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.

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