Two cats fought on the ledge of the 7th storey HDB flat. Both fell at 10 pm yesterday. The stray cat died. The home cat came for treatment as she has blood stained chin.
Simple case. A horizontal lacerated wound. Stitched up 3/0 nylon for chin lacerated wound. 5/0 nylon for tongue vertically lacerated wound (lower and upper area) . I advised nylon instead of dissolvable as the area was infected due to trauma and cat fight.
After the surgery, I took some pictures and saw the lice running around the face. Also tartar in the teeth of this 3 year old cat. I phoned the owner to advise dental scaling and he said OK. During scaling, the vet noted a big laceration of the tongue. The owner was phoned to give permission to stitch up. I advised 5/0 nylon and 3 simple interrupted stitches on top and 2 below the tongue surface.
Always examine the whole mouth from end to end as vet medicine springs surprises.
Thursday, June 21, 2012
1042. Failure to keep a proper record: $5,000 fine for senior cardiothoracic surgeon
Straits Times Jun 20, 2012
I showed the article to Dr Daniel and Dr Vanessa to illustrate the importance of meticulous recording to protect against litigation.
The cardiothoracic surgeon of the National Heart Centre was fined $5,000 by the Singapore Medical Council. He was censured and to give an undertaking that he would not repeat the clincial error and pay the cost of the legal proceedings.
What he did not do:
1. Failed to keep a proper record of his discussion with a patient's operation. Fined $5,000 for professional misconduct.
2. Failed to note the patient's consent to the operation (lobectomy).
3. Needed to maintain a higher standard as a senior doctor of 22 years so as to be a role model for junior doctors.
The Committee said that keeping proper medical records is part of patient treatment and these records avoid disputes between doctor and patient. The patient had given his informed consent but the surgeon had not recorded the informed consent given in this case. This is different from not obtaining informed consent.
FOR VETS
1. Patient to sign the informed consent form
2. Vet must record in writing that the patient has given informed consent (time, date).
The practice is usually to get the informed consent form signed by the pet owner.
I showed the article to Dr Daniel and Dr Vanessa to illustrate the importance of meticulous recording to protect against litigation.
The cardiothoracic surgeon of the National Heart Centre was fined $5,000 by the Singapore Medical Council. He was censured and to give an undertaking that he would not repeat the clincial error and pay the cost of the legal proceedings.
What he did not do:
1. Failed to keep a proper record of his discussion with a patient's operation. Fined $5,000 for professional misconduct.
2. Failed to note the patient's consent to the operation (lobectomy).
3. Needed to maintain a higher standard as a senior doctor of 22 years so as to be a role model for junior doctors.
The Committee said that keeping proper medical records is part of patient treatment and these records avoid disputes between doctor and patient. The patient had given his informed consent but the surgeon had not recorded the informed consent given in this case. This is different from not obtaining informed consent.
FOR VETS
1. Patient to sign the informed consent form
2. Vet must record in writing that the patient has given informed consent (time, date).
The practice is usually to get the informed consent form signed by the pet owner.
1041. Follow up: Beagle with bladder cancer (adenocarcinoma)
Today, June 21, 2012 I was surprised to see the Beagle, Male, 14 years old so alert and able to control his urination (in the daytime). It was a great joy to see the happy couple as I did not expect this old dog to survive the 2-hour surgery to remove his bladder cancer. But here he was today at 10.30 am with the happiest client. They had made an appointment with Dr Daniel who is their vet surgeon. I come to Toa Payoh Vets for the past 10 days at 9 am and so am able to manage my "trust and audit" of the associate vets.
The complaint was that the dog cried when the wife wipe the left hind hip area after bathing. As for the bladder, there was no complaint now. No more leakage of urine with blood. I checked the op area. The dissolvable stitches had fallen off. The lower part of the body was stained yellow and the owner confirmed that he could not control his bladder when he sleeps.
HISTORY
Beagle, Male, 14 years. Haematuria and urinary incontinence.
May 13, 12. Blood in the urine. Can't control the bladder at all. X-ray of bladder done but not so clear. I thought there were sharp stones. Blood and urine tests done. Case report written.
May 14, 12. I removed most of the bladder tumour near the neck of the bladder in with Dr Daniel assisting. A 2-hour surgery. Histopathology of bladder tumour: a moderately differentiated adenocarcinoma.
May 16, 12. Went home.
May 17, 12. Paraparesis. He had bolted from his confined space at home and a luggage fell on his back!
CONSULTATION ON June 21, 12 for painful left hip area. Dr Daniel extended left hip. The dog wanted to move away and yelped. There could be arthritis of the left hip as he had difficulty getting up immediately.
I was more interested in his bladder. "He looks younger," I said and had some pictures taken of him. A 14-year old looking like a younger Beagle. I palpated his bladder while he was standing on the consultation table. I could feel a bladder the size of an orange. Yet when Dr Daniel and Min went to collect urine
"No more drinking lots of water like before," the husband said. "Now he drinks around l litre, not 1.5 litres or more."
The complaint was that the dog cried when the wife wipe the left hind hip area after bathing. As for the bladder, there was no complaint now. No more leakage of urine with blood. I checked the op area. The dissolvable stitches had fallen off. The lower part of the body was stained yellow and the owner confirmed that he could not control his bladder when he sleeps.
HISTORY
Beagle, Male, 14 years. Haematuria and urinary incontinence.
May 13, 12. Blood in the urine. Can't control the bladder at all. X-ray of bladder done but not so clear. I thought there were sharp stones. Blood and urine tests done. Case report written.
May 14, 12. I removed most of the bladder tumour near the neck of the bladder in with Dr Daniel assisting. A 2-hour surgery. Histopathology of bladder tumour: a moderately differentiated adenocarcinoma.
May 16, 12. Went home.
May 17, 12. Paraparesis. He had bolted from his confined space at home and a luggage fell on his back!
CONSULTATION ON June 21, 12 for painful left hip area. Dr Daniel extended left hip. The dog wanted to move away and yelped. There could be arthritis of the left hip as he had difficulty getting up immediately.
I was more interested in his bladder. "He looks younger," I said and had some pictures taken of him. A 14-year old looking like a younger Beagle. I palpated his bladder while he was standing on the consultation table. I could feel a bladder the size of an orange. Yet when Dr Daniel and Min went to collect urine
"No more drinking lots of water like before," the husband said. "Now he drinks around l litre, not 1.5 litres or more."
1040. Executing my vision to be top 5 vet practice in Singapore
Yesterday, June 20, 2012, I stopped consultations and had another talk with Dr Vanessa and Dr Daniel seated opposite me to the left and right respectively, in the consultation room at around 12 noon. I know it is extremely difficult to get vets to buy into my vision to make Toa Payoh Vets a top 5 veterinary practice in Singapore.
It is always difficult in any business for the leader to execute a vision because each employee or associate vet has his or her own agendas.
1. "First Impression Counts," I said to Dr Daniel. "If a vet can be bothered to shave, it gives the impression that he can't be bothered to take good care of the customer's pets." I looked at Dr Vanessa's feet and said to Dr Daniel: "Wearing flip-flops and clogs to work is not permitted and a vet had done this in Toa Payoh Vets for some months."
2. My.hints and advices are ignored. "If vets don't accept hints to change their mindset to improve their standard of care, I will be frank. If vets bring down Toa Payoh Vets to the bottom 5 practice in Singapore, I will not hesitate to fire them. Simple as that. I will just close down the practice when I am unable to work. I don't believe in passing the practice to the next generation. I don't believe in leaving my legacy to the next generation. Dr Daniel will have to earn his stripes.
3. Practise evidence-based medicine and know what to do. For example, the rabbit came in with a jaw abscess and there was no advice from the vet to get an X-rays done to check the extent and location of the impacted and infected roots of the cheek teeth. This will not be tolerated by me. In this case, the owner was very knowledgeable about medical practices and was agreeable to the X-ray being done. But the associate vet did not even mention this. This should not be happening again nowadays when litigation and complaints are getting more common.
4. There are around 50 vet practices in Singapore. Why should the client come to Toa Payoh Vets if the practitioners are mediocre and cannot produce excellent clinical outcomes?
It is very hard to execute a vision to be top 5. Failure of associate vets to adopt best practices need to be monitored. Associate vets who don't meet my standards to implement my vision will have to go. It is no more open a practice and clients will come as in 20 years ago. A practice must be sustainable and not losing money over the years as operational costs keep escalating while fees are kept low due to competition. It is quite easy to lose money if the vets are not of a high standard to perform and so it will be better that they work elsewhere.
5. Working in a corporation. Employee and associate vets may feel they are independent contractors and don't take instructions from the licensee. In real life, the licensee is held accountable and if associate vets dress what they like and bring disrepute to the practice, it is best to fire them and just be a small surgery with good referrals and profitability rather than be a multi-doctor practice.
It is always difficult in any business for the leader to execute a vision because each employee or associate vet has his or her own agendas.
1. "First Impression Counts," I said to Dr Daniel. "If a vet can be bothered to shave, it gives the impression that he can't be bothered to take good care of the customer's pets." I looked at Dr Vanessa's feet and said to Dr Daniel: "Wearing flip-flops and clogs to work is not permitted and a vet had done this in Toa Payoh Vets for some months."
2. My.hints and advices are ignored. "If vets don't accept hints to change their mindset to improve their standard of care, I will be frank. If vets bring down Toa Payoh Vets to the bottom 5 practice in Singapore, I will not hesitate to fire them. Simple as that. I will just close down the practice when I am unable to work. I don't believe in passing the practice to the next generation. I don't believe in leaving my legacy to the next generation. Dr Daniel will have to earn his stripes.
3. Practise evidence-based medicine and know what to do. For example, the rabbit came in with a jaw abscess and there was no advice from the vet to get an X-rays done to check the extent and location of the impacted and infected roots of the cheek teeth. This will not be tolerated by me. In this case, the owner was very knowledgeable about medical practices and was agreeable to the X-ray being done. But the associate vet did not even mention this. This should not be happening again nowadays when litigation and complaints are getting more common.
4. There are around 50 vet practices in Singapore. Why should the client come to Toa Payoh Vets if the practitioners are mediocre and cannot produce excellent clinical outcomes?
It is very hard to execute a vision to be top 5. Failure of associate vets to adopt best practices need to be monitored. Associate vets who don't meet my standards to implement my vision will have to go. It is no more open a practice and clients will come as in 20 years ago. A practice must be sustainable and not losing money over the years as operational costs keep escalating while fees are kept low due to competition. It is quite easy to lose money if the vets are not of a high standard to perform and so it will be better that they work elsewhere.
5. Working in a corporation. Employee and associate vets may feel they are independent contractors and don't take instructions from the licensee. In real life, the licensee is held accountable and if associate vets dress what they like and bring disrepute to the practice, it is best to fire them and just be a small surgery with good referrals and profitability rather than be a multi-doctor practice.
Wednesday, June 20, 2012
1040. Follow up: Rabbit's hyphaema. Bleeding inside the eye.
Jun 20, 12
It is a rare case of bleeding in the rabbit's eye.
BEFORE TREATMENT
2 DAYS AFTER TREATMENT
2 DAYS AFTER TREATMENT
FOLLOW UP ON JUNE 20, 2012
Thanks for the trouble to give me the feedback today to say that the rabbit's eye is now normal and that the bleeding has disappeared 3-4 days after going home. Much appreciated.
Thanks for the trouble to give me the feedback today to say that the rabbit's eye is now normal and that the bleeding has disappeared 3-4 days after going home. Much appreciated.
1039. Follow up: Hypoglycaemia & Atypical lymhphocytes
June 20, 2012
"The Jack Russell X is normal now," the wife came in for more antibiotics for the urinary tract infection and was most happy. "I consulted a lady who can communicate with my dog. She graduated from overseas. My dog told her he is going soon when I ask whether my dog should take chemotherapy."
"I am open-minded," I said. "Your dog is on prednisolone which is a form of chemotherapy without the toxic side effects and so he is feeling much better now.".
"The Jack Russell X is normal now," the wife came in for more antibiotics for the urinary tract infection and was most happy. "I consulted a lady who can communicate with my dog. She graduated from overseas. My dog told her he is going soon when I ask whether my dog should take chemotherapy."
"I am open-minded," I said. "Your dog is on prednisolone which is a form of chemotherapy without the toxic side effects and so he is feeling much better now.".
1038. Follow-up: Pyometra Chihuahua
Jun 20, 2012
Phoned owner today. Excellent news.
Today is Day 6 after pyometra surgery to remove infectd womb on Junb 14, 2012
Eating well, everything OK, quite active.
The husband said: "Drinking a lot of water the last 2 days, but otherwise OK."
On Jun 17, complained of "bleeding" from operation, see image. I said it was due to the e-collar traumatising the right side of the surgical area but the owners insisted that the dog never did it.
"The dog does not do the scratching in front of the owner," I said. "The owner cannot be watching over the dog for 24 hours every minute of the day."
DAY OF SURGERY (Upper image)
2 DAYS AFTER SURGERY (Lower image)
I gave a very low dose of pred and the inflammation subsided satisfactory.
RETROSPECT
I should not have sent the dog home on the same day as surgery as pyometra is a big surgery. However, this dog ate and wagged her tail in the evening at 6 pm when I asked Dr Daniel to take her out for some sunshine, observation and photography.
At home, she must have walked around and felt the itch and pain and used her e-collar to rub the surgical area. The e-collar reached the right flank and the sharp edge also nicked and lacerated the base of the nipple sharply. It is hard for the owners to believe what I said as they said the dog never attempted to do it (in their presence).
Phoned owner today. Excellent news.
Today is Day 6 after pyometra surgery to remove infectd womb on Junb 14, 2012
Eating well, everything OK, quite active.
The husband said: "Drinking a lot of water the last 2 days, but otherwise OK."
On Jun 17, complained of "bleeding" from operation, see image. I said it was due to the e-collar traumatising the right side of the surgical area but the owners insisted that the dog never did it.
"The dog does not do the scratching in front of the owner," I said. "The owner cannot be watching over the dog for 24 hours every minute of the day."
DAY OF SURGERY (Upper image)
2 DAYS AFTER SURGERY (Lower image)
I gave a very low dose of pred and the inflammation subsided satisfactory.
RETROSPECT
I should not have sent the dog home on the same day as surgery as pyometra is a big surgery. However, this dog ate and wagged her tail in the evening at 6 pm when I asked Dr Daniel to take her out for some sunshine, observation and photography. At home, she must have walked around and felt the itch and pain and used her e-collar to rub the surgical area. The e-collar reached the right flank and the sharp edge also nicked and lacerated the base of the nipple sharply. It is hard for the owners to believe what I said as they said the dog never attempted to do it (in their presence).
1037. BE KIND AND BRAVE - ADOPT A STRAY
PROMOTING ADOPTION OF STRAYS
2012. My latest image inspired by a couple who adopted a cat from the Cat Welfare Society. "Adopt a female cat," I advised since the male cat had FLUTD and passed away during treatment at a veterinary practice, causing much sadness to the wife.
Compared to my older image in 2003. It is quite difficult to think of captions. Both cats were sterilised by me.
2012. My latest image inspired by a couple who adopted a cat from the Cat Welfare Society. "Adopt a female cat," I advised since the male cat had FLUTD and passed away during treatment at a veterinary practice, causing much sadness to the wife.
Compared to my older image in 2003. It is quite difficult to think of captions. Both cats were sterilised by me.
1036. Follow up: Constipated cat on Jun 19, 12
On Tue, Jun 19, 2012 at 4:13 PM, Mr Dong Liu <dong.liu@uqconnect.edu.au> wrote:
Dear Dr Sing,
I was reading your blog post 1033 Fecal impaction of the cat, I was just wondering how did you manage to pass the catheter into the cat? Did you use general anesthesia or Domitor on the patient?
Regards,
XXX
E-MAIL REPLY FROM DR SING DATE JUN 20, 12
This case was performed by Dr Daniel Sing. The cat wxxxas not aggressive and so no sedation and anaesthetic was used when the urethral catheter was inserted gently. The cat was very timid and did not mind.
In this case, there was a tube of enema given a few days earlier and two hard stools had passed out. Also, the oral laxative oil had been given and the cat had passed into the colon but no stools were passed.
In this case, there was a tube of enema given a few days earlier and two hard stools had passed out. Also, the oral laxative oil had been given and the cat had passed into the colon but no stools were passed.
The cat was X-rayed before the urethral catheterisation (2 images). They showed faecal impaction of the whole colon.
After the urethral catheter enema using normal saline of 70 ml by Dr Daniel, the cat passed another hard faecal tablet the next day.
June 20, 2012 TODAY
10.30 am. The owner phoned to say 5 hard faecal pellets had been passed out. He was quite happy. "My cat vomited as he pooped," he said. "Quite a lot of stools." That was good news. He will come with the cat tomorrow.
June 20, 2012 TODAY
10.30 am. The owner phoned to say 5 hard faecal pellets had been passed out. He was quite happy. "My cat vomited as he pooped," he said. "Quite a lot of stools." That was good news. He will come with the cat tomorrow.
MY DISCUSSION WITH A SENIOR VET ON JUN 18, 12
1. He said digital extraction of the stools. I clarified as this seemed to be drastic and traumatic.
He said to use forceps to pull out the stools.
2. I had done colonstomy to remove all the hard stools in one old cat with similar impacted stools in the whole large intestine. The cat was OK. In this case, the senior vet said no need to do such surgery. Use forceps to pull out the impacted faeces will do.
3. Such impacted faecal cases are not common compared to difficulty in passing urine.
1. He said digital extraction of the stools. I clarified as this seemed to be drastic and traumatic.
He said to use forceps to pull out the stools.
2. I had done colonstomy to remove all the hard stools in one old cat with similar impacted stools in the whole large intestine. The cat was OK. In this case, the senior vet said no need to do such surgery. Use forceps to pull out the impacted faeces will do.
3. Such impacted faecal cases are not common compared to difficulty in passing urine.
1035. Medical negligence of 2 embryologists
Straits Times Jun 20, 12 A2
IVF mix-up: mum seeks damages
In a medical negligence suit, it is not only the practising doctor or vet that is liable for damages as the following case shows:
1. Thomson Fertility Centre (TFC) waived all hospital and docotrs' charges
2. Thomson Medical was fined the maximum of $20,000 for failing to ensure suitable practices were followed
3. The woman who alleged negligence had a baby with a stranger's semen insgead of her husband's sued Thomson Medical, Thomson Fertility Clinic and 2 embryologists for special damages of $750,000
4. She wants the court to assess the amount of general damages.
5. Legal fees must be paid by the company and this could amount to $100,000 in protracted trials.
As TFC had admitted clinical error, the court will decide a "fair outcome" for all parties as regards the quantum of compensation
In conclusion, the licensee or key appointment holder and the Practice can be sued for damages, not just employee doctors or vets who performed the procedure. Therefore, strict monitoring and management of the employee or associates vets are necessary to prevent possible litigation and that includes "trust and audit" procedures to be done by the licensee regularly.
IVF mix-up: mum seeks damages
In a medical negligence suit, it is not only the practising doctor or vet that is liable for damages as the following case shows:
1. Thomson Fertility Centre (TFC) waived all hospital and docotrs' charges
2. Thomson Medical was fined the maximum of $20,000 for failing to ensure suitable practices were followed
3. The woman who alleged negligence had a baby with a stranger's semen insgead of her husband's sued Thomson Medical, Thomson Fertility Clinic and 2 embryologists for special damages of $750,000
4. She wants the court to assess the amount of general damages.
5. Legal fees must be paid by the company and this could amount to $100,000 in protracted trials.
As TFC had admitted clinical error, the court will decide a "fair outcome" for all parties as regards the quantum of compensation
In conclusion, the licensee or key appointment holder and the Practice can be sued for damages, not just employee doctors or vets who performed the procedure. Therefore, strict monitoring and management of the employee or associates vets are necessary to prevent possible litigation and that includes "trust and audit" procedures to be done by the licensee regularly.
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