs that are not neutered are likely to get perineal hernia and prostrate enlargement and infection.
Veterinary Pet Insurance Co (VPI), the oldest and largest pet health insurance in the USA received >1 million claims from pet owners each year. For 2009, the top 10 canine conditions are:
1. Ear infection
2. Skin allergy
3. Skin infection/hot spot
4. Gastritis/vomiting
5. Intestinal inflammation/diarrhoea
6. Bladder infection
7. Arthritis
8. Soft tissue trauma
9. Non-cancerous tumour
10. Eye infection
Most of the conditions affect all dogs, regardless of age.
At Toa Payoh Vets, Skin infection is the top canine condition in 2009 and 2010 seen by me. The others mentioned by VPI above are commonly seen but I don't have the statistics. As I have been in practice for over 30 years, many of my cases are old dogs as the children of my baby-boomer generation clientele have had grown up and become young adults taking over the care of their aged dogs.
An interesting case study of an old male dog problem is mentioned below.
Prostatitis in the old male dog
"I thought he had died," the mum said. The Shih Tzu, male, neutered, 8 years old was motionless. He had a right perineal hernia repair and then neutering 2 weeks ago and was Ok for a few days. Then he stopped eating for a few days and collapsed as if he had died.
23.8.10
On examination, he on 23.8.10, I found that he had a high fever and was pale.
1. Palpation: Bladder felt firm and enlarged. Urine by catherisation.
Urine test: Urinary Tract Infection. The dog went home the next day. 3 days later, he came back as he was licking his private parts and urine kept leaking out. Cloudy urine.
Palpation: Bladder felt firm and painful. It could be an enlarged bladder wall, bladder tumour or prostrate enlargement.
2. Empty bladder using cathether. 15 ml of urine came out. Palpated the bladder. A little amount of urine came out but a rounded lump of 3 cm x 3 cm. This was the enlarged prostate.
3. Rectal digital palpation when the bladder is emptied. This confirmed that the prostate was enlarged.
To check the prostate:
1. Palpation. There was painful reaction. I diagnosed this as prostatitis and enlargement. Also epithelial cells seen in urine test.
BLOOD TEST
23.8.10 Creatinine was below normal. Red cell below normal. Total White Cell Count above normal. Neutrophils 97% (Absolute 17.2 x 10^9/L), Lymphocytes 2.5% (Absolute 0.45X 10^9/L).
URINE TEST
Colourless, slightly turbid. pH 6.5 (5-8), SG 1.005 (1.005 - 1.030). Protein - trace. Blood 4+, White blood cells >2250, Red blood cells 20, epithelial cells 0, Mucus Threads Occasional, Bacterial Occasional. Possible haemolysis of RBC in urine.
24.8.10
Vomited white froth overnight
"Tongue colour pinker," the mother told me. "At 7 pm yesterday when I saw him, his tongue was very pale."
Another urine test was taken. Owner was advised that an X-ray or ultrasound scan might be required. "The dog had never been sick for the last 7 years," she said. Now there were some veterinary expenses and worries. The dog is still incontinent and more work need to be done.
CONCLUSION
"Can a dog die of UTI?" the mother asked me.
"A dog can die of UTI or any infection if he is not treated," I replied. "Older dogs are more likely to die when they are sick as they have lower immune system. Your dog is 8 years old and is considered an old dog."
Neutering the dog when he was young would have prevented the worries but many owners feel it cruel to sterilise dogs. Annual vet examination and health check may be advised. Statistically, male dogs that are not neutered are likely to get perineal hernia and prostrate enlargement and infection.
Wednesday, April 6, 2011
391. Real estate. What is "failed attempt" in collective sale?
"What is the definition of 'failed attempt'"? I interrupted the lecturer of the real estate course I was attending on April 2, 2011. For 2 months, I must attend this course Monday, Wednesday and Friday from 10am to 1 pm. It is a very intensive course with lots to remember for the test in late May.
The lecturer said: "Failed attempt means that the sales committee had not been able to find a buyer for the enbloc sale of the property."
I asked: "What if the sales committee cannot get the 80% or 90% of the owners to agree to the enbloc sale? Is it considered a failed attempt?"
The students started to talk amongst themselves and the lecturer insisted on his definition. He had to speak louder and said: "Don't ask 'what if' scenarios unless you are in a position to know." He is a very good lecturer and concerned about the students ability to pass exam. Most students are in their late 20s and much older. He must have got up from the wrong side of the bed that day.
I said: "I am familiar with the Ridgewood enbloc sale as I had one to sell. As there was no 80%, the sales committee wrote to the owners that they would have to wait 2 years before another enbloc sale will be attempted."
It is tough to be a lecturer actually as there are so many rules and regulations merrily made by the Singapore bureaucrats in response to complaints and feedback.
According to his notes, the Rules for Disposal By Collective Sale stated some rules as follows:
SEP 2008 RULES
1. The Collective Sales Agreement (CSA) will LAPSE AFTER ONE YEAR if NO BUYER is forthcoming.
2. The Sales Committee CEASES to exist."
JUN 2010 RULES
1. A failed attempt "RESTRICTION PERIOD OF 2 YEARS" shall be imposed, STARTING from the date of failed attempt.
2. Within this "restriction period",
2.1 FIRST RE-TRY EGM, RE-APPOINT a sales committee.
2.2 With MORE THAN 50% by share value OR total number of owners.
3. After 2 years
3.1 EGM to appoint a sales committee.
3.2 Need 20% by share value OR 25% total number of owners.
CONCLUSION
Readers can appreciate how difficult it is to pass this exam as many rules and regulations must be memorised for the exam. 20%? 25%? Why did the regulators not just state one figure - 25% or 20%?
I asked the lecturer to look into the rules and regulations of the STB (Strata Titles Board, not Singapore Tourism Board). I sense that he was sticking to his own interpretation. "Well, you just need 50% to pass the exam," I told my lady classmate in her 40s and curly haired, sitting behind me as she said she was so confused about this definition of "failed attempt".
So, does "failed attempt" include the failure to get 80% (for properties more than 10 years old) or 90% (for properties less than 10 years old) to agree to the enbloc sale? The answer is important because if the question of failed attempt is 5 marks. Each of the 2 answers is worth 2.5 marks. If only one answer is given, the student gets 2.5 marks only, due to the "failure of the lecturer to provide 2 answers"!
P.S
I am writing this article to educate myself for the exam. It is hard to remember every fact but the exam requires such facts and figures.
Another rule for "Private Properties - Disposal by Collective Sale"
SEP 2008 RULES
1. The majority CONSENT.
80% of the building's GFA (gross floor area) + 80% of the SHARE VALUE for projects >10 years old and 90% if less than 10 years old.
4-weekly UPDATES certified by a lawyer must be provided.
2. A LAWYER must be present whenever an owner signs a CSA and to explain the terms of the agreement. He assists in VETTING the minutes of the sales committee meeting and DRAFTRS motions for the general meeting.
3. A 5-day COOL OFF PERIOD for owners who have signed the CSA.
4. Upon legal completion, the fund and sinking fund must be RETURNED to the enbloc sellers according to THEIR share value allotments.
This is only 1% of the facts and figures I must remember. 5 out of 8 questions to be answered. 15 questions for 3 days of examinations. Must pass at one sitting. Or no licence. The May 2011 exam will be the first for the RES exam. It will be a killing field as the students are mature students and many are not even in real estate.
The lecturer said: "Failed attempt means that the sales committee had not been able to find a buyer for the enbloc sale of the property."
I asked: "What if the sales committee cannot get the 80% or 90% of the owners to agree to the enbloc sale? Is it considered a failed attempt?"
The students started to talk amongst themselves and the lecturer insisted on his definition. He had to speak louder and said: "Don't ask 'what if' scenarios unless you are in a position to know." He is a very good lecturer and concerned about the students ability to pass exam. Most students are in their late 20s and much older. He must have got up from the wrong side of the bed that day.
I said: "I am familiar with the Ridgewood enbloc sale as I had one to sell. As there was no 80%, the sales committee wrote to the owners that they would have to wait 2 years before another enbloc sale will be attempted."
It is tough to be a lecturer actually as there are so many rules and regulations merrily made by the Singapore bureaucrats in response to complaints and feedback.
According to his notes, the Rules for Disposal By Collective Sale stated some rules as follows:
SEP 2008 RULES
1. The Collective Sales Agreement (CSA) will LAPSE AFTER ONE YEAR if NO BUYER is forthcoming.
2. The Sales Committee CEASES to exist."
JUN 2010 RULES
1. A failed attempt "RESTRICTION PERIOD OF 2 YEARS" shall be imposed, STARTING from the date of failed attempt.
2. Within this "restriction period",
2.1 FIRST RE-TRY EGM, RE-APPOINT a sales committee.
2.2 With MORE THAN 50% by share value OR total number of owners.
3. After 2 years
3.1 EGM to appoint a sales committee.
3.2 Need 20% by share value OR 25% total number of owners.
CONCLUSION
Readers can appreciate how difficult it is to pass this exam as many rules and regulations must be memorised for the exam. 20%? 25%? Why did the regulators not just state one figure - 25% or 20%?
I asked the lecturer to look into the rules and regulations of the STB (Strata Titles Board, not Singapore Tourism Board). I sense that he was sticking to his own interpretation. "Well, you just need 50% to pass the exam," I told my lady classmate in her 40s and curly haired, sitting behind me as she said she was so confused about this definition of "failed attempt".
So, does "failed attempt" include the failure to get 80% (for properties more than 10 years old) or 90% (for properties less than 10 years old) to agree to the enbloc sale? The answer is important because if the question of failed attempt is 5 marks. Each of the 2 answers is worth 2.5 marks. If only one answer is given, the student gets 2.5 marks only, due to the "failure of the lecturer to provide 2 answers"!
P.S
I am writing this article to educate myself for the exam. It is hard to remember every fact but the exam requires such facts and figures.
Another rule for "Private Properties - Disposal by Collective Sale"
SEP 2008 RULES
1. The majority CONSENT.
80% of the building's GFA (gross floor area) + 80% of the SHARE VALUE for projects >10 years old and 90% if less than 10 years old.
4-weekly UPDATES certified by a lawyer must be provided.
2. A LAWYER must be present whenever an owner signs a CSA and to explain the terms of the agreement. He assists in VETTING the minutes of the sales committee meeting and DRAFTRS motions for the general meeting.
3. A 5-day COOL OFF PERIOD for owners who have signed the CSA.
4. Upon legal completion, the fund and sinking fund must be RETURNED to the enbloc sellers according to THEIR share value allotments.
This is only 1% of the facts and figures I must remember. 5 out of 8 questions to be answered. 15 questions for 3 days of examinations. Must pass at one sitting. Or no licence. The May 2011 exam will be the first for the RES exam. It will be a killing field as the students are mature students and many are not even in real estate.
390. An Australian veterinary student from Singapore in the top 5%
On Sunday, I took time off in the afternoon to bring Julia to her old hair-dresser in a shopping mall. She did not visit this hair-dresser for many years owing to the loss of personal attention as the hair-dresser expanded her business and asked her staff to attend to her. However, Julia asked about this hair-dresser and I took her to her shop. I knew this hair-dresser and her husband for over 15 years and I did go for some hair cuts in the past.
Hair-dressing and veterinary practice appears to be very personal. There are clients who will specify that they want Dr Vanessa only and there are some of my clients disappointed with me for not being available when they have to consult Dr Vanessa.
It was great to see her again. No health problems at the age of 60. No high cholesterol level unlike many Singaporeans. "You look lean and mean," I said. "As if you don't have enough to eat."
"I eat only 2 meals a day," she told us her secret of being healthy as most older Singaporeans of over 40 years are on anti-cholesterol and high blood pressure medication. Here she was as fit as a fiddle.
"I don't eat meat." She does eat some fish occasionally.
Her business was booming as the economy has recovered and she had said: "During SARS, I had to ask my staff to take some days off not to work. Now, I wish they work every day!" So, business must be very good.
"How's your son doing in his veterinary studies in Australia?" I had seen him as a pre-teen in Canberra some 15 years ago. He is an Australian citizen and so his veterinary fees of $300,000 for 5 years will not be paid by his parents.
"He's got free education as a citizen," the mum said. "He gets $1,500 scholarship for the next 4 years. So I don't have to pay anything till the 5th year."
"How did he get this scholarship for 4 years from the Australian Government? What is the name of this scholarship?" I asked.
"He was the top 5% in his first year in economics. Then he switched to veterinary medicine. I don't know the name. All I know is that he asks me to pay after the 4 years in vet course."
Academic excellence still counts in any part of the world. Scholarship for the top 5% to motivate the student.
I saw her hand worn out through years of treating clients and washing their hair. "Veins are very big in the hands if you are a hair-dresser," she showed me her big veins above her hand and then another male hair-dresser.
She did share with me her business management and success. I always ask to improve my own practice. In her practice, no hair-dresser is allowed to write name and address of clients so that they don't poach clients. In veterinary practice, vets who leave the practice can download the customer data base and inform clients when they go elsewhere if such vets want to be unethical.
She gave me the hair-dresser appointment book which is excellent and told me what she used it for in certain product and service recording. I will use it and improve my management.
Hair-dressing and veterinary practice appears to be very personal. There are clients who will specify that they want Dr Vanessa only and there are some of my clients disappointed with me for not being available when they have to consult Dr Vanessa.
It was great to see her again. No health problems at the age of 60. No high cholesterol level unlike many Singaporeans. "You look lean and mean," I said. "As if you don't have enough to eat."
"I eat only 2 meals a day," she told us her secret of being healthy as most older Singaporeans of over 40 years are on anti-cholesterol and high blood pressure medication. Here she was as fit as a fiddle.
"I don't eat meat." She does eat some fish occasionally.
Her business was booming as the economy has recovered and she had said: "During SARS, I had to ask my staff to take some days off not to work. Now, I wish they work every day!" So, business must be very good.
"How's your son doing in his veterinary studies in Australia?" I had seen him as a pre-teen in Canberra some 15 years ago. He is an Australian citizen and so his veterinary fees of $300,000 for 5 years will not be paid by his parents.
"He's got free education as a citizen," the mum said. "He gets $1,500 scholarship for the next 4 years. So I don't have to pay anything till the 5th year."
"How did he get this scholarship for 4 years from the Australian Government? What is the name of this scholarship?" I asked.
"He was the top 5% in his first year in economics. Then he switched to veterinary medicine. I don't know the name. All I know is that he asks me to pay after the 4 years in vet course."
Academic excellence still counts in any part of the world. Scholarship for the top 5% to motivate the student.
I saw her hand worn out through years of treating clients and washing their hair. "Veins are very big in the hands if you are a hair-dresser," she showed me her big veins above her hand and then another male hair-dresser.
She did share with me her business management and success. I always ask to improve my own practice. In her practice, no hair-dresser is allowed to write name and address of clients so that they don't poach clients. In veterinary practice, vets who leave the practice can download the customer data base and inform clients when they go elsewhere if such vets want to be unethical.
She gave me the hair-dresser appointment book which is excellent and told me what she used it for in certain product and service recording. I will use it and improve my management.
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