Monday, September 5, 2011

Surgery - Circum-anal and tail tumours in a very old male dog

Gigantic circum-anal tumours - a type of surgery where fools go in where angels fear to tread as the dog is very old and the post-operation complications of not healing well are present.

Other than the very anaesthetic risks of operating on a very old dog, the other challenge is getting sufficient skin to stitch after excision of the gigantic circum-anal tumours.

Should this case just be rejected as being in-operable? I study the 3 images. In this type of high risk case, a short surgery of less than 15 minutes under just isoflurane anaesthesia is best for survival. Unfortunately, this will be at least one hour operation!

I got the dog on antibiotics and Tardak injection for 7 days first. Blood test showed high liver ALT and urea. To operate or not to? It is a very difficult decision for the owner.



581. Hari Raya Puasa invitation

"You old people are afraid of the (Singapore) government," the hostess who had invited me to her HDB maisonette to celebrate Hari Raya Puasa on Saturday Sep 3, 2011 had asked me who I voted for as the 7th President of Singapore and I had said "Dr Tony Tan". She is around 40 years old and anybody past the age of 50 will be old. I am 61 actually.

The Prime Minister had given his support for Dr Tony Tan in one of his speeches and so he was deemed to be the government-backed horse. Many unions had voiced their support for him too.

Dr Tony Tan had been the Deputy Prime Minister and had held various high posts in politics, the government and in banking. "I voted for him as he was the best of the 4 candidates. He had the track record of international networking and financial experience," I said to my hostess who is a very vocal woman. I did not ask who she voted for at the beginning. She asked her best friend, a Chinese lady in her 40s. She said: "Dr Tan Cheng Bock." This was a satisfactory answer to the hostess.

"Why are you against Dr Tony Tan as President?" I asked.

"He is from a monied generation and from the elitist part of society. What does he know about the poor people's suffering? His mother was not a washer woman and so how would he know about the disadvantaged in society?"

I had no comment as I don't know Dr Tony Tan nor had I met him. For that matter, I had not met the Prime Minister personally too but I believe he was the best person to govern Singapore.

As the vocal minority of the younger generation grows bigger and bigger, the internet fans the flames of the opposition voices louder and louder. Change for the sake of change. More demands. More competition.

The same changes in politics applies to veterinary practice. Yesterday, Sunday, a senior vet of over 70 years asked me whether it is more competitive nowadays as I get presented a moon cake.

"Well, there are at least 43 veterinary practices now and soon it will be 50. Competition is inevitable. Much depends on the vet's ability to build up his reputation. His competence and track record will matter to the younger generation that is more sophisticated. If you don't want to spay big breeds and refer to the (brand-name) practice, you will just lose the confidence of your clients. This means less clientele as less referrals will be made."

Old vets will have to retire as the new generation prefers the younger vets. This is what is happening in politics too and that is why younger office holders are introduced.

As for my hostess, she voted for Mr Tan Jee Say who was from a poor family. He got around 25% of the votes while Dr Tony Tan got just around a thousand votes more than Dr Tan Cheng Bock and became the President of Singapore. The two doctors each got around 35% of the votes. So, there seems to be a political tsunami of Singaporeans wanting a change. When the old generation passes away, there will be a new political party in power. Unless the incumbent party politicians or the practising vet knows how to keep in touch with the common people or clients, many of the supporters will be lost to the opposition or competitors in 2016.







580. E-mail Query: Cost of neutering a 3-month-old guinea pig at Toa Payoh Vets



On Sun, Sep 4, 2011 at 8:50 PM, ...@yahoo.com.sg> wrote:

Hi,

I have a guinea pig close to 3 months old and I would like to send him for neutering.
what is the cost and how long does it take?

Regards,
...


E-MAIL REPLY FROM DR SING DATED MONDAY SEP 5, 2011

I am Dr Sing from Toa Payoh Vets. Thank you for your email.

The cost for surgery and anaesthesia is estimated to be around $75. An antibiotic and painkiller injection would be $30. Total is estimated to be around $105. It takes around 30 minutes for the whole process. Bring the guinea pig in the morning and take him home at 5 pm in the evening.

579. Elective Caesarean Section for a heavily pregnant Chihuahua - 60th day

"When is the best time to perform an elective Caesarean Section on a Chihuahua?" I asked a vet. "64th day?" was the reply.

"Much depends on the signs of impending birth," I said. "From my two hectic years of experience with the dog breeders in Pasir Ris, it will be around 60-63 days for a heavily pregnant Chihuahua. 58th day was the earliest I did to get viable puppies. It is best to do after 60th day as the pups are developed and not premature like being hairless."

One home breeder phoned me last week (without having met me at all) and I advised 60th day based on rectal temperature and signs. I advised him to buy a thermometer to monitor the rectal temperature and after that heard nothing from him by phone.

When the temperature drops and the dog stops eating or pants, it is time. I advised that there would be no point in just checking out the dam if she was OK unless he wanted ultrasound to be done. This was to save the home breeder some money as costs are important to many home breeders.

Below is an e-mail from this home-breeder.


E-MAIL TO DR SING DATED SUNDAY SEP 5, 2011, 10.51 PM


Dear Judy,

I am ... that called and fixed appt with Dr Sing for tomorrow's Ops on my Chihuahua (on her 60th day of pregnancy).

Pls help to check with Dr Sing and advise me on my mobile line ....( no matter at what time tonight, it is ok).

My Chihuahua is starting to show very abnormal sign of NO APPETITE for food from tonight( normally it is very excited on serving). She NOT EATING at all even we did not feed for the whole day. She was mated on 7th July and today is her 59th day. This is her first birth.

The rectal temperature measured daily for the last 7 days on every morning is between 38~38.3 degree celsius. This morning was 37.9.

Thanks a lot.
.....

PRICE OF CAESAREAN SECTION AT TOA PAYOH VETS

After office hours, the cost is much higher and would vary from $1,000 - $3,000 depending on the practice. For Toa Payoh Vets, it would be around $1,000.

In this case, the elective Caesarean section could be done on a Sunday afternoon but the owner did not phone as I was still working till 4.30 pm. I have not met the owner at all. Caesarean was done by my vet past midnight. I gave him free telephone advice on monitoring the rectal temperature. When it drops below 38 degrees and the dog has milk and shows signs, he should contact me by phone. I did phone him one day ago but got no response or reply.

The cost of around $1,000 was considered expensive by the owner (according to his text message reply to me at 4.40 am on Monday Sep 5, 2011 as I am writing this report). I texted "It costs more after office hours and is around market price."

IN RETROSPECT, the Caesarean section could have been done at 4 pm on Sunday afternoon but the owner did not phone nor keep in contact till after 10 pm when the dog showed more signs. That was around 10.51 pm. Caesarean section was done by Dr Jason Teo and all was OK. The price was around $1,000 which was not so OK with the owner. But it was market price.

Friday, September 2, 2011

DOA - Dead On Arrival - parvoviral Westie puppy

I said to the dog transport man today Fruiday Sep 3, 2011: "Be careful with the transport of the 16-year-old Fox Terrier. I hear that he had collapsed once. May have heart disease. I don't want a DOA - dead on arrival dog."

"Choi, choi," he replied, meaning some counter verses to ward off bad luck. The dog arrived alive.

But there was a DOA. A young man in a car brought a dead Westie puppy he had bought from the dog breeder. The breeder treated it for vomiting and diarrhoea without success and asked him to come to Toa Payoh Vets. It was DOA.

I asked Dr Vanessa to handle the case to see how she would handle this case sensitively and carefully. This is part of my mentoring lessons. Any careless allegations about vaccinations would have impact and led to grievances and litigation. This is where the old vet knows what to do.

There are certain procedures to be done in examination of a DOA puppy. A parvoviral test must be done. This was positive. A vet report must be written. Cremation to be discussed. Who to pay must be made clear as the breeder might not pay for the services. In this case, I showed how the case is handled.

577. Dog breeders in Singapore and parvoviruses killing puppies

"$280 for a Caesarean section of a dog is money-losing," I said to Dr Vanessa today. "I will like you to stop accepting any new breeder business." Whether she accepts my advice or not, time will tell.

In any business, it is best not to work for free or at a loss as money is needed to pay for good staff and replacement. I visited a new veterinary surgery recently. "How come the operating table is an old human operating table with pads?"

The vet said: "It is too expensive to buy the Shoreline veterinary operating table as it costs $7,000". I bought one to replace the old one. This specialised table has a grove in the middle to catch the blood and urine.

Using a human operating table for dog operations is not practical because the blood spills over the sides. In human hospitals in Singapore, there are many nurses and staff to suck out any fluid or blood. But this is not economical in a small vet practice.

In any case, a Shoreline operating table makes veterinary surgery so much more comfortable and pleasant.

To get such tools, the practice cannot afford to be offering free and cheap services to dog breeders as there will not be time to service the private clients and to earn a decent income to buy appropriate tools such as a veterinary operating table, electro-surgical equipment and anaesthetic machines.

This means that I don't accept dog breeders and pet shop operators for the past years as they make the vet work practically for nothing considering the time spent in treating their parvoviral puppies and the need to disinfect and prevent diseases in the practice.

I will put my foot down if my associate vets keep taking in new breeder clients as the practice needs to focus on providing excellent services to the private clients. There is just certain hours in a day and breeders and pet shop operators demand a lot of free consultations and time. Sometimes, I wonder how the other vets catering to breeders can sustain the profitablility of their practice.

At one time, I was serving several big breeders charging $10/vaccination at the farm because the previous vet had his licence suspended and I happened to be at the right place at the right time when a big breeder asked me to service his farm. $10/vaccine was sold to the breeders by this vet without having to go to the farm. I had earlier offered $15.00 and was unsuccessful.

Doing the dog breeder business meant travelling time of over one hour would not being billed. The hope is that new puppy buyers would come and visit me when they need a 3rd vaccination.

Soon, two younger lady vets came to Pasir Ris breeding farms with an offer no sensible dog breeder could refuse. $6.00 per vaccination from the eventual successful young lady vet finally wiped out all the other vets. However, there was another investor who used to bring his vet along in his car, after soliciting the vaccination business from the breeders and pet shops. His rate was lower than me, maybe at $8.00 but higher than the $6.00. I think he was also vanquished.

I exited the breeder's business and spent time with the interesting private clients. Those stay with the vet if the services are good and results are shown although they do stray, as for all service providers.

Today, a 16-year-old Fox Terrier owner and his two daughters now grown up to be in their late 20s came specifically to consult me as he had met me many years ago. It is a continuity and a pleasure to see his two daughters equal to him as adults and making decisions. However, they defer to the father's wishes to consult me and had to take leave from work to do that. I got a dog transport man to bring the dog in. Father and two daughters and a dog and a driver in a small van. It was fun to meet them again after all these years.

576. Walk The Talk - parvoviral infection in a Maltese puppy

"It is impossible to collect blood from the Maltese puppy," my assistant Min told me. "The blood just will not flow out from the vein."

The 2-month-old Maltese puppy was warded 18 hours ago for vomiting and diarrhoea by a dog breeder yesterday at 8 pm. Vet 1 gave an antibiotic and anti-vomiting injection.

The young lady turned up at 12 noon today to check out her puppy. There was no diarrhoea. I brought her to see her puppy in the crate. She had got him 5 days ago from the breeder and everything was OK till her mother gave the puppy an egg on the 5th day.

At the crate, he was inactive but standing. Suddenly he vomited yellow froth.

Based on the history of one vaccination, I suspected that this puppy had parvoviral infection. In any case of puppies having vomiting and diarrhoea, the process of examination should include faecal parvoviral test. However since this puppy was billed to the breeder, he had not wanted parvoviral and blood test to be done.

I took over the case since the owner came and would accept responsibility of payment for the treatment had this done today although the puppy was no longer purging. The test was positive.

I phoned the owner to let her know the bad news. I had earlier told her that the puppy had pale gums and was losing blood internally. "Parvoviruses are puppy killers," I said. "Chances of survival are very slim." She had given permission for blood test

So I had the blood test to be collected. As the puppy was dehydrated, the blood was dark blue and thick. So my assistant and another could not suck n blood and came to let me know. The cephalic vein could have had collapsed and this 850-g Maltese and so it was very hard to draw blood.

What to do? Just forget about it?

"Blood can be collected from the jugular vein," I said. "Have you collected blood from the jugular vein in the cow in Myanmar?" My assistant Min who is graduated as a vet in Myanmar said no. I had collected blood from the jugular vein in a few hundred racehorses when I was a horse vet and could apply the same procedure in collecting blood from the puppy. Depress the jugular grove and the base of the neck near the scapula.

I walk the talk. "Use a 1-ml syringe," I coached Min who always uses 2.5 ml syringe as a standard. "Push the piston in and out to ensure it moves freely." As one assistant held the puppy's head, the other pressed the jugular grove. I inserted the orange 25G needle into the distended jugular vein. Thick dark brown blood of near 0.8 ml was sucked out.

This is a very rare occasion I collect blood from the jugular vein of a 850-gram puppy. The blood is important to assess the viral infection of the blood system and the overall health of this puppy. The puppy pressed his head against the crate side. This was not a good sign as it could indicate "headache" or pain as I had seen many of such presentations in puppies with severe distemper viral infections.

Walk the talk is important if one is to lead. Or seek expertise to help.

House call to see a 16-year-old Fox Terrier

It was many years since I saw the Fox Terrier who now cannot stand up properly and has some lumps and infections in his backside. The owners asked me to make a house-call and did not mind paying the fee of $300 as the dog might be stressed out and die on the way to Toa Payoh Vets.

This is not the right way to practise veterinary medicine as a house-call would achieve nothing for the old dog. I said: "From your description, the old male dog would be suffering from anal sac infection and circum-anal tumours which need to be excised. So, a house-call would not help this dog at all and your money would be spent for with no valuable services to you."

I arranged the pet transport man to bring the dog down for inspection. That would be better for the old companion as proper nursing and surgery cannot be achieved at home.

In old dogs (over 8 years old) requiring surgery, don't use domitor or any sedative IV. Halothane + oxygen gas would be safest. Ensure that the dog has an IV drip and antibiotics some 4 hours prior to surgery. Usually the normal healthy old dog survives.

The emaciated Shih Tzu has pemphigus vulgaris? Reviewed 4 days later

Thursday, Sep 1, 2011

"My dog looks forward to coming to your Surgery," the daughter said to me. "She used to be afraid of going to the vet." I was surprised to see this 10-year-old Shih Tzu so much more energetic and wagging his tail, as if she wanted to enjoy every second of living.

4 days of medication and better food like meat and eggs and she looked so full of energy. I had scheduled the operation at 10 am but since the owners had problems getting a taxi on the road side, the dog's body felt very hot. I had to postpone the surgery to next Monday as it is not wise to operate a dog that is hyper-excited. This is an old dog with poor nutrition as Vet 1 had advised to feed only vegetables and rice as the dog suffered from skin diseases, including big ulcerations in both ears and below the pads of all paws. The owner said that the original skin problem started with the ears. Vet 1 had diagnosed an auto-immune skin condition called pemphigus* and so advised vegetables and rice only.

"We had been waiting for the taxi for one hour and under the sun," the daughter said. "Next time, I will book a taxi."

This could be a case of pemphigus vulgaris and pemphigus foliaceus. The owners complained that the dog had blisters or ulcers in the ears first (I took some pictures - pemphigus foliaceus starts as blisters in the ears and spreads to the body but does not involve the mouth).

In this case, the mouth got ulcers esp. at the skin-mouth junction. Pemphigus vulgaris involves the muco-cutaneous junctions but not pemphigus foliaceus). Now the dog also has "ulcers" in both ears, ulcers in the mouth-skin junctions and all the pads of the 4 limbs. I have images to show later.

The prednisolone injection given did suppress the auto-immune system. The submandibular lymph nodes are now not spreading caudally like a long cord involving the other lymph nodes, as at 4 days ago. The swelling is now localised at the submandibular lymph nodes which are around 3 cm x 3 cm x 2 cm - very large.

I took a blood test and would review the case 3 days later again. Biopsies for histopathology would need to be specially prepared to get good lab results and these may be costly.

In conclusion, this could be a case of pemphigus vulgaris and pemphigus foliaceus. Long-term immunosuppressive treatment and regular monitoring would be the treatment. Over-treatment will kill the dog and so there must be a long-term care and blood test for this dog.

*REFERENCE
Pemphigus and Pemphigoid in Domestic Animals:
An Overview - Can Vet J 1985; 26: 185-189.
LOW ELL J. AC K ERMAN
Denison Veterinary Services,
1151 Denison Street, Suite 2,
Markham, Ontario L3R 3 Y4
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1680036/pdf/canvetj00606-0015.pdf

In pemphigus foliaceus and vulgaris, diagnosis is based on history, clinical signs, histopathology and immunopathology. Therapy must be immunosuppressive to be effective and is palliative rather than curative.

In practice, it costs a lot of money to diagnose this skin disease. The owner had spent quite a large sum of $2,000 previously. In this case, rather than making the owner to spend more money on biopsy, I consider that it is best to get onto the immunosuppressive treatment and regular 3-monthly monitoring of blood to ensure that the dog is not killed by over-treatment of the immuno-suppressive drugs.

That would be in the best interest of the owner and the dog. I will review in 4 days' time, ie. on Monday. The dog is much well loved as a family member especially the daughter. Pemphigus is a rare skin disease in dogs and so is sometimes diagnosed as allergies to dry dog food - hence Vet 1's recommendation of home-cooked vegetables and rice.

Thursday, September 1, 2011

573. A biting Miniature Schnauzer has vomiting and diarrhoea

Time flies. A month has passed again and this was August 31, 2011. I was on reception duty as that is the best way to know more about the customer service provided by Toa Payoh Vets.

A father and son came at 6.30 pm with his son and a broad chested Miniature Schnauzer. I took out his case card. He was from a neighbourhood where there are two vet clinics nearby just opposite his apartment.

"Why didn't you just go to the clinics nearby?" I asked the father as part of my survey on customer service. This is what most Singaporean pet owners will do. Why go far away when the time can be spent better not travelling.

There are at least 45 vet clinics in Singapore nowadays. So, there is no shortage of vets to the benefit of consumers, as in most businesses.

"My daughter prefers Toa Payoh Vets," the father said. Female members of the family may have a higher say in the choice of vets and veterinary surgery, from my preliminary survey. A daughter who studies overseas in marine biology in Australia had just instructed her family members to bring a dog to me for treatment earlier. The other daughter who phoned me to make an appointment for her father's favourite Chinese Crested dog in the story of Sedation worries of a good daughter is another example of the young ladies making decisions as to their choice of vets.

Services count and Dr Vanessa must have had provided good services as nowadays she handles most of the cases. A time to pass the baton.

What to do with this biting Schnauzer who has vomiting and diarrhoea? "He even bit me when I tried to carry him," the son showed me his left arm which was now OK. "He was bashed with a slipper at the groomer till his nose bled last time and so now he bites whenever anyone tries to muzzle him."

"Has he been neutered?" I asked.
"Yes," he said.

So what to do?
I let Dr Vanessa handle this case. The dog went to the consultation room. The two owners went in. Min had gone out for dinner as it was already 6.30 pm. I waited outside in the reception area for around 15 minutes. Soon, the two owners and dog came out and waited outside the Surgery patiently as the sun was setting. A quiet peaceful time as twilight set in.

I was doing my administrative work, looking into past case cards and checking the vaccination reminders. Why were they outside for so long, another 15 minutes? I went out to ask if they were looking for a taxi. "No," the father said. "I am waiting for your assistant to come back from dinner." Dr Vanessa came out from the consultation room to inform me too. She could not give this dog his anti-vomiting and anti-diarrhoea injection as the owners could not carry the dog onto the consultation table without being bitten and she could not cover the dog's head with a towel which I noted was on her consultation table.

This Schnauzer was a bit plump but younger and alert. He does not growl. He does not threaten. He was merely cool. Just don't mess around with covering his head or muzzling him or carrying him onto the consultation table. He would just bite.
So, Dr Vanessa advised waiting for Min. Some clients do come during certain lunch and dinner time as Dr Vanessa does consult, unlike some surgeries where certain times are closed. So, this is one period where Min had gone out for dinner and she had to wait for him.

I phoned Min and he said he was having dinner. At around 7 pm, he returned and I said to the owners: "It is sometimes better that you don't be around while they restrain the dog for injection." They agreed to wait outside the Surgery.

I let Dr Vanessa handle this case as usual. Another 15 minutes had passed. The father had come in from outside and was sitting on the chair. There was loud barking in the back of the surgery. "How many dogs do you have?" He asked. "Around 5 dogs but from the barking, it seems I have hundreds," I said. The father laughed and said: "Young doctor taking a long time to inject the dog? Is she your daughter?"

Youthfulness can be an advantage as many Singaporeans, in my perception and research, prefer young vets. It is sometimes a disadvantage in a ferocious biting dog case.

It was already more than one hour since the owners had come. So, I opened the door to enter the back of the Surgery. What was taking so long? In the room, I saw Min holding a lasso rope which came out from a long stick while another assistant was holding the leash of the Schnauzer on the other side. Dr Vanessa was holding a bigger muzzle at the right side of the dog. Her sedative of domitor and ketamine for IM injection was on the table. The Schnauzer was wary of Min whose lasso seemed to be rigid and inflexible. His lasso had one end inside a hollow tube. He held the tube and tried to lasso the Schnauzer while the other assistant Tun held onto the leash. As this lasso was inflexible, it did not work. So back and forth. It was taking a very long time.

It was an impasse. Now, I had taught Min how to use the original lasso which was of flexible plastic wrapped rope. He had used his own make as this original lasso had come out from the hollow of the pipe.

I had to intervene, being the leader. There was no choice. It was already 7.30 pm. "Give me the original lasso," I said to Min. He took it from the wall at the back gate. It had no hollow tube as that had broken. But the lasso end was still intact and so I loosen the rope to make a bigger circle to lasso the dog, without the pole. The pole was meant to protect the person holding the lasso from being bitten as it gave some distance. But the pole had broken and so I was holding the lasso end and the remaining rope.

The Schnauzer moved his head. He did not threaten. Tun held onto the leash. At the 3rd try, I manage to put the lasso over his head and pulled it tight. The dog pulled back his head in reaction. Tun held on to the blue leash which was originally with the dog.

"Get ready to inject the domitor IM," I said to Dr Vanessa as I held the dog firmly and upwards for a few seconds. She said: "Domitor is ineffective. I tried earlier on another dog. I am using domitor + ketamine combination". I said: "OK."

She quickly held the dog's back leg and injected the back muscle in the wink of an eye. "Wait 10 minutes," I said. "The owner had instructed that he wanted the whole dog clipped and groomed, including ear cleaning, anal sac and toe nail clipping. At first he just wanted a sedative to clip the backside as the dog would not permit washing of the soiled backside from the diarrhoea."

The whole process took more than one hour. I have been focusing on shortening the process of veterinary work. In this case, it can't be helped as Min is still learning how to restrain ferocious dogs. Remember he was bitten by a dwarf hamster just a few days ago?

Hands-on experiences are learnt only from handling the real cases and this take time. Workplace safety for the staff is paramount.

Still there needs to be a solution to treatment of a ferocious dog for the owner who entrusts the vet to do it. A simple thing as a lasso can still be difficult to execute in practice as in this case when the tool presented is broken. Sometimes we can't have the ideal situation and I hope Min learnt from this coaching I had just presented.

Every person is afraid of being bitten by ferocious dogs but the vet is in charge and has to know what to do, to resolve the problem satisfactorily and safely. The dog was groomed without problem. "Don't bathe the dog?" Min asked me when I phoned at 8.30 pm. I said: "You must bathe the dog in warm water. His backside is dirty from the diarrhoea stools," I said. The dog could now be muzzled and bathe.

I still remember when I was a young vet. I muzzled a dog for vaccination when a pet shop operator brought it in. Later, I got a feedback from a client that this pet shop operator was bad-mouthing me and telling others behind my back: "Dr Sing is afraid of dogs! He muzzles dogs for vaccination."

I don't muzzle every dog for vaccination and in fact, seldom does it. Biting Pomeranians are muzzled as there was no point getting my fingers bitten by sharp canine tooth as I need my fingers for surgery.

But this pet shop operator expects vets to be bite-proof and to have hidden powers to soothe all ferocious beasts! Dog bites are the risk of veterinary science but it does not mean that the staff must be bitten at any time. Workplace safety is very important and it is the responsibility of the vet to ensure that the staff is safe from bites and scratches from dogs and eats. And even from a dwarf hamster!