Monday, January 9, 2012

808. Veterinary Surgery Productivity in Employee Vets

I have just updated the report today:

Jan 4, 2012. Wednesday. 2nd day at work.
 
A new client is difficult to come by as there are now 47 veterinary practices in Singapore. This was revealed to me by one veteran drugs salesman who saw me yesterday. We knew each other for more than 40 years and he had become busier now, with so many new practices compared to 4 when I first started out in 1982.
 
A quiet slim lady brought a black-brown Miniature Schnauzer to the Surgery as the dog had two loose front teeth. From her expressions and conversations directed at me, she would prefer me to handle her case. "I will do it together with Dr Vanessa as part of my mentoring process. When did the dog eat?"

"My dog ate at 10 am. Is it OK to do anaesthesia? "
"It is ideal that the dog should not have eaten for 10 hours before anaesthesia as the dog may vomit," I said. As the owner did not have time to postpone the tooth extraction, I said, "I will do it at 5 pm which is 6 hours later. It should be OK".

5-year Min Schnauzer, Female Spayed.
Chief complaint: 2 loose front tooth with exposed roots were surprisingly seen. Other teeth in good condition.
"i used the finger brush and gel," the owner said.
"You must have been brushing too vigorously," I replied. "The gums of the two incisors are exposed. It is best not to use the finger brush. In any case, the back teeth needs scaling."
Chief Complaint - My Schnauzer has two loose front teeth



Complaint No. 2 - My Schnauzer has a big ear lump that increases in size







4886 - 4895. Electro-surgery productivity



2nd complaint: R ear inflammatory nodule, firm, 7mmx7mmx5mm with central hole.
"A bee stung her tongue sometime ago," the lady said.
"Any bees seen in the last 2 weeks?" I asked as the owner said that the lump grows bigger in the past days. The dog had been scratching the right ear.
"It is best to excise it while the dog is under General Anaesthesia (GA) for dental scaling," I advised. "If you don't want histopathology, we will not know whether it is cancerous or not. A biopsy can be done but it costs money and delays. The best is for me to excise it since it is growing bigger day by day ."

The lady agreed to dental scaling and excision of the lump but not to blood test or histopathology. I asked Dr Vanessa to check the heart and pulse as well as general examination of the lungs. All were OK. So, the GA will be at 5pm to be done jointly.

I wanted to demonstrate how to be efficient and productive in veterinary surgery to my staff as it is one thing to lecture to young ones. Show how it is done will be best.

PLANNING
Scrub & clean ear well before sedation. "Any clipping of the ear?" Min asked me. "No need," I said.
I checked that Min had prepared the setting up of the electrosurgery equipment, dental scaling equipment and covered the operating table with a towel to prevent electric shocks to the vet on contact. After all this was done, the dog's dosage of IV anaesthesia was calculated. "Give 50% of the calculated dose and you have around 10 minutes of anaesthesia," I said to Dr Vanessa.

5 min after sedation, electro-excision by Dr Vanessa was completed within 60 seconds and then dental scaling was done. As the dog had little tartar due to the teacher's vigorous finger brushing, the dental scaling of the back teeth took a very short time.

Productivity means using the correct amount of anaesthetic drugs and least time to complete surgery and dental scaling. Therefore, the dog has the best chance of survival on the operating table. Delays by not preparing the equipment at first increases the risk and that would account for some deaths on the operating table.

The following is what happened as I asked my intern, Mr Lim to do the recording. Normally Min would do it but Mr Lim needed to be hands-on to learn if he wanted to be a vet after his National Service.
5.22 pm Sedate/IV anaesthesia at 50% dosage guideline*
5.25 pm Electro-excision
5.26 pm Dental scaling
5.36 pm End of dental scaling

*IV Anaesthesia Guideline Toa Payoh Vets and Dr Sing Kong Yuen
10kg, healthy, young dog. Domitor = 0.4 ml, Ketamine = 0.5ml IV combined
Usually no top up is required in a spay if done within 20-30 minutes.

This dog - 5 years is not young. The staff is to calculate on paper the dosage
D= 0.11ml + K=0.14 ml. Total = 0.25ml. Add 0.25ml Hartmann = 0.5 ml to be given IV.
 
Normally, the IV anaesthesia lasts around 15 minutes. I noted a very slight reaction to electro-incision which lasted less than 10 seconds. The dog was adequately sedated for dental scaling done by Dr Vanessa. Two teeth and nodule given to owner. I demonstrated that this case did NOT need any isoflurane and O2 top up if proper pre-op preparation had been done and the vet is skilful in using the electro-surgical instruments.

USE OF ELECTRODES
"Don't bend the circular wire," I said to Dr Vanessa as she looped the nodule and the wire tilted at 45 degrees. "It is a very thin wire. It will break and it is very expensive to buy." The wire loop was originally 90 degrees to the electrode. Training a person how to use the tools of the trade correctly is important and acquiring the correct skills makes a vet more productive. The Vet School provides some knowledge of electro-surgery but I doubt every of the 60 - 80 students has the chance to handle the electro-surgical equipment. So they acquire the skills after graduation.



WART OR NODULE?
I would say it is an inflammatory nodule (with a hole in its centre, possibly bee sting). Dr V thinks it is an ear wart. "Physically, it does not look like a wart," I argued. "A wart usually is cauliflower shaped or rough, not smooth. However, veterinary medicine has exceptions and I can't say this is not an ear wart. Since the owner does not want histopathology, we can't send the lump to the laboratory for examination. Therefore, there is no definitive diagnosis."

VACCINATION AND HEARTWORM PREVENTION
"I give heartworm tablets monthly," the owner said. "The last vaccination was 2 years ago." I explained to her the difference between the usual vaccination and heartworm.

"You may be getting your priority wrong. In the countryside like England, where most dogs don't meet other dogs, some dogs may be safe without further vaccination as they don't get exposed to many other dogs as in city living." I explained. "Parvovirus is still around. Distemper is still present in unvaccinated puppies. Have you been to England?" I asked. She said she was in England for two years and understood what I said.

VETERINARY PRODUCTIVITY & EFFICIENCY
Many employee vets and doctors are not aware of the need to manage financial costs as this subject is not taught in vet school in detail if at all. So, they use materials and waste time in surgery. After all, they don't pay out of their own pockets and so do not bother with using excessive packets of sutures or finding more efficient ways to stitch up a case.

If there is no proper planning, a lot of time and material are wasted. This dog would need top up IV anaesthesia or isoflurane gas to complete the job. As demonstrated by me, the whole process after sedation took 3 minutes for electro-excision and 10 minutes for dental scaling.

An example of poor productivity and efficiency in vet surgery would be as follows:
The dog was sedated for a spay. The legs were then anchored to the op table. The vet assistant started clipping the surgical area inside the surgery room. Then the area would be cleaned. A gas mask would be given to the dog to deliver isoflurane gas and O2. The dog struggled as sedation wore off. A lot of time had been wasted.

My usual method is as follows:
To clip the dog (not ferocious) at the Preparation Room. Clean the surgical area. Sedate with Domitor and Ketamine IV. Dog goes into Operation Room. Anchor legs to table and clean surgical area again. Wait 5 minutes (time spent after sedation would take 5 minutes). Gas mask to deliver isoflurane and O2. Intubate. Spay. A lot of time is saved and the dog is exposed to much less anaesthetic in this way.
OUTCOME
The dog in this case was groggy for over 1 hour as I did not use Antisedan to reverse the Domitor as I deem it not necessary to wake the dog up so early as she might feel the pain. Pain-killer and antibiotic injections were given. The dog went home without problems as at 12 hours at the time of writing this first draft report. However, in this final copy, the owner had texted me saying that the surgical area was weepy and inflamed and what should she do?
"Hi dr Sing, I'm .....Brought ....to ur clinic for teeth extraction n ear surgery on Wed. ....ear is not doing well...Had inflammation. Can I administer iodine on her ear? What shd I do? I gv her medication as indicated, didn't bring her out. Can y kindly advise? Thanks very much
Younger people prefer texting. I phoned her and advised daily cleaning with the iodine and to let the dog wear the e-collar as she had been scratching the surgical area. She would let me know if there are problems again.

AN EXAMPLE OF POOR PRODUCTIVITY WASTING MANY HOURS HAPPENED ON THE SAME DAY

The HDB contractor came to replace the wooden bathroom door (rotten base) with a plastic one. He dismantled the door and then found that the plastic one was too narrow to fit in. 3 weeks ago, another person had come to measure the dimensions. This was really a waste of time, being unproductive. This is what I mean by productivity and efficiency.


"Please put back the old door," I asked the thin Malaysian man from Malacca with jet black hair. "I have a lady vet and you can understand that she can't use the bathroom with no doors. She works to past 8 pm at night. For men, an open door may be OK"

The contractor actually took the trouble to fix back the old door and said, "OK. I will get the new door back to the factory to replace one with correct dimensions today." He had previously said it might take 2 weeks, since Chinese New Year falls on Jan 22, 2012 and most workers had gone home. I was surprised. He even gave me two discarded wooden boards for me as shelving.


More pictures are at:
http://www.sinpets.com/F6/20120107vigorous-finger-tooth-brush-exposed-roots-Schnauzer-singapore_ToaPayohVets.htm

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