Tuesday Jan 24, 2012
Chinese New Year 2nd day
Bright sunshine day. All neighbours closed

I came to check on my cat patient - a stray cat with badly wounded left fore paw and swollen right paw and do some stock checking and administration. A kind couple had been feeding this cat and admitted it for treatment of two badly lacerated front paws. I showed the interns how this wound is washed and cleaned as many Singaporeans have no experience in such matters, being urban dwellers.  

INTERESTING CASES ON 2ND DAY OF CHINESE NEW YEAR

1. Shih Tzu, Female, 11 years. Fever. EMACIATED. Sticky salivation as gums were ulcerated as if he had licked some poison some 4 days ago.

"Stinks the whole apartment smelly," the father said. The son of 24 years was very concerned. "Yellow liquid in his mouth. What is it?" he asked me. "Could be gastric juice vomited. Did he lick any liquid like paint or tick insecticide?"

"There was anti-mosquito fogging 5 days ago," the son said.
"Yes, it is possible the dog tried to lick off the smell. A blood test is recommended. But you have to decide."

"We are poor. Don't want the blood test," the father said. The son later told me that a vet had forced his father to take various tests leading to a hefty vet bill. So, the father is angry at all vets. However, his vet is off today. Treatment. IV drip, antibiotics and anti-fever.

2. Jack Russell, Male, 11 years. High fever. Massive swelling below R eye for past 5 days. The elder brother said: "The swelling comes and goes, but today, it expands. Can't open eye. What is it?"

No dental work for past 11 years. Malar abscess? "Any bee stings?" I asked. "Centipede sting possible as there are lots of centipedes in the house." A son and mum phoned at 5pm. "Not much changes," I said. Swelling has defined to a ping-pong sized lump after IV drip and medication. Will need sedation tomorrow to see inside the mouth as the dog prohibited opening of his mouth. Could be an abscess not related to malar abscess or a haematoma. Vet medicine is full of surprises.

3. Persian cat of son who is overseas. F, 13 years, not spayed. EMACIATED. Drooling. Emaciated. Mum went on holiday past 2 weeks and now the cat had problems not eating. salivation. Two large cystic swelling below and beside the tongue. Wandered outdoors as mum was not around. Could it be ingestion of poison? IV and medication.

4. Guinea Pig. 1 year +. Not eating. EMACIATED. Drooling. Had incisors clipped 2 weeks ago by Vet 1 who did not examine further. Still not eating well. "Examine the molars," I showed the young lady the inward pointing sharp points of the lower molars. Anaesthetic isoflurane gas using mask. Clipped teeth. Advised hard pellets. "Separate from the other GP who ate faster," I advised. "He might be bullied." The girl said: "The other GP will scream if separated." I said: "Get a grated barrier to separate them. This GP eats by herself and recover. We assume there is no bullying as we don't see it."

5. Dwarf Hamster, F, 1 year+, 59g. "He had gone (to heaven)," the lady in her late 20s said to me. "I let her swim (in the basin) longer while I took care of the other 3 hamsters. When I saw her, she was gone. Drowned. Flat out. No movement. I did heart massage a long time. She finally recovered. But she has this sound (like teeth chattering) from her chest. She ate a bit. "How many stool pellets she passed?" I asked. "Only 1 or 2. Normally many as she is a fat hamster and eats a lot."
I put my stethoscope. Yes, the heart sounds were there but there was these extra loud "crackling sound". Much louder than the heart sounds. Coming from the lungs. The hamster was shaking and breathing faster than normal.

"Have you treated hamsters before?" the lady asked me when I told her that I needed to give the hamster an injection of painkiller, lung fluid-draining medication and antibiotic. If the hamster dies, it will be due to her progression of illness and not due to the injection." She was doubtful about injections. "Well, I never had a case of a hamster that had drowned and had been returned to living," I said. "Singaporeans don't bathe hamsters or I have not got such a similar case. I have done hamster injections for anaesthesia and for itchiness."

"I suppose I have no choice," she gave permission to inject her hamster. My assistant Min held the thick cloth over the first half of the body. I injected the back area under the skin of 0.01 ml. Upon removal of the cloth, the hamster was motionless. The lady was very upset, stroking the hamster's chest and calling her name. I asked her to go outside the cold aircon consult room and into the evening sunlight outdoors. She stroked her hamster. There was a flicker of movement and the hamster's eye moved. She was happy. Booked a cab and thanked me.

So, this CNY Eve 2nd day showed a representative sample of pets common in Singapore - dogs, cats, guinea pigs and hamsters. No rabbits.

National Library, Jan 25, 2012 7.42 pm
Dr Daniel Sing's first day at work

3 cases, equivalent to senior citizens in age, seen by me yesterday needed dental attention as they strongly objected to my opening their mouths. The Persian cat had saliva stains on the chin and one front paw. The Shih Tzu snapped at me when I tried to open her mouth. She was drooling. The Jack Russell's right facial swelling below the right eye had rounded up after my IV drip and medication including steroids.

That meant sedation as I suspected inflammation of the mouth. You could tell from drooling of saliva that definitely two of them had stomatitis. The third one with a facial swelling leaking plasma blood and pus could be a malar abscess. I asked Dr Daniel Sing to let me know what he thought of the facial swelling - now half a ping-pong ball size encroaching on the lower eyelid. "It could be an abscess or haematoma," he said. "How about a carnaissal tooth abscess or malar abscess?" I asked. It was too large and he did not think so. "Well, the Jack Russell catches centipedes and he could have been stung. But he never had a dental scaling for the past 12 years of his life and that is why I am more inclined to put malar abscess as my first diagnosis."

Case 1.
Jack Russell. Male, 12 years old.

After taking some images at 9.30 am with Intern Mr Lim, the swelling burst like a dam.
"Where is your ACP (acetylpromazine)?" Daniel asked me when I told him to get ready to sedate the JR. "I don't use ACP," I said. "I know ACP is popular with the Australian vets." A new vet must adapt to the work environment. "ACP is commonly used in the Murdoch Univ school and by Australian vets giving IM sedation, but there are better alternatives in real world of private practice," I said. "I give Domitor + Ketamine IV and get a better faster sedation than ACP IM." When I was a vet student in the UK from 1969-1974, ACP was also commonly used by the UK vets. So, it is not as if I don't know what is ACP. So, Daniel got to see how effective Domitor and Ketamine was when given IV at 50% of the formula in an old JR.

The abscess had burst and he took a big bag of swabs and looked for the pink chlorhexidine to clean the big wound. "Where's the kidney dish?" he asked.

As that is what the Murdoch Univ lecturers must have taught him and all the new graduates. I did not comment as Daniel would learn the ropes.

For me, a large amount of clean water in a 20-ml syringe would flush away the debris and take 1 minute and worked effectively. Singapore's tap water can be drunk and it is therefore clean.

But Murdoch Univ professors cannot teach this simple method. No need for bags of swab. This was a dirty abscessed wound full of bacteria yesterday. My antibiotic Baytril via IV drip had killed them all.

Spending effective but short time is important. Being productive and that is what many younger vets can't understand. When a procedure can be done in 10 minutes, they take 30 minutes. For example, in this JR, a new vet would swab and swab away the discharge. Swab again. Apply the pink chlorhexidine from the bottle. Put the discharge in the kidney dish. This is what I would imagine them to be taught how to do.

There are other cases to do and if the vet takes 30 minutes hour to just clean the abscess, that time is gone. I put the bag of swab away from the operating table onto a side table as I knew it would be wet. Daniel wanted it on the operating table which was already wet with the JR being washed. Later I asked Min why the whole packet was wet. He said, "The water from the operating table."

I showed how Domitor + Ketamine at 50% of my calculated dose was used effectively and not to waste time. Isoflurane gas mask and intubation.

What was the cause of this abscess? Centipede sting? There was some pus when it burst. I checked whether the 4th maxillary premolar on the right upper jaw was rotten. This would be the main cause of infection to the cheek bones below the right eye. "The PM4 is strong," Min said to me. So, Daniel was correct. This was not a malar abscess since PM4 is usually implicated. I said to Min, "I will check the two molars behind the PM4." He had never seen molars causing malar abscess. So he was doubtful. Yet, the two molars were loose and rotten. They would be the cause of the infection to the cheek bones and below the eye, over time.

He was wobbly after abscess cleaning and cutting off the dead skin and cells, dental scaling and work. The whole process took one hour. The JR looked lethargic. I gave Antisedan 0.2ml IM. Within 10 minutes, he was alert. That was good. Now, what to do with such a big hole in his cheek? More than a 50-cent coin or 8 cm x 8 cm. I propose stitching up 5 days later. The owner wanted to bring him home. So, it will be against medical advice (AMA) but what the owner wants, the vet has to do and record AMA. At home, the wound may become dirtied and flies may lay eggs. But in a room and a big cage, and proper nursing, this can be good for the dog too. Then 5 days later, come back for review and stitching as I doubt that such a large wound can heal well. There are many nerves in the cheek area and it would be very painful to have a big exposed cheek area. Blood tests were done but still the economics would be important.

Case 2.
Persian cat. Emaciated. 12 years old. Tongue and gum ulcers.  No blood tests were granted. See images. Zoletil IV given by Dr Daniel Sing. 3 rotten teeth extracted. The dosage was 50% less the recommended. This old cat took >6 hours to be on his sternum. I had given SC 200 ml Hartmann's.  Ear cleaning and irrigation. Chin's saliva stains were washed off.

Case 3.
Shih Tzu, Female, Not spayed. 13 years old. The whole mouth, gums and inner cheeks are ulcerated. 3 teeth were extracted. Very bad. Emaciation and severe anaemia. I don't know whether she would survive the domitor + ketamine IV. I gave an Antisedan 0.2 ml to wake her up. This dog is so pale but blood tests were not granted by the owner. IV drips, Vit K1 and multivitamins. Chances of survival are very slim as the mouth is generally inflamed and ulcerated.

CONCLUSION
Dogs older than 5 years old need special attention as to their weight and appetite. "The dog or cat eats," is what the owner will say to me.  It does not mean much when he or she keeps losing weight.

Dental scaling will have given your pet a healthy mouth, not painful ulcers, drooling and "stinking the whole apartment. Your senior citizen dog or cat would eat and thrive. I note there is an increase in dental scaling cases at Toa Payoh Vets and from another practice. The younger generation is much more educated and informed and that is good for Singapore pets as they can live longer and pain-free.   

MENTORING
If clients see an old man inside the room while consulting Dr Vanessa Lin or Dr Daniel Sing, that person is me on the spot mentoring the younger vets and sharing my past 40 years of experience in small animal practice. Younger vets will have to accept my presence as auditing veterinary standards of care needs to go with trust, to ensure the highest standard of practice at Toa Payoh Vets.