Monday, March 12, 2012

904. Sunday's interesting cases. Mar 11, 2012 - Sedation to last stitch

Sunday, Mar 11, 2012

Sunday's interesting cases.
Sunday Mar 11, 2012

Singaporeans hate long waiting times at clinics to see a doctor and so I have started procedures to ensure that the waiting times should be less than 15 minutes. Many vets don't realise that clients hate to wait too long on Sundays.

For example, a neuter case on a Sunday can take up longer than 30 minutes (from sedation to last stitch) if the younger vet has no sense of time management. Or it could be done in 15 minutes with planning and pre-op preparation. Now I monitor the younger vets' efficiency in veterinary surgery by using time of sedation to last stitch and review the outcome of their surgeries (repeat stitching, stitch breakdown, infections etc).

Vets who don't make the mark will be asked to go. There is no other way because a higher standard of care must be achieved if Toa Payoh Vets is to be ranked by clients as the top 5 in Singapore. There are SOPs (Standard Operating Procedures) to be adopted and stuck to and I don't tolerate any lapse. AMA (Against Medical Advices) have to be recorded and medical records are to be written in greater detail than in the past.

A pug came in for neuter. I assigned the surgery to Dr Daniel and monitored the time he took. I ensured pre-op planning and preparation. Domitor and Ketamine at 50% and isoflurane gas. The sedation time to last stitch was around 30 minutes. It was OK but I said it could be shorter.

A dwarf hamster came in for left eye discharge and reddened left ear. Dr Vanessa was assigned the case. Not just some ear drops as the owner had been given such ear drops by the pet shop or Vet 1. Dr Vanessa scoped the ear. "A general anaesthesia had to be done to irrigate the ear," I said. The owner gave his consent. I asked Dr Vanessa to do a proper time management as she had other cases. In the end, I did the hamster myself with Dr Daniel as she other cases to attend to on this busy Sunday afternoon when clients came all together around 1-3 pm. I will have to follow up on this hamster.

A Schnauzer came in for a routine vaccination. Dr Daniel did it and told me that the dog had a black lump on the right of the backside and he had advised the owner to get it excised. It was good that he did a general examination and detected this lump. Some vets would just advise "wait till it grows bigger" but many tumours, if cancerous, grow bigger without the owner being aware of it, till it is too big.

The owner declined and wanted to wait and see. "The black lump is a melanoma," I said to the middle-aged couple with a teenaged daughter. "It has grown big but not that big yet. It is very black. Our advice to you is to remove it while it is easy to do so. And less expensive. You need not accept the advice. However, you cannot not say that the vets did not advise you during vaccination. When it grows bigger or spread to other parts of the body, you cannot blame the vets for not giving proper advice. Big tumours need big cuts and longer stitching. You have to pay much more. Older dogs like older people get tumours and it is better to get them cut away when they are small. Saves money and less worries of the tumours being cancerous and spreading later."

The couple was vacillating for some reasons. After all, they came to vaccinate their 5-year-old female Schnauzer. They were worried about the dog biting the wound and the lack of care-givers and wanted to wait later.

The vet's duty is to advise properly. "How much it will cost?" the father asked me. "$150 as it is a small tumour as anaesthesia will not be long and therefore the charges are less," I said. "Can surgery be done today?" he asked. "Yes," I said.

SURGERY
"This is a simple surgery," I said to Dr Daniel." It takes 5 minutes (from sedation to last stitch) to do the whole process." Dr Daniel looked at me incredulously. I was sure that he would adopt what the professors had taught him but that would be the traditional way. Sedate, intubate, use scalpel to make an elliptical incision with a wide margin. Undermine with scissors. Stitch up the two ends. How could the whole procedure take 5 minutes? I must be getting senile?

The dog was given Domitor and Ketamine at 50% IV. Isoflurane gas by mask was given though I would say it was unnecessary as you would see what I mean. From my experience, this dosage would be sufficient for a snip and a stitch.

"Pull up the elongated melanoma (1.5 cm x 0.5 cm, with a stalk) with forceps," I said to Dr Daniel. Snip it off with scissors around 3 mm away." Dr Daniel took a pair of curved scissors and snipped off the melanoma as advised.

The melanoma came off with about 50% of the dermis intact. There was the grey dermis but no subcutaneous tissues seen. "No need to stitch," I said as small bleeders ooze blood. "Just potassium permanganate powder to stop the bleeding. Cover the wound with plaster."

Dr Daniel had not seen such wounds being covered with plaster. This was the bulging backside area. Wouldn't the plaster just drop off, he must have wondered but did not speak his mind. I got two sticky plasters and covered the wound. The type you used when you cut your finger. They did not drop off.

This was one of those easiest surgeries in the world. Snip and stitch. But no need to stitch as the melanoma had a stalk and the skin was clear of melanomas by 3 mm. The owner did not want histopathology as they were also cost-conscious. So, none was done.

Veterinary surgeries present many variations. It is up to the vet to know what to do and how to do it efficiently. The surgery text book offers the standard method but there are better ways not described in the text book, as in this case.

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