Saturday, April 21, 2012

952. Epulis in an old chihuahua

952. Epulis in an old Chihuahua APRIL 22, 2012. ||


"Wait-and-see, take antibiotics" is not the appropriate advice to give to an owner of an old Chihuahua with a gingival growth, known as Epulis. Gingival growths in old dogs may not be Epulis and a biopsy is most important to confirm the diagnosis of Epulis or malignant tumour.

Surgical excision using electro-surgery involving the periodontal ligament should be advised. Some vet text books advise the complete removal of the tooth and periodontal ligament to prevent recurrence. A "wait-and-see" advice may be considered negligent advice.
5227. In old dogs, gingival tumours or growths should be excised, not being advised to "wait-and-see" after a course of antibiotics. Electro-excision of epulis including the periodontal ligament prevents recurrence. However, this means the whole tooth or teeth must be removed and this may not be what the owner desires. An informed decision must be made by the owner The vet should advise the surgical excision of all growths in dogs especially old dogs.

Whether the owner accepts the advice or not, depends on the wishes of the owner and this response must be recorded in writing in the case record in the presence of the owner.

This "Against Medical Advice" record is very important in cases of veterinary complaint investigation or litigation when family members find that the gingival growths had grown considerably, leading to pain, bleeding and dysphagia due to "wait-and-see" advice of the vet. Youtube website has one similar case of Epulis video: http://www.youtube.com/watch?v=1KDwaAWCY1s&feature=related

951. System, processes and protocols to prevent veterinary errors

Yesterday, April 20, 2012, I met the owner of the 14-year-old Chihuahua with a reddish gum growth extending downwards and covering the front upper teeth and asked what Dr Vanessa had advised. "Give antibiotics for 2 days, wait and see," she had spotted the growth since 7 days and it had "not grown much bigger." This dog had been looked after by me for many years. She had two operations to remove breast tumours last year. Now she had this gum growth which may or may not be malignant. Growths in old dogs should be advised to be removed early, not wait and see. "Do you expect the growth to disappear or become smaller after 2 days of antibiotics and an injection?" I asked her.

She was not sure. "I trust the vet's opinion." I asked Vet 1 whether she did advise a wait-and-see. She said she had advised surgery and blood test. "Were the advices recorded?" I looked at her case sheet. "It is best to record your advices in case of litigation. Oral evidence during litigation is one person's word against the other. The world nowadays is much more complex and owners are prone to sue. So, record down as you speak. For example, yesterday I spayed a 6-month-old Shih Tzu. I advised blood test to screen the health and to prevent misunderstanding from family members should the dog die on the operating table or after surgery.

I wrote on the case sheet, in font of the owner that he did not want a blood test. That is all that is needed. An informed consent." "Will advising surgery be like being pushy?" she asked. "Professional advices to take blood tests are optional as the pet owner has to pay for them. If the owner does not want the blood test, it is up to the vet whether he or she should undertake the anaesthetic risk to operate the dog.

Unlike the Singapore General Hospital, all surgery patients have to undergo blood tests, X-rays of the chest and ECG to check the heart before the surgeon will operate. This is to prevent litigation if the patient dies on the operating table. "However failure to record the advices may lead to a possibility of negligence or a lack of duty of care. This written recording is part of the vet's professionalism and protection in a court of law."

It should not take a law suit to make a vet wiser. I have instituted a system and process to record AMA (Against Medical Advices) and vets must adopt them for their own good. It is not that my vets must do hard-sell. If the owner does not want blood tests and surgery to remove an oral growth, this is AMA (Against Medical Advice). Record this down promptly in the presence of the owner. Not later. There is no need for a vet to do hard-selling in Toa Payoh Vets. For younger vets, they must be aware of the litigious world they are operating in and the sophistication of the Singaporean clientele.

The licensee (me) must beef up the system and processes to prevent veterinary errors in consultation and treatment. Also protocols for the diagnosis of diseases. There is no other way to protect the practice and the veterinary when litigation comes. P.S. In the human medicine area, a few Singapore surgeons and doctors had been sued for "negligence" and for failure to give informed consent.

Vets in private practice must learn from the reports of such cases and beef up their system, processes and protocols.

Any update will be at: Toa Payoh Vets webpage is at: http://www.sinpets.com/F5/20120418epulis-chihuahua-14years-female-spayed-singapore-ToaPayohVets.htm

No comments:

Post a Comment