E-MAIL TO DR SING DATED MAR 25, 2011
--- On Fri, 25/3/11, ...@hotmail.com> wrote:
Subject: Scaling for dogs
To: judy@toapayohvets.com
Received: Friday, 25 March, 2011, 2:00 PM
Hi,
I am looking for a trusted vet and doctor who can perform scaling on my 2 year old chihuahua. I am interested upon sending her to Toa Payoh Vets. I would like to know how much it would cost and what I should do to prepare her for the day of her visit.
Thank you,
Name given
E-MAIL REPLY FROM DR SING DATED MAR 26, 2011
Hi
I am Dr Sing from Toa Payoh Vets. Thank you for your email to Judy.
The dental scaling plus anaesthesia cost is around $250 normally. Decayed tooth extraction will be around $10-$20 per tooth extracted. Medication of antibiotics and pain-killer is estimated at around $20 if necessary. Blood test for pre-anaesthesia risk checking will not be done in normal healthy dogs and will cost $150 if it is needed but you will be informed first.
Do not feed or give water to your dog after 10 pm the night before the dental work. Bring your dog to Toa Payoh Vets are 10 a.m. The dog will go home around 5pm usually after rest and recovery from general anaesthesia.
Pl make an appointment at 6254 3326. Pl indicate which vet you will prefer. These are Dr Sing, Dr Vanessa Lin and Dr Jason Teo.
Saturday, March 26, 2011
Friday, March 25, 2011
Passing the buck - The pug with a perforated corneal ulcer
March 24, 2011 was a day to remember due to the following 3 incidents.
1. The Junior College student with straight As and 1 B and an excellent testimonial from her form teacher could not work "long hours." She had phoned me the previous night to let me know that she would not work the long hours of internship as it was "tiring". So, I told her that I would phone her back regarding her terms and conditions of work. That implied that she ought to stay at home till I decided since my offer was not accepted. Yet she presented herself at the Surgery today at 8 am as I had told my assistant Mr Saw that the intern would not be coming.
I asked if her father or mother was against her working hard? She had no objection to the hours of work during the interview yesterday and even arranged for her driving test lessons to take place at 5 pm on Friday. She would work 6 days a week with one weekend day off. She arranged for 6 weeks of internship - a very short period but that would give her some credentials as she had applied for an AVA veterinary undergraduate scholarship.
Apparently her father was against it. "You will be going overseas to study," I said sadly to this young personable lady who did not need to take the "O" level examinations unlike the average Singaporean student as she was the "top 10% of her cohort likely to go to the university."
"Your working hours are non-negotiable. In any case, you will be off before 5 pm on Friday for your driving test at Bukit Batok and you don't work on one Saturday or Sunday." I was rather sad that she could not put her foot down for her own future. "You need to think for yourself and not get tied to the apron's strings."
I wished her good luck and let her go. Over-protective Singaporean parents who think that the world owes their academic superstar-children a living will be in for a rude shock when their children goes to the real world of commerce as their attitude doesn't make the progeny street-wise and realistic.
2. Mr Saw phoned me at 11.30 am while I was at the Singapore General Hospital area to say he was not feeling well and would try his best. He had generalised muscular aches. I often told him: "You are a young man." But he would say "I have an old man's body."
Mr Saw is a very responsible assistant and if he was a Singaporean, he would make a very good vet. I could see that he has the passion during the past 3 years with me and I had mentored him with whatever knowledge of the skills of surgery and medicine I had.
I rushed back after taking a few photos of Everton and Spottiswood Park conservation houses (bright sunshine - good for pictures).
3. I told my associate vet that Mr Saw was sick and he would be taking time off. I would be the customer service officer taking money and processing the credit card and nets machine as my other staff was on leave. Another assistant Mr James Ang had retired at the age of 73 years as he was bent double for some unknown reason. I had to let him go in February after some 20 years with me. He would be giving prospective clients a bad impression compared to the nubile young girls at competitor's practice as he was hunched as if he could not stand straight.
Two days ago, the mother and adult daughter of a Maltese with red eyes had smiled at me when they saw me handling the payment at reception counter after consultation with my associate vet. They were old clients. The daughter had now become a grown up in her early 30s. I said: "Like the PAP who introduce new politicians at the elections, I must renew the vets at Toa Payoh Vets. Young vets, new ideas. Lots of energy."
Soon, 3 young adults in their early 30s (2 ladies and one gentleman) came in with a pug with a bleeding leaking eye. I got them registered as they were new clients. I could see that one of the two young ladies was quite distressed. My associate vet handled the case as usual. I could see that it was a case of a central corneal ulcer, a common problem in breeds with protruding eyeballs.
"So what happened?" I asked the gentleman who came out of the consultation room and sat on the yellow chair after some minutes of discussion with my associate vet. I had been inside the room to evaluate the eyeball at one time but left without comments. He said: "The doctor is making arrangements to hospitalise the pug."
I was extremely surprised. Associate vets do get some freedom to do their cases in the manner they deem fit. Toa Payoh Vets is equipped with anaesthetic and surgical facilities and is capable of handling a corneal ulcer case. Referring what I considered to be a simple case of corneal ulceration to be hospitalised in another practice in Singapore was a big shock to me.
I don't want the vets at Toa Payoh Vets to be known as the "Old School Vets". This term was made known to me from a staff of a practice I visited last week as I brought a young male intern with a blue golden lock of forehead hair to visit the practice to buy some vaccines.
The lady manager in this practice where the vets will refer every "difficult and potentially litigious" surgical case to a brand-name practice said to me: "My friend asks me which veterinary clinic I was working and when I told her, she said I was working with an 'Old School Vet'. I don't mind. I am very happy and well treated in this clinic."
So, this practice does vaccination, dental scaling, sterilisation and removal of lumps. Nothing more complicated. This definitely was not the sort of veterinary surgery I practise for the past 30 years.
Now my associate vet now making phone calls to another brand name practice to pass the case over.
This passing the buck of a simple case of corneal ulcer is not for associate vets of Toa Payoh Vets. If any associate vet can't perform surgery of a simple corneal ulcer and refers to a 2nd a brand name competitor, there is the "can't even do a simple corneal ulcer case" implication.
I know some vets dislike complicated surgeries as they are potentially litigious but this was a simple corneal ulcer case, in my observation. I went to the consultation room and asked my associate vet what was going on. Why was she referring to a brand name practice? She showed me the letter from Vet 1 to consult a certain vet in a brand name practice and since that vet was unavailable, she made alternative arrangements. Eye injuries are emergencies and ought to be treated within 4 hours. Now, it was 5 days post injury.
I was extremely surprised as my associate had at least 2 years of practice before joining me. If she could not deliver, she ought to consult me. There was this potential of the competitor's vet and staff labelling and bad-mouthing Toa Payoh Vets as being incompetent to handle a corneal ulcer.
I asked the owners to leave the consultation room, closed the door and had a private chat with my associate vet. I said: "This is going to be a highly contentious case as there is a lot of emotion involved as Vet 1 had given a name of a vet who would not take the case. The owners are much distressed. You just refer them to another practice.
That practice employs fresh graduates and rookie vets. You are not doing the dog a favour by just making appointment for an unknown vet to handle this case if the older vet was not available. I will take over this case as the owners are going to be unhappy should the other vet mis-treat this case."
If I refer a case to a vet, I must make sure that this vet has the relevant experience and a high standard of practice and will perform the surgery and not his fresh employee graduates. It does not mean that this vet must be employed in a brand name swanky practice.
I was in the consultation room earlier too but the associate did not introduce me and I did not introduce myself too. So, the distressed lady was apprehensive when I examined the dog's eye and tried to pull the dog back. So I left the room for my associate vet to manage the case.
I was around and yet she did not think of asking me for advice when issues and problems arise. Life for a practice manager is full of surprises and changes.
I told my associate to ask the clients to come in and to formally introduce me as that would be the correct way in professional practice. This case was high voltage and lightning had struck. The pug's eye was going to collapse any time soon and any miscommunication or bad referral resulting in the pug being blind would have cast Toa Payoh Vets in a bad light.
"The owners must be thinking I am just a receptionist since I was registering their case," I said to my associate. "This case is going to adversely affect the reputation of the Surgery if the brand name practice vet bungles the surgery. How do you know whether that this brand name practice will or will not assign a fresh vet with no experience in handling a Descemetocoele? This corneal ulcer is in a highly dangerous state as it is going to perforate soon.
"You know that this brand name practice's senior vet may not be available. If he assign a fresh vet to do it, the cornea perforates on the way to the vet, the pug goes blind. So, the owners would just bad-mouth Toa Payoh Vets as the practice that referred the case." I did not mention that this brand name practice charges top dollars and this case would set the owners back by over a thousand dollars.
My associate opened the door and asked the 3 adults and pug to come in. She introduced me as her boss.
"I am the founder of this practice," I elaborated. "I did not introduce myself earlier in the consultation room. I am responsible for the practice management." I was the licensee and any complaint or litigation would mean I have to waste time attending to investigations. I had assessed that the clients were sophisticated and knowledgeable and this is the profile of the younger generation. Whether they would complain about being passed the buck by Toa Payoh Vets would depend on how this emotional situation was handled and whether their pug's eyeball would be enucleated by the other vet. Owners just don't like the idea of their pets losing an eyeball.
This was a case that had a 50:50 chance of saving the dog's eye. If the vet knows how to resolve the problem.
The gentleman summarised the situation succinctly: "There is no one vet you can recommend to treat my pug." He must have superman's hearing as he was in the waiting area and he could not have had heard my conversation with the associage vet.
I said: "It is not necessary to refer the case at all as Toa Payoh Vets has the capability and experience to handle this case.
"I have handled several cases of corneal ulcerations and if you have no objection, I will do the 3rd eyelid flap. Have you visited Toa Payoh Vets' webpage on eye problems in the dog?"
Such sophisticated young adults would have had checked up Toa Payoh Vets' website at the waiting area with their iPhone 4 while I was having a closed-door discussion with my associate vet. The world has changed tremendously. Internet information flows freely and the clients know much more than the vet sometimes.
The gentleman said: "You operated mainly on Shih Tzus' eyes." This was an excellent feedback from him. I had not analysed my webpage on eye problems in the dog at www.toapayohvets.com. I had not posted other breeds I had treated as it is extremely time-consuming to create webpages to write the case report of all breeds I operated upon. I don't take pictures of all breeds too.
This article took 6 hours to write and to create the supporting images. There are so many things I want to do and I just can't have time to do many of my favourite things if I write case reports of all breeds having corneal ulcers. As a vet who does surgery, the range of surgical cases is from the head to the tail.
I replied: "Shih Tzus have the highest number of eye injury problems in my practice. Any breed with protruding eyeballs may suffer from this corneal ulceration problems. This includes the Pekinese and the Pug."
To cut a long story short, the owners had no objection in my performing the surgery. If they were not comfortable, I would just ask them to make their own decision to select their own vet.
My associate vet watched me doing the surgery. She said she had not seen me doing a surgery. Many of my surgical cases have been passed on to her to do and that was why I had less to do.
This is how I managed the corneal perforation case surgically:
INFORMED CONSENT. I took time to explain the risks of anaesthesia (death as this pug was infected for the past 5 days and could be infected in the blood stream. A delay of 24 hours with antibiotics prior to surgery would be preferred but this was an emergency as the cornea will perforate soon. I advise that I would give baytril antibiotics IV and perform the surgery soon).
I explained the risk of surgery (bleeding, pain, infection, collapse of the eyeball due to infection leading to the possibility of enucleation as the owner had not consulted the vet within 4 hours of the eye injury). The gentleman signed the form.
SEDATION & ANAESTHESIA
"Isoflurane gas alone is the safest anaesthetic for this young pug of 7 months with a possibility of infection of the past 5 days," I said to Mr Saw who takes close notes as he would be operating his own practice in Myanmar soon. "However, the pug's nose is flat and the pug will struggle a lot, leading to perforation of the cornea and collapse of the eyeball. So, what sedation would you give? Your favoured domitor and ketamine IV?"
Mr Saw was not so sure. This was a pug with suspect infection after 5 days or more of eye injury. The pug's eye look like an earthquake and tsunami disaster area as seen in the recent pictures of the calamity in Japan. Big patch of white gel and a stream of red-tinged flow of gel and blood at one end, measuring around 1.5 cm long. A continuous stream if you are observant. It reminded me of the oil spill in the Gulf of Mexico although I did not see the actual leak - only oil slicks in the ocean. Here, I could see the stream. It was fascinating as a case but extremely dangerous for the pug. A delay in treatment and the corneal hole would enlarge and the inside aqueous humour would just splash out. The end of the eyeball, although the vet can still stitch up the cornea. Most vets will not encounter such corneal ruptures or stitching and so it can be quite frightening to encounter this case.
I used 0.2 ml xylazine IV. Waited 5 minutes. The pug vomited out its food as this was the effect of xylazine (and even in domitor or domitor/ketamine IV) Then isoflurane gas.
SURGERY
The 3rd eyelid flap is done. Basically the needle goes into the upper eyelid, then under the 3rd eyelid and back out to the lower eyelid. Tied in a knot. "It will be easier if an assistant pulls out and upwards the 3rd eyelid for stitching," I said to my associate vet as Mr Saw automatically used forceps to do it for me.
SUTURE PATTERNS
Several combinations. For this case, I use 3 simple interrupted sutures. Another case, I used a horizontal mattress and one interrupted. Or just one horizontal mattress.
Question. "Are 3 sutures sufficient?" - Yes.
SUBCONJUCTIVAL INJECTION OF GENTAMYCIN AND DEXAMETHASONE.
I know some vets believe that steroids should not be used in eye ulcerations. Well, a small drop of dexamethasone will alleviate the inflammation and pain and does not cause harm.
"Get me the prednisolone," I said to Mr Saw. He got me the depot prednisolone and I rejected it. It is best to use dexamethasone or prednisolone meant for IV." Well, Mr Saw did as instructed but got the incorrect type. All vets must check the medication before injection. Well, Mr Saw learnt something from this participation in the case. "Use common sense," I said to Mr Saw. I wonder whether he knows what is the meaning of common sense as applied to his offer of depot prednisolone. Details of surgery and comments in 8 pictures at webpage of Toa Payoh Vets - goto DOGS - EYE PROBLEMS or at:
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm
POST-OP DAY 1 & 2
The IV drip continued. Tolfedine and baytril given SC. The pug was sleeping and woke up fresh the next day. Very active. At 3 pm on day 2, the gentleman and his wife visited. They took leave from work. It was one of those money can't buy joys to see the distressed lady back to her normal self.I expect the pug's ulcer to heal in 14 days' time and the pug to go home on Day 3. The outcome should be a white spot in the centre of the cornea and no eyeball collapse or infection.
RETROSPECTIVE REVIEW
1. Why did Vet 1 refer the case to a vet that is not available? This is a mystery to me. He probably thought that the cornea ulcer was extensive, needed stitching and he had no facilities to do it and had referred to my associate vet. However, I was on counter duty and saw the case first.
The eye ulcer looked terrible as if it had a big earthquake. It appeared to be a white reddish gel patch of at least 5-8 mm in diameter. Actually, it was 1-2 mm in diameter when I used a scalpel to scrape away the out flowing blood clot. After scrapping, I showed my assistant the black hole measuring around 1 mm in diameter. Aqueous humour leaked out from the hole. Surrounding the black hole was a circle of basement membrane measuring around 4-7 mm in diameter with the black hole as the centre. This membrane would rupture soon if the owners just don't bother to see Vet 1 who advised emergency eye treatment correctly and professionally.
To estimate the size of the corneal perforation, see the 'stream' of gel coming out as a streak. It was around 2-3 mm. See the images.
2. The pug had a perforated ulcer, not a Descemetocoele. The initial presentation was similar to a Descemetocoele with a streak of gelatinous or eye discharge. So, I said "Descemetocoele" to my associate at the examination room as the dog did not permit proper eye examination.
Under general anaesthesia, after scrapping away the blood clot, a black hole of 1mm x 1mm with watery aqueous seeping out indicates that the correct diagnosis is a perforated corneal ulcer also known as deep ulcerative keratitis.
3. Corneal wounds can be sutured with fine 6/0 sutures. Small perforations are best left to heal with the 3rd eyelid flap surgery. And they do heal very well if the inside of the eyeball is not infected. Can you see the pinkish-reddish blood sediment on the medial inner side of the eyeball in one of the pictures below?
I hope this report will be useful for undergraduates struggling to study so many subjects for their examinations to appreciate the anatomy of the dog's eye and its changes during ulceration.
For readers of my blog, updates and more pictures are in toapayohvets.com, goto DOGS - EYE PROBLEMS.
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm
For readers of my blog, updates and more pictures are in www.toapayohvets.com goto DOGS - EYE PROBLEMS.
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm
Details are in www.toapayohvets.com goto DOGS - EYE PROBLEMS.
1. The Junior College student with straight As and 1 B and an excellent testimonial from her form teacher could not work "long hours." She had phoned me the previous night to let me know that she would not work the long hours of internship as it was "tiring". So, I told her that I would phone her back regarding her terms and conditions of work. That implied that she ought to stay at home till I decided since my offer was not accepted. Yet she presented herself at the Surgery today at 8 am as I had told my assistant Mr Saw that the intern would not be coming.
I asked if her father or mother was against her working hard? She had no objection to the hours of work during the interview yesterday and even arranged for her driving test lessons to take place at 5 pm on Friday. She would work 6 days a week with one weekend day off. She arranged for 6 weeks of internship - a very short period but that would give her some credentials as she had applied for an AVA veterinary undergraduate scholarship.
Apparently her father was against it. "You will be going overseas to study," I said sadly to this young personable lady who did not need to take the "O" level examinations unlike the average Singaporean student as she was the "top 10% of her cohort likely to go to the university."
"Your working hours are non-negotiable. In any case, you will be off before 5 pm on Friday for your driving test at Bukit Batok and you don't work on one Saturday or Sunday." I was rather sad that she could not put her foot down for her own future. "You need to think for yourself and not get tied to the apron's strings."
I wished her good luck and let her go. Over-protective Singaporean parents who think that the world owes their academic superstar-children a living will be in for a rude shock when their children goes to the real world of commerce as their attitude doesn't make the progeny street-wise and realistic.
2. Mr Saw phoned me at 11.30 am while I was at the Singapore General Hospital area to say he was not feeling well and would try his best. He had generalised muscular aches. I often told him: "You are a young man." But he would say "I have an old man's body."
Mr Saw is a very responsible assistant and if he was a Singaporean, he would make a very good vet. I could see that he has the passion during the past 3 years with me and I had mentored him with whatever knowledge of the skills of surgery and medicine I had.
I rushed back after taking a few photos of Everton and Spottiswood Park conservation houses (bright sunshine - good for pictures).
3. I told my associate vet that Mr Saw was sick and he would be taking time off. I would be the customer service officer taking money and processing the credit card and nets machine as my other staff was on leave. Another assistant Mr James Ang had retired at the age of 73 years as he was bent double for some unknown reason. I had to let him go in February after some 20 years with me. He would be giving prospective clients a bad impression compared to the nubile young girls at competitor's practice as he was hunched as if he could not stand straight.
Two days ago, the mother and adult daughter of a Maltese with red eyes had smiled at me when they saw me handling the payment at reception counter after consultation with my associate vet. They were old clients. The daughter had now become a grown up in her early 30s. I said: "Like the PAP who introduce new politicians at the elections, I must renew the vets at Toa Payoh Vets. Young vets, new ideas. Lots of energy."
Soon, 3 young adults in their early 30s (2 ladies and one gentleman) came in with a pug with a bleeding leaking eye. I got them registered as they were new clients. I could see that one of the two young ladies was quite distressed. My associate vet handled the case as usual. I could see that it was a case of a central corneal ulcer, a common problem in breeds with protruding eyeballs.
"So what happened?" I asked the gentleman who came out of the consultation room and sat on the yellow chair after some minutes of discussion with my associate vet. I had been inside the room to evaluate the eyeball at one time but left without comments. He said: "The doctor is making arrangements to hospitalise the pug."
I was extremely surprised. Associate vets do get some freedom to do their cases in the manner they deem fit. Toa Payoh Vets is equipped with anaesthetic and surgical facilities and is capable of handling a corneal ulcer case. Referring what I considered to be a simple case of corneal ulceration to be hospitalised in another practice in Singapore was a big shock to me.
I don't want the vets at Toa Payoh Vets to be known as the "Old School Vets". This term was made known to me from a staff of a practice I visited last week as I brought a young male intern with a blue golden lock of forehead hair to visit the practice to buy some vaccines.
The lady manager in this practice where the vets will refer every "difficult and potentially litigious" surgical case to a brand-name practice said to me: "My friend asks me which veterinary clinic I was working and when I told her, she said I was working with an 'Old School Vet'. I don't mind. I am very happy and well treated in this clinic."
So, this practice does vaccination, dental scaling, sterilisation and removal of lumps. Nothing more complicated. This definitely was not the sort of veterinary surgery I practise for the past 30 years.
Now my associate vet now making phone calls to another brand name practice to pass the case over.
This passing the buck of a simple case of corneal ulcer is not for associate vets of Toa Payoh Vets. If any associate vet can't perform surgery of a simple corneal ulcer and refers to a 2nd a brand name competitor, there is the "can't even do a simple corneal ulcer case" implication.
I know some vets dislike complicated surgeries as they are potentially litigious but this was a simple corneal ulcer case, in my observation. I went to the consultation room and asked my associate vet what was going on. Why was she referring to a brand name practice? She showed me the letter from Vet 1 to consult a certain vet in a brand name practice and since that vet was unavailable, she made alternative arrangements. Eye injuries are emergencies and ought to be treated within 4 hours. Now, it was 5 days post injury.
I was extremely surprised as my associate had at least 2 years of practice before joining me. If she could not deliver, she ought to consult me. There was this potential of the competitor's vet and staff labelling and bad-mouthing Toa Payoh Vets as being incompetent to handle a corneal ulcer.
I asked the owners to leave the consultation room, closed the door and had a private chat with my associate vet. I said: "This is going to be a highly contentious case as there is a lot of emotion involved as Vet 1 had given a name of a vet who would not take the case. The owners are much distressed. You just refer them to another practice.
That practice employs fresh graduates and rookie vets. You are not doing the dog a favour by just making appointment for an unknown vet to handle this case if the older vet was not available. I will take over this case as the owners are going to be unhappy should the other vet mis-treat this case."
If I refer a case to a vet, I must make sure that this vet has the relevant experience and a high standard of practice and will perform the surgery and not his fresh employee graduates. It does not mean that this vet must be employed in a brand name swanky practice.
I was in the consultation room earlier too but the associate did not introduce me and I did not introduce myself too. So, the distressed lady was apprehensive when I examined the dog's eye and tried to pull the dog back. So I left the room for my associate vet to manage the case.
I was around and yet she did not think of asking me for advice when issues and problems arise. Life for a practice manager is full of surprises and changes.
I told my associate to ask the clients to come in and to formally introduce me as that would be the correct way in professional practice. This case was high voltage and lightning had struck. The pug's eye was going to collapse any time soon and any miscommunication or bad referral resulting in the pug being blind would have cast Toa Payoh Vets in a bad light.
"The owners must be thinking I am just a receptionist since I was registering their case," I said to my associate. "This case is going to adversely affect the reputation of the Surgery if the brand name practice vet bungles the surgery. How do you know whether that this brand name practice will or will not assign a fresh vet with no experience in handling a Descemetocoele? This corneal ulcer is in a highly dangerous state as it is going to perforate soon.
"You know that this brand name practice's senior vet may not be available. If he assign a fresh vet to do it, the cornea perforates on the way to the vet, the pug goes blind. So, the owners would just bad-mouth Toa Payoh Vets as the practice that referred the case." I did not mention that this brand name practice charges top dollars and this case would set the owners back by over a thousand dollars.
My associate opened the door and asked the 3 adults and pug to come in. She introduced me as her boss.
"I am the founder of this practice," I elaborated. "I did not introduce myself earlier in the consultation room. I am responsible for the practice management." I was the licensee and any complaint or litigation would mean I have to waste time attending to investigations. I had assessed that the clients were sophisticated and knowledgeable and this is the profile of the younger generation. Whether they would complain about being passed the buck by Toa Payoh Vets would depend on how this emotional situation was handled and whether their pug's eyeball would be enucleated by the other vet. Owners just don't like the idea of their pets losing an eyeball.
This was a case that had a 50:50 chance of saving the dog's eye. If the vet knows how to resolve the problem.
The gentleman summarised the situation succinctly: "There is no one vet you can recommend to treat my pug." He must have superman's hearing as he was in the waiting area and he could not have had heard my conversation with the associage vet.
I said: "It is not necessary to refer the case at all as Toa Payoh Vets has the capability and experience to handle this case.
"I have handled several cases of corneal ulcerations and if you have no objection, I will do the 3rd eyelid flap. Have you visited Toa Payoh Vets' webpage on eye problems in the dog?"
Such sophisticated young adults would have had checked up Toa Payoh Vets' website at the waiting area with their iPhone 4 while I was having a closed-door discussion with my associate vet. The world has changed tremendously. Internet information flows freely and the clients know much more than the vet sometimes.
The gentleman said: "You operated mainly on Shih Tzus' eyes." This was an excellent feedback from him. I had not analysed my webpage on eye problems in the dog at www.toapayohvets.com. I had not posted other breeds I had treated as it is extremely time-consuming to create webpages to write the case report of all breeds I operated upon. I don't take pictures of all breeds too.
This article took 6 hours to write and to create the supporting images. There are so many things I want to do and I just can't have time to do many of my favourite things if I write case reports of all breeds having corneal ulcers. As a vet who does surgery, the range of surgical cases is from the head to the tail.
I replied: "Shih Tzus have the highest number of eye injury problems in my practice. Any breed with protruding eyeballs may suffer from this corneal ulceration problems. This includes the Pekinese and the Pug."
To cut a long story short, the owners had no objection in my performing the surgery. If they were not comfortable, I would just ask them to make their own decision to select their own vet.
My associate vet watched me doing the surgery. She said she had not seen me doing a surgery. Many of my surgical cases have been passed on to her to do and that was why I had less to do.
This is how I managed the corneal perforation case surgically:
INFORMED CONSENT. I took time to explain the risks of anaesthesia (death as this pug was infected for the past 5 days and could be infected in the blood stream. A delay of 24 hours with antibiotics prior to surgery would be preferred but this was an emergency as the cornea will perforate soon. I advise that I would give baytril antibiotics IV and perform the surgery soon).
I explained the risk of surgery (bleeding, pain, infection, collapse of the eyeball due to infection leading to the possibility of enucleation as the owner had not consulted the vet within 4 hours of the eye injury). The gentleman signed the form.
SEDATION & ANAESTHESIA
"Isoflurane gas alone is the safest anaesthetic for this young pug of 7 months with a possibility of infection of the past 5 days," I said to Mr Saw who takes close notes as he would be operating his own practice in Myanmar soon. "However, the pug's nose is flat and the pug will struggle a lot, leading to perforation of the cornea and collapse of the eyeball. So, what sedation would you give? Your favoured domitor and ketamine IV?"
Mr Saw was not so sure. This was a pug with suspect infection after 5 days or more of eye injury. The pug's eye look like an earthquake and tsunami disaster area as seen in the recent pictures of the calamity in Japan. Big patch of white gel and a stream of red-tinged flow of gel and blood at one end, measuring around 1.5 cm long. A continuous stream if you are observant. It reminded me of the oil spill in the Gulf of Mexico although I did not see the actual leak - only oil slicks in the ocean. Here, I could see the stream. It was fascinating as a case but extremely dangerous for the pug. A delay in treatment and the corneal hole would enlarge and the inside aqueous humour would just splash out. The end of the eyeball, although the vet can still stitch up the cornea. Most vets will not encounter such corneal ruptures or stitching and so it can be quite frightening to encounter this case.
I used 0.2 ml xylazine IV. Waited 5 minutes. The pug vomited out its food as this was the effect of xylazine (and even in domitor or domitor/ketamine IV) Then isoflurane gas.
SURGERY
The 3rd eyelid flap is done. Basically the needle goes into the upper eyelid, then under the 3rd eyelid and back out to the lower eyelid. Tied in a knot. "It will be easier if an assistant pulls out and upwards the 3rd eyelid for stitching," I said to my associate vet as Mr Saw automatically used forceps to do it for me.
SUTURE PATTERNS
Several combinations. For this case, I use 3 simple interrupted sutures. Another case, I used a horizontal mattress and one interrupted. Or just one horizontal mattress.
Question. "Are 3 sutures sufficient?" - Yes.
SUBCONJUCTIVAL INJECTION OF GENTAMYCIN AND DEXAMETHASONE.
I know some vets believe that steroids should not be used in eye ulcerations. Well, a small drop of dexamethasone will alleviate the inflammation and pain and does not cause harm.
"Get me the prednisolone," I said to Mr Saw. He got me the depot prednisolone and I rejected it. It is best to use dexamethasone or prednisolone meant for IV." Well, Mr Saw did as instructed but got the incorrect type. All vets must check the medication before injection. Well, Mr Saw learnt something from this participation in the case. "Use common sense," I said to Mr Saw. I wonder whether he knows what is the meaning of common sense as applied to his offer of depot prednisolone. Details of surgery and comments in 8 pictures at webpage of Toa Payoh Vets - goto DOGS - EYE PROBLEMS or at:
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm
POST-OP DAY 1 & 2
The IV drip continued. Tolfedine and baytril given SC. The pug was sleeping and woke up fresh the next day. Very active. At 3 pm on day 2, the gentleman and his wife visited. They took leave from work. It was one of those money can't buy joys to see the distressed lady back to her normal self.I expect the pug's ulcer to heal in 14 days' time and the pug to go home on Day 3. The outcome should be a white spot in the centre of the cornea and no eyeball collapse or infection.
RETROSPECTIVE REVIEW
1. Why did Vet 1 refer the case to a vet that is not available? This is a mystery to me. He probably thought that the cornea ulcer was extensive, needed stitching and he had no facilities to do it and had referred to my associate vet. However, I was on counter duty and saw the case first.
The eye ulcer looked terrible as if it had a big earthquake. It appeared to be a white reddish gel patch of at least 5-8 mm in diameter. Actually, it was 1-2 mm in diameter when I used a scalpel to scrape away the out flowing blood clot. After scrapping, I showed my assistant the black hole measuring around 1 mm in diameter. Aqueous humour leaked out from the hole. Surrounding the black hole was a circle of basement membrane measuring around 4-7 mm in diameter with the black hole as the centre. This membrane would rupture soon if the owners just don't bother to see Vet 1 who advised emergency eye treatment correctly and professionally.
To estimate the size of the corneal perforation, see the 'stream' of gel coming out as a streak. It was around 2-3 mm. See the images.
2. The pug had a perforated ulcer, not a Descemetocoele. The initial presentation was similar to a Descemetocoele with a streak of gelatinous or eye discharge. So, I said "Descemetocoele" to my associate at the examination room as the dog did not permit proper eye examination.
Under general anaesthesia, after scrapping away the blood clot, a black hole of 1mm x 1mm with watery aqueous seeping out indicates that the correct diagnosis is a perforated corneal ulcer also known as deep ulcerative keratitis.
3. Corneal wounds can be sutured with fine 6/0 sutures. Small perforations are best left to heal with the 3rd eyelid flap surgery. And they do heal very well if the inside of the eyeball is not infected. Can you see the pinkish-reddish blood sediment on the medial inner side of the eyeball in one of the pictures below?
I hope this report will be useful for undergraduates struggling to study so many subjects for their examinations to appreciate the anatomy of the dog's eye and its changes during ulceration.
For readers of my blog, updates and more pictures are in toapayohvets.com, goto DOGS - EYE PROBLEMS.
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm
For readers of my blog, updates and more pictures are in www.toapayohvets.com goto DOGS - EYE PROBLEMS.
http://www.bekindtopets.com/animals/20081201PAGE3_
Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm
Details are in www.toapayohvets.com goto DOGS - EYE PROBLEMS.
368. Starting pay for new vet in Singapore?
Straits Times
ST Jan 1, 2011 Law & Accounting. The MONEY Page.
"Big Four" Accounting Firms - PricewaterhouseCoopers (PwC), Ernst & Young, KPMG and Deloitte pay new graduates more. Starting pay at mid-sized accounting firms $2,100 to $2,400. Big Four pay $2,600 and above.
Big law firms pay $4,500 - $5,000 for a fresh graduate. Foreign law firms $7,500 but with smaller bonuses. Small law firms pay $4,000 - $4,500. So, pay more upfront and less bonus to compete.
So what do fresh graduate vets in the Singapore private sector get paid? Is there a market rate? Or is it performance based?
ST Jan 1, 2011 Law & Accounting. The MONEY Page.
"Big Four" Accounting Firms - PricewaterhouseCoopers (PwC), Ernst & Young, KPMG and Deloitte pay new graduates more. Starting pay at mid-sized accounting firms $2,100 to $2,400. Big Four pay $2,600 and above.
Big law firms pay $4,500 - $5,000 for a fresh graduate. Foreign law firms $7,500 but with smaller bonuses. Small law firms pay $4,000 - $4,500. So, pay more upfront and less bonus to compete.
So what do fresh graduate vets in the Singapore private sector get paid? Is there a market rate? Or is it performance based?
Thursday, March 24, 2011
Internship: no knowledge, skills and discipline
I note that the younger generation doing their 2nd year Junior College and who applies for a veterinary internship has no knowledge, skills and discipline. The applicants are mainly ladies. Many of them have straight As and can get into any undergraduate studies they choose.
However, these Singaporean academic stars don't have hands-on experience nor interests in animal welfare and medicine. Straight As without passion in veterinary medicine. An unwillingness to work diligently and put in the hours.
I am thinking of terminating sponsorship of internship for Junior College students as my staff feels that they are a burden and they are. My assistant Mr Saw actually dislike them according to one of my feedback as they hinder his work. He has to teach them how to take temperature etc and why should he do that? I don't know what Dr Vanessa Lin and Dr Jason Teo think of them.
Many of these young interns and even veterinary undergraduates don't have simple social skills. They come for interviews silently. They don't know simple courtesies which will gain them brownie points, like greeting "Good morning, Dr Sing, Good afternoon Dr Vanessa or Good evening Dr Teo." Some fathers or mothers drive them to the Surgery and wait for them for the interview! They give me the impression that they can't be independent and are tied to the apron's strings.
Does the top school principals NOT impart such skills to their bright students? It is not that I am desperate to be greeted. Not being punctual, disappearing without letting me know. These are what some past interns do.
Therefore, I am thinking of terminating this program for such young people as they have been brought up in abundance and know no hardship. They don't want to work hard and seem to think that the world should suit their lifestyle and way of working late in the day (being night owls). Turning up late for work is a common trait too.
There are 3rd party injury liabilities too. What if the intern gets bitten or scratched by the dog and cat respectively? The parents will sue me to bankruptcy.
For the above reasons, it is wise for me not to accept interns unless they are highly passionate about veterinary medicine, rather than thinking of using the program to pad their resume.
However, these Singaporean academic stars don't have hands-on experience nor interests in animal welfare and medicine. Straight As without passion in veterinary medicine. An unwillingness to work diligently and put in the hours.
I am thinking of terminating sponsorship of internship for Junior College students as my staff feels that they are a burden and they are. My assistant Mr Saw actually dislike them according to one of my feedback as they hinder his work. He has to teach them how to take temperature etc and why should he do that? I don't know what Dr Vanessa Lin and Dr Jason Teo think of them.
Many of these young interns and even veterinary undergraduates don't have simple social skills. They come for interviews silently. They don't know simple courtesies which will gain them brownie points, like greeting "Good morning, Dr Sing, Good afternoon Dr Vanessa or Good evening Dr Teo." Some fathers or mothers drive them to the Surgery and wait for them for the interview! They give me the impression that they can't be independent and are tied to the apron's strings.
Does the top school principals NOT impart such skills to their bright students? It is not that I am desperate to be greeted. Not being punctual, disappearing without letting me know. These are what some past interns do.
Therefore, I am thinking of terminating this program for such young people as they have been brought up in abundance and know no hardship. They don't want to work hard and seem to think that the world should suit their lifestyle and way of working late in the day (being night owls). Turning up late for work is a common trait too.
There are 3rd party injury liabilities too. What if the intern gets bitten or scratched by the dog and cat respectively? The parents will sue me to bankruptcy.
For the above reasons, it is wise for me not to accept interns unless they are highly passionate about veterinary medicine, rather than thinking of using the program to pad their resume.
366. Happy retirement?
Dr Sing Kong Yuen
Dear Sir,
I am involved with recruitment for the Freeman Scholarship Program at Wesleyan University in Middletown, Connecticut in the US. We did a recruitment session recently for our finalists. One is a lady with a strong interest in becoming a veterinarian.
I believe we are badly-positioned to help her realize her dreams. Specifically, vet schools in the US are graduate programs, requiring the applicant first complete four years of undergraduate study …. Then take the MCAT exams and go through the entire school admissions process again!
I suggested to her school systems that work on the British system, such as Glasgow. I also suggested the AVA scholarship program. I noted from your website that you attended Glasgow on the Colombo Plan, served with the SAF Provost Dog Unit, tended race horses for the Bukit Timah Club, started your own clinic, and are now headed into happy retirement.
You have walked the path that she is considering. Might you have a moment to take a call from her and give her the wisdom that comes from real experience?
I am an ex-infantry officer who spent his life as a civil engineer building prisons, police compounds and the coastal barrier for the Singapore government. My ability to guide her is terribly limited.
Thank you so much for any help you can give.
With best regards,
Name given
REPLY FROM DR SING DATED MAR 24, 2011
Hi
Thank you for your email. I can always spare more than a few minutes to meet one-on-one to the young lady who wants to be a veterinarian. Phone calls are a waste of time if the persons are sincerely interested in knowing more about veterinary medicine and surgery. During the meeting, I can assess whether the young lady is really passionate about veterinary medicine and surgery. Phone calls and text messages and emails are preferred by the younger generation who don't have the real interests or passion and merely wants to go fishing.
Let me know as soon as possible. I don't know where you get the impression that I am into "happy retirement". I have an associate veterinarian who is younger and takes care of many of my old clientele as there is insufficient rooms for 2 vets at any one time. I still consult and yesterday I spayed a Fox Terrier as the owner wanted me to do it. I am even busier than before in veterinary medicine, travel and real estate.
I hope we can meet one day and not just e-mail. Best wishes.
Dear Sir,
I am involved with recruitment for the Freeman Scholarship Program at Wesleyan University in Middletown, Connecticut in the US. We did a recruitment session recently for our finalists. One is a lady with a strong interest in becoming a veterinarian.
I believe we are badly-positioned to help her realize her dreams. Specifically, vet schools in the US are graduate programs, requiring the applicant first complete four years of undergraduate study …. Then take the MCAT exams and go through the entire school admissions process again!
I suggested to her school systems that work on the British system, such as Glasgow. I also suggested the AVA scholarship program. I noted from your website that you attended Glasgow on the Colombo Plan, served with the SAF Provost Dog Unit, tended race horses for the Bukit Timah Club, started your own clinic, and are now headed into happy retirement.
You have walked the path that she is considering. Might you have a moment to take a call from her and give her the wisdom that comes from real experience?
I am an ex-infantry officer who spent his life as a civil engineer building prisons, police compounds and the coastal barrier for the Singapore government. My ability to guide her is terribly limited.
Thank you so much for any help you can give.
With best regards,
Name given
REPLY FROM DR SING DATED MAR 24, 2011
Hi
Thank you for your email. I can always spare more than a few minutes to meet one-on-one to the young lady who wants to be a veterinarian. Phone calls are a waste of time if the persons are sincerely interested in knowing more about veterinary medicine and surgery. During the meeting, I can assess whether the young lady is really passionate about veterinary medicine and surgery. Phone calls and text messages and emails are preferred by the younger generation who don't have the real interests or passion and merely wants to go fishing.
Let me know as soon as possible. I don't know where you get the impression that I am into "happy retirement". I have an associate veterinarian who is younger and takes care of many of my old clientele as there is insufficient rooms for 2 vets at any one time. I still consult and yesterday I spayed a Fox Terrier as the owner wanted me to do it. I am even busier than before in veterinary medicine, travel and real estate.
I hope we can meet one day and not just e-mail. Best wishes.
Monday, March 21, 2011
365. Sunday's case. The dog has no urethral obstruction.
Sunday Mar 20, 2011.
The owner of the Silkie came at 10.20 am on this fine sunshine Sunday. I asked whether she wanted to wait for another vet who would come in around 11 am or to consult me. She said she would not mind consulting me as that was her original intention. She said: "Everytime my dog drinks water, he lifts his leg for some time, but no urine come out. This only happens after the bladder stones were removed by Dr Vanessa." The surgery was done 11 days ago. I examined the dog and palpated the bladder. There was no pain. The bladder was not swollen at all and so there was no urethral obstruction at the os penis. I checked the stitches anterior to the prepuce. They were not inflamed. "The operation by the other vet is 100% successful," I said. "I will have the stitches taken out. As there is no urine in the bladder, I would like to hospitalise the dog for one day to observe and to take urine sample for analysis."
The client pointed to a right eye which had pus and red conjunctivitis. I examined it and showed the wife that the dog had a 10-12 o'clock patch of corneal ulcer. The owner had been using eye drops for the last one month but was unsuccessful.
Soon, the other vet arrived. I told the lady owner who came with her husband that I would work this case together with the other vet although she wanted me to handle it. Working together as a team should be the way in a group practice. However, I could see that the other vet was not too happy with this by-passing. She took the dog into the operating room, catherised it and found no urethral obstruction. She showed the owner that the catheter was passed in easily.
Now, I usually don't interfere with the other vet's clientele. However, many of the clients had been with me for years and therefore a new vet must understand the culture of the workplace and work as a team to be successful.
I had a one-on-one talk with the other vet as regards what she considered as my interference with one of "her" cases. I told her that the case of the Silkie with difficulty in peeing was one of my clients who had just told me that she wanted me to handle the case. However, she had operated on and had done a good job. Normally, I would let the other vet handle my client's cases if they come after 11 am though I would be available. Otherwise it is best not to have another vet present.
I explained to the other vet that I have a responsibility as a licensee to ensure that owners' complaints to me are handled personally. By ignoring their complaint, it would not be good for the practice as matters could get worse such as litigation and the regulatory authority stepping in to investigate.
"So far, only one veterinarian in Singapore had been suspended for 9 months," I told the other vet. "I don't want Toa Payoh Vets or its vets to be suspended due to my failure as the licensee to rectify matters brought to my attention. I could be suspended through actions of my failure to manage the practice vets diligently."
I told the other vet that many clients had been complaining about her dog barking at them in the waiting area. The dog was free to wander around and I had not banned this dog yet. He would eat out of a bowl in the waiting area and spilled its food onto the floor. I needed to get the waiting area cleaned up. I still remembered this tall sun-tanned blonde Caucasian woman with broad shoulders. She was visibly upset and held her cat close to her chest when Dr Vanessa's dog approached her in the waiting area. I was present at the receptionist counter and apologised to her saying: "This is the other vet's dog." She was consulting Dr Vanessa and managed a weak smile. She was too polite to say anything. This dog had a habit of going to the holding area to pee (urine marking) and barking at the other dogs for a short time.
If this dog belonged to the staff, I would ban the dog strictly or asked the staff to work at a big practice if she persisted. There is a limit to this dog's behaviour which upset clientele. And today, Sunday, I had to make a decision.
After so many years of living, I know that there is no point having the best vet or veterinary technician or intern in the world if he or she does not appreciate the culture and environment of the workplace. I would not hesitate to ask the staff to go.
Nowadays, I have to be stricter in the management of interns, veterinary technicians and vets. Singapore has become a litigious place. Veterinary surgery is becoming very competitive with many younger vets opening their practices. So, there is no point retaining non-performers as that would ultimately lead to the insidious decline of the practice. In any case, I am realistic enough to know that any new vet working in Toa Payoh Vets are just marking their time to open their own practice after gaining experience and clientele.
As for the dog that tried to pee when he drank water, bladder palpation would rule out any urethral obstruction. The dog was operated successfully and the bladder was not even full as catherisation by the other vet brought out no urine.
As the owner preferred me to handle her case, I told the owner that a urine sample was what I recommended just in case there is bacterial infection of the bladder or some small stones from the bladder as this was possible and said by the other vet.
I asked for the X-ray but the owner had kept it since the other vet had the practice of giving X-rays to the owner to keep.
I know that the dog was still on antibiotics but there is still the possiblility of cystitis if the bacteria is not sensitive to prescribed antibiotics. Since the bladder was palpated to be emptied, this showed that the dog could pee all urine at one go. I asked the owner: "Does your dog pass out all urine at one time?" The owner said: "Yes."
"It is possible that there may be stones from the kidney as the other vet had just said," I explained. "The dog may have some association with the need to urinate when he drinks. He might have this behaviour when he had urinary stones for some time and you might not have noticed that. The stitches are just removed and a pain-killer injection is given. We will wait another 7 days to see what happens."
I gave the owner a urine collection container as she did not want to hospitalise the dog nor treat the eye ulcer surgically. I asked the lady to sign a letter stating that she was bringing the dog home against medical advice to be hospitalised for observation and treatment of the eye ulcer. Nowadays, I advise all the vets has to record all instructions in writing as proof if there is litigation. The owner signed and left quite satisfied, in my opinion.
Opening a vet surgery does not mean the vet will be able to sustain his or her profitablility, I explained to the other vet. There are high capital investments and many new practices set up with the father's monies are not able to sustain their operations. A high standard of service and successful outcome in surgeries as perceived by the owner brings in referrals.
There are over 40 practices and the owner has a wide choice nowadays. There are practices full of waiting clients and there are also quiet ones. More practices will be opened as vets who can't work in group practices prefer to strike out on their own.
The owner of the Silkie came at 10.20 am on this fine sunshine Sunday. I asked whether she wanted to wait for another vet who would come in around 11 am or to consult me. She said she would not mind consulting me as that was her original intention. She said: "Everytime my dog drinks water, he lifts his leg for some time, but no urine come out. This only happens after the bladder stones were removed by Dr Vanessa." The surgery was done 11 days ago. I examined the dog and palpated the bladder. There was no pain. The bladder was not swollen at all and so there was no urethral obstruction at the os penis. I checked the stitches anterior to the prepuce. They were not inflamed. "The operation by the other vet is 100% successful," I said. "I will have the stitches taken out. As there is no urine in the bladder, I would like to hospitalise the dog for one day to observe and to take urine sample for analysis."
The client pointed to a right eye which had pus and red conjunctivitis. I examined it and showed the wife that the dog had a 10-12 o'clock patch of corneal ulcer. The owner had been using eye drops for the last one month but was unsuccessful.
Soon, the other vet arrived. I told the lady owner who came with her husband that I would work this case together with the other vet although she wanted me to handle it. Working together as a team should be the way in a group practice. However, I could see that the other vet was not too happy with this by-passing. She took the dog into the operating room, catherised it and found no urethral obstruction. She showed the owner that the catheter was passed in easily.
Now, I usually don't interfere with the other vet's clientele. However, many of the clients had been with me for years and therefore a new vet must understand the culture of the workplace and work as a team to be successful.
I had a one-on-one talk with the other vet as regards what she considered as my interference with one of "her" cases. I told her that the case of the Silkie with difficulty in peeing was one of my clients who had just told me that she wanted me to handle the case. However, she had operated on and had done a good job. Normally, I would let the other vet handle my client's cases if they come after 11 am though I would be available. Otherwise it is best not to have another vet present.
I explained to the other vet that I have a responsibility as a licensee to ensure that owners' complaints to me are handled personally. By ignoring their complaint, it would not be good for the practice as matters could get worse such as litigation and the regulatory authority stepping in to investigate.
"So far, only one veterinarian in Singapore had been suspended for 9 months," I told the other vet. "I don't want Toa Payoh Vets or its vets to be suspended due to my failure as the licensee to rectify matters brought to my attention. I could be suspended through actions of my failure to manage the practice vets diligently."
I told the other vet that many clients had been complaining about her dog barking at them in the waiting area. The dog was free to wander around and I had not banned this dog yet. He would eat out of a bowl in the waiting area and spilled its food onto the floor. I needed to get the waiting area cleaned up. I still remembered this tall sun-tanned blonde Caucasian woman with broad shoulders. She was visibly upset and held her cat close to her chest when Dr Vanessa's dog approached her in the waiting area. I was present at the receptionist counter and apologised to her saying: "This is the other vet's dog." She was consulting Dr Vanessa and managed a weak smile. She was too polite to say anything. This dog had a habit of going to the holding area to pee (urine marking) and barking at the other dogs for a short time.
If this dog belonged to the staff, I would ban the dog strictly or asked the staff to work at a big practice if she persisted. There is a limit to this dog's behaviour which upset clientele. And today, Sunday, I had to make a decision.
After so many years of living, I know that there is no point having the best vet or veterinary technician or intern in the world if he or she does not appreciate the culture and environment of the workplace. I would not hesitate to ask the staff to go.
Nowadays, I have to be stricter in the management of interns, veterinary technicians and vets. Singapore has become a litigious place. Veterinary surgery is becoming very competitive with many younger vets opening their practices. So, there is no point retaining non-performers as that would ultimately lead to the insidious decline of the practice. In any case, I am realistic enough to know that any new vet working in Toa Payoh Vets are just marking their time to open their own practice after gaining experience and clientele.
As for the dog that tried to pee when he drank water, bladder palpation would rule out any urethral obstruction. The dog was operated successfully and the bladder was not even full as catherisation by the other vet brought out no urine.
As the owner preferred me to handle her case, I told the owner that a urine sample was what I recommended just in case there is bacterial infection of the bladder or some small stones from the bladder as this was possible and said by the other vet.
I asked for the X-ray but the owner had kept it since the other vet had the practice of giving X-rays to the owner to keep.
I know that the dog was still on antibiotics but there is still the possiblility of cystitis if the bacteria is not sensitive to prescribed antibiotics. Since the bladder was palpated to be emptied, this showed that the dog could pee all urine at one go. I asked the owner: "Does your dog pass out all urine at one time?" The owner said: "Yes."
"It is possible that there may be stones from the kidney as the other vet had just said," I explained. "The dog may have some association with the need to urinate when he drinks. He might have this behaviour when he had urinary stones for some time and you might not have noticed that. The stitches are just removed and a pain-killer injection is given. We will wait another 7 days to see what happens."
I gave the owner a urine collection container as she did not want to hospitalise the dog nor treat the eye ulcer surgically. I asked the lady to sign a letter stating that she was bringing the dog home against medical advice to be hospitalised for observation and treatment of the eye ulcer. Nowadays, I advise all the vets has to record all instructions in writing as proof if there is litigation. The owner signed and left quite satisfied, in my opinion.
Opening a vet surgery does not mean the vet will be able to sustain his or her profitablility, I explained to the other vet. There are high capital investments and many new practices set up with the father's monies are not able to sustain their operations. A high standard of service and successful outcome in surgeries as perceived by the owner brings in referrals.
There are over 40 practices and the owner has a wide choice nowadays. There are practices full of waiting clients and there are also quiet ones. More practices will be opened as vets who can't work in group practices prefer to strike out on their own.
Sunday, March 20, 2011
364. Informed Consent and Against Medical Advice (AMD) - to get it in writing
Sometimes, I do not record in writing my advices to the pet owner to treat the dog or hamster and do not record that prognosis is poor. This is not a good practice as in litigation, the judges want to see the written word.
In one case reported in the Straits Times on March 18, 2011, I was shocked to read about a very experienced surgeon from the Singapore General Hospital being suspended for 3 months on one of the 3 charges of not giving INFORMED CONSENT. The 3 judges believed in the complainant and said that the case records and brochure put up as defence by the doctor did not mention the risks of pain, bleeding and infection being told to the patient. Definitely, the brochure did not mention the risks. Therefore, the judges decided to suspend him for 3 months for not giving informed consent. The patient had had abdominal pains after surgical removal of his piles in 2006. The rectal area was infected post-operation.
I was shocked because this surgeon provided excellent services to me when I underwent colonscopy by him. Excellent bedside manners. Efficient and competent. His nurses assured me that he would not take a long time to do the colonscopy as he is experienced. I was given a sedation by a lady, probably a nurse. She inserted another syringe (probably with saline) to give me the full dose. I just slept. No pain or groginess after colonscopy. It was as if I had a nap. I asked the doctor what injection it was and he did tell me.
In between reading the lines in the newspaper report (mentioned twice), it seemed that there was a warning to doctors to provide a higher standard of care and that means informed consent for everything and proper writing down of advices and risk given. I have an informed consent form for every tasks and procedure nowadays and read to the pet owner the content.
GOLDEN RETRIEVER PUPPY 5 MONTHS, MALE, WITH SMELLY BLOODY DIARRHOEA
The owner wanted me to treat his dog rather than Dr Vanessa and this is because I had treated his other dog for the past years. Dr Vanessa also had owners who just wanted her to treat their dogs or pets.
The puppy had pale gums but not white. It had passed smelly bloody diarrhoea for 2 days but no vomiting. Just give an injection and medication and send home? This would be the standard treatment.
No blood test, no X-ray and no IV drip? This case was not to be taken lightly as the puppy had passed smelly bloody diarrhoea for 2 days. I advised hospitalisation for 2-3 days. The owner insisted on taking the dog home in the evening, after IV drip and treatment. Some owners don't like dogs to be hospitalised and some don't like to pay more than necessary.
"Let the dog go home," I said to Dr Vanessa. "If the dog dies at home, the owner had been told that the dog needed to be hospitalised to give the IV drip." I ought to record in writing as I was the main vet handling the case and would be hauled up to court even though I did this case with Dr Vanessa. But I did not record this done. Nor did I record my prognosis of 50:50.
This would be a serious mistake if the puppy died of bleeding and infection and dehydration. Therefore, I have to be more careful to write "AMD". Family members might sue me, though the owner might not. Dogs are family. Times have changed. All doctors and vets have to be much more careful as litigation takes up a lot of time.
GOLDEN RETRIEVER
X-Ray - "Lots of gas in the large intestines with a lot of fine particles like soil," I discussed with Dr Vanessa. She was not really convinced but this is OK as each vet has his own opinion. The owner did not tell me that the dog had gone to the East Coast beach the day before diarrhoea and had eaten lots of sand. He told me and apologised for the omission the 2nd day when he took the dog back accepting my advice (dog panting, lethargic, did pass non-smelly stools in a soft lump, could eat). I said that the dog had no diarrhoea due to the drugs given. The intestines, being bleeding needed time to heal and the food intake irritates the gut.
Blood test from Day 1 showed:
haemoglobin 12.6 (12-18)
Red cell count 5.3 (5.5-8.5)
total WBC 17.9 (6-17)
Neutrophil 49.16% Abs 8.80
Lymphocytes 31.40% Abs 5.62
Monocytes 10.17% Abs 1.82
Eosinophils 8.66% Abs 1.55
Basophil 0.67% Abs 0.12
PCV 0.34 (0.37-0.55)
MCHC 37 (32-26)
Platelets 241 (200-500)
The owner accepted the advice to hospitalise the puppy for 2 days. Should be able to recover and go home well. Many vets read blood test as one single event. Actually, one should read it as a starting of a disease process. In this case, the intestines have bleed seriously and dehydration and bacterial infection had gained a foothold. Not so bad, but enough to cause the dog to pant (in pain and in infection) and lethargy. Without IV drip, I think it would just pass away due. In this case, there would be a failure to record advices given to the owner as to hospitalisation and IV drip, X-ray and blood tests if these procedures were not done. All bets are off if the puppy dies. It is a very emotional experience for the family and many question the competence of the vet. Litigation would be in their mind.
In one case reported in the Straits Times on March 18, 2011, I was shocked to read about a very experienced surgeon from the Singapore General Hospital being suspended for 3 months on one of the 3 charges of not giving INFORMED CONSENT. The 3 judges believed in the complainant and said that the case records and brochure put up as defence by the doctor did not mention the risks of pain, bleeding and infection being told to the patient. Definitely, the brochure did not mention the risks. Therefore, the judges decided to suspend him for 3 months for not giving informed consent. The patient had had abdominal pains after surgical removal of his piles in 2006. The rectal area was infected post-operation.
I was shocked because this surgeon provided excellent services to me when I underwent colonscopy by him. Excellent bedside manners. Efficient and competent. His nurses assured me that he would not take a long time to do the colonscopy as he is experienced. I was given a sedation by a lady, probably a nurse. She inserted another syringe (probably with saline) to give me the full dose. I just slept. No pain or groginess after colonscopy. It was as if I had a nap. I asked the doctor what injection it was and he did tell me.
In between reading the lines in the newspaper report (mentioned twice), it seemed that there was a warning to doctors to provide a higher standard of care and that means informed consent for everything and proper writing down of advices and risk given. I have an informed consent form for every tasks and procedure nowadays and read to the pet owner the content.
GOLDEN RETRIEVER PUPPY 5 MONTHS, MALE, WITH SMELLY BLOODY DIARRHOEA
The owner wanted me to treat his dog rather than Dr Vanessa and this is because I had treated his other dog for the past years. Dr Vanessa also had owners who just wanted her to treat their dogs or pets.
The puppy had pale gums but not white. It had passed smelly bloody diarrhoea for 2 days but no vomiting. Just give an injection and medication and send home? This would be the standard treatment.
No blood test, no X-ray and no IV drip? This case was not to be taken lightly as the puppy had passed smelly bloody diarrhoea for 2 days. I advised hospitalisation for 2-3 days. The owner insisted on taking the dog home in the evening, after IV drip and treatment. Some owners don't like dogs to be hospitalised and some don't like to pay more than necessary.
"Let the dog go home," I said to Dr Vanessa. "If the dog dies at home, the owner had been told that the dog needed to be hospitalised to give the IV drip." I ought to record in writing as I was the main vet handling the case and would be hauled up to court even though I did this case with Dr Vanessa. But I did not record this done. Nor did I record my prognosis of 50:50.
This would be a serious mistake if the puppy died of bleeding and infection and dehydration. Therefore, I have to be more careful to write "AMD". Family members might sue me, though the owner might not. Dogs are family. Times have changed. All doctors and vets have to be much more careful as litigation takes up a lot of time.
GOLDEN RETRIEVER
X-Ray - "Lots of gas in the large intestines with a lot of fine particles like soil," I discussed with Dr Vanessa. She was not really convinced but this is OK as each vet has his own opinion. The owner did not tell me that the dog had gone to the East Coast beach the day before diarrhoea and had eaten lots of sand. He told me and apologised for the omission the 2nd day when he took the dog back accepting my advice (dog panting, lethargic, did pass non-smelly stools in a soft lump, could eat). I said that the dog had no diarrhoea due to the drugs given. The intestines, being bleeding needed time to heal and the food intake irritates the gut.
Blood test from Day 1 showed:
haemoglobin 12.6 (12-18)
Red cell count 5.3 (5.5-8.5)
total WBC 17.9 (6-17)
Neutrophil 49.16% Abs 8.80
Lymphocytes 31.40% Abs 5.62
Monocytes 10.17% Abs 1.82
Eosinophils 8.66% Abs 1.55
Basophil 0.67% Abs 0.12
PCV 0.34 (0.37-0.55)
MCHC 37 (32-26)
Platelets 241 (200-500)
The owner accepted the advice to hospitalise the puppy for 2 days. Should be able to recover and go home well. Many vets read blood test as one single event. Actually, one should read it as a starting of a disease process. In this case, the intestines have bleed seriously and dehydration and bacterial infection had gained a foothold. Not so bad, but enough to cause the dog to pant (in pain and in infection) and lethargy. Without IV drip, I think it would just pass away due. In this case, there would be a failure to record advices given to the owner as to hospitalisation and IV drip, X-ray and blood tests if these procedures were not done. All bets are off if the puppy dies. It is a very emotional experience for the family and many question the competence of the vet. Litigation would be in their mind.
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