Dec 20, 2011
7 hours flight from Singapore to Dubai
7 hours flight from Dubai to Vienna
Compared to Dec 2010 when I also flew Emirates to Dubai, this year, the Dubai Airport looked subdued in lighting by 50% at 6.30 am. Not so bright. The Christmas trees were not decorated or lit. Lesson to be learnt.
1. Changes is the constant in life. Last year, Dubai airport must be at its top. Then it had to cut cost.
2. Free breakfast. Big place in the upper floor last year with choices of fruits, cakes and meat. This year, coupons to 3 cafes. I went to "Thai Express" with the coupon. A plate of rice with veg curry and one fried pop piah and one bottle of water.
3. Airport crowd. Less crowded but the Emirate plane from Singapore is still full of passengers as in last year, at around 100% full in economy class.
Wednesday, December 21, 2011
783. 782. Last day of work - Dec 19, 2011 - Part 2
"First impressions count a lot," I had gathered Dr Vanessa, Min, Intern Mr Lim and Administrative Executive Nicole at around 12 noon on Dec 19, 2011 before I went on leave this evening.
I sat on one side of the consultation table facing 4 of them and the main door. Since this was a very small room of 8 sq me, all 5 of us filled up the space. I prefer not to hold such management and performance meetings as I usually speak one-to-one but each internet employee has his own mind and personality and sometimes do not comply with instructions. Early Min was clicking his pen obsessively while I spoke one-to-one with him about his performance. "Stop clicking your pen," I said. "You may think that you can always go back to Yangon and get a job at a vet practice. Maybe US$500 a month but with not many variety and interesting cases to give you the hands-on experiences. Let's say you prefer not to work. One month finishes very fast and you get no income. If you want to start your own practice like Dr Saw who had worked for me for 3 years, you do not really have sufficient experience to be a good vet. Here, you learn from me as do teach you, especially in anaesthesia and surgery. No other vets will want to waste time teaching you.
"You also can see the cases of Dr Vanessa and Dr Jason. In a small practice like Toa Payoh Vets, you have lots to do. Unlike X (a famous practice), where you will be given one thing to do. For example, you will do ultrasound and lab test or you just do past mid-night assisting the vet. At the end of one year, you are only good in ultrasound and nothing else. Vet practice is much more than that, as you can see, if you want to open your own practice in Yangon.
"Of course, if you don't follow instructions, you get scoldings. You are not the only one 'scolded' for poor or lack of performances. When you needed a job, you phoned the agent daily enquiring about a job at Toa Payoh Vets.
"Now, you have a job but you start comparing to what others do in other clinics. Just complete the one-year contract and look for better employers," I said. "Just give me 2 months' notice like Dr Saw and we part amicably and happily." Myanmar vet graduates can't converse well in English and are seldom in demand compared to Filipinos whose command of English and service are top notch. I don't take Filipinos as this is part of my philosophy of 'making a difference' by mentoring Myanmar vets. It is a great disadvantage as regards poor service and interaction with clients as Singaporeans can't understand Myanmarese English. But this is part and parcel of my community service. Just like employing old man James till he was hunched double and could not work anymore. It is not that I can't afford to employ younger and smarter office assistants. It is part of a philosophy of giving back since I was a recipient of a Colombo Plan scholarship from the British government to study vet in Glasgow Univ. Every vet can make a small difference in this world and it is up to each vet to do what he can. For me, it is to help the Myanmar vet and Min is the 3rd one. All he needs is to stay one year and there will be other clinics who will pay him much more as Dr Saw was said to be offered $3,000 by Dr Jason Teo who had started his own practice.
Back to my meeting with all 4 today, I covered the topics of office attire, self-respect, initiative, eye contact by the vet with clients and productivity and performance expected of a vet, assistant, intern and employee. All these will make a long story and I will cover one topic - first impressions.
As regards first impressions, I looked under my table to see what footwear all four were wearing. Dr Vanessa had her clogs, a grey blouse and pants, Nicole wore slippers and no collar T-shirt, Intern Lim wore sports shoes and jeans and Min wore normal shoes and jeans.
"This is not your father's clinic," I said to all four. "Or your grandmother's office. I expect common sense as to what to wear to the office as an employee or intern, without me having to spell out the dress code. Clients who see you all dressed casually will think that their pets are also treated casually when they compare to other clinics with uniforms. This is what they think but they will not say it loud.
It has also to do with self-respect if you don't respect others. As a qualified vet, you set an example. Wearing slippers, sandals and clogs to work are not getting you the respect of others. You may not care. Self-respect is hard to define but it includes certain types of behaviour that is expected of a professional vet or employee. As for Min, he wears jeans. It may be because he has few clothing as he comes from Yangon but Mr Lim wearing jeans to the office is not acceptable.
I had to be frank with them. It is hard. "I have better and many things to do than to check on you," I said. "In 2012, I expect common sense and knowing what to do." If not, I will wield the big stick and start firing or replacing people who will not do what is right in the office. Otherwise, Toa Payoh Vets will just go down the drain and cease to exist as more than 50 vet practices will be set up in 2012. Firm leadership and good management is needed to improve business performance and sustainable profitablility. No short cuts. No casual and loose management anymore.
I sat on one side of the consultation table facing 4 of them and the main door. Since this was a very small room of 8 sq me, all 5 of us filled up the space. I prefer not to hold such management and performance meetings as I usually speak one-to-one but each internet employee has his own mind and personality and sometimes do not comply with instructions. Early Min was clicking his pen obsessively while I spoke one-to-one with him about his performance. "Stop clicking your pen," I said. "You may think that you can always go back to Yangon and get a job at a vet practice. Maybe US$500 a month but with not many variety and interesting cases to give you the hands-on experiences. Let's say you prefer not to work. One month finishes very fast and you get no income. If you want to start your own practice like Dr Saw who had worked for me for 3 years, you do not really have sufficient experience to be a good vet. Here, you learn from me as do teach you, especially in anaesthesia and surgery. No other vets will want to waste time teaching you.
"You also can see the cases of Dr Vanessa and Dr Jason. In a small practice like Toa Payoh Vets, you have lots to do. Unlike X (a famous practice), where you will be given one thing to do. For example, you will do ultrasound and lab test or you just do past mid-night assisting the vet. At the end of one year, you are only good in ultrasound and nothing else. Vet practice is much more than that, as you can see, if you want to open your own practice in Yangon.
"Of course, if you don't follow instructions, you get scoldings. You are not the only one 'scolded' for poor or lack of performances. When you needed a job, you phoned the agent daily enquiring about a job at Toa Payoh Vets.
"Now, you have a job but you start comparing to what others do in other clinics. Just complete the one-year contract and look for better employers," I said. "Just give me 2 months' notice like Dr Saw and we part amicably and happily." Myanmar vet graduates can't converse well in English and are seldom in demand compared to Filipinos whose command of English and service are top notch. I don't take Filipinos as this is part of my philosophy of 'making a difference' by mentoring Myanmar vets. It is a great disadvantage as regards poor service and interaction with clients as Singaporeans can't understand Myanmarese English. But this is part and parcel of my community service. Just like employing old man James till he was hunched double and could not work anymore. It is not that I can't afford to employ younger and smarter office assistants. It is part of a philosophy of giving back since I was a recipient of a Colombo Plan scholarship from the British government to study vet in Glasgow Univ. Every vet can make a small difference in this world and it is up to each vet to do what he can. For me, it is to help the Myanmar vet and Min is the 3rd one. All he needs is to stay one year and there will be other clinics who will pay him much more as Dr Saw was said to be offered $3,000 by Dr Jason Teo who had started his own practice.
Back to my meeting with all 4 today, I covered the topics of office attire, self-respect, initiative, eye contact by the vet with clients and productivity and performance expected of a vet, assistant, intern and employee. All these will make a long story and I will cover one topic - first impressions.
As regards first impressions, I looked under my table to see what footwear all four were wearing. Dr Vanessa had her clogs, a grey blouse and pants, Nicole wore slippers and no collar T-shirt, Intern Lim wore sports shoes and jeans and Min wore normal shoes and jeans.
"This is not your father's clinic," I said to all four. "Or your grandmother's office. I expect common sense as to what to wear to the office as an employee or intern, without me having to spell out the dress code. Clients who see you all dressed casually will think that their pets are also treated casually when they compare to other clinics with uniforms. This is what they think but they will not say it loud.
It has also to do with self-respect if you don't respect others. As a qualified vet, you set an example. Wearing slippers, sandals and clogs to work are not getting you the respect of others. You may not care. Self-respect is hard to define but it includes certain types of behaviour that is expected of a professional vet or employee. As for Min, he wears jeans. It may be because he has few clothing as he comes from Yangon but Mr Lim wearing jeans to the office is not acceptable.
I had to be frank with them. It is hard. "I have better and many things to do than to check on you," I said. "In 2012, I expect common sense and knowing what to do." If not, I will wield the big stick and start firing or replacing people who will not do what is right in the office. Otherwise, Toa Payoh Vets will just go down the drain and cease to exist as more than 50 vet practices will be set up in 2012. Firm leadership and good management is needed to improve business performance and sustainable profitablility. No short cuts. No casual and loose management anymore.
782. Last day of work - Dec 19, 2011 - Part 1
Wed Dec 21, 2011
Vienna, Hotel Bosei, Austria Trend, Austria
4.40 am
Singapore time 11.40 am
Monday Dec 19, 2011 was a dark thunderstorm day. I was at the office at 9.30 am to review the hospitalisation cases. A tall matronly Caucasian lady in a big SUV parked outside. I had seen her before some 3 days ago as Caucasian clientele form less than 1% of Toa Payoh Vets' practice and so they are outstanding.
"Good morning. Dr Vanessa will be in only after 11.30 am," I said. "Is there anything I can help you with while you wait for her. Has your dog recovered from diarrhoea?"
"Yes," she said. "For the past 4 days, he had not pooped. Shall I use the tube which is for treating people with constipation?"
"Yes,"I said. "Use the enema tube for children. You do know how to use it?"
"Yes," she told me. "You know, after the dog went home after treatment for diarrhoea, he had to go to the toilet so many times at night and past midnight to pee. I was so worried."
"That would be due to urine produced. When Dr Vanessa gave your dog the IV drip, your dog would produce more urine as the IV drip water was filtered by the dog's kidneys."
She said: "Nobody told me to expect this. I was very worried that my dog had to go to the toilet so many times after midnight! Now I am worried that he had not pooped for the past 4 days." Later I spoke to Dr Vanessa who told me that she had received a phone call and had settled the matter with her client.
"Stop the medication that Dr Vanessa gave and the dog should poo," I advised. "What is your dog's reference number so that I can take out his medical record. It is written inside the receipt."
The lady put her handbag on the green cloth of the receptionist table. The ccloth covered a plywood counter as the glass pane had cracked and Dr Teo had got a carpenter to put on plywood. As the plywood looked bad for a vet practice, I covered it with the big green towel. Overall, it was not a good impression unlike other new practices. But I had plans to renovate the receptionist room in 2012 and so the overall impression was not too good. I mean, no receptionist counter has a big green or blue towel covering the top! The clients would not comment but the poor impression was there as you would deduce later from this Caucasian lady's comments to me.
The lady digged deep into her bag and produced two veterinary receipts of another practice. Lots of things inside a lady's big bag. "I am sorry I can't find Dr Vanessa's receipt," she said.
I don't comment on seeing receipts of other practices as doctor-hopping is not uncommon in Singapore as this would be inconsiderate. Out of the blue, the lady said: "I use to go to X (name of a famous practice) for many years. It is nicer and has many equipment and doctors. But I prefer the services of Dr Vanessa." I deduce that Toa Payoh Vets need some more painting and repair. It is just not practical to rebuild again as the Surgery has to close for 2 months. In any case, a nice veterinary clinic is like a beauty without brains. The brains are that of the veterinary surgeon who must know what to do and arrive at a correct diagnosis and good clinical outcome. The brains are more important than the physical appearance but that does not mean that tthe practice is like a bombed out dirty place. Toa Payoh Vets need another consultation room and a new receptionist area and this takes time to plan as the space of 60 sq m is very small for dogs that need hospitalisation after surgery, unlike some newer parental financed practices which renovate at over $500,000.
A famous practice with vets that cannot meet the higher expectations of some clients like this European lady would lose such clients to the newer clinics and others. However, since Singaporeans are impressed by brand name (see my conversation with the taxi driver below), a famous established practice will unlikely close down unless it is poorly managed.
In the evening, I got a cab to go to the Changi Airport for my European travel. The taxi driver of around 60 years old was quite chatty and asked Daniel what job he was doing. On hearing that Daniel had graduated as a vet, he spoke about his old dog that his daughter had adopted and now he had to care for it. "The dog is famous amongst the senior vets in X," he said. "I spent $3,000 to fix his broken jaw. Recently he went to another branch of X for passing urine many times. All tests were done. I got some medication for two weeks. But my dog still cannot control his urine. It must be old age," he concluded.
"He will need to be reviewed again," I said softly. He was not interested in listening to outside vets and so I let it be. Unlike the European lady, this taxi-driver would not seek another opinion other than the brand name and this is why I say that brand name still pulls in clientele. But performance counts in the end. A beauty without brains is no good for the dog if the owner is sophisticated to know what to do and to seek a second, third or foureth opinion rather than going for the brand name mindlessly."
Vienna, Hotel Bosei, Austria Trend, Austria
4.40 am
Singapore time 11.40 am
Monday Dec 19, 2011 was a dark thunderstorm day. I was at the office at 9.30 am to review the hospitalisation cases. A tall matronly Caucasian lady in a big SUV parked outside. I had seen her before some 3 days ago as Caucasian clientele form less than 1% of Toa Payoh Vets' practice and so they are outstanding.
"Good morning. Dr Vanessa will be in only after 11.30 am," I said. "Is there anything I can help you with while you wait for her. Has your dog recovered from diarrhoea?"
"Yes," she said. "For the past 4 days, he had not pooped. Shall I use the tube which is for treating people with constipation?"
"Yes,"I said. "Use the enema tube for children. You do know how to use it?"
"Yes," she told me. "You know, after the dog went home after treatment for diarrhoea, he had to go to the toilet so many times at night and past midnight to pee. I was so worried."
"That would be due to urine produced. When Dr Vanessa gave your dog the IV drip, your dog would produce more urine as the IV drip water was filtered by the dog's kidneys."
She said: "Nobody told me to expect this. I was very worried that my dog had to go to the toilet so many times after midnight! Now I am worried that he had not pooped for the past 4 days." Later I spoke to Dr Vanessa who told me that she had received a phone call and had settled the matter with her client.
"Stop the medication that Dr Vanessa gave and the dog should poo," I advised. "What is your dog's reference number so that I can take out his medical record. It is written inside the receipt."
The lady put her handbag on the green cloth of the receptionist table. The ccloth covered a plywood counter as the glass pane had cracked and Dr Teo had got a carpenter to put on plywood. As the plywood looked bad for a vet practice, I covered it with the big green towel. Overall, it was not a good impression unlike other new practices. But I had plans to renovate the receptionist room in 2012 and so the overall impression was not too good. I mean, no receptionist counter has a big green or blue towel covering the top! The clients would not comment but the poor impression was there as you would deduce later from this Caucasian lady's comments to me.
The lady digged deep into her bag and produced two veterinary receipts of another practice. Lots of things inside a lady's big bag. "I am sorry I can't find Dr Vanessa's receipt," she said.
I don't comment on seeing receipts of other practices as doctor-hopping is not uncommon in Singapore as this would be inconsiderate. Out of the blue, the lady said: "I use to go to X (name of a famous practice) for many years. It is nicer and has many equipment and doctors. But I prefer the services of Dr Vanessa." I deduce that Toa Payoh Vets need some more painting and repair. It is just not practical to rebuild again as the Surgery has to close for 2 months. In any case, a nice veterinary clinic is like a beauty without brains. The brains are that of the veterinary surgeon who must know what to do and arrive at a correct diagnosis and good clinical outcome. The brains are more important than the physical appearance but that does not mean that tthe practice is like a bombed out dirty place. Toa Payoh Vets need another consultation room and a new receptionist area and this takes time to plan as the space of 60 sq m is very small for dogs that need hospitalisation after surgery, unlike some newer parental financed practices which renovate at over $500,000.
A famous practice with vets that cannot meet the higher expectations of some clients like this European lady would lose such clients to the newer clinics and others. However, since Singaporeans are impressed by brand name (see my conversation with the taxi driver below), a famous established practice will unlikely close down unless it is poorly managed.
In the evening, I got a cab to go to the Changi Airport for my European travel. The taxi driver of around 60 years old was quite chatty and asked Daniel what job he was doing. On hearing that Daniel had graduated as a vet, he spoke about his old dog that his daughter had adopted and now he had to care for it. "The dog is famous amongst the senior vets in X," he said. "I spent $3,000 to fix his broken jaw. Recently he went to another branch of X for passing urine many times. All tests were done. I got some medication for two weeks. But my dog still cannot control his urine. It must be old age," he concluded.
"He will need to be reviewed again," I said softly. He was not interested in listening to outside vets and so I let it be. Unlike the European lady, this taxi-driver would not seek another opinion other than the brand name and this is why I say that brand name still pulls in clientele. But performance counts in the end. A beauty without brains is no good for the dog if the owner is sophisticated to know what to do and to seek a second, third or foureth opinion rather than going for the brand name mindlessly."
Monday, December 19, 2011
781. The year 2012 will be difficult for vet practices and other businesses - Analytics
Some signs of economic recession amongst the pet owners in Singapore. Vet practices are still businesses that need to be profitable despite lofty ideals of animal care and welfare. If the practice can't make money to pay its staff and renovate and buy new equipment, it just does not exist anymore. I note that young employee vets do not have basic financial knowledge and the balance sheet.
Young employee vets who don't have to worry about the bottom-line will need to be properly assessed as regards their work performance and client outcomes. If the practice's business performance in a lull period is poor, young employee vets and staff will be out of jobs too as they become a liability.
ANALYTICS
The owner of vet practice needs to use analytics to make sense of large amounts of data from customers and business partners and social media like Facebook. If he knows what to do, he can improve business performance.
1. Highlight often-used products and services
2. Identify which market segment is growing and worth focusing on sales
3. Sales and marketing department to identify new customers, imp0rove cost control and increase sales
4. Banks to identify fraudsters - Vets to identify non-paying clients
5. Brand and reputation monitoring
6. Manage risks - credit given to pet shops and breders. Below cost services given by employee vets to breeders who don't bring in any referrals. Just taking advantage of below cost discounted vet services.
As pet owners are likely to spend less in 2012 recession, vet practice owners must use analytics to improve business performance and improve future business outcomes. Not doing it will cause the practice to decline and go into bankruptcy.
Young employee vets who don't have to worry about the bottom-line will need to be properly assessed as regards their work performance and client outcomes. If the practice's business performance in a lull period is poor, young employee vets and staff will be out of jobs too as they become a liability.
ANALYTICS
The owner of vet practice needs to use analytics to make sense of large amounts of data from customers and business partners and social media like Facebook. If he knows what to do, he can improve business performance.
1. Highlight often-used products and services
2. Identify which market segment is growing and worth focusing on sales
3. Sales and marketing department to identify new customers, imp0rove cost control and increase sales
4. Banks to identify fraudsters - Vets to identify non-paying clients
5. Brand and reputation monitoring
6. Manage risks - credit given to pet shops and breders. Below cost services given by employee vets to breeders who don't bring in any referrals. Just taking advantage of below cost discounted vet services.
As pet owners are likely to spend less in 2012 recession, vet practice owners must use analytics to improve business performance and improve future business outcomes. Not doing it will cause the practice to decline and go into bankruptcy.
780. Dr Sing's spay complications - report by Intern Kim
A COACHING SPAY SURGERY FOR MY ASSISTANT MR MIN AND INTERN KIM
- CORPUS LUTEUM
On Dec 18, 2011, a fine Sunday morning, I spayed a cat. There were 2 cats that came in for spaying. Normally my cat spays without complications take less than 15 minutues but this cat had some bleeding complications, being pregnant and has the corpus luteum.
Kim, the intern was able to see her first spay done by me. She sees practice on Sundays only whenever she is free. I asked her to write a report as writing can make her learn more. Here is her report (with my amendments in CAPITAL LETTERS):
Cat early pregnancy spay
3kg
Start time: 9.45am (SEDATION GIVEN IM. XYLAZINE 0.15 + KETAMINE 0.6 ML IM)
Start of surgery = SEDATION GIVEN
9.59am
Cut the skin (FIRST INCISION SKIN)
10.02am
Left ovary hooked out
10.07am
Scapel blade was used to cut off left ovary (CUT OFF LEFT OVARIAN LIGAMENTS AFTER LIGATION OF LIGAMENTS AND BV)
10.08am
Front paws were untied and body lifted up, cat started meowing (THE CAT WAS TILTED UPWARDS TO ASSESS THE RIGHT UTERINE HORN EASIER)
10.09am
Right ovary cut out
10.10am
Scapel blade was used to cut off Right ovary
10.13am
Extend incision bleeding (COPIOUS HAEMORRHAGE OBSERVED, USUALLY OMENTAL FAT BLEEDING)
10.16am
Slow breathing observed (I CAN'T FIGURE WHY INTERN KIM WROTE THIS AS CAT WAS UNDER INJECTABLE ANAESTHESIA)
10.17am
Ligate individual uterine twine (UTERINE HORNS)
10.18am
Check breathing again
Extend incision around 5mm
Clamp Uterine body
Check bleeding
10.20am
Bleeding controlled
Suspect torn uterine blood vessel
10.23am
Transfixing ligature uterine body to control bleeding
10.27am
(Cat on heat)
Bleeding again from ovarian fat
10.28am
Swab blood
Cut off uterine body
10.30am
Simple interrupted suture
Bleeding stop
Linear alba 3 stitches 3cm (LINEA ALBA 3 SIMPLE INTERRRUPTED SUTURES. 3 CM LONG)
10.32am
Check linear alba for hole
Stitch skin using horizontal mattress 2 stitches
Skin incision estimated to be around 3cm
10.33am
End of suture
Surgical time: First skin incision –> last stitch = 9:59- 10:33= 32mins
Operation time: Sedation-> Last stitch = 9:45- 10:33= 47mins
Suture used: 3/0 (ABSORBABLE PDS)
Amount used: 1 packet
Sedation dose: Isoflurorane gas 2% (NO ISOFLURANE GAS WAS GIVEN. XYLAZINE AND KETAMINE IM).
Conclusion by Dr Sing.
A good first draft written under time pressure. Vet interns are to write on their own first draft instead of being spoon-fed and then I will amend their report.
Corpus luteum yellow seen. Also small foetal lumps of 8 mm inside the uterine horns seen (Images taken). The cat owner was adamant that her cat Manja, 6 months old, had never been out or mated with another cat!
- CORPUS LUTEUM
On Dec 18, 2011, a fine Sunday morning, I spayed a cat. There were 2 cats that came in for spaying. Normally my cat spays without complications take less than 15 minutues but this cat had some bleeding complications, being pregnant and has the corpus luteum.
Kim, the intern was able to see her first spay done by me. She sees practice on Sundays only whenever she is free. I asked her to write a report as writing can make her learn more. Here is her report (with my amendments in CAPITAL LETTERS):
Cat early pregnancy spay
3kg
Start time: 9.45am (SEDATION GIVEN IM. XYLAZINE 0.15 + KETAMINE 0.6 ML IM)
Start of surgery = SEDATION GIVEN
9.59am
Cut the skin (FIRST INCISION SKIN)
10.02am
Left ovary hooked out
10.07am
Scapel blade was used to cut off left ovary (CUT OFF LEFT OVARIAN LIGAMENTS AFTER LIGATION OF LIGAMENTS AND BV)
10.08am
Front paws were untied and body lifted up, cat started meowing (THE CAT WAS TILTED UPWARDS TO ASSESS THE RIGHT UTERINE HORN EASIER)
10.09am
Right ovary cut out
10.10am
Scapel blade was used to cut off Right ovary
10.13am
Extend incision bleeding (COPIOUS HAEMORRHAGE OBSERVED, USUALLY OMENTAL FAT BLEEDING)
10.16am
Slow breathing observed (I CAN'T FIGURE WHY INTERN KIM WROTE THIS AS CAT WAS UNDER INJECTABLE ANAESTHESIA)
10.17am
Ligate individual uterine twine (UTERINE HORNS)
10.18am
Check breathing again
Extend incision around 5mm
Clamp Uterine body
Check bleeding
10.20am
Bleeding controlled
Suspect torn uterine blood vessel
10.23am
Transfixing ligature uterine body to control bleeding
10.27am
(Cat on heat)
Bleeding again from ovarian fat
10.28am
Swab blood
Cut off uterine body
10.30am
Simple interrupted suture
Bleeding stop
Linear alba 3 stitches 3cm (LINEA ALBA 3 SIMPLE INTERRRUPTED SUTURES. 3 CM LONG)
10.32am
Check linear alba for hole
Stitch skin using horizontal mattress 2 stitches
Skin incision estimated to be around 3cm
10.33am
End of suture
Surgical time: First skin incision –> last stitch = 9:59- 10:33= 32mins
Operation time: Sedation-> Last stitch = 9:45- 10:33= 47mins
Suture used: 3/0 (ABSORBABLE PDS)
Amount used: 1 packet
Sedation dose: Isoflurorane gas 2% (NO ISOFLURANE GAS WAS GIVEN. XYLAZINE AND KETAMINE IM).
Conclusion by Dr Sing.
A good first draft written under time pressure. Vet interns are to write on their own first draft instead of being spoon-fed and then I will amend their report.
Corpus luteum yellow seen. Also small foetal lumps of 8 mm inside the uterine horns seen (Images taken). The cat owner was adamant that her cat Manja, 6 months old, had never been out or mated with another cat!
779. Internship - Presenting sign of hyperoestrogenism in an old female Sheltie
2011/12/18 lim ..@hotmail.com>
Dear Dr Sing
I have attached a document on the case studies I have seen on the 2nd day of internship, 18 December 2011. Is this what you want of the daily case studies or does it have to be more detailed?
Yours Sincerely
Name of Intern
REPLY FROM DR SING DATED DEC 19, 2011
Thanks for email. During internship, one case study per day is to be recorded for me to review and discussed with you. Otherwise, being a bystander standing around the vet will not enable you to appreciate the diverse aspects of vet medicine and surgery and its varied clinical presentations and challenges to a correct diagnosis.
Evidence-based medicine and knowing how to arrive at a correct diagnosis is not so easy in some rare cases as in this Sheltie whose condition may be mis-diagnosed as ringworm when the actual cause of the hair loss is due to hormonal factors.
One Case study should be written with the following format using the Sheltie you saw yesterday Sunday as an example. You re-write your case study with as much info of the case under the following headings:
CASE NO. 1 DATE:
1. Description of patient - breed, gender, age, colour. Not spayed.
2. Chief complaint - hair loss. Other complaints -
3. History - Hair loss for the last 5 years. Hair grows back after the heat and problem of hair loss recurs. Not fully recovered. Seen 2 vets.
4. Presenting sign: Vulval enlarged over 20X normal. Hyperpigmented black.
5. Examination and tests (blood, urine, skin etc).
6. Diagnosis
7. Treatment/Advice
8. Review/Outcome/Follow up - 2 weeks later. Date to be written on medical record.
8. Against Medical Advices - to be written down
As reviewed by me, what should have been included in this case were:
1. Where were the medical records of other vets? This should be recorded if the owner does not bring them. If owner said "Blood test of other vet is OK," the vet should not take the owner's word for it and ask for the blood test results. Some owners do NOT want to pay for another blood test and this should be recorded under "Against Medical Advices".
2. When was the last heat? This should be asked.
From my review of the above case, the main diagnosis would be a case of hyperestrogenism rather than fungal infections of the dog. Fungal infections are present but the dog's problem will not be cured even if the ringworm is eliminated. So, the owner goes to another vet later for a 4th opinion or just accept that nothing can be done. The dog was put on a hypo-allergic diet by the previous vet for one month. This would be too early to eliminate dry food allergy as a cause of the hair loss.
Now, the Presenting Sign of a swollen vulva 3 months after the end of heat and its presence for over the last 5 years point to a high probability of hyperestrogenism.
The solution for this owner is to spay his dog after the skin infections are resolved in around 4 weeks' time. However the dog is old and there are high anaesthetic risks. This case is quite rare. I had seen less than 10 cases over the past 30 years of small animal practice. So a mis-diagnosis can easily be made as the skin signs of recurring hair loss distracts from the PRESENTING SIGN. A blood test for hormonal levels should be advised in theory and as part of the practice of evidence-based medicine.
Update at:
http://www.sinpets.com/dogs/20111219hyperestrogenism-old-female-Sheltie-internship-singapore_ToaPayohVets.htm
Dear Dr Sing
I have attached a document on the case studies I have seen on the 2nd day of internship, 18 December 2011. Is this what you want of the daily case studies or does it have to be more detailed?
Yours Sincerely
Name of Intern
REPLY FROM DR SING DATED DEC 19, 2011
Thanks for email. During internship, one case study per day is to be recorded for me to review and discussed with you. Otherwise, being a bystander standing around the vet will not enable you to appreciate the diverse aspects of vet medicine and surgery and its varied clinical presentations and challenges to a correct diagnosis.
Evidence-based medicine and knowing how to arrive at a correct diagnosis is not so easy in some rare cases as in this Sheltie whose condition may be mis-diagnosed as ringworm when the actual cause of the hair loss is due to hormonal factors.
One Case study should be written with the following format using the Sheltie you saw yesterday Sunday as an example. You re-write your case study with as much info of the case under the following headings:
CASE NO. 1 DATE:
1. Description of patient - breed, gender, age, colour. Not spayed.
2. Chief complaint - hair loss. Other complaints -
3. History - Hair loss for the last 5 years. Hair grows back after the heat and problem of hair loss recurs. Not fully recovered. Seen 2 vets.
4. Presenting sign: Vulval enlarged over 20X normal. Hyperpigmented black.
5. Examination and tests (blood, urine, skin etc).
6. Diagnosis
7. Treatment/Advice
8. Review/Outcome/Follow up - 2 weeks later. Date to be written on medical record.
8. Against Medical Advices - to be written down
As reviewed by me, what should have been included in this case were:
1. Where were the medical records of other vets? This should be recorded if the owner does not bring them. If owner said "Blood test of other vet is OK," the vet should not take the owner's word for it and ask for the blood test results. Some owners do NOT want to pay for another blood test and this should be recorded under "Against Medical Advices".
2. When was the last heat? This should be asked.
From my review of the above case, the main diagnosis would be a case of hyperestrogenism rather than fungal infections of the dog. Fungal infections are present but the dog's problem will not be cured even if the ringworm is eliminated. So, the owner goes to another vet later for a 4th opinion or just accept that nothing can be done. The dog was put on a hypo-allergic diet by the previous vet for one month. This would be too early to eliminate dry food allergy as a cause of the hair loss.
Now, the Presenting Sign of a swollen vulva 3 months after the end of heat and its presence for over the last 5 years point to a high probability of hyperestrogenism.
The solution for this owner is to spay his dog after the skin infections are resolved in around 4 weeks' time. However the dog is old and there are high anaesthetic risks. This case is quite rare. I had seen less than 10 cases over the past 30 years of small animal practice. So a mis-diagnosis can easily be made as the skin signs of recurring hair loss distracts from the PRESENTING SIGN. A blood test for hormonal levels should be advised in theory and as part of the practice of evidence-based medicine.
Update at:
http://www.sinpets.com/dogs/20111219hyperestrogenism-old-female-Sheltie-internship-singapore_ToaPayohVets.htm
Saturday, December 17, 2011
778. Myanmar stories from Peninsula Plaza - Lost a useful contact - case study
My thoughts and tips of the younger generation - the google generation.
Lady 28 years, single, Myanmar National
Had working experience of 2 years in Malaysia and 8 months in Singapore on a "S" pass. Her Singapore company was acquired and she was retrenched. She worked in the administrative side of both companies and has a good command of English and works hard. Presently she pays $500 to attend a diploma in business course but the college told her that the course would be 2 years. That is a lot of money as she is from a poor family.
My advice to her and all young people, including Singaporeans are:
1. Acquire important IT skills like a detailed knowledge of how to use Excel, Word,
video production and digital imaging. Real depth of knowledge of these software in database management and accounting. Not just superficial as many young people even from the Junior Colleges have. This makes you useful to prospective employer.
2. Willing to work hard and the longer hours. Yes, she does.
3. Can converse in English well. Yes. Written English is not so good as to be expected.
4. Positive outlook and lots of energy. Yes, as expected of a young person.
5. Get the testimonials of previous employers esp. the Singaporean company.
6. Unique Strength - Myanmar culture and language and speaking good English.
7. Be proactive. Do your own search and write to hundreds of employers (target 14 per week for example). Do not give up hope.
8. Resume must be up to standard and relevant. This needs outside professional help.
As "S" pass now require $2,000 payment by the employer, it is much more difficult to justify employing new graduates from Myanmar. But much depends on the education and skills and the demands of the relevant industry.
9. Do not job hop. Last month, I met a Filipino who switched to a Korean company for more pay. "However, I have to work on Sundays too," she told me as she visited Khin Khin Employment Agency to look for a job before her visa expires. It was too late. She had a earlier job which satisfied her work hour demands but the money was not there compared to the Korean company which told her that there would be no Sunday work. So this young lady resigned and without another employer, looked for a new employer. This is quite common. But her visa expires and her skills are common (administrative and sales). So, she had to go home.
10. Also save your network phone numbers in duplicate. This girl lost her old phone and all contact numbers esp. of the Accountant in the Singapore company. The Accountant was happy to give her and help. As is the case for young people, such contacts are not valued and phone number had disappeared. I advised her to be more proactive in searching for this mentor who could find jobs for her.
11. Many young people just do not bother with networks and people who will be of great help in their future job search. In conclusion, this case illustrates the importance of duplicating network contacts and being organised and careful. Young people with no specialised degree like accountancy will need to be more alert and pro-active in seeking work attachments and testimonials. New employers want testimonials and character references. "The Accountant told me that I can contact her anytime if I need help," she told me today as I met her at Peninsula Plaza while looking for a Myanmar travel agent. But she lost the phone.
12. Try and get along well with Singaporean colleagues of old job. Some may provide character references for you.
13. "Get married to a rich husband," I said to the young lady. Many Singapore wives stop work to look after their families if their husbands earn a good income. So this is what I advise her. "You are already 28 years old," I said. "How's your Italian boyfriend who contacts you daily from the UK?"
"It is not that easy," she told me. As I am more than twice her age, she does not feel offended in my advices. She needs to be more proactive in finding an employer who will apply for her the "S" pass.
Lady 28 years, single, Myanmar National
Had working experience of 2 years in Malaysia and 8 months in Singapore on a "S" pass. Her Singapore company was acquired and she was retrenched. She worked in the administrative side of both companies and has a good command of English and works hard. Presently she pays $500 to attend a diploma in business course but the college told her that the course would be 2 years. That is a lot of money as she is from a poor family.
My advice to her and all young people, including Singaporeans are:
1. Acquire important IT skills like a detailed knowledge of how to use Excel, Word,
video production and digital imaging. Real depth of knowledge of these software in database management and accounting. Not just superficial as many young people even from the Junior Colleges have. This makes you useful to prospective employer.
2. Willing to work hard and the longer hours. Yes, she does.
3. Can converse in English well. Yes. Written English is not so good as to be expected.
4. Positive outlook and lots of energy. Yes, as expected of a young person.
5. Get the testimonials of previous employers esp. the Singaporean company.
6. Unique Strength - Myanmar culture and language and speaking good English.
7. Be proactive. Do your own search and write to hundreds of employers (target 14 per week for example). Do not give up hope.
8. Resume must be up to standard and relevant. This needs outside professional help.
As "S" pass now require $2,000 payment by the employer, it is much more difficult to justify employing new graduates from Myanmar. But much depends on the education and skills and the demands of the relevant industry.
9. Do not job hop. Last month, I met a Filipino who switched to a Korean company for more pay. "However, I have to work on Sundays too," she told me as she visited Khin Khin Employment Agency to look for a job before her visa expires. It was too late. She had a earlier job which satisfied her work hour demands but the money was not there compared to the Korean company which told her that there would be no Sunday work. So this young lady resigned and without another employer, looked for a new employer. This is quite common. But her visa expires and her skills are common (administrative and sales). So, she had to go home.
10. Also save your network phone numbers in duplicate. This girl lost her old phone and all contact numbers esp. of the Accountant in the Singapore company. The Accountant was happy to give her and help. As is the case for young people, such contacts are not valued and phone number had disappeared. I advised her to be more proactive in searching for this mentor who could find jobs for her.
11. Many young people just do not bother with networks and people who will be of great help in their future job search. In conclusion, this case illustrates the importance of duplicating network contacts and being organised and careful. Young people with no specialised degree like accountancy will need to be more alert and pro-active in seeking work attachments and testimonials. New employers want testimonials and character references. "The Accountant told me that I can contact her anytime if I need help," she told me today as I met her at Peninsula Plaza while looking for a Myanmar travel agent. But she lost the phone.
12. Try and get along well with Singaporean colleagues of old job. Some may provide character references for you.
13. "Get married to a rich husband," I said to the young lady. Many Singapore wives stop work to look after their families if their husbands earn a good income. So this is what I advise her. "You are already 28 years old," I said. "How's your Italian boyfriend who contacts you daily from the UK?"
"It is not that easy," she told me. As I am more than twice her age, she does not feel offended in my advices. She needs to be more proactive in finding an employer who will apply for her the "S" pass.
777. Dog lame after Vet 1 injected his thigh
"Whether your injection is the cause of the lameness or not is hard to say," I advised Vet 1. "The dog owner had alleged that your injection was the cause as the dog was not lame before the injection and was lame some hours after the injection! Listen to the complaint and try not to antagonise the owner!
775. No dog
Friday Dec 17, 2011 was a significant day. Dr Vanessa's dog had not been brought to the surgery. On Thursday, I nearly fell as I slipped while going to a crate in the back Animal Handling Room to show a client another Shih Tzu with tarsorrhapy. Her dog peed a big puddle on the floor and did not see it. Obviously I don't look for urine in my own Surgery. This dog had a habit of letting go of large puddles of urine when let loose in the back room. My assistant Min had to clean up and that should NOT be his job. I don't see Dr Vanessa cleaning up and I had given her instruction NOT to let the dog loose anymore. The staff will inform me if she does not heed the instruction.
The dog barks at Min and at me whenever we go to the consultation room to talk to her about the cases. Dr Vanessa would just keep quiet and not discipline the dog as I had advised her. So the dog became bolder and barked to drown out any talk from me or Min. I just can't understand why she would permit such behaviour. This is just not appropriate behaviour for a vet.
The dog also barked at clients. Some Muslim clients cannot be near this dog but he was let loose and so wandered to sniff them or their cats.
It is over one year tolerating this dog's behaviour and copious urination. I hav e to decide as to whether to terminate Dr Vanessa's association with Toa Payoh Vets. Just last month, her dog charged at me when she and I were discussing a case of a dog warded. I just could not believe that she did nothing. Not even a word of scolding at this dog. She just held back the dog in time.
This story is so incredible that readers may think I have a fertile imagination.
The dog barks at Min and at me whenever we go to the consultation room to talk to her about the cases. Dr Vanessa would just keep quiet and not discipline the dog as I had advised her. So the dog became bolder and barked to drown out any talk from me or Min. I just can't understand why she would permit such behaviour. This is just not appropriate behaviour for a vet.
The dog also barked at clients. Some Muslim clients cannot be near this dog but he was let loose and so wandered to sniff them or their cats.
It is over one year tolerating this dog's behaviour and copious urination. I hav e to decide as to whether to terminate Dr Vanessa's association with Toa Payoh Vets. Just last month, her dog charged at me when she and I were discussing a case of a dog warded. I just could not believe that she did nothing. Not even a word of scolding at this dog. She just held back the dog in time.
This story is so incredible that readers may think I have a fertile imagination.
774. Friday Dec 16, 2011. Ear canal resection in an old Cocker Spaniel
Dec 16, 2011
A young man who had completed his A levels started first day as intern till his National Service in May 2012. He surprised me by turning up at 9 am today as I told him I had an ear operation on a dog and he would be welcome to see how it is done.
"This ear canal resection surgery is seldom performed as most Singapore owners don't want to do it," I told this young man. "So, a vet undergraduate who studies 5 or 6 years may not have seen such an operation performed in real life. It costs money and that is why many Singapore dog owners don't want to do it."
Since he appeared keen by being present so early, unlike most of my interns who would be clock-watching, I shared with him some tips. He recorded the following for me:
Dear Dr Sing
Sorry to have to send you an email at such a time as I only got home by 10 p.m.. I have attached a report for 16 December 2011. The following is the timeline of the dog ear electrosurgery operation.
Dog Ear Operation (Electrosurgery)
Age: 10 Years Old Weight: 9.5kg Temperature: 38.5 Degree Celsius
10.15am: Clean flush the ear
11.13am: Sedation of the dog ( D and K)
11.23am: Isoflurance
11.35am: Electro incision
11.37am: 1% isoflurance
11.46sm: Stitching Right Ear
11.47am: 1% isoflurance
11.50am: 1% isoflurance
11.55am: 1% isoflurance
12.00pm: 1% isoflurance, 30 rr per minute
12.05pm: 1% isoflurance, 24 rr per minute
12.08pm: Finish Suture
12.10pm: Weat Exercise
12.11pm: Eye Blinking
12.11pm: increase to 4% isoflurance
12.11pm: Two clamps on the left ear
12.13pm: 1% isoflurance
12.15pm: electro incision
12.17pm: 2.5% isoflurance
12.19pm: 1% isoflurance
12.20pm: First Stitch on the left ear
12.22pm: 24 rr, per minute
12.25pm: 1% isoflurance
12.30pm: 0.5% isoflurance
12.34pm: 0.25% isoflurance
12.35pm: 0% isoflurance, remove electrode
12.39pm: End of stitch, End Of Operation
I did not edit his email report. rr=respiratory rate. isoflurance = isoflurane + O2 gas. D=domitor IV K=ketamine IV
From the above, it could be seen that two-ear canal resection surgery in an old dog with skin disease started from 11.35am and ends 12.39 pm. Total is around 1 hour just for the surgery.
I will record my surgery for the benefit of others. The vet surgery textbook can only give the theory but the practice of vet surgery is so much different in old dogs with generalised skin diseases.
EAR CANAL RESECTION IN AN OLD COCKER SPANIEL
Cocker Spaniel, 9.5 kg
Generalised skin diseases for many years. Scratching whole body, neck. Dandruff. Oily skin. The busy owner would send to the vet for treatment but the skin disease re-appears again after a few months. I believe that no vets had suggested ear canal resection to him. This was the cause of the skin disease, in my opinion. Ear infection --- painful, itchy. Dog scratches ears and neck, bites flanks - skin trauma, bacterial infections, more body itchiness, more scratching --- whole body skin inflamed. Finally, left ear had a big ear wart. Dog bites. Nobody at home cleaned the ear canals. Pus, bacterial, dampness as ear flap floppy covers ear canal --- no ventilation -- dampness inside ear canals -- bacteria grows ---pain and irritation --- dog scratches ear neck and bites flank. Uses back paws to scratch flank and chest --- oily infected red skin all over the body including forehead. Will post some images later.
1. PRE-OP PREPARATION
Dog with serious skin diseases was warded for over 2 weeks for treatment and fed proper food to gain weight. Monitored. Good appetite. Skin condition less dandruff but still oily. No yeast inside ear canal (ear canal smear). Owner gave permission for ear surgery. On day of op, dog bites esp. when left ear is touched. So my assistant only bathed him.
PLANNING PRE-OP
1.1 Sedate with Domitor and Ketamine at 50% of calculated dose IV. Very weak. Sedated within 2 minutes.
1.2 Put dog on table and flush, irrigate ear canals vigorously.
1.3 I washed his outer ear skin area thoroughly with cloth and antiseptic myself.
The oily skin was scrubbed well. I did not permit my assistant Min to do it in this bad skin diseased case as I must be sure that the area is cleaned.
1.4 Dog went to surgery room. Mask with isoflurane and O2 for <2 minutes. Intubated with size 8.5 endotracheal tube. This size fitted tightly so no leakage of gas during surgery.
1.5 Ensure set up of electrosurgery machine, big towel, moist saline on swab for indifferent plate, cotton bud, marker pen and surgical equipment and suture. "Check isoflurane level inside the machine," I said to Min after checking oxygen amount. He had to top up the isoflurane liquid.
ELECTROSURGERY
1. Full power setting for electro-incision. I fitted the electrode into the handle.
2. Towel covers steel operating table to prevent electric shocks to staff and vet
3. Marker pen defined lowest level of vertical canal.
4. 2 forceps clamp either vertical side of canal.
5. Electro-incision of skin
6. Skin flap elevated and cut.
7. Arterioles shoot out blood into me. Clamped arterioles. Venous bleeding controlled by clamp.
SURGICAL PROCEDURE
Described in detail in www.toapayohvets.com, goto DOGS, goto EARS. 3/0 nylon 2 packets used in this surgery for 2 ears.
PRODUCTIVITY
How long it takes to do the surgery? Should be around 1 hour for both ears. More experience and planning carefully, less than 1 hour in younger dogs with no skin diseases. Good assistant to monitor vital signs and the vet is to keep proper anaesthetic record
POST-OP CARE
Tolfedine 1 ml + Baytril 1 ml SC
Wash ear bleeding thoroughly at end of op and not wait.
Post-op medication.
CONCLUSION
Dog OK. Woke up with no need for Antisedan reversal. Will check on Day 2 (Saturday 9.44 am as I write this report). This surgery ought to be done for dogs with recurring ear infections and floppy ears, when the dog was much younger, e.g. 3 years old but most Singapore owners will not do it. Breeds commonly affected are Cocker Spaniels and Miniature Schnauzers with hairy ears. Some Shih Tzus. Other breeds seldom have chronic otitis externa that can't be cured.
A young man who had completed his A levels started first day as intern till his National Service in May 2012. He surprised me by turning up at 9 am today as I told him I had an ear operation on a dog and he would be welcome to see how it is done.
"This ear canal resection surgery is seldom performed as most Singapore owners don't want to do it," I told this young man. "So, a vet undergraduate who studies 5 or 6 years may not have seen such an operation performed in real life. It costs money and that is why many Singapore dog owners don't want to do it."
Since he appeared keen by being present so early, unlike most of my interns who would be clock-watching, I shared with him some tips. He recorded the following for me:
Dear Dr Sing
Sorry to have to send you an email at such a time as I only got home by 10 p.m.. I have attached a report for 16 December 2011. The following is the timeline of the dog ear electrosurgery operation.
Dog Ear Operation (Electrosurgery)
Age: 10 Years Old Weight: 9.5kg Temperature: 38.5 Degree Celsius
10.15am: Clean flush the ear
11.13am: Sedation of the dog ( D and K)
11.23am: Isoflurance
11.35am: Electro incision
11.37am: 1% isoflurance
11.46sm: Stitching Right Ear
11.47am: 1% isoflurance
11.50am: 1% isoflurance
11.55am: 1% isoflurance
12.00pm: 1% isoflurance, 30 rr per minute
12.05pm: 1% isoflurance, 24 rr per minute
12.08pm: Finish Suture
12.10pm: Weat Exercise
12.11pm: Eye Blinking
12.11pm: increase to 4% isoflurance
12.11pm: Two clamps on the left ear
12.13pm: 1% isoflurance
12.15pm: electro incision
12.17pm: 2.5% isoflurance
12.19pm: 1% isoflurance
12.20pm: First Stitch on the left ear
12.22pm: 24 rr, per minute
12.25pm: 1% isoflurance
12.30pm: 0.5% isoflurance
12.34pm: 0.25% isoflurance
12.35pm: 0% isoflurance, remove electrode
12.39pm: End of stitch, End Of Operation
I did not edit his email report. rr=respiratory rate. isoflurance = isoflurane + O2 gas. D=domitor IV K=ketamine IV
From the above, it could be seen that two-ear canal resection surgery in an old dog with skin disease started from 11.35am and ends 12.39 pm. Total is around 1 hour just for the surgery.
I will record my surgery for the benefit of others. The vet surgery textbook can only give the theory but the practice of vet surgery is so much different in old dogs with generalised skin diseases.
EAR CANAL RESECTION IN AN OLD COCKER SPANIEL
Cocker Spaniel, 9.5 kg
Generalised skin diseases for many years. Scratching whole body, neck. Dandruff. Oily skin. The busy owner would send to the vet for treatment but the skin disease re-appears again after a few months. I believe that no vets had suggested ear canal resection to him. This was the cause of the skin disease, in my opinion. Ear infection --- painful, itchy. Dog scratches ears and neck, bites flanks - skin trauma, bacterial infections, more body itchiness, more scratching --- whole body skin inflamed. Finally, left ear had a big ear wart. Dog bites. Nobody at home cleaned the ear canals. Pus, bacterial, dampness as ear flap floppy covers ear canal --- no ventilation -- dampness inside ear canals -- bacteria grows ---pain and irritation --- dog scratches ear neck and bites flank. Uses back paws to scratch flank and chest --- oily infected red skin all over the body including forehead. Will post some images later.
1. PRE-OP PREPARATION
Dog with serious skin diseases was warded for over 2 weeks for treatment and fed proper food to gain weight. Monitored. Good appetite. Skin condition less dandruff but still oily. No yeast inside ear canal (ear canal smear). Owner gave permission for ear surgery. On day of op, dog bites esp. when left ear is touched. So my assistant only bathed him.
PLANNING PRE-OP
1.1 Sedate with Domitor and Ketamine at 50% of calculated dose IV. Very weak. Sedated within 2 minutes.
1.2 Put dog on table and flush, irrigate ear canals vigorously.
1.3 I washed his outer ear skin area thoroughly with cloth and antiseptic myself.
The oily skin was scrubbed well. I did not permit my assistant Min to do it in this bad skin diseased case as I must be sure that the area is cleaned.
1.4 Dog went to surgery room. Mask with isoflurane and O2 for <2 minutes. Intubated with size 8.5 endotracheal tube. This size fitted tightly so no leakage of gas during surgery.
1.5 Ensure set up of electrosurgery machine, big towel, moist saline on swab for indifferent plate, cotton bud, marker pen and surgical equipment and suture. "Check isoflurane level inside the machine," I said to Min after checking oxygen amount. He had to top up the isoflurane liquid.
ELECTROSURGERY
1. Full power setting for electro-incision. I fitted the electrode into the handle.
2. Towel covers steel operating table to prevent electric shocks to staff and vet
3. Marker pen defined lowest level of vertical canal.
4. 2 forceps clamp either vertical side of canal.
5. Electro-incision of skin
6. Skin flap elevated and cut.
7. Arterioles shoot out blood into me. Clamped arterioles. Venous bleeding controlled by clamp.
SURGICAL PROCEDURE
Described in detail in www.toapayohvets.com, goto DOGS, goto EARS. 3/0 nylon 2 packets used in this surgery for 2 ears.
PRODUCTIVITY
How long it takes to do the surgery? Should be around 1 hour for both ears. More experience and planning carefully, less than 1 hour in younger dogs with no skin diseases. Good assistant to monitor vital signs and the vet is to keep proper anaesthetic record
POST-OP CARE
Tolfedine 1 ml + Baytril 1 ml SC
Wash ear bleeding thoroughly at end of op and not wait.
Post-op medication.
CONCLUSION
Dog OK. Woke up with no need for Antisedan reversal. Will check on Day 2 (Saturday 9.44 am as I write this report). This surgery ought to be done for dogs with recurring ear infections and floppy ears, when the dog was much younger, e.g. 3 years old but most Singapore owners will not do it. Breeds commonly affected are Cocker Spaniels and Miniature Schnauzers with hairy ears. Some Shih Tzus. Other breeds seldom have chronic otitis externa that can't be cured.
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