304. Caesarean section in a Maltese

Jan 15. 2011

A phone call from a breeder woke me up at 2.35 am. He is Dr Vanessa Lin's client but she does not do after midnight calls. "First-time giving birth. Straining but can't give birth," the breeder said.

I phoned Dr Jason Teo but he was sick. I was surprised that a young man like him could be sick. "It is food poisoning," he said. "I just did a Caesarean at 5 pm yesterday."

So I attended to this emergency. Warm cool night with cloudy skies. Definitely not freezing cold as in Europe.

DURATION OF SURGERY: Caesarean section times
Start of incision into skin: 3.35 am
End of last stitch: 4.08 am. It takes about 30 minutes to do an uncomplicated Caesarean section using my surgical approach.

ANAESTHESIA:
Isoflurane gas only. Maintain at 1-2%. No sedation. This is the safest method.
Dog masked and then intubated.
"The dog is going to vomit," I said to Mr Saw as I pulled out the endotracheal tube. The vet has to be observant. He hanged the dog upside down to get out all vomitus. Re-anaesthesize again. No problem.

SURGICAL APPROACH:
A caesarean section must be completed fast. Use less anaesthetic time and achieve a good outcome. Nothing is more stressful than a dam dying on the operating table. Efficiency is important. The skin and linea alba incisions were around 8 cm long between the midpoint of mammary glands no. 4 (see photo). I extended the incision a cm caudally as the pups were large.

I incise at the uterine horn bifurcation on the midline of the uterine body. Extended incision to near cervix as pups were large in this case as I could not pull out the first pup via a shorter incision. I pulled out 3 pups head first, one with meconium (brown stools inside amniotic fluid). The last one was back legs first. Each uterine horn has 2 pups and they were larger. "Give all 4 pups to the breeder," I said to my assistant as he would normally do the puppies with my associate vets.

The breeder took the pups inside the amniotic sac and this saved at least 6 minutes of anaesthetic time if my assistant and I had to do it. In Caesarean, the shorter the better for survival outcomes.

STITCHING. 2 PACKETS WERE USED.
3/0 absorbable on uterus used. 2 rows of inverting suture. The first row was parallel to the incision. The second row was at right angles to the incision. Two artery forceps clamp either ends. Then I used 2/0 absorbable simple interrupted sutures to close the muscles and the skin (horizontal mattress). The four pups large and OK. The dam appeared frightened of pups, being first-time mother.
DR SING'S CAESAREAN SECTION AT TOA PAYOH VETS
I incised the skin and linea alba as short as possible (XY), sufficient to pop out the puppy's head or backside.

Uterine body is incised. Amniotic sac with pup inside pops out (left). I pull out the sac if not ruptured and clamped the umbilical cord. Cut off the cord. Gave the pup to the breeder. Pulled out the placenta.
The uterine horns with no more pups is pulled out entirely to check for hidden pups
This procedure is not applicable if the vet had pulled out the whole uterus prior to incision. This approach requires a much longer skin and linea incision which may irritate the dam and cause stitch breakdown
Uterine body stitched with 2 rows of continuous sutures 3/0 absorbable. 2 artery forceps anchor both ends
Maltese pups look overdue as they have a thicker coat and are larger than others

Oxytocin, tolfedine and baytril injection SC. Breeder asked for pain-killer tolfedine as I usually don't give it as a routine and in the past. Trimethoprim syrup given for post-op antibiotics. I don't irrigate the abdomen after surgery as some vets do and such actions do impress some breeders. Introducing saline into the abdomen, no matter how sterile, risk introducing bacteria. There was little bleeding in this case as I incised the midline of the uterine body and avoided the blood vessels at the side.

A Miniature Schnauzer had dystocia. I gave 1.0 ml oxytocin IM before I started Caesarean of the Maltese. She gave birth to one pup in the Surgery. "Should be OK," I said. The breeder said: "The first pup died as I arrived home too late." He had his cigarette smoke outside the surgery as I hurried him away so that my assistant can go back to sleep. It must be hard to be a breeder. I don't know him well but I had 2 years of Caesarean section and vaccination experiences with the Pasir Ris breeders in 2005 to know that dog breeding is a heart-breaking and back-breaking business. Some of my interesting Caesarean surgeries are at:

http://www.bekindtopets.com/animals/
20081201PAGE2_Dog_Surgery_Anaesthesia_ToaPayohVets.htm

I could not drive out as the road was blocked with whole-saler vegetable sellers from Malaysia. At least 50% less crowded than in 2005 when I did a lot of Caesarean sections for Pasir Ris breeders. I walked to see their activities. Younger men in bare top bodies. A few younger ladies. There was an old hunch-back woman picking up discarded red peppers and others in a plastic bag. Tinted bronze hair, weather beaten face, blouse and black pants.

The truck people (a young lady in pony tail looking at her mobile phone and two young bare-back muscular men) ignored her. It is always sad to see a senior citizen having to scavenge. Has she got children? Where had all her savings gone?

An alert Jack Russell from the truck looked at her and at me. The dog was still working at this hour! Most Singapore's Jack Russells would be sleeping in the apartments and houses.

I walked to a far away block of apartments and tried to shoot a picture of the dog with my zoom lens. Some 500 metres away. I went up the 2nd floor of an apartment.

It was very far away so that the wholesale vegetable people would not strangle me. Surprisingly, I saw a picture of this short-legged Jack Russell.

A Caesarean after midnight takes around 2 hours (from first phone call to waiting half an hour for the breeder who came late). The whole process ranged from 2.30 am to 4.30 am). Singapore was still a busy city at this time with many taxis prowling the roads. A McDonald bike was seen from my car at 5.30 am.

P.S
Some 5 hours later in the morning, the breeder phoned to say that there was another pup not born. Dr Jason Teo did the Caesarean to save the pup. It was alive.

303. Upgrading and best practices

There is always a generation gap between old and young vets. However some young vets have this confidence to communicate with older vets and that is good for them. Young vets who naturally want to group around with their peers and age group. This is commonly seen.

On Jan 13, 2011, I visited two competitor vet practices. It was great that the two younger vets I met were good at communication. One was clean shaven in his head. "Are you helping 'Hair for Hope - Singapore'?" I asked him to be bald to raise fund for the Children's Cancer Foundation? I had not seen a young vet bald in Singapore and he was the first one.

The second vet has 9 years of experience and was excellent at communications. First class, I would say. She offered me a cup of coffee as she could get rid of me after some conversation. She shared some interesting cases of pyometra (photo with yellowish disc in a spleen of a dog with pyometra - splenic abscesses?). She showed me an X-ray of a dog with a 20-cent coin in the stomach in which the endoscope of a referred vet was ineffective. It still needed gastrotomy after endoscope failure. "Is an endoscope so expensive?" I asked her when she mentioned $100,000 for one. I do not think it would cost that much unless it is for racehorses.

I learnt a few veterinary communications and related matters from her and the other competitor. It is good to see other practices in Singapore and in other countries to upgrade oneself and know the industry's best practices as no one vet can have all the vet knowledge in this world.

302. Taking advantage of distressed art

Jan 13, 2010

Khin Khin phoned me to say that the artist was selling her artwork I like (Myanmar market scenes) at fire-sale prices. "Give her $150 per painting," she advised. "She needs the money to pay the rent."

It is not good to take advantage. "No," I said. "I want to hang the art on my Surgery walls or home. I don't want to see it as one that is bought from an artist in distress. It is just not what I will do."

Artists need to sell. Vets need to diagnose and treat. It is just sad that this artist could not sell her artwork internationally. Much promotion and creating awareness is needed. I think an art gallery sponsor or patron is what make some talented artists successful. Talents can only go a short distance.

Follow up on maltese peeing just outside the pee tray

E-MAIL TO DR SING DATED JAN 13, 2011
Hi Dr Sing,

Above attached are the photos of my dog's pee tray and the surrounding of it.

The first pic is the tray.
2nd pic is the newspaper i put below it. And as you can see the urine patch there.
3rd pic is the floor where he will urine there at times, he will stand on the newspaper there and aim on the floor.

Btw, there is no change of environment or situation. Most probably i guess is because we hardly accompany him and hardly bring him for a walk.

Is there any effective ways to solve this problem? And, if i neutering him at the age of 3, will it be too late?

Thank you
Name of owner

REPLY FROM DR SING DATED JAN 13, 2011

You did change his routine by cutting down the regular outing. So he can't urine-mark downstairs and dare not urine mark the whole apartment (in fear of punishment). So, he made do with just outside the pee tray. I presume he will urine-mark the whole apartment if nobody is around and if he has not been confined to the crate.

Urine marking occurs in your dog due to deprivation of doing it outdoors. This is main reason as all dogs, like young children, are used to a routine and in some children's book, a routine makes a child feel more secure and happier.

Neutering may reduce this urine marking as the testosterone production is shut down. However, you still need to re-train the dog (routine to go downstairs after neutering for some weeks or months). Many still urine-mark but with reduced frequency. Neutralise the urine smell.

Go back to the routine or neuter. It is also possible that the pee tray is too small or the dog just does not want to dirty his paws. If only dogs can talk.
- Show quoted text -

E-MAIL TO DR SING DATED JAN 14, 2011
He will not urine-mark the whole apartment,only will pee outside the tray.
What should I do to neutralise the smell?

E-MAIL FROM DR SING DATED JAN 14, 2011
He may not do it now. If you leave him home alone in the apartment for the next few weeks, you may be surprised. That is why some male dogs in Singapore are crated when home alone or at night (to prevent urine-marking).

Try white vinegar + water at 1 part of vinegar to 3 parts of water and use tissues with this solution to wipe off all urine smells.

300. Soliciting for a veterinary job - poor resume introduction

I got a resume by e-mail as follows:


EMAIL TO DR SING DATED JAN 13, 2011

Greetings!

Im XXX. I am applying as "Veterinary Assistant" in your good clinic. Attached here in with is my resume.Thank you very much and more power!

MY COMMENTS

I don't bother to reply. This is an example of a poor introduction in a resume. More power? Is she referring to the "People Power" toppling Marcos or the blue pill power for erectile dysfunction?

DBS Corporate debit and credit card: 2nd opinions from the same bank

Jan 12, 2011

In Dec 2010, I opened a company bank account (Design Travel Pte Ltd, www.designtravelpl.com at DBS Toa Payoh. The helpful customer service officer told me that it was almost impossible to get a corporate credit card unless one is chosen. It was by invitation only. Two days ago, I asked her about a debit card in which I put money into the current account. She phoned the DBS banking somewhere and was told there was no such instrument. I was surprised that DBS is so provincial.

Then today, I went to DBS Bishan. Imagine my surprise when Ms Irene Foo there told me that there was no problem opening a corporate debit account for a private limited company and gave me the forms to sign and documents required. She said the corporate credit card might be given to a company with proof of income and a bank officer would check this.

So, I wasted 2 months believing there was no such thing as a DBS corporate credit and debit card.

This episode shows that one must be proactive to search for info. It is obvious that I was barking up the wrong DBS tree in Toa Payoh.

298. Toilet training email query

E-MAIL TO DR SING dated Jan 12, 2011

Hi,

I have 1 maltese cross, age 3 years old. He used to pee at the pee tray correctly. But for the recent months,he started to pee outside of the tray. We tried to place newspaper underneath the tray , but he will still pee outside the tray. Is there any solution for this problem? Will Neutering cure the problem?

kindly reply me asap as i need to solve this problem fast.


Thanks
XXX


E-MAIL REPLY FROM DR SING dated Jan 12, 2011
I am Dr Sing from Toa Payoh Vets. Most likely there has been a change of environment (new tray, room, etc) or situation (new pets, baby, dog next door or corridor etc) making him want to either get attention from you (by peeing outside the tray) or he wants to mark territory (outside the tray but can't do it further because of your scolding or spanking).

Neutering does help to reduce/stop territorial spraying when done at a young age. Pl email 2 images of your pee tray and surroundings. It is hard to advise without seeing the location and tools you use.

297. Jan 11, 2011. Resume is important

Jan 11, 2011

I met an old friend who used to have little time for me just to keep in contact. He was extremely hard working and had a lot of contacts. After retirement, he has more job offers and one important interview this Friday. "No need to bring a resume," he said. I advised him to do it as this is the way a corporation management can assess you. My reasons are as follows:

It was great meeting you yesterday and to know you have reduced weight since retirement.

Although your proven performance in your old company and your network is well known to the prospective recommending person in the same field of work as you were in, the general manager and other big shots know little about you and may be apprehensive as to whether you can perform for the new company. The advantage is that you have a proven track record and there is no need to hold your hands or worry about blunders.

A resume with relevant and excellent testimonials is important to carry along during the interview because it helps the general manager to approve financial compensation and benefits to you, without insulting you by under-paying nor over-paying you. A graduate degree is never important as many graduates actually can't perform in the field you are in.

A resume submission is part of hiring administration of a corporation. Resume should include your personal particulars and relevant work experiences (newspaper clippings, letters from bosses, customers, suppliers). Cases done per year and impact on the old organisation will be most relevant and useful. You just need to get your homework done and smoothen the path for your recommending person to hire you. I have young adults and veterinary undergraduate students who don't bother to submit a proper resume and assume that they will get the work attachment and internship based on their excellent academic grades or the fact that they are veterinary students.

The schools seem not to have taught them that excellent grades and in your case (experiences) open the door only to get you the interview. If you go to the interview without a resume, your behaviour implies an arrogance and that the world owes you a living. And since you are not hungry and have sufficient wealth, this may be true actually. If you are not hungry and do not need the income, why go for the interview? Just do nothing at home and smell the hibiscus flowers and let your brain cells deteriorate.

Best wishes.

Work attachment for JC 2 students at Toa Payoh Vets

MONDAY JAN 10, 2010 - INTERESTING AND ROUTINE CASES

Nowadays, I don't accept Junior College students who have NOT been accepted by Vet colleges for internship as a lot of time and resources are spent on students coming for work attachments.

However, JC2 students with initiatives can still e-mail to me. Good work attitude, excellent testimonials from teachers and chances of getting into Vet colleges in Australia (must have at least 3 As in JC2 preliminary exam) may be accepted as is the author of the case study report below.

Last month, I rejected a student who had top grades. She did not have time to come for an interview as she had to study for her A levels. I was OK with that. After her exams, she did not bring in copies of her testimonials during the interview. She promised to do so personally but a few days later, text me to ask if she "could fax them." I told her not to come for the work attachment.

ADVICE TO THE YOUNG ADULTS
If you are NOT meticulous by forgetting to comply with requirements and is accepted, you will need to know that you have been given a 2nd chance. If you expect an organisation to suit your time management (by faxing and saving your precious time), you may not realise that you have a poor work attitude. Excellent academic results definitely opens doors to what you want to do, but the commercial world does not owe you a living. Therefore, be realistic and humble. It is not what the organisation can do for you as a Junior College student or undergraduate vet. It is your work attitude and what you can contribute to the organisation.

For this first day, the report of this Junior College 2 student who has not taken Biology during her A levels is good. The info is as follows:


Case studies with Dr Sing


1) 1-year-old female hamster with right breast tumour

Diagnosis

Lump under the armpit was ~0.8 - 1.0 cm in size. It weighed about 38g. It could either have an abscess or tumour. Without an operation, the skin would eventually tear, revealing a large open wound.

Treatment

Surgery was performed to remove the tumour. It was required to stay in the clinic for 7 days.


DR SING'S COMMENTS
Infection and death follows when the tumour enlarges and gets ulcerated due to friction and self-induced trauma.

NOT REQUIRED TO STAY. HOWEVER THE OWNER WOULD BE GOING TO JAPAN FOR THE NEXT 7 DAYS AND THERE WAS NOBODY TO NURSE AND GIVE MEDICATION POST-OP. SURGERY - Zoletil 100 given in 3 drops + SALINE. Effective. Excise at base of tumour. Continuous 5/0 absorbable stitches.

2) 1-year-old male guinea pig with paralysed hind legs

Diagnosis

Guinea pig’s hind legs were immobile and it was described to be lethargic. It registered a low temperature of about 37°C. It weighed about 777g and was eating and drinking normally. However, there was pain between the shoulders, indicating possible nerve damage.

Treatment

An injection was administered to relieve the pain.
DR SING'S COMMENTS
Traumatic injury most likely due to a fall inside the crate. Sudden onset.

I asked: "Any sudden loud noise?". The young lady said: "Yes, at 2 pm. I was sleeping. I saw my guinea pig running fast (pacing) and hoping energetically."

She had consulted Vet 1 earlier. The vet clipped the front teeth and probably could not find out what was wrong.

Sometimes, the 2nd vet gets the diagnosis due to the GP not getting so excited and the medication of the first vet.

I suspected sudden onset traumatic injury. Palpation of the spinal area is important in this case. The GP shivered when C3-C5 was pressed and squealed when the area between the shoulders was palpated. Paraparesis. No placing reflexes. GP hops instead of walks.
Besides anti-inflammatory injection SC to relieve the pain, the guinea pig was given electrolytes. Vet 1 had prescribed Fibreplex and the GP was able to move the bowels. Was eating and drinking normally but getting weaker.


3) 12-year-old crossbred male dog

Diagnosis

It weighed about 17.4kg. It was described to have been scratching its face and legs, as well as shaking and having difficulty in walking properly for the past few months. It also had skin and ear infections and dental problems, thus experiencing toothache and earache. It had a painful anal sac.
Treatment

Ear injection had to be administered for ear mites. A blood test was to be taken to check for kidney and liver problems. Complete shaving was needed before treating the skin infections.

DR SING'S COMMENTS
A 12-YEAR-OLD CROSS-BRED WITH PAINFUL MOUTH. Not groomed for several months. Ears full of black wax, inguinal area black. Mouth painful when touched (quite dramatic as the dog bites). This was due to dental decay esp. the upper PM4 teeth. A risky thing to do to open the mouth but this needs to be done as part of diagnosis. Quite smelly. The Junior College student has to be hands-on. But this dog is a gentle one and so I know he would not bite when I lifted his side muzzle to show the grey receding gum upper PM4 to the owners (father and young adult daughter).
The main point was missed by the Junior College girl. Dental treatment needs to be done after 2 days of IV drips with antibiotics and painkiller first.

4) Sterilisation of male stray cat

Diagnosis

Ear mites and a 0.5 cm wound were observed.

Treatment

It had just eaten; hence it was unable to be sterilized on the same day. It had to stay for at least 1 night and an injection was administered.
DR SING'S COMMENTS
Stray cats. Infected bite wounds, ear mites and skin infections need to be treated first before neuter. Economics is the big problem in cat activists. Toa Payoh Vets do give discounted rates.

5) Vaccination lump in puppy

Diagnosis

Small abscess observed in the vaccination area.

Treatment

It was massaged to reduce the size of the lump and antibiotics were administered.
DR SING'S COMMENTS
It would be some bleeding as the puppy moved a lot during vaccination. So the pet shop owner had to bring it in for free treatment. Antibiotics must be given.

295. Permission to use photo from toapayohvets.com's dystocia case

Dear Judy,



I was reading with interest your website, and noticed this photo of a fox terrier pup stuck in the birth canal:

http://www.asiahomes.com/dogpix/030930tn_fox_terrier_dystocia_Singapore.jpg

I was wondering if it’s possible to get permission to use this in a first aid workshop in a remote community?



I work for a not-for-profit organisation that supports dog health in Australian Indigenous communities, and would like to use the photo to illustrate a discussion on birth problems and the benefits of desexing.



Please let me know if this is ok,

Sophie Constable

Education Officer



0418699627



cid:image003.png@01CB9B6A.8A6821F0 P.O.Box 1296 Ph (08) 8941 8813 DARWIN, NT, 0801 www.amrric.org



...I acknowledge the Traditional Elders, past, present, and future, on whose land I live and work...



Kind regards,




JAN 11, 2011. Permission has been given to use photo with acknowledgement as follows: Photo: toapayohvets.com