Dec 31, 2010. Last day of the year. I was on duty and finished work at 6.40 pm.
Bright sunshine and blue skies while some European and American airports are filled with snow and cold winds.
Traffic Warden. I happened to be in the waiting room and saw a parked golden car with its left side door at the side of the surgery marked: "Chubb and Enforcement". A slim bald man in his late 30s, wearing sunglasses, in white shirt and blue trousers stepped out of the car. I snapped a picture of him. He strode towards my car which was parked beside a fire hydrant as I was to go out soon and it was a shaded lot. I went out of the surgery and apologised to him. I drove my car away and put a parking coupon on my car dashboard. He drove off with his driver. So, it was all clear? Some 15 minutes later, I saw the same car in the same location (round the bend, at the side of the Surgery). The same warden was inside the car and looking at the rearview mirror. I was surprised. It seemed sneaky business. Why not use an unmarked car?
Only yesterday, 2 lady traffic wardens in similar starched white shirt and blue pants but from another private enforcement company (Certos?) were around in the afternoon. I saw them as I was in the waiting room and managed to avoid being booked. They were kind people and forgave me for not displaying a parking coupon. My parking area is one of the last rare lots in Singapore not boxed in by automated barriers and so these private wardens are employed to catch offenders.
Back to some interesting cases
Case 1. PROBLEM SOLVING IS WHAT THE OWNER WANTS
Shih Tzu of 3 months old has 3 eyelid growths in the left eye. Veterinary medicine is full of surprises. I am 60 years old and have seen 30 years of small animal practice. But a puppy with 3 eyelid growths is a rare occurrence. Older dogs do have them but "never" puppies. So, this was a big surprise on the last day of the year.
"I am still searching for a vet," the mother of 4 children said. Her puppy had 3 eyelid growths of around 3 mm x 2 mm. What were they? They exploded during the last 2 weeks. She bought the puppy 4 weeks ago.
"The first vet gave me an eye ointment tube to apply," the young-looking mother in her 40s said. "The growths were still there and I consulted Vet 2. He gave me this Surolan ear drops to apply. Not effective. That is why I am still looking for a vet!"
As the puppy is young and small, weighing around 1.3 kg, the eyelid growths look prominently big. "They look like warts. Give eye drops," my assistant gave his advice to me quietly. "Eye drops will not work," I explained to him. "These are solid growths on the eyelids."
Another merry-go-around with a different brand of eye drops would not do for this first-time puppy owner. "Surgery is needed to excise the 3 growths," I said. "There are no other solutions for this problem."
I knew that the other 2 vets did not want to suggest surgery as a 3-month-old puppy is a very high anaesthetic risk. According to one vet report I read, this is because the liver of the puppy is still immature and unable to clear the anaesthetic drug normally. So, the puppy dies.
You can't excise without anaesthesia as it would be painful and impossible. My assistant produced a anaesthetic consent form as he does for my associate vets. "No need," I usually don't use this form. I usually explain clearly orally the risks involved in any anaesthesia. As the mother was quite stressed out (going to a vet the 3rd time, puppy keeps rubbing the left eye), I did not tell her it would be high risk. If anaesthesia is done carefully, the risk is minimal.
ANAESTHESIA
"What anaesthesia will you use?" I asked my assistant (as part of mentoring process). "Diazepam and Ketamine," he said.
"You don't use two sedatives in the puppy," I advised. "One is already risky."
My assistant said: "Domitor?"
"Zoletil will be the best as it is said to be the safest. In the past I use xylazine with no problems."
So, Zoletil 100 at 0.01 ml with saline was injected IV. Isoflurane gas by mask was given at 5% to effect. "Don't wake till the eyelid reflexes are totally absent," I advised. "The puppy may be dead!".
I used electro-surgery to excise the 3 growths. (Pictures taken). Then 5/0 absorbable sutures to close the wound. E-collar and medication. Problem solved. That is what the owner wants. This is what I learn from my 30 years of experience. The same applies to car owners or other services.
INTERESTING OBSERVATION. I noted that the puppy kept pushing its tongue out and licking its nose, as if yawning, during Zoletil and isoflurane anaesthesia. This happened a few times. Could it be the effect of Zoletil? "Shivering" was the complaint of the owner some 1 hour after surgery. She had bought a puppy coat as the whole puppy had been clipped bald (ringworm infection of one toe and right neck). "This shivering is normal after anaesthesia in some puppies," I said as we put the puppy coat on. "It will go away soon.
Case 2. WILL MY FEMALE DOG BE PREGNANT AFTER SPAYING?
"I feel lucky today," the lady owner in her early 30s said when I told her that there was a small risk of bleeding in spaying a female dog in the middle of heat. Her male Jack Russell dog was pestering the female poodle and she could not sleep the whole night trying to ensure no mating. "The male dog just persists in smelling her backside," the owner explained. She had many questions to ask, like the owner of the Shih Tzu with the eyelid growths.
"No, the dog will not be pregnant after spaying," I assured her. "But the male dog will persist in wanting to mate with her for the next few days." There was no need to neuter the male dog for the time being as she was so desperate to prevent aother pregnancy. The puppies had died due to being stuck and delays in seeking a vet. They were born in Sep 2010. Now, the female had an extremely swollen vulva but no bleeding. "So was she in heat?" the lady asked. "Well, she would be in heat in July 2010. Pregnancy in September would be correct as that would be 2 months. From July, 6 months of interval between heat. Now it is nearly Jan 2011. So that is 6 months and she is definitely on heat."
The female was spayed. Domitor and isoflurane gas. I incised at MG 4 and MG 5 which was too low. I hooked up the two uterine bodies and horn from the 1-cm incision. The whole space was crowded and I had no space to pull out the ovary (which was large at 8 mm long when I saw it later). What to do?
The normal procedure is to extend the incision cranially by another 5 mm. Or I could push back the uterine bodies and hook again. Another solution was to ligate the uterine body first. The uterine blood vessels were 3 mm thick and the dog would bleed to death if they were not properly ligated. So, clamp, transfix ligature below the clamp. Unclamp and ligate again. Then excise uterine stump. Now there was space to pull out the ovaries and ligate once the cranial end by pulling the ovary out more. Check PROPERLY that the ligature was tight before putting the ovary inside the abdomen.
The dog was OK and the owner came later in the evening wanting to bring the dog home. She had no crate and reluctantly accepted my advice to hospitalise the dog for one night as the male dog would be frenzied in looking for the female. She would also have sufficient rest. All should be well by the next day.
Case 3. A cat with a badly infected left eyeball was operated. The eyeball had to be taken out.
Case 4. A woman who wore head scarf and her young adult daughter (studying political science) brought in a fat cat for spaying. She had booked an appointment for the spay at Vet 1 (who had rejected the Golden Retriever neuter case). So, she came to me. She had several stray cats neutered and ear clipped at her own expense.
"Are you sure you spayed her?" she asked me when she saw that the wound was around 8 mm in length. "One vet cut 3 cm long," she extended her thumb and forefinger. "Another did longer than yours."
I assured her that the cat was properly spayed. Each vet has his own method of incision but the owner makes comparisons.
Saturday, January 1, 2011
Friday, December 31, 2010
283. Common problems of the first-time Singapore Landlord
COMMON PROBLEMS OF THE FIRST-TIME SINGAPORE LANDLORD
E-MAIL TO DR SING DEC 31, 2010
Hi Dr Sing,
Thanks for the advice given on your web page (www.asiahomes.com), I am sure it has benefited a lot of people. I hope you can help advise me on my situation.
I am a first time landlord. My agent just told me that my new tenant has decided to break the lease barely 1 month into the contract. The reason being his company is not properly registered here hence he has to return to his home country.
Pls advise:
1. I have already paid the 1 month commission to the agent. Should the agent return me the pro rata commission since the lease has not been fulfilled to 2 years
2. The co-broke agent has been demanding his share of the commission, saying that I have already forfeited the tenant's 2 month's deposit, so he is entitled to it. I feel he does not deserve to be paid since he did not conduct his due diligence on the tenant hence causing unnecessary inconvenience to me.
3. My own agent took the full month's commission and said that I still need to pay commission if she finds me another tenant. All in I have to pay 2 month's commission through no fault of mine. Is this the norm or am I taken for a ride?
4. How do I recover compensation from the tenant? My agent advise me against it citing that it is difficult to do so since the tenant can easily return to his home country. She advises that u let things be and just pay up the commission and look for another tenant and thus incur another commission. I feel she is not acting in my interest.
5. The co broke agent refused to return me the keys, access cards and transponder unless he gets his commission. Does he have a right to? What recourse do I have.
Thank you so much for your time and I hope to hear from you soon.
Regards,
Ms Ang
Sent from my iPhone
In reply, see CAPITAL LETTERS BELOW
On Thu, Dec 30, 2010 at 7:59 PM, Orange Whale wrote:
Hi Dr Sing,
Thanks for the advice given on your web page, I am sure it has benefited a lot of people. I hope you can help advise me on my situation.
I am a first time landlord. My agent just told me that my new tenant has decided to break the lease barely 1 month into the contract. The reason being his company is not properly registered here hence he has to return to his home country.
Pls advise:
1. I have already paid the 1 month commission to the agent. Should the agent return me the pro rata commission since the lease has not been fulfilled to 2 years
THIS DEPENDS ON THE TERMS AND CONDITIONS OF THE COMMISSION AGREEMENT. I PRESUME YOU HAVE ONE. IF NOT, MUCH DEPENDS ON NEGOTIATION.
2. The co-broke agent has been demanding his share of the commission, saying that I have already forfeited the tenant's 2 month's deposit, so he is entitled to it. I feel he does not deserve to be paid since he did not conduct his due diligence on the tenant hence causing unnecessary inconvenience to me.
CO-BROKE AGENT? IS HE YOUR AGENT OR NOT? NORMALLY A LANDLORD HAS ONLY ONE AGENT TO ACT FOR HIM.
3. My own agent took the full month's commission and said that I still need to pay commission if she finds me another tenant. All in I have to pay 2 month's commission through no fault of mine. Is this the norm or am I taken for a ride?
IN REAL ESTATE, MUCH DEPENDS ON THE WRITTEN COMMISSION AGREEMENT OR CONTRACT OF REAL ESTATE. IN SOME AGREEMENTS, THE LANDLORD GETS BACK THE AGENCY COMMISSION PRO-RATED IF THE TENANCY IS TERMINATED PREMATURELY. IN OTHERS, NOTHING IS STATED AND THIS IS WHERE THE LANDLORD HAS PROBLEMS.
4. How do I recover compensation from the tenant? My agent advise me against it citing that it is difficult to do so since the tenant can easily return to his home country.
YOU NEED A GOOD LAWYER TO ACT FOR YOU FOR BREACH OF TENANCY AGREEMENT. IF THE TENANT RETURNS HOME, YOUR LAWYER CAN STILL SUE HIM ON YOUR BEHALF VIA THE COUNTRY'S LAWYER.
IF THE TENANT IS LEAVING THE COUNTRY, HE CAN PROVIDE DOCUMENTARY PROOF.
She advises that u let things be and just pay up the commission and look for another tenant and thus incur another commission. I feel she is not acting in my interest.
THE CEA (COUNCIL OF ESTATE AGENTS) HAS JUST BEEN FORMED IN NOV 2010 TO ADDRESS YOUR CONCERNS AND COMPLAINTS AGAINST THE PRACTICE OF HOUSING AGENTS. YOU MAY WISH TO CONTACT CEA AT 5TH FLOOR HDB HUB.
5. The co broke agent refused to return me the keys, access cards and transponder unless he gets his commission. Does he have a right to? What recourse do I have.
IS THERE A COMMISSION AGREEMENT YOU SIGNED WITH THE CO-BROKE AGENT? HAVE YOU BREACHED THE TERMS AND CONDITIONS OF THIS AGREEMENT? YOU CAN SEEK ADVICE FROM HIS HOUSING AGENCY AND/OR CONTACT THE CEA.
Thank you so much for your time and I hope to hear from you soon.
IN YOUR SITUATION, THE TENANCY AGREEMENT HAS BEEN SIGNED AND THEREFORE THE AGENTS HAVE COMPLETED THEIR TASKS. AS TO THE RETURN OF AGENCY COMMISSION ON A PRO-RATED BASIS, MUCH DEPENDS ON THE TERMS AND CONDITIONS OF THE COMMISSION AGREEMENT.
YOUR RECOVERY OF 2 MONTHS' RENTAL DEPOSIT FROM THE TENANT IS FOR BREACH OF TENANCY AGREEMENT.
THEREFORE THIS MATTER OF LOSS OF RENTAL INCOME AS CONTRASTED TO NOT PAYING THE CO-BROKE AGENT AND RECOVERY OF PRO-RATED COMMISSION FROM THE MAIN AGENT IS A SEPARATE ISSUE AS THERE ARE TWO SEPARATE CONTRACTS (tenancy agreement and commission payment agreement). If you agree to pay commission on securing of the tenancy (signing of the tenancy agreement) and have not stated on return of pro-rated commission on premature termination of the tenancy agreement, you will need to consider whether you need a lawyer to act for you. I am not a lawyer and so the above is free advice. I will advise you consult a good lawyer to act for you. Best wishes.
The written contract is usually the main document which the lawyers and judges will refer to.
E-MAIL TO DR SING DEC 31, 2010
Hi Dr Sing,
Thanks for the advice given on your web page (www.asiahomes.com), I am sure it has benefited a lot of people. I hope you can help advise me on my situation.
I am a first time landlord. My agent just told me that my new tenant has decided to break the lease barely 1 month into the contract. The reason being his company is not properly registered here hence he has to return to his home country.
Pls advise:
1. I have already paid the 1 month commission to the agent. Should the agent return me the pro rata commission since the lease has not been fulfilled to 2 years
2. The co-broke agent has been demanding his share of the commission, saying that I have already forfeited the tenant's 2 month's deposit, so he is entitled to it. I feel he does not deserve to be paid since he did not conduct his due diligence on the tenant hence causing unnecessary inconvenience to me.
3. My own agent took the full month's commission and said that I still need to pay commission if she finds me another tenant. All in I have to pay 2 month's commission through no fault of mine. Is this the norm or am I taken for a ride?
4. How do I recover compensation from the tenant? My agent advise me against it citing that it is difficult to do so since the tenant can easily return to his home country. She advises that u let things be and just pay up the commission and look for another tenant and thus incur another commission. I feel she is not acting in my interest.
5. The co broke agent refused to return me the keys, access cards and transponder unless he gets his commission. Does he have a right to? What recourse do I have.
Thank you so much for your time and I hope to hear from you soon.
Regards,
Ms Ang
Sent from my iPhone
In reply, see CAPITAL LETTERS BELOW
On Thu, Dec 30, 2010 at 7:59 PM, Orange Whale
Hi Dr Sing,
Thanks for the advice given on your web page, I am sure it has benefited a lot of people. I hope you can help advise me on my situation.
I am a first time landlord. My agent just told me that my new tenant has decided to break the lease barely 1 month into the contract. The reason being his company is not properly registered here hence he has to return to his home country.
Pls advise:
1. I have already paid the 1 month commission to the agent. Should the agent return me the pro rata commission since the lease has not been fulfilled to 2 years
THIS DEPENDS ON THE TERMS AND CONDITIONS OF THE COMMISSION AGREEMENT. I PRESUME YOU HAVE ONE. IF NOT, MUCH DEPENDS ON NEGOTIATION.
2. The co-broke agent has been demanding his share of the commission, saying that I have already forfeited the tenant's 2 month's deposit, so he is entitled to it. I feel he does not deserve to be paid since he did not conduct his due diligence on the tenant hence causing unnecessary inconvenience to me.
CO-BROKE AGENT? IS HE YOUR AGENT OR NOT? NORMALLY A LANDLORD HAS ONLY ONE AGENT TO ACT FOR HIM.
3. My own agent took the full month's commission and said that I still need to pay commission if she finds me another tenant. All in I have to pay 2 month's commission through no fault of mine. Is this the norm or am I taken for a ride?
IN REAL ESTATE, MUCH DEPENDS ON THE WRITTEN COMMISSION AGREEMENT OR CONTRACT OF REAL ESTATE. IN SOME AGREEMENTS, THE LANDLORD GETS BACK THE AGENCY COMMISSION PRO-RATED IF THE TENANCY IS TERMINATED PREMATURELY. IN OTHERS, NOTHING IS STATED AND THIS IS WHERE THE LANDLORD HAS PROBLEMS.
4. How do I recover compensation from the tenant? My agent advise me against it citing that it is difficult to do so since the tenant can easily return to his home country.
YOU NEED A GOOD LAWYER TO ACT FOR YOU FOR BREACH OF TENANCY AGREEMENT. IF THE TENANT RETURNS HOME, YOUR LAWYER CAN STILL SUE HIM ON YOUR BEHALF VIA THE COUNTRY'S LAWYER.
IF THE TENANT IS LEAVING THE COUNTRY, HE CAN PROVIDE DOCUMENTARY PROOF.
She advises that u let things be and just pay up the commission and look for another tenant and thus incur another commission. I feel she is not acting in my interest.
THE CEA (COUNCIL OF ESTATE AGENTS) HAS JUST BEEN FORMED IN NOV 2010 TO ADDRESS YOUR CONCERNS AND COMPLAINTS AGAINST THE PRACTICE OF HOUSING AGENTS. YOU MAY WISH TO CONTACT CEA AT 5TH FLOOR HDB HUB.
5. The co broke agent refused to return me the keys, access cards and transponder unless he gets his commission. Does he have a right to? What recourse do I have.
IS THERE A COMMISSION AGREEMENT YOU SIGNED WITH THE CO-BROKE AGENT? HAVE YOU BREACHED THE TERMS AND CONDITIONS OF THIS AGREEMENT? YOU CAN SEEK ADVICE FROM HIS HOUSING AGENCY AND/OR CONTACT THE CEA.
Thank you so much for your time and I hope to hear from you soon.
IN YOUR SITUATION, THE TENANCY AGREEMENT HAS BEEN SIGNED AND THEREFORE THE AGENTS HAVE COMPLETED THEIR TASKS. AS TO THE RETURN OF AGENCY COMMISSION ON A PRO-RATED BASIS, MUCH DEPENDS ON THE TERMS AND CONDITIONS OF THE COMMISSION AGREEMENT.
YOUR RECOVERY OF 2 MONTHS' RENTAL DEPOSIT FROM THE TENANT IS FOR BREACH OF TENANCY AGREEMENT.
THEREFORE THIS MATTER OF LOSS OF RENTAL INCOME AS CONTRASTED TO NOT PAYING THE CO-BROKE AGENT AND RECOVERY OF PRO-RATED COMMISSION FROM THE MAIN AGENT IS A SEPARATE ISSUE AS THERE ARE TWO SEPARATE CONTRACTS (tenancy agreement and commission payment agreement). If you agree to pay commission on securing of the tenancy (signing of the tenancy agreement) and have not stated on return of pro-rated commission on premature termination of the tenancy agreement, you will need to consider whether you need a lawyer to act for you. I am not a lawyer and so the above is free advice. I will advise you consult a good lawyer to act for you. Best wishes.
The written contract is usually the main document which the lawyers and judges will refer to.
282. Neutering big breeds and fluroescein dye in eye ulcers
Dec 30, 2010
INTERESTING CASES
2nd last day of 2010. Today was the low season (as in tourism) as I had only a handful of cases. But I could spend more time with each individual and this is the best part of veterinary medicine. If the vet has 40 cases a day, it is not possible to get to know the clients well since the waiting queues and dogs barking at each other in the very small reception room would be harassing.
Case 1. Neutering of big breeds
A young man in his 30s came with a big breed for neutering. He had been to the Surgery before. Since there are now over 40 veterinary practices in Singapore and the practice of vet-hopping is common and he lived in Changi which is a 30-minute drive to Toa Payoh Vets, I expected him to choose a vet based on proximity, not on reputation or skills. Therefore asked him: "You have several practices closer to your residence. Why do you come so far away to neuter your Golden Retriever?"
"Actually I phoned up Vet 1 (which is an established practice nearer to his residence than mine). The girl said that the practice does not neuter big breeds. So I come here."
I was surprised as I thought all vets in Singapore neuter all dogs irrespective of size. Neutering is a most common surgery in veterinary practices all over the world. Well, life is full of surprises and changes.
As to why Vet 1 does not neuter big dogs, I can only hazard a guess based on my observations and said to the young entrepreneur: "In big dogs, the bleeding complications after surgery can be very distressing. The scrotal sac swells to as big as a tennis ball if there is bleeding. Some dogs bite and lick the operation area vigorously and this is one cause of bleeding. The profuse bleeding leads to a lot of blood inside the scrotum and the owner becomes worried when they see it becoming a huge tennis ball." Big dogs seldom wear e-collars to prevent licking as some owners don't want it. E-collars should be worn for the first 48 hours but big dogs and owners don't like it. The dog finds it difficult to eat and drink properly. However, I have cases where e-collars do not prevent self-trauma licking and injury of the operation site. In such cases, pain-killers may not be effective or the dog is highly sensitive and clean.
In this case, I share with the vet students my surgical approach to get a good outcome of no post-operation trauma of the surgical site after neutering.
ANAESTHESIA. Golden Retriever, Male, 3 years
Domitor 0.3 ml IV. Wait 5 minutes. Isoflurane gas 2-3% maintenance. Intubated. Excellent surgical anaesthesia.
SURGERY. 2-cm incision in skin above scrotal area. (Some vets in Singapore incise the scrotal area apparently according to one of my clients). I took out one testicle. Then I clamp the tunica as a whole sheath enclosing the spermatic cord and blood vessels. 3 forceps are used to clamp.
TRANSFIXING LIGATURE. Below the lowest clamp (3rd forceps), I inserted the suture needle (2/0 absorbable) into the sheath away from the blood vessels. Then I ligate the blood vessel end. After that I ligate the opposite end.
DOUBLE LIGATURE. Then I release the clamp. I wrap one suture round the clamped area of the sheath and ligate. In this area, the suture is unlikely to slip. In any case, I knot on one side. Then I knot again on the other side.
I cut off the sheath between the lst and 2nd forceps. Push back the sheath into the inguinal canal. Checked for bleeding. There was none. I repeated the procedure on the other testicle.
SKIN INCISION. I put in 2 horizontal mattress sutures using the same 2/0 absorbable suture. There was profuse bleeding from the skin. This is quite common and not serious. I put on plaster to stop the bleeding which will be obvious.
POST-OP PAIN-KILLERS AND ANTIBIOTICS. Tolfedine and Baytril are given SC based on 10 kg post-surgery. The dog was OK. There was no need to give Anti-sedan to reverse the Domitor as the dog woke up after 10 minutes since I had reduced isoflurane gas go zero in the last 3 minutes before completion.
5 HOURS AFTER SURGERY. INSPECTION BEFORE GOING HOME. The owner and his wife came. The dog wagged his tail. There was no pain and he did not lick the area since tolfedine was effective. The owner rejected the e-collar. So I advised him to give tolfedine tablets 12 hours later (the next morning) and therefore for 7 days at one dosage per day. Antibiotics were prescribed. There ought to be no problem.
STITCH REMOVAL 10 DAYS LATER ADVISED. The owner was advised to wash the operation area and thigh with warm water as there was some blood stains.
TEETH SCALING AFTER NEUTERING. Some tartar in the back teeth. Teeth scaling was $100. This was a big discount to $250 since the dog was already under anaesthesia for neutering. Tooth brushing will prevent tartar formation.
This was a very friendly Golden Retriever. I took some pictures of him and tried a close up picture of his eye with my 18-55 mm lens. It was a most happy outcome for everybody as the dog appeared normal and happy.
Case 2. Shih Tzu with left eye corneal ulcer (generalised superficial keratitis).
"Vet 1 said that my dog must use artificial tears as my dog has dry eyes. She used a green dye on the eye and said it had dry eyes and conjunctivitis," two young ladies presented their Shih Tzu with a red left eye. Her father was present with her. The left eye was cloudy while the sclera was intensely red. It is unusual for a young dog to have dry eyes as this was what the young ladies reported as to what Vet 1 had said. However they had no medical report from Vet 1 with them and I did not want to go into the hassle of phoning Vet 1 to ask for medical records. Some vets would do it.
A simple eye examination would be practical and even if the dog had dry eyes, it would be possible and that would be some time ago. In any case, it had no dry eyes now. I asked: "How long has this left eye been so red?"
"Only 1 week." the older sister said.
I shone the torchlight on the eye. The cornea was cloudy for around 70% of the area esp. on the top half. I asked my assistant Mr Saw to put the fluorescein strip into the eye as part of my mentorship. He would be returning to Myanmar in 2011 to be involved in a new practice and as he has been working for me for 3 years, I wish him well and am sure he would be a better vet in Yangon after 3 hard years in Toa Payoh Vets.
Mr Saw came into the room and went to take a syringe, filled it with saline and squirted some onto the eye. Then he applied the fluorescein strip onto the eye. I was puzzled as why he did it this way. He had seen me doing it the direct way and here, he did it another way*.
The fluorescein strip started to disperse green dye onto the eye. However, the greenish was not so obvious as the saline squirted onto the eye was making the stain less green. In any case, the owners could see that the top half of the cornea was greenish, indicating ulcerations. I advised stitching up the eyelid for 7-10 days to enable ease of healing of the cornea which had been exposed to sunlight and wind and caused the dog to rub the left eye till it was red.
Domitor 0.1 ml IV was given. Isoflurane gas. The eyelids were stitched up. The dog went home. Eye ointment to be applied. Stitches should come out by itself in 7-14 days and there ought to be a good outcome. "Eye injuries are emergencies," I advised. "They should be treated within 24 hours of injury. The Shih Tzu commonly gets eye injuries. Sometimes it is the prominent nasal fold's hairs irritating the eyes," I said as I showed the illustration from the Ophthalmology book. "How much it costs for the surgery?" the father asked about the stitching of the eyelids. "Around $250." He was agreeable.
P.S. *I asked Mr Saw later as I showed him the direct way. He said this was what my associate vet did and therefore he did it. Mr Saw's friend came to visit, saw the faint green dye and said: "Nothing serious with the eye ulcer, no need to do surgery to stitch up the eye lids." This was his opinion as he clipped the dog bald including the eye area for my surgery.
During anaesthesia, I re-applied the strip directly onto the eye and this time, Mr Saw could see the intense green covering more than 50%of the cornea. The ulcers were obvious now since the green dye sticks onto the pitted cornea from 9 o'clock to 4 o'clock of the cornea mainly. I took a picture for record and educational purposes. "Show rather than tell" is the most effective way to mentor a person.
Life is full of surprises and changes. I told Mr Saw that the best way is to apply the fluorescein strip under the upper eye lid and there was no need of saline flushing first. I don't know whether he will remember but hands-on experience is the best way to learn. Nobody is perfect but sometimes I expect perfection in my veterinary assistants of procedures they have had seen done successfully. However, there are other ways to do a procedure in veterinary surgery and sometimes a new way is much better. So, it is hard to say that my way is the correct way and be narrow-minded.
INTERESTING CASES
2nd last day of 2010. Today was the low season (as in tourism) as I had only a handful of cases. But I could spend more time with each individual and this is the best part of veterinary medicine. If the vet has 40 cases a day, it is not possible to get to know the clients well since the waiting queues and dogs barking at each other in the very small reception room would be harassing.
Case 1. Neutering of big breeds
A young man in his 30s came with a big breed for neutering. He had been to the Surgery before. Since there are now over 40 veterinary practices in Singapore and the practice of vet-hopping is common and he lived in Changi which is a 30-minute drive to Toa Payoh Vets, I expected him to choose a vet based on proximity, not on reputation or skills. Therefore asked him: "You have several practices closer to your residence. Why do you come so far away to neuter your Golden Retriever?"
"Actually I phoned up Vet 1 (which is an established practice nearer to his residence than mine). The girl said that the practice does not neuter big breeds. So I come here."
I was surprised as I thought all vets in Singapore neuter all dogs irrespective of size. Neutering is a most common surgery in veterinary practices all over the world. Well, life is full of surprises and changes.
As to why Vet 1 does not neuter big dogs, I can only hazard a guess based on my observations and said to the young entrepreneur: "In big dogs, the bleeding complications after surgery can be very distressing. The scrotal sac swells to as big as a tennis ball if there is bleeding. Some dogs bite and lick the operation area vigorously and this is one cause of bleeding. The profuse bleeding leads to a lot of blood inside the scrotum and the owner becomes worried when they see it becoming a huge tennis ball." Big dogs seldom wear e-collars to prevent licking as some owners don't want it. E-collars should be worn for the first 48 hours but big dogs and owners don't like it. The dog finds it difficult to eat and drink properly. However, I have cases where e-collars do not prevent self-trauma licking and injury of the operation site. In such cases, pain-killers may not be effective or the dog is highly sensitive and clean.
In this case, I share with the vet students my surgical approach to get a good outcome of no post-operation trauma of the surgical site after neutering.
ANAESTHESIA. Golden Retriever, Male, 3 years
Domitor 0.3 ml IV. Wait 5 minutes. Isoflurane gas 2-3% maintenance. Intubated. Excellent surgical anaesthesia.
SURGERY. 2-cm incision in skin above scrotal area. (Some vets in Singapore incise the scrotal area apparently according to one of my clients). I took out one testicle. Then I clamp the tunica as a whole sheath enclosing the spermatic cord and blood vessels. 3 forceps are used to clamp.
TRANSFIXING LIGATURE. Below the lowest clamp (3rd forceps), I inserted the suture needle (2/0 absorbable) into the sheath away from the blood vessels. Then I ligate the blood vessel end. After that I ligate the opposite end.
DOUBLE LIGATURE. Then I release the clamp. I wrap one suture round the clamped area of the sheath and ligate. In this area, the suture is unlikely to slip. In any case, I knot on one side. Then I knot again on the other side.
I cut off the sheath between the lst and 2nd forceps. Push back the sheath into the inguinal canal. Checked for bleeding. There was none. I repeated the procedure on the other testicle.
SKIN INCISION. I put in 2 horizontal mattress sutures using the same 2/0 absorbable suture. There was profuse bleeding from the skin. This is quite common and not serious. I put on plaster to stop the bleeding which will be obvious.
POST-OP PAIN-KILLERS AND ANTIBIOTICS. Tolfedine and Baytril are given SC based on 10 kg post-surgery. The dog was OK. There was no need to give Anti-sedan to reverse the Domitor as the dog woke up after 10 minutes since I had reduced isoflurane gas go zero in the last 3 minutes before completion.
5 HOURS AFTER SURGERY. INSPECTION BEFORE GOING HOME. The owner and his wife came. The dog wagged his tail. There was no pain and he did not lick the area since tolfedine was effective. The owner rejected the e-collar. So I advised him to give tolfedine tablets 12 hours later (the next morning) and therefore for 7 days at one dosage per day. Antibiotics were prescribed. There ought to be no problem.
STITCH REMOVAL 10 DAYS LATER ADVISED. The owner was advised to wash the operation area and thigh with warm water as there was some blood stains.
TEETH SCALING AFTER NEUTERING. Some tartar in the back teeth. Teeth scaling was $100. This was a big discount to $250 since the dog was already under anaesthesia for neutering. Tooth brushing will prevent tartar formation.
This was a very friendly Golden Retriever. I took some pictures of him and tried a close up picture of his eye with my 18-55 mm lens. It was a most happy outcome for everybody as the dog appeared normal and happy.
Case 2. Shih Tzu with left eye corneal ulcer (generalised superficial keratitis).
"Vet 1 said that my dog must use artificial tears as my dog has dry eyes. She used a green dye on the eye and said it had dry eyes and conjunctivitis," two young ladies presented their Shih Tzu with a red left eye. Her father was present with her. The left eye was cloudy while the sclera was intensely red. It is unusual for a young dog to have dry eyes as this was what the young ladies reported as to what Vet 1 had said. However they had no medical report from Vet 1 with them and I did not want to go into the hassle of phoning Vet 1 to ask for medical records. Some vets would do it.
A simple eye examination would be practical and even if the dog had dry eyes, it would be possible and that would be some time ago. In any case, it had no dry eyes now. I asked: "How long has this left eye been so red?"
"Only 1 week." the older sister said.
I shone the torchlight on the eye. The cornea was cloudy for around 70% of the area esp. on the top half. I asked my assistant Mr Saw to put the fluorescein strip into the eye as part of my mentorship. He would be returning to Myanmar in 2011 to be involved in a new practice and as he has been working for me for 3 years, I wish him well and am sure he would be a better vet in Yangon after 3 hard years in Toa Payoh Vets.
Mr Saw came into the room and went to take a syringe, filled it with saline and squirted some onto the eye. Then he applied the fluorescein strip onto the eye. I was puzzled as why he did it this way. He had seen me doing it the direct way and here, he did it another way*.
The fluorescein strip started to disperse green dye onto the eye. However, the greenish was not so obvious as the saline squirted onto the eye was making the stain less green. In any case, the owners could see that the top half of the cornea was greenish, indicating ulcerations. I advised stitching up the eyelid for 7-10 days to enable ease of healing of the cornea which had been exposed to sunlight and wind and caused the dog to rub the left eye till it was red.
Domitor 0.1 ml IV was given. Isoflurane gas. The eyelids were stitched up. The dog went home. Eye ointment to be applied. Stitches should come out by itself in 7-14 days and there ought to be a good outcome. "Eye injuries are emergencies," I advised. "They should be treated within 24 hours of injury. The Shih Tzu commonly gets eye injuries. Sometimes it is the prominent nasal fold's hairs irritating the eyes," I said as I showed the illustration from the Ophthalmology book. "How much it costs for the surgery?" the father asked about the stitching of the eyelids. "Around $250." He was agreeable.
P.S. *I asked Mr Saw later as I showed him the direct way. He said this was what my associate vet did and therefore he did it. Mr Saw's friend came to visit, saw the faint green dye and said: "Nothing serious with the eye ulcer, no need to do surgery to stitch up the eye lids." This was his opinion as he clipped the dog bald including the eye area for my surgery.
During anaesthesia, I re-applied the strip directly onto the eye and this time, Mr Saw could see the intense green covering more than 50%of the cornea. The ulcers were obvious now since the green dye sticks onto the pitted cornea from 9 o'clock to 4 o'clock of the cornea mainly. I took a picture for record and educational purposes. "Show rather than tell" is the most effective way to mentor a person.
Life is full of surprises and changes. I told Mr Saw that the best way is to apply the fluorescein strip under the upper eye lid and there was no need of saline flushing first. I don't know whether he will remember but hands-on experience is the best way to learn. Nobody is perfect but sometimes I expect perfection in my veterinary assistants of procedures they have had seen done successfully. However, there are other ways to do a procedure in veterinary surgery and sometimes a new way is much better. So, it is hard to say that my way is the correct way and be narrow-minded.
Thursday, December 30, 2010
281. Ear problems and Injectable anaesthesia - xylazine & diazepam IV
Dec 29, 2010
I was on duty as Dr Vanessa Lin went on leave for the next 10 days. This was the 2nd day of work since I came back from the holidays. I thought it would be a quiet Wednesday and brought my laptop to do some writing and scheduled a house-call to micro-chip and vaccinate some dogs at Pets Zone in Dunearn Road at 4 pm. But it was a hectic day from 10 am to 8 p.m, with one-hour break at lunch-time. The cases were the usual ones of neutering and spaying, dental scaling, skin diseases, ear problems, eye infections in two stray kittens. Some interesting cases are as follows:
1. Animal activism in Singapore. A young lady wanted to know how much it would cost to hospitalise two stray kittens with flu for a few days while she looked for new homes for them. Her father would kill her if she brought these kittens home as she already had several. She was looking for the least cost veterinary care and dictating that the kittens should not be given antibiotics. This is a common situation encountered at all vet clinics. There is insufficient space at Toa Payoh Vets which is a small surgery of 60 sq metres. I do help a few stray cat cases but there is a limit in charitable work. A practice has high overheads although it does not look obvious to the average pet owner in Singapore. In this case of cat flu, home nursing would be best. I advised her to nurse the kittens herself as it would be better for the kittens.
2. Animal activism in Yangon. An old friend started to help homeless dogs and cats in a place in Yangon. This is his personal thing as he could better spend his time and skill earning more money in the IT field. However, the residents there wanted US$20,000 from him if he wanted to continue his mission. I had advised him of the risks of doing animal activism overseas as politics would become dominant. This happens even in Singapore, as cat welfare people tried in vain to get the Singapore Government to permit cat ownership for the average person living in HDB apartments.
From this incident, you can see that it is difficult for a Singaporean animal activist going across borders to help change the world unless he has powerful political connections. Politics and economics interact in animal activism and business. Such are the facts of life.
3. Ear problems. One dog had red ear flaps for many weeks. I did a microscopic examination of the hairs. It was ringworm. "A follow-up one month later is important," I said to the owner. Some owners blame the vet for not resolving their problem when they don't follow up but went to another vet.
4. Injectable anaesthesia. The following is one of many metods of injectable anaesthesia used safely in practices and countries with no access to isoflurane gas anaesthesia, unlike fortunate Singaporean pet owners where the best anaesthetic drugs are available for pets.
I am sharing this knowledge with vets working in such locations. The above dosage is a general guideline. An IV catheter is inserted so that top up injections can be given IV should the dog need more anaesthesia. For a 10-kg dog, the dosage of diazepam and ketamine in one syringe are respectively 0.4 ml + 0.4 ml IV.
Case 1. At 50% of the above dosage, ie. 0.2 ml diazepam + 0.2 ml ketamine in one syringe IV for a 10-kg mixed breed dog, the dog shows signs of head shaking sideways and salivation. It was not under surgical anaesthesia. I top up with 5% isoflurane gas by mask for a minute or two to effect and this provided excellent anaesthesia for neutering.
Case 2. At 100% of the above dosage, the dog's body muscles were tense. The dog's neck and legs were flexed. The eyes were open and the pupils dilated. However, dental scaling was done without pain or the need for top up.
CONCLUSION. Each vet has his own preferences in anaesthesia. As long as it is safe for the dog, injectable anaesthesia offers a cheaper alternative to isoflurane gas. The anaesthetic machine and isoflurance are expensive compared to the injectable anaesthetics. In an effort to lower veterinary costs, injectable anaesthetics are used. As for me, I prefer to use xylazine (or domitor) sedation and isoflurane gas anaesthesia as I find that the dog sleeps relaxed (not with tense muscles as in the diazepam and ketamine injectable anaesthesia) and surgery can be done smoothly without the need for topping up as the dog struggles when pain is experienced.
ECONOMICS OF PRACTICE. Each vet does what he prefers as long as the dog is safe and alive at the end of the day. I am just sharing my observations to benefit vets who may not have access to isoflurane facilities as not the isoflurane gas machine purchase cost and maintenance are very expensive. There are more less sophisticated pet owners who just want "cheap" veterinary anaesthesia and surgery and a veterinary practice needs to sustain its profitability to be around the next year. So, there is a need to reduce veterinary costs, sometimes performing loss-making surgeries!
INTERESTING CASE OF BLACK EAR DISCHARGE
"The (pet shop owner's son) was not in a good mood and so I talked to the counter staff," the matronly woman had brought the 7-month-old female salt and pepper Miniature Schnauzer in for his 3rd vaccination. Toa Payoh Vets had given the puppy 2 vaccinations earlier. She paid $350 for the dog which I thought was too cheap as it had such good physical characteristics. But older dogs are difficult to sell and only puppies fetch a premium price in Singapore.
"The young man may be having some personal problem," I said as the husband wanted the wife to complain that she was sold a dog with black ear discharge. "His father had died while delivering dog food and crashing his van. The hospital doctor did not diagnose that he had a head injury and sent him home. What ear drops have you been using to clean the dog's ears?"
"I use eucalyptus oil for the past few days," the lady said. "The next day, the black ear discharge appears again."
"This is is a good looking dog and you had got it at a cheap price," I could appreciate a Schnauzer with good conformation. A good sized head, proportionate body length and not too long legs. Not too bulky as Singaporeans prefer this type of size although dog show people will consider this dog under-sized. Female dogs of this size and shape are more valuable for breeders as there is a demand for "miniature" Miniature Schnauzers.
I took a cotton bud and spread some ear discharge on a slide and put it under the microscope but saw no mites. "You must have drowned all mites with oil," I said. "Not a mite can be seen."
What caused the blackness and the black particles inside the two ears? As black as black shoe polish. Ear discharge comes in all colours but pure black is rarely seen by me in practice over 40 years. It was as if the ear drops of oil were black in colour. I did not ask the owner the colour of the ear drops as it was an extremely hectic day and I still had not done the 3rd spay of the 3rd stray cat.
The owner who loves his 3 stray cats had brought in the 3rd one for spaying today. Yesterday, he got two in and I had neutered and spayed them. The 3rd one was "fierce" and was put inside a cardboard box, taped up but with gaps for the cat to breathe. It was as if he had a tiger inside the box and so we did not dare open the box and transfer the cat to the crate for the time being. The minutes ticked by and the whole afternoon had gone and still I had no time to spay this cat.
Spending time with the owner is essential in practice building but the other owners at the waiting room disliked waiting too long unfortunately. Some owners want fast service. I could see that the Schnauzer lady's husband was all ready to go to work. But he was the patient type who would wait for his wife to get the dog vaccinated. That was all she came for and vaccination should be fast. But for the black ear discharge, the dog would leave in 5 minutes.
I got the ears irrigated and taught the owner how to use the medicated ear drops. The best would be another ear irrigation the next day but I could sense that the husband was an extremely busy man but his wife mentioned about him working in an important post in a volunteer organisation. "You work for the famous Red Cross," I said to him as I was thinking of the excellent volunteerism and time it had done for so many unfortunate people in countries all over the world.
"The infamous Red Cross," he laughed. Yes, there was a newspaper report about some loss of money taken by a staff in the Singapore branch but I was not thinking of this matter. There will always be staff who steals money from the organisation all over the world.
In one case of a famous cosmetic surgeon in Singapore, I was shocked to read in the newspaper that he did not print his own receipt books. He bought commercial ones. So, he had 3 copies. The white for the client, the blue for audit and the yellow for the case file. Now, his billing staff found a way to milk him of over $100,000. She would buy another set of books. When she billed the client, she would give the client the white copy with say $1,000 and collected $1,000. Then she would write, say $500 on the blue and yellow copy from her own purchased set and discard the original blue and yellow copies of the surgeon's book. She could also under-declare the income by replacing the yellow or blue copies.
"How was she caught?" my wife asked me yesterday when I told her that the famous surgeon did not print his own receipt books which I found it hard to believe if not for this case in court.
"Well, another staff discovered that the blueness of the blue receipt was not similar to the blueness of the other receipts." But over $100,000 had been misappropriated and this sacked staff complained that the surgeon had not granted her medical leave.
I digressed. Back to the Schnauzer's black ears. The husband seemed appreciative when I asked the wife to use the medicated ear drops herself to clean the ears for the next 7 days and if the black discharge disappear, then there was no need to consult me.
This was one of the 4 interesting ear problems. The other one was the fiery red inside ear flap caused by ringworm infestation in both ears mentioned above. The 3rd one in a young cat with thick reddish black waxy ear discharge was even more interesting in the sense that I managed to find one dead ear mite under the microscope when I did an ear discharge examination.
"See the mite," I asked the young lady to peer into the microscope. "There is only one." The mite with a round body and six short legs in the front half was clearly visible and sharp under my newly purchased microscope. "Where's the mite," the lady asked. She was not into biology I presumed. I took out the Hill's Atlas of Clinical History and showed her the drawings. Maybe I should produce one myself. "See the book drawing of the mite," I showed her the cat and ear mite drawings inside the book. "What's the name of this ear mite in the cat?" I asked Mr Saw, my assistant who is qualified as a vet in Myanmar and would be returning home in April 2011. The book did not mention any name. Mr Saw shook his head. "It would be Otodectes cyanotis," I said. It was Greek to him and to all vet students. I got the ears irrigated and gave an anti-mite ivermectin injection. Follow up would be good.
It is 7.25 am and I have to get ready for work. The 4th ear case was one in which the young man's cotton tip fell into the dog's right ear canal while cleaning. The Pomeranian would bite when he tried to retrieve it deep inside the ear canal. "Surprisingly my dog did not shake his head. I would rather get it removed before it infects the ear. How long will it take?"
"That depends on whether the dog needs to be sedated," I said. I got the dog inside the surgery, muzzled it and Mr Saw held the dog properly. Mr Saw had wanted the ear scope to check out the ears. "No point in doing it," I said. "The ear scope will push the cotton bud deeper into the ear." Sometimes we have to visualise the impact of a particular procedure.
In theory, all ear examinations must be scoped. Sometimes it could even be considered negligent not to scope the ears as a routine. In practice, the dog owner had already given us the history that his cotton tip had dropped inside the right ear. Using an ear scope would push the cotton into the horizontal canal and that would be very difficult to extract.
I inserted a slim curved artery forceps into the right ear vertical canal to the base, open and clamp. Fortunately I got the cotton bud out at the first clamp. I showed the bud to the owner who was quite pleased. "It's time I buy good quality cotton buds to clean my dog's ears," he laughed.
So, in one day on Dec 29, 2010, I got at least 4 different causes of ear problems in 3 dogs and 1 cat. There was a 5th in a Westie. In this case, the Westie had itchy ears, paws and body. It could be a Westie-related genetic disease or allergy. So, there were actually 5 cases of variations of ear problems in dogs and cats in one day. And I thought this was going to be a laid-back day and smell the roses. At 8 pm, I completed my house-call vaccination and microchip at Pet's Zone in Dunearn Road apologising for the late arrival.
It was an unusual day of ears to remember. I record it to remember it when the years go by. I hope you did enjoy reading the report.
I was on duty as Dr Vanessa Lin went on leave for the next 10 days. This was the 2nd day of work since I came back from the holidays. I thought it would be a quiet Wednesday and brought my laptop to do some writing and scheduled a house-call to micro-chip and vaccinate some dogs at Pets Zone in Dunearn Road at 4 pm. But it was a hectic day from 10 am to 8 p.m, with one-hour break at lunch-time. The cases were the usual ones of neutering and spaying, dental scaling, skin diseases, ear problems, eye infections in two stray kittens. Some interesting cases are as follows:
1. Animal activism in Singapore. A young lady wanted to know how much it would cost to hospitalise two stray kittens with flu for a few days while she looked for new homes for them. Her father would kill her if she brought these kittens home as she already had several. She was looking for the least cost veterinary care and dictating that the kittens should not be given antibiotics. This is a common situation encountered at all vet clinics. There is insufficient space at Toa Payoh Vets which is a small surgery of 60 sq metres. I do help a few stray cat cases but there is a limit in charitable work. A practice has high overheads although it does not look obvious to the average pet owner in Singapore. In this case of cat flu, home nursing would be best. I advised her to nurse the kittens herself as it would be better for the kittens.
2. Animal activism in Yangon. An old friend started to help homeless dogs and cats in a place in Yangon. This is his personal thing as he could better spend his time and skill earning more money in the IT field. However, the residents there wanted US$20,000 from him if he wanted to continue his mission. I had advised him of the risks of doing animal activism overseas as politics would become dominant. This happens even in Singapore, as cat welfare people tried in vain to get the Singapore Government to permit cat ownership for the average person living in HDB apartments.
From this incident, you can see that it is difficult for a Singaporean animal activist going across borders to help change the world unless he has powerful political connections. Politics and economics interact in animal activism and business. Such are the facts of life.
3. Ear problems. One dog had red ear flaps for many weeks. I did a microscopic examination of the hairs. It was ringworm. "A follow-up one month later is important," I said to the owner. Some owners blame the vet for not resolving their problem when they don't follow up but went to another vet.
4. Injectable anaesthesia. The following is one of many metods of injectable anaesthesia used safely in practices and countries with no access to isoflurane gas anaesthesia, unlike fortunate Singaporean pet owners where the best anaesthetic drugs are available for pets.
I am sharing this knowledge with vets working in such locations. The above dosage is a general guideline. An IV catheter is inserted so that top up injections can be given IV should the dog need more anaesthesia. For a 10-kg dog, the dosage of diazepam and ketamine in one syringe are respectively 0.4 ml + 0.4 ml IV.
Case 1. At 50% of the above dosage, ie. 0.2 ml diazepam + 0.2 ml ketamine in one syringe IV for a 10-kg mixed breed dog, the dog shows signs of head shaking sideways and salivation. It was not under surgical anaesthesia. I top up with 5% isoflurane gas by mask for a minute or two to effect and this provided excellent anaesthesia for neutering.
Case 2. At 100% of the above dosage, the dog's body muscles were tense. The dog's neck and legs were flexed. The eyes were open and the pupils dilated. However, dental scaling was done without pain or the need for top up.
CONCLUSION. Each vet has his own preferences in anaesthesia. As long as it is safe for the dog, injectable anaesthesia offers a cheaper alternative to isoflurane gas. The anaesthetic machine and isoflurance are expensive compared to the injectable anaesthetics. In an effort to lower veterinary costs, injectable anaesthetics are used. As for me, I prefer to use xylazine (or domitor) sedation and isoflurane gas anaesthesia as I find that the dog sleeps relaxed (not with tense muscles as in the diazepam and ketamine injectable anaesthesia) and surgery can be done smoothly without the need for topping up as the dog struggles when pain is experienced.
ECONOMICS OF PRACTICE. Each vet does what he prefers as long as the dog is safe and alive at the end of the day. I am just sharing my observations to benefit vets who may not have access to isoflurane facilities as not the isoflurane gas machine purchase cost and maintenance are very expensive. There are more less sophisticated pet owners who just want "cheap" veterinary anaesthesia and surgery and a veterinary practice needs to sustain its profitability to be around the next year. So, there is a need to reduce veterinary costs, sometimes performing loss-making surgeries!
INTERESTING CASE OF BLACK EAR DISCHARGE
"The (pet shop owner's son) was not in a good mood and so I talked to the counter staff," the matronly woman had brought the 7-month-old female salt and pepper Miniature Schnauzer in for his 3rd vaccination. Toa Payoh Vets had given the puppy 2 vaccinations earlier. She paid $350 for the dog which I thought was too cheap as it had such good physical characteristics. But older dogs are difficult to sell and only puppies fetch a premium price in Singapore.
"The young man may be having some personal problem," I said as the husband wanted the wife to complain that she was sold a dog with black ear discharge. "His father had died while delivering dog food and crashing his van. The hospital doctor did not diagnose that he had a head injury and sent him home. What ear drops have you been using to clean the dog's ears?"
"I use eucalyptus oil for the past few days," the lady said. "The next day, the black ear discharge appears again."
"This is is a good looking dog and you had got it at a cheap price," I could appreciate a Schnauzer with good conformation. A good sized head, proportionate body length and not too long legs. Not too bulky as Singaporeans prefer this type of size although dog show people will consider this dog under-sized. Female dogs of this size and shape are more valuable for breeders as there is a demand for "miniature" Miniature Schnauzers.
I took a cotton bud and spread some ear discharge on a slide and put it under the microscope but saw no mites. "You must have drowned all mites with oil," I said. "Not a mite can be seen."
What caused the blackness and the black particles inside the two ears? As black as black shoe polish. Ear discharge comes in all colours but pure black is rarely seen by me in practice over 40 years. It was as if the ear drops of oil were black in colour. I did not ask the owner the colour of the ear drops as it was an extremely hectic day and I still had not done the 3rd spay of the 3rd stray cat.
The owner who loves his 3 stray cats had brought in the 3rd one for spaying today. Yesterday, he got two in and I had neutered and spayed them. The 3rd one was "fierce" and was put inside a cardboard box, taped up but with gaps for the cat to breathe. It was as if he had a tiger inside the box and so we did not dare open the box and transfer the cat to the crate for the time being. The minutes ticked by and the whole afternoon had gone and still I had no time to spay this cat.
Spending time with the owner is essential in practice building but the other owners at the waiting room disliked waiting too long unfortunately. Some owners want fast service. I could see that the Schnauzer lady's husband was all ready to go to work. But he was the patient type who would wait for his wife to get the dog vaccinated. That was all she came for and vaccination should be fast. But for the black ear discharge, the dog would leave in 5 minutes.
I got the ears irrigated and taught the owner how to use the medicated ear drops. The best would be another ear irrigation the next day but I could sense that the husband was an extremely busy man but his wife mentioned about him working in an important post in a volunteer organisation. "You work for the famous Red Cross," I said to him as I was thinking of the excellent volunteerism and time it had done for so many unfortunate people in countries all over the world.
"The infamous Red Cross," he laughed. Yes, there was a newspaper report about some loss of money taken by a staff in the Singapore branch but I was not thinking of this matter. There will always be staff who steals money from the organisation all over the world.
In one case of a famous cosmetic surgeon in Singapore, I was shocked to read in the newspaper that he did not print his own receipt books. He bought commercial ones. So, he had 3 copies. The white for the client, the blue for audit and the yellow for the case file. Now, his billing staff found a way to milk him of over $100,000. She would buy another set of books. When she billed the client, she would give the client the white copy with say $1,000 and collected $1,000. Then she would write, say $500 on the blue and yellow copy from her own purchased set and discard the original blue and yellow copies of the surgeon's book. She could also under-declare the income by replacing the yellow or blue copies.
"How was she caught?" my wife asked me yesterday when I told her that the famous surgeon did not print his own receipt books which I found it hard to believe if not for this case in court.
"Well, another staff discovered that the blueness of the blue receipt was not similar to the blueness of the other receipts." But over $100,000 had been misappropriated and this sacked staff complained that the surgeon had not granted her medical leave.
I digressed. Back to the Schnauzer's black ears. The husband seemed appreciative when I asked the wife to use the medicated ear drops herself to clean the ears for the next 7 days and if the black discharge disappear, then there was no need to consult me.
This was one of the 4 interesting ear problems. The other one was the fiery red inside ear flap caused by ringworm infestation in both ears mentioned above. The 3rd one in a young cat with thick reddish black waxy ear discharge was even more interesting in the sense that I managed to find one dead ear mite under the microscope when I did an ear discharge examination.
"See the mite," I asked the young lady to peer into the microscope. "There is only one." The mite with a round body and six short legs in the front half was clearly visible and sharp under my newly purchased microscope. "Where's the mite," the lady asked. She was not into biology I presumed. I took out the Hill's Atlas of Clinical History and showed her the drawings. Maybe I should produce one myself. "See the book drawing of the mite," I showed her the cat and ear mite drawings inside the book. "What's the name of this ear mite in the cat?" I asked Mr Saw, my assistant who is qualified as a vet in Myanmar and would be returning home in April 2011. The book did not mention any name. Mr Saw shook his head. "It would be Otodectes cyanotis," I said. It was Greek to him and to all vet students. I got the ears irrigated and gave an anti-mite ivermectin injection. Follow up would be good.
It is 7.25 am and I have to get ready for work. The 4th ear case was one in which the young man's cotton tip fell into the dog's right ear canal while cleaning. The Pomeranian would bite when he tried to retrieve it deep inside the ear canal. "Surprisingly my dog did not shake his head. I would rather get it removed before it infects the ear. How long will it take?"
"That depends on whether the dog needs to be sedated," I said. I got the dog inside the surgery, muzzled it and Mr Saw held the dog properly. Mr Saw had wanted the ear scope to check out the ears. "No point in doing it," I said. "The ear scope will push the cotton bud deeper into the ear." Sometimes we have to visualise the impact of a particular procedure.
In theory, all ear examinations must be scoped. Sometimes it could even be considered negligent not to scope the ears as a routine. In practice, the dog owner had already given us the history that his cotton tip had dropped inside the right ear. Using an ear scope would push the cotton into the horizontal canal and that would be very difficult to extract.
I inserted a slim curved artery forceps into the right ear vertical canal to the base, open and clamp. Fortunately I got the cotton bud out at the first clamp. I showed the bud to the owner who was quite pleased. "It's time I buy good quality cotton buds to clean my dog's ears," he laughed.
So, in one day on Dec 29, 2010, I got at least 4 different causes of ear problems in 3 dogs and 1 cat. There was a 5th in a Westie. In this case, the Westie had itchy ears, paws and body. It could be a Westie-related genetic disease or allergy. So, there were actually 5 cases of variations of ear problems in dogs and cats in one day. And I thought this was going to be a laid-back day and smell the roses. At 8 pm, I completed my house-call vaccination and microchip at Pet's Zone in Dunearn Road apologising for the late arrival.
It was an unusual day of ears to remember. I record it to remember it when the years go by. I hope you did enjoy reading the report.
Wednesday, December 29, 2010
280. Two para-police guards at the CEA office
I was surprised to see two senior para-police guards outside the CEA office as there were none two weeks ago. "We are protecting the CEA directors inside the offices. Many housing agents had their licences revoked and we have much experience handling such riotous people."
The CEA is set up to regulate the housing agents and started in Nov 2010. "There is a Chinese syndicate conning the people," the guard told me. I was surprised to know that. The world has changed and there may be more cunning scam and con men and women who want to make fast bucks without having to work.
The CEA is set up to regulate the housing agents and started in Nov 2010. "There is a Chinese syndicate conning the people," the guard told me. I was surprised to know that. The world has changed and there may be more cunning scam and con men and women who want to make fast bucks without having to work.
279. The man who loved 3 stray cats
Yesterday, Dec 28, 2010 was my first day back to work, after a 14-day packaged tour to Europe (Italy, Switzerland and France) and a subsidised stay in Dubai from Emirates Air and the Tourism Board.
It was extremely tiring as the tour leader had to rush us from one place to another. There was a group of 49 Singaporeans and a few would not be punctual throughout this packaged tour as they took their time to take photographs and eat their meals belatedly, making the majority wait for them.
Surprisingly, the Divine Powers had been kind to us as there were no major traffic jams from Rome to Turin to Switzerland and Paris. Nor were there delays in flights back from Paris to Singapore. Yet the the heavy snow falls affected road traffic and flights in London, the US and Europe at around this time (Dec 13 - 27, 2010). One Singapore Tour Group had to spend the night inside the coach from Milan to Rome as snowfall had caused traffic slowdown. We were clear all the way.
The only thing we missed was seeing The Colosseum in Rome. The students protested violently against Prime Minister's Belusconi's decision to cut funding for University research and expenditure and increased fees. So they burnt cars and caused closure of the Colosseum. The Eiffel Tower in Paris was closed before we arrived as there was strong winds or something but when we arrived, we could visit the 2nd floor. Strong winds did close the railway service to the top of Europe - the Jungfrau mountain or Matterhorn in Lake Interlaken, Switzerland. We went snow sledging. I did not want to risk my life as any mistake in rounding corners on the right could fling me down the ravine. I was no spring chicken and wanted to back out as the younger ones and some older folks took the risk of sitting on the snow sledge downhill.
I was the last one left holding the snow sledge as the others who did not want to do snow sledging were holed up in a cafe. Well, I took the risk. It could be death if I fell into the steep slope on the right and knocked my head.
The snow sledge's downhill slide was to be stopped by putting two heels down onto the snow as if braking a car. My heels were not deep into the snow and so the snow sledge continued to slip downhill increasing momentum as the gradient was steep, at around 45 degrees. I banged into the left side (of the hill) and slightly bruised my left shin. I did crash onto the right edge and quickly hopped off to avoid falling into the ravine below as my sledge could not turn left for two times. Midway down, I nearly crashed into a group standing around. There, the tour leader was phoning for ski patrol for help. A Singaporean was really flung down a bit of the ravine. A tree stopped his tumble further down and he received 4 stitches above his right eye-brow. That was the main excitement of the packaged tour. Fresh snow had just fallen a few days ago.
After snowsledging, we went to Lucerne for the night. The tour guide took the group there from Lucerne the next day and it was clear. I did not bother to take another 1.5-hour coach ride and explored the Lucerne town and its inhabitants and tourists. The two sons went skiing nearby.
Back to my first day at work. A family was too early and was waiting for Dr Vanessa to do dental scaling. An old client came with two stray cats. "The vet would only sterilise them at 6 months of age," he said. "However, these two cats were meowing and behaving like adults at 5 months of age. I want to sterilise them. There is a 3rd cat somewhere. I will get him later."
I examined the cats. The male was 2.8 kg. The female was 2.4 kg. Both could be sterilised and so I booked them in. I am teaching my veterinary staff to be efficient and not to waste material unnecessarily. I pointed out to them that the new $7,000 surgical operating table of two weeks had more than 30 scratches. "So, at the end of two months, the whole surface would be all scratched," I said. "This should not be the case. You need to put a tower on the table to protect it until the dog is under anaesthesia and surgery." The seller had delivered the table without informing me when I was on holiday. Sometimes it is common sense. Stainless steel surfaces should not be clawed by dogs as the scratches would rust later. So, use towels to protect the surface when a dog is awake and not fully sedated.
The examination table of over 10 years and sourced from the same U.S. manufacturer was hardier and did not suffer any serious scratches.
"Gauze?" my assistant got the gauze ready. "There is no need to use gauze," I said to him again. "There is little bleeding during a cat spay." That is the situation I encounter when I spay a cat.
"The start and end of the surgery must be recorded," I told my assistant. This will enable me to audit my surgery as well as those of my associates and learn from the situations needing unusual lengthy surgeries. An animal has a better survival rate if the surgery is as short as possible.
ANAESTHESIA
2.4 kg stray cat. Xylazine 0.1 ml and ketamine 0.4 ml in one syringe IM. Effective. There was no need for an assistant to hang around. I took around 25 minutes for the surgery doing it at a leisuredly pace. It could be done in 15 minutes.
VET-HOPPING
This is common in Singapore. Proximity and pricing would be the attracting factors. 6 months of age is the common recommendation for spay of dogs and cats. In this female cat, at 5 months, the ovaries and uterine bodies were enlarged with thick red blood vessles. Therefore the cat was on heat at 5 months.
2nd VACCINATION AND EAR CLIPPING. The gentleman in his late 50s said: "Clip the left ear so that the AVA would not grab the cat and kill it. My family is attached to these stray cats and that is why I want to sterilise them." He wanted to hospitalise them for a few days although I said it would not be necessary.
It was extremely tiring as the tour leader had to rush us from one place to another. There was a group of 49 Singaporeans and a few would not be punctual throughout this packaged tour as they took their time to take photographs and eat their meals belatedly, making the majority wait for them.
Surprisingly, the Divine Powers had been kind to us as there were no major traffic jams from Rome to Turin to Switzerland and Paris. Nor were there delays in flights back from Paris to Singapore. Yet the the heavy snow falls affected road traffic and flights in London, the US and Europe at around this time (Dec 13 - 27, 2010). One Singapore Tour Group had to spend the night inside the coach from Milan to Rome as snowfall had caused traffic slowdown. We were clear all the way.
The only thing we missed was seeing The Colosseum in Rome. The students protested violently against Prime Minister's Belusconi's decision to cut funding for University research and expenditure and increased fees. So they burnt cars and caused closure of the Colosseum. The Eiffel Tower in Paris was closed before we arrived as there was strong winds or something but when we arrived, we could visit the 2nd floor. Strong winds did close the railway service to the top of Europe - the Jungfrau mountain or Matterhorn in Lake Interlaken, Switzerland. We went snow sledging. I did not want to risk my life as any mistake in rounding corners on the right could fling me down the ravine. I was no spring chicken and wanted to back out as the younger ones and some older folks took the risk of sitting on the snow sledge downhill.
I was the last one left holding the snow sledge as the others who did not want to do snow sledging were holed up in a cafe. Well, I took the risk. It could be death if I fell into the steep slope on the right and knocked my head.
The snow sledge's downhill slide was to be stopped by putting two heels down onto the snow as if braking a car. My heels were not deep into the snow and so the snow sledge continued to slip downhill increasing momentum as the gradient was steep, at around 45 degrees. I banged into the left side (of the hill) and slightly bruised my left shin. I did crash onto the right edge and quickly hopped off to avoid falling into the ravine below as my sledge could not turn left for two times. Midway down, I nearly crashed into a group standing around. There, the tour leader was phoning for ski patrol for help. A Singaporean was really flung down a bit of the ravine. A tree stopped his tumble further down and he received 4 stitches above his right eye-brow. That was the main excitement of the packaged tour. Fresh snow had just fallen a few days ago.
After snowsledging, we went to Lucerne for the night. The tour guide took the group there from Lucerne the next day and it was clear. I did not bother to take another 1.5-hour coach ride and explored the Lucerne town and its inhabitants and tourists. The two sons went skiing nearby.
Back to my first day at work. A family was too early and was waiting for Dr Vanessa to do dental scaling. An old client came with two stray cats. "The vet would only sterilise them at 6 months of age," he said. "However, these two cats were meowing and behaving like adults at 5 months of age. I want to sterilise them. There is a 3rd cat somewhere. I will get him later."
I examined the cats. The male was 2.8 kg. The female was 2.4 kg. Both could be sterilised and so I booked them in. I am teaching my veterinary staff to be efficient and not to waste material unnecessarily. I pointed out to them that the new $7,000 surgical operating table of two weeks had more than 30 scratches. "So, at the end of two months, the whole surface would be all scratched," I said. "This should not be the case. You need to put a tower on the table to protect it until the dog is under anaesthesia and surgery." The seller had delivered the table without informing me when I was on holiday. Sometimes it is common sense. Stainless steel surfaces should not be clawed by dogs as the scratches would rust later. So, use towels to protect the surface when a dog is awake and not fully sedated.
The examination table of over 10 years and sourced from the same U.S. manufacturer was hardier and did not suffer any serious scratches.
"Gauze?" my assistant got the gauze ready. "There is no need to use gauze," I said to him again. "There is little bleeding during a cat spay." That is the situation I encounter when I spay a cat.
"The start and end of the surgery must be recorded," I told my assistant. This will enable me to audit my surgery as well as those of my associates and learn from the situations needing unusual lengthy surgeries. An animal has a better survival rate if the surgery is as short as possible.
ANAESTHESIA
2.4 kg stray cat. Xylazine 0.1 ml and ketamine 0.4 ml in one syringe IM. Effective. There was no need for an assistant to hang around. I took around 25 minutes for the surgery doing it at a leisuredly pace. It could be done in 15 minutes.
VET-HOPPING
This is common in Singapore. Proximity and pricing would be the attracting factors. 6 months of age is the common recommendation for spay of dogs and cats. In this female cat, at 5 months, the ovaries and uterine bodies were enlarged with thick red blood vessles. Therefore the cat was on heat at 5 months.
2nd VACCINATION AND EAR CLIPPING. The gentleman in his late 50s said: "Clip the left ear so that the AVA would not grab the cat and kill it. My family is attached to these stray cats and that is why I want to sterilise them." He wanted to hospitalise them for a few days although I said it would not be necessary.
Tuesday, December 28, 2010
278. Myanmar travel and tour travel agency
In December 2010, I have started Design Travel Pte Ltd, a travel agency focused on Myanamar travel and tours. The previous licence from the Singapore Tourism Board was for Asia USA Realty (S) asiahomes.com Pte Ltd in 2009. This was returned to the STB and replaced by a new licence for Design Travel Pte Ltd which is more appropriately named as a travel agency whereas the previous licence was part of a real estate agency.
My blog on my 2008 tours are at:
http://myanmar-singapore.blogspot.com/2009/03/asiahomes-start-up-travel-agency.html
My blog on my 2008 tours are at:
http://myanmar-singapore.blogspot.com/2009/03/asiahomes-start-up-travel-agency.html
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