Thursday, March 31, 2011

380. Keratoconjunctivitis sicca in old Shih Tzus - Duty of care

Many times, an owner of old Shih Tzus would consult the vet for some problems that are not related to the eyes, such as diarrhoea. Many times, the vet will see dry eyes as shown in the image.

Since the owner has not complained about the keratoconjunctivitis sicca, the vet would just treat the diarrhoea, ear infections or skin disease and that would all.

Has the vet a duty of care to educate the owner that she needs to use eyedrops to relieve the dog's discomfort & pain in dry eyes when the consultation is not related to the eyes?

What is a duty of care of a veterinarian when the dog is presented for diarrhoea? It is to correctly treat the diarrhoea. Therefore, the vet needs not bother with the dry eyes.

However, many Singapore pet owners are unaware that they can relieve the old Shih Tzu's dry eye discomfort and pain. The owner attributes dry eyes to old age and so what? The old dog rubs his ulcerated eyes daily. It is due to old age!

Once a vet bothers to educate the owner, she usually takes the time and trouble to ensure that the eyes are wetted and lubricated.

I usually advise clipping away the hairs around the eyes so that the facial area can be well cleaned and applying eye drops minimum twice a day. I was manning the counter to get a feel of the front-line veterinary matters.

Recently, an older woman phoned to get the eye drops prescribed by my associate vet. "I have to give you another brand," I said. "It is from the same company. The brand you want is being ordered."

"Please get for me ....eye drops next time," the woman in her 50s said. "The dog's eyes are now much cleaner with that brand."



P.S
Reference: http://www.businessdictionary.com/definition/duty-of-care.html

DUTY OF CARE


A responsibility or a legal obligation of a person or organization to avoid acts or omissions (which can be reasonably foreseen) to be likely to cause harm to others.

Duty of care is owed by an accountant in correctly preparing a firm's accounts, by an auditor in confirming an firm's financial statements correctly present its financial position, by a director to shareholders in husbanding the enterprise's resources, by a manufacturer to consumers for the safety of product, and by every party to a contract to the other contracting parties.

Wednesday, March 30, 2011

379. A scholarship in Political Science and Veterinary Science

E-MAIL TO DR SING DATED MAR 30, 2011 FROM AN AMERICAN VOLUNTEER
FOR HIS OLD UNIVERSITY FOR SCHOLARSHIP SELECTION OF ONE SINGAPOREAN

Thanks so much for taking the time to talk to .... yesterday. You gave her a great deal of good information. I support your advice to her to think carefully about her career choices. A clever interviewer will be alert to people who are not serious and are simply fishing for some way to pay their university tuition.
MY COMMENTS
The girl from a brand-name school, Raffles Institution could easily get into the top colleges in the U.S, U.K or Australia. A great number of her cohort of 1000 would probably get 3As but she has 6As. That was an excellent academic achievement.

It opens doors to any scholarship but she was the only candidate with Science and Maths amongst seven short-listed for a US scholarship interview. The scholarship was for a liberal arts degree in a US university which the volunteer told me is a sister school of Williams College attended by Senior Minister Goh Chok Tong. When well known names are thrown in, it gets attention of the other party

So this girl attended would have got Wesleyan Freeman Asian Scholarship if she would study Political Science, according to the volunteer whom I shall call Mr Baker.

Mr Baker was a volunteer but not an interviewer for his University which would offer 1 scholarship for each of the 11 Asian countries. I believed that this girl was top choice but she wanted to study Veterinary Science. Mr Baker said: "Political science is not veterinary science". He emailed to me to ask me if I would advise this girl by phone. Instead I advised meeting as phone calls were a waste of time if one is to advise a bright young lady on her career (as a volunteer).

Mr Baker arrived early by cycling from Clementi to Toa Payoh as I discovered later. I was surprised. "You must be one of those crazy and eccentric Ang Mos (Caucasians)," I was wondering how he could arrive at Toa Payoh Vets without sweat and how dangerous it was to cycle so far. I must say he was lean and fit at the age of 50 and could put many a younger 40-year-old man to shame in fitness.

The young lady arrived in a taxi on time. As my surgery was small in space, I suggested we had a talk at the coffee shop behind. A bespectacled fair lady with long bronze gold hair and of pleasant first impressions. We sat and Mr Baker offered to buy drinks though initially he planned to introduce us and go home. I insisted that he stay to "chaperone" me, not that I need one as it was a public place. Mr Baker with his receding forehead and baldness presents an energetic intelligent appearance and is the type who does not want to take up too much of my time.

Our talk lasted around 2 hours as Mr Baker offered to buy lunch too. We ate at the coffeeshop. So was this scholarly lady passionate about veterinary medicine? She has a dog. But not one substantial piece of evidence that she had cared for animals at the SPCA, veterinary surgeries or animal welfare groups or any activity related to animals in Singapore.

Her parents wanted her to study medicine or law as they considered veterinary medicine dirty. In any case, they can't support her to study veterinary medicine overseas and therefore she has to get a scholarship. In this modern age and in a developed modern Singapore, there are still Singapore parents who want their progeny to fulfill their dreams of not being able to become a doctor or lawyer! And to consider veterinary medicine as dirty! In the UK where I studied some 40 years ago, the demand for veterinary studies far exceed the demand to study medicine and I believe this is the situation in the U.S! Here, we have Singaporean parents looking down at a superstar academic who wants to study veterinary medicine.

Will she get the AVA veterinary scholarship? The 6As will get her into past the door into the interview room as this was what must have happened at the US university interview she attended recently. Academic excellence still give the best cherries despite some Singapore parents talking about over-stressing their children and asking for less pressure of homework in the Singapore tuition and education hot bed.

"But the AVA is looking for regulators and enforcers to check on far away farms in China and other countries to accredit them for export of meat to Singapore," I said to this girl. "SVA is not looking for practitioners in small or large animal medicine. You look kind of delicate," I said. She had said she was interested in farm practice with the large animals. Most vets have run away from rural veterinary practice and here she wanted to do that.

Typically and stereotypically, most bright Singaporean lady scholars completing their A levels spend most time studying very hard and therefore they are fair and delicate looking. At least those few ladies who applied for internship with me gave me this impression.

Will she get the AVA scholarship? She had to write 2 articles. What was her most important achievement and why she wanted to study vet medicine? Without supporting evidence, I wonder how she wrote about in the 2nd article required by AVA?

We hope she will get the scholarship. The kind gentleman aged 50 gave some advices like student loans, working for a few years first. He got a scholarship from the GI bill which provides scholarship for Americans who had served in the US Army. I thought he was the average man as he had retired and had said during our meeting: "I have one foot in the grave". Men who are past 50 and who tells me they have one foot in the grave don't impress me.

I said to this kind gentleman who is actually a top scholar at Harvard or some top US university and an inventor in military engineering after I asked him more about his background: "If you have one foot in the grave at the age of 50 years, I must be having one and a half foot in the grave as I am 60 years old!" Men who are in their 50s do think that way. I wonder if women of similar age do think similarly?

I say he is a kind man because he spent time to help this stranger, a girl with 6As to know more about veterinary science by contacting me. He was not happy with the interviewers of his old school wanting to direct this girl to study political science and thereby giving her the scholarship. Americans are always brutally honest and into your face if they like some behaviour?

In the end, the scholarship went to another girl and from what I know, this girl had the passion for the arts which included writing, literature and education as I was told that this girl with fuzzy hair (I think it was fuzzy hair) gave education classes at the School of Thought. Have you ever heard of such a school or have I got the wrong name?

Political science is far removed from veterinary science. But I would take the political science scholarship if I have 6As and study in the US. Excel in this scholarship and then get a scholarship to become a veterinarian if my parents have no money to sponsor me. After all, how many young Singaporeans can have a chance to study in a top liberal arts school in the US?

If a young adult has passion in veterinary medicine and the parents don't have the S$300,000 to pay the tuition fees, taking this US scholarship will broaden her mind and make him a better all rounded veterinarian if she studies vet medicine as a mature student.

But a lady with 6 straight As can have her pick of scholarships. So what if she can't get the AVA scholarship? She has others. So, does she have the passion for veterinary medicine or not? Was she fishing for the best scholarship? Most of her 100 friends in Raffles Institution want to be doctors and so I expect lesser competition for her.

Based on her lack of animal activism veterinary and welfare work in her past years at Raffles Institution, it would be hard for her to get the AVA scholarship if there are others with track records.

P.S
1. According to the kind gentleman, the Wesleyan Freeman Asian Scholarship Program provides expenses for a 4-year course to study "Political Science", not "Veterinary Science" for one exceptionally able Asian student annually from one Asian country. So, he was quite pissed off when the interviewers asked this girl to study Political Science instead, did some research and e-mailed to me to advise her about veterinary medicine.

In any case, the Wesleyan University, Middletown, Connecticut provides a liberal arts education. The Freeman Foundation provides the scholarship. Sadly, he told me that Mr Freeman, an original founder of AIG group has just passed away.

Selection criteria included academic achievement, intellectual curiosity, a high level of discipline and commitment, strong personal qualities, extracurricular involvement especially community service and English language ability.

2. Williams College, a highly selective private liberal arts college, Massachusetts.

3. Volunteerism is human kindness. Mr Baker is not paid by his University. In fact, he paid for the drinks and lunch. Volunteerism also open doors to meet other people when you help somebody.

4. Mr Baker appeared fresh and clean after cycling from Clementi to Toa Payoh because he changed his clothes at the Toa Payoh Swimming Pool. He has 3 engineering inventions of great interest. He must have graduated from a top engineering University in the US when I implied that in some unknown manner that he graduated from some average university after studying at Wesleyan University. Never judge a book by its cover! His inventions were in military engineering and quite impressive to me as a veterinarian. Actually if you think of it, his inventions to protect naval ships from small terrorist ships ramming with explosives are the equivalent of antibodies (with spiked attachments) fighting against antigens (foreign invaders like bacteria or terrorist)!

Tuesday, March 29, 2011

378. Why can't my Silkie pee normally after urinary stone removal?

DRAFT CASE REPORT
11 DAYS AFTER URINARY STONE REMOVAL CONSULTATION
A puzzling case of the male neutered Silkie, 6 years old who can't pee normally after urinary stone removal by an experienced vet. Around 11 days after surgery, the owner consulted me.

OWNER COMPLAINS ON DAY 11 AFTER SURGERY BY VET 1 THAT THE DOG HAD DIFFICULTY URINATING URINATE WHEN HE DRANK WATER. THIS HAPPENED >12 TIMES/DAY. WHY?

HE IS SUPPOSED TO BE ABLE TO PEE NORMALLY AFTER REMOVAL OF THE URINARY STONES BY VET 1. WHAT SHOULD I DO?

I palpated the bladder. It was empty. Therefore, there was no urethral obstruction in the sense of blockage of urine flow by the stones at behind the os penis (see X-ray of original condition before operation by Vet 1. Vet 1 had given the X-ray to the owner and I asked her to e-mail to me and this was done on Mar 27, 2011 for me to review.

I told the owner that there was no problem. If a vet wants to prove that there was no obstruction by catheterising the bladder in the presence of the owner, that does not prove anything as palpation had already revealed an emptied bladder and therefore no urethral obstruction.

Bladder palpation would have told the vet that there was no obstruction at that point of time. The dog did not have urethral obstruction generally. So what was the cause of this puzzling behaviour? Cystitis is a possibility. UTI possible. A small stone from the bladder obstructing the urethra? Possible as the X-ray would not take the kidney area traditionally.

(Tip: For good practice in veterinary medicine, it is best to keep an X-ray record if the vet wants to give away the X-ray or record that the owner has it).

As the owner is living far away from Toa Payoh and not to incur more veterinary costs for her, I advised observation on the initial complaint around 12 days post-stone removal by Vet 1. I had the nylon-like stitches in front of the prepuce removed at the same time and gave an anti-inflammatory and antibiotics. Then I prescribed antibiotics, SD diet x12 and asked for urine sample. X-ray of the bladder will be an option if necessary.

Some confusion from the owner's description of the dog's behaviour. Was the dog having difficulty peeing or starting to urine-mark when he was about to drink or he had some bladder infection or urinary stone stuck behind the os penis?

All stones had been taken out by Vet 1 in my opinion as I did not observe the surgery. It is possible that there is urethral obstruction from a stone or two from the bladder. However, economics deter more X-rays and tests for the time being and I did conservative treatment to "dissolve" the remaining stones (probably very small if present and from the kidneys) using S/D diet and monitoring of the urine.

Instead of another X-ray which would cause the owner stress and money, the owner was asked to monitor the dog's peeing behaviour and given S/D diet to dissolve the remaining stones. Vet 1 had not got the results of the crystals of the stones removed. The owner's e-mail report is as follows:
E-MAIL TO DR SING DATED MARCH 21, 2011
14 DAYS AFTER SURGERY TO REMOVE URINARY STONES BY VET 1

Subject: Dog X-Ray ID: 2496 Dog with urinal stones
Date: Mon, 21 Mar 2011 02:33:44 +0000


Dear Dr Sing,

As per your request, herewith my dog's x-ray given by (name given) Vet 1, there is only 1 photo of x-ray. i will be bringing his urine sample down on this Thursday 24/03/2011, around 7pm. Had spoken to you on Sunday 20th March morning, about my dog's urine behaviour after the urinal stones removal.



Duration Monitored: 30-45mins

Dogs behaviour:
- dog frequently try to pee especially after drinking water.
- out of 12 attempts, 1 attempt is successful*
- the one successful attempt is normal passing of urine
- the other 11 fail attempt: sometimes there is no urine at all, sometimes a little.

Other Conditions:
- Dog is eating normally
- Drinking not as much as before; Drunk half a bottle in 3days. In the past, dog drink half a bottle in 1day.
(Water bottle size is L12cm x W8cm x B8cm)
- Dog is playing and active as usual
- Currently on Dr Sing prescribe diet started 20/03/2011
- Previous Diet: brown rice with white rice, carrots, peas, tofu, a bit of garlic, salt and olive oil.
E-MAIL TO DR SING DATED MAR 29, 2011
22 DAYS AFTER SURGERY TO REMOVE URINARY STONES BY VET 1

Dear Dr Sing,

Updates of my dog condition after urinal stones removal operation since 7 march 2011.

Duration monitored: 30-45mins
Dog Behavior:
1) his attempts to urine has cut down from 12times to 4-5times
2) 1 successful attempts out of the 4-5 tries*
3) other attempts, urine amount is less than 3ml or no urine at all.


Other Conditions:
- Dog is eating normally
- Dog is starting to drink more; like his usual amount of intake before operation.

- Dog is playing and active as usual
- Currently on Dr Sing prescribe diet started 20/03/2011
- Previous Diet: brown rice with white rice, carrots, peas, tofu, a bit of garlic, salt and olive oil.

He is also on an eye drop, because he has ulcer in his right eye. It is improving, not as red as before.
I have not brought his urine sample down, because his condition is improving. Thus, i would like to monitor for a few more days.

Dr Sing, I truly appreciate your help in giving me advise on my dog's condition. I had brought my 1st pet, a cat, to you since 1990.
You are a good vet, please do not lose hope even when you have encounter more demanding pet's owners.
MARCH 29, 2011
I phoned the owner as e-mail writing can be misleading compared to personal conversation. She complains about a hard lump at the stitched area. Vet 1 had stitched with the absorbable nylon-like stitches in the muscle and the skin area after stone removal.

I had already got the skin stitches removed during the first complaint around 12 days of what I considered a successful surgery by Vet 1. This opinion is subject to an X-ray post-op but I did not consider the X-ray necessary at that point of time as it is likely to show no urethral obstruction based on my bladder palpation. The bladder was empty and so it would be morally unethical to advise another X-ray immediately. In any case, the original stones were removed as Vet 1 is an experienced vet and therefore I recommended conservative treatment.

Vet 1 should have got a urine sample for urinary stone crystal analysis to the Singapore laboratory pre-surgery in hind-sight. Vet 1 had sent the stones to the US lab for analysis. This would take some time but now ... I have a problem! And the owner had got her X-ray at home. So, I asked her to e-mail to me the X-ray which my Adobe Photoshop refused to download. I cropped and converted the X-ray to .tiff. This time Adobe Photoshop obliged and therefore I had the X-ray image cleaned up and presented in this report.

CONCLUSION
Post-operation complications do happen after surgeries for all vets. The owner must be informed before surgery but sometimes we are too busy to go into details of the risk of pain, infection and bleeding of surgery. Many times I don't inform the owner too as the consent form for surgery would have been signed by the owner. During my past 20 years, I seldom ask the owner to sign the consent form (for informed consent) but now I better be careful of possible litigation for "failure to provide informed consent."

It is hard to pin-point the cause of the dysuria in this dog. Certainly it is not the typical urethral obstruction at the os penis, in my experience and observation.

Dogs can't talk. That's the challenge of being a veterinarian. It takes a lot of time and patience to know what is going on in this case. From the owner's phone conversation and observation, I conclude that this dog might have some pain due to the muscle stitching and so he tried not to pee during the first 14 days post-op. As I know Vet 1 used those absorbable "nylon-like" stitches to suture, I infer that the stitches were irritating the dog at that critical area in front and below the prepuce. I had removed the skin sutures but below, there was another layer of muscle suture at the linea alba. This would be the area of pain which lessened with time and medication. So the dog now has much lesser frequency of urination pain and has improved considerably according to the owner's diligent monitoring of urination.
In conclusion, one main cause of the post-surgical dysuria is the pain at the stitched abdominal muscle area below the penis (to close up the operation after urinary stone removal).

My tip to vets will be to use the 3/0 absorbable non-nylon like sutures. There is no need to stitch the muscles at 0.5 mm apart resulting in many stitches. I stitch at 1 cm intervals. Also, I find that subcuticular stitches are not necessary but many vets do that. This means a lot of stitches (subcuticular and muscle) and this would result in stitch irritation especially when the vet uses the "nylon-like" absorbable stitches. This is probably what is happening to the dog in this case. Every time he pees, the heavily stitched muscle and subcuticular area causes pain.

So when he wants to drink water, he tries to pee first but feels the pain. At other times, he pees onto the pee tray with difficulty. The owner disputed my opinion of the male dog urine-marking as the dog has no such habit.

*So as at March 30, 2011 as I close this case, I have only this hypothesis of pain due to stitches, not urethral obstruction by urinary stones behind the os penis. 22 days after surgery, the dog has fewer episodes of dysuria (see owner's e-mails above) . If only dogs can talk! And if only we vets have more time to analyse the cases but we don't have the luxury of time! And Singaporean pet owners want instant answers!
I don't have any complaint in my urinary stone removal surgeries using such the 3/0 non-nylon suture type for closure of the bladder, abdominal muscle and skin . It dissolves usually in 28 days and that is more than sufficient time for healing of the operated wounds. I don't use subcuticular sutures as I found them unnecessary in these cases. The University professors in Australia (from my observation of some graduates' need to do subcuticular suturing) still teach the students the need to eliminate dead space under the skin and therefore subcuticular sutures are used by many fresh graduates.

"Nylon" type absorbable sutures will take a much longer time to dissolve. The owner can "feel" the "lump" for some time. In veterinary practice, perception is sometimes as important as competence. Why use nylon-like stitches to create "lumps" under the skin worrying the dog owner and risking loss of owner's confidence in the vet when good alternatives are available? As each vet has his own preference, it will be hard to convince such vets to switch suture types!

I may be fortunate in my cases of no complaints of post-operation dysuria. Or the owner might have gone to another vet for a second opinion as in this case!
FOR BLOG READERS, the Toa Payoh Vets website article is at:
http://www.sinpets.com/F5/20110320stones-post-op-dysuria-unhappy-owner-complains-toapayohvets.htm

Monday, March 28, 2011

378. Sunday Case. "My Jack Russell suddenly can't see"

I HOPE THIS REAL CASE WILL HELP THE 5TH YEAR VET STUDENT WITH THOUSANDS OF SUBJECTS TO REMEMBER AND BE EXAMINED BEFORE GRADUATION!

One look from my reception counter and I could see that this Jack Russell was suffering from Canine Lymphosarcoma. Some vets prefer to call it Canine Lymphoma. The two lumps of the size of ping-pong balls on the right and left lower jaws were too obvious to miss.

The owners were a young couple in their early 30s and an older woman and there was great emotions involved. The mum was distressed that the 8-year-old male Jack Russell walked into chairs and just could not see on this fine Sunday morning. Only the day before, the dog was zipping here and there when exercised outdoors. No accidents. No falls. No injuries. The dog just couldn't see! Why? What happened?

I decided to handle this case as the leading vet responsible for the outcome and together with my associate vet. Working as a team is a pleasure of veterinary medicine as we share our workload. I asked if she objected as she was on duty, but this was not her client. My associate said: "I am OK."

HISTORY
"What did Vet 1 say?" I asked when the owner showed me the report of a pre-scapular lymph node biopsy sent to the AVA lab.
"Vet 1 said that the AVA lab cannot confirm that the dog is suffering from lymphoma."

I read the report. It stated that it needed at least 2 biopsies from 2 lymph nodes and to relate to clinical signs. The presented biopsy cells could not confirm lymphoma.

So the owners must have concluded that the dog was not suffering from lymphoma!
No further treatment.

EYES
Blood inside both eyes preventing vision.
Note: In canine lymphoma, eye involved in 25% of cases). This can lead to bleeding within the eye, uveitis, glaucoma, retinal detachment and blindness.)

BLOOD TEST RESULTS OF DOG WITH LYMPHOMA OVER AT LEAST 1 MONTH
I was checking for infection (high WCC) or immune suppression (low WCC and platelets) or cancer (e.g. leukaemia with very high WCC), liver and kidney disorder.

Results are as follows:
Haemoglobin 13.9 (12-18)
Total WCC 11.8 (6-17)
Neutrophils 70.51 Abs 8.32
Lymphocytes 16.44 Abs 1.94
Monocytes 11.19 Abs 1.32
Eosinophils 0.09 Abs 0.01
Basophils 1.95 Abs 0.23

Red cell count 5.5 (5.5-8.5)
PCV 0.38 (0.37-0.55)
MCV 69 (60-77)
MCH 25 (20-25)
MCHC 36 (32-36)
RDW 14.1%

Platelets 90* (200-500). No platelet clumps seen.

LIVER PROFILE
ALT/SGPT 169 (<59) AST/SGOT 138 (<81) BONE/JOINT FUNCTION Calcium 2.58 (1.5 -3.6) Uric Acid 0.05 (<0.13) KIDNEY PROFILE Urea 8.3 (4.2 - 6.3) Creatinine 54 (89-177) WHAT STAGE OF LYMPHOMA IS THE DOG IN? I palpated the abdomen. There was mild anterior abdominal pain as the dog hunched but did not bite me. The liver and spleen were enlarged. The dog was eating and active. This is now Stage 4a (generalised lymph node involvement with liver or spleen involvement). It is developing into Stage 5a (Stage 4a with blood or bone marrow involvement - see low platelet counts in blood test but no anaemia or low white blood cells yet). Central nervous system involvement (bleeding in two eyes) but no seizures Guideline. Stage 5a means the dog is eating normally. Stage 5b means the dog is not eating. 4047 - 4049. Bleeding inside the eye in canine lymphoma. Blood test shows low platelet count WHAT THE OWNER ASKED ME 1. How long will the dog live without chemotherapy treatment? I said it would depend on which stage and infections. 2 months had been quoted in some reports. 2. How long will the dog live with chemotherapy? It depends on the disease and drugs. Remission (no enlarged lymph nodes) may be present for several months, prolonging the life of the dog. 3. Is there a permanent cure? No. 4. What's the cost? Varies with the type of treatment. Cost of blood monitoring. WHAT HAPPENED ON SUNDAY? There were free blood inside both eyes. The sclera were very red and from my experience the dog had rubbed his eyes vigorously due to pain in the abdomen. (From my cases of acute pancreatitis and reading other vet reports, the dog rubs his eyes to relieve his intense abdominal pain) causing bleeding. HOW DID I SOLVE THIS PROBLEM OF BLEEDING EYES AFFECTING VISION? 7 kg. BW. Domitor 0.1 ml, Ketamine 0.2 ml in one syringe IV. Dog stopped pacing and slept. Eye sclera became normal white (the owners could see this and were quite impressed). It is highly risky to give sedation in this situation. Give the lowest dose. Next day, the owner said the dog could see. The owner has to decide on whether to do chemotherapy.




376. Sunday case. No ringworm on post-purchase health check 3 weeks ago

INTERESTING CASES ON A SUNDAY
Sunday Mar 27, 2011

"My Jack Russell runs into chairs. He can't see today," I answered a phone call from a young lady on this unusually busy Sunday afternoon. "I wish to make an appointment." I usually don't work on Sunday afternoons and this was a bright sunshine day for photography. I have an associate vet on duty and that gives me time to smell the roses.

For some reasons, I decided to work this Sunday afternoon. The appointment system does not work in practice when patients bunch up their visits on Sunday afternoons. Some cases take longer (e.g minor surgery) and some patients don't come on time. The delays make several Singapore pet owners who come on time for their appointment very unhappy. The human medical hospitals have the same problem too. It is just not possible for the vet to see every patient punctually at the appointment time.

The best is no appointment. First come first served. But I prefer the appointment system as Toa Payoh Vets do perform surgeries even on Sundays.

So, on this particular Sunday afternoon, I skipped lunch and manned the reception counter to get a feel of the front-line phone calls and assess the waiting times. If my associate vet has to take some time in a case, I would step in. Otherwise, she would handle the cases as part of her working hours.

I usually arrive at 9.30 am on Sunday and weekday mornings to handle some cases while my associate comes at around 11 am. Sunday mornings seem to be quieter and I presume most Singaporeans are sleeping late or doing their own things.

At 10 am, a Caucasian couple in their late 30s came in with a cat. "My cat has ringworm and I also had ringworm," the lady said that she had her newly purchased cat examined 3 weeks ago by Vet 1 and was given a clear bill of health. Now she had ringworm and she diagnosed her cat with having ringworm.

I reviewed the medical record of Vet 1. I said: "There was a microscopic examination of the hairs and nothing abnormal was seen. It is possible that the ringworm takes time to develop and now 3 weeks later, the signs can be seen. The armpit and groin are big red circular patches of ringworm measuring at least 1 cm in diameter."

This is one of those post-purchase health-check for situations all vets will encounter. The animal is healthy at the time of examination to be free from signs and symptoms of contagious and infectious diseases. This must be stated in the form. In addition, I always draw the locations of the skin disease areas in the dog illustration in my case sheet and this is good practice so that the clients do not dispute that I have not checked the area and in cases of litigation.

As for Vet 1, the owner had complained to her about a small scab in the right armpit during her post-purchase examination 3 weeks ago. Vet 1 had checked it out by doing a microscopic examination of the hairs. No ringworm was reported by her.

Now, this is obviously a case of ringworm in the right armpit and groin area. The owner had now done her own diagnosis and she was spot on. "Ringworm can be transmitted from people to cats," I said. "It is not possible. I don't have ringworm before I purchased this cat 3 weeks ago. My kitten had a scab in the right armpit 3 weeks ago when I bought the cat to Vet 1."

The complainant was a lawyer by profession and it seemed she had evidence in her favour if this case goes to court. After all, she was a lawyer in a high flying firm and she can sue for failure to diagnose ringworm. The case for the defendant vet would be that she had done a competent job as what had been reasonably expected from a vet. This was the microscopic examination of the scab in the right armpit.

As Vet 1 did not record the location of the hairs she had taken for microscopic examination, I asked the lady owner.

When I asked the lady where the vet had plucked hairs for microscopic examination, she lifted the hairs from the spinal area indicating this area. This area was free from any skin disease!

Yet she told me she had complained about the scab in the right armpit area to Vet 1. So this would naturally be the area the vet had checked.

It is important for the vet to record in writing or by illustration or both locations of skin diseases.

As for this case, the treatment was the standard. I advised clipping of all hairs from the cat as there seems to be a generalised ringworm of the ventral part.

The lady did not want it and this was OK with me. If I had not advised and ringworm grows in the upper part of the body later (due to vigorous brushing and contamination of the upper body), I would suffer the same unhappiness of the owner.

"It is not nice to see a bald cat. I advise that the lower body of the cat be clipped bald so that you can apply the anti-fungal wash directly and then rinse off that infected skin area. The cat dislikes the whole body shampooing of the anti-fungal wash as there is a strong medicine smell."

The lady agreed to the lower body clipping and bathing and I advised her how to give the oral anti-fungal medication and to let me know if the cat had reactions to the drug.

One consultation would make an owner very happy as owners don't like repeat visits for ringworm! Happy owners usually are loyal clients. Therefore, be vigilant of a small scab in the armpit of the kitten, cat, puppy or dog during post-purchase examinations!

TIPS
POST-PURCHASE HEALTH CHECK
Ringworm may appear as a scab of 2 mm. I would advise that the area be thoroughly clipped and exposed. Then give it a wash and prescribe anti-ringworm wash. A microscopic examination negative for ringworm does NOT mean there is no ringworm. Veterinary medicine is always full of surprises.

PS
As for the Jack Russell that suddenly can't see, I will write the story in another report as it is 6.31 am on this Tuesday morning and I need to do other things.

Sunday, March 27, 2011

375. Sunday Case. Informed Decisions in veterinary medicine compared to real estate

Yesterday, Sunday, Mar 28, 2011, I saw the owner of the one-nose sneezing Miniature Schnauzer with his dog coming in for consultation with Dr Vanessa. I was present at Toa Payoh Vets from 9.30 am to 5.30 pm to help out and ensure that clients don't have to wait too long to consult Dr Vanessa who handles almost 100% of the caseload daily during her work hours. I would handle a case to shorten the waiting time on Sunday or if the client insists on seeing me.

The appointment system in human or veterinary medicine is not really efficient as clients don't come on time and vets can't complete cases on time too. Clients who make appointments and come on time may need to wait and they get angry.

I can't help them. Much depends on the complexity of the case and the number of clients and the need to force those without appointments to wait till the end of the day or to get lost as was a complaint to me by one client who went to a Chua Chu Kang practice without appointment! That is also not good for new clientele.

Now that I was stationed at the reception counter, I could see that some clients were quite annoyed at coming on time but having to wait. Yesterday was a busy Sunday for some reasons and I skipped lunch. My assistant Mr Saw needs to go out for lunch as his stomach cannot skip meals and so I manned the receptionist counter when he went for lunch. I would still be at the receptionist counter but Mr Saw would handle the payment if he was around. In this way, I could feel the pulse of the waiting room and supervise the associate vet as a licensee responsible for my licence to operate a veterinary clinic.

Some vets issue a ticket number and make sure that clients with no appointments are attended to last. But this is not practical as there are clients with appointments coming late.

3 incidents on this Sunday were memorable. I shall mention one here as I have not much time this Monday morning 7.28 am.

This was a matter related to INFORMED DECISIONS as related to real estate and veterinary medicine and I shall show the comparisons. I am studying the REA course (minimum 75% attendance at class of 12 weeks, 3x/week) which, if I pass will license me to be a KEO (Key Executive Officer) of www.asiahomes.com. In other words, a licensee to operate a real estate agency. Presently all vets with over a year of practice experience (supervision) can become a KEO or licensee when they want to open their own veterinary clinic or hospital. No exams are required. To be a KEO of a housing agency, the person must have 3 years of experience and handles at least 30 real estate cases. If not, he just become a salesperson after passing the RES examinations.

INFORMED DECISIONS IN REAL ESTATE
In real estate, the URA has mandated that the developers do the following:
1. Developers to issue price listings 2 days before a property launch. A price list 2 days before a property launch.
2. Developers to issue transacted prices weekly (compared to 2-6 weeks previously). Weekly transacted price list.
3. Developers to give accurate depictions of show flats (compared to fanciful and incorrect floor areas, knocked down walls to con the buyers).
4. URA extends control over web advertisements of developers.
I may get an exam question about the above in the REA exam in late May 2011!
INFORMED DECISIONS IN VETERINARY MEDICINE
1. Vets to issue a price list of common operations and procedures. This is mandated by the AVA. A list is displayed on the reception area. But no need to issue price list 2 days before the operation or consultation!

2. Vets don't have to show a price list weekly as regards new operations! A quotation is usually given by me.

3. Vets don't have to give accurate depictions of surgeries to be done! I do some illustrations and drawings of certain operations or refer some clients to my www.toapayohvets.com webpages for those operations so as to give them INFORMED DECISIONS.

4. Web advertisements by vets? This is a matter that is being studied by the AVA to the best of my knowledge. There is the code of ethics which the AVA may adopt from the SVA but I don't have the full details yet.
CONCLUSION
Informed decisions are the best way to build up the trust of the client. In the case of the one-nose sneezing Schnauzer, the owner first consulted me in Nov 2009 after he had been to a brand-name vet practice which had been too expensive for him. He had been to Toa Payoh Vets around once in 2 months to treat the sneezing or runny nose (one-sided).

I said to him yesterday again: "You know, a surgery to remove the infected fungal lump at the back of the nose will most likely resolve your dog's problem." He and his wife did not want the operation and after some days of anti-fungal drugs, the dog would recover. Then the dog would sneeze and a one-side runny nostril would be present. The brand name vet had quoted $4,000 for the surgery. In any case, his wife did not want the surgery and so, the dog comes in every 2 months from November 2009 to yesterday Mar 28, 2011.

I had given him an informed decision. It is up to the owners to decide. There is danger of the dog dying or getting infected from the surgery to open up the back of the nose and extract the fungal lump (seen on the X-ray from the brand-name Vet practice in Nov 2009) in one nostril.

Since he was well informed about the outcome without surgery, there would be no animosity or complaint should the dog fail to recover after some time on medical treatment as the fungal or nasal growth becomes enlarged. So far, he is satisfied and happy with treatment from my associate vet. I am happy for him too. For best practice, I ought to write down in the case sheet that I had spoken to him about the prognosis and surgical treatment.
.

Consumer rights websites in Singapore

Straits Times Mar 20, 2011
"Click and gripe" Hot 5

All Deals Leak, Redress.me and Boo-n-Bouquet (blog) champion Singapore's consumer rights. The Consumer Association of Singapore CASE is the main official channel for Singaporean complaints but it is quite a hassle to write to them. Now with these online service and product consumer rights websites that are not worried about being sued by the affected parties as they permit two sides of the story and also it is costly and impossible to get adverse posts removed, many service providers will receive bad publicity for services not up to expectations.

IMPLICATIONS FOR VETERINARIANS
I don't go around reading such websites and blogs although I have had seen one or two bad reviews of services of Toa Payoh Vets in a pet website called www.petschannel.com

This pet website just publishes all complaints and ratings. Competitors could just publish with impunity. The website just publish "Any opinions expressed are those of the individual reviewers. See disclaimer statement."

RIGHT OF REPLY
However one of the 3 above online posts say they e-mail the affected party and publish their replies.

PREVENTION
Prevention is best and as a licensee of Toa Payoh Vets, I have to ensure and check that my associate vets provide the standard of services expected from a "reasonable" man. It is just too much time consuming to surf the internet to read about complaints although they are excellent feedback to improve my veterinary services and care.

ANONYMOUS POSTINGS. There is much more power to the consumer since the one posting the complaints usually are anonymous.

One brand name vet practice had postings saying that their vets are bad and that their dogs die during treatment or anaesthesia there. Another reader would write to say he or she has better not go to this practice. "What is the name of the vet or the practice?" another writer would ask.

Sometimes I wonder whether it is the work of the competitors to run down the other party.

UPDATES AS AT MAR 28, 2011
I just log onto www.petschannel.com now at 3.46 am since I am writing this article on consumer rights online. I had not been to this website for several months. Some years ago, it publishes the good and bad comments of going to various vet clinics listed in this website. Now, it wants money from vet owners to write about the business and publish all members' reviews without limit.

I don't subscribe to this service and I note most of my competitors don't bother to do so.

As at Mar 28, 2011, Toa Payoh Vets has 15 reviews written.

I was surprised to read the latest two reviews (part published) by jologflg on Jan 10, 2011 and by samanthayap on Nov 10, 2010.

1. For jologflg, I can see his photo and he is a genuine client. He published in Jan 10, 2011 in Shoppe Place reviews as follows:

5 stars shown. Jan 10, 2011. Toa Payoh Vets>>Dr Sing-experienced, treats disease ot symptoms, good surgeon (2 ne...


If you click on the hyperlink above, you will get no more info as I don't pay to this website to get full reviews!

2. For samanthayap, there is a graphic photo of a young lady. In the Shoppe Place reviews, she wrote as follows:

4 stars shown. Nov 10, 2010. Toa Payoh Vets >>Dr Vanessa attended to me today and I would say, she's friendly and ca...

Well, since I didn't pay up, I can't read what the lady who has a picture of Hammie born Oct 2010 say about Dr Vanessa!

It is just like reading the opening paragraph of a page-turning novel. You got to buy it to know what is going to happen next! Well, I don't know as I don't subscribe to this website to get the good and the bad reviews!

The website used to give marks using a formula for reliability, frequency of postings etc. Since I don't pay, I don't get the grades. It is just too time-consuming to surf to consumer rights websites unless one has a lot of staff but they exist and so the vets must provide the best service and be street-wise as well. You don't want to end up with one comment about a competitor in this website. The comment is as follows:

2.5 stars. Mar 2, 2011>>XXX (name listed)>>I urge all of you not to go to thi...

CONCLUSION
The above can be a lesson in good writing. When you write a resume or look for a publisher, your cover letter should have a good "hook" to catch the reader's attention and consider reading your letter or buy your book.

Saturday, March 26, 2011

373. Continuing education - Veterinary Anaesthesia - sharing tips

The following tips from fellow vets were given to me at the Veterinary anaesthesia continuing education of Mar 26, 2011 by Dr Kieren Maddern, European Specialist in Veterinary Anaesthesia:


1. INJECTABLE ANAESTHESIA from a practice in Malacca.
According to the vet who runs a practice in Malacca, the UPM professors had been using the following formula safely and effectively for the past 15 years. He had been using it for the past 10 years.

1.1
Zoletil 100 (don't use the diluent provided).
Add in the bottle 8 ml of ketamine
Add in the bottle 2 ml of xylazine
Dose: 0.04ml/kg IM. 0.03ml/kg very slow IV.
Use isoflurane gas if needed or top up 1/2 to 1/3 dose IM when the dog wakes up.

1.2
Zoletil 50 (don't use the diluent provided).
Add in the bottle 4 ml of ketamine
Add in the bottle 1 ml of xylazine
Dose: 0.04ml/kg IM. 0.03ml/kg very slow IV.
Use isoflurane gas if needed or top up 1/2 to 1/3 dose IM when the dog wakes up.

1.3 For CATS
Be careful. Use the IV dosage for IM injection. That is 0.093 ml/kg for IM.
Top up if necessary.

Zoletil is an expensive drug and therefore the above combinations is less expensive and effective and safer.


2. Lecturer's tips
Ketamine & ACP - excellent for cats. Ketamine alone makes the cat's body
rigid. Seldom use atropine (makes throat dry).

3. A Singapore's vet's tips
Xyalzine + Atropine + Ketamine. Then use isoflurane gas.

Each vet has is own method. If he uses new drugs e.g. N2O, the dog may die.

372. Continuing education - Veterinary Anaesthesia & tarsorrhapy advice

Yesterday, Saturday March 27, 2011, I attended a continuing education lecture by a veterinary anaesthesia specialist, Dr Kieren Maddern, BVSc (Hons), MACVSc, Dip ECVAA, European Specialist in Veterinary Anaesthesia. The topic was "Overcoming the odds - Anaesthesia for difficult situations."

It was a very well attended lecture - some 70 people there. An excellent lecture. I caught up with a senior vet who has done a few thousand dog and cat surgeries over the last 40 years and asked his advices about young vets referring corneal ulcer cases to other practices.

He said: "The young vet may find that it is a difficult case or that the owners are the type liable to sue. So, just refer the case out. Or the young vet thinks that you can't do the surgery! He or she does not usually ask for advice but just refer!

"When the case goes from Toa Payoh Vets to the other vet, the other vet will just laugh and say 'Dr Sing does not even know how to operate a simple corneal ulcer case! What's wrong with him?' Maybe you should give instructions that all cases that your younger vets want to refer to others should go through you!"

I was not alone in having this problem of the younger vets doing their own thing without consulting the senior vets in the practice.

The senior vet told me: "Tarsorrhapy is very effective in corneal ulcer cases. Even in cases where the eyeball collapses. Just sew up the two eyelids and the outcome is usually very good. I find that the eyeball is seldom infected even with perforated ulcers."

I listened attentively for the free advice. The senior vet is 5 years older than me just in case but he puts in the very long hours and do the after hours emergencies. High energy and therefore he has more caseload experiences.

"By the way, how do you treat corneal ulcers in the dog?" my mentor asked.

"I am more kiasu," I said. "I do the 3rd eyelid flap and tarsorrhapy." Not all the time, but sometimes.

The pictures of my case in a Jack Russell are shown below.




Friday, March 25, 2011

371. Studying vet in the USA after A levels? Not possible?

Dr Sing Kong Yuen

Dear Sir,

I am involved with recruitment for the Freeman Scholarship Program at Wesleyan University in Middletown, Connecticut in the US. We did a recruitment session recently for our finalists. One is a lady with a strong interest in becoming a veterinarian.

I believe we are badly-positioned to help her realize her dreams. Specifically, vet schools in the US are graduate programs, requiring the applicant first complete four years of undergraduate study …. Then take the MCAT exams and go through the entire school admissions process again!

I suggested to her school systems that work on the British system, such as Glasgow. I also suggested the AVA scholarship program. I noted from your website that you attended Glasgow on the Colombo Plan, served with the SAF Provost Dog Unit, tended race horses for the Bukit Timah Club, started your own clinic, and are now headed into happy retirement.

You have walked the path that she is considering. Might you have a moment to take a call from her and give her the wisdom that comes from real experience?

I am an ex-infantry officer who spent his life as a civil engineer building prisons, police compounds and the coastal barrier for the Singapore government. My ability to guide her is terribly limited.

Thank you so much for any help you can give.


With best regards,
Name given


REPLY FROM DR SING DATED MAR 24, 2011


Hi

Thank you for your email. I can always spare more than a few minutes to meet one-on-one to the young lady who wants to be a veterinarian. Phone calls are a waste of time if the persons are sincerely interested in knowing more about veterinary medicine and surgery. During the meeting, I can assess whether the young lady is really passionate about veterinary medicine and surgery. Phone calls and text messages and emails are preferred by the younger generation who don't have the real interests or passion and merely wants to go fishing.

Let me know as soon as possible. I don't know where you get the impression that I am into "happy retirement". I have an associate veterinarian who is younger and takes care of many of my old clientele as there is insufficient rooms for 2 vets at any one time. I still consult and yesterday I spayed a Fox Terrier as the owner wanted me to do it. I am even busier than before in veterinary medicine, travel and real estate.

I hope we can meet one day and not just e-mail. Best wishes.




E-MAIL FROM DR SING DATED MAR 25, 2011
To: ....
Sent: Friday, March 25, 2011 12:44 AM
Subject: Re: Fw: For Dr Sing Kong Yuen

Hi

Yesterday, I told a prospective intern who had straight As (except one B) in her A levels to go home since she could not work the hours required of an intern. Her father had objected to her working "long hours" and she had phoned me yesterday wanting to negotiate to shorter hours. This young lady, about to venture overseas to study in the U.S and accepted by US vet school is still tied to the apron's strings. Can excellent "A" level results open a place to study vet medicine in US universities as apparently is the case in this lady.

REPLY TO DR SING DATED MAR 26, 2011


Dear Dr. Sing,

Thank you very much for taking so much time with me.

What that perspective/rejected intern told you does not make sense to me. I pulled the below off the Veterinary Medical College Application Service website:


Major- Choose a major in an area that interests you. You do not have to be a science major to go to osteopathic medical school. However, you must complete certain course requirements. Most osteopathic medical schools require the same courses as allopathic medical schools, listed below:

1 year of physics with lab
1 year of general chemistry with lab
1 year of organic chemistry with lab
1 year of biology with lab
1 year of english

Requirements do vary between schools. Many schools require biochemistry and genetics in addition .



As you can see, the American system requires one to take a four year undergraduate liberal arts curriculum before they even apply to vet school.

Might that prospective intern have been mistaken in her assumption she could apply directly to an American vet school?


P.S
On your second query: No I have never met Gerald of .... Properties! I train with a guy named Gerald at the NUSS gym, but I believe he is a teacher.

I am actually ex-US Army and ex-civil engineer (retired).

I was involved in a recruitment exercise for my old university held down in the (location given).

We got the usual collection of arts-stream types who all want to be writers or artists. But we got one applicant who stood out; this lady was math/science, wanted to be a vet, and seemed to have her priorities straight.

Our admissions officer made some ... comments about this student's career plans (apparently they wanted her to study political science!).

I had an ugly confrontation with the admissions officer after the meeting, then I went on the computer and started googling information on proper vet programs and veterinary career paths.

Your name stuck with me because you had been commander & veterinary officer of guard & tracker dogs with the Provost Guard Dog Unit. I also noted you had worked with race horses at Bukit Timah and now had your own clinic. You had been a government scholar.

I wrote you because you had the right background. I can tell this student not to waste her time with political science. But only you can set her on the right path.

If you have a moment, I can bring her by your clinic. She wrote me asking whether next Tuesday would be okay. If that day is convenient, I will bring her to:
Block 1002, Toa Payoh Lorong 8
#01-1477

Just let me know what time is convenient.

I will disappear during the meeting and you will be free to give her the good, the bad, and the ugly of her career choice.

Thanks so much.

Name given


-----------------
UPDATE MAR 27, 2011 FROM Dr Sing
Will meet prospective vet student on next Tues Mar 29, 2011 11 am at Toa Payoh Vets

370. Procedure and costs of dental scaling at Toa Payoh Vets in 2011

E-MAIL TO DR SING DATED MAR 25, 2011

--- On Fri, 25/3/11, ...@hotmail.com> wrote:


Subject: Scaling for dogs
To: judy@toapayohvets.com
Received: Friday, 25 March, 2011, 2:00 PM

Hi,

I am looking for a trusted vet and doctor who can perform scaling on my 2 year old chihuahua. I am interested upon sending her to Toa Payoh Vets. I would like to know how much it would cost and what I should do to prepare her for the day of her visit.

Thank you,
Name given


E-MAIL REPLY FROM DR SING DATED MAR 26, 2011

Hi

I am Dr Sing from Toa Payoh Vets. Thank you for your email to Judy.

The dental scaling plus anaesthesia cost is around $250 normally. Decayed tooth extraction will be around $10-$20 per tooth extracted. Medication of antibiotics and pain-killer is estimated at around $20 if necessary. Blood test for pre-anaesthesia risk checking will not be done in normal healthy dogs and will cost $150 if it is needed but you will be informed first.

Do not feed or give water to your dog after 10 pm the night before the dental work. Bring your dog to Toa Payoh Vets are 10 a.m. The dog will go home around 5pm usually after rest and recovery from general anaesthesia.

Pl make an appointment at 6254 3326. Pl indicate which vet you will prefer. These are Dr Sing, Dr Vanessa Lin and Dr Jason Teo.

Thursday, March 24, 2011

Passing the buck - The pug with a perforated corneal ulcer

March 24, 2011 was a day to remember due to the following 3 incidents.

1. The Junior College student with straight As and 1 B and an excellent testimonial from her form teacher could not work "long hours." She had phoned me the previous night to let me know that she would not work the long hours of internship as it was "tiring". So, I told her that I would phone her back regarding her terms and conditions of work. That implied that she ought to stay at home till I decided since my offer was not accepted. Yet she presented herself at the Surgery today at 8 am as I had told my assistant Mr Saw that the intern would not be coming.

I asked if her father or mother was against her working hard? She had no objection to the hours of work during the interview yesterday and even arranged for her driving test lessons to take place at 5 pm on Friday. She would work 6 days a week with one weekend day off. She arranged for 6 weeks of internship - a very short period but that would give her some credentials as she had applied for an AVA veterinary undergraduate scholarship.

Apparently her father was against it. "You will be going overseas to study," I said sadly to this young personable lady who did not need to take the "O" level examinations unlike the average Singaporean student as she was the "top 10% of her cohort likely to go to the university."

"Your working hours are non-negotiable. In any case, you will be off before 5 pm on Friday for your driving test at Bukit Batok and you don't work on one Saturday or Sunday." I was rather sad that she could not put her foot down for her own future. "You need to think for yourself and not get tied to the apron's strings."

I wished her good luck and let her go. Over-protective Singaporean parents who think that the world owes their academic superstar-children a living will be in for a rude shock when their children goes to the real world of commerce as their attitude doesn't make the progeny street-wise and realistic.

2. Mr Saw phoned me at 11.30 am while I was at the Singapore General Hospital area to say he was not feeling well and would try his best. He had generalised muscular aches. I often told him: "You are a young man." But he would say "I have an old man's body."

Mr Saw is a very responsible assistant and if he was a Singaporean, he would make a very good vet. I could see that he has the passion during the past 3 years with me and I had mentored him with whatever knowledge of the skills of surgery and medicine I had.

I rushed back after taking a few photos of Everton and Spottiswood Park conservation houses (bright sunshine - good for pictures).

3. I told my associate vet that Mr Saw was sick and he would be taking time off. I would be the customer service officer taking money and processing the credit card and nets machine as my other staff was on leave. Another assistant Mr James Ang had retired at the age of 73 years as he was bent double for some unknown reason. I had to let him go in February after some 20 years with me. He would be giving prospective clients a bad impression compared to the nubile young girls at competitor's practice as he was hunched as if he could not stand straight.

Two days ago, the mother and adult daughter of a Maltese with red eyes had smiled at me when they saw me handling the payment at reception counter after consultation with my associate vet. They were old clients. The daughter had now become a grown up in her early 30s. I said: "Like the PAP who introduce new politicians at the elections, I must renew the vets at Toa Payoh Vets. Young vets, new ideas. Lots of energy."

Soon, 3 young adults in their early 30s (2 ladies and one gentleman) came in with a pug with a bleeding leaking eye. I got them registered as they were new clients. I could see that one of the two young ladies was quite distressed. My associate vet handled the case as usual. I could see that it was a case of a central corneal ulcer, a common problem in breeds with protruding eyeballs.

"So what happened?" I asked the gentleman who came out of the consultation room and sat on the yellow chair after some minutes of discussion with my associate vet. I had been inside the room to evaluate the eyeball at one time but left without comments. He said: "The doctor is making arrangements to hospitalise the pug."

I was extremely surprised. Associate vets do get some freedom to do their cases in the manner they deem fit. Toa Payoh Vets is equipped with anaesthetic and surgical facilities and is capable of handling a corneal ulcer case. Referring what I considered to be a simple case of corneal ulceration to be hospitalised in another practice in Singapore was a big shock to me.

I don't want the vets at Toa Payoh Vets to be known as the "Old School Vets". This term was made known to me from a staff of a practice I visited last week as I brought a young male intern with a blue golden lock of forehead hair to visit the practice to buy some vaccines.

The lady manager in this practice where the vets will refer every "difficult and potentially litigious" surgical case to a brand-name practice said to me: "My friend asks me which veterinary clinic I was working and when I told her, she said I was working with an 'Old School Vet'. I don't mind. I am very happy and well treated in this clinic."

So, this practice does vaccination, dental scaling, sterilisation and removal of lumps. Nothing more complicated. This definitely was not the sort of veterinary surgery I practise for the past 30 years.

Now my associate vet now making phone calls to another brand name practice to pass the case over.

This passing the buck of a simple case of corneal ulcer is not for associate vets of Toa Payoh Vets. If any associate vet can't perform surgery of a simple corneal ulcer and refers to a 2nd a brand name competitor, there is the "can't even do a simple corneal ulcer case" implication.

I know some vets dislike complicated surgeries as they are potentially litigious but this was a simple corneal ulcer case, in my observation. I went to the consultation room and asked my associate vet what was going on. Why was she referring to a brand name practice? She showed me the letter from Vet 1 to consult a certain vet in a brand name practice and since that vet was unavailable, she made alternative arrangements. Eye injuries are emergencies and ought to be treated within 4 hours. Now, it was 5 days post injury.

I was extremely surprised as my associate had at least 2 years of practice before joining me. If she could not deliver, she ought to consult me. There was this potential of the competitor's vet and staff labelling and bad-mouthing Toa Payoh Vets as being incompetent to handle a corneal ulcer.

I asked the owners to leave the consultation room, closed the door and had a private chat with my associate vet. I said: "This is going to be a highly contentious case as there is a lot of emotion involved as Vet 1 had given a name of a vet who would not take the case. The owners are much distressed. You just refer them to another practice.

That practice employs fresh graduates and rookie vets. You are not doing the dog a favour by just making appointment for an unknown vet to handle this case if the older vet was not available. I will take over this case as the owners are going to be unhappy should the other vet mis-treat this case."

If I refer a case to a vet, I must make sure that this vet has the relevant experience and a high standard of practice and will perform the surgery and not his fresh employee graduates. It does not mean that this vet must be employed in a brand name swanky practice.

I was in the consultation room earlier too but the associate did not introduce me and I did not introduce myself too. So, the distressed lady was apprehensive when I examined the dog's eye and tried to pull the dog back. So I left the room for my associate vet to manage the case.

I was around and yet she did not think of asking me for advice when issues and problems arise. Life for a practice manager is full of surprises and changes.

I told my associate to ask the clients to come in and to formally introduce me as that would be the correct way in professional practice. This case was high voltage and lightning had struck. The pug's eye was going to collapse any time soon and any miscommunication or bad referral resulting in the pug being blind would have cast Toa Payoh Vets in a bad light.

"The owners must be thinking I am just a receptionist since I was registering their case," I said to my associate. "This case is going to adversely affect the reputation of the Surgery if the brand name practice vet bungles the surgery. How do you know whether that this brand name practice will or will not assign a fresh vet with no experience in handling a Descemetocoele? This corneal ulcer is in a highly dangerous state as it is going to perforate soon.

"You know that this brand name practice's senior vet may not be available. If he assign a fresh vet to do it, the cornea perforates on the way to the vet, the pug goes blind. So, the owners would just bad-mouth Toa Payoh Vets as the practice that referred the case." I did not mention that this brand name practice charges top dollars and this case would set the owners back by over a thousand dollars.

My associate opened the door and asked the 3 adults and pug to come in. She introduced me as her boss.

"I am the founder of this practice," I elaborated. "I did not introduce myself earlier in the consultation room. I am responsible for the practice management." I was the licensee and any complaint or litigation would mean I have to waste time attending to investigations. I had assessed that the clients were sophisticated and knowledgeable and this is the profile of the younger generation. Whether they would complain about being passed the buck by Toa Payoh Vets would depend on how this emotional situation was handled and whether their pug's eyeball would be enucleated by the other vet. Owners just don't like the idea of their pets losing an eyeball.

This was a case that had a 50:50 chance of saving the dog's eye. If the vet knows how to resolve the problem.

The gentleman summarised the situation succinctly: "There is no one vet you can recommend to treat my pug." He must have superman's hearing as he was in the waiting area and he could not have had heard my conversation with the associage vet.

I said: "It is not necessary to refer the case at all as Toa Payoh Vets has the capability and experience to handle this case.

"I have handled several cases of corneal ulcerations and if you have no objection, I will do the 3rd eyelid flap. Have you visited Toa Payoh Vets' webpage on eye problems in the dog?"

Such sophisticated young adults would have had checked up Toa Payoh Vets' website at the waiting area with their iPhone 4 while I was having a closed-door discussion with my associate vet. The world has changed tremendously. Internet information flows freely and the clients know much more than the vet sometimes.

The gentleman said: "You operated mainly on Shih Tzus' eyes." This was an excellent feedback from him. I had not analysed my webpage on eye problems in the dog at www.toapayohvets.com. I had not posted other breeds I had treated as it is extremely time-consuming to create webpages to write the case report of all breeds I operated upon. I don't take pictures of all breeds too.

This article took 6 hours to write and to create the supporting images. There are so many things I want to do and I just can't have time to do many of my favourite things if I write case reports of all breeds having corneal ulcers. As a vet who does surgery, the range of surgical cases is from the head to the tail.

I replied: "Shih Tzus have the highest number of eye injury problems in my practice. Any breed with protruding eyeballs may suffer from this corneal ulceration problems. This includes the Pekinese and the Pug."

To cut a long story short, the owners had no objection in my performing the surgery. If they were not comfortable, I would just ask them to make their own decision to select their own vet.

My associate vet watched me doing the surgery. She said she had not seen me doing a surgery. Many of my surgical cases have been passed on to her to do and that was why I had less to do.

This is how I managed the corneal perforation case surgically:

INFORMED CONSENT. I took time to explain the risks of anaesthesia (death as this pug was infected for the past 5 days and could be infected in the blood stream. A delay of 24 hours with antibiotics prior to surgery would be preferred but this was an emergency as the cornea will perforate soon. I advise that I would give baytril antibiotics IV and perform the surgery soon).

I explained the risk of surgery (bleeding, pain, infection, collapse of the eyeball due to infection leading to the possibility of enucleation as the owner had not consulted the vet within 4 hours of the eye injury). The gentleman signed the form.

SEDATION & ANAESTHESIA
"Isoflurane gas alone is the safest anaesthetic for this young pug of 7 months with a possibility of infection of the past 5 days," I said to Mr Saw who takes close notes as he would be operating his own practice in Myanmar soon. "However, the pug's nose is flat and the pug will struggle a lot, leading to perforation of the cornea and collapse of the eyeball. So, what sedation would you give? Your favoured domitor and ketamine IV?"

Mr Saw was not so sure. This was a pug with suspect infection after 5 days or more of eye injury. The pug's eye look like an earthquake and tsunami disaster area as seen in the recent pictures of the calamity in Japan. Big patch of white gel and a stream of red-tinged flow of gel and blood at one end, measuring around 1.5 cm long. A continuous stream if you are observant. It reminded me of the oil spill in the Gulf of Mexico although I did not see the actual leak - only oil slicks in the ocean. Here, I could see the stream. It was fascinating as a case but extremely dangerous for the pug. A delay in treatment and the corneal hole would enlarge and the inside aqueous humour would just splash out. The end of the eyeball, although the vet can still stitch up the cornea. Most vets will not encounter such corneal ruptures or stitching and so it can be quite frightening to encounter this case.

I used 0.2 ml xylazine IV. Waited 5 minutes. The pug vomited out its food as this was the effect of xylazine (and even in domitor or domitor/ketamine IV) Then isoflurane gas.

SURGERY
The 3rd eyelid flap is done. Basically the needle goes into the upper eyelid, then under the 3rd eyelid and back out to the lower eyelid. Tied in a knot. "It will be easier if an assistant pulls out and upwards the 3rd eyelid for stitching," I said to my associate vet as Mr Saw automatically used forceps to do it for me.

SUTURE PATTERNS
Several combinations. For this case, I use 3 simple interrupted sutures. Another case, I used a horizontal mattress and one interrupted. Or just one horizontal mattress.

Question. "Are 3 sutures sufficient?" - Yes.

SUBCONJUCTIVAL INJECTION OF GENTAMYCIN AND DEXAMETHASONE.
I know some vets believe that steroids should not be used in eye ulcerations. Well, a small drop of dexamethasone will alleviate the inflammation and pain and does not cause harm.

"Get me the prednisolone," I said to Mr Saw. He got me the depot prednisolone and I rejected it. It is best to use dexamethasone or prednisolone meant for IV." Well, Mr Saw did as instructed but got the incorrect type. All vets must check the medication before injection. Well, Mr Saw learnt something from this participation in the case. "Use common sense," I said to Mr Saw. I wonder whether he knows what is the meaning of common sense as applied to his offer of depot prednisolone. Details of surgery and comments in 8 pictures at webpage of Toa Payoh Vets - goto DOGS - EYE PROBLEMS or at:
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm

POST-OP DAY 1 & 2
The IV drip continued. Tolfedine and baytril given SC. The pug was sleeping and woke up fresh the next day. Very active. At 3 pm on day 2, the gentleman and his wife visited. They took leave from work. It was one of those money can't buy joys to see the distressed lady back to her normal self.I expect the pug's ulcer to heal in 14 days' time and the pug to go home on Day 3. The outcome should be a white spot in the centre of the cornea and no eyeball collapse or infection.

RETROSPECTIVE REVIEW
1. Why did Vet 1 refer the case to a vet that is not available? This is a mystery to me. He probably thought that the cornea ulcer was extensive, needed stitching and he had no facilities to do it and had referred to my associate vet. However, I was on counter duty and saw the case first.

The eye ulcer looked terrible as if it had a big earthquake. It appeared to be a white reddish gel patch of at least 5-8 mm in diameter. Actually, it was 1-2 mm in diameter when I used a scalpel to scrape away the out flowing blood clot. After scrapping, I showed my assistant the black hole measuring around 1 mm in diameter. Aqueous humour leaked out from the hole. Surrounding the black hole was a circle of basement membrane measuring around 4-7 mm in diameter with the black hole as the centre. This membrane would rupture soon if the owners just don't bother to see Vet 1 who advised emergency eye treatment correctly and professionally.

To estimate the size of the corneal perforation, see the 'stream' of gel coming out as a streak. It was around 2-3 mm. See the images.

2. The pug had a perforated ulcer, not a Descemetocoele. The initial presentation was similar to a Descemetocoele with a streak of gelatinous or eye discharge. So, I said "Descemetocoele" to my associate at the examination room as the dog did not permit proper eye examination.

Under general anaesthesia, after scrapping away the blood clot, a black hole of 1mm x 1mm with watery aqueous seeping out indicates that the correct diagnosis is a perforated corneal ulcer also known as deep ulcerative keratitis.

3. Corneal wounds can be sutured with fine 6/0 sutures. Small perforations are best left to heal with the 3rd eyelid flap surgery. And they do heal very well if the inside of the eyeball is not infected. Can you see the pinkish-reddish blood sediment on the medial inner side of the eyeball in one of the pictures below?

I hope this report will be useful for undergraduates struggling to study so many subjects for their examinations to appreciate the anatomy of the dog's eye and its changes during ulceration.

For readers of my blog, updates and more pictures are in toapayohvets.com, goto DOGS - EYE PROBLEMS.
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm


For readers of my blog, updates and more pictures are in www.toapayohvets.com goto DOGS - EYE PROBLEMS.
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm


Details are in www.toapayohvets.com goto DOGS - EYE PROBLEMS.

368. Starting pay for new vet in Singapore?

Straits Times

ST Jan 1, 2011 Law & Accounting. The MONEY Page.

"Big Four" Accounting Firms - PricewaterhouseCoopers (PwC), Ernst & Young, KPMG and Deloitte pay new graduates more. Starting pay at mid-sized accounting firms $2,100 to $2,400. Big Four pay $2,600 and above.

Big law firms pay $4,500 - $5,000 for a fresh graduate. Foreign law firms $7,500 but with smaller bonuses. Small law firms pay $4,000 - $4,500. So, pay more upfront and less bonus to compete.

So what do fresh graduate vets in the Singapore private sector get paid? Is there a market rate? Or is it performance based?

Wednesday, March 23, 2011

Internship: no knowledge, skills and discipline

I note that the younger generation doing their 2nd year Junior College and who applies for a veterinary internship has no knowledge, skills and discipline. The applicants are mainly ladies. Many of them have straight As and can get into any undergraduate studies they choose.

However, these Singaporean academic stars don't have hands-on experience nor interests in animal welfare and medicine. Straight As without passion in veterinary medicine. An unwillingness to work diligently and put in the hours.

I am thinking of terminating sponsorship of internship for Junior College students as my staff feels that they are a burden and they are. My assistant Mr Saw actually dislike them according to one of my feedback as they hinder his work. He has to teach them how to take temperature etc and why should he do that? I don't know what Dr Vanessa Lin and Dr Jason Teo think of them.

Many of these young interns and even veterinary undergraduates don't have simple social skills. They come for interviews silently. They don't know simple courtesies which will gain them brownie points, like greeting "Good morning, Dr Sing, Good afternoon Dr Vanessa or Good evening Dr Teo." Some fathers or mothers drive them to the Surgery and wait for them for the interview! They give me the impression that they can't be independent and are tied to the apron's strings.

Does the top school principals NOT impart such skills to their bright students? It is not that I am desperate to be greeted. Not being punctual, disappearing without letting me know. These are what some past interns do.

Therefore, I am thinking of terminating this program for such young people as they have been brought up in abundance and know no hardship. They don't want to work hard and seem to think that the world should suit their lifestyle and way of working late in the day (being night owls). Turning up late for work is a common trait too.

There are 3rd party injury liabilities too. What if the intern gets bitten or scratched by the dog and cat respectively? The parents will sue me to bankruptcy.

For the above reasons, it is wise for me not to accept interns unless they are highly passionate about veterinary medicine, rather than thinking of using the program to pad their resume.

366. Happy retirement?

Dr Sing Kong Yuen

Dear Sir,

I am involved with recruitment for the Freeman Scholarship Program at Wesleyan University in Middletown, Connecticut in the US. We did a recruitment session recently for our finalists. One is a lady with a strong interest in becoming a veterinarian.

I believe we are badly-positioned to help her realize her dreams. Specifically, vet schools in the US are graduate programs, requiring the applicant first complete four years of undergraduate study …. Then take the MCAT exams and go through the entire school admissions process again!

I suggested to her school systems that work on the British system, such as Glasgow. I also suggested the AVA scholarship program. I noted from your website that you attended Glasgow on the Colombo Plan, served with the SAF Provost Dog Unit, tended race horses for the Bukit Timah Club, started your own clinic, and are now headed into happy retirement.

You have walked the path that she is considering. Might you have a moment to take a call from her and give her the wisdom that comes from real experience?

I am an ex-infantry officer who spent his life as a civil engineer building prisons, police compounds and the coastal barrier for the Singapore government. My ability to guide her is terribly limited.

Thank you so much for any help you can give.


With best regards,
Name given


REPLY FROM DR SING DATED MAR 24, 2011


Hi

Thank you for your email. I can always spare more than a few minutes to meet one-on-one to the young lady who wants to be a veterinarian. Phone calls are a waste of time if the persons are sincerely interested in knowing more about veterinary medicine and surgery. During the meeting, I can assess whether the young lady is really passionate about veterinary medicine and surgery. Phone calls and text messages and emails are preferred by the younger generation who don't have the real interests or passion and merely wants to go fishing.

Let me know as soon as possible. I don't know where you get the impression that I am into "happy retirement". I have an associate veterinarian who is younger and takes care of many of my old clientele as there is insufficient rooms for 2 vets at any one time. I still consult and yesterday I spayed a Fox Terrier as the owner wanted me to do it. I am even busier than before in veterinary medicine, travel and real estate.

I hope we can meet one day and not just e-mail. Best wishes.

Sunday, March 20, 2011

365. Sunday's case. The dog has no urethral obstruction.

Sunday Mar 20, 2011.

The owner of the Silkie came at 10.20 am on this fine sunshine Sunday. I asked whether she wanted to wait for another vet who would come in around 11 am or to consult me. She said she would not mind consulting me as that was her original intention. She said: "Everytime my dog drinks water, he lifts his leg for some time, but no urine come out. This only happens after the bladder stones were removed by Dr Vanessa." The surgery was done 11 days ago. I examined the dog and palpated the bladder. There was no pain. The bladder was not swollen at all and so there was no urethral obstruction at the os penis. I checked the stitches anterior to the prepuce. They were not inflamed. "The operation by the other vet is 100% successful," I said. "I will have the stitches taken out. As there is no urine in the bladder, I would like to hospitalise the dog for one day to observe and to take urine sample for analysis."

The client pointed to a right eye which had pus and red conjunctivitis. I examined it and showed the wife that the dog had a 10-12 o'clock patch of corneal ulcer. The owner had been using eye drops for the last one month but was unsuccessful.

Soon, the other vet arrived. I told the lady owner who came with her husband that I would work this case together with the other vet although she wanted me to handle it. Working together as a team should be the way in a group practice. However, I could see that the other vet was not too happy with this by-passing. She took the dog into the operating room, catherised it and found no urethral obstruction. She showed the owner that the catheter was passed in easily.

Now, I usually don't interfere with the other vet's clientele. However, many of the clients had been with me for years and therefore a new vet must understand the culture of the workplace and work as a team to be successful.

I had a one-on-one talk with the other vet as regards what she considered as my interference with one of "her" cases. I told her that the case of the Silkie with difficulty in peeing was one of my clients who had just told me that she wanted me to handle the case. However, she had operated on and had done a good job. Normally, I would let the other vet handle my client's cases if they come after 11 am though I would be available. Otherwise it is best not to have another vet present.

I explained to the other vet that I have a responsibility as a licensee to ensure that owners' complaints to me are handled personally. By ignoring their complaint, it would not be good for the practice as matters could get worse such as litigation and the regulatory authority stepping in to investigate.

"So far, only one veterinarian in Singapore had been suspended for 9 months," I told the other vet. "I don't want Toa Payoh Vets or its vets to be suspended due to my failure as the licensee to rectify matters brought to my attention. I could be suspended through actions of my failure to manage the practice vets diligently."

I told the other vet that many clients had been complaining about her dog barking at them in the waiting area. The dog was free to wander around and I had not banned this dog yet. He would eat out of a bowl in the waiting area and spilled its food onto the floor. I needed to get the waiting area cleaned up. I still remembered this tall sun-tanned blonde Caucasian woman with broad shoulders. She was visibly upset and held her cat close to her chest when Dr Vanessa's dog approached her in the waiting area. I was present at the receptionist counter and apologised to her saying: "This is the other vet's dog." She was consulting Dr Vanessa and managed a weak smile. She was too polite to say anything. This dog had a habit of going to the holding area to pee (urine marking) and barking at the other dogs for a short time.

If this dog belonged to the staff, I would ban the dog strictly or asked the staff to work at a big practice if she persisted. There is a limit to this dog's behaviour which upset clientele. And today, Sunday, I had to make a decision.

After so many years of living, I know that there is no point having the best vet or veterinary technician or intern in the world if he or she does not appreciate the culture and environment of the workplace. I would not hesitate to ask the staff to go.

Nowadays, I have to be stricter in the management of interns, veterinary technicians and vets. Singapore has become a litigious place. Veterinary surgery is becoming very competitive with many younger vets opening their practices. So, there is no point retaining non-performers as that would ultimately lead to the insidious decline of the practice. In any case, I am realistic enough to know that any new vet working in Toa Payoh Vets are just marking their time to open their own practice after gaining experience and clientele.

As for the dog that tried to pee when he drank water, bladder palpation would rule out any urethral obstruction. The dog was operated successfully and the bladder was not even full as catherisation by the other vet brought out no urine.

As the owner preferred me to handle her case, I told the owner that a urine sample was what I recommended just in case there is bacterial infection of the bladder or some small stones from the bladder as this was possible and said by the other vet.

I asked for the X-ray but the owner had kept it since the other vet had the practice of giving X-rays to the owner to keep.

I know that the dog was still on antibiotics but there is still the possiblility of cystitis if the bacteria is not sensitive to prescribed antibiotics. Since the bladder was palpated to be emptied, this showed that the dog could pee all urine at one go. I asked the owner: "Does your dog pass out all urine at one time?" The owner said: "Yes."

"It is possible that there may be stones from the kidney as the other vet had just said," I explained. "The dog may have some association with the need to urinate when he drinks. He might have this behaviour when he had urinary stones for some time and you might not have noticed that. The stitches are just removed and a pain-killer injection is given. We will wait another 7 days to see what happens."

I gave the owner a urine collection container as she did not want to hospitalise the dog nor treat the eye ulcer surgically. I asked the lady to sign a letter stating that she was bringing the dog home against medical advice to be hospitalised for observation and treatment of the eye ulcer. Nowadays, I advise all the vets has to record all instructions in writing as proof if there is litigation. The owner signed and left quite satisfied, in my opinion.

Opening a vet surgery does not mean the vet will be able to sustain his or her profitablility, I explained to the other vet. There are high capital investments and many new practices set up with the father's monies are not able to sustain their operations. A high standard of service and successful outcome in surgeries as perceived by the owner brings in referrals.

There are over 40 practices and the owner has a wide choice nowadays. There are practices full of waiting clients and there are also quiet ones. More practices will be opened as vets who can't work in group practices prefer to strike out on their own.

Saturday, March 19, 2011

364. Informed Consent and Against Medical Advice (AMD) - to get it in writing

Sometimes, I do not record in writing my advices to the pet owner to treat the dog or hamster and do not record that prognosis is poor. This is not a good practice as in litigation, the judges want to see the written word.

In one case reported in the Straits Times on March 18, 2011, I was shocked to read about a very experienced surgeon from the Singapore General Hospital being suspended for 3 months on one of the 3 charges of not giving INFORMED CONSENT. The 3 judges believed in the complainant and said that the case records and brochure put up as defence by the doctor did not mention the risks of pain, bleeding and infection being told to the patient. Definitely, the brochure did not mention the risks. Therefore, the judges decided to suspend him for 3 months for not giving informed consent. The patient had had abdominal pains after surgical removal of his piles in 2006. The rectal area was infected post-operation.

I was shocked because this surgeon provided excellent services to me when I underwent colonscopy by him. Excellent bedside manners. Efficient and competent. His nurses assured me that he would not take a long time to do the colonscopy as he is experienced. I was given a sedation by a lady, probably a nurse. She inserted another syringe (probably with saline) to give me the full dose. I just slept. No pain or groginess after colonscopy. It was as if I had a nap. I asked the doctor what injection it was and he did tell me.

In between reading the lines in the newspaper report (mentioned twice), it seemed that there was a warning to doctors to provide a higher standard of care and that means informed consent for everything and proper writing down of advices and risk given. I have an informed consent form for every tasks and procedure nowadays and read to the pet owner the content.


GOLDEN RETRIEVER PUPPY 5 MONTHS, MALE, WITH SMELLY BLOODY DIARRHOEA

The owner wanted me to treat his dog rather than Dr Vanessa and this is because I had treated his other dog for the past years. Dr Vanessa also had owners who just wanted her to treat their dogs or pets.

The puppy had pale gums but not white. It had passed smelly bloody diarrhoea for 2 days but no vomiting. Just give an injection and medication and send home? This would be the standard treatment.

No blood test, no X-ray and no IV drip? This case was not to be taken lightly as the puppy had passed smelly bloody diarrhoea for 2 days. I advised hospitalisation for 2-3 days. The owner insisted on taking the dog home in the evening, after IV drip and treatment. Some owners don't like dogs to be hospitalised and some don't like to pay more than necessary.

"Let the dog go home," I said to Dr Vanessa. "If the dog dies at home, the owner had been told that the dog needed to be hospitalised to give the IV drip." I ought to record in writing as I was the main vet handling the case and would be hauled up to court even though I did this case with Dr Vanessa. But I did not record this done. Nor did I record my prognosis of 50:50.

This would be a serious mistake if the puppy died of bleeding and infection and dehydration. Therefore, I have to be more careful to write "AMD". Family members might sue me, though the owner might not. Dogs are family. Times have changed. All doctors and vets have to be much more careful as litigation takes up a lot of time.

GOLDEN RETRIEVER
X-Ray - "Lots of gas in the large intestines with a lot of fine particles like soil," I discussed with Dr Vanessa. She was not really convinced but this is OK as each vet has his own opinion. The owner did not tell me that the dog had gone to the East Coast beach the day before diarrhoea and had eaten lots of sand. He told me and apologised for the omission the 2nd day when he took the dog back accepting my advice (dog panting, lethargic, did pass non-smelly stools in a soft lump, could eat). I said that the dog had no diarrhoea due to the drugs given. The intestines, being bleeding needed time to heal and the food intake irritates the gut.

Blood test from Day 1 showed:

haemoglobin 12.6 (12-18)
Red cell count 5.3 (5.5-8.5)

total WBC 17.9 (6-17)
Neutrophil 49.16% Abs 8.80
Lymphocytes 31.40% Abs 5.62
Monocytes 10.17% Abs 1.82
Eosinophils 8.66% Abs 1.55
Basophil 0.67% Abs 0.12

PCV 0.34 (0.37-0.55)
MCHC 37 (32-26)
Platelets 241 (200-500)

The owner accepted the advice to hospitalise the puppy for 2 days. Should be able to recover and go home well. Many vets read blood test as one single event. Actually, one should read it as a starting of a disease process. In this case, the intestines have bleed seriously and dehydration and bacterial infection had gained a foothold. Not so bad, but enough to cause the dog to pant (in pain and in infection) and lethargy. Without IV drip, I think it would just pass away due. In this case, there would be a failure to record advices given to the owner as to hospitalisation and IV drip, X-ray and blood tests if these procedures were not done. All bets are off if the puppy dies. It is a very emotional experience for the family and many question the competence of the vet. Litigation would be in their mind.