Passing the buck - The pug with a perforated corneal ulcer

March 24, 2011 was a day to remember due to the following 3 incidents.

1. The Junior College student with straight As and 1 B and an excellent testimonial from her form teacher could not work "long hours." She had phoned me the previous night to let me know that she would not work the long hours of internship as it was "tiring". So, I told her that I would phone her back regarding her terms and conditions of work. That implied that she ought to stay at home till I decided since my offer was not accepted. Yet she presented herself at the Surgery today at 8 am as I had told my assistant Mr Saw that the intern would not be coming.

I asked if her father or mother was against her working hard? She had no objection to the hours of work during the interview yesterday and even arranged for her driving test lessons to take place at 5 pm on Friday. She would work 6 days a week with one weekend day off. She arranged for 6 weeks of internship - a very short period but that would give her some credentials as she had applied for an AVA veterinary undergraduate scholarship.

Apparently her father was against it. "You will be going overseas to study," I said sadly to this young personable lady who did not need to take the "O" level examinations unlike the average Singaporean student as she was the "top 10% of her cohort likely to go to the university."

"Your working hours are non-negotiable. In any case, you will be off before 5 pm on Friday for your driving test at Bukit Batok and you don't work on one Saturday or Sunday." I was rather sad that she could not put her foot down for her own future. "You need to think for yourself and not get tied to the apron's strings."

I wished her good luck and let her go. Over-protective Singaporean parents who think that the world owes their academic superstar-children a living will be in for a rude shock when their children goes to the real world of commerce as their attitude doesn't make the progeny street-wise and realistic.

2. Mr Saw phoned me at 11.30 am while I was at the Singapore General Hospital area to say he was not feeling well and would try his best. He had generalised muscular aches. I often told him: "You are a young man." But he would say "I have an old man's body."

Mr Saw is a very responsible assistant and if he was a Singaporean, he would make a very good vet. I could see that he has the passion during the past 3 years with me and I had mentored him with whatever knowledge of the skills of surgery and medicine I had.

I rushed back after taking a few photos of Everton and Spottiswood Park conservation houses (bright sunshine - good for pictures).

3. I told my associate vet that Mr Saw was sick and he would be taking time off. I would be the customer service officer taking money and processing the credit card and nets machine as my other staff was on leave. Another assistant Mr James Ang had retired at the age of 73 years as he was bent double for some unknown reason. I had to let him go in February after some 20 years with me. He would be giving prospective clients a bad impression compared to the nubile young girls at competitor's practice as he was hunched as if he could not stand straight.

Two days ago, the mother and adult daughter of a Maltese with red eyes had smiled at me when they saw me handling the payment at reception counter after consultation with my associate vet. They were old clients. The daughter had now become a grown up in her early 30s. I said: "Like the PAP who introduce new politicians at the elections, I must renew the vets at Toa Payoh Vets. Young vets, new ideas. Lots of energy."

Soon, 3 young adults in their early 30s (2 ladies and one gentleman) came in with a pug with a bleeding leaking eye. I got them registered as they were new clients. I could see that one of the two young ladies was quite distressed. My associate vet handled the case as usual. I could see that it was a case of a central corneal ulcer, a common problem in breeds with protruding eyeballs.

"So what happened?" I asked the gentleman who came out of the consultation room and sat on the yellow chair after some minutes of discussion with my associate vet. I had been inside the room to evaluate the eyeball at one time but left without comments. He said: "The doctor is making arrangements to hospitalise the pug."

I was extremely surprised. Associate vets do get some freedom to do their cases in the manner they deem fit. Toa Payoh Vets is equipped with anaesthetic and surgical facilities and is capable of handling a corneal ulcer case. Referring what I considered to be a simple case of corneal ulceration to be hospitalised in another practice in Singapore was a big shock to me.

I don't want the vets at Toa Payoh Vets to be known as the "Old School Vets". This term was made known to me from a staff of a practice I visited last week as I brought a young male intern with a blue golden lock of forehead hair to visit the practice to buy some vaccines.

The lady manager in this practice where the vets will refer every "difficult and potentially litigious" surgical case to a brand-name practice said to me: "My friend asks me which veterinary clinic I was working and when I told her, she said I was working with an 'Old School Vet'. I don't mind. I am very happy and well treated in this clinic."

So, this practice does vaccination, dental scaling, sterilisation and removal of lumps. Nothing more complicated. This definitely was not the sort of veterinary surgery I practise for the past 30 years.

Now my associate vet now making phone calls to another brand name practice to pass the case over.

This passing the buck of a simple case of corneal ulcer is not for associate vets of Toa Payoh Vets. If any associate vet can't perform surgery of a simple corneal ulcer and refers to a 2nd a brand name competitor, there is the "can't even do a simple corneal ulcer case" implication.

I know some vets dislike complicated surgeries as they are potentially litigious but this was a simple corneal ulcer case, in my observation. I went to the consultation room and asked my associate vet what was going on. Why was she referring to a brand name practice? She showed me the letter from Vet 1 to consult a certain vet in a brand name practice and since that vet was unavailable, she made alternative arrangements. Eye injuries are emergencies and ought to be treated within 4 hours. Now, it was 5 days post injury.

I was extremely surprised as my associate had at least 2 years of practice before joining me. If she could not deliver, she ought to consult me. There was this potential of the competitor's vet and staff labelling and bad-mouthing Toa Payoh Vets as being incompetent to handle a corneal ulcer.

I asked the owners to leave the consultation room, closed the door and had a private chat with my associate vet. I said: "This is going to be a highly contentious case as there is a lot of emotion involved as Vet 1 had given a name of a vet who would not take the case. The owners are much distressed. You just refer them to another practice.

That practice employs fresh graduates and rookie vets. You are not doing the dog a favour by just making appointment for an unknown vet to handle this case if the older vet was not available. I will take over this case as the owners are going to be unhappy should the other vet mis-treat this case."

If I refer a case to a vet, I must make sure that this vet has the relevant experience and a high standard of practice and will perform the surgery and not his fresh employee graduates. It does not mean that this vet must be employed in a brand name swanky practice.

I was in the consultation room earlier too but the associate did not introduce me and I did not introduce myself too. So, the distressed lady was apprehensive when I examined the dog's eye and tried to pull the dog back. So I left the room for my associate vet to manage the case.

I was around and yet she did not think of asking me for advice when issues and problems arise. Life for a practice manager is full of surprises and changes.

I told my associate to ask the clients to come in and to formally introduce me as that would be the correct way in professional practice. This case was high voltage and lightning had struck. The pug's eye was going to collapse any time soon and any miscommunication or bad referral resulting in the pug being blind would have cast Toa Payoh Vets in a bad light.

"The owners must be thinking I am just a receptionist since I was registering their case," I said to my associate. "This case is going to adversely affect the reputation of the Surgery if the brand name practice vet bungles the surgery. How do you know whether that this brand name practice will or will not assign a fresh vet with no experience in handling a Descemetocoele? This corneal ulcer is in a highly dangerous state as it is going to perforate soon.

"You know that this brand name practice's senior vet may not be available. If he assign a fresh vet to do it, the cornea perforates on the way to the vet, the pug goes blind. So, the owners would just bad-mouth Toa Payoh Vets as the practice that referred the case." I did not mention that this brand name practice charges top dollars and this case would set the owners back by over a thousand dollars.

My associate opened the door and asked the 3 adults and pug to come in. She introduced me as her boss.

"I am the founder of this practice," I elaborated. "I did not introduce myself earlier in the consultation room. I am responsible for the practice management." I was the licensee and any complaint or litigation would mean I have to waste time attending to investigations. I had assessed that the clients were sophisticated and knowledgeable and this is the profile of the younger generation. Whether they would complain about being passed the buck by Toa Payoh Vets would depend on how this emotional situation was handled and whether their pug's eyeball would be enucleated by the other vet. Owners just don't like the idea of their pets losing an eyeball.

This was a case that had a 50:50 chance of saving the dog's eye. If the vet knows how to resolve the problem.

The gentleman summarised the situation succinctly: "There is no one vet you can recommend to treat my pug." He must have superman's hearing as he was in the waiting area and he could not have had heard my conversation with the associage vet.

I said: "It is not necessary to refer the case at all as Toa Payoh Vets has the capability and experience to handle this case.

"I have handled several cases of corneal ulcerations and if you have no objection, I will do the 3rd eyelid flap. Have you visited Toa Payoh Vets' webpage on eye problems in the dog?"

Such sophisticated young adults would have had checked up Toa Payoh Vets' website at the waiting area with their iPhone 4 while I was having a closed-door discussion with my associate vet. The world has changed tremendously. Internet information flows freely and the clients know much more than the vet sometimes.

The gentleman said: "You operated mainly on Shih Tzus' eyes." This was an excellent feedback from him. I had not analysed my webpage on eye problems in the dog at www.toapayohvets.com. I had not posted other breeds I had treated as it is extremely time-consuming to create webpages to write the case report of all breeds I operated upon. I don't take pictures of all breeds too.

This article took 6 hours to write and to create the supporting images. There are so many things I want to do and I just can't have time to do many of my favourite things if I write case reports of all breeds having corneal ulcers. As a vet who does surgery, the range of surgical cases is from the head to the tail.

I replied: "Shih Tzus have the highest number of eye injury problems in my practice. Any breed with protruding eyeballs may suffer from this corneal ulceration problems. This includes the Pekinese and the Pug."

To cut a long story short, the owners had no objection in my performing the surgery. If they were not comfortable, I would just ask them to make their own decision to select their own vet.

My associate vet watched me doing the surgery. She said she had not seen me doing a surgery. Many of my surgical cases have been passed on to her to do and that was why I had less to do.

This is how I managed the corneal perforation case surgically:

INFORMED CONSENT. I took time to explain the risks of anaesthesia (death as this pug was infected for the past 5 days and could be infected in the blood stream. A delay of 24 hours with antibiotics prior to surgery would be preferred but this was an emergency as the cornea will perforate soon. I advise that I would give baytril antibiotics IV and perform the surgery soon).

I explained the risk of surgery (bleeding, pain, infection, collapse of the eyeball due to infection leading to the possibility of enucleation as the owner had not consulted the vet within 4 hours of the eye injury). The gentleman signed the form.

SEDATION & ANAESTHESIA
"Isoflurane gas alone is the safest anaesthetic for this young pug of 7 months with a possibility of infection of the past 5 days," I said to Mr Saw who takes close notes as he would be operating his own practice in Myanmar soon. "However, the pug's nose is flat and the pug will struggle a lot, leading to perforation of the cornea and collapse of the eyeball. So, what sedation would you give? Your favoured domitor and ketamine IV?"

Mr Saw was not so sure. This was a pug with suspect infection after 5 days or more of eye injury. The pug's eye look like an earthquake and tsunami disaster area as seen in the recent pictures of the calamity in Japan. Big patch of white gel and a stream of red-tinged flow of gel and blood at one end, measuring around 1.5 cm long. A continuous stream if you are observant. It reminded me of the oil spill in the Gulf of Mexico although I did not see the actual leak - only oil slicks in the ocean. Here, I could see the stream. It was fascinating as a case but extremely dangerous for the pug. A delay in treatment and the corneal hole would enlarge and the inside aqueous humour would just splash out. The end of the eyeball, although the vet can still stitch up the cornea. Most vets will not encounter such corneal ruptures or stitching and so it can be quite frightening to encounter this case.

I used 0.2 ml xylazine IV. Waited 5 minutes. The pug vomited out its food as this was the effect of xylazine (and even in domitor or domitor/ketamine IV) Then isoflurane gas.

SURGERY
The 3rd eyelid flap is done. Basically the needle goes into the upper eyelid, then under the 3rd eyelid and back out to the lower eyelid. Tied in a knot. "It will be easier if an assistant pulls out and upwards the 3rd eyelid for stitching," I said to my associate vet as Mr Saw automatically used forceps to do it for me.

SUTURE PATTERNS
Several combinations. For this case, I use 3 simple interrupted sutures. Another case, I used a horizontal mattress and one interrupted. Or just one horizontal mattress.

Question. "Are 3 sutures sufficient?" - Yes.

SUBCONJUCTIVAL INJECTION OF GENTAMYCIN AND DEXAMETHASONE.
I know some vets believe that steroids should not be used in eye ulcerations. Well, a small drop of dexamethasone will alleviate the inflammation and pain and does not cause harm.

"Get me the prednisolone," I said to Mr Saw. He got me the depot prednisolone and I rejected it. It is best to use dexamethasone or prednisolone meant for IV." Well, Mr Saw did as instructed but got the incorrect type. All vets must check the medication before injection. Well, Mr Saw learnt something from this participation in the case. "Use common sense," I said to Mr Saw. I wonder whether he knows what is the meaning of common sense as applied to his offer of depot prednisolone. Details of surgery and comments in 8 pictures at webpage of Toa Payoh Vets - goto DOGS - EYE PROBLEMS or at:
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm

POST-OP DAY 1 & 2
The IV drip continued. Tolfedine and baytril given SC. The pug was sleeping and woke up fresh the next day. Very active. At 3 pm on day 2, the gentleman and his wife visited. They took leave from work. It was one of those money can't buy joys to see the distressed lady back to her normal self.I expect the pug's ulcer to heal in 14 days' time and the pug to go home on Day 3. The outcome should be a white spot in the centre of the cornea and no eyeball collapse or infection.

RETROSPECTIVE REVIEW
1. Why did Vet 1 refer the case to a vet that is not available? This is a mystery to me. He probably thought that the cornea ulcer was extensive, needed stitching and he had no facilities to do it and had referred to my associate vet. However, I was on counter duty and saw the case first.

The eye ulcer looked terrible as if it had a big earthquake. It appeared to be a white reddish gel patch of at least 5-8 mm in diameter. Actually, it was 1-2 mm in diameter when I used a scalpel to scrape away the out flowing blood clot. After scrapping, I showed my assistant the black hole measuring around 1 mm in diameter. Aqueous humour leaked out from the hole. Surrounding the black hole was a circle of basement membrane measuring around 4-7 mm in diameter with the black hole as the centre. This membrane would rupture soon if the owners just don't bother to see Vet 1 who advised emergency eye treatment correctly and professionally.

To estimate the size of the corneal perforation, see the 'stream' of gel coming out as a streak. It was around 2-3 mm. See the images.

2. The pug had a perforated ulcer, not a Descemetocoele. The initial presentation was similar to a Descemetocoele with a streak of gelatinous or eye discharge. So, I said "Descemetocoele" to my associate at the examination room as the dog did not permit proper eye examination.

Under general anaesthesia, after scrapping away the blood clot, a black hole of 1mm x 1mm with watery aqueous seeping out indicates that the correct diagnosis is a perforated corneal ulcer also known as deep ulcerative keratitis.

3. Corneal wounds can be sutured with fine 6/0 sutures. Small perforations are best left to heal with the 3rd eyelid flap surgery. And they do heal very well if the inside of the eyeball is not infected. Can you see the pinkish-reddish blood sediment on the medial inner side of the eyeball in one of the pictures below?

I hope this report will be useful for undergraduates struggling to study so many subjects for their examinations to appreciate the anatomy of the dog's eye and its changes during ulceration.

For readers of my blog, updates and more pictures are in toapayohvets.com, goto DOGS - EYE PROBLEMS.
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm


For readers of my blog, updates and more pictures are in www.toapayohvets.com goto DOGS - EYE PROBLEMS.
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm


Details are in www.toapayohvets.com goto DOGS - EYE PROBLEMS.

368. Starting pay for new vet in Singapore?

Straits Times

ST Jan 1, 2011 Law & Accounting. The MONEY Page.

"Big Four" Accounting Firms - PricewaterhouseCoopers (PwC), Ernst & Young, KPMG and Deloitte pay new graduates more. Starting pay at mid-sized accounting firms $2,100 to $2,400. Big Four pay $2,600 and above.

Big law firms pay $4,500 - $5,000 for a fresh graduate. Foreign law firms $7,500 but with smaller bonuses. Small law firms pay $4,000 - $4,500. So, pay more upfront and less bonus to compete.

So what do fresh graduate vets in the Singapore private sector get paid? Is there a market rate? Or is it performance based?

Internship: no knowledge, skills and discipline

I note that the younger generation doing their 2nd year Junior College and who applies for a veterinary internship has no knowledge, skills and discipline. The applicants are mainly ladies. Many of them have straight As and can get into any undergraduate studies they choose.

However, these Singaporean academic stars don't have hands-on experience nor interests in animal welfare and medicine. Straight As without passion in veterinary medicine. An unwillingness to work diligently and put in the hours.

I am thinking of terminating sponsorship of internship for Junior College students as my staff feels that they are a burden and they are. My assistant Mr Saw actually dislike them according to one of my feedback as they hinder his work. He has to teach them how to take temperature etc and why should he do that? I don't know what Dr Vanessa Lin and Dr Jason Teo think of them.

Many of these young interns and even veterinary undergraduates don't have simple social skills. They come for interviews silently. They don't know simple courtesies which will gain them brownie points, like greeting "Good morning, Dr Sing, Good afternoon Dr Vanessa or Good evening Dr Teo." Some fathers or mothers drive them to the Surgery and wait for them for the interview! They give me the impression that they can't be independent and are tied to the apron's strings.

Does the top school principals NOT impart such skills to their bright students? It is not that I am desperate to be greeted. Not being punctual, disappearing without letting me know. These are what some past interns do.

Therefore, I am thinking of terminating this program for such young people as they have been brought up in abundance and know no hardship. They don't want to work hard and seem to think that the world should suit their lifestyle and way of working late in the day (being night owls). Turning up late for work is a common trait too.

There are 3rd party injury liabilities too. What if the intern gets bitten or scratched by the dog and cat respectively? The parents will sue me to bankruptcy.

For the above reasons, it is wise for me not to accept interns unless they are highly passionate about veterinary medicine, rather than thinking of using the program to pad their resume.

366. Happy retirement?

Dr Sing Kong Yuen

Dear Sir,

I am involved with recruitment for the Freeman Scholarship Program at Wesleyan University in Middletown, Connecticut in the US. We did a recruitment session recently for our finalists. One is a lady with a strong interest in becoming a veterinarian.

I believe we are badly-positioned to help her realize her dreams. Specifically, vet schools in the US are graduate programs, requiring the applicant first complete four years of undergraduate study …. Then take the MCAT exams and go through the entire school admissions process again!

I suggested to her school systems that work on the British system, such as Glasgow. I also suggested the AVA scholarship program. I noted from your website that you attended Glasgow on the Colombo Plan, served with the SAF Provost Dog Unit, tended race horses for the Bukit Timah Club, started your own clinic, and are now headed into happy retirement.

You have walked the path that she is considering. Might you have a moment to take a call from her and give her the wisdom that comes from real experience?

I am an ex-infantry officer who spent his life as a civil engineer building prisons, police compounds and the coastal barrier for the Singapore government. My ability to guide her is terribly limited.

Thank you so much for any help you can give.


With best regards,
Name given


REPLY FROM DR SING DATED MAR 24, 2011


Hi

Thank you for your email. I can always spare more than a few minutes to meet one-on-one to the young lady who wants to be a veterinarian. Phone calls are a waste of time if the persons are sincerely interested in knowing more about veterinary medicine and surgery. During the meeting, I can assess whether the young lady is really passionate about veterinary medicine and surgery. Phone calls and text messages and emails are preferred by the younger generation who don't have the real interests or passion and merely wants to go fishing.

Let me know as soon as possible. I don't know where you get the impression that I am into "happy retirement". I have an associate veterinarian who is younger and takes care of many of my old clientele as there is insufficient rooms for 2 vets at any one time. I still consult and yesterday I spayed a Fox Terrier as the owner wanted me to do it. I am even busier than before in veterinary medicine, travel and real estate.

I hope we can meet one day and not just e-mail. Best wishes.

365. Sunday's case. The dog has no urethral obstruction.

Sunday Mar 20, 2011.

The owner of the Silkie came at 10.20 am on this fine sunshine Sunday. I asked whether she wanted to wait for another vet who would come in around 11 am or to consult me. She said she would not mind consulting me as that was her original intention. She said: "Everytime my dog drinks water, he lifts his leg for some time, but no urine come out. This only happens after the bladder stones were removed by Dr Vanessa." The surgery was done 11 days ago. I examined the dog and palpated the bladder. There was no pain. The bladder was not swollen at all and so there was no urethral obstruction at the os penis. I checked the stitches anterior to the prepuce. They were not inflamed. "The operation by the other vet is 100% successful," I said. "I will have the stitches taken out. As there is no urine in the bladder, I would like to hospitalise the dog for one day to observe and to take urine sample for analysis."

The client pointed to a right eye which had pus and red conjunctivitis. I examined it and showed the wife that the dog had a 10-12 o'clock patch of corneal ulcer. The owner had been using eye drops for the last one month but was unsuccessful.

Soon, the other vet arrived. I told the lady owner who came with her husband that I would work this case together with the other vet although she wanted me to handle it. Working together as a team should be the way in a group practice. However, I could see that the other vet was not too happy with this by-passing. She took the dog into the operating room, catherised it and found no urethral obstruction. She showed the owner that the catheter was passed in easily.

Now, I usually don't interfere with the other vet's clientele. However, many of the clients had been with me for years and therefore a new vet must understand the culture of the workplace and work as a team to be successful.

I had a one-on-one talk with the other vet as regards what she considered as my interference with one of "her" cases. I told her that the case of the Silkie with difficulty in peeing was one of my clients who had just told me that she wanted me to handle the case. However, she had operated on and had done a good job. Normally, I would let the other vet handle my client's cases if they come after 11 am though I would be available. Otherwise it is best not to have another vet present.

I explained to the other vet that I have a responsibility as a licensee to ensure that owners' complaints to me are handled personally. By ignoring their complaint, it would not be good for the practice as matters could get worse such as litigation and the regulatory authority stepping in to investigate.

"So far, only one veterinarian in Singapore had been suspended for 9 months," I told the other vet. "I don't want Toa Payoh Vets or its vets to be suspended due to my failure as the licensee to rectify matters brought to my attention. I could be suspended through actions of my failure to manage the practice vets diligently."

I told the other vet that many clients had been complaining about her dog barking at them in the waiting area. The dog was free to wander around and I had not banned this dog yet. He would eat out of a bowl in the waiting area and spilled its food onto the floor. I needed to get the waiting area cleaned up. I still remembered this tall sun-tanned blonde Caucasian woman with broad shoulders. She was visibly upset and held her cat close to her chest when Dr Vanessa's dog approached her in the waiting area. I was present at the receptionist counter and apologised to her saying: "This is the other vet's dog." She was consulting Dr Vanessa and managed a weak smile. She was too polite to say anything. This dog had a habit of going to the holding area to pee (urine marking) and barking at the other dogs for a short time.

If this dog belonged to the staff, I would ban the dog strictly or asked the staff to work at a big practice if she persisted. There is a limit to this dog's behaviour which upset clientele. And today, Sunday, I had to make a decision.

After so many years of living, I know that there is no point having the best vet or veterinary technician or intern in the world if he or she does not appreciate the culture and environment of the workplace. I would not hesitate to ask the staff to go.

Nowadays, I have to be stricter in the management of interns, veterinary technicians and vets. Singapore has become a litigious place. Veterinary surgery is becoming very competitive with many younger vets opening their practices. So, there is no point retaining non-performers as that would ultimately lead to the insidious decline of the practice. In any case, I am realistic enough to know that any new vet working in Toa Payoh Vets are just marking their time to open their own practice after gaining experience and clientele.

As for the dog that tried to pee when he drank water, bladder palpation would rule out any urethral obstruction. The dog was operated successfully and the bladder was not even full as catherisation by the other vet brought out no urine.

As the owner preferred me to handle her case, I told the owner that a urine sample was what I recommended just in case there is bacterial infection of the bladder or some small stones from the bladder as this was possible and said by the other vet.

I asked for the X-ray but the owner had kept it since the other vet had the practice of giving X-rays to the owner to keep.

I know that the dog was still on antibiotics but there is still the possiblility of cystitis if the bacteria is not sensitive to prescribed antibiotics. Since the bladder was palpated to be emptied, this showed that the dog could pee all urine at one go. I asked the owner: "Does your dog pass out all urine at one time?" The owner said: "Yes."

"It is possible that there may be stones from the kidney as the other vet had just said," I explained. "The dog may have some association with the need to urinate when he drinks. He might have this behaviour when he had urinary stones for some time and you might not have noticed that. The stitches are just removed and a pain-killer injection is given. We will wait another 7 days to see what happens."

I gave the owner a urine collection container as she did not want to hospitalise the dog nor treat the eye ulcer surgically. I asked the lady to sign a letter stating that she was bringing the dog home against medical advice to be hospitalised for observation and treatment of the eye ulcer. Nowadays, I advise all the vets has to record all instructions in writing as proof if there is litigation. The owner signed and left quite satisfied, in my opinion.

Opening a vet surgery does not mean the vet will be able to sustain his or her profitablility, I explained to the other vet. There are high capital investments and many new practices set up with the father's monies are not able to sustain their operations. A high standard of service and successful outcome in surgeries as perceived by the owner brings in referrals.

There are over 40 practices and the owner has a wide choice nowadays. There are practices full of waiting clients and there are also quiet ones. More practices will be opened as vets who can't work in group practices prefer to strike out on their own.

364. Informed Consent and Against Medical Advice (AMD) - to get it in writing

Sometimes, I do not record in writing my advices to the pet owner to treat the dog or hamster and do not record that prognosis is poor. This is not a good practice as in litigation, the judges want to see the written word.

In one case reported in the Straits Times on March 18, 2011, I was shocked to read about a very experienced surgeon from the Singapore General Hospital being suspended for 3 months on one of the 3 charges of not giving INFORMED CONSENT. The 3 judges believed in the complainant and said that the case records and brochure put up as defence by the doctor did not mention the risks of pain, bleeding and infection being told to the patient. Definitely, the brochure did not mention the risks. Therefore, the judges decided to suspend him for 3 months for not giving informed consent. The patient had had abdominal pains after surgical removal of his piles in 2006. The rectal area was infected post-operation.

I was shocked because this surgeon provided excellent services to me when I underwent colonscopy by him. Excellent bedside manners. Efficient and competent. His nurses assured me that he would not take a long time to do the colonscopy as he is experienced. I was given a sedation by a lady, probably a nurse. She inserted another syringe (probably with saline) to give me the full dose. I just slept. No pain or groginess after colonscopy. It was as if I had a nap. I asked the doctor what injection it was and he did tell me.

In between reading the lines in the newspaper report (mentioned twice), it seemed that there was a warning to doctors to provide a higher standard of care and that means informed consent for everything and proper writing down of advices and risk given. I have an informed consent form for every tasks and procedure nowadays and read to the pet owner the content.


GOLDEN RETRIEVER PUPPY 5 MONTHS, MALE, WITH SMELLY BLOODY DIARRHOEA

The owner wanted me to treat his dog rather than Dr Vanessa and this is because I had treated his other dog for the past years. Dr Vanessa also had owners who just wanted her to treat their dogs or pets.

The puppy had pale gums but not white. It had passed smelly bloody diarrhoea for 2 days but no vomiting. Just give an injection and medication and send home? This would be the standard treatment.

No blood test, no X-ray and no IV drip? This case was not to be taken lightly as the puppy had passed smelly bloody diarrhoea for 2 days. I advised hospitalisation for 2-3 days. The owner insisted on taking the dog home in the evening, after IV drip and treatment. Some owners don't like dogs to be hospitalised and some don't like to pay more than necessary.

"Let the dog go home," I said to Dr Vanessa. "If the dog dies at home, the owner had been told that the dog needed to be hospitalised to give the IV drip." I ought to record in writing as I was the main vet handling the case and would be hauled up to court even though I did this case with Dr Vanessa. But I did not record this done. Nor did I record my prognosis of 50:50.

This would be a serious mistake if the puppy died of bleeding and infection and dehydration. Therefore, I have to be more careful to write "AMD". Family members might sue me, though the owner might not. Dogs are family. Times have changed. All doctors and vets have to be much more careful as litigation takes up a lot of time.

GOLDEN RETRIEVER
X-Ray - "Lots of gas in the large intestines with a lot of fine particles like soil," I discussed with Dr Vanessa. She was not really convinced but this is OK as each vet has his own opinion. The owner did not tell me that the dog had gone to the East Coast beach the day before diarrhoea and had eaten lots of sand. He told me and apologised for the omission the 2nd day when he took the dog back accepting my advice (dog panting, lethargic, did pass non-smelly stools in a soft lump, could eat). I said that the dog had no diarrhoea due to the drugs given. The intestines, being bleeding needed time to heal and the food intake irritates the gut.

Blood test from Day 1 showed:

haemoglobin 12.6 (12-18)
Red cell count 5.3 (5.5-8.5)

total WBC 17.9 (6-17)
Neutrophil 49.16% Abs 8.80
Lymphocytes 31.40% Abs 5.62
Monocytes 10.17% Abs 1.82
Eosinophils 8.66% Abs 1.55
Basophil 0.67% Abs 0.12

PCV 0.34 (0.37-0.55)
MCHC 37 (32-26)
Platelets 241 (200-500)

The owner accepted the advice to hospitalise the puppy for 2 days. Should be able to recover and go home well. Many vets read blood test as one single event. Actually, one should read it as a starting of a disease process. In this case, the intestines have bleed seriously and dehydration and bacterial infection had gained a foothold. Not so bad, but enough to cause the dog to pant (in pain and in infection) and lethargy. Without IV drip, I think it would just pass away due. In this case, there would be a failure to record advices given to the owner as to hospitalisation and IV drip, X-ray and blood tests if these procedures were not done. All bets are off if the puppy dies. It is a very emotional experience for the family and many question the competence of the vet. Litigation would be in their mind.

363. Sibling Illness 2 - The Vomiting Ragdoll - Part 2

Case written at Paya Lebar Public Library Mar 17, 2011 7.00pm
Takes an hour just to write this case of sibling illness!

Although the case was well handled by Dr Vanessa, I reviewed the case with the Australian owner as I am the licensee and have grave responsibilities to ensure that owners are satisfied with the services and to maintain the high standard of care expected by a reasonable man.

Continuing the review, I asked my assistant to take out the blood test results of Ragdoll 2 done recently by Dr Vanessa.

TWO BLOOD TESTS OF RAGDOLL 2.

March 9, 2011
Urea 6.3 (7.2 - 10.8)
Creatinine 89 (71-160)

Total White Cell Count 41.9 (5.5 - 19.5)
Neutrophils 93.32% Abs 39.10
Lymphocytes 4.25% Abs 1.78
Monocytes 1.77% Abs 0.74
Eosinophils 0.43% Abs 0.18
Basophils 0.12% Abs 0.05
Platelet 584 (300-800)


March 14, 2011
No kidney and liver tests done. The following were the results




Total White Cell Count 19.4 (5.5 - 19.5)
Neutrophils 80.41% Abs 15.6
Lymphocytes 13.30% Abs 2.58
Monocytes 3.87% Abs 0.75
Eosinophils 2.11% Abs 0.41
Basophils 0.67% Abs 0.13
Platelet 389 (300-800)


COMPARED TO RAGDOLL 1

BLOOD TEST OF RAGDOLL 1.
Date Mar 4, 2011 (date of admission to Toa Payoh Vets). Had 2 weeks of vomiting and treatment of 4X by another vet practice.

Urea 16.9 (7.2 - 10.8)
Creatinine 83 (71-160)

SGPT/ALT 91 (<121) SGOT/AST 214 (<67) Haemoglobin 6.6 (8 - 15)

Red cell count 5.1 (5 - 10)
Total white cell counnt 10.4 (5.5 - 19.5)

Neutrophils 95,00% Abs 9.88
Lymphocytes 2.50% Abs 0.26
Monocytes 1.44% Abs 0.15
Eosinophils 1.35% Abs 0.14
Basophils 0.00% Abs 0.00


PCV 0.21 (0.24 - 0.45)
Platelets 152 (300 - 800). No platelet clumps but few giant platelets present.


To cut a long story short, Ragdoll 1's lifestyle was to catch the gecko in the living area and ate it. No rats or cockroaches in the house. Ragdoll 2 does not catch but would eat part of it.

Therefore, Ragdoll 1 lost weight over time as some geckos could have had been poisoned by insecticide by neighbours as this Australian does not do it. When they come over, Ragdoll 1 pounced on them and ate them.

As evidence, the haemoglobin and platelet counts were low, meaning the bone marrow was depressed. A possiblity of toxaemia either from the bacteria and pesticide inside the gecko or both. The owner was quite satisfied with this epidemiological result and would keep the cat upstairs when he was not at home as there were no geckos upstairs. A chronic toxaemia would explain the weight loss in the young Ragdoll 1 and a big dose of bacteria in Ragdoll 2 from another gecko could explain its high fever from infectious bacteria. Would the reader agree?

362. Sibling Illness 1 - The Vomiting Ragdoll - Part 1

When one young sibling is ill, will the other sibling get infected? This depends on the diagnosis. Recently I encountered two cases of sibling illness. One case was of two male ragdoll cats, 11 months old.

The other case was not under my care but the owner, being my wife's ex-classmate phoned me for a second opinion as she was worried that the living 6-month old Golden Retriever X, now healthy might suffer from the same disease. This would be written in Sibling Illness 3 - The Vomiting Golden Retriever X

CASE 1.
"My wife consulted Vet 1 and Vet 2 for 4 times in the past 2 weeks, but the cat continued vomiting. We told the vets that the cat was not putting on weight compared to his sibling." He consulted Dr Jason who took a blood test and gave the necessary IV drip. The cat died overnight. I saw the owner the next day. He appeared upset and so, being the Practice Manager which is equivalent to the KEO or licensee, I spoke to Dr Jason as to what was going on. Dr Jason said that the owner thanked him and was not unhappy. This is the type of emotional situation where a blood test gave clues to the cause of illness and satisfy the owner.

BLOOD TEST OF RAGDOLL 1.
Date Mar 4, 2011 (date of admission to Toa Payoh Vets).
Urea 16.9 (7.2 - 10.8)
Creatinine 83 (71-160)

SGPT/ALT 91 (<121)
SGOT/AST 214 (<67)

Haemoglobin 6.6 (8 - 15)
PCV 0.21 (0.24 - 0.45)
Platelets 152 (300 - 800)

The cat was recumbent. 2.5 ml of blood was taken from the femoral vein and put into 3 tubes for laboratory analysis. With the blood results, Dr Jason had supporting clues as to why the cat had died and the owner was satisfied and his unhappiness was "why the other vet did not take blood test".

His questions to me today, Mar 17, 2011 when I met him again while his 2nd cat had been treated by Dr Vanessa for constipation and 6 days of hospitalisation earlier for fever (very high white cell count) were as follows:

1. Why didn't the vets take a blood test? He said it could be that the cat was treated by different vets in the practice.

2. Would the first deceased cat be saved if a blood test was taken earlier?

3. What was the cause of the illness, leading to weight loss compared to his sibling? Both lived in a house, had freedom to roam, fed canned food and given dry food unrestricted.

I took out his case sheet for the Ragdoll 1 to review the case and asked him more history. This required time and so time is seldom available for most vets.

"Did your first cat prey on lizards and cockroaches?" I asked since the 2nd cat treated for a high fever had a very high white cell count.

You can't teach an old dog new tricks?

Case study: You can't teach an old dog new tricks?

I am reminded of an English idiom I had to memorise and understand for my PSLE (Primary School Leaving Examination) exam in Primary Six in 1962 when I was 12 years old. The only dogs I saw in the Redhill area I lived (there was actually a real red hill) were stray dogs and no resident in the S.I.T (Singapore Improvement Trust) apartment keep dogs as pets. It was the 1960s and the residents were the working class. I am sure the rich families living in Cluny Road or the other areas keep dogs as pets. As for me, I had never seen dogs performing as there was probably no TV yet or at the most, a black and white one.

This idiom was: "You can't teach an old dog new tricks". What did it mean to a 12-year-old boy whose life was decades from being an old foggy.

When I encountered the real situation yesterday, March 16, 2011 during a class I had to attend at 60 years of age, I could understand the meaning of the idiom. See whether you agree with me as to whether the story explains the idiom succinctly?

On March 16, 2011, I attended a REA course which lasts 2 months with lectures 3x/week from 10am - 1 pm. A fair lady in her late 30s who is in the family of developers said: "I am too old to study. When is the examination? I have to go overseas in May."

"The exam is in May," I said. "After the end of the course, you will get a completion certificate (75% attendance needed). Then you can register for this examination conducted by Informatics. It is best to take this May exam after the lectures if you wish to have a better chance of passing."

Our lecturer, white-haired and trim in his late 60s said: "I can pass the exam and you are much younger. If you put your mind to it, you will pass. My student studies 3 hours/day and he passed."

I said: "You must have missed renewing your real estate licence with the IRAS (Inland Revenue of Singapore) before the CEA (Council of Estate Agents) takes over the regulatory functions in 2010. Otherwise, you will not need to take this course."

"Yes, for the last 3 years, I did not renew the licence with the IRAS."

All licences must be renewed but in this case, the IRAS did not provide the electronic debiting of licences unlike the CEA. The IRAS declared that all realtors had to self-renew and no reminders would be sent.

There were those who did not do so. When the CEA took over, these were the fishes trapped in the net and if they want to be the KEO (Key Executive Officers) of their realty firms, they have to take this REA examination. No mercy or compassion from the CEA even if you have the CEHA certificate. I had the CEHA but I had not renewed my licence. Bad luck to me. So that is why I am in class studying the laws of tort, contract, architecture notes and more regulations.

My class-mates appear to be over 30 years mainly and I presume we are all in the same boat as this developer.

The mind must not think "old" if one wants to live longer and be successful in examinations. Otherwise, the self-fulfilling prophecy kicks in - you think you are old and can't pass the exam or be successful. So, your mindset becomes negative and you really age soon.

The lecturer had 5 shophouses to sell at $14 million for re-development. He asked this developer firm for her name card. Then he threw his name card onto her table.* I asked for one too. One must network and think positively.

P.S. In some cultures, throwing the name card to another person may not be polite. It should be handed with two hands. You will see Japanese businessmen handing name cards with two hands as that is their way of doing things.

This lecturer was very supportive and encouraging. He is a very good lecturer. He said to me: "Just study my CD. Or you can download to your phone for reference." I was surprised that this could be done. He showed me his Nokia phone and there were the notes. According to some classmates, the notes in the CD needed to be printed in 400 pages! There are so many new technology and if one knows how to use it, one could just study from the smartphone when one is free. This may be a useful tip to veterinary undergraduates. The old lecturer had someone to download the CD for him as I asked how he did it. Always ask and you will find that people usually are kind and will answer your "stupid" question.

From this experience, write down a list of licences to be renewed on a piece of paper and display in front of your desk. Nowadays, most Singapore government departments don't do what the IRAS did to the realtors. They send e-reminders and that should be the way to serve the tax payers.

Sunday Mar 13, 2011's two interesting case

CASE 1. The case of pug with the swollen male private part.

The lady owner who has nursing knowledge apologised for phoning me on Saturday and said: "Remember my pug with the urinary stones? But now, my pug has a big swollen penis for some time. He could be humping. Is it serious? Will he recover with time? What is the cause? It can't be urinary tract infection as his urine is OK."

This is the type of question that is very difficult to answer. If I said yes and the pug self-mutilated his penis by further licking causing bleeding, I would get an unhappy owner who would lose confidence in my judgment. So, it was wiser to get her to bring the pug for examination and treatment to bring down the penile engorgement.

"I don't know," I said. "It is best to send the pug down for treatment."

The pug was still having the big swelling when the lady brought him to consult Dr Jason Teo who was on duty on Saturday. His injection brought down the swelling. I did advise collection of urine for analysis and hospitalisation for one day. It would be negligent not to do so.

Urine test showed no bacterial infection or urinary crystals with the pH being 6.5. However blood in the urine was 4+ (a lot) and there were protein casts.

So, what was the problem? Self-stimulation? Kidney trauma causing bleeding inside the urinary tract?

The dog developed fits during hospitalisation. So, could the dog have injured his penis when he had fits or penile engorgement due to fits? Since most fits have unknown causes, it was hard to say. I phoned the owner who had not witnessed any fits said: "So the cause was due to fits."

This was a strange case. I did advise neutering but she would not do it.

CASE 2. Left thyroid malignant tumour.
The couple had this Beagle for 15 years. When she was not eating properly, he sent to me for dental scaling last month. Then, last week, he showed me the video of the dog gulping and "snorting" after swallowing. A left throat lump, the size of a 50-cent coin

359. Mis-treatment by a famous surgeon

This was a story related to me by a 30+ lady who had her rabbit treated by me. Her friend, also 30+ had a tumour near her heart and consulted a famous experienced surgeon in a government hospital.

"This surgeon had done many of such cases before and they were benign tumours. So he opened up the chest but the tumour was malignant," the rabbit owner said. "Worse of all, he could not remove all the tumour tissue. Imagine my friend's distress. If it is diagnosed malignant before the operation, chemotherapy could be used to shrink the tumour before operating. Now, my friend could not be given chemo-therapy and must wait 6 weeks."

"Waiting with malignant tumour inside her chest was very stressful. And the surgeon is a well known doctor in this hospital."

"Could a biopsy of the tumour be done to see whether the chest tumour is cancerous or not before proceeding to sugery?" I asked. She didn't know and neither did I.

"Did your friend seek a second opinion to get an earlier date for chemotherapy?" I asked.

"No," the owner said.

"So, what happened?"

"Well, my friend had chemotherapy 6 weeks after the operation. She is recovering in Europe."

Medicine springs some surprises to doctors and veterinarians. It is wise to do biopsies for chest tumours unless the owner does not want it done. The common practice for surgeons may be just to take out the tumour and send for histopatholgy test, rather than wait for biopsy results.

358. Malignant tumour left neck - disc shaped

Sunday Mar 13, 2011 Blue skies, white clouds, sunshine
2 interesting cases

CASE 1. Beagle, 16-year old.
The owners, a couple in their 40s, were kind enough to permit me to use their dog case for education of vet students.

HISTORY
In

357. Singapore's education system data

Reference: Straits Times, Mar 7, 2011 A19 "An education in mobility"

What is the actual situation of the Singapore's education system? Does one's family background - rich v. poor parents affect the child's ability to stay at the top or bottom of the social ladder respectively? This means that the rich becomes richer and the poor becomes poorer in Singapore.

MINISTRY OF EDUCATION'S STATISTICS
said that students from poor homes can still move up, giving example that the top 5% of the Primary School Leaving Examination pupils are consistently distributed among the 95% of the primary schools and not just the elite ones. In addition, >90% of each cohort goes to publicly funded post-secondary institutes and almost 50% of students who live in one- to three-room HDB flats make it to universities and polytechnics.

In my opinion, almost 80% of the population lives in HDB apartments. How many % of the HDB group goes to universities which exclude long-distance studies? Did the MOE provide such figures? Unfortunately, I don't know.

Education is a priority for Asian families. The children from disadvantaged homes cannot afford the expensive early, pre-primary education and so, will be always at a disadvantage. But is it necessary that 80% of the students go to universities when there are not sufficient places and ability?


Reference Straits Times Mar 8, 2010 frontpage

Education Minister Ng Eng Hen said:
1. One in 10 children from one- to three-room flats goes to University. 4 in 10 goes to polytechnic.

2. 1 in 6 children from the bottom third of the socio-economic ladder scored in the top third of the PSLE (Primary School Leaving Exam) cohort. 1 in 2 scores in the top two-thirds.

3. Every primary school produces at least 10 pupils who score in the top third of the PSLE.

So, better opportunities for every child, said the minister.

356. Monday's 10 am appointments

Two clients wanted to consult me and so made an appointment at 10 am.

CASE 1. Cairn Terrier, Female, Not spayed, 2 years.

SKIN ITCHINESS
Keeps scratching all over the body. "Why?," the pastor asked me. "Can it be due to the dog food? I buy various brands and mix them."

"It is possible," I said. "Dry dog food allergy does occur, making the dog itchy." The only area with black spots due to dried up blood from skin pustules and scratching was the inguinal area, near the vulva. The vulval lips were much swollen around 20X and the mammary glands were full.

FALSE PREGNANCY
"Your dog had heat 2 months ago," I said to the pastor. "She will be behaving strangely, like carrying an object in her mouth, loses appetite, get aggressive or withdrawn?"

"None of the behaviour you mention," the pastor said. "As you know, dogs like air-conditioned rooms but lately, she just go to the kitchen to sleep. Very strange behaviour!"

"She thinks she wants to give birth soon," I expressed minute drop of milk from her mammary gland. Too little to be seen when I asked intern Michelle and the owner to see. However, another swollen nipple produced some secretion.

"Your dog is suffering from false pregnancy," I presumed the dog was not bred as the owner did not mention about breeding and from his looks, was very astonished at seeing swollen mammary glands and a bit of milk. "Was she mated 2 months ago?"

"No, no," the pastor said. "How to prevent this from happening again?"

"The only solution is to spay her," I said. "Otherwise, the false pregnancy comes again. Did you want to breed her and get some pretty Cairn Terrier pups?"

"Yes, but I can't find any male."

I said: "Enquire from the dog breeders in Pasir Ris, your seller or the Singapore Kennel Club. You may have to pay a fee of a few hundred dollars without guarantee of success. Spaying her would be better as she is likely to get pyometra in later life. Do you know what is pyometra?"

The pastor had no clue and I explained that it was an infection of the womb with lots of pus inside. Sometimes the dog can die from toxaemia due to delays in seeking vet treatment.

As for the skin itchiness, I checked the ear canals. Dark brown ear discharge. I asked the intern to check on the microscopic examination. Nothing was seen. "The brown stuff keeps coming back after ear cleaning," the pastor said.

I advised ear irrigation and let the pastor tried. He squirted the 20 ml syringe of water and wetted me and the whole table. I did it for him and lots of brown wax flushed out from the left ear.

The ear infection and the anal sac impaction (black liquid in moderate amounts) and the hormonal imbalance of false pregnancy could cause the dog to be itchy. "Resolve the basic problems first," I advised. "Before you think of dog food allergy."

Ear ointment was given. "10 drops/ear/week." I said. "Excuse me for saying this to a man of religion - you must apply the ointment religiously for one month or two and let me know if there is still scratching. If not, then the infection has cleared."

The pastor asked me: "Are you retired?"
"No," I said. "It is better for a younger vet to continue the services of Toa Payoh Vets as I am 60 years old and if I don't plan to have a successor, all my clients will suffer in the long term. That is why I don't hang around every day as Dr Vanessa is experienced."

CASE 2.
BACK ACHE

The old Shih Tzu had seen me in March 2010 for a deep central corneal ulcer which had healed. Black pigmented central area with opaque ring. I tried taking pictures under the sunlight with my assistant holding the head and everting the eyelids of the right eye, but they may not turn out well. Need to practise how to do it.

"The dog seems to be walking lame," the mum said. Her daughter is in Melbourne studying Masters of Nutrition. I put the dog on the floor and observed. The dog walked ataxic as if drunk. The hind legs were slower in movement. This looked like a case of spinal disc prolapse. I put the dog on the examination table, pressed the T/L spinal area from the neck backwards. The dog winced in pain.

"It is not serious now, but this dog must stop jumping from the sofa," I said. The daughter had been encouraging the dog to jump from puppyhood and now, after 8 years, he has backache problems.

This seemed to be the 2nd recent case of back pain. The first one was th Chihuahua which went for extensive testing by Vet 1. So, will there be a 3rd one? Things do come in 3s.

355. Sunday Mar 6, 2011 interesting cases

Bright sunshine day. My assistant phoned to say I had 2 appointments at 10 am.

CASE 1. A slim mother came with a black and white rabbit and two slim pre-teen daughters. The mother said: "The rabbit has this roughness on his feet and ears. What is the cause and whether the disease will infect people?

"I felt itchiness in my elbows," the mother flexed her left arm and scratched her left elbow.

"It is scabies mite infestation," I said to the mother and took out the Hills' Vet book of illustrations to show the mites. "Rabbit scabies don't infect people. However, it is possible that the mites may try to bite you but will not be successful. Hence you felt the itchiness in your elbow."

But Hills' book has only the dog scabies. "The mites look similar to these in the pictures," I said. "Rounded bodies burrowing under the skin and causing itchiness and pain to the rabbits."

I asked my assistant to scrape the skin to get the mites after intern Michelle failed to find any. After 3 failed attempts, Mr Saw scraped deeper into one paw till the blood showed. He got ready the bottle of oil to put a drop onto the slide. I stopped him, "There is no need to use oil," I said. "Oil is recommended by professors in college but actually a drop of water will be better. Michelle, get a cover slip to put on top of the skin scraping."

As Michelle who just got 3As in her A-level results on Friday and would be eligible to study veterinary medicine in Australia looked blankly at me, I realised that she did not take Biology in her A-levels. So, I asked Mr Saw to get one. Mr Saw has the habit of putting another slide on top of the skin scrapings for some peculiar reasons. It is difficult to change his mindset sometimes.

This will also do but is not the correct way to do microscopic examination as a cover slip is much thinner and allow better viewing. I took over the viewing of the skin scrapings as the interns and assistants were taking some time and I dislike making other clients wait. There was an owner with a Beagle pacing outside.

I spotted one moving fat brown mite and asked the mum and 2 daughters to see. "You need to adjust the focus," I said to the be-spectacled elder sister who had some difficulty seeing anything. The 3 members of the family finally saw the mite and so were convinced.

"Where do I buy the Hills' book?" Mum asked me. "You can't buy it," I said. "It is given free to vets. But nowadays, the internet will give you all the pictures of rabbit scabies, and so you will get all the information." Elder daughter nodded her head vigorously.

Younger sister was afraid of seeing the rabbit being injected with ivermection 0.1 ml with saline and closed her eyes. "This daughter can't become a doctor," I told the mum. "Elder sister can as she is not afraid of such things," mum said. The thin 1-year-old rabbit squealed after injection. "It can be quite painful," I said to the mum as elder sister looked worried. "I will rub the skin to spread the injection. This rabbit is very thin and it is not good for his health. Feed more hay and pellets."

The younger rabbit at home had the same problem. I gave a Revolution syringe and advised one drop on the skin weekly for 2 weeks as the younger one would be too thin for the injection. "Usually one injection would kill all mites and skin crust will drop off in 7 days' time," I said to the mum. "As to where the rabbit got infested, it would be from another rabbit in the pet shop or breeder. It is a curable disease."

"What happens if I don't get the rabbit treated by the vet? Will the rabbit die?"
"If the rabbit is healthy, it may not die soon. The crusts on the paws, ear edges, nose and eyelids get thicker and thicker. I have seen some becoming cauliflower in shape. It is a painful condition as the rabbit can't get rid of the mites by itself and the mites keep burrowing under the skin and reproducing."

"What about the male scabies mite?" the mum noted that Hills' book stated that female mites burrow under the skin and lay eggs which hatch to become mites. "Male mites do burrow too but the Hills' book did not mention the males." Sometimes, the illustrator or writer can overlook the fact that male scabies mites still need to burrow inside the skin to survive being washed off or killed by sunlight. I have no doubt that the male scabies must burrow under the skin to mate with the female. Well, the book can't mention every aspect of the scabies mite's sexual behaviour.

CASE 2. The 15-year-old Beagle had his dental treatment more than one month ago but now, she had a problem. The man in his 50s took out his video camera and showed me what was happening in real life. He switched on the camera. The Beagle started to eat heartily. Then he made a gulping sound or movement as he tried to swallow the dry dog food. "As if he had a bone inside his throat," the owner said. "I did feed him pork knucle bones after the dental treatment. Could there be pieces of bones stuck inside the throat?"

I put the dog on the examination table, asked my assistant for a torch-light. "The beagle bites," the owner forewarned me. The Beagle refused to open his mouth. My assistant suggested that he opened the mouth while I shine the torchlight and said: "There is a swelling on the left side of the throat." I had not gone into palpation yet as I wanted to see the inside of the mouth. The Beagle didn't co-operate.

"It is unlikely to be a bone fragment or abscess inside the throat for the past 4 weeks," I said. "There is a 50-cent lump on the left side of the neck, where the thyroid gland is located," I said. "It is a painless lump but large. It may be a thyroid tumour or infection. Or possibly a traumatic wound caused by some sharp object into the side of the throat."

The owner did not want blood test or X-rays. So it was difficult to get a definitive diagnosis. "There is slight pain when I palpated the lump deeper," I said as the dog objected in mild pain. At the age of 15 years, this dog had survived anaesthesia during dental work at Toa Payoh Vets some 4 weeks ago. The owner would not want another anaesthesia or surgery as this may kill off his favourite companion. Antibiotics and an anti-inflammatory injection were given and we would wait 7-14 days to see if the lump of 10 cm x 10 cm disappears. I would think it is a thyroid tumour in view of the dog's age of 15 years which is equivalent to a person at 105 years.


CASE 3. I thought I had seen all hamster conditions thanks to various Singaporean hamster owners over the years. Yet this hamster puzzled me. His right hind foot was swollen 50X in two parts. The foot and ankle was swollen as one lump of 1 cm x 0.5 cm. Then there was a narrow normal width of tissue which spreads out to another similar big swelling of the leg muscle.

"How did my hamster get two big swollen lumps in his leg?" the young lady owner asked me. She had previous hamsters treated by me before but this one sure was puzzling.

"It looks like the hamster's leg had been strangulated by a rubber band, stopping blood flow to the foot and toe at first," I said as the lady told me that she observed a swollen right hind foot first some 2-5 days ago. Then, another swelling above the foot. "Then the blood flow above the strangulated thin area is interrupted and the area swells 10X! Now, the hamster starts licking the swollen areas to relieve its pain. The area becomes shiny and purplish."

However the lady disputed my hypothesis. In any case, there is no such small rubber band inside the hamster's crate. Therefore, what would be the cause of the strangulation?

Fortunately, there was a square piece of cloth with holes and loose threads. This was the clue. "This hamster likes to chew towels and cloth," the lady said. "He lives alone."

"It was possible that the leg got trapped inside the hole and the threads wound round the leg above the ankle when the hamster tried to get free," I postulated. "The more he struggled, the tighter the threads wound round his leg, stopping blood supply for some hours. That is why you see a normal thin strip of leg in between the two bulging masses."

The owner was not fully convinced, I think and thought she could take the hamster home. The hamster was warded for treatment and observation. He had a good appetite and even exercised on his wheel despite his handicap. Facts are stranger than fiction sometimes. However, this hamster must be treated or the swellings would be severely infected by bacteria. The swellings have become purplish and that meant gangrenous.

I told the owner that the hamster might not survive long as gangrene had set in. If the right hind was to be amputated, the hamster might die during anaesthesia and so it was not wise to suggest amputation which should be the course of action. If a hamster died during surgery, the vet costs would be higher and the outcome of death would be the same as when the hamster would be treated conservatively with drugs. In either case, the outcome would be the same. Therefore, I did not advise amputation as the risk would be very high.

Veterinary medicine throws up some challenging cases now and then. In most days, cases are routine but the Divine Powers, if you believe there are such existing, throws in a surprise to keep the vet on his toes.

354. Chihuahua with Acute Abdomen.- Part 2

On March 4, 2011, Dr Vanessa and I discussed the case. The dog was Ok - active, eating and had passed stools and water. I noted that this dog had more dripping of urine on the floor of the consultation room as seen on March 2 when he was admitted and I. She phoned the owner to take the dog home.

The owner was reluctant to keep the dog in Toa Payoh Vets as Vet 1 charged around $35/day for hospitalisation according to the bill of over $75 for 2 days.

"We charge $15/day," I sensed that the owner just wanted treatment and bring the dog home. He had said that he could not afford Vet 1's veterinary bills. He was told by Vet 1 who had said: "Some owners had spent $3,000 - $5,000 and still the vet cannot tell what's wrong with his dog."

This was a case which had puzzled Vet 1 and so it would be in the interest of the dog to be warded for observation and urine testing via catheter.

There was no urine in the bladder (palpation) during admission as this dog urine-marked. In any case, he had urinary incontinence and was dripping large drops of urine on the floor of the consultation room when I placed him on the floor to assess his mobility. He could walk normally but was a bit depressed due to the effects of Tramadol given by Vet 1.

One has to be observant as the dog can't talk. I asked the owner: "Does your dog dribble urine onto the floor?" He said: "All the time, since young."

Now, if you take the owner's word at face value, you would think that there was nothing wrong with this dog. What the owner meant was that the male dog urine-marks, by spraying urine onto vertical areas since young. What I meant was that the dog has urinary incontinence which is not normal. It was a clue - a urinary tract infection which persisted despite 2 days of hospitalisation and treatment by Vet 1. Vet 1 had not performed a urine analysis but he had done blood test, X-ray with barium meal, plain X-ray without barium meal and an ultra-sound.

According to the owner, Vet 1 had said that nothing abnormal could be detected in his dog. After spending nearly $1,000 for 2 visits, the owner expected an answer as to why his dog was lethargic, not eating and had difficulty standing on his hind legs. His wife had remembered my vaccination card which was recorded for the puppy vaccination in 2003 and the husband phoned me to get a second opinion about his dog having a swollen "stomach" with no definitive diagnosis from Vet 1.

I had said: "Not all cases can give answers to the owner despite many tests. Such tests are expensive and therefore the vet bills can be high. Get all the records from Vet 1 if you can and let Vet 1 know one day in advance rather than taking the dog out immediately."

So, 2 days after hospitalisation at Vet 1, the dog came to me. Seeking 2nd opinions is a common occurrence and all vets do encounter such situations. It is best to provide the records to the owner directly. That was why I asked the owner to do it with kindness rather than abruptly taking the dog out from Vet 1 to cut costs.

When the owner came, I asked about the veterinary report. He said: "It will take a week for Vet 1 to write the report." I was surprised that Vet 1 would not provide him the report as is common practice. However, the blood test result, the ultra-sound and the CD of the X-rays were available and those were good enough. After all, Vet 1 had already said that he or she was puzzled by the case and so I let sleeping dogs lie.

I introduced Dr Vanessa to the couple and was also present as the couple wanted to consult me. Usual weighing and temperature taking, history taking and general examination were done by Dr Vanessa. I palpated the dog's abdomen after she had done.

During my palpation, the dog reacted in mild pain from the liver to the bladder and prostate area despite being given Tramadol (an opiate derivative) injection and tablets by Vet 1. I remembered my Glasgow Vet Professor calling the presenting sign as "Acute Abdomen". That was nearly 40 years ago and you can see how ancient I have become.

So, what are the differential diagnosis? This was a tough nut to crack as the dog had been given pain-killers by Vet 1 and was "eating" again according to the owner. He was also walking on 4 legs now. Except that he was dribbling urine onto the floor of the consultation room.

To make diagnosis more difficult, Vet 1's blood test showed an increase above normal of neutrophils and granulocytes (which consist of neutrophils, eosinophils and basophils) but with NO increase in white cell count. Normally in bacteraemia, the white cell count would have also increased. The L/N ratio was normal too. So, what was going on inside this dog's abdomen? Due to economic reasons, I did not suggest another blood test. I tried to diagnose this cost with as low cost as possible as the owner had said he could not afford to pay the vet fees anymore.

His wife would be giving birth soon and understandably there are much more expenses. "Will she be giving birth at Mount Elizabeth Hospital?" I asked as this is said to be the top dog in private hospital services. "No, no," he said.

Back to the dog. I tried to reduce as low as possible the costs.
Back to basic. I asked the owner again: "Was your dog unable to stand on his two hind legs?" He had said something to that effect but then all sick and anorexic dogs are lethargic and would not want to stand up at all or take a long time to stand up. But he had said "hind legs." So, that is one clue. It could be presented as a case of paraparesis.

On admission, the dog was walking and standing up on his two hind legs without problems! So, there was nothing to talk about. However, this dog had been given Tramadol pain-killers and since he had no pain, he would be standing on all legs. I was suspecting intravertebral disc lesions, normally at T/L or L or L/S spinal discs at this age. I would expect this Chihuahua to leap from sofa to floor for the past 8 years of his life and now would bear the consequence. Like joggers who pound the pavement when they are young. They get knee pain in middle age. So, this dog could have suffered IV disc prolapse but not on a serious mode yet.

With the dog standing on the consultation table, I pressed the spinal area from neck to tail. Despite Tramadol, the standing dog winced slightly when my two fingers depressed the lumbar area. I repeated the action and elicited the same reaction in front of the couple and Dr Vanessa. So, there was something wrong with this dog's spinal area and he might have got a painful disc. That was why he suffered paraparesis - an inability, temporarily, to stand up on his hind legs.

Pain diffused to cause his stomach to bloat as he could not pass stools normally. He also could not pass urine well and together with gas inside the intestines, leading to bloated stomach. Pain was diffuse causing acute abdomen as the pain of a partially slightly prolapsed IV disc hurt him badly. So, he did not feel like eating and moving. The owner's mother was worried and sent him to Vet 1.

All these hypothesis needed to be confirmed. As I was under the constraint not to add more vet cost to the owner, I asked Dr Vanessa to zoom in on the disc area of the X-ray of the dog's abdomen where barium meal was given and found in the large intestine.

Dr Vanessa put in Vet 1's CD in her lap-top. Suddenly Mandarin songs and music blasted out (Part 1 of the story) to our amazement. It was as if there was a bugle call to attention to soldiers for the forth-coming commander. It was unexpected and therefore quite funny.

In any case, the zoomed area showed some cloudiness over L1/L2 and L2/L3 IV area and slight narrowing of the IV space. With financial constraint, this was my approach to viewing this X-ray instead of a proper X-ray of the spinal disc. One has to be understanding of the owner's financial wishes as vet tests can add up.

However, the urine test was compulsory. It showed ph 8.0, bacteria ++, amorphous phosphate crystals ++, indicating an INFECTION-INDUCED STRUVITE UROLITH. Now, there was protein +++ in the urine which could indicate cystitis (thick-walled bladder felt by me during palpation before the dog goes home). This was another medical problem and needed to be followed up.

The dog was OK and went home with instructions of no more jumping from the sofa at all, antibiotics and advice to neuter (to prevent prostatic hypertrophy, infection or tumour). The dog needed urine analysis review. Old dogs need more care and annual health screeing if the owner wants the dog to live to a ripe old age and not to incur expensive vet bills. But sadly, most Singapore owners do not bother.

352. Chihuahua with Acute Abdomen.- Part 1

It was 2003 when I vaccinated this Chihuahua puppy and 8 years later, the original owners phoned me to ask for a second opinion of not eating and a "swollen stomach".

Vet 1, during the 2nd consultation, had taken blood test, barium-meal X-ray, ultrasound. According to the owner, the Vet 1 could not find anything wrong with the Chihuahua.

"I can't afford the vet fees anymore," the husband said as he had spent around $1,000. He had kept my vaccination card of 2003 and so gave me a call to quote my fees.

"If all the tests are done and nothing can be found in the abdomen, I would propose a laparotomy to open up the abdomen. This is risky as the dog is ill. If the dog has abdominal tumours, twisted intestines or stomach, inflamed livers or spleen, then this surgery would let you know the cause of the swollen painful stomach and you can decide what to do next. However, this would be the last thing to do. The cost is around $500 but I can't say exactly.

To save money, you need to get the case reports and test results from Vet 1," I discouraged him from taking the dog out immediately as it was under I/V drip for only 2 days and he should give Vet 1 some time to close the case. I gave him an appointment at 12 noon the following day and did not expect him to turn up.

He came without the case reports saying "Vet 1 says he needs to take one week to write the report!".

"It is Ok," I said. "In one week, it will be too late for the dog if he is not eating."

The husband took out a CD from Vet 1. I would handle this case together with Dr Vanessa Lin as two heads are better than one. She put the CD into her lap top and suddenly loud Chinese songs blasted through the silence.

"Wow, your laptop can play Chinese music with this CD!" I tried to inject some humour in this serious situation and to break the ice as the couple expected only me to handle their case. Normally, no music would be heard on insertion of a CD and I was thoroughly surprised by this laptop's behaviour. I wondered whether Vanessa had a new model?

351. Rabbit anaesthesia - sharing knowledge via the internet

Very few rabbits are spayed as most owners in Singapore and in other countries don't bother to do it. Therefore most vets in most countries don't have much opportunities to use anaesthetics to spay rabbits unlike in cases of dogs and cats.

Vets who work in rabbit shelters seldom share their knowledge as there is no monetary incentive.

However, injectable anaesthetics used are safe in the spay of normal rabbits. Use isoflurance by gas mask for a few seconds to top up moving patients. If no gas, use injectable anaesthestics in half or quarter doses. Analgesia is very effective. I did record four rabbits being spayed and neutered in one case in www.toapayohvets.com at:

http://www.bekindtopets.com/animals/20081129Rabbit_Anaesthesia_Spay_Neuter_ToaPayohVets.htm


Today I got an email from a young Italian vet who spayed a rabbit after reading my blog. It was great to know that she had good success. That is good news for rabbits too as rabbits do develop uterine cancer in old age and spaying prevents such cancers.

EMAIL FROM ITALIAN VET MARCH 3, 2011
dear dr Sing,
i'm an italian young vet, dr ....., and i read your blog about anesthesia for rabbits..and i used premedication with atropina and your method n 2 with zoletil and isofluorane and than analgesia for a rabbit neutering....it was fantastic!

i was scared to anesthetize a rabbits cause i never learnt anything about this at university..but i tried!!

everything was good except her uterus....it was so fragile...it's normal in a rabbit or it was cause she was in estrus?
now she is ok, and she ate few hours later anesthesia..
thank you so much...i hope i have your reply...

EMAIL REPLY FROM DR SING DATED MAR 3, 2011

Hi

It is good to hear from you. I was in Italy in 13 December 2011 just as snow started. Beautiful countryside and people. I like Venice, Pisa, Rome and Florence.

1. In reply, very few vets do spays on rabbits because the Singaporean owners do not usually request rabbit spays and there is the perception that anaesthesia is risky in rabbits. .
2. The uterus is more fragile than in dogs and cats especially when in estrus.
2. Can you share with me the weight, dosage of zoletil used and analgesia for my knowledge?
3. What is the address of my webpage you saw?


E-MAIL REPLY FROM ITALIAN VET MAR 4, 2O11

oh i 'm so happy you reply me so soon!
in italy, there are very very few people that request to have their own rabbits spayed...maybe because the majority of Italians eat rabbits!
...i live in the southern of Italy, and not all animals have the possibility to be visited by a vet...cultural problems may be..there are few rabbits in the houses and not many people know they need a vet!
so your...or...may be not your site is: http://singaporerabbits.blogspot.com/2010/01/2-anaesthesia-giant-rabbit-and-guinea.html

i used atropina in 0.5mg/kg and than zoletil 100 between 5-25mg/kg IM (my white rabbit was 3 kg and i do first 0.15ml of zoletil...but it was quite calm...so i do inject another 0.15 ml. she started to be very quiet..eyes closed...and so, after a few minutes, i put on her face a isofluorane mask on 2%, than 1% during all the spay.
Before I start to cut her skin i gave flumixin meglumine in 1mg/kg, so i used Finadine in 0.02ml/kg, i read its effect will start just 2 hours after administration IM.
20 minutes after the end of spay, she cried nervously for few seconds...and then she sat calmly in her little cage..
in 2 hours she started to eat normally, and now, 2 days after spay, she can standing up and she is very sweet!
I do not use antibiotics after surgery...because i'm scared to do it..
she is very good...i nurse her every day, and she cleans her cut, with intradermical sutures, she can't put off it.

i hope i can ask you in future just to have your help!


COMMENTS
An excellent description by the Italian vet.
Due to lack of time, some of my webpages are at blogger.com and some at www.toapayohvets.com. In blogger.com, it is easy for me. No need to upload files and link it as in toapayohvets.com. I could just type, click "post" and the webpage is there! In toapayohvets.com, I need to FTP the file to the site. Then I need to get the hyperlink and put it into my front page which is www.toapayohvets.com. This takes a few minutes.

FOR THE BENEFIT OF READERS,
The website refered to by the Italian vet is in one of my blogs at blogger.com. I reproduce as follows:
2. Anaesthesia - Giant Rabbit and Guinea Pig
BE KIND TO PETS
bekindtopets.com community education
Sharing knowledge with veterinarians

Giant Rabbit Neutering
The vast majority of Singapore pet owners keep small rabbits of around 2-3 kg. So my staff quoted the normal prices of $75.00 for neutering of a rabbit. A price list is displayed prominently at the reception. It says: "Castration, rabbit, $75.00"

However, a giant rabbit was presented after the owner phoned for a quotation. Unfortunately, my staff had never thought of asking its weight, unlike the case for dog neutering. A Giant Fleming Rabbit of 5.2 kg turned up. He was extremely hyperexcitable. This type of temperament is a high anaesthetic risk.

METHOD 1.
One method is to use injectable anaesthesia of zoletil IM, 5 minutes later, give domitor IV via the ear vein.
However, this method seems to be unsuitable as restraint and injection causes the rabbit to move a lot.

Zoletil 50 0.2 ml IM
Waited 15 minutes
Wanted to give Domitor 0.2 ml IV, ear vein.
Still struggling. Abandoned this method in favour of Method 2.
METHOD 2
Zoletil 50 0.2 ml IM given. In around 7 minutes, the rabbit staggers and by the 15th minute, the rabbit was recumbent.

However it exhibited excitation when the ear vein was pricked and moved away.

So, I used isoflurane 5% gas by mask.
Isoflurane gas - mask - maintenance at 0.5% - 1% was excellent. The rabbit was neutered without problems.
METHOD 3
Xylazine IM, Ketamine IM is another method I used for smaller rabbits of around 2 kg. Isoflurane Gas top up may be necessary.
This Giant Rabbit recovered after 30 minutes and went home. Method 2 is the best method for me but each vet has his own preferences.

Guinea Pig Neutering
In a 4-month-old, 700-gram male Guinea Pig I neutered recently, Zoletil 50 0.1 ml IM was given. Then a few seconds of isoflurane gas at 1-2% provided excellent surgical anaesthesia when the guinea pig moved. The guinea Pig woke up within 1 minute after neutering was completed.

As rabbits and guinea pigs are not starved 10 hours prior to anaesthesia and surgery, unlike dogs, I neutered this guinea pig 4 hours after the young lady owner brought him in for neutering to prevent breeding. "It is much safer to neuter than to spay the guinea pig," the young girl told me. "You are correct," I replied. "Spaying takes a much longer time and require internal access inside the abdomen."

After Zoletil injection, a copious amount of yellowish-brown fluid came out of the guinea pig's mouth. This appeared to be "vomitus". His mouth was cleaned before the gas mask was applied. This could be a side effect of Zoletil injection.

toapayohvets.com
Be Kind To Pets
Veterinary Educational
Project 2010-0001


REPLY TO ITALIAN VET DATED MAR 4, 2011
Thank you very much for your sharing of knowledge and your interesting description of your rabbit spay. In Singapore, the majority of the population does not eat rabbits. Now, the pets kept are dwarf rabbits mainly as the big ones are out of fashion. If you have a picture of your spayed rabbit, do email the surgical site to me for record.

Pl email if you have other questions on veterinary matter. The blog you gave in the e-mail was written by me. For other interesting veterinary cases on rabbits, I usually post the reports at www.toapayohvets.com. Goto "Rabbits" to read the cases of relevance to you. Best wishes.

350. Dr Sing's Travel Stories: Education of Myanmar children

Today, the Straits Times (MPs: Help needy kids move up in life, A8, The Straits Times, Mar 2, 2011) reported that Singapore MPs, on the 2nd day of the Budget Debate, made "calls to reduce disparity in opportunities for rich and poor students". They wanted higher quality teachers and IT resources for neighbourhood schools as their parental background sets them back when competing to get into top secondary schools.

Some MPs quoted Minister Mentor's Lee Kuan Yew's January 2011 statistics that students of top secondary schools like Raffles Institution have >than 50% of fathers who are graduates nowadays compared to the <10% for neighbourhood schools. The MPs remarked that the neighbourhood school students will be disadvantaged in time as they cannot be competitive academically as they get less opportunities to get scholarships or university places and graduate to get high paying jobs. Less opportunities for neighbourhood school students mean a growing social stratification with the rich becoming richer. Is there a solution to this resolving problem of lower academic excellence in neighbourhood schools? I don't know. However, there is an interesting development in Myanmar's education system. In Feb 2011, I visited around 7 primary and secondary schools and was surprised to see that the Ministry of Education publishes yearly a calendar of photos of top 10 students in the final secondary year national examination(Grade 11). Schools and some villages display this page.

In Singapore, this will be considered putting "pressure" on the students and such ranking of students had been thrown out of the door by parental complaints in the past years.

MYANMAR SCHOOL SYSTEM
1. Kindergarten (Grade 1). 5 years old student.
2. Primary School (Grade 2 to 6). Final exam in Feb
3. Middle School (Grade ). Final exam in Feb
4. High School (Grade 11) - recent change. Students will be 15 years old. It was called Grade 10 last year but since kindergarten is Grade 1, Grade 10 becomes Grade 11. It is equivalent to "O" levels. Final exam. A national exam for all students in Myanmar in March.
5. University.

SCHOOL EDUCATION SYSTEM
According to one Myanmar lady in Singapore, Science and Math are taught in the English language. English is also taught. Other subjects are in Myanmar language.

READING SKILLS COMPETITION
There is such a competition in villages. I did hear loud recitals by students in schools and once I chanced upon a young girl of around 12 years reading loudly (in French according to my guide) while trekking in the Inlay Lake district. I had to walk past her school. She was just sitting on her chair and reading loudly and continuously.

SCHOOL HOLIDAYS
1. March, April and May
2. October 10 days
3. December 10 days.

TEACHERS
Government teachers and volunteer teachers in villages. Some village school have no desk or tables for the children.

I can see that even in Myanmar, there is strong interest in education of the young children.

349. Veterinary Nurses Wanted

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March 1, 2011
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Pure Stupidity

"Pure stupidity," Julia said when I asked her what she thought about the case of a Singaporean man who purchased and smuggled a Golden Retriever puppy from Malaysia to Singapore. The case was reported in the Straits Times. A Dr Boon told this man to confess to the Singapore Government in 7 days or so or else the doctor would do it. The man did not. So, the doctor did. The AVA punished him and he lost "Princess".

I wonder what happened to the Golden Retriever puppy now. It was never mentioned in the newspapers.

Some pet shops are said to sell smuggled dogs. One man told me that he could get any breed of dog I wanted from Thailand. I told him I was not interested. Smuggling of dogs is an offence as rabies may be introduced to Singapore which has been rabies free for over 50 years.

347. A German Shepherd licks his foot pad

"He will never permit a barricade fencing to prevent the dog from leaping down to the car porch," the mother said to me. "When we put up fencing, Dad will take it down," the daughter in her undergraduate studies reinforced her mum's statement to me.

The mother phoned me because the dog had been licking his Right Fore foot pad for the past 2 days. "It is common," I said as the mum wondered whether I knew what she was talking about. She is an old friend of over 30 years but she would consult other vets as I don't charge.

"The dog will lick the big foot pad under the foot till the black covering becomes white," I replied. "Usually it is due to some wooden splinters or sand stuck inside the cut pad and the dog tries to get it out by licking vigorously."

"Yes," she confirmed that the pad was indeed white but she disputed that there were any foreign bodies inside as she could not see any.

"You can't see the small foreign body because it may be embedded horizontally or at an angle inside the pad, but the dog can feel its irritating presence."

Indeed this was the picture. "How does it happen?" the mum asked.
"Well, the dog could be pawing the garden."
"No," she replied. The domestic worker was present and she said yes, the dog did paw at certain patches of the garden.
"Maybe it is due to the dog leaping down from the higher garden to the car porch (a height of around 3 feet) and cut his pad. The bricked edge of the tiled border of the garden at the edge might have cut his pad."

There was a 0.5cm cut in the pad and this could support her hypothesis. Now, I advised fencing up this area to prevent the dog from leaping.

"Thomas will not permit it. He just takes down any raffia string fencing we put up as it makes the house looks untidy."

"Can you talk to him again?" I asked the mum and daughter. They shook their heads. It was none of my business too. I gave a steroid injection IM in the back muscles while the maid held the dog who was now muzzled and was also wearing an e-collar. "So quick?" the mum was surprised.

"I need to be fast or I will get bitten," I know of Singapore vets being badly bitten by German Shepherds during house calls.

I had this sadness in visiting this house as the eldest daughter had passed away in a car accident some months ago. She would have become a good veterinary surgeon as that was her passion. That was her dog. He had been X-rayed recently by another vet as the family had not consulted me about their dog's health care for many years as the mum would not want free veterinary services from me.

Should I phone the father to advise putting up the fencing? The wife and 3rd sister in the house had been much negative and I ought to leave family matters alone. For the sake of the dog, I phoned the father to let him know I had treated his family dog. "Your wife had spent $500 on X-rays and veterinary consultation for the dog's problem," I said to him. "If you continue to let him leap, you will need to spend thousands of dollars in veterinary fees for his injuries to his back or hips and that is a lot of money to be spent."

The father replied in a serious tone and I thought there was no hope. However, the wife happily told me that her husband had put up some fencing when I phoned the next day. I asked the wife whether the dog was still licking his right paw. She said, "No, he is wearing the e-collar."

I said, "It is not the e-collar. It is due to the steroid injection I gave. You can take away the e-collar."

Sometimes, the vet has to be proactive in contacting the other spouse to advise in the interest of the dog and this takes courage and time. In this no-hope case, the husband accepted the advice with great reluctance I am sure as he does not phone me back to let me know.

346. Cost of spaying a cat at Toa Payoh Vets, Singapore

On Wed, Feb 23, 2011 at 4:59 PM, ... wrote:

E-MAIL TO DR SING DATED FEB 23, 2011

Hi

I would like to enquire how much will be the cost for sterilise a cat?

COST IS AROUND S$150 WITH PAIN-KILLER AND ANTIBIOTIC MEDICATION AND E-COLLAR. LOWER FEES IF YOU DON'T WANT E-COLLAR WHICH PREVENTS LICKING.

How am i to go about it?
Do i need to make an appointment?
APPOINTMENT PREFERRED. TEL 6254-3326

Lastly where is your clinic located?
It is located at Blk 1002, Toa Payoh Lor 8, 01-1477, near the Golf Driving Range. See www.toapayohvets.com, click LOCATION or goto: Location of Toa Payoh Vets

|
http://maps.google.com/maps?f=q&source=s_q&hl=en&geocode=&q=Toa+Payoh+Vets,+Singapore&sll=1.352083,103.819836&sspn=0.631535,0.884399&ie=UTF8&ll=1.365265,103.850842&spn=0.078942,0.11055&z=13&iwloc=A

345. Teaching interns rabbit medicine

My assistant Mr Saw views interns as pests as he has to take time to teach them. He would never tell me directly but I hear this from Khin Khin. I don't blame him as not everybody cares about teaching interns as it really takes lots of time.

Being busy, he does not want to waste time on interns. Interns who are helpful will of course, be appreciated by him. However, there will be vets and vet assistants who don't want to waste their precious and busy time on interns.

Rabbit medicine - In this case of a rabbit not eating, I got the two interns to learn how to bathe a rabbit with stained feet. This thin 7-year-old rabbit had been de-matted yesterday and had some bath. However, his feet were all stained greenish-black and he tried to lick the stains off.

As the vet in charge, I inspected warded animals and checked the treatment. This rabbit's feet had not been cleaned. After bathing by the 2 interns under Mr Saw, the rabbit appeared to have excellent appetite. Intern Nathaniel Gay took 5 pictures with his latest iPhone 4 presented by his father. I showed him the craft of taking photos by zooming and using correct points of views.

He uploaded on Microsoft Silverlight and emailed to me the link to see. I thought it was youtube.com as he had given me the impression. It was a slide show and probably lasted for 5 days. Well, it was a learning experience for him.

This case of the skin-and-bone rabbit could be due to a lack of grooming care as the rabbit had excellent appetite after de-matting. Only that his feet were not washed by the groomer and I had to intervene by asking Mr Saw to show the interns how to bathe a rabbit. The intern first got the big blue tub for Golden Retriever puppies and switched on the hot water shower. Just as small plastic container sufficient to confine the rabbit and warm water from the boiling kettle would do. Sometimes, one must think about the situation and not bathe pets blindly, using big tubs and wasting lots of warm water.



Pic is shown here.

On Thu, Feb 17, 2011 at 11:11 PM, ... wrote:

Dear Doctor Sing,

I've previously brought 2 of my dwarf hamsters to your clinic for treatment (removal of tumor & ear growth).

I've another dwarf hamster turning 2yrs 4mths at the end of February. Just yesterday night I noticed there was some blood stain on the left side of her ear. Today, it got worst due to excessive scratching.

I've attached 2 pics for your review. As she's getting old, I wonder if there's any external medication/application that I can apply on her to stop her itch.

May I also check with you on the earliest slot that I can bring her over for your review @ your clinic.

Looking forward to hearing from you as soon as possible.

Thanks & regards,



Hi

I just came back from Myanmar. Please accept my apologies for the late reply as it is practically impossible to access the internet in Myanmar or it takes a long time. So, I did not access the internet.

Your pictures of the hamster shows an ear infection deep inside the ear canal and on the surface of the ear and may require ear irrigation and cleaning under anaesthesia.

Pl make appointment at 6254 3326 and let the receptionist know that you will be making appointment with me as there are 3 vets at Toa Payoh Vets.


BEST TO TELEPHONE 6254-3326 but young generation prefers email or text!

342. Educating and entertaining Vet Undergraduates Project

Feb 23, 2011

I am back from a trip to Myanmar to hike a trail and see the schools near Lake Inle and visit a village in the Ayeyawaddy Division to see the Future Foundation's primary school construction in progress. I met an 81-year-old artist in his Art Gallery. I was looking for an oil painting of a flower vendor in Myanmar. He did have one that was sold long ago. The next best thing was a painting of flowers and market. Will display in the Toa Payoh Vets later.

AUDIO-VIDEO veterinary education project is being done with the volunteer and help of 2nd year vet student Ms Daphne Low. This 2nd video really took me by surprise as i did not expect much from her (being a busy multi-tasking distracted young generation with many things to do). My comments are recorded as follows:



OVERVIEW. Ms Daphne Low has to create the video based on the outline. I should have said "Audio-Visual" Production as the creation had music but no voice over!

Video Production
1. Define condition
2. Diagnosis
3. Treatment

Topics
1. Anaesthesia (TPVets)
2. Surgery (what is involved)
3. Puppy Toilet Training in Singapore
4. Disease conditions
- Bladder stones
- FUS (Feline Urinary Syndrome) / CUS (Canine Urologic Syndrome)
- Ear problems
- Heartworm
- Periodental Disease
- Skin abscess: ringworm(fungal), dermatitis (bacteria), mites
5. Vomiting/Diarrhoea
6. Cesearian
7. Corneal Ulceration - esp in Shih Tzu
8. Spaying/Neutering

Vomiting/Diarrhoea
- if many times = emergency as possible death due to dehydration/bacteria intoxication
- blood test, check stools for parvovirus/foreign body, x-ray
- treatment: no food/water for intestines to recover, iv drip + medicine to control infection for 2-3days

Infection of Ear Canal
-non-stop scratching
-head scratching
-affect immune system
-groomer will treat but unsuccessful
-if unsuccessful for 2 times, lateral ear resection will be required


E-MAIL FROM MS LOW dated Feb 18, 2011

Hi Dr Sing,

Sorry i took so long to get back to you! I was so busy with cny and stuff. How was your cny? (: I just managed to do a video on cesarean which i have attached in this email. Please take a look and tell me if this is what you are looking for. I saw that you are overseas from 17feb to 22feb. Have a safe trip! I will send to you more videos once I have the time to do them!

Cheers,
Daphne




E-MAIL TO MS LOW dated Feb 23, 2011

Feb 23, 2011

Dear Daphne,

I just came back from Myanmar yesterday and expected to see a similar video production as the first video production you did for me. Thank you for spending time and effort to produce a beautiful "movie" which will help to educate and hopefully to entertain veterinary undergraduates in developing countries where there are no computers and facilities in the schools and where internet access is slow and expensive.

I just can't believe that you have had progressed to making a professional-looking video with music. Everything was well timed and clear. It is as if a rose bud has started to blossom, when I compared to your previous video production for me. Pl do not infringe on music copyright.

COMMENTS
1. No audio in this production unlike your first video you produced for me . Please make some comments about surgical techniques (the text is inside the pictures) so that the viewer does not need to strain to read the "subtitles" inside the images. Hearing is best. Reading subtitles deprives much of the fun in viewing as the viewer must focus on reading the small text. That is why foreign language non-English movies don't do well with the English-educated audience in Singapore.

2. For credits, just provide text as follows:

This is a "Be Kind To Pets" Audio-Visual Production with the objective to educate and entertain, thus making Veterinary Medicine & Surgery Alive for Veterinary Undergraduates in developing countries. This is Dr Sing Kong Yuen's Community Education Project made possible with the collaboration of veterinarians at Toa Payoh Vets. We thank the sponsors - Design Travel Pte Ltd and Asia USA Realty (S) asiahomes.com Pte Ltd, Singapore.

More information is at the respective websites:
bekindtopets.com, toapayohvets.com, designtravelpl.com and asiahomes.com.

Produced by Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Videography by: Ms Daphne Low, 2nd year, Veterinary Student, Sydney University, Australia. Feb 2011. All rights reserved.

3. Please upload this first draft to youtube.com as it is a pioneer batch.

4. I am glad that you are not wasting time on Farmville in Facebook and that it was a family member using your facebook account. Create beautiful educational "movies". Make a difference - make the world a better place for pets and children.

341. Follow up on the skin-and-bones megaoesophagus dog

On Feb 16 evening, I phoned the owner of the skin and bones dogs. I had proposed feeding every hourly from 7.30 am to midnight with small amounts of food (6 pellets and 1 tablespoonful of k/d diet) to get the dog to put on more weight and survive. In the past week, it was two-hourly and there was no more vomiting. Prior to consulting me, the lady owner fed small amounts of rice, cereal and other things like asparagus and multi-vitamin B's were fed by the husband 3x/day. The dog would "vomit" every day but not all the time. There was persistence in "vomiting". This was actually regurgitation of food eaten some minutes ago and finally, since the dog was depressed and unable to eat anymore and was tired out, the couple sought veterinary consultation, thinking the dog was suffering from stomach cancer.

"Didn't my wife phone you?" the husband said. "No," I said. She passed the phone to her wife. "My dog vomited at midnight after the last meal," she said. "I think every 2-hourly feeding would be fine," she suggested.

"It is a matter of trial and error in this case of megaoesophagus," I replied. "The gullet can't hold too much a large quantity of food and water and that is why I asked to feed every hourly to ensure she puts on weight."

The happy owner reiterated, "Now my dog does not have the pus discharge in her eyes every day and so I don't need to wipe off the eye discharge. She does not tire so easily and looked eagerly for her food when she hears the noise of crunching of her 6 pellets." The prescription d/d pellets are crushed into powder and mixed with the canned k/d diet so that they will not irritate the mucosa of the gullet and will pass into the stomach. 2.5 mg prednisolone was given daily too and would be stopped after 3 weeks. It reduced inflammation and promotes appetite effectively in this case. Trimaxazole antibiotics had been given and would be stopped after 3 weeks. We would wait and see.

"Is the dog putting on weight?" I asked.
"I can feel she is heavier when I carry her," the lady owner said. "She passes well-formed solid stools."
"Is she shivering?"
"No more, but she could be shivering due to your grooming clipping her bald to de-tick her last time," the lady owner was also getting the dog clothed and wrapped in a blanket at night in the air-conditioned room.
So far, no food regurgitation. The diagnosis of megaoesophagus was not a death sentence and this 8-year-old dog should live to an old age if there are no other health problems.

Earlier vet report about this "vomiting" skin-and-bone poodle is at http://www.toapayohvets.com/web1/20110204megaoesophagus-regurgitation-dog-toapayohvets-singapore.htm

This is NOT an easy case to diagnose. Regurgitation is often confused with vomiting by the owner and the owner often misled the vet by giving the incorrect complaint of "vomiting". I visited the apartment to see the dog in her natural environment and lifestyle. It is a rare case as most "vomiting" cases are really vomiting dogs!

P.S
Due to economic reasons, I did not ask the owner to X-ray the distal oesophagus with contrast medium as X-rays of the neck and abdomen had cost some money for these senior citizens. It would be good to do it, but at the owner's expense. In the X-ray, you can see that the oesophagus is dilated as gas and liquid filled up the dilated mid-oesophagus. The diagnosis is still megaoesophagus and the treatment depends on the cause. Feeding small amounts of food (powdered pellets and canned food) without regurgitation, the X-ray of mid-oesophagus and return to normal health supports the diagnosis of megaoesophagus. There appeared to be an area of granulation in the pharngeal area as the dog used to eat branches and grass for some years. It could be a granulation tissue. See the X-ray.

338. An intern flirts with the danger of being terminated from her internship

February 17, 2011

Yesterday, Feb 16, 2011 Michelle came to work late again for the 2nd time. This was despite being warned the day before! It was incredible. She behaved as if she was indispensable and was a top vet, a prima donna whom the practice revolved around. Without her, the practice would be shut down!

"Does your Victoria Junior College teachers teach you punctuality at work?" I asked her. She had been warned and yet she did it again, thereby flirting with danger of being dismissed from internship. Her mother sent her to work everyday and her father or mother picked her home unlike Nat who had to take a bus and get to work himself. Her teacher had imparted her the values of punctuality but she chose to flirt with danger. "So, what's your excuse?" I asked her as I sat down in a room to interview her. "The traffic was heavy," she said. "This is a common excuse," I said. "It is not acceptable. If you don't value your internship, don't do it. You have been warned twice now. The third time will mean termination of your internship." There are other interns whom I can't accept due to lack of space and if Michelle behaves as if her mother owns the practice, she has better go. A rotten apple spoils the whole barrel.

Nat had not been late during the past 4 days despite having to take a bus to work. He bothered to wake up early and ensure he was a bit early. In fact, Nat asked to work from 8.30 am to 10 pm. Michelle had been a clock watcher and was hoping to be just-in-time at work from 10 am to 7 pm. Both are not paid.

"Obviously, you are doing work attachment or internship because you want a testimonial," I said. "If you don't work hard, you will get a mediocre testimonial - satisfactory performance but not punctual. Is that what you want?" I do spend time teaching them some cases of veterinary medicine and if an intern persists in behaving as if the world owes her a living, she is better off staying at home.

"As for your mum driving you to work late, you will need to ensure that she wakes up early to do so," I told Michelle. In the first place, there is no need for an intelligent lady to be told in this way. Treating internship like a holiday camp or vacation or like your father's office is not tolerated. Parents who feel the need to drive their children to internship need to be alert and impart values of punctuality and be a role model for the young ones.

One more time, Michelle will be asked to go. She is setting a bad example for my staff and Nat and the rot will be like a cancer, affecting the behaviour of all employees.

I noted that the vet's dog was no longer present in the Surgery to create fears and worries in clients. There is much relief on my part. There are vets whose dogs and cats are well loved by clients if they behave responsibly. Just like interns, those who don't behave as expected will create tension and are best banned from the practice.

It is the responsibility of the Clinic Manager who is myself if there are any complaints. Every day, there are new incidents and many issues are needed to be regulated and to prevent possible litigation in this fast-paced society. Bad eggs are best asked to go. No more blind loyalty. Employees and vets that don't perform at work are best let go despite their years of work for the practice. Once they lose their interest in the practice, it is best that they work somewhere else.

I will be on leave from Feb 17 to 22, 2011 and I hope nothing unusual will happen in Toa Payoh Vets. I will be visiting a primary school built by Future Foundation and its volunteers and see whether I can be of help in the education of the children. There is a need for the building of a secondary school in this village and sponsors must be found. Some pictures of the Primary School are at:
http://www.designtravelpl.com/tours_Myanmar/20110124volunteer-tour-inn-ma-ywar-lay-primary-school-myanmar-design-travel-singapore.htm