I am collecting data to improve the processes and system and the productivity of vet surgery by an associate vets at Toa Payoh Vets. Timings depend on the complexity of the surgical case and therefore there is no fixed period of time.
Ferocious biting Shih Tzu, Male, 8 years. 13 urinary stones inside the bladder
TP 16915
Op Date: Jan 12, 2012
Surgeon: Associate vet
A. Sedation injection 3.11 pm
Skin prep, Isoflurane gas
B. Skin incision 3.38pm
C. Skin stitched up 4.11 pm
B-A = 27 minutes. Dog was ferocious and therefore prep had to be done after sedation
C-B = 33 minutes. This is acceptable for an experienced vet doing cystostomy alone. All 13 stones were inside the bladder and accounted for. Therefore there was no need to do urethrostomy. The stones must have been flushed back into the bladder under anaesthesia by Vet 1 during the after midnight visit.
Blood test by Vet 1 - Significant findings, 12.40am Jan 12, 2012
MCV high 79 (60-77)
WBC high 26 (5.5 -17)
NEU high 21 (2-12)
MONO high 3 (0.3-2)
BASO high 0.16 (0-1)
PLT high 660 (175-500)
BUN high 31 (7-27)
ALKP high 233 (23-212)
K high 6.5 (3.5-5.8)
Friday, January 13, 2012
818. How many urinary stones?
An X-ray of the Shih Tzu with a recurrent urolithiasis and an X-ray. "How many stones?" I asked my assistant Min as part of my mentoring process.
"Eleven," he said. "Well there are 13," I showed him the 2 stones hidden near the pelvic bones.
"Better make sure that you don't flush the bladder or urethra too vigorously duringb cystotomy," I said to Dr Vanessa who would be operating. "13 stones are expected." She got 13 stones. Well done. All stones were inside the bladder and she had used a bigger catheter to ensure no more stones are left behind.
"The stones must be sent for analysis," I said. "The dog had a previous surgery 1 year ago and the stones had recurred."
"Eleven," he said. "Well there are 13," I showed him the 2 stones hidden near the pelvic bones.
"Better make sure that you don't flush the bladder or urethra too vigorously duringb cystotomy," I said to Dr Vanessa who would be operating. "13 stones are expected." She got 13 stones. Well done. All stones were inside the bladder and she had used a bigger catheter to ensure no more stones are left behind.
"The stones must be sent for analysis," I said. "The dog had a previous surgery 1 year ago and the stones had recurred."
817. The Golden Retriever has a twitching eye
Vet 1 treated this 8-year-old Golden Retriever with a bottle of eye drops and asked the owner to return if the right eye infection (eyes 3/4 closed) had not cured. This was what the owner said to me. "Is the sunken eyeball normal?" I asked the owner as the right eyeball had retracted (enopthalmos), the upper eyelid had drooped (ptosis) and the nictitating membrane (3rd eyelid) had covered the eye.
"The right eyeball was of same size and position as the left," the lady said. She had phoned for a house-call but I advised her to bring the dog dog. Her dog had developed fits.
"This is not a simple case of eye infection," I said to my assistant. It appeared to be a 3rd cranial nerve or brain problem. A blood test and urine test are done. X-rays are advised but this would be costly. The fits were controlled and the dog went home after 3 days.
I had the dog bathed one day before he went home. His ear canals were irrigated (no ear infections).
I told Nicole to take a video of the right eyelid twitching. Very rare. The dog was very thin. Proteinuria and high blood urea. Could also have kidney disorder as well as 3rd cranial nerve palsy. Is there a cure?
"The right eyeball was of same size and position as the left," the lady said. She had phoned for a house-call but I advised her to bring the dog dog. Her dog had developed fits.
"This is not a simple case of eye infection," I said to my assistant. It appeared to be a 3rd cranial nerve or brain problem. A blood test and urine test are done. X-rays are advised but this would be costly. The fits were controlled and the dog went home after 3 days.
I had the dog bathed one day before he went home. His ear canals were irrigated (no ear infections).
I told Nicole to take a video of the right eyelid twitching. Very rare. The dog was very thin. Proteinuria and high blood urea. Could also have kidney disorder as well as 3rd cranial nerve palsy. Is there a cure?
816. First impressions of a new vet graduate
POST-SURGERY COMPLICATIONS
Yesterday, Jan 12, 2012, I had a chat with a new female vet graduate from Australia about bleeding in a neuter of a Labrador Retriever. Closed technique, 2 ligatures used by her but lots of bleeding. "A transfixing ligature and open technique may be wiser in big dog neutering to prevent ligature slippage," I said. The dog was OK after a repeat surgery at this practice I visited. For new vets, the tying of the ligature and the number of throws of the knot is important. I usually knot 5 times firmly using absorbable sutures. If you knot 3 times, you may find that the stitch breaks down and then post op return of the patient.
SPAY TIPS FOR NEW VETS
Keep surgery simple. Using intradermal or subcuticular stitching impress clients as they don't see the stitches which are hidden under the skin. However, your stitching technique has not been perfected yet. It the continuous intradermal stitches break down or irritate the cat or dog, there will be intense itching and post-op infections. Therefore, I usually advise one or two horizontal mattress sutures to close the skin. In the past 30 years of spay, I rarely encountered any return for post-op stitch breakdown or infections. Remember, your reputation is on the line. Clients will seldom refer you if your surgical outcome in a spay cause the client worries and return to be re-operated on due to post-op stitch breakdown and infections.
FIRST IMPRESSIONS
First impressions count for a new vet graduate. "Dr.... wears jeans and his staff wears sneakers," said one young male vet to me. For older vets, dressing may not be so important but it is still best to create a good first impression. For the lady vet, I noted that half of her left eye is covered by her falling hair, making it distracting to talk to her. She kept sweeping her hair to uncover her eye. Best to get a good hairstyle as clients may only see half of you!
In my surgery, younger vets and interns tend to dress casually. From 2012, I have stopped staff wearing sandals, sneaker, jeans and clogs to work. For those who persists, they will need to work or intern elsewhere. First impressions still count in a professional practice. Uniforms are sometimes used to ensure that the staff dress appropriately and create a good impression in some vet practices to resolve this tendency of the young to dress casually. I may implement this dress code.
Yesterday, Jan 12, 2012, I had a chat with a new female vet graduate from Australia about bleeding in a neuter of a Labrador Retriever. Closed technique, 2 ligatures used by her but lots of bleeding. "A transfixing ligature and open technique may be wiser in big dog neutering to prevent ligature slippage," I said. The dog was OK after a repeat surgery at this practice I visited. For new vets, the tying of the ligature and the number of throws of the knot is important. I usually knot 5 times firmly using absorbable sutures. If you knot 3 times, you may find that the stitch breaks down and then post op return of the patient.
SPAY TIPS FOR NEW VETS
Keep surgery simple. Using intradermal or subcuticular stitching impress clients as they don't see the stitches which are hidden under the skin. However, your stitching technique has not been perfected yet. It the continuous intradermal stitches break down or irritate the cat or dog, there will be intense itching and post-op infections. Therefore, I usually advise one or two horizontal mattress sutures to close the skin. In the past 30 years of spay, I rarely encountered any return for post-op stitch breakdown or infections. Remember, your reputation is on the line. Clients will seldom refer you if your surgical outcome in a spay cause the client worries and return to be re-operated on due to post-op stitch breakdown and infections.
FIRST IMPRESSIONS
First impressions count for a new vet graduate. "Dr.... wears jeans and his staff wears sneakers," said one young male vet to me. For older vets, dressing may not be so important but it is still best to create a good first impression. For the lady vet, I noted that half of her left eye is covered by her falling hair, making it distracting to talk to her. She kept sweeping her hair to uncover her eye. Best to get a good hairstyle as clients may only see half of you!
In my surgery, younger vets and interns tend to dress casually. From 2012, I have stopped staff wearing sandals, sneaker, jeans and clogs to work. For those who persists, they will need to work or intern elsewhere. First impressions still count in a professional practice. Uniforms are sometimes used to ensure that the staff dress appropriately and create a good impression in some vet practices to resolve this tendency of the young to dress casually. I may implement this dress code.
815. Follow up - The Cocker Spaniel that had tick fever
In Oct 2011, the Cocker Spaniel had pale gums. Tick fever was treated and the owner was most happy.
This case is reported in:
http://www.sinpets.com/dogs/20111039tick-fever-cocker-spaniel-singapore-toapayohvets.htm
On Jan 11, the owner messaged me to get her Cocker Spaniel vaccinated and checked. The Cocker wanted to bolt out of the door as she remembered me very well. It was great seeing a patient who had recovered from tick fever and put on weight.
She had put on weight and was very active. Her gums were pinker than normal. "It is best not to give too much liver," I advised. The dog had no fever. I took a blood test to review her health. Her owner did not bring any urine sample as she said: "Every time I tried to collect urine from her, she would stop peeing!"
The blood test revealed a low white cell count and very low platelet count. "Could it be the return of tick fever or a wrong blood sample being tested?" the owner asked me when I told her to stop using the tick wash and tick top up. The dog had a tick wash 2 days before as she still had small ticks.
"It is unlikely to be tick fever," I said. "The dog is eating well and is active. The lowered platelet count could be due to toxic blood. Your dog would have licked off the tick wash and ingested the poison over a period of time." The owner did not want a repeat blood sample so soon.
She sent in the urine sample for analysis. Results would be known tomorrow. With blood test, one assume that the dog is OK and keep giving tick washes (to prevent tick fever). The area where the dog exercises has ticks and that is why this dog has small ticks now and then. The owner is specially careful that she does not get tick fever again as it can be a killer.
This case is reported in:
http://www.sinpets.com/dogs/20111039tick-fever-cocker-spaniel-singapore-toapayohvets.htm
On Jan 11, the owner messaged me to get her Cocker Spaniel vaccinated and checked. The Cocker wanted to bolt out of the door as she remembered me very well. It was great seeing a patient who had recovered from tick fever and put on weight.
She had put on weight and was very active. Her gums were pinker than normal. "It is best not to give too much liver," I advised. The dog had no fever. I took a blood test to review her health. Her owner did not bring any urine sample as she said: "Every time I tried to collect urine from her, she would stop peeing!"
The blood test revealed a low white cell count and very low platelet count. "Could it be the return of tick fever or a wrong blood sample being tested?" the owner asked me when I told her to stop using the tick wash and tick top up. The dog had a tick wash 2 days before as she still had small ticks.
"It is unlikely to be tick fever," I said. "The dog is eating well and is active. The lowered platelet count could be due to toxic blood. Your dog would have licked off the tick wash and ingested the poison over a period of time." The owner did not want a repeat blood sample so soon.
She sent in the urine sample for analysis. Results would be known tomorrow. With blood test, one assume that the dog is OK and keep giving tick washes (to prevent tick fever). The area where the dog exercises has ticks and that is why this dog has small ticks now and then. The owner is specially careful that she does not get tick fever again as it can be a killer.
814. A duty to charge fairly for work done - lawyers overcharging
Straits Times Jan 12, 2012 Pg B2
"Two lawyers face disciplinary court for overcharging"
Tow lawyers of more than 18 years of practice had an agreement to charge 5% of the estate when its assets were sold. The estate value went up to $9.77 million in 2004 and they were entitled to $488,500. The disciplinary tribunal said that they overcharged by around $566,000 when the fees should be $170,000.
The lawyers' defence was that this fee agreement must be set aside before they can be said to overcharge. The tribunal rejected their defence as the charges showed that the lawyers wanted to profit from the rise in the value of assets rather than get paid for work done. In addition, the tribunal questioned the contents of their bill of costs. The two lawyers spent one hour in drafting two letters. One letter consisted of one sentence and the other three sentences. So, the lawyers were referred to the Court of Three Judges for gross professional misconduct.
"Two lawyers face disciplinary court for overcharging"
Tow lawyers of more than 18 years of practice had an agreement to charge 5% of the estate when its assets were sold. The estate value went up to $9.77 million in 2004 and they were entitled to $488,500. The disciplinary tribunal said that they overcharged by around $566,000 when the fees should be $170,000.
The lawyers' defence was that this fee agreement must be set aside before they can be said to overcharge. The tribunal rejected their defence as the charges showed that the lawyers wanted to profit from the rise in the value of assets rather than get paid for work done. In addition, the tribunal questioned the contents of their bill of costs. The two lawyers spent one hour in drafting two letters. One letter consisted of one sentence and the other three sentences. So, the lawyers were referred to the Court of Three Judges for gross professional misconduct.
Thursday, January 12, 2012
812. Anorexia nervosa?
A quick snap of a statue in Budapest while I was in the guided tour coach. Anorexia nervosa?
811. When to vaccinate a puppy who has kennel cough?
E-MAIL TO DR SING DATED JAN 11, 2012
Hi Dr Sing
Thank you for your follow up call on Pillow's recovery last Sunday. To
be quite honest, I was quite surprised to receive your call and was very
impressed with your concern and professional service :). Even my own
physician do not follow up on my visits, kudos for your kind concern
.... great customer service :)
PP was recovering quite well over the last few days and he should
finish the Antibiotics today. The 'coughing' has decreased
substantially but I still do hear him cough every now and then after
meals. Is this normal ? or should he stop coughing completely by now ?
He is eating well and playing well but breathes heavily at times when
running around.
Do I need to bring him back to you for a check up ?
The next appointment for his Vaccination is this Friday, do I proceed
with this or should I postpone till next Monday ? Appreciate your
advise, thanks
Best Regards
E-MAIL FROM DR SING DATED JAN 11, 2012
Dear ....
Thank you for your email and compliments. I try to follow up cases whenever possible to know the effectiveness of treatment and therefore acquire the knowledge that vet books and professors cannot impart.
In reply, PP is still coughing, though considerably less.
It is not possible to predict exactly when the coughing will cease after medication. The medication to treat bacterial infections of the upper respiratory tract. However, kennel cough is caused by a bacteria and a virus. There is no usual medication against viral infections and therefore the puppy needs time to recover.
Vaccination must be delayed till 7-14 days after the end of coughing as this will indicate that the puppy has fully recovered. In your case, the puppy has already got 2 vaccinations and the 3rd one has to wait 7-14 days after the date of no coughing from the puppy.
Pl let me know if you have more queries. Thank you for 3 pictures of PP. PP was my first case for 2012 and reminds me so much of my son's Bichon who is now 5 years old and is well behaved (no urine marking inside the house)
P.S
I have 2 Sec 3 students and Dr Vanessa Lin produced an educational video on kennel cough with one rehearsal only. Pl let me have your comments as to
1. whether you have a better understanding of kennel cough and
2. whether the video was fun to view or make you fall asleep and snore.
Feedback is important to improve my pet video educational work. The video is at:
http://www.youtube.com/watch?v=tmTYP8T95V4
Best wishes for the New Year
Hi Dr Sing
Thank you for your follow up call on Pillow's recovery last Sunday. To
be quite honest, I was quite surprised to receive your call and was very
impressed with your concern and professional service :). Even my own
physician do not follow up on my visits, kudos for your kind concern
.... great customer service :)
PP was recovering quite well over the last few days and he should
finish the Antibiotics today. The 'coughing' has decreased
substantially but I still do hear him cough every now and then after
meals. Is this normal ? or should he stop coughing completely by now ?
He is eating well and playing well but breathes heavily at times when
running around.
Do I need to bring him back to you for a check up ?
The next appointment for his Vaccination is this Friday, do I proceed
with this or should I postpone till next Monday ? Appreciate your
advise, thanks
Best Regards
E-MAIL FROM DR SING DATED JAN 11, 2012
Dear ....
Thank you for your email and compliments. I try to follow up cases whenever possible to know the effectiveness of treatment and therefore acquire the knowledge that vet books and professors cannot impart.
In reply, PP is still coughing, though considerably less.
It is not possible to predict exactly when the coughing will cease after medication. The medication to treat bacterial infections of the upper respiratory tract. However, kennel cough is caused by a bacteria and a virus. There is no usual medication against viral infections and therefore the puppy needs time to recover.
Vaccination must be delayed till 7-14 days after the end of coughing as this will indicate that the puppy has fully recovered. In your case, the puppy has already got 2 vaccinations and the 3rd one has to wait 7-14 days after the date of no coughing from the puppy.
Pl let me know if you have more queries. Thank you for 3 pictures of PP. PP was my first case for 2012 and reminds me so much of my son's Bichon who is now 5 years old and is well behaved (no urine marking inside the house)
P.S
I have 2 Sec 3 students and Dr Vanessa Lin produced an educational video on kennel cough with one rehearsal only. Pl let me have your comments as to
1. whether you have a better understanding of kennel cough and
2. whether the video was fun to view or make you fall asleep and snore.
Feedback is important to improve my pet video educational work. The video is at:
http://www.youtube.com/watch?v=tmTYP8T95V4
Best wishes for the New Year
Wednesday, January 11, 2012
810. Hands-Feet-Must-Quick Newspaper stand
Today I went to the HDB Hub newstand to buy my Straits Times. There was a queue of 4 people and so I stood at the 5th and read the papers. "You can go to the other girl if you want to pay," a kind lady told me.
I did not see the young girl as the last time, it was only Aunty working alone. Aunty is a slim Chinese lady in her 50s. She had told me that she would resign as the hours 9 am to 9 pm are too tiring for her. At that time I asked what happened to the young girls, usually in their early 20s, employed by this kiosk. They had quit.
Today, I assumed she was alone and the queue was waiting for her as she photocopied the documents. The young girl was next to her but I did not see her.
"Aunty, you still around?" I said (in Chinese translation). "Why don't you ask the young girl to do the photocopying and you collect money?"
"Hands-Feet-Must-Quick", the Aunty told me. The new girl would not be able to use the multi-function copier and she probably did not bother to teach her. This is quite a common situation in Singapore employment matters. Why teach the young ones when they don't stay long?
I paid up and left. Singapore has developed but the parents and the education system have had no time to teach the students to be able to do what the industry wants.
Chinese language usually has 4 words to express a situation and that is why I translated literally Aunty's reply to me.
I did not see the young girl as the last time, it was only Aunty working alone. Aunty is a slim Chinese lady in her 50s. She had told me that she would resign as the hours 9 am to 9 pm are too tiring for her. At that time I asked what happened to the young girls, usually in their early 20s, employed by this kiosk. They had quit.
Today, I assumed she was alone and the queue was waiting for her as she photocopied the documents. The young girl was next to her but I did not see her.
"Aunty, you still around?" I said (in Chinese translation). "Why don't you ask the young girl to do the photocopying and you collect money?"
"Hands-Feet-Must-Quick", the Aunty told me. The new girl would not be able to use the multi-function copier and she probably did not bother to teach her. This is quite a common situation in Singapore employment matters. Why teach the young ones when they don't stay long?
I paid up and left. Singapore has developed but the parents and the education system have had no time to teach the students to be able to do what the industry wants.
Chinese language usually has 4 words to express a situation and that is why I translated literally Aunty's reply to me.
Tuesday, January 10, 2012
809. Update Travel Stories; Young Adults Who Are Not Hungry
Just update the following:
Travel Stories. Dubai - Jan 1, 2012 Winchester Hotel 12.08 am
Many young adults in a free world of abundance like Singapore, live in a virtual world of the smart phone texting and connecting with friends day to day. No responsibilities of adulthood and parenthood.
How to pretty themselves? How to look cools? There seems to be a trend in Singapore's young adults from the middle and upper class to go for Laser Surgery of two eyes.
It is cool. Their peers do it and they desire it. A 5-hour eye test free of charge. They are sold on the benefits and want to book immediately.
Go for cosmetic eye surgery since other young adults in the middle class go for it. Side effects like dry eyes that need eye drops daily after laser operation and corneal damage affecting beauty and vision due to a possible mis-positioning or inadvertent mistake by the sophisticated eye laser machines or machine operator are ignored. Such side effects will not happen to them. How about long-term effects on vision loss. Well, the young adults are invincible. They are not 30 years old. Why think longer than 1 year later? They are not aware of the other young adults who have adverse effects after the cosmetic eye surgery as they don't want to know. They think high tech eye laser machines are perfect and will not damage their cornea. $4,000 is the price. So what?
In Europe now, I read that 40,000 breast implants which leak and may cause cancer are worrying so many women who had gone for breast cosmetic surgery. The standard of care was not there as manufacturers of breast implants use poor quality material. Who suffers daily worrying about the implants rupturing and causing cancer? How many celebrities with botched cosmetic surgeries have these young adults research? There is a website devoted to such cases but why bother to read them?
The years rush by. Time flies. Those young adults who acquire specialised relevant skills after graduation, works hard and is honest, get the good jobs globally as they are useful and indispensable to the employer.
Most of the old guards or senior citizens will never be able to compete in this global world for jobs needing more than a degree from the University and work experience. There is a need for specialised relevant technical experience in many high-paying jobs globally.
Many Singaporean young adults are blessed growing up in abundance in a Singapore, free of wars, natural disasters and crime from the 1950s - 2012 and are unprepared for the shocks of the real world. There are many hungry young adults in Eastern Europe and China who value time and money, and not cosmetic surgery to pretty themselves. They know the importance of hard work (not working 5 days a week, at 9-5 am) to succeed in life. Singaporean parents try to shelter their young ones from hard work and long hours, thinking that the world owes them a living. Or the Government will provide.
Many young Singaporeans don't bother to learn how to read the financial statements but will punt or accept a friend's advice to invest in some schemes which appear to be Pansy schemes. For example, buying a gold bar and paying for 20% below market price and getting regular returns above average. Sounds too good to be true and seems to me to be another version of Madoff's US$50 billion ponzi scheme on a small scale.
2012 appears to be another recession caused by the Euro crisis but how many young Singaporean adults can discuss in depth what is the Euro crisis and how it will impact their parents' livelihood, their own job prospects and their country's economy.
Webpage at:
http://www.sinpets.com/F6/20120110eye-cosmetic-cornea-laser-surgery-singapore_ToaPayohVets.htm
Travel Stories. Dubai - Jan 1, 2012 Winchester Hotel 12.08 am
Many young adults in a free world of abundance like Singapore, live in a virtual world of the smart phone texting and connecting with friends day to day. No responsibilities of adulthood and parenthood.
How to pretty themselves? How to look cools? There seems to be a trend in Singapore's young adults from the middle and upper class to go for Laser Surgery of two eyes.
It is cool. Their peers do it and they desire it. A 5-hour eye test free of charge. They are sold on the benefits and want to book immediately.
Go for cosmetic eye surgery since other young adults in the middle class go for it. Side effects like dry eyes that need eye drops daily after laser operation and corneal damage affecting beauty and vision due to a possible mis-positioning or inadvertent mistake by the sophisticated eye laser machines or machine operator are ignored. Such side effects will not happen to them. How about long-term effects on vision loss. Well, the young adults are invincible. They are not 30 years old. Why think longer than 1 year later? They are not aware of the other young adults who have adverse effects after the cosmetic eye surgery as they don't want to know. They think high tech eye laser machines are perfect and will not damage their cornea. $4,000 is the price. So what?
In Europe now, I read that 40,000 breast implants which leak and may cause cancer are worrying so many women who had gone for breast cosmetic surgery. The standard of care was not there as manufacturers of breast implants use poor quality material. Who suffers daily worrying about the implants rupturing and causing cancer? How many celebrities with botched cosmetic surgeries have these young adults research? There is a website devoted to such cases but why bother to read them?
The years rush by. Time flies. Those young adults who acquire specialised relevant skills after graduation, works hard and is honest, get the good jobs globally as they are useful and indispensable to the employer.
Most of the old guards or senior citizens will never be able to compete in this global world for jobs needing more than a degree from the University and work experience. There is a need for specialised relevant technical experience in many high-paying jobs globally.
Many Singaporean young adults are blessed growing up in abundance in a Singapore, free of wars, natural disasters and crime from the 1950s - 2012 and are unprepared for the shocks of the real world. There are many hungry young adults in Eastern Europe and China who value time and money, and not cosmetic surgery to pretty themselves. They know the importance of hard work (not working 5 days a week, at 9-5 am) to succeed in life. Singaporean parents try to shelter their young ones from hard work and long hours, thinking that the world owes them a living. Or the Government will provide.
Many young Singaporeans don't bother to learn how to read the financial statements but will punt or accept a friend's advice to invest in some schemes which appear to be Pansy schemes. For example, buying a gold bar and paying for 20% below market price and getting regular returns above average. Sounds too good to be true and seems to me to be another version of Madoff's US$50 billion ponzi scheme on a small scale.
2012 appears to be another recession caused by the Euro crisis but how many young Singaporean adults can discuss in depth what is the Euro crisis and how it will impact their parents' livelihood, their own job prospects and their country's economy.
Webpage at:
http://www.sinpets.com/F6/20120110eye-cosmetic-cornea-laser-surgery-singapore_ToaPayohVets.htm
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