Tuesday, June 14, 2016

59. Final Video Script - Where to find a bear vet to operate on a bear with ranulas?

HOOK

Bear parts and bear bile are in great demand in China and Asia.
Commercial poachers with guns enter the jungles of Myanmar.
Encounter a mother bear with 2 toddler cubs. Mother bear rushed towards them.
Gun shots. Mother bear died. Cubs dashed deeper into the forests.
Villagers found them. Brought them to the monastery which provides a sanctuary for them and for 2,500 aged and infirmed people.




4 months passed. The bear cubs grow up fast. But one of them has tongue growths from small sizes to gigantic sizes of tennis balls. Cannot eat solid food. Drinks only milk with bananas.






His tongue swellings continue to expand sideways from below the tongue on both sides. They are soft growths. They look like plastic bags filled with jelly. The bear cannot eat and swallow solid food properly. Malnutrition sets in. Left hind limb becomes swollen.

1.  What is the bear suffering from?  Ranulas or sublingual mucocoeles. Define. Illustration by intern.
2.  Is there a veterinary surgeon in Myanmar able to remove the growths.
The monks at the monastery searches for the vet in Myanmar. 






THIS IS A BE KIND TO PETS VETERINARY EDUCATIONAL VIDEO
IN COLLABORATION WITH VETERINARY FILES FROM MYANMAR
SPONSORED BY TOA PAYOH VETS.









IS THERE A BEAR VETERINARY SURGEON IN MYANMAR ABLE TO OPERATE ON THIS ASIATIC BLACK BEAR CUB WITH LARGE RANULAS?



INTRODUCTION
1. SEARCH FOR A BEAR EXPERIENCED VETERINARY SURGEON.

1.1. MYANMAR -
70 MILLION PEOPLE.
TWO ZOOS AT Naypytidaw and in Yangon.
IMAGES



UNIVERSITY OF VET SCIENCE, YEZIN produces around 100 graduates per year.









Is there a veterinary surgeon able to operate on this bear cub?



MIDDLE

1.  SEARCH FOR A BEAR VET.

1.1 SURGICAL AND ANAESTHETIC EXPERIENCE COUNTS
SKILLS HONED BY MANY YEARS OF EXPERIENCE IN THOUSANDS OF SURGERIES OF DIFFERENT SYSTEMS

1.2. RELEVANT BEAR EXPERIENCE
1.3. SPECIALIST EXPERIENCE
1.4. OPERATING EQUIPMENT & POST-OP CARE FACILITIES


2. BEAR SURGERY

2.1 GIGANTIC SUBLINGUAL MUCOCOELES OR RANULAS. Define - obstruction of the flow of saliva inside the salivary duct. 


Illustration by intern.  Normal and swollen tongue of bear. 2 drawings.  Coloour.


2.2 SURGICAL TREATMENT 
   2.2.1  EXCISION OF GLAND

    2.2.2  MARSUPIALIZATION. Excise a piece of excessive swollen tongue tissues. The duct is seen. Suture the edges of the duct to the tongue to createa pouch (fistula, pocket) so that the saliva will drain out directly from the salivary gland. The distal put of the excised area is stitched up while the pouch of around 2 cm wide is created nearer to the proximal part of the tongue nearer to the sublingual salivary gland. 3/0 absorbable stitches are used.

NARRATE IMAGES' TEXT









 



3. BEAR ANAESTHESIA

3.1  Drug combination  from Dr Bacon, the bear vet.
Zoletil + Medetomidine combination for sedation IM. In a Zoletil 50 bottle with Zoletil 50 mg powder, add in 2.5 ml of Medetomidine (Domitor).  Dosage of combined drug is 1.0-1.5 ml/100kg IM.

3.2  After sedation, intubation. Isoflurane+ oxygen gas given to effect.

3.3 In the first operation on Jun 5, 2016,  the bear, weighing 10 kg, was given IM 0.1 ml by the bear vet,  Dr Bacon. After 15 minutes, 0.05 ml was given.   Ms Caroline Nelson was the veterinary nurses monitoring the anaesthesia. Isoflurane + Oxygen gas maintenance safely sustained the operation.








3.4  In the second operation on June 6, 2016, videoed by Dr Sing Kong Yuen, the bear was less stressed. One injection of 0.15 ml IM was given. The bear was sedated within 60 seconds. Dr Bacon scruffed his neck, got him intubated on the operating table and maintained the ansesthesia with isoflurane + oxygen gas.



CONCLUSION
The interest of the bear comes first. As there is an experienced bear vet and bear vet nurse available, they are the best choice. However, I believe that Dr Thein Tun Aung will make a best second choice as he had more than 16 years of practice in veterinary surgery and anaesthesia in Singapore (10 years) and in his own Royal Asia Veterinary Surgery practice (4 years since start up in 2012)










----------------------------------------------------------------------------------------------------------------























58. Edited Video: Bear Ranulas



HOOK






Around 5 months ago, in the jungles of Myanmar, the mother bear with two cubs rushed towards an approaching commercial poacher. He shot and killed her. Her two bear cubs dashed into the jungle and were rescued by the villagers. The villagers sent them to be safe and cared for at the monastery known as Thabawar Centre in Thanlyin, Myanmar.






But one of the two cubs had soft swellings of around 2 cm x 2 cm below the back of the tongue.  The swellings were soft and filled with fluid. They began to grow bigger and bigger over the next 4 months. The cub had difficulty eating and swallowing solid food. He could drink only liquid - mainly milk with bananas only.

The swellings would get infected, the bear would die from malnutrition and loss of appetite if his tongue growths continued to expand to bigger than the size of oranges.




This bear cub's tongue growths were two ranulas. Ranula is a Latin word for "frog". The cystic swellings due to the obstruction of the sublingual salivary duct are soft and fluctuant resembling the underbelly of the frog.

A veterinary surgeon would be needed to help this bear before it is too late.

Is there a vet in Myanmar who has the skills and surgical expertise to operate on this bear?  The zoo vet did not have experience in bear anaesthesia and surgery and so the bear carers looked for local vets. Where to find a competent Myanmar veterinary surgeon out of the 70 million people living in Myanmar? 



------------------------------------------------------


(Narrate)   This is a Be Kind To Pets Veterinary Educational Video
and Veterinary Case Files From Myanmar video sponsored by Toa Payoh Vets.


SUBLINGUAL MUCOCOELES (RANULAS) IN AN ASIATIC BLACK BEAR
 Who in Myanmar can operate on the Asiatic Black Bear with two ranulas?






---------------------------------------------------------------------------------


The monastery people contacted Dr Thein Tun Aung of Royal Asia Veterinary  Surgery in Yangon.
Dr Aung is a skilled and experienced veterinary surgeon, having worked for over 10 years in Singapore's veterinary surgeries and now has a thriving Royal Asia Veterinary Surgery in Yangon started in 2012.

His caseload is heavy every day and the workalcoholic had performed various operations, mainly in dogs and cats. Bone fracture repairs, perineal urethrostomy for male cats not able to pee, Caesarean sections, spays and neuters, hernias and a diverse range of surgeries.

He had also operated on ranulas in dogs. But he has no bear veterinary anaesthetic experience. The  operation in this bear cub on a 5-month-old male Asiatic Black Bear who had two gigantic soft tongue swellings below the tongue would not be a problem.



IMAGE OF RANULAS IN THE BEAR CUB




SUNDAY JUN 5, 2016 SURGERY - MARSUPIALIZATION

However, a vet qualified in zoo medicine and a vet nurse experienced in bear anaesthesia had volunteered to do the surgery and anesthesia earlier.They were the better choices and would operate on Sunday June 5, 2016.

I had already paid my airfares to arrive in Yangon on Friday, Jun 3, 2016 to assist Dr Thein Tun Aung on the invitation of Dr Thin Thin Soe.

I was redundant. So went sight-seeing in Myitkyina from June 3 to June 5 and go back to Singapore on June 6. The bear cub was in excellent hands and the 2-hour operation would be done on Sunday Jun 5, 2016.

There are 2 surgical treatments for ranulas

1. Excision of the sublingual salivary gland which is a more complicated operation.
2. Marsupialization.
Marsupialization in this bear involves the cutting away of a large piece of the swollen tongue tissue, creating a pocket (pouch, fistula) by suturing the edges of the gap of around 2.5 cm wide so that saliva will flow out freely.    

ILLUSTRATION OF MARSUPIALIZATION BY INTERN





MON JUN 6, 2016
9am

I visited the the bear on Jun 6, 2016 at 9 am at the Royal Asia Veterinary Surgery. He was energetic. and much of his tongue growths had been cut away. Around 80% of the sublingual mcocoele was cut off. There was still a swelling on one side.

VIDEO OF BEAR AT 9 AM .




----------------------------------------

MONDAY JUN 6, 2016
3 PM

Around 3 pm,  the bear vet and nurse came. I introduced myself to Dr Heather Jane Bacon, the bear vet and Ms Caroline Nelson, the bear anaesthetist. Dr Bacon  wanted to operate on the remainder of the swelling on the left side. She did not remove 100% of the ranulas as they were extremely large. 

"No point gong back to your downtown hotel to get the surgical and monitoring equipment as there will be massive traffic jams," I said. Dr Aung had the drugs and equipment they needed.   

IMAGE OF TRAFFIC JAM IN DOWNTOWN YANGON



I videoed most of the anaesthesia and operation before I had to go to the airport to catch my Silk Air flight to Singapore. Dr Bacon shared her surgical experiences.

ANAESTHESIA
She injected the sedation in the backside muscle while Ms Nelson distracted the bear cub. The bear cub yelped when injected as you can see in the video. He was sedated in less than 60 seconds. Dr Bacon scruffed his neck and brought him to the operating table. Dr Aung assisted in anaesthesia while Ms Nelson monitored the vital signs.

IMAGES OF SURGERY.


 




 


 






POST-OP CARE BY DR AUNG FOR 6 DAYS


The bear was hospitalised at the  Royal Asia Veterinary Surgery for 6 days before returning back to the Thabawar Centre to be with his sibling.  His sibling has a normal tongue.












CONCLUSION
There is no Myanmar vet who is experienced in bear anaesthesia and surgery. However, I can say that Dr Thein Tun Aung has the necessary equipment, facilities for hospitalisation, skills and experience in veterinary anaesthesia and surgery to operate on the bear's ranulas if no bear vets are available. 

His credentials are:
1987. Graduated from University of Veterinary Science, Yezin. Worked in Kachin State as a vet.
1992 - 2012. Veterinary Assistant for 4 busy veterinary surgeries in Singapore.
2012. Started his own practice,  Royal Asia Veterinary Surgery, Yangon, Myanmar. The practice is very busy every day.

Dr Aung shares his experiences with local vets at lectures and in seminars despite his hectic caseload.  In 2014, he devoted a day to demonstrate surgery to final year students at Yezin University of Veterinary Science.

IMAGES

Needless to say, the better choice is to get a bear vet and nurse in the best interest of the bear. I was glad that the bear cub can now eat solid food (dry dog food and others). He was malnourished as he had been drinking milk with bananas.
















ACKNOWLEDGEMENTS
A big thank you to the following who helped to make this bear operation possible:


1.  Maiken Fransisca
Co-founder and CEO
Giving A Future Animal Aid
http://givingafuture.org/

2.   Dr Heather Jane Bacon, BSc (Hons), BVSc. CertZooMed, MRCVS
Scottish Advanced Practitioner in Zoological Medicine


3.  Ms Caronline Nelson, RVN, BSc
Vietnam Bear Rescue Centre
http://animalsasia.org/






4. Dr Thein Tun Aung, BVS (Yezin)
http://www.royalasiaveterinarysurgery.com/

5. Dr Thin Thin Soe, BVS (Yezin)
http://www.royalasiaveterinarysurgery.com/

6. Dr Khyne U Mar, BVS, MPhil, MSc (Wild Animal Health), PhD, FRCVS



7. Staff and bear caregiver at Thabarwa Center

A BE KIND TO PETS
VETERINARY EDUCATIONAL VIDEO




 & VETERINARY FILES FROM MYANMAR VIDEO
















PRODUCED BY:

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
www.toapayohvets.com
www.queensvets.com


CREDITS
















Wednesday, June 8, 2016

57. A 5-year-old terrapin does not eat for 4 days

Terrapin,M, more than 5 years
Fed shrimps only for the past year

Not eating for 4 days.Why?



Owner is pleased that the shell is no longer white and pale as in the abandoned turtles in the condo pond. Dr Daniel had prescribed medication for shell.

Follow up 3 days post treatment by tel.
Terrapin is eating 6-8 pellets now.
Water has been changed daily in this apartment terrapin.

Many people abandon the terrapins into the condo pond. Now the condo is filled with terrapins with pale shells when the children do not want them. These pale shells could be fungal infections.

56. VIDEO. Who in Myanmar can operate on the 5-month-old Asiatic Black Bear with two ranulas?






HOOK






Around 5 months ago, in the jungles of Myanmar, the mother bear with two cubs rushed towards an approaching commercial poacher. He shot and killed her. Her two bear cubs dashed into the jungle and were rescued by the villagers. The villagers sent them to be safe and cared for at the monastery known as Thabawar Centre in Thanlyin, Myanmar.






But one of the two cubs had soft swellings of around 2 cm x 2 cm below the back of the tongue.  The swellings were soft and filled with fluid. They began to grow bigger and bigger over the next 4 months. The cub had difficulty eating and swallowing solid food. He could drink only liquid - mainly milk with bananas only.

The swellings would get infected, the bear would die from malnutrition and loss of appetite if his tongue growths continued to expand to bigger than the size of oranges.




This bear cub's tongue growths were two ranulas. Ranula is a Latin word for "frog". The cystic swellings due to the obstruction of the sublingual salivary duct are soft and fluctuant resembling the underbelly of the frog.

A veterinary surgeon would be needed to help this bear before it is too late.

Is there a vet in Myanmar who has the skills and surgical expertise to operate on this bear?  The zoo vet did not have experience in bear anaesthesia and surgery and so the bear carers looked for local vets. Where to find a competent Myanmar veterinary surgeon out of the 70 million people living in Myanmar? 



------------------------------------------------------


(Narrate)   This is a Be Kind To Pets Veterinary Educational Video
and Veterinary Case Files From Myanmar video sponsored by Toa Payoh Vets.


SUBLINGUAL MUCOCOELES (RANULAS) IN AN ASIATIC BLACK BEAR
 Who in Myanmar can operate on the Asiatic Black Bear with two ranulas?






---------------------------------------------------------------------------------


The monastery people contacted Dr Thein Tun Aung of Royal Asia Veterinary  Surgery in Yangon.
Dr Aung is a skilled and experienced veterinary surgeon, having worked for over 10 years in Singapore's veterinary surgeries and now has a thriving Royal Asia Veterinary Surgery in Yangon started in 2012.

His caseload is heavy every day and the workalcoholic had performed various operations, mainly in dogs and cats. Bone fracture repairs, perineal urethrostomy for male cats not able to pee, Caesarean sections, spays and neuters, hernias and a diverse range of surgeries.

He had also operated on ranulas in dogs. But he has no bear veterinary anaesthetic experience. The  operation in this bear cub on a 5-month-old male Asiatic Black Bear who had two gigantic soft tongue swellings below the tongue would not be a problem.



IMAGE OF RANULAS IN THE BEAR CUB




SUNDAY JUN 5, 2016 SURGERY - MARSUPIALIZATION

However, a vet qualified in zoo medicine and a vet nurse experienced in bear anaesthesia had volunteered to do the surgery and anesthesia earlier.They were the better choices and would operate on Sunday June 5, 2016.

I had already paid my airfares to arrive in Yangon on Friday, Jun 3, 2016 to assist Dr Thein Tun Aung on the invitation of Dr Thin Thin Soe.

I was redundant. So went sight-seeing in Myitkyina from June 3 to June 5 and go back to Singapore on June 6. The bear cub was in excellent hands and the 2-hour operation would be done on Sunday Jun 5, 2016.

There are 2 surgical treatments for ranulas

1. Excision of the sublingual salivary gland which is a more complicated operation.
2. Marsupialization.
Marsupialization in this bear involves the cutting away of a large piece of the swollen tongue tissue, creating a pocket (pouch, fistula) by suturing the edges of the gap of around 2.5 cm wide so that saliva will flow out freely.    

ILLUSTRATION OF MARSUPIALIZATION BY INTERN





MON JUN 6, 2016
9am

I visited the the bear on Jun 6, 2016 at 9 am at the Royal Asia Veterinary Surgery. He was energetic. and much of his tongue growths had been cut away. Around 80% of the sublingual mcocoele was cut off. There was still a swelling on one side.

VIDEO OF BEAR AT 9 AM .




----------------------------------------

MONDAY JUN 6, 2016
3 PM

Around 3 pm,  the bear vet and nurse came. I introduced myself to Dr Heather Jane Bacon, the bear vet and Ms Caroline Nelson, the bear anaesthetist. Dr Bacon  wanted to operate on the remainder of the swelling on the left side. She did not remove 100% of the ranulas as they were extremely large. 

"No point gong back to your downtown hotel to get the surgical and monitoring equipment as there will be massive traffic jams," I said. Dr Aung had the drugs and equipment they needed.   

IMAGE OF TRAFFIC JAM IN DOWNTOWN YANGON



I videoed most of the anaesthesia and operation before I had to go to the airport to catch my Silk Air flight to Singapore. Dr Bacon shared her surgical experiences.

ANAESTHESIA
She injected the sedation in the backside muscle while Ms Nelson distracted the bear cub. The bear cub yelped when injected as you can see in the video. He was sedated in less than 60 seconds. Dr Bacon scruffed his neck and brought him to the operating table. Dr Aung assisted in anaesthesia while Ms Nelson monitored the vital signs.

IMAGES OF SURGERY.


 




 


 






POST-OP CARE BY DR AUNG FOR 6 DAYS


The bear was hospitalised at the  Royal Asia Veterinary Surgery for 6 days before returning back to the Thabawar Centre to be with his sibling.  His sibling has a normal tongue.








CONCLUSION
There is no Myanmar vet who is experienced in bear anaesthesia and surgery. However, I can say that Dr Thein Tun Aung has the necessary equipment, facilities for hospitalisation, skills and experience in veterinary anaesthesia and surgery to operate on the bear's ranulas if no bear vets are available. 

His credentials are:
1987. Graduated from University of Veterinary Science, Yezin. Worked in Kachin State as a vet.
1992 - 2012. Veterinary Assistant for 4 busy veterinary surgeries in Singapore.
2012. Started his own practice,  Royal Asia Veterinary Surgery, Yangon, Myanmar. The practice is very busy every day.

Dr Aung shares his experiences with local vets at lectures and in seminars despite his hectic caseload.  In 2014, he devoted a day to demonstrate surgery to final year students at Yezin University of Veterinary Science.

IMAGES

Needless to say, the better choice is to get a bear vet and nurse in the best interest of the bear. I was glad that the bear cub can now eat solid food (dry dog food and others). He was malnourished as he had been drinking milk with bananas.
















ACKNOWLEDGEMENTS
A big thank you to the following who helped to make this bear operation possible:


1.  Maiken Fransisca
Co-founder and CEO
Giving A Future Animal Aid
http://givingafuture.org/

2.   Dr Heather Jane Bacon, BSc (Hons), BVSc. CertZooMed, MRCVS
Scottish Advanced Practitioner in Zoological Medicine


3.  Ms Caronline Nelson, RVN, BSc
Vietnam Bear Rescue Centre
http://animalsasia.org/






4. Dr Thein Tun Aung, BVS (Yezin)
http://www.royalasiaveterinarysurgery.com/

5. Dr Thin Thin Soe, BVS (Yezin)
http://www.royalasiaveterinarysurgery.com/

6. Dr Khyne U Mar, BVS, MPhil, MSc (Wild Animal Health), PhD, FRCVS



7. Staff and bear caregiver at Thabarwa Center

A BE KIND TO PETS
VETERINARY EDUCATIONAL VIDEO




 & VETERINARY FILES FROM MYANMAR VIDEO
















PRODUCED BY:

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
www.toapayohvets.com
www.queensvets.com


CREDITS
















Thursday, June 2, 2016

55. INTERN CLARA VIDEO PRODUCTION - a male cat cannot pee for one day - FLUTD

Feline Lower Urinary Tract Disease is a common disease in male cats in Singapore.



Use the two images

URINE TEST -  Get the lab results of urine test and blood test (key in significant findings)  and discuss finding with Dr Daniel




TREATMENT.   Urinary catheter   Bladder irrigation with saline 

54. INTERN CLARA Heartworm disease in 2 dogs in Singapore

Jun 2, 2016



HOOK
Case 1.  In 2008, a coughing young Rottweiler from a Pasir Ris farm collapsed on arrival at Toa Payoh Vets. What is the cause of his death before his time?


See bottom of page or goto
(Images and Toa Payoh Vets case study at)
http://www.bekindtopets.com/animals/20090139Heartworm_Rottweiler_Singapore_ToaPayohVets.htm

Extract gist of article and adopt same structure as for Case 2. How does the vet diagnose and treat heartworm?


Case 2. In 2016, a stray dog was adopted by a Singaporean family. He had an examination at a veterinary practice.  vet.......heartworm disease.  







BKTP





(Narrate slide)

INTRODUCTION

Mosquitoes can never be eliminated in Singapore. They transmit diseases like denque fever in people and heartworm disease in Singapore. This video is a case study of an adopted stray dog that had heartworm disease.



CONCLUSION


Deaths of the dog depend on the severity of the infection  (Class 1, 2, 3).
Prevention is by oral medication monthly or by an annual injection at your vet.
Heartworm test yearly is advised but few owners do it.



REFERENCE

http://www.bekindtopets.com/animals/20090139Heartworm_Rottweiler_Singapore_ToaPayohVets.htm


CREDITS



--------------------------------------------------------------------------------------
 

Case recorded: Jan 29, 2008 (Chinese New Year 4th Day)
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

"There is an emergency," my assistant interrupted my consultation. I excused myself Singapore Rottweiler sudden death heartworm disease. Toa Payoh Vetsand walked quickly to the outside of my Surgery on this bright sunny afternoon of August 27, 2008. The eyes of the other clients followed my move to see a large Rottweiler struggling to stand up.

My assistant inserted a thermometer to take the rectal temperature. It was 39.9 deg C.  The male Rottweiler shook and shivered on the floor as if he had an epileptic fit. Within a few seconds, he collapsed and stretched out motionless on the floor. He died fast. I examined his eyelids and opened his mouth. The eyelids were snow white. The mucous membranes of his mouth and tongue were cyanotic. 

"Doc, what happened?" the gentleman asked. "Last week, my workers brought the dog to Vet 1 for treatment of coughing. Vet 1 said he had heartworm infection. Vet 1 gave me Proheart tablets to bring home and give them once a month to the dog. The dog did not feel well for the past few days and I bring him to you."
Ask your vet to do an annual blood test for heartworms. Singapore.Toa Payoh Vets"From the signs, the dog died due to a lot of internal bleeding," I said. "Why did you give Proheart tablets when the dog was suffering from heartworm infestation?" Proheart tablets are meant to prevent heartworm infestation. When a dog has heartworms, he should be treated by another drug but not Proheart. 

"There is another Rottweiler - a female," I remembered having sourced a pair for this gentleman. The female had no signs of coughing and was eating normally. 

"Get her tested for heartworm."  I advised. She was tested positive for the microfilaria, but her blood sample did not show anaemia. She still had healthy pink gums and had no fever. Therefore, her heartworm infestation was mild. At this stage, X-rays of the heart and nearby blood vessels were not taken although it would be ideal. The owner had a budget for treatment and X-rays would increase his costs.     

The owner kept the appointments to get the female injected on 2 days by a drug called Immiticide into the left back muscles on August 29 and then on the right back muscles on August 30, 2008. 

Then she was rested in a cage for one month, that is, without exercise. After one month, the owner brought her for blood testing. There was negative heartworm and no anaemia.  

"You can either use Proheart tablets to give her monthly or get her a Proheart injection yearly," I advised. "As the tablets come in six tablets per package, you will need to remember to buy the tablets every 6 monthly." The owner opted for the injection.
Rottweiler. Female, 4 years. Singapore. Occult Dirofilariasis (no detectable microfilaria). Toa Payoh Vets.Did Vet 1 give him Proheart tablets after diagnosing heartworm via blood tests?  He or she would open himself or herself to a case of medical negligence. 

I did not instigate the owner to commence legal action. The burden of proof of medical negligence would be on the owner. The only beneficiary would be the lawyer who would charge thousands of dollars and that would not be good for this gentleman.    

I just felt sad that this dog was one I helped the owner to buy and therefore had vaccinated him as a puppy. He did not come for vaccinations after puppyhood. The owner had high expectations of the pair producing babies but nothing happened.

After the excitement of puppyhood, many Singapore dog owners forget about the yearly vaccinations. Many bring their dogs to the groomers to beautify the dogs every 2 months. But when it comes to vaccinations, they forget about it. When they are told about heartworm prevention, they are simply not interested. With better education, the younger dog owners are more careful. 

Rottweiler, Female, 4 years. First Immiticide injection IM given on left epaxial muscle. Toa Payoh VetsAs at January 29, 2009, the female Rottweiler is in good health as I write this case. The owner brought a male Rottweiler soon as Singapore does not have many Rottweilers for sale at any one time. I did not get to see the puppy. The puppy was given Proheart tablets monthly. I expect the owner would not forget the monthly medication.  In conclusion,  no heartworm prevention tablets should be given to a dog with heartworm infestation in general. As Immiticide injections are very expensive, it is hard to expect stray dogs to be treated with this drug. 

NOTE:  Additional Tests:
X-rays of the heart and the blood vessels (swelling of right side of the heart and blood vessels, view of adult heartworm), blood tests for anaemia (eg. severe anaemia indicates severe infestation) and urine tests for proteinuria (marked urinary protein loss indicates severe infestation) are ideal to determine the severity of heartworm infestation and the progress of Immiticide treatment. The financial costs of so many tests need to be discussed with the owner first as the overall cost of treatment amount to over $2,000 in Singapore and gives the owner a financial shock. In this case, only blood tests before and after the Immiticide injections were carried out so as to fit the budget of the owner.

Wednesday, June 1, 2016

53. INTERN CLARA. Research on canine Caesarean sections by Toa Payoh Vets you


HOOK




What shall the breeder do? His Shih Tzu has a water bag going in and coming out for the past 2 hours. Yet, no puppy was delivered naturally.  Shall he wait longer? Shall he rupture the water bag himself and pull the puppy out? The puppy may be stuck tightly inside the pelvic canal and he will not be able to pull it out.











This is a BE KIND TO PETS Veterinary Educational Video sponsored by Toa Payoh Vets, Singapore.The objective is to bring Veterinary Medicine and Surgery Alive to pet owners and veterinary studuents.

This video shares practical tips and advices gained from performing over 200 cases of Caesarean sections at Toa Payoh Vets from 2003 to 2016.

INTRODUCTION


In 2003, most of the professional dog breeders in Singapore sent their dogs to Dr Sing Kong Yuen of Toa Payoh Vets for Caesarean sections. Their vet was suspended from practising.

From 2003 to 2006 and from 2015 and 2016, around 200 canine caesarean sections were performed. 

Most of these cases are recorded in www.toapayohvets.com at:



http://www.bekindtopets.com/animals/20081201PAGE2_Dog_Surgery_Anaesthesia_ToaPayohVets.htm


MIDDLE
In the Shih Tzu mentioned above, Dr Sing did an emergency caesarean section and a healthy pup was delivered alive. 

This video discusses the process involved in managing the 2 types of caesarean sections, also called C-sections in dogs. These are the Elective and the Emergency C-sections.


PART 1. -  ELECTIVE C-SECTION

Much planning must be done to ensure a good outcome for the dam and her puppies. The following are the guidelines:

1.  59 - 60 from the first breeding date usually results in mature, vigorous, active puppies in small breeds like the Chihuahua and Yorkshire Terriers in Singapore.

2. Serum Luteinizing Hormone (LH) assay is a very excellent laboratory test to schedule an elective Caesarean section. I have heard of this method being done by an English Bulldog breeder in Thailand as this breed sells at a very good price when exported to Britain. The progesterone concentration is approximately 2 ng/ml at the initial stage of ovulation. This level indicates an LH surge. Most bitches will whelp 65 days after the LH surge. The first breeding is advised at Day 3 and Day 5 after the progesterone level reaches 2 ng/ml.     

3. If the serum LH assay is not available, an ultrasound scan at Day 23 after the first breeding may be done. The gestational vesicle is usually round at Day 23 and oval at Day 25.  Foetal death/resorption and early pyometra may be detected during the ultrasound scan.

4. Resting rectal temperatures from Day 55 after the first breeding to be done by the breeder.
Rectal temperatures drop to 99 degrees F (37.2 degrees C), 8 -12 hours before the onset of labour.  A breeder can be advised to monitor the resting rectal temperature from Day 55.  For practical purposes, I advise Day 58.

PART 2 - EMERGENCY C-SECTION.
The guidelines are as follows:


Dystocia (difficulty in giving birth) is the reason for seeking Emergency C-sections. Some cases are shown

(Clara to read the text/image) rather than flashing them by. 

 


PROCESS AT TOA PAYOH VETS

1. The bitch is weighed. Rectal temperature is taken. A physical examination is done.


 

2. Blood for a serum chemistry panel and ultrasound scan are advised.
3. Anaesthesia & Surgery Record book.  Performance of a vet is monitored. Time when the dog is given gas via the gas mask to time at completion of stitching.



4. Pre-anaesthetic medication. Glycopyrrolate + butorphanol is not done for all the bitches of the small breeds as I find that there is rarely any excitement phase during induction by isoflurane gas in the mask in the small breeds.

4.1 Some Singapore vets induce with propofol IV, intubate and then maintain with isoflurane + oxygen. Since 2003, over 200 Caesarean sections, mostly small breeds for the dog breeders have no pre-anaesthetic medication. Butorphanol may be given after Caesarean section so as not to cause drowsiness in the pups.

5. The bitch may be given oxygen therapy by mask for at least 5 minutes before induction if she is distressed. 

6. An IV Hartmann's Solution is given.  5% glucose IV for 5 minutes will be given if the bitch is in distress.


GAS ANAESTHESIA. The dam is given isoflurane and oxygen gas via a gas mask.. 

 

When the dam is sleepy, an endotracheal tube is inserted to continue giving the gas to the dog.

















Nearly 100% of the small breed cases do not show excitement during induction by gas mask and therefore pre-medication anaesthetic is not given. For fractious dogs, a container instead of a mask can be used. Healthy puppies are vigorous and cry within 2 minutes after delivery.



SURGERY
1.  There are 3 surgical approaches for C-sections. Each vet has his or her own way. These are:


1.1  Exteriorise the whole uterus. A longer skin and abdominal incision is needed.
1.2  Two uterine horn incisions. This is said to be speedier in removing pups.
1.3  Uterine body incision.  Some vets are worried that the cervix may be incised.

Dr Sing Kong Yuen practised the uterine body incision for his over 200 Caesarean sections. The skin wound is also much shorter and the stitches are less likely to break down.  (Clara to narrate the text in the image)

 


ILLUSTRATION OF SURGERY (Clara to read the text in the illustrations)






2. The pup is removed from the uterus and the chorionic and amniotic sacs are opened. The umbilical cord is clamped 1 cm away from the puppy's abdomen. Another forceps clamp lower down. The umbilicus is cut. I do not find any difficulty in removing the placentas from the uterus, using gentle manipulation to loosen the attachments.

 




2.1  It is very important to exteriorise the empty uterine horns including the ovaries. This will ensure that there is no hidden pup near the ovaries. Dr Sing also palpate the pelvic area to check for pups stuck near the cervix.

If this inspection procedure is not done, some breeders may return with a pup born naturally after Caesarean section!

3. The assistant or breeder takes over the pup. The pup's mouth and nostril are cleared with a gauze swab. The pup is rubbed on the neck with his head down to stimulate breathing and to clear the lungs of fluid. Neck skin pinching may be used to stimulate breathing.

4. Swinging the distressed pup does not cause intracranial bleeding in Dr Sing'sexperience. There are vets and breeders who believes differently. Dr Sing grips the pup's head with both hands, stand with my legs apart and swing the pup from above my head downwards. A firm grip is necessary to prevent the pup slipping through the hand and dropping onto the floor. 

ILLUSTRATION


Clara
google "swinging puppies toa payoh vets" and show the video clip (relevant section).

5. Stitching the uterus. Two rows of inverting continuous sutures. I use absorbable 2/0 or 3/0 sutures for all closing of the uterus, muscle, fascia and skin in simple interrupted sutures. Buried subcuticular layers may break down and cause irritation under the skin and so I have not used them.  

6. Oxytocin and antibiotic injections are given SC. Some vets give buprenorphine (0.075mg/10lb) IM.

7. A bloody vaginal discharge after Caesarean section is normal and does not last more than 3 days.

8. Ensure that the puppies are introduced to the dam and suckle before they go home. The owner is advised to supervise the dam closely for the next 24 hours as some do kill the puppies.

9. If the puppies do not eat after 24 hours or gain weight, tube feeding with supplemental milk is advised.


10. A calcium injection SC is given for small-breed dams producing more than 3 puppies. Some distressed dams are sent home with another bottle of IV Hartmann's solution. Some dams do not eat for the past 2 days before the estimated due date of 58th day for Chihuahua. An IV calcium drip may save the pups are in this case.



CONCLUSION

 Dr Sing's best advices to dog breeders who do not want to incur high medical costs are as follows:

1.  The water bag appears at the vagina but there is no puppy delivered naturally.  If the first puppy is not born within an hour of these strong contractions, take the bitch to the veterinary surgeon for an emergency Caesarean section.  By the time the surgery is done, 2 hours will have passed.

2.   Seek an emergency C-section if labour does NOT resume within 2 hours after the birth of the previous puppy or the bitch is restless, feverish, ignores her puppy or has a bloody and/or foul-smelling vaginal discharge.   



Clara to narrate the main points of the text of all slides, not just showing them







3.  In small breeds like the Chihuahua and Yorkshire Terriers,less than 2 hours after the birth of the previous puppy is best practice. Chances of puppy survival are slim if delay is more than 3 hours. There will be distressed puppies and puppies not suckling after the surgery.

4. Breeds like the Chihuahua (small pelvis), Pekingese, Bulldog (big head), Boston Terrier, Toy Poodle may require Caesarean deliveries if you wish to have healthy live puppies.



REFERENCES

www.toapayohvets.com

http://www.bekindtopets.com/animals/20081201Dog_Surgery_Anaesthesia_ToaPayohVets.htm

http://www.bekindtopets.com/animals/20081201PAGE2_Dog_Surgery_Anaesthesia_ToaPayohVets.htm


EXAMPLES OF CASES DONE BY DR SING KONG YUEN
 Clara to narrate the text's main message


 Infections do occur in mid-pregnancy. Blood tests show kidney failure in this dam.





Chihuahua not giving birth after 2 hours of labour pains. An emergency C-section saves some pups if performed less than 2 hours after labour pains.








A black greenish vaginal discharge indicates puppy death and placental necrosis.




8 hours' delay in seeking C-section results in a dead pup.


A large pup obstructs other smaller pups from being born.




SINGLE PUP SYNDROME refers to only one pup conceived. The pups grows bigger every day but there are no signs of labour pains.

Occasionally, a single pup over 70th day may be born naturally. But most will die as they have grown too big in size to be born via the vagina.








70TH DAY. PUP ALIVE. One breeder claims that 73rd day, single pup can be born naturally. But this is the exception rather than the rule.


EXTRA-LARGE PUPS NEED C-SECTION TO SURVIVE




LARGE PUPS JAMMED INSIDE UTERUS






lst PUP BORN BY VAGINA. NO 2ND PUP. HOW LONG TO WAIT?


MUMMIFIED FOETUS AND STILLBORNS.  Ultrasound.




Much depends on the breeder's judgment on when to go for the C-section. The earlier it is done, the higher the chances of puppy survival.

A






Yorkshire Terriers usually require elective C-sections although some may be born naturally. As most Singapore dog breeders do not wish to incur medical costs on regular ultrasound scans and check ups, an elective C-section will be advised for small breeds with many puppies. 











The above are a selection of Dr Sing's interesting C-section cases.  Many home breeders have no time to research on the reproduction of the dog as they lead hectic lives. 









They may find the following information useful
REPRODUCTION IN THE DOG


1.  By 4 months of age, male dogs may mount the owner or show interest in the sexually receptive female.  However, males usually can't successfully breed till they are over 9 months old.

2.  Female dogs experience their first bleeding at about 6 months of age (the first breeding cycle).  The cycle is usually twice a year but may be more than two or less. The Basenji cycle once a year.

3.  Large breeds of both sexes may take 18 - 24 months to become sexually mature.

4.  A healthy bitch will have "heat" all her life but reproductive problems occur generally after 8 years of age.  Some vets advise no breeding after 5 years of age as puppy quality is poor.

5.  The CANINE "HEAT" has 4 stages.

5.1  PROESTRUS. Around 9 days. Swelling of vulva and a dark, bloody red vaginal discharge.

5.2  ESTRUS. Around 7-9 days. When the progesterone concentration is approximately 2 ng/ml, this indicates the initial stage of ovulation. This stage is known as the Luteinizing Hormone (LH) surge. Most bitches whelp at 65 days after the LH surge. Vaginal discharge is now a faint pink colour and the bitch is sexually receptive. Some vet reports advise first breeding to be at the 3rd and 6th day of estrus.

5.3  DIESTRUS. Around 2 months.

5.4  ANESTRUS. Around 4.5 months.

6. GESTATION (Conception to birth period of time).  Average is 63 - 65 days.  Puppies may also be born between day 56 - 72.  Some reports mention gestation as 59 - 63 days after first mating.  In the SINGLE PUP SYNDROME, the pup may be born naturally at the 72nd day but a Caesarean section is advised for small breeds like the Chihuahua as there will be dystocia and foetal distress. 

7.  PREGNANCY DIAGNOSIS BY THE VET. Day 23 - 27 after the first breeding is preferred for abdominal palpation of spherical gestational vesicles.  Some vets advise ultrasound at Day 23 when spherical gestational vesicles can be seen and at Day 25 when these vesicles become oval. Foetal death/resorption and early pyometra may be seen during ultrasound scan at Day 23 and 25.  

8.  ABDOMINAL SWELLING is usually seen at Day 35 or 42.  Large dogs that carry puppies high beneath their rib cage may not look pregnant. 

9.  NIPPLE SWELLING and colour from darken to rosy pink at Day 40. 

10.  RESTING RECTAL TEMPERATURES drop to 99 degrees F (37.2 degrees C), 8 -12 hours before the onset of labour.  A breeder can be advised to monitor the resting rectal temperature from Day 55. 

11.  lst STAGE of labour  lasts 6 - 24 hours.  Restless, pant, shiver, vomit, pace, scratch floor, vomit.
 

12.  2nd STAGE of labour - birth of puppy.
 


13.  3rd STAGE of labour - explusion of the placenta. Usually passed out 5-15 minutes of each puppy birth.

14.  If there is more than 1 puppy, 2nd and 3rd stages alternate.

15.  VAGINAL DISCHARGE shows imminent birth. Then involuntary muscle contractions. The water bag may appear at the vagina but there is no puppy delivered naturally.  If the first puppy is not born within an hour of these strong contractions, take the bitch to the veterinary surgeon for an emergency Caesarean section. 





16.  See your vet for an emergency Caesarean section if labour does NOT resume within 4 hours after the birth of the puppy or the bitch is restless, feverish, ignores her puppy or has a foul-smelling vaginal discharge.  In small breeds like the Chihuahua and Yorkshire Terriers, I will advise less than 2 hours after the birth of the puppy as chances of survival are slim if further delay leads to distressed puppies and puppies not suckling after the surgery.     




CREDITS









Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

Toa Payoh Vets, Singapore
www.toapayohvets.com



Queens Veterinary Surgery, Singapore
queensvets.com

Consultant, Royal Asia Veterinary Surgery, Yangon, Myanmar
www.royalasiaveterinarysurgery.com



Written by Dr Sing Kong Yuen: 
June 5, 2016
Hotel Madira, Myitkyina, Myanmar

Dr Daniel Sing etc
Clara   etc.