942. Lack of humility in the young

Yesterday I was at Khin Khin Employment Agency to advise on her business operations as she was new to the game of entrepreneurship.

"This girl is very good staff material. Very pretty. Can speak English very well as she has worked in Singapore for 2 years. She's got an Employment Pass. I would like to employ her as the other girl can't even speak good English."

She phoned the pretty woman and asked me to interview her by phone after showing me the resume. Certainly, the woman could not stop carrying on a conversation by greeting me and taling.

Of the few questions, I asked this: "What do you mean by increasing 72% of the sales since you joined the Singapore company?". Her resume also showed that she had increased 72% of the sales when she worked for a Myanmar company before joining this Singapore company. This was not possible. Exactly 72% increase in sales in both companies.

She gave an evasive answer and was quite impatient. I passed her back to Khin Khin who told me that the pretty woman said that if I was serious to employ her, she would bring her manager down from Kuala Lumpur to testify for her.

"I am not employing her," I said to Khin Khin. "You are the one interested."
"She's aggressive and much better than this other girl. I need such aggressive and able to speak good English staff for my business."
"Then, employ her," I said. "She does not have an E Pass and you, as the boss of the agency should present the facts correctly. She had an S Pass. An aggressive employee will be good for sales.

"But you can get your tail bitten off by an aggressive dog if you are not careful. You have need always to be careful. Besides she does not have the relevant experience. How do you know she will produce sales?

Khin Khin thinks that a pretty face and good English will get into the hearts of prospective Singapore employers. There is some truth in this.

However, this interview revealed an aggressiveness, lack of humility and respect and impatience to a young pretty woman looking for a good job. This is a time bomb when the interview reveals such a personality and I don't employ such a person if I was the prospective employer. Unlikely to be a team player. No respect for the boss or anyone.

Young people looking for good jobs need to be humble and respectful. The world does not owe them a living.

941. The 5-year-old Maltese "vomited" and collapsed at 10 pm - Standard Operating Procedure

"Why you did not give diazepam injection first and then take blood sample?" Dr Daniel asked me when we attended to this emergency. "Diazepam will not affect the blood test analysis."

The Maltese's neck extended skywards and he was recumbent. "His eyes are so staring and he has saliva coming out of his mouth," the mother said to me while the father and teenaged daughter were worried.

Naturally, the first thing to do is to give the diazepam to resolve the sky-looking head.

I don't know whether diazepam will affect the blood analysis but I prefer to do the basic. Take the blood before any drug is administered. That will be the basic of scientific research, in my opinion.

"We need to check for glucose level to see if there is hypoglycaemia," I said. "We can take some more blood after giving the IV drip." I had also included the glucose and multivitamin amounts to be added in the normal saline drip. The Hartmann's solution would be given soon.

"You can't take the blood to check for glucose level after administering glucose", Dr Daniel had pointed out.

After taking the blood, we gave glucose 50 ml IV, Normal saline and diazepam amongst others.

Within 1 minute, the dog's neck returned to normal position and was not rigid anymore. I asked the owners to come and see. The daughter's eyes were red.

"His eyes are closed and no more staring," the mum noted. Eyes are windows to the soul in this case. I mean, dilated pupils can indicate impending death from uncontrolled seizures and the mum must have meant "staring dilated pupils" as staring eyes.

"What's the cause of this seizure?," the mum asked me. She had consulted me earlier about this Maltese having ear infections 5 months ago but there is no more redness or ear itchiness now.

"It is hard to say. If it is sudden, it could be an injury to the brain. Is the Maltese a very active dog?" I asked.
"Yes, yes," the mum said. "He jumps up and down, to greet us, and he was doing it before dinner."

"The blood test will give us some answers," I said.
Dr Daniel said to me that the dog could be suffering from hypoglycaemia and went into fits as he was fed only once a day instead of twice a day. "Possible," I said. "Wait for the blood glucose result."

In conclusion, the standard operation procedure of taking the blood before treatment is still the best. Take blood before doing any treatment will NOT result in conflicting test results as, for example, after administering glucose and taking blood during emergency confusion will make the test for glucose invalid. There must always be a SOP in emergencies.

940. Veterinary anaesthesia to spay stray cats & multiple ovarian cysts

Yesterday, April 11, 2012, I visited a vet who had spayed thousands of stray cats. The young cat was laid on a metallic M-shaped holder (apparently commonly seen in Australian vet spays), without the need to tie up the legs. She tried to hook out the ovary but could not. She extended the skin incision to bigger than the width of her forefinger and could hook out the left uterine horn.

The cat had been pregnant and therefore the uterine horn was not easily hooked out. There seemed to be something stuck to the left ovary as she could not pull it out. I saw large veins from the uterine body to the ovary. "I have to refer to Vet 1", she said. Complicated surgical and medical cases are farmed out to Vet 1, as this is the policy.

"Just extend the skin incision by 1 to 2 cm more," I advised. "You will see what's been affecting the ovary." She used the scissors and cut further. It was a huge surprise. Around 3 big ovarian cysts of around 1 cm in diameter. had prevented the pulling out of the ovary till the incision was extended.

"I need to take a picture," I said as this type of medical condition is very rare. She had not seen it too despite many years of spaying stray cats. She said OK and I rushed to the car park to get my camera. When I returned, she had taken out the ovary but the cyst had ruptured. There was one cyst I managed to photograph for vet students to appreciate. We are taught about ovarian cysts but in the real world, they are uncommon. "Take another picture of the normal ovary to compare," she said as I had not thought of it. I got a few tips from her.

HOW TO ENSURE THAT SPAYED STRAY CATS DON'T GET STITCH BREAKDOWN
1. Suture muscle layer and linea alba with cat gut.
2. Subcutaneous suture, interrupted, at either ends of the fatty tissue with monofilament
3. Subcutaneous suture of the fatty tissues with continuous
4. Two horizontal mattress sutures of the skin, with one interrupted suture knot stitching out at one end. I can't figure this out as it is supposed to be buried.
No complaints of stitch breakdown with this method. The other knot at the other end was buried.

I just do Steps 1 and 4 in all cats and have no problems with stitch breakdown. Too many layers (Step 2) irritate the cat and dog during healing and also likely introduce pathogens. Keep spay simple is my policy.

Each vet has his own tested method and will not change his or her mindset when the method is successful. The important thing is the client's perception as many Singaporean clients appreciate excellent stitching (which may be a buried subcuticular suture, continuous i.e. Step 2 without Step 3.)

VETERINARY ANAESTHESIA FOR STRAY CATS IN THIS PRACTICE
Well tested and proven to be effective and does not involve "ketamine."
I saw two cats well anaesthesized with this procedure. The dosage is as follows:

Spay
3kg young
Zoletil 100. 0.2ml. IM. Separate syringe.
Xylazine 20. 0.2ml. IM. Separate syringe.
duration >25min
Hartmann SC post op

DOG
Eg Jack Russell
Xyla 0.3 ml first.
Zoe 100. O.3 ml. Slow IV
To effect

Each vet has his or her own method. This method works very well and the vet sees no need to change. For me, in cats, I give a one-syringe Xylazine+ketamine combination IM. So, the cat gets one injection IM instead of 2. The less the better for our patients as injections may cause irritation. It is hard to change mindsets of most vets when they are used to a successful method of anaesthesia. Younger vets want to introduce propofol and althesin but these are expensive and add to the inventory. It is best that young vets adopt what is effective in the practice unless their method is more superior as for example, diazepam and xylazine is said to be safer than domitor and xylazine IV but I am used to the latter and find it effective. Diazepam is said to be safer than domitor in anaesthesia by not "affecting blood pressure or cardiac rate" according to one vet I spoke to.

But how much safer? So, I don't also go for another type as I find my present formula very effective and safe. In other words, there are many injectable anaesthestics and the vet must focus on one combination. Peferably one injection.

939. The hot dog growls at the vet

Tuesday, April 10, 2012

"More active, no more vomiting," the lady said. "The dog has not recovered fully from hepatitis yet," I said. I prescribed some liver supplements and anitbiotics. Every family member is happy. The dog was warded 4 days for lethargy and recurring fever. 10 days ago, I had operated on him and removed a big epidermal cyst. The dog was rubbing his back area where
the cyst had been removed. So, the grandpa applied bright yellow powder onto the wound. It looked like yellow sulphur, which is toxic.

Saturday, April 8, 2012
The owner had brought the dog to see me last Wednesday with complaint of lethargy and fever. I boarded him for observation and on Saturday, the whole family of 2 ladies, their husbands and grandparents came to visit this miniature schnauzer of 5 years, male. Saturday was my day off, but I went back to Toa Payoh Vets to see this dog. That was how I met the group outside. The dog growled when I approached him to palpate his abdomen to see whether it was still tense and hard. "That is a good sign of recovery to health," I said. "Yesterday, Dr Daniel said he stood like a statute for a few minutes when let out."
"Maybe he is frightened," the young lady said.
"Possibly," I asked the owner to hold his muzzle while I palpated his abdomen. Not tense as before. So,I decided to let him go home. He would recover faster at home.

Well, he did recover. As to the cause of his tense stomach area, I can only sketch this scenario as follows:


1. The wound was contaminated by the yellow powder. Toxins and bacteria entered the wound. Blood test showed high liver enzymes. Low red cell count.

2. Stomach was full. Impaction. I had given anti-spasmodic inj to cool him down. The tense anterior abdomen was due to his liver inflammation.

938. Close-circuit anaesthesia is efficient and economical

Two days ago, I met a senior vet. He was reiterating the way the younger vets now use gaseous anaesthesia with a very high flow rate of oxygen, using an open circuit, thereby wasting a lot of anaesthesia and Oxygen. The younger vets would not accept his method of using closed circuit. This was also a method I used. Now I used the semi-open method.

"Take it easy," I said. "The younger vets have their mindsets so much different from us. Their vet professors have had trained them and they did it the professors' way. After all, vet professors don't have to account for the bottom-line. Neither do the younger employee vets. So, they don't worry since they don't have to pay to replace fast-consumed isoflurane which is extremely expensive.

I used oxygen flow rate of 0.5 in a closed circuit, while the younger vets used 2 litres/min. In a long surgery of 2 hours, the volume of oxygen and isoflurane gas used is considerable and costly.

"Maybe the younger vet is afraid that in a closed circuit, the isoflurane level increses and then kills the dog," I said.

"No," the senior vet said. "Just switch off the oxygen or lower the flow. The 2% maintenance isoflurane in a closed circuit may go down to 1.8% but will not increase."

"Maybe the younger vet is afraid that the carbon dioxide will accumulate inside the closed circuit, killing the patient. I know, soda lime absorbs the CO2, but the younger vet may be worried."

"Yes, the soda lime removes the CO2. So, there is no worry. I had long discussions with a human anaesthestist on the closed circuit and that's the most economical way. Don't use nitrous oxide though as some dogs do die."

"But young vets who are employees don't have to pay for any amount of isoflurane they use. So, a high oxygen flow rate (over 2 litres/min) use up a lot of isoflurane in an open circuit - so what? They don't need to pay. So, they can't be bothered," I said.

This senior vet is irked by inefficiency and unnecessary wastage but the younger vet refused to adopt the closed circuit. Maybe, they have their reasons. I have not talked to them.

Each vet has his own peculiarities. This senior vet uses electro-surgical coagulation in the castration of dogs. I don't. Seldom do other vets. "I wonder how I manage without it?" I asked one young vet as this senior vet uses it for all surgeries except spay.

937. Breathing heavily and coughing in the older dog - 3 cases

Yesterday, I saw the 3rd case, similar to the other two I wrote sometime ago. Previous vets had been consulted but the respiratory problem remains or recurs.

A young man in his 30s, accompanied by his senior citizen father, brought in his 12-year-old Shih Tzu that coughs non-stop. He had consulted my associate some 2 weeks ago.

"Can you hear the heart sounds?" I asked Dr Daniel. "Was the old dog suffering from heart disease?"
"Not possible. The lungs were crackling with loud sounds. The mouth has large ulcers, a tumour. The teeth and gums were all infected."

New graduates will quickly do the ABC. Airways, Breathing and Circulation. So, the first thing their vet professor had taught would be to give oxygen therapy. I had seen this being done by new graduates. The dog's tongue was purplish and therefore lacking in oxygen. He could not stop panting.

"He had a seizure when he fell down," the gentleman said to Dr Daniel. Later I told Dr Daniel that the owner had got the process all wrong. There is a stage just before seizure when the dog is unsteady in balance. Seizure comes, he falls down. More fits. Saliva foaming. To the owner, the fall causes the seizures!

What to do in this case? Put on oxygen mask for half an hour?
The professor's lectures of "ABC" are still vivid. The professors may also give the impression or may not, that old vets are outdated.

So, must do ABC with oxygen therapy first. Gas mask. Switch on the oxygen.

In my experience, a simple IV injection of Lasix will help the dog breathe easy and normal. A bit of dexamethasone perhaps but it is the Lasix that does the trick. So, I advised Lasix. "Give SC and IM," I said as Dr Daniel felt that the dog may be too stressed to be given IV. His tongue was cyanotic and he was about to pass away from lack of oxygen in his blood stream. This is a serious matter. Life and death is always a serious matter.

After 10 minutes, the dog's breathing was back to normal. As I expected. Then we got the dog for the X-ray as the lung fields will be clearer. I don't know whether the professor teaches this procedure or not. In academic lectures, it is probably not possible to teach this way. In real life, the most practical and efficient way in such respiratory distress cases, is the Lasix. One vial. Why Lasix? Because it is a branded product. I could use generic and they should work as well.

X-rays- small nodules in the lungs. "Engorged blood vessels seen end-to-end," the young vet would venture his opinion when I said these would be likely micro-abscesses or tumour metasized to the lung from the pedunculated one in the umbilical area and from the oral tumour. Each vet has his own opinion as only the MRI scan (too expensive) would confirm. I asked sleepy-eyed Dr Gladys for her opinion as two heads are better than one. She had attended a wake and was really tired. She said: "It could be the small tumours forming. It could be abscesses."

The dog did have a high fever but it could be due to panting. The blood test results should come in today.

CONCLUSION
Much time must be spent with the owner to educate and explain the consequences of not taking the heart drugs. Failure to do so lead to an unhappy owner who hops to another doctor. Usually the last doctor benefits from the history and well, every vet will have such clientele.

936. Chronic Otitis Externa - Ear surgery

On Sunday, April 8, 2012, at 3 pm, I met an old client at Toa Payoh Vets. Nowadays, I seldom consult on a Sunday afternoon. But on this Sunday afternoon, I was around to do my "audit and trust" review of cases done by associate vets. This is to ensure a high standard of veterinary care to be provided by Toa Payoh Vets.

Mr Ong had come to pick up his poodle. My associate vet had told him that his poodle required a "medical bath" yesterday and somebody called him to pick up his dog at Toa Payoh Vets. The dog was at another place. When the dog arrived, I examined his dog. The sides of the ears were blackened due to continuous scratching over many years and the neck skin was bald.

"Your dog need an ear surgery," I said to him. I checked his dog's medical records and noted that he had sought itchy ear treatments since 2009. He told me about his poodle's continuous scratching since young. "You had advised an ear surgery before," he said to me. "I went to see Dr Jason enquiring about an ear surgery. He said that the ear surgery is very complicated. The cause of this poodle's ear problems could be genetic or food allergy. Therefore, he recommended a medical bath and medication."

The ear surgery is called lateral canal resection. It is described using images of an operation I did on a Miniature Schnauzer to educate dog owners.

Any updates on the poodle to be operated by me 8 days later will be at the Website:
http://www.kongyuensing.com/folder8/20120408ear-resection-surgery-smelly-ears-chronic_ToaPayohVets.htm