Thursday, May 10, 2012

989. Update: Consent is the best form of defence

"The dog has been passing blood in the stools for 14 days. You don't just give a jab and ask the owner to go home, " I said to Dr Vanessa as the owner wanted treatment on the spot and no hospitalisation for the 13-year-old Beagle X. A gentle giant looking Beagle with a white face. I was also in the consultation room.

"Should the old dog die soon, the vet may be sued."

"For negligence," the young lady asked whether the dog had colitis as there was fresh blood in the stools and I had said that the likely area of bleeding would be in the colon. This indicated a young lady with knowledge and the vet must be able to provide the standard of care expected by his peers in such situations.

"Consent is the best form of defence," the young fair lady in her late 20s said.

"This case is more a standard and duty of care rather than (informed) consent (to specific treatments as requested by the owner," I said. "A dog that had diarrhoea for 14 days resulting in more frequency of diarrhoea and blood loss and loss of appetite cannot be treated as a simple case with one injection and sent home. The dog may die due to dehydration and that would be negligence on the part of the vet who had not given the IV drip and relevant medication inside the drip. Just one injection and some medication home will not be the reasonable standard of care in this (severe gastroenteritis) situation."  

Actually I can't figure out where "consent " comes into play in this situation. This must be a lawyer or legally trained owner. Later I saw her studying her book placed on a brown table in the waiting room as she waited for the treatment of IV drip. I had instructed what type of treatment to be given inside the IV.

The 500-ml 5% glucose saline IV drip normally runs over one hour. As this lady seemed capable and knowledgeable, I advised her to continue the IV drip at home as this would take around 2 hours.

She said she was OK. So, I helped her to take the dog to the father's car. The father would drive the car closer and reversed at the front of the clinic and open the back left door.

I held the IV drip bag high up and she carried the dog of 18kg out of the Surgery as we walked together closely. "Put the dog on the floor of the car," I said as she noted that the bright red blood gushed back into the drip set due to the lack of gravity for the drip to flow. The front car seat was pushed forward by the father. She entered the left front door and held the IV line as high as possible. In this small car, she held the IV bag at the ceiling of the car and her father zoomed home.

The IV drip droplets flowed again pushing the blood back into the system. We rarely asked the owner to go home with the IV drip bag as many owners would not know what to do if the dog moved and the drip fell out, oozing lots of blood. But this lady had medical knowledge and was capable and so after some education on the taking out of the drip, I got her and the dog home.


I phoned today Day 3. Dr Vanessa had phoned earlier twice. The dog was OK. "The dog can only be certified OK if he has passed normal stools," I said to Dr V at 2pm. "Due to the spasmogesic drug, he had not passed stools for 2 days. That does not mean he is OK." The lady returned my call at 3.30pm and provided the following feedback:

Day 1. Had diarrhoea for 14 days with increasing frequency of diarrhoea. Dog would drink but pushed away the food. Sought vet treatment at Toa Payoh Vets. Bundled home with IV drip set in car as the owner did not want to leave the dog in clinic. According to the owner, vomited lst day, diarrhoea for one week 1-2x/day, then more and blood seen. last few days, diarrhoea 4-5X.

Day 2. No stools. Ate plain rice and chicken.

Day 3. Ate plain rice and chicken. At 3 pm, normal stools passed. "The first faecal pellet was firm, then semi-soft but no blood," she said.

1.  Blood test - Neutrophils 47%, Lymphocytes =17% but the total White Blood Cell Count was normal. Normal % of Neutrophils and Lymphocytes should be higher. Was there some pathogens affecting the ratio of N/L? A subclinical parvo-viral infection? It is hard to say. Liver enzymes were high.

2. Stool examination - Erythrocytes +. No leucocytes, ova, cysts, parasites seen.

3. Parvovirus test on faeces. Owner did not want it. This was recorded. No more vaccination for this dog for some years. Old dogs can still be infected by parvoviruses causing diarrhoea and blood in the stools. In this case, there was fresh blood and so "colitis" was correctly stated by this young lady owner. But what was the cause of colitis?' There is no answer. Practise evidence-based medicine unless the owner is against it.

This case was done by Dr Vanessa. As it was one of those cases of "Trust and Audit" I have instituted at Toa Payoh Vets, I was present to monitor and ensure that a high standard of veterinary care is presented. Later, the owner told me she was not too happy with "mis-representation of the cost of spay or some surgery" by a vet who has a practice nearer her home and that was why she did not go there for this treatment. It is extremely difficult to be a vet nowadays with the government increasing the cost of doing business. For example, the Health Services decided to have every imported medical device to be certified and that means hefty "certification" fees.

So, a small dental instrument or a cathether must be "certified" or prohibited from being imported although it had been certified in the developed countries. The Singapore supplier must pay and pay the fees for every piece of equipment to be imported. This leads to high increase in health care costs but it seems that the bureaucrats are unaware of the implications.

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