Paper training --- One month later. What to do?

Nov 16, 2007. Case study. Vaccination 3rd done today.

Questions asked by a young couple:

1. Should we restrict the feeding amounts? The pet shop seller advised leaving the food all day as the Shih Tzu was small sized.

2. How many times a day should we feed?


PUPPY
Shih Tzu, Male, Born Aug 2, 2007. 2.4 kg. Now 14 weeks old. Small sized. Pet shop puppy seller advised to leave feed bowl for 24 hours. Active.

HOUSING
Playpen.
1. Lower left quadrant --- Pee pan with newspaper. Urine spray liquid at one end (left most).
2. Front middle --- Water bottle. Middle because water seepage will go onto tray instead of the floor.
3. Upper right corner. Feed bowl. Feed topped up. Free feeding.
4. Upper left quadrant. Basket bed --- sleeps in bed or corner of bed outside at night.

POOPS 3x/day. No specific time. Poops onto pee tray as well as lower right corner. Pees many times on tray and on lower front half of the playpen.

"Did you change newspapers every day and regularly?"
"Once a week," the young man said.

I repeated my question.

"Once a week," the young man said. "Sometimes we change papers after 3 days."

"The puppy likes a clean newspaper to eliminate," I explained. "He will poop on the lower right corner or pee throughout the lower half of the playpen to avoid stepping on the soiled newspapers if he can help it."

Change newspapers daily or more often.



CONCLUSION
1. It has been one month. The puppy was not paper-trained as soiled papers were not replaced regularly (several times a day).

2. At one month, the puppy would be paper-trained if it has access to clean papers and the playpen could be removed. The puppy should go to the pee tray's newspapers to eliminate.

3. Give sufficient feed 3x/day. Remove the feed after 10 minutes. This encourages the puppy to poop after eating (in many cases). Do not distract the puppy before he poops.

4. Exercise. Evening outdoors. The puppy will eliminate downstairs. Get a fixed timing. Let it eliminate on newspapers after dinner before going downstairs.

5. A time-table for feeding and exercise is necessary for early success in paper-training. Pee tray is a good idea as this prevents the tiled floor of the living area from being soiled. But the puppy does not go into it if the papers are soiled. Changing papers a few times a day and praises and treats on successful elimination on newspapers are needed for early success.

99. The Pom's face wound would not heal --- Oronasal fistula.

"Why didn't you come for the surgery?" I gently admonished the lady owner of the Pomeranian. "You wasted more money buying antibiotic powder to dust onto the facial wound after consultation."

Her dog had a weeping wound of around 5 mm in diameter below the left eye, above the maxillary 4th premolar tooth. It did not heal over the past weeks despite various medications and powders she had sprinkled on. Pet shops sell wound powders.

Some 14 days ago, I had patiently explained to her that there was an infection from the root of the maxillary 4th premolar. The infection went through into the nose below the eye. The bacteria from the decayed roots of this premolar attacked the nasal bone area and made a hole. This was an oronasal fistula and surgery to remove the infected premolar would resolve her Pomeranian's non-healing wound problem once and for all.

I guessed she could not understand how a rotten tooth inside the left upper jaw could be related to a hole on the skin below the left eye. Her husband thought, "This doctor is nuts. Mouth and nose. So far apart. How could there be a connection?"



"Surgery was to be done 7 days ago after antibiotics were given but you did not turn up till today --- 14 days later. Why spend more money on wound powders when they don't work?" It was not good for the dog. The anaesthesia and tooth surgery was $200 which was affordable for most pet owners. If it was $2,000, it would be high.




Sometimes it is good bedside manners not to elaborate in such situations and just simply accept the case. There was an optimal time to do extraction of the infected and decayed tooth. It was after 7 days of antibiotics and she had been given an appointment. She did not turn up and now the effects of antibiotics were no more. The bacteria in the infected teeth had returned.

The lady smiled sheepishly. "My husband wanted to use the $200 for the anaesthesia and surgery to go to India lah!"

Now that the dog is no longer on antibiotics, should I operate? There was no urgency in the sense that it was an emergency.

But it would be in the best interest of this poor dog to be cured as soon as possible.

The decayed 4th premolar and lst molar were loose as their roots had shrivelled from bacterial attack. They were extracted.





The wound should heal and the Pomeranian should have a face with no wet weeping hole.

98. The big-eared dwarf hamster

"The hamster is sleepy now," my assistant said as the owner and myself were observing the hamster inside a transparent anaesthetic container in the surgery room. This was part two of the procedure. In part one, the owner was absent and the large lump beside the hamster's left ear had been removed. Now, the owner was present for the stitching of the wound as he was interested in seeing it.




This container had a hole through which a breathing tube carrying anaesthetic gas was pumped in. The hamster breathed the gas and would fall asleep, permitting me to operate. The problem with anaesthesia of the dwarf hamster is that the vet needs to be very careful. A bit too much or a few seconds more of the anaesthetic gas means that the hamster dies.

No second chance. No cardiac massage or emergency resuscitation unlike the dog or cat.

The hamster closed his eyes. I picked him up to stitch the wound of his left ear area. A big fat tumour, globular in shape and 5mm in diameter had been removed some time ago. There was now a big gaping hole of around 8 mm exposing the pink flesh. Bleeding was profuse but had stopped.

The young entrepreneur in his thirties was in the operating room as he wanted to watch the surgery after I had removed the tumour.

His wife waited outside as she could bear to see blood spurting over the hamster's head. She would not want to see the hamster bathed in red blood covering his whole head and neck.

I picked up the hamster and put him on a face towel held by the owner. This 'portly' hamster was tame and did not bite me. As I put in the first stitch, the hamster squeaked and moved. The pain of the needle had wakened him from his drowsiness.

How could that be? The hamster had been in the gas container and should be anaesthesized. I ran through my check. My assistant James had switched off the oxygen which would have mixed with the anaesthetic gas to make the hamster sleep. He was 71 years old but had not done this before. The presence of the owner had distracted him and me.

"Damn it, the gas was not given," I said. I apologised to the owner. It is important that the owner not be present during surgery as he could be distracting as in this case. It could be humiliating and humbling too.

The hamster was put back into the container to breathe the gas. Then as his eyelids closed, I took him out, placed him on the towel held by the palm of the owner and stitched him. 3 fine stitches of 5/0 absorbable. He squeaked at the prick of the needle uniting his torn skin. He was fine and alive.



I taught the owner how to wipe off the blood from the hamster's body. "Use a cotton bud and do it slowly so as not to stress the hamster."
"What about the ear lump?" the owner asked.

"If it grows so big and so fast in the last 5 days," I said, "It would be cancerous and would re-grow." I did not suggest sending the lump for histopathology to confirm whether it was malignant or not as total costs would add up and the results would not help the hamster to survive longer. Cancer treatment for a dwarf hamster is out of question.

The histopathology analysis of a tumour would cost over $200. The hamster's operation and anaesthesia was kept as low as possible at $75.00. Now, the cost of a new hamster would be around $10.00.

The owner and his wife appeared satisfied as they packed the hamster in his cage to bring home to their daughter. From this experience, it is best not to permit owners to observe surgery as they can be distracting to the assistant.

97. The teacher's pet

Dr Sing Kong Yuen
www.toapayohvets.com


“My rabbit keeps biting his toes,” the young teacher cradled her 3-month-old Netherlands dwarf rabbit in the nook of her left hand. “What is the cause?”

“Put the rabbit on the table so I can examine properly." I advised.

The young lady took out 2 bottles of medicine from her plastic bag, “As you were on leave, I consulted a vet when my rabbit leapt and then limped. The vet diagnosed a leg sprain.”

“The rabbit looked thinner since I saw him 6 days ago.” I encircled the rabbit with the fingers of my left hand as he tried to scamper away. The teacher’s pet was fighting to be slimmer than the teacher.

“He’s very picky and eats only the green dry food,” the teacher laughed. “I don’t know what to do to make him eat more.”

The rabbit’s crusty toes caused by the scabies mites, except for two, were now normal skin. That was good news as the scabies mites had stopped multiplying and burrowing under the skin of the toes. The scabies mites caused considerable itchiness in the rabbit, leading to licking and biting to relieve the itch.



“But why was the rabbit still biting his toes?” the teacher asked when I declared that his mite infestation was no more.

I removed a scab on the right fore paw. There was a red 4-mm diameter wound. I pressed the lower part of the skin below the wound. Thick creamy pus oozed out. The rabbit squealed suddenly. The teacher uttered a sharp cry as if she was stabbed. Sometimes it is best not to have owners around but their presence and interaction educate them more on pet care than talking and books.

“It is best to clip off all the hairs of the paws,” I advised. “In this way, we can examine all toes thoroughly. Can you do it?” Most Singaporeans of her generation do not have contact with Nature and animals and she was not able to restrain the rabbit, afraid of hurting the little one. The teacher, in her early thirties cradled the rabbit. She scissored the paws in vain. The rabbit shifted and withdrew his paws.

“Grip the skin with the fingers of your right hand,” I demonstrated. “The fingers curl onto the scruff of the neck. Hold the rabbit upside down, like what his mother would have done to carry him. He would be quiet.” The rabbit appeared ‘hypnotised; as I snipped the hairs off the paws.

“Can you do it?” I asked the teacher. She tried but the rabbit would move. “It is cruel,” she must have thought. Her groomer would take care of the entire nail clipping and grooming.

To save time, I cut off all the hairs. There were 2 more abscesses with pus.

“What do secondary school children read nowadays?” I asked. “Do they read books about animals as I am thinking of writing one for the children and want to know the prospects of sale?”

“I doubt my students read. The English teacher gives them books to bring home to read. They return the books. No questions asked. I teach Mathematics and Chemistry and so do not know about their reading habits. But I know many spend lots of money to buy gaming books.”

Maybe there is no audience for the animal story books for children in Singapore.

“Thank you for your feedback. Fiction like ghost stories seems to be preferred by the Secondary school students.”



I advised observation of the rabbit’s appetite, daily cleaning of the wounds, removal of the chewed-out plastic spoon and stopping the medication meant for another 6 days.

The thin rabbit must eat good food. So should this ultra slim educator but it would be rude of me to say so.

"No plastic spoons as the bits and pieces of gnawed plastic ingested will kill the rabbit," I reiterated. The teacher's pet was not thriving.

In the 1960s, a student who carried books for the teacher to the common room to mark was called “the teacher’s pet.” Was it a privilege? What do you think? I was proud to be a teacher’s pet in primary school.

Do secondary school students carry books for this teacher in 2007? I did not ask her. I hope she learnt something today on rabbit care and that the dwarf rabbit would eat all day to gain weight and thrive.

96. Follow up on 94. The stars of timing.

"The vet must guarantee that the dog will not die under general anesthesia," the owner of the Yorkshire Terrier told the pet shop girl who had referred the case to me. Should I handle this case or not?

If the dog has an inherited poor heart condition and dies under anaesthesia, the owner is sure to tell everybody about the vet. No doubt about this.

Anasesthetic death opens the door to litigation and demands for explanation from the veterinary authority should a complaint be made. So much emotions are involved in an anaesthetic death. Family members may want to sue.

Why risk my reputation built over a life-time? Just pass the case to another veterinarian. This should be a wise decision. Pass the buck of potential death.

Yet this Yorkshire Terrier was young, active and examined. He was apparently healthy. Still, there may be hidden heart arrhythmias or ventricular tachycardia which manifests during general anaesthesia resulting in heart failure and death.

I did not pursue the matter as I asked the pet shop girl to let the owner decide. Maybe she had her own vet.

The owner decided to operate on an auspicious day and time and told the pet shop girl. I had never met the owner.

This auspicious day would be a Sunday and the pet shop girl made an appointment. Sunday is a busy time for vets as most Singaporeans are free. I did not object to surgery on a Sunday. But the Sunday happened to be busy and I could not finish the cases before noon.

"Doc," the owner said to me as I was in the middle of consultation. "I understand that you have to clear your consultation cases. Please make the first incision before noon."

Her adviser had given her the safest time for surgery of her dog. It ought to start before noon and on this Sunday. Wow, I did not know about the time.

It was obvious to her that I could not complete my morning consultation in time to start surgery.

"It is best you postpone the surgery to another day, after consulting your adviser," I said to the owner. She had this kind and pleasant personality when we talked. I would sense that she was not the litigious type.

But the stars of timing are now against me. I don't want to claim to be superstitious but it is best not to antagonise the stars of timing.

"Why not wait?" I asked the owner.

"It will be 2 weeks later," she sighed. She decided on the operation in the afternoon. She did not tell me then but she was worried that the leakage of "mercury" from the defective chip would kill her dog if she waited much longer. She had already two weeks of worries and hassling the pet shop owner to get remedial action.

The pet shop girl had warned about the "lighter patch" of hair colour for the Yorkshire Terrier at the surgically shaved area. So, the owner asked me not to shave too much of the hair so that the new hair colour patch would not be so obvious.

"No," I said. "I need a large area to operate to remove the chip fragments. If I cut a small area, I may stitch the hair into the wound. The best is to shave the whole body bald and the new hair growth would be of the same colour."

The owner agreed. I asked my groomer Mark about the pricing. $60.00 was too much for her. So she drove to her pet shop to get it done. When she came back, it was still before noon, but the Surgery was crowded.

I must say that not all my Sundays are bustling and I could complete the cases before noon on most Sundays. This Sunday was an auspicious operating date for the owner of the Yorkshire Terrier. Many Chinese pick auspicious dates for marriages too and so I am not a bit surprised that operating dates must be auspicious for the best result of the Yorkshire Terrier.

"My mother's poodle died under anaesthetic at the vet," the owner explained to me although I never asked her as to why she wanted a guarantee that the vet who operated on her Yorkshire should guarantee against any death. "She still keeps the dog's accessories and renew his dog licence."



I did not comment as anaesthetic deaths happen to all vets for various reasons. Now, I am in this situation where the auspicious time had passed. I should not operate. Choose another day.



But the owner had concerns about the toxicity of the fragmented microchip. Not one hard lump under the neck. Two lumps. And 2 weeks had passed. She had not told me about her concerns nor did I have much time to talk to her on this Sunday morning as I was busy with cases.

I did not have any prayers to any God as I operated during lunch time. Used gas only. Intubated the dog in case of the need to give emergency oxygen should the heart fail. Nothing eventful. The lightest anaesthesia was given. The dog woke up before the last stitch was inserted.

The dog came around 3 pm. She was the happiest pet owner in the world as she held her dog up for me to take a picture.

95. The hatchet man

"My son told me he got 16 out of 20 marks for his essay, no thanks to you," the mum spoke to me as a matter of fact. "You had severely criticised his writing when he asked you to review his essay."

Mother Juliet is a very good people manager in a corporation. I believe the her subordinates love her and wants to work with her when she is transferred out of the section.



As for me, I don't have time for being nice to students who need to complete their writing project. I just have little time for myself.

Juliet's son had not written an essay which was easy to read. I said it was written as a quick draft and needed to be re-written with more references.

Why not let Mum Juliet review his essay? She would not do it. So, the hatchet man gets the blame and no credit for his success!

In another case, a mother asked me to help her polytechnic son who wanted to profile me as a "successful" professional. The son had to write on "industry, person or company" success story. The poor teenager, probably around 17 years old interviewed me. We went to a puppy pet shop. I read his second draft after a good lunch treat from the mother and met the family at Crystal Jade in Toa Payoh. The mother had presented me mooncakes and a nice grasshopper present.

Still the poor boy's draft of me was not reading smoothly. I had to tell him to re-write the 3rd time if he wanted good marks. He is still at it. I spent some few hours with him.

Writing is hard work. A hatchet man's job for students of writing is even harder and time consuming!

94. The petshop girl was between the devil and the deep blue sea.

"It was silly of her to tell the dog owner that she had micro-chipped the dog," Mark said to me.

"It is good for her to be honest. If she said a vet did it, the owner would sue the vet or ask for clarification and she would be found defective in her character." I said. "I believe there is no legal requirement that vets must do the microchipping."

Now that the owner was vigorously pursuing this matter of the big lump and the dog crying all the time, the pet shop girl had to do something. She consulted a vet, namely me.

"She is between the devil and the deep blue sea," I said to Mark. Meaning that she had to decide to tell a lie or a truth. They were both difficult choices for her.




I had told the pet shop girl that the big round 0.5 mm swelling at a grain of rice was a microchip which had caused reaction after implant into the dog. The owner had complained that the dog was crying all the time after micro chipping as the dog had a big lump under the skin above the shoulder area.

I examined the active dog. There was no fever or pain in the area between the shoulders.

"The microchip scanner did show pick up the digits," the pet shop girl told me. "When I asked the seller about defective chips, he said I ought to scan first before implant."

"Well," I said. "My scanner cannot show the digits. It is most likely a defective chip but was it defective before the implantation or after?"

"Oh, this dog moved quite a bit during implantation" the pet shop girl said.

"It is possible that the microchip was not intact or well manufactured. After implantation, the body tissue fluids leaked inside the wall of the microchip and so the chip was spoilt. The scanner would not be able to scan it."

She had not thought of the "after implantation" possibility although she did mention about the chip breaking up during implantation.

So there were 3 possibilities of defects - before, during and after. It was good to brainstorm.

But now the owner was not happy. What should the vet advise?

"It is best to remove the big lump," I said. "Though the dog appears healthy today, what happens if he dies in the next few weeks. The owner could attribute to the toxic release of the substances inside the defective chip. Soon you would be sued."

The pet shop girl was vacillating, "I have to pay for the surgery. How much is it?"

"$150 is the cheapest I can offer to help you," I said.

"Can you do it now?"

"Better ask the owner first," I said. This is a potential litigation case. Mark volunteered to talk to the owner.

"It is best that the pet shop girl talk to the owner," I assessed the situation correctly. "Otherwise, the owner thinks there is something she is hiding."

The pet shop girl nodded her head. She had an half-an-hour teleconversation with the owner while I cancelled my lunch appointment! All because of a microchip!

The pet shop girl said gravely, "The owner wants you to guarantee that the dog will not die during the anaesthesia and surgery to remove the chip. Otherwise she would sue your pants off. I told her no vet in the world can guarantee that!"

So that was part of the long teleconversation she had with the owner.

I felt sorry for the dog owner, the pet shop girl and the dog.

I would like to help out. Another case of "Fools rush in where angels fear to tread"? This seems to be such a case. I should opt out. Where taint my reputation for $150 and a potential litigation.

"Chances are good that this young active dog would not die during anaesthesia," I said. "I will use just gas anaesthesia and no tranquilisers. It is much safer." There was an excellent pet shop girl-veterinarian relationship and I would help if I could.

The pet shop girl was "between the devil and the deep blue sea", I think. It was no longer a matter of her paying for the operation. It was whether the dog would die under anaesthesia or should the dog not be operated and die later and get sued for alleged intoxication from leakage of the microchip.

I was encountering a case of "Fools rush in where angels fear to tread".

"Let the owner think about it," I said. "In any case, the dog had eaten and would not be suitable for the anaesthesia. It is best to starve the dog 12 hours before anaesthesia. I want to maximise my chances of success."

So, the pet shop girl reluctantly went back and would let the owner decide. An hour was spent for this matter! The pet shop girl text-messaged to me that I had not charged her for the consultation. Now, how much should I charge for an hour of worries - of the dog owner, the pet shop girl and the vet? Life is full of problems and is not a matter of dollars and cents sometimes!