1374. Yangon veterinary talk to vets - July 5, 2014. Pyometra & Uroliths (treatment & prevention)

Veterinary Articles for a video production for presentation to vets in Yangon on July 5, 2014:


Treatment & Prevention

1. Calcium oxalate to struvite stones
http://www.sinpets.com/dogs/20120218recurrent-urolithiasis-urinary-stones-calcium-oxalate-struvites-toa-payoh-vets_Singapore_ToaPayohVets.htm



2. How to create a compelling educational video
http://www.youtube.com/watch?v=xAlGLSCFfuI&feature=youtu.be





3. How I suture the bladder in 2 layers after stone removal - Images of a case
http://www.toapayohvets.com/surgery/20080818Shih_Tzu_Urolith_Dysuria_ToaPayohVets.htm

2007 Case. Dysuria (difficulty in peeing)
Shih Tzu, Female, 5 years. Peeing a bit here
and there many times a day for many months

Middle-aged and older dogs are seldom given much attention by many owners all over the world, unlike puppies. Such dogs don't live long lives if their sickness is not treated.  After many months of painful urination, the owner consulted me. I palpated a large bladder stone and advised surgery after 10 days of antibiotics. The owner forgot about the surgery and the difficulty in urination problem recurred. Surgery was inevitable to resolve the problem. But was it too late and would the old dog survive the anaesthesia and not die on the operating table or after surgery? The owner understood the risk. The dog was alive after the surgery. The pictures of the surgery are shown below.
I prefer to incise the ventral wall of the bladder and find no problem of "the heavy weight of the internal organs pressing down on the bladder" and therefore adversely affecting the healing.	Thick and reddish bladder wall of nearly 5 mm in thickness indicates that the bladder infection has gone on for many years. Some dogs die as bacterial infection spreads to the kidneys and into the blood.	The submucosa of the bladder is stitched with an inverting suture pattern.
2nd layer of inverting suture is now placed. Forceps on the left anchors the knot of the first layer. No omental fat layer is sutured onto the suture line although some vets do it. CASE 4 POOR VETERINARY WORK - Some vets, not only in Singapore but elsewhere consider urine analysis unnecessary as in this case   2010 Case. Dysuria (difficulty in peeing)  at the end stage of urination Feb 26, 2010.  At 13 years of age, he just had dental scaling at another vet practice. The vet had performed 2 blood tests 3 weeks apart and this indicated excellent health. Then the owner consulted another practice (Vet 1) as the dog took a long time to pee at the end part of urination. Vet 1 advised surgery. The owner phoned me for advice after Vet 1 had been consulted. I had not seen the case and I asked "Was the dog's urine analysed?  Struvite urinary stones, if small, may be dissolved by the acidification of urine."  The young lady owner said, "No." Later, she told me that Vet 1 considered urinalysis unnecessary.     I saw the case and got the owner's permission to do a urine analysis. The urine pH was 6.5 and there were no crystals in the urine on urinalysis. So, these tests indicated that the urinary stones might not be struvites and therefore acidification of the urine would not be effective. Surgical removal, as advised by Vet 1 was my recommendation. But will the dog that growled at me,  die on the operating table as he was so old?    ---------------------------------------------- THERE ARE OWNERS WHO DO NOT WANT SURGERY TO REMOVE BLADDER STONES  Case 1: 2010 - The Shih Tzu keeps passing blood in the urine every day X-rays and blood tests would be best but sometimes it is not possible due to economic reasons. The vet has to be compassionate when the owner request least-cost surgery. However the diagnosis must be spot-on and the surgery must be planned to ensure survival of a dog during anaesthesia.   "Your Shih Tzu needs an operation to remove the big bladder stone I felt," I advised the young man whose female dog passes blood in the urine for the past 2 months. I could feel the creptitus (gas-like feeling) in the bladder. But the owner did not want an X-ray nor surgery. He wanted drugs. One month later, his dog had not stopped passing red blood. He requested surgery, but no blood tests or X-rays. I was OK with this request. "It is an open-and-shut case," I thought when I saw one stone coming out. "This was the big stone I had palpated. Stitch up the bladder and go home. Another big stone was stuck partially in the urethra as my catheter could not pass through. What to do? The stone was stuck fast. Finally the forceps managed to grip one end and pull it out  Smaller stones spilled out like small bombs when the bladder was flushed. Catheter was earlier passed out via the vagina No more urinary stones after irrigation of the bladder   Day 3 after surgery. There has been difficulty in passing urine but the dog eats and has no fever. Antibiotics and pain-killers are given. I phone the owner that the dog can't go back today Sep 6, 2010 as the dog has dysuria. REFERENCES http://www.cvm.umn.edu/depts/minnesotaurolithcenter/   RECOMMENDATIONS ON TYPES OF STONES http://www.cvm.umn.edu/depts/minnesotaurolithcenter/recommendations/home.html	Dog warded 3 days for observation. Goes home. No complaint about difficulty in urination for the next 18 months.	The gentleman owner was not interested in follow up health checks and urine testing. Urinary stone (right) is from the bladder of this Shih Tzu. The two stones (left) are from another dog.

A drooling Chinchilla - anaesthesia

June 9, 2014
Case study on the effects of an injectable anaesthesia on a chinchilla

TP 43843
Chinchilla, Female, 1 year 10 months, 350 g.

"She has wet mouth since March," the owner said. "I thought she was suckling the kid she just gave birth to. But it is now Jun 5 and the mouth is still wet!"

"Your rabbit is drooling," I said. "Usually the cause is sharp molar teeth or mis-aligned front teeth."
It is hard to check the molars as the chinchilla would run back into the cage after grabbing the food pellet given by the owner to entice her to come out.

XYLAZINE & KETAMINE SEDATION
Formula for rabbit applied to chinchilla
Xylazine 20 + Ketamine 100 at 0.25ml/kg + 0.35 ml/kg IM

At 350 g, X=0.08 ml + K=0.12 ml IM
At 50% dosage, I gave X=0.04 + K=0.06 ml IM in one syringe.

FOLLOW UP WITH OWNER on MONDAY JUNE 9, 2014

End of January- Gave birth. One kid, still alive.
Beginning of March - mouth wet. Owner thought she was producing milk and milk had overflowed onto the mouth area. The Chinchilla stopped gnawing the apple stick after giving birth.

Friday Jun 5, 2014. Injection of X + K given at 50% calculated dose IM
Lower molar spurs laterally (image and video), on both mandibles clipped. Maxillary molars worn out, no spurs. Went home recumbent with shallow chest movements. She took 2-3 hours to wake up and was very tired till Sunday Jun 7, 2014.

Saturday Jun 6, 2014. 6 pm. Ate "pellets softened with water."
Started to eat hard pellets on Sunday.

Drooling much less. "A lot better," said the owner today Monday Jun 9, 2014.

Apple stick gnawing is now not favoured by this Chinchilla. So molar spurs may return.

1372. Optional tour - volcano & hot springs

It is up to the tour manager to market the volcano tour as the agency did not help him. In the agency brochure, there is only one sentence: "Suggested optional: Volcano boat tour".   No more information. So, some think that there are poisonous hydrogen sulphide acid and gas spurting out from the volcano, risking their health. I did not hear the manager giving a briefing and he might have done so.

The volcano is dormant. There is also the visit to the "Hot Spring" and a swim towards it.

I decided to go to this tour at the last minute and asked the manager to arrange it. Outside the booking booth, the advert said: "15 Euros".  There was some pricing exclamation from some members of the tour group.
"How much did you pay?" I asked Jamie.
"55 Euros," she said. "Are you going to pay the manager?"
It was a savings of 40 Euros apparently. As the tour manager was with us on the tour taking care of us, I should not begrudge him his commissions as he does not get much from his agency, esp. if he is a freelancer.

1371. Anaesthetic challenge. Leg amputation in a dwarf hamster

A dragging fractured hind limb is usually not tolerated by an active dwarf hamster. In this 1-year-9-month-old hamster, the right limb was fractured at the distal tibia. The fractured area became red and swollen over the last 5 days as the hamster felt the pain and the burden.




Amputation was the choice as infection and gangrene would set in. However, anaesthesia is a challenge in this case as the margin of safety is low in such small creatures. A bit more anaesthesia would kill. I gave 2 drops of Zoletil 50 IM and operated fast, within 10 minutes to remove the leg. Details are in the illustration and video.

As at 7 days after surgery, the hamster is OK and active.
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1370. Caesarean section of a Corgi using xyazine + ketamine + gas

May 26, 2014.

Corgi, F, 3 years was said to be 63 days pregnant, being mated on Mar 24, 2014 and had no obvious uterine contractions today May 26, 2014. The attending vet took 2 X-rays which showed 5 or 6 pups as one pup "could be deep inside the rib cage area".

Her ultrasound showed 2 or 3 pups with strong heart beats. But she had no manpower to perform the elective Caesarean section. Uterine inertia has happened and the overdue pups may die if the home breeder waits longer. Little milk seen when I expressed the nipples. Dog had abnormal sized nipples as if she had given birth before. "Six puppies likely," I said as the swollen belly was symmetrically enlarged.

ANAESTHESIA
1. Isoflurane + O2 gas only. I had performed over 200 C-sections using this method. The disadvantage is that some dams struggled a lot on inhaling the gas and it takes a much longer time. Some vets think that the dam will die of heart attack. I would take off the mask when such dams struggle and re-mask. All this takes a lot of time.

2. Xylazine + Ketamine at 1 ml + 0.5 ml IV induction for a 20-kg dog as a guideline and depending on the dog's health. 0.1-0.2 ml + 0.05-0.1 ml for a 2-3 kg Chihuahua. Just sufficient to intubate.

No struggling of the dam. I decided on this method in this Corgi.
For this Corgi, 14.1 kg, 38 deg C, normal heart and lungs, I gave Xylazine 0.3 ml + Ketamine 0.15 ml IV at 50% of the calculated dose. It was insufficient to intubate the dog. The dog vomited food after 5 minutes.

She was masked, intubated and given the isoflurane + O2 gas. Maintenance of gas was at 2% initially to 1% to 0% at the stitching of the linea alba and skin. The dog opened her eyes wide just after my last skin stitch of the skin as if from a deep sleep.

TRANSPLACENTAL EFECTS ON THE PUPS
According to a senior vet who practises the Xylazine + Ketamine IV sedation for many years, there is no transplacental transmission to make the pups sleepy. Even for pentobarbitone which he used many years ago, a minimal amount was used. He said pups would take some time to cry loudly but he had pups who cried immediately. His tip was to wait for the dam to have uterine contractions before Caesarean section. This would decrease lots of bleeding even the surgery was done before contractions. As the Corgi had no contractions at 63rd day, possibly uterine inertia, I had seen much more bleeding during the C-section when I extracted the placentas.    

SURGERY

Skin incised around 3 cm from umbilicus. Length of incision around 8 cm long. Vet textbooks advised much longer incision to exteriorise the whole uterus, probably needing 15 cm in this Corgi as the pups were large and long, the longest being around 15 cm.
I located the bifurcation of the two horns, incised at right angles to the bifurcation, around 8 cm long and manipulated the 6 pups into this opening. I could exteriorise the uterus after removal of the pups to ensure no more trapped pups. One pup was deep under the rib cage and it took some time to extract him out. 

Six puppies were delivered. They appeared "dead". I held each with both hands, stood with my legs apart and swung it 5-6 times in an arc vigorously, to expel any water in the lungs. My assistant would massage the top part of the neck with the head downwards and stimulate the hard palate and cleaned the mucus off the nostrils. It took over 5 minutes to get faint cries and some movement. At an average of 10 minutes, the C-section took a long time. It was around one hour before loud cries from two pups were heard. The surgery started around 7.30 pm and ended around 9 pm.

Two pups wee not crying and their noses were cyanotic in colour, after completion of stitching of the dam. But they had tongue movements.

"No hope for this biggest pup," I said as >45 minutes had passed with the pup still gasping. "Some pups do recover with prolonged neck massage." I swung this pup 5 times and dislodged some lung mucus.  Then I put the pup into my mouth and blew into his lungs. I could hear the lungs opening up. The husband continued massaging this pup after he had successfully revived the other pup. (see video). Incredibly, this large pup cried (see video). The owners brought the pups home.

MEDICATION
Oxytocin 2 ml SC, Baytril 1.5 ml SC and Tolfedine 1.5 ml SC. On reaching home, the dam had milk for the pups and so there was no need for bottle feeding. 4 males and 2 females.  Sire and dam were brown/white. Mating was once, on Mar 24, 2014 by bringing the dam to the sire who belonged to the friend.

CONCLUSION
The home-breeders were happy as 6 pups and the dam were alive. It is not a guarantee that such the vet will get successful outcomes. Know how to swing the pups and massage them. Blow air into their lungs may be needed although some vets may not like to do this. In this case, the largest pup had air blown to inflate his lungs and he did survive.  The C-section took me, with experience, 1.5 hours as each of the 6 pups needed swinging and revival. Assuming each pup takes 5 minutes of my time with the assistant, 30 minutes had been spent on this. Fortunately, the dam did not die and was well anaesthesized at 1% - 1.5% maintenance.

For vets with no experience in C-sections or capable assistants, it is best to avoid doing this surgery as owners are just not happy to receive dead dams or pups, blaming the vets. Read up on how to revive distressed pups.  The anaesthesia and surgery was $900 but the stresses on delivery of "dead" pups were tremendous.      

X-RAYS BY THE FIRST VET.  Two weeks earlier (could see only 5 pups on ventral dorsal view) and yesterday (on lateral view, 2 skeletons).  Ultrasound (2 pups with strong heart beats, one with weak beats).

FOLLOW UP ON MAY 27, 2014, 10 AM.  
The dam had milk on reaching home at around 10 pm. The pups are suckling and active. A whelping box prevents pups from wandering. Vaccination advised 6-8 weeks. 3 vaccinations. Weaning to puppy food at 4th week.

1369. Mountainous monasteries, Greece. Images of tourists

The group of 35 tourists got along very well with each other. Good weather, bright sunshine, blue skies, white clouds and beautiful sights when you visit Greece in May as it is off-peak season. During the peak season in July, you have no room in the alleyways to walk freely about, according to the local guide.

1368. An outstanding Greek tour guide - Irene

May 18, 2014. Athens

Irene, a Greek tour guide who has a personality and temperament that captivated the 34 Singaporean and Malaysian packaged tour group with her story telling of Greek mythology which mirrored real life affairs of mortals. For example, the "naughty god" Zeus who slept with various Goddesses.  Zeus promised to grant any wish and his wife instigated Zeus' mistress to reveal his true self. The mistress asked Zeus who appeared as thunder, thereby killing the mistress.

As she told us she was a Fullbright opera scholar, some of us asked her to sing. She did sing "Auld Lang Syne" suddenly and I was able to capture part of this most memorable experience of the tour to share with viewers.

Athens tour guide

Athens tour guide sings Auld Lang Syne

 The following are some Singaporean travelers on the "Blue Horizon" ferry, from Crete to Athens. We had beds in this ferry.

A tour guide in Crete explaining the history of the Minoan Palace.

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