Tuesday, June 26, 2007

I am using the Google Docs & Spreadsheets for the first time to document this case. Pictures are at www.toapayohvets.
Be Kind To Pets educational story is to share my veterinary experiences with younger vets in other parts of the world as most veterinary surgical books are too brief on the overall management of the case of a large oval anal wound in a cat.

Jun 26, 2007 3.17 pm

What to do with such a large infected oval wound near the anus? The cat had licked out the fatty tissues under the skin. A big gap of 0.5 cm deep. She had stopped pooping. How to close such a big gap successfully?

1. Ideally, put the cat on antibiotics for a few days. Was the wound. But the wound is large.
2. The cat was fat, at 5.5 kg. Would she be able to survive the injectable general anaesthetic?
3. Anaesthesize the cat using xylazine and ketamine.
4. Clip the hairs, wash the areas. Syringe in 6% hydrogen peroxide.
5. Debride --- cut off dead skin edges and remove dead tissues from inside.
6. Relieve anal sacs of oil. Greyish brown oil seen from left gland. Right gland must have had ruptured resulting in a big hole.
7. Trim edges of wound --- convert to diamond shaped wound.
8. Undermine tissues to get loose skin.
9. Cut lowest end to extend the wound. Z-shaped wounds sutured.
10. Avoid anal sphincter (near the anal ring).
11. Elizabeth collar size 10.
12. Best to ward cat for 10 days but owner wants her home.
13. Warn the owner to confine the cat and if she runs around the home, she may rub stitches off.

14. In 14 days, wound will heal and stitches to be removed.

Tuesday, June 12, 2007

I am using the Google Docs & Spreadsheets for the first time to document this case. Pictures are at www.toapayohvets.
Be Kind To Pets educational story is to share my veterinary experiences with younger vets in other parts of the world as most veterinary surgical books are too brief on the overall management of the case of urethral and bladder stones surgery.

June 12, 2007

For a veterinarian, it is a happy scene to see a male dog peeing normally within one second of leg lifting on day 6 of the surgery.

At 4 p.m on June 12, 2007 (day 6) after surgery , the Silkie Terrier was taken out from his crate. "He prefers the grass patch to pee," James said. The 8-year-old male dog with urethral and bladder stone removal surgery on June 7, 2007 lifted up his left hind leg and easily peed light yellow urine. Before surgery, he put up his hind leg for over an eternity of several seconds with little or no dark brown urine coming out.

Back to the beginning of the story. On Jun 7, 2007 (day 1), 8% halothane gas. Dog intubated.

Urohydropropulsion - Put dog on sternum. Finger inside rectum to press on urethra. Inject via catheter 20 ml of sterile saline. Release digital pressure. The theory is that the saline will flush the stones into the bladder. Therefore, no need urethral surgery to remove stones. With large stones (seen in X-ray), this procedure was a waste of time. However, I tried it. It was ineffective.

Urethrotomy
--- Insert F/8 sterile catheter into urethra. It could not get into the bladder as the stones behind os penis blocks it. At least 4 urethral stones were removed. 2 big stones around 3 mm in diameter blocked urethra behind the os penis (penile bone).
Urethra stitched up with 5/0 interrupted absorbable suture. Skin then stitched up with 3/0 interrupted absorbable suture.

Cystotomy --- 40 ml saline flushed into bladder via catheter to dilute and drain out the dark brown urine. Then more saline to inflate the bladder. I incise 1 cm into the thick bladder wall at its apex, ventral surface. Took the bladder out of the body as much as possible. Thick walled. Big wide red veins on its surface indicating that infection (cystitis) had been present for some months. As I cut the bladder, urine and saline shot out. I made sure that the urine shooting out did not get inside the peritoneal cavity of the dog otherwise there will be peritonitis.

Flushing the bladder of all debri and stones --- I clamped the 1-cm muscle wall of the bladder. My assistant inject another 40 ml of saline via the catheter into the bladder twice. I removed the clamp and let the urine and saline shoot outside the body. The liquid spurted onto the floor and would have splattered onto me if the position of the surgical site was directed at me. All bladder stones and debri should have been flushed out from the 1 cm incision. From the X-ray, the stones could be around 0.6 cm in diameter.

Catherisation --- Not more than 5 days are recommended. On day 1, the catheter was pulled out by the dog from the inside out. The 2 nylon stitches anchoring the outer end of the catheter to the groin skin were intact. "The catheter came out from inside," my veterinary assistant said. The Elizabeth collar had been taken out too and the dog licked the operation areas. Blood plus urine leaked out from the behind the os penis surgical site.

Post-op care very important --- At least 5 days hospitalisation --- Post-operation nursing is very important as the owner seldom knows what to do if the dog is sent home after surgery. In this case, the catheter was pulled out by the dog. A new one was inserted. But it was hard to get it into the bladder as the dog was laid on his side on the operation table. What to do? Anaesthesize the dog with gas. The urethral muscles relaxed and the catheter was inserted. This time, sticky bandaged the catheter tip to the prepuce and wrap the elastoplast bandage around the body.
On day 3, the elastoplast was removed. Some blood plus urine leaked out from the prepuce. The area was cleaned up. A bigger Elizabeth collar was used. The dog was spoon fed with home-cooked food and given water. No dry food.

On day 5, the catheter "dropped off" as the self-adhesive bandage wrapped round the body of the dog was not sufficient to prevent him getting the catheter out. He was observed to pass urine normally. Large red purple areas around his surgery site indicated attempts to lick the whole area. I gave the dog an inflammatory injection. He felt so much better and the redness receded by at least 50% on day 6.

For a veterinarian, it is a happy scene to see a male dog peeing normally within one second of leg lifting on day 6 of the surgery.

At the time of this report, it was 4 p.m on day 6 after surgery , the Silkie Terrier was taken out from his crate. "He prefers the grass patch to pee," James said. The 8-year-old male dog with urethral and bladder stone removal surgery on June 7, 2007 lifted up his left hind leg and easily peed light yellow urine. Before surgery, he put up his hind leg for over an eternity of several seconds with little or no dark brown urine coming out.

Economics --- The total cost of consultation, anaesthesia and 2 surgeries (urethral and bladder) was S$600. X-rays were taken by another veterinary surgery. Blood tests ought to be done but that would add up to the cost. Prescription diet was to be recommended but home-cooked food was more economical.

Owner's permission to talk to the other vet. It is always ethical to get the permission from the owner to talk to the veterinarian who first saw the case. She is an experienced veterinarian who used to be my intern as a 20-year-old who was doing "A" levels at night. A girl who wanted to be a veterinarian. She saw practice for a few months before she went for her foundation studies in Kuala Lumpur and later studied veterinary medicine in Australia. That was at least 15 - 20 years ago. I have no doubt about her competence to do the surgery as she was with a top veterinary practice for some years before setting up her own practice. She was kind enough to share her surgical experiences about urohydropropulsion using lubricant and saline and the surgical procedures.

Pictures are at: www.toapayohvets.com







Friday, February 9, 2007

Veterinary studies in Murdoch University - Be a Creator, not a Consumer

"If your son does not have 3 "As", he will not be accepted by Murdoch University's undergraduate veterinary course," the Singapore agent 1 said. "The demand from foreign students is much higher than the 32 vacancies alloted to them. Just too bad for your son."

"I didn't know that," my son said.

"You ought to have studied harder," I recalled the minimal amount of time this young man with the ear stud studied. He was more interested in looking cool and fashionable, like his cohort. Last-minute mugging in the 2 months before the final examinations. "Top grades open the doors of any University in the world to you. Now, you have to settle for a second best choice!"

Should we give up? He had been accepted by the Singapore Management University for a business course 2 years after his full-time National Service. His one "A" and 3 "B" grades at A levels qualified him. To me, these were above-average grades. To the recruitment agents, he was an academic loser if he wanted to be a vet.

I asked Singapore agent 2 for a second opinion. He said, "3 'As' or a above 90% for the Foundation studies at Murdoch College." Some Singapore students study at the College after "O" levels instead of spending 2 years at "A levels" in Singapore, thereby saving 1 year to qualify for veterinary undergraduate studies in Australia.

So, there is no hope. Just go for second choice. He was resigned to his fate. His buddy had 4 "As" but failed his General Paper Examination. This young man was rejected by Singapore University's Dentistry Course but Murdoch University accepted him to be a vet within 1 week of his application. As an Australian Permanent Resident, his fees were 25% of a foreign student's A$33,000 a year.

Should my son give up applying? I would say that the Singapore education system at "A" levels do not prepare young people like him to be pro-active. Or how to be positive despite setbacks.

Digressing, I had a girl had 87% in the Murdoch College foundation studies and was rejected by the Murdoch University while another classmate with a 84% had been accepted. She wanted to know why? She e-mailed for reasons. She engaged Singapore recruitment agent 3 who advised that she applied to "pre-vet" course at Melbourne. After the first year, she would have a 90% chance of getting into Melbourne Veterinary Course.

Her father made an appointment to see me, together with his daughter, for advice. "I was confident she could qualify," he said. "So, I did not advise her to seek veterinary experience."

I asked the daughter, "Why did the agent not advise you to study the Biomedical course at Murdoch University for the first year. If your grades are good, you go straight to the 2nd year of the veterinary course."

She said, "The agent advised that I have 90% chances of getting into the 2nd year at Melbourne University but only 70% in getting to Murdoch University."

"How do you substantiate this 90%?" I asked her. "Did you ask the agent?" No doubt, Murdoch University may be in greater demand, but how did the agent get this 90% probability.

"Nobody can predict the future and the competition for places during the 2nd year at Melbourne or Murdoch University."

She did not know how the agent derived the 90%. Many young Singaporeans do not now how to ask relevant questions, accepting statements as if they were facts.

"Why do you want to be a vet?" I asked the daughter. "Interest and passion," she said succinctly.

"So would every prospective veterinary applicant say the same thing," I replied. "Did you write a report about your animal handling or veterinary experience, as required by Murdoch University?" I asked.

"No," she said. "The Murdoch College submitted my grades and applied for me directly."

Yet the girl with the 84% did submit a report of her veterinary experience at a Singapore veterinary practice.

Would that be the reason the 84% classmate was accepted over the 87%? Higher grades, unless they are above 90% were not strong reasons. Another girl with 92% was accepted like a cool summer breeze but Singaporeans would equate more with a cool sea breeze as we don't have 4 seasons here.

Again, top grades open doors. But should this girl give up? The father made an effort to see me. How could I help?

"Definitely, I am not writing a reference to say that she had seen practice with me as this was not true," the agent who might handle her case presumed that I was doing that and had been chasing me for that reference.

How to help this girl with the 87%?

"I think there is no hope," the father said. "Let her study the pre-vet course at Melbourne University for the first year as advised by the agent." He was an extremely busy man.

Was the lack of animal experience the deciding factor for this girl? It sounded like it. The course would start on February 19 and it was 10 days to go.

"There must be a really good recruitment agent who is keen to help to appeal for her, rather than advising the pre-vet course," I phoned the father who had more or less accept the reality of the situation.

I continued, "Your daughter was born into a world of animals --- the grandparents were farmers and the family is still in the pet industry. She has the necessary animal husbandry and management experience rarely found in Singaporeans since she was able to talk. Singapore is urbanised. So, there are very few farmers and opportunities for would-be vets to gain animal experience.

The only problem may be that the appeal for a review based on animal experience is too late. All places have had been filled. The demand exceeded supply.

What to do? Accept reality. Do not appeal? How to write the appeal? The content and the way it is written is very important. The messenger is the recruitment agent. But the messenger can't do much if the story of the appeal is not worth reading.

The girl with the 87% should write the appeal. It was difficult. The Singapore education system does not seem to produce good writers at "A" or "O" levels. The father should write, but it was easier said than done.

"Give me the facts," I said. "I would write for you. You must not give up hope so easily."

The appeal was submitted. It may be too late as time was of the essence and the quota was filled. I keep my fingers crossed for the 87% girl.



As for the boy who was given a place at Murdoch University despite not getting straight "As", I ask him to be humble. Perth may be a boring place initially but there are many new things to explore.

To spend time gaining knowledge and creating things. To read widely various magazines and newspapers. To create things like writing a game. Do not be a consumer by being an addicted online gamer. Be a creator, not a consumer.

Tuesday, January 30, 2007

1. Signs of elimination

Can you draw the pictures in the scenario below?


FIRST 2 WEEKS IN THE NEW HOME. Small breed puppy in the Singapore apartment. Dr Sing's case files of toilet training research from 2003 - 2007.


1. Picture 1. Young working couple at the vet's consultation room. Puppy on the table. Man carries laptop, handphone on ear, lady in office suit, bag.

"Doc, it is easier for you to say 'monitor closely for signs of elimination like sniffing, turning, squatting'," the young couple said. "The puppy just squatted and peed before I can carry him to the toilet area!"

"You were watching TV? The puppy was free to roam in the living and dining area."


2. Picture 2. Vet (Dr Sing) said "PREVENTION OF ACCIDENTS help in toilet training the puppy faster. For the first 2 weeks in the new home, it is important that the owner spend time with the puppy after work to toilet train him."

Picture 3. Vet says: This includes waking up past midnight to change the soiled newspapers.

Picture 4. Vet says: "Closely monitoring the puppy's signs of elimination. No TV watching for the time you are playing with the puppy near its toilet area.

Picture 5. Owner says: "What to we look for?"

Pictures 6 - 13 .
VISUAL SIGNS OF ELIMINATION.
6. Puppy is suddenly quiet.
7. Puppy sniffs the floor (nose down onto the ground).
8. Puppy turns to look for a spot to eliminate.
9. Puppy squatting.
10. Puppy squats and poops. Eats poo.
11. Squats and pees.
12 Owner shouts loudly "NO!!." Shit half way stuck in the anus.
13.
Owner raises his hand to spank the puppy. Puppy frighten of owner. Runs under bed.

14. Puppy dares not shit in front of the owner. Owner says "Pee pee" but nothing comes out. When owner goes away, the puppy pees.

15. Frightened puppy poops under the dining table. Owner steps onto it.

16. Frightened puppy pees behind the sofa. Owner's friends smells urine. Complains.

17. Puppy "eats the stool" to get rid of the evidence.

18. SOUNDS OF ELIMINATION


Clock shows past midnight.
Owner sleeping. Puppy in the crate, barks, scratches sides of crate desperately, whining. Now 1 am and 4 am.

Picture 18 shows "thoughts of puppy inside the wire crate -- Owner , please change change soiled newspapers in the playpen. Owner continues sleeping. Puppy steps on shit. Owner cursing about dirty puppy. Mother complains "Needs to bathe it everyday many times".

Picture 19 shows "thoughts of puppy inside the playpen -- Owner , please change change soiled newspapers in the playpen. Owner continues sleeping. Puppy steps on shit. Owner cursing about dirty puppy. Needs to bathe it everyday many times.

Picture 20. Puppy in owner's bedroom, below his bed. Puppy whines, paws at sleepy owner to go to the toilet. Owner sleeps. Next day, owner steps onto "shit" beside his bed.

Picture 21. Vets says: "Correct thing to do: Owner wakes up on hearing barking and change the soiled newspapers without talking to the puppy. Goes to sleep.

FREEDOM TO ROAM THE APARTMENT.

Picture 22. Owner (NS man in army uniform) feels that it is cruel to "cage" the puppy. Let it roam everywhere on first 2 days. Pee puddles everywhere. Shit in all bedrooms and living room. Family members step onto shit or pee. Mother very upset. She has to clean up.

Picture 23. Vet says: "Confine to a tiled area like the common bathroom or kitchen. Baby gate so that the puppy can see people as he is a social animal. 2-3 weeks if owner is working.

Picture 24. Vets says: "Crate training. Every 3 hours, take the puppy from the crate to the toilet area. e.g. puppy training pad on pee pan, newspapers with urine smell at edge on the pee pan, toilet floor.

Picture 25. Vet says: Leash the puppy to the window grille. Papers around.

CONCLUSION:

Picture 26. Vet says: "The apartment is like a football field to the puppy. So he can't find his toilet area. He cannot control his bladder and bowel at this age of 3-4 months. So he pees and poos anywhere.

The owner must also confine the puppy to a small area when playing with him so that he can carry the puppy to the toilet area. If he is in a big area and watching TV, he is too far away to watch for signs of elimination.

Picture 27. Owner asks: How long to confine him?

Vet says:
Picture 28. "2-3 weeks strictly confined to a room or leashed."

Picture 29. "1 week if you are full-time training the puppy. Monitor for signs. Schedule of exercise, eating, pooping after eating before playing. Sleeps beside the puppy to hear whining.

Friends very impressed with this career girl who took 1 week's leave full time with the puppy. "1 week to paper-train your Miniature Schnauzer? How you do it"