Sunday, February 12, 2012

875. Sunday's interesting cases

Sunday, Feb 12, 2012

Bright sunny day. Two vets, excluding me are needed on Sunday to reduce waiting time to less than 15 minutes per client. Some cases like dental scaling takes around 30 minutes and if there is one vet, the clients who come later can complain of waiting over 2 hours. I had an early meeting with Dr Daniel, Mr Min and Mr Lim (intern) in the consultation room to discuss about work attitudes, behaviour, stock inventory, anaesthetic records, case records, surgical processes, efficiency and productivity, wastage of resources and time and consistency to enable my vision of Toa Payoh Vets to be the top 5 practices in Singapore. I asked Mr Lim to take minutes of this first meeting. Clients are younger and much more sophisticated as you can see from the cases described below.

Case 1
Golden Retriever's toe fracture as the wife had stepped on him. Review. Much less swollen. Still lame. I showed Dr Daniel how I would handle this case as I would have done in a racehorse. Outside the clinic, trotting and walking. He was limping but we knew which leg. Got X-rays. Cost the owners a bit of money.

"How's your daughter's guinea pig?" I enquired as I had clipped its overgrown cheek teeth and it was not eating for the next day. Vet 1 had treated it earlier with some injections but the GP was still not eating and had lost weight. I had the GP under anaesthesia to check the mouth and the cheek teeth were overgrown. So, this was the problem as the GP had become very thin by then.

"The GP is OK now. Eating," the wife said. "My daughter is a medical undergraduate. She ordered the emergency mixture via the internet and it cost a lot of money."

"I did advise her to go to a pet shop that specialises in GP and rabbits and will have it. In any case, how do you know it is expensive?"

Mum said: "I paid $50.00 for the goods delivered on the same day."

The internet is now what young adults do. I don't stock the mixture as there are not many cases of GP or rabbits. I had advised her to hand-fed the mashed up pellets and also the medication 6X/day in small amounts and also electrolytes. But she wanted prompt results of return to feeding and ordered the emergency mixture. It ended well for the GP. This case illustrates the importance of checking the cheek teeth and not just the front teeth. A similar case in a rabbit recently had been written in www.toapayohets.com

Case 2.
I did not expect any early birds as this was Sunday. Suddenly 2 young ladies came in at 10 am with an Italian Greyhound, 4 years, excellent bodily condition, and wanted dental scaling done. "Has the dog eaten?" I asked. "It may vomit out the food during anaesthesia or sedation."

"At 9am," one lady said. "Just a small amount. When I phoned for appointment yesterday, nobody told me not to feed the dog before surgery."
"I will do it at 4 pm, sufficient time to let the food pass through," I said.
"We live in Tampines," the lady said. This would take some time to go back and forth, at least 30 minutes.

To be practical, I got the dog done with Dr Daniel Sing, mentoring him by showing how I would do it. No problem using 50% of calculated dom and ket combination ination and isoflurane gas. Dog did not vomit. Went home to a happy lady after one hour.

Case 3
An elderly man came in specifically to see me to get his 8-year-old Jack Russell dental work. No dental done before. Dog was given same as the Italian Greyhound. But older. This is a higher risk. As before, I mentored Dr Daniel Sing. He had his own ideas from his professors and this is to be expected of young graduates. Full of theories and latest knowledge of vet medicine and that is good as you can see from one case of the sheltie with nasal discharge and the excellent X-rays taken.

However, the dog stopped breathing, according to Min. I was out a while but came back within 10 seconds, according to Dr Daniel in review of this case later. No time to test his theories. I know what the professors would have taught about injecting the emergency adrenalin etc. Time is of the essence.

I did cardiac massage, blew air into the lungs by cutting the tightly tied endotracheal tube to both jaws (I don't tie this way but the professors would have taught this is the correct way, in normal situations, correctly). "Give Antisedan inj IV" I said. Dog revived and was OK. Alert as a guard dog standing up. "Propofol to continue anaesthesia," Dr Daniel said as there was two teeth left to be scaled and the dog could bite.

"No more IV in this case as the dog's heart may stop," I said. "Just isoflurane gas by mask and it will take a longer time." The dog was treated.

P.S Propofol seems to be a favourite of recent Murdoch Univ trained vet graduates and is used much in the University. But I don't use propofol and there is no need for it as there are other alternatives available. New graduates must adapt to the workplace rather than replicating or using what they have seen being used by their professors.

A practice has to manage cost so as to provide the cheapest competitive veterinary services. It cannot stock similar drugs as they do expire and led to a high wastage of resources and money.

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