47. Telephone diagnosis in Caesarean can give the vet trouble

"My husband had ruptured the water bag but the puppy could not come out," the breeder's wife phoned me as I was going out for my lunch appointment. "What she I do?"

I asked: "Are you sure the water bag is broken and it is not the watery discharge before birth?"

"I am sure it was the water bag."

"Normally a Miniature Schnauzer has no problems giving birth," I advised. "You can wait for half to one hour."

"Will this puppy die?" the breeder's wife asked.

"I don't know. Perhaps you can wait half an hour. However, the decision to do Caesarean is up to you. Please note that I can't predict whether the puppy will die or not if you don't get a Caesarean done."

This is the type of telephone diagnosis I presume veterinarians all over the world dislike. If the puppies die, the veterinarian gets cursed for incorrect advice.

I got one bad experience of such telephone diagnosis. This Singaporean caller whom I did not have veterinary relationship with wanted free advice over the phone.

The next morning, the government vet in charge of private veterinary matters phoned me to enquire whether I had given advice such as whether the "greenish vaginal discharge had come out or not?" Such experiences harden the attitude of private veterinarians towards free telephone diagnoses.

The breeder came to the Surgery. A puppy was pulled out. In the midst of anaesthesia, a water bag was seen. With some straining, I managed to take out a second puppy. Now what?

Can I just use oxytocin and/or wait? I don't play God. Breeders want one thing --- live puppies. No explanation acceptable if the puppies are dead or stillborn and worse, if a belated Caesarean is done.

Who knows whether the remaining puppies inside the dam would be born easily? I estimated four or five in total. Two had popped out.

The breeder decided on Caesarean. The anaesthesia was smooth. The dam sleeps peacefully but did not strain to pass out more puppies even though I reduced the anaesthesia to 1% instead of 2%. It could be secondary uterine inertia.

I inserted my right forefinger and third finger into the 3-cm incision of the uterine body. I could cut a bigger incision in the skin and then into the uterine horns. However, it would be best to hook out the puppies.

The puppies played hard to get. The mother had stopped contracting. The puppies hid deep inside the horn, near the ovaries. Should I enlarge the skin incision? Try again. With time, the 2 puppies could be fished out without bigger cuts.

All were vigorous and active.

I wanted to take pictures outside the Surgery as there was better lighting. The breeder's wife took pictures with her handphone. She said to the two kids as we crossed the small road to the other side where sunlight fell onto the walls of the building, "Stay inside the Surgery."

"Go and take the kids out," I said, taking over the wife's basket of 4 puppies. "Let them learn about your business."

The little daughter must have felt nauseous as you can see from a chance picture of her. I appreciate this rare action people and dog photo very much as it is one that tells a thousand words.




"Why don't you dock the tails now?" the breeder's wife asked.

"Better not," I said. "The mother may be upset. The puppies may not suckle or be stressed."

Some advices on how to care for the puppies were given.

The breeders seemed grateful and most happy. This was the first time they encountered their Schnauzer giving birth during the daytime. This Caesarean was without complications.

The breeder's wife phoned some one hour later, "One puppy is not suckling well. Milk comes out of his mouth."

"I don't know what's happening. Is there a hole in the roof of the mouth. Check the mouth." It was difficult for her to know what the roof of the mouth means.

See what I mean? I hate telephone diagnosis. I asked her to bring the puppy for me to check. She did not turn up. I guessed all would be all right with the puppies.

46. "Dr, cut only a small piece of my cat's left ear"

"Doc, please cut a small piece of her ear after spay," the 65-year-old lady with such young looks of unwrinkled forehead and black hair that I could assume she was around 50 years old. "Is it painful for the cat?"

The lady had reared this black cat as a kitten. Now the cat caterwauls. She wanted her spayed, ear tipped by cutting off a piece of the tip of the left ear and put downstairs as she felt that changing of the litter was inconvenient. Her husband had passed away some time ago. Her children had grown up and had their own families.

"It is better to cut a bigger piece," I said. "Otherwise, the cat catcher would not know she had been spayed."

"Yes, it is better," a thin tom-boyish self-employed dog transport woman with crew cut hair interjected her remarks. She had bought in a female dog on heat for spay as the owner wanted a cheaper dog licence. An intact female dog licence is around $70.00 while a spayed one costs $14.00.



I looked at the 65-year-old lady who was accompanied by a much older senior citizen to 'protect her' she had jested. I thought: "This lady would be better off with a cat to keep her company as she was still grieving over the loss of her husband who would not see the doctor for some abdominal pain for one year."

By the time the husband consulted the doctor, he had some pancreatic tumour and passed away soon. The lady had seen me yesterday to spay her cat but the cat had eaten. Spay is recommended when the cat has been starved for the past twelve hours.

The lady said, "Maybe you cut the ear another time?"

I was surprised that she vacillated in her decision to spay and abandon the cat.

I said, "The cat would require some anaesthesia the next time. It would be better to tip the ears today after the spay."

The lady could not decide.

"Do you understand that your black cat may disappear once you leave her out of your apartment?"

"It will never happen," she said. "I see the two stray cats downstairs in the void deck every day."

"There is no guarantee in life that you will always see your cat at the void deck. Government cat catchers had been reported to use nets to trap and remove stray cats. There are town council people who cannot put up with cat complaints and get rid of them. There are pest control and town-council approved contractors who dislike cats being paid by those who dislike cats to capture your black cat. Or simply a naughty man who abuses cat."

The lady was distressed at such possibilities.



"But these are realities of life. If we don't give protection to the animal we love, they are at the mercy of many bad people and environment."

She still loved this cat. Other than the need to change cat litters and the strong smell of cat urine, I don't know why she wanted to get rid of this young cat.
I did not ask more.

As she could not decide, I said, "Let me spay her. When the time comes for you to give her up to fend for herself, let me know. Then I will cut the ear tip. In the meantime, she will stay overnight at the surgery after spay, without charge and go home tomorrow."

She seemed happy at this advice and went back home. This was one of the rare times I had some free time to talk to an owner. If not, it would just be spay, tip the ear and abandonment of this gentle 6-month-old cat.

45. Visiting NANAS by appointment only

"Nobody is permitted to visit NANAS if I am not around," Mr Raymund Wee said over the telephone. "Prior appointments are needed."

I could not understand why. Surely it is in the best interest of NANAS to encourage more visits. It is like the Giant Panda attracting over 40,000 visitors at the American zoo at one time. With exposure to members of the public, it will be good for fundraising. After all, Raymund said that the expenses for the maintenance of 1,000 animal residents come up to $700,000 per year. And there is never sufficient money.

Raymund explained: "There are at least 500 free roaming dogs in NANAS. NANAS does not put dogs to sleep unlike other animal shelters. The dogs get excited if some new person arrives. What if a visitor gets bitten? NANAS may suffer litigation costing millions of dollars".

"Has any visitor been bitten?" I asked.

"No,"



"How do you manage to control the tick infestations of so many dogs?" I asked. This is an important question as Singapore dog breeders do have to control ticks in their breeding farm.

Raymund told me the various names of insecticide used, "I rotate various insecticides as the ticks become resistant to them after a while. Ivomectin injection is the better method to once a month oral but it is too costly to use injections for so many dogs. Furthermore, injection has to be done carefully otherwise ivomectin goes directly to the blood stream. There are certain dogs that will never allow injection.

"Is garlic effective in tick control?" I asked as there were some proponents of the use of garlic for mosquito control in the U.S.A.

"No." Raymund said. "Garlic can be toxic. On the other hand, the sanctuary cannot be totally sterile and free from any disease causing organism. It is not practical and not good for the dogs as they don't build immunity."

"Why don't you plan ahead and employ newly graduated veterinarians from overseas to do sterilisation of dogs and cats?" I suggested in reply to his complaint that experienced veterinarians are not interested in performing batch of sterilisations for 8 hours at a stretch.



This is because each colony of cats is sterilised at one time and returned back. In this way, there is disease control and prevention of viral spread to all cats in other colonies. So, the veterinarian must be able to be productive and competent. Competence comes from experience.

"I thought young graduates would gain considerable surgical experience in NANAS," I said.

"The main problem is that some young vets, being inexperienced, are slow and needs supervision. Some of them leave behind remnants of ovarian tissues and do not ligate tightly, leading to bleeding. Some also do not ask for help.

Sometimes, just make a bigger incision would do. Some vets prefer flank (side of the body) incisions for sterilisation and may not be competent to do it. It is not as easy as midline incisions (middle lower part of the body).

Wow, animal shelter medicine is definitely so much different from my private practice. There must be a way whereby experienced veterinarians are decently paid to carry out animal shelter surgery without being mentally exhausted to do factory production line sterilisations for 8 hours a day.

According to Raymund, at least 85% of the street dog and cat population in a place need to be sterilised before any results can be seen. Can he get government or town council grants to do it? There is no easy answer as governments have their priorities and their public relations advertisments and political show-offs.

44. The Swamp Dogs. Chapters DRAFT

DRAFT
THE SWAMP DOGS OF SINGAPORE
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

The Swamp Dogs of Singapore - Contents
Chapter 1. Did the Animal Activist Fail in Her Mission?
Chapter 2. A Volunteer with Passion Is worth 40 Merely Interested.
Chapter 3. The Looters Attacked the Pack Leader.
Chapter 4. If Only We Can Turn Back the Clock for the Pack Leader...
Chapter 5. NANAS. Swamp Dogs Saved From Lethal Injections.

43. Veterinary Ethics is such a boring subject?

September 4, 2007

To: A Boy who said to his mum that "Veterinary Ethics at Murdoch University is a very boring subject"

BLACK SHEEP IN THE PROFESSION

"Sign these AVA (Agri-Food & Veterinary Authority) forms to certify that you have had implanted the microchip in the puppies I will be selling. From September 1, 2007, every puppy sold in Singapore must be microchipped before sale," the dog breeder gave me a written list of microchipped numbers.

The AVA form had the following particulars needed to be certified by the veterinarian:

MICROCHIP DETAILS:
1. Microchip Number
2. Date of chip implantation.
3. Chip implanted by:





All I had to do was to copy the microchipped numbers onto the forms and certified that I had implanted them at a fictitious date. If I don't do it, there will be other veterinarians who will oblige. This breeder had 3 veterinarians who had solicited business from him.

There are many ethical issues involved in servicing breeders. This story is one example of the ethical issues I encountered.

I used to service all the big breeders and numerous pet shops in Singapore in 2005 because of an unusual situation in that they lost their vaccine suppliers (believed to be two) whom they bought vaccines wholesale and vaccinated their own dogs.

However, in 2006 and 2007, young and unsuspicious veterinarians and an investor of veterinary clinic solicited business from the breeders. The breeders now had bargaining power and were able to get what they wanted.

However, there was a breeder who hedged his bets by engaging my services regularly.

I knew from my research that he would bid the pricing of one professional veterinarian against another to get the lowest price. I was now getting the crumbs of his puppy vaccination as I could be overpriced in my Caesarean sections. The younger vets charged as low as $150 - $200 per Caesarean section while I was already charging more. He started asking for injectable drugs which he could not obtain himself and I had to say no. Well, there are other veterinarians who are more flexible.

He was a big breeder and knew that veterinarians who desired his patronage would need to be flexible and cheap. Big corporations all over the world do it all the time to bring down their expenses.

If you read widely financial articles and other books, you would know that many big corporations use child labour, destroy the environment, compromise the integrity of professional accountants and lawyers, Chief Executive Officers and other means to achieve their aims of being profitable.

The more the service provider salivates at the prospect of big volumes at low cost, the more demanding the big business is of them, to the extent of compromising their integrity and making them lose their professional licence.

Now, how do I resolve this problem? Sign the forms to certify that I had implanted the microchips. This was false certification and ethically, if not legally wrong. The big corporations exploit the desperation of the service provider to get business.

In my case, I must be desperate. Otherwise, why did I still drive up to his farm to vaccinate a very small number of puppies per week? A young veterinarian was doing the majority of his vaccinations and his work. He could have asked her to sign the forms. How would the regulators know?

"Trust me" is the common statment of people who want their self interest served even if the professional licence may be revoked by the misconduct of the service provider. When you hear "Trust Me," you ought to be very careful.

In this case, I told an intermediary to return the AVA forms to this breeder and to tell him that I would not be signing nor doing business with him.

The breeder phoned me: "Those forms I asked you to sign were the puppies you vaccinated!" This was an intelligent and successful breeder but yet he made such a stupid statement. Should I capitulate? That means signing blank cheques. He obviously had no respect for the veterinary profession.

I had to be frank. "I did vaccinate the 5 puppies. But I did not microchip the puppies. So I will not be certifying that the chip was implanted by me."

Dealing with big business is not a win-win situation if the big business has no respect for the professionalism of the veterinarian. Unfortunately, there will always be black sheep in the profession who are willing to take risks to get their business. So, there should be no problem for the big breeders.



"The best veterinary clientele and those of the highest quality are the individual private pet owners" --- two well wishers advised me some time ago to get away from the big business. They were correct.

CONCLUSION:
I hope you will find Veterinary Ethics really interesting and very useful. Your mum has high hopes for you and misses you a lot.

If you can reduce your online gaming time, as all youths are addicted to and devote much more time to creating, reading and learning new craft and doing veterinary research, you will find that veterinary ethics is a fascinating subject as the big business world is quite devious and has no qualms compromising the ethical standards of a professional.

42. 2.5-year-old Maltese purposely pees outside the kitchen bathroom and drinks urine inside

Monday Sep 3, 2007 6.07 pm

The Maltese stopped breathing just before the spay surgery. Her tongue was a dried maroon blue colour with more red hues. There was time to revive her. I grasped her chest with my right hand. A few breaths. Then no breathing movements. Her tongue was still the same colour. I could feel her faint heart beats.

"Disconnect the general anaesthesia," I said to my assistant. I put the endotracheal tube into my mouth and blew air into her lungs three times and compressed her chest three times. A sweetish smell of anaesthetic gas came out of the Maltese mouth. She was responding slowly. Her breathing started.



The rest of the surgery was uneventful as the dog breathed regularly. I incised the skin about 2.5 cm from the umbilicus. I could see the dark brown lobes of the liver. I inserted the spay hook and hooked out the left ovary. I thanked the owner for presenting a female dog that was not on heat. Spaying a female dog during heat was risky as there would be much bleeding as the fragile blood vessel and womb tissue break when clamped by the artery forceps. Lots of bleeding and maybe death later. But this case was a dream boat. No bleeding.

I reduced the anaesthesia to 0.5% and then to zero 5 minutes before the end of surgery. This was a thin Maltese weighing around 3.5 kg and the usual 2% maintenance dose was not necessary. The Maltese woke up 2 minutes later as if she had a nap.

At 5 p.m, the young lady owner came to pick up the Maltese. I had some time to do some research on how Singaporeans keep dogs and invited the lady to sit down and talked about the subject she loved most, besides her husband.

"How did you toilet-train your Maltese during the first week?" I asked.

"It was so long ago," she said as she took out the puppy papers from a folder. "I put newspapers covering the whole floor of the kitchen and the bathroom nearby. Then I removed the newspapers gradually till only the bathroom had newspapers. I want the puppy to eliminate in the bathroom."

"How long did you take to successfully paper-train her?" I presumed she had success in paper-training.

"Can't remember," the lady said. "Now she is 2 years and 4 months old. She goes to the bathroom floor near the kitchen to eliminate. My maid will then hose the urine away."

The lady made a surprising statement: "The Maltese purposely pees outside the door of the bathroom sometimes. Especially after midnight and when nobody is at home. But this would not be done regularly."

I thought: "This must be urine marking. Female dogs seldom do it but I am sure that some will urine marking. Maybe alpha female dogs?"

Yet this was the only spot that the Maltese would pee deliberately. As an adult dog, I presumed she would know better than to soil the place.

I put a piece of paper for the lady to sketch the floor plan of the bathroom and the kitchen and explained the routine of the Maltese.

Why would this Maltese behave so strangely, especially after midnight? She sleeps in the master bedroom but would never go the the master bathroom. When she needed to pee, she would run out and just pees outside the door of the kitchen bathroom.

Why this unusual canine behaviour?
"I don't think there is much space inside the bathroom," I noted from the sketch and from my visits to the typical HDB (Housing and Development Board)apartment. "Most likely, the dog just did not want to dirty her paws by stepping into the kitchen bathroom which could be soiled with urine at, say, 9 p.m. Do you or your maid hose the bathroom before you go to bed?"

"Too tired to do that," the lady in her late 20s shook her head. She worked long hours as she climbed the corporate ladder of a famous multinational company.

"So, the answer for this 'misbehaviour' could most probably be that the Maltese disliked peeing on the soiled floor. All dogs don't like to dirty themselves if they can help it.

It was a surprising revelation for both of us.

"Use a rag. Dip it in white vinegar:water 1:3 and neutralise the urine smell outside the kitchen bathroom. Hose the floor before you sleep. Do let me know in 3 months' time if you are successful." Case closed. Time to go home.

But there was another strange behaviour of this active Maltese who would not step into the veterinary surgery when she reached the place, according to the owner.

"She drinks her urine for the past 6 months," the lady said. "She had never done it as a puppy."

"That is strange," I said. "I have heard of some puppies drinking their urine during my research in toilet training. Adult dogs eat poo. But this is the first time I hear an adult dog drinking urine!"

Why and when?

"The Maltese goes to the kitchen bathroom before bedtime, around 11 p.m," the lady owner said. "I say 'Go shee shee' and she would go to the bathroom. I close the sliding door. Even if she has no urine, she would try to do it. I could see her licking her urine sometimes. Why would she do it?"

I had no instant answer. This Maltese was obedient.

I suggested, "Place a puppy diaper on the kitchen bathroom floor. This absorbs all urine and she would not be able to lick them. Otherwise she would persist and the vice would be hard to eliminate. A diaper costs money and it may be changed every 2 days in the case of the puppy. But your dog is an adult and may need regular daily changes."

My solution did not seem practical or appealing.

"You could buy those human diapers for incontinent people. They are much cheaper." I said.

"Won't the dog shred it?" the lady asked.

"The puppy diapers with stick-on tapes would be more lasting. They have a urine smell to attract the puppy to pee onto it."

"Oh," the lady remembered. "The puppy training aid (liquid) was so disgustingly smelly that the Maltese hated it when I used it to toilet train her on newspapers!"

Somehow she had gone on a different train of thought. I had better not get distracted too.

"Since the Maltese finds that you scold or get angry if she licks urine, she could be seeking attention. The more she does it, the more she gets scolded. Any attention is better than none since you work long hours." I had another brainwave.

So what's the solution?



No puppy diapers. No scolding. Hose the floor before bedtime. Neutralise the floor outside the kitchen bathroom. Do NOT force the adult dog to go to the bathroom before bedtime.

I don't know how much of my advices will be useful and whether this lady would feedback to me the progress in 3 months' time.

This was an educated and well informed owner. I was glad that her then boyfriend had purchased this Maltese as a birthday present for her. I hope all 3 live happily ever after.

41. "Puppy knows he has misbehaved, went to hide"

Seldom do I meet a 1.8 m tall gentleman - A Chinese, towering over me.
His wife was taller than me.
A red toy poodle male purchased 3 weeks ago and put inside a playpen (4 panels of fencing) with a bed occupying 50% (top half) and newspapers (bottom half). Water bottle attached to left fence. Living area.

Couple and mother worked. So, the puppy is home alone during office hours. But after 3 weeks he was paper-trained.

"He knows he has been a bad boy and goes to hide," the young man anthropomorphized. "I will discover that he has peed under the dining table."

This is a very common comment from puppy owners all over the world, from my research reading on books and on the internet.

The puppy actually does not know what he has had done wrong. But on seeing the owner's angry face, he has to hide or be spanked.

"Do you spank him?" I asked.

"Yes," he said. I scold him, give a light spank on his backside and put him into the playpen when I discovered he had accidents.

"Inside his playpen, he knows how to eliminate on the newspapers. Once outside, as I take out the 4th fencing, he just pees and poos everywhere in the apartment. He runs away when he sees me because he knows he has misbehaved!"

"Really?" I asked. "Does he pee inside your bedroom too?"

"No," the young man laughed. "He dares not enter my bedroom. He sees me and just get scolded. But mum's room gets peed on. He does not know how to go back to the newspapers in the open playpen to do his business."

"He pees outside the main door of your bedroom?" I asked.

"Yes," the man said and the wife smiled.

Does he also pee inside the kitchen?" I asked.

"Yes, I guess he cannot control his bladder".

"You are correct," I said. "At 3 months of age, the poodle usually pee every 2 hours, according to some N-1 formula in some puppy books. N=no. of months of the puppy. So, at 3 months, he pees every (3-1) hour.

"He does not go back to the newspapers in the playpen because your mum distracted him to play and did not watch out for signs of elimination. Also he was given too much space to roam before he is fully paper-trained.


SOLUTIONS
1. Barricade kitchen entrance with one panel of fence from the playpen.
2. Close all bedroom doors.
3. Puppy to be confined to living-cum-dining area only.
4. Give him a 2nd toilet location in the dining area. 2nd piece of soiled newspapers on a pee pan.
5. Neutralise urine smell with white vinegar:water 1:3. The owner had done it but said, "The puppy just pee and poop any place."
Well, since the urine smell had been neutralised, the puppy just eliminates randomly as most of them go back to the same spots. In this situation, the whole apartment has urine smell and neutralising may not be effective. So, it appears that the puppy eliminates randomly. Why? The whole apartment, except the master bedroom is full of urine smells to attract him.