E-MAIL TO DR SING DATED MAR 26, 2011
Subject: Scaling for dogs
To: judy@toapayohvets.com
Received: Friday, 25 March, 2011, 2:00 PM
Hi,
I am looking for a trusted vet and doctor who can perform scaling on my 2 year old Chihuahua. I am interested upon sending her to Toa Payoh Vets. I would like to know how much it would cost and what I should do to prepare her for the day of her visit.
Thank you,
Name given
E-MAIL REPLY TO DR SING
DATED MAR 28, 2011
Thank you so much.
E-MAIL REPLY FROM DR SING DATED MAR 26, 2011
Hi
I am Dr Sing from Toa Payoh Vets. Thank you for your email to Judy.
The dental scaling plus anaesthesia cost is around $250 normally. Decayed tooth extraction will be around $10-$20 per tooth extracted. Medication of antibiotics and pain-killer is estimated at around $20 if necessary. Blood test for pre-anaesthesia risk checking will not be done in normal healthy dogs and will cost $150 if it is needed but you will be informed first.
Do not feed or give water to your dog after 10 pm the night before the dental work. Bring your dog to Toa Payoh Vets at 10 a.m. The dog will go home around 5pm usually, after rest and recovery from general anaesthesia.
Please make an appointment at 6254 3326. Please indicate which vet you prefer. These are Dr Sing, Dr Vanessa Lin and Dr Jason Teo.
Saturday, April 2, 2011
Fools rush in where angels fear to tread - A hamster's large neck tumour
SURGICAL AREA
A big soft lump from below one ear to another and dangling under the neck in an old Syrian hamster (female, 20 months). This is the type of surgical condition I dread most. Performing this type of surgery is "fools rush in where angels fear to tread". The neck area has many important nerves, arteries and veins and it is not a very dangerous area to remove tumours especially in a hamster. That area below the throat is so small (less than 1 cm) compared to a dog or cat. A few thousand times smaller. There is no luxury of using an operating microscope and in any case, the surgery must be short as the hamster can't survive long anaesthesias of more than 1 minute, in my experience. You can't top up anaesthesia as in the dog and cat. Any more anaesthesia, the hamster just dies.
ANAESTHESIA
Very risky in a lethargic hamster. That means the hamster is not normal and healthy. The owner of this case waited till the neck tumour becomes very large. Is it inoperable? In any case, the chances of the old and lethargic hamster surviving are much lower. Less than 10%. So why take the case and risk damaging one's hard-built reputation as a "killer" of hamsters when this Syrian hamster dies on the operating table? Why not pass the buck to other vets?
DOSAGE OF INJECTABLE ANAESTHESIA IS HARD TO CALCULATE
"How much to give?" I asked my assistant Mr Saw (as part of my training of the past 3 years with me). He will be going to greener pastures in 2 weeks' time. "One drop of Zoletil will do," Mr Saw said. The owner had already said the hamster was lethargic for the past 2 weeks and the lump had exploded to big size during this time. Therefore, minimal dose as recommended by Mr Saw was the correct thing to do.
I gave one drop of Zoletil by injection IM into the left backside muscle. Waited for 5 minutes. The hamster looked at me and behaved normally, walking around inside the plastic container. She ought to be sleepy but she was much wide awake.
I waited another 5 minutes. She was active and had produced more faecal pellets. So, this dosage given was not effective. "In Syrian hamsters (160g), you need to give 4 times the dosage of a dwarf hamster (40 g)," I said to Mr Saw. But how do you calculate the dosage? It is easy in dogs and cats because they weight in kg when adult. But in this adult old hamster, she was 160 g.
"Give 2 drops," I asked Mr Saw to prepare the Zoletil. He filled up Zoletil 100 in one one-ml syringe and then push out one drop from its tips. Then I should use another one-ml syringe with a fine needle to aspirate the two drops.
"Hey, it is better you rest your elbows on top of the operating table," I said as it is hard to be precise in the present set up. "I also put my hands on top of the table." I then used the tip of my 25G needle attached to my one-ml syringe and aspirated two full drops from Mr Saw's one-ml syringe tip.
I injected into the right backside muscle. Within one minute, the hamster was lying down on his back.
So far, the Providence had been kind to me. The hamster was down but not out. Not dead I mean.
IV DRIPS
Impossible to do in a hamster. The veins are too small. SC injection of up to 3 ml dextrose saline is possible and was done in this case post-op.
SURGERY
After being sedated with the correct, safe and effective amount of Zoletil 100, the hamster went down sideways. There was a window of analgesia for around 1 minute to get the lump excised and the skin sutured.
I incised the skin 1 cm. A glistening membrane of the lump appeared under the skin. It seemed to be cyst but it was not 100% fluid filled lump. I saw a large vein from the lump (see illustration). "Is it the jugular vein?" I asked Mr Saw to make him think. He kept quiet. We had never seen jugular veins in hamsters in previous surgeries. Well, this location of the tumour was the second one I encountered during the past years of practice.
Know your anatomy well. It was not the jugular vein. I was just making my assistant think about hamster anatomy. He photocopied many veterinary notes and illustrations to prepare himself for the setting up of a private practice in Yangon later in the year. But nothing beats photocopies like seeing the real thing.
"Is it the jugular?" I asked my assistant again. He did not reply. It certainly was the biggest widest blue vein we had seen under the neck but it was connected to the tumour some below the tumour mass. It was unlikely to be a jugular but since the neck area is so small in size compared to that of a dog or cat, it would be hard to discount its presence. As a guideline, any large vein connected to a big tumour would be a feeder vein and the artery would be next to it. The tumour needed more nutrients and the blood vessels seem to enlarge to supply the ravenous growth.
I clamped the tumour and excised. Immediately blue blood spilled out. This vein was hard to ligate initially as it was very close to the pharynx. I dared not ligate as the needle might perforate the pharynx. So I excised the tumour first. Around 3 ml of blood splashed out. "Swabs," I said. Mr Saw provided the 3 swabs I needed to clear the bloodied area. I could see the bleeding vein. Ligated it. Then another big spurt appeared. It was probably the artery injured during the first ligation. I ligated this second bleeder. No more bleeding.
"Stretch the 2 cm skin wound by putting your thumb and index finger on either side," I said to my assistant. In this way, the skin wound is stretched out and I could appose the cut skin with 3 horizontal mattress sutures quickly. The hamster's neck was not straight in this type of surgery. No luxury of tying up 4 legs and positioning the head on a pillow as in the dog surgery. The hamster was just too small to do all these. Time is of the essence. Surgery must be short.
My assistant said as I cut out the bits and pieces of this mixed tumour and started wiping off the large amount of blood from below the eyes to shoulder: "Stop, I can clean the blood off later. The hamster is going into shock soon. Stop and wait. Do not stress the hamster."
I tried to clean up as much blood as possible as bacteria from the surrounding will infect the hamster via this outside blood.
The hamster started panting. Breathing at more than 100x/minute. Why? Stress had set in. Was she going to die?
My 2nd assistant took out a hair dryer, set to lowest warmth and warm up the hamster. "Give 3 ml of dextrose saline SC," I asked Mr Saw to stop as he started to get normal saline. It was not possible to give an IV catheter as in the dog because it is practically impossible to get a hamster's vein and I doubt if anybody can do it. The hamster is just so small and everything is miniaturised. So subcutaneous fluid was OK. But it must be dextrose saline in my opinion and this can be given by SC. Glucose itself cannot be given SC.
As everything was so tense, the vet must have a clear mind and ensure that proper drugs and saline are given by being observant.
After an eternity of more than 30 minutes of being kept in a warm room, the hamster breathed normally. I took a photo of her trying to stand up. It was a good sign. In 24 hours, I took her photograph and was glad that she was alive. Not all stories end happily all the time for all vets. It is best for owners to check their older hamster early for small tumours. These are easier to remove and take a much shorter time.
More pictures are at www.toapayohvets.com. Click HAMSTERS
For more pictures of the surgery: goto
http://www.sinpets.com/F6/20110323massive-neck-tumour-syrian-hamster-surgery-toapayohvets.htm
A big soft lump from below one ear to another and dangling under the neck in an old Syrian hamster (female, 20 months). This is the type of surgical condition I dread most. Performing this type of surgery is "fools rush in where angels fear to tread". The neck area has many important nerves, arteries and veins and it is not a very dangerous area to remove tumours especially in a hamster. That area below the throat is so small (less than 1 cm) compared to a dog or cat. A few thousand times smaller. There is no luxury of using an operating microscope and in any case, the surgery must be short as the hamster can't survive long anaesthesias of more than 1 minute, in my experience. You can't top up anaesthesia as in the dog and cat. Any more anaesthesia, the hamster just dies.
ANAESTHESIA
Very risky in a lethargic hamster. That means the hamster is not normal and healthy. The owner of this case waited till the neck tumour becomes very large. Is it inoperable? In any case, the chances of the old and lethargic hamster surviving are much lower. Less than 10%. So why take the case and risk damaging one's hard-built reputation as a "killer" of hamsters when this Syrian hamster dies on the operating table? Why not pass the buck to other vets?
DOSAGE OF INJECTABLE ANAESTHESIA IS HARD TO CALCULATE
"How much to give?" I asked my assistant Mr Saw (as part of my training of the past 3 years with me). He will be going to greener pastures in 2 weeks' time. "One drop of Zoletil will do," Mr Saw said. The owner had already said the hamster was lethargic for the past 2 weeks and the lump had exploded to big size during this time. Therefore, minimal dose as recommended by Mr Saw was the correct thing to do.
I gave one drop of Zoletil by injection IM into the left backside muscle. Waited for 5 minutes. The hamster looked at me and behaved normally, walking around inside the plastic container. She ought to be sleepy but she was much wide awake.
I waited another 5 minutes. She was active and had produced more faecal pellets. So, this dosage given was not effective. "In Syrian hamsters (160g), you need to give 4 times the dosage of a dwarf hamster (40 g)," I said to Mr Saw. But how do you calculate the dosage? It is easy in dogs and cats because they weight in kg when adult. But in this adult old hamster, she was 160 g.
"Give 2 drops," I asked Mr Saw to prepare the Zoletil. He filled up Zoletil 100 in one one-ml syringe and then push out one drop from its tips. Then I should use another one-ml syringe with a fine needle to aspirate the two drops.
"Hey, it is better you rest your elbows on top of the operating table," I said as it is hard to be precise in the present set up. "I also put my hands on top of the table." I then used the tip of my 25G needle attached to my one-ml syringe and aspirated two full drops from Mr Saw's one-ml syringe tip.
I injected into the right backside muscle. Within one minute, the hamster was lying down on his back.
So far, the Providence had been kind to me. The hamster was down but not out. Not dead I mean.
IV DRIPS
Impossible to do in a hamster. The veins are too small. SC injection of up to 3 ml dextrose saline is possible and was done in this case post-op.
SURGERY
After being sedated with the correct, safe and effective amount of Zoletil 100, the hamster went down sideways. There was a window of analgesia for around 1 minute to get the lump excised and the skin sutured.
I incised the skin 1 cm. A glistening membrane of the lump appeared under the skin. It seemed to be cyst but it was not 100% fluid filled lump. I saw a large vein from the lump (see illustration). "Is it the jugular vein?" I asked Mr Saw to make him think. He kept quiet. We had never seen jugular veins in hamsters in previous surgeries. Well, this location of the tumour was the second one I encountered during the past years of practice.
Know your anatomy well. It was not the jugular vein. I was just making my assistant think about hamster anatomy. He photocopied many veterinary notes and illustrations to prepare himself for the setting up of a private practice in Yangon later in the year. But nothing beats photocopies like seeing the real thing.
"Is it the jugular?" I asked my assistant again. He did not reply. It certainly was the biggest widest blue vein we had seen under the neck but it was connected to the tumour some below the tumour mass. It was unlikely to be a jugular but since the neck area is so small in size compared to that of a dog or cat, it would be hard to discount its presence. As a guideline, any large vein connected to a big tumour would be a feeder vein and the artery would be next to it. The tumour needed more nutrients and the blood vessels seem to enlarge to supply the ravenous growth.
I clamped the tumour and excised. Immediately blue blood spilled out. This vein was hard to ligate initially as it was very close to the pharynx. I dared not ligate as the needle might perforate the pharynx. So I excised the tumour first. Around 3 ml of blood splashed out. "Swabs," I said. Mr Saw provided the 3 swabs I needed to clear the bloodied area. I could see the bleeding vein. Ligated it. Then another big spurt appeared. It was probably the artery injured during the first ligation. I ligated this second bleeder. No more bleeding.
"Stretch the 2 cm skin wound by putting your thumb and index finger on either side," I said to my assistant. In this way, the skin wound is stretched out and I could appose the cut skin with 3 horizontal mattress sutures quickly. The hamster's neck was not straight in this type of surgery. No luxury of tying up 4 legs and positioning the head on a pillow as in the dog surgery. The hamster was just too small to do all these. Time is of the essence. Surgery must be short.
My assistant said as I cut out the bits and pieces of this mixed tumour and started wiping off the large amount of blood from below the eyes to shoulder: "Stop, I can clean the blood off later. The hamster is going into shock soon. Stop and wait. Do not stress the hamster."
I tried to clean up as much blood as possible as bacteria from the surrounding will infect the hamster via this outside blood.
The hamster started panting. Breathing at more than 100x/minute. Why? Stress had set in. Was she going to die?
My 2nd assistant took out a hair dryer, set to lowest warmth and warm up the hamster. "Give 3 ml of dextrose saline SC," I asked Mr Saw to stop as he started to get normal saline. It was not possible to give an IV catheter as in the dog because it is practically impossible to get a hamster's vein and I doubt if anybody can do it. The hamster is just so small and everything is miniaturised. So subcutaneous fluid was OK. But it must be dextrose saline in my opinion and this can be given by SC. Glucose itself cannot be given SC.
As everything was so tense, the vet must have a clear mind and ensure that proper drugs and saline are given by being observant.
After an eternity of more than 30 minutes of being kept in a warm room, the hamster breathed normally. I took a photo of her trying to stand up. It was a good sign. In 24 hours, I took her photograph and was glad that she was alive. Not all stories end happily all the time for all vets. It is best for owners to check their older hamster early for small tumours. These are easier to remove and take a much shorter time.
More pictures are at www.toapayohvets.com. Click HAMSTERS
For more pictures of the surgery: goto
http://www.sinpets.com/F6/20110323massive-neck-tumour-syrian-hamster-surgery-toapayohvets.htm
Spay guinea pigs
REPLY TO AN E-MAIL QUERY
We do sterilise female guinea pig. Cost is from $250 - $300. Pl make appointment with Dr Sing at 6254 3326. The guinea pig must be at least 6 months old and be healthy. Pl note that there is always a risk of death from anaesthesia in any surgery in guinea pigs and other animals.
We do sterilise female guinea pig. Cost is from $250 - $300. Pl make appointment with Dr Sing at 6254 3326. The guinea pig must be at least 6 months old and be healthy. Pl note that there is always a risk of death from anaesthesia in any surgery in guinea pigs and other animals.
381. Hamster injuries can be infected
E-MAIL TO DR SING DATED MAR 31, 2011
2011/3/31 ...@hotmail.com>
Hi there,
I own a hamster which was previously owned by two different owners. When the hamster was taken care by the 1st owner, she placed him with another hamster which bit him. He was then given to the 2nd owner, whose mother didn't want her to keep him, so she gave him to me.
The problem is that he has bumps on his ear and around his eye. Over time his eye got worse and it covered his whole eye thus, now he is blind in one eye.
Should I bring him for a check up?
Name of owner
E-MAIL FROM DR SING DATED MAR 31, 2011
Date: Fri, 1 Apr 2011 07:43:21 +0800
Subject: Re: About my hamster
From: 99pups@gmail.com
To: ,,,@hotmail.com
Yes. Pl make an appointment at 6254 3326 to see Dr Sing at 9.30 am or let the receptionist know.
Friday, April 1, 2011
380. Keratoconjunctivitis sicca in old Shih Tzus - Duty of care
Many times, an owner of old Shih Tzus would consult the vet for some problems that are not related to the eyes, such as diarrhoea. Many times, the vet will see dry eyes as shown in the image.
Since the owner has not complained about the keratoconjunctivitis sicca, the vet would just treat the diarrhoea, ear infections or skin disease and that would all.
Has the vet a duty of care to educate the owner that she needs to use eyedrops to relieve the dog's discomfort & pain in dry eyes when the consultation is not related to the eyes?
What is a duty of care of a veterinarian when the dog is presented for diarrhoea? It is to correctly treat the diarrhoea. Therefore, the vet needs not bother with the dry eyes.
However, many Singapore pet owners are unaware that they can relieve the old Shih Tzu's dry eye discomfort and pain. The owner attributes dry eyes to old age and so what? The old dog rubs his ulcerated eyes daily. It is due to old age!
Once a vet bothers to educate the owner, she usually takes the time and trouble to ensure that the eyes are wetted and lubricated.
I usually advise clipping away the hairs around the eyes so that the facial area can be well cleaned and applying eye drops minimum twice a day. I was manning the counter to get a feel of the front-line veterinary matters.
Recently, an older woman phoned to get the eye drops prescribed by my associate vet. "I have to give you another brand," I said. "It is from the same company. The brand you want is being ordered."
"Please get for me ....eye drops next time," the woman in her 50s said. "The dog's eyes are now much cleaner with that brand."
P.S
Reference: http://www.businessdictionary.com/definition/duty-of-care.html
DUTY OF CARE
A responsibility or a legal obligation of a person or organization to avoid acts or omissions (which can be reasonably foreseen) to be likely to cause harm to others.
Duty of care is owed by an accountant in correctly preparing a firm's accounts, by an auditor in confirming an firm's financial statements correctly present its financial position, by a director to shareholders in husbanding the enterprise's resources, by a manufacturer to consumers for the safety of product, and by every party to a contract to the other contracting parties.
Since the owner has not complained about the keratoconjunctivitis sicca, the vet would just treat the diarrhoea, ear infections or skin disease and that would all.
Has the vet a duty of care to educate the owner that she needs to use eyedrops to relieve the dog's discomfort & pain in dry eyes when the consultation is not related to the eyes?
What is a duty of care of a veterinarian when the dog is presented for diarrhoea? It is to correctly treat the diarrhoea. Therefore, the vet needs not bother with the dry eyes.
However, many Singapore pet owners are unaware that they can relieve the old Shih Tzu's dry eye discomfort and pain. The owner attributes dry eyes to old age and so what? The old dog rubs his ulcerated eyes daily. It is due to old age!
Once a vet bothers to educate the owner, she usually takes the time and trouble to ensure that the eyes are wetted and lubricated.
I usually advise clipping away the hairs around the eyes so that the facial area can be well cleaned and applying eye drops minimum twice a day. I was manning the counter to get a feel of the front-line veterinary matters.
Recently, an older woman phoned to get the eye drops prescribed by my associate vet. "I have to give you another brand," I said. "It is from the same company. The brand you want is being ordered."
"Please get for me ....eye drops next time," the woman in her 50s said. "The dog's eyes are now much cleaner with that brand."
P.S
Reference: http://www.businessdictionary.com/definition/duty-of-care.html
DUTY OF CARE
A responsibility or a legal obligation of a person or organization to avoid acts or omissions (which can be reasonably foreseen) to be likely to cause harm to others.
Duty of care is owed by an accountant in correctly preparing a firm's accounts, by an auditor in confirming an firm's financial statements correctly present its financial position, by a director to shareholders in husbanding the enterprise's resources, by a manufacturer to consumers for the safety of product, and by every party to a contract to the other contracting parties.
Thursday, March 31, 2011
379. A scholarship in Political Science and Veterinary Science
E-MAIL TO DR SING DATED MAR 30, 2011 FROM AN AMERICAN VOLUNTEER
FOR HIS OLD UNIVERSITY FOR SCHOLARSHIP SELECTION OF ONE SINGAPOREAN
Thanks so much for taking the time to talk to .... yesterday. You gave her a great deal of good information. I support your advice to her to think carefully about her career choices. A clever interviewer will be alert to people who are not serious and are simply fishing for some way to pay their university tuition.
MY COMMENTS
The girl from a brand-name school, Raffles Institution could easily get into the top colleges in the U.S, U.K or Australia. A great number of her cohort of 1000 would probably get 3As but she has 6As. That was an excellent academic achievement.
It opens doors to any scholarship but she was the only candidate with Science and Maths amongst seven short-listed for a US scholarship interview. The scholarship was for a liberal arts degree in a US university which the volunteer told me is a sister school of Williams College attended by Senior Minister Goh Chok Tong. When well known names are thrown in, it gets attention of the other party
So this girl attended would have got Wesleyan Freeman Asian Scholarship if she would study Political Science, according to the volunteer whom I shall call Mr Baker.
Mr Baker was a volunteer but not an interviewer for his University which would offer 1 scholarship for each of the 11 Asian countries. I believed that this girl was top choice but she wanted to study Veterinary Science. Mr Baker said: "Political science is not veterinary science". He emailed to me to ask me if I would advise this girl by phone. Instead I advised meeting as phone calls were a waste of time if one is to advise a bright young lady on her career (as a volunteer).
Mr Baker arrived early by cycling from Clementi to Toa Payoh as I discovered later. I was surprised. "You must be one of those crazy and eccentric Ang Mos (Caucasians)," I was wondering how he could arrive at Toa Payoh Vets without sweat and how dangerous it was to cycle so far. I must say he was lean and fit at the age of 50 and could put many a younger 40-year-old man to shame in fitness.
The young lady arrived in a taxi on time. As my surgery was small in space, I suggested we had a talk at the coffee shop behind. A bespectacled fair lady with long bronze gold hair and of pleasant first impressions. We sat and Mr Baker offered to buy drinks though initially he planned to introduce us and go home. I insisted that he stay to "chaperone" me, not that I need one as it was a public place. Mr Baker with his receding forehead and baldness presents an energetic intelligent appearance and is the type who does not want to take up too much of my time.
Our talk lasted around 2 hours as Mr Baker offered to buy lunch too. We ate at the coffeeshop. So was this scholarly lady passionate about veterinary medicine? She has a dog. But not one substantial piece of evidence that she had cared for animals at the SPCA, veterinary surgeries or animal welfare groups or any activity related to animals in Singapore.
Her parents wanted her to study medicine or law as they considered veterinary medicine dirty. In any case, they can't support her to study veterinary medicine overseas and therefore she has to get a scholarship. In this modern age and in a developed modern Singapore, there are still Singapore parents who want their progeny to fulfill their dreams of not being able to become a doctor or lawyer! And to consider veterinary medicine as dirty! In the UK where I studied some 40 years ago, the demand for veterinary studies far exceed the demand to study medicine and I believe this is the situation in the U.S! Here, we have Singaporean parents looking down at a superstar academic who wants to study veterinary medicine.
Will she get the AVA veterinary scholarship? The 6As will get her into past the door into the interview room as this was what must have happened at the US university interview she attended recently. Academic excellence still give the best cherries despite some Singapore parents talking about over-stressing their children and asking for less pressure of homework in the Singapore tuition and education hot bed.
"But the AVA is looking for regulators and enforcers to check on far away farms in China and other countries to accredit them for export of meat to Singapore," I said to this girl. "SVA is not looking for practitioners in small or large animal medicine. You look kind of delicate," I said. She had said she was interested in farm practice with the large animals. Most vets have run away from rural veterinary practice and here she wanted to do that.
Typically and stereotypically, most bright Singaporean lady scholars completing their A levels spend most time studying very hard and therefore they are fair and delicate looking. At least those few ladies who applied for internship with me gave me this impression.
Will she get the AVA scholarship? She had to write 2 articles. What was her most important achievement and why she wanted to study vet medicine? Without supporting evidence, I wonder how she wrote about in the 2nd article required by AVA?
We hope she will get the scholarship. The kind gentleman aged 50 gave some advices like student loans, working for a few years first. He got a scholarship from the GI bill which provides scholarship for Americans who had served in the US Army. I thought he was the average man as he had retired and had said during our meeting: "I have one foot in the grave". Men who are past 50 and who tells me they have one foot in the grave don't impress me.
I said to this kind gentleman who is actually a top scholar at Harvard or some top US university and an inventor in military engineering after I asked him more about his background: "If you have one foot in the grave at the age of 50 years, I must be having one and a half foot in the grave as I am 60 years old!" Men who are in their 50s do think that way. I wonder if women of similar age do think similarly?
I say he is a kind man because he spent time to help this stranger, a girl with 6As to know more about veterinary science by contacting me. He was not happy with the interviewers of his old school wanting to direct this girl to study political science and thereby giving her the scholarship. Americans are always brutally honest and into your face if they like some behaviour?
In the end, the scholarship went to another girl and from what I know, this girl had the passion for the arts which included writing, literature and education as I was told that this girl with fuzzy hair (I think it was fuzzy hair) gave education classes at the School of Thought. Have you ever heard of such a school or have I got the wrong name?
Political science is far removed from veterinary science. But I would take the political science scholarship if I have 6As and study in the US. Excel in this scholarship and then get a scholarship to become a veterinarian if my parents have no money to sponsor me. After all, how many young Singaporeans can have a chance to study in a top liberal arts school in the US?
If a young adult has passion in veterinary medicine and the parents don't have the S$300,000 to pay the tuition fees, taking this US scholarship will broaden her mind and make him a better all rounded veterinarian if she studies vet medicine as a mature student.
But a lady with 6 straight As can have her pick of scholarships. So what if she can't get the AVA scholarship? She has others. So, does she have the passion for veterinary medicine or not? Was she fishing for the best scholarship? Most of her 100 friends in Raffles Institution want to be doctors and so I expect lesser competition for her.
Based on her lack of animal activism veterinary and welfare work in her past years at Raffles Institution, it would be hard for her to get the AVA scholarship if there are others with track records.
P.S
1. According to the kind gentleman, the Wesleyan Freeman Asian Scholarship Program provides expenses for a 4-year course to study "Political Science", not "Veterinary Science" for one exceptionally able Asian student annually from one Asian country. So, he was quite pissed off when the interviewers asked this girl to study Political Science instead, did some research and e-mailed to me to advise her about veterinary medicine.
In any case, the Wesleyan University, Middletown, Connecticut provides a liberal arts education. The Freeman Foundation provides the scholarship. Sadly, he told me that Mr Freeman, an original founder of AIG group has just passed away.
Selection criteria included academic achievement, intellectual curiosity, a high level of discipline and commitment, strong personal qualities, extracurricular involvement especially community service and English language ability.
2. Williams College, a highly selective private liberal arts college, Massachusetts.
3. Volunteerism is human kindness. Mr Baker is not paid by his University. In fact, he paid for the drinks and lunch. Volunteerism also open doors to meet other people when you help somebody.
4. Mr Baker appeared fresh and clean after cycling from Clementi to Toa Payoh because he changed his clothes at the Toa Payoh Swimming Pool. He has 3 engineering inventions of great interest. He must have graduated from a top engineering University in the US when I implied that in some unknown manner that he graduated from some average university after studying at Wesleyan University. Never judge a book by its cover! His inventions were in military engineering and quite impressive to me as a veterinarian. Actually if you think of it, his inventions to protect naval ships from small terrorist ships ramming with explosives are the equivalent of antibodies (with spiked attachments) fighting against antigens (foreign invaders like bacteria or terrorist)!
FOR HIS OLD UNIVERSITY FOR SCHOLARSHIP SELECTION OF ONE SINGAPOREAN
Thanks so much for taking the time to talk to .... yesterday. You gave her a great deal of good information. I support your advice to her to think carefully about her career choices. A clever interviewer will be alert to people who are not serious and are simply fishing for some way to pay their university tuition.
MY COMMENTS
The girl from a brand-name school, Raffles Institution could easily get into the top colleges in the U.S, U.K or Australia. A great number of her cohort of 1000 would probably get 3As but she has 6As. That was an excellent academic achievement.
It opens doors to any scholarship but she was the only candidate with Science and Maths amongst seven short-listed for a US scholarship interview. The scholarship was for a liberal arts degree in a US university which the volunteer told me is a sister school of Williams College attended by Senior Minister Goh Chok Tong. When well known names are thrown in, it gets attention of the other party
So this girl attended would have got Wesleyan Freeman Asian Scholarship if she would study Political Science, according to the volunteer whom I shall call Mr Baker.
Mr Baker was a volunteer but not an interviewer for his University which would offer 1 scholarship for each of the 11 Asian countries. I believed that this girl was top choice but she wanted to study Veterinary Science. Mr Baker said: "Political science is not veterinary science". He emailed to me to ask me if I would advise this girl by phone. Instead I advised meeting as phone calls were a waste of time if one is to advise a bright young lady on her career (as a volunteer).
Mr Baker arrived early by cycling from Clementi to Toa Payoh as I discovered later. I was surprised. "You must be one of those crazy and eccentric Ang Mos (Caucasians)," I was wondering how he could arrive at Toa Payoh Vets without sweat and how dangerous it was to cycle so far. I must say he was lean and fit at the age of 50 and could put many a younger 40-year-old man to shame in fitness.
The young lady arrived in a taxi on time. As my surgery was small in space, I suggested we had a talk at the coffee shop behind. A bespectacled fair lady with long bronze gold hair and of pleasant first impressions. We sat and Mr Baker offered to buy drinks though initially he planned to introduce us and go home. I insisted that he stay to "chaperone" me, not that I need one as it was a public place. Mr Baker with his receding forehead and baldness presents an energetic intelligent appearance and is the type who does not want to take up too much of my time.
Our talk lasted around 2 hours as Mr Baker offered to buy lunch too. We ate at the coffeeshop. So was this scholarly lady passionate about veterinary medicine? She has a dog. But not one substantial piece of evidence that she had cared for animals at the SPCA, veterinary surgeries or animal welfare groups or any activity related to animals in Singapore.
Her parents wanted her to study medicine or law as they considered veterinary medicine dirty. In any case, they can't support her to study veterinary medicine overseas and therefore she has to get a scholarship. In this modern age and in a developed modern Singapore, there are still Singapore parents who want their progeny to fulfill their dreams of not being able to become a doctor or lawyer! And to consider veterinary medicine as dirty! In the UK where I studied some 40 years ago, the demand for veterinary studies far exceed the demand to study medicine and I believe this is the situation in the U.S! Here, we have Singaporean parents looking down at a superstar academic who wants to study veterinary medicine.
Will she get the AVA veterinary scholarship? The 6As will get her into past the door into the interview room as this was what must have happened at the US university interview she attended recently. Academic excellence still give the best cherries despite some Singapore parents talking about over-stressing their children and asking for less pressure of homework in the Singapore tuition and education hot bed.
"But the AVA is looking for regulators and enforcers to check on far away farms in China and other countries to accredit them for export of meat to Singapore," I said to this girl. "SVA is not looking for practitioners in small or large animal medicine. You look kind of delicate," I said. She had said she was interested in farm practice with the large animals. Most vets have run away from rural veterinary practice and here she wanted to do that.
Typically and stereotypically, most bright Singaporean lady scholars completing their A levels spend most time studying very hard and therefore they are fair and delicate looking. At least those few ladies who applied for internship with me gave me this impression.
Will she get the AVA scholarship? She had to write 2 articles. What was her most important achievement and why she wanted to study vet medicine? Without supporting evidence, I wonder how she wrote about in the 2nd article required by AVA?
We hope she will get the scholarship. The kind gentleman aged 50 gave some advices like student loans, working for a few years first. He got a scholarship from the GI bill which provides scholarship for Americans who had served in the US Army. I thought he was the average man as he had retired and had said during our meeting: "I have one foot in the grave". Men who are past 50 and who tells me they have one foot in the grave don't impress me.
I said to this kind gentleman who is actually a top scholar at Harvard or some top US university and an inventor in military engineering after I asked him more about his background: "If you have one foot in the grave at the age of 50 years, I must be having one and a half foot in the grave as I am 60 years old!" Men who are in their 50s do think that way. I wonder if women of similar age do think similarly?
I say he is a kind man because he spent time to help this stranger, a girl with 6As to know more about veterinary science by contacting me. He was not happy with the interviewers of his old school wanting to direct this girl to study political science and thereby giving her the scholarship. Americans are always brutally honest and into your face if they like some behaviour?
In the end, the scholarship went to another girl and from what I know, this girl had the passion for the arts which included writing, literature and education as I was told that this girl with fuzzy hair (I think it was fuzzy hair) gave education classes at the School of Thought. Have you ever heard of such a school or have I got the wrong name?
Political science is far removed from veterinary science. But I would take the political science scholarship if I have 6As and study in the US. Excel in this scholarship and then get a scholarship to become a veterinarian if my parents have no money to sponsor me. After all, how many young Singaporeans can have a chance to study in a top liberal arts school in the US?
If a young adult has passion in veterinary medicine and the parents don't have the S$300,000 to pay the tuition fees, taking this US scholarship will broaden her mind and make him a better all rounded veterinarian if she studies vet medicine as a mature student.
But a lady with 6 straight As can have her pick of scholarships. So what if she can't get the AVA scholarship? She has others. So, does she have the passion for veterinary medicine or not? Was she fishing for the best scholarship? Most of her 100 friends in Raffles Institution want to be doctors and so I expect lesser competition for her.
Based on her lack of animal activism veterinary and welfare work in her past years at Raffles Institution, it would be hard for her to get the AVA scholarship if there are others with track records.
P.S
1. According to the kind gentleman, the Wesleyan Freeman Asian Scholarship Program provides expenses for a 4-year course to study "Political Science", not "Veterinary Science" for one exceptionally able Asian student annually from one Asian country. So, he was quite pissed off when the interviewers asked this girl to study Political Science instead, did some research and e-mailed to me to advise her about veterinary medicine.
In any case, the Wesleyan University, Middletown, Connecticut provides a liberal arts education. The Freeman Foundation provides the scholarship. Sadly, he told me that Mr Freeman, an original founder of AIG group has just passed away.
Selection criteria included academic achievement, intellectual curiosity, a high level of discipline and commitment, strong personal qualities, extracurricular involvement especially community service and English language ability.
2. Williams College, a highly selective private liberal arts college, Massachusetts.
3. Volunteerism is human kindness. Mr Baker is not paid by his University. In fact, he paid for the drinks and lunch. Volunteerism also open doors to meet other people when you help somebody.
4. Mr Baker appeared fresh and clean after cycling from Clementi to Toa Payoh because he changed his clothes at the Toa Payoh Swimming Pool. He has 3 engineering inventions of great interest. He must have graduated from a top engineering University in the US when I implied that in some unknown manner that he graduated from some average university after studying at Wesleyan University. Never judge a book by its cover! His inventions were in military engineering and quite impressive to me as a veterinarian. Actually if you think of it, his inventions to protect naval ships from small terrorist ships ramming with explosives are the equivalent of antibodies (with spiked attachments) fighting against antigens (foreign invaders like bacteria or terrorist)!
Tuesday, March 29, 2011
378. Why can't my Silkie pee normally after urinary stone removal?
DRAFT CASE REPORT
11 DAYS AFTER URINARY STONE REMOVAL CONSULTATION
A puzzling case of the male neutered Silkie, 6 years old who can't pee normally after urinary stone removal by an experienced vet. Around 11 days after surgery, the owner consulted me.
OWNER COMPLAINS ON DAY 11 AFTER SURGERY BY VET 1 THAT THE DOG HAD DIFFICULTY URINATING URINATE WHEN HE DRANK WATER. THIS HAPPENED >12 TIMES/DAY. WHY?
HE IS SUPPOSED TO BE ABLE TO PEE NORMALLY AFTER REMOVAL OF THE URINARY STONES BY VET 1. WHAT SHOULD I DO?
I palpated the bladder. It was empty. Therefore, there was no urethral obstruction in the sense of blockage of urine flow by the stones at behind the os penis (see X-ray of original condition before operation by Vet 1. Vet 1 had given the X-ray to the owner and I asked her to e-mail to me and this was done on Mar 27, 2011 for me to review.
I told the owner that there was no problem. If a vet wants to prove that there was no obstruction by catheterising the bladder in the presence of the owner, that does not prove anything as palpation had already revealed an emptied bladder and therefore no urethral obstruction.
Bladder palpation would have told the vet that there was no obstruction at that point of time. The dog did not have urethral obstruction generally. So what was the cause of this puzzling behaviour? Cystitis is a possibility. UTI possible. A small stone from the bladder obstructing the urethra? Possible as the X-ray would not take the kidney area traditionally.
(Tip: For good practice in veterinary medicine, it is best to keep an X-ray record if the vet wants to give away the X-ray or record that the owner has it).
As the owner is living far away from Toa Payoh and not to incur more veterinary costs for her, I advised observation on the initial complaint around 12 days post-stone removal by Vet 1. I had the nylon-like stitches in front of the prepuce removed at the same time and gave an anti-inflammatory and antibiotics. Then I prescribed antibiotics, SD diet x12 and asked for urine sample. X-ray of the bladder will be an option if necessary.
Some confusion from the owner's description of the dog's behaviour. Was the dog having difficulty peeing or starting to urine-mark when he was about to drink or he had some bladder infection or urinary stone stuck behind the os penis?
All stones had been taken out by Vet 1 in my opinion as I did not observe the surgery. It is possible that there is urethral obstruction from a stone or two from the bladder. However, economics deter more X-rays and tests for the time being and I did conservative treatment to "dissolve" the remaining stones (probably very small if present and from the kidneys) using S/D diet and monitoring of the urine.
Instead of another X-ray which would cause the owner stress and money, the owner was asked to monitor the dog's peeing behaviour and given S/D diet to dissolve the remaining stones. Vet 1 had not got the results of the crystals of the stones removed. The owner's e-mail report is as follows:
E-MAIL TO DR SING DATED MARCH 21, 2011
14 DAYS AFTER SURGERY TO REMOVE URINARY STONES BY VET 1
Subject: Dog X-Ray ID: 2496 Dog with urinal stones
Date: Mon, 21 Mar 2011 02:33:44 +0000
Dear Dr Sing,
As per your request, herewith my dog's x-ray given by (name given) Vet 1, there is only 1 photo of x-ray. i will be bringing his urine sample down on this Thursday 24/03/2011, around 7pm. Had spoken to you on Sunday 20th March morning, about my dog's urine behaviour after the urinal stones removal.
Duration Monitored: 30-45mins
Dogs behaviour:
- dog frequently try to pee especially after drinking water.
- out of 12 attempts, 1 attempt is successful*
- the one successful attempt is normal passing of urine
- the other 11 fail attempt: sometimes there is no urine at all, sometimes a little.
Other Conditions:
- Dog is eating normally
- Drinking not as much as before; Drunk half a bottle in 3days. In the past, dog drink half a bottle in 1day.
(Water bottle size is L12cm x W8cm x B8cm)
- Dog is playing and active as usual
- Currently on Dr Sing prescribe diet started 20/03/2011
- Previous Diet: brown rice with white rice, carrots, peas, tofu, a bit of garlic, salt and olive oil.
E-MAIL TO DR SING DATED MAR 29, 2011
22 DAYS AFTER SURGERY TO REMOVE URINARY STONES BY VET 1
Dear Dr Sing,
Updates of my dog condition after urinal stones removal operation since 7 march 2011.
Duration monitored: 30-45mins
Dog Behavior:
1) his attempts to urine has cut down from 12times to 4-5times
2) 1 successful attempts out of the 4-5 tries*
3) other attempts, urine amount is less than 3ml or no urine at all.
Other Conditions:
- Dog is eating normally
- Dog is starting to drink more; like his usual amount of intake before operation.
- Dog is playing and active as usual
- Currently on Dr Sing prescribe diet started 20/03/2011
- Previous Diet: brown rice with white rice, carrots, peas, tofu, a bit of garlic, salt and olive oil.
He is also on an eye drop, because he has ulcer in his right eye. It is improving, not as red as before.
I have not brought his urine sample down, because his condition is improving. Thus, i would like to monitor for a few more days.
Dr Sing, I truly appreciate your help in giving me advise on my dog's condition. I had brought my 1st pet, a cat, to you since 1990.
You are a good vet, please do not lose hope even when you have encounter more demanding pet's owners.
MARCH 29, 2011
I phoned the owner as e-mail writing can be misleading compared to personal conversation. She complains about a hard lump at the stitched area. Vet 1 had stitched with the absorbable nylon-like stitches in the muscle and the skin area after stone removal.
I had already got the skin stitches removed during the first complaint around 12 days of what I considered a successful surgery by Vet 1. This opinion is subject to an X-ray post-op but I did not consider the X-ray necessary at that point of time as it is likely to show no urethral obstruction based on my bladder palpation. The bladder was empty and so it would be morally unethical to advise another X-ray immediately. In any case, the original stones were removed as Vet 1 is an experienced vet and therefore I recommended conservative treatment.
Vet 1 should have got a urine sample for urinary stone crystal analysis to the Singapore laboratory pre-surgery in hind-sight. Vet 1 had sent the stones to the US lab for analysis. This would take some time but now ... I have a problem! And the owner had got her X-ray at home. So, I asked her to e-mail to me the X-ray which my Adobe Photoshop refused to download. I cropped and converted the X-ray to .tiff. This time Adobe Photoshop obliged and therefore I had the X-ray image cleaned up and presented in this report.
CONCLUSION
Post-operation complications do happen after surgeries for all vets. The owner must be informed before surgery but sometimes we are too busy to go into details of the risk of pain, infection and bleeding of surgery. Many times I don't inform the owner too as the consent form for surgery would have been signed by the owner. During my past 20 years, I seldom ask the owner to sign the consent form (for informed consent) but now I better be careful of possible litigation for "failure to provide informed consent."
It is hard to pin-point the cause of the dysuria in this dog. Certainly it is not the typical urethral obstruction at the os penis, in my experience and observation.
Dogs can't talk. That's the challenge of being a veterinarian. It takes a lot of time and patience to know what is going on in this case. From the owner's phone conversation and observation, I conclude that this dog might have some pain due to the muscle stitching and so he tried not to pee during the first 14 days post-op. As I know Vet 1 used those absorbable "nylon-like" stitches to suture, I infer that the stitches were irritating the dog at that critical area in front and below the prepuce. I had removed the skin sutures but below, there was another layer of muscle suture at the linea alba. This would be the area of pain which lessened with time and medication. So the dog now has much lesser frequency of urination pain and has improved considerably according to the owner's diligent monitoring of urination.
In conclusion, one main cause of the post-surgical dysuria is the pain at the stitched abdominal muscle area below the penis (to close up the operation after urinary stone removal).
My tip to vets will be to use the 3/0 absorbable non-nylon like sutures. There is no need to stitch the muscles at 0.5 mm apart resulting in many stitches. I stitch at 1 cm intervals. Also, I find that subcuticular stitches are not necessary but many vets do that. This means a lot of stitches (subcuticular and muscle) and this would result in stitch irritation especially when the vet uses the "nylon-like" absorbable stitches. This is probably what is happening to the dog in this case. Every time he pees, the heavily stitched muscle and subcuticular area causes pain.
So when he wants to drink water, he tries to pee first but feels the pain. At other times, he pees onto the pee tray with difficulty. The owner disputed my opinion of the male dog urine-marking as the dog has no such habit.
*So as at March 30, 2011 as I close this case, I have only this hypothesis of pain due to stitches, not urethral obstruction by urinary stones behind the os penis. 22 days after surgery, the dog has fewer episodes of dysuria (see owner's e-mails above) . If only dogs can talk! And if only we vets have more time to analyse the cases but we don't have the luxury of time! And Singaporean pet owners want instant answers!
I don't have any complaint in my urinary stone removal surgeries using such the 3/0 non-nylon suture type for closure of the bladder, abdominal muscle and skin . It dissolves usually in 28 days and that is more than sufficient time for healing of the operated wounds. I don't use subcuticular sutures as I found them unnecessary in these cases. The University professors in Australia (from my observation of some graduates' need to do subcuticular suturing) still teach the students the need to eliminate dead space under the skin and therefore subcuticular sutures are used by many fresh graduates.
"Nylon" type absorbable sutures will take a much longer time to dissolve. The owner can "feel" the "lump" for some time. In veterinary practice, perception is sometimes as important as competence. Why use nylon-like stitches to create "lumps" under the skin worrying the dog owner and risking loss of owner's confidence in the vet when good alternatives are available? As each vet has his own preference, it will be hard to convince such vets to switch suture types!
I may be fortunate in my cases of no complaints of post-operation dysuria. Or the owner might have gone to another vet for a second opinion as in this case!
FOR BLOG READERS, the Toa Payoh Vets website article is at:
http://www.sinpets.com/F5/20110320stones-post-op-dysuria-unhappy-owner-complains-toapayohvets.htm
11 DAYS AFTER URINARY STONE REMOVAL CONSULTATION
A puzzling case of the male neutered Silkie, 6 years old who can't pee normally after urinary stone removal by an experienced vet. Around 11 days after surgery, the owner consulted me.
OWNER COMPLAINS ON DAY 11 AFTER SURGERY BY VET 1 THAT THE DOG HAD DIFFICULTY URINATING URINATE WHEN HE DRANK WATER. THIS HAPPENED >12 TIMES/DAY. WHY?
HE IS SUPPOSED TO BE ABLE TO PEE NORMALLY AFTER REMOVAL OF THE URINARY STONES BY VET 1. WHAT SHOULD I DO?
I palpated the bladder. It was empty. Therefore, there was no urethral obstruction in the sense of blockage of urine flow by the stones at behind the os penis (see X-ray of original condition before operation by Vet 1. Vet 1 had given the X-ray to the owner and I asked her to e-mail to me and this was done on Mar 27, 2011 for me to review.
I told the owner that there was no problem. If a vet wants to prove that there was no obstruction by catheterising the bladder in the presence of the owner, that does not prove anything as palpation had already revealed an emptied bladder and therefore no urethral obstruction.
Bladder palpation would have told the vet that there was no obstruction at that point of time. The dog did not have urethral obstruction generally. So what was the cause of this puzzling behaviour? Cystitis is a possibility. UTI possible. A small stone from the bladder obstructing the urethra? Possible as the X-ray would not take the kidney area traditionally.
(Tip: For good practice in veterinary medicine, it is best to keep an X-ray record if the vet wants to give away the X-ray or record that the owner has it).
As the owner is living far away from Toa Payoh and not to incur more veterinary costs for her, I advised observation on the initial complaint around 12 days post-stone removal by Vet 1. I had the nylon-like stitches in front of the prepuce removed at the same time and gave an anti-inflammatory and antibiotics. Then I prescribed antibiotics, SD diet x12 and asked for urine sample. X-ray of the bladder will be an option if necessary.
Some confusion from the owner's description of the dog's behaviour. Was the dog having difficulty peeing or starting to urine-mark when he was about to drink or he had some bladder infection or urinary stone stuck behind the os penis?
All stones had been taken out by Vet 1 in my opinion as I did not observe the surgery. It is possible that there is urethral obstruction from a stone or two from the bladder. However, economics deter more X-rays and tests for the time being and I did conservative treatment to "dissolve" the remaining stones (probably very small if present and from the kidneys) using S/D diet and monitoring of the urine.
Instead of another X-ray which would cause the owner stress and money, the owner was asked to monitor the dog's peeing behaviour and given S/D diet to dissolve the remaining stones. Vet 1 had not got the results of the crystals of the stones removed. The owner's e-mail report is as follows:
E-MAIL TO DR SING DATED MARCH 21, 2011
14 DAYS AFTER SURGERY TO REMOVE URINARY STONES BY VET 1
Subject: Dog X-Ray ID: 2496 Dog with urinal stones
Date: Mon, 21 Mar 2011 02:33:44 +0000
Dear Dr Sing,
As per your request, herewith my dog's x-ray given by (name given) Vet 1, there is only 1 photo of x-ray. i will be bringing his urine sample down on this Thursday 24/03/2011, around 7pm. Had spoken to you on Sunday 20th March morning, about my dog's urine behaviour after the urinal stones removal.
Duration Monitored: 30-45mins
Dogs behaviour:
- dog frequently try to pee especially after drinking water.
- out of 12 attempts, 1 attempt is successful*
- the one successful attempt is normal passing of urine
- the other 11 fail attempt: sometimes there is no urine at all, sometimes a little.
Other Conditions:
- Dog is eating normally
- Drinking not as much as before; Drunk half a bottle in 3days. In the past, dog drink half a bottle in 1day.
(Water bottle size is L12cm x W8cm x B8cm)
- Dog is playing and active as usual
- Currently on Dr Sing prescribe diet started 20/03/2011
- Previous Diet: brown rice with white rice, carrots, peas, tofu, a bit of garlic, salt and olive oil.
E-MAIL TO DR SING DATED MAR 29, 2011
22 DAYS AFTER SURGERY TO REMOVE URINARY STONES BY VET 1
Dear Dr Sing,
Updates of my dog condition after urinal stones removal operation since 7 march 2011.
Duration monitored: 30-45mins
Dog Behavior:
1) his attempts to urine has cut down from 12times to 4-5times
2) 1 successful attempts out of the 4-5 tries*
3) other attempts, urine amount is less than 3ml or no urine at all.
Other Conditions:
- Dog is eating normally
- Dog is starting to drink more; like his usual amount of intake before operation.
- Dog is playing and active as usual
- Currently on Dr Sing prescribe diet started 20/03/2011
- Previous Diet: brown rice with white rice, carrots, peas, tofu, a bit of garlic, salt and olive oil.
He is also on an eye drop, because he has ulcer in his right eye. It is improving, not as red as before.
I have not brought his urine sample down, because his condition is improving. Thus, i would like to monitor for a few more days.
Dr Sing, I truly appreciate your help in giving me advise on my dog's condition. I had brought my 1st pet, a cat, to you since 1990.
You are a good vet, please do not lose hope even when you have encounter more demanding pet's owners.
MARCH 29, 2011
I phoned the owner as e-mail writing can be misleading compared to personal conversation. She complains about a hard lump at the stitched area. Vet 1 had stitched with the absorbable nylon-like stitches in the muscle and the skin area after stone removal.
I had already got the skin stitches removed during the first complaint around 12 days of what I considered a successful surgery by Vet 1. This opinion is subject to an X-ray post-op but I did not consider the X-ray necessary at that point of time as it is likely to show no urethral obstruction based on my bladder palpation. The bladder was empty and so it would be morally unethical to advise another X-ray immediately. In any case, the original stones were removed as Vet 1 is an experienced vet and therefore I recommended conservative treatment.
Vet 1 should have got a urine sample for urinary stone crystal analysis to the Singapore laboratory pre-surgery in hind-sight. Vet 1 had sent the stones to the US lab for analysis. This would take some time but now ... I have a problem! And the owner had got her X-ray at home. So, I asked her to e-mail to me the X-ray which my Adobe Photoshop refused to download. I cropped and converted the X-ray to .tiff. This time Adobe Photoshop obliged and therefore I had the X-ray image cleaned up and presented in this report.
CONCLUSION
Post-operation complications do happen after surgeries for all vets. The owner must be informed before surgery but sometimes we are too busy to go into details of the risk of pain, infection and bleeding of surgery. Many times I don't inform the owner too as the consent form for surgery would have been signed by the owner. During my past 20 years, I seldom ask the owner to sign the consent form (for informed consent) but now I better be careful of possible litigation for "failure to provide informed consent."
It is hard to pin-point the cause of the dysuria in this dog. Certainly it is not the typical urethral obstruction at the os penis, in my experience and observation.
Dogs can't talk. That's the challenge of being a veterinarian. It takes a lot of time and patience to know what is going on in this case. From the owner's phone conversation and observation, I conclude that this dog might have some pain due to the muscle stitching and so he tried not to pee during the first 14 days post-op. As I know Vet 1 used those absorbable "nylon-like" stitches to suture, I infer that the stitches were irritating the dog at that critical area in front and below the prepuce. I had removed the skin sutures but below, there was another layer of muscle suture at the linea alba. This would be the area of pain which lessened with time and medication. So the dog now has much lesser frequency of urination pain and has improved considerably according to the owner's diligent monitoring of urination.
In conclusion, one main cause of the post-surgical dysuria is the pain at the stitched abdominal muscle area below the penis (to close up the operation after urinary stone removal).
My tip to vets will be to use the 3/0 absorbable non-nylon like sutures. There is no need to stitch the muscles at 0.5 mm apart resulting in many stitches. I stitch at 1 cm intervals. Also, I find that subcuticular stitches are not necessary but many vets do that. This means a lot of stitches (subcuticular and muscle) and this would result in stitch irritation especially when the vet uses the "nylon-like" absorbable stitches. This is probably what is happening to the dog in this case. Every time he pees, the heavily stitched muscle and subcuticular area causes pain.
So when he wants to drink water, he tries to pee first but feels the pain. At other times, he pees onto the pee tray with difficulty. The owner disputed my opinion of the male dog urine-marking as the dog has no such habit.
*So as at March 30, 2011 as I close this case, I have only this hypothesis of pain due to stitches, not urethral obstruction by urinary stones behind the os penis. 22 days after surgery, the dog has fewer episodes of dysuria (see owner's e-mails above) . If only dogs can talk! And if only we vets have more time to analyse the cases but we don't have the luxury of time! And Singaporean pet owners want instant answers!
I don't have any complaint in my urinary stone removal surgeries using such the 3/0 non-nylon suture type for closure of the bladder, abdominal muscle and skin . It dissolves usually in 28 days and that is more than sufficient time for healing of the operated wounds. I don't use subcuticular sutures as I found them unnecessary in these cases. The University professors in Australia (from my observation of some graduates' need to do subcuticular suturing) still teach the students the need to eliminate dead space under the skin and therefore subcuticular sutures are used by many fresh graduates.
"Nylon" type absorbable sutures will take a much longer time to dissolve. The owner can "feel" the "lump" for some time. In veterinary practice, perception is sometimes as important as competence. Why use nylon-like stitches to create "lumps" under the skin worrying the dog owner and risking loss of owner's confidence in the vet when good alternatives are available? As each vet has his own preference, it will be hard to convince such vets to switch suture types!
I may be fortunate in my cases of no complaints of post-operation dysuria. Or the owner might have gone to another vet for a second opinion as in this case!
FOR BLOG READERS, the Toa Payoh Vets website article is at:
http://www.sinpets.com/F5/20110320stones-post-op-dysuria-unhappy-owner-complains-toapayohvets.htm
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