On Friday Dec 9, 2011, at 11.40 am, I was in the consultation room facing Dr Vanessa and Mr Min on the other side of the consultation table. I conducted a meeting regarding work performance to ensure that the quality of veterinary service is up to my standard and to be free of clientele complaints.
"In many companies, there is a monthly meeting to discuss work matters like problems and solutions," I said to both of them. "I don't do it monthly as I expect both of you to do your part and to adopt my advices for changes. However, I have to discuss with both of you work matters today."
One of the topics I spoke about was the need for direct eye-contact with clients to connect well.
"When a client comes into the consultation room, stand up and greet him, rather than sit down and look up to him," I said. "You may be tired but still this is the proper way to do. You may get a chair and ask the client to sit down if you wish to sit down to discuss the dog's health. I always stand up to greet the client throughout my years of practice or invite them to sit. There was a complaint of one unfriendly vet who sat down and looked up at the client...."
I illustrated with my personal anecdotes and gave my tips as how to handle several cases by Dr Vanessa and Min who is a vet from Myanmar.
As regards examination of the severely "paralysed" recumbent panting dog that came in yesterday as a second opinion, the important things to do would be to collect blood and urine samples first, before any treatment like IV drip. If the owner objected to it due to the fact that Vet 1 had just done the blood test, record this objection, time and name of the owner. "The dog was diagnosed as having spinal injuries by Vet 1. How do you know whether the dog at the time of arrival half dead and panting and unable to stand up was also suffering from hypoglycaemia which would be obvious from a simple blood test?" This morning, I took the dog outside for a review and he was walking unsteadily as he had been given IV drip, painkillers and frequent feeding.
I said: "A quadriplegic dog with a cervical fracture or dislocation would not be able to walk at all. In addition, there is no rush to do an X-ray which was done yesterday as the dog's head was twisted and the X-ray views were not so good," I said. "Go back to basics of neurology. A quadriplegic dog cannot normally be having spinal problems in the lumbo-sacral area as the brain stem and cervical spinal area would be the likely area of traumatic injury. It is possible that there is injury in the tail spinal area as evident by the presence of pain on palpation, but the primary diagnosis should be the brain stem and cervical area.
"Stabilise the dog, give the IV and medication and take the neck X-ray later in cases where the dog had a twisted neck on admission." We all learn by experiences of handling a case and that include me even though I have practised for over 40 years. This was an unusual case. The dog could put weight on the right fore but limped on the other 3 legs. What was he suffering from? Was it head concussion, bleeding and traumatic injury as I suspected? A kick to the side of the head. So, the right eye pupil constricts on direct light but the left eye pupil does not constrict and is dilated even this morning. Yet he can stand up on his own on the right fore limb and walk a distance like a drunken. I am still suspecting a brain stem injury and am reviewing this mysterious case.
P.S. In the evening, the lady and her husband who read on the internet about IVDD (intervertebral disc disease) came after work. I was still around as I booked in a 6-week-old male guinea pig for neutering and showed another Shih Tzu with eye injury in to Dr Vanessa's room for her to treat.
As for the couple, I placed their Shih Tzu on the table and shone bright lights onto each eye. The left eye pupil was dilated despite the bright light. The right eye pupil was constricted. I said to the couple: "This showed that the left eye does not have a direct pupillary response to light." As for consensual pupillary response, the left eye does not constrict even when the bright light was shone onto the right eye.
So, the left eye also did not have consensual pupillary response. The neurological explanation will sound too technical to the owners and so I did not want to confuse them by elaborating.
"Basically, I would say that the traumatic injury is around the brain stem," I said. "The X-rays showed two microchips. One was on top of the cervical spinal bone. Whether this would cause the present problem, I do not know. The other one was in the armpit area.
However, the dog could put weight on the right fore limb and this morning, he could walk upright or limped a distance of over 5 metres before collapsing," I said. I pinched the toes of all 4 limbs in front of the couple. Only the left fore limb had no withdrawal to pinching reflex pain sensation. In veterinary practice, showing is communication to the owner as nowadays, the young Singaporeans are so much more sophisticated.
"There is some improvement," I said and the couple could see it too. "We feed the dog around 4 times a day and give the necessary vitamins. He can't eat on his own. He has got the energy and alertness now. But he needs complete rest and so please do not stay long." The couple adjusted the water bottle height and reluctantly left at 7.30 pm.
A HAPPY LADY IN RED CAME TO THE SURGERY
A fair lady in red sheath dress, with black eyeliner suddenly came into the waiting room and waved at me from the outside. My consultation room's door has a glass window on the top half and so I could see who was coming into the waiting area. This lady, in her prime at around early 30s, looked quite familiar and since she waved to me, she must have met me. I had to stop the meeting which had taken over 30 minutes as I guess my assistants had enough of my reiterations of things to do, government and legal processes to be complied with and records to be written meticulously. Reminders to staff appear to be part of a manager's job and it is a role I rather not be involved in. But I was the licensee and the ultimate responsibility of any clientele complaint, investigation and litigation is with the licensee.
I said hi to the lady in red. Fairness and bright red always demand attention. The lady in red said: "Do you remember the Corgi? I am coming for the S/D diet."
"I am sorry I can't recognise you," I said. "But I do remember Oreo. She had seen a few vets and always passed smelly urine after a course of antibiotics. For at least 2 years or so. Is she OK now?" I had thought of following up but had not done so and now one month had flown by. Just like that.
"Well," the lady beamed. "She is no longer passing smelly urine after one month of treatment. Your medication has been taken and is no more. Her urine is clearer. Best of all, I don't have any smelly urine in the apartment after the end of antibiotics as in the past."
"How many times does Oreo pee and how much does she drink per day?" I asked. "Did you measure the amount of water she drinks a day?" It was difficult for her to answer precisely as she did not take note. She said: "I can't measure the amount because Oreo drinks only fresh water and so the bowl of left over water has to be replaced."
I was surprised that her female spayed dog peed all over the apartment at such an old age. "An adult dog usually pees twice a day, in most cases," I said. "The fault lies with the owner if she pees many times a day," I said. "The owner has no properly house-training the dog as a puppy." This frankness was not good bedside manners.
"Well, I did," she said. "She would hold her urine and then let go a lot." She spread her arms wide. "Is it common for dogs to pass a vast amount of urine every day"
"A dog would pass a lot of urine in the morning for one time," I said. "But not several times. Your dog has been withholding the urine until she can't stand it anymore. You must be beating her up when she had peed all over the apartment when she was younger," I said. "Holding urine leads to bladder infection and the smelly urine that the various vets you consulted before could not cure. Your dog is not fully cured yet. It is only one month.
"You need 3 months of S/D diet to know whether she will be free of urinary tract infection as the S/D diet acidifies the urine and prevents bacteria forming struvite sand in the bladder, leading to bad smelly urine. No other food, dog treats or any other pills."
"My dog loves apples," she said. "Can I give her apples? She looks at me appealingly for apples when I eat one."
"It is best not to," I said. "You had suffered over 2 years of this problem of smelly urine after antibiotics after seeing a vet. Now, her urine is not smelly without antibiotics. Why take risks? Let her urinary tract system stabilise over 3 months of eating S/D diet and drinking plain water. Then you may give her apples."
As regards whether the Corgi was harshly disciplined when she was younger, the lady in red said: "Yes, she got spanked when she peed everywhere." the lady said. "This may be why she withholds her urine till the last moment and urinated a very large puddle of urine onto the floor. What do you suggest I do now?"
At first I advised confinement and removing the urine smell in the floor apartments using white vinegar + water at 1 part to 3 parts water.
As she was moving to a new apartment away from Woodlands soon, I advised: "Complete confinement for 24 hours in a room, with a baby gate, for 4-6 weeks. Newspapers with her urine smell on one side and bed on the other. Confinement is the key to success. Let the dog out when you are at home and pick her up when she is about to pee on the floor and put her into the confined area. Say in a firm tone 'Pee here.' Give a treat if she does that or a praise. Persevere. Old dogs can learn new tricks too especially when you start from a new house."
This case of recurrent UTI seems to be successful but urine monitoring per month should be done. I gave her a urine collection bottle and asked her to know volume of water drank per 24 hours. I hope the new apartment will be free of dog urine smells as friends can smell it but owners who live there will not smell it as their noses are used to it.
Will wait and see. The "living happily ever after" story has not concluded but it seems that there is a good clinical outcome of my recommendations and that is what the lady in red wanted and what all owners whose pets have long suffering diseases demanded.
PREVIOUS REPORT
Written in Oct 31, 2011 (>1 month ago), Recurrent UTI in an old Corgi is at:
http://www.sinpets.com/dogs/20111044blood-urine-recurs-over10times-old-corgi-female-toapayohvets.htm
The blog has brief version:
http://2010vets.blogspot.com/2011/10/717-recurrent-uti-in-old-corgi-is-hard.html
THE WEBSITE FOR THIS FOLLOW UP REPORT WRITTEN DEC 10, 2011 IS AT:
http://www.sinpets.com/F6/20111210recurrent-urinary-tract-infection-old-female-spayed-corgi-singapore-toapayohvets.htm
