475. Rare case of pyometra in a young female dog

After over 30 years in small animal practice, I thought I have seen all pyometras. Pyometra is an infection of the womb in the female dog, mostly in dogs over 5 years old.

Yet, this female dog just had her first heat 2 months ago. I checked her before spay and saw mucoid yellow vaginal discharge. "Is she really 10 months old?" I asked Mr Min, my assistant. She was as her teeth were all white as snow and her puppy canine tooth was still present and white.

I am happy to say she is OK after spay. Small animal veterinary medicine is full of surprises every day.

474. Watery pus in shar pei's eyes - entropion?

I have a 6 years old male Shar Pei and have been having watery
eyes and yellow sticky discharge.
I am cleaning him a few times a day with eye wash and the problem
keep coming back.
I understand that surgery on the eye lid is necessary to stop this problem.
Can I know what will be the total cost for this surgery. And how long do I
have to leave him there.


E-MAIL REPLY BY DR SING
I am Dr Sing from Toa Payoh Vets. Thank you for your email. Estimated costs are around $600 - $700 for both eyes as general anaesthetic gas is used. Bring the dog in at 9.30 am and bring home in the evening. No food and water the night before after 10 pm. Phone 9668 6468 or 254 3326 for appointment.


Costs include all fees and medication.
Blood test to check whether the dog is healthy is not included and is advised. Cost is $150. However, this depends on the owner as to whether he wants the blood test or not.

E-MAIL TO DR SING DATED JUN 16, 2011
Can I make a appointment to consult Dr. Sing tregarding my dog's eye and to advise
if he needs entropion surgery.
Mon.11.30am or Wednesday, or Thursday 11.30am or but not Tuesday.
Please call me to confirm the appointment.
Thanks !

Ande Lai h/p  xxxx



- Show quoted text -

473. Deep eye ulcer in a 3-month-old Shih Tzu puppy

Yesterday, Jun 16, 2011, I operated on a 3-month-old Shih Tzu with corneal ulcers on both eyes. The owner was referred to me by the sister who had sent the hamster with the large cauliflower ear wart to me 3 days ago.

I am still much worried about anaesthesia of 3-month-old puppies as they are not strong enough.

"No injection?" Mr Min asked me as he has been used to vets giving sedation and then gas anaesthetic for the last 2 months or so. He had replaced Mr Saw and was new to the small animal veterinary world although he had some experience in Malaysia and had graduated some 10 years ago in Myanmar.

"Only isoflurane gas," I replied. "If you know how to do it." I showed him how to hold the puppy and give anaesthesia gas via the mask. "Hold the scruff of the neck, angle the head at 45 degrees and give the mask," I said. Yet he did it his way and when I corrected him, he said "I don't want the mask to touch the corneal ulcer!"

It needs a lot of impatience to teach the young ones and sometimes I feel that they just want to do it their own way. I said: "At 45 degrees, the puppy can breathe normally. At 90 degrees (to the mask), it is unnatural and the gas cannot flow through smoothly!". Teaching Min is important as he assists my two other associate vets who have their own styles. But there must be one standard operating procedure which is safe, efficient and least costly (wasting of the very expensive isoflurance gas).

My previous technician, Mr Saw had learnt what to do after 3 years of working with me, but he had decided to retire to greener pastures in Yangon where he was promised a "partnership" in a practice. So, a new technician had to be supervised and mentored again.

For this puppy, the owner is very worried, as do all owners of puppies and parents of babies. The anaesthetic risk is so much higher and it was no surprise that the vet near her apartment had prescribed just antibiotics eye drops and atropine eye drops and vibravet oral tablets. Then she was referred to the parent company's vet who was unfortunately fully booked. So, that was how the case came to me from my successful handling of the hamster with the large ear wart with Dr Vanessa 3 days ago. Well, if the hamster had died under anaesthesia, I doubt this referral would come. So much depends on the anaesthetic outcome in veterinary anaesthesia.

HOW THIS CASE WAS DONE
1. Isoflurane gas by mask at 5%. Observe signs of surgical anaesthesia by me. Don't depend on inexperienced vet technician Min. Proper angle of the neck and nose at 45 degrees.

2. Intubate just when the puppy was not fully anaesthesized. Be alert. There was a "vomiting" sound. I quickly pulled out the endo-tracheal tube but there was no vomiting. If negligent, the vomitus goes into the lungs.

3. Give 2% isoflurane. The temptation of the technician or vet is to give 5% via the tube as the puppy moves. Close the mouth with hands and be patient. It takes time for the puppy to be under surgical anaesthesia.

4. Flush hairs and debris off the eye thoroughly. Ensure the 3rd eyelid is opened up and irrigate all hairs trapped inside.

5. Check eye is clear of debri. I put in terramycin eye ointment and the atropine drops.

5.1 In infected eyes, I do inject subconjunctival gentamycin but not in this case as it was 4 days old.

6. A horizontal mattress suture, 3/0 absorbable sews up lower and upper eyelids. Eye-lashes must be completely shaved off.

7. E-collar. The puppy wakes up fast as if she has a short nap.

DISCUSSION WITH A 5TH YEAR VET STUDENT FROM MURDOCH UNIV
Each vet has his own approach. The student, Daniel said he would swab the ulcer, get a bacterial culture. Give appropriate eye drop antibiotics, atropine, e-collar and let the ulcer heal. NSAID pain-killers. Perhaps an eye patch.

IN REALITY
The first vet had essentially prescribed what Daniel had proposed except for NSAID. The owner had great difficulty putting eye drops on the puppy as the naughty one shifts right and left. Both corneas were ulcerated (will show images later). Puppy's sclera gets redder by the day. Itchy, rubbing eyes.

LEFT EYE
Deep ulcerative keratitis. The cornea ulcer of the left eye was deep. A red blood vessel forms at 11 to 2 o'clock above this ulcer.

RIGHT EYE
Superficial ulcerative keratitis from 6 o'clock to 11 o'clock.

So, the owner is worried that the puppy will become blind.

472. Sharing knowledge of veterinary anaesthesia from Malaysia

Many Malaysian vets I meet during continuing education talks have found the following effective for injectable general anaesthesia. Here is one from a helpful vet in Johor Bahru.

Hi there Dr. Sing,

For me, in terms of injectable zoletil most of us vets here uses the TKX mixture. here is how you do it:

1. take zoletil 100
2. discard the water diluent
3. mix 2 ml of xylazine 100mg/ml
4. mix 8 ml of ketamine 100mg/ml

then you will have 10ml of TKX (zoletil plus ket plus xylazine) where 0.1ml of this tkx should knock down an animal about 3kg for a decent 15-20 minutes. very good for short procedures and also the muscles are quite relaxed unlike those if you use in pure zoletil.

i personally use my own concoction of 3ml xylazine and 7 ml ketamine and i find that this mixture gives me a knock down of 20-25 minutes and the animal 'sleeps' longer. i maintain my animals on gas if the procedure takes any longer than 15 minutes. the only worry is the chance of hypotension (due to xylazine) and we should be mindful of older animals or those with cardiac insufficiency.

COMMENTS
I have seen the above TKX used effectively in cat spays in NANAS, an animal shelter in Johor some 2 years ago. It is said to be safe.

471. AMA (Against Medical Advice) Form

Vomiting and diarrhoea in a dog, several times a day and over 2 days.

TREATMENT
1. Don't just give an injection and some antibiotics as this may be what the pet owner wants. The owner wants the pet to go home, but in such severe cases, it is best to hospitalise the dog, get IV fluids.

2. Check potassium levels. If it is low, the dog can get hypokalemic which can lead to life-threatening cardiac arrhythmias and death.

ONE CASE
The owner insisted on antibiotic injection and oral antibiotics first. If the dog still has vomiting and diarrhoea, she would bring it back. But the dog could not stop vomiting and passed watery stools past midnight. The next day, the angry son came with the owner (the mother) and verbally abused me.

A written form of discharge stating that IV fluids and hospitalisation is advised but the dog owner wants the dog back AMA (Against Medical Advice) would be best. In this case, the mum was rather embarrassed at the son's wanting the money back. I request him to send the dog to another vet for treatment. When the trust is not there and oral allegations of negligence set in, it is best not to continue with the case.

The AMA form is used in human medicine and this may be adapted for use in veterinary medicine as family members who are not present during consultation may start to get litigious when the clinical outcome is not to their favour, due to restrictions imposed or AMA behaviour of the primary caregiver who is present during consultation.

470. Continuing Education: Adverse Reactions to food in the dog and cat

On Jun 7, 2011, I attended this seminar and was surprised to see most of the participants are young people of around 20-30 years of age. Probably from Malaysia and Indonesia.

I met Dr Lee who has a surgery in Johor Bahru's industrial area (small breeds 20% compared to my practice which is 95%; large breeds and mixed breeds 80%). He says there are around 15 vet clinics in JB. I said there are around 50 in Singapore. He mentioned about a very good 3-in-one sedation. "Just 0.1 ml IV and you can intubate the dog of 30 kg."

He said that he had attended a teaching seminar conducted by some European Vet Association in China (no Singapore vets were there). The European vets just use one layer of continuous appositional suture to close the bladder or intestinal incisions, unlike the American textbook recommendations of 2 layers of inverting sutures. He also said that in gastric torsion, the European vet just tears off the falciform ligament from the dog, exposing the twisted stomach for correction. No ill effect. Excellent teaching of ultrasound interpretation. He was generous as to share vet knowledge as most vets would just keep silent.

469. Continuing Education - SAP Summit 2011 - The Future State - Engaging the customer

On Jun 8, 2011, I attended the SAP Summit 2011 - The Future State. The 9.10 am topic for the panelists was "The Secrets of Making A Best-Run Government Run Better; The Changing Mandate; The Shocking Disasters; The Future State

The Panelists were: Dr Anthony M Cresswell, Deputy Director, Center for Technology in Government, University at Albany, NY, USA; Zaqy Mohamad, Member of Parliament, Choa Chu Kang GRC, Singapore and Adaire Fox-Martin, SVP, Industry Business Solutions, SAP Asia Pacific Japan.

Mr Zaqy spoke about the better use of social media by politicians to engage the segment of the public. Apparently this had not been done effectively in the recent General Elections in Singapore if I heard Mr Zaqy Mohamad correctly.

The other panelist, Dr Anthony Cresswell talked about President Obama's Open Government's initiatives in the US and the difficulty of evaluating the key performance indicators of the services provided. It was an eye-opener for me when he said that over 80% of government computerisation projects fail.

What is the relevance of social media to veterinary surgeons in practice? There is a segment of the pet owners who are younger and would only be engaged through the use of social media. They will search for topics of relevance to their pet's illness and want to know which vet has the ability and experience to treat their beloved pets. Their own vet may not provide such a service.

Social media using webpages or blog requires the content to be created daily. There is now the twitter novel (short novels of 140 words are popular with netizens of China). Whatever the form, the contents must be updated daily or weekly to get a stream of "fans". Writing is very hard work for those who prefer not to touch a pen as there need to be research to produce a useful article. There are so many distractions and better things to do than to create good content after a hard day's work at the Surgery!

To illustrate the amount of work involved to produce a useful article, I will let readers know how I produced the article, "What Makes A Horse Racing Club Profitable?" This article was written in 1989 and the scanned pages are at Horses, starting with the first page at: http://www.asiahomes.com/dev/Stc1.JPG

On a recent encounter, 2 days ago on Jun 9, 2011, I met an aunty and her niece who brought a hamster with a large dangling ear wart to Toa Payoh Vets. This wart was initially very small but her vet said she would not operate due to the high anaesthetic risks. As the wart grew bigger over the last 4-5 months, her vet referred her to another vet whose location was quite far to her residence. So this aunty googled for "hamster, warts" and an asiahomes webpage, probably similar http://www.asiahomes.com/singaporetpvet/ popped out.
I was at the Surgery at that time and so I got the above-mentioned feedback from her. This episode demonstrated the culture and lifestyle of the younger generation. The aunty was around 30-40 years old. The niece was a teenager. I paid special attention to this case as I collaborated with Dr Vanessa to ensure that the outcome of anaesthesia was what the aunty hoped for. Signing an informed anaesthesia consent form is one thing. I don't usually request it but Dr Vanessa does.

What was important was that the hamster come out of the surgery room alive and biting (this hamster bites, the aunty had said). Obviously, I would bite if anybody messes around with my wart. The hamster was anaesthesized under isoflurane gas.

I kept a close eye on my assistant Mr Min telling him not to be distracted by looking for sutures etc while anaesthesizing the hamster. At one time, his eyes and one hand were on a drawer to take out a packet of suture for Dr Vanessa.

I told him off not to do it. "Hamsters die because there is no 100% focus on anaesthesia by one person or the vet." Unfortunately, new vet assistants and new vets need to be mentored closely. There is no other way to prevent anaesthetic deaths in hamsters. Deaths on the operating table damages the reputation of Toa Payoh Vets and I am very strict on anaesthetic training and procedures to ensure that no healthy pets should die on the operating table at all times.

Dr Vanessa excised the wart and sutured the wound. I proposed no suturing as the wound in the ear was so small and that bleeding would stop with pressure. As each vet has his or her own ideas, I will not interfere whenever an associate vet operates in most cases but I do monitor the handwork - the post-operation complications and the complaints. This is my duty of care for Toa Payoh Vets clientele.

Dr Vanessa decided to stitch up the wound. I recommended potassium permanganate to stop the bleeding. Each vet has his or her approach to a surgical case and there are several satisfactory outcomes on any approach. Bleeding still came back as I had predicted in this case. This bleeding was not life-threatening.

The hamster was now free of "shouldering" a burden. Actually, the wart of 1.5 cm x 1.2 cm x 0.5 cm looked so much like one of those big dangling ear rings worn by some ladies. The hamster scratched his left ear where the wound was. The aunty was concerned. So I proposed a paper e-collar. "The hamster hates it very much," I said to the aunty as she put the e-collar on. The hamster used all his two hands to pull out the hamster. Vigorously and angrily I think. So, no more e-collar. "Just use the clean tissue to wipe off the blood," I advised the aunty. "And take the medication." The niece did not say a word but I presumed she was the real owner of this beloved hamster and was happy.

P.S. What are the Secrets of Making A Best-Run Government Run Better? There were no clear list of secrets enumerated as far as I know. The political party who knows how to engage the Generation Y effectively will be the one to win their votes and get the increased mandate to govern if the Generation Y is the vote swinger. The Government is now said to be a business. So, the Government who provides "public value" to the citizens will be a better-run government.