Sinuses are empty air spaces in the skull bones. They have openings to drain mucus from the sinus into the nose. People have 4 pairs of sinuses in the spaces.
The frontal sinuses near the eyebrows, the maxillary sinuses inside the cheekbones, the ethmoid sinuses between the eyes and the sphenoid sinuses behind the ethmoid sinuses.
Sinusitis is an infection of the sinuses in the face. Swelling and inflammation of the sinus mucosa blocking up the sinus passages to the nose. Obstruction can also be due to nasal polyps, a deviated septum or enlarged sinus turbinates.
Tuesday, April 24, 2012
Follow up: Lateral ear resection poodle, cat eosinophilia
Monday April 23, 2012 report
LATERAL EAR CANAL RESECTION POST-OP COMPLICATONS
All vet surgeons will encounter post-surgical complications no matter how experienced they are. So, I got one case now. Yesterday Sunday, I re-stitched the two ears (day 5 of surgery). Took over 1 hour under isoflurane gas only. Stitch breakdown uncommon but does occur in any surgery. Phoned owner not to take the dog back as scheduled as I need to nurse it again. Why stitch breakdown? Many reasons probably.
1. I noted that the ears had oozed thick fluid on Day 2 and Day 3, unlike other dogs and took some images.
2. High tension stitching?
3. Handling of ears by my assistant Min to give oral medication painkillers and antibiotics, ear powder, cleaning surgical area, disturbing the stability of the ear sutures? Most likely. I told Min not to touch the dog. Today I used a scoop and drop water at a height to wash away the oozing fluid in one ear (left?, check images). The other ear was dry.
4. I need another 5 days.
UPDATE ON APRIL 26, 2012. Ear wounds still oozing with fluid. Unusual. Used antibiotic powder to dry wound. Owner visited yesterday.
CAT EOSINOPHILIC GRANULOMA COMPLEX Cat went home on last Saturday. Gum and palate ulcers have shrunk 30% by observation of less redness and size after the steroid injection.
Advised 4 weeks to review and cat is on medication.
Blood test results on April 17, 2012
Glucose 11 (normal 3.9 - 6)
SGPT/ALT 294 (121) SGOT/AST 121 (67)
Total WBCC 13.5 (5.5 - 19.5)
N 64.4 8.69 (absolute)
L 23.6 3.19
M 5.7% 0.77
E 6% 0.81 B 0.3% 0.04
GOLDEN RETRIEVER, 9 YEARS, MALE, TICK FEVER
PASSED AWAY YESTERDAY
Positive for Ehr +ve Babesiosis +ve
4 weeks ago
Apr 21, 2012 haemoglobin 5.2 (10.8 -15.6)
Total RCC 2 (3.8 - 5.8)
Total WBCC 102 (5.5 - 19.5)
Dog died one day later
Extremely high total WBCC and loss of blood.
For some reasons, the owner did not follow up and delayed treatment of the tick fever.
LATERAL EAR CANAL RESECTION POST-OP COMPLICATONS
All vet surgeons will encounter post-surgical complications no matter how experienced they are. So, I got one case now. Yesterday Sunday, I re-stitched the two ears (day 5 of surgery). Took over 1 hour under isoflurane gas only. Stitch breakdown uncommon but does occur in any surgery. Phoned owner not to take the dog back as scheduled as I need to nurse it again. Why stitch breakdown? Many reasons probably.
1. I noted that the ears had oozed thick fluid on Day 2 and Day 3, unlike other dogs and took some images.
2. High tension stitching?
3. Handling of ears by my assistant Min to give oral medication painkillers and antibiotics, ear powder, cleaning surgical area, disturbing the stability of the ear sutures? Most likely. I told Min not to touch the dog. Today I used a scoop and drop water at a height to wash away the oozing fluid in one ear (left?, check images). The other ear was dry.
4. I need another 5 days.
UPDATE ON APRIL 26, 2012. Ear wounds still oozing with fluid. Unusual. Used antibiotic powder to dry wound. Owner visited yesterday.
CAT EOSINOPHILIC GRANULOMA COMPLEX Cat went home on last Saturday. Gum and palate ulcers have shrunk 30% by observation of less redness and size after the steroid injection.
Advised 4 weeks to review and cat is on medication.
Blood test results on April 17, 2012
Glucose 11 (normal 3.9 - 6)
SGPT/ALT 294 (121) SGOT/AST 121 (67)
Total WBCC 13.5 (5.5 - 19.5)
N 64.4 8.69 (absolute)
L 23.6 3.19
M 5.7% 0.77
E 6% 0.81 B 0.3% 0.04
GOLDEN RETRIEVER, 9 YEARS, MALE, TICK FEVER
PASSED AWAY YESTERDAY
Positive for Ehr +ve Babesiosis +ve
4 weeks ago
Apr 21, 2012 haemoglobin 5.2 (10.8 -15.6)
Total RCC 2 (3.8 - 5.8)
Total WBCC 102 (5.5 - 19.5)
Dog died one day later
Extremely high total WBCC and loss of blood.
For some reasons, the owner did not follow up and delayed treatment of the tick fever.
Monday, April 23, 2012
Sunday's interesting cases
Sunday April 22, 2012
Case 1: The hot dog farted on abdominal palpation again! The two young ladies came with the hot dog for a review and blood test. "The Miniature Schnauzer bites," one young lady held the dog's head with both hands as I palpated the abdomen with my left hand. "No more vomiting. Normal now." Suddenly the dog farted as I palpated the back half of the abdomen.
This was a loud cracking sound. It was a reproduction of the same incident when I saw him on April 8, 2012. Scientific experiments are valid if others can reproduce the outcome and in this case, I was able to do it again. It is not a common occurrence and so I was much surprised with this loud puffing crack from his backside. "Something wrong with the intestines producing too much gas," I said. The dog was on LD prescription diet and some dog treats, but he still farted. I asked the owners to wait 4 weeks from the first blood test to take blood to check whether the liver has recovered.
I gave the young lady a bottle to collect the dog's urine in the morning as he pees a lot and then dribbles with difficulty (I suspect urine marking as some male non-neutered dogs will try their best even to pee nothing!). In any case, the first urine test show struvite + and spermatozoa 2+ and so we need to review again. The male dog had no more urine and so I did not bother to catherise to collect the urine.
Case 2: Two shrivelled front teeth in a 5-year-old Maltese. The marketing books say "Give what the owner wants." Well, the wife did not want the teeth to be extracted and had been to Vet 1 who did recommend that. "It is not good for the dog," I showed that the gum had receded considerably. "The dog does feel the pain and bacteria will continue to grow after antibiotics.
The teeth may then crack." After much discussion, the wife agreed one bent front tooth to be extracted. Giving what the customer wants is good marketing. I asked the couple to think about it as the dog would need another anaesthesia if the other tooth fracture due to shrivelled root and instability. "It is not stable anymore," I said. "Like tree with rotten roots. During thunderstorms, the tree topples. This root will break and part remains in."
Much time was spent in discussion. It was up to the wife. Much time would have been saved and more fees earned if the vet just do what the customer wants as there will be two anaesthesias involved. The first to do dental scaling of the two front teeth. The later one to extract. However, this cost the owner money and the dog more pain in the delay. Finally, the wife agreed to extraction of the two front teeth and dental scaling.
During anaesthesia, another right upper molar tooth was loose after tartar removal. I did not extract it, knowing the wife's preference to have teeth present in this 5-year-old Maltese. It was loose but not that unstable. Yet all the other teeth were quite strong and relatively clean. The two loose front teeth were a surprising revelation as the other teeth were solid. Veterinary dentistry can be full of surprises. Domitor + Ketamine 50% and isoflurane was safe and fast. Owner wanted a blood test which was done.
Case 3. Phone review of the Maltese with acute bacterial meningitis 10 days ago. I phoned the owner. She said the Maltese was OK and she would come for a blood test later.
Case is written in: http://www.sinpets.com/F5/20120414acute-meningitis-dog-singapore-ToaPayohVets.htm
Signficant blood test results at time of stiff neck is as follows:
April 12, 2012 Maltese, 5 years, Male
Glucose **. Specimen grossly haemolsed. Query glycolysis, suggest to repeat.
Plasma glucose = 20mg/dL Liver Profile. ALT/SGPT normal. AST/SGOT 95 (normal = 81)
Total WCC 19.3 (6-17)
Neutrophils 94% 18.16 Lymphocytes 5.4% 1.04
Monocystes 0.4% 0.08
Eosinophils 0% 0 Basophils 0% 0
Based on sudden onset clinical signs and the total tal WCC and very high Neutrophils, this would be a case of acute bacterial meningitis.
Case 4. The spayed cat caterwauling loudly for the past 4 weeks, starting from first month after being spayed by Vet 1. The young couple showed me their phone video of the cat rolling over, tail up, backside up as if ready for mating. However, no audio. "Most likely, there is a bit of ovarian tissue left behind by Vet 1," I said. "It will be very difficult to find this tissue even if there is a repeat spay." What to do?
Case 5. A 2.5-year-old dwarf hamster had a much swollen right eye. The lower eyelid was as round as a ball, around 4 mm X 4 mm. Squeezing out the pus with fingers had been done by Vet 1 but the swelling remains as solid as ever. A small hole released the pus if you press the lower eyelid. "The best way is to cut a big cut and release the pus," I said to the mother who said this was her favourite "Small White" hamster and was concerned that the hamster would die under anaesthesia. "The hamster is at the end of his lifespan," she said.
"If he dies on the operating table, there is no more." "He will die if he does not eat or drink. Within 2 weeks," I predicted."No antibiotics and eyedrops will help. This is a large conjuntival abscess that needs to be cut around 3 mm to let the thick pus out. Anaesthesia is needed. The hamster may just die during surgery."
So, the 40-year-old mother with a small boy did not know what to do. The older man who could be her father was more aware of the no chance with eye drop and antibiotic treatment. Finally, she decided. I got it done.
A big cut. The hamster survived with a much normal sized lower eyelid and went home.
UPDATE: APRIL 26, 2012. No complaint from the owner
Case 6. The previous blog is below: 939. The hot dog growls at the vet Tuesday, April 10, 2012 "More active, no more vomiting," the lady said. "The dog has not recovered fully from hepatitis yet," I said. I prescribed some liver supplements and anitbiotics. Every family member is happy. The dog was warded 4 days for lethargy and recurring fever.
10 days ago, I had operated on him and removed a big epidermal cyst. The dog was rubbing his back area where the cyst had been removed. So, the grandpa applied bright yellow powder onto the wound. It looked like yellow sulphur, which is toxic. Saturday, April 8, 2012 The owner had brought the dog to see me last Wednesday with complaint of lethargy and fever.
I boarded him for observation and on Saturday, the whole family of 2 ladies, their husbands and grandparents came to visit this miniature schnauzer of 5 years, male. Saturday was my day off, but I went back to Toa Payoh Vets to see this dog. That was how I met the group outside. The dog growled when I approached him to palpate his abdomen to see whether it was still tense and hard. "That is a good sign of recovery to health," I said.
"Yesterday, Dr Daniel said he stood like a statute for a few minutes when let out." "Maybe he is frightened," the young lady said. "Possibly," I asked the owner to hold his muzzle while I palpated his abdomen. Not tense as before.
So,I decided to let him go home. He would recover faster at home. Well, he did recover. As to the cause of his tense stomach area, I can only sketch this scenario as follows: 1. The wound was contaminated by the yellow powder. Toxins and bacteria entered the wound.
Blood test showed high liver enzymes. Low red cell count. The stomach was full. Impaction. I had given anti-spasmodic inj to cool him down. The tense anterior abdomen was due to his liver inflammation.
APRIL 26, 2011Urine test did not reveal any struvite crystals.
This morning, the owner phoned to say the dog had 4 partly swollen paws and red eyes. Yesterday, he had fever and was treated by me with one anti-fever injection. Eating and drinking normally this morning. Had vomited once on going home and after eating the AD canned food.
I asked her to wait and see. Could the liver be inflamed again?
Case 1: The hot dog farted on abdominal palpation again! The two young ladies came with the hot dog for a review and blood test. "The Miniature Schnauzer bites," one young lady held the dog's head with both hands as I palpated the abdomen with my left hand. "No more vomiting. Normal now." Suddenly the dog farted as I palpated the back half of the abdomen.
This was a loud cracking sound. It was a reproduction of the same incident when I saw him on April 8, 2012. Scientific experiments are valid if others can reproduce the outcome and in this case, I was able to do it again. It is not a common occurrence and so I was much surprised with this loud puffing crack from his backside. "Something wrong with the intestines producing too much gas," I said. The dog was on LD prescription diet and some dog treats, but he still farted. I asked the owners to wait 4 weeks from the first blood test to take blood to check whether the liver has recovered.
I gave the young lady a bottle to collect the dog's urine in the morning as he pees a lot and then dribbles with difficulty (I suspect urine marking as some male non-neutered dogs will try their best even to pee nothing!). In any case, the first urine test show struvite + and spermatozoa 2+ and so we need to review again. The male dog had no more urine and so I did not bother to catherise to collect the urine.
Case 2: Two shrivelled front teeth in a 5-year-old Maltese. The marketing books say "Give what the owner wants." Well, the wife did not want the teeth to be extracted and had been to Vet 1 who did recommend that. "It is not good for the dog," I showed that the gum had receded considerably. "The dog does feel the pain and bacteria will continue to grow after antibiotics.
The teeth may then crack." After much discussion, the wife agreed one bent front tooth to be extracted. Giving what the customer wants is good marketing. I asked the couple to think about it as the dog would need another anaesthesia if the other tooth fracture due to shrivelled root and instability. "It is not stable anymore," I said. "Like tree with rotten roots. During thunderstorms, the tree topples. This root will break and part remains in."
Much time was spent in discussion. It was up to the wife. Much time would have been saved and more fees earned if the vet just do what the customer wants as there will be two anaesthesias involved. The first to do dental scaling of the two front teeth. The later one to extract. However, this cost the owner money and the dog more pain in the delay. Finally, the wife agreed to extraction of the two front teeth and dental scaling.
During anaesthesia, another right upper molar tooth was loose after tartar removal. I did not extract it, knowing the wife's preference to have teeth present in this 5-year-old Maltese. It was loose but not that unstable. Yet all the other teeth were quite strong and relatively clean. The two loose front teeth were a surprising revelation as the other teeth were solid. Veterinary dentistry can be full of surprises. Domitor + Ketamine 50% and isoflurane was safe and fast. Owner wanted a blood test which was done.
Case 3. Phone review of the Maltese with acute bacterial meningitis 10 days ago. I phoned the owner. She said the Maltese was OK and she would come for a blood test later.
Case is written in: http://www.sinpets.com/F5/20120414acute-meningitis-dog-singapore-ToaPayohVets.htm
Signficant blood test results at time of stiff neck is as follows:
April 12, 2012 Maltese, 5 years, Male
Glucose **. Specimen grossly haemolsed. Query glycolysis, suggest to repeat.
Plasma glucose = 20mg/dL Liver Profile. ALT/SGPT normal. AST/SGOT 95 (normal = 81)
Total WCC 19.3 (6-17)
Neutrophils 94% 18.16 Lymphocytes 5.4% 1.04
Monocystes 0.4% 0.08
Eosinophils 0% 0 Basophils 0% 0
Based on sudden onset clinical signs and the total tal WCC and very high Neutrophils, this would be a case of acute bacterial meningitis.
Case 4. The spayed cat caterwauling loudly for the past 4 weeks, starting from first month after being spayed by Vet 1. The young couple showed me their phone video of the cat rolling over, tail up, backside up as if ready for mating. However, no audio. "Most likely, there is a bit of ovarian tissue left behind by Vet 1," I said. "It will be very difficult to find this tissue even if there is a repeat spay." What to do?
Case 5. A 2.5-year-old dwarf hamster had a much swollen right eye. The lower eyelid was as round as a ball, around 4 mm X 4 mm. Squeezing out the pus with fingers had been done by Vet 1 but the swelling remains as solid as ever. A small hole released the pus if you press the lower eyelid. "The best way is to cut a big cut and release the pus," I said to the mother who said this was her favourite "Small White" hamster and was concerned that the hamster would die under anaesthesia. "The hamster is at the end of his lifespan," she said.
"If he dies on the operating table, there is no more." "He will die if he does not eat or drink. Within 2 weeks," I predicted."No antibiotics and eyedrops will help. This is a large conjuntival abscess that needs to be cut around 3 mm to let the thick pus out. Anaesthesia is needed. The hamster may just die during surgery."
So, the 40-year-old mother with a small boy did not know what to do. The older man who could be her father was more aware of the no chance with eye drop and antibiotic treatment. Finally, she decided. I got it done.
A big cut. The hamster survived with a much normal sized lower eyelid and went home.
UPDATE: APRIL 26, 2012. No complaint from the owner
Case 6. The previous blog is below: 939. The hot dog growls at the vet Tuesday, April 10, 2012 "More active, no more vomiting," the lady said. "The dog has not recovered fully from hepatitis yet," I said. I prescribed some liver supplements and anitbiotics. Every family member is happy. The dog was warded 4 days for lethargy and recurring fever.
10 days ago, I had operated on him and removed a big epidermal cyst. The dog was rubbing his back area where the cyst had been removed. So, the grandpa applied bright yellow powder onto the wound. It looked like yellow sulphur, which is toxic. Saturday, April 8, 2012 The owner had brought the dog to see me last Wednesday with complaint of lethargy and fever.
I boarded him for observation and on Saturday, the whole family of 2 ladies, their husbands and grandparents came to visit this miniature schnauzer of 5 years, male. Saturday was my day off, but I went back to Toa Payoh Vets to see this dog. That was how I met the group outside. The dog growled when I approached him to palpate his abdomen to see whether it was still tense and hard. "That is a good sign of recovery to health," I said.
"Yesterday, Dr Daniel said he stood like a statute for a few minutes when let out." "Maybe he is frightened," the young lady said. "Possibly," I asked the owner to hold his muzzle while I palpated his abdomen. Not tense as before.
So,I decided to let him go home. He would recover faster at home. Well, he did recover. As to the cause of his tense stomach area, I can only sketch this scenario as follows: 1. The wound was contaminated by the yellow powder. Toxins and bacteria entered the wound.
Blood test showed high liver enzymes. Low red cell count. The stomach was full. Impaction. I had given anti-spasmodic inj to cool him down. The tense anterior abdomen was due to his liver inflammation.
APRIL 26, 2011Urine test did not reveal any struvite crystals.
This morning, the owner phoned to say the dog had 4 partly swollen paws and red eyes. Yesterday, he had fever and was treated by me with one anti-fever injection. Eating and drinking normally this morning. Had vomited once on going home and after eating the AD canned food.
I asked her to wait and see. Could the liver be inflamed again?
Sunday, April 22, 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
"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.
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
Friday, April 20, 2012
951. System, processes and protocols to prevent veterinanry 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 Dr Vanessa 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 erros 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 surgeons and doctors had been sued for negligence and vets should learn from such cases
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 Dr Vanessa 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 erros 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 surgeons and doctors had been sued for negligence and vets should learn from such cases
950. Follow up - lateral ear resection of poodle - operated on Apr 17, 2012
April 19, 2012
Ear operation areas were wet. Took some images. Cleaned up the ears. Gave 2.5 mg pred PO. Painkillers and antibiotics. Dog was eating. No pain on touching ears. Applied trimetho powder onto wound to dry it. No chemicals like iodine or KMnO4 as the area is stitched up and such chemicals irritate and delay healing.
April 20, 2012
Review in the morning. Ear operation area much drier. Dog looks happier. It takes lots of nursing in such operations. At least 7 days to clean wound to ensure proper healing.
Ear operation areas were wet. Took some images. Cleaned up the ears. Gave 2.5 mg pred PO. Painkillers and antibiotics. Dog was eating. No pain on touching ears. Applied trimetho powder onto wound to dry it. No chemicals like iodine or KMnO4 as the area is stitched up and such chemicals irritate and delay healing.
April 20, 2012
Review in the morning. Ear operation area much drier. Dog looks happier. It takes lots of nursing in such operations. At least 7 days to clean wound to ensure proper healing.
949. Clinic Inspection on April 19, 2012
Yesterday, Toa Payoh Vets was inspected by the AVA before its operating licence can be renewed. It was the same AVA vet who did the inspection the previous time and I wanted Dr Daniel to be present. Somehow he was not around during the inspection of the waiting area and reception counter. Then, during inspection of the surgery room, he had to answer a phone call.
It is important that the operating vets be around at the inspection although they are not licensee as many regulatory matters are best learnt from being on the spot. Sometimes, new inspection surprises are introduced. This time, there was a check on 3 medical records. I took out the recent 3, all of which were done by Dr Vanessa. A dog and two hamster cases done.
There is a checklist for inspection but it is not available on the AVA website. Some years ago, the two AVA vets who came to inspect were behaving like the army non-commissioned officers. One Dr Lau placed his fingers on the window sill to check for the presence of dust during his inspection. Later, when I could not meet the AVA deadline to complete my clinic renovation, he decided to close me down. The reasons being that I had not installed the wall cabinets and the reception counter.
"You ought to penalise the contractor in the contract for not be able to complete on time," he said to me as he marched off. He had closed the first Vet Surgery in Singapore for the AVA. A record. The surgery had all facilities available - water, electricity, air conditioning, all regulatory rooms, drugs and medication. I got a table and chairs and mobile cabinets but he was not interested in the fact that this clinic was operational. I had to write in to appeal to the Dr Ngiam Tong Tau to state my case and was permitted to commence operations. Yet, the HDB which is my landlord offered advices on how to get contractors and expedite planning permission. Two government organisations. One tried to kill the business. The other tried to help it start fast.
There was another AVA vet, Dr Liow who referred me to the Singapore Veterinary Association for using "xylazine to induce dogs". She had asked me what drugs I used to induce dogs, like those professors doing viva for final year students. I said I used xylazine and then halothane mask. She did not come back to me for clarification but instead wrote to the SVA. I was not called up by the SVA but I was told by the President of the SVA that she had written to the SVA to lodge a complaint.
So, you can see why I am wary of the AVA vets nowadays. However, the recent AVA vet, Dr Joanna Khoo did not come to penalise but gave excellent advices on veterinary matters like controlled drugs of importance to the HSA and on a vet practice that require other vets to call him personally if they want to refer after-office hour patients. Too much business is good for this vet practice. When more referral practices are opened, this practice may be relieved.
It is important that the operating vets be around at the inspection although they are not licensee as many regulatory matters are best learnt from being on the spot. Sometimes, new inspection surprises are introduced. This time, there was a check on 3 medical records. I took out the recent 3, all of which were done by Dr Vanessa. A dog and two hamster cases done.
There is a checklist for inspection but it is not available on the AVA website. Some years ago, the two AVA vets who came to inspect were behaving like the army non-commissioned officers. One Dr Lau placed his fingers on the window sill to check for the presence of dust during his inspection. Later, when I could not meet the AVA deadline to complete my clinic renovation, he decided to close me down. The reasons being that I had not installed the wall cabinets and the reception counter.
"You ought to penalise the contractor in the contract for not be able to complete on time," he said to me as he marched off. He had closed the first Vet Surgery in Singapore for the AVA. A record. The surgery had all facilities available - water, electricity, air conditioning, all regulatory rooms, drugs and medication. I got a table and chairs and mobile cabinets but he was not interested in the fact that this clinic was operational. I had to write in to appeal to the Dr Ngiam Tong Tau to state my case and was permitted to commence operations. Yet, the HDB which is my landlord offered advices on how to get contractors and expedite planning permission. Two government organisations. One tried to kill the business. The other tried to help it start fast.
There was another AVA vet, Dr Liow who referred me to the Singapore Veterinary Association for using "xylazine to induce dogs". She had asked me what drugs I used to induce dogs, like those professors doing viva for final year students. I said I used xylazine and then halothane mask. She did not come back to me for clarification but instead wrote to the SVA. I was not called up by the SVA but I was told by the President of the SVA that she had written to the SVA to lodge a complaint.
So, you can see why I am wary of the AVA vets nowadays. However, the recent AVA vet, Dr Joanna Khoo did not come to penalise but gave excellent advices on veterinary matters like controlled drugs of importance to the HSA and on a vet practice that require other vets to call him personally if they want to refer after-office hour patients. Too much business is good for this vet practice. When more referral practices are opened, this practice may be relieved.
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