Monday, October 8, 2012

1130. Urban stress & barking dogs

On Saturday, Oct 6, 2012, I was having a business meeting with a 62-year-old slim man who was introduced to me by an old acquaintance realtor. This businessman had this offer of a S$150,000 rental commission per year from an oil rig company sending expatriates to Singapore. As he is not a licensed Singapore realtor, he could not handle this "lucrative" account. S$150,000 is a large source of revenue for a small-time realty.

My acquaintance said I needed only to pay 15% of the commissions to this man and to house the expats in serviced apartments. I agreed to meet him.   

During the meeting, he said the 15% would go to the American who would give him the exclusive deal. "I will get 40% of the commissions from you," he said. "This is a $150,000 yearly income. Both sides will sign an agreement to pay a penalty of 10% if they don't fulfill their obligations. However, you and I have to pay this American $6,000 upfront, otherwise, he will not give us the deal. You foot $3,000. This $3,000 is deductable from the 15% of the commissions you get. I give you 2 days to consider before I contact my other agents."

So, I was to pay $3,000 to somebody I don't know. I have to pay this American 15% and then 40% of the commissions to this broker. The expat arrivals would live in long term housing which means I have to co-broke with other agents at 50:50.

Assuming $150,000 commissions per year and 2/3 of it is due to co-broking as the other agent represents the Landlord. The gross income from co-broking will be 50:50 and this equals to 2/3x$150,000/2 = $100,000. 50% is given to the co-broker. So, the balance will be $50,000 for me. 15% goes to the American. The balance for me is $42,500. 40% goes to this man. I get $25,500.

Assume 1/3 of $150,000 is full commission to me.  Following the above formula, I get $25,500. The estimated income per year is $50,000. This assumes that there is $150,000 worth of business. I would have to provide 24-hour services to pick up the expat on arrival in Singapore at any hour of the day and give advices on education and provide after-sales services.

The man gets $50,000 for introducing this expat to me. He wants the $3,000 upfront and 2 days to decide.

Suddenly a thin balding man with a worried look passed by.  I knew him as an industrial park tenant and as a Landlord of a cluster bungalow in Punggol for many years. He had come to my Surgery 3 weeks ago to complain that the dogs were barking and depriving him of sleep. Now he brought up the same topic that I was not feeding the dogs and that was why they barked all day long.

"Please have a seat," I said to him. He did not want to sit.
"Why are you confrontational?" I asked him. "You came suddenly to complain about the dogs barking as they did not get fed some 3 weeks ago. I invited you into my Surgery to see the dogs. You saw the feed bowls were filled with dog food. Water bowls were full. "
"Your dogs are still barking today. They are not fed."
I was patient with him as I understood he had some loss in his business in this extremely competitive world where China is the world's factory, leaving little for the small-time businessman or manufacturer.
    

Wednesday, October 3, 2012

1129. A schwanoma in a dwarf hamster?

"Why didn't you see such a large tumour on the hamster's hand?" I asked the mother who brought it in for surgery and hoped that it would not die under anaesthesia as the one.
"Usually he hides inside the litter and eat and so we didn't see it."

Big tumours in the hand or leg may be inoperable. The whole paw will then need to be amputated. Front paws are like our hands and are very important for the hamster.

"What is your surgical approach to this case?" I asked Dr Daniel.
"Amputate the paw," he replied.
"That's what I thought at first," I asked him to hold the gentle 18-month-old dwarf hamster for me to take digital images of various positions of the hand tumour. The hamster was put in a bowl and we observed him climbing out of the bowl.

The tumour was gigantic. Imagine your hand having the biggest durian growing out of it.
"It is possible to excise the tumour without amputation," I said to Dr Daniel. "But the vet needs to produce a live hamster at the end of the surgery. To succeed, the surgery must be short and the anaesthesia must be sufficient to prevent pain. Severe pain may kill the hamster as in the bird."



No point doing an excellent surgery and showing a dead hamster on the operating table. "Isoflurane gas anaesthesia is too short and too risky if prolonged," I said to Dr Daniel. "I will use Zoletil  50 IM."

In a cat and dog, IM injections are common and routine. In a dwarf hamster, the needle must be just into the thin backside muscle. Not much of the muscles. Dr Daniel held the hamster while I injected 0.02 ml Zoletil 50 diluted with 0.03 ml saline and injected IM.

"The hamster will become groggy if the IM injection is given correctly," I said. In 60 seconds, the hamster stumbled. Dr Daniel operated. "Give isoflurane gas top up when the hamster moves," I said. "Otherwise he may die from fright and severe pain." The whole procedure took less than one minute.

"Should more tumour tissues be cut off," Dr Daniel asked. "No," I said. "The area is down to the bone and tendons. Any further incision will damage the superficial flexor tendons and the hamster will not be able to hold his seeds and grains with the right hand."








The hamster appeared groggly during the first hour after anaesthesia and this is a common observation. The mother was very happy to see him alive as her son was the one most concerned. Produce good anaesthetic outcome and you get more referrals. It is extremely risky to anaesthesia hamsters for long surgeries as they don't survive. Be observant and be careful.

The owner did not want histopathology as it would cost money. It was a firm white tumour. Could it be a schwannoma? A nerve sheath tumour?  Examine your hamster daily and get small tumours excised by your vet early. Tumours don't disappear with antibiotics and so, find a vet who operates on hamsters.

I saw another case of a lady who brought in a hamster saying there was a small lump on the belly area. This hamster had been licking bald the lower part of the belly, below the navel. I held the hamster and felt the nodule which was around 2 mm in diameter. The hamster squealed. However, the owner's preferred vet could not feel any nodule and so sent the hamster home with oral medication and asked to review it in 2 weeks' time. Owners know their hamsters best and if they find a nodule, it is usually there.   

More pic at
 http://www.sinpets.com/hamsters/20121005dwarf_hamster_hand_tumour_toapayohvets.htm

1128. A guinea pig drools for weeks and loses weight

The young couple's guinea pig kept losing weight and kept drooling despite treatments and 5 X-rays in a veterinary practice. "What is the cause?" the wife asked. "I hand feed the critical care but she loses weight to 370 g. She had given birth to two litters and her offspring is 800 g. She would be interested in food but wouldn't eat it."

This is a very complex and emotional situation for the wife. What more could be done? They consulted me for a 2nd opinion. I said: "Anaesthesia is necessary to examine the mouth properly." But the guinea pig is so weak and so thin. So the wife deferred any such examination and went home 2 days ago. I asked her to get all the medical records from the other vet who was most helpful. Today, she came with her husband at 2pm sharp. I reviewed the records. "Very good records," I said. "Dr X is a very good vet," the husband replied. "But she just can't put her finger on what causes this drooling."

There were 5 x-rays. Only one showed the head. "There seemed to be a curved "tooth" coming from the hard palate to the floor of the mouth," I said to the other vet. She looked at her X-ray copy simultaneously and said it could be the maxilla. In any case, I advised another X-ray of the side and bottom top view of the skull and also the chest and abdomen. I told her I do not have X-ray facilities and she was happy to help out.

The couple went there and then phoned me to say they would not want any anaesthesia to open the mouth for examination today. They would go home to feed the guinea pig. I said it was OK with me.

This guinea pig had drooling, slobbering (wet chin), runny nose, loss of weight, not able to eat. These are signs of dental problems in the guinea pig. So, what is the cause of the dental problem? Malocclusion? Another "entrapment of the tongue" by the arching cheek teeth? Protrusions of the cheek teeth not obvious?

This is a complete mystery till I see the X-rays tomorrow. As the X-ray did not require anaesthesia, the couple was happy. Still, the mouth cannot be examined properly just by opening it. It needs anaesthesia. But the risk is so high. So, we are back to square one.

NOTES
1. Dental disease. Runny eyes, runny nose, drooling, teeth grinding, selective eating, not eating, weight loss, slobbering.

2.  Guinea pig may not have the palpable protrusions at the ventral aspects of the mandible or at the lateral aspects of the maxilla as in the rabbit or chinchilla. Therefore, it may be hard to detect malocclusion.

3. GP + chinchilla
2(I1/1, C0/0, PM 1/1, M3/3) = 20 teeth.

Rabbit has I2/1 in case you don't know. It has 4 obvious front teeth and 2 more shorter and smaller upper front teeth behind the front teeth!  

1127. Follow up: 3rd sister and 13-year-old X with 3 bladder stones

Oct 2, 2012, a Tuesday. I took time off and went to Khin Khin Employment Agency at Peninsula Plaza to teach her manager more about the management of the business. The Government had increased increased the foreign worker quota and clamped down on phantom workers.

Now, a company must employ 5 Singaporeans before it can employ 1 foreign worker instead of 4 to 1. In addition, many companies have been fined for using "phantom workers" who are mainly retirees and others not gainfully employed by the company to make up the 4 Singaporeans to get approval for 1 foreign worker.

After the elections in which foreign workers were said to depress wages of Singaporeans, the foreign worker quota is raised and the foreign worker levy on employer is increased.   "Many of the retirees are now out of CPF contributions since they were phantom workers," I observed.

The euro crisis and economic recession reduced the demand for foreign workers. Some have to be sent home due to the increased quota and loss of phantom workers. So Khin Khin and other employment agencies find that they have little demand for their services from the small businesses looking for waitresses and drivers. No quota at all. Close shop or do other services.

As Khin Khin is in Yangon, I dropped in to check on her manager Ni Ni. He had been working 6 months on the S Pass and is supporting his wife and son in Yangon.

Suddenly a young lady in her late 20s and wearing greyish dental braces appeared at the door. Khin Khin's office door does not shut unlike other offices. She came closer and said to me: "Have I seen you somewhere before?" I was astonished. I could not recall. I did see her somewhere. "Are you Dr Sing?" she asked. "Yes," I said.
"Do you remember my dog Brandy?"
 "Yes," I said. "The 13-year-old cross bred with three bladder stones.
What a coincidence. I phoned her earlier to tell enquire about her dog's urination situation. The dog was OK but not eating the S/D.

I did advise neutering to reduce the enlarged and inflammed prostate to be done on Monday. But it is Wednesday today. The dog was no longer painful in the prostate when I discharged it 3 days ago but it was very painful when I took over the case. An enlarged painful prostate with bacteria in the bladder can cause painful and difficult urination, other than the 3 bladder stones. But it is hard to explain to the 3 sisters. After all, the dog is peeing normally. Owner compliance is much more difficult.

I did not remove the bladder stones because this dog was so skinny and might die under anaesthesia. Neutering is a short surgery and so I advised it to prevent prostate enlargement and inflammation. But it is extremely difficult to convince the owner to do it and this is a common situation in all medical practices.

Monday, October 1, 2012

1126. Audit - intestinal surgery - removal of foreign body

Every vet at Toa Payoh Vets is required to maintain a proper record of anaesthesia and surgery in a book dedicated to each vet. I audit some cases now and then.  This case is interesting as it has been performed in a short time, using only domitor and ketamine, without isoflurane gas.

AUDIT OF ANAESTHESIA & SURGERY BY ASSOCIATE VET
Bichon, Male, 3 months
Vomiting over 5 days
Ate prayer food

Hard lump 3x2x2 cm in large intestine. Painful

ANAESTHESIA
Sep 30, 2012 (Sunday) 1.8 kg 3 months

Dom/Ket  0.07/0.09
50% given  0.04/0.05 IV

A: Injection D+K IV   3.47 pm
D: First skin incision   3.56 pm
E: Completion of skin stitching  4.11 pm
No isoflurane gas used for enterotomy

E-A  = 24 min
E-D  = 5 min

SURGERY
Around 3 cm incision. Big greenish hairy hard lump taken out.
"Apricot seed," my vet said.
3/0 monosyn appositional stitches.
I saw the intestinal wall as over 4 mm in width. Blackish edge over red inflamed patch where hard Foreign Body was lodged. Gangrene had set in. That was why dog was vomiting.
Vet has 3 years of experience. A good surgery done.

No blood test and no x-ray due to financial reasons. The owner decided on surgery on Friday evening but I advised the associate vet to wait 2 more days to strengthen the health (vomiting for past 5 days due to financial reasons, not seeking vet treatment). On Sunday afternoon, this dog was operated and today, he looks as good as gold.
Day 2  Oct 1, 2012  11.32 am, I checked the dog and took some pictures. Active. Disliked e-collar.

Sunday, September 30, 2012

1125. Sunday's interesting cases - Sep 30, 2012

Sep 30, 2012

Bright sunny day
Case 1. Red-eared slider with "smaller and sunken" left eye. The husband and wife came for a review. "How many turtles have you treated?" she asked me.

"Around seven cases last year," I said. "Singaporeans seldom keep turtles to an older age like yours and there are not many."  Maybe Toa Payoh Vets get less turtle cases. Who knows?

"They release the turtles to the reservoirs," the slim wife with dark rimmed glasses said. "What type of cases you see?"

"Mostly eye problems like closed eyes. Rectal prolapse, cracked shells and not eating."

2 days ago, the husband brought the turtle for consultation as he observed the left eye sunken and smaller than the right eye. He is an observant man as his wife did not know any eye change.

I could see the haziness in the upper part of the cornea of the smaller left eye and took some images to document corneal ulceration (green flurosecein stain). Dr Daniel gave an IM injection in the back thigh muscle of an anti-inflam and antibiotics.

I advised cleaning up the turtle as it smelled fishy, giving eyedrops 3x/day and not letting the eye get wet unless eating time. After eating, wash the eye with boiled water. "Or tap water left overnight as there is chlorine in the water and that will evaporate overnight," I said.
However the husband said: "The tap water has only fluoride, not chlorine." I can't substantiate this and so said nothing.

Today, the husband was to bring the turtle for review and he did so. The turtle's left eye looked so much clearer. It is still sunken but lesser. How to prove it? It was difficult as the turtle did not permit me to take image head-on of both eyes on the reception counter. He was restless and moving. "Do it inside the consultation room after switching off the lights, as before," the husband advised. "Use ISO 3200."

"The images are not so good compared to natural light in the waiting room," I said. "I used ISO 6400 the last time." As I did not want to upset the owner, I took images inside the darkened consultation room. The turtle was calmer. The cornea looked much more transparent esp. in the 11 to 2 o'clock area where there was cloudiness 2 days ago.
Case 2.
 Shih Tzu, 1 year old, with red ear lumps in both ears but the lady in her 40s said that there was no scratching. The right ear was more painful when I palpated the vertical canal and the dog cried.
She had seen my associate vet for the past 3 times with the same problems. Antibiotics, injection and ear flushing again.
"I had spent much money in the eye ulceration treatment last time," she said to me when I advised lateral ear resection surgery. Now she trimmed the hairs around the eyes and put eye drops daily. No more eye ulcerations but this ear inflammation and pus could not be resolved since Jan 2012.
"It is usually the money matters," I said. "Ear surgery is the solution to open up the vertical canal to enable the horizontal canal to be ventilated and drained as the shih tzu's floppy ears covered up the canals 24 hours/day. But most owners will not accept the surgery due to its costs."

"How much?" she asked.
"I estimate $500 for one ear, including nursing care for around 7 days post surgery. It is just an estimate."
Now she had seen my associate vet 4 times and tried to clean the ears and give medication. The total costs and her time would be $600.
"It is just the luck of the owner," I said. "Some families have children with health problems and incur lots of medical expenses. I just have a case of a Shih Tzu dog owner who spent over $8,000 just for 5 bladder stones removal in the dog. Other Shih Tzu owners have no need to spend a cent."

Case 3.
An apricot seed inside the large intestine of the Maltese. I came back to the surgery at 3.30 pm to check whether my associate vet had operated on this Maltese. The owner had delayed operation but the dog kept vomiting and she decided on the operation on Friday. I advised against immediate operation for expediency as Saturday was the day off for my associate vet. The dog needed the IV drip and antibiotics to recover. Today, Sunday, the dog was in much better health but still vomited. My associate vet took out the apricot seed, put in interrupted appositional stitches to close up the wound. The large intestines were inflamed to 6 mm in depth of mucosa and serosa. The dog was alert and well after surgery. That was good.  
Case 4
The old Minature Schnauzer with the bloated stomach of closed pyometra came back for stitch removal as required by Dr Vanessaa. I asked Dr Daniel to remove the stitches. The pyometra surgery was done on 31 August. None of the nylon stitches were present now as it is past one month since surgery. This dog had pus in the hairy ears and dry skin problems in the forearm and body. At least she did survive the surgery as I thought the pyometra would burst if you see the images in my case studies.  



"Today, there is a white spot in the left eye," the wife said.

1124. Cost, Duration & Complications of spaying a 3-year-old jack russell query

 
 
On Sun, Sep 30, 2012 at 2:39 PM, ...1989@hotmail.com> wrote:
Hi,

I have a female jack russell coming 36 months but has yet to be spay.. Can i knw if there're any complications doing this procedure at this age? And roughly the duration and cost of it? Kindly advise, thank you.

Cheers,
J Y
 
 
 
EMAIL REPLY FROM DR SING DATED SEP 30, 2012 
 
Thank you for your email. I am Dr Sing K Y from Toa Payoh Vets.

Generally, all healthy female dogs at around 36 months of age will have no complications during or after spay.
Complications refer to anaesthetic deaths, post-op deaths, bleeding and infections. The duration of spay should be less than 30 minutes and the estimated total cost is around $250-350 at Toa Payoh Vets ( including anaesthesia, surgery, post-op injections and medication and e-collar). Pl make an appointment at 6254 3326 one day in advance.

The best time to spay is 2-3 months after the last heat (bleeding)