1455. AMA - Against Medical Advices - A case study

TOA PAYOH VETS toapayohvets.com Date:   14 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits Against Medical Advices (AMA) Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   14 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 "Vet 1 did not advise me to get an X-ray to check whether the cause of blood in my dog's urine is due to urinary stones," the owner said to me. I had reviewed Vet 1's medical records of this poodle and Vet 1 had not written his advices to get X-rays done. Earlier, I had asked Vet 1 whether he did advise X-ray since the owner told me he was not told. "I always advise X-ray and urine test when a dog passes blood in the urine," Vet 1 said to me. "The owner wanted to wait and see after a course of antibiotics." A urine test was done as there was a report which showed "No crystals in the urine." I told the owner that I had written "owner does not want radiography" on the urine test report as I had reviewed this case done by Vet 1 and had asked him why he did not advise X-ray during the consultation. Vet 1 had said that the owner did not wish to have X-ray. However there was no AMA in his medical report and I had not pursued the matter further. I was present when the owner came as his dog had passed blood in the urine after the course of antibiotics.  Sometimes, I don't record every medical advice to the owners too and this can be held against me when there is a negligence complaint to the authorities or in litigation. It is one man's word against another. Who to believe? I got the owner's permission to do a blood test, X-ray and urine test. I asked my assistant to use "Whats App" from his mobile phone to send him all the 3 results. The owner replied instantly with queries and this showed that he was much concerned about his old dog's health. Many old dogs are family members. This case shows that the vet must be proactive and consistent in his veterinary process, protocols and systems to provide evidence-based medicine. Many times we want to save money for the owner by not doing tests. But such kindness could turn against the vet if the dog dies. By recording AMA (Against Medical Advices) in the medical records during consultation, no ambiguity arise when there is litigation or complaint to the vet authorities. I usually write as I talk to the owner. Some vets do their writing at the end of consultation and this is where he or she forgets to record medical matters and advices. If the owner has been given the X-rays or lab test reports, this should also be written down in the case sheets.  Nowadays, Singapore owners are more sophisticated, veterinary competition is more intense. Vets have to deliver results or justify their treatment and this can be done by being meticulous and aware of the need to have a proper process, system and protocols in veterinary diagnosis and treatment of diseases in pets. This case illustrates the importance of AMAs in the practice of medicine and the need to practise defensive and evidence-based medicine in a developed country like Singapore.    P.S. The dog will be operated by me today, Jun 14, 2013 after another course of antibiotics and when she eats and is active. The blood tests showed a high total white cell count of 25 and very high number of neutrophils indicating a bacterial infection at the time of consultation with me. Urine test this time showed struvites crystals. X-rays of the female dog with urethral catherisation and 30 ml of air showed a big urinary stone and no bladder tumour. The owner has been told that kidney stones are also present in the left bladder. Only the bladder stone will be removed in today's surgery. Every old dog anaesthesia is high risk and this dog is 10 years old and much loved by the family. Pressures are high for any vet as nobody can guarantee no anaesthetic death on the operating table.           6189. Female dog urethral catherisation and 30 ml of air into bladder provides excellent contrast X-rays Update will be on this webpage: http://www.sinpets.com/F5/20130614 against_medical_advices_toapayohvets.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: June 14, 2013 Toa Payoh Vets

1454. Myanmar stories - The man from Rangoon

Yesterday Jun 11, 2013, I visited Khin Khin. She was subletting half her office at $850 to another person as the employment agency business had gone downhill with the Singapore Government's clamp down on the hiring of foreigners by Singapore employers. During the election, the foreigners were a hot issue, said to deprive Singaporeans of jobs and lowering the salaries. So, nowadays, many applications are rejected as compared to liberal approvals over 2 years ago. Other countries like the UK and USA also have restricted foreigners from gaining employment.

I met a tall slim dark skinned man who had resigned from working in a recycling company after 2 weeks of work. He had this black hair creamed and curved into a wave at the left side, just the style some 50 years ago. He could speak some English and I asked why he resigned.

"Shouting and shouting by the manager," he put his left hand on his heart area. "Every time shout. If I put the wrong item into the container, I have to re-do again. For example, if I put aluminium can into the steel container, I have to start and sort all again. More shouting. I just can't take this anymore."

"Where are you from and how old are you?" I asked.
"I am from Rangoon. I am 38 years old."

I was surprised he said "Rangoon" instead of "Yangon".

His father had passed away and his mother is a retired civil servant who has pensions.
He is a Myanmar graduate in Zoology. I felt sad for him as he must have spent a lot of money coming here and now he is looking for another job.

"I was new to this job," the Rangoon man said. "If they give me 3 months, I will be more experienced. But the manager shouted and shouted at me all the time. I have to work for the forklift driver and the others too. But they all shouted at me."

"What are your working hours?" I asked.
"7.30 am to 6.30 pm and sometimes to 7.30 pm when the delivery truck comes late."
"Do you work on Sundays?" I asked.
"Every Sunday but I get one weekday off a week."


"It is not so easy to find another employer as you have no experience and Singapore employers are not allowed to hire freely as before," I knew of many applications rejected by the MOM although the employer has the required quota. "You may face shouting employers again. Will you then resign again?"

"I will not resign," he said.
I asked him to contact Bernard the agent who got him this job.
He took out his Zit phone which looked like the very ancient Nokia phone without camera and frills and dialled the number. Nobody answered. I dialled the same number on my phone and Bernard said that the S Pass had been cancelled and he had one month to go home or find another employer.
"I thought he said he had given a month's notice," I said.
"No need," Bernard said. "He was on probation and since he resigned, he would not need to give notice."

It is too late. In addition, this man would lose 50% of his agency fee if he loses his job within 6 months, according to the MOM rules and regulations.But he did not get sacked. He resigned and therefore he could lose all. There were 4 other foreign workers in this recycling firm and they were Chinese Nationals. Sometimes, they could be ganging to oust him by scolding a novice and getting him to work faster and be more productive. I don't know.   




 

1453. Sunday's interesting case. Veterinary Anaesthesia - A father becomes responsibile for Golden Retriever

TOA PAYOH VETS toapayohvets.com Date:   11 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits Vet anaesthesia - A rattled Golden Retriever snaps at the vet Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   11 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Monday, June 10, 2013 1453. Sunday's interesting case. Veterinary Anaesthesia - A father becomes responsible for a Golden Retriever "I could have spent my time making more money," the man in his late 50s had spent his free time washing the Golden Retriever daily for the last 4 weeks. The dog had generalised ringworm. Reddish skin in the face and body and a black lower body. A very itchy dog.  I shaved it and instructed that its infected skin be washed daily with two types of washes I prescribed and give the anti-ringworm, antibiotic and a multivitamin + zinc medication. Owners who complied with my instructions generally find good outcomes but many don't come back for a skin review after a month. In this case, the owner came because the 5-year-old Golden Retriever had a very itchy right ear - all inflamed and red. The son had bought the dog but is too busy to care for him when the dog had generalised ringworm. I said to the father, "Your situation is common in Singapore. Children buy the dog but have no time to care for them such as daily walks. The parents take over the responsibility and some love the dog to bits. "Why don't you give this dog away? After all, you did not buy this dog. Golden Retrievers with their long coat are high maintenance." The older generation of Singaporeans are generally not dog lovers owing to the harsh economic times they were brought up and so this generation tends to be frugal and dog ownership is a luxury. "A relationship is established," the father said. "Do you go for walks with this dog?" I asked. "Yes," he said. "Dogs are better than human beings," I replied. "Dogs have time for you but people have their own agendas. Dogs don't get upset or angry with you for various reasons, unlike people." He seem to appreciate his dog more after my talk . because he asked me whether his dog would be all right. I had the sedated the dog to irrigate his right ear thoroughly and did dental scaling to scale off the hard tartar in his back teeth and helped to carry his dog to the back seat of his car. The dog was still drowsy as it was just 30 minutes after sedation on this bright sunny Sunday afternoon near closing time of 4.30 pm.  Dental scaling under sedation at the same time as ear irrigation would save some money for the owner. In any case, the hard tartar in the back teeth ought to be removed to prevent periodontitis and gum diseases. The owner came in just for ear problem but the vet ought to advise what other health care is needed. It is up to the owner to accept the advices such as dental scaling for the first time for this 5-year-old dog. It will be for the dog's good as his back teeth would last longer. It is not practical for the busy owner to brush the dog's teeth daily when he has no time for himself. So I was glad that this owner accepted the advice and did not say much about the need for tooth brushing. The dog is fed chicken and dog food and is quite trim owing to walks. Not one of those fat Golden Retrievers that have no outdoor exercises.  As the dog was still drowsy and the owner worried, I rushed into the surgery to get the antidote of 0.8 ml Antisedan and injected it IM on the backside muscle of the dog in the back seat. "Your dog will wake up before you reach home," I said. The owner was quite happy as he worried about anaesthetic deaths. In this case, I gave 0.8 ml domitor and 1.0 ml ketamine IV for a 33-kg Golden Retriever. This IV anaesthesia was sufficient for 15 minutes to do dental scaling of the back teeth and ear irrigation. The operating table was tilted downwards so that the water from the mouth during dental scaling flowed out. P.S. 1. Sharing my experience with this IV anaesthesia regime for other vets: The formula is 0.4 ml domitor + 0.5 ml ketamine IV for a 10-kg young healthy dog. This provides around 20-30 minutes of general anaesthesia. With this formula, I reduced the dosage for this 33-kg Golden Retriever as he does not need >15 minutes. Antisedan IM wakes up the dog and this puts the owner's mind at ease.  P.S. 2. The dog's ringworm was not fully cured. "It is around 80% cured," I said to the owner who had taped up a wet wound below the right hock. I took off the tape which revealed a weepy wound due to licking and cover up. There were black skin spots with scales but in general the new hairs had grown and the dog was no longer itchy. I showed the owner that the lower body was no longer black as before. I prescribed another course of ringworm medication. Maybe a reminder card or SMS ought to be sent a month after skin disease treatment? P.S. 3 This dog snapped at me suddenly at the waiting room when I tried to touch his head to show the owner that the ringworm lesions had gone. He was sitting with the owner at the consultation room after I had examined him on the consultation room table. He did not object to my manipulations and ear checking then. This was unusual behaviour for a Golden Retriever but he must be angry with me for examining his ears and for previous injections. This time I did not give any injections and so I was surprised he snapped. It seems that gentle dogs do get rattled too, like people, for various reasons! But this dog was angry at me for the ear checking and previous treatments and injections, not with his beloved owner.    P.S. 4 I phoned the owner on Monday afternoon to follow up, but his mobile phone call terminated abruptly twice. Should have sms him. Update will be on this webpage: www.sinpets.com/F5/20130611ringworm _scaling_teeth_toapayohvets.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: June 11, 2013 Toa Payoh Vets

  



 

1454. An ice-cream factory being approved

On June 10, 2013, I visited a new ice-cream factory in Jurong, being approved by the AVA together with its founder. This is the 2nd ice-cream factory I have seen.

Although there seems to be no connection to veterinary medicine, I met  Linda, a building engineer from a professional engineering consultant firm told me that she had advised via the related contractors on fire safety in veterinary clinics in Redhill and a new one near Changi Prison. 

"It is hard for a new vet to find a FS firm to get AVA approval," I said. "Unlike doctors, vets and lawyers listed on the yellow pages, it is hard to know who does Fire Safety for new vet practices."

"There are more than 1,500 professional engineer firms," she said. "But not all do fire-safety consultancy."
I saw my old Mercedes car in the factory premises. I sold this 8-year-old it as it had cost me $6,000 to repair the leaking coolant system in Singapore, without success. "Check coolant level" warning came out again last 2 months ago and I decided to sell it. The experienced mechanic said there might be need to overhaul and change the system, costing over $4,000. I sold to the founder for S$2,000 (car body price) and got back my COE refund of $33,000. Now I have to rent a car at $1,450 per month for the time being. Car prices are incredibly high in Singapore and car loans are now restricted by the government to 50% and 5 year payment. Yet COE prices have gone up to $70,000 this month though they were around $100,000 3 months ago.    
 
"How did you repair the car in Johor?" I had gone with the founder of this ice-cream factory to Iskander and saw a busy mechanic. "Is it done by the mechanic at Iskandar?"

"Yes," he said. "There seemed to be over-heating of the engine with lots of glue and sticky liquid found inside the coolant system and the gasket had been damaged."

"The glue would be due to the white-haired man servicing Mercedes at a Caltex petrol station off Dunearn Road," I said. "He pumped in glue to seal the leak. It didn't work and he also replaced a new water radiator. Then another mechanic in Tagore Lane sealed a leaking joint and there was no leak for a few months. After that there was coolant leak again and I had to top up the water every 2 days. So, that's why I decided to sell off this car as I had spent over $6,000 for repairs. How much was the repair?"

"S$2,000 and it took a week," the founder said. "My experienced Jaguar car mechanic spoke to this Malaysian mechanic and assessed he could do the job. In Singapore, the cost would be over $4,000."

"It is hard for me to find a good mechanic in Singapore," I said. "I thought the white-haired men in Dunearn Road, specialising in Mercedes car servicing would do a good job." I can't afford to spend time at workshops when my old car broke down and so I sold it. I like this E200 car very much for its design and comfort but it seems that continental cars over 8 years tend to give mechanical problems. Cars that lasted more than 8 years need much repairs but are cheaper than buying new cars.     

1452. Update: 6 cases of urinary stones in dogs

TOA PAYOH VETS toapayohvets.com Date:   10 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles and rabbits Surgical Process in bladder stone removal and economics (video) Dr Sing Kong Yuen, BVMS (Glasgow), Date:   10 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Vet surgery: The steps in bladder stone removal in the cat and dog I surfed the net and found the following: http://www.youtube.com/watch?v=6nnIHqEoDVI This is a good surgery video done by the Silsistra Veterinary Clinic in Bulgaria. The process of surgery must be systematic so that a high standard of care is achieved. 1. Bladder is taken out and is packed and surrounded by gauze swabs so that there is no backflow of urine into the abdomen (seen in the video). 2. Two anchor sutures on either side of the incision. (I don't find this process necessary but some surgery books show this). 3. A syringe to take out a urine sample for analysis (this is done by me) if no urine sample had been collected earlier. 4. Bladder incision below the apex of the bladder away from blood vessels. 5. Stone removal using forceps. 6. I do a 360-degree sweep of the inside of the bladder using artery forceps to feel for more stones. A gritty feeling.  (However, X-rays will show the number of radio-dense stones). 6. Irrigate the bladder with normal saline (via urinary catheter or syringe in saline). 7. Pass a catheter from inside the bladder into the urethra to ensure no stones obstruct the urethra, especially in the female cat (seen in the video) or dog. 8. 2 layers of inverting sutures. I find that artery forceps to anchor one end of the first continuous layer which is knotted at both ends. Then another artery forceps to anchor the other end of the 2nd continuous layer. These forceps are useful in providing traction in tightening the continuous sutures. *9. A syringe of saline is injected into the cat's bladder to ensure that there is no leak from the sutured area (seen in the video). Or syringe in saline from the penile urethra end catheter in male cats or dogs. Dogs with stones behind the os penis may need to be syringed with a 20-ml syringe of saline to push the stones into the bladder so that they are removed via the bladder incision. 10. I account for all stones removed as shown in the X-rays. The stones are shown to the owner and the numbers are recorded in the medical records. Unless there are thousands. It will be good to take digital images for recording. 11. Some clinics do another X-ray of the bladder after stone removal to prove that no stones are present. This is an additional cost but may be wise in defensive medicine. X-rays show include the kidneys. 12. I make it mandatory for all my vets to send the stones for chemical analysis even if the owner does not agree to it.  13. Advices on the regular monitoring of urine and special diet are ignored by most owners for various reasons. So, some cases of bladder stones do recur.  P.S. 1.  I have a video produced on the cost of bladder stone surgery in the dogs and cats in Singapore. The video is at: Video: Costs of bladder stone surgery. The costs just for anaesthesia and surgery are from $800 to $2,000 depending on the time taken to do the surgery. P.S 2. It is like feast and famine. Sometimes bladder stone cases come together to Toa Payoh Vets.  Images of 5 recent bladder stone surgeries done by Dr Daniel at Toa Payoh Vets are shown below: Case 1. Female dog pees out urinary stones recently   6138 - 6141. Multiple bladder stones. As the dog pees outdoors, the owner said she did not notice any stones being urinated out, till recently when the dog was indoors. Analysis showed they were struvites. Case 2. Male dog has blood in the urine 6149 - 6156. A bladder stone in a Jack Russell was removed. Analysis showed it was struvites. Video: Costs of bladder stone surgery Case 3. Female dog vomits and has a large abdominal distension 6135 - 6136. Bladder rupture in a 12-year-old Maltese. The urethra had been obstructed with stones for some weeks. The dog presented as a swollen abdomen. Blood tests in the vomiting dog showed kidney failure.  The owners requested euthanasia after Dr Daniel had repaired the bladder.  Case 4.  Male dog has blood in the urine 6170. Urinary stones in a Shih Tzu. The surgery was done on June 4, 2013. The bladder mucosa was 1-cm thick as the owner procrastinated on doing X-rays and surgery for many weeks. The big stone was >2 cm across. The case report is at:  Urinary stones in a Shih Tzu Case 5. Male dog with fits had blood in the urine 6179. A fifth case of another Shih Tzu with fits had calcium oxalate bladder stones removed. He was a rare type who howled for a long time, as if he was being abused. He does it at home too. He had bruised his surgical area extensively after surgery despite wearing an e-collar. "It is not subcutaneous bleeding," I said to Dr Daniel. "Somehow he used his e-collar's edge to traumatise the surgical area." NSAID painkiller injections and oral tablets were given   Case 6. Female dog with recurring blood in the urine initially had no "crystal" in the urine. A female poodle with blood in the urine around 2 weeks after consultation with Dr Daniel who had done a urine analysis. "No crystals" were seen in the urine. The dog went home on antibiotics and was OK for around 2 weeks.  I asked the owner why he did not want an X-ray done as I had written that he did not want an X-ray on the urine analysis report. This was done after I had checked with Dr Daniel whether he had advised X-ray. The owner said he was not advised to X-ray his dog and Dr Daniel told him that the haematuria could be due to infection, tumour or stones. I do review all cases done by my associate vets. In this case, the vet ought to have recorded in his writing in the medical case sheet that the owner did not accept his advice to X-ray. I got the dog X-ray using air contrast radiography showing a large bladder stone but no mucosal bladder tumours. The dog was catherised to empty the bladder. Then 30 ml of air was syringed into the bladder just before the X-ray. As the dog had fever and the total white cell count was very high at 41, I advised that the dog be on antibiotics for 7 days and surgery to be done when the dog could eat and is active. Urine tests showed triple phosphate crystals this time.  My intern will be producing this case  an educational video. This case illustrated the need for writing down "AMA" (Against Medical Advices) when the owner declined X-rays.   Sometimes we want to save money for the owner by not advising X-rays for urinary stones for blood in the urine. Or just take the lateral view. However, this may not be a best practice in haematuria cases. In this case, I took the ventro-dorsal views too and this view show whether the left kidney has stones. The right kidney has stones as well as the bladder. Without the ventro-dorsal view, it will be hard to tell the owner who actually wanted to know whether the left kidney has stones. I had two views of the air-contrasted bladder and could use evidence-based medicine to show him that the left kidney was the one with stones. That means that removal of the bladder stones may still result in blood in the urine as the left kidney has stones. Sometimes I do one view to lower medical costs for the owner but this is not a best practice. Some vets just X-ray the bladder, forgetting the kidneys.  Some vets don't analyse the urine. A systematic process is best.      This case illustrated that "NO crystals" do NOT mean no urinary stones and that most owners want to know what is happening to his dog but desire to pay the least medical cost. The cost of living is very high in Singapore and vets do understand the need to provide least cost medicine for the heartlanders. But sometimes, vet get sued or complaints for not doing a proper diagnosis owing to this mindset of least costs to help the average man.  Updates will be on this webpage: www.sinpets.com/F6/stone_surgery_cat_toapayohvets.htm   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: June 10, 2013 Toa Payoh Vets