Wednesday, December 8, 2010

The old dog with the recurring cheek tumour goes home

2 days after surgery. The 11-year-old dog looks good and will be going home today. His pustules which spread all over his body had disappeared due to the intensive IV drip with baytril, metronidazole and a bit of dexamethasone.

I spoke to the young lady yesterday. "Spend time with your dog. Give him good food and water. It is unlikely that he will survive a 5th anaesthesia and operation. The tumours had spread to his lymph nodes."

I popped out a 1.5x1.0 cm popliteal lymph node which is usually not palpable to show the young lady. I said: "It is unlikely that the immuno-suppressive azathioprine 50 mg (1/4 tab/day for the next 14 days at 1.5 mg/kg/day initially). The drug will stop the fast growth of this tumour. The dog may be vomiting and not eating on this drug.

It is back to square one after excision of the cheek tumour for the 4th time. This time, the cancer had spread aggressively back into the gums and the bones of the lower jaw. "If chemotherapy works, his cheek tumour will not grow back again. It will be a miracle." It will be Christmas in 17 days' time. If miracles do happen, it will be known by Christmas day.

266. Eat, Love, Pray & Warts

"Are you waiting for Dr Vanessa?" I asked the couple who popped in today while I was about to operate on the old Shih Tzu with the open wound in a left neck lump of around 1.5 x 1.5 cm.

The lady owner had scheduled this surgery after the dog suddenly had this crazy scratching of the enlarged lump some 2 weeks ago. I had treated the swelling which was 5 times the present size. Much earlier I had advised surgical excision but she did not want to do it. The lump had swelled and gone down over the last 2 years and so it was nothing to worry about. Till two weeks ago, when it exploded like a volcano (see image). I was surprised too. This will be another story.

Back to the couple with the old Miniature Schnauzer limping and biting the owner should they touch his left fore limb. "Actually, we want to see a vet immediately," the young trim lady in make up and green dress said softly.

So I had to abandon my surgery case to attend to this dog.
"He must be suffering from an ingrown toe nail like last time," the man in his 40s said. "Remember, you need a tranquiliser to trim his toe nail." I checked the records. It was done by Dr Jason Teo and the limb affected was right fore.

"This dog has lots of ear hairs and his ears are painful. Did the groomer pluck his ear hairs?" I examined the ear canal after muzzling the dog and noted that the left ear was dirty with wax. "Mum is the groomer, and she cannot do it."

I got the groomer to clip the dog's left fore paw under domitor sedation. He has a puncture wound in his pad which contained pus.

The man had been flying for the past 20 years internationally. "Did you take any pictures of the various cultures and people you meet?" I asked. "People like me don't get to see the world as it is too costly and time-consuming. You have the opportunity to document the fascinating diversity of people and culture."

"I will get a SLR to do it," the man said he did not do photography. "Travel stories with pictures are fascinating to many people," I said. "You may become rich if you author an interesting travel story that is made into a movie. Have you watched the movie "Eat, Love, Pray"?

"Bali," the girlfriend said.
"Bali is the place where the writer found her true love. Italy is the place where she eats good food and makes good friends without bothering about her weight gain. India is where she meditates and clears her mind."

I hope the man will take pictures and document his travels. It is very rare for a person to write travel stories but buying a camera is a start to create memories.

As for the old Schnauzer, I got the dog's left elbow wart (blackest one I had seen) excised. A papilloma behind the left shoulder was excised. I asked the intern to write the "surgery" of this case plus the one on the Shih Tzu with the neck abscess. He can write but like most interns of 4th year, they prefer not to document. Writing will help him in his forthcoming examinations as he sees real cases. Books and lecture notes can be most boring.

As for the Shih Tzu, he saw the operation when he came in after 10 am. He was fortunate as I wanted to complete the operation before 10 am if the couple with the Schnauzer had not stepped in. So, he could see and understand the principles of tumour and growth excision. How it is done and what is the post-op care. I asked him to write this record.

As for post-op injection, I asked him where to inject the tolfedine l.0 ml with half IM and half SC said: "My professor teaches me to inject in the dog's neck for IM."

I said sadly to him and to my assistant: "Sometimes two of you make me so angry because you said something which cannot be done." Obviously, the dog's neck had surgery and was bandaged up. So, there was no possibility of neck IM injection. "I usually inject IM in the back muscles," I showed the intern the location. This is the first time I hear dogs being given neck IM injection for sedation. Since the intern's Murdoch University does it as a routine, it must be OK. In racehorses, I use IM neck injection as the neck is muscular and large.

"I know of a Filipino vet graduate who injects IM into the muscles above the knee joint," I said to the intern. "So the professor in her university must have taught her that way." There are many ways of IM injection in the dog apparently. I stick to the backside muscles.

265. A vet catches a cat


7 Dec 2010 was an ordinary sunny morning. 


Suddenly a Caucasian man in his late 40s entered my Surgery while I was preparing to operate. I usually operate at around 9.30 am as that is the best time when no clients or phone calls interrupt me. 


"Can I help you?" I asked. "Yes," he showed me his two pale hands criss-crossed with angry red long scratches. “My cat ran away and is hiding inside some wooden boxes. He scratched me all over my hands. My wife is there trying to catch him." 


He was carrying his cat in his hands and on reaching the surgery the cat jumped off the taxi and sprinted away. So, there was no cat for neutering. 


I imagined a ferocious cat. I didn't want to be involved. It was a job for the professional catch-catcher, a pest-controller, not for a vet. 


My university professors in Glasgow did not teach me how to catch a cat that runs away from the veterinary surgery.

I doubt any professor has time for such tasks as there are so many subjects and animals to lecture.

"I can give you some cat food to lure the cat to you," I asked my assistant to give me a small plastic bag of cat food. 


Then I went off with him to catch the cat, probably cornered somewhere and ready to pounce on me or claw my hands. I brought along a cat carrier bag, looked for but could not find a cat net. I brought a dog lasso pole instead but this would be useless as the wire is stiff and the cat would jump off in a split second when I lasso his neck. It was better than nothing. 


At the industrial park behind, the wife was down on her knees trying to coax the cat out. The cat was too far in at the left corner (if you view from the front) of the box of pallets. They are called wooden pallets. Pallets are used to hold heavy things. It has a 6-inch gap between two wooden planks so that the forklift truck can insert its two long iron bars on the right and left end to jack up the pallet with its load. 


The cat squeezed inside this gap. The pallet was the 2nd from the lowest most and on top there were more pallets. I lowered myself like a soldier in the prone position. Two yellow eyes fixed on me from far inside. 


"Come this side to help me," the wife thought of shifting the wooden pallets to one side and grab the cat. The industrial worker was not helpful as he had to work and the culture in Singapore is not to help animals in distress, generally. There are more young adults more concerned with animal welfare than ten years ago, but it needs time for the immigrants to be animal activists.


 So, it was the owner and I that must do the rescue while the other industrial park employees and bosses go about in their jobs.

"I better be at the right side," I replied. "If I go to your side, the cat may just run out from this end." It is just like military training during my national service. The military strategy is to outflank and seal up the escape route, not to focus on one area as the cat does have a way out if I go to the owner's side which is the front left side of the pallet. 


If you see the images, the back and left of the pallets are blocked and so the cat can escape only from the right side since the owner is on the front end. He would rather trust the owner than the vet starting at him too. The wife could not reach the cat with her hands as she kneeled down. What to do? I pushed my lasso stick which was around 4 feet long inside the gap. It was too short! I tried to push the wired lasso out. It was not effective. 


The two yellow eyes of a black cat stared intensely at me. The sun was blazing on my back. What should I do now? If I abandon the wife, the cat may run out this side and disappeared forever. The expatriate husband had disappeared and I presumed he had to work. This was a problem that needed a solution. I looked for a longer plank. There was one. I pushed it in. And patted the cat's backside. The cat did not move. 


"Call him, talk to him without stopping," I said to the wife. I gave the cat a slight whack. He moved a bit forward. The wife managed to grip one of his fore limb. But she could not pull him out as the other pallets were weighing down and blocking her access. I went to the factory to ask a young man for help. He did help reluctantly to pull out the pallet load. 


The wife had more space. "Grip the scruff of the neck," I advised. "In this way, the cat can be restrained." She managed to do it but the cat would not volunteer to come out. "Try. Talk to make the cat relax. I better go away from you." 


When she finally got the cat out, it was almost one hour. I had the carrier bag opened. She dropped the cat in. "No surgery today," I advised. "The cat had been stressed. Wait two days." The wife borrowed the carrier and wanted to put it on her back while she cycled home. "It's only down the road," she said. 


"It is not safe," I said. "Put the carrier on the back seat which has a container. Then you can focus on your cycling." "I guess you don't do cat catching often," the wife said. "Never did it for the past 30 years of practice," I replied. "I usually ask my assistant to do it. But the assistant is not available today." It was fortuna


te for me that I performed to expectations. Or the cat would not be in the bag.





The cat went home to rest till he is back to normal eating and drinking. Never carry pets in your hands when you go out as they do escape suddenly. 


"Never let the cat out of the bag" I remember my Primary Six School English teacher's English idioms which I had to study for my Primary Six Leaving Examination! That was some 48 years ago but I still find that this idiom seems to apply to this situation. But this idiom has a different meaning from my advice to put the cat inside the bag (carrier) when you go to the vet. "Never let the cat out of the bag" means "never reveal a secret accidentally". 







Updated article is at: http://www.kongyuensing.com/folder5/201006231cat-escape-hides-inside-wooden-pallet-vet-to-rescue-him-ToaPayohVets.htm







Tuesday, December 7, 2010

264. 4th surgery in an old dog's cheek

Surgery Report for ROY (11 Y/O mixed breed male dog)
PRE-OP
History:
Roy was presented with a malignant tumour on the Right cheek. Tumour was persistent, with ill-defined margins and had a rough 7cm circumference. It also had a history of dermatitis with multi-focal exudative pustules and papules located primarily on the proximal fore and hindlimbs, with severe scaly and crusted regions of epidermis on the caudal elbow and knee joints. Roy was otherwise eating normally.
Physical Exam (PRE-OP):
On physical examination, Roy displayed an obdunted attitude. Heart, respiratory rate and temperature were within normal limits at 102 bpm, 30bpm and 39.2degrees Celsius respectively. Peripheral perfusion seemed normal with mucous membranes being moist and pink and CRT < 2 secs. Breath was malodorous (possibility of bacterial / fungal overgrowth inside the mouth).
Treatment Plan:
Palliative and curative.
To surgically excise the malignant cheek tumour via electrocautery and check for observable metastasis to regional lymph nodes under general anaesthesia.
OPERATION
Surgical and Anaesthetic details:
Roy was not sedated prior to anaesthetic induction as there was sufficient restraint to hold him down.
Catheterization was performed via a 22G needle into his left cephalic vein for easy intravenous (IV) access before anaesthetic induction with Diazepam (0.4ml) and Ketamine (0.4ml) totaling 0.8ml IV. Roy was deemed sufficiently induced after 10minutes and surgery proceeded. Surgical site was prepped with chlorhexidine and alcohol and a transverse incision across the tumour was made via electrocautery.
The epidermis above the tumour site was undermined to relieve skin tension and provide easier excision of the tumour itself. Roy was also given an IV drip of 5% dextrose wit 0.45% NaCl to compensate for electrolyte losses and to prevent dehydration and hypovolaemia.
Care was taken not to sever the facial nerve although part of it might have been as the tumour margins were large and irregular and the base of the tumour was located deep within the facial cavity, thus requiring aggressive surgical therapy. Upon tumour excision, tumour was found to have metastasized to the bone as well as the upper gingiva. As the effects of the induction drugs weared off, gaseous anaesthesia for maintenance was administered. 5% isoflurane was administered initially and slowly decreased over the course of the surgery up to 0.2% during the muscle, subcutaneous and skin closure at the excision site. 0.1% zoletil was also administered IV during the course of the surgery as Roy was still deemed too light. After 40 minutes, tumour was partially resected and wound closure commenced so as to decrease anaesthetic risk and toxicity. Muscle, subcutaneous and skin closure was performed using 2-0 synthetic polysorb, absorbable suture for all layers. Muscle and subcutaneous layers were closed using a simple interrupted pattern while the skin layer was closed using a mattress suture pattern.
POST-OPERATION
Surgical site was washed and swiped clean with sterile saline to reduce risk of sepsis and 1ml of Tolfenamic Acid (Tolfedine) was administered IV as post-op analgesia. Roy was then placed back in his cage and equipped with an E-collar while he continued to receive the remainder of the 5% dextrose and 0.45% NaCl at maintenance rates followed by another 500ml of Hartmann’s after, also at maintenance flow rates to prevent dehydration, hypovolaemia and to maintain electrolyte balance. Blood sample was taken for CBC and biochemistry while a tumour sample was also submitted to QuestLabs for histopathology.
DRUGS USED AND PRECAUTIONS
Ketamine:
- Mode of action: Acts at the N-methyl-D-Aspartic (NMDA) receptors and blocks central sensitization. It is useful for patients with chronic pains and patients that fail to respond to conventional analgesic therapy. Can also be used (mostly in combination with other drugs such as Xylazine and Diazepam) for sedation and anaesthetic induction.
- Precautions: AVOID the use of ketamine in patients with traumatic head injury as it increases cerebral blood flow and may increase intra-cranial pressure.
Diazepam:
- Mode of action: Diazepam is a benzodiazepine that binds to a specific subunit on the gamma-aminobutyric acid (GABA) receptor at a site distinct from the binding site of the endogenous GABA molecule. Therefore it works as an allosteric modulator of GABA, enhancing its effects and provides good anxiolytic, anti-convulsant, hypnotic and amnestic properties. Used especially in the management of seizure cases.
- Precautions: IV administration of diazepam should be performed slowly, particularly when injected into the smaller veins such as the cephalic vein because of the potential of thrombophlebitis and cardiotoxicity due to the propylene glycol base.
Diazepam may cause weakness, drowsiness and loss of motor coordination. In rare cases, it may result in paradoxical excitement, unexpected aggression or unusual behavourial changes.
Zoletil
- Mode of action: Combination of 2 drugs, tiletamine and zolazepam. Tiletamine’s mode of action is similar to that of ketamine as it is a NMDA receptor antagonist and blocks central sensitization as well. Zolazepam’s mode of action is similar to diazepam as it is a pyrazolodiazepinone derivative that is structurally similar to the benzodiazepine drugs.
- Precautions: Contraindicated in animals with CNS signs, hyperthyroidism, cardiac disease, pancreatic or renal disease, pregnancy, glaucoma or penetrating eye injuries.

REFLECTIONS
As tumour was incompletely resected, the chance of recurrence is very high. Prognosis of this dog is very poor as well as it is old and there has already been evident local metastasis to bone and gingival. Distant metastasis has not been diagnosed but is possible, which will further decrease its prognosis for survival.
In my opinion, if cost is not an issue for the client, I would recommend palliative treatment with NSAIDs such as acetaminophen, aspirin, meloxicam as well as prophylactic broad spectrum antibiotics such as Trimethoprim Sulphate (TMS) or Amoxicillin Clavulanate (Amoxy-clav) along with neoplasia excision again when the tumour grows again to a clinically significant size.
As the surgery had to be aggressive, part of the facial nerve might have been severed in the process which might have resulted in the post-op excessive salivation, drooping of the lip and ear on the ipsilateral side of the lesion. Dog should also be examined for signs of nystagmus, head tilt, asymmetrical pupil size dropping of food and ataxia to further confirm the suspicion of facial nerve paresis or paralysis. Part of the sublingual and mandibular salivary glands and/or their ducts might have also been severed in the process, resulting in excessive salivation. Due to traumatic injury to the glands and/or ducts, in my opinion, I would expect the dog to develop a sialocele which would then require further surgical intervention. Diagosis of this could be confirmed with fine needle aspirate should a SOFT, palpable mass develop near the mouth region. Needle aspirate can also help differentiate a sialocele from a neoplastic process.
On a separate note, the dermatological processes should also be looked into if the client is willing. Punch biopsies should be done on the pustules and papules, centered in the middle of the biopsy specimen. Punch biopsies should also be obtained from the scaly and crusted areas AS WELL AS from the normal skin. This is to allow comparisons of the epidermis and stratum corneum of the 2 sites by the pathologist. This is done to diagnose the nature of the skin lesions and to determine an appropriate treatment plan for Roy with systemic treatment such as injectable or oral cephalosporins, enrofloxacin etc. Adjunctive therapy could include topical treatments such as Chlorhexidine gluconate (Pyohex Dermcare) shampoos as well as benzoyl peroxide (Pyoben Virbac)


Done by:
Geoffrey Yeo


COMMENTS FROM DR SING
A good report written by a 4th year Murdoch Univ student on first day of internship at Toa Payoh Vets. Interns are expected to write report of interesting cases to make them good vets as merely observing surgeries and anaesthesia during internship will not be effective in training of a vet student. In this way, veterinary surgery is brought alive to the student and hopefully, he or she will remember the case study during his final year examinations or after graduation.


The following is additional information for my record and to share my knowledge with other vets

HISTORY
Previous handling of the case including anaesthesia and surgery are documented at:
1. http://www.toapayohvets.com/surgery/20100618cheek_tumour_old_dog_electrosurgery_ToaPayohVets.htm

2. http://www.asiahomes.com/singaporetpvet/dogs/20100690emergency_anaesthetic_death_cheek_tumours_old_dog_excision_ToaPayohVets.htm

On this 4th surgery case study, the submandibular and popliteal lymph nodes of the dog are enlarged to around 1 cm in diameter. The mouth was very painful and the dog has poor appetite till painkillers are given. The owner gave rimadyrl tablet earlier and the dog did not feel any pain and therefore ate canned food.

PRE-OPERATION
The Miniature Schnauzer, male, 12 years old was operated 3 times. The cheek tumour was malignant and recurs within a month. It keeps growing bigger and has spread to the bones and gums now. The owner had declined cytotoxic drugs or euthanasia and expected the old dog not to die on the operating table. She was informed that this was a high risk anaesthetic case. She wanted the surgery to be postponed on Sunday as she felt that nursing would be better on Monday. So, the dog was operated on Monday.

Prior to this 4th surgery, the dog was on 2 days of IV drips, baytril and metronidazole IV as the mouth was smelly due to the large infected cheek tumour. On the day of the surgery (Monday, Dec 6, 2010 at 2 pm), the bad breath was 90% absent.

PAIN-KILLERS
Sufficient pain must be given during surgery and post-operation. The dog was whining
1. during surgery at times when the IV general anaesthetic of ketamine 0.4 ml and diazepam 0.4 ml in one syringe, totally 0.8 ml. Initially at 0.4 ml of the mixture was given via the IV cathether. This was insufficient analgesia for this 10-kg dog.

2. Isoflurane gas 5% was given for less than one minute by mask when the dog whines during the surgery. "Intubation is not practical," I told my assistant who asked for an endotracheal tube. "The cheek tumour is too large and the tube would be obstructing the excision and view." I got a small mask (usually for cats) and supplied gas at the nose level. It was effective. The tongue remained pinkish, the intern practised on taking the heart rate which was normal. Maintenance dose varies from 5% to 0.2% to effect.

3. Zoletil 100 at 0.1 ml IV was given towards the 30th minute of surgery as the dog was whining when isoflurane gas was reduced considerably. The dog stopped whining within a few seconds.

4. Tolfedine 4% at 1.0 ml given IV towards the completion of surgery as the dog was whining in pain as he had waken up at the 45th minute when the last stitching was done. I supervised the intern to give the injection IV via the IV set. "Not direct injection," I stopped him. "Stop the IV flow first, inject and continue the IV drip".
Within 60 seconds, the dog stopped whining in pain and for the next 12 hours after surgery. This shows that Tolfedine acts effectively.


NOTES: The intern was told that the IV flow must be stopped by rolling down the control wheel before injection of the drug. He asked whether there was another solution to inject the remaining drug and was told there was none - in human IV anaesthesia, another syringe with saline of 2 ml would be injected to flush in the remaining small amount of drug in the needle of the first syringe which is removed first.

FACIAL NERVE
The intern was asked to identify the large 3-mm wide white nerve seen between the right eye and the commissure of the lips, above the cheek muscle. He said it would be the trigeminal nerve.

HISTOPATHOLOGY
The intern was asked to send the greyish white fatty-like tumour for histopathology.

BLOOD TEST 2 DAYS BEFORE SURGERY
TELEPHONE FROM THE OWNER. The young lady phoned me and was told the good news that the dog was OK. Another bottle of IV drip of Hartmann's solution would be given. Metronidazole and 0.1 ml of dexamethasone IV would be in the drip. The dog would be on immunosuppressive drug.

BLOOD TEST 2 DAYS BEFORE THE SURGERY. I asked the intern to comment on the report. The total WBC was 25 (very high). The platelet count was above normal.Why? I asked him to comment in his report.


CONCLUSION
It is too early to know whether this dog will survive post-operation as it is only 14 hours post-op. Dogs do die post-op too.

Saturday, December 4, 2010

Two stray cats - caterwaul, spay & nursing

HISTORY
2 stray cats along streets picked up by a young couple who has hamsters too.
Cat 1 - Black & White, Female, around 8 months, 2.6 kg. Vaccinated her as a kitten and so she would be at the correct age.
Cat 2 - Grey striped, Female, around 9 months, 2.9 kg. Signs of one birth based on changes in mammary gland area were seen.

"Both make a lot of noise (caterwaul) for 5 the past 5 days straight before I bring them to you. Want to go out of the apartment!" the young man said to me. "Neighbours do not complain as they have cats too." Bought into surgery on Thursday Dec 2, 2010 at night.


Friday Dec 3, 2010

Spayed by me from around 10 am. Cat 1 done first followed by Cat 2.

ANAESTHESIA by injection
Both given xylazine 2% at 0.15 ml mixed with ketamine 100 at 0.6 ml totalling 0.75 ml in one syringe IM. I noted that Cat 2 received around 0.70 ml IM due to some movement as my assistant did not gripe the scruff of the neck well. Cat 2 was more active.

SURGERY
5-10 minutes after anaesthetic injection.
Cat 1 - excellent surgical anaesthesia.
Cat 2 - was moving even at 10th minute. "She is heavier," my assistant said. Isoflurane gas for one minute by mask at 5% was sufficient to bring her down to surgical anaesthesia. I was able to spay.

UTERINE BODIES & FULL BLADDER
Cat 1 - peed before surgery onto surgical drape. Hooked out the left ovary at 2nd trial.
Cat 2 - bladder full but could not be expressed manually. I did not persist. Just hooked out the ovary. Took several trials as the bladder was obstructing. Uterine body 5 x larger and wider than that of Cat 1. Yellow corpus luteum seen prominently and larger. Why? Took pictures. Both cats not let out of apartment and so would not be pregnant.



















GOES HOME AND HOME NURSING
Owner wanted to take the cats home one hour after surgery. I advised him to let the cat rest in the surgery as they may get choked and die during transport on the way home.

Went home at 8 pm Friday Dec 3, 2010. Both cats at home vomited when they tried to eat. Cat 1 was more groggy. Both were not so active.

Saturday Dec 4, 2010. 11 am. Owner phoned me.
1. Cat 2 was back to normal, but Cat 1 was not so active. Running here and there.
Cat 2 had licked off her plaster. I advised putting on another one or wrap a bandage round her.

2. 2/0 absorbable suture will dissolve. No need to return for stitch removal. Only one skin horizontal mattress suture. Cat 2 may lick it off but owner says she does not bother with the stitch. She started to eat at 11 a.m, but not Cat 1.


FOOD - Dry food from Royal Canin
Wet food from Whiskas
WATER - freely available.

3. Post op antibiotics. Baytril PO x 1 tablet each at 1/4 tab per day for 4 days. I don't advise e-collars in cat spays. Plaster usually sufficient. I use only one suture pack of 2/0 per cat. The muscle cut was closed with just 2 interrupted sutures at 5 mm apart. The skin incision was approx 1.2 cm from umbilical scar. The incision of skin was around 1 cm. I asked the assistant to untie the front legs and lift up front lower half of Cat 1 if I could not hook out the right uterine horn after ligating left ovary. In Cat 2, there was no problem.

DURATION OF SURGERY
I had my assistant record the start and end of surgery. For Cat 1, it was 7 minutes. Smooth and easy. For Cat 2, it took much longer due to full bladder, abdominal fat which I cut off a piece and extra large uterine bodies.

MY ADVICE TO VETS
There is no need to insert another layer of subcutaneous stitching in my over 20 years of spaying cats. However, some vets deem that necessary as the university professors teach this method to close the dead space and prevent haematoma. However, they also stitch the skin incision.

Some cats and dogs do get irritated by this extra S/C layer of stitching and lick the wound vigorously. You will see a red inflamed area in some cases. Simple method is best. Less is best.

It saves time, money (some vets use 2 packets of sutures to spay a cat or a small breed dog) and less painful irritation to the pet. Each vet has his own style. It is hard to change mindsets esp. if University lecturers teach S/C layer to close a spay wound or "concealed" stitching.

As for injectable anaesthesia, xylazine 0.2 ml + ketamine 0.8 ml in one syringe IM is safe for cat spay at 3-5 kg bodyweight. At 2-3 kg, I use xylazine 0.15 ml + ketamine 0.6 ml as in the above two cats. The duration of surgical anaesthesia is sufficient if you start surgery 5-10 minutes after the IM injection and can complete your surgery in 10 minutes as in Cat 1.

Topping up can be done using isoflurane gas at 5% by mask for <60 seconds to effect or by injection of the combination. I don't use the latter method although I have seen it done using small doses e.g. 0.1 ml of the combination. The above applies to Singapore cats. Each country has its own cat sizes and climate and the dosage may vary.

UPDATES are at www.toapayohvets.com

Do you have a muse for a "tai-tai" artist?

Over 30 years of practice, some clients do become good friends of the veterinarian. The "tai tai" artist is one of them. "Tai tai" is a Cantonese term for a woman of leisure and wealth; one who does need to work for a living.

Her children had grown up and are in their 30s and when I first saw them, they were teenagers studying in Secondary Schools. The mum has a natural talent. Her classmates would retain her drawings. She would present her favoured surgeon a present of her painting. She did present me a chalk drawing of a monitor lizard puffed up to fight off an attacking dog for me after I gave her a picture of the scene.

In her house, I always get attracted to a very large painting of a wealthy young girl with bright eyes and adorned with a webbed necklace in a solemn light brown dress and darker brown background. This painting is hung on the wall of the living room.

She had commissioned an experienced old Chinese painter to paint her daughter. To me, this painting appeared to be painted quite fast as her necklace of several connecting precious stones were all painted blurred. Maybe that was purposely so as not to distract the viewer from looking at her bright and distant somewhat sad eyes. I appreciate more realistic portraits of ladies with sharper focused jewellry or dogs as shown in some European paintings.

Mum said to me as I appreciated this painting on the rare occasions I visited her: "The painter drew her hands too long." I did not realise that the hands were unusually long but after her criticism, I improved my observations and knowledge of art appreciation.

Every time I visited, I would ask: "Have you sold any of your paintings?" She would paint many but would not complete many of the oil or acrylic paintings. She does not need to sell paintings for a living and would paint any theme whenever she wants to. That is why I call her a "tai tai" artist.

I approve of her Madonna and Child painting prominently displayed on one side of the living room and asked whether she was selling it.

"My pastor wants me to sell my painting of Madonna and Child," the artist said. "I paid $400 for the frame as it is a good type."

I teased her: "The frame costs more than the painting."

"No, no," she replied in her gentle voice. "I can get $4,000 to $5,000 for this painting if I sell it at the Church through the pastor. Religious paintings of this type are in great demand."

"Really?" I was surprised that a copied painting of the Virgin and Child cost this amount and be able to attract buyers. I am not into religious paintings. I appreciate market place paintings of less developed countries like Myanmar. I have one displayed at Toa Payoh Vets. It was a present from an old friend who bought it from the market in Yangon. It costs around S$100. I don't know whether the artist is well known or not. It seems to represent tribal women from the villages selling their farm produce at the market in the town.




"Your paintings are of no value," I said. "You don't sell them." If an artist does not sell his or her paintings, how does one valuate the worth of their production?

"The pastor said my painting of the Madonna and child can sell for $4,000 to the member of the congregation", she replied. "Of course, the church would expect me to donate some part of the sales proceeds. Such religious paintings sell very well, do you know?"

"If there is such a great demand as you said, why don't entrepreneurs in China and Vietnam have Madonna and Child copied and sell them to churches in Singapore?" I asked.

"Those are scanned copies and will not sell," she said. "They are flat computer scanned images. Paintings done by hand look different."

"There are talented painters in China and Vietnam who can really copy using computer software and then use the real paint to complete the paintings of Madonna and Child," I said. "Surely, they will sell very well in Singapore and make profits for the entrepreneurs."

She did not think so. Professional painters work every day but she might paint once in a blue moon.

"Why are your finger nails greyish?" I asked as I sipped the coffee and biscuits she prepared for me. I hope she was not in poor health as she looked pale. "Oh, these are due to the paint," she said.

Somebody phoned me to get back to the Surgery. I said goodbye. I always encourage her not to copy portraits from the other painters or photographers and use her imagination.

Before I left, we checked her website where painters meet and gave points to one another and commented and criticised each other's paintings.

"I have got 50 points," she showed me her painting image of 4 Indian village women with pots on their head.

"Click to enlarge the thumbnail image," I said.

"I have removed the enlarged image after I got the assessment and points," she said. "This is to prevent others from copying my painting."

I could not see much. It was surprising to me that she was worried that others might copy her painting and sell them. Imitation is the sincerest form of flattery.

Paintings are meant to be enjoyed by others and selling them is one way of growing an artist's reputation. "Famous painters in the past have patrons to support them and commission paintings," I said, after spending some time reading some arts magazines. "Maybe their assistants paint for them as it takes a long time to paint oil and acrylic paintings."

"Don't go into the sale of painting business," the artist advised me. I don't know why she thought I was going to be an arts gallery owner.

Since this artist does not produce many original portraiture and landscape paintings, her artistic talents are wasted. But then, she is a "tai tai" (woman with wealth) and so she can afford the luxury of painting whenever she is in the mood. What she needs is a muse. And muses seem to have flown the coop.



Updates will be at toapayohvets.com

Friday, December 3, 2010

Vomiting and diarrhoea

Vomiting and diarrhoea in dogs may not be a one or two-day cure. Prevention of dehydration using IV saline and treatment with IV antibiotics and drugs are the ideal way to treat such cases. Blood tests were taken in this case. The dog was hospitalised for 3 days. My associate sent the dog home as he had recovered. The next day the distressed owner came back to say that the dog was vomiting. The stools were soft and had white specks (medicine tablets probably). A few spots of blood. So, I got the dog hospitalised and x-rayed. X-ray revealed no big foreign bodies. "Better to hospitalise more than 2 days," I advised my associate vet. "I will bear the responsibility of complaints if the dog dies." Defensive medicine is sometimes necessary.



An X-ray would have to be taken if the dog continues vomiting after 2 days.



If the dog dies and x-rays were not taken, there may be a case of negligence or incompetence. We try to save money for the young lady who was cost-conscious, but sometimes, vomiting can be longer than 3 days and sending the dog home to save on costs may be of good intentions. But in a complaint or litigation, it counts for nothing if the dog has had died and no x-rays had been taken. Blood test did reveal a low platelet count and this could be toxaemia.