Saturday Jan 7, 2012
I went to work although it is my day off. Checked on the cat that passed blood in the urine and under Dr V's care. The lady owner phoned: "How's Toto?" I said: "I am Dr Sing. Dr V is off today. Toto has not been passing blood in the urine since yesterday's admission to the Surgery." The cat was in a grated flooring and dark brown urine was seen, no more red blood."
"It was my grandpa who said that the cat had passed blood in the urine," the young lady said. "I don't see it."
"Well, grandpa is correct," I replied. "I saw the red blood myself when Dr V was sedating the cat. I was present and had tried to express some urine for the urine test." Around 1 ml was expressed after sedation. Bladder was empty. I did not palpate any big stone or thick wall suggstive of tumour. So this was likely an infection of the bladder, cystitis.
FLASHBACK YESTERDAY
A lady in her late 30s and her grandpa came with a brown cat to see Dr V. A vet had treated this cat, prescribed antibiotics and a Eukanaba dry food "guaranteeing" that the urination problem would be resolved if this dry food was consumed.
"This cat is fierce," the lady said. So, Dr V, Min, Nicole and Mr Lim were in the room
Saturday, January 7, 2012
Thursday, January 5, 2012
806.. Old mother died from post-op infections in the ward
I read this somewhere in the Straits Times in Dec 2011.
The surgeon operated successfully on the heart of the old mother. She became infected in the ward and it seemed that the doctors had not attended to her. She died. Civil suit. The registrar resigned and the surgical intern gave up his surgical internship.
Post-op infections can be very serious in old people and dogs.
The surgeon operated successfully on the heart of the old mother. She became infected in the ward and it seemed that the doctors had not attended to her. She died. Civil suit. The registrar resigned and the surgical intern gave up his surgical internship.
Post-op infections can be very serious in old people and dogs.
804. Against Hospital Advice: Biopsy and lumbar tap discouraged for 76-year-old mother diagnosed with massive stroke
AGAINST HOSPITAL ADVICE
I read in www.asiaone.com.sg while in Eastern Europe last week. The writer said he sent his mum to Changi General Hospital. 2 neutosurgeons and 2 visiting ones said his mum could have brain cancer and would not do a biopsy and lumbar tap due to high risk v. benefit.
The son scoured the internet and found a specialist who treated his mother at Tan Tock Seng Hospital and did the two tests. His mother had a brain infection and had since recovered!
No comments from CGH
I read in www.asiaone.com.sg while in Eastern Europe last week. The writer said he sent his mum to Changi General Hospital. 2 neutosurgeons and 2 visiting ones said his mum could have brain cancer and would not do a biopsy and lumbar tap due to high risk v. benefit.
The son scoured the internet and found a specialist who treated his mother at Tan Tock Seng Hospital and did the two tests. His mother had a brain infection and had since recovered!
No comments from CGH
803. Liposuction death of Mr Heng was due to too much sedative
Straits Times Prime News Jan 5, 2012 Pg A3
"Doctors gave patient too much sedative: Coroner"
Heavily sedated man eventually died from the effects of asphyxia. His tongue was said to block his breathing. The more he struggled, the more sedative of propofol was given. This lead to the possibility that the patient could have suffocated leading to cardiac arrest, tongue rolled back causing obstruction of the airway.
13 intestinal perforations during liposuction not immediate cause of death -no massive bleeding or infections do not occur so fast.
LESSONS FOR VET ANAESTHESIA
1. I don't use propofol nor IV anaesthesia. However, some practices may not have isoflurane gas machine and theefore need to top up with IV anaesthetic drugs.
2. Keeping an accurate and meticulous record of sedation
2.1 The coroner said the two doctors "tailored" the figures - titration of the propofol and the total amount of propofol administered
2.2 The monitoring of the patient under sedation was treated with caution by the coroner. Dr Zhu could recall the sequence of titration and elvel of propoful tritratred during the entire procedure (of 3 hours) when no contemporarneous record was ever made of the number of times the propoful was adjusted or the level titrated. So the coroner was incredulous that she could recall the details.
The timing in Dr Wong's notes had been amended. Although 60 ml of propofol was claimed to have been given, this was actually more than 60 ml.
2.3 Dr Wong's nurse often paused when answering straightforard questions and claimed not to remembver important facts. So the nurse's demeanour in court was less forthcoming.
CIVIL SUIT filed against the two doctors.
For vet anaesthesia, keep proper and accurate anaesthetic records that can be believed.
"Doctors gave patient too much sedative: Coroner"
Heavily sedated man eventually died from the effects of asphyxia. His tongue was said to block his breathing. The more he struggled, the more sedative of propofol was given. This lead to the possibility that the patient could have suffocated leading to cardiac arrest, tongue rolled back causing obstruction of the airway.
13 intestinal perforations during liposuction not immediate cause of death -no massive bleeding or infections do not occur so fast.
LESSONS FOR VET ANAESTHESIA
1. I don't use propofol nor IV anaesthesia. However, some practices may not have isoflurane gas machine and theefore need to top up with IV anaesthetic drugs.
2. Keeping an accurate and meticulous record of sedation
2.1 The coroner said the two doctors "tailored" the figures - titration of the propofol and the total amount of propofol administered
2.2 The monitoring of the patient under sedation was treated with caution by the coroner. Dr Zhu could recall the sequence of titration and elvel of propoful tritratred during the entire procedure (of 3 hours) when no contemporarneous record was ever made of the number of times the propoful was adjusted or the level titrated. So the coroner was incredulous that she could recall the details.
The timing in Dr Wong's notes had been amended. Although 60 ml of propofol was claimed to have been given, this was actually more than 60 ml.
2.3 Dr Wong's nurse often paused when answering straightforard questions and claimed not to remembver important facts. So the nurse's demeanour in court was less forthcoming.
CIVIL SUIT filed against the two doctors.
For vet anaesthesia, keep proper and accurate anaesthetic records that can be believed.
802. HSA laboratory error making solutions - applicable to vet anaesthesia
Straits Times Review Jan 5, 2012 Pg A36
"To err is human, to confess remarkable"
Mistake: A senior lab manager misread the concentration of the reagent used for DNA tests. He made a solution 10 times as strong as it should be.
This reagent tested the DNA samples of 400 criminal cases.
How HSA prevents a similar occurrence in the future?
It had not double-checked the solutions used and none in the world does that as it is only a basic tool.
NOW every batch is checked by an independent laboratory
"Why no test was done on the solution before?" No answer to this question.
APPLICATION TO VET ANAESTHESIA - DOMITOR AND KETAMINE IV
Using IV anaesthesia, I want the vet to write down on the anaesthesia record and calculate the dosage based on weight and age and % discounted for old dogs. I do this myself and monitor my associate vets doing it.
IV sedation should not be overdosed, otherwise the dog dies. So, it is important to have a system and process of checking by the Senior Vet.
"To err is human, to confess remarkable"
Mistake: A senior lab manager misread the concentration of the reagent used for DNA tests. He made a solution 10 times as strong as it should be.
This reagent tested the DNA samples of 400 criminal cases.
How HSA prevents a similar occurrence in the future?
It had not double-checked the solutions used and none in the world does that as it is only a basic tool.
NOW every batch is checked by an independent laboratory
"Why no test was done on the solution before?" No answer to this question.
APPLICATION TO VET ANAESTHESIA - DOMITOR AND KETAMINE IV
Using IV anaesthesia, I want the vet to write down on the anaesthesia record and calculate the dosage based on weight and age and % discounted for old dogs. I do this myself and monitor my associate vets doing it.
IV sedation should not be overdosed, otherwise the dog dies. So, it is important to have a system and process of checking by the Senior Vet.
801. Shih Tzu with possible GME - follow up on Jan 4, 2012
4 Jan 2012
The Shih Tzu had been treated for a fever 2 days by Dr Vanessa. I was overseas. I saw him at 7 pm when the young couple came to take him home and observed his walking. He could walk on 4 limbs but not for long. Left eye pupil had no response to light and was dilated fully. Right eye pupil reacted to the bright white light I shone on, but constricted around 70% normal.
Blood test was taken. Showed very low WCC and higher figures of elevated liver enyzmes and higher than normal platelet count. Previous blood test showed normal WCC and elevated liver enzymes.
The dog did not have much appetite but was otherwise normal.
GME - Granulo-meningo encephalitis.
Cause is unknown. Said to be an auto-immune disease.
I did advise pred 2.5mg 2x/day for 2 weeks when the owner said that the dog had panted hard but it was only today I saw the dog again.
Prognosis is usually poor and the owner must be informed. "Feed small amounts and around 6x/day with sweet multivitamins," I advised. "You have 4 weeks." The dog rejected hand feeding but this must be done. Liver Prescription Diet 2 cans and antibiotics were prescribed by Dr Vanessa
The important issues here are prognosis and feeding several times a day at home as the owner wanted the dog back.
The Shih Tzu had been treated for a fever 2 days by Dr Vanessa. I was overseas. I saw him at 7 pm when the young couple came to take him home and observed his walking. He could walk on 4 limbs but not for long. Left eye pupil had no response to light and was dilated fully. Right eye pupil reacted to the bright white light I shone on, but constricted around 70% normal.
Blood test was taken. Showed very low WCC and higher figures of elevated liver enyzmes and higher than normal platelet count. Previous blood test showed normal WCC and elevated liver enzymes.
The dog did not have much appetite but was otherwise normal.
GME - Granulo-meningo encephalitis.
Cause is unknown. Said to be an auto-immune disease.
I did advise pred 2.5mg 2x/day for 2 weeks when the owner said that the dog had panted hard but it was only today I saw the dog again.
Prognosis is usually poor and the owner must be informed. "Feed small amounts and around 6x/day with sweet multivitamins," I advised. "You have 4 weeks." The dog rejected hand feeding but this must be done. Liver Prescription Diet 2 cans and antibiotics were prescribed by Dr Vanessa
The important issues here are prognosis and feeding several times a day at home as the owner wanted the dog back.
Wednesday, January 4, 2012
Day 2 of work - Productivity & Efficiency in Vet Surgery - dental and electro-excision
Jan 4, 2012. Wednesday. 2nd day at work.
A new client is difficult to come by as there are now 47 veterinary practices in Singapore. This was revealed to me by one veteran drugs salesman who saw me yesterday. We knew each other for more than 40 years and he had become busier now, with so many new practices compared to 4 when I first started out in 1982.
A quiet slim lady brought a black-brown Miniature Schnauzer to the Surgery as the dog had two loose front teeth. From her expressions and conversations directed at me, she would prefer me to handle her case. "I will do it together with Dr Vanessa as part of my mentoring process. When did the dog eat?"
"My dog ate at 10 am. Is it OK to do anaesthesia? "
"It is ideal that the dog should not have eaten for 10 hours before anaesthesia as the dog may vomit," I said. As the owner did not have time to postpone the tooth extraction, I said, "I will do it at 5 pm which is 6 hours later. It should be OK".
5-year Min Schnauzer, Female Spayed.
Chief complaint: 2 loose front tooth with exposed roots were surprisingly seen. Other teeth in good condition.
"i used the finger brush and gel," the owner said.
"You must have been brushing too vigorously," I replied. "The gums of the two incisors are exposed. It is best not to use the finger brush. In any case, the back teeth needs scaling."
Chief Complaint - My Schnauzer has two loose front teeth
Complaint No. 2 - My Schnauzer has a big ear lump that increases in size
4886 - 4895. Electro-surgery productivity
2nd complaint: R ear inflammatory nodule, firm, 7mmx7mmx5mm with central hole.
"A bee stung her tongue sometime ago," the lady said.
"Any bees seen in the last 2 weeks?" I asked as the owner said that the lump grows bigger in the past days. The dog had been scratching the right ear.
"It is best to excise it while the dog is under General Anaesthesia (GA) for dental scaling," I advised. "If you don't want histopathology, we will not know whether it is cancerous or not. A biopsy can be done but it costs money and delays. The best is for me to excise it since it is growing bigger day by day ."
The lady agreed to dental scaling and excision of the lump but not to blood test or histopathology. I asked Dr Vanessa to check the heart and pulse as well as general examination of the lungs. All were OK. So, the GA will be at 5pm to be done jointly.
I wanted to demonstrate how to be efficient and productive in veterinary surgery to my staff as it is one thing to lecture to young ones. Show how it is done will be best.
PLANNING
Scrub & clean ear well before sedation. "Any clipping of the ear?" Min asked me. "No need," I said.
I checked that Min had prepared the setting up of the electrosurgery equipment, dental scaling equipment and covered the operating table with a towel to prevent electric shocks to the vet on contact. After all this was done, the dog's dosage of IV anaesthesia was calculated. "Give 50% of the calculated dose and you have around 10 minutes of anaesthesia," I said to Dr Vanessa.
5 min after sedation, electro-excision by Dr Vanessa was completed within 60 seconds and then dental scaling was done. As the dog had little tartar due to the teacher's vigorous finger brushing, the dental scaling of the back teeth took a very short time.
Productivity means using the correct amount of anaesthetic drugs and least time to complete surgery and dental scaling. Therefore, the dog has the best chance of survival on the operating table. Delays by not preparing the equipment at first increases the risk and that would account for some deaths on the operating table.
The following is what happened as I asked my intern, Mr Lim to do the recording. Normally Min would do it but Mr Lim needed to be hands-on to learn if he wanted to be a vet after his National Service.
5.22 pm Sedate at 50% calculated dosage*
5.25 pm Electro-excision
5.26 pm Dental scaling
5.36 pm End of dental scaling
*10kg, healthy, young dog Domitor = 0.4 ml, Ketamine = 0.5ml IV combined
This dog - 5 years is not young. The staff is to calculate on paper the dosage
D= 0.11ml + K=0.14 ml. Total = 0.25ml. Add 0.25ml Hartmann = 0.5 ml to be given IV.
Normally, the IV anaesthesia lasts around 15-30 minutes. Very slight reaction to electro-incision but was OK for dental scaling done by Dr Vanessa. Two teeth and nodule given to owner.
USE OF ELECTRODES
"Don't bend the circular wire," I said to Dr Vanessa as she looped the nodule and the wire tilted at 45 degrees. "It is a very thin wire. It will break and it is very expensive to buy." The wire loop was originally 90 degrees to the electrode. Training a person how to use the tools of the trade correctly is important and acquiring the correct skills makes a vet more productive. The Vet School provides some knowledge of electro-surgery but I doubt every of the 60 - 80 students has the chance to handle the electro-surgical equipment. So they acquire the skills after graduation.
WART OR NODULE?
I would say it is an inflammatory nodule (with a hole in its centre, possibly bee sting). Dr V thinks it is an ear wart. "Physically, it does not look like a wart," I argued. "A wart usually is cauliflower shaped or rough, not smooth. However, veterinary medicine has exceptions and I can't say this is not an ear wart. Since the owner does not want histopathology, we can't send the lump to the laboratory for examination. Therefore, there is no definitive diagnosis."
VACCINATION AND HEARTWORM PREVENTION
"I give heartworm tablets monthly," the owner said. "The last vaccination was 2 years ago." I explained to her the difference between the usual vaccination and heartworm.
"You may be getting your priority wrong. In the countryside like England, where most dogs don't meet other dogs, some dogs may be safe without further vaccination as they don't get exposed to many other dogs as in city living." I explained. "Parvovirus is still around. Distemper is still present in unvaccinated puppies. Have you been to England?" I asked. She said she was in England for two years and understood what I said.
PRODUCTIVITY & EFFICIENCY
If there is no proper planning, a lot of time is wasted. This dog would need top up IV anaesthesia or isoflurane gas to complete the job. As demonstrated by me, the whole process after sedation took 3 minutes for electro-excision and 10 minutes for dental scaling.
OUTCOME
The dog was groggy for over 1 hour as I did not use Antisedan. Went home without problems as at 12 hours at the time of writing this first draft report. However, in this final copy, the owner had texted me saying that the surgical area was weepy and inflamed and what should she do?
"Hi dr Sing, I'm .....Brought ....to ur clinic for teeth extraction n ear surgery on Wed. ....ear is not doing well...Had inflammation. Can I administer iodine on her ear? What shd I do? I gv her medication as indicated, didn't bring her out. Can y kindly advise? Thanks very much
Younger people prefer texting. I phoned her and advised daily cleaning with the iodine and to let the dog wear the e-collar as she had been scratching the surgical area. She would let me know if there are problems again.
AN EXAMPLE OF POOR PRODUCTIVITY WASTING MANY HOURS HAPPENED ON THE SAME DAY
The HDB contractor came to replace the wooden bathroom door (rotten base) with a plastic one. He dismantled the door and then found that the plastic one was too narrow to fit in. 3 weeks ago, another person had come to measure the dimensions. This was really a waste of time, being unproductive. This is what I mean by productivity and efficiency.
"Please put back the old door," I asked the thin Malaysian man from Malacca with jet black hair. "I have a lady vet and you can understand that she can't use the bathroom with no doors. She works to past 8 pm at night. For men, an open door may be OK"
The contractor actually took the trouble to fix back the old door and said, "OK. I will get the new door back to the factory to replace one with correct dimensions today." He had previously said it might take 2 weeks, since Chinese New Year falls on Jan 22, 2012 and most workers had gone home. I was surprised. He even gave me two discarded wooden boards for me as shelving.
UPDATES AND MORE PICTURES AT:
http://www.sinpets.com/F6/20120107vigorous-finger-tooth-brush-exposed-roots-Schnauzer-singapore_ToaPayohVets.htm
A new client is difficult to come by as there are now 47 veterinary practices in Singapore. This was revealed to me by one veteran drugs salesman who saw me yesterday. We knew each other for more than 40 years and he had become busier now, with so many new practices compared to 4 when I first started out in 1982.
A quiet slim lady brought a black-brown Miniature Schnauzer to the Surgery as the dog had two loose front teeth. From her expressions and conversations directed at me, she would prefer me to handle her case. "I will do it together with Dr Vanessa as part of my mentoring process. When did the dog eat?"
"My dog ate at 10 am. Is it OK to do anaesthesia? "
"It is ideal that the dog should not have eaten for 10 hours before anaesthesia as the dog may vomit," I said. As the owner did not have time to postpone the tooth extraction, I said, "I will do it at 5 pm which is 6 hours later. It should be OK".
5-year Min Schnauzer, Female Spayed.
Chief complaint: 2 loose front tooth with exposed roots were surprisingly seen. Other teeth in good condition.
"i used the finger brush and gel," the owner said.
"You must have been brushing too vigorously," I replied. "The gums of the two incisors are exposed. It is best not to use the finger brush. In any case, the back teeth needs scaling."
Chief Complaint - My Schnauzer has two loose front teeth
Complaint No. 2 - My Schnauzer has a big ear lump that increases in size
4886 - 4895. Electro-surgery productivity
2nd complaint: R ear inflammatory nodule, firm, 7mmx7mmx5mm with central hole.
"A bee stung her tongue sometime ago," the lady said.
"Any bees seen in the last 2 weeks?" I asked as the owner said that the lump grows bigger in the past days. The dog had been scratching the right ear.
"It is best to excise it while the dog is under General Anaesthesia (GA) for dental scaling," I advised. "If you don't want histopathology, we will not know whether it is cancerous or not. A biopsy can be done but it costs money and delays. The best is for me to excise it since it is growing bigger day by day ."
The lady agreed to dental scaling and excision of the lump but not to blood test or histopathology. I asked Dr Vanessa to check the heart and pulse as well as general examination of the lungs. All were OK. So, the GA will be at 5pm to be done jointly.
I wanted to demonstrate how to be efficient and productive in veterinary surgery to my staff as it is one thing to lecture to young ones. Show how it is done will be best.
PLANNING
Scrub & clean ear well before sedation. "Any clipping of the ear?" Min asked me. "No need," I said.
I checked that Min had prepared the setting up of the electrosurgery equipment, dental scaling equipment and covered the operating table with a towel to prevent electric shocks to the vet on contact. After all this was done, the dog's dosage of IV anaesthesia was calculated. "Give 50% of the calculated dose and you have around 10 minutes of anaesthesia," I said to Dr Vanessa.
5 min after sedation, electro-excision by Dr Vanessa was completed within 60 seconds and then dental scaling was done. As the dog had little tartar due to the teacher's vigorous finger brushing, the dental scaling of the back teeth took a very short time.
Productivity means using the correct amount of anaesthetic drugs and least time to complete surgery and dental scaling. Therefore, the dog has the best chance of survival on the operating table. Delays by not preparing the equipment at first increases the risk and that would account for some deaths on the operating table.
The following is what happened as I asked my intern, Mr Lim to do the recording. Normally Min would do it but Mr Lim needed to be hands-on to learn if he wanted to be a vet after his National Service.
5.22 pm Sedate at 50% calculated dosage*
5.25 pm Electro-excision
5.26 pm Dental scaling
5.36 pm End of dental scaling
*10kg, healthy, young dog Domitor = 0.4 ml, Ketamine = 0.5ml IV combined
This dog - 5 years is not young. The staff is to calculate on paper the dosage
D= 0.11ml + K=0.14 ml. Total = 0.25ml. Add 0.25ml Hartmann = 0.5 ml to be given IV.
Normally, the IV anaesthesia lasts around 15-30 minutes. Very slight reaction to electro-incision but was OK for dental scaling done by Dr Vanessa. Two teeth and nodule given to owner.
USE OF ELECTRODES
"Don't bend the circular wire," I said to Dr Vanessa as she looped the nodule and the wire tilted at 45 degrees. "It is a very thin wire. It will break and it is very expensive to buy." The wire loop was originally 90 degrees to the electrode. Training a person how to use the tools of the trade correctly is important and acquiring the correct skills makes a vet more productive. The Vet School provides some knowledge of electro-surgery but I doubt every of the 60 - 80 students has the chance to handle the electro-surgical equipment. So they acquire the skills after graduation.
WART OR NODULE?
I would say it is an inflammatory nodule (with a hole in its centre, possibly bee sting). Dr V thinks it is an ear wart. "Physically, it does not look like a wart," I argued. "A wart usually is cauliflower shaped or rough, not smooth. However, veterinary medicine has exceptions and I can't say this is not an ear wart. Since the owner does not want histopathology, we can't send the lump to the laboratory for examination. Therefore, there is no definitive diagnosis."
VACCINATION AND HEARTWORM PREVENTION
"I give heartworm tablets monthly," the owner said. "The last vaccination was 2 years ago." I explained to her the difference between the usual vaccination and heartworm.
"You may be getting your priority wrong. In the countryside like England, where most dogs don't meet other dogs, some dogs may be safe without further vaccination as they don't get exposed to many other dogs as in city living." I explained. "Parvovirus is still around. Distemper is still present in unvaccinated puppies. Have you been to England?" I asked. She said she was in England for two years and understood what I said.
PRODUCTIVITY & EFFICIENCY
If there is no proper planning, a lot of time is wasted. This dog would need top up IV anaesthesia or isoflurane gas to complete the job. As demonstrated by me, the whole process after sedation took 3 minutes for electro-excision and 10 minutes for dental scaling.
OUTCOME
The dog was groggy for over 1 hour as I did not use Antisedan. Went home without problems as at 12 hours at the time of writing this first draft report. However, in this final copy, the owner had texted me saying that the surgical area was weepy and inflamed and what should she do?
"Hi dr Sing, I'm .....Brought ....to ur clinic for teeth extraction n ear surgery on Wed. ....ear is not doing well...Had inflammation. Can I administer iodine on her ear? What shd I do? I gv her medication as indicated, didn't bring her out. Can y kindly advise? Thanks very much
Younger people prefer texting. I phoned her and advised daily cleaning with the iodine and to let the dog wear the e-collar as she had been scratching the surgical area. She would let me know if there are problems again.
AN EXAMPLE OF POOR PRODUCTIVITY WASTING MANY HOURS HAPPENED ON THE SAME DAY
The HDB contractor came to replace the wooden bathroom door (rotten base) with a plastic one. He dismantled the door and then found that the plastic one was too narrow to fit in. 3 weeks ago, another person had come to measure the dimensions. This was really a waste of time, being unproductive. This is what I mean by productivity and efficiency.
"Please put back the old door," I asked the thin Malaysian man from Malacca with jet black hair. "I have a lady vet and you can understand that she can't use the bathroom with no doors. She works to past 8 pm at night. For men, an open door may be OK"
The contractor actually took the trouble to fix back the old door and said, "OK. I will get the new door back to the factory to replace one with correct dimensions today." He had previously said it might take 2 weeks, since Chinese New Year falls on Jan 22, 2012 and most workers had gone home. I was surprised. He even gave me two discarded wooden boards for me as shelving.
UPDATES AND MORE PICTURES AT:
http://www.sinpets.com/F6/20120107vigorous-finger-tooth-brush-exposed-roots-Schnauzer-singapore_ToaPayohVets.htm
Subscribe to:
Posts (Atom)