1808. Cambodia Khmao Project

Dear Dr Sing.

Some information about myself and The Khmao Project.

I moved to Cambodia 3 years ago and instantly recognised the plight of animals here, it is extremely difficult not too, regardless of your education and background.

Being a developing country, Cambodia is still coming to terms with genocide, war, widespread corruption and heartbreaking poverty.

Animals in Cambodia that do not have financial value (livestock having monetary value) are not considered companion animals or pets, as they are in western cultures.

They merely exist, and have to fend for themselves for food, shelter, health wise.

Cambodia, being a buddhist country, also does not believe in desexing or an interruption to "the natural order"..therefore euthanasia is also against their beliefs.
Everyday here, you are confronted with neglect on such a massive scale. Hence the need for an animal welfare project here in Siem Reap.

There are Khmer "vets" here, but their level of training is very minimal (if any), this is of great concern, when they can advertise themselves as Veterinarians

The only other western vet is 6 hours away..not great in the case of an emergency!

I also have access to a laboratory at a western run hospital, where I can take various pathology samples in for analysis then I send the results to a vet friend in Australia for diagnosis and a treatment plan. This has proven to be invaluable!

All of the female desexings I refer to Phnom Penh (the capital-6 hours away).

I am lucky that the French vet in Phnom Penh supplies me with antibiotics etc..but these items can prove quite costly as they are imported from France. Obviously the cheaper alternative are available here in Cambodia, but mostly these items are not of great quality,(also are "copy medications, non generic) and have been stored in the correct manner and therefore lose their effectiveness. I try to go to Bangkok as much as possible, (to source anesthetics in particular) but sometimes this is difficult.

About The Khmao Project...

The project is in its infancy stages at the moment. Currently we are treating a small amount of local/stray dogs and cats for various conditions, offering vaccinations, general health care and re homing them to expats once they are healthy.

The plan is to (once we have the appropriate funding) to open a facility with a veterinary clinic,(proceeds of this go back into the project) kennels to house stray dogs and cats, offer desexing, vaccinations, health care. Eventually we would like to have a mobile clinic to go out to the various provinces in Cambodia and continue to offer free treatment to Cambodians.
Obviously once we have the facilities etc we will be asking for volunteer vets from overseas to come and donate their time. We will also be employing local Khmer staff and training them in animal care and husbandry. Eventually we would also like to offer further sustainable training for Cambodian vets by western trained veterinarians.

This is a massive task and we are hoping to be able to achieve this.
If there are ANY items in the future that you would be able to supply..it would be greatly appreciated!

Please feel free to contact me if you have any queries or questions. Hoping soon to face our Facebook page up and running so we can keep you up to date The Khmao Project, if you wish.












Katie Beattie V.N

1808. Too risky pyometra surgery

EMAIL TO DR SING DATED JUL 24, 2012
On Tue, Jul 24, 2012 at 2:17 PM, Jan Cavan wrote:

Hi Dr Yuen,
I was researching about Pyometra and came across your blog. I really need your help. I'm very desperate.

My dog has pyometra, but the vet does not recommend surgery for the following reasons. If they ever perform surgery (when she gets better), they won't do it without injectable anesthesia/complete sedation. But based on your blog, gaseous anesthesia is actually okay to use too.

1. her age (she will be 13 years old this December)
2. she has kidney problems (creatinine was 5.0, gone down to 2.0 after some medication, but is now back up to 13)
3. she is anemic

But I believe that 2 and 3 above are caused by pyometra. Right now, she is taking:
1. antibiotics for pyometra
2. Nefrotec to make her urinate and release the toxins
3. Red Cell for some iron supplement
4. She is currently in IV fluids to rehydrate her as she appears to be dehydrated

I am in California and my dog is in Cebu, Philippines with my parents. I wish I could fly her out to Singapore so you can maybe help her out, but that is no longer an option at this point since we need to make decisions immediately as my dog is getting weaker. I would actually also fly you to Cebu to perform the surgery and we rent out a veterinary clinic's equipment here. If that is something you would consider, please let me know as soon as you can. It's 11PM here and I might sign off soon. If this is something you would consider, would you be able to please contact my parents? The Philippines and Singapore have the same timezones.
....
I understand that you may not be like the usual emails that you get, but I'm really, really, very desperate right now. My initial plan was to postpone surgery until she recovers so I can bring her to CA with me. But now, I am desperate. I really, really, really need your help. I am a complete wreck.
Looking forward to hear from you.
Thanks,

EMAIL REPLY FROM DR SING DATED JUL 24 2012
There will be other vets in Philippines that can operate on pyometra using gaseous isoflurane anaesthesia and IV drips. You need to find them, esp. those in bigger practices and hospitals, maybe in the city? Your country is large, unlike Singapore and there will be more vets who can do the surgery. You may need to drive the dog to the particular vet or vet school.

I am sure there will be one vet who will do it but it may be too far from your place.
However, gaseous anaethesia is NOT a guarantee that your dog will survive the surgery or post-surgery and you need to understand and give the informed consent you have to give to the vet.
Best wishes.

1807. Wanting to be rich

My advice to a Filipino vet from a middle-income family. She couldnt' find a vet tech job or a waitress job in Singapore on a recent visit. She had sprained her shoulders and back and left limb having been a medical transcriptist for past 7 years as it paid S$1,000/mth compared to vet job and wanted to do some work without typing. Singapore has tightened its rules and so approvals are very difficult.


EMAIL TO DR SING DATED JUL 17, 2012
 Hello Dr. Sing,


Eileen here...I just want to express my utmost gratitude for all your words of wisdom yesterday. Maybe I still need time to do a bit of internalizing to figure out what I really want to do. You are right, I really am confused about what career move I should make. I have booked a ticket going back to the Philippines to clear my head and get a better perspective. Thank you so much for the chance of experience. Learning is quite priceless.


Regards,
Eileen




Thank you and good luck. Life is never easy for most people who want to be rich. There must be a passion and a compassion in such person and lots of personal sacrifices (health, personal, friends, family) if they want to be really rich. 

1086. sunday July 22, 12 interesting cases

July 22, 12
Bright sunshine, blue skies, white clouds
6 pm

1. Maltese with fever last night. Saw Vet 1 and given treatment. Blood test showed unusual high RBC and Hb. So, unlikely to be tick fever. "Sudden onset, not wanting to move yesterday evening" was the clue. I palpated spinal area inT7 - 13 area. Dog was already on pain killers from Vet 1 but responded with a soft "ha ha " sound which I could reproduced to let the young lady owners hear. As to the cause of fever 40C today at 10 am, I suspected there could be extreme pain and panting - increasing body temp but why increase in RB  C and HB? Gave IV drip and tolfedine and to observe. "Must I come back on Monday?" the young lady asked. "No need if the dog is active and eating." I said. "Continue with anti-fever and other medication. I will check the blood." A case of PUO? Pyrexia of unknown origin.

2. Golden Retriever with the most smelly neck. Can't stand this smell. Cellulitis.  "Must we complete 10 days of medication?" the lady asked me. "Yes," I said. "The stinking smell is due to a flesh-eating bacteria and 3 days will not be sufficient." "Need antiseptic daily?" she asked. "Yes, use the wash." "Any cream?" she asked. "No need." I said.

3. Roborskvi with backside cellulitis. Lady owner could not cure it. On 29 Jun 2012, one of  the two siblings was treated by Dr Daniel for similar backside wound and had healed after 5 days of hospitalisation. Owner asked to separate the siblings but she put them together again. "What happened to the other hamster?" I asked. "He drowned." "How?" I asked as she was living in a Toa Payoh HDB flat. "He fell into the hole," she said. "What hole?" I was shocked. "The hole where my washing machine pipe discharged the water."  Now, this sibling's backside had got bad and needed hospitalisation. 

3. Chihuahua spayed 5 days ago with pyometra came at last minute. "Dog was licking the side of the spay wound causing a reddish patch to the side. Why?. Also a blood spot on my cushion," the lady owner said. "Is this normal?"
"This is normal in that residual blood get passed out after spay from pyometra, but is not serious. Is the dog active and eating?"
"Very well," she said. "Probably plaster is irritating," I checked the spay wound and removed the plaster. No inflammation on wound, so that was ok. Gave injection and sent the dog home. No need plaster. 

4. Shih Tzu with both ear pinnae inflamed. "Came at 3.30pm, now it is nearly 6 pm", the lady said to me. I had done the eye ulcer tarsorrhapy on one eye and Dr V had done the other. Both eyes are OK but she said ear problem came soon after wearing the e-collar. She had the dog spayed at another practice. The vet said ears were dirty and prescribed ear drops of 2 bottles. Now the ears are itchy.  She preferred Dr V and had to wait. Personalised services are like that, otherwise the clients will be assigned to me or Dr Daniel Sing if they can't wait. "Ear problems are common in Shih Tzu," she was so busy that she has no time for the dog and would not want hospitalisation. So she was waiting for ear irrigation. I sedated the dog first and told Dr V about it, so she could save some time. It was already 6 pm and the client from Changi had to pick up her daughter from the enrichment lessons somewhere.  

5. A young cat vomited food half an hour or more after eating 4 x in the past 4 months. Losing weight compared to the other cat. Both fed separately.

Is this a case of some foreign bodies inside the stomach or a stomach diverticula? The couple wanted immediate X-rays and blood test and I referred them to another vet with complete facilities but who does not work on Sunday.    

1085. Blood tests and X-rays in the diagnosis of pyometra in dogs

Recent history of estrus, clinical signs  and abdominal swelling and pain on palpation may be sufficient. However, blood tests give an indication of the health status and the anaethetic risks using evidence-based medicine in case the dog dies during or after surgery.

TWO RECENT CASES as example
Both female dogs around 4 years old.

Date: Jul 16, 2012
CKC with closed pyometra
Estrus said to be less than 1 month ago.
Goes home 5 days after surgery as she needed IV drips. Wagged tail on Day 3.
Womb looks about to rupture. It was extremely swollen and has petechial haemorrahges. See images
However good news. Went home.

Hb 11.6 (12-18)
RBC  4.9  (5.5-8.5)
Platelets 11 (200-500)
PCV 0.34 (0.37-0.55)
Total WCC  127 (6-17)
N=95%
L=5%
M=0.5%
E=0.3%
B=0%
Blood cells show degenerative changes ? age/transport. Several abnormal cells seen. No platelet clumps seen.

NOTES: Actually degenerative cells due to toxins of bacterial infection in the uterus.
Compare to chihuahua with open pyometra
Abnormal

SGOT/AST 117 (<81)
Urea 36 (4.2-6.3)
Creatinine 174 (89-177) - normal
No X-ray though advised.








Chihuahua. Consulted vet early when dog was not eating and was lethargic but discharge of pus from vagina for around 10 days.
Goes home 3 days after surgery as she was more alert than the CKC, growling all the time.

X-ray showed enlarged uterus (arrows compared to image of uterus) but some vets may not agree with me.

Hb 17 (12-18)
RBC 7.2 (5.5-8.5)
Platelets 208 (200-500)
PCV 0.49 (0.37-0.55)
Total WCC 6.2 (6-17) N=75%
L=10%
M=13%
E=0.3%
B=1.2%

Abnormal
SGOT/AST  115 (<81)
Urea 3.7 (4.2-6.3)
Creatinine 53 (89-177)

1083. The internet connections open the door....

"I went to the internet and typed "Singapore Vets," the gentleman told me yesterday, July 18, 2012 as he and his wife came to take the chihuahua home at 4 pm. "I skipped church as I saw that my dog did not want to eat her breakfast and was sleepy. The internet showed Toa Payoh Vets being open on Sundays and the opening hours and so I came to your surgery. Normally my wife goes to another vet in Ang Mo Kio but she was overseas on that Sunday." 

I told them that the dog was operated by Dr Daniel Sing who had not minded discharging the dog after surgery. But I had intervened and strongly advised the gentleman to hospitalise her for 3 days as pyometra is a serious illness and the daily temperature needed to be monitored at Toa Payoh Vets. There could be stitch breakdown due to the dog jumping at home and unhappiness in having to re-stitch. At least 2 days of hospitalisation and also not to wait till the wife return from the UK to see the dog before surgery as pyometra is life-threatening. I advised that the dog returned home when the wife came back from overseas and this meant 3 days of hospitalisation which was good for this fierce chihuahua who growls whenever she sees me. She remembered me palpating her swollen abdomen for the enlarged uterus to confirm pyometra (without X-ray or blood test if the owner didn't want the tests). It caused her pain and she never forgave me.

The dog was visited by the family including the adult daughter and her friend during the past 3 days.

The wife has her favourite vet and so this would be the last time I see the dog as the wife is the one in charge of the chihuahua's health.

The internet has opened the door for Dr Daniel Sing to gain a new client. Can he retain the loyalty of the client? A good surgical outcome helps but there is more to make the connections with a new client.

As for me, I have made the connections because the wife asked for my name and then for my name card. Dr Daniel was in Bangkok at this time, otherwise he would be present.

The internet connects open the door. Will Dr Daniel be able to connect with this new client? The veterinary professors have not taught him how to do it as this is not their main job.

1082. Connect with the client - The Power of Prayer

I have no doubt that the story as narrated by a friend I have known for over 30 years is true though I did not witness it. So I advised Dr Daniel to communicate with him by talking about the "power of prayer". But he did do it.

The story was that one day, a New Zealander couple came to this friend's cafe for breakfast. The husband was in a wheel chair and had been paralysed a long time. So he would use the stick to get up and hopped with his wife's support. My friend asked permission to pray for the husband's recovery. Permission was granted. At the end of the prayer, the husband stood up and then threw away his stick as he could walk normally. I guessed Dr Daniel found it hard to believe in the power of prayer and did not mention this to my friend who had brought in a Golden Retriever with muzzle inflammation for treatment. This dog was seen twice by Vet 1 near his place but had not responded. He wanted a second opinion.

I asked Dr Daniel to follow up 3 days after our treatment. It is always excellent service to follow up. He phoned but there was no response. My friend phoned me later and said: "I can see some hairs growing in the muzzle skin. I guess it is recovering."

So I told Dr Daniel. "Do you think it is the power of prayer?" I asked him. I doubt that my friend prayed for the dog to recover in this case and I did not ask him as it sounds too frivolous. Dr Daniel still would not believe in the New Zealander story. "Well, you connect to a client not just on dog skin disease," I said. "It is on topics that interest him. By the way, he narrated another episode of healing. A woman was paralysed and could not even walk. She recovered after he prayed for her..."  Dr Daniel rolled his eyes and would not talk further.

1082. Update: Imizole was effective against Babesia gibsoni in this stray dog

SUNDAY'S INTERESTING CASES Oct 30, 2011 On Friday, Oct 28, 2011, I got a text message from a young lady caring for a Singapore Rescue Group's stray dog with tick fever diagnosed by Vet 1 consulted by the Group. According to her, Vet 1 said that the imizole commonly used for treatment of tick fever would be ineffective as this dog had Babesia gibsoni. As imizole is "ineffective" against Babesia gibsoni, Vet 1 wanted to use the "3 effective" drugs atovaquone, clindamycine and azithromycin. However, it would cost the Rescue Group $1,000. Berenil was cheaper but might cause anaphylaxic shock and in any case there was no stock at that time.   The Rescue Group asked her to top up the bill but she did not have the means to do so. So, she texted me for advice and alternative options. Below are my replies to her. It is kind of you to do dog rescue work. There are many financial considerations. Combination of atovaquone, clindamycine and azithromycin by (required by Vet 1) as said by you, is claimed by Vet 1 to be effective against Babesia gibsoni infections in this dog. Vet 1 had said that imizole is ineffective against Babesia gibsoni. I will not comment further as I don't use these expensive drugs. Success rate depends on follow up, not just one injection. Blood transfusion 1.5 bags at $500/bag and hospitalisation will be more than $600 budget from the Rescue group. Berenil is cheap but anaphylaxis according to your text. Hb at 5 is low for your affected dog, but you also need to know total RBC. In conclusion, anti-tick fever treatment is not cheap due to prolonged treatment and follow ups. E-MAIL TO DR SING DATED Oct 29 (2 days ago) Thank you very much Dr Sing. I am heading out to check on the dog this morning. If the rescue doesn't want to pay for treatment, I think I will bring the dog home to die as she doesn't like the cage... Thanks again. Will email u soon. Name given COMMENTS The dog was sent home without the expensive treatment or imizole. The lady activist thought that the dog was "alone" at the vet clinic and she would take the dog home to die. Berenil would be available possibly 2 days later. Coincidentally, I was following up on an English cocker spaniel, 11.5 kg with Babesia gibsoni and Ehrlichia tick fever 10 days ago. A Cocker Spaniel has tick fever in 2011 is the case report.  Day 1 to Day 5 of tick fever She came today (Sunday Oct 30, 2011) for her 2nd imizole injection (0.6 ml SC today) 10 days after the first injection (0.5 ml SC). Based on her active normal behaviour and much pinker gums, the first imizole injection had worked. Otherwise she should be dead by now. So, should Vet 1 have given imizole to that stray dog rather than wait for the cheaper Berenil to be available later? Is imizole totally ineffective against Babesia gibsoni? I related the story of the stray dog with tick fever to the cocker spaniel and she was worried that I had not given the correct treatment. Day 1 --->   Day 4 & 5 --->   Day 4 & 5 ---> Day 4 & 5 ---> Day 10 ---> "Will you dog be active and rushing out to play and have pink gums 10 days after the first injection if imizole was ineffective?" I asked her as I gave the 2nd injection today. As the dog still had ticks attached to her head and spinal area, I asked: "Does your dog go under the bed?". She said "Yes, my dog likes to sleep under the bed." I said: "Ticks may be present on the under part of the bed and attaches to the dog. Advantix should work as this spot-on was given 10 days ago when the dog came in. Give another dose in 4 days." I wanted to prescribe the anti-tick wash but did not as I asked her to use the Advantix and the dog had not many ticks.  My thoughts on this fine Sunday morning were for that stray dog and the caregiver who was a student. The young Singaporeans prefer to text and on Saturday, Oct 29, 2011, 2.53 pm,  I got the following: "Dr Sing, I brought the dog home as they could not do anything for her. Rescue opted to try Berenil but can't get for a few days so we are waiting. She is very weak. I think she may be dying. How much is one shot of imizole? Do u think it is worth a try? If not too expensive, I don't mind trying myself. What else can we do for her in the meantime?   I phoned her on Saturday and told her to bring the dog for the imizole injection on Saturday at 9.30 am. But she said that the transport was not available. In any case, the Berenil may be available on Monday and the dog was still alive.  So I hope that this dog had the Berenil treatment soon.  As for the English Cocker Spaniel, as at Nov 3, 2011, the dog is normal. "Except that she tires easily," the owner said to me. She submitted a urine sample for testing. The values were normal. The urine SG was high, at 1.041 (range should be 1.005 -1.030), pH was 7.0 and struvite crystals were present. "Could it be the high liver I am feeding?" the lady asked me. "Should I stop feeding the liver?" She was also feeding iron supplements and all the good home-cooked food. "Since your dog tires easily, she has not fully recovered her normal red cell amount," I said. "The high urine SG is unusual. It shows that the kidneys can concentrate the urine well but what causes it is hard to say."  I may need to have another urine test 2 weeks later.  Nov 3, 2011, as I update this report, I had been thinking about the high urine SG. My hypothesis is that the destruction of so many red and white blood cells damaged by the Babesia and Ehrlichia organisms during the past 14 days would have contributed to a large amount of protein damage for the past few days. The kidneys are normal and have to work hard to excrete the urea. This resulted in a high urine SG. There may be a high blood urea but I did not take a blood sample when the urine sample was sent. Since the kidneys and bladder were normal, there was no proteinuria during urinalysis. Is this hypothesis sound? These are the types of questions the professor may ask in a case study during the final exam of the 5th year vet student. I remembered my "viva" or "oral exam" on a case study during my final year by my Professor of Vet Medicine and an external examiner and I presume Murdoch vet students still get this oral test. A reply or hypothesis may not be possible for a vet student so much burdened with 5 years of vet knowledge memorised to pass the Final examination in November 2011 if the Professor of Vet Medicine asked about the high SG during the oral test!    Earlier report: A Cocker Spaniel has tick fever in 2011 or http://www.sinpets.com/dogs/20111039tick-fever-cocker-spaniel-singapore-toapayohvets.htm      Update on animal activist's help of a tick fever rescue dog The Rescue Group's vet had said that imizole would not be effective against Babesia gibsoni and advised a triple-drug combination costing $1,000. The rescue group wanted this activist to pay $600 to top up the $600 budget from the rescue group. The activist sought my advice by text and there was some delays as the Rescue Group's vet said that Berenil would be available as a cheap alternative in a few days' time. So the activist waited. But no Berenil. The activist was pro-active and posted online for help. A donor responded and would pay for treatment by the donor's vet. It seems that this rescue dog will survive the tick fever and that is good news for her and for anyone. The following is her reply to my follow-up on her rescue dog's status E-MAIL TO DR SING DATED NOV 2, 2011 ...@hotmail.com> Hi, Its been a busy few days. The Berenil is discontinued in Singapore already, and the rescue people told me I have to pay myself or let her die. We brought her home on Saturday and on Sunday she was having difficulty breathing and could not stand up. I posted her pictures online and a very kind stranger offered to pay for her treatment on the condition that we go to her vet. ... is being treated at (Name of vet practice given) as requested by the donor. Her red count had dropped even further, and her platelets dropped to only 12. She stayed there for 2 nights and they gave her lots of supportive fluid therapy, erythropoietin and used steroids to stop the hemolysis. She perked up very well and is now resting at home. We will repeat her blood count on Friday and give her Imizole on Saturday if all goes well. For now she is on pred, metronidazole, Doxycycline and some other supplements. I was also force-feeding her Hill's a/d several times a day. As of this morning she was willingly eating herself! I think things are looking up and Dr ... thinks she will survive. I hope the Imizole works to cure the infection. I'm sorry we were not able to take her to you. I have great faith in your clinic, but unfortunately the money is not mine! :( Thank you so much for your concern, you are very kind.. Btw, she's not my dog! We are just fostering her and hopefully will find her a home. Smile, Name E-MAIL REPLY FROM DR SING DATED NOV 3, 2011 I thank you for being proactive in helping the stray dog. The vet is doing a great job and I am quite sure imizole will be effective. Best wishes. UPDATE ON JULY 18, 2012 I met the young undergraduate activist in May 2012. The above-mentioned stray dog was treated by the sponsored vet and is well. Based on this anecdote, imizole was effective against Babesia gibsoni infections in a stray dog. Updates will be at webpage: http://www.sinpets.com/dogs/20111036babesia-gibsoni-treatment-drug-imizole-success-singapore-toapayohvets.htm

1081. Tick fever in a great dane, cocker spaniel and a samoyed video production

July 18, 2012  5.15 am

I am trying to get an educational video produced high-lighting the diagnosis and treatment on the 3 cases of tick fever in Singapore,

for the vet students studying hard in their little rooms. The cases are at:
http://www.asiahomes.com/army/2010067tick_control_bites_infestation-parasites-dogs-singapore-ToaPayohVets.htm

A lot of time is needed to summarise and compare the significant points of the 3 cases

1080. Veterinary leadership

Managing a practice seems easy to the outsider. I have 3 associate vets. I can sleep late and come to office whenever I wish. This is the wrong perception of outsiders. This is because employees start to slacken as the boss is seldom around. If the boss does not bother or become a womaniser as in some successful employment agencies I know, the whole business goes down the drain.

From Monday to Friday and some Saturdays, I leave home at 7.30 am, take a feeder bus to the subway, then another feeder bus or walk to Toa Payoh Vets.  On weekends and public holidays, I drive and reach the surgery before 9 am.

GETTING FEEDBACK ON SERVICES
1. I man the phone calls in the morning and get complaints or feedback on services provided by associate vets. It is better to receive negative feedback so that we can improve. One of them is long waiting time, as long as two hours in one case. I had spoken to my associate that waiting time should be less than 15 minutes in general.

2. Coming back for stitch removal after spay or neuter. I told my associate vets that this need to return must be stopped as we use dissolvable stitches. I don't ask the patients to come back in 10-14 days after surgery but my associates do. So, there is an inconsistency in services from the same company.

3. No offer of chair for client during one-on-one consultation. I simply grab a chair for the client when I see my associate vet not doing this despite my advice. Mindsets of the young ones are hard to change as they are brought up in a different affluent culture. But excellent services retains customers and the associate vets should be aware of this. We get more new customers but where are the old ones?" I asked them