833. A dog with recurrent bladder stones - The Standard Operating Procedures (SOP)

First Written: Chinese New Year Jan 23, 2012 1.06 pm
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

RECURRENT UROLITHIASIS - CALCIUM PHOSPHATE URINARY STONES

When a dog has urinary stones again, the following will be the Standard Operating Procedures (SOP) at Toa Payoh Vets to provide the highest standard of care. This SOP defends the vet during allegations of negligence litigation or complaint if the dog has another episode of recurrent urolithiasis.

1. HISTORY. Record all vaccinations done and dates and by whom. Do not forget to do so. Record your analysis of why the dog had recurrent urolithiasisa. In this case study of the Shih Tzu with 13 calcium phosphate urinary stones, the dog came to Toa Payoh Vets for recurrent urolithiasis and I took charge of this case which was operated by Vet 1.

Vet 1 had not done stone analysis, did not advise (in writing) on post-operation prevention and follow-through tests which would permit non-surgical treatment (e.g. voiding urohydropropulsion and urinary catheterisation when small stones are detected via X-rays 3-monthly). Could it also be some metabolic disorders of the parathyroid glands as calcium phosphate is quite rare in dogs?

2. GENERAL EXAMINATION. Demeanour. Weight, rectal temperature, pulse and respiratory rate. Abdominal pain, gas in the GIT and other observations.

3. DETAILED EXAMINATION. Urine test, blood test, radiography (calcium phosphate isradio-dense, check kidneys for calcium phosphate), ultrasonography (possible in calcium phosphate) and calculi analysis. There may be a case for veterinary negligence if the tests has not been advised or done. The advices must be recorded in the case sheets clearly.

4. TREATMENT. According to symptoms. IV, SC or oral fluid therapy depending on dehydration situation. Antibiotics to treat UTI. Urinary catheterisation to relieve urethral obstruction.

The vet in charge of the case is responsible for details of time, amount and other information will be recorded in the hospitalisation sheet.

5. COMMUNICATIONS WITH THE OWNER IN WRITING. A veterinary report explaining the significance of the tests and case must be given to the owner on discharge/death of the puppy. It is best to keep the owner informed daily of the health of the dog. Such phone calls must be recorded in the medical case files.

6. RECORD AMA (Against Medical Advice) the owner's rejection of advices of the test in your medical record. Failure to do so implies that the vet has not advised at all in cases of litigation/complaint. As Singapore is becoming a litigious society, I advise that the highest standard of care to be given at all times. An example of a case done by me is down shown in the images.

TOA PAYOH VETS CASE STUDY BY DR SING

Chinese New Year Eve 4.56pm
Jan 22, 2012

PATIENT: Shih Tzu, Male, 8 years, not neutered
Around 12 months ago, Vet 1 removed many "urinary stones" but no stone analysis or other tests or follow throughs were advised. I don't know the reasons and will not speculate.

It is important to confirm the nature of the stones and a stone or calculi analysis should have been done and must be done to confirm the diagnosis. This must be recorded in the case sheet and advices of prevention of recurrence be given and recorded.

The dog recently had urethral obstruction. 13 urinary stones on X-ray were removed. Stone analysis done showed pure calcium phosphate crystals and urine tests showed bacterial infection UTI.

DIAGNOSIS: Calcium phosphate urolithiasis

CASE MANAGEMENT AT TOA PAYOH VETS

14.1.12 Calculi analysis by the NUH Dept of Lab Medicine.
Calcium stone positive, phosphate stones positive. Negative for stones of oxalate, urate, magnesium, cystine, ammonia and bicarbonate.

8.2.11 Blood test. SGPT/ALT increased, SGOT/AST increased, Urea increased 8.9 (4.2-6.3). Platelet 522 (200-500)/ Blood calcium 1.99 (1.5-3.60) is normal.

13.12.12 Urine test. ph=7, SG 1.012, Protein ++, Blood ++++, WBC 468, RBC 25, Bacteria +++. There is UTI and possibly kidney involvement. X-rays - any stones in the kidneys? Not seen. No crystals seen in the urine but this does NOT mean that the dog does not have stones when urine test is negative as in this case.

Radiography at 3-monthly intervals post-op would have picked up the stones when they were small but very rarely do Singaporean owners bother to do this. When stones are small, they can be "sucked" out using the urinary catheter and voiding urohydropropulsion. That is the reason for radiography.

X-ray in this case showed 13 radiodense uroliths. Calcium phosphate stones are radiodense.

TREATMENT
1. Medical dissolution using prescription diets. This is not possible for calcium phosphate stones.

2. Surgical removal. Done.
3. Non-surgical methods like voiding urohydropropulsion and aspiration into a urinary catheter not possible. 13 big stones with 2/13 stuck in the penile urethra.

4. Non-surgical method. Lithotripsy is not available in Singapore.
5. Metabolic disorder. Correction of hyperparathyroidism or other causes of hypercalcemia should minimise further urolith formation.

HOW TO PREVENT RECURRENCE?
1. Post-op radiography every 3 monthly is the best advice.
2. Urine test monthly to check for bacterial infection (UTI).

REFERENCE: The 5-min veterinary consult - Tiley Smith

1. PURE calcium phosphate uroliths are usually associated with metabolic disorders such as primary hyperparathyroidsim, rental tubular acidosis and excessive dietary calcium and phosphorus. This dog was fed on dry dog food.

2. A higher % of calcium phosphate uroliths are found in the kidneys than in the urinary bladder

OTHER LAB TESTS
1. Calculi analysis is necessary and was done.
2. Serum concentrations of parathyroid hormone,parathyroid hormone-related peptide
and hydroxycholecalciferol may be useful.

PREVENTION/AVOIDANCE
1. Hill's Prescription Diet U/D is formulated to reduce calcium extretion, is phosphorus-restricted and reduces formation of concentrated urine.
2. Canned diets are more effective than dry diets in preventing recurrence due to high moisture content
3. Avoid excessive acidfication or alkanisation of urine.

INTERESTING INFO
Hill's book recommends treatment of bacterial UTI and then give C/D

FOLLOW UP
1. X-ray after surgery to verify complete urolith removal is essential. This was not done as surgical removal of 13 stones were presented.
2. Abdominal radiography or ultrasonography every 3 months to detect early recurrence and prevent repeat surgery (e.g. using non-surgical methods to remove easily by voiding urohydropropulsion or catheter retrieval.

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 time taken for cystotomy for an experienced vet. 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)

Jan 23, 2012. Chinese New Year.
I am keeping an eye on the follow through of this case. So far, the owner said she is busy and had not come down to get the CD canned diet.

TOA PAYOH VETS webpage will be written later:

833. Chinese New Year's Eve Reunion Dinner stories

Jan 22, 2012 Sunday was Chinese New Year's Eve Reunion Dinner. Time to catch up. My advice to the young adults would be to ask questions to sustain a conversation rather than keep looking at their smartphones and texting. Ask what your cousins or uncles and aunties have been doing and you can learn much.

There were two Chinese idioms which I can't translate into English.

1. Teochew expression of 6 words. The Teochew mother expresses herself in Teochew and has dropped hints to the late 20s son who does not contribute one cent to the household by giving a bit of his salary to the mother. The daughter gives money monthly but the son forgets about it. In Chinese custom, children should give some part of their pay to the mother as they still live with the parents. So she said the six words. Nobody could translate into English. "It means scrounger," Julia said. Well, that is a public hint to the son to part with a bit of his salary to the mum. It will be like talking to the wall as he said that he is on hard times, having to save up for his wedding and his new HDB apartment renovation. In any case, the parents don't need his money. It is just a custom of some Chinese mothers to expect children to give some token to them when they start work and still live in the parents' house. As for the father, he said to me when I asked his opinion: "If my children don't ask money from me, I am OK!"

2. Teochew expression regarding a "golden chair". This refers to a young man who should marry an older woman. After all, an older woman is secure financially (hence the golden chair) while a younger woman wants money and security from the man. So, the niece with the fairest famed complexion of the Teochew ladies advised Jason not to marry wives younger than himself. "2 years older," she gave an example of a man dating a woman 8 years older but failing in the relationship. "Why not build your own golden chair?" her brother suggested.

Conversations can be sustained if you asked about the other party's welfare. Dogs are one favourite part in conversation. "How do you know it is dangling?" I asked the brother of the fair lady who had asked Daniel some advice about the cost of removal of a lump which keeps growing bigger in a 13-year-old Cross bred of her boyfriend. This boyfriend loves animals and she related an incredible story. One day, his favourite Jack Russell escaped and was hit by a car. The dog waited for him to return home from work. Once he reached home, the dog passed away. "He was holding on to life till he had seen his owner," she said.

To return to the dangling lump, the brother of the fair lady said he had not seen the dog. Daniel presumed it to be a growth from the groin area. I asked in more detail from the fair lady: "Where is the lump? Is it in the breast area?" She said: "No, it is dangling from between the legs and keeps growing bigger fast every day."

Since this is a male old dog, I said: "It is likely to be a testicular cancer. I can arrange a transport man to bring it down for surgery. The earlier it is done, the better for the dog." I doubt that there will be any follow through action by this young lady as it is not her dog.

Sadly, many dog owners feed their dogs and do not bother when there are growths or bad breath. However, recently, it seems that there are more cases of dental work being requested on dogs.

As can be seen in a last-minute request by a mother and her two pre-teen daughters bringing a 13-year-old small breed dog today at 4pm as the dog was not eating. As the dog had eaten at 6 am, I proposed dental work after a general examination. "This dog will not bite," I said to Dr Vanessa as she tried to muzzle him and examine his mouth via the muzzle. This small breed does look ferocious and open-eyed, being a mini-pinscher cross and so I did not blame her for being careful. I lifted the side of the dog's mouth to expose the back teeth full of tartar. "Give an IV drip plus antibiotic IV before dental work," I advised. There was a need for blood test and an anaesthetic consent form. However, the blood test would add up the cost and so this was not done. A general examination would do. Domitor 0.1 ml and isoflurane gas. 3 teeth extracted by Dr Vanessa.

The dog went home to a happy mother with two daughters on Chinese New Year's eve. Many of such cases need dental work but can get frightened by warnings about deaths from anaesthesia from the vet. Obviously the vet has to cover himself by getting the consent form signed as this is an old dog and could die. Hospital doctors do the same too. In this case, no consent form was asked to be signed. Careful anaesthesia resulted in a happy outcome for this dog. Old dogs seldom die from dental work if there is careful anaesthesia and no chatting between the vet and the assistant. Focus on the patient and in my 30 years of experience, I can be confident that the old dog will not die on the operating table as the anaesthesia duration is very short if the vet prepares and knows what to do efficiently and productively.

832. Tonsillitis in an old dog

E-MAIL TO DR SING DATED JAN 21, 2012

Dear Dr. Sing,

Patient Ref. No. ... (... (Silkie, 8.5 yrs old))

We were at your clinic last Sunday (15 Jan).

I'd like to have a better understanding regarding B's lump at his throat:

On 11 Dec 2011 after his dental scaling (during which you checked on his throat), we were told that the tip of his epiglottis was red. Antibiotics prescribed, to be reviewed.
15 Jan 2012 review: we were told there is a lump at his left tonsil (right tonsil could not be seen as Bowie was struggling too much). I forgot to ask, what about the redness at tip of epiglottis?

Your advice was to put him on antibiotics first and to review again in 1-2 months' time. As B is such a nervous dog, he'll be sedated for a proper diagnosis for his next review. You said that if it is indeed a lump, the tonsil/s will be removed. Is tonsil/s removal the only treatment option, even though the lump may be benign? Without tonsil/s, wouldn't he be more susceptible to virus infection in the future? What if the lump is a cyst or an abscess?

Your reply via e-mail will be greatly appreciated, Dr. Sing. Thank you!

PHONE REPLY FROM DR SING
It is best to speak by phone as email replies can be misinterpreted. Questions can be answered immediately and clarification can be made immediately too.

In this case, tonsil removal is advised in case the tonsil is a growing malignant tonsillar carcinoma as the dog is old. The red lump of the is around 0.5 cm x 0.5 cm and visible. An aspiration biopsy can also be done in this case to check whether the tonsil is an abscess, cyst or cancerous. Sedation will be needed and anaesthetic risks are always there.

It is worrisome for the owner. The vet's duty is to inform the owner of the presence of the tonsillar growth. Excision or biopsy depends on the economics and malignancy or otherwise of the growth.

I have an image of an 8-year-old Chihuahua with tonsillitis and will post it later. 13 teeth were extracted.

831. The Shih Tzu has reccurent urolithiasis. 13 calcium phosphate stones

Chinese New Year Eve 4.56pm
Jan 22, 2012

PATIENT: Shih Tzu, Male, 8 years, not neutered
Around 12 months ago, Vet 1 removed many "urinary stones" but no stone analysis or other tests or follow throughs were advised. I don't know the reasons and will not speculate.

It is important to confirm the nature of the stones and a stone or calculi analysis should have been done and must be done to confirm the diagnosis. This must be recorded in the case sheet and advices of prevention of recurrence be given and recorded.

The dog recently had urethral obstruction. 13 urinary stones on X-ray were removed. Stone analysis done showed pure calcium phosphate crystals and urine tests showed bacterial infection UTI.

DIAGNOSIS: Calcium phosphate urolithiasis

CASE MANAGEMENT AT TOA PAYOH VETS

14.1.12 Calculi analysis by the NUH Dept of Lab Medicine.
Calcium stone positive, phosphate stones positive. Negative for stones of oxalate, urate, magnesium, cystine, ammonia and bicarbonate.

8.2.11 Blood test. SGPT/ALT increased, SGOT/AST increased, Urea increased 8.9 (4.2-6.3). Platelet 522 (200-500)/ Blood calcium 1.99 (1.5-3.60) is normal.

13.12.12 Urine test. ph=7, SG 1.012, Protein ++, Blood ++++, WBC 468, RBC 25, Bacteria +++. There is UTI and possibly kidney involvement. X-rays - any stones in the kidneys? Not seen. No crystals seen in the urine but this does NOT mean that the dog does not have stones when urine test is negative as in this case.

Radiography at 3-monthly intervals post-op would have picked up the stones when they were small but very rarely do Singaporean owners bother to do this. When stones are small, they can be "sucked" out using the urinary catheter and voiding urohydropropulsion. That is the reason for radiography.

X-ray in this case showed 13 radiodense uroliths. Calcium phosphate stones are radiodense.

TREATMENT
1. Medical dissolution using prescription diets. This is not possible for calcium phosphate stones.

2. Surgical removal. Done.
3. Non-surgical methods like voiding urohydropropulsion and aspiration into a urinary catheter not possible. 13 big stones with 2/13 stuck in the penile urethra.

4. Non-surgical method. Lithotripsy is not available in Singapore.
5. Metabolic disorder. Correction of hyperparathyroidism or other causes of hypercalcemia should minimise further urolith formation.

HOW TO PREVENT RECURRENCE?
1. Post-op radiography every 3 monthly is the best advice.
2. Urine test monthly to check for bacterial infection (UTI).

REFERENCE: The 5-min veterinary consult - Tiley Smith

1. PURE calcium phosphate uroliths are usually associated with metabolic disorders such as primary hyperparathyroidsim, rental tubular acidosis and excessive dietary calcium and phosphorus. This dog was fed on dry dog food.

2. A higher % of calcium phosphate uroliths are found in the kidneys than in the urinary bladder

OTHER LAB TESTS
1. Calculi analysis is necessary and was done.
2. Serum concentrations of parathyroid hormone,parathyroid hormone-related peptide
and hydroxycholecalciferol may be useful.

PREVENTION/AVOIDANCE
1. Hill's Prescription Diet U/D is formulated to reduce calcium extretion, is phosphorus-restricted and reduces formation of concentrated urine.
2. Canned diets are more effective than dry diets in preventing recurrence due to high moisture content
3. Avoid excessive acidfication or alkanisation of urine.

INTERESTING INFO
Hill's book recommends treatment of bacterial UTI and then give C/D

FOLLOW UP
1. X-ray after surgery to verify complete urolith removal is essential. This was not done as surgical removal of 13 stones were presented.
2. Abdominal radiography or ultrasonography every 3 months to detect early recurrence and prevent repeat surgery (e.g. using non-surgical methods to remove easily by voiding urohydropropulsion or catheter retrieval.

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 time taken for cystotomy for an experienced vet. 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)

Jan 23, 2012. Chinese New Year.
I am keeping an eye on the follow through of this case. So far, the owner said she is busy and had not come down to get the CD canned diet.

830. Sunday's Jan 22, 2012 interesting case (Chinese New Year's Eve)

Sunday, bright. sunny. Most vet practices close in the afternoon as there would be no clients. Toa Payoh Vets open till 5 pm. In the afternoon, no clients as at 3 pm when I am writing this report on a new client whose poodle, male, neutered, vomited blood yesterday and vomtied without blood today.

General exam was normal.
ABDOMINAL PALPATION
The dog arched his back when his ant aabdomen was palpated. "Hunched" said the lady owner. Mild pain in the liver, kidney, gastric area. The lady owner said: "Hunch back."

HISTORY
Since young, the dog had been vomiting every 1-2 months. Usually threw up without food. Vet 1 said nothing was wrong. I proposed X-ray or ultrasound after the Chinese New Year. For the time being, put on antibioitcs for 10 days.

TREATMENT
1. Dextrose saine 500 ml IV drip + anti-spasmogesic + antibiotic. Goes home later.

ADVICES
My hypothesis. Most likely the dog had been eating outside objects on the grass when walked by the domestic worker during the evening. Domestic workers meet their friends when they walk the dog and so it was possible that the dog gets fed some food or had gone onto the grass to eat anything . It is hard to say.

Blood test, X-ray and ultrasound can be done a few days later if vomiting continues. Cost is nto a problem with this owner. I said: "It is also possible that this dog has a small gastric foreign body that can't be vomited out nor passed through the intestines and so the dog vomits 1-2 monthly due to gastric inflammation and irritation by the movement of this foreign body and bacterial infection of the stomach (gastric mucosa)."

RIGHT EYE TEARING AND ITCHY
Swollen eyelids of the right eye due to rubbing. "Fluorescein eye stain is useful to check whether the eye cornea has ulcers or not," I put the fluroescein strip under the upper eyelid of both eyes. "Can you see the green stain on the cornea?" I shone the white light tangentially at the the right eye. "Yes," the lady owner said; "Green patches in the central cornea and at 12 o'clock and 2 o'clock. What is an ulcer?" she asked me as she could not understand. "It is a wound like the skin that has been cut, you will get a skin ulcer. A broken surface." She understood and translated it into Mandarin. I don't know how to translate ulcers in Mandarin. I must learn Mandarin as there are more Chinese Nationals nowadays and many Singaporeans speak Mandarin!

3 EMERGENCY CASES
1. One year old, female, Corgi, itchy back, wet areas. Their Vet is off, but the dog is still v. itchy. "Very good appetite after Shincort inj by Vet 1," the owner said. Wife and young son came. I advised clipping all bald just as Dr V wanted to clip just the back half. "There may be other areas and it is best to get hairs grow together." Owner said he saw "flea dirt," although Vet 1 saw a tick. A flea bite allergy not controlled by Vet 1's Shin cort injection?

2. Westie now not eating again. Wanted to see Dr Vanessa.

3. A dog with loose teeth or bad teeth. Made an appointment. Saw Dr Jason Teo yesterday.

829. The chattering chihuahua

Jan 20, 2012 Friday

The young couple came with the Chihuahua as scheduled. Death on the operating table is the main concern with the fair lady. Vet 1 had insisted that they sign the anaesthetic consent form hihglighting the risk of death in an old dog undergoing dental work. "This is the common practice," I explained. "Even the human hospitals will ask you to sign the form if you go for anaesthesia and surgery."

I had seen the couple on last Sunday and had advised antibiotics for the next few days and getting the dental work done on Friday. I told Dr Vanessa I would be handling the case myself as there was great worries for the fair lady. Sunday will be Chinese New Year's Eve. So the dog was done today. Blood test taken revealed nothing abnormal

Chihuahua, Male, 8 years, Severe stage 4 periodontal disease.

Isoflurane + oxygen anaesthesia only.
Proper sized endotracheal tube which was 6.5
Only 3 teeth left. Around 16 extracted.

The dog coughed when the owners came to pick up 2 hours later.
"It is caused by throat irritation of the endotracheal tube," I explained. "I inserted the tube into the windpipe to give the anaesthetic gas. I will give an injection."

It was one of those satisfying moments to see the young lady smile and freed of worries since her Chihuahua had not died on the op table and was as alert as if he had not been under anaesthesia. Isoflurane anaesthesia effect disappears within 5 minutes and that is why this dog was as alert as normal.

However, it takes a longer time to anesthesize the dog and there is a certain technique which I taught my assistant Min so as not to injure the dog when he is struggling before being asleep. If a sedation injection is given first, there is virtually no struggling. As I had promised the owner that I will use gas only, I kept my word.

826. Teeth scaling an 8 year old male silkie terrier

Dec 12, 2011

Nervous silkie terrier. Slight pain in larynx.


Blood test - SGPT/ALT 109 (<59) but otherwise all normal.
Urine test bacteria +++.
Surprising to find bacteria in the urine of a male dog. Licks ventral area.



Calculated dosage 10 kg young dog D=0.4 K=0.5
This is old dog, 7.4 kg. Give 50% of calculated dose

Domitor = 0.15 Ketamine = 0.18 Total 0.33 IV sufficient
Teeth still strong. So only dental scaling




Noted tip of epiglottis red but tonsils normal.

Tibetan Mastiff sedation

"Do you do house-calls for a very big dog with itchy ears?" an old client and friend asked me the fees to treat a very big dog at the home of her friend.

"It will be a waste of your money," I said. "Ear disease diagnosis need a microscope and other assistants to help out."

Tibetan Mastiff, Male, 7 months, 53kg. Healthy. Ear canals with black wax seen daily. Had lots of ticks recently when walked outdoors.

EAR IRRIGATION & LICK GRANULOMA INJECTION
A gentle giant but still it is best not to traumatise him. My client said: "My friend's dog was hit by a car, bit the owner's arm later."

SEDATION
Do a proper calculation as follows:
My guideline IV anaesthesia
10 kg young dog Domitor = 0.4 ml, Ketamine = 0.5 ml combined IV
53 kg young dog D= 2.12ml K=2.65ml
I gave 40%, D=0.85 K=1.06 Total = 1.85ml IV as this would be a short anaesthesia of around 10 minutes needed for me to irrigate the ears and inject the 3 lick granulomas with prednisolone intra-lesionally.

"My dog will not get up on the table," the owner said.
"No dog will climb up a veterinary table," I explained to the gentleman. "I will carry his back half and you carry his chest. Talk to your dog while we carry or he will feel he is being murdered."
The dog was carried up on the table by the owner and my assistant Min without a protest.

Now, to find that leg vein as the coat is so thick. The foreleg was thick as this was a man-sized dog. I don't clip off the hairs to see the vein as it is not acceptable.

"Tighten the tourniquet," I said to Min who had not seen large a gigantic dog. Singapore's dogs are usually small breeds and Tibetan Mastiffs are as rare as snowfall.

I pressed the swelling and drew the blood into the syringe. I injected the 1.85 ml IV.

The dog slept at this 40% of calculated dosage. I taught the owner how to check the ear canal and insert the cotton bud, smell it and then I irrigated the ear canals.

After that I injected pred into the 3 lick granulomas. The dog did twitched a little on the 3rd lick granuloma being injected but was otherwise knocked out.












4949 - 4958. Itchy ears and three interdigital cysts/lick granulomas must be treated early - Tibetan Mastiff. If itchiness of ears and paws are not treated early by your vet, the dog self-mutilates to relieve himself of the intense itchiness. Hair loss and skin infections present themselves soon
"I need to wake up the dog," I said as I injected Antisedan 1.0 ml IM on the right hip muscles. He woke up 10 minutes later and that was great.

The above 40% dosage was sufficient for a short painless ear irrigation and lick granuloma injection of less than 10 minutes.

Know how to check the ears and prevent interdigital cysts and lick granulomas in a big furry breed as it is a high maintenance breed. Brush daily and inspect daily. Clean ears. It is extremely difficult to avoid ticks. Wear booties or check paws after a walk. "I avoid the grass," the owner just walked the dog in the evenings along the road.

The following advices to the owner who had bought a very strong hair blower for Tibetan Mastiff were:

1. Daily brushing of the coat with the slicker and another brush rather than hot air blowing everyday as the dog has some skin itchiness and eczema, probably due to the earlier tick bite infestations.
2. Daily inspection of the ears
3. No rough cotton wool to dig the ears
4. There is no need to pour his ear lotion by pumping into the ears every day if the ears are clean. He use to do it every day. Daily ear dropping had resulted in brown black wax being produced.
To check the ear canals as to whether they are clean or not, I taught him how to insert the cotton bud into the ear canal. See the colour of the tip and smell it. If the colour is clear, the ear has no dirt.
5. Washing of the paws with an anti-fungal solution and rinsing.
6. A long bath tub is needed if he wants to de-tick his dog.
7. Get a big table (as long as my surgery table) and put the dog on top of the table to do his grooming. This is easier on his back.
8. Avoid tick areas. Inspect the four paws when the dog is back from outside walks. He had used Frontline sprays and spots-on insecticides but these have become ineffective over time. Wearing of booties when going out for walks is not practical as the dog needs to wear out his nails. So, daily inspection of the paws for the smallest baby tick after exercise.

This was about the biggest dog in Singapore. As big as a young man. A very gentle giant. If he bites the vet, the vet's fingers can be crushed to pieces. So it is important that he be treated gently and to use sedation if there is pain during treatment, as there is, in the intra-lesion injection of his lick granulomas.

Overall, he was good and could walk back to the car. I helped to carry him onto the boot of the friend's SUV. The owner's BMW was probably not big enough! It was great to meet up with this old client who had consulted Dr Vanessa for the past times as I was seldom around in the afternoons. I asked her to make an appointment to let me check out her dog's skin condition when she said that "old" vets are more experienced. Every vet needs to start at the beginning but young vets need to gain the experience with time. Experience is gained not only be practising but by reading a lot of veterinary literature on relevant situations and consulting other vets for how they treat certain conditions. It may sound stupid to ask other vets but much can be learned from asking.

NINE more images are at:
http://www.sinpets.com/dogs/20120119Tibetan-Mastiff-lick-granulomas-ear-itchiness-singapore_ToaPayohVets.htm

824. Vet surgery - productivity - cat spay

I am sharing my 30 years of experiences of a cat spay with others interested and to assess my timing as a guide for associate vets

Cat, 1 year +, Female, 2.6 kg
Sent in for spay toeday Jan 17, 2012
Surgeon: Dr Sing
Suture: 2-0 Polysorb braided lactomer C14 cutting 24 mm 3/8

Preparation: Cat was clipped bald before sedation. This saves a lot of time.

Sedation:
xylazine 0.1 ml + ketamine 0.4 ml IM
Wait 10 minutes. Still alert
Need top up isoflurane for few seconds - good analgesia


Timing
10.33am xylazine + ketamine IM
10.43 am Isoflurane 5% start reducing to 0.5%
10.52 am Skin incision started
10.54 am lst ovary (left) hooked
10.59 am 2nd overy (right) hooked
11.02 am uterine body ligated. 2 ligatures
11.08 am stitch linea alba 3 simple interrupted
11.11 am stitched skin 2 horizontal mattress
11.12 am skin stitched up

Sedation to skin stitched 10.33 - 11.12 am = 39 minutes

Tolfedine and baytril injection SC
One bandage on wound to be replaced on Day 3 with new one. I usually don't prescribe e-collar as cats hate them
Baytril x 1 tab 1/4 tab/day

Total cost of spay $150

Sunday Jan 15, 2012 interesting cases - tonsillar tumours

Bright sunshine, blue skies, white cloud.

Case 1.
A 12-year-old well cared for female, Golden Retriever, drooling on the left side only.
Vet 1 did dental scaling and extraction. Dog then started "drooling on left side."
Vet 1 then smoothened left lower PM4 since the upper PM4 and others had been extracted. Still the drooling persisted.
Vet 2 was "thorough" according to the owner. He X-rayed and ultrasound the whole body. "How about the head and neck area?" I asked. The owner did not think this was done.

According to the owner, said a big lump was present on the left back of mouth and a spherical lump on left neck below the submandibular. He recommended steroids as an alternative to euthanasia and surgery. When the dog was on steroids, she was very hungry and drank a lot. When given Tramadol, the drooling stopped. The dog had lost a lot of weight.

The dog did not want the mouth to be opened but I managed to open it and showed the owner and her sister (anaesthetist) the large tonsillar tumour (at least 3 cm x 2 cm). Pain and ulcerations there would be the cause of drooling.

CASE 2
Surprising an 8-year-old small breed came in for review after this Golden Retriever. I had done dental scaling 4 weeks ago. The dog objected strongly to the mouth being opened, but I could see the right tonsil as reddish lump 0.5 x 0.5 cm. I had told the owner of this lump seen during dental scaling. It could be a tonsillar tumour. The owner would wait and see.

If dog owners regularly check the dog's teeth and keep it cleaned or scaled yearly or two-yearly, many oral tumours would not form. This is the same with human beings too. A poor hygiene in the mouth predisposes to oral tumours and this is commonly reported.

CASE 3
"See the lump under the right eye," I had pointed it out to her at the waiting area. Later, she gave me permission to take a photo. "That is the beginning of a malar abscess - infection from the root of the back tooth into the sinus and bulging out." She had come for advice as Vet 1 wanted her to sign an indemnity form for dental work in case the dog dies under anaesthesia.

"How many deaths were under you while you did dental scaling?" the young lady was very worried about her 8-year-old chihuahua who had Stage 4 periodontal disease (the worst stage) and asked Dr Vanessa who was handling the case together with me. She did most of the talking. Many times, I would see the case together with her and most of the time, she would be doing the talking. Some owners would think I am an assistant and know nothing and so why was I giving medical advices? I usually identify myself as a vet first.

"How many?" the young lady asked again. "Ask Dr Sing," Dr Vanessa replied.

"In my over 30 years of dental scaling and I can only speak for myself, I don't have any cases of dogs doing dental work dying on the operating table," I replied. "Dental work or scaling takes a short time of less than 15 minutes unlike long surgeries and therefore, anaesthetic deaths are uncommon in many senior dogs. A very close focus on anaethesia by the vet and his assistant is very important. In old dogs, I don't give IV sedation but just isoflurane gas only."

The young lady was already red-eyed but well read about anaesthetic deaths of dogs on the operating table. I could understand her concern for the Chihuahua which was in good bodily condition unlike those skinny ones. A bit plump is better as this indicated that this dog was well cared for and had a good appetite (meaning good health too.)

"A blood test is taken to screen the dog's health first," Dr Vanessa said as she examined the heart and lungs and found them OK.
"A 10-day course of antibiotics before dental scaling is what I recommend usually to clients," I said. "The dental scaling is done around 7-10 days later and the mouth would be free of bacteria."
The boyfriend asked the young lady (in her late 20s) to wait for the blood test. So, it was quite an emotional consultation.

This Sunday was an eventful one as my assistant Min fell sick with flu. He left at 10 am to see the doctor and had the day off. Ms Ong, a junior college student with an offer from Glasgow Univ for vet studies came for her first day and so she got to see all the cases since the other three interns (Kim quitted suddenly as she found that it was too costly to study vet medicine, Mr Lim was said to have denque fever, Grace, going to 2nd year vet student from Sydney Univ would come only on Monday.

It was a bright sunshine Sunday and we managed to close at 5.30 pm. I advised Dr Vanessa to record as she communicate to the client as this is what I do, but she had her own style of writing only after everything. So there was much delay. Record what the client said e.g. history on the spot. That would be the efficient way as many clients dislike waiting too long. Some of the clients had to wait more than an hour and from my view at the reception, many prefer short consultations and getting the problem resolved. Waiting more than 15 minutes at the doctor is not a happy event for any Singaporean on a Sunday when there are so many things to do!

822. A twitching eye. Acquired Oculomotor Nerve Palsy in a Golden Retriever

"Is the right sunken eyeball present since puppyhood?" I asked the lady owner who showed me a bottle of eyedrops prescribed by Vet 1. No other medication was given by Vet 1 who diagnosed eye infection and advised review if the eye condition did not improve.

Case of the Golden Retriever with a twitching eye
Golden Retriever, Male, 8 years. Weight below normal.
Complaint: Fits 2 days ago. I advised bringing the dog to the Surgery rather than a house-call which would waste money as the dog needed more detailed examination.
History: Right eye is smaller than left eye. Vet 1 prescribed eye drops.

Right eye: Drooping eyelid, retracted eyeball, twitching uncontrollably as if blinking at me when reviewed. Occasional twitching (videoed by Nicole).
3rd eyelid covered the right eyeball partially since it has sunken in.
Hospitalised. Blood and urine tests are minimum tests done.

Lumbar puncture for cerebrospinal fluid analysis, MRI scan of the brain are not done at this stage to lower vet costs.




Oculomotor nerve palsy and brain involvement leading to ptosis & fits





OCULOMOTOR NERVE is the 3rd cranial nerve. It innervates the muscles co controlling eye movements, the upper eyelid muscle and the muscles controlling pupil constriction.

In this dog, the Oculomotor nerve and its branches had been damaged or inflamed causing the eyeball to sink inwards, the eyelid to droop. However, since the dog suffered from fits, the lesion is likely to be inside the brain e.g. brain tumour or aneurysm near the Oculomotor nerve or inflammation.

Blood test - high serum urea
Urine test - proteinuria
Brain scan and lumbar puncture are costly options which need to be discussed with the owner.

Other contributing causes
Trigeminal neuralgia involving only the ophthalmic nerve? The trigeminal nerve has 3 branches - ophthalmic nerve, maxillary nerve and mandibular nerve. There does not appear to be facial spasm or dropped jaw and so, the maxillary and mandibular nerves are not involved. The ophthalmic nerve may be involved.

Diagnosis
Brain scan and lumbar puncture are needed for a definitive diagnosis of acquired Oculomotor nerve palsy in this dog but it is costly.

Treatment
Anti-fits and review. The dog can eat and drink and has no more fits when on anti-fit medication. Steroids were not prescribed. To review.


Updates and more pictures at:
http://www.sinpets.com/dogs/20120115oculomotor-nerve-palsy-golden-retriever-fits-singapore_ToaPayohVets.htm

Educational Video from Toa Payoh Vets - Itchy joints in a dwarf hamster

http://www.youtube.com/watch?v=D3yl4GmBBU4&feature=youtu.be


UTI = Urinary Tract Infection

820. E-mail case study. Basic principles in toilet training a puppy in Singapore

E-MAIL TO DR SING JAN 12, 2012

Hi Dr Sing Kong Yuen,




I really need help toilet training my new puppy. We have tried different things from fencing to open roaming and back to fencing.

She is a Female Tibetan terrier

Presently (3.5-4)months old

Born 20/09/2012 In Brisbane
where had lots of space to play and was fenced up with siblings
Came to Singapore from breeder in Australia when 2.5-3 months old
Flew with brother to new home in Singapore

When she flew over, she was confined to a small cage with brother

for over 10 hours so had to pee/ poo there while travelling




We stay in a 2 story house with a garden.

We have 2 young kids who adore her and who keep going into her fenced area to play with her or taking her out to run.
Kids laughing just seems to excite her and so confuses her when being told off by me bur kids giggling.
We have an 8 year old male Tibetan terrier who is an angel ( very passive) and is toilet trained to pee outside in garden twice a day when we take him out.



Fencing and toilet- training:

We brought her home and fenced her with collapsible fence(1.8 by 1.8)m.

During the day, she stayed in the fenced area downstairs.

One side had sleeping box & toys & water bottle and food served on other side. Newspaper with pee smell on side wall of fence (for soilage)as in photo. At same time,also, tried taking her to shower cubicle to pee/poo with pee tray or newspaper. Failed miserably. Would sleep there or whine. We would wait and cajole for over (15-20) min but she would not do her business and then soon after that she would come out and she wiuld pee on toilet floor or room floor/mat.




At night, Slept upstairs in bedroom in smaller fenced area (0.6 by 0.6)m with sleeping box and water bottle. When we suspected she needed to pee/poo, she was taken to a different upstairs shower cubicle but same result of sleeping / whining in there and peeing later outside.




Feeding:

Being Fed 3x/day since she came.

(7am/12.30pm/7pm)

For first week, Food was left in pen till finished and sometimes hand fed as figured puppy was getting used to new environment and separation anxiety.

About 2 weeks later, once started eating fairly well, we picked up food after one hour whether eaten or not. Tried a bit of cajoling if not eaten much but figured will learn to eat faster when realises food not there all the time.

Also, had to get water bottle as she had tendency to jump into water bowl and splash and play with water and bowl.




We would let her run around for a while on & off around the house and with kids and other dog and then re- fence her but she would soil anytime & anywhere.




2-3 weeks into her arrival, we changed strategies. We made mistake of letting her loose in house all day and only putting newspaper on outside balcony near garden. We thought we had confused her earlier with where to pee/ poo (too many options for locations to pee/poo including upstairs bathroom cubicle and paper in fence and downstairs bathroom cubicle, so we changed it to one location near balcony with paper and put a (0.6 by 0.6)m fence around. So when saw her sniffing we would put her there. But she would go to sleep in there and pee/ poo once out.




A while later,we changed to not confining/ fencing peeing area as we thought she was confused with fence also being used to punish her. But without fence she kept running off the newspaper and then of course she peed/ pooed in wrong place. As a punishment, we would make her see/ smell the pee/ poo and at same time say 'no no' and then place her in fenced area (0.6 by 0.6)m Would say' bad girl'or 'no, no' after pointing to the wrong location for soiling.




A month after she arrived, we have started smacking her bum for:

biting/ barking/ nipping people/ nipping other dogs/eating wrong things(ie: poo/ shoes) /running out of gate/ eating leaves in garden.

We also tried the loud noise ( old empty drink can with coins) to teach her it's wrong but seems to scare her quite a bit.

Is this correct? What's your opinion on this?




We are frustrated as now:

•She pees/ poos whenever she eats & everywhere and house smelling

•She refuses to pee when take her to newspaper with pee trainer smell and instead will sleep on the paper and whine softly but no pee/poo there and soon after being 'released' she will pee/ poo somewhere else ( no fixed place). No matter how long you wait.

•She might then eat/ play with her poo

•She whines/barks when confined / alone in punishment fence




Plays with her poo/ Tries to eat poo

Seems confused about toilet place

Sleeps in toilet confined area/ in toilet cubicle/ on newspaper with pee- trainer smell

When realize she wants to poo/pee so take her to open area with newspaper to pee/ poo she runs away or sleeps on newspaper and soon after does it somewhere else on floor/ carpet

. Sometimes chews newspaper




As of today, after reading some of your cases, we have decided to refence her (1.8 by 1.8)m with toys on one side and newspaper at other side and food placed near toys at meal time. Also decided to feed her earlier 7am/ 12.30 & 5pm so that has time to empty bladder before sleeping.

For example today,

She ate at 5pm and at 7.30pm still just sleeping on the paper. Not peed/ pooed.

So at 7.30pm i decided i will get her out to exercise and run and instead she ran to kitchen and peed there. We brought her back to the newspaper in fence and she went to sleep on it.

At 8pm kids went into fence to play for 20min. Then she peed just next to paper on wooden floor.

At 8.30pm, not pooed yet.

At 10pm plan to take her to sleep in fenced area in bedroom. ( does not like to sleep alone and once upstairs she goes to bed).

What do I do if she keeps peeing in fenced area but not on newspaper?

Do dogs poo after every meal? How long do I wait for her to pee/poo before allowing her to go to bedroom?

Also, aiming to slowly move to 2 meals a day by 6 months. Is that ok?

Please please help and advice me about toilet training her.

About to pull my hair out.




This is becoming a battle of wills.

I'm also worried she might be stubborn enough to not pee/ poo in fenced area on paper and may end up with kidney/ urine infections.

How long do I just let her not pee/poo in the fenced area? Basically, how long do I wait?

What if she does not do it on newspaper and does it in other parts of fenced area? What do I do?

Do I need to cover entire fenced area with newspaper?

Every time she pees on floor in fence, I spray the smell repellant and disinfectant and wipe it off. Is that correct?




Should elimination area be in/ out of playpen?
At night, can she sleep in fenced area in bedroom?




At what age can we take puppy for walk on leash?




Eventually want him to pee outside the house once toilet -trained like my older dog.

Does paper-training confuse or hamper that?

I was hoping to take her for walks with older dog in hope that would copy older dog when peeing/pooing but she tries to bite leash and lies on floor & refuses to walk and hates collar so unable to do that.




Will send you photos of the fenced area and her sleeping fence too.




Really waiting eagerly for your wise words as really quite lost & frustrated!!!




Yours sincerely,




Name of Owner


E-MAIL REPLY FROM DR SING DATED JAN 14, 2012


Thank you for your email and details. My reply focuses on toilet training as you will need to read up or get a dog trainer to answer the other questions. Books are available at the National Library and the info is in the internet.

In this reply, I can only provide you the concept and principles of toilet training a puppy in Singapore based on success achieved by other Singaporeans in my survey of over 600 puppies.

1. It takes 2-8 weeks of confinement of a puppy to achieve success. Much depends on the intelligence of the puppy, the hard work and time spent by the owner, the distractions of family members and friends. For example, a couple living alone with the puppy will have a higher rate of success within 2-4 weeks than a big family with so many interferences and distractions affecting toilet training.

2. Patience and perseverance and research of the owner. Many owners are sabotaged by their family members giving various instructions and treats affecting the success in toilet training.

3. Focus on one method of confinement e.g playpen fencing confinement.

4. My case studies would have given you some ideas of the successes of various types of housing plans for puppies. Basically, strict confinement 2-8 weeks is the main part of toilet training. Positive or negative reinforcement training and others are needed.

It is not possible for me to advise you in detail in your case as each puppy has different management.

819. Performance of the vet surgeon: Urinary stone surgery

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)

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."

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?

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.

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.

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.

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

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.

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

808. Veterinary Surgery Productivity in Employee Vets

I have just updated the report today:

Jan 4, 2012. Wednesday. 2nd day at work.

A new client is difficult to come by as there are now 47 veterinary practices in Singapore. This was revealed to me by one veteran drugs salesman who saw me yesterday. We knew each other for more than 40 years and he had become busier now, with so many new practices compared to 4 when I first started out in 1982.

A quiet slim lady brought a black-brown Miniature Schnauzer to the Surgery as the dog had two loose front teeth. From her expressions and conversations directed at me, she would prefer me to handle her case. "I will do it together with Dr Vanessa as part of my mentoring process. When did the dog eat?"

"My dog ate at 10 am. Is it OK to do anaesthesia? "
"It is ideal that the dog should not have eaten for 10 hours before anaesthesia as the dog may vomit," I said. As the owner did not have time to postpone the tooth extraction, I said, "I will do it at 5 pm which is 6 hours later. It should be OK".

5-year Min Schnauzer, Female Spayed.
Chief complaint: 2 loose front tooth with exposed roots were surprisingly seen. Other teeth in good condition.
"i used the finger brush and gel," the owner said.
"You must have been brushing too vigorously," I replied. "The gums of the two incisors are exposed. It is best not to use the finger brush. In any case, the back teeth needs scaling."
Chief Complaint - My Schnauzer has two loose front teeth



Complaint No. 2 - My Schnauzer has a big ear lump that increases in size







4886 - 4895. Electro-surgery productivity



2nd complaint: R ear inflammatory nodule, firm, 7mmx7mmx5mm with central hole.

"A bee stung her tongue sometime ago," the lady said.
"Any bees seen in the last 2 weeks?" I asked as the owner said that the lump grows bigger in the past days. The dog had been scratching the right ear.

"It is best to excise it while the dog is under General Anaesthesia (GA) for dental scaling," I advised. "If you don't want histopathology, we will not know whether it is cancerous or not. A biopsy can be done but it costs money and delays. The best is for me to excise it since it is growing bigger day by day ."

The lady agreed to dental scaling and excision of the lump but not to blood test or histopathology. I asked Dr Vanessa to check the heart and pulse as well as general examination of the lungs. All were OK. So, the GA will be at 5pm to be done jointly.

I wanted to demonstrate how to be efficient and productive in veterinary surgery to my staff as it is one thing to lecture to young ones. Show how it is done will be best.

PLANNING
Scrub and clean ear well before sedation. "Any clipping of the ear?" Min asked me. "No need," I said.
I checked that Min had prepared the setting up of the electrosurgery equipment, dental scaling equipment and covered the operating table with a towel to prevent electric shocks to the vet on contact.

After all this was done, the dog's dosage of IV anaesthesia was calculated. "Give 50% of the calculated dose and you have around 10 minutes of anaesthesia," I said to Dr V

5 min after sedation, electro-excision by Dr Vanessa was completed within 60 seconds and then dental scaling was done. As the dog had little tartar due to the teacher's vigorous finger brushing, the dental scaling of the back teeth took a very short time.

Productivity means using the correct amount of anaesthetic drugs and least time to complete surgery and dental scaling. Therefore, the dog has the best chance of survival on the operating table. Delays by not preparing the equipment at first increases the risk and that would account for some deaths on the operating table.

The following is what happened as I asked my intern, Mr Lim to do the recording. Normally Min would do it but Mr Lim needed to be hands-on to learn if he wanted to be a vet after his National Service.


5.22 pm Sedate/IV anaesthesia at 50% dosage guideline*
5.25 pm Electro-excision
5.26 pm Dental scaling
5.36 pm End of dental scaling

*IV Anaesthesia Guideline Toa Payoh Vets and Dr Sing Kong Yuen
10kg, healthy, young dog. Domitor = 0.4 ml, Ketamine = 0.5ml IV combined
Usually no top up is required in a spay if done within 20-30 minutes.

This dog - 5 years is not young. The staff is to calculate on paper the dosage
D= 0.11ml + K=0.14 ml. Total = 0.25ml. Add 0.25ml Hartmann = 0.5 ml to be given IV.

Normally, the IV anaesthesia lasts around 15 minutes. I noted a very slight reaction to electro-incision which lasted less than 10 seconds. The dog was adequately sedated for dental scaling done by Dr V. Two teeth and nodule given to owner. I demonstrated that this case did NOT need any isoflurane and O2 top up if proper pre-op preparation had been done and the vet is skilful in using the electro-surgical instruments.

USE OF ELECTRODES

"Be careful not to bend the circular wire," I said to Dr V as she looped the nodule and the wire tilted at 45 degrees. "It is a very thin wire. It will break and it is very expensive to buy." The wire loop was originally 90 degrees to the electrode.

Training a person how to use the tools of the trade correctly is important and acquiring the correct skills makes a vet more productive. The Vet School provides some knowledge of electro-surgery but it is not possible to let every of the 60 - 80 students a chance to handle the electro-surgical equipment.

So they acquire the skills after graduation.

WART OR NODULE?
I would say it is an inflammatory nodule (with a hole in its centre, possibly bee sting). Dr V thinks it is an ear wart. "Physically, it does not look like a wart," I argued. "A wart usually is cauliflower shaped or rough, not smooth.

However, veterinary medicine has exceptions and I can't say this is not an ear wart. Since the owner does not want histopathology, we can't send the lump to the laboratory for examination. Therefore, there is no definitive diagnosis."

VACCINATION AND HEARTWORM PREVENTION
"I give heartworm tablets monthly," the owner said. "The last vaccination was 2 years ago." I explained to her the difference between the usual vaccination and heartworm.

"You may be getting your priority wrong. In the countryside like England, where most dogs don't meet other dogs, some dogs may be safe without further vaccination as they don't get exposed to many other dogs as in city living." I explained. "Parvovirus is still around. Distemper is still present in unvaccinated puppies. Have you been to England?" I asked. She said she was in England for two years and understood what I said.

VETERINARY PRODUCTIVITY AND EFFICIENCY
Many employee vets and doctors are not aware of the need to manage financial costs as this subject is not taught in vet school in detail if at all. So, they use materials and waste time in surgery. After all, they don't pay out of their own pockets and so do not bother with using excessive packets of sutures or finding more efficient ways to stitch up a case.

If there is no proper planning, a lot of time and material are wasted. This dog would need top up IV anaesthesia or isoflurane gas to complete the job. As demonstrated by me, the whole process after sedation took 3 minutes for electro-excision and 10 minutes for dental scaling.

An example of poor productivity and efficiency in vet surgery would be as follows:
The dog was sedated for a spay. The legs were then anchored to the op table. The vet assistant started clipping the surgical area inside the surgery room. Then the area would be cleaned. A gas mask would be given to the dog to deliver isoflurane gas and O2. The dog struggled as sedation wore off. A lot of time had been wasted.

My usual method is as follows:
To clip the dog (not ferocious) at the Preparation Room. Clean the surgical area. Sedate with Domitor and Ketamine IV. Dog goes into Operation Room. Anchor legs to table and clean surgical area again. Wait 5 minutes (time spent after sedation would take 5 minutes). Gas mask to deliver isoflurane and O2. Intubate. Spay. A lot of time is saved and the dog is exposed to much less anaesthetic in this way

.
OUTCOME
The dog in this case was groggy for over 1 hour as I did not use Antisedan to reverse the Domitor as I deem it not necessary to wake the dog up so early as she might feel the pain. Pain-killer and antibiotic injections were given.

The dog went home without problems as at 12 hours at the time of writing this first draft report. However, in this final copy, the owner had texted me saying that the surgical area was weepy and inflamed and what should she do?

"Hi dr Sing, I'm .....Brought ....to ur clinic for teeth extraction n ear surgery on Wed. ....ear is not doing well...Had inflammation. Can I administer iodine on her ear? What shd I do? I gv her medication as indicated, didn't bring her out. Can y kindly advise? Thanks very much

Younger people prefer texting. I phoned her and advised daily cleaning with the iodine and to let the dog wear the e-collar as she had been scratching the surgical area. She would let me know if there are problems again.

AN EXAMPLE OF POOR PRODUCTIVITY WASTING MANY HOURS HAPPENED ON THE SAME DAY

The HDB contractor came to replace the wooden bathroom door (rotten base) with a plastic one. He dismantled the door and then found that the plastic one was too narrow to fit in. 3 weeks ago, another person had come to measure the dimensions. This was really a waste of time, being unproductive. This is what I mean by productivity and efficiency.


"Please put back the old door," I asked the thin Malaysian man from Malacca with jet black hair. "I have a lady vet and you can understand that she can't use the bathroom with no doors. She works to past 8 pm at night. For men, an open door may be OK"

The contractor actually took the trouble to fix back the old door and said, "OK. I will get the new door back to the factory to replace one with correct dimensions today." He had previously said it might take 2 weeks, since Chinese New Year falls on Jan 22, 2012 and most workers had gone home. I was surprised. He even gave me two discarded wooden boards for me as shelving.


More pictures are at:
http://www.sinpets.com/F6/20120107vigorous-finger-tooth-brush-exposed-roots-Schnauzer-singapore_ToaPayohVets.htm

807. Sunday's interesting cases Jan 8, 2012

Case 1. Follow up of my first case seen in 2012 - The coughing Bichon puppy
The owner was surprised and appreciative to receive my call.
He said: "More active and much less coughing now. You are correct in that the puppy looks more like a Bichon than a poodle as we had checked the dog books.

"Does he still pee a bit to get treats?" I asked.
"Yes, he is a manipulative puppy as you had said."
This is a smart puppy.

Case 2. The 13-year-old male Shih Tzu barks when touched.
"This time, I decide to bring in my dog earlier than in Nov 5, 2011 when my dog barks when my wife wanted to clean him after eating or when he lay sideways. Dr Jason Teo prescribed rimadyl 25 mg for 7 days and he was OK."

On spending time with him, he said that Dr Jason Teo had got an X-ray done and nothing abnormal was seen. He had also asked for another 7 days of rimadyl and he dog was OK till Jan 6, 2012 (2 days ago).

PRESENTING SIGNS. Hunched back.
After Dr V had examined, I did an abdominal palpation and spinal area palpation.
"A hunched back indicates pain in the abdomen," I said to the owner.
"Where?"
I put my left hand on the front part of the abdomen and pressed. There was some sweling in the liver and spleen area to the kidneys. The dog yelped in reaction.

A painful liver/spleen area. The dog coughed violently when I palpated the pharynx.

So, there was pain. What's the cause? Tumour and/or inflammation of the kidneys, stomach, liver?

Blood test and urine test doe

806. The ferocious female cat passing red blood in the urine

Saturday Jan 7, 2012

I went to work although it is my day off. Checked on the cat that passed blood in the urine and under Dr V's care. The lady owner phoned: "How's Toto?" I said: "I am Dr Sing. Dr V is off today. Toto has not been passing blood in the urine since yesterday's admission to the Surgery." The cat was in a grated flooring and dark brown urine was seen, no more red blood."

"It was my grandpa who said that the cat had passed blood in the urine," the young lady said. "I don't see it."

"Well, grandpa is correct," I replied. "I saw the red blood myself when Dr V was sedating the cat. I was present and had tried to express some urine for the urine test." Around 1 ml was expressed after sedation. Bladder was empty. I did not palpate any big stone or thick wall suggstive of tumour. So this was likely an infection of the bladder, cystitis.

FLASHBACK YESTERDAY
A lady in her late 30s and her grandpa came with a brown cat to see Dr V. A vet had treated this cat, prescribed antibiotics and a Eukanaba dry food "guaranteeing" that the urination problem would be resolved if this dry food was consumed.

"This cat is fierce," the lady said. So, Dr V, Min, Nicole and Mr Lim were in the room

806.. Old mother died from post-op infections in the ward

I read this somewhere in the Straits Times in Dec 2011.

The surgeon operated successfully on the heart of the old mother. She became infected in the ward and it seemed that the doctors had not attended to her. She died. Civil suit. The registrar resigned and the surgical intern gave up his surgical internship.

Post-op infections can be very serious in old people and dogs.

804. Against Hospital Advice: Biopsy and lumbar tap discouraged for 76-year-old mother diagnosed with massive stroke

AGAINST HOSPITAL ADVICE

I read in www.asiaone.com.sg while in Eastern Europe last week. The writer said he sent his mum to Changi General Hospital. 2 neutosurgeons and 2 visiting ones said his mum could have brain cancer and would not do a biopsy and lumbar tap due to high risk v. benefit.

The son scoured the internet and found a specialist who treated his mother at Tan Tock Seng Hospital and did the two tests. His mother had a brain infection and had since recovered!

No comments from CGH

803. Liposuction death of Mr Heng was due to too much sedative

Straits Times Prime News Jan 5, 2012 Pg A3
"Doctors gave patient too much sedative: Coroner"

Heavily sedated man eventually died from the effects of asphyxia. His tongue was said to block his breathing. The more he struggled, the more sedative of propofol was given. This lead to the possibility that the patient could have suffocated leading to cardiac arrest, tongue rolled back causing obstruction of the airway.

13 intestinal perforations during liposuction not immediate cause of death -no massive bleeding or infections do not occur so fast.

LESSONS FOR VET ANAESTHESIA

1. I don't use propofol nor IV anaesthesia. However, some practices may not have isoflurane gas machine and theefore need to top up with IV anaesthetic drugs.

2. Keeping an accurate and meticulous record of sedation
2.1 The coroner said the two doctors "tailored" the figures - titration of the propofol and the total amount of propofol administered

2.2 The monitoring of the patient under sedation was treated with caution by the coroner. Dr Zhu could recall the sequence of titration and elvel of propoful tritratred during the entire procedure (of 3 hours) when no contemporarneous record was ever made of the number of times the propoful was adjusted or the level titrated. So the coroner was incredulous that she could recall the details.

The timing in Dr Wong's notes had been amended. Although 60 ml of propofol was claimed to have been given, this was actually more than 60 ml.

2.3 Dr Wong's nurse often paused when answering straightforard questions and claimed not to remembver important facts. So the nurse's demeanour in court was less forthcoming.

CIVIL SUIT filed against the two doctors.

For vet anaesthesia, keep proper and accurate anaesthetic records that can be believed.

802. HSA laboratory error making solutions - applicable to vet anaesthesia

Straits Times Review Jan 5, 2012 Pg A36
"To err is human, to confess remarkable"

Mistake: A senior lab manager misread the concentration of the reagent used for DNA tests. He made a solution 10 times as strong as it should be.
This reagent tested the DNA samples of 400 criminal cases.

How HSA prevents a similar occurrence in the future?
It had not double-checked the solutions used and none in the world does that as it is only a basic tool.

NOW every batch is checked by an independent laboratory
"Why no test was done on the solution before?" No answer to this question.

APPLICATION TO VET ANAESTHESIA - DOMITOR AND KETAMINE IV

Using IV anaesthesia, I want the vet to write down on the anaesthesia record and calculate the dosage based on weight and age and % discounted for old dogs. I do this myself and monitor my associate vets doing it.

IV sedation should not be overdosed, otherwise the dog dies. So, it is important to have a system and process of checking by the Senior Vet.

801. Shih Tzu with possible GME - follow up on Jan 4, 2012

4 Jan 2012
The Shih Tzu had been treated for a fever 2 days by Dr Vanessa. I was overseas. I saw him at 7 pm when the young couple came to take him home and observed his walking. He could walk on 4 limbs but not for long. Left eye pupil had no response to light and was dilated fully. Right eye pupil reacted to the bright white light I shone on, but constricted around 70% normal.

Blood test was taken. Showed very low WCC and higher figures of elevated liver enyzmes and higher than normal platelet count. Previous blood test showed normal WCC and elevated liver enzymes.

The dog did not have much appetite but was otherwise normal.

GME - Granulo-meningo encephalitis.
Cause is unknown. Said to be an auto-immune disease.
I did advise pred 2.5mg 2x/day for 2 weeks when the owner said that the dog had panted hard but it was only today I saw the dog again.

Prognosis is usually poor and the owner must be informed. "Feed small amounts and around 6x/day with sweet multivitamins," I advised. "You have 4 weeks." The dog rejected hand feeding but this must be done. Liver Prescription Diet 2 cans and antibiotics were prescribed by Dr Vanessa

The important issues here are prognosis and feeding several times a day at home as the owner wanted the dog back.

Day 2 of work - Productivity & Efficiency in Vet Surgery - dental and electro-excision

Jan 4, 2012. Wednesday. 2nd day at work.

A new client is difficult to come by as there are now 47 veterinary practices in Singapore. This was revealed to me by one veteran drugs salesman who saw me yesterday. We knew each other for more than 40 years and he had become busier now, with so many new practices compared to 4 when I first started out in 1982.

A quiet slim lady brought a black-brown Miniature Schnauzer to the Surgery as the dog had two loose front teeth. From her expressions and conversations directed at me, she would prefer me to handle her case. "I will do it together with Dr Vanessa as part of my mentoring process. When did the dog eat?"

"My dog ate at 10 am. Is it OK to do anaesthesia? "
"It is ideal that the dog should not have eaten for 10 hours before anaesthesia as the dog may vomit," I said. As the owner did not have time to postpone the tooth extraction, I said, "I will do it at 5 pm which is 6 hours later. It should be OK".

5-year Min Schnauzer, Female Spayed.
Chief complaint: 2 loose front tooth with exposed roots were surprisingly seen. Other teeth in good condition.
"i used the finger brush and gel," the owner said.
"You must have been brushing too vigorously," I replied. "The gums of the two incisors are exposed. It is best not to use the finger brush. In any case, the back teeth needs scaling."
Chief Complaint - My Schnauzer has two loose front teeth



Complaint No. 2 - My Schnauzer has a big ear lump that increases in size







4886 - 4895. Electro-surgery productivity



2nd complaint: R ear inflammatory nodule, firm, 7mmx7mmx5mm with central hole.
"A bee stung her tongue sometime ago," the lady said.
"Any bees seen in the last 2 weeks?" I asked as the owner said that the lump grows bigger in the past days. The dog had been scratching the right ear.
"It is best to excise it while the dog is under General Anaesthesia (GA) for dental scaling," I advised. "If you don't want histopathology, we will not know whether it is cancerous or not. A biopsy can be done but it costs money and delays. The best is for me to excise it since it is growing bigger day by day ."

The lady agreed to dental scaling and excision of the lump but not to blood test or histopathology. I asked Dr Vanessa to check the heart and pulse as well as general examination of the lungs. All were OK. So, the GA will be at 5pm to be done jointly.

I wanted to demonstrate how to be efficient and productive in veterinary surgery to my staff as it is one thing to lecture to young ones. Show how it is done will be best.

PLANNING
Scrub & clean ear well before sedation. "Any clipping of the ear?" Min asked me. "No need," I said.
I checked that Min had prepared the setting up of the electrosurgery equipment, dental scaling equipment and covered the operating table with a towel to prevent electric shocks to the vet on contact. After all this was done, the dog's dosage of IV anaesthesia was calculated. "Give 50% of the calculated dose and you have around 10 minutes of anaesthesia," I said to Dr Vanessa.

5 min after sedation, electro-excision by Dr Vanessa was completed within 60 seconds and then dental scaling was done. As the dog had little tartar due to the teacher's vigorous finger brushing, the dental scaling of the back teeth took a very short time.

Productivity means using the correct amount of anaesthetic drugs and least time to complete surgery and dental scaling. Therefore, the dog has the best chance of survival on the operating table. Delays by not preparing the equipment at first increases the risk and that would account for some deaths on the operating table.

The following is what happened as I asked my intern, Mr Lim to do the recording. Normally Min would do it but Mr Lim needed to be hands-on to learn if he wanted to be a vet after his National Service.

5.22 pm Sedate at 50% calculated dosage*
5.25 pm Electro-excision
5.26 pm Dental scaling
5.36 pm End of dental scaling
*10kg, healthy, young dog Domitor = 0.4 ml, Ketamine = 0.5ml IV combined

This dog - 5 years is not young. The staff is to calculate on paper the dosage
D= 0.11ml + K=0.14 ml. Total = 0.25ml. Add 0.25ml Hartmann = 0.5 ml to be given IV.

Normally, the IV anaesthesia lasts around 15-30 minutes. Very slight reaction to electro-incision but was OK for dental scaling done by Dr Vanessa. Two teeth and nodule given to owner.

USE OF ELECTRODES
"Don't bend the circular wire," I said to Dr Vanessa as she looped the nodule and the wire tilted at 45 degrees. "It is a very thin wire. It will break and it is very expensive to buy." The wire loop was originally 90 degrees to the electrode. Training a person how to use the tools of the trade correctly is important and acquiring the correct skills makes a vet more productive. The Vet School provides some knowledge of electro-surgery but I doubt every of the 60 - 80 students has the chance to handle the electro-surgical equipment. So they acquire the skills after graduation.

WART OR NODULE?
I would say it is an inflammatory nodule (with a hole in its centre, possibly bee sting). Dr V thinks it is an ear wart. "Physically, it does not look like a wart," I argued. "A wart usually is cauliflower shaped or rough, not smooth. However, veterinary medicine has exceptions and I can't say this is not an ear wart. Since the owner does not want histopathology, we can't send the lump to the laboratory for examination. Therefore, there is no definitive diagnosis."

VACCINATION AND HEARTWORM PREVENTION
"I give heartworm tablets monthly," the owner said. "The last vaccination was 2 years ago." I explained to her the difference between the usual vaccination and heartworm.

"You may be getting your priority wrong. In the countryside like England, where most dogs don't meet other dogs, some dogs may be safe without further vaccination as they don't get exposed to many other dogs as in city living." I explained. "Parvovirus is still around. Distemper is still present in unvaccinated puppies. Have you been to England?" I asked. She said she was in England for two years and understood what I said.

PRODUCTIVITY & EFFICIENCY
If there is no proper planning, a lot of time is wasted. This dog would need top up IV anaesthesia or isoflurane gas to complete the job. As demonstrated by me, the whole process after sedation took 3 minutes for electro-excision and 10 minutes for dental scaling.
OUTCOME
The dog was groggy for over 1 hour as I did not use Antisedan. Went home without problems as at 12 hours at the time of writing this first draft report. However, in this final copy, the owner had texted me saying that the surgical area was weepy and inflamed and what should she do?
"Hi dr Sing, I'm .....Brought ....to ur clinic for teeth extraction n ear surgery on Wed. ....ear is not doing well...Had inflammation. Can I administer iodine on her ear? What shd I do? I gv her medication as indicated, didn't bring her out. Can y kindly advise? Thanks very much
Younger people prefer texting. I phoned her and advised daily cleaning with the iodine and to let the dog wear the e-collar as she had been scratching the surgical area. She would let me know if there are problems again.

AN EXAMPLE OF POOR PRODUCTIVITY WASTING MANY HOURS HAPPENED ON THE SAME DAY

The HDB contractor came to replace the wooden bathroom door (rotten base) with a plastic one. He dismantled the door and then found that the plastic one was too narrow to fit in. 3 weeks ago, another person had come to measure the dimensions. This was really a waste of time, being unproductive. This is what I mean by productivity and efficiency.

"Please put back the old door," I asked the thin Malaysian man from Malacca with jet black hair. "I have a lady vet and you can understand that she can't use the bathroom with no doors. She works to past 8 pm at night. For men, an open door may be OK"

The contractor actually took the trouble to fix back the old door and said, "OK. I will get the new door back to the factory to replace one with correct dimensions today." He had previously said it might take 2 weeks, since Chinese New Year falls on Jan 22, 2012 and most workers had gone home. I was surprised. He even gave me two discarded wooden boards for me as shelving.


UPDATES AND MORE PICTURES AT:
http://www.sinpets.com/F6/20120107vigorous-finger-tooth-brush-exposed-roots-Schnauzer-singapore_ToaPayohVets.htm

799. lst case of 2012. A white puppy that coughs like an old man

Jan 3, 2012 10.30 am



My first case of the year. Poodle, Male, 3 months. Bought 7 days ago. Past 3 days, cough as if choked. Some runny nose with clear discharge. Excellent appetite. Had 2 vaccinations. 1 free vaccination voucher from a vet for 3rd vaccination and therefore I don't expect the father to see me for the 3rd vaccination.

The father had phoned for check up and the time. He came in the morning before 12 noon and I was on duty. As regards toilet training, I was surprised that the puppy was so intelligent as he would wait for treats by peeing a little bit first. There was one other case of a "manipulative" puppy reported to me during my over 600 case studies of house-breaking in puppies. One particular puppy I remember well is that this puppy would pick up all the toys and put them in a box when retiring to sleep at night.

"How's the puppy toilet trained?" I asked. The puppy was confined closely for grate training (plastic grate on one half, on top of grated floor, according to the father). He was very kind as to e-mail me 3 pictures of the most handsome "Bichon" I have ever seen and I share them with my readers. The Seller said it was a poodle but I said it looked more like a Bichon.




4935. Crate training and treats for a smart puppy. He would go to the grate and pees a bit waiting for treats!

Examination as follows:
1. General exam - mouth and throat palpation - coughed
2. Detailed exam - opened mouth, puppy resisted, shone white torchlight - no tonsillitis, no ulcers
Auscultation of lungs - no lung sounds

"Overall, the puppy had kennel cough," I said. "It is not serious and he will recover in 10 days' time provided no exertion."

QUESTIONS ASKED
1. What causes kennel cough? A virus and bacteria usually from other dogs inside the breeder's premises. The breeders in Singapore do not vaccinate against kennel cough and so the kennel cough germs persist in the kennels. However they vaccinate the puppies against parvovirus as they have had suffered heavy losses for not doing it. So, most puppies sold in Singapore are immune to parvoviral infections causing severe diarrhoea and vomiting. And deaths."

2. "But the puppy had no cough when we brought her home for the first 3 days," the daughter said. "Many breeders gave the puppy cough mixtures and medication and so the cough was suppressed for the first 3 days," I said. "If the breeder said that the puppy for sale has coughing, the owner will not buy him. So, it is difficult for him to be honest. In your case, the puppy is 3 months old and is stronger and so the kennel cough should not be a big problem. Those puppies at 2 months old suffer more as their immune system may be poorer. Some of them die from pneumonia!"

"The breeder is also selling smaller puppies," the father said. "Size may not be correlated with age," I said.

3. "When should I send my puppy for the 3rd vaccination?" the father had e-mailed me later.
This depends on how fast the puppy recovers. As a guideline, 7-14 days after the puppy has stopped coughing.

Educational Video: Kennel Cough in Puppies produced by two St Andrews' Sec 3
students in collaboration with Dr Sing
I was surprised to meet a busy multinational company employee father and his daughter in junior college and her cousin. Singapore is too small for international corporations to survive if they focus on Singapore for business. Previously, Caucasian expats were employed for regional positions but now are replaced by locals. Which means a lot of travelling and less time for the family. However, children need money if they study overseas and a salaried employee working in Singapore mainly may not be able to afford overseas education for their children. I am always happy to see a busy father bringing the daughter and puppy to see the vet as the Singapore fathers are usually very busy and delegate the duty to the mother!

Webpage at:

798. Young Adults Face Intense Global Competition

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.

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 indispensible 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. Many 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 Ponzi 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.