33. Breast nodules in 6-year-old Maltese

As many Singapore dog owners want the cheapest veterinary surgery, many breast tumours in dogs are not sent for histopathology. In this 6-year-old female Maltese which I operated to remove the closed pyometra womb and recorded in:
http://www.bekindtopets.com /dogs/20100135Video_Education_Closed_Pyometra_ToaPayohVets.htm,

the nodules were analysed. The report is as follows:

GROSS DESCRIPTION. A piece of tissue measuring 1.7 cm x 1.5 cm x 0.7cm.
MICROSCOPIC DESCRIPTION. Section shows skin with a well circumscribed nodule in the dermis. It consists of elongated and dilated ducts lined by hyperplastic columnar epithelium with papillary infoldings and which join up to form lobules. A loose fibroblastic stroma is present within the vicinity of the lobules and other areas show lobules of mature cartilage. No malignancy is seen.

DIAGNOSIS
Breast tissue. Benign mixed tumour of the skin


I was surprised. I thought it was a breast tumour. The lab doctor said this was a skin tumour which happened to be over the breast. She would consult another doctor for a second opinion.












Human pathology is applied to this case as the lab does human. She gets dog and cat growth from various vets in Singapore. Mast cell tumours from the limbs in dogs from her experience. Overall, tumours are classified according to human medicine and she said there were differences.

"I believe a cancerous cell is the same, whether from the dog and cat or from human beings," I said.

"There was a vet pathologist I knew many years ago, I can't remember her name," she said. "You know, you can send your biopsy samples to a veterinary pathology lab in Singapore. I don't know why vets send samples to us. We are doing the vets a favour as we do human histopathology," the lady doctor said over the phone.

"I have never heard of a veterinary pathologist in Singapore," I said. "Vet pathologists are post-graduate specialists and I don't know of any vet who is this specialist. Pl let me know the name of the specialist."

"I will phone you back after I find it," she said.

Her text message: "The lab that accepts animal histo is CVL-AVA tel 6316 5172". The lab is in my "backyard!"

31. Old dogs take a longer time to heal

Young people recover fast. But old people take a longer time to recover from illness and surgery. Does this apply to old dogs? Yes.

Each vet has his or her own idea on whether to spay a dog presented with breast tumours and excise the tumours in one anaesthesia and surgery. I always advise spay first and tumour removal 2 weeks later so that the old dog had a higher survival rate during and after surgery. Spaying a dog would take some time. Breast tumour removal takes more time.

As most Singaporean owners are interested in economics, one procedure would satisfy the owner. If the dog does not die. If the dog dies, too bad for the owner. He still has to pay up as he has had signed a surgery and anesthesia consent form informing him of the risks involved.

What about the interest of the old dog? This ought to be paramount. Survival rates are much higher if the anaesthesia is not prolonged as the dog's health is not so good. But the owner has to be sophisticated and educated to understand. And many don't. I had a case of closed pyometra and breast tumours. After spaying to resolve the pyometra problem and not excising the breast tumours at the same time so as to shorten the anaesthetic time and enhance survival rate, the owner forgot about the breast tumour removal advices. That is the typical attitude of many dog owners of older dogs.

So, some vets may feel that it is better to spay and excise breast tumours at one go and this is OK if the dog does not die.

In one case I encounter, the dog had spay, breast tumour removal and dental scaling by a vet. This 13-year-old Pom just looked half dead the next day. I thought it was the end. A maroon redness spread over the breast area. The next day, the sternal area was also red maroon. That meant the whole belly and groin area was dark red due to scratching or licking. The dog seemed to feel very painful despite pain-killer medication.

The dog would not eat and had to be hand-fed with canned food for the next 7 days but she looked brighter on day 7. I/V drips were given. Medication too. Still the dog would not eat on her own.

"Was there any blood test done?" I asked the owner. Apparently not. The couple was lucky to have a dog alive. In such cases, much depends on the vet's decision and the consent of the owner to take the risk in a 3-in-one operation. If the dog lives, it is considered "lucky". If the old dog dies after surgery, it is considered "unlucky."

31. A Puppy & Old Dog with Itchy Backsides

Today is the second Sunday I came back from a break in Perth Australia. Last Sunday, I wrote about 2 related cases of house-breaking in two Cocker spaniels. Today, I saw two cases related to the anus of the dog. One in a 4-month-old Silkie and one in a 5-year-old Pomeranian.

CASE 1. OLD DOG. ANAL SQUAMOUS CELL CARCINOMA

History
Around 3 weeks before the surgery on March 23, 2010, Vet 1 diagnosed anal sacculitis, expressed the anal sacs and sent the dog home. As the dog was still licking the anal area, the owner came to me for a second opinion. "Vet 1 said it is anal sac infection," the personable lady in her 30s said. A wound that does not heal would need review.

KNOWLEDGE OF ANATOMY
In 99% of the cases, it will be anal sacculitis. But in this case, the lump was vertically below the anus, not at 4 or 8 o'clock position. This is where the vet student will find need to apply their knowledge of anatomy, a dull subject. Could this Pom be suffering from a chronic anal sacculitis?











Perianal (circum-anal) tumour resection in a Pomeranian. The anal sacs were normal. A lot of yellow oil was expressed out prior to surgery

Follow-up on Sunday, April 18, 2010
The daughter in her 30s together with her dad, came for a review, 3 weeks after the anal surgery of her male Pom, 5 years old. Many Singapore owners don't bother to come in for reviews as the dog's problems had resolved by surgical excision. The culture of Singaporeans is to be frugal and so they do not go for reviews of their dogs. But this attitude is at the expense of the older dog with tumours, some of which can be prevented.

"What's the result of the pathology report on the tumour?" she asked after I took out the stitches. The details of the histopathology report are as follows:
GROSS DESCRIPTION
The ellipse of skin measures 1.2 cm x 1.0 cm. It has a darkish lesion measures 0.7 cm x 0.6 cm. The underlying subcutaneous fat measures 0.4 cm thick.

MICROSCOPIC EXAMINATION.
The skin sections show ulceration of the epidermis. Beneath the ulcer is an infiltrative squamous cell carcinoma which is composed of irregular, closely-packed nests of atypical squamous cells. There is focal keratin pearl formation. Other areas show irregular anastomosing trabeculae of tumour cells. Most of the atypical squamous cells have voluminous eosinophilic calcification. There is surrounding desmoplasia and focal dystrophic calcification. The tumour reaches the resection margin. No lymphovascular tumour embolus is seen.

DIAGNOSIS
ANAL LESION, EXCISION BIOPSY. Well to moderately-differentiated squamous cell carcinoma.
ADVICES TO OWNER
1. Inspect anal region weekly for any hard lump as the tumour has spread past the resection margins. I explained that it was not possible to cut bigger as the wound will have difficulty in healing.
2. Get lump excised when it is small.
3. Get two retained testicles removed as soon as possible.

CONCLUSION
Many Singapore dog owners don't bother with the dog's backside tumours and so they grow larger. If this circum anal tumour was excised at 0.5cm x 0.5 cm when it was very small and Tardak (androgen inhibition drug) the prognosis is said to be good, according to the Tardak manufacturer.

A red ulcerated bleeding hard lump? I suspected it was a circum anal tumour due to its position. In my 30 years in practice, I had not seen anal sac discharge at the 6 o'clock position, ventral to the anus. This does not mean it will never happen. The probability is rare. So, the owner accepted my advice to get the tumour excised and sent for histopathology. It was a squamous cell carcinoma.

Circum anal tumours occur in old dogs. Dogs are said to be old when they are over 5 years of age. Hard swollen lumps even at the 4 and 8 o'clock position can still be circum anal tumours or perianal tumours. So, be vigilant and not be sued for misdiagnosis in this litigious age.


CASE 2. PUPPY - Clipper Burns. Silkie X, 4 months, male

"Do you think that the groomer was did not do a professional job?" the father of a 5-year-old daughter with big curious eyes asked me. "Before going to the groomer yesterday, he was normal. Today, he would rub his backside and lick it all the time. He was sleepy and did not want to eat. I felt that he has a fever."

The puppy had fever. His anal area had been shaved. His anus had a raised, reddish ring. His scrotal area was brownish for 75% of the area. 3 small brown patches of skin looked as if they were clipper burns.

"Talk to the groomer," I said. "Was the puppy having itchy backside prior to grooming?"

"This will be the last time I send my dog to her," he said. "Where do you find certified dog groomers?"

"Some groomers don't express anal sacs," I said to the groomer when the owner phoned her. "This is because some dogs feel the pain and the owner blames the groomer."

"But the course tells us to express anal sacs as part of the grooming services," the groomer said. "You know about this compulsory course conducted in the Temasek polytechnic?"

"I am only saying that some groomers learn from experiences similar to what has happened know and so, to avoid bad complaints, do not express the anal sac." I said to the young lady who must be a newbie.

"Does it mean groomers don't operate on the anal sac?"

"No, no," I answered. The owner was listening. "It is just that some dogs will experience intense pain after the groomer had expressed the anal sac. You may have to let the owner know after grooming, next time."

In this case, I suspected it was the clipper burns around the shaved anal area and near the scrotal area and subsequent application of a anti-bleeding purplish black potassium permanganate or iodine powder that burned the anal area and scrotum and caused the intense itchiness. The puppy just had to rub her backside to relieve herself of the itch.

The groomer's clipper had nicked the superficial skin of the anal area and below it and the groomer had dabbled he powder onto the wound, as this is the common practice in Singapore. I expressed the anal sacs. There was a very small amount of brown oil plus numerous specks of blackish powder which would be the potassium permanganate or iodine. But to prove it would require money and time.

So I better not instigate the owner who was already angry and would then had a big ugly fight with the poor groomer.

"Will you let me know how much it costs?" the groomer said. "OK," I asked my assistant to phone her after the owner had paid the bill.

This was a case where the vet could pour oil into the fire and made the owner extremely angry. Puppies are like babies. They are especially loved. This could lead to litigation and complaints to the veterinary authorities if the vet or his assistants played the game of running down other professions.

As for the fever, it could be a bacterial infection caused by clipper wounds. Or a viral infection as the dog vaccines protect against the major diseases. In any case, this puppy's primary complaint was an itchy backside and the problem needed to be resolved promptly with medication.

30. Closed pyometra in a 10-year-old Maltese

"My dog could not stand up yesterday," the son took time off to drive his mum, an woman in her late 50s and the family Maltese to consult me. He is really a good son as many grown up sons don't bother or delay. "Today, she can stand. But she is not eating."

HISTORY
This is the type of history the average Singaporean owner would tell the vet. The vet need to ask pertinent questions like vomiting (vomited 2x), polydipsia which is -drinking a lot of water (yes).

PHYSICAL EXAMINATION
Rectal temperature was 38.5C. Normal. Mucous membrane slightly cyanotic and pale.
A large distended abdomen was obvious. An old female dog not spayed. The first diagnosis was closed pyometra. Examine the vulva. A red spot of blood hung out from the vulva gave me the clue.

PALPATION OF ABDOMEN
No pain at all. Pain in the lower 1/3 of the abdomen is said to be present in closed pyometra and the swollen uterus can be palpated. The whole abdomen was just a swollen balloon and so it was difficult to palpate the two internal uterine horns. There seemed to be various swellings, some big. some small.

X-RAYS
X-rays can be done to show the swollen uterine bodies and to increase the income for the practice. A diagnosis of closed pyometra by history and clinical findings will cost the owner less. I did not milk the owner by getting X-rays done to protect myself from litigation. However, I insisted on a blood test to ensure that the dog's kidneys and liver are in good condition since the dog was vomiting. Vomiting could be due to high blood urea or liver disorder from the toxaemia.


BLOOD TEST
An increased white cell count is said to indicate a high bacteria infection. However, a normal white cell count does not mean that the dog has no pyometra as will be discussed in another case. I had blood test done in this case. There was a marked decrease in white cell count. A decrease in platelet count. Blood test is an ancillary aid to diagnosis and should never be relied upon to advise the owner on the closed pyometra case. If the owner wants to save money, I don't insist on a blood test but would advise the owner that he had been informed.
DIAGNOSIS
What is the instant diagnosis? Normal temperature and no fever. A drop of bright red bloody vaginal discharge. Just not eating much or not eating for 2 days. But there is polydipsia, polyuria and vomiting.

BE BRUTALLY FRANK ABOUT THE PROGNOSIS.
Due to the tendency of a few Singaporeans to complain and be litigious when outcomes are not to their satisfaction, I am nowadays brutally frank to dog owners when their dog's lives are in danger. Cut to the chase. I said to the son, "Your dog has a very serious womb infection. She will die within 2 days if you don't operate. If you operate she may die on the operating table as she is very old. Had you got her spayed when she was young, you would not have this worry."

"What are the chances of survival?" the son asked.
"50:50," I estimated. "If you permit her to be operated soon. Not wait till tomorrow."
"So low?"
"For most dogs in the same age group, I give less than 50%," I said. "Your dog is in good condition and not skinny. She has no fever and was sick only '2 days'. She has no heart disease but I don't know about the liver and kidneys." This dog looked well fed and could be considered a bit on the plump side. But since she collapsed yesterday and could not stand up, this was a warning sign not to give optimistic predictions. Blood test show toxaemia and yet this dog had a normal rectal temperature and looked bright. Most owners are worried about the poor chances of survival. So they delayed surgery or took their dog to another vet for another opinion and costing. This is OK if the dog is not in a toxic stage but who can tell?

TWO CHOICES?
"So, we have 2 choices," the son said. "To operate and not to operate."

PROPER COMMUNICATION IS IMPORTANT
"You have no choice," I said. "Your dog is going to die if you don't get her operated. Your mum may be seeing this dog for the last time before I operate today. It is very important I do it today as the womb is very swollen with toxic pus.

EMERGENCY SURGERY
In this case, I operated within one hour after giving her an IV drip. The dog ate the next day and is normal as at day 3 when I write this report. Soon, she would be going home. The surgery is illustrated in pictures below.




"Why you said the uterus is going to rupture soon?" the young intern asked me. It is good to ask why. The browning of the uterine walls indicated cellular necrosis and death. Within 2-4 days, the uterus would rupture leaking out pus and killing off the dog. If the owner procrastinated, don't blame the vet. The vet must give a letter of advice to protect himself or herself against frivolous complaints, should the owner want the dog discharged to seek a second opinion and the dog dies at the 2nd vet.
EARLY DETECTION, DECISIVENESS OF THE OWNER AND TRUST IN THE VET'S DIAGNOSIS AND SURGICAL COMPETENCE. A happy outcome in this case was not due to luck. When old dogs survive a toxic closed pyometra, surgery, it is not a matter of luck. It is knowing the fundamentals and the technicals of the diagnosis of closed pyometra, the anaesthesia, surgery and IV support and in excellent communications with the owner.


More pictures at www.toapayohvets.com DOGS OR
goto: http://www.bekindtopets.com/dogs/20100416closed_pyometra_old_maltese_toapayohvets.htm

29. Commodities Investment

The following is a draft report, before I forget.

An e-mail to invite me to the talk below. 2 reminder phone calls from the organisation the day below and on the day when I was late, showed that this organisation means business. In talks, it is best to take notes if you want to learn from another industry and to review. The talk was well attended as the room was almost full of older people above 30 years of age.

My impressions from this talk:
1. The Singapore's savings and fixed deposit interests are less than 1% and inflation will erode the spending power of the savings.

2. Investment in high quality funds over 5 to 30 years as part of your investment diversification should be done. Expect around 5% return per annum over the 5 years.

3. Expect around 8% return per annum when investing in funds dealing with good quality shares.

4. Do research to find out which funds are high quality and their portfolio.

5. Regular investment in a balanced fund. Invest monthly so that you need not worry when the market rises or crashes. 5% return per annum is better than fixed deposit interest rate of less than 1%. For example, monthly investment of $250. Global equiies return 7.44% and global bonds return 5.23% per annum as long term investment in the last 20 years. Much higher returns than fixed deposits. The average Singaporean retirees normally invest in fixed deposits in the POSB and do not know any other alternatives. CPF rates are 3.03%? Fixed deposit rates are 2% in Singapore. Mini-bonds are NOT bonds.

In 1939 - 2003
1. 70% you make money
2. 30% you lose money.
Any 3-year period, you make money
Any 5-year period, it is good for you.
Any 10-year period (long term), you should have better returns.

6. The Straits Times Index has shot up 100% as at April 2010 compared to Oct 2008. Oct 2008 was the economic crisis level when shares were at the bottom. Therefore many people have had missed the boat. The STI was 1,500 in Jan 2009. Now in April 2010, it is 3,000. Its peak is 3,800. When will it peak? Economic cycles are shorter nowadays. 4 years from now, it will peak at 3,800? I can't understand how the speaker comes to this conclusion or I have heard incorrectly.

May 1932 Great depression
Jul 1982 Worse recession in 25 years
Dec 1994 Most dramatic Fed tightening
Oct 2008 Economic crisis
Apr 2010 Said to be in the expansion (boom) period. Commodities will outperform. Interest rates will rise.

Australia. The following may be of interest in students studying in Australia.

1. Interest rates are record lows except in Australia.
2. Unemployment has decreased more than expectations.
3. Australia is a commodity producer.
(Implication? Invest in a country that is a commodity producer). Buy commodity shares in Australian companies?

Singapore News in Apr 15, 2010
Singapore's inflation rate will increase from 2% to 2.5% according to April 15, 2010 news I have just heard. The economy has rebounded unexpectedly.


4. The following topic was educational as the speaker said 2010

Gold prices still have not reached their peak. In Jan 1980, the lady speaker said that gold was selling at the peak of US$1,816 but two participants said it was S$800 as they bought or sold gold for their wives.

The speaker said it was US$800. The US$1,816 was the figure adjusted for inflation at 2010 rates, the lady explained. "In 1980, an HDB flat was not selling for $1 million dollars!". I can't recall HDB flats selling for $1 million in 2010.

ENERGY V. GOLD ASSESSMENT
Focus on gold as the real interest rate is low and gold is relatively cheap. To evaluate, assess how many number of barrels of oil will buy 1 oz of gold. In Jan 1980, gold prices were at its peak of US$1,816 and the number of barrels was 48.2. In Nov 2009, gold was cheap when it could buy 15.2 barrels. This is because gold supply is down. The trend is for central banks to buy gold and so demand will increase.

Silver - Smaller market. Silver outperforms gold if its price rises. Invest in 10% of your diversified portfolio.

Platinum - Still high demand despite recession as European Union regulations require cars to have catalyst to reduce toxic emissions. Auto catalyst needs platinum. Invest in 5% of your diversified portfolio.

In summary, hold commodities esp. gold and metals to hedge against inflation for a long-term portfolio. Base metals prices were high last year (2009). The last 20 years were deflationary. Now, we are in the inflationary environment and the 20% bond and 80% equities formula may not be relevant. Commodities should do better than both.

In the economic cycle
1. Slow down
2. Recession
3. Recovery - equities and properties
4. Expansion

Agriculture, metal and energy. Agriculture is the last one to rally. Metals had their best performance in 2009. In 2010, consider gold price as an alternative investment for growth.

A simple rule: Be fearful when others are greedy but be greedy when they are fearful.

---------------------------------------------------------------------------
LECTURE

An International Portfolio in Commodities (lst Hour)

Because commodities are an area which have not been represented in investment portfolios, this market is relatively inefficient. Opportunities to outperform the market are much more likely to occur in an inefficient rather than a more developed market environment.” And like many asset classes, the long term is made up of a series of medium-term cycles, in which prices move up and down as supply and demand fall into and out of alignment with each other.

Looking ahead to the next few years, we see good reasons why the long-term and medium-term trends are highly encouraging for commodity investors.

· Why Commodity Futures?

· Outlook for Commodities in the 3 broad groups: Metals, Agriculture and Energy.

· How to take part of the exciting opportunities of Commodity Futures?

A Winning Investment Vehicle – Zurich (2nd Hour)

· How best to position yourself to take charge of the market rally

· What are the best periods in history to invest?

· A winning investment strategy with Zurich

Key Speakers:
1. A substitute lady speaker from Schroeders
2. Alan Tang - Chartered Financial Consultant, Certified Financial Planner, Chartered Life Underwriter , Senior Branch manager (PIAS), Money Sense Speaker (MAS)

Having done more than a thousand talks for corporations, unions, ministries and statutory boards, Alan is a revered speaker in the financial seminar circuit. He is not just effective in delivering the message, but his lessons will dramatically improve your finances.

28. Enterotomy, enterectomy, gastrostomy practical

To excel in veterinary surgery, one must have lots of practice. In human medicine, surgery is a post-graduate study and specialty but vets after 5 or 6 years of undergraduate studies are expected to be competent in veterinary surgery. There are veterinary specialists in surgery but he or she will not be able to earn a living in Singapore or in many countries.

Therefore, it is good to know that the 4th year students are given hands-on experience on intestinal surgery in the pig. 3 in a group. One would be a surgeon, one would be an anaesthestist and one would be a recorder at any one session. Anne was the one doing surgery yesterday. She had the short stick of the draw.

I did advise her to practise a lot on stitching pig intestines prior to the test. Reading notes and watching video may give the theory. But in the real McCoy, she needed to demonstrate competence if she was to get HD (High Distinction). For this high-achieving student, failure is not an option. Failure means having to repeat the test but I doubt that the University would be funding a pig for this repeat. It must be expensive and time-consuming. So, yesterday would be her trial by fire.

I discovered that she was a high-achieving student when her mother told me. It is rare to meet high-achievers doing internship in my practice and in veterinary medicine and surgery. There are around 70 graduates per year. 150 students might have started first year. The drop-out rate is high. In 70 students, only one veterinary graduate may get the University Medal for being amongst the top 7 in the whole campus. I presume the winner will be from the crop of the top 2%. It is not easy.

Veterinary medicine and surgery is a very tough subject unlike human medicine where only homo sapiens is the only species being studied to death.

A vet student has to study so many animals and each animal has its own diseases and various medicines to treat them. It is a wonder how the undergraduates can memorise and pass the examinations.

"How's the practical test on your intestinal surgery today?" I phoned Anne who was the surgeon in a group of 3. I had advised lots of practice on pig's intestines prior to the test if she wanted to get high marks. No 4th year student or even new graduates can demonstrate competence in stitching up the intestines because of the Western model of veterinary education which prohibits practices on live animals due to animal welfare concerns.

I was surprised that Anne accepted my advice and sourced for pig intestines from the butcher's shop to practise surgery. A butcher told her that pig intestines are never sold in Perth. Yet she found one selling at Northbridge. So, she practised and the vets and nurses at the vet surgery she stayed helped out.

I had many questions to ask about how she did the surgery on the pig. I don't do pigs. "Enterectomy, enterotomy and gastrostomy," she said. "How long did it take? Around one hour?" I asked optimistically. "The total surgery including stitching of the linea alba and skin stretched from 1.30pm to 4 pm."

I was just interested in one result regarding intestinal anastomosis. "Did the intestines leak after joining the two parts of the cut intestines?" Performance counts. You fail if your appositional sutures did not close the defect. The patient would suffer peritonitis and there will be a need to operate again.

"Did the intestines leak?" I asked again. This was her first intestinal surgery and she had diligently practised. "In a live pig, the intestines are mobile," Anne said. "It is not easy to stitch (unlike the dead specimens from Northbridge. The mucosa is hard to stitch up."

"So, did the intestines leak?" I asked patiently again. I could not afford to talk too long in international phone calls and this was the answer I wanted to know. You can have beautiful stitching. But the life and death issue is whether the patient's intestines, uterus, bladder, heart, blood vessel leak contents after your stitching.

"Yes," Anne explained to me that it was hard to stitch interrupted appositional sutures to join the two intestines. The sutures should not evert or invert. They should just close up tightly as in simple interrupted sutures in the skin. "Why don't you use inverting sutures on the serosa?" I asked. "Fine 4/0 absorbable sutures inverting the serosa as in gastrostomy?" Anne said, "The professors said that only one layer of appositional sutures would do as there may be intestinal blockage."

Well, I did read the lecture notes which taught what Anne just did. It also said wrapping of the omentum and tacking it to close the anastomosed area. Or a serosal patch after intestinal anastomosis.

This anastomosis of intestines is a rare surgery in a general practice. Practice on Caesarean sections would help a vet hone his skills. Unfortunately, there are not many Caesearean sections unless the vet has lots of dog breeders and provide dirt-cheap surgeries attracting them. "Why was there a leak?" I wanted to know. "Didn't you check after stitching?"

It is easy to criticise when one is not on the hot seat.
"It was closing time," Anne said. "I had to rush." Failure is really hard on high performers. Nobody wants to talk about the pains of failures. "Do you know your marks?" I asked. "No," she said. I think she would not get a HD for this surgery. And after all her hard work.

27. FAQ - Breast tumours in a 13-year-old Pomeranian

On this first Sunday after my return from Perth, I was still around at 6 pm when a couple came in with their 13-year-old Pomeranian with nodular breast tumours in the MG 4 and MG 5 glands, left side.

HIGH ANAESTHETIC RISK
"We are bringing in our dog for surgery," the couple explained to me that my associate had booked for them the appointment for surgery on Monday. "Will my dog be able to survive the anaesthesia? I hear it is very risky."

PRE-ANAESTHETIC BLOOD TEST
I checked the dog generally and the heart. "The dog's heart was OK and the general health is good," I said. "There is the gum and tooth disease as you had not done any dental work for the dog for the past 13 years. Generally, there should be no anaesthetic problem but please note that your dog is not as young as a 5-year-old female dog. There is the kidney and liver function which can be assessed by a blood test. This costs money." Owners must be advised fully the risks and a blood test will be good. But in practice, the owner may not want to pay for the blood test.

SPAY AND BREAST TUMOUOR REMOVAL
I advised separate anaesthesias to remove the breast tumours and the do the spay. "Won't the dog be having two risks in anaesthesia?" the husband asked.

"Anaesthesia in dogs older than 5 years is risky," I explained. "However, the shorter the surgery, the shorter the duration of anaesthesia. Therefore, the lower the risk of dying on the operating table. If a vet takes 1 hour to do a spay and breast tumour removal in your dog," I explained, "the higher the chance of the old dog's heart failing. If one surgery is done and this takes 15 minutes, the dog will be at much lower risk of death."

"Two surgeries in one is much cheaper," I said. "Many vets do that in the case of breast tumours plus spay. However, which owner will be happy when the dog dies on the operating table? If I charge you $5.00 and your dog passes away on the operating table after I completed two surgeries, will you be happy at all?"

I don't know whether the couple understand my explanation. I ask them to speak to my associate vet who will be handling their case. In old dog anaesthesias, the owner actually understands and takes the risk. The vet must produce a live dog at the end of the day. I mean, if there are 5 breast tumours and you remove all completely. The dog dies on the operating table or 2 days later because it is old and can't take the lengthy anaesthesia and surgery, no owner is going to refer any friends to you. Deaths do occur, but the trick of the trade is to make anaesthesia short and if surgeries need to be performed twice or thrice, inform the owner. An old dog is very much like an old family member. Every owner wants him or her alive at the end of the surgery and go home walking.